Y2

West Visayas State University – College of Medicine | AUREUM B9

M61
Andropause L61

BY: Dr. Antonio S. Reyes | 09/21/2022 |10-12 NN

OUTLINE ○ Pituitary gland disorders

○ Medications (e.g. opioids, morphine,
I. Andropause
A. Male Gonads in Aging steroids)
B. Sertoli cells ○ Alcohol
C. Leydig cells ○ Liver cirrhosis
D. Testosterone in Aging Men ○ Renal Failure
II. Hormonal Alterations ○ Obesity
A. Growth Hormone ○ Uncontrolled Type II DM
B. Insulin-like Growth Factor
○ Children born with congenital defect that
C. Melatonin
D. Leptin lowers testosterone
III. Clinical Manifestations • Athletes who intake steroids to gain muscle mass can
A. Dysfunction during the sexual 50’s also get breast tissue and smaller testicles and penis
B. Sexual Dysfunction during Andropause side as a result of suppressed testosterone levels
IV. Laboratory Diagnosis • Hormones for prostate cancer suppress testosterone
A. Total Serum Testosterone
V. Management and Treatment • This does not happen to all men and symptoms does
A. Low Testosterone/Andropause Treatment not affect women
B. 7 Reasons for Low Testosterone levels Some men may get few symptoms and some may
C. 10 Ways to increase Testosterone levels have all symptoms
VI. Therapeutic Consideration • Male climacterium and PADAM (Partial Androgen
VII. Additional Notes from ASP Trans
Deficiency in the Aging Male
A. History
B. Organic and Psychogenic • Known as male equivalent of menopause (but
C. Partial Androgen Deficiency in Aging Men according to Doc Reyes, this is a misnomer or not
(PADAM) equivalent)
D. Menopause vs Andropause Why is it a misnomer: “pause” suggests an abrupt
E. Clinical Manifestations phenomenon and an onset of complaints and
F. Human Sexuality
health problems related to a sudden deprivation of
G. Sexual Dysfunction During Menopause
H. Menopause and Sexuality sex hormones
I. Biochemical Changes However, andropause is a gradual process unlike
J. Gonadotropins menopause and the age of onset is variable
K. Adjunctive Test • Some men will have it in their 40’s, some in their 50’s
L. Management of the Climacteric and majority in 60-70’s
M. Therapy for PADAM
• It is clinically inappropriate but adequately conveys
N. Goals of Andropause Treatment
O. Testosterone Preparations the concept of emotional and physical changes that
P. Therapeutic Considerations are associated with significant hormonal alterations
Q. Conclusion related to aging in general.
VIII. Summary But unlike women, it is generally acknowledged that
IX. References men DO NOT experience an abrupt decline in
gonadal function as early as in the fifth decade.
I. ANDROPAUSE • Biologically incorrect because it does not happen
• Also known as testosterone deficiency syndrome suddenly; A gradual decline in androgen levels has
Main feature is testosterone decline in men as they consistently been observed with the advancement of
age age, independently of previous diseases and resulting
Testosterone is produced by testicles and it is from in some cases inconsiderably lower levels at older age.
the adrenal glands No discontinuation of reproductive life
Testosterone perform functions similar to estrogen Associated with decrease in Leydig cell volume and
and influences sexual desire, development of decline in Sertoli cell population
sexual characteristics, physical and mental energy, Associated in decrease of total volume of the testis
muscle mass, fight or flight response and muscle occupied by seminiferous tubules which makes up
mass 80% of testicular size and a decrease in actual tube
Causes of change in testosterone levels: length.
○ Injury to testicles
○ Chemotherapy for any kind of cancer
Table 1. Comparison of Sertoli Cells and Germ Cells in • Exists in several forms in plasma:
Younger and Older men 1. Free/Unbound: 1-2%
AGE RANGE Fully bioavailable
TESTIS PARAMETER 20-48 50-85 2. Albumin bound (more freely bioavailable): 58-60%
YEARS YEARS 3. Sex Hormone Binding Globulin (SHBG) (inactive): 40%
Average Testis Weight 19 g 16 g Protein bound testosterone is partly bioavailable
No of Sertoli Cells/Testis 503 mil 312 mil with albumin-bound more bioavailable than SHBG-
33 mil/g 41 mil/g bound which is considered inactive.
No of round spermatids
testis testis • Aging is associated with increased SHBG
No of spermatids/Sertoli More SHBG, more testosterone it binds, the lesser
4.0 4.3
Cells testoserone you get which would lead to symptoms
mentioned below
A. THE MALE GONADS IN AGING • Plasma free testosterone levels decline by 1.2% per
• In aging, there are changes that occur in the male year by the 3rd decade of life (Massachusetts Male
gonads Aging Study); symptoms (vary from none to many):
• Associated with decrease of Leydig cell volume Mental symptoms
Leydig cells produce testosterone; they are located ○ Mood changes
in the surroundings of seminiferous tubules ○ Irritability
• Anatomical studies of Sertoli Cells populations reveal ○ Anxiety
age-related decline in Sertoli Cells populations ○ Depression
○ Loss of confidence
Sertoli cells provide matrix and are responsible in
sperm cell maturations ○ Loss of motivation
○ Insomnia
• Decrease in Leydig cells and Sertoli cells during aging
Physical symptoms
will decrease testosterone and spermatozoa
○ Weight gain
production ○ Erectile dysfunction
• Associated in decrease in total volume of the testes ○ Fatigue
occupied by seminiferous tubules and a decrease in ○ Loss of energy
actual tubule length. ○ More breast tissue
○ Heat sensations changes: sweating, flushes
B. SERTOLI CELLS ○ Headaches
• Sertoli cells found in seminiferous tubules produce ○ Reduction in muscle mass
tight junctions that propel the spermatozoa from the ○ Reduced bone density
basal membrane into the lumen.
• Anatomical studies of Sertoli cells reveal age-related TESTOSTERONE SECRETION
decline in Sertoli cells population and is concurrent • Peaks at about 20 years, followed by a gradual decline
with decline of testicular mass and number of round • Massachusetts Male Ageing Study: plasma-free
spermatids. testosterone levels decline by 1.2% per year by the 3rd
• “Increasing age = decrease in fertility” decade of life (age 30)
• So, andropause generally is seen around age of 50
C. LEYDIG CELLS • At age 70, a man can expect to have half of
• Found in interstitial space between seminiferous testosterone he has in 20’s
tubules. • Androgen deficiency (morning plasma T<12 nmol/L)
• Responsible for the production of 95% of adult male Morning levels are taken because it is normally the
testosterone (other 5% comes from the adrenal highest measurement due to the circadian cycle
glands).
• Pair of young testes (20y/o) contain 700M Leydig cells
and undergoes attrition of about 80M cells per decade
of life.

