Rapid Responses to:
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does it exist? • For • Against
Rapid Responses: Rapid Responses published:
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Just a GP`s silly questions
- Regina Stroebele (24 March 2000)
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Testosterone Replacement Therapy for Men
- Malcolm Carruthers (24 March 2000)
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Medications for and against "male menopause"
- Cándido Hernández-López (24 March 2000)
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Re: Testosterone Replacement Therapy for Men
- Howard Jacobs (25 March 2000)
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Terminology inappropriate
- Prakashbhan S Persad (26 March 2000)
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Male menopause
- Michael J Diver (31 March 2000)
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Beyond the bedroom
- Steve Rhyan (31 March 2000)
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Andropause Does Exist!
- Annie (7 March 2001)
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Andropause Exists, Treatment Unlikly
- Charles (12 August 2001)
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Regina Stroebele
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For what is Prolactin a "marker"? Does its level increase in old men like Gonadotrophin in female menopause? (Well, I suppose Prolactin does not DEcrease, as it is not needed at all in YOUNG MALES...) And if Prolactin levels increase, couldn`t this be a sign for a HYPOTHALAMIC process associated with / responsible for ageing in both males and females? Is "becoming old" such a mess for men, that it needs a treatment? "Leave your old postmenopausal wife, look for at least an HR-treated one under 50"? |
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Malcolm Carruthers
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Editor - Howard Jacobs' unfair sex discrimination against men in matters relating to HRT is all the more surprising because of his enthusiastic advocacy of it in women1. His frequently quoted argument that there is no such thing as a male menopause or andropause because the mean fall in both total testosterone and free testosterone concentrations with ageing are only 25% and 50% respectively, is not applied to other endocrine disorders such as hypothyroidism. Why should there not be such a critical level in hypogonadism, particularly in some "High-Testosterone" men, such as politicians, lawyers, tycoons and technocrats who appear to depend on high levels of the hormone for dominance and competitive drive?2. In relation to his second point, the characteristic andropausal symptoms described in a huge series of articles over the past 60 years appear in a range of low testosterone states, the balance of evidence being that they can indeed be reversed with a wide variety of hormonal replacement regimes. He quotes a study in healthy men given relatively weak androgen treatment in the form of patches, which failed to show an improvement in the strength of one group of muscles. However, other well- controlled studies have shown that testosterone does increase muscle bulk and strength3. Therefore evidence on this point is inconsistent, provides insufficient grounds to reject either the use of testosterone for relieving andropausal symptoms or it's preventive medical benefits. The final point that "So far as sexual activity is concerned, the role of testosterone in elderly men is still not well defined", on any critical analysis again fails to support his case against hypogonadism contributing to the multifactorial aetiology of the large majority of cases of erectile dysfunction. As Dr Gould has previously confirmed, it is the shared experience of clinicians treating andropausal men with testosterone, that as well as libido improving, erectile dysfunction is relieved in two-thirds of cases, and when this is combined with sildenafil, this increases to over 90%4. This can be explained by recent research showing that castration in the rat reduces both the erectile response and penile nitric oxide synthase activity upon which the action of sildenafil depends, and these effects are prevented by androgen administration5. Overall, as shown by the mass of papers presented at the WHO sponsored 2nd Aging Male Conference in Geneva last month, the balance of evidence strongly supports the existence of the andropause as a very real group of symptoms arising from an absolute or relative insufficiency of testosterone, which can and should be treated. Surely HRT for men is a long-neglected idea whose time has now come. Malcolm Carruthers 1. Gould DC, Petty R, Jacobs HS. The male menopause - does it exist? BMJ 2000;320:858-861. 2. Carruthers M. Maximising Manhood:Beating the male menopause. HarperCollins, London, 1997; 3. Bhasin S, Bross R, Storer TW, Casaburi R. Androgens and muscles. In: Nieschlag E, Behre HM, eds. Testosterone:Action,deficiency,substitution. Berlin: Springer Verlag, 1998;209-227. 4. Gould D. Combined testosterone and sildenafil treatment more effective than sildenafil alone. Int.J Impot.Res. 1999;11:237-238. 5. Lugg J, Ng C, Rajfer J, Gonzalez-Cadavid N. Cavernosal nerve stimulation in the rat reverses castration-induced decrease in penile NOS activity. Am.J Physiol. 1996;271:354-361 |
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Cándido Hernández-López, clinical pharmacology resident IMIM-Hosp. del Mar (Barcelona-Spain)
