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When men go through The Change

Thinning bones, a lowered sex drive, trouble sleeping:
Doctors are finally paying attention to andropause, Menopause for MEN

By Dr. Shafiq Qaadri, MD

TORONTO -- 'I was having hot flashes, I felt tired and irritable all the time. I was losing my sex life, and I couldn't sleep or concentrate. They didn't know what was going on with me," the 48-year-old patient said.

A woman going through the typical symptoms of menopause? Not quite: It was a man suffering through andropause, the male version of menopause. And despite the number of physical, psychological and sexual symptoms, it took doctors three years to correctly diagnose and treat him.

Had this patient been in Europe, he might have been diagnosed earlier, as European physicians seem to be more attuned to men's health issues. Indeed, just as women have dedicated gynecologists, men in Europe often have dedicated andrologists.

Some blame this neglect on men themselves. Facing midlife challenges, men tend to focus on erection problems, for which excellent therapies exist. But andropause entails a broader set of issues. "I thought I could pop some Viagra," as one 52-year-old said, "but I had more problems. I was turning into a grumpy old man and feeling down and depressed."

One patient's wife blames what she calls the "male attitude" for the lack of attention. "Men are so afraid to admit that anything wrong is going on in their body," she says. Indeed, a national poll shows that women are more aware of the notion of andropause than are men.

But the neglect, in fact, runs deeper. Physicians and researchers are also at fault. For example, consider the disorder of bone-thinning -- osteoporosis -- which till now has been thought to be almost exclusively a women's problem. Advertising, public-awareness campaigns, calcium supplements and prescribed medications -- all overwhelmingly target women. And the largest osteoporosis studies have involved thousands of women but no men.

It's as if physicians haven't realized that men have bones too. "Osteoporotic fractures in men have been, until recently, a neglected health problem," says Dr. Robert Josse, a bone-metabolism expert at the University of Toronto. Yet men do get osteoporosis, and in significant numbers. Men account for 30 per cent of hip fractures; 15 per cent of men over age 45 have related fractures.

Dr. Jack Barkin, for one, a Toronto urologist and director of the Male Health Centre, wants to bring men's health issues to the forefront, stating simply that "andropause is fact not fiction." But with little teaching in this field, doctors remain largely uninformed, despite ever-growing andropause research.

The Canadian Andropause Society was created to disseminate emerging findings, and teach physicians and pharmacists about related men's health issues. Dr. Roland Tremblay, an endocrinologist at Laval University in Quebec, and president of the CAS, says the association's goal is to help health-care providers master "the diagnosis, treatment and monitoring of aging men complaining of the clinical manifestations of [hormone] deficiency." The goal is to provoke a quiet revolution of andropausal men, who at this point remain largely ignored, undiagnosed and untreated.

Doctors and teenage boys know the dozens of effects of the male hormone testosterone, which first surges at puberty, so it is surprising that andropause -- a time of fading testosterone -- was not better understood earlier. Testosterone is, after all, the hormone of manhood: It shapes body muscularity, strengthens the bones, deepens the voice, leads to body hair, ripens sexuality and affects emotions, ambition and drive. In sum, it leads to all the features of masculinization, and even heightens self-esteem.

Dr. Malcolm Carruthers, a pioneer andrologist from the United Kingdom, and outspoken author of Maximizing Manhood, believes there are several reasons for doctors failing to diagnose falling testosterone levels to the same degree they have tracked women's loss of estrogen. Most significantly, men's loss of testosterone is slower -- spread out over decades -- without any signpost akin to the cessation of a woman's periods. Still, he thinks not recognizing the symptom cluster of andropause amounts to "unfair sex discrimination against men."

Biochemical tests appear to support his view. Research has revealed that men's testosterone levels, starting at age 30, decline about 5 per cent every five years. And although the tests are imperfect, and to be used only as part of a broader assessment, it is estimated that 30 per cent of men over the age of 50 might qualify for the diagnosis of andropause, based on blood tests alone.

But the biochemical tests are not definitive, for a variety of reasons. All men's testosterone levels decline, but the thresholds for developing symptoms vary between men. If you were a particularly highly sexed teenager, used to high hormone levels, you may feel the decline more acutely. Also, the specific test -- for bioavailable testosterone, the amount of hormone ready to act on tissues -- is not easily available, and not covered by provincial health-care plans. The upshot is that there are many practical barriers to a timely diagnosis.

As a result, any diagnosis of andropause is currently made by a physician primarily on the basis of a patient's story and symptoms -- resulting in what is effectively a subjective impression on the part of the doctor. Once the diagnosis has been made, according to the recommendation of The Journal of Sexual & Reproductive Medicine, the patient should then be given a three-month trial prescription of testosterone-replacement therapy.

But there is considerable resistance to such a game plan, and important questions remain unanswered, according to many patient groups, consumer advocates and doctors. Among them: Is andropause a bona fide condition? How can it be reliably diagnosed? Should all men be treated?

Definitive replies require more research, and the answers are still emerging. Some men's-health advocates envision a day when the majority of older men will be taking TRT routinely. Some consumer groups, on the other hand, have expressed concerns that such a scenario simply plays into the hands of the pharmaceutical industry -- a case of drugs looking for a manufactured disorder.

Men thinking of TRT must be rigorously assessed for prostate cancer -- although this is an emerging area of study and the connections are not quite as clear they are for women.

In addition, prescribing TRT for andropause raises questions concerning the dividing line between legitimate medical need and cosmetic enhancement: Why don't baby boomers age as quietly as earlier generations? And how much of any midlife change should society work to reverse or delay?

As with any new medical-paradigm shift, doctors -- and the broader society -- generally move from ignorance to awareness, and often from grudging acceptance to out-and-out advocacy. In the meantime, the best that can be hoped for is that all sides learn more about andropause.

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

Andropause: The symptoms
1 Mood disorders
Sadness, grumpiness
Lethargy, low mental energy, decreased capacity to make decisions
Unusual fright and anxiety
Pessimism, proneness to solitude, difficulties with short-term memory
Decreased sense of wellbeing
2 Nervous problems
Flushing, sweats, insomnia
3 Sexual problems
Decreased interest or desire for sex leading to decreased sexual performance and activity
Erection weakness
Decreased quality of orgasm
Decreased sensitivity
4 Masculinization problems
Decreased vigour and physical activity
Frequent joint and muscle aches
Diminished muscle mass and strength
Loss of sexual body hair
Increased obesity
Source: Journal of Sexual & Reproductive Medicine

What to watch for
1. Do you have a decrease in libido (sex drive)?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decreased enjoyment of life?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noted a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?
Source: St. Louis VA Medical Center

Terminology
Andro-: Greek prefix for "male."
Andropause: Male menopause, caused by declining levels of the hormone testosterone in aging men. Men can experience symptoms over a wide age-range, from their 40s to 70s. Symptoms include physical, psychological and sexual problems.

Andrologists: Physicians who have special training and interest in men's health issues, usually endocrinologists, urologists, psychiatrists or family physicians. The counterpart of women's gynecologists.

TRT: Testosterone Replacement Therapy. TRT comes in many forms: pills, patches, gels and injections.

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