Understanding andropause: The subtle hormonal shift in men

Hormonal fluctuations do not affect women alone. As they age, some men may experience them as well. Decreased libido, persistent fatigue, mood changes… symptoms that can signal a late-onset androgen deficiency, particularly testosterone, more commonly known as andropause.

“Testosterone deficiency can begin as early as age 40, but it most commonly appears around 60 to 65,” explains Dr. Charles Saab, a specialist in endocrinology and metabolic diseases. According to studies published by different scientific societies, mean serum testosterone decreases by approximately 1% per year after age 50.

Unlike menopause, which follows an average of five years of perimenopause and then occurs abruptly marked by the sudden cessation of estrogen and progesterone production in all women andropause is always progressive and affects 80% of men, although not all will experience noticeable symptoms.

“There isn’t an abrupt halt in testosterone production. However, this can occur in certain cases, such as hemorrhage, trauma, specific medical treatments, or the removal of testes. Men with chronic conditions such as obesity and diabetes may experience andropause earlier,” Dr. Saab insists. An unhealthy lifestyle including excessive alcohol consumption, heavy smoking, and a sedentary routine can also contribute to its development, from an epidemiologic perspective. Still, not all men with these habits will develop symptoms.

Recognizing andropause

Andropause manifests as “a decrease in male secondary sexual characteristics,” Dr. Saab notes. Symptoms include loss of body hair, reduced libido, erectile dysfunction, muscle loss, abdominal fat, persistent fatigue, depression, and lack of self-confidence. Over the long term, it can lead to osteoporosis.

If any of these symptoms appear and persist, it is strongly advised to seek the advice of a specialist. According to Dr. Saab, “the consultation starts with a questionnaire, routinely offered to all men starting at age 50, regardless of their medical background whether they have diabetes, high cholesterol, thyroid issues, or other endocrine conditions. The questionnaire helps assess sexual health, including erectile difficulties and the ability to achieve orgasm.”

Depending on the results and the patient’s medical background, relevant blood tests may be recommended. For non-diabetic men, for instance, a hypothalamo-gonadal assessment is performed to evaluate the hormonal axis that goes from the pituitary to the testes which regulates testicular function and male fertility. If the testes are impaired, testosterone levels will be low, while FSH and LH the pituitary hormones that help regulate testosterone will be elevated. In these cases, Sex Hormone Binding Globulin (SHBG) is also measured. SHBG is a protein that binds testosterone in the blood. During andropause, SHBG levels can rise, reducing the amount of free, active testosterone available in the body.

Conversely, if both FSH/LH and testosterone levels are low, the problem is usually of pituitary origin.  In such cases, the underlying cause must be investigated, as this is no longer a classic case of andropause. Possible causes include hemorrhage or a benign pituitary tumor causing compression.

Treatments

In some cases, a prolactin test is performed to rule out the presence of a proclatin-secreting pituitary adenoma. “This condition is relatively common in men in their 40s and 50s,” Dr Saab says. “In such cases, surgery or some medication is often recommended, as it can resolve the problem and effectively reverse the symptoms of andropause.”

If the problem lies in the testes, testosterone replacement therapy may be administrated via patches, oral medication, or injections. If the issue originates in the pituitary gland, synthetic FSH and LH may be prescribed, particularly in younger men who wish to preserve fertility.

“It is important to weigh the benefits and risks of treatment before administering it,” Dr. Saab stresses. “When there is a clear medical indication, therapy should be started without hesitation, especially since andropause can lead to protein loss including in bones and muscles and a decrease in overall muscle mass, including the heart. Consequently, andropause may contribute to heart failure if it is not already present.”

“However, testosterone therapy without a physiological need can be risky, as any form of androgen treatment carries a small risk of prostate cancer. In men with existing prostate cancer, testosterone therapy is strictly contraindicated,” he adds.

The good news is that andropause can be often delayed, particularly through a healthy lifestyle and, when medically indicated, appropriate treatment.