Associate Professor Mark Wenitong

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1 The Healthy Male NEWSLETTER OF ANDROLOGY AUSTRALIA Australian Centre of Excellence in Male Reproductive Health Summer 2014 issue 53 CONTENTS 1 Engaging Indigenous men in primary health A new guide for health professionals 2 From the Director 2 Inbox Letter to the editor 2 Health Spot Chronic pelvic pain syndrome 3 Focus On Testing the testosterone myths 5 Professional education Canadian review recommends against PSA screening 5 Research round-up Anxiety and distress with active surveillance 6 Latest News The fertility knowledge of young Australian men 6 News in brief Associate Professor Mark Wenitong Engaging Indigenous men The recently released Productivity Commission report on Overcoming Indigenous Disadvantage found that almost half of Indigenous people who did not see a GP in the previous 12 months avoided the doctor for personal reasons, which include being too busy (work, personal or family responsibilities), discrimination, service not culturally appropriate, language problems, disliking the service or health professional, being afraid or embarrassed, not trusting the hospital, or feeling that the service would be inadequate. In an effort to break down some of these barriers, Andrology Australia has developed a new Clinical Summary Guide for health professionals titled, Engaging Aboriginal and Torres Strait Islander men in primary care settings, which details strategies for health services and encourages cultural competency training. Associate Professor Mark Wenitong, Chair of Andrology Australia s Aboriginal and Torres Strait Islander Male Health Working Group, said there are many factors influencing health service access and help-seeking behaviour for Indigenous men, especially when it involved discussing sexual issues. These include societal concerns such as masculinity and gender roles and illness stigma, as well as cultural, for example traditional gender-related lore. Cultural competency training is essential to overcome barriers affecting how Aboriginal and Torres Strait Islander men access health services, and our Clinical Summary Guide suggests some culturally appropriate strategies for discussing sexual health issues. It is very important to provide a safe, private and comfortable environment that supports open and free dialogue. Development of the Clinical Summary Guide was supported with input and guidance from the Andrology Australia Aboriginal and Torres Strait Islander Male Health Reference group. The Productivity Commission Report Overcoming Indigenous Disadvantage: Key Indicators 2014 can be found at

From the Director Testosterone gets a lot of attention these days, and not all of it is good. In the media it s blamed for violence in males and is implicated in drugsin-sport scandals.

2 From the Director Testosterone gets a lot of attention these days, and not all of it is good. In the media it s blamed for violence in males and is implicated in drugsin-sport scandals. In modern folklore it s linked to sexual prowess and is desired by gym junkies. And lately it s even promoted as a tonic for ageing. Wow, that s a lot for one hormone to deal with! But how many of us really understand what testosterone is, what it does, and why it s important? We look into these matters in this issue of The Healthy Male. We were pleased recently to release a new clinical summary guide for health professionals on Engaging Aboriginal and Torres Strait Islander Men in Primary Health Care. This important guide adds to Andrology Australia s contribution to the national effort to close the gap in Indigenous male health, and builds on knowledge gained through the development of our men s health DVD A lot of Aboriginal men sort of keep it to themselves. Professor Rob McLachlan Inbox Health spot Chronic Pelvic Pain Syndrome Recalling from roughly 50 years ago the mystery and the real, passing concerns of a very naive young male moving into pubescence ( Am I normal? wet dreams!), I find it ironic that despite a good, open, professional relationship with my GPs, I ve entered an older-male stage where uro-genital changes are once more becoming a bit of a mystery. I find your publication reassuring as it seeks to provide in-your-pants reproductive and associated topics in an honest, simple-to-absorb style. If your articles don t always relate to my evolving situation, just their arrival each quarter often provides indicators or search terms that send me off to seek more information specific to what s happening to me now? stages, viz. LUTS, possible pharmaceutical intervention, side-effects and (coming full circle) good to know I m not abnormal! Remaining cautious of the little-knowledge syndrome, such research can help me formulate better questions to take to my GPs. Thank you! Ray Thanks Ray. We welcome feedback from readers about The Healthy Male and topics you would like us to cover. Chronic Pelvic Pain Syndrome (CPPS) is a common and disabling condition. It is any pelvic pain that lasts for more than six months and is estimated to affect one in 10 men. It is the third most common diagnosis of men under 50 years of age presenting to urologists. Symptoms significantly diminish quality of life and impair physical and psychological function. It presents as pain or discomfort in the lower abdomen, perineum (between testes and the anus), the penis, testes, anus, low back, buttock or the tailbone. Bladder, bowel and sexual pain and changes in function of these organs are common. Possible causes include: vasectomy, inguinal hernia repair, prostate radiation therapy, chronic prostate inflammation and previous sexually transmitted infection. It is often diagnosed as prostatitis and treated with antibiotics, however 90% of cases do not respond to this management. This leaves sufferers experiencing pain that impacts their whole life, especially their ability to sit, to concentrate at work, to sleep, to exercise and to have sex, negatively impacting relationships, work productivity, enjoyment of daily activities and their mental health. The problem that originally caused the pain may have lessened or even disappeared completely, but the pain continues with most investigations coming back negative. New pain generators develop in surrounding muscles and nerves transmitting sensations from painful areas can become excessively sensitive. Due to the mind-body connections, pelvic pain can become all-consuming, affecting sleep, concentration, mood, gut and energy levels. For treatment to be effective it needs to therefore address the body and the mind and it needs a multidisciplinary team of health care professionals to thoroughly assess and design an individualised management plan. This team may include a urologist, a pain medicine specialist, a pelvic floor physiotherapist and a psychologist. The Pelvic Pain Foundation of Australia ( provides sufferers with information regarding symptoms, self-help management strategies and where to access appropriate health care providers. Andrology Australia thanks Shan Morrison (FACP), contributing author to the Pelvic Pain Foundation of Australia and Director of Women s & Men s Health Physiotherapy, for this article.

