This was the second presentation gibven on MZarch 29, 2019 at the Manlove Psychiagtric Group and Brain Injury Institute spring conference in Rapid City, SD. In this presentation, Dr. Cady carefully goes over the necessity of integrating and overview and awareness of hormones and their levels in the elucidation of what truly is going on with the patient. This was an overview lecture only. Dr. Cady will be presenting a 16 hour CME program in Austin Texas on June 22 and 23 for the National Procedures Institute, and will explore all aspects of all relevant hormones and what can be done to manage and optimize them.

1. Thyroid, Adrenals & Sex
Hormones: A Balancing Act
The Manlove Group Spring Conference
Rapid City, South Dakota March 29, 2019
Louis B. Cady, MD – CEO & Founder – Cady Wellness InstituteLouis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Professor – Indiana University School of Medicine
Functional & Integrative Neuropsychiatry – Evansville, Indiana

2. Louis B. Cady, MD, FAPA – CEO & Founder – Cady Wellness InstituteLouis B. Cady, MD, FAPA – CEO & Founder – Cady Wellness Institute
Adjunct Clinical Lecturer – Indiana University School of Medicine
Department of Psychiatry
Functional & Integrative Neuropsychiatry – Evansville, Indiana
THYROID, ADRENALS, AND HORMONES: A
Balancing Act
The Manlove Group Spring Conference
Rapid City, South Dakota March 23 2019

3. Framework for this presentation:
“Slumber not in
the tents of your
fathers.
The world is
advancing.
Advance with it.”
- Giuseppe Mazzine

4. Orientation to this talk
• Sketch in the fundamental differences
between “wnl” and OPTIMAL
• Quick review of hormones having to do with
FATIGUE and DEPRESSION:
– Thyroid
– DHEA
– Testosterone/estradiol/progesterone
– IGF-1 (“foot soldier” of growth hormone)
• Exposure to the literature/stimulation

5. American Journal of Health Promotion;
November/December, 2002
19% of those
surveyed
were
completely
healthy with
high levels of
both physical
and mental
health and a
low level of
illness.
18.8%
completely
unhealthy,
defined as
having low
levels of health
with high
levels of
illness.
Two-thirds of the adults
reported some
degree of mental
or physical
illness that kept them
from being completely
healthy.
“Incompletely healthy.”
HEALTH continuum
DEAD
O
66%
“Incompletely healthy”

6. VISION: “We dramatically
transform the lives of our
patients and clients to levels of
peak physical and mental health,
supporting a lifetime of
maximum performance and
happiness.”

7. BODY
M
IN
D
A
C
TIO
N
S

8. Critical area of concern for men &
women. Things that will make them:
• Tired &/or depressed
• Unable to cope
• “Mean”
• Stressed
• Deficient in libido or in the bedroom
• Demented

9. Depression & Anxiety Dx in 1 Easy Lesson
DEPRESSION
SIG: E- CAPS!
• Sleep
• Sadness
• Interest loss
• Guilt
• *Energy
• Concentration
• Appetite
• Psychomotor Sx
• Suicidal thinking
Gen. ANXIETY D.O.
•Somatic Sx (“energy”,etc.)
•WORRY
•Irritability
•Concentration
•Keyed up
•Insomnia (“sleep”)
•Restlessness
SWICKIR is Quicker:
Worry + 3 = GAD (Baughman)
5of 9 with 1 of 2 x 2 weeks
*MUST MUST MUST exclude “mood disorder
due to a general medical condition”

10. ♦ Depressed mood 100%
♦ Reduced energy: 97%3
♦ Fatigue or loss of energy: 94%2
♦ Impaired concentration: 84%3
♦ Tiredness:73%1
♦ Hypersomnia: 10%–16%4
(Insomnia)
Useful Target Symptoms in MDDUseful Target Symptoms in MDD
1. Tylee et al. Int Clin Psychopharmacol 1999;14:139-151. 2. Maurice-Tison et al. Br J Gen
Pract 1998;48:1245-1246. 3. Baker et al. Comp Psychiatry 1971;12:354-65. 4. Horwath et
al. J Affect Disord 1992;26:117-25. 5. Reynolds and Kupfer. Sleep 1987;10:199-215.

