Is andropause real, or is it just a label?

“Andropause” is a borrowed word. Someone noticed that testosterone declines as men age, thought of menopause and drew the parallel. The comparison stuck. It became a headline and the name of a treatment, but it is a poor description of what actually happens in the male body.

In women, menopause is a well-defined event. The ovaries stop producing hormones, menstruation ends, and there is a date you could mark on the calendar. Nothing equivalent happens in men. Testosterone production declines slowly, over decades, at a pace that varies widely from one man to the next, and many men grow old without ever reaching a level that warrants treatment.

So the answer to the question in the title has two parts. Andropause, understood as a male menopause, does not exist. The condition the word is trying to describe, however, is real: it has its own name, diagnostic criteria and treatment. Confusing the two is what leads many men to take hormones they don't need, while many others who genuinely need a workup are never evaluated at all.

What the word “andropause” leaves out

The “pause” in andropause suggests a stop, and a stop is exactly what does not happen in men.

Male testosterone declines gradually. According to the Brazilian Society of Urology (SBU), the drop is around 1% a year from age 40 onward. That is small from one year to the next and substantial over twenty years, which explains why the symptoms tend to be read as ordinary aging rather than as a change worth seeing a doctor about.

There is a second difference, and when it comes to deciding on treatment it matters more than the first. Virtually every woman goes through menopause. Not every man develops a hormonal decline with clinical consequences. Whether he does depends on his own starting point, on how fast the decline happens, and on other health conditions that interfere with hormone production.

Its proper name is late-onset hypogonadism

When falling testosterone starts to cause symptoms, it stops being just aging and becomes a diagnosis. Medicine calls this condition late-onset hypogonadism. In the literature it also appears as testosterone deficiency or androgen deficiency of the aging male.

The change of name is not pedantry, because the two terms describe different things. “Andropause” names a stage of life, something that would happen to everyone and that would leave no decision to make. Late-onset hypogonadism names a clinical condition: one that some men have, that is confirmed by defined criteria, and that is treated once confirmed. It is the first framing, andropause as an inevitable stage of life, that props up the offer of testosterone replacement therapy to men with no indication for it whatsoever.

At what age does andropause begin?

It helps to separate two questions that usually come bundled together.

The hormonal decline begins around age 40, at the rate of roughly 1% a year mentioned above. This is physiological, and it happens silently.

Men seek medical care much later. In clinical practice, the man who comes in with symptoms bothersome enough to prompt a workup is usually over 45 or 50. Before that the symptoms are there, but they rarely bother him enough to send him to a doctor.

As for how common the condition is, figures published by the Brazilian Society of Urology help put it in perspective. According to the SBU, late-onset hypogonadism affects 5% to 7% of men over 40, a proportion that rises to somewhere between 20% and 30% after 60. In other words, the vast majority of men over 40 do not have androgen deficiency, and the condition only becomes common in the oldest age group.

Andropause symptoms, and why they mislead

The symptoms most often linked to low testosterone are reduced or absent sex drive, difficulty with erections, fatigue that rest doesn't relieve, loss of muscle mass and strength, mood changes, irritability, trouble concentrating, poorer sleep and reduced bone density.

The problem with this list is that none of its items is specific. Each of these symptoms has several causes that are more common than a drop in hormones. Sleep apnea, depression, hypothyroidism, certain medications, excess weight, diabetes, heavy drinking and chronic sleep deprivation produce exactly the same set of complaints, and do so far more often.

The consequence is straightforward. The symptom list justifies a medical evaluation, and nothing more. It does not establish a diagnosis, and any article that suggests otherwise is simplifying something that cannot be simplified.

Why the lab's “normal” isn't the doctor's “normal”

This is the part that almost never appears in articles on the subject, and it answers most of the questions from men who have already had the test and still don't know what to make of it.

When you have your total testosterone measured, the report shows your result alongside a reference range. That range is statistical. It describes what is usually found in the population that took the same test at the same laboratory, a group that includes men in their twenties and in their seventies, healthy and sick alike. It was never designed to define who needs treatment.

Clinical decisions rely on a different number, called the cutoff, and it sits higher than most people imagine. The American Urological Association (AUA) uses 300 ng/dL as a reasonable cutoff for investigating testosterone deficiency. The European Association of Urology (EAU) works with a value close to 350 ng/dL. Dr. Nilson uses 350 ng/dL in his practice. It is the more conservative of the two criteria, and it brings into the workup men whom the 300 cutoff would leave out.

It is worth saying right away that none of these numbers decides anything on its own. A single measurement, with no associated symptoms, has no diagnostic value. The cutoff exists to interpret the test of someone who has already come in with a complaint, never to turn a lab result into a diagnosis by itself.

What follows from this is common in practice. A man with obvious symptoms and a testosterone level of 320 gets a report that labels the result within range, concludes the matter is settled and leaves without a workup. It wasn't settled.

Two measurements, both in the morning

Testosterone fluctuates over the course of the day. It peaks in the morning and falls as the hours pass, so a sample drawn in the afternoon can show a low value in someone whose production is perfectly normal.

That is why the accepted criterion calls for two total testosterone measurements, drawn on different days and both in the morning, preferably before 10 a.m. A single measurement is a clue, not a diagnosis.

And even an abnormal result is not enough on its own

This completes the reasoning. An abnormal test without symptoms does not amount to late-onset hypogonadism, and neither do symptoms with a normal test. The diagnosis requires both at the same time.

The American Urological Association guideline is explicit on this point. Testosterone deficiency is a clinical syndrome, not a lab number, which is why men without symptoms should not be treated just because a test came back low.

What is at stake when you treat without a diagnosis

Testosterone is not a supplement. It is a hormonal medication, and using it without an indication has predictable consequences that usually go unmentioned.

The main one is that testosterone given from outside shuts down the body's own production. The body senses that there is already enough hormone in circulation and cuts back on what it was making. Sperm production falls along with it, which impairs fertility, sometimes for a long time. For a man who still plans to have children, this changes the decision, and it is rarely brought up before treatment starts.

Other effects also call for follow-up, such as a rise in hematocrit, which has to be monitored with periodic blood tests for as long as treatment continues.

As for the most common question of all, whether testosterone replacement causes prostate cancer: the evidence available today does not support a causal link.

That is far from meaning the hormone can be started casually. Before any testosterone replacement, the patient needs a thorough overall evaluation, and that evaluation must include the prostate. This applies all the more to men who already have risk factors for prostate cancer, such as a family history of the disease or a previous abnormal test, and monitoring continues throughout treatment. The absence of a proven causal link in the literature is no substitute for that evaluation, and no one should start hormone replacement without it.

None of this is an argument against treatment. It is an argument for treating the men who have a diagnosis, and for ruling out other possible causes first, since in many cases the fatigue and low libido come from something hormone replacement would not fix.

When to seek an evaluation

If you are over 40 and living with a lower sex drive, difficulty with erections, fatigue that rest doesn't relieve or loss of muscle mass, the next step is not to start hormones, and not to order the test on your own.

The right path is an evaluation by a urologist trained in andrology, who will look into the other causes that can produce these same symptoms, order the measurements correctly, interpret the result against the clinical criterion rather than the range printed on the report and, if there is a diagnosis, manage treatment with proper follow-up.

Andropause, understood as a shutdown of hormone production, is a label that does not match what actually happens. Testosterone deficiency associated with aging is real, has criteria for diagnosis and can be treated in the men who actually have it.