In 1980, an 18-year veteran police detective in Ontario with a previously spotless record stole approximately $1000.00 worth of items from the evidence room of his department. He persuaded the judge in his case to spare him a prison sentence, claiming that “male menopause” had clouded his judgment.
Ever since the term “male menopause” was first coined in 1949, there have been debates about whether men go though a psychological and physiological change that is similar to menopause in women. The problem is that menopause literally means “the end of menses,” so it describes the loss of something that men never have. Despite that, men do experience physical changes as they age that, like menopause, are caused by a decrease in hormone production. Unlike menopause, this decrease in hormone production is drawn out over most of a man’s adult life. This has lead to a series of attempts to find a better term to describe what is happening. Many doctor use the term “andropause” to describe the age-related hormone changes in men. Irritability, fatigue, depression, reduced libido and erection problems are hallmark signs of andropause.
Andropause can be taken to mean “the end of male-ness.” More accurately, it should be thought of as a reduction in the production of hormones called “androgens” that produce male sexual characteristics. The chief androgen in humans is testosterone. Testosterone is the hormone that makes men, men.
Testosterone production varies throughout a man’s life. Before birth, testosterone and other androgens drive the differentiation of the embryo into a male baby. In early infancy, testosterone levels rise and then retreat for reasons that are not well-understood. Through childhood, testosterone is very low, but then it increases greatly in puberty. Starting at about age 30, testosterone production drops approximately 1% to 3% a year and this decrease continues until the end of life.
What principally distinguishes menopause from andropause, therefore, is the time scale and rate at which sex hormone production changes. In women, menopause is a distinct life stage lasting 1-10 years. Once menopause is complete, production of sex hormones remains at a steady lower level until the end of life. By contrast, men normally experience no such abrupt change in sex hormone production and the decline of production continues throughout old age.
Another way menopause is different from andropause is in how it changes fertility. Although there are many women who mistake the appearance of menopause symptoms for the end of fertility, earlier at some point in the peri-menopause transition the ovaries will stop producing new eggs and she will no longer be able to become pregnant. In men, however, the production of sperm can continue until very late in life at levels high enough to cause pregnancy.
Despite these differences in timing and fertility, however, there is a real biological change happening in men as they age. While there is not yet any officially recognized diagnosis of andropause, researchers have been defining a wide range of ways the reduction in testosterone affects men, using terms like Symptomatic Late-Onset Hypogonadism (SLOH) and Androgen Deficiency in the Aging Male (ADAM). These terms may be more accurate ways of describing testosterone deficiency that has dropped enough to produce recognizable symptoms.
Testosterone production varies not only with age but also daily and in response to stress. Peak production occurs in the morning decreasing through the day to a valley in the evening. Testosterone is produced by the testicles and adrenal glands and released into the blood stream where most is bound to proteins called sex-hormone binding globulin (SHBG) other proteins such as albumin. The SHBG-bound portion is very tightly bound making it unavailable for use by the body, leaving approximately 2% “free” testosterone and 23% loosely-bound “bioavailable” testosterone[1]. When it reaches its target, a small portion of testosterone is converted into a more potent metabolite called dihydrotestosterone (DHT).
Like menopause, testosterone deficiency is an endocrine condition that causes changes in a man’s metabolism with short and long-term effects in many different organs and systems. The musculoskeletal system shows lower density in the bones and weaker muscles. In the cardiovascular system, testosterone deficiency is associated with atherosclerosis, coronary artery disease, and other cardiovascular diseases[2]. In the nervous system, low testosterone shows up as decreased libido, increased rates of depression and cognitive difficulties. It is also linked to erectile dysfunction, alterations of body hair and skin thickness, increased visceral fat, and infertility.
