What is male menopause?

"I have some menopausal symptoms," one woman said, "but my husband has more!"

"I think I'm married to a menopausal man," groans another. "He's 47, withdrawn, moody, and angry that he's ageing and losing his hair."

Menopause is something we typically associate with women, but men also undergo changes as they age. Testosterone is an important hormone in men's bodies and the decrease in testosterone production can be referred to as a form of "male menopause." In our September 1993 issue, we looked at male menopause and talked about how it affects men across the globe.

Although mainly anecdotal, the evidence hints at a phenomenon with physical, hormonal, psychological and sociological components that may begin in many men's lives in their forties, fifties or sixties. Are we talking simply about getting older? Yes, but also about a larger challenge to a man's virility and vitality.

Physically, a man may notice a gradual decrease in muscle mass and strength. Common psychological symptoms include lethargy, depression, irritability, mood swings and loss of a sense of well-being. He may also notice the first faltering of potency or a slackening of sexual desire.

Unless a man is in a good relationship with an understanding partner, the shock of these changes may bring on a powerful psychological crisis, which can frighten a man into impotence.

Millions of men experience male menopause, but many won't talk about it with their wives or with other men. 

If female menopause is a silent passage, the loss of potency that can accompany male menopause is the unspeakable passage, fraught with secrecy, shame and denial. It strikes at the core of what it is to be a man.

When applied to men, menopause is actually a misnomer. Their reproductive glands do not all shut down the way women's ovaries do. What happens is more gradual than the menopause, and not universal.

But, after conducting 60 interviews in Britain and the United States—with healthy males aged 40 to 70 and experts who study and treat impotence— a consensus was reached that suggested male sexual changes in middle age commonly produce a virility crisis. In Britain the phenomenon has sometimes been called Viropause and, in Europe, Andropause.

Since the Kinsey Report in 1948, only one large-scale epidemiological study of male sexual behaviour has been conducted—the Massachusetts Male Ageing Study of 1984-89. It looked at a cross-sectional, random sample of 1,709 men between the ages of 40 and 70. Subjects were interviewed about demographics and lifestyle, surveyed regarding a variety of physical factors and asked to complete a questionnaire about sexual activity.

According to their self-reports, 51 per cent of normal, healthy males in this age group experience some degree of impotence. The steepest change over the 30-year age span was in the onset of moderate impotence—a man who has trouble with erections half the time. The prevalence of total impotence tripled from five per cent at the age of 40 to 15 per cent at the age of 70.

In the UK population of the same age group —9.7 million men in 1991—problems of declining sexual potency affect around five million men. 

Apparently, a loss of potency can occur intermittently over time. This baffling, if gradual, chafe in sexual response can be psychologically toxic. Once it begins, the decline of potency can create the performance anxiety that triggers real problems. From then on there is a "spectator" in bed with a man and his partner, as veteran sexologist Dr William Masters has described the phenomenon. This judgemental inner voice—what Fitzgerald terms the "scorekeeper"—can lead a man to impotence.

Many women who have a partner experiencing male menopause may blame themselves, but that couldn't be further from the truth. Men struggling with impotence are rarely struggling because of a loss of attraction to their wives. The real cause is shame.

Married men who disclose their problem to a doctor are usually encouraged to bring their wives for an interview as well. Sometimes just breaking through the silence and shame in a doctor's office, and being assured he is normal, is enough for the man to communicate with his frustrated wife. "Once somebody recognises that it's not any failure of his adequacy as a male, but mainly a physical problem, he is thrilled," reports endocrinologist Dr Richard Spark.

According to Dr Irwin Goldstein, who helped analyse the impotence data from the Massachusetts study, organic factors contribute to impotence in up to 80 per cent of men affected. The most common factor is impairment of the blood supply to the penis due to vascular problems. This can be caused by diabetes, smoking and other lifestyle choices.

