Involuntarily nodding off in the afternoons is not conducive to the work of a GP, so it was with some alarm that Dr Dan Hegarty found himself doing it at a mere 41 years old. But his biggest shock of all came when he was told what was wrong with him – he was going through the menopause.
"The male menopause was a term I'd never heard of as a doctor," says Hegarty, now 54. "But I happened to read an article about it in a GP publication and the symptoms described me. My concentration was lagging to the extent that I couldn't even watch a film all the way through and I had to swap the quality papers for the tabloids. I was feeling really fatigued, I was getting irritating muscle aches in my legs and I also experienced a decrease in libido."
He wasn't convinced about following it up. On the one hand, there has been huge controversy around the so-called male menopause, with most studies flatly denying its existence and pointing out that most of the symptoms – which can also include depression, weight gain, irritability, night sweats and hot flushes – are, to put it bluntly, due to men getting on a bit. Either that or they're suffering from obesity, general poor health, unemployment or partner-fatigue. On the other hand, what harm could it do just to check if he had become testosterone deficient? He booked the appointment.
Dr Hegarty, who has since become an occupational health physician, chose to see the doctor who'd written the article – Dr Malcolm Carruthers, who turned out to be one of the biggest names in the field of male menopause. At his clinic in Harley Street, Dr Carruthers gave him a thorough physical examination, including checks for prostate problems, diabetes, anaemia, liver and kidney function, thyroid gland, cholesterol and finally testosterone levels. "Depending on the symptoms and findings, he tells you whether you're suffering from the male menopause," says Dr Hegarty – or, as Dr Carruthers prefers to call it, "late-onset hypogonadism" (literally, getting on in years and underwhelmed in the gonads). "I fitted the bill," says Dr Hegarty.
Testosterone replacement therapy (TRT) comes in a number of forms, but most common at that time was pellets that can be implanted into men's buttocks (just as HRT is implanted into the abdomen of women) and pills. "I took the pills," says Dr Hegarty, who had 40mg five times a day.
"Within six months, I felt energetic and my concentration was back. The muscle aches went and although I didn't turn into an sex god overnight, my libido picked up enough to have what most people would consider a normal private life."
Dr Hegarty's confidence improved too. "I don't think it would be exaggerating to say TRT could save a marriage. At the time I started taking it, my marriage had ended but because of the TRT – and I really do believe it was because of the TRT – I entered a new phase of life and remarried."
Eleven years later, TRT has moved on apace and there are not only long-acting injections but a gel, which Dr Hegarty uses. "I rub on the Testogel on my shoulders once a day after my shower and by the time I've brushed my teeth, it's dry," he says.
Over the past two decades, Dr Carruthers has treated over 2,000 men who, like Dr Hegarty, believe they are going through the male menopause. "In the more extreme cases, their libido has fallen away to nothing and they've given up jobs – sometimes even selling their company – despite having previously always loved work. In some cases, their marriage has nearly broken up and some are suicidal."
The average age of the men he sees is 55. "But most have been bouncing between GPs and specialists for some years before they reach me, so I'd say the usual age on onset is 50. That said, some men, like Dr Hegarty, are as young as 40."
This, he explains, is because causes are complex. Unlike the female menopause, where a drop in the hormone oestrogen occurs for natural reasons, Dr Carruthers says a fall in testosterone can also be due to a man having had mumps or various testicular conditions and infections. Antidepressants don't help either. "What happens is the man goes to the GP, explains his symptoms and the GP concludes he's feeling down and puts him on antidepressants. Antidepressants make testosterone levels worse. One that's called Effexor is now known in medical circles as No-sex-or," he says.
Even by Dr Carruthers' admission, many men claiming to be going through the menopause are found to have normal testosterone levels, albeit on the lower end. Many studies have concluded the male menopause simply doesn't exist. But Dr Carruthers says: "It's a bit like testing for adult-onset diabetes, where people are found to have a high level of insulin, but further delving shows the person's body is resistant to it. The same thing can happen with testosterone – the body has a higher testosterone resistance. Unfortunately, because we live in a lab-obsessed society, and this testosterone resistance isn't something you can measure, studies have traditionally been sceptical."
