Chapter Four - How it Happens
Why should one man suffer all the miseries of the male menopause in his forties or fifties and another in his seventies or eighties escape them entirely? I am reminded of the Viking warrior, cold, damp and miserable on a bleak landscape in a thunderstorm, shaking his fist at the sky and crying out "Why me O Lord? Why me?". After a pause for thought, a thunderous voice from the heavens replies "Why not?". Similarly, though the roots of this condition can usually be traced to one or several of the hammer blows of fate which affect us throughout life, sometimes its causes remain unknown.
Lets look first at how testosterone is produced and the key role it plays as a major contributor to the force of destiny which shapes both our beginnings and ends, "rough‑hew them as we may".
Hormone of Kings ‑ King of Hormones
The hormone testosterone brings us into being. It regulates the sex drive in both men and women, it develops the male sexual characteristics such as dominance, drive, assertiveness, strength, body shape, hairiness, and even odour in the form of sex‑steroid breakdown products called pheromones, which may turn women on or off. It governs sperm production as well as potency, and therefore has the casting vote on whether or not conception takes place.
Being mainly released by the testes in the male, it is a major factor in deciding, both physically and mentally, whether we develop into a man or a woman, a homosexual or heterosexual, a poet or a boxer, a wimp or a champ. As described in the book "Brain Sex " it even literally shapes our brain, decides our creativity, intellectual skills, thought patterns, and our drive and determination to explore ideas and follow them through. It is an over‑riding influence in controlling not only our potential, but also the use we make of it. It governs our sexual and social history.
Testosterone also affects our health throughout life ‑ how we grow as children whether we thrive and whether we become a muscular Adonis in our teens, or a weed with acne, and even whether we die in a fight or motorcycle accident in our youth. It affects to what extent stress will undermine our health in middle age, how we will die from the premature ageing that testosterone deficiency can cause, especially in the heart, and therefore controls both our vitality and longevity.
It can also be regarded as the "Success Hormone". A study funded by the National Institute of Health in the United States compared testosterone levels with personality type in over 1,700 men. It was found, according to Dr John McKinley the medical statistician who analysed the results, that typically the male with high testosterone "attempts to influence and control other people, who expresses his opinion forcibly and his anger freely, and who dominates social interactions". This made them more aggressive, competitive and sometimes more successful.
These findings closely mirrored those of Professor James Dabbs a psychologist at Georgia State University. He studied 5,000 Vietnam war veterans and found that antisocial "sensation seeking" behaviour more often occurred in high‑testosterone men with little education and low income jobs. Those with more education and money had opportunities for a wider range of outlets for this type of behaviour. "They can do things that are both exciting and sociably acceptable ‑ driving fast cars rather than stealing them, and arguing instead of fighting" said Dabbs. He also found that both men and women in more extrovert and expressive occupations such as actors, entertainers, football players and even women lawyers had high levels of testosterone, while clergymen had low levels. In this way it seems that testosterone affects every aspect of our lives as men.
The command centre for testosterone control is the brain. This has a variety of interrelated checks and balances which promote or suppress production, according to the needs of the body at that stage in life and at that particular time.
The highest functional part of the brain, the cerebral cortex, stimulates testosterone production when we are aroused, and feel we are succeeding in life. When we are bored or angry with our partners or overstressed and feel we are losing in life's battles, research has shown our testosterone goes down. These reactions are controlled day to day by the "concert organiser", the so-called hypothalamus at the base of the brain, and hour to hour by the "conductor of the hormone orchestra of the body", the pituitary gland. This vital gland is the size and shape of a small cherry in the adult, and is suspended by a short stalk from the hypothalamus from which it receives its regulatory messages. Accordingly it produces a wide variety of key hormones which stimulate or suppress the various glands in the body, including the testes.
The pituitary hormones which control the sexual organs in both men and women are called gonadotrophins. There are two of these, named according to their functions in the female. One is called Follicle Stimulating Hormone (FSH) because it stimulates the growth of the follicles in the ovary which contain the eggs, though in the male it is mainly concerned with promoting sperm production. The other is called Luteinising Hormone (LH), and regulates the production of oestrogen by the ovaries, and testosterone by the testes in the male. However recent research suggests that there are some interactions between these hormones in controlling testosterone production.
