He argues than men go through major life phases. Within these phases are times of stability, generally lasting about 6-10 years and transitional periods which may last about 4-5 years. The primary task of every stable period is to build a life structure, to make key choices, form a structure around them and to pursue goals and values within this structure. This may be a tranquil or stressful times as options are weighed and choices made. A transitional period terminates existing life structures and creates the possibility for a new one. "The primary tasks of every transition period are to question and reappraise the existing structure, to explore the various possibilities for change in self and world, and to move toward a commitment to crucial choices that form a basis for a new life structure in the ensuing stable period."
(The Seasons of a man’s life
70
65 late adult transition
60 ending middle adulthood
55 age 50 transition
50 entering middle adulthood
45 mid-life transition
40 settling down
33 age 30 transition
28 entering the adult world
22 early adult transition
As men complete a development phase called "settling down", they enter into a life period which Levinson calls "Becoming One's Own Man" (age 36-39). A man becomes a senior member in his own world, he speaks with his own voice, and he has a greater measure of authority. He carries the burden of greater responsibilities and pressures. He gives up more of the "little boy within". Hopefully, he fulfills his "Dream." Many men do not complete this settling down in terms which are satisfactory to them. They do not achieve their "Dream", they find themselves trapped in dead end occupations, their marriages are no longer the Hollywood fantasy of perfection and they enter into Mid-life with unresolved developmental issues. Others, while quite successful in their lives, still struggle with the new developmental tasks of mid-life since this is perfectly normal. He will still ask "what have I done with my life? What do I really get from and give to my wife, family friends, etc.?" He yearns for a life in which his actual desires, values, talents and aspirations can be expressed (and often he doesn't know what they are). Much of this developmental turmoil may be "below the surface" since many men are only marginally aware of their own disquietude and/or do not communicate what is really happening to others. However, it breaks through in strange ways and behaviors-- often being precipitated by acute crises or events in his life. Since clinical depression is a common hallmark of repressed anger, ambivalence, and unresolved inner turmoil, a typical characteristic of this time in a man's life is depression which clinically appears far differently in man than women.
A man has several major tasks to work on during this transition. Awareness of this by others may provide one tool for assistance so that this transition is not too destructive.
He must terminate early adulthood. He has to review and reappraise this era of his life.
He often has to discover who he really his-- not the "self" of social expectations, parental scripts, corporate environments, etc. He may begin to modify negative elements of his existing life structure. This may require experimentation and even failures until the redefinition is clear.
He has to deal with the polarities of his life. There are:
Young/Old--the mid-life male is caught between poles. "Young" symbolizes birth, growth, possibility, initiation, openness, energy, and potential. "Old" symbolizes termination, fruition, stability, completion, and death. Young can be heroic, fragile, and impulsive. Old can be senile, tyrannical, and unconnected. The task of mid-life is to reintegrate these poles-- to seek new energy for creation but with wisdom and balance. One of the major problems here can be the inappropriate "quest for immortality" and all the destructiveness this can lead to. Another aspect of this polarity is man's quest for a "Legacy"-- what he passes on to the next generation. This may take the form of satisfaction from children, work with charitable organizations, mentoring, recognition for professional work etc.
Destruction/Creation--as a man reviews his life, he becomes aware of how destructiveness everywhere inhibits creativity. He needs to understand the destructiveness in his own life.. He needs to take responsibility for his own destructive capabilities. He needs to resolve issues of guilt, ambivalence, old anger, and grief over lost opportunities. A man's new creativity in middle adulthood comes in part with the relationship with his own destructiveness and from intensification of the loving, life-affirming aspects of self.
Masculine/Feminine--these polarities-- strength vs. weakness
Attachment/Separation-- to be attached is to be engaged, involved, rooted, plugged in. To be separated is to be more deeply involved in one's inner world. Separateness promotes creative adaptation and inner growth. During the mid-life transition, men need to reduce their heavy involvement in the external world. To do the work of re-appraisal and dis-illusionment, he must turn inward. As he leaves the dependencies of his earlier life (and this may be a very negative and destructive act), he forms a more universal sense of good and evil driven by his own newly emerging values as opposed to that of the community. He strives to find a better balance between needs of self and needs of society. With increased self caring and self awareness comes self development and integrity.
Levinson states that as the mid-life transition begins to resolve and reintegration of the Self occurs, that the man effects changes in three components of the life structure:
The "Dream"--this symbolizes youth, omnipotence, illusion, inspiration, and heroic drama. At mid-life, this imagery needs to be modulated and the conflicts engendered by this resolved.
Mentoring--As the man gives up the "Dream", so he also gives up being mentored, He must accept the loss and disappointment of being ejected from the youthful generation. He much become the mentor and derive satisfaction from furthering the development of younger men and women--facilitating their efforts to form and live out their own Dreams. Mentoring involves altruism, self-rejuvenation, and creativity. The hazards of inappropriate control, exploitation, jealousy, and excessive involvement are well known.
Marriage--A man may come to recognize that his marriage was flawed from the start. As he comes to know himself better, he comes to know his wife as a real person. He needs to either recommitment to his marriage on new terms and, in doing that, accept some responsibility for his own motivation and character or enter into a new primary relationship. Obviously issues with the Young/Old polarity create major problems here.
So, where does a couple in struggling with the throes of a man's mild-life tumult go. For a few reflections, please see .
Perhaps the principal reason male menopause has never been in the public spotlight is because men who experience the characteristic decline in virility during middle age are reluctant or even unwilling to acknowledge the condition. In fact, in many instances, this condition goes untreated until the male's spouse or companion brings it to the attention of a physician. The Institute of Endocrinology and Reproductive Medicine now offers a comprehensive treatment program for male menopause, a condition that received scant attention from the medical establishment, the media or from the men it affects-- at least until Viagra was released in the Spring of 1998. Dr. Karpas first published research on this subject in 1977, and he has done extensive research on the effects of aging on male hormone levels ever since.
Symptoms
The symptoms of male menopause are not as overwhelming as the wholesale changes women experience, and male menopause does not affect all men. Approximately 40% of men in their 40s, 50s and 60s will experience some degree of lethargy, depression, increased irritability, mood swings, and difficulty in attaining and sustaining erections that characterize male menopause. For these individuals, such unanticipated physical and psychological changes can be cause for concern or even crisis. Without an understanding partner, these problems may result in a powerful combination of anxieties and doubts, which can lead to total impotence and sexual frustration. A recent aging study surveyed 1700 middle-aged men from the greater Boston area. According to their reports, 51% of normal, healthy males age 40 to 70 experience some degree of impotence - defined as a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse. This problem cannot be attributed to the aging process alone, however, because well over 40% of males remain sexually active at 70 years of age and beyond.
CAUSES
Although the causes of male menopause have not been fully researched, some factors that are known to contribute to this condition are hormone deficiencies, excessive alcohol consumption, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems. The few doctors who profess to be experts in this area have widely divergent opinions. However, all of the experts do agree that a general decline in male potency at mid-life can be expected in a significant proportion of the male population.
TESTOSTERONE
Many endocrinologists and scientists who have pioneered hormone studies say the phenomenon of male menopause correlates with a decline in testosterone levels. Testosterone is the hormone that stimulates sexual development in the male infant, bone and muscle growth in man and is responsible for sexual drive. Dr. Karpas and other experts have found that even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it was just ten years before. In fact, by age 80, most male hormone levels have decreased to pre-puberty levels. Low testosterone has been found to cause fatigue, depression, loss of concentration, as well as decreased muscle strength and endurance. Testosterone is more important in libido or sex drive than in the erectile mechanism. Men with low testosterone levels will have problems with erections.
HEART DISEASE
Despite the apparent correlation between decreasing hormone levels and decreasing virility, many urologists question the importance of hormones. After examining the results of an aging study, one of the study's principal investigators questioned the evidence of a relationship between a mild deficiency of testosterone and impotence. Other conditions such as obesity, hypertension, smoking, and high cholesterol - all of which are factors contributing to heart disease are also known to contribute to impotence. Impotence is often primarily a vascular problem resulting in a loss of elasticity in the arteries - a condition causing poor circulation and impairing blood flow. Healthy circulation and blood flow are necessary to maintain an erection. The aging study bears out this thesis. Nearly two-thirds of 40 year old men diagnosed with heart disease exhibited at least moderate impotence.
