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visceral obesity, decreased muscle mass and strength, and decreased bone density.86-88 Many hypogonadal aging men experience symptoms of low libido, changes in erectile function, and possibly changes in morning erec- tion frequency, reduced sperm production (oligosper- mia), and sexual satisfaction.89 In several studies, falling testosterone levels have been associated with declining strength and muscle mass.90-93 There is a strong associa- tion between low bone density, bone loss, osteoporosis, and low testosterone levels in aging males.13,14,94,95 There has also been an association of increased risk of fractures in men with hypogonadal states.96-98
The age-related bone loss often begins in the fourth decade of life.
The SWAN study reported that there were eth- nic differences in the decline in bone density in pre- menopausal versus perimenopausal bone loss, but this decline was also affected by body weight.183 Unlike in postmenopausal women, the BMD and rate of bone loss of premenopausal and early perimenopausal women is better correlated inversely with serum FSH than estra- diol.183 Bone loss becomes more pronounced as the men- ses become less frequent with rapid loss during the years shortly after the last menses.183
The use of transdermal estrogen has been associated with increased libido and sexually satisfying events per month.184 Estrogen with or without a progestin can decrease early postmenopausal bone loss.184 Estrogen therapy improves bone mass in late postmenopause (near equivalent to the bisphosphonates).184 Selective estrogen receptor modulators such as raloxifene have also been found to improve BMD and reduce vertebral but not hip fractures.184
Initial studies suggested that cortisol levels in aging individuals were inversely related to BMD, rate of bone loss, and risk of clinical fractures.267,298 In aging individ- uals, cortisol appears to have gender-specific effects on BMD (measured by DEXA) with increased BMD loss in the lumbar spine of men and increased loss of BMD in the femur/hip of women.299 In addition to changes in adrenal production of cortisol, studies have suggested that the cortisone conversion to cortisol and cortisol production within osteoblasts also appears to increase with age.300 The use of exogenous steroids (e.g.
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