Men with low testosterone levels have higher risks of osteoporosis and fractures. As testosterone decreases, deposition of new bone also decreases, reducing bone strength and density. Osteoporotic men given testosterone supplementation reduce the rate of bone degradation and increase bone density. Fractures, especially hip fractures, in the elderly are very dangerous to both men and women. Men are more likely to die following hip fracture than women. The one year mortality rate following hip fracture for men is double that of women.[3]
As both men and women age, they lose muscle strength. Testosterone is an anabolic steroid, which builds muscle, so it makes sense that reduced levels would reduce muscle mass and strength. The loss of independence and increased overall frailness we associate with old age are partly a consequence of this decline of the anabolic effects of testosterone. Older me with relatively low testosterone levels are at increased risk of frailty than those with higher levels.[4] Elderly men that have higher testosterone levels have better physical capacity as measured by physical fitness tests. They also are better able to carry out normal daily activities, like writing, eating, walking, and dressing. Men given testosterone supplementation have reduced body fat, increased lean muscle mass, and increased grip strength. They also gain upper and lower body strength and aerobic endurance.
It has been a long-standing belief in the medical community that higher levels of testosterone put men at increased risk for heart disease. The exact opposite is in fact true – lowered amounts of testosterone increase the risk of heart disease over normal men. Men that have coronary artery disease have lower levels of testosterone than men without blocked arteries. No study so far, in fact, shows a relation between higher testosterone and coronary artery disease. Neither does an increased testosterone level from supplementation lead to increased heart disease. This overturns years of dogma and leads to the question whether testosterone supplementation can help men with cardiovascular disease?
Fortunately, men with decreased testosterone and coronary artery disease do show improvement when given testosterone supplementation. Angina frequency and intensity are reduced, they tolerate exercise longer before experiencing chest pain, and have improved mood.
Mood and other emotional and cognitive disturbances are another group of symptoms that men and women share and may be related to hormonal changes. The brain produces testosterone and receptors for testosterone are common in the brain. We are just beginning to understand the effects on the brain of late-life testosterone deficiency.
Elderly men in one study that had higher levels of bioavailabile testosterone did better on tests that are designed to find brain damage or dementia. Declining testosterone also appears to reduce the type of thinking called “spatial cognition” – tasks that require attention to objects in three-dimensional space like visual perception, object perception, and visual memory. Men with lower levels of testosterone also report greater levels of memory problems and other dementia symptoms as they age. Testosterone also appears to both help protect and heal nerve cells in the brain. In laboratory studies, testosterone protects neurons from attack by a variety of possible toxins. It also helps heal severed nerves and produces other chemicals that help nerves re-grow after injury.
With all these effects on the brain, it is no surprise it is being looked at as a way to treat one of the worst diseases of aging, Alzheimer’s disease (AD). AD is characterized by progressive loss of higher brain functions and the deposition of plaque in the brain. Testosterone and other hormones appear to possibly impact this process and are being considered as therapies for AD. In some laboratory studies, testosterone significantly reduced the impact of AD on memory loss and the production of these plaques.
Another effect of menopause is that declining sex hormone production reduces interest in sex. Men also experience a decline in sexual desire with reduced testosterone levels. In fact, decreased libido with no other cause is a standard symptom for clinically-significant decreased testosterone. Men with decreased testosterone also have more trouble producing or maintaining an erection. Several small studies have shown that testosterone supplementation in older men results in both increases in libido and in a higher sense of well-being and satisfaction.
Weight gain in elderly women is frequently blamed on the hormonal and metabolic changes caused by menopause. Similarly, decreased testosterone is linked to increased body fat, especially “visceral” fat. Visceral fat is also called abdominal fat or organ fat. It is the fat that is located inside the abdomen instead of just under the skin where most fat deposits are located. Packed in among and around the abdominal organs, visceral fat is associated with a much greater risk of cardiovascular disease, diabetes, hypertension, atherosclerosis and premature death.
Any doctor that sees middle-aged men is asked: “Do men have male menopause?” or: “Does male menopause exist?” Because of the very different ways that men and women’s bodies change the production and availability of sex hormones, these are really the wrong questions. The question that we should ask is: “Should men be evaluated for sex-hormone changes in later life?” This answer to this question is a very firm and unequivocal: “Yes.”
