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L
ate
-
onset
hypogonadism
or
ADAM:
treatment
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):404-414
405
G
rade
of
recommendation
and
strength
of
evidence
A:
Experimental and observational studies with high con-
sistency.
B:
Experimental and observational studies with low con-
sistency.
C:
Case reports (non-controlled studies).
D:
Opinions without critical evaluation, based on con-
sensus, physiological studies, or animal models.
O
bjective
To recommend evidence-based approaches to treat late-
-onset hypogonadism.
I
ntroduction
The benefits of androgen replacement therapy in hypo-
gonadal young men are well documented, especially gi-
ven that the restoration of testosterone concentrations
to normal limits maintains and restores sexual function,
energy, mood, the development of muscle mass and in-
creases bone mass. However, the cost/benefit relationship
of testosterone replacement in Androgen Deficiency in
the Aging Male (ADAM) remains controversial (
A
).
1
W
hat
is
the
role
of
androgen
replacement
therapy
(ART)
to
restore
bone mass
,
muscular
strength
and
body
composition
?
There is no doubt that ART has a positive effect on bone
mass. The treatment with testosterone determines a sig-
nificant improvement in bone mass in hypogonadal men
of all ages (
B
).
2
This effect becomes even more evident the
longer the treatment time and the more severe the hypo-
gonadism (
A
).
3
The effects of ART on muscular strength in men with
ADAM are generally evaluated indirectly through analysis
of the performance of physical activities and body compo-
sition. Therefore, the use of transdermal testosterone at a
dose of 50mg/day for a 6 month period has been shown
to be capable of increasing muscular strength and lean
mass in patients, improving their physical function and
quality of life (
A
).
4
Direct evaluation of muscle size in el-
derly patients with chronic diseases with a loss in mus-
cle mass and ADAM have shown that testosterone the-
rapy in older patients leads to an increase in muscle size
and improved muscular strength, improving performan-
ce in physical activities (
B
).
5
The most reproducible effect of testosterone treat-
ment is the increase in lean mass both in hypogonadal
patients and healthy males. Even if for a short period of
time, transdermal testosterone treatment increases mus-
cle mass in hypogonadal men aged over 40 years (
A
)
3
(
B
).
6
On the other hand, studies evaluating the reduction
in body fat as a direct effect of testosterone treatment are
controversial. A slight reduction in body fat in patients
being treated has sometimes been observed (
A
).
3
Tes-
tosterone treatment results in a significant reduction in
waist circumference, which is an indicator of visceral fat
(
A
).
7
However, this benefit has not been shown in short
acting treatments (
A
).
8
The reduction in BMI and waist circumference may
not occur in all patients, but the reduction in visceral fat
is evident when analyzed directly using magnetic reso-
nance imaging. Therefore, testosterone therapy selecti-
vely reduces the accumulation of visceral fat, though the
change in total body composition is not observed in all
patients (
B
)
6
(
A
).
9
This discrepancy in the findings in relation to the ef-
fects of testosterone on the reduction of lean mass may
be related to the dose or route of testosterone adminis-
tration, or the direct effect of testosterone on the increa-
se in lean mass. Ultimately, testosterone replacement im-
proves the body composition of patients with low levels
of the hormone (
B
).
2
The use of GH in association with testosterone ap-
pears to present a synergic effect on the improvement in
body composition, muscular strength and, consequently,
the quality of life of men with ADAM, and can be a treat-
ment option to be considered in such patients (
A
).
10,11
Recommendation
Testosterone replacement therapy improves bone mass,
muscular strength and body composition in patients with
ADAM and the effects increase with the length of treat-
ment and severity of hypogonadism. The use of testoste-
rone in patients with ADAM is strongly recommended
to increase bone mass, muscular strength and body com-
position.
W
hat
is
the
role
of
androgen
replacement
therapy
(ART)
to
restore
libido
and
sexual
function
?
The effectiveness of testosterone replacement therapy on
sexual symptoms has been well established, regardless of
the route of administration; nevertheless, the works are
controversial in relation to the effectiveness of the oral
route. Treatment with testosterone, regardless of the rou-
te of administration, improves and restores the libido in
men with lower testosterone levels (
B
)
12-15
in the first th-
ree months of treatment (
C
).
16
However, testosterone does