When men feel fatigued, have low energy, and have lost their libido.

One need only turn on the television set these days to see what the consumer marketers are plying upon men on this country.  The image is one of either a rugged looking guy doing something manly like freeing his horses from a bog (Cialis).  Or it is one in which the fit, slightly greying man is receiving a salacious, come hither look from his equally ‘hot’ and grey-streaked wife (Viagra). 

Still others hook into the vernacular of  modern man with allusions to low “T”, or testosterone, like the shibboleth at a speakeasy.  If you know the special knock, you can gain entry- no pun intended- to the special club of the aging man with the testosterone level of a 30 year-old.

Marketing and cultural allusion aside, current science is showing that similar to women, men as they age are experiencing a decline of testosterone.  In women the condition has a name that is well known in our society; menopause.  This is a state of declining ovarian function, and decreases of the ovarian hormones estrogen and progesterone.  As we age both women and men experience a decrease of the adrenal hormone DHEA, and to the detriment of our health, an increase of  the stress hormone cortisol.

In men, the term to express this decline in testicular function is known as andropause, as the male’s androgenic hormones, testosterone and DHEA, decrease.  It is thought that typically after the age of 30, a man experiences a 1% drop in testosterone yearly.  But as with all biological processes, there often is a range around a mean.  Some men find themselves with a declining testosterone at age 20; other men are able to maintain youthful levels of testosterone well into their 60’s and 70’s. 

I think that most men begin to notice a decrease in their testosterone levels in their 40’s.  The state of menopause, in which a woman undergoes similar hormonal, metabolic and hormonal changes, is punctuated by a very distinct event: the cessation of the menstrual cycle.  Andropause tends to be a bit more cryptic and insidious for two reasons.  The first is that guys, unlike most women in our country, tend not to go see a physician unless there is really a problem.  Men have no recommended yearly pap smears, or breast exams, and in my experience have historically had a hard time getting pregnant.  So we physicians don’t have the typical metrics that we follow with our female patients, such as small changes in blood pressure, increase of weight and abdominal girth, or decreases in lean muscle mass.  In fact, most men don’t make it into their doctor’s office until the chest pain is too much to bear, and by then we find that the cardiovascular horse is already out of the barn. 

And if you thought it was hard to get a guy into the doctor’s office for something simple for a generalized complaint such as fatigue, weight gain, or poor sleeping, imagine how hard it is to have an apparently fit man sit down and tell you that his libido is down and that he can’t keep an erection.  The truth is that men tend to be stoic, and acknowledging a change in one’s emotional and physical capacity is felt to be an acquiescence of age, an acceptance of failure. 

There is ample information in the news, on the web, or in the gym to give an American man some insight into why he has lost the drive to “rule the world”.  But unfortunately this is greatly simplified with a capital “T”.  Testosterone may be, and often is, a strong contributor to the spectrum of male andropause.  But it is not the only component.  I believe that the barrage of information driving men to drugs, whether hormone replacement or erection prolonging pills, is providing only a partial service; this only allows the man to work on only one part of the picture.  The male health picture needs to be drawn with a Functional pen, and it needs to consider not only the replacement of the lowered hormones, but the biological events leading up to, and contributing to, the lowered testosterone levels as well.

The media would have all men think that the loss of sexual function was the sine qua non of the andropausal state, but in terms of presenting symptoms in a doctor’s office, this may be only one of many.  I used the word insidious to reflect on the onset of a male’s hormonal decline, because without a seminal event like the cessation of periods, a man may not even notice that his health, sexuality and performance is waning. 

Take a moment to reflect upon the symptoms that may be encountered by an aging male.  A simple on-line survey known as the ADAM (Androgen Deficiency in the Aging Male) is a good screening test to open up a man’s eyes to the fact that he may be experiencing a decline in testosterone.  It can be accessed at the web link below.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2834355/figure/fig1/

A positive score is a “yes” response to questions 1 and/or 7, or positive responses to 3 of the other questions suggests a low testosterone level.  The link above is to the scientific paper (with graphs) that correlated increasing scores to decreasing testosterone.  But I feel that these 10 questions only represent a small number of the symptoms that I might see in clinical practice.  I would add the additional questions; “Do you find yourself easily angered?”, “Do you have a decrease of sexual fantasies?” and perhaps the most important neglected symptom of male andropause, “How are you sleeping?”.  An easily frustrated man with evolving poor sleep hygiene has low testosterone until proven otherwise. 

Some of the signs I look for may be a reflection of a man’s declining testosterone in the face of increasing cortisol or estrogen levels.  These signs may be seen in an enlarging “beer gut”, increased breast size, or changes in the force of the urinary stream.  Low testosterone can also contribute to changed hair patterns on the head, decreased hair on the front of the legs and calves, and a change in body odor.

So typically, the man with the clinical presentation above presents to his physician, and is started on testosterone replacement.  We’ll assume that his provider had the insight to check and correctly interpret a testosterone level.  But recall that testosterone itself is only one hormonal component of a man’s health.  To be thorough we need to evaluate both total and free testosterone, DHEA, SHBG and all of the estrogen metabolites.  If these values have not been checked by your doc, with testosterone replacement you may be increasing your risk of heart disease and prostate cancer.

With initial mainistream hormonal replacement, the man usually feels great for the first weeks to months:  his erections are firmer and his fantasies return; he begins to sleep better; he feels like he has more energy.  But typically this honeymoon ends when the piper asks to be paid.   The conventional medical doctor has failed to address the metabolic, psychological and nutritional derangements that precipitated the decline in testosterone in the first place.  A vicious cycle ensues as the doses of testosterone are sequentially increased, often to amounts that far exceed what our body normally produces.  The testosterone metabolites, estrogen and estrone increase, and once again on goes the body fat, down goes the libido and up go the angry voices at the dinner table.

The reason that this has transpired is that the patient’s health wasn’t approached in a rational, functional manner.  Yes, the patient has a lower testosterone level, but one is required to ask the question, “Why?”  To address the question of why a male patient complains of low energy, low libido and poor concentration, it is incumbent upon the doctor to also consider the effects of stress upon the patient and to have a quiver of therapies available to diagnose and address these stress-driven changes.  Your provider needs to look into other causes of poor hormone metabolism, with answers found in your genes, in your diet and bowel function.  We need to strongly consider nutritional deficiencies, and deficiencies in trace minerals such as zinc and selenium.  We need to evaluate the patient for potential toxic or chemical exposures that could be interfering with his ability to synthesize the hormone, and we need to look at components of his diet.  We need to study the patient’s medication list, and consider the possibility of severe nutritional depletions caused by various medications.

The bottom line is that we as physicians need to look at the whole patient, and not just simply a single laboratory test.   Male menopause, or andropause, unquestionably exists, and it is causing lasting effects on our aging male population.  Simply Google the words “male,  low testosterone, cardiovascular disease, cancer, Alzheimer’s disease, diabetes, and almost any other condition you can think of with the letters ‘ncbi’ (National Center for Biotechnology Information), and you will find a trove of studies that associates low testosterone with any number of different diseases.  Don’t just take my word on it; look at the studies yourself to become educated in the strong association between low testosterone and virtually all chronic disease.

So my final thought is, “don’t be a statistic, be a man.”  Find a doctor who understands the complexity of the body, and the interplay of genes, the environment, hormones, and foods.  Find a functional medicine doc and get yourself well.