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What is Andropause – is it real?
In recent years, there is an increasing awareness amongst males about andropause. To be more accurate, there is no such condition called andropause which was coined initially to reflect that the hormonal changes specifically testosterone and its associated symptoms in males as their age is somewhat similar to those in women as they undergo menopause.
However, the degree of decline of testosterone levels in males as they age is not as much as the drop in estrogen levels in females when they undergo menopause. In fact, the decrease in testosterone in males over the age of 40 is approximately about 1% each year of life, with an estimate of 1 in 10 older males having low testosterone levels.
In this article, we illustrate 2 examples of androgen deficiency and testosterone deficiency (names and backgrounds have been changed).
Example 1: Alex, 42 years old
Alex has experienced a decrease in his sex drive and experienced issues getting and sustaining an erection for the past few months. He is obese, hypertensive, and perhaps too busy at work. Due to his decline in sex drive, his wife suspected he was having an affair and has caused much arguments. So he sought medical help.
When Alex came to the clinic, he was anxious and nervous as he did not know how to discuss about his condition with a doctor, as he was worried the doctor may feel that he is a sex maniac. The doctor reassured him that he is there to help assess his concerns and that his concerns are not uncommon, and sexual needs is part and parcel of life.
Alex did some blood tests to ascertain his testosterone and associated hormone levels. The tests returned a low testosterone level. It was assessed that his symptoms of decreasing sex drive and issues with erection is likely due to the low testosterone level.
To treat his condition, Alex was prescribed an increase in activity levels with 20min walks, 3 to 4 times a week to first get his weight down as it is known that high body fat can result in the conversion of testosterone to estrogen. After losing 3kg, his testosterone still returned a low level on subsequent blood tests. Hence, Alex was prescribed testosterone therapy over the next 9months. In a few months, Alex reported a definitive improvement in his sex drive as he felt as if he was in his 30s and he finds that his erection are improving. Although he has more weight to lose, I assured him that weight loss will be a lifelong battle and encouraged him to continue his walks, exercises, and diet.
Example 2: Toh, 53 years old
Toh was happily married with 2 grown up children and 2 grandchildren. In recent years, his relationship with his family had become more strained as he frequently became irrationally angry. He frequently experiences hot flushes which is an embarrassment to him, and his colleagues have jokingly asked him why he is blushing so much lately. He has a history of hypertension and high cholesterol which is under medication control.
Toh has seen other doctors and was told that everything was normal, and one even suggested for him to see a psychologist and he felt that the doctor thinks that he is crazy. As a result, he feels that no one understands what he is going through and has self-doubts as to whether he is indeed going crazy.
When he saw a doctor, he was reassured that further investigations are required before concluding. On review, his testosterone levels were indeed low and that his symptoms of mood changes and hot flushes are likely caused by low testosterone levels. Toh was prescribed testosterone replacement, which saw improvements in his symptoms after 6 months. He finds that he is experiencing less mood swings and less irritable with his family and his work colleagues and his hot flushes are mostly gone. His relationship with his wife and family is on the mend and they are planning to go on a holiday together.
From these 2 examples, men who are suffering from androgen deficiency have subtle and ill-defined symptoms and can easily be mistaken for other medical/ mental conditions. Yet the amount of distress it causes is usually quite significant – self-doubts, depression, sexual dysfunction, stress on relationship and family and work.
How do I suspect if I may be suffering from Androgen deficiency?
You can use the questionnaire below as a tool to assess the possibility of being testosterone deficient
- Do you have a decrease in libido (sex drive)?
- Do you have a lack of energy?
- Do you have a decrease in strength and/or endurance?
- Have you lost height?
- Have you noticed a decreased ‘enjoyment of life’?
- Are you sad and/or grumpy?
- Are your erections less strong?
- Have you noted a recent deterioration in your ability to play sports?
- Are you falling asleep after dinner?
- Has there been a recent deterioration in your work performance?
If you answer yes to Question 1 or 7 and any other 3 questions, then you may want to see your doctor to discuss about testosterone deficiency.
What treatments are available if one is diagnosed with androgen deficiency?
If you have the symptoms suggestive that you may be suffering from androgen deficiency and you have done a blood test to show that you are low in testosterone, there are various options for testosterone replacement that are available in Singapore.
Testosterone injection: This is an option for those who do not wish to take medication on a daily basis. Generally, this injection is given once every 8-12 weeks depending on individual.
Testosterone Capsules: This is an option for those who do not like needles and prefer the oral route. The absorption of the capsule dependent on the fat content of the food intake, it is better absorbed with higher fat food intake.
Testosterone gel: This option provides the best absorption and most stable levels compared to the other 2 routes of administration. It is also the easiest option for most people as it only requires you to apply the gel on the skin. There is precaution of accidentally transferring the testosterone to partners or children, especially if the partner or children comes in contact with the gel before it dries completely.
Risks of Testosterone replacement therapy
There were initially concerns that testosterone replacement may increase the risk of developing prostate cancer. However that has generally been debunked through numerous studies. However, if you do have prostate cancer, then it is not advisable to undergo testosterone replacement at least until you have been treated and should seek the urologist opinion before starting it. In addition, your doctor will also examine your prostate prior to starting the therapy and monitor the Prostate Specific Antigen (PSA) in your blood during the therapy, and would advise you accordingly if it becomes abnormal.
Those with undiagnosed or uncontrolled Obstructive Sleep Apnea may cause breathing to repeatedly stop and start during sleep. Such persons should not be started on the testosterone replacement therapy until they have undergone treatment for it.
There is also a small risk of causing blood clots but generally your doctor will monitor your blood during the therapy to determine if there is your blood is too thick and therefore at risk of blood clots. If your blood results show that the blood is too thick, your doctor may advise you to temporarily stop or decrease the frequency of our testosterone replacement therapy.
Also men who are planning to have children should seek their doctor’s advice before starting on the therapy. It can cause a decrease in fertility as sperm production will be decreased or even stopped when they are on testosterone replacement therapy. It is not a guarantee that sperm production will be restored to normal 6-8 months after stopping therapy.
Conclusion
Males do suffer from androgen deficiency, which can affect them in terms of sexual function, mood swings, energy levels, and even weight gain. Consult your doctor if you think you may be suffering from androgen deficiency, and drill down to the last diagnostic possibility.
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