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  The Aging Male

Do testosterone levels decline with aging?

Yes. In men, serum testosterone concentrations decline gradually and progressively with aging, such that an increasing proportion of older men have testosterone levels below the normal range for young men. It is estimated that decline occurs at a rate of approximately 1% per year after age 30 years. Approximately 20% of men in their 60s and approximately 50% of men in their 80s have serum testosterone levels significantly below those of young men.

What is the reason for the age-related decline in testosterone levels?

With aging alone, there is both diminished testicular production and reduced secretion of certain hormones from the brain (the hypothalamus and pituitary glands).

Among older men, who are at increased risk?

Compared with healthy aging males, sick older men have a higher prevalence of testosterone levels below the normal range for young men. These men have chronic illnesses such kidney, liver and lung diseases, and often are malnourished. This problem is also more common in men with cancer, and those who take certain medications like steroids.

What physiological functions are affected by low testosterone levels?

A number of androgen (testosterone)-regulated physiological functions are affected including changes in body composition and body hair, decreased energy and muscle strength, reduced sexual desire and function, changes in well-being and mood, change of sleep pattern, and diminished cognitive function (or intellectual capacity).

What is hypogonadism?

Hypogonadism in the aging male is most appropriately defined as a decline in serum testosterone to levels below the normal range for young men, with associated clinical symptoms consistent with androgen deficiency (low testosterone). Another often used term is Andropause.

Besides low testosterone levels, what other factors affect physiological functions in aging men?

It is true that age-related alterations (changes) in physiological function are usually a result of multiple causes. It is important to evaluate and treat other factors (e.g. poor nutrition, confounding illness and medication, inactivity, and excessive alcohol use) in addition to low testosterone levels that may contribute to the clinical symptoms in older men with hypogonadism.

Have there been clinical trials of testosterone therapy in older men?

To date, relatively few randomized controlled studies of up to 3 yearsí duration have been performed. These studies have used a variety of testosterone formulations to treat small numbers of mostly healthy older men with testosterone levels slightly below or in the lower part of the normal range for young men, and different methods were used to assess outcomes. These initial studies suggest that testosterone replacement in older men may have beneficial effects on body composition (increased lean body mass and decreased fat mass), bone mineral density, and possibly on muscle strength, sexual function, general well-being, aspects of cognitive function, low-density lipoprotein cholesterol, angina, and exercise-induced heart attacks.

What donít we currently know about testosterone therapy?

Although testosterone therapy in older men has been tolerated well in these initial controlled studies, we do not have information of its long-term risks, particularly risks of prostate disease (prostate enlargement or BPH, and prostate cancer) and cardiovascular disease.

Whom and When to Treat?

Testosterone treatment should only be undertaken after a careful evaluation of the potential risks and benefits. Initial low levels are often confirmed with a second measurement. It is also important that testosterone measurements are obtained between 8:00 and 11:00 AM. Since clinical symptoms can vary widely among individuals, questionnaires have been developed to help physicians to screen for and monitor response to therapy. These questionnaires have been useful, serving as valid and reproducible instruments to evaluate men with androgen deficiency. The key premise is that the symptoms that are the most important to measure are those that matter most to the patients. Deciding who should be offered testosterone replacement can be difficult due to this variability of symptoms. We do know that these clinical changes need not all be present to make a diagnosis of andropause; but whatever symptoms exist, there should also be a decreased in measurable testosterone or other androgens. It follows that it is not possible to identify who should be treated with establishing a reason and a risk. A firm reason for treatment should be established before treatment is begun. The goals of testosterone treatment are the reversal of the clinical symptoms that are attributable to hypogonadism of aging.

What is the current selection of testosterone replacement therapy?

Selection of a specific type of testosterone replacement therapy should include consideration of treatment efficacy, side-effect profiles, reversibility of side-effects should they occur, and patient preferences. Unfortunately, insurance drug coverage and affordability are also real concerns. Testosterone preparations are currently available in pills, injections, implantable pellets, patches, and gels. All forms of testosterone replacement are probably efficacious for any target response if adequate blood levels are obtained. Potential side-effects applicable to all forms of testosterone delivery include fluid retention, breast enlargement, increasing blood cell count, worsening of sleep apnea, mood fluctuations, change in cardio-vascular disease risk, and alterations in prostate health. More specific concerns of the different preparations are as follows. Orally administered testosterone (pills) can cause substantial liver side effects. Injectable agents can have super normal peak levels as well as lower than normal trough levels, and may cause wide mood changes. Newer preparations of patches and gels give more steady-state levels, and are currently preferred.

What do we now know about testosterone supplementation and prostate cancer risk?

Several studies have found a positive correlation between serum hormone levels and prostate cancer, whereas several other studies have failed to show this relationship. No clear evidence exists that adding supplemental testosterone in the face of low testosterone levels is harmful. Patients need to be thoroughly evaluated to rule out prostate cancer before starting therapy and carefully monitored for changes once treatment begins.

What are the observed benefits of testosterone replacement?

Long-term hypogonadism in the aging male is associated with the increased risk of osteoporosis, mood disturbances, and sexual dysfunction. Treatment has been shown to provide long-term physical and mental improvement.

What donít we currently know about testosterone therapy?

Although testosterone therapy in older men has been tolerated well in these initial controlled studies, we do not have information of its long-term risks, particularly risks of prostate disease (prostate enlargement or BPH, and prostate cancer) and cardiovascular disease.

*  This information is not intended to substitute for a consultation with a urologist. It is offered to educate patients on the basis of urological conditions in order to get the most out of their office visits and consultations. Please see our web page disclaimer for addition information.


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