Andrologi sjukdomarsfamportal.s3.amazonaws.com/files/57dfd27df003a4050051c640/Stefan... · Andrologi – mannens könsspecifika sjukdomar ST-dagar i Allmänmedicin Kalmar 20160915

Andrologi ndash mannens koumlnsspecifika sjukdomar

ST-dagar i Allmaumlnmedicin Kalmar 20160915

Stefan Arver

ANOVA

Karolinska UniversitetssjukhusetHuddinge

Institutionen foumlr MedicinHuddinge Karolinska Institutet

ST dagar i Kalmar 2016

Oumlversikt

ST Dagar i Allmaumlnmedicin Kalmar September 2016

Hands-on Diagnostik labanalyser handlaumlggning Vanliga andrologiska problem 1 Hypogonadism 2 Infertiliet 3 Sexuell Dysfunktion

Bakgrund Patofysiologi epidemiologi betydelse av co-morbiditeter Risker kopplade till sjukdom (symtom) och risker med behandling


Skapas Avvecklas

Foster nyfoumldd barn pubertet vuxen medelaringlders aringlderman Genetik praumlgling Foumlrvaltning - Livsstil

Konsekvenser Sjukdomsprocess Funktionsproblem

Sjukvaringrd

Pubertet Infertilitet 7 av maumln testikelcancer

Sexuell dysfunktion

Hjaumlrtkaumlrlsjukdom

SuicidVaringldsam doumld Olycka Kriminalitet Missbruk + + +

Mannen

MaleFemale

Cancer 175

CVD 152

Accidents 291

Diabetes 13

Suicide 37


Cardio Vascular Disease mortality


0

100

200

300

400

500

600

700

800

900

EU27 BG LV LT RO EE MK SK HU

HR PL

CZ FI SI LU EL MT

DE

AT

BE SE CY

DK IE UK PT IT IS

NO CH NL

ES FR

Country

Per 100000

Male Female

Age standardised mortality for CVD by sex and country all ages

Testosteron ndash Dina Associationer

bull Foumlrklaring till att maumln doumlr tidigare aumln kvinnor

bull Oumlkar risken foumlr hjaumlrtkaumlrlsjukdom

bull Styr maumlns aggressivitet och goumlr maumln varingldsamma

bull Oumlkar sexdriften och potensen

bull Hierarkin paring jobbet styrs av testosteron


Low Testosterone and Increased Mortality (N gt500)

Studies HR (95 CI) Nature Men n Follow-Up

y Mortality

Shores 2006 188 (134ndash263) Retrospective 858 8 All-cause

Laughlin 2008 138 (102ndash185) Prospective 794 20 CVD

Khaw 2007 229 (160ndash326) Prospective 2314 of 11606

10 All-cause and

CVD

Haring 2010 232 (138ndash389) Prospective 1954 72 All-cause

256 (115-652) CVD

Malkin 2010 227 (145ndash360) Prospective 930 69

All-cause in men with coronary disease

Tivesten 2009 165 (129ndash212) Prospective 3014 45 All-cause

Menke 2010 143 (109ndash187) Prospective 1114 9 All-cause

Vikan 2009 124 (101ndash154) Prospective 1568 112 All-cause

Corona 2010 71 (18ndash286) Prospective 1687 43 CVD

HR=hazard ratio CI=confidence interval ST dagar i Kalmar 2016

Mortalitet relaterad till testosteron nivaringer Veterans Administration oumlppenvaringrd


Free Tgt26 nmolL

Free Tlt26 nmolL

Men T2D adjusted for ager BMI HbA1c Roumlkning

VMuraleedharan et al European J Endocrinology 2013 Sept 2


Vigen R et al J Am Med Assoc 310(17) 1829-1836 (2013) ST dagar i Kalmar 2016

Proportion of All Events (Composite of All-cause Mortality Myocardial Infarction and Stroke) in Hypogonadal Patients () with or without Testosterone Replacement Therapy (TRT)

91

56

65

55

19

27

0

2

4

6

8

10

Death Myocardial infarction Stroke

no TRT TRT

Data from Vigen R et al J Am Med Assoc 310(17) 1829-1836 (2013)

