[Series Part 3] Male Menopause and Fatigue — Understanding the Often-Overlooked LOH Syndrome

【Important Notice】

This article is provided for informational purposes by a counseling salon with medically-trained staff and is not intended to provide medical diagnosis, treatment, or prescriptions. If you are experiencing serious physical or mental symptoms, please consult a medical facility. Our services provide counseling, care, and support, and are not a substitute for medical treatment.

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Introduction — The Misconception That “Men Don’t Have Menopause”

In our previous article, we explored how women’s menopause and declining estrogen impact fatigue. Many female readers shared that understanding their symptoms as menopausal brought them relief and clarity.

However, we also received numerous questions:

“My husband is experiencing similar symptoms. Do men have menopause too?” “My partner has been increasingly tired and irritable lately—I’m worried.” “I’m a man in my 50s struggling with unexplained fatigue and loss of motivation.”

The answer is yes—men experience menopause too.

Yet compared to women’s menopause, awareness of male menopause remains extremely low. The assumption that “menopause is only for women” persists, causing many men—and those around them—to miss recognizing these symptoms as menopause-related.

Consequently, countless men suffer without appropriate support, resigning themselves to “it’s just aging” or being misdiagnosed with “depression.”

Today, we’ll thoroughly explore this “often-overlooked male menopause (LOH syndrome)” in clear, accessible terms. We encourage not just men in their 40s-60s, but also partners and family members seeking to understand and support the men in their lives.

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What Is Male Menopause (LOH Syndrome)? — The Official Medical Term

Male menopause is medically termed “LOH syndrome (Late Onset Hypogonadism)” or “aging male hypogonadism.”

What Is Testosterone? — The Multifaceted Role of “Male Hormone”

Just as women have estrogen, men have testosterone (male hormone). Testosterone is primarily secreted by the testes and influences men’s bodies and minds in numerous ways.

Primary Functions of Testosterone:

Physical Functions:

• Muscle synthesis and maintenance—creating masculine, muscular physique
• Bone density maintenance—keeping bones strong
• Red blood cell production—promoting hematopoiesis
• Fat breakdown—particularly suppressing visceral fat accumulation
• Sexual function maintenance—libido, erectile function

Mental Functions:

• Motivation and drive maintenance—fostering “forward-looking challenge” mindset
• Concentration and judgment maintenance—work performance
• Mood stability—positive mood, confidence
• Stress resilience—strength to confront difficulties
• Aggression control—appropriate competitiveness, leadership

Thus, testosterone isn’t merely a “sex hormone”—it’s a crucial hormone supporting overall male physical and mental health and vitality.

Age-Related Testosterone Changes — Gradual Decline Is Characteristic

Unlike women’s estrogen, which drops sharply at menopause, men’s testosterone declines gradually and continuously.

Typically peaking in the 20s, testosterone decreases approximately 1-2% annually from the 30s onward. A 50-year-old man’s testosterone may be 20-30% lower than his peak 20s levels, and by 60, potentially 30-40% lower.

This gradual decline shows significant individual variation:

Men Maintaining High Testosterone:

• Remain youthful and active into their 60s-70s
• Preserve muscle mass with low body fat
• Stay motivated, continually pursuing new challenges

Men with Rapid Testosterone Decline:

• Notice pronounced fatigue and decreased motivation from their 40s
• Experience muscle loss with increasing abdominal fat
• Increased mood depression and irritability

This variation stems from genetic factors, lifestyle (exercise, diet, sleep, stress), and psychological factors (purpose, goal presence).

LOH Syndrome Definition and Diagnostic Criteria

While all men experience testosterone decline, “LOH syndrome” diagnosis requires meeting these conditions:

1. Low Testosterone Levels: Blood test shows free testosterone below reference range (generally under 8.5 pg/mL)

2. Characteristic Symptoms Present: Existence of physical, mental, or sexual symptoms (described below) interfering with daily life

3. Other Conditions Excluded: Similar-symptom conditions like hypothyroidism, depression, sleep apnea ruled out

Importantly, low testosterone alone doesn’t constitute “LOH syndrome” diagnosis. Without symptoms despite low values, treatment isn’t indicated. Conversely, even with normal-range values, strong symptoms may warrant treatment consideration.

