In Our Prime (30 page)

Nicholas DiNubile, an orthopedic surgeon at the Hospital of the University of Pennsylvania, is the other vice president. A sports medicine
specialist, DiNubile counts among his patients towering players from the Philadelphia 76ers and willowy dancers from the Pennsylvania Ballet. It was the middle-aged clerks, salesmen, and lawyers who limped into his office after a weekend of tennis, soccer, or a prolonged workout at the gym, however, who pushed the doctor into middle age medicine. These patients were demanding help for a whole series of injuries that had not traditionally been associated with the 40-plus crowd. Knee and hip replacements, cartilage tears, ligament damage, stress fractures, tendonitis, arthritis, bursitis—what DiNubile calls “fix-me-itis” and ultimately named (and trademarked) “boomeritis.”

“The number one reason people go to the doctor is musculoskeletal problems,” he told the crowded hall. “Our frame is failing us because we're aging.” In DiNubile's view, a good deal of the physical decline that has long been associated with age can be blamed on a La-Z-Boy lifestyle. “You have some control over aging's time clock,” he said. “You can change the aging curve.” Researchers believe that lack of use accounts for about half the functional losses that usually occur between the ages of 30 and 70, with some claiming that exercise in middle age can set the clock back by as many as twenty-five years.

Like Maroon, he knows that medical advances can have as much to do with scientific breakthroughs as with consumer demand. “
Boomers are the first generation
that grew up exercising, and the first that expects, indeed demands, that they be able to exercise into their 70s,” DiNubile has said. “But evolution doesn't work that quick. Physically, you can't necessarily do at 50 what you did at 25. We've worn out the warranty on some body parts. That's why so many boomers are breaking down. It ought to be called Generation Ouch.”

The rising number of such sports-related injuries among middle-aged Americans is altering medical practices, from prognoses to interventions. “
When I first started practicing
, ACLs had a cut-off at 40,” he said, referring to operations that reconstruct the knee's anterior cruciate ligament. “Now 60-year-olds get it. They want to keep skiing moguls.” This motivated surgeons to develop less invasive procedures like arthroscopy and pharmaceutical companies to develop new instruments. An ACL surgery used to mean being in a cast for six weeks, with a stiff knee and a long
rehabilitation afterward. Today, the operation can be done with a small incision and a short rehab. Other common sports-related operations, like rotator cuff or complex elbow and ankle repairs, which were once limited to patients 40 or younger, have similarly become commonplace for the middle-aged. That is a great boon for people in midlife.

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.

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 marketing 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.

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.