Chapter Eight - Secrets of Vitality and Virility
What conclusions can be drawn from these ideas about factors affecting men's health at different times of life? I believe there are lessons for society, as well as individuals living in that society, and what affects the well-being of one will affect the well-being of the other. Pollution of the external environment with xeno-oestrogens for example, can have life-long effects on the male, from causing the birth of a child with impaired sexuality, to creating a subfertile male more prone to having a severe mid-life crisis, and premature andropause. Probably the best way of drawing these strands together is to consider the causes of the andropause and the possibilities for avoiding and treating this drop in both vitality and virility, one by one.
Early prevention in terms of producing a male infant best equiped to maintain his masculinity for life is largely up to society to identify the sources and then reduce the levels of xeno-oestrogens in the environment so as to minimise this "threat to the male". This fight for masculinity is a life-long battle, with both chemical and psychological warfare involved.
In the battle of the sexes, men are losing the fight, and have been described as being "Out for the Count". This is not just in relation to the falling sperm count, but is being seen throughout life. It could also be called the battle of the hormones, because generally male and female hormones have opposite and opposing actions. Many of the battlegrounds are social and psychological and these also need to be considered when planning for the future health of men.
This struggle is evident in everything from clothing to work. For example, as well as reducing fertility and testosterone levels by raising the temperature of the testes, jeans are also symbolic of the identity and role crisis in the adolescent male. If everyone is wearing the trousers, mentally as well as physically, what's so special about being male? "Me Tarzan - You Jane" doesn't really seem to cover the situation now.
Also there is a trend for women to be more sexually assertive, both in the East and West. In Japan, a few of what used to be shy retiring office girls are flaunting their sexuality, dancing provocatively in the scantiest of costumes during bodycon (body consciousness) evenings, stuffing bank notes into the posing pouches of hunky male strippers, and choosing a string of lovers. In the West, the feminists, having got most people thoroughly confused about what is really expected of the "New Man" are tending to turn on each other, and there is a fashion to alternate between heterosexual and homosexual relationships. Groups are starting up for women who want to experience dressing, walking and talking like a man. Meanwhile, some young girls are tasting the delights of gang warfare, and forming bands of highly aggressive muggers.
Increasing numbers of men who used to bond with body contact activities such as the rugby scrum, are now holding hands and exploring the feminine side of themselves in encounter groups. Many men stagger away from the divorce courts with little more than the cloths they stand up in, while alimony, palimony and child support lessen their financial independance. Loss of work from factors such as computerisation and the world-wide recession can also at any time cast them in the unaccustomed role of "House-Husband".
In my practice I am seeing increasing numbers of young men in their teens and twenties with what could be called the locker-room syndrome. This is an anxiety state where they do not feel sufficiently masculine in terms of their physique, body hair or penile proportions. In its fully developed state it can cause agonising self-doubt to the extent of avoiding sexual relationships altogether, stopping playing team sports which might involve communal bathing afterwards, and in extreme cases even avoiding public urinals where unfavourable comparisons might be made.
This is made worse by the increasing sexual experience of women, who may have had several better endowed lovers in the past, or have seen hard or soft-porn videos or magazines, who as the young men are painfully aware, always feature handsome, muscular males well equipped to have sex non-stop, "bonking like beam engines" as one woman TV interviewer put it, for hours on end. As one Indian Army officer said after watching a mammoth performance by an elephant in must servicing a female, "That's a tough act to follow".
This is a difficult condition to treat, and endless reassurance about "Its not the size that counts" doesn't seem to help. General psycho-sexual counselling, sometimes over several months, together with assertiveness training, and hopefully a loving supportive relationship with a partner, give the best hopes of a cure. Sometimes a brief course of testosterone in low doses can cause more feelings of assertiveness, boost confidence and induce a more macho mood, where the penis feels more adequate and erections are stronger and seem bigger. Penile extension operations, even in men who are in stable relationships and have fathered children, are beginning to be performed on National Health Service patients in Britain. However, this may well not be successful, and seems an expensive physical approach to what is essentially a psychological problem.
There are other factors also which are making women, particularly in mid-life , sometimes feel sexier and act more assertively than their male counterparts. In particular there are the problems caused by the andropause, which as mentioned earlier is generally neither recognised nor treated, in contrast to that in women which is treated much more seriously and more often, as described earlier. Just as increasing numbers of men are fading fast, many women are coming into their managerial prime, and both in business and in bed men feel they can't keep up with them.
Does this mean that businessmen are now beginning to feel sexually harassed? Well, probably not in this country yet. In America increasing numbers of men claim to be, and lawyers specialising in this new crime in the office jungle are thriving. This may be partly because the American female is supposed to be more emancipated and " up-front " about her sexual needs than her British counterpart.
Then there is the interesting research finding that more confident and dominant women show higher levels of testosterone than less assertive, stay at home, types. It has long been known that power is an aphrodisiac throughout the animal kingdom, but particularly in human beings. The principle of survival of the fittest has meant that high-ranking males sought out high-ranking females and vice-versa. From Queen B to Mrs T, that is Boadicea to Thatcher, some men have been turned on by the aura of power, while other usually less confident ones have been turned off by it.
Even male politicians, who by tradition enjoy and take full advantage of the aphrodisiac of power, are now feeling more threatened. The more politically correct labour party in Britain is introducing positive discrimination in favour of women in the selection of parliamentary candidates and ministers for shadow-cabinet posts.
In the sparring-match between the previous and present Prime-ministers, in the red corner is Baroness Thatcher, Mrs T or the Iron Lady, pumping testosterone and iron in equal proportions, while in the grey corner, taking a terrible battering below the belt, is John Major, who has been described as the "Testosterone-Free" Prime-Minister.
No wonder the male mid-life crisis is striking with increasing frequency and severity. Suicide rates in men, always more frequent than in women, are increasing rapidly. A recent study in Britain by the Samaritans organisation called "Behind the Mask" showed that over the last 15 years women's suicide rates had halved, while men are four times as likely, especially between the ages of 35 and 44 the peak mid-life crisis years. The world-wide recession is adding to this toll, with middle-aged men fearing that if they lose their jobs they may never work again. Many are having to face complete role reversal, staying at home as house-husbands, while their wives go to work as the bread-winner.
