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Dealing with the challenges of diagnosing andropause

Testosterone deficiency can increase the risk of strokes, heart disease and osteoporosis, and must be treated

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Male patients in the later parts of their life have lots of symptoms that include loss of libido, lack of energy, loss of strength, sadness, fatigue, poor sleep, lack of focus and concentration.

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There are many ways to replace testosterone, from patches to buccal adhesive tablets to implants under the skin.

ANDROPAUSE? In women, we have a definite menopause with symptoms. However in men, we do not have a definite male andropause, and there is actually lot of difficulty in diagnosing andropause in men.

Male patients in the later parts of their life have lots of symptoms that include loss of libido, lack of energy, loss of strength, sadness, fatigue, poor sleep, lack of focus and concentration.

Some complain that they have loss of morning erections, erectile dysfunction, poor effort tolerance for exercise, difficulty in bending, squatting, stooping and they cannot get up from a chair. These symptoms are difficult to evaluate as they are non-specific and could well be due to ageing.

We do know that we can measure testosterone, and that can give us an idea of the problem. The level that most experts agree is 10 nmol/L or 300 ng/dL and below; most agree that this constitutes testosterone deficiency and should be treated.

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To complicate the situation, we know that testosterone level in men drops by about 1-1.4 per cent every year probably from about 40 years onwards. We also know that the amount of muscle loss every year is about half a kilogram every year from 40 years onwards.

The process of deterioration is slow and hence our metabolic rate drops. We may eat the same amount but we tend to put on weight as we burn less calories. Our visceral fat increases and fat turns testosterone into estrogen, dropping our testosterone level even further.

A big study in 2010 in Europe on men aged from 40 to 79 years found that the symptoms of loss of morning erection, erectile dysfunction and loss of libido are important. The other symptoms are not reliable enough to diagnose andropause. These three symptoms must be accompanied with a low testosterone level of 11 nmol/L or 320 ng/dL. Having said that, we must realise that some illnesses or medicines can cause testosterone levels to drop.

Now that we have figured out how we diagnose andropause, we should understand what this does to the body. We know that the body reduces in muscle and increases in fat, especially visceral fat. That can trigger insulin resistance, diabetes and metabolic syndrome. This in turn increases the risk of heart disease and strokes.

Other things that low testosterone can do is cause osteoporosis, and it can even cause fractures. As well, blood counts are affected by testosterone and we know that low testosterone level can cause anemia.

The brain is also affected by the low hormone level. There seems to be decline in visual and verbal memory and cognitive function. There is also evidence that the low levels of testosterone affects mood.

We treat patients with low testosterone with replacement therapy. Sometimes I ask my patients to try supervised weight lifting so as not to get injured. There are also DHEA supplements, and some of my patients have tried TCM.

I have seen my patient's testosterone double with exercise. We should give patients the benefit of the doubt instead of replacing immediately. Once a patient undergoes replacement therapy, his own production of testosterone may cease and he is dependent on the replacement for the rest of his life.

If we do replace testosterone, there are many ways: from applying gel to testosterone patches to buccal adhesive tablets to implants under the skin. For injections, there are those that you give every month to those that can last up to three months.

When we replace testosterone, we need to monitor the patient and check the hemoglobin, hematocrit and Prostatic Surface Antigen before starting therapy. These tests should be done regularly while on treatment.

Risk of prostate cancer has not been shown to be increased by testosterone treatment. However prostate cancer is hastened by testosterone treatment. Therefore, we would usually stop the treatment if the doctors suspect that there is a possibility of prostate cancer.

We have to understand that with testosterone replacement, the patient must still take care of himself. This includes a good balanced diet, exercise and sleep.

I would ask patients to go on a diet with complex carbohydrates and reduce the intake of refined carbohydrates. I would also ask them to reduce intake of red meats and increase intake of vegetables and fruits.

I would ask them to increase the exercise by walking half an hour three or more times weekly. Sleep is important with good sleep hygiene, regular sleeping times and adequate number of hours.

This series is produced in collaboration with Singapore Medical Specialists Centre