men’s health issues - osteopathic family physician · men’s health issues ... risk is an...

MEN’S HEALTH ISSUES

• Committee Established by

• ACOFP President

• Special Assistance from:

– Paul Ziajka MD,

– Amanda Houge ARNP

– Gus, Lovie, Rosie

MEN’S HEALTH

MIND

BODY

SPIRIT

SEXUALITY- for a later discussion

©LECS

Men and Women are Different

WHY MEN’S HEALTH

• HIGHEST DEALTH RATES FROM CANCER

• HIGHEST DEATH RATES FROM SUICIDE

• HIGHEST DEATH RATES FROM HOMOCIDE

• EARLIER DEATH FROM HEART DISEASE

• HIGHEST DEATH RATES FROM AT LEAST 9/10 OF THE LEADING CAUSES OF DEATH FROM THE CDC

IGNORING MEN’S HEALTH

• CHRONIC MEDICAL CONDITIONS

• CHRONIC PSYCH ISSUES

• IMPACT OF FAMILY UNIT

– DECREASED EARNINGS

– DISABILITY

– DOMESTIC VIOLENCE

– ROLE REVERSALS

– POVERTY

PREVENTION

• GOD BLESSED WOMAN AND THEIR HEALTH BY GIVING THEM A CERVIX; THEY ROUTINELY ENCOUNTER THEIR PRIMARY CARE PHYSICIANS FOR WELLNESS EXAMS.

• MEN ON THE OTHERHAND RARELY HAVE PREVENTIVE EXAMS OR HEALTH ENCOUNTERS – EXCEPTION 1) ACUTE ILLNESS OF PROBLEM

– EXCEPTION 2) SIGNIFICANT OTHER DRAGS THEM IN FOR AN EVALUATION

STEREOTYPICALLY: THE REAL MAN

LIKE FATHER LIKE SON

SOCIALIZATION OF BOYS

• SUCK IT UP

• BIG BOYS DON’T CRY

• PUT SOME DIRT ON IT ANG GET BACK OUT THERE – CONCUSSION

– WIN AT ALL COSTS INCLUDING CHEATING

• IGNORE PAIN – IGNORE STD

– IGNORE CHEST PAIN LATER IN LIFE

BODY

• CV issues

• Lipids Issues

• Hormones

©LECS

Introduction

• >50% of all men will die from CVD (n=386,436 in 2010)

– 75% of all CABG patients are male

– 67% of PCI patients are male

• 50% of men who die from CVD have had no previous symptoms

• 32% of men have LDL>130 mg% and 32% have HDL<40 mg%

AHA Statistical Fact Sheet – 2013 Update

CDC Men and Heart Disease Fact Sheet 2013

©LECS

Men and Women are Different

• Effects of age on lipid levels

• Effects of lipids on risk prediction and “residual risk”

• Effects of diet and weight loss on lipid levels

• Source and effect of psychological stress on CHD risk

©LECS

• HDL: – ♂: levels flat after age 10 until ~60 yo, then

marked increase

– ♀: gradual increase throughout life

• LDL – ♂: gradual increase to ~50 yo, then level

– ♀: gradual increase to ~50 yo, then marked increase with age

• associated with reduction in LDL receptor activity

♂ vs. ♀: The Effect of Age on Lipids

©LECS

• LDL is a stronger predictor of risk in men than in women

• HDL and triglycerides are a stronger predictor of risk in women than in men

♂ vs. ♀: The Effect of Lipids

©LECS

• In most clinical trials, even in high risk groups, the RRR for CVD events with aggressive LDL lowering with statin therapy is only ~20-25%

• The remaining risk is referred to as “residual risk”

♂ vs. ♀: Residual Risk

©LECS

• In women the main contributor to residual risk is an elevated Lp(a)

• In men the main contributor to residual risk is a low HDL-2 sub-fraction

♂ vs. ♀: Residual Risk

©LECS

♂ vs. ♀: Effect of Weight Loss

-20

-15

-10

-5

0

5

Body Weight HDL-C LDL-C

Men

Women

Per

cen

t D

iffe

ren

ce f

rom

Co

ntr

ol

Brownell; Arch Int Med 141:1142 (1981)

©LECS

♂ vs. ♀: Effects of Diet

-25

-20

-15

-10

-5

0

Vegetarian AHA-I

Men

Women

% C

ha

ng

e in

LD

L-C

Masarei; Am J Clin Nutr 40:468 (1984)

Ernsf; Lancet 1:111 (1980)

©LECS

Stress and CVD Risk

©LECS

“In the worry and strain of modern life,

arterial degeneration is not only very

common but develops at a relatively early

age. For this I believe that the high

pressure at which men live and the habit of

working the machine to its maximum

capacity are responsible, rather than

excesses in eating and drinking.”

