Previously I have expressed my gratitude to you for your diagnostic and therapeutic acumen which is so far ahead of the curve that it seems to befuddle many of your and my colleagues. You know that my wife and I are grateful for what you have done for both of us. We follow your blogs diligently and recommend them to our friends. I continue to encourage my colleagues and patients to read them regularly and carefully. We read your previous post on "Sex, Hormones & Identity." After some thought and discussion my wife suggested that I write this letter to you with permission to publish it on your blog for the benefit of others. I will continue as a first-person narrative. Given that I'm an orthopedic surgeon, my wife, an English major has edited it for intelligibility.
I am a 58-year-old male, married for 29 years to a wonderful woman. We have four healthy, wonderful children. We have been blessed with a good life and good health. My practice has done well and we are financially OK. Not to say that we have not had our share of marital squabbles, parental angst, and a fair ration of aggravation from our children, we have had it better than most.
To get to the point, our sex life followed a reasonably typical curve. Hot and heavy when we met, dated and first married. It became attenuated through pregnancies, child-rearing, long days, nights and weekends in the emergency room and surgery; and many times when either or both of us were simply too tired, frazzled or upset about something to get it on. Notwithstanding all of the above we have remained faithful to one another throughout everything.
Obviously I always saw myself as the always ready, willing, and extremely able stud. And as that male "stud" I had my share of frustration when my wife wasn't in the mood, or had a headache, and so forth. And no I did not have a great depth of insight and understanding into my wife's feelings that she had somehow become less attractive and less desirable because she was a 40 something mother whose full breasts sagged a little bit and who had this little postpartum pooch at the bottom of her tummy. She thought that I was patronizing her or lying when I bought her sexy lingerie or suggested that she wear a tight sexy dress. At that time she did not understand or believe me when I told her that I thought she was more beautiful than ever, more sexual, sensual, and desirable, and that a man took great pride in that little pooch. I tried to make her understand that in some basic manner it made a young man feel great to show up with a gorgeous, desirable woman on his arm. And that it made that still young man feel great to show up with his young, beautiful and pregnant wife. You know, that smug grin that says "oh yeah, she's mine, and she let me do that with her." Or that it made a middle-aged man feel even greater to show up with his still deliciously beautiful wife in a sexy dress and heels that displayed that little pooch, to hold her close and display that even more smug grin that says, "yep, she's still gorgeous, and yeah, see, she's given me children!" By the end of this letter I think you will see that we both understand each other much better now. She even looks forward to the surprise packages that arrive with lingerie, dresses and high heels. Now, mind you some of this only I get to see but some of this we proudly display in restaurants, at parties and medical staff dinners. The sneers, looks and remarks of the other women; the stares and oogling by the other men and the resultant annoyance of their wives does give us a small measure of pleasure. But the larger measure of pleasure we reserve for ourselves.
Actually this has been rather a long foreword. Our marriage was falling apart and would have ended if not for your help.
Approximately 10 or 11 years ago there were subtle and gradual changes in me that neither I nor my wife perceived at the time. Professionally I continued to function quite well. That was never a problem. But personally, emotionally, sexually and cognitively there were some changes. I made some very bad business decisions. As a result I will be working and paying for my children's education a lot longer than many of my peers. But such is life.
My energy levels were diminished. My enthusiasm for many things dwindled. My sleep became fitful and I found myself in my den drinking a little too much single malt scotch, ruminating uselessly and for the first time surfing the Web for some soft erotic porn. My libido seemed to have evaporated. Whereas in past years I was always the Energizer Bunny, eager at night and with a morning erection that I was happy to use, I more or less went to bed and more or less went to sleep. My wife became aware of this. At first she said nothing. Then she actually (and for the first time in quite a while) attempted to initiate intimacy and sex. I had a few hard ons, a few soft ons and a few failures. Charitably we attributed this to overwork, fatigue and too much scotch. Then, one night when the children were all asleep she came into the bedroom with her hair done, and nails painted red with lipstick to match and a lot of I guess slutty makeup (it looked really good!) and an exquisitely provocative baby doll. To say the least I was intrigued and excited and we began to get in on hot and heavy. Except of course I couldn't get it up. My wife was, quite appropriately I believe, furiously angry and deeply hurt. She was convinced that I no longer found her attractive and/or that I was having an affair. Neither could be farther from the truth.
