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It is dif cult to distinguish the signs and symptoms of androgen de ciency from GH de ciency as they are quite similar [168] Both androgens and GH decrease with age, making evaluation of cause and effect dif cult if the cause may be due to a pituitary problem Also, GH replacement reverses the same symptoms as does T-replacement [335] The biologic effects of GH and androgens are mutually interdependent and synergistic [336] But in boys with micropenis and GH and T de iciency, treatment with GH alone resulted in a normal penis size [337] Most biologic effects of GH are not mediated by itself but by insulinlike growth factor (IGF)-1 which is synthesized in the liver cells following stimulation by GH, or locally in target tissues of GH, and is released into the bloodstream from there In acromegaly the state of GH excess sexual dysfunction is noted, but these tumors are large and there is often extensive destruction of the pituitary gland, frequently causing hypogonadism and causing confusion as to the etiology of the symptoms Hypogonadism may also occur in the 40% of patients with acromegaly who also hypersecrete prolactin another cause of secondary hypogonadism [338]

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18 In conclusion, except in the rare condition of acromegaly, abnormal GH secretion does not seem involved in sexual dysfunctions and there is no need for routine determination of this hormone unless other symptoms of this condition are present

It is evident from the previous discussion that there are signi cant challenges in utilizing existing IDS tools in a MANET environment A new intrusion detection architecture that is much more distributed and cooperative needs to be introduced Such an approach will be able to detect more attacks reliably In order to create such an architecture there are some fundamental questions that need to be considered A key question that will have to be answered rst is related to the roles that a node can have in a MANET intrusion detection architecture These roles include the following:

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Evaluating GH de ciency is also dif cult because the various conditions that may cause it may also cause T de ciency at the same time Most cases of pan-hypopituitarism are caused by destruction of the gland from a large pituitary adenoma or else by autoimmune destruction that is also rather devastating to the entire pituitary gland [339] Lymphocytic hypophysitis, once thought to be found exclusively in women, is now being reported more in men, and has even been shown to present with ED [340] Even metastatic carcinoma to the pituitary gland, although rare, has been reported to cause pituitary destruction and present with sexual dysfunction [341] Little data is available relative to growth hormone therapy alone for sexual function, but Brill et al gave physiologic doses of GH and testosterone to older men for one month, without no effect on sexual function and mood whether the GH was given alone or in combination with testosterone The lack of response might have been due to the short duration of therapy or due to the fact that the men were not severely growth hormone-de cient to begin with [342] When GH has been given to GH-de cient men over a long period of time, a positive effect was noted on peripheral circulation needed for sexual function, and on positive mood [343] It has to be mentioned that during erection a 90% intracavernosal increase of GH concentrations was observed in a study of 35 voluntary potent men, and recombinant human GH elicited dose-dependent relaxation of human corpus cavernosum strips in vitro [334] This relaxant potency of recombinant human GH was accompanied by an elevation of the intracellular cGMP concentrations A recent study on isolated human corpus cavernosum strips provided evidence that GH may in uence corpus cavernosum smooth muscle cells by an NO-independent effect on guanylyl cyclase activity [345] This new data should stimulate further research in this areaOn the other hand, any good effects have to be balanced against possible side effects GH therapy has been shown to possibly induce peripheral edema, arthralgias, carpal tunnel syndrome, gynecomastia, and mild glucose intolerance There is also the possibility that patients who have excess GH may develop abnormal cell proliferation, as various tumors and cancers have a higher prevalence in acromegaly [347,348].

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