Andropause or male menopause reviewed, and the link to impotence and erectile dysfunction explored. The use of  Viagra explained. The male menopause and the mid-life crisis. Testosterone replacement therapy.

Andropause or Male Menopause & The Mid-Life Crisis

Does this sound familiar?

The typical story is of a middle age man who gradually loses his drive, strength, energy and enthusiasm for life and love. Action man has become inaction man. An all-enveloping mental and physical tiredness descends on him, often for no apparent reason. He changes from being a positive, bullish person who it is good to be around to a negative, pessimistic, depressed bear with a sore head and it is increasingly difficult to live or work with him. At work he is seen to have 'gone off the boil' and no amount of encouragement or urging will improve his performance.  At home, family relations tend to become increasingly strained, and social life and activities dwindle and wilt. His sexual life is usually a disaster area, with loss of libido and intermittent failure to achieve an erection leading to performance anxiety and eventually complete impotence. This creates a downward spiral of failing function both in bedroom and boardroom. (Dr Malcolm Carruthers,  Maximizing Manhood, page ix.) 

Or this? A personal account of the andropause

You know if it's happening to you

I want to stop at this point in the personal story and consider some wider issues. But if you want to know what happened to the man above, whom I interviewed personally after advertising for men who had gone through the male menopause or andropause, as it tends to be known in Europe, don't worry, we will return to his story later. (By the way, there is a link to order all the books mentioned on this page further down the page, which may be helpful if you want more information.)

And so, at this point we enter a field full of fragmented opinions. You need to know that I have no doubt about the existence of two separate male challenges that can occur in men (but may not do so) between the ages of about forty (occasionally earlier) and fifty-five, say. These are the mid-life crisis and the male menopause, also called the andropause or viropause. They are not concepts that have found universal acceptance. But I believe that to dismiss not only a weight of experience from men who have gone through what can be profound and agonizing crises, but also firm scientific evidence from the few doctors who have specialized in the field is ridiculous. The male-mid life crisis is essentially emotional in nature; the andropause has a basis in falling hormone levels, and in that sense at least is physical, although the consequences of changes in hormone levels are not just physical. The two are not independent of each other, as we shall see. If you aren't having a mid-life crisis, but you are feeling sexually less confident than before, you might want to skip the next section, and go straight to the words - by clicking here - on the andropause. 

Just what is a mid-life crisis?

I hope I won't be contradicted when I say that even if you aren't a developmental psychologist, it is intuitively obvious that a change from one phase of life to another has to be accompanied by psychological adjustment and a reassessment of one's identity. For example, over the years the women's movement has focused on the psychological changes that women have to go through around the time of their menopause. For women, the transition from the child-bearing years to the post-child-bearing years must be a profound experience. Before the menopause,  a major element of a woman's sense of identity is her fertility, her menstruation, her ability to give life and birth to new people; after it, she has to redefine her sense of self to accommodate the knowledge that she will not - oddities of IVF apart - be able to fulfill these roles, nor have the evidence of her fertility that the monthly bleeding represents. Whatever psychological changes are involved in this are expected, tend to be discussed somewhat openly with older women and contemporaries, and are acknowledged as a reality. Could there be analogous processes for men?  My view is very much so, and in what follows, I depend for much of my writing on the work of Dr Malcolm Carruthers, Dr Eugene Shippen, and Jed Diamond, who have all studied the crises to which masculinity is subject in great detail. There are  references to their work below, if you want more information. 

So what about men in modern society? Do we have a similar transition? You might feel that the answer has to be "no" if the implication of women's experience is that their transition is promoted by the changes in the female hormonal system. And yet, and yet, and yet......consider the following synopses of the dilemma of the middle-aged man:

The hormone production levels are dropping, the head is balding, the sexual vigor is diminishing, the stress is unending, the children are leaving, the parents are dying, the job horizons are narrowing, the friends are having their first heart attack; the past floats by in a fog of hopes not realized, opportunities not grasped, women not bedded, potential not fulfilled, and the future is a confrontation with one's own mortality. (Theories of the Male Mid-life Crisis, Counselling Psychologist, 1976, Vol 6, 2-9).

"Sometimes I feel time is running out," says Jack wistfully. "I'm feeling 'last chance' anxiety about my being able to find work that is creative, life goals that are satisfying, and a sex life that I can live with." (The Male Menopause, Jed Diamond, p37.)

"Men are constantly defining themselves through their force and power. It's all physical. There is little understanding of spiritual power. It's very rare to meet the male that understands the power of the spirit...and if that's all you have, and you start to feel your power easing away, as you do in middle-age, if you don't have another force, you're going to feel a great loss. It would be healthy if men had a vehicle for expressing that loss..." (as above, p 41.)

Dr Malcolm Carruthers - who has worked with thousands of male patients in his London clinic - takes the view that the male mid-life crisis is essentially emotional in origin but if severe enough or long enough may have physical consequences, especially if alcohol or drugs are used to blunt the pain of the crisis. Typically, he says, the age group most prone to the crisis is around 40, mainly between 35 and 45, which is earlier than the andropause, which usually starts around the age of 50, say 45 to 55.  Dr Carruthers suggests that many mid-life crises go unnoticed and are passed off as the effects of a change of job, a change of house, or a change of spouse. Only occasionally does the drama turn into a full-blown existential crisis in which the man may feel he is stuck in a career which under- or over-extends him, producing the prospect of burn-out; or in a dead  marriage or relationship which gives him the choice of divorce or separation and its consequent traumas, financial ruin, and starting over again. He also lists a number of factors that seem to predispose men to a traumatic mid-life crisis - in essence, these are things that destabilize him from childhood onwards: being born with a sensitive nature, distant or unloving parents, the loss of a parent, especially the father (which I would interpret as meaning either emotional loss or a physical loss, since many fathers are physically present but emotionally absent), loss or separation from a loved one or role model, and repeated failure or, paradoxically, repeated success in his career.

