Putting the 'men' in menopause

Testosterone therapy replaces Porsches for guys going through 'the Change'

By John Thompson

"My body was deteriorating a lot faster than I thought it should," he says. He was gaining weight, his bones seemed frail (he broke his arm three times), and worst of all his sex drive was "abysmally low." He couldn't figure out what was up.

After reading about andropause, everything fell into place. He wasn't just getting older or having a 'midlife crisis.' It was a hormonal change thing. He immediately went to his doctor. Since then the 53-year old psychologist has been popping by the office for a low dose injection of testosterone every three weeks.

Duncan credits these shots in his hips for his newfound energy — and libido. His skin, prone to rashes, has also toughened up and his beard grows in thicker. He also finds himself more willing to stand his ground in disputes, although he adds he hasn't lost his sensitivity: he still writes poetry and plays the cello when he isn't busy counselling his patients.

MENOPAUSE FOR MEN?
The concept that andropause, also known as 'angry male syndrome,' exists, first emerged in the late 1980s. Researchers now agree that as men age their testosterone levels fall, although the hormonal change isn't as dramatic as what women experience. What's disputed is whether symptoms ranging from moodiness, low energy levels and low libido to increased fat, lost bone density and reduced muscle mass can be tied to this drop in hormone levels — and whether testosterone therapy is an effective remedy. Or, for that matter, if it explains why some middle- aged men have affairs with younger women and buy expensive sports cars.

What's really important isn't just how much testosterone is in the body, says Dr Jerald Bain, a staff physician at Mount Sinai Hospital, professor emeritus at the University of Toronto and president of the Canadian Society for the Study of the Aging Male, but what type of testosterone. Past the age of 30, testosterone levels not only drop, but an increasing amount binds with a protein, making it "biologically unavailable."

"So while the total diminishes, the bioavailable testosterone diminishes more drastically," says Dr Bain. By age 50, about 20% of men experience a significant drop in testosterone. But 50% of men will have significantly reduced amounts of 'bioavailable' testosterone. "We don't know how many of that 50% are symptomatic, but we're assuming quite a few are," adds Dr Bain.

EVIDENCE IN INFANCY
Others remain sceptical. Dr Mike Evans, a staff physician at University Health Network of Toronto's Western division and assistant professor in family and community medicine at the University of Toronto, says there's still debate over the exact role testosterone plays, as well as how to measure it. He worries the label andropause attaches a 'condition' to a normal life event, much like the medicalization of menopause. "I'm not sure we should be actually treating it," he says. "Looking at the evidence, I just don't think testosterone is a fountain of youth."

Dr Evans says the evidence base is still in its infancy, pointing out that only one trial exists with more than 100 patients held over one year. He also questions the outcome of the trials, which studied areas ranging from brain activity, physical strength, mood and sex drive. In some cases, hormone therapy showed no difference for mood and depression, and studies on physical strength were similarly inconclusive.

He adds there's no good evidence it helps for erectile dysfunction, either, and that other studies have shown a large placebo effect. In November 2003 the Institute of Medicine concluded, after a systemic review of testosterone therapy, there was no clear evidence of health benefits.

So why the hype? Dr Evans blames the marketing push for two new forms of testosterone replacement therapy, a patch and a gel.

CANCER CAUSING?
Negative effects from testosterone therapy include shrinking testes, blood thickening and sleep apnea, although the biggest concern is its alleged link to prostate cancer. Evidence suggests testosterone treatment causes the prostate to swell, although there's no proven connection between this and cancer. Dr Bain goes so far as to say that the testosterone could have a positive impact on prostate cancer because some candidates for the therapy have had prostate cancer caught early by check-ups spurred by their hormone treatment.

Dr Evans remains unconvinced. He adds that for other andropause-related symptoms, like depression and osteoporosis, there are much better treatments than testosterone. "When I walk through the pros and cons, I don't see any actual advantage for the average aging male," he says.

But as for Duncan Blackman, he hasn't experienced any serious side effects and is thoroughly enjoying what he calls his new lease on life. And so is his wife. "She likes the new me," he says happily.