In Our Prime

by Patricia Cohen

  To DiNubile, the medical establishment still lags in serving its middle-aged patients when it comes to education. “I’ve been trying to put exercise on the medical school curriculum for ten years,” he told me. Doctors know that exercise is good, but “they are not comfortable in outlining programs for their patients over the age of 50. . . . It’s the weak link.” Ambitious novices go to a gym without having a good understanding of what they can and cannot do, sometimes injuring themselves. He noted that SilverSneakers, a fitness program established in 1992 for people over 50 and offered at more than nine thousand gyms and fitness centers, has been underwritten by a number of health insurance companies because they recognized the preventive benefit.

  The pressure from consumers has both its positive and negative sides. Demand for better treatments from middle-aged patients encouraged scientific advances and helped shift the mind-set of many orthopedists from treating injuries to prevention and lifestyle. At the last boomeritis gathering he attended—an annual conference that the American Academy of Orthopedic Surgeons established in 2007—DiNubile marveled at the lack of sessions pushing surgery. “There wasn’t one bloody picture during the whole conference,” he said. “That’s a dramatic shift.”

  On the downside, people often have unrealistic expectations of their own abilities as well as the medical limits on fixing what breaks, which can result in a reckless run-up of costs.

  Well-insured patients can shop for a doctor until they find the one who says yes to surgery. Some midlifers have had more than a dozen to repeatedly fix faltering parts. “This is a highly motivated group of people,” DiNubile noted. “And sometimes you just have to inject a sense of realism.”

  No distinction is made between reasonable optimism and magical thinking. Self-improving middle-agers can easily end up indulging in frivolous and dangerous treatments because they believe the stories of miraculous regeneration they hear from pitchmen, doctors, and the Internet. Just as baseball players and cyclists want steroids to power their batting or increase their stamina in spite of the long-term dangers, people want thinner bodies, smoother skin, and more sexual vitality regardless of the higher risk of developing cancer or having a heart attack at some unspecified time in the future.

  12

  Middle Age Sex

  Love in the prime of life

  Life begins at forty

  That’s when love and living start to become a gentle art

  A woman who’s been careful finds that’s when she’s in her prime

  And a good man when he’s forty knows just how to take his time

  Conservative or sporty, it’s not until you’re forty

  That you learn the how and why and the what and when

  In the twenties and the thirties you want your love in large amounts

  But after you reach forty, it’s the quality that counts

  —“Life Begins at Forty,” music and lyrics by Jack Yellen and Ted Shapiro

  H. L. Mencken was famous for his hard-nosed skepticism about religious, political, and medical claims. In 1924, the American Mercury, the monthly magazine he co-founded, published an article ridiculing Eugen Steinach’s vasectomy and X-ray rejuvenation treatments: the facts “seem to shatter this theory completely.” Yet, in 1936, at age 56, Mencken himself succumbed to the lure of Steinach’s age-prolonging vasectomy. He may have been encouraged by a breakthrough the previous year that enabled scientists to isolate and manufacture testosterone, a discovery that generated fevered excitement about the possibility of rejuvenation. The predecessors of today’s antiaging researchers promoted the hormone as a youth serum for middle-aged men and the supposed problems of “male menopause,” also referred to as andropause. Oreton, a drug manufactured by the Schering Corporation in 1934, claimed to be “a highly effective means of ‘finding’ the man who is ‘lost in his forties.’” An ad for Perandren, another testosterone drug, showed a photograph of a downcast man dressed in a tux titled, “The Fifth Age of Man,” and explained that “the male decline” meant sexual decline.

  During the Depression, when middle-aged men were desperate for any edge in the job search, the potential of hormonal youth-inducing “miracle drugs” sparked interest. Henry Harrower’s Gonad Tablets, concocted by the endocrinologist Dr. Harrower in his California-based laboratory, promised to elevate physical and mental energy. Efforts to restore male vigor focused on performance, strength, and other physical attributes of masculinity. As drug companies made versions of testosterone, estrogen, and cortisone, hormones were added to the physician’s menu of aids. Commerce and medicine established an alliance that was high in profitability and low in ethics and efficacy. Some doctors struck deals with pharmaceutical manufacturers to be the sole dispenser of a particular drug, which they then sold out of their office at a substantial profit.

