The prime of life, or the time of life?

Why should so many middle-aged men, prosperous and healthy, feel miserable? Some doctors believe a hormone implant can help. Annabel Ferriman reports on the male menopause

TUBBY Passmore, the 53-year-old hero of David Lodge's new book, Therapy, is rather like an overweight Woody Allen. He is a prosperous television sitcom writer, full of angst. His cognitive behaviour therapist, the one he sees on Tuesdays (as opposed to his physiotherapist whom he sees on Mondays, and his acupuncturist whom he sees on Fridays), makes him write a list of all the good things about his life and all the bad things. In the "Good" column, he writes: "professionally successful, well- off, good health, stable marriage, kids successfully launched in adult life, nice house, great car, as many holidays as I want." Under the "Bad" heading, he writes just one thing: "feel unhappy most of the time".

Tubby calls his problem IDK - the I Don't Know syndrome - but some doctors would say he is suffering from the male menopause. Instead of all the therapy and philosophising he goes in for (he discovers Kierkegaard in a big way), what he really needs is a dose of male hormones.

These doctors would claim that, just as women suffer from a decline in the female hormone oestrogen after their menopause (which can be remedied by hormone replacement therapy), so men suffer from a decline in the male hormone testosterone during their late fifties and early sixties (which can be remedied by the addition of a few synthetic androgens). What is sauce for the goose is sauce for the gander.

Their message has reached the public, and more men are demanding the treatment. Some see it as a cure for sexual problems (about 20 per cent of men in their fifties and half those in their seventies have difficulty getting an erection), others as a cure for anxiety or depression brought on by redundancy or the increased competition of today. Many just hope it will solve their general malaise - their I Don't Know syndrome.

But is there such a thing as the male menopause - and if there is, can doctors do anything about it? The whole "condition" could simply be a Harley Street invention, something that enables private doctors to charge unhappy middle-aged and elderly men a lot of money for what is essentially a placebo drug.

Doctors in the past have dismissed the idea of a male menopause because most men maintain into old age both their fertility and their secondary sexual characteristics, such as beard, bodily hair and bodily contours. But as doctors' understanding of sex hormones has grown, so they have been able to show that the level of testosterone circulating in the blood declines significantly with age. The decline is a result of two simultaneous trends: a reduction in the production of testosterone by the testes, and an increase in the production of sex hormone binding globulin (SHBG), which mops up test- osterone. The result is that there is less "free" testosterone available circulating in the blood.

"The male menopause really does exist, but it is much more variable and spread-out than its equivalent in women," says Professor Michael Besser, a consultant endocrinologist at St Bartholomew's Hospital, London. "It is not as dramatic or as easily identifiable as when women stop having periods. It can start as early as 55, but in some men it is very gradual. They can die with their boots on, so to speak. Look at Sir Thomas Beecham, who got married for the third time at about the age of 83."

While Professor Besser believes something that could be called "the male menopause" exists, Professor Howard Jacobs, consultant endocrinologist at the University College London Hospitals, does not "buy whole the syndrome". He thinks that what some doctors regard as "symptoms" of the male menopause are hard to distinguish from the normal signs of the ageing process.

"The decline in testosterone," he says, "is happening 10-15 years later in men than the decline in sex- hormone levels in women. It happens to men in their mid- to late-sixties. To differentiate between endocrine effects and ageing is difficult. What are the symptoms of so-called androgen deficiency? There is a general decline in muscle strength, well-being and vigour, but these occur in women as well as men. Then there is a loss of libido and potency, which often prompts patients to seek help.

"What is happening in some places is that old age is being treated as if it were a testosterone deficiency. While I don't mind looking for the elixir of life, I don't really think that it's going to be found in a bottle of synthetic testosterone."

One doctor who thoroughly disagrees with Professor Jacobs' analysis is Dr Malcolm Carruthers, a consultant andrologist with a practice in Harley Street. Not only is he a passionate believer in the quantifiable and frequently devastating effects of the male menopause, but also believes they can be impressively counteracted with synthetic sex hormones. However, believing that the term male menopause "sounds wimpish", he prefers to refer to the condition he treats as the andro-pause or the viropause.

"I started treating men seven or eight years ago," he says, "and have seen nearly 1,000 patients. Their symptoms are remarkably close to those of the female menopause, and the results have been very good. Usually, the men who come to me have tried everything else. They have started with their GP and tried antidepressants and psychosexual counselling, but these have not worked."

Dr Carruthers uses three forms of treatment: two types of pill, and pellet implants of testosterone into the buttock for long-term maintenance. These implants are changed every six months. Though no scientific trials have been conducted using control groups and placebos, Dr Carruthers says the comments of his patients are testimony that androgen replacement therapy works.

