Chapter Seven - Sexual Satisfaction
Though physical sexual activity tends to decrease to a variable extent in most men around the age of fifty, overall sexual dissatisfaction was the commonest complaint of all in my heterosexual andropausal patients (92%), as well as their partners (84%). While in no way wishing to suggest that sex is the be all and end all of a marriage, or other long term partnership, as one patient put it, "It is more than just the icing on the cake - It is one of the most important and binding of the basic ingredients". Even the Catholic Church recognises non-consummation as one of the few grounds for nullifying a marriage, and there is an old saying that the rocks on which a marriage breaks up are usually to be found in the bed. So what can you do when as the perennially active rock star of the Rolling Stones, Mick Jagger, sings you "can't get no satisfaction".
Though most people assume that sexual activity is likely to decrease with age in both men and women, it is difficult to assess what reduction is essentially physical, and how much is psychological, a combination of expectations, attitude, and monogamy leading to monotony. Though in the swinging sixties, when the young rediscovered sex and assumed it was largely their preserve, the experts at that time, led by that pioneer explorer of human sexuality, Kinsey, gave a rather different picture. They, together with more recent investigators, found that sexual interest and morning erections, a good marker for either actual or potential erectile power, declined only gradually with age, and only went below the fifty percent mark in the nineties.
Compared with the potential market for this important product, even in hormonally unstimulated populations, the actual frequency of sexual intercourse dropped away much more rapidly, and reached the fifty percent mark at around seventy, mainly due to erectile failure.
Shakespeare recognised this problem four hundred years ago when he wrote "Is it not strange that desire should so many years outlive performance?", a question which taxes the minds of doctors and their patients to this day. The answer could well be that lower levels of testosterone are needed to maintain libido than are required for potency and there are many complex circulatory factors involved in obtaining an erection, and well as the hormonal drive. The spirit is still willing often long after the flesh has weakened, though following repeated erectile failures, the desire tends eventually to fade also.
This is likely to become even more of a problem as more and more women go on long term HRT at the menopause. There is evidence that by maintaining their looks and sex appeal, as well as preventing vaginal atrophy and dryness, their expectations of continuing sexual activity are rising year by year, and men are literally not able to keep up with them. The big drop in sexual interest and enjoyment which was well documented for women in their fifties has declined or even been reversed. This is just the time when andropausal men are experiencing the biggest decline in both libido and potency. Particularly as men tend to marry women a few years younger than themselves, increasingly the couple are likely to get sexually out of step, with the male left lagging further and further behind.
There is also evidence from a recent study by a Dr David Weeks, a clinical neuropsychologist at the Edinburgh Royal Infirmary that suggest that the ageing process can be delayed by making love more than twice a week. He compared a group of people in Europe and America who claimed to look and feel much younger than they actually were to send him their photos and fill in a life-style questionnaire. He also asked a control group from the same part of each country to do the same, and then got independent assessors to guess the age of all three and a half thousand people, who ranged in age from their twenties to over a hundred.
The results were clear-cut, the youthful test group being rated as twelve to fourteen years on average younger than they actually were, and the control group one or two years younger. The differences on the questionnaire were even more striking, the “Young- Lovers” having sex much more often than their peers, many, both men and women, having much younger partners. However, an important feature of any relationship was that it was a loving and happy one, where they regarded their lover as their best friend. This is similar to the results on factors which prevent coronary heart disease where a group in the Netherlands showed that feeling loved was one of the most important things that kept heart trouble away. As Woody Allen says “Love is the answer, but sex raises some interesting questions”. Perhaps if we can answer some of these questions, the loving element will have a greater chance to express itself.
Testosterone is the hormone which largely regulates desire in both men and women, although its levels are ten to twenty times higher generally in the male. It is thought to act both directly on the brain, and indirectly in making the genital areas more sensitive and responsive, and enlarging the penis or clitoris. Thus it is generally a sexual stimulant for both sexes, up to a ceiling, which is set by social conditioning.
