Testosterone replacement

Testosterone Testosterone ReplacementReplacement

forfor

Men and WomenMen and Women

Testosterone Testosterone ReplacementReplacement

forfor

Men and WomenMen and Women

www.freelivedoctor.comwww.freelivedoctor.com


Presenting from the Premises Presenting from the Premises of Port Powerof Port Power


While testosterone While testosterone replacement is being used in replacement is being used in women with good women with good effect…effect…

it isit is used without the used without the approval of the Australian approval of the Australian

Drug Evaluation Drug Evaluation CommitteeCommittee

…and the individual …and the individual practitioner must take practitioner must take

individual responsibility for individual responsibility for it’s useit’s use


The human ovary The human ovary produces more produces more

testosterone than testosterone than oestrogen- weight for oestrogen- weight for

weightweight

The postmenopausal ovary The postmenopausal ovary continues to produce continues to produce testosterone after the testosterone after the

cessation of follicular activity cessation of follicular activity cuts off the supply of cuts off the supply of

oestrogenoestrogen


As the ovary fails, it continues to As the ovary fails, it continues to produce testosterone and produce testosterone and

perhaps in perhaps in increasedincreased amounts… amounts…for a variable number of years.for a variable number of years.

This is the so called…This is the so called…

“continuation of ovarian function “continuation of ovarian function postmenopausally”.postmenopausally”.

i.e. progressive androgenisation!i.e. progressive androgenisation!


With the introduction of HRT With the introduction of HRT (oestrogen only or ERT), (oestrogen only or ERT), testosterone status falls to testosterone status falls to zero.zero.This is due to two factorsThis is due to two factors

cessation of production from the ovary by suppression of LH

binding of testosterone by SHBG


It follows therefore, that any It follows therefore, that any woman taking oestrogen or woman taking oestrogen or

producing excess oestrogens is producing excess oestrogens is relatively or absolutely relatively or absolutely testosterone deficienttestosterone deficient

e.g.e.g. the oral contraceptivethe oral contraceptivemulticystic ovarymulticystic ovary

oestrogen replacementoestrogen replacement


Oestrogen and progesterone are Oestrogen and progesterone are the mainstay of ERT.the mainstay of ERT.

Testosterone may still be viewed Testosterone may still be viewed as the,as the,

“Cinderella of the hormonal “Cinderella of the hormonal ball”…ball”…

but she got to marry Prince but she got to marry Prince Charming!Charming!


SymptomsSymptoms

Testosterone replacement is Testosterone replacement is generally regarded as indicated generally regarded as indicated

for loss of libidofor loss of libido

(by a predominantly male (by a predominantly male profession)profession)

…….. and while this .. and while this may be true, may be true, other symptoms are of greater other symptoms are of greater

importance.importance.


Indications for Indications for testosterone testosterone replacementreplacement

SymptomsSymptomsVulval discomfortVulval discomfort? Voiding dysfunction? Voiding dysfunctionPainful benign breast diseasePainful benign breast disease? Prevention of breast cancer? Prevention of breast cancerOsteoporosisOsteoporosis


Symptoms Symptoms relievedrelieved

Variable mood state-tearful or Variable mood state-tearful or aggressiveaggressive Loss of energy and staminaLoss of energy and stamina Impaired concentration and memoryImpaired concentration and memory General skin and scalp hair drynessGeneral skin and scalp hair dryness Loss of sexual arousabilityLoss of sexual arousability Painful breastsPainful breasts Vulval skin dryness/ discomfort/ Vulval skin dryness/ discomfort/ itchingitching Voiding disorder ?Voiding disorder ? Restored/ increased muscle strengthRestored/ increased muscle strength


Odds and endsOdds and ends

may improve tachycardiasmay improve tachycardias seems to suppress petit malseems to suppress petit mal

(despite warnings on the P.I.)(despite warnings on the P.I.) some headaches improvesome headaches improve neck and back painneck and back pain improves athletic competitionimproves athletic competition improved sleep qualityimproved sleep quality increases insulin sensitivityincreases insulin sensitivity lichen sclerosislichen sclerosis


Objective aims ofObjective aims ofAndrogen Replacement Therapy Androgen Replacement Therapy

(ART)(ART)

improved quality of lifeimproved quality of life increase bone density (5-12% p.a.)increase bone density (5-12% p.a.) suppression benign breast diseasesuppression benign breast disease reduction of the incidence of breast reduction of the incidence of breast

cancercancer maintain the cardioprotective effect maintain the cardioprotective effect of of ERTERT improved muscle strength (skeletal improved muscle strength (skeletal and and myocardial)myocardial)


