Andropause (age-related testosterone deficiency)

Andropause, or the "male menopause", is the name usually given to the cluster of complaints men bring to the doctor once past forty: desire has gone, erections are weaker, energy has drained away, the temper has soured, sleep has become broken, muscle has melted and the waistline has grown. The name is a poor one, because it promises an exact counterpart of the female menopause and no such thing exists. In women hormone production stops within a few years and on a timetable of its own; in men testosterone falls slowly, and in many it never reaches a level that explains how they feel. The complaints, however, are entirely real. They simply have many possible causes, and hormones are not the commonest of them. Sorting it out is worth the effort precisely because nearly every one of those causes can be treated.

What happens to testosterone with age

From around thirty-five to forty, testosterone falls by about one per cent a year on average. That is very little: a decade costs roughly a tenth, and in a healthy man that decline usually shows no signs at all. Even at seventy most men still have readings within the normal range.

There is a second side to it. With age the protein that carries the sex hormones increases, so a growing share of testosterone ends up bound to it and therefore inactive. Free hormone consequently falls faster than total hormone, and sometimes that is precisely what explains the symptoms when the blood test looks normal at first glance.

Genuine deficiency, the kind that needs treating, is a good deal less common than the talk about it suggests: it affects a small percentage of middle-aged and older men. It is not a normal feature of ageing but a distinct condition with causes of its own, and it has to be confirmed rather than assumed.

What men come in with

The doctor sorts the complaints into two groups. The first, by far the more telling where hormones are concerned, is everything sexual: desire gone or markedly reduced, weaker erections and, above all, the disappearance of morning erections. If desire is intact and erections only fail in particular circumstances, hormones are usually not the answer.

The second group is general and non-specific: tiredness that rest does not touch, low mood and irritability, trouble concentrating and remembering everyday things, poor sleep, less stamina, loss of muscle and strength alongside a growing waist, and enlargement of the breast tissue. Each of these on its own turns up in a dozen other situations, from sleep deprivation and depression to thyroid disease and anaemia.

When deficiency is severe and long-standing, less familiar features appear: hot flushes and sweating, thinning of facial and body hair, and falling bone density with fractures after minor falls. These say the problem has been running for a long time.

It is usually not the hormones

Before asking for a testosterone test, look honestly at how your life is arranged: the answer is usually there.

Chronic lack of sleep lowers testosterone within a week. Sleep apnoea deserves separate mention, with snoring broken by pauses, waking unrefreshed and daytime sleepiness. It hits hormones, mood and the heart at once, and treating it frequently restores both energy and desire.

Depression and anxiety produce exactly the same picture as hormone deficiency and are what gets mistaken for it most often in the consulting room. Regular alcohol suppresses testosterone production directly. Excess weight does the same: fat tissue converts testosterone into the female sex hormone, while the waist in turn grows because testosterone is low, and the circle closes.

A separate cause, and one of the most frequently missed, is medication. Opioid painkillers, steroids, some antidepressants and drugs for an enlarged prostate all affect either sexual function or the hormone itself. Anabolic steroids taken for the sake of physique shut down the body's own testosterone production, and after stopping them recovery takes months and is sometimes incomplete.

When the deficiency is real

Genuine age-related testosterone deficiency is called late-onset hypogonadism. There are two types and telling them apart matters, because behind the second there may be a disease that must not be missed.

In the first, the testicles themselves are failing: after mumps caught in adult life, after injury or surgery, after radiotherapy or chemotherapy, or following an undescended testicle in childhood. Klinefelter syndrome belongs here too, a condition present from birth that is not infrequently first picked up in an adult who has come about infertility.

In the second the testicles are healthy but receive no instruction from the pituitary gland. The cause can be a pituitary tumour, usually benign and producing prolactin; headache, loss of the outer field of vision and discharge from the nipple all raise the suspicion. Another is haemochromatosis, an inherited build-up of iron that damages the pituitary, the liver, the pancreas and the joints. Both are treatable and both show up on an ordinary blood test, provided somebody thinks of them.

Far more often, though, the deficiency is reversible: the obesity, type 2 diabetes, sleep apnoea and opioids already mentioned suppress production only temporarily. Here the cause is treated and testosterone returns on its own.

