Myths and Truths of men over 35
The ADAM syndrome
By Juan J. Remos,M.D., M.B.A.

Do you find yourself more and more often coming home exhausted after a day's work, unwilling to accept social engagements because you have no energy? Do you seem to be more irritable, the gym does not give you the results you seek anymore, do you go to bed just to sleep, sexual fantasies are scarce and usually only in your days off, while good erections take longer to reach? Is your good memory simply not accessible anymore? What about those extra pounds around your waist, insidiously settling in over the last few years, with no farewell in sight, no matter how hard you try? If you are experiencing any of these symptoms you are suffering from ADAM, Androgen Deficiency of the Aging Male syndrome, scientifically termed Late Onset Hypogonadism or Andropause, a more descriptive name as I will later explain.

We have always been very familiar with and have fully embraced the concept of Menopause. For more than half a century hormonal replacement therapy (HRT) was synonym with the end of the child bearing age for women. But what about the male sex?. Is it that men were spared by the creator from this drastic biological downturn? Or was it that our gender was expected to tough it out honoring the title of the 'stronger sex'?

Neither one is true. Men experience also a 'male menopause' mainly because of a decline in Testosterone (T) production by the Leydig cells in the testes. At thirty we start to lose about 1 to 2 % of T per year. From the 700 million Leydig cells you are born with, 6 million will die every year after you turn thirty, resulting in an incidence of LOH of 5% of men 40 years of age, and 50% to 70% for those 70 years of age. The onset of ADAM is highly variable in intensity and variety of symptoms. Keep in mind that the human body is a multisystem, intelligently designed genus, and no component can function independently. So singling out T as the sole agent responsible for the biological changes of the aging male would leave out many elements of the physiology of Andropause and therefore fall short of its adequate treatment. But first let T have its fifteen minutes of fame.

T is produced in the testicles under the rule of a central commander in the brain, the pituitary gland which, via secretion of Luteinizing Hormone, primes Leydig cells in the male genitals to keep testosterone at a level mother nature considers ideal to mate and procreate. When that capacity of male gonads to perform at peak dwindles, we start to experience loss of sex drive, we may develop difficulty achieving or maintaining erections; memory, attention, concentration and mood suffer a turn for the worse, muscle strength and muscle mass diminish while fat tissue accumulates, bone density is affected, and energy and vigor seem to be less and less. Sperm count and ejaculate lessen, cholesterol profile may become unhealthy, and the list continues. The good news is that today you can greatly and safely correct and reverse all of these warning signs. A lot of misconceptions exist about HRT for men

Diagnosis of ADAM

First of all, to correctly make a diagnosis of ADAM you will need a measurement of bioavailable T. Most T is carried by SHBG (sexual hormone binding globulin) which renders it too big of a complex to penetrate the cells to carry out its duties. The one that circulates free plus the one loosely accompanied by Albumin constitutes the active T, the bioavailable one, small enough to get to the nuclear DNA and make us virile. Obesity, lack of exercise, high Estrogen levels, and age, all increase SHBG, causing more 'sequestering' of bioavailable T and aggravating the ADAM syndrome.

Second, and this is also very important, do not get fixated in the T level normal for your age. A T level that is in the 'normal range' for a 50 year old would make a 30 year old feel sick. Here is a good analogy: an 80 year old may have eyesight of 20/80, but we do not tell him 'this is normal eyesight for your age, go walk around nearly blind'. No, we give them corrective lenses trying to equip him with a 20/20 vision. In the treatment of Andropause same principle applies: we aim to bring patients to a T level of a 30 year old, where it is proven to be healthier. 'Normal ranges' are a statistical average of the prevalent values for a certain age range, and have nothing to do with the "healthy range' for that age group. So even if your doctor tells you your T level is normal for your age, you may already have Hypogonadism and if he does not raise your T levels, he is not treating your disease, leaving you exposed and vulnerable to the avatars of Andropause.

Treatment of ADAM

There are several ways to restore T to a younger value: from T boosters like human Choriogonadotropin Hormone (HCG), to creams, patches, gels and injections. If you are younger than 60, probably HCG alone or in combination with some T is the best for you. It is a lot more physiological, prevents infertility, and does not cause the wild swings in plasma T concentration that you may get using intramuscular T. Our preferred method of supplementing T when indicated is a compounded gel used at night. It reproduces the natural daily rhythm of T secretion, does not have many of the side effects of other forms, and it is not passed on to your partner on contact. It is also a lot cheaper than the commercially available gels. You could also be prescribed intramuscular injections, once a week, but there are peaks and valleys in T blood levels with consequent variations in mood and sexuality, and they can be painful and challenging to self administer. In Europe there is a new form of injectable T that is applied once every 3 months with good results. No oral form is available in the US. There is also an oral medication that is given to free up T from SHBG, therefore raising the bioavailable T. This modality is used mostly in Canada.

