Male Menopause (Andropause)

This is an excellent web-site that covers this subject well.


Male MenopauseFemale menopause has been known for centuries, but it has only recently been discovered that males also go through a similar phenomenon with identical symptoms.

Synonyms: Late Onset Hypogonadism (LOH), Male Climacteric, Andropause, Viropause, ADAM (Androgen Deficiency in the Aging Male) and PADAM (Partial Androgen Deficiency in the Aging Male).

he medical profession has long debated the existence of male menopause. Does it really exist ? If so, at what age does it affect men ? What are the symptoms ? Are they reversible with treatment ? What precautions can a man take to prevent/postpone its arrival ? How is it similar to/ different from female menopause ?

Or, on the other hand, is it a non-existent entity ? Is it just a another ploy to emasculate men further ? Are senile eighty-year old men who are seen dating nubile young women really as capable as they appear to be or are they merely fooling both their partners and themselves ? Or are their partners fooling them ?

Until recently, the entire subject of the andropause was steeped in confusion and controversy. While women were accused of going through middle-aged crises and menopause-related aberrations, their male counterparts got away with propagating the myth of the ‘ageless male’ and boasted of virility all the way to their graves.

So what’s the real score ?

There is no doubt that a man’s sexuality changes with advancing age. The instant, anytime, ‘as-many-times-as-you-want’ erections that are more the rule than the exception at 18, do not last forever. With advancing age, the urge reduces, erections take time to come on, any time is not always a good time and the penis requires more direct stimulation in order to get aroused. Besides, the erections may not be as angled and rigid, and ejaculation becomes more feeble. The refractory period (interval) between erections gets prolonged.

Is all this because of the maturation (maturity) process ? Is it because by middle age man has had enough sex so as not to be unnaturally preoccupied with it any longer ? Is this because his wife has aged a bit and is no longer as attractive/ interested as before ? Or is it because of the pressures at the work-place, the demands of parenthood, or pre-occupation with the lives of grown-up children and aging parents ?

Is there really something called a middle-age crisis ? If so, how is it different from male menopause ?

Yes, there is something known as a mid-life crisis.This is often a time in a man’s life when stability has been achieved and the struggles that were once a large part of life are now at an end. This new awareness that a life change has taken place can sometimes trigger a crisis. For some men, new-found stability may signify an end to vitality or youth. Many men find that after spending a lifetime working towards the goals of family and peers, the end result is unfulfilling. This is also often a time of change. Major shifts in career, marriage and parenting often occur during this time period. And, along with the physical signs of aging comes a realization of impending old age, retirement and eventually death. This time of life will only become a crisis if the changes become too difficult to cope with.

Mid-life crisis, thus, is essentially a problem of psycho-social adjustment. It need not necessarily have a bearing on a man’s sex life. It is thus not synonymous with the andropause although there is frequently a superimposition of male menopausal factors in middle-aged men going through crises and this makes the picture hazy.

Andropause, on the other hand, is a distinct physiological phenomenon that is in many ways akin to, yet in some ways quite different from the female menopause.

Menopause is a condition most often associated with women. It occurs in a woman when she ceases to menstruate and can no longer become pregnant (usually). Men experience a different type of ‘menopause’ or life change. It usually occurs between the ages of 45 and 60 – but sometimes as early as age 30. Unlike women, men can continue to father children, but the production of the male sex hormone (testosterone) diminishes gradually after age 40.

Testosterone is the hormone that stimulates sexual development in the male infant, bone and muscle growth in adult males, and is responsible for sexual drive. It has been found that even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it is just ten years earlier. In fact, by age 80, most male hormone levels decrease to pre-puberty levels.

One hundred and fifty years ago, a German Professor called Berthold showed that transplant of a cock’s testis prevented atrophy of the comb after castration. In 1944, what we now describe as the andropause was reported in a key article by two American doctors, Carl Heller and Gordon Myers. They compared the symptoms with those of the female menopause, and did a blind controlled trial showing the effectiveness of testosterone treatment. Unfortunately, like many pioneering efforts, these went unnoticed. Men were unwilling to accept that they could attain ‘menopause’ and such research was often hurriedly brushed under the carpet. Men with genuine symptoms were told that ‘this is just a mid-life crisis’ – just like men with erectile dysfunction were told that ‘it’s all in the mind’. Besides, testosterone therapy had come into disrepute because of its abuse by athletes and the concept of testosterone replacement therapy for male menopausal symptoms was not received very well. Further, there was much hype about the side effects of testosterone, especially prostate cancer.

