Introduction

Have you ever noticed people assigned male at birth in their forties joking about back pain, wanting more sleep, and craving coffee just to feel normal? It is not just a part of getting older. We all must be familiar with the term menopause in people assigned female at birth, but have you heard of andropause? Yes, andropause is the male menopause.^1,2 The name may be dramatic, but it echoes a slow, creeping shift. Andropause, also known as late-onset hypogonadism, is a clinical condition characterised by a gradual decline in testosterone and other androgens in ageing people assigned male at birth.³

Unlike female menopause, which occurs abruptly, andropause is not a sudden, overnight change. It is more gradual and quiet, typically beginning after the age of 40.^1,3 Symptoms differ individually and are often misunderstood as general fatigue caused due to ageing or lifestyle factors.² Testosterone, the hormone which defines male vitality, decreases steadily at a rate of 1% annually from the fourth decade of life.¹ Andropause does not make one infertile. But, if left untreated, it greatly impacts the quality of life and physical health in people assigned male at birth.² Overall, 20% of people assigned male at birth aged 60 to 80 experience andropause, while most cases remain undiagnosed.¹

Hormonal changes in andropause

The hallmark feature of andropause is the steady decline in testosterone.³ This hormone is crucial in maintaining bone density, fueling sexual desire, muscle building, supporting mood stability and sustaining energy.^3,4 The main cause of andropause is the natural process of ageing, where the testicular cells get old and there is a gradual fall in the production of testosterone.^3,5 But ageing is not the only contributing factor. 

Other factors, such as lifestyle changes, poor diet, and health conditions, such as diabetes, obesity, and heart problems, go hand in hand with low levels of testosterone. Also, there is a decrease in the levels of DHEA and androstenedione. The sex hormone-binding globulin (SHBG) often increases, further declining active testosterone levels.⁴ Other hormones, such as luteinising hormone (LH) and follicle-stimulating hormone (FSH), are also dysregulated due to feedback disruption in the hypothalamic-pituitary-gonadal axis, the hormonal system involving the hypothalamus in the brain, the pituitary gland, and the gonads.^3,4

Clinical features and symptoms

Andropause presents a mixed bag of symptoms across physical, sexual, psychological, and cognitive domains, which are often neglected as ageing changes.^1,3 Common symptoms include:

• Fatigue and reduced energy: Men may feel unusually tired and lack motivation^1,3,6
• Decreased muscle strength^3,4
• Mood changes: irritability, depression and difficulty in concentration are the most common^3,6
• Reduced bone density: increased risk of osteoporosis and fractures³
• Increased body fat: especially around the abdomen^1,3
• Disruptions in sleep: lack of sleep or oversleeping¹
• Cognitive changes: brain fog or memory issues^3,4
• Reduced sexual desire and erectile dysfunction^3,4,6

Some people assigned male at birth may experience hot flashes. All these symptoms mimic menopausal symptoms in people assigned female at birth. Furthermore, people assigned male at birth possess a higher risk of cardiovascular problems.^3,7

Diagnosis

Diagnosis of andropause is made following a series of evaluations, such as thorough assessment of symptoms, medical history, and lab investigations.^3,6 

Blood tests measuring the serum testosterone levels are often made. The recommended way to proceed is to test two blood samples on two separate occasions early in the morning.³

Clinical screening tools like the ADAM (Androgen Deficiency in the Ageing Male) questionnaire are often used. However, ruling out differential diagnoses such as depression, hypothyroidism, diabetes or chronic liver disease is essential.³

Laboratory tests may also include LH, FSH, DHEA-S, estradiol, and SHBG to better understand the hormonal landscape and determine the appropriateness of treatment.^3,4

Additional screening tests for anaemia, thyroid dysfunction and depression are also necessary.⁶

Management and treatment options

Managing andropause is not as complex as it seems. It mainly focuses on relieving the symptoms and enhancing the quality of life. Treatment plans are personalised according to the individual’s symptoms, medical history and preferences.

Lifestyle modifications

Physical and mental well-being begin with a healthy lifestyle. Adapting to a healthy diet with food rich in zinc, magnesium and vitamin D can be highly beneficial.^3,6,8

Regular exercise, such as walking and aerobic exercises, can boost mood and help elevate testosterone. They can also improve bone strength and muscle mass.

Smoking and excessive alcohol consumption should be avoided.^3,6,8

Stress reduction through mindfulness, yoga, and meditation, along with adequate sleep hygiene, contributes significantly to symptom relief.^6,8

Testosterone replacement therapy (TRT)

TRT is the most direct approach to treating testosterone deficiency. It can improve sexual function, mood, energy levels, bone density, and body composition.^3,5,6

Various formulations are available:

• Gels (topical): easy to apply and stable absorption
• Injections: common, but may cause hormonal peaks and troughs
• Patches: convenient, but may cause skin irritation^3,5
  

The individuals are selected carefully. TRT is not recommended for people assigned male at birth with untreated prostate cancer, severe sleep apnea or uncontrolled heart failure. Regular monitoring of hematocrit, PSA and lipid levels is necessary during treatment.^5,6

Psychological support

Cognitive-behavioural therapy (CBT) or other counselling methods can help manage mood changes, anxiety, and self-esteem issues. Addressing the psychological impact is crucial because most people assigned male at birth are hesitant to accept these hormonal changes in themselves and pursue treatment.^6,8

Medications

Specific symptoms such as erectile dysfunction, depression and others may be treated with prescribed drugs.⁶

Monitoring and follow-up

Follow-up includes clinical review every 3 to 6 months during the first year of TRT, and annually thereafter. Monitoring parameters include testosterone levels, hematocrit, PSA to check for prostate growth, liver function, and symptom resolution.^5,6

Risks and controversies

Though testosterone replacement therapy has shown a lot of benefits, it also possesses some disadvantages. While TRT offers symptomatic relief, it is not without risk. One of the most debated concerns is the potential association with prostate cancer. Although earlier studies hinted at this link, more recent research suggests that appropriately dosed testosterone does not significantly elevate prostate cancer risk.^5,7

There is also a risk of cardiovascular issues. Some studies have found the association of TRT with increased risks of stroke or heart attacks, while others report cardiovascular benefits when testosterone levels are restored to normal ranges.⁵

This evidence is inconsistent and research is going on to find the potential benefits and risks associated with TRT. Patients should be well aware of both the benefits and risks before the treatment. The therapy must be given under close medical supervision.⁷

Research on andropause management has been evolving. Studies are being done to rule out the exact mechanism behind the decline of testosterone, improving diagnostic criteria and developing safe treatment options. Very soon, tailored inventions may emerge to address unique needs and customised management of this condition.^5,7

Summary

Andropause is a recognised medical condition that significantly affects the physical, emotional, and sexual well-being of ageing people assigned male at birth. Despite its gradual onset, the impact on quality of life can be profound. It may sound complex, but it is a common part of the ageing journey. By understanding its nature and symptoms, people assigned male at birth can face it with confidence.^3,6

Awareness about andropause and its effects may help many people assigned male at birth to make informed decisions about their health. Regular health checkups, maintaining a healthy diet, lifestyle modifications and managing symptoms proactively can greatly support both physical and mental well-being.

With a combination of lifestyle adjustments, hormonal therapy where appropriate, and psychological support, andropause can be effectively managed. Tailored, patient-specific care plans and regular follow-up can help men navigate this transition and live healthier, more fulfilling lives.