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ANDROGEN DEFICIENCY IN THE ADULT AND ITS RELEVANCE TO PRIMARY CARE

Professor Louis Gooren,

Andrology Unit, Division of Endocrinology,

Vrije Universiteit Medical Centre, Amsterdam, The Netherlands

Primary care physicians serve as gatekeepers of the healthcare system. It is their task to provide medical care, guide patients to the appropriate medical specialty, and survey treatments given by medical specialists. The primary care physician is in the unique position that s/he generally knows the affective and social network of the patient. There is also a pro-active role for the primary care physician: to make their patients aware of new developments in health care and guide them in making judicious use.

Androgen deficiency is not a lethal condition. There is no serious evidence that (even long-standing) androgen deficiency shortens the life span. It has, however, a profound effect on quality of life. Signs and symptoms of androgen deficiency depend very much on the age when it occurs. Prenatally, it will produce sexual ambiguity. Pubertally, it will lead to a sluggish sexual maturation and virilization. After 25 years in reproductive endocrinology, I must conclude that the expertise on androgen deficiency in primary medical care is shockingly deficient. Medical education in male reproductive and sexual endocrinology is usually virtually non-existent. At the same time there is an undue inhibition / shyness to do a proper assessment of male sexual development, even though this can be done at virtually no cost: use your senses. In sum: androgen deficiency in the adult male is widely overlooked at the expense of a patient’s quality of life.

It is becoming increasing clear that testosterone levels fall in ageing men though not  in all men to the same degree. Of the men above 60 years of age 20-35% are testosterone deficient by conventional laboratory criteria. They will show signs of testosterone deficiency, such as osteoporosis, loss of muscle mass and strength and impaired mental functioning. The clinical diagnosis is not easy since the signs and symptoms largely overlap with those of aging. Particularly, the not so healthy aging men are at risk of testosterone deficiency. Men do benefit from testosterone replacement provided they are truly testosterone deficient. Prescribing testosterone to aging men meets with strong reservation of the medical profession. One of the reasons is the perpetuated misconception that androgens induce prostate disease. This belief is bolstered by the observation that drug interventions reducing androgen effects on the prostate are beneficial in the treatment of prostate disease. This is, however, no scientific proof that androgens do actually induce prostate disease. Prostate disease in aging men typically occurs when androgen levels are falling, so it sounds reasonable to assume that other factors might be responsible. Indeed, studies indicate that the higher oestrogen/androgen ratio, and the higher insulin and leptin levels in obese men might be factors in the development of prostate disease in old age.

For the reasons given above, primary care physicians are pivotal in the decision to provide androgen treatment, and even more so in the continuation of androgen treatment.

Professor LOUIS GOOREN, MD, PhD

Andrology Unit, Division of Endocrinology,

Vrije Universiteit Medical Centre,

P.O. Box 7057, 1007 MB Amsterdam, The   Netherlands

E-mail: ljg.gooren@vumc.nl

Present position: Professor of Medicine at the hospital of the Vrije Universiteit of Amsterdam, the Netherlands. Head of Andrology Unit, Division of Endocrinolgy, Department of Internal Medicine.

Medical education: University of Nijmegen, the Netherlands, 1962-1970

Training in internal medicine and endocrinology at the hospital of the Vrije Universiteit of Amsterdam, the Netherlands, 1972-1977.

PhD thesis in 1981: Testicular hormones and the secretion of LH, FSH and prolactin.

Appointments: since 1979 staff endocrinologist and head of the andrology unit. Apart from purely andrological problems, also disorders of sexual differentiation and transsexualism are addressed.

In 1988 appointment as full professor of endocrinology with special attention for gender problems and psychoneuro-endocrinology.

Since 1982 chairman of the genderteam of the world’s largest sex reassignment centre. This centre provides all services needed for sex-reassignment treatment (psychological/psychiatric diagnostic work-up, hormonal and surgical treatment ). Álso intersexed patients receive treatment here.

Scientific interests. 1) The role of androgens/estrogens in psycho-endocrinology 2) the role of androgens/estrogens in bone and cardiovascular pathophysiology and the immune system, particularly with regard to aging.

Recent contributions to the field of the aging male:

The Aging Male, edited by Louis Gooren and Peter Lim Huat Chye,

       Meditech Media Asia Pacific, Singapore, 2002

Textbook of Men's Health, edited by Bruno Lunenfeld and Louis Gooren (International Society for the Study of the Aging Male, ISBN 1-84214-011-6, Boca Raton, Fla, Parthenon Publishing, 2002.