Secrets of Abang Sado : Effects of testosterone therapy. Azraai Nasruddin

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1 + Secrets of Abang Sado : Effects of testosterone therapy Azraai Nasruddin

2 + Testosterone Testosterone : Steroid hormone - Made primarily by the testicles in males - Small amounts produced by the adrenal glands in both sexes, and small amount in ovaries of women - Associated with masculinity; symbol of youth, fertility and strength in men

3 + Testosterone Testosterone expression in the fetus Results in development of male sexual organs May program the brain and future behaviour Neonatal surge in testosterone Priming of sexual organs for future growth and maturation Inprinting of sexual orientation and behaviour Increase in testosterone during puberty Secondary sexual characteristics : armpit and pubic hair, deepening of voice, penile enlargement Growth spurt

4 + Testosterone Peak levels during late puberty / early adulthood, gradually decline with ageing after the age of 40

5 + Testosterone

6 + Testosterone Regulation of testosterone levels Brain stimulates production of testosterone AND sperm by testes The brain senses the amount of testosterone produced The various signalling hormones enable dynamic control of testosterone levels from hour-to-hour and from day-to-day

7 + Diurnal variation of testosterone

8 + Testosterone Serum testosterone levels in men following coronary artery bypass graft surgery

9 + Testosterone

10 + Testosterone Impact of obesity and diabetes on testosterone decline over time

11 + Testosterone levels Change with age Change with time of day Change with illness Acute illness Chronic illness Change with obesity To interpret the significance of a low testosterone level requires information : when it was taken the circumstances of the patient at the time of the blood test

12 + Testosterone levels Not always easy to know if it is abnormally low

13 + Testosterone therapy Who? Why? When? How? Side-effects? Should ageing men take testosterone?

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15 + Testosterone Testosterone is converted into Estradiol in fat cells by the enzyme Aromatase - Estradiol is the primary sex hormone in females

16 + Not always Sado! Glandular Breast enlargement (gynaecomastia) is an uncommon / rare side-effect of testosterone therapy Excessive testosterone / anabolic steroids Obese men

17 + Testosterone :fertility Normal Brain stimulates production of testosterone AND sperm by testes Testosterone use High levels of testosterone sensed by brain Switches off stimulation to testes Result : High testosterone but NO sperm

18 + Badan Sado tapi tembak peluru kosong Testosterone therapy at high doses lead to Suppression of sperm production Atrophy (shrinkage) of testes with long-term use Occasionally permanent

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21 + Testosterone boosters D-Aspartic Acid Vitamins B Complex, D3, K2 Ginseng Fenugreek Mucuna Pruriens Oyster extract Tribulus Terrestris Trace minerals Zinc, Selenium Tongkat Ali

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24 + Effect of high dose testosterone Gave healthy men either placebo or 6 times the usual dose of testosterone for 10 weeks (600mg injection every week!!) Testosterone levels in the blood were increased by about 5-6 times the normal levels Muscle strength increased by about 20% Muscle size increased by about 10-15% Haemoglobin and Red blood cells increased slightly HDL (good cholestrol) decreased by 10%

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27 + 12 weeks 1 year

28 + Steroid cocktail

29 + Testosterone Taking testosterone is unlikely to make you SADO (unless you take huge doses and do significant weight training) Testosterone boosters claims of many online products are not supported by evidence : either claims are EXAGGERATED or contains actual testosterone/anabolic steroid compounds so beware!

30 + Adverse effects of supraphysiological testosterone Acne Jaundice, liver impairment liver failure Testicular atrophy (shrinkage) Azoospermia (infertility) either temporary or long-term Reduced HDL cholesterol (increased cardiovascular risk) Psychological dependence N Engl J Med Mar 14;334(11):

31 + Testosterone therapy in elderly men what are the issues? Patient awareness / reluctance to seek medical assistance Who to treat? Benefits and Potential Harm Safety How to treat and monitoring treatment

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33 + Who to treat? Testosterone levels should be checked in men who present with symptoms or signs of testosterone deficiency OR has a condition which is associated with testosterone deficiency Testosterone therapy should ONLY be considered in men with low testosterone levels

34 + Diagnosing testosterone deficiency What was the blood level of testosterone? What time of day was it taken? Has it been performed at least twice? Was it done during acute illness / hospitalisation? Does the patient have any chronic illnesses?

