1. A memorandum on andropause management
Dr. Claude Chauchard
Paris, FRANCE
Chairman & CEO - La Clinique de Paris Group
Former Assistant Professor of
Montpellier University
Anti-aging Medicine World Congress
Monte Carlo, Monaco
April 8-10, 2010 1
© Claude Chauchard La Clinique de Paris 2009

2. Goal of Anti-Ageing Medicine
Increase Health Span not just lifespan
Increase lifespan if:
strong and vigorous
happy content creative
spiritually satisfied
No one wants to live longer with debility or chronic illness or cognitive impairment 2
© Claude Chauchard La Clinique de Paris 2009

3. Balanced hormone replacement therapy
All hormones restored to years old level and monitored by regular serum levels
Natural (Bioidentical) hormones
Identical molecular structure to hormones produced by human female or male
Not xeno hormones or horse hormones
Synthetically produced 3
© Claude Chauchard La Clinique de Paris 2009

4. Balanced HRT Claude.ch@lcdpi.com Human growth hormone
DHEA, Pregnenolone, Melatonin
Testosterone in men and women
Estrogens and Progesterone in women (Bio-identical hormones)
Not Premarin or Provera (MPA)
Thyroid (T3 and T4, not just T4) 4
© Claude Chauchard La Clinique de Paris 2009

5. We age because our hormones decline, our hormones don’t decline because we age
Testosterone replacement therapy is safe and can provide dramatic benefits 5
© Claude Chauchard La Clinique de Paris 2009

6. Andropause & Menopause
Breast Cancer 
Prostate Cancer 
Osteoporosis 
Cardiovascular Disease 
Sexual function 
Well being 
Body Fat 
Estrogen 
Testosterone  6
© Claude Chauchard La Clinique de Paris 2009

7. Symptoms of Change of Life
Male
Female 7
© Claude Chauchard La Clinique de Paris 2009

8. Testosterone & Prostate8
© Claude Chauchard La Clinique de Paris

9. How to evaluate the right patient for HRT and Prostate Prevention?
Overview
How to evaluate the right patient for HRT and Prostate Prevention?
Clinical Symptoms of Male Menopause
Physical Exam
Blood Pressure
Prostate condition - Rectal Touch (smooth or not)
Lean Mass
Fat Mass
Loss Hair on Legs
PSA
Free PSA
PSA Velocity
FSH, LH, Test., Free T, SHBG, E2
CBP
Kidney & Liver Function
Prostate Sonography – study of urinary flow
Bone Density
Abdominal Sonography
Bladder Full
UIV
ECBU 9
© Claude Chauchard La Clinique de Paris

10. Male Menopause = Andropause
Less sudden in onset than female menopause
Just as severe in long term consequences
The cause …
Decreased bioavailable
TESTOSTERONE 10
© Claude Chauchard La Clinique de Paris 2009

11. Male Menopause Claude.ch@lcdpi.com Fatigue Depression Irritability
Reduced libido and potency
Decreased desire and fantasies
Decreased morning erections
Decreased erectile tension
Longer recovery time between orgasms
Decreased intensity of orgasms 11
© Claude Chauchard La Clinique de Paris 2009

12. Male Menopause Claude.ch@lcdpi.com
Increased aging of heart and circulation
Increased MI’s and CVA’s
Decreased hemodynamic function
Increased brain aging
Decreased memory
Decreased intelligence
Increased Dementia, Alzheimer’s 12
© Claude Chauchard La Clinique de Paris 2009

13. Male Menopause Claude.ch@lcdpi.com Loss of drive and competitive edge
Stiffness and pain in muscles and joints
Falling level of fitness
Decreased effectiveness of workouts 13
© Claude Chauchard La Clinique de Paris 2009

14. Male Menopause TESTOSTERONE Claude.ch@lcdpi.com The cause …
Decreased bioavailable
TESTOSTERONE
Plus
Stress
Alcohol
Increased fat especially abdominal fat
Lack of exercise 14
© Claude Chauchard La Clinique de Paris 2009

15. Does T decline with age ? Claude.ch@lcdpi.com
Older studies showed no difference
Did not measure free T
Did not get AM samples
Total T, Free T, Bioavailable T, E1 and E2 decline with age
T declines 10 ng/dl per year
Free T 1% per year
All T measures correlated with strength, BMD body composition, fat mass 15
© Claude Chauchard La Clinique de Paris 2009

