Journal of Gerontology: MEDICAL SCIENCES

2002, Vol. 57A, No. 12, M793M796

Copyright 2002 by The Gerontological Society of America

Andropause: Knowledge and Perceptions Among the

General Public and Health Care Professionals
Joy K. Anderson,1 Sandy Faulkner,1 Carole Cranor,2 Jennifer Briley,2 Felicia Gevirtz,2
and Susan Roberts2
1Unimed
2PPD

Pharmaceuticals, Inc., Deerfield, Illinois.

Development, Inc., Wilmington, North Carolina.

Methods. Brief surveys were administered to HCPs and members of the general public who called a medical information telephone line. Trained clinical interviewers surveyed participants for experiences with andropause and TRT and
knowledge about nonsexual effects of low testosterone in men.
Results. Of 443 general public callers, 377 (85%) agreed to participate in the survey. Of these participants, 77% had
heard of andropause or male menopause, and 63% had taken TRT. Of 88 HCP callers, 57 (65%) participated. Of these
participants, 65% were pharmacists, 80% had encountered patients with symptoms of low testosterone, and 50% reported that patients rarely or never initiated conversations about low testosterone. Among HCPs and the general public,
respectively, 98% and 91% knew that low testosterone is treatable with medication, and 60% and 57% knew that it results in osteoporosis. Only 25% of HCPs and 14% of the general public knew that low testosterone does not cause loss
of urinary control.
Conclusions. HCPs and members of the general public are knowledgeable about some aspects of low testosterone
and have misconceptions about others. Educational initiatives are needed.

NDROPAUSE, or age-related hypogonadism, is a term

used to describe the natural age-related decline in testosterone in men. Testosterone replacement therapy (TRT), the
primary treatment for other types of male hypogonadism, has
well documented sexual and nonsexual benefits. Its use in andropause is more controversial and has been researched less.
Among aging men, the nonsexual benefits of TRT may be especially important, because TRT can reduce the negative
health consequences of age-related frailty (1). It is not known
whether health care professionals (HCPs) and members of the
general public are aware of these nonsexual benefits.
Other terms used to describe age-related male hypogonadism include male menopause, male climacteric, and androgen decline in the aging male (ADAM) (2). Male hypogonadism, or androgen deficiency, is characterized by a
decrease in testosterone production in the Leydig cells of the
testes, a dysfunction in the hypothalamicpituitary axis, or
both. Testosterone is the predominant androgenic hormone
responsible for the primary and secondary male sex characteristics. Not only is it essential for maintaining male pattern
hair growth, libido, and spermatogenesis, but it is necessary for maintaining lean body mass, bone density, muscle
strength, and erythropoiesis throughout the life cycle (36).
The medical literature on male hypogonadism has only
recently begun to address the prevalence, diagnosis, and
treatment of andropause (3,57). Epidemiological support
for andropause is found in cross-sectional and longitudinal
studies (3,8). When these analyses control for confounding

age-related factors, such as concurrent medications and coexisting diseases, the results demonstrate that the circulating
concentrations of free, protein bound, and total testosterone
decrease at a rate of 1% to 2% per year after the age of 30
years (2,3). Approximately 20% of men older than 60 and
50% of men older than 80 have serum testosterone concentrations below the normal range for young men; however,
many elderly men maintain normal concentrations (6).
The diagnosis of andropause should be based on a combination of signs and symptoms and low serum testosterone.
Diagnosing andropause is complicated, because testosterone declines gradually over many years and this decline
lacks easily defined signs and symptoms that are comparable with the cessation of ovulation and menstruation seen in
menopause. Additionally, the signs and symptoms of andropause are similar to or occur concurrently with other diseases of aging and can be misdiagnosed by physicians or
unrecognized by patients. The nonsexual symptoms of andropause include depression, anger, mood changes, fatigue,
loss of cognitive skills, and reduced well-being; reduced
lean body mass, muscle volume, and strength; loss of body
hair and skin changes; decreased bone mass and osteoporosis; and increased body fat (2,3,9). Two new screening instruments, the ADAM (10) and the Massachusetts Male
Ageing Study (MMAS) (11), may make it easier to identify
men at risk for low testosterone and andropause (6).
Published treatment guidance has begun to address the
use of TRT in andropause.(6) Treatment guidelines for
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Background. Andropause, the natural age-related decline in testosterone in men, has been debated in the literature. The
nonsexual benefits of testosterone replacement therapy (TRT) in male hypogonadism are well documented, but whether
health care professionals (HCPs) and members of the general public are aware of these benefits is not known. This study
assesses the knowledge and perceptions of andropause and TRT among HCPs and members of the general public.

