Sunday November 30, 2008
Shrinking willies
By DATUK PROF TAN HUI MENG and ASSOC PROF ZULKIFLI MD ZAINUDDIN
Late onset hypogonadism (LOH) is a very real prospect for men as they grow older.
MEN in their 50s experience a decline of their “qi” in the kidneys, liver, ligaments and brain. This is quoted in the 2,500-year-old book, Chinese Internal Medicine.
Late onset hypogonadism (LOH) or testosterone deficiency syndrome (TDS) is currently defined as a symptom resulting from age-related decline in testosterone levels in men. The common clinical signs and symptoms include abnormal body composition (increase body fat over muscle), abnormal bone mineral density, decline in cognition (brain function), memory loss, irritability, mood swings, decline in sexual desire and function, and declining strength and energy.
Comparing men with normal and low testosterone levels, a study carried out in the US found that two-thirds (66%) of men with low testosterone will complain of one or more of the following symptoms: decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality or decline in general feeling of well being.
Overall, the prevalence of men above 40 years suffering from LOH or TDS ranges from 10 to 50%. Two Malaysian studies (The 2003 PJ Men’s Health Study and The 2006 Subang and Kelana Jaya Men’s Health Research) confirmed a prevalence of 20% in men above 40 years of age.
Dire consequences
The potential consequences of LOH are not just confined to declining quality of life, declining sexual function or declining mental function, irritability or depression, but include life threatening consequences of male osteoporosis, metabolic syndrome, diabetes mellitus and cardiovascular disease.
Osteoporosis and bone fractures are not just a female disease. About 30% of hip fractures occur in men, and the prognosis or after-effects are bad. About 25% of men with hip fracture die in the short term, another 25% die in the longer term and only 20% of them return to their former quality of life. The majority of those who survive need assistance with the activities of daily living.
Studies on men’s health
One of the most renowned study on men’s health and ageing, the Massachusetts Male Aging Study, quoted that men in the lowest quarter (25%) of testosterone levels had a 2.64 relative risk of developing metabolic syndrome after adjustment for age, BMI, and metabolic syndrome score (high BP, self-reported diabetes mellitus, low HDL-cholesterol, waist circumference of more than 40 inches, smoking).
In our 2006 Subang and Kelana Study involving 1,046 men (40 years and above), about one third of these urban men were found to have metabolic syndrome (MS). MS is a serious medical condition as men with MS have a three-fold increased risk of cardiovascular events and five-fold increased risk of developing diabetes mellitus.
Our Malaysian research clearly showed that men with low total testosterone levels (<11.0nmol/L) have about a 2.25 higher chance of being diagnosed with metabolic syndrome. Our analysis on these cohort of Malaysian men staying in Subang and Kelana Jaya also showed that those who have MS have more than a two-fold higher chance of suffering from erectile dysfunction (ED).
The Subang and Kelana Jaya research data have been confirmed by numerous studies worldwide.
Currently, low testosterone levels in men is considered an early marker for disturbance in glucose metabolism, and the subsequent development of diabetes and the metabolic syndrome.
Overall, men in the lowest quarter of free testosterone levels have four times more the risk of diabetes compared with men in the highest quarter.
These findings of may explain the results of several studies linking testosterone levels and the development of cardiovascular related mortality, all-cause mortality and cancer mortality. The latter is probably associated with obesity-related cancers.
A study done in Seattle and published in the Archives of Internal Medicine (Aug 2006) showed that men with low testosterone levels had an increased mortality risk of 88% greater than men with normal testosterone levels. This result is arrived at after adjusting for other factors like age, medical morbidities, BMI, race and other clinical factors.
Another study evaluating the relationship between testosterone and all-cause mortality found that men in the lowest quartile were 40% more likely to die than those with higher levels of testosterone.
These findings hold true regardless of age, lipid levels and other variables.
A third study, published by the Cambridge, UK, study group involving 11,000 patients aged 40-79 years followed over eight years, concluded that testosterone levels at baseline were inversely and significantly associated with mortality from cardiovascular disease, cancer and all causes. The authors also concluded that after adjustment for variables, an increase of 6nmol/L of serum testosterone was associated with a 81% decrease in overall mortality.
The American HIM study showed that men with low testosterone levels were more likely to report a higher prevalence of hypertension, hyperlipidaemia, diabetes mellitus, obesity and respiratory disease.
Our Klang Valley studies also confirmed that men with abnormal testosterone (<11nmol/L) were found to be at higher risk of obesity (measured by BMI or waist circumference), self-reported hypertension, diabetes mellitus, abnormal serum cholesterol and high blood sugar level.
Screening for low testosterone
As the manifestation of testosterone deficiency syndrome is generally a slow process and can occur at varying ages, doctors need to be aware of the conditions. The symptoms of TDS are generally non-specific and the onset can be imperceptibly gradual.
Doctors need to identify men who should undergo screening for TDS. These include men with symptoms of decreased sexual function, feeling depressed, irritability, fatigue or lack of vigour, and less commonly, symptoms of sleep disturbance, lack of concentration or decline in cognitive function, memory loss or hot flushes.
Men at risk of TDS also include patients with cardiovascular disease, diabetes, obesity (especially abdominal obesity) and chronic illnesses such as renal failure and HIV.
Generally, the earliest symptoms, which are also the commonest, are lack of libido and loss of vigour, and these symptoms may occur in men with testosterone levels between 12 and 15nmol/L.
Symptoms of hot flushes and erectile dysfunction due to low testosterone are often seen only when testosterone levels decline to very low levels (below 8nmol/L).
In our Klang Valley Study, we used a screening questionnaire called the Aging Male Symptoms’ scales (AMS) and other scales to detect men with ED, depression, prostatic disease, and men with metabolic syndrome. Our data showed definite statistical differences in men who have a high score of AMS (>27 total score) for the above condition compared with men with low AMS score.
This screening tool can be used to detect men with low testosterone levels and overall ageing problems.
Men who suspect they have testosterone deficiency syndrome are invited to fill up the AMS questionnaire. If the score is more than 27, and if you want to participate in our study, you may want to call the following: Jeya at 016-2817650, Jenny at 013-2341488 or Shirley at 012-6639965 for an appointment to have your blood tested for testosterone levels.
References:
1. Stellato RK et al (2000). Diabetes Care; 23(4): 490-494
2. Oh JY et al (2002). Diabetes Care; 25(1):
55-60
3. Laaksonen DE et al (2004). Diabetes Care;
27 (5): 1036-41
4. Muller M et al (2005). J Clin Endocrinol Metab; 90(5): 2618-23
5. Kupelian V et al (2006). J Urol; 176(6):
2584-8
6. Selvin E et al (2007). Diabetes Care; 30(2): 234-238
7. Shore MM et al (2006). Arch Intern Med; 166(15): 1660-5
8. Laughlin GA et al (2007). J Clin Endocrinol Metab; 93(1): 68-75
9. Khaw KT et al (2007). Circulation; 116(23): 2694-701
> This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public.
The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.
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