Ask a Doc: Is "Low T" the cause of "Manopause"?

April 01, 2015

Is “LOW T” the Cause of “MANOPAUSE”? 

  • Up to 1 in 4 men over age 30 may have low testosterone (low T)
  • Low T may cause a variety of symptoms previously attributed to aging. 
  • Treating Low T can result in weight loss and sense of well-being. 
  • T treatment may have potential side effects. 

Dear Doc,

I am a 45 year-old male.  I am healthy except being 15 lbs. overweight but I still feel run down and old.  I have seen ads for “LOW T.”  Is testosterone (T) replacement safe and for me? 


Testosterone (T) is a male sex hormone made primarily in the testes and to a lesser degree in the adrenal glands. T is involved in the development of male sex organs before birth, and the development of the male characteristics at puberty, such as voice deepening and growth of facial and body hair. T plays a role in sex drive, sperm production, fat distribution, and the maintenance of muscle strength and mass. Adequate levels of T promote a sense of well-being in men.  

T levels peak in your 20s and then fall by 1 to 2% per year. Lower T levels are a "natural" part of aging.  When T levels get too low, signs and symptoms may include fatigue, weight gain, reduced sex drive, erectile dysfunction, depression, increased abdominal fat and loss of muscle mass.  Most agree T treatment is appropriate when there is a low T level detected via a blood test with these symptoms.  However, the FDA is concerned about some doctors treating patients with normal T levels who are trying to prevent symptoms that some say are inevitable and a natural part of aging.  

Low T treatment and its cure, testosterone replacement, has resulted in some of the best advertising in years, promising men the idea of regaining youth.  I would say better advertising then the erectile dysfunction pill that advertises with the man and woman in separate bath tubs.  Better than the car commercials that have Oscar winner Mathew McCaughey driving around aimlessly in a luxury car talking nonsense to himself.  And, no doubt, better than any ad from a local car dealership or injury attorney!

In fact, over 150 million dollars are spent a year advertising T treatments (which come in gels, patches and injections).  This explains in part why testosterone prescriptions written in the U.S. grew from 2.9 million in 2007 to 7.5 million scripts in 2013.  T prescription sales hit 2.4 billion dollars in 2013 and are expected to increase to 3.8 billion in 2018.  It is estimated  that one out of four men over 30 have low testosterone levels, but only one out of every 20 men have clinical symptoms linked to such a deficiency. That's about 5 million men in the U.S. that have the diagnosis hypogonadism, symptomatic low T.  It is estimated that only about 5% of those are receiving T treatment. 

Could T replacement be the cure for a man’s midlife crisis or "Manopause"?  If so, then we might see a lot fewer middle age men irrationally buying sports cars and dating younger woman in order to feel younger and more alive!  Years of research shows T replacement increase muscle mass, helps depression, decreases body fat, improves sex drive and improves a sense of well-being.  Studies in the past have shown T to be relatively safe.  Millions of men today swear their lives have been dramatically improved due to T treatment.  But are there risks? 

Despite previous studies suggesting T replacement was safe; a study in 2014 looking at the records of 55,000 patients concluded that T replacement in certain men increased the risk of heart attacks and strokes.  These results were consistent with a 2013 study of more than 8,000 patients in the Veteran’s Administration system linking T replacement to an increase in heart attacks.  But many who champion the benefits of T replacement point to flaws in the way these studies were conducted. They also point out that T is already naturally occurring in men's bodies. Also, in replacement therapy, T levels are simply being replaced to previous "normal levels."  Some ask if T was the cause of heart attacks, why are men in their 20s not having heart attacks when T is at its highest. 

Advocates for T replacement point to an even more recent study in 2014 looking at a review of 25,000 Medicare patients that found no elevated risk of heart attacks.  Also, two additional studies recently presented at the American College of Cardiology in March 2015 suggested no cardiovascular risk with T therapy. The FDA concludes more comprehensive studies should be done regarding the cardiac and stroke risk with testosterone. For now the FDA warns T replacement MAY increase the risk of heart attacks and strokes in certain men. 

Treatment may cause other side effects including increasing the risk of blood clots, worsening symptoms of enlarged prostate, worsening sleep apnea and lowering sperm counts. 

Some natural ways to increase your T levels include decreasing stress, losing weight, improving your sleep habits, improving your diet, ensuring you’re getting enough vitamin D, and increasing your exercise. 

If these non-pharmacologic efforts fail to restore your energy and T levels, consider seeking a physician who has experience in treating low T.  You may seek out a hormone specialist or urologist.  Your doctor will discuss the risks and benefits of T therapy.  You will have certain critical parameters including your PSA level, blood count and hormone levels monitored. And, you might just save some money on the next car you purchase… 

Stay healthy and remember the quote by Michael Caine, "To me, growing old is great.  It's the very best thing - considering the alternative."


Dr. Nagpaul is a medical doctor and is board-certified in Internal Medicine.  He currently is the Medical Director at Newark-Wayne Community Hospital, DeMay Living Center, Wayne County Public Health and at Blossomview Nursing Home. This column is meant to be educational and not intended to be used to make individual treatment decisions. Prior to starting or stopping any treatment, please confer with your own health care provider. To send questions, please email Dr. Nagpaul at Arun.Nagpaul@rochestergeneral org and put “Ask a Doc” in the subject line.