Edward Lichten, M.D.,PC
180 East Brown Street
Birmingham, MI 48009 
248.593.9999

Is there a Male 'Menopause?'
The correct term is 'viropause', and, YES, men do go through it. The symptoms are much more gradual than the female menopause, and only rarely do men get the 'hot flushes.' But they do find an increase in nightly and morning fatigue, decreased interest in sex and more irritability... just like their menopausal partners. All men in the past, would rely on denial. Each would rationalize that the stress at work and the financial pressures at mid-life are the problem. But even with vacation and his attentive partner, his erections are less often, less firm, and ejaculation less often. But being a man, he will rarely discuss this with his friends or go to a physician. "It must be normal... and ... there is nothing that can be done," are the keystones to his inactivity.

"Although women authors including Gail Sheehy and Susan Rako, M.D. have described this deficient testosterone state in men, almost no one talks about it and almost no one does anything about it," states Dr. Lichten. "When I experienced the 'hot flashes' at 48 years of age tnat would wake me with night shirts soaking wet, no one suggested to me to measure my hormones. They said male 'menopause' was an illusion!"
But I did measure my hormones and found testosterone levels to be below 350 ng/dl. My pituitary was demanding a testosterone production that the testes could not produce. With this biochemical information, testosterone replacement followed.

"And I found not only relief from night sweats,
but a better night's sleep and renewed sexual energy."

"I do not think that I am the only 50+ year old male
with a TESTOSTERONE 'hormonal' deficiency!"

Testosterone is recognized as the hormone of puberty: it makes muscles for boys and turns them into sexually functional men. But as men age, testosterone's effect regulates muscle development and skin and penile turgor. The decreases in testosterone experienced with time can have profound effects on a man's health.

 The normal range of testosterone is reported as 350- 1200ng/dl. Studies in the 1940's showed the average testosterone level to be at 700 ng/dl, 300 ng/dl higher than for men today. In the past, a drop in testosterone levels to 250 ng/dl was rarely reported before men were 80 years of age. Yet today, it is not an uncommon value for middle aged men!

Testosterone levels are highest in the early twenties. The decrease in serum levels is now occurring at an even earlier age. Up to 50% of all men at 40 now have testosterone levels below what was considered the normal range of 450 ng/dl. Recent studies imply that the pesticides and preservatives in foods and the hormone pellets to fatten up cattle, pork and chicken act as "hormonal disruptors." Based on the low sperm counts, infertility, obesity and low serum testosteroneI see in younger men, I fear this is true.

Physiology:
Testosterone is produced in the testes. These gonads are present within the scrotal sacs. Testosterone's effect start in utero; both genitalia and brain development are influenced by this hormone. With the surge at puberty, secondary sexual characteristics including facial hair, deepening voice, body shape, and increase size of sex organs are noted.

Detecting Insufficient Testosterone Levels:
In young men, infections such as mumps or viral infections, removal of the testes due to cancer or trauma, and a genetic abnormality may cause Testosterone Insufficiency. However, for most, the development of testosterone insufficiency is directly related to aging.

With 80 percent of the baby boomers showing decreased levels of testosterone by 50 years of age, testosterone deficiency is a major unrecognized health problem.

Self Diagnostic Quiz
See St. Louis A.D.A.M. questionnaire on right.

The Laboratory Test: Detecting the Problem

Testing is easily accomplished, once the decision is made. The blood test measures the serum levels of testosterone and the 'free' testosterone as well. Deficiency is denoted by a testosterone serum level below 350 ng/dl. The blood sample should be draw in the morning because there may be significant variation depending on stress at work, exercise, or other hormonal therapy (such as DHEA, thyroid, growth hormone]. Free testosterone measurements are reported differently by different laboratories

In Europe, a more sensitive test of Free Testosterone function is measured. It is called the F.A.I.; free androgen index. This is my definitive test. The value is determined by dividing the level of total testosterone by the sex hormone binding globulin. Since testosterone is measured in ng/dl, and SHBG is measured in nmol/L you must multiply this by a conversion factor of .035 to get the true ratio. "This key ratio should normally be in the range of 0.70- 1.00 and andropausal symptoms are almost always present when the F.A.I. falls below 50 per cent." Malcolm Carruthers, MD. p.132 Maximizing Manhood:Male Menopause: Restoring Vitality and Virility. HarperCollins Publishing. London, England. 1996

Lastly, measurements of FSH (follicle stimulating hormone) and LH (luteining hormone) are elevated in more men than ever considered: I find them elevated in 50% of the men with complaints of "andropause." Normal values are less than 5; often much less.

Ongoing Research

Research in our facility is now focusing on the increased role estrogens have in the aging male. Elevated levels of estrogens are associated with central obesity, gynecomastia and increased cardiovascular mortality. The physiology of estrogen in the aging male may be treatable with new drug therapies that lower estrogen and sex hormone binding globulin. In the future, physicians may be able to maintain a man's virility well into his 90's by modifying his hormone balance!

The Prostate Examination:
Before starting on testosterone replacement, every male needs to have a prostate examination. This examination, often by a urologist, is to document the status of the prostate gland. Any irregularities, hypertrophy, or urinary complaints needs to be documented and treated, prior, to starting testosterone.