35 + Diagnosing testosterone deficiency What was the blood level of testosterone? Very low investigate for any diseases that may cause hypogonadism Slightly low does repeat test show consistent result? Does the patient have any symptoms of low testosterone? (Low libido, Erectile dysfunction, Fatigue) What time of day was it taken? Should be performed in the morning testosterone levels vary with time of day, with peak levels in the morning Has it been performed at least twice? Testosterone levels can fluctuate. Needs to be consistently low Was it done during acute illness / hospitalisation? Testosterone usually falls to significantly low levels during acute illness Does the patient have any chronic illnesses? Low testosterone may be seen in patients with underlying chronic illnesses

36 + Diagnosing testosterone deficiency Distinguishing clearly low testosterone levels from mild/borderline/slightly low testosterone levels Very low testosterone levels : evidence of benefit of treatment Slightly low testosterone levels :? Low testosterone is a marker of chronic illness Testosterone levels vary with time of day (peak in the morning) diurnal variation There exists difficulties with laboratory measurement of testosterone Testosterone is mainly bound to carrier proteins in blood. Most labs measure total testosterone, not free

37 + Low testosterone in elderly men Partial Androgen Deficiency of the Ageing Male (PADAM) OR Late-onset Hypogonadism (LOH) Lowish testosterone levels associated with symptoms of low testosterone with no obvious underlying cause

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41 + Should an elderly man take testosterone? STEP 1 : Should all elderly men take testosterone? No. Consider only if testosterone levels are low

42 + Should an elderly man take testosterone? STEP 2 : Should all elderly men with low testosterone levels take testosterone? No. Establish whether has symptoms of low testosterone. Establish whether slight low, or very low testosterone levels. Establish whether test repeated and done in the morning. Establish whether has significant frailty/critical illness

43 + Should an elderly man take testosterone? STEP 3 : Should an elderly man who has slightly low early morning testosterone levels on multiple occasions, with symptoms of low testosterone, and who is not frail or critically ill, take testosterone? Probably. Counsel patient regarding possible benefits and risks of taking testosterone. Check for any existing prostate disease

44 + Should an elderly man take testosterone? STEP 4: Has he discussed with his partner? Testosterone therapy has impact not just on the man, but also his partner

45 + Should an elderly man take testosterone? STEP 5 : Should an elderly man who has slightly low early morning testosterone levels on multiple occasions, with symptoms of low testosterone, and who is not frail or critically ill, and who wishes treatment after having been counselled on risks/benefits, and with no evidence of significant prostate disease take testosterone? Yes. Discuss a trial of testosterone therapy Agree on aim of therapy, and duration of trial. Monitor for improvement in symptoms and any adverse effects of therapy

46 + Trial of therapy 3-6 month trial Check serum testosterone level Assess for any symptomatic benefits Improvement in libido Improvement in erectile function Improvement in energy levels (Improvement in questionnaire scores) Monitor for any adverse effects Increase in haematocrit (Red blood cell concentration in blood) Increase in PSA Prostatic symptoms

47 + Available testosterone products

48 + Not available in Malaysia

49 + Does it work?.. Sexual function Physical Strength Longevity Mood

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54 + Sexual Activity

55 + Walking ability

56 + Fatigue

57 + Conclusions Testosterone therapy improves overall sex drive, sexual activity and erectile dysfunction in older men with low testosterone AND low libido No beneficial effect in men with normal testosterone and no symptoms Effects of testosterone on physical function in older men with LOH is unclear. Some evidence of improvement in muscle strength but no evidence of improvement in actual function / disability / risk of fractures / falls Long-term effects on Cardiovascular disease and prostate remains unclear (small study, short-term)

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62 + Is it safe?

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64 + November 6, 2013

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67 + Testosterone No testosterone Cardiac events at 6 months 21.6% 4.8%

68 + 29% increased risk with testosterone therapy

69 + No difference in narrowing of blood vessels with testosterone therapy

70 + 18% reduced heart attack risk with testosterone 30% reduced stroke risk with testosterone

71 + Testosterone and Heart In men without previous heart attack/stroke, normalising testosterone levels may be beneficial Overall, testosterone therapy is probably safe However, in frail men with significant chronic diseases, testosterone therapy may be associated with harm. Long-term prospectives studies still required to fully answer the question of cardiovascular safety

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73 + Testosterone and Prostate No evidence that testosterone therapy causes prostate cancer Testosterone therapy may increase prostate gland volume Possible worsening of prostatic symptoms in patients existing enlarged prostate Usually does not cause problems Potential harm if testosterone therapy given to patients with undiagnosed prostate cancer One of the treatments for prostate cancer is to significantly lower testosterone levels Screening for possible prostate cancer is recommended BEFORE starting testosterone therapy in older men PSA blood test Prostate examination (digital rectal examination)

74 + Alternatives to testosterone treatment? Weight loss Exercise Natural remedies PDE5 inhibitors (Viagra, Cialis)

75 +

76 + Summary Discussed function of testosterone How testosterone levels fluctuate Diagnosing testosterone deficiency Benefits and Risks of testosterone therapy in older men Secrets of Abang Sado..

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