MEN-O-PAUSE: The Andropause, the male menopuase.

Menopause in females is a well delineated and abrupt of decline of estrogenic hormones, and reproductive function, somatic and psychological functions.

Whereas ANDROPAUSE in males is a controversial concept: not widely accepted.

In males andropause there is a gradual decline of functioning. As described by Morales and Lunenfeld (International Society for the Study of the Aging Male) it’s a “biochemical syndrome associated with advancing age and characterized by a deficiency in serum androgen levels with or without a decreased genomic sensitivity to androgens”

The decline in testosterone with aging is related to decreases in both hypothalamic (HPA axis less sensitive, less GNRH-less LH) and testicular function (Leydig cells decrease)

There is a   lack of established normal testosterone levels for different age groups (Approx 1-2% decline from 40-70yrs)

For now it’s a diagnosis of exclusion after ruling out other causes of gonadal dysfunction like medication side effects, thyroid problems, depression and excessive alcohol use, obstructive sleep apnea.

Diagnosis is based on the psychological and cognitive hints of andropause including loss of cognitive function, depression, and “loss of drive”, chronic fatigue, lethargy, hot flashes, ED, decrease libido,  ?midlife/latelife crisis. On Physical Examination there decrease in lean body mass(l ess muscles and more fat) and changes in hair, skin, and fat distribution, osteopenia and osteoporosis.

Plus a low testosterone level (a concomitant raised LH indicates testicular deficiency)

Testosterone replacement Therapy(TRT) in this population is anabolic,  including increase in lean body mass and associated decrease in fat mass, increased bone mineral density, increase in muscle strength and sexual function, improved generalized feelings of well-being, and improved cognitive function

Side effects of TRT being Promotion of fluid retention, Increase in cardiovascular disease risk, Precipitation or worsening of sleep apnea, Gynecomastia, Polycythemia, Fluctuations in mood, Worsening of pre-existing prostatic disease(possibly does not induce)

There is absence of long-term placebo-controlled trials of TRT.

A few points of cation: Andropause is not a widely accepted construct, is not universal as female menopause. There is lack of age appropriate standardized values of serum testosterone. When its there, its very gradual in onset and difficult to detect.

Sexual Disorders: Premature Ejaculation

According to the tenth revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10, WHO), sexual dysfunction refers to a person's inability to “participate in a sexual relationship as he or she would wish.” The dysfunction is expressed as a lack of desire or of pleasure or as a physiological inability to begin, maintain, or complete sexual interaction.”
They can be lifelong or acquired, generalized or situational, and due to psychological factors, physiological factors, or combined factors. They can be attributable entirely or partially to a medical condition, drug/alcohol use, or adverse effects of medication.

PREMATURE EJACULATION (PME)
From an evolutionary point of view, a rapid completion of coitus is more adaptive in situations where predators are at large, but then we have moved out of jungles a long time back.
In PME, the man repeatedly reaches orgasm and ejaculation occurs before he desires to do so...and before there is full satisfaction in the sexual act. There is no definite time frame within which to define the dysfunction. The diagnosis is made when the man regularly ejaculates before or immediately after entering the vagina or after minimal sexual stimulation. Sometimes 15 seconds taken as the upper time limit, at other times when a man could not control ejaculation long enough during intravaginal containment to satisfy his partner in at least half of their episodes of coitus).

Duration = ?

The factors that affect duration of the excitement phase, such as age, novelty of the sexual partner, and the frequency and duration of coitus should also be considered before making a diagnosis.

Difficulty in ejaculatory control is sometimes associated with anxiety regarding the sexual act. Both anxiety and ejaculation are mediated by the sympathetic nervous system. Other psychological factors that can contribute are sexual guilt, a history of parent–child conflict, interpersonal hypersensitivity, and perfectionism or unrealistic expectations about sexual performance.

Few men are more vulnerable to sympathetic stimulation, hence, they ejaculate rapidly. Others have found a shorter bulbocavernosus reflex nerve latency time in men with lifelong premature ejaculation than in men who had acquired the dysfunction.

Premature ejaculation also may result from negative conditioning. The man who has most of his early sexual contacts in situations in which discovery would be embarrassing, such as there is lack of privacy or with has had prior intercourses with prostitutes who demand that the sex act proceed quickly, become conditioned to achieving orgasm rapidly.
A stressful marriage exacerbates the disorder.

The problem is quiet common, but under reported due to obvious reasons. About that 30 percent of the male population are reported to suffer, and approximately 40 percent of men treated for sexual disorders have premature ejaculation as the chief complaint.

Sex therapy

This shoud be done under supervision of an expert only. In cases of premature ejaculation, an exercise known as the squeeze technique is used for the purpose of raising the threshold of penile excitability. In this exercise, the man or the woman stimulates the erect penis until the earliest sensations of impending orgasm and ejaculation are felt. Penile stimulation is then abruptly stopped, and the coronal ridge of the penis is squeezed for several seconds. The technique is repeated several times.

Another variation is the stop–start technique, in which stimulation is interrupted for several seconds but no squeeze is applied. The man is encouraged to focus on sensations of excitement rather than distract himself from them. This makes him more familiar with his excitement pattern and lets him feel in control rather than overwhelmed by sensations of arousal. Communication between the partners is improved because the man must let his partner know his level of sexual excitement so that she can squeeze the penis before the ejaculatory process has started. Sex therapy has been successful with some premature ejaculators; however, a subgroup of dysfunctional men may need pharmacotherapy as well.

Medications

Delayed orgasm is a peculiar side effect of Selective Serotonergic Reuptake Inhibitors type of antidepressants, and this aspect has been used to prolong the sexual response in patients with premature ejaculation. This approach is particularly useful in patients refractory to behavioral techniques or who may have physiologically determined premature ejaculation.
Dapoxetine is a new, short acting SSRI specifically developed to treat premature ejaculation.
Other on demand treatment for premature ejaculation is topical anaesthetic such as lidocaine cream or spray in mild strength, which is applied to the glans of the penis.

Again all these approaches are to be used only under medical supervision.