Male Menopause: What’s Behind Men’s Midlife Health?

It has many names and monikers.

Male menopause.


Age-related testosterone deficiency.


Manopause, my personal favorite.

Although it isn’t as sharply defined as female menopause, male menopause is a catch-all for the gradual cascade of mental and physical health issues that men face as they approach and pass middle age and their testosterone drops. Wherever possible, I will insert “man” puns into the symptoms and conditions. Consider yourself warned.

Female menopause—as defined by the loss of fertility—happens to every woman no matter her genetics or lifestyle, dietary, or exercise choices. It’s a simple fact of human biology that women undergo menopause and the subsequent decline in sex hormones. They can certainly mitigate the negative symptoms with hormonal therapies, herbal concoctions, diet, and other means. Some will never experience any negative symptoms associated with the change. But a woman’s supply of eggs is finite. Fertility isn’t a lifelong state for women.

Not so with men. The health of an aging man entering “manopause” or male menopause depends almost entirely on the choices he makes, the food he eats (and how much of it), and the exercise he does or doesn’t do. This is liberating, but it’s also daunting: You can’t really complain if you aren’t doing anything about it. It’s all up to you. And even if it’s not up to you, acting as if it is gives you the best shot at countering the negative effects.

Today, I’m going to explore the most common changes that befall middle-aged men, why they happen, and what you can do to reduce their impact on your life.

What Tends To Happen To Men At Middle-Age?

They get fat: Middle aged men have higher rates of obesity than any other male age group.

They lose muscle: According to Harvard, after age 30, men begin losing about 3-5% of their muscle every 10 years. I’m a little skeptical of that notion—it sounds like one of those “facts” that people parrot without knowing the provenance—but it’s definitely true that and all else being equal, men lose strength as they age.

They get insulin resistant: Insulin resistance tends to rise with age, though that’s probably more a function of weight gain than chronology.

They have heart trouble: Heart attack, stroke, and heart failure rates go way up in middle aged males. The majority of them occur between the ages of 35 and 64.

They lose energy: While the previous study found that age-related insulin resistance is more a function of age-related weight gain than chronological age itself, it did find that age was a strong predictor of reduced mitochondrial production of ATP.

Their bones get weaker: Middle aged men have a lower risk of osteoporosis than middle aged women, but it’s still an issue.

They suffer mojo deficiency: Getting hard gets harder.

They get anxious: It’s not one of the classic menopausal symptoms, but it’s common. The mid 40s to the early 50s is a strange time for men. There’s a lot at stake. Either you’ve “arrived,” and you’re worried about losing everything, or you’re still drifting, and you’re worried about ever achieving anything. When I was in my mid 40s, it was my anxiety about building a life I was truly proud of that got me to take a big risk and start Primal Nutrition (with almost nothing in the bank and a wife and two kids at home).

Anxiety is there. If you harness and use it as fuel for focus and purpose, anxiety can help you.

They consider suicide: Suicide rate are highest (and still climbing) among middle-aged men.

The good news is that you are not destined to feel these effects. Before I get into that, let’s explore some of the causes of andropause.

What Explains These Age-Related Changes?

What are some causes (because “old age” isn’t a good answer)?

A lot of it comes down to the same things we talk about on this blog all the time.

Bad diets full of processed junk, industrial seed oils, refined carbohydrates, and grains.

Sedentary lifestyles bereft of regular physical activity, intense training, and low-level aerobic work.

Inadequate sleep and dysfunctional circadian rhythms.

And compound interest.

Consider this: If you’re 45 years old and you’ve spent the last twenty years getting 6 hours of sleep a night, sitting for 12 hours a day, and eating fast food five nights a week—all that damage is going to accumulate. Bad sleep compounds. Bad food compounds. A lack of exercise compounds. Part of the whole manopause thing is that middle age is when the body begins to really buckle under the weight of an unhealthy diet and lifestyle.

So, What Can Fix It?

Eat low-carb Primal, maybe even keto. But keep protein relatively high, as it will help you maintain muscle mass and bone density. Also, the older you are, the more protein you need to get the job done.

Lift heavy things twice a week. This will build muscle, strengthen bone, and improve depression.

Move around a lot at a slow pace. Long walks, hikes, easy runs/swims/cycling. Move as much as you can without making it an intense workout.

Sleep 8 hours a night. Start there and titrate up or down depending on your symptoms. But 8 is probably what you’ll need.

What About Testosterone?

Another major issue is low testosterone. As men approach middle-age, the testicles stop producing as much testosterone, and testosterone levels drop. The drop off is more gradual than a woman’s shift into menopause, but it’s a drop nonetheless.

