Last summer, my 44-year-old brother-in-law, a tall guy who works for a power company and owns cows for fun, started having the sweats. “I don’t know what the problem is,” he complained, wiping his sweat-shiny face. “It’s male menopause!” joked his mother. The rest of us laughed.
But I was curious. Is there such a thing as “male menopause”? Google responded with a walloping yes. But you and I both know that just because people have published a million articles about something on the internet doesn’t make it so. For a dose of reality, I turned to Ryan Smith, MD, a urologist here at UVA whose daily job is to help men with their hormones.
The Rise and Fall of Testosterone
Male menopause, while not exactly an actual medical term, “is a known entity,” he said. In fact, hormonal changes tend to begin in all men in their early 30s. That’s when testosterone levels start to drop at a rate of about 1-2 percent a year.
Low testosterone, or low T, Smith says, “is one of the most common things I see men for.”
So, why is female menopause so well known, yet we don’t have a similar concept for men? Both sexes experience a drop in hormone production as they grow older. However, the speed of the hormone level changes and their impacts differ between the sexes.
As with puberty, women universally experience a more drastic hormone shift (menstruation, menopause). The rise and fall of sex hormone levels in men occurs more gradually, with less obvious changes. That difference results in a lot of misunderstandings about hormones in men and what they do.
Most men aren’t even aware that low testosterone levels can affect their health. “When men come in feeling tired, unable to concentrate, having sexual concerns, and we diagnose them with low T, they’re shocked,” Smith notes.
Hypogonadism in Men
In men, low T often masks a more serious condition: hypogonadism. Caused by genetics, testicular problems, autoimmune issues, pituitary tumors or disease, hypogonadism causes abnormally low testosterone levels. By age 45, 40 percent of men have abnormally low testosterone levels.
Hypogonadism can cause quite disruptive results:
- Decreased libido
- Erectile dysfunction
- Decreased volume of ejaculate
- Loss of body and facial hair
- Decreased bone density
- Decreased lean body mass
- Increased body fat
While the onset of symptoms can closely resemble the intensity of menopause, calling this condition male menopause or andropause is inaccurate. “We diagnose people with hypogonadism or low T, and treat them appropriately,” Smith says.
We ALL Have Gonads
Fun fact: Although the slang term “nads” is used for males, in actuality, both men and women have “gonads.” The term refers to the glands that produce sex hormones (women have ovaries, men have testes, and both generate testosterone.) Both sexes can experience hypogonadism when their hormone levels fall below normal.
The Effects of Low-T
Whatever the cause, reduced testosterone can have serious negative health impacts, increasing men’s risk for osteoporosis, diabetes, obesity, COPD, prostate disease and hypertension.
“Testosterone has myriad things it impacts,” Smith explains. “If you don’t treat men with low T, they can have worse heart and bone density outcomes.” Together with Justin Smith, MD, a UVA psychiatrist, Smith currently runs a study looking into the relationship of low T and depression. “We’re looking at the overlap. There’s a close tie-in that is incompletely understood right now.”
But Smith doesn’t go right to handing out testosterone therapy to patients with low T symptoms. “When a man comes in, the first thing we do is counsel him, especially if it appears he hasn’t taken care of himself, such as not exercising or obesity. We encourage him to lose weight, see a nutritionist, get regular exercise. Getting healthy can reverse the process of decline.”
For men willing and able to diet and exercise, Smith says, they can bring up their baseline testosterone levels. “And they come out of a range of needing therapy to one where they don’t.”
Treating Low T: 3 Barriers
But getting men in for treatment generally proves challenging. First of all, most men don’t often go to the doctor. “Men are 25 percent less likely to see a doctor than a woman,” Smith says. “We are ourselves the biggest barrier. We see it as – we don’t need the doctor. We’re not advocates for our health.”
Hormone Therapy for Men: Fears & No Data
A second, and perhaps more problematic, barrier arose a few years ago with the release of studies showing an increased risk of heart attack and stroke in men on low-T therapy. In reaction, the FDA produced a severe warning regarding the use of testosterone products.
“This made doctors uneasy. That being said, there’s a lot of data predating that warning – and also data following – that shows less of a risk when men are diagnosed, followed and treated appropriately. While low-T therapy remains controversial, most of us feel that warning wasn’t a fair assessment. We need more data.”
Smith remembers, too, that at the time a number of doctors tended to over-prescribe testosterone, causing a rash of side effects.
Today, Smith and the other urologists at UVA approach hormone therapy as they do any drug. “We do the due diligence to treat and monitor according to national guidelines. We tell them the risks of therapy and counsel them appropriately about how the FDA has made warning statements.” What matters? “The right diagnosis.”
Anyway You Want It: Ways to Treat “Male Menopause”
Hormone therapy for men comes in a variety of forms. You can choose from:
- Nasal spray
A third barrier to getting the proper therapy: Men self-medicate with testosterone obtained online. Whether suffering from low T or not, some men take testosterone out of the mistaken belief that it’s a wonder drug. And this can have unwanted results.
“Some think it’s an age-reversing drug – takes men back to age 18. It’s not the fountain of youth, as some men think,” Smith says, referring to those who, in search of youth and strength, buy unregulated testosterone online. “You get a big rise in testosterone from these injections,” Smith explains. “But only for a couple of days. Then you crash, a rollercoaster effect. This can suppress your normal hormonal process and cause permanent problems to your pituitary gland and fertility.”
It’s not surprising men try to self-medicate. “The symptoms are somewhat widespread, even without a diagnosis of low T,” he says. “A decrease in energy levels, poor exercise tolerance, changes in mood or concentration, sexual dysfunction – you can have all those and have normal hormone levels, even though they tend to be more prevalent in low T.”
Additionally, online “men’s health clinics” providing testosterone do not always get a thorough assessment of a patient’s bloodwork or provide safe doses and types of hormone, Smith notes. Still, “a sizeable portion of men trying to go to the gym and maximize their lifting” buy these online products. Recently, Smith has seen more young men in high school starting on regimens they’ve read about online.
They have no clue about the health ramifications.
The High Stakes of Hormones
Smith emphasizes that he and his colleagues are fellowship-trained, a fact that distinguishes them not only from dubious online clinics, but also from private practices nearby. The causes, effects and risks associated with testosterone can prove complicated and tricky.
One effect most people don’t realize: Being on testosterone can actually suppress male fertility.
Smith says, “I’ve seen young people on it, and it has a contraceptive effect. A lot of primary doctors don’t realize testosterone will suppress fertility. About 7 percent of all male infertility visits are related to testosterone effects.”
Male Menopause: Therapy for Low T
Feeling down, lacking in energy?
See a UVA men’s health expert.
Treat Your Low-T (Really)
The fact is, whether we call it male menopause, andropause or low T, the effects of hormone loss in men can cause just as much suffering and ill health to men as menopause does to women. We need to start encouraging the males in our lives to visit their primary care doctors and, yes, talk about their feelings.
According to Smith, they’ll be glad if they do. He reports that when patients do come in and find out they can blame low testosterone levels for their lethargy and erectile difficulty, they often express relief. “They say, ‘OK, great! Now I know there’s a reason I’ve felt this way.’”