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7 July 2001
Testosterone Therapy For Older Men
by George Atkinson

A spotlight is at last being turned on to the health needs of older men and there will be an upsurge of interest in combating the hormonal problems of male ageing, an international conference on reproductive medicine heard recently.

Professor Eberhard Nieschlag from the Institute of Reproductive Medicine, University of Münster in Germany, predicted that there would be a worldwide increase of interest in andrology in response to demands from the public for more attention to be paid to hormonal treatments for older men.

He said that although more than 30 years had passed since the declining endocrine capacity of the testis was recognised as an age-related phenomenon, hormone replacement therapy for men had been slow to develop. This was in contrast to HRT for women, which was well established and had lead to dramatic improvements in the quality of life for many older women. No such substitution for prevention and relief of symptoms of ageing based on large-scale clinical trials had found an equivalent place in routine treatment of older men.

"Some physicians, aware of the discrepancy between options for men and women, are overcome by therapeutic nihilism while others resort to empirical lifestyle methods and anti-ageing gurus offering lifestyle measures and drugs with no track record in evidence-based medicine", Pofessor Nieschlag told the European Society of Human Reproduction and Embryology. He blamed the situation on a general lack of knowledge about male reproductive functions and those functions that depended on reproductive hormones.

"While obstetrics and gynaecology have been a classical field since Adam and Eve, the male only came into focus in the last quarter of the 20th century. As there is no male menopause equivalent to the abrupt and complete cessation of reproductive function experienced by women, there has been no comparative urgency to do something for men. In addition, the long life expectancy of women meant that there was more pressure on them to care for the quality of their later years."

But all this is about to change, he predicted. "Male life expectancy is increasing and the quality of life for ageing men plays a more and more important role; and of course, women notice the benefits of HRT and wonder why there is nothing equivalent for their partners."

Professor Nieschlag said that reduced testicular function (hypgonadism) was characterised by lack of energy, depression, erectile dysfunction, anaemia, reduced muscle mass, obesity and osteopororis. These were all symptoms of androgen deficiency and the incidence increased with advancing age. He said that it was vital not to overlook that these symptoms could have other causes which must be differentiated because they would not be helped by testosterone treatment, and it was important to acknowledge that testosterone treatment would benefit only those men with lower than normal levels. However, it was also important to recognise that testosterone deficiency became increasingly common over the age of 50. In men between the ages of 50 and 60, 7% were deficient, between 60 and 80 years 21% were deficient and over 80 years more than a third were deficient.

But testosterone deficiency (serum testosterone levels below 12 nmol/l) diagnosed at any age and accompanied by symptoms, could be treated by testosterone therapy provided that prostate cancer had been excluded. For younger men, long-acting injections were useful. In older men, shorter-acting preparations such as tablets or patches were preferable so that they could be easily withdrawn if treatment needed to be stopped quickly because of unwanted side effects or the advent of a disease such as prostate cancer.

Professor Nieschlag said that as well as systemic testosterone therapy there may be a place for targeting organs that might also play a modulating role in affecting androgen action. Future studies would reveal whether specific androgen receptor modulators (SARMS) or synthetic androgens such as 7alpha-methyl-19-nortestosterone (MENT) were useful.

He added: "While we can conclude that an 'andropause' as a male correlate to the female menopause does not exist, symptoms of androgen deficiency do increase with advancing age and they can be alleviated or compensated for by testosterone substitution therapy."




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