Millions must confront male menopause
June 16, 2000
By Mike Falcon
With medical adviser Stephen A. Shoop, M.D.
A Doctor In Your House.com

Fat, flaccid, fearful, fretful, and forgetful.

Are these merely the inevitable signs of aging manhood? Or are they signatures of andropause - the masculine equivalent of menopause - a bona fide change of life that includes significant physical and psychological effects? "Male menopause is a medical reality," says Dr. Abraham H. Kryger, a Monterey, Calif., family physician who also specializes in treating the condition. "It's similar to female menopause in that it's caused by measurable hormonal changes that occur as we age, principally a gradual decline in testosterone." The condition can actually appear in men as young as 35 or wait to manifest itself until 30 years later. For most, it happens somewhere in between. With over 25 million men in the USA today between 40-55 and an expected 57 million in that age bracket by 2020, andropause - sometimes called viropause or ADAM (androgen deficiency in the aging male) - is not something to be taken lightly. The changes men go through can make life extremely difficult. Physical symptoms driven by decreasing testosterone are fairly easy to discern. Some experts think the list should be expanded to include weight gain, lengthier injury or illness recoveries, and loss of bone density. Psychological factors might be added as well, says psychologist Jed Diamond, author of Male Menopause. "The changes are not just physical, but involve an array of work-related, family-oriented, commitment, and spiritual issues as well." These can include - but are not limited to - decreased memory and concentration, indecisiveness, and loss of self-confidence. Although the list is merely a guideline, proponents suggest that any combination of four or more symptoms - or just the first two - indicate candidacy for treatment via testosterone replacement therapy (TRT).

Counter claims

But some authorities are unconvinced that male menopause even exists. Others doubt there is a direct correlation between endocrine changes and the physical symptoms ascribed to the condition. "The association of a symptom with a particular hormone concentration does not indicate causation," argues Dr. Howard S. Jacobs, emeritus professor of reproductive endocrinology, Royal Free and University College School of Medicine, Middlesex Hospital, London. In fact, unlike the rapid cessation of menstruation, which abruptly signals the end of child-bearing for women, there is no corresponding reproductive event for men. Males can usually produce viable sperm well into senior citizen status - even though they may have retired from virtually all other life functions (except perhaps eating, sleeping, and watching television in their underwear.) Additionally, androgen production - which includes all "male" hormones - degenerates far more gradually than does estrogen in women. It's the difference between rolling down a slow decline and falling off a cliff. In the absence of such a definitive hormonal event, some experts wonder: Where's the proof that lowered testosterone actually brings on the symptoms in the list above? Writing in the current issue of the British Medical Journal, Jacobs poses a critical challenge: "Prove that hormone replacement therapy in physiological doses reverses these processes. If lack of male hormones causes this state of affairs, then its replacement would have to reverse it."

Testosterone replacement therapy

"As far as I can see, the proof's there," says Kryger, "TRT works for many of the symptoms."

Weight gain - Numerous studies indicate a reduction in body fat and an increase in lean muscle when men take supplemental testosterone.

Sexual function - Testosterone can restore sexual vitality in otherwise healthy men who have low levels of the androgen. The catch? "Less than 5% of men with erectile dysfunction have secondary low levels of testosterone," says Dr. Kenneth A. Goldberg, medical director of the Male Health Center in Dallas.

Memory, learning, and cognition - "It's sad, but we seem to sort of 'dumb down' as testosterone decreases," says Kryger. Johns Hopkins scientists studying testosterone replacement therapy report that the primary male sex hormone may improve some visual and perceptual learning skills, along with memory enhancement. These new findings may provide additional insight into testosterone's role in general brain function.

Strength, muscle mass, and bone density - Muscular power and mass are negatively affected by decreasing testosterone levels. Numerous studies of young men, aging men, and those with AIDS-related muscle wasting support this observation. Older men and those undergoing corticosteroid therapy can increase bone density with supplementation as well, an effect that may be magnified by muscle mass enhancement from a combination of testosterone supplementation and progressive weight-bearing resistance exercise.

Depression - A trio of Penn State University sociologists found a relationship between testosterone levels and depression and aggression, as reported last year in the Journal of Health and Social Behavior. "It's not a simple relationship, and much more study needs to be done," advises Dr. Alan Booth, professor of sociology and human development, "but the relationship seems significant." "In men with low levels of testosterone, additional supplementation can help elevate mood," he explains. "In men with already high levels, additional testosterone can result in aggressive, anti-social, and needlessly high risk behavior, unless there is a safety net of support and stabilizing factors such as marriage and steady employment." Possible downsides to TRT may threaten even the most stable long-term relationships. "Introduce a markedly increased libido from one partner into a 30-year marriage that has gone through a long maturation process and you could be asking for trouble," notes Booth. "And what happens if a kindly grandfather becomes aggressive and overbearing with children? That's not the caring and supportive role the parents probably had in mind." "It could happen," says Goldberg. "Additional testosterone, when called for, can make some adverse behavioral differences in men who have ADAM. There are a variety of medical drawbacks too, including possible risks of prostate enlargement and cancer, blood thickening, and increases in HDL (bad) cholesterol levels. It's a medical decision that needs to be carefully weighed."

Gaining perspective
The possibility of unexpected physical and personality changes - with or without TRT - underscores the destabilizing nature of the andropausal years. Observers note that fatherless adolescents and male menopausals whose fathers have died both lack older counsel who could help in recognizing and dealing with life's transitions. Often the results are self-created maladapative rites of passage: gangs, drugs, rebellious behavior, and indiscriminate sex for the young male; divorce, fast cars, shallow relationships, and trophy sex for the older male. The key to a better outcome? Understanding that profound natural changes will inevitably occur, and that they can lead to a significantly different but genuinely satisfying life stage. "Male menopause is not a thing you simply take something for," emphasizes Diamond. "It's a complex weave which involves an integration of the physical, emotional, spiritual, and cultural possibilities which are no less rich or challenging or sometimes confusing than when we transitioned from childhood to puberty." If you feel that andropause could be a potential problem for you or a loved one, don't hesitate to seek help from an experienced health professional. Male menopause can seriously affect quality of life. Be aware, prepare, and take care.