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This website obviously centers on the penis and what it does for us as men. In our mid-life, it can be a profound shock to realize that the penis is not performing as it always has, as we have assumed it always will. This can be an assault on our sense of manhood and maleness, and combined with emotional challenges of depression and a sense of failure, may render a man truly impotent. Just what is the andropause? It is the effect of an inadequate supply of male hormones in a man's body, an inadequacy which can develop for a variety of reasons as he gets older, and which produces a profound and widespread range of symptoms. I quote again from Malcolm Carruthers: Its onset can be at any time from the age of 30 onwards, though typically it is in the fifties. One of the reasons it's often missed is that it is usually more gradual in onset than the menopause in the female...it is a crisis of vitality just as much as virility, even though its most obvious sign is loss of both interest in sex and of erectile power. This change is surprisingly often overlooked or ignored, either because the man is so pressurized by the rest of his life that he assumes it is an inevitable part of growing older or because his sexual partner has lost interest as well. Besides lack of libido, there is often loss of drive in professional or business life...also often fatigue, lethargy, exhaustion and depression, with a sense of hopelessness and helplessness. All too often men change their jobs or their women - anything to ease the malaise they feel - usually with little relief....Physically, there is often stiffness and pain in the muscles and joints or symptoms of gout and a rapidly deteriorating level of fitness. There may also be signs of accelerated ageing of the heart and circulation. (Maximizing Manhood, p 39-40) The andropause is the explanation of why the vitality and virility of millions of men has faded in middle age or later. It is the explanation of much misery, depression and unhappiness, loss of sexual performance, failing lives, failing health and failing relationships, and above all, it is the cause of impotence and loss of sexual function. But it would be a mistake to see this as merely a sexual issue. Consider the hormone testosterone. It permeates every aspect of the male body, every nerve, every muscle fiber, every brain cell. It is responsible for the development of the male body from the androgynous embryo, which will otherwise develop into the female form. If the testosterone receptors in the fetus are not working, or insensitive to the hormone, the development of the normal features of the male body will be incomplete or abnormal, or an intersex human will grow. If the hormone doesn't make its reappearance at the time of puberty, the male body will not develop secondary sexual characteristics such as a larger penis, beard and body hair, a deeper voice, and a male sexual drive. If the hormone doesn't flow around a boy's bloodstream adequately, his musculature will fail to develop as it should. Only the presence of testosterone in his blood will let him know of his maleness through spontaneous erections, either at night or during the day, and that classic male pre-occupation with sexy thoughts, feelings and images which interrupt a man's more practical thoughts in the way that we are so used to. Moreover, if testosterone doesn't act on a man's brain cells, he will lack drive and ambition, and take fewer risks. Now, what do you think will happen if a man's testosterone levels start to fall at some point in his middle years? Will the areas of the body whose metabolism is so dependent on testosterone remain fully and effectively functional? It hardly seems likely, does it? There's no doubt that man's sexuality changes as he ages. Think of the sexual urgency of the eighteen year-old. By the time he's forty, this virility may well have vanished, and spontaneous erections may be but a distant memory. He may still be able to get aroused in sexual situations, but his erection will take longer to get hard, and he will ejaculate more weakly, and he can't ejaculate as often as he once did. Symptoms of the Andropause The following symptoms may be caused by a decline in a man's hormone levels. Sleeplessness and/or fatigue - a pronounced drop in energy levels. Lack of masculine power - perhaps more accurately loss of confidence, and an air of weakness. Other signs might be a loss of interest in completing projects, coming up with new ideas, and a reduced desire to compete with other men. Depression - this depression is often regarded as a "conventional" emotional problem, a response to life events, when in fact it may be the direct result of changing brain biochemistry due to a decrease in testosterone levels. Nervousness, anxiety and irritability - moodiness and irritability is of course no laughing matter for the man concerned, his subordinates, colleagues or family, especially if it is completely out of line with his previous character. Reduced