What Is Andropause? The Mental Health Side No One Mentions
Most men have never heard the word “andropause.” And that’s part of the problem.
Women have menopause — a well-known, widely discussed biological transition with its own medical specialty, support communities, and growing cultural awareness. Men have… very little. A vague sense that things change as you get older, maybe a passing reference to “low T” in a late-night commercial, and not much else.
But the biological reality is that men go through their own hormonal transition at midlife. It’s slower and more gradual than menopause, which is part of why it’s so easy to miss. And its effects on mental health are significant, under-recognized, and almost never addressed in therapy.
What Andropause Actually Is
Andropause refers to the gradual decline in testosterone and other androgens that begins around age 30 and accelerates through the 40s and 50s. Unlike menopause — which involves a relatively rapid drop in estrogen over a period of years — andropause is a slow, incremental process. Testosterone levels typically decrease about 1–2% per year, which means the changes accumulate so gradually that most men don’t notice a clear “before and after.”
Instead, they notice symptoms: less energy, less motivation, less mental clarity, less interest in things they used to enjoy. Sleep gets worse. Recovery from exercise takes longer. The drive that used to feel automatic now requires conscious effort.
Many men chalk this up to aging, stress, or simply “how things are now.” And while aging and stress are certainly factors, the hormonal dimension is often a meaningful contributor that goes completely unexamined.
The Mental Health Effects of Andropause
Testosterone doesn’t just affect libido and muscle mass. It plays a role in mood regulation, cognitive function, sleep architecture, and emotional resilience. When levels decline, the psychological effects can be substantial:
Depression and Low Mood
The relationship between low testosterone and depression is well-documented, though the clinical picture is more nuanced than popular media suggests. Declining testosterone can contribute to reduced motivation, persistent low mood, and a diminished capacity for pleasure — the clinical term is anhedonia. For many men, this manifests not as crying or visible sadness, but as a flatness or emotional numbness that’s difficult to articulate.
The Endocrine Society’s 2018 Clinical Practice Guideline addresses this directly: testosterone therapy can improve mood modestly, but it does not treat clinical depression. However, research has found an association between low testosterone and late-onset, low-grade persistent depressive disorder (what used to be called dysthymia) — a chronic, simmering low mood that falls below the threshold of major depression but still erodes quality of life. There is limited evidence that testosterone replacement may improve this type of depressive symptom in men who also have confirmed low testosterone levels.
This distinction matters: if you’re experiencing major depression, testosterone is not the treatment. But if you’re experiencing a chronic, low-grade heaviness — that persistent “blah” — alongside other signs of low testosterone, addressing the hormonal component may be part of the picture. It’s not either/or. It’s often both.
Anxiety and Irritability
Hormonal shifts can increase vulnerability to anxiety — the free-floating, hard-to-pin-down kind that makes you feel on edge without a clear reason. Irritability often accompanies this, creating a pattern where you’re simultaneously anxious and short-tempered, which can be confusing for both you and the people around you.
Cognitive Changes
Difficulty concentrating, mental fog, trouble finding words, and a general sense that your brain isn’t as sharp as it used to be. Research on the cognitive effects of andropause is still developing, but many men report these changes and find them distressing — particularly in demanding professional roles where cognitive performance is central to identity.
Sleep Disruption
Testosterone plays a role in sleep quality, and declining levels can contribute to difficulty falling asleep, staying asleep, or feeling rested upon waking. Poor sleep, in turn, worsens mood, cognitive function, and emotional regulation — creating a cycle that’s difficult to break without addressing multiple factors simultaneously.
Loss of Confidence and Identity
For men who have built their self-concept around strength, capability, and drive, the subtle erosion of these qualities can feel deeply destabilizing. The result isn’t always dramatic — it’s often a quiet loss of confidence, a growing sense of self-doubt, a feeling of being diminished in ways that are hard to name.
Should You Get Your Testosterone Checked? What the Guidelines Actually Say
There’s a lot of noise around testosterone testing — from “low T” clinics marketing aggressively to men who may not need treatment, to physicians who dismiss symptoms without ever ordering a lab panel. The clinical guidelines offer a clearer, evidence-based framework.
Who Should Be Tested
Neither the Endocrine Society nor the American Urological Association (AUA) recommends routine testosterone screening of all men. Instead, both guidelines recommend testing men who present with symptoms consistent with testosterone deficiency. These symptoms include reduced sexual desire, erectile dysfunction, fatigue, depressed mood, difficulty concentrating, sleep disturbance, decreased energy, and diminished physical performance.
The AUA guideline adds that testosterone should also be measured in men with conditions associated with higher risk of low testosterone — even if they don’t have obvious symptoms. This includes men with type 2 diabetes, obesity, HIV, chronic opioid use, and certain pituitary conditions. The American Association of Clinical Endocrinologists specifically recommends that men with type 2 diabetes be evaluated for testosterone deficiency.
How Testing Should Be Done
Both the Endocrine Society and the AUA agree on testing protocol. The initial test should be a fasting morning total testosterone level, drawn using an accurate assay. Morning matters — testosterone levels fluctuate throughout the day and are highest in the morning. Fasting matters because food intake can lower measured levels.
Critically, the diagnosis requires two separate low readings, not just one. A single low result needs to be confirmed with a repeat measurement on a different day. This prevents treatment based on a transient dip caused by illness, poor sleep, stress, or normal biological variation.
In men whose total testosterone is near the lower limit of normal, or who have conditions that affect sex hormone–binding globulin (SHBG) — such as obesity, aging, or thyroid disease — the Endocrine Society recommends also measuring free testosterone levels for a more accurate picture.
