Andropause - Testing and Treatment Options

Even a GP may titter when hearing patients mention the Andropause, often making testing hormones a difficult subject to approach even with a primary health provider. This is mainly because there is controversy regarding whether Andropause should be considered a condition at all and even if it exists (1). Yet, testosterone effects so many areas of health especially as we pass the age of 40 that it is worth the exploration (2).

These include:

• Cardio-vascular health (3)
• Bone health (4)
• Sexual health (5)
• Brain health (6)
• Promotes and maintains development of secondary sexual characteristics
  • Increased muscle
  • Growth/Maintenance of body hair

Conventional testing is not offered routinely and often not even if asked for.

Although I recommend all men over 40 have a regular testosterone test (as correct levels can so positively influence health as we age), the following quick questionnaire may help assess if you actually need a test:

IS YOUR TESTOSTERONE LOW? (7)

1. Is your sex drive tailing off?
2. Do you lack energy?
3. Is strength and /or stamina failing?
4. Have you lost height?
5. Do you feel they are enjoying life less?
6. Are you often unhappy or irritable?
7. Are erections less strong?
8. Have you lost sporting prowess?
9. Do you fall asleep after meals?
10. Is your mental work or performance deteriorating?

Testing for Testosterone

Saliva testing is becoming a gold-standard for measuring hormones in the eyes of some authorities (8). It is preferable to serum hormone testing because it measures active free hormone levels and thus represents physiologic function. Salivary testing using direct assay methods can detect down to less than one picogram of your body’s level of steroid hormones and is a very effective method for measurement. Highly sensitive this analysis provided by Labrix Clinical Laboratories, is reflective of the free unbound steroid hormones present physiologically in saliva

Saliva testing is convenient, easy to perform through home testing kits and should be, arguably, considered a routine screen. The accuracy of salivary androgen measurement for diagnosing age-related “Andropause” exceeds 98.5% which is remarkably high for any test and this method “has satisfactory applicability” in the diagnosis of late-onset hypogonadism (9).

At this time conventional prescribing by GPs and Endocrinologists follows blood tests which should measure free testosterone as it is this that is active. The majority of this hormone travels around the body bound to Sex Hormone Binding Globulin and another liver made protein, albumin. SHBG prevents testosterone’s action, slows down the breakdown and its conversion to another active metabolite known as dihydrotestosterone, so is very relevant to measurements.

Free testosterone is equivalent to salivary testosterone for initial testing but for prescribing, traditional blood tests tend to be preferred by doctors. Minimally these include total testosterone and SHBG. With these levels doctors can calculate the Free Androgen Index (known as the Free Testosterone Index (FTI) in the USA) .

FAI = Total Testosterone x 100
SHBG

The normal FAI range is 0.7-1.0. If one’s FAI is below 0.7, testosterone therapy should considered.

Salivary monitoring along with symptom improvement and infrequent blood testing can be used to determine ongoing prescribing.

Interpretation of Testosterone results

First of all an individual should not try to interpret results without the guidance of an experienced practitioner and certainly NEVER supplement with testosterone available off the internet. Really a dangerous thing to do as heaven only knows what you might be taking . NEVER mess with hormones without professional guidance and only after measurement. Interpretation must take into account two areas (and interpretation is very much based on the experience of the practitioner) - the levels of a combination of hormonal results and most importantly, and sadly frequently ignored, the symptoms of the patient .

If levels are above mid-normal range supplementation may not be of benefit. Low levels obviously need to be treated and levels in the lower half of the normal range should be considered potentially abnormally low if symptoms of deficiency or investigations indicate organ or system problems. GPs and even specialists may not accept this and patients may need to find an Integrated Physician with an interest in this area.

Other recommended tests

Prior to initiation of testosterone therapy the PSA level needs to be within the expected range. There is no conclusive evidence that testosterone increases the risk of prostate gland cancer but if cancer has already developed testosterone may accelerate its growth. The PSA test is not conclusive of anything sinister but is part of investigation. The Research Genetic Cancer Centre, offer a pioneering test for the presence of prostate cancer cells in a blood sample. (www.rgcc-genlab.com)

Oestrogens and progesterone block some testosterone processes, so higher than normal levels of oestrogen and progesterone may counteract what appear to be normal levels of testosterone. Saliva is also a medium through which estrogens, progesterone, testosterone, DHEA and cortisol can be measured. (www.labrix.com)

Androstenediol glucuronide, a major metabolite reflecting androgen activity can guide supplement level prescribing best if necessary due to poor expected response.(4)

Further investigations can give a clue as to whether testosterone is likely to be of benefit.