D. TESTOSTERONE IN AGING MEN

• Mechanism of decline in PADAM is due to the decline
of testicular Leydig cell mass and changes in circadian
Figure 1. Testosterone Secretion
rhythm and hypothalamic-pituitary homeostatic
control of LH secretion?

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 TARGET ORGANS • Difficulties with short-term memory
• Brain – cognition, visual-spatial skills, memory, libido, • Depressive symptoms
aggression, and mood • Low self-esteem
• Male sexual organs – penile growth, spermatogenesis, • Unusual fright
prostate growth and function, erection
• Skin – hair growth, balding, sebum production MAN’S SEXUALITY ACTIVITY
(associated with acne) • Age 20: Thrice daily
• Heart – coronary vasodilation • Age 30: Thrice weekly
• Hair – body hair growth and facial hair • Age 40: Tries weekly
• Muscle – increase in strength and muscle • Age 50: Tries weakly
• Fat – body and viscera fat reduction • Age 60: Tries and tries and tries…
• Liver – synthesis of serum proteins
• Kidney – stimulation of erythropoietin production, II. HORMONAL ALTERATIONS
hypotesteronemia leads to anemia A. GROWTH HORMONE
• Bone marrow – stimulation of stem cells • Production after puberty decreases with age by ~14%
• Bone – accelerates linear growth, closure of per decade
epiphyses.
INSULIN-LIKE GROWTH FACTOR 1 (IGF-1)
• IGF-1 prevents degeneration of neurofibril proteins
seen in Alzheimer’s disease
• IGF-1 acts on certain cellular receptors that ultimately
lead to inhibition of premature aging
• GH and IGF-1 are controlled by GH levels
• Both will decrease together, which will bring about:
Changes in lean muscle mass
Changes in bone density
Changes in hair distribution
Hypogonadal obesity pattern

MELATONIN
• Secreted by pineal gland (epiphysis cerebri) in
response to hypoglycemia and darkness
Figure 2. Male Hypothalamic-Pituitary-Gonadal Axis • Decreases with age regardless of these stimuli
• Recent evidence was presented indicating that
DECREASED TESTOSTERONE LEADS TO: administration of melatonin slows the growth of
• Tiredness cancer cells in rodents
• Decrease in muscle strength
• Lack of energy PINEAL GLAND (EPIPHYSES) FUNCTIONS
• Sleep disorders • Regulation of gonadal function
• Decrease in libido and sexual activity • Regulation of biorhythms
• Erectile dysfunction or impotence • Analgesia – due to release of endorphins like in
• Senile osteoporosis orgasm
• Prostatic hyperplasia • Anti-oxidative
• Prostatic carcinoma • Laughing → Immunomodulation → ↑immune function
• Atherosclerosis • Improves sleep disorders seen in elderly
• Men are cranky, irritable, and distressed
LEPTIN
• A relatively recently described hormone from
MOOD DISORDERS & COGNITIVE CHANGES
• Irritability, lethargy adipocytes
• Altered in men with hypotestosteronemia – which
• Decreased sense of well-being
explains in part some of the observed changes in fat
• Lack of motivation
distribution
• Low mental energy

