Manopause
Scientists like Morley have long known that a man’s testosterone level begins a slow downhill slide as early as age 30, dropping, on average, one percent a year after age 50. Add that to the fact that other sex hormones and brain chemicals also begin to fluctuate, and middle-aged men can conceivably look forward to an array of “change of life” symptoms, including loss of muscle mass, fatigue, depression, erectile dysfunction and even hot flashes.
It’s because the condition is exceedingly hard to test for—and historically difficult to discuss—that it has remained under the radar for doctors and patients alike, explains licensed psychotherapist Jed Diamond, author of Male Menopause. “If you go to your average doctor as a guy and say ‘I think I’m going through male menopause’, most of them will still laugh at you,” says Diamond. “Men tend to deny anything in themselves that is remotely feminine.”
As studies begin to link low testosterone levels with heart disease, cognitive decline and bone loss, and aging Baby Boomers still insist on a thriving sex life well into their golden years, organizations like the National Institutes of Health and the American Association of Clinical Endocrinologists have called for more research into the phenomenon of waning testosterone.
The burning questions are: When and how should manopause be treated? Is treatment safe? Meanwhile, thousands are opting not to wait for the answer; instead they’re flocking to specialty clinics for everything from testosterone shots to acupuncture and herbal supplements.
“I hit a wall and traditional medicine just couldn’t help,” says California filmmaker John Upton, who, at age 50, declined recommendations of antidepressants and instead turned to Diamond, for help. “I found myself, at 48, carrying around 70 pounds of body fat, not being able to get an erection, not feeling good, twice divorced and not in good shape at all.
“Jed said, ‘Go to a doctor and get your hormones checked.’ I did, and they determined my testosterone was low.”
Naming the Issue
Despite more than three dozen clinical trials on the subject and scores more in the works, the notion of male menopause is far from universally accepted.
A widely heralded report commissioned in 2004 by the U.S. National Institute of Aging and the National Cancer Institute concludes, “There is scant evidence that male menopause exists.” The researchers also point out that “the likelihood a man will ever experience a major shutdown of hormone production similar to a woman’s menopause is remote,” and calls for further research.
At the root of the controversy, says Morley, lies semantics: because menopause, by definition, means the end of menses, calling the male experience by the same name often ruffles feathers. So, some call it hypogonadism, which means low hormone production, but that can occur in men of all ages. Others call it andropause. Morley prefers Androgen Deficiency in the Aging Male (ADAM). “It will never be fully recognized until people can find one title they can agree on,” he notes.
Although menopause comes on fairly rapidly for all women, halting production of progesterone and estrogen and signaling the end of fertility, the male process comes on more subtly and varies in severity, depending on the man’s lifestyle, experts say. “It is a slow, insidious, hard-to-figure-out process,” says Dr. Todd Dorfman, a Boulder, Colorado physician who specializes in treating male menopause. “Men come in with one or two issues (libido problems are their priority), and I have to drag the rest out of them.”
While the female “change of life” can lead to fairly specific health issues, such as rapid bone loss and hot flashes, linking testosterone loss to conditions like weight gain, erectile dysfunction and depression—all of which can have numerous other causes—can be tricky. Because men, even in their 30s and 40s, often turn to potentially risky testosterone treatments to quell those changes, the subject remains controversial.
“A lot of patients who come to me are already on testosterone and they have never even had their levels measured,” says Mark Carney, a doctor of naturopathy and licensed acupuncturist in Denver. “In my opinion, that is very poor medicine.
Testing Testosterone
How can a man know for sure if low testosterone is the problem? That’s another tricky question. Testosterone levels normally fluctuate throughout the day (higher in the morning) and from season to season (highest in the fall and lowest in the spring), and can vary according to stress levels and diet. It can be tough to distinguish whether testosterone levels have truly dipped, or if the test was performed at an inopportune time.
Assuming that age-related testosterone loss is truly the problem, another question then arises: How low is too low? A normal, healthy, adult male’s total testosterone concentration can range anywhere from 300 to 1,000 nanograms per deciliter (ng/dL). Those with levels of 200 to 319 ng/dL are good candidates for therapy.
By those measures, one in 10 men between the ages of 40 and 60 has abnormally low testosterone levels. After age 75, the ratio rises to 3 in 10. But because some men naturally produce more testosterone in their youth, those benchmarks can be misleading, explains Diamond.
