Post Reproductive Health

During male ageing important changes occur in the neuroendocrine environment. The most remarkable are the decreased secretion of melatonin, growth hormone, dehydroepiandrosterone, and testosterone. Hormone replacement with each one of these substances has been proposed, but few data are available on the long-term effects. Today, testosterone replacement seems to offer the most promising option. New delivery systems are under development that can restore circulating physiological testosterone levels, including circadian variability. Limited experience with a novel sustained release buccal tablet given to ageing men with subnormal testosterone concentrations suggests that optimal replacement decreases cholesterol, triglycerides, and prostate specific antigen (PSA) levels, without inducing any change in haematocrit or other vital parameters.

In men treated with castration because of prostatic carcinoma hot flushes are as common as in women after menopause. Flushes also occur in normal ageing men, but the prevalence is unknown. Hot flushes are probably caused by an instability in the thermoregulatory centre, because of decreased sex hormone concentrations. Calcitonin gene-related peptide (CGRP) is involved in menopausal hot flushes in women and possibly in men with castrational therapy. Serotonin may also be implicated. Alternative treatments for hot flushes are needed, since men with prostatic carcinoma may not be treated with testosterone, and oestrogen therapy in men has many draw-backs. Therefore, development of a CGRP-antagonist may be useful. In conclusion vasomotor symptoms are common in men with castrational therapy and also exist in normal, ageing men. Since CGRP, serotonin and a decrease in sex steroids seem to be involved in hot flushes, the mechanisms behind hot flushes in men and women may be similar.

Although urinary incontinence (UI) in men is an increasing problem, it has not been investigated to the same degree as that in women. In an urbanised environment, with diverse demands on health professionals, incontinence remains a problem difficult to solve not only for the individual patient but also in terms of a public health strategy, since costs related to urinary incontinence are impressive.

The prevalence of UI is increasing since this complaint is much more common in the elderly - and this section of the population is increasing in Western societies. Greater public awareness and education are further increasing demands for effective therapy for the male population.

Steroid hormones such as oestradiol and testosterone have long been viewed as a key to long-term health. Although men do not undergo the precipitous fall in endogenous steroid hormone levels characteristic of the menopause, there is substantial interest in the therapeutic potential of low dose androgen therapies to maintain mental, skeletal and other aspects of health. Testosterone and other androgens seem to conform to the "clutch pedal" theory of hormone action. In terms of atherosclerosis, if plasma androgen levels are too low they may cause disease, but, if they are too high, atherosclerosis may also become a problem. Thus, the rationale for the use of low doses of androgens in ageing males is becoming compelling. Studies of arterial disease surrogates, such as plasma protein levels, may help optimise these therapies but the final answer on disease can only come from formal placebo-controlled trials of clinical endpoints.

Herbal medicinal products are often sold as a safe and effective alternative to HRT. Sizeable sets of trial data exist for black cohosh and soy. For other herbal medicines, only isolated trials have emerged, and their number is too low to enable one to arrive at valid conclusions. Collectively the data for black cohosh do not prove efficacy. The evidence for soy is encouraging but not compelling. Neither black cohosh nor soy is associated with major safety problems. Further research is warranted to closer define the role of herbal medicines for the menopause.