3 Focus on: Testing the testosterone It s said that testosterone is what makes men, men. But it s a myth that more testosterone makes you more of a man. In fact there are some health risks that come with too much or too little testosterone. As with most things, the secret to good health is finding the right balance. What is testosterone? Testosterone is the most important androgen (male sex hormone) in men and it is needed for normal reproductive and sexual function. Hormones are chemical messengers made by glands in the body that are carried in the blood to act on various organs. Testosterone is important for the physical changes that happen during male puberty, such as development of the penis and testes, and for the features typical of adult men such as facial and body hair. Testosterone also acts on cells in the testes to make sperm. Testosterone is also important for overall good health. It helps the growth of bones and muscles, and it affects mood, libido (sex drive) and certain aspects of mental ability. Although people link testosterone with aggression, studies have not shown this to be true. However, research is showing that testosterone levels are associated with particular traits such as care-giving and empathy. Where is testosterone made? Testosterone is mainly made in the testes by cells (called Leydig cells) that lie between the small tubes that make sperm (the seminiferous tubules). Testosterone is carried in the blood to its target organs throughout the body. (A small amount of testosterone is also made by the adrenal glands, which are walnut- sized glands that sit on top of the kidneys.) Lumen Leydig cells Leydig cells lie between the seminiferous tubules Seminiferous tubule Developing sperm Supporting or Nurse cell (also called Sertoli cell) How is the brain involved? The pituitary gland and the hypothalamus, located at the base of the brain, control the production of male hormones and sperm. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) are the two important messenger hormones made by the pituitary gland that act on the testes. LH is needed for the Leydig cells in the testes to make testosterone. The testosterone and FSH from the pituitary gland then act together on the seminiferous tubules in the testes to make sperm. LH and FSH are the two important messenger hormones made by the pituitary gland that act on the testes How do testosterone levels change over life? Testosterone is present in the body from the early stages of fetal life to old age. At the earliest stage of development, in utero, testosterone helps the fetus develop both a male body and a male brain. Testosterone levels are highest between the ages of 20 and 30 years. As men age, testosterone levels fall by about 1-2% per year; however, recent research suggests that not all men have a decline in testosterone as they age. It seems that a large part of the drop in testosterone levels in older men is due to chronic conditions such as obesity and diabetes. If men remain very healthy into old age, their testosterone levels may stay the same as when they were younger.

