Chapter Two - The Male Menopause

Chapter Two - The Male Menopause or Andropause.

What's in a name? Well, in the case of the Male Menopause, a lot. It is probably one of the main reasons why the condition has failed to achieve the recognition it deserves. It is the joke disorder that is no joke. When any middle-aged male character in a sit-com behaves in an unexpected or seemingly irrational fashion, it is usually wrongly attributed to the Male Menopause.

For the sake of both clarity, brevity and to ease acceptance by both the general public and the medical establishment, who already recognise the name if not the disorder, from now on I will mainly use the term "Andropause" when referring to this condition in men, and "Menopause" when referring to the equivalent condition in women.

After all, the term "menopause" was introduced by French doctors in the 1870"s, combining two Greek words menses (periods) and pausis (stop), to indicate the time in a woman's life when the monthly periods stop, just as the word "menarche" combining menses (periods) and arkhe (start), means their beginning. hen applied to men, the term is therefore both inaccurate and somewhat derogatory. One of the aims of this book is to change that image and make the whole subject easier for men to talk about and think about.

"Andropause" however combines two Greek words andro (male) and pausis (stop), and means when masculinity ceases, which is a much better and more accurate description of the condition. It is doubly appropriate because the root of the problem is an inadequate supply of androgens, especially testosterone, the hormones which provide manliness, andro (male) gen (give), and which can be used as an effective remedy for the problem when it occurs.

Women are used to visiting their gynaecologist - gynaeco (female) -logist(scientist), to sort out their problems, especially after the menopause with the use of Hormone Replacement Therapy, which appropriately enough often restarts their periods. I suggest that men should be equally willing to consult their "Andrologists", who are beginning to have an expanding role outside that of male fertility, and are now in a good situation to advise on Testosterone Replacement Therapy to treat the andropause.

Let's start with a brief sketch of the condition, how it begins and how we can recognise it is happening to us or those around us. It's often insidious onset can be at any time from the age of thirty onwards, though typically it is in the fifties. One of the reasons it's often missed is that this equivalent of the menopause in the female is usually more gradual in onset but more severe in its long-term consequences. It is a crisis of vitality just as much as virility, even though the most obvious sign of the crisis is loss both of interest in sex and of erectile power.

This change is surprisingly often overlooked or ignored, either because the man is so pressurised 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, so that the leader becomes the led, the tiger becomes the sheep.

There is 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, and sometimes things are made much worse because of the additional stress these changes bring. 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.

Typical of the andropause case history is that of John:

"I'm just fifty now and I've been very successful in my family's retail business. Because of the recession it is harder to make a living than it was, and work is stressful and not much fun.

My health has always been pretty good , except for one attack of prostatitis associated with a urinary infection 5 years ago. This non-specific urethritis as they called it had me up peeing five to ten times a night till it was treated with a four month long course of antibiotics, but it seemed to clear up completely after that.

Since that time however, though I love my wife and we have a good life together, with four delightful children, my libido has just faded away to nothing compared to the healthy sexual appetite I've had for the rest of our twenty-five years of happy married life. I've never been one to have affairs, but now I'm not even interested in "window-shopping". I just feel cocooned and detached from even the prettiest girls, as though I'm just not in the same world as them!

My erections aren’t what they were either, and I'm having more and more failures in that department, especially when I'm tired or had a few drinks. Morning erections are few and far between, and my wife isn't really turned on at that time in the morning. Sex between us is down from two to three times a week to once a month now, especially as I don't like to go into battle if I'm not sure my guns will fire. In some ways I don't miss sex all that much, though my wife does, just as you don't miss food if your appetite has gone.

Worst still, I completely lost my drive and ambition over the last five years. When I get up in the morning, I feel energyless and completely lethargic, and instead of looking forward to the day, just wonder what time I can get back to bed. I'm really envious of older people with more energy than me. I'm not giving much time to my wife or the children, which really makes me feel guilty about them, especially as I'm usually as scratchy as a bear with a sore head, and that's not like me.

There have been physical changes in me too. My feet and ankles, knees and back are really stiff in the mornings, which makes me feel old and decrepit, and even less like getting out of bed. Often the bed is wringing wet in the mornings because I sweat a lot more than I use to, and sometimes this is so bad that my wife has to change the sheets. I find that I flush easily when the room is warm, but that my feet and hands are cold most of the time. What with that, the night sweats and the lack of sex, my wife is threatening me with single beds!

I don't go to my doctor often, but a year or so ago I went to see him feeling thoroughly depressed and convinced that something must be wrong with me. He's a good fellow and heard me out sympathetically. But when I said that I thought that my symptoms were just like my wife had had before she went on Hormone Replacement Therapy, and wasn't there something similar he could give me, he nearly threw me out of the surgery! I was told to forget it and given a choice of antidepressants or marriage guidance counselling, or both, but I didn't feel either of these were right for me.