“Let’s say you have a guy in his 20s who has a testosterone level of 1,000, and by the time he gets to be 50, his levels drop down to 500. He has lost half of his testosterone and is likely to have symptoms. On the other hand, you might have a guy who is at 400 in his 20s and drops to 250, which is considered abnormal. Yet, he may not have any symptoms.”
Dorfman runs an array of blood tests, asks patients to fill out a lengthy lifestyle questionnaire, and sits down for an in-depth interview with each man before making a diagnosis. If he can blame age-related hormone changes, he says he has good news: “It can be forestalled and it can be reversed.”
Natural Solutions
It is possible to rebuild testosterone levels naturally. The following three options constitute a good, safe way to start.
• EXERCISE
“Since there is a direct relationship between muscle mass and testosterone, one natural way a person can raise his testosterone levels is by getting into a weight-lifting program,” says Carney, who specializes in men’s health.
Studies have shown that as few as two sessions of strength training per week can increase muscle strength by more than 30 percent, while also boosting bone density, speeding up metabolism and pushing up production of testosterone and other sex hormones. Exercises that target several large muscle groups, such as squats or bench presses, pump up testosterone levels more than those that train isolated muscles, like curls.
Aerobic exercise boosts the production of feel-good neurotransmitters in the brain, which also have a tendency to get thrown out of balance as men age. So, having a well-rounded exercise program helps.
Keeping weight in check also makes a difference, advises Diamond. Because fat cells tend to convert circulating testosterone into estrogen, having too much fat around the middle can sabotage what little testosterone the body still produces. “If you are overweight, you are really working against yourself,” he says. On the flip side, overtraining and undereating can also wreak havoc on testosterone production.
In one study, volunteer male soldiers undergoing an intense, eight-week training course also ate a restricted-calorie diet (about 1,200 calories less than what they needed). Their testosterone levels dipped to levels far below normal, while their levels of sex hormone binding globulin (SHBG), which binds to testosterone and makes it less available to the body, went through the roof. Once they started getting enough calories again, their levels returned to normal.
• NUTRITION
Men should eat enough good carbohydrates, protein and good fat, confirms Carney. Research shows that protein helps maintain lean muscle mass. Lack of carbohydrates can lead to decreased serotonin levels and consequently, irritability. It also takes a certain amount of fat to keep testosterone production at healthy levels.
One study of 36 middle-aged, white, healthy men showed that switching to a strict, low-fat diet for eight weeks reduced circulating male hormone levels by 12 percent on average.
Generally, experts recommend that men get roughly 30 percent of their calories from fat—good fat, like that found in nuts, oily fish and olive oil. “Cholesterol is a building block of many of the hormones, and if you don’t have enough of it, you can’t build the house,” says Carney.
Another key piece of dietary advice: Cut back on the alcohol, which studies show also decreases testosterone levels. “Contrary to what many men think—that a few drinks make them sexier—they are really taking away their testosterone,” says psychotherapist Diamond, who is also a certified addictions counselor.
• HERBS AND SUPPLEMENTS
Schuyler McHenry, a doctor of naturopathy with Southwest College of Naturopathic Medicine in Tempe, Arizona, recommends B vitamins, which can help with stress and boost energy; C vitamins, which can stabilize production of stress hormones; and herbs such as ashwagandha and ginseng.
McHenry also recommends acupuncture, herbs and Chinese patent formulas aimed at strengthening the kidneys, considered the hearth of male sexual energy in Chinese medicine. “If there is anything that damages the kidneys, it can lead to weakness of the sexual organs,” McHenry comments.
Perhaps the number one over-the-counter dietary supplement for addressing male menopause is dehydroepiandrosterone (DHEA). It’s a building block for sex hormones that the body naturally produces, but tends to decline rapidly with age. Sales of DHEA supplements, often derived from yams, jumped from just $1 million in 1998 to $48 million in 2004, according to Nutrition Business Journal, as word got out that studies suggested that it can improve skin, sex drive, mood and strength in aging men.
Practitioners continue to warn, however, that overuse of hormones like DHEA can result in serious side effects. Before adding DHEA to a daily supplement regimen, it’s vital to have blood DHEA levels tested first, then retested periodically.
Other popular supplements used for male menopausal symptoms include fish oil, or omega-3 supplements, which have been shown to improve cognitive function, boost energy and prevent heart attacks. Also, L-arginine, an amino acid that helps dilate constricted blood vessels associated with erectile dysfunction, has become popular.
Pulling It All Together
For John Upton, using a combination of treatments has been his key to good health. He started with acupuncture, which he says lifted the “fog” he’d been in for years. “I remembered what it was like to be hopeful again,” he says.
