(reproduced with thanks to Roland Tremblay, President)
Vol 1, No 1 January 2001
INTRODUCTION
One of the difficult tasks for a rather juvenile
society resides in the renewal of its membership.
Therefore, one of the goals fixed by your executive
for year 2000 was to bring this process to a successful
conclusion during the last two months of this year.
Any period of membership renewal in any society generates
some fears about the ratio between desertions and
new comers; desertions find their explanation by changes
in the interests of investigators, because the society
lacks of visibility, because of financial problems
in the society and the most frequently evoked reason
is simply that there are too many societies and too
many journals to read on a weekly basis. The new comers
in a society believe in the message and/or the general
goals proposed by the entity and they generally expect
positive repercussions in their clinical practice.
They anticipate an easy bringing to light of their
knowledge in a new field of activity, such as andropause,
that is moving and promising for the future. After
35 years of clinical research in the field of hormonal
substitution at menopause, the debate about several
issues is far from being closed. To shorten my introduction,
we lost 13 members and the Society was priviledged
to welcome 11 new members whose names are indicated
by an asterisk on the list of the members in annex.
THE QUESTIONNAIRE
Prior to writing this Newsletter, I got the idea
to underline your personal contributions for year
2000 in the Society at dawn of this millenium. A few
questions were specifically addressed to illustrate
the actual trends in the Society and to serve as indicators
for a Gallup poll in year 2010!!
The questionnaire was sent to all members (N=83)
of the Society on November 27, 2000 and it was accompanied
by an envelope bearing the address of the President
and a post stamp of her Majesty the Queen; the deadline
to receive your answers was deliberately short (December
15, 2000) in order to avoid a burying syndrome beneath
your medical files or research protocols. The very
last answer reached my office in early January 2001.
What a postal service we have in this country!
To be serious, 50% of the members (plus 1) condescended
to answer the questionnaire and the information so-gathered
appeared highly relevant for the future. Thirty (30)
members of CAS were at the origin of 115 lectures
or conferences either to groups of physicians or to
public audiences across the country. Thirty-five (35)
members did participate either actively (guest speakers)
or as listeners in national or international meetings.
Twenty (20) members were involved in TV, radio or
newspaper releases for a minimum number of 84 events.
Twelve (12) members were committed in publications,
but the references shall be available for inclusion
in the summer Newsletter. Basically, one must conclude
that our Society has been highly active in promoting
andropause awareness as such and its consequences
in men's life (osteoporosis and erectile dysfunction).
The number of events at all should be considered as
an underestimation of the reality because of the percentage
(50%) of responders. Other important issues are under
development (cardiovascular diseases, cognitive functions
and androgens, actions of androgens in the brain)
and new mediums of information and/or education (case
report analysis) must be developed by the Society
to facilitate the decision-making process of our colleagues.
Partial androgen deficiency does not appear as an
easy diagnosis at least for endocrinologists who raise
questions related to the diagnostic tools and also
for those members of the Society who do not have access
to bioavailable T (12 out of 43) nor to calculated
free T (16 out of 43) neither. Too many physicians
across the country look like living during the New
Stone Age because they must use total testosterone
values to help in their clinical diagnosis of andropause.
Could it be that our clinical biochemists have an
unquestionable trust in "kits" with code
numbers from USA?
THE KIT SYNDROME
The question appears with such an acuteness at the
beginning of this century that it deserves some more
comments in addition to the content of the July Newsletter
of the Society in 2000. The KIT syndrome could have
been largely attenuated in 1998 while the First International
Meeting for the Study of the Aging Male (ISSAM) was
taking place in Geneva. The majority of the senior
investigators knew very well at this time that Sex
Hormone Binding Globulin (SHBG) was progressively
increasing with the aging process. As a consequence,
a rather firm statement about the useful assays to
be selected in evaluation of aged men's androgenicity
could have eliminated :
- - idle talks inside and between countries;
- - clinical studies based on normal values for
total testosterone (TT);
- - clinical trials with non conclusive results
because of the normal state of androgenicity;
- - misdiagnosis of andropause;
- - impossibility to perform meta-analysis in 2025.
With a few exceptions, the literature of the last
three (3) years reflects a serious lack of methodological
discipline to exploit the clinical data which will
be collected around the world. Such is human experience:
difficulties to learn from the past errors. Think
about the impressive literature about the cardiovascular
protection of estrogens at menopause. Where is the
consensus?
If one cannot surmont the "kit syndrome",
let's play the game with these quite robust assays,
namely the total T assay and the SHBG assay, but your
executive urges you to introduce the TT and SHBG values
so obtained in the mathematical model of Södergard
and to work with a "calculated free testosterone"
(CFT) value. The model was validated with the publication
of Vermeulen et al. (J Clin Endocrinol Metab 84: 3666-72)
in December 1999 and I recommend two things :
- reading the article a couple of times;
- paying attention to Fig. 4, page 3671 : on the
Y axis, the non SHBG-T corresponds to bioavailable
T (BT) determined by the ammonium sulfate precipitation
method and the X axis corresponds to the calculated
free testosterone (CFT). The "r" value
is high (0.97) and this graph illustrates the quite
good correlation between BT and CFT. According to
my experience, as shown in the figure I proposed
to you last July (2000), you will not underdiagnose
andropause, nor you will propose a testosterone
treatment, without any success, to a man whose total
T is 9.2 nmol/L, but SHBG is 24 m-nol/L. CFT, to
the same extent as BT, shall remain absolutely normal.
As a corollary to this proposal, any medical file
should contain at least one of the two sets of biological
data regarding androgens :
SHBG
Calculated free testosterone very high correlation
- Bioavailable testosterone
For those of you members who want to subscribe to
an evidence-based medicine, we propose to correlate
the clinical data of your patients either with bioavailable
T or CFT, when available. The nomogram to obtain CFT
(proposed reference range below 200 pmol/L for andropausic
men) is available in PC or MAC versions (free diskette),
or on a mini-calculator VISOR ($350.00). With VISOR
the software is already installed and you simply feed
the minicomputer with two numbers (total T and SHBG),
with or without the albumin concentration, and the
CFT is immediately available on the screen. Please
communicate with the secretariat of the Society or
by e-mail for more information.
The executive members of your Society wish you the
best in your life and your medical practice for the
new year. We thank those of you who helped the Society
during two years and we highly welcome the new members
who will guarantee the progress of the Society.
Roland R. Tremblay, D.Sc. M.D. Ph.D.
President, Canadian Andropause Society, CHUL Research
Center, Room T3-67 2705 Laurier Boulevard Sainte-Foy
(Quebec) G IV 4G2 Tel: (418) 654-2733; FAX: (418)
654-2215 E-mail: Roland.R.Tremblay@crchul.ulaval.ca