What Counts as “Low”
This is where professional organizations diverge somewhat. The AUA uses a threshold of 300 ng/dL, while the Endocrine Society uses a slightly lower threshold of 264 ng/dL (harmonized to the CDC standard in healthy young men). Other international bodies propose thresholds ranging from 200 to 350 ng/dL.
The important takeaway: “low” is not defined by a single universal number, and a testosterone level that is technically within the reference range can still be clinically significant if it’s accompanied by symptoms. This is why the guidelines consistently emphasize that diagnosis requires both confirmed low levels and consistent symptoms — not either one alone.
What About Treatment? What the Evidence Shows
If testing confirms low testosterone in the context of appropriate symptoms, testosterone replacement therapy (TRT) is one treatment option — but it comes with important considerations.
What TRT Can Help With
The TRAVERSE trial — published in the New England Journal of Medicine in 2023, the largest randomized controlled trial of testosterone therapy to date, enrolling over 5,200 men — found that TRT improved sexual desire and activity, depressive symptoms, and anemia in men with confirmed hypogonadism. An earlier set of coordinated trials known as the Testosterone Trials (TTrials) found similar benefits for libido and sexual function, with modest improvements in mood.
Cardiovascular Safety: The Question That Held the Field Back
For years, concerns about cardiovascular risk made many physicians hesitant to prescribe TRT. The TRAVERSE trial was specifically designed to answer this question. The result: testosterone replacement therapy was noninferior to placebo for major adverse cardiac events — meaning it did not increase the risk of heart attack, stroke, or cardiovascular death in men with confirmed hypogonadism and preexisting or high cardiovascular risk.
A 2025 position statement from the European Expert Panel for Testosterone Research confirmed this finding, concluding that TRT, when prescribed to appropriately selected and monitored patients, is safe from a cardiovascular standpoint.
However, the trial did find a higher incidence of nonfatal arrhythmias (including atrial fibrillation) and acute kidney injury in the testosterone group, so ongoing medical monitoring remains essential. The investigators were also clear that these safety findings apply only to men with documented hypogonadism, not to men without clinical indications who seek testosterone through commercial “low T” clinics.
Important Contraindications
The Endocrine Society recommends against TRT in men who are planning to conceive in the near term (exogenous testosterone suppresses sperm production), men with breast or prostate cancer, men with elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, or those who have had a heart attack or stroke within the last six months.
The AUA guideline also notes that, contrary to longstanding fears, there is no evidence linking testosterone therapy to the development of prostate cancer — though prostate monitoring is still recommended for men over 55 who begin treatment.
What TRT Does Not Do
This is the point that gets lost in the marketing: testosterone therapy does not treat clinical depression. The Endocrine Society is explicit about this. While TRT may modestly improve mood and may help with chronic low-grade depressive symptoms in men with confirmed low testosterone, it is not a substitute for psychotherapy or psychiatric treatment of major depressive disorder.
Similarly, TRT does not address the psychological, relational, and existential dimensions of midlife distress — the identity questions, the grief, the relationship disconnection, the loss of purpose. These require a different kind of work.
A Biopsychosocial Approach: Why Both Matter
Here’s what I believe matters most, and what distinguishes my approach: andropause is real, and it’s not the whole story.
The mistake some providers make is reducing everything to hormones — “your testosterone is low, here’s a prescription.” The other mistake — equally common — is ignoring the biology entirely and treating midlife distress as purely psychological.
Neither approach serves men well. What works is an integrated, biopsychosocial lens that considers all three dimensions: what’s happening in your body (hormonal changes, sleep, physical health), what’s happening in your mind (thought patterns, emotional processing, identity), and what’s happening in your world (relationships, career, losses, role transitions).
As one of the few psychologists who also holds certification through the Menopause Society (MSCP), I bring an understanding of hormonal transitions across the lifespan that most therapists simply don’t have. I can help you make sense of the biological dimension without reducing your experience to it — and I can coordinate with your physician when medical evaluation is warranted.
Practical Next Steps
If you suspect andropause may be playing a role in what you’re experiencing:
Talk to your physician about testing. Request a fasting morning total testosterone level. If it comes back low, ask for a repeat test on a separate day. If your total testosterone is borderline or you have conditions that affect SHBG, ask about free testosterone as well. A comprehensive panel — not just total testosterone — gives a clearer clinical picture.
Address the modifiable factors. Regular resistance training, adequate sleep, stress management, and balanced nutrition all support hormonal health and have direct mental health benefits. These aren’t substitutes for treatment, but they’re foundational.
Don’t stop at the blood work. Even if your testosterone is low and your physician recommends treatment, the psychological, relational, and identity dimensions of midlife still need attention. Therapy can help you develop strategies for managing the mood, cognitive, and identity challenges that accompany this transition — and can prevent these challenges from cascading into clinical depression, substance use, or relationship breakdown.
Be wary of oversimplification. If a provider tells you testosterone will “fix” your depression, mood, or marriage, seek a second opinion. If a provider dismisses your symptoms entirely without testing, do the same. The best care lives in the middle: thorough evaluation, evidence-based treatment, and attention to the whole person.
→ Learn more about my approach to men’s midlife mental health
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Dr. Julie Rashkis, Psy.D., MSCP — Licensed Psychologist & Menopause Society Certified Practitioner. Virtual therapy for midlife, available across PSYPACT states.
Clinical Guidelines & Research Referenced in This Article
Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744.
Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200(2):423–432.
Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy (TRAVERSE Trial). N Engl J Med. 2023;389(2):107–117.
Zitzmann M, et al. Cardiovascular Safety of Testosterone Therapy — Insights from the TRAVERSE Trial and Beyond: A Position Statement of the European Expert Panel for Testosterone Research. Andrology. 2025.
Walia R. Testosterone Replacement, Where Are We in 2025? Trends in Urology & Men’s Health. 2025.
