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MANopause: Is It for Real?

A Physician’s Perspective on the Male Change of Life

iStock 000016009283SmallLosing one’s sexuality is NOT an inevitable fact of aging. It is true, however, that most everyone, male and female alike, experiences some physiological and psychological changes in their systems caused by decreasing levels of sex hormones in the body: estrogen for women and testosterone for men.

Relative to what happens in men, female menopause comes on rather suddenly and happens quicker; the symptoms are perhaps more acute. “Menopause,” as most of us know, indicates that the woman’s reproductive system is completing its cycle and ceasing entirely. Menstrual periods end and women can experience hot flashes, difficulty sleeping, and mood swings—symptoms that typically last for only a few years.

“Manopause,” a term sometimes used for the male change of life, is usually more subtle, can last for decades, and often goes undiagnosed. Clinically referred to as “andropause,” or “hypogonadism” (a term which defines low testosterone levels), is actually quite similar to the hormonal drop that women experience. Countless American males suffer from the symptoms of manopause and may not even know what it is. In fact, the FDA estimates they may number 4-5 million men, only 5% of whom are correctly diagnosed.

Now, manopause has been a somewhat controversial topic for many years, and has only recently become widely accepted as a real condition in the United States. As baby boomers are aging and becoming more willing to talk openly with their spouses/partners and physicians, it is becoming less mysterious and better recognized. The psycho-social concept of “midlife crisis” is part of our popular culture and may be linked with the physiological symptoms of decreasing testosterone, which can include:

  • Decrease in sex drive, erectile dysfunction, and infertility
  • Loss of height, muscle, strength, endurance, and diminished athletic performance
  • Decreased bone density/osteoporosis
  • Fatigue, diminished energy
  • Memory loss, poor concentration, lack of motivation and difficulty focusing
  • Increase in body fat, with or without weight gain (muscle decreases/fat increases)
  • Anger, anxiety, aggression
  • Sadness and depression
  • Anemia (low red blood cell count)
  • Loss of body/pubic hair, swollen or tender breasts, shrinking testes
  • Sleep problems, including sleep apnea
  • Heart disease

And, yes, even hot flashes and sweats.

iStock 000015657747SmallAnd now, for my signature diagnosis: none of these is an inevitable sign of aging. The good news is that decreased testosterone levels and the related symptoms can be addressed once they have been properly diagnosed by your physician. Testosterone Replacement Therapy (TRT), may be a good solution for many men.

First, we must rule out other possible causes, including side effects from other medications you may be taking. This should be done through a thorough physical exam in which the physician asks you about your symptoms and medications (and you answer honestly and completely!). A complete panel of blood tests should be taken, including a special test to evaluate your Serum FAT (“Free Available Testosterone”), that is, the amount of testosterone that’s actually available to your system vs. your total testosterone level. It is very important to get this right! You should never begin TRT without determining whether it’s really the right thing for you. And even if your doctor determines that TRT will help you today, you should be re-evaluated every three to six months.

The testosterone level in men can begin decreasing as early as age 30 and typically drops about 1% per year beginning at age 50. It’s hard to know what a “low” testosterone level really is, as every man is unique. A low level in one person may be perfectly normal in another. Levels can vary among men of different ethnicities and can even fluctuate in your body based on your emotions and the time of day. And some men who have “low” levels may experience absolutely no symptoms.

TRT comes in creams, gels, and patches that allow the hormone to be absorbed by the skin. Some people believe they need to apply these substances to particular anatomical body parts in order for them to be effective, but that’s not true. There are also self-administered injections available, but I don’t recommend these.

What are the risks? There are some side effects to TRT which must be carefully considered—it’s not for everyone. However, if you are using an appropriate dose under the supervision of a physician with a proper diagnosis, your risks should be minimal. Because TRT can elevate your red blood cell count, it may increase the possibility of stroke in those whose counts are already normal. It can also potentially increase the symptoms of sleep apnea or trigger anger and aggression in some men. Probably the biggest concern is that supplemental testosterone could increase the size of the prostate and potentially tip off prostate cancer.

Conversely, prostate cancer treatment medications are often the cause of reduced testosterone. There’s no good evidence that these drugs will actually prolong life in men over 80 years of age. Because it is not common for older men to die from prostate cancer, physicians should carefully evaluate whether such a course of treatment is truly necessary and/or appropriate.

Here’s a real story about how lives can be compromised by inappropriate treatment. An 85-year-old man was brought in to my office in a wheelchair by his daughter. He had repeatedly fallen over the previous four years, had broken multiple bones, and had incurred more than $100,000 in related medical costs, surgeries, and hospitalizations. No one had been able to sleuth out the reason behind his falls. I waded through his chart, which was inches thick, searching for clues. Sure enough, I discovered that he had been diagnosed with prostate cancer years before and had undergone an orchiectomy (removal of the testicles). Of course this would lead to dramatically reduced testosterone levels—the culprit of the bone weakness and resulting breaks. We put him on a course of TRT and, within six months, he was dancing!  He lived for four more vital and happy years thanks to the testosterone replenishment, and he did not die of prostate cancer.

Besides TRT, what can you do to combat symptoms related to diminished testosterone? It’s the same basic common sense things we doctors repeat to keep you healthy in every way:

Exercise within your physical limits. Weight bearing exercises, especially, will increase lean muscle mass (which will boost testosterone), improve bone density and increase metabolism.

  • Eat a healthy diet and watch your weight.  Choose lean proteins, fiber rich foods, and plenty of fruits and vegetables.
  • Limit alcohol and caffeine, and stop smoking.
  • Get plenty of rest.
  • Keep your brain sharp. Read, do crossword and Sudoku puzzles, teach your grandson to play chess.
  • Take supplements, such as vitamins B and C, and fish oils & Omega 3 supplements for brain function and energy.
  • Watch for depression. This can cause a vicious cycle: low testosterone can cause depression; depression can lower testosterone. Get help if you feel chronically sad or depressed.
  • Confide in your spouse or partner and be 100% direct and honest with your physician. Harboring worries and fears about your symptoms will not make them go away!

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