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The hormonal changes associated with menopause are often profound, affecting physical, mental, and social well-being. In much the same way, many men experience a critical drop in their testosterone level with symptoms that can impact their quality of life and overall well-being. 

While the condition associated with male menopause, also referred to as andropause, exists, the term andropause is perhaps a misnomer, similar to a popular board game: Chinese Checkers. While some similarities exist, Chinese checkers have nothing to do with China and are quite different from traditional Checkers. Similarly, some have used the term andropause to describe a male version of female menopause. While male and female "menopause" share similarities, they differ in many aspects. 

Right off the bat, unlike menopause, the root word meaning of andropause does not make logical sense. The word menopause means the ceasing of menstruation. "Meno" refers to the menstrual cycle, and "pause" refers to the cycle stopping–menopause involves a pause or stop in estrogen production, resulting in the inability to have children. On the other hand, andro means male, and pause referencing a stop in a cycle or testosterone ceasing does not make sense, as testosterone may decrease, but the production does not cease.

The term "male menopause" was first used in 1944 to describe complaints by aging males that seemed to mirror symptoms of menopause in women. Many of these similarities are still recognized. However, since men do not undergo the same biological process menopausal women experience, clinicians and researchers have not embraced the term male menopause and instead prefer late-onset hypogonadism (LOH).

The decrease in androgen hormone levels in menopause and andropause begins at roughly the same time. The female menopause transition starts between 45 and 55 and lasts about seven years. In most men, testosterone levels begin to decrease at about age 40, with an abrupt rise in testosterone deficiency between ages 45 and 50. In addition, menopause and andropause share many symptoms related to decreases in the androgen hormones estrogen and testosterone, respectively.

Female and male menopause often produce many of the same symptoms, including: 

• Irritability 
• Weight gain 
• Low sex drive and function 
• Sleeping problems 
• Depression 
• Fatigue 
• Loss of strength 
• Hot flashes

Many men in their 40s or 50s begin experiencing depression, decreased sex drive, erectile dysfunction, foggy mind, fatigue, increased fat, and decreased lean muscle mass. Since the onset of these symptoms can interfere with the quality of life, it is essential to find out the underlying cause and seek treatment. In addition to andropause, or hypogonadism, multiple causes may be responsible for these symptoms, including:

• Stress
• Depression and anxiety
• Lack of sleep
• Lack of exercise
• Smoking and excessive alcohol use
• Low self-esteem
• "Midlife crisis"
• Heart problems

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Low reproductive hormone levels and associated symptoms diagnose hypogonadism. Female menopause marks the end of the female reproductive cycle. In women, levels of estrogen, the primary female sex hormone that remains high for decades, take a plunge around age 50. In men, testosterone decreases gradually, at about 1% per year, beginning around age 30–it is so gradual that many men don't notice the effects for several decades.

The amount and rate at which testosterone levels decrease as men age varies, with men experiencing different levels of testosterone deficiency at different levels–most men do not experience hypogonadism. In addition, many men with low testosterone levels don't experience symptoms. Symptoms of male hypogonadism include: 

• Loss of strength and muscle mass
• Increased body fat
• Decreased energy and fatigue
• Decreased libido
• Erectile dysfunction

Most laboratories and physicians consider the "normal" total testosterone range from 300 to 1,000 ng/dL. Since some people may have normal total testosterone levels but low free testosterone, clinicians should evaluate both total and free testosterone. A free testosterone level of less than 50-65 pg/mL is generally considered low.

Late-onset hypogonadism happens more frequently in men who are obese or have chronic conditions such as type 2 diabetes. Researchers estimate that 35% of men aged 45 and 30-50% with obesity or type 2 diabetes have hypogonadism.

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Why is Testosterone So Important?

Testosterone is an androgen hormone secreted by the testes' Leydig cells in response to chemical messengers sent from the brain. Testosterone is responsible for male characteristics such as facial, pubic, body hair, and muscle. 

