Andrew B. Dott, MD, MPH

--meaning porous, fragile bones --is a disease in which there is exaggerated loss of quantity and quality of bone, causing an increase in the risk of fractures. It's normal for the bones of both women and men to get thinner and more fragile with age. But when the bones become so fragile that they break easily and health is endangered, that's the disease osteoporosis. Like other body tissues, bones continuously renew and repair. Old bone is removed and replaced by new bone. Osteoporosis occurs when there is an imbalance in bone metabolism. Either too much old bone has been removed or not enough new bone has been formed --or both. As a result, the honeycomb structure of bones becomes so hollow and fragile from the loss of mineral that they may break with only slight trauma such as opening a window, and sometimes can occur with no trauma at all. While the exact causes of this imbalance are unknown, osteoporosis is generally preventable and treatable. Age is the most important risk factor. Certain physical or lifestyle factors --such as a low calcium diet, lack of exercise, and smoking --can contribute to bone weakness in both sexes.

All bones suffer from this disease. But the majority of fractures occur in the vertebrae (spine), hip, and wrist. Fortunately, of those who have spine fractures, only a small percentage will be troubled by them. Fracture of the hip can be of considerable concern, since this injury often leads to immobility and loss of independence. A woman's risk of having a hip fracture is equal to the risk of breast, uterine, and ovarian cancer combined. Approximately 30% of women having a hip fracture die within six months.

Certain women are at special risk for osteoporosis. Women typically have lighter frames than do men, so they have less bone mass to draw from. Women also lose bone more rapidly during the first five to ten years following menopause when their ovaries produce less estrogen --the hormone that appears to protect against bone loss. Every woman's body goes through bone loss, bone replacement, and more rapid bone loss after menopause. Not every women, however, will develop osteoporosis.

There are certain risk factors for osteoporosis. These include:

Gender; women are at greater risk than men.

Race; white and Asian women are at special risk.

Heredity; if osteoporosis runs in the family.

Inadequate diet, especially not enough calcium and vitamin D.

Certain bone-robbing medications (such as steroids and anti-seizure drugs).

Being past menopause; women experiencing early menopause (before age 40), whether occurring naturally or medically 	induced (through surgical removal of ovaries, or ovarian damage from drugs or x-rays), have a higher osteoporosis 	risk because they live a longer time without estrogen's protection.

Excessive exercise or extreme weight loss

. Rate of bone loss is also increased by conditions that result in 	stopping menstrual periods before menopause

Osteoporosis is not easy to detect since most warning signs don't usually occur until the disease has become advanced. One clue is prolonged and severe pain in the middle part of the back. Other clues involve changes in the shape of the spine. But even without these warning signs, bones could still be getting thin. Therefore, often health care providers recommend that the density of the bones be measured; the gold standard today in bone density testing is dual energy x-ray absorptiometry (called DEXA for short). There are several new laboratory tests (Pyri-Links measure the rate of change in bone metabolism. These tests require an early morning urine specimen and may be used to monitor the effectiveness of therapy.

Estrogen replacement therapy (ERT), used to prevent osteoporosis, has also been proven effective in treating the disease. The bisphosphonate family of drugs is another approach. Within this family, alendronate (Fosamax) is known to inhibit bone breakdown, increase spine and hip bone mass, and decrease spinal and hip fractures. Alendronate is best reserved for treatment when estrogen is not appropriate; it can also cause irritation of the stomach and esophagus. Another bisphosphonate, etidronate (along with calcium), is available for osteoporosis treatment in some countries (but not in the U.S.) as Didrocal; in the U.S., etidronate (without calcium) is FDA-approved only for Paget's disease and is sold under the brand name Didronel. Other options for osteoporosis treatment include calcitonin --available as injections (Calcimar, Miacalcin) --and a nasal spray (Miacalcin; not available in Canada). All drugs effective in treating osteoporosis need adequate calcium to work effectively. Not every drug is right for every woman. Each woman's decision to begin treatment must be made after a complete discussion with her health care provider of each drug's benefits and risks, as well as her own circumstances.

