Chapter One The Testosterone Story Hormones have a long, exciting and chequered history, and that of testosterone

e is the longest, most exciting and most chequered. However its history is part of the problem in getting the Male Menopause accepted as a real condition, so lets look back to see where the maze of myths surrounding testosterone starts. The word hormone was introduced in !"# by a $ritish physiologist, %rofessor &rnest 'tarling, in a lecture he was giving at the (oyal )ollege of %hysicians in *ondon. +t was derived by two scholarly dons in )ambridge from the ,reek verb hormao, meaning to put into quick motion, to excite or to arouse. He used it to describe the -chemical messengersthat were released into the blood.stream by the body/s ductless, or endocrine glands 0 endon. internal 1 krino . secrete22, such as the testis, thyroid, and adrenals, from the external 0exo . outside 2 secretions of glands with ducts, the exocrine glands, such as those that produce saliva or tears. This heralded the birth of the science of hormones, or endocrinology, which lived up to its prophetic name by making rapid advances, which excited both the public and medical imagination and often aroused great passion and controversy. Typically the history of any one hormone goes through four stages3 4irstly there is the observation that a gland or organ produces an internal secretion that has a general effect on the body. 'econdly, methods of detecting the internal secretion and measuring its effects are developed. This is usually initially by biological assay, seeing what action the preparation containing the hormone has on an animal or organ lacking it. *ater chemical methods of measurement can be found. Thirdly, the hormone is extracted from the gland or organ, and isolated in a pure form. 4ourthly, chemists define its structure and synthesise it. 5e will see how testosterone was unique in being the first hormone to be recognised and measured, but because of the complexity of its molecule was relatively slow in being isolated and synthesised. Antiquity The observation that castration makes the eunuch, properly credited to primitive man, ushered in the dawn of hormone research. The fact that the testes are so easily removed in many species, including man, with dramatic, obvious and widespread consequences, have caused them to be described as the oldest key to the treasure trove of knowledge about hormones. To emulate one of 'ir 5inston )hurchill/s most famous sayings -6ever in the field of human science was so much learned by so many by the removal of so little-. 7s the 8ournalist %aul de 9ruif put in his brilliant book on -The Male Hormone : 7 new gleam of hope for prolonging man/s prime of life-, printed in !;#, -4rom the beginning of human record, priests, saints, medicine men, farmers and sultans had been demonstrating how clear:cut, sure and simple it was to take the vigour of animals and men away. How< $y removing their testicles.-

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He goes on to put the important question -5hy didn/t they reason that older men, losing their youth gradually, might also be suffering a slow, chemical castration taking place invisibly with the passage of time<-. He then documents the slow march of the -Hormone Hunters- towards their goal of the -(escue of $roken Men- and providing them with a -6ew *ease on *ife- by isolating and then synthesising testosterone. However, his message has had to wait another fifty years to be heard. )astration carried out on young boys was always recognised as preventing the onset of puberty, with lack of body hair or beard, more feminine fat distribution and a high pitched voice much valued in singing. This was thought to be worth the sacrifice by some +talian singers, the -castrati-, or at least their managers, as graphically shown in the recent film -4arinelli, +l )astrato-. &unuchs were also known not to develop the male pattern of baldness, and to be less muscular. =epending on how long after puberty it was performed, castration as well as making the eunuch infertile, reduced his sexual and other drives, but did not invariably make him lose erectile power. The more potent were used by (oman women, particularly when their husbands were away fighting for the &mpire, for occupation without procreation. &unuchs were also known to be less competitive and aggressive. +n the $yzantine period, for the thousand years from about ;"" 7=, the &mpire was run increasingly by eunuchs, who were efficient, but predictably unadventurous and did what they were told. 'imilarly they played an important part in administration of the +mperial )ourt. They presumably knew their place, and posed no threat to the &mperor or those vying for power. 'imilarly farmers of antiquity knew that castration could be used to fatten pigs, bullocks and cockerels to produce capons. The taming of wild animals for domestic purposes, and tempering the fiery nature of both horses and dogs, made the psychological effects of castration in other species equally apparent. 7bout four thousand years ago the %en Tsao, the )hinese -,reat Herbal- recommended the use of the semen of young men for treatment of sexual weakness in the elderly, a remedy doubtless popular with the wives of the impotent potentates. +n +ndia, the Hindu 7yervedic system of medicine which developed from ,;"" $) onwards suggested the consumption of testicular tissue to treat impotence and obesity. +t was also known at that time that hot baths could reduce fertility, which is still news over three thousand years later. The great physician Hippocrates, who is said to have created medicine as both an art and science, lived during the golden age of ,reek culture, being born in ;>" $) and dying at over the age of ninety. His contemporaries included 'ocrates, %lato, 7ristophanes, &uripides and 'ophocles and yet of all these his reputation is probably the greatest. His is the moral medical code still used as the basis of medical ethics. +n the many classic writings noted by his pupils, he observed that gout does not appear before puberty, and that eunuchs do not develop it at all. Modern theory would suggest that the high levels of uric acid needed to cause this exquisitely painful condition of the 8oints, characteristically of the feet, come from the breakdown of the protein in the large muscle masses which testosterone produces in the postpubertal male. 7nother interesting observation he made was that women did not suffer from it till after the menopause.

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He also knew that mumps could be followed by the inflammation of the testes known as orchitis, and then sterility. 7s described later, this, together with other viral illnesses such as glandular fever which cause testicular damage, can contribute to an early onset of the male menopause. 6early two thousand years ago, the ,reek physician %liny recommended eating animal testicles to improve sexual function. This remedy is still popular in many countries, especially 'pain, where cooked bulls testes are served as the delicacy known as -)o8ones-. 6ot coincidently, this is also the 'panish word for courage. ?nfortunately, any benefits obtained from eating such dishes are likely to be more morale boosting than hormone boosting, because though most of the body/s supply of testosterone is made in the testes, it is rapidly exported to the rest of the body in the blood stream and there is little on site at any one time. 4or example, when chemists first extracted the hormone from bulls testes in the early !@"/s, it took several tons to produce a few hundred milligrams, the dose presently used one day/s supply for a patient. This makes using this dietary source on a regular basis a daunting taskA To make things worse, testosterone taken by mouth, unless it is in a special easily absorbed and stable form, is broken down in the liver, and never gets into the general circulation. This makes %liny/s treatment, though it must have sounded like a theoretically good idea at the time, practically useless apart from the doubtless strong placebo effect of many exotic remedies. *ater, the (oman physician 7retaeus, who gave the first detailed description of sugar diabetes, wrote -4or it is the semen, when possessed of vitality, which makes us to be men, hot, well braced in limbs, well.voiced, spirited, strong to think and act-. He added the rider that -4or when the semen is not possessed of its vitality, persons become shrivelled-, which is a good description of the wrinkled skin and wasted muscles of the testosterone deficient male. The message in Budaic medicine derived from the Cld testament is that health is the gift of ,od and disease his wrath. This can therefore only be prevented by submission, atonement, prayer, moral reform or sacrifice, which are still unpopular remedies, and may be ineffective if left too late. +t was also recognised that stress, disease, fatigue and starvation could reduce the amount of semen, which are all factors now known to lower testosterone levels, particularly in older men. The $ible differentiated between those who because of diseased or undescended testes developed eunuchoid features, known in &gypt as those -castrated by (a-, the sungod, -sun.castrates- and those castrated by man, -man.castrates-. 5hen this was performed for religious reasons, the penis was often removed as well, a mutilation now only seen in some transvestites. This differentiation is described in Matthew, )hapter !, verse D, Besus is quoted as saying -4or there are some eunuchs, which were so born from their mothers womb3 and there are some eunuchs, which were made eunuchs of men3 and there be eunuchs which have made them.selves eunuchs for the kingdom of heavens sake.- +n the latter category, he appears to be referring to priests who achieved celibacy without going to such extreme measures. These two types of testicular insufficiency or hypogonadism are recognised today as being either -primary-, originating before birth, or -secondary-, following some damage to the testis or interference with the production or action of testosterone. The Male Menopause falls within the secondary category, but occasionally there are elements of a primary cause

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which has been overlooked, as when one or both testes fail to develop or descend fully. Then there may be sufficient hormone to take the boy through an apparently normal puberty, and even become fertile, but in his thirties or forties the other factors which contribute to the andropause cause the limited supply of testosterone to become insufficient. +n +ndia, those who renounce sexual activity because they believe it dissipates their spiritual energy, are known as bramacharya. +n the Hindu tradition, it is one of the requirements of becoming a monk or 'wami. 7 vegetarian diet may help them to make this difficult sacrifice and keep from straying from the spiritual path by decreasing the amount of cholesterol available for testosterone production. This was confirmed in !E; when a 'wedish study showed that switching from a high to a low fat diet, particularly one high in polyunsaturates, lowered blood testosterone levels by "F. This makes sense in evolutionary terms as the aggressive killer instinct of the hunter, red in tooth and claw, would be enhanced by the higher level of testosterone produced by having a higher fat, higher cholesterol diet than his more placid herbivorous prey. The beadle of the orphanage in =ickens/s story -Cliver Twist-, Mr. $umble, rebuked the undertaker who employed Cliver till he got into a fight with the words, -Gou never should have given the boy meat. Meat heats the blood-. %erhaps the old man who for many years used to wander up and down Cxford 'treet in *ondon with sandwich boards denouncing the -%assion %roteins- in meat and declaring that they led to war, may have stumbled onto an important truth. 7lso the oestrogens present in many plants, phytoestrogens, can antagonise the effects of testosterone and give a more female type of fat distribution. The plants richest in these phytoestrogens are 'oya, particularly tofu and miso, citrus fruits, wheat, liquorice, alfalfa, fennel and celery. which may be why some vegetarian yogi/s have enlarged breasts, a condition known as gynaecomastia, and large abdomens. %liny recorded D,""" years ago that -Hempseed and chondrion make men impotent-. 7lso, heavy beer drinkers, because of the phytoestrogens in hops, as well as the calories from the alcohol, and its damaging effect on the testes and liver, can show enlarged breasts, and -beer.belly- as well as the erection problems described as -brewer/s droop-. The most influential physician of (oman times, was ,alen 0 @".D"" 7=2, who is considered the greatest medical man of antiquity after Hippocrates. He wrote more than "" books whose influence carried on for more than fifteen hundred years, well into the renaissance period and beyond. However, he could also be thought of as the founding father of medical dogmatism in that his system was so authoritative and rigid that it almost completely stifled fresh ideas throughout that time. +n spite of this, ,alen could be thought of as the forerunner of sex hormone theory and research. He describes how the -maleness- of men could cease with castration, and the -femaleness- of women with disease or ageing of the ovaries. He noted that these sexual characteristics were generalised throughout the body in all the species he studied, and were not purely genital, being seen for example in the lion/s mane, the cox/s comb and the boar/s tusk. These remote and widespread effects are the characteristic features of hormonal action. He also raised a key question of great importance to our thinking in relation to the reduction in vitality as well as virility seen in the menopausal male when he asked in his book -%eri

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'permatos- 0Cn The 'eed2, -5hat is, therefore, the cause, that castrates slow down in their whole vital capacity<-. He remarks in this book that castrated animals lose not only the power to procreate, but also the desire to do so, as well as undergoing the characteristic changes in normal male fat and hair distribution, well recognised in eunuchs. +n modern medical parlance, they show all the signs of testosterone deficiency. Renaissance Period. +t was only with the wave of radical new thinking that swept through &urope at the beginning of the sixteenth century that medicine broke free of the bondage imposed on it by ,alen/s words. This rebirth in both the arts and sciences was precipitated by two events. Cne was the fall of )onstantinople in ;#@ which ended the $yzantine empire and caused many scholars to move from there to +taly. 7s a result there was a revival of ,reek medical thought in terms of the ideas and observations of Hippocrates, rather than the unquestionable dogma of ,alen. The other was the information revolution started by the printing of the ,utenberg $ible in ;#;, which soon spread to the production of medical of medical texts. *et/s hope that the new information revolution produced by the computer and the internet, which is starting to give us access to medical databases all over the world, will produce even greater advances in freedom of thought on all medical sub8ects including the andropause. Cne of my heroes from this period is %aracelsus 0 ;!@. #; 2, or to give him his full title, 7ureolus Theophrastus $ombastus von Hohenheim, the most important medical thinker of the sixteenth century. 7s his name suggests, he was a 'wiss, swashbuckling physician and chemist, who not only had the audacity to challenge ,alen/s ideas, but publicly burned his books. He revived Hippocratic thought and ideals in medicine and introduced many new ones of his own, especially in relation to thyroid disease. He died unloved and unrecognised by the medical establishment of his day, but left a legacy of original thought which became part of the active ferment which led to fresh medical thinking and experimentation on hormonal factors in health and disease. +t influenced )harles =arwin who appealed to scientists to abandon intellectual -idolatry-. %aracelsus introduced a new vision of disease as a distinct explicable entity which could and should be treated, rather than the ,alenic view that most conditions were untreatable and encouraged the population to bear with fatalistic resignation. 4or example he successfully introduced mercurials for the treatment of syphilis, the most feared disease of the sixteenth century, which was viewed in the same light as 7+=' is in the present day. %erhaps we need to invoke the spirit of %aracelsus today to encourage wider discussion of topic of the Male Menopause. How did the intelligent public view ageing in the male at that time< 5ith his usual intuitive clinical accuracy, 'hakespeare about four hundred years ago described in his play -7s you like it- the seven ages of man and we can now recognise how each age is influenced by the effects of testosterone. -7t first the infant, Mewling and puking in the nurse/s arms- 0". " years2. +n the infant there is no real difference between the testosterone levels in boys and girls, though intrauterine differences have left their physical and emotional imprints. -7nd then the whining schoolboy, with his satchel, 7nd shining morning face, creeping like snail, ?nwillingly to school.- . The surge of testosterone at puberty generates the

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rebellious male nature, as well as the increase in skin.oil or sebum, which makes the skin shine and later in excess causes acne. The sexual characteristics of the adult male appear. -7nd then the lover, 'ighing like furnace, with a woeful ballad Made to his mistress/ eyebrow.- . 5ith the libido driven by the peaking levels of testosterone going full blast, and rampant priapic power available, mating and nest.building activities normally tend to predominate. -Then a soldier, 4ull of strange oaths, and bearded like the pard, Bealous in honour, sudden and quick in quarrel, seeking the bubble reputation &ven in the )anon/s mouth.- . %lenty of testosterone still making him belligerent and driving him through what is often a period of questing and hasty decisions, the -Mid.life )risis-. -7nd then the Bustice, +n fair round belly with good capon lin/d, 5ith eyes severe, and beard of formal cut, 4ull of wise saws and modern instancesH- . 5ith testosterone activity declining the scene is set for the Male Menopause to appear along with the fatty degeneration shared with the capon, showed by weight gain and the muscle deterioration seen first in the &lizabethan -couch potato/s- expanding waistline. -The sixth age shifts into the lean and slipper/d pantaloon, 5ith spectacles on nose and pouch on side, His Gouthful hose well sav/d a world to wide 4or his shrunk shankH and his big manly voice, Turning again towards childish treble, pipes 7nd whistles in his sound.- . The decreasing free testosterone levels and lack of physical activity fail to maintain muscle mass, particularly in the legs, so that the calves and thighs shrink. *ack of testosterone also results in thinning of the vocal chords, which return to their prepubertal state giving a higher pitch. -*ast scene of all, that ends this strange eventful history, +s second childishness, and mere oblivion, 'ans teeth, sans eyes, sans taste, sans everything.- . The old saying that what you don/t use you lose comes sadly true at this stage of life, and there is considerable evidence to suggest that testosterone treatment can slow the rate of physical and mental deterioration in the final stages of life, and help men to maintain both the will and ability to continue active life till they drop. Gou now have the choiceA 'hakespeare also wrote -+s it not strange that desire should so many years outlive performance<-, a question which taxes the minds of doctors and their patients to this day. The answer could well be that lower levels of testosterone are needed to maintain libido than are required for potency and there are many complex circulatory factors involved in obtaining an erection, and well as the hormonal drive. The spirit is still willing often long after the flesh has weakened, though following repeated erectile failures, the desire tends eventually to fade also. Eighteenth and Nineteenth Centuries The dominant figure in experimental medicine in the eighteenth century was the &nglish surgeon Bohn Hunter 0 IDE. I!@2. 7mong his amazing range of original studies, were the experiments supporting his view that sexual characteristics -depend on the effects that the ovaria and testicles have upon the constitution-. He obtained evidence for this statement in a variety of ways. 7n interesting experiment on how the testes enlarged in the mating season in a variety of animals was carried out by killing and preserving a series of *ondon cock.sparrow/s at monthly intervals from mid.winter to spring. His students later reported Hunter/s

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demonstration that -The one killed in =ecember has testes not bigger than a small pin/s head, the rest are gradually larger, the testes of the last, killed in 7pril, are as large as the top of your little finger.- 5e now know that this seasonal growth of the testes, with its accompanying surge in testosterone, is due to the longer days triggering the pineal gland at the base of the brain to switch off production of its -Hibernation Hormone- Melatonin. This in turn causes the pituitary gland to produce more of the hormones which rouse the dormant testes to spring fever pitch. +t seems however that the bright city lights are now suppressing this seasonal cycle, and causing mating activity in cosmopolitan sparrow/s all year round. Though in humans there is a slight surge in conception rates around holiday periods such as )hristmas, there is a larger rise in late spring and early summer, so we retain this link between sunshine and sex. 5hat has not been sufficiently recognised is that he carried out transplantation experiments which showed that if the spur of a hen was transplanted to a cock, it would grow to the size of a cock/s spur. He went on to demonstrate that if the small spur of a young cock was transplanted to a hen, it failed to grow at all. He also in II transplanted cock/s testicles into their abdomens, and observed that they continued to grow there, and into the same site in hen/s, with some evidence of a masculinising effect. However, he failed to publish his results, illustrating the truth of that old medical dictum -%ublish or perish-. +t was not until over seventy years later, in E;! that a ,erman %rofessor at the ?niversity of ,ottingen, 7dolf $erthold, who knew of Hunters work, repeated the experiment, showing that capons could grow into normal cocks following testicular transplants. He wrote -They crowed quite considerably, often fought among themselves and with other young roosters, and showed a normal inclination to hens-. +n particular the transplants prevented atrophy of the comb, restoring this dramatic red crowning glory of the male of the species which signals his sexual maturity. This was clear proof that the testis produced a substance which travelled in the blood to maintain the sexual characteristics of the adult male animal. This first well documented successful hormone replacement therapy inaugurated a century of attempts to use testicular extracts or implants to re8uvenate men. However, most of these attempts were either of doubtful effectiveness, mainly relying on the placebo effect of giving patients a novel form of treatment, or fraudulent confidence tricks based on the instinctive wish for a long and active life. +t is difficult to this day to decide whether doctors offering re8uvenation treatments are -leading edge pioneers- or -medical buccaneers- who navigate -this poorly charted sea of medical research-. Time and future research will tell. Cne who must certainly be regarded as a pioneer, was the eminent neurologist and physiologist )harles &douard $rown 'equard 0 E I. E!;2. He had a distinguished career in 4rance, where he had been the successor of the celebrated physiologist )laude $ernard at the 'orbonne in %aris, and had held posts in &ngland and 7merica, as well as being the first to demonstrate that the adrenal glands were essential to life. However his colleagues became critical of his ideas when in E>! he suggested that -the feebleness of old men is in part due to the diminution in function of the testicles-. He also said that -if it were possible to in8ect, without danger, sperm into the veins of old men, one would be able to obtain with them some manifestations of re8uvenation at once with respect to intellectual work and the physical powers of the organism-. They were even more sceptical when in EE!, still actively researching his ideas at the age of ID he announced at a learned gathering in %aris that he had mentally and physically re8uvenated himself with subcutaneous in8ections of extracts of the testicles of dogs and

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guinea.pigs. 5ithin three weeks the $ritish Medical Bournal had published a report on his lecture criticising his ideas and manner of their presentation. ?nder the heading of /The pentacle of re8uvenescence- it said sarcastically that -The statements he made . which unfortunately attracted a good deal of attention in the public press . recall the wild imaginings of mediaeval philosophers in search of an elixir vitae-. 'imilar responses to reports on the benefits of treating the male menopause are still prevalent over a hundred years later. *ooking back, $rown.'equard/s ghost might well comment -*a plus ca change, la plus c/est le meme chose-. +n &ngland and 7merica his results were said to be due to autosuggestion, or even hypnosis which was very fashionable in 4rance at the time. He tried to counteract this notion by not giving the patients any idea of the results he was expecting, though any treatment by such a distinguished and imposing %rofessor must have had some placebo effect. He also sent his extracts to sympathetic colleagues in &ngland and 7merica, and though some reported good results, the general medical reaction in $ritain to what rapidly became known as one type of /organotherapy/, treatment with glandular extracts or transplants, was hostile. However some of the critics were given pause for thought by work going on at the same time on the more obvious, reproducible and clear.cut benefits of treating thyroid deficient, myxoedematous, patients with thyroid extracts. +n 7merica however, the reactions to $rown.'equard/s work was over.enthusiastic, and the testicular extract was widely inflicted by charlatans on a gullible public as -The &lixir of *ifefor every type of ailment from senility to tuberculosis. This and other -organotherapiesbecame even more fashionable because of the simultaneous introduction of -serotherapiesthe use of sera and vaccines of animal origin for the prevention and treatment of infectious diseases. %articularly in Jictorian &ngland studies in matters relating to sexual activity were considered -not quite nice-, and unsuitable topics for research. $rown 'equard died a discredited man, who -made the blunder that put the male hormone in the scientific dog: house-as %aul de 9ruif points out. Moralists were quick to 8ump on this failure in therapy, and as he documents, the ridicule that it brought to the whole field of research into the hormonal functions of the testis has lasted to the present day, and is an unfortutunate legacy. $rown:'equard/s mistake at the end of a long and innovative carreer in research was still being used by one learned professor as evidence against the existance of the Male Menopause even this year in a television documentary on the sub8ect. &ven learned and very influential physiologists such as 'ir &dward 'chafer who wrote many papers and a book on -&ndocrine organs- had a 4reudian block about reproductive hormones, and in a lecture on -+nternal 'ecretions- given to the $ritish Medical 7ssociation in *ondon in E!#, denied that the testes had any endocrine actions. +t is amazing that so great a pioneer in other areas of endocrinology could have so complete a blind spot to the millennia of evidence to the contrary. However we hear echoes of this disapproval of research into the effects of testosterone treatment in relation to slowing the ageing process even now. 5hat also had a bad but unforeseen long term result in terms of the acceptance of testosterone treatment by doctors and the general public, was an experiment by two 7ustrian doctors in E!> who claimed that testicular extracts of bull/s testicles could improve the strength of their hand muscles. They concluded that -The training of athletes offers an opportunity for further research in this area-. This report foreshadowed the damaging influence of steroid abuse by athletes on the medical and public image of testosterone treatment.

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Twentieth Century Though -organotherapy- using extracts of different glands, particularly the thyroid and adrenal, continued to be the sub8ect of much speculation and experimentation, it soon became clear that testicular extracts were not sufficiently powerful to have the hoped.for and much publicised effects originally claimed. This was because the minute amount of testosterone produced in the testes is continuously being swept away into the blood stream, and is not stock.piled in the gland. (emembering the work of Hunter and $erthold, doctors attempted what would be a difficult feat even nowadays, that of transplanting testicles from man to man. +n ! D and ! @ there were reports of the first two apparently successful operations in 7merica. The second of these was performed by a =r Jictor =. *espinasse of )hicago, who reported full restoration of libido and sexual function over a two year period in a man previously without desire and impotent from loss of both testes. Though the 'econd 5orld 5ar held up endocrine research and held up communication between doctors working in different &uropean countries for many years, there was an interesting report that the famous =anish surgeon Thorkild (ovsing carried out an experiment which seemed to indicate that testicular function might be important in relation to the circulation, as indeed $rown.'equard had claimed. 7fter a young soldier had been killed in battle, (ovsing transplanted his testicles into an old man with gangrene, which then according to the case report healed completely. +n ! E the resident physician in 'an Kuentin prison in )alifornia, =r. *eo *. 'tanley, who had access to many fresh testicles -donated- by executed prisoners, started transplanting them into other inmates of various ages. 'ome of these regained their sexual potency, though how this was measured in the prison is unclear, and freedom is a great aphrodisiac. Two years later, because of -the scarcity of human material- even in that situation, he moved onto transplanting into his rapidly expanding patient population, the testes of rams, goats, deer and boars, which, perhaps suspiciously, seemed to be equally effective. +nterestingly, as with (ovsing, gangrene was among the wide range of conditions from senility to diabetes which he claimed to benefit. +n the early !D"/s, a flamboyant (ussian.4rench surgeon called 'erge Joronoff working in 7lgiers, made his fame and fortune by transplanting chimpanzee and baboon testicles into humans, and claimed they had powerful re8uvenating effects. This work naturally attracted great medical and public interest, and international deputation/s of doctors as well as patients from many countries made the pilgrimage to 7lgiers to investigate his -monkey gland- treatment. +f Joronoff was 8ust fooling people, he did so with a lot of detailed evidence and seemingly convincing results for at least a decade. &ven my first professor of physiology at the Middlesex Hospital in *ondon, 'amson 5right described JoronoffLLs work in detail in his standard textbook of the day in !D>. -+n successful cases it is claimed that very striking results are obtained from this operation. Cld people, with marked signs of senility, are claimed to be thus transformed into vigorous energetic individuals. %reviously castrated person/s may regain their secondary sex character . e.g. growth of beard and moustache may occur-.

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The same writer obviously took this work seriously because he went on to say -5hile JoronoffLLs operation appears quite 8ustifiable in young sub8ects in whom the testes have been damaged or destroyed by in8ury or disease, the treatment of senility by this method is more questionable. 5e have no proof whatever that senility is solely due to atrophic changes in the testisH it is almost certain that many other factors are concerned. Though the testicular graft may stimulate physical activity and sexual desire, it cannot restore the worn heart, arteries and essential organs to their normal state. There is a grave danger that excessive strain may be put on damaged structures, with disastrous results-. These are the same lines of argument still used today by doctors urging the fatalistic -do. nothing- option in relation to the possibility of hormone replacement treatment for men, saying -+ts 8ust your age . 5hat do you expect at fifty, sixty, seventy or whatever your age is<- 7long with women who are experiencing the many benefits of H(T, the answer should be as with =ickens/s -Cliver-, a definite -MoreA-. 'omething is going to fail at some time in one of our body/s systems, but shouldn/t we at least be looking at every reasonable option for staying as mentally and physically active as we can, for as long as possible< Ges, the benefits have to be weighed against costs and dangers, but doctors should be continually assessing the evidence for and against each treatment and offering it to the patients to decide for themselves, and not pre8udging the issues. Pure Testosterone 7s the war clouds cleared in &urope after the first 5orld 5ar, a great pharmacological arms race developed with three drug firms competing to be the first to produce the active ingredient of the testicles in pure chemical form. +t is an amazing story of synchronicity that after a search for the essence of manhood lasting over four thousand years, the three different groups passed the finishing post within four months of each other. 4irst past the post on the DIth of May !@#, was &rnst *aqueur, a %rofessor of pharmacology in 7msterdam, who lead an excellent research team for the Crganon drug company, and emerged triumphant with a few precious crystals from a veritable mountain of bulls testicles, and submitted a paper called -Cn crystalline male hormone from testiclesand coined the name testosterone for it. 'econd was a formidable, dynamic ,erman chemist with a duelling scar on his left cheek, %rofessor 7dolf $utenandt. He was working for the 'chering )ompany in $erlin, which had managed to survive the first 5orld 5ar with its manufacturing capacity intact, and in !D@ thanks to hyper:inflation made a profit of DE> million billion marks, after tax, giving the shareholders a dividend of two billion percent. 'ome of this profit it invested in collecting D#,""" litres of policemen/s urine, enough to fill an Clympic size swimming pool. 4rom this $utenandt with bravery clearly above and beyond the call of duty, extracted #mg, a few crystals, of a relatively inactive urinary breakdown product of testosterone called androsterone. He then decided that method of preparation was too much like hard work, and thought up the much more commercial way by which testosterone is made to this day. He methodically worked out its structure and then produced it, as does the body, from cholesterol, its natural precursor. He sent his paper on this process and the structure of testosterone itself to the ,erman Bournal of %hysiological )hemistry on the D;th 7ugust !@#. Bust one week later a 'wiss chemical 8ournal received a paper from *eopold (uzicka, a Bugoslavian chemist working for the )iba company in Murich, announcing a patent on the

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method of production of testosterone from cholesterol. 4or this work, he and $utenandt received the 6obel %rize in !@!. 5ithin two years of these momentous discoveries a variety of testosterone preparations were in clinical use. +t had soon been found that because it was an oily substance which didn/t dissolve readily in water, that in the pure form it couldn/t be absorbed by mouth. 7 slow release form that could be given by in8ection, testosterone propionate, was one of the most widely used and proved very successful in patients whose testes were insufficiently active for a variety of reasons. (ather like insulin in8ections for diabetics which had been introduced fifteen years earlier, it was dramatically effective in restoring the two big J/s in men/s lives, Jitality and Jirility. 6ow that you could /get it in a bottle/, testicular transplants and extracts went out of the window. 'tudies on patients in the late thirties and throughout the thirties and forties showed a wide range of benefits in several serious medical conditions, ranging from heart and circulatory problems, including even gangrene, and diabetes. Though the in8ections lasted about three days, another form of testosterone as compressed crystals fused together to form tablets and later small cylindrical pellets, which under local anaesthetic could be implanted under the skin of the buttock or abdomen was introduced. This was both effective and convenient, as the implant continued to act for six months. 'ixty years later this is still one of the best methods of giving long term testosterone treatment. There are few medical preparations, particularly in endocrinology, which have stood the test of time so well. 7 third type of preparation which was also made in the early years was a water soluble form called methyl testosterone. ?nfortunately, though effective in relieving symptoms, this proved very toxic, especially to the liver. 7s it was so widely used for over fifty years, and was included in a wide range of under.the.counter, gold and silver covered pills, claiming almost magical powers in the sexual arena, it has done a great deal of harm to the safety image of testosterone in many doctors minds. +t is amazing that it is still almost the only form of oral testosterone preparation to be available in the ?nited 'tates, when its dangers have so long been recognised, and it has been taken off the market throughout the rest of the 5orld where several safe oral forms have been introduced. Testosterone used to treat the Male Menopause 4rom !;" onwards, largely because of the obvious improvements brought about by testosterone, it was generally accepted by many doctors that there was a group of symptoms commonly experienced by men in their fifties that were similar to the female menopause or climacteric, from the ,reek word klimacter , meaning the rung of a ladder, and hence a critical period in life at which the vital force begins to decline. 7n outstanding paper of this time, which used testosterone as definitive proof of the existence of the male menopause, was published in the prestigious Bournal of the 7merican Medical 7ssociation in !;;. +t was called -The Male )limacteric, it/s 'ymptomatology, =iagnosis and Treatment- and was by two 7merican doctors, )arl ,. Heller and ,ordon $. Myers. +t is well worth looking at this paper in detail, as the case has seldom if ever been better made. The symptoms which they attributed to the male climacteric were exactly as described in the last chapter of this book, i.e. nervousness, depression, impaired memory, the inability to concentrate, easy fatiguability, insomnia, hot flushes, sweating, and loss of libido and

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potency. They began by listing all the points raised by those who were sceptical of the existence of this condition, and then used their clinical studies to answer them one by one. The ma8ority of these queries were based on the general view that no ob8ective evidence had been put forward to prove it was an actual clinical entity, or to differentiate it from neurosis or impotence of purely emotional origin. 7lso many men remained fertile to an advanced age, and did not show the marked physical changes in body form that women showed in the days before H(T became common.place. To study these points, they developed a measure of testicular function based on the hormonal feedback mechanism which exists to control the production of testosterone by the testis in men, and oestrogen by the ovary in women. 5hen the level of testosterone in the former or oestrogen in the latter drops, the small gland at the base of the brain which is in over.all control, the pituitary releases more of two hormones, gonadotrophins, so.called because they stimulate these sex.glands. 5hen the level of testosterone is adequate for the body/s needs, the gonadotrophins fall to a low level. 6ow they can be measured by sensitive chemical tests on the blood, which can be used in the diagnosis and treatment of both the male and female menopause. +n those days they had to extract a twelve hour over.night sample of each man/s urine, in8ect the extract into immature female rats, and measure the increase in the weight of their ovaries caused by the gonadotrophins in the sample. This simple biological test gave surprisingly clear.cut results. The urine of normal men, or those whose symptoms were due to anxiety or neurosis, showed virtually no gonadotrophin activity in the urine. Those whose symptoms were due to a true male.climacteric syndrome showed high levels of urinary gonadotrophins, as demonstrated by the ovaries of the test rats doubling or trebling in size. This carefully performed and detailed study gave unequivocal evidence that the male menopause was a physical fact, and not 8ust a fiction created by the emotionally disturbed and neurotic. 7lso, when a therapeutic test was carried out on samples of both groups of men by giving in8ections of testosterone propionate, the neurotic group -experienced little, if any, improvement in potency or in well.being-. $y contrast, in the male menopause group -=efinite improvement in the 'ymptomatology was noted by the end of the second week in all of the twenty cases treated. )omplete abolition of all vasomotor, psychic, constitutional and urinary symptoms was accomplished by the end of the third week in I of the D" cases treated. +n the remaining three cases vasomotor and urinary symptoms were abolished but the psychic and constitutional symptoms persisted in spite of continuation of treatment for several months and doubling the dosage for brief periods. +t was concluded that these three persons were suffering from involutional melancholia -0depression of old age2. The same study also answered a frequent criticism of testosterone treatment to this day, that it will restore libido but not help problems with erections, leaving the patient more frustrated than before. Heller and Myers experience coincides with my own when they stated -'exual potency was restored to normal with these doses in all but D cases, in one of which involutional melancholia was present.- They go on to remark that with increased dosage, -sexual vigour in both previously refractory cases exceeded that of normal men-. They further gave evidence that this is a real response to testosterone treatment and not 8ust a placebo effect. -+n ; cases therapy was subsequently withheld for from four to fourteen weeks and in all instances the symptoms returned and sexual potency was again

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lost. Cn resumption of the therapy with testosterone propionate, relief of symptoms was again afforded and sexual potency returned. Thus the specificity of therapy was established. To investigate further the possibility that the improvement may have been due to suggestion, placebo in8ections were administered. 7mpoules containing cc of sesame oil, packaged similarly to the original testosterone propionate, were substituted without the patients knowledge in several cases. 6o improvement was noted in any case.7s well as recommending pellet implants for long term treatment, they made two final important points in this historic paper. These were that -the male climacteric is not confined to middle and old age but may occur as early as the third decade-, and they concluded that, -whereas in the female the menopause is an invariable and physiologic accompaniment of the ageing process, in the male the climacteric is an infrequent and pathologic accompaniment of the ageing process-. 5e will see later why the male menopause may have become more common half a century on and yet is still not being properly diagnosed or treated. r Ti!erius Reiter 'tarting in !#", a ,erman physician who trained in $erlin, &dinburgh and ,lasgow, but set up in private practice in *ondon/s Harley street, used testosterone pellet implants to treat men in their ;"/s, #"/s, >"/s and I"/s suffering what he called +=?T syndrome. These initials indicated the main features of the condition which were +mpotence, =epression, ?rinary disturbances and Thyroid over activity, and he attributed all these to testosterone deficiency. +ncluded in the latter term were irritability, headaches and attacks of rapid heart beats, particularly at nights, which 8ust about completes the classic picture of the male menopause. Cver twenty years he treated about #"" patients with very good clinical results. These he wrote up in considerable detail in five eloquent articles, and carefully documented the improvements in each symptom on his own rating scale. He also wrote a monograph describing his method of implanting testosterone pellets into the buttocks for Crganon, the company who made the implants, and this is the method and materials that + use to this day. Having spoken to his medical colleagues, several of his patients, and his widow 6ancy (eiter, an interesting picture emerges of this remarkable man. He was a dynamic, charismatic individual who delighted in the improvements he saw in his patients condition. He too believed in a broad approach to treatment, and would sometimes take his patients to his favourite fish restaurant to teach them at a pleasant practical level of the benefits to virility of eating oysters, because of their high zinc content. 7s 6ancy put it, he was regarded with -plenty of scepticism from the Medical 5orld . $ut the patients kept comingA- 7 prophet unrecognised in $ritain, he was well received in 7merica where he published articles in the Bournal of the 7merican ,eriatrics 'ociety in !>@, !>; and !>#, and in the latter year lectured at their DDnd 7nnual Meeting in 6ew Gork )ity, receiving considerable interest and approval. +n $ritain he could still not get his message across, and so he devised a -cunning plan-. He went to a meeting on endocrinology at the prestigious -(oyal 'ociety of Medicine-, the heart of the medical establishment, in 5impole street in *ondon, and stood up at question time at the end, to give a long fiery diatribe about the virtues of testosterone treatment.

