Sexual Health: Sex and the middle-aged man
The so-called male menopause can leave men depressed and sexually unfulfilled - and the treatment is as puzzling as the condition. Steve Dow reports.
Nearly 60 years ago, at age five, Jed Diamond almost lost his dad. It was a “dark day in November”, the US men’s health author and psychotherapist recalls, when his 42-year-old father, who had been increasingly irritable and withdrawn, deliberately took an overdose of sleeping pills and almost died.
Four decades later, in the late 1980s, the son found himself in a similar funk when he reached 45. At first, Diamond put his growing marriage problems down to his wife Carin’s menopause, but soon came to believe the cause was a fall in male hormones, not female. He was suffering, he says, from “irritable male syndrome”, which he attributes to stress, a “loss of male identity” and falls in natural testosterone.
“I took testosterone for a while when the irritable male syndrome was bad,” the California-based Diamond, now 63, says. “For six months, I rubbed Androgel [a testosterone cream] onto the skin once a day.” The treatment, he says, increased his sex drive and made him feel stronger, relaxed and confident: “I now know that testosterone is not just a sex hormone, but affects many other parts of our bodies, minds, and spirits.”
Diamond, who says he has no ties to any drug company, blames testosterone decline in part for tiredness, irritability, sexual dysfunction and even depression in men over 40. As the author of Male Menopause and The Irritable Male Syndrome, he advocates counselling, diet and exercise, but also testosterone “when needed and used under the direction of a good doctor”.
Clinicians do not yet widely accept the term “irritable male syndrome”, coined only in 2001 by the Edinburgh-based reproduction biologist Gerard Lincoln, another advocate of testosterone use in ageing men. Simpler terms - “andropause” and “male menopause” - with virtually the same meaning, have circulated wider and longer, but are just as inflammatory. In 2002, a London doctor, Malcolm Carruthers, was barred from carrying out any medical practice through a website or prescribing drugs outside their recommendations for 18 months, after he diagnosed male menopause in a 70-year-old patient, based on an online questionnaire, and prescribed testosterone. The patient turned out to have dementia.
Many scientists and doctors worldwide question whether male menopause exists. Yet drug marketers promote andropause as a disease through newspaper and magazine ads and the internet, and these ads are now attracting the attention of federal health authorities in Australia.
Last year, David Handelsman, a professor of reproductive endocrinology and andrology and director of Sydney’s Anzac Research Institute, wrote in the Medical Journal of Australia that testosterone “misuse”, which he defines as the “systematic over-prescribing for unproven medical conditions” is “increasingly evident for male ageing, andropause”.
While it is normal for men’s blood testosterone concentrations to decline after about age 40 by roughly 1 per cent per year, Handelsman wrote, the clinical significance of “so-called andropause” remains “unclear and contentious”. He told the Herald: “It’s certainly questionable. It may be ineffective or even harmful.”
Handelsman says older men often seek testosterone treatment because of sexual difficulties, yet erectile dysfunction in older men “has predominantly a neurovascular rather than hormonal aetiology”. Put simply, testosterone is unlikely to give men an erection if their erections are failing in older age.
But type “testosterone” into a Google search in Australia, and the top sponsored hit, prominently on the top left-hand corner of the page, is for a Bondi Junction company called Supplemax, whose website promotes a 1300 number. Website visitors are invited to take a quiz, Do I Have Andropause?, leading to this advice: “A decrease in libido or reduced strength of erections are primary indicators of androgen (testosterone) deficiency.”
Answering “yes” to a couple of key questions “should prompt you to contact Supplemax and seek a confidential consultation from one of our specialist registered doctors” who are based “all over Australia”, the website reads. The company’s testosterone cream or lozenges are priced at $800 for a six-month daily course.
The director of Supplemax is British-born Guy Hudson, 34, of Burleigh Waters, Queensland, according to company records. Supplemax came to the attention of the NSW Parliament in October, when the Shooters Party MP Robert Brown questioned its newspaper advertisements about a “brand new daily treatment program” that could “revolutionise life” for “thousands suffering health problems associated with low levels of the male hormone, testosterone”.