Experience with patients, and research reviewed by Professor Bancroft of the Medical Research Council Reproductive Biology Unit in Edinburgh, in his book "Human Sexuality and Its Problems" suggests that there is less overlap between the laboratory "Normal Range" of testosterone, and its "Behaviourly Relevant Range" in men than in women. This means that if the laboratory measures testosterone levels in a hundred "Normal" men, age and sexual activity often unspecified, in 95% values of say 10-30 nmol/l may be recorded. Many studies, including my own, have shown that the libido will be increased by testosterone treatment in men whose values lie in the range 5-15nmol/l, though the proportion of free, biologically active, hormone is as emphasised elsewhere also very important.
However, in women, the "Normal range" is only 1-2 nmol/l, but libido may go on rising up to 7-10nmol/l or even higher. This is shown by testosterone treatment, both orally and by pellet implant, for those suffering lack of desire or who lose their ability to have an orgasm for no obvious psychological reason. It is also reported in women self-medicating with very high doses of testosterone, either in athletes or those wishing to become "The Third Sex".
That the level of biologically active testosterone is vital to libido in both sexes and sexual function in the male is shown by studies on epileptics. Anti-epileptic drugs raise the Sex Hormone Binding Globulin protein holding the testosterone in the blood, and preventing it acting. Both the libido and morning erections are reduced while patients take these drugs, and are restored when they come off them, the binding protein falls, and their testosterone is freed-up again. This is a perfect model of the male menopause, and conclusively demonstrates its reversibility.
Poets and song writers have mused for millenia why it is that men and women fall in love. The psychologists and pharmacologists may now have cracked the problem between them, and though it may not immediately improve their love life or ours, it offers hope for an understanding.
The psychologists tellus about the effects of early imprinting and bonding which occur at birth and in infancy. The newborn child is not the passive plastic doll it was once thought to be. It is a highly receptive, rapidly developing, sentiate being which is aware of, responds to, and learns from, the complex inputs from all its faculties. Even in the womb it is thought to be soothed by the rythmic beating of the mothers heart, the whooshing of the blood flowing in her abdominal vessels, and the inner reverberations of her voice. At birth, and in the first few minutes and hours afterwards, like all mammals, there is a complex emotional and physical bonding process involving all the senses, which will last for life. If this goes well it can lay firm foundations for emotional stability throughout childhood and adult life. If it is disrupted by separation, illness or emotional or physical trauma to mother or child, it can leave lasting psychological damage.
From the soothing sounds and subdued pink gloom of its intrauterine existance, which it floated in a warm bath of amniotic fluid laced with natural opium-like compounds called endorphins, it is catapulted into the blinding light of a chilly operating theatre, held upside down and slapped until it cries as its mother screams with the pain of childbirth. In the best of natural childbirth practices, though hi-tech help is at hand if needed, the child is immediately reunited with its mother, held lovingly in her arms, gazes through the accurately fixed focus of its eyes at her face, and listens to her soft and gentle voice.
These first impressions go very deep, and it is probable that the variations and mishaps which occur in this bonding process leave the corresponding small or large psychological scars which decide whether and how we are going to bond from puberty onwards. After all, dogs separated from their mothers in the first few hours or days of life, and weaned by humans, often seem to assume they are human, and relate more to human beings than they do to other dogs. The biologist Konrad Lorenz first reported how geese he held immediately after hatching, and fed for the first few days of life became imprinted on him and for the rest of their lives wadled after him convinced they were biologists. Cygnets similarly reared by a cameraman, would follow him anywhere whether he was walking, in a car or in a boat. They could then be trained to carry light cameras on their backs and acheive beautiful films of formations of swans in flight from literally a bird's eye view.
With models like this is any wonder that men tend to fall in love with women who resemble in at least some important respects their mothers, either in their looks, the the tone of their voices or possibly even the way they smell, an important part of sexual chemistry.
