Lakeview Health System
Male Menopause

Definition: TD (Testosterone Deficiency) has been described in a few different terms, including male menopause, andropause, hypogonadism and androgen deficiency, to name a few. Classically, TD is marked by a combination of symptoms and low blood testosterone (T) levels, however questions do remain about this condition-Is TD a natural phenomena or a health problem? Does treatment really benefit the patient in the long run? What are some of the side effects of treating TD? How is the best way to treat TD?

Symptoms: There are really 2 categories of symptoms of TD - sexual and metabolic. Sexual symptoms can include poor sperm production (decreased fertility) and decreased libido (desire) and ED (erectile dysfunction). Metabolic symptoms can include low bone density (osteoporosis), decreased muscle mass and strength, fatigue, and increased body fat mass.

Epidemiology: TD increases with age (10-20% age 50, 30-50% age 70). It also appears men with other medical problems are predisposed to TD - obesity, diabetes, hypertension and hyperlipidemia, to name a few.

Potential Risks of TD: This is still an area of research and much is still unproven, but there does appear to be a relationship between TD and developing obesity, diabetes and even cardiovascular disease. There may also be a correlation between TD and developing a higher grade of prostate cancer.

Measuring T levels: Generally, measuring total T levels is the first screening test done-300ng/dL is considered "normal". Because T levels can vary throughout the day, they are best measured in the morning and in general are repeated for confirmation. Free T levels can be measured if there is an equivocal total T level, and may be a more accurate marker of T in extremely obese men.

Potential Benefits of Testosterone Replacement (TR): Although there are few published studies on this, most short term studies do show significant benefits to TR, only if the T is low. Libido and ED improve almost immediately, and body composition changes continue to improve over months of treatment. These body changes include increased bone density, increased muscle mass (avg 4 lbs) and decreased fat mass (avg 4 lbs). It needs to be clearly stated that muscle strength does NOT improve with TR alone, not surprisingly, since most of the muscle mass increase occurs in the trunk, not in the arms and legs. There is growing evidence that "triple" treatment of TD (TR combined with exercise and diet) provides the most body mass benefits including increased strength. All the long term benefits of TR are still unproven and unclear.

Potential Side Effects of TR: In general, TR is considered safe, but there are some potential risks. It is well known that prostate growth is under the control of T, and there is conflicting evidence on whether growth is significantly stimulated by TR. While there is no conclusive evidence that TR increases the risk of prostate cancer, it is a major concern for any man receiving T. Erythrocytosis, or increased red blood cell levels, can occur and may result in the TR dosing to be decreased if the hematocrit level exceeds 50%. Decreased sperm production, sometimes permanent, can also occur, so TR should be strictly avoided in all men who plan to have children. Acne, oily skin, mild fluid retention, breast enlargement, decreased testicle size and sleep apnea have also been associated with TR. While uncertainties exist, men with prostate or breast cancer should be very cautious about undergoing TR therapy.

**There is growing evidence that testosterone transfer to children and partners from the use of topical testosterone (gel) can occur. The following are some FDA warnings:
1. Patients should wash their hands immediately with soap and water after applying testosterone gel.
2. Patients should cover the application sites with clothing after the gel has dried. If unwashed skin does come into direct contact with the skin of another person, the general area of contact should be washed with soap and water.
3. Women (especially pregnant) and children should avoid skin contact with topical testosterone application sites in men. Changes in body hair distribution, significant increase in acne or other signs of virilization should be brought to the attention of a physician.



Monitoring of TR:
It is unclear what risk is posed if T levels get too high, thus the goal of TR is to raise T levels to the "mid-normal" range, usually checked at the mid point of therapy, to avoid measuring "peaks and troughs". To follow progression after treatment, and to observe for side effects, T levels, PSA blood tests and hematocrit are checked initially and every 3-12 months, depending on the individual situation.

Treatment Options: There are different ways for patients to supplement T, each with their own advantages and disadvantages. Currently injections and skin gels are the most popular supplements.

Every patient can respond differently to each formulation, and there are some men in whom normal levels of T cannot be achieved, no matter what the type of T supplement or dosing.

Type

Dosing

Advantages

Disadvantages

Oral

40mg once daily

Convenient, discreet

Not recommended-may cause cholesterol, heart, liver and clotting problems

Buccal

30 mg twice daily



Discreet-sticky material applied to gum.

Consistent release

Oral irritation and halitosis

Twice daily

Cost

Skin Gel

5 gm daily

Convenient dosing

Hi patient compliance

Consistent release

Concerns about transference to others

Variable absorption

Cost

Patch

5 mg nightly

Consistent release

Low incidence erythrocytosis

Visible

Skin Irritation, and shaving required

May be difficult to achieve good levels

Cost



Injection

200 mg 2-4 weeks

Cheap

Effective

Convenient if can be taught to self-administer



Wide variations, "peak and trough" effect

Usually requires office visits for injection



Long Acting Subcutaneous Pellets

Every 4-6 months

Convenient dosing

10 minute office procedure



Conclusions:
Despite the lack of long-term scientific evidence, testosterone therapy is rapidly growing in popularity. TR therapy does have some potential benefits and is generally safe, but patients need to be monitored appropriately and understand that long term health benefits and risks are not clear cut.