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• Decrease in testosterone → increase in leptin → more
fat deposition
• Leptin levels can be decreased by Androgen
supplementation which usually results in
improvement in obesity
III. CLINICAL MANIFESTATIONS
• Insidious onset and slow progression
• Diagnosis is straightforward: proper history and
physical exam
• Seen more clearly in ablative hormonal treatment as
in castration in cases of prostate cancer:
Bilateral orchiectomy is indicated because prostate
cancer is testosterone dependent
○ Target organs of testosterone are the testes
A. DYSFUNCTION DURING THE SEXUAL 50’S: A
HIDDEN SYMPTOM
• Variable coping and attributions (cultural background)
“normal symptom of age”
“has to be accepted, or not important”
DIFFICULTIES IN PATIENT-DOCTOR
COMMUNICATION
• Talking about sexuality in the consultation may be
difficult for patient and doctor
B. SEXUAL DYSFUNCTION DURING ANDROPAUSE:
REDUCED SEX DRIVE OR LIBIDO
• Reduced sex drive or libido
• Require more touch and intense physical stimulation
to get and maintain an erection
• Reduction of sexual activity
• Reduced volume of ejaculation
• Less sexual thoughts and fantasies
• Longer time for penile erection
• Climax not as strong but remains a pleasurable
experience
GENITAL CHANGES
• These are the reasons why there’s erectile dysfunction
in older men
• Hardening of blood vessels, more difficult to get an
erection
• Sagging and wrinkling of scrotal tissue
• Shrinking and loss of firmness in the testes
• Thickening and degeneration of the seminiferous
tubules → inhibits sperm production
• Enlargement of prostate gland (↓ testosterone,
relative ↑ estrogen) → difficult urination, weaker
contractions, reduced force of ejaculation
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IV. LABORATORY DIAGNOSTICS
• According to Doc, diagnosis of andropause is
straightforward. You only need to recognize the signs
and symptoms by taking a good history and physical
exam.
• Basic hormonal assessment includes:
Serum Testosterone
○ 2 blood tests (hormonal fluctuations) –
timing of extractions
○ Done at 9:00 in the morning – peak of
testosterone (with fasting)
LH
FSH
Prolactin
SHBG
A. TOTAL SERUM TESTOSTERONE
• Normal men exhibit a wide range: 270-1070 ng/dL
and varies with age
• Timing of the test has an impact on the results
Obtained between 7am-11am (peaks at 9:00am)
Waxes and wanes over a 24-hour cycle
• >350 ng/dL
PADAM is ruled out
• Between 230 and 350 ng/dL
should be confirmed with additional testing with a
repeat serum total testosterone, bioavailable
testosterone, free testosterone, or calculated free
testosterone.
• <230 ng/dL
confirms diagnosis of testosterone deficiency
• <150ng/dL
should be tested with serum prolactin to evaluate
possibility of prolactinemia.
• Free testosterone vs Bound Testosterone (Albumin-
bound or SHBG [Sex Hormone Binding Globulin])
Aging men have increasing SHBG, since
laboratories measure total testosterone, it is
difficult to say that an elderly man’s testosterone is
normal due to difficulty in separating bioavailable
and non-bioavailable testosterone.
Since level of testosterone has a wide range of
normal values, levels may not correlate well with the
symptoms of andropause.
V. MANAGEMENT AND TREATMENT
A. LOW TESTOSTERONE/ANDROPAUSE TREATMENT
• Most are lifestyle-driven changes towards improving
relationship of elderly couples
Having a healthy, active sex life
○ Keeps testosterone high and is important for
mental health (does not mean penetration
only, also includes intimacy and foreplay)
Dietary modification: less fat
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 ○ Cut out meat, processed food, salt, sugar,
preferring plant-based, mediterranean-style
diet
Exercise: 30 minutes a day
○ Raises testosterone levels and is also good
for mental health, motivation, lessen fatigue
Sleep Hygiene
Stress Reduction Techniques
○ Mindfulness,meditation, psychotherapy to
aid in lessening mood changes and irritability
Avoid steroids, herbal medications
○ There are herbal medications that can have
severe side effects aimed at raising
testosterone. There is very little evidence for
DHEA (often promoted as a testosterone
supplement). Better to talk to your general
practitioner about side effects.
B. 7 REASONS FOR LOW TESTOSTERONE LEVELS
• Bisphenol A
One of the largest contributors to low testosterone
Lowers testosterone and adrostenedione
Found in polycarbonate plastic (ex. Water bottles)
Nearly 90% of men who go to fertility clinics have
Bisphenol A in their urine
• Being Overweight/Obese
Adipose tissue contains aromatase which converts
testosterone to estrogen
Diabetes reduces testosterone levels
• Reduced Sleep
Increases cortisol levels
Lowers morning testosterone levels
2nd half of the night is more important
Staying up late is more preferable than getting up
early
