Men oh pause!

Even men suffer from menopause.

woman flirting with mature manHollywood comedienne Rita Rudner once said: “Male menopause is a lot more fun than female menopause. With female menopause, you gain weight and get hot flushes. Male menopause? You get to date young girls and drive motorcycles.”

Many who have followed President Bill Clinton’s sexcapades[1] or have watched Dev Anand running around trees at age 80 will readily agree with Rita Rudner. But how right is she? Do men really suffer a ‘menopause’?

Late Onset Hypogonadism [LOH], male climacteric, androgen deficiency in the ageing male, andropause or male menopause—whatever we call it, they all mean the same. And this condition most emphatically exists.

What is Late Onset Hypogonadism?

The Endocrine Society defines male hypogonadism as a clinical syndrome that results from failure of the testes to produce normal levels of testosterone [androgen deficiency] and the normal number of spermatozoa [mature sperm cells].

Unlike in a woman, where there is a sudden cessation of ovarian function and oestrogen production comes to an abrupt standstill, LOH in a man is characterised by a more gradual decline in the levels of free available testosterone [FAT or bioavailable testosterone], which is measured with the help of sophisticated tests that are available only at few specialised centres.

Unfortunately, neither the LOH nor the tests available for its evaluation are widely known among physicians and some doctors will simply pooh-pooh the very entity of LOH out of sheer ignorance. Awareness on this subject is slowly spreading though, both among medical professionals as well as the laity.

Men with Late Onset Hypogonadism, however, can continue to father children. This is unlike in menopausal women; nearly all menopausal women are rendered infertile by menopause.

The prevalence of hypogonadism does not differ between racial and ethnic groups[2] and older men are more likely to have low testosterone levels. In fact, 19 per cent of men over 60 years have low testosterone and the overall prevalence of hypogonadism in men aged 45 years or older is approximately 39 per cent. In spite of these high numbers only 5–35 per cent of hypogonadal men actually receive treatment for their condition.

It happens to most

Even in healthy men, by the age of 55, the amount of free testosterone in the blood is significantly lower than it was just 10 years earlier. In fact, by age 80, the blood testosterone levels in most men become like that in small boys before adolescence.

At least 40 per cent of men between 40 and 60 experience lethargy, lack of energy, decreased work performance, depression, increased irritability, mood swings, reduced enjoyment of life, hot flushes, insomnia, decreased libido, weak orgasms, reduced strength and stamina, weakness, loss of both lean body mass and bone mass [making them susceptible to hip fractures], reduced erectile rigidity, and difficulty in attaining and sustaining erection [impotence].

But don’t sit back thinking there’s still time, LOH can strike as early as at age 35. And the population of young `andropausal’ men is increasing rapidly today, thanks to stress, unhealthy diets, poor sleep, sedentary lives, substance abuse, and multiple failed or dysfunctional relationships.

By contrast, there are many men in their 60s, 70s and 80s who look amazingly young, and are fit and sexually active. Sometimes, such youthfulness and vitality is genetic, but more often, it is the reward for a lifetime of sound physical, emotional and mental health practices.

Hypogonadism increases with age and is significantly associated with various co-morbidities such as obesity, type-2 diabetes, hypertension, other cardiovascular disease, hyperlipidemia, osteoporosis, asthma, chronic obstructive pulmonary disease and the metabolic syndrome.

Are there symptoms?

Symptoms include sweating, palpitations, hot flashes, easy fatigability, reduced libido and erectile dysfunction, constipation and skin atrophy [thinning of the top two layers of the skin]. Men also experience decreased productivity, poor concentration, mood and sleep disturbances, memory lapses and reduced mental agility, passivity, abulia [diminished will power], timidity, unrest, nervousness and diffidence or lack of self-confidence, and hypochondriasis.

A decline in sexual potency at mid-life can be expected in a significant proportion of men, since testosterone, the hormone that declines in men with LOH, is also the same hormone that is responsible for sexual drive and libido in both sexes. Testosterone also has a direct beneficial effect on erection.

However, a man can have low testosterone levels but no clinically significant symptom. Further, hypogonadal symptoms are nonspecific. The Massachusetts Male Ageing Study [MMAS] measured a combination of testosterone levels and hypogonadal symptoms in men to find that only between six per cent and 12 per cent men had symptomatic androgen deficiency.

An interesting observation from the MMAS was that half of the men found to have symptomatic androgen deficiency at one stage had normal hormone levels when tested again at a later stage. Perhaps that’s because testosterone secretion and the threshold where symptoms become manifest differs from one man to another. So, get your testosterone checked again at a later stage before considering treatment.


Some of the factors known to contribute to the onset and severity of the Late Onset Hypogonadism:

  • Hypothalamic and testes insufficiency
  • Obesity
  • Hormone deficiencies
  • Excessive alcohol consumption and smoking
  • Hypertension
  • Drugs
  • Unbalanced diets
  • Lack of exercise
  • Poor circulation
  • Stressful lifestyles
  • Psychological problems.

Can it be treated?

Majority of patients get relief by making lifestyle changes that include finding new ways to relieve stress; eating a nutritious, low-fat, high-fibre diet with special food supplements; getting plenty of sleep; exercising regularly; finding supportive groups and sharing experiences; limiting consumption of alcohol and caffeine and drinking lots of water.

Some men do require hormone replacement therapy and they should get it administered by responsible physicians only. Even though the newer forms of testosterone are extremely safe and well-tolerated, long term administration and monitoring requires expert knowledge and commitment in order to minimise potential complications.

Also, testosterone must not be used as a tonic for vague, non-specific complaints, without proper clinical and laboratory corroboration, as it can cause serious side effects, including aggravation of prostate cancer. Patients with proven low serum FAT [free available testosterone] levels are offered testosterone therapy only if they fulfil the other clinical criteria as well. Before starting, a complete general check up and some special tests are conducted. These must be repeated at intervals for as long as treatment is continued.

Testosterone is available in oral, buccal, injectable, skin patch, cream, gel and subcutaneous implant forms. Doses must be tailored to achieve normal FAT levels and amelioration of symptoms. Significant symptom relief can be expected with treatment. However, all impotence may not respond to testosterone and some more special tests and additional treatment may sometimes be necessary.

Don’t ignore it

So now you know why athletes and many other sportsmen hang up their boots while still relatively young. They understand reality.

And the next time you see a middle-aged man making a buffoon of himself on the dance floor with a pretty young girl; it might be a good idea to ask him to see his andrologist. After all, sensible ladies his age do see their gynaecologists.

And if you are wondering whether it is Late Onset Hypogonadism that made you buy those ultra-tight jeans and cowboy boots last week, the ones that hurt your crotch and compelled you to walk with your feet placed three feet apart, you can bet that it almost certainly IS Late Onset Hypogonadism.

Sudhakar Krishnamurti
Dr Sudhakar Krishnamurti is an internationally recognised andrologist, infertility microsurgeon and sexual health expert. His book, Sex is Not a Four-Letter Word has been nominated for the SSTAR International Award, USA, 2010, for best book on sexual health education. His website has won 14 international awards. He is the Director of Andromeda Andrology Center in Hyderabad, India's first andrology centre.


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