As they age, both men and women both experience a decline in the hormones that play a role in fertility and sexual traits. In women, this biological shift is called menopause, and the change in hormonal levels is relatively sudden and drastic. So do men experience a “male menopause” when testosterone levels decline? The question is controversial, but the blunt answer is: No, there’s technically no such thing as male menopause or andropause.
“The word ‘pause’ implies a sudden abruption in hormone levels, as is the case with female menopause. And that is not physiologically what happens in men,” explains Vinita Tandon, M.D., an endocrinologist, hormone researcher, and medical director of the personalized health and wellness service company Lifeforce. “So the term ‘male menopause’ or even ‘andropause’ is a bit of a misnomer.”
However, Tandon notes, the issue is a bit more nuanced than the controversy would suggest. Men experience a very real, if gradual, decrease in testosterone beginning around age 30, at which point testosterone levels drop, on average, 1% per year.
“Low testosterone is one of the most under-diagnosed conditions in American men,” Tandon says. “An epidemiological study found that out of a group of men who visited their primary care doctor with a variety of symptoms, up to 55% of them tested positive for low testosterone.”
The Difference Between Menopause and Andropause
Men and women experience age-related hormonal declines in distinctly different ways. This has less to do with the differences between estrogen and progesterone versus testosterone than it does the rate at which these hormones stop being available to the organs in the body that use them.
Menopause is marked by the immediate cessation in the release of eggs in the ovaries. With no release of eggs, women become infertile and their monthly menstruation cycle ends. The symptoms of these changes — including hot flashes, night sweats, mood changes, and sleeplessness — come on quickly and can be debilitating. This experience is nearly universal for cisgender women.
The decrease in testosterone levels during andropause is much more gradual. During the shift, men continue to produce sperm and can remain fertile into old age. Still, the drop in testosterone can lead to symptoms including erectile dysfunction, fatigue, mood changes, a decline in motivation, reduced muscle mass, and increased body fat. But unlike women, not all cisgender men will experience these symptoms as they age.
How Is Andropause Diagnosed?
Although all men will experience a decrease in testosterone, the drop isn’t recognized as a medical condition covered by insurance until men become hypogonadal; hypogonadism is a medical condition indicated by low testosterone and diagnosed through a blood test.
Many men experiencing andropause may not reach clinical levels of low testosterone, but that doesn’t mean their symptoms or the decrease in testosterone isn’t real. “There is no question that it’s real, just like it’s real for a woman,” says Jason De Leon, M.D., and emergency medicine physician and co-founder of D&G Optimized Wellness and Hormones.
Low testosterone is one of the most under-diagnosed conditions in American men.
De Leon speaks from experience. “Right before COVID hit, I personally was feeling really crummy, just weak and tired,” De Leon says. His symptoms were consistent with andropause, but upon visiting his doctor, his testosterone levels weren’t low enough to be considered hypogonadal. Although his insurance wouldn’t cover testosterone therapy, he did find a physician to prescribe the hormone off-label, or outside of the FDA-approved indication.
Since starting testosterone replacement therapy (TRT), De Leon says his health has improved. “Things have moved in the right direction, but more importantly, I feel well,” he says. “I went from weighing 250 pounds to 195. I’m no longer tired at three o’clock.”
How Is Andropause Treated?
Both doctors who prescribe testosterone for hypogonadal men and clinics prescribing the hormone off-label use bioidentical exogenous testosterone. This testosterone mimics the hormone naturally produced by the body and can be taken via injection or topical cream.
TRT can boost testosterone levels by up to 50% and is the quickest and most reliable method of increasing levels of the hormone. However, like any medication, it requires careful management, and there can be side effects.
Many men experiencing andropause may not reach clinical levels of low testosterone, but that doesn’t mean their symptoms or the decrease in testosterone isn’t real.
“TRT often leads to decreased natural testosterone production, which can affect fertility,” Tandon says. “It involves either needles or a cream that must be carefully managed to avoid accidental transference to other people by skin-on-skin contact. And it may require additional pharmaceuticals to maintain balance and mitigate side effects such as oily skin or change in hair growth patterns.”
These risks are present regardless of how a man might access TRT. Having a physician to monitor use and side effects is always the best way forward.
Do All Men Need Testosterone Therapy for Andropause?
Men experience decreased testosterone in different ways. For some, andropause may not come with any symptoms, or may be easily managed with diet and exercise. So not every guy will need TRT as he ages.
“It depends on the degree of symptoms and the hormone levels,” says Tandon. “Some men continue to feel great, without symptoms, and don’t exhibit any medical risk, so treatment would not necessarily be indicated.”
Even if a man is experiencing mild symptoms of andropause, there are non-testosterone supplements to help boost testosterone levels, Tandon says. “DHEA, zinc, Vitamin D, ashwagandha, and magnesium, for example, have been shown to help the body naturally produce testosterone,” she notes.
One study related to ashwagandha in the American Journal of Men’s Health found a significant increase in testosterone levels over eight weeks of using the supplement. However, researchers could not conclude if the increase was directly from ashwagandha or decreased stress — a proven effect of the herb. Lower stress means lower cortisol levels, and cortisol can lead to a decrease in testosterone. Magnesium has similar stress-reducing effects.
The Risks of Testosterone Replacement Therapy
When monitored by a physician, men who are truly experiencing low testosterone levels will have the least risks from TRT. The risks increase for men who are taking testosterone outside of a clinic, or who may already have adequate testosterone levels.
De Leon is particularly concerned about men who are taking black market testosterone at home or the gym. “Those medications are often some weird anabolic steroid, or it may be testosterone with a blocker to prevent the conversion of testosterone to estrogen,” he says. That’s an important safety consideration because estrogen has been shown to decrease heart health issues. When estrogen is blocked, there’s a greater risk of heart attack or the development of heart conditions. The risk increases with prolonged use.
Although it’s difficult to quantify the black market use of anabolic steroids, most users appear to be young men concerned with body image. In a 2020 study published in the Journal of Men’s Health, researchers found that of 2,385 men who responded to a survey about steroid use, 43% were between the ages of 22 and 30, and 7% began their use under the age of 18.
And without guidance, steroids can be incredibly hard to quit. In the same study, half of respondents had attempted to quit, with 60% returning to steroid use.
Some of the most debilitating side effects come when TRT raises men’s testosterone levels higher than they normally should be, Tandon says. “Men may experience increased risk for acne, balding, overproduction of red blood cells (which can lead to increased blood viscosity), a decline in HDL, and worsening mood or aggression.”
So although it might not be accurate to call andropause “male menopause,” it’s important for men to keep tabs on their testosterone levels as they age. As andropause progresses after the age of 40, it may be helpful to try testosterone therapy if symptoms are particularly bad. But to decrease the risk of side effects, it’s always best to pursue treatment under the watchful eye of a physician.