Dr. Qaadri

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Andropause-Menopause for Men

By Dr. Shafiq Qaadri, M.D.

A Puzzling Presentation
A 34-year-old male patient had a puzzling constellation of symptoms, which became a lesson in not attributing things to somatization. His symptoms included: feeling constantly tired, hot flashes, irritability, loss of sexual desire, mild headache, and vague joint pains. His hair was quite short, yet he stated that he had not had a haircut for two years. He denied being depressed, and was in fact a successful businessman who enjoyed his work and marriage.

What struck me most about the patient’s symptoms was that he seemed to have all the problems of a woman going through menopause.

Initial History and Exam reveal little
The physical exam was entirely unremarkable. His preliminary bloodwork was also all normal, except for a mild Iron deficiency anemia, Hb 138 (140-180 ref. range). In particular, his thyroid indices were normal, as were his renal function, rheumatoid status, and a drug screen.

The number of diffuse symptoms made me consider a psychosomatic problem, and I had the patient complete some depression and anxiety questionnaires. But these were all negative.

So his many symptoms, and the earnestness with which he wanted help, continued to trouble me.
A corridor consultation with a neurologist

As I was about to attribute this diffuse constellation of problems to somatization, I happened to speak to a neurology colleague. He advised that I should get a full hormonal screen: Prolactin, FSH, LH, and free Testosterone levels. The neurologist too was struck by the female menopausal quality of the symptoms, and advised that I read about andropause, the male version of menopause.

The results revealed that the patient had hyperprolactinemia, which was depressing his free testosterone and LH levels:

Prolactin 46.6 (4.1 -18.4 ug /L)
Free testosterone 28.1 (31.0 -94.0 pmol / L)

The patient was experiencing a chemical andropause, which opposed the androgens, leading to the menopausal quality of the symptoms.

A subsequent MRI revealed a 7 mm density in the sella turcica, a pituitary microadenoma according to radiology. On the advice of the neurology consultant, I started the patient on bromocriptine (Parlodel) 1.25 mg tid, and his microadenoma and symptoms are resolving steadily.

This case highlights the importance of a detailed history, that consultation and direction from colleagues is welcome, and that we MDs should not ascribe what we're not entirely familiar with to that black box—somatization or ‘stress.’

· Andropause is the clinical manifestation of declining androgen levels in the aging male. Androgen deficiency in the Aging Male (ADAM) is the one of the diagnostic terms.

· There is a wide age-range that men may experience symptoms, usually from their 40s to 70s. Symptoms include physical, psychological, and sexual difficulties.

· Testosterone declines in all men, but thresholds vary for symptoms. Starting at approximately age 30, levels decline by 1% per year.

· Free (bioavailable) testosterone measurements are only a guide; the diagnosis is based on a subjective global impression.

· Some men are offered Testosterone Replacement Therapy (TRT), though prostate cancer potential must be monitored closely.

· Though less common, some patients experience a chemical andropause secondary to an endocrinopathy, such as the prolactin-secreting tumor discussed in this Case History.

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

1. Qaadri, S. 'When men go through The Change,' The Globe and Mail, Ed. Joan Ramsay. January 22, 2002.

2. Casey, Richard (Ed.) et al. Journal of Sexual & Reproductive Medicine, Autumn 2001.

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