Sir Wiliam Osler, 1897

©LECS

27th Bethesda Conference

“Psycho-social risk factors are clearly

associated with increased coronary risk, which

if modified might lower the incidence

of coronary events.”

JACC 27:957 (1996)

©LECS

♂ vs. ♀: The Effect and Sources of Chronic Stress

Relative Risk Increase for CHD Event

Marital Stress Occupational Stress

Women 300% 0%

Men 0% 600%

Nordstrum; Epid 12:180 (2001)

Orth-Gomer; JAMA 284:3008 (2000)

©LECS

Testosterone: Basic Science

©LECS


• Produced mainly in the Leydig cells of the testis in response to LH released from the pituitary gland

• Made by 5 enzymatic steps from cholesterol

• In target cells testosterone and active metabolites bind to intracellular receptors

• Testosterone and active metabolites are metabolized in the liver and excreted in the urine

Becker et al; Primary Card 20(3):26 (1994)

Potenza et al; J Clin Lipid 2:71 (2008)

©LECS


©LECS

Case #1

• 53 yo ♂ presenting for a physical with a c/o of “ED”

• PMHx: ø

• VS: BP=160/90; BMI=31

• PE: remarkable only for central obesity

• In house labs:

– FBS=114; TC=263; trigs=230; HDL=31; LDL=186

©LECS

Case #1

• On detailed questioning regarding c/o ED, Sx’s really more a lack of interest and libido

• Total testosterone level sent to the reference lab came back 120 ng/dL

• Dx: (1º) Hypogonadism

©LECS

Hypogonadism

Primary Hypogonadism- The Testes

• Congenital: Klinefelter’s Syndrome, Chromosomal Abnormalities, Mutation, Crypyorchidism, Disorders of androgen biosynthesis, Myotonic dystrophy, Varicocele

• Acquired: Infections, Radiation, Steroids, Trauma, torsion, antineoplastic agents, ketoconazole, Orchiectomy, Cirrhosis, CKD, HIV, Idiopathic, Chronic Illness

Secondary Hypogonadism-Pituatary

• Abnormal Hypothalmus, Pituatary Tumors, Treatment of Pituatary Disease, Inflammatory diseases such as Sarcoidosis, Histiocytosis, Tuberculosis,

• HIV, Obesity, Diabetes Mellitus, Alcoholism, Chronic Pain Syndrome, Long term use of Medications to include Legal and Illegal Substances to include Opiates and Synthetic RX, THC

• Aging, Depression, Stress of Acute illness and Surgery

©LECS

Hypogonadism

• Associated with CVD death (OR 2.0 – 3.0 dependent on age)

– obesity (OR=2.4)

– diabetes (OR=1.8)

– HTN (OR=1.8)

– dyslipidemia (OR=1.5)

– increased all-cause mortality (OR=1.4)

• Hypogonadism causes ↓ libido, ↓ muscle mass and strength, ↓ bone mass, cognitive decline and ↑ abdominal fat

Vonk et al; JAMA 299:39 (2008)


©LECS

Hypogonadism

• Causes ↑ TC, ↑ LDL-C, ↓ HDL-C and ↑ trigs

• Secondary causes include iatrogenic (i.e. opioids), traumatic brain injury, autoimmune disease, liver dysfunction and hyperprolactinemia

Vonk et al; JAMA 299:39 (2008)


Bagatell et al; Ann Int Med 116:967 (1992)

©LECS

Hypogonadism

• Testosterone replacement is prescribed for 3% of American men over 40 yo

• Annual prescriptions for testosterone have increased 500% from 2000 to 2011

– 5.3M Rx’s per year and a $1.6B market in 2011

Oppenheim et al; Ann Int Med 111:288 (1989)

Vigen et al; JAMA 310:1829 (2013)

