Andropause

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Andropause or male menopause,[1] 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.[2] It is also associated with a decrease in Leydig cells.[3] A steady decline in testosterone levels with age (in both men and women) is well documented.[4]

Symptoms[edit]

Symptoms caused by a drop in the male hormone testosterone include:[5]

  • Anger and social withdrawal[6]
  • Irritability
  • Hypersensitivity
  • Anxiety
  • Hot Flashes
  • Mood swings
  • Depression
  • Lack of libido
  • Back and head aches
  • Insomnia

External causes[edit]

External factors that can[citation needed] 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.[7]

Internal Causes[edit]

Andropause is preceded by a condition called Hypogonadotropic hypogonadism.[8] 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.[9]

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.[10]

As a "state"[edit]

The impact of low levels of testosterone has been previously reported. In 1944, Heller and Myers[11] 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.

Andropause has been observed in association with Alzheimer's disease.[12]

In one study, 98.0% of primary care physicians believed that andropause and osteoporosis risk were related.[13]

The term "symptomatic late onset hypogonadism" (or "SLOH") is sometimes considered to refer to the same condition as the word "andropause".[14][15]

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[16] (in contrast to the more abrupt change associated with menopause[citation needed].) The "D" is sometimes given as "decline" instead of "deficiency".[14] In some contexts, the term "partial androgen deficiency in aging males" ("PADAM") is used instead.[17]

As a disorder[edit]

Proponents[edit]

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.[citation needed]

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.[18] 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[19]). But Diamond claims that, in terms of other life impacts, women’s and men’s experience are somewhat similar phenomena.[20][21][22]

The concept of andropause is perhaps more widely accepted in Australia and some parts of Europe than it is in the United States.[23]

Opponents[edit]

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.[22] There is opposition to the concept of andropause in Europe as well as the U.S.[24]

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[edit]

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.[25] After reaching 80 years of age, the rate of testosterone secretion decreases about 50% for men.[25]

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.[citation needed]

Experts said the study, published in the September 12[year needed] issue of the New England Journal of Medicine,[citation needed] 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.[citation needed] Previously, age-related decreases in free testosterone were once accepted as normal.[citation needed] Currently, they are not considered normal.[by whom?] Patients with borderline testosterone levels warrant a clinical trial of testosterone according to some endocrinologists in 2003.[26] Researchers are skeptical about the simplicity of ads about "low T" and testosterone supplements and their impact on men.[citation needed] 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.[citation needed]

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.[citation needed]

Agreement on the threshold of testosterone values 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.[citation needed] To confirm the low levels of testosterone, doctors recommend repeating the measurement of morning total testosterone.[citation needed] 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.[citation needed] Researchers at the Boston University School of Medicine, recommend testosterone therapy for men with androgen deficiencies who have low testosterone levels.[citation needed] Therapy allows men to maintain sex characteristics, which can improve their sexual function.[citation needed] Testosterone supplemental therapy can also increase a sense of well being, muscle mass and strength, and bone density in men.[27]

Adverse effects of testosterone supplementation may include increased cardiovascular events (including strokes and heart attacks) and deaths based on three peer-reviewed studies involving men taking FDA-approved testosterone-replacement.[28] In addition, an increase of 30% in deaths and heart attacks in older men has been reported.[29] Due to an increased incidence of adverse cardiovascular events compared to a placebo group, a Testosterone in Older Men with Mobility Limitations (TOM) trial (a National Institute of Aging randomized trial) was halted early by the Data Safety and Monitoring Committee.[30] On January 31, 2014, reports of strokes, heart attacks, and deaths in men taking FDA-approved testosterone-replacement led the Food and Drug Administration (FDA) to announce that it would be investigating the issue.[31] Later, in September 2014, the FDA announced, as a result of the "potential for adverse cardiovascular outcomes", a review of the appropriateness and safety of Testosterone Replacement Therapy (TRT).[32][33][34]

