Andropause, the Male Menopause

The sex steroid testosterone provides both men and women with their sexual desire. Differences in people’s drive for sex, their libido, are largely due to differences in the levels of testosterone they make. This is especially true for men. As men age, testosterone (T) levels begin to decline, which can result in men feeling apathetic about sex. It is important to clarify that a low sex drive in men most often comes from Low T.

While erectile dysfunction drugs such as Viagra can help a man have a harder, more certain erection, these types of medication do not improve sexual desire.

Understanding Male Menopause

This is crucial to remember. If a man rarely wants sex because of aging decreases in T, all the Viagra in the world may not help this. And the decreasing T seen in aging men is not just about sex, it also can result in degenerative body and mind changes, similar to those we seen in the menopausal woman. The declining T in men is called andropause: After age 40 T levels in men normally decline by 2% a year.

man riding a bike

Just like in women, as men age, the brain and gonad communication that controls T formation stops working and T levels plummet with a specific set of symptoms (see below). The medical names for this condition include Late Onset Hypogonadism or Androgen Deficiency in the Aging Male; we will call it low T.

Missing Mojo

You may know a man with low T. He may be aware of declining “mojo.” He may have built a proverbial “beer belly.” His face may have taken on a smooth round appearance and his once strong upper torso may have shrunk, as has his height (though this might be invisible to him). He might be using Viagra at home and found that it stopped working “very well.” Many of these men will be diagnosed with diabetes and be on Lipitor for high cholesterol.

Finding the Right Doctor: Sexual Medicine and the Aging Male

And many of these men will receive bad advice from physicians who know little about low T.

Diagnosis of and treatment planning for low T should be done in conjunction with physicians who are up to date on this rapidly changing field and belong to medical societies that have the terms “aging male” or “sexual medicine” in their credentials.  These specialists can better interpret the blood T levels as well as ensure men take the Aging Male survey to screen symptoms for correct diagnosis.

Symptoms of Andropause

The current physician guidelines suggest that low T be considered in all mid-life or older men who are symptomatic for any of the following:

  • Low libido
  • Poor or infrequent morning erections (less than three a week)
  • Erectile dysfunction
  • Depressed mood and/or fatigue
  • Cognitive Impairment (poor performance at work)
  • Insulin resistance
  • Obesity
  • Metabolic Syndrome
  • Diabetes Mellitus Type 2
  • Decreased muscle mass and strength
  • Decreased bone mineral density and osteoporosis
  • Decreased vitality
  • Vitamin D deficiency
  • On glucocorticoids (such as prednisone or Kenalog)
  • On narcotics (such as hydrocodone )

To diagnose Low T, the Androgen Deficiency in the Aging Male (ADAM) Survey is available to your physician, and a T blood test should be given to every man who responds that he has these symptoms.

Impact of Low T

Having low T can decrease a man’s quality of life, his sex life, and how long he livesA lot is at stake here.

Low T can cause increased risk of cardiovascular disease and severe, treatment-resistant depression. Taking steroids chronically (such as prednisone or Kenalog) can dramatically lower T levels, as can narcotics (the T decrease is sustained and sharp with opioids). Recent evidence also suggests that statins (such as Lipitor) may decrease T levels.

In spite of the very real beneficial impact on men’s health and lives that T therapy can have, millions of men remain undiagnosed and untreated for this condition. This is because a blood test alone does not necessarily diagnose low T. In fact, there is presently NO consensus regarding the lowest “normal” level of T.

I am going to say this again…doctors simply do not know how low is too low a T for normal function. This is partly the case because:

  • What is normal for one man may not be normal for another;
  • T receptors stop working in aging men (so even if blood levels are normal the T may not be physiologically functional); and
  • As men age the normal carriers for T in their blood become more stingy and won’t release the T to the receptors they need to interact with in the body.

When a man undergoes a T blood test, to get the best results, the International Society on Sexual Medicine recommends:

  • Blood draws between 7 and 11 a.m
  • Total T levels be used
  •  If Total T levels are not low and the man has symptoms or if the man is obese, then Free T should be done
  •  Free T levels are only diagnostic using “equilibrium dialysis.”  Other assays are not reliable and should NOT be used diagnostically.

If you read all that and thought “too complicated!” please take that list to your doctor so that you can see if he or she can put it to use for and with you.

Also talk to your doctor about the ADAM survey. All men with Low T symptoms (as above) should take the ADAM survey. If your doctor doesn’t give an ADAM survey as well as do the T blood test, be concerned that the clinic you are working with is not well enough informed to be giving accurate medical advice on this condition.

Be assertive. Find a different doctor or show your doctor the ISSM Guidelines and ask them why they are not complying with them. You have the right to question your doctor’s viewpoint (and that is all that medical advice is) and to try medically appropriate interventions.

How low a T is too low?

In general:

  • T levels below 433 ng/dL can be associated with a loss of libido and erectile function;
  • Levels of T below 288 ng/dL are associated with depression;
  • The International Society for Study of the Aging Male suggests that Te therapy should be required for men with lower than 231 ng/dL if there is no reason that he can’t take the T enhancing medications.
  • For men with T levels between 231 to 345 ng/dL and multiple symptoms on the ADAM survey, the physician generated guidelines suggest trying T therapy for three months to look at patient response.   This is where most men will end up, and where many American physicians will fail to appropriately intervene with trial T therapy.
  • The free T levels the ISSM suggest require treatment are below 225pmol/L (65 pg/mL).

Again, don’t worry about this seeming very technical—if you show this information to your doctor or specialist, that person should be able to understand it immediately.


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