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5hen the chairman of the meeting finally managed to shut him up, which took some doing because he was doing a very determined filibuster, he went to the front entrance of that august 'ociety/s imposing building, and met a group of 8ournalists he had previously summoned. He then gave them full details of his learned address to the (oyal 'ociety, which was duly printed together with his picture in the newspaper that evening. %erhaps not surprisingly, such direct action did not endear him to academic doctors, but he died much loved by his patients in !ID, truly another hero of the hormonal revolution. r. "ens Moller. The =anish doctor Bens Moller was one of the great pioneers of testosterone treatment. 5ith all the fire and tenacity of his Jiking ancestors he fought a thirty year war for its use against the medical establishment in =enmark and throughout &urope. + had the privilege of working with him during the last ten years of that war, and it was he who in !II first interested me in testosterone. 7t the time + had been working as 'enior *ecturer in )hemical %athology at 't. Mary/s Hospital Medical 'chool in *ondon. Though my office and research laboratory were located within the =epartment of %rofessor Jivian Bames, one of the 5orld/s leading researchers on 'teroid $iochemistry, which includes the study of testosterone, oestrogens, cortisol and other related hormones, + was more excited by the stress hormones such as adrenaline and noradrenaline which appeared more directly related to my theories on stress, tension and heart disease, my main area of research at the time. However, + was very much interested in the benefits of exercise as a means of balancing up the effects of stress and a way of protecting the heart from its effects. 7s part of this programme of research, + was taking part in a study set up by the Medical (esearch )ouncil at the )ity ,ymnasium at Moorgate in *ondon. The founder and owner of this gymnasium was an ex.Clympic weight lifting coach called 7listair Murray, who with tremendous energy and enthusiasm originated the use of vigorous but not violent exercise in the form of circuit training in both the prevention and treatment of heart disease in *ondon businessmen. 5e later wrote a book together called -4;" . 4itness on 4orty Minutes a 5eek- based on his ideas and reporting this research. Cne day while + was at the gym he called me into his office to meet a tall =ane with what + thought was a tall story. Though friendly, this doctor had a military bearing and the charm of a diplomat which he could switch on or off at will, and when it was off he could be what he described as -very direct-. +n his seventies, though with the brisk manner and energy of a man twenty years younger, as + learned later he had a varied career which involved an amazing tale of how the sub8ect of testosterone treatment could arouse extreme passions in the minds of medical men. $orn in 6orth Butland in !";, he left home at the age of >, and even without a university education, became a successful entrepreneur, working in turn in %aris, *ondon and $erlin. &ven with money to burn he found his business career meaningless, and at the end of 5orld 5ar ++ he enrolled at the ?niversity medical school in )openhagen, getting his entry qualifications in three months rather than the usual year. He qualified five years later at the age of fifty, and began his medical career, which was to be as unusual and turbulent as his previous one in business. 7fter a variety of work in hospitals and the pharmaceutical industry, he decided he wanted to be a neurosurgeon and worked in 'weden for a time. 7s neurosurgical 8obs were few

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and far between, he took a locum 8ob with a private physician working in )openhagen, a decision which was to alter the course of the rest of his career. =octor Tvedegaard, whose name + shall abbreviate to =r. T for reasons soon to be explained, was already a controversial figure in =anish medicine because of his use of testosterone to treat severe arterial disease, particularly in the legs. He had studied the use of this hormone by ,erman =octors and seen amazing results even in the most severe cases with gangrene spreading from the toes to the rest of the leg especially in diabetic cases. The typical history given by his patients was one of painful cramps in the calves of the legs on walking, especially uphill on cold days, a condition known as intermittent claudication. 7s the blood supply became worse this gradually progressed to more continuous pain even at rest, and in bed at night, so that the patient would have to hang his leg out of bed to ease the intense discomfort. &ventually the limb would stay cold and blue most of the time, and an otherwise trivial in8ury to the foot would turn into an infection leading to gangrene of one or more toes. 7ccording to conventional practice at the time, these would then have to be amputated, and the surgeons would start on what often turned out to be a series of amputations, nibbling their way up one or both legs to above the knee. Testosterone in8ections, often in considerably higher doses than generally prescribed, seemed to have halted or in some cases even reversed the otherwise inexorable process at almost any stage. 5alking distances would be prolonged because the cramps in the calves would come on later and later, and even disappear, leaving a very happy wanderer. 6ight cramps would also go, which greatly improved the quality of sleep. )old, blue painful feet and legs would become pink and comfortable as the circulation mysteriously improved. &ven gangrene would heal without surgical intervention, much to the relief and delight of the patient/s and their relatives. Though this did not necessarily prolong their lives indefinitely, it did give them a much better quality of life and could prevent them becoming crippled by their circulatory problems. Many was the patient who went happier to their graves with two whole legs rather than one or none as a result of this testosterone treatment. 6ow this was very strange, and at the time inexplicable. However, even more curious was that instead of other doctors becoming interested in this treatment, investigating it further in an open.minded spirit of scientific enquiry, and perhaps even trying it on some of their more severe cases, who had nothing to loose except their legs, the reverse occurred. $ecause testosterone treatment did not fit the medical orthodoxy of the time, was not recognised in the groves of academia, and was a dirty foreign product originating in still deeply detested ,ermany of all places, =anish doctors closed ranks and minds against it. +t seemed that the rigid, doctrinal, ,alenic attitude had once again triumphed over the investigative, clinical, Hippocratic one. Though burning at the stake, other than intellectually, had rather gone out of fashion, doctors had other ways of dealing with troublesome medical heretics. 'uppressing their ideas by turning down their papers for medical meetings and publications is a good start. =r. T wrote three papers for =anish medical 8ournals, but they were re8ected. +f the theories are not published or discussed they cant be any good can they< This is the cold.shoulder, ignore them and they/ll go away attitude which often works, but not in this case. =r. T was often outspoken and critical of his colleagues attitude and made many enemies among them. More drastic action was needed and an opportunity for discrediting =r.

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Tvedegaard presented itself and was eagerly seized. +n =enmark at that time the law relating to medicines said that conditions could be only be treated with the drugs officially recognised as being effective in those disorders. $ecause of prevailing medical opinion, not only in =enmark but in most other countries as well, testosterone was not on the list of drugs to be used for circulatory problems. &ven if an army of a thousand people whose limbs had been saved marched up and down outside the =anish %arliament for a week, the law was the law, and medical opinion could not be moved to change it for sweet reason/s sake. 5orse still, patients could have some of the costs of certain -vital medicines- refunded provided the condition for which they were given were on the authorised list, and the prescriptions were written on the appropriate red forms. =r. T/s deeply held view was that testosterone was a literally life.saving -vital medicine- and because it came mainly from the testes, found a category of -genital insufficiency- which he thought qualified its use in the cases he saw. ?nfortunately this came to the notice of the =anish Health 'ervice officials who reacted in a surprisingly dramatic fashion one day in 7ugust !#I. (ather than take the case up through the usual medical disciplinary channels, they sent the 'tate %olice round the same day to officially charge =r. T and =r. Moller that because testosterone was not a -Jital Medicine- they were betraying the ,overnment for money. This rapidly escalated into a very public -cause celebre- with many court hearings, and questions were asked in the =anish %arliament. =r. T/s health soon deteriorated under the strain, so =r. Moller who was made of sterner stuff as you may have gathered by now, was left holding the testosterone baby. ?ndeterred by rulings against them in the courts, he mobilised public opinion in their favour. He did a detailed study of the literature and went to ,ermany to discuss the use of testosterone with the leading endocrinologists of the day, who were very supportive of these ideas. He then organised a public meeting of over fifteen hundred patients and relatives to raise funds for the fight. He lined up doctors from the health authority in the front row, deluged them with this new scientific evidence and then said -contradict me if you can-. They couldn/t, and left the hall in a state of confusion and acute embarrassment. The fight then got very dirty, and the police tried to seize all the patients case notes and deprive the defendants of their evidence. =r. Moller took the case notes home and piled them in the fireplace, telling his wife to set fire to them if the police called while he was out. The prosecution even made up stories from patients about they way they had been treated, who when they found out totally denied them. 4ortunately, they had many grateful and influential patients who kept up the legal battle on his behalf as literally their lives and limbs depended on it. &ventually a Minister of Bustice who was on the 'tate Medical &thics )ommittee, and had a close relative who was greatly helped by =r. Moller/s treatment, got the court/s decision reversed and the case called off after a battle which had lasted two years. 6ot only that, but the =irector of the =anish Health 7uthority, who had been one of =r. Moller/s fiercest opponents, saw the effects of the treatment on his family and friends, and changed to the extent that he became =irector of *$9, the organisation which was set up to promote the use of testosterone. The facts in this amazing case are documented in a book called -The Tvedegaard.Moller Trial3 7 4ight 7gainst +n8ustice- written a year later by another =anish doctor who had supported their cause.

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Though the medical establishment in =enmark generally remained hostile to the -=r. Tvedegaard Treatment-, which they used to tell their students was -Hormonal Humbug-, =r. Mollers practice flourished. He used to see fifty or more patients a day, who sometimes had to queue in the street outside his clinic in the fashionable 'tore 9ongensgade 0,reat 9ing 'treet2. 7s is traditional with native prophets, he began to receive much more recognition from the many distinguished doctors from 7merica, $ritain and all over &urope who came to visit his clinic than he did from those in =enmark who seldom came to call except when they wanted research funds from his rapidly growing charitable foundations. 6ot unnaturally these experiences left =r. Moller feeling somewhat paranoid, and it became his mission for the rest of his life to hammer home the message of the effectiveness and safety of testosterone. To this end he established the -&uropean Crganisation for the )ontrol of )irculatory =iseases- or &C))=, at a meeting of the &uropean %arliament in 'trasbourg in !I>, and enlisted many prominent politicians as well as doctors in his fight against what he called -The international enemy- of these disorders. 4rom !II onwards + made many visits to his clinic in )openhagen and saw for myself the dramatic benefits of testosterone treatment to the circulation, especially in the legs. + came to realise how testosterone had its effects, and helped =r. Moller to edit the books he was writing into acceptable &nglish. 7lso + went with him as he charged round &urope in his capacity of %resident of the &C))= holding meetings in *ondon, *uxembourg, 'trasbourg, $onn, $erlin and Munich. 5e visited many eminent authorities throughout &urope, and he achieved a great deal of scientific support for his ideas. +t was difficult to keep up with him even when he entered his eighties, and it soon became apparent that he certainly took his own medicine, which was as effective for him as it was his patients. 5hen he finally died in !E!, active to the last, he left thriving national and international organisations which are carrying on his work under the direction of his able young successor, =r. Michael Hansen. This seems a fitting guarantee that =r. Bens Moller/s heroic work in the service of testosterone will continue to bear fruit. This brings the testosterone story almost up to the present day. My own experiences in trying to prove the existence of the -Male Menopause- have closely mirrored those of many of the characters featured in this story, particularly %aul de 9ruif, =r Tiberius (eiter and =r Bens Moller. 7ttempts to debate the condition and its treatment with other doctors, especially those in related specialities such as endocrinology and urology, have met more with what could best be described as blatantly illogical denial. This has been laced with emotion and rhetoric far exceeding the spirit of detached scientific debate. +nterestingly, the broad minded family doctors with whom + have had the opportunity of discussing the sub8ect individually, and in teaching seminars have been much more interested and open: minded in their responses, than the specialists. +t seems that history is likely to repeat itself, as it often does, and that Testosterone (eplacement Therapy for men will arrive by the same route as Cestrogen (eplacement Therapy for women in treating and preventing the miseries of the menopause. +t was the enthusiasm of the women themselves experiencing the benefits of the treatment as received from the few medical pioneers first brave enough to prescribe it, which gathered converts to the cause. 7fter several years of intense opposition, and predictions of doom and disaster from the ma8ority of gynaecologists, doctors were carried kicking and screaming into the field. The situation has now changed to the point where the ma8ority are in favour, and a few have become evangelical about, while still remaining generally hostile

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to the idea of providing similar treatment to men. 7 recent poll in a ma8or $ritish national newspaper established that !IF of its readers believed that the male menopause was a fact and should be treated. However, in the same month at a meeting of urological specialists at 't. $artholomew/s Hospital in *ondon, only one third agreed the condition existed, and even fewer considered treatment might be safe or effective. *et/s look at the experiences of some of the thousand or so patients + have seen over the last twenty years who have experienced symptoms they put down to the male menopause so that you can better make up your own mind on whether this is a fictitious condition, or one which is real and should be treated.

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Chapter Two : The Male Menopause or Andropause. 5hat/s in a name< 5ell, in the case of the Male Menopause, a lot. +t is probably one of the main reasons why the condition has failed to achieve the recognition it deserves. +t is the 8oke disorder that is no 8oke. 5hen any middle:aged male character in a sit:com behaves in an unexpected or seemingly irrational fashion, it is usually wrongly attributed to the Male Menopause. 4or the sake of both clarity, brevity and to ease acceptance by both the general public and the medical establishment, who already recognise the name if not the disorder, from now on + will mainly use the term -7ndropause- when referring to this condition in men, and -Menopause- when referring to the equivalent condition in women. 7fter all, the term -menopause- was introduced by 4rench doctors in the EI"-s, combining two ,reek words menses 0periods2 and pausis 0stop2, to indicate the time in a woman/s life when the monthly periods stop, 8ust as the word -menarche" combining menses 0periods2 and arkhe 0start2, means their beginning. hen applied to men, the term is therefore both inaccurate and somewhat derogatory. Cne of the aims of this book is to change that image and make the whole sub8ect easier for men to talk about and think about. -7ndropause- however combines two ,reek words andro 0male2 and pausis 0stop2, and means when masculinity ceases, which is a much better and more accurate description of the condition. +t is doubly appropriate because the root of the problem is an inadequate supply of androgens, especially testosterone, the hormones which provide manliness, andro 0male2 gen 0give2, and which can be used as an effective remedy for the problem when it occurs. 5omen are used to visiting their gynaecologist : gynaeco 0female2 :logist(scientist2, to sort out their problems, especially after the menopause with the use of Hormone (eplacement Therapy, which appropriately enough often restarts their periods. + suggest that men should be equally willing to consult their -7ndrologists-, who are beginning to have an expanding role outside that of male fertility, and are now in a good situation to advise on Testosterone (eplacement Therapy to treat the andropause. *et/s start with a brief sketch of the condition, how it begins and how we can recognise it is happening to us or those around us. +t/s often insidious onset can be at any time from the age of thirty onwards, though typically it is in the fifties. Cne of the reasons it/s often missed is that this equivalent of the menopause in the female is usually more gradual in onset but more severe in its long:term consequences. +t is a crisis of vitality 8ust as much as virility, even though the most obvious sign of the crisis is loss both of interest in sex and of erectile power. This change is surprisingly often overlooked or ignored, either because the man is so pressurised 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. $esides lack of sex drive, there is often loss of drive in professional or business life, so that the leader becomes the led, the tiger becomes the sheep. There is also often fatigue, lethargy, exhaustion, and depression with a sense of hopelessness and helplessness. 7ll too often men change their 8obs or their women :

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anything to ease the malaise they feel, usually with little relief, and sometimes things are made much worse because of the additional stress these changes bring. %hysically there is often stiffness and pain in the muscles and 8oints, or symptoms of gout, and a rapidly deteriorating level of fitness. There may also be signs of accelerated ageing of the heart and circulation. Typical of the andropause case history is that of Bohn3 -I'm just fifty now and I've been very successful in my family's retail business. Because of the recession it is harder to make a living than it was, and work is stressful and not much fun. y health has always been pretty good , e!cept for one attack of prostatitis associated with a urinary infection " years ago. #his non$specific urethritis as they called it had me up peeing five to ten times a night till it was treated with a four month long course of antibiotics, but it seemed to clear up completely after that. %ince that time however, though I love my wife and we have a good life together, with four delightful children, my libido has just faded away to nothing compared to the healthy se!ual appetite I've had for the rest of our twenty$five years of happy married life. I've never been one to have affairs, but now I'm not even interested in "window$shopping". I just feel cocooned and detached from even the prettiest girls, as though I'm just not in the same world as them& y erections aren't what they were either, and I'm having more and more failures in that department, especially when I'm tired or had a few drinks. orning erections are few and far between, and my wife isn't really turned on at that time in the morning. %e! between us is down from two to three times a week to once a month now, especially as I don't like to go into battle if I'm not sure my guns will fire. In some ways I don't miss se! all that much, though my wife does, just as you don't miss food if your appetite has gone. (orst still, I completely lost my drive and ambition over the last five years. (hen I get up in the morning, I feel energyless and completely lethargic, and instead of looking forward to the day, just wonder what time I can get back to bed. I'm really envious of older people with more energy than me. I'm not giving much time to my wife or the children, which really makes me feel guilty about them, especially as I'm usually as scratchy as a bear with a sore head, and that's not like me. #here have been physical changes in me too. y feet and ankles, knees and back are really stiff in the mornings, which makes me feel old and decrepit, and even less like getting out of bed. )ften the bed is wringing wet in the mornings because I sweat a lot more than I use to, and sometimes this is so bad that my wife has to change the sheets. I find that I flush easily when the room is warm, but that my feet and hands are cold most of the time. (hat with that, the night sweats and the lack of se!, my wife is threatening me with single beds& I don't go to my doctor often, but a year or so ago I went to see him feeling thoroughly depressed and convinced that something must be wrong with me. *e's a good fellow and heard me out sympathetically. But when I said that I thought that my symptoms were just like my wife had had before she went on *ormone +eplacement #herapy, and wasn't there something similar he could give me, he nearly threw me out of the surgery& I was told to forget it and given a choice of antidepressants or marriage guidance counselling, or both, but I didn't feel either of these were right for me.

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,ust as I was getting really desperate, my wife saw an article in a maga-ine about the male menopause being a real condition that could be positively identified and safely treated with testosterone. %he said the case described was an e!act picture of me. I went through the appropriate tests and safety checks, and started on testosterone capsules by mouth. (ithin two weeks the symptoms had improved, and within a month they had gone. y marriage, my family life and my business have all benefited, I feel like I did ten years ago. y wife and I would like to know why did I have to have all those wasted unhappy years when my hormone deficiency could have been detected and put right so easily. It seems a reasonable .uestion to ask". + spend a lot of time going over these case histories the first time men come to my consulting room, and they all tend to be variations on the same theme. 6o one symptom is essential, but the picture is consistent enough to usually be able to make the diagnosis even before examining the patient or doing the detailed blood tests. $ased on the histories of over a thousand men who have been to see me over the past ten years, and a detailed analysis of the symptoms shown by the first four hundred of these, + have built up an -identikit picture- of the andropausal male. 'ee if it fits anyone you know. The main complaints can be described as being either mental, such as fatigue, depression, irritability and reduced libido, or physical such as ageing, aches and pains, sweating and flushing, and failing sexual performance. Gou can see as we go through this list how close is the comparison with the menopause in women. *ets consider these one by one in more detail so that you can recognise the andropause when you see it coming. 7bove all, remember it is usually treatable, and as it says on page one of =ouglas 7dams -Hitch:hikers ,uide to the ,alaxy- : =onLt %anicA

#AT$%&E 4atigue is the main expression of the loss of overall vitality which characterises the andropause, and in my first series of ;"" men it was present in over eighty percent of cases. +t/s as though the man/s get up and go has got up and gone. This is hardly suprising when you look at this as a hormone deficient state. 7fter all, the original meaning of the ,reek word for these -chemical messengers- of the body 0hormon2 means -setting in motion-. The patients describe this drop in energy levels, and its return on treatment very graphically, as in $ruce/s case. "/ifty was a turning point for me. #ill then I had been pretty active as an advertising e!ecutive, but at that time I just seemed to grind to halt. I felt tired at work, couldn't concentrate, lost my competitive edge and found my job more and more difficult. 0artly this was because I was getting more and more short tempered, and I started drinking fairly heavily in the evenings. 1t home, I wasn't e!actly a bundle of fun either, falling asleep on the sofa every evening. #hough everyone told me I needed a good holiday, I was so tired and negative, the interest and energy needed to organise one just didn't seem to be there. y libido had dropped to

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the point where even a "%aturday 2ight %pecial" was usually too much trouble, especially as my erections let me down increasingly often. #his was all very depressing, especially when a close friend about my age suddenly died of a heart attack. 1fter having had these symptoms for four years, my marriage was falling apart, and I seemed likely to lose my job. #hen I read an article in a maga-ine and felt the writer was writing about me, he described my symptoms so e!actly. It all seemed so unfair as there wasn't anything in my medical history that I felt was relevant, and my family doctor had told me that I had nothing but a touch of depression. *owever the tests clearly showed a low "/ree #estosterone", and I started straight away on capsules to boost levels of the hormone.. #he results were dramatic. (ithin a month I felt as though the treatment had lifted a veil over my life, and I felt generally more vibrant and more virile. 1fter three months my performance at work was back up to speed again, and to managerial jargon I was more "0ro$active". 1lso, both at home and at work I was rated " r 2ice 3uy", my se! life has improved, and my wife is delighted with the results of treatment. #hings are going well across the board, and feeling more positive about myself and life in general, I have got on top of the alcohol problem, just having a moderate amount of wine at home over the weekend, and none during the week." )onventional female wisdom has it that it is not the man in your life that matters, so much as the life in your man. This refers to energy and drive of all sorts, and not 8ust sexual activity, though they often seem to go hand in hand. This seems to be why women are attracted to energetic men of all shapes, size and ages, the shakers and stirrers of life. 4rom 7ttila the Hun to Morba the ,reek women are drawn to them. Testosterone drive is probably the most important force underlying both mental and physical energy. The ability to reproduce by sexual activity is the essential biological function of all animals, the biological imperative, subordinate only to the needs of staying alive long enough to do it and ensure survival of the offspring. ?rged on by some of the stress hormones such as noradrenaline, which as + shall describe later is what gives us a -buzz- in certain situations rather than the more publicised adrenaline surge, testosterone drives men on to fame or fortune, to daring do or die for a mate. +n the animal kingdom, its what makes rutting stags lock horns in mortal combat for hours on end, until the vanquished male limps off to the forest to lick his wounds or die, while the victor on a -testosterone high- triumphantly services the herd-. &lephant seal bulls wrestle, roar and bite each other, often inflicting serious damage, before the winner takes all, and the loser slides back into the sea to go fishing and recover. Many and varied are the ritual tests of manhood. 4ull scale battles throughout history, individual combat for love, honour, and to decide who would be the dominant male, chief or king, are as old as mankind itself. +n ,ermany ritual duelling with swords, inflicting facial scarring, was fashionable before the second world war. +n 'pain, the young men still show their bravery and impress the girls, by running in front of the bulls in the streets of %amplona. Triumphant racing:drivers world:wide en8oy the heady symbolism of spraying champagne over adoring crowds. +n 7merica depending on the amount of money available, which is a form of financial testosterone, you arm wrestle, play -chicken- by riding motor:cycles at other young men

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down the middle of the road, or drive your 4errari Testarossa as fast and as dangerously as you can. &ither way hormones have the last word, often literally. This then is the hormonal power source that drives men on for a large part of their lives, and along with intelligence, is often the deciding factor in deciding their social and sexual history. +t can be thought of as the -'uccess Hormone-. 5hen a man is winning life/s battle/s it is high, and when he/s losing it falls, and his sexual activity usually follows these highs and lows. 5hen it gives out on them because of age or any of the many other factors affecting testosterone production or activity described later on, men feel their energy levels drop, and often wonder -5ho or what pulled the plug<-. 7s their drive in both bedroom and boardroom fades, they go onto -emergency power-, and cut down on all non:essential activity. 7t home, sex goes out of the window and social activities, as well as gardening and feathering the family nest dwindle and die away. 7ll this sets up enormous tensions and resentments within the entire family. The worsening cycle of failures and recrimination tends to disturb sleep, and is made worse by the -(ide of the night:time naggers-, with the wife keeping the husband awake by reciting his escalating list of errors of omission and commission. 7fter a bad night, the man goes to work feeling -lower than a snake/s belly-, drained of energy and enthusiasm, and tries to get -lift:off- by drinking endless cups of coffee. These may 8ust make him more nervous, twitchy and raise his anxiety levels even higher. His attention span and ability to concentrate also deteriorate, as does his memory which are similar to the problems experienced by women at the menopause, and may have a similar hormonal basis. 7part from reducing his ability to think up new ideas or put them into action, his ability to sell himself and his pro8ects slumps. )ustomers and competitors alike have an unerring ability to spot when a man is down and out of testosterone, even when he is trying his hardest to put on a brave face. $ody language can give clues as to whether a person is in a shrinking -little:C- mood, slouching in with an apologetic, round:shouldered, crouching look, or striding in, standing tall, shoulders back, arms outstretched, looking and feeling great, as an expansive, confident -big:N-. The voice may be high pitched and wavering and anxious, or low:pitched and steady, like , as 7braham *incoln put it, someone speaking softly and carrying a big stick. +t may also have something to do with -pheromones-, those airborne hormone/s derived from the sex hormones, and given off by the skin all over the body, but particularly the genitals and armpits. These can either send out the sweet smell of success or the sour scent of failure. *ike hounds chasing the nervous intruder, people seem to instinctively know which mode you are in. Cne famous captain of industry in $ritain, 'ir Bohn Harvey Bones when tackled at a meeting in *ondon by an 7merican lady reporter researching the sub8ect of the male menopause, who prodded him in the mid:rife with her pocket tape recorder to goad him into activity, urbanely replied that he felt sure there was such a condition. He said he had often seen previously dynamic, hard:driving, successful managers -go off the boil- as he put it, sometimes with disastrous consequences for them or their organisations.

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+ndeed he felt had been through one such -fallow period- in his own career about the age of fifty, but had fortunately come through it spontaneously. He went on to suggest that the careers of men who ran into such problems could often be saved, with great benefits to the companies for which they worked, if ways could be found to help them through such difficult times. 7ll too often however, in a period of recession, the opportunity is taken to fire the andropausal man who performance is dropping without inquiring, or him admitting, the reason why. To make the situation worse, this frequently happens at the same time that the man is -fired- from the marriage bed for under:achieving at home as well. To continue the analogy with going off the boil, many patients describe -running out of steam-. This is the steam that drives them at home and at work, that makes the carousel of their lives go round, and that pumps up their penis to give them erections. +t is indeed the essence of both their vitality and virility, the link being testosterone.

EPRESS$ON Jariously described by the patients as negative or low mood, depression is one of the commonest features of the andropause, and in my first series was present in seventy percent of cases. Though only rated as mild to moderate on one of the standard psychiatric rating scales used in this study, it was one of the most difficult of the symptoms for the men and their families to live with. 7fter all, together with life and liberty, the pursuit of happiness is written into the 7merican constitution, and most of the patients didn/t feel up to pursuing anything, especially happiness. Typical of their stories is that of )olinH "4ight years ago the bottom dropped out of the stock market and my life at the same time. /irst my investments went, then my beautiful country home and finally my job as a promoter. #here were plenty of reasons to be depressed, but I felt sure there was something more than just a natural reaction to all these problems. y brain felt full of what I can only describe as to!ic sludge. I couldn't focus on anything and was very irritable, as well as being tired and weepy. 3oing along with my doctors view that it was just plain depression, I went to see a psychiatrist who tried polypharmacy with every antidepressant under the sun, including 0ro-ac, but without success. 1s a hopeless case, I was threatened with "4lectro$5onvulsive #herapy", but protested and was let off with psychotherapy, which got me into tears and then anger in a big way. ,ust when I'd given up hope there was an article in a maga-ine which talking about hormonally based depression in the " ale enopause". 1 light went on in my head, when I read how the combination of the vasectomy twenty years ago when I was just thirty, and the large amounts of alcohol taken to blunt the pain of my financial ruin, might have made my depression very much longer and more severe by affecting my testosterone levels. y doctor was fortunately open$minded enough to encourage me to take the tests, and they showed twice the usual level of a binding protein in the blood which as he e!plained it was "tying up" my testosterone so very little of it was active. )n the hormone treatment,

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the depression gradually lifted over three or four months. %i! months later, my energy and drive have doubled, and I'm employable again now. I still occasionally suffer bouts of depression, but they are much shallower an .uicker to recede. I'm back on an even keel again much more rapidly now, and looking forward to life being plain sailing again after the terrible storm which nearly sank me." 'ometimes it is difficult to tell which came first, the depression or the other symptoms since if you are severely depressed, tiredness and loss of libido and potency can result. However, only in a very small proportion of cases was the depression severe enough to account for the other symptoms. Most of these cases had already been treated with antidepressants without improvement, and some had even got worse. This is because they can make feelings of tiredness worse, and the ma8ority of these compounds seem to interfere with erections, though fortunately, there are exceptions as described later. %ersonally, + don/t usually use any antidepressants until testosterone treatment has been tried on its own for three to six months, unless the depression is exceptionally severe and life, 8ob or marriage threatening. This is because my original ratings showed, and my consistent experience is, that T(T on its own gently but firmly lifts the depression, often completely, at the same time as it relieves the other andropausal symptoms. Together with fatigue, the depression can also make a man less optimistic at work and less likely to suggest, start or carry through new pro8ects at work. 5hen selling himself, which is supposed to be one of the most important factors in selling anything, he is less cheerful, less confident and less convincing. &specially as visions of doom and gloom tend to be self: fulfilling prophesies, this is not a recipe for success. -'mile while you/re making it : 'mile while you/re taking it- run/s the song in the film -Ch *ucky Man-, and smiles are hard to come by when a man is feeling emotionally down and out. 7t home, depression can not only cast a black cloud over the whole house, but can narrow the social horizons. This can continue to the point where he never goes out to visit family or friends, who soon get the message that he doesn/t want to see them either at home or away. This worsens the marriage already weakened by his inactivity round the house, so that he is usually to be found slumped in front of the television in a torpid heap. This escalates still further because of his lack of libido and increasingly frequent erectile failures. 7ll this causes the social support inside and outside the family to fall away. However, especially when revitalised by H(T themselves, partners can be amazingly supportive for many years. 6ervousness, anxiety about everything and everybody, and lack of self:confidence often go hand in hand with the depression, as was recognised in studies of the -Male )limacteric- as it was then called, fifty years ago. This can also be accompanied by sleep problems, both in getting off to sleep because of intrusive thoughts and worries, and in the early waking at four or five in the morning characteristic of depression. ?nfortunately sleeping pills may 8ust worsen the tiredness during the day, and contribute to erectile problems at night. Though the man may after years of depression reach the point where he feels tired of life, fortunately it is not usually sufficiently severe to cause him to commit suicide, and he seems to lack even energy enough to carry it through.

$RR$TA'$($T)

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Cne of the most distressing symptoms of the andropause, both for the men suffering from it and their families is irritability. This if often entirely unusual for the person concerned ,or it can be seen as an even shorter fuse in somebody with an already low flash point. +t may be about trivial issues, as much if not more than important ones. The man may well be aware that he is being unreasonable and be ashamed of it , but still unable to do anything about it. 7t work, the firm starts to recruit nothing but idiots, trains them to work against him, and there are no dirty tricks they wont try 8ust to irritate him. 7t home the whole family deliberately tries to annoy him and succeeds brilliantlyA ,oading the bear with the sore head becomes their chief delight. They seem to do all the wrong things at all the wrong times in all the wrong ways. 5ithout having to try he gets into endless arguments with them, and ends up infuriated, with all his patience, like the rest of him, utterly exhausted. $ernard describes this well3 "I suppose it all began when I contracted mumps at the age of 67. #his was one of the most serious illnesses I had e!perienced. y testicles became swollen, so much so I could hardly walk. I had to wear a support just to go to the toilet. 4very footstep was agony. I also lost a couple of days, I was delirious and remember very little. #hree to four weeks later I was almost back to normal although one testicle was smaller than the other. 2othing seemed to have been adversely effected and, whilst not ravenous, my se!ual appetite seemed normal. %everal years later, around the age of forty I seemed to be e!periencing a number of things. /irst and foremost I was irritable, irrationally moody and intolerant of other people. #he supermarket checkout was constructed just to annoy me. #he shop assistant was an idiot and out to obstruct me. #he other car driver was a moron and should never have been given a license. #hey were all trying to cut me up, hinder me and generally make life difficult for me. I invented both trolley and +oad +age & )n top of this my se!ual appetite was -ero, and erections often failed me. y wife by this time was convinced I was having an affair. It all added up, no se! and an attitude to boot& /inally my wife gave me the ultimatum, see a doctor or we split. 1 week later I had an interview and a blood test which confirmed a hormone deficiency, and that treatment would be appropriate. I was prescribed a course of testosterone capsules which I started immediately. #en days later I was a changed man. I felt a tremendous burden had been taken from me. I felt energetic, I became more assertive and I had regained my se!ual appetite. y job became easier, I made decisions more easily and I had the energy and determination to see the job through. I felt more optimistic and no longer had this feeling of frailty or vulnerability. y erection was much stronger and didn't fail me at the crucial moment. y attitude change, I returned to being the laid$back, happy and contented person I had been. 2o more anger, no more moods. I could now enjoy life instead of feeling angry as it passed me by. %i! years later I'm still on the treatment. y job hasn't changed very much but I can handle it much more easily and confidently. I am more successful at doing what is needed. I've gained a lot of self confidence and I'm not at all susceptible to bouts of depression. y family life is very much happier and the relationship between myself and my stepson has moved much further forward. y wife and I have regained our loving relationship and whilst the opportunities haven't got better, the outcome is much more satisfactory to us both.

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Time and again stories like this completely go against the idea of testosterone being the hormone responsible for male aggression and violent behaviour. ?sually what is often described all too literally as -impotent rage- is associated with low levels of testosterone activity. 5hen they are restored to normal by treatment the man feels more confident and assertive, though this doesn/t seem to overshoot into aggression. 7t home, they may have got used to having a human doormat around, and the marked change may not always be welcome as the new man puts his foot down with a firm hand. RE &CE ($'$ O

The word libido means sex drive, and is the same word in *atin where it was taken to mean desire or lust. Cne thing that men and women have in common is that their level of libido at any one time is governed by both the higher centres in the brain, conditioned by life experience and social factors, and by hormonal factors, principally testosterone. This is surprising, since men normally have about twenty times the testosterone level of women, but though men may set the ball rolling more often, most couples end up with a fair measure of agreement about a happy level of sexual activity between them. &xtreme exceptions such as when a man is a multiple rapist or a misogynist, or a woman a nymphomaniac or totally frigid throughout her life, are nearly always due to psychological causes rather than hormonal ones. However, because the baseline level is so much lower in women, relatively small variations may cause big swings in libido. 4or example, at the middle of the menstrual cycle, when the woman is ovulating and at her most fertile, there is a surge in her testosterone level to put her in the mood for sex. 5omen who are more assertive, and take up more traditionally masculine roles in society such as solicitors or business bosses, have been found to have slightly higher testosterone levels and frequently are sexually more active. +n the ?'7 complaints of sexual harassment of male employees by their female bosses are becoming relatively commonplace, which was unheard of a few years ago. Though the factors affecting libido are complex, and are the sub8ect of a series of books -The disorders of sexual desire- by the 7merican sexologist, =r. Helen 'inger )aplan, many women with low libido, particularly around the time of the menopause, can be helped by carefully administered low dosage testosterone. +f the dose is excessive, not only may masculinising effects such as increased facial hair and enlargement of the clitoris occur, but the libido may become excessive. The 7ustralian feminist ,ermane ,reer described on a television programme how she was put in an embarrassing situation when a doctor gave her too much of a long acting testosterone compound, and she suddenly found out -what a rapist felt like-. +n the 'tates, a group of women who call themselves -The Third 'ex- deliberately take high doses of testosterone. =espite having to shave hair all over their body frequently, and getting shrinkage of their breasts, they reckon that the overall buzz they get from it, and the almost insatiable sexual appetite that goes with clitoral enlargement, makes it worth the chemical sex change. 5ith the andropause, one of the commonest complaints, present in eighty per cent of cases, is a reduction in libido. This usually comes on gradually over a period of months or years, as the level of active testosterone wanes. +f the onset is sudden, or related to a particular event such as illness, the arrival of the first child in the family or finding out that the wife or

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girl:friend is having an affair, this suggests a physical or emotional cause rather than a hormonal change. However in extreme cases one can lead to the other. The fall in libido affects every aspect of a man/s sex life, reducing the frequency of sexual thoughts, fantasies and even dreams. The number of times he feels in the mood for sex goes down, and the partner may be convinced, usually entirely wrongly, that he has gone right off her, is having an affair, or both. This can often cause problems in the relationship, which further saps the libido, because it can be difficult to be sexually turned on by an angry partner. +n nearly half the cases, the woman/s libido 8oints the downward spiralling of desire, so that neither party may think it worthwhile to seek help, resulting in what could be described as a -dead heat-. This is when the most beautiful, attractive or available of women fails to raise the slightest sexual interest. +n the most extreme cases even the head:turning reflex that causes the male gaze to briefly lock onto any remotely interesting female, can disappear. The laws of the -)hemistry of )harisma- also dictate that as a man/s desire decreases, so generally does his desirability. The sexual chemistry that at every level drives what 6oel )oward called that -sly biological urge-, is no longer working and the song of -*et/s do itbecomes -+ won/t dance : =on/t ask me-. RE &CE POTENC)

(educed potency, in terms of obtaining or maintaining an erection is one of the most distressing symptoms of the andropause in about eighty percent of cases. The many associations of the word -potent-, from the same *atin word meaning to have power, strength, ability or authority, or to be able to achieve the sexual penetration of a woman and to father children, seem to contain the essence of masculinity. 5hen it is even temporarily lacking, usually the person feels much less of a man in all areas of his life and is often more ashamed of this than any other symptom. Bust using the modern medical parlance of -erectile dysfunction- doesn/t help a lot when the blunt fact of the matter is that in all senses of the term you can/t get it up or keep it up, and you feel down about it. 7fter all, when you talk about a potentate, you mean a ruler or a monarch who leads any group or endeavour, and has the power and position to rule over others. +n many &astern countries it is traditionally accepted that a ruler can have many wives or mistresses to demonstrate his position of dominance. 5hen however his sexual vigour falls, and it becomes common knowledge that it has, his fall from power often occurs soon afterwards. The onset of erection problems is usually gradual, and often starts insidiously with fewer early morning spontaneous erections, or -Morning ,lories- as some people call them. 7s the comedian (obin 5illiams, who himself looks like a regular -High:T ,uy- quipped in a recent stage show televised at the Metropolitan opera House in 6ew Gork, the penis is usually up and on parade five minutes before you are in the mornings. +ndeed the penis can be compared to a stand:up comedian who if he has a few bad shows, and worse still gets booed by the audience, gets nervous and doesn/t want to stand up and do his act. This is appropriately called performance anxiety. Though usually brief, these spontaneous morning erections are an important sign that the erection mechanism is working properly and has been primed by the testosterone surge which normally occurs around wake:up time. This is probably due to the overall decrease in free testosterone which + have shown in the andropause and by the reduction in its daily

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variation with increasing age reported by other researchers. This view is supported by the fact that early morning erections are one of the earliest signs of restoration of potency by testosterone, and this often happens within a week or two of starting treatment. 7nother way in which erection problems begin is with occasional failures when tired, stressed or having had a few drinks, and then they become more regular events, or non:events depending on which way you look at it. The progress of the problem is frequently erratic, and depends to some extent on the attitude of the partner. +f she is relaxed about it, encouraging and supportive, and willing to help by trying massage, oral sex or different positions, the problem may not progress or may even be temporary. +f however she is uptight, dismissive and hypercritical of his performance as a lover, performance anxiety soon sets in and with several such -put down/s- he is likely to stop trying all together. 6othing is more destructive of the male ego than criticism of either his ability to drive a car or maintain a satisfactory erection. +t is made even worse if news of his short:comings is leaked to her friends or his. This of course is why men are reluctant to own up to having this problem, even when talking to their best friend or their doctor. +t is a ma8or reason why men try to laugh off the idea of there being any such condition as the Male Menopause because the idea is too threatening to their self:image as potent males. 7s we shall see later when the causes and treatment of erection problems are discussed, this is a view which is very much in need of change, especially as there are a whole range of methods, including testosterone treatment in particular, which can relieve this particularly distressing symptom of the andropause. $ecause the erection starts more slowly, is more difficult to maintain and often lasts a shorter time, sexual activity may often be rushed and is less satisfying for the woman who is often slower to become aroused and to reach orgasm especially when they themselves are post:menopausal. 7nxiety makes the situation worse and can lead to premature e8aculation, complained of by a quarter of my patients, as they hurried to completion while they still had an erection. 7lternatively, because of the decreased sensitivity of the penis which seems to occur in low testosterone states, there may be delayed e8aculation, as was experienced by another quarter of my patients. 7nother factor contributing to this problem is the lack of tone and development in the pubococcygeal 0%)2 muscles around the urethra and base of the bladder. These contract, as do the corresponding %) muscles around a woman/s vagina, during orgasm. *ike other muscles in the body, with testosterone inactivity and lack of use, their contractions get weaker, and as the patients put it, the earth no longer moves for them or their partners. (educed penile size, particularly when erect, sometimes accompanies severe testosterone deficiency, and can also become a problem for both partners. Though it is often said that size doesn/t matter, most males are acutely aware of the usual size of their penis, both flaccid and erect, and get very upset if this area of their vital statistics is on the way down. (ecent research has finally caught up with common experience when considering factors affecting the woman/s views on penile size. Though in the >"/s Masters and Bohnson the 7merican sexologists tried to make out that a woman/s pleasure and orgasm was solely the function of the little bundle of erectile tissue and nerves called the clitoris, the man who can only deliver stimulation there is likely to be operating in an erroneous rather than erogenous zone.