There is an intuitive sense in which one can see how a man could come to a point where the stress of life, baggaged on top of these unstable foundations and a life lived without emotional certainty or stability, could cause a breakdown in mid-life: and so, though it takes us some time, we get there at last: we find ourselves in the midst of the mid-life crisis. It is all about dissatisfaction with oneself, and what one has achieved, or, to put it another way, the sense that life has not dealt the cards fairly, and somehow the winning hand has eluded one - all the way through the game. To make this worse, the things that have kept one going - job, friends, family, social structure, drive for goals, sporting activities, minor or major achievements, sex, a sense of being masculine, a feeling of being important, if only in some minor way, in the world one has created - may suddenly or gradually be exposed as insubstantial, insignificant, and unimportant in the face of issues of life and death. (What, one friend said to me, will be my memorial on Earth? Who will remember me, and for what? I had no answer for him, for his question struck a deep dark chord with me.)

Sometimes the things that kept one going are simply not there: the friends move away, the children grow up, leave home and don't visit, the aged parents die, and your body can't keep up with the younger men in sport anymore. It is not surprising that escapist behavior might seem to be the solution: changing job, changing house, changing partner, changing lifestyle, getting the motorbike before it really is too late......... 

And the answers to the mid-life crisis?

There are solutions. Some men don't experience much of a crisis anyway, they just continue living through the first part of their life and into the second. Others go through a period of great turbulence but then are redeemed and find a new course and approach for the second passage of their lives. This may involve a new set of challenges, a new direction, or a coming to terms with what they have got. Often the new paths are more spiritual and less driven than those of their youth. But a few may succumb to disaster in the form of drug, alcohol and sexual addiction, or spend the rest of their lives drifting around aimlessly in a state of depression.    Yes, I know, I've been there, and I know men who are currently there, in this "dark night of the soul". Here is the advice which Malcolm Carruthers offers, a précis of what he says in his book.

First, decide where you want to go: make a map. Decide on your priorities and whether or not scaling a second set of peaks, so to speak, in the second half of your life is important for you. You might prefer to stay in the valley, and live a comfortable life?

Second, assess realistically the resources that you have available to you for this journey. These are not just tangible assets like wealth and health, but emotional resources like the support of your friends and family. Would the assistance of a counselor or psychotherapist be of any use to you? Can you identify your weaknesses and decide what to do about them? The underpinning principle needs to be one of realism but optimism, guided by a map of the journey.

I feel the importance of therapy shouldn't be underestimated. The problem, of course, is finding a therapist who is good, mature, or wise enough to help in the transition from one side of the crisis to the other. But they are out there, and they can ease the pain and provide support. It might follow that you would want to see a male therapist since this issue at least is one that a male might be better qualified to understand. With or without therapy, there is no doubt that for men who have a crisis, it can be no laughing matter, for it often seems to be based on unsolved issues from the past that cause self-doubt about the present and fear of what the future holds. Jed Diamond has much to say about the nature of the changes that men go through as they approach and pass through the mid-life stage. He emphasizes the need to come to terms with the changes that we face, and quotes Dr Harry Wilmer: "The mid-life crisis, even when it brings on depression, despair, anxiety or fear, is a time of great challenge, out of which come symbols of transformation." And he quotes Mark Gerzon, author of Listening to Midlife: "As we age, we human beings yearn for wholeness. We yearn for parts of ourselves that have been in the dark to find sunlight, and those that were sunburned to find shade. We yearn for the parts that have been underdeveloped to grow, and those that were overdeveloped to be pruned. We yearn for the parts that have been silent to speak, and those that were noisy to be still. We yearn for the parts that have been alone to find companionship, and those that have been overcrowded to find solitude." He sums it up thus: "We yearn to live our unlived lives." How true. What can I say for you, now, that will help you to find a way through? 

You might want to enroll in a men's group, and experience the support of other men for your masculinity and maleness, for a sad thing is that men's sense of self-worth seems challenged on every front in our society. Of course, as a man you may have some inhibition against speaking in an intimate way with other men; and this could present a challenge to dealing with the issues you face. Perhaps seeing a counselor or therapist would help here. If this seems like too big a challenge, you might want to buy relevant books and gain a sense of not being alone in what you're experiencing. You might like to look at some of the internet web-sites listed below, which present a male perspective on these issues, and in some sense form a community of supportive peers. Even if your problems are not entirely sexual, you could look at some of the alt.newsgroups on the web (see links below) where you can feel part of a very supportive community of men without the difficulty of speaking face to face. And, perhaps most surprisingly of all, you could engage in an intimate dialogue with your partner about the difficulties you are facing, whether gay or straight. I think many men probably have little understanding of the depth of support an intimate relationship with a partner can offer, because we are so conditioned not to open up. Take a risk! 

Andropause

Just what is the andropause?

It is the effect of an inadequate supply of male hormones in a man's body, an inadequacy which can develop for a variety of reasons as he gets older, and which produces a profound and widespread range of symptoms.  I quote again from Malcolm Carruthers:

Its often insidious onset can be at any time from the age of 30 onwards, though typically it is in the fifties. One of the reasons it's often missed is that it is usually more gradual in onset than the menopause in the female...it is a crisis of vitality just as much as virility, even though its most obvious sign is loss of both interest in sex and of erectile power. This change is surprisingly often overlooked or ignored, either because the man is so pressurized by the rest of his life that he assumes it is an inevitable part of growing older or because his sexual partner has lost interest as well. Besides lack of sex drive, there is often loss of drive in professional or business life...also often fatigue, lethargy, exhaustion and depression, with a sense of hopelessness and helplessness. All too often men change their jobs or their women - anything to ease the malaise they feel - usually with little relief....Physically, there is often stiffness and pain in the muscles and joints or symptoms of gout and a rapidly deteriorating level of fitness. There may also be signs of accelerated ageing of the heart and circulation. (Maximizing Manhood, p 39 -40)