It was only after HRT (Hormone Replacement Therapy) with estrogens produced tangible symptomatic improvement and ‘aging reversal’ in post-menopausal women that men sat up and, not wanting to get left behind their womenfolk, began to take notice !!


The symptoms of andropause are similar to the ones women experience and can sometimes be as overwhelming. However, the male menopause does not affect all men, at least not with the same intensity. Approximately 40 % of men between 40 and 60 will experience some degree of lethargy, depression, increased irritability, mood swings, hot flushes, insomnia, decreased libido, weakness, loss of both lean body mass and bone mass (making them susceptible to hip fractures) and difficulty in attaining and sustaining erections (impotence).

For these individuals, such unanticipated physical and psychological changes can be a major 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 showed that 51 % of normal, healthy males aged 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. Other factors, notably the co-existence of degenerative or other diseases, are culpable.


18 symptoms of testosterone deficiency

Physical function

Reduced muscle strength

Impaired physical co-ordination

Impaired balance

Physical frailty

Cognitive function

Impaired concentration

Impaired verbal memory

Impaired visual-spatial awareness


Sleep dysfunction including narcolepsy and insomnia


Reduced sense of general wellbeing

Reduced energy and motivation




Sexual function

Reduced sexual desire

Infrequent or absent nocturnal erection and erection on wakening

Impaired erectile function

Impaired ejaculatory function

Impaired orgasmic function


Although all the causes of male menopause have not been fully researched, some factors that are known to contribute to this condition are hypothalamic sluggishness, hormone deficiencies, excessive alcohol consumption, obesity, smoking, hypertension, prescription and non-prescription medications, poor diet, lack of exercise, poor circulation, and psychological problems, notably mid-life depression. A general decline in potency at mid-life can be expected in a significant proportion of the male population. A relative increase in circulating levels of estrogen (which competes with testosterone for cellular receptor sites) can tilt the testosterone- estrogen balance unfavourably and can reduce the availability of testosterone to target cells.

  • Find new ways to relieve stress.
  • Eat a nutritious, low-fat, high-fiber diet.
  • Get plenty of sleep.
  • Exercise regularly.
  • Find a supportive friend or group and talk to them about what you’re going through.
  • Limit your consumption of alcohol and caffeine.
  • Drink lots of water.

Testosterone Replacement Therapy (TRT) must be always administered only by very responsible physicians and under strict case selection criteria and supervision. Testosterone must not be used as a tonic for vague complaints as it can cause serious side effects, including prostate cancer. The risk of prostate cancer with TRT has been much hyped. Recent evidence suggests that the fear of prostate cancer is perhaps exaggerated, since prostatic disease is estrogen-dependent rather than testosterone-dependent. However, it is true that testosterone administered to a patient who already has cancer of the prostate can cause a flare up and aggravation of the disease. Hence the importance of a thorough check-up and investigation before starting testosterone.

Patients with significant ‘andropausal’ complaints should be taken up for investigation. Serum FAT (Free Available Testosterone) is measured in a pooled early morning blood sample and, if low, testosterone therapy can be considered. Before starting testosterone, a complete general check up including a rectal examination is conducted followed by tests like the hematocrit, lipid profile, cardiac function tests, liver function tests, measurement of PSA (Prostate Specific Antigen)and a trans-rectal ultrasound (TRUS). The important side effects of testosterone are thrombophlebitis and hypercoagulability of blood, liver toxicity (with some oral testosterone preparations) and(??!!) prostate cancer. These tests must be repeated at 3 or 6 monthly intervals for as long as treatment is continued.

Testosterone is available in many forms – oral, injectable, trans-dermal and implants. The oral route is generally not recommended because of the high risk of liver toxicity. Some newer oral forms of testosterone are purportedly absorbed through the lymphatics. These bypass the liver and cause much less toxicity. Injectable testosterone is safe but the blood levels are not uniformly maintained and any excess is converted to estrogens, which is counter-productive since it might alter the testosterone- estrogen balance. Doses must be tailored to the needs of the patient in order to achieve normal blood levels of FAT. A significant improvement in symptoms can be expected with proper therapy. More recently, patches, pellets, creams and gels have entered the fray. The choice of route and preparation will depend on availability, safety, the socio-economic status of the patient, proven long term safety and efficacy and the preference of the patient and the prescribing andrologist.

