Both men and women experience symptoms related to production of sex hormones (sex steroids) as they get older.
These changes are inevitable, but affect individuals differently. For men, the production of testosterone (the principal male-determining sex steroid) falls gradually and progressively from the 40s onwards. This is a natural process and not a disease, and can be helped with medical treatment effectively.
The fall in sex hormone production is much more gradual for men, developing over decades rather than months or years. Mental and physical changes can occur, and are much more subtle in onset and often easily be missed. As such, the term 'male menopause', or andropause, is not really accurate, instead, andrology experts prefer to talk about 'partial androgen deficiency of the ageing male' (PADAM).
The diagnosis of PADAM is based on the presence of clinical symptoms together with evidence of reduced testosterone, however they can be numerous and non-specific, so it is not an easy condition to diagnose.
They may include the following;
However some studies have suggested no correlation between testosterone levels and these symptoms and conditions other than male menopause may cause similar symptoms in some men.
Male Menopause or Andropause is treated at the Cadogan Clinic by our award-winning Consultant Uro-Andrologist, Mr Giulio Garaffa who has over 20 years’ international medical experience in this area. Mr Garaffa has a global reputation for his excellence in uro-andrology and is one of the leading experts in this field.
It would be comforting to think that a simple blood test could identify androgen deficiency. Unfortunately, this is not the case.
Widespread disagreement exists over what the normal range of testosterone levels are and what, exactly, should be measured in the blood to assess androgen deficiency.
The existing 'normal' range for total testosterone is based upon statistical analysis of pooled samples from all men, including those who might have PADAM. So 'normal' testosterone levels are not necessarily the same as healthy levels.
Testosterone is released into the bloodstream in pulses, and levels vary through the day (diurnal variation). In general, the testicles release more testosterone in the morning than later in the day.
Blood samples should therefore be taken between 8am and 10am, and at least two separate, consistent results are needed to establish that there is a problem with testosterone levels.
About 60 – 70% of the total testosterone is tightly bound to a protein, present in the blood, called sex hormone binding globulin (SHBG). This protein-binding is a common way in which hormones are transported in the bloodstream and it is effectively a circulating store of testosterone. The testosterone only becomes active when the link to SHBG is broken, and this is a process which occurs at a certain rate all the time.
Older men produce relatively more SHBG, as do heavy drinkers and men with thyroid disorders, thus reducing the amount of 'free' testosterone.
Another 30 – 40% of the total testosterone is more loosely bound to another protein, called albumen. Testosterone bound to albumen is also inactive, so free testosterone probably accounts for only 1-2% of the total.
Measurement of total testosterone is therefore a poor measure of active testosterone. Free testosterone levels are expensive to measure and are not widely available.
Free Androgen Index (FAI = total testosterone/SHBG x100) is an alternative measure of androgen state that is not as reliable as free testosterone, but is better than relying solely on total testosterone.
All this is confusing for doctors, too!
There is evidence to show that treatment with testosterone supplements will improve symptoms related to 'partial androgen deficiency of the ageing male' (PADAM). In one study two months of treatment improved the symptoms although there was no obvious association between the symptom improvement and the level of testosterone.
Androgens are steroid hormones with play very important effects on muscle, fat, skin, hair and brain. Although they play important roles in both men and women, they are produced in much larger quantities in men.
In men after puberty, the vast majority of androgens are produced by the testicles, mainly as testosterone. Androgen deficiency can occur in men of all ages, even in children and adolescents, as a result of testicular damage, genetic disorders or metabolic disorders or the administration of certain medications.
It's very important that young patients receive expert assessment by an endocrinologist at an early stage and receive androgen replacement therapy. This is established medical practice and uncontroversial, unlike androgen supplementation therapy in PADAM ('partial androgen deficiency of the ageing male').
There are no definitive test for PADAM and low blood levels of testosterone alone are insufficient to make the diagnosis.
The combination of several different suggestive symptoms and physical signs, together with low blood levels of testosterone, should raise suspicion that PADAM is present.
As this is a complex condition that can present itself in a variety of ways. At present, a practical approach is probably the most helpful. If multiple symptoms of PADAM are present your consultant may recommend a 'therapeutic trial' of testosterone supplement therapy for up to 3 months. If there has been no improvement in symptoms, after 3 months of therapy, then continuation of treatment is probably not worthwhile.
A very high placebo response to treatment probably occurs, so it is important to check that the improvement is maintained over time.
Men receiving testosterone supplements should have regular medical checks every 3 months for the first year of treatment, which must include a rectal examination of the prostate gland (which sits beneath the bladder producing fluids that nourish and protect sperm) and a Prostate Specific Antigen blood test. The latter two tests indicate whether or not a risk of prostate cancer exists. Abnormalities in either test should be investigated as testosterone replacement therapy is contraindicated in men with proven prostate cancer. After that period, at least yearly checks are necessary.
Testosterone is available as:
- injections (eg Nebido, Sustanon, Virormone)
- patches (eg Andropatch)
- gels (eg Testim gel, Testogel).
Capsules do not always provide steady blood levels. Patches are probably the easiest form of testosterone to use, although they are reasonably expensive.
All these preparations can only be prescribed under specialist's advice.
Headache, weight gain, acne, increased aggression and male-pattern baldness have all been reported with testosterone treatment, but are uncommon if free testosterone levels are maintained within the normal range.
Considerable controversy exists over the effect of testosterone upon the prostate gland. Men with abnormally low levels of testosterone have small prostate glands.
Replacement therapy causes the prostate to grow to about the average size predicted for their age.
Current evidence indicates that testosterone does not cause abnormal prostate enlargement (benign prostatic hypertrophy).
Testosterone should not be given to men who have symptoms of restricted urine flow (urinary outflow obstruction) due to prostate enlargement.
Testosterone supplements are not thought to cause prostate cancer. However, the hormone does help existing prostate cancers grow and must not be given to men with prostate cancer.
If a man lives long enough, he will probably develop prostate cancer (up to 80%of 80-year-old men are found to have prostate cancer at post-mortem examination) so whether testosterone supplements will affect mortality in older men is unknown.
Cholesterol levels and production of red blood cells are affected by testosterone, and must be closely monitored, particularly during the first year of treatment.
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