The truth about 'manopause': the slow, insidious signs of low testosterone men overlook

Andropause, commonly dubbed "manopause," refers to age-related declines in testosterone that can produce a range of physical and psychological symptoms that many men and clinicians miss or attribute to normal aging.

An estimated five million men in the United States struggle with low testosterone, and levels begin to decline around age 30, specialists said. Some men report reductions of as much as 50 percent by age 70 compared with peak levels. Dr. Pete Stahl, head of men’s health at Hims, told The Post that signs can be "slow and insidious," and therefore frequently go unrecognized.

Early symptoms commonly include a drop in libido and persistent fatigue despite adequate sleep. Over time, patients may notice loss of muscle mass and strength, increased body fat concentrated around the midsection, and erectile dysfunction. Mental changes such as mood swings, irritability, difficulty sleeping, "brain fog" and poor concentration also can occur, Stahl said.

Stahl estimated that testosterone deficiency affects 30 to 40 percent of men by their 40s or 50s, with declines faster and more pronounced among men with chronic illnesses, particularly obesity. He cautioned that while some men feel effects in their 30s or 40s, others maintain healthy testosterone levels into advanced age; unlike menopause in women, the timing and degree of decline in men are highly variable.

Physicians and researchers note that low testosterone is not only a quality-of-life issue. In the longer term, testosterone deficiency has been associated with metabolic and systemic consequences. Stahl said low testosterone has links to insulin resistance that can contribute to diabetes, decreased bone mineral density that raises fracture risk, reduced red blood cell production that can cause anemia, and unfavorable cholesterol changes associated with cardiovascular disease.

Treatment approaches vary depending on the underlying cause, patient goals and fertility considerations. Providers may address reversible contributors to low testosterone, prescribe medications that stimulate the body’s natural testosterone production, or use testosterone replacement therapy (TRT). Stahl described medications that promote endogenous testosterone production as an effective first-line option, noting that unlike TRT they typically do not affect fertility.

Stahl also acknowledged persistent concerns about the safety of testosterone therapy. He said that lingering fears among patients and doctors stem in part from older studies that suggested cardiovascular risks, but that those findings have been reexamined and in many cases debunked. Despite evolving evidence, the stigma around testosterone treatment and residual safety worries can limit care.

Telehealth provider Hims recently began offering evaluation and personalized treatment plans for men with low testosterone, including compounded enclomiphene, a drug that can stimulate natural testosterone production. The company said it plans next year to offer an oral formulation of TRT called Kyzatrex, which clinical data show can restore testosterone levels in a high percentage of treated men with a relatively low rate of side effects.

Clinical guidelines generally recommend confirming low testosterone with blood tests on more than one occasion and correlating laboratory results with symptoms before initiating therapy. Decisions about treatment take into account age, symptom severity, comorbid conditions, desire for fertility and the balance of benefits and risks.

Experts said increased awareness among patients and clinicians is important because men often normalize symptoms or are reluctant to seek care. Stahl said that for men who have both symptoms and low measured testosterone, restoring levels to a healthy range can substantially improve quality of life and extend healthspan.

As research continues to refine understanding of the risks and benefits of different therapies, clinicians advise that men who suspect testosterone deficiency discuss symptoms and testing with a health care provider to determine an individualized, evidence-based plan of care.