Even more than by sight and sound, throughout the animal kingdom, from Pharoah ant to the Pharoah himself, cupid's arrows are carried by bodily scents. Though perfumes were developed thousands of years ago mainly to cover up unpleasant body odours with more attractive ones, the more skilled producers learned from the well recognised ability of animals to smell and be sexually attracted by the opposite sex before they catch sight of them. Dogs seeking out the bitch on heat, the musk ox that can scent a potential mate miles away, and the stallion that catches the scent of the mare are timeless examples.
The term "pheromone" was coined by the German Biochemist Adolf Butenandt in 1959, and was another of his major contributions to science, the first being the discovery and synthesis of testosterone nearly 25 years previously. The term is derived from the Greek phero (carry) and hormao (excite), in which is an apt description of these airborne chemical messages promising sexual excitement, a sort of long-range biological dating agency.
Though first described in female silkworm moths, similar chemicals were found in female monkeys, and in women, where it peaked at the time of ovulation and was under the control of the oestrogen hormone. Thus it was shown that from the time when oestrogens surged at puberty, the inner female hormones started the production of these outer chemical signs of sexual maturity and availability.
Similarly the main sex hormone in men, the androgen testosterone, is broken down to two components called androstenone and androstenol, which at a subliminal level are thought to be powerful sexual attractants. They are released in the odours of the armpits and scrotum, in urine and in saliva. Androstenone gives a characteristic smell to male urine, and is what the sow is detecting when snuffling for truffles, which is perhaps why this rare and exotic fungus has a reputation for being an aphrodisiac. Androstenol has a musky odour, which is less obvious, but probably equally potent.
As the average female nose is at the height of the average male armpit, dancing can be seen as an intense form of exchange of bodily gases preceeding the exchange of bodily fluids. After the andropause, because of the low testosterone levels, the phermonally deprived male does not feel as sexy or smell as sexy as the pungent sexually active man in his prime. Research urgently needs to be done to see whether these are restored by hormone replacement therapy with the parent compound, testosterone.
Why is it that in spring a young man's fancy lightly turns to thoughts of love? Well, even though the mating season isn't what it used to be, probably because of all the year round stimulation by artificial lighting and television, there are good reasons for this in terms of the hormonal rites of spring.
As the urban cave dweller emerges blinking into the spring sunshine, he drinks up the sun. This is seen particularly in the more northern countries such as Scandinavia, where the winter nights are long and the days often overcast with clouds. There people often just sit out in the open sunning themselves as though mentally thawing-out.
The bright light has the effect of reducing the level of a hormone called melatonin, which is produced by a small gland lying between the hemispheres of the brain, called the pineal. This could be thought of as the "Hibernation Hormone", and when its levels are high it makes us feel sleepy and lethargic, and not very sexy. Some people seem to get a surge of this hormone in the Autumn and it makes them feel quite torpid and depressed, a condition known as Seasonal Affective Disorder or SAD for short. This can be prevented or treated by mid-winter sunshine holidays or by bursts of intense artificial daylight.
The lengthening days as winter turns to spring, combined with the increasing brightness of the light, which via connections with the optic nerve, together get the message through to the pineal gland, which has been appropriately called the third eye, to switch off its production of melatonin. This not only causes generally greater mental alertness, but raises levels of a variety of brain chemicals, called neurotransmitters, which stimulate and arouse us, making us feel full of the joy's of spring, and as lively as a spring chicken.
Because these neurotransmitters regulate mood, they have been the target for intensive study by most of the major pharmaceutical companies, who see the potential market for the chemical production of happiness, peace and love in bottled form. Since Aldous Huxley in his book "Brave New World" back in the 1920's first coined the advertising slogan for the mythical drug he called "Soma" of "Take a gram and don't give a damn" there have been many false dawns. The prototypic tranquilliser Valium was originally market with pictures of tigers changed into pussy-cats. Unfortunately it was found that if you take the edge off the "Razor-blade of life down which we slide" according to the American humorist Tom Lehrer, you take the edge off many of life's joy's also and blunt performance and creativity.