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-Jaginal sensitivity is an anatomical reality- says Bohn %erry, a clinical sexologist and co: author of -The , 'pot-. 5hile there may not always be a distinct, raised , spot, the higher part of the front wall of the vagina, especially close to the urinary passage, the urethra, is richly endowed with nerves that play a ma8or part in helping a woman reach orgasm. %art of the secret of sexual satisfaction therefore is to have this , spot stimulated by the tip of the penis. This can be achieved by having the right size penis in the right sized vagina, or by varying the position to improve penetration. 7s well as reducing the firmness of pressure on both the clitoris and , spot, testosterone inactivity can shrink the penis to the point where partners who have been physically compatible in this area throughout a long mutually en8oyable sexual relationship gradually become incompatible, to the distress of both. Though to some extent it can be regarded as natural for the frequency and firmness of erections to reduce gradually with age, it is rapid acceleration of the process over a few months or years which should be thought of as abnormal and certainly worth investigation by a doctor specialising in this complicated field of general medicine, the 7ndrologist + described earlier. The causes of erectile problems are many and varied, and by the time the patient comes for treatment several overlapping factors are usually present at the same time. There may be narrowing of the arteries by which blood is pumped in to expand the penis. There may be too much blood leaking out of it though ageing veins, like a leaky cycle tyre. There may be poor nerve control as with sugar diabetes or as a result of the side effects of tranquillisers, anti: depressants or the drugs used to treat high blood pressure. &specially after the problem has been causing great distress to both partners, there are certainly likely to be relationship problems as well as the dreaded performance anxiety. 7 very broad approach is therefore needed to treating what may seem like a simple mechanical fault, and important though + believe such treatment is, it is not 8ust enough to throw testosterone at it and hope the problem will go away and stay away. To do the 8ob properly the whole man has to be screened and a range of treatments appropriate for that patient needs to be advised.

PREMAT&RE A%E$N% 5ith the increasing use of Hormone (eplacement Therapy for women, who are managing to feel and look far younger than their mothers did at the same age, men are also beginning to wonder whether there isn/t some hormonal treatment which would help them stay happier and healthier for longer. H&7(T To a great extent the andropause can be thought of as a form of premature but reversible hormonal ageing, and + believe that T(T offers great hope in preventing as well as treating many of the conditions associated with advancing years in the male. ,enerally you/re as young as your heart and brain, which largely depends on how good the circulation is to these two vital organs. 5hen H(T for women was first cautiously introduced over thirty years ago, doctors feared it might contribute to diseases of the blood vessels,

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and if a menopausal woman had even a family history of heart trouble, let alone cardiac disease herself, they said H(T was contraindicated, in other words it wasn/t for her. Much to their surprise, actual experience over thirty years has shown the reverse to be true. +n other words, they found half the number of heart attacks in women who took H(T than in women who didn/t. 5ith some reluctance, the doctors began to change their tack and said the treatment was positively indicated in women prone to heart disease. The situation is the same with testosterone. Cver the last fifty years, most doctors, including cardiologists, took the view that testosterone must be bad for the heart for two totally fallacious reasons. 4irstly, under the age of fifty, men get five times as many heart attacks as women in most western countries, though the women catch up soon after that age unless they are on H(T. 7ccording to this line of reasoning, therefore testosterone is bad for the circulation and oestrogen is good. 'econdly, because of the uniquely bad effects of the most commonly used preparation taken by mouth, methyl testosterone, and its abuse by athletes taking the wrong drugs, in the wrong doses for the wrong reasons, anabolic steroids had a very bad medical and lay press. + used to share these views myself until about twenty years ago when as described in the previous chapter + met the =anish physician, =r. Bens Moller, who totally changed my view of testosterone and lead me eventually to see it as a very important and beneficial hormone for preventing and treating heart and circulatory problems. +t was truly a case of seeing the light on the road to )openhagenA 'everal studies both from $ritain and 7merica have more recently shown lower levels of testosterone, and sometimes higher levels of oestrogens, in patients who later developed heart disease than in normal control sub8ects the same age. Cther studies have shown the benefits of anabolic steroids in treating a range of circulatory problems from ulcers on the feet to strokes in the brain. )+()?*7T+C6 4ortunately, the problems experienced by the typical andropausal patient are relatively mild, and limited to cold feet and hands, especially in the winter. 5hat confuses the issue still further however is that the smaller blood vessels also become less stable in their reactions to heat, cold, alcohol and other stimuli. Though less common than in menopausal women, men with this condition can experience attacks of a feeling of redness and warmth in the face, which may spread to the skin of their neck and face in warm surroundings or with alcohol. These -hot flushes- or -hot flashes- as they are called in the states, can be very marked, and are acutely embarrassing to the men who suffer them. +magine how a senior executive feels when he stands up to make his key presentation at a sales meeting, and starts by going beetroot red as though he was deeply ashamed of his pitch. This is made even worse by the tendency to sweat profusely so that the man looks both hot and bothered. Though less than a quarter of the men + originally studied had hot flushes, over half complained of increased sweating, especially at night. This could sometimes be severe so that not only the night clothes but the sheets as well may be drenched with sweat. 'ome of the men even felt they might have caught these symptoms off their menopausal partners. M?')*&' 76= $C6&'

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7nother common symptom of the andropause is a general feeling of deteriorating physical condition. This is partly due to the decrease in muscle bulk and strength which accompanies the reduced level of testosterone activity. 7lso there is often diffuse aches, pains and stiffness both in the back and many 8oints in the body, particularly in the hands, ankles and knees, causing the -4rankenstein 'yndrome- as the first few creaking steps are taken on rising first thing in the morning. This is remarkably similar to the 8oint symptoms experienced by many menopausal women, closely mimicking arthritis, and fortunately usually shows similar dramatic improvements on hormone treatment. Csteoporosis, the thinning and weakening of the bones which causes older people to lose height from shrinkage and even collapse of the vertebrae, the dowagers hump in women, is also a source of much pain, unhappiness and disability in men. Though generally not as common or severe it tends to come on later in life, in men of seventy onwards, and affects the spine where it causes back pain and stiffness especially in the neck, and in the hips, where it contributes to osteoarthritic degeneration, and sometimes fractures. These symptoms are made worse, and the osteoporotic process is probably accelerated, by the reduced size and strength of the muscles which accompanies the reduced activity of testosterone which occurs in the andropause. Testosterone and exercise are the two main factors controlling muscle mass and strength in the male, 8ust as together with calcium and protein supply, they have a important effect in maintaining bone mass and strength. This is why as well as the 8oint pain and stiffness, many andropausal men complain of a generally deterioration in their level of physical fitness. This is particularly noticeable if they are used to high levels of performance such as 8ogging or marathon running, when they find that their times for a given distance are going up and up. Those who like to work out in a gym notice that their exercise volume, the amount of work they can perform in a session, is decreasing, and the number of repetitions of exercises such as press:ups or sit:ups they can do goes down. They also find that their overall strength in terms of the weights they can lift goes right down. This, together with the decrease in muscle bulk that causes the pectoral muscles, biceps and thigh and buttock muscles to lose their hard:earned splendour, as well as the overall lack of drive and motivation, may even make the man give up exercise 8ust when he most needs it. +ts all very discouraging, and even the sexual athlete may start making excuses to avoid having to perform. H7+( 7nother area of male vanity affected by the andropause is the hair. Bust because a man has typical male pattern baldness and plenty of hair on his chest does not mean, as is frequently assumed and quoted even by doctors who should know better, that his testosterone activity is normal. $aldness in men is almost entirely hereditary, and even if a man/s hair is going to go, its going to happen whatever his testosterone level, unless he has been castrated before puberty. Though the amount of hair on the chest is also hereditary, it is also affected by lifelong testosterone levels, and sometimes if it is very much reduced, and the man only has to shave once or twice a week, it can indicate a life:long insufficiency of the hormone. 7lso, on testosterone treatment more hair may appear on the chest, back and pubic region which improves the man/s macho image of himself.

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However, the condition of the hair and scalp, and possibly its colour is affected by testosterone. +n the andropausal male the hair is often dull, dry and lifeless with a tendency to dandruff. The patient may say he is going grey very quickly, and its interesting that some notice a return of colour to their hair on testosterone treatment. 7 few have even been accused by friends and relations of using hair colour restorer, and many notice the improved condition of the hair and scalp. 4ortunately, testosterone treatment does not accelerate the rate of going bald, and may even slightly slow it down. '9+6 *ike the hair, the skin is also sensitive to the action of testosterone. Cne of the ways in which the hormone is excreted from the body is as the sebum which normally oils our skin, and makes us more water resistant and drip:dry. This is why when teenagers get a pubescent surge of testosterone, they often suffer acne from blocked pores choked with surplus sebum. This also is sometimes seen in athletes overdosing on anabolic steroids. +n the andropausal male there is insufficient sebum and so the skin, particularly on the face and hands is noticeably dry in nearly half the cases. There may also be thinning of the skin as collagen production is decreased, which makes it look thinner and more wrinkled. This could be why one of the derogatory terms for older people is -wrinklies-. 7gain this process is reversed by T(T, and the person often appears more -shrink:wrapped- as one patient/s wife remarked. This wide range of mental and physical symptoms of the andropause often feels like the onset of old age to a man in his fifties or later, and causes great but fortunately unnecessary alarm. He feels he is definitely over the hill, and going fast down the other side. &ven the patient/ s doctor, especially if suffering from similar symptoms himself, all too often fails to spot the need for male hormone replacement treatment, or may not even know of its existence. -+t/s your age- he says, -6othing can be done-. +ts my goal in writing this book to make the point that though age may be one of its causes, there is a lot of other factors involved in the andropause, and in most cases a great deal that can effectively and safely be done about itA The first thing is to make the diagnosis and the second is to treat the condition. +n my experience, the patient and his partner are often as good, if not better, than the doctor in deciding when the andropause has arrived . Many of my patients were referred to me by their wives, who had accurately assessed their symptoms, related them to their own experience of the menopause, and in some desperation asked if there was any equivalent to the hormone treatment which had given them so much benefit. *et/s recap at this stage with a brief list of the symptoms of the andropause, and compare them with the menopausal symptoms in women.

S)MPTOMS O# T*E #EMA(E MENOPA&SE M&6T7* 4atigue %HG'+)7* 7geing

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=epression +rritability (educed *ibido

7ches and %ains 'weating and 4lushing 'exual &n8oyment =ecreased

S)MPTOMS O# T*E MA(E MENOPA&SE +AN ROPA&SE, M&6T7* 4atigue =epression +rritability (educed *ibido %HG'+)7* 7geing 7ches and %ains 'weating and 4lushing 'exual %erformance =ecreased

The picture of the andropause is often, as you will see from the comparison of symptoms above, 8ust as obvious as the female menopause and essentially the same, but to serve as a more detailed guide + have designed the following andropausal check list, which is a shortened version of the one + use in my clinic. This will enable you to determine with a fair degree of probability whether you, a friend or a partner is andropausal, though only assessment by a doctor experienced in this field and a full hormonal profile will confirm or exclude the diagnosis.

AN ROPA&SE C*EC- ($ST OOOOOOOOOOOOOOOOOOOOOOOOOOO P 6one P'lightPMediumP'everePTotalP 4atigue, tiredness or loss of energy P =epression, low or negative mood P +rritability, anger or bad temper 7nxiety or nervousness *oss of memory or concentration (elationship problem with partner *oss of sex drive or libido P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P

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&rection or potency problems =ry skin on face or hands &xcessive sweating, day or night $ack ache, 8oint pains or stiffness Heavy drinking, past or present More than "F over ideal weight 4eeling over:stressed

P P P P P P P

P P P P P P P @"/s P P

P P P P P P P ;"/s P P #"/s P P P D

P P P P P P P >"/s P P P @

P P P P P P P

P P P P P P P

The age you feel

I"/s 1 P P P ; P P

QnbspTCT7* T+)9' Multiply ticks in each column by3 P

"

TCT7* ')C(&'

+f there has been mumps orchitis or other testicular problems, a prostate operation or inflammation, persistant urinary infection or vasectomy, each adds four points to the total scores. TCT7* 76=(C%7?'& ')C(& P P AN ROPA&SE RAT$N%. /01 &N($-E()2 3/031 POSS$'(E2 4/041 PRO'A'(E2 5/051 E#$N$TE2 6/7 A 8ANCE .

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Chapter Three 0 Not the Mid0(i9e Crisis Though the male mid:life crisis may precede or even overlap the male menopause or andropause, they are essentially separate and distinct conditions. +n popular writing however they are still usually lumped together which causes endless confusion and prevents proper consideration and understanding of either. The word crisis, coming from the ,reek krisis meaning decision, suggests a time of change, transition and opportunity. +t also has the meaning of a turning:point or cross:roads, when you decide that you are on the wrong road and need to change direction in one or more parts of your life, or that you are generally on the right road and 8ust need to keep going. +ts like half time in a football match, where the manager tells the team to change their tactics if they want to win, or that they are playing 8ust right and should keep up the good work, you hopefully being the manager of your life though other people may compete for the 8ob. Many people decide that they either have no need or no opportunity to make dramatic changes at mid:life, and so the crisis may go unnoticed either by themselves or by other people. Cthers have agonising decisions to make, which may take them to the brink of emotional, physicla or financial disaster or push them over the edge. 'ome make profoundly beneficial changes which ensure the second halves of their lives are much happier, more creative and more satisfying then the first. The choice is one of breaking down and R or breaking through, and we will be looking at what factors predispose to a severe crisis and how some famous people have come though it for better or worse. 5hat/s your mental picture of the male mid:life crisis< +ts often seen as a bit of a 8oke, a topic for party small:talk and gossipy columnists. +ts middle:aged men taking leave of their senses, their wives, their 8obs, everything that they had worked for up to that point in their lives, and running off in search of new lives and loves. There is even a party game simply called M$ 0($#E CR$S$S made by a firm in the ?'7, The ,ames 5orks inc., which is really very amusing and informative on the sub8ect. The stated ob8ective of this board:game for -D:> adult players in their prime- is -To get through your middle years with more money, less stress and fewer divorce points than your opponents or to declare a M+=:*+4& )(+'+', in which case you must go broke, get divorced and crack up before anyone else reaches the end of the game-. +f you are male and in the danger zone of @#:;#, or have come through this and want to look back in amusement, + recommend it to you. Cne of the best and most readable of the many articles and books written on this sub8ect was by a =r. M. 5. *ear who in !I@ neatly summarised the dilemma of the archetypal middle:aged male. -The hormone production levels are dropping, the head is balding, the sexual vigour is diminishing, the stress is unending, the children are leaving, the parents are dying, the 8ob horizons are narrowing, the friends are having their first heart attackH the past floats by in a fog of hopes not realised opportunities not grasped, women not bedded, potentials not fulfilled, and the future is a confrontation with ones own mortality-. This last point, about looking at the hour:glass of life and seeing that so much of the limited sand of this life:time has run through, has been recently taken up by several novelists, in particular Martin 7mis in his book "#he Information". This examines the tortuous competitive interaction, it can hardly be called friendship, between two middle:aged writers.

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*ike 7mis the younger, they are 8ust turning forty, with extreme misgivings and -comprehensive anxiety-. They are both living lies, one successfully, the other not. Cne has an unexpected best selling novel on his hands and is surfing high on a wave of success, with all the attendant froth of money, public adoration, a titled lady as his wife, and is looking and feeling good for his age. The other is floundering in the foam, feeling and looking a total wash:out mentally, physically, socially and financially. He has been working on a novel called 8ntitled for several years, which is still unpublished. -stacked against him in the future, he knew, were yet further novels, successively entitled 8nfinished, 8nwritten, 8nattempted and, eventually, 8nconceived-. 5hat makes it worse is that in spite all his thwarted attempts to get his book published, and the totally disastrous and humiliating response when he eventually does, he has a lingering belief in his ability as an author, where as he is sure the other -can/t write for toffee-. +t seems that getting your book published is the nearest thing to childbirth that a man can achieve, and he is as 8ealous as a woman who has had several stillbirths might be of a neighbouring mother whose child has 8ust won a top modelling agency contract, and whose picture is in every paper and on every screen. This exploration of the seeming unfairness of life, wrestling with the issues of male creativity and the resulting problem of treating those two great impostors, as (udyard 9ipling called them in his poem -+f-, success and failure, 8ust the same. +t can be seen as the authors own efforts to resolve the conflicts in his life, work and marriage, through the rivalry of his two characters in his novel. The message comes through that -The +nformation- is the depressing news that our expanding view of the universe has revealed 8ust great vistas of nothingness and cosmic and individual dissolution, or what might be termed -7mislessness-. ?nhappily, though it succeeds in painting in vivid colours some of the -sad dreams- of men in mid:life, which causes them to wake crying in the night and to seek the solace of sex, alcohol, tranquillisers, and homicidal or suicidal behaviour to relieve what in 7mis/s words is a -terrible state, that of consciousness-, it fails to resolve them. *et/s take a serious look at the causes of what + believe is a genuine and sometimes profound emotional crisis in a man/s life, and how it differs from the male menopause or andropause. Many of the patients with the classic picture of the male menopause give an equally characteristic story of a series of events precipitating a mid:life crisis some five to ten years earlier. +t is important to differentiate between the two conditions because the confusion between the two means that they are often bracketed together and laughed off as a temporary emotional crisis without any physical cause. They are then considered to be 8ust an excuse for a man to behave badly toward the women in their lives, and avoid their social or family responsibilities. This failure to differentiate what are two distinct and separate conditions blurs the issues terribly and provides grounds for attacking the concept of the male menopause. 5hat makes a man prone to mid:life crisis< 5ell, anything that de:stabilises him from childhood onwards. This can include being born with a sensitive or artistic nature, distant or unloving parents, loss of one parent, particularly the father at an early age, loss or separation from a loved one or role model, and repeated failure or paradoxically repeated success in his career. 7s Cscar 5ilde said -+n this life there are only two tragedies. Cne is

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not getting what one wants, and the other is getting it.- 5e can see the same pattern emerge in the lives of many famous people, and may come to recognise it in our family, our friends or even ourselves. Many, if not most mid:life crises go unnoticed, and are passed off as a change of 8ob, a change of house or a change of spouse. Cnly occasionally does the crisis turn into a drama. Typically the age group most prone to the male mid:life crisis is around forty, mainly between thirty:five and forty:five. This is earlier than, but may occassionally over:lap, the andropause which usually starts around the age of fifty, say forty:five to fifty:five, though it can sometimes be earlier or later. 5hile the male menopause is mainly a hormonal condition due to insufficient testosterone activity, as described earlier, it can also have profound emotional effects. The male mid:life crisis is essentially emotional in origin but if severe enough or long enough may have physical consequences, especially if alcohol or drugs are used to blunt the pain of this crisis. Mid:life can trigger an existential crisis in which the man may feel he is stuck in a career which either under:extends or over: extends him so that he is faced with rust:out or burn: out. He may also be in a dead:end 8ob or in a marriage that has gone stale and having to choose between staying in that relationship or the traumas of divorce, particularly the pain of separation from his children, and often having to start over again financially. These perils of the -roaring forties of his life may lead on to the @:= syndrome of depression, drink and divorce which as we shall see can set the scene for the male menopause to follow. Cften this crisis is seen in show business celebrities whose careers have taken off , or unstable relationships have broken down. These events bring with them large scale publicity which can lead in all but the most experienced, to what has recently been described by the $ritish 8ournalist 7 7 ,ill as -over:exposure on the media mountain-. $linded by flashbulbs, exhausted by interviews which deplete them of their vital stores of essential nutrients such as sensible things to say, and constantly breathing the oxygen of publicity which has a narcotic effect on the brain, they succumb to -Media Mountain Madness-. +n the terminal stages of this, fortunately usually only seen high up on the Hallucinatory Hills of Hollywood, but with an increasing number of cases now appearing around 6ew Gork, they stumble around pursued by packs of ravening reporters, until they fall into bottomless chasms of obscurity or are buried under an avalanche of hype. &ven at lower levels of exposure to publicity, life in the -,old:fish bowl- distorts not only the view of the people looking in, but of the fish looking out. This can warp their self:image to the point where they either come to believe their own publicity, or knowing that it is out of touch with the reality of how they see themselves, they despair of ever living up to this magnified artificial image of themselves. This can drive them either to mania or depression, or both in turn, and cause totally erratic and unpredictable behaviour. +ts at this stage that the -@:= 'yndrome- of drink, drugs and divorce can set in as the celebrity frantically tries to reconcile what he feels he is or should be, with his publicity image. 7s with the &nglish entertainer Michael $arrymore, this can bring them to the brink of personal disaster, from which only a fortunate few return. 5ith this rapidly changing kaleidoscopic view of themselves, and the self:in8ury that this can cause, some never recover. *ike the $ritish comedian Tony Hancock they may commit suicide, or like %eter 'ellors drive themselves to heart attacks, which are often due to the inner enemies of anger and despair.

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i99erences 'etween the Mid0li9e Crisis and Male Menopause Time and again in newspaper articles and television programmes, and even medical debates, these two conditions are written and talked about as though they were one and the same. They are not, and this confusion prevents either condition from being recognised or treated. *et/s run through a check:list to spell out the differences3 7ge : The Mid:life )risis usually is confined to the ages of @# to ;#, while the Male Menopause is characteristicaly ;# to ##, as with the female menopause. However, if there was previous damage to the testes, such as from mumps, alcohol or vasectomy, the Male Menopause may happen earlier. )hildhood : 7 disturbed, unsupportive childhood, starved of love and affection, especially if accompanied by physical or mental abuse, is much more common in the background of someone experiencing the Mid:life )risis. Triggers : The death or serious illness of a parent or close friend is a common trigger of the Mid:life )risis, as such events bring you face to face with your own mortality. They make you feel that you are next in the firing:line, which brings up thoughts and feelings about the meaning of your life, and your past, present and future goals and acheivements. %aradoxically this crisis can come after a period of success even more often than after a dismal failure. +t may even come when you find the love of your life, either in a person or an occupation, but feel it is too late or an impossible dream. 7s the word suggests, it is decision time, but you agonise over the choices. Gou consider changing your 8ob, your partner or your whole way of life. $y contrast, the Menopause comes after redundency, after heavy financial losses, after the business has failed, after divorce, rather than during the period leading up to them. (elationships : The )risis is by its nature often very much about personal and business relationships. Kuestions about whether you want to go living with that person, or working with another, or in that organisation, are often uppermost in your mind. Gou think about them again and again, and you even may dream about them again and again at night. =uring the Menopause, you are more likely to feel too weary to want to make any changes, and too tired to even dream about doing so. $ecause of this lethargy, your marriage and business relationships may be falling to pieces around you, but you feel powerless to do anything about it. 'ex:drive : This is most often increased during the )risis, either as a form of escapism, or as a conscious or subconscious way of bringing matters to a head. 'ometimes however when a man is depressed by these events, as with other forms of depression, the libido may decrease. 5ith the Menopause the libido is almost always decreased, though occasionally there may be an affair to try to revive waining sexual powers. %otency : 7s with most things there are few absolute rules about this, but apart from obvious physical causes such as diabetes, or the side effects of medicines such as those used to lower blood pressure or treat depression, or where triggered by severe psycho: sexual problems, only during the Menopause is potency consistently decreased over several months or years.

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%hysical 'ymptoms : 4atigue, aches, pains and stiffness in the 8oints, nights sweats and other physical symptoms which are typical of the Menopause are usually absent in the )risis. Hormone %atterns : These are nearly always normal during the )risis, unless there is deep depression or heavy drinking. Though total testosterone is often normal during the Menopause, the free, biologically active testosterone is typically decreased, as described in the next chapter. There are also often other more subtle markers of this condition to confirm the diagnosis which can be found by careful and extensive hormone profiles of the blood. (esponses to treatment : The treatment of the )risis is mainly by councelling and support to help the person resolve the issues which are troubling them. Tranquillisers or antidepressants can occassionally be effective for short term treatment if anxiety or depression are overwhelming. However they can be addictive, and actually delay solving the problems which life has thrown up. Testosterone will not help the person experiencing the )risis, but as described in )hapter 'ix, is likely to cause dramatic benefit to those suffering the miseries of the Menopause.

M$ 0($#E CR$S$S C*EC- ($ST . 7ge D. =eath of %arent 5ithin @. =eath of )lose 4riend 5ithin ;. )hange or *oss of Bob 5ithin #. )hange or *oss of %artner 5ithin >. 'atisfaction 5ith %resent %artner I. 'atisfaction 5ith %resent 5ork E. 'atisfaction 5ith Gour )hildhood !. )onfidence 7bout (ole in *ife ".)onfidence That *ife Has Meaning . 'ex =rive 0*ibido2 D. %otency 0&rections2 @. Mental &nergy ;. =oing Too Many Things at Cnce #. =ay =reaming P P P P P @"/s P Gr Gr Gr Gr ;"/s P #"/s P @Gr P @Gr P @Gr P @Gr P 4air 4air 4air 4air 4air %oor P >"/s P ;Gr ;Gr ;Gr ;Gr P P P P

P D Gr P P D Gr P P D Gr P P D Gr P P %oor P P %oor P P %oor P P %oor P P %oor P

P $ad P $ad P $ad P $ad P $ad

P ,ood P P ,ood P P ,ood P P ,ood P P ,ood P $ad P P P

P &xcess P ,ood P P &xcess P ,ood P P &xcess P ,ood P

%oor P $ad %oor P $ad

P (egularP Cften P 'eldomP 6one P P (egularP Cften P 'eldomP 6one P

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>. 6ight =reaming I. Heavy =rinking E. Tranquilliser ?se !. Thoughts 7bout =ying

P (egularP Cften P 'eldomP 6one P P (egularP Cften P 'eldomP 6one P P (egularP Cften P 'eldomP 6one P P (egularP Cften P 'eldomP 6oneP

D". Thoughts 7bout Ma8or *ife )hanges P (egularP Cften P 'eldomP 6one P

TCT7* T+)9' Multiply ticks in each column by3 TCT7* ')C(&'

P P P @

P P P D

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M$ 0($#E CR$S$S RAT$N%. /01 &N($-E()2 3/031 POSS$'(E2 4/041 PRO'A'(E2 5/051 E#$N$TE2 6/7 A 8ANCE . The %a:e o9 Mid0(i9e Crisis Sur;i;al There is a Bames $ond storey called 9ou )nly :ive #wice. 4or some men some men its as though they have an opportunity to begin a second new life at forty, which gives a new meaning to the saying -*ife begins at forty- 4or many who are on a plateau, or steadily on the way up, this may 8ust be a natural continuation of the old life and they don/t experience it as a crisis. 4or others there is a period of great unrest and inner turbulence, the -=ark night of the 'oul-, but they come through and either decide to climb on up to fresh peaks or settle for comfortable life in the valley. 7 few unfortunately fall down one of the slippery slopes of addiction to alcohol, drugs, sexual over:activity, or risk taking behaviour to ease what has become a very painful transition period in their lives, and may or may not survive the experience. Cthers get lost and spend the rest of their lives wandering aimlessly or fall prey to the black bear of depression. 'ometimes they find themselves and make successful changes in their lives, or sometimes the climate of opinion or fashion changes in their favour and they get a helicopter ride up the mountain.

Sur;i;ing the Mid0(i9e Crisis. There is a great deal to learn from all these stories about how to come through your own mid:life crisis if you are having one, or how to help other people through theirs. +f you can see clearly how you yourself or others got lost on the mountain you may be able to help

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guide them safely down, or you may decide to call in a professional mid:life mountain rescue team. Make a map 4or the person who decides that they have reached mid:life, or those trying to help them, it helps to make a map. 5here are you, and where, if anywhere, do you want to get to< 'ome people are destined to climb mountains and achieve one peak of achievement or creativity, often in their twenties or thirties, and then plateau off at mid:life, or go down: hill. Cthers achieve a second, perhaps even higher peak later in life having successfully dealt with their mid:life crisis, using the experience, knowledge and wisdom built up in the first half of their lives. This can happen in all walks of life, but particularly with writers, who breath in experience and breath out prose, with applied scientists, and sometimes with business:men who may have hit the financial rocks in mid:life, but learn important lessons, and go on to rebuild their empires. =ecisions again3 5hat realistically are your goals and how worthwhile are they to you< How high do you want to climb< How much effort are you willing to put in and what risks are you willing to take< 7re you content with what you have achieved and got out of life so far< 7s the financier $ernie )ornfeld who created the huge financial bubble of +nvestors in Cverseas 'ecurities, +C', or as it could have been more accurately called, +C?, put it -=o you sincerely want to be rich<-, or do you have other priorities<. (esources for the Bourney Having decided where you want to go, or at least in which direction you feel your future lies you need to make a full and fearless inventory of your resources in terms of health, finances and as near as you can assess them, your abilities. =on/t forget to include the emotional support of your family and friends among your assets, as they can be crucial, especially if you are making radical changes to your life. 7lso make a list of your weaknesses and the emotional baggage you are carrying. How much of it is necessary, and how much can you drop as being -6ot needed on the 8ourney-< How much -unfinished business- do you have with a difficult childhood or family relationships< )ould you finish it, if necessary with the help of a psychotherapist or analyst< 5hat are your addictions, if any : alcohol : drugs : work : chocolate : food : sex< Think about where can you get help with these, because they can cripple you on the next part of your 8ourney or even stop you ever getting started. 5hat/s your 7chilles heel and how can you guard it< +n the final analysis you have to decide what you can change in yourself, as it has to be accepted that you can/t change the 5orld or others. +f you decide you do wish, and are able, to make changes, probably the best idea is to follow the business tradition of making a five year plan to aid you in your 8ourney, and decide what you would like to have achieved by then. -(ealistic, but optimistic- is probably the best motto, but think carefully whether you will be able to live at peace with yourself and those around you if realise your new ambition or continue with your old one. +f you think you can cope with, or have coped with the hazards of the mid:life crisis, you may well be interested in lessening your chances of experiencing the andropause. The next chapter tells you how it happens, and how your response to the mid:life crisis may have either set you up for it, or protected you from ever getting it.

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Chapter #our 0 *ow it *appens 5hy should one man suffer all the miseries of the male menopause in his forties or fifties and another in his seventies or eighties escape them entirely< + am reminded of the Jiking warrior, cold, damp and miserable on a bleak landscape in a thunderstorm, shaking his fist at the sky and crying out -5hy me C *ord< 5hy me<-. 7fter a pause for thought, a thunderous voice from the heavens replies -5hy not<-. 'imilarly, though the roots of this condition can usually be traced to one or several of the hammer blows of fate which affect us throughout life, sometimes its causes remain unknown. *ets look first at how testosterone is produced and the key role it plays as a ma8or contributor to the force of destiny which shapes both our beginnings and ends, -rough.hew them as we may-. *or:one o9 -ings -ing o9 *or:ones The hormone testosterone brings us into being. +t regulates the sex drive in both men and women, it develops the male sexual characteristics such as dominance, drive, assertiveness, strength, body shape, hairiness, and even odour in the form of sex.steroid breakdown products called pheromones, which may turn women on or off. +t governs sperm production as well as potency, and therefore has the casting vote on whether or not conception takes place. $eing mainly released by the testes in the male, it is a ma8or factor in deciding, both physically and mentally, whether we develop into a man or a woman, a homosexual or heterosexual, a poet or a boxer, a wimp or a champ. 7s described in the book -$rain 'ex it even literally shapes our brain, decides our creativity, intellectual skills, thought patterns, and our drive and determination to explore ideas and follow them through. +t is an over. riding influence in controlling not only our potential, but also the use we make of it. +t governs our sexual and social history. Testosterone also affects our health throughout life . how we grow as children whether we thrive and whether we become a muscular 7donis in our teens, or a weed with acne, and even whether we die in a fight or motorcycle accident in our youth. +t affects to what extent stress will undermine our health in middle age, how we will die from the premature ageing that testosterone deficiency can cause, especially in the heart, and therefore controls both our vitality and longevity. +t can also be regarded as the -'uccess Hormone-. 7 study funded by the 6ational +nstitute of Health in the ?nited 'tates compared testosterone levels with personality type in over ,I"" men. +t was found, according to =r Bohn Mc9inley the medical statistician who analysed the results, that typically the male with high testosterone -attempts to influence and control other people, who expresses his opinion forcibly and his anger freely, and who dominates social interactions-. This made them more aggressive, competitive and sometimes more successful. These findings closely mirrored those of %rofessor Bames =abbs a psychologist at ,eorgia 'tate ?niversity. He studied #,""" Jietnam war veterans and found that antisocial -sensation seeking- behaviour more often occurred in high.testosterone men with little education and low income 8obs. Those with more education and money had opportunities for a wider range of outlets for this type of behaviour. -They can do things that are both

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exciting and sociably acceptable . driving fast cars rather than stealing them, and arguing instead of fighting- said =abbs. He also found that both men and women in more extrovert and expressive occupations such as actors, entertainers, football players and even women lawyers had high levels of testosterone, while clergymen had low levels. +n this way it seems that testosterone affects every aspect of our lives as men. Testosterone Production The command centre for testosterone control is the brain. This has a variety of interrelated checks and balances which promote or suppress production, according to the needs of the body at that stage in life and at that particular time. The highest functional part of the brain, the cerebral cortex, stimulates testosterone production when we are aroused, and feel we are succeeding in life. 5hen we are bored or angry with our partners or overstressed and feel we are losing in life/s battles, research has shown our testosterone goes down. These reactions are controlled day to day by the -concert organiser-, the so:called hypothalamus at the base of the brain, and hour to hour by the -conductor of the hormone orchestra of the body-, the pituitary gland. This vital gland is the size and shape of a small cherry in the adult, and is suspended by a short stalk from the hypothalamus from which it receives its regulatory messages. 7ccordingly it produces a wide variety of key hormones which stimulate or suppress the various glands in the body, including the testes. The pituitary hormones which control the sexual organs in both men and women are called gonadotrophins. There are two of these, named according to their functions in the female. Cne is called 4ollicle 'timulating Hormone 04'H2 because it stimulates the growth of the follicles in the ovary which contain the eggs, though in the male it is mainly concerned with promoting sperm production. The other is called *uteinising Hormone 0*H2, and regulates the production of oestrogen by the ovaries, and testosterone by the testes in the male. However recent research suggests that there are some interactions between these hormones in controlling testosterone production. (esearch has shown that over !#F of the >.I mg of the testosterone produced daily by the young male comes from the #"" million -interstitial- or -*eydig- cells in the testes, the remaining #F coming from the adrenal glands capping both kidneys. $lood levels in men are usually about twenty times those in women, where the adrenals and ovaries are the main production sites. &unuchs are therefore likely to have the same testosterone levels as women, 8ust as men usually have the same oestrogen levels as post.menopausal women whose ovaries have stopped its production. The raw material from which testosterone is synthesised in the body is cholesterol, and it was shown in !E; by a group of 4innish researchers that low fat diets, especially when the proportion of the -healthy- unsaturated fats was increased, lowered both total and free testosterone levels in the blood. This may be one explanation for the sad fact that any decrease in heart disease produced by these diets or cholesterol lowering drugs tends to be outweighed by increasing deaths from suicide, homicide and accidents. Though life isn/t any longer, it seems a lot longer low.fat, low.fun, low.sex diets. +t seems unfair that the limp.lettuce diet foisted on an unsuspecting public by dietary dogmatists might be contributing to the lower testosterone levels, and the impotence seen in many menopausal males. Cne wonders what the more drastic cholesterol lowering drugs that some of my patients have been put on 8ust before the onset of andropausal symptoms are doing to their androgen levels.

