OVERVIEW

Low T, or Andropause, describes an emotional and physical change that many men experience as they age. Although the symptoms are generally related to aging, they are also associated with significant hormonal alterations. Andropause is a natural subtle decline in hormones that happens as men age. While medical professionals have known for a long time that the production of hormones by the testes slowly decreases as men age, interest has developed only recently in the clinical implications of andropause.

Andropause is also referred to as male menopause, male climacteric andropause, male andropause, late onset hypogonadism, or androgen decline in the aging male (ADAM). The term andropause may be considered somewhat inaccurate because the process is not universal and occurs subtly over time. In women, menopause occurs universally and usually happens dramatically, over a few years.

ADAM or andropause is a fairly common condition and the incidence of andropause (or hypogonadism) increases with age. The incidence from ages 40-49 is estimated between 2%-5%. From ages 50-59, the incidence is estimated between 6% and 40%. From ages 60-69, the incidence is estimated between 20%-45%. The incidence from ages 70-79 is estimated between 34% and 70%. The incidence of hypogonadism in men older than 80 is estimated at 91%. The spread of estimated ranges is quite large because different specialists use different ways to measure androgens and use different minimum levels to define andropause. The important thing is that if a patient feels there are reasons for concern, he should visit a doctor to learn more.

OCCURRENCE

Low testosterone is a problem that can affect both men and women. Testosterone levels are measured by a simple blood test, but they must be interpreted by a specialist since tests may superficially appear normal while the testosterone level is still low.

Low testosterone must be diagnosed by a medical professional. Many diseases and conditions may share symptoms and a medical professional who specializes in low testosterone will be able to identify the issue and create a treatment protocol. The doctor will interpret medical test results in conjunction with physical symptoms. Symptoms of low testosterone include low sex drive and impotence, fatigue or decreased energy, loss of muscle mass and strength, fat accumulation, depressed mood, increased risk of osteoporosis and bone fractures, and increased risk of cardiovascular disease. 

Low Male Testosterone

There remains significant controversy as to how best to measure testosterone levels. It is well accepted that if total testosterone is less than 200 ng/dl, a man will be considered as having a low testosterone level. If his total testosterone is greater than 600 ng/dl, a low testosterone level may be ruled out.

The analog-free testosterone method is the most commonly used in the United States by most large commercial labs, but it is not considered a very accurate way of measuring testosterone. At this point in time, it appears that the most effective measurement of androgen status is either “free testosterone” or “bioavailable testosterone.” However, these can be measured in different ways and may only be available through specialty laboratories. Blood work should be done in the morning before ten o’clock to capture the potential peak values.

Low Female Testosterone

The medical community has only begun treating women with testosterone therapy fairly recently and there is little research available. Therefore, there is little agreement about “normal” testosterone levels. If a woman goes to a general physician and is told that her testosterone levels are “normal” all that means is that they are in a range of women who are not ill. It does not mean that the levels fall into a range that women need for optimal health and functioning.

However, the good news is that research has begun in this area and experts in the field have started testing various levels with women, paying attention to anecdotal evidence (what women are telling them) and sharing information with each other. As a result, rudimentary “normal levels” are being established although there is still a great deal of debate about the limits for each age. Each specialist in the field might have a slightly different range and may use different measurements for diagnosis including total testosterone, bio-available testosterone, free androgen index or free testosterone.

A woman who would like her testosterone levels assessed in order to better understand her low libido should find a specialist in the field of female sexuality and have them test her levels. It is important to have a specialty laboratory test the hormones and to use the same laboratory every time the blood is tested. Studies have shown that there is a huge variation in lab results, specifically when dealing with testosterone, both from lab to lab and, in some cases, within a lab from test to test. You really need to have a laboratory you can trust testing your bloods, as the percent and level of increase is as important as the initial levels themselves.

SYMPTOMS

As we’ve said, andropause is not a sudden condition; it creeps up on you gradually. You might detect the onset of andropause if any or all of these occur:

  • Diminished sexual desire and erectile quality. In particular, a decrease in nocturnal erections is a significant sign of decreased androgens with a decrease in intellectual activity, fatigue, depression, anger, and poor spatial orientation.
  • A loss of body hair.
  • Bone density decreases resulting in osteoporosis. Osteoporosis can lead to the occurrence of bone fractures and breaks.
    An increase in fat around internal organs.
  • Understand that these are symptom guidelines. Andropause affects different men in different ways and to different degrees. There are men who may get one or two of these symptoms, and may just notice the other symptoms occurring minimally or not at all.