Waking up earlier than normal lowers testosterone
levels than if sleep was sacrified at the 1st half of
the night (staying up late)
• Dietary Factors
Consuming soy foods reduces testosterone
Soy is similar in structure to estrogen and this can
lead to suppressed testosterone levels
Low fat diets reduce testosterone
Zinc deficiency reduces testosterone
Vitamin E and C deficiency reduces testosterone
Vitamins E and C protect against zinc loss
• Stress
Increases cortisol levels, which increase
Gonadotropin-Inhibiting Hormone
Reduces testosterone levels
• Alcohol Consumption
Hops in beer are estrogenic
• Asexuality
Lower desire for sex = lower libido = lower
testosterone levels
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C. 10 WAYS TO INCREASE TESTOSTERONE LEVELS
1. Avoid use of plastics; drink from glass or stainless steel
2. Avoid eating soy products
3. Limit consumption of alcohol
4. Avoid drinking beer – vodka instead (limited)
5. Sleep in a dark room (at least 8 hours per night)
6. Reduce stress through relaxation
7. Lose weight
8. Increase zinc consumptions (oysters, beef, pork,
poultry, plant-based alternatives like beans and nuts,
etc)
9. Increase consumption of healthy fats (fish, plant, olive,
coconut oils)
10. Have a healthy sexual life
VI. THERAPEUTIC CONSIDERATIONS
Doc’s Thoughts on Pharmacologic Treatment:
“Personally consider it to be a last resort. Often know as
testosterone replacement. Used in a similar way to
Hormone Replacement Therapy in menopausing
women.”
On possible treatments:
“DHEA possesses some anti-aging properties “
“I don’t believe in oral testosterone because of its
diminished activity after FPE. More appropriate forms to
consider would be topical gels, transdermal or buccal
tablets.
“Taking pharmacological treatments also give side
effects such as priapism(non-pleasurable sustained
erections), impotence(high testosterone can cause
negative feedback), decreased spermatogenesis,
gynecomastia, increased risk of prostate
cancer(hormone dependent type of cancer)and
increased risk of acute MI (seen in patients taking
testosterone therapy) hence my dislike of giving this type
of treatment.
FAQs:
Q: Is andropause the same as hypogonadism?
A: “No, andropause is a physiologic process, it’s a gradual
process that hits older men(50s-70s). Hypogonadism is
different in a way because hypogonadism means a
problem in the pituitary gland or in the hypothalamus. In
general patients with hypogonadism are younger
patients and may require testosterone replacement for
practically all their lives”
Q: Does PDE5 inhibitors (i.e Sildenafil, Tadalafil) result in
androgen increase?
A: “This question stems from the fact that men taking
these type of drug have better confidence, sexual
performance and increased libido. Biologically speaking,
they do not increase testosterone, BUT I think the type of
effect these drugs have are psychologic so that may be
the reason it is mistaken to increase androgens. In a
practical sense, when I see patients having sexual
dysfunction problems (i.e weakness, loss of motivation) I
5 | 13
 don’t immediately think giving them testosterone. I tend C. PARTIAL ANDROGEN DEFICIENCY IN AGING
to give them drugs like Sildenafil if the chief complain is MEN (PADAM)
poor sexual performance and that usually solves their • “male climacteric”
problem. I have observed that men who have better • “male menopause”
performance usually do better in bed and everything else
• “andropause”
follows.”
• “penopause” (penis + menopause)
• “hypogonadism”/ “late onset hypogonadism” (LOH)
VII. ADDITIONAL NOTES FROM ASP TRANS
A. HISTORY
D. MENOPAUSE VS. ANDROPAUSE
HIPPOCRATES Table 2. Menopuse vs Andropause
• Reported many cases of male impotence among rich
MENOPAUSE ANDROPAUSE
inhabitants of Scythia and ascribed it to excessive
Testosterone
horseback riding Problem Estrogen deficiency
deficiency
• Study shows that impotence is common among bikers
If PADAM occurs, it
because narrow bike seats compress the perineal Around 50 or earlier
When does not occur at a
nerves. (if induced surgically)
specific age
All women will Not all men will
Who
ARISTOTLE undergo menopause experience PADAM
• Stated that there are three branches of nerves that Loss of libido seldom Loss of libido is a
carry spirit and energy to the penis; that erection is talked about primary conern
produced by an influx of air.
• Inflating with fluid is currently used in penile
implantation. E. CLINICAL MANIFESTATIONS
SYMPTOMS
LEONARDO DA VINCI • These manifestations need not all be present to
• Noted a large amount of blood in the erect penis of identify the syndrome
hanged men and doubted the concept of the air-filled • In addition, the severity of 1 or more manifestations
penis. does not necessarily match that of others, nor do we
• His writings were kept secret until the 20th century yet understand their uneven appearance