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Cn the other hand we have the sexual athletic performances of the sixteenth century legendary lover ,iacomo )asanova, who boosted his testosterone levels with large numbers of raw eggs before each of his amorous marathons. +t was reputedly the pox rather than heart disease which killed him at the age of I@. 7lso, as pointed out in my book -The 5estern 5ay of =eath : 'tress, Tension and Heart =isease-, I#F of the cholesterol circulating in the blood stream is made in the body by the liver, and is increased by stress, and only D#F comes in from the diet. 'tress, as well as reducing testosterone secretion, has other harmful effects such as raising blood pressure and increasing blood clotting, so there is a lot of evidence that where heart disease is concerned -+ts not so much a matter of what you eat as what/s eating you-. Cne of the many compounds produced on the long production line leading from cholesterol to testosterone re8oices in the name of dehydroepiandrosterone, known to its aficionados as =H&7. This is an interesting steroid because its production rate is directly related to that of testosterone, and it has been shown to decrease linearly with age which gives further evidence about the possible origin of the male menopause. +t has even been given clinically in one trial on ageing men, and provided some of the benefits of testosterone treatment. However, it is more expensive than the latter, and seems a roundabout way of promoting its synthesis if that is what is needed. 7lso, some may be converted into oestrogen, which antagonises testosterone actions, and so in certain patients it could be counterproductive. However it is certainly worth looking at further as a way of increasing natural testosterone production in the body. 'imilarly a hormone from the pituitary gland, growth hormone, can boost the action of testosterone, and has been claimed to have re8uvenated a small number of 7merican Jeterans on whom it was tried. However it needed twice weekly in8ections, was about ten times as expensive as testosterone, and unlike that very safe medication, caused rises in blood pressure and sugar levels. Testosterone Throughout (i9e &ven in the womb, there are larger amounts of testosterone present in the blood of males than females. This starts as early as six weeks after conception, reaches a peak of five to six times higher at twelve weeks, and then falls back to female levels at about six months of intra:uterine life. $y that time of course, development of all the organs in the body are nearly complete, and mentally and physically the die is cast either in the male or female image. This not only applies to the genitals, where the development of the penis, and the descent of the testes into the scrotum prepared to receive them is largely under the control of testosterone, but also the brain, where the balance in function between the two hemispheres is supposed to be influenced by this hormonal difference. The mountain of inescapable evidence that men are different from women in a whole range of aptitudes, skills, and abilities, and that these differences depend much more on hormonal nature than social nurture is brilliantly reviewed in the book by 7nne Moir and =avid Besell, -$rain 'ex : The real difference between men and women-. 7fter birth there is another surge of testosterone going up almost to adult male levels, starting at about two weeks, reaching a peak at " weeks, and then dropping back to female levels at six months and staying there till puberty. These early months are also a period of active brain growth and development during which further sexual differentiation

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can arise. +t seems likely that the traumas of birth and the first six months of life afterwards, such as prematurity, failure of maternal bonding, malnutrition and infections might all reduce testosterone production, and be one of the factors which predispose a sickly infant to being a sickly adult. 7t puberty in the male, the testosterone rises rapidly, reaching a maximum of about twenty to thirty times the infant level at about age eighteen. This causes the pubertal development of hair on the face, armpits, pubes, and to a more variable extent which is mainly due to hereditary factors, on the rest of the body, particularly arms, legs and chest. 5hether a man goes bald or not later in life again seems to be more down to heredity than hormones, as unless he is castrated before puberty, its what/s in his genes that decides whether he keeps his hair for life, rather than what/s in his 8eans. 4ortunately, giving the adult male extra testosterone does not seem to contribute to baldness, and some even report improved hair condition and restoration of hair colour. 7lso at puberty, the testes enlarge and descend into the scrotum, libido surges, the penis enlarges, erections occur spontaneously particularly at night and in the early morning, and if not relieved by masturbation or intercourse, spontaneous emissions or -wet dreamshappen, all of which can be associated with an unreasonable amount of adolescent emotional upset and guilt. 7t the same time the voice tone deepens and -breaks- due to thickening of the vocal cords, and the excess hormones and closely related sexual scents, the pheromones, are pour out in the sweat and skin oil, the sebum, which causes the social and physical discomforts of acne. Helped by growth hormone from the pituitary gland, there is an increase in muscle and bone growth in the male, but above a certain level testosterone switches off the later, and between the ages of eighteen and twenty growth usually ceases. +n eunuchs, and men with low levels of testosterone because the testes fail to develop or descend, growth may continue and the man gets taller than other men in his family. 7t the other extreme, high levels of testosterone may arrest bone growth, and a highly sexed and hairy, shorter man result. This could be the hormonal history of cuddly =udley Moore, once described as a -sex.thimble-, and the far less cuddly, but also sexually active, 6apoleon $oneparte. The statue of him standing naked in heroic pose on show in 7psley House at Hyde %ark )orner in *ondon, indicates that he was well endowded in sexual stucture as well as function. However, by the time he died, a beaten man possibly suffering lead poisoning, 6apoleon was found to have severe genital atrophy. 5onderful are the permutations and combinations of heredity, hormones and history which produce the individual physique and temperament. Testosterone and the Male Menopause. Cne of the main reasons why the idea of the male menopause has proved so controversial is that unlike the female menopause, where there is a clear and easily measurable precipitous drop in oestrogen level, it is difficult to show any such fall in the male suffering similar symptoms. To understand why this is so, we must enterprisingly -boldly go- a little deeper into the mechanics of testosterone control and action. The small but vital amounts of testosterone produced in the testes are immediately swept away round the body in the blood stream, and are mainly bound to a special carrier protein called -'ex Hormone $inding ,lobulin-. This 'H$, as it is usually called is a key player in this -5ho stole the testosterone- mystery, since it grabs the hormone and runs, and seems

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reluctant to part with it. The more 'H$, there is, the less free, active, -$io.availabletestosterone is able to get out of the blood into the cells to do its 8ob. The availability of the testosterone can be measured as the -4ree 7ndrogen +ndex- or 47+, which is the total testosterone level in the blood divided by the 'H$, level multiplied by a hundred, and is usually between I" and ""F. +t is when the 47+ falls below #"F that symptoms of the andropause usually appear, which has been one of the key findings in my research in over one thousand patients presenting with andropausal symptoms at my clinic in *ondon. This seems to be because the way in which the body regulates the amount of testosterone available at any one time works well in youth, when there is usually plenty of testosterone, whose level of activity is controlled by a roughly equivalent amount of 'H$,. +f testosterone levels drop temporarily for any reason, the 'H$, falls to compensate for this, and so the amount of testosterone available, expressed by the 47+, is kept constant. However, later in life, especially around the age of fifty, this -Testostat- mechanism seems to break down in many men, and the andropause results. 7 car:dealer patient of mine called 'H$, S'ex Hand:$rake ,lobulinT because he felt his engine was revving, but his brakes were on. 5hat goes wrong in this key part of the body/s hormonal balance< The possible explanations are that either the amount of testosterone -income falls- due to understimulation of the testes by the hypothalamus and pituitary, deficiency of raw materials for its production and wearing out of the testes, or that the -expenditure- in terms of amount taken up by the 'H$, and that used up in repairing the ravages of age, stress, alcohol and other forms of wear and tear rises. 7lso the cells all over the body which are the targets for )upid/s testosterone arrows may get tougher with age, more difficult to penetrate, and less responsive to its effects. 7 life.long programme of research by a $elgian %rofessor 7lex Jermeulen at the ?niversity of ,hent has shown that all stages in the production and action of testosterone can be affected by the ageing process. %articularly after middle age, the amount of testosterone produced falls because of ageing of the interstitial cells that produce it in the testis. Thirty years ago this was very clear because the amount of testosterone appearing in the urine was found to drop steadily with age, since it represents the -free-, active hormone. 7lso, twenty years ago a group of )anadian doctors showed that from about the age of forty onwards, testicular size and the amount of free testosterone began to decrease, and the pituitary driving force increased to try and compensate. However, what still confuses critics of the male menopause theory even to the present day is that the level of total testosterone as measured in the blood only falls slightly up to the age of seventy. +t is because the hormone is being held in the blood by rising levels of 'H$,, and so less is -bio:available- to be taken up by the target receptors in the tissues or excreted in the urine. This has been confirmed in nearly a thousand of my male menopause patients, where only @F showed abnormally low total testosterone levels in the blood, but mainly because of raised 'H$, levels, about I#F had a low 4ree 7ndrogen +ndex which is the key diagnostic finding in this condition. 7bout I" F of the patients also showed raised levels of the pituitary hormones which stimulate the testis, the *H and 4'H, which confirms that the level of testosterone activity is insufficient for the body/s needs. This situation was recognised and proved from urinary studies fifty years ago, but thanks to the complications introduced by blood tests, doctors are still able to argue about it and keep the Male Menopause controversy going. There are many patients who have come to me

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saying that they had classic andropausal symptoms, but their doctors measured their total testosterone levels, found it normal or low normal, and said that there was nothing wrong with their hormones, and it must all be psychological. 4ortunately some persevere in the belief that it is their hormones that are out of order rather than their minds, and get the additional tests done to complete the diagnosis and start rationally based testosterone treatment. Early istur!ances

The normal patterns in hormonal development can be delayed, arrested or modified at any stage of life. 7bout "F of the male menopause patients + have seen probably had lower than normal testosterone levels from puberty onwards. These cases were sometimes due to the testes never having functioned properly because of failure to descend into the scrotum, only partially descending, or retracting back into the abdomen too easily. These varying degrees of partial non:functioning or impaired development are known as primary hypogonadism, meaning that the testes have never become fully active, to distinguish these conditions from those where the testes only failed later in adult life, secondary hypogonadism. Mild degrees of primary testicular insufficiency may not be obvious, or indeed interfere with sexual characteristics or function noticeably till middle.age or later, and it can be difficult to tell what is primary and what is secondary. The Oestrogen Threat to The Male Much of this life.long threat to fertility and virility can be explained by increasing exposure to chemicals in the environment with actions similar to those of the female hormone, oestrogen, the so called Neno:oestrogens, and others which have recently been found to have an anti:testosterone action, 7nti:androgens, as well as the decreasing amounts and activity of this male hormone. Cestrogens, though essential for the development of female characteristics, seem to work against the actions of testosterone in the male. This was seen most dramatically in women given the strong synthetic oestrogen 'tilboestrol during pregnancy to reduce the chances of a miscarriage. 5hen their sons were born, a considerable number had undescended testes, and abnormal genital development. *ater in life they were also noticed to be infertile because of low sperm counts. (ising levels of these Neno.oestrogens, derived from everything from plastics to pesticides, are thought to be having a harmful effect on fertility, sexual development of male offspring, and even in contributing to rising testicular and prostate cancer rates. %erhaps future generations of archaeologists will come across thick strata of plastic bags, marking the demise of -homo plasticus- or -plastic bag man- who was neutered by the by:products of the consumer society. 4or a wide and increasing variety of reasons men seem to be drowning in this sea of oestrogens. &ven the uterine bath water they swim in during the first nine months of life inside the mother is laced with rising levels of such hormonally.active compounds. &vidence of this is the increasing numbers of boys being born with hormonally caused birth defects in their sexual characteristics This is especially marked in the condition known as hypospadias, where the penis is poorly developed and opens towards the base rather than at the tip. 7lso, because of the continuing influence of these oestrogenic compounds, the

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testes increasingly often fail to descend from the abdomen into the scrotum, which not only decreases their ability to produce sperm, but also reduces their testosterone producing capacity. &xposure to oestrogens at any time of life can have a bad effect in the male, particularly around the time of puberty. Cne patient of mine, when he was at university in his late teens, made the mistake of telling his college doctor that he felt over.sexed. The doctor over.reacted by giving him a month/s course of oestrogen. +t worked well, his libido died overnight, and he was able to concentrate on his studies. The unfortunate thing was that his libido never recovered, he never married or had children, and when he came to see me at the age of forty.five it seemed that he had a premature menopause, with no other apparent cause. 7n interesting sub:group of my patients which appeared to show occupational risk factors for the andropause were farmers. The health of these -front:line- troops in the agrochemical arms race towards greater productivity and profitability, makes an interesting study in relation to chemical pollution of the environment. +n some the causative agent of their symptoms appeared obvious. The main relevant feature of their case:histories was that they had worked on farms when they were young men caponising chickens or turkeys with oestrogen pellet implants or creams, to make the birds plumper and more tender. ?nfortunately, though it might be considered poetic 8ustice, they must have taken in large amounts of oestrogen either by absorption of the oestrogen through the skin or lungs, or by eating the birds shortly after the treatment, which caused them to partly become caponised themselves. +n a similar case in cattle, an andropausal patient from )anada recently told me how on his farm he and his brother often ate beef, without waiting for the ;E hour so.called safety limit to expire, after giving their cattle long.acting hormone cocktails supposed to promote growth for up to three months. &ither they misread the instructions, or they were being seriously mislead by the manufacturers of these dollar.a.shot mixtures. )linically, as well as severe andropausal symptoms of fatigue, depression, irritability and loss of libido and potency, there was usually enlargement of their breasts 0gynaecomastia2, testicular atrophy, low total testosterone, high 'H$, giving a reduced free androgen index, and elevated 4'H and *H levels, similar to those seen in primary hypogonadism. 7nother subgroup of farmers however had similar symptoms, but gave a history of exposure to other potentially anti:testosterone hormones or pesticides used in farming. Here the clinical and endocrine features were less marked, and fortunately both groups responded well to androgen treatment either orally, or by testosterone pellet implant. The latter group however could well have been examples of anti:androgen activity from any one of a wide range of antimicrobial agents, pesticides and fungicides. 4or example it was observed twenty:five years ago that coccidiostats given to chickens produced maximum weight gain for minimum food intake, but as with the use of oestrogens they were banned because they caused men to develop large womanly breasts and infertility. 7 wide range of drugs used in medicine are known to have this property. =etailed studies of such compounds, taking into account the possibly differing effects of different forms of the same molecule 0stereoisomers2, may give clues as to their complex hormonal interactions.

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My first %rofessor of $iochemistry at the Middlesex Hospital in *ondon, 'ir )harles =odds, working with a group in Cxford, was the first to describe Neno:oestrogens in an article in 6ature dated #th 4ebruary !@E -The Cestrogenic 7ctivity of )ertain 'ynthetic )ompounds-. He compared the structure of what he proposed should be called stilboestrol, which his group had 8ust synthesised, with naturally occurring hormone called oestrone. *ater the same year he described the oestrogenic actions of a range of related compounds and noted the -large effects of relatively small changes- in related molecules. These two historic papers set the scene for mass production of oestrogenic compounds for both therapeutic and veterinary purposes, and could explain some of our present concerns on the effects of xenoestrogens and androgen receptor antagonists. Bust as small changes in molecules can greatly increase their oestrogenic activity, so apparently minor modifications can make them much more powerful anti:androgens. This was dramatically demonstrated by 9elce and his co:workers in an article in 6ature in Bune !# which showed how the ma8or and persistent metabolite of ==T, p,p/:==& had little oestrogenic activity, but fifteen times the antiandrogen effect of the parent compound. This was one:fifth of the potency, if that is the right word, of the most powerful anti: androgen used in medical and veterinary practice, flutamide, the well:known side effects of which are to induce severe andropausal symptoms and gynaecomastia. The similarities in the structural formulae of these compounds, together with that of the known antiandrogen vinclozolin, used in agriculture as a fungicide is apparent when you look at their molecular structures. 4ortunately, the chemical castration of man and beast by the use of overtly oestrogenic compounds in veterinary practice was banned in the ?9 in !E>, and in the remainder of the &uropean )ommunity by a hormonal growth promoter ban in !EE. However the practice still continues as an underground activity in some countries, along with the dangerous business of giving a large range of chemical cocktails to many different farmyard animals to improve the amount and texture of meat, or more recently milk yield by using genetically engineered $ovine 'omatotrophin 0r$'T2. 7s well as recognised hormonally active products, it is suggested that the effects on both oestrogen and androgen receptors of a wide range of products used in veterinary medicine and agriculture should be investigated as a matter of urgency, and any of the heavy commercial pressures to reverse the &&) ban on Hormonal ,rowth %romoter resisted until a great deal more research has been done to clear such compounds of any possible threat to human health. +t is alarming to note that in 4rance food inspectors trying to obtain meat samples to stem this tide of agricultural abuse of hormones have been threatened and even allegedly murdered. 7s in athletics, more random and widespread checks, leading to legal action where necessary, together with a public information campaign emphasising the medical dangers to producers and consumers alike, should be brought in. +t took fifty years to learn the lesson spelt out by 'ir )harles =odds in !@E and ban oestrogenic substances from veterinary practice, but now apparently we have a seven year itch to unlearn it. 'hould we perhaps be going -$ack to 6ature- to learn the !!# message from 9elce and his co:workers about the possible anti:androgenic effects of a wide range of agrochemical<

8iral and 'acterial $n9ections

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Mumps is the best known cause of testicular damage due to infections, and two thousand years ago Hippocrates recognised it sometimes caused shrinkage and infertility later in life. +n general, anything which affects fertility in the male is also likely to influence testosterone production. However, it is not appreciated even by the medical profession how a long forgotten childhood illness can contribute to precipitating the male menopause thirty or forty years later. The testis seems only liable to be damaged by the mumps virus, and perhaps other viruses, from the first stirrings of puberty onwards. This seems to be because this is a time of intense activity, cell division, and growth in the testis which is being stimulated by hormones from the pituitary gland at the base of the brain, known as the -conductor of the hormone orchestra of the body-. +t is like a bomb going off in the middle of a crowded symphony concert, rather than before the hall has opened. $efore the age of ten or twelve, mumps is a highly infectious viral illness passing from child to child, causing a mild fever and the very characteristic swelling of the parotid salivary glands in front of both ears, which usually passes off without complications within a few days. 7n attack of mumps at this age is usually entirely harmless, and gives valuable immunity which frequently lasts for life. More immunisation of boys should be carried out early in infancy, because if it happens later it can permanently damage a man/s fertility and virility. +f he picks up the infection any time beyond this age, he is likely to be generally more ill, and one or both testes may become very painful, swollen and inflamed, a condition known as orchitis. This very uncomfortable condition, sometimes described by the name of the tune -great balls of fire-, can last one or two weeks or even longer. +t then subsides, often leaving scarring of one or both testes, which may be shown by shrinkage or softening. +nfertility after mumps is fortunately uncommon, but there may be in many cases damage to the testosterone producing cells which becomes apparent later in life. F of my male menopause patients gave a history of mumps after the age of twelve, and in these cases, which tended to be the younger patients, there was often no other obvious cause. Though mumps is by far the most obvious and common virus attacking the testis, there is some evidence that a wide range of other ones may sometimes be involved, and their influence overlooked because the orchitis a less prominent feature of a generalised feverish illness making the patient feel rotten all over. 7gain, it is probably when the testis is most active, around the age of puberty, that it is most susceptible to damage by viruses. 7nother virus which has been definitely recorded as occasionally causing orchitis is glandular fever, also known as infectious mononucleosis or the -kissing disease- as outbreaks seemed to spread among boys and girls in this way, though this could 8ust be parental propaganda. 'ometimes patients date their male menopause symptoms from some unidentified viral illness, though whether this directly affected their testosterone production, or was 8ust the last straw that caused a hormonal breakdown, is unclear. The fatigue, depression and loss of libido that accompanies many viral conditions, especially myalgic encephalitis 0M&2, can mimic many of the symptoms of the male menopause, and careful history taking and hormonal tests are needed to distinguish between them. 'imilarly, the general malaise affecting patients during a severe attack of 8aundice, whether due to hepatitis 7, $ or the

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newly discovered insidious variety ), is likely to reduce the patients testosterone production, whether the testes are directly affected or not. Cther infections of the testes and prostate also seem liable to affect testosterone levels, whether its the common cause of penile soreness and discharge, so.called non.specific urethritis, or the better recognised and more easily treated sexually transmitted diseases such as syphilis or gonorrhoea. 'ometimes infections of the prostate and testis can also occur after surgery to the prostate or bladder, and cause reductions in levels of the hormone. The possible involvement of so many infections in contributing to the male menopause underlines the need for doctors involved in its treatment to take a full history, and much further research is needed to see which infections, at what age, need to be avoided or treated to maintain full testicular function. Stress *ack of desire and performance in relation to sex are commonly seen in men under stress, particularly when they grow older. 5hile younger men, especially those going through the male mid:life crisis, may as described later become sexually over:active, and use sex as a means of relieving tension or trying to restore confidence, over the age of fifty the stressed male is more likely to go right off it. This is a natural biological reaction, and is seen throughout the animal kingdom. The classic case is the defeated stag, after a long antler: locking confrontation with one or several rivals, limps off to the forest with his tail between his legs, while the winner -takes all- and mounts everything in sight. 'imilarly stress assessed as excessive -life events- appeared to be the factor which precipitated the andropause in over half of the men seen in my clinic. This is much more evident with the stresses of failure and defeat in life/s battles, than those associated with success. =ivorce, insolvency, heavy financial losses, unemployment, recession in business and losing court cases were all big put downs mentally and then physically. )onversely, successful remarriage, the start of a new relationship, getting a desired 8ob or promotion or winning the lottery could fan the flames, or sometimes even the ashes, of both virility and vitality. &ven a good relaxing holiday can sometimes have the same effect, though all too often the benefits fade as rapidly as a sun tan when the man returns to his stressful workaday world. How does stress have such a powerful effect on peoples sex lives< Cbviously it is partly a direct psychological effect since the brain has been described as the biggest sex organ in the body, and if its attentions are mainly directed towards survival in the urban 8ungle, sexual activity has a low priority and little time, attention or energy is given to it. Though anger can sometimes act as an aphrodisiac in both men and women, probably through a surge in the -kick:drive- hormone noradrenaline, anxiety is a definite turn:off. 'o:called -performance anxiety-, the self:fulfilling prophesy about erectile failure is part of the downward spiral in which many andropausal men find themselves. &xcessive stress, stress overload, can also act by reducing testosterone levels. This has been shown in a wide variety of situations by research studies carried out over the last thirty years. Cne of the first of these was a study + made with an 7rgentinean =octor, =r &mil 7rguelles, as part of a study of the stress of airline travel. He was able to show that exposure to a couple of hours of air:turbine noise in young men working in a factory, was sufficient to halve their blood testosterone levels.

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Moderately stressful events, such as taking exams in an army officer cadet training school, could lower testosterone levels, though this was less pronounced in successful candidates. &ven less intense stress, such as losing a tennis match where the winner would get one hundred dollars, was sufficient to cause a noticeable drop in testosterone. 5hile mild to moderately intense physical stress, including intercourse, seems to increase testosterone levels, severe exertion such as running marathons was found to lower them. 7 final action of stress is to cause the release of -'tress Hormones- such as adrenaline, noradrenaline and cortisol, which are break:down -catabolic hormones- which work against the build:up -anabolic hormones- principally testosterone. The former raise blood sugar and fat levels and increase oxygen consumption, while the latter has the opposite action. Alcohol 'hakespeare, in what is called the -'cottish %lay-, describes drink as provoking the desire, but taking away performance. Many quite young men experience the embarrassment of fancying a girl like mad after a party, but being unable to perform, and this is one of the common ways in which erectile problems associated with the andropause first begin to show during middle age. This contrasts with women who are more susceptible to the effects of alcohol than men and yet are more sexually stimulated by it. (ecent research in 'weden showed that three glasses of wine rapidly raised testosterone levels in girls in their twenties, and to a greater degree than a group of men the same age. This combination of lessening of inhibitions, and increase in the hormone which stimulates the libido, explains the old saying that -)andy is dandy, but liquor is quicker-. (ather as with men however, many women find that it is more difficult to have an orgasm when drunk. +t is surprising how strong a poison to the testis alcohol is. +t may act directly, or through its immediate breakdown product, acetaldehyde. &ither way, even in moderate drinkers, blood testosterone levels fall as alcohol levels increase. $inge drinking to a level sufficient to cause a hangover lowered testosterone levels D to D" hours later, in one study to D"F of their pre.party levels. %erhaps sagging hormone levels are one of the reasons why a hangover feels so awful, and might explain why some of the eye.opening hangover cures are based on boosting cholesterol levels with raw eggs. This makes it less surprising that later in life, both because of long.term testicular damage, and its short.term actions in reducing testosterone levels and erectile function, alcohol can take away both desire and performance in men. Thirty percent of the first four hundred andropausal men reported currently drinking more than D units of alcohol a week, and many two, three or four times that amount. Cne unit remember is a half pint of beer, a glass of wine or a measure of spirit. The situation has recently been made worse in &urope because our heavier drinking, or more generous, partners in the &&) have 8ust raised the volume of the standard measure of spirit from twelve millilitres to fourteen, causing about a seventeen percent increase in chance of damaging the testis with every glassA Though several studies have suggested that up to forty units of alcohol, especially as red wine, may protect the heart, perhaps by having both antioxidant and anti.coagulant effects, from the sexual function point of view, alcohol is generally bad news both in the short and

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long term. $eer and lagers appear to be particularly toxic to the testis because they contain plant oestrogens, phyto.oestrogens, from the hops and other ingredients. &ven low alcohol lagers and other drinks might contain these oestrogens, and more research is needed on this important topic of international concern. 7 sixteenth )entury +talian physician called )oronaro wrote -The excesses of our youth are like drafts upon our old age, payable with interest about twenty years after date-. This is certainly true in relation to alcohol, and as well as those who are drinking too much when they present with andropausal symptoms, about another ten percent give a history of excess alcohol consumption in the past for over a year or more. ?nfortunately, this does not seem to improve very much even if they stop drinking for several years. This is in contrast to smoking, where most of the hazards such as lung cancer and heart disease decrease dramatically within five to ten years of giving up. The testis lacks the power to regenerate en8oyed by the liver and never fully recovers, as is shown by infertility, impotence and loss of libido in chronic alcoholics even after drying out. The liver forgives and forgets, but the testis remembers, so the larger louts of today are likely to be the lousy lovers of tomorrow. The sensitivity of the testis to alcohol was clearly shown by recent studies by a research group in Milan who found that compared to non.drinkers those who drank ;.D units of alcohol per week were twice as likely to be sub.fertile, and DE units and over, nearly four times more likely. This factor is well recognised in infertility clinics, particularly as a cause of poor sperm motility. +t seems that unlike the men who make them, sperm 8ust don/t drink and drive. O;erheating The scrotum is not a design fault by our creator to use up spare skin, as the 'cottish comedian $illy )onnelly insists. 6ature does not risk putting vital and sensitive glands in such an exposed position without an excellent reason. This is because to function properly they need to be a few crucial degrees cooler than the rest of the body. +ts as though the testis has to pluck up the courage to make a small step outside the body into the cooler scrotum, and testosterone drives it to do so. This is truly a giant leap for mankind, because unless it happens, neither the desire nor the ability to father children develops. 7s has been mentioned previously, Nenooestrogens, because they antagonise testosterone production and action, may have contributed to the increased incidence of non:descent seen in recent Gears. This temperature question can also cause problems during and after puberty where the scrotum is increasingly kept warm by G.front pants and tight 8eans, which together are likely to be as bad as the padded cod.piece which reduced the fertility of Henry J+++ th and his courtiers. There is an old country saying that -(ams wrapped in wool breed no lambs-, and this principle has been used by the Bapanese who have recently introduced a male contraceptive device consisting of a scrotal support with a furry nylon lining. 5orn continuously, it is said to be very effective after the D.@ month period needed to allow already produced sperm to die off. Cther studies have suggested that the polyester component of underwear may generate electromagnetic fields which impair testicular function. *oose.fitting underpants make of a leather cloth soft enough not to chafe the skin were worn by Jiking warriors when invading $ritain @,""" years ago according to a recent archaeological find. However, the extremes of this advice to -stay cool and hang loose-

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were seen in soldiers of the $lack 5atch Highland (egiment, who were forbidden to wear anything under their kilts. To enter or leave the barracks they had to walk over mirrors in the guard house, with their privates on parade so to speak, to make sure they were obeying orders. This was presumably to ensure they maximised their testosterone production, which made them the strong and fearsome soldiers they are known to be. &ven mental imaging techniques , as where some university students were asked to imagine warming of the scrotum as part of their system of 7utogenic mental exercises, is said to have produced a marked reduction in sperm count within a couple of months. The importance of testicular cooling has recently received scientific proof in an article in the +nternational Bournal of andrology by a research group in Milan, where they know a thing or two about male fashion and its penalties. +nfertility was nearly twice as common in men wearing tight G.front underpants, as men wearing loose boxer.short types, and one and a half times as common in men wearing tight trousers, including 8eans, as loose trousers. +f you combined the two, and wore tight pants and trousers, the risk was two and a half times those who did neither. 7s testosterone production and sperm production appear, not surprisingly, to be closely linked, to promote virility as well as fertility it seems a good idea to recommend large, loose.fitting, light weight, cotton or silk boxer.type underpants to those wishing to stay healthy in this department. %erhaps -$urn your G.fronts- might be a good motto for -Men/s *ib-. The S'ting in the tailT of this explanation of the many ways in which the bodyLs supplies of testosterone may be reduced or inactivated by the S'lingLs and arrows of outrageous fortuneT throughout a manLs life would be incomplete without a chapter on the important part unwittingly played by doctors themselves.

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Chapter #i;e 0 8asecto:y. The &n<indest Cut o9 All The idea that vasectomy could be a ma8or cause of the andropause makes the many doctors who recommend it, and those who inflict it on unsuspecting patients rush to its defence, with faith, but usually little detailed knowledge of the many possible adverse reactions to it. 'ince it first came into fashion over thirty years ago, this seemingly trivial operation has variously been described as -The most loving thing that a man can do for a woman-, to -The unkindest cut of all- : a S'urgical 'word of =amoclesT threatening the testes. +t/s been carried out in men for 8ust over a hundred years now, and the operation is still surrounded by controversy. The first human vasectomy was performed in E!; by a $ritish surgeon to reduce the size of an enlarged prostate, which it apparently failed to do. However, the operation never became widespread till in ! > a Jienese surgeon, *udvig 'teinach, proclaimed it was a method of re8uvenating the male. His theory was that if the part of the testicular factory manufacturing sperm was shut down, it would leave more room for the testosterone producing cells to flourish, which would reduce ageing. The idea proved popular, and on the basis of many reports from patients who claimed the operations had done wonders for them, thousands of men were -'teinachered-. There were even reports that the illustrious father of psychoanalysis, 'igmund 4reud, who also lived in Jienna underwent the operation to promote longevity and revive his sexual powers, but perhaps this was 8ust to overcome a psychological block. +t was also from !"! onwards, used as a tool in social engineering, to limit reproduction by any people considered as -defective individuals-. 7 particular enthusiast for this for of eugenics was a =r Harry 'harp, resident physician at the Beffersonville (eformatory +ndiana. He compulsorily vasectomised two hundred and eighty men because they had defects of character such as -selfishness, ingratitude, inconstancy, egotism, and inability to resist any impulse or desire/. or masturbated excessively. 5hile these traits must obviously have been very rare in the population in those days, at least in +ndiana, a considerable number might now be considered as elligible for this procedure on these grounds in most countries. %eople on whom this form of involuntary sterilisation could be inflicted ranged from colour. blind individuals to those offspring it wished to limit because of their colour or creed. 4rom !@@ onwards, under the law /%revention of Hereditary =isease in %osterity- the ,erman ,overnment forced over a million men it considered unfit, including probably not coincidentally a large proportion of Bewish people, to undergo vasectomy. +n the ?nited 'tates in !DD thirty.one states had statutes permitting involuntary sterilisation of -defective individuals-. &ven with the outcry over its abuses by the 6azis, twenty.one states retained these laws after the second 5orld 5ar, and as recently as !I@ Tennessee, Mississippi, Chio and +llinois introduced bills ordering the sterilisation of those on welfare with two or more children. )alifornia and Cklahoma made vasectomy a condition of suspending prison sentences in those convicted of robbery or not supporting their families, whereas the )hild 'upport 7gency in $ritain seem to prefer financial castration. +n +ndia it has been vigorously promoted as a part of government population policy. 7 new 5orld record was achieved in !I by holding a -Jasectomy )amp- which sterilised >@,""" men in one month, with "" surgeons working non.stop round the clock, and a variety of

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circus side shows to entertain those waiting their turn. Three years later it was revealed that gangs of -motivators- who had been offered small sums to encourage men to undergo the operation had misled or forcibly press.ganged or blackmailed men to undergo the operation, and nearly half wished they had never had it done. +n $ritain in !!; an alarming increase in vasectomy rates in men in their early twenties was thought to be due to the recession and 8ob losses making it difficult to afford the cost of housing a family. Cne wonders how many of these men will regret the decision that was forced on them at such an early age. =espite this chequered history, vasectomy really took off as a means of contraception from the !>"/s onwards, and it has been estimated that currently #"", """ 7mericans, D", """ $ritish, and ",""" +rish have the operation each year. My first experience of the clinical effects of vasectomy was in !I! when + first visited the clinic of =r. Bens Moller in )openhagen, one of the -Heroes of the Hormonal (evolution- as described in the first chapter. 7 surprising number of his patients who nearly all were being treated with testosterone for severe problems with the circulation in their legs, often with heart disease as well, had had a vasectomy many years previously. 5hen + commented on this =r. Moller simply said -7h yes. 5hen + hear a patient has had a vasectomy, + know he is a case for meA-. This seemed at the time to be a rather extreme remark to make, but it prompted me to look up the literature on the sub8ect. (ather to my surprise, because it was such a commonly accepted operation which + had only 8ust escaped having myself in the nick of time so to speak, + found that there was a considerable amount of evidence to support =r. Moller/s view that it might have harmful effects on the heart and circulation in some patients. 4or over thirty years the operation had been sold to the unsuspecting public, as it still is, as a snip, which stands for 'imply 6o +mmediate %roblems. ?nlike any other operation however minor, no general medical examination is done beforehand, no central records are kept of how many operations have been performed, and counselling is limited to the fact that it is irreversible so be sure you want it done. 7ny questions about -5hat happens to the sperm<- are brushed aside with facile answers such as -They are 8ust absorbed . its quite safe really-. *et/s look first at what happens during and after the operation, and then at what can and does go wrong. +t is a deceptively simple /minor/ operation which can be, and often is, carried out by the most 8unior and inexperienced of surgeons. +t takes quarter to half an hour and so lends itself to mass application in clinics set up for the purpose on a conveyor belt system, with a surgeon running from cubicle to cubicle trying to set a new lap record for what is a seemingly simple repetitive task. The actual procedure is carried out under local anaesthetic, and through a small incision the tube carrying the sperm from the testis on each side to the prostate gland below the bladder, the vas deferens which gives the operation its name, is exposed. +t is then dissected free of the fine nerves and blood vessels which run alongside it in the spermatic cord, and sealed off. This may be done by cutting it and tying off one or both ends, by frying it with electrocautery, or by blocking it with a plastic spigot which is claimed to be more easily reversible. To the patient and surgeon alike it is seen as a simple plumbing 8ob to turn off the stop. cocks and prevent sperm getting out of the testes. +t is presented as a cheap and effective

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form of contraception, for which one is awarded a portable radio for an act of social conscience in +ndia, and a tie inscribed +C4$, standing for -+ Cnly 4ire $lanks- in $ritain. 7s the anti.vasection lobby gathers strength, refusenick member may well come to sport ties inscribed +C4*7, standing for -+ Cnly 4ire *ive 7mmunition-. 7 drug, such as testosterone, has to have in the packaging a formidable list of every complication, however rare, ever recorded in association with the use of that compound, and often for good measure every related compound. 6ot surprisingly, unless reassured how very infrequent these are, and whether or not they have been reported with that particular compound, patients cannot make an informed decision about whether to take the prescription. The same should apply when an operation such as vasectomy is prescribed, but the possible complications discussed here are rarely mentioned, and certainly not covered in the detail deserved by such an important topic, which may affect the man for literally the rest of his life. Jasectomy is after all a ma8or surgical insult to a very sensitive, delicate and highly tuned organ. The vas is 8ust one of the structures in the spermatic cord which may be damaged by the operation and the bruising, infection and scarring which can follow. (unning alongside it in the cord is a sheath of fine blood vessels, nerves and lymph vessels which nourish the testis, control its temperature to within very critical limits, and drain fluid away from it. Temperature control of the testis has been showed to be impaired after vasectomy, as has the drainage of fluid from around it so, that collections of fluid called hydrocele are formed in many cases. This -water.8acketing- tends to raise its temperature which can have a harmful effect on the testes ability to produce both sperm and testosterone. 7lso, there are nerve connections between the two testes, and damage to one can affect the other in a variety of ways. 7fter the operation there may be a variety of other complications, which can be divided into short and long term. There is often mild to moderate discomfort which may cause the patient to be off work for anything from an hour to a week, depending on his pain threshold, motivation and how many of the fine nerve endings that run alongside the vas get caught up in the operation. 4ortunately quite infrequently, a variety of other changes can occur which cause a persistent and disabling -post.vasectomy pain syndrome-. These seem to be associated with the development of small lumps in the scrotum due to overgrowth of the trapped nerve fibres, called neurones, or swellings at the severed ends of the vas due to a local tissue reaction to sperm, called granulomas. These have been estimated to occur in up to !"F of cases but are usually small and pain.free. They may however increase the chances of antibodies against the patients own sperm. 7lso there may be scarring of the testis from the bruising, and damming.back of the sperm and other products of the testis which now have nowhere to go into small swellings of the vas, called cysts. Gou only have to meet a few of these post.vasectomy cripples to be far more cautious about recommending the operation. Cne of these cases is Harry3 "I had my vasectomy ;< years ago now and I havn't had a happy, pain=free day since. Its been a nightmare from beginning to end, and its not over yet.