In conclusion, it may be stated that the andropause does exist. It affects many men over 40 years of age (sometimes earlier). Symptoms are gradual and usually not as pronounced as in the female. Early diagnosis and hormone replacement therapy can improve symptoms.

Impotence (in contradistinction to impaired libido) is not usually amenable to hormone replacement alone and will need further investigation and treatment. These are discussed in What Every Adult Needs to Know about Impotence.


Men after 50 go into Andropause due to declining hormone levels, just as happens in women.

Low testosterone

What is testosterone?

Testosterone is the most important androgen (male sex hormone) in men and plays a key role in reproductive and sexual function. Testosterone is responsible for producing the physical characteristics of male puberty such as penis development and testicular growth, and for those features typical of adult men such as facial and body hair. Testosterone also stimulates cells in the testes to assist in the production of sperm.

In addition, testosterone is important for the good health of many nonreproductive tissues in the body. It plays an important role in the growth of bones and muscles, and affects mood, sex drive and certain aspects of mental ability.

How is testosterone production controlled?

Luteinizing hormone (LH) and follicle stimulating hormone (FSH) are the two important messengers made by the pituitary gland in the brain that act to trigger testis function. Once stimulated with LH, the cells in the testes produce testosterone.

What is testosterone deficiency?

Testosterone (or androgen) deficiency is when the body is unable to produce enough testosterone for the body to function normally. Although not a life-threatening condition, it can have a major affect on quality of life.

How common is testosterone deficiency?

Testosterone deficiency affects about one in 200 men under 60 years of age. It is usually the result of genetic disorders (e.g. Klinefelter’s syndrome), damage to the testes (infection, trauma, medications, chemo/radiotherapy), undescended testes, or rarely, a lack of hormones produced by the brain (e.g. Kallman’s syndrome or disorders of the pituitary gland).

The number of men over 60 years who are testosterone deficient is uncertain with some estimates suggesting that one in 10 older men may have low testosterone levels.

The ageing process, medical illnesses and obesity all affect testosterone levels.

Do all men get low testosterone levels as they age?

Unlike women, whose oestrogen levels fall rapidly when they go through menopause, men’s testosterone levels fall much more gradually and over a longer period of time. Furthermore, not all men are affected by a drop in testosterone levels.

Testosterone levels in men are at their highest between the ages of 20 to 30 years; then testosterone begins to fall by about a third between the ages of 30 to 80 years.

Some men will experience a greater drop in these hormone levels. However, many men aged over 80 years will have relatively normal testosterone levels.

What are the symptoms and signs of testosterone deficiency?

The signs of low testosterone are different depending on the age when testosterone levels fall below the normal range. Many of the symptoms and signs are nonspecific and may occur with other medical illnesses and in other circumstances (e.g. physical or psychological stress).

Showing these symptoms therefore does not automatically mean that such men should have testosterone treatment.

Stages Of Life Possible Symptoms & Signs
Early Childhood • Penis and testes do not grow to expected size
Early teenage years (puberty) • Penis and testes do not grow to expected size
• Failure to go through full normal puberty
• Poor development of facial, body or pubic hair
• Poor muscle development
• Voice does not deepen
• Poor growth (height) surge
• Breast development
Adulthood • Mood changes (low mood and irritability)
• Poor concentration
• Low energy
• Reduced muscle strength
• Longer time to recover from exercise
• Low interest in sex (decreased libido)
• Difficulty getting and keeping erections
• Hot flushes, sweats
• Breast development
• Osteoporosis (thinning of bones)
• Low semen volume
• Reduced beard or body hair growth
Later life (after 60 years) • Easy fatigue
• Poor muscle strength
• Low mood and irritability
• Poor concentration
• Low interest in sex (decreased libido)
• Osteoporosis (thinning of bones)
• Difficulty getting and keeping erections

Last Date Modified Jan 2012


Erectile Dysfunction.

Erectile dysfunction

What is erectile dysfunction?

Erectile dysfunction (impotence) is when a man is unable to get and/or keep an erection that allows sexual activity with penetration. It is not a disease, but a symptom of some other problem, either physical, psychological or a mixture of both.

Erectile dysfunction should not be confused with low libido (little interest in sex) or the inability to reach an orgasm or ejaculate. Premature (too early) and retrograde ejaculation (into the bladder) are also different problems that need a different approach to diagnosis and treatment.