Though women generally complain more about their health, to family, friends and their doctors, the amount of life threatening illnesses they suffer is generally less than the male, and more is spent on their health care. Apart from their higher suicide rates, more men die from accidents at all ages, particularly when young from road traffic injuries. Under the age of fifty, men get five times as many heart attacks as men. Women have millions of pounds of National Health Service money spent on screening for cancers of the breast and cervix, which are decreasing, while men have virtually nothing spent on detecting prostatic or testicular cancers, which are becoming more common.
As a result of these combined factors, the life expectancy of men in most Western Countries, including the UK and USA is 7-8 years less than that of women. Is this an unalterable fact of life, or would better health care for men, including hormone replacement therapy with testosterone, narrow the gap? We should urgently be trying to find out.
One of the countries with the lowest gap in life expectancies is Greece. Greek men also have one of the lowest heart attack rates in Europe. Though this is doubtless partly due to sharing with equally low attack countries such as Italy and France the benefits attributed to a "Mediterranean Diet", there would seem to be other psychological and cultural factors at work also, and it is worth looking to see what we might learn from their experience.
In Greece the birth of a male child is a matter for great rejoicing, congratulations and celebrations, whereas the parents receive sympathy when a girl is born. Sons are the centre of attention in the family, and are spoiled continuously and indulged by their mother, sisters and grandmothers. At school the boys are outgoing, and develop a wide circle of friends, which during adolescent form his own supportive in-group or "parea" who stand by him loyally for the rest of his life. Youthful depression and suicide are relatively rare, though road accidents, drugs and AIDS are taking an increasing toll. Marriage tends to be late and to a considerably younger woman, and according to the Greek Orthodox tradition, divorce is relatively rare. Partly this is due to having a well worn escape route down to the local cafeneon, where he can be comforted by his all male support group, the parea.
Unlike the majority of British men with their usual constant distant manor and stiff upper lip, physical contact and letting their feelings out is part of the way of life for Greek men at all ages. Both men and women sing, dance, laugh, weep, hug, kiss and literally pat each other on the back at every opportunity. As well as being in touch physically, they enjoy eloquent, spirited emotionally charged conversations punctuated by laughter and decorated with gesture. Being cool, cut-off and alone are thought of as leading to loneliness, which is considered to be the worst of human afflictions, whereas good company, together with food and wine is the elixir of life.
He often does more than one job, which tends to keep him active and employed to a respected and ripe old age. Late in life he is lovingly supported by his wife, sisters, daughters and daughter-in-laws, and generally cared for at home until he dies. This life-long pattern keeps his testosterone and level of sexual activity high throughout.
A recent study of young Greek soldiers showed levels of testosterone right at the upper limit of normal, and very high rates of sexual activity, with one ejaculation per day on average. This seemed to be proportional to the amount of one of the breakdown products of testosterone, dihydrotestosterone (DHT), rather than testosterone itself. However this may have been a result rather than a cause of their vigorous sex lives, and doesn't agree with other evidence that suggests that testosterone is more important in regulating libido.
At the other end of the scale you have the Greek Prime Minister, with the appropriately doubly, if not trebly, androgenic name of Andreas Papandreou, who in his eighties scandalised his nation by marrying an actress in her twenties. This does not mean that I recommend such drastic remedies to my patients, or that such idyllic female support as Greek men traditionally enjoy is widely available in most men's lives, but I do think that there are important lessons to be learned from Greek male life patterns, and you will hear them echoed throughout this discussion on how to retain vitality and virility.
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Life can be compared to a trip in a glider when, after being catapulted in our teens and early twenties to the peak of our innate physical and mental abilities by a powerful cocktail of hormones, including particularly the sex hormones testosterone and oestrogen, we then go into a variable glide path for the rest of our lives, the rate of descent largely being controlled by the body's hormonal balance.
Some hormones, particularly the stress hormones such as adrenaline, noradrenaline, and cortisol, increase wear and tear and the rate at which we use up our energy, having what is known as a catabolic (or break-down) action. Others, particularly testosterone and oestrogen, have the opposite, or what is called anabolic (or build-up) effect. This can explain why some people burn themselves out and go into a nose-dive, their health crashing at the age of 50 or earlier, while others glide gently on into their 80s or even 100.
These ageing processes affect particularly the heart and blood vessels and, in the from of heart attacks and strokes, are the number one killer of western people, as I described in a book "The Western Way of Death: Stress, Tension, and Heart Disease." Coronary heart disease is also the main reason why, on average, the life expectancy of men in Western society is seven to eight years less than that of women.
In general, both physically and mentally, you're as young as your arteries. Testosterone and oestrogen have both been used to prevent and treat heart and circulatory disease. Their beneficial actions have been proved in many research studies and these hormones also maintain the condition of the skin, muscles and bones. Therefore it seems reasonable to expect that, by giving nature a helping hand on a scientifically regulated and carefully monitored basis, we could slow down the ageing processes and prolong active and enjoyable life.
As discussed in chapter three, the main factors in bringing on the male menopause are age, stress, alcohol and drugs, so any plan to maintain vitality and virility must take these into account. Though you can do this on your own with the help of this book, it is much better to have a medical advisor to guide you.
At the risk, as elsewhere in this book, of offending the politically correct lobby, I would suggest this advisor should be male, and probably in his forties, fifties or sixties so that he has plenty of experience and knowledge of the problems, having successfully solved many of them himself. Ideally he should be one of that currently rare breed, the Andrologist, with a broad range of postgraduate training and specialist interest in endocrinology as it applies to men, as well as knowledge of fertility, erectile and psycho-sexual problems. Alternatively an experienced General Practictioner who has read widely on the subject, particularly if he has attended courses on the more specialist areas of andrology, could be a good advisor. Perhaps most important of all, is to find one who you can confide in and relate to, and whose opinion you respect.
Whoever you chose, he should be able to tell whether you are going through a mid-life crisis or male menopause, and to help you through both. In other words, by a review of your long term health record, of how you feel and how you function, and by a detailed medical screen as described in the previous chapter, you need to find out which glide path you're on and what flight corrections are needed. Many of these corrections will be self-evident from the discussions of the different factors discussed in other sections of this book, while others will need a more objective or detailed analysis by your medical advisor.
A population peak of "Baby Boomers is now reaching the age of fifty. This affluent group with a high disposable income have generally more leisure than earlier generations and are tending to retire earlier. They therefore have higher expectations for the quality of their lives from fifty onwards and are unwilling to passively tolerate the symptoms of the menopause, male or female. Having the wealth, they want the health and happiness to go with it in what should be the "Golden Years".
