What is Andropause?
The impact of decreasing androgens is known as andropause, also called "male menopause" or PADAM: Partial Androgen Deficiency in the Aging Male. It is a normal part of aging, although for some men, it is accompanied by a gradual and undesired decline in their sexuality, mood and overall energy. Sometimes it can even expose men to more serious health risks.

By the time men are between the ages of 40 and 55, they can experience a phenomenon similar to the female menopause, called andropause. As with women, andropause in males begins at a time when life often offers some of its greatest rewards. But unlike women, men do not have a clear-cut signpost such as the cessation of menstruation to mark this transition. Andropausal body changes occur very gradually in men and may be accompanied by changes in attitudes and moods, fatigue, a loss of energy, sex drive and physical agility.

What's more, studies show that the decline in testosterone during andropause can actually put one at risk for other health problems like heart disease and weak bones. Since all this happens at a time of life when many men begin to question their values, accomplishments and direction in life, it's often difficult to realize that the changes occurring are related to more than just external conditions. Attitude, psychological stress, alcohol, injuries or surgery, medications, obesity and infections can contribute to its onset.

Although with age, a decline in testosterone levels will occur in virtually all men, there is no way of predicting who will experience andropausal symptoms of sufficient severity to seek medical help. Neither is it predictable at what age symptoms will occur in a particular individual. Each man's symptoms may be also different.

Is this a new phenomenon?
Yes and no. In fact, andropause was first described in medical literature in the 1940's. So it's not really new. But, our ability to diagnose it properly is. Sensitive tests for bioavailable testosterone weren't available until recently, so andropause has gone through a long period where it was underdiagnosed and undertreated.

Now that men are living longer, there is heightened interest in andropause and this will help to advance our approach to this important life stage which was identified so long ago. The existence of andropause is recognized by some of the best researchers in medical science, including the international medical community. In fact, a recent World Health Organization (WHO) report states that “male androgens progressively decline with age.” The study tested androgen levels at different ages, and by age 70, androgen levels were only 10 percent of what they were during youth.

Increased diagnostic capability
Another reason why andropause has been underdiagnosed over the years is that symptoms can be vague and can vary a lot among individuals. Some men find it difficult to admit that there's even a problem. And often physicians didn't always think of low-testosterone levels as a possible culprit. So these factors often led doctors to conclude that symptoms were related to other medical conditions (i.e. depression) or were simply related to aging, and they often encouraged their patients to accept that "they were no longer spring chickens."

This situation is changing. New blood testing methods are available and there is an increased interest in men's aging among medical researchers. So much attention is being focused on andropause, that major efforts are underway to quickly share emerging scientific information with the international medical community.

Causes
Starting at about age 30, testosterone levels drop by about 10 percent every decade. At the same time, another factor in the body called Sex Binding Hormone Globulin, or SHBG, is increasing. SHBG traps much of the testosterone that is still circulating and makes it unavailable to exert its effects in the body's tissues. What's left over does the beneficial work and is known as "bioavailable" testosterone. Andropause is associated with low bioavailable testosterone levels.

Every man experiences a decline of bioavailable testosterone, but some men's levels dip lower than others. And when this happens these men can experience andropausal symptoms. These symptoms can impact their quality of life and may expose them to other, longer-term risks of low-testosterone. It is estimated that 30 percent of men in their 50s will have testosterone levels low enough to be causing symptoms or putting them at risk.

Typical responses to low bioavailable testosterone levels include:

• Low sex drive 
• Emotional, psychological and behavioral changes
• Decreased muscle mass 
• Loss of muscle strength 
• Increased upper and central body fat 
• Osteoporosis or weak bones and back pain
• Cardiovascular risk

Importance of Testosterone
Testosterone is a hormone that has a unique effect on a man's total body. Testosterone is produced in the testes and in the adrenal glands. It is to males what estrogen is to females. Testosterone helps to build protein and is essential for normal sexual behavior and producing erections. It also affects many metabolic activities such as production of blood cells in the bone marrow, bone formation, lipid metabolism, carbohydrate metabolism, liver function and prostate gland growth. 

