Men cringe at the mere thought and many scoff at the idea that men go through a form of menopause later in life. Yet more and more research is pointing to the fact there may be more to this than meets the eye.
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A recent workshop held by two prominent South African experts has added even more weight to this controversial debate, and concluded that age-related hormone changes have just as much of a health impact on men as they do in women. So why does the concept of andropause, more commonly referred to as male menopause, still carry such a taboo?
The answer, according to Professor Mohamed Haffejee (Head of Urology, University of Witwatersrand), is quite simple: men just don't take it seriously. They also don't know what they're looking for.
"In women, the changes that come with menopause are sudden, but with men they're gradual and therefore many assume they're just getting older and attribute the changes to normal aging," he said.
The science behind male menopause
Male menopause, also referred to as androgen decline in the aging male (ADAM), or late onset hypogonadism (LOH) or testosterone deficiency syndrome (TDS), is when the levels of the sex hormone, testosterone start declining. This is usually related to age.
Men experience a gradual decline in the production of the male hormone testosterone from their late-thirties onwards, but the good news is that it's entirely treatable. Especially if the symptoms are recognised in time and the appropriate medical support is given.
However, according to the experts, the biggest problem is that most men don't actually know what to look out for. The symptoms are disregarded by many due to their subtle and unsurprising nature and the danger is that declining hormone levels can lead to life threatening spin-offs, such as cancer and heart disease.
As men aged the number of risk factors, like stress, obesity, hypertension and diabetes, increase, which is why it's so vitally important for men to consult a health professional annually.
As the testosterone levels decrease, the number of risk factors increase, which is why it's so vitally important for men to consult a health professional timeously.
So which comes first; low testosterone levels or the risk factors? Does one lead to the other or do they occur separately and then exacerbate each other? Haffejee explains: "Obesity lowers your testosterone levels and a low testosterone is associated with obesity. It's the same with diabetes. It would be safe to say that each risk factor compounds the next and that each risk factor needs to be addressed on its own merit."
Just to clarify, symptoms of TDS include:
A lack of energy and vitality
Loss of sexual desire or libido
A decrease in the quality of erections
Mood swings and depression.
Ignorance and denial can be deadly
"Men are not educated enough on this and are often in denial about their symptoms with the 'it will get better' attitude. This is one of the reasons the rates of self-inflicted death such as cancer and heart disease, are much higher in men than women, , and why men die prematurely," said Haffejee.
He added that generally men have short-term goals when it comes to their health, and unlike women, they don't see looking after their health as an investment. This, he said, was why a new approach towards men's healthcare was urgently needed.
It was with this in mind he urged women to take note of the changes in their partner and ensure they seek medical advice as soon as possible.
"Symptoms such as erectile dysfunction should be seen as an opportunity for the patient and doctor to undertake an overall health check rather than simply prescribe medications such as Viagra, Levitra or Cialis. While these medications may assist with the ED they do nothing to treat the potential underlying causes such as heart disease. Often the symptom of ED is a precursor to cardiovascular disease - it should thus be seen as an 'early warning'," he said.
And just in case the seriousness of the situation is not clear enough, he added that if the symptoms of ED are ignored, this will almost certainly result in one, if not more of the following:
Decreased life expectancy
Increased cardiovascular risk (including type 2 diabetes)
Poor lipid profile and obesity
Decreased bone density with increased risk of fractures
Overall decrease in quality of life issues such as decreased sex drive, sleep disturbances, lack of energy, poor concentration and goal directed activity, erectile dysfunction and loss of muscle mass.
Doctors agree – awareness is key
Dr Sindeep Bhana (Physician / Endocrinologist at Chris Hani Baragwanath Hospital) believes that part of this new approach should include an awareness of how chronic diseases such as diabetes and metabolic syndrome, affect men. And more importantly, how this affects their testosterone levels and overall health.
"It may sound confusing, but each risk factor carries a number of other risk factors with it. For example erectile dysfunction (ED) puts men at risk of high cholesterol, diabetes, cardiovascular disease. And the longer the risk factors go untreated, the harder it will be to combat them," he said.
