The male mid life crisis

Sometime around mid life many men find they begin to experience penis problems as part of a broader picture of failing sexual performance.

For example, they may not be able to get an erection as they once did; they may not get erections in the night or early morning. They may lose their desire to make love, or they find that they cannot sustain an erection. Their penis may appear to have shrunk.

They may become grumpy, irritable and demotivated, and they may have physical aches and pains. All of these things - and many more - can be a part of the male andropause or mid-life crisis.

The andropause, and mid-life sexual problems in men

The typical story is of a middle age man who gradually loses his drive, strength, energy and enthusiasm for life and love. An all-enveloping mental and physical tiredness descends on him, often for no apparent reason.

He changes from being a positive, bullish person who it is good to be around to a negative, pessimistic, depressed bear with a sore head and it is increasingly difficult to live or work with him. At work he is seen to perform poorly and no amount of encouragement or urging will improve his performance.

At home, family relations tend to become increasingly strained, and social life and activities dwindle and wilt. His sexual life is usually a disaster area, with loss of sex drive and intermittent failure to achieve an erection leading to performance anxiety and eventually complete impotence. This creates a downward spiral of failing function both in bedroom and office. (From the book by Dr Malcolm Carruthers, Maximizing Manhood, page ix.)

One man's account of the andropause

The changes came over me very gradually, just around my fortieth birthday. I didn't know what was happening.

Without realizing it, I became incredibly irritable, depressed and moody, losing my temper at random and with little or no provocation. Once I actually stormed out of the office when given an extra piece of work, and drove home, feeling entirely justified. Of course the reaction to this was not good, and it forced me to consider what was going on.

While I was counting up the other changes that had come over me, it occurred to me that I had lost much of my libido: you might think it's surprising I hadn't noticed this before, but I'm not married, and my last relationship had been nine months before.

From being ready for sex, whenever it was available, or even when it wasn't, with a firm erection most mornings, and a strong impulse to masturbate two or three times a week, I realized that I didn't really care about sex any more, and I wasn't masturbating at all.

My morning erections were weak and seemed smaller and less firm, which was particularly distressing since my penis is not very big anyway. And then the tiredness and depression started: I got out of bed feeling awful, and remained so all day. At one point I could hardly drag myself into the office.

Friends began to point out my failings - most often, it seemed, by avoiding me. But then, I didn't really want to do anything - even to see my friends, with whom I had spent many happy times. Somehow it all seemed too much effort.

At some point in the process I realized that my weight had gone up, and I had become, well, not to put too fine a point on it, fat. I ate and drank a lot, but it seemed like comfort eating, and my cholesterol level began to climb steadily. Of course, it's always possible to rationalize things away, and I think this can be a source of comfort, especially when we don't have the knowledge of what is actually happening.

And so I began to explain things to myself: "It's stress - and no wonder - look what's happening: the company is in trouble, extra pressure, threat of redundancy." And on a personal level: "I'm so dissatisfied and disillusioned with what I have achieved in life. No wonder I'm unhappy, stressed, grumpy."

This, I thought, must be the famous mid-life crisis, brought on in my case, I thought, by the sudden insight that I was probably half-way through my life and feeling that I had accomplished few things of significance.

Particularly significant was the fact that I hadn't been able to start my own family, a desire which, while rooted in my belief that I would be a fantastic father, was also something to do with a desire to leave something on the Earth after I had gone.

But, I wondered, did the idea of a mid-life crisis explain the aches and pains in my body? The lower back ache? The tiredness? What about the unexpected and unexplained hot flushes, which left me soaking in sweat at night, and the more embarrassing flushing of my face that occurred during the day, also apparently at random?

 Did it explain my impotence, by now, about a year after this had all started, almost complete? And did it explain the fact that my penis seemed permanently shrunk and tiny? And there's no doubt I was depressed. I don't know what it was in the end that made me see sense, but I guess it was the sexual aspect of the situation. I booked into a men's clinic for a check up, and discovered my testosterone was well below the levels considered normal.

Just what is a mid-life crisis?

It's obvious that a change from one phase of life to another has to be accompanied by psychological adjustment and a reassessment of one's identity.

For women, the transition from the child-bearing years to the post-child-bearing years must be a profound experience.

Before the menopause, a major element of a woman's sense of identity is her fertility, her menstruation, her ability to give life and birth to new people; after it, she has to redefine her sense of self to accommodate the knowledge that she is no longer fertile. Could there be a similar process for men?

