The Clear Picture · Practical Guides

Andropause and Bone Health

Is andropause really a male menopause?

Not in the usual sense. Testosterone levels can fall gradually as men grow older, but there is no single age at which every man’s testosterone suddenly drops. Men do not all develop symptoms, and there is no universal end to fertility.

The word andropause is therefore a convenient public term rather than a precise description. When a man has relevant symptoms together with repeatedly low testosterone levels, the more accurate terms are testosterone deficiency, male hypogonadism or, when it develops later in life, late-onset hypogonadism.

The symptoms are real, but testosterone is only one possible explanation. Poor sleep, stress, depression, obesity, diabetes, vascular disease, medicines and other health conditions can produce a very similar picture.

What does testosterone normally do?

Testosterone is produced mainly in the testes under signals from the brain and pituitary gland. It is important throughout adult life, not only for sexual function. It contributes to sperm production, red-blood-cell production, muscle mass, physical strength, body-fat distribution, mood and the maintenance of bone.

Some testosterone acts directly. Some is converted into oestradiol, a form of oestrogen. Men need both androgen and oestrogen activity for healthy bone remodelling. Oestrogen is not exclusively a female hormone, just as testosterone is not exclusively a male hormone.

Recognising possible testosterone deficiency

Which symptoms are more suggestive?

Sexual changes tend to be more closely linked with testosterone deficiency than general symptoms such as tiredness. Possible features include:

• A clear and persistent reduction in sexual desire.
• Fewer spontaneous or early-morning erections.
• Difficulty obtaining or maintaining an erection.
• Reduced frequency of shaving or reduced body hair.
• Reduced fertility or difficulty producing sperm.
• Hot flushes or sweats when testosterone deficiency is marked.

Erectile difficulty does not automatically mean low testosterone. Blood-vessel disease, diabetes, medicines, smoking, anxiety and relationship factors are common causes. Because erectile difficulty can sometimes be an early sign of cardiovascular disease, it deserves a proper health review rather than being dismissed as ageing.

What other changes can occur?

A man may also notice:

• Lower energy, drive or motivation.
• Low mood, irritability, reduced confidence or poor concentration.
• Loss of muscle bulk, strength or exercise capacity.
• An increase in abdominal fat.
• Breast tenderness or enlargement.
• Poor sleep or increased daytime tiredness.
• Unexplained anaemia.
• Low bone density or a fracture after relatively minor trauma.

These symptoms are not specific. Their pattern, severity, duration and effect on daily life matter more than simply counting how many are present.

What else can produce the same picture?

Middle and later life often bring changes that affect energy, sleep, mood, sexual function and body composition. Possible contributors include:

• Obesity, metabolic syndrome and type 2 diabetes.
• Obstructive sleep apnoea or persistent poor-quality sleep.
• Stress, anxiety, depression or relationship difficulties.
• Thyroid disorders, anaemia, liver or kidney disease and other long-term illness.
• A very low energy intake, significant weight loss or excessive training without adequate recovery.
• Medicines such as long-term opioids or corticosteroids.
• Previous anabolic-steroid use, because natural testosterone production can remain suppressed after stopping.
• Testicular injury, infection, surgery, chemotherapy or radiotherapy.
• Conditions affecting the pituitary gland or the hormone signals from the brain.

Some of these factors lower testosterone. Others cause similar symptoms without true testosterone deficiency. More than one factor may be present at the same time.

Understanding the bone connection

How do male sex hormones protect bone?

Bone is living tissue. Old or damaged bone is continually removed and replaced. This process is called bone remodelling. Testosterone and oestradiol help keep removal and replacement in balance.

Oestradiol helps restrain excessive bone breakdown. A proportion of a man’s testosterone is converted into oestradiol inside the body.

Testosterone also acts through androgen receptors and supports bone formation, bone size and the maintenance of the skeleton.

Testosterone helps preserve muscle mass and strength. Strong muscles place useful mechanical loads on bone and help support balance and mobility. Better strength and function may reduce the likelihood of some falls. Hormone deficiency can therefore affect fracture risk through both the bone and the person around the bone.

What happens when testosterone remains low?

When testosterone is markedly or persistently low, oestradiol levels may also become too low. Bone breakdown can then outpace bone replacement. Over time, bone density may fall and the internal structure of bone may become less robust.

At the same time, loss of muscle and strength can reduce the healthy loading that bones receive. Reduced activity, poorer balance and frailty may increase the chance of falling. The result is not one simple pathway: bone strength, muscle strength and falls can all be affected.

Does low testosterone always cause osteoporosis?

No. A mildly low or borderline result does not prove that a man’s bones are weak, and not every man with testosterone deficiency develops osteoporosis. The duration and severity of the deficiency matter, as do age, genetics, nutrition, activity, smoking, alcohol, medicines, illness and previous fractures.

