For the first 20 years post-graduation, I was totally unconvinced about male Hormonal Replacement Therapy (HRT) for Late Onset Hypogonadism (LOH). From an academic stanpoint, I did not see enough data in reputable medical journals to convince me on the merits and safety of Male HRT. It did not help that I saw a lot of articles in non-academic platforms telling me how great it is! The protocols were not defined and there was a lot of Traditional Chinese Medicine (TCM) stuff floating around.
Female HRT has been around for a long time and appears to be working well for most of my urology lady patients especially in the area of postmenopausal cystitis, vaginitis and overactive bladder. I concluded that if case selection was proper, we will be able to reap the benefits for women and eventually men as well.
More data was being published recently and newer and better studied male HRT options were been introduced with proper protocols and better safety profile studies with longer follow-ups
Men are different from women!! All women have a significant drop in hormones when they reach menopause. Men on the other hand, for the most part, tend to maintain their hormonal levels despite the aging process and only a minority has significant low levels. Publications coming out from Europe and Alexandra hospital in Singapore supported this observation eg even at age 70 years, only about 30% have LO H and not all are symptomatic! This means only a minority need HRT if indicated. Case selection is crucial. Majority of tired and/or Erectile Dysfunction (ED) men in my urology clinic do not have LOH and Do Not needs HRT. We need to look for other non-hormonal causes as well!
LOH is more than just ED. As we get drawn into a narrow interpretation about LOH, we need to begin to see it as a multi-organ issue with relationship implications. In select individuals with LOH associated with Obesity, high cholesterol, Hypertension and/or Late Onset Type 2 Diabetes, a controlled male HRT reaps significant medical benefits with a reduction in mortality and morbidity. In Older men with OP related Fractures with minimal muscle strength, careful HRT will help in mobility and rehab. For Men in a downward spiral relationship with their wives coupled with depression on both sides, Protocol based HRT will be beneficial. From a viewpoint of NO WAY! I have changed to careful selection and close monitoring with great outcomes.
What is the level of testosterone for my symptomatic patient before I start treatment and what is the goal of HRT? In general, the lower the starting level the better is the response to HRT. I noticed that when the starting levels are below 8 nmol/L the after effects of HRT are great! This tend to be not great when the individual is about 11-12 nmol/L. there are of course exceptions to the rule and I am still learning as there are always other medical and social factors to consider. The endpoint is important in HRT, we know that high levels with overstimulation is not beneficial in the long run and that most LOH symptoms are resolved at around 12-15 nmol/L (Zitzmann JCEM 2006). My take is to bring the individual to low/normal levels where most symptoms like lethargy, hot flushes, obesity are for the most part reduced and see what other needs are left unmet and consider other nonhormonal options. Trying to put men at too high a level > 20 nmol/L may overstimulate the individual and is not sustainable with low long term compliance.
LOH is already present in your clinical practice and you do not need to put up a sign on your door to attract these patients. Individuals with Late Onset Type 2 Diabetes, Obesity, hard to treat ED (in this group we expect LO H at 20%) who are symptomatic can be screened for total testosterone levels during the next blood taking in the morning. When LO H is proven, FSH and LH needs to be ordered to decide whether this is primary or secondary issue as this would determine therapy options. When this is due to Secondary LO H I would refer toan endocrinologist to relook at his hypothalamus and pituitary gland. If it is primary or testicular issue, I would like to know if this is an aging issue or a urology issue. For the most part, it is a primary testicular hypofunction and after careful counselling, we can consider HRT under close supervision.
Be very conservative in case selection.
Treat only very low testosterone levels with symptoms to have a good clinical outcome.
Avoid anxious patients who want a trial of HRT but have low/ normal testosterone levels and look for other causes of lethargy eg: latent diabetes and hypothyroidism.
Only give if he is willing to be monitored.
Remember the man who may want children down the road as male HRT may adversely affect sperm quality. Counselling is key!
Review closely what symptoms are improved as the levels slowly go up with time and realize not all symptoms can be solved with HRT but remember that most symptoms are resolved at btw 12-15.
Medical Director & Senior Consultant Urologist
FAMS (Urology), FICS (USA), FRCS (Edinburgh),
M Med (Surgery), MBBS (S’pore)
Dr Michael Wong is a Senior Consultant Urologist who is internationally recognized for his surgical expertise and academic contribution to the field of Urology, in particular the subspecialized field of minimally invasive Endourology.
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