The andropause is the explanation of why the vitality and virility of millions of men has faded in middle age or later. It is the explanation of much misery, depression and unhappiness, loss of sexual performance, failing lives, failing health and failing relationships, and above all, it is the cause of impotence and loss of sexual function. But it would be a mistake to see this as merely a sexual issue. Consider the hormone testosterone. It permeates every aspect of the male body, every nerve, every muscle fiber, every brain cell. It is responsible for the development of the male body from the androgynous embryo, which will otherwise develop into the female form. If the testosterone receptors in the fetus are not working, or insensitive to the hormone, the development of the normal features of the male body will be incomplete or abnormal, or an intersex human will grow. If the hormone doesn't make its reappearance at the time of puberty, the male body will not develop secondary sexual characteristics such as a larger penis, beard and body hair, a deeper voice, and a male sexual drive. If the hormone doesn't flow around a boy's bloodstream adequately, his musculature will fail to develop as it should. Only the presence of testosterone in his blood will let him know of his maleness through spontaneous erections, either at night or during the day, and that classic male pre-occupation with sexy thoughts, feelings and images which interrupt a man's more practical thoughts in the way that we are so used to. Moreover, if testosterone doesn't act on a man's brain cells, he will lack drive and ambition, and take fewer risks.  Now, what do you think will happen if a man's testosterone levels start to fall at some point in his middle years? Will the areas of the body whose metabolism is so dependent on testosterone remain fully and effectively functional? It hardly seems likely, does it? 

There's no doubt that man's sexuality changes as he ages. Think of the randiness of the eighteen year-old, usually ready for sex whenever, wherever - sometimes inconveniently, as erections spring upon him unannounced and uninvited. (Well, it was never quite as dramatic as that for me, but you know what I mean, I'm sure.) By the time he's forty, this randiness may well have vanished, and spontaneous erections are but a distant memory. He may still be arousable in sexual situations, but his erection will take longer to get hard, and he will ejaculate more weakly, and his refractory period will be longer (which means he can't come three times in an hour or eight times in a day). He may secretly want hugs and cuddles more than sex, but he may be afraid to say so. Is all this a natural process? Is it because his brain has had enough of sex? Or is it because of the stress she faces in his life and work? Or is it because of something else, like falling testosterone levels? In other words, because of the andropause?

Symptoms of the Andropause

Many of the effects of growing older have been accepted as an inevitable part of the ageing process. I know that this sounds like a circularity, but it hides an interesting paradox. If the decline in our functions can be halted by the administration of the hormones which decline as we age, is that ageing process a natural one? On the face of it, the answer is one that has been given by many physicians over the years to their patients; it's inevitable, and you must just learn to live with it. But just suppose for a minute that the decline in hormones that may occur with age, and the consequences of such decline, are reversible. In biological terms this would not be too surprising - man did not evolve in an environment where he was likely to survive beyond what we now see as middle age. It may be that his systems, his physiology, his hormones, all evolved to cover a lifespan much shorter than the one we have now. If that were so, would that fact alone mean it was unjustified to administer hormones in such a way that the youthful levels in a man's system were restored? Whatever you think the answer to that question may be, where does that leave the men who are experiencing any or all of the following symptoms because of the decline in their hormonal levels?

Sleeplessness and/or fatigue - a pronounced drop in energy levels, leading to a state where a man falls asleep on the sofa every night, or even has to go and lie down for a nap in the afternoon.

Lack of masculine power - a subjective term, I know, but one quite resonant with the experience of many men I spoke to with the condition. It would be manifested by signs such as a non-upright stance, lack - or perhaps more accurately loss - of confidence,  slouchy posture, wavering voice pitch and an air of weakness. Other signs might be a loss of interest in completing projects, coming up with new ideas, and a reduced desire to compete with other men.

Depression - maybe more than any other symptom, this seems to be the one which occurs again and again. Depression is a bad experience at any time in life, with its tendency to demotivate and de-energize the person who experiences it. But when a man in mid-life succumbs to its black grip, he is in an unhappy situation, for he is deprived of the motivation he needs to change his situation. The danger seems to be that this depression is regarded as a "conventional" emotional problem, a reactive depression, a response to life events, when in fact it may be the direct result of changing brain biochemistry due to a decrease in testosterone levels. 

Nervousness, anxiety and irritability - I remember that one of my interviewees said that he had been accused by a (female) boss of being "far worse to work with than any woman", a distressing and, he felt, somewhat insulting comment, but one which he subsequently admitted had given him an insight into the uncontrollable nature of PMS for many women. Such moodiness and irritability is of course no laughing matter for the man concerned, his subordinates, colleagues or family, especially if it is completely out of line with his previous character. 

Reduced libido - a very distressing symptom for men and for their partners, if they have one. It comes on gradually over a period of months or years, and affects a man's sexuality in every way. One man I spoke to said that he knew he had a problem when he realized that "he didn't care if he never had sex again". Men report an absence of sexual thoughts, feelings and behavior, with no fantasy or sexual responsiveness. One man said that while he still looked at women appreciatively, it was almost as if he couldn't remember why he was looking at them - he could appreciate their beauty in a kind of distant, almost non-sexual way, but there was no sense of lust or sexuality about it.

Reduced potency and/or penis size - reduced potency means a reduced ability to achieve an erection, and to keep it once achieved. The significance of erections for men is so profound and fundamental to our sense of masculine well-being that it is taken for granted. After all, waking with a morning erection is a good feeling, and gives one a sense of pride, a reassurance in one's fecundity and sexual power. What does it signify, then, when morning erections are absent? And what if no erections occur during the night? This is a classic test for the nature of impotence - if night-time erections occur, then impotence at other times is psychological. But the man who has no erections at all senses that he is not a real man in some fundamental way any longer. Worse, perhaps, is the man who reports reduced penile size, especially when erect, for this is a blow to his sense of self in a way like no other.

Decreased ejaculatory force and volume - which really speak for themselves, and both serve to diminish a man's sexual pleasure and his sense of masculinity. The cause lies in the weakening of the muscles of the ejaculation mechanism, which have a very high concentration of testosterone receptors. 

Hot flushes or "flashes", blushing and sweating -  redness of the face and neck can be a major problem, since it affects the most visible areas of the body, and signals some message about your emotional state to the people around you which might not be accurate. The night sweats can leave sheets, bed, and the man concerned so wet that the sheets need to be washed each day. 