Yes! Dr Malcolm Carruthers, Dr Eugene Shippen, and Jed Diamond have all studied the crises to which masculinity is subject in great detail. There are references to their work below, if you want more information.

So what about men in modern society? Do we have a similar transition? Dr Malcolm Carruthers - who has worked with thousands of male patients in his London clinic - thinks that the male mid-life crisis is emotional in origin but if severe enough or long enough may have physical consequences, especially if alcohol or drugs are used to blunt the pain of the crisis.

Typically, he says, the age group most prone to the crisis is around 40, mainly between 35 and 45, which is earlier than the andropause, which usually starts around the age of 50, say 45 to 55. Dr Carruthers suggests that many mid-life crises go unnoticed and are passed off as the effects of a change of job, a change of house, or a change of spouse.

Only occasionally does the drama turn into a full-blown crisis in which the man may feel he is stuck in a career which under- or over-extends him, producing the prospect of burn-out; or in a dead marriage or relationship which gives him the choice of divorce or separation and its consequent traumas, financial ruin, and starting over again.

He also lists a number of factors that seem to predispose men to a traumatic mid-life crisis - in essence, these are things that destabilize him from childhood onwards: being born with a sensitive nature, distant or unloving parents, the loss of a parent, especially the father, loss or separation from a loved one or role model, and repeated failure or even repeated success in his career.

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

What to do about the mid-life crisis

There are solutions. Some men don't experience much of a crisis anyway, they just continue living through the first part of their life and into the second.

Others go through a period of great turbulence but then find a new course and approach for the second passage of their lives. This may involve a new set of challenges, a new direction, or a coming to terms with what they have got.

Often the new paths are more spiritual and less driven than those of their youth. But a few may succumb to disaster in the form of drug, alcohol and sexual addiction, or spend the rest of their lives drifting around aimlessly in a state of depression.

The book by Dr Malcolm Carruthers contains vital information on what you can do if this applies to you: "The mid-life crisis, even when it brings on depression, despair, anxiety or fear, is a time of great challenge, out of which come symbols of transformation. As we age, we human beings yearn for wholeness. We yearn for parts of ourselves that have been in the dark to find sunlight, and those that were sunburned to find shade. We yearn for the parts that have been underdeveloped to grow, and those that were overdeveloped to be pruned. We yearn for the parts that have been silent to speak, and those that were noisy to be still. We yearn for the parts that have been alone to find companionship, and those that have been overcrowded to find solitude. In short, we yearn to live our unlived lives."

Just what is the andropause?

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

Its onset can be at any time from the age of 30 onwards, though typically it is in the fifties. One of the reasons it's often missed is that it is usually more gradual in onset than the menopause in the is a crisis of vitality just as much as virility, even though its most obvious sign is loss of both interest in sex and of erectile power.

This change is surprisingly often overlooked or ignored, either because the man is so pressurized by the rest of his life that he assumes it is an inevitable part of growing older or because his sexual partner has lost interest as well.

Besides lack of libido, there is often loss of drive in professional or business life...also often fatigue, lethargy, exhaustion and depression, with a sense of hopelessness and helplessness. All too often men change their jobs or their women - anything to ease the malaise they feel - usually with little relief....Physically, there is often stiffness and pain in the muscles and joints or symptoms of gout and a rapidly deteriorating level of fitness. There may also be signs of accelerated ageing of the heart and circulation. (Maximizing Manhood, p 39-40)

The andropause is the explanation of why the vitality and virility of millions of men has faded in middle age or later. It is the explanation of much misery, depression and unhappiness, loss of sexual performance, failing lives, failing health and failing relationships, and above all, it is the cause of impotence and loss of sexual function. But it would be a mistake to see this as merely a sexual issue.

Consider the hormone testosterone. It permeates every aspect of the male body, every nerve, every muscle fiber, every brain cell. It is responsible for the development of the male body from the androgynous embryo, which will otherwise develop into the female form.

If the testosterone receptors in the fetus are not working, or insensitive to the hormone, the development of the normal features of the male body will be incomplete or abnormal, or an intersex human will grow. If the hormone doesn't make its reappearance at the time of puberty, the male body will not develop secondary sexual characteristics such as a larger penis, beard and body hair, a deeper voice, and a male sexual drive.