16. Sex Hormone Binding Globullin (SHBG) binds T > E
20-60 nmol/l male
nmol/l female
Free Androgen Index
Testosterone x 1000 / SHBG
T is tightly bound to SHBG and loosely bound to albumin
Free T is unbound to SHBG or albumin
Bioavailable T = unbound + loosely bound 16
© Claude Chauchard La Clinique de Paris 2009

17. Claude.ch@lcdpi.com 17 © Claude Chauchard La Clinique de Paris 2009
Serum Concentration (ng/dl)
800
700
Young Men
600
500
Old Men
400
Clock Time (Hours) 17
© Claude Chauchard La Clinique de Paris 2009

18. Claude.ch@lcdpi.com 18 Hypothalamus Aromatase DHT Anterior Pituitary
GnRH
Aromatase
DHT
Estrogens
Anterior
Pituitary
5-alpha Reductase
FSH LH
TESTOSTERONE
Inhibin
Leydig cell
Sperm
Sertoli cell
Testes 18
© Claude Chauchard La Clinique de Paris 2009

19. Methods of TRT Claude.ch@lcdpi.com
Injections of T enathate or T cypionate
Older method 200 mg q 2 weeks
Roller coaster effect
Suprahysiologic levels followed by low levels
More aromatization to Estradiol
More polycythemia
Less DHT increase thatn transdermal
Weekly dose 100 mg
More physiologic stable levels
Less aromatization to Estradiol 19
© Claude Chauchard La Clinique de Paris 2009

20. Methods of TRT Claude.ch@lcdpi.com Oral – Methyltestosterone
Hepatotoxic, contraindicated
Oral – T undecanoate (Andriol)
Lymphatic absorption, no hepatic toxicity reported
Must use TID
No available in US
Subcutaneous pellets
Minor surgical procedure
Last 2-3 months 20
© Claude Chauchard La Clinique de Paris 2009

21. Transdermal Claude.ch@lcdpi.com
Well absorbed as proven by serum levels
More DHT since hair follicles contain 5 alpha reductase
Steady state after 24 hours
Scrotal (Testoderm) – shaved scrotum required, inconvenient, high DHT
Patches (Androderm) – Delivers 5 mg per day, inconvenient, expensive 21
© Claude Chauchard La Clinique de Paris 2009

22. Transdermal Claude.ch@lcdpi.com Androgel Compounding pharmacies
1% transdermal gel
Commercially available
50, 75 or 100 mg packages
Compounding pharmacies
Can custom produce transdermal gel
Can titrate to serum levels by varying percentage and dose
Preferred method in most men 22
© Claude Chauchard La Clinique de Paris 2009

23. T gel precautions Claude.ch@lcdpi.com Avoid scrotum (increased DHT)
Avoid getting gel on females and kids
Rub in well over large surface area
Can increase hair growth in area of application but (unfortunately) not on head 23
© Claude Chauchard La Clinique de Paris 2009

24. Dihydro Testosterone Claude.ch@lcdpi.com More potent than T (2-5x)
Conversion of T to DHT via 5-alpha- reductase
Not aromatizeable to Estrogens
Is DHT an important beneficial androgen or is DHT the evil twin of Testosterone ? 24
© Claude Chauchard La Clinique de Paris 2009

25. DHT Gel 70mg Vs. Placebo Claude.ch@lcdpi.com
Men > 60 yo, T < 15 nMol/l = 428 ng/dl
Decreased LDL, no change HDL
Increased Hemoglobin/Hematocrit
Decreased Fat Mass
Knee strength increased not other muscles
No change QOL
No change PSA or prostate volume
Ly LP et al. Randomized Clinical Trial of Transdermal Dihydrotestosterone Gel on Muscular Strength, Mobility and Quality of Life in Older Men with Partial Androgen Deficiency
J Clin Endocrinol Metab : 25
© Claude Chauchard La Clinique de Paris 2009

26. DHT RT Reduces Prostate Size
1.8 year study
BPH requires both DHT and E2
De Lignieres B Transdermal dihydrotestosterone treatment of ‘andropause’
Ann Med Jun; 25(3):235-41 26
© Claude Chauchard La Clinique de Paris 2009

27. DHT For Andropause Claude.ch@lcdpi.com
DHT gel mg/day vs Placebo x 6 months
Improved erections and morning erections
Decreased LH, FSH, E2, T and SHBG
No change lipids or hepatic function
Hg/Hct increased
No change in prostate weight or PSA
Kunelius P et al. The effects of transdermal dihydrotestosterone in the aging male: a prospective, randomized, double blind study. J Clin Endocrinol Metab Apr; 57(4): 27
© Claude Chauchard La Clinique de Paris 2009