Occasional erectile dysfunction is normal. There is no need to worry about the occasional failure to get or keep an erection. Some of the causes of occasional erectile dysfunction include excessive intake of alcohol, anxiety and tiredness. One of the most common causes of erectile dysfunction in middle-aged men is lack of sleep.

How common is erectile dysfunction?

Erectile dysfunction is very common and becomes even more common in older men. An Australian survey shows that at least one in five men over the age of 40 years, increasing to about two in three men over the age of 70 years, often experience erectile problems, and about one in ten men are completely unable to have erections.

With each decade of age, the chance of having erectile problems increases.

How does an erection happen?

At a superficial level, getting an erection is a simple process. There are two tubes of spongy tissue that run along the length of the penis, and this spongy material is surrounded by a tough fibrous, partially elastic covering.

A message is sent through nerves that leave the lower spinal cord, telling the blood vessels entering the spongy tissue of the penis to let more blood in. The flow of blood out of the penis is then blocked off so the penis fills with blood and stretches within the outer casing. This creates an erection.

Underlying this relatively simple explanation is a very complex range of chemicals in the body that also work together to get an erection. At any one time, the muscle cells in the spongy tissue and in the blood vessels are influenced by a balance of chemical factors, some which cause an erection and some which encourage a flaccid (soft) penis.

What causes erectile dysfunction?

Many factors can interfere with getting an erection and often two or three factors are present at one time. Sometimes there can appear to be no obvious cause for the erectile dysfunction; however, most cases of erectile dysfunction are physical in origin.

Apart from the physical causes of erectile dysfunction due to an event such as prostate surgery or the introduction of a medication that affects sexual function, erectile dysfunction due to physical causes often begins gradually.

Known causes of erectile dysfunction

Psychosocial problems • Performance anxiety
• Sexual attitudes and upbringing
• Relationship problems
• Employment and financial pressures
• Depression
• Psychiatric disorders
Metabolic problems affecting blood vessel function • Diabetes
• High blood pressure
• Obesity
• Renal failure
• High cholesterol
• Sleep apnoea
Reduced blood flow • Atherosclerosis (narrowing of the arteries)
• Surgical damage to blood vessels
Interference by medication,
alcohol and other drugs
• Cigarettes
• Alcohol and drug abuse
• Some medicines used to treat:
> Blood pressure
> Cholesterol
> Depression
> Psychiatric disorders
> Prostate cancer
Interference with nerve function • Parkinson’s disease
• Alzheimer’s disease
• Spinal cord trauma
• Multiple sclerosis
• Diabetic neuropathy
• Pelvic surgery (prostate, bowel)
Urological problems • Peyronie’s disease
• Pelvic trauma
There are many diseases that interfere with how the penis functions by either reducing blood flow or affecting the nerves. Importantly, when the first signs of erectile dysfunction happen, there is often an unknown underlying cause such as diabetes, hypertension or high cholesterol.About one in 10 cases of erectile dysfunction is caused by psychological factors. A man’s sex drive (libido) can be affected by stress such as problems at work or financial worries. Feeling depressed and anxious about poor sexual performance can also lead to erectile problems.Psychological causes of erectile dysfunction can happen together with physical causes.

Is erectile dysfunction a part of getting old?

There is no doubt that the ageing penis has less responsive muscle cells, which interfere with good erections. Like the rest of the ageing body, ‘muscle tone’ in the penis reduces with age, as do many other aspects of sexual function. Arousal can take longer, it may take much longer before a second erection happens, and usually the erection is not as firm.

Last Date Modified Jan 2012


Man Boobs:

What is gynaecomastia or ‘man boobs’?

Gynaecomastia (often referred to as ‘man boobs’) is the enlargement of male breast tissue. The condition appears as a rubbery or firm mass that starts from underneath the nipples and then spreads outwards over the breast area. The tissue is enlargement of glandular tissue and is not fat tissue.

In about half of cases, enlargement is found in both breasts; in the remainder it only affects one breast.

Gynaecomastia can happen in males of any age or weight.

Obese men can appear to have man boobs as they have fat tissue all over the body including the breasts, but this is not true gynaecomastia.

How common is gynaecomastia?

Gynaecomastia is very common in boys going through puberty, happening in more than half of all normal adolescent males, and usually resolves completely.

In older men, enlargement of the breast tissue happens in one to two thirds of men.

