What is it?

A controversial condition or syndrome which some doctors and psychologists thinks affects many men in their 30s, 40s and 50s. Some believe it has mainly psychological causes while others argue that it's related to hormonal changes. Other health professionals argue that there's no such condition, however, and that the symptoms often associated with mid-life crisis have other causes.

What are the main symptoms?

From Reggie Perrin to American Beauty, we're all familiar with the stereotype of the man who reaches 50 and trades his wife in for a younger model or chucks in his job to go off and travel the world. The term "mid-life crisis" conjures up images of a dissatisfied man in middle age who suddenly goes through a series of sudden and violent changes of behaviour.

Those doctors and psychologists who believe the mid-life crisis is a genuine condition have identified a wide range of symptoms. Frequently reported problems include:

• Irritability
• Loss of libido (sex drive)
• Erectile dysfunction (impotence)
• Fatigue
• Depression, charactised by low moods and (often apparently unaccountable) feelings of sadness and lethargy. At least one study has suggested that those undergoing mid-life difficulties may be distinguished from other men affected by depression by their sense of urgency. Such men are driven to keep on being active, sometimes even more active than they were before the crisis.

Some men may also be affected by:

• Stiffness in the muscles and joints
• Night sweats
• Dry skin
• Hair loss
• Weight gain
• A loss of ability to recover quickly from injuries

Several of these symptoms, occurring together, might understandably provoke a sense of crisis in a man.

What's the risk?

• Some experts argue that men are at risk of suffering the symptoms of mid-life crisis from the age of 30, although the period from the late 30s to age 50 is generally nearer the mark for most.
• The proportion of men who experience emotional difficulties during mid-life is unknown. A few psychologists argue that almost all men go through a mid-life crisis to some degree — they all have to deal with what is a time of transition and adjust to a new perspective on life.
• Classically, any man for whom work is his main source of personal identity, or who starts to feel or show his age, is a strong candidate.
• There is some evidence that men most affected by the mid-life crisis are those who have given little thought to such inevitable upheavals as ageing and retirement. Studies have shown that the condition is associated with a tendency to avoid problems and an uncertainty about the future.
• On the other hand, it's also the case that many men seem to pass through this stage of life without any apparent difficulties at all.

What causes it?

Not only is the existence of the mid-life crisis questionable, those who believe it exists also disagree about the causes. Is it psychological, even sociological, in origin? Or hormonal? Or a bit of both?

Psychological causes

While the Reggie Perrin stereotype is richly comic, it isn't difficult to see that in real-life cases such drastic behaviour may be motivated by deeper issues that are all too serious. Many of us are aware of feelings of disillusionment and irritability setting in in middle age, attributable perhaps to a heightened sense of our own mortality and/or feelings of dissatisfaction at the way life has turned out. Very often such gloomy insights are brought on by a specific trigger: a redundancy or divorce, perhaps, or a more trivial event like a milestone birthday.

In a society which puts a particularly high value on youth, and sidelines older people, it's difficult for many people to move smoothly into their middle years. Men reaching mid-life may feel a loss of masculinity and confusion about their future role. Divorce, insecurity at work and the changing role of men add to the uncertainty many feel during this time of transition.

Many men find the changes in sexual function which come with getting older unsettling. Suddenly, you can't do it three times a night any more, it's harder to get an erection. Is this the start of the slippery slope? And where will it end?

By middle age, men may have achieved most of their realistic goals and be unclear about their future direction. Relationships may also change, and are often adversely affected, especially when children leave the parental home.

Men are better educated, healthier and likely to live longer when they enter mid-life than at any time in the past. This can lead to a greater degree of reflection, and often, introspection, on what has happened during the first part of life and what the future holds.

Sleep may be another factor. According to a report in the Journal of the American Medical Association, mid-life crises may be linked with a growing inability to sleep deeply. Men in their 30s and 40s sleep far more patchily and lightly than in younger years — even when they sleep the same number of hours as before. By the age of 45, according to the report, few manage deep sleep at all, leading them to grow fatter and more unfit because they cease to generate growth hormone.

