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a Unimed Pharmaceuticals, Inc., Deerfield, Illinois
b PPD Development, Inc., Wilmington, North Carolina
Carole Cranor, PPD Development, Inc., 3900 Paramount Parkway, Morrisville, NC 27560 E-mail: carole.cranor{at}rtp.ppdi.com.
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Abstract |
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Methods. Brief surveys were administered to HCPs and members of the general public who called a medical information telephone line. Trained clinical interviewers surveyed participants for experiences with andropause and TRT and knowledge about nonsexual effects of low testosterone in men.
Results. Of 443 general public callers, 377 (85%) agreed to participate in the survey. Of these participants, 77% had heard of andropause or male menopause, and 63% had taken TRT. Of 88 HCP callers, 57 (65%) participated. Of these participants, 65% were pharmacists, 80% had encountered patients with symptoms of low testosterone, and 50% reported that patients rarely or never initiated conversations about low testosterone. Among HCPs and the general public, respectively, 98% and 91% knew that low testosterone is treatable with medication, and 60% and 57% knew that it results in osteoporosis. Only 25% of HCPs and 14% of the general public knew that low testosterone does not cause loss of urinary control.
Conclusions. HCPs and members of the general public are knowledgeable about some aspects of low testosterone and have misconceptions about others. Educational initiatives are needed.
ANDROPAUSE, or age-related hypogonadism, is a term used to describe the natural age-related decline in testosterone in men. Testosterone replacement therapy (TRT), the primary treatment for other types of male hypogonadism, has well documented sexual and nonsexual benefits. Its use in andropause is more controversial and has been researched less. Among aging men, the nonsexual benefits of TRT may be especially important, because TRT can reduce the negative health consequences of age-related frailty (1). It is not known whether health care professionals (HCPs) and members of the general public are aware of these nonsexual benefits.
Other terms used to describe age-related male hypogonadism include male menopause, male climacteric, and androgen decline in the aging male (ADAM) (2). Male hypogonadism, or androgen deficiency, is characterized by a decrease in testosterone production in the Leydig cells of the testes, a dysfunction in the hypothalamic–pituitary axis, or both. Testosterone is the predominant androgenic hormone responsible for the primary and secondary male sex characteristics. Not only is it essential for maintaining male pattern hair growth, libido, and spermatogenesis, but it is necessary for maintaining lean body mass, bone density, muscle strength, and erythropoiesis throughout the life cycle (3)(4)(5)(6).
The medical literature on male hypogonadism has only recently begun to address the prevalence, diagnosis, and treatment of andropause (3)(5)(6)(7). Epidemiological support for andropause is found in cross-sectional and longitudinal studies (3)(8). When these analyses control for confounding age-related factors, such as concurrent medications and coexisting diseases, the results demonstrate that the circulating concentrations of free, protein bound, and total testosterone decrease at a rate of 1% to 2% per year after the age of 30 years (2)(3). Approximately 20% of men older than 60 and 50% of men older than 80 have serum testosterone concentrations below the normal range for young men; however, many elderly men maintain normal concentrations (6).
The diagnosis of andropause should be based on a combination of signs and symptoms and low serum testosterone. Diagnosing andropause is complicated, because testosterone declines gradually over many years and this decline lacks easily defined signs and symptoms that are comparable with the cessation of ovulation and menstruation seen in menopause. Additionally, the signs and symptoms of andropause are similar to or occur concurrently with other diseases of aging and can be misdiagnosed by physicians or unrecognized by patients. The nonsexual symptoms of andropause include depression, anger, mood changes, fatigue, loss of cognitive skills, and reduced well-being; reduced lean body mass, muscle volume, and strength; loss of body hair and skin changes; decreased bone mass and osteoporosis; and increased body fat (2)(3)(9). Two new screening instruments, the ADAM (10) and the Massachusetts Male Ageing Study (MMAS) (11), may make it easier to identify men at risk for low testosterone and andropause (6).
Published treatment guidance has begun to address the use of TRT in andropause.(6) Treatment guidelines for other types of symptomatic hypogonadism suggest that the treatment goals are to increase the total serum testosterone concentration to a normal range of 300–1200 ng/dl, and to restore sexual function, libido, and well-being. Important treatment goals for elderly men include increasing bone mineral density, energy, muscle mass, strength, and stamina, and decreasing total body fat (12)(13)(14)(15)(16)(17). Some research suggests that TRT improves symptoms of depression in older men with low testosterone (18). Additionally, some clinical practice guidelines emphasize the importance of TRT in improving not only the duration of life but also the quality of life (19).
Despite the current interest in andropause and the potential benefits of TRT, andropause is not an officially recognized diagnosis, nor is it an approved indication for TRT. However, in the coming decades, as the population of middle-aged and elderly men increases, this situation is likely to change. In preparation for this change, health care researchers and HCPs will need a baseline estimate of the current level of knowledge about andropause and its treatment. The study described here seeks to (a) characterize the current state of knowledge about andropause and the nonsexual effects of low testosterone among the general public and HCPs, and (b) discuss the findings in relation to the published literature on the benefits of TRT. The results of the study will provide insight into the need for general public and professional education about andropause and its treatment.
