Late-onset hypogonadism
Late-onset hypogonadism | |
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Specialty | Endocrinology |
Late-onset hypogonadism (LOH) or testosterone deficiency syndrome (TDS)[1][2] is a condition in older men characterized by measurably low testosterone levels and clinical symptoms mostly of a sexual nature, including decreased desire for mating, fewer spontaneous erections, and erectile dysfunction.[3] It is the result of a gradual drop in testosterone; a steady decline in testosterone levels of about 1% per year can happen and is well documented in both men and women.[4][5]
Signs and symptoms
Some men present with symptoms, but they have normal testosterone levels, while others with low testosterone levels have no symptoms. The reasons for this phenomenon are currently unknown.[3][6]
In their late 40s and early 50s, some men may experience depression, loss of libido, erectile dysfunction, and other physical and emotional symptoms. These symptoms include irritability, loss of muscle mass and reduced ability to exercise, weight gain, lack of energy, difficulty sleeping, or poor concentration. It is important to note that many of these symptoms may arise from a midlife crisis or as the results of a long-term unhealthy lifestyle (smoking, excess drinking, overeating, lack of exercise) and may be best addressed by lifestyle changes, therapy, or antidepressants.[7]
Causes
Testosterone levels are well-documented to decline with aging at about 1% per year in both men and women after a certain age; the causes are not well understood.[3][4][5][8][9]
Diagnosis
As of 2016, the International Society for the Study of the Aging Male defines late-onset hypogonadism as a series of symptoms in older adults related to testosterone deficiency that combines features of both primary and secondary hypogonadism; the European Male Aging Study (a prospective study of ~3000 men)[10] defined the condition by the presence of at least three sexual symptoms (e.g. reduced libido, reduced spontaneous erections, and erectile dysfunction) and total testosterone concentrations less than 11 nmol/L (3.2 ng/mL) and free testosterone concentrations less than 220 pmol/L (64 pg/mL).[3]
If a person has symptoms of late-onset hypogonadism, testosterone is measured by taking blood in the morning on at least two days; while
Screening
Due to difficulty and expense of testing, and the ambiguity of the results, screening is not recommended.[3][6] While some clinical instruments (standard surveys) had been developed as of 2016, their specificity was too low to be useful clinically.[3]
Management
The significance of a decrease in testosterone levels is debated and its treatment with replacement is controversial. The Food and Drug Administration (FDA) stated in 2015 that neither the benefits nor the safety of testosterone have been established in older men with low testosterone levels.[13] Testosterone replacement therapy should only be started if low levels have been confirmed;[11] in the US, this confirmation is not done about 25% of the time, as of 2015.[12] Testosterone levels should also be monitored during therapy.[11]
Route | Medication | Major brand names | Form | Dosage |
---|---|---|---|---|
Oral | Testosteronea | – | Tablet | 400–800 mg/day (in divided doses) |
Testosterone undecanoate | Andriol, Jatenzo | Capsule | 40–80 mg/2–4x day (with meals) | |
Methyltestosteroneb | Android, Metandren, Testred | Tablet | 10–50 mg/day | |
Fluoxymesteroneb | Halotestin, Ora-Testryl, Ultandren | Tablet | 5–20 mg/day | |
Metandienoneb | Dianabol | Tablet | 5–15 mg/day | |
Mesteroloneb | Proviron | Tablet | 25–150 mg/day | |
Sublingual | Testosteroneb | Testoral | Tablet | 5–10 mg 1–4x/day |
Methyltestosteroneb | Metandren, Oreton Methyl | Tablet | 10–30 mg/day | |
Buccal | Testosterone | Striant | Tablet | 30 mg 2x/day |
Methyltestosteroneb | Metandren, Oreton Methyl | Tablet | 5–25 mg/day | |
Transdermal |
Testosterone | AndroGel, Testim, TestoGel | Gel | 25–125 mg/day |
Androderm, AndroPatch, TestoPatch | Non-scrotal patch | 2.5–15 mg/day | ||
Testoderm | Scrotal patch | 4–6 mg/day | ||
Axiron | Axillary solution | 30–120 mg/day | ||
Androstanolone (DHT) | Andractim | Gel | 100–250 mg/day | |
Rectal | Testosterone | Rektandron, Testosteronb | Suppository | 40 mg 2–3x/day |
SC ) |
Testosterone | Andronaq, Sterotate, Virosterone | Aqueous suspension | 10–50 mg 2–3x/week |
Testosterone propionateb | Testoviron | Oil solution | 10–50 mg 2–3x/week | |
Testosterone enanthate | Delatestryl | Oil solution | 50–250 mg 1x/1–4 weeks | |
Xyosted | Auto-injector | 50–100 mg 1x/week | ||
Testosterone cypionate | Depo-Testosterone | Oil solution | 50–250 mg 1x/1–4 weeks | |
Testosterone isobutyrate | Agovirin Depot | Aqueous suspension | 50–100 mg 1x/1–2 weeks | |
Testosterone phenylacetateb | Perandren, Androject | Oil solution | 50–200 mg 1x/3–5 weeks | |
Mixed testosterone esters | Sustanon 100, Sustanon 250 | Oil solution | 50–250 mg 1x/2–4 weeks | |
Testosterone undecanoate | Aveed, Nebido | Oil solution | 750–1,000 mg 1x/10–14 weeks | |
Testosterone buciclatea | – | Aqueous suspension | 600–1,000 mg 1x/12–20 weeks | |
Implant | Testosterone | Testopel | Pellet | 150–1,200 mg/3–6 months |
Notes: Men produce about 3 to 11 mg testosterone per day (mean 7 mg/day in young men). Footnotes: a = Never marketed. b = No longer used and/or no longer marketed. Sources: See template. |
Adverse effects
Adverse effects of testosterone supplementation may include increased cardiovascular (CV) events (including