Health maintenance, or what used to be called preventive medicine, is a relatively undeveloped and unsuccessful science, at least as far as the middle and later years are concerned. Coronary prevention studies such as the Multiple Risk Factor Intervention Trial, mistermed MR FIT, have generally proved uniformly unsuccessful, any small reduction in heart disease being outweighed by increased deaths from accidental deaths and suicides.
Similarly, as an article in the Times newspaper "Behind the Screens" recently pointed out, routine medical screens though seeming like a good idea at the time, and taking up considerable private and public resources, have not in fact made any appreciable impact on either morbidity or mortality in any area, especially cancer. Indeed, as this thought-provoking article points out, by causing needless expensive and anxiety provoking further tests, and causing investigation and treatment related disease, screening has so far done virtually nothing to either add years to life, or life to years.
There are however some rays of hope on this otherwise gloomy scene. We need to look in some new directions. The most promising of these appear to be:
To slow down the ageing process is a combined operation. You need to promote those activities which maintain, build up, or restore mental and physical function, and reduce those which cause wear and tear and breakdown. In chemical terms this is called balancing anabolism and catabolism. While there is of course much more to ageing than hormonal decline, I believe there is a strong case for promoting and prolonging a youthful balance of hormones by careful supplementation of the "hormones of youth", oestrogens in women and testosterone in men, both of which can be regarded as anabolic or build-up steroids.
The safety and effectiveness of carefully and cautiously applied testosterone treatment is described in detail in the previous chapter, and shares many of the benefits in both the treatment of symptoms of the menopause and in all-round mental and physical health maintenance as does oestrogen replacement therapy in women.
If the woman in a man's life is either younger in terms of years than him, or hormonally younger because of hormone replacement therapy, it seems to help to keep him young also. The idea of "His and Hers Hormones" has a lot to recommend it. It is certainly usually preferable to a man getting a divorce to marry a much younger woman to regain his lost youth. Apart from the pain to the spouse and the rest of the family, there is the emotional, social and financial stress caused to the man involved, the most painful part often being separation from his children. Though the new marriage may appear to be working for a year or two, as the divergence in interests and energy levels becomes more marked, the much older man is usually left trailing mentally, physically and perhaps most important sexually, and the relationship often falls apart with extreme unhappiness on both sides.
Attitude to ageing is also important. With improved health care throughout life, and especially with HRT, women are coming to expect to remain mentally and physically active, and to look and feel good, for longer and longer. They see celebrities such as Joan Collins, Catherine Deneuve, and Elizabeth Taylor looking as young and attractive in their fifties and sixties as they did in their forties, and have similar expectations for themselves. Increasingly men are having to think seriously about how they are going to keep up with their hormonally reactivated wives.
Some just give up and become couch potatoes slumped inert in front of the television. Others try to rise to the occasion by going on a diet, giving up smoking, and joining a gym or playing more golf, but these efforts often fade rapidly with the negative mood and inertia accompanying the male menopause. Maintaining a positive attitude is an important part of the "Flight Plan for Life" and is greatly helped by testosterone treatment..
Stress is one of the major factors contributing to the andropause, and as described in the chapter on Mechanics, works against testosterone both by reducing its production, and by releasing stress hormones such as adrenaline, noradrenaline and cortisol which have a catabolic action opposing its anabolic effects. It is important therefore that as part of your flight plan you become aware of your "stress payload" and how well or badly you are handling it. The initial screen should have given you a clear picture of this and suggest some ideas for what adjustments you need to make.
This is not to suggest that you should become a stress avoiding vegetable. Stress has had a bad press, but it can in fact be the spice of life and a certain amount is essential for our health. It is often presented as public enemy number one in present-day life and is related to a vast range of social, mental and physical problems. This is because of a fundamental misunderstanding of the nature of stress and a lack of appreciation of the "Joy of Stress".
The original definition of stress in engineering terms is that it is "A force which when applied to a body sets up strains within it". So stress can be seen as a very necessary force like electricity, which powers our lives. It is related to pleasure, performance and productivity by an inverted U shaped curve, which varies from person according to the amount of "current " which is right for us.. In just the right amounts, what could be called the "Work-out" sector of the curve, the upper half of the left-hand part of the curve, it makes us fizz and function at an optimal level. Where the bad image of stress arises is when the amount of stress increases to the point where we are pushed over the peak of the curve into the slippery slope of the "Burn-out" sector on the right-hand side.
As with a machine with a limited current-carrying capacity we may then blow a mental "fuse" and have a nervous breakdown or slide into a depression, or a physical fuse, and have a heart attack or develop a stomach ulcer. Some of us, notably certain politicians, are 30 amp cooker fuse people and can carry amounts of stress that would fry lesser mortals, and other more sensitive souls, who are often creative and artistic, are 3 amp lighting fuse types. finding high stress situations difficult or impossible to cope with.
It is also possible to have too little stress or stimulation in your life. This is the Rust-out situation at the bottom left-hand side of the Pleasure-Stress curve and is seen in the unemployed, those made redundant, and in some people who have to retire earlier than they feel they should. This can be just as much a cause of "dystress" as the "Burn-Out" situation, and may be one of the reasons why there is more social unrest and crime in times of recession, when the devil is making work for idle hands.
This is because stress is actually very addictive, a big turn-on, and the common chemical pathway to pleasure is noradrenaline. This hormone is released in response to a variety of situations which we have by experience found to turn on the right dose of this self administered drug of addiction, which we have found to stimulate pleasure centres in the brain. These are what I call the six-C situations of competition, car-driving, cigarette smoking, caffeine consumption, cold bracing conditions and copulation or other vigorous physical activity. This has been confirmed from blood samples taken in all these situations. As you might expect, in my early days of stress research I found Guinness book of Record levels of this exciting stress hormone in the blood of racing drivers immediately after this intensely competitive form of car-driving, especially where they did well, though it was difficult to catch up with them later to study the other situations mentioned.
It is easier to tell when we are under stimulated and bored then when we are overloaded with stress. We tend to overlook the early warning signs of excess stress such as work and social life becoming a no fun game, falling function in both, anxiety and depression, and physical signs such as migraine or tension headaches, hypertension, raised blood cholesterol, eczema, asthma and a variety of other psychosomatic ailments.
What can we do to reduce our chances of getting into this over- stressed, "Burnout" state?