1. Diminished sexual desire and erectile quality,

AMBROISE PARE (1585)
• Ten Books on Surgery and Book on Reproduction:
“When the man becomes inflamed with lust and
desire, blood rushes to the male member and causes
it to erect”
• Most accurate among the people of the 15th century.
• The importance of retaining blood in the penis was
stressed by:
Dionis (1718) quoted by Philippe Brenot (1994) –
attributed to the muscle cramping the veins at the
proximal end.
John Hunter (1787) – thought that venous spasms
prevented the exit of blood from the penis.
• Current fact: veins remain same in caliber but there is
increased uptake; arteries are the ones that dilate.
particularly nocturnal erections
2. Changes in mood with concomitant decrease in
intellectual activity, spatial orientation ability, fatigue,
depression, and anger
3. Decrease in lean body mass with associated
diminution muscle volume and strength
4. Decrease in body hair and skin alterations
5. Decrease in bone mineral density resulting in
osteoporosis
6. Increase in visceral fat
7. Diminished work performance and sleep disturbances
8. Flushes/sweating, breast discomfort or gynecomastia,
and infertility.

B. ORGANIC VS PSYCHOGENIC
• Patient asked to sleep (during sleep, all inhibitions are
gone)
• A special tape is wrapped around the penis.
• If he awakes and the tape is broken, the cause of
impotence is psychogenic and not organic.

Y2 B9 M6 L6 | Andropause 6 | 13
Table 3. Quick Facts About Prostate Cancer Decrease in vaginal secretion
CHARACTERISTICS DESCRIPTION Loss of vaginal elasticity
90% arise in outer glands • Leads to lack of regular sexual intercourse
(adenocarcinomas) and are
Site
palpable by digital rectal H. MENOPAUSE AND SEXUALITY
examination • Estrogen-dependent
Regional pelvic lymph nodes,
Lack of lubrication
Metastases bone, seminal vesicles, bladder,
Dyspareunia
and periurethral zones
Vaginal atrophy
Hormonal (androgens), genetic,
Etiology • Androgen-dependent
environmental factors
Motivation
Increased in African-Americans
Prevalence Clitoral reactivity
and Scandinavians, few in Japan
Vascular engorgement
Reduced sex drive or libido
F. HUMAN SEXUALITY
• Misconceptions I. BIOCHEMICAL CHANGES
Elderly do not and should not have sexual desire or
TESTOSTERONE AND SHBG
sexual activities
• Testosterone decreases with age, generally approx. 1
Ignores the elder’s need for sex and inhibits
discussion % per year after 50 yrs.
• The truth Variable, 7% in men <60y/o; 20% in >60y/o
• SHBG increase of which translates into a further
All human beings, young or old, have a natural need
for sex both physiologically and psychologically. decrease in bioavailability of testosterone.
50% of men >60y/o have below normal levels of
non-SHBG-bound testosterone.

CIRCADIAN RHYTHM
• Flattening of circadian rhythm leads to a steady low
level of androgens throughout the 24-hr cycle.

ANDROGEN DEFICIENCY
• Androgen deficiency in men with low levels of serum
testosterone in the presence of elevated LH, 2 SD
Figure 3. Sexuality and Well-being Survey (Italy, 2001) below normal values for young men is conclusively
abnormal
• In older men, there is variable response by the target
organs (brain, bone, prostate muscle, etc.) to
androgen levels.

DHEA & DHEAS

Decreased Dehydroepiandrosterone (DHEA) and its
Sulfate (DHEAs)
• Weak androgens secreted primarily by the adrenals.
• Touted as cure-alls for the afflictions of aging
• DHEAs
neurosteroid synthesized in the brain that promotes
neuronal growth and regeneration
An inverse correlation has also been reported
between organic brain syndrome and DHEAs
Figure 4. “Pause” Years and Sexuality Nevertheless, behavioral correlates of DHEA and
DHEAs in males are inconsistent and consensus on
G. SEXUAL DYSFUNCTION DURING MENOPAUSE their usefulness does not exist
• Reduced sex drive or libido • Almost exclusively secreted by the adrenal cortex at
Arousal takes a longer time about 35 mg/day;
• Vaginal dysfunction Both are interconvertible in plasma
Y2 B9 M6 L6 | Andropause 7 | 13
• Secreted almost synchronously with cortisol
Cortisol secretion is constant throughout the entire
lifespan
Total absorption - soft tissue absorption = bone
absorption (converted to density equivalents)
Levels and production rates decrease by 2% per
year → 80-year plasma levels are only 20% of levels
at age 20 years
• DHEA
Is a weak androgen which in peripheral tissues is
transformed in androstenedione, testosterone, as
well as estrone
• Decrease in DHEA and DHEAS
Is a much more constant feature of advancing age
than hypogonadism
By the 5th decade of life DHEA levels decrease to
less than 30% of those in men younger than 30 yrs
There is widespread belief that declining levels of
DHEA parallel a decrease in well-being
• Morales et al reported that supplemental exogenous
DHEA results in involvement in quality of life
parameters
• Progression from microscopic prostate cancer to
clinical prostate cancer occurs only in a minority of
men
• Lifestyles
Exercise
Nutrition e.g. Calcium
Avoidance of smoking and alcohol
• Non-hormonal medications
E.g. sedatives, tranquilizers, vitamins
• Hormone treatment
M. THERAPY FOR PADAM
• Problem: Androgen Deficiency
• Solution: Androgen Replacement Therapy (ART)
• Pharmacologic treatment: Last resort
DHEAL Anti-aging
Oral Testosterone: first-pass effect (transdermal,
topical gels, buccal tablets)
Adverse effects: priaprism, impotence, decreases
spermatogenesis, gynecomastia, increased risk of
prostate cancer, acute MI