The first step is to achieve the greatest possible bone mass during the peak bone mass years of age 20 to 30. Then, the risk factors that can be controlled must be reduced or eliminated. Adequate calcium intake is critical. Most adults should get 1,000 mg per day of total calcium intake --or 1,500 mg for postmenopausal women who do not have adequate estrogen levels. One portion of dairy food, such as a glass of skim milk or a cup of yogurt, has 300 mg of calcium. Adults should consume 4-5 portions of dairy foods a day. In you cannot tolerate dairy products, you might want to consider taking 1 large TUMS (500mg) as a replacement for 2 portions of dairy food. Adequate vitamin D is also important; certain foods, sunshine, and/or taking a one-a-day multivitamin can help reach the recommended 400 IU daily. Exercise also helps build strong bones. Smoking and drinking alcohol also interfere with bone health. And for women at risk for osteoporosis, avoiding falls takes on added importance. Women at high risk for developing the disease may also want to consider taking estrogen replacement therapy (ERT); if taken for many years, ERT can reduce the risk of spine, hip, and wrist fractures by 50% to 70%.

Institute of Endocrinology and Reproductive Medicine

Articles

Osteoporosis --meaning porous, fragile bones --is a disease in which there is exaggerated loss of quantity and quality of bone, causing an increase in the risk of fractures. It's normal for the bones of both women and men to get thinner and more fragile with age.

Osteoporosis Medications and Prevention

Reprinted with the kind permission                         from 

Andrew                         Dott, MD, MPH

Institute                         of Endocrinology and Reproductive Medicine

Progesterone is a         natural hormone which is produced by the ovary during the second half of         the menstrual cycle

. It's biological function is to change the lining of         the uterus so that the cells which line the uterus can provide nutrition         to the developing embryo during the earliest phases of development after         conception. If conception fails to occur, the drop in progesterone and         estrogen levels in the blood lead to menstruation which is a shedding of         the lining of the uterus. This periodic shedding is an important         prevention of the development of uterine cancer. Women who lack         progesterone and who produce or are exposed to persistent levels of         estrogen are at greater risk for this form of cancer. Other biological         effects of progesterone include assisting in the final development of         the female breast during puberty. Progesterone had mild sedative         effects. Many clinicians feel that Premenstrual Syndrome (PMS) is         related to progesterone although this is poorly understood. Side effects         from progesterone administration may include fluid retention,         irritability, depression, and hypoglycemic attacks.

There are two general forms of progesterone

 available         pharmacologically in the United States--progesterone and progestins.         Progesterone has 21 carbon atoms. Progestins are derived from         testosterone, a powerful male hormone, which has 19 carbon atoms. Their         chemical structure is very similar. By changing the testosterone         molecule, one can get more progesterone-like effects and few androgenic         (or male-directed) effects.

There were two reasons why it was necessary to develop these         synthetic progestins: First, progesterone has unpredictable absorption         and side effects such as sedation and second, it was more expensive to         produce than synthetic progestins. Today, however, the progesterone         molecule can be manufactured from many plant sources such as Mexican         wild yam and soy.

The progesterone most commonly used in the United States for         menopause management is Medroxyprogesterone acetate (Provera®, Amen®,         Cycrin®) which comes in 2.5 mg, 5.0 mg, and 10.0 mg tablets.         Unfortunately, many women have side effects to this preparation-         particularly the 10mg dose which is now felt to be unnecessary for most         women and probably an overdose. There are other progestins including         Norethindrone acetate (Aygestin®) 5 mg which is a bit too potent for         most women and Norethindrone (NorQD®, Micronor®) 0.35 mg and dl-Norgestrel         (Ovrette®) 0.075 mg which are birth control pills

 and are not potent         enough to reverse the effects of estrogen on the uterus. Megestrol         acetate (Megace®) 20 mg, 40 mg is also a progesterone used in the         treatment of cancer and endometriosis. Published studies have         demonstrated the use of dosages of 2.5-7.5mg daily will protect the         uterus. The formulations available in the United States are probably too         potent for menopause management.