212

101

0

5

10

15

20

25

all events



Men T2D with and with without Testosterone therapy

Free Tlt26 nmolL

Free Tgt26 nmolL

Testosterone treatment


J Clin Endocrinol Metab2008 93(7)2737ndash2745

Testosterone and age


Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol


HYPOGONADAL-OBESITY-ADIPOCYTOKINE HYPOTHESIS


Effect of Weight Loss on Testosterone Levels

Grossman M JCEM 2011962341-2353

Bariatric Surgery

Dietary and exercise


LL Lower limit MH-OR Mantel-Haenszel odds ratio UL Upper limit

Odds Ratio for Major Adverse Cardiovascular Events (MACE) in Subjects Treated

with Testosterone or Placebo MACE cardiovascular death non-fatal myocardial infarction stroke acute coronary syndromes andor heart failure

Corona G et al Expert Opin Drug Saf published online August 19 2014

TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS

Source MH - OR LL Events Patients Events Patients

Copenhagen SG 1986 (31) 197 008 4882 068 Hall et al 1996 (34) 032 001 823 049 Sih et al 1997 (36) 088 005 1533 093 Snyder et al 1999 (40) 204 018 2317 057 English et al 2000 (42) 312 012 8039 049 Seidman et al 2001 (47) 041 002 1083 059 Steidle et al 2003 (52) 283 011 7027 053 Armory et al 2004 (54) 313 012 8068 049 Kenn et al 2004 (56) 023 001 705 040 Svartberg et al 2004 (60) 029 001 774 046 Brockenbrough et al 2006 (63) 375 036 3959 027 Malkin et al 2006 (69) 217 019 2501 053 Nair et al 2006 (72) 570 026 12378 027 Svartberg et al 2008 (81) 316 012 8264 049 Chapman et al 2009 (84) 100 005 2083 100 Legros et al 2009 (85) 101 004 2501 100 Aversa et al 2010 (89) 008 000 207 013 Aversa et al 2010 (90) 007 000 197 012 Basaria et al 2010 (11) 1339 074 24078 008 Kalinchenko et al 2010 (92) 021 001 515 034 Srinivas- Shankar et al 2010 (93) 101 014 731 099 Ho et al 2011 (95) 100 006 1637 100 Jones et al 2011 (96) 051 005 575 059 Kaufman et al 2011 (97) 087 004 1848 093 Behre et al 2012 (99) 295 012 7291 051 Hildreth et al 2013 (100) 015 002 153 011 Overall 101 057 177 096

1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism

Age at onset of hypogonadsim

Intra-uterine Prepubertal Adult

Age at onset ndash Duration - Severty


Adopted from Maggio M and Basaria S Int J Impot Res 21 261-264 (2009)

Clinical Implication of Testosterone Deficiency

Metabolic Syndrome

Atherosclerosis

Insulin Resistance

Diabetes Sexual Dysfunction

Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY


Naumlr Testosteron faller Blir vissa symtom vanligare

Symtom

Troumltther Foumlrlust av

libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL


Probability of Symptoms on the Basis of Levels of Total Testosterone and Free Testosterone

Wu FC et al N Engl J Med 2010363123-135

Wu F et al N Engl J Med 2010 363123-35

Symptom thresholds EMAS study


Hypogonadism - Lab diagnostik

bull S-Testosteron SHBG LH

bull T gt 12nmolL Sannolikt normalt T 8 ndash 12 nmolL Graringzon T lt 8nmolL Sannolikt brist LH houmlgt = Primaumlr hypogonadism LH laringgt = Sekundaumlr hypogonadism LH normalt = Mixed etiologi

Morgonprov fastande ST dagar i Kalmar 2016

Metoder att tillfoumlra testosteron

Nebido intramuskulaumlra injektioner

Testim 50mgtubl Testogel 50 mgdoskudde

Tostrex 2 gel pump


Behandling

bull Transdermalt (Testogel Tostrex Testim) 5-10 mg tillfoumlrt dygn

bull Injektioner Nebido (T-undecanoat) 750 -1000mg var 10 ndash 14e vecka (3-4mL im)

bull Oumlverdoseringseffekter sekundaumlr erythrocytos ndash minska dos evt kortare intervall (Nebido 2-3 mL var 8 ndash 10 v)


Foumlre behandling bull Prostata palp PSA Hb

bull Soumlmn apneacute ndash utred-behandla

bull Hjaumlrtsvikt ndash dostitrera upparingt

bull Aumlldre maumln med CVD ndash undvik houmlga nivaringer

bull Prostata Ca Broumlst Ca - Kontraindikation


Monitorering

bull Dosjustering 2v ndash14 v (maringl laumlgsta nivaring gt 12 houmlgsta gt 17nmolL)

bull Gel maumlt peak 2-4 tim efter applikation bull Nebido maumlt dalvaumlrde ndash OBS foumlre 3e ndash 4e inj bull 3-6 maringnader Prostata palp PSA Hb bull Aringrligen (Prostata palp) PSA Hb


bull ldquoFrom this report of the practical use of testosterone in clinical medicine it is obvious that the drug is a potent one particularly in hypogonadism in males In this condition its effectiveness as substitution therapy is uniformly acceptedrdquo