Testosterone plays a mechanistic role in every single one of the symptoms or health conditions I listed above:

It helps you gain and maintain lean muscle mass. Testosterone activates the satellite cells that initiate muscle growth.

It has an inverse correlation with obesity. Replacing low testosterone increases fat loss.

It’s necessary for glucose uptake. For instance, after bariatric surgery, a man’s testosterone and insulin sensitivity are coupled. As the former rises, so does the latter.

It’s inversely correlated with mortality from heart failure and protects against heart attacks.

It’s required for strong bones.

It improves erectile quality and function.

Men with severe depression have lower testosterone, and augmenting testosterone in depressed older men seems to improve the depression.

If you’re suffering from these issues and the healthy diet, exercise, and lifestyle measures aren’t working like they should, talk to your doctor about your testosterone testing and even testosterone replacement therapy Get tested, get your blood work done, and see what’s going on.

Oh, and there’s one more common characteristic among middle aged men that could be causing problems: statins.

The Possible Role Of Statins?

About half of men over the age of 45 are taking statins. Now, I won’t get into the question of whether statins are advisable or even work. I’ve covered that territory before. I suggest you visit those posts. Suffice it to say, it’s a personal decision between you and your doctor based on a number of factors.

That said, statins undoubtedly contribute to many of the negative health effects associated with male menopause. They do, because they’re so good at what they do:

Statins lower cholesterol levels by inhibiting the HMG-CoA reductase, an enzyme that sits upstream of cholesterol synthesis. The problem is that many other important production pathways lie downstream of HMG-CoA reductase, too—not just cholesterol (although that’s also important). When we block HMG-CoA with statins, we impact the production of CoQ10, Vitamin K2, and even testosterone. Why do these compounds matter for middle-aged men?

CoQ10 helps generate ATP to power our cells, tissues, and structures. Deficiencies in CoQ10 have been linked to heart failure and high blood pressure, two common afflictions in male menopause. While supplemental CoQ10 is effective at countering some of the muscle-wasting effects of statins, a man’s ability to convert the inactive ubiquinone form of CoQ10 into the active ubiquinol form drops off around age 40. Go with the latter.

Vitamin K2 is crucial for the maintenance of bone health, insulin sensitivity, and testosterone production.

Testosterone is, well, testosterone. I just explained why it’s so important for middle-aged men.

Statins also make a vital practice for middle-aged men—exercise—harder to follow, less effective, and more dangerous by impairing muscle adaptations to exercise, increasing muscle pain,  increasing the risk of injury, and reducing the amount of ATP your mitochondria are able to generate. All this means that exercise is much less effective and sustainable in men taking statins.

Okay, we’re done. Take a deep breath….

Believe it or not, despite the studies and symptoms and correlations described in today’s post, there is plenty of hope to go around. All is not lost. The day can still be won. Your testicles, however middle-aged they may be, can still produce sperm and testosterone—and you can make the necessary lifestyle modifications to make it happen.

Get to it and good luck, middle-aged brethren.


Karakelides H, Irving BA, Short KR, O’brien P, Nair KS. Age, obesity, and sex effects on insulin sensitivity and skeletal muscle mitochondrial function. Diabetes. 2010;59(1):89-97.

Tuck SP, Francis RM. Testosterone, bone and osteoporosis. Front Horm Res. 2009;37:123-32.

De maddalena C, Vodo S, Petroni A, Aloisi AM. Impact of testosterone on body fat composition. J Cell Physiol. 2012;227(12):3744-8.

Fillo J, Breza J, Ondrusova M, et al. Results of long term testosterone replacement therapy in men with abdominal obesity, erectile dysfunction and testosterone deficiency. Bratisl Lek Listy. 2018;119(9):577-580.

Rao PM, Kelly DM, Jones TH. Testosterone and insulin resistance in the metabolic syndrome and T2DM in men. Nat Rev Endocrinol. 2013;9(8):479-93.

Yoshihisa A, Suzuki S, Sato Y, et al. Relation of Testosterone Levels to Mortality in Men With Heart Failure. Am J Cardiol. 2018;121(11):1321-1327.

Traish AM, Haider A, Haider KS, Doros G, Saad F. Long-Term Testosterone Therapy Improves Cardiometabolic Function and Reduces Risk of Cardiovascular Disease in Men with Hypogonadism: A Real-Life Observational Registry Study Setting Comparing Treated and Untreated (Control) Groups. J Cardiovasc Pharmacol Ther. 2017;22(5):414-433.

Giltay EJ, Van der mast RC, Lauwen E, Heijboer AC, De waal MWM, Comijs HC. Plasma Testosterone and the Course of Major Depressive Disorder in Older Men and Women. Am J Geriatr Psychiatry. 2017;25(4):425-437.