DRUGS
A wide variety of drugs have also been shown to increase the probability of impotence. While a very small amount of alcohol may not impair sexual performance for most men, alcohol in general can create problems for men of middle age and beyond. The immediate effect of alcohol to increase vasodilatation which makes it more difficult for the body to send blood to the penile tissues. The long term effects of excessive alcohol use are more dangerous. Tissue samples from patients with chronic alcoholism (10 or 15 years of heavy drinking) demonstrate that prolonged alcohol abuse causes irreversible damage to the nerves inside the penis.
As devastating as alcohol can be, many doctors cite smoking as the major cause of male sexual dysfunction. In addition to its other detrimental effects, smoking also damages the tiny blood vessels in the penis that must enlarge to accept the substantial onrush of blood during an erection.
Hypertension and the medications for hypertension (beta blockers) also significantly increase the chances of impotence. A patient may have to try several different drugs before finding one that controls blood pressure but does not affect potency. Other prescription and non-prescription medications that increase the incidence of impotence include but are not limited to antidepressants, especially Prozac and Zoloft, diuretics, antihistamines, antispasmodics, digestive medicines and cold and flu remedies.
DIET AND EXERCISE
The importance of proper diet and regular exercise cannot be discounted. The aging study produced the first evidence that cholesterol level is related to impotence. In fact, high levels of HDL (the "good" cholesterol) were significantly associated with reduced levels of impotence. A healthy diet low in saturated fat and sugars, coupled with regular exercise has been shown to play a significant role in lowering cholesterol levels, maintaining testosterone levels, increasing libido and boosting self image. In fact, throughout the life cycle, men who exercise regularly report greater sexual drives and greater sexual satisfaction than sedentary men.
DIAGNOSING IMPOTENCE
In case where impotence has been diagnosed, it is important to determine whether the cause is principally physical or psychological. One reliable test is to check nocturnal penile tumescence - the number and quality of erections that occur while the patient is asleep. If the results are within the normal range for men of a certain age, it can be hypothesized that the problems are not physical, but psychological, and the appropriate treatment programs can be begun.
If the results of nocturnal penile tumescence testing indicate a physical problem, then another test which determines penile blood pressure may be used. In this test, a cuff is supplied around the penis to determine the penile blood pressure, which should be the same as the blood pressure throughout the body. If the penile blood pressure is lower than expected, the cause of the impotence may be a vascular problem.
POSSIBLE REMEDIES
Usually there is more than one explanation or cure for the phenomenon known as male menopause. Aging, hormones and overall physical and mental well-being all factor into the condition. Many doctors agree that if a man has an understanding partner, monitors his medications, alcohol intake and eating habits, stops smoking, and improves the health of his vascular system through aerobic workouts, he will almost certainly see an improvement in his overall wellness and sexual potency.
In cases where specialized treatment is needed, new findings from English studies suggest that men can improve in sexual function, muscle strength, and general well-being if they are treated with supplements to bring their testosterone levels into a high - normal range. Hormone Replacement Therapy (HRT) is now regarded by many physicians as the future of preventative medicine for both men and women in the second half of life. In fact, the National Institute of Health recently asked for research proposals to investigate whether testosterone supplemen- tation might benefit older men by preventing bone loss, depression and other symptoms associated with aging.
Currently there are several methods of testosterone supplementation including shots, implants and a transdermal patch. If injections are indicated, they should be administered at least every two weeks to ensure that testosterone blood levels are constant throughout the treatment. Another option is testosterone implants which are surgically placed behind the gluteus muscle in order to release a steady level of testosterone into the bloodstream. An even newer treatment is the transdermal patch. This patch is placed on the scrotum, and the patient must shave the area where the patch will be affixed and apply a new patch daily. All of these treatments boost testosterone levels in the blood to therapeutic levels, and the patient must determine with the help of his doctor which is the best for him. Unfortunately, testosterone is not particularly effective in treating erectile dysfunction (impotence).
In the past, effective treatments for impotence included vacumn pumps, injections of medications (Caverjet) into the base of the penis, and prosthetic implants. A number of newer medications have become available in the last several years including:
Alprostadil (Muse)-- a pellet placed within the urethra (the passage in the penis where urine comes out)
Sildenafil (Viagra)--an oral tablet which doses not cause an erection but enhances one.
New oral compounds in late stage clinical development include apomorphine and phentolamine (Vasomax). There are also topical creams, sublingual tablets, other intraurethral tablets, and injections being studied at this time.
Testosterone And The Aging Male by Anthony Karpas, M.D., originally published in Atlanta Medicine, Spring, 2001
Men reach ages once thought unattainable. They have sought, since Ponce de Leon got lost in the swamps of Florida, to reverse effects of normal aging. Testosterone production in men starts at puberty. Unlike women, there is no abrupt cutoff of hormone production at midlife. The decline is more gradual. Testosterone is a pulsatile hormone under the control of LH or luteinizing hormone produced by the pituitary gland. As men age, the testis may become less responsive to the LH pulses. Older healthy men have been shown to have less diurnal variation in testosterone levels than their younger counterparts. The nocturnal surge, which typically doubles the testosterone concentration in the early hours, diminishes by age 60. Pituitary production of LH also declines with aging. We did a study to ascertain the pituitary output of aged castrated rats. The young animals had vigorous LH pulses, middle-aged animals had lower amplitude pulses, while extremely old animals had severe declines in both pulse amplitude and frequency. Studies have been done in older men showing a diminished response to LHRH, the LH precursor given intravenously. While there is not a major difference between testosterone levels of healthy younger and older men at midday, total 24-hour production diminishes with aging.
Many other factors affect testosterone levels. Alcohol directly inhibits the Sertoli cell’s testosterone production and increases estrogen conversion in the liver. This results in pituitary suppression of testosterone production. The high levels of estrogen in chronic alcoholics can cause such feminizing effects as gynaecomastia and loss of body hair. Chronic illness such as congestive heart failure, C.O.P.D., H.I.V., renal failure and severe metabolic diseases can result in extremely low testosterone levels. Another common disorder that is frequently missed is sleep apnoea. Patients present with sluggishness, fatigue, impotence and weight gain. Both testosterone and LH levels are low. A sleep study will differentiate sleep apnoea from pituitary disease. Levels usually return to normal once therapy is initiated.
Erectile Function: The role of testosterone in men is debated. It is clear that testosterone is necessary for puberty to take place. There is an obvious role for testosterone in fertility maintenance. High intra-testicular testosterone concentrations are required for sperm production. Since testosterone is produced in the testis, levels are much higher than in the serum. The presence of some FSH secretion from the pituitary is required. Reasonable fertility has been maintained at low levels of serum testosterone as long as pituitary function is adequate.
While testosterone is important for libido, its role in achieving and maintaining erections is less certain. Low levels are not incompatible with sexual function since even young boys have frequent erections. The physiology of erectile function is complex. Stroking of the upper thigh or penis or a full bladder causes the erectile reflex. This is maintained in men who have had transection of the spinal cord. Obviously, cortical control causes erections during sexual fantasies. It is possible to separate the cortical component from the spinal reflex. Interestingly, syphilis causes loss of the reflex component while the fantasy effect is maintained. Testosterone is required for both since castration will prevent erectile function. When the tissue has not been exposed to hormones for a prolonged period, it is very sensitive. Even low serum levels may initiate erections in hypogonadal men and prepubertal boys.
Testosterone is important for prostatic secretion and semen production. Sensation and pressure in the prostate is a factor in erectile function. This may explain why some men cannot have a second erection after sex. Volume expansion of blood vessels in the corpus cavernosum is the mechanism by which erection occurs. Increase in arterial and arteriolar pressure is the major factor. Venous congestion may occur but it is not, as previously thought, the major mechanism. Since arteriolar diseases, such as atherosclerosis, will adversely affect function, cardiovascular disease may present with impotence as the initial symptom. Diabetes causes destruction of the spinal autonomic reflex pathways as well as vascular problems. In order to completely evaluate impotence, Doppler pressure studies may be required. Many devices have been used to try and measure erectile frequency and quality.
