It is well known that total testosterone declines with age in men from 50-55 y. by 0.8-1.6% / year, while free testosterone starts to drop from 30-35 years at the rate of 2-3% per year. By age 70, a man’s testosterone level can drop by as much as 50 percent. The problem of testosterone decline is one of the most urgent in medicine. Today we know that males go into andropause with age, similar to the female menopause.
The reasons of this decline is in malfunction of the hypothalamus-pituitary- testicles axis (HPTA), as well as an increase in the concentration of sex hormone binding globulin.
Previously, it was believed that the role of testosterone is important only for secondary sexual characteristics, libido and in the production of sperm, but now it has been proven that this hormone affects almost all vital systems of the body. Testosterone acts on the genitourinary system, brain, muscle, bone, adipose tissue and skin cells. Recently it has been discovered that low testosterone levels increase the risk of diabetes. Besides testosterone is responsible for the blood supply to tissues, as low levels of testosterone can lead to impaired blood flow.
Clinical signs of andropause
Testosterone deficiency leads to disturbances in almost all systems and tissues. “memory is impaired, concentration of attention decreases, mental alertness is lost. The patient’s eyes seem to fade, the head and shoulders are lowered, the muscles become more sluggish, the abdomen enlarges, the chest becomes more like a woman’s. Due to the low testosterone level, the bones become fragile and skin gets thinner.
The main signs and symptoms of andropause are:
- Genitourinary disorders:
- decreased sex drive and erectile dysfunction
- decreased fertility
- frequent urination
- Vascular disorders:
- sudden hyperemia of the face, neck, upper body
- hot flashes
- fluctuations in blood pressure
- pain in the heart
- feeling short of breath
- Mental disorders:
- increased irritability
- fast fatigue
- weakening of memory and attention
- depressive conditions
- decrease in general health and performance
- Somatic disorders:
- decrease of muscle mass and strength
- fragility of bones
- thinning of the skin
- decrease in the level of total and bioavailable testosterone
- increased levels of estradiol and sex hormone binding globulin
- increased cholesterol
Age of andropause
The likelihood of andropause onset increases with age.
Age of Andropause
- 40-49 years 2-5%
- 50-59 years 6-40%
- 60-69 years 20-45%
- 70-79 years 34-70%
- over 80 years 90%
Side effects of anabolic steroids in old age
For older athletes, the risk of hypertension, vascular atherosclerosis, myocardial ischemia and malignant tumors (prostate, mammary glands, intestines, etc.) is much higher and increases with age. Since anabolic steroids increase the rate of cell division, it was previously believed that these drugs can increase the frequency of mutations. If in youth the number of mutant cells is lower, and the immune system is more active, the body copes with this problem. But after 40 years, the immune system weakens, the number of mutated cells begins to grow rapidly – as a result, tumors may appear. However, modern experimental data deny the carcinogenic effect of steroids, with the exception of the prostate and liver (in the case of the use of hepatotoxic 17-alkylated drugs).
Swelling and hypertrophy of the prostate
The use of 5-alpha-reductase inhibitors is highly effective in benign prostatic hyperplasia (BPH). In this regard, it has been hypothesized about the possible negative effect of exogenous androgens on the prostate gland. At the same time, it was noted that most often these diseases occur in old age, i.e. despite the decrease of androgens levels.
Numerous molecular studies have shown that the main pathogenetic factor in the development of BPH is an intracellular increase in 5-alpha-reductase activity, leading to an increase in the level of 5-alpha-dihydrotestosterone in prostate cells, and not an increased plasma testosterone level.
Thus, BPH is not considered to be a contraindication to androgen replacement therapy. Many studies have not found a correlation between plasma testosterone levels and the incidence of prostate cancer.
In the presence of prostatic hypertrophy, testosterone is used in combination with 5-alpha-reductase inhibitors (Finasteride) as hormone replacement therapy. This somewhat reduces the effectiveness of the cycle, but significantly reduces the development of androgenic side effects, including on the prostate gland. In addition, it is recommended to perform a preventive examination 2 times a year, as well as laboratory measurement of prostate specific antigen.
Scalp hair loss is also associated with an increase in DHT, so combination therapy with Finasteride or Dutasteride can effectively prevent hair loss.
Suppression of testosterone secretion
As you know, with the use of androgens, it is possible to suppress the endocrine function of the testes and spermatogenesis through the mechanism of negative feedback. This effect is especially noted with long-term use of anabolic steroids in high dosages.
At the same time, intake of 240 mg of testosterone undecanoate (ANDRIOL) for 6 months was not accompanied by a decrease in the initial normal level of spermatogenesis. Other studies also did not show significant suppression of normal gonadotropin levels or endogenous testosterone with this drug, which is likely due to the short half-life of testosterone undecanoate.
Thus, adequate post-cycle therapy can eliminate this complication if andropause has not yet occurred. After the onset of andropause, continuous hormonal therapy is recommended.
Due to the suppression of the secretion of gonadotropins by the feedback mechanism, with prolonged use of anabolic steroids, atrophy and desensitization of the testicles can develop. In other words, after discontinuation of exogenous testosterone, the testes do not restore the ability to secrete their own testosterone. Therefore, long cycles should be accompanied by gonadotropin.
Testosterone therapy often leads to an increase in hematocrit above physiological values due to the constant stimulation of erythropoiesis (associated with increased production of erythropoietin under the influence of androgens). Most authors recommend reducing the dose of steroids when hematocrit values are above 51% and discontinuation of the drug when the values are more than 54%.
A controversial issue is the effect of exogenous androgens on blood lipid levels. Traditionally, it is believed that the increased risk of atherosclerosis and coronary heart disease in men compared with women of reproductive age is associated with a negative effect of androgens on the lipid profile. However, several studies have shown that testosterone administration leads to a decrease in atherogenic VLDL and LDL levels, while anti-atherogenic HDL levels are relatively unchanged.
TRT for the elderly
The main drugs for androgen replacement therapy in men are testosterone esters. There are oral, injectable and transdermal drugs. Currently, C17-alkylated testosterone (methyltestosterone), which have toxic and carcinogenic effect on the liver when taken orally, are practically out of use. Growth hormone is gaining popularity, which is able to rejuvenate the skin, as well as strengthen joints and ligaments.
Testosterone Enanthate and Testosterone Cypionate are the most common testosterone in the United States. Thus, an adequate dosing regimen is intramuscular administration of the drug in a dose of 1 ml once every 3 weeks. Often, a replacement dose is prescribed within 3 months, followed by cancellation for up to 3 months.
Scientists are constantly looking for more perfect drugs. Now, for example, the injectable drug Nebido appeared, which needs to be injected four times a year. The drug provides a stable concentration of testosterone for three months: due to gradual release from the “oil depot”.
Testogels and testosterone patches are gaining popularity around the world, since they need to be applied on the skin once a day.
Relatively recently, a new form of testosterone administration was created – tablet under the tongue, or plates that are attached to the gums. These methods are undergoing clinical trials.