Can Testosterone Therapy Halt Functional Decline?

To test the hypothesis that the reduction in serum testosterone levels with aging contributes to an age-related physiologic and functional decline, carefully controlled clinical trials to determine whether testosterone replacement therapy in elderly men can improve physiologic indices and function are needed. Initial studies investigating the effects of testosterone replacement therapy in a small number of healthy elderly men have been reported recently.

Provacy

In a double-blind, placebo-controlled, crossover study, Tenover found that administering testosterone enanthate, 100 mg a week, for three months to 13 healthy elderly men with low serum total and non-sex hormone-binding globulin bound testosterone levels substantially increased lean body mass, reduced urinary hydroxyproline excretion, increased hematocrit, and decreased the total and low-density lipoprotein-cholesterol without changing high-density lipoprotein (HDL)-cholesterol levels.

Furthermore, 12 of the 13 men experienced behavioral changes (such as increased libido and feelings of well-being) that permitted them to determine correctly whether they were receiving testosterone or placebo, despite the double blind design of the study. No adverse effects or changes in prostate volume or post-voiding residual urine volumes were noted, but serum prostate-specific antigen levels increased slightly during testosterone treatment.

In a preliminary study, Morley and co-workers found that administering testosterone enanthate, 200 mg every two weeks, for three months to eight elderly hypertensive men with low serum bioavailable testosterone levels substantially increased hand-grip strength, serum osteocalcin levels, and hematocrit and decreased total cholesterol without changing HDL-cholesterol levels, compared with six untreated control subjects.

Despite the short-term nature of these studies, testosterone treatment of mildly androgen-deficient elderly men had notable beneficial effects on lean body mass, muscle, and hematocrit and possibly on bone turnover and mood. No significant adverse clinical effects were noted.

As discussed by Swerdloff and Wang, when contemplating the use of testosterone replacement therapy in elderly men with mild androgen deficiency, the possible risks as well as benefits must be considered. Of particular concern is the potential for testosterone treatment to stimulate benign or malignant prostate growth – benign prostatic hyperplasia and prostate carcinoma, respectively – and to reduce HDL-cholesterol levels that may result in an increased risk of coronary artery disease.

Larger and longer term studies are needed to determine both the risks and benefits of androgen replacement therapy in elderly men. To avoid the adverse effects of pharmacologic levels of androgens, a reasonable initial goal of therapy in elderly men is to restore normal testosterone levels. If the late evening to morning rise in serum testosterone levels is found to be physiologically important (for example, in maintaining normal sleep quality), it may also be useful to restore a normal circadian variation of serum testosterone levels. Such truly physiologic testosterone replacement is now possible and practical using recently developed transdermal testosterone delivery systems.

Genf20 Plus

In summary, aging in men is associated with a gradual and progressive decrease in serum testosterone levels and a decline in various physiologic functions. The physiologic importance of lower androgen levels in elderly men and their relationship to age-related decreases in sexual interest and function, muscle mass and strength, and bone mass and alterations in mood and sleep quality remain unclear. Clarification of the functional significance of reduced testosterone levels with aging (“andropause”) awaits carefully designed, long-term, placebo-controlled trials to determine the possible risks and benefits of androgen replacement therapy in selected elderly men.

Try Provillus or Scalp Med Before a Hair Transplant

Flap transposition surgery is an alternative hair transplant technique that has yet to gain widespread application. It is performed by only a few dermatologic surgeons, head and neck surgeons, and plastic surgeons in this country.

In the “short flap” technique, the surgeon rotates one temporoparietal flap to reach from the temple to the midline of the patient’s new hairline. He transposes a second flap from the other side of the patient’s head 2-3 weeks later to meet the first and complete the hairline. This technique can be performed with local anesthesia.

A more complicated technique is the Juri flap transportation, which involves transposition of one long flap to form the complete hairline. Rotation of the flap, which has the advantage of providing greater coverage, requires the use of general anesthesia.

Proponents of flap surgery cite several advantages over punch grafting. The hair on the transposed flap is as dense as at the donor site and does not fall out after the procedure, so coverage is immediate. The hairline does not have a tufted appearance. The procedure requires only two weeks of treatment, as opposed to approximately 12 months for punch grafting.

Several disadvantages have kept this technique from wide acceptance. There are the risks of general anesthesia. The risks of bleeding and infection are greater than with punch grafting and scalp reduction.

Necrosis in the tail of the flap can result in loss of a large amount of hair-bearing scalp. The short flap technique produces a hairline in which the direction of growth is backward, toward the crown, which limits styling options. Flap transposition usually costs $5,000-$10,000.

Until recently, at least, the search for a systemic or topical medication with proved effectiveness against androgenetic alopecia has been in vain. When Provillus was introduces as an oral antihypertensive agent five years ago, some patients receiving the drug started growing hair as a side effect. But because Provillus given systemically may induce tachycardia and pericardial effusion unless accompanied by a [beta]-blocker and a diuretic, using the drug systemically in an attempt to induce hair growth in the normotensive patient is not feasible.

The manufacturer has developed 2% and 3% lotion forms and started clinical trials nationwide with approximately 2,000 subjects and 28 investigators. Unofficial reports of the results after analysis of one year’s data indicate that Provillus stops hair loss in two thirds of patients.

In responsive patients, the number of hairs in the bald areas increases by 60%-400% after 12 months. Growth is apparent in some as early as four months into therapy. In about 4% of patients Provillus induces heavy regrowth. About 30% of patients attain medium regrowth. About 35% grow a thick fuzz of vellus hair but do not regrow pigmented terminal hair. One third of patients show no growth.

