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Male Menopause - Fact or Fiction?            

Why is it that the 'male menopause', otherwise known as the 'andropause', is still neither recognised nor treated by the majority of general practitioners, urologists or even andrologists? I suggest that the main reasons can be grouped together as historical, medical and marketing image problems, and illustrate how ideas come into fashion and go out of style in a cyclical fashion.

Historical Factors

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. This first clearly documented case of successful hormone replacement therapy inaugurated a century of attempts to use testicular transplants and extracts to rejuvenate the male, which has resulted in the dubious "monkey-gland" image of testosterone treatment which persists to this day.

It was only with the isolation and synthesis of testosterone 60 years ago that effective replacement therapy with this hormone became possible. Testosterone was immediately introduced into clinical medicine either as pellets of the crystals, which is still the most effective and convenient form of treatment available so far, or as the oral form methyl testosterone, which unfortunately is toxic to the liver and heart, and has adversely coloured the thinking of the two intervening generations of physicians.

Medical Factors

In 1944 what we now describe as the male menopause 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 Even with this excellent article, the condition and treatment with testosterone in general, other than in obvious cases of testicular insufficiency, failed to achieve general acceptance.

Because of this,  over 1000 men have been studied at the London AndroScreen Center complaining of symptoms which they or their GPs attributed to the male menopause. The nature of the complaints and their frequency were remarkably similar to those reported in the Heller and Myers study.

These included fatigue 82%, depression 70%, irritability 61%, reduced libido 79%, awareness of premature ageing 43%, aching and stiff joints in the hands and feet 63%, increased sweating especially at night 53%, and classic hot flushes 22%. Last but not least, 80% suffered erectile dysfunction, reduced early morning erections often being an early warning sign.

The age range of 31-80 (mean 54) was wider than that of the menopause in women (45-55) reflecting the importance of the wide range of factors influencing its onset. The overlapping associated factors appeared to be psychosocial stress (59%), alcohol (35%), injuries or operations, particularly vasectomy, (32%), medication (31%), smoking (26%), obesity (22%), infections, such as the orchitis caused by mumps and glandular fever, and prostatitis (11%) and impaired descent of the testes (5%).

The hormonal picture clearly demonstrated the reasons why this condition remains undiagnosed. Total testosterone, which is all that is usually measured in men complaining of these symptoms, was only low in 13% of cases. However, more detailed blood analyses showed that the Free Active Testosterone (FAT) obtained by dividing total plasma testosterone level by that of the important carrier protein, Sex Hormone Binding Globulin (SHBG), was decreased in 74%, mainly because of high levels of the later.

One obvious difference between the female menopause and the andropause is the contrast between the abrupt fall in oestrogen which generally precipitates symptoms in the former, with the apparently slow decline of total plasma testosterone levels with age in men. However, there is a range of factors which can cause a relative rather than absolute deficiency of testosterone in men from mid-life onwards. Free, biologically active, testosterone in the blood and tissues decreases markedly with age, mainly because of rising levels of a binding protein in the blood, which "Zaps" the testosterone before it can get into the cells to exert its many important functions. There is also decreased production of testosterone by the testes, because of stress, illness, low fat diets, and altered hormonal balance in the body due to ageing.

The findings in this cross-sectional survey indicated that impairment of the many actions of testosterone crucial to both vitality and virility causes symptoms of the Andropause to emerge when the FAT falls to a critical level of around 50%, or the total testosterone is subnormal.

There was a significant dose related relief of the andropausal symptoms with two oral forms of treatment, and especially with testosterone implants. The safety of the forms of testosterone treatment used in this carefully monitored group of men, particularly in relation to the heart, liver and prostate gland was confirmed by detailed serial tests at periods of three to six months for up to five years.

Marketing Factors

There are a variety of what can best be described as marketing problems connected with the image of the male menopause and the use of testosterone to treat it. Firstly the name of the condition, even if dignified with the medical title of Andropause, appears an unacceptable threat to their masculinity, their "macho" self-image. It is seen as the end of their life as potent males, as leaders and as lovers. While women are willing to discuss with each other, and with their medical advisors, their menopausal symptoms and HRT to mitigate them, men are remarkably reluctant to turn to either unless desperate.

Also, the condition is often incorrectly confused with the psychological traumas of the "Male Mid-life Crisis". Secondly, because of reports of the abuse of anabolic steroids by athletes, testosterone has suffered a very bad press. Together with deliberately exaggerated horror stories of their physical and psychological dangers, which have filled the newspapers at increasingly frequent intervals over the last twenty years, this "pharmacological arms race" has damaged testosterone's image.

Thirdly, there is the public perception of testosterone as the hormone responsible for undesirable male traits such as aggression and hypersexuality. The unfounded fear that such treatment will "bring out the beast in men", and turn them into rapacious monsters as portrayed by Jack Nicholson in the recent film "Wolf", holds many andropausal men, who unlike him cannot claim to have "retained my testosterone longer than most males", back from treatment.

Lastly, there is the same argument that women had to overcome in relation to HRT, that it was flying in the face of nature and they should learn to grow old gracefully. Given the wide range of benefits to psyche, soma and sexuality that oestrogens are being shown to offer postmenopausal women in adding life to years as well as years to life, increasing numbers see it more as modern science giving nature a helping hand. It seems likely that men will come to the same view of living their lives like alkaline batteries, going full charge to the end.

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