11. Stahl, SM. Symptoms & Criuits, Part 1 Major Depressive Disorder.
“Brainstorms.” J Clin Psych 64:11, Nov 2003:1282-1283.
“Each symptom may be mediated by separate and
distinct neuronal [AND PHYSIOLOGICAL –
(Cady)] circuits.”

12. Death
OptimalHealth
Traditional
Medicine
Functional
& Informed
Lab TestingNoDisease=Health
Vitamins, HRT, Nutrition, Exercise
INTEGRATED
Medicine
Diagnose and
Treat Disease
New DrugsNew Drugs
New SurgicalNew Surgical
TechniquesTechniques
Forestall and
PREVENT Disease –
Optimize Mood &
Function
Toward an INTEGRATED approach:

15. Modern Medicine’s Paradigm:
Two Standard Deviations – “if you are not
sick, then you must be well.”
“NORMAL”
OPTIMAL

16. 4

17. Releasing
Factors
Releasing
Factors
Adrenal
Gland
Adrenal
Gland OvariesOvariesTesticlesTesticles ThyroidThyroidLiverLiver
Testosterone EstrogenCortisol
DHEA Progesterone
T3 & T4
GHLH & FSH TSHProlactinACTH
IGF-1
Pituitary
Brain
HypothalamusHypothalamus
DHEA
BreastsBreasts

18. “But the doctor told me my thyroid
was fine.”
• Can be “wnl” but suboptimal.
• TSH frequently only thing checked.
• Nothing known about Free T4 or Free T3.
• Free T4 can be converted to Reverse T3 under
stress (cortisol)
• Free T4 can be underconverted to T3.
• Can have normal levels (or slightly elevated
levels) of everything and have auto-immune
thyroid disease.

19. “the foot soldier” “the evil twin”

20. “Thyrotropin (Thyroid-Stimulating
Hormone or TSH). Measuring TSH is the
most sensitive indicator of
hypothyroidism.” (hunh?!)
http://www.umm.edu/patiented/articles/how_serious_hypothyroidism
Accessed: 9/5/2011

21. “the foot soldier” “the evil twin”
CORTISOL
Se

22. Transthyretin (a systemic amyloid precursor)
may be protective for Alzheimer’s (Why?)
Li X et al. J Neurosci 2011 Aug 31;31(55):12483-90

23. Per HRSD – 17, remission in:
15.9% on Li
24.7% on T3
Per QIDS-SR16, remission in:
13.2% on Li
24.7% for T3 *
* Fava & Covino: Augmentation/Combination Therapy in STAR*D Trial,
Medscape Psychiatry
LEVEL III RESULTS:

24. T3 and thyroid augmentation -
depression
• Pharmacological management of refractory
depression.
– Kennedy SH, Joffe RT. Can J Psychiatry. 1989 Jun;343(5):451-6.
• Use of thyroid hormone shortens depressive
illness.
– 15 clinical studies, {1969-1987} with 353
patients
– Vegt M et al. Acta Neuropsychiatr. 1991 Jun;3(2):17-21.
• “Thyroid augmentation depression” – www.pubmed.gov:
– 92 citations as of 03 04 2019

25. “the foot soldier” “the evil twin”
CORTISOL
Se

26. • BACKGROUND:
• Clinicians may not consider using the thyroid hormone
liothyronine sodium (levorotary isomer of triiodothyronine
[T3]) for augmentation of antidepressant drugs in
depressed patients who are also receiving the precursor
hormone levothyroxine (levorotary isomer of thyroxine
[T4]) for thyroid disease. We now report on the successful
use of T3 augmentation therapy in seven of nine
depressed patients who were also receiving T4
for thyroid disease.

29. “No duh” obvious thyroid teaching
points:
• You must check the thyroid and you must
check ALL OF IT (not just “TSH.”)
• Stress and/or selenium deficiency can
PROFOUNDLY alter it.
• Do you want “normal” or “optimal”?

