Andropause is known by many other names including Age Related Hypogonadism, Testosterone Deficiency Syndrome and Late onset Hypogonadism.

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1 Men's Health Andropause: Testosterone is the primary sex hormone produced by the male body. It regulates the male sex drive, supports sperm production and causes the development of secondary sex characteristics (e.g. genitals, body hair, deep voice). As men age, there is a decreasing level of testosterone and dehydroepiandrosterone which may result in the testosterone levels dropping below that of a normal physiological level leading to what is commonly termed hypogonadism. Andropause is known by many other names including Age Related Hypogonadism, Testosterone Deficiency Syndrome and Late onset Hypogonadism. In the United States, there are 25,172,000 men between the ages of forty and fifty-five who are now going through the Andropause. Worldwide that number is 408 million. The impacts of low levels of testosterone may result in the following symptoms: - Loss of libido and potency - Depression - Impaired memory - Insomnia - Increased body fat - Loss of muscle mass - Lack of energy - Irritability Low testosterone levels have also been associated with increased risks of : - Depression - Osteoporosis - Cardiovascular disease - Diabetes Mellitus - High cholesterol levels - High Blood pressure Diagnosis and management: A simple early morning blood sample would reveal the total testosterone levels and be used as an initial assessment of the testosterone levels in the male. If it is found to be low, testosterone replacement can be initiated. Testosterone replacements are available in the form of tablets, gel applications or injections. Testosterone gel is easy and convenient to use. A single application in the morning before you head out to work on either the chest, shoulders or thigh area. Patients are adviced to not bathe or swim for 6 hours after application to allow the gel to be absorbed. Testosterone pills are also available. It is taken 2-3 a day and should be taken with food preferably with some oil content to aid absorption. Testosterone injections are also available for the busy individual. One injection is only required every 3 months, allowing the individual to enjoy the full effects of the testosterone replacements without the hassle of daily application of gels or popping of pills. A simple Prostate examination and blood test would be done prior to initiation of testosterone replacement.

2 Male Pattern Hair Loss: More than 95% of hair loss in men are male pattern hair loss also known as Androgenic alopecia. It is often characterised by thinning hair on the sides of the forehead and or a thinning crown. About 25% of men start to bald in their 30s and up to 67% begin balding in their 60s. The trigger for this male pattern baldness is DHT, as sex hormone that promotes facial and body hair growth. DHT causes the miniaturization of the hair follicles and eventual deterioration of the hair follicles leading to a loss hair. There are 2 forms of treatments for male pattern hair loss available now: 1. Medications a. Early stages of hair loss can be slowed or reversed with the use of finasteride or minoxidil b. Finasteride works by blocking the conversion of testosterone to DHT and thus aiding in the slow down and reversal of hair loss c. Minoxidil is a vasodilator medication which dilates the blood vessels around the hair follicles when applied, allowing more oxygen and nutrients to reach the hair, aiding in the reversal of hair loss. 2. Low level laser treatment

3 a. Studies have shown that low level laser therapy (LLLT) has been shown to increase hairgrowth up to 39 percent in 16 weeks. b. igrow hair growth system works via 51 low level red laser and LED lights to reenergize the hair follicles and cause a regeneration of hair. 3. Hair transplant a. It is an office based procedure done under local anaesthesia b. Healthy hair is taken from the back and sides of the head and transplanted to the areas of hair thinning c. The procedure typically takes a few hours and repeat follow up sessions may be needed to make the hair look thicker

4 Erectile Dysfunction : Erectile Dysfunction is a sexual dysfunction when one is unable to develop or maintain an erection during sexual performance. A study of Singapore men over 30 found that at least 51% of the men interviewed had expressed some degree of erectile dysfunction. Causes: - Cardiovascular - Diabetes - Nerve trauma from prostatectomy - Hormonal insufficiencies - Drug side effects - Psychological Screening: There are multiple ways of screening for erectile dysfunction, but one of the most commonly used ways is a nocturnal penile tumescence test. A normal male would have on averagr 4-6 erections in their sleep, often at the REM stage. A snap gauge can be used to assess the the presence or absence of such NPT. Another commonly used test is the International Index of Erectile Function ( IIEF-5) Over the past 6 months: 1. How do you rate your confidence that you could get and keep an erection? Very low 1 Low 2 Moderate 3 High 4 Very high 5 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? Almost never/never 1 A few less than half the time) 2 Some (about half the time) 3 Most more than half the time) 4 Almost always/always 5 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Almost never/never 1 A few less than half the time) 2 Some (about half the time) 3 Most more than half the time)4 Almost always/always 5 4. During sexual intercourse, how difficultwas it to maintain your erection to completion of intercourse? Extremely difficult 1 Very difficult 2 Difficult 3 Slightly difficult 4 Not difficult 5 5. When you attempted Almost A few Some Most Almost

5 sexual intercourse,how often was it satisfactory for you? never/never 1 less than half the time) 2 (about half the time) 3 more than half the time) 4 always/always 5 IIEF-5 scoring: The IIEF-5 score is the sum of the ordinal responses to the 5 items : No erectile dysfunction 17-21: Mild erectile dysfunction 12-16: Mild to moderate erectile dysfunction 8-11: Moderate erectile dysfunction 5-7: Severe erectile dysfunction Treatment: Besides treating the underlying causes, often the first line of treatment would be that of PDE5 inhibitors such as Viagra, Cialis. If Testosterone levels are found to be low, testosterone replacement therapy can also be initiated either concurrently or separately.

