Pondering Male Menopause

The noshes were good. There were hors d'oeuvres, hard and soft cheeses, fresh fruits, and tiny iced cakes. And the setting--a softly lit conference room in one of Victoria's better hotels--evoked calm and comfort. The topic, which had drawn 30 or so health-care professionals here on an early spring evening, dealt with what was being purported as one of medical science's latest discoveries. A new affliction, or, as presenter and pharmacist John Forster-Coull put it, "a new clinical entity", had recently been recognized as real.

Andropause, or male menopause, is no longer a myth but a widespread condition caused by low levels of testosterone, Forster-Coull, a UBC graduate and co-owner of a Victoria compounding pharmacy, told the group. Although all men's testosterone decreases with age, some men's will decline so much they experience unwanted, unpleasant, and even dangerous effects, he explained. His lecture--titled Andropause: Dispelling the Myths--was part of a UBC continuing-education series presented by the faculty of pharmaceutical sciences.

Educational sessions like this one recently toured B.C., visiting 12 communities from Terrace to Castlegar to Vancouver. Apotex Inc., Canada's largest pharmaceutical company, sponsored the lectures, including the Victoria one. (Apotex gives some money in the form of "unrestricted educational grant" to UBC to hold the seminars, which are considered "continuing pharmaceutical education".) And even though drug companies have been selling testosterone supplements for decades, some people in the medical community have only recently begun taking andropause seriously.

With the help of videos, slides, and text, Forster-Coull shot down what he said was one andropause misconception after another, the first being that andropause is merely a myth. Others were: the disorder does not only affect older men, does not only reduce libido, and is not merely an inconvenience but can also lead to serious health risks like heart disease and weak bones. False beliefs about treatment also deserve debunking, he said. Testosterone replacement therapy (TRT)--hormone-laden gels, patches, capsules, or injectable preparations--does not cause more harm than good.

"There's awesome evidence that testosterone is safe," he said.

During the hour-and-a half program Forster-Coull covered everything from the disorder's prevalence (no one really knows, but the Canadian Society for the Study of the Aging Male, formally the Canadian Andropause Society, says a third of men in their 50s will have testosterone levels low enough to benefit from treatment) to symptoms (no energy, no motivation, no desire for sex) to benefits of treatment (more energy, more motivation, more desire for sex).

Forster-Coull then touched on known side effects of TRT (acne, weight gain, sleep apnea, and enlargement of the breasts) and its risks. (Testosterone may stimulate growth of existing prostate or breast cancer, and long-term risks are unknown.) As well, he said, research trials conducted to date have not been well-designed. Still, he said, cancer risks can be managed by yearly PSA (prostate specific antigen) tests and yearly digital exams. His conclusion was that for most men with andropausal symptoms, the benefits of TRT outweigh the risks.

As simple as the UBC educational blitz sounded, medical conditions are rarely so straightforward. Could andropause be just another word for male aging? What is the evidence that naturally declining hormone levels pose a potential health risk for men? Aren't many andropausal symptoms such as tiredness, irritability, increased waistline, and poor sleep normal signs of maturation coupled with a stressful lifestyle? Is TRT a boon to men's health or a blatant bid by pharmaceutical companies to create a disorder to match their "treatment"?

Andropause is more of a "quagmire" than a myth, says Surrey general practitioner and men's-health specialist Barry Rich.

Although it definitely exists, symptoms can be vague, confusing, and overlap with other conditions such as depression and stress-induced fatigue. That makes andropause difficult, but not impossible, to diagnose.

"What I try to do is if somebody has symptoms they want treated and you have a blood test [that confirms low testosterone] and you've ruled out secondary causes [such as a pituitary tumour] and ruled out contraindications [like prostate cancer], I like to offer them a three-month trial of testosterone," Rich says in a phone interview.

Complicating things, however, is the lack of rigorous data on the long-term safety of TRT. That scientific gap, Rich says, stems from the fact that men's specific health issues do not receive the same kind of attention that women's do, and because most TRT research is done by researchers who receive money from the pharmaceutical industry.

"The answers aren't clear--some of the studies are contradictory, and there aren't enough of them, and they're not large enough to draw valid conclusions--but there is some good stuff to suggest there may well be lots of benefits over and above feeling better," he says.

To women of a certain age, andropause symptoms and treatment sound all too familiar. We, too, were told that medical science had found our fountain of youth. It was called estrogen. For decades, millions of women followed their doctors' advice and embraced hormone-replacement therapy, believing it would prolong not only their femininity but also their lives.

Then science discovered its mistake. In the past two years, a string of studies has undermined the reputation of HRT. They show that HRT comes with increased risks of blood clotting, stroke, heart attack, and breast cancer. Although andropause may not be equivalent to menopause, some wonder if men will heed any lessons from women's experience with hormones.

Alan Cassels, a drug-policy researcher at the University of Victoria, is one of them.

"What I'd like to see is some proof that we've learned our lessons from the HRT debacle, and, before medicating every grumpy middle-aged guy with testosterone, prove in a scientific way that the long-term harms associated with TRT do not exceed the benefits," Cassels says in a phone interview from Victoria. Until then, "if men are going to take TRT as long-term therapy, it's caveat emptor."

Cassels has another, more cosmological problem with TRT.

"In a world probably already suffering adverse effects of way too much testosterone--wars, domestic violence, and other conflicts--I question the very principle of giving more testosterone to men."