Mens Health Issues

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Symptoms of Male Andropause

SYMPTOMS

The symptoms of male menopause are similar to the ones women experience and can sometimes be as overwhelming. However, the male menopause does not affect all men, at least not with the same intensity. Approximately 40 % of men between 40 and 60 will experience some degree of lethargy, depression, increased irritability, mood swings, hot flushes, insomnia, decreased libido, weakness, loss of both lean body mass and bone mass (making them susceptible to hip fractures) and difficulty in attaining and
sustaining erections (impotence).

For these individuals, such unanticipated physical and psychological changes can be a major cause for concern or even crisis. Without an understanding partner, these
problems may result in a powerful combination of anxieties and doubts, which can lead to total impotence and sexual frustration. A recent aging study showed that 51 % of normal, healthy males aged 40 to 70 experience some degree of impotence defined as
a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse. This problem cannot be attributed to the aging process alone, however, because well over 40 % of males remain sexually active at 70 years of age and beyond. Other factors, notably the co-existence of degenerative or other diseases, are culpable.

SYMPTOM CHECK LIST

Decrease in sex drive.
Lack of energy.
Decrease in strength and/or endurance.
Lost height.
Decreased "enjoyment of life."
Sad and/or grumpy.
Erections less strong.
Deterioration in sports ability.
Falling asleep after dinner.
Decreased work performance.
Men experiencing problems 1, 7, or a combination of any four or more might be
candidates for replacement therapy.

CAUSES

Although all the causes of male menopause have not been fully researched, some factors that are known to contribute to this condition are hypothalamic sluggishness, hormone deficiencies, excessive alcohol consumption, obesity, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems, notably mid-life depression. A general decline in potency at mid-life can be expected in a significant proportion of the male population. A relative increase in circulating levels of estrogen (which competes with testosterone for cellular receptor sites) can tilt the testosterone-estrogen balance unfavourably and can reduce the availability of testosterone to target cells.

TIPS TO COPE WITH CHANGE

Find new ways to relieve stress.
Eat a nutritious, low-fat, high-fiber diet.
Get plenty of sleep.
Exercise regularly.
Find a supportive friend or group and talk to them about what you're going through.
Limit your consumption of alcohol and caffeine.
Drink lots of water.

TREATMENT

Testosterone Replacement Therapy (TRT) must be always administered only by very responsible physicians and under strict case selection criteria and supervision. Testosterone must not be used as a tonic for vague complaints as it can cause serious side effects, including prostate cancer. The risk of prostate cancer with TRT has been much hyped. Recent evidence suggests that the fear of prostate cancer is perhaps
exaggerated, since prostatic disease is estrogen-dependent rather than testosterone-dependent. However, it is true that testosterone administered to a patient who already has cancer of the prostate can cause a flare up and aggravation of the disease. Hence the importance of thorough check-up and investigation before starting testosterone.

Patients with significant `menopausal' complaints should be taken up for investigation. Serum FAT (Free Available Testosterone) is measured in a pooled early
morning blood sample and, if low, testosterone therapy can be considered. Before starting testosterone, a complete general check up including a rectal examination is conducted followed by tests like the hematocrit, lipid profile, cardiac function tests, liver function tests, measurement of PSA (Prostate Specific Antigen)and a trans-rectalultrasound (TRUS). The important side effects of testosterone are
thrombophlebitis and hypercoagulability of blood, liver toxicity (with some oral testosterone preparations) and prostate cancer. These tests must be repeated at 3 or 6
monthly intervals for as long as treatment is continued.

Testosterone is available in many forms - oral, injectable, trans-dermal and implants. The oral route is generally not recommended because of the high risk of liver toxicity. Some newer oral forms of testosterone are purportedly absorbed through the lymphatics.
These bypass the liver and cause much less toxicity. Injectable testosterone is safe but the blood levels are not uniformly maintained and any excess is converted to estrogens, which is counter-productive since it might alter the testosterone- estrogen balance. Doses must
be tailored to the needs of the patient in order to achieve normal blood levels of FAT. A significant improvement in symptoms can be expected with proper therapy. More recently, patches, pellets, creams and gels have entered the fray. The choice of route and
preparation will depend on availability, safety, the socio-economic status of the patient, proven long term safety and efficacy and the preference of the patient and the prescribing andrologist.