6 Benign Prostatic Hypertrophy: The prostate is a part of the male reproductive system that helps make and store seminal fluid. In adult men, a typical prostate is about 3 centimeters long and weighs about 20 grams. It is located in the pelvis, under the bladder and in front of the rectum. The prostate surrounds part of the urethra, the tube that carries urine from the bladder during urination and semen during ejaculation. Benign Prostatic Hypertrophy or increase in the size of the prostate occurs typically in men after the age of 30. It is caused by the presence of male sex hormones testosterone and DHT. DHT has a far greater effect on the growth of the prostate as it is about 10 x more potent in effect as compared to testosterone. BPH involves the increase in size of the cells in the prostate especially around the urethra region. When they get significantly large in size, they can occlude the urethral canal leading to partial or some complete obstruction of the urethra causing interference to the urine flow. Symptoms: - Urinary frequency - Frequent urgency - Needing to wait a while for urination to begin - Intermittent flow of urine - Needing to strain to urinate - Dribbling at the end of a urine flow - Nocturia (waking up at night to urinate) Diagnosis: A simple pre rectal examination done in the clinic can help to determine the size, shape and consistency of the prostate. Often, blood tests to check for the Prostate Specific Antigen levels are also used to help monitor and screen for any red flags that might warrant further investigations. Management: Medications are available to help manage BPH. Alpha blockers like terazosin are used which relaxes the smooth muscles in the prostate and bladder neck, thus relieving the obstruction caused by the BPH. 5 alpha reductaseinhinbitors are also used like finasteride which inhibits the production of DHT and thus reducing the growth of the prostate. If medications fail, then surgical options to remove the prostate has to be considered. Prostate Cancer: Prostate Cancer is the no. 3 cancer in men in Singapore. As the symptoms are often similar to that of BPH, we often advice our patients to do regular health check ups especially if they are experiencing symptoms as mentioned above. Prognosis of prostate cancer is dependent upon the stage at which the cancer is detected. Thus the earlier the cancer is picked up, the better the chances of survival and cure.

7 Hepatitis Screening: Hepatitis A: Hepatitis A is an acute infectious disease of the liver caused by the hepatitis A virus, an RNA virus, usually spread by the fecal-oral route; transmitted person-to-person by ingestion of contaminated food or water or through direct contact with an infectious person. The average time between infection and the appearance of symptoms is about 6 weeks. Some of the symptoms of Hepatitis A infection are: - Fatigue - Fever - Nausea - Loss of appetite - Jaundice - Pale stools - Very dark tea coloured urine Diagnosis: A simple blood test can be done to test for antibodies in the blood that can tell us if you have an acute infection or have immunity towards the Hepatitis A virus. If one is found to not have immunity, vaccination is available. The vaccine should be given in the muscle of the upper arm and be given in two doses for the best protection. Hepatitis B: Hepatitis B is an infectious inflammatory illness of the liver caused by the hepatitis B virus. The virus is transmitted by exposure to infectious blood or body fluids such as semen and vaginal fluids, while viral DNA has been detected in the saliva, tears, and urine of chronic carriers. It can also be transmitted from mother to child during delivery if the mother is infected. Other risk factors for developing HBV infection includes healthcare workers and people travelling to endemic countries. However, hepatitis B viruses cannot be spread by holding hands, sharing eating utensils or drinking glasses, coughing, sneezing, or breastfeeding. A little known fact is that hepatitis B is x more infective than the infamous HIV virus. That means that if exposed to the 2 viruses, the chance that one gets infected with Hepatitis B is x more than getting the HIV virus. Hepatitis B virus ( HBV ) is the most common human hepatitis virus in Singapore. HBV infection and its chronic sequelae are major world-wide health problems. It is estimated that around 6% of the Singapore population are hepatitis B carriers. It is estimated that between 25 to 50 percent of these carriers die prematurely, either as a result of chronic liver inflammation and liver failure (cirrhosis) or the development of liver cancer. Symptoms: - Fever - Loss of appetite - Myalgia

8 - Pale stools - Dark tea coloured urine - Fatigue However for chronic carriers, many may not experience any symptoms at all. Hepatitis B virus infection may be either acute (self-limiting) or chronic (long-standing). Persons with self-limiting infection clear the infection spontaneously within weeks to months. Due to the increased risks of developing cirrhosis of the liver and cancer of the liver (HCC), chronic carriers are adviced to do the following: - liver screen every 6 months - Ultrasound imaging of the liver every year Prevention: A 3 course vaccination is available to protect yourself from the hepatitis B virus. The course of the vaccination is taken on the day of injection, 1 month later and then 6 months from the first injection date. Hepatitis C: Hepatitis C is transmitted via blood to blood contact via poorly steralized medical instruments, intravenous drug use or transfusions. It is an infective disease that mainly infects the liver. The infection is often asymptomatic but it can lead to chronic infection and scarring of the liver. Some will go on to develop liver failure or liver cancer. There is currently no vaccine against the hepatitis C virus.

9 Stool Investigations: Fecal Occult blood test or FOBT in short is a test to check for hidden (occult) blood in the faeces that is not visible to the naked eye. The main purpose of this test is to detect any subtle bleed from the gastro-intestinal tract. If the FOBT test is positive, it would suggest the possibility of an upper or lower gastrointestinal bleed. Further investigations would then be needed to rule out any possibilities of peptic ulcers or malignancies such as colon cancer. This simple test involves the collection of 2 separate samples of stool from 2 separate bowel movements. Containers will be provided with a small scoop built in to ensure a convenient and hygienic means of collection.