What are the main causes of gynaecomastia?

Gynaecomastia commonly appears during infancy, puberty and older age. All men have the male sex hormone testosterone as well as low levels of the female hormone oestrogen which controls breast tissue growth.

When the testosterone to oestrogen ratio changes (that is, there is an imbalance in the levels of these two hormones favouring relatively higher amounts of oestrogen), breast tissue can grow. Some men with gynaecomastia have elevated oestrogen levels.

Sixty to 90 per cent of newborn male babies have enlarged breast tissue because of transfer of oestrogen from the mother during pregnancy. As these high levels of oestrogen disappear after birth, this type of gynaecomastia is temporary.

Gynaecomastia is common during mid to late puberty as more oestrogen than testosterone is produced by the maturing testis before testosterone production by the testes ‘kicks in’ and reaches adult levels.

Gynaecomastia appearing during puberty often goes away, and less than one in 20 affected adolescent boys have gynaecomastia that continues into adulthood.

In older men, the gradual decrease in testosterone production (and therefore increase in oestrogen relative to testosterone) seen with ageing can lead to gynaecomastia.

As well as the natural hormone changes that happen in with puberty and ageing, gynaecomastia can also be caused by genetic problems, chronic diseases (especially kidney and liver) or various drugs.

Men who take anabolic steroids to enhance sporting performance or to help with body building often develop gynaecomastia. Very rarely gynaecomastia can also be caused by oestrogen secreting tumours of the testis and the adrenal glands.

Another possible cause is exposure over time to oestrogens that may be present in the environment.

What genetic problems can cause gynaecomastia?

Klinefelter’s syndrome affects one in every 650 males and is the main genetic cause of gynaecomastia. Men with Klinefelter’s syndrome have an extra X chromosome and do not produce enough testosterone for the body to function normally.

Male physical and reproductive development is affected and men with Klinefelter’s have small testes, are usually infertile and often develop gynaecomastia.

Men with Klinefelter’s syndrome have an imbalance in their oestrogen to testosterone ratio because they have low testosterone levels.Testosterone replacement therapy increases the amount of testosterone in the body, corrects the imbalance in hormones and the degree of gynaecomastia can be reduced but often persists and may need surgical intervention.

How can drugs cause gynaecomastia?

Medications that can promote breast growth in men include certain antidepressants, drugs used for high blood pressure and tuberculosis, as well as some chemotherapy drugs.

Antibiotics, anti-ulcer and cardiovascular medications have sometimes been found to affect the balance of hormones in the body.

Drug abuse, especially the use of anabolic steroids, but also marijuana, opioids and excessive alcohol that has led to chronic liver disease can cause gynaecomastia.

Drugs that block the effects of testosterone are used in the treatment of prostate cancer and can lead to gynaecomastia.

Rarely, the partners of women using topical oestrogen cream or gel for hormone replacement therapy may absorb sufficient oestrogen through regular, prolonged contact to cause gynaecomastia.

Can gynaecomastia be painful?

The growth of breast tissue can be accompanied by pain and tenderness.

This should always be checked by a doctor. Gynaecomastia can appear as a small lump and becomes tender as the mass becomes larger.

Last Date Modified Jan 2012

Midlife Crisis

Jean Coleman MSc, Andropause Society Secretary and Consultant Clinical Psychologist writes:The midlife crisis is not another way of describing Testosterone Deficiency Syndrome, also known as Andropause, Hypogonadism, the Male Menopause or androgen deficiency in the aging male (ADAM).

Emotional, not Hormonal? – The midlife crisis is concerned with emotional issues, Andropause or Testosterone Deficiency Syndrome as it’s increasingly being termed, is a condition caused by imbalance of hormones.

The midlife crisis strikes in the thirties in most cases.  Recently, because of the way some young people can achieve material goals more rapidly, the onset may be earlier, early thirties or even late twenties.

Testosterone Deficiency Syndrome is encountered later in life – in most cases.  Depending on predisposing events earlier in life, patients can begin to suffer from the typical symptoms much earlier than the usual late fifties to sixties.  This syndrome can occasionally manifest in the thirties and even more rarely, in the late twenties.

The midlife crisis is not biased against either sex, both men and women can suffer from it. Testosterone Deficiency Syndrome is rarely found in the female of the species.

Technically, of course, it is possible for a man to suffer from both conditions at once.  Not a pleasant combination with even more confusion arising for both the patient and those trying to help him.

