Articles

Men's Health Report: Andropause, Obesity, Depression, Diabetes, ED, and Prostate

By Pete Hueseman, R.Ph.

The obesity epidemic has contributed to an increase in comorbidities such as hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, sleep apnea, and respiratory problems. (1) In addition to such problems, men with obesity face an increased risk of prostate cancer, infertility, and erectile dysfunction. The possibility of life with any of these conditions should provide the needed impetus for men to lose weight. Pharmacists can help communicate the risks and reasons effectively.(2)

Low testosterone levels are established in clinical literature to be associated with elevated risk for heart disease, carotid atherosclerosis, dyslipidemia, angina and depression. A study published in Diabetes Care in 2004 demonstrated that low levels of androgens are significantly associated with measure of central adiposity in men. This study showed that the inverse association between testosterone and insulin resistance, independent of SHBG, was mediated through body fat. (3)

In late 2006, JAMA published a paper discussing the effects of low testosterone in men. The authors stated, low testosterone levels are associated with a host of symptoms and signs, which are estimated to affect between 2 million and 4 million men in the United States alone. These symptoms include decreased muscle mass and bone mineral density, decreased libido and energy; and increase fat mass, central obesity; insulin resistance, emotional irritability, and dysphoria. Low testosterone may also increase mortality. (4) Most of the health issues mentioned evolve naturally when men reach andropause, and the symptoms could be any of the above. Andropause is the "male menopause" that usually starts around the age of 50 when testosterone has had a sharp decline from earlier levels. Testosterone starts to decline at an average of 1% per year starting around 30 years of age.

In a recent article, low serum testosterone was defined as a total testosterone level of less than 250 ng/dL (8.68 nmol/L), or a free testosterone level less than 0.75 ng/dL (0.03 nmol/L), men with low testosterone level had a mortality rate of 35% over the 8-year study period compared with a mortality rate of only 20% among men with normal testosterone levels.(5) Most men with 300 to 400 ng/dL have a normal sexual desire and function. But men who have been depleted of testosterone at levels less than 200 ng/dL to 250 ng/dL for months or years will likely suffer from decreased sexual desire, sexual motivation, and erectile dysfunction. When men are given testosterone therapy, their sexual interest typically returns. They often have better erectile function, if no other significant intervening medical factors exist. Even men who use erectile drugs report more satisfactory erections after four to eight weeks of testosterone therapy. That is because testosterone provides nitric oxide, which enhances the effectiveness of erectile drugs.

Dietary modifications are essential in the weight loss process.(2) An individually planned diet that results in a deduction of 500 to 1,000 kcal/day will result in an average weekly weight loss of 1 to 2 pounds. In general, most men can be placed on a low-calorie diet that contains 1,200 to 1,600 kcal/day. Specific dietary recommendations endorsed by the National Heart, Lung, and Blood Institute (NHLBI) are summarized in Table 1.

Table 1. Low-calorie step 1 diet

Patients should try lifestyle modifications for at least 6 months before initiating drug therapy.(6) Pharmacotherapy is primarily indicated as an adjunct to lifestyle modifications in patients who have been unable to lose weight or maintain weight loss with conventional nondrug therapies.

Testosterone does metabolize into estradiol in the male. We try to keep men’s levels less than 32 pg/ml; if it goes above that, a man can get prostate swelling, and other complications. A possible therapy to prevent prostate problems, when using testosterone therapy, would be a low dose of Anastrazole (an aromatase inhibitor) to be taken along with the testosterone.