At this point I knew that something was wrong. I spoke with our mutual friend, the urologist. He ordered some blood tests and I went to see him. The examination was unremarkable and so were the laboratory results. My total testosterone was 440. He shrugged and said something along the lines of this is what I should expect, I was getting older, things didn't work as well, get used to it, and blah blah blah. He gave me a brochure on cock rings. By the way this was before the release of Viagra and related prescriptions. And those drugs enhance performance, not libido, of which mine was nonexistent.
I did not know what to do. For the first time in our marriage my wife began to wear pajamas, not nightgowns. She stopped wearing makeup, nail polish and dresses. She chopped off her beautiful long hair. Our communications were minimal, businesslike and barely cordial.
I bumped into you in the hospital parking lot. You took one look at me and asked me what was wrong. Rudely I said nothing, what are you talking about and hurried off. Luckily later that day some lucid thought occurred in my thick surgeon's skull and I called you up both to apologize for my behavior and to schedule a consultation.
I'd never seen a shrink before, professionally. Yet we were barely 7 minutes into the initial consultation when you asked me why I was not being treated for hypogonadism! I was taken aback, then said why would I be treated for hypogonadism with the testosterone level 440? Your reply and explanation, obviously colored with frustration and irritation at many of our colleagues, explicated that the psychiatric literature, for those who read it, has been increasingly on top of this issue for years. It seemed that many urologists and endocrinologists, those who followed the curve rather than set it-like you-simply went by the numbers without any clinical correlation. With a few more blood tests, a discussion of risk factors and the brief call with my internist I began testosterone gel. Mind you, all of this was being done without my wife's knowledge at the time. Showing her the blood results with a supposedly normal testosterone level did not give strong support to my " excuses."
Unfortunately the topical testosterone has an 11% failure rate. And I refreshed my biochemistry from medical school to remember that testosterone is metabolized into estradiol, estrogen. So, for a few months I slapped this goop on my abdomen every day. I knew that despite blood levels medical response could take as much as three months or more. In my case in three months I was a little more pudgy, had breast tenderness and obvious gynecomastia. At this point my wife decided I was a closet transsexual secretly taking female hormones preparatory to a sex change operation. Medical literature and drug package inserts were of zero benefit to a wife who felt rejected and whose husband had a limp penis and was growing breasts.
The internist with whom we had consulted recommended that I double the dose of transdermal testosterone. Thankfully you disagreed and recommended we move directly to the injectable depot testosterone (I thought i'd be in a B cup in 3 more months). I got the first shot at the internists office then gave myself the next two or three shots in the butt until I convinced my wife to do it for me as it was a bit awkward to look over my shoulder in the mirror and try to get the needle in the right place. She admitted later on that she thought it was all a bunch of hogwash but took upon herself the task of the injections because it gave her the opportunity to stick a sharp needle in my ass every week or so (ultimately we determined the best regimen to be every sixth day to maintain the most even testosterone levels; going beyond that period of time led to an excessive rise in estradiol and a grumpy, moody irritability equivalent to PMS!).
To bring this long letter to a conclusion let me say that the treatment worked and now so do I. Finally my wife accepts that I had a metabolic problem and not a mistress. As my metabolism improved so did my weight, energy, mood, and overall performance. Particularly my sexual performance much to the initial surprise and pleasure of my wife to the point that she accused me of being like a horny teenager. My response to that was to tell her to get used to it and that if it was a problem in any way we'd have to go check her hormone levels (which, by the way she did and she takes a tiny dose of testosterone and enjoys the benefits in every way).
I will add that one Saturday morning she returned after spending two days with her sister in Santa Barbara only to see the van from a charity pulling out of our driveway. She was a bit perplexed and asked me why they'd been here. Calmly I informed her that I had donated all of her pajamas, pants, jeans, sweat suits; essentially 90% of her wardrobe, shoes included. She began to become cross, then grinned mischievously and said that I would have to buy her a whole new wardrobe. I told her it would be my pleasure except I would pick out every single item and that she would try each one on for me and that we could spend as much time at the mall as she wanted. She grinned and said let's go now. I told her that I had purchased a few small items for tonight and tomorrow and that the shopping would commence tomorrow morning because she had a several hour salon/spa appointment and that they had been given very specific instructions about hair, make up, manicures and all those girl things and that she would have absolutely no say so about what was going to happen. She set her jaw, glowered at me and then she smiled and laughed. As it worked out we ended up a little bit late for that appointment but the delay was worth it.
I hope this letter helps you help more than just the patients you help in your office but the ones who read your blogs and struggle with these issues in other locales. Thanks again and all the best.
xxxxxx & xxxyyy