Andropause or male menopause, is a name that has been given, in some parts of the English-speaking world, to a set of effects that appears in some aging men, and which have some superficial similarities to menopause effects in women.
The condition "andropause" is currently not recognized by the World Health Organization and its ICD-10 medical classification. Hypogonadism when it occurs in men is however considered to be a deficiency state in which the hormone testosterone goes below the normal range for an aging male.
This set of effects sometimes called "andropause" may be related to the slow but steady reduction of the production of the hormones testosterone and dehydroepiandrosterone in middle-aged men, and the consequences of that reduction. It is also associated with a decrease in Leydig cells. A steady decline in testosterone levels with age (in both men and women) is well documented.
Symptoms caused by a drop in the male hormone testosterone include:
- Anger and social withdrawal
- Hot Flashes
- Mood swings
- Lack of libido
- Back and head aches
External factors that can cause testosterone levels to fall include certain forms of medication, poor diet, excessive alcohol consumption, illness, lack of sleep, lack of sex, stress or surgery. It can also be a symptom of neuroendocrine dysfunction after a mild traumatic brain injury.
Andropause is preceded by a condition called Hypogonadotropic hypogonadism. A downturn in the circulation of testosterone should cause the hypothalamus and pituitary gland to trigger a release of brain hormones that stimulate the testicles to ramp up production of testosterone.
Although, as men age, despite low Testosterone, the levels of gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH) will not rise. The luteinizing hormone, gonadotropic releasing hormone, and testosterone all are dropping below what’s considered normal. Low GnRH, low LH, low testosterone indicate the syndrome of hypogonadotropic hypogonadism, and it is a downward trend that takes men closer to andropause. This phenomenon typically begins in the early forties.
Eventually, testosterone levels drop to such low levels, the hypothalamus and pituitary kick in and produce high levels of GnRH and LH to compensate. This triggers the production of testosterone, which will generally work for a while, but then will fall again. That’s when men enter andropause. They have a low testosterone and a high LH and GnRH, whereas before they had a low testosterone as well as low LH and GnRH.
This shift in hormonal patterns occurs in all men at some point. The female version, a similar hormonal shift that occurs in women happens in a more narrow age grouping, from early forties to late fifties.
As a "state"
The impact of low levels of testosterone has been previously reported. In 1944, Heller and Myers identified symptoms of what they labeled the "male climacteric" including loss of libido and potency, nervousness, depression, impaired memory, the inability to concentrate, fatigue, insomnia, hot flushes, and sweating. Heller and Myers found that their subjects had lower than normal levels of testosterone, and that symptoms decreased dramatically when patients were given replacement doses of testosterone.
Some researchers prefer the term "androgen deficiency of the aging male" ("ADAM"), to more accurately reflect the fact that the loss of testosterone production is gradual and asymptotic (in contrast to the more abrupt change associated with menopause.) The "D" is sometimes given as "decline" instead of "deficiency". In some contexts, the term "partial androgen deficiency in aging males" ("PADAM") is used instead.
As a disorder
Proponents of andropause as a distinct condition claim that it is a biological change experienced by men during mid-life, and often compare it to female menopause. Menopause, however, is a complete cessation of reproductive ability caused by the shutting down of the female reproductive system. Andropause is a decline in the male hormone testosterone. This drop in testosterone levels is considered to lead in some cases to erectile dysfunction, diabetes, loss of energy and concentration, depression, and mood swings. While andropause does not cause a man's reproductive system to stop working altogether, many experience bouts of impotence.
The theory is that andropause is caused by a very gradual testosterone deficiency and an increase in sex hormone-binding globulin (SHBG) that occurs from age 40 onwards. By contrast, women have a more rapid onset of menopause at an average age of 51. Testosterone declines 10% every decade after age 30 (1% per year).
What is known as premature andropause is theorized to occur in males who experience excessive female hormone stimulation through workplace exposure to estrogen. Men who work in the pharmaceutical industry, plastics factories, near incinerators, and on farms that use pesticides are high-risk for early andropause.
Proponents claim that by their mid-50s, about 30 percent of men experience andropause. It is thought that about 5 million American men do not produce adequate testosterone, which leads to early andropause. In Australia, about 1 in every 200 men under the age of 60 and about 1 in every 10 men over 60 have low testosterone. Regardless of location, the most likely males to develop early andropause are those with diabetes, hypertension, and genetic disorders that produce hypogonadism, including Klinefelter's, Wilson-Turner, and Androgen insensitivity syndromes.
Much of the current popular interest in the concept of andropause has been fueled by the book Male Menopause, written by Jed Diamond, a lay person. According to Diamond's view, andropause is a change of life in middle-aged men, which has hormonal, physical, psychological, interpersonal, social, sexual, and spiritual aspects. Diamond claims that this change occurs in all men, generally between the ages of 40 and 55, though it can occur as early as 35 or as late as 65. The term "male menopause" may be a misnomer, as unlike women, men's reproductive systems do not cease to work completely in mid-life; some men continue to father children late into their lives (at age 90 or older). But Diamond claims that, in terms of other life impacts, women’s and men’s experience are somewhat similar phenomena.
Many clinicians believe that andropause is not a valid concept. Men can continue to reproduce into old age; their reproductive systems do not stop working completely in midlife, and therefore they do not exhibit the sudden and dramatic drops in hormone levels characteristic of women going through menopause.
Other clinicians are of the opinion that andropause is simply synonymous with hypogonadism or unusually low testosterone levels. There is opposition to the concept of andropause in Europe as well as the U.S.
