We’ve all heard the stories about men dealing with a midlife crisis by acquiring a mistress and a sports car. But, says Johannesburg GP Lorraine Becker, the men who consult her about male menopause are too tired for any of this.

"They are falling asleep on the couch in front of the TV; they haven’t got the energy to handle a mistress," she said.

Andropause is real and it’s no joke. Just like women who experience menopause symptoms due to a decline in sex hormones, ageing affects men’s hormones — especially the male steroid hormones testosterone, progesterone and oestrogen.

The balance between hormones is important. Oestrogen dominance can be destructive and causes "man boobs" or gynaecomastia, clinical pharmacist David Arthur said.

"A friend who is a plastic surgeon says he does a lot of surgery to remove man boobs," he said at a talk at the Integrative Medical Centre in Bryanston.

Other symptoms associated with andropause include an expanding waistline, loss of virility, and thinning skin and hair. As a drop in testosterone can lead to cognitive problems and depression the caricature of the "grumpy old man" is not inaccurate. The cause is largely physiological. "Human beings are designed to live until about 40," Arthur said. "But due to technology and medical science, we are living well beyond that."

Integrative or functional medicine helps people attain optimum health with drugs, supplements, bioidentical hormone therapy, nutraceuticals and alternative therapies. Diet and exercise are emphasised. But for stubborn middle-age spread, Arthur says exercise has a limited effect.

A big stomach can be deadly, leading to breathing complications and causing insomnia, sleep apnoea and anxiety.

"When you are not breathing properly, there is insufficient oxygen going to the brain, which can cause panic. The increased stress produces sugars," Arthur said. It adds to the vicious cycle of weight gain.

It is no coincidence that the extra abdominal mass is called a beer boep. "Fizzy drinks like beer and cider disrupt the gut microbiome," Arthur said, referring to the ecosystem of organisms such as bacteria and yeasts that aid digestion. The toxins that aren’t eliminated are stored in the abdominal mass.

"Testosterone is important for cognition, so a drop in the levels … can result in cognitive decline," Arthur said.

"Added to this, men don’t talk about their problems. Sometimes they will head for the pub, but this has consequences of their own. Alcohol contains oestrogen-like compounds from plants; they mimic oestrogen in the body, contributing to oestrogen dominance."

Harmful xenoestrogens are found commercially raised meat and dairy products, which contain bovine hormone growth hormones, as well as in pesticides and plastic bottles and packaging. Arthur recommends eating organic foods.

Men over 40 often find their skin is becoming thinner and losing its elasticity, and their hair is falling out. Thinning skin is caused by an oestrogen deficiency and hair loss by too much testosterone converting to dihydrotestosterone.

Maintaining good insulin levels is an important part of the solution, as well as avoiding insulin resistance — which makes middle-age spread impossible to budge but can lead to oestrogen dominance, causing mental fatigue, memory problems, poor concentration, irritability and emotional hypersensitivity. Boosting energy with coffee or tea isn’t a good idea either; caffeinated beverages are oestrogen-dominance triggers.

One of the most worrying aspects for men experiencing andropause is a decrease in sexual desire, caused by testicular atrophy due to lowered testosterone, Arthur said.

Some medications, such as heartburn and indigestion solutions, leech calcium from bones. Bone complications such as osteoporosis and curvature of the spine can also be linked to cell inflammation, which medical studies are increasingly citing as the cause of disease.

Being overweight, and especially when it is concentrated around the middle, contributes to cell inflammation.

Food allergies, indicated by hives or stomach bloating, are markers for inflammation, said Dhesan Moodley, a specialist in anti-ageing and functional metabolic medicine at the Integrative Medical Centre.

When treating a patient in andropause, Moodley says he takes "a detailed sexual history, I look at the heart and what medications are being taken. Is the person on statins, for example, as these reduce testosterone."

Patients are sent for blood tests to assess hormone deficiencies and imbalances. Other screening includes a full blood count, lipid profile, fasting blood glucose, insulin, thyroid and a liver function test.

Most of the hormone replacement therapy (HRT) drugs are taken orally but replacing testosterone is best done using a transdermal cream. Becker prescribes HRT drugs but also bioidentical hormones such as DHEA (dehydroepiandrosterone).

Arthur said andropause symptoms could be minimised with daily exercise and getting seven to nine hours sleep a night. The sleep cycle can be restored by taking melatonin.

Men should eat more cruciferous green vegetables, such as broccoli, that promote healthy hormonal balance.

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