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1fter seven years on the pill, my wife was advised to stop taking it, and so I decided I'd have a vasectomy. )n the day of the operation at our local hospital I had no second thoughts at all because I had heard that the procedure was .uite straightforward. I was surprised therefore to wake from the general anaesthetic with a tremendous pain in my stomach. #he nurse reassured me the pain would go away and gave me a valium. But when my friend arrived to take me home an hour later, I was still bent double with pain. 1fter a couple of days with no respite, I called in my own doctor who confirmed that it would settle down. But for the ne!t few weeks I was only comfortable when I was lying down. (alking or lifting things was impossible and there was no .uestion of being able to work. I was getting increasingly an!ious as I had never really been ill before, but since both the hospital and my doctor were adamant there was nothing to worry about, I was prepared to give it time. #hen two months after the operation I found two small and painful lumps in each testicle. I was told these were sperm granulomas, the sperm not being properly absorbed into the body, and was shocked when the consultant told me he wasn't e!perienced in dealing with such problems and wanted to refer me to another hospital. By the time this appointment came up, the lumps had grown from being the si-e of match heads to the si-e of peas and they, together with the continuing ache in my stomach region, were causing me such discomfort that it was interfering with my se! life. #he new consultant performed an operation to remove the lumps. 1fterwards he told me he believed too much of the had been cut during the vasectomy which e!plained the painful pulling sensation in my stomach. I was very angry. #he lumps kept recurring and this was complicated by bouts of urinary infection that caused a painful inflammation in both testicles. #o help this the surgeon finally had to remove the inflamed outer casing of the left testicle, the epididymis. 4ven this went wrong, and five months later the testis on that side began to shrink, and I had to have it removed and a plastic prosthesis put in. By now I felt e!tremely low and tired and couldn't understand why. %ome tests done down in :ondon showed a very low testosterone level and that I was so allergic to my own sperm that even when they diluted my blood more than 6,<<< times they could still get an antisperm reaction. I was started on some tablets called 0roviron and these made me feel slightly better, but it took testosterone injections to make me feel much fitter, but even these wore off after a time. :ast year I had to have the same series of operations on my right testicle, with removal of a granuloma, and then the epididymis, and now the testicle gets inflamed and is shrinking, so I may have to have even that removed. Its been such a terrible time since the first operation. which I'd had for eighteen years before the vasectomy because it all got too much and we weren't having any times over the last few years when the pain and worry but things are slightly better now. y job as a fork=lift truck driver is gone ,and my wife left me fun or any se!. #here have been have made me think of ending it all,

1ll this has been a result of a vasectomy gone wrong, probably because it was performed in a hurry by someone ine!perienced, though I'm told it sometimes happens in the best of hands. #his surgery sentenced me to ten years pain and misery".

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*ong term complications of vasectomy may be much more common and diverse than is generally recognised. Cf the limited amount of research which has been done, some is reassuring and some rather worrying. -5hat happens to the dammed.back products of the testis<- you may well ask. +f both ends of the vas have been tied off, the pressure in the stump attached to the testis builds up, and sometimes cysts form in the sperm collecting tubules surrounding the testis, which can be felt as small lumps. 'ometimes the cysts in the epididymis burst open and granulomas arise. +f the vas has been left open, then the sperm spill out into the loose tissue in the scrotum, and granulomas are then more likely to form than cysts. +n either case, but particularly where granulomas have formed, the body reacts to this highly unnatural no.exit situation by becoming allergic to its own sperm, and producing anti.sperm antibodies. This is because sperm are only produced after puberty and are normally kept shielded from the body/s immune system which would otherwise attack them and form antibodies, reacting as it would to other -alien- proteins such as those produced by bacteria and viruses. Jasectomy spills sperm into the tissues around the testis, and exposes them to the antibody producing cells. 7ntisperm antibodies are found in up to three:quarters of vasectomised men, as has been widely recognised and accepted for many years. Cne medical textbook on the sub8ect cheerfully says -Jasectomy can be considered a particular form of experimental autoimmunisation-. 'ome of my patients reported a prolonged and debilitating flu.like illness within the first few months after vasectomy, which is when immune reactions would be expected, and granulomas appear. $ut apart from causing infertility problems in patients wanting the vasectomy reversed, which happens in F of men, no.one seems to have thought through the other likely consequences. +ts like tying a knot in the barrel of a rifle, and being surprised when it blows back in your faceA 5ith this in mind, + have been carrying out detailed antibody profiles in the post:vasectomy patients who have come to see me. There are some interesting but inconsistent findings which + am now analysing in detail. 'ome patients show an active generalised immune process as shown by raised levels in the blood of a protein called -+mmune complement- which has been linked to the possibility of increased heart and circulatory disease after vasectomy. The ma8ority show anti.sperm antibodies as would be expected. 7n interesting and as far + know unexplained sex difference is apparent here. 5hen women develop antisperm antibodies, these usually cause the sperm to clump together -Head:to:Head-, whereas the ma8ority of my post: vasectomy men seem to have -Tail to Tail- antibodies, sometimes active when their plasma is diluted over >,""" times. *ogic suggests that if you have antibodies against sperm, you might well develop antibodies against sperm.producing cells in the testis, the 'ertoli or nurse cells, and indeed this is found in a proportion of cases. 5hat was not expected was the finding in other cases of antibodies against the testosterone producing, interstitial cells, though this again seems logical. The sperm and testosterone producing cells work together, literally side by side, on the common mission of producing and launching these -&gg.seeking Missiles-. (ecent research has shown 8ust how closely these functions are linked in many ways, including their own hormonal communications, the so.called paracrine actions. +f you suddenly shut down one half of the factory, common sense would indicate that you might have some effects on the other. Testicular biopsies from vasectomised men have shown 8ust such changes, and from my research and that of others there is evidence that this is indeed the case.

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8asecto:y and the Andropause Cver the last ten years, + have been impressed by the fact that 8ust over D"" out of the thousand men in my practice complaining of symptoms of the andropause have had vasectomies, usually ". # years previously. +t is difficult to get accurate reports on the proportion of men in different countries who have had vasectomies because the operation is assumed safe and thought too trivial to be worth recording. However, as the best estimate of the frequency of vasectomy in the general population of this age and social group is around "F, there seems to be a significantly higher proportion of men who have had this operation in the andropausal group. 6ot only are these patients on average # years younger than the rest, but often this operation appears to be the only risk factor present. The most common time for the symptoms to appear is ten to fifteen years after the vasectomy. This time scale was confirmed independently by another group in *ondon, who also showed a fall in testosterone levels at this time. Cther studies from &gypt and $elgium have shown that the amount of testosterone and one of its active fractions dihydrotestosterone 0=HT2 in the e8aculate are reduced to one third by vasectomy. Most of the studies of the effects of vasectomy on hormone production are relatively short. term, being over three to five years at most. 7lmost all were carried out ten to twenty years ago, before vital factors such as 'ex Hormone $inding ,lobulin 0'H$,2 and %rostate 'pecific 7ntigen 0%'72 were being included in even research studies. +t/s true they excluded any dramatic drop in total testosterone levels in the first five years after vasectomy, and some even showed an increase in one of its active fractions, dihydrotestosterone 0=HT2 and one of the pituitary gland hormones which promotes the production of both, 4ollicle 'timulating Hormone 04'H2. However this indicates at least some hormonal changes occur even in this relatively short time scale, which could be taken to show some disturbance in testicular function, if not actual damage to its structure (ather than vasectomy making you sexier as suggested by one study recently, since =HT is not the primary hormone governing libido, a more likely explanation is that the pituitary gland is trying to compensate for impaired testosterone production by spurring the testis to greater activity, and increasing its turnover rate. The surge in these two hormones could also explain why there have been several reports of an increased number of cases of testicular cancer within the first four years after vasectomy, reaching a maximum after two, though there are other studies which contradict this. The tumour, which is increasing at a rate of about two percent per annum, particularly in young men, is most common when the testicles fail to descend, which is a condition also associated with raised 4'H/s. +t has recently been linked to environmental oestrogens, which may have a similar effect in contributing to testicular failure and high 4'H levels. +t is fortunate that this is one form of cancer where great advances have been made in treatment. 7nother form of cancer which has been linked to vasectomy in some studies but not in others is that of the prostate. &vidence is particularly conflicting here but again if it is proven could be explained by long term hormonal disturbances.. (educed semen flow through the prostate has been suggested as another possible link, but seems unlikely as vasectomy only reduces semen volume by #F, and this form of cancer is not particularly common in men leading a celibate life such as monks.

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Typical of the menopausal men + have seen where vasectomy seemed to be the most likely cause of the problems is the ;! year old dentist Tom. "I had my vasectomy ;< years ago, it was very painful and I had a lot of bruising. %uddenly, for no apparent reason, " years ago the bottom dropped out of my se! life. I used to be .uite a flirt but then the se!ual chemistry went. and totally unlike me, se! never entered my head.. 1bout the same time, .uite suddenly my morning erections disappeared, and soon the evening ones went out of the door with them especially when I wanted them most. #his made me so worried that a bit like my golfing swing, which worsened at the same time, I got paralysis by analysis. 1lso, while I used to really fi-- all the time, I became a real slouch, stopped going to parties, and started feeling old before my time. #hen the circulation in my fingers and toes got .uite bad even in the mild weather, and my feet started going numb. 4ven my joints started sei-ing up and got very stiff first thing in the morning and after golf or going running, both of which I used to enjoy, but turned into a real bore and chore with all these symptoms. 1t this stage I went and had a thorough check=up by my andrologist, who showed that the free testosterone in my blood was very much reduced. 5apsules of testosterone by mouth gave a lot of improvement, but it wasn't until I started on the pellet implants into the buttock that the symptoms really went away and I got back to my old se!y self. Best of all my golf improved enormously, my handicap which had deteriorated badly over the previous four years, went down by about five, and I started to beat the club champion and do well in away matches. #he main difference was in my swing which had become hasty and snatched, but on testosterone is really flowed. )ther people noticed the difference , especially my coach, and asked what I was on, but I havn't told them. I don't think it's my imagination either because every five or si! months when my implant is running down, my golf gets worse, as does my temper and se! life, and they are only restored by another shot of testosterone". &specially when there are other causes of testicular failure such as alcohol or mumps, vasectomy definitely seems to lower the age at which menopausal symptoms appear. 8asecto:y2 the *eart2 and Circulatory isease.

7 great deal of work has been done on the possible link between vasectomy and heart and circulatory disease, and + find the evidence very persuasive. +t also coincides with my clinical experience and that of =r. Bens Moller and his successor =r. Michael Hanson in =enmark. +ts true that a lot of the evidence implicating vasectomy in these conditions is from animal studies, but a lot of it is from experiments with monkeys, which are generally considered as the closest one can get to the human condition. Cver twenty years ago it was shown that baboons given a high fat diet, and inoculated with antibody producing proteins, developed more arterial disease. 7 few years after that the 7merican Kueen of research in this field, =r. 6ancy 7lexander, and her colleague =r. )larkson, showed that diet.induced arterial disease developed more in vasectomised cynomolgus monkeys than in sham.operated controls. They therefore suggested that -The immunological response to sperm antigens that often accompanies vasectomy may

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exacerbate atherosclerosis-, this being the form of arterial degeneration underlying most coronary heart disease. They followed up this early work with longer term studies which showed even more marked changes. This was largely confirmed in studies on primates by several other groups of researchers, particularly where the monkeys were overfed and underexercised. Though the link in monkeys between vasectomy and arterial disease is very clearly established, that in humans is much less so. 'ome studies such as the 4ramingham study of heart disease risk factors in 7merica, found an association while others such as the Cxford (ecord *inkage 'tudy did not. The debate continues and the case has yet to be proved either way. 7s well as the antibody related theories, there are a variety of reasons why vasectomy might contribute to circulatory problems. 7nything which reduces the production of testosterone or antagonises its actions is likely to contribute to these conditions, for all the reasons which =r. Moller lists in his book entitled -Testosterone treatment of circulatory diseases-. Mainly this is because of imbalance between the body/s anabolic building.up, restorative, energy producing activities, activities and its catabolic, breaking.down, energy consuming activities. 7s a result, the blood pressure and fat levels rise, blood clots happen more easily, flow of blood in the small blood vessel becomes sluggish, and the cells throughout the body become less efficient at taking up oxygen and using it. )onsequently the natural rate of wear and tear on the heart and arteries escalates, and this leads to their premature ageing. The most dramatic case + saw where vasectomy seemed to be directly linked with circulatory problems was Bames, a young milkman from 'outh *ondon3 " I was fine till I was 6;, and then I got the mumps. It was so bad that my testicles swelled to the si-e of grapefruit, and I had to borrow a bra from my mum to carry them and ease the pain when I stood up. #hey seemed to settle down all right after an uncomfortable couple of weeks, but there must have been some damage because my wife had difficulty conceiving with her first child, and the clinic said my sperm count was low. (e made up for lost time though after that, and after the first ,we had two more .uickly, so I thought it was time to have a vasectomy. #here was a little counselling beforehand, but no medical checks. as I looked and felt completely fit, and was only >?. 2o one asked me about the mumps, so I didn' t think it could be relevant. #he operation went fine, and within a week I was back to my old se!y self, or even better. #en months later though I didn't feel nearly so good. I found that on my milk rounds, especially on cold winter mornings, I started getting really bad cramps in first my right calf and then my left. I was hobbling up the garden paths like an old man, and my rounds started taking longer and longer. I told my 30 about this and he said these symptoms sounded like not enough blood was getting to the leg muscles, but he had never seen this in anyone so young before. #he surgeon he sent me to was also very pu--led, and said surgery was needed, but I didn't fancy it and tried to treat myself by stopping smoking, and e!ercising in a gym. #his helped for a bit, but within a year I had to give in and have some of the furring=up in the main artery in the right leg taken out.

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#his only helped for a couple of months, and then I was back in hospital having a whole series of complicated plumbing operations, trying to bypass the blockages with plastic tubes. 2one of these operations lasted more than a month or two, and I couldn't do my rounds even when I was out of hospital because of the leg cramps. It got to the point of getting cramp in my right leg at night in bed, and the surgeons started talking about amputation. I was desperate and would rather have committed suicide than live life as a legless cripple. %till, I'm a philosophical sort of man who meditates, and I still believed something would happen to save my legs. well, was lying in a bed on the surgical ward one morning going through the %unday #imes and there was this article about a @r. oller in 5openhagen who was treating cases like mine with testosterone injections. /ate seemed too have been very kind to me , because a British doctor who was mentioned in the same article and seemed to believe in the treatment was working in the hospital just across the road from where I was. *e and my surgeon got together and agreed it was worth a try. 1fter all, what had I got to lose, apart from my legsA @r. 5arruthers really had to fight for the injections. #hough my surgeon had given his permission, the hospital pharmacist said he thought the dose suggested was far too high and among other dire warnings, thought it might suppress my sperm production, which showed how little he knew about my case. #his made the junior doctor who was told to give the injections, as no=one else would, so nervous that he spilt half the dose out of the syringe each time. 4ven so, it really was ama-ing. 1 few days after I started on the twice a week injections, my legs seemed to come alive again. #he calf pain started taking longer and longer to come on, and I was able to leave the ward and take up my milk rounds, which badly needed my attention. )ne improvement I hadn't e!pected was that my erections returned nearly to normal after being very lame affairs for a couple of years, and I was only slightly tired for a couple of days after se! rather than being shattered for a week. 1part from a setback a couple of months later when the old plastic piping the surgeons had left in my right leg got infected and had to be taken out. #his briefly made the blood flow in my right foot very bad indeed so that gangrene nearly set in, but despite this setback things went very well on the injections which my family doctor arranged for me to have twice a week. I gave up going to the hospital who seemed to lose interest in me when I didn't need any more surgery, and I wasn't sorry to stay out of their hands. Its now si! years since I started the testosterone treatment , and I work out in a gym for an hour most days, swim twice a week, enjoy a great se! life, and having given up the stressful job of being a milkman, I am much happier teaching #ai 5hi. #he funny thing is though, none of the surgeons I used to consult seemed interested in why things went wrong so soon after the vasectomy or why I'm not in a wheel chair now, si! years after they said amputation was then only option left ." More typical of the cases + see where vasectomy appears to have played an important part in bringing on early heart disease is 9en, a motor dealer in his fiftiesH "#en years ago, as we had two kid's and didn't want any more, my wife and I talked it over, and we decided that vasectomy was the best option. #here was a brief counselling session

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with the clinic nurse limited to a discussion of its irreversibility , but no medical .uestions or e!amination, and then straight in to have the operation. #he operation proved difficult and took an hours fiddling about down below rather than the twenty minutes I'd been told. It was also more painful than I'd e!pected, both during and for two days afterwards. It was also .uite a lot of bruising in my scrotum, which swelled up and went all colours of the rainbow for weeks afterwards $ not a pretty sight& 1fter twenty$si! years of reasonably happy marriage, my wife seemed to go off me following the vasectomy, and we split up two years later. /ortunately, I soon met another woman and we married immediately the divorce came through. 1s I'd had pain in the testicles when I ejaculated right since the operation, though my new wife wanted children, I didn't fancy trying to have the operation reversed. #hen five years ago, when I was just forty$eight, my libido suddenly dropped, and I started sweating heavily at nights, and early morning erections disappeared. #hen I got depressed, and my wife thought I'd lost interest in her because from being two or three times a week, it was an effort to have se! once a month, and even then it wasn't a great event. I went and had a B(ell$manC check by our family doctor, who said I was fine, but perhaps I'd been overworking, which wasn't the case and didn't really help much. #hen one evening I saw a television programme about the B ale enopauseC and the description seemed to fit me to a #. (hen I had a detailed e!amination, including a 0%1 blood test and ultrasound scan to e!clude prostate cancer, the level of /ree 1ctive #estosterone in my blood was found to be low, even though the total level was normal, and there was evidence of an autoimmune reaction following the vasectomy. #his included antisperm antibodies, immune comple!es, and some wonderful things that sounded like a woodland bird, but I would rather have been without, called B%peckled /121'sC. ore important than all this interesting information was the news that the condition could be helped by testosterone treatment. I was started straight away on testosterone capsules by mouth, and within a month my libido had picked up, and life was more interesting again for both me and my wife, who had nearly lost hope before that. I started feeling very fit, and was generally more active, in bed and out, especially when I went on the pellet implants. I've been keeping very well on these for over three years now, and when they begin to run out after si! months, my wife says I should think about her, and go back for a Btop$upC, which I'm happy to do, especially as I get a full check$up each time to make sure it's safe.C +f you look at the research studies which have been done on the effects of vasectomy on humans, you find widely conflicting reports. Most of them unfortunately are relatively short:term, lasting only two to five years, certainly before the complications + see ten to fifteen years later arise. Cne of the best conducted and reassuring studies was reported from Cxford in !!D, and found that SJasectomy was not associated with an increased risk of testicular cancer or the other diseases studied. 5ith respect to prostate cancer, while we found no cause for concern, longer periods of observation on large numbers of men are requiredT. However this study did not cover impaired sexual function and other symptoms of the andropause, and it is difficult when seeing case after case of severe menopausal and circulatory disease problems which appear to be directly associated with vasectomy to be entirely convinced of its safety by the statistics of very artificial population studies. 7lso the vasectomised men are likely to be a very atypical self.selected group of clean living, well informed, health.conscious men in stable and loving relationships, who might be

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expected to en8oy better health all round, and yet are being compared with control populations who may lack these benefits. There are also powerful lobbies both inside and outside the medical profession with vested interests in maintaining the -safe- image of vasectomy. 4irstly, doctors who have been promoting it for many years don/t want to change their tune and to have to face the possibility of being in the wrong. + saw this very clearly in !I! when alarmed by the similarities between =r. Mollers experience with his men, and the evidence from the research in monkeys, + encouraged a very well.informed and level headed medical correspondent for a popular national newspaper to write an article analysing the vasectomy dilemma, and coming to the conclusion that -+t/s safer to wait-. Having done his homework very thoroughly, to the extent of visiting =r. Moller/s clinic in )openhagen, he stated in his article -The view + have reached can be summarised as follows3 with the present state of knowledge, + wouldn/t dream of having a vasectomy myself-. Though his article was carefully researched and cautious by 8ournalistic standards, there was an immediate outcry by the medical establishment. The $ritish %regnancy 7dvisory 'ervice dismissed his report as -scare.mongering- and other experts he had consulted to get a balanced view before publication asked him not to write about it at all. + was involved in several radio and television debates on the question at the time, and the main argument of the antagonistic doctors was -Jasectomy operations have been carried out for about a century and there have never been reports of an association between vasectomy and atherosclerosis in man-. 5ould they have dismissed such evidence of arterial damage in monkeys, the experimental animal generally considered closest to man, if it had been produced by a drug rather than an operation< +t is more likely there would have been a public outcry, and the drug would have been taken off the market pending further research. 7ll this fierce opposition to even a pause for thought on the vasectomy issue was before the questions of any possibility of it affecting liability to testicular or prostatic cancer, or contributing to the hormonal disturbances involved in the male menopause, had been raised. This reluctance of the medical profession to discuss issues it does not wish to think about is likely to be even greater when the financial considerations of the vasectomy industry are taken into account. +n 7merica for example, it is estimated that #"",""" vasectomies are being carried out each year. 7ssuming on average, with operative fees and all the associated costs such as testing for absence of sperm three months after the operation, the cost of each vasectomy is U;"", that is an annual turnover of two hundred million dollars. 7dd in another fifteen million dollars for the F of men who want the operation reversed at U@,""" dollars each, and a similar amount for treating the other short.term complications such as infection, pain, cysts, granulomas and so on, and this is quite a big business, well worth protecting. There is however one consideration which might give 7merican doctors in particular cause for thought before they continue to recommend and perform vasectomies. This is that 8ust as the drug companies are having to defend some very large.scale group actions for everything from breast implants to drugs such as Thalidomide and 6orplant. +f convincing evidence was produced that serious damage might result from either the antibody formation or hormonal changes which many studies have already shown to occur after the operation, this would open the floodgates for a torrent of highly emotive litigation cases.

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Having enquired in my male menopause clinic for details about their vasectomy in over D"" cases, from not 8ust $ritain and +reland but 7merica and )anada as well, there is usually very brief counselling by non.medical staff, limited to the issue that the procedure must be considered irreversible, and seldom if ever any medical or psychological checks. 6o enquiries are made about previous histories of mumps or the other infections already mentioned as damaging the testes, or of relevant family histories of heart disease, high blood pressure or diabetes. The brochure selling vasectomy in one large clinic in *ondon contains much less information than would be allowed for any medicine which was prescribed for patients. The details are very brief and so incomplete and inaccurate as to flout advertising standards, let alone medical guidelines for informed consent to treatment. There are four brief paragraphs on possible hazards of the operation, which + quote in their entirety so that you can form your own impression whether this is a full and fair advice in view of what was send earlier3 "5omplications, although very rare, can occur with any surgical procedure, however minor, and if you are worried about anything please feel free to call us for advice, or alternatively, if it is convenient, your own 30." "#here is no evidence of any long=term risk to men's health after vasectomy, in fact many couples find greater enjoyment once the risk of unwanted pregnancy has been removed. )rgasm and ejaculation are not affected.C C%perm continues to be produced by the testicles but its passage to the penis is blocked, so it is reabsorbed by the body, just as the body continually re=absorbs all unused cells.C BDasectomy has absolutely no effect on the production of male hormones, the only difference is purely mechanical in that the semen no longer contains sperm". )ontinuing with this limited -purely mechanical- view, the form the patient completes before the operation usually has more room for payment details than medical details. Cften immediately after signing this form the young man, who may be only in his twenties or thirties, without even the time to reconsider which he would have if he were buying a washing machine, is led off to have an operation with possible life.long complications of which he knows little, performed by a doctor of whom he knows less. *awyers defending such cases in the future may have a hard time proving that the individual or organisations performing vasectomies under these conditions were acting responsibly towards their patients. ,overnments also see vasectomy as the cheap and simple answer to population control, and don/t want to hear any bad news about it. This was seen in March !! when *ord 7nthony $lyth in the House of *ords asked Her Ma8estyLs ,overnment -5hether they will take steps to discourage the vasectomy operation in view of the possible harmful effects in the long term.T The Minister, answering on behalf of the ,overnment, *ord Henley, immediately said S6o, my *ords. The decision as to whether or not a vasectomy should be performed in any particular case is one for the patient and doctor concerned, taking full account of all the clinical issues involved. #he patient is entitled to have sufficient information on which to make a balanced judgement. +t is for the doctor, as part of the counselling process, to

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decide what risks, if any, the patient should be warned of and the terms in which any warning should be given.T 0My italics2. ?nder further questioning the Minister confirmed that the ,overnment were satisfied that men were indeed being given adequate advice, discounted the studies associating vasectomy with testicular or prostatic cancer, and omitted to mention any of the studies relating to circulatory disease. 7nother *ord was of the opinion that S+f there was any evidence of harmful effects from this comparatively minor operation, whether in the short or long:term, should not the chief medical officer of the department inform general practitioners of that fact< 7s he has not taken that step, am + entitled to assume that there are no such dangers<T. The Minister confirmed he was. + entirely agree with critics who say that the evidence against vasectomy is not conclusive yet, and much more research is needed. However, as elsewhere in this book, discussion of the topic has deliberately been made provocative to stimulate research and informed debate. Those who have had vasectomies should not be unduly alarmed because most of the long.term complications described are likely to be infrequent, and andropausal symptoms generally respond very well to testosterone treatment. However, sometimes higher doses seem needed in this situation, and because the condition is not reversible, treatment may need to be prolonged. 7lso, unless it is needed to restore fertility, the chances of success decreasing with time, reversal of the vasectomy is not recommended, and might even stir up a fresh storm of antibody production. +t is also quite an expensive operation, and there are only a few surgeons who have the expertise needed for this delicate form of microsurgery, which even in the most experienced hands has its own range of post.operative complications. The first recorded vasectomy was by a $ritish surgeon, 'ir 7stley )ooper who ED@ vasectomised his dog. My clinical experience over the past fifteen years has completely turned me against the operation and made me firmly of the opinion that it shouldn/t even happen to a dog. +f you or a friend are thinking of having the knot of vasectomy tied, my earnest advice to you would be the same as Mr %unch/s to those about to tie the knot of marriage . =on/tA Having answered at least some of the questions about how the Male Menopause or 7ndropause happens, and the part which vasectomy may play, it/s time to find out the good news, that it can usually be safely and effectively treated by giving testosterone.

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Chapter Si= 0 Testosterone Replace:ent Therapy +TRT, 7s will be emphasised in the concluding chapter, T(T is one of the broad range of methods for preventing and treating the male menopause. Cften however it proves the key to the door to recovery, and puts men in a more positive frame of mind to undertake the other necessary steps such as managing stress better, drinking less, losing weight and exercising which they know would help them, but lack the energy or willpower to do. $efore deciding whether T(T is suitable, and what additional treatments are needed to maximise its effects, the physician prescribing it will need to undertake a detailed -work:up-. 5hen you go to him, your health history will should be taken carefully and fully, particularly seeking factors which might have damaged the testes or stopped them functioning properly, such as non:descent, inflammations or orchitis such as mumps, vasectomy and other traumas, and local anatomical abnormalities. Then there needs to be an -7ndropause )heck *ist- similar to the one given in the second chapter. This will establish whether you have the symptoms which could be attributed to the andropause and how severe they are, as well as giving a baseline against which the effects of treatment can be measured. 6ext comes a life:style and stress assessment questionnaire, which can now be computerised to make it easier to apply and to analyse. Cne version which + have devised and used for over ten years is called H&7*TH)H&)9. ?sing as far as possible established and generally accepted questionnaires which have been tried and tested in written form for many years, it assesses the health history, lifestyle factors such as alcohol intake, diet, exercise, relaxation, and smoking habits, and stress related factors. +t measure the amount of stress in your life by getting you to answer which of a list of stressful life events have happened in the last year or you are expecting to happen over the next year, and how much you were upset by them. +t then assesses your anxiety or depression levels over the last month, and how Type:7 or quick:fire, hard:driving, time, time and deadline conscious, as compared to more easy:going, relaxed, laid:back Type:$ behaviour you show. 4inally it does an -&nergy $alance 'heet-, looking at your energy income in terms of satisfactions in different areas of your life, including work, finances, friends, family and relationships, and then the energy drains such as tiredness, health worries, lack of control, down moods and bad habits. +t then instantly analyses the results and gives a detailed print:out of all the good and bad points in an easy to understand report. 6ext comes a physical check with special emphasis on the heart and arteries, testicles, penis and of course digital rectal examination of the prostate gland. 4or those over fifty, it is advisable to have a Transrectal ?lltrasound examination of the prostate, in addition to the mandatory %rostate 'pecific 7ntigen 0%'72 blood test which is the best overall early warning system to exclude prostate cancer, and is essential before considering treatment with testosterone. 6ewer advances in %'7 testing, measuring total and free forms of %'7 may make the ultrasound examination, which is quite expensive and seldom popular, necessary less often. Though the case for early detection of prostate cancer is still being fiercely debated by the for and against early treatment lobbies, five cases of early non:invasive prostate cancer

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were found prior to testosterone treatment in my first thousand patients, and only one developed it during treatment in my first thousand cases, and was picked up by the six: monthly repeat screens at an early, treatable stage. +n both cases this is a lower incidence than would be expected in a group of men the ma8ority of which are over fifty, and would suggest that, by providing the benefit of this careful repeated screening, testosterone treatment is overall more likely to save lives from prostate cancer than to cause it. 4inally, a detailed fasting blood profile including a hormone profile, full biochemistry with checks on the liver, kidneys, blood fats and sugar, and haematological measurements of the red and white cells, is carried out in the laboratory. The hormone measurements include the total testosterone, and the protein in the blood which limits its action, 'ex Hormone $inding ,lobulin 0'H$,2, from which the active fraction, the 4ree 7ndrogen +ndex 047+2 can be calculated by dividing the first by the second and multiplying by a hundred to give a percentage. This key factor should normally be in the range I" to "" per cent, and andropausal symptoms are almost always present when it falls below #"F. 4or reasons mentioned in )hapter 4our on causes of the 7ndropause, while the total testosterone level is often normal, even if in the lower part of the range, the 47+ is usually significantly reduced before treatment, and is the most reliable hormonal marker of the andropause. 6o assessment of a man with symptoms which might be related to the andropause is complete without it. However, time after time in my practice, men tell me -My doctor says it can/t be anything to do with my hormones because he measured my testosterone and said it was normal-. 6early always this means that, as in I#F of my patients, the total testosterone level was normal, but the 'H$, had not been measured, or the crucial 47+ calculated. Gou have to delve more deeply into this complicated hormonal clockwork to get the diagnosis. 7lso measured in the hormone profile are the two pituitary gland hormones which stimulate the testes, the 4ollicle 'timulating Hormone 04'H2 and *uteinising Hormone 0*H2. 4or the reasons again described in )hapter 4our, the former, against textbook theory, is usually raised more than the latter in many, but not all, cases of the andropause. 7nother important hormone which should be included on the initial screen is one from the pituitary gland, prolactin, which as its name suggests in women stimulates breast milk production. +t also acts as a natural contraceptive, reducing fertility while women are breast feeding, and helping to space out pregnancies. +t may be raised in both sexes during periods of stress, which reduces fertility, and can lower testosterone production in the male. (arely, there is a benign tumour of the pituitary called a prolactinoma, which produces large amounts of this hormone, and testosterone levels fall dramatically. This results in loss of libido and potency, and all the other signs of testosterone deficiency. Cne positive benefit of the detailed hormonal profiling carried out in all cases before starting testosterone treatment, was that these tumours are detected at an early stage, before other side effects of the pituitary enlargement such as headaches and impaired vision due to pressure on the optic nerves are felt. 4ortunately, in the five cases seen in my first thousand patients, their symptoms were dramatically relieved by an anti:prolactin drug called bromocriptin, which also shrank the enlarged pituitary gland back to a normal size and avoided neurosurgery. Cne of the oestrogen group of hormones, oestradiol 0&D2, is also included and sometimes gives interesting information. 'ince it is produced in men mainly by the metabolism of testosterone, where that is in short supply the &D often goes down. 5hen the patient is

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overweight, there is a tendency for more of the natural testosterone, and even that given as treatment, to be converted to &D, and this may then rise to a level where it causes breast enlargement and may even reduce the action of the parent hormone. This paradoxical reaction for unknown reasons only seems to happen in a few patients. +t can be reduced by a variety of changes in the treatment given, as some forms of testosterone are not converted to &D. + am currently investigating the use of the newer forms of anti:oestrogen drugs, which are proving very effective in the treatment of breast cancer in women, and show promise as an additional weapon in the treatment of andropausal men. ?nfortunately, as yet there is no convenient blood test for the oestrogen mimics, Neno: oestrogens, or the anti:androgens discussed in )hapter 4our, which may be playing a part in bringing on the andropause, and this would be a great boon to mankind, both in relation to this condition and falling sperm counts. 5hen the results of all these tests are in, which can usually be done within a day if you are eager to get started, then a second session is needed with your doctor. 7t this you go over the results together, and draw up an overall treatment programme, which is usually not 8ust giving testosterone, but also involves active input on your part, modifying your life style in a variety of ways, reducing weight and alcohol intake, moving to boxer shorts, and adopting stress coping strategies if necessary. 7lways remember, you are in the pilot/s seat and in overall control of your life. +n relation to testosterone treatment, having had the risks and likely benefits explained and your questions clearly answered, you have to decide whether to have the treatment and literally, call the shots. T(T can be given in the form of in8ections, pills, pellets and patches. The decision who to treat, with which preparation in what doses , and for how long, must rest with the individual physician, as part of a 8oint and informed venture with the patient. Here + can only give my personal experience, and views derived from that and a review of the extensive literature on the sub8ect. Though when asked where these testosterone preparations come from, doctors sometimes tell patients that it is extracted from %eruvian $ull/s testicles in the mating season, both to explain the cost of the treatment and maximise the placebo effect, that/s a lot of -$ullreally. +n actual fact it is made synthetically in a large scale drug manufacturing process, from cholesterol the same raw material as the body uses to produce it. The cost of these preparations at present is usually roughly two to three times that of equivalent oestrogen preparations used for female H(T, but hopefully as T(T is used more often, drug companies will be able to reduce this sex hormone discrimination against men. 5hen testosterone was first produced back in !@# it was realised that being poorly absorbed and rapidly broken down in the liver, it would not be effective when taken by mouth. The answer was to find different routes of administration so as to bye:pass the liver and chemically modify the molecule to slow its rate of absorption and breakdown. Cne of the most effective means of doing this was to attach side chains to the testosterone molecule and form compounds called esters, the longer the side chain in general, the slower the rate of breakdown. $n>ections +n8ections of pure testosterone were tried early on, but were found to work for only two hours, and though the effects were nice while they lasted, some means had to be found of