Other forms of progesterone include micronized progesterone capsules         and vaginal suppositories (manufactured by pharmacists (25 mg, 50 mg,         100 mg, 200 mg), progesterone in oil injection 50 mg/ml,         depo-medroxyprogesterone acetate, and progesterone creams (manufactured         by pharmacists) in varying concentrations. A 10% concentration is fairly         typical. Crinolin® vaginal gel is manufactured in an 8% concentration.

Recent studies have shown that 100mg of micronized progesterone (Prometrium®)         twice a day for 14 days or daily for 28 days is adequate for menopause         management. There is some data to suggest that this form might have         fewer side effects such as depression, bloating, and weight gain than         synthetic progestins. Many progestins reverse some of the beneficial         effect of estrogen on serum lipid profiles (which effect the risk for heart disease). There is some evidence to suggest that so called         "natural progesterone" has less of these effects than some         synthetic progesterones. There are no long term epidemiological studies         whether this makes a practical difference or not.

The use of natural progesterone for the management of PMS remains         very controversial. Studies in the 1980s could not demonstrate any         effectiveness but other people claim they feel better. Newer theories         suggest that PMS may be due to estrogen deficiency, not progesterone         deficiency.

One can purchase progesterone creams and gels in health food stores.         They range in potency from 5mg / tsp. to 1000mg / tsp.!! Absorption         through the skin is very variable depending upon the type of vehicle         (ointment, gel, cream) the medicine is placed in and where on the skin         it is applied. So be careful with these!!! Depending on which         preparation you use, you may experience no effects or an overdose with         all of the problems mentioned above. If you are using topical hormones,         it is important to let your health provider know. There are no long term         epidemiological studies on the effectiveness of these preparations in         menopause management.

Natural     Estrogen, Selective Estrogens, and Fantasy Estrogens.

Dr. Andrew Dott      teaches advances hysteroscopic and laparoscopic surgical techniques, is on     the speaker's panels for several American pharmaceutical companies and is a     professional lecturer.  Among his lecture topics are female and male     menopause, menopause, herbs and medications, endometriosis, and     contraception.  He is available to travel and give seminars on the     topics covered in this website both nationally and internationally.

Progesterone is a natural hormone which is produced by the ovary during the second half of the menstrual cycle. It's biological function is to change the lining of the uterus so that the cells which line the uterus can provide nutrition to the developing embryo during the earliest phases of development after conception.

Natural Progesterone

There are many ways to take estrogens and many philosophies of management. The views expressed on this page represent the opinion of the author and may or may not conform to the current "standard of care" prevalent in the United States today. These opinions are not meant to constitute medical advice-- merely one person's philosophy. The ultimate decision and responsibility for medical management is between you and your health care practitioner.

Each woman is unique and each woman has different needs at different times in her lifetime. There has been a prevalent philosophy in the US for many years that "one dose (of Premarin) fits all". I disagree with this and I hope this page will offer some justification for my philosophy.

Lets start with some basic biology. Throughout the body, there are cells which respond to stimulation by estrogen. These cells are found in the brain, breast, skin, liver, uterus, vagina, and bladder as well as other site. On the surface of these cells are small areas called receptors. A receptor is like a keyhole. It something touches it which fits, than the cell responds in a certain way (like growth of the lining of the uterus). Conversely, the absence of stimulation of a receptor site can cause the cell to act in a different way (such as triggering hot flashes

). Interestingly enough, when there is a lot of a substance around for a long period of time, more receptor sites become established. Likewise, if there is an absence of a substance for a long period of time, the receptor sites become fewer. From a practical perspective, this means:

that an individual (a young woman) who had a lot of receptor sites because their body is accustomed to the 	presence of a lot of estrogen will need more estrogen to achieve the same effect than the individual who has fewer 	receptors

that the individual (an elderly woman) who has few receptor sites will need less hormone

As estrogen receptors are induced by hormone administration or production, or depleted by lowering levels of 	estrogen, an individual may need more or less estrogen over time to achieve the same biological effect.

The reverse is also true. The individual with few receptor sites will bind less estrogen so there is more available in the circulation of the blood for each site. This can result in overstimulation and symptoms of hormone excess with relatively low dosages in estrogen depleted individuals.

