Hormone replacement therapy for men

The actor Charles Dance claims to be suffering from the male menopause, according to press reports. Difficult to imagine the glamorous Mr Dance (recently playing Maxim de Winter in the TV version of Rebecca) suffering from decidedly unglamorous symptoms such as night sweats, dry skin, depression, irritability and loss of erectile function, even if he has hit 50. Should he try hormone replacement therapy?

Almost certainly yes, if the considerable hype surrounding testosterone, the "king" of hormones, is anything to go by. Its keenest advocates claim that in men over 40 low testosterone levels are common and cause fatigue, moodiness and loss of libido - symptoms usually associated with a psychological mid- life crisis. Just as menopausal women can recharge their batteries with HRT, runs the argument, men undergoing the "andropause" need testosterone replacement therapy (TRT).

Is there any truth in the hype? Certainly testosterone, produced by the testes (and in smaller amounts by the ovaries in women) is the most potent of the androgens, or male sex hormones: it stimulates bone and muscle growth and sexual development and regulates sex drive in both men and women. The synthetic version, derived from cholesterol (and not, as some GPs tell their patients, from Peruvian bulls' testicles), is already used to initiate puberty in cases of hormone deficiency and to treat men with pituitary or testicular disorders. The trouble is that although testosterone levels do drop slightly with age in some men, there is no hard evidence that the hormone declines dramatically in the same way as oestrogen does in women. One theory has it that the important thing to measure is not blood levels of testosterone but the amount of SHBG, a sex-hormone-binding globulin which mops up the testosterone: some doctors believe this increases with age, thereby reducing the amount of free-acting testosterone available.

Unless a hormone deficiency can be demonstrated, most doctors are understandably cautious about handing out the drug over long periods of time. Neither, in recent years, has there been any major scientific study of the effects of TRT. And although it may be useful in men with reduced levels of testosterone, it is certainly no miracle cure for the failing marriage, narrowing job horizons and balding pate of the archetypal middle-aged male. TRT can improve libido but some doctors point out it is not as effective in cases of impotence, which are more often caused by vascular disorders.

In addition, there is a theoretical risk that, just as unopposed oestrogen has been implicated in cancer of the lining of the womb, testosterone therapy could induce prostate cancer, although most specialists using it are careful to monitor patients. Fears that it could provoke heart attacks appear to be unfounded while horror stories about aggression and hypersexuality are largely based on the abuse of anabolic steroids, of which testosterone is the basic compound.

TRT comes in the form of implants (they last for six months), pills (taken two or three times a day) or patches (two of the latter, launched last year, are applied every night). Unless you have marked hormonal deficiencies, TRT is difficult to obtain on the NHS; privately, costs start at about pounds 450 for initial testsn

Cherrill Hicks