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getting a longer period of action if the treatment was to become popular. The first attempt at this was by making an ester called testosterone propionate. Having a short side:chain it only lasted two or three days, but this enabled it to be used clinically even if it meant in8ections two or three times a week. This was the preparation used in !;; by Heller and Myers to demonstrate for once, if not for all, that the male menopause, or male climacteric as it was called then, is due to testosterone deficiency. They also showed in a controlled trial using placebo in8ections of sesame oil, how the symptoms of this very real hormonal disorder, including erection problems, could be abolished by T(T. 7fter the 'econd 5orld 5ar research on finding newer and more effective preparations got under way, and an ester called testosterone enanthate 0%rimo:Teston =epot2 was produced by the 'chering company in $erlin and found to be clinically very effective. Having a longer side chain, it was broken down even more slowly, and in8ections lasted two or three weeks. +t was this preparation which =r. Bens Moller, who first interested me in this treatment, used with such impressive results in his clinic in )openhagen for over thirty years in treating circulatory disorders. +t was given in high doses of D#"mg weekly or even in severe cases twice:weekly, and as in the case of Bames described in )hapter three, usually gave a dramatic relief of symptoms within a few days. +t is also the best in8ectable form widely available in the ?nited 'tates at present, and it produced excellent results in a -Hormonal Healthcare )entre- + set up in Hawaii. The patients + saw there showed 8ust the same symptoms as the ones coming for treatment to *ondon, and it seems that the andropause can strike with equal force even in the -%aradise +slands-. There are other esters, and cocktail mixtures of esters such as the commonly used 'ustenon, available but they seem to have no advantage over testosterone enanthate. They all share the problem that they give a peak of testosterone after a few hours, which is higher than needed and might have some harmful effects, for example on the liver, or the surplus can be converted to oestrogen, which is again undesirable. The level then falls steadily over a week or two to a trough which may be insufficient to relieve the menopausal or circulatory symptoms. The patient is aware of these ups and downs of the testosterone levels, and his life can be a roller:coaster ride of emotional and sexual highs and lows which most men, and their partners at home and in business, do not appreciate. 7lso the in8ections, usually given into the buttock, are somewhat painful and quite expensive, which limit their availability and popularity especially for long:term use. To overcome some of these disadvantages, several very promising new in8ections are now undergoing clinical trials, and offer the possibility of an extended action lasting between two and four months per shot. This would also get round the problems of poor and variable absorption of the oral forms, where #" to E"F of this expensive hormone goes down the toilet, the problem of fluctuating blood levels, and the natural dislike of most men to taking medicine two or three times a day, perhaps for years on end. Pills +t was a tragedy for testosterone treatment that the first oral form to be produced back in !@# was methyl testosterone. This is because it was effective but had some very dangerous side:effects which have tarnished the medical image of testosterone to this day. &ven though we now have much safer preparations, it can be obtained over the counter, without prescription, in many parts of the far &ast and this is still the only oral form of

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testosterone available in the ?nited 'tates. 5hy is that watchdog of 7merican Medicine, the 4ederal =rug 7dministration 04=72, still asleep in allowing this drug on the market, while keeping the much better and safer varieties of this vital hormone out< +t/s harmful side effects include a particularly bad effect on the liver, causing damage to the cells, resulting in cysts and even cancer, which is usually rare as a primary site. ?nlike other forms of testosterone which generally have a good effect, it sends up blood fat levels, particularly cholesterol. This is why one of the doctors who is a leading authority on testosterone, %rofessor &berhard 6eischlag from Munich, firmly stated in his !!" review of different forms of testosterone treatment3 -$ecause of the side:effects methyl testosterone should no longer be used therapeutically, in particular since effective alternatives are available. The ,erman &ndocrine 'ociety declared methyl testosterone obsolete in !E and the ,erman 4ederal Health 7uthority ruled that methyl testosterone should be withdrawn from the market in !EE. +n other countries, however, methyl testosterone is still in use, a practice which should be terminated.- These are harsh words indeed, with which + entirely agree. The dangers of this compound being foisted an a largely unsuspecting public were vividly brought home to me recently by the story of an engineer called 9en who had been forced to go overseas to get his testosterone supplies. "1t the tender age of thirty$seven I started to feel a severe lack of energy, and losing interest in everything, life just seemed too much bother. y work as a service engineer involved new techni.ues using computers, and I started only just being able to keep up with the rapidly advancing technology, instead of being ahead of it as I had been before. #his, and my reduced libido and increasing difficulty with erections all combined to make me feel mildly depressed and generally flat. 4ven my physi.ue started to deteriorate, and when playing s.uash, or even carrying a heavy tool bo! up stairs, began to make me puff and pant. 1fter trying all sorts of things from hypnosis to acupuncture and herbal remedies for three years, I went to my family doctor, who checked me over. 1fter a blood test he said my testosterone was low normal, but said he didn't advise any treatment. (hen I persisted, he got .uite irritable, and said "(ell, your work takes you round the (orld a lot $ (hy don't you get some on your travelsA". 1t the time I was spending alternate months in #hailand, so on my very ne!t trip I went into a drug store over there, where you can get about anything over the counter with no .uestions asked, and got some " etesto". #he label on the bottle said that each white tablet contained 6"mg of ethyltestosterone, made in Bangkok, so it sounded like just what I needed. #he instructions were in #hai, so as there were a hundred tablets in the bottle and I wanted them to last a month, I decided that one three times a day would be the right dose, and away I went. I must say, within a few days I began to feel much better, .uite my old self. y wife said I looked better when I got home at the end of the month, but the job finished and when the pills ran out, all the old symptoms came back. #his time I went to a specialist in the field, who after detailed tests said my testosterone was now only a tenth of what it should be, and the form of testosterone I'd taken had caused some hopefully temporary liver damage and raised my blood cholesterol. *e put me on a safer preparation also taken by mouth and within three months I was feeling fine again, and my liver function and cholesterol were back down to normal.

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2ow two years later I'm having pellet implants of testosterone, which keep me feeling very well and fit. #he funny thing is that my wife, who is going through the menopause and couldn't keep up with my libido, which has returned to what it was before my problems started, is having just a touch of testosterone in with her oestrogen pellet implants, so that we have ended up on the same medicine. There are two much safer oral preparations available in &urope, 'outh 7frica, and 7ustralia, and + have used them both extensively over the past seven years in treating over a thousand patients with symptoms of the andropause. The effectiveness of these treatments and the lack of adverse side effects are described later in this chapter. The stronger of the two preparations is a long chain fatty acid ester called testosterone undecanoate, first used clinically about twenty years ago. +t is known under the trade names given to it by the $elgian company Crganon that makes it, of (estandol in &urope, and 7ndriol in the rest of the world, including )anada where it has only recently come onto the market. +t is made in small oval reddish:brown oval capsules containing ;"mg of the ester, equivalent to D# mg of testosterone. +t is dissolved in arachis oil so that when taken after a meal it is absorbed by the fat droplets coming from the small intestine, goes into the lymphatic drainage, and bye:passes the liver so that it is not immediately broken down. %eak serum levels are reached after two to four hours, and most is broken down by eight hours, so that this form needs to be taken two or ideally three times a day. The other safe oral preparation is mesterolone 0%ro:Jiron2, which comes in the form of white D# mg tablets made by the ,erman firm of 'chering. ?nlike testosterone itself, and other testosterone derivatives, which are broken down to both an active product called dihyrotestosterone 0=HT2 and oestrogens, mesterolone only produces raised levels of the former, which makes it a weaker androgen, particularly in relation to improving both libido and potency. However for unknown reasons, it still sometimes seems to work when the undecanoate fails, and so is a useful reserve form, especially when it is wished to maintain or even improve fertility, which the other preparations may suppress. +t can for example help young men with the -locker:room syndrome- mentioned earlier, and those who wish to have more facial and body hair to make them feel more -macho-. 7n example of this type of case is 6ick3 #hough I'm twenty$two now, and managed to finish my course at university where all my friends claimed to have scored one or more times with girls, without .uite managing it. %ince someone said my penis seemed rather small in the showers one day after a rugby match two years ago, it really seems to be shrinking. #his shattered my confidence and I stopped getting firm erections even when I masturbated.. I felt so bad about this that I gave up athletics and football, and became what you call a computer nerd, preferring the internet to basketball. #hough I took some drugs in my teens, I think it was more a very bad attack of glandular fever I had when I was fifteen that caused the trouble. Because I was very worried about this I went to see a psychiatrist who tried some tran.uillisers on me which didn't seem to help at all, and probably made the erection problem worse. #hen I saw a urologist, who took one look at me and said i was a perfectly normal si-e and should forget about it. But as I couldn't, I went to see an andrologist who took a careful history, e!amined me fully and did a detailed hormone profile. #his showed a slight decrease in the free, active

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testosterone, perhaps due to the glandular fever or the stress of my final university e!ams, and he said that he would give me a short course of a mild form of testosterone called 0ro$ Diron to boost my confidence. #hat was si! months ago, and it seemed to give me a kick start and make me feel confident enough to start a relationship with a girl, with whom I'm having regular se!. %he really is very complimentary about my penis and it seems to respond very well to this, even though I've been off the 0ro$Diron for three months now. Pellets %ellets made of crystals of pure testosterone fused together under pressure or by heat have been made by the $elgian company Crganon and used clinically since !@I. The safety and effectiveness of this preparation can be 8udged from the fact that it has been used virtually unchanged for nearly >" years and has an excellent -track record-. ?nder a local anaesthetic, six to ten of the small cylindrical pellets, each containing D""mg of testosterone, are introduced though a single large needle deep into the fat of the buttock or lower abdominal wall. 7part from the initial sting of the local anaesthetic it is a painless procedure taking about half an hour. +t gives good levels of testosterone for around six months, and is still the longest acting and most steadily effective form of T(T available. Many patients en8oy the freedom from taking the testosterone undecanoate capsules on which they usually start, and feel, like the petrol advertisement, that it puts a -tiger in their tanks-, for six months at a time. +t also gives the most sustained and natural pattern of testosterone related hormones, with no excessive rise in =HT. The only occasional side effect is that one or more of the pellets tracks to the surface, and discharges itself, after which the puncture site heals over again. Cne reason for believing that the very effective relief of andropausal symptoms is not a placebo reaction, is not only that it goes on working for year after year, but that even when he does not know what to expect, the patient experiences a gradual return of symptoms which is obvious both to himself and his family every six months or so. This is often reported as -My battery is running down and + need a top:up-. The long:term safety of correctly applied testosterone treatment in general, and this method in particular, has been clearly demonstrated by over a hundred patients attending my clinic who have been kept free of andropausal symptoms by the implants for over five years now, especially two who have overall been treated for primary testicular failure since their teens with testosterone implants for twenty:five and fifty years respectively. The later was one of the first patients in $ritain to be treated by this method, and $enLs story is part of its history. S(hen I was a young boy, only twelve in fact, my father spotted that my testicles were not in the usual place, having stayed up in my abdomen. #his was very worrying to me and my parents who though I was never destined to go through puberty or become a proper man because I was suffering the then untreatable condition of what was called "0rimary *ypogonadism". #hen at the age of seventeen, with no sign of a breaking voice or body hair like the other boys in my class at school, I had a lucky break by being referred to a @r 0eter Bishop, who was 0rofessor of 4ndocrinology at 3uys *ospital in :ondon. *e had just been over to the 8nited %tates and learned of a techni.ue of implanting pellets of pure crystalline testosterone which they were using over there.

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/rom ;E?? onwards I started having the implants every si! months into the side of my thighs, which was where they did them then. I got to know the clinic staff very well over the years, and they shared my pleasure in going through a normal, though somewhat late puberty, getting a job in the civil service, and then getting married at the age of twenty$ four. I had a happy, se!ually active married life, but with no children of course as the undescended testicles never worked, and had to be removed when I was twenty$si! to prevent them developing cancer. 1t the end of every si! months, I could feel the effects of the testosterone beginning to wear off. 1t about the same time I started to feel tired, my interest in making love to my wife would die away, and it became too much like hard work. #he most severe of these withdrawal symptoms though were violent headaches, like bad migraine. 1lso my penis seems to shrink in, and my confidence just goes. (ithin a fortnight of each implant I felt like 5hris Its true I had a prolonged adolescence, which seemed to go on till middle age, but I never e!pected it to merge straight into what seemed suspiciously like a " ale enopause". (hat a young lad again, and generally more "cock$sure" in every sense of the term. 3irls looked nicer, my beard growth speeded up, my blood felt hotter and I seemed to glow with health. Imagine my surprise and distress then when after being on the implants for over forty$ seven years, I got a letter from the consultant who had taken over running the clinic to say that because of "e!treme cash pressures" they would no longer be providing an implant service, and we would have to go to our family doctors to get injections every two or three weeks. %ometimes when I'd missed an appointment at the clinic, I'd had to try these injections for a month or two, and like the couple of hundred other regulars at the clinic I knew these injections were not nearly as good or as convenient, and certainly didn't give anything like the same steady reliable benefits as the implants. It seemed a rather cynical move on some administrators part to shift the e!pense of our testosterone treatment off the hospital budget into that of family doctors round the country. #hen I had my second lucky break, and found a private doctor who was using the good old fashioned pellet system and everything is fine again now. I've been having the implants for another five years, taking me over the half century of implants mark. #his must say something about the safety of testosterone treatment as my si! monthly blood checks show my body chemistry is fine, especially the prostate test which is as low as that of a thirty year old. #hough I've retired now, I feel very fit, and have taken up growing moustaches of different styles, which I think make me look rather distinguished really. 5ertainly my wife must be very tickled by them, as we had se! five times last week, which is not bad for a nearly seventy year old who got off to a slow start in this area of his life. Patches =ifferent nationalities seem to have different favoured routes for taking medicines. The $ritish are given grace to persevere with their oral tradition, and have a pill for every ill. The 7merican/s are more impatient and direct, preferring in8ections, and have a shot for every spot. The 4rench are a more sensuous race, favouring suppositories and creams, and find a pessary very necessary and that a balm can make you calm. 'o it was naturally a 4rench doctor, =r. Bayle who as long ago as !;D prepared a cream containing testosterone, and it

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became quite popular, with 4rench men at least, who claimed it did wonders for their amour propre. 4rench women were not so enamoured with this treatment because they found that the cream rubbed off onto them, and while it enhanced desire, it put hair on their chest and face, as reported by another 4rench doctor, =r =elanoe in !E;. ?ndeterred, the 4rench went on to develop a gel called 7ndractim containing one of the active derivatives of testosterone, dihydrotestosterone 0=HT2, which they assured the ladies was quite safe because it was rapidly absorbed even when rubbed over a large area of manly chest twice a day.To make doubly sure however, they recommended controlling passion for ten minutes after application of the gel, and then having a shower to wash off any excess. 5e must 8ust hope that they read and obey the writing on the tube every time, because men usually need a large dose of testosterone to improve andropausal symptoms, while in women a little goes a long way. 7lso =HT alone, while promoting facial and body hair growth, as seen with mesterolone treatment which trebles =HT levels, has generally less effect on libido or erection problems in most cases than the pellet implant which leaves =HT levels unchanged. The big breakthrough in patches came with the development by an 7merican, =r.Jirgil %lace, working for the 7*M7 )orporation in %alo 7lto, )alifornia. He developed a whole series of Transdermal Therapeutic 'ystems 0TT'2, including the H(T patch for women, called &straderm. 7s he told me once, he had -a heck of a 8ob- getting the female patch accepted. +t was rather like the incredulity that 'ir 5alter (aleigh met with when he returned from 7merica with a new drug delivery system consisting of the leaves of a plant which you dried, rolled up, and then set fire to before you inhaled the smoke. However, like that system, once it was marketed properly, it soon became a multi:million pound industry 5orld:wide, but unlike smoking, is a much healthier habit giving benefit to millions of menopausal women. 7s =r %lace explained however, developing the male patch and getting it accepted gave even greater problems. 4irstly, a much larger dose of testosterone has to be delivered in the hormone deficient male than the minute amount of oestrogen needed in the menopausal female. 'econdly, the only area of skin thin enough for the testosterone to get through was thought to be the scrotum, and there the skin was hairy and so sensitive that you couldn/t use adhesives, which are irritant, to stick them on. 'o he came up with a patch called Testoderm, which was applied in the morning to the shaved scrotum, itself a ticklish business, and was renewed each day. This appliance of science became known as the -$als: %ratsch %atch-, named after =r. Monica $als:%ratsch of Munich ?niversity who was the first to report in !E> a clinically successful trial using the system. However, extensive trials of the system showed that it was inconvenient to use, likely to be expensive long:term, and had the theoretical disadvantage of producing an abnormal hormone profile. This was because the scrotal skin happened to be the only area of the body rich in an enzyme called #:alpha reductase which converted the testosterone to =HT while it was being absorbed. 4or all these reasons, Testoderm was never marketed on a commercial basis, and has now been superseded by a patch with an even more efficient delivery system which can be applied to any area of skin, even like the female H(T patch, to the buttock. -7ndroderm-, as the new patch is called, was developed by an 7merican company called Theratech +nc., and is being marketed worldwide by 'mith9line $eecham. This is a very promising development, and has undergone multicentre controlled clinical trials showing its safety and efficacy in studies at Bohns Hopkins ?niversity, the ?niversity of ?tah, and 9arolinska Hospital in 'tockholm, 'weden. +t was found that two patches applied every night for periods of up to a year restored a normal hormonal pattern to nearly a hundred

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-hypogonadal- aged # to >#. The main side:effects were limited to slight skin irritation at the site of the patches, a common complication of the female H(T patch. 5ith this excellent research data behind it, the patch received 4ederal =rug 7dministration marketing approval in 7merica with a speed that surprised even the manufacturers, and has 8ust been released in the ?9 as -Testopatch-, causing renewed media interest in the whole sub8ect of the andropause. Here again controversy arises because to meet with orthodox medical approval the manufacturers have obtained a licence to market the new patch for the treatment of male -Hypogonadism-, which is an elastic:sided term meaning many different things to many different doctors. They might well take the view quoted in *ewis )arroll/s -Through the *ooking ,lass- : -5hen + use a word- Humpty =umpty said in a rather scornful tone, -+t means 8ust what + choose it to mean : neither more nor less-. The conventional medical definition would be where the total plasma testosterone is below the -normal range-. $ut we have seen, and the ma8ority of andrologists would agree, that it is the free, biologically active, as represented by the -4ree 7ndrogen +ndex-, which in actual fact determines the adequacy of testosterone for the body/s needs. 'trict application of the former definition, as my research has shown, would exclude over E# F of patients with clear:cut andropausal symptoms from the benefits of treatment with any testosterone preparation, including now the patch. 7lso, there is no real agreement about what the so:called normal range actually is, particularly in men over the age of forty. %rofessor 7lex Jermeulen in the ?niversity of ,hent in $elgium has spent a large part of his long and distinguished career in trying to establish this very point. He has found that that studies to establish plasma levels of the male hormones at different ages can get totally different results according to whether you include or exclude either sick, or exceptionally healthy men, particularly those over the age of sixty, and this does not include the effects on the levels of tissue testosterone and =HT which are more than halved. How do you establish a normal range to diagnose a condition, when fifty, sixty or seventy percent or more may be suffering some related symptoms which could be helped by treatment< 7dd to that the variation of testosterone levels as measured in the same sample in different laboratories using a wide variety of methods, often giving different results, and the textbook definition of -Hypogonadism- looses most of its meaning in the real clinical world. The situation is made even worse by the fact that the units in which all the sex hormones are measured differ between 7merica and ,reat $ritain, together with the rest of &urope, two great nations divided by uncommon units, so that frequently doctors on one side of the 7tlantic don/t know what reference ranges the other side are using. However, if the new patch can breakthrough the current terminology barrier limiting its use, it is likely to be a highly acceptable system and to some patients who find other routes of treatment unattractive represents a breakthrough in treatment of the andropause. +t will also be ideal for the type of double:blind controlled trials which are thought to be necessary to prove that drugs are effective in a particular condition. However already some men are reporting being alarmed to find that they wake up in the morning with their partners H(T patch sticking to them, it having rubbed off in the night and transferred itself. 4ortunately, as the makers say, its an unlikely accident, but how will the women feel when they wake up wearing a 9ing:size male patch, and have to get up and shave< 7h well, medicine is an imperfect scienceA

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Results o9 TRT The results of the study carried out on of the first ;"" of now over ,""" of my patients in *ondon gives + think good evidence that the male menopause is a reality, due to either an absolute or relative deficiency of testosterone, which can be treated safely and effectively with T(T. The age of the sub8ects ranged from @ :E", the mean being #;, which indicates the diverse range of often overlapping factors which can bring on the andropause. This gives it a wider age span than the traditional ;#:## which covers the onset of the menopause in women. 'ince the symptoms had on average been present for around four years however, the peak time of onset is identical. The mental symptoms included fatigue in EDF, depression in I"F, and increased irritability in >"F. The physical symptoms were aches, pains and stiffness, particularly in the hands and feet, in over >"F, night sweats in #"F and yet dryness and thinning of the skin in ;>F. 'exual problems were present in over !"F, and included loss of libido and erectile problems in around E"F. 4or the reasons described in )hapter @, in addition to the changes associated with ageing, possible overlapping causes of these symptoms were stress in >"F, alcohol in ;#F, a wide variety of medicines known to affect potency or which might lower testosterone in over @"F, operations or in8uries which might damage the testes or impair erection, especially in the D"F with vasectomy, another @"F, infections such as mumps, smoking, and obesity all at around D"F each. $ecause of uncertainty about which form of testosterone might be most effective in relieving symptoms, and wishing to have a controlled comparison of the two treatment groups in this prospective study for research purposes, the patients were randomly allocated to medication with either mesterolone 0M'2 or testosterone undecanoate0T?2. $oth groups also received advice on general measures such as relaxation, drinking less, weight loss, exercise and wearing loss fitting boxer shorts, and were followed:up with the same range of detailed blood tests, andropausal symptom check list and computerised psycho:social tests as in the initial -work:up- before treatment. =epending on response and the patients wishes, after six months of either of the oral treatments, testosterone pellet implantation 0T+2 was offered as a choice for long:term treatment. )linically there was an over:all feeling of increased vitality and well:being in all groups. =rive and assertiveness were observed to be increased by both the patients and their partners, but not to the point of aggression. +n fact many became happier, less irritable and generally easier to live with, and felt they were coping better at work and in their family lives. +ncreased hair growth, particularly on the chest and pubic region was often noted by the patients. There was no hair loss from the scalp, and many felt the condition of their hair and skin had improved, with a markedly enhanced ability to tan. 7 few noted their hair colour had been restored. %enile enlargement and increased genital sensitivity were also noted with satisfaction by some. ?npleasant side effects were minimal, and limited to mild gastric irritation in a few patients on T?, and the occasional loss of one or more pellets when the implants were re8ected,

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which is an infrequent complication of this otherwise very convenient and effective form of treatment. 7ndropausal symptom scores all fell statistically significantly and total sexual activity, which includes both intercourse and masturbation increased in all three treatment groups. The benefits were most marked in the implant group, particularly in terms of increasing sexual activity and improving the relationship with the partner. =epression measures also decreased and went from being moderately severe back into the normal range. Cn the safety side, blood pressures were unchanged or even fell slightly in the T? group after six months treatment. There were no adverse changes in blood fat patterns, glucose, liver function tests, or any part of the detailed blood profile. +n particular, the early warning sign for prostate cancer, the %rostate 'pecific 7ntigen 0%'72, did not change at repeated tests up to five years, there were no signs of enlargement of the prostate clinically, or on ultrasound scanning, and no tumours developed. Though a degree of placebo effect cannot be excluded in this type of study, it would not seem to account for either the magnitude or duration of the benefits, or the hormone changes in the expected direction which accompanied them. The very low test doses of either of the two oral testosterone derivatives given for the first month was effectively a form of placebo treatment to which the sub8ects usually failed to respond, when the placebo effect should have been strongest. Cnly when the dose was doubled or trebled to therapeutic levels did they begin to feel the benefits. 7lso with the implant treatment, it was only after two weeks, when the testosterone levels had risen, that the effects were experienced. 'imilarly the observed benefits wore off and the symptoms, especially of fatigue, returned at around six months after the implant, when the hormone levels were dropping back towards their pre:treatment values. i99iculties o9 dou!le0!lind trials. ,eorge $ernard 'haw once remarked that doctors pour medicines, of which they know little, into patients, of which they know less. +n day to day clinical practice, the sum of knowledge is probably much the same, but the former is probably increasing, often at the expense of the latter. Medicine has now become much more of a science than an art. 5hat once seemed simple is now complex. =octors used to give medicines and observe carefully what happened. +f the patients seemed to improve they continued to use the treatment, and if they didn/t, they stopped. Hormone treatments such as cortisone, thyroid hormone and insulin were introduced in this way because the benefits were blindingly obvious to doctors and patients alike, and could make the difference between life and death. +n his use of testosterone in patients with severe arterial disease in the legs, =r. Bens Moller saw the dramatic benefits of treatment in preventing amputation for gangrene in the same light as giving insulin to diabetics, and felt it would be unethical not to do so. However, medical science, before it will accept any line of treatment as being proven, now demands what are known as -=ouble:blind )ontrol Trials-. This means that the treatment on trial has to be given without either the patient or the doctor knowing whether active or placebo drug is being given at any one time. =epending on the design of the study, whether it is cross:sectional, longitudinal, cross:over or the exotic -*atin:square-, this can double, or even quadruple, the number of patients, the time needed, and often the cost as well. +t

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obviously limits the number of doctors who, without extensive and expensive research facilities, are able to undertake such studies, record and analyse them in the required statistical detail. 7lso you now need to tell the patients that they are taking part in a trial, and for them to give informed consent. This makes them dubious about the medicine, and in private practice patients want to be sure that the specialist they see is not acting -blindly-, but giving them the best medicine he could choose for their particular case and that they are they are getting it straight away. 5here the medicine is effective in relieving their symptoms, in a double: blind trial the patients usually know before the doctor whether they are on the active drug or placebo. There is also the confounding effect of the other range of life:style modifications which the doctor will recommend in some patients and not in others, and the variable placebo power of different doctors in encouraging the patients to undertake them. The situation is even more difficult with testosterone treatments because, as was explained to me when + tried initially to get research funds, many of the preparations have been around for between twenty and fifty years, so that they are not only out of patent protection, but in the case of pellet implants, out of the product license period. This limits the interest of drug companies in such products, unless there is a new and difficult to reproduce drug delivery system involved, and they can see a large and guaranteed market. Having said all this, some of the newer testosterone preparations such as the long:acting in8ections and patches may prove to be sufficiently -sexy- for the drug companies or medical research organisations to subsidise scientifically -pure- trials. +n the mean time we will probably have to present the relatively -impure- evidence of the practical experience of patients on treatment, combined with evidence from the literature and the type of cross: sectional research information on changes in symptoms and hormone levels reported in this chapter. The data is there, carefully gathered over seven years in computerised format, testifying particularly to the safety and effectiveness of long term testosterone treatment, and + cordially invite my medical colleagues from an academic medical background to examine, analyse and report on what + regard as a gold:mine of interesting, important and exciting information. #uture irections in Testosterone Treat:ent

+t seems certain that testosterone is a hormone whose time has finally come, and that T(T for men will take its rightful and very necessary place alongside H(T with oestrogen for women, as an integral part of preventive medicine in the Twenty.first )entury. +t is equally certain that new testosterone preparations will have to be introduced, as none of those presently available are ideal. 7s an alternative to these treatments, it may be possible to stimulate the body/s own natural production of testosterone, to slow its use and breakdown, or lessen the factors antagonising its action. +t may also be feasible to liberate and activate the testosterone already produced by the body which would give a form of testosterone.free testosterone treatment, an interesting therapeutic paradox.

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Chapter Se;en 0 Se=ual Satis9action Though physical sexual activity tends to decrease to a variable extent in most men around the age of fifty, overall sexual dissatisfaction was the commonest complaint of all in my heterosexual andropausal patients 0!DF2, as well as their partners 0E;F2. 5hile in no way wishing to suggest that sex is the be all and end all of a marriage, or other long term partnership, as one patient put it, -+t is more than 8ust the icing on the cake : +t is one of the most important and binding of the basic ingredients-. &ven the )atholic )hurch recognises non:consummation as one of the few grounds for nullifying a marriage, and there is an old saying that the rocks on which a marriage breaks up are usually to be found in the bed. 'o what can you do when as the perennially active rock star of the (olling 'tones, Mick Bagger, sings you -can/t get no satisfaction-. $s it your age? Though most people assume that sexual activity is likely to decrease with age in both men and women, it is difficult to assess what reduction is essentially physical, and how much is psychological, a combination of expectations, attitude, and monogamy leading to monotony. Though in the swinging sixties, when the young rediscovered sex and assumed it was largely their preserve, the experts at that time, led by that pioneer explorer of human sexuality, 9insey, gave a rather different picture. They, together with more recent investigators, found that sexual interest and morning erections, a good marker for either actual or potential erectile power, declined only gradually with age, and only went below the fifty percent mark in the nineties. )ompared with the potential market for this important product, even in hormonally unstimulated populations, the actual frequency of sexual intercourse dropped away much more rapidly, and reached the fifty percent mark at around seventy, mainly due to erectile failure. 'hakespeare recognised this problem four hundred years ago when he wrote -+s it not strange that desire should so many years outlive performance<-, a question which taxes the minds of doctors and their patients to this day. The answer could well be that lower levels of testosterone are needed to maintain libido than are required for potency and there are many complex circulatory factors involved in obtaining an erection, and well as the hormonal drive. The spirit is still willing often long after the flesh has weakened, though following repeated erectile failures, the desire tends eventually to fade also. This is likely to become even more of a problem as more and more women go on long term H(T at the menopause. There is evidence that by maintaining their looks and sex appeal, as well as preventing vaginal atrophy and dryness, their expectations of continuing sexual activity are rising year by year, and men are literally not able to keep up with them. The big drop in sexual interest and en8oyment which was well documented for women in their fifties has declined or even been reversed. This is 8ust the time when andropausal men are experiencing the biggest decline in both libido and potency. %articularly as men tend to marry women a few years younger than themselves, increasingly the couple are likely to get sexually out of step, with the male left lagging further and further behind. There is also evidence from a recent study by a =r =avid 5eeks, a clinical neuropsychologist at the &dinburgh (oyal +nfirmary that suggest that the ageing process can be delayed by

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making love more than twice a week. He compared a group of people in &urope and 7merica who claimed to look and feel much younger than they actually were to send him their photos and fill in a life:style questionnaire. He also asked a control group from the same part of each country to do the same, and then got independent assessors to guess the age of all three and a half thousand people, who ranged in age from their twenties to over a hundred. The results were clear:cut, the youthful test group being rated as twelve to fourteen years on average younger than they actually were, and the control group one or two years younger. The differences on the questionnaire were even more striking, the SGoung: *oversT having sex much more often than their peers, many, both men and women, having much younger partners. However, an important feature of any relationship was that it was a loving and happy one, where they regarded their lover as their best friend. This is similar to the results on factors which prevent coronary heart disease where a group in the 6etherlands showed that feeling loved was one of the most important things that kept heart trouble away. 7s 5oody 7llen says S*ove is the answer, but sex raises some interesting questionsT. %erhaps if we can answer some of these questions, the loving element will have a greater chance to express itself. Se=ual Che:istry Testosterone is the hormone which largely regulates desire in both men and women, although its levels are ten to twenty times higher generally in the male. +t is thought to act both directly on the brain, and indirectly in making the genital areas more sensitive and responsive, and enlarging the penis or clitoris. Thus it is generally a sexual stimulant for both sexes, up to a ceiling, which is set by social conditioning. &xperience with patients, and research reviewed by %rofessor $ancroft of the Medical (esearch )ouncil (eproductive $iology ?nit in &dinburgh, in his book -Human 'exuality and +ts %roblems- suggests that there is less overlap between the laboratory -6ormal (ange- of testosterone, and its -$ehaviourly (elevant (ange- in men than in women. This means that if the laboratory measures testosterone levels in a hundred -6ormal- men, age and sexual activity often unspecified, in !#F values of say ":@" nmolRl may be recorded. Many studies, including my own, have shown that the libido will be increased by testosterone treatment in men whose values lie in the range #: #nmolRl, though the proportion of free, biologically active, hormone is as emphasised elsewhere also very important. However, in women, the -6ormal range- is only :D nmolRl, but libido may go on rising up to I: "nmolRl or even higher. This is shown by testosterone treatment, both orally and by pellet implant, for those suffering lack of desire or who lose their ability to have an orgasm for no obvious psychological reason. +t is also reported in women self:medicating with very high doses of testosterone, either in athletes or those wishing to become -The Third 'ex-. That the level of biologically active testosterone is vital to libido in both sexes and sexual function in the male is shown by studies on epileptics. 7nti:epileptic drugs raise the 'ex Hormone $inding ,lobulin protein holding the testosterone in the blood, and preventing it acting. $oth the libido and morning erections are reduced while patients take these drugs, and are restored when they come off them, the binding protein falls, and their testosterone is freed:up again. This is a perfect model of the male menopause, and conclusively demonstrates its reversibility. Science o9 Se=ual Attraction

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%oets and song writers have mused for millenia why it is that men and women fall in love. The psychologists and pharmacologists may now have cracked the problem between them, and though it may not immediately improve their love life or ours, it offers hope for an understanding. The psychologists tellus about the effects of early imprinting and bonding which occur at birth and in infancy. The newborn child is not the passive plastic doll it was once thought to be. +t is a highly receptive, rapidly developing, sentiate being which is aware of, responds to, and learns from, the complex inputs from all its faculties. &ven in the womb it is thought to be soothed by the rythmic beating of the mothers heart, the whooshing of the blood flowing in her abdominal vessels, and the inner reverberations of her voice. 7t birth, and in the first few minutes and hours afterwards, like all mammals, there is a complex emotional and physical bonding process involving all the senses, which will last for life. +f this goes well it can lay firm foundations for emotional stability throughout childhood and adult life. +f it is disrupted by separation, illness or emotional or physical trauma to mother or child, it can leave lasting psychological damage. 4rom the soothing sounds and subdued pink gloom of its intrauterine existance, which it floated in a warm bath of amniotic fluid laced with natural opium:like compounds called endorphins, it is catapulted into the blinding light of a chilly operating theatre, held upside down and slapped until it cries as its mother screams with the pain of childbirth. +n the best of natural childbirth practices, though hi:tech help is at hand if needed, the child is immediately reunited with its mother, held lovingly in her arms, gazes through the accurately fixed focus of its eyes at her face, and listens to her soft and gentle voice. These first impressions go very deep, and it is probable that the variations and mishaps which occur in this bonding process leave the corresponding small or large psychological scars which decide whether and how we are going to bond from puberty onwards. 7fter all, dogs separated from their mothers in the first few hours or days of life, and weaned by humans, often seem to assume they are human, and relate more to human beings than they do to other dogs. The biologist 9onrad *orenz first reported how geese he held immediately after hatching, and fed for the first few days of life became imprinted on him and for the rest of their lives wadled after him convinced they were biologists. )ygnets similarly reared by a cameraman, would follow him anywhere whether he was walking, in a car or in a boat. They could then be trained to carry light cameras on their backs and acheive beautiful films of formations of swans in flight from literally a bird/s eye view. 5ith models like this is any wonder that men tend to fall in love with women who resemble in at least some important respects their mothers, either in their looks, the the tone of their voices or possibly even the way they smell, an important part of sexual chemistry. Phero:ones &ven more than by sight and sound, throughout the animal kingdom, from %haroah ant to the %haroah himself, cupid/s arrows are carried by bodily scents. Though perfumes were developed thousands of years ago mainly to cover up unpleasant body odours with more attractive ones, the more skilled producers learned from the well recognised ability of animals to smell and be sexually attracted by the opposite sex before they catch sight of them. =ogs seeking out the bitch on heat, the musk ox that can scent a potential mate miles away, and the stallion that catches the scent of the mare are timeless examples.