J. GONADOTROPINS Table 4. Andropause and Art

• Chronically elevated gonadotropin makes a clear TARGET ANDROPAUSE
ART EFFECTS
diagnosis of primary hypogonadism or testicular ORGAN EFFECTS
failure. Increase bone
Example: Increased LH and FSH and decreased mineral density
Bone Osteoporosis
testosterone-Primary Testicular Failure (incurable) (BMD) preventing
osteoporosis
Increase fat body Decrease fat body
K. ADJUNCTIVE TEST Body
mass & loss of mass & increase
• Red cell mass with Hgb or Hct composition
lean body mass lean body mass
may help confirm hypogonadal anemia Mood, libido,
• DEXA Scan-Dual Energy X-ray Diminish/change Restore
cognition
Absorptiometry: 2 distinct energy peaks through
the body
N. GOALS OF ANDROPAUSE TREATMENT
○ one peak is absorbed mainly by soft tissue
• Restore sexual function, libido, maintain virilization
and the other by bone
Total Absorption – Soft tissue Absorption = • Prevent osteoporosis and optimize bone density
absorption (converted to density equivalents) • Improve mental acuity and restore sense of well-being
• DEXA Scoring • Restore normal GH levels
T Scoring: • Low Testosterone/Andropause Treatment:
○ >-1 = normal Healthy, active sex life
○ -1 to -2.5 = Osteopenia (first stage bone Dietary modification: less fat
loss) Exercise (~30 mins a day)
○ < -2.5 = osteoporosis Sleep hygiene
Z Scoring: Stress reduction techniques
○ Reflects the amount of bone present Avoiding steroids, herbal medications
compared with others of similar age, size and
gender.

L. MANAGEMENT OF THE CLIMACTERIC AGING

PROSTATE
• Men aged 70 years and older have:
BPH >80%
RISKS OF TESTOSTERONE SUPPLEMENTATION IN
Microscopic prostate cancer >50%
OLDER MEN: ANDROGEN ORGANS OF INTEREST
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• Cardiovascular system Prostate monitoring: PSA or DRE
• Prostate Duration of use: 495 man-years
Longest follow-up: 3 years
Table 5. Effects of T Undecanoate in the Treatment of • 11 of 13 studies: No increase in PSA
PANDAM • 5 of 5 studies: No change in prostate size, No change
in urine flow rates
PLACEBO ANDRIOL
(N=10) (N=10)
TESTOSTERONE SUPPLEMENTATION
Testosterone (mg/dl) 367→366 369→421*
• Testosterone replacement therapy (TRT) causes a
DHT – Dihydro-
42→40 38→40.1 significant decrease in total cholesterol and LDL
testosterone (mg/dL)
cholesterol levels.
Libido (score)* 1.0→1.0 0.9→2.2**
TRT does not affect HDL, triglycerides, and Apo 1
levels
Erections (score)* 1.3→1.1 1.1→1.9**
• Testosterone decline may partly explain the greater
risk of cardiovascular disease with advancing age
Ejaculations (score)* 1.1→1.1 1.2→1.6
• Physiological T – levels may protect men
• Scores:
0=absent 1=reduced 2=moderately reduced 3=normal Testosterone Replacement
*: p<0.05 vs. pre-treatment • Improves libido and overall sexuality
**: p<0.01 vs pre-treatment • Increases energy, lean muscle mass, and bone density
• Decreases fat mass
O. TESTOSTERONE PREPARATIONS
ORAL TESTOSTERONE
Table 6. Preparations • Absorption:
TRADE NAME MG/DOSE Oral, but is then degraded during the first pass
Transdermal Androderm, through the liver
6 (daily)
testosterone patch testoderm ○ may fail to establish satisfactory serum level
Oral: • Alkylated preparation (17α-Alkylated derivatives of
Fluoxymesterone Halotestin testosterone)
Methyltestosterone Metandren 5-20 daily are resistant to hepatic degradation
(Proverone) 10-30 daily However, may have risk of adverse liver side effects
Andriol including:
Testosterone (available in 120-240 daily ○ hepatocellular adenoma (hepatoma)
Undecanoate Philippines) ○ jaundice
○ hemorrhagic liver cysts (peliosis)
Injectables: should not be used for testosterone replacement
200-400 every
Testosterone Depo- ○ exception: Hereditary angioedema due to C1
3-4 weeks esterase deficiency
cypionate testosterone
cypionate ○ in this condition, alkylated testosterones are
200-400 every useful because they stimulate hepatic
Testosterone Delatestryl
4 weeks synthesis of the C1 esterase inhibitor
enanthate
• Undecanoate preparations
free of hepatic toxicity
P. THERAPEUTIC CONSIDERATIONS
can attain satisfactory serum levels but may have
TESTOSTERONE REPLACEMENT THERAPY DIGITAL supraphysiologic side effects of DHT and may have
RECTAL EXAMINATION GI side effects hence must be taken with meals.
Prostate Monitoring
• Digital Rectal Examination
• Prostate Specific Antigen
• Transrectal Ultrasound of Prostate

