The medical profession has long debated the existence of male menopause. Does it really exist ? Until recently, the entire subject of male menopause was steeped in confusion and controversy. There is no doubt that a man's sexuality changes with advancing age. The instant, anytime, `as-many-times-as-you-want' erections that are more the rule rather than the exception at 18, do not last forever. With advancing age, the urge reduces, erections take time to come on, any time is not always a good time and the penis requires more direct stimulation in order to get aroused. Besides, the erections may not be as angled and rigid, and ejaculation becomes more feeble. The refractory period (interval) between erections gets prolonged.

Is all of this common because of maturation? Is it because by middle age man has had enough sex so they are not preoccupied with it any longer? Is this because his wife has aged a bit and is no longer as attractive/interested as before? Or is it because of the pressures at the work-place, the demands of parenthood, or pre-occupation with the lives of grown-up children and aging parents?

Yes, there is something known as a mid-life crisis. This is often a time in life when stability has been achieved and the struggles that were once a large part of life are now at an end. This new awareness that a life change has taken place can sometimes trigger a crisis. For some men, new-found stability may signify an end to vitality or youth. Many men find that after spending a lifetime working towards the goals of family and peers, the end result is unfulfilling. This is also often a time of change. Major shifts in career, marriage and parenting often occur during this time period. And, along with the physical signs of aging comes a realization of impending old age, retirement and eventually death. This time of life will only become a crisis if the changes become too difficult to cope with.

Mid-life crisis, thus, is essentially a problem of psycho-social adjustment. It need not necessarily have a bearing on a man's sex life. Which means it is not synonymous with male menopause, although there is frequently a superimposition of male menopausal factors in middle-aged men going through crises and this makes the picture hazy. Male menopause, on the other hand, is a distinct physiological phenomenon that is in many ways akin to, yet in some ways quite different from the female menopause.

Menopause is a condition most often associated with women. It occurs in a woman when she ceases to menstruate and can no longer become pregnant (usually). Men experience a different type of `menopause' or life change. It usually occurs between the ages of 45 and 60 - but sometimes as early as age 30. Unlike women, men can continue to father children, but the production of the male sex hormone (testosterone) diminishes gradually after age 40.

Testosterone is the hormone that stimulates sexual development in the male infant, bone and muscle growth in adult
males, and is responsible for sexual drive. It has been found that even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it is just ten years earlier. In fact, by age 80, most male hormone levels decrease to pre-puberty levels.

It was only after HRT (Hormone Replacement Therapy) was developed for post-menopausal women that men sat up and, not wanting to get left behind their womenfolk, began to take notice!

Symptoms
The symptoms of male menopause are similar to the ones women experience and can sometimes be as overwhelming. However, male menopause does not affect all men, at least not with the same intensity. Approximately 40 % of men between 40 and 60 will experience some degree of lethargy, depression, increased irritability, mood swings, hot flashes, insomnia, decreased libido, weakness, loss of both lean body mass and bone mass (making them susceptible to hip fractures) and difficulty in attaining and sustaining erections (impotence).

For these individuals, such unanticipated physical and psychological changes can be a major 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 showed that 51 % of normal, healthy males aged 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. Other factors, notably the co-existence of degenerative or other diseases, are possibilities.

Causes:
Although all 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, obesity, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems, notably mid-life depression. A general decline in potency at mid-life can be expected in a significant proportion of the male population.

Tips to cope with change:
Find new ways to relieve stress.
Eat a nutritious, low-fat, high-fiber diet.
Get plenty of sleep.
Exercise regularly.
Find a supportive friend or group and talk to them about what you're going through.
Limit your consumption of alcohol and caffeine.
Drink lots of water.

Treatment
Testosterone Replacement Therapy (TRT) must be always administered only by very responsible physicians and under strict case selection criteria and supervision. Testosterone must not be used as a tonic for vague complaints as it can cause serious side effects, including prostate cancer. The risk of prostate cancer with TRT has been much hyped. Recent evidence suggests that the fear of prostate cancer is perhaps exaggerated, since prostatic disease is estrogen-dependent rather than testosterone-dependent. However, it is true that testosterone administered to a patient who already has cancer of the prostate can cause a flare up and aggravation of the disease. Hence the importance of thorough check-up and investigation before starting testosterone.

Patients with significant `menopausal' complaints should be taken up for investigation. Serum FAT (Free Available Testosterone) is measured in a pooled early morning blood sample and, if low, testosterone therapy can be considered. Before starting testosterone, a complete general check up including a rectal examination is conducted followed by tests like the hematocrit, lipid profile, cardiac function tests, liver function tests, measurement of PSA (Prostate Specific Antigen) and a trans-rectal ultrasound (TRUS). The important side effects of testosterone are thrombophlebitis (a type of blood clotting) and hypercoagulability of blood, liver toxicity (with some oral testosterone preparations) and prostate cancer. These tests must be repeated at 3 or 6 monthly intervals for as long as treatment is continued.

Testosterone is available in many forms - oral, injectable, trans-dermal and implants. The oral route is generally not recommended because of the high risk of liver toxicity. More recently, patches, pellets, creams and gels have entered the fray. The choice of route and preparation will depend on availability, safety, the socio-economic status of the patient, proven long term safety and efficacy and the preference of the patient and the prescribing andrologist.

In conclusion, it may be stated that male menopause does exist. It affects many men over 40 years of age (sometimes earlier). It is not synonymous with mid-life crisis though the two can co-exist and compound one another. Symptoms are gradual and usually not as pronounced as in the female. Early diagnosis and hormone replacement therapy can improve symptoms.

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