libido - a very distressing symptom for men and for their partners. Men report an absence of sexual thoughts, feelings and behavior, with no fantasy or sexual responsiveness. One man said that while he still looked at women appreciatively, it was almost as if he couldn't remember why he was looking at them - he could appreciate their beauty in a kind of distant, almost non-sexual way, but there was no sense of lust or sexuality about it. Reduced potency and/or penis size - reduced potency means a reduced ability to achieve an erection, and to keep it once achieved. The significance of erections for men is so profound and fundamental to our sense of masculine well-being that it is taken for granted. What does it signify, then, when morning erections are absent? And what if no erections occur during the night? This is a classic test for the nature of impotence - if night-time erections occur, then impotence at other times is psychological. But the man who has no erections at all senses that he is not a real man in some fundamental way any longer. Worse, perhaps, is the man who reports reduced penile size, especially when erect, for this is a blow to his sense of self in a way like no other. Decreased ejaculation force and volume - both serve to diminish a man's sexual pleasure and his sense of masculinity. The cause lies in the weakening of the muscles of the ejaculation mechanism, which have a very high concentration of testosterone receptors. Hot flushes or "flashes", blushing and sweating - redness of the face and neck can be a major problem, since it affects the most visible areas of the body. The night sweats can leave the bed and the man soaking with sweat. Aches and pains - are a very common problem, especially in the lower back and joints. Bone deterioration - in advanced or prolonged cases of testosterone deficiency, osteoporosis can set in. The consequences of this can obviously be very severe for the older man. Hair and skin - the wrinkly, dry skin which may develop in an andropausal man is due to the lack of sebum in his sebaceous glands, which would normally be stimulated by the testosterone in his blood stream into the production of oils essential for the maintenance of his skin in a healthy state. Circulatory problems - testosterone seems to have a role in promoting the circulation of blood. And there is evidence that it can protect the heart and reduce the incidence of heart disease in men. A few facts about testosterone levels and age In their late teens, boys are typically at the lifetime highs of testosterone - between 800 and 1200 nanograms per deciliter (ng/dl) of blood. This is why they are so sexual - why their penis is so constantly active! These levels are maintained for about ten or twenty years, after which they begin to decline at the rate of about 1 percent a year for the absolute testosterone level and 1.2 percent a year for the free testosterone level (a term explained below). However, these levels are so widely different between individuals that they cannot be regarded as anything more than a statistical average. As Dr Eugene Shippen points out in his book The Testosterone Syndrome, male testosterone decline is highly variable and dependent on many interlocking factors. Some men are in andropause by the time they are 40, and their testosterone levels are only 200 - 300 ng/dl when tested. Other men are still at 800 ng/dl at 70 years of age. This may be one of the reasons why testosterone deficiency has not been widely accepted as a valid medical syndrome - surely, the logic goes, if men with the symptoms of the andropause have high levels of testosterone, there can be no connection between the andropause and testosterone levels? But it isn't so simple. (By the way, the units used to express testosterone levels in Europe are different to the American ones quoted here, and they cannot be directly compared. The European unit of measurement is nanomoles per litre, or nmol/l. To convert from American to European, divide the American units by 28.57) The significance of free testosterone The absolute level of testosterone in a man's bloodstream does not represent the potential for the hormone to act in his body. Most of the testosterone in the blood stream of a man is actually bound to proteins, and typically only about two percent will be available for assimilation by the body's cells. The most significant protein that binds to the testosterone is called Sex Hormone Binding Globulin (SHBG), a protein whose levels increase with age. The more SHBG in a man's bloodstream, the less testosterone is actually available to act on his cells. Dr Malcolm Carruthers has emphasized the importance of what he terms the Free Androgen Index or FAI, which is the level of testosterone in the blood divided by the SHBG and multiplied by 100. It is when the FAI falls below 50 percent that symptoms of the andropause often appear. Clearly either a fall in absolute levels of testosterone or a rise in SHBG levels will have much the same effect - a man is deprived of the hormone that