Adam and Ebb
Waning testosterone in the mid-life male can produce the symptoms of andropause

Marcia Kaye

Throughout his late 40s and into his 50s, Richard Hébert blamed his constant fatigue on professional burnout.

The Montreal entrepreneur — and the doctors he consulted — assumed that his busy, stressful work life was the logical cause of his exhaustion, low sexual desire, bad temper and declining lack of motivation.

But when he started experiencing chaleurs — hot flashes and night sweats that were much worse than those of his wife, who was in her early 50s — he suspected a hormonal problem and sought out an andropause specialist. The doctor prescribed testosterone replacement therapy (TRT). “It took time, but now I love life the way I never did before,” says a delighted Richard, now 63. While he acknowledges that he’s still no alpha male sexually, his vitality and optimism have increased dramatically. “It’s been a miracle,” he says.

Andropause is the popular term for the time in a man’s life when ebbing hormone levels sap his physical, mental and sexual vigour. The condition has also been called male menopause, male climacteric and even, cheekily, manopause. It was first identified in 1939 among men in their 50s as a collection of symptoms  that include nervousness, depression, impaired memory, fatigue, hot flashes and sexual dysfunction. But long before then, it was known that male hormones had a lot to do with making a man feel macho. In the late 19th century, the French physician Charles-Edouard Brown-Sequard reported in his 70s that he felt completely rejuvenated after injecting himself with an extract from the testicles of a dog.

But andropause may be something of a misnomer. There’s no evidence whatsoever that all men, or even most men, go through a stage of life that corresponds to menopause in women. “Most men don’t experience a cessation of the production of hormones the way women do,” says Dr. Alvaro Morales, director of the Centre for Applied Urological Research at Queen’s University in Kingston, Ont., and a longtime researcher  in men’s health. “It’s very different from menopause.” Hormone levels in a healthy male do decline but do so extremely gradually, with testosterone decreasing about 1% per year starting in a man’s 30s (see “The Truth About Testosterone”).

The very idea of andropause causes confusion, notes Vancouver endocrinologist Dr. David Shu. “Part of the problem with all these symptoms attributed to andropause is that they can be caused by other medical conditions,” he says. “Some people find their symptoms on an Internet site about andropause and think, Wow, I must have this condition.”

Doctors today are moving away from the idea that all grumpy old men have a treatable condition called andropause. Instead, they’re moving toward a new concept: a minority of men suffer from a true hormone deficiency that seriously affects their quality of life, and these men can benefit from carefully monitored hormone therapy.        

Even the term andropause is making way for a new phrase: testosterone deficiency syndrome. Morales notes  that at least 20,000 Canadian men a year are developing the syndrome, which adds up to hundreds of thousands. In 2006, pharmacists in Canada filled a total of 327,000 prescriptions for products containing testosterone. Still, Morales believes the syndrome remains under-diagnosed because doctors and patients alike are poorly informed.

The main symptoms of testosterone deficiency syndrome are fatigue, weakness, loss of muscle mass, osteoporosis (with a possible loss in height), irritability, disturbed sleep, loss of motivation, hot flashes, night sweats and little interest in sex. Since many of these can be caused by a host of other conditions, such as thyroid problems, diabetes, depression, hypertension, medications or major stress, you should not diagnose yourself.

Low testosterone, or low T, may also be a result of radiation therapy, hormonal therapy, trauma to the testicles, undescended testicles or surgical or chemical castration for such diseases as prostate cancer. It may also be caused by simple genetics. Two 60-year-old men could have identical low T levels, but if one had a far higher testosterone level to begin with, the greater drop could be causing him symptoms, while the other might be symptom-free. It can happen, too, that if a man has always been fairly low-T but functional, the normal decline of testosterone as he ages may plunge him into the deficiency range.

