Family doctor

male menopause

Overview:

• There is ongoing debate over whether male menopause actually exists
• Some experts believe a reduction in the hormone testosterone as men grow older is responsible for male menopause
• Testosterone levels fall at a rate of 1 percent per year after mid-life
• Symptoms of testosterone deficiency include depression, irritability, sexual dysfunction, fatigue and problems with mental functioning
• Testosterone replacement therapy is the main treatment for male menopause that is definitely linked to low testosterone levels

What is it?

Male menopause is a term to describe a drop in male hormone levels after middle age leading to depression, anxiety and low libido.

The term has also been used to describe a mid-life crisis that happens to some men during their late thirties and early forties. However, this is outside the scope of this article which deals with physical symptoms caused by low testosterone levels.

There is controversy about whether male menopause actually exists because it is not associated with a sharp drop in hormones and the cessation of a bodily function like in the case of female menopause when women's periods stop.

However, testosterone is produced at smaller amounts by the testicles and in pituitary gonadotrophin secretion in middle aged and elderly men which is believed to lead to the symptoms of male menopause.

Testosterone production and plasma levels fall in most men as they age, and there appears to be a threshold at which lower levels may result in sexual dysfunction. However, there appears to be a wide variation among men at what level they may experience problems with falling testosterone levels.

Studies show that plasma concentration testosterone levels begin falling in early middle age, and bioavailable testosterone is nearly halved between the ages of 25 and 75. Total testosterone levels fall about 1 percent per year from mid-life but it is not clear whether this is medically significant.

Experts who dismiss the male menopause theory argue that because men's testosterone levels fall gradually, their bodies should naturally adapt to lower levels over time.

What are the symptoms?

The symptoms of male menopause include depression, sadness, irritability, low libido, erectile dysfunction, anxiety, hot flushes and sweating, and memory and concentration problems.

These symptoms are also commonly caused by other conditions and are very non-specific.

Although erectile dysfunction is often due to other causes, a proportion could be due to testosterone deficiency.

Men who complain of symptoms associated with a testosterone deficiency should be investigated for this, with blood testing to assess testosterone levels.

Low testosterone levels have been defined as 11nmol/l as only 1 percent of healthy men between the ages of 20 and 40 will have levels below this point.

There are other causes of low testosterone levels in men such as testicular dysfunction or trauma, and possible inherited factors - these may require specialist review by an endocrinologist.

What can be done?

Hormone replacement therapy for men is prescribed when they have low testosterone levels and symptoms that are definitely associated with this.

Male depression and irritability has been shown in uncontrolled studies to improve significantly with testosterone replacement treatment. However, this needs to be proved in properly controlled trials.

Testosterone replacement has also been linked to improvement in men's mental functioning, night sweats, bone density and muscle mass.

Opponents of the male menopause theory argue that studies have so far failed to prove that testosterone replacement improves muscle strength and sexual dysfunction in elderly men.

Older men often seek hormone therapy for erectile dysfunction but it is generally ineffective in such men unless there is a true androgen deficiency (very low levels). However, small doses of testosterone have been shown to increase libido in younger men with well documented hormone deficiency.

Eighty percent of erectile dysfunction is due to medical causes such as diabetes, heart disease and neurological disorders, and not due to low testosterone levels. It is believed to be safer to treat men with sexual dysfunction with Viagra than testosterone replacement.

Testosterone Replacement Therapy

Testosterone Replacement Therapy is also known as androgen replacement therapy, and its goal is to eliminate symptoms in men experiencing male menopause. As testosterone deficiency is a normally a permanent condition and lifelong treatment is usually required.

Testosterone Replacement Therapy can be prescribed as an oral medication, injections, implants or provided in transdermal patches and gels.

Testosterone injections are usually given approximately once every fortnight.

The oral capsules are reserved for men who cannot tolerate the injections or implants.

Patches are another option that provide a steady release of testosterone.

The implants are inserted in the lower abdomen or hip under anaesthetic. They provide treatment which lasts up to six months and are well tolerated by most men.

Testosterone levels should be maintained at optimal levels to provide the best benefit. This may be judged by a combination of blood tests and the clinical response.

Side effects

Androgen therapy does lead to recovery of a normal prostate size (the prostate shrinks when testosterone levels are low). It does not affect prostate specific antigen (PSA) levels.

Androgen therapy is not thought to increase the risk of prostate cancer above that of men with naturally higher testosterone levels of the same age.

However, the safety of androgen therapy on the cardiovascular system, prostate and mental functioning still needs to be properly studied. Further well conducted investigations into whether androgen therapy benefits bone and muscle are also needed.

Androgen therapy is believed to be a risk factor for heart disease but the existing studies are inconclusive. In fact, low testosterone levels have been recorded prior to heart attacks which may indicate that hormone therapy could help protect against cardiovascular disease.

The use of androgens should also be used with caution in older men who may have undiagnosed prostate cancer.

Sleep apnoea is also an occasional risk factor with androgen therapy.

Getting help

Your doctor or endocrinologist will be able to help assess your hormone levels and what therapy may be required.