4 myths What are the causes of low testosterone? Low testosterone is usually caused by a genetic disorder (such as Klinefelter s syndrome) or damage to the testes or, in rare cases, a lack of LH and FSH hormones made by the brain. It is thought that about one in 200 men under 60 years of age and about one in 10 older men may have low testosterone levels but exact numbers are not known. However, not every older man with low testosterone will need treatment. What happens if a man has low levels of testosterone? Low testosterone levels have a variety of effects at different ages. In young boys and teenagers, low testosterone means that the testes and penis don t grow properly and there is poor development of muscles and facial and pubic hair. Also, they may be taller than their peers and the voice may not deepen. In adults, low energy levels, mood swings, irritability, poor concentration, reduced muscle strength and changes in body fat distribution, and low sex drive may result from low testosterone which is not to say that low testosterone is the only possible cause of these signs and symptoms. Research suggests that men with low testosterone may also have a higher risk of chronic conditions like stroke and heart disease. Older men with low testosterone will have thinning of their bones that puts them at risk of osteoporosis and fractures. If testosterone is so important, can a man have too much? Australian research shows that for men, living longer is associated with testosterone levels in the mid-range not too high or too low and this work supports the idea that too much or too little testosterone is best avoided. In men with prostate cancer, testosterone can feed the growth of cancer cells so some men are treated with medicines that stop testosterone. Although this can stop the cancer cells from growing as fast, the man then experiences the effects of low testosterone. What about testosterone supplements? For men with a clinical diagnosis of low testosterone, treatment with testosterone therapy to bring their levels back to normal will restore and maintain good health and, in young boys, restore sexual development. Treatment is given by injection or via the skin (gels, lotions, creams) or by oral medicines. For men with normal testosterone levels, taking testosterone is not appropriate and can cause problems. Testosterone supplements generally stop the normal production of the pituitary hormones FSH and LH, which reduces the size of the testes and can lower or stop sperm being made. If sperm production was normal before taking testosterone, it can take many months to go back to normal once the man stops taking testosterone. There is some controversy with research suggesting that older men taking testosterone have an increased risk of heart attacks and strokes. The jury is still out on this question, however there appears to be little risk to men having treatment for confirmed low testosterone. And there is not good evidence for the much-publicised benefits of testosterone supplements in older age, except for men with clinically diagnosed low testosterone. The symptoms of low testosterone are non-specific and other possible causes need to be investigated and eliminated before testosterone treatments are introduced. Testosterone should never be taken without a doctor s diagnosis and prescription. This article is for education purposes only. If you have any concerns about your testosterone levels Andrology Australia recommends that you seek the advice of a doctor. For more information see Andrology Australia s Low Testosterone fact sheet ( or the free Androgen Deficiency booklet (

Professional education Canadian review recommends against PSA screening A NEW examination reduces deaths when used in conjunction with the PSA test.

without a detailed discussion with the patient. This is consistent with other recommendations and guidelines, as reviewed by Andrology Australia earlier this year (see The Healthy Male no.

Bell N, Connor Gorber S, Shane A, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test. CMAJ 4 Nov 2014, DOI: 10.1503/cmaj.

5 Professional education Canadian review recommends against PSA screening A NEW examination reduces deaths when used in conjunction with the PSA test. CLINICAL guideline on prostate cancer screening by the Canadian Task Force on Preventive Health Care 1 has recommended that the prostatespecific antigen (PSA) test should not be used for screening without a detailed discussion with the patient. This is consistent with other recommendations and guidelines, as reviewed by Andrology Australia earlier this year (see The Healthy Male no. 52, Spring 2014), which generally agree that using the PSA test for mass population screening is not warranted. The Canadian review also found no evidence that digital rectal 1.Bell N, Connor Gorber S, Shane A, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test. CMAJ 4 Nov 2014, DOI: /cmaj The Task Force stated that there is no evidence that PSA screening reduces overall mortality among men of any age, that there is conflicting evidence suggesting a small and uncertain potential reduction in prostate cancer mortality among men aged years, and that there is consistent evidence that screening and active treatment lead to harm. The harms of PSA screening, as identified by the Task Force, include investigation and treatment of prostate cancer in men (with both positive and false-positive test results) and over diagnosis of men whose detected prostate cancer would not have caused them symptoms or death. It should be highlighted that the recommendations do not apply to the use of the PSA test for monitoring after diagnosis or during treatment of prostate cancer. Research round-up Anxiety and distress in men undergoing active surveillance for prostate cancer TO AVOID the side-effects of treatment for early prostate cancer, it is becoming increasingly common for men to choose to have surveillance rather than treatment such as radical prostatectomy. Active surveillance (AS) involves regular PSA tests and biopsies. If the cancer develops the man will then have other treatment options. A recent study from the Netherlands published in Psycho-Oncology 1 assessed whether AS leads to anxiety or distress, and whether highly anxious men would be more likely to swap to active treatment during the study period. 129 men following an AS protocol had anxiety and distress 1. Venderbos L, van den Bergh RCN, Roobol MJ, et al. A longitudinal study on the impact of active surveillance for prostate cancer on anxiety and distress levels. Psycho-Oncology 2014; DOI: /pon.3657 (online) levels measured, using validated scales, at three time points over 18 months, the first being soon after diagnosis. Average levels of anxiety and distress remained low over the 18-month period and there was a trend towards lower levels of fear of the cancer progressing. Only six men (5%) discontinued AS due for non-medical reasons, most likely due to anxiety. Although this was a relatively small study, it provides some reassurance to men considering AS for early stage prostate cancer, that their anxieties arising from the diagnosis and fear of cancer progression are not likely to get worse over time. Furthermore, there are substantial benefits of AS in avoiding or delaying the side-effects of prostate cancer treatments such as sexual or urinary problems.