For many years, it had been assumed that loss of erectile function was mainly psychological and much time was spent trying to determine the cause of the problem. We now know it is 90% physiological. Uses of devices such as vacuum pumps are effective but unwieldy. Herbal products such as yohimbe are aggressively marketed on the Internet and through health food stores. Intracavernosal injections with alprostadil (Caverjet®), papaverine and regitine in various combinations are effective and are still used as a test of vascular function. Intra-urethral alprostadil (Muse®) is occasionally helpful. Sildenafil (Viagra®) created a revolution in the perception of male sexual dysfunction. The medications increase blood vessel nitrous oxide production. Even if arterial pressure is low or if there is nerve damage from diabetes, the increased sensitivity allows the blood vessels to dilate. Low testosterone is an important cause of impotence due to its effect on libido, as well as the sensitization of the nerve and muscle pathways. Testosterone needs to be measured as part of the assessment of impotence and needs to be replaced if low. However, since impotence is a multi-factorial disorder, testosterone rarely is the entire solution to the problem. The addition of sildenafil and other similar drugs still under investigation have increased treatment choices. When modern medications fail, older treatment methods such as vacuum pumps and surgical penile implants remain effective.
Effects Of Testosterone: Testosterone does increase and maintain muscle mass and the absence of testosterone causes a loss of strength and muscle bulk. Although treatment with testosterone in hypogonadal men decreases body fat and improves endurance and athletic performance, supplemental testosterone within physiologically normal levels does not cause major improvements in normal men.
The well-known anabolic effects occur at blood levels vastly in excess of physiologic replacement. Anabolic steroids are 10-50 times more potent than testosterone. Anabolic steroid abuse is obvious among wrestlers and other sports figures on primetime national T.V and media. On the other hand, anabolic steroids may be quite beneficial in wasting disorders such as cancer and AIDS. Testosterone-deficient men complain of lethargy, lack of motivation, poor concentration, depression and low libido. On the other hand, men with high testosterone levels may exhibit more aggressive behavior. Some patients complain of irritability immediately following an injection where levels are high. Most men experience a sense of well being when levels are adequate. Testosterone seems to improve focus and concentration according to the studies of Dr Jim Dabbs, a noted psychologist.
For many years, testosterone therapy was considered potentially harmful. Concerns were raised over its effect on heart disease, lipid disorders, prostate cancer and liver disorders. Studies results have not supported this concern. A recent study, in fact, reported that men with lower testosterone levels were more likely to get heart disease. While prostate cancer is sensitive to testosterone, testosterone has not been shown to be a direct cause. No adverse lipid changes have been shown to occur with parentally administered testosterone. Oral methyl-testosterone is associated with liver enzyme abnormalities and lipid disorders. High levels of testosterone will cause polycythaemia.
Men who are low in testosterone are at risk for osteoporosis. One third of all hip fractures occur in men. The effects of these fractures are more severe than in women because they tend to occur in older, taller men whose fractures are more severe. The effect of testosterone on bone is both direct as well as mediated through estrogen. Men who lack the ability to aromatize testosterone into estrogen have been found to have severe osteoporosis. Estrogen may play other roles in men. Older men are noted to have higher conversion rates of testosterone to estrogen and subsequently higher estrogen levels. In fact, sixty-year-old men have higher estrogen levels than 60-year-old women. This may help to explain the surprising finding that men with higher testosterone levels have lower heart attack rates.
Diagnosis Of Testosterone Deficiency: Testosterone levels fall with aging. The problem is that not all men are symptomatic and not all men have a need for treatment. A recent consensus conference tried to define who were candidates for therapy. Testosterone levels in young men are probably normal above 400. Any level above this is normal. Older men may have levels as low as 280 and not be symptomatic. A level of less than 200 is definitely low and needs further evaluation. Free testosterone levels may be helpful as sex hormone binding protein goes up with age. LH and FSH levels, if elevated, may suggest primary testicular failure. When they are low and testosterone is below 200, a pituitary tumor should be considered. Elevated prolactin increases suspicion of a tumor and should be measured. A pituitary MRI should be done in this situation. Pituitary depression due to acute disease should be obvious but chronic severe disease such as severe sleep apnoea, AIDS, COPD, renal and hepatic failure can cause severe depression of testosterone levels and should be ruled out. Another less obvious cause of low testosterone levels is recent previous use which suppresses pituitary hormone stimulation.
The primary reason to diagnose and treat male patients is often made on clinical grounds. The most common complaint is impotence. On further questioning, the problem often is not a problem with achieving an erection but a lack of desire. Inability to sustain or achieve an erection is more likely a vascular problem. While lethargy, depression and lack of concentration are common findings, loss of muscle mass and strength may also present. Increased body fat can be a complaint. Clinical exam may reveal some loss of pubic hair, gynaecomastia and soft or shrunken testes. Depending on the duration of the problem the prostate may be either reduced, if the problem was of long duration, or enlarged, if the problem was recent. Cluster headaches have also been associated with testosterone deficiency. Testosterone therapy should be instituted if levels are below 280ng/ml and considered if levels are below 400ng/ml. The physician should check PSA levels and the prostate digital examination before treatment as well as 3 and 6 months after the onset of therapy. An increase in PSA of more than 1.5 from baseline should be regarded as suspicious and prompt a urological investigation. CBC levels should also be measured every six months since polycythaemia is a common side effect of therapy. Bone density testing should be done on men who have low levels since they are at increased risk of osteoporosis.
Treatment: Testosterone depot injections 200mg/ml 1cc every 10-to14 days will usually result in a high physiologic blood level. Testosterone patches (Androderm® or Testoderm® ) 5mg/day will also bring levels into an acceptable ranges. A new therapy, Androgel ® 5mg cream, is currently available and achieves physiological testosterone levels if applied regularly once a day and allowed to dry. Testosterone subdermal pellets are inserted every 4-6 months and also give very consistent levels. Clomiphene (Clomid®) 25mg works well for men with pituitary disorders and raises testosterone into the mid physiologic range. Men still desiring fertility may benefit from shots of HCG 2500u twice weekly if Clomid® is ineffective.
Readings
American Association of Clinical Endocrinology, Guidelines on Testosterone Replacement Therapy
Dabbs, James. Heroes Rogues and Lovers, Testosterone and Behavior, McGraw Hill, 2000.
Mayo Clinic Proceedings: Symposium Testosterone Replacement in Elderly Men, Jan. 2000.
Swerloff,, E., ed . Endocrine Society Annual Consensus Meeting. April 2000.
There are a number of different meanings for the word impotence or erectile dysfunction. For the purpose of this discussion, impotence shall be defined as "the inability to have or sustain and erection long enough to have meaningful (within reason) sexual intercourse." Impotence is often primarily a vascular problem resulting in a loss of elasticity in the arteries - a condition causing poor circulation and impairing blood flow. Healthy circulation and blood flow are necessary to maintain an erection. There are several forms of impotence:
Organic erectile dysfunction: This tends to occur gradually until the male never has night time or early morning erections.
Psychogenic impotence: This tends to occur suddenly but the male continues to have spontaneous erections at night or in the early morning (often associated with a full bladder).
Partial erectile dysfunction: Where the male will develop an erection but it either goes away prior to intercourse or is so flaccid that successful intercourse does not occur
Facts
50% of men in their 80s and 90s experience night time and morning erections
50% of men age 70 are still sexually active
51% of normal, healthy males age 40 to 70 experience some degree of impotence - defined as a persistent problem attaining and maintaining an erection rigid enough for sexual intercourse.
Approximately 40% of men in their 40s, 50s and 60s will experience some degree of lethargy, depression, increased irritability, mood swings, and difficulty in attaining and sustaining erections that characterize male menopause.
Two-thirds of 40 year old men diagnosed with heart disease exhibited at least moderate impotence.
Tissue samples from patients with chronic alcoholism (10 or 15 years of heavy drinking) demonstrate that prolonged alcohol abuse causes irreversible damage to the nerves inside the penis.
