Is andropause the same as 'male menopause,' and should men worry?

By Michael Merschel, American Heart Association News

FG Trade/E+ via Getty Images
(FG Trade/E+ via Getty Images)

Thanks to menopause, almost everyone knows something about how age affects hormone levels – in women.

But while menopause has launched a thousand hot-flash jokes, men have their own version. It's called andropause, and though it's less of a pop-culture presence, it's a medical reality that's subject to misconceptions, experts say.

Starting with equating it to menopause.

In women, menopause is when menstruation stops. The ovaries stop producing eggs, and the production of estrogen declines. It typically happens around the age of 50 but can begin earlier.

In men, andropause is a decline in testosterone levels that can begin in middle age, then it's "a gradual fall," said Dr. Robert H. Eckel, a professor of medicine emeritus in the Division of Endocrinology, Metabolism and Diabetes and the Division of Cardiology at the University of Colorado Anschutz Medical Campus in Aurora. "It's nothing like menopause, which occurs over a finite period of time."

According to the American College of Physicians, a man's testosterone level begins to drop in his mid-30s and continues to fall at an average rate of 1.6% a year. A study published in the journal Virulence in 2016 calculated that by age 75, a typical man will have lost about 30% of the testosterone he had at 25.

Testosterone plays roles in sexual function, bone health, fat metabolism, muscle mass and strength. Levels surge in adolescence with puberty. But advice varies on when low levels should be a cause for concern.

Low testosterone is sometimes referred to as hypogonadism, and andropause can also be referred to as age-related hypogonadism, among other names. Low testosterone by itself, without symptoms, is not a cause for concern, Eckel said. "Andropause is part of the aging process, but it isn't a disease on its own."

Dr. Nannan Thirumavalavan, chief of male reproductive and sexual health at the Urology Institute of University Hospitals in Cleveland, said there's no "perfect answer" for how to distinguish between normal age-related decline and a more serious problem.

When testosterone levels fall, the most specific symptoms are a decreased sex drive or erectile dysfunction, said Thirumavalavan, who also is an assistant professor of urology at Case Western Reserve University School of Medicine. Other symptoms can include difficulty concentrating, decreased energy or even depression.

Of course, "there are many, many things that could cause those symptoms," he said.

In younger men, low testosterone can indicate problems with the pituitary gland or the testicles, Thirumavalavan said. But testosterone levels also can be affected by some of the same factors linked to cardiovascular disease, such as obesity, sleep quality and sleep apnea.

People with Type 2 diabetes, another cardiovascular risk factor, or kidney disease also tend to have lower testosterone levels, Eckel said, adding that "it needs to be made clear that, although related, the causation is not clear."

Observational studies have shown that men with unusually low testosterone levels appear to have a higher risk of cardiovascular disease, but that's not the same as showing a cause and effect, Eckel said. "Is the risk for cardiovascular disease that occurs in those settings entirely due to lower levels of testosterone? Certainly not."

A declining testosterone level, Eckel said, isn't necessarily a concern unless it goes beyond a modest decline in sexual function. But if lower testosterone is accompanied by a loss of muscle, excess fatigue, anemia or profound sexual dysfunction, then the patient should be evaluated by an endocrinologist, he said.

"Male hypogonadism in the older man is a challenging diagnosis to make," Eckel said, requiring "both biochemical measurements and a good history and physical examination."

The diagnosis requires multiple blood tests, Thirumavalavan said. A normal testosterone reading can vary from man to man, and levels fluctuate throughout the day. "We never want to just treat a number," he said.

But while treatments for low testosterone – sometimes called "low T" – have been heavily marketed in recent years, Eckel said guidelines from the Endocrine Society don't support routine testing of testosterone levels. Those guidelines say low testosterone readings alone, without symptoms, don't establish hypogonadism, and the benefits and adverse consequences of long-term testosterone therapy "on patient-important outcomes in asymptomatic men with low T concentrations remain unclear."

For men older than 65, the guidelines suggest offering therapy "on an individualized basis after explicit discussion of the potential risks and benefits."

Many men seek testosterone therapy because of libido issues. "There's no question that sexual function declines with age, and that's probably normal aging," Eckel said. Testosterone therapy provides "a modest improvement in sexual function," he said. It won't turn a 75-year-old man into a 25-year-old, "but it's a little bit better."

A man seeking help for symptoms of low testosterone could start by talking to his primary care doctor, urologist or endocrinologist for a workup, Thirumavalavan said. But testosterone therapy is not a casual treatment, he said. It "basically will shut down your own testicles," he said, ceasing sperm production – a problem for someone hoping to father children. (Testosterone is being studied as a hormonal form of birth control for men.)

Other potential side effects, Thirumavalavan said, include acne and increased blood pressure. Eckel said testosterone therapy also can lead to an enlarged prostate.

The Food and Drug Administration requires manufacturers of testosterone products to warn users about a possible increased risk of heart attacks and strokes. Eckel noted, however, that a major study published last year in the New England Journal of Medicine showed that testosterone replacement therapy did not increase risks of major cardiac problems in middle-aged and older men. It was an important step in showing that testosterone replacement can be done safely, Eckel said.

American Urological Association guidelines say that someone who has had a cardiovascular event should not begin testosterone therapy until three to six months afterward.

Over-the-counter supplements are not an alternative, Thirumavalavan said. Although the market is booming, there's no evidence that the most common ingredients in them work, according to a review he co-wrote that was published in 2019 in The Journal of Sexual Medicine.

Generally, he said, men can improve their testosterone levels by getting quality sleep, losing excess weight, eating a healthy diet and exercising.

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