Could it be his hormones?

The male mid-life crisis is distressing for all concerned. Now there is compelling evidence that its causes may be medical as well as psychological. Is there a 'male menopause', and could hormone treatments be the answer?

Hormonal specialist, Dr John Moran, likes to tell the tale of a middle-aged patient looking in the window of a branch of John Lewis thinking "Who is that old bugger with a bald head?", then turning round and finding nobody there. "When he came to see me shortly afterwards, his free testosterone count was 10 (the lowest normal measure is 20), he complained of low energy, poor memory, zero libido and unreliable erections. We ran tests and supplied testosterone replacement therapy (as a gel rubbed in the forearm). Afterwards, his free testosterone level hit 51.2 and he described his sex life as bliss. He hasn't noticed the ghost of an old bugger lately." Does this suggest the existence of a biologically-based male menopause (which is also called "andropause")?

Now there is, of course, a well-defined psychological condition called the "male mid-life adjustment disorder" or "male mid-life crisis". Even 100 years back, it was written up under doom-laden titles like What Every Man of 45 Ought to Know, by the Reverend Doctor Sylvanus Stall.

Men go through an emotional change of life, just as women do. They have to come to terms with loss of youthful looks and loss of control over life events. They may have to settle for less promotion at work and less personal stress. They need a new self-image. This can be intensely painful for all concerned, including family, since the experience may be depressive or aggressive. Some men take to their beds. Others dye their hair black or re-watch American Beauty.

Strategies include denial ("I can out-dance my kids") to projecting distress on to others ("It's all your fault I've never won a Nobel Prize").

But unlike women, men do not reach a menopause, after which they become uniformly infertile and their bodies cease to produce sex hormones. Or do they?

The World Health Organisation recently organised a conference on The Ageing Male in Geneva. Attended by more than 700 delegates from around the world, although few were British, it came up with the following: there is definitely a male biological menopause - called the andropause. There is definitely a case for male hormone replacement therapy. There is definitely a problem of osteoporosis in men as well as women. There is an increased risk of heart attack from waning testosterone levels

Compared to Germany and Canada, where specialist andropause clinics abound, Britain is laggard in recognising these facts.

The case for the male menopause starts with testosterone, where levels in men decline by 1.7 per cent per year. Testosterone is mainly produced in the testes; some from the adrenals. It is directly responsible for energy, sex-drive levels and above all for the hardness of erections. Lack of testosterone can also shrink your bones.

The critical measurement, however, is called "bio-available" testosterone. As testosterone declines, another factor in the body called Sex Hormone Binding Globulin, or SHBG, is increasing. SHBG traps much of the testosterone that is still circulating and makes it unable to exert its effects on the body's tissues. What's left over does the beneficial work and is known as "bioavailable" testosterone. Alas, it's this active component which radically declines from about the age of 45 - whereas total testosterone may stay "normal" till the seventies - and that's why many doctors continue to think nothing is wrong. Studies from Germany, America and Poland all reported improved levels of energy and libido in patients given testosterone replacement therapy. It can even make men more verbally fluent.

However, it's the decline of a second hormone called DHEA (a steroid produced by the adrenals) which may play a bigger role in causing the andropause than testosterone. Here, the critical levels do diminish dramatically in the early thirties. DHEA has multiple functions - it elevates mood, cognition, immune response, promotes lean body mass, increases sexual drive, diminishes fatigue and prevents hardening of the arteries. Above all, DHEA appears to improve brain function and repairs that memory loss which is such an insidious part of growing older. So why aren't we all on it? "Why do you think?" says Dr Moran. "Its cost. The Government would have a blue fit."

So how can a man tell if he is "andropausal"? A questionnaire developed by Professor Morley of the St Louis VA Medical Center asked men about the following symptoms:

1 Decrease in sex drive 2 Lack of energy 3 Decrease in strength and endurance. 4 Loss of height. 5 Decreased "enjoyment of life". 6 Sadness and/or grumpiness. 7 Erections that are less strong. 8 Deterioration in sporting ability. 9 Tiredness. 10 Deterioration in work performance.

Men who had experienced numbers one and seven, and/or any other three symptoms, may be andropausal.

A further significant sign of the "andropause" is osteoporosis, and this is far more common in men than you might think. The reason we've paid little attention is that it occurs about five years later in men than in women and is usually ascribed to the effects of older age, not mid-life. But the conference heard from Dr Chris de Laet of Rotterdam University that the same cause is at work: failing hormone levels.

But the most compelling contributions at the conference came from UK-based cardiologists D Cook and P Collins. By 2020, ischaemic heart disease will probably be the world's biggest killer. According to these doctors, replacement testosterone can prove beneficial in preventing cardio-vascular damage. Two pieces of research, the latest in the American Journal of Cardiology, support their findings.

Other research suggests replacement androgens can negate the risk factor from existing arterial and plaque conditions, lower the level of triglycerides and shift abdominal fat.

Are there any complications? The gurus are divided. Dr Malcolm Carruthers, author of The Male Menopause (Thorsons), happily prescribes HRT for men; others, like Dr Alan Riley (professor of sexual medicine at the University of Central Lancashire), express concern about its impact on rates of prostate cancer. In the UK as a whole, there is a generally conservative tradition on the subject. Dr Moran says the latest findings show there is little cancer risk if the disease is not already present. "If it is present, preliminary tests will pick up many of the 30 per cent of men who suffer undiagnosed carcinoma of the prostate and this at a stage where anti-cancer treatments are effective".

Moran also prescribes phyto-oestrogens (derived from soya and seaweed products) to all male HRT patients because of their proven protective effect against prostatic enlargement. Extra testosterone may, of course, make men more aggressive than sexy. Concerns about liver damage remain unproven.

When looking at the symptoms of the "male menopause", it is also vital to screen separately for cases of thyroid disorder and depression

The latest claims of gerontology threaten us with a lifespan of up to 120 years. "Middle age" in these circumstances kicks in at around 60. So "normal" is as "normal" does. Yet over 25 per cent of the male lifespan after 60 is spent with some disability. We need to take into account not just life expectancy but health expectancy. Sadly, men's health expectancy continues to be significantly inferior to that of women in most regions of the world.

As a psychodynamically trained psychotherapist, I don't have time for purely biological explanations of life-distress. There are abundant psychological reasons for male mid-life malaise. But as an open-minded man I have to say I find the evidence and argument in favour of a biological trigger to this condition very hard to resist. Accordingly, I will perhaps practice what I preach. My next contribution could well be written under the influence of a mini-cocktail of testosterone and DHEA, if my tests suggest it's necessary. It might not make for better journalism, but at least I'll be able to tell you if any part of me grows longer, taller and stronger.

Phillip Hodson is a Fellow the British Association for Counselling

Comments