Well, firstly we try "Stress Reduction" and consider how we can reduce unnecessary and unenjoyable forms of stress as far as possible. Some work-related and family-related stresses are unavoidable, but some just pile up unnoticed over time and can be weeded out when you think about them or write them down as a "Stress Inventory". Some are just due to trying to cram too many things into the day, and so choices have to be made. Some are due to hard-driving time and deadline conscious Type-A behaviour patterns, or "Hurry Disease" as described by the American cardiologist Dr. Ray Rosenman in his book "Type-A Behaviour and Your Heart", in which he gives Type-A drills to modify this harmful life-style. The "Time Management" skills taught in business school can come in useful here.
Avoiding people and situations which we recognise as being stressful to us can also be helpful where it can be managed. There is a certain type of person who is a "Stress Carrier" rather like "Typhoid Mary" who go round spreading the germs of stress. Though they usually show no signs of being stressed themselves, they leave a trail of devastation behind them in the form of over stressed people. As one American admiral put it when asked how he coped with the stress of his job "I don't take it in- I dish it out!".
How can one cope with these people? Sometimes you can avoid them like the plague they are and not be around when they call. Others are unavoidable, but you may be able to explain to them the way they make you feel, and work out a way in which your contacts with them can become less stressful. A very good manual of survival strategies in this situation is "Nasty People and How to Deal with them without becoming one yourself" by Jay Carter. The skills in the technique of Transactional Analysis described in the books of the American psychologist Eric Byrne, especially "The Games People Play" can also help defuse tension arising from contact with stress carriers and hopefully prevent it happening again.
The car is also a great stress generating machine, as my research into stress hormone levels in different situations showed. The racing drivers that my research cardiologist friend Dr. Peter Taggart and I studied as a test-bed of stress, showed record levels of the "Drive" hormone, noradrenaline. This had the effect of raising blood fat levels, particularly neutral fat or triglyceride, so that the blood plasma became opalescent and milky after the race. We also found that even in everyday motoring, noradrenaline and adrenaline levels shot up in most drivers, particularly when getting angry with other drivers, snarled up in a traffic jam or getting fined for parking.
As I described in "The Western Way of Death: Stress, Tension and Heart Disease", men particularly are very attached to their "Ego Chariots", and "Machismo Machines". You see rage reactions in and around cars during bumper to bumper mortal combat in traffic, that you seldom see in other situations except in hand to hand mortal combat in wartime. At work, pecking order equals parking order. It is worth considering whether you can let the train take the strain for some of the intercity journeys or travelling to work, or let the cabby's coronaries take the strain for getting around town. Again, society has a part to play in encouraging governments to limit pollution of the external environment by exhaust fumes from the traffic that clogs our roads, and of our internal environment from the stress-related fats which clog our arteries, by improving public transport.
Accidents are another source of stress and rapid ageing, very often related to Type-A behaviour, stress, tranquilliser use, drinking and driving, both on the road, at work and in the home. You may have seen in friends or relations how much a serious accident, perhaps even more than a serious operation, can age a person. Careful and cautious driving, as taught by the Institute of Advanced Motorists in Britain, in cars with all the latest safety features, is to be recommended in avoiding accelerated ageing.
My research on the effects of major trauma showed very high levels of stress hormones, and marked lowering of testosterone levels, which reached crisis point about a week after the accident, and could cause delayed deaths at that time from multiple organ damage, especially to the heart and brain. Some of these effects could be reduced by stress-blocking drugs such as the beta-blockers. Many of my patients dated the sudden onset of their andropausal symptoms to an accident or major operation, particularly involving surgery of the heart or prostate gland so the fewer the operations you have the better. Among its other advantages, so-called "Key-hole Surgery" using endoscopic instruments, may help to minimise operative trauma, and post-operative complications and immobility to lessen the wear and tear associated with operations, especially in the elderly.
We have not changed essentially in our mental and physical constitution for thousands of years. Modern space-age man still has his stone-age psychology, physiology, biochemistry and endocrinology. His hormonal responses to a stressful situation are still the same whether its fighting a hostile take-over bid in the boardroom, or a sabre-toothed tiger in the jungle. In either stressful situation the primitive fight-flight mechanism comes into action, and the body is put into a state of emergency by the autonomic or automatic nervous system and the associated hormones.
Adrenaline speeds up the heart and mobilises sugar into the blood stream, while noradrenaline turns arouses and alerts you, and raises blood pressure and fat levels to pump these fuels into the muscles, giving you extra energy for fighting or running away. At the same time that these breakdown, catabolic processes are being switched on, the build-up, anabolic processes linked with testosterone are being switched off, because this is a time to make war not love. Let's look at the various ways of balancing up our stress responses.
The problem in modern times is that much as we might feel like it, when in danger, when in doubt, we can't scream and shout and run about. Our instinctual stone-age reactions to stress have become inappropriate for our space-age setting. Physical exercise is one of the best and most natural ways of getting these mental and physical reactions to stress back into balance again.
After exercise, the mind calms down, the tension in the previously coiled springs of the muscles has been reduced, and the sugars and fats mobilised into the blood stream have been used up. In this state of rest, relaxation and restoration, testosterone levels rise again, as has been shown in many research studies on people exercising. If you overdo it however, and the exercise itself is pushed to the point where it becomes stressful, testosterone levels fall, as was shown in marathon runners. Train, don't strain, and remember exercise doesn't have to hurt to do you good - quite the reverse. No pain means safer gain!
With this in mind, and because the andropause is mainly a condition seen in men around the age of fifty, as I described in a book F/40 - 'Fitness on Forty Minutes a Week" written for the British Sports Council with Al Murray, a pioneer in the gentle art of getting middle-aged businessmen physically fit, exercise in this group should be designed according to the acronym SAFE. This stands for Safe, Acceptable, Fitness producing and Economic.
S- Safety is the essential requirement for exercise in this age-group of men. It should be ideally be vigorous but not violent, calming and not over-competitive, and isotonic, or dynamic, rather than isometric, or static, which causes the blood pressure to rise too much. A good safety check is the pulse rate, which can be checked by feeling it at the wrist, or using a pulse monitor. This should not rise above a safe level, which can be calculated according to your age, fitness and medical condition.
A - Acceptability is essential as it is no use having the best system of exercises in the world if you never use it. Find the form of exercise you find acceptable to you, and use that. The right surroundings are important, and if you don't feel like going to a gym or swimming pool a personal fitness trainer in your home may be the answer, as well as providing the necessary motivation.