Which tests are needed

Blood for testosterone is taken in the morning and fasting: the hormone swings considerably through the day, and an evening sample tells you nothing. One result decides nothing either: a low value must be checked with a second sample on another day. Blood is not taken during an acute illness, during a flare of a long-term one, or straight after heavy exertion, because testosterone falls predictably in those circumstances and the picture comes out false.

If the fall is confirmed, the pituitary hormones that govern the testicles are measured next, and they show where the fault lies. Prolactin is checked, and if it is raised or testosterone is very low, imaging of the pituitary is arranged. The protein that carries the sex hormones is also measured, since it helps to interpret borderline results.

Alongside this, the doctor looks for whatever else produces the same complaints: full blood count, glucose handling, thyroid, iron stores, vitamin D and lipids. Snoring with pauses earns a referral for a sleep study. A man who plans to have children also has a semen analysis, before any treatment starts rather than after.

What genuinely helps

Treatment always begins with the cause, and in most cases that is enough. Losing weight is the single most effective measure where there is obesity: a smaller waist raises a man's own testosterone with no drug at all. Strength work two or three times a week combined with walking restores muscle and stamina better than any supplement. Seven hours of sleep or more, cutting down alcohol, treating sleep apnoea and reviewing medication with a doctor produce an effect that is often wrongly credited to hormones.

Low mood and anxiety are treated separately and properly, with talking therapy and, where needed, medication. Erectile difficulty is treated with PDE5 inhibitors. And here is something important: persistent erectile difficulty in middle age is often the first sign of disease in the blood vessels and precedes heart trouble by several years. That is why blood pressure, cholesterol and blood sugar are checked at the same time, and it is not a formality.

Testosterone replacement is used only for a confirmed deficiency with symptoms, not "for a bit of vigour". It is prescribed and supervised by a doctor, usually an endocrinologist or urologist, as a gel or by injection.

What you are warned about before hormone treatment

Testosterone treatment has consequences worth knowing about before the first dose.

The main one for anyone hoping to have children: testosterone given from outside shuts down the body's own production of the hormone and of sperm, sometimes to the point of none at all. Recovery after stopping takes months and does not always come. If children are in the plan, this is discussed before treatment starts, because other approaches exist that do not compromise fertility.

Testosterone thickens the blood by raising the proportion of red cells, so a blood count is monitored regularly and, if it thickens too much, the dose is reduced or the treatment paused. It can worsen sleep apnoea; acne, fluid retention and breast enlargement are also possible.

It is not prescribed in prostate cancer or in male breast cancer, and the prostate and PSA are watched during treatment. The gel has one unobvious property: it transfers by touch, so after applying it the area is covered with clothing and skin-to-skin contact with women and children is avoided.

And if after a few months nothing feels different, the treatment is stopped: that means the hormone was not the cause of the complaints.

When urgent help is needed

Call an ambulance (in European countries on the single number 112) if:

• thoughts of suicide or an intention to self-harm appear: this is an emergency and waiting for an appointment is not an option;
• a crushing or burning chest pain develops, spreading to the arm, neck or jaw, with breathlessness, sweating or faintness;
• a sudden and very severe headache comes on together with double vision, loss of part of the visual field or abrupt weakness;
• an erection is painful and will not subside after several hours: this damages the tissue and needs help straight away;
• sudden pain in a testicle develops with swelling and nausea.

See a doctor within days, without putting it off, for a painless lump in a testicle, a hard one-sided nodule under the nipple, a pulled-in nipple or discharge from it, and also if breast enlargement is growing fast or is painful.

Online consultation

A remote appointment suits the first step very well, because here it is the conversation that does the work. The doctor will ask in detail about sleep, work, physical activity, alcohol, mood and the medicines you take, will separate the complaints that point to hormones from those that point to exhaustion or depression, and will draw up the list of tests, specifying that they be done in the morning and fasting so that nothing has to be repeated.

Once the results are in, they are easy to go through online: what a borderline testosterone means, what the pituitary hormones and prolactin are for, whether an endocrinologist is needed. If deficiency is confirmed, the doctor will explain what treatment can be expected to do, which measurements will have to be followed and why the question of children is settled before the first injection. And if there is no deficiency, the conversation turns to what really lies behind the tiredness and the loss of desire, which is usually a far more hopeful conversation.

This material is for information only and does not replace medical advice.