Why Men Should Explore their Hormone Replacement Options | July 2009

By Angela Fernandez

Feeling sluggish? Lost interest in sex? Cranky? Have you had these symptoms for a while now and just can’t shake the feeling that something’s not right? You could be experiencing andropause.

Andropause is the term many people are using to describe the gradual loss of testosterone in men. Often compared to menopause, this MANopause is characterized by irritability, sleep problems, diminished libido, erectile problems, muscle loss, weight gain, memory loss, thinning hair, decreased bone density and depression.

The Mayo Clinic reports that older men generally have lower testosterone levels than younger men do. As men age, there’s a continuous decrease in testosterone production. The rate at which testosterone declines varies greatly among men. As many as 30 percent of men older than 75 have a testosterone level that’s below normal, according to the American Association of Clinical Endocrinologists.

While both menopause and andropause seem to be conditions associated with the aging process, there are important differences between the two. “There needs to be a distinction because we’re dealing with two different situations,” says Todd Nippoldt, M.D., an endocrinologist at Mayo Clinic, Rochester, Minnesota. “In women, ovulation ceases and female hormone production plummets over a relatively short time frame. In men, there’s a gradual decline in the production of male hormones.” Age-related decline in testosterone levels is also called testosterone deficiency, androgen decline in the aging male (ADAM) or late onset hypogonadism (LOH).

Dr. Tomas Griebling, Associate Professor of Urology, Vice Chair of Urology, and Assistant Scientist in the Center on Aging at the University of Kansas School of Medicine in Kansas City, explains the nuances between menopause and andropause. “They are similar in the physiologic changes that are associated with hormone levels, but the changes tend to be perhaps slower and more progressive in men, and more subtle at times than in women. That change for some women is more abrupt,” he says.

Scientists and physicians alike have been monitoring the effects of these gradual changes. “There’s been a lot of research looking at the hormonal changes that occur with aging and men and women,” says Griebling. “There are changes that occur and research to show that there tends to be a decrease in circulating serum testosterone levels as men age. What effect that has on a variety of different health systems for the patient is still under investigation.”

Researches and physicians at the Cleveland Clinic, a not-for-profit, multispecialty academic medical center that integrates clinical and hospital care with research and education, report that changes associated with testosterone deficiency include:

• A decrease in muscle mass
• Variable effects on cholesterol metabolism
• A decrease in hemoglobin and possibly anemia
• Fragile bones (osteoporosis)
• A decrease in body hair

To understand the possible complications of low serum testosterone levels, it is important to recognize how testosterone is critical to metabolic processes. Testosterone is a hormone produced by the testicles and is responsible for the proper development of male sexual characteristics. Testosterone is also important for maintain muscle bulk, adequate levels of red blood cells, bone growth, sense of well-being, and sexual function. It promotes a high energy level, healthy mood, fertility and sexual desire. Testosterone deficiency doesn’t just affect sex drive and function- it has been linked to a number of medical problems, according to The Endocrine Society. These include the metabolic syndrome- a cluster of metabolic risk factors that increase the chances of developing heart disease, stroke, and type 2 diabetes. Nonalcoholic fatty liver disease, also called fatty liver, commonly co-occurs with the metabolic syndrome and may aggravate the metabolic problems.

To receive a diagnosis of the metabolic syndrome, patients must have three of the following five risk factors: abdominal obesity (a large waist line), low HDL (“good”) cholesterol, high triglycerides (fats in the flood), high blood pressure and high blood sugar.

Low levels of testosterone have been associated with increased risk for heart disease. Studies by different sources, including a 2007 study by University of Cambridge School of Clinical Medicine in Britain and a 2008 study published in the Journal of Clinical Endocrinology and Metabolism point to a connection between naturally occurring testosterone levels and heart disease. Further research is being conducted to determine if hormone replacement therapy would benefit men with low testosterone levels with respect to heart disease.

Other studies point to a link between Alzheimer’s Disease and low testosterone levels in men. A John Hopkins Health Alert revealed the results of a long-term study in the journal Neurology. Researchers found that, in a group of U.S. men followed for decades, those with low blood levels of free testosterone had an elevated risk of developing Alzheimer’s disease. Free testosterone is a form of the hormone that is not bound to a protein in the blood and is therefore available to body tissue.