If the hormone doesn't flow around a boy's bloodstream adequately, his musculature will fail to develop as it should.

Only the presence of testosterone in his blood will let him know of his maleness through spontaneous erections, either at night or during the day, and that classic male pre-occupation with sexy thoughts, feelings and images which interrupt a man's more practical thoughts in the way that we are so used to.

Moreover, if testosterone doesn't act on a man's brain cells, he will lack drive and ambition, and take fewer risks.

Now, what do you think will happen if a man's testosterone levels start to fall at some point in his middle years? Will the areas of the body whose metabolism is so dependent on testosterone remain fully and effectively functional? It hardly seems likely, does it?

There's no doubt that man's sexuality changes as he ages. Think of the sexual urgency of the eighteen year-old.

By the time he's forty, this virility may well have vanished, and spontaneous erections may be but a distant memory. He may still be able to get aroused in sexual situations, but his erection will take longer to get hard, and he will ejaculate more weakly, and he can't ejaculate as often as he once did.

Symptoms of the Andropause

The following symptoms may be caused by a decline in a man's hormone levels.

Sleeplessness and/or fatigue - a pronounced drop in energy levels.

Lack of masculine power - perhaps more accurately loss of confidence, and an air of weakness. Other signs might be a loss of interest in completing projects, coming up with new ideas, and a reduced desire to compete with other men.

Depression - this depression is often regarded as a "conventional" emotional problem, a response to life events, when in fact it may be the direct result of changing brain biochemistry due to a decrease in testosterone levels.

Nervousness, anxiety and irritability - moodiness and irritability is of course no laughing matter for the man concerned, his subordinates, colleagues or family, especially if it is completely out of line with his previous character.

Reduced libido - a very distressing symptom for men and for their partners. Men report an absence of sexual thoughts, feelings and behavior, with no fantasy or sexual responsiveness.

One man said that while he still looked at women appreciatively, it was almost as if he couldn't remember why he was looking at them - he could appreciate their beauty in a kind of distant, almost non-sexual way, but there was no sense of lust or sexuality about it.

Reduced potency and/or penis size - reduced potency means a reduced ability to achieve an erection, and to keep it once achieved.

The significance of erections for men is so profound and fundamental to our sense of masculine well-being that it is taken for granted. What does it signify, then, when morning erections are absent?

And what if no erections occur during the night? This is a classic test for the nature of impotence - if night-time erections occur, then impotence at other times is psychological.

But the man who has no erections at all senses that he is not a real man in some fundamental way any longer. Worse, perhaps, is the man who reports reduced penile size, especially when erect, for this is a blow to his sense of self in a way like no other.

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

Hot flushes or "flashes", blushing and sweating - redness of the face and neck can be a major problem, since it affects the most visible areas of the body. The night sweats can leave the bed and the man soaking with sweat.

Aches and pains - are a very common problem, especially in the lower back and joints.

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

Hair and skin - the wrinkly, dry skin which may develop in an andropausal man is due to the lack of sebum in his sebaceous glands, which would normally be stimulated by the testosterone in his blood stream into the production of oils essential for the maintenance of his skin in a healthy state.

Circulatory problems - testosterone seems to have a role in promoting the circulation of blood. And there is evidence that it can protect the heart and reduce the incidence of heart disease in men.

A few facts about testosterone levels and age

In their late teens, boys are typically at the lifetime highs of testosterone - between 800 and 1200 nanograms per deciliter (ng/dl) of blood. This is why they are so sexual - why their penis is so constantly active!

These levels are maintained for about ten or twenty years, after which they begin to decline at the rate of about 1 percent a year for the absolute testosterone level and 1.2 percent a year for the free testosterone level (a term explained below).

However, these levels are so widely different between individuals that they cannot be regarded as anything more than a statistical average.

As Dr Eugene Shippen points out in his book The Testosterone Syndrome, male testosterone decline is highly variable and dependent on many interlocking factors. Some men are in andropause by the time they are 40, and their testosterone levels are only 200 - 300 ng/dl when tested. Other men are still at 800 ng/dl at 70 years of age.

This may be one of the reasons why testosterone deficiency has not been widely accepted as a valid medical syndrome - surely, the logic goes, if men with the symptoms of the andropause have high levels of testosterone, there can be no connection between the andropause and testosterone levels? But it isn't so simple.

