Andropause: Man’s Problem For the Ages
Male menopause currently affects up to 10 million American men, who can benefit from a customized exercise program.By far, the “Aging of America” is one of the greatest healthcare concerns facing the country today. Different health organizations estimate that the population of Americans over the age of 65 years will double (yes, double!) to 70 million by the year 2040 (Hurley & Hagberg 1998). Worldwide, the number of people aged 60 years or older is projected to increase from 593 million in 1999 to 1.97 billion by 2050 (Wyllie 2003).
As they age, men and women share many common health problems, such as loss of muscle mass and strength, increases in fat mass (particularly in the abdominal region), progressive loss of bone mass, and overall decreases in feelings of psychological and physical well-being. However, while menopause usually marks the onset of these changes in women, there is not one physiological event that signifies a change in life for men. In fact, the signs of aging in males are usually much more subtle and they progress over time, often beginning in men’s 40s or early 50s and possibly culminating in their 60s or 70s. Often referred to as “male menopause,” this slow onset is known in the scientific community as “andropause.”
Working with older male clients can pose a challenge for fitness professionals because the outward andropause symptoms stem from multiple body processes and are not easy to identify until they become obvious problems. However, with knowledge and experience, personal fitness trainers and group exercise instructors can design appropriate exercise programs to help their male clients adjust to andropause.
What Is Andropause?
The physiological phenomenon known as andropause was first alluded to in 16th century Chinese medical literature (Morley & Perry 2000). Today, it is thought that roughly 5–10 million men in the United States are affected by or experiencing andropause symptoms (Tan 2001a).
Andropause is a clinical and biochemical syndrome associated with advancing age in males and mainly characterized by a deficiency in serum (blood) androgen, mostly testosterone, levels (Wyllie 2003). The condition is sometimes referred to as androgen decline in the aging male (ADAM), partial androgen deficiency in the aging male (PADAM) or aging-associated androgen deficiency (AAAD) (Matsumoto 2002; Morales, Heaton & Carson 2000). Although the term andropause is used most often in the scientific literature, it is actually something of a misnomer because androgen release never fully stops or “pauses” in the majority of aging men. Whatever name you choose to describe it by, andropause is clearly associated with an age-related decline in serum testosterone, with levels falling below those normally seen in younger individuals (Matsumoto 2002).
The Role of Testosterone
Testosterone is an anabolic hormone secreted by the testes under the control of hormones released by the brain. Most testosterone is transported bound to two different carrier proteins in the blood, while a small percent (1%–2%) circulates unbound or free (Matsumoto 2002). As men age, a greater percentage of the testosterone in the blood remains tightly bound to one of the carrier proteins. This causes a decline in the amount of testosterone available for use by body tissues, thereby influencing the gradual development of andropause (Matsumoto 2002).
Serum testosterone levels rapidly increase in males at the onset of puberty and then begin to decrease progressively at a rate of approximately 1% per year, starting as early as age 30 (Morales, Heaton & Carson 2000). This decline in serum testosterone concentrations can be attributed to an overall drop in production by the testes and impairments in the brain’s ability to stimulate the release of testosterone (Matsumoto 2002). Scientists estimate that 20% of men over age 60 and 50% of men over age 80 have serum testosterone levels below the normal range for young men (Morales, Heaton & Carson 2000).
The change in testosterone levels often results in significant alterations in a man’s quality of life and contributes to a decline in physical function that parallels the development of age- related diseases of the kidney, liver, heart and lungs (Matsumoto 2002). For a look at some of the clinical manifestations of the condition, see “Signs & Symptoms of Andropause” on page 55.
Physiological Effects of Andropause
Scientists have identified five clinical domains affected by andropause:
- substance (lean body mass, visceral fat, bone density and hematocrit)
- surface (hair and skin alterations)
- central nervous system (mood and cognition)
- sex (libido and erectile dysfunction)
- prostate health (Heaton & Morales 2001)
The decrease in testosterone levels associated with andropause has been linked to decreased muscle mass and bone density, increased visceral fat, loss of muscle strength and power, lower functional capacity, decreased sexual function and libido, depression and mood changes, and decreased cognitive function (Lunenfeld 2001; Matsumoto 2002; Wespes & Schulman 2002). The bad news is that many of these conditions interact, which can significantly increase the risk of frailty and loss of independence in older men. The good news is that almost all of these andropause conditions can be positively impacted by exercise training.
