The "male menopause" versus low testosterone: what is the difference?

The NHS says some men develop depression, loss of sex drive, erectile dysfunction and other physical and emotional symptoms in their late 40s to early 50s, and describes the "male menopause" (sometimes called andropause) as an unhelpful term. It says the label is misleading because it suggests the symptoms result from a sudden drop in testosterone in middle age, similar to the female menopause, and that this is not true.

The NHS explains that testosterone levels do fall as men age, but the decline is steady at about 1 per cent a year from around age 30 to 40, and this is unlikely to cause problems in itself. The distinction matters because it changes what is investigated and treated: a collection of symptoms is not the same thing as a hormone deficiency.

The NHS lists the following as common symptoms at this age:

• Depression, loss of sex drive and erectile dysfunction.

• Mood swings and irritability.

• Loss of muscle mass and reduced ability to exercise.

• Fat redistribution, such as a larger belly or enlarged breasts (gynaecomastia).

• A general lack of enthusiasm or energy, difficulty sleeping or increased tiredness.

• Poor concentration and short-term memory.

The NHS says lifestyle factors or psychological problems can be responsible for many of these symptoms, including erectile dysfunction, low sex drive and mood swings, which may result from stress, depression or anxiety. There are also physical causes of erectile dysfunction, such as smoking or heart problems. Psychological problems are typically brought on by work or relationship issues, money problems or worrying about ageing parents, and a midlife crisis can play a part. Other possible causes include lack of sleep, a poor diet, lack of exercise, drinking too much alcohol, smoking and low self-esteem.

This is why the NHS advises seeing a GP, who will ask about your work and personal life to see whether a mental health issue such as stress or anxiety is involved. If so, medication or a talking therapy such as cognitive behavioural therapy may help, and exercise and relaxation can also help.

The NHS says that where lifestyle or psychological problems do not seem responsible, symptoms may be due to hypogonadism, in which the testes produce few or no hormones. It can be present from birth, with delayed puberty and small testes, or develop later in life, particularly in men who are obese or have type 2 diabetes, which is known as late-onset hypogonadism. The NHS stresses that this is an uncommon and specific medical condition that is not a normal part of ageing, and that diagnosis can usually be made from symptoms and blood tests measuring testosterone.

The European Association of Urology (EAU) describes late-onset hypogonadism as often diagnosed when no classical cause is present, with prevalence rising with age, and as requiring both persistent specific symptoms and biochemical evidence of testosterone deficiency. It notes that obesity and chronic inflammation can suppress the hormone axis, that the role of ageing alone up to age 80 seems relatively small, and that this suppression is functional and potentially reversible through measures such as weight loss.

The EAU says the mainstay of diagnosis is signs and symptoms consistent with hypogonadism together with low morning total testosterone on two or more occasions, measured with a reliable assay in fasting conditions. Its list of more specific symptoms includes reduced libido, erectile dysfunction, fewer spontaneous morning erections, reduced vigorous activity, low mood, decreased motivation and fatigue, while hot flushes, sleep disturbance and poor concentration are listed as less specific. It warns that these symptoms are not exclusive to hypogonadism and must be interpreted cautiously, and that questionnaires should not be used for systematic screening.

It recommends measuring BMI and waist circumference in all men, because obesity is frequently associated with hypogonadism, and says testosterone should not be measured during acute illness. The NHS says a GP may order a blood test, and if it suggests testosterone deficiency you may be referred to an endocrinologist, who confirms the diagnosis before any treatment.

The NHS says that if a specialist confirms testosterone deficiency, testosterone replacement may be offered, by injection or gel, to correct the deficiency. This is a prescription-only treatment that needs specialist assessment and monitoring. The EAU guideline says men with symptomatic hypogonadism (total testosterone below 12 nmol/L) and no contraindications are suitable candidates, and that untreated breast and prostate cancer are absolute contraindications, as is an active wish to have children, because testosterone therapy suppresses sperm production. It advises monitoring haematocrit, and withdrawing or adjusting treatment if it rises above 54 per cent.

The EAU also says weight loss and lifestyle change should be the first approach for overweight or obese men with hypogonadism, though testosterone gains from this are small, and that testosterone therapy should not be used to reduce weight or to improve cognition, vitality or physical strength in ageing men. Thresholds used by UK laboratories and clinics may differ, so values should be interpreted by a clinician.

The usual NHS route is a GP appointment, blood tests and, if indicated, endocrinology referral. Private men's health services often advertise testosterone testing and treatment directly. Be cautious of any service that diagnoses from a single result or from a symptom questionnaire alone, treats without checking other causes, or promotes a prescription medicine as a general anti-ageing solution. Ask whether tests were taken in the morning and repeated, what else was ruled out, who monitors blood counts and prostate health, and what the plan is if you want to father children.