At 42, Jeremy Kareken was exhausted, overweight and sad. “It took more of an effort to get out of bed and do the things I enjoyed,” says the playwright and actor between London and New York. “I was too tired to exercise, and when I did, the gains were much smaller; the gym was harder work. I had no sex drive. My two children, then aged six and three, were growing up, so I knew that wasn’t what was tiring me out. I was worried I was on a slow slide to the grave, with diminishing pleasure in my life.”
Kareken, who is now 53, was already on antidepressants: his doctor tried a new drug that had unpleasant side effects, including insomnia, so he stopped taking those. “My GP joked that my problem must be the menopause, he thought he should probably test my blood,” says Kareken. “It turned out, as well as having a vitamin D deficiency, I was particularly low in testosterone. So I was started on a programme of daily testosterone gel supplementation.”
While the phrase “male menopause” – or worse “manopause” – pops up in discussions from time to time, it isn’t a correct medical term. The NHS website describes it as “misleading”. As the prestigious US Mayo Clinic explains: “Ageing-related hormone changes in women and men are different. In women, ovulation ends and hormone production plummets during a relatively short period of time. This is known as menopause. In men, production of testosterone and other hormones declines over a period of many years and the consequences aren’t necessarily clear.”
“Manopause” or not, it’s increasingly accepted that the gradual decline of testosterone can have significant effects on the wellbeing of men in midlife and older. Depending on which source you use, between 2-5 per cent of the male population are said to suffer from a shortage of the hormone and the subsequent effects. This rises to 8 per cent of over-50s and half of those over 80. Low testosterone is more common in overweight men and those with diabetes.
Many doctors now agree that these men could benefit from testosterone replacement therapy (TRT).
Conversations around TRT are about to step up a gear, with the publication later in July of a new study in a leading medical journal. The study was conducted in 11 countries, including the UK, the US, and Australia. Dr Channa Jayasena, a consultant in reproductive endocrinology at Imperial College, London, is heading up the study.
“In the old days, testosterone was only prescribed for men with rare problems following cancer treatments or a condition called hypogonadism,” says Dr Jayasena. (Hypogonadism is a state of low testosterone, either inherited or caused by an injury or infection.) “More recently, hormone supplementation has become available to a wider variety of men, particularly in middle age,” he says. “The question now is: should you give TRT to these men?”
TRT is currently more common in the United States and in certain private UK clinics. It’s unusual to receive it on the NHS for “lifestyle” reasons.
Testosterone score
“We don’t really know why a loss of testosterone happens,” says Dr Clive Morrison, a GP specialising in reproductive health in people with diabetes, who now also sees non-diabetic patients at the private Centre for Men’s Health, which has branches in London’s Harley Street and Manchester. “It could be genetic; it could be triggered by high stress. But what isn’t in doubt are the symptoms: low mood, brain fog, weight gain and erectile dysfunction,” he adds.
Morrison says his patients are referred by personal trainers who have seen a slowdown in performance, or more commonly, by their partners. “One man told me his wife was accusing him of having an affair. He told me that was the last thing on his mind,” says Dr Morrison.
As often happens with women reaching menopause, and as Kareken also discovered, men struggling with low mood in midlife are sometimes fobbed off with antidepressants. “When a man in his 40s or 50s comes to see me, I ask about his general mood and concentration, as well as questions about erectile dysfunction,” says Dr Morrison. “But Viagra won’t work in 50 per cent of men who have low testosterone. On the other hand, if a man of a certain age goes to his GP complaining of low self-esteem, he’ll get packed off to his ‘man shed’. We need to be looking at the whole package of symptoms – and the best way to get to the bottom of it is through a blood test, which also rules out conditions such as anaemia or thyroid problems.”
Clinicians use a testosterone “score” to decide whether a man is in need of TRT or not. “Unlike a condition such as diabetes, there’s no widely agreed cut-off for whether testosterone is low or not,” says Dr Jayasena. “But in general, a level of above 12 is likely to be normal, and below eight is likely to be abnormal.”
Then, if results suggest the patient might benefit from testosterone supplementation, the man is either given a gel to rub into his upper arms or shoulders or an injection lasting three months (treatment costs £70 a month at the Centre for Men’s Health). As with HRT, getting the dose right can be trial and error, and it can take several weeks to see the benefits.
At first Kareken – who scored 7.69 – failed to see an improvement. He returned to see his doctor, who upped the dose of gel. After three months, he started to experience significant positive changes in his mood and performance in the gym. “When the doctor first suggested I should supplement with testosterone, I wasn’t actually surprised,” he says. “In the States, where I’m from, it’s advertised all over the place on TV, where commercials demand: ‘Do you have low T?’ I was relieved there appeared to be a simple answer to what had been making me so miserable. And no, I wasn’t embarrassed. If you had a broken arm, you wouldn’t be embarrassed to wear a cast, would you?”
Kareken was delighted to lose weight and build muscle in the gym. He was generally in a far better mood. “I normally get SAD (seasonal affective disorder, a kind of depression) in the winter, but while on TRT, it diminishes,” he says. “Plus, people think testosterone might make you more aggressive, but I actually felt calmer in disagreements. And my sex drive went up considerably.”
He says he had no significant side effects. “The hair on the top of my head and on my beard may have thinned slightly – this is a known possible side effect – but this might have been happening with age anyway,” he says. “I also had to make sure I continued with my yearly blood tests because of the slight risk of blood clots.”
TRT as a springboard
Until recently there was widespread concern among scientists that the use of TRT raises the risk of thrombosis, or blood clots. However, in June this year, a major study of 5,000 men (followed for two years) was published in the New England Journal of Medicine. It found that the risk of “major adverse cardiac events” was not raised by the use of TRT. “The research was reassuring,” says Dr Jayasena. “It showed that, if used appropriately, testosterone is not in the medium term associated with heart attacks and strokes. But the big question still is: should we be giving it at all?”
Doctors in the UK have historically been over-cautious about prescribing testosterone, not only because of the apparent blood clot risk. “In the US, healthcare is more patient-centred,” says Dr Morrison. “The NHS was founded to save or extend lives, and testosterone does neither. There’s also a negative cultural association with the hormone. Testosterone is seen as a sex drug, or something misused by body builders.”
NHS endocrinologists feel the Americans – and the UK private sector – have been overprescribing, says Dr Jayasena. “But where does that leave the poor bloke in the middle who would benefit from testosterone supplementation?”
Dr Jayasena’s paper asks whether giving testosterone to older men makes them feel “a bit better, compared with placebo. If there are moderate gains we still need to see the wood for the trees,” he says. “They have low testosterone simply by being unfit from smoking, having a bad diet and not exercising. If we gave these men testosterone, they would still be unfit.”
In other words, would testosterone therapy just be a “sticking plaster” that gives unhealthy men the excuse not to change their habits? “I often ask these men, ‘Would you like to meet your grandchildren?’ says Dr Jayasena. “Testosterone might make you feel better, but it won’t give you that. Only getting fit can help you live longer.”
The holy grail, it would seem, is for men in midlife to use TRT as a springboard to get to a point where they don’t need it as much. Which is exactly what happened to Kareken. Last year, nine years after starting to use TRT, he began to taper off. “Since I lost weight and started exercising more, my testosterone levels went up naturally, and stabilised,” he says. “I now only use the gel once every other day. At 53, I’m in better shape than I’ve ever been.” He no longer has the need to take antidepressants either.
“I’m not saying that every man should use testosterone,” Kareken says. “However, I do feel that every man should have the opportunity to see a doctor to have his testosterone levels checked. TRT has changed my life for the better, in every possible way.”