Dr. Barry Dworkin

Originally published in The Ottawa Citizen March 26, 2002

Every man desires to live long; but no man
would be old. – Jonathan Swift (1667-1745)

Many men in their forties and early fifties begin to re-evaluate their lives. Physiologic changes and lifestyle choices can affect their physical, spiritual and emotional health.

One physiologic change starts at age 30 is a gradual decrease in testosterone levels. By age 70 levels are ten percent of what they originally were at age 30.

The testes (testicles) produce testosterone. Testosterone can be bound to a protein called Sex Hormone Binding Globulin (SHBG) or float freely within the bloodstream. The latter is free to exert its effect on the body and is called Bioavailable Testosterone (BT). As men age, SHBG levels increase whilst testosterone production levels decrease. The net effect is more testosterone remains bound to SHBG and thus BT levels decrease.

This condition is called Andropause. It is slowly becoming recognized as a cause of some of the problems seen in men as they age. About 30 percent of men in their fifties will have low testosterone levels low enough to cause symptoms.

Testosterone levels vary in men. Patients with normal levels may have symptoms of deficiency while others do not.. The clinical picture of Andropause varies. It can include depression, fatigue, irritability, reduced sex drive (libido), aches and pains, sweating and flushing, decreased sexual performance, reduction in muscle strength and mass, increased upper and central body fat, osteoporosis (calcium loss from bone) and a possible increased risk of cardiovascular disease.

Excess alcohol intake, psychological stress, infections, medications, surgery, excess weight and lack of exercise can contribute to its onset. Other diseases such as diabetes, depression and thyroid disease among others can cause similar symptoms and must be considered. A full diagnostic evaluation is essential to determine the cause.

The ADAM (Androgen Deficiency in Aging Males) screening questionnaire is used if a patient presents with the aforementioned symptoms.

• Do you have a decrease in libido (sex drive)?
• Do you have lack of energy?
• Do you have a decrease in strength and/or endurance?
• Have you lost height?
• Have you noticed a decreased “enjoyment of life”?
• Are you sad or grumpy?
• Are your erections less strong?
• Have you had a recent deterioration in your ability to play sports?
• Are you falling asleep after dinner?
• Has there been a recent deterioration in your work performance?
• A “yes” answer to either question one or seven or to any three questions increases the clinical suspicion for Andropause. The next step is a blood test to check the level of BT. This test is not covered by OHIP and costs about $75. (What would people say if estrogen and progesterone blood tests were not covered?)

If the BT level is low, testosterone replacement (TR) is suggested not unlike hormonal replacement therapy for menopausal women. Testosterone comes in many forms: gels, injectables, and pills. The pill form is the usual method used for testosterone replacement therapy. The dose is individualized for each patient. BT levels are checked three months after therapy begins.

A reversal of many of the symptoms occurs within the first six weeks of treatment. The patient’s mood and sense of well being improves, they have increases in physical and emotional energy, libido and sexual function, muscle strength, lean body mass and improved quality of sleep. Over the longer term, bone mass and integrity is preserved which helps combat osteoporosis.

Men who suffer from prostate or breast cancer should never use testosterone since it can worsen these conditions. For those who may have liver or heart disease, swelling of the feet, face or hands, enlarged prostate, diabetes or kidney disease, TR may not be indicated.

Your doctor will closely follow your progress repeating several blood tests that measure the effect of testosterone upon cholesterol, triglyceride and PSA (prostatic specific antigen) levels, periodic liver function tests and red blood cell production. The size of the prostate must be evaluated because testosterone can cause enlargement of the prostate.

These effects are not commonly seen since the amount of testosterone used is just enough to replace what was missing. Muscle mass does not increase to body builder size because of the low replacement dose. However, there are practice recommendations to be followed in order to maximize safety and efficacy of the treatment.

The biggest hurdle for men tends to be feeling ashamed or embarrassed by their symptoms. It is not a sign of weakness to suffer from this condition. It can be easily corrected and improve quality of life. Consult your doctor if you suspect that you may have this condition.