Dismissed. Treated as a joke. Told simply to get on with it. Until a few years ago, this was how menopausal women were treated. There’s still a long way to go, of course, but we’ve made huge strides forward.
For too long women were told their debilitating mood swings, hot flushes and insomnia – now known to be directly linked to plummeting hormone levels, and treatable with hormone replacement therapy (HRT) – were empty nest syndrome or depression.
But what if I told you that some men are enduring surprisingly similar issues now? And that many are suffering from a little-understood hormonal condition – this one linked directly to a decline in the male sex hormone testosterone, which can also cause life-changing symptoms – which is being dismissed and under-treated in the same way?
Let me first be really clear: what I’m not saying is that there is such a thing as the male menopause.
Before and after: How Stephen Webb responded to testosterone treatment
Despite loud claims to the contrary, often from muscled-up testosterone aficionados on TikTok and Instagram who like to insist most men would benefit from testosterone-based HRT, the male menopause doesn’t exist.
Only women who eventually stop having periods – the literal definition of menopause – will go through it as levels of their sex hormones, oestrogen and progesterone, fall at some point in mid-life.
Most men, by contrast, continue to produce sperm and testosterone all their lives.
But what does happen in men is that testosterone, which is produced in the testes, naturally declines with age. Levels fall by around one per cent every year after the age of 40. Most men won’t notice the difference, but for some, whose levels decline far more sharply, for myriad reasons, it can have a devastating impact.
The true numbers affected are unknown because it’s a condition which is understudied and, we think, vastly underdiagnosed. Some studies suggest it’s just two per cent of men – others estimate it could be ten times that, affecting as many as one in five.
Part of the reason it goes undetected is because the symptoms can mimic other problems.
The most common relate to sexual dysfunction – not surprising, given the leading role testosterone plays in the male libido. This might include problems getting or maintaining an erection, producing less semen, a low libido or delays reaching an orgasm.
There might be mood changes, such as irritability and anger, and difficulties with memory and
concentration. Other problems can include insomnia and fatigue, decreased body and facial hair, shrinking testes and even gynaecomastia (developing breasts). It’s also linked to serious chronic problems such as anaemia, type 2 diabetes and brittle bones.
All of these things can have an impact on work, relationships, sex lives and general wellbeing. Yet all too often it’s dismissed as depression, or stress, or treated using drugs such as Viagra and antidepressants without tackling the underlying cause.
Few doctors even consider the idea that low testosterone might be driving it all, let alone test for it. It isn’t part of standard blood tests, and one study of GP records found just 66,000 men – 0.2 per cent of the adult male UK population – had their testosterone levels checked over a ten-year period to 2011.
Yet for those men with a diagnosed testosterone deficiency, also known as late-onset hypogonadism, it can be easy to treat. Simply topping up testosterone levels with hormone replacement therapy, either in a gel or as a jab, can prove transformative.
Former Take That singer Robbie Williams and Happy Mondays star Shaun Ryder have both hailed the treatment for propping up their flagging libidos and restoring energy levels.
Former Gogglebox star Stephen Webb, 52, has said he felt ‘30 again’ after months of injecting himself with testosterone.
The TV personality revealed he had lost his sex drive and was told by a doctor that he was depressed. But after talking therapy failed, tests found his testosterone levels were those of a 75-year-old.
Mr Webb – who it was revealed last week had split from his husband Daniel Lustig – says testosterone therapy gave him the energy to begin exercising regularly, which meant he lost weight. ‘All the mood swings, anxiety, feeling lethargic, have gone,’ Mr Webb said last year. ‘It’s just unreal. My sex drive was on the floor, and that’s back. I’m telling anyone who will listen – have you had your testosterone checked? It’s life-changing.’
Stephen on Gogglebox with his then husband Daniel Lustig
I’ve seen similarly positive results in my own patients.
One 52-year-old man, Martin, came to see me only because his wife persuaded him.
Martin was exhausted and feeling sad and flat all the time. His sex drive had vanished, he struggled to get an erection and this affected his mood even further. Another doctor had performed some blood tests for fatigue – which don’t look for low testosterone – and, when they failed to show anything, had suggested antidepressants. By the time I saw him, a few months down the line, his sexual dysfunction had worsened and he was developing what he thought were breasts.