Just as I was getting really desperate, my wife saw an article in a magazine about the male menopause being a real condition that could be positively identified and safely treated with testosterone. She said the case described was an exact picture of me. I went through the appropriate tests and safety checks, and started on testosterone capsules by mouth. Within two weeks the symptoms had improved, and within a month they had gone. My marriage, my family life and my business have all benefited, I feel like I did ten years ago. My wife and I would like to know why did I have to have all those wasted unhappy years when my hormone deficiency could have been detected and put right so easily. It seems a reasonable question to ask".

I spend a lot of time going over these case histories the first time men come to my consulting room, and they all tend to be variations on the same theme. No one symptom is essential, but the picture is consistent enough to usually be able to make the diagnosis even before examining the patient or doing the detailed blood tests.

Based on the histories of over a thousand men who have been to see me over the past ten years, and a detailed analysis of the symptoms shown by the first four hundred of these, I have built up an "identikit picture" of the andropausal male. See if it fits anyone you know.

The main complaints can be described as being either mental, such as fatigue, depression, irritability and reduced libido, or physical such as ageing, aches and pains, sweating and flushing, and failing sexual performance. You can see as we go through this list how close is the comparison with the menopause in women.

Lets consider these one by one in more detail so that you can recognise the andropause when you see it coming. Above all, remember it is usually treatable, and as it says on page one of Douglas Adams "Hitch-hikers Guide to the Galaxy" - Don’t Panic!

FATIGUE

Fatigue is the main expression of the loss of overall vitality which characterises the andropause, and in my first series of 400 men it was present in over eighty percent of cases. It's as though the man's get up and go has got up and gone. This is hardly suprising when you look at this as a hormone deficient state. After all, the original meaning of the Greek word for these "chemical messengers" of the body (hormon) means "setting in motion".

The patients describe this drop in energy levels, and its return on treatment very graphically, as in Bruce's case.

"Fifty was a turning point for me. Till then I had been pretty active as an advertising executive, but at that time I just seemed to grind to halt. I felt tired at work, couldn't concentrate, lost my competitive edge and found my job more and more difficult. Partly this was because I was getting more and more short tempered, and I started drinking fairly heavily in the evenings.

At home, I wasn't exactly a bundle of fun either, falling asleep on the sofa every evening. Though everyone told me I needed a good holiday, I was so tired and negative, the interest and energy needed to organise one just didn't seem to be there. My libido had dropped to the point where even a "Saturday Night Special" was usually too much trouble, especially as my erections let me down increasingly often.

This was all very depressing, especially when a close friend about my age suddenly died of a heart attack. After having had these symptoms for four years, my marriage was falling apart, and I seemed likely to lose my job. Then I read an article in a magazine and felt the writer was writing about me, he described my symptoms so exactly. It all seemed so unfair as there wasn't anything in my medical history that I felt was relevant, and my family doctor had told me that I had nothing but a touch of depression. However the tests clearly showed a low "Free Testosterone", and I started straight away on capsules to boost levels of the hormone..

The results were dramatic. Within a month I felt as though the treatment had lifted a veil over my life, and I felt generally more vibrant and more virile. After three months my performance at work was back up to speed again, and to managerial jargon I was more "Pro-active". Also, both at home and at work I was rated "Mr Nice Guy", my sex life has improved, and my wife is delighted with the results of treatment. Things are going well across the board, and feeling more positive about myself and life in general, I have got on top of the alcohol problem, just having a moderate amount of wine at home over the weekend, and none during the week."

Conventional female wisdom has it that it is not the man in your life that matters, so much as the life in your man. This refers to energy and drive of all sorts, and not just sexual activity, though they often seem to go hand in hand. This seems to be why women are attracted to energetic men of all shapes, size and ages, the shakers and stirrers of life. From Attila the Hun to Zorba the Greek women are drawn to them.

Testosterone drive is probably the most important force underlying both mental and physical energy. The ability to reproduce by sexual activity is the essential biological function of all animals, the biological imperative, subordinate only to the needs of staying alive long enough to do it and ensure survival of the offspring.

Urged on by some of the stress hormones such as noradrenaline, which as I shall describe later is what gives us a "buzz" in certain situations rather than the more publicised adrenaline surge, testosterone drives men on to fame or fortune, to daring do or die for a mate.

In the animal kingdom, its what makes rutting stags lock horns in mortal combat for hours on end, until the vanquished male limps off to the forest to lick his wounds or die, while the victor on a "testosterone high" triumphantly services the herd". Elephant seal bulls wrestle, roar and bite each other, often inflicting serious damage, before the winner takes all, and the loser slides back into the sea to go fishing and recover.

Many and varied are the ritual tests of manhood. Full scale battles throughout history, individual combat for love, honour, and to decide who would be the dominant male, chief or king, are as old as mankind itself. In Germany ritual duelling with swords, inflicting facial scarring, was fashionable before the second world war. In Spain, the young men still show their bravery and impress the girls, by running in front of the bulls in the streets of Pamplona. Triumphant racing-drivers world-wide enjoy the heady symbolism of spraying champagne over adoring crowds.

In America depending on the amount of money available, which is a form of financial testosterone, you arm wrestle, play "chicken" by riding motor-cycles at other young men down the middle of the road, or drive your Ferrari Testarossa as fast and as dangerously as you can. Either way hormones have the last word, often literally.