Finally, a cell does not have a brain and it cannot distinguish between estrogen and estrogen-receptor stimulating compounds. Whatever fits the keyhole will work. It does not matter to the receptor site if the substance is natural, synthetic, derived from a plant, or is a toxic chemical (for example, did you know that DDT binds to estrogen receptors?)

A 16 year old girl has never had a period and had no breast development. She is tall for her age. She does not have functioning ovaries and needs to be taken through puberty artificially and than maintained as a woman for the duration of her adult life.

Obviously this girl has very low levels of estrogen receptors and the natural evolution of puberty needs to be simulated. She would be started on low dosages of estrogen alone which would be increased every few months (receptor induction) over the course of 1-3 years until she feminizes. Measurements of serum estrogen and FSH levels would be done to ensure adult female hormone levels. Than progesterone, the hormone of the second half of the menstrual cycle would be added for 10-14 days each month. She might also need low dosages of testosterone since the ovary is a complex organ which produces many substances. Once full development and feminization is completed, birth control pills 

 could be substituted because the packaging is convenient. Contraception obviously is not needed.

A comment on taking testosterone is appropriate here for this and the next several discussions. Testosterone for women is discussed on another page. One way of doing this is to create a daily "foundation" of estrogen by continuous use of estrogen patches and/or pills and than allowing the woman to "play with" her testosterone dose by taking Estratest HS or Estratest (see below) anywhere from 2-7 times a week. If she takes too much, she will develop acne, increased facial and abdominal hair growth or even slight loss of hair on the sides of her forehead. So she can adjust the dose until she feels well and still has no side effects realizing that her estrogen dosage is being held relatively constant. Testosterone supplementation is not necessary for users of oral contraceptives since the progestin found in oral contraceptives have mild male directed tissue effects.

A 29 year old woman has had a pelvic infection resulting in the removal of both ovaries (surgical castration). She has been placed on the "standard menopause" dose of Premarin (0.625mg) and she is miserable. She has hot flashes, irritability, trouble sleeping, loss of energy, vaginal dryness, and loss of sex drive. She is told that her problems are "psychological" because she will not be able to have children.

Obviously, this young woman is loaded with estrogen receptors since she was acutely castrated in the prime of her reproductive life and she needs replacement with high dosages of estrogen as well as small amounts of testosterone to feel well and function well. There is good data suggesting that "standard menopause" doses of estrogen will not give her adequate long term protection from osteoporosis and heart disease. Birth control pills provide higher than physiological levels of estrogen and contain progesterone-like compounds with mild male directed activities and could be very appropriate for her until age 50 (assuming she does not smoke).

A 29 year old woman has had endometriosis resulting in the removal of both ovaries (surgical castration). She has been told she cannot take estrogen since this will stimulate the return of endometriosis and she is miserable. She has hot flashes, irritability, trouble sleeping, loss of energy, vaginal dryness, and loss of sex drive. She has been told that if she waits a few years, the symptoms of menopause will subside (receptor depletion) and she will feel better. She has tried all sorts of naturopathic remedies with mixed results. Her marriage is about to end.

I get E-Mails from suffering women all over the world who are experiencing this scenario. The management of the patient with endometriosis after surgical castration is complex, difficult, and depends on many factors such as the degree of residual disease. The ultimate management decisions need to be made between the informed woman and her physician. These women are a major risk for heart disease and osteoporosis not to mention the social and emotional consequences of acute defeminization if left without adequate hormone replacement therapy for a number of years. It is true that estrogen alone may stimulate the return of endometriosis. It is important to know that progesterone in whatever form causes endometriosis to shrink and to lose biological activity. Therefore estrogen administered with a fairly potent progesterone can provide adequate estrogen replacement while blocking or slowing the return of endometriosis. Examples could include progestationally dominant birth control pills (which contain higher than physiological estrogen replacement) or administering higher doses of estrogens formulated for menopausal use (which approximate normal estrogen levels in pre-menopausal women) such as Estradiol 2mg or Premarin 1.25-2.5mg along with higher dose progesterone replacement such as norethindrine 5mg (Aygestin) or megestrol (Megace). Again, There is good data suggesting that "standard menopause" doses of estrogen such as (0.625mg of conjugated estrogens (Premarin) or 1mg estradiol (Estrace) will not give her adequate long term protection from osteoporosis and heart disease in young women. Other therapies for endometriosis after removal of ovaries include GnRH agonists {(depo-Lupron) and danacrine (Danazol)} which are no longer appropriate since they are intended to block ovarian functioning, and high dose progestins without estrogen, such as depo-medroxyprogesterone (Depo-Provera) which may alleviate some of the acute symptoms but probably do not provide long term health benefits and may actually be harmful in terms of effects on lipids, depression, and weight gain. In addition, she may need low doses of testosterone to help her with libido and a general sense of energy and well being