Other adverse effects of testosterone supplementation may include increased hematocrit (which may require venipuncture in order to treat), exacerbation of sleep apnea and acceleration of pre-existing prostate cancer growth in individuals having undergone androgen deprivation.[citation needed] Other adverse effects may include minor side-effects such as acne and oily skin as well as significant hair loss and/or thinning of the hair which may be prevented with 5-alpha reductase inhibitors ordinarily used for the treatment of benign prostatic hyperplasia such as finasteride or dutasteride.[citation needed] Exogenous testosterone may also cause suppression of spermatogenesis, leading to infertility.[35] It is recommended that physicians screen for prostate cancer with a digital rectal exam and prostate-specific antigen (PSA) level before starting therapy, and monitor hematocrit and PSA levels closely during therapy.[citation needed]

In popular culture[edit]

In the 154th episode of the animated television series King of the Hill ("The Incredible Hank"), Hank is diagnosed with irritable male syndrome, and is prescribed testosterone. [36]

In the 98th episode of the series "Yes, Dear" ("Jimmy Has Changed"), Jimmy is diagnosed with andropause after coming down with a case of the sweats and a decreased interest in sex. [37]

See also[edit]

References[edit]

  1. ^ "Male Menopause". Archived from the original on 12 December 2007. Retrieved 2007-12-17. 
  2. ^ Andropause at the US National Library of Medicine Medical Subject Headings (MeSH)
  3. ^ Mahmoud A, Comhaire FH (2006). "Mechanisms of disease: late-onset hypogonadism". Nat Clin Pract Urol 3 (8): 430–8. doi:10.1038/ncpuro0560. PMID 16902519. 
  4. ^ Mooradian AD, Korenman SG (2006). "Management of the cardinal features of andropause". Am J Ther 13 (2): 145–60. doi:10.1097/01.mjt.0000132252.80403.c9. PMID 16645432. 
  5. ^ Sternbach, Harvey (October 1998). "Age-Associated Testosterone Decline in Men: Clinical Issues for Psychiatry". American Journal of Psychiatry 155 (10): 1310–1318. 
  6. ^ Lincoln G (2001). "The irritable male syndrome". Reprod Fertil Dev 13 (7-8): 567–76. doi:10.1071/RD01077. PMID 11999307. 
  7. ^ "DCoE Clinical Recommendation | August 2012 Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild Traumatic Brain Injury". DCOE Defense Centers of Excellence. Retrieved 2 December 2013. 
  8. ^ "Testosterone Deficiency (Primary Hypogonadism and Secondary/Hypogonadotrophic Hypogonadism)". What is Testosterone Deficiency. Virtual Medical Center. 
  9. ^ Florence Comite (November 21, 2103). "Why You Should Avoid Carbs at Bedtime". Men's Health. 
  10. ^ "Hormonal Expression of Androgen Decline in Aging Men (ADAM)". Florence Comite. The Endocrine Society. 
  11. ^ Heller, C.G., Myers, G.B., “The Male climacteric: Its symptomatology, diagnosis and treatment.” JAMA 1944; 126:472-77.
  12. ^ 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. 
  13. ^ Pommerville PJ, Zakus P (2006). "Andropause: knowledge and awareness among primary care physicians in Victoria, BC, Canada". Aging Male 9 (4): 215–20. doi:10.1080/13685530601040661. PMID 17178557. 
  14. ^ a b "Columbia Presbyterian - Department of Urology". Retrieved 2007-12-17. [dead link]
  15. ^ "There's help for "grumpy old men", but they're reluctant to admit to problem, says Queen's urologist". Retrieved 2007-12-17. 
  16. ^ Morales A (2004). "Andropause (or symptomatic late-onset hypogonadism): facts, fiction and controversies". Aging Male 7 (4): 297–303. doi:10.1080/13685530400016664. PMID 15799125. 
