Testosterone Replacement Therapy for Aging Men

The number of men in the United States 65 years of age or older is projected to increase from 14.5 million in 2000 to 31.3 million in 2030. Approximately 30% of men aged 60-70 years and 70% of men aged 70-80 have low levels of testosterone in forms that the body can use (bioavailable; unbound; free). Testosterone is in a class of hormones known as androgens.

Hypogonadism is a clinical condition in which low levels of serum testosterone (bioavailable testosterone less than 60 ng/dl) are found in association with specific signs and symptoms, including diminished sex drive and sense of vitality, erectile dysfunction, depression, anemia, reduced muscle mass and bone density, increased fat mass, frailty, and osteoporosis. When hypogonadism occurs in an older man, the condition is often called andropause, or Androgen Deficiency of the Aging Male (ADAM).

Proper monitoring of laboratory values and clinical response are essential when prescribing testosterone replacement therapy.
A man may be considered hypogonadal at any age if total testosterone (bound and free) is less than 200 ng/dl. It is recommended that elderly men with symptoms of hypogonadism and a total testosterone level less than 300 ng/dl be started on hormone replacement.1

Bioavailable testosterone levels are significantly lower for depressed men, perhaps because an associated decrease in sexual function results in depression, irritability, and mood swings. Testosterone therapy might improve depressed mood in older men who have low levels of bioavailable testosterone.2,3

Osteoporosis-related fractures occur in 12% of all men over 50 years of age. Twenty-five percent of all hip fractures occur in men, and 33% of these patients die within one year of fracture. Gradual loss of testosterone is one of the major causes of osteoporosis in elderly men. Studies have reported beneficial effects of testosterone therapy on bone in older men, showing an increase in bone mineral density (BMD) and slowing of bone degeneration. Testosterone therapy in older men with low serum testosterone levels also increases lean body mass and decreases fat mass, improving physical performance and strength.4

Testosterone replacement therapy (TRT) has relieved symptoms and improved the quality of life for many men. TRT is well tolerated, and long term TRT appears to be a safe and effective means of treating hypogonadal elderly males, provided that frequent follow-up blood tests and examinations are performed.

The only absolute contraindication to androgen replacement therapy is the presence of prostate or breast cancer. Guidelines recommend that TRT should not be initiated in older men with PSA serum levels above the normal range. Testosterone should be used with caution in men with severe heart, kidney or liver disease, increased red blood cell counts, and sleep apnea.5 Side effects of testosterone therapy can include mood swings, leg swelling, skin reactions, acne, alopecia, breast enlargement, and infertility. Liver toxicity has not been reported following testosterone administration using transdermal gels in physiologic doses.6 (Toxicity has occurred with methyltestosterone.)

Testosterone is well-absorbed from transdermal creams, gels, and lotions. A satisfactory response can be achieved with twice daily dosing. Compounded preparations can be very advantageous because:

• the exact amount of hormone needed by each man can be applied as a single dose
• there is no need to shave the scrotum to apply one or more patches
• there is no skin irritation from patch adhesive.

A healthy lifestyle is associated with higher hormone levels, and higher hormone levels seem to induce a more active, healthier lifestyle. When levels of hormones such as testosterone decline, people become less active and gain weight, which results in hormones being stored in fat and unavailable to meet the body’s demands. Lack of exercise, excessive alcohol use, and many diseases can reduce the levels of bioavailable hormones. For optimal results, it is vital that hormone replacement therapy be combined with adequate exercise, proper nutrition, and appropriate use of supplements.

 References:
1 Am J Med. 2001 May;110(7):563-72.
2 J Clin Psychiatry. 2009 Jul;70(7):1009-16.
3 J Clin Psychopharmacol. 2009 Jun;29(3):216-21.
4 J Clin Endocrinol Metab. 2005 Mar;90(3):1502-10.
5  Ther Clin Risk Manag. 2009 Jun;5(3):427-48.
6 Expert Opin Drug Saf. 2004 Nov;3(6):599-606.

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