Dr Sikiru Adebayo, a urologist with the University College Hospital (UCH), Ibadan, in this interview by SADE OGUNTOLA, speaks on andropause, a condition in men similar to menopause in women.
What is andropause and how does it differ from menopause in women?
The consequences of declining testosterone in aging men has been variously termed male menopause, male climacteric, andropause or more appropriately “partial androgen deficiency of the aging male (PADAM). Andropause is the male equivalent of menopause except that because men do not have a clear cut sign as women, in whom menopause is heralded by cessation of menstrual flow. There is no equivalent of that in men so andropause is usually missed. Otherwise, their symptoms could be similar.
Andropause is associated with low plasma level of testosterone, the male hormone, whereas menopause is associated with reduced level of oestrogen, the female hormone in women. In post menopausal females, the reduced plasma level of estrogens is associated with symptoms such as hot flush, heat intolerance, chills, and psychosomatic symptoms like mood disturbances and dryness of the vagina. The commonest symptom that most men complain of is loss of libido. Some however, develop depression, loss of sexual drive and other physical and emotional symptoms, decreased motivation, low energy level, excessive tiredness and difficulty concentrating.
But generally, how does it affect men’s daily life?
Andropause is associated with excessive tiredness and sometimes general lack of interest in things that usually interest them before. If one feels uninterested in what one does on a daily basis, certainly that will affect daily activities. They may wake up and still feel like going back to bed, all of these definitely will affect the daily activities or daily life of such individual.
Above the age of 50, about how many men are likely experience andropause?
I wouldn’t want to quote a figure because this is not something that you can readily point out in an average aging man. We only talk about it in men who come to us because of their loss of libido or some other issues like excessive tiredness. We then start to think of andropause after we had rule out other common conditions that would explain their symptoms and we only found out that they have a low testosterone level, without other discernable clinical or biochemical abnormality. But, it’s an entity that is under reported. In fact, some men who have its symptoms attribute their symptoms to other health challenges. So it’s something that is generally or usually missed; thus it is probably more common than we thought.
Andropause occurs more in older men. So, how can andropause be differentiated from normal signs of aging in men?
Generally, a lot of times, some of the things that people notice in old age could overlap with symptoms of andropause. So a lot of times, andropause is missed in most men. It is after all the other things that could have explained the man’s symptoms have been excluded and out of curiosity because the associated loss of erection or poor libido, tests now shows low plasma testosterone level. We then say perhaps the man is having andropause.
What was the age range of these men suspected had andropause?
Andropause starts at no particular age in men, just like menopause in women. But we only know that it starts from middle age or thereabouts. I have seen women that had menopause in their mid-thirties. Some also attain menopause at 60. The same thing happens to men, except that andropause tend to happen at a later age than you have menopause in women. Generally, men in their seventh decade have mean plasma testosterone level 35 per cent lower than young men.
What are risk factors for andropause?
Let me answer that question rhetorically. What are the risk factors for menopause in women? Just as there is no known risk factor for menopause, there is also no known risk factor for andropause. However, the cause of age related decline in the hypothalamo-pituitary-gonadal axis function is multi-factorial. Testosterone production is reduced because of fewer testosterone producing (Leydig) cells, and more testosterone binding proteins results in reduced level of free or active testosterone. Diurnal variation of testosterone secretion is also lost in the elderly. Circumstances that result in loss of testicles or suppression of testicular function could result in early andropuse, same way that a woman could undergo premature menopause when the womb and ovaries (oestrogen producing organ in females) are removed for whatever reason.
Is andropause associated with other health conditions such as heart disease and osteoporosis?
Now, testosterone, the male hormone, does more than drive men’s libido. It’s also responsible for maintaining the man’s muscle bulk. When there is less testosterone in the system, sometimes maybe because the testicle is removed, what is termed castration, some of the other functions of testosterone that we usually overlook, now start to manifest. The man may start feeling tired, loss muscle bulk, have increased fat deposit in the abdominal area, and they could have demineralization of bone, what is called osteoporosis. Other complications of low testosterone levels is anemia, that is why when a man is castrated, part of the treatment is to give them blood tonics, calcium and vitamin D, in order to lower the risk of these complication.
Does andropause affect men’s fertility and sexual function?
The straightforward answer to that question is yes. Sex hormone is what drives libido. So if a man’s libido is less, then sexual function is reduced, because his interest in sex is generally reduced. We know that having a baby will require having intercourse, except in cases of assisted conception. So if a man cannot have intercourse, because his interest in sex is reduced, then his ability to make babies is also reduced. Second, normal level of testosterone is also required for normal spermatogenesis (production of sperms). So except the low testosterone is corrected, sperm production and maturation, and quality may not be sustained.
How does andropause impart mental health and emotional wellbeing of a man?
If a man cannot fulfill his sexual function, apart from putting money down for household expenses, his relationship will be strained. And when relationship is strained, mental health issues come in. So, if a man is depressed because he cannot satisfy his wife, and the woman is nagging him, and it seems like life is not worth living any longer, of course, he could have suicidal ideation. Also, mood swings is a consequence of low testosterone. And when you have high level too, you may also start manifesting some aggressive tendency.
Are there natural remedies or lifestyle changes to help alleviate these symptoms men experience around that period?