  In 1939, the prestigious Journal of the American Medical Association ran an article that claimed men went through a “climeratic” that included hot flashes, low sex drive, crying, and memory problems. Severe cases led to psychosis. Testosterone produced a “remarkable clinical improvement” that included a marked increase in the “sex urge and in the capacity to respond with proper emotions not only to intercourse but also to other acts such as kissing or embracing.”

  The culture found inspiration in the news. An issue of the science-fiction magazine Amazing Stories featured Gland Superman, a regular guy enhanced by hormones. Satirizing the hormone mania, Ray Bourbon, a gay performer, released a record in 1941 called Gland Opera:

  Ain’t science marvelous, ain’t science grand?

  It’ll make worn-out libidos lib by grafting on new glands.

  Now a certain worn-out bachelor, who had gone from

  frail to frailer,

  They had no stevedore’s glands in stock,

  So they gave him a ladies tailor’s.

  The Male Sex Hormone, a 1951 film produced by Schering, advocated using testosterone to address the ills of male menopause. But the medical establishment ultimately denounced the treatments and declared andropause did not exist. Hormone therapy for men didn’t catch on until the antiaging industry of the 1990s revived interest in it.

  In 2002, the Commission of the European Communities sponsored the European Male Aging Study, an ambitious effort to identify and measure symptoms and disabilities associated with aging and settle the question of whether there is a clinical condition similar to female menopause. In June 2010, the New England Journal of Medicine published a preliminary account of the 3,219 men between 40 and 79 who were participating and concluded that reports of andropause were highly exaggerated. Testosterone levels naturally drop about one percent a year beginning at age 30. Researchers, for the most part, found that there was barely any connection between levels of testosterone and falloffs in physical, mental, and sexual health. Low sex drive, depression, and sagging energy levels were more likely to be caused by stress, poor eating habits, and laziness than diminished hormone levels. Indeed, another set of scientists made headlines in 2011 when they discovered that fatherly activities from changing diapers to playing peekaboo lower testosterone even in 20-somethings.

  Discussions of “male menopause” and andropause nonetheless continue to proliferate, particularly on the Internet. Advertisements for topical forms of testosterone, like AndroGel, promote the idea that men who put on a few pounds and notice a dip in sexual drive may suffer from a medical disorder. As one critic put it, these hormonal products have become “an all-out escape hatch for middle age.” Replacement therapy sales increased with a compound annual growth rate of more than twenty-five percent between 2005 and 2009, surpassing $800 million at the end of the four years. In November 2010, the FDA approved Axiron, a topical testosterone applied under the arms. Testosterone supplements are enthusiastically hawked at Anti-Aging Academy conferences.

  Testosterone falls into the same category of anabolic steroids that have been at the heart of drug-doping scandals in sports, yet they have escaped censure because of shrewd m
arketing and willing believers. Promoters in Las Vegas and elsewhere dismissed the medical establishment’s concerns about links to cancer and side effects like lowered sperm count, shrunken testicles, increased risk of heart attack and stroke, enlarged prostates, and swollen breasts. The long-term effects of additional testosterone on healthy men are still unknown. The National Institute on Aging undertook a study in 2009, recruiting eight hundred men over 65 with low testosterone levels who had difficulty walking, low vitality, and sexual or cognitive problems. Results will not be available until 2015. That has not deterred advocates, who frequently appear on news programs and daytime talk shows to praise testosterone therapy. Even without a doctor, anyone who wants to take testosterone can get it from the hundred or more “rejuvenation clinics” now operating, or order it on the Web. “Beat the Ban,” a headline in the online bodybuilding magazine Flex announced, referring to an article advising how to get around the FDA’s prohibition of prohormones, substances that act like steroids.

