Debunking the “Male Menopause”

By Anna Huang

Since the average life expectancy of a typical male has increased in the past few decades, aging related health problems have garnered interest in the medical community (Nandy et al., 2008). A variety of hormonal changes occur in the bodies of aging men, including dropping plasma androgen levels. This androgen decline in aging male (ADAM) is commonly being referred to as ‘andropause’ (from the Greek ‘andras’ for male and ‘pause’ for cessation) (Singh, 2013). Previous descriptions of these changes as ‘male menopause’ or ‘male climacteric’ are now considered to be inaccurate because males do not experience the precipitous changes which females experience during the menopausal transition (Nandy et al., 2008). Unlike menopause, which is a well-characterized timed process associated with absolute gonadal failure, the decrease in testicular function that males experience is gradual (Singh, 2013). In addition, many associated symptoms, both somatic and psychiatric, are vague and not specifically defined enough (Hollander & Samons, 2003; Nandy et al., 2008).

During the past decade, there have been lively discussions about whether ‘andropause’ is a real clinical syndrome or a normal state of aging that is being medicalized in attempt to sell pharmaceutical products (Hollander & Samons, 2003). Most recently published articles state that only men who have completely lost testicular function due to diseases or accidents, or men with advanced prostate cancer subjected to surgical or medical castration experience true ‘andropause’ (Singh, 2013). Instead, a differentiation is now made between the age-related decrease of testosterone production (which is often a nonspecific effect caused by the comorbidities that accumulate during ageing) and late onset hypogonadism (LOH), a condition where a dysfunction of the testicles prevents the body from producing enough androgens and/or sperm (Rivas et al., 2014; Singh, 2013).

LOH is now regarded as a clinical and biochemical that is defined as low serum testosterone in ageing men (<300 ng/dL according to the guidelines published by the Endocrine Society) and the presence of three sexual symptoms (Rivas et al., 2014). The purpose of the detailed definition for LOH is to help health care professionals identify individuals who are likely to be experiencing symptoms purely from androgen deficiency, not from other chronic medical illnesses associated with ageing, and would therefore benefit from hormonal replacement therapy (TRT) (Rivas et al., 2014). 

Symptoms associated with LOH are highly nonspecific and are varied. They include: Low libido and erectile dysfunction, decreased frequency of sexual thoughts, decreased muscle mass and bone density as well as increased body fat, decreased bone mineral density and osteoporosis (a condition which causes bones to become brittle), and also depression (Singh, 2013). The differentiation of these symptoms from those which are caused by ageing per se is a challenging task, which is made easier by the concept of LOH. Because sexual symptoms are more strongly associated with androgen deficiency, they are specified in the definition of LOH (Wu et al., 2010).

Despite the publication of guidelines by the Endocrine Society for the diagnosis of LOH, the nonspecific symptoms and indiscriminant testing can easily lead to overtreatment as individuals seek out medical solutions to the bothersome symptoms. Even the sexual symptoms can be due to conditions other than LOH, such as chronic alcohol use, depressive disorders and vascular disease (Rivas et al., 2014). Therefore, only with accurately measured serum testosterone can the diagnosis of LOH be confirmed and subsequent testosterone replacement therapy (TRT) be considered with the goals of improving secondary sexual characteristics, sexual function, sense of well-being, and bone mineral density (Rivas et al., 2014). Intense lifestyle interventions and weight loss can also increase testosterone levels, so it is important to recommend weight loss prior to or parallel with TRT to patients struggling with obesity (Rivas et al., 2014; Wang et al., 2008). 

Whilst TRT seems promising, an issue to be aware its long-term safety. TRT is still under scrutiny as the effect of TRT on cardiovascular risk is still uncertain and its role in stimulating metastatic prostate cancer and breast cancer (Andersen et al., 2011; Rivas et al., 2014) . Further studies are therefore needed to assess the long-term safety of TRT on the human body. Moreover, the general area of hypogonadism also still requires much more research as few data on hypogonadism in aging men are available due to lack of evidence regarding the exact criteria for identifying testosterone deficiency in older men who do not have pathological hypogonadism (Rivas et al., 2014; Wu et al., 2010).

References:

Andersen, M. L., Alvarenga, T. F., Mazaro-Costa, R., Hachul, H. C. & Tufik, S. (2011) The association of testosterone, sleep, and sexual function in men and women. Brain Research. 1416 80-104. Available from: https://search.datacite.org/works/10.1016/j.brainres.2011.07.060. Available from: doi: 10.1016/j.brainres.2011.07.060. 

Hollander, E. & Samons, D. M. (2003) Male Menopause: An Unexplored Area of Men’s Health. Psychiatric Annals. 33 (8), 497-500. Available from: https://search.proquest.com/docview/217058360. Available from: doi: 10.3928/0048-5713-20030801-06. 

Nandy, P., Singh, D., Madhusoodanan, P. & Sandhu, A. (2008) Male andropause: A myth or reality. Medical Journal. Armed Forces India. 64 (3), 244-249. Available from: http://dx.doi.org/10.1016/S0377-1237(08)80105-0. Available from: doi: 10.1016/S0377-1237(08)80105-0. 

Rivas, A. M., Mulkey, Z., Lado-Abeal, J. & Yarbrough, S. (2014) Diagnosing and managing low serum testosterone. Proceedings – Baylor University. Medical Center. 27 (4), 321-324. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25484498. 

Singh, P. (2013) Andropause: Current concepts. Indian Journal of Endocrinology and Metabolism. 17 (9), 621-S629. Available from: https://search.datacite.org/works/10.4103/2230-8210.123552. Available from: doi: 10.4103/2230-8210.123552. 

Wang, C., Nieschlag, E., Swerdloff, R., Behre, H. M., Hellstrom, W. J., Gooren, L. J., Kaufman, J. M., Legros, J., Lunenfeld, B., Morales, A., Morley, J. E., Schulman, C., Thompson, I. M., Weidner, W. & Wu, F. C. W. (2008) Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA and ASA recommendations. European Journal of Endocrinology. 159 (5), 507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18955511. Available from: doi: 10.1530/EJE-08-0601. 

Wu, F. C. W., Tajar, A., Beynon, J. M., Pye, S. R., Silman, A. J., Finn, J. D., O’Neill, T. W., Bartfai, G., Casanueva, F. F., Forti, G., Giwercman, A., Han, T. S., Kula, K., Lean, M. E. J., Pendleton, N., Punab, M., Boonen, S., Vanderschueren, D., Labrie, F. & Huhtaniemi, I. T. (2010) Identification of Late-Onset Hypogonadism in Middle-Aged and Elderly Men. The New England Journal of Medicine. 363 (2), 123-135. Available from: https://search.datacite.org/works/10.1056/nejmoa0911101. Available from: doi: 10.1056/nejmoa0911101.