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

The significance of free testosterone

The absolute level of testosterone in a man's bloodstream does not represent the potential for the hormone to act in his body.

Most of the testosterone in the blood stream of a man is actually bound to proteins, and typically only about two percent will be available for assimilation by the body's cells. The most significant protein that binds to the testosterone is called Sex Hormone Binding Globulin (SHBG), a protein whose levels increase with age.

The more SHBG in a man's bloodstream, the less testosterone is actually available to act on his cells. Dr Malcolm Carruthers has emphasized the importance of what he terms the Free Androgen Index or FAI, which is the level of testosterone in the blood divided by the SHBG and multiplied by 100.

 It is when the FAI falls below 50 percent that symptoms of the andropause often appear. Clearly either a fall in absolute levels of testosterone or a rise in SHBG levels will have much the same effect - a man is deprived of the hormone that makes him, and keeps him, a man.

The causes of low testosterone or low FAI

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

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

There is no clear understanding of why testosterone production may fall as a man ages, although it may have something to do with the overall control of the testes by the pituitary gland in the brain. This gland secretes two hormones, LH and FSH, which act on the testes and stimulate them to produce both sperm and testosterone.

In some cases it seems that the sensitivity of the testes to these chemical messengers from the brain decreases with age, and the overall mechanism of the hormone production system becomes less efficient. In others, the testes would work if stimulated, but the hormonal messengers from the brain cease to function effectively.

Anyone who wants to study the male hormonal system in minute scientific detail can find all the information they need, presented in a very highly technical way, in the book Testosterone, which is listed below. But this is not a work for the average lay reader. You need a scientific training to read it (not to mention being fanatically interested in the subject!).

Secondly, there is a more complicated form of the condition which results in an andropausal man getting some or all of the symptoms listed above, but when tested for hormone levels, he may be found to have physiologically normal testosterone levels.

 It is this fact which may have accounted for some of the skepticism about the value of administering testosterone to men with these problems, particularly the oft-repeated assertion that testosterone is of very limited value in helping men with erectile dysfunction or impotence.

If so, it is a serious failure on the part of the doctors who don't understand this issue, for, as a brief visit to any of the support groups on the net that cover the subject of hormone replacement will reveal, very often the patients themselves are extremely aware of the problems that they are going through, and have a grasp of the technicalities which seems to have eluded their doctors - which is yet another reason to see an expert in the field, an andrologist (male specialist) or endocrinologist (hormone specialist) at the very least, rather than a urologist (the equivalent, roughly speaking, for men of a gynecologist), as so often seems to happen.

This more complicated version of the andropause is related to changes in the normal male hormonal balance caused by excess levels of estrogen floating around in a man's system. Estrogen, or more accurately, estradiol, is a vital component of the male physiology, and in fact is made from testosterone in the cells of every man's body.

However, although it has an important role to play in his physiology, it can sit on the cellular receptors for testosterone and stop testosterone working as it should.

There is a very fine line between balance and imbalance in estradiol levels in a man - if it rises too high, no matter what his testosterone levels, he is in deep trouble, for the effects of excessively high estradiol levels on a man's physiology are almost exclusively very negative.

Dr Eugene Shippen discusses this issue at length in his book The Testosterone Syndrome, and he also makes the point that any man who is experiencing high estradiol levels will also produce more SHBG, thereby reducing his unbound, free testosterone even further.

The point that he makes is this: certain methods of testosterone supplementation can promote the metabolization of testosterone to estradiol so effectively that the ratio of estrogen to testosterone exceeds anything that can be considered physiologically normal, and the man is effectively neutered by the treatment he has received.

There is also some suggestion in the book Testosterone (p58, second edition) that if part of a man's problem is that he is physiologically insensitive to testosterone anyway, he is much more prone to metabolize testosterone to estradiol, thereby compounding the problems he faces. The moral of all of this being what, exactly?

You may well ask. In a word, it is this: the treatment of the andropause needs an expert, who knows what he (or she) is doing, and can check for the less obvious aspects of hormonal physiology like LH, FSH and estradiol levels in a man's system. And the type of treatment on offer will have some impact on its effectiveness, as well.

Testosterone Replacement Therapy

Many men with andropausal symptoms, especially impotence, could be helped by testosterone supplementation. Unfortunately, many doctors think testosterone doesn't restore sexual function because they don't understand the role of SHBG and estradiol in male physiology.