In addition, testosterone helps maintain sex drive, sperm production, and bone health. In addition, testosterone is responsible for sexual development, which includes testicular descent, enlargement of the penis and testes, and increasing libido. 

Testosterone also regulates secondary male characteristics, which lead to masculinity. Secondary sex characteristics include male hair patterns, vocal changes, voice deepening, and anabolic effects. In addition, testosterone stimulates red blood cell production.

According to urologist Nannan Thirumavalavan, M.D., "to give you a sense of how age is involved, less than 10% of all men younger than 50 have testosterone deficiency. In contrast, nearly half of men over 80 have low testosterone."

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When is Testosterone Replacement Therapy an Option?

Testosterone replacement therapy (TRT) aims to alleviate hypogonadal symptoms by restoring physiological levels of serum testosterone. If you have low testosterone levels with symptoms, the first course of action is to look at reversible factors that may be contributing. For example, diet, exercise, and sleep improvements may reduce or eliminate testosterone deficiency symptoms and increase testosterone levels.  

In addition, clinicians should eliminate reversible causes of low testosterone. For example, a decrease in testosterone may be a side effect of certain prescription medications such as:

• Ketoconazole
• Glucocorticoids
• Cimetidine
• Spironolactone
• Some antidepressants
• Chemotherapy
• Opioids
• Statins

If you are taking a prescription medication known to lower testosterone levels, your doctor may be able to put you on an alternative medicine.

Some medical conditions, which may be reversible, are associated with testosterone deficiency, such as:

• Obesity
• Hypertension
• Hyperlipidemia
• Chronic Obstructive Pulmonary Disease
• Rheumatoid arthritis
• Chronic kidney disease
• Alcohol abuse
• HIV
• Peyronie's disease

If you are a candidate for TRT, there are now multiple options, including a new, recently FDA-approved oral capsule.

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Is it Testosterone Deficiency or Normal Aging?

Serum testosterone levels gradually decline in virtually all men. However, the amount of decline and associated symptoms are variable. Recognizing the clinical importance of declining testosterone as a function of "normal aging" versus treatable testosterone deficiency is challenging and controversial. In older men, persistently low testosterone and symptoms related to low testosterone suggest treatable androgen deficiency.

The symptoms associated with testosterone deficiency are often nonspecific and can frequently be caused by other common disorders. For example, a study found that in older men who complained of sexual dysfunction, up to 25% had normal testosterone levels.

Treatment should be individualized and dependent on risks versus benefits in patients diagnosed with LOH. In addition to the traditional benefits of TRT on sexual function, mood, strength, quality of life, bone density, and obesity, evidence shows that restoring testosterone levels can reduce the risk of certain heart events.

Clinicians must weigh TRT's benefits against potential concerns such as prostate disease and increased red blood cells. 

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Consequences of TRT in the Absence of Hypogonadism

TRT can help reverse symptoms of hypogonadism, but it is less clear if testosterone benefits otherwise healthy older men. According to the American College of Physicians (ACP), testosterone might improve sexual function in older healthy men but may not improve other functions such as vitality and energy. 

The ACP recommends that physicians discuss with healthy patients with low testosterone whether to initiate TRT to enhance sexual and erectile function. Clinicians should inform patients of TRT's potential benefits, harms, and costs and consider the patient's preference.  In addition, if TRT is initiated for healthy patients with low testosterone, physicians should re-evaluate symptoms at 12 months, then periodically after that, and discontinue treatment if sexual function does not improve. The ACP advises against initiating TRT for age-related low testosterone to improve energy, vitality, physical function, or cognition since evidence shows little benefit. 

The American Urological Association guidelines state that the clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with signs and symptoms.

As some men age, their testosterone levels drop enough to develop symptoms such as low libido, erectile dysfunction, and other symptoms that negatively affect their quality of life, or LOH. If healthy lifestyle changes aren't enough to improve symptoms or raise testosterone levels, TRT is the treatment of choice for many men.

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