Understand that these are symptom guidelines. Andropause affects different men in different ways and to different degrees. There are men who may get one or two of these symptoms, and may just notice the other symptoms occurring minimally or not at all.

As you work your way through this website, print and fill out the Aging Male Symptoms PDF if you’re concerned that you might have andropause. It’s a simple and effective way to detect this condition. Now, just because you have a few of these symptoms doesn’t necessarily mean you have andropause. It could be some other cause, so a blood test is the best way to make a diagnosis.

DIAGNOSIS

To determine if you have andropause a blood test is usually necessary and while it’s true that decreased testosterone levels is a factor, other issues may weigh in. For instance, more sex hormone-binding globulin may limit testosterone from traveling to the tissues. It helps to understand that where testosterone levels would rise and fall when you were younger, you may now be experiencing a flattening and lower level of production.

A few issues you should know:

  • The definition of low testosterone varies. Generally, two standard deviations below the usual rate for a younger man is considered deficient.
  • It’s important to look at your testosterone levels over a period of time because they may vary from one day to the next.
  • In older men, affected organs may respond differently to androgens

There is no one “right” level of testosterone for all men to maintain proper function of their brain, bone, prostate, or muscle cells. It’s better for you and your physician to work together to find the level of testosterone that is most effective for you.

It is accepted that if your testosterone is below 200 ng/dl it’s considered low. If it’s over 600 ng/dl then low testosterone is probably not be the cause of andropause.

What’s the best way of measuring testosterone levels and diagnosing andropause? Opinions vary. The analog free testosterone method is most widely used by large commercial U.S. labs. However, we feel that a more accurate measurement is either free testosterone or bioavailable testosterone done in a specialty laboratory setting. While there is some variation in what tests should be used, it’s widely accepted that blood work should be done prior to 10 a.m. to capture peak values. These measurements may only be available through specialty laboratories.

TREATMENT

Testosterone Replacement Therapy

The good news is that therapy is often very effective. The goals are to restore sexual functioning, increase libido and sense of well-being, prevention of osteoporosis by optimizing bone density, restoring muscle strength and improving mental functions. Our aim is to bring your levels of serum testosterone back to normal levels, but beyond this, to normalize secondary hormones affected by testosterone levels as well. These include DHT and estradiol.

There are a number of ways to treat this condition including oral tablets or capsules, injections, long-acting slow release pellets and transdermal (through the skin) patches and gels. We feel that testosterone replacement done through the skin is the most advantageous (and is the method used most often) because:

  • It is easy to apply.
  • It is relatively safe with low incidence of side effects.
  • It more closely mimics your natural body rhythms — more is produced in the morning, less as the day goes on.

Efficacy
While it’s true that studies are being conducted regarding hormone replacement therapy in men, we’re about 20 years behind studies of hormone replacement therapy of postmenopausal women. However, while many of the men’s studies are preliminary they show the benefits of testosterone replacement:

  • Improved erectile function: Erectile function is a bit more complicated. There is a proven significant interaction between the hormonal level and sexual functioning, but many other factors are involved. Newer studies seem to show that men and women will respond more effectively to traditional treatments for sexual dysfunction (including oral medications and injections) if they have adequate testosterone levels.
  • Improved mood: In recent studies, older men on testosterone seem to report an improved sense of well-being and an overall improvement in mood when compared with similar men who have received a placebo. Energy levels often also improve.
  • Improved body composition and strength: Interestingly, when we look at studies of the body, we see that with testosterone therapy, there is a decline in body fat, an increase in lean body mass (largely muscle mass), or an improvement in both. Several studies indicate that muscle strength improves, affecting the upper and lower extremities such as hands, arms, and legs.
  • Increased bone density: Low bone density or osteoporosis is an increasing problem in men. Men with osteoporosis have a relatively high incidence of bone fractures and, most significantly, hip fractures. Hip fractures in older men are closely associated with disability and death. Testosterone therapy has been shown to increase bone mineral density, especially in the spine. It has been shown to decrease the rate at which bone is lost.
  • Improved cardiovascular system: Yes, men do get more cardiovascular disease and have more cardiovascular-related deaths than women. It is not known whether this is due to the beneficial effects of female hormones (estrogens) or lifestyle patterns of women, or whether male hormones play a negative role in the cardiovascular system. However, it is believed that androgens may help lower the risk factors for cardiovascular disease, including serum lipoprotein profiles, vascular tone, platelet and red blood cell clotting parameters, and the process of atherosclerosis.

