Dr. Qaadri

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Andropause Discussion

By Dr. Shafiq Qaadri, MD

What is Andropause?
It is a complex question. Andropause occurs in the aging male, men over 40. It’s a symptom cluster caused by decreasing testosterone levels, and these Andropause symptoms are ameliorated by treatment with testosterone.

What are the symptoms?
There are two broad categories: sexual and non-sexual. The sexual symptoms get the greatest emphasis: decreased libido and erectile dysfunction. Yet these may not be the most important in terms of metabolic function.

The non-sexual side symptoms are weakness, fatigue, moodiness, irritability, decreased self-confidence, decreased motivation; the associated osteoporosis can also cause symptoms.

All these symptoms are based on the multiple physiologic effects of testosterone insufficiency.

Is it a real clinical entity?
This is a frequently posed question. We do know that as men age they develop some of the symptoms that I’ve described. There’s no dispute about that.

There’s also no dispute that as men age, testosterone levels tend to drift downward (particularly bioavailable testosterone).

We also know that some men with these symptoms, who have low testosterone levels, respond when they are given testosterone.

What shall we call this? By international acceptance, we call it Andropause.

How is it diagnosed, on history or are there tests?
It’s diagnosed on history, physical examination, and laboratory studies.
On history, you will get the specific symptoms I’ve highlighted. That will give you a clue, particularly in a man over 40.

There may be some findings on physical examination. If you have very severe loss of testosterone, you may have a diminution of body, facial, and pubic hair. You may get frank muscle wasting and diminution in the size of the testes. But sometimes physical examination isn’t all that revealing.

The other finding is that a man with symptoms, who may not have any physical findings, has a reduced testosterone level.

What is the concept of relative testosterone deficiency?
When you order a serum testosterone level, the lab will give you a range. The lab might even adjust that range on the basis of age. A relative androgen deficiency is a testosterone level that is within the normal range but toward the low end.

Such a man would still qualify as being an andropausal candidate, since his testosterone was lowish. For example, let’s say the normal range for total testosterone is 10-35 nmol/L. So 11 nmol/L would still be normal, but perhaps that man was accustomed to have a level of 25 nmol/L in his youth. That man, although his testosterone level is still within the normal range—may be androgen insufficient.

Do you recommend testing at all? And if so, are there any specific tests?
It depends on the symptomatology. Testosterone levels should be part of the testing. A man should also have his hemoglobin, thyroid function, and possibly liver function measured.

There’s another point: many physicians see male patients with anemia. How many physicians think of that anemia being related to low testosterone?

One of things that testosterone does is stimulate erythropoietin, a hormone in the kidneys, which then enhances and stimulates hematopoiesis. So men with low levels of hemoglobin, particularly if there’s no other obvious cause, should have their testosterone levels measured. It can be very rewarding to treat a patient with a low testosterone, and then observe the hemoglobin responding.

What are the treatment options?
Let’s focus on testosterone, since Andropause is a testosterone deficiency state.

We don’t want to ignore other elements of the patient’s general health. For example, the man may be depressed, and testosterone may alleviate the depression to a certain extent, but he may need other forms of therapy.

For testosterone, there are several options: the classical treatment for has been the intramuscular injection. For a few years in Canada, we’ve had an oral form of testosterone, and now we have two topical forms, the patch and the gel.

Are the non-injectable testosterone replacements an improvement over the injectables, from a pharmacodynamic point of view?
Yes. The injection gives you an immediate—within a day or two—high level, usually super-physiologic. This then tapers off, reaching pre-treatment levels after two weeks.

The other forms of testosterone treatment—the tablets and topical forms—give steady blood levels, if given in adequate doses.

I should also mention that blood levels are not always the important factor. The most important factor is how much testosterone is getting to the end organ. There’s no measure for that, except the patient’s responsiveness.

The great disadvantage with the injectable form (given every two weeks), is that some patients experience a bit of a let down. They respond, but they have a let down three days prior to the next injection.
It would, therefore, be preferable for them to have testosterone treatment that provides a more steady level.

Is there any way to distinguish between Andropause and depression, as the symptoms seem to overlap?
There are several approaches. An Andropausal man may have a true depression.

One way to see if you’re going to have an effect with testosterone, is to treat the man with testosterone. Often men who are depressed, whether or not they’re on an antidepressant, will feel better if you give them testosterone, especially if they have a lowish testosterone.

Is osteoporosis in men a concern?
It’s a very definite concern. Osteoporosis in men occurs much more frequently than we think.

For the most part, we don’t know the exact cause of osteoporosis in at least 50% of men. Whether a significant aspect of that causation is going to be Andropause, studies are still underway.

We do know that when you give testosterone to mildly hypogonadal men, their bone mineral density will increase. Does this result in a decreased incidence of fracture? We don’t know yet. Those studies are in progress.

What is the controversy with regard to testosterone replacement therapy and BPH (benign prostatic hypertrophy) and prostate cancer?
Let’s take BPH first. There’s not much of a controversy as far as I’m concerned, of course with appropriate caution. I do treat men with testosterone if so indicated. There are very few patients who have further prostate enlargement when given testosterone replacement therapy.

The question of prostate cancer is the main concern.

We do not have any evidence that testosterone will lead to new cancers. The issue is, will we stimulate the development of an existing prostate cancer?

It will take many more years of study to determine if we will. We have to be cautious of starting testosterone in men, and we have to have a reasonable degree of confidence that they do not already have a prostate cancer, which we can never know for sure. We must monitor men, and be watchful of any changes on the digital rectal examination, or PSA levels.

We should also be watchful of hemoglobin in patients on testosterone therapy. A certain percentage of men, between 10-25%, will develop hemoglobin levels that are inappropriately high. That means cutting back the dose of testosterone, not stopping.

Is Andropause primarily a lifestyle or quality of life disorder?
Is hypothyroidism a lifestyle disorder? If you’re thyroid-insufficient, and you’re symptomatic from it, the patient’s lifestyle will improve if you treat the patient with thyroid hormone.

If one has a physiological insufficiency state, which is causing symptoms, that’s not just a lifestyle issue. Treating Andropausal men with testosterone is replacing that which is missing.

There’s even early evidence to suggest that testosterone treatment may be cardioprotective.

What is the CAS?
The CAS is the Canadian Andropause Society. Our mandate is to promote further knowledge and research about Andropause, both for physicians and the general public—on how to look for Andropause, how to monitor, how to treat.

What’s your final advice to physicians who want to learn more about Andropause?
If patients present with some of the symptoms we’ve discussed, send them for a serum testosterone level. (The bioavailable testosterone is the best level.) This will help determine if they are candidates for testosterone replacement therapy.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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