F - Fitness in terms of feeling and looking better, and greater strength and mobility, together with the relief or prevention of andropausal symptoms are some of the benefits of exercise. These can be especially marked during treatment with testosterone.
E - Economy both in terms of time and money is attractive to most people taking up exercise. Two twenty minute periods of vigorous exercise each week, or three times that amount of light exercise, are sufficient to maintain a reasonable level of fitness in most men, help weight control, raise testosterone levels, and help to keep them sexually active.
Having covered the basic principles of exercise to maintain vitality and virility, lets take specific examples:
Walking - This, like cycling, is a much underestimated and under-used form of exercise which can not only be used to replace much stressful driving, but is a good basis on which to get fit enough for more vigorous physical activity. To give maximum benefit it needs to be brisk enough to raise the pulse rate to over 100 beats per minute, at least in the unfit. This means really striding out, what I call "Power Walking", and twenty minutes of this daily will give a good level of fitness in most men over the age of fifty.
Golf can also be a good way to encourage walking in pleasant company providing it does not become too competitive. Unless you find walking very difficult for any reason, beware the buggy, which can spoil the exercise element in golf. Many patients find that testosterone treatment reduces their golf handicap, improves their concentration and strengthens their drive. Perhaps golf clubs will have to have special competition categories for those on or off anabolic steroids.
Swimming is excellent whole-body exercise, especially for those trying to lose weight. It could be said that you got "Double-bubble Benefit" with swimming, because you are not only burning off a lot of calories by exercising the main muscle masses of the body, but still more by keeping warm because of the heat loss even in water at a comfortable temperature. Unlike land -based exercise, any excess weight is supported in the water, and does not throw strain on the joints. It's also a sociable, and enjoyable form of exercise, and the sight of a range of attractive women in revealing costumes may do wonders for the libido of the andropausal male.
Gymnasium exercise is becoming increasingly popular, and some enlightened firms are even providing it in-house. Ten years ago, with Al Murray, I helped to establish a gym in the House of Commons to encourage Members of Parliament to be at least physically fit to govern, though it seems to still be seriously underused. Favoured exercises amongst politicians however still seem to be horizontal jogging, running opponents down, and leaping to conclusions.
Good facilities in a gym should include properly trained and experienced instructors who carry out an initial fitness assessment, including measurements of heart attack risk factors such as blood pressure, and keep a continuing watchful and encouraging eye on your progress. Exercise schedules should be tailor-made to the individual and progress carefully monitored in terms of "Perceived Exertion", how hard the exercise feels, as well as by pulse rate measurements.
Straining at heavy weights is to be avoided, as are "press-ups". The motto should be "Down with Press-ups" as you are lifting three-quarters of the body weight, and this is too much like maximal isometric exercise. The blood pressure is greatly raised by this type of activity, and because of the increased pressure in the chest, blood cannot get back to the heart.
Also to be avoided is prolonged exposure to high temperature sauna baths after exercise. Research we carried out at Al Murray's City Gym in London and reported in the British Medical Journal showed that at high temperatures large amounts of adrenaline are released which makes the heart beat rapidly and erratically. This can be more unsafe than strenuous exercise, particularly in those with high blood pressure or heart trouble. Cold plunges after the sauna are also not a good idea as we showed that they cause the release of the noradrenaline stress hormone, which produces a dramatic surge in blood pressure. All these violent circulatory gymnastics are best avoided if you are seriously interested in longevity.
Running and Jogging
Unless you are already in training, running and jogging are generally too vigorous to take up immediately without a period of "Power Walking" for several weeks beforehand. Even then these forms of exercise have been accused of "mass murder" by Dr Meyer Friedman a leading American cardiologist, who would agree with the cautionary saying that "The grim reaper also wears a track suit". One of his recent victims was Jim Fix, the American running populist, who abruptly dropped dead in his tracks.
He also obviously had designs on several American Presidents, who unlike British leaders, tend to overdo the fitness kick. Carter had to be carted off from one run, Bush was so bushed on another he collapsed, and Clinton is visibly declining every time he is seen jogging. They must have got confused at an early age about the literal and metaphorical meaning of Presidents needing to run for office. Either that or they are running-scared of the 25th amendment to the American constitution, introduced after the cover-up of President Dwight Eisenhower's stroke in the 1950's, in which a President can be declared unfit to govern for health reasons. Or perhaps they think they would be more popular if they emulated the film character Forrest Gump, who in his frequent meetings with American Presidents, showed how to compensate for intellectual impairment by a spectacular ability to run. Even he however worked out on his third coast to coast walk across America, that this was not the way to enlightenment, and hung up his running shoes.
Apart from the dangers to the heart and circulation, in some cities there is an increasing risk of getting mugged or run over. Knee and ankle injuries are also common, and running on hard pavements has been shown to cause blood to appear in the urine from trauma to the kidneys. As with walking, well designed shoes with shock absorbent in-soles are vital for both safety and comfort.
Mental exercise as an antidote to stress
While many doctors know about meditation in relieving anxiety, few realise just how powerful a tool it can be in stress management. Lectures in medical school mainly tend to focus on the wonders of medication, giving a message which is reinforced throughout the medical career by bombardment with literature and free samples from the drug companies. There are so many drugs to regulate our mental state on the market now that you might be forgiven for wondering if any of them work effectively in the majority of stress-related conditions. Also there are many worrying reports of side-effects of many of these drugs from valium to prozac.
The depressing truth is that if we take the edge off the razor-blade of life down which we slide, as the American humorist Tom Lehrer put in one of his songs, we also blunt many of life's pleasures, experiences as well as performance. Stress related symptoms are trying to warn us of something, and it's like turning off the fire alarm because you don't like the noise of the bells. Many patients tell of a zombie-like, switched-off state they experience on tranquillisers.
Malcolm Lader, professor of psychopharmacology in the leading research centre in the field, the Institute of Psychiatry in London, had reported on the severe habituation which comes with long-term tranquilliser use, their addictive properties and the acute withdrawal symptoms which occasionally occur with suddenly coming off them. He also created alarm and despondency among doctors and patients alike when he reported that CAT scans showed that long-term tranquilliser use caused shrinkage of the brain similar to that seen in alcoholics, apparently due to "neuronal drop-out".