This then is the hormonal power source that drives men on for a large part of their lives, and along with intelligence, is often the deciding factor in deciding their social and sexual history. It can be thought of as the "Success Hormone". When a man is winning life's battle's it is high, and when he's losing it falls, and his sexual activity usually follows these highs and lows.

When it gives out on them because of age or any of the many other factors affecting testosterone production or activity described later on, men feel their energy levels drop, and often wonder "Who or what pulled the plug?".

As their drive in both bedroom and boardroom fades, they go onto "emergency power", and cut down on all non-essential activity. At home, sex goes out of the window and social activities, as well as gardening and feathering the family nest dwindle and die away. All this sets up enormous tensions and resentments within the entire family. The worsening cycle of failures and recrimination tends to disturb sleep, and is made worse by the "Ride of the night-time naggers", with the wife keeping the husband awake by reciting his escalating list of errors of omission and commission.

After a bad night, the man goes to work feeling "lower than a snake's belly", drained of energy and enthusiasm, and tries to get "lift-off" by drinking endless cups of coffee. These may just make him more nervous, twitchy and raise his anxiety levels even higher. His attention span and ability to concentrate also deteriorate, as does his memory which are similar to the problems experienced by women at the menopause, and may have a similar hormonal basis.

Apart from reducing his ability to think up new ideas or put them into action, his ability to sell himself and his projects slumps. Customers and competitors alike have an unerring ability to spot when a man is down and out of testosterone, even when he is trying his hardest to put on a brave face.

Body language can give clues as to whether a person is in a shrinking "little-O" mood, slouching in with an apologetic, round-shouldered, crouching look, or striding in, standing tall, shoulders back, arms outstretched, looking and feeling great, as an expansive, confident "big-X". The voice may be high pitched and wavering and anxious, or low-pitched and steady, like , as Abraham Lincoln put it, someone speaking softly and carrying a big stick.

It may also have something to do with "pheromones", those airborne hormone's derived from the sex hormones, and given off by the skin all over the body, but particularly the genitals and armpits. These can either send out the sweet smell of success or the sour scent of failure. Like hounds chasing the nervous intruder, people seem to instinctively know which mode you are in.

One famous captain of industry in Britain, Sir John Harvey Jones when tackled at a meeting in London by an American lady reporter researching the subject of the male menopause, who prodded him in the mid-rife with her pocket tape recorder to goad him into activity, urbanely replied that he felt sure there was such a condition. He said he had often seen previously dynamic, hard-driving, successful managers "go off the boil" as he put it, sometimes with disastrous consequences for them or their organisations.

Indeed he felt had been through one such "fallow period" in his own career about the age of fifty, but had fortunately come through it spontaneously. He went on to suggest that the careers of men who ran into such problems could often be saved, with great benefits to the companies for which they worked, if ways could be found to help them through such difficult times.

All too often however, in a period of recession, the opportunity is taken to fire the andropausal man who performance is dropping without inquiring, or him admitting, the reason why. To make the situation worse, this frequently happens at the same time that the man is "fired" from the marriage bed for under-achieving at home as well.

To continue the analogy with going off the boil, many patients describe "running out of steam". This is the steam that drives them at home and at work, that makes the carousel of their lives go round, and that pumps up their penis to give them erections. It is indeed the essence of both their vitality and virility, the link being testosterone.

DEPRESSION

Variously described by the patients as negative or low mood, depression is one of the commonest features of the andropause, and in my first series was present in seventy percent of cases.

Though only rated as mild to moderate on one of the standard psychiatric rating scales used in this study, it was one of the most difficult of the symptoms for the men and their families to live with. After all, together with life and liberty, the pursuit of happiness is written into the American constitution, and most of the patients didn't feel up to pursuing anything, especially happiness.

Typical of their stories is that of Colin;

"Eight years ago the bottom dropped out of the stock market and my life at the same time. First my investments went, then my beautiful country home and finally my job as a promoter. There were plenty of reasons to be depressed, but I felt sure there was something more than just a natural reaction to all these problems. My brain felt full of what I can only describe as toxic sludge. I couldn't focus on anything and was very irritable, as well as being tired and weepy.

Going along with my doctors view that it was just plain depression, I went to see a psychiatrist who tried polypharmacy with every antidepressant under the sun, including Prozac, but without success. As a hopeless case, I was threatened with "Electro-Convulsive Therapy", but protested and was let off with psychotherapy, which got me into tears and then anger in a big way. Just when I'd given up hope there was an article in a magazine which talking about hormonally based depression in the "Male Menopause". A light went on in my head, when I read how the combination of the vasectomy twenty years ago when I was just thirty, and the large amounts of alcohol taken to blunt the pain of my financial ruin, might have made my depression very much longer and more severe by affecting my testosterone levels.