However, established hypogonadism is a recognised secondary cause of osteoporosis in men. It becomes particularly relevant when a man is younger than expected for low bone density, has sustained a fragility fracture, has lost height, or has other features of hormone deficiency.

Why does prostate cancer hormone therapy matter?

Androgen deprivation therapy for prostate cancer deliberately lowers testosterone or blocks its action. This can produce a much larger and faster hormonal change than ordinary ageing. Bone loss and fracture risk can increase, particularly when therapy continues for a long time.

Men starting or receiving androgen deprivation therapy should have bone and fracture risk considered as part of their wider support. They may need a bone-density assessment, attention to calcium and vitamin D, suitable exercise and, when risk is high, a specific bone-protective medicine. Testosterone replacement is not normally appropriate when testosterone is being suppressed as part of prostate cancer management.

Would weakening bones cause symptoms?

Usually not. Low bone density often causes no pain or warning signs. A vertebral fracture may sometimes be silent, or it may present as sudden back pain, height loss or an increasingly rounded upper back. For some men, the first clear sign is a fracture.

Getting the right assessment

When is testosterone testing reasonable?

Testing is most useful when there are persistent symptoms or signs that could reasonably reflect testosterone deficiency. It may also be considered when a man has unexplained low bone density, a fragility fracture, unexplained anaemia, infertility, very small testes, pituitary disease or a history of treatment that could affect the testes or pituitary gland.

Routine testing of every middle-aged man without symptoms is not generally recommended. The aim is to investigate a meaningful health question, not to search for an age-related number in isolation.

Why is one testosterone test not enough?

Testosterone changes during the day and is usually highest in the morning. It can also fall temporarily after poor sleep, a meal, acute illness, heavy physical stress or certain medicines. Laboratory methods and reference ranges are not identical.

Confirmation therefore normally requires at least two separate early-morning blood tests, preferably while fasting and when the man is otherwise well. For shift workers, timing may need to reflect the normal sleep-wake pattern. A result taken during acute illness may need to be repeated after recovery.

What do total testosterone and free testosterone mean?

Most testosterone travels in the blood attached to proteins, especially sex hormone-binding globulin, known as SHBG, and albumin. Total testosterone measures the attached and unattached hormone together. Free testosterone refers to the small portion that is not tightly bound and is more readily available to tissues.

Changes in SHBG can make total testosterone harder to interpret. Obesity and insulin resistance may lower SHBG, while ageing, thyroid or liver conditions and some medicines may raise it. When the total result is borderline or SHBG may be unusual, SHBG and a calculated free-testosterone result can add useful context.

What further blood tests may be considered?

Further tests help explain why testosterone is low and whether another condition is contributing. These may include:

• LH and FSH, the pituitary hormones that signal the testes. Their pattern helps distinguish a testicular problem from reduced signalling by the brain or pituitary gland.
• Prolactin, particularly when pituitary signalling appears reduced or there are headaches, visual symptoms or breast discharge.
• SHBG and albumin, when a calculated free-testosterone estimate is needed.
• A full blood count, thyroid function, glucose or HbA1c, and liver or kidney tests when clinically relevant.
• Other pituitary tests or imaging when the history and hormone pattern suggest a pituitary cause.

When should bone health be assessed?

A clinician may consider bone-density and fracture-risk assessment when testosterone deficiency is marked or prolonged, or when other bone-health concerns are present. Important reasons include:

• A fracture following relatively minor trauma.
• Unexplained low bone density or a previous osteoporosis assessment.
• Loss of height, sudden back pain or concern about vertebral fractures.
• Androgen deprivation therapy for prostate cancer.
• Long-term corticosteroid use, significant immobility or another condition that increases bone loss.
• Several risk factors occurring together.

DXA is the established clinical method for measuring bone mineral density. REMS is an ultrasound-based assessment that can also provide bone-density information and, where available, additional fragility information. The choice depends on the clinical question, local pathway and the individual. Neither assessment should be interpreted in isolation from fractures, falls, medicines, health history and other risk factors.

Support and protecting bone

Start with the underlying cause

The first step is to understand why testosterone is low. Addressing obstructive sleep apnoea, improving diabetes control, reviewing an opioid or corticosteroid prescription, correcting undernutrition, or addressing a pituitary or testicular condition may be more important than focusing only on the testosterone number.

In men carrying excess weight, testosterone may improve with sustainable weight reduction and better metabolic health. This does not mean symptoms should be blamed on weight; it means that body composition and hormones influence one another and deserve respectful, practical support.

Which everyday measures support hormones, muscle and bone?

