Is there such a thing as male menopause?
Andropause, the male equivalent of menopause, is a much more gradual event than the relatively sudden loss in women of the female hormone estrogen. In the male, the process is more subtle, but no less disturbing when it occurs.
While it is normal for a man’s testosterone to gradually wane over time, in some men the process is steeper and more dramatic, with a significant loss in sexual desire, strength and muscle mass, as well as the onset of depression or loss of joie de vivre (the “joy of life”).
What are the symptoms and risks of low testosterone in men?
While there are a myriad of symptoms that may occur, the following are the most common:
- less “drive”
- loss of sexual desire
- difficulty in either getting or maintaining an erection
- loss of muscle mass
- low-grade depression
What therapy may be helpful?
Andropause always involves the excessive loss of the male hormone testosterone, so the cornerstone of therapy involves testosterone replacement or supplementation. Adjunct therapeutic modalities should include lifestyle work involving proper diet (smaller portions of complex carbs and protein, more of a plant-based diet), stress reduction, and most certainly an ongoing, flexible, regular exercise routine. Some specific herbs and supplements may be marginally helpful. Testosterone alone won’t do it; the lifestyle work is imperative!
What are the different delivery systems for testosterone in men and the advantages and disadvantages of each?
Testosterone may be given as oral capsules (not a good way as it's poorly absorbed), transdermal cream, gel or patches, regular (every 1-2 weeks) injections, and as time-release pellets injected under the skin of the buttocks/hips.
The advantages of cream/gel/patches are ease of use and relatively low expense; disadvantages include often inadequate testosterone tissue levels and the necessity of daily usage, as well as the possibility of transfer of the testosterone to the skin of another person (female partner, child), causing adverse side effects.
The advantages of shots are excellent tissue levels; disadvantages include the inconvenience of having to get a shot every 1-2 weeks and the expense therein if you are unable to give your own shots.
The advantages of pellets are the fact that they need to be inserted only every 3-4+ months (3 times/year is average) and that they maintain a relatively stable level of the hormone; disadvantages are occasional pain or infection in the insertion site and symptoms of too much or too little testosterone if your practitioner doesn’t quite get the dose right.
How should your doctor test you for low testosterone? What other lab tests are helpful?
Not by solely doing a testosterone lab test! The normal range of a man’s testosterone is so broad that most men fall within that range, but some still may have functionally low testosterone. Do not take “your testosterone is normal for your age” as an answer!
The proper tests are a total, free and bioavailable testosterone, including a “SHBG” (sex hormone binding globulin) level. Many men may have decent total testosterone levels but have elevated binding proteins such that the “free” testosterone actually available for use in their system is significantly lowered. Other important testing parameters are “LH” (testing pituitary gland stimulation of the testes), “PSA” (testing for possible prostate hypertrophy of tumor), TSH (testing for thyroid levels), and testing for diabetes and cholesterol.
What is the connection between testosterone levels, erectile disfunction, and incipient coronary vascular disease?
Recent evidence-based research has made it clear that chronically low testosterone is an etiological factor in heart and cardiovascular disease and certainly is a causative factor in male osteoporosis. Additionally, since the penile artery – which fills the penis with blood thereby causing an erection – is a narrow artery, if a relatively young man (40’s or 50’s) experiences erectile difficulties, this may be an early sign of incipient coronary vascular disease and should be investigated. I have caught a couple of young men who were “heart attacks waiting to happen” whose only presenting issue was erectile problems at a relatively young age.
Who is the right health care practitioner to visit for Andrology issues?
See only a practitioner who is interested in, and trained in, male hormonal issues (Andrology). Few family practitioners or internists are so trained or interested, and only a modest percentage of urologists have an interest in the area. Ask specifically if the practitioner is interested and trained in Andrology issues.
What therapies are there for erectile difficulties in men?
We all are aware of the various erectile meds for men (Viagra, Cialis, Levitra, etc.), but these agents work poorly in the face of low testosterone. My first recommendation for erectile therapy is to have a thorough and candid discussion of the problem with a health care practitioner, whether it be your PCP, your urologist or another person trained in Andrology who has the time, interest and personality to work with these issues.
That said, my recommendations include:
- Therapy to tease out exactly what are your issues, mental, hormonal, physical and relationship-wise, so as to outline a multidimensional treatment plan
- A positive, workable exercise, stress-reduction and dietary plan
- Testosterone supplementation if warranted
- An erectile drug, if warranted
What medical risks are inherent with chronically low testosterone?
These include, but not necessarily limited to osteoporosis, depression, fatigue, sexual disinterest and erectile dysfunction, cardiovascular disease, balance problems, or loss of muscle mass.
What can or should be done to prevent testosterone from being metabolized into excessive estradiol or other offensive metabolic byproducts?
I recommend the supplement DIM (diindolemethane), the active ingredient found in cruciferous vegetables (broccoli, cauliflower, cabbage, etc.) to all men taking supplemental testosterone. If testosterone supplementation suppresses my patient’s normal endogenous testosterone production by suppressing his pituitary gland (LH production) or causing excessive metabolism of testosterone to estrogen (estradiol), I recommend the addition of either anastrazole, clomiphene or tamoxifen.
What are the risks of testosterone therapy in men?
A risk is present only if too much testosterone is given, or if it is given to a man who already has plenty. Increased risk of heart attack is seen in men with too much, as well as too little, testosterone. Aggression, irritability and hair loss may also be noticed in men given too high a dose of testosterone.