My doctor was fortunately open-minded enough to encourage me to take the tests, and they showed twice the usual level of a binding protein in the blood which as he explained it was "tying up" my testosterone so very little of it was active. On the hormone treatment, the depression gradually lifted over three or four months. Six months later, my energy and drive have doubled, and I'm employable again now. I still occasionally suffer bouts of depression, but they are much shallower an quicker to recede. I'm back on an even keel again much more rapidly now, and looking forward to life being plain sailing again after the terrible storm which nearly sank me."

Sometimes it is difficult to tell which came first, the depression or the other symptoms since if you are severely depressed, tiredness and loss of libido and potency can result. However, only in a very small proportion of cases was the depression severe enough to account for the other symptoms. Most of these cases had already been treated with antidepressants without improvement, and some had even got worse. This is because they can make feelings of tiredness worse, and the majority of these compounds seem to interfere with erections, though fortunately, there are exceptions as described later.

Personally, I don't usually use any antidepressants until testosterone treatment has been tried on its own for three to six months, unless the depression is exceptionally severe and life, job or marriage threatening. This is because my original ratings showed, and my consistent experience is, that TRT on its own gently but firmly lifts the depression, often completely, at the same time as it relieves the other andropausal symptoms.

Together with fatigue, the depression can also make a man less optimistic at work and less likely to suggest, start or carry through new projects at work. When selling himself, which is supposed to be one of the most important factors in selling anything, he is less cheerful, less confident and less convincing. Especially as visions of doom and gloom tend to be self-fulfilling prophesies, this is not a recipe for success. "Smile while you're making it - Smile while you're taking it" run's the song in the film "Oh Lucky Man", and smiles are hard to come by when a man is feeling emotionally down and out.

At home, depression can not only cast a black cloud over the whole house, but can narrow the social horizons. This can continue to the point where he never goes out to visit family or friends, who soon get the message that he doesn't want to see them either at home or away. This worsens the marriage already weakened by his inactivity round the house, so that he is usually to be found slumped in front of the television in a torpid heap. This escalates still further because of his lack of libido and increasingly frequent erectile failures. All this causes the social support inside and outside the family to fall away. However, especially when revitalised by HRT themselves, partners can be amazingly supportive for many years.

Nervousness, anxiety about everything and everybody, and lack of self-confidence often go hand in hand with the depression, as was recognised in studies of the "Male Climacteric" as it was then called, fifty years ago. This can also be accompanied by sleep problems, both in getting off to sleep because of intrusive thoughts and worries, and in the early waking at four or five in the morning characteristic of depression. Unfortunately sleeping pills may just worsen the tiredness during the day, and contribute to erectile problems at night.

Though the man may after years of depression reach the point where he feels tired of life, fortunately it is not usually sufficiently severe to cause him to commit suicide, and he seems to lack even energy enough to carry it through.

IRRITABILITY

One of the most distressing symptoms of the andropause, both for the men suffering from it and their families is irritability. This if often entirely unusual for the person concerned ,or it can be seen as an even shorter fuse in somebody with an already low flash point. It may be about trivial issues, as much if not more than important ones. The man may well be aware that he is being unreasonable and be ashamed of it , but still unable to do anything about it.

At work, the firm starts to recruit nothing but idiots, trains them to work against him, and there are no dirty tricks they wont try just to irritate him. At home the whole family deliberately tries to annoy him and succeeds brilliantly! Goading the bear with the sore head becomes their chief delight. They seem to do all the wrong things at all the wrong times in all the wrong ways. Without having to try he gets into endless arguments with them, and ends up infuriated, with all his patience, like the rest of him, utterly exhausted. Bernard describes this well:

"I suppose it all began when I contracted mumps at the age of 26. This was one of the most serious illnesses I had experienced. My testicles became swollen, so much so I could hardly walk. I had to wear a support just to go to the toilet. Every footstep was agony. I also lost a couple of days, I was delirious and remember very little. Three to four weeks later I was almost back to normal although one testicle was smaller than the other. Nothing seemed to have been adversely effected and, whilst not ravenous, my sexual appetite seemed normal.

Several years later, around the age of forty I seemed to be experiencing a number of things. First and foremost I was irritable, irrationally moody and intolerant of other people. The supermarket checkout was constructed just to annoy me. The shop assistant was an idiot and out to obstruct me. The other car driver was a moron and should never have been given a license. They were all trying to cut me up, hinder me and generally make life difficult for me. I invented both trolley and Road Rage !

On top of this my sexual appetite was zero, and erections often failed me. My wife by this time was convinced I was having an affair. It all added up, no sex and an attitude to boot! Finally my wife gave me the ultimatum, see a doctor or we split. A week later I had an interview and a blood test which confirmed a hormone deficiency, and that treatment would be appropriate. I was prescribed a course of testosterone capsules which I started immediately.

Ten days later I was a changed man. I felt a tremendous burden had been taken from me. I felt energetic, I became more assertive and I had regained my sexual appetite. My job became easier, I made decisions more easily and I had the energy and determination to see the job through. I felt more optimistic and no longer had this feeling of frailty or vulnerability. My erection was much stronger and didn't fail me at the crucial moment. My attitude change, I returned to being the laid-back, happy and contented person I had been. No more anger, no more moods. I could now enjoy life instead of feeling angry as it passed me by.