M794

ANDERSON ET AL.

METHODS
Data Collection
Study participants consisted of two convenience samples
of individuals who called a medical information line to inquire about a variety of products. A testosterone replacement formulation was among the products supported by this
service. The telephone interviewers were clinical personnel
trained to answer questions about all of the products, administer the andropause questionnaires, and enter the responses
into a database. The surveys were administered from July 1,
2001 through April 1, 2002.

RESULTS
Description of the General Public Sample
The sample from the general public consisted of nonclinical persons who called about one of the products supported
by the medical information service. Of the 443 callers, 377
(85%) agreed to participate in the survey. Of the 377 participants, 315 (84%) called to inquire about testosterone gel,
and 310 (82%) were male. Forty-nine percent of general
public participants were aged 50 or younger, and 50% were
aged 51 or older (four participants did not report age). With
regard to their knowledge of or personal experience with
andropause, 79% reported having heard of male menopause
or andropause, 63% had taken testosterone replacement personally, and 3% reported that the person for whom they
were calling had taken testosterone.
Table 1 summarizes the sources of health-related information used by the general public. The three most frequently cited clinical sources of health-related information
were primary care physician (47%), other clinical source
(11%), and pharmacist (10%). The most frequently cited
nonclinical source of health-related information was the Internet (52%), followed by the popular press (18%). The Internet was the most frequently cited source overall.
Description of the HCP Sample
A total of 88 HCPs called to receive information about
one of the products supported by this medical information
service. Of the 57 (65%) HCPs who agreed to participate in
the survey, over half were pharmacists (n  37; 65%).
Twelve (21%) callers were physicians, and 7 (12%) were
registered nurses.
All 57 HCPs (including pharmacists) were asked how often their patients initiated conversations about low testosterone (Table 2). Three quarters of respondents reported that
their patients never (33%) or rarely (42%) initiated such
conversations. Only 5 (9%) reported that patients frequently
initiated such conversations, and 9 (16%) reported that they
sometimes did.

Survey Description
Demographics and practice setting information.The
interviewer asked a series of questions designed to collect
descriptive information specific to each group (general public or HCP) and information about each callers awareness
of andropause and experience with TRT. The HCP survey,
which was designed to gather practice-specific data, included two identical multipart questions for physicians,
nurses, and pharmacists. These questions concerned primary licensure and frequency of patient-initiated discussions about low testosterone. Physicians and nurses were
asked four additional questions to determine their practice
setting and the extent of their experience prescribing testosterone replacement.
Knowledge survey.Both survey samples (general public and HCPs) were asked the same set of truefalse questions
to determine each callers knowledge of andropause and TRT.

Table 1. Sources of Health-Related Information: General Public

Survey Participants
Information Source
Clinical source
Primary care doctor
Another clinician
Pharmacist
Scientific journal
Other
Nonclinical source
Family/friends
Popular press
Internet
TV/radio
Other

n (%)
176 (46.7)
13 (3.4)
38 (10.1)
24 (6.4)
41 (10.9)
10 (2.7)
68 (18.0)
196 (52.0)
21 (5.6)
47 (12.5)

Notes: Participants may indicate more than one response. Percentages may
not sum to 100; percentages are out of the 377 general public survey participants.