Research has shown that over 95% of the 6‑7 mg of the testosterone produced daily by the young male comes from the 500 million "interstitial" or "Leydig" cells in the testes, the remaining 5% coming from the adrenal glands capping both kidneys. Blood levels in men are usually about twenty times those in women, where the adrenals and ovaries are the main production sites. Eunuchs are therefore likely to have the same testosterone levels as women, just as men usually have the same oestrogen levels as post‑menopausal women whose ovaries have stopped its production.
The raw material from which testosterone is synthesised in the body is cholesterol, and it was shown in 1984 by a group of Finnish researchers that low fat diets, especially when the proportion of the "healthy" unsaturated fats was increased, lowered both total and free testosterone levels in the blood. This may be one explanation for the sad fact that any decrease in heart disease produced by these diets or cholesterol lowering drugs tends to be outweighed by increasing deaths from suicide, homicide and accidents. Though life isn't any longer, it seems a lot longer low‑fat, low‑fun, low‑sex diets.
It seems unfair that the limp‑lettuce diet foisted on an unsuspecting public by dietary dogmatists might be contributing to the lower testosterone levels, and the impotence seen in many menopausal males. One wonders what the more drastic cholesterol lowering drugs that some of my patients have been put on just before the onset of andropausal symptoms are doing to their androgen levels.
On the other hand we have the sexual athletic performances of the sixteenth century legendary lover Giacomo Casanova, who boosted his testosterone levels with large numbers of raw eggs before each of his amorous marathons. It was reputedly the pox rather than heart disease which killed him at the age of 73.
Also, as pointed out in my book "The Western Way of Death - Stress, Tension and Heart Disease", 75% of the cholesterol circulating in the blood stream is made in the body by the liver, and is increased by stress, and only 25% comes in from the diet. Stress, as well as reducing testosterone secretion, has other harmful effects such as raising blood pressure and increasing blood clotting, so there is a lot of evidence that where heart disease is concerned "Its not so much a matter of what you eat as what's eating you".
One of the many compounds produced on the long production line leading from cholesterol to testosterone rejoices in the name of dehydroepiandrosterone, known to its aficionados as DHEA. This is an interesting steroid because its production rate is directly related to that of testosterone, and it has been shown to decrease linearly with age which gives further evidence about the possible origin of the male menopause. It has even been given clinically in one trial on ageing men, and provided some of the benefits of testosterone treatment. However, it is more expensive than the latter, and seems a roundabout way of promoting its synthesis if that is what is needed. Also, some may be converted into oestrogen, which antagonises testosterone actions, and so in certain patients it could be counterproductive. However it is certainly worth looking at further as a way of increasing natural testosterone production in the body.
Similarly a hormone from the pituitary gland, growth hormone, can boost the action of testosterone, and has been claimed to have rejuvenated a small number of American Veterans on whom it was tried. However it needed twice weekly injections, was about ten times as expensive as testosterone, and unlike that very safe medication, caused rises in blood pressure and sugar levels.
Even in the womb, there are larger amounts of testosterone present in the blood of males than females. This starts as early as six weeks after conception, reaches a peak of five to six times higher at twelve weeks, and then falls back to female levels at about six months of intra-uterine life. By that time of course, development of all the organs in the body are nearly complete, and mentally and physically the die is cast either in the male or female image.
This not only applies to the genitals, where the development of the penis, and the descent of the testes into the scrotum prepared to receive them is largely under the control of testosterone, but also the brain, where the balance in function between the two hemispheres is supposed to be influenced by this hormonal difference. The mountain of inescapable evidence that men are different from women in a whole range of aptitudes, skills, and abilities, and that these differences depend much more on hormonal nature than social nurture is brilliantly reviewed in the book by Anne Moir and David Jesell, "Brain Sex - The real difference between men and women".
After birth there is another surge of testosterone going up almost to adult male levels, starting at about two weeks, reaching a peak at 10 weeks, and then dropping back to female levels at six months and staying there till puberty. These early months are also a period of active brain growth and development during which further sexual differentiation can arise. It seems likely that the traumas of birth and the first six months of life afterwards, such as prematurity, failure of maternal bonding, malnutrition and infections might all reduce testosterone production, and be one of the factors which predispose a sickly infant to being a sickly adult.
At puberty in the male, the testosterone rises rapidly, reaching a maximum of about twenty to thirty times the infant level at about age eighteen. This causes the pubertal development of hair on the face, armpits, pubes, and to a more variable extent which is mainly due to hereditary factors, on the rest of the body, particularly arms, legs and chest. Whether a man goes bald or not later in life again seems to be more down to heredity than hormones, as unless he is castrated before puberty, its what's in his genes that decides whether he keeps his hair for life, rather than what's in his jeans. Fortunately, giving the adult male extra testosterone does not seem to contribute to baldness, and some even report improved hair condition and restoration of hair colour.