 So if you want to try testosterone supplementation, you may have a hard time persuading your doctor to prescribe it. I know of men who have felt terrible, tired and depressed, and whose libido has disappeared, who've managed to persuade their doctors to test for testosterone, and had their concerns dismissed when the tests showed low levels that are "in the normal range".

Apart from the tragedy of this, and the despair that men in this position are liable to feel, what strikes me is the arrogance of so many doctors who do not hear what their patients are saying to them.

Faced with the evidence of a patient complaining that the whole basis of his existence and sense of maleness has changed on the one hand, and on the other the results of tests to which they apply "normal" reference levels of testosterone, the doctors ignore the patient and go with the scientific evidence. At least, they do if they are untrained in, and insensitive to, male issues.

The key is to find someone who knows what he is doing. You can make a start on this by reading the books recommended below, and then searching the web on key words such as "andropause", "testosterone", "male menopause", "hormone replacement", and "impotence".

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

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

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

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

And not all impotence does stem from low hormone levels, a fact about which there is more information below.

The issue of replacement therapy for men with low levels of testosterone is very complicated. You need the help of an expert. There are many ways of providing testosterone: injections, creams, pellet implants, oral preparations, and, most recently developed, gel and patches to put on the skin.

The prescribing of oral testosterone has been controversial in the past, and has perhaps even done this field of medicine some harm. However, modern oral preparations of testosterone esters are quite safe and have no effect on the liver.

There are two main oral compounds: the first is testosterone undecanoate, the second is a milder androgen called mesterolone.

 These are marketed under various brand names - Restandol and Andriol (for the undecanoate), and Proviron (for the mesterolone). As a mild treatment, these may be the first prescriptions that a testosterone deficient male receives. How effective are they? The general consensus seems to be "variable".

The reason lies in the rapid processing of the hormones by the liver. Testosterone undecanoate relies on absorption into the body via the fatty products of digestion passing into the lymphatic system. If you take it, you can certainly feel it kick in, with sexy thoughts and often an erection, but you can also feel its effects disappear after a few hours. It is metabolized out of the system quite quickly.

This means that repeated doses through the day may be necessary, which is potentially inconvenient, besides being expensive and in some cases upsetting to the stomach because of the oil in which the testosterone is dispersed.

The next step in treatment might be the classic route of injections of long-acting (i.e. one, two or three weeks) testosterone esters in an oil-based carrier into the muscles of the buttock. There are various preparations available, which last for different lengths of time. They all work on the same principle - they are metabolized to testosterone at the site of injection.

The problem commonly reported with these preparations is that each injection gives a supra-normal level of testosterone, which has an immediately positive effect on the patient's energy, drive, mood, and libido, but as time elapses, the levels of hormone in the man's system may drop below the "normal" range, thereby giving him a few days of irritability, mood swings, and low libido before the next injection.

This can be a major problem for men on this regime.

However, the treatment does have some advantages as well: it is cheap, easy to administer (in fact it can be administered by the patient) and it is effective.

One man on a regime using an injectable preparation made of a mixture of different testosterone esters told me that he was very happy with his situation - he was sexier and fitter at 56 than he had been at 18, and boasted of being able to have sex as many times a week as he wanted.

Other men have reported that they have been able to overcome the mood and libido swings by self-injecting smaller doses on a more regular basis, that is to say, splitting the prescription into smaller units and injecting, say, weekly, instead of every two weeks. The evidence seems to suggest that with some experimentation, and a helpful doctor, treatment can work quite well.

I think testosterone replacement is rarely a perfect remedy for the problems it seeks to cure, for the complexity of the human hormonal system is profound.

For one thing, testosterone delivered at a constant level through a hormone replacement regime will switch off the production of testicle stimulating hormones like LH and FSH (which come from the pituitary).

The consequence of this is that you may stop producing sperm (although this is a fully reversible effect!) and your testes may shrink somewhat.

One man said that of all the changes that the failure of his hormonal system and the therapy he was now on had produced, the hardest for him to deal with was the shrinkage of his testicles.

There are some new preparations under development - testosterone cyclodextrin and testosterone buciclate being two of them. These are longer acting esters of testosterone. There was also an investigation into injectable microspheres of pure testosterone, although this work did not progress very far.

