The male menopause—does it exist?ForAgainst
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.858 (Published 25 March 2000) Cite this as: BMJ 2000;320:858
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For anyone who does not believe in "male menopause" should read the
book by Jed Diamond, "Surviving Male Menopause." This book is great for
the women in this world who have noticed a change in their husband and
can't figure out what is happening to their husband and relationship! It
is a relief to find out about this and to finally know what is going on
and try to understand it instead of giving up and throwing away a good
marriage!
Competing interests: No competing interests
At our clinic, it has been my observation that men on testosterone
and or growth hormone "supplements" seem to respond more favorably to
physical training than those who are not supplemented. Understanding that
there is a genetic variation to adaptation to almost everything,
especially physical tasks, the men on hormone supplements appear to adapt
more readily to training loads. When asked how each training session
"feels" most respond at a much lower RPE value. Measurable parameters
like resting heart rate, blood pressure, body fat, muscle girths, 1RM
values, heart rates at fixed work loads on leg ergometers & treadmills
generally are better overall. Then there is the issue of
"better sleep " and "tighter skin" that is told to me by those on
"supplements".
After reading the articles concerning andropause I found few if any
of the responses looking at hormone replacement plus physical training,
not recreation, and how the man "feels". Do they feel better, healthier,
more alive. Certainly, improving wellness must account for something.
Competing interests: No competing interests
EDITOR-Evidence that the so-called male menopause is attributable to
a reduction in testosterone is scanty1.
Much of the argument is based on interpretation of an estimate of the
total serum testosterone concentration. To ascribe a single testosterone
concentration of 'around' 10.4 nmol/l or 11 nmol/L as 'critical' is
fraught with problems. Testosterone concentration is subject to both
episodic and diurnal variation. In our study2 of 10 young men sampled
every 30 minutes for 24 hours, we confirmed a marked diurnal variation in
total, bioavailable and free testosterone, with differences in serum total
testosterone between 0700 hours and 1000 hours ranging from 11.9 nmol/L -
38.7 nmol/L. In a similar study in 6 men aged 55 - 64 years, differences
ranged from 10.9 nmol/L - 25.7 nmol/L.
In a carefully-controlled group of 114 healthy men aged 21 - 84 years, we
find no correlation (r = 0.158, p = 0.105) between age and total
testosterone in a.m.samples. We do, however, find a significant positive
correlation between age and SHBG (r = 0.47, p <0.0001), and an equally
significant negative correlation between age and measured bioavailable
testosterone (r = -0.41, p <_0.0001. p="p"/>An audit of 1986 requests in our hospital, showed a poor, though highly
significant, correlation between age and serum testosterone (r = -0.14, p
<_0.0001. in="in" _564="_564" men="men" complaining="complaining" of="of" impotence="impotence" there="there" was="was" a="a" similar="similar" relationship="relationship" between="between" age="age" and="and" serum="serum" testosterone="testosterone" r="-0.19," p="p" _="_" _0.0001.="_0.0001." the1986="the1986" requests="requests" _84.1="_84.1" had="had"/>10.4
nmol/L: of the 564 impotent, 84.6% were >10.4 nmol/L.
Overall, at 23.8 ±3 years the mean testosterone was 17.76 ± 6.3 nmol/L (n=
120) while at 72.6 ± 2.6 years the mean testosterone was 15.0 ±5.3 nmol/l
(n= 120). Although this represents a statistically significant difference
(p<_0.05 the="the" mean="mean" concentrations="concentrations" are="are" well="well" above="above" that="that" considered="considered" to="to" suggest="suggest" hypogonadism1.="hypogonadism1." p="p"/>In the impotent group, at 34.6 ± 6.2 years the mean testosterone was 16.6
nmol/L ( 8.8 - 31.2 nmol/L),and at 69.5 ± 4.2 years was 13.6 nmol/L ( 6.9-
26.8 nmol/L). Our data suggest erectile dysfunction has little to do with
serum testosterone.
Men do not become depleted of germ cells and provided that adequate
androgen is available are capable of ejaculation.
The concentration of testosterone required for sexual arousal and
ejaculation is unknown but these are readily evidenced when total,
bioavailable and free testosterone are at their nadir, late in the day.
Men may display any of the symptoms referred to3. It is difficult to base
these on a serum testosterone concentration.
Michael J. Diver
Senior Lecturer
William D. Fraser
Reader/Hon Consultant
Department of Clinical Chemistry,
Royal Liverpool University Hospital,
Prescot Street,
Liverpool L7 8XP
1. Gould DC, Petty R, Jacobs HS. The male menopause-does it exist?
BMJ 2000:320:858-61.
2. Diver MJ, Scutt D, Manning JT, Gage AR, Fraser WD. Pituitary
insufficiency. Lancet 1998 352; 816-7.
3. Heller CG, Myers GB. The male climacteric, its symptomatology,
diagnosis and treatment. JAMA 1994;112;1441-3.
