Leonard S. Marks, M.D. Medical Director, USRF	Synonyms for Male Menopause
USRF Study of Testosterone Replacement Presented at 2006 AUA and Featured in Urology Times

3rd Quarter, 2000 - MENOPAUSE refers to the permanent cessation of menses, now occurring in the U.S. at an average age of 51 years. Is there a male counterpart of the menopause? Is there a specific syndrome attributable to androgen (testosterone) decline in the aging male, like that seen with estrogen decline in the aging female? The question has never been more important, because soon men will be facing the decision of whether or not to use AndroGel , the most user-friendly form of testosterone yet available.

Three books, a major review article in the medical literature, and a Time magazine cover story) have all been dedicated to this subject in the last two years. So what's the conclusion, is there a male menopause? The answer is the proverbial, 'Yes and No.'

Estrogen levels decline by approximately 80% during the several year period preceding the average menopause. In men, no such precipitous decline in testosterone is found. Instead the testosterone decline is a gradual one, beginning much earlier in life and continuing progressively thereafter. On average, the serum testosterone levels found in elderly men are approximately half the levels seen in young men. Thus, the hormonal changes in women are more abrupt and more profound than those seen in men.

According to Morales et al, the male menopause, or andropause syndrome is characterized by the following clinical features:

1. diminished sexual desire and erectile quality, particularly nocturnal erections;
2. changes in mood with concomitant decreases in intellectual activity, spatial orientation ability, fatigue, depression and anger;
3. decrease in lean body mass with associated diminution in muscle volume and strength;
4. decrease in body hair and skin alterations
5. decrease in bone mineral density resulting in osteoporosis
6. increase in visceral fat.

Since the above features may be found to a greater or lesser extent in nearly all aging men, and with over 25 million American men currently in the 40 - 55 year old bracket, the syndrome assumes a major public health significance.

Diagnosis is made on the basis of clinical features and confirmed by hormonal studies showing abnormally low levels of testosterone, especially free testosterone, in association with elevated levels of gonadotropins. An excellent diagnostic algorithm has been proposed by Morales et al. Treatment is with testosterone administration, most often in the injectable enanthate or cypionate form at a dose of 200 - 300 mg every 2 or 3 weeks. These agents have clearly been demonstrated to improve libido, sexual function, potency, energy level, bone density and mood if these abnormalities are caused by androgen deficiency. Transdermal testosterone patches (Androderm and Testoderm) have the theoretical advantage of more sustained serum levels with less of the 'peak and valley' effect seen with injections, but they are relatively expensive. Oral forms of testosterone are not recommended because of unreliable serum levels and potential liver toxicity.

The newest and most user-friendly of the methods of testosterone administration is AndroGel, a testosterone gel which was approved by the U.S. FDA in February, 2000. The gel is applied to the skin of the shoulders, chest, and upper arms on a daily basis; it is rapidly absorbed and produces sustained levels of serum testosterone. A recently published article confirms the manufacturer's claims for the product.

The only absolute contraindication to testosterone administration in the hypogonadal male is carcinoma of the prostate or breast. Other safety issues are addressed in the recent review article by Morales et al. AndroGel has been the subject of generally favorable reviews by The Medical Letter (6/12/2000) and The Pharmacist's Letter (6/2000).

RECOMMENDED LINKS:

"The Male Menopause - Does it Exist?"
Pro and Con from the British Medical Journal
(requires Adobe Acrobat Reader)

"Testosterone Replacement Therapy"
Wayne J.G. Hellstrom, M.D. in the Digital Urology Journal

Interview with Professor Lunenfeld

TIME cover story

"A Fact of Life for Men Too"

History of Testosterone Replacement