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other types of symptomatic hypogonadism suggest that the

treatment goals are to increase the total serum testosterone
concentration to a normal range of 3001200 ng/dl, and to
restore sexual function, libido, and well-being. Important
treatment goals for elderly men include increasing bone
mineral density, energy, muscle mass, strength, and stamina, and decreasing total body fat (1217). Some research
suggests that TRT improves symptoms of depression in
older men with low testosterone (18). Additionally, some
clinical practice guidelines emphasize the importance of
TRT in improving not only the duration of life but also the
quality of life (19).
Despite the current interest in andropause and the potential benefits of TRT, andropause is not an officially recognized diagnosis, nor is it an approved indication for TRT.
However, in the coming decades, as the population of middle-aged and elderly men increases, this situation is likely to
change. In preparation for this change, health care researchers and HCPs will need a baseline estimate of the current
level of knowledge about andropause and its treatment. The
study described here seeks to (a) characterize the current
state of knowledge about andropause and the nonsexual effects of low testosterone among the general public and HCPs,
and (b) discuss the findings in relation to the published literature on the benefits of TRT. The results of the study will
provide insight into the need for general public and professional education about andropause and its treatment.

ANDROPAUSE: KNOWLEDGE AND PERCEPTIONS

Table 2. Testosterone Replacement Therapy: Health Care

Professional Practice Characteristics
Descriptive Characteristic

n (%)
testosterone
19 (33.3)
24 (42.1)
9 (15.8)
5 (8.8)
16 (80.0)
3 (15.0)
8 (40.0)
2 (10.0)
1 (5.0)
7 (35.0)
3 (30.0)
0 (0.0)
1 (10.0)
0 (0.0)
1 (10.0)
5 (50.0)

Percentages

are out of the 57 health care professional survey participants.

are out of the 20 physician and nurse survey participants.
Participants may indicate more than one response. Percentages may not
sum to 100.
Percentages

Knowledge Survey: General Public and HCP Samples

Table 3 summarizes the familiarity with andropause by
survey sample. The two groups displayed similar levels of
knowledge. When asked whether low testosterone can be
treated with medication, 342 (91%) general public callers
and 56 (98%) HCP callers answered correctly. Similarly,
89% and 84% of the general public callers and 86% and
84% of HCPs knew that low testosterone could result in low
energy levels or negative mood, respectively. Fewer callers
from both groups knew that testosterone decreases with age
in all men (78% of the general public and 63% of HCPs) or
Table 3. Knowledge About Andropause: Summary of
Correct Responses
Percentage of Participants
With Correct Response
Knowledge Question
Low testosterone cannot
be treated with medication
Low testosterone can result
in low energy levels
Low testosterone can result
in negative mood
Testosterone decreases with
age in all men
Low testosterone can result
in decreased lean body mass
Low testosterone can result
in osteoporosis
Low testosterone can result
in loss of urinary control
Percentages
Percentages

Correct
Response

General
Public

Health Care
Professionals

False

90.7

98.2

True

88.9

86.0

True

84.4

84.2

True

77.5

63.2

True

76.4

77.2

True

57.0

59.6

False

13.8

24.6

are out of the 377 general public survey participants.

are out of the 57 health care professional survey participants.