Aches and pains - a problem which I can testify to from my own experience. Getting out of bed in the morning became something of a challenge, and the first few shuffling steps were a real challenge. My lower back ached painfully, which always seemed strange after a night's rest (not that the nights were that restful, really), and I had diffuse and non-specific joint pain. At the time I was very reluctant to go and see a doctor because I thought I might seem hypochondriacal, and, in what I suppose I thought was a manly fashion, decided to put up with the problem. Not, as it turned out, a sensible decision. There was never any guarantee that my family doctor would have recognized the symptoms for what they were, but at least I would have had more chance of finding out the truth sooner than I did!

Bone deterioration - in advanced or prolonged cases of testosterone deficiency, osteoporosis can set in. The consequences of this can obviously be very severe for the older man.

Hair and skin - the wrinkly, dry skin which may develop in an andropausal man is due to the lack of sebum in his sebaceous glands, which would normally be stimulated by the testosterone in his blood stream into the production of oils essential for the maintenance of his skin in a healthy state. The interviewee quoted at the top of the page referred to the dry skin and dandruff as the first sign of his own andropause.

Circulatory problems - testosterone seems to have a role in promoting the circulation of blood to the extremities. And there is evidence that it can protect the heart and reduce the incidence of heart disease in male populations who have higher testosterone levels compared to those who are testosterone deficient.

I know much of the above is controversial. I haven't tried to present all the evidence in support of these assertions, because it is available in the source material if you want to read it. And so, perhaps in part because of this, you may still be wondering -

But does the andropause really exist?

Well, it's true that there are two opposing camps. One is fervent in the propagation of the existence of the andropause, the other denies it absolutely. For example: 

What are we to make of this? There are many possible answers, which range from the reluctance of medical science to accept new ideas, to the negative effects of past events by unscrupulous or bogus physicians on current perceptions, or even a perception that androgenic hormones are dangerous because of their use by body-builders. One of the older preparations of testosterone (methyl testosterone), which has been banned in Europe, causes liver toxicity, and this too may have had some impact on the idea of  treating men who have low testosterone levels with administered testosterone. There is also the possibility that personal experience, or exposure to patients who have benefited from the treatment over and over again, may be a defining factor in allowing a physician to accept that both the andropause and its correction are realities. Set against the position outlined in the article above is the evidence that has accrued in the scientific literature from 1944 onwards, when the first study appeared in the Journal of the American Medical Association (1944; 126(8): 472-477)

Dr Carl Heller and Dr Gordon Myers studied 38 men in mid-life who had a wide variety of symptoms such as irritability, depression, crying spells, suicidal tendencies, hot flashes, sweating, palpitations, increased pulse rate, weakness, muscle pains, reduced libido and decreased erections. Not all the men had an apparent testosterone deficiency, but they were all given supplements by injection. The control group, who showed no symptoms, received the same injections. The results:  85% of the men who combined sexual dysfunction and low testosterone levels were "cured" by the injections, and their symptoms were alleviated or disappeared. Now, there is of course an implication here that at least some sexual dysfunction isn't cause by testosterone deficiency, and this may well be the case: anxiety is a prime contender as another cause of sexual dysfunction. Sometimes circulation problems can cause erectile dysfunction or impotence, too. But the issue for us here is that this was the first study which demonstrated the connection between low testosterone and a variety of symptoms of the andropause. It did not, however, lead to a great breakthrough in medical science or treatment, and the development of testosterone replacement therapy for andropausal patients remained the preserve of a very few specialist doctors for a long time. Perhaps, as the above quotation suggests, even now this may still be the case. If you want to read more evidence that supports the existence of the andropause, there is plenty quoted in the books which I list in the references below.

A few facts about testosterone levels and age

In their late teens, boys are typically at the lifetime highs of testosterone - between 800 and 1200 nanograms per deciliter (ng/dl) of blood. These levels are maintained for about ten or twenty years, after which they begin to decline at the rate of about 1 percent a year for the absolute testosterone level and 1.2 percent a year for the free testosterone level (a term explained below). However, these levels are so widely different between individuals that they cannot be regarded as anything more than a statistical average. As Dr Eugene Shippen points out in his book The Testosterone Syndrome, male testosterone decline is highly variable and dependent on many interlocking factors. Some men are in andropause by the time they are 40, and their testosterone levels are only 200 - 300 ng/dl when tested. Other men are still at 800 ng/dl at 70 years of age.  This may be one of the reasons why testosterone deficiency has not been widely accepted as a valid medical syndrome - surely, the logic goes, if men with the symptoms of the andropause have high levels of testosterone, there can be no connection between the andropause and testosterone levels? But it isn't so simple. 

 (By the way, the units used to express testosterone levels in Europe are different  to the American ones quoted here, and they cannot be directly compared. The European unit of measurement is nanomoles per litre, or nmol/l. To convert from American to European, divide the American units by 28.57) 

The significance of free testosterone

The absolute level of testosterone in a man's bloodstream does not represent the potential for the hormone to act in his body. Most of the testosterone in the blood stream of a man is actually bound to proteins, and typically only about two percent will be available for assimilation by the body's cells. The most significant protein that binds to the testosterone is called Sex Hormone Binding Globulin (SHBG), a protein whose levels increase with age. The more SHBG in a man's bloodstream, the less testosterone is actually available to act on his cells. Dr Malcolm Carruthers has emphasized the importance of what he terms the Free Androgen Index or FAI, which is the level of testosterone in the blood divided by the SHBG and multiplied by 100. It is when the FAI falls below 50 percent that symptoms of the andropause often appear. Clearly either a fall in absolute levels of testosterone or a rise in SHBG levels will have much the same effect - a man is deprived of the hormone that makes him, and keeps him, a man.

The causes of low testosterone or low FAI

First, and most simply, a man may have low testosterone production. 

There are two forms of testosterone deficiency - called by the medics primary hypogonadism and secondary hypogonadism. In both cases, hypogonadic men produce smaller amounts of testosterone than normal; the division into primary and secondary categories refers respectively to testicular failure, for whatever reason, as against some failure higher up the hormonal system that results in the testes' normal activity being switched off. 