Given such information, many people would prefer to control the stress in their lives by meditation rather than medication. Doctors generally know little about meditation, as it isn't taught in medical schools and only a few find out the many benefits for themselves. It can however be very effective in the control of stress reactions, whether in its original form as one of the different forms of yoga, or in its modern Western forms.
Meditation is simply the direction of flow of attention according to Patanjali, the eight century Indian sage who systematised yoga. Most of the time our attention is directed outwardly. This focuses your attention on all the different forms of stress in your life, and in susceptible people creates a vicious circle of stress leading to increasing stress hormones such as adrenaline, noradrenaline and cortisol, and decreasing testosterone release, which all causes symptoms which generate more stress and further unfavourable hormonal changes.
When attention is directed inwardly, which is what people usually understand by meditation, you become uncoupled from the stresses in your life, and the body's self-healing, restorative relaxation responses take over. This produces a switch from over-activity of the fight-flight system to increased activity of the rest-restore-relaxation system, with corresponding hormonal benefits including restoration of testosterone levels.
Such voluntary control over the body's involuntary nervous system, the autopilot which regulates our responses to stress, is remarkably easy to achieve with a whole range of techniques. These originated with yoga methods in India, moved to China as Buddhist meditation, and then to Japan as Zen meditation.
Autogenic Training is a Westernised rediscovery of the basic principles of Eastern forms of meditation. The essential basis of Autogenic training is the sequence of the six Standard Exercises developed sixty years ago by Dr. Johannes Schultz, a German psychiatrist working in Berlin, where there is an institute dedicated to his memory. This type of "Mental Circuit Training" involves focusing the mind by silent repetition of "verbal formulae" suggesting sensations of heaviness and warmth in the arms and legs, a calm regular heart-beat, easy natural breathing, abdominal warmth and cooling of the forehead.
Under medical supervision these mental exercises are progressively introduced at individual or small-group training sessions held once a week over an eight to ten week period. The patients then practice them in a comfortable, stable sitting position on the edge of a chair, in an arm-chair or lying flat-out on their backs. Whether at home, in the office or travelling, they can usually at any time find an opportunity for a session of "Autogenics". Usually they are recommended to practice for ten to fifteen minutes three or four times a day.
You don't have to be a burnt out stress victim to benefit from Autogenic Training as is a powerful stress management technique from which everyone can benefit. It has been widely used in industry, and being non-competitive and non-intrusive, it can be taught on in-house courses. It has also been taught to airline pilots, and was helpful in coping with jet-lag. It was one factor that the training of both astronauts and cosmonauts had in common. It has also been used extensively with competitive sportsmen and women, together with musicians an others in the performing arts. There are many fringe benefits such as reducing the amount of sleep required, and promoting creative thinking by balancing up the two sides of the brain, the logical, linear thinking left, and the intuitive, more feeling creative right which is often relatively inactive.
For the andropausal patient, as well as reducing stress, it can help control alcohol and food intake, gently but firmly over a period of weeks. The psychological effects can also help the person sort out long-standing emotional problems both at home and at work. However, it must be emphasised that it is a practical skill, like learning to drive a car, and you need a well-trained instructor. Though it is relatively unknown outside Europe, Britain is fortunate to have an organisation called the British Association for Autogenic Training and Therapy (BAFATT) which can provide a list of trainers in most areas of the UK.
Siddha Meditation is the one Eastern technique which I have practical experience and can warmly recommend as being a very straightforward form of meditation, which is based on an ancient tradition and philosophies which help control and reduce stress. The current head of this lineage of meditation teachers is a beautiful Indian teacher called Gurumayi Chidvilasananda. It is a very spontaneous and easy to learn form of meditation, which is taught in over three hundred centres all over the world, including North and South America, Britain and the rest of Europe, Australia as well as India where it originated and is respected as a great tradition. There is a branch of the Siddha Yoga Foundation in most countries.
The technique basically involves calming the mind by focusing it on a simple word formula or mantra, linked with the breathing. This makes use of the age-old observation that when the mind is disturbed, the breathing is usually disturbed also. Conversely controlling the breathing can help to control the mind also. When the mind goes still, great feelings of peace and calm can arise from within, and subtly but powerfully change the person's life. as I and several of my patients have found.
There is an old saying that what you don't use you lose. This is true in terms of mental, physical and sexual function. You see it every day in people who retire, sink into apathy, and often die soon after. It is also seen in younger people made redundant who give up hope, and give up trying to get a new job. In this situation it is probably better to do anything than do nothing.
It is one of the tragedies of modern life that there seems to be polarisation of the work force. At one end you have the over-employed, who are risking burn-out by working longer and harder to keep their jobs in the face of seemingly ever increasing competition. At the other end you have the growing ranks of the rust-outs who are unemployed or have been forced into early retirement by redundancy, rationalisation and down-sizing of their firms. Both groups can be equally unhappy, but for opposite reasons.
Every person has an optimal level of stimulation or stress, and above and below it lie unhappiness. Once our basic survival needs are taken care of, as they increasingly are in most societies, and we had fulfilled our "biological imperative" by having and bringing up our children, what do we do then? "Me Tarzan. You Jane" male and female roles no longer apply, and in an increasing number of families the male isn't even the breadwinner any more. In this situation, it is difficult for him to remain either vital or virile.
The Protestant work ethic isn't working any longer either because it is increasingly absent for a large number of people for a large part of their lives. This century more and more people are moving into urban environments, and the proportion working in farming and agriculture in America for example has fallen from about 20% to 2% in that time. The 9 - 5 till age 65 is no longer even the structure of the city dweller's life any more. What's to take its place?
Beer and circuses were the answer during the decline and fall of the Roman empire, and many are drawing comparison's with that and the state of the Western World today. Perhaps beer, games shows and the rest of pulp TV are the modern equivalent. Beer, combining the hazards of both alcohol and phytoestrogens certainly doesn't do much for either vitality or virility, and TV mainly promotes endless unsatisfying consumerism and discontent.
What are the alternatives? It is surprising how little either politicians or sociologists appear to be looking into this question, since it seems that one of the main problems to be faced during the next millennium is that work as we know it today is set to become a luxury item. Perhaps, occupation, how we are going to spend our time, should become our preoccupation. Here are some suggestions to fuel the debate, since they have a bearing on how we face up to both the male mid-life crisis and the male menopause. A man without a function often ceases to function as a man.
