OR02-06 Sexual Symptoms Predict All-Cause Mortality Independently of Sex Steroids in Ageing Men

Background: The association between low testosterone (T) and higher mortality in men remains controversial. Most studies focus only on the association between total T (TT) and mortality. While TT declines with age, free T (FT) shows a greater fall, due to the rise in SHBG. Moreover, higher LH as well as sexual dysfunction, often co-existing with low T, have also been associated with mortality in ageing men.

Objective: To study the interrelationships between sex steroids, gonadotrophins and sexual symptoms with all-cause mortality in a large prospective cohort of European men.

Methods: 1913 community-dwelling men, aged 40-79, participated in the European Male Ageing Study (EMAS) between 2003-2005. Sexual symptoms were assessed via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. In 5 of 8 EMAS centres, survival status was available until 1 April 2018. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality. Because of the wide age range at study entry, age was used as time-scale, instead of years since inclusion adjusting for age. Results were expressed as hazard ratios (HR) with 95% confidence intervals, adjusted for centre, BMI and smoking.

Results: 483 (25.3%) men died during a mean follow-up of 12.4±3.3 years. Men who died had a higher BMI (p=0.002), but smoking status did not differ. TT levels were similar in both groups, but FT was lower in those who died (mean±SD: 312±86 pmol/L vs 270±84, p<0.001) and LH was higher (5.7±3.3 U/L vs 7.8±5.8, p<0.001). Men in the lowest FT quartile had higher mortality risk compared to men in the highest quartile (HR 1.43 (1.06-1.95); p=0.021). Also men in the highest FSH quartile had increased mortality risk (HR 1.38 (1.02-1.88); p=0.036). However, there was no association with TT, E2 or LH. Men with 3 sexual symptoms had a higher mortality risk compared to men with no sexual symptoms (HR 1.77 (1.28-2.41); p<0.001). In particular erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.15-1.73); p=0.001; HR 1.30 (1.06-1.60); p=0.012; HR 1.14 (0.93-1.40); p=0.203 respectively). Further adjusting for TT and FT did not influence the observed HRs. Also in men with normal TT (>12 nmol/L), the presence of sexual symptoms increased mortality risk (HR 1.51 (1.15-1.97); p=0.003). Finally, men with TT<8 nmol/L and sexual symptoms had a higher mortality risk compared to men with normal TT and no sexual symptoms (HR 1.92 (1.05-3.52); p=0.035).

Conclusions: Men with the lowest FT and highest FSH levels have an increased mortality risk. Sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of T levels. As both vascular disease and low T can influence erectile function, sexual symptoms can be an early sign for increased cardiovascular risk and mortality, as well as a sequela of low T.

Endocrinological aspects of aging in men: is hormone replacement of benefit?

Age-related decreases of serum testosterone (total, free and bioavailable), DHEA, DHEA-S, growth hormone (GH) and IGF-I are well established in elderly healthy men. Although substantial, the decrease of these hormones is small compared to the estrogen changes observed in postmenopausal women. Elderly men also loose bone and muscle, gain fat and have less sexual appetite. Therefore, the assumption that hormonal therapy is a potential 'fountain of youth' appears logical. At present, however, the effects of replacement of testosterone, DHEA and GH in healthy elderly men have been studied in only a few randomised placebo-controlled trials. These studies were small and of short duration. Although some significant overall effects of either androgen or GH replacement on body composition (less fat and more muscle) were found, the effects of such therapy on muscle strength, on metabolic and sexual function and on skeletal homeostasis have been less consistent. Also, the safety of such therapy should be better documented. Moreover, data obtained in healthy elderly men cannot be transposed to non-healthy elderly men. In conclusion, more scientific work is needed before general replacement of the 'falling hormones' should be regarded as beneficial for elderly men.

[Hormone treatment of pedophilia]

Pedophilia is only one of the sexual deviations that can be treated by chemical castration and it is presently unclear whether pedophilia responds better or worse to this therapy in sexual offenders. Antiandrogens are most often used for chemical castration. With respect to the treatment of sexual deviations, LH-antagonists or the combination of antiandrogens and LH-agonists were not studied very extensively. Long-term effects and side-effects of chemical castration are also presently unclear. Although, there is some indication that recidivism will decrease following chemical castration, its use is limited by a high refusal and drop-out rate. The indications of chemical castration in the treatment of sexual deviation raises important ethical questions.