HRT in Andropause

4/2/2017
Andropause
HORMONE REPLACEMENT THERAPY
IN ANDROPAUSE The signs, symptoms and complaints
caused by decreased or deficient
46 testosterone in men46
Wimpie Pangkahila
Other names:
Department of Andrology and Sexology
Post Graduate Program in Anti-Aging Medicine
Medical Faculty Udayana University
LOH = Late Onset Hypogonadism
Indonesian Center for Anti-Aging Medicine TDS = Testosterone Deficiency Syndrome
(INCAAM)
Email/FB: wimpie.pangkahila@gmail.com
Testosterone Needed For Sexual Function

Action of Androgens in Men and Women
Men Women
Comparison of Men and Women:
Libido
• Testosterone is needed for pubertal
development
46 46
Arousal
• Testosterone is needed for sexual
functioning Orgasm
• Testosterone stimulates muscle, bone

and blood
• Testosterone enhances energy, cognitive
function and well-being
1
4/2/2017
Testosterone Enhances Energy,

Testosterone Stimulates Muscle, Bone, Blood Cognitive Function and Well-being
Men Women Men Women
Let’s go!
Get lost !
Muscle Energy
46 46
Cognitive
Function
Bone
Well-being
Blood
Decreased testosterone level results in

decreases of the following aspects: In the other side, there are increases in:
1.General well-being 1.Fat mass which change the body

composition, especially visceral obesity
2.Sexual function and46spermatogenesis 46
3.Cognitive function 2.Cardiovascular accidents
4.Red blood cell volume 3.Mood and sleep disorder
5.Muscle strength
6.Bone mass with an increased fracture
risk
7.Immune competence
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The Physiological Window of Testosterone

↑↑ Dyslipidemia
Diagnosis based on:
Supra- ↑ HTn, Cardiomegaly
physiological ↑ Risk of Stroke, MI, and SD
Zone ↑ Abdominal adiposity
↓ Insulin sensitivity 1. Signs and symptoms
↑ Insulin sensitivity
Questionnaires 46
↓ Dyslipidemia
Physiological ↓ Abdominal adiposity
↓ Blood pressure
2. Physical examination
Zone
↑ Anti-thrombotic effects
↓ CVD risk 3. Supported by laboratory test
?
Partial ↓ Insulin sensitivity
Androgen ↑ Dyslipidemia
Deficiency ↑ Abdominal adiposity
_ 1 +
Cardiovascular disease risk
Wimpie Pangkahila - Center for Study of Anti-Aging Medicine, Department of Andrology and Sexology
Medical Faculty Udayana University - Indonesian Center for Anti-Aging Medicine
Blouin K et al. J Steroid Biochem Mol Biol 108: 272 (2008)
Diagnosis ADAM screening questionnaire

1 Do you have a decrease in libido (sex
For men: drive)?
Signs and symptoms:
ADAM questionnaire 2 Do you have a lack of energy?
AMS 3 Do you have a decrease in strength and/or
endurance?
Physical examination 4 Have you lost height?
Laboratory tests 5 Have you noticed a decrease in
"enjoyment of life"?
Wimpie Pangkahila - Center for Study of Anti-Aging Medicine, Department of Andrology and Sexology Wimpie Pangkahila - Center for Study of Anti-Aging Medicine, Department of Andrology and Sexology
Medical Faculty Udayana University - Indonesian Center for Anti-Aging Medicine Medical Faculty Udayana University - Indonesian Center for Anti-Aging Medicine
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4/2/2017
ADAM screening questionnaire

The interpretation
6 Are you sad and/or grumpy?
Screening + if the answer:
7 Are your erections less strong?
8 Have you noted a recent
YES to question 1 or question 7
deterioration in your ability to play
sports? or
9 Are you falling asleep after dinner? YES to any other three questions
10 Has there been a recent
deterioration in your work
performance?
T level considered as andropause
Another tool: < 200 ng/dl or 7 nmol/l or

Aging Males’ Symptoms (AMS) < 6.5 ng/dl (0.23 nmol/l) for free T
questionnaire
(Rosner et al., 2007)
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4/2/2017
However, the study of Pangkahila (2009) showed Practical guideline

that mean level of total and free testosterone of
Indonesian men with andropause complaints was Based on many studies, it is clear that
still in the normal range
level of T and its susceptibility are
Age Total T Total T Free T Free T different between ethnic groups due to
level range level range difference in diet composition.
ng/dl ng/dl pg/ml pg/ml
45-59 461.61 280-800 10.97 7.2-23 Therefore the signs and symptoms of
60-70 493.99 280-800 10.10 5.6-19 andropause in Indonesian men have
appeared even though the level of total
and free T is still in normal range
The consequence of this result, TRT might