Six years later I'm still on the treatment. My job hasn't changed very much but I can handle it much more easily and confidently. I am more successful at doing what is needed. I've gained a lot of self confidence and I'm not at all susceptible to bouts of depression. My family life is very much happier and the relationship between myself and my stepson has moved much further forward. My wife and I have regained our loving relationship and whilst the opportunities haven't got better, the outcome is much more satisfactory to us both.

Time and again stories like this completely go against the idea of testosterone being the hormone responsible for male aggression and violent behaviour. Usually what is often described all too literally as "impotent rage" is associated with low levels of testosterone activity. When they are restored to normal by treatment the man feels more confident and assertive, though this doesn't seem to overshoot into aggression. At home, they may have got used to having a human doormat around, and the marked change may not always be welcome as the new man puts his foot down with a firm hand.

REDUCED LIBIDO

The word libido means sex drive, and is the same word in Latin where it was taken to mean desire or lust. One thing that men and women have in common is that their level of libido at any one time is governed by both the higher centres in the brain, conditioned by life experience and social factors, and by hormonal factors, principally testosterone.

This is surprising, since men normally have about twenty times the testosterone level of women, but though men may set the ball rolling more often, most couples end up with a fair measure of agreement about a happy level of sexual activity between them. Extreme exceptions such as when a man is a multiple rapist or a misogynist, or a woman a nymphomaniac or totally frigid throughout her life, are nearly always due to psychological causes rather than hormonal ones.

However, because the baseline level is so much lower in women, relatively small variations may cause big swings in libido. For example, at the middle of the menstrual cycle, when the woman is ovulating and at her most fertile, there is a surge in her testosterone level to put her in the mood for sex. Women who are more assertive, and take up more traditionally masculine roles in society such as solicitors or business bosses, have been found to have slightly higher testosterone levels and frequently are sexually more active. In the USA complaints of sexual harassment of male employees by their female bosses are becoming relatively commonplace, which was unheard of a few years ago.

Though the factors affecting libido are complex, and are the subject of a series of books "The disorders of sexual desire" by the American sexologist, Dr. Helen Singer Caplan, many women with low libido, particularly around the time of the menopause, can be helped by carefully administered low dosage testosterone. If the dose is excessive, not only may masculinising effects such as increased facial hair and enlargement of the clitoris occur, but the libido may become excessive. The Australian feminist Germane Greer described on a television programme how she was put in an embarrassing situation when a doctor gave her too much of a long acting testosterone compound, and she suddenly found out "what a rapist felt like".

In the States, a group of women who call themselves "The Third Sex" deliberately take high doses of testosterone. Despite having to shave hair all over their body frequently, and getting shrinkage of their breasts, they reckon that the overall buzz they get from it, and the almost insatiable sexual appetite that goes with clitoral enlargement, makes it worth the chemical sex change.

With the andropause, one of the commonest complaints, present in eighty per cent of cases, is a reduction in libido. This usually comes on gradually over a period of months or years, as the level of active testosterone wanes. If the onset is sudden, or related to a particular event such as illness, the arrival of the first child in the family or finding out that the wife or girl-friend is having an affair, this suggests a physical or emotional cause rather than a hormonal change. However in extreme cases one can lead to the other.

The fall in libido affects every aspect of a man's sex life, reducing the frequency of sexual thoughts, fantasies and even dreams. The number of times he feels in the mood for sex goes down, and the partner may be convinced, usually entirely wrongly, that he has gone right off her, is having an affair, or both. This can often cause problems in the relationship, which further saps the libido, because it can be difficult to be sexually turned on by an angry partner.

In nearly half the cases, the woman's libido joints the downward spiralling of desire, so that neither party may think it worthwhile to seek help, resulting in what could be described as a "dead heat". This is when the most beautiful, attractive or available of women fails to raise the slightest sexual interest. In the most extreme cases even the head-turning reflex that causes the male gaze to briefly lock onto any remotely interesting female, can disappear.

The laws of the "Chemistry of Charisma" also dictate that as a man's desire decreases, so generally does his desirability. The sexual chemistry that at every level drives what Noel Coward called that "sly biological urge", is no longer working and the song of "Let's do it" becomes "I won't dance - Don't ask me".

REDUCED POTENCY

Reduced potency, in terms of obtaining or maintaining an erection is one of the most distressing symptoms of the andropause in about eighty percent of cases. The many associations of the word "potent", from the same Latin word meaning to have power, strength, ability or authority, or to be able to achieve the sexual penetration of a woman and to father children, seem to contain the essence of masculinity. When it is even temporarily lacking, usually the person feels much less of a man in all areas of his life and is often more ashamed of this than any other symptom. Just using the modern medical parlance of "erectile dysfunction" doesn't help a lot when the blunt fact of the matter is that in all senses of the term you can't get it up or keep it up, and you feel down about it.

After all, when you talk about a potentate, you mean a ruler or a monarch who leads any group or endeavour, and has the power and position to rule over others. In many Eastern countries it is traditionally accepted that a ruler can have many wives or mistresses to demonstrate his position of dominance. When however his sexual vigour falls, and it becomes common knowledge that it has, his fall from power often occurs soon afterwards.