"I know the effect is not a placebo one, because many of my patients describe so accurately, without any prompting, what happens to them near the end of the six months when the effects of the implant are wearing off. A few even say that their golfing handicap goes down when the implant is working well, and goes up again when it is not."

Several of his patients happily testify to the wondrous effects of their implants. John Smith (not his real name), a 58-year-old banker from the Home Counties, went to Dr Carruthers after he had been made redundant for a third time.

"I was 54. Everything was getting on top of me: the sweating, lack of sexual activity, irritability. I did not have erectile problems, just a lack of interest in sex. I didn't have any energy or concentration, and had become lackadaisical and lacklustre. A lot of men in their fifties are having a very bad time. An awful lot of people are out of work, and I myself have had that problem.

"At first, Dr Carruthers put me on some tablets. They worked a bit, but were not very effective. He then gave me an implant, and I now feel I can handle things pretty well. I can still keep up with the young lads. I can't see myself stopping the treatment, while I am working flat-out. It improves the quality of my life."

Another patient who found the treatment useful is 54-year-old Robert Bain, who runs his own newsagents' business in Surrey. "I went to see Dr Carruthers," he explains, "because I was experiencing lethargy, loss of muscle strength and night sweats. The most worrying thing was that I lost the ability to get an erection. I could have put up with the other symptoms, but not being able to get an erection was devastating." The treatment worked, and Mr Bain has suffered no side-effects. "It has been perfect for me," he says.

Though erectile problems in middle-aged and elderly men are common, not many doctors put the problem down solely to a drop in testosterone levels. Masters and Johnson suggested as long ago as 1970 that lowered levels of male hormones could be partly to blame, but they also attributed men's reduced sexual desire to such non-hormonal causes as monotony in a long-term relationship, worry about money and jobs, the stress of going through what is probably the most competitive phase of their careers, mental and physical fatigue, and over- indulgence in food and alcohol.

Unfortunately for the proponents of testosterone, or androgen replacement therapy, there is no scientific proof that it works. Professor Howard Jacobs, for one, is sceptical. "There is a pleasing symmetry," he says, "which says that the menopause should exist in men and that they could be helped by hormone replacement therapy. But there is no evidence for it. I have never seen the result of a controlled clinical trial in which symptoms got better among those on synthetic testosterone, compared with those in a control group."

Dr Carruthers may believe the evidence presented to him by his patients, but to convince other doctors he would need a control group which was also being given surgical implants containing no active ingredient at all. It is well recognised that, if a doctor gives you a pill and tells you it is going to work, it often does. This is known as the placebo effect.

Moreover, the treatment has its dangers. Two problems in particular stand out. Some men in their sixties have small, asymptomatic cancers of the prostate which, left alone, might grow so slowly that they never threaten their lives. Studies have shown that two-fifths of men over 65 who have died from other causes had cancer of the prostate. But these cancers are testosterone-dependent; if you give a man extra testosterone, it could make the cancers grow.

Second, testosterone can raise fat levels in the blood. The result is that fat gets laid down in the arteries and the arteries become narrower, making blood clots and heart attacks more likely. Dr Carruthers says he is well aware of these problems, and tackles them by doing a full medical check-up of all his patients, including three separate investigations for cancer of the prostate. "I reckon I save more men from cancer of the prostate than I cause, by picking up early cases." In the 1,000 men he has treated over the last seven years, he has picked up four cases.

But other specialists in male reproductive disorders believe there are alternative treatments to give to men suffering from lethargy, depression and erection problems in middle life, which do not have any dangerous side-effects. Mr Anthony Hirsh, consultant andrologist at Whipps Cross Hospital, Essex, and Harley Street, says: "I usually start patients off with a series of oral medicines which are not hormonal, and do not have the inherent dangers hormones can have if given long-term. These include vitamin preparations and extracts of the yohimbe tree, from west Africa, which has been shown to work in a controlled trial reported in The Lancet."

In extreme cases, where patients cannot get an erection, he also offers injections of a prostaglandin or the drug papaverine, a smooth muscle- relaxant extracted from poppies. After receiving the initial injection from him at his surgery, the patient learns how to inject himself.

"Often," Mr Hirsh explains, "patients do not need to continue with the injections anyway. Some-times the psychological effect of getting an erection from the first injection, after years of being unable to do so, is enough to cure the problem. There is no simple correlation between impotence and low androgen levels, because some men with low androgen levels have perfectly normal sex lives."

While nobody should minimise the misery caused by impotence, depression and lethargy, few doctors believe the solution to these problems is simple. "As one gets nearer to becoming elderly and frail," says Professor Jacobs, "it is nice to think there is something that could help, but that does not mean there is. I believe what an elderly leader of the medical profession once old me: 'Three things are necessary for a happy old age - a set of comfortable false teeth, a good pipe and a total lack of libido'." Perhaps a few more men should take a leaf out of his book. !