In the same way, some of the early anti-depressant drugs showed pictures of space rockets lifting off for the moon, to illustrates the hoped-for lifting of spirits of the depressed person. However, though they proved usefull in some cases of severe depression, they have not proved a panacea, and the results of such treatments have often been somewhat depressing to patients and doctors alike. It seems that the complex mysteries of the human brain still elude our grasp, and though improvements in psychopharmacology are steadily improving the drugs available for mental ailments, we cannot safely manipulate mood without risking severe side effects. Though the wonders of modern science, we have been able to get to the Sea of Tranquillity on the moon, but but still come back to a sea of tranquillisers on the Earth.
Unfortunately, is is in the field of sexual activity that the undesirable side effects of tranquillisers, antidepressants and sleeping pills are most severe and unpleasant. For liveliness, loving, libido and the pursuit of sexual fulfillment, we need just the right mixture of hormones and neurtransmitters, in the right brain cells, at the right time. At present we seem like the sourcerers apprentice, either gettin insufficient response, or swamping the delicate brain systems involved in arousal, erection and orgasmic satisfaction with floods of neurotransmitters which drowns their responses rather than restoring them. This is why unless the anxiety or depression is very severe and prolonged it is generally better to use gentle non-drug approaches such as psychotherapy, psychosexual councelling and non-drug relation techniques, meditation rather medication.
As well as music for putting you in the mood for love, there are some foods which may gently help to regulate brain chemistry to enhance both desire and sexual activity. Two of the most importantant neurotransmitters in the brain are serotonin and the mono-amines.
Serotonin is derived from a plasma amino acid called tryptophan, and after this is taken up into the brain, a good supply of vitamin B6 is needed for the conversion. Most diets contain sufficient protein to supply the necessary tryptophan, and too much protein may increase competition from other amino acids for uptake into the brain. Simple sugars such as glucose and sucrose cause the release of insulin, which removes these competing amino acids, and improves the uptake of tryptophan, and hence the production of serotonin.
The predominant brain mono-amine is noradrenaline, which is produced in the brain, again with the help of vitamin B6, from the amino-acid tyrosine. This is again present in most proteins, and is easily taken up into the brain in proportion to the amount of protein in the diet. Another mono-amine is phenylethylamine which is present in chocolate and may account for its reputed aphrodaesic properties.
Armed with all this essential biochemical information, we can boldly go forth to try a meal guarenteed to stimulate passion. After the relaxing champagne, which also stimulates female testosterone production, we have the suggestive goats-cheese starter, redolent with mono-amines. This is followed by the minute steak, to boost tyrosine, new potatoes with butter to again help testosterone production, and a fresh green salad to enhance vitamin C levels. The coup de Grace is the "Death by Chocolate" cake, topped with B6-rich walnuts. This is surely a recipe for sexual success, providing it doesn't bring on a splitting migraine headache in the woman, or an instant heart attack in the man.
Can Sexual Satisfaction be Improved?
Certainly it is possible in the vast majority of cases to improve sexual satisfaction for both partners, not only by Testosterone Replacement Therapy, but also by a range of additional techniques such as sex education, focusing particularly on the physical, hormonal and emotional changes occurring at this time of life in the male, and where necessary psychosexual counselling or couples therapy. With reassurance that there may be a physical basis for the male partner's apparent lack of desire, as well as his unwillingness or inability to perform, a tense situation can often be defused and the relationship helped on the road to recovery.
In particular emphasising the good non-sexual areas of the relationship, and the enjoyment that both partners get from this, can reduce the friction which prevents either from enjoying any aspect of physical contact and be a good start to setting the scene for resumption of a good sex life. One or both may also need to learn a good relaxation technique as described in the next chapter, and small amounts of alcohol, such as a shared bottle of wine can help, but too much can hinder.
