ANDROPAUSE, TESTOSTERONE & MALE MENOPAUSE
Frequently Asked Questions (FAQs)
This information is
under copyright by Harvey S. Bartnof, M.D. and California Longevity and
Vitality Medical Institute®.
It may be copied only for individual, personal use and is not for
distribution or publication of any type without the explicit written
permission of Dr. Bartnof.
Andropause
is a state of lowered “androgen” (male-type) hormone levels in men,
particularly testosterone. It also has been referred to as “ADAM” or
androgen deficiency (decline) in aging men, “PADAM” or partial androgen
deficiency (decline) in aging men, “male menopause” (similar to the
decline in female hormones in women in middle age or older), male
“climacteric,” and even “viropause” (decline in virility).
Common
symptoms include (not all are always present): decreased libido (less or
loss of interest in sex), weakness/ fatigue/ tiredness, memory changes
(may be subtle), and erectile dysfunction (“ED”). Other symptoms may
include (not all are always present): decreased stamina (workouts,
etc.), decreased mental “sharpness,” decreased productivity, decreased
cognition (thinking, ability to understand), decreased concentration,
irritability, nervousness, depression, moodiness, night sweats, “hot
flashes,” and “palpitations” (sensation of abnormal heart beating).
Note that several of these symptoms may be non-specific, meaning they
may be due to causes other than andropause. Also note that there is
increasing research that low testosterone may be a co-factor for
Alzheimer’s disease (brain disease) in men and possibly women.
Common
signs include (not all are always present): decreased muscle mass,
decreased muscle strength, increased fat mass, decreased axillary
(armpit) hair, decreased pubic hair, possible decreased size of
testicles, decreased bone mass (possible osteopenia and even
osteoporosis), decreased sperm count with possible infertility and dry
skin. Note that some of these symptoms may be non-specific, meaning
they may be due to causes other than andropause.
Just as in
any other medical condition, a diagnosis is made based upon a patient’s
history (symptoms), physical examination, laboratory tests and possibly
other additional tests.
After a
diagnosis is made, the benefits and risks are discussed by Dr. Bartnof
with the patient. If treatment is indicated, a decision is made, based
upon the preference of the patient and his informed consent, to begin
treatment. Treatment is almost always with replacement testosterone.
Androgens
refer to the male-like hormones, although women also have androgens—but
lower levels than men. The main androgens are: testosterone,
dihydrotestosterone (DHT), androstenedione, and DHEA (dehydroepiandrosterone,
from the adrenal glands on top of each kidney). Testosterone
increases libido (interest in sexual activity), is anabolic (will
build body tissues, including muscles and bones), helps
maintain normal oil secretion in the skin and hair, and has effects,
directly or indirectly on the brain, that are partly responsible for
normal cognition (thinking), mental sharpness and concentration,
visual-spatial abilities, sense of well-being, sense of stamina, sense
of energy and normal mood. Androgens are necessary for normal
erectile functioning, while testosterone is a necessary co-factor
for sperm production and fertility. Androgens lead to male sexual
characteristics, including facial (and in many men) body hair
and a deeper voice. Testosterone has beneficial benefits on
the heart and arteries—it was used to treat angina (heart
pain due to artery blockage) in the 1940s. Several studies have shown
that testosterone dilates the heart and other arteries, although the
effects may be due to its conversion to estradiol. Several modern
studies have shown beneficial effects of testosterone on results of
exercise treadmill testing, reducing abnormal changes on
electrocardiograms (ST depression improves) and improving angina. Low
testosterone levels in men are associated with “atherosclerotic”
(blockages) disease in the heart arteries. Testosterone will decrease
total and LDL (“bad”) cholesterol, but, in some men, will also
decrease the HDL (“good”) cholesterol somewhat. This decrease is
counterbalanced by increased clearance (decrease in blood level of) of
total cholesterol. Low HDL can be treated with lifestyle intervention
and/or prescriptive and non-prescriptive medication.
Usually,
testosterone is prescribed as a periodic injection (every 7 or 10 days)
or as a topical cream or gel, either once or twice daily. A less
commonly-used formulation is pellets implanted under the skin every few
months. Other formulations include skin patches, a small patch used in
the mouth on the gums and a sublingual (under the tongue) tablet. There
are advantages and disadvantages and benefits/ risks for each of the
formulations. Oral testosterone as a sole medication is not available
in the US.
