This summer the government in the UK decided not to make the menopause a ‘protected characteristic’ for women, something which might have helped them see off workplace discrimination as a consequence of the often debilitating symptoms experienced during this challenging mid-life phase. The reasons for not doing so, however, came as a surprise to many. The menopause wasn’t a protected characteristic for women, the lawyers argued, because men experience the menopause too.
That suggestion likely had a lot of men who read this news raising a quizzical eyebrow. But perhaps at the same time they also yawned for the hundredth time since waking super-early again, mopped the sweat from their brow, wondered where that expanding gut had come from, snapped unwarranted at whoever was nearby, wondered where that expanding gut had come from (wait, didn’t they just do that?) and decided to look into what all this meant but, in the end, just couldn’t be bothered.
Maybe that’s because, alongside a loss of libido, tiredness, fat redistribution and loss of muscle mass, irritability and mood swings, poor concentration and short-term memory, hot flushes and a general lack of enthusiasm or energy are, indeed, all symptoms of the male menopause.
At least, this set of symptoms falls under the umbrella term ‘male menopause’, even if many in the medical profession don’t much like the phrase. “It’s a trivialisation of what can be a very serious issue — to the extent that we have patients coming to us with thoughts of suicide,” says Dr. Robert Stevens, of The Men’s Health Clinic, a leading specialist in this field.
That’s also because what men experience is not the menopause, defined as that is by a clear-cut event: the end of a 12 month long spell during which a woman has had no period, and won’t have again, marking the end of her child-bearing years. Nonetheless a combination of usage by the media, and by private treatment services, has popularised ‘male menopause’ for having a catchy call-to-action ring about it. Some have even referred to it as the andropause. Or, yes, the manopause.
Rather, what we’re talking about here in men is a hormonal shift or imbalance. Yes, many of the somewhat random package of symptoms that men might experience during their ‘menopause’ are similar to those experienced by women during their actual menopause. They tend to be experienced by men in their 40s and 50s (though can happen at any time due to other, epigenetic causes). The same age range goes for women. And for women too the event is driven by a hormonal shift, a drop in their levels of oestrogen – hence HRT or Hormone Replacement Therapy. For men it’s all about testosterone – and TRT or Testosterone Replacement Therapy. That’s why it’s been proposed that the male menopause be more properly called Testosterone Deficiency Syndrome. It’s just not as snappy.
That snappiness might matter though, in terms of building recognition. Men know remarkably little about the female menopause – it was only two years ago that the Menopause Experts Group, an international campaign group, created the first ever training program designed specifically to make men more knowledgeable of this still somewhat mysterious and stigmatised biological phenomena which almost every woman will go through. But they know even less about the form of menopause many, if not all, will go through themselves. According to a study by men’s healthcare company Numan this year, 44% of men questioned are unclear about what the andropause is and what its symptoms may be.
Part of this is down to the fact that the andropause is considered more of a slow-burn process, with what physical and bio-chemical symptoms there may be likely spread out over many years – and these may not come at all. Sounds vague, right? No wonder that some endocrinologists – specialists in hormones – express concern that there’s no clear-cut pathology to the andropause. It has only been a subject of medical research for around a decade (which, given the complexity of conducting scientifically reliable studies, isn’t long) and it shows.
“The andropause is a real thing, but, as with many aspects of male sexual health, there’s a lot we don’t understand,” says Professor Jim Hotaling, director of men’s health at the University of Utah. “It’s why andropausal men get misdiagnosed as depressive, when you can have all of the symptoms of the andropause and not be depressive at all. Our understanding is getting better but there’s a long way to go.”
Then there is the very vagueness of the symptoms, especially in middle-age. “It used to be that a man might see his doctor, say that’s he’s gaining weight, doesn’t feel like sex, his mood isn’t what it was, that he doesn’t feel like he used to, and he’d be told, ‘yeah, you’re getting old, deal with it’,” says Dr. Chris Airey, medical director of the London-based Manual men’s health clinic.
After all, doesn’t every man in mid-life – possibly with school-age children, a peaking career, the tribulations of a long-term relationship, all topped off with the existential angst of maybe having lived more of their life than there is yet to live – feel irritable, tired, distracted and deflated.