Orengo CA, Fullerton G, Tan R. Male depression: a review of gender concerns and testosterone therapy. Geriatrics. 2004;59(10):24-30.

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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28 thoughts on “Male Menopause: What’s Behind Men’s Midlife Health?”

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  1. So glad to have switched to a Primal lifestyle at 47. At 54, mojo still intact!

    1. I enjoyed the article but I second your motion LOL, I would love to see Mark address the issue of prostate health. Not the “sexiest” of topics, but a pretty important male health topic none-the-less.

      1. Prostate health has been on my mind for a while now, Chris et al. Thanks for the nudge, and look for a feature on it in the coming weeks.

  2. I think the decline of glucose tolerance for humans at about age 40 is not caused by obesity. It is because many of the adaptations to an agricultural diet are expressed genetically as elements of the childhood/young adult development and reproductive genetics, and after these traits play out, our metabolisms revert to the “we basically eat the fat from giant herbivores” metabolism that doesn’t coexist well with an agricultural lifestyle.

    1. Makes sense. Adaptation should be fastest for the prime reproductive years — after all if not then when.

      You are not going to do it later if you are incapable then.

      My tai–Chi teacher said “You may be able to do as much later in life as younger, if you remain in Principle.

  3. Great article! Thanks to reading Mark’s web stuff I’ve been doing most of what he suggests in the “So, What Can Fix It?” section since I was 52-53… & I’m 59 now & feel great! Better than when I was 40. Almost as good as 30!

    One problem is the sleep thing… I’ve never been able to get 8 hours. 7 if I’m lucky, & wake often. Hip/lower back pain will usually wake me up along with visits to the restroom. I suppose I should just keep looking for solutions.

    1. Matthew Walker is a sleep researcher at UC Berkeley, I’ve attended a lecture of his in San Fran and listened to him on a Joe Rogan podcast. His info on sleep and the costs of sleep debt will scare the ?out of you but it’s great motivation to get the best out of your rest

      1. Yes, I’ve heard Matthew Walker multiple times on NPR, plus Hidden Brain & Fresh Air. Thanks for the suggestion, maybe I should buy his book.

      2. We are all different. I’ve tracked my sleep cycles with a FitbIt for 4 years and wake refreshed without an alarm clock and my consistent sleep cycle is almost exactly 6 hours. If I sleep less, I do usually need more and if I sleep more, I feel groggy that day and it disrupts my next sleep cycle to where I may then only get 5 hours of so the next night to reset my internal clock.
        Eight may be a good starting point for most, but some of us need more and others just need less. The sleep studies may represent the norm, but I guarantee that 8 hours would reduce my abilities to perform any tests one would choose to give me and 6 or so would improve them.

    2. Hi Joe
      try Trigger Point Therapy for hip lower back pain, self diagnose and self treat. Or get your massage therapist to help.
      I am the same with sleep now but for other reasons.
      Good luck.

      1. Thanks Grack. I think I need to find a therapist that is skilled at Trigger Point Therapy. I’ve tried almost everything so it can’t hurt. Degenerative disk plus some arthritis in my hip.

  4. Come on man, you missed the one thing you’ve been advocating much as of late. IF, or periodic fasts, since adding them to my repertoire I’m putting on lean muscle w/o any exercise. The key is to stay fat adapted.

  5. Great read! The only thing I wasn’t a fan of was how it made me realize that I’m suddenly only two short years away from 40! Glad I got a head start on this 6 years ago!

  6. Testosterone replacement? Unlike hormones for women it is a far-more controlled drug because, after all, it is poison. If a woman wants hormones folks will fall over to provide them. If a man wants said there are rules and requirements and god help you if your doctor is female. They have no ^%$#@! sympathy or empathy at all.

    1. Yes, it can be difficult if you don’t have the resources & can’t change doctors easily. Plus the COST! $500 a month for Androgel. Compounded creams would cost 80% less but good luck getting it covered. It’s insane for a substance that exists in nature.

  7. Hey Mark I read some time ago that sleep cycles are 90 min so waking up after 8 will be harder since it’s mid cycle than 7.5 hours which would 3 full cycles

  8. Hey Mark,
    I’ve heard others mention HIIT as a must for older guys.
    You failed to mention it in the how to fix it section and I was wondering if that was intentional or just an oversight. Thoughts?

  9. The best natural way to keep T up, or increase it is sex. The winner thing. Of course, if you can’t get it up easily, or you and your partner just aren’t into each other much anymore, it’s a rather circular gotcha. And masturbation doesn’t do it, it has to be the real deal. In fact, ejaculation isn’t even needed, just that time spent doing duh deed.