The objective of any treatment is to produce hormone replacement that approximates as nearly as possible to a steady-state regime with no resultant mood swings and changes in libido. These new compounds also hold out the prospect of longer intervals between injections, which will certainly increase the acceptability of these treatment methods for the patient.

Subdermal implants of pure crystallized testosterone have used by some doctors. The benefits are: convenience, long intervals between treatments (up to six months), effective replacement with consistent levels of hormone, and restoration of normal mood, libido, levels of energy and motivation.

Of course, the question arises as to why this method has not found greater favor if it is so good.

The pellets come in two sizes, 100mg and 200mg sizes. Between four and ten of them are implanted, under local anesthetic in the doctor's office, through a small incision in one of various sites such as the subdermal fatty tissue just above the buttocks. The wound heals quickly and is accompanied only by minor temporary discomfort.

 The testosterone leaches from the pellets into the intercellular fluid. The pellets are designed in such a way that the rate of hormonal release, after an initial surge which lasts only for a day or so, is constant throughout the life of the pellets.

A 200mg pellet releases about 1.3 mg of testosterone per day, compared to the average production in a healthy young man's testes of 6 - 7 mg per day, which implies that about 6 pellets would produce a physiological dose, although individual variability could mean more were required.

The pellets have few side-effects and are generally well-tolerated. Sometimes one or more of the pellets will track back along the insertion line, and pop out, but this is quite rare. This is a convenient method for those who find regular injections inconvenient.

However, there are problems. First, there is the limited availability of this approach. And it isn't especially cheap, although the exact cost depends on local health care systems. If you are paying for it yourself, it is cheaper than oral medication, and about the same as injectable testosterone.

Second, I actually had this testosterone treatment myself for a while, and the biggest problem I had with it was the rather brutal nature of the operation needed to implant the pellets. It is quite traumatic to the tissues, and you might prefer testosterone injections. These work quite well if you can establish how long between injections suits you.

One of the more recent developments in the field of replacement therapy for men has been the development of the patch. The book Testosterone (see below) offers some suggestions as to whether or not they are helpful.

The patches come in two sizes, and deliver either 2.5 or 5 mg of testosterone per 24 hours. In the book, the authors reviewing this treatment method state that the patches are effective in raising testosterone levels to a normal range, on a fairly consistent basis (60 % in the first 12 hours, 40% in the second 12 hours).

They do observe that according to when the patches are freshly applied, it is possible to mimic the normal daily rhythm of testosterone production in the male body, which is at its highest in the morning.

 The patches were clearly superior in keeping estradiol levels within the normal range when compared to injectable preparations (pg 401), which for men who have a sensitivity to estradiol, or a high rate of conversion, could be an important factor in the effectiveness of their treatment.

The authors observe that transdermal patches are as effective as injected testosterone (and pellets) in restoring erectile function, and observe that "these studies are in agreement with other studies showing that androgen therapy improves erectile function." (p 405). However, when I tried these patches, they left sore and inflamed places on my skin.

There is, as Dr Carruthers has pointed out, now a new preparation, which is applied to the skin of the scrotum, skin which is much more permeable to testosterone than other skin, and this has been a great success!

Finally, there is a slightly different route to testosterone replacement, which is for a man to take human gonadotropin - the hormone that stimulates the testicles to produce testosterone and sperm. By taking this, a man can achieve higher production of his own testosterone and a much more normal routine of sexual arousal and penile erections.

Whatever the way it is delivered, androgen therapy restores sexual function and libido and eliminates hot flushes, impotence and depression. The final choice of treatment may actually be based on what is available in your area as well as the doctor's view.

Viagra, impotence, and hormone replacement therapy

Viagra can be very useful for men with penile problems like erectile difficulties. It doesn't increase your sex drive - you have to have a pre-existing libido - but it can certainly help many men to maintain a firm erection. A combination of Viagra and testosterone therapy is often used by the doctors who specialize in male sexual dysfunction. You can read more about this at the Gold Cross Medical Center link below.

The prostate and hormone replacement therapy

As men age, the prostate tends to enlarge, causing a variety of "gentlemen's problems", chief among which is difficulty in urinating or the need to urinate frequently. Whether the prostate is growing benignly or malignantly, a test for prostate specific antigen in the blood - the PSA test - can reveal much about the health of this organ.