Competing interests: No competing interests
Whether or not there is some clinically significant hormonal decline
in men is still subject to debate. What cannot be, however, is the term
menopause applied to the condition. Menopause literally means cessation of
the monthly periods. We should therefore, avoid this term in any
discussion regarding dwindling testosterone in elderly males.
Competing interests: No competing interests
In answer to Dr Carruthers:
In my contribution to this debate, I tried to distinguish between
full dose androgen therapy of patients with proven hypogonadism (no
problem) and the treatment of fragile elderly men with testosterone in
physiologically relevant amounts. It is the latter situation which, in my
opinion, is relevant to a debate concerning the existence of an
andropause. And it is this very group of men that seems to have fared so
disappointingly when given testosterone therapy over a 3 year period in
doses that raised their testosterone concentrations to those seen in men
in their twenties (1, 2).
Dr Carruthers makes a number of assertions concerning the value of
testosterone therapy but for them to be convincing he will need to quote
results from randomised controlled trials performed in appropriate
subjects. He has not done so. He does, however, refer to the chapter by
Bhasin and his colleagues in the excellent text of Nieschlag and Behere
(3). It is helpful to quote directly two of the authors "key messages":
"There is consensus that replacement doses of testosterone in hypogonadal
men and supraphysiological doses given to eugonadal men increase fat free
mass, muscle size and strength" and "We do not know whether testosterone
supplementation can produce clinically significant improvement in muscle
function in older men…"
The value of the menopause as a model for the gradual decline in
gonadal function that occurs in ageing men remains to be demonstrated.
The case for androgen replacement therapy in elderly men who do not have
biochemically proven testosterone deficiency (clinical hypogonadism)
remains to be proven.
Howard Jacobs
(1) Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone
treatment on bone mineral density in men over 65 years of age.
J.Clin.Endocrinol.Metab. 1999;84:1966-1972.
(2) Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone
treatment on body composition and muscle strength in men over 65 years of
age. J.Clin.Endocrinol.Metab. 1999;84:2647-2653.
(3) Bhasin S, Bross R, Storer TW, Casaburi R. Androgens and muscles.
In: Nieschlag E, Behre HM, eds. Testosterone: Action, deficiency,
substitution. Berlin: Springer Verlag, 1998;209-227.
Competing interests: No competing interests
Gould, Petty, and Jacobs debated in the BMJ about facts for and
against existing of male menopause. Both two positions focused on
sexual dysfunction. Indeed, Jacobs referred to a new class of drugs that
offer significant therapeutic potential for male erectile disorder. But,
none mentioned the role of drug abuse or drug therapy on the decline in
sexual interest and potency.
For example, it has been described that more
than 41% of hospital inpatients aged 65 years and over were found to use
benzodiazepines and alcohol in excess1, and that medications account for
erectile dysfunction in approximately 25% of cases2. In developed
countries, ageing (male or female) is associated with an increase in
medication consumption. This fact contributes to improve ageing health,
although also increases risk of adverse events related to drug therapy. I
have observed that drug-related sexual dysfunctions distribute dependent
on age and gender (data not published). So, sexual dysfunction should be
more prevalent in young women (commonly because of psychotherapeutic drugs),
whereas in the male population, old men should be more affected
(antihypertensive and psychotherapeutics principally).
In conclusion,
the lifestyle in developed countries could play a
part in sexual dysfunction that is more important than physiologic changes related to ageing. Drug therapy
is a significant matter in this lifestyle and could explain more cases of
sexual dysfunction initially attributed to the supposed male “climateric”.
Nowadays, the media are focused on therapeutic novelties against sexual
dysfunctions, and they forget that drugs also produce it.
1. McInnes E, Powell J. Drug and alcohol referrals: are elderly
substance abuse diagnoses and referrals being missed?. BMJ 1994; 308: 444-
6
2. Keene LC, Davies PH. Drug-related erectile dysfunction. Adverse Drug
React Toxicol Rev 1999; 18: 5-24
Competing interests: No competing interests
Editor - Howard Jacobs' unfair sex discrimination against men in
matters relating to HRT is all the more surprising because of his
enthusiastic advocacy of it in women1.
His frequently quoted argument that there is no such thing as a male
menopause or andropause because the mean fall in both total testosterone
and free testosterone concentrations with ageing are only 25% and 50%
respectively, is not applied to other endocrine disorders such as
hypothyroidism. Why should there not be such a critical level in
hypogonadism, particularly in some "High-Testosterone" men, such as
politicians, lawyers, tycoons and technocrats who appear to depend on high
levels of the hormone for dominance and competitive drive?2.
In relation to his second point, the characteristic andropausal
symptoms described in a huge series of articles over the past 60 years
appear in a range of low testosterone states, the balance of evidence
being that they can indeed be reversed with a wide variety of hormonal
replacement regimes. He quotes a study in healthy men given relatively
weak androgen treatment in the form of patches, which failed to show an
improvement in the strength of one group of muscles. However, other well-
controlled studies have shown that testosterone does increase muscle bulk
and strength3. Therefore evidence on this point is inconsistent, provides
insufficient grounds to reject either the use of testosterone for
relieving andropausal symptoms or it's preventive medical benefits.