LOH syndrome diagnosis and treatment evaluate not just “numbers” but “symptoms” and “life impact” comprehensively.

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Male Menopause Symptoms — Understanding Through “Three Categories”

LOH syndrome symptoms fall into three broad categories: physical, mental, and sexual function symptoms.

Physical Symptoms — Signs Manifesting as “Body Changes”

1. Chronic Fatigue and Malaise

This is the most common complaint in male menopause, particularly noticeable in men aged 40-60.

“I wake up tired” “I’m exhausted by midafternoon” “Rest doesn’t relieve fatigue” “Work that used to be manageable now completely drains me”

This fatigue partly results from declining testosterone reducing energy metabolism efficiency. Additionally, decreased sleep quality (discussed later), muscle loss, and mood depression amplify fatigue.

Like women’s menopausal fatigue, male menopausal fatigue isn’t simply “physical tiredness”—it’s complex fatigue intertwined with psychological and social factors.

2. Decreased Muscle Mass and Strength

Testosterone promotes muscle synthesis (protein synthesis). Decline causes:

“My muscles have diminished, my body feels thinner” “I lack strength, can’t lift heavy objects” “Climbing stairs is exhausting” “Despite exercising, muscle doesn’t build like before”

Muscle loss leads to decreased basal metabolism, increased fatigue, body sagging, and heightened fall risk.

Men in their 40s-60s feeling “my body has changed recently” may be experiencing muscle mass reduction.

3. Visceral Fat Increase — Shift to “Metabolic Syndrome Body Type”

Testosterone aids fat breakdown, particularly suppressing visceral fat accumulation. Decline causes:

“Fat accumulates around my abdomen” “I used to be slim, now I’m middle-aged spread” “My pants waistband is tight”

Visceral fat increase isn’t just aesthetic—it leads to metabolic syndrome (hypertension, dyslipidemia, diabetes risk) and increased cardiovascular disease risk.

Interestingly, increased visceral fat secretes “aromatase” enzyme, converting testosterone to estrogen. This creates a vicious cycle: “testosterone decline → visceral fat increase → further testosterone decline.”

4. Decreased Bone Density

Testosterone promotes bone formation and maintains bone density. Decline causes:

“Health checkup revealed decreased bone density” “Increased back pain, lower back pain” “Concerned about fracture risk”

While osteoporosis is considered a “women’s disease,” men with declining testosterone also experience reduced bone density and increased fracture risk. Male fractures particularly in the 70s+ are as serious as women’s.

5. Hot Flashes and Sweating

While less frequent than women’s hot flashes, men may experience:

“Sudden facial heat” “Waking from night sweats” “Sweating without being hot”

These result from autonomic nervous system imbalance.

6. Sleep Disorders

“Difficulty falling asleep” “Frequent nighttime awakenings (especially for bathroom trips)” “Early morning awakening” “Shallow sleep with constant dreaming”

Testosterone decline reduces sleep quality. Additionally, prostate enlargement causing nighttime urination, common in men 40-60+, disrupts sleep.

Poor sleep quality prevents fatigue recovery, leading to daytime performance decline and mood deterioration.

Mental Symptoms — Signs Manifesting as “Mental Changes”

Even more troubling than physical symptoms for patients and those around them are mental symptoms.

1. Decreased Motivation and Drive

This is one of male menopause’s most characteristic symptoms, particularly impactful for men in their 40s-60s still active in careers.

“I don’t want to do anything” “No motivation for work” “Can’t enjoy hobbies anymore” “No energy to try new things” “‘Too much trouble’ has become my catchphrase”

Testosterone supports “challenge,” “achievement,” and “competition”—so-called “masculine” drives. Decline reduces these motivations, sometimes causing feelings of “I don’t understand why I’m working hard.”

