Ok, now back to topic. A patient of mine e-mailed me today complaining that her husband, over the past 2 years or so has started developing symptoms such as heart burn, lost of appetite, lost of weight, decreased sexual drive, labile mood (frequent alternating moods) with sudden violent outbursts, feeling insecure about their husband-wife relationship, suspiciousness, decreased sleep. Now, I've not seen or spoken to her husband before, so i advised her to bring him in for a consult. She told me that she has been surfing the net and wanted to know more about male menopause. I gave her a brief explanation but insisted to see her husband for a more nuanced understanding of his problems before making any diagnosis.
What is male menopause? You'd be surprised as to how many men are unaware of such a problem. I have friends who actually ridiculed me when i told them that even men can experience menopause. The male menopause usually occurs in a male in his early to mid 40s where his performance begins to slow and when physical and mental changes begin to occur.
What is the etiology of male menopause?
The male menopause is caused by a decline in the levels of the male hormones called androgens, thus it's alternate name, andropause. Androgens are the hormones that give the masculine gender it's masculinity and plays a very significant role in men's health. The types of androgens in men include testosterone, dihydrotestosterone (DHT), androstenedione, androstenediol, and dehydroepiandrosterone (DHEA). Testosterone is the most active among the androgens. These are the hormones that promotes the development of masculine characteristics during puberty such as widening of the shoulders, deepening of the voice and facial hair growth. Now, when the average adult male ages (usually beginning in the early 40's), the level of androgens, particularly testosterone starts declining, resulting in low androgens, especially testosterone.
Now here's the beef, every male will experience symptoms of male menopause in varying degrees.
Among the common symptoms of male menopause are:
- Decreasing sex drive (libido) - less interest in sex, having sex less frequently and sex becomes less enjoyable.
- Fatigue and lethargy - the pace of sexual activity (endurance) slows significantly (same physical, but longer time and with considerably more effort).
- Forgetfulness and decreased concentration - ability to register and recollect gets impaired. Ability to focus and hold the focus deteriorates (ordinarily is one of the male strengths).
- Irritability, anger, anxiety, depression - tolerance level takes a dip and easily angered.
- Weight gain - increase in body fat, usually around the middle section, increase in body weight and loss of muscle mass. Did you know that a sedentary male loses about 10% of his muscle each decade?
- Sleep disturbances - difficulty in falling asleep, interrupted sleep, not sleeping well and having a restless time during the last part of sleep before awakening.
- Confusion, indecisiveness, declining self-confidence - a very distressing change for a man. He loses his ability and attributes as 'the man' of the house or the man of the family.
- Osteoporosis - Yup, it can also happen to men.
Treatment and management of the male menopause
1. Hormone replacement and supplementation:
- Testosterone - Prior to testosterone replacement therapy (TRT), a complete medical history, complete physical exam, blood tests, including a PSA (Prostate Specific Antigen) test to be sure prostate cancer cells are not present is done. TRT requires regular injections and that means regular follow up with doctor.
- DHEA (dehydroepiandrosterone) - mostly produced in the adrenal glands, DHEA also plays an active role in the immune system, central nervous system, mood, and it is related to circulatory system health, for example. DHEA production declines about 10% every five years after the age of 30 years. Studies have shown that the lower the levels of DHEA-S (DHEA Sulfate- a metabolite of DHEA), the greater the risk for Alzheimer's, cardiovascular disease, cancer and diabetes. Daily supplements of DHEA have been reported to significantly improve the way a patient felt physically and emotionally. Higher doses have been used to treat erectile dysfunction as well. This results in them feeling better and their sex lives also have been reported to improve. DHEA is best taken at night to coinciding with the desired effect required during this period of the day.
DHEA is contraindicated in patients with malignancies such as cancer of the breast, ovarian or prostate.
- Growth Hormone - the production of GH begins to decline in the early twenties. People with underlying medical or metabolic disorders such as Diabetes, raised lipid levels, cancer, liver impairment, etc can lead to some serious complications and will require very stringent assessment and monitoring under the watchful eyes of a doctor..
- Progesterone - made in the testes and adrenal glands, the Progesterone plays a multiple roles in the body. Among them are functions such as balancing the effects of excess estrogen which can suppress the production of testosterone. Osteoporosis is also a possible outcome of deficiency of both progesterone and testosterone which play a role in growth of new bone tissue. Progesterone has also been used as an aphrodisiac for people suffering from decreased libido and also commonly used to treat Benign Prostate Hypertrophy as it can help shrink the enlarged prostate gland in men with this condition. Natural progesterone cream would be the best method of supplementation by rubbing it on the skin daily.
- Pregnenolone - Pregnolone is known to increase energy levels and improve the immune system. It also supports memory, mental performance, mood and quality of sleep. It is actually a precursor of DHEA.
- Androstenedione - is produced by the adrenal glands, the testes and in the ovaries for women. It is used to increase testosterone levels. Supplementation only requires low doses of this hormone to achieve desired changes.
N.B: androstenedione can be abused by athletes to enhance physical performance.
- Melatonin - deficiency of melatonin, which is produced in the pineal gland, can lead to disturbances in quality and pattern of sleep. So, this hormone supplementation should be taken at night.
The rule of thumb for initiation of hormone supplementation is to begin with low dosages and increase slowly if required, based on the symptoms and how the patient feels.
2. Lifestyle Modification:
- Stop Smoking, alcohol consumption should be stopped or reduced to one drink a day
- Regular exercise and destressing for energy and general well-being should be made a part of our everyday life.
- Proper diet control and nutrition - does not require any elaborations as i assume everyone more or less already knows the types of food to avoid or limit and the types of food that is healthy. I shall not bore you with the same details again.
- Proper nutritional supplement such as antioxidants, multivitamins, fish oil, etc are an important part of your diet.
Due to the many irregularities and ambiguities in the regulations governing the manufacturing of dietary supplements, you need to be extra careful when buying these supplements off the counter. Their efficacy might be rather questionable due to low potency and even worse high, due to high levels of contaminants. It is thus, advisable to see a doctor prior to starting any of the supplements.
Before beginning a hormone replacement therapy supplementation , always ensure that you do a baseline hormone level screening first. You can do this yourself at home or at the nearest clinic or hospital.The saliva hormone assay test (subject to availability in Malaysia) is a kit in which you collect your saliva and send the sample to the laboratory or hospital concerned.
The hormone levels that you can test are Testosterone, Androstenedione, Estradiol, GH, Progesterone and DHEA-S (For Malaysians, some of these hormone level screening might have to be sent overseas if not done locally here).