©LECS

Elevated Endogenous Testosterone

©LECS

Elevated Endogenous Testosterone

• Increased endogenous testosterone levels in elderly men is associated with a 29% increased risk for CAD for each standard deviation in total testosterone

Sueoka; presented at 2010 Annual Meeting of the Endo Soc

©LECS

Case #2

• 30 yo ♂ referred to the lipid clinic by his PCP with new onset dyslipidemia

• Lipid panel:

– 3 years ago: TC=181; LDL=110; trigs=120; HDL=47

– Now: TC=188; LDL=160; trigs=115; HDL=5

• PMHx, ROS: ø

• Meds: ø

©LECS

Case #2

• On detailed questioning patient states he started working out at a gym 6 months ago where his personal trainer is supplying him with a “supplement” to help him build muscle mass

• Dx: Anabolic steroid abuse

©LECS

Anabolic Steroids

©LECS

Anabolic Steroids (AS)

• AS include more than 40 natural and synthetic derivatives of testosterone

• AS were first developed and used clinically in 1939

– were banned in the Olympics in 1976

• Lipid effects of AS (except on HDL) are not dose-dependent

Glazer; Arch Int Med 1991;151:1925-1933

©LECS

• Marked reduction in HDL: 40-70% with <52%> – lowers HDL2 70-80%

– increases hepatic lipase activity 150-230%

• Increases LDL <36%> – increases apo-B 35-40%

• TC unchanged – drop in HDL offset by increase in LDL

• Usually a modest decrease in trigs


Stone; Management of Lipids in Clinical Practice; Prof. Comm., NY (2005)


Durrington; Hyperlipidemia; Butterworth, Oxford (1995)

©LECS

• Lipid effects maximized within 1-2 weeks of AS initiation

• Lipids return to baseline within 1-5 month of AS discontinuation



Dhar; Mayo Cl Proc 2005;80:1307

©LECS

• New “designer” steroids such as prostanozol and methasterol are available over the internet – banned by the World Anti-Doping Agency but not

illegal

• >3M people in the US regularly abuse AS – 6.5% of HS athletes use AS

• Self reported rates in ♂ bodybuilders: 30-70%


Becker at al; Primary Card 20(3):26 (1994)

Achar et al; AJC 106:893 (2010)

©LECS

• AS are FDA approved for the wasting syndrome in AIDS, hypogonadism, anemia associated with renal disease and bone marrow failure

• Abusers typically use 5 – 15X recommended clinical doses of AS



Achar et al; AJC 106:893 (2010)

©LECS

• Dyslipidemia

• ↑’d myocardial cell apoptosis

• ↑’d ventricular arrythmias and LVH

• ↑’d venous and arterial thrombotic events – ↓ fibrinolysis, ↑ platelet activity, ↑ coagulation factor

concentrations, ↑ PAI-1, ↓ prostacyclin and ↑ endothelin

• AS users have a 3x greater RR for CHD than age-matched non-users

AS – Cardiovascular Side

Effects


Achar et al; AJC 106:893 (2010)

©LECS

AS – Non-Cardiovascular Side Effects

• ↓ Libido (60% of users)

• Gynecomastia

• Hepatotoxicity

– cholestatic jaundice, hepatic adenoma

• Ψ disease

– depression, psychosis, hostility

• Erythrocytosis

• Urinary retention Becker at al; Primary Card 20(3):26 (1994)

Achar et al; AJC 106:893 (2010)

©LECS

AS / Testosterone Replacement

• Smaller lipid effects with IM and transdermal preparations

– transdermal replacement at therapeutic doses has no effect on HDL-C

• Synthetic AS have a much greater lipid effect than testosterone


Bagatell et al; Ann Int Med 116:967 (1992)

©LECS

Association between ED and CVD Risk

• ED prevalence increases with ↑’ing age

– 5-10% at age 40 yo

– 40-60% at age 70 yo

• ED is associated with an 80% ↑RR for CAD across all ages

– 50x ↑ 10 year incidence of CHD in ♂ age 40-49 yo with ED

Inman et al; Mayo Clin Proc 84:108 (2009)

Gupta et al; Arch In Med 171:1797 (2011)

©LECS

• ED and CAD: different manifestations of a common vascular pathology

• Slow, progressive vascular occlusion +/- endothelial dysfunction are the causes of both ED and CVD

