Male menopause

Disease Description (Causes and Symptoms)

• Definition: Male menopause (Andropause) is a group of symptoms caused by a gradual decrease in the secretion of male hormones, primarily testosterone, with aging.
• Causes/pathophysiology: Total and free testosterone decrease by approximately 1% per year beginning in the late 30s. Reduced function of the brain (hypothalamus–pituitary) and testes, chronic diseases (diabetes, obesity, cardiovascular disease), smoking, excessive alcohol consumption, stress, and certain medications (steroids, cimetidine, spironolactone, ketoconazole, etc.) contribute.
• Main symptoms: Decreased libido, reduced erectile function, decreased sexual function, chronic fatigue and lack of energy, depression and reduced concentration, sleep disorders, decreased muscle strength and skeletal muscle mass, abdominal obesity and reduced body hair, joint pain and skin aging, hot flashes and sweating, increased risk of osteoporosis, etc. Symptoms progress gradually and often go unrecognized.
• Diagnostic points: Measure in the morning (usually 07:00–11:00), taking into account diurnal variation in total blood testosterone. Suggested criteria (for reference): male menopause is suspected when total testosterone is < 3.5 ng/mL; active treatment may be considered at ≤ 3.0 ng/mL (criteria vary by institution).

Treatment Methods

• General principles: Make decisions by considering symptoms and blood hormone results together, proceeding from non-pharmacological management to medication therapy (if necessary). The goals of treatment are to improve symptoms and quality of life, and side effects and contraindications must be checked carefully.
• Lifestyle management (always recommended)
  • Regular aerobic and resistance (strength) exercise, weight loss (correction of obesity)
  • Smoking cessation, moderation of alcohol consumption, improved sleep hygiene, and stress management
  • Active treatment of underlying diseases such as diabetes, hypertension, and dyslipidemia
  • Diet: Focus on zinc (oysters, seafood, beans, pumpkin seeds, etc.), protein, and vegetables; limit saturated fat and excessive alcohol
• Medication therapy (testosterone replacement therapy, TRT)
  • Administration forms:
    • Intramuscular injection (testosterone esters, at 2–4-week intervals) — relatively easy to maintain blood concentrations
    • Transdermal preparations (gel, patch) — convenient to use; daily administration (gel) or patch
    • Oral lipophilic preparations (testosterone undecanoate, etc.) — less hepatotoxic (however, some oral 17α-alkylated agents carry a risk of hepatotoxicity)
  • Benefits: May improve libido, erectile function, muscle strength, mood, and bone mineral density
  • Main risks and side effects: Increased red blood cells (increased hematocrit), prostate enlargement and worsening of symptoms, possibility of prostate cancer (contraindicated in the presence of existing cancer), infertility (suppression of sperm production), acne and oily skin, possible worsening of sleep apnea, and controversy regarding the association with cardiovascular events
  • Monitoring: Regularly test PSA, digital rectal examination (DRE), blood count (hematocrit), liver function and lipids, and blood testosterone before, during, and after treatment
• Alternative and complementary treatments
  • If fertility is desired: Consider stimulating endogenous testosterone with clomiphene, hCG, etc., instead of TRT
  • If erectile dysfunction is present: PDE-5 inhibitors
  • If depression or sleep problems are present: Combine treatment for mental health issues (medication and counseling)
• Contraindications/precautions
  • TRT is contraindicated in patients with diagnosed prostate cancer or breast cancer, or when active prostate cancer is suspected
  • Use with caution in cases of heart failure, arterial thrombosis, severe pulmonary disease, etc.
  • If there is a partner who wishes to become pregnant, consult before starting TRT

Outpatient Visit Checklist (Preparation and Example Questions)

• Items/materials to prepare
  • List of currently used medications and supplements (including emergency medications)
  • Medical history: History of prostate-related conditions, cancer, cardiovascular disease, sleep apnea, liver disease, or thrombosis
  • Recent test results (if possible, PSA, recent blood tests, glycated hemoglobin, etc.)
  • Record the time and pattern of symptom onset and diurnal changes (changes in sexual function, fatigue, mood changes, etc.) and symptom severity (for example, the ADAM questionnaire may be used)
  • Lifestyle information (alcohol consumption, smoking, exercise, and sleep)
• Items to record yourself before the outpatient visit (useful during the examination)
  • Year/month of symptom onset, factors that worsen or improve symptoms, and specific patterns of changes in sexual function
  • Recent weight changes and changes in muscle strength and exercise capacity
  • Family history (such as prostate cancer)
  • Whether there are plans for pregnancy (including the partner)

Examples of General Questions to Ask the Doctor

• What are the expected benefits and possible side effects of this medication (or treatment)?
• If I start TRT, what will happen to my fertility (sperm)? What alternative options are available if needed?
• What tests should I undergo during TRT, and how often? (For example, PSA, hematocrit, liver function, etc.)
• What are the risks in relation to my existing conditions (cardiovascular disease, sleep apnea, etc.)?
• How will my symptoms change if I stop treatment? Will long-term administration be necessary?

Examples of Disease-Specific Questions

• Regarding sexual function and fertility
  • When did your recent decreased libido and reduced erectile function begin? To what extent do they affect your relationship with your partner?
  • Do you wish to have children in the future? If so, you should discuss sperm preservation (semen freezing) or non-TRT alternative therapies.
• Regarding the prostate and cancer
  • Do you have recent PSA test and digital rectal examination results? Is there a family history of prostate cancer?
• Regarding monitoring and lifestyle
  • Do you have symptoms of sleep apnea (loud snoring and daytime sleepiness)? What are your current smoking and alcohol consumption levels and exercise habits?

Additional information: For accurate confirmation, tests (especially blood testosterone) should be performed at least twice in the morning (07:00–11:00). Decide whether to receive treatment and which method to use by discussing it with a specialist, taking into account your symptoms, test results, coexisting conditions, and reproductive plans.