What andropause really looks like

"Andropause" is a lazy word. It borrows the medical weight of menopause but describes a different biology and a different experience. There is no equivalent of the menstrual-cycle ending. Testosterone declines gradually by roughly one to two percent per year from the thirties onwards, and most men notice nothing because life accounts for most of what they feel. A smaller group develops late-onset hypogonadism, where testosterone falls low enough to cause real symptoms and real biochemical changes. That group benefits from treatment. The rest do not.

Getting the difference right matters, because treating normal ageing with testosterone is expensive, lifelong, and brings risks without benefits.

What low testosterone actually causes

The symptoms that genuinely track with biochemical hypogonadism are sexual. Reduced libido, reduced morning erections, erectile dysfunction with an organic (not psychogenic) pattern, and reduced spontaneous sexual thoughts. If these are present, low testosterone is a real candidate diagnosis. If these are absent, low testosterone is unlikely to explain the rest, even if numbers come back low.

Secondary symptoms include reduced body hair (slow to appear, often over years), small-volume testicles, reduced muscle strength and mass for given training effort, gynaecomastia in some men, and anaemia. Weak erections without libido loss are usually vascular. Fatigue without libido change is usually sleep, stress, or metabolic.

What many men worry about but is usually not testosterone

Fatigue, poor concentration, irritability, mild low mood, reduced gym performance, and weight gain are all commonly attributed to "low T" in online discourse. In practice, when we work these up, most men with these complaints have normal testosterone and a different explanation: sleep debt, untreated apnoea, subclinical depression, alcohol, iron deficiency, or the cumulative effect of ten years of weight gain and deconditioning. Testosterone is sometimes the issue. More often it is not.

The commercial sector benefits from blurring this. A borderline low reading plus vague symptoms gets labelled "low T" and treated with TRT, which is a long-term commitment. We think this is dishonest. Our job is to work out which of the competing diagnoses applies to you and treat the right one.

The clinical picture for genuine late-onset hypogonadism

A typical genuinely-hypogonadal man looks something like this: late forties to sixties, progressive loss of libido over a year or two, morning erections now rare, energy blunted but not flattened, mild weight gain particularly around the middle, gradual loss of chest and body hair, and on bloods two morning total testosterone measurements below about 8 to 10 nmol/L with LH either elevated (primary testicular failure) or normal-to-low (secondary, pituitary). Reversible causes have been looked for and excluded.

This man does well on testosterone replacement, typically within three months of reaching a stable dose, with clear improvements in libido, morning erections, energy, and sense of wellbeing. His bloods normalise, his body composition improves modestly, and his cardiovascular risk profile does not worsen.

What the population numbers actually say

Prevalence of symptomatic testosterone deficiency in UK men aged 40 to 79 is roughly 2 to 6 percent depending on the study and threshold. At any given time, a larger group (perhaps 15 to 20 percent of men over 50) have biochemistry below reference range but without significant symptoms. Treating this second group does not improve outcomes in controlled trials.

Put differently: if you take 100 men off the street, about 3 to 5 will have true late-onset hypogonadism and benefit from assessment. The rest have other problems or no problem. The service that says yes to everyone is not serving its patients.

How we make the diagnosis

Two morning total testosterone measurements taken at 8 to 10 AM on different days, both below the lab reference range (typically below 12 nmol/L with concern below 8). Plus a symptom picture consistent with androgen deficiency (ADAM questionnaire gives a structured screen, but sexual symptoms are the key). Plus exclusion of reversible causes: significant obesity, untreated sleep apnoea, chronic opioid use, uncontrolled diabetes, pituitary disease, haemochromatosis.

Secondary markers matter. Free testosterone (calculated from total T, SHBG, and albumin) catches the men whose SHBG is high and whose bioavailable hormone is lower than their total suggests. LH and FSH tell us whether the testes are failing (primary, both elevated) or whether the pituitary is not stimulating them (secondary, both low). Prolactin catches the rare prolactin-secreting pituitary tumour.

What we do if you are borderline

Borderline testosterone (10 to 14 nmol/L) with vague symptoms is the most common presentation we see. Our first step is never TRT. It is to work on the competing causes: a structured weight-loss plan if BMI is elevated, a sleep study if apnoea is suspected, investigation for depression if mood is the dominant symptom, and a two-to-three-month review. A meaningful fraction of men in this group normalise their testosterone without medication once the competing problem is fixed.

The honest bottom line

Genuine andropause is real, treatable, and transformative for the men who have it. Marketed-andropause is a commercial category that catches many men who do not have it and starts them on a lifelong medication they do not need. Our job at first assessment is to work out which of these you are and to tell you honestly. If TRT is the right answer we say so. If it is not, we say that instead.

Ready to start?

If this article has made you think an assessment might help, the next step is a short consultation with one of our men's health doctors.

Begin your consultation at this link. Online or in person at Westfield London.