A no-name condition that affects 487,000 men per year… It’s not your wife’s menopause
Hot flashes and lackluster libido have long frustrated menopausal women, but men aren’t immune to the vagaries of dwindling hormone levels, either. While menopause is clearly defined and predictable in women, it is an insidious yet relentless process dogging every aging male—and right now, there is no miracle cure.
Exiting the Estrogen Express
Beginning at puberty, a woman’s ovaries steadily produce estrogen, the female sex hormone. The cyclical production of estrogen and other related hormones causes her body to mature and ensures fertility while protecting her from weak bones and soaring cholesterol levels among other things. Then, at about age fifty, estrogen production stops abruptly, seemingly going from sixty to zero in nothing flat and signaling the onset of menopause. Men, too, experience a drop in sex hormones, but their trip is more akin to coasting to a gradual stop.
The Testosterone Timetable
Soon after conception, babies destined to become boys begin producing testosterone. The hormone level remains high throughout development but decreases just prior to birth when a boy’s level is only a bit higher than a girl’s. Except for a brief rise in testosterone between three and six months of age, the level remains low until puberty when the brain signals the testicles to begin full-scale production.
Testosterone is the most potent of the male hormones known collectively as androgens. The resulting hormonal surge produces the physical and metabolic changes characteristic of men such as a deepened voice, bulkier muscles and stronger bones and it stimulates the bone marrow to produce red blood cells. Of course, testosterone, like its female counterpart, estrogen, is responsible for sexual maturation. It initiates and maintains sperm production, sex drive, and sexual performance, but testosterone also has a dark side.
For example, in the liver, testosterone causes the liver to crank out LDL cholesterol, the “bad” fat that sticks to the lining of the arteries promoting strokes and heart attacks. Dihydrotestosterone (DHT), a testosterone byproduct, also creates problems for men.
Signs and Symptoms of Low Testosterone
According to studies, 487,000 men will develop testosterone deficiency each year. While doctor’s choice of a name for the condition may vary, most physicians agree that treatment is controversial and should be limited to men with low levels who are also experiencing symptoms.
- Decreased sexual function
- Low red blood cell count (anemia)
- Depression and/or mood changes
- Decreased bone density
- Decreased energy
- Loss of muscle mass and strength
- Increased body fat
- Memory loss
In the skin, DHT causes acne and is the agent responsible for balding heads and hairy chests. In the prostate, however, its effect is more ominous, leading to benign prostate hypertrophy (BPH) and in some men, prostate cancer. On the other hand, low androgen levels create problems as well – problems that may start sooner than is realized.
While testosterone levels peak at age seventeen, for most men it begins a gradual decline of one percent per year starting around age 40. For example, a seventy year-old man’s testosterone level may decline by 30%, a decrease that may or may not be symptomatic. However, by age 80, one in two men is deficient in testosterone.
While it sounds straightforward, it’s not easy to obtain an accurate testosterone level. Currently, the normal level ranges from 300 to 1,000 nanograms per deciliter (ng/dL), but the level fluctuates depending on the time of day and how the hormone is measured. Furthermore, active testosterone travels through the blood stream unattached to other molecules while the inactive or ineffective form is attached or bound to a protein carrier. The more commonly available testosterone tests do not differentiate between free and bound testosterone, which makes it difficult to diagnose those men with levels truly below normal.
Even if a man is low in testosterone, his doctor may not diagnose his condition because the medical community is still at odds over the idea of male menopause. In fact, physicians can’t even agree on a name for the condition.
Male menopause, androgen decline in the aging male (ADAM), partial androgen decline in the aging male (PADAM), late onset hypogonadism (LOH), testosterone deficiency syndrome (TDS): These are all names for the gradual decline in testosterone that occurs with aging and is associated with symptoms.
To Treat or Not to Treat
Physicians know that testosterone replacement due to testicular failure, or hypogonadism, is beneficial, but treating the normal decline of aging remains questionable. Short term studies have shown that although testosterone replacement therapy (TRT) does improve muscle mass, red blood cell counts, and mood, it also increases the prostate-specific antigen (PSA) level, causing concerns over a potential relationship between TRT and prostate disease.
When it comes to prostate cancer, however, studies have so far failed to show that TRT is harmful, but researchers remain cautious and are not fully convinced that giving testosterone to otherwise healthy men is a good idea. More studies are needed to determine how testosterone supplementation affects the cardiovascular system. While anemia may respond well to TRT, increasing the red blood cell count above normal can promote clotting, posing potential problems for men already at risk for vascular disease. Other studies suggest that some men may develop sleep apnea due to TRT. So when should a man receive treatment for testosterone deficiency syndrome?
No Bitter Pill to Swallow
In general, TDS is recognized as a testosterone level below 200 ng/dL combined with any of the associated signs and symptoms. The physician will likely obtain two or three early morning testosterone levels to verify the diagnosis before initiating treatment – but a man should not expect him or her to give a prescription for a daily tablet.
Contrary to what men may think, low testosterone does not generally cause erectile dysfunction (ED). Instead, ED is most often a complication of diabetes, high blood pressure or vascular disease.
Oral doses of testosterone are metabolized by the liver where the drug is sometimes toxic, so pills are avoided. Instead, testosterone is administered as a gel, patch, intramuscular injection, or pellets implanted below the skin. Each form has its pros and cons, but no matter how a man receives testosterone, his doctor will monitor him closely for possible complications and side effects. However, if he or his doctor is reluctant to supplement with testosterone, there are things a man can do to lessen the symptoms of TDS.
Treating TDS without Testosterone
- Consume an adequate amount of protein to support muscle mass.
- Combine aerobic, resistance, and strengthening exercises regularly to build muscle strength and mass and bone density.
- Take 1200 mg of calcium and 800 IU of vitamin D daily to prevent osteoporosis.
Menopause for a woman is an abrupt collision compared to the slow, subtle decline in hormones experienced by men, but both sexes agree that life is better under their influence. Today, testosterone deficiency and male hormone replacement remain controversial but at least men and their doctors are beginning to recognize that the problem exists. No matter the debate, no one is arguing that the journey with less testosterone is a rough road to travel.
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"A no-name condition that affects 487,000 men per year… It’s not your wife’s menopause"
Dr. Thomas has been board certified by the American Academy of Family Physicians since 1990. She is a member of the American Medical Association and the North Carolina Medical Society. She is a columnist for the Washington Daily News in Washington, N...