So, what is the Midlife Crisis? – This characterized by low mood, dissatisfaction with life, a feeling of pointlessness in life. It is not always distinguishable from clinical depression.  Patients are often treated with antidepressants, and this may be appropriate.

Those in crisis may show their distress by reacting in several different ways: by denial (by escape or overcompensation), by decompensation (with anxiety, depression or rage), or by regression.  An individual may become discontented at work, resort to alcohol or risk taking behaviour.

The range of feelings experienced have been variously described as hollowness and lack of genuine enjoyment, emptiness and uncertainty, a mixture of strain and boredom, floating unfocussed melancholy and depression.  This is the time when people are believed to be vulnerable to hypochondria, accidents, illness, alcoholism and suicide.

Midlife crisis is described as an existential crisis, that is to say, it is centred about issues of meaning and purpose in life.  This is why it arises at the time it does, because by the mid thirties, young people have often achieved their initial goals in life (or realized they are not attainable).‘The hormone production levels are dropping, the head is balding, then sexual vigour is diminishing, the stress is unending, the children are leaving, the parents are dying, the job horizons are narrowing, the friends are having their first heart attacks; the past floats by in a fog of hopes not realized, opportunities not grasped, women not bedded, potentials not fulfilled and the future is a confrontation with one’s own mortality.’ (M.W.Lear, 1973).  This brings the person to appoint in life where they need to review their life. Is this what I want to be doing? Do I want to do this job forever?  Is this really the person I want to be with for the rest of my life?

Crisis, Transition or Life Review? – For most people, this period of review is not really that critical.  It is a transition period to the second half of adult life and may not be experienced as a major problem.  Where it does become a problem is with individuals who have significant unresolved issues from earlier in life, usually from childhood.

Becoming your own Person – For example, Tony spent his childhood trying always to be the person his controlling parents wanted him to be. He was given the responsibility for his younger siblings at the age of 6, and woe betide him if anything untoward happened!  At only 17, he escaped to live with, and then marry, a lady who was ten years his senior and very happily spent the next 17 years being looking after by her, but in a much less unpleasant way, still trying to be the person she and her children needed.  Suddenly he became very depressed, fled the marital home on a number of occasions and was found to be sleeping rough in his car.  He felt he could not go on in this way and needed to change his life and be on his own.

He was overwhelmed with guilt at the way he felt he was letting down this gentle lady who unbeknownst to her, had been re-parenting him for all these years. Fond of her still, he felt a strong need at last, to go out into the world and live his own life, to be his own person.  Often in similar cases, another woman is involved. In this case, it was not.

He never returned to his wife, and she had a difficult time coming to terms with his leaving, but the divorce was amicable and they continue to be friends.  He couldn’t continue to be a family man because this involved continuing to be what other people needed him to be. He needed to live for himself for a while and learn to find his true identity.

Choosing the Right Goals – Young people set out in life as adults with a series of goals they wish to achieve.  This is what they believe will make them happy.  To marry well, to have this many children, to achieve this in my career, to buy my own mansion; these are examples of life goals. When these have been achieved, what do you do next?

Sometimes the goals set are inappropriate, as in the case of Peter.  Peter was a highly intelligent child, but he got in with the wrong set where brawn rather than brains was the thing to aspire to.  He became leader of the gang, the school bully and learned to use coercion to get what he wanted.

Soon after the birth of his first daughter, he found he had no interest in his job as a store man.  He could do this standing on his head. He was paid well and already had his own, small, house.  His main interest suddenly was in nature and wildlife.  There was no one to share this with.  He no longer loved his wife and felt she’d be better off without him and his aggressive outbursts.  His friends didn’t understand him and wanted nothing more than to drink to oblivion or get into a fight.

He became depressed and thought of ending it all. Eventually, he gave up his job and left his wife and child in the family home to escape off round the world where at least he could find interest in plants and animals.  Peter had ended up in the wrong life altogether as a result of his poor choices earlier in life.

A Sense of one’s own Mortality –  Completing one’s initial life goals may be one precipitant. Another is said to be a sudden clear awareness of ones own mortality.  Midlife crisis is often preceded by the death of a parent or other close family member; or even worse, the death of a friend close to one’s own age.

It’s as if the person suddenly feels vulnerable, ‘my parents generation is old, we children are now the grown ups in this society.  We are the next generation who will die.  What’s the point of all this if we are going to die anyway!’