Diagnosis
The diagnosis of largely based on a careful medical and psychological history. At times, measurement devices can be placed on the penis to determine if spontaneous night time erections occur and to compare the blood pressure within the penis with the blood pressure in an arm. Common causes for impotence need to be sought out including:
Medical Problems:
Diabetes
Vascular disease
Low testosterone levels
Other endocrine disorders such as an underactive thyroid
Poor habits
excessive alcohol use
smoking (causes microvascular disease)
obesity
lack of exercise
Medications
Anti-hypertensive medications such as diuretics and beta blockers
Anti-depressants-- both tricyclic antidepressants such as Elavil (imipramine) and the new SSRIs, particularly Prozac and Zoloft
Tranquilizers
Anti-histamines
Asthma medications such as ephedrine
Digestive medications such as Tagamet
Psychological problems
Stress
Depression
Fatigue from overwork
Marital Problems
History of Vasectomy
Treatment
The treatment for impotence is usually more complicated than one single approach. First, a distinction needs to be made between men with organic erectile dysfunction and those with so-called "psychogenic" impotence.
Men who never experience an erection because of vascular disease should be referred to a urological specialist. Caution should be taken with the use of medications which dilate blood vessels, such as Viagra, because men with advanced vascular disease in the penis probably have a similar condition in the heart and other tissues and are at great risk of major complications from drug use (such as a heart attack or stroke). Men who use nitroglycerin type medications for angina should be especially cautious and should consult with their cardiologists before strenuous sexual activity or the use of any sexual enhancing drug.
With respect to so-called "psychogenic impotence", it is rarely purely psychological. Aging, hormones and overall physical and mental well-being all factor into the condition. The psychological problems of the male mid-life crisis along with depression are also major contributing factors. Many doctors agree that if a man has an understanding partner, monitors his medications, alcohol intake and eating habits, stops smoking, and improves the health of his vascular system through aerobic workouts, he will almost certainly see an improvement in his overall wellness and sexual potency.
In cases where men have a depressed serum testosterone level (only 8-16% of men with impotence have low testosterone levels), specialized treatment is needed. New findings from English studies suggest that men can improve sexual function, muscle strength, and general well-being if they are treated with supplements to bring their testosterone levels into a high - normal range. Estrogen Replacement Therapy (ERT) is now almost universally accepted by physicians as the future of preventative medicine for women in the second half of life. Will Testosterone Replacement Therapy be far behind?
Currently there are several methods of testosterone supplementation including shots, implants and a transdermal patch. If injections are indicated, they should be administered at least every two weeks to ensure that testosterone blood levels are constant throughout the treatment. Another option is testosterone implants which are surgically placed behind the gluteus muscle in order to release a steady level of testosterone into the bloodstream. An even newer treatment is the transdermal patch (Testoderm). This patch is placed on the scrotum. Unfortunately, the patient must shave the area where the patch will be affixed and apply a new patch daily. Another transdermal patch (Androderm) has the advantage of being placed on the skin of the abdomen or back. All of these treatments boost testosterone levels in the blood to therapeutic levels, and the patient must determine with the help of his doctor which is the best for him. Unfortunately, testosterone is not particularly effective in treating erectile dysfunction (impotence) except in instances of markedly depressed testosterone levels. Even eunuchs from ancient times who were castrated after puberty were capable of maintaining erections. It was a custom in ancient Rome that women would use more potent eunuchs for pleasure without the risk of procreation (Carruthers, 1997).
In the past, effective treatments for impotence included vacuum pumps, injections of medications (Papaverine, Caverjet) into the base of the penis, and prosthetic implants. A number of newer medications have become available in the last several years including:
Alprostadil (Muse)-- a pellet placed within the urethra (the passage in the penis where urine comes out)
Sildenafil (Viagra)--an oral tablet which doses not cause an erection but enhances one. This should be used very cautiously in men with vascular disease.
New oral compounds in late stage clinical development include apomorphine and phentolamine (Vasomax). There are also topical creams, sublingual tablets, other intraurethral tablets, and injections being studied at this time.
Drs. Caroline Dott and Andrew Dott are professional lecturers and teachers with a special interest in the interactions between the biological and psychological basis of human behavior at midlife. Among their lecture topics are female and male menopause, the hormonal basis of human behavior, and issues related to depression and anxiety. They are available to travel and give seminars on the topics covered in this website both nationally and internationally.
Many developmental theorists now feel that men continue to change, psychologically, during their adult life. In a sense, men experience two or even three adulthoods. The first extends from the end of puberty until the forties. Than many men experience "the midlife crisis" or the "Corvette syndrome" or a psychological "male menopause". This can become a very difficult period of transition for men and women which, if successfully resolved, leads into a man's second adulthood. Among contemporary writers who discuss this transition is Jed Diamond in his book Male Menopause and Gail Sheehy who wrote Understanding Men's Passages. These are excellent references for couples struggling with these changes.
The first question is whether men have always been this way or whether this behavior has been precipitated by the profound changes in the roles of men and women which have occurred in the 20th century. Another issue is that these changes in the relationships between men and women, which started around the time of the Second World War when women first moved into the work place in large numbers has undergone another profound change in the 1970s and 1980s as the roles of men and women in the workplace have been equalized. No longer is the man the sole provider for this family or the provider who is assisted by his wife, but now they are joint providers and many American families are now experiencing the situation where the woman is the dominant provider. The men and women who come from the generation of this last change are just entering their mid-forties now so there really have been no experience with the passage of these couples through their "midlife crisis". This chapter will unfold in the next decade.
So what happens to men. Some men experience a true biological menopause like women do. This is called viropause or andropause and will be discussed in another article. Most men however experience a developmental change in their psyche as they reach a point in their lives where the need to fulfill the traditional roles of achieving power, wealth, success, fame is resolved, either through success or failure or simply being tired. While the relationships of early adulthood between the sexes has been traditionally one of separation and marked differences because the woman is tied up with her children and home and the man with work, things change and the roles of men and women often tend to converge and even cross over so that the role of the man and women are quite different in late adulthood. Many men in their fifties develop a nurturing, artistic and expressive self while many women of the same age become more assertive, focused, and political. Gail Sheehy refers to this as "the sexual diamond". There is even some data coming from research in the neurosciences which suggest that the right side of the brain (which regulates logic, orderly thinking and cognitive type skills) is larger than the left side of the brain (which regulates feelings, sensitivity, and artistic qualities) in young men but as the man ages, the sizes become equal. On the other hand, in women, the two sides are equal in young adulthood but then the right side increases with aging. Of course this data is very preliminary.
What precipitates the male midlife crisis? In the simplest terms, a man begins to feel that there is something else in life other than where he is. Men either feel they have progressed as far as they can with whatever their life script is or a crisis is precipitated by a sudden change which makes a man feel obsolete, vulnerable, unsure or not competent. Typical events can include:
Loss or Downsizing of a Job
Separation and/or Divorce
A Health Crisis
Death or Illness of a Peer or Family Member
Children Leaving Home
Displacement by a Younger Male
Becoming a Grandparent
Experiencing Erectile Failure Twice in a Row
The most typical response of the male to this is depression which, in the male, is often expressed differently from symptoms which are classically attributed to depression. As a result, it is commonly not recognized. See the article on Depression in Men for a more thorough discussion about the differences between male and female depression.
Drs. Caroline Dott and Andrew Dott are professional lecturers and teachers with a special interest in the interactions between the biological and psychological basis of human behavior at midlife. Among their lecture topics are female and male menopause, the hormonal basis of human behavior, and issues related to depression and anxiety. They are available to travel and give seminars on the topics covered in this website both nationally and internationally.
Depression in Men--Its Different! by Caroline Dott, Ph.D., L.C.S.W. and Andrew B. Dott, M.D., M.P.H., originally published in Atlanta Medicine, Spring, 2001.
Willy Loman in Death of a Salesman exemplifies the quintessential depressed midlife man whose inner rage at his life prompts tumultuous actions resulting in self-destruction. How many men unconsciously replicate Faust’s “contract with the Devil” in their 20's, only to find that the “ole Devil” has gotten the best of them by their mid-40's? What do these characters from great literature have in common?
