As a man ages, his hormonal environment changes. These changes are easily recognised in women with oestrogen deficiency who display symptoms of menopause characterised by hot flashes, vaginal dryness, mood swings, etc. But what effect, if any, does a fall in male sex hormones cause in middle-age men? This week, we will wade into the controversy to clarify the issues.

What is andropause?

Andropause is defined as 'an age-related decline in serum testosterone levels in older men to below the normal range in young men that is associated with signs and symptoms related to androgen (testosterone) deficiency'.

It is also called androgen decline in the ageing male (ADAM), male climacteric, shifting hormones in the ageing male (SHAM), partial androgen deficiency in the ageing male (PADAM), symptomatic late onset hypogonadism (SLOH), or machopause.

How prevalent is it?

The Baltimore Longitudinal Study of ageing reported in 2001 revealed that hypogonadism (low testosterone levels) was found in 10 per cent of men in their 50s 20 per cent in their 60s and 30 per cent in their 70s.

What is testosterone?

Testosterone is a substance produced in the testes and in the adrenal glands that helps to build protein and is essential for normal sexual behaviour and the development of masculine characteristics such as a deep voice, broad shoulders, and hair growth.

It also affects many metabolic activities, such as production of blood cells in the bone marrow, bone formation, fat metabolism, carbohydrate metabolism, liver function and prostate gland growth. Additionally, normal testosterone levels maintain energy level, good mood, fertility and sexual desire

Low testosterone levels are typically defined as less than 300ng/dL (nanograms per decilitre) of total testosterone and less than 5ng/dL of free testosterone.

What causes andropause?

The root cause of andropause is a decrease in testosterone levels in men over time, called hypogonadism.

Acute hypogonadism is caused by a sudden decline in testosterone levels. The major causes are: infections or injury to the testes, alcoholism, chemotherapy radiation exposure, brain tumours and head injury.

Chronic hypogonadism is caused by a steady decline in testosterone levels due to ageing, stress, malnutrition, obesity, psychiatric conditions, excessive alcohol consumption, smoking, diabetes, hypertension, AIDS, anabolic steroid use, chronic renal failure, rheumatoid arthritis, poor diet and lack of exercise.

Typical signs and symptoms

Decreased libido or interest in sex (the senior slump) and erectile dysfunction. Interestingly, the frequency of sex declines rapidly with age from about four times per week at age 25, to once a week at age 50, three times a month at age 70, and 1.7 times a month between the age of 75 and 79 years.

Decrease in lean body mass (LBM) - diminished muscle energy and strength and significant increase in body fat, especially abdominal fat.

Decreased bone density - osteoporosis.

Decreased energy with mood swings, irritability, depression, apathy, social isolation, anxiety and insomnia (inability to sleep).

Hot flashes, night sweating, decreased exercise tolerance.

Reduced body hair and skin changes.

Anaemia from impaired red blood cell production.

Decrease in the size or firmness of the testes.

Infertility

How is it diagnosed?

Your doctor will review your history to assess your physical and mental status to determine if you have acute or chronic hypogonadism. He will then do a comprehensive physical exam to assess all your organ systems, especially your genitals and your prostate and perform a battery of tests to rule out underlying diseases and to determine your free testosterone levels.

Andropause is treated as outlined below:

Lifestyle modification

We recommend that you follow an anti-ageing exercise programme, which includes flexibility training, cardiovascular training (aerobic exercises), and strength training. You should get adequate rest at nights, discontinue smoking, avoid heavy alcohol intake and carbonated drinks, eat balanced meals and practise proper stress-management skills. You should also take adequate supplements of vitamins and minerals.

Testosterone replacement therapy (TRT)

Several testosterone delivery methods exist as outlined below:

Depot esters (depo-testosterone) are injected deeply into the muscles once every two weeks; these injections are safe and effective.

Nongenital skin patch (androderm) and genital skin patch (testoderm). These patches, which contain testosterone, are applied each night to your back, abdomen, upper arm, thigh or scrotum.

(Androgel; Testim): You rub testosterone gel into your skin on your lower abdomen, upper arm or shoulder. As the gel dries, your body absorbs the hormone.

Gum and cheek: Striant, a small putty-like substance, delivers testosterone through the natural depression above your top teeth where your gum meets your upper lip.

Oral: Taking testosterone orally is not recommended for long-term hormone replacement. Doing that may cause liver problems, raise your cholesterol and increase risk of heart disease.

Benefits of TRT

Men with low testosterone levels may not notice the benefits of testosterone supplementation at first. But with continued treatment, most will note an improvement in sexual desire and function within three months, It also re-energises the body, increases lean muscle mass, and reverses the fat accumulation and muscular atrophy (wasting) characteristic of ageing. TRT improves the mood, well-being and intellectual capacity of middle-age men, and may also prolong their lifespan by reducing the severity of age-associated diseases such as osteoporosis and heart disease.

The drawbacks of TRT are: frequent or persistent erections (priapism), nausea, vomiting, jaundice, fluid retention and ankle swelling, polycythemia (excess red blood cells), heart failure, precipitation or worsening of sleep apnea (difficulty breathing at night), prostate enlargement and liver damage. Body hair may increase while scalp hair recedes, and acne may worsen. Breast enlargement can also develop as testosterone can be converted to oestrogen via the enzyme aromatase.

Who should avoid TRT

TRT should not be given to men with carcinoma of the breast, known or suspected carcinoma of the prostate, known hypersensitivity to TRTs, heart, kidney or liver disease, sleep apnea, severe benign prostatic hyperplasia and elevated levels of prostate-specific antigen.

If you are a middle-age man and have the symptoms of andropause, don't despair, visit your doctor and let him determine if you are a candidate for TRT therapy.

Dr Alverston Bailey is a medical doctor and immediate past president of the Medical Association of Jamaica. Email comments and questions to editor@gleanerjm.com or fax 922-6223.

Source

American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients - 2002 update. Endocr. Pract. 2002;8:440-456.