I am very interested in osteoporosis and the andropause. I read that antiresorptive drugs, such as palmidronate, are actually counter-productive for bone density.-HB, Wilton........
As modern medicine has turned menopause into a disease, so it has now manufactured the male equivalent. Dr Malcolm Carruthers, a Harley Street psychiatrist and author of Maximising Manhood: Beating the Male Menopause, is one of those most responsible for coining the term "male menopause". Although the condition was described in a medical article in 1944 (JAMA, 1944; 126: 472), it wasn't accepted or dignified with the euphemism "andropause" until recently.
Carruthers became interested in the condition after studying 1000 men attending his London clinic complaining of numerous symptoms similar to those mentioned in the early study. These included fatigue (82 per cent), depression (70 per cent), irritability (61 per cent), reduced libido (79 per cent), awareness of premature ageing (43 per cent), aching and stiff joints in the hands and feet (63 per cent), increased sweating, especially at night (53 per cent) and even classic hot flushes (22 per cent). Some 80 per cent reported erectile dysfunction, or reduced early morning erections-an early warning sign.
Much as many like to think of this as equivalent to female menopause, there are a number of important differences between the male and female condition. The collection of symptoms reported in Carruthers's men didn't come on at a set threshold of life, as they do, in the main, with women. In Carruthers's study, the men were aged anywhere from 31 to 80.
So-called andropause also doesn't appear to be an inherent condition of being male, but one that is brought on by a variety of external factors. Ordinarily in healthy men, bioavailable levels of testosterone decline by about one per cent every year between ages 40 and 70. But this decline is more pronounced in men who aren't healthy (Ann Med, 1993; 25: 235-41).
In Carruthers's study, most patients had suffered some psychological or physical stress which triggered their symptoms. Nearly two-thirds reported suffering from psychosocial stress, a third had problems with alcohol consumption and a quarter with smoking. Nearly a third had suffered injuries or underwent an operation, particularly vasectomy, and almost a third were taking some form of medication. A fifth were too fat, a tenth had had some form of infection, such as the orchitis caused by mumps, glandular fever or prostatitis, and one in 20 had undescended testes.
In other words, not all men go through the menopause, as all women do. Rather than a natural diminishing of hormones, the male menopause is an unnatural insult to the male body.
There is no question, however, that this insult affects levels of testosterone, the most important male hormone. Although total testosterone levels, which is all that is usually measured in men complaining of these symptoms, were only low in 13 per cent of Carruthers's cases, levels
of the carrier protein, Sex Hormone Binding Globulin (SHBG), were too high. These caused levels of the Free Active Testosterone (FAT), obtained by dividing total blood testosterone level by SHBG, to decrease in 74 per cent of his cases.
Carruthers argues that this biologically active testosterone in the blood and tissues decreases markedly with age. In Carruthers's survey, andropause symptoms appear when the FAT levels fall to around 50 per cent, or if the total testosterone level is subnormal.
The problem, of course, is that the definition of andropause is so elastic that any man over 35 suffering from stress could fall into this category. Fatigue, loss of energy, depression, excessive sweating, irritability and anxiety could be symptoms of stress, undiagnosed allergies or even AIDS. Loss of memory could be due to drinking, ageing or mobile phones. A low sex drive could be caused by low levels of a variety of nutrients, or difficulties in a relationship. Most of these problems could have a source in nutritional deficiencies, which also occur more often with ageing if not addressed. In a landmark study, Dr Stephen Davies demonstrated that most adults have marked deficiencies of chromium as they age (J Nutri Environ Med, 1997; 46: 1-4).
As with women, medicine treats andropause with a magic bullet - in this instance, testosterone replacement therapy (TRT). In the US, synthetic testosterone is given by tablet or injection.
Methyl testosterone, the oral synthetic variety, has been removed from the market in Europe because of potential liver toxicity and even a possible cancer risk. Both countries offer natural testosterone implant pellets, which, when inserted under the skin, deliver testosterone over four months. America's Food and Drug Administration recently approved a transdermal patch of natural testosterone, and pharmaceutical companies, who sniff the financial implications of discovering a new type of menopause, are at work on creams and gels.
Luckily, men are more reluctant than women to take hormone replacement and for good reason. TRT is often confused with its synthetic version, anabolic steroids, which are often abused by athletes. It's also associated with hypersexual criminal behaviour.
