February 21, 2020
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Adam's Eventide

A silent enemy may be robbing Indian males of their best years. It's a social health crisis we didn't even know about.

Adam's Eventide
Madhu Kapparath
Adam's Eventide
And You Are Not Alone
  • A recent study of 40-plus Indian men found that almost 75 per cent experienced lower energy levels, handled stress poorly, suffered exhaustion and sexual dysfunction.

  • A man’s social and professional responsibilities peak after 40. Yet this is precisely the age when andropause strikes.

  • The age at which andropause occurs is declining; lifestyle factors like stress, high expectations from life, bad diet and lack of exercise contribute.

  • Andropause societies in the UK and Canada now recommend monitoring of men’s health from age 30 onward. Earlier it was believed necessary only after age 50.

Tired and irritated in office all the time? Or often sleepless? Or maybe you have grown a paunch recently? This time it may actually not be the grouch in the corner office who's making you miserable. If you are male and over 40, chances are, you are a victim of andropause, the latest big scare from the medical world. It is a condition that is afflicting men worldwide, no matter what their race, financial or social strata.

Andropause or late onset hypogonadism is a condition that can, in a limited way, be compared to menopause in women. While technically men do not reach an end of their reproductive careers as women do, they tend to share many of their symptoms (see box on Page 65) as their age progresses. This has been connected to a fall in the levels of testosterone, the vital male hormone.

Recently Organon, a $3-billion, US-based healthcare company, did a perception study among SEC A and B men in the 40-plus age category across the four metros of Mumbai, Delhi, Calcutta and Chennai. It found almost three-fourth of these men experiencing undesirable changes in them after the age of 40. These changes mainly related to decreased energy levels, tiredness, inability to cope with stress. Those above 45 years of age complained more of sexual dysfunction. All of which is in keeping with trends globally.

What is more disturbing is that there is increasing evidence of much younger men getting afflicted. Take Rakesh Mathur (name changed), a 31-year-old IT professional from Delhi. When his wife couldn't conceive, the couple visited a doctor only to find out that he was virtually infertile. This was not a problem he had always had because his wife had conceived four years earlier. Neither was this a lone case. Others with similar case histories can be found in doctors' records.

While age and severity of onset would vary from person to person, studies worldwide are also showing that there is a decline in the age of the onset of these symptoms. This is largely due to lifestyle factors like modern urban stress, higher expectations from life, poor dietary and exercise habits. While earlier the onset would be above the age of 50, Dr D. Narayana Reddy, chairman, Indian Andropause Society, highlights that even 40-plus Indian men could need monitoring. The UK and Canadian andropause societies are now recommending monitoring of men's health from the age of 30 against the earlier 50.

So, this serves up as a double whammy. At 40-plus, a man is at the peak of his social and professional responsibilities. Concurrent decrease in fitness levels due to androgen deficiency or any other reason can cause considerable disruption in his life. Approximately 100 million men in India are above the age group of 40 and this figure is expected to double in the next decade.

When life wasn't so complicated, all this was called plain ageing. But science has extended life and being alive for long years has its own dynamics for the individual, the society and nations. Says Dr N.K. Mohanty, consultant and head of department, urology, V.M. Medical College & Safdarjang Hospital, "Medical science today considers the ageing process a disease. The average age of the male has increased, so he will have to live with these symptoms for a considerable part of his life".

The average life expectancy of the Indian male that Dr Mohanty is talking about has increased to 67 years from 45 in the last five decades. By 2010, India will have 49 million men above the age of 65, accounting for 18 per cent of the world's elderly males. "This will definitely be a great concern and a major health as well as an economic problem for the country in the years to come," explains Dr Reddy.

Lending another perspective to the problem, Prof B.Lunenfeld, chairman, International Society for the Study of the Ageing Male (ISSAM), and professor, faculty of life sciences, Bar Ilan University, Israel, says, "The western countries became developed before they became old. In this region, the countries (India and China) are getting old while developing. Therefore, they stand before an 'Agequake'." The past century has witnessed a transition from a high mortality-high fertility pattern to a low mortality-low fertility one. This has resulted in a world where there is an ageing population that is growing in numbers as well as the proportion of the entire population. "Society today caters to a kind of demographic profile which no longer exists, due to an increase in life expectancy from 35 years to 75 years and significant decrease in fertility rate (around 2.4 per cent in India today, which was 6 per cent in 1950). One needs to start catering to an age group which was non-existent 20 years ago," says Lunenfeld. This comprises largely of the elderly—classified as over 65 years of age—who will double in number by 2025 from 418 million in 2000. And then there are the "oldest-old" over 80 who will more than double in the same period from 66 million. More than half of them will be in India and China. Catering to them essentially means bringing male health centrestage where early diagnosis and preventive care is key.

The Organon study indicated that almost 80 per cent of men with these symptoms do not see it as a medical problem and hence don't seek medical advice. Instead, 38 per cent undertake self-treatment and 42 per cent perceive these symptoms as part of ageing. The remaining 20 per cent seek advice from doctors of various specialities like urologists, psychiatrists, sexologists, endocrinologists, consulting physicians and family physicians. Patients seeking medical advice show higher concern towards non-sexual aspects and tend to de-emphasise sexual ones. Says Sunit Kishore, product manager, Organon, "Male patients go to doctors only for harder issues like acute depression or chronic exhaustion and body ache, rarely for softer concerns like increased irritability or say sleeplessness. Of these, even fewer go with concerns of sexual dysfunction." Urban men especially tend to see this as a consequence of their tough, demanding work schedules and blame the environment rather than consider it a medical condition. Says Dr Mrugesh Vaishnav, consultant psychiatrist and sex therapist from Ahmedabad, "Though gradually men are accepting the condition, the Indian male largely feels that he can never pause or retire." "It doesn't help that males do not have a gender-specific specialist like women have gynaecologists," adds Annapurna Das, manager, marketing, Organon. (Andrologists are still a largely unheard-of species in India.) Worse, women know that menopause is on its way and an irreversible physical change is going to mark its arrival. Men have never heard of andropause.