For most couples, when the first flush of passion is over, a sexual session needs time and energy. Erections are much harder for a man to maintain when he is rushed or tired or both, and his fight-flight alarm system is working against the penile pump-up system. If one or both partners are under pressure, a “dating” system may help when they together chose a time and place they feel most relaxed and happiest together. One patient, when I suggested this, said he and his wife had such different conflicting time deadlines in their busy lives, that it was rather like timing a moon shot. If it works however, by some mysterious process it usually gets easier and easier to find the moon in the seventh high.
Massage, especially in subdued light or candlelight, and with music to soothe the savage breast, can be both relaxing and a turn-on, as well as being part of “getting in touch”. Kind, loving, encouraging comments on the other person and the effect they are having on you, work much better than even the most constructive criticism. Fortunately, nature is kind in that we tend to get long-sighted around the age of fifty, so that skin blemishes and the occasional wrinkle are blurred over, and hopefully we remember how we wanted our partners to look, or they did look, in their physical prime.
Such methods are all part of encouraging the realisation, that sexual activity can be pleasant and satisfying even without penetration, and that usually under sufficiently relaxed conditions both partners can have orgasms by mutual masturbation, oral sex or any of the increasing variety of “Sex-aids” that can be bought mail-order or from a local store. Sexy garments, perhaps chosen by the other person, all have their part to play in setting the scene.
Fortunately, with the more frank approach that medical assessment and treatment encourages, combined with these common-sense self-help measures, the situation usually improves to the point where full intercourse resumes or becomes more satisfying. If this doesn’t happen, and there still appears to be a large anxiety or emotional part to the problem, then the more gradual approach under the guidance of a properly qualified sex-therapist, who often uses a technique known as “Sensate focus” should be tried. This involves stages of being touched for your own pleasure without genital contact, then giving feedback on what you find enjoyable as well as unpleasant, and finally enjoying the experience of touching and being touched including genital contact, and if it happens, orgasm, though this is not the aim.
Premature ejaculation, which often accompanies erectile difficulties, be treated by medication, as described later, or by a “stop-start” technique, initially by hand, and then with the woman sitting astride the man to give better control of withdrawal and re-entry. Alternatively, the “squeeze” method described originally by Masters and Johnson in 1970, can be used, where when the man is about to ejaculate, the woman gently but firmly squeezes the base of the head of the penis, until the impulse to ejaculate immediately subsides.
One worrying statistic is that in one community-based study in the United States of the sample aged between forty and seventy, just over half felt that their erections were inadequate. This is a major health problem which is seldom adequately investigated or treated. At this stage it is appropriate to describe how erections happen so that we can better understand what can go wrong, especially with age or an insufficient hormonal head of steam, and how it can be helped and encouraged.
Man’s ability to have an erection, which has been worshipped from the earliest of times, as in the Shiva Lingam in India, and at the vast temple of Karnac in Egypt dedicated to the God Yamuna, is a recurring miracle of hydraulic engineering. It is brought about by a complex series of chemical changes and nerve reflexes, which work together to increase the amount of blood flowing into the penis, and temporarily decrease the amount going out. This event, which is achieved with effortless and sometimes embarrassing ease in the teens and twenties, usually becomes a more difficult feat in the thirties and forties, can be variable in the fifties and sixties, and often a disappointingly brief and infrequent wonder in the seventies and beyond, especially in the “Hormonally Challenged” andropausal male.
For the amount of blood going into the penis to be adequate to it pump up the two elongated blood sacks which become engorged and create the erection, the corpora cavernosa, there needs to be a good flow of blood in the artery to the penis, relaxation of the blood vessels inside it, and reduction of the amount of blood draining out. It is rather like pumping up a bicycle tyre and hoping for a smooth ride. It you don’t pump hard enough, the walls of the inner tube are perished or stuck together, or the valve is leaky and lets the air out as fast as it goes in, only hopes are inflated.
Sometimes the small artery supplying blood to the penis is clogged up because of a generalised arterial degeneration called atheromatosis, which is the commonest cause of coronary heart disease. This is more frequent in those with high blood cholesterol levels, in diabetics and in smokers, who are more prone to erection problems. Fortunately, it is seldom sufficient on its own to cause the problem, and when it is, arterial surgery to provide additional blood supply is occasionally successful.
