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Men’s Health
Dr. Martin de Villiers
MB ChB (Stell.) DOM FCFP (SA) MBL
Family Physician
Men’s Health
The purpose To heighten the awareness of preventable health problems; Encourage early detection and treatment of disease among men and boys.
LIFE EXPECTANCY SOUTH AFRICA USA
Women 62 80
Men 56 75
PROBABILITY OF
DYING BETWEEN
15 AND 60 / 1000
Women 350
Men 463
WHY?
• Part of the answer is that we don’t know
• Biological / genetic differences might play a part -
testosterone
• The persisting myth that men don’t visit their doctors and
that they don’t like to talk about their health problems.
• Behavioural differences with men more likely to smoke, drink
alcohol and drive fast.
Corona et al., J Sex Med 2011;8:3869.
male external
& internal genitalia
Testosterone
male external
& internal genitalia
o Increased prevalence of NCD compared to women of similar age
o Mental health
o Sexual and Genito-urinary health: o Prostate o Erectile dysfunction (ED)
o Endocrine Health
o Hypogonadism and Testosterone deficiency syndrome (TDS)
o
Key Issues in Mens Health
Hypogonadism / Testosterone Deficiency
What is it?
• Inadequate function of the testes
o Primary – problem in testes
o Secondary – hypothalamus / pituitary
Focus today: Adulthood / Late onset
TD is a clinical AND biochemical syndrome associated with
age and characterized by a deficiency of serum testosterone
levels.
It may affect the function of multiple organ systems, and result
in significant detriment in the quality of life, including
alterations in sexual function (EBMl 2).
-
Definition of Testosterone Deficiency (TD)
Buvat et al., J Sex Med. 2013;10:245
Threshold levels for the biochemical diagnosis of
TD
- TT > 12 nmol/L does not usually require substitution (EBMI1)
- Based on the data of young hypogonadal men, men with TT <
8 nmol/L usually benefit from T treatment (EBMI1)
Buvat et al., J Sex Med. 2013;10:245
Aging male symptoms
• Lethargy & fatigue
• Muscle and joint pains, osteoporosis
• Increased sweating
• Reduced muscle mass and strength
• Abdominal obesity
• Reduced body and facial hair
• Gynaecomastia
• Cognitive: Poor concentration, reduced memory
• Psychological: Depressed mood , Irritability
Most specific and frequent signs and symptoms:
Signs and symptoms indicative of testosterone
deficiency (TD)
BMI, body mass index
Reduced sexual desire
Erectile dysfunction
Decreased spontaneous erections
Increased BMI, visceral obesity
Corona et al., J Sex Med 2011;8:3869.
Libido and Sexual Performance
• Decreased libido
– Is it not strange that desire should so many years outlive performance? W Shakespeare (Henry iv part2)
• ED
• Ejaculatory disturbance
Prevalence of Hypogonadism for Selected
Co-Morbidities in 2,162 Patients (mean age:
60.5 years) Attending Doctors’ Offices
Medical Condition Hypogonadism
Prevalence Rate
(95% C.I.)
Obesity 52.4 (47.9–56.9)
Diabetes 50.0 (45.4–54.5)
Hypertension 42.4 (39.6–45.2)
Dyslipidaemia 40.4 (37.6–43.3)
Mulligan T et al. Int J Clin Pract 60: 762-769 (2006)
Metabolic Syndrome
19
The Metabolic Syndrome
Metabolic syndrome is a collection of cardio-vascular risk
factors that increase your chance of developing heart
disease, stroke, and diabetes.
• Obesity – umbilical circumference >94cm and BMI>30kg/m² • A blood pressure of 130/85 mm Hg • A fasting blood glucose >5.6mmol/L • A high density lipoprotein level (HDL) <1mmol/L • A triglyceride level >1.7mmol/L
94 cm – start working on it
102 – danger zone
21
Subcutaneous vs. Visceral (Abdominal) Obesity
Central obesity(abdominal fat) is
more likely to be linked with insulin
resistance .
Adipose tissue as endocrine
active organ
Abdominal fat can adversely impact insulin sensitivity in numerous ways
including the production of potentially harmful levels of cytokines.
Insulin Resistance: An Inherent Metabolic
Abnormality of Type 2 Diabetes and CVD
Increased Free Fatty
Acids
Increased Glucose
Production
Visceral Obesity
Atherosclerosis
Insulin Resistance
Hyperinsulinemia
Type 2 Diabetes
Inflammation (CRP)
Endothelial Dysfunction
Hypertension
Impaired Fibrinolysis (PAI-1)
Dyslipidemia (HDL, sdLDL, TG)
Environment Genes
Towards Men’s Health and Wellness
What you can we do?
Go for regular check-up
Men’s Health tracking sheet
Erectile Dysfunction:
A New Appreciation
NIH Consensus Statement. 1992 Dec 7-9;10(4):1-35.
