What is androgen deficiency?
Androgens are male hormones that affect a host of processes ranging from mental outlook to the growth of structures and organs. Androgen Deficiency (AD) occurs when these hormones fall below specific age-related levels. Androgen deficiency, when properly diagnosed, can be treated effectively and many of the symptoms can be reversed or eliminated. This condition is also commonly known as male hypogonadism if the cause is deficiency in testicular production of reproductive hormones.
Androgen deficiency affects 1 in 200 men under 60 years old. However, most men experience a 1% decline in total testosterone yearly starting in their late 30s and early 40s. After the age of 60, as many as 1 in 10 men are affected by low testosterone.
If androgen levels are too low in younger people, it can impair normal sexual development which if left uncorrected may result in infertility later in life.
What are the causes of androgen deficiency?
Androgen deficiency can be caused by a number of different underlying conditions which impact the proper functioning of the testicles. Some examples include:
Despite the marketing blitz about "male menopause," and the need for supplements to ease those symptoms, androgen deficiency affects only a fraction of the male population. A survey by the Massachusetts Male Aging Study estimates that 12.2% of men between the ages of 40 and 69 are ‘possibly’ androgen deficient and 2.3% are ‘definitely’ androgen deficient.
How is androgen deficiency diagnosed?
The diagnostic procedure for androgen deficiency includes a comprehensive medical history, a physical examination and laboratory tests. The medical history will include a discussion of childhood development, questions about fertility, established testicular abnormalities, exposure to medications or occupational toxins, and recent changes in sexual functions. Questions will also be asked to ascertain the onset and severity of many of the previously mentioned symptoms.
The physical examination will include palpation of the testes to check for volume and consistency, assessment of secondary sexual characteristics such as body hair distribution, musculature and breast size. There will often be a digital rectal examination, particularly in men 50 and older, to check prostate size.
Laboratory tests will be conducted to measure testosterone levels as well as other hormones such as luteinizing hormone (LH) and follicle stimulating hormone (FSH). Testosterone is released in pulses at specific intervals during the day. Experts recommend that blood samples be taken between 8 and 10 a.m. on two separate days. Only when the levels of these hormones are determined and evaluated in the context of physical symptoms can a reliable diagnosis of androgen deficiency be made.
What are the symptoms of androgen deficiency?
Just like women, men experience a decline in sex hormone levels beginning in their 40s. However, the decline in men is gradual and proceeds over a number of years. As a result, the onset of symptoms may be subtle and ill-defined. Symptoms are varied and may include hot flashes, sweating, insomnia, nervousness, irritability, tiredness, loss of motivation, short-term memory problems, declining self-esteem, depression, decreased energy levels, diminished muscle strength, decline or loss of libido or sexual desire, poor erections, reduced orgasmic quality, reduced volume of semen, diminished muscle mass, hair loss, and abdominal obesity.
Other symptoms that have been related to AD include a reduction in high-density lipoprotein (HDL) cholesterol, an increase in total body fat, osteoporosis, and a reduction of the proportion of red cells in plasma. Erectile dysfunction or the inability to achieve and maintain an erection through the completion of the sex act is rarely linked to AD. If sexual desire exists but function does not, the problem does not stem from low testosterone levels and testosterone replacement is not indicated as a therapy. Other effective therapies apply.
As can be seen, many of these symptoms may emanate from other disorders or they may be a normal aspects of getting older. For this reason, diagnosis of AD never rests on symptoms alone.
How is androgen deficiency treated?
Testosterone replacement therapies are a common method of treatment for patients with androgen deficiency. Testosterone replacement therapies exist in a variety of preparations. These include long and short acting intramuscular injections (injections made into the muscle tissue), transdermal (skin) and scrotal patches, transdermal gels and oral preparations. The appropriate therapy will be determined in consultation with the patient and specialist. The costs of the varied preparations may be a factor and are given consideration during this discussion.
The goal of testosterone supplementation is to bring testosterone into the normal range but not exceed that range. The therapy should not have unwanted effects on the prostate, serum lipids, or cardiovascular, liver and lung functions. Patients should be able to administer it themselves with minimal discomfort and it should be affordable.
Intramuscular injections do not mimic normal fluctuating testosterone levels. There is a peak above normal levels soon after injection. This falls to below normal before the next injection to produce what some call a "roller coaster" effect. Oral preparations can produce above normal high concentrations of the hormone that vary significantly between administrations and vary significantly between individuals. The use of oral methyltestosterone is not supported by professional organizations because it carries a significant potential for liver toxicity.
A buccal formulation (held between the cheek and gums) was introduced in 2003. It is seen to be safe and effective. The transdermal gel is applied as a cream and produces serum levels of testosterone in the normal range. Users can acquire a degree of control by varying the amount they apply. The gel was introduced in 2000 and long term data on its effects have yet to appear. Scrotal and transdermal patches also create testosterone levels that approximate those produced by normal physiologic processes. The scrotal patch requires that the scrotum be shaved to allow good adhesion. Both the dermal and scrotal patch may engender allergic skin reactions but in most instances, these reactions can be managed with over-the-counter hydrocortisone or antihistamines.
Often a therapy is given a trial of up to three months during which testosterone levels are monitored and symptoms are watched for changes. If the therapy provides benefits and is pursued, testosterone levels, symptom monitoring and routine check ups should be conducted at three month intervals during the first year of therapy. Cholesterol levels and red blood cell production are affected by testosterone and must be monitored during the first year of therapy. There is also a positive relationship between testosterone and prostate cancer.
While the hormone does not cause the cancer, it may enhance its growth if it is present. Age is a risk factor for prostate cancer and studies suggest that a majority of men over 80 may have subclinical (non-symptomatic) prostate cancer. This cancer normally grow slowly and may have started earlier in their lives. This observation makes age a consideration when discussing the therapy.