Particularly for men in their 40s-60s in responsible management positions, this motivation decline is severe. Many suffer the dilemma: “I must lead subordinates, yet I have no motivation myself.”

2. Decreased Concentration and Memory

“During meetings, information doesn’t register” “Can’t recall people’s names” “Forget what I intended to do” “Reading doesn’t retain content” “Work errors have increased”

Testosterone relates to cognitive function—particularly concentration, judgment, and memory. Decline reduces these functions, directly impacting work performance.

This can cause loss of confidence—”Have I become incompetent?”—creating a downward spiral of further mental decline.

3. Irritability and Anger

“Minor things irritate me” “I lash out at subordinates or family” “Quick to anger” “Difficulty controlling emotions”

While testosterone provides appropriate aggression (competitiveness, leadership), decline can manifest as “uncontrolled aggression.”

Additionally, stress from fatigue, decreased motivation, and lost confidence often expresses as irritability.

4. Anxiety and Restlessness

“Vague anxiety” “Constant worry about the future” “Restlessness, inability to sit still” “Anticipatory anxiety about bad things happening”

Testosterone enhances stress resilience and reduces anxiety. Decline strengthens anxiety, making trivial concerns overwhelming.

5. Depressive Mood and Lost Confidence

“Feeling down” “Nothing brings joy” “I think I’m worthless” “Life feels meaningless” “Thoughts of death”

These closely resemble depression symptoms. LOH syndrome is frequently misdiagnosed as “depression.”

The distinction: LOH syndrome involves low testosterone, and symptoms improve with testosterone replacement therapy. However, LOH syndrome and depression can coexist, requiring specialist differentiation.

Critical: If experiencing suicidal ideation (thoughts of death), immediately consult psychiatry/psychosomatic medicine.

6. Social Withdrawal

“Meeting people feels burdensome” “Don’t want to attend gatherings or drinks” “Spend weekends lounging at home” “Going out is troublesome”

Combined decreased motivation, fatigue, and lost confidence lead to social withdrawal. This causes workplace communication deficits and family isolation, potentially worsening symptoms.

Sexual Function Symptoms — Signs Related to “Masculine Confidence”

1. Decreased Libido

“Lost interest in sexual matters” “Intimacy with partner feels burdensome” “Virtually no sexual desire”

Testosterone governs libido. Decline significantly reduces sexual desire. For many men, particularly those in their 40s-60s still in active relationships, this directly impacts “masculine confidence,” causing substantial psychological damage.

2. Erectile Dysfunction (ED)

“Difficulty achieving or maintaining erection” “Morning erections have disappeared” “Lack confidence in sexual activity”

Testosterone relates to erectile function. However, ED causes are diverse (vascular issues, nerve problems, psychological factors, medication side effects)—testosterone decline isn’t always the sole cause.

3. Psychological Impact of Sexual Dysfunction

Sexual function decline creates not just physical but serious psychological effects:

“Feel I’ve lost value as a man” “Feel apologetic toward partner” “Marital relationship has become strained” “Lost self-confidence”

This psychological stress can further decrease testosterone, worsening symptoms in a vicious cycle.

Individual Variation and Fluctuation in Symptoms

These symptoms don’t manifest identically in all men.

Some primarily experience physical symptoms (fatigue, muscle loss), others mainly mental symptoms (decreased motivation, depression), while others find sexual function symptoms most concerning—variation is extremely wide.

Even within individuals, symptom strength and types vary over time. During high-stress periods, mental symptoms may worsen, improving with rest.

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Why Is Male Menopause Often Overlooked? — Five Reasons

Compared to women’s menopause, male menopause recognition remains low and easily overlooked for several reasons.

Reason 1: Gradual Symptom Onset

Women’s menopause involves clear physical change (menstruation cessation), with symptoms appearing relatively rapidly over several years.