Treatment of ADAM should always be under the supervision of an experienced physician with adequate training in this field, an internist, endocrinologist, or primary care physician, who stays up to date in the latest modalities available for treatment of ADAM. Pre-treatment assessment and periodic monitoring of PSA, hematocrit (blood thickness), Estrogen, Dihydrotestosterone (responsible for hair loss and prostate enlargement), T levels, lipid profiles, and subjective progress, are all paramount to a successful HRT for men.

Testosterone Supplementation and Sexuality

It is important that your doctor understands your goals of treatment and sets realistic expectations regarding treatment outcomes, especially because T alone may not restore your sex life back to where it used to be. And this is because, even though male genitals are the only organ left outside the body, they are not autonomous from the rest of organs and physiological functions, and sexual life will be influenced by many factors such as stress, moods, the hormonal equilibrium, diet, cigarette smoking, alcohol consumption, exercise, relationship difficulties and sleeping problems. That is why I said earlier that T is not alone in this natural course of events for men over 35, and the term Andropause better reflects the complexity of this stage in the life of a man.

Erectile dysfunction, the inability to reach or keep an erection hard enough for intercourse, called impotence until 1992, is a frequent symptom of Andropause. This can have serious implications to a man's self esteem, relationships, moods, and overall feeling of well-being. Higher T levels correlate well with sexual desires, number of sexual fantasies and thoughts, and sex life in general. On the other hand, a clear relationship between erectile function and T level has not been established. What we know is that sildenafil (Viagra) and other phophodiesterase inhibitors (Cialis, Levitra) do work a lot better if there is higher T. ED is successfully treated in most cases taking into consideration all aspects of an individual's life: physical, emotional, cultural, social and spiritual.

Testosterone and the Brain

There are receptors of T everywhere in our body, however the brain is particularly rich. Among the many benefits of T supplementation, such as increase in muscle strength, lean mass, and bone density, loss of fat tissue, greater stamina and sexual drive, improvement in cognitive functions, such as memory, attention, concentration and, visuo-spatial abilities are notorious and well documented. However, As Dr. Halpern published in 2,000, women still outperform us in tests of verbal fluency, vocabulary and verbal memory.

Healthy T levels have been associated with marked improvement of depression, and prevention of dementia. In studies published in 2004 by The Journal of Neurology as well as the Journal of the American Medical Association, Alzheimer's disease is strongly associated with low levels of T.

Other hormones and Andropause

Other very important changes occur with aging: there will be reduced secretions of DHEA, and human Growth Hormone, both contributing to a functional decline, while there will be a raise in Cortisol, which impairs memory, creates fat and can render you hypertensive and diabetic. Compound this risk with an insulin and thyroid hormone resistance and you have now with certainty a formula for a progressive decline in your quality of life, and a greater chance of diseases, like the ones mentioned above plus heart disease, stroke, dementia, obesity, infections and osteoporosis.

Major food intolerances are a vastly ignored culprit of the decline of older age. Creating sensitivities to foods we eat every day, will bring inflammation that will interfere with our absorption of vitamins, mineral, essential fatty acids, and other nutrients, leaving us vulnerable to toxins, depression, arthritis, migraines, and much more. What's more, and as Pam Smith M.D. puts it in her new book, 'Demistifying Weight Loss', food intolerances are the main reason people gain or cannot lose weight.

Age Youthfully

Preventing and correcting all of these problems is not only desirable, but possible, and it is done on an everyday basis in competent and successful medical practices like ours in Miami, where we take the human being as a whole, and work under the principle that there has to be internal harmony as well as a healthy exchange with the environment. This is crucial and it is becoming a pivotal point in the human race, as Medicine evolves from a paradigm of focusing on the treatment of disease to one of researching, cherishing, and keeping a healthy existence by applying scientifically sound preventive methods.

It is for this reason that we can no longer approach Andropause, or the physiological changes of the aging male, as a simplistic, purely hormonal model. We must look at the whole picture in order to attain the optimal peak performance of our bodies. Disease starts at the cellular level, be it heart disease, high blood pressure, cancer, or high cholesterol. We have nowadays the scientific means to look at the cellular function, and its antioxidant and detoxification abilities, what foods you are intolerant to, and what your genetic map is, and we can engineer that internal harmony that will bring your performance in all spheres of life to new heights never thought attainable before to people 30, 50 or 70 years of age. If you feel reverence when you enter a temple, wouldn't you do a lot more for your body, which is the 'temple of the soul'?

For more information, contact: Laura Bierbaum
Behrman Communications: 212.986.7000