There is no clear understanding of why testosterone production may fall as a man ages, although it may  have something to do with the overall control of the testes by the pituitary gland in the brain. This gland secretes two hormones, LH and FSH, which act on the testes and stimulate them to produce both sperm and testosterone. In some cases it seems that the sensitivity of the testes to these chemical messengers from the brain decreases with age, and the overall mechanism of the hormone production system becomes less efficient. In others, the testes would work if stimulated, but the hormonal messengers from the brain cease to function effectively. Anyone who wants to study the male hormonal system in minute scientific detail can find all the information they need, presented in a very highly technical way, in the book  Testosterone, which is listed below. But this is not a work for the average lay reader. You need a scientific training to read it (not to mention being fanatically interested in the subject!).

Secondly, there is a more complicated form of the condition which results in an andropausal man getting some or all of the symptoms listed above, but when tested for hormone levels, he may be found to have physiologically normal testosterone levels. It is this fact which may have accounted for some of the skepticism about the value of administering testosterone to men with these problems, particularly the oft-repeated assertion that testosterone is of very limited value in helping men with erectile dysfunction or impotence. If so, it is a serious failure on the part of the medics who fail to understand the issue, for, as a brief visit to any of the support groups on the net that cover the subject of hormone replacement will reveal, very often the patients themselves are extremely aware of the problems that they are going through, and have a grasp of the technicalities which seems to have eluded their doctors - which is yet another reason to see an expert in the field, an andrologist (male specialist) or endocrinologist (hormone specialist) at the very least, rather than a urologist (the equivalent, roughly speaking, for men of a gynecologist), as so often seems to happen. 

This more complicated version of the andropause is related to changes in the normal male hormonal balance caused by excess levels of estrogen floating around in a man's system. Estrogen, or more accurately, estradiol, is a vital component of the male physiology, and in fact is made from testosterone in the cells of every man's body. However, although it has an important role to play in his physiology, it can sit on the cellular receptors for testosterone and stop testosterone working as it should. There is a very fine line between balance and imbalance in estradiol levels in a man - if it rises too high, no matter what his testosterone levels, he is in deep trouble, for the effects of excessively high estradiol levels on a man's physiology are almost exclusively very negative. Dr Eugene Shippen discusses this issue at length in his book The Testosterone Syndrome, and he also makes the point that nay man who is experiencing high estradiol levels will also produce more SHBG, thereby reducing his unbound, free testosterone even further. The point that he makes is this: certain methods of testosterone supplementation can promote the metabolization of testosterone to estradiol so effectively, that the ratio of estrogen to testosterone exceeds anything that can be considered physiologically normal, and the man is effectively neutered by the treatment he has received.

There is also some suggestion in the book Testosterone (p58, second edition) that if part of a man's problem is that he is physiologically insensitive to testosterone anyway (which is not an uncommon condition - see the information on androgen insensitivity on the Hypospadias page), he is much more prone to metabolize testosterone to estradiol, thereby compounding the problems he faces. The moral of all of this being what, exactly? You may well ask. In a word, it is this: the treatment of the andropause needs an expert, who knows what he (or she) is doing, and can check for the less obvious aspects of hormonal physiology like LH, FSH and estradiol levels in a man's system. And the type of treatment on offer will have some impact on its effectiveness, as well.

Testosterone Replacement Therapy

Again, I want to emphasize that I am starting from the assumption that there is a significant number of men who can benefit from testosterone treatment, and whose andropausal symptoms, especially impotence, can be helped by testosterone supplementation. I hinted above that many doctors would not see it this way: the prevailing view is perhaps that testosterone is of limited use for restoring sexual function. However, at the risk of laboring the point, when you go behind this superficial statement, and start to consider the evidence, and weigh up the role of SHBG and estradiol in male physiology, you see that the issue is not so clear cut at all. Now, you may have a hard time persuading your doctor of this. I know of men who have felt terrible, tired and depressed, and whose libido has disappeared, who have managed to persuade their doctors to test for testosterone, and on the strength of low levels that are nonetheless "in the normal range", have had their concerns dismissed by their doctors. Apart from the tragedy of this, and the despair that men in this position are liable to feel, what strikes me is the arrogance of so many doctors who do not hear what their patients are saying to them. Faced, it seems, with the evidence of a patient complaining that the whole basis of his existence and sense of maleness has changed on the one hand, and on the other the results of tests to which they apply "normal" reference levels of testosterone, the doctors ignore the patient and go with the scientific evidence. At least, they do if they are untrained in, and insensitive to, male issues. The key is to find someone who knows what he is doing - easier said than done, perhaps, but you can make a start by reading the books I have listed, and then searching the web on key words such as "andropause", "testosterone", "male menopause", "hormone replacement", and "impotence".

The other factor to keep in mind is that the range of testosterone that makes a man function effectively can be very different between individuals. A normal reference range might be considered to be

Testosterone: 13 - 40 nmol/l     or     370 - 1100 ng/dl

Estradiol:        55 -165 pmol/l      or    10 - 30 ng/dl

The point about these numbers is that they represent such a wide range of "normality" that it seems intuitive that assessing a man's hormonal state on the strength of his absolute blood hormone levels is not an approach which will necessarily lead to the correct solutions for his problems. In other words, the doctor must exercise judgment about what is right for each patient. 

Additionally, of course, not all impotence does stem from low hormone levels, a fact  on which there is more information below.  There I also discuss the connection between androgen levels and impotence.

The issue of replacement therapy for men with low levels of testosterone is very complicated - another reason why you need the help of an expert. There are many ways of addressing the issue: injections, creams, pelleted implants, oral preparations, and, most recently developed, patches to put on the skin. The prescribing of oral testosterone has been controversial in the past, and has perhaps even done this field of medicine some harm. The preparation which was once used in America, methyl testosterone, can damage the liver, and has quite correctly been banned in Europe. However, modern oral preparations of testosterone esters are quite safe and have no effect on the liver (if you remember your high school chemistry, you might know what an ester is - if not, think of it as simply a chemical compound that can be metabolized by the body to bio-available testosterone). 