The
purpose of testosterone therapy is to treat the symptoms and body
changes listed under questions 2 and 3 above. However, as with any
treatment, there are potential side effects. They are often manageable;
however, if a side effect cannot be managed or begins to outweigh
potential benefits, then a decision may be made to stop treatment. Side
effects include: more natural oil on the skin (particularly the
head) that when excessive may lead to oily skin or hair and even acne;
increased red cell counts (treatable or avoidable); excessive
libido; and possible prostate growth. The prostate issue in
testosterone therapy is a controversial one. It appears that the
hormones that testosterone converts into (DHT and probably estradiol)
are the ones involved in prostate growth. Therefore these other
hormones also generally require monitoring and natural supplements or
prescriptive medications may be used to keep those hormones in a normal
range. Regular monitoring of the PSA (prostate specific antigen) blood
test, red cell counts and examination of the prostate is necessary. A
man who has had a history of prostate cancer or breast cancer (yes, men
do sometimes get breast cancer) has a relative contraindication to
(should not take) testosterone replacement therapy. However, if a man
with either of those cancers has been cured and enough time has passed,
he may be a candidate for testosterone replacement. DHT (made from
testosterone) may induce scalp hair loss in susceptible men,
unless the DHT is blocked or inhibited with specific treatments. A few
men are susceptible to subtle, female-type breast appearance, but
this is preventable and treatable with specific therapies. Some men may
notice a slight decrease in the size of their testicles, but this
can be avoided with specific treatments, if necessary. The decrease
occurs because of a feedback loop that shuts off the normal brain signal
to the testicles. This same mechanism may decrease sperm counts
and decrease fertility—if a man still desires to father a child, there
are treatments to allow for normal sperm counts. Sometimes,
testosterone can worsen “sleep apnea,” a condition whereby
breathing temporarily stops during sleep—this is more likely to occur in
men who are overweight or obese. In some men, testosterone may decrease
the HDL (“good”) cholesterol somewhat. This decrease is
counterbalanced by increased clearance (decrease in blood level of) of
total cholesterol. Low HDL can be treated with lifestyle intervention
and/or prescriptive and non-prescriptive medication. When testosterone
levels are within normal limits, “rhoid rage” (excessive anger) does not
occur—but may occur when levels are too high or “supraphysiologic,” as
when it is abused by some “body-builders.” Oral testosterone is not
available in the US as a sole drug, and certain types can cause liver
problems.
Hypogonadism in men is a strict medical definition primarily based on a
blood testosterone level that falls below a specified level that varies
from laboratory to laboratory. A patient’s symptoms and physical
examination is also used to make that diagnosis. Andropause refers more
generally to a state of declining androgens or male-like hormones.
Also, a patient’s history, physical examination and laboratory results
are used to make the diagnosis. However, not all physicians even
believe that andropause exists (more and more of them will in the future
as they and the public become more educated). Also, some physician
researchers may include a decline of other hormones in their definition
of andropause, specifically DHEA (dehydroepiandrosterone from the
adrenal glands) and somatotropin (growth hormone). Yet other physicians
will use other “-pause” terms to refer to those hormones that are
declining, specifically adrenopause for the decline in DHEA and
somatopause for the decline in somatotropin.
Several
research studies have shown a significant association between low
testosterone levels in men and Alzheimer’s disease of the brain. In the
January 27, 2004 issue of the journal Neurology, 574 men were followed
for an average of 19 years in the Baltimore Longitudinal Study of
Aging. The results showed that higher free (unbound)
testosterone levels in men predicted a decreased future risk of
developing Alzheimer’s. Put another way, for every 50% increase
in free testosterone at baseline, there was a 26% decreased risk of
developing the disease. This “dose-response” relationship is something
that statistics researchers use to add credence to the results and
significantly adds weight to the conclusions. At the end of the study,
those men with Alzheimer’s had about half the level of free testosterone
as those men who did not have the disease. For more information about
this study,
CLICK HERE
.The same researchers had reported previously that older men with
higher levels of free testosterone have better visual memory, better
verbal memory and better performance on “spatial” tasks than those men
with lower levels.
Robert S. Tan, MD, of
the University of Texas at Houston, reported in 2003 in the journal
Aging Male his results of a pilot study of 10 men with dementia (loss of
brain function, a prominent finding in Alzheimer’s) and who had low
testosterone blood levels (hypogonadal). After testosterone replacement
therapy, quarterly measurements for 1 year revealed significant
improvements in thinking abilities (MMSE, Mini-Mental State Examination)
and visual-spatial abilities (Clock-Drawing test). This is only a pilot
study and additional research is necessary. For more information about
this study,
CLICK HERE .
To see more
references about testosterone and Alzheimer’s/ memory loss,
CLICK HERE
The effects on man by subcutaneous injections of a liquid
obtained from the testicles of animals.
Sequard B. The
Lancet 1889 July 20:105-107 (not available on PubMed).
1944-1946
(JAMA)
The male climacteric, its symptomatology, diagnosis
and treatment.
Heller CG and Myers
G. Journal of the American Medical Association 1944;
126(8):472-477 (not available on PubMed).
The male climacteric:
report of 273 cases.
Werner AA. Journal
of the American Medical Association 1946; 132:188-194 (not available
on PubMed).
Current
References of Interest-General
“The Andropause Mystery”
by Robert S. Tan, MD;
publisher AMRED Publishing, 2001. (Paperback , 186 pages) Available for
purchase at Amazon.com
“The Testosterone
Syndrome”
by Eugene Shippen, MD; publisher M. Evans & Co, 1998.
(Paperback, 220 pages)
Current References of
Interest-General Medical
Is it andropause?
Recognizing androgen deficiency in aging men.