that low testosterone can result in decreased lean body mass

(76% of the general public and 77% of HCPs). Finally, only
57% of the general public and 60% of HCPs knew that low
testosterone can result in osteoporosis, and only 14% of the
general public and 25% of HCPs knew that low testosterone
does not cause loss of urinary control.
DISCUSSION
This study demonstrates that general public and HCP
callers alike are knowledgeable about some nonsexual aspects of low testosterone but have misconceptions about
others. Interestingly, both groups displayed similar patterns
of knowledge and deficiency. Specifically, both the general
public and HCPs scored lower on questions pertaining to
testosterones effects on lean body mass, osteoporosis, and
loss of urinary control. Surprisingly, compared with the
general public, a smaller proportion of HCPs knew that testosterone decreases with age in all men.
The respondents from the general public in this sample
may have more knowledge about andropause and the effects
of TRT than a random sample of the general public. Most of
them had heard of andropause or male menopause, most
were male, and most called to inquire about testosterone
gel, indicating they had prior knowledge about the drug.
Additionally, these callers may be unusually proactive in
seeking medical information, because they called a medical
information line, and more than half of them reported obtaining health-related information from the Internet.
It was difficult to measure trends among the HCP sample,
because both the sample size and the response rate were
lower compared with that of the general public. Most HCP
callers were pharmacists, and most reported that their patients rarely or never initiated conversations about low testosterone. Less than half of the physician and nurse respondents reported frequently or sometimes prescribing TRT.
The small sample size made it impossible to adequately assess the reasons TRT was rarely or never prescribed.
A more accurate indication of prescribing practices is obtained from TRT prescription sales, which have increased
dramatically in recent years (Figure 1). For the 5-year period ending in May 2002, the number of prescriptions for all
dosage forms of testosterone increased from 341,000 to
1,451,000, with the newer transdermal products increasing
from 274,000 to 1,140,000 during the same period (20).
This increase in TRT prescribing rates suggests that physicians are becoming more familiar with the concept of hypogonadism and andropause.
Because this study was based on a convenience sample,
selection bias cannot be ruled out as a limitation, and the results should be interpreted accordingly. The small number
of HCP participants limits our ability to make inferences
about their knowledge or practice styles. Nonetheless, several recommendations for future research and education initiatives can be made.
Conclusions
The U.S. Food and Drug Administration reported that
only approximately 5% of the 4 to 5 million American men
estimated to have hypogonadism receive TRT (21). As the
population continues to age and the prevalence of andro-

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Frequency of patient-initiated conversations about low

Never
Rarely
Sometimes
Frequently
Ever see patients with symptoms of low testosterone
Yes
No
Frequency of prescribing testosterone replacement therapy
Never
Rarely
Sometimes
Frequently
If rarely/never prescribed, why?,
Never see patients with low testosterone
Consider testosterone replacement therapy ineffective
Not satisfied with current treatment
Risks of therapy greater than benefit
Unaware of therapeutic benefits of treatment
Other

M795

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ANDERSON ET AL.

members of the general public harbor misconceptions about

the nonsexual aspects of andropause. Future research and
educational initiatives are needed.
Acknowledgment
Address correspondence to Carole Cranor, PPD Development, Inc.,
3900 Paramount Parkway, Morrisville, NC 27560. E-mail: carole.cranor@
rtp.ppdi.com
References

pause increases, both the general public and HCPs can benefit from education about andropause and its treatment. This
study of a relatively informed general public indicates aspects that warrant attention. First, andropause is a testosterone deficiency that develops gradually over a number of
years in all men aged 50 and older. Andropause can be
treated with TRT. Second, andropause is associated with an
increased risk of osteoporosis and bone fractures. TRT can
decrease this risk by increasing bone mineral density. Third,
andropause does not cause loss of urinary control. This
common symptom in aging men is more likely caused by an
enlarged prostate. Fourth, TRT can increase the lean body
mass necessary for adequate muscle strength. Fifth, other
benefits of TRT in andropause include improved mood and
higher energy levels. The effects of such education should
be evaluated by using large randomized surveys of the general public and HCPs to more adequately assess the current
state of knowledge about andropause and its treatment.
Additional research is needed in other areas as well. Accurate epidemiological data are necessary to adequately measure the prevalence and incidence of andropause. Research is
needed to assess the current costs associated with andropause
(i.e., the costs of andropause that has not been treated with
TRT). Such studies should include retrospective analyses as
well as predictive economic models of future costs. Prospective studies of the clinical, economic, and quality of life outcomes associated with TRT in andropause are also needed.
As the population continues to age, the prevalence of andropause will increase. Without adequate TRT, andropause
can be expected to increase medical care utilization and
costs. The results of this survey suggest that HCPs and

Received June 17, 2002

Accepted August 1, 2002

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Figure 1. Number of testosterone prescriptions dispensed in U.S.

retail pharmacies from May 1997 through May 2002 (on average, one
prescription provides 30 days of treatment).

