MEN'S HEALTH MATTERS:The onset of andropause is gradual and often a clinical diagnosis can be difficult to make, writes THOMAS LYNCH
Q I read recently in one of my wife’s magazines that men like women can go through a menopause. I am 58 years old and have had a steady decline over the past year in energy levels, mood swings and decreased interest in sexual activity. Am I going through the male menopause and can anything be done about it?
A Hormone replacement therapy in women has long been the standard of care to obviate menopausal symptoms resulting from oestrogen deficiency.
It is increasingly widely recognised that similar decreases in serum testosterone with resulting symptoms can occur in some ageing men.
This testosterone reduction and associated symptom complex has been variously referred to as andropause or androgen deficiency in the ageing male (ADAM). It has been established that testosterone decreases by approximately 1 per cent per year after age 30.
About 20 per cent of men in their 60s have biochemical evidence of androgen deficiency, increasing to 50 per cent of men in the eighth decade of life.
Because the onset of andropause is gradual and many of its symptoms mirror those associated with medications or disease states common in the elderly, a clinical diagnosis can be difficult to make.
Additionally, because of a lack of established normal testosterone levels for different age groups, as well as confusion regarding what subset of testosterone to measure, simply testing testosterone levels is inadequate.
This is particularly problematic given the fact that the level of serum testosterone required for wellbeing may be variable. If a man is accustomed to a serum testosterone level in the high-normal range, reduction to a lower level, even though still within the established normal range, may no longer be adequate for maintenance of wellbeing.
Reduction in testosterone results in a number of physiologic changes. These include alteration in body composition (decrease in lean body mass, increase in fat mass), decrease in energy and muscle strength, decreased libido and erections, increased osteoporosis, mood changes, and reduction in cognitive function.
Despite these observations, specific studies demonstrating the connection between reduction in testosterone and these physiologic events have found only a weak correlation. This is perhaps explained by the myriad of other disease states occurring in the ageing male that can also give rise to these symptoms.
Another confounding factor is the fact that many of the symptoms of andropause can be caused by other co-morbid disease processes or side effects from commonly utilised medications in this population.
Among the possible side effects of testosterone replacement therapy (TRT) is an increased risk of prostate cancer.
While there is no evidence that supplemental testosterone will initiate prostate cancer or cause clinically significant progression of an established occult (hidden) malignancy, the initial evaluation of patients prior to administration of testosterone requires screening for prostatic carcinoma.
One could argue that it might pick up cancers which would otherwise have gone undetected because patients receiving TRT will be monitored more closely.
Prior to commencing TRT, a physical examination, including digital rectal examination of the prostate, a prostate-related symptom assessment, PSA level should be performed and at regular intervals thereafter.
Medical history for potential sleep apnoea, congestive heart failure and a personal or family history of breast cancer should be clarified because in general you should not have TRT if you have or have had one of these diseases. Patients should be informed that testosterone therapy may also affect fertility.
A number of side effects have been reported in connection with testosterone therapy, among them an increase in body weight related to fluid retention.
A number of testosterone preparations are suitable for men with andropause symptoms. These include oral agents, injectable formulations, transdermal patches, transdermal gels and buccal tablets.
Theoretically, each of these can restore the physiologic levels of testosterone. While many of the potential adverse effects of testosterone are universal with all preparations, different formulations provide individual benefits and side effects.
The easiest to administer are the transdermal gels and are the preferred modality of therapy today.
The considerable variability of testosterone levels obtained with oral preparations renders it not useful in the opinion of most doctors.
There is also considerable variability in the testosterone levels achieved with injections and the levels may not be constant giving rise to low levels of testosterone immediately prior to injection.
With testosterone therapy, one’s attitude may improve, reinforcing self-esteem and self-confidence at work, as well as an increased energy at home and in social activities.
Most men will feel more vigorous, experience improved energy levels, mood, concentration, cognition, libido, sexual performance and an overall sense of wellbeing. These effects are usually noted within three to six weeks.
Other potential benefits include maintenance or improvement in bone density, improved body composition, muscle mass and muscle strength, as well as improvement in visual-spatial skills.
It took many years for women to accept hormone replacement therapy and men are now accepting that testosterone may be beneficial but with any medication it should be taken only under a doctor’s care, with appropriate follow-up evaluations.
The American Society of Andrology suggests that TRT in ageing men is only indicated when both clinical symptoms and signs suggestive of androgen deficiency and decreased testosterone levels are present.
In summary the andropause is the progressive decline of the sex hormone testosterone in men as they age which can cause an array of unwanted physiological changes.
Testosterone replacement therapy can alleviate and, in some cases, reverse many of these symptoms but will only be indicated in a small number of men as directed by your doctor.
- This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, Dublin
- Please send your questions to healthsupplement@irishtimes.com