Male menopause, with gradual testosterone decline, manifests symptoms slowly. Both men themselves and those around them attribute this to “just aging” or “just tired,” missing the menopause connection.

Reason 2: “Menopause Is for Women” Assumption

Socially, “menopause = women” imagery persists strongly, with men themselves often believing “men don’t have menopause.”

Even healthcare professionals sometimes lack sufficient male menopause knowledge, preventing appropriate diagnosis.

Reason 3: “Men Can’t Show Weakness” Cultural Context

Japanese culture strongly values men being “strong” and “not showing weakness.”

Consequently, even feeling fatigue or mood depression, many men endure thinking “I shouldn’t complain about this,” consulting no one.

Particularly men in their 40s-60s face workplace expectations as “strong leaders” in management and home expectations as “reliable husbands/fathers.” Fulfilling these roles means continuously hiding weakness.

Reason 4: Confusion with Depression

Male menopause mental symptoms (decreased motivation, depressive mood, anxiety, irritability) closely resemble depression symptoms.

Therefore, psychosomatic medicine or psychiatry consultations often result in “depression” diagnosis with antidepressant prescriptions. While depression treatment is important, when underlying testosterone decline exists, testosterone replacement therapy may prove effective.

Conversely, treating with only antidepressants while missing LOH syndrome may yield insufficient improvement.

Reason 5: Difficulty Discussing Sexual Function Issues

Sexual function problems like decreased libido and ED are extremely sensitive concerns for men. Many find these difficult to discuss even with physicians, suffering alone.

Additionally, many resign themselves to “it’s age,” unaware these are treatable conditions.

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LOH Syndrome Diagnosis — Where and How Diagnosis Occurs

If thinking “I might have LOH syndrome,” where should you consult?

Medical Departments to Consult

Urology: The specialty specifically treating male menopause. Many urology departments can diagnose and treat LOH syndrome.

Male Menopause Clinics: Some hospitals and clinics have specialized male menopause departments.

Internal Medicine/General Practice: Initial internal medicine consultation with specialist referral as needed is also possible.

Psychosomatic Medicine/Psychiatry: With strong mental symptoms, initial consultation here is common. Requesting testosterone measurement is advisable.

Diagnostic Process

1. Medical Interview

Physicians inquire detailed symptoms:

• When symptoms began
• What symptoms exist (physical, mental, sexual function)
• Daily life impact
• Medical history, current conditions, medications
• Lifestyle (exercise, diet, sleep, stress, alcohol, smoking)
• Work situation, family circumstances

This interview is crucial. Honest, detailed symptom reporting leads to accurate diagnosis.

2. Questionnaire Evaluation

Many facilities use the “AMS (Aging Males’ Symptoms) Score” questionnaire. Seventeen questions rate symptom severity numerically.

This questionnaire can be completed at home. Pre-visit completion smooths consultation.

3. Physical Examination

• Blood pressure, pulse, weight, BMI measurement
• Waist circumference measurement (visceral fat evaluation)
• Testicular palpation (size, firmness assessment)
• Prostate palpation (as needed)

4. Blood Tests

The most important examination.

Testosterone Level Measurement:

• Total testosterone
• Free testosterone (active form, more important)

Collection Timing: Testosterone shows diurnal variation—highest morning, declining evening. Therefore, morning collection (ideally by 10 AM) is standard.

Other Tests:

• LH (luteinizing hormone), FSH (follicle-stimulating hormone)—testicular function evaluation
• Prolactin—high levels suppress testosterone
• Thyroid hormones (TSH, FT4)—hypothyroidism exclusion
• Blood glucose, HbA1c, lipids—metabolic syndrome evaluation
• Liver function, kidney function—overall health evaluation
• PSA (prostate-specific antigen)—prostate cancer screening

5. Additional Tests

As needed:

• Bone density measurement—osteoporosis evaluation
• Sleep apnea testing—when sleep disorders suspected
• Psychological testing—depression differentiation

Diagnostic Criteria

LOH syndrome diagnosis requires meeting these conditions:

1. Free testosterone below 8.5 pg/mL (total testosterone below 300 ng/dL also reference)
2. Characteristic symptoms present (AMS score above threshold, etc.)
3. Other conditions excluded (hypothyroidism, depression, etc.)