Difference in Testosterone level
be considered even though total or free T is
not in deficient level. This indicates that to
The level of T for diagnosing andropause
apply TRT doctors do not have to wait until
generally based on studies in Caucasians
T falls in deficient level.
men.
However, the result of laboratory test
Report of Rosner et al (2007) described
should be used to confirm the clinical
that the level of T considered as
signs, symptoms, and physical
andropause is < 200 ng/dl or 7 nmol/l or
examination.
< 6.5 ng/dl (0.23 nmol/l) for free T
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4/2/2017
Compared to the general guideline, the

hormone level in this study even is still far
above the lowest level in the range. The possible answer is Indonesian men
have higher susceptibility to testosterone
The question is why have the complaints of compared to Caucasian men.
andropause already appeared whereas the
levels of total and free T are still in the normal If this is true, there should be a different
range?
procedure in treating andropause patients
with TRT for Indonesian men.
The differences in T biosynthesis and The possible difference in susceptibility to

metabolism between ethnic groups could be sex steroid hormone has been showed by
due to a study of hormonal contraception in
genetic control Indonesian men (Pangkahila, 1991).
environmental influences, including diet and This study demonstrated that all subjects
life style achieved azoospermia after injected with
the combination of androgen and
The difference results in
progestin. Such a high frequency of
difference in susceptibility to testosterone
azoospermia induced by sex steroid
hormone has not been reported before in
other ethnic groups.
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4/2/2017
In general, traditional Asian diet, Study of Longcope et al (2000) showed

including Indonesian diet is low in fat and that diets low in protein in elderly men
protein but high in carbohydrates, may lead to elevated SHBG levels and
whereas Western diet is high in fat and decreased T bioactivity.
protein.
In contrary, a high protein diet could
The difference in diet may be one of the increase bioavailable T and decrease the
causes of difference in response to T or effects of the age-related declined
other sex steroids. hormone.
The role of diet also showed by a study where

diet can alter steroid hormone profiles, and
The differences result in different incidence
thereby modify prostate cancer risk throughout of prostate cancer among African
life. Diet with high animal fat and low fibers result Americans, white Americans, and Asians
in increased circulating T (Chinese and Japanese) men.
Study of Ross et al (1998) described that Both native Chinese and Japanese men
African-American men may be exposed to higher appear to have substantially lower 5-alpha
levels of T, literally from the start, because of diet
reductase activity than U.S. whites or
related hormonal influences.
Young adult African-American men have at least
African-Americans.
10% higher circulating T levels than young adult
white men.
7
4/2/2017
Link Between Hypogonadism

A study of Rohrmann et al (2007) showed that and Metabolic Syndrome
Mexican-Americans had higher T than whites
but similar estradiol and SHBG concentrations.
Ethnic difference also showed by Orwoll et al
(2010) that Asian men in Hong Kong and Japan,
but not in the United States, had levels of total T
approximately 20% higher than in other groups.
However, a study of Heald et al (2003)
demonstrated T levels of Pakistani men were
significantly lower compared to the level of
Europeans.
Medical Faculty Udayana University - Indonesian Center for Anti-Aging Medicine Journal of Andrology Medical Faculty Udayana University - Indonesian Center for Anti-Aging Medicine
Volume 30, Issue 4, pages 370-376, 2 JAN 2013 DOI: 10.2164/jandrol.108.006015
http://onlinelibrary.wiley.com/doi/10.2164/jandrol.108.006015/full#f1
Visceral
Therefore a number of epidemiological adiposity
studies support associations of obesity, TG ↑ Low T

the MES, type 2 diabetes, and low serum
T with sexual dysfunction including ED
ED
HDL ↓ BP ↑
Glucose ↑
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4/2/2017
Hormone Replacement Therapy is “the The following condition must be

drug of choice” for andropause. considered in testosterone treatment:
All complaints will decline and 1.Indication

46
furthermore the treatment will increase 2.Contraindication 46
the quality of life. 3.Preparation of testosterone
4.Dosage
5.Evaluation and follow up
6.Monitoring
Many data show the benefit of Testosterone replacement therapy

Testosterone Replacement Therapy in
andropause. • Should maintain T level within the range
of physiological and avoid
46 treatment is
In women, testosterone supraphysiological values
relatively new in medical practice • Androgen therapy is usually long-term
compared to estrogen and progesterone. requiring regular follow-up, frequent
monitoring of blood levels and beneficial
However, many basic and clinical data and adverse therapeutic responses
demonstrate the benefit of testosterone
treatment in women. Wimpie Pangkahila - Center for Study of Anti-Aging Medicine, Department of Andrology and Sexology
9
4/2/2017
Preparation Misuse
TP, TC, TE No indication

Testoderm Nebido
Andriol
Bodypatch No physical examination
Androderm
46 Testim No laboratory tests46
Androgel/
TestoGel
No monitoring
Striant Only for money
Never consider patient’s risk and
consequences
Professional doctors will not misuse

hormone treatment
Thank you
46
10

HRT in Andropause

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4/2/2017

Testosterone Needed For Sexual Function

• Testosterone stimulates muscle, bone

Testosterone Enhances Energy,

Decreased testosterone level results in

1.General well-being 1.Fat mass which change the body

The Physiological Window of Testosterone

Diagnosis ADAM screening questionnaire

ADAM screening questionnaire

T level considered as andropause

Another tool: < 200 ng/dl or 7 nmol/l or

However, the study of Pangkahila (2009) showed Practical guideline

The consequence of this result, TRT might

Compared to the general guideline, the

The differences in T biosynthesis and The possible difference in susceptibility to

In general, traditional Asian diet, Study of Longcope et al (2000) showed

The role of diet also showed by a study where

Link Between Hypogonadism

studies support associations of obesity, TG ↑ Low T

Hormone Replacement Therapy is “the The following condition must be

All complaints will decline and 1.Indication

Many data show the benefit of Testosterone replacement therapy

TP, TC, TE No indication

Professional doctors will not misuse

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