Author: noorali

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Male Menopause (Andropause)

Dear Dr. B: My doctor recently told me that I have male menopause. Can you please tell me more about this? Yours: Mr. Menopause.

Dear Mr. Menopause: The correct name for this condition is “andropause”. “Andro” stands for androgen – a male sex hormone, such as testosterone or androsterone, that controls the development and maintenance of masculine characteristics.

Andropause is also known as ADAM (androgen decline in the aging male). The onset of andropause is unpredictable. Its clinical manifestations are subtle and variable.

The symptoms of andropause include fatigue, depression, hot flushes, sweats, decreased libido, erectile dysfunction, changes in cognition (like poor concentration and memory) and mood. Since these symptoms are more subjective than objective, some experts have trouble accepting andropause as a clinical condition.

Physical examination of an aging male patient with andropause may be quite normal. There may be presence of gynaecomastia (enlargement of male breast) and/or soft small testicles. Low testosterone level does not produce any specific organ changes. Another reason why some experts have trouble accepting andropause as a clinical condition.

Diagnosis of andropause is made by symptoms, physical signs and early morning non-fasting specimen of blood for testosterone level. Testosterone level is highest in early morning and can decrease by 35 percent in the midafternoon and evening.

Early morning testosterone level less that 7 nmol/l indicates that a man has poor gonadal function. This will warrant further investigation to find the reason for low testosterone level. Is it the normal aging process or some other pathology?

Testosterone level found to be critical for sexual function in men lies around 10.4 nmol/l. There can be some variation between individuals.

Normally men experience a continuous slow (an average of one to two percent a year) decline in serum testosterone level after about age 30 years. This is due to decrease in testosterone production. There are many other reasons why testicular function may fail – injury, infection, tumours, surgery, effect of other hormonal problems etc.

The goals of treatment for poor gonadal function are to improve erectile function, restore libido, and improve psychological well-being and mood. It is important to remember that in men over 50, cause for erectile dysfunction may be other than low testosterone level. So testosterone replacement therapy will improve libido and psychological well-being in this age group but may occasionally improve erectile dysfunction.

Testosterone replacement therapy improves bone mass, coronary artery disease, reduces total cholesterol and LDL (bad cholesterol) levels.

What are the contraindications?

Testosterone should not be given to individuals with prostate or breast cancer. Sleep apnea has been shown to contribute to low serum testosterone levels and testosterone therapy has been reported to make sleep apnea worse. Testosterone therapy may make blood thick (polycythemia), promote benign and malignant changes in the prostate, and can cause tenderness and enlargement of breasts.

Before starting an individual on testosterone therapy, the physician should screen the patient for sleep apnea, prostatic symptoms, and family history of prostate cancer. Do digital rectal examination, complete blood count, lipid profile and PSA. These tests should be repeated every six months.

Testosterone is available for clinical use in many forms: injectable, oral pill, skin patch, gel, and implantable formulations. Each one has advantages and disadvantages. Your physician will advice you the best formulation for you. The physician should monitor the treatment to check for any side-effects and for any long term complications like prostate cancer.

So, Mr. Menopause (or rather Mr. Andropause or Mr. ADAM), we haven’t heard the last word on this condition. Data on the benefits and risks of testosterone replacement therapy for older testosterone-deficient man are scanty, but new clinical information continues to be generated. So there is hope for aging men too!

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Hypertension

When was the last time you had your blood pressure checked?

High blood pressure (hypertension) is the leading reason why so many people see their doctor. And widespread treatment of hypertension is also the main reason why there is a decrease in the incidence of stroke, heart disease, and kidney failure in the last 30 years.

It is not enough to get your blood pressure checked and then do nothing about it. If the blood pressure is normal then adopt measures to keep it normal. As we get older, the arteries tend to harden and the blood pressure goes up. If the blood pressure is high then make sure you follow the advice of your doctor. And medication is not always the best answer. There is more you can do to control hypertension than just popping pills once or twice a day.

What is the normal blood pressure?

Normal blood pressure is defined as systolic blood pressure of less than 140 mm Hg (mercury) and diastolic blood pressure of less than 90 mm Hg. It is written as – systolic over diastolic (for example 120/80 mm Hg).

Why do people have hypertension?

Hypertension affects 22 percent of Canadians. The incidence of hypertension increases with age. Most elderly Canadians have high blood pressure. No cause is identified in 80 to 95 percent of people with hypertension. This is known as idiopathic or essential hypertension. Others have hypertension due primary disease of kidneys or due to certain hormonal disorders.

What is the effect of hypertension?

For close to 100 years, it is known that hypertension causes premature death. It negatively affects the heart, brain, kidneys, and retina. It causes heart disease, stroke, kidney failure and retinal damage – blindness.

What can you do to prevent and control hypertension?

Hypertension can be prevented and/or treated with lifestyle changes with or without medication. Life style modification requires significant amount of changes in what you do and what you eat. Here are some of the things you can change:

-Lose weight if you are overweight

-Don’t smoke

-Limit alcohol intake

-Eat a low salt diet

-Do regular exercise – three to five times a week

-Relax and learn to manage stress

Hypertension is a silent killer. You may have high blood pressure but have no symptoms.
It is estimated that 25 percent of the 42 million people with high blood pressure in the United States are unaware that they have high blood pressure and approximately three fourths of those with known hypertension have blood pressure that exceeds the recommended level! This is dangerous!

