Is there a male menopause and should we treat it?
Do men undergo a hormonal change similar to the female menopause? If so, should testosterone replacement therapy be recommended? Dr Duncan Gould and Dr Gerard Conway debate the issues
Dr Duncan Gould and Dr Gerard Conway debate the issues
Does the male menopause exist?
Of course men cannot have a 'menopause' as, literally, the word means cessation of periods. So if we mean by the male menopause that at or around the age of 50 all men experience a catastrophic decline in male sex hormone levels then the answer is obviously no. If, however, we are talking about a progressive linear decline in androgens that occurs to a degree in some men associated with symptoms indicative of hypogonadism, then the answer is yes.
Because of this misunderstanding more accurate alternative descriptors have been introduced, such as the andropause, the viropause, androgen deficiency in the adult male (ADAM) and, as recently proposed by the International Society for the Study of the Aging Male (ISSAM), late onset hypogonadism.
Hypogonadism does exist – it's in the textbooks. Longitudinal and cross-sectional studies of community adult men have determined that total and bioavailable testosterone levels decline with age at a rate of 1 and 2 per cent per annum respectively. Such declines may be steeper in some men than others due to genetic factors, testicular aging, disease or damage, dysfunction in the hypothalamic-pituitary controlling mechanisms, drugs and lifestyle or systemic disease.
More precipitous declines may result in testosterone levels where symptoms of hypogonadism become apparent. Such symptoms are generally vague and include a reduction in libido, erectile dysfunction, ejaculatory disorders, fatigue, mood disturbance and sweats (see table).
Patients complaining of symptoms should be investigated to include early-morning plasma testosterone and SHBG levels. Thyroid function tests, blood biochemistry, haematology and a PSA (after counselling) should be considered to exclude other conditions and to assist in monitoring testosterone replacement therapy.
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It is important to exclude the presence of prostate cancer before treatment and patients should be followed up regularly after initiation in line with the ISSAM guidelines.
Hypogonadism, like hypothyroidism or diabetes, is a real condition and if left untreated may have deleterious effects on sexual functioning and general health.
Duncan Gould is a consultant and men's health specialist at Goldcross Medical Services, London
International Society for the Study of the Aging Male: www.issam.ch
There is no andropause. Serum testosterone concentrations in men fall gradually and modestly by approximately 1 per cent per year from the age of 40, so that 20 per cent of men over 60 will have levels below the quoted normal range.
A similar decline in circulating hormone concentrations with age also applies to growth hormone, IGF1 and DHEAS (curiously, age-specific normal ranges are given for IGF1 but not for testosterone).
Many observers have noted features of aging that intuitively would be testosterone responsive: fatigue and depression with decreases in muscle mass, libido and bone density, increases in fat mass and sexual dysfunction.
Indeed, short-term studies have shown benefits in some of these factors from various testosterone treatments given to ageing men. That testosterone makes you feel better is not in doubt – so might thyroxine or hydrocortisone.
Is there ever justification for testosterone treatment? Yes. Hypogonadal men obtain a clear benefit from testosterone replacement. Primary hypogonadism is easily identified in those men with raised LH and FSH concentrations. In the absence of hypogonadism there is often a worry that mild hypopituitarism might be in play. Hypopituitarism is fairly rare and there is no evidence that screening for it in the elderly reveals significant pathology.
Is there ever justification for testosterone treatment in men based on symptoms, a low testosterone measurement but normal gonadotrophin concentrations? No. This is the realm of recreational or lifestyle drug use.
One website that advocates this treatment states: 'There is no evidence that testosterone replacement therapy causes prostate cancer.'
This type of comment is disingenuous; lack of evidence does not make it safe. There is every reason to think that higher circulating testosterone concentrations will increase the risk of prostate cancer. The likely reason that no adverse evidence exists is that most clinics providing this service are motivated to highlight short-term benefits of an intervention – there is no motivation to identify long-term risks.
Clinics that try to justify the use of testosterone in aging men routinely obfuscate risk.
Consider this quote from a website of one such clinic: 'Haemoglobin levels often rise, but this is as a rule beneficial, as men with low testosterone levels tend to have lower haemoglobin levels with some being actually anaemic.'
On the contrary, the erythropoietin-like effects of testosterone are a real worry in a population with an increasing risk of stroke.
A physician whose primary concern is for the well-being of the aging male will have one issue in mind – how can we clarify for men tempted by using testosterone treatment the risks compared with the short-term benefits? It took the profession 30 years to be convinced that HRT caused breast cancer; let us learn from this experience.
Gerard Conway is consultant endocrinologist at the Middlesex Hospital, London