There are two main oral compounds: the first is testosterone undecanoate, the second is a milder androgen called mesterolone. These are marketed under various brand names - Restandol and Andriol (for the undecanoate), and Proviron (for the mesterolone).  As a mild treatment, these may be the first prescriptions that a testosterone deficient male receives. How effective are they? The general consensus of members of the internet newsgroup "alt.support.impotence" - and I speak purely from my own opinion here, not on behalf of anyone else - seems to be "variable". The reason lies in the rapid processing of the hormones by the liver. Testosterone undecanoate relies on absorption into the body via the fatty products of digestion passing into the lymphatic system. If you take it, you can certainly feel it kick in, with sexy thoughts and often an erection, but you can also feel its effects disappear after a few hours. It is metabolized out of the system quite quickly. This means that repeated doses through the day may be necessary, which is potentially inconvenient, besides being expensive and in some cases upsetting to the stomach because of the oil in which the testosterone is dispersed.

The next step in treatment might be the classic route of injections of  long-acting (i.e. one, two or three weeks) testosterone esters in an oil-based carrier  into the muscles of the buttock. There are various preparations available, which last for different lengths of time. They all work on the same principle - they are metabolized to testosterone at the site of injection. The problem commonly reported with these preparations is that each injection gives a supra-normal level of testosterone, which has an immediately positive effect on the patient's energy, drive, mood, and libido, but as time elapses, the levels of hormone in the man's system may drop below the "normal" range, thereby giving him a few days of irritability, mood swings, and low libido before the next injection. This can be a major problem for men on this regime. However, I think it is only fair to point out that the treatment does have some advantages as well: it is cheap, easy to administer (in fact it can be administered by the patient) and it is effective. One man on a regime using an injectable preparation made of a mixture of different  testosterone esters told me that he was very happy with his situation - he was sexier and fitter at 56 than he had been at 18, and boasted of being able to have sex as many times a week as he wanted. Other men have reported that they have been able to overcome the mood and libido swings by self-injecting smaller doses on a more regular basis, that is to say, splitting the prescription into smaller units and injecting, say, weekly, instead of every two weeks. I am  not offering medical advice, but what I  would say is that the evidence seems to suggest that with some experimentation, and a co-operative endocrinologist, a treatment regime that will work quite well can be found. 

I think it is also necessary to say that my impression is that testosterone replacement is rarely a perfect remedy for the problems it seeks to cure: it would be surprising if it were, for the complexity of the human hormonal system is profound. For one thing, testosterone delivered at a constant level through a hormone replacement regime will switch off the production of testicle stimulating hormones like LH and FSH.  The consequence of this is that you may stop producing sperm (although this is a fully reversible effect!) and your testes may shrink somewhat. (By about a quarter.) One man said that of all the changes that the failure of his hormonal system and the therapy he was now on had produced, the hardest for him to deal with was the shrinkage of his balls - he suddenly realized what women had to go through when they had a breast removed, or the difficulties a fat person had with their changing body image, and the degree of anxiety, depression and moodiness it could produce.

There are some new preparations under development - testosterone cyclodextrin and testosterone buciclate, being two of them. These are longer acting esters of testosterone. There was also an investigation into injectable microspheres of pure testosterone, although I think I am right in saying that this work did not progress very far. The objective, of course, is to produce a regime of hormone replacement that approximates as nearly as possible to a steady-state regime with no resultant mood swings and changes in libido. These new compounds also hold out the prospect of longer intervals between injections, which will certainly increase the acceptability of these treatment methods for the patient. 

Subdermal implants of pure crystallized testosterone have found favor in a few quarters. Interestingly enough, this method has been investigated and reported as being most satisfactory by those doctors who seem to have been amongst the most active proponents of the principle of testosterone replacement therapy. The benefits  they list are: convenience, long intervals between treatments (up to six months), effective replacement with consistent levels of hormone, and restoration of normal mood, libido, levels of energy and motivation. Of course, the question arises as to why this method has not found greater favor if it is so good, and it is a question which deserves a considered answer. Sadly, I can't offer you one. One of the pioneers of the treatment, Dr Tiberius Reiter, seems to have been outspoken and possibly disrespectful of the medical establishment, which can't have done him or the reputation of testosterone treatment much good. The next main proponent of the treatment, Dr Tvedgaard, a Danish doctor, seems to have had even less regard for medical convention in his desire to promote the benefits of treatment. If you want the full story it is in Dr Malcolm Carruther's book, in which he says that his own experiences in trying to prove the existence of the male menopause have closely mirrored those of many of the pioneers of the past. He says that attempts to debate the condition and its treatment have met with blatantly illogical denial, especially from endocrinological specialists, who, I guess, have more to lose in terms of reputation and prestige than family doctors, who, Carruthers states, are much more receptive to the idea of a male menopause. 

But whatever the history of this approach, perhaps the important issue now is only whether or not it works. I have taken the material that follows from the textbook Testosterone, and tried to offer a few comments from a scientific point of view. 

The pellets come in two sizes, 100mg and 200mg sizes. Between four and ten of them are implanted, under local anesthetic in the doctor's office, through a small incision in one of various sites such as the subdermal fatty tissue just above the buttocks. The wound heals quickly and is accompanied only by minor temporary discomfort. The testosterone leaches from the pellets into the intercellular fluid. The pellets are designed in such a way that the rate of hormonal release, after an initial surge which lasts only for a day or so, is constant throughout the life of the pellets. A 200mg pellet releases about 1.3 mg of testosterone per day, compared to the average production in a healthy young man's testes of 6 - 7 mg per day, which implies that about 6 pellets would produce a physiological dose, although individual variability could mean more were required. The authors of the book say that the pellets have few side-effects and are generally well-tolerated. Sometimes one or more of the pellets will track back along the insertion line, and pop out, but this is quite rare. They state that this is a convenient method for those who find regular injections inconvenient. From a medical point of view, they conclude that "pellets were clearly superior in durability and stability of clinical effects .....far more convenient....and facilitate long-term androgen therapy."  Well, you pays your money and you takes your choice, or at least, you might want to, but there are problems. First, there is the limited availability of this approach. And it isn't that cheap, although the exact cost depends on local health care systems. If you are paying for it yourself, it is cheaper than  oral medication, and about the same as injectable testosterone. My suggestion would be that you get the books listed in the references and read up about it, then try and find a physician offering it near you. It is without doubt a method worth considering.

