From: www.tiscali.co.uk/lifestyle/
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Does the male menopause exist?
Both men and women undoubtedly experience symptoms related to reduced production of sex hormones (sex steroids) as they get older. These changes are inevitable, but affect individuals differently. Some people experience very few symptoms, whereas others are completely disabled by them. It is important to remember that this fall in sex hormone production is a natural process and not a disease. However, many unpleasant natural processes can be helped with medical treatment just as effectively as diseases.
In women, the fall in sex hormone production is quite abrupt and usually occurs over a few months or years in their 40s or 50s. The ovaries dramatically reduce their production of oestrogens (the female-determining sex steroids), a woman's periods become disturbed and eventually stop (thus the term, menopause). Menopausal women may also experience:
In men, the fall in sex hormone production is much more gradual, developing over decades rather than months or years. Mental and physical changes can occur, but they are much more subtle in onset and can easily be missed. As such, the term 'male menopause', or andropause, is probably not accurate. Instead, experts prefer to talk about 'partial androgen deficiency of the ageing male' (PADAM).
Production of testosterone (the principal male-determining sex steroid) falls gradually and progressively from the 40s onwards. Other hormones are also affected, including growth hormone, insulin-like growth factor-1 (IGF-1), parathyroid hormone and melanocyte-stimulating hormone. The significance of these changes is not well understood. Other endocrine (hormonal) disorders, such as hypothyroidism (thyroid underactivity) and diabetes, are also more common with advancing age but are better understood.
Lack of research
A great deal of effort has gone into research on treatment for
the menopause in women, but very little research has been undertaken into PADAM
and the effects of treatment. A very considerable body of evidence supports the
use of oestrogen replacement in menopausal women, but hormone supplementation
in ageing men is highly controversial. A little evidence shows that such
therapy is beneficial and equally little shows that it isn't! A similar
situation prevailed over 30 years ago when hormone-replacement therapy (HRT)
for women was first proposed. As a result, much of the information in this
article is based on observation, experience and small studies, so must be
treated with some caution. Only time and further research will confirm the
role, if any, of hormone supplementation in PADAM
What are androgens?
Androgens are steroid hormones with specific effects on tissue
growth (muscle, fat, skin, hair and others) and brain function. They play
important roles in both men and women, but are produced in much larger
quantities in men. In men after puberty, the majority of androgens are produced
by the testicles, mainly as testosterone. Other androgens -
dehydroepiandrostenedione (DHEA), its sulphate (DHEAS), and dihydrotestosterone
(DHT) - are produced in the adrenal cortex, skin and liver. Several man-made
androgens are also available.
Androgen deficiency can occur in younger men, and even in children and adolescents, as a result of testicular damage, genetic disorders or metabolic disorders. It is very important that they receive expert assessment by an endocrinologist at an early stage and receive androgen replacement therapy. This is established medical practice and uncontroversial, unlike androgen supplementation therapy in PADAM.
What are the symptoms of androgen deficiency?
The symptoms of PADAM are numerous and non-specific, so it is
not an easy condition to diagnose. They include problems with:
Mood and cognitive (higher mental) function
Masculinity and virility
Sexuality
Physical features include
Several other effects on body chemistry and metabolism occur,
such as:
What are the consequences of androgen deficiency
(PADAM)?
The symptoms, signs and metabolic consequences of androgen
deficiency are largely reversible, and can be corrected by replacement
therapy.
How is androgen deficiency (PADAM) diagnosed?
The problem with measuring testosterone levels
Testosterone is released into the bloodstream in pulses, and
levels vary through the day (diurnal variation). In general, the testicles
release more testosterone in the morning than later in the day. Blood samples
should therefore be taken between 8 and 10am, and at least two separate,
consistent results are needed to establish that there is a problem with
testosterone levels.
About 60-70 per cent of the total testosterone is tightly bound
to a protein, present in the blood, called sex hormone binding globulin (SHBG).
This protein-binding is a common way in which hormones are transported in the
bloodstream and it is effectively a circulating store of testosterone. The
testosterone only becomes active when the link to SHBG is broken, and this is a
process which occurs at a certain rate all the time. Older men produce
relatively more SHBG, as do heavy drinkers and men with thyroid disorders, thus
reducing the amount of 'free' testosterone.