Sarcopenia, Obesity & Bone Density
During andropause the most common chronic change that contributes significantly to the rate and severity of disability in older men is sarcopenia. Sarcopenia is the loss of muscle mass that occurs with aging (Muhlberg & Sieber 2004). The consequences of sarcopenia are decreased muscle strength and power; loss of mobility; and neuromuscular impairments that affect balance. Ultimately, these consequences lead to an increased risk of falling and developing fractures that can further impair mobility and overall independence. Sarcopenia can also affect endurance capacity. In a study of 53 men who had adropause symptoms, 66% reported a significant decrease in endurance (Wu, Yu & Chen 2000).
Obesity has been shown to be another strong predictor of low testosterone levels (Tan & Pu 2002). Aging-related decreases in lean body mass usually translate into increases in visceral (intra-abdominal) fat. Men with low testosterone levels have a much lower percentage of lean body mass and a higher percentage of fat mass than normal men of the same age (Katznelson et al. 1996). Testosterone levels are negatively (a good thing, in this case) correlated with factors associated with metabolic syndrome, such as total and LDL cholesterol levels, hypertension, insulin levels and glucose levels (Matsumoto 2002).
Decreasing bone density has also been linked to declining testosterone levels in men. However, the overall changes in men’s bone density due to andropause do not rival the rate of decline in bone density that women typically experience following menopause (Matsumoto 2002). Instead, the change in bone density in men is affected more by decreased activity brought about by the progressive sarcopenia and, in some cases, malnutrition associated with andropause. Strategies to treat or reverse this bone density decline in men should include weight-bearing exercise (resistance and cardiorespiratory) and a proper nutrition program that emphasizes optimal protein intake.
Mood & Cognition
Cognition encompasses all the mental processes carried out by the brain, including—but not limited to—language, calculation, reasoning, memory and learning (Tan & Pu 2001). Memory loss is one of the most important andropause symptoms. One study observed the effects of andropause and decreased testosterone levels on memory loss in older adults (Tan 2001b). Out of 302 subjects (71% of whom were 60 years or older), 36% reported some type of memory loss and decrease in cognition. In a study by Wu and colleagues (2000) of 53 men (over 50 years old) with physiological changes consistent with andropause, 91% reported decreased libido, 89% lack of energy, 77% memory impairment and 51% deterioration in work performance.
The same researchers observed negative mood changes in 68% of men over the age of 50 with low levels of serum testosterone (Wu, Yu & Chen 2000). Mood swings or depression can be manifested in many ways, including loss of function or independence, which often occurs with a decrease in testosterone levels and the subsequent effect on muscle mass and strength.
Managing the Symptoms of Andropause
Treating and managing andropause symptoms requires a multidimensional approach (Matsumoto 2002). In other words, strategies used to alleviate problems should do more than just correct low testosterone levels. The two main forms of andropause treatment options that will be discussed in this article are hormone therapy and exercise, both of which can help manage the physical manifestations of andropause.
Unfortunately, there are very limited data suggesting that exercise has a beneficial effect on cognitive-function and mood changes related to andropause. There is also no scientific consensus that other therapies, such as testosterone replacement, improve cognitive function in the andropausal population. However, some studies have shown that hormone therapy can positively affect mood and depression (Barrett-Connor et al. 1999; Matsumoto 2002), and my own experiences working with this population suggest that exercise training can improve men’s sense of well-being and self-worth and provide an outlet to combat depression. This is especially true in the group setting, since group interaction and social support are crucial for males dealing with andropause symptoms.
Hormone therapy can be administered in several ways—through testosterone injections every 2 weeks, by daily application of a transdermal patch or gel, or via “designer” androgens (Matsumoto 2002). Injections are typically the cheapest delivery method, but they are also associated with the most side effects, owing to large fluctuations in serum levels after administration. The transdermal patch and gel both appear to be better options because the smaller dose of testosterone administered via these routes limits side effects. The newer “designer” androgens have very low side effects but are much more expensive and need further research. In general, long-term research studies demonstrating safety and effectiveness are lacking for all types of testosterone treatments, so universal treatment of andropause symptoms with testosterone supplementation is not routinely recommended (Vermeulen 2000). The next best treatment option for andropause is lifestyle modification, with diet and exercise at the forefront of symptom management.
Testosterone replacement has proven moderately effective at increasing muscle mass and strength, but it has the most consistent effect on muscle mass decline. A study that involved the use of testosterone replacement gels demonstrated significant increases (22–29 pounds) in lower-body muscular strength accompanied by increases in muscle mass in 227 men with symptoms consistent with andropause (Wang et al. 2000).
