Andropause: is there a male menopause? Signs, causes and blood tests

What is andropause?

Andropause is an everyday word for the male menopause: the idea that men, like women, go through a hormonal shift in their 40s or 50s. The word is misleading. In women, oestrogen drops sharply at menopause. In men, testosterone falls slowly: in the American MMAS study by around 1.6% per year for total testosterone and a little faster for free testosterone.

Doctors therefore do not use "andropause" as a diagnosis. They talk about late-onset hypogonadism, meaning low testosterone that appears later in life. It requires the same criteria as in younger men: symptoms plus repeatedly low measurements.

Is there a male menopause?

Not as a phase that every man goes through. In the EMAS study of more than 3,000 European men aged 40–79, only 2.1% met both the symptom and the blood test criteria (other studies, using higher thresholds, have found low testosterone in about 30–70% of selected risk groups; see the note further down). Most men over 50 therefore do not have andropause in the medical sense, even though their testosterone is a little lower than in their 20s.

That does not mean the complaints are imagined. It means the cause is often something other than age alone.

Which signs are linked to andropause?

The signs most closely linked to low testosterone are sexual: fewer morning erections, lower sex drive and erection problems. Fatigue, low mood and loss of muscle mass are also often linked to andropause, but they have many other possible causes, such as sleep apnoea, stress, thyroid problems and depression. You will find the full overview on the page about symptoms of low testosterone.

What is normal testosterone for a man over 40?

The European Association of Urology (EAU) uses a total testosterone level below about 12.1 nmol/L as the level where deficiency becomes likely, and below about 8 nmol/L as the level where treatment is more often considered. The limits are the same regardless of age. Between the two figures lies a grey zone where free testosterone and SHBG matter a great deal. You can read more in SHBG and free testosterone.

What causes low testosterone as men get older?

The causes fall into two groups. In primary hypogonadism the testicles produce too little, for example after mumps, injury, chemotherapy or in Klinefelter syndrome. In secondary hypogonadism the pituitary gland sends signals that are too weak (LH and FSH).

The secondary type is the most common in adult men, and it is often linked to something that can be changed:

• overweight and type 2 diabetes
• sleep apnoea and very little sleep
• certain medicines, such as opioids and glucocorticoids
• previous use of anabolic steroids
• prolonged serious illness

Age plays a part, but rarely on its own. That is why a thorough assessment also measures LH, and often prolactin, rather than looking at testosterone alone.

How low testosterone is measured

A correct blood test is taken in the morning, typically between 7 and 11 am, and preferably fasting, because testosterone is highest in the morning and falls after a meal. If the first value is low, it is repeated on another day. The Endocrine Society recommends exactly two low morning measurements before the diagnosis is made.

A good testosterone panel includes at least:

Measurement	Why
Total testosterone	The baseline value, compared with the laboratory's range
SHBG	Determines how much of the testosterone is free
Free testosterone (calculated)	Important in the grey zone of 8–12 nmol/L
LH	Distinguishes between a primary and a secondary cause

You can order a combined panel such as our testosterone blood test or see all blood tests and hormone measurements. The first test can be taken locally where you live. If your results look normal but the symptoms persist, you can read why a normal testosterone result can be misleading.

What happens if testosterone is low?

First, a doctor needs to assess the cause. If it is overweight, sleep apnoea or medication, that is where you start, and the testosterone level sometimes rises on its own. If the deficiency is confirmed and persistent, testosterone therapy may be an option, but only after a medical assessment and with follow-up blood tests.

Treatment also has downsides you should know about in advance. It suppresses the body's own sperm production, so it is a poor fit if you want to have children. It can increase the number of red blood cells (haematocrit), and it requires regular monitoring of, among other things, PSA. You can see how a medically supervised programme is structured on the page about TRT and treatment programmes. If you want to get started with an assessment quickly, you can begin with low testosterone: quick assessment. More answers to practical questions are in our frequently asked questions.

Note: why EMAS found such a low prevalence

The European Male Ageing Study (Wu et al., NEJM 2010) measured 3,369 randomly selected men aged 40–79 in eight European cities. The study defined late-onset hypogonadism (LOH) strictly: at least three sexual symptoms (fewer morning erections, reduced desire and erection difficulties) together with total testosterone below 11 nmol/L and free testosterone below 220 pmol/L. With that definition, about 2.1% of the men met the criteria.

The figure is low because every requirement had to be met at once. Fatigue, low mood and reduced physical strength were also linked to lower testosterone, but not specifically enough to be part of the definition. A man with low testosterone and two of the three symptoms therefore does not count.

Other studies have used higher thresholds and found far more men with low values:

• Zitzmann et al. (JCEM 2006), 434 male patients aged 50–86: loss of desire and energy became more common below about 15 nmol/L.
• Lackner et al. (BJU Int 2011), 675 men: links with symptoms around 13.5–14.4 nmol/L, although part of this was explained by age.
• Fillo et al. (Int Urol Nephrol 2012), 167 Slovak men with abdominal obesity: 67.6% had total testosterone below 14 nmol/L.
• Carrero et al. (Nephrol Dial Transplant 2011), 260 men with end-stage kidney failure: 44% below 10 nmol/L, 33% between 10 and 14 and only 23% above 14.
• Dhindsa et al. (JCEM 2004): about a third of men with type 2 diabetes were hypogonadal.
• The T4DM trial used total testosterone of at most 14 nmol/L as an inclusion criterion.

The conclusion is that prevalence depends on which criteria are used. It does not mean that everyone with a value below 14 needs treatment, but that "only 2%" is the answer to a very narrow question.

First step

Start with a symptom test. It takes a few minutes and is based on the international AMS questionnaire (Aging Males' Symptoms). The result shows whether your symptoms are worth measuring with a blood test, and it is a good starting point for a conversation with a doctor. If you are worried that low testosterone may be a contributing factor, talk to your own doctor about the options. If you would rather act quickly through a private clinic, you can also order a blood test here on the site.