N Engl J Med 1940 222877-881


Diagnosis


Subfertilitet hos maumln ndash en riskfaktor

Relative risk of death according to fertility status and semen quality Jensen TK et al

Am J Epidemiol 2009


Gemensam orsak till olika sjukdoms tillstaringnd i mannens fortplantningssystem

Poor semen quality

Testicular cancer

Cryptorchidism Hypospadias

Germinal cell

Sertoli cell

Leydig cell Foetal life

Environment life style genetic predisposition

Postnatal life

Testosteronbrist

Skakkebaek et al

Human Reprod 2001 ST dagar i Kalmar 2016

Kronisk njursjukdom Reumatsk sjukdom

HIV infektion KOL

Genomgaringngen cancerbehandling Opiat behandling

Korticosteroid behandling Sub - Infertilitet

Tillstaringnd och sjukdomar med houmlg Prevalens laringga testosteronnivaringer och hypogonadism


Longitudinal Relation of Hypogonadism and Incident Depression in 278 Elderly Men (mean age 624 years)

Shores MM et al Arch Gen Psychiatry 61 162-167 (2004)

0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)


Amanatkar et al Annals of Clinical Psychiatry 2014 26(1)19-32

Behandlingsstudier med testosteron hos maumln med depression

Lack of dose

response relation

between S-testosterone

and sexual function

once above the

threshold level

Grey et al JCEM 2005 Jul90(7)3838-46

Sexual Functionactivity


Testosteron effekt paring aggressivitet

Tveksam

Figure 1 Distribution of reported payoffs

Wibral M Dohmen T Klingmuumlller D Weber B Falk A (2012) Testosterone Administration Reduces Lying in Men PLoS ONE 7(10)

e46774 doi101371journalpone0046774

http1270018081plosonearticleid=infodoi101371journalpone0046774

Paringlitlighet



Sexuell dysfunktion

bull Lustproblem

bull Erektionsproblem

bull Prematur ejakulation

bull Foumlrdroumljd eller ingen ejakulation

bull Retrograd ejakulation

bull Smaumlrtsam erektionndash Peyronies Disease

bull Krokpenis


Erektion en perifer reaktion paring sexuell stimulering


Erektion aumlr avslappning

Erektionsnerver

Anti- Erektionsnerver

Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur

Kaumlrlkonstriktion=

ingen erektion


2-stegs raket

Initial dilatation Neurogen

NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF

Musicki et al PNAS 331171 1005

eNOS


Inman et al Mayo Clin Proc 2009 84 (2)108-113 ST dagar i Kalmar 2016

ED riskfaktor foumlr CVD redan vid 40 ndash 50 aringaring

Br J Clin Pharmacol 2006 Mar61(3)280-8J Clin Pharmacol 2005 Sep45(9)987-1003 Review

Viagra Cialis Levitra

25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb



Vitaros kraumlm Bondil gel

Alternativ foumlr injektioner


Vakumpump Erektionsprotes

Take Home Message

Laringgt testosteron predikterar oumlkad morbiditet och mortalitet Maumln med normala testosteronnivaringer har reducerad sjukdomsrisk Det aumlr maumln med testikulaumlr dysfunktion som loumlper oumlkad risk foumlr prematur doumld Ett foumlrsta tecken paring testikulaumlr dysfunktion aumlr nedsatt fertiliet Obesitas aumlr en riskfaktor foumlr hypogonadism inte aringlder Metabolt Syndrom Hypogonadism och LUTS aumlr associerade med varandra


Diagnostik aumlr kliniskt beslutfattande baserat paring labvaumlrden och klinisk utvaumlrdering av symtom

Oumlversikt


Hands-on Diagnostik labanalyser handlaumlggning Vanliga andrologiska problem 1 Hypogonadism 2 Infertiliet 3 Sexuell Dysfunktion

Bakgrund Patofysiologi epidemiologi betydelse av co-morbiditeter Risker kopplade till sjukdom (symtom) och risker med behandling


