DISCLOSURES HORMONE THERAPY IN AGING MALE ATHLETES No relevant affiliations or financial interests When, Why and is it Safe? OBJECTIVES Summarize the benefits of optimizing hormone balance Examine the risks and controversies surrounding testosterone therapy Discuss monitoring and managing therapy for maximum benefit AGING the fundamental manifestation of aging is an overall decline in the functional capacity of various organs to maintain tissue homeostasis and to respond adequately to physiological needs under stress. Kirkland, TB, Understanding the odd science of aging, Cell 120, 437 447 (2005) SUCCESSFUL AGING Low probability of disease and disease related disability High cognitive and physical functional capacity Active engagement with life JW Rowe & RL Kahn, Successful Aging, The Gerantologist, vol 37, no. 4, pg 433 440, 1997 Jack Lalanne 1
INFORMED CHOICES FUTURE VISION LIFE YOU WANT TO LIVE Generally oxygen uptake declines 10 15% per decade after age 20 An accumulation of body fat and a decrease in habitual physical activity accounts for about half of that age related decrease. Calvo JA, Daniels, TG, et al. Muscle specific expression of PPAR(gamma) coactivator1(alpha) improves exercise performance and peak oxygen uptake. J Appl Physio 2008; 104:1304 1312 SARCOPENIA AGING ATHLETE Largest loss of muscle mass occurs between age 50 75 Decline in anabolic hormones loss of muscle mass Muscles Ligaments Tendons J. 2013 Oct Dec; 3(4): 346 350 reduced strength reduced aerobic capacity diminished performance ANABOLIC HORMONES Testosterone Increases lean muscle Reduces body fat Improves cognition Enhances sex drive Improves erectile quality Increases energy Enhances mood and wellbeing HGH Increases lean muscle Reduces body fat (VAT) Improves sexual desire Increases bone density Improves skin elasticity Enhances mood Up to 1 in 3.5 men over 50 will suffer a fracture due to osteoporosis 2
CONTROVERSY: PROSTATE CANCER RISK Age associated decline in anabolic hormone levels (testosterone, DHEA and growth hormone) is a strong predictor of mortality in older men. withholding of testosterone replacement therapy in men because of fear of prostate cancer risk or progression is no longer tenable in an age of evidence based medicine, because neither evidence nor theory supports this position. Maggio M, Lauretani F, et al, Relationship Between Low Levels of Anabolic Hormones and 6 Year Mortality in Older Men Arch Intern Med. 2007;167(20):2249 2254. doi:10.1001/archinte.167.20.2249 Morgantaler A, meta analysis Harvard University, 2007 PILOT STUDY: TESTOSTERONE IN ADVANCED PROSTATE CANCER All patients reported symptomatic benefits, including improved energy, cognition, libido, sexual function, and sense of well being. There were no cases of disease flare, acute pain, or vertebral collapse. Sexual Medicine Society of North America (SMSNA) Fall 2017 Scientific Meeting. Abstracts 132 and 340. Presented October 26, 2017. CONTROVERSY: CARDIAC RISK In 2014, two methodologically flawed retrospective studies suggested an increased CV risk associated with testosterone therapy FDA issued a drug safety alert Results are contradicted by dozens of studies showing CV benefits testosterone therapy, or higher endogenous levels, including placebo controlled studies in men with known heart disease Morgentaler, A. Controversies and advances with testosterone therapy: A 40 Year Perspective. TESTOTERONE LOWERS CVD RISK 83,000 veterans, 3 groups: Rx/normal, Rx/low, non Rx/low Normalization of TT levels after TRT was associated with a significant reduction in all cause mortality, MI and stroke Treated men were 56% less likely to die, 24% less likely to have an MI and 36% less likely to have a stroke Journal of cardiovascular pharmacology and therapeutics. 2017:epub. Traish A, Haider A, Haider K, Doros G, Saad F Sharma, R. et al. (2015). Normalization of testosterone level is associated with reduced incidence of myocardial infarction and mortality in men. European Heart Journal. 3
TESTOSTERONE THERAPY IS SAFE AND EFFECTIVE We agree with the current opinions of the AACE/ACE as well as the international expert consensus panel that testosterone treatment should be considered for symptomatic men with clinically confirmed hypogonadism. The benefits of treatment of low testosterone levels with testosterone therapy in men and women substantially outweigh any risks, according to the current data. HOW TO DIAGNOSE LOW T Rigid interpretation of testosterone ranges should not dictate clinical decision making Give equivalent weight to signs and symptoms of hypogonadism and to laboratory assessment Elagizi A, Kohler T, Lavie C, Testosterone and Cardiovascular Health, Mayo Clinic Proceedings, Jan 2018 Bankhead, C (2014). Need more than Lab Test to determine Low T. Urology. TESTOSTERONE RANGES GRADE TOTAL TESTOSTERONE (ng/dl) A > 900 >150 FREE TESTOSTERONE (pg/ml) B 650 900 110 150 C 450 650 70 110 D 250 450 35 70 F < 250 < 35 ANDROGEN ASSAYS Though laboratory assays can support a diagnosis of androgen deficiency in men, they should not be used to exclude it. There needs to be greater reliance on the history and clinical features and where necessary a therapeutic trial of androgen treatment given Carruthers, Trinick, Wheeler (2007). The validity of androgen assays. The Aging Male. 10 (3) p. 165 172. TESTOSTERONE METABOLISM ESSENTIAL LABS TO EVALUATE LOW T DHEA 5 alpha reductase DHT Androstenidione Testosterone aromatase Estradiol Testosterone, free and total Dihydrotestosterone (DHT) Estradiol DHEA S Sex Hormone Binding Globulin (SHBG) CBC Luteinizing Hormone (LH) Prolactin 4
Therapy Options Testosterone Injections Topical Pellets HCG Clomid 51 YEAR OLD HOCKEY PLAYER Total T (mg/dl) Free T (pg/ml) VO2 (ml/kg/min) Lean (lbs) Body Fat% Before 214 44 33.1 152 27 1yr later 908 230 43.5 164 14 KEY TAKEAWAYS Hormone therapy can improve performance, reduce disease risk and premature death. Testosterone therapy is safe and effective Signs and symptoms should carry an equivalent weight to lab analysis in clinical decision making Enhancing performance is the best method for optimizing your personal health and well being, achieving your goals and living your life as the best version of yourself 5
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