Some clinicians argue that many of the cited symptoms are not specific enough to warrant describing a new condition. For example, people who are overweight may be misguided into treating a new illness rather than addressing the lifestyle that led to their being overweight. Similarly, energy levels vary from person to person, and for people who are generally inactive, energy levels will automatically be lower overall.
While it is true that active and otherwise healthy men could in theory develop andropause-like symptoms, how common and widespread the phenomenon is, and whether genetics, lifestyle, environment, or a combination of factors are responsible, is not known.
Hormone replacement therapy
Testosterone levels (T-levels) decline gradually as humans age. Unlike females going through menopause, the decline in testosterone in men is gradual, and there is variation among individuals. After reaching 80 years of age, the rate of testosterone secretion decreases about 50% for men.
The clinical significance of this decrease is debated. There is disagreement between doctors about when and how to treat men with decreasing T-levels. The American Society of Andrology's position states that testosterone replacement therapy is recommended when both clinical symptoms and signs of androgen deficiency (male equivalent of menopause) and decreased testosterone levels are present in aging men.
Experts said the study, published in the Sept. 12 issue of the New England Journal of Medicine, deepens researchers' understanding of the hormonal shifts that occur as men age. Additionally, The American Association of Clinical Endocrinologists defines hypogonadism as a testosterone level that is below the lower limit of normal for young adult control subjects. Previously, age-related decreases in free testosterone were once accepted as normal. Currently, they are not considered normal. Patients with borderline testosterone levels warrant a clinical trial of testosterone. Researchers are skeptical about the simplicity of ads about "low T" and testosterone supplements and their impact on men. Instead, researchers conclude there is no black-and-white cutoff for "low" or "suboptimal" testosterone. Different symptoms show up at different testosterone thresholds: Muscle mass and strength do not decline until testosterone drops quite low (significantly below normal levels) whereas libido may dampen with relatively small decreases in the hormone.
According to Joel Finkelstein, associate director of the Bone Density Center at Massachusetts General Hospital in Boston, men’s functioning is not impaired solely by a loss of testosterone, but by a loss of estrogen as well.
Agreement on the threshold of testosterone value below which a man would be considered hypogonadal has not been reached (currently, there are no standards as to when to treat women). Testosterone can be measured as "free" (that is, bioavailable and unbound) or, more commonly, "total" (including the percentage that is chemically bound and unavailable). In the United States, male total testosterone levels below 300 ng/dL from a morning serum sample (most accurate measurement) are generally considered low. To confirm the low levels of testosterone, doctors recommend repeated the measurement of morning total testosterone. Identification of inadequate testosterone in an aging male by symptoms alone can be difficult, especially because many different factors can be involved.
Testosterone supplemental therapy is available in the form of topical gels, patches, and injections and can cost up to $300 a month. Researchers at the Boston University School of Medicine, recommend testosterone therapy for men with androgen deficiencies who have low testosterone levels. Therapy allows men to maintain sex characteristics, which can improve their sexual function. Testosterone supplemental therapy can also increase a sense of well being, muscle mass and strength, and bone density in men. Adverse effects of testosterone supplementation therapy include minor side-effects such as acne and oily skin, and more significant complications such as increased hematocrit, which can require venipuncture in order to treat, exacerbation of sleep apnea and acceleration of pre-existing prostate cancer growth in individuals having undergone androgen deprivation. Another adverse effect may be significant hair loss and/or thinning of the hair. This may be prevented with 5-alpha reductase inhibitors ordinarily used for the treatment of benign prostatic hyperplasia such as finasteride or dutasteride. Exogenous testosterone also causes suppression of spermatogenesis and can lead to infertility. The long term side effects of testosterone therapy are unknown. There has not been a wide-range study, like the one examining HRT use in women and the effect that has on the likelihood of heart disease and breast cancer.
In popular culture
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- Fuller SJ, Tan RS, Martins RN (2007). "Androgens in the etiology of Alzheimer's disease in aging men and possible therapeutic interventions". J. Alzheimers Dis. 12 (2): 129–42. PMID 17917157.
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- Diamond, Jed (1998). Male Menopause. Naperville, Ill: Sourcebooks. ISBN 1-57071-397-9.
- "Father, 90, shows off new baby" - timesonline.co.uk, retrieved 9/08/07
- Cetel, Nancy (2002). Double Menopause: What to Do When Both You and Your Mate Have Hormonal Changes Together. New York: Wiley. ISBN 0-471-40262-1.
- Diamond, Jed (2000). Surviving Male Menopause. A Guide for Women and Men. Naperville, Ill: Sourcebooks. ISBN 1-57071-433-9.
- Tan, Robert S. (2001). The andropause mystery: unraveling truths about the male menopause. Houston, Tex: AMRED Pub. ISBN 0-9707061-0-3.
- Carruthers, Malcolm (2004). Androgen Deficiency in the Aging Male. London: Taylor & Francis Group. ISBN 1-84214-032-9.
- Juul, A.; Skakkebaek, N. E. (2002). "Testosterone treatment of elderly men. The so called andropause doesn't exist.". Ugeskr. Laeg. (in Danish) 164 (42): 4941–2. PMID 12416079.
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- Bhasin, S.; Cunningham, G.R; Hayes, F.J; Matsumoto, A. M; Snyder, P.J; Swerdloff, R.S; Montori, V.M (2010). "Testosterone Therapy in Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology and Metabolism 95 (6).
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