There are lifestyle changes that a man could adopt that could delay onset of andropause or militate against its consequences. A man should eat well, live well, do everything in moderation, exercise more and avoid those things that are associated with early onset of andropause, such as excessive consumption of alcohol and smoking. Those are what I consider as natural remedies. However, if you are asking about supplement, herbs or special dietary measures, that question may have to be answered by the naturopathists: I am an orthodox medical practitioner with limited knowledge of naturopathy.
Is there treatment for the condition?
Treatment is to identify and reverse the cause of premature andropause (if reversible). Otherwise, testosterone replacement should be instituted. Testosterone replacement comes in different formulation such as tablets, testosterone patch, implants or injectable, to continue to sustain the level of the testosterone in the body.
Are there side effects or contraindications for the use of these testosterone medications? Are there people that cannot use those medications?
Certainly yes, like many other treatment modalities. It has to be established that the man actually has testosterone deficiency. Higher than normal plasma level of testosterone in the body may actually be detrimental to the wellbeing of an individual. For instance, testosterone therapy in a man with low sperm counts without establishing that the testosterone level in the body is low is wrong. It could actually be counterproductive. The sperm counts could reduce further. Testosterone therapy is a replacement in people who have lower levels, not an addition to someone who has a normal level.
In men with prostate cancer, a testosterone supplement may aggravate the condition and cause rapid progression of the cancer. Additionally, testosterone excess had also at one time being associated with aggressive or deviant behavior in some men.
Are there any long-term complications of untreated andropause?
Generally, majority of men who have andropause may not even know that they have the condition. In fact, some of what is considered complications of the low testosterone may actually be some other issues associated with aging (as stated earlier). So it’s difficult identifying the long-term complications of untreated andropause because these are people who may have multiple other medical conditions like diabetes and hypertension because of advancing age. So, to say some of their healthy challenges are particularly from low testosterone and not from other co-morbid factors may be difficult.
You run clinics taking care of men with prostate issues. Of every hundred patients you see about how many actually come complaining of symptoms or things suggestive of andropause?
A retrospective study published in 2016 by Dr Takure, myself and our senior colleagues at the UCH put the proportion of men attending our clinic for erectile dysfunction to two per cent of all patients seen in our clinic over a five year period..Nigerian men are usually secretive. They will probably come pretending that they have some other issues and after they have gained your confidence, they come out to say that they also have low libido. If you never get around to talking about it, they will just be parabulating and still leave without telling you about that. They then resort to unorthodox treatment, which may not be effective. Or when running up the consultations and the person will ask if low libido or erectile dysfunction is caused by a prostate problem, too. They wouldn’t introduce the topic directly.
But men are not talking about andropause, does it have anything to do with low awareness of it in the community or people just assume it’s part of life?
I think, number one, in the context of the cultural environment where we live in, people assume that when you are growing old, some things will have to come with it. Some health practitioners also have limited knowledge of the condition too. When people come and they complain that that they have such issues, they attribute it to aging and counsel them to put it aside. They also are not comfortable discussing it either because of their own limited knowledge of it. Some may not even be aware of the entity.
So we can therefore say that men really are not taking it serious because they don’t know that they can be helped. Am I correct?
Yes to the second leg of your question, but not that they are not taking it seriously. Rather, I would say what the heart does not know; the mind does not grief about. When they have erectile dysfunction, they could come but they would not relate it to andropause. They just know that they have poor libido and they will start attributing it to some other things.
Will all men have it? Will all men experience andropause?
Not necessarily. Why I said not necessarily is because quite unlike women, that the concept of menopause is well established because the menstrual flow is something that they have regularly but by the time there is menopause, they no longer have menses. It ceased. At what age? It differs. So if you want to take it by extension to men too. We’ve had men that have no issues living normally as a male until way into their 90s or 100s so if we don’t have something to really tag it onto as we can tag menopause to no longer menstruate in women. It may be difficult to say this is the proportion of men having it. Some may have it to a certain degree that is not bothersome to them. For some, it may be difficult.
The common belief is that men till they go into their grave are fertile and can father a child. Is this a misconception?
People generally don’t know that there is a difference between sexual prowess and ability to reproduce. There are two different things. A man could be able to have sex like a stud. But he may not be able to father a child. That’s why I said there is a difference between sexual function and reproductive function. A man may be able to have sexual intercourse with two, three, four different women in a day. But he might not have released any spermatozoa at all. Whereas another man may only barely be able to achieve erection, so that he could have sexual intercourse can father a child so long as what he releases is rich in sperm. So there are two different things. Therefore, some men could; but by no means all men.
In essence, not every man that could have sexual intercourse will be able to father a child. So a man in his 20s may be able to have sex more than two times a day, but yet unable to father a child. Whereas a man in his 90s that could barely get it up, but still produceing quality semen could father a child. If a man has no issues producing quality spermatozoa , as a young man, and he is able to carry that attribute to old age, he can father a child at 100. But not all men can do that.
Now we are talking about a lot of things happening at a younger age; menopause hitting early; women developing breast cancer at earlier ages, and so on. Is andropause also a condition that might be hitting men also at a younger age?
Yes. It is possible, the reason being that we are in the jet age now. Men’s lifestyle has changed greatly. More people drink all sorts of things now. For instance, alcohol as one of the drugs that could have detrimental effects to the testes, the primary source of testosterone. More men are getting exposed to different environmental toxins that may affect their testis and its ability to continue to perform its function optimally. So it’s possible. Just as we are having challenges with most other conditions and we are seeing them at a younger age, it is also possible because there are so many things in the environment now that were never there before.
ALSO READ: ‘My good friend’, Atiku salutes Obi at 63
and then