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ANDROPAUSE
- THE MALE MENOPAUSE
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Diagnosing
Hypodonadism In Males
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Diagnosing
androgen deficiency and other causes of Hypogonadism in aging
men (ADAM ) and other causes of Hypogonadism
A frank discussion of symptoms is essential to confirm androgen
deficiency in aging men (ADAM ) or to identify an alternative
cause of hypotestosteronemia. It is these symptoms (e.g. erectile
dysfunction, decreased libido, and reduced muscle mass) and
the degree, which they affect the patient's life that should
be taken in account. Since at times individuals with very
low levels of free and total testosterone are completely asymptomatic
while at other times patients with borderline low testosterone
levels maybe extremely symptomatic. This is why a extensive
clinical history is just as important to making the diagnosis
as the blood work.
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Metabolic
Hypogonadism
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Blood
work-up will reveal:
- elevated
estradiol
- elevated
SHBG
- Normal
to slightly decrease total testosterone
- decrease
free testosterone and %free testosterone
- normal
LH and FSH
- Decrease
T:E ratio
- Prolactin
should be normal. If elevated you need MRI of the
brain to
rule out micro-pituitary adenom
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Primary
Hypogonadism
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Total
testosterone is the amount of all the testosterone in
the body both bound and unbound. This level will decrease
in some men whom testes lose their ability to produce
testosterone
Blood work-up will reveal:
- Low
total and free testosterone (At times you will find
in patients with very low total testosterone a increase
in % free due to the bodys attempt to compensate for
such low levels) total testosterone is decreased (=200
ng/dL)
- Elevated
LH and FSH levels may be (>13 IU/L and >15 IU/L,
respectively)
- Normal
estrogen
- Decreased
or normal SHBG
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Secondary
Hypogonadism
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One
other cause of low testosterone known as "Secondary
hypogonadism"(hypogonadotropic hypogonadism) which
occurs when the hypothalmus-Pituitary axis fails to
sense a low testosterone level and thus doesn't produce
any increase in LH or FSH ( LH and FSH (<1.0 mIU/L[12])]
In these patients, magnetic resonance imaging of the
pituitary gland may be warranted.
Blood
work-up will reveal:
- Low
total and free testosterone
- Normal
estradiol
- Normal
to low SHBG
- Low
LH and FSH despite low testosterone
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Thus
you can see why just getting a Total testosterone level doesn't
nearly give the whole picture.
When
I evaluate a patient for andropause I look at the following:
- The
free testosterone and I like to see that equal to 2% of
the total testosterone
- Calculate
the "Free Androgen Index" which is the total testosterone
divided by the SHBG then multiple by 100. A FAI less than
50% requires replacement, FAI 50-70% depends on clinical
presentation and medical history, FAI>70% normal
- Testosterone/Estradiol
ratio less than 10 requires some intervention
For
more information regarding evaluation guidelines you may
download the following PDF file by right clicking on the
link below, choosing the 'save target as' option and then
saving to your hard drive. If you prefer you may also click
on the link to open it in your browser.
