March

Male menopause

Richard, a 76 year old man, was referred to me by his GP with generalized tiredness, sleep problems and feeling low in mood. He'd already had treatments with antidepressants with very little improvement, and had been seen by various specialists in the last 2 years: his many investigations did not show anything to worry about.

During the comprehensive assessment I gathered that in the last 10 years he suffered many broken bones. Some were results of accidental falls, but others were not so easy to explain. This led me to think that he might have an osteoporosis, which is a brittle bone condition. The commonest cause of osteoporosis, both in men and women, is menopause.

Male menopause also known as andropause, testosterone (T) deficiency, androgen deficiency of the ageing male and late-onset hypogonadism.

The term applies to hormonal changes that happen with ageing in a male body as a result of low testosterone production by the testes. Unlike with women, the changes are gradual, and develop over many months or years and might result in delayed diagnoses. The symptoms are very non-specific: decreased energy, motivation, initiative, poor concentration and memory, mild anaemia, reduced sexual desire, feeling of sadness and many others, including osteoporosis and fractures. Physical changes include lower muscle mass and strength, increased fat, swollen and tender breasts, also known as gynaecomastia, hair loss and even hot flushes.

Before rushing to the GP to check T levels it is important to remember that older men do have lower levels, although medical conditions such as diabetes and obesity may cause the T levels to fall too. Between the ages of 40 and 70 the T levels decrease by approximately 1.2% every year. By the age of 70, the levels might have dropped by 50%. However, in one study only 9.4% of men aged 60-80 years were actually diagnosed with clinical hypogonadism (low T levels+symptoms). Most men do not experience major changes with lower hormone levels and adjust to them without problems.

If male menopause is suspected a visit to GP is essential. There has to be an honest discussion about symptoms, as older persons are at times reluctant to talk about their sex life, and generally tend to blame everything on "old age". A comprehensive assessment and blood tests measuring T levels will help to determine if the symptoms are truly due to the lower levels of hormones as medical conditions such as low thyroid hormone levels or medication side effects may be responsible for many symptoms seen in male menopause too.

Some men in order to help their menopause might get tempted by hormonal supplements and other "anti-ageing" miraculous remedies. Whereas there is no clear evidence that they help, some actually may be dangerous and can cause cancer when used long term.

Hormonal replacement with testosterone is the choice of treatment for male menopause but it is not for everyone. Testosterone replacement therapy may increase the risk of prostate problems, contraindicated in patients with severe heart problems and obstructive sleep apnoea (a condition where there is a problem with the collapse of the airways at night due to the anatomy of the neck). Once it has been decided that testosterone is the right treatment is can be given as an injection into a muscle, as a patch or applied to skin as a gel. Regular monitoring by checking that symptoms are getting better and doing specific blood tests such as PSA (prostate specific antigen) is very important.

Richard's blood tests showed very low T levels and this amalgamated with his presenting symptoms led to the diagnoses of male menopause. After careful consideration of all the risks and benefits he was started on treatment with testosterone injections. When he came to see me 3 months later Richard was delighted with the treatment and now has enough energy and enthusiasm to babysit his little granddaughter 3 times a week.

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