30. “Hypoadrenia”: The Adrenal Problem that most
conventionally trained physicians don’t know about.
• Non-Addison’s hypoadrenia
• Subclinical hypoadrenia
• Neurasthenia
• Adrenal neurasthenia
• Adrenal apathy
• Adrenal fatigue
• “Adrenal burnout”
• “Chronic fatigue syndrome”?!!

31. Fatigue from Adrenal Dysfunction - The
Worst Case Scensario:
Addison’s Disease

32. Signs & Symptoms of Adrenal FATIGUE
• Difficulty getting up in a.m.
• Ongoing lethargy during the day.
• Continued fatigue not relieved by sleep.
• Craving for salt or salty foods.
• Increased effort to do daily tasks
• LESS PRODUCTIVE
• Decreased sex drive
• Decreased ability to handle stress.
• Light-headed when standing up quickly
• Increased recovery time for illness
• Generally less happy about life.

33. The state of adrenal exhaustion can
be determined
Early-stage Chronic
Stress Response
Mid-stage Chronic
Stress Response
End-stage (exhausted)
Chronic Stress
Response

34. DHEA – the critical hormone most
doctors never check
• Produced in the adrenal cortex
– Humans and primates are unique in secreting large
amounts
• Immune system booster
• Insulin regulator
• Energy increase – remarkable
• Boosts growth hormone
– 20% in men; 30% in women in one study
• [Yen, Morales Khorram – one year double-blind placebo
controlled crossover experiment – with 100mg DHEA]

35. Pub Med search Jan 25, 2019 –
“DHEA Supplementation” 421 citations
• Improves sexual function in older premenopausal
women with low baseline FSFI scores (Female
Sexual Function Index)
– Kushner VA. Endocrine 2018 Oct 11.
• Ameliorates abnormal mitochondrial dynamics
and mitophagy of cumulus cells in poor ovarian
responders (in IVF work) . “DHEA may prevent
mitochondrial dysfunction through regulating
mitochondrial homeostasis and mitophagy.”
– Li CJ et al. J Clin Med. 2018 Sep 20:7(10)

36. Pub Med search Jan 25, 2019 – “DHEA
Supplementation”(cont.)
• (mouse studies) - Improves insulin secretion of pancreas;
increases insulin sensitivity of the liver, adipose tissue and
muscle. (Not yet demonstrated to have effect in human
AODM)
– Aoki K et al. Viamin Horm. 2018; 108:365-365}
• Several interesting studies noted correlations between
DHEA and multiple physiological functions:
– Neurological, cognition, memory, depression, decreased bone
mineral density, obesity, diabetes, increased CV mortality,
ERECTILE DYSFXN, and decreased libido.
– Dehydroepiandrossterone and erectile function: A review. El-
SakkaAI. World J Mens Health. 2018 Sep 36 (3):183-191

37. Dehydroepiandrosterone Monotherapy in
Midlife-Onset Major and Minor Depression
• Double blind, randomized, placebo–controlled,
crossover study (Jan 4 1996 – August 31, 2002) at
NIMH Midlife Outpatient Clinic
– 23 men, 23 women, aged 45 – 65
– Midlife onset of major or minor depression.
• “We find DHEA to be an effective
treatment for midlife-onset major and
minor depression.”
Schmidt PJ, Daly RC, Bloch M, et al. Dehydroepiandrosterone monotherapy in midlife-onset major and minor
depression. Arch Gen Psychiatry. 2005 Feb;62(2):154-162.

38. DHEA – some ‘faves” from the literature
• DHEA treatment improves HRQOL with regard to mental
well-being and sexuality.
– Nordmark G, Bengtsson C, Larsson A, et al. Effects of dehydroepiandrosterone supplement on
health-related quality of life in glucocorticoid treated female patients with systemic lupus
erythematosus. Autoimmunity. 2005 Nov;38(7):531-540.
• DHEA Tx could play a role in the prevention and tx of metabolic
syndrome associated with abdominal obesity.
– Villareal & Holloszy. JAMA. 2004 Nov 10;292(18):2243-8.
• DHEA – modest and selective benefical effect on BMD & bone
resorption in women.
– Von Mühlen D, Laughlin GA, Kritz-Silverstein D, et al. Osteoporos Int. 2008
May;19(5):699-707.
• Improved memory, recollection and mood; decreased trough cortisol
levels.
– Alhaj HA, Massey AE, McAllister-Williams RH. Effects of DHEA administration on
episodic memory, cortisol and mood in healthy young men: a double-blind, placebo-
controlled study. Psychopharmacology (Berl). 2006 Nov;188(4):541-551.