    Last fall I got into relationship with a perimenopausal woman, just spotting for seven months. I’d not been in a reliable sexual life for many, many years; I’m 72 and K is 52. Like most new relationships, sex was as close to 24/7 as we could make it.

    Well, whaddya know. Six weeks after we met, she had a full blown period. And they continued until things fell apart for us. About the same time she noticed that I looked younger. A mirror examination showed that was true; muscles that had been wasting were filling back out.

    Now, four months later, I can see the reversion taking place, and the, uh, symptom of lower testosterone.

    Oh, yes, the matter of masturbation not cutting it is in “the literature.” It’s been examined. Probably because you feel more like a loser than a winner! Ha ha…………

  10. I think this is probably one of the most important articles you have written, Mark. I will share it with my husband and sons.

    The only thing I would add is the importance of getting enough sunlight– something I learned from you!

  11. This article = me. I’m 45 and have aged TEN YEARS in the last 2. Taking swellfies one day, then BOOM, taking Prilosec and Ambien the next… Wondering just who the hell this sunken-eyed, moob-chested, bony-armed, fat-bellied, gray-haired, nervous, pasty excuse for a man(?) in the mirror is!?!? Honest to God. It’s like a horrific After-and-Before.

    I’ve recently given up caffeine and chocolate (i.e. my primary sources of energy and joy), since they “aggravate my GERD”…the doctors *think*.?. I eat ridiculous amounts of sugar (mostly to find gratification in SOMETHING!) I haven’t had sex in years (wife’s been through cancer and menopause), and I’ve lost the drive to work out entirely. I’ve worked a job and a half for 15 years, and I *do* make good money, but I’ve also got three other families outside of my own that depend on me, so I can’t enjoy it for fear of losing it…

    Mostly, I could NOT be. more. miserable… Something’s gotta give.

    I’m Desperate.

    1. P., I hope you can find a good Primal health coach. You could feel so much better with just a few changes! And if that’s not financially feasible, maybe find a fellow middle-aged friend who’s feeling similar things, with whom to partner, and agree to help each other. If you can’t work out, start with morning walks; it will help your sleep, among other things. Prilosec is worse for GERD than is chocolate or coffee. Read about it and all the negative effects of lowering stomach acid. And Ambien is a nightmare. Check out Doc Parsley’s sleep remedy. Ditch the sugar, and lots of things will get better. Good luck!

    2. I was prescribed Prilosec (Omeprezole) and Famotadine and by a doctor at age 57 after a diagnosis of Barret’s Esophagus. I asked him how long I would need to take these and he told me for the rest of my life! Clearly I had reflux issues but the antacids were severely reducing stomach acid and if I forgot one the heartburn amped up to an outrageous level. After reading about the effects of Omeprazole I decided to wean myself off of it and take DGL and Rolaids instead. It was hell at first, the acid rebound is awful. But I realized that the GERD was primarily at night so I bought a 7″ foam wedge from Amazon and acclimated to sleeping elevated on it every night. Worked like a charm, although it took some months to eliminate the symptoms completely. I kept a jar of Rolaids bedside and whenever I woke up with a taste of acid I would eat one or two and go back to sleep. Gradually it got better and better and I have long since ceased to use DGL and rarely need a Rolaids anymore. I drink coffee and eat salsa and hot sauces etc with no problem. The mere act elevating my upper body kept the acid from refluxing up and further damaging the esophageal sphincter. It is my impression that the sphincter has probably healed over the succeeding years as the GERD has become close to non existent. I am turning 64 this month and am so glad I didn’t listen to that doctor.

    3. Have you tried melatonin for sleep aid? I have used it nightly for the last 5-6 years and I sleep better than ever even though nowadays I wake up twice a night to urinate.
      I like Natrol Calm Sleep fast dissolve strawberry flavor 6mg melatonin with 25mg L-theanine. Keep it by the bedside, after I urinate if I feel very awake I take one and it helps to get bck to sleep and the L-theanine helps to go into a deep sleep for hours. These are effective even though at that point I have already slept 3 or 4 hours and would have difficulty going back to sleep without them. I also keep the Natrol 3mg fast dissolves as well, that is plenty for helping get to sleep initially at bedtime although.

      Melatonin has no downside as far as I can tell and it has been great for me.

    4. Look into Adrenal Fatique by Dr. Eric Berg.

      I’ve been primal for 8 years and even Keto (lost hair on that one) and felt okay but never in superior health…until I started watching some of Dr. Berg’s videos.
      Most of the ‘meno/andropausal’ symptoms are NOT normal and have everything to do with your Adrenal glands which sit on top of your kidneys.
      Also check out his videos on the gallbladder !

      Please do !!! You won’t regret it 🙂

  12. And keep estrogen et al. levels in check. I’ve heard that DIM and choline are helpful here.