NHS prescriptions for testosterone have increased by 20 per cent over the past three years. On the face of it, the rise is puzzling, because there are very few conditions recognised as requiring male hormone replacement therapy (mHRT). Some men suffer testicular failure following trauma. Others lose the capacity to produce testosterone after treatment for certain brain tumours. And there are a few genetic syndromes that affect production. But all of these conditions are rare, and none is becoming more common.
Instead, it is possible that the upswing in testosterone prescribing reflects the spread of a relatively new and disputed concept: the male menopause. It is common knowledge that women experience an abrupt decline in sex hormone production, typically in their early fifties, and there is a range of symptoms that can arise as a result. Many women will ride these out; they usually settle spontaneously after a few years. But for some, a period of treatment with female HRT can be a godsend.
In contrast, medicine doesn’t currently recognise an equivalent process in men. After the age of 30, male sex hormone production begins tailing off by about 1 per cent a year, but this slow and steady reduction has not been thought to be responsible for significant symptoms. Have we been missing something important?
The idea of the male menopause (“andropause”) has been around since the late 1970s, but it has taken off in the past 15 years. It has particularly caught on in the States, where testosterone prescriptions have increased tenfold over the past decade (US drug companies are allowed to market direct to patients, driving demand).
Here’s the reasoning. Men suffering from low testosterone experience characteristic symptoms: erectile dysfunction, fatigue, loss of muscle mass, reduced libido and depression, to name just five. These usually respond to testosterone replacement. Now, if you ask a bunch of chaps in mid-life and beyond, you’ll find a fair few experience the same sorts of problems. And we know their testosterone levels are falling inexorably. So it seems an open-and-shut case of cause and effect.
That is certainly what andropause evangelists would argue, along with the idea that mHRT should do a good job of reversing what have hitherto been assumed to be normal consequences of ageing. However, there is actually a poor correlation between symptoms and testosterone levels: many symptomatic men have normal levels; many with low levels report no problems. And we know that all sorts of other changes – both physical and psychological – which cluster in life’s later decades can also cause problems with mood and energy, as well as sexual dysfunction.
So, is the andropause just a modern myth, and is mHRT merely the latest candidate in our quest for the elusive elixir of eternal youth? Two linked conditions, obesity and Type 2 diabetes, both of which are becoming ever more prevalent, give pause for thought. Both are known to cause more precipitate falls in testosterone levels than would be expected for age. Early indications from clinical trials suggest that testosterone does improve the impairments in sexual function, mood and energy that patients commonly experience. And it does not appear that fears that mHRT might provoke heart disease and prostate cancer are borne out – indeed, there may even be a protective effect on the heart.
We may be entering an era when measuring testosterone levels becomes a standard part of men’s health assessment, and provision of mHRT becomes more widespread. But first we need to know much more about who mHRT might help, whether prescribing hormones is the best answer (lifestyle measures would probably be better) and whether testosterone is indeed as safe as it’s cracked up to be. Failure to address these questions may lead us sleepwalking into the next mass-medication disaster.
Phil Whitaker’s latest novel, “Sister Sebastian’s Library”, is published by Salt
This article appears in the 01 Nov 2016 issue of the New Statesman, The closing of the liberal mind