Male Menopause (Andropause)

Dear Dr. B: My doctor recently told me that I have male menopause. Can you please tell me more about this? Yours: Mr. Menopause.

Dear Mr. Menopause: The correct name for this condition is “andropause”. “Andro” stands for androgen – a male sex hormone, such as testosterone or androsterone, that controls the development and maintenance of masculine characteristics.

Andropause is also known as ADAM (androgen decline in the aging male). The onset of andropause is unpredictable. Its clinical manifestations are subtle and variable.

The symptoms of andropause include fatigue, depression, hot flushes, sweats, decreased libido, erectile dysfunction, changes in cognition (like poor concentration and memory) and mood. Since these symptoms are more subjective than objective, some experts have trouble accepting andropause as a clinical condition.

Physical examination of an aging male patient with andropause may be quite normal. There may be presence of gynaecomastia (enlargement of male breast) and/or soft small testicles. Low testosterone level does not produce any specific organ changes. Another reason why some experts have trouble accepting andropause as a clinical condition.

Diagnosis of andropause is made by symptoms, physical signs and early morning non-fasting specimen of blood for testosterone level. Testosterone level is highest in early morning and can decrease by 35 percent in the midafternoon and evening.

Early morning testosterone level less that 7 nmol/l indicates that a man has poor gonadal function. This will warrant further investigation to find the reason for low testosterone level. Is it the normal aging process or some other pathology?

Testosterone level found to be critical for sexual function in men lies around 10.4 nmol/l. There can be some variation between individuals.

Normally men experience a continuous slow (an average of one to two percent a year) decline in serum testosterone level after about age 30 years. This is due to decrease in testosterone production. There are many other reasons why testicular function may fail – injury, infection, tumours, surgery, effect of other hormonal problems etc.

The goals of treatment for poor gonadal function are to improve erectile function, restore libido, and improve psychological well-being and mood. It is important to remember that in men over 50, cause for erectile dysfunction may be other than low testosterone level. So testosterone replacement therapy will improve libido and psychological well-being in this age group but may occasionally improve erectile dysfunction.

Testosterone replacement therapy improves bone mass, coronary artery disease, reduces total cholesterol and LDL (bad cholesterol) levels.

What are the contraindications?

Testosterone should not be given to individuals with prostate or breast cancer. Sleep apnea has been shown to contribute to low serum testosterone levels and testosterone therapy has been reported to make sleep apnea worse. Testosterone therapy may make blood thick (polycythemia), promote benign and malignant changes in the prostate, and can cause tenderness and enlargement of breasts.

Before starting an individual on testosterone therapy, the physician should screen the patient for sleep apnea, prostatic symptoms, and family history of prostate cancer. Do digital rectal examination, complete blood count, lipid profile and PSA. These tests should be repeated every six months.

Testosterone is available for clinical use in many forms: injectable, oral pill, skin patch, gel, and implantable formulations. Each one has advantages and disadvantages. Your physician will advice you the best formulation for you. The physician should monitor the treatment to check for any side-effects and for any long term complications like prostate cancer.

So, Mr. Menopause (or rather Mr. Andropause or Mr. ADAM), we haven’t heard the last word on this condition. Data on the benefits and risks of testosterone replacement therapy for older testosterone-deficient man are scanty, but new clinical information continues to be generated. So there is hope for aging men too!

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