Tan RS, Pu SJ.
Postgraduate Medicine 2004 Jan; 115(1): 62-6.
http://www.postgradmed.com/issues/2004/01_04/tan.htm
(PubMed abstract:)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14755879
An integrative review
on current evidence of testosterone replacement therapy for the
andropause.
Tan RS, Culberson
JW. Maturitas. 2003 May 30; 45(1): 15-27 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12753940
Andropause: an old concept in
new clothing.
Morley JE, Perry HM. Clinics in Geriatric Medicine 2003 August;
19(3): 507-528 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14567004
Andropause:
clinical implications of the decline in serum testosterone levels with
aging in men.
Matsumoto AM. Journals of Gerontology Series A: Biological Sciences
and Medical Sciences. 2002 Feb; 57(2): M76-99 (review, no abstract
available on PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11818427
Andropause,
testosterone therapy, and quality of
life in aging men.
Morley JE.
Cleveland Clinic Journal of Medicine. 2000 Dec; 67(12): 880-2.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11127982
Urologic aspects of
andropause.
Stas SN,
Anastasiadis AG, Fisch H, Benson MC, Shabsigh R.
Urology.
2003 Feb; 61(2): 261-6 (review, no abstract available on PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12597927
Andropause:
is it time for the geriatrician to treat it?
Morley JE. Journals of Gerontology Series A: Biological Sciences and
Medical Sciences. 2001 May; 56(5): M263-5 (editorial, no abstract
available on PubMed)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11320104
Andropause:
introducing the concept of 'relative hypogonadism' in aging males.
Tan RS. International
Journal of Impotence Research 2002 Aug; 14(4): 319 (no abstract
available on PubMed).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12152125
Andropause:
endocrinology, erectile dysfunction, and prostate pathophysiology.
Hafez B, Hafez ES.
Archives of Andrology. 2004 Mar-Apr; 50(2): 45-68 (review).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14761837
Perceptions
of and risk factors for andropause.
Tan RS, Philip
PS. Archives of Andrology. 1999 Nov-Dec; 43(3):
227-33.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10624507
Current References of
Interest-
Alzheimer’s, memory loss, other
Low Free
Testosterone Levels Linked to
Alzheimer's Disease in Older Men
(National Institute
of Aging)
http://209.70.85.166/cgi-bin/s.cgi?cs=&q=Testosterone&ch=http:%2F%2Fwww.alzheimers.org%2Fnianews%2Fnianews62.html&fm=off
Free testosterone and
risk for Alzheimer disease in
older men.
Moffat SD, Zonderman
AB, Metter EJ, Kawas C, Blackman MR, Harman SM, Resnick SM.
Neurology. 2004 Jan 27; 62(2): 188-93.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14745052
A pilot study on the
effects of testosterone in hypogonadal aging male patients with
Alzheimer's disease.
Tan RS, Pu SJ.
Aging Male. 2003 Mar; 6(1): 13-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12809076
Role of androgens in
mild cognitive [thinking]
impairment and possible interventions during
andropause.
Tan RS, Pu SJ,
Culberson JW. Medical Hypotheses. 2004; 62(1): 14-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14728998
Longitudinal
assessment of serum free testosterone concentration predicts
memory performance and
cognitive [thinking] status in
elderly men.
Moffat SD, Zonderman
AB, Metter EJ, Blackman MR, Harman SM, Resnick SM.
Journal of Clinical Endocrinology and Metabolism. 2002 Nov; 87(11):
5001-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12414864&dopt=Abstract
Plasma testosterone
levels in Alzheimer and
Parkinson diseases.
Okun MS.and
others. Neurology. 2004 Feb 10; 62(3): 411-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14872022
Low androgenization
index in elderly women and elderly men
with Alzheimer's disease.
Paoletti AM and
others. Neurology. 2004 Jan 27; 62(2): 301-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14745075
Effects of transdermal testosterone
on bone and muscle in older men
with low bioavailable testosterone levels.
Kenny AM, Prestwood KM, Gruman CA, Marcello
KM, Raisz LG. Journals of Gerontology Series A: Biological Sciences
and Medical Sciences. 2001 May; 56(5): M266-72.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11320105
Impact of
obesity on hypogonadism in the
andropause.
Tan RS, Pu SJ.
International Journal of Andrology 2002 Aug; 25(4): 195-201.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12121568
Official guidelines
of the International Society for the Study of the Aging Male (ISSAM)
Cuzin B, Giuliano F, Jamin C, Legros JJ, Lejeune H, Rigot JM, Roger M.
Prog Urology. 2004 Feb; 14(1): 1-14.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15098744
American Association
of Clinical Endocrinologists Medical Guidelines for Clinical Practice
for Evaluation and Treatment of Hypogonadism [classical testosterone
deficiency] in Adult Male Patients—2002
Update
http://www.aace.com/clin/guidelines/hypogonadism.pdf
Institute of Medicine
Report: Testosterone and Aging
(November 12, 2003)
http://www.iom.edu/report.asp?id=16398
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