This article discusses andropause or viropause -- a syndrome associated with lack of or absence of testosterone.  Even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it was just ten years before. In fact, by age 80, most male hormone levels have decreased to pre-puberty levels. There are two general forms found in adult men who had normal hormone levels through puberty and young adulthood and who experience normal sexual development.  One form, analogous to female menopause, as associated with the rapid drop of testosterone levels.  Typical symptoms of this include:

• Fatigue, loss of a sense of well being -- 82%
• Joint aches and stiffness of hands -- 60%
• Hot flashes, sleep disturbances -- 50%
• Depression -- 70%
• Irritability and anger -- 60%
• Reduced libido -- 80%
• Reduced potency -- 80%
• Premature aging
• Changes in hair growth and skin quality

Sounds familiar..... for women at midlife..... because it is the same condition because the relationship between the ovaries, estrogen, the brain, and the pituitary are exactly the same as the relationship between the testis, testosterone, the brain, and the pituitary.   Acute andropause in men is relatively uncommon, compared to acute menopause in women, because testicular function declines gradually in most men.  There are a number of common causes, however, for acute testicular failure in adult men and these include:

• viral infections such as mumps (which fortunately has been eradicated by immunization)
• surgical removal of or surgical injury to the testis and male reproductive tract ( testicular cancer, hernia repairs, ??vasectomies)
• diseases when the immune system attacks and destroys the testis such as variations of systemic lupus erythematosis
• subtle genetic abnormalities which permit normal adult development but lead to premature testicular failure (such as chromosomal mosaicism)
• generalized vascular diseases such as diabetes and perhaps even problems caused by heavy smoking
• chemotherapy
• pituitary tumors (very rare)

The second form of this syndrome is more insidious since it occurs gradually.  It is often confused with male midlife psychological adjustment disorders because it exactly mimics depression in midlife men.  Male hormones decline gradually.  Testosterone (from the testis), human growth hormone (from the pituitary), and DHEA and androstenedione (from the adrenal gland) all begin to drop.   For many men, this does not occur until their 60s or 70s but there are older where it occurs much earlier.  In addition, there is proteins in the blood which bind testosterone in a biologically inactive form.  These are called sex human binding proteins or globulins.  Their levels can rise in response to many conditions including medical disorders and exposure to other hormones including phytoestrogens (estrogens derived from plant sources such as soy) and other environmental estrogen -like compounds (pesticides, hormones used in agribusiness to produce fatter animals, etc.)   As an example, there is some data suggesting that men on low fat or vegetarian diets have lower testosterone levels.  The overall effect of rising sex hormone binding proteins is that there is less bio-available testosterone.

Diagnosis

First, men need to disassociate their ego from their testicles.  Men needs to realize and accept that this disorder exists, that it is a simple endocrine problem which is no different than thyroid disease or diabetes, and that it can be treated. Spouses and employers also need to be aware that this is real so they can identify these men at risk early before their work, home, and families are disrupted.  Perhaps, more important, physicians, psychologists, and other health providers need to be taught about this condition.  The current paradigm in medicine is that there is no biological basis for behavioral changes in midlife men so it is ignored.  But the diagnosis is quite simple--namely measuring either free testosterone blood levels or, as recommended by Dr. Malcolm Carruthers, computing the free androgen index <FAI>  (total testosterone x 100 /sex hormone binding globulin).  There is some controversy as to what level of testosterone in men is normal with low end values ranging from 250-400ng/dl.

At a free androgen index less than 50% , symptoms of andropause appears.  Of course, good medical care dictates that a comprehensive medical and psychological assessment along with a thorough laboratory assessment are necessary.

Testosterone Replacement Therapy

There is good evidence that testosterone levels drop as a man ages.  There is a huge debate whether the testosterone level in older men should be adjusted up the mean testosterone levels in younger men.

What are the risks?