While the full benefits and drawbacks of giving older men testosterone to ward of Alzheimer’s Disease is far from clear, the study authors say their findings should spur more research into the possibility.

“There is research going on to answer some of those questions,” says Griebling. “There is some question about the relationship between testosterone and estrogen levels and their relationship to heart disease and to Alzheimer’s and other cognitive changes.” The Most recent study present in June of 2009 at the annual meeting of The Endocrine Society looked at men receiving testosterone replacement for 24-30 months. Following six months of testosterone administration, BMI, waist circumference and LDL levels declined progressively over the study period while HDL levels significantly increased. Serum cholesterol and triglycerides progressively and significantly declined over the first nine to 12 months and then stabilized.

So how do you know if testosterone replacement therapy is right for you? A visit to your doctor and a quick blood test can determine if your testosterone levels are low. “Typically it is recommended that it’s done in the morning because there can be some variation in serum testosterone levels that occur naturally through a daily cycle,” explains Griebling. “Testosterone tends to be higher in the morning and somewhat lower in the afternoon.”

To prepare for your appointment, the Mayo Clinic recommends the following:

• Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements that you’re taking.
• Write down questions to ask your doctor.

If you and your doctor determine that hormone replacement is right for you, you should be aware of the way testosterone is administered.

“There are no oral supplements that are useful for that purpose. Oral testosterone is not well absorbed and actually can cause dangerous effects on the liver,” says Griebling. “Testosterone replacement is generally given as an intramuscular injection or transdermally, so either as a skin patch or a gel that’s absorbed through the skin, but not as a pill.”

The Mayo Clinic explains the various forms of testosterone replacement therapy:

• INJECTION. Testosterone injections are very effective. Injections are given in a muscle about every two weeks. Your symptoms may come and go between doses. You or a family member can learn to give testosterone replacement therapy injections at home. If you’re uncomfortable giving yourself injections, a nurse or doctor can give the injections.
• PATCH. A patch containing testosterone is applied each night to your back, abdomen, upper arm, or thigh. The site of the application is rotated to maintain seven-day intervals between applications to the same site to lessen skin reactions.
• GEL. You rub testosterone gel into your skin on your lower abdomen, upper arm, or shoulder. As the gel dries, your body absorbs testosterone through your skin. Gel application of testosterone replacement therapy appears to cause fewer skin reactions than patches do. Don’t shower or bathe for several hours after a gel application to be sure it gets absorbed.

Dr. Kent Holtorf, of the Holtorf Medical Group, the Center for Hormone Imbalance, Hypothyroidism and Fatigue, is a leader in hormone replacement therapies. On his Web site (www.holtorfmed.com), he explains the far-reaching ramifications of low testosterone levels.

“Many men suffer needlessly because their testosterone is never checked or the wrong test is ordered. Men as young as 25 to 30 years in age are presenting with low levels of testosterone, which was not the case 10 or 20 years ago,” he explains.

“This is possibly a result of environmental toxins, plastics, pesticides, pollutants, and/or xenoestrogens in the environment. A large percentage of men who have been told their testosterone is fine actually have low testosterone. Often the total amount of testosterone is read as adequate, but the amount of usable testosterone is low,” says Dr. Holtorf. “Men with low testosterone may have subtle to profound symptoms, ranging from poor motivation, anxiety, weight gain, and loss sense of well being to profound depression, and loss of sex drive. Men with low testosterone cannot only enjoy an improved quality of life with testosterone supplementation, but it will also provide a significant decreased risk for heart disease, cancer, diabetes and death.”

If you think hormone replacement therapy is right for you, please consult with your physician. Men considering therapy should have their PSA levels checked.

Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor takes a blood sample, and the amount of PSA is measured in a laboratory. Because PSA is produced by the body and can be used to detect disease, it is sometimes called a biological marker or a tumor marker.

Griebling has two important pieces of advice for men considering hormone replacement therapy: “One is that if men are experiencing symptoms, they should discuss it with their health care provider and possibly get their testosterone level checked to determine if there is a problem,” he says.

“The second issue is related to prostate cancer. There’s always a concern about that with testosterone replacement. The misconception is often that testosterone causes prostate cancer. That’s not true. Prostate cancer often is driven by testosterone. To start any type of therapy with hormone replacement, they need to be screened for prostate cancer to make sure they do not have undiagnosed prostate cancer.”