Health risks associated with male andropause

Health risks associated with male andropause

Andropause, also called male menopause, is a term used to describe symptoms which can appear in aging men due to slow, progressive decline in production of testosterone and DHEA mostly in Leydig cells. Other than aging factors which may add to reduction of gonadal function in men are stress, obesity, illness and some medications.                                                                                                                                                                  

It needs to be noted that lower testosterone levels can be found in healthy, asymptomatic men as already from age of 30, serum levels of testosterone begin to slowly decline. By the age of 70 plasma testosterone levels are often 35% lower comparing to the young men and by the age of 80 the male hormones levels drop to the pre-puberty levels.

It is believed that testosterone levels decrease on average 1% per year starting at age of 30.

In physiological state up to 98% of testosterone is protein bound: one third to albumin, weak bound, and two thirds to sex hormone-binding globulin (SHBG), tight bound. Only 1-2 % in circulation is free testosterone. Once testosterone reaches target cells it is transformed to active forms: DHT (dihydrotestosterone) and estradiol.

The causes of testosterone decline related to aging are multifactoral:

• Decreased number of Leydig cells
• Loss of physiological morning peak in testosterone release
• Increased concentration of SHBG and secondary decrease of free testosterone level
• Some degree of impairment of hypothalamic- pituitary function

There is a general agreement that symptoms of andropause usually develop once the plasma testosterone levels drop below 200-300 ng/dl.

Because the decline is very gradual (not like in female menopause) the clinical presentation might be difficult to recognize. Usually the first signs include decrease in energy levels, irritability, mild cognitive impairment, loss of morning erections

There are many health risks associated with male andropause

1. Andropause may lead to increased mortality due to:

• Cardiovascular disease
• Stroke
• Cancer
• Suicides due to depression

2. Andropause may lead to increased morbidity due to:

• Osteoporosis with increased risk of fracture
• Anaemia
• Atherosclerosis (cerebral, coronary arteries)
• Diabetes and pre-diabetes
• Overweight and obesity
• Dyslipidemia (high TG, low HDL)
• Metabolic syndrome
• Depression
• Dementia
• Frailty syndrome (reduced functional reserve)

3. Andropause may cause decreased quality of life due to:

• Fatigue, reduced activity
• Decreased libido
• Erectile dysfunction,
• Decline in sexual satisfaction and quality of erections
• Decline in physical capability
• Decreased muscle mass
• Increased body fat, central and upper
• Depressed mood, irritability
• Cognitive impairment, poor memory, poor concentration
• Insomnia, poor quality of sleep leading to increased need for napping
• Decreased motivation
• Some men might report hot flashes

On physical examination the practitioner may also notice decreased body hair (beard, armpits and pubic area), gynecomastia as well as aged, thinner skin with loss of tonus.

The following conditions may predispose to male andropause:

• Pre-diabetes and diabetes
• Alcoholism
• Obesity
• Chronic renal disease
• Liver cirrhosis
• Sleep apnea
• COPD
• AIDS
• Steroid and narcotic medications abuse

It is difficult to establish the exact pathophysiology between the above symptoms and low levels of testosterone, but there is lots of evidence proving improvement of these symptoms once the testosterone replacement therapy is initiated.

Decreased muscular mass and strength related to low levels of testosterone is easy understood. Testosterone has anabolic effects therefore its lack will lead to these problems.

It might be difficult to distinguish between sexual dysfunction and other conditions like depression or vascular disease. Absence of nocturnal erections usually is typical for andropause. The diagnosis might be confirmed with presence of other symptoms and signs.

It is believed that CVI and cardiovascular diseases are secondary to atherogenic dyslipidemias (high TG and low HDL) resulting from low testosterone levels.

Summary

Male andropause is a commonly occurring syndrome in aged men. It initial diagnosis might be difficult as symptoms develop gradually and over a prolonged time. Diagnosis is crucial in order to treat and to prevent many health risks, which include increased mortality, morbidity and poor quality of life.

References:

1. Testosterone: The Male HRT for Andropause. 2000 Drugs and Therapy Perspectives 16(10)
2. Seidman S.N., Normative Hypogonadism and Depression: Does “Andropause Exist? 2006 International Journal of Impotence Research18(5):415-422
3. Brawer M.K., Testosterone Replacement in Men and Andropause: An Overview. 2004 Reviews in Urology 6(Suppl 6): S9-S15
4. Bassil N., Alkaade S., Morley J., The benefits and risks of testosterone replacement therapy: a review. 2009 Therapeutics and Clinical Risk Management 5:427-448
5. Ramasamy R., Fisher E.S. Schlegel P.N., Testosterone replacement and prostate cancer. 2012 Indian Journal of Urology Apr-Jun;28(2):123-128
6. Schwarz E.R., Phan A., Willix R.D., Andropause and the development of cardiovascular disease presentation-more than epi-phenomenon. 2011 Journal of Geriatric Cardiology Mar;891):35-43
7. Golding C., Testosterone and Andropause 2013 Advanced Diploma in Aesthetic Medicine Module 2 Edition 2 FPD