Scope of the Problem. Depression is one of the most common responses of men to “Male Menopause.” Midlife men often do not see themselves in the mirror of major depressive responses which include persistent sad moods, diminished ability to think or concentrate, feeling worthless, sleeping too much, low energy, significant weight loss or gain, loss of pleasure in activities, and recurrent thoughts of death. Approximately 40% of men in the forty to sixty midlife age ranges will experience some degree of depression. Whereas men complete 20% of all suicides in the United States, the suicide rate triples in midlife men and increases seven times in men over age 65. Having a history of depression makes the risk of suicide 78 times greater. The proper recognition and diagnosis of depression can take up to ten years and three or more healthcare professionals. Even though 80-90% of people seeking help for depression obtain relief, 60-80% of depressed adults never receive available professional help (Diamond, 1998).
What contributes to depression in men at midlife? To answer this question, the incidences of physical, emotional, and spiritual challenges either already present, or that appears at midlife, needs to be addressed. Depression may be a reaction to acute or chronic illness such as cancer, heart disease, or HIV. There are a number of physiological imbalances—especially endocrine and metabolic disorders, that can be accompanied by depression. Sub optimal nutrition can reinforce and worsen a depressive state. The depressive effects of alcohol on the body and psyche are well known. In general, because depression negatively impacts the immune system, its unrecognized and untreated presence contributes to compromised health overall. Finally, occupational and environmental pollutants may result in compromised energy resources that can contribute to or cause depression. As an example, while changes in the functioning of the thyroid gland are far more common in midlife women than in men at midlife, the decreased hormone output of the thyroid gland, or hypothyroidism, is often accompanied by depression. Men may mask real depression connected with low thyroid functioning by presenting with,” I’m tired, exhausted and can’t function the way I used to” (Arem, 1999, p. 20). Adjusting to these feelings and struggling to appear normal to avoid the cultural stigma placed on emotional conditions, men may deny and dismiss their own symptoms and inner pain, not seeking professional help. Men and doctors may miss a correct diagnosis of malfunctioning thyroid by focusing on and treating resulting physical symptoms rather than diagnosing the underlying thyroid disease.
Other hormone changes such as a decrease in testosterone, the “male hormone,” DHEA, or insulin may result in the neurochemically-based feeling of depression. Psychologist James Dabbs (Dabbs & Dabbs, 2000) found that his own testosterone level was lower when he was depressed and higher when he was optimistic. Endocrinologists have found that low testosterone results in lowered energy and reduced sexual activity. There is some evidence (Steiger, et al, 1991) that very low levels of testosterone may be associated with clinical depression, although this is controversial. Most studies to date do not confirm this finding (Rubin et al., 1989).
Testosterone interacts with other hormones such as cortisol, serotonin, and prolactin, which moderate the effects of testosterone. Cortisol lowers testosterone in men (Cumming et al, 1983). Released in stressful situations, cortisol contributes to the body’s fight-or-flight response by providing energy to help one deal with emergencies. Men who are chronically high in cortisol and low in testosterone are not particularly aggressive or likely to confront others. Instead, they tend to be less friendly and cheerful than other men with low testosterone with an increase in anxiety related to high cortisol levels (p. 167).
Serotonin is a neurotransmitter that affects the brain and behavior by stimulating a pleasant outlook. Elevated levels of serotonin tend to produce calmness, confidence, lowered irritability, increased optimism, less impulsivity, and increased pleasantness. Studies show that high-serotonin male vervet monkeys are dominant and calm whereas high-testosterone male vervet monkeys are dominant and more aggressive. An uncommon spate of other physiological changes in midlife men may contribute to feelings of depression. Thus, men can optimize their own health and continuous normal functioning by seeking informed professional help immediately for distressing symptoms rather than adjusting to and doing nothing about them.
Normal Male Psychological Development. Psychological and emotional stressors are the largest contributors to depression in midlife men. In order to understand these challenges, we need to know normal male psychological development. Daniel Levinson, in his enlightening book The Seasons of a Man’s Life, outlines male adult developmental stages. During the major life phases of adolescence and young adulthood, life structures are built, defining choices are made, and goals and values are pursued within that structure. Following each major life phase is a transition period of 4 to 5 years when a man completes existing life tasks and creates new opportunities for growth and development.
In the pre-midlife stage of Adulthood, men achieve the life goal of “Becoming a Man.” This formidable accomplishment includes speaking with their own voice; becoming a senior, authoritative member in their world; and carrying the burden of increasing responsibility and its accompanying stress. These achievements lead to fulfilling their “Dream.” At midlife, a man must terminate Early Adulthood. Perhaps the most significant task is discovering who he really is--not the “self” of social, business/professional or family expectations.
What are the primary tasks of every transition period?
1. Questioning and reappraising existing life structures,
2. Exploring various options for change in oneself and in one’s surrounding environments,
3. Moving toward a commitment to defining choices that form the basis for a new life structure in the next major life phase.
For most men, this transition period evokes tumultuous struggles within the self and with their external world leading to moderate to severe crises. Men question every aspect of their life, often experiencing some sense of horror at what they discover. They blame themselves and others severely for their life situation. Realizing they cannot continue as before, they require time either to choose a new path or to modify the old one. A man may begin to change the unacceptable parts of his existing life structure, entering a time of confusion, experimentation and, inevitably, some mistakes. Thus, in some ways, the midlife transition mirrors the earlier stage of adolescence.
What are the common events that precipitate men entering into midlife? These events fall into three major categories--personal, family, and occupational. In the personal realm, a man may experience some health crisis, separation or divorce, or experience erectile failure twice in a row. Family events include the death or illness of a family member or peer, children leaving or returning home, or becoming a grandparent. Occupationally, he may be the unwilling victim of involuntary retirement, non-advancement or of being displaced by a younger male. That old culprit, stress, accumulating in midlife men who are also in their peak years of responsibility, productivity, and financial output, may stimulate panic, anxiety or depression. Stress, vascular disease, normal aging, and/or lowered testosterone levels can lead to compromised erectile functioning. Approximately 40% of men between the ages of forty and sixty will experience some degree of difficulty in attaining and sustaining an erection. Closely associated responses include lethargy, depression, increased irritability, and mood swings. Many men may develop a reactive depression secondary to issues relating to loss of virility and sexual identity.
Each of these major events can stimulate emotional reactions involving varying degrees of personal pain. Changes in any one or all major life areas may result in feelings of loss of power and self-esteem, questioning virility and personal desirability, and performance or global anxiety and/or depression which frequently occur together.
Why don’t we recognize depression in men? The signs and symptoms of depression in men commonly are not recognized for several reasons:
1. The behavioral expression of depression in men is often quite different from the classic symptoms people in our culture define as “depressed.”
2. Men in our culture often are not aware when they are depressed because of the association with being “weak” when men are taught to “be strong.”
3. Men do not allow themselves to admit to themselves that they are having a problem with sexual expression and do not understand its relationship to depression.
4. The behavioral expression of male depression is not familiar to family members or healthcare providers who do not recognize it.
Depression Looks Different in Men and Women. Empirically and anecdotally, women generally turn inward when they are depressed, whereas men are more likely to act out their unrecognized and denied feelings of depression. Jed Diamond, PhD, in his book, Male Menopause (1998), details the differences between men’s and women’s expression of depression (Table 1).
Table 1: Differences between Male and Female Depression
Depression Male Depression
Blame themselves Blame others
Feel sad, apathetic, worthless Feel angry, irritable
Feel anxious, scared Feel suspicious, guarded
Avoid conflict at all costs Create conflict
Always try to be nice Overtly or covertly hostile
Withdraw when feeling hurt Attack when feeling hurt
Have little self-respect Demand respect from others
Feel they were born to fail Feel the world set them up to fail
Slowed down and nervous Restless and agitated
Chronic procrastinator Compulsive time keeper
Sleep too much Sleep too little
Trouble setting boundaries Control everything, everybody
Feel guilty for everything Feel ashamed for who they are
Uncomfortable receiving praise Frustrated if not praised enough
Easily talk about weaknesses, doubts Terrified to admit weaknesses, doubts
Strong fear of success Strong fear of failure
Need to "blend in" to feel safe Need to be "top dog" to feel safe
Use food, friends, and "love" to self-medicate Use alcohol, TV, sports, and sex to self-medicate
Believe their problems could be solved only if they could be a better spouse, co-worker, parent, friend Believe their problems could be solved only if their spouse, co-worker, parent, friend would treat them better
Constantly wonder, "Am I loveable enough? Constantly think, "I’m not getting enough love”
Adapted from Male Menopause by Jed Diamond, PhD, Naperville, Ill: Sourcebooks, Inc., 1998.