A Purpose in Life –  It’s answering this last question that resolves the midlife crisis. The person needs to find something which gives them a purpose in life or which makes life worth living. What this might be is different for everyone.  For some it may be grandchildren, for others it might be a new wife, a new job, revisiting an interest from the past or becoming involved in spiritual matters.

If the question is successfully answered, the person can move on into a potentially more productive or creative phase of life. If it has not been dealt with, then the person may continue to be depressed or unhappy indefinitely.  Some writers maintain that the person in continuing crisis may go on repeating unhelpful patterns of behaviour or be subject to physical health problems . Some may decide to end it all.

Midlife Crisis and Creativity –  Jaques (1965) maintained that the pattern of midlife crisis is often seen in the lives of writers, composers and artists. Their early work flows easily from pen, brush, chisel or whatever.  In the second half of life, things progress more slowly and with more of a struggle; but the results are more meaningful, stronger, in many people’s eyes, they are greater works of art.

Shakespeare’s earlier works had a lighter, often more comedic style; but it is his later works of tragedy that have the deeper messages.  So it is also with musicians and other artists. Jaques would maintain that the great work of Bach, Constable and Goya emerged in mid-life.

Jaques studied ‘some 310 painters, composers, poets, writers and sculptors of undoubted greatness or genius’. In this study, he found a tendency for creativity either to cease, sometimes the person actually died, or subsequent works were changed in nature.  The quality of work is no longer a spontaneous expression but becomes a ‘sculpted creativity’.

‘There is no longer a need for obsessional attempts at perfection, because inevitable imperfection is no longer felt as bitter persecuting failure.  Out of this mature resignation comes the serenity in the work of genius, true serenity, serenity which transcends imperfection by accepting it.’

Levinson (1976) also comments on the link between resolution of the crisis and continuing effective creativity, ‘Men such as Freud, Jung, Eugene O’Neill, Frank Lloyd Wright, Goya and Ghandi went through a profound crisis at around 40 and made tremendous creative gains through it.  There are also men like Dylan Thomas and F. Scott Fitzgerald who could not manage this crisis and who destroyed themselves in it.

Surviving the Midlife Crisis – Although many writers describe the possible negative outcomes of this transitional period of life, [‘psychological disturbance, depressive breakdown, strengthening of manic defences’, Jaques, ‘under severe conditions many do not survive it and commit suicide’ Rogers (1974), Levinson (1976), others are more positive in their conclusions.

Marmor (1968) asserts that ‘the significance of the crisis, psychotherapeutically, is that at such periods of stress, properly presented interventions can be of maximum efficacy’.  Brim (1976) concludes that ‘these changes, even when they occur in crisis dimensions, bring for many men more happiness than they had found in younger days’.


Mayo Clin Proc. 2015 Feb;90(2):224-51.

Testosterone therapy and cardiovascular risk: advances and controversies.


Two recent studies raised new concerns regarding cardiovascular (CV) risks with testosterone (T) therapy. This article reviews those studies as well as the extensive literature on T and CV risks. A MEDLINE search was performed for the years 1940 to August 2014 using the following key words: testosterone, androgens, human, male, cardiovascular, stroke, cerebrovascular accident, myocardial infarction, heart attack, death, and mortality. The weight and direction of evidence was evaluated and level of evidence (LOE) assigned. Only 4 articles were identified that suggested increased CV risks with T prescriptions: 2 retrospective analyses with serious methodological limitations, 1 placebo-controlled trial with few major adverse cardiac events, and 1 meta-analysis that included questionable studies and events. In contrast, several dozen studies have reported a beneficial effect of normal T levels on CV risks and mortality. Mortality and incident coronary artery disease are inversely associated with serum T concentrations (LOE IIa), as is severity of coronary artery disease (LOE IIa). Testosterone therapy is associated with reduced obesity, fat mass, and waist circumference (LOE Ib) and also improves glycemic control (LOE IIa). Mortality was reduced with T therapy in 2 retrospective studies. Several RCTs in men with coronary artery disease or heart failure reported improved function in men who received T compared with placebo. The largest meta-analysis to date revealed no increase in CV risks in men who received T and reduced CV risk among those with metabolic disease. In summary, there is no convincing evidence of increased CV risks with T therapy. On the contrary, there appears to be a strong beneficial relationship between normal T and CV health that has not yet been widely appreciated.

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