Table 7. The protective value of sex hormone on CHD

Testosterone and Prostate appears to be sex-specific
ESTROGEN
• 13 studies
Women Low level Increased risk
Age: 40-89 years
Y2 B9 M6 L6 | Andropause 9 | 13
 Men High level Increased risk • Follow-up studies demonstrated improved sexual
TESTOSTERONE function, libido, nocturnal penile tumescence;
Women High level Increased risk maintenance of normal Hct, lipid profile, PSA,
Men Low level Increased risk prostatic volume
• Cons:
inconvenient to apply
BUCCAL ADHESIVE TESTOSTERONE
dermatitis or skin irritation
• Tablet that adheres to the buccal mucosa that is used
chemical burns
twice-daily (30-mg)
• Adverse effects: Gel
Buccal ulceration
• Can maintain total and free testosterone
Gum problems
concentration in the normal range when applied
topically to the skin
INJECTABLE TESTOSTERONE • Advantages:
• Injectable forms of testosterone are esterified at the ease of application
17β-hydroxy position, making them hydrophobic and flexibility of dosing
extending its duration of action • Concerns:
The longer the side chain, the greater the transfer of the gel to a sexual partner or children
hydrophobicity, the longer its duration of action who come in close contact with the patient
Examples
○ Testosterone enanthate
○ Testosterone cypionate ORAL ANDROGEN PREPARATION
○ Testosterone undecanoate • Testosterone undecanoate (Andriol®)
○ Testosterone proprionate (also oil-based, but • Mesterolone
is shorter) • Methyltestosterone
• Drug timeline: • Fluoxymesterone
Concentration rises into the high-normal or
supraphysiologic range within 24 hours
PARENTERAL ANDROGEN PREPARATION
○ Supraphysiologic levels may:
INTRAMUSCULAR INJECTIONS
○ occur which results to breast tenderness and
• Primoteston
gynecomastia;
○ result in infertility due to suppression of FSH • Sustanon
and LH production • Testoviron
Obtain maximum concentration in 72 hrs after
injection
TESTOSTERONE IMPLANTS
○ Sexual aggressiveness and over-all
• Testosterone patch, Scrotal patch, Dermal patch
aggressive behavior observed during peak
Gradually declines in 10 to 14 days, going back to • Implants can be inserted in the subcutaneous tissue
the hypogonadal range by means of a trocar through a small skin incision
Because of this timeline, it has a bimonthly regimen • Can maintain testosterone levels for up to 6 months
• Do not provide normal circadian patterns
RISKS OF ANDROGEN THERAPY
TRANSDERMAL TESTOSTERONE PATCHES • Fluids and electrolytes disturbances
• Drug timeline: water retention
Normalize testosterone, DHT, and estradiol levels hypertension
after 4-12 hours after application peripheral edema
• More expensive but more physiologic exacerbation of congestive heart failure—weight
• Available in scrotal and non-scrotal patches and BP monitoring important
using elemental testosterone absorbed • Hematologic reactions
transdermally Polycythemia: Hct levels above 50 has been
achieve normal serum testosterone and reproduce associated with increased risk of strokes
diurnal physiologic variations observed in normal suppression of clotting factors II, V, VII,
human testosterone secretion bleeding in px on concomitant anticoagulant
• Androgen levels do not increase above normal with therapy
these systems hence no detrimental changes in the • Infertility
mood Spermatogenic arrest through negative feedback
mechanism. Inhibition of both pituitary LH and FSH.
Y2 B9 M6 L6 | Andropause 10 | 13
 Azoospermia occurs in >90% of patients in 10 ○ Partner and sexual counseling
weeks of therapy cessation.
Sperm levels may or may not in 18 months.
WHEN IS TESTOSTERONE SUPPLEMENTATION
• Altered cholesterol levels JUSTIFIED?
Can lower HDL • “…if clinical evidence for a latent or overt testosterone
• Exacerbation of sleep apnea deficiency is present and serum testosterone levels in
• Gynecomastia the morning are below the normal value for younger
Estrogen levels may increase (metabolite of men of 12.0 nmol/L, testosterone substitution can be
testosterone) considered…”
• Effects on prostate gland
• However, the typical symptoms as previously
may exacerbate BPH and Prostate cancer
discussed may also occur in elderly men with plasma
testosterone levels >12.0 nmol/L
CONTRAINDICATIONS FOR TESTOSTERONE
SUPPLEMENTATION THERAPY
Q. CONCLUSION
Very High Risk
• The menopause and andropause have a significant
• Hormone-dependent tumors negative effect on quality of life (QoL).
Prostate carcinoma
• A holistic approach to menopause/andropause
Mammary carcinoma
management is important
Moderate To High Risk • Conventional Hormone replacement therapy (HRT)
has been proven to improve QoL but has drawbacks –
• Undiagnosed prostate nodule or induration
increase risk of Breast CA and Endometrial CA and
• PSA >4 ng/ml
abnormal bleeding
• Erythrocytosis/polycythemia (hematocrit>50%)
• Close monitoring is important “benefits must outweigh
• Sever lower urinary tract symptoms associated with
risks in treatment especially in surgical operations”
benign prostatic hypertrophy
• Uncontrolled hypertension
• Cardiac insufficiency, poor/uncontrolled congestive
heart failure

