William Aiken

The 50-year-old man who starts riding a motor bike, takes up bungee jumping, pierces his ears, ditches his wife and starts dating girls the age of his children, is believed by many to be suffering from 'the male menopause', but this man would, however, best be thought of as facing a crisis of identity at mid-life.

Unlike women who experience a well-defined and abrupt event which heralds a cumulative decline in their ovarian function, men rarely experience a similar watershed period in their sexual function. Apart from those instances in which the testicles are surgically removed or medically defunctioned (usually for treatment of advanced prostate cancer), men do not usually experience an equivalent symptom complex as women in menopause do.

This is not to say that men do not experience a decline in their testicular and sexual function, but the decline experienced is a gradual one over decades. Symptoms of waning testicular function in men include a decline in libido, interest in and desire for sex, erectile dysfunction, mood swings, loss of drive, weakness, irritability, insomnia, and weight gain due to increased fat deposition.

Recognising that there is really no naturally occurring equivalent event in men to the menopause in women, doctors prefer to call the symptoms resulting from the gradual decline in testosterone - Partial Androgen Deficiency in the Ageing Male (PADAM).

Testosterone declines

Testosterone, referred to as the male hormone, is the main hormone responsible for the sex drive in men (and women). Testosterone is not only responsible for the sex drive, but is also partly responsible for general drive and vitality, aggression, maintaining strong and healthy bones, maintaining strong blood thereby preventing anaemia, and maintaining lean muscle mass. It is no wonder that athletes, hoping to gain an unfair competitive advantage, commonly abuse analogues of this hormone.

From the late 20s onwards the level of the active component of testosterone in the bloodstream (free testosterone) starts to decline and continues inexorably until its level may cross a threshold value in a particular man whereby symptoms such as those described above may appear. If this man goes to his doctor complaining of these symptoms and is found to have a low free testosterone for his age he may be diagnosed as having PADAM.

There are some problems though - the symptoms of PADAM are very non-specific and could equally result from depression or from PADAM; there are no universally accepted age specific testosterone levels at which PADAM can be unequivocally diagnosed; moreover, many factors affect testosterone levels such as the stress from acute illness and trauma and possible coexisting illnesses which are increasingly common with advancing age. For these and other reasons this diagnosis is sometimes a seemingly nebulous one.

Testosterone treatment

Nevertheless, there are cases in which it is strongly believed to be present and in which treatment by testosterone replacement of one kind or another is thought to be beneficial. But, herein lies yet another potential dilemma - as men get older, the likelihood of their harbouring occult prostate cancer cells destined to either remain silent or to become clinically manifest increases such that by 90 years of age, 100 per cent of men will have prostate cancer though only a small fraction of these men would die as a consequence of it. Why is this observation important? It is important because giving a man testosterone who is harbouring prostate cancer of which he is unaware, is tantamount to throwing gasoline on an open flame! For this reason, it is important to actively search for and exclude prostate cancer in older men who are being considered for androgen replacement therapy.

Notwithstanding this precaution, studies have shown that it is quite safe to give appropriately selected men androgen replacement therapy, even those who have been successfully treated for prostate cancer in which there is no evidence of residual disease after an interval of post-treatment monitoring. Is there such a thing as the male menopause? You be the judge.