Diagnosis and treatment

Diagnosing low T can be as much an art as a science. Some physicians, such as Morales, believe the most reliable test measures total testosterone, with the normal range falling between 10 and 20 nanomoles per litre of blood (nmol/L). Others, such as endocrinologist Dr. Jean Mailhot, director of the Laval Andropause Clinic in Quebec City, prefer to measure bioavailable testosterone, the amount the body can access on demand. Most of it is bound to a protein called sex hormone–binding globulin (SHBG) and cannot activate cell receptors. Normally, bioavailable levels are above 6.5 nmol/L, says Mailhot. The tests are done in the morning, when testosterone levels are highest, then repeated on a second occasion. Assays for total T are covered by provincial health insurance, while those for bioavailable T are not.

But the blood tests are only part of the story. If a man’s hormone levels are in the low end of normal and he’s experiencing symptoms, the doctor may have him complete the ADAM (Androgen Deficiency in Aging Men) questionnaire and evaluation. It is available at www.andropause.ca.

The ADAM, combined with the man’s symptoms, his blood tests, his medical history and a physical exam, all contribute to making a clear diagnosis. “Like many things in medicine, you have to put all the pieces together,” says Morales.

Testosterone supplements come in injections, pills or gels. Patches are rarely used now, as the adhesives cause skin rashes in most people. Private insurance and some provincial health plans cover the cost of treatment, which runs from $20 to $130 a month. Since hormone therapy with testosterone may aggravate an existing cancer, men with prostate or breast cancer cannot take testosterone, and men with an enlarged prostate and difficulty urinating must be carefully examined, as androgen replacement could exacerbate these.

Testosterone can also increase red blood cell counts, so men with high hemoglobin who take T supplements are at risk for blood clots, embolism, thrombosis and heart attack. Large long-term studies on the efficacy and safety of TRT have not yet been done. “For men, there’s been nothing even close to the Women’s Health Initiative study,” says Shu, referring to the large U.S. study of the health effects of hormone replacement therapy (HRT) in older women. This study found a small but significant rise in the risk of clots, stroke, heart attack and breast cancer with long-term HRT.

Furthermore, T therapy may be a trial-and-error business. “We see it all the time. After three months on testosterone, a patient will come back a changed man — enthusiastic about life, with a strong sex life,” says Morales. “We also see people who experience no change, and then we have to look for another diagnosis.”

Erectile dysfunction

Studies are contradictory about the connection between testosterone and erectile dysfunction (ED), but Morales notes that while all men with ED should have their
T levels checked, only about 20% of ED cases can be attributed to low T. Still, those men who tried Cialis, Levitra or Viagra with poor results before their  diagnosis of low T may have greater success with these drugs once their T levels are back to normal, Morales says. The testosterone therapy helps increase their desire; Viagra et al., which can be taken safely with testosterone, may then help enhance their performance.

While hormone replacement has a role in correcting a true T deficiency, men will have to look elsewhere for that elusive fountain of youth. As Shu cautions, “Testosterone is not a magic anti-aging formula.”

10 Low-T Tipoffs

1 Are you experiencing a reduced sex drive?
2 Do you have weaker erections?
3 Do you feel you have a lot less energy?
4 Are you experiencing a decrease in strength and/or endurance?
5 Have you lost height?
6 Are you enjoying life less?
7 Do you feel sad or irritable a lot of the time?
8 Has your ability to play sports deteriorated recently?
9 Are you falling asleep after dinner?
10 Has your work performance declined recently?

— Adapted from the ADAM Questionnaire, developed by Dr. John Morley, St. Louis University School of Medicine

Low T, Higher Risk

A study from the University of California at San Diego found that men over 50 with low T had a one-third higher risk of dying over the next 18 years than their higher-T peers.

They were more likely to have elevated levels of inflammatory cytokines, immune-system proteins that  play a role in many diseases, plus a larger accumulation of fat around the waist, a risk factor for type 2 diabetes and heart disease. Men on long-term anti-T therapy for prostate cancer run more risk of heart attacks and bone fractures.