That men are often reluctant to seek medical advice – full stop – but are all the more reluctant with matters of an even vaguely sexual nature – such as, among the andropause’s possible symptoms, loss of libido – only further curtails medicine’s understanding of it. Culturally, we’re also prone to sideline these symptoms to the cliche of ‘mid-life crisis’ – remedied, naturally, by a super-boosting of one’s chutzpah through buying a Harley, or running off with the secretary. Or we speak of ‘grumpy old men’. What if both crisis and grumpiness alike are products of the andropause?
Unhelpfully, it seems to come down to being a matter of what you can handle. Initially, it’s a matter of self-assessment. “You have to consider someone’s ‘pre-morbid personality’ – maybe they’ve always been miserable. Are you going to fix them with a bit of testosterone? Probably not. Likewise you can’t have borderline testosterone levels but no symptoms [and expect TRT],” says Airey. “The key indicator for me is when men say ‘I never used to feel like this’. They’ve noticed a real change. Other people have noticed it.”
In other words, you may experience some or all of these symptoms but live a more or less functional life. There are, studies suggest, an estimated 20-25% of men who suffer some effect of low testosterone. But then there are those men who, while none of the individual symptoms may be make-or-break, find their collective effect crippling. They have completely lost their mojo. They feel crap nearly all the time and have little enjoyment in life. They need to see their doctor.
And they really should see their doctor, not least because the impact of all this typically goes beyond the individual. As Dee Murray, CEO of the Menopause Experts Group stresses, much as the menopause can have a devastating effect on a woman’s performance at work – her very employability – and seriously damage her relationships with friends, family and partner, the same is true of men suffering the andropause.
Indeed, while women might well have just cause to be irritated by the spotlight being shone on the andropause – just as the actual menopause is getting the research and media attention it needs, along come men men claiming the menopause as their own – it’s often a partner who spots the symptoms in their man and encourages medical investigation.
“We know that, statistically, more marriages fail while women are going through the menopause,” says Murray. “But I’d suggest that picture is further complicated by the fact that, unacknowledged, men are going through the andropause at the same time. The fact is that we need less of a stigma around both the menopause and the andropause. For the andropause to face the same discrimination that the menopause has faced would only push the whole subject of hormonal health further under the carpet. And hormonal health – in children as in adults too – is a subject that needs much greater appreciation for its relevance to our overall health and to our psyches.”
But back to testosterone, a subject also not well-taught in most medical schools. Not helping the situation is the extent of misunderstanding surrounding not just the andropause but, more specifically, of what is sometimes called ‘the male hormone’. Often mischaracterised as a driver of alleged ‘toxic’ masculinity, as the stuff of performance enhancement, something body-builders inject and bar-brawlers have too much of, testosterone is, in fact, just another normal hormone in a human body that is regulated almost entirely by hormones.
Much as men also have oestrogen – ‘the female hormone’ – so women have testosterone. It’s the levels of each that differ. And it’s a drop off in these levels of testosterone that is, so far, the most clear cut identifier of the andropause.
Pretty much every man will experience some drop off in their testosterone levels. Men typically see about two percent testosterone decline per year over their thirties and beyond, most often without noticeable consequences. The effects can be real enough though: testosterone’s decline is linked to muscle atrophy, reduced bone density and a susceptibility to depression; and there’s an inverse correlation with obesity and mortality from heart failure – the less testosterone you have, the more prone you are to both issues.
Chris Airey argues that a more holistic understanding of the role of testosterone could have important ramifications for a society in which we’re all living longer, in which ‘middle-age’ is getting closer to actually being the middle of your lifespan. “Is [the use of TRT] a roundabout way of trying to fix aging? Sort of,” he concedes. “But if you address a man’s falling testosterone levels earlier they may hold on to good muscle mass and bone density later, so when they fall over in their 80s do they break or do they bounce? There are important implications here for aging well, much as there are if you look after yourself during middle-age too.”
