There has been debate about whether or not the male menopause (andropause) exists but the simple answer is that it does,” says Dr Deirdre Forde, a GP who specialises in menopause at her Céile Medical clinic in Athlone.
“We look at the male menopause (testosterone deficiency) similarly to the female menopause because obviously hormones start to deplete as people get older so that’s why we consider this to be a real-life event. However, some men may be affected more than others, unlike women who are all affected by menopause.”
Dr Forde began treating men for testosterone deficiency after female menopause patients spoke of their partners experiencing similar symptoms to what they were experiencing, like fatigue and night sweats.
She explains that while women’s menopause occurs because no oestrogen, progesterone or testosterone is being produced from the ovaries – usually in women over 50 years of age – men’s testosterone levels decline gradually with age.
“By comparison, men’s (menopause) is a gradual decline (in testosterone levels) over the years. It usually starts at the age of 30 and there is about a 1% decrease per year after that so by the time they are 40 there is a 10% decrease.”
Men can have similar symptoms
Studies have shown that 13% of men have below optimum testosterone levels, she says.
“A lot of these men will present with similar symptoms to the female. They will go to the doctor saying, ‘I just don’t feel myself’. While loss of sexual function may be the trigger for them going, there can be emotional as well as physical symptoms involved.”
On the emotional side her symptom checker list includes:
“We would check what symptoms they are having first then check their testosterone levels by doing blood tests,” Deirdre says.
“The consultation is very detailed and if the man’s levels are very low he would be referred to a specialist, a consultant endocrinologist. If his levels are on the low side of normal (sub-optimal) we would generally do two blood tests over a period of several weeks. Depending on what the results show we may or may not prescribe testosterone replacement therapy. If it’s needed it’s about getting their levels up to normal and also about getting the men motivated to change their lifestyle, if that’s an issue.”
Prostate specific antigen (PSA) and fasting blood sugar levels are also checked to make sure they do not have prostate issues and are not pre-diabetic.
“We also have to look at how they are sleeping because their sleep can be very severely impacted with loss of testosterone,” she adds. “We would also ask what’s happening in their life, what their diet is like – all that kind of thing. It’s a very holistic approach.”
The testosterone replacement therapy to treat deficiency comes in the form of a gel prescribed in pump or sachet form and is transdermal i.e. it is applied to the skin (back, shoulder or thigh) from where it soaks into the blood stream.
“The man typically uses one sachet on an arm or leg and generally if his levels are low his symptoms will diminish with this treatment. I would review after three months by doing another blood test. If his testosterone level is now normal, I would reduce the gel because we don’t know, long term, the effects of testosterone if you keep giving it to men all the time. It’s really about getting them back to feeling motivated again to improve their life.”
She adds that this testosterone replacement gel should never be given to men without first checking their hormone and prostate levels.
“If you did and the person wasn’t monitored you could end up doing more harm than good. A lot more studies need to be done around this. If you give a man testosterone who doesn’t need it or who isn’t being monitored you are at risk of stimulating too much red blood cell production which can lead to clots.
“You are also at risk of stimulating the prostate gland into a benign prostate enlargement or growing an existing prostate cancer, so it’s not something to be done lightly.”
Dr Emmett Byrne, former Leinster rugby player, runs a men’s health clinic in Bray, Co Wicklow, and a website entitled Testosterone.ie
He treats many men aged from their late 40s to mid-60s with low testosterone levels.
“Andropause is a bit of an overall term that really isn’t accepted anymore,” he says. “The term was used as a parallel with menopause but it’s not entirely accurate. Testosterone deficiency would be the correct term now. It is the second most prevalent endocrine problem that men have, second only to diabetes.”
Testosterone is the most well-known of the androgen group of hormones – the hormones that give men their male characteristics.
He agrees that there is no definite entering of a menopause stage for men and that it doesn’t happen to all men.
“Some guys mightn’t notice any change if it’s gradual but if there is a big drop they would.”
He points out that men are treated for testosterone deficiency based on the British Society for Sexual Medicine guidelines and that there are two types of testosterone deficiency: classical and age-related.
“The classical deficiency is where you’re born with low levels. There may be a genetic disadvantage where some disease is causing a problem with the testicles, for example. Then there is the age-related deficiency which causes symptoms like fatigue, anxiety, reduced sexual function and so on.”
Ageing male hormonal decline usually occurs with comorbidities. That’s where the man has other medical problems as well, states Dr Byrne.
“It runs parallel with comorbidities. Men who are unwell metabolically, ie they are pre-diabetic, diabetic, have heart disease, are obese or have non-alcoholic fatty liver disease would all be more likely to have a deficiency in testosterone.”
Trigger for seeking help
But what symptom brings men to his clinic?
“You’d think the majority would come in about loss of sex drive, but in my experience anxiety is a big reason,” he says. “A lot of men get highly anxious (as their testosterone levels reduce). They might have a predisposition to it, but as they get older it gets worse and as their testosterone levels drop, it becomes significantly worse. I have people coming in with panic attacks who normally wouldn’t be having panic attacks, for example.”
He adds that as well as the gel version of testosterone deficiency therapy that is rubbed into the skin there is also an injection that can be administered.
“This is usually into the glute (one of the muscles in the buttocks). That is a much slower-release form and works over 10 to 12 weeks. ”
Testosterone – protective
against type two diabetes
Both doctors mention that testing men’s testosterone levels early on could lead to the prevention of type two diabetes.
“Many men with extra weight around the tummy can be at risk of diabetes,” Dr Deirdre Forde says, “so really if we could identify these men at pre-diabetic stage and give them a small amount of testosterone and motivate them to change their lifestyles we might be able to prevent them developing type two diabetes.”
Dr Byrne mentions studies in Australia that have proven testosterone’s protectiveness against diabetes.
“It increases glucose metabolism in the cells so basically it protects against diabetes. People with diabetes, therefore, if they have low testosterone and use the gel, it can actually not just treat the testosterone deficiency per se but protect against diabetes – as does low-dose metformin. Metformin is the number one drug for diabetes at the moment so there are promising things happening there.
Research papers are also showing that if low testosterone levels are treated it may be protective against cardiovascular disease as well, so testosterone replacement therapy has wide-ranging effects.”
Body-building – danger of too much testosterone
Too much testosterone can cause problems, however.
“The problem with testosterone is that it is very much associated with body building and doping in sports,” Dr Byrne states.
“If you dope and use what’s called super physiological doses of testosterone for body-building performance you actually do the opposite to helping yourself – you put yourself at risk of illness. But if you correct a low testosterone level and bring it into the normal range then it’s protective.”