MONITORING ON PATIENTS ON HORMONAL

THERAPY
• Liver
liver function test, jaundice, hepatic carcinoma
• Lipid profile and cardiovascular disease
LDL levels, hypotestosteronemia is a factor for
Coronary Artery Disease
• Prostate Benign Prostatic Hyperplasia and CaP
(Prostate Cancer)
prostatic volume and PSA (Prostate Specific
Antigen) Figure 5. Algorithm for the Laboratory Diagnosis of
• Sleep disorders Androgen Deficiency in the Male
sleep apnea
• Sexual behavior and emotional state
sexual aggressiveness

SUPPLEMENTARY VIDEOS
MANAGEMENT OF SEXUAL DYSFUNCTION DURING
THE 50’S • Andropause – the Male Menopause by Dr Renee:
• Sexual practices https://www.youtube.com/watch?v=ztbBaRGMH_o
Adequate rest before having sex • Low Testosterone (Hypogonadism): 7 Causes (Dietary,
Lengthen foreplay etc.) and Ways to Increase Testosterone Levels by JJ
Adopt a less physically-demanding sexual position Medicine:
Use of artificial lubricant like KY jelly https://www.youtube.com/watch?v=JlmbGi0MlDE
Psychoeducative intervention
○ Information giving
SUMMARY
Y2 B9 M6 L6 | Andropause 11 | 13
• ANDROPAUSE – Aka: testosterone deficiency
syndrome
Main feature is testosterone decline in men as they
age
Causes of change in testosterone levels:
○ Injury to testicles
○ Chemotherapy for any kind of cancer
○ Pituitary gland disorders
○ Medications (e.g. opiods, morphine, steroids)
○ Alcohol
○ Liver cirrhosis
○ Renal Failure
○ Obesity
○ Uncontrolled Type II DM
○ Children born with congenital defect that
lowers testosterone
• “Increasing age = decrease in fertility”
• Peaks at about 20 years, followed by a gradual decline
• Andropause generally is seen around age of 50
• At age 70, a man can expect to have half of
testosterone he has in 20’s
• Testosterone replacement therapy (TRT) causes a
significant decrease in total cholesterol and LDL
cholesterol levels.
• Benefits of TRT inlcude:
Improves libido and overall sexuality
Increases energy, lean muscle mass, and bone
density
Decreases fat mass
• Patient Monitoring on TRT
• Liver
liver function test, jaundice, hepatic carcinoma
• Lipid profile and cardiovascular disease
LDL levels, hypotestosteronemia is a factor for
Coronary Artery Disease
• Prostate Benign Prostatic Hyperplasia and CaP
(Prostate Cancer)
prostatic volume and PSA (Prostate Specific
Antigen)
• Sleep disorders
sleep apnea
• Sexual behavior and emotional state
sexual aggressiveness
C. Shrinking and firmness in the testes
D. Longer time for penile erection
3. One of the reasons for reduced testosterone levels is
reduced sleep. Which of the following is true?
A. Cortisol levels are decreased
B. Stress inhibits Gonadotropin-Inhibiting Hormone
C. Waking up early increases testosterone levels
D. The 1st half of sleep is less important than the
2nd half
4. Which of the ff. is true of andropause
A. Andropause is the male equivalent of menopause
in women
B. Andropause is a physiologic process that affects
mostly younger men
C. PDE5 Inhibitors such as Sildenafil cause an
increase in androgen production and can be
prescribed to patients having sexual dysfunction
D. Unlike menopause, andropause is a gradual
process of androgen level decline.
5. The following are side effects of testosterone
replacement EXCEPT:
A. Increased risk of MI
B. Impotence
C. Improved sexy time performance
D. Increased risk of prostate cancer
Answer: 1.B, 2.C, 3.D, 4.D, 5.C
TRANS COMM
Prepared by: Capalla, Catalan, Castor
Editor: Catalan

REVIEW QUESTIONS
1. The following are true about andropause except:
A. Its main feature is testosterone decline
B. It is the male equivalent of menopause
C. This is constituted by gradual decline in androgen
levels
D. This is associated with decreased volume of
Leydig cells and Sertoli cells

2. Sexual Dysfunction during andropause includes all of

the ff. EXCEPT;
A. Sagging and wrinkling of scrotal tissue
B. Climax not as strong but remains a pleasurable
experience
Y2 B9 M6 L6 | Andropause 12 | 13
REFERENCES
• Reyes III, A.S., 2021. Andropause
• WVSU-COM Batch MADIWA, 2024 (09/29/2021)
Andropause
• WVSU-COM Batch ASP, 2023 (2020, Oct 13).
Andropause
• Smith & Tanagho’s General Urology (18th Edition) *
and supplementary videos listed above

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