However, even with above-reference testosterone, strong symptoms may warrant “relative testosterone decline” treatment consideration.

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LOH Syndrome Treatment — Testosterone Replacement Therapy and Other Options

Upon LOH syndrome diagnosis, several treatment options exist.

1. Testosterone Replacement Therapy (TRT)

Supplementing declined testosterone pharmacologically.

Administration Methods

Injection: Most common method.

• Testosterone enanthate every 2-4 weeks via intramuscular injection
• Relatively inexpensive with reliable effect

Topical Gel:

• Daily application to upper arms or abdomen
• Suitable for injection-averse individuals
• Requires caution regarding family contact (especially women, children)

Patches:

• Daily replacement
• Not widely used in Japan

Effects

Testosterone replacement therapy may improve these symptoms:

Physical Symptoms:

• Reduced fatigue
• Increased muscle mass and strength
• Decreased visceral fat
• Improved bone density

Mental Symptoms:

• Restored motivation and drive
• Improved mood
• Enhanced concentration and memory
• Reduced irritability

Sexual Function Symptoms:

• Restored libido
• Improved erectile function

Time to effect varies by symptom:

• Libido, mood: 2-4 weeks
• Fatigue, strength: 3-6 months
• Bone density: 6+ months

Side Effects and Precautions

While effective, testosterone replacement therapy involves these side effects and considerations:

Polycythemia: Excessive red blood cell increase, blood thickening. Regular blood testing required.

Prostate Effects: Benign prostatic hyperplasia worsening, prostate cancer risk. Regular PSA monitoring necessary.

Liver Function Effects: Rare liver function abnormalities. Regular liver function testing required.

Acne, Oily Skin: Increased sebum secretion.

Sleep Apnea Worsening: Those with existing sleep apnea require caution.

Contraindications (Cannot Use):

• Prostate cancer, breast cancer patients
• Severe heart failure patients
• Polycythemia patients

Regular Follow-up

After starting testosterone replacement therapy, regular examinations (approximately every 3 months) are necessary:

• Symptom improvement evaluation
• Blood tests (testosterone levels, hematocrit, liver function, lipids, etc.)
• PSA measurement
• Prostate palpation

2. Traditional Medicine

For those resistant to testosterone replacement therapy or with mild symptoms, traditional medicine offers alternatives.

Common Traditional Medicines for Male Menopause:

• Hochu-ekki-to: Fatigue, decreased vitality, appetite loss
• Hachimi-jio-gan: Lower body weakness, frequent urination, sexual dysfunction
• Saiko-ka-ryukotsu-borei-to: Anxiety, irritability, insomnia

Traditional medicine is prescribed according to constitution, so consulting specialists (traditional medicine specialists, male menopause-knowledgeable physicians) is recommended.

3. Lifestyle Modifications

For mild LOH syndrome, lifestyle improvements alone may alleviate symptoms. Combined with testosterone replacement therapy, effects amplify.

Exercise:

• Especially resistance training (strength training) effective
• Promotes testosterone secretion
• Maintains/increases muscle mass
• Reduces visceral fat
• 2-3 times weekly, 30 minutes

Diet:

• Balanced nutrition
• Adequate protein intake
• Zinc (oysters, red meat, nuts)—necessary for testosterone synthesis
• Vitamin D (fish, sunlight exposure)
• Avoid extreme carbohydrate restriction (testosterone decline risk)

Sleep:

• Quality sleep (7-8 hours)
• Testosterone secreted during sleep
• Sleep deprivation decreases testosterone

Stress Management:

• Chronic stress decreases testosterone
• Relaxation, hobbies, counseling, etc.