Schroeder and colleagues (2004) studied the effects of testosterone therapy on adipose tissue in 32 overweight men (60–87 years old) and found a decline in subcutaneous and visceral fat that correlated with an improvement in insulin sensitivity. The authors concluded that hormone therapy may reduce the overall risk of metabolic syndrome and associated problems, such as hypertension, high cholesterol and high blood sugar. The same researchers found that fat mass decreased as a result of testosterone therapy, but no changes were observed in blood lipids (total, HDL or LDL cholesterol). The effect of hormone therapy on blood lipid levels is highly variable and based on the dose of testosterone. On the whole, HDL cholesterol levels remain unchanged when the testosterone dose is low (Schleich & Legros 2004). In contrast, LDL and total cholesterol levels have been shown to decrease with lower doses of testosterone (Matsumoto 2002; Schleich & Legros 2004).
Bone density can also be favorably affected by testosterone therapy. Kenny et al. (2001) demonstrated an increase in bone mineral density in subjects receiving a transdermal form of testosterone. In addition, these subjects experienced an increase in lean body mass and a decrease in percent body fat.
For older men who wish to improve or maintain muscle mass, resistance training is more effective than simply taking hormone therapy. Although the majority of resistance training studies have failed to demonstrate a change in resting baseline testosterone levels following strength training in older men, all the research has reported a greater release of testosterone following acute bouts of heavy (up to 80% 1RM) resistance training (Hakkinen et al. 2000; Hakkinen et al. 2002; Izquierdo et al. 2001; Kraemer et al. 1999; Nicklas et al. 1995; Yarasheski et al. 1999). Generally, all these studies indicated significant increases in muscle mass and/or strength following strength training. Some also demonstrated favorable changes in fat mass (Nicklas et al. 1995) and power (Hakkinen et al. 2002; Izquierdo et al. 2001). Such findings suggest that increases in muscle mass and strength over time are due to acute resistance training responses, and that training requires a consistent effort to elicit these changes. Chronic training adaptations do not appear to affect baseline levels of testosterone, suggesting that acute exercise is the key to muscle growth and strength.
Two studies (Casaburi et al. 2004; Giorgi, Weatherby & Murphy 1999) examined the benefits of combining resistance training with hormone therapy to improve upper- or lower-body strength. Both studies reported significant increases in strength, and one (Casaburi et al. 2004) also showed significant increases in lean body mass, compared to either hormone therapy or resistance training alone. While these results are intriguing, further research is required to determine the long-term benefits of such a concurrent regimen.
Studies have shown that a cardiorespiratory exercise program can help men undergoing andropause improve their health, especially in terms of diminishing visceral adiposity. The basic goal when developing a suitable exercise program for men going through andropause is to maximize caloric expenditure by increasing the frequency and duration of physical activity, while slowly introducing intensity over time.
Boudou and others (2000) studied 20 middle-aged, male diabetics over an 8-week period to observe the acute and chronic effects of a continuous and interval cardiorespiratory endurance program on anabolic hormones, visceral adiposity and other factors related to diabetes. The researchers reported significant increases in cardiorespiratory fitness, insulin sensitivity and glucose tolerance by the end of the 8-week training. Visceral adiposity decreased by 44% during the study, although weight and body mass index did not change. Testosterone responses to acute exercise increased, but no changes were observed in resting testosterone levels following training. The transient effects on testosterone levels suggest that consistent training needs to be maintained over time in order to increase muscle mass. Other researchers have reached similar conclusions about the effect of endurance training on minimally active men ranging in age from 60 to 70: Cooper and others (1998) determined that while endurance training was ineffective at preventing the aging-related decline in testosterone levels, it did significantly lower visceral fat amounts in those trained.
Designing an Exercise Program
When designing an exercise regimen for a client with andropause, fitness professionals need to consider the following elements:
Screening and Exercise Participation. Prior to working with any male who presents with or has a history of symptoms associated with andropause, verify that a physician has screened the client. After the physical exam, review the findings for information on underlying cardiovascular disease and diabetes (or risk factors for these), level of cognitive impairment and evidence of depression, as these are common andropause symptoms. This information will help you decide on issues affecting safety and allow you to plan for exercise progression, program complexity and overall adherence. Some health professionals—myself included—have found that males with lower cognitive function can get confused, become frustrated and lose interest quickly if their programs are too complex and difficult to follow.
Hormone Therapy. Prior to designing an exercise program, be sure to ask the client about past, current or anticipated use of hormone replacement therapy. This type of therapy offers many significant benefits that can improve the quality of life for men suffering from low serum testosterone levels. However, testosterone supplements can pose some risks for clients during training. The most common risks are increases in blood hematocrit (i.e., red blood cell concentration) and edema. Increases in hematocrit affect the body’s cardiovascular response to exercise by increasing heart rate and blood pressure, which can lead to stroke or heart attack. Physical activity can also exacerbate the symptoms of pre-existing prostate disease or cancer. Carefully screen any client who is taking hormones. Refer the client to a physician if you observe any changes in blood pressure and heart rate or if he complains of chest pain or dizziness with normal exercise activities.
