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Drug firms and doctors tout treatments for 'male menopause'; others are cautious

"Male Menopause," by Jed Diamond. (Jed Diamond - Jed Diamond)
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Monday, October 4, 2010; 5:56 PM

When it comes to the peculiar burdens of womanhood, menopause has to be somewhere near the top of the list, right alongside childbirth and bikini waxes.

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But it seems that midlife hot flashes, mood swings and dwindling libidos may not be entirely female concerns after all: Doctors, researchers and drug companies have begun making the case that men also experience a change of life. This male menopause - "manopause, " if you will - is said to stem from an age-related decline in testosterone, the hormone that plays a key role in everything from puberty to maintaining muscle strength and bone mass to sex drive.

"What we see is that for men, often beginning in their late 30s or early 40s, there is a gradual drop in testosterone of about 1 to 2 percent a year," explains Robert Brannigan, a urologist at Northwestern Memorial Hospital in Chicago who has been researching the phenomenon. "It's not as dramatic or as abrupt a change as is often the case in women, but there is this subtle shift in hormone levels that can result, over time, in a man crossing a threshold where he then has a deficit of testosterone."

This can result in a range of symptoms that "have a huge overall impact on day-to-day life," he says, including depression, irritability, low energy, decreased muscle mass, weight gain, sexual dysfunction and even the occasional hot flash or night sweats.

"We're talking about a lot of men here," adds Brannigan, who estimates that at least 5 million U.S. men are affected by late-onset hypogonadism, which is the clinical term for the condition. "Unfortunately, the vast majority are undiagnosed."

That's partly because this newly recognized condition is hard to identify given it's laundry list of possible symptoms. But research published recently in the New England Journal of Medicine definitively linked low testosterone levels to low sexual desire, and erectile dysfunction, and a poor morning erection, and concluded that these three symptoms must be present to diagnose late-onset hypogonadism. The study, which tracked 3,369 European men between the ages of 40 and 79, also showed that low testosterone was only somewhat related to such physical and psychological problems as an inability to engage in vigorous activity, sadness and fatigue.

Still, the notion of male menopause remains controversial. In fact, a recent article in the Drug and Therapeutics Bulletin that reviewed dozens of studies found that men's testosterone levels do not always drop with age, that low levels in older men do not necessarily produceany specific symptoms and that men with normal hormone levels experience many of the problems commonly associated with low testosterone, including sexual dysfunction, diminished strength and depression.

Indeed, critics suggest that most of the symptoms that have been blamed on "low T" are normal consequences of aging.

"It's still controversial as to whether low levels of testosterone represent a medical problem," says Jason Wexler, an endocrinologist at Washington Hospital Center, who notes that issues such as a lack of energy and motivation, poor memory and weight gain are "highly nonspecific" and can also be related to a slew of other medical conditions. . In most cases, he said, "I don't think there's a direct correlation between the way men feel as they get older and their testosterone levels. So for me, there is great reluctance to call that a disease."

Such informed skepticism hasn't stopped some pharmaceutical companies from marketing the bejesus out of the concepts of low T and male menopause - and it hasn't stopped men from seeking tests and receiving testosterone prescriptions, which have skyrocketed from 2.4 million in 2005 to nearly 3.9 million in 2009, according to the consulting firm IMS Health.

"I think the problem is that you have a captive audience," says Andrew Kramer, a University of Maryland School of Medicine urologist and surgeon. "When a commercial [for low-testosterone-related products] asks, 'Do you have lower energy? Are you not sleeping as well? Is your libido down? Are your erections not as good as they used to be?' every man, of course, is like, 'Yeah, that fits.' "

The fear is that this sort of hyper-awareness will lead to an overscreening of the aging male population, either because patients demand it or because doctors feel they must cover all their bases in this litigious age.

"There is this potential setup for men to be screened when they shouldn't be, and for low testosterone levels that don't represent a problem to be 'discovered' on lab testing and then get misinterpreted as being a low level that requires some intervention," says Wexler. "And that men who should never have been screened, whose testosterone levels have nothing to do with how they feel, are now going to get supplementation, when we really don't have a good body of scientific literature to tell us whether testosterone supplementation in aging men is even safe in the long run." He wonders if the cost and risks of this hormone replacement are worth it, when the benefits are also largely unknown at this point.

Northwestern's Brannigan says yes, largely because of the potential impact on a man's quality of life.

"The question is this: Do patients sit back and let these changes occur and deal with the change in how they feel and function, or do they actually pursue available treatments that in many cases can help?" he says, noting that he has had great success in his clinical practice with topical, injectable and implanted testosterone supplements as well as with medications that stimulate the body's production of testosterone.

Still, Brannigan stresses that men with prostate cancer, a history of breast cancer or untreated sleep apnea and those who are trying to conceive a baby shouldn't use the synthetic hormone. "It's not the answer for everybody, but I find that for many patients, it can restore or optimize how they feel on a day-to-day basis, and in many instances it's not only impacting [a man] but also his relationship with an intimate partner, who is also a part of this equation."

Regardless of where they stand on the matter, experts seem to agree on one thing: Though catchy and hard to ignore, terms such as "male menopause" and "manopause" send the wrong message.

" 'Male menopause' is a loaded term, " says Wexler. "It's got so much baggage, this idea that there's this condition that is somehow equivalent to the female menopause.

"There are definitely men out there who have symptoms, who have low testosterone levels and can benefit from therapy, but the term 'male menopause' or 'andropause' implies that this happens to all men as they age, like menopause happens to all women as they get older, and that's just not the case."



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