Doppler Ultrasound of carotid arteries showing increased thickness of the muscle walls or early development of atherosclerosis can identify early arterial disease which can be treated with testosterone.

The Arteriograph is a measure of arterial flexibility but the equipment for this test, popular in parts of Europe, is not common in the UK. The test is an early reflection of arterial disease. A Stress ECG is easier to find but may not show changes in arterial health until the coronary arteries are 70 %blocked.

Bone density, effecting 7 in 100 men, is positively influenced by testosterone. Measurement by Dual-energy x-ray Absorptiometry (DEXA-scanning) showing decreased bone density for the age of the individual can lead to prescribing. The accuracy of salivary androgen measurement for diagnosing age-related “Andropause” exceeds 98.5% which is remarkably high for any test and this method “has satisfactory applicability” in the diagnosis of late-onset hypogonadism (10).

Treatment options

Life Style

Optimal, as opposed to excessive, muscle building ( resistance) exercise increases testosterone levels in both sexes. Excessive exercise uses up testosterone and leads to an overall decrease in levels. This is temporary unless the excessive exercise is from endurance sports.

Emotional stress uses up testosterone whereas spending time happy, listening to uplifting music and encouraging sexual contact and sexy thoughts all increase testosterone levels and activity.

Being overweight reduces testosterone as fat makes enzymes (aromatases) that converts testosterone to oestrogen.

Sleep increases testosterone production and a deficiency is associated with sleep apnoea – a tendency to cease breathing for periods of time then gasping for air. This is often associated with snoring.

Diet

Protein and cholesterol foods may raise testosterone levels whereas sugar and refined carbohydrates, more so than complex carbohydrates, decreases testosterone.

Fibre binds with testosterone and removes it from the body. Testosterone being a steroid hormone is recycled through the liver and the breakdown products as well certain amounts of testosterone leave the liver through the bile into the gut. Fibre has its benefits in other areas, but like with most things, everything in moderation. A too high fibre diet may lead to reduced testosterone levels.

Supplementation

The following have evidence of increasing testosterone levels:

• Vitamin D
• Magnesium
• Zinc

Testosterone Replacement.

Trans-dermal testosterone gel, preferably in a form know as liposomal, is the best way to raise testosterone levels. Oral treatments are common but not best as the digestive juices break it down and the testosterone has to pass through the liver which breaks it down further before reaching the blood stream.

Men would most probably be prescribed 50mg daily. (Women around 3mg daily). These doses can be increased by up to 3 times depending on symptoms and test results. Monitoring is important as there is unlikely to be a benefit by having higher than reference range levels. Men seem to react more quickly than women to testosterone supplementation, seeing benefits sometimes within a few days but generally energy in men improves within 3 weeks. Erectile dysfunction is usually benefitted by 10 weeks. Physical improvements such as increased muscle strength and bone density can take up to nine months(11)


REFERENCES

1. ^ Juul, A.; Skakkebaek, N. E. (2002). "Testosterone treatment of elderly men. The so called andropause doesn't exist.". Ugeskr. Laeg. (in Danish) 164 (42): 4941–2. PMID 12416079.
2. “Journal of Endocrinology and Metabolism” 1997: 82(2) 682-685
3. Murphy, S. et al; Sex hormones and bone mineral density in elderly men – “Bone Mineral” 1993; 20:133–140. Jackson, J. A. et al; Testosterone deficiency as a risk factor for hip fractures in men: a case controlled study “American Journal of Medical Science” 1992; 304: 4-8
4. Carroll , Bancroft Br J Psychiatry. 1984 Aug;145:146-51.
5. Kenny et al, J Gerontol A Biol Sci Med Sci(2002) 57 (5)
6. Morales et al The Journal of Urology Volume 163, Issue 3, March 2000, Pages 705–712
7. (Adapted from recommendations from Morley et al, Metabolism. 2000:49 Pgs 1239 -1242
8. Shibayama Y et al. J Chromatogr B Analyt Technol Biomed Life Sci. 2009 Sep 1;877(25):2615-23.,
9. Labrie, F et al J Steroid Biochem Mol Biol. 2006 Jun;99(4-5):182-8. Epub 2006 Apr 18.
10. Morley et al, Metabolism 2000:49 Pgs 1239 -1242 2012 The Ageing Man
11. James M. Dabbs Jr.Physiology & Behavior Volume 48, Issue 1, July 1990, Pages 83–86 ale ISSN 1368-5538

Author: Dr Rajendra Sharma: www.drsharmadiagnostics.com

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