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Male menopause: Real or imaginary?

Is male menopause a real disease or an excuse for doctors to prescribe testosterone? New guidelines may add to the controversy.

Women go through menopause, so why not men?  Some doctors believe that low testosterone in men is a disease and not a normal part of aging.  The Canadian Medical Association Journal just published new guidelines on the diagnosis and treatment of a condition that sceptics think doesn't exist. 

The guidelines - created by doctors with the Canadian Men's Health Foundation - say that the condition is real. They call it testosterone deficiency syndrome, which they define as a syndrome caused by a deficiency of the male hormone testosterone that occurs in aging men. The symptoms include fatigue, mood changes, weight gain, decreased muscle bulk and strength, sleep disturbance, and erectile dysfunction. To be diagnosed, you have to have the symptoms together with a blood test showing low testosterone levels.

The guidelines say doctors should do a thorough history and physical examination and take a blood test of total testosterone levels in the morning .Once the diagnosis is made, assuming there are no medical reasons not to, the guidelines call for men to receive a three month trial of testosterone replacement therapy. The options include testosterone patches, gels, injections, and preparations that are absorbed through the inside the mouth. Pills aren't prescribed that often because they may be more likely to cause liver toxicity. The choice of testosterone rests between doctor and patient, and is based on factors like effectiveness, tolerability, preference, cost and safety.

The guidelines acknowledge that there are risks testosterone treatment. Men with prostate cancer should not take testosterone because it can make a prostate cancer grow larger. Testosterone therapy can also make sleep apnea -- (repetitive pauses in breathing with loud snoring) worse. The drug can cause acne and other skin rashes. It can cause breast enlargement.  It can also cause shrinking of the testicles and low sperm count, and should not be taken by men who hope to father children.  There's an increased risk of blood clots in the legs and in the lungs.

It was long believed that testosterone increases the risk of heart disease, but the current guidelines say men with stable heart disease can take testosterone safely.

Beyond safety concerns, critics are dead set against the idea of treating older men with testosterone. Some believe testosterone deficiency syndrome is a made up diagnosis to encourage the prescribing of testosterone. 

An editorial in the Journal of the American Geriatric Society said direct-to-consumer advertising for testosterone products and lenient prescribing guidelines has led to a 10-fold increase in testosterone prescriptions in the US, and a 40-fold increase in Canada over a 10 year period. A recent study found just six per cent of Canadian men over the age of 65 given testosterone by their doctor actually had a conclusive diagnosis of low testosterone. 

One big reason is that doctors learn about testosterone from courses sponsored by drug companies. An investigative report published earlier this month by MedPage Today and the Milwaukee Journal Sentinel found that of 75 industry sponsored courses, 65 had at least one doctor receiving fees from a drug company that sells testosterone products. 

The Canadian guidelines are sensible, but if you think doctors will read them, you're dreaming. Most get their information from drug companies - one of which told doctors in the US that testosterone is no longer ruled out for men with active low grade prostate cancer - a statement flatly contradicted by the US Food and Drug Administration.

Things like that tell me you can't trust drug companies to deliver the straight goods.  In my opinion, the Canadian guidelines would have served a much more useful purpose had they given a strong list of warnings about testosterone off the top. As written, they make it seem to doctors as if prescribing testosterone is no big deal, when critics think it's very controversial.