28. HCG Injections Claude.ch@lcdpi.com Human Chorionic Gonadotropin (HCG)
Polypeptide hormone produced by the human placenta
Alpha and beta sub-unit
Alpha sub-unit is essentially identical to the alpha sub-units of LH and FSH 28
© Claude Chauchard La Clinique de Paris 2009

29. HCG Claude.ch@lcdpi.com
If there is no Leydig cell failure can treat hypogonadism with HCG injections
units per week
No decrease in testicular size or sperm count
Can use as TRT (measure free T to confirm success) or cycle with TRT every 6 months
Zilzmann M Hormone substitution in male hypogonadiam Mol Cell Endocrinol Mar 30; 161(1-2):73-88 29
© Claude Chauchard La Clinique de Paris 2009

30. Claude.ch@lcdpi.com Improved with patch and gel With gel but not patch
Sexual function
Mood
Muscle strength, leg > arm
Subjects did not exercise
With gel but not patch
Improved lean body mass and fat mass
Correlated with serum level of T obtained 30
© Claude Chauchard La Clinique de Paris 2009

31. Claude.ch@lcdpi.com No change in lipid profile including HDL
Skin Irritation
5.5% gel, 66% patch
Hg/Hct increase in 100 mg gel group
Mean 1.3/4.1
PSA
Small increase with gel but not patch
Correlated with serum T
Remained within normal range
Stabilized on day 90
50 mg 0.17 increase 100 mg 0.2 increase
Prostate symptom score : no change 31
© Claude Chauchard La Clinique de Paris 2009

32. S e x Claude.ch@lcdpi.com Improved
Enjoyment with partner
Erection firmness
Sexual performance
Sexual desire
Not related to dose or method of delivery or serum T obtained 32
© Claude Chauchard La Clinique de Paris 2009

33. T and Erectile Function
T > Placebo
Transdermal (81%) > Oral (51%) or IM (53%)
All statis. Significant
Jain P et al. TESTOSTERONE SUPPLEMENTATION FOR ERECTILE DYSFUNCTION: RESULTS OF A META- ANALYSIS : J Urol 2000 Aug; 164(2): 33
© Claude Chauchard La Clinique de Paris 2009

34. T and Memory Claude.ch@lcdpi.com
T supplementation increased working memory in men
No similar charge with estrogen in women
Janowsky J et al. Sex Steroids modify working memory J Cogn Neurosci May; 12(3):407-14 34
© Claude Chauchard La Clinique de Paris 2009

35. T and Mood (and Erections)
Effective when psych drugs do not work in pts with low T
Cooper MA. Testosterone Replacement Therapy for Anxlety Am J Psychiatry 157:1884, Novermber 2000
TRT increases nocturnal and spontaneous erections and improves mood.
Burris A et al. A long-term, prospective study of the physiologic and behavioral effects of hormone replacement in untreated hypogonadal men. J Androl 1993 Jul-Aug; 13(4): 35
© Claude Chauchard La Clinique de Paris 2009

36. Does TRT increase angry behavior ?No
Tricker R et al. The effects of supraphysiological doses of testosterone on angry behavior in healthy eugonadal men- a clinical research center study
J Clin Endocrinol Metab 1996 Oct; 81(10):3754-8 36
© Claude Chauchard La Clinique de Paris 2009

37. Adverse Effects Claude.ch@lcdpi.com Fluid retention (rare)
Does TRT accelerate male pattern hair loss ? No Info.
Possible increase in sleep apnea
Possible decrease in testicular size
Decreased sperm count 37
© Claude Chauchard La Clinique de Paris 2009

38. Testosterone Replacement in men improves:
Libido
Erectile Function
Mood
Memory
Angina
Type 2 diabetes
Muscle mass
Fat 38
© Claude Chauchard La Clinique de Paris 2009

39. Testosterone Replacement in men may prevent:
Heart Disease
Diabetes
Insulin Resistance
Alzheimer
Osteoporosis 39
© Claude Chauchard La Clinique de Paris 2009

40. Sexy Increased libido Increased sexual pleasure and performance
Improved body image 40
© Claude Chauchard La Clinique de Paris 2009

41. This is how much the male hormone replacement can keep you younger
All my wishes to you 41