A digital examination through the anus by a doctor can be helpful too, of course, although it's less likely to be attractive to the patient. (Fortunately there is now an ultrasonic scan which doesn't need the anal probe.) Some doctors have suggested that high testosterone is a factor in the development of prostate cancer.

In his book, Eugene Shippen refers to several studies which demonstrated absolutely no link between testosterone levels and the development of prostates cancer or raised PSA levels. More interestingly, he points out that there was a striking correlation between the levels of estrogen in a man's blood and the chances of him developing prostate disease.

In an interesting reversal of the normal perspective, Shippen puts a convincing case forward that testosterone therapy actually inhibits prostate disease. And apart from the case that he argues in his book, he also points out that the experience of doctors administering hormone replacement therapy is highly suggestive - prostate disease is rare among patients who are on hormone replacement therapy.

It's a powerful argument, and although not proven, it seems clear to me that testosterone does not encourage the development of prostate disease - if anything, it inhibits it.

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

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

Dr Eugene Shipman describes this in great detail. To sum up what he says: two muscles extend forward from the bones on which we sit, to support and anchor the base of the penis.

The fibers of one of these muscles, called the ischio cavernosa, surround the main chambers of the penis, the corpora cavernosa, at their base, and are mainly responsible for allowing arterial dilation and promoting venous constriction during an erection so that blood cannot escape. There is in fact up to eight times more blood in an erect penis than a flaccid one.

Another muscle of the penis is called the bulbo cavernosa; it causes the expansion in the chamber at the head of the penis. It also allows a man to "twitch" his penis upwards, and is responsible for the force of ejaculation and the pleasurable sensations that go with it.

All of the muscles - and even the nerve fibers - in the genital region have many more testosterone receptors than those in other parts of the body. This is no coincidence.

As Shippen emphasizes, it is testosterone that maintains the conditioning of the vital muscles of the genital region. Without hormonal input, the muscles gradually wither and sustained fullness of erection becomes impossible.

Even more catastrophically, a decrease in the tension of the ischio cavernosa prevents blood from being maintained in the chambers of the penis, with results as "deflating to the ego as a flat tire in the Indianapolis 500".

Shippen says hormonal solutions to erectile dysfunction will work in a majority of cases, although he does admit that not every man gets erectile function back after hormone administration.

 He points out that many things can damage the circulatory system of the penis: drinking, smoking, fatty deposits in the arteries, and the actions of certain drugs can all destroy the workings of the arteries and veins of the penis.

Indeed, one of the tests of correct functioning is a blood pressure test. If the pressure in the man's penis is not the same as in his arm, there may have been some permanent degeneration of the vascular system in the penis that means he can't be restored to sexual function.

And Shippen also points out that estrogen, or more correctly estradiol, can be as much of an enemy on the testosterone receptors of the genital region as it is elsewhere on a man's body. He also emphasizes that restoration of sexual function may take a while as the muscles and nerves regenerate to a fully effective state.

 Indeed, he says that it may take as long as a year, but he maintains that the majority of his patients are restored to sexual function.

You may have heard of the Kegel exercises that women are encouraged to undergo when they experience weakness of the muscles of the sphincters of the bladder or anus. Men have these muscles too - known as the levator ani muscles - and with regular Kegel exercises, men can achieve an improvement in sexual function.

 The object of Kegels is to strengthen all of the elements of the sexual system, not just the penis, so they work at full effectiveness and provide maximum sexual pleasure and sensation.


The books - highly recommended

Male Menopause, Jed Diamond, pub by Sourcebooks, Inc, Naperville, 1997. Essential reading for anyone facing andropausal challenges.

Maximizing Manhood, Dr Malcolm Carruthers, published by Harper Collins, London (1997) Malcolm Carruthers' book is the definitive statement about the andropause based on his experience of treating thousands of men experiencing these problems. It is a must-read if you are over 40. Clear and concise, but not written in technical language, it will help you understand what is happening to you and what you CAN do about it. You'll breath a sigh of relief when you read his accounts of other men's andropause experience ("I'm not alone in this!" - and you're not, of course).

The Testosterone Syndrome, Eugene Shippen, published by M Evans & Co, New York (1998) Another great book on the subject: clear, concise, very well-written, accessible to all men. Dr Eugene Shippen is an expert, like Dr Carruthers, and he has the answers to so many men's questions about failing sexual performance and ageing. His burning passion to save men from the sense that they are demasculinized by their failing sexual ability is very clear too.

Other pages

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