Also at puberty, the testes enlarge and descend into the scrotum, libido surges, the penis enlarges, erections occur spontaneously particularly at night and in the early morning, and if not relieved by masturbation or intercourse, spontaneous emissions or "wet dreams" happen, all of which can be associated with an unreasonable amount of adolescent emotional upset and guilt. At the same time the voice tone deepens and "breaks" due to thickening of the vocal cords, and the excess hormones and closely related sexual scents, the pheromones, are pour out in the sweat and skin oil, the sebum, which causes the social and physical discomforts of acne. Helped by growth hormone from the pituitary gland, there is an increase in muscle and bone growth in the male, but above a certain level testosterone switches off the later, and between the ages of eighteen and twenty growth usually ceases.
In eunuchs, and men with low levels of testosterone because the testes fail to develop or descend, growth may continue and the man gets taller than other men in his family. At the other extreme, high levels of testosterone may arrest bone growth, and a highly sexed and hairy, shorter man result. This could be the hormonal history of cuddly Dudley Moore, once described as a "sex‑thimble", and the far less cuddly, but also sexually active, Napoleon Boneparte. The statue of him standing naked in heroic pose on show in Apsley House at Hyde Park Corner in London, indicates that he was well endowded in sexual stucture as well as function. However, by the time he died, a beaten man possibly suffering lead poisoning, Napoleon was found to have severe genital atrophy. Wonderful are the permutations and combinations of heredity, hormones and history which produce the individual physique and temperament.
Testosterone and the Male Menopause.
One of the main reasons why the idea of the male menopause has proved so controversial is that unlike the female menopause, where there is a clear and easily measurable precipitous drop in oestrogen level, it is difficult to show any such fall in the male suffering similar symptoms. To understand why this is so, we must enterprisingly "boldly go" a little deeper into the mechanics of testosterone control and action.
The small but vital amounts of testosterone produced in the testes are immediately swept away round the body in the blood stream, and are mainly bound to a special carrier protein called "Sex Hormone Binding Globulin". This SHBG as it is usually called is a key player in this "Who stole the testosterone" mystery, since it grabs the hormone and runs, and seems reluctant to part with it. The more SHBG there is, the less free, active, "Bio‑available" testosterone is able to get out of the blood into the cells to do its job.
The availability of the testosterone can be measured as the "Free Androgen Index" or FAI, which is the total testosterone level in the blood divided by the SHBG level multiplied by a hundred, and is usually between 70 and 100%. It is when the FAI falls below 50% that symptoms of the andropause usually appear, which has been one of the key findings in my research in over one thousand patients presenting with andropausal symptoms at my clinic in London.
This seems to be because the way in which the body regulates the amount of testosterone available at any one time works well in youth, when there is usually plenty of testosterone, whose level of activity is controlled by a roughly equivalent amount of SHBG. If testosterone levels drop temporarily for any reason, the SHBG falls to compensate for this, and so the amount of testosterone available, expressed by the FAI, is kept constant. However, later in life, especially around the age of fifty, this "Testostat" mechanism seems to break down in many men, and the andropause results. A car-dealer patient of mine called SHBG “Sex Hand-Brake Globulin” because he felt his engine was revving, but his brakes were on.
What goes wrong in this key part of the body's hormonal balance? The possible explanations are that either the amount of testosterone "income falls" due to understimulation of the testes by the hypothalamus and pituitary, deficiency of raw materials for its production and wearing out of the testes, or that the "expenditure" in terms of amount taken up by the SHBG and that used up in repairing the ravages of age, stress, alcohol and other forms of wear and tear rises. Also the cells all over the body which are the targets for Cupid's testosterone arrows may get tougher with age, more difficult to penetrate, and less responsive to its effects.
A life‑long programme of research by a Belgian Professor Alex Vermeulen at the University of Ghent has shown that all stages in the production and action of testosterone can be affected by the ageing process. Particularly after middle age, the amount of testosterone produced falls because of ageing of the interstitial cells that produce it in the testis. Thirty years ago this was very clear because the amount of testosterone appearing in the urine was found to drop steadily with age, since it represents the "free", active hormone. Also, twenty years ago a group of Canadian doctors showed that from about the age of forty onwards, testicular size and the amount of free testosterone began to decrease, and the pituitary driving force increased to try and compensate.
