Testosterone replacement therapy: dilemmas and challenges in China and Asia

instrument for older Chinese men in population. It was also suggested that AMS might be useful for therapeutic monitoring of TRT in older Chinese men due to its moderate specificity. However, another study of questionnaires for population surveys and screening of clinical signs and symptoms of androgen deficiency and low serum T in Shanghai, China, showed that the sensitivity and specificity of ADAM questionnaire were only 78.7% and 14.8%, and those of AMS questionnaires were also low at 54.0% and 41.2%, respectively.8 Furthermore, a study performed in Taiwan, China, also reported that both questionnaires had low sensitivity and specificity to detect androgen deficiency and low serum T.9 In addition, this study recommended that a complete physical and biochemical checkup should also be conducted in patients at risk or suspected of androgen deficiency. Thus, both ADAM and AMS questionnaires have limited value in Chinese populations. Recently, two TRT studies of aging men in Taiwan, China and Shanghai, China, evaluated the correlation between sexual function as assessed by the International Index of Erectile Function (IIEF‐15) scores and symptoms of LOH.10,11 The findings from these studies suggested a significant improvement in IIEF‐15 scores after TRT, which was in agreement with the evaluation of ADAM and AMS questionnaires. However, investigators from the United Arab Emirates (UAE) recommend the AMS scale for assessing clinical symptoms of hypogonadism, while doctors in Korea studied various types of questionnaires to evaluate LOH.12,13 Therefore, these questionnaires may have limited value in screening for the presence of androgen deficiency, while they may capture an improvement in symptoms in the setting of TRT. In the recent years, Chinese andrologists have proposed a simplified version of the AMS (concise scale of AMS [cAMS]) using correlation analysis between serum androgen (TT, cFT, or free testosterone index [FTI]) concentrations and symptoms of androgen deficiency in a large clinical multicenter study with 5980 participants (age ≥40 years old). In this study, 10 of 17 symptoms of AMS were significantly correlated with cFT and FTI. When comparing the scores from androgen deficiency symptom scales and serum cFT or FTI level, the total scores including the sexual function, autonomic nervous disorder symptom, or psychological and physical symptom ≥17 points were considered to be positive for cAMS (unpublished article). Therefore, the AMS and ADAM questionnaires that were designed and tested first in older, non‐Asian men need to be modified for the older Asian men. However, the use of such questionnaires should not replace a careful clinical assessment for relevant symptoms and signs before making a diagnosis of androgen deficiency.