The combination of symptoms made me consider testosterone deficiency. We did some tests – it involves taking blood in the morning, after fasting overnight, because testosterone levels are highest in the morning. These tests have to be taken again after four weeks to check what we’re seeing is persistent.
If a man has three or more sexual symptoms, plus levels of testosterone which are considered exceptionally low, I’d diagnose testosterone deficiency and refer to an endocrinologist.
Martin’s symptoms were obvious, and his blood tests came back with what I’d suspected – low testosterone. I referred him to a hormone specialist who was able to start him on testosterone replacement gel, which he has to rub into his skin daily. It wasn’t a quick fix – it took months for his symptoms to resolve – but he now has more energy and feels much better in himself.
Some men feel emasculated by a diagnosis like this, and ashamed that it makes them feel somehow less manly, but Martin was relieved to have an answer.
What causes it to happen in the first place is more complex to unpick. There are lots of reasons why men may find themselves with low testosterone in later life – and, explains endocrinologist Dr Annice Mukherjee, not all of them will need to be treated with testosterone replacement therapy, or TRT.
For most it’s a part of ageing, and levels drop over time. It’s not clear why, for some men, they drop far more significantly, although lifestyle and genetics can be a factor.
There can be a physical cause, such as damage to the testicles. Someone who has suffered an injury to that area earlier in life, causing the testes to produce less testosterone, might be completely fine until their testosterone levels start to naturally decline with age.
An issue with the pituitary gland in the brain – which produces hormones that instruct the testicles to produce testosterone – also has to be ruled out. The long-term use of some medication, such as codeine and steroids, can also affect production.
However, one of the biggest factors driving low testosterone is obesity, and obesity-related conditions such as type 2 diabetes.
‘We’re in the middle of an obesity epidemic, and being overweight – particularly carrying weight around your tummy and waist – is known to directly suppress testosterone,’ Dr Mukherjee says.
‘But if those men went on testosterone treatment, they might not feel much better, and it might increase their risk of a blood clot. There is now lots of research showing that if a man loses weight, his testosterone levels recover.’
One of the biggest factors driving low testosterone is rising levels of obesity
In other words, TRT is not a panacea for everyone.
It wasn’t for another of my patients, 56-year-old Sandeep. He came to see me after reading his wife’s menopause book which made him wonder if something similar might be affecting him. He too was diagnosed with testosterone deficiency, but while treatment helped many of his symptoms, his mood did not improve much.
There had been a lot of stress and other factors in his life and he’d had depression a few decades earlier. He did get better with a combination of talking therapy and antidepressants, but the testosterone could only help the symptoms which were related to testosterone deficiency, and not all were.
It’s also important to point out that not all men can take testosterone. For example, if they have prostate cancer or breast cancer, it can potentially drive the disease. If you want to have children you also shouldn’t take it as it can affect fertility by reducing sperm count. It can also have other side-effects, such as hair loss.
This is why I am concerned at the worrying number of young men taking testosterone to help them bulk out muscles. These men – often influenced by social media – buy TRT online or from someone at their gym. Without a prescription, this is illegal.
They read that testosterone can increase their energy levels and muscle mass. But they do not realise these drugs can suppress their natural levels of testosterone and affect their fertility.
However, for men with low testosterone without a reversible cause, TRT can be, quite simply, life-changing.
And it’s not just because it can boost their mood and sex drive. Low testosterone is linked to an increased risk of type 2 diabetes, cardiovascular disease and Alzheimer’s, although the role it plays in these conditions is unclear.
A Lancet study found that 50 per cent of men with type 2 diabetes also had low levels of testosterone.
So we need much more research, not just on the wider impact that low testosterone is having on men’s health, but on who would most benefit from treatment.
For that, of course, we need more men to come forward if they’re having problems.
If we can diagnose more men with what can be a genuinely disabling condition, we can better work out what might be causing it.
So don’t suffer in silence. And if you have problems with your sex life, perhaps ask your GP to be tested for low testosterone.
