| Andropause (Male Menopause) - Does it really exist ?! |
| ANDROLOGY : The Science of Dysfunctions of the Male Reproductive System |
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| Sex is Not a Four-Letter Word | |
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| A G A S S I 'Ageing, Gender, Andrology, & Sexual (Sciences), Society of India'
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Synonyms: Late Onset Hypogonadism (LOH), Male Climacteric, Andropause, Viropause, ADAM (Androgen
Deficiency in the Aging Male) and PADAM (Partial Androgen Deficiency in the Aging Male). he medical profession has long debated the existence of male menopause. Does it really exist ? If so, at what age does it affect men ? What are the symptoms ? Are they reversible with treatment ? What precautions can
a man take to prevent/postpone its arrival ? How is it similar to/ different from female menopause ?
Or, on the other hand, is it a non-existent entity ? Is it just a another ploy to emasculate men further ? Are senile eighty-year old men who are seen dating nubile young women really as capable as they appear to be or are they merely fooling both their partners and themselves ? Or are their partners fooling them ?
Until recently, the entire subject of the andropause was steeped in confusion and controversy. While women were accused of going through middle-aged crises and menopause-related aberrations, their male counterparts got away with propagating the myth of the 'ageless male' and boasted of virility all the way to their graves.
So what's the real score ?
There is no doubt that a man's sexuality changes with advancing age. The instant, anytime, 'as-many-times-as-you-want' erections that are more the rule than the exception at 18, do not last forever. With advancing age, the urge reduces, erections take time to come on, any time is not always a good time and the penis requires more direct stimulation in order to get aroused. Besides, the erections may not be as angled and rigid, and ejaculation becomes more feeble. The refractory period (interval) between erections gets prolonged.
Is all this because of the maturation (maturity) process ? Is it because by middle age man has had enough sex so as not to be unnaturally preoccupied with it any longer ? Is this because his wife has aged a bit and is no longer as attractive/ interested as before ? Or is it because of the pressures at the work-place, the demands of parenthood, or pre-occupation with the lives of grown-up children and aging parents ?
Is there really something called a middle-age crisis ? If so, how is it different from male
menopause ?
Yes, there is something known as a mid-life crisis.This is often a time in a man's life when stability has been achieved and the struggles that were once a large part of life are now at an end. This new awareness that a life change has taken place can sometimes trigger a crisis. For some men, new-found stability may signify an end to vitality or youth. Many men find that after spending a lifetime working towards the goals of family and peers, the end result is unfulfilling. This is also often a time of change. Major shifts in career, marriage and parenting often occur during this time period. And, along with the physical signs of aging comes a realization of impending old age, retirement and eventually death. This time of life will only become a crisis if the changes become too difficult to cope with.
Mid-life crisis, thus, is essentially a problem of psycho-social adjustment. It need not necessarily have a bearing on a man's sex life. It is thus not synonymous with the andropause although there is
frequently a superimposition of male menopausal factors in middle-aged men going through crises and this makes the picture hazy.
Andropause, on the other hand, is a distinct physiological phenomenon that is in many ways akin to, yet in some ways quite different from the female menopause.
Menopause is a condition most often associated with women. It occurs in a woman when she ceases to menstruate and can no longer become pregnant (usually). Men experience a different type of 'menopause' or life change. It usually occurs between the ages of 45 and 60 - but sometimes as early as age 30. Unlike women, men can continue to father children, but the production of the male sex hormone (testosterone) diminishes gradually after age 40.
Testosterone is the hormone that stimulates sexual development in the male infant, bone and muscle growth in adult males, and is responsible for sexual drive. It has been found that even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it is just ten years earlier. In fact, by age 80, most male hormone levels decrease to pre-puberty levels.
One hundred and fifty years ago, a German Professor called Berthold showed that transplant of a cock's testis prevented atrophy of the comb after castration. In 1944, what we now describe as the andropause was reported in a key article by two American doctors, Carl Heller and Gordon Myers. They compared the symptoms with those of the female menopause, and did a blind controlled trial showing the effectiveness of testosterone treatment. Unfortunately, like many pioneering efforts, these went unnoticed. Men were unwilling to accept that they could attain 'menopause' and such research was often hurriedly brushed under the carpet. Men with genuine symptoms were told that 'this is just a mid-life crisis' - just like men with erectile dysfunction were told that 'it's all in the mind'. Besides, testosterone therapy had come into disrepute because of its abuse by athletes and the concept of testosterone replacement therapy for male menopausal symptoms was not received very well. Further, there was much hype about the side effects of testosterone, especially prostate cancer.
