Deficiencia androgénica en la madurez (ADAM) Dr. Román Carvajal Urólogo

Durante el siglo 20, el promedio de vida en el mundo occidental aumento de 49 años al inicio del mismo a75 años en México en la última década. En estos hombres adultos mayores ocurrirán cambios hormonales en particular la deficiencia androgénica. Gran cantidad de adultos mayores están interesados en la terapia hormonal como medio para preservar su virilidad o como búsqueda de la fuente de la juventud. (ADAM)

Desafortunadamente el hipogonadismo masculino se encuentra infradiagnósticado e infratratado. Solo 5% de 5 millones de hombres con hipogonadismo son tratados en (USA). Los hombres experimentan una lenta pero continua disminución de la testosterona (1-2% por año) después de la edad de 30 años.

El sistema endocrino cambia con la edad Further Endocrine Changes in the Aging Male Aging is characterized by the reduced production of a number of hormones. These include dehydroepiandrosterone (DHEA), growth hormone and melatonin. These changes do not take place in isolation but influence each other and lead together to increasing desynchronisation of the body's organisation. A good example of this is the interaction of melatonin and growth hormone. Thus, the decreasing melatonin production is thought to be partly responsible for the age-related sleep disturbances. Sleep, on the other hand, is the strongest stimulus for the secretion of growth hormone. It is also known that a number of these changes influence the hypothalamic-pituitary system (e.g. gonadotropin secretion) and may thus modulate the production of testosterone. Dehydroepiandrosterone (DHEA) and its metabolite dehydroepiandrosterone sulfate (DHEAS) are prohormones of testosterone and estrogen produced in the adrenal cortex. It is assumed that DHEAS is not only a prohormone but also has hormonal actions of its own. In particular, these include positive effects on the immune system. It is also thought that low DHEAS levels may be correlated with diabetes mellitus, rheumatoid arthritis and coronary heart disease. The highest plasma levels of DHEAS are reached at the age of 20 to 25, after which levels fall continuously. In some countries, DHEA is classed as a food supplement and is widely used in the context of anti-aging campaigns. However, DHEA supplementation in old age cannot be generally recommended until results of large placebo-controlled studies are available. Concentrations of growth hormone (somatotropin, STH, HGH) also decrease with age (somatopause). The symptoms of a growth hormone deficiency partly resemble those of testosterone deficiency. Production of melatonin also decreases with age. Melatonin is produced in the pineal body and regulates the body's day-night rhythm. The increased occurrence of sleep disturbances with increasing age is also thought to be causally linked to the declining production of melatonin. www.get-back-on-track.com

Deficiencia androgénica por la edad Las causas de hipogonadismo relacionada a la edad no han sido totalmente descritas. Pareciera que el origen es disregulación hipotalámica: Disminución de la secreción de GnRH por el hipotálamo Disminución de la respuesta de las células de Leydig a la estimulación por LH. ADAM, LOH, PADAM, Andropausia,

Deficiencia androgénica por la edad Síndrome Clínico-bioquímico: edad-deficiencia testosterona +/- sensibilidad disminuida a andrógenos. Con alteración en QoL y compromiso en diferentes órganos y sistemas. (Rec 1) * Cuestionarios: Androgen Deficiency in the aging male (ADAM-questionary-St Louis): 88% sensibilidad & 60% especificidad. Massachusetts Male Aging Study (MMAS): 76% sensibilidad & 49% especificidad. El Principal indicador es la disminución de la Testosterona libre For calculation please see www.issam.ch Testosterone Determination in the Aging Male The circadian rhythm of testosterone production becomes less marked with increasing age. Nevertheless, to ensure better reproducibility, collection of blood samples in the morning is still recommended. Androgen deficiency of the aging male is characterised particularly by a decrease in free testosterone accompanied by an increase in the biologically inactive fractions bound to SHBG. Therefore, determination of free testosterone would permit more precise evaluation in older patients. However, determination of free testosterone is very expensive and there are currently no reliable routine methods available. Until such time as suitable tests are established the free testosterone can be calculated relatively accurately from the total testosterone and SHBG. * ISSAM (Morales, 2002) (Berlin 2002) ISA-ISSAM-EAU (Nieschlag, 2005) (Praga 2004)

Cuestionario St. Louis Un cuestionario es positivo si las respuestas son AFIRMATIVAS en las preguntas 1 o 7 , o a tres preguntas cualquiera. For the AMS see UMAC, www.get-back-on-track.com or other sources. The AMS was validated in many languages. I allows a more detailed assessment as well as giving first information about severity of symptoms

ISSAM-ISA-EAU (Nieschlag, 2005) LOH : clínica (Rec 2)* Disminución líbido, disfunción eréctil Psicológicas-cognitivas Transtornos del sueño Disminución de masa magra, volumen muscular y fuerza muscular. Incremento de la grasa visceral Alteraciones en pelo corporal (pecho, pubis) y piel Osteopenia / osteoporosis For calculation please see www.issam.ch Testosterone Determination in the Aging Male The circadian rhythm of testosterone production becomes less marked with increasing age. Nevertheless, to ensure better reproducibility, collection of blood samples in the morning is still recommended. Androgen deficiency of the aging male is characterised particularly by a decrease in free testosterone accompanied by an increase in the biologically inactive fractions bound to SHBG. Therefore, determination of free testosterone would permit more precise evaluation in older patients. However, determination of free testosterone is very expensive and there are currently no reliable routine methods available. Until such time as suitable tests are established the free testosterone can be calculated relatively accurately from the total testosterone and SHBG. * ISSAM (Morales, 2002) ISSAM-ISA-EAU (Nieschlag, 2005)

Nebido - Características Indicación: Hipogonadismo primario y secundario Dosificación: 1000 mg c/ 10-14 semanas. 1 y 2 dosis: 6 semanas 2 y 3; 3 y 4, etc : cada 12 semanas Presentación: 1000 mg TU en 4 ml (aceite de castor y benzoato de bencilo)

Nebido - Características Indicación: Hipogonadismo primario y secundario Dosificación: 1000 mg c/ 10-14 semanas. Presentación: 1000 mg TU en 4 ml (aceite de castor y benzoato de bencilo) T media: 12 días, duración de efecto de 84 días. Permite obtener niveles fisiológicos. Buen cumplimiento con 4 a 5 inyecciones por año Niveles se mantienen sostenibles entre dosis

Nuevas Tendencias en la terapia con Testosterona Síndrome metabólico en el varón (OMS, EGIR 1999) Síndrome de la civilización (Björntorp 1993) Síndrome X / neuroendocrino Frailty (def. cognitiva, física, sensorial, nutricional). Alto riesgo de comorbilidades. Disminución de masa muscular: HIV, caquexia; inclusive en mujeres. Anticonceptivo masculino: NETE 200 mg + TU 1000 mg c/8semanas (Meriggiola-Bologna-2005) LNG + TU (Si-Tian Liu-Shangai-2004)