Perhaps some of the answers to the problems being created by technology may lie in the applications of technology. For some people loss of a job has meant that they can discover new skills and abilities, and a new lease of creative life through the computer, and may even take to surfing on the internet.
Others are seeking a low-tech answer, and welcome the increased time available to them for pure recreation or self- development in a variety of ways. Some take to the worship of the small round spherical object known as the golf-ball, playing two rounds a day every day the weather allows them to. Some take up the search for spiritual enlightenment, and enjoy the structured life and discipline that either the church or yoga and meditation can provide them. Perhaps we need counselling centres to help people find their individual answers, or even your friendly neighbourhood Andrologist could give some advice, information and guidance.
As the number of hours of work needed to perform various jobs falls due to automation and computerisation, so the need to share this now precious commodity increases. The trend towards teleworking makes such sharing potentially easier and more attractive in some areas. This can open up a new career working from home via the modems, faxes and video-conferencing, without the expenditure of time, energy and money involved in commuting.
Imagine a system where the norm was a sixteen hour working week, either two eight-hour days, or preferably four four-hour shifts. If you were a morning person, you could leap out of bed and work in the morning, or an evening person could surface more gently, and work in the afternoons. Moonlighting workaholics would be gently weaned off their addiction in work-withdrawal programmes, led by teams of easy-going idlers. They would be reminded that the working-day of the cave-man was only three or four hours long, and the rest of the time was spent in social activities such as tribal dancing or grooming oneself before an evening round the camp-fire.
Not only might the working week be shortened, but the years worked might be shortened to thirty or even twenty. The Brahmin ideal of life in India has four approximately twenty year periods, of student, householder, progressive detachment and ultimate contentment. Having finished your education around the age of twenty, you would then have the privilege of working for twenty years to establish your position in a less competitive society, bring up your family if you decided you wanted one, and have some extra consumer goodies above the guaranteed social norm.
After your twenty years work, the mid-life crisis would be much less of a problem, because it would be expected that you would take up some more creative or leisurely past-time, or go back to study something that you found really interested you more than the work you had been doing. Rather than "retiring", you would be advancing in some new direction and might wish to take a few years to attend a "University of Mid-life" as a mature student to go deeper into something that you might have missed out on previously. The "Open University" is an encouraging development that many people faced with early loss of employment have found, often to their surprise, to give them a new and absorbing view on life.
This period of detachment could also lead to more unpaid voluntary work in the community, and perhaps be a time for some to do more social work, counselling, or even following political pursuits having had more life experience and with more maturity than the average career politician. It may be however by that time in his life, he will have come to the same conclusion as the philosopher who set out as a young man to change the world, and with increasing experience progressively narrowed his activity to changing his community, to changing his family and friends, to finally just trying to change himself.
There are some jobs, mainly in the so-called service industries, that just can't be automated. These range from psychotherapy to hairdressing, sorting out the inside and outside of the head, and from medicine to massage, making the inside and outside of the body feel better. Shifting work into these often overstretched professions would create many new satisfying jobs, and could well improve the sum of human health and happiness. For those who wished a more action-packed time in their lives, short periods of voluntary overseas service in teaching survival skills or bringing aid to developing countries or disaster stricken areas might provide the ideal opportunity.
A study of the health of Civil Servants, the so-called Whitehall Study, which has been going on for about thirty years in London, has shown that those in senior positions, the "Mandarins", enjoy better health and tend to live longer than those in the middle or lower echelons. Perhaps the answer to this interesting observation lies in the original meaning of the word Mandarin, which was "A high civil servant thought to exercise wide undefined powers outside political control". The power element may well be linked to testosterone levels, because it is the sense of power which promotes secretion of this hormone as was described in relation to stress and production of this hormone. This is seen throughout the animal kingdom, but particularly in ageing stags, bull-seals and male primates.
Taking this idea a step further, sharing power and empowering people in different areas of their life could well help to maintain their hormone levels. This would range from setting up managerial structures with a broader power-base, to setting up production lines, as in the Volvo experiment in Sweden, where one worker sees his product through as from one end to the other, rather than performing one limited task only. Similarly, the American telecommunications company AT and T, have extended the powers of an increasing number of their operatives to follow-up and provide a larger range of services to the customer who first contacts them and becomes "their client".
The rapid improvement in communications may also empower people by letting them take part in decision making processes at both a local and national level. Via telephone and fibre-optic links they could make their views felt in polls and referenda, and even add a new dimension to the deliberations of their governments by voting, live on issues which concern them, making democracy a more exciting, interactive process. It is a frustrating sight to see the low level of interest and poor attendance rates in the British Parliament, either in The House of Commons or House of Lords when matters of national importance are being discussed in televised debates. Immediate feed-back on their often dismal performance from the general public might revitalise these debates, and even inject some hormonal life into them.
Alcohol is one of the major factors contributing to the male menopause, and if there is a serious alcohol problem it is not worth giving testosterone until it has been treated with the help of one of the effective agencies such as alcoholics anonymous. Also as described in Chapter Four, the testis is very sensitive to both the short and long term effects of alcohol even in amounts which are insufficient to damage the liver or cause social problems.
Because of general insecurity, greater unemployment in young people and a general sense of aimlessness and disillusion, the consumption of both alcohol and potentially testicle-damaging drugs such as cannabis is increasing among young men. The average alcohol intake of men aged 18-24 in Britain is now 22 units per week, just above the 21 units which used to be the safety guideline set by the Health Education Council, though this has now I think incorrectly from the point of view of testicular function, been reset at 28 units. This means that over half of them are at risk of damaging their health, particularly their sexual health including fertility, by their drinking habits.
The most common drink in this age group is beer, which is most likely to damage the testis and feminize the male. By contrast it has been shown by researchers in Sweden that a few alcoholic drinks in women, especially the wine which they more commonly like than beer, causes a surge in testosterone levels. This causes their libido to be highest when the men are most likely to be drunk and incapable.
Because of these sobering facts, so as to prevent more testicular damage, improve the chances of relationships surviving, and see if some improvement in function can be obtained, I usually recommend a return to well within the twenty-one units of alcohol per week limit, and sometimes the patients find even less is better. Also, because of the phyto-oestrogens in beer which work against testosterone, there is a serious message in the British Health Education Council message that "There is one part all beers will reach" and the Australian low-alcohol lager advertisement which claims it will prevent "your diggery-do turning into diggery-don't". Because there is also the possibility that phytoestrogens may still be present even in low alcohol beers, it seems worth trading the beer intake for wine, especially red wine.
