Unit II - ReproductionUnit II - Reproduction

AndropauseAndropause

Dr. Jennifer MacIsaac, MD, CCFPDr. Jennifer MacIsaac, MD, CCFP

Family Physician and Women’s Health Family Physician and Women’s Health SpecialistSpecialist

Faculty of MedicineFaculty of Medicine

University of OttawaUniversity of Ottawa

ObjectivesObjectives

Definitions Definitions Physiological and hormonal Physiological and hormonal

changeschanges Review signs and symptoms of Review signs and symptoms of

andropauseandropause Biopsychosocial impactBiopsychosocial impact Appropriate investigationsAppropriate investigations Treatment optionsTreatment options

DefinitionsDefinitions

AndropauseAndropause

Unlike "menopause”, the word Unlike "menopause”, the word

"andropause" is not currently "andropause" is not currently

recognized by the World recognized by the World

Health Organization and its Health Organization and its

ICD-10 medical classificationICD-10 medical classification

DefinitionsDefinitions

AndropauseAndropause

Menopause-like condition in Menopause-like condition in

aging menaging men

Otherwise known as “male Otherwise known as “male

menopause”menopause”

Physiology of Physiology of AndropauseAndropause

- A decrease in - A decrease in Leydig cellsLeydig cells

associated with a slow and steady associated with a slow and steady

reduction of the production of the reduction of the production of the

hormones hormones testosteronetestosterone and and

DHEADHEA (dehydroepiandrosterone) (dehydroepiandrosterone)

in middle-aged men, and the in middle-aged men, and the

consequences of that reductionconsequences of that reduction

Mooradian AD, et al. Am J Ther 2006; 13(2): 145–60.

Features of Features of AndropauseAndropause

40-50 years of age40-50 years of age Not all men experience symptomsNot all men experience symptoms Affects 30% of men in their 50’sAffects 30% of men in their 50’s Very slow decline in testosteroneVery slow decline in testosterone Symptom onset may be very gradualSymptom onset may be very gradual 10% of androgen levels by age 7010% of androgen levels by age 70

PhysiologyPhysiology Declining Declining

TestosteroneTestosterone Starting at the age of Starting at the age of

30, men experience a 30, men experience a drop in testosterone by drop in testosterone by about 10% every about 10% every decadedecade

Increasing SHBGIncreasing SHBG Sex Hormone Binding Sex Hormone Binding

GlobulinGlobulin Testosterone produced Testosterone produced

is is

less available to tissuesless available to tissues

PhysiologyPhysiology- Testosterone is Testosterone is

necessary for necessary for

normal sperm normal sperm

development. It development. It

activates genes activates genes

in in Sertoli cells, ,

which promote which promote

differentiation of differentiation of spermatogonia

Role of TestosteroneRole of Testosterone Anabolic effectsAnabolic effects

Muscle mass & Muscle mass & strengthstrength

Bone density & Bone density & strengthstrength

Stimulation of Stimulation of linear growth & linear growth & bone maturationbone maturation

Prostate growthProstate growth

Androgenic effects Androgenic effects (2ndary sex (2ndary sex characteristics)characteristics) Sex organ Sex organ

maturationmaturation Voice deepeningVoice deepening Facial and Facial and

axillary hairaxillary hair

Role of TestosteroneRole of Testosterone

LibidoLibido Clitoral Clitoral

engorgement/ engorgement/ penile erection penile erection frequency frequency

Mental and physical Mental and physical energy energy

Decrease visceral Decrease visceral fat massfat mass

Decrease total Decrease total cholesterolcholesterol

Glycemic controlGlycemic control Liver functionLiver function

Symptoms of Symptoms of AndropauseAndropause

low sex drive low sex drive difficulties getting difficulties getting

erections or erections or erections that are erections that are not as strong as not as strong as usual usual

lack of energy lack of energy depression depression

irritability and irritability and mood swings mood swings

loss of strength or loss of strength or muscle mass muscle mass

increased body increased body fat / weight gainfat / weight gain

hot flushes hot flushes

Signs of AndropauseSigns of Andropause Decreased muscle massDecreased muscle mass Increased abdominal circumferenceIncreased abdominal circumference Weight gainWeight gain Loss of axillary or facial hairLoss of axillary or facial hair Depression / IrritabilityDepression / Irritability OsteoporosisOsteoporosis Memory changesMemory changes Poor glycemic controlPoor glycemic control