However, what still confuses critics of the male menopause theory even to the present day is that the level of total testosterone as measured in the blood only falls slightly up to the age of seventy. It is because the hormone is being held in the blood by rising levels of SHBG, and so less is "bio-available" to be taken up by the target receptors in the tissues or excreted in the urine. This has been confirmed in nearly a thousand of my male menopause patients, where only 13% showed abnormally low total testosterone levels in the blood, but mainly because of raised SHBG levels, about 75% had a low Free Androgen Index which is the key diagnostic finding in this condition. About 70 % of the patients also showed raised levels of the pituitary hormones which stimulate the testis, the LH and FSH, which confirms that the level of testosterone activity is insufficient for the body's needs.
This situation was recognised and proved from urinary studies fifty years ago, but thanks to the complications introduced by blood tests, doctors are still able to argue about it and keep the Male Menopause controversy going. There are many patients who have come to me saying that they had classic andropausal symptoms, but their doctors measured their total testosterone levels, found it normal or low normal, and said that there was nothing wrong with their hormones, and it must all be psychological. Fortunately some persevere in the belief that it is their hormones that are out of order rather than their minds, and get the additional tests done to complete the diagnosis and start rationally based testosterone treatment.
The normal patterns in hormonal development can be delayed, arrested or modified at any stage of life. About 10% of the male menopause patients I have seen probably had lower than normal testosterone levels from puberty onwards. These cases were sometimes due to the testes never having functioned properly because of failure to descend into the scrotum, only partially descending, or retracting back into the abdomen too easily.
These varying degrees of partial non-functioning or impaired development are known as primary hypogonadism, meaning that the testes have never become fully active, to distinguish these conditions from those where the testes only failed later in adult life, secondary hypogonadism. Mild degrees of primary testicular insufficiency may not be obvious, or indeed interfere with sexual characteristics or function noticeably till middle‑age or later, and it can be difficult to tell what is primary and what is secondary.
The Oestrogen Threat to The Male
Much of this life‑long threat to fertility and virility can be explained by increasing exposure to chemicals in the environment with actions similar to those of the female hormone, oestrogen, the so called Xeno-oestrogens, and others which have recently been found to have an anti-testosterone action, Anti-androgens, as well as the decreasing amounts and activity of this male hormone.
Oestrogens, though essential for the development of female characteristics, seem to work against the actions of testosterone in the male. This was seen most dramatically in women given the strong synthetic oestrogen Stilboestrol during pregnancy to reduce the chances of a miscarriage. When their sons were born, a considerable number had undescended testes, and abnormal genital development. Later in life they were also noticed to be infertile because of low sperm counts.
Rising levels of these Xeno‑oestrogens, derived from everything from plastics to pesticides, are thought to be having a harmful effect on fertility, sexual development of male offspring, and even in contributing to rising testicular and prostate cancer rates. Perhaps future generations of archaeologists will come across thick strata of plastic bags, marking the demise of "homo plasticus" or "plastic bag man" who was neutered by the by-products of the consumer society.
For a wide and increasing variety of reasons men seem to be drowning in this sea of oestrogens. Even the uterine bath water they swim in during the first nine months of life inside the mother is laced with rising levels of such hormonally‑active compounds. Evidence of this is the increasing numbers of boys being born with hormonally caused birth defects in their sexual characteristics This is especially marked in the condition known as hypospadias, where the penis is poorly developed and opens towards the base rather than at the tip. Also, because of the continuing influence of these oestrogenic compounds, the testes increasingly often fail to descend from the abdomen into the scrotum, which not only decreases their ability to produce sperm, but also reduces their testosterone producing capacity.
Exposure to oestrogens at any time of life can have a bad effect in the male, particularly around the time of puberty. One patient of mine, when he was at university in his late teens, made the mistake of telling his college doctor that he felt over‑sexed. The doctor over‑reacted by giving him a month's course of oestrogen. It worked well, his libido died overnight, and he was able to concentrate on his studies. The unfortunate thing was that his libido never recovered, he never married or had children, and when he came to see me at the age of forty‑five it seemed that he had a premature menopause, with no other apparent cause.
