Manhood is so deeply buried under an avalanche of macho images that the very thought of men becoming bundles of nerves-confused, tired, insomniac and low on libido-is an uncomfortable one. Perhaps that is why a psycho-physical breakdown in men remained unaccepted for many years. Andropause, the condition in men comparable to menopause in women, was declared a hype of pharmaceutical companies, looking for an excuse to sell testosterone to fatigued, depressed, middle-aged men, with low levels of the male hormone.

Recent research, however, is settling that lopsided debate. Studies prove that testosterone works and it is safe. So as testosterone supplements hit the Indian market, hormone therapy for men is gaining new ground. Endocrinologists in India have also begun prescribing testosterone to treat muscle loss, decreased sex drive, depleted energy and symptoms of hypo-gonadism (underactivity of the testes). Ask Mahesh Dwivedi, a Delhi-based executive. He tried in vain to make sense of the constellation of changes he underwent-mood swings, restlessness, fatigue and a drooping sex drive. "I felt low all the time," he says. Finally, Dwivedi was diagnosed with low testosterone levels and was put on hormone supplements. Dwivedi is just one of the lakhs of middle-aged men in India who either refuse to admit that things are not as good as they can be or if they do, shrug it off as a passing phase.

"TRT works but is unable to correct mood swings sometimes." Neeru Gera, endocrinologist

Andropause was first reported in 1944 by two American doctors, Carl Heller and Gordon Myers. They did a blind-controlled trial on the effectiveness of testosterone treatment. Unfortunately, their efforts went unnoticed. But recently, Harrison Pope, professor of psychiatry at Harvard Medical School, US, found that depressed men who didn't respond to the usual anti-depressant treatment improved greatly with testosterone supplements. Mumbai-based sexologist Dr Prakash Kothari says there is a proven decline in hormones with age in men as in women. "But, Indian men resist accepting this," he says. Kothari handles at least 10 such cases every month at the OPD of K.E.M. Hospital, Mumbai. "Most are treatable. All they need is testosterone supplements and some diet and lifestyle changes," he adds.

Andropause, also known as male climacteric, viropause, ADAM (Androgen Deficiency in the Ageing Male) and PADAM (Partial Androgen Deficiency in the Ageing Male), is defined as a condition that can produce a roller-coaster of emotional and physical effects-from an unexplained burst of energy to snappishness in the initial stage to immense tiredness, sexual dysfunction and moderate to severe depression later. Delhi-based endocrinologist Dr Neeru Gera explains that andropause presents itself as a wasting of muscles, fatigue without obvious reasons and loss of libido or erectile dysfunction in some. "Sometimes irritability, insomnia, forgetfulness and anxiety too occur," she adds.

While andropause is not synonymous with a mid-life crisis, sometimes they strike together compounding one another. Like it happened with Rob Thomas, 56, a university professor, who went into repetitive snappy moods after a death in the family. "I went to my physician saying I had no urge to work, to socialise or to have sex and that I was becoming temperamental," recalls Thomas. Ironically, Thomas' physician told him that it was normal because even sex had a retirement age. It was only when Thomas consulted Dr Kothari that his testosterone levels were checked.

Andropause afflicts at least 40 per cent of men between 40 and 70 years of age. Those who are obese, smoke and drink excessively, are hypertensive and do not exercise are more likely to experience andropausal symptoms than those who are fit. Supported by recent clinical correlations, endocrinologists say unlike female menopause, andropause can be reversed with early diagnosis and hormonal supplements (see box). Individual differences apart, what is irrefutable is the fall in testosterone levels. "Even in healthy men, by the age of 55, the testosterone secreted into the bloodstream is significantly lower than earlier," explains physician Dr Sandeep Budhiraja.

Testosterone is the hormone that has been understood as the symbolic (and sometimes literal) explanation for all the good and bad that men do, why they surf channels, bang doors, are insensitive, ruthless, sleep around or lift heavy objects. Also, traits such as aggression, competitiveness and risk taking, typically thought of as male behaviour, are linked to testosterone. Incidentally, both men and women produce testosterone in their bodies. But in men the levels are higher-the average healthy male has 260-1,000 nanograms of testosterone per decilitre of blood, while the range among women is 15 to 70. In his book The Testosterone Revolution, Dr Malcolm Carruthers, one of the world's leading experts on andropause, explains how depressed men can be effectively treated with carefully monitored testosterone replacement therapy (TRT).

But like every medical intervention, TRT too comes with riders. The most emphatic debates have been on the possibility of liver damage and whether it can accelerate prostate cancer. Besides, as Dr Gera says, "TRT works, but may not relieve all symptoms. Sometimes mood swings cannot be corrected."

"Low sex drive is embarrassing and patients avoid talking about it." Samir Parikh, psychiatrist

But more often than not, the effects are beneficial. Take for instance Nilesh Vohra, a 49-year-old businessman. "I went to the doctor complaining of a loss of interest in sex and was told to take controlled doses of testosterone," he says. Vohra says the result has been positive not only in terms of enhanced sexual drive but overall health too: "Now I feel like working out and involving myself in sporting activities." Vohra also adds that after the first course of injections, he felt more confident than he did even in his youth. "At times, though, I did feel irritable and fidgety," he admits.

However, testosterone, warn endocrinologists, should be prescribed with discretion and certainly not for vague feelings of low sexual drive. The problem doesn't lie in treating andropause, it is in recognising the need for testosterone supplements. "It is an embarrassing subject and many patients try to avoid it, resisting treatment," says psychiatrist Dr Samir Parikh.

Ironically, observe doctors, the very paradigm of modern masculinity-the whole idea of being tolerant and not complaining-prevents men from taking medical help to get out of their crisis. And that is something that can't be reversed with testosterone supplements.

Names have been changed to protect identities.