Objective: This presentation will detail the follow up of unselected male patients diagnosed with andropause and related aging-male disorders within a stable suburban family practice.

Method: Phase III is a 6th year follow up of 275 andropausal patients. All underwent regular history-physical exams including digital rectal, blood screening, PSA, free testosterone, ADAM, Beck Depression Index, and stress tests. Management was multimodal, and included counseling for lifestyle issues (smoking, alcohol, substance abuse), programs for obesity (nutritional counseling, fitness training), stress and depression counseling-management, and family support. Each module included educational handout materials. Testosterone replacement therapy (TRT) was based on the clinical practice guideline algorithm developed from Phase II of this study (combination of clinical issues, testosterone levels, and TRT response).

Results: TRT contributed to beneficial responses in most of the male gender-specific health problems in the majority of patients; compliance to its use was over 90%.

OBJECTIVES: The determination of the systemic testosterone concentration (TC) has been fairly established in the diagnostic workup of erectile dysfunction (ED). The purpose of our study was to determine TC in the cavernous and peripheral blood taken during different penile conditions from healthy males and patients suffering from ED in order to evaluate whether or not TC levels change during tumescence, (rigidity) and detumescence and whether these T courses are different in healthy subjects and patients.

METHODS: Blood samples were drawn from the corpus cavernosum (CC) and the cubital vein (P) of 54 healthy males and 46 patients with ED during the penile stages of flaccidity, tumescence, rigidity (healthy males only) and detumescence. Tumescence and rigidity was induced by audiovisual and tactile stimulation. TC (ng/ml) was determined by means of an radioimmunoassay.

RESULTS: In the flaccid phase, the TC in the CC plasma was 2.9 ± 1.2. During tumescence (4.3 ± 1.3) and rigidity (4.4 ± 1.4), TC increased significantly (p < 0.001). In the phase of detumescence, TC decreased appreciably to 3.5 ± 1.4. In the peripheral blood, the increase from flaccidity (4.1 ± 1.1) to tumescence (4.4 ± 1.4) was found to be significant (p = 0.001) and no further increase was detected during rigidity. From rigidity to detumescence, peripheral TC dropped to 4.1 ± 1.2. In the flaccid phase, mean cavernous TC in the healthy subjects was found to be 30% lower than the level in the peripheral blood whereas, in the patients, this difference was only 13%. In the patients, the mean increase in systemic and cavernous T levels from flaccidity (P 2.6, CC 3.0) to tumescence (P 3.0, CC 3.2) was found to be less pronounced.

 The aim of our study was to recruit hypotestosteronemic men suffering from symptoms associated with age-related hypogonadism to testosterone replacement therapy (TRT). All the 40-70 -year-old men (28 622) in the Turku City Area were sent a questionnaire enquiring about such symptoms as decreased sense of well-being, decreased libido, increased erectile dysfunction and decreased muscle strength etc. 15991 men filled in and returned the questionnaire. 2513 of these men were then called in for blood hormone measurements as their symptom score reached the diagnostic limit of andropause. 1764 met the appointment for blood measurements of serum testosterone and luteinizing hormone. According to this single measurement, 243 men (13.7 %) were hypogonadal (S-T less than 9.8 nmol/l), while 232 (13.1 %) had a finding of subclinical hypogonadism (S-T more than 9.8 nmol/l, but S-LH more than 6.0 IU/l). In order to evaluate the stability of symptoms, these 475 men were called in three months later for a repeat symptom questionnaire. 119 of the 243 hypogonadal men, while 116 of the 232 subclinically hypogonadal men were still symptomatic. From these 235 men still 17 men had to be excluded due to disorders in medical history.

Following this vigorous screening of symptoms and hormone parameters, 218 men of the entire population (0.8 %) were invited to take part in the randomized, double blind, placebo-controlled TRT trial. 175 men signed up for this. They went through a thorough physical examination and blood tests to exclude individuals with any significant clinical contraindications for the use of TRT. Prostatic hypertrophy, obesity, hypercholesterolemia and other abnormal laboratory values were amongst the most frequently met exclusion criteria. Furthermore, a significant proportion of the men were excluded because the symptom criteria were not fulfilled in a third evaluation. Following this final screening, only 29 men of the total fulfilled all inclusion criteria (0.01 %). At this point it was decided that the trial should be discontinued since the statistical power needed for proof of any benefit of the treatment could not be obtained with such a small number of subjects.