An interesting sub-group of my patients which appeared to show occupational risk factors for the andropause were farmers. The health of these "front-line" troops in the agrochemical arms race towards greater productivity and profitability, makes an interesting study in relation to chemical pollution of the environment.
In some the causative agent of their symptoms appeared obvious. The main relevant feature of their case-histories was that they had worked on farms when they were young men caponising chickens or turkeys with oestrogen pellet implants or creams, to make the birds plumper and more tender. Unfortunately, though it might be considered poetic justice, they must have taken in large amounts of oestrogen either by absorption of the oestrogen through the skin or lungs, or by eating the birds shortly after the treatment, which caused them to partly become caponised themselves.
In a similar case in cattle, an andropausal patient from Canada recently told me how on his farm he and his brother often ate beef, without waiting for the 48 hour so‑called safety limit to expire, after giving their cattle long‑acting hormone cocktails supposed to promote growth for up to three months. Either they misread the instructions, or they were being seriously mislead by the manufacturers of these dollar‑a‑shot mixtures.
Clinically, as well as severe andropausal symptoms of fatigue, depression, irritability and loss of libido and potency, there was usually enlargement of their breasts (gynaecomastia), testicular atrophy, low total testosterone, high SHBG giving a reduced free androgen index, and elevated FSH and LH levels, similar to those seen in primary hypogonadism.
Another subgroup of farmers however had similar symptoms, but gave a history of exposure to other potentially anti-testosterone hormones or pesticides used in farming. Here the clinical and endocrine features were less marked, and fortunately both groups responded well to androgen treatment either orally, or by testosterone pellet implant.
The latter group however could well have been examples of anti-androgen activity from any one of a wide range of antimicrobial agents, pesticides and fungicides. For example it was observed twenty-five years ago that coccidiostats given to chickens produced maximum weight gain for minimum food intake, but as with the use of oestrogens they were banned because they caused men to develop large womanly breasts and infertility.
A wide range of drugs used in medicine are known to have this property. Detailed studies of such compounds, taking into account the possibly differing effects of different forms of the same molecule (stereoisomers), may give clues as to their complex hormonal interactions.
My first Professor of Biochemistry at the Middlesex Hospital in London, Sir Charles Dodds, working with a group in Oxford, was the first to describe Xeno-oestrogens in an article in Nature dated 5th February 1938 "The Oestrogenic Activity of Certain Synthetic Compounds". He compared the structure of what he proposed should be called stilboestrol, which his group had just synthesised, with naturally occurring hormone called oestrone.
Later the same year he described the oestrogenic actions of a range of related compounds and noted the "large effects of relatively small changes" in related molecules. These two historic papers set the scene for mass production of oestrogenic compounds for both therapeutic and veterinary purposes, and could explain some of our present concerns on the effects of xenoestrogens and androgen receptor antagonists.
Just as small changes in molecules can greatly increase their oestrogenic activity, so apparently minor modifications can make them much more powerful anti-androgens. This was dramatically demonstrated by Kelce and his co-workers in an article in Nature in June 95 which showed how the major and persistent metabolite of DDT, p,p'-DDE had little oestrogenic activity, but fifteen times the antiandrogen effect of the parent compound.
This was one-fifth of the potency, if that is the right word, of the most powerful anti-androgen used in medical and veterinary practice, flutamide, the well-known side effects of which are to induce severe andropausal symptoms and gynaecomastia. The similarities in the structural formulae of these compounds, together with that of the known antiandrogen vinclozolin, used in agriculture as a fungicide is apparent when you look at their molecular structures.
Fortunately, the chemical castration of man and beast by the use of overtly oestrogenic compounds in veterinary practice was banned in the UK in 1986, and in the remainder of the European Community by a hormonal growth promoter ban in 1988. However the practice still continues as an underground activity in some countries, along with the dangerous business of giving a large range of chemical cocktails to many different farmyard animals to improve the amount and texture of meat, or more recently milk yield by using genetically engineered Bovine Somatotrophin (rBST).
As well as recognised hormonally active products, it is suggested that the effects on both oestrogen and androgen receptors of a wide range of products used in veterinary medicine and agriculture should be investigated as a matter of urgency, and any of the heavy commercial pressures to reverse the EEC ban on Hormonal Growth Promoter resisted until a great deal more research has been done to clear such compounds of any possible threat to human health. It is alarming to note that in France food inspectors trying to obtain meat samples to stem this tide of agricultural abuse of hormones have been threatened and even allegedly murdered. As in athletics, more random and widespread checks, leading to legal action where necessary, together with a public information campaign emphasising the medical dangers to producers and consumers alike, should be brought in.
