Embed Size (px)
Citation preview
+
Secrets of Abang Sado : Effects of
testosterone therapy
Azraai Nasruddin
+Testosterone
Testosterone : Steroid hormone
- Made primarily by the testicles in males
- Small amounts produced by the adrenal glands in both
sexes, and small amount in ovaries of women
- Associated with masculinity; symbol of youth, fertility and
strength in men
+Testosterone
Testosterone expression in the fetus
Results in development of male sexual organs
May program the brain and future behaviour
Neonatal surge in testosterone
Priming of sexual organs for future growth and maturation
Inprinting of sexual orientation and behaviour
Increase in testosterone during puberty
Secondary sexual characteristics : armpit and pubic hair,
deepening of voice, penile enlargement
Growth spurt
+Testosterone
Peak levels during late puberty / early adulthood, gradually
decline with ageing after the age of 40
+Testosterone
+Testosterone
Regulation of testosterone levels
• Brain stimulates production of
testosterone AND sperm by testes
• The brain senses the amount of
testosterone produced
• The various signalling hormones
enable dynamic control of
testosterone levels from hour-to-hour
and from day-to-day
+Diurnal variation of testosterone
+Testosterone
Serum testosterone levels in men following coronary artery
bypass graft surgery
+Testosterone
+Testosterone
Impact of obesity and diabetes on testosterone decline over time
+Testosterone levels
Change with age
Change with time of day
Change with illness
Acute illness
Chronic illness
Change with obesity
To interpret the significance of a low testosterone level
requires information :
• when it was taken
• the circumstances of the patient at the time of the blood test
+Testosterone levels
Not always easy to know if it is abnormally low
+Testosterone therapy
Who?
Why?
When?
How?
Side-effects?
Should ageing men take testosterone?
+
+Testosterone
Testosterone is converted into Estradiol in fat cells
by the enzyme Aromatase
- Estradiol is the primary sex hormone
in females
+… Not always Sado !
Glandular Breast enlargement
(gynaecomastia) is an uncommon / rare
side-effect of testosterone therapy• Excessive testosterone / anabolic steroids
• Obese men
+Testosterone :fertility
Normal
• Brain stimulates production of
testosterone AND sperm by testes
Testosterone use
• High levels of testosterone sensed by
brain
• Switches off stimulation to testes
• Result : High testosterone but NO
sperm
+Badan Sado … tapi “tembak
peluru kosong”
Testosterone therapy at high doses lead to
Suppression of sperm production
Atrophy (shrinkage) of testes with long-term use
Occasionally permanent
+
+
+Testosterone “boosters”
D-Aspartic Acid
Vitamins – B Complex, D3, K2
Ginseng
Fenugreek
Mucuna Pruriens
Oyster extract
Tribulus Terrestris
Trace minerals – Zinc, Selenium
Tongkat Ali
+
+
+Effect of high dose testosterone
Gave healthy men either placebo or 6 times the usual dose of
testosterone for 10 weeks (600mg injection every week!!)
Testosterone levels in the blood were increased by about 5-6
times the normal levels
Muscle strength increased by about 20%
Muscle size increased by about 10-15%
Haemoglobin and Red blood cells increased slightly
HDL (good cholestrol) decreased by 10%
+
+
+
12 weeks 1 year
+Steroid cocktail ……
+Testosterone
Taking testosterone is unlikely to make you SADO (unless
you take huge doses and do significant weight training)
Testosterone boosters – claims of many online products are
not supported by evidence : either claims are
EXAGGERATED or contains actual testosterone/anabolic
steroid compounds – so beware!
+Adverse effects of
supraphysiological testosterone
Acne
Jaundice, liver impairment liver failure
Testicular atrophy (shrinkage)
Azoospermia (infertility) either temporary or long-term
Reduced HDL cholesterol (increased cardiovascular risk)
Psychological dependence
N Engl J Med. 1996 Mar 14;334(11):707-14.
+Testosterone therapy in elderly
men – what are the issues?
Patient awareness / reluctance to seek medical assistance …
Who to treat?
Benefits and Potential Harm
Safety
How to treat and monitoring treatment
+
+Who to treat?
Testosterone levels should be checked in men who present
with symptoms or signs of testosterone deficiency OR has a
condition which is associated with testosterone deficiency
Testosterone therapy should ONLY be considered in men
with low testosterone levels
+Diagnosing “testosterone
deficiency”
What was the blood level of testosterone?
What time of day was it taken?
Has it been performed at least twice?
Was it done during acute illness / hospitalisation?
Does the patient have any chronic illnesses?
+Diagnosing “testosterone
deficiency”
What was the blood level of testosterone?
Very low – investigate for any diseases that may cause hypogonadism
Slightly low – does repeat test show consistent result? Does the patient have any symptoms of low testosterone? (Low libido, Erectile dysfunction, Fatigue)
What time of day was it taken?
Should be performed in the morning – testosterone levels vary with time of day, with peak levels in the morning
Has it been performed at least twice?
