Considerable attention is being paid to the quality of life as men age—and why not? As men age, they still want to remain productive, active and, of course, healthy. Unfortunately, it seems that nature is cruel. For men, this cruelty starts immediately after college, when they begin to notice, ever so subtly, that the refractory period between their erectile events increases. As men enter their forties, they begin to notice that their erections have started to change, such that the erections may not be as rigid as they once were or do not seem to last as long. Some men even begin to lose that “every moment’s interest in sex” that seems to define their persona during youth. This change in sexuality, coupled with the other phenotypic evidence of aging, such as losing one’s hair and increasing one’s waistline, begs the question—what’s next? As most men who have already traveled that road know so well, it does not get any better. What men also have to look forward to with aging is an increasing sense of lethargy, occasional bouts of memory failure, recognition of no longer being a Samson, and, sometimes, depression. Yes, they can become grumpy, overweight, old men.
These aforementioned symptoms and signs are referred to as andropause or androgen deficiency of the aging man (ADAM). As men age, their testosterone levels—particularly their free testosterone levels—decrease. There are many reasons for this but, suffice it to say, this does occur in many men. If these symptoms of aging result from a decrease in testosterone levels, it makes sense that such men may benefit from exogenous androgen treatment. Many men opt for this treatment when confronted with their midlife changes because the evidence suggests that many of these afflictions of aging are ameliorated with androgen replacement.
Prostate-Specific Antigen Changes in Hypogonadal Men Treated with Testosterone Replacement
Gerstenbluth RE, Maniam PN, Corty EW, Seftel AD.
J Androl. 2002;23:922–926.
Like any medication, testosterone has certain side effects. Most troubling to physicians is whether exogenous androgen treatment induces the development of prostate cancer, because this cancer is an androgen-dependent tumor. Many investigators have addressed this issue in the past. Recently, Gerstenbluth and colleagues revisited this question in a study of 54 patients, with a mean age of 60 years, who received exogenous intramuscular androgen treatment and were followed for a mean of 30 months with digital rectal examinations (DREs) and prostate-specific antigen (PSA) tests. From a mean baseline of 1.86 ng/mL, PSA level rose to a mean of 2.82 ng/mL in these patients. In 6 patients, however, PSA rose to a level above 4.0 ng/mL; all 6 patients underwent prostate biopsy, and only 1 showed histologic evidence of prostate cancer.
The results of this study reinforce what most urologists should be doing today when a patient is placed on exogenous androgen treatment; that is, a DRE and baseline PSA test should be performed prior to initiating androgen therapy. A repeat PSA test should be done at 6 weeks to 3 months and every 6 months thereafter while the patient is receiving testosterone therapy. DREs should be performed semiannually during treatment. Any suspicious changes in the DRE or PSA level warrant a biopsy. If the biopsy is positive, androgen therapy should be withheld and appropriate therapy for the cancer entertained. If the biopsy is negative, informed consent should be provided to the patient describing the benefits and risks of continuing the androgen therapy, because prostate biopsy is not 100% sensitive in detecting prostate cancer. In instances in which the patient has benefited clinically from the androgen replacement, it is often possible to continue androgen treatment and repeat a biopsy within 3 to 6 months. In many men, treatment with androgen therapy has led to a marked improvement in quality of life, and the urologist should play a leading role in the diagnosis and treatment of andropause.