It appears it is a vicious cycle, and, as Bhana pointed out, it is all up to men to make sure they are aware of what is going on in their bodies. He also encouraged men to ask their doctors for a test to measure their testosterone levels.
"TDS can decrease sexual desire, affect erections and alter the body's composition; this affects the other organs in the body and therefore affects one's quality of life. But through a healthy diet, management of testosterone levels and exercise, risk factors can be reduced and prevented," he said.
How dangerous is LOH?
According to Bhana, it's likely that hypogonadism is a fundamental component of the Metabolic Syndrome.
"Testosterone treatment may not only treat hypogonadism, but may also have tremendous potential to slow or halt the progression from metabolic syndrome to overt diabetes or cardiovascular disease," he said.
And by default, all components of metabolic syndrome (hypertension, dyslipidemia, diabetes, obesity etc) are underlying conditions for erectile dysfunction. Thus, men should be alerted that if they wake up without morning erections they should have themselves checked out by their doctors immediately.
Bhana said that abdominal obesity is the number one risk factor in metabolic syndrome and testosterone deficiency syndrome is a proven risk factor for all the metabolic syndrome components according to most recent research.
"Many patients with metabolic syndrome are locked in a vicious circle: Abdominal fat tissue reduces testosterone but testosterone reduces the fat tissue," he said.
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In summary, he pointed out that:
Epidemiological studies show associations between testosterone and components of the Metabolic Syndrome.
Hypogonadism is common in patients with type 2 diabetes.
Men with central obesity have lower testosterone levels than non-obese men.
Androgen deprivation leads to insulin resistance.
Pilot studies using testosterone in men with hypogonadism and Metabolic
Syndrome suggests an improvement of the Metabolic Syndrome.
Another reason to live healthy and exercise
Haffejee and Bhana both said that healthy living can make a huge difference and they both strongly advocate exercise and a balanced diet as effective ways to reduce the likelihood of developing some of the more nasty risk factors such as type 2 diabetes.
"The key is to avoid developing the risk factors in the first place, that's vitally important," said Bhana.
Is testosterone treatment effective?
Yet, while for many, healthy living is still strongly advised, testosterone treatment may be the only option left. And while the experts agree the evidence appears to point at the fact that testosterone treatment is effective - moderation is recommended.
"Testosterone treatment has received a lot of bad press recently because of its abuse by gym goers. An excess of testosterone has many nasty side-effects such as acne, weight-gain, aggression and hair loss. But since clinical trials all show long-acting testosterone has many benefits, in moderation it is an effective treatment," said Bhana.
So how does it actually work? Haffejee explained that "in the context of testosterone replacement therapy in the ageing male we see a gradual decline in the body's ability to produce testosterone resulting in a constellation of symptoms including loss of libido, decreased energy levels, lack of concentration, erectile dysfunction, decreased muscle and bone mass, as well as obesity. By replacing testosterone the aim is to restore normal circulating levels of the hormone and restore these functions."
He added that preparations are available as tablets, gels, patches, pellets and injection.
"Currently available in South Africa we have the long-acting intramuscular injection which usually needs to be administered every three months. The gels are not available locally yet and the short-acting injectables are not ideal in that blood levels are not constant, and may result in supranormal levels which are responsible for largely preventable side effects which include mood swings including 'roid rage', acne and breast enlargement in men. Oral preparations need to be taken three times a day which makes compliance difficult," he said.
The downside to testosterone treatment
Yet while the benefits of testosterone treatment are many, as with most things, there is a downside to it. Men who still wish to have children are strongly advised not to undergo the treatment.
And for those involved in sports, dreams of turning professional after starting testosterone treatment will have to be put on hold as one's testosterone levels will be increased and most sporting bodies test for raised levels of testosterone when conducting doping tests.
"There are some sporting events which will allow you to declare that you are on the treatment for medical reasons, but this is still a grey area in the world of sport,' said Bhana.
The third major drawback is the price; at between R4 000 and R5 000 a year, it is not available to everyone and has to be motivated before medical aid will pay for it.
Sources: Professor Mohamed Haffejee (Head of Urology, University of Witwatersrand); Dr Sindeep Bhana (Physician / Endocrinologist at Chris Hani Baragwanath Hospital)
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