SEXUAL MEDICINE

 

This topic often receives short shrift in doctors' offices for various reasons, among which include privacy issues, embarrassments, and time constraints. No wonder people often turn to the internet for answers. Yet, those searches often lead to gross distortions, unregulated, illegitimate, and often expensive products, and insufficient results.

 

Among men, the most common problem is erectile dysfunction. Despite frequently aired commercials, this is not due to low testosterone. Indeed, one study of 1022 men with ED found only 4% below the age of 50 and 9% over the age of 50 had low testosterone. It appears that screening for low testosterone makes sense only in the group who complain of low desire or libido, not ED. In fact, in this latter group it's also important to screen for prolactin, a pituitary hormone that elevates in certain pituitary tumors and causes low testosterone.

 

There are important clues that assist with the diagnosis. Spontaneous erections during sleep or upon awakening attests to the integrity of the nerve reflexes and penile blood flow. An isolated sexual failure is more likely due to anxiety or alcohol, as opposed to someone after prostate cancer surgery. Headaches, visual field cuts, or gynecomastia warrant checking a few hormone levels. Diminished peripheral pulses suggest a vascular cause. And penile plaques suggest Peyronie's disease, a condition made famous by President Clinton.

 

Viagra/Cialis/Levitra drugs are very helpful for this condition, regardless of the cause, and certainly weight loss, exercise, and anxiety management are important adjuncts. Finally, erectile dysfunction can represent an early marker for cardiovascular disease and it would be important to look for and treat other risk factors for heart disease, as well.

 

Among women, 40 - 60% report sexual concerns, typically reduced libido, arousal, or associated pain with intercourse, or various combinations of those. It's not always easy to quantify those symptoms, since commonly they arise in the context of various relationship issues and reflect problems with limited communication and underlying conflicts. Besides various medical or physical problems, an important consideration is the use of anti-depressant drugs, due to side effects. Depression, anxiety, substance abuse, fatigue, obesity, and overwhelming stress are common contributors.

 

The women's health initiative, which included over 27,000 post-menopausal women, showed no heart benefit from taking estrogens, but also no sexual benefits. Yet, a woman with a previously satisfying sex life, presenting with new problems in association with the onset of hot flashes, night sweats, poor sleep, and resulting fatigue, would certainly be a good candidate for estrogens.

 

A common complaint has been termed hypoactive sexual desire disorder (HSDD). The largest randomized trial with testosterone in these post-menopausal women revealed rather modest results. For example, women receiving placebo patches noticed a 0.9 increase in events over baseline compared to those using testosterone patches, who noticed a 1.9 event increase over the course of one month. And having sex one more time a month is not much to write home about, especially when you consider the side effects of mild acne, facial hair growth, adverse lipid and liver blood tests, and the potential for breast lumps and even breast cancer, since testosterone gets metabolized in the blood to estrogen. Consequently, the FDA has not approved this treatment. And previously approved Estratest, a combination of estrogen and testosterone, was taken off the market in 2009, because of 'first pass through the liver' effects, when taken orally as a pill.

 

Nevertheless, the most commonly used option is 'off label' testosterone cream or patches, with or without estrogens, from compounding pharmacies. This should be avoided in pre-menopausal women due to the adverse effects on potential pregnancies. Viagra type drugs are not effective, unless used in conjunction with the offending anti-depressant medication. Though, in that case, a more reasonable option would be to switch to a different anti-depressant. For example, Wellbutrin, another anti-depressant, has shown some benefits with HSDD. DHEA is ineffective. Some web sites advertise Oxytocin as a nasal spray. This is a pituitary hormone which gets released following an affectionate hug. Though, there is no data to support that it works in reverse and makes you want to hug. Most importantly, since the FDA does not regulate any of these herbs and internet sold products, there is a high likelihood that the alleged ingredients are not even present in what they are selling you.

 

Finally, relationship research consistently finds increased libido and pleasure in new relationships. This is not to suggest that women should simply be advised to find new partners, but rather that they should be encouraged to bring novelty to their current relationships. In other words, expanding ones sexual repertoire seems to be a worthwhile endeavor. There are several books or other resources I could recommend, if you're interested.

 

Since I consider myself a kind of modern doctor, feel free to bring up any particular concerns you may have regarding these issues.