Testosterone Replacement for Men and Women

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Testosterone ReplacementforMen and Women
Robert A. Jones Memorial Medical
Centre Adelaide South Australia
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Presenting from the Premises of Port Power
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While testosterone replacement is being used in
women with good effectit is used without the
approval of the Australian Drug Evaluation
Committeeand the individual practitioner must
take individual responsibility for its use
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The human ovary produces more testosterone than
oestrogen- weight for weight

• The postmenopausal ovary continues to produce
  testosterone after the cessation of follicular
  activity cuts off the supply of oestrogen

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As the ovary fails, it continues to produce
testosterone and perhaps in increased amountsfor
a variable number of years.This is the so
called continuation of ovarian function
postmenopausally.i.e. progressive
androgenisation!
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With the introduction of HRT (oestrogen only or
ERT), testosterone status falls to zero.This is
due to two factors
? cessation of production from the ovary by
suppression of LH? binding of testosterone by
SHBG
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It follows therefore, that any woman taking
oestrogen or producing excess oestrogens is
relatively or absolutely testosterone
deficiente.g. the oral contraceptive multicys
tic ovary oestrogen replacement
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Oestrogen and progesterone are the mainstay of
ERT.Testosterone may still be viewed as
the,Cinderella of the hormonal ballbut she
got to marry Prince Charming!
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Symptoms

• Testosterone replacement is generally regarded as
  indicated for loss of libido
• (by a predominantly male profession)
• .. and while this may be true, other symptoms
  are of greater importance.

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Indications for testosterone replacement

• Symptoms
• Vulval discomfort
• ? Voiding dysfunction
• Painful benign breast disease
• ? Prevention of breast cancer
• Osteoporosis

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Symptoms relieved

• Variable mood state-tearful or aggressive
• Loss of energy and stamina
• Impaired concentration and memory
• General skin and scalp hair dryness
• Loss of sexual arousability
• Painful breasts
• Vulval skin dryness/ discomfort/ itching
• Voiding disorder ?
• Restored/ increased muscle strength

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Odds and ends

• may improve tachycardias
• seems to suppress petit mal
• (despite warnings on the P.I.)
• some headaches improve
• neck and back pain
• improves athletic competition
• improved sleep quality
• increases insulin sensitivity
• lichen sclerosis

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Objective aims ofAndrogen Replacement Therapy
(ART)

• improved quality of life
• increase bone density (5-12 p.a.)
• suppression benign breast disease
• reduction of the incidence of breast
  cancer
• maintain the cardioprotective effect of
  ERT
• improved muscle strength (skeletal and
  myocardial)

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Side Effects ?

• evening restlessness
• excess libido
• nightmares
• possible relationship disruption
• facial greasiness and acne
• male type scalp hair loss
• facial hair

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Interpretation of blood test

• blood best taken in the morning
• assay is not very accurate
• misleading to do only total testosterone
• always request- testosterone/SHBG
• only free/active testosterone is relevant
• control of the SHBG allows the effect or
  controls excess replacement

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Preparations ? ?

• Oral- andriol
• Patch- Androderm
• Injections- sustanon
• Implants- crystalline testosterone
• Topical-locally made (cetomagrocol aqueous cream
  not ointment) 2-5
• or as Andro-Feme/ Andromen 1-10

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Oestrogen and Testosterone Implants

• Insertion technique
• Dr Rob Baber
• North Shore Menopause Clinic
• 4mins 50secs

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There is very little data on the human
femaleThere has been a data collection from my
practice, undertaken on 512 women over 12 years.
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While my conclusions are therefore predominantly
derived from my own clinical observations, there
is current intense interest from the basic
scientists.
My data is currently under continuing
biostatistical analysis withThe National
Institute of HealthBethesda, Maryland, USA.in
an attempt to correlate the epidemiology with the
basic science
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This analysis will focus mainly on the prevention
of breast cancer but must include the parameters
of
? HDL/LDL cholesterol ? Bone density in addition
to ? Breast cancer
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Breast cancer results

• Study group(ERTART) 7 breast cancers
• Expected incidence ERT only) 12(14)
• However
• the 10-year breast cancer free survival rate
  for patients in the trial was lt97.41.(no.
  reduced from 8 to 7)
• (95 c.i. 95.5-99.29)
• Compared to
• the expected rate of 97.52.
• It would appear then that the survival from the
  diagnosis breast cancer did not differ from that
  of the South Australian population at large of
  whom 44.3 were taking oestrogens but
• may be shown to be reduced to statistical
  significance when compared to a population of
  100 oestrogen users.

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Bone density
Change in Lumbar Density

• The initial improvement in bone density of only
  3.1 in either area fell short of expectation as
  did the overall loss.
• Declining densities in smaller numbers was
  attributed to non- responders to HRT

Change in Hip Density
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Cholesterol
HDL Cholesterol

• It would appear that there was no serious
  adverse effect by the testosterone on these two
  markers.
• The mean levels while varying over time, would
  be acceptable.

LDL Cholesterol
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The Male Menopause
Good news and bad news! The bad news is that the
male menopause does existit is a reality and
should be taken seriously...
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The good news is that it is synchronous with
death!

• Prof. David Purdie

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Grumpy old men
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Testosterone can be dangerous stuff!
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Partial androgen deficiencyPADAM

• should be distinguished from absolute deficiency
  (agonadism, Klinefelters, haemochromatosis,
  pituitary tumours etc.)
• ? multiple aetiologies (alchohol, obesity,
  stress, aging etc.)

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Symptom complex

• ? Precisely the same as for women except for
  breast soreness and vulval skin problems
• ? suggestion that cholesterol profile may be
  improved
• ? expectation that osteoporosis will be improved

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Obesity

• Appetite results from the expression of
  neuropeptide Y by the hypothalamus
• Leptin is expressed as a function of the ob
  gene in the fat deposits
• Leptin induces negative feedback on
  neuropeptideY
• Testosterone decreases the production of leptin
  and may therefore increase appetite
• This may be overcome by an increase in B.M.R.

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A.R.T. and CAD

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

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A.R.T. and Neuropsychology

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

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Suggested Management

• deal with lifestyle issues
• ? dietary control (central obesity and
  hyperinsulinism)
• ? substance abuse (drugs, alchohol,
  smoking)
• ? exercise and stress reduction
• trial of testosterone
• ?andriol, androderm, andromen or testosterone
  implant
• Correct both and look for spontaneous recovery

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Beware the
pumpkin
prostate!!
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Something to aspire to
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Ultimate objective
Can we be seen to be producing a long living
generation of superwomen (and men-?)