39. Why isn’t adrenal fatigue diagnosed?
• Not severe enough to be an
emergency
• Symptoms can be attributed to other
things, including “just neurotic” or
“avoidant”
• “Functional medicine” testing not
typically done (& rarely is DHEA-S
checked)
• Modern medicine focuses on the
treatment of sickness, not “less than
optimal” function.
• “Bell Curve” paradigm

40. Modern Medicine’s Paradigm:
2 Standard Deviations – a model
“NORMAL”
OPTIMAL

41. 432 citations on DHEA with depression
as of 9/5/2011
“Neuroeconomic paramaters predicted to be
related to suicidal behavior.” DHEA is related
to these, acting in amygdala.
Low levels of DHEA/DHEA-S assoc. with depression, as
per Western studies. “DHEA was significantly assoc. w/
[Chinese] Geriatric Depression Scale (GDS).”

42. 628 citations on DHEA with depression
as of 3/4/2019

43. Neurobiological & neuropsychiatric effects
of DHEA & DHEAS [Maninger N et al. Front
Neuroendocrinology 2009]
• DHEA & DHEAS synthesized in adrenals
AND BRAIN.
• Biological actions of DHEA/DHEA-S:
– Neuroprotection
– Neurite growth
– Antagonistic effects on oxidants & glucocorticoids
• “accumulating data suggest abnormal DHEA
(S) concentrations in several neuropsychiatric
conditions.”

44. Key concept
“ADRENALS
BEFORE
THYROID.”

45. 59 year old female, post-menopausal,
on no hormones
• On aggressive supplement regimen with daily MVI
and others
• Not ill
• Top rated medical care with previous labs done
• Nothing identified as seriously abnormal
• “Just interested in having my hormones checked.”

46. Relevant labs – 59 yo female
• CBC, CMP wnl
• TFT’s
– TSH 1.670 {0.45 – 4.5]
– Free T4 1.12 {0.82-1.778}
– Free T3 2.7 {2.0 – 4.4}
• Vitamin D 23.6 (L) {30 – 100; 50 – 80}
• Hormones
– DHEA-S 148.5 {“18.9 – 205.0”}
– Total testosterone 15 {“3 – 41”}
– Free Testosterone 0.5 {0.0 – 2.2}
– Estradiol 12.7 {12.5 – 166 follicular, vs
<6.0 – 54.7 = post-menopausal}
– Progesterone 0.3 {0.2 – 1.5 vs. 0.1 – 0.8}
– IGF -1 100 {81-225}
• CRP 5.1(H) {0 – 4.9}

47. Treatment for this “normal” patient
1. porcine thyroid (T4 + T3 + T2 + T1) – ¼ grain for 1
week, then ½ grain. (Aiming for T3 in “high 3’s.”
2. DHEA – 25 mg SR micronized, compounded – in
a.m.
3. Progesterone – 50 mg SR compounded – at night.
4. Testosterone – 3mg topical per day x 1 wk, then 6
mg. “Decrease dosing as needed for side effects.”
5. Vitamin D – 5,000 IU twice daily x 3 weeks, then
decrease to one dose per day.
6. Fish oil – 4.6 grams (c. 1660 mg EPA and 1,250 mg
DHA by compound weight, plus misc. Omega 3)

49. What’s life like now?
• “it’s like the colors of the rainbow have gotten more into the
pink.”
• “My computer will survive – I use to ‘lose it’ over
my computer. I would swear obscenities.”
• “I’ve gotten into a zen like mode. Handling
everything that life can throw at me.”
• “It’s almost as if I’ve taken a pill or drug that jus
makes me handle everything that life is throwing at
me. I can roll with it.”
• “I’m not irritable any more. Time pressure has just
one away.”