The onset of erection problems is usually gradual, and often starts insidiously with fewer early morning spontaneous erections, or "Morning Glories" as some people call them. As the comedian Robin Williams, who himself looks like a regular "High-T Guy" quipped in a recent stage show televised at the Metropolitan opera House in New York, the penis is usually up and on parade five minutes before you are in the mornings. Indeed the penis can be compared to a stand-up comedian who if he has a few bad shows, and worse still gets booed by the audience, gets nervous and doesn't want to stand up and do his act. This is appropriately called performance anxiety.

Though usually brief, these spontaneous morning erections are an important sign that the erection mechanism is working properly and has been primed by the testosterone surge which normally occurs around wake-up time. This is probably due to the overall decrease in free testosterone which I have shown in the andropause and by the reduction in its daily variation with increasing age reported by other researchers. This view is supported by the fact that early morning erections are one of the earliest signs of restoration of potency by testosterone, and this often happens within a week or two of starting treatment.

Another way in which erection problems begin is with occasional failures when tired, stressed or having had a few drinks, and then they become more regular events, or non-events depending on which way you look at it. The progress of the problem is frequently erratic, and depends to some extent on the attitude of the partner. If she is relaxed about it, encouraging and supportive, and willing to help by trying massage, oral sex or different positions, the problem may not progress or may even be temporary. If however she is uptight, dismissive and hypercritical of his performance as a lover, performance anxiety soon sets in and with several such "put down's" he is likely to stop trying all together. Nothing is more destructive of the male ego than criticism of either his ability to drive a car or maintain a satisfactory erection.

It is made even worse if news of his short-comings is leaked to her friends or his. This of course is why men are reluctant to own up to having this problem, even when talking to their best friend or their doctor. It is a major reason why men try to laugh off the idea of there being any such condition as the Male Menopause because the idea is too threatening to their self-image as potent males. As we shall see later when the causes and treatment of erection problems are discussed, this is a view which is very much in need of change, especially as there are a whole range of methods, including testosterone treatment in particular, which can relieve this particularly distressing symptom of the andropause.

Because the erection starts more slowly, is more difficult to maintain and often lasts a shorter time, sexual activity may often be rushed and is less satisfying for the woman who is often slower to become aroused and to reach orgasm especially when they themselves are post-menopausal. Anxiety makes the situation worse and can lead to premature ejaculation, complained of by a quarter of my patients, as they hurried to completion while they still had an erection.

Alternatively, because of the decreased sensitivity of the penis which seems to occur in low testosterone states, there may be delayed ejaculation, as was experienced by another quarter of my patients.

Another factor contributing to this problem is the lack of tone and development in the pubococcygeal (PC) muscles around the urethra and base of the bladder. These contract, as do the corresponding PC muscles around a woman's vagina, during orgasm. Like other muscles in the body, with testosterone inactivity and lack of use, their contractions get weaker, and as the patients put it, the earth no longer moves for them or their partners.

Reduced penile size, particularly when erect, sometimes accompanies severe testosterone deficiency, and can also become a problem for both partners. Though it is often said that size doesn't matter, most males are acutely aware of the usual size of their penis, both flaccid and erect, and get very upset if this area of their vital statistics is on the way down.

Recent research has finally caught up with common experience when considering factors affecting the woman's views on penile size. Though in the 60's Masters and Johnson the American sexologists tried to make out that a woman's pleasure and orgasm was solely the function of the little bundle of erectile tissue and nerves called the clitoris, the man who can only deliver stimulation there is likely to be operating in an erroneous rather than erogenous zone.

"Vaginal sensitivity is an anatomical reality" says John Perry, a clinical sexologist and co-author of "The G Spot". While there may not always be a distinct, raised G spot, the higher part of the front wall of the vagina, especially close to the urinary passage, the urethra, is richly endowed with nerves that play a major part in helping a woman reach orgasm. Part of the secret of sexual satisfaction therefore is to have this G spot stimulated by the tip of the penis. This can be achieved by having the right size penis in the right sized vagina, or by varying the position to improve penetration. As well as reducing the firmness of pressure on both the clitoris and G spot, testosterone inactivity can shrink the penis to the point where partners who have been physically compatible in this area throughout a long mutually enjoyable sexual relationship gradually become incompatible, to the distress of both.

Though to some extent it can be regarded as natural for the frequency and firmness of erections to reduce gradually with age, it is rapid acceleration of the process over a few months or years which should be thought of as abnormal and certainly worth investigation by a doctor specialising in this complicated field of general medicine, the Andrologist I described earlier.

The causes of erectile problems are many and varied, and by the time the patient comes for treatment several overlapping factors are usually present at the same time. There may be narrowing of the arteries by which blood is pumped in to expand the penis. There may be too much blood leaking out of it though ageing veins, like a leaky cycle tyre. There may be poor nerve control as with sugar diabetes or as a result of the side effects of tranquillisers, anti-depressants or the drugs used to treat high blood pressure. Especially after the problem has been causing great distress to both partners, there are certainly likely to be relationship problems as well as the dreaded performance anxiety.