So, when was the last time you had your blood pressure checked?

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Death of Dr. Ivan Witt

On August 18th, 2001 I was one of the hundreds of people who packed the Medicine Hat College Theatre to bid final good-bye to my friend and partner, Dr. Ivan Witt.

Ivan was larger than life. He worked hard and thoroughly enjoyed the fruits of his labour. He cared about his family, friends and patients. Many of us will miss his sense of humour. His zest for life and work.

Ivan’s sudden and premature death affected people in many different ways. To me it brought back memories of similar tragedies in my own life. Please allow me to share with you some thoughts.

In the afternoon of August 4th, when my phone rang, I could not believe what I heard – that Ivan and his family were involved in an accident and Ivan had died at the scene. My mind immediately flashed back to Sunday, October 14th, 1984 when my phone rang at about 10 pm to let me know that my younger brother, Mansur, was killed in a motor vehicle accident near his home in Royston, B.C.

Mansur was 36. He had two young children, girl seven, and boy five. Few months prior to Mansur’s death, his daughter had spent about six months in a Vancouver hospital with debilitating effects of viral infection of the brain. The family had to go through two major setbacks in one year. How many of us can understand the magnitude of the situation?

My sister, Gulshan, used to live in Uganda. She had three children. She was expecting a fourth child when she was blessed with triplets. Three and three makes six! Then came the terror of Idi Amin (some of you may remember him). Gulshan’s family, with six infants and a sick father-in-law, had to leave Uganda overnight penniless. Canada was kind enough to take them as refugees. They settled in Quebec City.

They eventually moved to Vancouver. By 1996, all the kids were old enough to leave home. Gulshan celebrated her 60th birthday and was looking forward to some easy time and relaxation. She wanted to go back to Quebec City and visit many friends who had helped her survive the trauma of dislocation. She wanted to go to London, England. She had never been there before.

But fate had planned a different journey for her. In July 1996, she was diagnosed with cancer of the pancreas and died two months later. Few years before her death, her oldest daughter was diagnosed with multiple sclerosis and has been physically challenged since.

Unfortunately, almost every family has sad stories like these. But do we learn anything from these stories or by attending funeral services?

Certainly the message is quite clear. Life is too short and we are all going to die one day. If that is the case then why are we in this world? What is the purpose of our existence?

The answer to these questions come in the next tragic story I read in the Golf Digest. This is the story of a 45-year-old Pete Farricker, Golf Digest’s equipment editor. Pete was diagnosed with Lou Gehrig’s disease. The author of the article says “the disease goes on to ravage the victim, in a cruel twist, shutting down the body while leaving the mind intact.” While Pete was waiting to die, he wrote his own eulogy that was read by his wife at his funeral service.

In part this is what he said:

“…. it was the never-ending gifts of love that came my way, which convinced me that the main reason why we’re all here is to simply love one another. We all have what seem like complicated lives, and we often get caught up in the daily minutiae of work, family and school…It’s love that makes us strong – and love that solves the mysteries.”

Ivan was good example of this. He loved his work. He loved the people he came in touch with. And he loved a good life. To Ivan, I would like to say: Partner, thanks for the memories. You will be missed! To his family, I would like to say: Have faith and be strong. New life is just beginning and many people are praying for you.

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Hard work needed in MD crisis.

August 24, 2001

The Editor,
Medicine Hat News,
Medicine Hat.

Dear Sir:

RE: Dr. Ruzycki’s letter – Service failing at Hat hospital.

I agree with Dr. Ruzycki that there is a significant crisis in the medical services offered to the people of Palliser Health Authority (PHA). It takes longer to see a specialist than getting surgery done. For example, it may take up to three months to see certain specialist. But after you have seen one, you can get in for surgery within a couple of weeks. It used to be the other way round.

Alberta Health is not interested in the welfare of specialists in places like Medicine Hat. Traditionally, specialists here have provided round the clock coverage at great cost to their own health and family life. For obvious political reasons, Albert Health only cares about specialists in Calgary and Edmonton.

The solution to the problem has to be found locally. I suggest the following five points:

1. PHA should have a proactive aggressive recruitment and retention policy. Have a recruitment officer who can foresee future trends in manpower needs. Recruitment is an ongoing project and requires time and devotion. It takes at least a year to find a physician.

2. Specialists in Internal Medicine, General Surgery, Paediatrics, Anaesthesia, Orthopaedics and Obstetrics should have one more specialist locally than what they think they need. This means drop in income but a better life style and on-call coverage. PHA should subsidies the escalating overhead costs for these specialists.

3. PHA should provide resources (operating room time, equipment and other special needs) to accommodate these extra specialists.

4. Aging specialists who do not want to provide full time service should be asked to give up certain privileges or use of resources to make room for new recruits. This should be fairly applied and not selectively favoured.

5. There should be less talk and more action to find solution to manpower needs of PHA. None of the ideas mentioned here are new. These have been discussed over the years and even recently by medical staff.

As we know, solution to any problem requires leadership, hard work, good will and teamwork. The Palliser Medical Staff and the Palliser Health Authority have people with plenty of these skills. So, what is missing?

Yours Sincerely,

Noorali Bharwani

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