American Academy
of Clinical Endocrinology clinical guides for hypogonadism
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Sex
Hormone Levels In Men By Age
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Two
studies of Sex Hormone Levels in men, by age group
1
Mean
Plasma Sex Hormone Level in healthy men 2
Measurements
in European Units (nmol/L)
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Age
|
Number
of
Subjects |
Total
Testosterone |
Standard
Deviation |
Free
Testosterone |
Standard
Deviation |
SHBG |
Standard
Deviation |
| 25-34 |
45 |
21.38 |
5.90 |
0.428 |
0.098 |
35.5 |
8.8 |
| 35-44 |
22 |
23.14 |
7.36 |
0.356 |
0.043 |
40.1 |
7.9 |
| 45-54 |
23 |
21.02 |
7.37 |
0.314 |
0.075 |
44.6 |
8.2 |
| 55-64 |
43 |
19.49 |
6.75 |
0.288 |
0.073 |
45.5 |
8.8 |
| 65-74 |
47 |
18.15 |
6.83 |
0.239 |
0.078 |
48.7 |
14.2 |
| 75-84 |
48 |
16.32 |
5.85 |
0.207 |
0.081 |
51.0 |
22.7 |
| 85-100 |
21 |
13.05 |
4.63 |
0.186 |
0.080 |
65.9 |
22.8 |
Measurements
converted to ng/dl
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Age
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Number
of
Subjects |
Total
Testosterone |
Standard
Deviation |
Free
Testosterone |
Standard
Deviation |
SHBG |
Standard
Deviation |
| 25-34 |
45 |
617 |
170 |
12.3 |
2.8 |
1024 |
254 |
| 35-44 |
22 |
668 |
212 |
10.3 |
1.2 |
1157 |
228 |
| 45-54 |
23 |
606 |
213 |
9.1 |
2.2 |
1287 |
237 |
| 55-64 |
43 |
562 |
195 |
8.3 |
2.1 |
1313 |
254 |
| 65-74 |
47 |
524 |
197 |
6.9 |
2.3 |
1405 |
410 |
| 75-84 |
48 |
471 |
169 |
6 |
2.3 |
1471 |
655 |
| 85-100 |
21 |
376 |
134 |
5.4 |
2.3 |
1901 |
658 |
Plasma
Total Testosterone in healthy non-diabetic men 3
Measurements
in European Units (nmol/L)
| Age |
Number
of
Subjects |
Mean |
Standard
Deviation |
Median |
5th
Percentile |
10th
Percentile |
95th
Percentile |
| <
25 |
125 |
23.97 |
5.48 |
24.15 |
14.15 |
16.22 |
33.12 |
| 25-29 |
354 |
23.18 |
7.14 |
22.08 |
13.46 |
15.18 |
34.84 |
| 30-34 |
330 |
21.53 |
6.72 |
20.70 |
12.07 |
13.46 |
33.81 |
| 35-39 |
212 |
20.70 |
6.55 |
19.66 |
11.39 |
13.46 |
32.77 |
| 40-44 |
148 |
20.70 |
6.87 |
20.70 |
11.04 |
13.11 |
32.43 |
| 45-49 |
154 |
18.91 |
5.66 |
18.28 |
11.39 |
12.42 |
29.32 |
| 50-54 |
164 |
18.87 |
6.49 |
17.94 |
10.01 |
12.07 |
32.43 |
| 55-59 |
155 |
19.14 |
6.04 |
18.97 |
11.04 |
11.73 |
30.01 |
Measurements
converted to ng/dl
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Age
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Number
of
Subjects |
Mean |
Standard
Deviation |
Median |
5th
Percentile |
10th
Percentile |
95th
Percentile |
| <
25 |
125 |
692 |
158 |
697 |
408 |
468 |
956 |
| 25-29 |
354 |
669 |
206 |
637 |
388 |
438 |
1005 |
| 30-34 |
330 |
621 |
194 |
597 |
348 |
388 |
975 |
| 35-39 |
212 |
597 |
189 |
567 |
329 |
388 |
945 |
| 40-44 |
148 |
597 |
198 |
597 |
319 |
378 |
936 |
| 45-49 |
154 |
546 |
163 |
527 |
329 |
358 |
846 |
| 50-54 |
164 |
544 |
187 |
518 |
289 |
348 |
936 |
| 55-59 |
155 |
552 |
174 |
547 |
319 |
338 |
866 |
1
- Source for charts: http://www.weymouthclinic.co.uk/wellman/paper2.html
2
- Vermeulen A. Declining androgens with age - an overview,
In: Androgens and the ageing male. Eds. Oddens B. Vermeulen
A. Parthenon Publishing. New York. 1996
3
- Simon D. Nahoul K. Chades MA. Sex hormones, ageing,
ethnicity and insulin sensitivity in men : an overview
of the Telecom study. In: Androgens and the ageing male.
Eds. Oddens B. Vermeulen A. Parthenon Publishing. New
York. 1996
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Disclaimer: The
information contained on this website has not been evaluated by the
FDA. This information is not intended to treat, diagnose, cure or
prevent any disease. All material provided in the Dr. Brizel's web
site is provided for educational purposes only. Always seek the advice
of your physician or other qualified health care provider with any
questions you have regarding a medical condition, and before undertaking
any diet, exercise or other health program.
©2002,
All Rights Reserved, Center For Clinical Age Management, Inc.
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