That's not necessarily their fault, though. The term 'andropause' was coined just five years ago. In 2000, the World Health Organisation used the descriptor "andropause" in its published report titled, 'Men, Ageing and Health'. The report concluded that maintenance of the required level of testosterone in men could help prevent or manage many debilitating conditions.

The condition had been observed earlier, however.It was labelled "male climacteric" by a scientist, Werner, in 1939.Several researchers identified testosterone deficiency since then but it was not considered significant. The names given to this condition ranged from low testosterone syndrome to the vague and euphemistic "mid-life crisis". Subsequently, different researchers coined different terms like viropause, testo dwindle, penopause and the self-explanatory male menopause.The wise of ancient India, however, seemed to know. One ancient Hindu text, Mani Nag, held that seminal fluid is life-maintaining as well as life-generating.

In any case, even if a patient does reach a doctor of a specialisation related to his symptoms, he may yet not be guided correctly. "The word is still to enter the medical practitioner's dictionary as a clear-cut diagnostic entity," observes Dr Vaishnav. Doctors themselves need to be educated. Diagnosis is critical here because the host of symptoms is easily indicative of other ailments ranging from diabetes to psychiatric problems. The Indian Andropause Society and corporations like Organon that make testosterone supplements understandably are doing everything possible to spread the word.

How bad can the condition actually get? A businessman aged 67 came to Dr Vaishnav with loss of weight of more than 10 kilos in four months. A battery of investigations revealed no signs of cancerous malignancy as was feared. He was diagnosed as a case of major depressive disorder and was treated with anti-depressants but he yet did not recover. He was investigated for lipid profile, diabetes and hormone level. Nothing showed up till his testosterone level was checked. It was at a pre-puberty level. Supplementing oral testosterone improved his condition dramatically in three months.

While a decrease in hormonal levels is related to the process of growing older, lifestyle plays a significant part. High stress can show up in strange ways. After the earthquake and riots in Gujarat, several 50-plus males, with normal sexual lives earlier, complained of impotence along with depression and general lethargy. "The environmental stressor reduced their testosterone level that was resolved with supplementation of oral testosterone for just a month," says Ahmedabad-based Dr Vaishnav who treated many of them.

Says Dr Mohanty, "There is no need to panic about this condition as it is curable and progresses slowly. But we should be aware and alert so that it can be nipped in the bud." All the doctors we spoke to say that though the threat of early onset is real, given poor lifestyles, most cases of andropause are way above the age of 50. Also, andropause gains significance as a separate condition due to the change in sensibilities. People earlier took ageing as a part of normal physiological change that had no remedies and accepted it as a way of life. Hindu texts suggested "vaanaprasthashram" or retiring from sexual life. "It is the stage a man is supposed to enter at the age of 50 years and also indirectly indicates male climacteric," says Dr Vaishnav. But the 21st century man certainly wants more than that. "People in this age group want to enjoy the same quality of life as they did in their younger days," says Dr Mohanty.

Better awareness that can lead to better preventive care, better lifestyle habits and careful monitoring can delay the onset of andropause much like that of several lifestyle diseases. Ancient Indian literature suggests consumption of bull testes to increase sexual vigour and vitality in old age. But modern suggestions are kinder to the ageing male. Testosterone Replacement Therapy (TRT) is a line of treatment where a patient is given supplemental testosterone to increase it to the required level. The dosage and length of treatment obviously varies with the severity of the case.

Dr Prakash Kothari, professor and head, department of sexual medicine, kem Hospital, and a well-known voice on sex education, doesn't hit the tablet immediately.He first recommends a yogic practice from the Bihar School of Yoga. The Surya Namaskar is known to balance hormones. Alongside, he advises the patient a testosterone-rich diet that includes urad dal, garlic, green vegetables, cow's milk and ghee made from it.Even after all this, if the patient doesn't show signs of improving, he conducts tests for a clinical and metabolic deficiency of testosterone.If both reveal a deficiency of testosterone, he goes on to the prostate specific antigen test (PSA) that is known to indicate microscopic cancer of the prostate gland. If that is clear, he uses testosterone undecanoate, which he considers the most effective molecule available today in the oral or injectible form. Proper diagnosis is critical and tests have to be thorough. After that, the drug has proven to be completely safe, claims Das of Organon, the company that owns the molecule. And what of Viagra, that cure-all for erectile dysfunction most men were swearing by not so long ago? Since one of the reasons for sexual deficiency could be drop in testosterone levels, pills like Viagra, explains Dr Kothari, will only be of temporary benefit. For a complete cure, a man would need HRT or hormone replacement therapy.

Age will come. But, as Dr Kothari says, growing old doesn't have to bring all the attendant aches and pains—certainly not before time. The not-so-secret mantra is adhering to good lifestyle practices like eating simple and light, exercising, meditating, getting periodic medical check-ups and looking at life a bit more philosophically, going easy on smoking and drinking. Rural men are a good example. Dr Kothari speaks of patients who come directly to him for reduced sexual performance at even close to 90 years. Their concern for this vital function makes them live long, have healthy, engaging lives. While the medical world awaits a more detailed baseline study on the testosterone levels of Indian males, this is a cue, he says, the urban male must pick up quickly.

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