Partial Androgen Deficiency of Aging (PADA) in adults is possibly the missing major-disease link, leading to early adiposity-Metabolic Syndrome in spite of ‘normal’ BMI. Gray’s 1991 metanalysis in men (affirming modest s-T fall with age) did not study optimal s-T levels. Convention permits T restoration (TRT) only in patients with s-T below the cut-off value ~10 nmol/l. The cut-off value for s-T does not approximate the average mean, let alone "optimal", level found in men.

The Aim of this study was to determine the mean level of s-T in healthy men. Conventional Wisdom is that "modest fatness, a BMI ~27kg/sqm, body fat ~25%, and sT ~10nmol/l (even for erection) are acceptable. Above this s-T threshold, TRT is not recommended; and TRT to a level of 15 in a man seems to be considered adequate" by default.

Methods and Results: Our literature analysis of over 80 papers over the past 40 years in > 11 000 men confirmed the prevalent all-age mean s-T in (~white) men was ~21nmol/l. Similar mean s-T was found in 2269 US Vietnam Veterans (age 31- 68: means: 44 yrs, body fat ~21%) (in whom dioxin exposure had affected neither s-T nor sperm levels); however, when ranking the youngest age group (31-41 yrs, n=985) by body fat%, the mean s-T was 34 nmol/l with body fat <10%, and ~15 nmol/l with body fat >40%. In South African men, s-T was surprisingly lower compared to the world mean (Bornman et al, 2002).

Mean s-T levels in men decrease by 30% from 25 to 75 years, while mean body fat often doubles. Most labs use s-T of 12-32nmol/L as all-age "normal" reference range. But in "healthy" men, s-T may fall by 2/3 in adult lifetime yet still be within the conventional "normal" range.

Aim: ADAM stands for Androgen Deficiency at the Aging Male, but this abbreviation is also understood as Androgen Deficiency at the Adult Male. This viewpoint creates a novel approach to the issue. Until now an aging male has been a man who is over 65 years old, and suffers from many diseases resulting from ADAM. Hyperglycemia, persisting for many years (because of untreated, masked Type 2 diabetes), leads to diabetic angiopathy and neuropathy. While growing older a man develops hyperlipidemia, which in turn creates atherosclerosis and arterial hypertension. Abnormally high calcium resorption from bones results in osteoporosis, and increased transport of calcium in blood vessels leads to quick calcification of sclerotic plaque. Due to the same mechanism, calcium excretion through kidneys is higher, which leads to stone formation. Testosterone (T) level starts its drop at a man’s age of 30, giving noticeable symptoms and signs 10 - 20 years later. Thus diagnosis and prophylaxis of destructive processes present in men with ADAM should be begun much earlier than it is commonly done now. The authors propose a new HRT - they suggest that instead of classical HRT, i.e. applying exogenous T, natural, endogenous T synthesis should be induced. What is also important is that this is the synthesis which uses up LDL-cholesterol. The clinical results of such therapy are much better.

Method: The paper is a result of a 2.5-year study carried out at two different centers. The study covered 625 men with ADAM aged 40-87. T level increase resulted from hCG administration. The follow-up has been 1.5 - 2.5 years.

Results: hCG therapy results in almost 250% increase of T level (p<0.000...). Men are more fit both mentally and physically, have better memory, their libido and potency reappear. The lipid profile improves or becomes normal. Type 2 diabetic patients tolerate glucose better - in a way similar to that of antidiabetic drugs. In osteoporotic patients, hCG therapy significantly restores good bone calcification and, at the same time, decreases calcium excretion with urine - which both decrease the risk of osteoporosis and nephrolithiasis.

It is well known that impotent men (140 million in the world) prefer to suffer in silence and don´t seek medical advice because they are afraid to show weakness to others in a crucial issue closely related with their"manhood" and self esteem. Internet is the perfect screening tool to help such a huge collective of people.

My web page "The Impotency Practice on Internet" at www.impotencia.org <http://www.impotencia.org> has been visited by more than a million and a half men in a short period of time. Here, they have the opportunity of filling in a five question, free "Quick test" and get an immediate answer about their situation. If their score is on the lower side, they have the option of filling in a more in depth, 57 question free "Test" and get a more specific opinion about their problem on the spot ( both tests are processed by computer programs) and a request to perform the following analytical test at any local laboratory: Glucose, Total Testosterone, FreeTestosterone, FSH, LH, Prolactin, Estradyol (E2) and PSA. The analytical data must be sent by e-mail to doctor@impotencia.org <mailto:doctor@impotencia.org>.