Before starting testosterone replacement, the man needs to have a PSA (prostate specific antigen) blood test. Values that are raised are followed by a PSA II test that may identify prostatic hypertrophy. Testosterone replacement is absolutely contraindicated in men with prostate cancer until cleared by a urologist..

Men should repeat this prostate and PSA testing every six months or as directed by their physician.

Treatment Alternatives:

Since in healthy young men, testosterone is secreted all day long with a peak in early morning, the ideal replacement would follow this pattern. There are two common delivery mechanisms for testosterone: oral and parenteral. Parenteral refers to through the skin or injections.
While oral tablets may be easy to use, they are not natural, physiologic or healthy. Oral testosterone may dramatically raise the testosterone level, only to have it drop a few hours later. The major drawback to oral testosterone is the "first pass effect." This means that the oral testosterone is absorbed and sent directly to the liver. In the liver, the testosterone effects many enzyme systems and raise the potential for liver dysfunction and even tumors. Most of the oral testosterone is deactivated by liver cells. Oral methyl-testosterone raises 'bad' cholesterol and lowers 'good.' It is banned in all modern countries except Canada and the United States.

The pharmaceutical companies tried to avoid this liver-toxicity issue by inventing the testosterone patch. One company, Alza Corporation, produced a scrotal patch called Testoderm®^. The individual applied the patch to a shaved scrotum and it delivered 2.5-4 mg of testosterone. It is somewhat awkward and uncomfortable.
Ciba-Geigy Corporation produced a larger testosterone patch worn on the back; Androderm® Although it contains 12.5 mg of testosterone, because of the thicker skin on the back it delivers only 2.5 mg of testosterone. You need to wear two patches and change them daily. Most men need two Androderm(® patches, and are not comfortable with either method. A double sized patch is now available. A testosterone gel by Unimed, a division of Solvay Pharmaceuticals was made available in the fall on 2000. It is called Androgel®and its sales have reached $1.5 billion in 2005.

The best delivery system, used most often since the 1940's has been intramuscular injections of testosterone. There are five injectable testosterone approved in the United States:

1. Aqueous Testosterone: very short acting (1-2 days)

2. Testosterone Cyprionate: short acting (2-4 days)

3. Testosterone Proprionate: short acting (2-4 days)

4. Testosterone Enthanate: longer acting {7-10 days)

5. Deca-Durabolin: longer acting, offering superior muscle pain relief (7-10 days)

Physicians once mixed two or three of these to get a longer and mixed effect. With the short acting testosterones, some men will feel a rush due to the unnaturally high levels for a few days. Occasionally, they may become more aggressive and experience fluctuations in mood, energy and sexual function. But reduction of the dose and education are usually sufficient to modify his behavior.

Some compounding pharmacists will make testosterone gel in 3-10% solutions. This works similarly to the patch, but is applied twice daily. More rapid absorption occurs over thin skin (scrotum, face) while slower absorption occurs over the abdomen. This is aqueous testosterone-- do not use methyl -testosterone as it has liver toxicity effects.

However, we feel the best delivery system for high daily levels of testosterone is the testosterone pellets. Studies in the United States, Europe and the Far East show that testosterone pellets can maintain a stable hormonal level for up to 30-120 days. Although there is individual variation from manufacturer and by patient, this delivery system has been the easiest for men to accept when long term replacement is indicated. This is the method most often used in our office.

Additional Steps to Be Taken:
Men on testosterone replacement should take 160 mg of Saw Palmetto with Pygeum twice daily. This herb will block the conversion of testosterone to dihydrotestosterone (DHT) which affects prostate hypertrophy and possibly cancer development. There were no significant side-effects to this herb. In higher dosages, it is registered as Proscar®.

Risks of Low Testosterone:
Until recently, few men in the United States elected testosterone replacement because of the fear of prostate cancer. In Europe, testosterone replacement is much more common. Recent studies imply that U.S. men are misinformed. Rather, the medical literature documents that low levels of testosterone are directly correlated to:

• heart disease and myocardial infarction

• strokes and cardiovascular disease
• prostate cancer (yes, low levels are higher risk)
• senile dementia
• osteoporosis and hip fracture

Ongoing Research
Total testosterone is not as important as the Free or unbound testosterone, as the latter is bio-available to the tissue. High levels of estrogen and sex hormone binding globulin reduce bio-available testosterone. Medical publications show that gels and patches raise sex hormone binding globulin. High levels of testosterone from an intramuscular injection raises the estradiol level. That is why low-level, even release pellets are the best modality available today for the man who needs testosterone replacement.

Conclusion:
A new philosophy directs the replacement of testosterone in men. Higher testosterone levels have systemic effects, not only improved sexual performance, but also, decreased stress, stronger muscles and possibly less heart, bone, and blood vessel disease.

references:
Malcolm Carruthers, MD.Male Menopause: Restoring Vitality and Virility. HarperCollins Publishing. London, England. 1996, p.132

Eugene Shippen, M.D. Testosterone Syndrome: The Critical Factor for Energy, Health, & Sexuality-- Reversing the Male Menopause. M. Evans & Co., New York, 1998.

Are you Testosterone Deficient?

Tom's video interview

 St. Louis
A.D.A.M. Questionnaire

A list of questions to help you understand how testosterone deficiency affects you. And to urge you to get appropriate laboratory testing.

1 and 2 or any 4 answered as 'yes' is Testosterone deficient!