Common side effects include acne, increased body hair growth, increased male pattern baldness, and increased muscle mass. Doctors are advised to monitor a patient's liver function, and to stop their patients from taking the hormone if there is any change. Since exogenous testosterone suppresses the production of luteinizing hormone and follicle stimulating hormone, TRT lowers sperm count and general testicular volume. The longer lasting injectable preparations, which are synthetic steroids, have numerous potentially dangerous side effects, including liver toxicity from excessive doses.
The greatest issue about TRT concerns whether it causes benign enlargement of the prostate or prostate cancer, since high levels of testosterone are present in both conditions. Carruthers says that in his study, TRT did not adversely affect heart, liver or prostate gland over five years of continual monitoring.
Many enthusiasts like to tout TRT as helping to "prevent" prostate disease. Carruthers says that in his study, 12 cases of early non invasive prostate cancer were found prior to testosterone treatment in his first 1000 patients. During treatment, he says, only two developed it, and they were picked up by repeated screening at an early, treatable stage. "This would suggest that by providing the benefit of this careful repeated screening, testosterone treatment is overall more likely to save lives from prostate cancer than to cause it," says Carruthers.
By test, presumably he means the prostate specific antigen (PSA) test, which has been wrong in detecting cancer 52 per cent of the time (JAMA, 1995; 273: 289-94). Even a recent ejaculation can send PSA levels soaring (Urology, 1996; 47: 511-16).
This echoes the logic used by many doctors in their claims that HRT, by requiring constant monitoring to detect whether it has caused breast cancer, actually helps "prevent" it.
In the medical literature, Carruthers argues that testosterone treatment has been used in a multitude of studies right round the world often in much higher doses than those used to treat the andropause without any convincing evidence of it causing either benign enlargement or cancer.
It's true that little evidence exists on the effects of long term TRT. However, a few medical reports have established a relationship between TRT and prostate cancer or prostatic disease (Arch Intern Med, 1989;149: 2365-6).
Furthermore, animal studies have shown that synthetic testosterone supplementation is twice as potent in stimulating prostate growth as ordinary testosterone (J Clin Endocrinol Metab, 1998; 83: 4212-9). Other animal tests show that synthetic testosterone causes significant growth of cells in the prostate (Anat Rec, 1998; 252: 637-45). While these animals studies may be irrelevant to human experience, they do raise significant questions.
In one other human study, which followed 23 middle aged men given TRT for eight months, the average prostate volume increased by 12 per cent (Prostate, 1993; 23: 99-106). However, TRT may only have this effect on older men; a study of healthy young men with a normal prostate who were given testosterone injections didn't show any increased prostate size or activity (Urol, 1998; 159: 441-3).
This means that TRT may have a negative effect only on the population most likely to use it. Indeed, one other study showed that prostate size increases with age in men with low levels of hormone treated with testosterone (Clin Endocrinol [Oxf]. 1994; 40: 341-9).
As with female HRT, TRT is being promoted as the equivalent of a male fountain of youth, which will help to stave off heart and bone problems. Testosterone is an anabolic hormone, which helps to build protein tissue, muscles, bones and connective tissue hence why synthetic versions help pump up athletes. Therefore, the argument goes, taking testosterone must serve a function in preventing osteoporosis. Although a few studies show that bone mineral density increases during TRT (Pol Arch Med Wewn, 1998; 100: 212-21), no solid evidence has demonstrated that testosterone will actually prevent bone loss, any more than there is good evidence that HRT prevents osteoporosis in women (see WDDTY Guide to the Menopause).
Palidronate, originally developed for bone problems in cancer patients and Paget's disease of bone, is now being (wrongly) used to treat bog standard osteoporosis. One common side effect is low levels of blood calcium and magnesium, which would exacerbate osteoporosis.
Instead of relying on a magic bullet, any man suffering from what he considers the "andropause" might do better to work with a good nutritionist, who will suggest a nutrient dense diet with appropriate supplements and regular exercise. As with women, as WDDTY panel member Annemarie Colbin writes in her new book Food and Our Bones (New York: Dutton-Plume, 1998), bone loss is not inevitable with ageing or loss of sexual hormones, but has more to do with Western diet. See WDDTY vol 9, no 10 for a detailed dietary programme for minimising bone loss. Briefly, eat fresh, unrefined and organic foods, good quality plant or animal protein, soy products, high iodine sea vegetables, whole grains and lots of water.
Harald Gaier is on holiday. His Alternatives column will return next month.