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L
ate
-
onset
hypogonadism
or
ADAM:
diagnosis
R
ev
A
ssoc
M
ed
B
ras
2014; 60(4):286-294
287
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.
Conflict of interest
No conflict of interest informed.
I
ntroduction
1
(A)
For many years, hormone replacement strategies were
mainly based on the treatment of women during the me-
nopause. However, the use of testosterone replacement
therapy to prevent and treat aspects of ADAM (Andro-
gen Deficiency of the aging Male) has gained the interest
of researchers and physicians. This fact coincides with
the trend of demographic data relating to aging, which
show an increase in the percentage of older males, inclu-
ding in Latin America
2
(
D
).
Male aging is accompanied by signs and symptoms si-
milar to androgen deficiency in young adults, as well as a
decrease in muscle mass and strength, and increase in ab-
dominal fat, especially visceral fat with insulin resistance
and an atherogenic lipid profile, a decrease in libido and
pubic hair, osteopenia, decreased cognitive performance,
depression, insomnia, perspiration and a decrease in the
general sense of wellbeing.
It is tempting to relate these symptoms to the decrea-
se in androgen associated with aging.
Generally, there is a correlation, albeit weak, between
these symptoms and testosterone levels. The decrease in
testosterone levels is only one of the factors responsible
for the symptoms of aging, which have a multifactorial
origin
3
(
B
).
For this reason, the diagnosis of androgen deficiency
in the aging male should be based on clinical symptoms
and testosterone biochemistry below the minimum level
in young adults
4
(
B
).
Various studies with good evidence indicate that the-
re is a partial reduction in testosterone levels during aging
and an increase in SHBG, or sex hormone binding glo-
bulin. Based on men aged 40 to 70 years, monitored for
7 to 10 years, there is tendency for a fall of 1.6% per year
in total testosterone levels, as well as bioavailable testos-
terone at 2% to 3% per year, and an increase in sex hor-
mone binding globulin at 1.3% per year
5
(
B
). These la-
boratory observations are correlated with the health of
such patients
6
(
B
).
The process leading to partial hypogonadism during
male aging is known as the andropause, or more appro-
priately late onset hypogonadism (LOH), or androgen de-
ficiency in the aging male (ADAM), or partial androgen
deficiency in the aging male (PADAM)
7
(
D
).
W
hat
are
the main
signs
and
symptoms
involved
in
late
-
onset
hypogonadism
?
The main signs and symptoms involved in late-onset hypo-
gonadism are:
•
•
Erectile dysfunction and decreased libido
8,9
(
A
);
•
•
Depression: hypogonadism in middle-age appears
to be associated with a history of depressive symp-
toms; research suggests that hypogonadism may be
an important factor in male depression
10
(
A
);
•
•
Decrease in muscle tissue, increase in muscular fi-
brous tissue and decrease in some aspects of mus-
cular strength
11
(
C
);
•
•
Increase in total adipose tissue and redistribution
of fat: various authors report an inverse correlation
with testosterone, suggesting that the fall in testos-
terone levels has a causal role in the accumulation
of visceral fat connected to male aging
12,13
(
A
);
•
•
Osteopenia and osteoporosis: decrease in bone mi-
neral density
14,15
(
B
);
•
•
Decrease in testicular volume
16
(
B
).
Recommendation
It is recommendable to carry out a diagnosis of late-onset
hypogonadism only in men with some of the main signs
and symptoms involved: decrease libido, erectile dysfunc-
tion, depression, decrease in muscle tissue, increase in to-
tal adipose tissue and redistribution of fat, decrease in bone
mineral density, and decrease in testicular volume.
W
hat
are
the main
instruments
used
in
the
definition
and
diagnostic
evaluation
of
male
aging
?
The main instruments used in the definition and diag-
nostic assessment of male aging are the clinical aspects
of hypogonadism
17
(
A
) and demonstration morning se-
rum testosterone level below the minimum reference va-
lue of young adults
18
(
A
).
Three questionnaires, the ADAM (Androgen Defi-
ciency in aging Male), AMS (aging Male’s Symptoms Sca-
le), and the scale used by Smith et al. in the MMAS (Mas-
sachusetts Male Ageing Study) have been developed as
potential instruments for the triage of hypogonadism in
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