It took fifty years to learn the lesson spelt out by Sir Charles Dodds in 1938 and ban oestrogenic substances from veterinary practice, but now apparently we have a seven year itch to unlearn it. Should we perhaps be going "Back to Nature" to learn the 1995 message from Kelce and his co-workers about the possible anti-androgenic effects of a wide range of agrochemical?
Viral and Bacterial Infections
Mumps is the best known cause of testicular damage due to infections, and two thousand years ago Hippocrates recognised it sometimes caused shrinkage and infertility later in life. In general, anything which affects fertility in the male is also likely to influence testosterone production. However, it is not appreciated even by the medical profession how a long forgotten childhood illness can contribute to precipitating the male menopause thirty or forty years later.
The testis seems only liable to be damaged by the mumps virus, and perhaps other viruses, from the first stirrings of puberty onwards. This seems to be because this is a time of intense activity, cell division, and growth in the testis which is being stimulated by hormones from the pituitary gland at the base of the brain, known as the "conductor of the hormone orchestra of the body". It is like a bomb going off in the middle of a crowded symphony concert, rather than before the hall has opened.
Before the age of ten or twelve, mumps is a highly infectious viral illness passing from child to child, causing a mild fever and the very characteristic swelling of the parotid salivary glands in front of both ears, which usually passes off without complications within a few days. An attack of mumps at this age is usually entirely harmless, and gives valuable immunity which frequently lasts for life. More immunisation of boys should be carried out early in infancy, because if it happens later it can permanently damage a man's fertility and virility.
If he picks up the infection any time beyond this age, he is likely to be generally more ill, and one or both testes may become very painful, swollen and inflamed, a condition known as orchitis. This very uncomfortable condition, sometimes described by the name of the tune "great balls of fire", can last one or two weeks or even longer. It then subsides, often leaving scarring of one or both testes, which may be shown by shrinkage or softening.
Infertility after mumps is fortunately uncommon, but there may be in many cases damage to the testosterone producing cells which becomes apparent later in life. 11% of my male menopause patients gave a history of mumps after the age of twelve, and in these cases, which tended to be the younger patients, there was often no other obvious cause.
Though mumps is by far the most obvious and common virus attacking the testis, there is some evidence that a wide range of other ones may sometimes be involved, and their influence overlooked because the orchitis a less prominent feature of a generalised feverish illness making the patient feel rotten all over. Again, it is probably when the testis is most active, around the age of puberty, that it is most susceptible to damage by viruses.
Another virus which has been definitely recorded as occasionally causing orchitis is glandular fever, also known as infectious mononucleosis or the "kissing disease" as outbreaks seemed to spread among boys and girls in this way, though this could just be parental propaganda.
Sometimes patients date their male menopause symptoms from some unidentified viral illness, though whether this directly affected their testosterone production, or was just the last straw that caused a hormonal breakdown, is unclear. The fatigue, depression and loss of libido that accompanies many viral conditions, especially myalgic encephalitis (ME), can mimic many of the symptoms of the male menopause, and careful history taking and hormonal tests are needed to distinguish between them. Similarly, the general malaise affecting patients during a severe attack of jaundice, whether due to hepatitis A, B or the newly discovered insidious variety C, is likely to reduce the patients testosterone production, whether the testes are directly affected or not.
Other infections of the testes and prostate also seem liable to affect testosterone levels, whether its the common cause of penile soreness and discharge, so‑called non‑specific urethritis, or the better recognised and more easily treated sexually transmitted diseases such as syphilis or gonorrhoea. Sometimes infections of the prostate and testis can also occur after surgery to the prostate or bladder, and cause reductions in levels of the hormone.
The possible involvement of so many infections in contributing to the male menopause underlines the need for doctors involved in its treatment to take a full history, and much further research is needed to see which infections, at what age, need to be avoided or treated to maintain full testicular function.
Lack of desire and performance in relation to sex are commonly seen in men under stress, particularly when they grow older. While younger men, especially those going through the male mid-life crisis, may as described later become sexually over-active, and use sex as a means of relieving tension or trying to restore confidence, over the age of fifty the stressed male is more likely to go right off it. This is a natural biological reaction, and is seen throughout the animal kingdom. The classic case is the defeated stag, after a long antler-locking confrontation with one or several rivals, limps off to the forest with his tail between his legs, while the winner "takes all" and mounts everything in sight.
