explanation of age related physiological changes leading to sexual dysfunction and associated problems

1. SUMANTRA DEY
ANDROPAUSE

2. ALSO KNOWN AS…
Androgen deficiency in ageing male
Late onset hypogonadism
Male menopause
Male climacteric
Androclise
Androgen decline in ageing male (ADAM)
Ageing male syndrome

3. DEFINITION
• Defined as a syndrome associated with a decrease in sexual
satisfaction or a decline in a feeling of general well-being with low
levels of testosterone in older man
• Investigators have generally taken two approaches; one is purely
statistical (lower 2.5th percentile of testosterone adult value), whereas the
other is clinical (use of questionnaires)

4. PATHOPHYSIOLOGY
• Frequency of the condition in 40–79-year old community-dwelling men
is 2.1%
• Slow gradual decline in testicular testosterone (T) production as the man
ages
• The decline of T is usually small, 1–2% per year, but in some men it is more
profound and may lead to clinical hypogonadism
• Majority men fulfilling the strict criteria of andropause are overweight or obese. The
lean men with andropause have often chronic health conditions (e.g. cardiovascular
disease, diabetes, frailty)

5. DIAGNOSIS OF LOH
CLINICAL DIAGNOSIS
• COMMON SYMPTOMS
Loss of libido (most commonly reported)
erectile dysfunction
decreased muscle mass and strength
increased body fat, decreased bone mineral density and osteoporosis
decreased vitality and depressed mood
• presence of three sexual symptoms (decreased libido, morning erections, and
erectile dysfunction) combined with a total testosterone level of less than 11 nmol/l
and a free testosterone level of less than 220 pmol/l, can be considered the minimum
criteria for the diagnosis of LOH in aging men.

6. DIAGNOSIS OF LOH
LAB DIAGNOSIS
• serum sample for total testosterone determination should be obtained between
0700 and 1100 h
• Total serum testosterone = unbound T + protein bound T ( SHBG & Albumin)
• Bioavailable testosterone = unbound T + Albumin-T
• Free or bioavailable testosterone concentrations should be measured when
total testosterone concentrations are close to the lower limit of the normal range
and when altered SHBG levels are suspected
• average testosterone threshold corresponded to the lower limit of the normal
range for young men, that is, 300 ng/dl (10.4 nmol/l)

7. DIAGNOSIS OF LOH
FURTHER EVALUATION
• To differentiate between primary and secondary hypogonadism -
• Estimation of serum FSH + LH
• If low T is associated with elevated LH, the man has primary hypogonadism, and if LH is
either low or inappropriately normal in the face of low T, hypogonadism is secondary,
caused by a disturbance at the hypothalamic-pituitary level. Both conditions are observed in
andropause
• Depression, hypothyroidism, acute illness, chronic alcoholism, and use of medications such
as corticosteroids, cimetidine, spironolactone, digoxin, opioid analgesics, antidepressants,
antifungal agents should be excluded before making a diagnosis of LOH
• Endocrinological diseases should be suspected with signs/symptoms & clinical evaluation
accordingly

8. INDICATION FOR REPLACEMENT
THERAPY
SYMPTOMS OF LOH PRESENT
TESTOSTERONE
>350 NG/ML
>12 NMOL/ML
<230 NG/ML
<8 NMOL/ML
INBETWEEN
NO SUBSTITUTION NECESSARY
WILL BENEFIT WITH
REPLACEMENT
REPEAT TEST,
CONSIDER BIOAVAILABLE
TESTOSTERONE

9. POTENTIAL BENEFITS OF TESTOSTERONE REPLACEMENT
BODY COMPOSITION, MUSCLE MASS & STRENGTH
• Decrease in fat mass and increased lean body mass
• No overall change of body weight
• Inconsistant increase in muscle strength

10. POTENTIAL BENEFITS OF TESTOSTERONE REPLACEMENT
BONE DENSITY AND FRACTURE RATE
• Osteopenia, osteoporosis and fractures very common with LOS
• Bone density consistently increased with therapy, specially lumbar spine BMD

11. POTENTIAL BENEFITS OF TESTOSTERONE REPLACEMENT
SEXUAL FUNCTION
• Erectile dysfunction +/- decreased libido with documented testosterone
deficiency are candidates for replacement therapy.
• Testosterone treatment moderately improved the number of nocturnal
erections, sexual thoughts and motivation, number of successful intercourses,
scores of erection function, and overall sexual satisfaction
• consistent effect has been noted only on libido than on erection function

12. POTENTIAL BENEFITS OF TESTOSTERONE REPLACEMENT
METABOLIC SYNDROME
• obesity, hypertension, dyslipidemia, impaired glucose regulation, and insulin
resistance - common symptoms
• Low serum testosterone associated with cardiovascular morbidity
• Low SHBG and/or androgen deficiency - early warning signs for
cardiovascular risk and scope for early intervention in non obese men
• Replacement shows no consistent effect seen on diabetes and hyperlipidemia
• ANEMIA - stimulate erythropoiesis and increase reticulocyte count,
hemoglobin, and bone marrow erythropoietic activity

13. POTENTIAL EFFECTS OF TESTOSTERONE REPLACEMENT
COGNITIVE FUNCTION, MOOD, ENERGY, QOL
• Decrease in testosterone leads to decline in verbal and visual memory and
visuospatial performance - effects of replacement show mixed results
• Beneficial effect with mood seen in studies with hypogonadism a/w AIDS

14. POTENTIAL BENEFITS OF TESTOSTERONE REPLACEMENT
PROSTATE CANCER AND BPH
• No conclusive evidence that
Treatment increases risk of prostate cancer
Converts subclinical CA prostate into clinically significant one
• Proven deterioration of symptoms and stimulation of growth in known cases of
locally advanced and metastatic cancer prostate
• DRE + PSA essential before starting therapy, but blind biopsy not
recommended

16. ASSESSMENT OF TREATMENT OUTCOME
CONTINUATION OF TREATMENT
• Acceptable time frame for improvement of symptoms - 3 to 6 months for
sexual function, loss of libido, muscle strength and body fat, bone mineral
density take longer time to improve
• Failure to improve in desired time - discontinue treatment and evaluate further
for other causes

17. ASSESSMENT OF TREATMENT OUTCOME
MONITORING DURING THERAPY
• Testosterone level should be checked every 3-6 months
• Hematocrit checked as baseline and every 3-6 years. If HCT >54%, stop
therapy till it decreases to normal level and then restart at lower dose
• BMD after 1-2yrs of replacement
• PSA at onset, 3-6 months and then according to screening protocol. Urology
consultation necessary if rising PSA or deteriorating IPSS score
• Psychiatric evaluation and formulation specific check-up at each visit

18. CONTRAINDICATIONS TO REPLACEMENT
• Prostate or breast cancer
• Guidelines from Endocrine Society recommend against starting testosterone therapy in
1. palpable prostate nodule or induration
2. prostate specific antigen greater than 4 ng/ml or greater than 3 ng/ml in men at
high risk for prostate cancer
3. severe lower urinary tract symptoms with IPSS > 19.
• Significant erythrocytosis with HCT >50%, untreated obstructive sleep apnoea, poorly
controlled heart failure - replacement should not be started before resolution of
comorbid condition

19. CONCLUSION
• A relatively important public health issue generally overlooked in our society
• Awareness amongst doctors may help in early identification of at-risk
individuals for cardiovascular disease, reduce fracture related morbidity

21. Thank you