We’re seeing some early studies showing that testosterone therapy may help to lessen clumping of platelets and dilate blood vessels. Both of these would be very beneficial to the cardiovascular system. Interestingly, and very importantly, testosterone therapy in older men has led to a decrease in total cholesterol levels. It has also led to a decrease in low-density lipoprotein cholesterol (bad cholesterol levels). These changes, however, have been modest. There has been no significant change in high-density lipoprotein cholesterol levels (HDL or good cholesterol levels) as a result of testosterone therapy. Basically, the effects of androgens on cardiovascular disease are unknown.

Testosterone Therapy Side Effects

It’s important to know that if you’re a man with a history of prostate cancer or breast cancer you are absolutely not a candidate for testosterone therapy. The testosterone can make both of these hormonally sensitive cancers grow more rapidly.

There are other negative factors to consider:

  • Fluid retention: It is possible, especially within the first few months of treatment, for a man to retain fluid. Studies of healthy older men have shown problems with fluid retention leading to ankle or leg swelling, worsening of high blood pressure, or congestive heart failure. It is unclear whether there would be an effect in men who are ill, for example, those with congestive heart failure.
  • Liver toxicity: There have been no reports of liver toxicity from transdermal testosterone replacement. However, oral testosterone replacement can cause significant liver problems. Interestingly, every manufacturer (even those producing transdermal testosterone) mentions the possibility of liver problems. This should be taken into account.
  • Problems with fertility: Spermatogenesis (the production of sperm) in all men is dependent on production of testosterone by the testes. If testosterone is given from outside the testes (exogenous testosterone), as in testosterone replacement therapy, the testes will then stop producing their own testosterone. This will actually shut down sperm production either significantly or completely in almost all men. This may be a temporary or permanent effect. It is very important that younger men who still plan to have a family take this into account. There are men who “bank” their sperm (for more information on this subject visit www.SpermBankDirectory.com). Other men have delayed testosterone replacement until they have finished having children. It is important that any man considering a family be very careful in starting testosterone treatment of any kind.
  • Sleep Apnea: Sleep apnea is a condition in which an individual stops breathing for periods of time while sleeping. This can have significant medical effects. There have been reports that increased testosterone levels exacerbate pre-existing sleep apnea. However, a recent 36-month trial of testosterone therapy in older men reported no effect of treatment on apneic or hypoapneic episodes.
  • Tender or enlarged breasts: This may occur in some older men who are on testosterone therapy and is due to the conversion of testosterone to estrogen. Breast tissue in both men and women is very estrogen sensitive. Sometimes this side effect can be overcome by decreasing the testosterone dose.
  • Increased red blood cell concentration (Polycythemia): One of the most important side effects of testosterone replacement therapy can be an increase in the red blood cell mass and hemoglobin levels. This is particularly true of older men. Increased blood cell mass may increase thromboembolic events (heart attacks, strokes, or peripheral clotting in the veins). Men who develop increased hematocrit can decrease testosterone replacement or donate blood to decrease their blood cell mass.
  • Prostate growth: The growth of the prostate can have a negative effect on men in two ways. First, the prostate may increase in size (benign prostatic hyperplasia or BPH). This may cause problems with urination. Second, it may promote the growth of cancerous prostate cells. It is important to remember that prostate cancer is a common cancer for older men and is the second most common cause of cancer deaths in older men.

Decreasing testosterone levels has been a method used to treat diseases related to both the “benign” and the cancerous groups of cells, but it is still unclear whether testosterone therapy for the older man places him at increased risk of developing prostate disease (i.e., whether testosterone replacement therapy makes benign prostatic hyperplasia progress or makes previously unknown prostate cancer spread).

The vast majority of studies following PSA (prostate specific antigen made by both cancer cells at a higher rate and benign prostate cells) show that it does not increase significantly with testosterone therapy. All of the short-term studies have shown no negative effects on prostate size, maximum urination flow rates, and prostate symptom scores. It appears that testosterone replacement therapy has little short-term effect on the prostate. Long-term data, however, is not yet available.

Monitoring During Treatment

While you many start hormone replacement treatment for a variety of reasons, once you do it is usually maintained for life. Since patients must be monitored for the duration of time that they are on testosterone replacement, essentially, the monitoring is a lifetime commitment.

There’s still differing thought about how men with testosterone replacement should be monitored. It’s clear that if you’ve begun testosterone replacement for a particular symptom, that symptom carefully observed. For example, a patient using testosterone because of problems with osteoporosis should have regular serial bone density screens. Patients with mood or libido changes must be carefully evaluated, too.

In general, we recommend that dosage begin low. Hormone levels and subjective impressions should then be checked two to three months afterward. If adequate blood hormone levels have not been reached, the dosage should be increased, and, again, the patient should return in another two to three months for blood work.

