Andropause, an inappropriate term

Women would not be the only ones experiencing a decline in their hormonal activity with age. Even if the decrease in testosterone is not as brutal in man, it would not be without consequence. Is there a need for substitution treatment? Who to book? All these questions are at the heart of a lively debate.

DALA, your unforgiving universe

Lower libido, fatigue, increased cardiovascular risk, irritability, increased waist circumference ... All these symptoms common in mature men could hide a testosterone deficiency. During the last congress of the French Association of Urology (AFU), the specialists took stock of this controversial subject.

A diagnosis difficult to carry

Like women, would men see their hormones fall to their fifties? Much less brutal than the upset of menopause, age-related testosterone deficiency (ALAD) would translate into a progressive decrease in this hormone. Not a male fatality (unlike the menopause that affects all women), this slow transition allows most men to maintain their reproductive function until later in life. This is why the term DALA is preferred to that of andropause.

When to deal with

According to some studies, this decrease in testosterone would begin at the age of 30 years at 1 to 2% per year 1.2. But important personal factors play because some men will retain a high testosterone all their lives while others will have very low testosterone levels. Other causes can cause such a deficit: lesions of the testicles (trauma, surgical removal, irradiation, chemotherapy ...), hormonal disorders (certain diseases of the pituitary gland), certain drugs and genetic abnormalities

A difficult assessment of the benefit-risk balance

The number of men involved is the subject of controversial hypotheses. According to the report of the French Association of Urology 3, "at least 20% of men over 60 (...) and about 50% of those over 80 years have an abnormally lowered testosterone." Figures to be compared with the aging of the population. In the United States in 2010, those over 65 will represent 20% of men and even more in 2050 where the life expectancy of men should reach 82 years!

Produced by Leydig cells within the testicles, testosterone acts on many organs: muscles, vessels, liver, prostate, genitals, brain, bone, skin, hair, and so on. Settling insidiously, disorders are difficult to dissociate from the natural manifestations of aging.

During the congress of the French Association of Urology, Prof. Dominique Rossi of the CHU of Marseilles and Jacques Tostain of the CHU of Saint-Etienne reminds that the DALA can manifest itself by symptoms of banal appearance after 50 years

But it is neither obligatory nor frequent that all these manifestations are simultaneously present. The assimilation of these symptoms frequently associated with physiological aging could lead to an underestimation of the problem ... or to a medicalization of a natural phenomenon.

"Faced with these uncharacteristic symptoms, it is the concordance of these signs that will cause the doctor to think of a DALA, whose sexual problems cover only about a third of the cases," says Professor Rossi. But ultimately, only a hormonal assessment can confirm the diagnosis. Dosage should be done on an empty stomach in the morning between 7 am and 10 am, the time of day when testosterone levels are highest. Normal values ​​are usually between 3 and 10 ng / ml, but the results may depend on the laboratory and the results of other assays. In case of abnormally low results, the dosage should be repeated to confirm the permanence of the hormonal deficit. Additional assays are sometimes necessary to verify the functioning of the pituitary 4.

But again, the rub is hurting, since it is not easy to determine the threshold value of testosterone below which it makes sense to treat. The value of testosterone sufficient to maintain libido or muscle tissue could vary from one man to another ...

As the list of misdemeanors attributed to low testosterone levels (an increase in cardiovascular disease 5, a decrease in bone density 6), the justifications for hormone therapy remain open for debate. Br>

Already, many products offer different modes of administration of testosterone (tablets, oily and intramuscular injections, patches, gel ...). Despite this astonishing diversity, there is little scientific evidence to suggest that these hormonal supplements can help older men. Most studies are only extrapolations from studies conducted in young men with early testosterone deficiency (hypogonadism). 7,8

In addition to their low numbers, DALA studies advocate such treatment with restoration of libido, sleep, spatial memory, improved mood, reduced body fat, and increased Muscle mass and muscle strength 9,10,11 ... Knowing that this androgen deficiency is a usually permanent condition, the treatment would be a lifetime treatment. A time to be compared with the small decline on these products that does not exceed 4 years.

Side effects include increased red blood cell count, worsening sleep apnea, moderate increase in prostate size, and a risk of developing a prostate microcancer.
Currently, the long-term effects of androgen replacement therapy remain unknown, particularly with regard to prostate and cardiovascular risk. Stimulated by the dangers of HRT in menopause, some scientists fear that these treatments will encourage the occurrence of hormone-dependent cancers (whose growth is promoted by hormones). In humans, prostate cancer is androgen-dependent and high testosterone levels could rapidly advance micro-cancers. Consequences that could be countered by more regular screening

Such a prescription must therefore be made only after an analysis of the benefits and risks specific to each patient who must be clearly informed.

Men with a particular risk of prostate cancer (colored men, men over 40 years of age with prostate cancer relatives and fifty-year-olds will have to undergo specific screening before the treatment begins). - indicated to men with a history of prostate or breast cancers, this management requires strict supervision, conducted in consultation with a blood test (PSA), first at 3 months then at a rate Variable which will never be greater than 12 months, and the treatment may be interrupted at any time without any particular risk, other than a return to the initial situation.

While some speak of an under-diagnosis of DALA, others regret some blurred diagnostic criteria and a lack of retreat on the long-term effects of treatments. To remedy this, an observatory of the treated men could be set up. Its data could also help to identify the causes and risk factors for this hormonal deficiency.

But right now the mistake would be to fall into the "all hormone", which had dangerously prevailed around HRT in the 1990s. Many other factors affect the quality of aging, many of which are modifiable: balanced diet, lack of Smoking and alcoholism and regular physical activity ... Put on your sneakers, the ball is in your court!

1 - Hum Reprod Update 2002 Sept-Oct, 8 (5): 423-33; 2 - Pharmacotherapy 1999 Aug, 19 (8): 951-6; 3 - Press Conference at the 96th French Congress of Urology 4 - Andrology 2003,13,11-21; 5 - Heart 2003 Feb, 89 (2): 121-2; J Clin Endocrinol Metab 2003 Jan, 88 (1): 204-10; 20010000 27 Mar. Apr., 18 (2): 103-6; 10 - Neurology. 2001 J Clin Endocrinol Metab 1997 Jun, 82 (6): 1661-7

Sexual disorders with impaired libido, sexual activity, erectile function, pleasure and ejaculation deemed insufficient Functional symptoms such as asthenia and increased fatigability, sleep disorders but also hypersudation, Changes in body pattern: decreased muscle mass and strength, increased visceral fat, pubic and axillary depilation, testicular hypotrophy Character disorders: irritability or indifference, loss of esteem Self, lack of motivation and combativity, disorders of concentration, recent memory; The development of osteoporosis.