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Gould, Petty, and Jacobs debated in the BMJ about facts for and against existing of male menopause. Both two positions focused on sexual dysfunction. Indeed, Jacobs referred to a new class of drugs that offer significant therapeutic potential for male erectile disorder. But, none mentioned the role of drug abuse or drug therapy on the decline in sexual interest and potency. For example, it has been described that more than 41% of hospital inpatients aged 65 years and over were found to use benzodiazepines and alcohol in excess1, and that medications account for erectile dysfunction in approximately 25% of cases2. In developed countries, ageing (male or female) is associated with an increase in medication consumption. This fact contributes to improve ageing health, although also increases risk of adverse events related to drug therapy. I have observed that drug-related sexual dysfunctions distribute dependent on age and gender (data not published). So, sexual dysfunction should be more prevalent in young women (commonly because of psychotherapeutic drugs), whereas in the male population, old men should be more affected (antihypertensive and psychotherapeutics principally). In conclusion, the lifestyle in developed countries could play a part in sexual dysfunction that is more important than physiologic changes related to ageing. Drug therapy is a significant matter in this lifestyle and could explain more cases of sexual dysfunction initially attributed to the supposed male “climateric”. Nowadays, the media are focused on therapeutic novelties against sexual dysfunctions, and they forget that drugs also produce it. 1. McInnes E, Powell J. Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed?. BMJ 1994; 308: 444- 6 2. Keene LC, Davies PH. Drug-related erectile dysfunction. Adverse Drug React Toxicol Rev 1999; 18: 5-24 |
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Howard Jacobs, Emeritus Professor of Reproductive Endocrinology Royal Free & UCL Medical School
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In answer to Dr Carruthers: In my contribution to this debate, I tried to distinguish between full dose androgen therapy of patients with proven hypogonadism (no problem) and the treatment of fragile elderly men with testosterone in physiologically relevant amounts. It is the latter situation which, in my opinion, is relevant to a debate concerning the existence of an andropause. And it is this very group of men that seems to have fared so disappointingly when given testosterone therapy over a 3 year period in doses that raised their testosterone concentrations to those seen in men in their twenties (1, 2). Dr Carruthers makes a number of assertions concerning the value of testosterone therapy but for them to be convincing he will need to quote results from randomised controlled trials performed in appropriate subjects. He has not done so. He does, however, refer to the chapter by Bhasin and his colleagues in the excellent text of Nieschlag and Behere (3). It is helpful to quote directly two of the authors "key messages": "There is consensus that replacement doses of testosterone in hypogonadal men and supraphysiological doses given to eugonadal men increase fat free mass, muscle size and strength" and "We do not know whether testosterone supplementation can produce clinically significant improvement in muscle function in older men…" The value of the menopause as a model for the gradual decline in gonadal function that occurs in ageing men remains to be demonstrated. The case for androgen replacement therapy in elderly men who do not have biochemically proven testosterone deficiency (clinical hypogonadism) remains to be proven. Howard Jacobs (1) Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on bone mineral density in men over 65 years of age. J.Clin.Endocrinol.Metab. 1999;84:1966-1972. (2) Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on body composition and muscle strength in men over 65 years of age. J.Clin.Endocrinol.Metab. 1999;84:2647-2653. (3) Bhasin S, Bross R, Storer TW, Casaburi R. Androgens and muscles. In: Nieschlag E, Behre HM, eds. Testosterone: Action, deficiency, substitution. Berlin: Springer Verlag, 1998;209-227. |
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Prakashbhan S Persad, Consultant Obstetrician & Gyanecologist General Hospital, San Fernando, Trinidad
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Whether or not there is some clinically significant hormonal decline in men is still subject to debate. What cannot be, however, is the term menopause applied to the condition. Menopause literally means cessation of the monthly periods. We should therefore, avoid this term in any discussion regarding dwindling testosterone in elderly males. |
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Michael J Diver
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EDITOR-Evidence that the so-called male menopause is attributable to a reduction in testosterone is scanty1. Much of the argument is based on interpretation of an estimate of the total serum testosterone concentration. To ascribe a single testosterone concentration of 'around' 10.4 nmol/l or 11 nmol/L as 'critical' is fraught with problems. Testosterone concentration is subject to both episodic and diurnal variation. In our study2 of 10 young men sampled every 30 minutes for 24 hours, we confirmed a marked diurnal variation in total, bioavailable and free testosterone, with differences in serum total testosterone between 0700 hours and 1000 hours ranging from 11.9 nmol/L - 38.7 nmol/L. In a similar study in 6 men aged 55 - 64 years, differences ranged from 10.9 nmol/L - 25.7 nmol/L. In a carefully-controlled group of 114 healthy men aged 21 - 84 years, we find no correlation (r = 0.158, p = 0.105) between age and total testosterone in a.m.samples. We do, however, find a significant positive correlation between age and SHBG (r = 0.47, p < 0.0001), and an equally significant negative correlation between age and measured bioavailable testosterone (r = -0.41, p <0.0001). An audit of 1986 requests in our hospital, showed a poor, though highly significant, correlation between age and serum testosterone (r = -0.14, p <0.0001). In 564 men complaining of impotence there was a similar relationship between age and serum testosterone (r = -0.19, p < 0.0001). Of the1986 requests 84.1% had a serum testosterone >10.4 nmol/L: of the 564 impotent, 84.6% were >10.4 nmol/L. Overall, at 23.8 ±3 years the mean testosterone was 17.76 ± 6.3 nmol/L (n= 120) while at 72.6 ± 2.6 years the mean testosterone was 15.0 ±5.3 nmol/l (n= 120). Although this