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The myth of the male menopause

My old friend and fellow pharmacist Sid Dajani has been making passionate pleas on your pages and elsewhere for pharmacists to identify testosterone deficiency (The Pharmaceutical Journal 2016;297:364). He is confident that, among men of a certain age, a dangerous lack of male hormone puts them at perilous health risks.

There is emerging evidence that for testosterone deficiencies producing clinical effects, replacement may bring benefits. But this evidence remains weak and the challenge is to translate this into clinical guidance before big pharma dictates what constitutes normality and where the risk–benefit lines lie.

The testosterone replacement therapy (TRT) bandwagon has been moving aggressively forward for some time and it is sad that good pharmacists like Dajani have been encouraged to put their shoulders to the wheel.

A few years ago, just after the economic downturn, a young Dublin GP told me that the big new thing in the Republic of Ireland was TRT; a sure-fire therapy for the flagging middle-aged male. She was being encouraged by her medical partners (males) to discuss with male patients the possibility that their tiredness, low mood and general difficulties with life may not be just symptoms of a mid-life crisis, but may be symptoms of the male menopause. “If testosterone levels are sub-normal, each man is a candidate for TRT,” she confided.

I expressed scepticism. “You’re right, its boll**ks,” she replied with forthright clarity. “And a shame on my profession,” she continued. “But the male menopause is merely a symptom of the financial downturn as GPs supply the TRT.”

Research evidence supports her colourful critique of TRT. A study (Basaria S. N Engl J Med 2010;363:109–122)[1] into the safety and efficacy of TRT was stopped in 2009 on grounds of safety; a small matter of a four-fold increase in cardiac events and the appearance of that appalling phenomenon “man boobs” plus increases in prostate cancer prevalence and breathing problems during sleep.

The BMJ also says that the male menopause is a myth (2012;345:e4967), explaining that only 0.1% of men aged over 40 years have low testosterone and this goes up to only 5% of men in their 70s[2]. Yet the marketing men persist as we now live in a “you-only-think-you’re-fine” culture so when you start gaining weight, have a noticeable reduction in energy and start to lose interest in (or performance during) sex then sensibly something is wrong and seeking a medical solution seems only rational.

Yet according to the research in The BMJ, the link to an age-related reduction in testosterone levels and specific symptoms remains weak. Notwithstanding this there is a section of the medical fraternity that is committed to making all age-related phenomena into diseases. And 13 million Americans cannot be wrong (The BMJ 2012;345:e6905)[3], which is the number converted to monthly TRT.

Community pharmacists should avoid the medicalisation of life and focus in our day-to-day practice on what makes us really unhealthy: smoking, poor nutrition, lack of exercise and excess alcohol consumption.

Terry Maguire

Belfast

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2017.20202149

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