One of the more recent developments in the field of replacement therapy for men has been the development of the patch. Well, actually, there are two types of patch - one is designed to be worn on the scrotum, the other on the skin of the back, arm, abdomen or chest (although the chest is less effective at absorbing the testosterone through than the other sites mentioned). There are some links below to the information site provided by the manufactures of the non-scrotal patches. But again, the book Testosterone offers some suggestions as to whether or not they are helpful. The patches come in two sizes, and deliver either 2.5 or 5 mg of testosterone per 24 hours. In the book, the authors reviewing this treatment method state that the patches are effective in raising testosterone levels to a normal range, on a fairly consistent basis (60 % in the first 12 hours, 40% in the second 12 hours). They do observe that according to when the patches are freshly applied, it is possible to mimic the normal daily rhythm of testosterone production in the male body, which is at its highest in the morning.  The patches were clearly superior in keeping estradiol levels within the normal range when compared to injectable preparations (pg 401), which for men who have a sensitivity to estradiol, or a high rate of conversion, could be an important factor in the effectiveness  of their treatment. The authors observe that transdermal patches are as effective as injected testosterone (and pellets) in restoring erectile function, and observe that "these studies are in agreement with other studies showing that androgen therapy improves erectile function." (p 405). 

They also make the point that androgen therapy has the effect of restoring sexual function and libido and eliminating hot flushes, impotence and depression whatever way it is administered, which is unhelpful for someone trying to choose between the options at what can be a trying time anyway. The end decision may actually be based on what is available in your locality, as well as the clinical aspects of a decision about what could be the best option for you - after all, you will only get the full range of options if you have an open-minded doctor who supports you in trying out different hormone replacement systems.  I have made several references to the internet newsgroup alt.support.impotence, but it is a valuable resource with intelligent and knowledgeable men who can answer most questions on androgen replacement - both its pitfalls and benefits.

Viagra, impotence, and hormone replacement therapy

The following paragraph also appears on the male sexuality page of this web-site.

I want to say a little about Viagra (also known as sildenafil) because it clearly is a medicine of great potential for at least some men with erectile difficulties. The story of Viagra is probably quite well-known by now - it was designed as a heart drug, but the trials seemed to do more for the men's sex lives than their circulation. When the pharmacists looked into this, they found that Viagra has a special effect on the penis: it sustains the presence of nitric oxide in the penis, which is important because it is that chemical which promotes the penile blood vessels to dilate or relax and allow blood to flow into the penis more effectively. This means a harder, firmer and longer lasting erection should occur. The drug is a fairly potent one, I think, and it has effects on many body systems other than the penis, because the enzyme which it has to inhibit so that the supply of nitric oxide is maintained is found not just in the penis. This means it can cause side-effects such as a headache, a flushed face and a bluish tinge to one's vision. These effects, while alarming, are not a problem.  However, what in practice a doctor would wish to do is strike a balance between an effective physiological dose which hardens the penis, and one which is low enough to avoid producing unpleasant side-effects.

A typical routine might be for a doctor to prescribe a low test dose of perhaps 25mg (half of a 50mg tablet). The idea is to start low and work up. If there is some anxiety about the likely success of intercourse, it might be best to establish a suitable dosage through trying to masturbate. Viagra, I should mention, is not a drug that will increase libido: there needs to be a pre-existing sexual urge or arousal, even if there is no erection, for it to work. This is why a combination of Viagra and testosterone therapy has found favor with some doctors who have specialized in male reproductive dysfunction. You can read more about this at the Gold Cross Medical Center link below.

I must emphasize that anyone taking Viagra, or thinking of doing so, would be well advised to see a doctor qualified  in andrology. The fact is, however, that the rules in America currently permit on-line consultations, and Viagra purchases are easily made over the web. If you are thinking of this, you will wish to use a reputable supplier. On that basis, you may wish to try these suppliers. (Click here.) Please, please, please, don't take it if you have a heart problem, and read the advice of the supplier very carefully. 

The prostate and hormone replacement therapy

I haven't referred as yet to the contentious issue of prostate cancer, which has featured many times as a justification in many people's eyes for depriving men of hormone replacement therapy. Once again, things are not what they seem. The basic, widely held, idea is that prostate cancer is stimulated by testosterone, and therefore, as the chance of prostate cancer developing is higher in older men, older men should not have testosterone therapy. And in some ways, there is an association of facts that seems to support that point of view - for example, men who have been castrated for some reason before puberty rarely show signs of prostate disease. But to argue that this proves anything is simply illogical. 

As men age, the prostate tends to enlarge, causing a variety of "gentlemen's problems", chief among which is difficulty in urinating or the need to urinate frequently. Whether the prostate is growing benignly or malignantly, a test for prostate specific antigen in the blood - the PSA test - can reveal much about the health of this organ. A manual examination by a doctor can be helpful too, of course, although less likely to be attractive to the patient. In his book, Eugene Shippen refers to several studies which demonstrated absolutely no link between testosterone levels and the development of prostates cancer or raised PSA levels.  More interestingly, he points out that there was a striking correlation between the levels of estrogen in a man's blood and the chances of  him developing prostate disease. In an interesting reversal of the normal perspective, Shippen puts a convincing case forward that testosterone therapy actually inhibits prostate disease. And apart from the case that he argues in his book, he also points out that the experience of doctors administering hormone replacement therapy is highly suggestive - prostate disease is rare among patients who are on hormone replacement therapy. It's a powerful argument, and although not proven, it seems clear to me that testosterone does not encourage the development of prostate disease - if anything, it inhibits it. 

Impotence, one reason why it can happen, and how hormones may help    

As many as 3% of men at age forty may be impotent. This is a  terrible figure and it does not get any better as men get older. By age seventy, 40+ % of men are impotent. Why is this? To understand one possible cause, we need to look at the mechanism of erection.

