Resources

Male Menopause - Myth or reality
Are doctors being unreasonably sceptical about the andropause?

Caroline Finucane explores the arguments for its existence

Hot flushes, depression, mood swings, loss of libido - probably nothing a good dose of HRT can't sort out.

But what if the patient is a man?
Undoubtedly, many men who reach a certain age experience a host of symptoms similar to those experienced by menopausal women. Because these symptoms occur at a time
when testosterone levels are falling, a 'male menopause' seems plausible.
At the same time, it's also possible that a receding hairline and muscle wastage are nothing more than a natural result of ageing; and depression and loss of libido, a result of marital problems or stress.

And that is exactly what doctors cannot agree on: does testosterone deficiency cause these so-called andropausal symptoms, or is it simply ageing and the stresses that come with this that cause symptoms, and the fall in testosterone?

back to top

This question is important, as it determines how big a role testosterone treatment will have.
The reality is that UK doctors are a sceptical bunch, with most GPs and urologists failing to recognise or treat the andropause. In a survey of more than 500 GPs conducted by Doctor last year, 65% regarded it as a 'non-disease'- rarely or never a medical problem that needed treatment.

Because of the lack of long-term randomised controlled trials, these doctors are not likely to budge on their stance until there is stronger evidence for testosterone deficiency causing significant adverse clinical effects, and for testosterone supplements being a worthwhile treatment.

In their view, the steady decline of testosterone about 1 % per year from around the age of 30 - does not compare to the precipitous drop in oestrogen that comes with the menopause. What's more, there are plenty of men with low testosterone levels who are youthful and full of energy; just as there are men with perfectly normal testosterone levels who suffer pitiably.

back to top

Hugely frustrating

These views are hugely frustrating to the andrologists and sympathetic men's health charities campaigning for the recognition and treatment of the condition.
According to the Society for the Study of Androgen Deficiency, which recently presented some positive data from controlled studies at its international conference, there are three principal reasons for doctors' scepticism.

First, doctors are unaware of how real the problem of androgen deficiency is. Levels of sex hormone binding globulin (SHBG), a carrier protein in the blood, rise from the age of 50. Nearly all of the testosterone in the blood is bound to SHBG, and is therefore inactive. So measuring total testosterone levels, as laboratories do, rather than just the 'bio available' testosterone, is inaccurate and misleading.

Second, oral methyl testosterone - known to be toxic to the heart and liver and taken off the market here nearly 20 years ago has adversely coloured doctors’ thinking about the safety of treatment. Add to that confusion of the condition with the ‘male midlife crisis', and it's no wonder many doctors see the andropause as lacking in clinical significance.

back to top

But the andropause is as real as any other medical condition, such as heart disease or diabetes, according to Dr Malcolm Carruthers, medical director of Harley Street's Centre for Men's Health, in London. He says that symptoms in men of reduced energy, drive and libido, erectile dysfunction, depression, irritability and impaired memory (see panel), along with physical symptoms resembling those of oestrogen deficiency in menopausal women - such as arthralgia, night sweats and occasional hot flushes also most commonly occur around the age of 50.

'The symptoms are not caused by depression, as they fail to respond to antidepressants and are often made worse by them,' he stresses. 'They are not just ageing, because they can be reversed long-term, by testosterone treatment.'

Dr Carruthers accepts that not all men will go on to develop symptoms and that, unlike the menopause, the andropause strikes at various ages.

back to top

And while age plays an important part in declining androgen production, it is not the only factor: both mental and physical stress reduce the synthesis of testosterone and increase levels of antagonistic hormones such as cortisol, adrenaline and noradrenaline.

So why blame testosterone deficiency for symptoms?
Take the characteristic 'chicken legs' and prominent paunch - a physique that creeps up on many men as they enter middle age. Testosterone is responsible for the differentiation and metabolism of tissue stem cells that develop into either fat or muscle, so it makes sense that men deficient in testosterone gain abdominal fat and lose muscle mass.

Dr Carruthers believes that these body changes can be reversed easily by testosterone treatment. Equally, doses of the hormone can restore normal erectile function in men with ED who do not respond to drugs such as sildenafil. This, he explains, is because the same tissue changes can be seen in the penis.

Symptoms occur not only from an age-related decline in testicular hormone production, says the doctor, but from the increasing resistance of tissues to the action of testosterone. It is rather like insulin resistance in maturity-onset diabetes. Dr Carruthers explains: 'Minor variations in the androgen receptor gene can have major consequences in deciding the structure and function of androgen responsive tissues throughout life. These can render the measurements of androgen levels largely irrelevant in deciding whether or not the older man is androgen-deficient, and would benefit from testosterone treatment.' He adds that it doesn't help that testosterone measurements are notoriously unreliable 'being prone to sampling, analytical and interpretation problems, which render them largely invalid as a diagnostic tool'.

back to top

It is these factors that cause doubt in doctors' minds about the reality of the andropause, says Dr Carruthers. He would like to see doctors take symptoms such as night sweats and loss of libido a lot more seriously.

'They should raise the suspicion of androgen deficiency,' he says. 'Providing it is safe to do so, such men can then be offered a therapeutic trial of testosterone treatment, with great potential benefit to their long-term health and quality of life.'

Resisting the theory

This seems a convincing argument, and with further supporting evidence emerging all the time, perhaps one day dissenting doctors will change their views. The potential benefits are clear: along with treatment comes not only the relief of symptoms, but confirmation of the diagnosis and reassurance for the patient.

Yet, for many doctors who disapprove of over-medicalisation, there are plenty of reasons to remain cynical.

An andropause diagnosis would be a convenient excuse for a patient's expanding waistline, and his waning energy and libido, and emphasising the importance of sexual function would place pressure on men to be bedroom superstars. The diagnosis would also put an additional strain on an already stretched health service.

At the least, hesitancy about testosterone would seem wise until we know more about it.
Were we not, after all, a little hasty in advocating HRT for women?

back to top