Andropause Revisited By Carlon M. Colker, M.D., FACN
We know that women experience menopause— a condition whereby the defining female physiology begins to shut down and menstruation ceases, as a woman waves goodbye to her childbearing years. Fat gain, wrinkles, a double chin and brittle bones are coupled with hot flashes, facial hair growth and sagging breasts. Not your problem? Well, it is if you're married to it! But all joking aside, men don't exactly escape aging unscathed, either. While men don't suffer menopause, they do suffer a parallel form of shutdown often referred to as 'andropause.'
When a man is in his 20s, he cruises through life feeling the benefits of ample testosterone coursing through his veins. Young and virile, seemingly invincible and impervious to the ills that others around seem to be suffering from, young men find the ravages that older men suffer from almost laughable. There was a time when almost all of us thought the ills of aging would never come knocking on our doors. Such is the naiveté of youth. But then it happens. The male armor begins to gradually show signs of weakening. The once-seemingly invincible foundation begins to crack. Andropause has arrived!
Maybe it starts with a bit of fatigue. Then, despite your efforts to train harder, heavier, and with more frequency, you find your weights dropping, your stamina fading, and you simply struggle to get your ass in the gym. Forget about extreme muscle— you can't even get an extreme hard-on! Dragging through your workouts becomes a monumental task. Your motivation sinks as you begin to experience difficulty sleeping. Then, perhaps the most troublesome of all, your sex drive grinds to a complete halt (Table 1.1).
Signs and Symptoms of Andropause
Common Symptoms Rarer Symptoms
This all-too typical story is a classic description of the unwelcome arrival of andropause. Yikes! What a bummer. As if it isn't enough dodging the bullets of cardiovascular disease, cancer and prostate problems as we men get older! Now we've got a male version of menopause to contend with.
The concept of a 'male menopause' is not a new idea. In fact, I wrote about it years ago. Though little has changed in terms of defining it, we know quite a bit more about how to handle it. This once-vague symptomatology in otherwise healthy, older men was described nearly half a century ago. But over the years, physicians have become more adept at identifying these cases, and the public has become more educated.
Andropause has traditionally hit men in their 50s and 60s. But in recent years, with more aggressive testing and physicians who are more familiar with the disorder, cases of andropause in men as young as their mid-30s are cropping up in record numbers. We're not sure what causes andropause, but we believe that genetic pre-programming plays a big role. Nonetheless, there are many factors that influence this condition that cause it to occur at an earlier age— while making the symptoms far more severe and seemingly unlivable.
One thing is for sure— excess stress in your life as a result of everything from financial difficulties, spousal pressure, to work strain can 'spur on' andropause. Interestingly, a high degree of physical stress can also be a precipitating factor. I've seen quite a number of individuals whose andropause is caused simply by being overtrained. Heavy weight training at high frequency puts different demands on the body than low-intensity cardio. Some guys can't get themselves out of the gym or even find the self-control to shorten their workouts. In fact, most of these deluded souls have convinced themselves that they are actually not working out hard enough, or in the gym long enough!
This mentality leads to one of the most peculiar, addictive and destructive cycles a sports physician can witness. The addiction to working out is driven by a self-perpetuating fear and anxiety that guys need to do more to escape their predicament, rather than by some achieved pleasure from the activity. If this sounds like it's happening to you, back off your workouts for a while and see how you feel— before the 'itch' to train excessively consumes you and brings out full-blown andropause. As a norm, I usually suggest never training more than two days in a row without at least a day off.
Testing for andropause can be tricky if your doctor is not familiar with this area of medicine. There are several blood tests your physician can perform that are extremely helpful in pinpointing the diagnosis (Table 1.2). The types and priority of these tests performed at our centers have changed over the years, and warrant revisiting. Although testing must be individualized for each person to rule out any number of possibilities, there are some specific common tests and several additional tests that we have found quite useful.
Blood Testing for Andropause
Common Screening Tests Additional Tests
Sex Hormone-Binding Globulin
PSA (Total, Free, and Percent Free)
TSH, T4, and T3
In terms of treatment, there are three basic approaches commonly selected by physicians experienced in treating andropause (Table 1.3). The first is the conservative approach, which involves restructuring the diet and activities of daily living. Although applied to nearly everyone, this approach is one I commonly use with younger to middle-aged patients, individuals where considerable life stress seems to be precipitating or magnifying the condition, and those with overtraining syndrome, which I've mentioned. The gist here is to reduce carbohydrates in the diet (especially those from refined sugar), increase fiber content, and focus on getting more healthy fats from fish oils. This approach is synonymous with a healthy lifestyle.
Encouraging more rest, addressing sleep quality and quantity, encouraging travel vacation/time off, exercise restructuring, massage therapy, yoga, and occasionally a course on stress management can also work wonders in very mild cases of testosterone suppression.
In mild-to-moderate cases of andropause, oftentimes supplementation of the non-prescriptive sort is warranted. In such cases, the testosterone precursors of dehydroepiandrosterone (DHEA) and occasionally androstenedione are logical choices. There are also a host of other non-prescriptive homeopathic substances like Testis compositum, Cerebrum compositum, Coenzyme compositum and Galium-Heel. One must be careful with these substances, because of less-known safety concerns and their ability to form estradiol (the female sex hormone). We have found that this approach meets with little success, tends to be a 'dead end' and we end up using testosterone therapy. So it's not an approach we endorse anymore, but one we will try in rare cases where a patient is firm about wanting to give it whirl before turning to medication.
The third approach in the treatment of andropause involves supplementation with prescription substances. The most logical and common choice is testosterone, because it is so often the case that a deficiency of this hormone is the issue. During evaluation, it is critical for your physician to assess the nature of the deficiency and whether it is occurring at the level of the testes or higher up (thus, the need for testing pituitary hormones LH and FSH). Coupled occasionally with fertility testing and a psychosocial assessment, this information will dictate the best course of action.
Almost invariably, the treatment is to use testosterone therapy in some form (gel, patch or injection). In some cases when we need to coax the pituitary-testicular axis back into action, we use fertility drugs like Clomid or human chorionic gonadotropin (HCG). In recent years, Clomid has been used both in our practice and in numerous fertility clinics around the country— with a dramatic increase in frequency. This is because of its success in boosting testosterone as well as sperm count, whereas testosterone therapy may actually reduce sperm count over time— which is why so many heavy testosterone abusers end up infertile.
Treatment Possibilities for Andropause
• Conservative Approach (for mild cases): Restructuring diet and activities of daily living.
• Supplementation With a Non-Prescriptive Approach (for moderate cases and rarely used with success): Trial of DHEA supplementation (oral), androstenedione supplementation (oral or gel), or homeopathic remedy.
• Prescriptive Approach (for moderate to severe cases): Testosterone replacement (gel, patch or injection), human chorionic gonadotropin (HCG) or Clomid.
Andropause is a very real and treatable condition that's being diagnosed in an ever-increasing number of otherwise-healthy males. It is not just important to address this issue because you want to keep your quality of life in the form of muscle mass and hold on to your big bench press for a few more years. Rather, it is of critical importance because of the health problems that come from missing the diagnosis. In addition to what was mentioned, decreased bone density, anemia, insulin resistance, depression, memory loss, and frailty are all waiting— if the issue of andropause arises and is not properly addressed.