Similarly stress assessed as excessive "life events" appeared to be the factor which precipitated the andropause in over half of the men seen in my clinic. This is much more evident with the stresses of failure and defeat in life's battles, than those associated with success. Divorce, insolvency, heavy financial losses, unemployment, recession in business and losing court cases were all big put downs mentally and then physically. Conversely, successful remarriage, the start of a new relationship, getting a desired job or promotion or winning the lottery could fan the flames, or sometimes even the ashes, of both virility and vitality. Even a good relaxing holiday can sometimes have the same effect, though all too often the benefits fade as rapidly as a sun tan when the man returns to his stressful workaday world.
How does stress have such a powerful effect on peoples sex lives? Obviously it is partly a direct psychological effect since the brain has been described as the biggest sex organ in the body, and if its attentions are mainly directed towards survival in the urban jungle, sexual activity has a low priority and little time, attention or energy is given to it.
Though anger can sometimes act as an aphrodisiac in both men and women, probably through a surge in the "kick-drive" hormone noradrenaline, anxiety is a definite turn-off. So-called "performance anxiety", the self-fulfilling prophesy about erectile failure is part of the downward spiral in which many andropausal men find themselves.
Excessive stress, stress overload, can also act by reducing testosterone levels. This has been shown in a wide variety of situations by research studies carried out over the last thirty years. One of the first of these was a study I made with an Argentinean Doctor, Dr Emil Arguelles, as part of a study of the stress of airline travel. He was able to show that exposure to a couple of hours of air-turbine noise in young men working in a factory, was sufficient to halve their blood testosterone levels.
Moderately stressful events, such as taking exams in an army officer cadet training school, could lower testosterone levels, though this was less pronounced in successful candidates.
Even less intense stress, such as losing a tennis match where the winner would get one hundred dollars, was sufficient to cause a noticeable drop in testosterone. While mild to moderately intense physical stress, including intercourse, seems to increase testosterone levels, severe exertion such as running marathons was found to lower them.
A final action of stress is to cause the release of "Stress Hormones" such as adrenaline, noradrenaline and cortisol, which are break-down "catabolic hormones" which work against the build-up "anabolic hormones" principally testosterone. The former raise blood sugar and fat levels and increase oxygen consumption, while the latter has the opposite action.
Shakespeare, in what is called the "Scottish Play", describes drink as provoking the desire, but taking away performance. Many quite young men experience the embarrassment of fancying a girl like mad after a party, but being unable to perform, and this is one of the common ways in which erectile problems associated with the andropause first begin to show during middle age.
This contrasts with women who are more susceptible to the effects of alcohol than men and yet are more sexually stimulated by it. Recent research in Sweden showed that three glasses of wine rapidly raised testosterone levels in girls in their twenties, and to a greater degree than a group of men the same age. This combination of lessening of inhibitions, and increase in the hormone which stimulates the libido, explains the old saying that "Candy is dandy, but liquor is quicker". Rather as with men however, many women find that it is more difficult to have an orgasm when drunk.
It is surprising how strong a poison to the testis alcohol is. It may act directly, or through its immediate breakdown product, acetaldehyde. Either way, even in moderate drinkers, blood testosterone levels fall as alcohol levels increase. Binge drinking to a level sufficient to cause a hangover lowered testosterone levels 12 to 20 hours later, in one study to 20% of their pre‑party levels. Perhaps sagging hormone levels are one of the reasons why a hangover feels so awful, and might explain why some of the eye‑opening hangover cures are based on boosting cholesterol levels with raw eggs.
This makes it less surprising that later in life, both because of long‑term testicular damage, and its short‑term actions in reducing testosterone levels and erectile function, alcohol can take away both desire and performance in men. Thirty percent of the first four hundred andropausal men reported currently drinking more than 21 units of alcohol a week, and many two, three or four times that amount. One unit remember is a half pint of beer, a glass of wine or a measure of spirit.
The situation has recently been made worse in Europe because our heavier drinking, or more generous, partners in the EEC have just raised the volume of the standard measure of spirit from twelve millilitres to fourteen, causing about a seventeen percent increase in chance of damaging the testis with every glass!