Side Effects Side Effects ♀♀

evening restlessnessevening restlessness excess libidoexcess libido nightmaresnightmares possible relationship possible relationship

disruptiondisruption facial greasiness and facial greasiness and acneacne male type scalp hair male type scalp hair lossloss facial hairfacial hair


Interpretation of blood Interpretation of blood testtest

blood best taken in the morningblood best taken in the morning assay is not very accurateassay is not very accurate misleading to do only total misleading to do only total testosteronetestosterone always request- always request- “testosterone/SHBG”“testosterone/SHBG” only free/active testosterone is only free/active testosterone is relevantrelevant control of the SHBG allows the effect control of the SHBG allows the effect or or controls excess replacementcontrols excess replacement


Preparations Preparations ♂ & ♀♂ & ♀

Oral- andriolOral- andriolPatch- AndrodermPatch- AndrodermInjections- sustanonInjections- sustanonImplants- crystalline testosteroneImplants- crystalline testosteroneTopical-Topical-locally made locally made (cetomagrocol aqueous (cetomagrocol aqueous cream cream not not ointment) 2-5%ointment) 2-5%

or as Andro-Feme/ Andromen 1-10%or as Andro-Feme/ Andromen 1-10%


Oestrogen and Oestrogen and Testosterone Testosterone

ImplantsImplants

Insertion techniqueInsertion techniqueDr Rob BaberDr Rob Baber

North Shore Menopause North Shore Menopause ClinicClinic

4mins 50secs4mins 50secs


There is very little data on There is very little data on the human femalethe human female

There has been a data There has been a data collection from my practice, collection from my practice, undertaken on 512 women undertaken on 512 women

over 12 years.over 12 years.


My data is currently under My data is currently under continuing biostatistical analysis continuing biostatistical analysis

withwithThe National Institute of HealthThe National Institute of Health

Bethesda, Maryland, USA.Bethesda, Maryland, USA.in an attempt to correlate the in an attempt to correlate the epidemiology with the basic epidemiology with the basic

sciencescience

While my conclusions are therefore While my conclusions are therefore predominantly derived from my own predominantly derived from my own clinical observations, there is current clinical observations, there is current

intense interest from the basic intense interest from the basic scientists.scientists.


This analysis will focus mainly on This analysis will focus mainly on the prevention of breast cancer the prevention of breast cancer

but must include the parameters but must include the parameters ofof

HDL/LDL cholesterolHDL/LDL cholesterol

Bone densityBone density

in addition toin addition to

Breast cancerBreast cancer


Breast cancer resultsBreast cancer resultsStudy group(ERT+ART)Study group(ERT+ART) 77 breast cancersbreast cancersExpected incidence ERT only)Expected incidence ERT only) 12(14) “ “12(14) “ “

HoweverHoweverthe 10-year breast cancer ‘free survival rate’ for the 10-year breast cancer ‘free survival rate’ for patients in the trial waspatients in the trial was <<97.41%.(no. reduced 97.41%.(no. reduced from 8 to 7)from 8 to 7)

(95% c.i. 95.5-99.29%)(95% c.i. 95.5-99.29%)

Compared toCompared tothe the expectedexpected rate of rate of 97.52%.97.52%.

It would appear then that the survival from the It would appear then that the survival from the diagnosis breast cancer did not differ from that of the diagnosis breast cancer did not differ from that of the South Australian population at large of whom 44.3% South Australian population at large of whom 44.3%

were taking oestrogens butwere taking oestrogens but

may be shown to be reduced to statistical may be shown to be reduced to statistical significance when compared to a significance when compared to a

population of 100% oestrogen userspopulation of 100% oestrogen users..


Bone densityBone density

The initial improvement The initial improvement in bone density of only in bone density of only 3.1% in either area fell 3.1% in either area fell short of expectation as short of expectation as did the overall loss.did the overall loss.

Declining densities in Declining densities in smaller numbers was smaller numbers was attributed to non- attributed to non- responders to HRTresponders to HRT

1

1.01

1.02

1.03

1.04

1.05

1.06

1 2 3

Lumbar Spine Density

BM

D

mean

0.72

0.73

0.74

0.75

0.76

0.77

1 2 2

Hip Density

BM

Dmean

Change in Hip Density

Change in Lumbar Density


CholesterolCholesterol It would appear that It would appear that

there was no serious there was no serious adverse effect by adverse effect by the testosterone on the testosterone on these two markers.these two markers.

