In the fourth and fifth decades of life, testosterone levels in men can start to decline. The rate of decline varies between individuals and is affected by chronic diseases and lifestyle choices. It is an often underdiagnosed and undertreated condition, with it being estimated that only 5-35% of those experiencing andropause receive treatment. The World Health Organization estimates that the world's population aged 60 years or older will double by 2050 to nearly 2.1 billion. In an increasingly aging population, understanding how to identify and support men with andropause is important. (9)
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What is Andropause?
Andropause is a condition associated with decreasing testosterone levels in men as they age. It is also referred to as late-onset hypogonadism (LOH) and androgen deficiency in the aging male (ADAM). Although the term "andropause" makes it seem like it is the equivalent of menopause experienced by women, this is not the case. In andropause, there is not a complete cessation of reproductive function, and it does not affect all men. In fact, some research shows that andropause might not affect older men who are in excellent health. A diagnosis of late-onset hypogonadism requires both clinical symptoms of androgen deficiency as well as low serum testosterone levels. (6,7)
What Causes Andropause?
Normal changes related to aging can cause andropause, but certain underlying conditions can also lower testosterone levels. Possible conditions include chronic kidney disease, COPD, obesity, type 2 diabetes, sleep apnea, chronic stress and mental health conditions, hypertension, and high cholesterol. Certain lifestyle choices like substance and alcohol abuse, sleep restriction, and lack of physical activity can also contribute to hormone changes in andropause.
What Age Does Andropause Occur?
Studies in male aging show that testosterone levels decline about 1% per year after age 30, but a noticeable decline typically occurs after 50 years old. If or when men experience andropause symptoms depends upon testosterone declining to a pathogenic level. It affects an estimated 10% of men over 50 years old and up to 20% of men over 60 years old. (1)
Symptoms And Effects Of Andropause
The nonspecific nature of andropause symptoms can make it difficult to identify based on symptoms alone. Some characteristic symptoms include:
- Erectile dysfunction
- Decreased sexual activity
- Loss of libido
- Decreased strength
- Decreased energy
- Hot flashes
- Gynecomastia (Enlarged breast tissue)
Other less specific symptoms include:
- Decreased self-confidence
- Decreased motivation
- Depression
- Decreased concentration
- Memory changes
- Insomnia
Impact On Overall Well-Being And Quality Of Life
Men with low testosterone levels report higher levels of depression and lower quality of life, especially related to lower energy and sexual functioning. Andropause is also correlated to certain health risks, which are affected by the age of onset and the severity of testosterone deficiency. These include anemia, decreased bone density, decreased muscle mass, obesity, and insulin resistance. Men with testosterone deficiency have an increased risk of mortality in general than men with normal testosterone levels. (4,8)
Importance Of Personalized Care And Treatment Plans Based On Lab Test Results
Andropause often presents with nonspecific symptoms and can vary between individuals. It is important to learn how to identify individuals experiencing andropause because proper treatment can improve health and quality of life.
Physical Examination and Medical History
Screening tools exist to help clinicians identify men potentially in andropause based on reported symptoms. Such tools include the 'Aging Males Symptoms' (AMS) questionnaire and the 'Androgen Deficiency in the Aging Male' (ADAM) questionnaire. Important symptoms to consider include fatigue, decreased stamina, depressed mood, changes in libido, and sexual dysfunction. Since these are nonspecific symptoms, a physical examination can be helpful in identifying more specific signs of andropause, like increased central obesity, decreased testicular volume, decreased muscle mass, increased body fat, and gynecomastia. A thorough medical history can also identify certain health conditions that increase the risk of andropause, such as diabetes, hypertension, cardiovascular disease, COPD, and autoimmune diseases. Medications should also be reviewed since certain drugs like opiates, corticosteroids, anabolic steroids, and ketoconazole can affect testosterone levels. Lab testing should be considered in either individuals who report signs and symptoms of testosterone deficiency or individuals whose medical history is positive for any of the aforementioned medical conditions or medications.