Cardiorespiratory Endurance Training. Exercise stimulates the brain to release hormones that activate higher levels of testosterone released from the testes. Interestingly, both a lack of exercise and overtraining (high-intensity, long-duration exercise) have been found to decrease testosterone levels (Tan 2001a). That’s why experts recommend starting with moderate-intensity (RPE 11–14, 60%–75% HRmax) exercise for up to 30 minutes, three times a week, for andropausal men. Past research has demonstrated that short bouts of intense exercise may be more effective than continuous, lower-intensity exercise for peripheral adaptations (e.g., muscle endurance) and overall testosterone response (Tan 2001a). While your client’s exercise program should focus mostly on weight-bearing activities—because of their greater benefits for maintaining or improving bone density—it is still a good idea to mix in non-weight-bearing activities, such as swimming and biking, for variety. Remember to include some group exercise experiences, which will promote social activity and interaction with other clients.
Resistance Training. Resistance training should be a part of any comprehensive fitness program for a client experiencing andropausal symptoms. Studies have demonstrated the benefits of both a low-volume program (Kostka et al. 2003) and a periodized, heavy resistance training program (Hakkinen et al. 2000; Hakkinen et al. 2002; Izquierdo et al. 2001; Kraemer et al. 1999; Nicklas et al. 1995). Program design will depend on how well the client tolerates exercise. Start off with multijoint exercises using resistance bands or machine-type modalities until your client is ready for free weights.
Balance and Power Training. Since the client’s main goal should be to increase physical function and maintain lifelong independence, you will also want to include exercises that improve balance and power, both of which can decrease the risk of falling and fractures. These are two main factors that influence independence in older adults. Begin with simple balance exercises on the floor or using resistance/therapy balls, and progress to more challenging exercises involving balance boards or foam pads to stimulate proprioceptive adaptations.
The Nutrition Element
Making specific nutrition recommendations is outside a fitness professional’s scope of practice, but it is important for men experiencing andropause to know that food choices can affect their health. To fully reap the benefits of any type of exercise program, clients experiencing andropause need to adopt a sound nutrition program with a focus on adequate protein and controlled carbohydrate intake (Tan 2001a). One barrier to training improvements in this population is an increased incidence of malnutrition.
In general, ingesting foods that are high in protein and relatively low in carbohydrate can increase and sustain serum levels of testosterone. Because sarcopenia and increased visceral fat are significant problems for men with low testosterone levels, protein replacement is important for normal growth and maintenance of muscle mass (as well as bone!). Carbohydrates should be ingested in the form of fruits and vegetables, which contribute valuable antioxidants and have anti-aging properties (Tan 2001a).
Men experiencing andropause should also be careful not to remove fat entirely from their daily diet, as some dietary fat is required to produce testosterone. Calcium and vitamin D are important for normal bone health and maintenance of bone density with andropause. For a more in-depth nutrition program, refer clients to a local registered dietitian who specializes in the nutrition needs of older adults.
Andropause is an unpreventable event that occurs in the normal life span of men. Many of the andropause symptoms or changes (e.g., sarcopenia, decreased strength, loss of bone mineral density, increased visceral adiposity, depression, decreased cognitive function, etc.) can be managed through hormonal therapy and lifestyle changes that include regular aerobic and resistance exercise accompanied by a sound nutrition plan.
Personal fitness trainers and, to some extent, group exercise instructors, can facilitate clients’ transition through this period by designing appropriate, individualized exercise programs. The focus of these andropause programs should be on increasing strength and possibly muscle mass; maximizing energy expenditure with aerobic and resistance training in order to decrease abdominal obesity and the risk of diabetes and cardiovascular disease; carefully monitoring any level of cognitive impairment; and encouraging clients to participate in a group exercise setting to promote social interaction and support. Using these kinds of strategies, fitness professionals can help their older male clients meet the challenges of aging with the confidence that andropause signals a new chapter in their lives.
This section of the article is still in the process of conversion to the web
Organon International, www.andropause.com/—good website for clients, very consumer driven
The Andropause Society, www.andropause.org.uk/—good consumer and professional information site
The European Menopause and Andropause Society, http://emas.obgyn.net/ —one of the biggest, most comprehensive sites on the Web; has consumer and professional information and links
The Andropause Mystery: Unraveling Truths About the Male Menopause by Robert Tan, MD—worth reading, written by one of the leading researchers/scholars in this field
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