  17. ^ Tancredi A, Reginster JY, Luyckx F, Legros JJ (2005). "No major month to month variation in free testosterone levels in aging males. Minor impact on the biological diagnosis of 'andropause'". Psychoneuroendocrinology 30 (7): 638–46. doi:10.1016/j.psyneuen.2005.02.002. PMID 15854780. 
  18. ^ Diamond, Jed (1998). Male Menopause. Naperville, Ill: Sourcebooks. ISBN 1-57071-397-9. 
  19. ^ "Father, 90, shows off new baby" - timesonline.co.uk, retrieved 9/08/07
  20. ^ 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. 
  21. ^ Diamond, Jed (2000). Surviving Male Menopause. A Guide for Women and Men. Naperville, Ill: Sourcebooks. ISBN 1-57071-433-9. 
  22. ^ a b Tan, Robert S. (2001). The andropause mystery: unraveling truths about the male menopause. Houston, Tex: AMRED Pub. ISBN 0-9707061-0-3. 
  23. ^ Carruthers, Malcolm (2004). Androgen Deficiency in the Aging Male. London: Taylor & Francis Group. ISBN 1-84214-032-9. 
  24. ^ 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. 
  25. ^ a b Borst, S.E.; Mulligan, T (2007). "Testosterone Replacement Therapy for Older Men". Clinical Interventions in Aging 4 (2). 
  26. ^ Guay AT, Spark RF, Bansal S, Cunningham GR, Goodman NF, Nankin HR, Petak SM, Perez JB (2003). "American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: a couple's problem—2003 update". Endocr Pract 9 (1): 77–95. doi:10.4158/EP.9.1.77. PMID 12917096. 
  27. ^ 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). 
  28. ^ Finkle WD, Greenland S, Ridgeway GK, Adams JL, Frasco MA, Cook MB, Fraumeni JF, Hoover RN (January 2014). "Increased Risk of Non-fatal Myocardial Infarction Following Testosterone Therapy Prescription in Men". PLoS ONE 9 (1): e85805. doi:10.1371/journal.pone.0085805. PMC 3905977. PMID 24489673. 
  29. ^ Vigen R, O'Donnell CI, Barón AE, Grunwald GK, Maddox TM, Bradley SM, Barqawi A, Woning G, Wierman ME, Plomondon ME, Rumsfeld JS, Ho PM (2013). "Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels". Journal of the American Medical Association 310 (17): 1829–36. doi:10.1001/jama.2013.280386. PMID 24193080. 
  30. ^ Basaria S, et al. (Jul 2010). "Adverse Events Associated with Testosterone Administration". New England Journal of Medicine 363 (2): 109–22. doi:10.1056/NEJMoa1000485. PMC 3440621. PMID 20592293. 
  31. ^ Staff (January 31, 2014). "FDA evaluating risk of stroke, heart attack and death with FDA-approved testosterone products" (PDF). U.S. Food and Drug Administration. Retrieved September 17, 2014. 
  32. ^ Tavernise, Sabrina (September 17, 2014). "F.D.A. Panel Backs Limits on Testosterone Drugs". New York Times. Retrieved September 18, 2014. 
  33. ^ Staff (September 5, 2014). "FDA Panel To Review Testosterone Therapy Appropriateness and Safety". CNN News. Retrieved September 14, 2014. 
  34. ^ Staff (September 17, 2014). "Joint Meeting for Bone, Reproductive and Urologic Drugs Advisory Committee (BRUDAC) and the Drug Safety And Risk Management Advisory Committee (DSARM AC) - FDA background documents for the discussion of two major issues in testosterone replacement therapy (TRT): 1. The appropriate indicated population for TRT, and 2. The potential for adverse cardiovascular outcomes associated with use of TRT" (PDF). Food and Drug Administration. Retrieved September 14, 2014. 
  35. ^ "Contraceptive efficacy of testosterone-induced azoospermia in normal men. World Health Organization Task Force on methods for the regulation of male fertility". Lancet 336 (8721): 955–9. October 1990. doi:10.1016/0140-6736(90)92416-F. PMID 1977002. 
  36. ^ "Episode plot "The Incredible Hank"". IMDb. Retrieved 30 August 2014. 
  37. ^ "Episode plot "Jimmy has changed"". IMDb. Retrieved 30 August 2014. 

External links[edit]