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

Testosterone Replacement Therapy

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!!