Another 30-40 per cent of the total testosterone is more loosely
bound to another protein, called albumen. Testosterone bound to albumen is also
inactive, so free testosterone probably accounts for only 1-2 per cent of the
total. Measurement of total testosterone is therefore a poor measure of active
testosterone. Free testosterone levels are expensive to measure and are not
widely available.
Free Androgen Index (FAI = total testosterone/SHBG x100) is an
alternative measure of androgen state that is not as reliable as free
testosterone, but is better than relying solely on total testosterone.
All this is confusing for doctors, too!
Treatment
Men receiving testosterone supplements should have regular
medical checks every three months for the first year of treatment, which must
include a rectal examination of the prostate gland (which sits beneath the
bladder producing fluids that nourish and protect sperm) and blood tests. After
that period, at least yearly checks are necessary.
Testosterone preparations
Capsules do not always provide steady blood levels. Patches are
probably the easiest form of testosterone to take, although they are reasonably
expensive. All these preparations can be prescribed on the NHS, although a GP
would be unlikely to agree to prescribe these mediations for PADAM without a
specialist's advice.
Side effects
Considerable controversy exists over the effect of testosterone
upon the prostate gland. Men with abnormally low levels of testosterone have
small prostate glands. Replacement therapy causes the prostate to grow to about
the average size predicted for their age. Current evidence indicates that
testosterone does not cause abnormal prostate enlargement (benign prostatic
hypertrophy). Testosterone should not be given to men who have symptoms of
restricted urine flow (urinary outflow obstruction) due to prostate
enlargement.
Testosterone supplements are not thought to cause prostate
cancer. However, the hormone does help existing prostate cancers grow and must
not be given to men with prostate cancer. If a man lives long enough, he will
probably develop prostate cancer (up to 80 per cent of 80-year-old men are
found to have prostate cancer at post-mortem examination) so whether
testosterone supplements will affect mortality in older men is unknown.
Cholesterol levels and production of red blood cells are
affected by testosterone, and must be closely monitored, particularly during
the first year of treatment.
Conclusions
Changes caused by PADAM could potentially affect health in
several ways:
No definitive test for PADAM exists. Low blood levels of
testosterone alone are insufficient to make the diagnosis. The combination of
several different suggestive symptoms and physical signs, together with low
blood levels of testosterone, should raise suspicion that PADAM is
present.
It would be comforting to think that a simple blood test could
identify androgen deficiency. Unfortunately, this is not the case. Widespread
disagreement exists over what is the normal range of testosterone levels and
what, exactly, should be measured in the blood to assess androgen deficiency.
The existing 'normal' range for total testosterone is based upon statistical
analysis of pooled samples from all men, including those who might have PADAM.
So 'normal' testosterone levels are not necessarily the same as healthy
levels.
Many doctors do not believe that PADAM exists and will not offer
treatment. Others are 'believers' and see it everywhere. At present, a
practical approach is probably the most helpful. If multiple symptoms of PADAM
are present and FAI is below normal or in the lower part of the normal range, a
'therapeutic trial' of testosterone supplement therapy for up to three months
can be worthwhile. If there has been no improvement in symptoms, despite a rise
in FAI after three months of therapy, then continuation of treatment is
probably not worthwhile. If there is an improvement in symptoms, persevering
with treatment is worthwhile for as long as the improvement is maintained. A
very high placebo response to treatment probably occurs, so it is important to
check that the improvement is maintained over time.
Testosterone is available as:
Headache, weight gain, acne, increased aggression and
male-pattern baldness have all been reported with testosterone treatment, but
are uncommon if free testosterone levels are maintained within the normal
range.
The long-term benefit of testosterone supplements in older men
with symptoms of PADAM is unclear. However, testosterone is probably worth
trying in men with disabling symptoms, provided that they are properly
counselled and receive adequate follow up. More research is urgently needed to
clarify this controversial area.
The documents contained in this web site are presented for information purposes only. The material is in no way intended to replace professional medical care or attention by a qualified practitioner. The materials in this web site cannot and should not be used as a basis for diagnosis or choice of treatment. Conditions for use
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