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The face of Androgen deficiency

The face of Androgen deficiency. Androgen Deficiency. Erectile Dysfunction. Erectile Dysfunction and Androgen Deficiency Are Independently Distributed Disorders. Between 2.1% and 21% of men with ED have low testosterone, depending on the test used to measure testosterone.

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The face of Androgen deficiency

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  1. The face of Androgen deficiency

  2. Androgen Deficiency Erectile Dysfunction Erectile Dysfunction and Androgen Deficiency Are Independently Distributed Disorders • Between 2.1% and 21% of men with ED have low testosterone, depending on the test used to measure testosterone Korenman et al. J Clin Endocrinol Metab. 1990;71:963-969. Buvat and Lemaire. J Urol. 1997;158:1764-1767. Nehra A. Mayo Clin Proc. 2000;75 Suppl:S40-S45. Shabsigh R. Int J Impot Res. 2003;15 Suppl 4:S9-S13.

  3. Issues covered: Hormonal Diagnosis of Androgen deficiency Etiological approach to Low T Therapeutic aspects

  4. Hormonal Diagnosis Testosterone Measurement Total T Free T Albumin bound T Bio available Testosterone Bound to SHBG Which one to measure?

  5. Testosterone Measurements Need to be measured close to 8 am Assays at a reputable reference lab Total T and calculated free T usually correlate Free T is more accurate when SHBG is altered Obesity DM Renal/Hepatic Thyroid ds

  6. What defines a low Testosterone? “Normal range” 300-900ng/dl (age relevant) Total T less than 200-250 = “low” Total T between 250 -300 = “Borderline” Free T (n=> 65 pg/ml) helps when total T is borderline or a Affected by changes in SHBG T levels affected by drugs Anabolic steroids Gluco corticoids Opioids

  7. Issues covered: Hormonal Diagnosis of Androgen deficiency Etiological approach to Low T Therapeutic aspects

  8. - T - - Inhibin The Hypothalamic Pituitary Gonadal Axis GnRH LH FSH Testosterone Spermatogenesis

  9. Low TESTOSTERONE High LH Primary Gonadal Failure Klinefelter’s syndrome Adult testicular failure Orchitis Testicular trauma Chemo/Radiation Ketoconazole High LH HYPER GONADOTROPHIC HYPOGONADISM

  10. Low TESTOSTERONE Low LH SecondryGonadal Failure Steroids Alcohol Opioids Kallman Syndrome Pituitary failure Pituitary tumor Prolactinoma Hemochromatosis HIV Primary Hypothyroid Anorexia Nervosa Low LH HYPOGONADOTROPHIC HYPOGONADISM

  11. Low TESTOSTERONE Normal LH Seen in clinical practice in association with Several common conditions Metabolic syndrome Type 2 Diabetes Obstructive Sleep Apnea Aging

  12. Androgen Deficiency in the Aging Male

  13. 68% 42% 22% 12% Age-Dependent Prevalence of Androgen Deficiency Hypogonadism defined as serum T <300 ng/dL % Hypogonadal * 50-59 60-69 70-79 >80 Age (years) *Hypogonadal: at least 1 free testosterone value <11.3 nmol/L (325 ng/dL). Harman et al. J Clin Endocrinol Metab. 2001;86:724-731.

  14. Issues covered: Hormonal Diagnosis of Androgen deficiency Etiological approach to Low T Therapeutic aspects

  15. Osteoporosis Increased Fractures Clinical Problems Associated With Androgen Deficiency SexualDysfunction Muscle Wasting Androgen Deficiency DecreasedBody Hair PoorConcentration Ability DecreasedHematopoiesis Increased Fat AACE Guidelines. Endocr Pract. 2002;8:439-456.Harman et al. J Clin Endocrinol Metab. 2001;86:724-731.

  16. Androgen deficiency in aging male: ”ADAM” Issues: Total, free T dramatically decline after age 60 ED can be multifactorial in males > 60 Age, depression, atherosclerosis, co morbidities and meds contribute to ED Symptoms and T levels may not correlate

  17. Sexual Enounter Profile (SEP) Questions SEP consists of 5 questions rate from 1-5 for each 1. Were you able to achieve at least some erection? 2. Were you able to insert your penis into your partner’s vagina? 3. Did your erection last long enough to have successful intercourse? 4. Were you satisfied with the hardness of your erection? 5. Were you satisfied with the overall sexual experience? Mulhall JP et al. J Urol. 2003;170:353-358.

  18. Depression “Burn out” Stress Hostility Bored with partner Loss of attraction Hostility Guilt ?Testosterone Deficiency

  19. Androgen Therapy NOT recommended unless the Testosterone level is low!!

  20. Testosterone Replacement: Initiation and Risk Assessment • Examination/laboratory tests • Digital rectal examination, PSA, breast evaluation • Eliminate absolute contraindications • Prostate cancer • Breast cancer • Consider relative contraindications • Sleep apnea, Polycythemia Rhoden EL, Morgentaler A. N Engl J Med 2004;350:482-492; accessed January 29, 2004. Endocr Pract. 2002;8:439-456.

  21. Testosterone Replacement Options • Parenteral • Testosterone Cypionate • Enanthate 200 q 2 weeks • Dermal patch: • (Androderm) 5 mg patches • Gel: • Androgel1% or 1.62% • Testim • Fortesta 2% • Liquid Axiron • Buccal • Gum (Striant) • Pellets

  22. 0.96 Serum PSA (ng/mL) Pretreatment Posttreatment Effects of Testosterone Therapy on Prostate-Specific Antigen (PSA) 652 Hypogonadal men (T<300ng/dL) Dose=200-300 mg, q 2-4 Weeks 6 Biopsies, 1 prostate cancer Mean follow-up=30.2 months Mean age= 60.4 years N=54; P<.01; PSA=prostate-specific antigen. *Testosterone replacement in hypogonadal men defined as testosterone <300 ng/dL. Gerstenbluth et al. J Androl. 2002;23:922-929.

  23. Androgen Deficiency in Men:Summary • Aging is associated with •  In prevalence of androgen deficiency • Testosterone replacement in hypogonadal men •  Strength, lean body mass •  Bone mass •  Libido •  Sense of “well-being” • May augment the treatment of ED with PD5 inhibitors

  24. Effect of Testosterone on Response to Sildenafil in Men with ED • Erectile dysfunction and low testosterone frequently occur together • Study to evaluate whether the addition of testosterone to sildenafil improves erectile function in men with low T (total T <330 ng/dl or free T < 50 pg/ml) • 140 Men 40 -70 y/o with EFD of IIEF scores of <25 randomized to 10-g daily of transdermal testosterone gel or placebo after sildenafil dose was optimized • EFD score improvement analyzed after 14 weeks Spitzer, M. et.al… Ann Internal Med. 2012;157:681-691

  25. Effect of Testosterone on Response to Sildenafil in Men with ED Baseline Characteristics at Randomization Spitzer, M. et.al… Ann Internal Med. 2012;157:681-691

  26. Effect of Testosterone on Response to Sildenafil in Men with ED Results There was no effect of age, BMI, disease state, initial T level, EFD score, or response to sildenafil alone on the results Spitzer, M. et.al… Ann Internal Med. 2012;157:681-691

  27. Effect of Testosterone on Response to Sildenafil in Men with ED • There was no additional benefit of adding testosterone therapy to optimized sildenafil treatment on ED (though there was also no increase in adverse events) • However, this should not preclude use of testosterone for its other beneficial effects • A confounder may be the 100 ng/ml increase in testosterone seen in the sildenafil run-in period Spitzer, M. et.al… Ann Internal Med. 2012;157:681-691

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