New guidelines will help pharmacists identify and treat testosterone deficiency as men age

Fatigue, weight gain and low libido are just three of the symptoms middle-aged and older men face as their testosterone levels decline, but many don't realize what's going on.

Sometimes referred to as "male menopause" or "manopause" in reference to the symptoms women experience when their estrogen levels drop, the medical term for men is "late-onset hypogonadism."

A pair of University of Alberta pharmacy professors have published guidelines to help pharmacists support men experiencing the common but underdiagnosed problem.

Unlike women's menopause, which usually occurs over a few years in the 50s, men's sex hormones may start to drop as early as the late 20s, with symptoms progressing gradually over subsequent decades.

"Men can have trouble sleeping, they can have difficulties with erection, they can have a depressed mood because of other reasons, or people think, 'I'm just under stress,'" said lead author Cheryl Sadowski, professor in the Faculty of Pharmacy & Pharmaceutical Sciences.

"Low testosterone is not the first thing that comes to mind for patients or their physicians."

It's not like the sudden drop-off that happens in menopause, Sadowski added. "So the way to assess it and determine when to start treating it is more difficult than for women."

Pharmacists have role to play

Pharmacists can help men understand that their symptoms aren't just a normal part of aging and that they may be treatable, said co-author Nathan Beahm, assistant clinical professor.

"Pharmacists may see patients more often than physicians and interact with them more," Beahm said. "Pharmacists can engage in screening and ask some initial questions to identify patients who might benefit from treatment and might otherwise slip through the cracks of the system."

The researchers said the evidence so far indicates that 50 percent of men will experience symptoms at some time during their lives, but more study is needed to determine the exact prevalence of late-onset hypogonadism.

Men with diabetes, obesity, kidney disease or rheumatoid arthritis, or who are on long-term opioids and some cancer therapies, are more prone to dropping testosterone levels. While not everyone with low testosterone will experience negative symptoms, the condition can be difficult to diagnose because the symptoms can be caused by other medical issues as well.

The new guidelines, published in the Canadian Pharmacists Journal, are designed to give pharmacists the tools to screen patients, address risk factors, initiate and counsel for lab testing, and collaborate with primary care physicians to manage treatment.

The authors began the project when they found they needed better resources for a class they were teaching to U of A pharmacy students.

Overcoming taboos

Testosterone levels are easily measured with a blood test but it is not part of routine blood work.

The test can be ordered by either a pharmacist or a doctor, but only MDs can prescribe the treatment—testosterone supplementation—because it is a controlled substance.

Testosterone supplements are available in various forms, including a pill, nasal spray, gel, injection or patch, depending on what is most convenient and best tolerated by the patient.

This treatment is generally not recommended for people with a history of prostate cancer, those with poorly controlled sleep apnea and those who are at risk of a blood clot. It will also interfere with sperm production, so is not recommended for those who are trying to become parents.

Beahm and Sadowski said they hope the taboos around talking about men's sexual health will fall away, just as they have around menopause, mental health and other topics.

"In geriatrics, we talk about a lot of things that you could say are uncomfortable, but we try to take care of all aspects of health for the patient," said Sadowski. "We don't just measure the blood pressure—we ask about sexual activity, social relationships, financial security, things which are very sensitive issues.

"It's about creating a safe space for the patient. We have to start the discussion."