Dr. Karpas on Male Menopause

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.

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 <FAI> (total testosterone x 100 /sex hormone binding globulin). There is some controversy as to what level of testosterone in men is normal with low end values ranging from 250-400ng/dl.

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 Drs. Caroline Dott and Andrew Dott are professional lecturers and teachers with a special interest in the interactions between the biological and psychological bases of human behavior at midlife. Among their lecture topics are female and male menopause, the hormonal bases 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.

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.

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.

At this time, there is no one best agent for the pharmacological management of the unique
issues associated with male depression at midlife.

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.