Though several studies have suggested that up to forty units of alcohol, especially as red wine, may protect the heart, perhaps by having both antioxidant and anti‑coagulant effects, from the sexual function point of view, alcohol is generally bad news both in the short and long term. Beer and lagers appear to be particularly toxic to the testis because they contain plant oestrogens, phyto‑oestrogens, from the hops and other ingredients. Even low alcohol lagers and other drinks might contain these oestrogens, and more research is needed on this important topic of international concern.
A sixteenth Century Italian physician called Coronaro wrote "The excesses of our youth are like drafts upon our old age, payable with interest about twenty years after date". This is certainly true in relation to alcohol, and as well as those who are drinking too much when they present with andropausal symptoms, about another ten percent give a history of excess alcohol consumption in the past for over a year or more. Unfortunately, this does not seem to improve very much even if they stop drinking for several years.
This is in contrast to smoking, where most of the hazards such as lung cancer and heart disease decrease dramatically within five to ten years of giving up. The testis lacks the power to regenerate enjoyed by the liver and never fully recovers, as is shown by infertility, impotence and loss of libido in chronic alcoholics even after drying out. The liver forgives and forgets, but the testis remembers, so the larger louts of today are likely to be the lousy lovers of tomorrow.
The sensitivity of the testis to alcohol was clearly shown by recent studies by a research group in Milan who found that compared to non‑drinkers those who drank 14‑21 units of alcohol per week were twice as likely to be sub‑fertile, and 28 units and over, nearly four times more likely. This factor is well recognised in infertility clinics, particularly as a cause of poor sperm motility. It seems that unlike the men who make them, sperm just don't drink and drive.
The scrotum is not a design fault by our creator to use up spare skin, as the Scottish comedian Billy Connelly insists. Nature does not risk putting vital and sensitive glands in such an exposed position without an excellent reason. This is because to function properly they need to be a few crucial degrees cooler than the rest of the body. Its as though the testis has to pluck up the courage to make a small step outside the body into the cooler scrotum, and testosterone drives it to do so. This is truly a giant leap for mankind, because unless it happens, neither the desire nor the ability to father children develops. As has been mentioned previously, Xenooestrogens, because they antagonise testosterone production and action, may have contributed to the increased incidence of non-descent seen in recent Years.
This temperature question can also cause problems during and after puberty where the scrotum is increasingly kept warm by Y‑front pants and tight jeans, which together are likely to be as bad as the padded cod‑piece which reduced the fertility of Henry VIII th and his courtiers. There is an old country saying that "Rams wrapped in wool breed no lambs", and this principle has been used by the Japanese who have recently introduced a male contraceptive device consisting of a scrotal support with a furry nylon lining. Worn continuously, it is said to be very effective after the 2‑3 month period needed to allow already produced sperm to die off. Other studies have suggested that the polyester component of underwear may generate electromagnetic fields which impair testicular function.
Loose‑fitting underpants make of a leather cloth soft enough not to chafe the skin were worn by Viking warriors when invading Britain 3,000 years ago according to a recent archaeological find. However, the extremes of this advice to "stay cool and hang loose" were seen in soldiers of the Black Watch Highland Regiment, who were forbidden to wear anything under their kilts. To enter or leave the barracks they had to walk over mirrors in the guard house, with their privates on parade so to speak, to make sure they were obeying orders. This was presumably to ensure they maximised their testosterone production, which made them the strong and fearsome soldiers they are known to be.
Even mental imaging techniques , as where some university students were asked to imagine warming of the scrotum as part of their system of Autogenic mental exercises, is said to have produced a marked reduction in sperm count within a couple of months.
The importance of testicular cooling has recently received scientific proof in an article in the International Journal of andrology by a research group in Milan, where they know a thing or two about male fashion and its penalties. Infertility was nearly twice as common in men wearing tight Y‑front underpants, as men wearing loose boxer‑short types, and one and a half times as common in men wearing tight trousers, including jeans, as loose trousers. If you combined the two, and wore tight pants and trousers, the risk was two and a half times those who did neither.
As testosterone production and sperm production appear, not surprisingly, to be closely linked, to promote virility as well as fertility it seems a good idea to recommend large, loose‑fitting, light weight, cotton or silk boxer‑type underpants to those wishing to stay healthy in this department. Perhaps "Burn your Y‑fronts" might be a good motto for "Men's Lib".
The “Sting in the tail” of this explanation of the many ways in which the body’s supplies of testosterone may be reduced or inactivated by the “Sling’s and arrows of outrageous fortune” throughout a man’s life would be incomplete without a chapter on the important part unwittingly played by doctors themselves.