Mid-Life Crisis, Male Menopause & Andropause.

What are Andropause and Late Onset Hypogonadism (LOH)?

Testosterone – the main male sex hormone –  goes through a slow, steady and progressive drop at a rate of about 1% per year starting in men’s 30s and 40s. This is not a medical condition, rather it is a normal and natural part of aging. The rate of decline in testosterone levels varies in different individuals and it can be affected by chronic disease, excess weight, illness, serious emotional stress, and medication side-effects. This natural rate of testosterone decline can be slowed (but not stopped) by making changes to lifestyle and behaviours. 

There are medical diagnoses resulting from low testosterone levels. Andropause is a medical condition that exists when there are no or extremely low testosterone levels. True andropause exists only in men who have no functioning testicles, due to illness, disease or accident. This can happen at any time of life – some men are born with andropause – so andropause is not specific to mid-life, although it may be diagnosed at that time if the testes stop functioning due to an illness or injury that happens mid-life.  

Testosterone deficiency that develops after midlife is diagnosed by endocrinologists and is known as late onset hypogonadism (LOH). LOH may be responsible for some male midlife symptoms, but many symptoms are not associated with hormones at all. [1] [2] [3] [4]

It is common to use the term andropause to describe changes many men experience starting in their late 40s and 50s, including sexual symptoms like loss of libido, erectile dysfunction, loss of muscle mass, depression and mood swings. This is incorrect unless the testes stop functioning during a man’s mid-life. 

The media often use the term ‘manopause’ and male menopause interchangeably with andropause. This is incorrect. These conditions are different – the underlying cause of andropause is a diagnosable medical condition of low or no testosterone whereas male menopause does not have a hormonal basis comparable to female menopause. And to add more complexity, LOH, not andropause, is the proper term for testosterone deficiency starting at or after mid-life that may cause the symptoms experienced in men. 

It is easy to think that male and female menopause must have a similar underlying hormonal basis, however, this isn’t true. In females, estrogen – the main female sex hormone – begins an abrupt decline after a woman’s reproductive years, followed by years of variability before finally settling into steady but low levels that will persist throughout their lives. 

In contrast, testosterone – the main male sex hormone –  goes through a slow, steady and progressive drop at a rate of about 1% per year starting in men’s 30s and 40s. This is not the medical condition of either andropause or LOH. Instead the decline is a normal and natural part of aging. The rate of decline in testosterone levels varies in different individuals and it can be affected by chronic disease, excess weight, illness, serious emotional stress, and medication side-effects. This natural rate of testosterone decline can be slowed (but not stopped) by making changes to lifestyle and behaviours. [1][2] [3] [4]

[INSERT art of graph showing levels of estrogen vs testosterone decline] 

What is Erectile Dysfunction? 

Experiencing difficulty achieving and maintaining an erection sufficient to participate in sexual activity can be very hard to accept but there are ways to manage and overcome this symptom. Many men don’t seek or delay getting help because they are embarrassed. Don’t be! Ongoing ED severe enough to be reported to a physician affects over 30 million men in the US alone. 

Erectile dysfunction (ED) does happen to almost every man at some point in their lives. The penis contains two sponge-like structures called the corpora cavernosa. These are basically two cylinders that extend the length of the penis. Sexual arousal causes increased blood flow to both of these cylinders and the influx of blood causes an erection by expanding, straightening, and stiffening the penis. [13]

The causes of ED can be physical or they can stem from emotional and psychological issues. 

The physical causes of ED include: 

•  Not enough blood flow to the penis. This can happen for a number of reasons including heart and cardiovascular disease, diabetes (which can cause small blood vessel and/or nerve damage), and smoking.
• The penis cannot hold available blood. If blood doesn’t stay in the penis, erection isn’t possible.
• Nerve signals from the brain or spinal cord do not reach the penis. This can happen as a result of some diseases, injuries, or nerve damage in the pelvic region. 
• Surgery and or radiation for cancers in the lower abdomen or pelvis. ED is a common side effect of prostate, colon-rectal or bladder cancer treatments. 
• Other medications used to treat other health problems. 