A very broad approach is therefore needed to treating what may seem like a simple mechanical fault, and important though I believe such treatment is, it is not just enough to throw testosterone at it and hope the problem will go away and stay away. To do the job properly the whole man has to be screened and a range of treatments appropriate for that patient needs to be advised.

PREMATURE AGEING

With the increasing use of Hormone Replacement Therapy for women, who are managing to feel and look far younger than their mothers did at the same age, men are also beginning to wonder whether there isn't some hormonal treatment which would help them stay happier and healthier for longer.

HEART

To a great extent the andropause can be thought of as a form of premature but reversible hormonal ageing, and I believe that TRT offers great hope in preventing as well as treating many of the conditions associated with advancing years in the male.

Generally you're as young as your heart and brain, which largely depends on how good the circulation is to these two vital organs. When HRT for women was first cautiously introduced over thirty years ago, doctors feared it might contribute to diseases of the blood vessels, and if a menopausal woman had even a family history of heart trouble, let alone cardiac disease herself, they said HRT was contraindicated, in other words it wasn't for her. Much to their surprise, actual experience over thirty years has shown the reverse to be true. In other words, they found half the number of heart attacks in women who took HRT than in women who didn't. With some reluctance, the doctors began to change their tack and said the treatment was positively indicated in women prone to heart disease.

The situation is the same with testosterone. Over the last fifty years, most doctors, including cardiologists, took the view that testosterone must be bad for the heart for two totally fallacious reasons. Firstly, under the age of fifty, men get five times as many heart attacks as women in most western countries, though the women catch up soon after that age unless they are on HRT. According to this line of reasoning, therefore testosterone is bad for the circulation and oestrogen is good. Secondly, because of the uniquely bad effects of the most commonly used preparation taken by mouth, methyl testosterone, and its abuse by athletes taking the wrong drugs, in the wrong doses for the wrong reasons, anabolic steroids had a very bad medical and lay press.

I used to share these views myself until about twenty years ago when as described in the previous chapter I met the Danish physician, Dr. Jens Moller, who totally changed my view of testosterone and lead me eventually to see it as a very important and beneficial hormone for preventing and treating heart and circulatory problems. It was truly a case of seeing the light on the road to Copenhagen!

Several studies both from Britain and America have more recently shown lower levels of testosterone, and sometimes higher levels of oestrogens, in patients who later developed heart disease than in normal control subjects the same age. Other studies have shown the benefits of anabolic steroids in treating a range of circulatory problems from ulcers on the feet to strokes in the brain.

CIRCULATION

Fortunately, the problems experienced by the typical andropausal patient are relatively mild, and limited to cold feet and hands, especially in the winter. What confuses the issue still further however is that the smaller blood vessels also become less stable in their reactions to heat, cold, alcohol and other stimuli. Though less common than in menopausal women, men with this condition can experience attacks of a feeling of redness and warmth in the face, which may spread to the skin of their neck and face in warm surroundings or with alcohol.

These "hot flushes" or "hot flashes" as they are called in the states, can be very marked, and are acutely embarrassing to the men who suffer them.

Imagine how a senior executive feels when he stands up to make his key presentation at a sales meeting, and starts by going beetroot red as though he was deeply ashamed of his pitch. This is made even worse by the tendency to sweat profusely so that the man looks both hot and bothered. Though less than a quarter of the men I originally studied had hot flushes, over half complained of increased sweating, especially at night. This could sometimes be severe so that not only the night clothes but the sheets as well may be drenched with sweat. Some of the men even felt they might have caught these symptoms off their menopausal partners.

MUSCLES AND BONES

Another common symptom of the andropause is a general feeling of deteriorating physical condition. This is partly due to the decrease in muscle bulk and strength which accompanies the reduced level of testosterone activity. Also there is often diffuse aches, pains and stiffness both in the back and many joints in the body, particularly in the hands, ankles and knees, causing the "Frankenstein Syndrome" as the first few creaking steps are taken on rising first thing in the morning. This is remarkably similar to the joint symptoms experienced by many menopausal women, closely mimicking arthritis, and fortunately usually shows similar dramatic improvements on hormone treatment.

Osteoporosis, the thinning and weakening of the bones which causes older people to lose height from shrinkage and even collapse of the vertebrae, the dowagers hump in women, is also a source of much pain, unhappiness and disability in men. Though generally not as common or severe it tends to come on later in life, in men of seventy onwards, and affects the spine where it causes back pain and stiffness especially in the neck, and in the hips, where it contributes to osteoarthritic degeneration, and sometimes fractures.

These symptoms are made worse, and the osteoporotic process is probably accelerated, by the reduced size and strength of the muscles which accompanies the reduced activity of testosterone which occurs in the andropause. Testosterone and exercise are the two main factors controlling muscle mass and strength in the male, just as together with calcium and protein supply, they have a important effect in maintaining bone mass and strength.