Apart from the impact that low testosterone may have on your quality of life, there are other longer-term and silent effects of andropause that are harder to track: increased cardiovascular risk and osteoporosis.

Andropause & Osteoporosis
In a healthy individual, bone tissue is constantly being broken down and rebuilt. In an individual with osteoporosis, more bone tissue is lost than is regenerated. We've all heard of women suffering from weaker bones, or osteoporosis, after menopause. In men, testosterone is thought to play a role in helping to maintain bone density.

Between the ages of 40 and 70 years, male bone density falls by up to 15 percent. Unfortunately, with advancing age and declining testosterone levels, men, like women, seem to demonstrate a similar pattern of risk for osteoporosis. What's more, approximately one in eight men over age 50 actually have osteoporosis. The incidence of hip fractures rises exponentially in aging men. In Canada, 20-30 percent of osteoporotic fractures occur in men. The incidence of fractures has been increasing in men, whereas it seems to be stabilizing in women—likely due to their lifestyle changes, calcium supplements and hormone replacement therapies (HRT).

Low bone density puts one at risk of frequent fractures, associated pain, and in many cases, loss of independence. Wrists, hips, spine and ribs are most commonly affected. Two important consequences of osteoporosis are often seen as a slow but progressive rounding of the shoulders as well as a loss of height and back pain. Particularly devastating seem to be hip fractures, where up to one third of patients never seem to regain full mobility.

Cardiovascular risk*
It is now well accepted that women's risk of atherosclerosis (hardening of the arteries) increases after menopause. Estrogen replacement therapy seems to reverse this trend. New evidence suggests that a similar phenomenon occurs in men as their testosterone levels diminish with age. While research is not as complete as for women, the clinical findings point to an association between low testosterone levels and an increase in cardiovascular risk factors in men.

*A cause and effect relationship has not yet been established in large clinical trials. Further clinical research is needed into this important area of study.

Testosterone Replacement Therapy
In many instances, testosterone replacement in men with andropause can be highly effective and beneficial. It's not for every man, of course. Even those who show symptoms may have other health problems at the root of it all. You should discuss with your doctor if you would be a good candidate for testosterone replacement therapy.

In various clinical studies, very good responses to testosterone have been reported for men with low-testosterone and they include:

• Improvement in mood and sense of well-being 
• Increased mental and physical energy 
• Decreased anger, irritability, sadness, tiredness, nervousness 
• Improved quality of sleep 
• Improved libido and sexual performance 
• An increase in lean body mass, a decline in fat mass 
• An increase in muscle strength (hand grip, upper and lower extremities) 
• Potentially, a decrease in the risk of heart disease

With testosterone therapy, one's attitude improves, reinforcing self-esteem and self-confidence at work, as well as an increased energy at home and in social activities. Most men will feel more vigorous, experience improved energy levels, mood, concentration, cognition, libido, sexual performance and an overall sense of well-being. These effects are usually noted within 3 to 6 weeks. Other potential benefits include maintenance or improvement in bone density, improved body composition, muscle mass and muscle strength, as well as improvement in visual-spatial skills.

Lifestyle
Of course, any ongoing strategy to reduce the symptoms and risks of andropause should incorporate lifestyle approaches such as optimal diet, regular exercise, stress-management and the reduction of tobacco and alcohol intake.
 
Understanding Risks
There are several conditions in which you should never use testosterone replacement therapy. These include:

• Breast cancer (in males)
• Prostate cancer

In some other cases testosterone replacement therapy may not be right for you. If one of the conditions below is applicable to you, your doctor will decide whether (in your specific case) testosterone replacement therapy is the right solution.

• Liver disease
• Heart or blood vessel disease
• Edema (swelling of face, hands, feet, or lower legs)
• Enlarged prostate
• Kidney disease 
• Diabetes mellitus (sugar diabetes)

To help your doctor determine your best treatment plan, you should also discuss the following:

• If you have ever had any unusual or allergic reaction to androgens or anabolic steroids.
• If you are an adult male who plans to have children; high doses of androgens may cause infertility.
• If you are bedridden.
• If you are now taking any other prescription or nonprescription (OTC) medicine,  especially anticoagulants (blood thinners).