51. Fast food (low Zn) is bad for you.
• Fast food = high energy density = low essential
micronutrient density, ESPECIALLY ZINC
• Antioxidant processes are dependent on Zinc
• Fast food = severe decrease in antioxidant
vitamins and zinc, correlating with
inflammation in testicular tissue – with
underdevelopment of testicular tissue and
decreased testosterone levels

52. Special needs - Zinc
• Low Zinc- associated with low testosterone
– Per USDA, 60% of US men between 20 – 49
years of age do not get enough.
– N.B.: Do not supplement with > 50 mg daily
(can interfere with Cu+ metabolism)
• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto,
W.Y. (2000). Low serum testosterone level as a
predictor of increased visceral fat in Japanese-
American men.
International Journal of Obesity and Related Metabolic Dis
24, 485-491

53. Testosterone functions (Men AND
Women)
• Enhances sex drive
• Builds muscle & decreases
fat
• Elevates mood
• Prevents osteoporosis
• Improves memory
• Lowers cholesterol
• Protects against heart
disease

54. “Hence, among older men reporting excellent
asymptomatic health, age has no effect on
serum T or E2 with a minor increase in DHT
while obesity decreases serum androgens…”

55. • Decline in male sex steroids not as
abrupt as menopause, but equally
debilitating
–Between 40 – 70, average male
loses:
• Nearly 2" of height
• 15% of bone density
• 10 – 20 pounds of muscle
•At 70 yoa, 15% completely
impotent
Testosterone (Men)

56. Andropause: Characteristics of
Change
• Insidious & unpredictable onset
• Slow progression
• Subtle & variable manifestations
• Cannot be linked directly to a decrease in
the hormone testosterone
• Very different from menopause in women!
Charlton R. JMHG. 1(2004): 55-9
Kaufman JM. Endocrine Reviews. 26(2005):833-76

57. T vs Cognitive Function
Rosario ER. JAMA. 292(2004):1431-2

58. T vs Cognitive Function
Rosario ER. JAMA. 2004(292):1431-2
“Testosterone depletion likely precedes and thus may
contribute to rather than result from the development of AD,
since low brain testosterone is observed in men with early
indications of AD neuropathology”

59. CLINICAL VIGNETTE

60. #1: The Case of the Phrustrated Pharmacist
(8/3/2014)
• 73 yo MWM retired (2009) R.Ph. “burned out.”
Essentially sitting home depressed, not going
anywhere
• Presenting Rx:
– Fluoxetine – 40 mg
– Quetiapine – 50 mg XR for sleep (??)
– Hydralazine, amlodipine, simvastatin, metformin,
ASA
• ROS: Decrease in libido, Profound fatigue

61. Mental Status Examination
• Depression:
– Sad/depressed/down in the dumps
– Lack of/loss of interest in things
– Trouble concentrating
– Insomnia/trouble sleeping at times
– Decreased energy
– Guilty/worthless – which is irrational – he has nothing to feel
guilty about it. (6 total symptoms; 5 = required)
• Other symptoms:
– Weakness, hopeless, feeling life is not worth living, sleeping
too much, loss of libido, and full diagnostic criteria met for
generalized anxiety disorder

62. Relevant Markers
• Thyroid Functions
– TSH 0.43 {0.34 – 5.61}
– Free T4 1.34 {0.587 – 1.64}
– Free T3 2.8 {2.0 – 4.4}
– Reverse T3 32.1 (H) {9.2 – 24.1}
• Sex Hormone
– LH 8.7 (H) {1.24 – 8.62}
– Total testosterone 199 (L) {348 – 1197}
– Free Testosterone 3.6 (L) {6.6 – 18.1}
– PSA 0.24 {0.0 – 4.0]
– Estradiol 13.6 {7.6 – 42.6}
• Coenzyme Q10 0.75 {0.37-2.20}

63. Interventions – 8/14/2013
• Testosterone IM
– 200 mg ASAP, then 100 mg every 4 days until
levels better
• DHEA – 25 mg timed release
• Liothyronine – timed release
• High potency MVI (200% Selenium; 100% Zinc
RDA)
• (Continued fluoxetine)

