Grumpy young men

It's not just women who get hormonal mood swings. A male form of PMS can strike at any age, doctors now believe. Hugh Wilson reports

Robert was barely out of his mid-thirties when the symptoms started. He noticed the loss of energy first, then the loss of libido. He had never been a particularly moody person before, but now his mood swings were affecting his marriage.

Robert was barely out of his mid-thirties when the symptoms started. He noticed the loss of energy first, then the loss of libido. He had never been a particularly moody person before, but now his mood swings were affecting his marriage.

"I was like a bear with a sore head all the time," he says. "I had no sex drive, I was angry, I couldn't be bothered to do anything. It got so bad between my wife and I that we weren't far off divorce. But I went to my GP twice and he said there was nothing wrong and I had to try harder."

The maladies that affect large numbers of men entering early middle age are usually blamed on a pesky little condition called "getting on a bit", and the usual remedy is a sports car and an office affair. Now, symptoms such as Robert's have another name. According to the American psychotherapist Jed Diamond, Irritable Male Syndrome (IMS) is as real and damaging as any of the hormonal fluctuations that affect women, and, crucially, it's also treatable.

Diamond has written a book, Irritable Male Syndrome, based on his own experiences and those of thousands of other men who have written to him or visited his Californian clinic. He defines IMS as "a state of hypersensitivity, anxiety, frustration and anger that occurs in males", with causes as diverse as "hormonal fluctuations, stress and loss of male identity".

Diamond says that IMS can start to appear in men at any age, and can produce a level of anger, frustration and irritability that strains the strongest relationships. To add to the obvious parallels with premenstrual syndrome, it can also be cyclical. But if anything, he adds, IMS can be worse.

"Irritable Male Syndrome sounds so benign," Diamond explains. "If we're living with a woman going through PMS, we understand she feels irritable, uncomfortable and out of sorts, but we know it won't last long. IMS may start out like that. But at its worst the man is totally out of touch with reality, is out of his mind and yet he is convinced he is the only sane one about."

Diamond believes that low testosterone is often the main cause of IMS, and he's not the first researcher to point an accusatory finger at male hormonal fluctuations. In fact, he's not the first to talk of an Irritable Male Syndrome. A couple of years ago, Dr Gerald Lincoln, of the Medical Research Council's Human Reproductive Sciences Unit in Edinburgh, coined the phrase when he found that, as testosterone levels in a group of males fell, they became nervous, withdrawn and tetchy. The males in question were sheep, but his findings were taken up by proponents of male hormone problems anyway. While Dr Lincoln observed the same effects in deer and elephants, Diamond noticed them in himself and his human patients.

But in that, too, he is not the first. Dr Richard Petty runs the Wellman Clinic in London and, though he balks at the terminology, believes that the symptoms of low testosterone in men do reflect Diamond's definition of the hormonally irritable male. "Yes, irritability, frustration, mood swings, a drop in libido and energy, and a general feeling of malaise are all symptoms of low testosterone," he says. "Fifty per cent of men at the age of 50 are suffering some of these types of symptoms. Men have hormonal imbalances, too."

Where Dr Petty's experience dovetails with Diamond's IMS thesis is in the ever-more youthful profile of his patients. "Testosterone declines naturally with age, and my patients used to be exclusively elderly," he says. "Now, perhaps because of extra stress, or perhaps because they're better informed, I'm seeing a lot of men in their thirties and forties with these sorts of symptoms."

Stress plays a crucial role in IMS. Not only do stressed men seem moody anyway, but stress creates a vicious circle by inhibiting the production of testosterone. Other factors, such as obesity and alcohol abuse, can have a similar effect. Some experts believe that the rise in these self-destructive habits helps to explain the temporary or cyclical nature of IMS-like symptoms in some men, and the fact that they are now afflicting men barely past their chest-beating prime.

In a few cases, low testosterone, exacerbated by any of these factors, can cause more extreme reactions. The male menopause - also known as andropause - combines the emotional symptoms of IMS with physiological reactions commonly associated with the female menopause. "I believe that all men going through andropause will likely have to deal with IMS between the ages of 40 and 55," says Diamond.

Reg Eagle was in his mid-forties when, like Robert, he started feeling irritable. His work was highly stressful, but stress alone could not explain the symptoms that emerged over the next couple of years, including night sweats, hot flushes, memory loss, irrational anger and frustration, and waning libido. Frankly, he was terrified.

"I didn't know what was happening to me. I thought I might have ME, or HIV, because the night sweats were like a virus. My relationships were suffering. But all the tests were negative. The doctor wasn't interested after that. He said I was just getting old, but I was still in my forties. I was depressed and very, very ratty."

According to Dr Petty, thousands of men in the UK could be approaching GPs with symptoms associated with low testosterone, and being told that it's down to their age, or the everyday maladies of modern life. Some are offered antidepressants, but many are just told to "play more golf and have less stress". To some doctors, IMS sounds a bit like that old excuse for male misbehaviour, the mid-life crisis.

"It's a subject fraught with controversy," says Dr Ian Banks, president of the Men's Health Forum. "We're not sure whether these symptoms are environmental or hormonal. Certainly, testosterone levels decline gradually with age, and there is the potential effect of stress and alcohol. On the other hand, symptoms like moodiness, anger and tiredness are very subjective, and things like marital disharmony or stress at work can produce them. But I think more research is needed."

Dr Petty believes that by traditional measures, GPs indeed can't find anything wrong. Both Reg and Robert had testosterone levels at the low end of a normal spectrum. What that spectrum fails to take into account, however, is the effect of sex-hormone binding globulin (SHBG), a substance that neutralises testosterone and is produced in greater quantities in times of stress. When he eventually saw a specialist, Reg was told that 80 per cent of the testosterone in his body was being "knocked out" by SHBG.

Both men sought independent advice, were found to be deficient in "free" testosterone, and ended up on Testosterone Replacement Therapy (TRT). Reg says it "saved my life". Robert says it made "an incredible difference". But worries about testosterone supplements could be the very reason many doctors are unwilling to explore the possibility of hormone imbalance with their patients. Despite some recent evidence to the contrary, many doctors and organisations - including the Prostate Cancer Charity - are yet to be convinced that no link exists between TRT and prostate cancer.

"Most GPs won't get involved in this," says Dr Laurence Gerlis, a London GP. "Testosterone is a fairly toxic substance, and there hasn't been enough research done to stop me being nervous about it. Men may well get problems associated with testosterone, but how to deal with them is not straightforward."

This attitude seems to mirror that of the wider medical community, in the UK at least. Until TRT is proved to be safe, few doctors will take the possibility of hormonally unbalanced men too seriously. In the meantime, Dr Petty, Diamond and many others believe that men are being short-changed. In a few years' time, they believe, thousands of irritable males will be blaming mood swings and lethargy on their plunging hormones, and male hormone replacement therapies will be as popular as their female counterparts.

DO YOU HAVE IRRITABLE MALE SYNDROME?

Mood swings are the chief symptom of IMS. If your moods have become more volatile, and you have any of the following symptoms, you may have IMS.

* You feel angry, frustrated or anxious without any obvious cause.

* You feel sad or depressed without any obvious cause.

* You are unusually aggressive - when driving, say, or playing games or sports.

* You are tired all the time, without doing anything physically exhausting.

* Your mood swings are straining your relationships (you may need to ask your partner about this).

* You are told that you are becoming more difficult to live with, but can't see that anything has changed.

* You are bored by things or activities that you used to find interesting.

* You've gone off sex.

* You are smoking or drinking more.

* All or any of these symptoms have come on recently. You haven't always been like this.