The final point that "So far as sexual activity is concerned, the
role of testosterone in elderly men is still not well defined", on any
critical analysis again fails to support his case against hypogonadism
contributing to the multifactorial aetiology of the large majority of
cases of erectile dysfunction. As Dr Gould has previously confirmed, it
is the shared experience of clinicians treating andropausal men with
testosterone, that as well as libido improving, erectile dysfunction is
relieved in two-thirds of cases, and when this is combined with
sildenafil, this increases to over 90%4. This can be explained by recent
research showing that castration in the rat reduces both the erectile
response and penile nitric oxide synthase activity upon which the action
of sildenafil depends, and these effects are prevented by androgen
administration5.
Overall, as shown by the mass of papers presented at the WHO
sponsored 2nd Aging Male Conference in Geneva last month, the balance of
evidence strongly supports the existence of the andropause as a very real
group of symptoms arising from an absolute or relative insufficiency of
testosterone, which can and should be treated. Surely HRT for men is a
long-neglected idea whose time has now come.
Malcolm Carruthers
consultant andrologist
e-medicine andrology
centre, 20/20 Harley Street, London, W1N 1AL
carruthers@e-medicine.co.uk
1. Gould DC, Petty R, Jacobs HS. The male menopause - does it exist?
BMJ 2000;320:858-861.
2. Carruthers M. Maximising Manhood:Beating the male menopause.
HarperCollins, London, 1997;
3. Bhasin S, Bross R, Storer TW, Casaburi R. Androgens and muscles.
In: Nieschlag E, Behre HM, eds.
Testosterone:Action,deficiency,substitution. Berlin: Springer Verlag,
1998;209-227.
4. Gould D. Combined testosterone and sildenafil treatment more
effective than sildenafil alone. Int.J Impot.Res. 1999;11:237-238.
5. Lugg J, Ng C, Rajfer J, Gonzalez-Cadavid N. Cavernosal nerve
stimulation in the rat reverses castration-induced decrease in penile NOS
activity. Am.J Physiol. 1996;271:354-361
Competing interests: No competing interests
For what is Prolactin a "marker"? Does its level increase in old men
like Gonadotrophin in female menopause? (Well, I suppose Prolactin does
not DEcrease, as it is not needed at all in YOUNG MALES...) And if
Prolactin levels increase, couldn`t this be a sign for a HYPOTHALAMIC
process associated with / responsible for ageing in both males and
females? Is "becoming old" such a mess for men, that it needs a treatment?
"Leave your old postmenopausal wife, look for at least an HR-treated one under
50"?
Competing interests: No competing interests
Andropause Exists, Treatment Unlikly
An interesting debate, but for me Howard Jacobs misses or skirts
around the real point. Some men certainly do go through body changes even
in middle age, I have and am doing this.
No its not the same as women, so what.
The rate of onset is gradual, so what.
A perfect understanding doesn't exist, so work with what we do know.
He asks "we do well to consider how many of the changes in men as
they pass from middle to old age should be attributed to the passage of
years and how many to a decline in hormone concentrations." interesting
but what is this passing years doing physiologically?
At 58 years I've gone through vasomotor instability (hot flashes,
sweating) which came on over a period of a few months, was circadian
(onset near 3 am), intense enough to wake me nearly every night for many
months slowly decayed in frequency. I've been loosing muscle mass,
stamina, more easily fatigued. Possible loss in bone density. I've had
the decrease in libido, erectile dysfunction. Not on any drugs, low
alcohol intake, good exercise, general physiology checks out OK. The
symptoms all correlate well with descriptions of andropause. I think it
exists!
No, my symptoms have not been specifically linked to endocrinological
changes as its impossible to get anyone to try linking them. Measuring
bioactive testosterone is not straight forward so only the total level is
measured with no account being taken of increased binding with sex hormone
binding globulin that occurs with age (or the individual). Also not
enough longitudinal studies have been done to know if changes are due to
relative or absolute levels. So, why not consider symptoms? Note plural,
consider the whole person.
Why should hypogonadism have to be clearly shown? This seems to be
the let out to not treating men who have a range of symptoms which
circumstantially point in the direction of andropause changes.
Circumstantial evidence is used in many other treatments, how often is the
specific bacteria causing an infection positively identified before the
use of an antibiotic? Why isn't testosterone treatment tried to see if an
improvement of conditions results. Even higher than normal 20 years' old
levels might be useful. If levels are not too much above those levels
little evidence of a deleterious consequences exist.
Yes, other common endocrine disorders exist as do other medical
disorders but this does not show the lack of an andropause and may even be
the result of it in some cases. They seem to be brought in here just to
confuse and side step the issue that some men may be helped with
testosterone treatment at pre- hypogonadism levels. Yes, the
endocrinology of ageing is broad but Howard Jacobs, in this rebuttal,
seems set against the concept that some men of middle age might have
deleterious physiological changes which could be treatable after only
considering symptoms instead of practically impossible to achieve proofs.
Competing interests: No competing interests