Without proper evaluation of androgen levels, many treatable symptoms will go unaddressed. With proper evaluation, men can be treated in ways that will improve general health, longevity, and quality of life.
Unfortunately, most clinicians either do not recognize the symptoms of testosterone deficiency or believe that these symptoms are “normal aging.” When doctors miss addressing testosterone deficiency, they cheat their patients of powerful treatment options.
Complicating evaluation and treatment of androgen deficiency, however, is the difficulty in measuring or defining what is an abnormally low level. Men’s testosterone levels in later life are variable and poorly-defined. Among the issues: there are multiple protocols for testing androgens, each with different reference values, there are different androgen fractions (free testosterone vs. bioavailabile testosterone, etc.) that can mask the amount actually available for use by the body, and the reference standards for the “normal” range are incredibly broad.
The biggest issue in simply using blood tests to determine if a man is testosterone deficient is that the blood levels will vary greatly form one day to the next. Even if the test is drawn the same time of day on successive days, the blood levels of testosterone can be very different. This is why a full evaluation that considers the combination of clinical symptoms and blood tests is so important.
Just as with estrogen replacement therapy in women, however, there has been a great deal of controversy about possible hormone replacement therapy in men. The chief concern has been worries that testosterone replacement could stimulate heart disease or prostate cancer. Fortunately, the concerns for both negative side-effects appear to be overblown. As said, there is growing evidence that testosterone can help protect the heart from cardiovascular disease.
The case of prostate cancer is a bit more complicated. Many treatments for prostate cancer attempts to reduce testosterone to suppress tumor growth. Obviously, giving testosterone to a man with a prostate tumor is therefore not an option. The question has been: will testosterone supplements provoke prostate cancer? Fortunately, the answer appears to be, “No.”[5] Increased testosterone levels are not linked to higher rates of prostate cancer or more deaths from prostate cancer. In fact, it is quite the opposite. Men with higher amounts of testosterone show lower incidence and mortality for prostate cancer, as well as for cardiovascular disease and for all causes of death[6].
The decline in late-life androgen production is a very real and very treatable phenomenon. Unfortunately, 50 years of debate about whether there is such a thing as “male menopause” has obscured these hormonal changes. There is a growing realization that proper evaluation and treatment of testosterone deficiency is both appropriate and beneficial for many men. For optimal results, I recommend seeking out a physician experienced in bioidentical hormone replacement therapy within a broader program addressing overall lifestyle modification and enhancement.
[1] Diver, M.J., Imtiaz, K.E., Ahmad, A.M., Vora, J.P. & Fraser, W.D. (2003) Diurnal rhythms of serum total, free and bioavailable testosterone and of SHBG in middle-aged men compared with those in young men. Clinical Endocrinology, 58, 710-717.
[2] Liu PY, Death AK, Handelsman DJ. Androgens and cardiovascular disease. Endocrine Review. 2003 Jun;24(3):313-40.
[3] Haentjens P, Magaziner J, et al. Meta-analysis: Excess Mortality After Hip Fracture Among Older Women and Men. Annals Intern Med 2010; 152:380-390
[4] Hyde Z, Flicker L, Almeida OP, et al. Low Testosterone Tied to Frailty in Older Men. J Clin Endocrinol Metab. Pub Online April 24, 2010; doi:10.1210/jc.2009-2754
[5] Eaton NE, Reeves GK, Appleby PN, Key TJ. Endogenous sex hormones and prostate cancer: a quantitative review of prospective studies. British Journal of Cancer. 1999 Jun;80(7):930-4
[6] Khaw, KT, Dowsett, M, Folkerd E, et al. Endogenous testosterone and mortality due to all causes, cardiovascular disease, and cancer in men: European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) prospective patient study. Circulation. 2007 Dec 4;116(23):2694-701.