The pooling of blood in the penis which produces its rigidity is dependant on hormonal priming, local chemical factors and a balance of nerve stimulation. Because of the complexity of this mechanism, it is easily upset by hormonal insufficiency, a wide range of medications and emotional reactions, especially anxiety. Each of these needs to be considered in cases of erectile difficulty, and corrected where possible.
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. Especially after the problem has been causing great distress to both partners for some months, or even years, 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. Often the patient and his partners efforts to overcome the problem are just as important as the doctor's.
There is the story that seems appropriate here of the man who went to seek medical advice and was given treatment which needed a lot of life-style changes and self effort. Being by nature a lazy fellow, before he left the consulting-room he disbelievingly asked the white-coated man sitting behind the desk "Are you a real doctor?". "The question is" said the doctor, "Are you a real patient?'.
Testosterone and Erectile Function
Though it is difficult to say precisely what part testosterone plays in helping to produce erections, it certainly both primes the penis and triggers the chain of events which bring it about, controlling as it does libidinal impulses. You will remember Mae West’s famous remark to an enthusiastic cowboy who came to her saloon, “Is that a gun in your pocket, or are you just glad to see me?”
It is surprising but gratifying how often when adequate testosterone therapy is given, all the symptoms of the andropause disappear, including erectile difficulties, within a few weeks or months, particularly when other factors contributing to its onset or continuation are dealt with. A statistically highly significant improvement in erectile function occurred in over seventy percent of my first four hundred cases treated with a variety of different forms of testosterone. This was particularly marked with the more powerful oral preparation, Restandol, which sometimes needed to be given in high but safe doses, and with the pellet implants.
Though this use of testosterone to help erection problems is controversial, and not acknowledged by some authorities which say it only increases frustration, without giving back the means to perform, this is certainly not my experience in this large group of patients. The efficiency of testosterone is restoring potency is a common experience with doctors prepared to give it an adequate trial. It was even recognised over fifty years ago in the article on the “Male Climacteric” by Drs Heller and Myers described in detail in the first chapter of this book, who found that erectile function returned in nearly all the patients they had shown to be testosterone deficient when they gave the hormone, and went away again when they stopped.
Even though it is more difficult to restore function than desire, unless the source of the problems is obviously psychological, it seems logical to investigate the level of free active testosterone, and boost it if it is low. It The accompanying increases in libido, confidence and energy greatly encourage the patient to try supplementary mechanical and medicinal methods where these are needed in addition, at least until confidence is restored.
Sex is the most vigorous form of exercise most people take, and for some it is the only form. Measurements of pulse rate, blood pressure and hormones before during and after exercise have shown surges in the stress hormones during sexual activity, together with rises in heart rate and blood pressure. Fortunately, these go down to baseline levels or even below in the recovery phase afterwards, and there is then an increase in testosterone.
Regular sexual activity, even if the man cannot always achieve penetration, is to be encouraged in the prevention and treatment of the andropause. If this is not possible because a partner is either not available or not willing, then masturbation about once a week stops the erectile system "going rusty", and may stimulate testosterone production. As Woody Allen says "At least masturbation is sex with someone you love" and is a legitimate way of maintaining sexual competence providing it doesn’t take over from other forms of sexual activity. From the medical point of view occasional masturbation can be beneficial, as long as it doesn't get out of hand.
Drugs which help and drugs which hinder
Drugs given for medical reasons can often play apart in bringing on the erectile problems which contribute to the menopause. The motto is “If in doubt, check it out”. They include in particular virtually any drug used to reduce the blood pressure, but especially the so-called beta-blockers. It is a problem to know how to keep the blood pressure under control but avoid these side effects. Because hypertension is often stress related and "Not so much an illness, more a way of life", stress management by the methods described above, particularly Autogenic Training, can be tried with mild to moderate elevations in blood pressure, and will help to reduce the "Performance Anxiety" element in erection problems.