• Regular resistance exercise to maintain or rebuild muscle strength.
• Weight-bearing activity suited to the person’s mobility and fracture risk.
• Balance work when falls are a concern.
• Adequate energy and protein intake rather than severe or repeated crash dieting.
• Enough calcium from food where possible, with vitamin D assessed or supplemented when appropriate.
• Good sleep and assessment for sleep apnoea when there is loud snoring, witnessed pauses in breathing or marked daytime sleepiness.
• Avoiding smoking and keeping alcohol within recommended limits.

These measures do not guarantee that testosterone will normalise, and they do not replace other options when fracture risk is high. They support the wider system in which hormones, muscles and bones function.

When may testosterone replacement be considered?

Testosterone replacement therapy may be considered when a man has consistent symptoms, repeatedly low levels and an assessed cause for the deficiency. It should not be prescribed simply as an anti-ageing tonic or in response to one borderline result.

Depending on the individual, replacement may improve sexual desire, some aspects of sexual function, anaemia, lean body mass and wellbeing. The response is variable. Erectile difficulties caused mainly by vascular disease, diabetes or psychological factors may not resolve with testosterone alone.

What can testosterone replacement do for bone?

In men with genuine testosterone deficiency, replacement can increase bone mineral density, particularly at the spine, and may improve estimates of bone strength. These changes usually take time and are not a reason to judge progress after only a few weeks.

However, an improvement in bone density is not the same as proof that fewer fractures will occur. Large clinical research has not shown that testosterone replacement can be relied upon to prevent fractures. A man with osteoporosis or high fracture risk may still need a separate bone-protection plan even when his testosterone deficiency is being addressed.

What should be considered before and during replacement?

The potential benefits and disadvantages should be discussed individually. Important considerations include fertility wishes, prostate and breast history, blood count, cardiovascular health, sleep apnoea and urinary symptoms. Monitoring commonly includes symptoms, testosterone level, full blood count and age-appropriate prostate assessment.

Possible unwanted effects include acne or oily skin, breast tenderness, fluid retention and an excessive rise in red blood cells. Testosterone replacement can reduce sperm production and may shrink the testes. It should not be started without proper assessment, and non-prescribed testosterone or anabolic steroids carry additional risks.

Why must fertility be discussed first?

Testosterone taken from outside the body can switch down the pituitary signals that drive sperm production. A man may feel better while his sperm count falls substantially. Anyone who wants to conceive now or in the future should say so before starting replacement, because other specialist approaches may be more appropriate.

Putting the results into perspective

What might different result patterns mean?

These examples show why the whole pattern matters:

• Symptoms plus two low morning results: This supports genuine testosterone deficiency and should lead to assessment of the cause. Bone health becomes especially relevant if the deficiency is severe or prolonged, or if there has been a fragility fracture or low bone density.
• Symptoms but consistently normal testosterone: The symptoms still matter, but another explanation is more likely. Sleep, mood, vascular health, diabetes, thyroid function, anaemia, medicines and relationship factors may need attention.
• One low result during illness or after poor sleep: This may be temporary. It should not be used alone to label a man or begin replacement. Repeat testing under appropriate conditions is usually needed.
• Low testosterone with apparently satisfactory bone density: This does not make the hormone finding irrelevant. Bone density is only one outcome and may not yet have changed. The cause and other symptoms still deserve assessment.
• Low bone density with normal testosterone: Testosterone is unlikely to be the main explanation. Other causes and the man’s overall fracture risk should be considered.
• Androgen deprivation therapy: The low testosterone is intentional, but its effects on bone remain important. Bone and fracture-risk support should sit alongside the cancer pathway.

When should a man seek prompt advice?

A routine appointment is appropriate for persistent sexual, physical or emotional symptoms. More urgent advice is needed for sudden severe headache with visual disturbance, a new testicular lump, severe testicular pain, a suspected fracture, new severe back pain with weakness or altered bladder or bowel control, or thoughts of self-harm.

Questions worth asking

• Which of my symptoms are most suggestive of testosterone deficiency, and what else could explain them?
• Were my testosterone tests taken at the right time and repeated under suitable conditions?
• Do I need SHBG, calculated free testosterone, LH, FSH or prolactin checked?
• Could my medicines, sleep, weight, diabetes or another condition be affecting the result?
• Does my fracture history or bone-density result justify a fuller bone-health assessment?
• If replacement is being considered, what benefits are realistic for me and how will it be monitored?
• Could replacement affect my fertility?
• Do I need a separate plan to protect my bones and reduce falls?

Produced for educational purposes by the Education Directorate of IIMHE. This guide supports discussion and does not replace individual clinical advice. IIMHE · The Clear Picture · Practical Guides · September 2026.