Introduction to Male Menopause

Perhaps the principal reason male menopause has never been in the public spotlight is because men who experience the characteristic decline in virility during middle age are reluctant or even unwilling to acknowledge the condition. In fact, in many instances, this condition goes untreated until the male's spouse or companion brings it to the attention of a physician. The Institute of Endocrinology and Reproductive Medicine now offers a comprehensive treatment program for male menopause, a condition that received scant attention from the medical establishment, the media or from the men it affects-- at least until Viagra was released in the Spring of 1998. Dr. Karpas first published research on this subject in 1977, and he has done extensive research on the effects of aging on male hormone levels ever since.

Symptoms
The symptoms of male menopause are not as overwhelming as the wholesale changes women experience, and male menopause does not affect all men. Approximately 40% of men in their 40s, 50s and 60s will experience some degree of lethargy, depression, increased irritability, mood swings, and difficulty in attaining and sustaining erections that characterize male menopause. For these individuals, such unanticipated physical and psychological changes can be cause for concern or even crisis. Without an understanding partner, these problems may result in a powerful combination of anxieties and doubts, which can lead to total impotence and sexual frustration. A recent aging study surveyed 1700 middle-aged men from the greater Boston area. According to their reports, 51% of normal, healthy males age 40 to 70 experience some degree of impotence - defined as a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse. This problem cannot be attributed to the aging process alone, however, because well over 40% of males remain sexually active at 70 years of age and beyond.

Causes
Although the causes of male menopause have not been fully researched, some factors that are known to contribute to this condition are hormone deficiencies, excessive alcohol consumption, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems. The few doctors who profess to be experts in this area have widely divergent opinions. However, all of the experts do agree that a general decline in male potency at mid-life can be expected in a significant proportion of the male population.

Testosterone
Many endocrinologists and scientists who have pioneered hormone studies say the phenomenon of male menopause correlates with a decline in testosterone levels. Testosterone is the hormone that stimulates sexual development in the male infant, bone and muscle growth in man and is responsible for sexual drive. Dr. Karpas and other experts have found that even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it was just ten years before. In fact, by age 80, most male hormone levels have decreased to pre-puberty levels. Low testosterone has been found to cause fatigue, depression, loss of concentration, as well as decreased muscle strength and endurance. Testosterone is more important in libido or sex drive than in the erectile mechanism. Men with low testosterone levels will have problems with erections. 

Heart Disease
Despite the apparent correlation between decreasing hormone levels and decreasing virility, many urologists question the importance of hormones. After examining the results of an aging study, one of the study's principal investigators questioned the evidence of a relationship between a mild deficiency of testosterone and impotence. Other conditions such as obesity, hypertension, smoking, and high cholesterol - all of which are factors contributing to heart disease are also known to contribute to impotence. Impotence is often primarily a vascular problem resulting in a loss of elasticity in the arteries - a condition causing poor circulation and impairing blood flow. Healthy circulation and blood flow are necessary to maintain an erection. The aging study bears out this thesis. Nearly two-thirds of 40 year old men diagnosed with heart disease exhibited at least moderate impotence.

Drugs
A wide variety of drugs have also been shown to increase the probability of impotence. While a very small amount of alcohol may not impair sexual performance for most men, alcohol in general can create problems for men of middle age and beyond. The immediate effect of alcohol to increase vasodilatation which makes it more difficult for the body to send blood to the penile tissues. The long term effects of excessive alcohol use are more dangerous. Tissue samples from patients with chronic alcoholism (10 or 15 years of heavy drinking) demonstrate that prolonged alcohol abuse causes irreversible damage to the nerves inside the penis.

As devastating as alcohol can be, many doctors cite smoking as the major cause of male sexual dysfunction. In addition to its other detrimental effects, smoking also damages the tiny blood vessels in the penis that must enlarge to accept the substantial onrush of blood during an erection.

Hypertension and the medications for hypertension (beta blockers) also significantly increase the chances of impotence. A patient may have to try several different drugs before finding one that controls blood pressure but does not affect potency. Other prescription and non-prescription medications that increase the incidence of impotence include but are not limited to antidepressants, especially Prozac and Zoloft, diuretics, antihistamines, antispasmodics, digestive medicines and cold and flu remedies.

Diet and Exercise
The importance of proper diet and regular exercise cannot be discounted. The aging study produced the first evidence that cholesterol level is related to impotence. In fact, high levels of HDL (the "good" cholesterol) were significantly associated with reduced levels of impotence. A healthy diet low in saturated fat and sugars, coupled with regular exercise has been shown to play a significant role in lowering cholesterol levels, maintaining testosterone levels, increasing libido and boosting self image. In fact, throughout the life cycle, men who exercise regularly report greater sexual drives and greater sexual satisfaction than sedentary men.

Diagnosing Impotence
In case where impotence has been diagnosed, it is important to determine whether the cause is principally physical or psychological. One reliable test is to check nocturnal penile tumescence - the number and quality of erections that occur while the patient is asleep. If the results are within the normal range for men of a certain age, it can be hypothesized that the problems are not physical, but psychological, and the appropriate treatment programs can be begun.

If the results of nocturnal penile tumescence testing indicate a physical problem, then another test which determines penile blood pressure may be used. In this test, a cuff is supplied around the penis to determine the penile blood pressure, which should be the same as the blood pressure throughout the body. If the penile blood pressure is lower than expected, the cause of the impotence may be a vascular problem.

Possible Remedies
Usually there is more than one explanation or cure for the phenomenon known as male menopause. Aging, hormones and overall physical and mental well-being all factor into the condition. Many doctors agree that if a man has an understanding partner, monitors his medications, alcohol intake and eating habits, stops smoking, and improves the health of his vascular system through aerobic workouts, he will almost certainly see an improvement in his overall wellness and sexual potency.

In cases where specialized treatment is needed, new findings from English studies suggest that men can improve in sexual function, muscle strength, and general well-being if they are treated with supplements to bring their testosterone levels into a high - normal range. Hormone Replacement Therapy (HRT) is now regarded by many physicians as the future of preventative medicine for both men and women in the second half of life. In fact, the National Institute of Health recently asked for research proposals to investigate whether testosterone supplemen- tation might benefit older men by preventing bone loss, depression and other symptoms associated with aging.

Currently there are several methods of testosterone supplementation including shots, implants and a transdermal patch. If injections are indicated, they should be administered at least every two weeks to ensure that testosterone blood levels are constant throughout the treatment. Another option is testosterone implants which are surgically placed behind the gluteus muscle in order to release a steady level of testosterone into the bloodstream. An even newer treatment is the transdermal patch. This patch is placed on the scrotum, and the patient must shave the area where the patch will be affixed and apply a new patch daily. All of these treatments boost testosterone levels in the blood to therapeutic levels, and the patient must determine with the help of his doctor which is the best for him. Unfortunately, testosterone is not particularly effective in treating erectile dysfunction (impotence).

In the past, effective treatments for impotence included vacumn pumps, injections of medications (Caverjet) into the base of the penis, and prosthetic implants. A number of newer medications have become available in the last several years including:

Alprostadil (Muse)-- a pellet placed within the urethra (the passage in the penis where urine comes out)

Sildenafil (Viagra)--an oral tablet which doses not cause an erection but enhances one.

New oral compounds in late stage clinical development include apomorphine and phentolamine (Vasomax). There are also topical creams, sublingual tablets, other intraurethral tablets, and injections being studied at this time.

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