The most striking overall difference between the ways women and men handle depression can be described best as polar opposite behaviors. For example, one common emotion that underlies depression in both men and women is anger. Women usually hold in their anger and this negative energy lodges inside the body down to the cellular level, depressing the whole system. Men, on the other hand, more often express their unrecognized inner feelings of depression by showing increasing impatience, irritability, hostility and anger toward those with whom they are closest emotionally, and often toward others as well.
What Can Men Do About Their Depression? Unfortunately, because most men do not recognize that they are depressed or because they deny it, there is little they do to seek help. If and when their own inner pain finally becomes unbearable, they may inadvertently and, at times, impulsively “try out” some new behaviors in a desperate and misdirected attempt to rid themselves of inescapable and painful situations. These often unconscious attempts at “fixing” an ill-defined and often-denied painful state may result in behaviors which are self-destructive and destructive to those closest to them---thus we have the full blown “midlife crisis.” In actuality, it is not necessarily the stage of midlife that creates the crisis for the man but his response to his own midlife stress and confusion.
Often we receive questions on our website, www.midlife-passages.com, from distressed women who wonder what is happening to their partner. For example:
“My husband has just separated from me after 22 years of marriage. I don’t know what happened but he has changed overnight. He says he loves me but he doesn’t want to live with me any more. Our friends and our children are angry with him because they think he is acting crazy. I am hurt, confused and don’t know what to do. I still love him. Please help!! “
Without further information, we cannot make a definite determination about the underlying cause of this man’s distress, but this type of situation is described frequently enough on our website. We can speculate that this man may be feeling depressed, may not recognize it or may deny it, and is handling it in the only way his current repertoire of coping mechanisms allows him--i.e., to “escape” the situation which generally is not a viable solution. This is an example of the way in which some men are not aware of the reasons for their depression and may react impulsively rather than create thoughtful, proactive solutions. Lack of awareness is a common emotional defense in many men.
Why is this defense so common in men? In the emotional realm, men often do not want to face the fact that they need to “fix” something about themselves that feels threatening or painful. They can avoid the whole uncomfortable “fixing” process by denying that they have a “problem.” Thus, most men seek help only when pressured to do so by significant people in their life who recognize that they are struggling and in distress.
Men can be helped or help themselves through a variety of approaches. Through loving, gentle encouragement, a partner can help a man begin to realize he needs help in identifying the major stressors in his life. The partner can take the lead in rallying support for him from family members, friends, and co-workers who can assist him to modify the situations and environments that are stress provoking. A partner can assist him in determining how to modify what he provides for family members, emphasizing his increasing need for better self-care while still addressing family members’ needs.
Other time-honored and effective methods for achieving and maintaining harmony and balance in a man’s life include:
1. Having a thorough medical evaluation
2. Exercising regularly
3. Starting an individualized nutritional program
4. Learning to love and accept themselves for whom they are
5. Recreating close social supports they have lost and/or learning to create closeness and intimacy they never had
6. Growing spiritually
7. Engaging in individual and/or group psychotherapy or support groups
8. Taking appropriate medications and/or hormones
How effective is exercise in reducing depression? We know that people who exercise tend to be less depressed than those who do not exercise (Goleman & Gurin, 1993). What we do not know is whether the primary stimulus that differentiates more depressed from less depressed people is the exercise or the depression. By itself, exercise is unlikely to help a man with long-term depression or an acute severely depressive episode. There is evidence that exercise is an effective adjunct for moderate types of depression that still require professional help.
Two different studies (Griest et al., 1979; Schwartz et al., 1978) investigated the differential benefits of exercise, time-limited or long-term psychotherapy, and meditation training. Results indicated that exercise is similar to or better than standard medical treatment for moderate depression. Other studies show that exercise is ameliorative for mild, transient forms of depression experienced at times by most people. Mild depression may include acute feelings of sadness, discouragement, and self-deprecation. Probably, the effect of an integrated approach of both psychology and physiology determines how exercise benefits mood.
What if the man does know he is suffering, is depressed or is in pain? What can he do to help himself? He needs to have the courage to share his vulnerabilities with his partner, family, and close friends, asking for their understanding and support. He must do whatever he needs to do to take care of his distress, including seeking outside professional help. Hopefully in time, those closest to him will hear his distress and assist him in his recovery.
Medications: Excellent antidepressant medications are available. No one medication is perfect and it is very important to choose and monitor therapy carefully. These medications include:
1. Tricyclic Antidepressants (TCAs)—amitriptyline (Elavil®), desipramine (Norpramin®), doxepin (Sinequan®), protriptyline (Vivactil®) etc. These are generic and cheap but have side effects including sedation, dry mouth, and urinary retention.
2. SSRIs—fluoxetine (Prozac®), sertraline (Zoloft®), citalopram (Celexa®), paroxetine (Paxil®), and fluvoxamine (Luvox®)-- the drugs of choice in the 1990s. They eliminate virtually all the side effects of TCAs but they are not perfect. Each medication has a slightly different profile of side effects so it may be necessary to try several different preparations to obtain the optimal response. One of the most common side effects of this class of medications is sexual dysfunction (Table 2)
Table 2: Reported incidence of Sexually Related Side Effects in Men with Common Anti-Depressants (PDR-2001) (Reported vs. Control)
Abnormal Ejaculation Decreased Libido Impotence
Prozac 7% >1% 4% 0% 2% >1%
Zoloft 14 1 6 1 N.A.
Paxil 13 0 3 1 10 0
Celexa 6.1 1 3.8 1 2.8 1
Wellbutrin No data 3.1 1.6 3.4 3.1
Effexor 17 1 6 2 6 1
Serzone >1 1 >1 >1
Luvox 8 1 2 1 2 1
Compiled from the Physicians Desk Reference (PDR-2001), 55th ed., Montvale, N.J.: Medical Economics, 2001.
3. Reported incidence of sexual problems is as high as 17%. Obviously these medications would be a poor choice for a male in mid-life crisis who is obsessing about inadequate sexual performance. These medications should be used cautiously when combined with weight reduction pills, agents used in smoking cessation such as buproprion (Zyban®), tryptophan, St. John's Wort and other serotonin-like agents.
4. Atypical Antidepressants— buproprion (Wellbutrin®), venlafaxine (Effexor®), and nefazodone (Serzone®). These act on the brain through the inhibition of both serotonin and norepinephrine uptake. Buproprion and nefazodone, in particular, have a lower incidence of sexual side effects. At this time, there is no one best agent for the pharmacological management of the unique issues associated with male depression at midlife.
5. Amphetamines and MAO Inhibitors--tranylcypromine (Parnate®) and phenelzine (Nardil®)-- these are dangerous and should be dispensed only by psychiatrists highly skilled in their use. They are rarely used today.
Ultimate recovery from midlife depression is possible with the working through of relevant issues, the loving support of partner, family, and friends and appropriate professional help. The courageous man who takes on this “last great dragon” gives himself and others the gift of his full passion, well-honed powers and mutual fulfillment.
References
Arem, Ridha, MD. The Thyroid Solution: A Mind-Body Program for Beating Depression and Regaining Your Emotional and Physical Health. New York: Ballantine Books, 1999.
Carruthers, Malcolm, MD. Maximizing Manhood: Beating the Male Menopause. Hammersmith, London: Harper/Collins, 1997.
Cumming, D. C., Quigley, M. E., and Yen, S. S. C. “Acute Suppression of circulating testosterone levels by cortisol in men,” Journal of Clinical Enocrinology and Metabolism, Vol. 57 (1983), pp. 671-673.)
Dabbs, J. M. and Dabbs, M. G. Heroes, Rogues, and Lovers: Testosterone and Behavior. New York: McGraw-Hill, 2000.
Diamond, Jed, PhD. Male Menopause. Napierville, Ill: Sourcebooks, Inc., 1998.
Diamond, Jed, PhD. Surviving Male Menopause: A Guide for Women and Men. Naperville, Ill: Sourcebooks, Inc., 2000.
