The Diagnosis and Treatment of Andropause

Andropause is a word that's sometimes used to describe two different conditions.

One meaning of andropause is the typical, expected decline in testosterone production that happens to men as they age. People may use this term to correlate male aging and hormonal changes with those that happen to women with menopause.

However, this phenomenon is very different (and easier) in males. Whereas women normally have a steep drop in estrogen production around age 50, it's normal for men to have their testosterone gradually decline over decades.

Men's testosterone levels are expected to dip about 1 percent per year beginning between ages 30 and 40, according to Mayo Clinic. However, if you start with normal testosterone levels as a young man, this natural decline is nothing to worry about, and you might not even notice it.

"I had to write a book chapter on andropause a couple of years ago, so it's definitely a term that's used, but I don't really use it in my practice," said Neel Parekh, M.D., a urologist and fertility specialist with Cleveland Clinic. "I just usually talk about it as 'lower testosterone,' and that's something I tell patients every day: It's just a normal part of aging."

Your testosterone levels are likely to decline, but a healthy lifestyle goes a long way toward battling these natural declines.

The second meaning that may be indicated by the word andropause is testosterone deficiency or late-onset hypogonadism. This is a clinically diagnosed condition that affects about 2 percent to 8 percent of men, according to Cleveland Clinic, in which a man's body doesn't produce sufficient testosterone.

It's defined as having total testosterone levels of less than 300 nanograms per deciliter (ng/dL), along with the symptoms described below.

How is andropause diagnosed?

If you suspect you may have low testosterone beyond the normal decline for your age, you'll be asked to come in for a physical exam first. Your healthcare provider will also take a history and check for conditions that can be linked to hypogonadism, including the following:

• Absence of testicles
• An undescended testicle
• Alcohol use
• Anabolic steroid use
• Certain medications
• Cirrhosis of the liver
• A history of chemotherapy or radiation therapy
• HIV/AIDS
• Orchitis or inflammation of the testicles
• Obesity
• Obstructive sleep apnea
• Opioid use
• Poorly controlled type 2 diabetes
• Testicle injury
• Tumors

Next, you'll be scheduled to undergo two separate blood draws. These will take place between 8 a.m. and 10 a.m., a week or two apart, to test your total testosterone levels. Morning is typically when men's testosterone levels are highest, so this is the ideal time to get an accurate count of how much your body is producing.

If you've recently been sick, be sure to tell your provider since illness can affect your results.

They'll also test for a couple of other hormones that are less well-known but also important: luteinizing hormone (LH) and prolactin.

Luteinizing hormone

This is a crucial hormone produced in your pituitary gland that instructs your testicles to make testosterone. Its levels should remain stable after puberty. If the LH levels are low, it may indicate a low testosterone problem that originates in the pituitary gland.

Prolactin

Prolactin is a hormone that contributes to numerous bodily functions in both men and women, including breast tissue development and lactation in pregnant women. For men, prolactin levels are typically below 20 nanograms per milliliter (ng/mL). Higher levels can cause erectile dysfunction (ED), low testosterone and gynecomastia (development of breast tissue in males).

What are the symptoms of andropause?

Identifying symptoms of low testosterone or late-onset hypogonadism may seem relatively straightforward at first, but it can get complicated. Keep in mind that in order to come to a diagnosis of hypogonadism, the patient must show two consecutive tests with total testosterone levels lower than 300 ng/dL, as well as some of the following symptoms:

• Brain fog
• Breast swelling or discomfort (gynecomastia)
• Decreased energy
• Decreased motivation
• Decreased spontaneous erections or ED
• Depression
• Difficulty concentrating
• Flushing, sweats or hot flashes
• Height loss, low-trauma fractures or low bone density
• Increased body fat
• Infertility
• Insomnia
• Lower self-confidence
• Reduced libido
• Reduced muscle mass

"We don't just treat a lower testosterone level unless they're having symptoms," Parekh said. "We don't just treat a number."

The tricky part—and where the other meaning of andropause as natural testosterone decline with age comes into play—is that many of these symptoms are also linked to various other conditions that go along with getting older.

For instance, stress can lead to ED, insomnia, difficulty concentrating and depression. Also, obesity involves increased body fat and may contribute to decreased energy, lower self-confidence, ED, depression, etc.

That's why healthcare providers need to reach their diagnosis using the criteria listed above: two testosterone tests confirming low total testosterone and additional symptoms.

"Whenever I have someone with lower testosterone, I order a confirmatory testosterone level in the morning, then also order some additional blood tests like LH, prolactin, a thyroid panel, PSA, those sort of things," Parekh said. "But a lot of guys are getting testosterone when they don't have a true diagnosis of primary or secondary hypogonadism. If you come in with those signs and symptoms, they can be pretty vague. They can be associated with a lot of other medical conditions, so it's important not to get fixated on that."

Treatment of andropause

Men can wield a great deal of control over andropause and its symptoms. Many lifestyle choices can improve testosterone levels, and they are relatively easy to accomplish, including the following:

• Eat whole, natural foods and reduce highly processed foods
• Get at least the recommended 150 minutes of exercise per week
• Get good quality sleep
• Maintain a healthy body weight
• Quit smoking
• Reduce alcohol intake

Even if you are diagnosed with clinically low testosterone or late-onset hypogonadism, your healthcare provider will likely discuss your fertility plans, whether you plan on having children at some point. That's because taking testosterone supplements—aka exogenous testosterone, or testosterone that comes from outside the body—can cause your testicles to stop producing sperm.

In some cases, this change can be permanent.

You should be counseled on fertility issues and the possibility of banking sperm if you might want to have children. Healthcare providers then may suggest one or more of the following:

• Intramuscular testosterone injections
• Testosterone nasal gel
• Testosterone patches
• Testosterone pellet implants
• Testosterone skin gels

Conclusions about andropause

There's good news and bad news about andropause. Your testosterone levels are likely to decline, but you have a great deal of control over them. A healthy lifestyle goes a long way toward battling these natural declines.

If you have clinical hypogonadism, the treatments are relatively simple, inexpensive, modifiable to each individual's needs and widely available. Just be sure to get the properly administered tests and diagnoses to confirm a true need, and remain open to the possibility of other factors contributing to any symptoms you may be experiencing.