In conclusion, it may be stated that the male menopause does exist. It affects many men over 40 years of age (sometimes earlier). It is not synonymous with the mid-life crisis though the two can co-exist and compound one another. Symptoms are gradual and usually not as pronounced as in the female. Early diagnosis and hormone replacement therapy can improve symptoms.

Impotence (in contradistinction to impaired libido) is not usually amenable to hormone replacement alone and will need further investigation and treatment. These
are discussed in What Every Adult Needs to Know about Impotence.

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HORMONE BALANCE IN MALES

by John R. Lee, M.D.

Commentary on an Article by Jerome Groopman, published in the New Yorker magazine, July 29, 2002

Mr. Groopman discusses the commercialization of “andropause,” a moniker that implies a fall in androgen hormones similar to the menopausal fall of estrogen in women. The commercialization comes via Unimed, a division of Solvay, a Belgian conglomerate that includes pharmaceuticals. Unimed hopes to broaden the concept of andropause to include men with symptoms of fatigue, low sex drive, depressed mood, or poor erections. Their product, AndroGel, is a 1% transdermal gel, i.e., containing 1 mg of testosterone per gram of gel. Their recommended dose, as listed by their three page ad in this weeks TIME magazine, is 5 grams of gel (5 mg of testosterone).

The author points out that FDA approval of AndroGel was given for treating rather rare disorders such as Klinefelter’s syndrome (a rare genetic disorder causing underdeveloped testes), or testes damaged by viral inflammation or trauma, and pituitary disorders that lead to loss of testicular function, and not for “andropause.” Once a drug is approved for sale, however, physicians can legally prescribe it for any clinical condition he thinks might benefit from it.

Mr. Groopman’s article describes the dichotomy between physicians who find it useful (and remunerative) for practically every man entering their offices, and medical scientists who are still uneasy about the definition of andropause and question the use of supplemental testosterone. Points of difference include the questionable value of blood tests and the wide variability of testosterone levels in men without any sign of andropause symptoms, the subjective nature of so-called benefits, as well as testosterone’s potential risk of heart attacks and prostate cancer, and the claims that testosterone prevents aging. Unfortunately, Mr. Groopman does not seem to understand that risk of hormone side effects is largely a matter of dosage.

In his conclusion, the author regards the present surge of testosterone replacement therapy by approximately a quarter of a million American men to be a vast, uncontrolled experiment, whose consequences remain uncertain. He feels that what is needed is large scale study involving “many thousands of men” over a period of many years, such as was done for women in the Women’s Health Initiative (WHI) study of conventional HRT.

Medicine’s Lack of Understanding about Male Hormone Balance

I find the article, written in the cool, cosmopolitan style so adored by the New Yorker magazine, to be glib and mistaken in its underlying hypotheses. Yes, there is a parallel with the problems uncovered by the recently stopped WHI study. The major problem is conventional medicine’s lack of understanding of the realities of hormone balancing. Any single hormone does not work in isolation – it works something like a member of a large orchestra with many different players. The question of testosterone’s role can not be determined, in most cases, by knowing merely its serum concentration. What is the right level for one person may not be right for another person. Absolute levels are deceptive. Far more relevant is the ratio between testosterone and estradiol concentrations. Testosterone is an antagonist of estradiol; it acts to oppose estradiol’s actions. Thus, a given estradiol level will lead to breast growth in a man with low testosterone, and not in a man with higher testosterone levels.