makes him, and keeps him, a man. The causes of low testosterone or low FAI First, and most simply, a man may have low testosterone production. There are two forms of testosterone deficiency - called by the medics primary hypogonadism and secondary hypogonadism. In both cases, hypogonadic men produce smaller amounts of testosterone than normal; the division into primary and secondary categories refers respectively to testicular failure, for whatever reason, as against some failure higher up the hormonal system that results in the testes' normal activity being switched off. There is no clear understanding of why testosterone production may fall as a man ages, although it may have something to do with the overall control of the testes by the pituitary gland in the brain. This gland secretes two hormones, LH and FSH, which act on the testes and stimulate them to produce both sperm and testosterone. In some cases it seems that the sensitivity of the testes to these chemical messengers from the brain decreases with age, and the overall mechanism of the hormone production system becomes less efficient. In others, the testes would work if stimulated, but the hormonal messengers from the brain cease to function effectively. Anyone who wants to study the male hormonal system in minute scientific detail can find all the information they need, presented in a very highly technical way, in the book Testosterone, which is listed below. But this is not a work for the average lay reader. You need a scientific training to read it (not to mention being fanatically interested in the subject!). Secondly, there is a more complicated form of the condition which results in an andropausal man getting some or all of the symptoms listed above, but when tested for hormone levels, he may be found to have physiologically normal testosterone levels. It is this fact which may have accounted for some of the skepticism about the value of administering testosterone to men with these problems, particularly the oft-repeated assertion that testosterone is of very limited value in helping men with erectile dysfunction or impotence. If so, it is a serious failure on the part of the doctors who don't understand this issue, for, as a brief visit to any of the support groups on the net that cover the subject of hormone replacement will reveal, very often the patients themselves are extremely aware of the problems that they are going through. They have a grasp of the technicalities which seems to have eluded their doctors - which is yet another reason to see an expert in the field, an andrologist (male specialist) or endocrinologist (hormone specialist) at the very least, rather than a urologist (the equivalent, roughly speaking, for men of a gynecologist), as so often seems to happen. This more complicated version of the andropause is related to changes in the normal male hormonal balance caused by excess levels of estrogen floating around in a man's system. Estrogen, or more accurately, estradiol, is a vital component of the male physiology, and in fact is made from testosterone in the cells of every man's body. However, although it has an important role to play in his physiology, it can sit on the cellular receptors for testosterone and stop testosterone working as it should. There is a very fine line between balance and imbalance in estradiol levels in a man - if it rises too high, no matter what his testosterone levels, he is in deep trouble, for the effects of excessively high estradiol levels on a man's physiology are almost exclusively very negative. Dr Eugene Shippen discusses this issue at length in his book The Testosterone Syndrome, and he also makes the point that any man who is experiencing high estradiol levels will also produce more SHBG, thereby reducing his unbound, free testosterone even further. The point that he makes is this: certain methods of testosterone supplementation can promote the metabolization of testosterone to estradiol so effectively that the ratio of estrogen to testosterone exceeds anything that can be considered physiologically normal, and the man is effectively neutered by the treatment he has received. There is also some suggestion in the book Testosterone (p58, second edition) that if part of a man's problem is that he is physiologically insensitive to testosterone anyway (which is not an uncommon condition - see the information on androgen insensitivity on the Hypospadias page), he is much more prone to metabolize testosterone to estradiol, thereby compounding the problems he faces. The moral of all of this being what, exactly? You may well ask. In a word, it is this: the treatment of the andropause needs an expert, who knows what he (or she) is doing, and can check for the less obvious aspects of hormonal physiology like LH, FSH and estradiol levels in a man's system. And the type of treatment on offer will have some impact on its effectiveness, as well. Continued on Andropause page 3: All about testosterone replacement therapy |
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