• Prostate cancer-- At autopsies, most men by age 50 have nests of atypical cells in their prostate which look like prostate cancer cells.  There is a great deal of concern among urologists-- particularly in the US when medical malpractice suits are a major concern-- that increasing testosterone levels might activate prostate cancer.  On the other hand, there is a fair screening test called Prostate Specific Antigen (PSA) which all men over age 50 should have performed annually and which is relatively effective in detecting early prostate cancer.  There is no evidence in the medical literature that testosterone replacement therapy increases the risk of prostate cancer.
• Heart disease--there is a major concern that increasing male androgen levels would also increase serum cholesterol and serum LDL-Cholesterol levels.  Oral methyl testosterone in particular will raise blood cholesterol levels.  This increases the risk for coronary artery disease.  On the other hand, "good" cholesterol (HDL-Cholesterol increases with exercise.  Men using testosterone supplementation should have their serum lipids carefully evaluated and rechecked periodically.
• Liver Disease--the only orally available forms of testosterone for men in the USA contain methyl testosterone.  Unfortunately, if used for sustained periods of time, it can damage the liver.  The Physicians Desk Reference cites several different forms of liver damage from high dose methyl- testosterone including liver cancer, cholestatic hepatitis, and other liver diseases.
• Suppression of testicular function--As a general principle, whenever any hormone is administered, the gland which normal produces it ceases to function and recovery may be variable.  Patients with borderline low testosterone levels may commit themselves to lifelong therapy if they start with testosterone replacement.

What are the benefits?

There is no doubt that the administration to testosterone to men with true testosterone deficiency states will improve their health and sense of well being.  The symptoms listed above will disappear.  Unfortunately, impotence, or the inability to sustain and erection, does not respond well to testosterone therapy except perhaps only in men with severe hormone deficiencies.  This comprises approximately 8-16% of men presenting to physicians with erectile disorders.  There is no evidence that administering testosterone to men with borderline low testosterone levels will improve sexual functioning.  For more information on erectile disorders, see our article on Impotence.

Forms of Testosterone for Men

Pills

Methyltestosterone (Android,Virilon,Testred, Oreton)     10mg, 25mg (not recommended)

Testosterone undecanoate (Restandol, Andriol) 40mg, essentially a testosterone in oil preparation (not available in the USA)

Mesterolone (Proviron) 25mg -- less potent (not available in the USA)

Transdermal Preparations

Testosterone--transdermal (Testoderm, Testoderm TTS, Androderm)

Injections

The following forms of injectable testosterone is available in the USA.

• Testosterone Cyprionate 100 mg/ml
• Testosterone Propionate in Oil 100 mg/ml
• Testosterone Enanthanate 200 mg/ml

The usual dose is 1cc injected weekly or bi-weekly.  This route of administration eliminates the risk of liver damage which may be caused by methyl testosterone as well as eliminating the theoretical risk of changes in cholesterol caused by oral medications.  The problem is fluctuating hormone levels and the discomfort of administration.

Sub dermal Pellets

Many years ago, the Food and Drug Administration approved the use of testosterone pellets for male hormone deficiencies.  They are manufactured in our office by a compounding pharmacist. We place 6-8 testosterone pellets under the skin.   These pellets dissolve slowly  over a period of approximately  three to four months.   This provides a normal and very stable serum testosterone level.   I feel that the addition of androgens in this form causes less lowering of HDL cholesterol, as this does not pass through the liver.

The implant procedure consists of a small incision through which a trocar and cannula are inserted. The pellets are inserted through the cannula, and then the cannula is withdrawn. The incision is then closed with a Steri-Strip, and pressure is applied until bleeding stops, and the area is then covered with a dressing. We have not had any major problems in terms of side effects from this procedure. Some expertise is required in terms of placing the pellets so that underlying structures are not traumatized. 

The average cost per visit (approximately every 3 months) is in the range of $500. Insertion Fee is $160.00 and Pellets cost $40 apiece.

The requirement for the use of sub dermal pellets include

• Good General Health
• No evidence for heart disease
• Normal Cholesterol levels
• Normal PSA levels
• Normal prostate examination, no history of prostate disease

For a good reference, check out Malcolm Carruthers MD, Maximising Manhood, Harper Collins, London, 1997