Our goal is to get you in the mid-range of the testosterone values. Once this has occurred, you will be monitored at regular intervals both in terms of symptoms and blood work.

We’ll be monitoring your blood fairly frequently. Once we achieve the right dosage of hormone, we follow your progress and draw blood every three months for at least a year. The following year, we evaluate you and draw blood every four months. Thereafter, appointments and blood work are required every six months.

During the initial follow-up appointments, we evaluate you psychologically and physically. Blood work includes hormone levels, a complete chemistry profile including chemistries, lipids (fat profiles), and liver function tests. We also perform a complete blood cell count to check your hematocrit (an increased hematocrit is a common side effect of testosterone replacement therapy). It is important that you receive serial prostate exams at all of these visits as well as a PSA test. It’s important to discuss any sleep disorders and to assess your mood, libido, and emotional state.

More Information About Male Hormones or Androgens

Andropause is identified as a drop in androgens, the overall grouping of male hormones. They are made in the testes and in the adrenal gland (a small gland located above the kidney that produces a significant number of hormones). The main functions of androgens are:

  • Initiation and maintenance of spermatogenesis, the signal in a man’s body to produce sperm.
  • Determination, during pregnancy, that a fetus will be male.
  • Sexual maturation at puberty, controlling sexual drive and potency.

Relative Androgenic Activity of Adrenal Androgens  
Dihydrotestosterone 300
Testosterone 100
Androstenedione 10
DHEA, DHEA-S 5

In men, androgens are known to affect muscle, bone, the central nervous system, prostate, bone marrow and sexual function.

We know that testosterone causes “the androgenic effects,” determining and shaping the male reproductive tract in an infant as well as the development of secondary sexual characteristics (body hair and male pattern baldness are examples). In addition, androgens are responsible for prenatal differentiation of the male fetus and for the development of the male reproductive tract. Androgens play an important role in stimulating and maintaining sexual function in men. Testosterone is necessary for normal libido, ejaculation, and spontaneous erections.

Anabolic effects are those that promote growth. They affect other tissues such as muscle mass and bone density. Androgens increase lean body mass and affect body weight as well. Androgens are required to maintain bone density in men. It is still not clear whether the androgens are needed themselves to affect the bone or whether it is important that they be present so that when they are converted to estrogens, the estrogens have an effect on the density of the bones.

Androgens can affect red blood cell production and they appear to have an effect on blood fats and cholesterol. The most well-known effect of androgens is their effect on growth of the prostate. They affect both the non-cancerous and potentially cancerous cells in the prostate. 

Androgens also play an activating role in cognitive function throughout life, keeping men sharp and alert. The relationship between androgens and mood is still unclear, but in-depth exploration has begun.

Androgen Decrease

If you have andropause you may be wondering how you got it. Other factors may be contributors, but the primary one is that as men get older, their testes don’t work as well. Something called “leydic cells” produce testosterone less frequently and in a lesser quantity.

Other reasons are that the hormones that produce testosterone just aren’t creating as much and some of that testosterone is being converted to other hormones like estradiol and DHT.

Testosterone

As we just mentioned, specialized cells in the testis, called Leydic cells, make testosterone. As an adult male you produce about five grams of testosterone per day. You do this in bursts and there is a daily pattern, with a peak occurring early in the morning and a low point in the late evening.

Only certain cells in your body can receive the testosterone and a number of these cells later convert the testosterone into Dihydro-testosterone (DHT). DHT is three times as potent as the testosterone itself. Interestingly, the testosterone can also be converted into estrogens (the main female hormone). This occurs particularly in fat cells.

Most testosterone in the body is bound or “attached” to proteins. Thirty percent is bound to a type of protein known as sex hormone-binding globulin (SHBG). The testosterone binds very tightly to SHBG, which has a tendency to increase as men age. The remaining testosterone is bound much less tightly to other proteins in the blood, the most prevalent being albumin.

Two percent of the testosterone is unbound (not attached to any other protein) and is called free testosterone. Free and albumin-bound portions of testosterone make up the measure known as “bioavailable testosterone.” This is the testosterone that is seen in the tissue and that has the most effect on the body. So, any change will affect the total amount of available testosterone. The amount of SHBG, or blood proteins, also will affect the amount of available testosterone and will have an effect on the body.

What happens is that as you get older, your SHBG increases, meaning you have less available testosterone. Other hormones can affect SHBG, too. Elevated female hormones and thyroid hormones will increase SHBG, which will then, in turn, affect the bioavailable testosterone.