– penile artery: 1-2 mm; coronary artery: 3-4 mm; carotid artery: 5-7 mm




©LECS

• There is a strong commonality between risk factors for CAD and ED

– DM, smoking, HTN, old age, dyslipidemia

• Lifestyle modification for CVD RF’s like diet, ↑’d PA, smoking cessation ... are associated with significant improvement in sexual function

• Patients with ED age>40 yo had improvement in Sx’s after 6 months of simvastatin 40 mg qD




Trivedi et al;BJU International 111:324 (2012)

©LECS


• Several observational studies show a relationship between statin use and cancer incidence reduction, especially with prostate cancer

• Retrospective observational study of 30,076 patients

• Looked at rate of hospital admission with a dx of cancer

Karp et al; Am J Med 2008; 121:302-309

©LECS

• Overall n=30,076

– n=18,738 non-statin users

– n=5,323 low dose statin users

– n=6,015 high dose statin users

• Rates of hospital admission per 1000 person years: non vs low vs high

– all cancer: 26.0 vs 17.2 vs 13.9

– prostate cancer: 5.3 vs 2.3 vs 1.8


Karp et al; Am J Med 2008; 121:302-309

©LECS

• Preoperative statin use, in a dose-dependent fashion, reduces the risk of recurrence of prostate cancer after radical prostatectomy by up to 50%

• Men on statins during radiotherapy for cancer had a 15% increase in relapse-free status after a 10 year observation period


Hamilton et al; Cancer 2010;116:3389-98

Zelefsky; presented at 2008 Am Soc for Theurp Rad and Oncol

MINDIt's Not About The Nail (small).mp4

Controversy: NO ONE ONLINE AGREES. AFTER SEARCHING

THROUGH MANY ARTICLES ON THE FOLLOWING POINTS:

FOR EVERY ARTICLE THERE SEEMS TO BE AN ARTICLE TO

DISPUTE.

The differences may be cultural, ethnic, or geographic. For

example,

MEN do better in Math and WOMEN do better in Language.

Mind of a Man in linear ----- ----- ----- ------ ------ ------ GOAL

Mind of a Woman is tangential GOAL

It's Not About The Nail (small).mp4



Brain Structure and Function

Hormones may control the difference vs the are innate

differences

Men’s brains are 11-12 % heavier that Women’s Brain vs Men

are heavier and larger than Women

White matter and Gray matter- is it brain size? But consistant

after controlling difference for brain volume

Some studies show that the in greater intralobe neural

communication in male brains and greater interlobe

communication (between the right and left hemishere) in

women

SEX HORMONES

Testosterone, estrogen, progesterone,…..

EXAMPLE: Sexual motivation

Men- testosterone

suppressed with meds- decreased desire

elevated- polymorphous relationships

Women- at different times of menstral cycle differences in desire

Another study shows at ovulation woman prefer

masculine faces, greater affinity to other males than

current partner, Another set of studies show preference

for males with preferential genes (good genes hypothesis)

EXAMPLE: Gender roles- socialization issues: BUT

girls focus on a face

boys focus on mechanical mobils

Girls with congenital hyperplasia (high androgen during pregancy)

play with more boy toys and fewer girl toys

INTELLIGENCE

IQ Tests: Currently designed to minimize the difference between Men and

Women, however there tends to be suttle difference

Extreme controversy- girls score better than boys at the same age

but when older boys score better…..Social issues, health

variables….the difference disappear when there are male vs

female advantages

Math performance: 20 years ago boys scored better, but boys took advance

math classes. Now scores are similar

Spatial Ability: Overall no difference but males have advantage with mental

rotation and assessing horizonatal and vertical. Men have an

advantage in spatial memory. Hypothesis: happened because of

role evolution. Men hunt, women store

Estrogen vs testosterone????

PERSONALITY, AGGRESSIVE,

MEMORY TRAITS

Just more controversy

EMPATHY, EMOTION, MENTAL HEALTH

WHAT DO YOU THINK?

SPIRIT

ANIMAL BEHAVIOR IMG_0303.lnk

RELIGION: Polygamy, adultery, bigamy,

LEARNED BEHAVIOR: Lifestyles

IMG_0303.lnk

men’s health issues - osteopathic family physician · men’s health issues ... risk is an...

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