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)

Diagnosis
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.’

Summary
· 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

References:
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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