Doctors are becoming increasingly aware of the importance of testosterone deficiency syndrome, writes MICHAEL KELLY.
TESTOSTERONE deficiency syndrome (TDS) is one of the most common endocrine disorders in men, but also the least commonly diagnosed and treated, according to Dr Malcolm Carruthers, president of the Society for the Study of Androgen Deficiency.
Carruthers, who is also Medical Director at the Centre for Men’s Health in Harley Street in London, estimates that up to 110,000 of the half a million men who are aged over 50 in Ireland may be suffering from the condition.
“The medical profession is only now waking up to how common this is,” he says. “Only about one per cent, or 1,000 of those men are undergoing treatment for the condition.”
In men, testosterone is produced in the testes and helps maintain bone density, fat distribution, muscle mass and strength, and red blood cell production. It is also responsible for sex drive (libido) and sperm production. Reduced testosterone levels are part and parcel of aging – from the age of about 30 years the decline in testosterone increases at a rate of about two per cent per annum and by the time a man reaches the age of 50, his testosterone levels will have declined by an average of 20 per cent of what they were when he was in his 30s.
The story of TDS is however more complex than these simple equations would suggest.
First of all, not all men with decreasing testosterone levels will experiences the symptoms of TDS and, while it occurs most commonly in men over the age of 50, it can occur earlier or later than that (Harman et al suggest that TDS occurs in eight per cent of men in their 40s, 12 per cent in their 50s and 19 per cent in their 60s).
Secondly, a man may have normal testosterone levels but still experience TDS because his body has developed a greater resistance to the action of testosterone. And, finally, there is also evidence to suggest that lifestyle and environmental factors may be contributing to a general decline in testosterone levels in men globally.
The characteristic symptoms of TDS include loss of energy and libido, erectile dysfunction and impotence, irritability, excessive sweating, weight gain, joint pains and stiffness, memory impairment, irritability and depression.
While these symptoms can undoubtedly have a very serious quality of life impact, testosterone also has a much broader role in maintaining men’s health.
According to Carruthers, there is increasing evidence to suggest a connection between TDS and a number of chronic illnesses such as heart disease, obesity, osteoporosis, diabetes and even Alzheimer’s. A 2005 Columbia University report found that the symptoms of testosterone deficiency and erectile dysfunction may be early warning ‘markers’ of important men’s health issues, such as cardiovascular disease, diabetes, metabolic syndrome and depression.
Why are so many men willing to put up with the symptoms of TDS and risk the more serious health conditions which may follow?
A 2004 report from the Men’s Health Forum suggested that Irish men are reluctant to visit their GP as they don’t believe that their symptoms are serious enough.
Carruthers believes that an additional problem lies in the fact that the condition is often referred to as the male menopause (or “andropause”).
“The male menopause sounds so wimpish and most men just don’t want to own up to symptoms which are connected to that.”
He tells an interesting anecdote that highlights just how averse men are to the term. Some years back he wrote a book on the topic, called Male Menopause, which he says nobody bought. “We had a think about this and decided to change the name of the book to Maximising Manhood and it became a bestseller.”
Outside of the natural decrease in testosterone levels associated with aging, a number of environmental factors are thought to contribute to TDS, according to Dr Pearse Phelan, a specialist physician at the Dublin Medical Centre.
“Stress can have an impact on testosterone levels at any age,” he says. “We also know that while alcohol increases levels of testosterone for a number of hours after drinking, the testosterone levels will go down significantly the following day.”
Interestingly, while obesity is a known symptom of TDS, it can also cause testosterone levels to fall, according to Phelan.
“Testosterone and oestrogen are remarkably similar and the enzyme aromatase, which is abundant in fatty tissue, actually converts excess testosterone in to oestrogen. This can lead to testosterone deficiency.”
Treatment of TDS comes in the form of an administration of a synthetic form of testosterone. It is considered to be a highly effective and fast-acting treatment.
A structured trial in men over 60 concluded that when administered testosterone, men with low testosterone levels were likely to experience improvements in general wellbeing, bone density, libido and erectile function.
“We get very dramatic results among patients with TDS,” says Phelan. “It’s not just about an interest in sex, though that does improve. They come alive in every sense. It improves their cognitive ability and mood and physically it reduces fat, builds muscle and reduces cholesterol.”
The improvements are so dramatic in fact, that the Andropause Society in the UK was moved to highlight the fact that testosterone replacement therapy should be only used in the treatment of TDS and not for cosmetic, aphrodisiac or anti-aging reasons.
Testosterone replacement therapy remains controversial, however, mainly due to disagreements over what constitutes normal levels of testosterone in the bloodstream. Phelan believes the treatment is greatly misunderstood.
“A doctor may carry out blood tests to confirm suspicions about a patient who has presented with the symptoms of TDS. They then discover that the testosterone levels are within the normal range. This is confusing but what constitutes the normal range for the population at large tells you very little about an individual patient.”
Carruthers also refers to another point of considerable controversy – a long-held misconception that testosterone replacement may be linked to prostrate cancer. “This is a myth that has been found to be completely untrue,” he says.
The Society for the Study of Androgen Deficiency in the UK highlighted that while testosterone may exacerbate prostate cancer that is already present, it is not thought to have a role in the initiation of cancers.
The society concluded that “overwhelming evidence supports testosterone replacement as one of the safest forms of pharmacology.”
ONLINE CHECKS
The AMS questionnaire developed by Professor Lothar Heinemann is used frequently by doctors in the diagnosis of testosterone deficiency. A number of websites including that of the Andropause Society ( www.andropause.org.uk) and the Dublin Medical Centre ( www.mediserve.ie) have online calculators which will evaluate your risk of TDS. The Testosterone Deficiency Advisory Board website www.lustforlife.iealso has information on TDS.