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Methods |
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Survey Description
Demographics and practice setting information.--
The interviewer asked a series of questions designed to collect descriptive information specific to each group (general public or HCP) and information about each caller's awareness of andropause and experience with TRT. The HCP survey, which was designed to gather practice-specific data, included two identical multipart questions for physicians, nurses, and pharmacists. These questions concerned primary licensure and frequency of patient-initiated discussions about low testosterone. Physicians and nurses were asked four additional questions to determine their practice setting and the extent of their experience prescribing testosterone replacement.
Knowledge survey.-- Both survey samples (general public and HCPs) were asked the same set of true–false questions to determine each caller's knowledge of andropause and TRT.
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Results |
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Table 1 summarizes the sources of health-related information used by the general public. The three most frequently cited clinical sources of health-related information were primary care physician (47%), other clinical source (11%), and pharmacist (10%). The most frequently cited nonclinical source of health-related information was the Internet (52%), followed by the popular press (18%). The Internet was the most frequently cited source overall.
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All 57 HCPs (including pharmacists) were asked how often their patients initiated conversations about low testosterone (Table 2 ). Three quarters of respondents reported that their patients never (33%) or rarely (42%) initiated such conversations. Only 5 (9%) reported that patients frequently initiated such conversations, and 9 (16%) reported that they sometimes did.
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Discussion |
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The respondents from the general public in this sample may have more knowledge about andropause and the effects of TRT than a random sample of the general public. Most of them had heard of andropause or male menopause, most were male, and most called to inquire about testosterone gel, indicating they had prior knowledge about the drug. Additionally, these callers may be unusually proactive in seeking medical information, because they called a medical information line, and more than half of them reported obtaining health-related information from the Internet.
It was difficult to measure trends among the HCP sample, because both the sample size and the response rate were lower compared with that of the general public. Most HCP callers were pharmacists, and most reported that their patients rarely or never initiated conversations about low testosterone. Less than half of the physician and nurse respondents reported frequently or sometimes prescribing TRT. The small sample size made it impossible to adequately assess the reasons TRT was rarely or never prescribed.
A more accurate indication of prescribing practices is obtained from TRT prescription sales, which have increased dramatically in recent years (Fig. 1). For the 5-year period ending in May 2002, the number of prescriptions for all dosage forms of testosterone increased from 341,000 to 1,451,000, with the newer transdermal products increasing from 274,000 to 1,140,000 during the same period (20). This increase in TRT prescribing rates suggests that physicians are becoming more familiar with the concept of hypogonadism and andropause.
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Conclusions
The U.S. Food and Drug Administration reported that only approximately 5% of the 4 to 5 million American men estimated to have hypogonadism receive TRT (21). As the population continues to age and the prevalence of andropause increases, both the general public and HCPs can benefit from education about andropause and its treatment. This study of a relatively informed general public indicates aspects that warrant attention. First, andropause is a testosterone deficiency that develops gradually over a number of years in all men aged 50 and older. Andropause can be treated with TRT. Second, andropause is associated with an increased risk of osteoporosis and bone fractures. TRT can decrease this risk by increasing bone mineral density. Third, andropause does not cause loss of urinary control. This common symptom in aging men is more likely caused by an enlarged prostate. Fourth, TRT can increase the lean body mass necessary for adequate muscle strength. Fifth, other benefits of TRT in andropause include improved mood and higher energy levels. The effects of such education should be evaluated by using large randomized surveys of the general public and HCPs to more adequately assess the current state of knowledge about andropause and its treatment.
Additional research is needed in other areas as well. Accurate epidemiological data are necessary to adequately measure the prevalence and incidence of andropause. Research is needed to assess the current costs associated with andropause (i.e., the costs of andropause that has not been treated with TRT). Such studies should include retrospective analyses as well as predictive economic models of future costs. Prospective studies of the clinical, economic, and quality of life outcomes associated with TRT in andropause are also needed.
As the population continues to age, the prevalence of andropause will increase. Without adequate TRT, andropause can be expected to increase medical care utilization and costs. The results of this survey suggest that HCPs and members of the general public harbor misconceptions about the nonsexual aspects of andropause. Future research and educational initiatives are needed.
Received June 17, 2002
Accepted August 1, 2002
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This article has been cited by other articles:
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  J. E. Morley The Need for a Men's Health Initiative J. Gerontol. A Biol. Sci. Med. Sci., July 1, 2003; 58(7): M614 - 617. [Full Text] [PDF]
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S. H. Tariq MD KNOWLEDGE ABOUT LOW TESTOSTERONE IN OLDER MEN J. Gerontol. A Biol. Sci. Med. Sci., April 1, 2003; 58(4): M382 - 383. [Full Text] [PDF]
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