Physical causes

Some doctors argue that the crisis of confidence and the unpleasant mid-life symptoms some men experience are not primarily psychological in origin. While there may be common psychological problems arising as a reaction to life events and the consequences of getting older, they argue for the existence of a "male menopause" involving hormonal changes in the body, analogous to the female menopause.

In fact, it may be possible that some men have to go through both a psychological crisis AND a hormonal one!

The very phrase "male menopause" is misleading, however, since menopause strictly refers to the cessation of menstruation. If there is a male equivalent, the experts have yet to agree on the name: the terms "andropause", "viropause" or "endopause" have all been put forward.

The male menopause has been defined by its proponents as the hormonal, physiological and chemical changes which occur in men between around 40 and 55.

It's argued that the symptoms of the male menopause — the main one being a loss of libido — are caused in middle-aged men by the decreasing level (and effect) of testosterone, the hormone responsible for secondary sexual characteristics such as muscle strength and facial hair, as well as sexual drive and the production of other hormones, such as DHEA (dehydroepiandrosterone).

Testosterone levels gradually decrease from the late 20s, and, by the time a man reaches 80 they will be at pre-puberty levels. However, unlike oestrogen in women, there is no sudden, measurable drop in testosterone in men in middle age, and often the testosterone levels of men complaining of andropausal symptoms can still be measured as normal.

What does appear to happen is that a carrier protein called sex hormone binding globulin (SHBG) increases in mid-life men. This increase is believed to undermine the body's ability to make use of its own testosterone. In addition, the cells in the body also tend to thicken with age, so they are less able to absorb testosterone.

Opponents of the male menopause theory don't deny that testosterone levels fall steadily with age or that SHBG levels may rise. What they do say, however, is that these changes aren't sufficient to produce any noticeable symptoms in the vast majority of men. 

How can I prevent it?

If you believe that falling testosterone levels and rising SHBG levels are responsible for a male menopause then there's not much you can do about it.

If you believe in a mid-life crisis that's primarily psychological in origin, then you could take steps to head it off by:

• Finding better ways of tackling stress. Try to avoid the temptation to use alcohol, nicotine or other drugs to relieve it. Instead, try some de-stressing treatments and exercises. Many complementary approaches, such as aromatherapy, massage and yoga, can all have a powerful relaxing effect. Self-hypnosis tapes, meditation and other "mindful" techniques which help you to switch off can be useful too. The effects of exercise in promoting positive moods and reducing mild depression are well-documented.
• Accepting that you're no longer young and that you're not immortal. The journey from youth to middle age and on into old age may seem frightening and painful, but you can also see it as an opportunity to re-evaluate and perhaps change the direction of your life. Rather than believing that ageing is simply about having to give things up, try to think about what you'd like to start. When you reach 60, you could still be only two-thirds of the way through your life. That leaves a great deal of time to broaden your interests, travel, return to education, learn new work skills or take up new sports.

Should I see a doctor?

Yes, if need be. Many symptoms linked to the mid-life crisis need to be checked out for underlying physical causes. For example, erectile dysfunction (impotence) can be caused by depression, diabetes or heart disease. If you feel you'd rather talk your problems over with a sympathetic stranger, such as a counsellor, your GP can refer you. (If you can afford to see someone privately, however, you may save yourself a long wait.) Talk it over. Don't be afraid to ask for help.

What are the main treatments?

Advocates of the male menopause believe TRT (testosterone replacement therapy) is the answer.

If the debate on the existence of the male menopause is heated, TRT has caused even more controversy. This treatment involves administering doses of extra testosterone through patches, injections, pills or creams to those suffering male-menopausal symptoms.

According to its proponents, many men who have received TRT have reported almost miraculous results. These include:

• increased vitality and well-being
• less irritability and depression
• more "drive"
• increased sexual activity
• increased hair growth
• a general ability to cope better with life

So why are some healthcare experts so opposed to it?