Other significant adverse effects of testosterone supplementation include acceleration of pre-existing prostate cancer growth; increased hematocrit, which can require venipuncture to treat; and, exacerbation of sleep apnea.[3]
Adverse effects may also include minor side effects such as acne and oily skin, as well as significant hair loss and/or thinning of the hair, which may be prevented with
Exogenous testosterone may also cause suppression of spermatogenesis, leading to, in some cases, infertility.[3]
Prognosis
As of 2015, the evidence is inconclusive as to whether testosterone replacement therapy can help with erectile dysfunction in men with late-onset hypogonadism.[12] It appears that testosterone replacement therapy may benefit men with symptoms of frailty who have late-onset hypogonadism.[12]
Epidemiology
The epidemiology is not clear; 20% of men in their 60s and 30% of men in their 70s have low testosterone;[4][12] around 5% of men between 70 and 79 have both low testosterone and the symptoms, so are diagnosed with late-onset hypogonadism.[4] The UK National Health Service describes it as rare.[7]
History
The impact of low levels of
Society and culture
The 1997 book Male Menopause[17][18] by Jed Diamond, a psychologist with a PhD in international health,[19] fueled popular interest in the concept of "andropause".[citation needed] Diamond regards andropause as a change of life in middle-aged men which has hormonal, physical, psychological, interpersonal, social, sexual, and spiritual aspects. Diamond claims that this change occurs in all men, that it may occur as early as age 45 to 50 and more dramatically after the age of 70 in some men, and that women's and men's experiences are somewhat similar phenomena.[20][21] The medical community has rejected the term "andropause" and its supposed parallels with menopause.[22][23]
Thomas Perls and David J. Handelsman, in a 2015 editorial in the
Terminology
Late-onset hypogonadism is an
The terms "male menopause" and "andropause" are used in the popular media but are misleading, as they imply a sudden change in hormone levels similar to what women experience in menopause.[7] A decrease in libido in men as a result of age is sometimes colloquially referred to as penopause.[25]
Research directions
As of 2016, research was necessary to find better ways to measure testosterone and to be better able to understand the measurements in any given person, and to understand why some people with low testosterone do not present with symptoms and some with seemingly adequate levels do present with symptoms.[3] Research was also necessary to better understand the cardiovascular risks of testosterone replacement therapy in older men.[3]
A relationship between late-onset hypogonadism and risk of Alzheimer's disease has been hypothesized, and some small clinical studies have been conducted to investigate the prevention of Alzheimer's disease in men with late-onset hypogonadism; as of 2009, results were inconclusive.[26]
See also
References
- ^ "Middle-age dread". 15 June 2013.
- An Irishman Abroad (Podcast) (297 ed.). SoundCloud. Archivedfrom the original on 27 May 2019. Retrieved 27 May 2019.
- ^ PMID 26614257.
- ^ PMID 25092967.
- ^ S2CID 10928315.
- ^ S2CID 30479724.
- ^ a b c "Male Menopause". www.nhs.uk. NHS Choices. April 8, 2016. Retrieved October 7, 2016.
- ^ "Could you have low testosterone?: MedlinePlus Medical Encyclopedia". NIH: Medline Plus. September 18, 2014.
- PMID 24407185.
- S2CID 15635078.
- ^ S2CID 20816995.
- ^ PMID 26205546.
- ^ New York Times. Retrieved March 19, 2015.
- PMID 25360240.
- PMID 27132584.
- .
- ^
Diamond, Jed (1997). Male Menopause (reprint ed.). ISBN 9781570711435. Retrieved 7 August 2020.
- ISBN 978-1-57071-397-2.
- ^
James, Susan Donaldson (8 August 2009). "Low-T Syndrome: Another Word for Male Menopause". ABC News. ABC News Internet Ventures. Retrieved 7 August 2020.
'Male menopause is real,' said Jed Diamond, a psychologist and author of a series of books on the topic, including, 'Irritable Male Syndrome.' [...] 'Men are more in denial about this than women,' said Diamond, who has a Ph.D. in international health and a master's degree in social work.
- ISBN 978-1-57071-433-7.
- ISBN 978-0-9707061-0-2.
- ^
"The 'male menopause'". NHS. NHS. 19 February 2019. Retrieved 7 August 2020.
The 'male menopause' (sometimes called the andropause) is an unhelpful term sometimes used in the media.
- ^ Compare: Gorski, David (November 25, 2013). ""Low T": The triumph of marketing over science « Science-Based Medicine". Science-Based Medicine.
There is a paucity of evidence that 'low T' is the problem that it is advertised to be and even less evidence that testosterone replacement therapy corrects the problems attributed to 'low T.' Before pharmaceutical companies launch big money campaigns to make millions of men 'aware' of low T, they should be required to do what they have to do before introducing a new drug for a new indication: the appropriate large-scale randomized trials to demonstrate that testosterone therapy for otherwise-healthy aging men whose testosterone levels are below the normal range for young men does more good than harm. Right now, we don't have that evidence, and we're not likely to get it from pharmaceutical companies.
- ^ PMID 25809947.
- ^ Gooren, L. J. G. "The age‐related decline of androgen levels in men: clinically significant?." British journal of urology 78.5 (1996): 763-768.
- )
External links
- Late-onset hypogonadism at Curlie