This is why as well as the joint pain and stiffness, many andropausal men complain of a generally deterioration in their level of physical fitness. This is particularly noticeable if they are used to high levels of performance such as jogging or marathon running, when they find that their times for a given distance are going up and up. Those who like to work out in a gym notice that their exercise volume, the amount of work they can perform in a session, is decreasing, and the number of repetitions of exercises such as press-ups or sit-ups they can do goes down.

They also find that their overall strength in terms of the weights they can lift goes right down. This, together with the decrease in muscle bulk that causes the pectoral muscles, biceps and thigh and buttock muscles to lose their hard-earned splendour, as well as the overall lack of drive and motivation, may even make the man give up exercise just when he most needs it. Its all very discouraging, and even the sexual athlete may start making excuses to avoid having to perform.

HAIR

Another area of male vanity affected by the andropause is the hair. Just because a man has typical male pattern baldness and plenty of hair on his chest does not mean, as is frequently assumed and quoted even by doctors who should know better, that his testosterone activity is normal. Baldness in men is almost entirely hereditary, and even if a man's hair is going to go, its going to happen whatever his testosterone level, unless he has been castrated before puberty.

Though the amount of hair on the chest is also hereditary, it is also affected by lifelong testosterone levels, and sometimes if it is very much reduced, and the man only has to shave once or twice a week, it can indicate a life-long insufficiency of the hormone. Also, on testosterone treatment more hair may appear on the chest, back and pubic region which improves the man's macho image of himself.

However, the condition of the hair and scalp, and possibly its colour is affected by testosterone. In the andropausal male the hair is often dull, dry and lifeless with a tendency to dandruff. The patient may say he is going grey very quickly, and its interesting that some notice a return of colour to their hair on testosterone treatment. A few have even been accused by friends and relations of using hair colour restorer, and many notice the improved condition of the hair and scalp. Fortunately, testosterone treatment does not accelerate the rate of going bald, and may even slightly slow it down.

SKIN

Like the hair, the skin is also sensitive to the action of testosterone. One of the ways in which the hormone is excreted from the body is as the sebum which normally oils our skin, and makes us more water resistant and drip-dry. This is why when teenagers get a pubescent surge of testosterone, they often suffer acne from blocked pores choked with surplus sebum. This also is sometimes seen in athletes overdosing on anabolic steroids.

In the andropausal male there is insufficient sebum and so the skin, particularly on the face and hands is noticeably dry in nearly half the cases. There may also be thinning of the skin as collagen production is decreased, which makes it look thinner and more wrinkled. This could be why one of the derogatory terms for older people is "wrinklies". Again this process is reversed by TRT, and the person often appears more "shrink-wrapped" as one patient's wife remarked.

This wide range of mental and physical symptoms of the andropause often feels like the onset of old age to a man in his fifties or later, and causes great but fortunately unnecessary alarm. He feels he is definitely over the hill, and going fast down the other side. Even the patient' s doctor, especially if suffering from similar symptoms himself, all too often fails to spot the need for male hormone replacement treatment, or may not even know of its existence. "It's your age" he says, "Nothing can be done".

Its my goal in writing this book to make the point that though age may be one of its causes, there is a lot of other factors involved in the andropause, and in most cases a great deal that can effectively and safely be done about it!

The first thing is to make the diagnosis and the second is to treat the condition. In my experience, the patient and his partner are often as good, if not better, than the doctor in deciding when the andropause has arrived . Many of my patients were referred to me by their wives, who had accurately assessed their symptoms, related them to their own experience of the menopause, and in some desperation asked if there was any equivalent to the hormone treatment which had given them so much benefit.

Let's recap at this stage with a brief list of the symptoms of the andropause, and compare them with the menopausal symptoms in women.

SYMPTOMS OF THE FEMALE MENOPAUSE

MENTAL PHYSICAL

Fatigue Ageing

Depression Aches and Pains

Irritability Sweating and Flushing

Reduced Libido Sexual Enjoyment Decreased

SYMPTOMS OF THE MALE MENOPAUSE (ANDROPAUSE)

MENTAL PHYSICAL

Fatigue Ageing

Depression Aches and Pains

Irritability Sweating and Flushing

Reduced Libido Sexual Performance Decreased

The picture of the andropause is often, as you will see from the comparison of symptoms above, just as obvious as the female menopause and essentially the same, but to serve as a more detailed guide I have designed the following andropausal check list, which is a shortened version of the one I use in my clinic.

This will enable you to determine with a fair degree of probability whether you, a friend or a partner is andropausal, though only assessment by a doctor experienced in this field and a full hormonal profile will confirm or exclude the diagnosis.

ANDROPAUSE CHECK LIST

___________________________

30's 40's 50's 60's 70's +

Multiply ticks in each column by: | 0 | 1 | 2 | 3 | 4 |

If there has been mumps orchitis or other testicular problems, a prostate operation or inflammation, persistant urinary infection or vasectomy, each adds four points to the total scores.

TOTAL ANDROPAUSE SCORE | |

ANDROPAUSE RATING: 0-9 UNLIKELY, 10-19 POSSIBLE, 20-29 PROBABLE,

30-39 DEFINITE, 40+ ADVANCED.