Among the many features characterizing the aging process is the progressive alteration in the hormonal environment. In women, this ovarian failure is known as menopause. It is predictable and clinically obvious and leads to a number of clinical and biochemical changes. In men, on the other hand, these changes are not universal and their manifestations are subtle. Male menopause has been termed andropause, but perhaps a better term is “androgen deficiency, or altered hormones in the aging male”. It is not only the sex hormones that are altered in the aging male as other hormones are also affected. While the manifestations of their deficiencies are difficult to separate, androgen deficiency is readily diagnosed and treated.
The world population doubled between 1950 and 1990 and should again double by 2025. Although this is a matter of concern for governmental planners, the most important and worrisome issue is the increased mean age of the population. In 1950 less than 5% of the population was over the age of 65, but by 2025, this figure will increase to over 15%. Thus, illnesses and infirmities affecting the aged will increase dramatically through the first quarter of the new century.
Andropause is characterized by 1) the well recognized alterations in libido and erectile function, 2) diminution in muscle mass and strength, 3) fatigue, 4) depression, irritability and diminution of mental acuity, 5) alterations in skin and hair distribution, 6) alterations in body fat distribution, 7) decrease in bone mineral density resulting in osteoporosis, and 8) hot flashes. Not all symptoms will appear either simultaneously or in all men and those that do appear will vary in intensity. True andropause is often seen in men undergoing treatment for prostate cancer that involves suppression of the male hormones, either chemically or surgically.
One of the best places to start is diagnosing male andropause is with a blood test to detect serum total testosterone (measuring the amount of testosterone). Although there are additional blood tests that can be performed, the serum testosterone is the best place to start.
Other hormones may be affected by aging including those involved with the endocrine system including the adrenal gland, melatonin (a product of the pineal gland) which plays a critical role in the regulation of bio-rhythms including sleep, growth hormone which declines over time and whose decline is linked to a decrease in muscle mass and strength, and possibly also leptin, a hormone which may share responsibility with androgens in maintaining a lean body mass. It is not believed that the corticosteriods change with age.
Testosterone replacement can be given via intramuscular injection, orally or transdermally (skin patch). Intramuscular injections are effective, safe and inexpensive but need to be repeated every 2 – 3 weeks and tend to have a roller-coaster effect (high levels during the first week after administration followed by a rapid decline). Some oral preparations have erratic absorption rates and the potential for liver toxicity, others are not available in the US; others are expensive and must be taken with certain types of foods. Testosterone patches are safe and effective but expensive. Their main drawback is the potential to develop dermatitis at the site of the application. Recently a testosterone gel was introduced in the US; while it may avoid dermatitis, it has the ability to be passed to others.
This is the most important aspect of androgen therapy. When a patient is started on testosterone supplementation, it is generally for life. Special attention must be paid to the prostate, both monitoring its size and any increases in prostate specific antigen (PSA). Contraindications to testosterone supplementation include patients with significant obstructive symptoms or suspected or documented prostate or breast cancer. Monitoring of other lab values including lipid profiles and liver studies is also very important. Sleep apnea can be exacerbated with testosterone supplementation, as can polycythemia (increase in the number of red blood cells) which can carry significant health risks in elderly men. Thus, the risks and benefits of testosterone replacement therapy must be carefully weighed before supplementation is begun.