The Massachusetts study bears out the blood-flow thesis. "Even at the age of 40, nearly two-thirds of those reporting a diagnosis of heart disease exhibit at least moderate impotence," says a director of the study.

Prescription drugs can be another enemy. Taking medication for high blood pressure, for example, can vastly increase the risk of impotence. The Kinsey Institute is deluged with letters from men whose doctors haven't warned them about their hypertension medication.

"The response to these medications is highly idiosyncratic," says June Reinisch, former director of The Kinsey Institute. "A man may have to try five different prescriptions before he finds one that does not affect his potency."

Alcohol is also treacherous for a man of middle age. Chronic use can seriously affect potency. "The steady drinkers of today are the lousy lovers of tomorrow," says researcher Dr Malcolm Carruthers of the privately funded Hormonal Healthcare Centre in London. "When we look at the tissue from patients with chronic alcoholism," confirms Dr Tom Lue, a professor of urology, "the nerve is killed inside the penis. It's almost impossible to revive."

"Smoking is absolutely devastating," says Dr Spark. "It's probably the major contributing cause of male sexual dysfunction. Smoking damages the tiny blood vessels in the penis, so they cannot enlarge to allow the substantial on rush of blood needed to create an erection."

Diet matters too. The Massachusetts study produced the first evidence that cholesterol level is related to impotence. High levels of HDL (high-density lipoprotein, the "good" cholesterol) were significantly associated with reduced levels of impotence.

Endocrinologists, who have pioneered the science of hormones, say that many, perhaps most, men experience a decline in testosterone levels as they age. "Most men begin to taper off in their mid-fifties to sixties," says Dr Pentti Siiteri, an authority on hormonal mechanisms. The hormone, which stimulates sexual development and bone and muscle growth, also affects a man's sense of well-being and stirs sexual desire.

Although older men's testosterone levels may be normal, they have usually experienced a decline in available testosterone over time. Production of testosterone decreases and production of a protein called sex hormone-binding globulin increases as men age. Testosterone links with the protein, reducing its availability to the tissues.

"The average testosterone level in men declines by 50 per cent with ageing, but the actual amount of testosterone available to the tissues falls by about two-thirds," says a reproductive endocrinologist.

Only some men experience a significant drop in the male sex hormone. In these instances, men exhibit many symptoms associated with female menopause—including hot flushes—plus severely diminished sexual desire.

It's quite likely that a man can become potent again. Episodes of impotence need not necessarily become permanent. If a man makes the right changes in his medications and in his smoking and eating habits, and does enough aerobic activity to improve his vascular system, he may see improvement in his potency. Otherwise, it's off to the specialists.

Intriguing new data suggests that some men may improve in muscle strength and general well-being if they are treated with supplements to bring their testosterone levels to somewhat higher-than-normal range. Some doctors are advocates for hormone replacement therapy, a form of prescribed testosterone.

Typically, a patient is given a course of tablets followed by an implant of pellets that release testosterone over a period of six months. When the effects wear off, another implant is administered. 

Most doctors are wary of this controversial approach. Some doctors worry that some men's testicles may atrophy and they may have a high red-blood-cell count. The hormone therapy may accelerate prostate cancer growth. 

However, some doctors say any emaciation of the testicles is minor and reversible, and patients are always screened for prostate cancer before and during treatment.

Doctors who believe in more conventional methods say the impact of a man's partner cannot be overemphasised. Indeed, as a man gets older, intimacy and trust with his partner become critical. Sex after 40 is a powerful interpersonal event; trust and security in a relationship are essential in fighting impotence.

A change in sexual technique, together with a closer, more intimate relationship with a partner, will compensate for some effects of age-related slowdown. Many older men report to The Kinsey Institute that they find they don't need to have an orgasm every time they have sex, and they can still enjoy it. This allows the next encounter to be more robust.

If you have a partner that supports you and you understand how lifestyle affects hormones in your body, impotence doesn't have to cause problems in your life. You cannot let impotence control you, but you can control it.