Testosterone levels can fluctuate. Needs to be consistently low
Was it done during acute illness / hospitalisation?
Testosterone usually falls to significantly low levels during acute illness
Does the patient have any chronic illnesses?
Low testosterone may be seen in patients with underlying chronic illnesses
+Diagnosing “testosterone
deficiency”
Distinguishing clearly low testosterone levels from mild/borderline/slightly low testosterone levels
Very low testosterone levels : evidence of benefit of treatment
Slightly low testosterone levels : ?
Low testosterone is a marker of chronic illness
Testosterone levels vary with time of day (peak in the morning) – diurnal variation
There exists difficulties with laboratory measurement of testosterone
Testosterone is mainly bound to carrier proteins in blood.
Most labs measure total testosterone, not free
+Low testosterone in elderly men
Partial Androgen Deficiency of the Ageing Male (PADAM)
OR
Late-onset Hypogonadism (LOH)
Lowish testosterone levels associated with symptoms of low
testosterone – with no obvious underlying cause
+
+
+
+Should an elderly man take
testosterone?
STEP 1 : Should all elderly men take testosterone?
No.
Consider only if testosterone levels are low
+Should an elderly man take
testosterone?
STEP 2 : Should all elderly men with low testosterone levels
take testosterone?
No.
Establish whether has symptoms of low testosterone.
Establish whether slight low, or very low testosterone levels.
Establish whether test repeated and done in the morning.
Establish whether has significant frailty/critical illness
+Should an elderly man take
testosterone?
STEP 3 : Should an elderly man who has slightly low early
morning testosterone levels on multiple occasions, with
symptoms of low testosterone, and who is not frail or
critically ill, take testosterone?
Probably.
Counsel patient regarding possible benefits and risks of taking
testosterone.
Check for any existing prostate disease
+Should an elderly man take
testosterone?
STEP 4: Has he discussed with his partner?
Testosterone therapy has impact not just on the man, but also his
partner
+Should an elderly man take
testosterone?
STEP 5 : Should an elderly man who has slightly low early morning testosterone levels on multiple occasions, with symptoms of low testosterone, and who is not frail or critically ill, and who wishes treatment after having been counselled on risks/benefits, and with no evidence of significant prostate disease take testosterone?
Yes.
Discuss a trial of testosterone therapy
Agree on aim of therapy, and duration of trial.
Monitor for improvement in symptoms and any adverse effects of therapy
+Trial of therapy
3- 6 month trial
Check serum testosterone level
Assess for any symptomatic benefits
Improvement in libido
Improvement in erectile function
Improvement in energy levels
(Improvement in questionnaire scores)
Monitor for any adverse effects
Increase in haematocrit (Red blood cell concentration in blood)
Increase in PSA
Prostatic symptoms
+Available testosterone products
+Not available in Malaysia
+Does it work? …..
Sexual function
Physical Strength
Longevity
Mood
+
+
+
+
+Sexual Activity
+Walking ability
+Fatigue
+Conclusions
Testosterone therapy improves overall sex drive, sexual activity and erectile dysfunction in older men with low testosterone AND low libido
No beneficial effect in men with normal testosterone and no symptoms
Effects of testosterone on physical function in older men with LOH is unclear.
Some evidence of improvement in muscle strength
but no evidence of improvement in actual function / disability / risk of fractures / falls
Long-term effects on Cardiovascular disease and prostate remains unclear (small study, short-term)
+
+
+
+
+Is it safe?
+
+
November 6, 2013
+
+
+
Testosterone No testosterone
Cardiac events
at 6 months
21.6% 4.8%
+
29% increased risk with testosterone therapy
+
No difference in narrowing of blood vessels
with testosterone therapy
+
18% reduced heart attack risk with testosterone
30% reduced stroke risk with testosterone
+Testosterone and Heart
In men without previous heart attack/stroke, normalising
testosterone levels may be beneficial
Overall, testosterone therapy is probably safe
However, in frail men with significant chronic diseases,
testosterone therapy may be associated with harm .
Long-term prospectives studies still required to fully answer
the question of cardiovascular safety
+
+Testosterone and Prostate
No evidence that testosterone therapy causes prostate cancer
Testosterone therapy may increase prostate gland volume
Possible worsening of prostatic symptoms in patients existing enlarged prostate
Usually does not cause problems
Potential harm if testosterone therapy given to patients with undiagnosed prostate cancer
One of the treatments for prostate cancer is to significantly lower testosterone levels
Screening for possible prostate cancer is recommended BEFORE starting testosterone therapy in older men
PSA blood test
Prostate examination – (digital rectal examination)
+Alternatives to testosterone
treatment…?
Weight loss
Exercise
Natural remedies
PDE5 inhibitors (Viagra, Cialis)
+
+Summary
Discussed function of testosterone
How testosterone levels fluctuate
Diagnosing testosterone deficiency
Benefits and Risks of testosterone therapy in older men
Secrets of Abang Sado …..