  Middle Age and Menopause

  Menopause has always elicited conflicting responses in the medical community. Gynecologists and psychoanalysts frequently portrayed menopause as a scary, disfiguring ailment that occurred when the ovaries met their “inevitable demise.” In the 1930s, the advice writer W. Beran Wolfe claimed that many large hospitals had sections for mentally disturbed menopausal women. So-called pathological conditions like “vaginal atrophy” were identified. Although there were physicians who derided such pronouncements, others warned that menopause amounted to a rehearsal for death and endorsed hormone therapy.

  A range of female hormonal therapies using artificially synthesized progesterone and estrogen was offered in the 1930s in an assortment of combinations and potencies, but treatments did not really catch on until the following decade, when less expensive versions could be administered in a pill instead of by injection at a doctor’s office. In 1942, the FDA approved hormone replacement therapy to treat hot flashes, mood swings, insomnia, and other menopausal symptoms. Because of regular gynecological and obstetrical visits, doctors had many more opportunities to persuade their patients to take hormone supplements and women ended up embracing replacement therapy more eagerly than men. (A similar dynamic encouraged women to try surgical and chemical youth treatments at the end of the twenties.) And unlike the vague symptoms and timing of purported andropause, menopause was clearly marked by the end of menstruation and fertility. The substances were also cheaper.

  In their book The Pursuit of Perfection, David and Sheila Rothman recount how hormone therapy, like plastic surgery, pushed medicine to expand its purpose to include promoting happiness. In the 1930s and 1940s, Emil Novak, a gynecologist at Johns Hopkins, enthusiastically prescribed estrogen for menopausal patients who were depressed. Most gynecologists believed the psychological benefits outweighed the potential risk of cancer. Withholding estrogen because of “a slight theoretical possibility,” said Novak, was “carrying conservatism and caution to an extreme.” The failing of medical hormones has always been that its claims outran the evidence.

  Therapies were marketed with the familiar combination of appeals to empowerment and self-improvement. In the fifties, ads for estrogen featured photographs of kicking showgirls and beauty queens, suggesting that prolonged youth was possible. “There Goes A Happy Woman,” one ad trumpeted above a picture of a woman exiting her doctor’s office. Charm, a magazine for working women, promoted hormone treatments in advertisement and articles. “After 35 you can fool all of the people all of the time by treating your face, throat and hands regularly with a hormone cream or lotion,” an article in 1954 gushed. “There are hundreds of other ‘miracles’ made possible by the progress of science and chemistry.”

  In the 1950s, William Masters, who later won worldwide fame for the sex research he conducted with Virginia Johnson, fervidly promoted hormone therapy to reverse women’s aging. Like Elie Metchnikoff and others before him, Masters believed aging was a disease, and one that science should attack with the same enthusiasm it mustered in the fight against polio or tuberculosis. “One of the greatest public health problems of the present and future, is the rapid increase in our aging population,” he wrote in a 1955 paper. Masters laid out an ambitious plan at the 1957 annual meeting of the American Gynecological Society. “The only known member of the female gender to live past her period of reproductivity is the human female,” he told doctors who gathered at Washington University School of Medicine in St. Louis. “The postmenopausal years represent, for her, a socially conditioned phenomenon.” Medical advances, along with social progress, had increased the human life span far beyond what Masters considered normal; now it was science’s obligation to undo the side effects of their success and care for these middle-aged women.

