Male menopause, androgen deficiency and PADAM

Written by Dr John Dean, Specialist in Sexual Medicine, South Devon Healthcare NHS Trust

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:

hot flushes

sweating

mood changes

weight changes

breast changes

alterations in sexual response, such as vaginal dryness

changes in the level of sexual interest.

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:

Circulation and the nervous system

hot flushes

sweating

insomnia

nervousness.

Mood and cognitive (higher mental) function

irritability and tiredness

decreased sense of well-being

lack of motivation

low mental energy

difficulty with short-term memory

depression

low self-esteem

being easily frightened.

Masculinity and virility

decreased vigour and physical energy

diminished muscle strength.

Sexuality

decreased interest in or desire for sex

less sexual activity

poor erections

reduced quality of orgasm

weakness of ejaculation

reduced volume of ejaculated fluid.

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