Functional Medicine Labs That Can Help Individualize Treatment for Patients With Andropause
The AUA (American Urological Association) recommends that a clinical diagnosis can be made in those individuals who report symptoms of testosterone deficiency and also have a testosterone level measuring below 300 ng/dl on two occasions. Serum testosterone levels vary throughout the day, so it is recommended to measure testosterone between 7 AM and 11 AM. Free testosterone and sex hormone-binding globulin (SHBG) should also be measured because lifestyle choices and chronic health conditions associated with andropause can increase SHBG. (1)
Since the development of andropause is multifactorial and varies between individuals, additional functional tests can be considered to help personalize treatment.
DUTCH Test
Decreasing testosterone levels are the primary driver of andropause, but other hormonal changes can be experienced as well. Often, DHEA levels will decrease, and estrogen will increase. Chronic stress and HPA axis dysfunction can contribute to the development of andropause. The DUTCH test is a dried urine test that assesses sex and adrenal hormone metabolites as well as the daily cortisol pattern. This allows practitioners to create a more comprehensive treatment for all of the hormone imbalances patients might be experiencing. (2,3)
Comprehensive Stool Test
The more we study the microbiome, the more ways we learn that it affects our health - including our hormones Comprehensive stool tests assess digestive function, intestinal inflammation, and the intestinal microbiome composition. Certain strains of bacteria produce the enzyme beta-glucuronidase, which impacts estrogen metabolism. An overabundance of this enzyme can lead to higher circulating levels of estrogen in the body, one of the potential hormone imbalances of concern in andropause. Furthermore, researchers have identified that certain microbiome compositions are associated with testosterone deficiency.
Body Composition Analysis
Andropause is associated with changes in men's body compositions, specifically decreasing muscle mass and increasing body fat. Anthropometric measurements are simple, noninvasive measurements to help track body composition. These include body mass index (BMI), body circumference (waist, hip, and limbs), and skin fold thickness using calipers. Bioelectric impedance is another option that passes a small electrical current through the body to measure the electrical resistance. This resistance, along with your height and weight, can be used to calculate body fat; however, it can be easily affected by how much water is in your body and where the electrodes are placed. More accurate but also more expensive measurements of body composition include hydrodensitometry (underwater weighing) and dual-energy X-ray absorptiometry (DXA). (9)
Psychological Evaluation
Andropause is associated with both mood and cognitive changes in some men. Both the Aging Males Symptoms (AMS) questionnaire and the Androgen Deficiency in the Aging Male (ADAM) questionnaire include questions about mood. To gather more detailed information on psychological health, practitioners can utilize questionnaires like the PHQ-9. If cognitive or memory changes are of significant concern, practitioners can administer the Mini Mental State Examination (MMSE) to identify those individuals with mild cognitive impairment.
Additional Diagnostic Tests
The following tests can be considered as part of a health screening for men with andropause:
DEXA
Age-related hormone changes in men put them at higher risk of decreased bone density. A DEXA scan measures bone density using small doses of ionizing radiation to take images of the lumbar spine and hips. The Endocrine Society recommends that all men aged 50 and over with low testosterone undergo DEXA screening.
Cardiometabolic Panel
Low testosterone levels are associated with both cardiovascular and metabolic dysfunction. An NMR LipoProfile measures the amount of cholesterol in the body and can give more information about the size and density of the lipid particles to more accurately assess cardiovascular risk. The Diabetes Panel can help identify individuals at risk of developing diabetes by measuring markers like blood sugar, insulin, and hemoglobin A1c. The Boston Heart Expanded Cardiometabolic Panel is a very comprehensive panel that measures both cardiovascular risk markers and metabolic risk factors in one test. (5)
Prostate Health
It is recommended that men in andropause who are interested in testosterone replacement therapy receive a prostate health exam. This includes a PSA test at 3, 6, and 12 months and a digital rectal examination at 3-6 months and 1 year after beginning therapy. Both should be continued annually after that. All men over the age of 50, even if they are not interested in testosterone replacement therapy, should also receive a digital rectal exam as part of general age-related cancer screening.
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Summary
Andropause is a condition that some men will experience as they age due to decreasing levels of testosterone. The development of andropause is multifactorial, and its presentation varies significantly between individuals. Because of this, andropause is a condition that lends itself well to a functional medicine approach.
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