  Masters’s campaign to correct what he characterized as a defect gained many adherents in the profession in the 1960s and 1970s. Middle-aged women, frequently dismissed by doctors as they went through “the change,” were suddenly alluring to physicians and pharmaceutical companies once hormone therapy became widely available. The boundless fortune that could be made by convincing every middle-aged woman to buy a preparation to cope with menopause was an irresistible incentive for drug companies. Psychotropic drugs were similarly marketed as menopausal aids to women in midlife. Between 1966 and 1971, doctors prescribed tranquilizers and antidepressants to seventeen percent of all women (compared with eight percent of men). Their median age was 44. A drug marketing executive explained the general process of building a consumer base: “It’s not just about branding the drug; it’s branding the condition and, by inference, a branding of the patient. . . . What kind of patient does a blockbuster create? We’re creating patient populations just as we’re creating medicine, to make sure that products become blockbusters.”

  The end of fertility was commonly portrayed as marring women’s desirability so that unattractiveness and frigidity revolved around menopause like satellites. Simone de Beauvoir observed that a woman “is still relatively young when she loses the erotic attractiveness and the fertility which, in the view of society and in her own, provide the justification for her existence and her opportunity for happiness. With no future, she still has about one half of her adult life to live. . . . The crisis of the ‘change of life’ is felt much less keenly by women who have not staked everything on their femininity.”

  Conversations about menopause took place in whispers, as if the subject were unseemly or distasteful. It is “probably the least glamorous topic imaginable; and this is interesting, because it is one of the very few topics to which cling some shreds and remnants of taboo,” wrote the feminist novelist Ursula Le Guin. “A serious mention of menopause is usually met with uneasy silence: a sneering reference to it is usually met with relieved sniggers.”

  Physicians made authoritative pronouncements about the dire physical and psychological effects of menopause, even though barely any research had been done. (Only in 1991, when Dr. Bernadine Healy, the first woman to run the National Institutes of Health, launched the Women’s Health Initiative, a $625 million study on middle-aged women, did researchers shift their gaze from men to women.) The gynecologist Sherwin Kaufman wrote in the January 1965 issue of Ladies’ Home Journal: “It is perfectly natural for women to wish to slow up the aging process and to remain more attractive. They don’t hesitate to use contact lenses for failing eyesight, color rinses for drab-looking hair or caps for their teeth. Then why should they put up with the discomforts that afflict about half of them in middle age, when the menopause begins? . . . Treatment doesn’t make a woman younger, but it does make her younger-looking.”

  A year later, in 1966, the British-born gynecologist Robert Wilson published Feminine Forever, arguing that menopause was “chemical castration.” The title was a swipe at Friedan’s 1963 seminal work The Feminine Mystique. In his eyes, femininity was not the problem but the answer. A menopausal woman becomes the “equivalent of a eunuch,” he wrote. “The entire genital syste
m dries up. The breasts become flabby and shrink, and the vagina becomes stiff and unyielding. The brittleness often causes chronic inflammation and skin cracks that become infected and make sexual intercourse impossible. . . . Multiplied by millions, she is a focus of bitterness and discontent in the whole fabric of our civilization.” Menopause was a disease, he declared in his bestselling account, which convinced millions of women to sign up for hormone replacement therapy.

  Throughout the sixties and seventies, gynecologists encouraged every woman approaching menopause—and many younger women as well—to down an estrogen pill. Wilson suggested using estrogen from “puberty to the grave.” If relief of menopausal-related symptoms like hot flashes and night sweats were not enough to persuade middle-aged women to buy the drug, then the promise of looking younger might. If your doctor disagreed, Wilson counseled, then find another doctor. Only after his death did documents—and his son—confirm that Wilson had been paid by a pharmaceutical company.

  The elitist bias that infused the work of rejuvenation specialists in the 1920s was discernible in the 1960s. Wilson saw hormones as a tool for the wealthy to maintain class differences, writing a nasty, mean-spirited description of those who were unable to afford hormone treatments after menopause. These undeserving women gradually sink “into a state of almost bovine passivity,” he wrote. “Such women generally flock together in small groups of three or four. Not that they have anything to share but their boredom and trivial gossip. Clustering together in monotonous gregariousness, they hid themselves from the rest of the world. They go together to the same hairdresser to have their hair tinted purple. As though they were schoolgirls again, they dress alike and buy the same little hats.”