Dym, Barry & Glenn, M. L. Couples--Exploring and Understanding the Cycles of Intimate Relationships. San Francisco: Harper/Collins, 1993.
Goleman, Daniel, PhD. Emotional Intelligence. New York: Bantam, 1996.
Goleman, Daniel, PhD, and Gurin, Joel (Eds.). Mind*Body Medicine: How To Use Your Mind For Better Health. New York: Consumer Reports Books, 1993.
Griest, J.H., Klein, M.H., Eischens, R.R., Faris, J., Gurman, A.S., & Morgan, W. P. “Running as a Treatment for Depression.” Comparative Psychiatry, 53(1979): pp. 20-41.
Hudson, F. M., PhD, & McLean, P. D., PhD. Life Launch: A Passionate Guide to the Rest of Your Life. Santa Barbara, CA. The Hudson Institute Press, 1995.
Levinson, Daniel. The Seasons of a Man’s Life. New York: Knopf, 1978.
Oppenheim, Michael, MD. The Man’s Health Book. New Jersey: Prentice-Hall, 1994.
Osherman, Samuel, PhD. Wrestling with Love: How Men Struggle with Intimacy. New York: Fawcett Columbine, 1992.
Osherman, Samuel, PhD. Finding our Fathers: How a Man’s Life is Shaped by His Relationship with His Father. New York: Fawcett Columbine, 1986.
Rubin, R. T., Poland, R. E., and Lesser, I. M. “Neuroendocrine Aspects of Primary Endogenous Depression VIII. Pituitary-Gonadal Axis Activity in Male Patients and Matched Control Subjects,” Psychoneuroendocrinology, Vol. 14 (1989), pp. 217-229.
Schwartz, G. E., Davidson, R. J., & Goleman, D. J. “Patterning of Cognitive and Somatic Processes in the Self-Regulation of Anxiety: Effects of Meditation Versus Exercise.” Psychosomatic Medicine, 40(1978); pp. 321-328.
Sheehy, Gail. Understanding Men’s Passages: Discovering the New Map of Men’s Lives. New York: Random House, 1998.
Steiger, A., von Bardeleben, U., Wiedemann, K., and Holsboer, F. “Sleep EEG and Nocturnal Secretion of Testosterone and Cortisol in Patients with Major Endogenous Depression During Acute Phase and after Remission,” Journal of Psychiatric Research, Vol.25 (1991), pp. 169-177.
Tatelbaum, Judy. The Courage to Grieve: Creative Living, Recovery, and Growth Through Grief. New York: Harper & Row, 1980.
Viorst, Judith. Necessary Losses. New York: Simon & Schuster, 1986.
Whitehead, E. Douglas, MD. Viagra: The Wonder Drug for Peak Performance. New York: Dell, 1999.
Keywords:symptoms,problems,problem,symptom,suicides,suicide,relationship,professionals, physicians,mental,menopause.,increased,health,family,fail,erections,disease,difficulty, consequences,classic,60s,50s,40s,lethargy,experience, depression, impotence, male, menopause, midlife, crisis, men, sexuality, infidelity, adultery, psychology, human, behavior, Atlanta, psychology, impotence, sex, irritability,moods, swing, sexual, frustration, alcohol, alcoholism, anti-depressants,behavior, human,hormone, testosterone, androgen
The most common problem associated with male menopause is depression which is closely related to impotence and problems with male sexuality. Approximately 40% of men in their 40s, 50s and 60s will experience some degree of difficulty in attaining and sustaining erections, lethargy, depression, increased irritability, and mood swings that characterize male menopause. The symptoms of depression in men are commonly not recognized for several reasons:
The symptoms of male depression are different than the classic symptoms we think of as depression
Men deny they have problems because they are supposed to "be strong"
Men deny they have a problem with their sexuality and don't understand the relationship with depression
The symptom cluster of male depression is not well known so family members, physicians, and mental health professionals fail to recognize it.
Male depression is a disease with devastating consequences. To paraphrase from Jed Diamond's book Male Menopause
80% of all suicides in the US are men
The male suicide rate at midlife is three times higher; for men over 65, seven times higher
The history of depression makes the risk of suicide seventy-eight times greater (Sweden)
20 million American will experience depression sometimes in their lifetime
60-80% of depressed adults never get professional help
It can take up to ten years and three health professionals to properly diagnose this disorder
80-90% of people seeking help get relief from their symptoms
Differences between Male and Female depression:
Men are more likely to act out their inner turmoil while women are more likely to turn their feelings inward. The following chart from Jed Diamond's book, Male Menopause, illustrates these differences.
Female depression Male depression
Blame themselves Feel others are to blame
Feel sad, apathetic, and worthless Feel angry, irritable, and ego inflated
Feel anxious and scared Feel suspicious and guarded
Avoids conflicts at all costs Creates conflicts
Always tries to be nice Overtly or covertly hostile
Withdraws when feeling hurt Attacks when feeling hurt
Has trouble with self respect Demands respect from other
Feels they were born to fail Feels the world set them up to fail
Slowed down and nervous Restless and agitated
Chronic procrastinator Compulsive time keeper
Sleeps too much Sleeps too little
Trouble setting boundaries Needs control at all costs
Feels guilty for what they do Feels ashamed for who they are
Uncomfortable receiving praise Frustrated if not praised enough
Finds it easy to talk about weaknesses and doubts Terrified to talk about weaknesses and doubts
Strong fear of success Strong fear of failure
Needs to "blend in" to feel safe Needs to be "top dog" to feel safe
Uses food, friends, and "love" to self-medicate Uses alcohol, TV, sports, and sex to self medicate
Believe their problems could be solved only if they could be a better (spouse, co-worker, parent, friend) Believe their problems could be solved only if their (spouse, co-worker, parent, friend) would treat them better
Constantly wonder, "Am I loveable enough?" Constantly wonder, "Am I being loved enough?"
What to Do About It?
Often we receive questions at our website from distressed women who wonder what is happening to their husbands or partners or co-workers and how they can help.
It is important to recognize the syndrome because most men will not see it in themselves since their most basic psychological defense is denial.
It is important to realize that most men seek help only when pressured to do so by significant people in their life.
It is important to realize than men can be helped through a variety of approaches including
exercise
diet
getting in touch with their spirituality
individual and group psychotherapy
medications
teaching men to recreate the social supports they have lost or never had
teaching men to love and accept themselves for whom they are
Medications
There are a number of excellent antidepressant medications now available. No one medication is perfect and it is very important to choose and monitor therapy carefully.
There are the following classes of medications:
Amphetamines and MAO Inhibitors (Parnate and Nardil)-- these are dangerous and should be dispensed only by psychiatrists highly skilled in their use. They are rarely used today.
Tricyclic Antidepressants (TCAs)-- Elavil, imipramine, trazadone, doxepin, nortriptyline etc. These are generic and cheap but have a lot of side effects including sedation, dry mouth, urinary retention.
SSRIs (Prozac, Zoloft, Paxil, Luvox)-- the drugs of choice in the 1990s since they eliminate virtually all the side effects of the TCAs but they are not perfect. Each medication has a slightly different profile of side effects so it may be necessary to try several different preparations to get the optimal response. One of the most common side effects of Prozac and Zoloft is sexual dysfunction. Reported incidence of impotence can be as high as 30%. Obviously these medications would be a very poor choice for a male in mid-life crisis who is obsessing about inadequate sexual performance. Another disadvantage is that these agents are expensive. Caution should be used mixing these agents with weight reduction pills, agents used in smoking cessation (Zyban--buproprion), tryptophan and St. John's Wort marketed in health food stores, and other serotonin-like agents
Other drugs include Wellbutrin (buproprion), Effexor, and Serzone. These effect the brain through other biochemical pathways.
Table 2 Reported vs. Placebo Incidence of Sexual Dysfunction Associated with Various Antidepressants (PDR, 2001)
abnormal ejaculation decreased libido impotence
reported placebo reported placebo reported placebo
Prozac 7% >1% 4% 0% 2% >1%
Zoloft 14 1 6 1 N.A.