Smoking Cessation, Moderate Alcohol:

• Smoking and excessive drinking decrease testosterone

4. Psychological Counseling

LOH syndrome symptoms significantly involve psychological and social factors:

• Work stress
• Family issues
• Life transitions (children’s independence, parental care, retirement)
• Fluctuating self-worth

Psychological counseling effectively addresses these.

Cognitive Behavioral Therapy (CBT): Revises thought patterns, reduces stress Mindfulness: Focuses on “here and now,” eases anxiety Interpersonal Therapy: Addresses relationship stress

At AzulMar, leveraging physician-on-staff advantages, we provide psychological counseling and spiritual care while collaborating with medical facilities.

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Summary: Male Menopause Isn’t “Weakness” — It’s Addressable Physical Change

Today we’ve thoroughly explored often-overlooked male menopause (LOH syndrome).

Key Points:

1. Men also experience menopause (LOH syndrome), commonly emerging in 40s-60s
2. Testosterone decline causes diverse physical, mental, and sexual function symptoms
3. Often dismissed as “just aging” or “depression”—proper diagnosis and treatment crucial
4. Options include testosterone replacement therapy, traditional medicine, lifestyle improvements, counseling
5. Not something to “endure”—support improves quality of life

“It’s Okay to Show Vulnerability” — Men Deserve Self-Care Too

Japanese men have lived under values of “be strong” and “don’t show weakness.” However, bodily changes are natural—suffering isn’t “weakness.”

When feeling fatigue, decreased motivation, or mood depression, rather than enduring with “I shouldn’t complain about this,” choose “caring for my body and mind.”

Consulting specialists, receiving counseling, talking with family—these aren’t “weakness” but “wise self-care.”

To Partners and Family — Understanding and Supporting Male Menopause

If your partner or family member:

• Seems increasingly tired lately
• Has become more irritable
• No longer enjoys hobbies
• “Too much trouble” has become a catchphrase

These may signal male menopause.

Rather than concluding “it’s age” or “personality changed,” show understanding that “it might be physical change” and gently suggest “maybe get checked?”

Men find showing vulnerability difficult. Family understanding and support create the first step toward consultation and treatment.

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Next Preview: Part 4 “Autonomic Nervous System and Sleep — Fatigue Recovery Mechanisms and Practical Methods”

Next time, we’ll thoroughly explore autonomic nervous system and sleep, most crucial for fatigue recovery.

• Concrete methods to balance autonomic nervous system
• Practical approaches to improve sleep quality
• Sleep disorder types and responses
• “No relief despite rest” mechanisms
• Self-care practices starting today

We’ll share methods to enhance fatigue recovery by regulating autonomic nervous system and sleep, often disrupted during menopause (women and men).

Next Publication: November 12, 2025

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AzulMar’s Integrated Support

For male menopause symptoms and fatigue, AzulMar provides integrated support:

Medically-Trained Staff:

• Understanding from medical perspectives
• Recommending medical facilities when necessary
• Team-based support

Psychological Counseling:

• Cognitive Behavioral Therapy for stress management
• Mindfulness practices
• Support through life transitions
• Emotional processing

Physical Care:

• Medical aromatherapy
• Body treatment for muscle tension
• Relaxation for autonomic balance

Spiritual Care:

• Finding meaning in midlife transitions
• Exploring purpose beyond career
• Life direction visioning

Online・English Available:

• Accessible nationwide
• English-speaking support for expatriates and military families

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【Recommended Articles】

• [[Series Part 2] Women’s Menopause and Fatigue]
• [[Series Part 1] Unexplained Fatigue: A Message from Your Heart]
• [Supporting Your Partner Through Menopause]

【Tags】
#MaleMenopause #LOHSyndrome #TestosteroneDecline #40s50s60sMen #UnexplainedFatigue #DecreasedMotivation #MaleDepression #TestosteroneReplacementTherapy #PhysicianLedCounseling #HolisticCare #OnlineCounseling #AzulMar