Dr Eugene Shipman describes this in great detail. To sum up what he says: two muscles extend forward from the bones on which we sit, to support and anchor the base of the penis. The fibers of one of these muscles, called the ischio cavernosa, surround the main chambers of the penis, the corporae cavernosae, at their base, and are mainly responsible for allowing arterial dilation and promoting venous constriction during an erection so that blood cannot escape. There is in fact up to eight times more blood in an erect penis than a flaccid one. Another muscle of the penis is called the bulbo cavernosa;  it causes the expansion in the chamber at the head of the penis. It also allows a man to "twitch" his penis upwards, and is responsible for the force of ejaculation and the pleasurable sensations that go with it. All of the muscles - and even the nerve fibers - in the genital region have many more testosterone receptors than those in other parts of the body. This is no coincidence. 

As Shippen emphasizes, it is testosterone that maintains the conditioning of the vital muscles of the genital region. Without hormonal input, the muscles gradually wither and sustained fullness of erection becomes impossible. Even more catastrophically, a decrease in the tension of the ischio cavernosa prevents blood from being maintained in the chambers of the penis, with results as "deflating to the ego as a flat tire in the Indianapolis 500".

The fact that testosterone is responsible for much of the functioning of a man's sexual organs has been demonstrated by studies in rats. When male rats are castrated, the muscle fibers in the genital muscles degenerate rapidly: even the nerve-endings cease to transmit messages effectively. The rat, perhaps not surprisingly, begins to lose interest in sex as well as his capacity to produce an erection. Needless to say, when testosterone is administered, the rats regenerate both muscles and nerves and their sexual function is brought back almost one hundred percent. It seems that although mankind may differ from rats in many ways in this respect of our physiology we have much in common.

Shippen takes the view that hormonal solutions to erectile dysfunction will work in a majority of cases, although he does admit that not every man gets erectile function back after hormone administration. He points out that many things can damage the circulatory system of the penis: drinking, smoking, fatty deposits in the arteries, and the actions of certain drugs can all destroy the capacity of the penile vascular system to function correctly. Indeed, one of the tests of correct functioning is a blood pressure test. If the pressure in the man's penis is not  the same as in his arm, it implies there has been some permanent degeneration of the vascular system in the penis that bodes ill for his ability to be restored to sexual function. And Shippen also points out that estrogen, or more correctly estradiol, can be as much of an enemy on the testosterone receptors of the genital region as it is elsewhere on a man's body. He also emphasizes that restoration of sexual function may take a while as the muscles and nerves regenerate to a fully effective state. Indeed, he says that it may take as long as a year, but he maintains that the majority of his patients are restored to sexual function. 

Shippen makes other important points to support his case. For example, the overall importance of adequate testosterone levels in the sexually active man is illustrated by the subtlety of its effects, which extend to the biochemical: testosterone in the penis seems to stimulate the production of nitric oxide gas. Nitric oxide is a neurotransmitter that stimulates nerves and stimulates  vasodilatation, erections and hence full sexual function.

You may have heard of the Kegel exercises that women are encouraged to undergo when they experience weakness of the muscles of the sphincters of the bladder or anus. You may not be surprised to learn, perhaps, that men have these muscles - known as the levator ani muscles - and that an improvement in sexual function can be obtained with regular Kegel exercises in men. The object  is to strengthen all of the elements of the system so that they work at full effectiveness and provide maximum sexual pleasure and sensation.

If you are interested in pursuing the issue of hormone replacement therapy, my suggestion would be that you begin by reading up on the subject (see links). You might then want to look at the Gold Cross Medical site, to judge for yourself whether the subject matter outlined above applies to you. If you think that it does, then I would feel inclined to look for a reputable doctor via the Internet, or by asking participants in alt.support.impotence if they know of a sympathetic andrologist or endocrinologist in your area. If you live in the UK, you can see your GP - but be warned - he may not know enough about the balance between estradiol and testosterone to make effective decisions about referring you to a specialist. I think I am right in saying that it is not in fact necessary to go through your GP to see a specialist privately, although of course this would probably be frowned on by your regular doctor were he to discover you had done so. It is a difficult issue, and there is no simple answer:  one key thing to hold on to is that if your testosterone levels are low, or your sexual function is diminished, and you have the  symptoms above, then you do have every reason to press for a visit to a specialist in the field. As far as the other causes of impotence like vascular degeneration are concerned, you will need the help of a wider range of specialists, such as a urologist. Fred's page of impotence information is a complete reference encyclopedia in itself, with links to everything you could ever wish to know about this subject. Good luck.

Another personal reaction to the information above, which I received by email.

Very interesting. I had all those symptoms and some tooth loss a few years ago. Here's what I found that has reversed male menopause:

  DHEA 50mg L Arginine 5-7grams daily. It produces the necessary Nitric oxide. 

Andro Teston by GVI Labs. 2-3 daily each has androstendione and 4 androstendiol the precursors to testosterone. 100mg each per pill. 

DL phenylalanine 500mg to increase the dopamine levels in the brain adds to the intensity of orgasm.

  Avena Sativa 1 week every 3 months once a day to free up the binding testosterone. 

I am almost 55, achieve a strong erection and  I ejaculate "in buckets." It's almost embarrassing if I wasn't so damn happy about it. Before I started this regimen, it was very difficult to get an erection and my ejaculate dribbled  out. I had the night sweats , I put on weight the circulation to my feet was not the best. I also had bad lower back pain every a.m. It's now a pleasure to be "able to shoot" some 4 feet with strong repeat pulsation. Look, I'm not  physician. I am just looking to share my experience with getting older. Viagra didn't help when I needed it and now I don't need it. I feel the secret is L Arginine which produces the nitric oxide, like Viagra, to dilate the veins and arteries to get the blood where it is needed for erection. It is the Natural Viagra. This is the message to get out to the Baby Boomers. Help is in your Health Supplement Store! Sincerely, Rich

Links                                

1 The books - highly recommended

2 Male resources on the andropause, ageing and impotence 

Fred's site - see below - is the best resource ever on the subject, I recommend it.

3 The Men's Movement and male health