Needle in a haystack
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Recent interest in the clinical consequenses of relative androgen deficiency in the aging male is well served by the series of papers from the Canadian Andropause Society in the present issue of the Journal of Sexual & Reproductive Medicine. Does this heightened interest herald the acceptance of the andropause syndrome by the mainstream medical community? Not yet.
The effects of androgen deprivation are well documented, as are the clinical benefits of androgen supplementation in hypogonadal men. The much larger population of potential patients with relative androgen deficiency who may benefit from androgen therapy remains unsorted. All men experience a relative decrease in bioavailable testosterone levels as they age. Bone loss, decreased muscle mass, reduced cognitive ability and diminished libido are all consequences of aging. Attention to diet, the elimination of risk factors (such as tobacco consumption), regular exercise and an interested sexual partner can mitigate these eventual consequences. Lifestyle management has always been less attractive to patients than a written prescription. The cost of widespread hormone replacement therapy would be astronomical.Without well-constructed, placebo-controlled, prospective clinical trials supporting the clinical benefits (and, indirectly, the cost benefits) of testosterone therapy, the use of testosterone in the graying population remains unscientific and unsupported, other than by anecdotal evidence.
The group of patients who will truly benefit from hormone replacement therapy needs to be better defined, and physicians need to resist the pressure from industry to use the various forms of testosterone therapies that are now available. In the past five years, physicians have seen the introduction of a safe oral testosterone, a scrotal patch, an androgen gel and a transdermal delivery system. Hopefully, the next five years will allow physicians to determine what subgroup of male patients will be served by these novel delivery systems. Organizations such as the Canadian Andropause Society will be instrumental in providing physicians with the tools necessary to serve their aging male patients.