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The term -pheromone- was coined by the ,erman $iochemist 7dolf $utenandt in !#!, and was another of his ma8or contributions to science, the first being the discovery and synthesis of testosterone nearly D# years previously. The term is derived from the ,reek phero 0carry2 and hormao 0excite2, in which is an apt description of these airborne chemical messages promising sexual excitement, a sort of long:range biological dating agency. Though first described in female silkworm moths, similar chemicals were found in female monkeys, and in women, where it peaked at the time of ovulation and was under the control of the oestrogen hormone. Thus it was shown that from the time when oestrogens surged at puberty, the inner female hormones started the production of these outer chemical signs of sexual maturity and availability. 'imilarly the main sex hormone in men, the androgen testosterone, is broken down to two components called androstenone and androstenol, which at a subliminal level are thought to be powerful sexual attractants. They are released in the odours of the armpits and scrotum, in urine and in saliva. 7ndrostenone gives a characteristic smell to male urine, and is what the sow is detecting when snuffling for truffles, which is perhaps why this rare and exotic fungus has a reputation for being an aphrodisiac. 7ndrostenol has a musky odour, which is less obvious, but probably equally potent. 7s the average female nose is at the height of the average male armpit, dancing can be seen as an intense form of exchange of bodily gases preceeding the exchange of bodily fluids. 7fter the andropause, because of the low testosterone levels, the phermonally deprived male does not feel as sexy or smell as sexy as the pungent sexually active man in his prime. (esearch urgently needs to be done to see whether these are restored by hormone replacement therapy with the parent compound, testosterone. Ready 9or (o;e 5hy is it that in spring a young man/s fancy lightly turns to thoughts of love< 5ell, even though the mating season isn/t what it used to be, probably because of all the year round stimulation by artificial lighting and television, there are good reasons for this in terms of the hormonal rites of spring. 7s the urban cave dweller emerges blinking into the spring sunshine, he drinks up the sun. This is seen particularly in the more northern countries such as 'candinavia, where the winter nights are long and the days often overcast with clouds. There people often 8ust sit out in the open sunning themselves as though mentally thawing:out. The bright light has the effect of reducing the level of a hormone called melatonin, which is produced by a small gland lying between the hemispheres of the brain, called the pineal. This could be thought of as the -Hibernation Hormone-, and when its levels are high it makes us feel sleepy and lethargic, and not very sexy. 'ome people seem to get a surge of this hormone in the 7utumn and it makes them feel quite torpid and depressed, a condition known as 'easonal 7ffective =isorder or '7= for short. This can be prevented or treated by mid:winter sunshine holidays or by bursts of intense artificial daylight. The lengthening days as winter turns to spring, combined with the increasing brightness of the light, which via connections with the optic nerve, together get the message through to the pineal gland, which has been appropriately called the third eye, to switch off its production of melatonin. This not only causes generally greater mental alertness, but raises

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levels of a variety of brain chemicals, called neurotransmitters, which stimulate and arouse us, making us feel full of the 8oy/s of spring, and as lively as a spring chicken. $ecause these neurotransmitters regulate mood, they have been the target for intensive study by most of the ma8or pharmaceutical companies, who see the potential market for the chemical production of happiness, peace and love in bottled form. 'ince 7ldous Huxley in his book -$rave 6ew 5orld- back in the !D"/s first coined the advertising slogan for the mythical drug he called -'oma- of -Take a gram and don/t give a damn- there have been many false dawns. The prototypic tranquilliser Jalium was originally market with pictures of tigers changed into pussy:cats. ?nfortunately it was found that if you take the edge off the -(azor:blade of life down which we slide- according to the 7merican humorist Tom *ehrer, you take the edge off many of life/s 8oy/s also and blunt performance and creativity. +n the same way, some of the early anti:depressant drugs showed pictures of space rockets lifting off for the moon, to illustrates the hoped:for lifting of spirits of the depressed person. However, though they proved usefull in some cases of severe depression, they have not proved a panacea, and the results of such treatments have often been somewhat depressing to patients and doctors alike. +t seems that the complex mysteries of the human brain still elude our grasp, and though improvements in psychopharmacology are steadily improving the drugs available for mental ailments, we cannot safely manipulate mood without risking severe side effects. Though the wonders of modern science, we have been able to get to the 'ea of Tranquillity on the moon, but but still come back to a sea of tranquillisers on the &arth. ?nfortunately, is is in the field of sexual activity that the undesirable side effects of tranquillisers, antidepressants and sleeping pills are most severe and unpleasant. 4or liveliness, loving, libido and the pursuit of sexual fulfillment, we need 8ust the right mixture of hormones and neurtransmitters, in the right brain cells, at the right time. 7t present we seem like the sourcerers apprentice, either gettin insufficient response, or swamping the delicate brain systems involved in arousal, erection and orgasmic satisfaction with floods of neurotransmitters which drowns their responses rather than restoring them. This is why unless the anxiety or depression is very severe and prolonged it is generally better to use gentle non:drug approaches such as psychotherapy, psychosexual councelling and non:drug relation techniques, meditation rather medication. The #ood o9 (o;e 7s well as music for putting you in the mood for love, there are some foods which may gently help to regulate brain chemistry to enhance both desire and sexual activity. Two of the most importantant neurotransmitters in the brain are serotonin and the mono:amines. 'erotonin is derived from a plasma amino acid called tryptophan, and after this is taken up into the brain, a good supply of vitamin $> is needed for the conversion. Most diets contain sufficient protein to supply the necessary tryptophan, and too much protein may increase competition from other amino acids for uptake into the brain. 'imple sugars such as glucose and sucrose cause the release of insulin, which removes these competing amino acids, and improves the uptake of tryptophan, and hence the production of serotonin. The predominant brain mono:amine is noradrenaline, which is produced in the brain, again with the help of vitamin $>, from the amino:acid tyrosine. This is again present in most proteins, and is easily taken up into the brain in proportion to the amount of protein in the

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diet. 7nother mono:amine is phenylethylamine which is present in chocolate and may account for its reputed aphrodaesic properties. 7rmed with all this essential biochemical information, we can boldly go forth to try a meal guarenteed to stimulate passion. 7fter the relaxing champagne, which also stimulates female testosterone production, we have the suggestive goats:cheese starter, redolent with mono:amines. This is followed by the minute steak, to boost tyrosine, new potatoes with butter to again help testosterone production, and a fresh green salad to enhance vitamin ) levels. The coup de ,race is the -=eath by )hocolate- cake, topped with $>:rich walnuts. This is surely a recipe for sexual success, providing it doesn/t bring on a splitting migraine headache in the woman, or an instant heart attack in the man. Can Se=ual Satis9action !e $:pro;ed? )ertainly it is possible in the vast ma8ority of cases to improve sexual satisfaction for both partners, not only by Testosterone (eplacement Therapy, but also by a range of additional techniques such as sex education, focusing particularly on the physical, hormonal and emotional changes occurring at this time of life in the male, and where necessary psychosexual counselling or couples therapy. 5ith reassurance that there may be a physical basis for the male partner/s apparent lack of desire, as well as his unwillingness or inability to perform, a tense situation can often be defused and the relationship helped on the road to recovery. +n particular emphasising the good non:sexual areas of the relationship, and the en8oyment that both partners get from this, can reduce the friction which prevents either from en8oying any aspect of physical contact and be a good start to setting the scene for resumption of a good sex life. Cne or both may also need to learn a good relaxation technique as described in the next chapter, and small amounts of alcohol, such as a shared bottle of wine can help, but too much can hinder. 4or most couples, when the first flush of passion is over, a sexual session needs time and energy. &rections are much harder for a man to maintain when he is rushed or tired or both, and his fight:flight alarm system is working against the penile pump:up system. +f one or both partners are under pressure, a SdatingT system may help when they together chose a time and place they feel most relaxed and happiest together. Cne patient, when + suggested this, said he and his wife had such different conflicting time deadlines in their busy lives, that it was rather like timing a moon shot. +f it works however, by some mysterious process it usually gets easier and easier to find the moon in the seventh high. Massage, especially in subdued light or candlelight, and with music to soothe the savage breast, can be both relaxing and a turn:on, as well as being part of Sgetting in touchT. 9ind, loving, encouraging comments on the other person and the effect they are having on you, work much better than even the most constructive criticism. 4ortunately, nature is kind in that we tend to get long:sighted around the age of fifty, so that skin blemishes and the occasional wrinkle are blurred over, and hopefully we remember how we wanted our partners to look, or they did look, in their physical prime. 'uch methods are all part of encouraging the realisation, that sexual activity can be pleasant and satisfying even without penetration, and that usually under sufficiently relaxed conditions both partners can have orgasms by mutual masturbation, oral sex or any of the increasing variety of S'ex:aidsT that can be bought mail:order or from a local store. 'exy

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garments, perhaps chosen by the other person, all have their part to play in setting the scene. 4ortunately, with the more frank approach that medical assessment and treatment encourages, combined with these common:sense self:help measures, the situation usually improves to the point where full intercourse resumes or becomes more satisfying. +f this doesnLt happen, and there still appears to be a large anxiety or emotional part to the problem, then the more gradual approach under the guidance of a properly qualified sex: therapist, who often uses a technique known as S'ensate focusT should be tried. This involves stages of being touched for your own pleasure without genital contact, then giving feedback on what you find en8oyable as well as unpleasant, and finally en8oying the experience of touching and being touched including genital contact, and if it happens, orgasm, though this is not the aim. %remature e8aculation, which often accompanies erectile difficulties, be treated by medication, as described later, or by a Sstop:startT technique, initially by hand, and then with the woman sitting astride the man to give better control of withdrawal and re:entry. 7lternatively, the SsqueezeT method described originally by Masters and Bohnson in !I", can be used, where when the man is about to e8aculate, the woman gently but firmly squeezes the base of the head of the penis, until the impulse to e8aculate immediately subsides. Cne worrying statistic is that in one community:based study in the ?nited 'tates of the sample aged between forty and seventy, 8ust over half felt that their erections were inadequate. This is a ma8or health problem which is seldom adequately investigated or treated. 7t this stage it is appropriate to describe how erections happen so that we can better understand what can go wrong, especially with age or an insufficient hormonal head of steam, and how it can be helped and encouraged. Mechanics o9 erection ManLs ability to have an erection, which has been worshipped from the earliest of times, as in the 'hiva *ingam in +ndia, and at the vast temple of 9arnac in &gypt dedicated to the ,od Gamuna, is a recurring miracle of hydraulic engineering. +t is brought about by a complex series of chemical changes and nerve reflexes, which work together to increase the amount of blood flowing into the penis, and temporarily decrease the amount going out. This event, which is achieved with effortless and sometimes embarrassing ease in the teens and twenties, usually becomes a more difficult feat in the thirties and forties, can be variable in the fifties and sixties, and often a disappointingly brief and infrequent wonder in the seventies and beyond, especially in the SHormonally )hallengedT andropausal male. 4or the amount of blood going into the penis to be adequate to it pump up the two elongated blood sacks which become engorged and create the erection, the corpora cavernosa, there needs to be a good flow of blood in the artery to the penis, relaxation of the blood vessels inside it, and reduction of the amount of blood draining out. +t is rather like pumping up a bicycle tyre and hoping for a smooth ride. +t you donLt pump hard enough, the walls of the inner tube are perished or stuck together, or the valve is leaky and lets the air out as fast as it goes in, only hopes are inflated. 'ometimes the small artery supplying blood to the penis is clogged up because of a generalised arterial degeneration called atheromatosis, which is the commonest cause of coronary heart disease. This is more frequent in those with high blood cholesterol levels, in

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diabetics and in smokers, who are more prone to erection problems. 4ortunately, it is seldom sufficient on its own to cause the problem, and when it is, arterial surgery to provide additional blood supply is occasionally successful. The pooling of blood in the penis which produces its rigidity is dependant on hormonal priming, local chemical factors and a balance of nerve stimulation. $ecause of the complexity of this mechanism, it is easily upset by hormonal insufficiency, a wide range of medications and emotional reactions, especially anxiety. &ach of these needs to be considered in cases of erectile difficulty, and corrected where possible. The causes of erectile problems are many and varied, and by the time the patient comes for treatment several overlapping factors are usually present at the same time. &specially after the problem has been causing great distress to both partners for some months, or even years, there are certainly likely to be relationship problems as well as the dreaded performance anxiety. 7 very broad approach is therefore needed to treating what may seem like a simple mechanical fault, and important though + believe such treatment is, it is not 8ust enough to throw testosterone at it and hope the problem will go away and stay away. To do the 8ob properly the whole man has to be screened and a range of treatments appropriate for that patient needs to be advised. Cften the patient and his partners efforts to overcome the problem are 8ust as important as the doctor/s. There is the story that seems appropriate here of the man who went to seek medical advice and was given treatment which needed a lot of life:style changes and self effort. $eing by nature a lazy fellow, before he left the consulting:room he disbelievingly asked the white: coated man sitting behind the desk -7re you a real doctor<-. -The question is- said the doctor, -7re you a real patient</. Testosterone and Erectile #unction Though it is difficult to say precisely what part testosterone plays in helping to produce erections, it certainly both primes the penis and triggers the chain of events which bring it about, controlling as it does libidinal impulses. Gou will remember Mae 5estLs famous remark to an enthusiastic cowboy who came to her saloon, S+s that a gun in your pocket, or are you 8ust glad to see me<T +t is surprising but gratifying how often when adequate testosterone therapy is given, all the symptoms of the andropause disappear, including erectile difficulties, within a few weeks or months, particularly when other factors contributing to its onset or continuation are dealt with. 7 statistically highly significant improvement in erectile function occurred in over seventy percent of my first four hundred cases treated with a variety of different forms of testosterone. This was particularly marked with the more powerful oral preparation, (estandol, which sometimes needed to be given in high but safe doses, and with the pellet implants. Though this use of testosterone to help erection problems is controversial, and not acknowledged by some authorities which say it only increases frustration, without giving back the means to perform, this is certainly not my experience in this large group of patients. The efficiency of testosterone is restoring potency is a common experience with doctors prepared to give it an adequate trial. +t was even recognised over fifty years ago in the article on the SMale )limactericT by =rs Heller and Myers described in detail in the first

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chapter of this book, who found that erectile function returned in nearly all the patients they had shown to be testosterone deficient when they gave the hormone, and went away again when they stopped. &ven though it is more difficult to restore function than desire, unless the source of the problems is obviously psychological, it seems logical to investigate the level of free active testosterone, and boost it if it is low. +t The accompanying increases in libido, confidence and energy greatly encourage the patient to try supplementary mechanical and medicinal methods where these are needed in addition, at least until confidence is restored. Se=ercise 'ex is the most vigorous form of exercise most people take, and for some it is the only form. Measurements of pulse rate, blood pressure and hormones before during and after exercise have shown surges in the stress hormones during sexual activity, together with rises in heart rate and blood pressure. 4ortunately, these go down to baseline levels or even below in the recovery phase afterwards, and there is then an increase in testosterone. (egular sexual activity, even if the man cannot always achieve penetration, is to be encouraged in the prevention and treatment of the andropause. +f this is not possible because a partner is either not available or not willing, then masturbation about once a week stops the erectile system -going rusty-, and may stimulate testosterone production. 7s 5oody 7llen says -7t least masturbation is sex with someone you love- and is a legitimate way of maintaining sexual competence providing it doesnLt take over from other forms of sexual activity. 4rom the medical point of view occasional masturbation can be beneficial, as long as it doesn/t get out of hand. rugs which help and drugs which hinder =rugs given for medical reasons can often play apart in bringing on the erectile problems which contribute to the menopause. The motto is S+f in doubt, check it outT. They include in particular virtually any drug used to reduce the blood pressure, but especially the so:called beta:blockers. +t is a problem to know how to keep the blood pressure under control but avoid these side effects. $ecause hypertension is often stress related and -6ot so much an illness, more a way of life-, stress management by the methods described above, particularly 7utogenic Training, can be tried with mild to moderate elevations in blood pressure, and will help to reduce the -%erformance 7nxiety- element in erection problems. 7lternatively, sometimes switching to a different preparation, such as *abetolol 0Tranxene2 or the new S7lpha:blockersT which seems to interfere less with erections, can be helpful in combination with testosterone treatment, which does not itself generally raise blood pressure and may in some cases lower it. 7 wide variety of tranquillisers and antidepressants are also associated with impaired erections and are used to treat many conditions with symptoms which overlap with those of the menopause, so it is not clear which is doing what. %rozac is occasionally helpful in treating depressions associated with the andropause, as it also seems to reduce the common tendency to premature e8aculation which accompanies difficulty in maintaining an erection. Jirtually all antidepressants can have a harmful effect, except possibly the newer generation of drugs such as %rozac. These have a different action on the brain from the other

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compounds used to treat depression, by inhibiting the uptake of a chemical by which one brain cell activates another, # hydroxy:tryptamine 0#HT2. 'ome specialists are sufficiently enthusiastic about this type of compound to recommend its use in premature e8aculation, though through limited experience this may prove to be a case of premature e8udication. 7n antidepressant called Jenlafaxine 0&fexor2 made by 5yeth is reputed to had the least effect on libido or erectile function, and few side effects generally. 7nother possible exception is the older anti:depressant, Trasadone, marketed in the ?9 as Molypaxin. ,iven as a single dose of I# to #"mg half an hour before sex, it can in some cases help in obtaining erections over a one to two hour period. +ts effectiveness varies widely from person to person, and may 8ust make them feel sleepy, which is no usually the desired effect. 7sthma treatments such as ephedrine and many other inhalers can also sometimes make erection problems worse, and a trial of withdrawing treatment where possible, or switching to a different treatment can help. &ven stomach medicines such as Tagamet have infrequently been shown to cause problems, as have a seemingly endless list of medicines. =rugs of addiction appear only to be a problem if being used in large amounts and causing psychological or social problems. They may however accompany an alcohol problem, or be used to avoid facing up to the issues contributing to the andropause. 7gain the appropriate agencies such as narcotics anonymous may need to be involved. Though erection problems often decrease or even disappear with combined treatment with testosterone and the other measures described, particularly in diabetics or those with heart and circulatory problems, there may be some continuing difficulty. +f they fail to respond, or testosterone treatment is unsuitable or unacceptable, there are a range of other measures which can usually solve the problem one way or another. Gohimbine, marketed in $ritain and the ? ' 7 as Gocon, is a preparation of the bark of an 7frican tree, %ausinystalia yohimbe, which when taken by mouth in some cases seems to act on the brain both as a sexual stimulant, boosting the libido, and improving erections, particularly in people on testosterone. +t is usually taken as one #.;mg tablet three times a day, or alternatively between one and three tablets half to one hour before intercourse, which + have found to be a more effective and economic method. +t shouldnLt be given to nervous individuals, who can become more anxious on it, or in those with high blood pressure where it can have an unpredictable effect. There are a variety of substances which can be in8ected into the penis by the patient himself 8ust before intercourse to provide a serviceable and sustained erection. Many urologists encourage the patient to go straight for this option, without detailed examination for signs and symptoms of the andropause. This is a pity as many men find it a bit cold:blooded and premeditated, and their women find it unromantic, mechanical and sometimes an insult to their sex:appeal. 7s one wife said, inaccurately in her husband/s case, -+f + were as attractive as Marilyn Monroe, he would get an erection immediately, wouldnLt he<-. Though it has a high success rate, usually around two:thirds of even resistant cases responding, about half the people who say they/ll try the treatment drop out because they or their partners find it unacceptable. %apaverine is the most commonly used of these in8ections, and is a cheap and stable preparation. +t is in8ected through a short and very fine needle into the shaft of the penis, and increases the flow of blood into the two spongy corpora cavernosa running along both

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sides of the penis, helping to produce and maintain an erection. 7ccording to the carefully regulated amount in8ected from the small syringe provided, which is similar to that used by diabetics, the length of time the erection is maintained can be ad8usted, according to taste and 8oint enthusiasm of the partners, from quarter of an hour, to one hour or more. Moreover it carries on even after the man has reached orgasm and e8aculated, which some couples find adds to their en8oyment. 7part from its artificiality, the slight stinging pain experienced when the needle is 8abbed into this very sensitive part of the male anatomy, and the possibility of bruising especially if the patient is on anticoagulants or even aspirin, sometimes erections persist for several hours or more, which can be dangerous as well as uncomfortable and socially inconvenient +f it lasts for more than four hours, it is known medically as priapism, and this should be dealt with as soon as possible in a hospital casualty department to avoid bruising which may last days if not weeks. More gentle in its action, and less liable to cause priapism, is another in8ection used in 8ust the same way, similar to the natural substance in the body called prostaglandin & . This has recently been introduced in this country by, appropriately, ?p8ohn %harmaceuticals, as )aver8ect 0alprostadil2. This is a definite advance, but tends to cost about the same as a bottle of champagne for each shot, and even if you can afford the expense, unlike champagne, it is not recommended for use more than three times a week. There are rumours however of a real breakthrough being tested in +srael, in the form of a prostaglandin cream which can be absorbed through the skin. There is also a cream made by the 7lza )orporation in %ala 7lto in )alifornia, which can be squeezed into the opening of the urethra at the tip of the penis, massaged up the penis, and be rapidly absorbed into the cavernosae. These preparations will hopefully have the same effect as the in8ections, but be less painful, less expensive and much more acceptable to both partners. Mechanical Methods There are a variety of mechanical devices which can be used to promote the flow of blood into the penis, and lessen the amount going out if other methods fail or are unnacceptable. The simplest of these is a rubber ring, usually called the $lako ring, which comes in different sizes, and when rolled down the semi:erect penis, rduces the outflow of blood in the veins, which can help to obtain and maintain a full erection. 7nother device is a suction device consisting of a glass tube which is slipped over the penis and applies negative pressure gently to it by means of a mechanical pump. 5hen a full erection has been acheived, a tight elastic band similar to the $lako ring is slipped off the end of the tube nearest the patient, and prevents the blood in the penis from flowing away. However, many patients find this way of getting an erection cumbersome, unromantic and even painfull, so it leaves a lot to be desired. Surgical Techniques (arely, none of these treatments work, and then the opinion of a urologist specialising in this field should be sought. 7fter investigation of the arterial inflow and venous outflow of the penis, he may recommend vascular surgery, or one of the inflatable or soft metal, bendy: toy, penile implants. 7ll these methods can produce good results in the right hands, but none of them are much use if the other symptoms of the menopause, especially lack of libido, are untreated.

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%ood Ti:es Co:ing 4inally, there is good news long term, in that within three to five years erection problems may largely be a thing of the past. (ecently there have been very promising new developments in the field of nitrous oxide and the erectile mechanism. 7 new type of nerve has recently been discovered in many organs in the body, including the penis, which amongst other important actions, relaxes the smooth muscle fibres controlling the diameter of small blood vessels. These are known as S6itrurgicT nerves because by releasing nitrous oxide they allow the blood vessels in the penis to dilate, which then become engorged with blood, producing an erection. 7nything which helps nitrous oxide production encourages the erection. This is why in the nineteenth )entury, S*aughing ,asT %arties became popular in some social circles, where the gentry and their ladies sat and lay about inhaling nitrous oxide. This gave the men erections, and the ladies the giggles, with a general aphrodisiac air all round. 'imilarly, amyl nitrate has been used for sexual stimulation, and its ability to relax smooth muscle in various parts of the body. %harmacologists have as you can imagine been working round the clock to synthesise a drug which would help promote the increased formation or decreased breakdown of nitrous oxide, which has been described as SThe key mediator of erectionsT. 7t present %fizer drug company appear to be ahead of the field, and have come up with an orally active drug which stops the breakdown of nitrous oxide, so that it accumulates in the walls of the blood vessels, keeping them relaxed and the penis erect. This eagerly awaited preparation is called J+7,(7, and one tablet brings on a sustained erection lasting for up to three hours in !"F of cases. +t is currently undergoing its S%hase @T trials, and should be on the market before the end of the century : truly a giant leap for mankind.

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Chapter Eight 0 Secrets o9 8itality and 8irility 5hat conclusions can be drawn from these ideas about factors affecting men/s health at different times of life< + believe there are lessons for society, as well as individuals living in that society, and what affects the well:being of one will affect the well:being of the other. %ollution of the external environment with xeno:oestrogens for example, can have life:long effects on the male, from causing the birth of a child with impaired sexuality, to creating a subfertile male more prone to having a severe mid:life crisis, and premature andropause. %robably the best way of drawing these strands together is to consider the causes of the andropause and the possibilities for avoiding and treating this drop in both vitality and virility, one by one. Male Psyche &nder Threat &arly prevention in terms of producing a male infant best equiped to maintain his masculinity for life is largely up to society to identify the sources and then reduce the levels of xeno: oestrogens in the environment so as to minimise this -threat to the male-. This fight for masculinity is a life:long battle, with both chemical and psychological warfare involved. +n the battle of the sexes, men are losing the fight, and have been described as being -Cut for the )ount-. This is not 8ust in relation to the falling sperm count, but is being seen throughout life. +t could also be called the battle of the hormones, because generally male and female hormones have opposite and opposing actions. Many of the battlegrounds are social and psychological and these also need to be considered when planning for the future health of men. This struggle is evident in everything from clothing to work. 4or example, as well as reducing fertility and testosterone levels by raising the temperature of the testes, 8eans are also symbolic of the identity and role crisis in the adolescent male. +f everyone is wearing the trousers, mentally as well as physically, what/s so special about being male< -Me Tarzan : Gou Bane- doesn/t really seem to cover the situation now. 7lso there is a trend for women to be more sexually assertive, both in the &ast and 5est. +n Bapan, a few of what used to be shy retiring office girls are flaunting their sexuality, dancing provocatively in the scantiest of costumes during bodycon 0body consciousness2 evenings, stuffing bank notes into the posing pouches of hunky male strippers, and choosing a string of lovers. +n the 5est, the feminists, having got most people thoroughly confused about what is really expected of the -6ew Man- are tending to turn on each other, and there is a fashion to alternate between heterosexual and homosexual relationships. ,roups are starting up for women who want to experience dressing, walking and talking like a man. Meanwhile, some young girls are tasting the delights of gang warfare, and forming bands of highly aggressive muggers. +ncreasing numbers of men who used to bond with body contact activities such as the rugby scrum, are now holding hands and exploring the feminine side of themselves in encounter groups. Many men stagger away from the divorce courts with little more than the cloths they stand up in, while alimony, palimony and child support lessen their financial independance. *oss of work from factors such as computerisation and the world:wide recession can also at any time cast them in the unaccustomed role of -House:Husband-.

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+n my practice + am seeing increasing numbers of young men in their teens and twenties with what could be called the locker:room syndrome. This is an anxiety state where they do not feel sufficiently masculine in terms of their physique, body hair or penile proportions. +n its fully developed state it can cause agonising self:doubt to the extent of avoiding sexual relationships altogether, stopping playing team sports which might involve communal bathing afterwards, and in extreme cases even avoiding public urinals where unfavourable comparisons might be made. This is made worse by the increasing sexual experience of women, who may have had several better endowed lovers in the past, or have seen hard or soft:porn videos or magazines, who as the young men are painfully aware, always feature handsome, muscular males well equipped to have sex non:stop, -bonking like beam engines- as one woman TJ interviewer put it, for hours on end. 7s one +ndian 7rmy officer said after watching a mammoth performance by an elephant in must servicing a female, -That/s a tough act to follow-. This is a difficult condition to treat, and endless reassurance about -+ts not the size that counts- doesn/t seem to help. ,eneral psycho:sexual counselling, sometimes over several months, together with assertiveness training, and hopefully a loving supportive relationship with a partner, give the best hopes of a cure. 'ometimes a brief course of testosterone in low doses can cause more feelings of assertiveness, boost confidence and induce a more macho mood, where the penis feels more adequate and erections are stronger and seem bigger. %enile extension operations, even in men who are in stable relationships and have fathered children, are beginning to be performed on 6ational Health 'ervice patients in $ritain. However, this may well not be successful, and seems an expensive physical approach to what is essentially a psychological problem. There are other factors also which are making women, particularly in mid:life , sometimes feel sexier and act more assertively than their male counterparts. +n particular there are the problems caused by the andropause, which as mentioned earlier is generally neither recognised nor treated, in contrast to that in women which is treated much more seriously and more often, as described earlier. Bust as increasing numbers of men are fading fast, many women are coming into their managerial prime, and both in business and in bed men feel they can/t keep up with them. =oes this mean that businessmen are now beginning to feel sexually harassed< 5ell, probably not in this country yet. +n 7merica increasing numbers of men claim to be, and lawyers specialising in this new crime in the office 8ungle are thriving. This may be partly because the 7merican female is supposed to be more emancipated and - up:front - about her sexual needs than her $ritish counterpart. Then there is the interesting research finding that more confident and dominant women show higher levels of testosterone than less assertive, stay at home, types. +t has long been known that power is an aphrodisiac throughout the animal kingdom, but particularly in human beings. The principle of survival of the fittest has meant that high:ranking males sought out high:ranking females and vice:versa. 4rom Kueen $ to Mrs T, that is $oadicea to Thatcher, some men have been turned on by the aura of power, while other usually less confident ones have been turned off by it. &ven male politicians, who by tradition en8oy and take full advantage of the aphrodisiac of power, are now feeling more threatened. The more politically correct labour party in $ritain

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is introducing positive discrimination in favour of women in the selection of parliamentary candidates and ministers for shadow:cabinet posts. +n the sparring:match between the previous and present %rime:ministers, in the red corner is $aroness Thatcher, Mrs T or the +ron *ady, pumping testosterone and iron in equal proportions, while in the grey corner, taking a terrible battering below the belt, is Bohn Ma8or, who has been described as the -Testosterone:4ree- %rime:Minister. 6o wonder the male mid:life crisis is striking with increasing frequency and severity. 'uicide rates in men, always more frequent than in women, are increasing rapidly. 7 recent study in $ritain by the 'amaritans organisation called -$ehind the Mask- showed that over the last # years women/s suicide rates had halved, while men are four times as likely, especially between the ages of @# and ;; the peak mid:life crisis years. The world:wide recession is adding to this toll, with middle:aged men fearing that if they lose their 8obs they may never work again. Many are having to face complete role reversal, staying at home as house:husbands, while their wives go to work as the bread:winner. Though women generally complain more about their health, to family, friends and their doctors, the amount of life threatening illnesses they suffer is generally less than the male, and more is spent on their health care. 7part from their higher suicide rates, more men die from accidents at all ages, particularly when young from road traffic in8uries. ?nder the age of fifty, men get five times as many heart attacks as men. 5omen have millions of pounds of 6ational Health 'ervice money spent on screening for cancers of the breast and cervix, which are decreasing, while men have virtually nothing spent on detecting prostatic or testicular cancers, which are becoming more common. 7s a result of these combined factors, the life expectancy of men in most 5estern )ountries, including the ?9 and ?'7 is I:E years less than that of women. +s this an unalterable fact of life, or would better health care for men, including hormone replacement therapy with testosterone, narrow the gap< 5e should urgently be trying to find out. Cne of the countries with the lowest gap in life expectancies is ,reece. ,reek men also have one of the lowest heart attack rates in &urope. Though this is doubtless partly due to sharing with equally low attack countries such as +taly and 4rance the benefits attributed to a -Mediterranean =iet-, there would seem to be other psychological and cultural factors at work also, and it is worth looking to see what we might learn from their experience. +n ,reece the birth of a male child is a matter for great re8oicing, congratulations and celebrations, whereas the parents receive sympathy when a girl is born. 'ons are the centre of attention in the family, and are spoiled continuously and indulged by their mother, sisters and grandmothers. 7t school the boys are outgoing, and develop a wide circle of friends, which during adolescent form his own supportive in:group or -parea- who stand by him loyally for the rest of his life. Gouthful depression and suicide are relatively rare, though road accidents, drugs and 7+=' are taking an increasing toll. Marriage tends to be late and to a considerably younger woman, and according to the ,reek Crthodox tradition, divorce is relatively rare. %artly this is due to having a well worn escape route down to the local cafeneon, where he can be comforted by his all male support group, the parea. ?nlike the ma8ority of $ritish men with their usual constant distant manor and stiff upper lip, physical contact and letting their feelings out is part of the way of life for ,reek men at all ages. $oth men and women sing, dance, laugh, weep, hug, kiss and literally pat each other on the back at every opportunity. 7s well as being in touch physically, they en8oy eloquent, spirited emotionally charged conversations punctuated by laughter and decorated

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with gesture. $eing cool, cut:off and alone are thought of as leading to loneliness, which is considered to be the worst of human afflictions, whereas good company, together with food and wine is the elixir of life. He often does more than one 8ob, which tends to keep him active and employed to a respected and ripe old age. *ate in life he is lovingly supported by his wife, sisters, daughters and daughter:in:laws, and generally cared for at home until he dies. This life: long pattern keeps his testosterone and level of sexual activity high throughout. 7 recent study of young ,reek soldiers showed levels of testosterone right at the upper limit of normal, and very high rates of sexual activity, with one e8aculation per day on average. This seemed to be proportional to the amount of one of the breakdown products of testosterone, dihydrotestosterone 0=HT2, rather than testosterone itself. However this may have been a result rather than a cause of their vigorous sex lives, and doesn/t agree with other evidence that suggests that testosterone is more important in regulating libido. 7t the other end of the scale you have the ,reek %rime Minister, with the appropriately doubly, if not trebly, androgenic name of 7ndreas %apandreou, who in his eighties scandalised his nation by marrying an actress in her twenties. This does not mean that + recommend such drastic remedies to my patients, or that such idyllic female support as ,reek men traditionally en8oy is widely available in most men/s lives, but + do think that there are important lessons to be learned from ,reek male life patterns, and you will hear them echoed throughout this discussion on how to retain vitality and virility. . The #light Plan 9or (i9e *ife can be compared to a trip in a glider when, after being catapulted in our teens and early twenties to the peak of our innate physical and mental abilities by a powerful cocktail of hormones, including particularly the sex hormones testosterone and oestrogen, we then go into a variable glide path for the rest of our lives, the rate of descent largely being controlled by the body/s hormonal balance. 'ome hormones, particularly the stress hormones such as adrenaline, noradrenaline, and cortisol, increase wear and tear and the rate at which we use up our energy, having what is known as a catabolic 0or break:down2 action. Cthers, particularly testosterone and oestrogen, have the opposite, or what is called anabolic 0or build:up2 effect. This can explain why some people burn themselves out and go into a nose:dive, their health crashing at the age of #" or earlier, while others glide gently on into their E"s or even "". These ageing processes affect particularly the heart and blood vessels and, in the from of heart attacks and strokes, are the number one killer of western people, as + described in a book -The 5estern 5ay of =eath3 'tress, Tension, and Heart =isease.- )oronary heart disease is also the main reason why, on average, the life expectancy of men in 5estern society is seven to eight years less than that of women. +n general, both physically and mentally, you/re as young as your arteries. Testosterone and oestrogen have both been used to prevent and treat heart and circulatory disease. Their beneficial actions have been proved in many research studies and these hormones also maintain the condition of the skin, muscles and bones. Therefore it seems reasonable to expect that, by giving nature a helping hand on a scientifically regulated and carefully monitored basis, we could slow down the ageing processes and prolong active and en8oyable life.