A 46 year old woman is still menstruating but her cycles are becoming a bit strange with variable and heavier flow and perhaps fewer pre-menstrual symptoms. She is chronically tired and irritable and does not feel right. Her thyroid tests are normal but her FSH and estradiol levels suggest that she in entering menopause. One of the problems of the pre-menopausal period is instability of hormones which create problems with sleeping as well as cycle disturbances. At an extreme, these women can become very depressed and even end up undergoing extensive medical evaluations or even hospitalization for depression, malaise and fatigue, and anxiety. Women in their 40s with strange symptoms related to depression, anxiety, malaise, fatigue, difficulty coping, joint aches should always be assessed for biochemical evidence of early menopause. Problems with hormones should be corrected before more aggressive medical management protocols are undertaken. Often hormonal corrections will help stabilize their condition. This woman is young and still has a lot of hormone receptor activity. If she does not smoke, one appropriate therapy is to return to low dose birth control pills for cycle stabilization and hormone supplementation. The birth control pill is especially nice since the dosing is stable and uniform and may also protect her from a "surprise" late in her reproductive life. Oral contraceptives are contraindicated in women who smoke after age 35 since this is another good reason to quit smoking if she has not done it yet.

A 51 year old woman has not had a period for 5 months and she is having 20-30 hot flashes a day. She is embarrassed by this. She is also having problems sleeping and feels bad. Her work performance has deteriorated and she is at risk of losing hew job. This, of course, is the classic menopausal woman. She has been experiencing a gradual decline of estrogen over the previous several years and probably has fewer receptors than the younger woman. The vast majority of these women will respond to classic hormone replacement therapy with a combination of estrogen (conjugated estrogen  0.625mg or Estradiol  1mg) and medroxyprogesterone (Provera). Prempro and Premphase are a convenient packaging which puts it all together. With Premphase, she will probably continue to have a light menstrual period. With Premphase, she might experience irregular menstrual spotting. This is normal.

This 61 year old woman never experienced a hot flash and never had menopause symptoms. She has never taken hormones and she was doing fine. Because she had a history of systemic lupus erythematosis and took steroids in the past, her physician suggested she get a bone density study done. This study showed early osteoporosis. She also has a sister with breast cancer.

This woman would be a candidate for one of these newer estrogen-like substances called a SERM. An example is raloxifen (Evista). This medication will help to rebuild her bones along with a high calcium diet, exercise, and medications to stimulate bone growth such as alendronate (Fosamax) or etidronate disodium (Didronil) or salmon calcitonin (Miacalcin). Evista has the advantage of protecting the breast and uterus from cancer, creating a favorable lipid profile for cardiac protection, and rebuilding the bone. It can make hot flashes worse so it is a better agent for a woman who is not acutely menopausal.

This 85 year old woman has never used estrogen. She has just broken her hip and, in addition, is having some mild problems with forgetfulness. An X-Ray show significant osteoporosis. This elderly woman would probably benefit from estrogen particularly since there is some suggestion that estrogen may improve mildly impaired cognitive functioning. Obviously, she had profound depletion of her estrogen receptors and needs to start on the lowest possible dose of estrogen such as conjugated estrogens (0.3mg) or estradiol (0.05mg). Otherwise, she will experience symptoms of estrogen overdose such as breast tenderness, vulvar irritation, or bad dreams. Although recent publications suggest that these low dosages of hormones are adequate for osteoporosis prevention, it might not be inappropriate after 3-6 months to gradually increase the dosing to the standard regimen after induction of receptors has occurred. 
 