Dr Mike Perring, the medical director of Optimal Health, another Harley Street clinic, adds that the criteria of what constitutes "normal" testosterone levels is both arbitrary and limiting. "There are, in my experience, a significant proportion of people in the lower quartile for whom a trial course of TRT for three months causes a significant improvement in symptoms. So it's better to aim for an optimal level rather than work within some strict yet illogical measure of what's normal. We've been arguing this for 20 years but I think finally we are starting to be heard. You have to remember that even with female HRT, there's still disagreement about what is appropriate criteria."
The latest study on the health of middle-aged men certainly suggests the male menopause is an issue – although usually exclusively in the testicles. Researchers at the University of Manchester have identified three key symptoms – lack of an erection in the morning, decreased sex drive and erectile dysfunction – which, along with low levels of testosterone, can help to diagnose the condition. The research, published in The New England Journal of Medicine this summer and based on men aged 40 to 79, started by taking 32 different symptoms ranging from fatigue to poor concentration to impotence, but they concluded all bar three were not linked to the male menopause and were more likely to have been the result of poor health or obesity.
Lead author Dr Fred Wu said: "We can conclude that yes, the male menopause does exist." But, he adds, unlike the female menopause, the male version affects only 2 per cent of men. "It's wonderful that a notable study finally acknowledges the existence of this condition that can ruin men's lives, but I think 2 per cent is an underestimate," retorts Dr Carruthers. "My own research suggests 20 per cent of men over 50 are suffering testosterone deficiency."
Dr Perring reckons the real figure probably lies somewhere between the two, something that Hugh Jones, consultant physician and endocrinologist at Barnsley Hospital, also agrees with: "There was one study from Boston which says it occurs in 8.4 per cent of 50- to 79-year-olds and I think that's probably about right," he says. "What we know for sure is that there are many men out there who are undiagnosed and when you consider the dramatic improvements that can happen following TRT, it seems a great shame. I've seen it time and again in my own clinic. Patients not only feel better from a sexual point of view, but they have more energy, are less moody and more motivated to get up in the morning. I've seen people lose their jobs and three months after treatment, they're working again. I had one guy who put a stairlift in and after three months of TRT, he ripped it out. We get wives coming in saying their own lives have changed because their husbands are so much easier to live with."
But some medical experts smell a rat, accusing Harley Street doctors of systematically overdosing with testosterone every man that walks through their doors for financial gain. It's a view you can relate to upon reading one email that a Harley Street practice manager sent to his consultant, following a request from The Independent to interview him. It read: "This could be useful as increased bookings have always followed press articles."
Professor Ashley Grossman, consultant endocrinologist at St Bartholomew's Hospital in London, is in no doubt that both Harley Street doctors and pharmaceutical companies are treading an ethical tightrope.
"You can just see the pharmaceutical companies thinking, 'OK, we've got as far as we can with the female menopause for now, but what about the male one?'" Professor Grossman says. "But while females suffer a sharp fall in the hormone oestrogen when they go through the menopause, men need to realise that testosterone levels in men naturally fall by 1 to 2 per cent a year from the age of 40."
Harley Street doctors point out that TRT is in fact available on the NHS and that they support the fast-growing numbers of GPs prescribing it – and it's not as if it costs much anyway, usually working out around £2 a day. But the reality is that most men who visit Harley Street self-refer and even if they go back to their GP to get their prescription, they tend to receive their regular follow-up tests back in Harley Street.
In any case, says Dr Wu, it is a false notion that just because a man responds to treatment he is going through the male menopause. "Where men do respond to treatment, then the effect is likely to be a placebo effect. This has been clearly shown in scientific treatment trials."
It's all too easy for men not to care. "What the hell? If there's a chance it will work, give it to me," they think. But this is a dangerous road, cautions Dr Wu. "In addition to being an expensive placebo, the treatment may worsen for example prostatis problems, sleep apnoea and raise blood cell count too high, which may increase the risk of a stroke."
Dr Hegarty isn't worried. "I've had no side-effects whatsoever and I go twice a year to have blood and urine tests, among others," he says. "I'm well aware there are concerns about the treatment, particularly around its promoting prostate cancers, but I've never found firm evidence of that and my levels of prostate specific antigen have remained stable for 13 years. Why would I be concerned about health risks? I feel healthier than ever."
There is still considerable controversy over which symptoms suggest 'male menopause', but possible indications of the condition are:
* Declining sex drive
* Fatigue and lessening energy
* Inability to concentrate
* Anger, anxiety, irritability and depression
* Weight gain
* Sleep problems
* Confusion and indecisiveness
* Declining self-confidence
* Hot flushes and night sweatsReuse content