In brief PSA guidelines for review Cancer Coucil Australia (CCA) and the Prostate Cancer Foundation of Australia (PCFA) are working together to develop clinical practice guidelines PSA Testing and

6 In brief PSA guidelines for review Cancer Coucil Australia (CCA) and the Prostate Cancer Foundation of Australia (PCFA) are working together to develop clinical practice guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer. The draft of these guidelines is open for public consultation from 4 December 2014 to 16 January 2015, and community and professional input is being sought. Health professionals and the public are invited to review and comment on the draft guidelines at wiki.cancer.org.au/ australia/guidelines:psatesting. Correction The Latest News column of issue 52 ( Get your timing right, baby ), included the statement, Ovulation happens about 14 days after a period starts. This is not correct, and should have read, Ovulation happens about 14 days before a period starts. We apologise for any confusion resulting from this. Christmas closure The Andrology Australia office will be closed over the Christmas New year period. Phones and won t be attended between Monday 22 Dec 2014 and Tuesday 13 Jan Our online order form will remain open. Season s greetings to all of our readers and we wish you the best of health in 2015 and beyond. Using Andrology Australia material If you would like to republish articles from The Healthy Male please info@andrologyaustralia.org, or call Appropriate acknowledgement of Andrology Australia as the source is requested. Latest News The fertility knowledge of young Australian men ANDROLOGY AUSTRALIA is working in partnership with the Australian Fertility Medicine Foundation (AFMF) to plan a new research study aimed at finding out more about the fertility knowledge and health literacy of young Australian men (18 40 years), and how they seek help for fertility issues. The findings will be used to develop educational campaigns to raise the awareness of the importance of fertility preservation in young men. The information may also be relevant to couples experiencing difficulty in conceiving where male infertility may be a contributing factor. Fertility health is generally perceived as the domain of women, despite opposite-sex couples often adopting a shared approach to contraception and family planning. Yet male infertility is estimated to be a sole or contributing factor in up to 50% of infertile couples. However, there is little data available on the prevalence, knowledge and health literacy of male infertility in Australia. The Men in Australia Telephone Survey (MATeS), conducted by Andrology Australia in 2003, reported an involuntary infertility rate of just under eight per cent the best estimate to date of untreatable male infertility (albeit for Australian men, over 40 years). MATeS also found that about eight per cent of men never seek to be fathers, which is similar to the findings of other Australian studies in younger men and school-aged boys. While such estimates give us some indication of the numbers of men affected by a diagnosis of infertility, few studies have explored male fertility knowledge and health literacy in a representative population of young adult males. Understanding those factors that influence young men s aspirations for a family in the future is important to develop strategies that support men when information about family planning is needed. Men often don t think they will have a problem having a family, so unless a problem arises, men tend not to seek information about fertility health. And some men may be sceptical about messages that warn of adverse effects of unhealthy lifestyles on their fertility. Despite relatively low rates of male infertility (about 1 in 20 men), a diagnosis of infertility can have a significant impact on men and their partners, particularly if this news is unexpected. Sexual health education to young adults is often focused on contraception but we also need to better understand what young men know about looking after their sperm. Do they understand the links between sexually transmitted infections (STIs) and possible later infertility? A pilot of the new study will kick-off in 2015, starting with focus groups to refine the research questions and guide development of a suitable tool for further survey investigations. Subscribe Today! FREE SUBSCRIPTION Register on our website or call to receive this quarterly publication and other items from Andrology Australia. NEWSLETTER OF ANDROLOGY AUSTRALIA Australian Centre of Excellence in Male Reproductive Health The Andrology Australia project is supported by funding from the Australian Government under the Health System Capacity Development fund, and is administered by Monash University. Postal Address: Andrology Australia School of Public Health and Preventive Medicine PO Box 315, Prahran, Victoria, Australia, 3181 Street Address: 99 Commercial Road, Melbourne, Victoria 3004 Telephone: Web: info@andrologyaustralia.org Facebook: AndrologyAustralia DISCLAIMER: This newsletter is provided as an information service. Information contained in this newsletter is based on current medical evidence but should not take the place of proper medical advice from a qualified health professional. The services of a qualified medical practitioner should be sought before applying the information to particular circumstances.

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