 

For further information visit MIDLIFE PASSAGES at 

There are many ways to take estrogens and many philosophies of management. The views expressed on this page represent the opinion of the author and may or may not conform to the current "standard of care" prevalent in the United States today.

Estrogen through the ages

Perhaps the principal reason male menopause has never been in the public     spotlight is because men who experience the characteristic decline in virility during     middle age are reluctant or even unwilling to acknowledge the condition. In fact, in     many instances, this condition goes untreated until the male's spouse or companion     brings it to the attention of a physician. The Institute of Endocrinology and     Reproductive Medicine now offers a comprehensive treatment program for male     menopause, a condition that   received scant attention from the medical     establishment, the media or from the men it affects-- at least until Viagra was     released in the Spring of 1998.   Dr. Karpas first published research on this subject     in 1977, and he has done extensive research on the effects of aging on male     hormone levels ever since.
           
           


     The symptoms of male menopause are not as overwhelming as the wholesale     changes women experience, and male menopause does not affect all men.     Approximately 40% of men in their 40s, 50s and 60s will experience some degree     of lethargy, depression, increased irritability, mood swings, and difficulty in attaining     and sustaining erections that characterize male menopause. For these individuals,     such unanticipated physical and psychological changes can be 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 surveyed 1700 middle-aged men from     the greater Boston area. According to their reports, 51% of normal, healthy males     age 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.
           
           


     Although the causes of male menopause have not been fully researched, some     factors that are known to contribute to this condition are hormone deficiencies,     excessive alcohol consumption, smoking, hypertension, prescription and     non-prescription medications, poor diet, lack of exercise, poor circulation, and           psychological problems. The few doctors who profess to be experts in this area     have widely divergent opinions. However, all of the experts do agree that a general     decline in male potency at mid-life can be expected in a significant proportion of the     male population.
           
           


     Many endocrinologists and scientists who have pioneered hormone studies say the     phenomenon of male menopause correlates with a decline in testosterone levels.     Testosterone is the hormone that stimulates sexual development in the male infant,     bone and muscle growth in man and is responsible for sexual drive. Dr. Karpas and     other experts have found that even in healthy men, by the age of 55, the amount of     testosterone secreted into the bloodstream is significantly lower than it was just ten     years before. In fact, by age 80, most male hormone levels have decreased to     pre-puberty levels. Low testosterone has been found to cause fatigue, depression,     loss of concentration, as well as decreased muscle strength and endurance.     Testosterone is more important in libido or sex drive than in the erectile     mechanism. Men with low testosterone levels will have problems with erections. 
           
           


     Despite the apparent correlation between decreasing hormone levels and     decreasing virility, many urologists question the importance of hormones. After     examining the results of an aging study, one of the study's principal investigators     questioned the evidence of a relationship between a mild deficiency of testosterone     and impotence. Other conditions such as obesity, hypertension, smoking, and high     cholesterol - all of which are factors contributing to heart disease are also known to     contribute to impotence. Impotence is often primarily a vascular problem resulting in     a loss of elasticity in the arteries - a condition causing poor circulation and     impairing blood flow. Healthy circulation and blood flow are necessary to maintain     an erection. The aging study bears out this thesis. Nearly two-thirds of 40 year old     men diagnosed with heart disease exhibited at least moderate impotence.
           
           


     A wide variety of drugs have also been shown to increase the probability of     impotence. While a very small amount of alcohol may not impair sexual     performance for most men, alcohol in general can create problems for men of     middle age and beyond. The immediate effect of alcohol to increase vasodilatation     which makes it more difficult for the body to send blood to the penile tissues. The     long term effects of excessive alcohol use are more dangerous. Tissue samples     from patients with chronic alcoholism (10 or 15 years of heavy drinking)     demonstrate that prolonged alcohol abuse causes irreversible damage to the     nerves inside the penis.
           
     As devastating as alcohol can be, many doctors cite smoking as the major cause of     male sexual dysfunction. In addition to its other detrimental effects, smoking also     damages the tiny blood vessels in the penis that must enlarge to accept the     substantial onrush of blood during an erection.
           
