Andropause

# Overview
Andropause may or may not actually exist as a clinical phenomenon. Its proponents claim it is a biological change experienced by men during their mid-life, and is often inaccurately compared to the female menopause. It would perhaps be more reasonable to speak of a steady age-related decline in testosterone levels in men, since men's reproductive systems slowly and gradually decline with age, but do not stop working altogether in mid-life, as women's do. It is also not clear how much this supposedly universal male phenomenon can be related to a psychological mid-life crisis, and to overall negative bodily changes in mid-life due not only to aging, but also to the accumulated effects of a lack of exercise, poor diet and so on.
Andropause is also known as androgen decline in the aging male (ADAM), late onset hypogonadism (LOH) and testosterone deficiency syndrome (TDS). There is no cut off age at which andropause starts as there is variability among men in terms of age of onset.
Endocrine Society Guideline and the European Association of Urology Recommendations defines andropause as the following: TDS/LOH is a clinical and biochemical syndrome associated with advancing age and characterized by symptoms and a deficiency in serum testosterone levels. It may result in significant detriment in the quality of life and adversely affect the function of multiple organ systems.

# Historical Perspective
Much of the current interest in this alleged phenomenon has been fueled by the book Male Menopause, written by Jed Diamond.  It should be noted that Diamond is neither an MD nor a PhD. According to the book's author, andropause (another term for "male menopause") is a change of life in middle-aged men, which has hormonal, physical, psychological, interpersonal, social, sexual, and spiritual aspects. Diamond claims that this change occurs in all men, generally between the ages of 40 and 55, though it can occur as early as 35 or as late as 65.
The term "male menopause" is a misnomer, as men dont have menstrual periods, and therefore cannot stop having them.  Unlike women, men's reproductive systems do not cease to work completely in mid-life; some men continue to father children late into their lives (at age 90 or older). But Diamond claims that, in terms of other life impacts, womens and mens experience are somewhat similar phenomena.
The concept of andropause is perhaps more widely accepted in Australia and some parts of Europe than it is in the United States. In the U.S., many clinicians believe that, since men can continue to reproduce into old age, and do not show the same dramatic drops in hormone levels characteristic of menopause in women, andropause is nonexistent. Others feel that andropause is real, but is synonymous with hypogonadism or low testosterone levels .

# Pathophysiology
- Aging affects the hypothalamus- pituitary- gonadal axis and causes a decrease in the production of gonadotropin releasing hormone (GnRH) by the hypothalamus and a decrease in the production of LH by the pituitary.
- Aging is associated with decrease in the number Leydig cells as well as decrease in their sensitivity to LH resulting in decrease production of testosterone.
- Age related changes in androgen receptor, a ligand inducible transcription factor, has been reported to be associated with less androgenic effects of the testosterone.

# Epidemiology and Demographics
The prevalence of andropause has not been accurately reported. According to the Massachusetts Male Aging Study (MMAS) has estimated the crude prevalence of andropause in American men between 40 and 69 years old to be around 481,000 new cases per year.

# Screening
Several questionnaires have been developed as a screening tool for andropause. These questionnaires include the following:
- St. Louis Universitys ADAM
- Aging Male Survey (AMS)
- Massachusetts Male Aging Study questionnaire (MMAS)

# Symptoms
The impact of low levels of testosterone has been previously reported. Heller and Myers identified symptoms of what they labeled the "male climacteric" including loss of libido and potency, nervousness, depression, impaired memory, the inability to concentrate, fatigue, insomnia, hot flushes, and sweating.  Heller and Myers found that their subjects had lower than normal levels of testosterone, and that symptoms improved dramatically when patients were given replacement doses of testosterone.
Testosterone deficiency has also been linked to metabolic syndrome and mood disturbances mainly depression.

# Diagnosis
The diagnosis of andropause is difficult since the clinical diagnosis alone or biochemical assays alone are not sufficient. When symptoms of andropause are clinically present along with low or borderline-low free testosterone levels, the diagnosis can be established. According to Morley et al, the diagnosis requires a positive response to testosterone treatment along with the initial clinical and biochemical diagnostic clues..
The biochemical diagnostic clues include measuring the free testosterone level. It is important that the measurement is done in the morning due to the variability of testosterone levels associated with the circadian rhythm. The testosterone measurement should be repeated in two weeks due to week to week variability.

# Treatment
Several intervention strategies have been found to be effective  . These include:
- Hormone replacement therapy,
- Exercise, dietary changes, stress reduction,
- Couple counseling, career refocusing, and spiritual support,
- Chemical dependency treatment, sexual compulsivity treatment,
- Treatment for depression,
- Finding and engaging ones calling in the second half of life.