The mean levels The mean levels while varying over while varying over time, would be time, would be acceptable.acceptable.

3.45

3.5

3.55

3.6

3.65

3.7

3.75

3.8

3.85

Year0-2

Year2-4

Year4-6

Year6-8

Year8-10

mean LDL

LDL Cholesterol

1.4

1.45

1.5

1.55

1.6

Year0-2

Year2-4

Year4-6

Year6-8

Year8-10

mean HDL

HDL Cholesterol


The Male MenopauseThe Male Menopause

Good news and bad Good news and bad news!news!

The bad news is that the male The bad news is that the male menopause does exist…it is a menopause does exist…it is a reality and should be taken reality and should be taken

seriously...seriously...


The good news is The good news is that it is that it is

synchronous withsynchronous with

Prof. David PurdieProf. David Purdie

deathdeath!!


Testosterone can be Testosterone can be dangerous stuff!dangerous stuff!


Partial androgen Partial androgen deficiencydeficiency““PADAMPADAM””

should be distinguished from should be distinguished from absolute deficiency (agonadism, absolute deficiency (agonadism, Klinefelter’s, haemochromatosis, Klinefelter’s, haemochromatosis, pituitary tumours etc.)pituitary tumours etc.)

multiple aetiologies multiple aetiologies (alchohol, obesity, stress, aging (alchohol, obesity, stress, aging etc.)etc.)


Symptom complexSymptom complex

Precisely the same as for Precisely the same as for women except for breast women except for breast soreness and vulval skin soreness and vulval skin problemsproblems

suggestion that suggestion that cholesterol profile may be cholesterol profile may be improvedimproved

expectation that expectation that osteoporosis will be improvedosteoporosis will be improved


ObesityObesity

Appetite results from the expression of neuropeptide Y by the Appetite results from the expression of neuropeptide Y by the hypothalamushypothalamus Leptin is expressed as a function of the ‘ob gene’ in the fat Leptin is expressed as a function of the ‘ob gene’ in the fat depositsdeposits Leptin induces negative feedback on neuropeptideYLeptin induces negative feedback on neuropeptideY

Testosterone decreases the production Testosterone decreases the production of leptin and may therefore increase of leptin and may therefore increase appetiteappetite

This may be overcome by an increase in This may be overcome by an increase in B.M.R.B.M.R.


A.R.T. and CADA.R.T. and CAD

No improvement in CAD rates for No improvement in CAD rates for offspring of fathers (white males) with offspring of fathers (white males) with premature coronary deathpremature coronary death Low endogenous testosterone Low endogenous testosterone correlates with increased coronary ratescorrelates with increased coronary rates Disagreement about effect on Disagreement about effect on HDL/LDL and triglycerides- ? transient HDL/LDL and triglycerides- ? transient benefit- ? result of oestrogen production benefit- ? result of oestrogen production by aromatisationby aromatisation No change in carbohydrate No change in carbohydrate metabolismmetabolism


A.R.T. and A.R.T. and NeuropsychologyNeuropsychology

General anabolic and energising General anabolic and energising effecteffect

e.g. high dose ART to depressed males e.g. high dose ART to depressed males improves affectimproves affect ? A degree of aromatisation of ? A degree of aromatisation of testosterone to oestradiol centrally testosterone to oestradiol centrally (catechol oestrogens)(catechol oestrogens) Oestrogen displaces albumen bound Oestrogen displaces albumen bound tryptophane (the precursor of serotonin), tryptophane (the precursor of serotonin), effectively increasing serotonin uptakeeffectively increasing serotonin uptake


Suggested Suggested ManagementManagement

deal with lifestyle issues:deal with lifestyle issues: dietary control (central obesity and dietary control (central obesity and

hyperinsulinism)hyperinsulinism) substance abuse (drugs, alchohol, substance abuse (drugs, alchohol,

smoking)smoking) exercise and stress reductionexercise and stress reduction

trial of testosteronetrial of testosteroneandriol, androderm, andromen or testosterone andriol, androderm, andromen or testosterone

implantimplant

Correct both and look for spontaneous Correct both and look for spontaneous recoveryrecovery


Beware Beware thethe

prostate!prostate!!!

pumpkipumpkinn


SomethinSomething to g to

aspire aspire to…to…


Can we be Can we be seen to be seen to be

producing a producing a long living long living generationgeneration

ofof

superwomensuperwomen

(and men-?)(and men-?)

Ultimate Ultimate objectiveobjective

Testosterone replacement

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