Emotional and psychological causes of ED include:

• depression
• anxiety
• relationship problems
• stress
• lack of self-confidence about sexual performance. 

If you have a partner going through the menopause transition who has a diminished interest in sex, feelings of inadequacy and frustration can take over, causing issues for your own sexuality. Women taking medications for depression or anxiety may also experience a loss of libido or inability to orgasm which can be frustrating for both of you.

What can I do about ED?

Knowing the likely cause(s) of ED is the key to resolving it with the correct therapy. Physical treatments will use medications – either new ones or adjusting and changing your existing ones. You may also need to make lifestyle changes that include improving your nutrition, getting adequate sleep, and increasing your movement and activity levels. 

In some cases, men may be prescribed a vacuum constriction device (VCD), also known as a penis pump. This device is an external cylindrical pump that is placed over the penis. Air is pumped out of the cylinder it creates a vacuum, and this vacuum draws blood into the shaft of the penis. The blood will cause the penis to swell and become erect. Once the erection is achieved, a retaining band is placed at the base of the penis to hold the blood in. The pump is removed and the band can safely stay in place for up to 30 minutes, allowing for intercourse. Use of the VCD will cause an erection, but there are differences when compared to a natural erection. Side effects from using the pump include a purplish colour to the penis, numbness, bruising and swelling of the penis and difficulty achieving orgasm. Additionally, ejaculation is unlikely and the penis will be cold. Warm compresses can be used to increase the penis temperature before intercourse. [14]

If the causes of your ED are emotional or psychological, counselling, talk therapy, meditation, and/or breathing exercises can help. The vacuum constriction device discussed earlier in this section is safe and has few long-term side effects. Because of this, it may be prescribed for use when the cause of ED is psychological. This is not a permanent solution, but will allow for successful intercourse while other treatments such as counselling, are ongoing. Talk to your healthcare provider to find a solution that works for you. [13 [14] [15]

Decreased Libido (Decreased Sex Drive)

A decrease in your libido means you have a lowered sex drive, reducing your desire to have sex. You will have less frequent sexual thoughts and fantasies and you may engage in sexual activity less frequently. When libido is low, sexual stimulation can fail to cause interest. 

Libido is not usually associated with the ability to achieve an erection, so men with a low libido can still engage in sexual activity to satisfy their partner. Having to do this, however, may impact your overall relationship with your partner and can also have significant psychological effects for you. [16] 

There is no ‘typical’ level of libido, and sex drive varies among men. As men age, there is a tendency to see a gradual decrease in libido, but age-related changes are gradual, if at all. Fatigue, anxiety, stress, or other conditions may cause temporary reductions in libido and this is normal throughout a man’s life. When noticeable changes to your libido develop after years of ‘normal’ levels of sexual desire, this can be very disruptive to relationships, and can also affect your self-esteem.  

Psychological factors, such as long lasting depression, anxiety, alcoholism, illicit drug use, chronic fatigue, and/or relationship stress are often the root cause of low libido. Physical factors such as chronic kidney disease can decrease libido, as can some drugs, including those used to treat depression, anxiety, or advanced prostate cancer. These types of drugs may decrease blood levels of testosterone resulting in a lower libido. [16] [17] 

What can I do about my low libido?

Treatment for low libido depends on the root cause. Treatments for psychological and emotional issues include talk therapy as described in a different section of this page, as well as practices described in the Self-care section. These include practicing meditation and/or breathing exercise, journaling your thoughts and feelings, joining a support group or a peer group and/or practicing Mind Body Wellness therapies. Refer to the Herstasis therapy page Mind Body Wellness to explore options for alternative and complementary treatments that may help you. Yoga, biofeedback and relaxation therapy, hypnosis, aromatherapy, meditative movement such as Tai Chi or Qigong, are all described in detail, as are several others. You may get inspired to try one or more of these and see if it helps any of your symptoms. [1]

A blood test can measure the level of testosterone in the blood. If this is the root cause of a low libido, it can be treated with testosterone replacement therapy (TRT) as described in a separate section.