     Hypertension and the medications for hypertension (beta blockers) also     significantly increase the chances of impotence. A patient may have to try several     different drugs before finding one that controls blood pressure but does not affect     potency. Other prescription and non-prescription medications that increase the     incidence of impotence include but are not limited to antidepressants, especially     Prozac and Zoloft, diuretics, antihistamines, antispasmodics, digestive medicines     and cold and flu remedies.
           
           


     The importance of proper diet and regular exercise cannot be discounted. The     aging study produced the first evidence that cholesterol level is related to     impotence. In fact, high levels of HDL (the "good" cholesterol) were significantly     associated with reduced levels of impotence. A healthy diet low in saturated fat and     sugars, coupled with regular exercise has been shown to play a significant role in     lowering cholesterol levels, maintaining testosterone levels, increasing libido and     boosting self image. In fact, throughout the life cycle, men who exercise regularly     report greater sexual drives and greater sexual satisfaction than sedentary men.
           
           


     In case where impotence has been diagnosed, it is important to determine whether     the cause is principally physical or psychological. One reliable test is to check     nocturnal penile tumescence - the number and quality of erections that occur while     the patient is asleep. If the results are within the normal range for men of a certain     age, it can be hypothesized that the problems are not physical, but psychological,     and the appropriate treatment programs can be begun.
           
     If the results of nocturnal penile tumescence testing indicate a physical problem,     then another test which determines penile blood pressure may be used. In this test,     a cuff is supplied around the penis to determine the penile blood pressure, which     should be the same as the blood pressure throughout the body. If the penile blood     pressure is lower than expected, the cause of the impotence may be a vascular     problem.
           
           


     Usually there is more than one explanation or cure for the phenomenon known as     male menopause. Aging, hormones and overall physical and mental well-being all     factor into the condition. Many doctors agree that if a man has an understanding     partner, monitors his medications, alcohol intake and eating habits, stops smoking,     and improves the health of his vascular system through aerobic workouts, he will     almost certainly see an improvement in his overall wellness and sexual potency.
           
     In cases where specialized treatment is needed, new findings from English studies     suggest that men can improve in sexual function, muscle strength, and general     well-being if they are treated with supplements to bring their testosterone levels into     a high - normal range. Hormone Replacement Therapy (HRT) is now regarded by     many physicians as the future of preventative medicine for both men and women in     the second half of life. In fact, the National Institute of Health recently asked for     research proposals to investigate whether testosterone supplemen- tation might     benefit older men by preventing bone loss, depression and other symptoms     associated with aging.
           
     Currently there are several methods of testosterone supplementation including     shots, implants and a transdermal patch. If injections are indicated, they should be     administered at least every two weeks to ensure that testosterone blood levels are     constant throughout the treatment. Another option is testosterone implants which     are surgically placed behind the gluteus muscle in order to release a steady level of     testosterone into the bloodstream. An even newer treatment is the transdermal     patch. This patch is placed on the scrotum, and the patient must shave the area     where the patch will be affixed and apply a new patch daily. All of these treatments     boost testosterone levels in the blood to therapeutic levels, and the patient must     determine with the help of his doctor which is the best for him.  Unfortunately,     testosterone is not particularly effective in treating erectile dysfunction (impotence).
           
     In the past,  effective treatments for impotence included vacumn pumps, injections     of medications (Caverjet) into the base of the penis, and prosthetic implants.  A     number of newer medications have become available in the last several years     including:
           
     Alprostadil (Muse)-- a pellet placed within the urethra (the passage in the penis     where urine comes out)
           
     Sildenafil (Viagra)--an oral tablet which doses not cause an erection but enhances     one.
           
     New oral compounds in late stage clinical development include apomorphine and     phentolamine (Vasomax).  There are also topical creams, sublingual tablets, other     intraurethral tablets, and injections being studied at this time.

Perhaps the principal reason male menopause has never been in the public spotlight is because men who experience the characteristic decline in virility during middle age are reluctant or even unwilling to acknowledge the condition.

Andrew B. Dott, MD, MPH

Articles

Osteoporosis Medications and Prevention

Natural Progesterone

Estrogen through the ages

Introduction to Male Menopause