64. The Phrustrated Pharmacist:
What Happened?
• 11/26/2013 – (3 ½ months later)
– Going to all grandchildren’s soccer games
– Out mowing his yard and mulching leaves
– Depressive symptoms ELIMINATED
– Appetite has gone up; but clothes fitting better
– Plenty of energy
• 1/16/2014
– “I’ve been doing good – I’m doing everything. I walk the dog
every day. I go to the soccer games.”
– Has gone to get OSA checked
– Has lost so much weight (60 lbs.) he’s using clothes pins on
pajamas

65. What Happened to Labs (1/6/2014)?
• Thyroid functions
– TSH 0.47 {0.34 – 5.61}
– Free T4 0.67 {0.587 – 1.64}
– Free T3 3.8  {2.0 – 4.4}
– Reverse T3 14.5  {9.2 – 24.1}
• Hormones (Rx of 80 mg T twice weekly)
– Total testosterone 582 {348 – 1197}
– Free Testosterone 12.0 {6.6 – 18.1}
– DHEA-Sulfate 378 (“H”) {30.9 – 295.6”;
OPTIMAL RANGE – per Cenegenics is about 500

66. Final Follow-up of Frustrated Pharmacist –
4/15/2014
• Animated and alert
• Got hired to tutor pharmacology at local
community college
• Playing in handbell choir again
– “I’m not very good – they let me play the half notes
and whole notes with the great big bells.”
• Quipped about a customer he recalled who came in
(in past) and asked for “methyl-testosteroney.”
• On CPAP for six weeks, Doing well

67. Teaching Points
• No change in antidepressants required to
ELIMINATE depression
• Thyroid and testosterone optimized
• High potency nutritional supplementation
given
• Appropriate allopathic care given
• Predictable results occurred
• BUT WHAT ABOUT THE LAST 20 YEARS?
• This way of thinking works in ALL specialties

68. Testosterone and “Prostate Cancer risk”
• Prostate CA found 2.15 & 2.26 times more
likely in lowest compared to highest tertile
of total and free testosterone
• “. . . there are several papers showing a
relationship between LOW testosterone
and prostate cancer. Specifically, low
testosterone has been associated with
high-grade tumors, advanced stage of
presentation, and worse prognosis.”
Morgentaler A. Eur Urol. 50(2006):935-9
Morgentaler A. Urology. 68(2006):1263-7

69. Risk of Venous Thromboembolism in
Men Receiving Testosterone Therapy
• 30,572 men >/=40 years of age. In nation’s largest
commercial insurance programs – 1/1/2007 –
12/31/2014.
• Identified cases – men with dx of VTE who
received anticoagulant drug in the 60 days after
their diagnosis.
• “Exposure to testosterone therapy in the 154
days before the even/index date was not
associated with an increased risk of VTE.”
Baillargeon J et al (incl. Morgentaler) – Mayo Clinic Proceedings, August 2015, vol 90, issue 8: 1038-1045.

70. Risk of Venous Thromboembolism in
Men Receiving Testosterone Therapy
• “Having filled a prescription for
testosterone therapy was not
associated with an increased risk
of VTE in commercially insured
middle-aged and older men.”
Baillargeon J et al (incl. Morgentaler) – Mayo Clinic Proceedings, August 2015, vol 90, issue 8: 1038-1045.

71. A 2nd
Paper on Risks of Testosterone
• “In this population of older men with limitations in
mobility and a high prevalence of chronic disease,
the application of a testosterone gel was
associated with an increased risk of cardiovascular
adverse events.”
• Subjects: 65 yo or older, mobility limitations;
testosterone level of {100-350 ng/dL}
– Baseline: “a high prevalence rate” of HTN,
DM, hyperlipidemia, and obesity”
Basaria S et al. Adverse events associated with testosterone administration. N Engl J
Med 2010 Jul8;363(2)

72. “For me, the practice of medicine has
opened the door to the greatest adventure in
life. Medicine is like a hallway lined with
doors, each door opening into a different
room, and each room opening
into another hallway,
again lined with doors.
Medicine is always
wonderful and never will
be finished.”
- Charles H. Mayo, M.D.

