MEN’S HEALTH: Hormonal Replacement Therapy更換荷爾蒙治療法(HRT)

Male menopause do occur although it manifests in a insidious manner and it is also not
as common as in females. Medical guidelines have been published, e.g. in European
Urology 2005 Volume 48, Page 1 – 4. There are other terminology used for this
condition, namely, Andropause, ADAM or Androgen Deficiency in Aging Male, PADAM,
Partial Androgen Deficiency in Aging Male, LOH or Late Onset Hypogonadism. The
latest description is that of TDS, Testosterone Deficiency Syndrome. The various
names illustrates that there is probably no sharp drop in the testosterone level but rather
a gradual decrease in level. In addition, there is often a variation in individual level as
well as a wide variation among the population of the level of male hormone. There is
probably also a normal natural decline of the male hormone with graceful aging. Other
hormonal replacements are still undergoing trials.

DEFINITION:

The definition of male menopause would be that of a “clinical and biochemical condition
associated with aging male”.

The clinical features would include decreased libido, erectile dysfunction (ED), sleep
disturbances, changes in mental status e.g. irritability, tiredness and poor memory.
There may also be bodily changes e.g. increase in visceral fat, decrease in lean body
mass and osteoporosis.

The scientific measurement is that of the blood total testosterone determination taken in
the morning between 7 – 11 am. The current lower limit of total testosterone is that of
<11 ng/L.

ASSOCIATED CO-MORBIDITY:

There are some conditions which are associated with an increased incidence of
TDS and these include diabetes, hypertension, obesity (waist circumference >90
cm for Asians), osteoporosis and dyslipidaemia. Some group these conditions as
the “metabolic syndrome”.

Precautions before starting on testosterone replacement therapy include exclusion of
prostatic cancer. The growth of prostate cancer depends on testosterone. Therefore,
before the initiation of testosterone replacement therapy, one would need to do an
examination of the prostate, usually a digital rectal examination, DRE and also to
measure the blood level for prostatic specific antigen, PSA. However, prostatic cancer
is extremely common and testosterone replacement therapy is only contraindicated in
patients with a clinically active prostate cancer. Testosterone replacement therapy in
men with untreated subclinical prostate cancer is not associated with prostate cancer
progression in the short to middle term of a few years (Journal of Urology 2011; Vol.
185: 1256-1261).

WHICH HORMONAL PREPARATION TO USE?

There have been many preparations used over the years including tablets, creams and
injections. The aim is to have testosterone replacement therapy, not to give supra-
physiological levels. Orally absorbed testosterone will have to pass through the liver,

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giving rise to liver toxicity. In addition, there is a question of compliance when the
patient has to take the capsules, usually twice a day. There are also some gels which
can be applied to the skin, in an attempt to mimic the diurnal rhythm of the normal
testosterone. In humid hot climate, gels may not be comfortable. Previously, there were
injections but these tend to give supra-physiological levels during the early days of the
injections. Moreover, many of these preparations were short acting, usually for about 3
weeks.

Obviously, injection therapy which can give a sustained replacement dose over a period
of months would be the most suitable formulation. One such formulation is that of
injection Nebido. This can be given every 3 monthly, although an earlier second dose
would be needed (usually at 6 weeks) to top up the testosterone level.

FOLLOW-UP:

Testosterone replacement therapy is an expensive medical treatment. Therefore,
patients should follow up with their doctor to review their progress including a prostatic
evaluation on an annual basis.



Dr Clarence Lei Chang Moh
Consultant Urologist


Enquries to : clarencelei@gmail.com
kuchingurology.com


Date: 15.6.2011