Skapas Avvecklas



Sjukvaringrd


Sexuell dysfunktion



Mannen

MaleFemale

Cancer 175

CVD 152

Accidents 291

Diabetes 13

Suicide 37




0

100

200

300

400

500

600

700

800

900


HR PL

CZ FI SI LU EL MT

DE

AT

BE SE CY

DK IE UK PT IT IS

NO CH NL

ES FR

Country

Per 100000

Male Female











y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Skapas Avvecklas



Sjukvaringrd


Sexuell dysfunktion



Mannen

MaleFemale

Cancer 175

CVD 152

Accidents 291

Diabetes 13

Suicide 37




0

100

200

300

400

500

600

700

800

900


HR PL

CZ FI SI LU EL MT

DE

AT

BE SE CY

DK IE UK PT IT IS

NO CH NL

ES FR

Country

Per 100000

Male Female











y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




MaleFemale

Cancer 175

CVD 152

Accidents 291

Diabetes 13

Suicide 37




0

100

200

300

400

500

600

700

800

900


HR PL

CZ FI SI LU EL MT

DE

AT

BE SE CY

DK IE UK PT IT IS

NO CH NL

ES FR

Country

Per 100000

Male Female











y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






0

100

200

300

400

500

600

700

800

900


HR PL

CZ FI SI LU EL MT

DE

AT

BE SE CY

DK IE UK PT IT IS

NO CH NL

ES FR

Country

Per 100000

Male Female











y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message













y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






y Mortality




10 All-cause and

CVD


256 (115-652) CVD










Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Free Tgt26 nmolL

Free Tlt26 nmolL






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





91

56

65

55

19

27

0

2

4

6

8

10


no TRT TRT


212

101

0

5

10

15

20

25

all events




Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Free Tlt26 nmolL

Free Tgt26 nmolL






Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message







Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Hypothalamus

GnRH

Pituitary

FSH LH

Testosterone

-

-

Inhibin

-

Estradiol






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message








Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Bariatric Surgery







TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message








TRT Placebo

001 01 1 10 100

Odds ratio for MACE

Placebo TS



1 134 0 87 0 35 1 35 1 17 1 15 2 54 1 54 1 25 0 25 0 13 1 17 1 106 0 99 1 24 0 24 0 6 1 5 0 15 1 14 3 19 1 21 2 37 1 39 2 30 0 32 1 19 0 19 1 6 1 6 1 237 0 79 0 40 1 10 0 42 1 10 6 106 0 103 0 113 1 71 2 136 2 138 1 60 1 60 1 108 2 112 2 234 0 40 1 183 0 179 1 96 3 47

31 1895 20 1341

UL p



Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Hypogonadism







Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message










Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Metabolic Syndrome

Atherosclerosis

Insulin Resistance


Dyslipidemia

Vascular Stiffness

Inflammation

Hypertension

MORTALITY

TESTOSTERONE

DEFICIENCY



Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Symtom


libido

Fetma Depression

soumlmnproblem

koncentrations

svaringrigehter

Diabetes

Erektions probem

svettningar

15

lt810

12

Testosteron nmolL














Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message
















Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message











Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message







Tostrex 2 gel pump


Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Behandling











Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message










Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Monitorering





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





N Engl J Med 1940 222877-881


Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Diagnosis




Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Am J Epidemiol 2009



Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Poor semen quality

Testicular cancer


Germinal cell

Sertoli cell



Postnatal life

Testosteronbrist

Skakkebaek et al



HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





HIV infektion KOL







0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






0

5

10

15

20

25

30

35

150 ngdL

521 nmolL

200 ngdL

694 nmolL

250 ngdL

868 nmolL

300 ngdL

1041 nmolL

350 ngdL

1214 nmolL

2-y

dep

ressio

n i

ncid

en

ce (

)




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Lack of dose

response relation


and sexual function

once above the

threshold level





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Tveksam





Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message








Paringlitlighet



Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Sexuell dysfunktion

bull Lustproblem






bull Krokpenis





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message







Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message





Erektionsnerver


Kaumlrlvidgning

=

Avslappning

av glatt

muskulatur


ingen erektion


2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




2-stegs raket


NO

Erektionsnerver

nNOS


Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message




Fortsatt dilatation

Shear Stress VEGF

NO

Erektionsnerver

nNOS NO

VEGF


eNOS






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message








25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message






25-50-100 mg 5 mg 1x1 10 ndash 20 mg vb

10 ndash 20 mg vb







Take Home Message









Take Home Message








Take Home Message




Take Home Message




Documents

Andrologi sjukdomarsfamportal.s3.amazonaws.com/files/57dfd27df003a4050051c640/Stefan... · Andrologi – mannens könsspecifika sjukdomar ST-dagar i Allmänmedicin Kalmar 20160915