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Male menopause out of the closet

As men age, their testosterone levels gradually decline and some men go through what is now called male menopause. But many never get diagnosed or treated because, until now, little has been known about the condition.
/ Source: contributor

Several years ago Dave O'Neal, 47, was having serious health problems that no one could diagnose.  The Columbia, Ill., man was totally uninterested in sex and had very low energy levels. O'Neal went to several doctors and even a therapist but no one could tell him what was wrong.  Eventually O'Neal was diagnosed with androgen deficiency, a problem of low testosterone levels in the body, also known as male menopause.

"One doctor just told me to take some vitamins and I thought it was depression, but they would never diagnose it as full blown depression," says O'Neal.

As men age, their testosterone levels gradually decline and some men go through what is now called male menopause. But many never get diagnosed or treated because until now male menopause has been in the closet.

"The male ego doesn't usually ever want to admit to having a problem. Men want to be macho and if they have a problem they just don't want to talk about it," says O'Neal. "I have had several guys come up to me and ask me questions. But the guys will only talk to me in private."
O'Neal thinks the issue is now becoming more mainstream in part because he and so many other men are finally beginning to discuss their experiences.

O'Neal has been giving himself testosterone injections twice a month for the past 5 years and now has no symptoms of male menopause. He also has few problems with depression and says he has a healthy sex life.

Signs and symptoms
While menopause is relative easy to diagnose in women -- their menstrual periods stop -- diagnosing male menopause (also known as andropause) in men is trickier and requires a blood test to check testosterone levels. Consequently, the condition often goes undetected.
"Very few people are addressing the problem of male menopause and the profound consequences the loss of testosterone can take on a man," says Dr. David Thomas, a professor of geriatrics at St. Louis University School of Medicine.

Thomas says of the estimated 4 million to 5 million American men with low testosterone, only 5 percent currently are being treated.  About one in every 10 men between the ages of 40 and 60 has low testosterone. Among men over the age of 60, the numbers jump to one in every five men, according to researchers.

"I think it is still in the closet but it is gradually coming out of the closet," says Dr. John Morley, who heads up the department of geriatrics at St. Louis University. "Low testosterone is a real condition that can cause men problems with their sex drive, strength and memory, and make them susceptible to weakened bones. But detecting the problem can be sticky because many men don't want to admit their sex drive isn't what it used to be."
Morley has now created a 10-question, Androgen Deficiency in Aging Men (ADAM) screening tool to help physicians detect the problem.

A horomone study for men?
In addition, Morley is calling on the federal government to fund a major study that would assess the long-term risks and benefits of treating middle-aged men with testosterone therapy. He is pushing the National Institutes of Health to fund a Men's Health Initiative that would cost up to $200 million. The study would be an 8-to-10-year project involving 16,000 to 20,000 men who have low testosterone and would examine the effect of testosterone therapy on prostate cancer and cardiovascular disease, as well as on improvements in mobility and decreases in spinal fractures.

"The delay in doing the Women's Health Initiative resulted in many women using an estrogen/progestin combination to prevent heart disease when it clearly increased it," says Morley. "We have the opportunity not to make the same mistake in men."

Currently, a small number of studies have shown that testosterone replacement in men who have low levels of the hormone can improve libido and enhance sexual function. The studies have also shown that testosterone replacement therapy can increase bone mineral density, muscle mass and strength, and help improve mood. However, research to date has not documented whether testosterone replacement therapy has adverse side effects.

"I am not sure it has to be done at the same level as the Women's Health Initiative but we need something. They had 20,000 women. We think a study with 6,000 men could answer the questions in a 5-to-6-year study," says Dr. Glenn Cunningham, a professor of medicine at Baylor College of Medicine in Houston.

For now, a key concern is whether long-term testosterone therapy may affect a man's risk for prostate cancer. It's possible that the treatment could raise hormone levels in the body and accelerate the growth of pre-existing prostate cancer tumors, experts say.

O'Neal, who has been injecting testosterone twice a month for more than 6 years, gets screened for prostate cancer every 6 months.  He undergoes a PSA (prostate specific antigen) exam, a routine blood test that helps detect prostate cancer.

"I think this is where the man has to have a relationship with his physician and his physician has to be an educator and have a thorough discussion of what are the man's symptoms. Right now, the risks appear to be low when it comes to prostate cancer. But we need to quantify those risks," says Dr. Kevin Loughlin, a professor of surgery at Harvard Medical School and a senior surgeon at Brigham and Women's Hospital in Boston.

Getting the word out
While many men have never heard of male menopause, often their physicians are hesitant to bring up the issue because there are still so many unanswered questions about who would benefit from replacement therapy.

"I think it's a joke," says Paul Joste, a 45-year-old painter in St. Louis. Joste believes lower testosterone levels are part of the natural aging process and should not be turned into a medical problem. Like many other men in his age group, Joste doesn't want to visit a doctor for regular checkups and don't see a need for hormone therapy.

But Morley and other experts contend that Joste is terribly misinformed. They say many men who are middle-aged today will live well into their 80s and 90s and need to be concerned about the issue.

Dr. Larry Lipshultz, a professor of urology at Baylor College, says Joste and other men like him will soon be changing their minds once they are better educated -- or once they develop more severe symptoms.

"I know men are interested in it and I know more men are showing up for a diagnosis and treatment. You can just see that more prescriptions for testosterone are being given out. There is steady growth," says Lipshultz.

For now, most medical experts agree that only men over the age of 40 with symptoms of low testosterone should have a blood test and be screened.

The NIH has asked the Institute of Medicine to determine whether a large study on testosterone replacement therapy, similar to the Women's Health Initiative, is justified. Committee members at the IOM have been interviewing experts on testosterone therapy, including Morley, and a recommendation is expected later in October.