BIOLOGICAL CHANGE OF LIFE

Tom and Diane made a handsome couple: he with his trim physique, graying hair, and healthy complexion; she with her petite athletic figure, bouncing pageboy haircut, and sparkling eyes. They had initially come to see me when Diane's hormonal transition at menopause had decreased her sex drive. Her female brain was suddenly getting a lot less sex hormones, and she was experiencing a new biological reality that her husband couldn't relate to. Tom had always been a loving husband and father, but what he didn't know was that the combination of Diane's hormones and his lack of attention was making things worse with her libido. Diane had been angry because Tom's work always seemed to come before her. During the menopause, one wrong word or even just a look from Tom could send her slamming doors throughout the house and taking refuge in her greenhouse for a private sobfest. Her interest in sex was deader than a doornail.

On the other hand, Tom had long resented that Diane didn't appreciate how hard he worked to provide her and the kids with the lifestyle she wanted. Only when Tom was at his wit's end from being sexually rejected by her had he finally agreed to come to counseling. Working through their issues at that time had helped them to decide on some compromises and to renegotiate parts of their "marriage contract." Tom agreed to work less, and Diane agreed to be more attentive to his sexual needs. For some reason, many couples think they can't renegotiate the unwritten marriage contract--or "revisit the prenup," as I put it. To them I say, "Of course you can. Your life depends on it."

For Tom and Diane, the couples counseling and Diane's hormone-replacement therapy made all the difference. Consequently, I hadn't seen them in a few years. But now Diane was calling to say she thought Tom had better come in to see me, this time about his hormones.

Hormones in the brain and the penis are what make a man a man. They activate the sex-specific brain circuits required for male-typical thoughts and behaviors. When the male brain and body start making less of these hormones, he enters the so-called andropause, or male menopause. A century ago, andropause was relatively rare, because men didn't live long enough to experience it. Even in the late nineteenth and early twentieth centuries, the average age of death for men in the United States was forty-five. Nowadays, thank goodness, there's plenty of life after andropause. Men in the United States can expect to live decades after their hormones start to decline. But according to researchers, many men aren't happy unless this stage of life also includes sex. And for Tom, this was where the rubber met the road.

Over the phone, Diane explained to me that there were a few times lately when Tom couldn't get a firm enough erection to have intercourse. She said, "I personally don't think it's that big a deal. I mean he is sixty-four. The first two times it happened, he was upset about it, but he thought maybe he was just tired. But when it happened last night, he got up, got dressed, and stormed out to his woodshop. Do you think it could be hormones?"

Based on Diane's description, I agreed that Tom's testosterone could be low, but it could also be many other things. So I suggested that he come into the office to discuss what was going on and see how I might help.

Women can't imagine how changes in sexual function can affect a man's self-perception so much at this stage in life. He's the same man he's always been, and yet he's not. The body part that has brought him the most pleasure, the very symbol of his manhood, may no longer be reliable. As Tom sat down in my office, I could tell this was clearly taking a big toll on him. He said, in his usual get-down-to-business manner, "I'm sure Diane's filled you in. What do you think I should do?"

Tom was in good health, so I wanted to know what else might have changed since the trouble in the bedroom began. He said his last checkup and tests with his primary-care doctor were normal, even though he was feeling tired all the time and his thinking wasn't as sharp as it used to be. He complained that he'd lost strength, even though he exercised, and he noticed that his beard wasn't growing as fast as it used to. Otherwise, he said, he was "as good as ever." After hearing Tom's symptoms, I suspected that his testosterone level might be low and recommended that he get it tested.
The hormone tests confirmed that Tom was going through andropause. On average, men go through this hormonal transition between age fifty and sixty-five. During this stage, their testicles produce one third to a half the testosterone that they produced in their twenties. It was a good thing Tom came in, because this was a biological problem that was quickly becoming a marital problem.

As it turned out, Tom's testosterone level was substantially lower
Researchers have
than average for a man his age. found that when this hormone

dramatically decreases, the brain and spinal cord don't get as much stimulation as they need to keep his sexual thoughts and organs working at full capacity. At all ages, the male brain, spinal nerves, and penis need testosterone to function.

Although Tom was discouraged by his penis's lack of reliability, he confided that on the positive side of the coin, he didn't mind being a little less sexually driven. He was glad that the "I need it now or I will die" urges that he used to have in his younger years had subsided. Now he could wait. But when the waiting was over, he wanted to be ready for action.

He said, "I was hoping that staying in shape would keep things going down there. Now I'm not so sure. My brother's doctor started him on testosterone replacement a few months ago, and he swears by it. Does that stuff do any good?"
Although studies in the United States are few and far between, researchers in the Netherlands found that giving testosterone to men with abnormally low levels improved the men's physical and mental health. They found that it revived libido and penile function too. In addition, the men in the study had better muscle elasticity and bone density. They also reported improvements in their mood and their cognitive ability. And as a bonus, the study showed that increasing testosterone can kick-start abdominal weight loss.

I told Tom that research does show that exercising and staying sexually active can help men make more androgens, like dehydroepiandrosterone (DHEA) and testosterone. But for some men, that's still not enough. Being tired all the time and having foggy thinking aren't a natural part of getting older. When those symptoms are caused by abnormally low levels of androgens, some men get good results from androgen-replacement therapy. But its safety is still controversial, and it's not for everyone. For many men, there may be other answers.

In a study I conducted at UCSF in 1996, I compared the replacement of DHEA, an androgen similar to testosterone, with placebo in men over sixty. During this yearlong study, for an entire day once a month, the male subjects would come to UCSF's pleasant, spa-like clinical facility for testing. My friendly female nurses and psychologists would spend the day with the men while administering cognitive tests, collecting blood samples, and discussing details about their sex lives. Our results showed that by the end of the year, men taking the DHEA had improved their cognition, well-being, and sexual function by an impressive 40 percent. But the big surprise was that those taking the placebo had improved in all those same functions by 41 percent! I was forced to conclude that the therapeutic power of monthly social interaction with a group of caring, interested females was just as potent--or more so--to these andropausal men as the hormone DHEA.