Biopsychosocial ImpactBiopsychosocial Impact

Increased risk for osteoporosis and Increased risk for osteoporosis and cardiovascular problems such as atherosclerosiscardiovascular problems such as atherosclerosis

Loss of intimacy in relationshipsLoss of intimacy in relationships Effects on work performance and interpersonal Effects on work performance and interpersonal

interactioninteraction Negative impact on maintaining healthy lifestyleNegative impact on maintaining healthy lifestyle Only 5% of an estimated 4-5 million men in the Only 5% of an estimated 4-5 million men in the

U.S. & 400,000-500,000 in Canada are treatedU.S. & 400,000-500,000 in Canada are treated

InvestigationsInvestigations

Testosterone levelsTestosterone levels TotalTotal FreeFree BioavailableBioavailable

SHBGSHBG OtherOther

Testicular biopsyTesticular biopsy Semen analysisSemen analysis Brain MRIBrain MRI

CBCCBC FerritinFerritin Vitamin B12, FolateVitamin B12, Folate TSH + free T4TSH + free T4 Fasting Blood Fasting Blood

GlucoseGlucose LFTsLFTs Renal functionRenal function PTH / Calcium / POPTH / Calcium / PO44

TreatmentTreatment

Testosterone replacement therapyTestosterone replacement therapy

Shown to improve energy levels, muscle Shown to improve energy levels, muscle mass, bone density, glycemic control, mass, bone density, glycemic control, sleep, and sex drivesleep, and sex drive

Shown to reduce osteoporosis & Shown to reduce osteoporosis & cardiovascular risk, depression, irritability, cardiovascular risk, depression, irritability, anxiety, body fat, and cholesterolanxiety, body fat, and cholesterol

Testosterone Testosterone ReplacementReplacement

The American Society of Andrology's The American Society of Andrology's position is that:position is that:

"... testosterone replacement "... testosterone replacement therapy in aging men is indicated therapy in aging men is indicated when both clinical symptoms & signs when both clinical symptoms & signs suggestive of androgen deficiency & suggestive of androgen deficiency & decreased testosterone levels are decreased testosterone levels are present."present."

J. Androl 2006; 27 (2): 133–4.

Testosterone Testosterone ReplacementReplacement

The American Association of Clinical The American Association of Clinical Endocrinologists says:Endocrinologists says:

"Hypogonadism is defined as a free "Hypogonadism is defined as a free testosterone level that is below the lower testosterone level that is below the lower limit of normal for young adult control limit of normal for young adult control subjects. Previously, age-related decreases in subjects. Previously, age-related decreases in free testosterone were once accepted as free testosterone were once accepted as normal. Currently, they are not considered normal. Currently, they are not considered normal. Patients with low-normal to normal. Patients with low-normal to subnormal range testosterone levels warrant subnormal range testosterone levels warrant a clinical trial of testosterone."a clinical trial of testosterone."

Guay AT, et al. Endocr Pract 2003; 9 (1): 77–95.

Testosterone Testosterone ReplacementReplacement

Target level may vary depending on Target level may vary depending on the patient’s agethe patient’s age

Various formsVarious forms GelsGels InjectionsInjections PatchesPatches PillsPills

Testosterone Testosterone SupplementsSupplements

PatchPatch only delivery method that only delivery method that

mimics the natural daily mimics the natural daily rhythm of testosterone rhythm of testosterone production in healthy young production in healthy young menmen

applied once daily and worn applied once daily and worn for 24 hoursfor 24 hours

can exercise, swim, bathe, can exercise, swim, bathe, and shower like normal and shower like normal

Testosterone Testosterone SupplementsSupplements

GelsGels Applied once daily to clean, dry Applied once daily to clean, dry

skin on the shoulders, upper skin on the shoulders, upper arm, or abdomenarm, or abdomen