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7s discussed in chapter three, the main factors in bringing on the male menopause are age, stress, alcohol and drugs, so any plan to maintain vitality and virility must take these into account. Though you can do this on your own with the help of this book, it is much better to have a medical advisor to guide you. 7t the risk, as elsewhere in this book, of offending the politically correct lobby, + would suggest this advisor should be male, and probably in his forties, fifties or sixties so that he has plenty of experience and knowledge of the problems, having successfully solved many of them himself. +deally he should be one of that currently rare breed, the 7ndrologist, with a broad range of postgraduate training and specialist interest in endocrinology as it applies to men, as well as knowledge of fertility, erectile and psycho:sexual problems. 7lternatively an experienced ,eneral %ractictioner who has read widely on the sub8ect, particularly if he has attended courses on the more specialist areas of andrology, could be a good advisor. %erhaps most important of all, is to find one who you can confide in and relate to, and whose opinion you respect. 5hoever you chose, he should be able to tell whether you are going through a mid:life crisis or male menopause, and to help you through both. +n other words, by a review of your long term health record, of how you feel and how you function, and by a detailed medical screen as described in the previous chapter, you need to find out which glide path you/re on and what flight corrections are needed. Many of these corrections will be self:evident from the discussions of the different factors discussed in other sections of this book, while others will need a more ob8ective or detailed analysis by your medical advisor. Slowing Ageing 7 population peak of -$aby $oomers is now reaching the age of fifty. This affluent group with a high disposable income have generally more leisure than earlier generations and are tending to retire earlier. They therefore have higher expectations for the quality of their lives from fifty onwards and are unwilling to passively tolerate the symptoms of the menopause, male or female. Having the wealth, they want the health and happiness to go with it in what should be the -,olden Gears-. Health maintenance, or what used to be called preventive medicine, is a relatively undeveloped and unsuccessful science, at least as far as the middle and later years are concerned. )oronary prevention studies such as the Multiple (isk 4actor +ntervention Trial, mistermed M( 4+T, have generally proved uniformly unsuccessful, any small reduction in heart disease being outweighed by increased deaths from accidental deaths and suicides. 'imilarly, as an article in the Times newspaper -$ehind the 'creens- recently pointed out, routine medical screens though seeming like a good idea at the time, and taking up considerable private and public resources, have not in fact made any appreciable impact on either morbidity or mortality in any area, especially cancer. +ndeed, as this thought: provoking article points out, by causing needless expensive and anxiety provoking further tests, and causing investigation and treatment related disease, screening has so far done virtually nothing to either add years to life, or life to years. There are however some rays of hope on this otherwise gloomy scene. 5e need to look in some new directions. The most promising of these appear to be3

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*or:one Replace:ent Therapy. To slow down the ageing process is a combined operation. Gou need to promote those activities which maintain, build up, or restore mental and physical function, and reduce those which cause wear and tear and breakdown. +n chemical terms this is called balancing anabolism and catabolism. 5hile there is of course much more to ageing than hormonal decline, + believe there is a strong case for promoting and prolonging a youthful balance of hormones by careful supplementation of the -hormones of youth-, oestrogens in women and testosterone in men, both of which can be regarded as anabolic or build:up steroids. The safety and effectiveness of carefully and cautiously applied testosterone treatment is described in detail in the previous chapter, and shares many of the benefits in both the treatment of symptoms of the menopause and in all:round mental and physical health maintenance as does oestrogen replacement therapy in women. +f the woman in a man/s life is either younger in terms of years than him, or hormonally younger because of hormone replacement therapy, it seems to help to keep him young also. The idea of -His and Hers Hormones- has a lot to recommend it. +t is certainly usually preferable to a man getting a divorce to marry a much younger woman to regain his lost youth. 7part from the pain to the spouse and the rest of the family, there is the emotional, social and financial stress caused to the man involved, the most painful part often being separation from his children. Though the new marriage may appear to be working for a year or two, as the divergence in interests and energy levels becomes more marked, the much older man is usually left trailing mentally, physically and perhaps most important sexually, and the relationship often falls apart with extreme unhappiness on both sides. 7ttitude to ageing is also important. 5ith improved health care throughout life, and especially with H(T, women are coming to expect to remain mentally and physically active, and to look and feel good, for longer and longer. They see celebrities such as Boan )ollins, )atherine =eneuve, and &lizabeth Taylor looking as young and attractive in their fifties and sixties as they did in their forties, and have similar expectations for themselves. +ncreasingly men are having to think seriously about how they are going to keep up with their hormonally reactivated wives. 'ome 8ust give up and become couch potatoes slumped inert in front of the television. Cthers try to rise to the occasion by going on a diet, giving up smoking, and 8oining a gym or playing more golf, but these efforts often fade rapidly with the negative mood and inertia accompanying the male menopause. Maintaining a positive attitude is an important part of the -4light %lan for *ife- and is greatly helped by testosterone treatment.. Stress Manage:ent 'tress is one of the ma8or factors contributing to the andropause, and as described in the chapter on Mechanics, works against testosterone both by reducing its production, and by releasing stress hormones such as adrenaline, noradrenaline and cortisol which have a catabolic action opposing its anabolic effects. +t is important therefore that as part of your flight plan you become aware of your -stress payload- and how well or badly you are handling it. The initial screen should have given you a clear picture of this and suggest some ideas for what ad8ustments you need to make. This is not to suggest that you should become a stress avoiding vegetable. 'tress has had a bad press, but it can in fact be the spice of life and a certain amount is essential for our

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health. +t is often presented as public enemy number one in present:day life and is related to a vast range of social, mental and physical problems. This is because of a fundamental misunderstanding of the nature of stress and a lack of appreciation of the -Boy of 'tress-. The original definition of stress in engineering terms is that it is -7 force which when applied to a body sets up strains within it-. 'o stress can be seen as a very necessary force like electricity, which powers our lives. +t is related to pleasure, performance and productivity by an inverted ? shaped curve, which varies from person according to the amount of -current - which is right for us.. +n 8ust the right amounts, what could be called the -5ork: out- sector of the curve, the upper half of the left:hand part of the curve, it makes us fizz and function at an optimal level. 5here the bad image of stress arises is when the amount of stress increases to the point where we are pushed over the peak of the curve into the slippery slope of the -$urn:out- sector on the right:hand side. 7s with a machine with a limited current:carrying capacity we may then blow a mental -fuse- and have a nervous breakdown or slide into a depression, or a physical fuse, and have a heart attack or develop a stomach ulcer. 'ome of us, notably certain politicians, are @" amp cooker fuse people and can carry amounts of stress that would fry lesser mortals, and other more sensitive souls, who are often creative and artistic, are @ amp lighting fuse types. finding high stress situations difficult or impossible to cope with. +t is also possible to have too little stress or stimulation in your life. This is the (ust:out situation at the bottom left:hand side of the %leasure:'tress curve and is seen in the unemployed, those made redundant, and in some people who have to retire earlier than they feel they should. This can be 8ust as much a cause of -dystress- as the -$urn:Cut- situation, and may be one of the reasons why there is more social unrest and crime in times of recession, when the devil is making work for idle hands. This is because stress is actually very addictive, a big turn:on, and the common chemical pathway to pleasure is noradrenaline. This hormone is released in response to a variety of situations which we have by experience found to turn on the right dose of this self administered drug of addiction, which we have found to stimulate pleasure centres in the brain. These are what + call the six:) situations of competition, car:driving, cigarette smoking, caffeine consumption, cold bracing conditions and copulation or other vigorous physical activity. This has been confirmed from blood samples taken in all these situations. 7s you might expect, in my early days of stress research + found ,uinness book of (ecord levels of this exciting stress hormone in the blood of racing drivers immediately after this intensely competitive form of car:driving, especially where they did well, though it was difficult to catch up with them later to study the other situations mentioned. +t is easier to tell when we are under stimulated and bored then when we are overloaded with stress. 5e tend to overlook the early warning signs of excess stress such as work and social life becoming a no fun game, falling function in both, anxiety and depression, and physical signs such as migraine or tension headaches, hypertension, raised blood cholesterol, eczema, asthma and a variety of other psychosomatic ailments. 5hat can we do to reduce our chances of getting into this over: stressed, -$urnout- state< 5ell, firstly we try -'tress (eduction- and consider how we can reduce unnecessary and unen8oyable forms of stress as far as possible. 'ome work:related and family:related stresses are unavoidable, but some 8ust pile up unnoticed over time and can be weeded out when you think about them or write them down as a -'tress +nventory-. 'ome are 8ust due to trying to cram too many things into the day, and so choices have to be made. 'ome are due to hard:driving time and deadline conscious Type:7 behaviour patterns, or -Hurry

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=isease- as described by the 7merican cardiologist =r. (ay (osenman in his book -Type:7 $ehaviour and Gour Heart-, in which he gives Type:7 drills to modify this harmful life:style. The -Time Management- skills taught in business school can come in useful here. 7voiding people and situations which we recognise as being stressful to us can also be helpful where it can be managed. There is a certain type of person who is a -'tress )arrierrather like -Typhoid Mary- who go round spreading the germs of stress. Though they usually show no signs of being stressed themselves, they leave a trail of devastation behind them in the form of over stressed people. 7s one 7merican admiral put it when asked how he coped with the stress of his 8ob -+ don/t take it in: + dish it outA-. How can one cope with these people< 'ometimes you can avoid them like the plague they are and not be around when they call. Cthers are unavoidable, but you may be able to explain to them the way they make you feel, and work out a way in which your contacts with them can become less stressful. 7 very good manual of survival strategies in this situation is -6asty %eople and How to =eal with them without becoming one yourself- by Bay )arter. The skills in the technique of Transactional 7nalysis described in the books of the 7merican psychologist &ric $yrne, especially -The ,ames %eople %lay- can also help defuse tension arising from contact with stress carriers and hopefully prevent it happening again. The car is also a great stress generating machine, as my research into stress hormone levels in different situations showed. The racing drivers that my research cardiologist friend =r. %eter Taggart and + studied as a test:bed of stress, showed record levels of the -=rivehormone, noradrenaline. This had the effect of raising blood fat levels, particularly neutral fat or triglyceride, so that the blood plasma became opalescent and milky after the race. 5e also found that even in everyday motoring, noradrenaline and adrenaline levels shot up in most drivers, particularly when getting angry with other drivers, snarled up in a traffic 8am or getting fined for parking. 7s + described in -The 5estern 5ay of =eath3 'tress, Tension and Heart =isease-, men particularly are very attached to their -&go )hariots-, and -Machismo Machines-. Gou see rage reactions in and around cars during bumper to bumper mortal combat in traffic, that you seldom see in other situations except in hand to hand mortal combat in wartime. 7t work, pecking order equals parking order. +t is worth considering whether you can let the train take the strain for some of the intercity 8ourneys or travelling to work, or let the cabby/s coronaries take the strain for getting around town. 7gain, society has a part to play in encouraging governments to limit pollution of the external environment by exhaust fumes from the traffic that clogs our roads, and of our internal environment from the stress:related fats which clog our arteries, by improving public transport. 7ccidents are another source of stress and rapid ageing, very often related to Type:7 behaviour, stress, tranquilliser use, drinking and driving, both on the road, at work and in the home. Gou may have seen in friends or relations how much a serious accident, perhaps even more than a serious operation, can age a person. )areful and cautious driving, as taught by the +nstitute of 7dvanced Motorists in $ritain, in cars with all the latest safety features, is to be recommended in avoiding accelerated ageing. My research on the effects of ma8or trauma showed very high levels of stress hormones, and marked lowering of testosterone levels, which reached crisis point about a week after the accident, and could cause delayed deaths at that time from multiple organ damage, especially to the heart and brain. 'ome of these effects could be reduced by stress:blocking drugs such as the beta:blockers. Many of my patients dated the sudden onset of their andropausal symptoms to an accident or ma8or operation, particularly involving surgery of

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the heart or prostate gland so the fewer the operations you have the better. 7mong its other advantages, so:called -9ey:hole 'urgery- using endoscopic instruments, may help to minimise operative trauma, and post:operative complications and immobility to lessen the wear and tear associated with operations, especially in the elderly. A;oiding 'urn0out 5e have not changed essentially in our mental and physical constitution for thousands of years. Modern space:age man still has his stone:age psychology, physiology, biochemistry and endocrinology. His hormonal responses to a stressful situation are still the same whether its fighting a hostile take:over bid in the boardroom, or a sabre:toothed tiger in the 8ungle. +n either stressful situation the primitive fight:flight mechanism comes into action, and the body is put into a state of emergency by the autonomic or automatic nervous system and the associated hormones. 7drenaline speeds up the heart and mobilises sugar into the blood stream, while noradrenaline turns arouses and alerts you, and raises blood pressure and fat levels to pump these fuels into the muscles, giving you extra energy for fighting or running away. 7t the same time that these breakdown, catabolic processes are being switched on, the build:up, anabolic processes linked with testosterone are being switched off, because this is a time to make war not love. *et/s look at the various ways of balancing up our stress responses. E=ercise The problem in modern times is that much as we might feel like it, when in danger, when in doubt, we can/t scream and shout and run about. Cur instinctual stone:age reactions to stress have become inappropriate for our space:age setting. %hysical exercise is one of the best and most natural ways of getting these mental and physical reactions to stress back into balance again. 7fter exercise, the mind calms down, the tension in the previously coiled springs of the muscles has been reduced, and the sugars and fats mobilised into the blood stream have been used up. +n this state of rest, relaxation and restoration, testosterone levels rise again, as has been shown in many research studies on people exercising. +f you overdo it however, and the exercise itself is pushed to the point where it becomes stressful, testosterone levels fall, as was shown in marathon runners. Train, don/t strain, and remember exercise doesn/t have to hurt to do you good : quite the reverse. 6o pain means safer gainA 5ith this in mind, and because the andropause is mainly a condition seen in men around the age of fifty, as + described in a book 4R;" : /4itness on 4orty Minutes a 5eek- written for the $ritish 'ports )ouncil with 7l Murray, a pioneer in the gentle art of getting middle:aged businessmen physically fit, exercise in this group should be designed according to the acronym '74&. This stands for 'afe, 7cceptable, 4itness producing and &conomic. ': 'afety is the essential requirement for exercise in this age:group of men. +t should be ideally be vigorous but not violent, calming and not over:competitive, and isotonic, or dynamic, rather than isometric, or static, which causes the blood pressure to rise too much. 7 good safety check is the pulse rate, which can be checked by feeling it at the wrist, or using a pulse monitor. This should not rise above a safe level, which can be calculated according to your age, fitness and medical condition.

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7 : 7cceptability is essential as it is no use having the best system of exercises in the world if you never use it. 4ind the form of exercise you find acceptable to you, and use that. The right surroundings are important, and if you don/t feel like going to a gym or swimming pool a personal fitness trainer in your home may be the answer, as well as providing the necessary motivation. 4 : 4itness in terms of feeling and looking better, and greater strength and mobility, together with the relief or prevention of andropausal symptoms are some of the benefits of exercise. These can be especially marked during treatment with testosterone. & : &conomy both in terms of time and money is attractive to most people taking up exercise. Two twenty minute periods of vigorous exercise each week, or three times that amount of light exercise, are sufficient to maintain a reasonable level of fitness in most men, help weight control, raise testosterone levels, and help to keep them sexually active. Having covered the basic principles of exercise to maintain vitality and virility, lets take specific examples3 5alking : This, like cycling, is a much underestimated and under:used form of exercise which can not only be used to replace much stressful driving, but is a good basis on which to get fit enough for more vigorous physical activity. To give maximum benefit it needs to be brisk enough to raise the pulse rate to over "" beats per minute, at least in the unfit. This means really striding out, what + call -%ower 5alking-, and twenty minutes of this daily will give a good level of fitness in most men over the age of fifty. ,olf can also be a good way to encourage walking in pleasant company providing it does not become too competitive. ?nless you find walking very difficult for any reason, beware the buggy, which can spoil the exercise element in golf. Many patients find that testosterone treatment reduces their golf handicap, improves their concentration and strengthens their drive. %erhaps golf clubs will have to have special competition categories for those on or off anabolic steroids. 'wimming is excellent whole:body exercise, especially for those trying to lose weight. +t could be said that you got -=ouble:bubble $enefit- with swimming, because you are not only burning off a lot of calories by exercising the main muscle masses of the body, but still more by keeping warm because of the heat loss even in water at a comfortable temperature. ?nlike land :based exercise, any excess weight is supported in the water, and does not throw strain on the 8oints. +t/s also a sociable, and en8oyable form of exercise, and the sight of a range of attractive women in revealing costumes may do wonders for the libido of the andropausal male. ,ymnasium exercise is becoming increasingly popular, and some enlightened firms are even providing it in:house. Ten years ago, with 7l Murray, + helped to establish a gym in the House of )ommons to encourage Members of %arliament to be at least physically fit to govern, though it seems to still be seriously underused. 4avoured exercises amongst politicians however still seem to be horizontal 8ogging, running opponents down, and leaping to conclusions. ,ood facilities in a gym should include properly trained and experienced instructors who carry out an initial fitness assessment, including measurements of heart attack risk factors such as blood pressure, and keep a continuing watchful and encouraging eye on your progress. &xercise schedules should be tailor:made to the individual and progress carefully

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monitored in terms of -%erceived &xertion-, how hard the exercise feels, as well as by pulse rate measurements. 'training at heavy weights is to be avoided, as are -press:ups-. The motto should be -=own with %ress:ups- as you are lifting three:quarters of the body weight, and this is too much like maximal isometric exercise. The blood pressure is greatly raised by this type of activity, and because of the increased pressure in the chest, blood cannot get back to the heart. 7lso to be avoided is prolonged exposure to high temperature sauna baths after exercise. (esearch we carried out at 7l Murray/s )ity ,ym in *ondon and reported in the $ritish Medical Bournal showed that at high temperatures large amounts of adrenaline are released which makes the heart beat rapidly and erratically. This can be more unsafe than strenuous exercise, particularly in those with high blood pressure or heart trouble. )old plunges after the sauna are also not a good idea as we showed that they cause the release of the noradrenaline stress hormone, which produces a dramatic surge in blood pressure. 7ll these violent circulatory gymnastics are best avoided if you are seriously interested in longevity. (unning and Bogging ?nless you are already in training, running and 8ogging are generally too vigorous to take up immediately without a period of -%ower 5alking- for several weeks beforehand. &ven then these forms of exercise have been accused of -mass murder- by =r Meyer 4riedman a leading 7merican cardiologist, who would agree with the cautionary saying that -The grim reaper also wears a track suit-. Cne of his recent victims was Bim 4ix, the 7merican running populist, who abruptly dropped dead in his tracks. He also obviously had designs on several 7merican %residents, who unlike $ritish leaders, tend to overdo the fitness kick. )arter had to be carted off from one run, $ush was so bushed on another he collapsed, and )linton is visibly declining every time he is seen 8ogging. They must have got confused at an early age about the literal and metaphorical meaning of %residents needing to run for office. &ither that or they are running:scared of the D#th amendment to the 7merican constitution, introduced after the cover:up of %resident =wight &isenhower/s stroke in the !#"/s, in which a %resident can be declared unfit to govern for health reasons. Cr perhaps they think they would be more popular if they emulated the film character 4orrest ,ump, who in his frequent meetings with 7merican %residents, showed how to compensate for intellectual impairment by a spectacular ability to run. &ven he however worked out on his third coast to coast walk across 7merica, that this was not the way to enlightenment, and hung up his running shoes. 7part from the dangers to the heart and circulation, in some cities there is an increasing risk of getting mugged or run over. 9nee and ankle in8uries are also common, and running on hard pavements has been shown to cause blood to appear in the urine from trauma to the kidneys. 7s with walking, well designed shoes with shock absorbent in:soles are vital for both safety and comfort. Mental e=ercise as an antidote to stress 5hile many doctors know about meditation in relieving anxiety, few realise 8ust how powerful a tool it can be in stress management. *ectures in medical school mainly tend to focus on the wonders of medication, giving a message which is reinforced throughout the medical career by bombardment with literature and free samples from the drug companies. There are so many drugs to regulate our mental state on the market now that you might be

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forgiven for wondering if any of them work effectively in the ma8ority of stress:related conditions. 7lso there are many worrying reports of side:effects of many of these drugs from valium to prozac. The depressing truth is that if we take the edge off the razor:blade of life down which we slide, as the 7merican humorist Tom *ehrer put in one of his songs, we also blunt many of life/s pleasures, experiences as well as performance. 'tress related symptoms are trying to warn us of something, and it/s like turning off the fire alarm because you don/t like the noise of the bells. Many patients tell of a zombie:like, switched:off state they experience on tranquillisers. Malcolm *ader, professor of psychopharmacology in the leading research centre in the field, the +nstitute of %sychiatry in *ondon, had reported on the severe habituation which comes with long:term tranquilliser use, their addictive properties and the acute withdrawal symptoms which occasionally occur with suddenly coming off them. He also created alarm and despondency among doctors and patients alike when he reported that )7T scans showed that long:term tranquilliser use caused shrinkage of the brain similar to that seen in alcoholics, apparently due to -neuronal drop:out-. ,iven such information, many people would prefer to control the stress in their lives by meditation rather than medication. =octors generally know little about meditation, as it isn/t taught in medical schools and only a few find out the many benefits for themselves. +t can however be very effective in the control of stress reactions, whether in its original form as one of the different forms of yoga, or in its modern 5estern forms. Meditation is simply the direction of flow of attention according to %atan8ali, the eight century +ndian sage who systematised yoga. Most of the time our attention is directed outwardly. This focuses your attention on all the different forms of stress in your life, and in susceptible people creates a vicious circle of stress leading to increasing stress hormones such as adrenaline, noradrenaline and cortisol, and decreasing testosterone release, which all causes symptoms which generate more stress and further unfavourable hormonal changes. 5hen attention is directed inwardly, which is what people usually understand by meditation, you become uncoupled from the stresses in your life, and the body/s self:healing, restorative relaxation responses take over. This produces a switch from over:activity of the fight:flight system to increased activity of the rest:restore:relaxation system, with corresponding hormonal benefits including restoration of testosterone levels. 'uch voluntary control over the body/s involuntary nervous system, the autopilot which regulates our responses to stress, is remarkably easy to achieve with a whole range of techniques. These originated with yoga methods in +ndia, moved to )hina as $uddhist meditation, and then to Bapan as Men meditation. 7utogenic Training is a 5esternised rediscovery of the basic principles of &astern forms of meditation. The essential basis of 7utogenic training is the sequence of the six 'tandard &xercises developed sixty years ago by =r. Bohannes 'chultz, a ,erman psychiatrist working in $erlin, where there is an institute dedicated to his memory. This type of -Mental )ircuit Training- involves focusing the mind by silent repetition of -verbal formulae- suggesting sensations of heaviness and warmth in the arms and legs, a calm regular heart:beat, easy natural breathing, abdominal warmth and cooling of the forehead. ?nder medical supervision these mental exercises are progressively introduced at individual or small:group training sessions held once a week over an eight to ten week period. The

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patients then practice them in a comfortable, stable sitting position on the edge of a chair, in an arm:chair or lying flat:out on their backs. 5hether at home, in the office or travelling, they can usually at any time find an opportunity for a session of -7utogenics-. ?sually they are recommended to practice for ten to fifteen minutes three or four times a day. Gou don/t have to be a burnt out stress victim to benefit from 7utogenic Training as is a powerful stress management technique from which everyone can benefit. +t has been widely used in industry, and being non:competitive and non:intrusive, it can be taught on in:house courses. +t has also been taught to airline pilots, and was helpful in coping with 8et:lag. +t was one factor that the training of both astronauts and cosmonauts had in common. +t has also been used extensively with competitive sportsmen and women, together with musicians an others in the performing arts. There are many fringe benefits such as reducing the amount of sleep required, and promoting creative thinking by balancing up the two sides of the brain, the logical, linear thinking left, and the intuitive, more feeling creative right which is often relatively inactive. 4or the andropausal patient, as well as reducing stress, it can help control alcohol and food intake, gently but firmly over a period of weeks. The psychological effects can also help the person sort out long:standing emotional problems both at home and at work. However, it must be emphasised that it is a practical skill, like learning to drive a car, and you need a well:trained instructor. Though it is relatively unknown outside &urope, $ritain is fortunate to have an organisation called the $ritish 7ssociation for 7utogenic Training and Therapy 0$747TT2 which can provide a list of trainers in most areas of the ?9. 'iddha Meditation is the one &astern technique which + have practical experience and can warmly recommend as being a very straightforward form of meditation, which is based on an ancient tradition and philosophies which help control and reduce stress. The current head of this lineage of meditation teachers is a beautiful +ndian teacher called ,urumayi )hidvilasananda. +t is a very spontaneous and easy to learn form of meditation, which is taught in over three hundred centres all over the world, including 6orth and 'outh 7merica, $ritain and the rest of &urope, 7ustralia as well as +ndia where it originated and is respected as a great tradition. There is a branch of the 'iddha Goga 4oundation in most countries. The technique basically involves calming the mind by focusing it on a simple word formula or mantra, linked with the breathing. This makes use of the age:old observation that when the mind is disturbed, the breathing is usually disturbed also. )onversely controlling the breathing can help to control the mind also. 5hen the mind goes still, great feelings of peace and calm can arise from within, and subtly but powerfully change the person/s life. as + and several of my patients have found. A;oiding Rust0Out There is an old saying that what you don/t use you lose. This is true in terms of mental, physical and sexual function. Gou see it every day in people who retire, sink into apathy, and often die soon after. +t is also seen in younger people made redundant who give up hope, and give up trying to get a new 8ob. +n this situation it is probably better to do anything than do nothing. +t is one of the tragedies of modern life that there seems to be polarisation of the work force. 7t one end you have the over:employed, who are risking burn:out by working longer and harder to keep their 8obs in the face of seemingly ever increasing competition. 7t the other end you have the growing ranks of the rust:outs who are unemployed or have been forced

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into early retirement by redundancy, rationalisation and down:sizing of their firms. $oth groups can be equally unhappy, but for opposite reasons. &very person has an optimal level of stimulation or stress, and above and below it lie unhappiness. Cnce our basic survival needs are taken care of, as they increasingly are in most societies, and we had fulfilled our -biological imperative- by having and bringing up our children, what do we do then< -Me Tarzan. Gou Bane- male and female roles no longer apply, and in an increasing number of families the male isn/t even the breadwinner any more. +n this situation, it is difficult for him to remain either vital or virile. The %rotestant work ethic isn/t working any longer either because it is increasingly absent for a large number of people for a large part of their lives. This century more and more people are moving into urban environments, and the proportion working in farming and agriculture in 7merica for example has fallen from about D"F to DF in that time. The ! : # till age ># is no longer even the structure of the city dweller/s life any more. 5hat/s to take its place< $eer and circuses were the answer during the decline and fall of the (oman empire, and many are drawing comparison/s with that and the state of the 5estern 5orld today. %erhaps beer, games shows and the rest of pulp TJ are the modern equivalent. $eer, combining the hazards of both alcohol and phytoestrogens certainly doesn/t do much for either vitality or virility, and TJ mainly promotes endless unsatisfying consumerism and discontent. 5hat are the alternatives< +t is surprising how little either politicians or sociologists appear to be looking into this question, since it seems that one of the main problems to be faced during the next millennium is that work as we know it today is set to become a luxury item. %erhaps, occupation, how we are going to spend our time, should become our preoccupation. Here are some suggestions to fuel the debate, since they have a bearing on how we face up to both the male mid:life crisis and the male menopause. 7 man without a function often ceases to function as a man. Alternati;es to @or< %erhaps some of the answers to the problems being created by technology may lie in the applications of technology. 4or some people loss of a 8ob has meant that they can discover new skills and abilities, and a new lease of creative life through the computer, and may even take to surfing on the internet. Cthers are seeking a low:tech answer, and welcome the increased time available to them for pure recreation or self: development in a variety of ways. 'ome take to the worship of the small round spherical ob8ect known as the golf:ball, playing two rounds a day every day the weather allows them to. 'ome take up the search for spiritual enlightenment, and en8oy the structured life and discipline that either the church or yoga and meditation can provide them. %erhaps we need counselling centres to help people find their individual answers, or even your friendly neighbourhood 7ndrologist could give some advice, information and guidance. @or< Sharing

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7s the number of hours of work needed to perform various 8obs falls due to automation and computerisation, so the need to share this now precious commodity increases. The trend towards teleworking makes such sharing potentially easier and more attractive in some areas. This can open up a new career working from home via the modems, faxes and video: conferencing, without the expenditure of time, energy and money involved in commuting. +magine a system where the norm was a sixteen hour working week, either two eight:hour days, or preferably four four:hour shifts. +f you were a morning person, you could leap out of bed and work in the morning, or an evening person could surface more gently, and work in the afternoons. Moonlighting workaholics would be gently weaned off their addiction in work:withdrawal programmes, led by teams of easy:going idlers. They would be reminded that the working:day of the cave:man was only three or four hours long, and the rest of the time was spent in social activities such as tribal dancing or grooming oneself before an evening round the camp:fire. @or< shortening 6ot only might the working week be shortened, but the years worked might be shortened to thirty or even twenty. The $rahmin ideal of life in +ndia has four approximately twenty year periods, of student, householder, progressive detachment and ultimate contentment. Having finished your education around the age of twenty, you would then have the privilege of working for twenty years to establish your position in a less competitive society, bring up your family if you decided you wanted one, and have some extra consumer goodies above the guaranteed social norm. 7fter your twenty years work, the mid:life crisis would be much less of a problem, because it would be expected that you would take up some more creative or leisurely past:time, or go back to study something that you found really interested you more than the work you had been doing. (ather than -retiring-, you would be advancing in some new direction and might wish to take a few years to attend a -?niversity of Mid:life- as a mature student to go deeper into something that you might have missed out on previously. The -Cpen ?niversityis an encouraging development that many people faced with early loss of employment have found, often to their surprise, to give them a new and absorbing view on life. This period of detachment could also lead to more unpaid voluntary work in the community, and perhaps be a time for some to do more social work, counselling, or even following political pursuits having had more life experience and with more maturity than the average career politician. +t may be however by that time in his life, he will have come to the same conclusion as the philosopher who set out as a young man to change the world, and with increasing experience progressively narrowed his activity to changing his community, to changing his family and friends, to finally 8ust trying to change himself. @or< Shi9ting There are some 8obs, mainly in the so:called service industries, that 8ust can/t be automated. These range from psychotherapy to hairdressing, sorting out the inside and outside of the head, and from medicine to massage, making the inside and outside of the body feel better. 'hifting work into these often overstretched professions would create many new satisfying 8obs, and could well improve the sum of human health and happiness. 4or those who wished a more action:packed time in their lives, short periods of voluntary overseas service in teaching survival skills or bringing aid to developing countries or disaster stricken areas might provide the ideal opportunity.

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Power0sharing 7 study of the health of )ivil 'ervants, the so:called 5hitehall 'tudy, which has been going on for about thirty years in *ondon, has shown that those in senior positions, the -Mandarins-, en8oy better health and tend to live longer than those in the middle or lower echelons. %erhaps the answer to this interesting observation lies in the original meaning of the word Mandarin, which was -7 high civil servant thought to exercise wide undefined powers outside political control-. The power element may well be linked to testosterone levels, because it is the sense of power which promotes secretion of this hormone as was described in relation to stress and production of this hormone. This is seen throughout the animal kingdom, but particularly in ageing stags, bull:seals and male primates. Taking this idea a step further, sharing power and empowering people in different areas of their life could well help to maintain their hormone levels. This would range from setting up managerial structures with a broader power:base, to setting up production lines, as in the Jolvo experiment in 'weden, where one worker sees his product through as from one end to the other, rather than performing one limited task only. 'imilarly, the 7merican telecommunications company 7T and T, have extended the powers of an increasing number of their operatives to follow:up and provide a larger range of services to the customer who first contacts them and becomes -their client-. The rapid improvement in communications may also empower people by letting them take part in decision making processes at both a local and national level. Jia telephone and fibre: optic links they could make their views felt in polls and referenda, and even add a new dimension to the deliberations of their governments by voting, live on issues which concern them, making democracy a more exciting, interactive process. +t is a frustrating sight to see the low level of interest and poor attendance rates in the $ritish %arliament, either in The House of )ommons or House of *ords when matters of national importance are being discussed in televised debates. +mmediate feed:back on their often dismal performance from the general public might revitalise these debates, and even in8ect some hormonal life into them. rin< 7lcohol is one of the ma8or factors contributing to the male menopause, and if there is a serious alcohol problem it is not worth giving testosterone until it has been treated with the help of one of the effective agencies such as alcoholics anonymous. 7lso as described in )hapter 4our, the testis is very sensitive to both the short and long term effects of alcohol even in amounts which are insufficient to damage the liver or cause social problems. $ecause of general insecurity, greater unemployment in young people and a general sense of aimlessness and disillusion, the consumption of both alcohol and potentially testicle: damaging drugs such as cannabis is increasing among young men. The average alcohol intake of men aged E:D; in $ritain is now DD units per week, 8ust above the D units which used to be the safety guideline set by the Health &ducation )ouncil, though this has now + think incorrectly from the point of view of testicular function, been reset at DE units. This means that over half of them are at risk of damaging their health, particularly their sexual health including fertility, by their drinking habits.

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The most common drink in this age group is beer, which is most likely to damage the testis and feminize the male. $y contrast it has been shown by researchers in 'weden that a few alcoholic drinks in women, especially the wine which they more commonly like than beer, causes a surge in testosterone levels. This causes their libido to be highest when the men are most likely to be drunk and incapable. $ecause of these sobering facts, so as to prevent more testicular damage, improve the chances of relationships surviving, and see if some improvement in function can be obtained, + usually recommend a return to well within the twenty:one units of alcohol per week limit, and sometimes the patients find even less is better. 7lso, because of the phyto: oestrogens in beer which work against testosterone, there is a serious message in the $ritish Health &ducation )ouncil message that -There is one part all beers will reach- and the 7ustralian low:alcohol lager advertisement which claims it will prevent -your diggery:do turning into diggery:don/t-. $ecause there is also the possibility that phytoestrogens may still be present even in low alcohol beers, it seems worth trading the beer intake for wine, especially red wine. iet 5eight reduction is often needed to help in the treatment of andropausal symptoms. 5eight gain which doesn/t respond to diet is one of the most common and demoralising effects of this condition. Cften this is mainly in the lower abdomen, giving the appearance of -$eer $elly-. Cne witty 8ournalist said that till the age of forty he used to be proud of the breadth of his mind and the narrowness of his waist. Then he woke up one morning and found they had changed places, and he was sure middle age had really set in. The spreading waistline is both a sign of the andropause and makes it more severe. This female type of fat distribution, is partly due to the action of oestrogenic factors which may have helped to produce it, and partly because when there is more fat in the body, resistance to the action of testosterone increases and more of it is converted to oestrogen. There is also a general tendency to put on weight which is very difficult to remove by dieting because testosterone deficiency causes more sugar and protein to be converted to fat. 7s the couch potato ripens, energy decreases, less exercise is taken and lacking both activity and testosterone drive to build them up, the abdominal muscles melt away as the paunch appears. 4ortunately, as well as restoring the will:power, or rather the won/t:power needed for successful dieting, and bringing back a more positive and energetic mood, treatment with testosterone improves sugar metabolism so that less is converted to fat and more goes to rebuilding the muscles. The effectiveness of this form of hormone replacement treatment for men was shown in a study in ,othenburg in 'weden, where the cosmetic effect in reducing beer bellies, as well as the other benefits of testosterone treatment were greatly appreciated by both the patients and their wives. 7s with alcohol related problems, expert guidance in specialist groups such as 5eight 5atchers or in the many health clinics specialising in this area, may be needed to help the patient really tackle his weight problem after many years of inertia. 5here there is marked obesity, this can be a very important factor contributing to resistance to the action of testosterone, essentially similar to the insulin resistance seen in adult onset diabetes. %sycho:pharmacology is making rapid advances in the field of so:called -'mart =rugs- which claim to slow mental ageing and the loss of memory which goes with it. These widely

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discussed but little applied drugs, combined with psychotherapeutic mental exercises and relaxation techniques, and the benefits of H(T in both sexes on cerebral function and circulation, should have enormous potential for -$rain Maintenance-. 'imilarly, there are various dietary supplements, which are claimed to increase libido and help avoid prostate problems. +n particular there is an interesting 'wiss Cat preparation which is supposed to free up testosterone by reducing the inhibitory -'ex Hormone $inding ,lobulin- and this may be one of the natural plant hormones which will find a place in the treatment of patients who want to avoid long term orthodox hormone treatments. Antio=idants and :icro nutrients. 7ntioxidant/s, especially Jitamins 7, ) and &, together with micro nutrients such as selenium and zinc, are widely discussed and taken, both to improve vitality and potency and to reduce heart disease and cancer. However, this is largely on a haphazard basis, without any medical authority or guidance. + think there is now compelling evidence that vitamin supplements may have a generally beneficial effect in maintaining health, and may well reduce heart disease in the long term. These effects may well be due specifically to their antioxidant effect, perhaps by reducing the so:called -free radicals- which are supposed to contribute to these conditions. Minc is concentrated by the prostate gland, and is an important ingredient of the seminal vesicle fluid which 8oins the semen as it is pumped though the e8aculatory ducts in the prostate gland. +t/s function seems to be to activate the sperm, which appear to pump zinc 8ust as the muscles pump iron. *ike the Jitamins, in sensible amounts it appears non:toxic and may be beneficial. MenAs (i! 5hat + am advocating is boosting the vitality, strength and longevity of men of all ages, but particularly past the age of fifty, to the point where it equals that of women, especially when the latter are on H(T. This is a physical and mental balancing act to maximise the many benefits of testosterone in men. +n no way does this mean testosterone for all, male H(T being only given when needed to treat the male menopause or for long term health maintenance in older men who choose that option. ,enerally it involves maintaining the body/s natural supply of testosterone, seeing that like the man, it remains free and active, and that it/s actions are not blocked by factors such as 'H$,, oestrogens or stress. Men are about @" years behind women when it comes to H(T for the wide variety of historical, medical and marketing reasons already mentioned. Hopefully they will now catch up rapidly as the male menopause is more widely recognised to be a real condition which can and should be treated, and as the safety, effectiveness and many benefits to physical and mental health of T(T become recognised. + have tried to spell out clearly the primary importance of testosterone in maintaining vitality as well as virility, but we need more doctors with a special interest in men/s health issues, andrologists, willing to act as leaders in the fight for what could be called -Men/s *ib-.

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This is not an anti:feminist movement, but a way of recognising the need to empower men and help them to remain active and equal partners throughout long and healthy lives. The -5omen/s *ib- movement, has helped women achieve social and hormonal emancipation, but the men are now lagging behind. &ven in terms of longevity, women have a life expectancy five to seven years greater. 5hen combined with the tendency for their men: folk to be on average three to five years older according to actuarial statistics, this means women lose their partners an average of ten years or more before they die, which can make for a sad and lonely end to life. +t was the interest, enthusiasm and favourable experiences of the female public at large which brought in H(T with oestrogens as a treatment for the menopause. The doctors generally either were not interested, or prophesied doom and disaster in the form of breast cancer and heart disease, but were coerced into giving short three to six month courses for the relief of severe menopausal symptoms. 'oon, many of the women felt so well and looked so good on H(T that they wanted to stay on the treatment indefinitely. Though there were initial problems with a few women developing cancer of the uterus, this was overcome by giving combined treatment with progesterone to cause withdrawal bleeding, and overall it proved very safe. ,radually the many benefits to both mind and body became apparent, especially in preventing the brittle bones caused by osteoporosis, and in reducing by up to half the amount of heart disease. 7t that stage the medical profession belatedly woke up to the potential of H(T, and suddenly became enthusiastic, as did the drug companies, and sales of these preparations world wide boomed to #" million pounds annually on top of the already lucrative market in oral contraceptives. Cne well:known $ritish gynaecologist went as far as to say -Hormone replacement therapy is without doubt the most important item of preventive medicine in the 5estern world for half a century. 6othing else has brought such huge benefits to so many people-. +t is my view that recognition of the reality and importance of the male menopause, together with the present careful research in the rapidly expanding field of Hormonal (eplacement Therapy in both sexes, will lay the foundation for preventive medicine in the D st )entury. + suggest that it is only by such advances that the people in the 5est during the second half of their lives will achieve the 5orld Health Crganisation/s goal of -Health for all by the year D"""-.

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