represents a statistically significant difference (p<0.05) the mean concentrations are well above that considered to suggest hypogonadism1. In the impotent group, at 34.6 ± 6.2 years the mean testosterone was 16.6 nmol/L ( 8.8 - 31.2 nmol/L),and at 69.5 ± 4.2 years was 13.6 nmol/L ( 6.9- 26.8 nmol/L). Our data suggest erectile dysfunction has little to do with serum testosterone. Men do not become depleted of germ cells and provided that adequate androgen is available are capable of ejaculation. The concentration of testosterone required for sexual arousal and ejaculation is unknown but these are readily evidenced when total, bioavailable and free testosterone are at their nadir, late in the day. Men may display any of the symptoms referred to3. It is difficult to base these on a serum testosterone concentration. Michael J. Diver William D. Fraser Department of Clinical Chemistry, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP 1. Gould DC, Petty R, Jacobs HS. The male menopause-does it exist? BMJ 2000:320:858-61. 2. Diver MJ, Scutt D, Manning JT, Gage AR, Fraser WD. Pituitary insufficiency. Lancet 1998 352; 816-7. 3. Heller CG, Myers GB. The male climacteric, its symptomatology, diagnosis and treatment. JAMA 1994;112;1441-3. |
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Steve Rhyan, exercise physiologist the Exercise Clinic
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At our clinic, it has been my observation that men on testosterone and or growth hormone "supplements" seem to respond more favorably to physical training than those who are not supplemented. Understanding that there is a genetic variation to adaptation to almost everything, especially physical tasks, the men on hormone supplements appear to adapt more readily to training loads. When asked how each training session "feels" most respond at a much lower RPE value. Measurable parameters like resting heart rate, blood pressure, body fat, muscle girths, 1RM values, heart rates at fixed work loads on leg ergometers & treadmills generally are better overall. Then there is the issue of "better sleep " and "tighter skin" that is told to me by those on "supplements". After reading the articles concerning andropause I found few if any of the responses looking at hormone replacement plus physical training, not recreation, and how the man "feels". Do they feel better, healthier, more alive. Certainly, improving wellness must account for something. |
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Annie Homemaker
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For anyone who does not believe in "male menopause" should read the book by Jed Diamond, "Surviving Male Menopause." This book is great for the women in this world who have noticed a change in their husband and can't figure out what is happening to their husband and relationship! It is a relief to find out about this and to finally know what is going on and try to understand it instead of giving up and throwing away a good marriage! |
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Charles , a common man N/A
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An interesting debate, but for me Howard Jacobs misses or skirts around the real point. Some men certainly do go through body changes even in middle age, I have and am doing this. No its not the same as women, so what. The rate of onset is gradual, so what. A perfect understanding doesn't exist, so work with what we do know. He asks "we do well to consider how many of the changes in men as they pass from middle to old age should be attributed to the passage of years and how many to a decline in hormone concentrations." interesting but what is this passing years doing physiologically? At 58 years I've gone through vasomotor instability (hot flashes, sweating) which came on over a period of a few months, was circadian (onset near 3 am), intense enough to wake me nearly every night for many months slowly decayed in frequency. I've been loosing muscle mass, stamina, more easily fatigued. Possible loss in bone density. I've had the decrease in libido, erectile dysfunction. Not on any drugs, low alcohol intake, good exercise, general physiology checks out OK. The symptoms all correlate well with descriptions of andropause. I think it exists! No, my symptoms have not been specifically linked to endocrinological changes as its impossible to get anyone to try linking them. Measuring bioactive testosterone is not straight forward so only the total level is measured with no account being taken of increased binding with sex hormone binding globulin that occurs with age (or the individual). Also not enough longitudinal studies have been done to know if changes are due to relative or absolute levels. So, why not consider symptoms? Note plural, consider the whole person. Why should hypogonadism have to be clearly shown? This seems to be the let out to not treating men who have a range of symptoms which circumstantially point in the direction of andropause changes. Circumstantial evidence is used in many other treatments, how often is the specific bacteria causing an infection positively identified before the use of an antibiotic? Why isn't testosterone treatment tried to see if an improvement of conditions results. Even higher than normal 20 years' old levels might be useful. If levels are not too much above those levels little evidence of a deleterious consequences exist. Yes, other common endocrine disorders exist as do other medical disorders but this does not show the lack of an andropause and may even be the result of it in some cases. They seem to be brought in here just to confuse and side step the issue that some men may be helped with testosterone treatment at pre- hypogonadism levels. Yes, the endocrinology of ageing is broad but Howard Jacobs, in this rebuttal, seems set against the concept that some men of middle age might have deleterious physiological changes which could be treatable after only considering symptoms instead of practically impossible to achieve proofs. |
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