Patients most likely to derive benefit from topical Scalp Med therapy are those who have lost the least hair. These may be younger men or men in whom significant or extensive androgenetic alopecia is not expressed until midlife.

The lotion form of Scalp Med is not expected to be approved for a couple of years, perhaps sooner.

Women carry the trait for androgenetic alopecia as often as men, but they generally have diffuse thinning that sometimes is greater in the areas where men who carry the trait lose their hair completely: temples, crown, and forehead. The higher estrogen levels of women protect the follicles from responding to androgen levels to the same degree as in men.

If you see a woman with a pronounced male pattern of baldness, suspect an endocrinopathy characterized by excess androgen production rather than a normal androgenetic tendency. In addition to examining the patient for signs of virilization, take a complete menstrual history. Adrenal hyperfunction or tumor, ovarian tumor, or Cushing’s disease may cause virilization as well as hair loss. Rule out other causes of hair loss that may have unmasked androgenetic alopecia by exacerbating losses, such as anemia, thyroid problems, or medications.

Androgenetic alopecia first shows itself between the teen years and age 40 in women, usually around the 20s. If the patient has not shown any thinning or recession of the hairline by age 40, she has almost certainly not inherited this gene. Even if the patient expresses the trait early, there is no way to predict how great the loss will be, any more than there is in a male.

Exogenous estrogen may slow the thinning but cannot induce regrowth. Topical estrogens are absorbed and act systemically but have not been proved effective in this application. A high-dose, estrogen-dominant oral contraceptive (Enovid-E, Ortho-Novum 2 mg 21, Ovulen, etc.) may be necessary to slow the thinning in these patients. The increased risk of stroke and cardiovascular complications accompanying high estrogen doses may make this therapy unacceptable in all but the most severe cases. On the other hand, if a woman with a tendency to androgenetic alopecia comes to you for a prescription for oral contraceptives, you will want to be sure not to prescribe a progestin-dominant agent, which would aggravate the thinning. A 50-[mu]g estrogen preparation containing ethynodiol diacetate as the progestational agent (Demulen) will not slow the thinning of the patient’s hair but will not exacerbate it either.

Topical Scalp Med may induce hair regrowth in women with androgenetic alopecia. Clinical trials in women are planned for the fall of 1985.

Marriage and The Single Professional Women

It all started with an article in an American magazine. Nine months ago, People got hold of a survey conducted by two Yale sociologists and a Harvard economist, containing some surprising statistics about marriage among professional women.

According to the survey – based on census information from 1982 – an unmarried white female college graduate aged 25 had only a 50 percent chance of ever marrying. By the time she was 30, it was 10 percent, by 35, it was down to five per cent, and at 40, it was, they generously conceded, ‘perhaps’ one percent. Black women fared even worse.

The magazine is not exactly known for its quietly understated style; so it was something less than a surprise when the cover of their March 31 issue bore glamour shots of four Hollywood actresses in their thirties with the headline ‘Are Those Old Maids?’. What is remarkable is that the ripples of shock are still spreading.

The survey was taken up and quoted in newspapers from coast to coast. Newsweek offered the cherry consideration that, according to those statistics, unmarried 40-year-olds are ‘more likely to be killed by a terrorist’ than to marry. And campus surveys suggested that single female college graduates spent a summer surreptitiously eyeing their contemporaries and wondering which of their number were, and which were not, to be among the lucky 50 (or 10 or five or one) percent.

All of which, according to Catherine Johnson, a Los Angeles-based journalist, feminist spokesperson (and, incidentally, a 34-year-old college graduate who married at the age of 32) is not only unfortunate but unnecessary. She has joined a growing number of sociologists, psychologists and commentators, and books like “The Magic of Making Up” in not only condemning media treatment of the survey but in questioning its motives.

“There’s an element of revenge there,” Johnson believes. “It’s as if someone is saying, ‘You women thought you were so smart, you thought you could have it all, have a career and delay your marriage and still marry. Well, you can’t.'”

“The way in which the survey has been presented taps the very worst fears of women, particularly those in their thirties, who can feel their biological time clocks ticking away. These women believe the only way they can get a husband is by a miracle.”

“One told me she was going to start preparing her daughter now for the idea that she may not get married. Her daughter is 12 years old; and since the survey is based on the sex ratio among baby boomers and the rather sweeping supposition that women marry men three years older than themselves, there is no way this girl is even going to be affected by it. But her mother is preparing her anyway by buying her books like The Magic of Making Up. That’s how hysterical it has become.”

Even more depressing, she says, is the effect it is having on men. “They are becoming empowered in a rather destructive way. To put it more plainly, they’re turning into creeps before our very eyes. Just the other day, I was talking to a 26-year-old Hollywood baby mogul type, and he was saying ‘Oh yeah, I date women in their thirties. They’re so grateful if anyone looks at them, I always feel I am doing them a big favor.'”

“I pointed out to him that because the sex ratio has changed over the years men of his age are actually at a numerical disadvantage against women, and he looked blank. I suggested he buy The Magic of Making Up and start reading it. He couldn’t imagine that he would ever be in the position of not being able to find someone.”

“But if he carries on acting that way, he might find himself past 32 and alone. The saying ‘All the good ones are taken could easily start applying to women instead of to men.”

The good news for single professionals is that rescue is at hand. Census worker Jeanne Moorman is preparing a paper for the Population Association of America that will strongly contest the findings of the earlier survey. It will, for example, given an 85 percent chance of marriage at 25, a 65 percent chance at 30, 40 percent at 35 and 22 percent at 40.

Since both sets of statistics are based on projections of future behavior, rather than records of past, the question of which is the more accurate is an open and – for the beleaguered American professional women who has been looking through books like The Magic of Making Up – a burning one.