73. “For me, the practice of medicine has
opened the door to the greatest adventure in
life. Medicine is like a hallway lined with
doors, each door opening into a different
room, and each room opening
into another hallway,
again lined with doors.
Medicine is always
wonderful and never will
be finished.”
- Charles H. Mayo, M.D.

74. Appendix

75. Extra slides for further
background follow in notes 
Contact info:
Louis B. Cady, M.D.
www.cadywellness.com
Office: 812-429-0772

76. Fundamental Concepts Regarding
Testosterone Deficiency & Treatment:
International Expert Consensus
Resolutions
• International expert consensus panel
convened in Prague, Czech Republic on
Oct 2, 2015.
• Specialties represented:
– Urology, endocrinology, diabetology, internal
medicine, and basic science research.
– Nine resolutions were debated, with
unanimous approval.
Morgentaler A et al. – Mayo Clinic Proceedings. 2016 Jul;91(7):881-96.

77. 9 Unanimous Resolutions
1. TD (testosterone deficiency) is well
established, clinically significant, and
affects male sexuality.
2. S/Sxs of TD occur as a result of low levels
of T and may benefit from treatment
regardless of whether there is an identified
underlying etiology.
3. TD is a global health concern.
4. T therapy for men is effective, rational, and
evidence-based.
Morgentaler A et al. – Mayo Clinic Proceedings. 2016 Jul;91(7):881-96.

78. 9 Unanimous Resolutions
5. There is no T threshold that reliably
distinguishes those who will reliably
respond to tx from those who will not.
6. There is no scientific basis for any age-
specific recommendations against the use
of T therapy in men
7. The evidence does not support increased
risks of cardiac event with T therapy.
Morgentaler A et al. – Mayo Clinic Proceedings. 2016 Jul;91(7):881-96.

79. 9 Unanimous Resolutions
8. The evidence does not support increased
risk of prostate cancer with T therapy.
9. The evidence supports a major research
initiative to explore possible benefits of T
therapy for cardiometabolic disease,
including diabetes.
“These resolutions may be considered points
of agreement by a broad range of experts
based on the best available science."
Morgentaler A et al. – Mayo Clinic Proceedings. 2016 Jul;91(7):881-96.

80. T vs Cognitive Function
• 400 independently living men, 40-80yo
– 100 in each age decade
– MMSE 21-30, average 28
– TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
• HIGHER T = better cognitive performance in
OLDEST AGE category
• Men with lowest 1/5 T = worse than men with
highest 1/5 T
• Highest Bio-available T more significant
than TT, age, intelligence level, mood,
smoking, and alcohol.
Muller M. Neurology. 64(2005):866-71

81. T vs Mood in men
• Study: 278 men, >45yo, followed 2 years
• Compared to eugonadal patients,
hypogonadal men w/TT <200ng/dL had
– 4-fold increase risk of depression
– Significantly shorter time to depression
diagnosis
• Depression risk inversely related to TT
w/statistical significance <280ng/dL
Shores MM, Arch Gen Psychiatry. 61(2004):162-7

82. Treatment options – not just
“the needle”

83. Health is a state of complete
physical, mental and social
well-being, and not merely
the absence of disease or
infirmity.
- World Health Organization

84. ADAM Questionnaire
• Do you have a decrease in libido (sex
drive)?
• Do you have a lack of energy?
• Do you have a decrease in strength and/or
endurance?
• Have you lost height?
• Have you noticed a decreased “enjoyment
of life”?
Tancredi A. Eur J Endocrinol. 151(2004):355-60

85. ADAM Questionnaire
• Are you sad and/or grumpy?
• Are your erections less strong?
• Have you noted a recent deterioration in
your ability to play sport?
• Are you falling asleep after dinner?
• Has there been a recent deterioration in
your work performance?
Tancredi A. Eur J Endocrinol. 151(2004):355-60

86. ADAM Questionnaire
• Positive result if yes to
– answer 1 or 7
– any three other questions
• High sensitivity (~80%) to identifying aging
males w/low free testosterone levels
• Low specificity (~20%)
• Validated in other languages
Tancredi A. Eur J Endocrinol. 151(2004):355-60