Must wait several minutes for Must wait several minutes for the gel to dry before dressingthe gel to dry before dressing

Must wait 5 - 6 hours before Must wait 5 - 6 hours before showering, bathing, or showering, bathing, or swimmingswimming

Easily absorbed – CAUTION – Do Easily absorbed – CAUTION – Do not to allow others to contact not to allow others to contact medicated skinmedicated skin

Testosterone Testosterone SupplementsSupplements

PillsPills Taken twice daily after Taken twice daily after

mealsmeals Must monitor liver enzymesMust monitor liver enzymes

InjectionsInjections IntramuscularIntramuscular Administered at the doctor's Administered at the doctor's

office every 3 - 4 weeks office every 3 - 4 weeks

Testosterone Testosterone ReplacementReplacement

Side effects Side effects Acne or oily skinAcne or oily skin Prostate growth & growth of pre-existing Prostate growth & growth of pre-existing

cancerscancers Sleep problems (apnea)Sleep problems (apnea) Increased blood cell production Increased blood cell production

(hematocrit)(hematocrit) InfertilityInfertility Other effects specific to dosage form Other effects specific to dosage form MUSTMUST monitor CBC and PSA levels monitor CBC and PSA levels

TreatmentTreatment Lifestyle changesLifestyle changes

Regular exerciseRegular exercise Adequate sleepAdequate sleep Good nutritionGood nutrition Reducing smoking, Reducing smoking,

caffeine and alcoholcaffeine and alcohol Relaxation via Relaxation via

breathing exercise, breathing exercise, yoga, meditationyoga, meditation

Psychosocial Psychosocial counselingcounseling

Case 1 – Mr. SmithCase 1 – Mr. Smith

52 year old male52 year old male 8 month history of night sweats on & off8 month history of night sweats on & off Lost 30 lbs with aggressive exercise 1y agoLost 30 lbs with aggressive exercise 1y ago Then gained 10 lbs slowly despite exerciseThen gained 10 lbs slowly despite exercise Mostly abdominal weight gainMostly abdominal weight gain More irritable moodMore irritable mood ROS unremarkableROS unremarkable

Case 2 – Mr. JonesCase 2 – Mr. Jones

48 year old male48 year old male 6 months history of fatigue & myalgias6 months history of fatigue & myalgias Proximal muscle weaknessProximal muscle weakness Osteopenia (T score -2.0)Osteopenia (T score -2.0) PalpitationsPalpitations Lack of mental clarityLack of mental clarity Weight gainWeight gain

QuestionQuestion

Which gentleman is more likely to Which gentleman is more likely to suffer from andropause?suffer from andropause?

A.A. Mr. SmithMr. Smith

B.B. Mr. JonesMr. Jones

InvestigationsInvestigations

CBC NCBC N TSH NTSH N FBG NFBG N LFTs NLFTs N Renal function NRenal function N Calcium / POCalcium / PO44 N N Total & free Total & free

testosterone both testosterone both lowlow

CBC NCBC N TSH elevated & free TSH elevated & free

T4 lowT4 low FBG elevatedFBG elevated LFTs NLFTs N Renal function NRenal function N PTH & Ca elevatedPTH & Ca elevated Testosterone levels NTestosterone levels N

Mr. Smith

Mr. Jones

QuestionQuestion

Which gentleman is more likely to Which gentleman is more likely to suffer from andropause?suffer from andropause?

A.A. Mr. SmithMr. Smith

B.B. Mr. JonesMr. Jones

TreatmentTreatment

Mr. Smith chose Mr. Smith chose testosterone injections testosterone injections every 3-4 weeksevery 3-4 weeks

He has had 3 injections He has had 3 injections over the past 3 monthsover the past 3 months

His night sweats have His night sweats have resolvedresolved

He has lost 10 lbs in the He has lost 10 lbs in the past 3 monthspast 3 months

His mood has stabilizedHis mood has stabilized

THANK YOU!!!THANK YOU!!!