Testosterone and Estrogen in Men

It is well known that the estradiol level in 55-year old men, for example, is usually a bit higher than that of a 55-year old woman. The man, however, does not develop breasts because he has a higher testosterone level than women do. As men age, their estradiol levels gradually rise, whereas their progesterone and testosterone levels gradually fall. The hormone balance changes. These gradual changes lead to reduction in testosterone benefits and eventually to estrogen dominance. That is, his estradiol effects emerge since his testosterone level is not sufficient to block or balance them. Estrogen dominance stimulates breast cell growth and endometrial cell proliferation in women. In men, estrogen dominance stimulates breast cell growth and prostate hypertrophy. Estrogen dominance is responsible for the majority of breast cancers and is the only known cause of endometrial cancer in women. Since the male prostate is the embryonic equivalent of the uterus, is should not be surprising that estrogen dominance is also a major cause of prostate cancer.

Testosterone Supplementation in Men

Testosterone supplementation is the obvious treatment for men with testosterone deficiency relative to their estradiol levels. If the estradiol, progesterone, and testosterone balance that prevails in younger men (when they do not get prostate cancer) is a healthy one, why not restore the hormone levels in older men to that same healthy balance?

To achieve this desired goal of a healthy balance between these major sex hormones, one must learn how to accurately measure their levels. All steroid hormones are fat-soluble. When they circulate through the liver they wrapped up, so-to-speak, by a protein coating, a process known as protein binding. When protein-bound, the hormones are water soluble but less bioavailable. Being water-soluble, the protein-bound hormones pass through the kidneys and are excreted in the urine. The non-protein-bound hormone (referred to a “free” hormone) on the other hand, is the bioavailable form of the hormone. It is fat-soluble and is carried in blood by red blood cells rather than in the serum, that is the watery, non-cellular portion of the blood. When the blood circulates through the tissue of the salivary glands, the “free” hormone, whether in red blood cells or in the serum, filters through into the saliva, whereas the protein-bound form does not. If one wished to know the concentration of “free” bioavailable hormone in the blood, it is obvious that saliva hormone levels are more accurate and more relevant than serum hormone levels.

Serum vs. Saliva Holds True for Men Too

For reasons that escape rational thinking, conventional medicine persists in using serum tests rather than saliva tests. The results have been disastrous. When using hormone creams or gels, the hormone is absorbed through the skin and into the blood without first passing through the liver. Thus, they are essentially all absorbed in the “free” form. When given orally, they pass first through the liver and 90% of them become protein-bound. For this reason, transdermal dosing is at least 10 times more efficient than oral dosing. If one uses serum testing to measure the blood levels achieved by transdermal dosing, the test will fail to measure all the hormone carried by red blood cells. As a consequence, physicians are apt to greatly over-dose their patients.

When using saliva testing, it is found that the transdermal dose of testosterone when treating someone with testosterone deficiency is only 0.25-0.5 mg in women, and 1-2 mg in men. As the New Yorker article indicated, the transdermal doses of testosterone ranged from 5 mg to 100 mg a day. The same is observed in estrogen replacement therapy – the doses are generally all greatly excessive. The same hormone that brought good health without side effects when in normal endogenous levels will bring on very bad side effects when given in grossly excessive doses.

The problem is not the hormone, per se, the problem is the dosing.

Some physicians have attempted to measure “free” hormones in serum. Regardless of how well this is done, such tests fail to measure the “free” hormone being carried by red blood cells.

Use Only Bio-identical, Natural Hormones

The final correction that must be made is equally obvious – when treating someone with a hormone deficiency, use only bio-identical hormone. Altered, synthetic versions of our natural hormones will not do – they are foreign to the body, do not convey the same benefits as the real hormone, and all are fraught with undesirable side effects not conveyed by the real hormone.

Our problems in using hormones can be solved by the four guidelines summarized below:

Learn how to measure total “free” hormone.
Use physiologic doses rather than pharmacologic doses.
Use only bio-identical hormones.
Learn how to achieve hormone ratios that produce proper hormone balance.
Failure to follow these three guidelines is the principal cause of the problems exposed by the Women’s Health Initiatives. The makers of AndroGel use bio-identical testosterone but their dosing regulations are faulty and dangerous. Any good compounding pharmacist can make up a testosterone cream that will more easily supply the right dose of testosterone in men with estrogen dominance due to testosterone deficiency.

For more information on this topic, please read Hormone Balance for Men a booklet by John R. Lee, M.D.