The symptoms that are associated with a loss of androgens may also be caused by decreases in other hormones, so testosterone replacement may not completely resolve all of the issues. However, at this point, there appears to be good evidence that testosterone replacement can improve many of these symptoms.

DHEA

Many of the active androgens in the body are not produced by the testes but by the adrenal glands. The major androgens created by the adrenal glands are DHEA, DHEA-S, and androstenedione. Although these androgens are not very strong, they are converted to the much stronger androgens: testosterone and DHT. However, they are a small percentage of the total androgens available in men. In men, the adrenal gland secretes approximately 3 to 4 mg of DHEA per day, 7 to 14 mg of DHEA-S per day, and 1 to 1.5 mg of androstenedione per day.

The adrenal steroid, DHEA-S, is the most plentiful steroid in circulation in the body. The amount of DHEA-S concentrated in the body is very dependent on age. Men have the most in their 20’s and 30’s. By his 70’s, a man’s DHEA-S level is down, on average, to twenty percent of its highest value.

While there has been a lot of research, interestingly, we still don’t know a lot about what DHEA-S does in the body. However, we think it has a “protective” role. It seems that the higher the DHEA/DHEA-S level is, the lower the incidence of cardiovascular disease and various forms of cancer, as well as many other aspects of cellular aging.

DHEA is considered the “mother” hormone. It is the hormone in the body that is later converted into other hormones, including testosterone. DHEA is first produced in children at the age of seven years. It reaches its peak production for men in their teens and twenties. From that point, it subtly decreases over a lifetime. Synthetic DHEA is widely available and widely used and it appears to be relatively safe. However, right now we don’t know whether or not it is effective in creating any changes in the aging male.

Growth Hormones

Growth hormone levels control the production of insulin-like Growth Factor 1 (IGF-1) that affects the body’s composition, lean body mass, and bone density. As growth hormones decrease, so does IGF-1. Growth hormone production decreases after puberty at a rate of approximately 14% every 10 years. This decrease in growth hormone is called somatopause (similar to the decrease in androgens being called andropause). It appears that administration of growth hormone can help improve body composition with increases in lean body mass and bone density.

Thyroid Hormones

The pituitary hormone that stimulates the thyroid to make thyroid hormones is called TSH. As men get older, TSH decreases and the thyroid becomes less responsive to TSH. What happens is that there is a decrease in the circulating amounts of thyroid hormones, and this may result in symptoms of hypothyroidism or decreased thyroid in the elderly. Decreased energy, metabolism and mental acuity are some of the symptoms. It is estimated that close to 20% of elderly men suffer from these symptoms.

Aging Male Symptoms Score (AMS)

Determining your Aging Male Symptoms Score (AMS) is a simple and effective way to detect whether you may have andropause. Based on a set of 17 factors, the score is designed to determine whether there is a general indication for andropause. If you are concerned that you may have andropause, simply score yourself using the form below. You can also download the Aging Male Symptoms PDF and score yourself, and take it with you when you visit your doctor. 

Each item is rated on a scale from 1 to 5; 1 representing an absence of symptoms, and 5 representing those that are extremely severe. Simply rate each item on the scale, then add up your score. There are 17 in total, so the minimum score is 17 and the maximum score is 85.

It’s important to keep in mind that having some of these symptoms isn’t necessarily an indication you have andropause. They could be related to some other cause, so a blood test is the best way to make a diagnosis.

The best way to complete the form is to not overthink each item. 


Symptom

1

None

2

Mild

3

Moderate

4

Severe

5

Extreme

Decline in your feeling of general well being (general state of health, subjective feeling)          
Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)          
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)          
Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)          
Increased need for sleep, often feeling tired          
Irritability (feeling aggressive, easily upset about little things, moody)          
Nervousness (inner tension, restlessness)          
Anxiety (feeling panicky)          
Physical exhaustion/lacking vitality (general decrease in performance, reduced activity, feeling of getting less done, of having to force oneself to undertake activities)          
Decrease in muscular strength (feeling weak)          
Depressive mood (feeling down, sad, on the verge of tears, mood swings)          
Feeling that you have passed your peak          
Feeling burnt out, having hit rock-bottom          
Decrease in beard growth          
Decrease in the number of morning erections          
Decrease in ability /frequency to perform sexually          
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for intercourse)          

The implications of your score are as follows:

  • 26 or less means that you have no significant symptoms consistent with a low testosterone
  • 27-36 means that you have mild symptoms consistent with a low testosterone
  • 37-49 means that you have moderate symptoms consistent with a low testosterone
  • 50 or greater means that have severe symptoms consistent with a low testosterone

Thus we would suggest that if your score is 27 or greater your hormone levels be tested.