Alternatively, sometimes switching to a different preparation, such as Labetolol (Tranxene) or the new “Alpha-blockers” which seems to interfere less with erections, can be helpful in combination with testosterone treatment, which does not itself generally raise blood pressure and may in some cases lower it.
A wide variety of tranquillisers and antidepressants are also associated with impaired erections and are used to treat many conditions with symptoms which overlap with those of the menopause, so it is not clear which is doing what. Prozac is occasionally helpful in treating depressions associated with the andropause, as it also seems to reduce the common tendency to premature ejaculation which accompanies difficulty in maintaining an erection.
Virtually all antidepressants can have a harmful effect, except possibly the newer generation of drugs such as Prozac. These have a different action on the brain from the other compounds used to treat depression, by inhibiting the uptake of a chemical by which one brain cell activates another, 5 hydroxy-tryptamine (5HT). Some specialists are sufficiently enthusiastic about this type of compound to recommend its use in premature ejaculation, though through limited experience this may prove to be a case of premature ejudication. An antidepressant called Venlafaxine (Efexor) made by Wyeth is reputed to had the least effect on libido or erectile function, and few side effects generally.
Another possible exception is the older anti-depressant, Trasadone, marketed in the UK as Molypaxin. Given as a single dose of 75 to 150mg half an hour before sex, it can in some cases help in obtaining erections over a one to two hour period. Its effectiveness varies widely from person to person, and may just make them feel sleepy, which is no usually the desired effect.
Asthma treatments such as ephedrine and many other inhalers can also sometimes make erection problems worse, and a trial of withdrawing treatment where possible, or switching to a different treatment can help. Even stomach medicines such as Tagamet have infrequently been shown to cause problems, as have a seemingly endless list of medicines.
Drugs of addiction appear only to be a problem if being used in large amounts and causing psychological or social problems. They may however accompany an alcohol problem, or be used to avoid facing up to the issues contributing to the andropause. Again the appropriate agencies such as narcotics anonymous may need to be involved.
Though erection problems often decrease or even disappear with combined treatment with testosterone and the other measures described, particularly in diabetics or those with heart and circulatory problems, there may be some continuing difficulty. If they fail to respond, or testosterone treatment is unsuitable or unacceptable, there are a range of other measures which can usually solve the problem one way or another.
Yohimbine, marketed in Britain and the U S A as Yocon, is a preparation of the bark of an African tree, Pausinystalia yohimbe, which when taken by mouth in some cases seems to act on the brain both as a sexual stimulant, boosting the libido, and improving erections, particularly in people on testosterone. It is usually taken as one 5.4mg tablet three times a day, or alternatively between one and three tablets half to one hour before intercourse, which I have found to be a more effective and economic method. It shouldn’t be given to nervous individuals, who can become more anxious on it, or in those with high blood pressure where it can have an unpredictable effect.
There are a variety of substances which can be injected into the penis by the patient himself just before intercourse to provide a serviceable and sustained erection. Many urologists encourage the patient to go straight for this option, without detailed examination for signs and symptoms of the andropause. This is a pity as many men find it a bit cold-blooded and premeditated, and their women find it unromantic, mechanical and sometimes an insult to their sex-appeal. As one wife said, inaccurately in her husband's case, "If I were as attractive as Marilyn Monroe, he would get an erection immediately, wouldn’t he?".
Though it has a high success rate, usually around two-thirds of even resistant cases responding, about half the people who say they'll try the treatment drop out because they or their partners find it unacceptable.
Papaverine is the most commonly used of these injections, and is a cheap and stable preparation. It is injected through a short and very fine needle into the shaft of the penis, and increases the flow of blood into the two spongy corpora cavernosa running along both sides of the penis, helping to produce and maintain an erection. According to the carefully regulated amount injected from the small syringe provided, which is similar to that used by diabetics, the length of time the erection is maintained can be adjusted, according to taste and joint enthusiasm of the partners, from quarter of an hour, to one hour or more. Moreover it carries on even after the man has reached orgasm and ejaculated, which some couples find adds to their enjoyment.