It was only after HRT (Hormone Replacement Therapy) with estrogens produced tangible symptomatic improvement and 'aging reversal' in post-menopausal women that men sat up and, not wanting to get left behind their womenfolk, began to take notice !!
The symptoms of andropause are similar to the ones women experience and can sometimes be as overwhelming. However, the male menopause does not affect all men, at least not with the same intensity. Approximately 40 % of men between 40 and 60 will experience some degree of lethargy,
depression, increased irritability, mood swings, hot flushes, insomnia, decreased libido, weakness, loss of both lean body mass and bone mass (making them susceptible to hip fractures) and difficulty in attaining and sustaining erections (impotence).
For these individuals, such unanticipated physical and psychological changes can be a major cause for concern or even crisis. Without an understanding partner, these problems may result in a powerful combination of anxieties and doubts, which can lead to total impotence and sexual frustration. A recent aging study showed that 51 % of normal, healthy males aged 40 to 70 experience some degree of impotence - defined as a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse. This problem cannot be attributed to the aging process alone, however, because well over 40 % of males remain sexually active at 70 years of age and beyond. Other factors, notably the co-existence of degenerative or other diseases, are culpable.
The St. Louis ADAM (Androgen Deficiency in the Aging Male) questionnaire
asks for the following symptoms:
This symptom score, however, is only a rough set of guidelines and is
not absolute.
Although all the causes of male menopause have not been fully researched, some factors that are known to contribute to this condition are hypothalamic sluggishness, hormone deficiencies, excessive alcohol consumption, obesity, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems, notably mid-life depression. A general decline in potency at mid-life can be expected in a significant proportion of the male population. A relative increase in circulating levels of estrogen (which competes with testosterone for cellular receptor sites) can tilt the testosterone- estrogen balance unfavourably and can reduce the availability of testosterone to target cells.
Testosterone Replacement Therapy (TRT) must be always administered only by very responsible physicians and under strict case selection criteria and supervision. Testosterone must not be used as a tonic for vague complaints as it can cause serious side effects, including prostate cancer. The risk of prostate cancer with TRT has been much hyped. Recent evidence suggests that the fear of prostate cancer is perhaps exaggerated, since prostatic disease is estrogen-dependent rather than testosterone-dependent. However, it is true that testosterone administered to a patient who already has cancer of the prostate can cause a flare up and aggravation of the disease. Hence the importance of a thorough check-up and investigation before starting testosterone.
Patients with significant 'andropausal' complaints should be taken up for investigation. Serum FAT (Free Available Testosterone) is measured in a pooled early morning blood sample and, if low, testosterone therapy can be considered. Before starting testosterone, a complete general check up including a rectal examination is conducted followed by tests like the hematocrit, lipid profile, cardiac function tests, liver function tests, measurement of PSA (Prostate Specific Antigen)and a trans-rectal ultrasound (TRUS). The important side effects of testosterone are thrombophlebitis and hypercoagulability of blood, liver toxicity (with some oral testosterone preparations) and(??!!) prostate cancer. These tests must be repeated at 3 or 6 monthly intervals for as long as treatment is continued.
Testosterone is available in many forms - oral, injectable, trans-dermal and implants. The oral route is generally not recommended because of the high risk of liver toxicity. Some newer oral forms of testosterone are purportedly absorbed through the lymphatics. These bypass the liver and cause much less toxicity. Injectable testosterone is safe but the blood levels are not uniformly maintained and any excess is converted to estrogens, which is counter-productive since it might alter the testosterone- estrogen balance. Doses must be tailored to the needs of the patient in order to achieve normal blood levels of FAT. A significant improvement in symptoms can be expected with proper therapy. More recently, patches, pellets, creams and gels have entered the fray. The choice of route and preparation will depend on availability, safety, the socio-economic status of the patient, proven long term safety and efficacy and the preference of the patient and the prescribing andrologist.
In conclusion, it may be stated that the andropause does exist. It affects many men over 40 years of age (sometimes earlier). Symptoms are gradual and usually not as pronounced as in the female. Early diagnosis and hormone replacement therapy can improve symptoms.
Impotence (in contradistinction to impaired libido) is not usually amenable to hormone replacement alone and will need further investigation and treatment. These are discussed in What Every Adult Needs to Know about Impotence.
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Female menopause has been known for centuries, but it has only recently
been discovered that males also go through a similar phenomenon with identical symptoms.