Members of the Opposition benches were heard to giggle. “Do the advertisements offer consultation and diagnosis by telephone?” Brown pressed on. “Does testosterone, in fact, feed potential prostate cancer, especially in men over 40?”
NSW Fair Trading found that Supplemax had committed no breaches. The NSW Medical Board’s legal director, Anthony Johnson, confirms the board has a policy permitting telephone consultations, although the doctor “must be confident that a direct physical examination would not add important information to inform their treatment decisions or advice to the patient”.
Handelsman says that while testosterone at “standard doses for andropause is probably more poor or misguided medicine and a waste rather than truly dangerous”, the answer to whether testosterone supplementation might increase the risk of prostate cancer or heart disease is not known.
A spokeswoman for the NSW Health Minister, Reba Meagher, says the Supplemax website “talks about the benefits of testosterone, therefore it is not an advertisement for a product”. But a spokeswoman for the federal Minister for Health, Tony Abbott, takes a different view: “It is unlawful to advertise prescription-only medicines such as testosterone to consumers and unless specific approval has been granted, it is also unlawful to advertise any therapeutic goods to consumers for ’serious’ conditions”, she says, adding that the Federal Government’s Therapeutic Goods Administration would pursue the website issues with Supplemax.
Supplemax’s general manager, Chibuzo Okereke, says it is “completely valid” to do doctor consultations over the phone, and the company is not advertising testosterone. “The same care and attention can be taken over the telephone as [in] a face-to-face consultation,” he says. Pathology forms are sent out so that patients are given blood tests: “There’s no difference, apart from there’s no eye-to-eye contact.”
Okereke quotes as evidence of the existence of andropause a September 2006 Archives of Internal Medicine US study that showed low testosterone levels were associated with increased mortality in male veterans, but this study concluded further studies were needed. The Supplemax website also points to a Journal of the American Medical Association study by Carl Heller and Gordon Myers in which the authors identified the “male climacteric” including loss of libido and depression, which were improved with testosterone supplementation. But the study dates to 1944.
“We run programs, so if a person ends up having a prescription medication, that’s between them and the doctor,” Okereke says. “The doctors don’t work for us, they’re independent doctors. We pay [the doctors] for their consultations, whether they prescribe or not.” A doctor might simply provide dietary or exercise advice, he says.
Supplemax’s marketing manager, Brenton Le Grand, says the company’s reorder rates for its testosterone cream and lozenges are “great” and “around 90 per cent”, so men are “definitely seeing an improvement in their moods, energy and libido”.
As for andropause and male menopause, however, even Diamond concedes the names are “misnomers” given that men don’t have the sudden drop in hormones that women have. Indeed, some men can produce children into their 60s and 70s: think Charlie Chaplin and Rupert Murdoch.
What is needed, Handelsman says, is a large-scale, placebo-controlled clinical trial to show whether or not a 30 per cent testosterone fall between ages 40 and 70 actually matters, and if testosterone supplementation in such men is safe and efficacious. A 2004 review by the US Institute of Medicine found there was not even good short-term - about one year - efficacy evidence of testosterone use from studies to justify recommending large-scale clinical trials.
Given this lack of evidence, the Federal Government has resisted subsidising testosterone treatment for male ageing. A 2004 study by Handelsman found there had been two surges in subsidised testosterone prescribing in Australia in the 1990s, mostly in oral and implantable forms, but the overall increase was nothing compared with the 20-fold rise in testosterone sales revenue the US experienced in the decade to 2001.
But the full Australian picture is unknown, as the number of ageing men prepared to pay $800 for a six-month course of testosterone without government subsidy is commercial in confidence information.
Handelsman draws a distinction between unproven testosterone treatment for ageing men, and the need to educate the community about genuine androgen deficiency in younger men suffering gonadal disorders (known as hypogonadism), for which there is a government subsidy and a long efficacy and safety record for testosterone-replacement therapy.
Such a deficiency becomes evident from adolescence - facial and body hair fail to sprout and the voice fails to deepen, among other signs - and Handelsman tells the Herald there could be more than 10,000 Australians undiagnosed and, therefore, untreated.
David Handelsman’s research into androgen physiology and pharmacology receives funding on a costs-recovery basis from companies marketing testosterone.