Weight reduction is often needed to help in the treatment of andropausal symptoms. Weight gain which doesn't respond to diet is one of the most common and demoralising effects of this condition. Often this is mainly in the lower abdomen, giving the appearance of "Beer Belly". One witty journalist said that till the age of forty he used to be proud of the breadth of his mind and the narrowness of his waist. Then he woke up one morning and found they had changed places, and he was sure middle age had really set in.
The spreading waistline is both a sign of the andropause and makes it more severe. This female type of fat distribution, is partly due to the action of oestrogenic factors which may have helped to produce it, and partly because when there is more fat in the body, resistance to the action of testosterone increases and more of it is converted to oestrogen. There is also a general tendency to put on weight which is very difficult to remove by dieting because testosterone deficiency causes more sugar and protein to be converted to fat. As the couch potato ripens, energy decreases, less exercise is taken and lacking both activity and testosterone drive to build them up, the abdominal muscles melt away as the paunch appears.
Fortunately, as well as restoring the will-power, or rather the won't-power needed for successful dieting, and bringing back a more positive and energetic mood, treatment with testosterone improves sugar metabolism so that less is converted to fat and more goes to rebuilding the muscles. The effectiveness of this form of hormone replacement treatment for men was shown in a study in Gothenburg in Sweden, where the cosmetic effect in reducing beer bellies, as well as the other benefits of testosterone treatment were greatly appreciated by both the patients and their wives.
As with alcohol related problems, expert guidance in specialist groups such as Weight Watchers or in the many health clinics specialising in this area, may be needed to help the patient really tackle his weight problem after many years of inertia. Where there is marked obesity, this can be a very important factor contributing to resistance to the action of testosterone, essentially similar to the insulin resistance seen in adult onset diabetes.
Psycho-pharmacology is making rapid advances in the field of so-called "Smart Drugs" which claim to slow mental ageing and the loss of memory which goes with it. These widely discussed but little applied drugs, combined with psychotherapeutic mental exercises and relaxation techniques, and the benefits of HRT in both sexes on cerebral function and circulation, should have enormous potential for "Brain Maintenance".
Similarly, there are various dietary supplements, which are claimed to increase libido and help avoid prostate problems. In particular there is an interesting Swiss Oat preparation which is supposed to free up testosterone by reducing the inhibitory "Sex Hormone Binding Globulin" and this may be one of the natural plant hormones which will find a place in the treatment of patients who want to avoid long term orthodox hormone treatments.
Antioxidants and micro nutrients.
Antioxidant's, especially Vitamins A, C and E, together with micro nutrients such as selenium and zinc, are widely discussed and taken, both to improve vitality and potency and to reduce heart disease and cancer. However, this is largely on a haphazard basis, without any medical authority or guidance.
I think there is now compelling evidence that vitamin supplements may have a generally beneficial effect in maintaining health, and may well reduce heart disease in the long term. These effects may well be due specifically to their antioxidant effect, perhaps by reducing the so-called "free radicals" which are supposed to contribute to these conditions.
Zinc is concentrated by the prostate gland, and is an important ingredient of the seminal vesicle fluid which joins the semen as it is pumped though the ejaculatory ducts in the prostate gland. It's function seems to be to activate the sperm, which appear to pump zinc just as the muscles pump iron. Like the Vitamins, in sensible amounts it appears non-toxic and may be beneficial.
What I am advocating is boosting the vitality, strength and longevity of men of all ages, but particularly past the age of fifty, to the point where it equals that of women, especially when the latter are on HRT.
This is a physical and mental balancing act to maximise the many benefits of testosterone in men. In no way does this mean testosterone for all, male HRT being only given when needed to treat the male menopause or for long term health maintenance in older men who choose that option. Generally it involves maintaining the body's natural supply of testosterone, seeing that like the man, it remains free and active, and that it's actions are not blocked by factors such as SHBG, oestrogens or stress.
Men are about 30 years behind women when it comes to HRT for the wide variety of historical, medical and marketing reasons already mentioned. Hopefully they will now catch up rapidly as the male menopause is more widely recognised to be a real condition which can and should be treated, and as the safety, effectiveness and many benefits to physical and mental health of TRT become recognised. I have tried to spell out clearly the primary importance of testosterone in maintaining vitality as well as virility, but we need more doctors with a special interest in men's health issues, andrologists, willing to act as leaders in the fight for what could be called "Men's Lib".
This is not an anti-feminist movement, but a way of recognising the need to empower men and help them to remain active and equal partners throughout long and healthy lives. The "Women's Lib" movement, has helped women achieve social and hormonal emancipation, but the men are now lagging behind. Even in terms of longevity, women have a life expectancy five to seven years greater. When combined with the tendency for their men-folk to be on average three to five years older according to actuarial statistics, this means women lose their partners an average of ten years or more before they die, which can make for a sad and lonely end to life.
It was the interest, enthusiasm and favourable experiences of the female public at large which brought in HRT with oestrogens as a treatment for the menopause. The doctors generally either were not interested, or prophesied doom and disaster in the form of breast cancer and heart disease, but were coerced into giving short three to six month courses for the relief of severe menopausal symptoms. Soon, many of the women felt so well and looked so good on HRT that they wanted to stay on the treatment indefinitely. Though there were initial problems with a few women developing cancer of the uterus, this was overcome by giving combined treatment with progesterone to cause withdrawal bleeding, and overall it proved very safe.
Gradually the many benefits to both mind and body became apparent, especially in preventing the brittle bones caused by osteoporosis, and in reducing by up to half the amount of heart disease. At that stage the medical profession belatedly woke up to the potential of HRT, and suddenly became enthusiastic, as did the drug companies, and sales of these preparations world wide boomed to 50 million pounds annually on top of the already lucrative market in oral contraceptives.
One well-known British gynaecologist went as far as to say "Hormone replacement therapy is without doubt the most important item of preventive medicine in the Western world for half a century. Nothing else has brought such huge benefits to so many people".
It is my view that recognition of the reality and importance of the male menopause, together with the present careful research in the rapidly expanding field of Hormonal Replacement Therapy in both sexes, will lay the foundation for preventive medicine in the 21st Century. I suggest that it is only by such advances that the people in the West during the second half of their lives will achieve the World Health Organisation's goal of "Health for all by the year 2000".