Apart from its artificiality, the slight stinging pain experienced when the needle is jabbed into this very sensitive part of the male anatomy, and the possibility of bruising especially if the patient is on anticoagulants or even aspirin, sometimes erections persist for several hours or more, which can be dangerous as well as uncomfortable and socially inconvenient If it lasts for more than four hours, it is known medically as priapism, and this should be dealt with as soon as possible in a hospital casualty department to avoid bruising which may last days if not weeks.
More gentle in its action, and less liable to cause priapism, is another injection used in just the same way, similar to the natural substance in the body called prostaglandin E1. This has recently been introduced in this country by, appropriately, Upjohn Pharmaceuticals, as Caverject (alprostadil). This is a definite advance, but tends to cost about the same as a bottle of champagne for each shot, and even if you can afford the expense, unlike champagne, it is not recommended for use more than three times a week.
There are rumours however of a real breakthrough being tested in Israel, in the form of a prostaglandin cream which can be absorbed through the skin. There is also a cream made by the Alza Corporation in Pala Alto in California, which can be squeezed into the opening of the urethra at the tip of the penis, massaged up the penis, and be rapidly absorbed into the cavernosae. These preparations will hopefully have the same effect as the injections, but be less painful, less expensive and much more acceptable to both partners.
There are a variety of mechanical devices which can be used to promote the flow of blood into the penis, and lessen the amount going out if other methods fail or are unnacceptable. The simplest of these is a rubber ring, usually called the Blako ring, which comes in different sizes, and when rolled down the semi-erect penis, rduces the outflow of blood in the veins, which can help to obtain and maintain a full erection.
Another device is a suction device consisting of a glass tube which is slipped over the penis and applies negative pressure gently to it by means of a mechanical pump. When a full erection has been acheived, a tight elastic band similar to the Blako ring is slipped off the end of the tube nearest the patient, and prevents the blood in the penis from flowing away. However, many patients find this way of getting an erection cumbersome, unromantic and even painfull, so it leaves a lot to be desired.
Rarely, none of these treatments work, and then the opinion of a urologist specialising in this field should be sought. After investigation of the arterial inflow and venous outflow of the penis, he may recommend vascular surgery, or one of the inflatable or soft metal, bendy-toy, penile implants. All these methods can produce good results in the right hands, but none of them are much use if the other symptoms of the menopause, especially lack of libido, are untreated.
Finally, there is good news long term, in that within three to five years erection problems may largely be a thing of the past. Recently there have been very promising new developments in the field of nitrous oxide and the erectile mechanism. A new type of nerve has recently been discovered in many organs in the body, including the penis, which amongst other important actions, relaxes the smooth muscle fibres controlling the diameter of small blood vessels. These are known as “Nitrurgic” nerves because by releasing nitrous oxide they allow the blood vessels in the penis to dilate, which then become engorged with blood, producing an erection.
Anything which helps nitrous oxide production encourages the erection. This is why in the nineteenth Century, “Laughing Gas” Parties became popular in some social circles, where the gentry and their ladies sat and lay about inhaling nitrous oxide. This gave the men erections, and the ladies the giggles, with a general aphrodisiac air all round. Similarly, amyl nitrate has been used for sexual stimulation, and its ability to relax smooth muscle in various parts of the body.
Pharmacologists have as you can imagine been working round the clock to synthesise a drug which would help promote the increased formation or decreased breakdown of nitrous oxide, which has been described as “The key mediator of erections”. At present Pfizer drug company appear to be ahead of the field, and have come up with an orally active drug which stops the breakdown of nitrous oxide, so that it accumulates in the walls of the blood vessels, keeping them relaxed and the penis erect. This eagerly awaited preparation is called VIAGRA, and one tablet brings on a sustained erection lasting for up to three hours in 90% of cases. It is currently undergoing its “Phase 3” trials, and should be on the market before the end of the century - truly a giant leap for mankind.