But there is no clear cut agreement, for example, on what the ‘right’ levels of testosterone are for a man – they can differ wildly between one man and the next, without differences in functionality. And it’s hard to tell if any individual man is in their normal range now without knowing what their levels were years before. “There are vast differences in the ranges for what might be considered a healthy or unhealthy testosterone level,” says Stevens, “and until there’s more research we won’t have some unity of thinking about when to treat with testosterone. Is that research going on? No.”
Nor is it certain whether the andropause is all about testosterone alone, or, as current thinking suggests, more about a broader package of metabolic changes in the levels of various key hormones, among them prolactin, gonadotropin, DHEA and others without testosterone’s publicist. Nor whether testosterone replacement is the best path of treatment – so for every doctor over-enthusiastic in prescribing testosterone, possibly through a mis-reading of the symptoms, there’s one more circumspect and reluctant to do so. Certainly there are other crucially important questions to ask first, chiefly around matters of lifestyle.
That confusion about whether andropausal symptoms are just a reflection of being middle-aged… In the same way, these symptoms can be a product of the way we live, badly – lack of sleep and exercise, poor diet, maybe smoking and drinking too much alcohol, not keeping lean (because a high body fat percentage convinces the body to convert testosterone to oestrogen, confusing the brain into dialling back testosterone production further still). Stress is another major factor – again, something that mid-life circumstances might well bring to a head. These, obviously, are all things any man should be addressing anyway.
That’s why, Robert Stevens stresses, testosterone deficiency should always be a diagnosis of exclusion. That means ruling out many other possible causes – not just lifestyle factors but, for example, thyroid or liver issues, pathologies that are easier to treat and also more common in middle-age. Since some hormones are produced in the gut, and absorption drops as we get older, it’s worth checking there too. “You need to do all this before committing someone to a lifelong treatment,” says Stevens.
Yes, you read that right: once you’re on TRT, your own testosterone production can be suppressed, leading to ‘dependency’ on treatment. While it’s possible to use TRT for a few months or years, coming off it – or, as some public healthcare services around the world do, withdrawing it from a patient after a certain time – is likely to see your testosterone levels the drop back to whatever level they would naturally be at after those months or years. Likewise, a trial period of testosterone treatment that brings no perceived benefits to the patient – to outweigh the potentials risks – should bring an end to that treatment.
So, effectively, once you’re on TRT and it’s seen to work, you’re on it for life. That has its costs. For one, TRT is literally not cheap: maybe AED500 a month. There is also the hassle of visiting a clinic once or twice a week for injections (though some systems use a topical gel).
All of which may be as nothing for the improved quality of life that it might bring, of course. But clearly there are serious considerations to make before opting for TRT, an approach not being helped by a growing buzz around testosterone. This is such that clinicians find themselves dealing with men with stable levels of testosterone, entirely fitting with normal physiological function, but who are nonetheless convinced that testosterone is the answer to their problems. There has, similarly, been a huge and not uncontroversial spike in demand for HRT treatment among women too.
“We’re now in a situation in which some menopausal women actually feel embarrassed because they’re not on HRT – such is the social pressure to be so – while others are absolutely dependent on it, even though other lifestyle factors are likely to be in play,” says Murray. “And that should be some warning for the future use of testosterone to treat the andropause.”
For good or ill, there’s already a rapidly growing industry there ready to profit from its uptake – though, admittedly, even in nations with public healthcare, private healthcare is often the only way to get TRT. Not everyone is a fan of these private clinics.
“There is the potential for causing harm without a proper doctor assessment,” argues Stevens. “Mainstream medicine will never take testosterone deficiency and TRT seriously with online companies not showing due diligence and promoting TRT as a cure-all fix-all solution to all of life’s problems. Without getting conspiratorial the pharmaceutical industry is there telling us it has an effective treatment for men who present with these symptoms, and that encourages a model of the quick fix rather than taking a more preventative approach [through lifestyle changes]. But the idea that testosterone can be used as some kind of quick fix is a sales pitch.”
As with all sales pitches, the buyer should beware. But, before that, just be aware: be aware of what’s happening to your body, and your mental health, especially in middle-age. And at least know that such a thing as the andropause does occur and can have certain effects. The path to understanding may not necessarily end in injections, but it may at least save the latter part of your life from being down in the dumps when you could still be reaching those highs.