ED – more than just performance!!
Penile Artery
(1-2mm) Coronary
Artery (3-4mm)
Internal Carotid Artery
(5-7mm)
Femoral Artery
(6-8mm)
Montorsi et al, 2004
Obesity
Diabetes Hypertension
Dyslipidaemia
• Insulin resistance was seen in 79.2% of the ED population
vs. 25% in the general population
• ED should be considered a sentinel for CV disease
Guay et al. J Sex Med 2004, 1(Suppl 1): 75.
Remember obstructive sleep apnoea
o Significant sleep disturbances
o Snoring
o Possible pauses
o Daytime drowsiness
May benefit from further investigation for a treatable sleep-related breathing disorder,
MANAGEMENT
Testosterone
Replacement Therapy
Indications
Low s-Testosterone and
• Sexual health problems
• Metabolic syndrome
Testosterone cypionate IM
Testosterone undecanoate IM
One Year Testosterone Therapy with Testosterone Undecanoate (TU) Improves Body Composition in Men (60-80 years)
4.2kg
-5.4kg
-1.2kg
-6
-4
-2
0
2
4
6
TU
Placebo
Fat-Free Mass Fat Mass
p<0.001
p<0.001
Total Body Mass
N=16 N=18
N=16 N=18 N=17 N=18
Mean
Ch
an
ge (
DE
XA
)
Svartberg J et al. Int J Impot Res 20: 378-387 (2008)
Effects of Long-Acting TU on Waist Circumference (cm) in 40
Hypogonadal Men (T<11.1 nmol/L) with Metabolic Syndrome
(IDF criteria)
109
107
101
98
96
108
107 107
109
108
90
100
110
baseline 6 months 12 months 24 months 36 months
Wais
t C
ircu
mfe
ren
ce (
cm
)
Testosterone (n=20) Control (n=20)
*
**
**
*p<0.001
**p<0.0001
- 13 cm
Aversa A et al. Aging Male 15(2): 96-102 (2012)
8.27
7.92 7.93
7.7
7.46
7.67
7.54
7
7.5
8
8.5
baseline 18 weeks 30 weeks 82 weeks
Hb
A1
c (
%)
Testosterone Placebo
Hackett G et al. J Sex Med 9 (Suppl. 4): 205 (2012)
Significant improvement in insulin resistance and positive
impact on T2D and metabolic syndrome
TRT the treatment for ED?
• Will improve sexual desire
• Will improve ejaculatory and orgasmic function
• Improvement in general well-being, depression, cognitive function and quality of life.
AGING IS OPPORTUNITY!
Life in old age depends
• on what we make of it
• and in what state of health we reach that stage.
Brundtland 1998
Cancer in Males
Prostate 24%
Lung 13%
Colorectal 9% Liver
6%
Haem 5%
Kaposi 4%
Melanoma 3%
Bladder 3%
Oesofagus 9%
Pancreas 2%
Larynx 2%
Other 20%
Cancer Incidence: Men
Women 170.1 / 100 000
Men 254.8 / 100 000
Prostate Cancer
Prostate Cancer
May 2008
No Warning!
• Since symptoms can be caused by other conditions annual testing is KEY!
• Prostate Specific Antigen (PSA), a blood test
• Digital Rectal Examination (DRE), a physical exam
Age Recommended screening
< 40 No routine screening
Identify high-risk individuals
40 – 50
DRE (digital rectal examination) Annual PSA -
Only high-risk
>50-75 DRE Annually
PSA Annually
>75 No screening
How does early detection help?
• Survival rate at 5 years is 99% for those whose cancer is still just in the prostate gland (localized).
• Survival rate at 5 years for those whose cancer has spread beyond the gland (late diagnosis) is only 31%
Treatment options
• Deferred treatment
• Watchful waiting
• Active surveillance
• Radical prostatectomy
• Radiation
• Ablative treatment options
• Cryotherapy
• Ultrasound - High-intensity focused ultrasound
(HIFU)
Testicular Cancer
The Burden of Testicular Cancer
Annual incidence of 4 per 100,000 men About 1% of all male cancers Most common cancer in males aged 15-34 years Early detection and treatment yields better patient outcomes
o 5-year survival rate of 92% (Stage I >97%) o Cure rates greater than 80% (for all Stages)
“I always had the size difference there, but I didn’t know…
I would’ve still been waiting if it hadn’t started hurting, it just got so painful I couldn’t sit on my bike anymore.”
Other Cancers
Remember the Breast!!
The incidence of breast cancer in males is increasing
a family history of breast cancer
Lung Cancer
• Family History
• Polyps
• Change in bowel habits
• Bleeding
Doctor must know of it!!
Colorectal Cancer
56
Closing Thought
Make mens health a priority.
Encourage men to take action daily to live a healthier and
productive life.
Thanks!!