• First, there is the issue of whether the male menopause actually exists. If it does not, then TRT can be seen as an attempt to provide a medical quick-fix for problems which are not primarily medical in origin. Giving hormones instead of looking at the root causes of these problems means they may remain unaddressed. Sceptics point out, too, that those most vociferously in favour of TRT are often doctors in private practice who stand to make money from dispensing the treatment.
• Second, testosterone is associated with prostate cancer, one of the biggest killers of men in the UK. (It seems that while testosterone doesn't actually cause prostate cancer it does stimulate its growth when it's already there.) If you do decide to have TRT you should be checked for prostate cancer every six months. There are also fears that the side-effects of TRT may include heart and liver damage.
• Third, extra testosterone may increase the sex drive, but it may not do anything for the ability to perform, leading to even greater frustration!
• Fourth, there is a lack of long-term studies into the effects of testosterone supplementation.

Other treatments

Talking about your problems is all very well, but sometimes it isn't possible to talk to your friends or partner. Counselling can help for individuals, and an intermediary can also be effective in dealing with problems in relationships. Contact your GP or Relate. Psychotherapy can help with more deep-seated difficulties, but may not be easily available on the NHS.

A short course of antidepressants or tranquillisers may be prescribed to combat depression in those suffering from a mid-life crisis. Alternatively, you could try a natural remedy such as St John's Wort. Also known as hypericum, the herb — available as a supplement in tincture or capsule form — has been shown to alleviate feelings of anxiety, agitation, disinterest and despair. In a study carried out by the Berlin Depression Self-Help Group, 34 men took extracts of the herb three times a day for six weeks. After just five weeks three out of four showed a marked improvement, and one in three became symptom-free.

Doctors may also be able to treat any specific conditions such as erectile dysfunction (impotence) or skin problems.

How can I help myself?

• Men are famously reticent when it comes to sharing their feelings — especially problematic ones. Talking things over, however, can be a powerful remedy for anxiety and depression in itself. Try to talk to your partner, your friends, men of a similar age — anyone you feel comfortable with.
• Be positive. Yes, our society is negative about ageing, but that doesn't mean you have to be. Middle age is a time of great change, and that can mean beneficial changes too. You have a chance to review your life so far and to alter its direction in a positive way. A crisis can be used as an opportunity to change your life for the better.
• Eat well. Make sure you eat regular meals throughout the day and avoid too many refined foods, saturated fats and cholesterol. Also make sure you get enough rest and practise good sleep "hygiene". Attending to these simple needs may make a surprising amount of difference.
• Vitamin and nutritional supplements can promote better health. Vitamin B complex in particular is thought to be helpful for stress. Taking a daily multivitamin and mineral supplement will act as a "health insurance policy", ensuring that you do not suffer from any dietary deficiencies which might affect mood and energy levels.
• Take regular exercise. It's easy just to slob out, especially when you're feeling lethargic and down, but keeping fit will help to relieve stress and mild depression, and work out feelings of frustration. For all-round benefits, try to combine aerobic exercise, such as running, cycling or swimming, with some resistance work, such as weight training. It's vital to get into a routine that you won't find difficult to stick to. Playing a team sport and/or joining a club is a powerful motivator, as you won't want to let the lads down. It may well allow you to meet other men beyond the familiar circles of work and family, which can be refreshing and even therapeutic; chances are, others will be experiencing similar problems.
• So your sex life may be changing — don't fight it, get used to it. Go for quality rather than quantity, and explore the possibilities of real intimacy.
• Find a balance between work and home. Britons work the longest hours in Europe, yet report the lowest levels of job satisfaction. Too often we compromise our personal lives and relationships through fear of losing our jobs, and by succumbing to the pressures of an ever-accelerating workplace. Cut down on the hours and spend more time with your friends and family by:
  • Learning to delegate or even saying "No" to tasks where appropriate
  • Not claiming to be more available than you actually are
  • Developing better time-management skills
  • Treating arrangements with family and friends as seriously as you would work appointments

What's the outlook?

Potentially good. Ultimately, the mid-life crisis is about managing change of one kind or another, and as millions of older men can testify, there lies a fresh perspective and new satisfactions on the other side of the transition. Never suffer in silence: always ask for help if you need it, and explore every avenue. And remember: life can begin at any age.

Page created on May 9th, 2003