Today, Upton takes dozens of dietary supplements daily, spending $300 to $500 a month. He eats a high-protein, low-glycemic index diet, lifts weights regularly, sees a counselor and injects prescription testosterone to keep his levels within normal range.
“The difference is stunning,” he attests. “I’d never want to go back.” Just how many American men are willing to go to such lengths, expense, and potential risk to slow down the ticking clock? That remains to be seen. But whether they should will likely remain a hot topic of conversation for some time.
Lisa Ann Marshall is an award-winning journalist who writes regularly for newspapers and magazines.
Hormone Replacement Therapy for Men?
By far the most controversial hormone treatment for men today is prescription testosterone, which comes in the form of twice-monthly self-injections, prescription gels or skin patches.
According to IMS Health, a pharmaceutical market research firm, sales of prescription testosterone soared to $568 million in 2006, nearly double what they were in 2002. With a host of new easier-to-use products in the pipeline, those numbers are expected to rise. Some studies have shown that supplemental testosterone can restore sexual function and muscle strength, improve memory, prevent bone loss and possibly protect against heart disease.
But supplemental testosterone has potential risks. Too much can trigger aggression and cause breast enlargement; it also thickens blood, potentially increasing the risk of stroke; and it has been shown to cause sleep apnea in some men.
Although research to date remains inconclusive, some researchers fear excess testosterone may fuel the growth of prostate cancer. That concern has prompted many—fans and critics of testosterone replacement alike—to call for more long-term health studies, such as that by the Women’s Health Initiative, which ultimately exposed the risk of hormone replacement therapy in women.
“We are lacking the Women’s Health Initiative equivalent for men and we need that,” says Dr. John Morley, head of the geriatrics division at Saint Louis University Medical School. “Everybody knows that until we do one large study that includes side effects, we won’t have a clue.”
Many practitioners say that they prescribe testosterone in cases when needed, but only after rigorous testing. Dr. Todd Dorfman, a Boulder, Colorado physician who specializes in treating male menopause, says that in some cases he can use other, more benign synthetic hormones, such as a self-injected luteinizing hormone, intended to amplify the signal from the pituitary to the testes and jumpstart the body into making its own testosterone. That way, he says, “I’m using the patient’s own physiological mechanism to get him to produce his own testosterone.”
When he does put men on testosterone supplementation, he prescribes plant-based bioidentical testosterone, which some experts believe is less disruptive to the hormone system. He also checks the patient’s Prostate Specific Antigen (PSA) levels every six months. “The bottom line is that there are not yet any good quantifiable long-term papers about the safety of bioidentical testosterone,” cautions Dorfman. “I very specifically describe to my patients the fact that I do not know what the long-term consequences will be.
“Their typical answer? They are willing to take the risk.”
Primary Sources: Natural Solutions: Vibrant Health, Balanced Living; Alternative Medicine; InnoVision Health Media
10 herbs & supplements to Quell Male Menopause Symptoms
DHEA (dehydroepiandrosterone). An over-the-counter supplement designed to mimic natural hormone building blocks that decline in the body with age. Improves mood, exercise capacity, sex drive and skin conditions, such as lupus.
Maca (Lepidium meyenii, L. Peruvianum). A root used for centuries in Peru for its fertility and libido-enhancing properties.
Horny goat weed (Epimedium sagittatum, D. Grandiflorum). A Chinese herb, also called yin yang huo, used to increase libido and address erectile dysfunction and premature ejaculation.
Yohimbe (Pausinystalia yohimba). Some studies show that yohimbe, which comes from the bark of an African tree, can be effective in addressing erectile dysfunction.
Ginseng. This age-old standby promotes energy, stamina and endurance, affects hormonal imbalance and nourishes the kidneys, considered vital organs for supporting sexual health.
Ashwagandha (Withania somnifera). A powdered root used in the East as an aphrodisiac for 3,000 years.
Damiana (Turnera diffusa; var. T. Aphrodisiaca). This mood-elevating aromatic herb helps calm anxiety.
Chaste tree (Vitex agnus-castus). Historically used to reduce male libido in monks and others entering the priesthood, it has since been used to help normalize hormonal changes associated with male menopause.
L-arginine. An amino acid that helps dilate constricted blood vessels associated with erectile dysfunction. Not advised for men who have experienced a heart attack.
Fish oil or omega-3 supplements. Both improve cognitive function, prevent heart disease, and serve as an energy source.
Sources: The Male Herbal by herbalist James Green; Mark Camey, doctor of naturopathy.