Paxil 13 0 3 1 10 0
Celexa 6.1 1 3.8 1 2.8 1
Wellbutrin N.A. 3.1 .6 3.4 3.1
Effexor 17 1 6 2 6 1
Serazone >1 1 >1 >1
Luvox 8 1 2 1 2 1
At this time, there is no one best agent for the pharmacological management of the unique issues associated with male depression at midlife.
This article discusses andropause or viropause -- a syndrome associated with lack of or absence of testosterone. Even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it was just ten years before. In fact, by age 80, most male hormone levels have decreased to pre-puberty levels. There are two general forms found in adult men who had normal hormone levels through puberty and young adulthood and who experience normal sexual development. One form, analogous to female menopause, as associated with the rapid drop of testosterone levels. Typical symptoms of this include:
Fatigue, loss of a sense of well being -- 82%
Joint aches and stiffness of hands -- 60%
Hot flashes, sleep disturbances -- 50%
Depression -- 70%
Irritability and anger -- 60%
Reduced libido -- 80%
Reduced potency -- 80%
Premature aging
Changes in hair growth and skin quality
Sounds familar..... for women at midlife..... because it is the same condition because the relationship between the ovaries, estrogen, the brain, and the pituitary are exactly the same as the relationship between the testis, testosterone, the brain, and the pituitary. Acute andropause in men is relatively uncommon, compared to acute menopause in women, because testicular function declines gradually in most men. There are a number of common causes, however, for acute testicular failure in adult men and these include:
viral infections such as mumps (which fortunately has been eradiacated by immunization)
surgical removal of or surgical injury to the testis and male reproductive tract ( testicular cancer, hernia repairs, ??vasectomies)
diseases when the immune system attacks and destroys the testis such as variations of systemic lupus erythematosis
subtle genetic abnormalities which permit normal adult development but lead to premature testicular failure (such as chromosomal mosaicism)
generalized vascular diseases such as diabetes and perhaps even problems caused by heavy smoking
chemotherapy
pituitary tumors (very rare)
The second form of this syndrome is more insidious since it occurs gradually. It is often confused with male midlife psychological adjustment disorders because it exactly mimics depression in midlife men. Male hormones decline gradually. Testosterone (from the testis), human growth hormone (from the pituitary), and DHEA and androstenedione (from the adrenal gland) all begin to drop. For many men, this does not occur until their 60s or 70s but there are older where it occurs much earlier. In addition, there is proteins in the blood which bind testosterone in a biologically inactive form. These are called sex human binding proteins or globulins. Their levels can rise in response to many conditions including medical disorders and exposure to other hormones including phytoestrogens (estrogens derived from plant sources such as soy) and other environmental estrogen -like compounds (pesticides, hormones used in agribusiness to produce fatter animals, etc.) As an example, there is some data suggesting that men on low fat or vegetarian diets have lower testosterone levels. The overall effect of rising sex hormone binding proteins is that there is less bio-available testosterone.
Diagnosis
First, men need to disassociate their ego from their testicles. Men needs to realize and accept that this disorder exists, that it is a simple endocrine problem which is no different than thyroid disease or diabetes, and that it can be treated. Spouses and employers also need to be aware that this is real so they can identify these men at risk early before their work, home, and families are disrupted. Perhaps, more important, physicians, psychologists, and other health providers need to be taught about this condition. The current paradigm in medicine is that there is no biological basis for behavioral changes in midlife men so it is ignored. But the diagnosis is quite simple--namely measuring either free testosterone blood levels or, as recommended by Dr. Malcolm Carruthers, computing the free androgen index
NORMAL ANDROGEN LEVELS mean range
Free testosterone -- men 700 ng/dl 300-1100
Free testosterone -- women 40 ng/dl 15-70
Free Androgen Index 70-100%
At a free androgen index less than 50% , symptoms of andropause appears. Of course, good medical care dictates that a comprehensive medical and psychological assessment along with a thorough laboratory assessment are necessary.
Testosterone Replacement Therapy
There is good evidence that testosterone levels drop as a man ages. There is a huge debate whether the testosterone level in older men should be adjusted up the mean testosterone levels in younger men.
What are the risks?
Prostate cancer-- At autopsies, most men by age 50 have nests of atypical cells in their prostate which look like prostate cancer cells. There is a great deal of concern among urologists-- particularly in the US when medical malpractice suits are a major concern-- that increasing testosterone levels might activate prostate cancer. On the other hand, there is a good screening test called Prostate Specific Antigen (PSA) which all men over age 50 should have performed annually and which is relatively effective in detecting early prostate cancer. There is no evidence in the medical literature that testosterone replacement therapy increases the risk of prostate cancer.
Heart disease--there is a major concern that increasing male androgen levels would also increase serum cholesterol and serum LDL-Cholesterol levels. Oral methyltestosterone in particular will raise blood cholesterol levels. This increases the risk for coronary artery disease. On the other hand, "good" cholesterol (HDL-Cholesterol increases with exercise. Men using testosterone supplementation should have their serum lipids carefully evaluated and rechecked periodically.
Liver Disease--the only orally available forms of testosterone for men in the USA contain methyltestosterone. Unfortunately, if used for sustained periods of time, it can damage the liver. The Physicians Desk Reference cites several different forms of liver damage from high dose methyl- testosterone including liver cancer, cholestatic hepatitis, and other liver diseases.
Suppression of testicular function--As a general principle, whenever any hormone is administered, the gland which normal produces it ceases to function and recovery may be variable. Patients with borderline low testosterone levels may commit themselves to lifelong therapy if they start with testosterone replacement.
What are the benefits?
There is no doubt that the administration to testosterone to men with true testosterone deficency states will improve their health and sense of well being. The symptoms listed above will disappear. Unfortunately, impotence, or the inability to sustain and erection, does not respond well to testosterone therapy except perhaps only in men with severe hormone deficiencies. This comprises approximately 8-16% of men presenting to physicians with erectile disorders. There is no evidence that administering testosterone to men with borderline low testosterone levels will improve sexual functioning. For more information on erectile disorders, see our article on Impotence.
Forms of Testosterone for Men
Pills
Methyltestosterone (Android,Virilon,Testred, Oreton) 10mg, 25mg (not recommended)
Testosterone undecanoate (Restandol, Andriol) 40mg, essentially a testosterone in oil preparation (not available in the USA)
Mesterolone (Proviron) 25mg -- less potent (not available in the USA)
Transdermal Preparations
Testosterone--transdermal (Testoderm, Testoderm TTS, Androderm)
Injections
The following forms of injectable testosterone is available in the USA.
Testosterone Cypionate 100 mg/ml
Testosterone Propionate in Oil 100 mg/ml
Testosterone Enanthanate 200 mg/ml
The usual dose is 1cc injected weekly or bi-weekly. This route of administration eliminates the risk of liver damage which may be caused by methyltestosterone as well as eliminating the theoretical risk of changes in cholesterol caused by oral medications. The problem is fluctuating hormone levels and the discomfort of administration.
Subdermal Pellets
Many years ago, the Food and Drug Administration approved the use of testosterone pellets for male hormone deficencies. They are manufactured in our office by a compounding pharmacist. We place 6-8 testosterone pellets under the skin. These pellets dissolve slowly over a period of approximately three to four months. This provides a normal and very stable serum testosterone level. I feel that the addition of androgens in this form causes less lowering of HDL cholesterol, as this does not pass through the liver.
The implant procedure consists of a small incision through which a trocar and cannula are inserted. The pellets are inserted through the cannula, and then the cannula is withdrawn. The incision is then closed with a Steri-Strip, and pressure is applied until bleeding stops, and the area is then covered with a dressing. We have not had any major problems in terms of side effects from this procedure. Some expertise is required in terms of placing the pellets so that underlying structures are not traumatized.
The average cost per visit (approximately every 3 months) is in the range of $400. Insertion Fee is $160.00 and Pellets cost $33.00 apiece.
The requirement for the use of subdermal pellets include
Good General Health
No evidence for heart disease
Normal Cholesterol levels
Normal PSA levels
Normal prostate examination, no history of prostate disease
For a good reference, check out Malcolm Carruthers MD, Maximising Manhood, Harper Collins, London, 1997
1 comment:
Proviron-Mesterolone. This is really a nice blog posting...
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