1. Morley JE. Andropause: is it time for the geriatrician to treat it? (Editorial). J Gerontol Med Sci. 2001;56A:M263M265.
2. Morales A, Heaton JPW, Carson CC. Andropause: a misnomer for a
true clinical entity. J Urol. 2000;163:705712.
3. Tenover, JL. Male hormone replacement therapy including andropause. Endocrinol Metab Clin North Am. 1998;27:969987.
4. Winters SJ. Current status of testosterone replacement therapy in men.
Arch Fam Med. 1999;8:257263.
5. Gould DC, Petty R, Jacobs HS. For and against: the male menopausedoes it exist? Br Med J. 2000;320:858861.
6. Matsumoto AM. Andropause: clinical implications of the decline in
serum testosterone levels with aging in men. J Gerontol Med Sci.
2002;57A:M76M99.
7. Swerdloff RS, Bhasin S, Blackman MR, et al. Summary of the Consensus Session from the 1st Annual Andropause Consensus 2000 Meeting.
Bethesda, MD: The Endocrine Society; 2000:16.
8. Morley JE, Kaiser FE, Perry HM, et al. Longitudinal changes in testosterone, luteinizing hormone, and follicle-stimulating hormone in
healthy older men. Metabolism. 1997;46:410413.
9. Basaria S, Dobs AS. Hypogonadism and androgen replacement therapy in elderly men. Am J Med. 2001;110:563572.
10. Morley JE, Charlton E, Patrick P, et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;
49:12391242.
11. Smith KW, Feldman HA, McKinlay JB. Construction and field validation of a self-administered screener for testosterone deficiency (hypogonadism) in ageing men. Clin Endocrinol (Oxf). 2000;53:703711.
12. AHFS Drug Information. [Book on online database]. Jackson, WY:
Teton Data Systems; 2002. Based on: AHFS Drug Information, forty
fourth edition. Bethesda, MD: American Society of Health System
Pharmacists; 2002. STAT!-Ref Medical Reference Library.
13. Snyder PJ, Peachey H, Berlin JA, et al. Effects of testosterone replacement in hypogonadal men. J Clin Endocrinol Metab. 2000;85:26702677.
14. Marin P, Arver S. Androgens and abdominal obesity. Baill Clin Endrocrinol Metab. 1998;12:441451.
15. Basaria S, Dobs AS. Risks versus benefits of testosterone therapy in
elderly men. Drugs Aging. 1999;15:131142.
16. Wang C, Swerdloff RS, Iranmanesh A, et al. Transdermal testosterone
gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men. J Clin Endocrinol Metab.
2000;85:28392853.
17. Kenny AM, Prestwood KM, Gruman CA, Marcello KM, Raisz LG.
Effects of transdermal testosterone on bone and muscle in older men
with low bioavailable testosterone levels. J Gerontol Med Sci. 2001;
56A:M266M272.
18. Barrett-Connor E, von Muhlen DG, Kritz-Silverstein D. Bioavailable
testosterone and depressed mood in older men: the Rancho Bernardo
study. J Clin Endocrinol Metab. 1999;84:573577.
19. American Association of Clinical Endocrinologists, American College
of Endocrinology. AACE clinical practice guidelines for the evaluation and treatment of hypogonadism in adult male patients. Endocr
Prac. 1996;Nov/Dec:439453.
20. Scott-Levin Source Prescription Audit, Quintiles Transnational Corp.
Research Triangle Park, NC.
21. U.S. Food and Drug Administration Updates. Skin patch replaces testosterone. Food and Drug Administration Web site. Available at
www.verity.fda.gov/search97dgi. Accessed December 10, 1999.