Sexual Healing by Dr. Margarita Kressin

After our determination that Joe (worth repeating here that all of my "patient" names and stories are made up) has erectile dysfunction, we then reviewed his medical history (he has mild blood pressure problems and pre-diabetes that is supposed to be diet controlled), surgical history (none), social history (used to smoke a pack per day, but quit 10 years ago). He is not following a diabetic diet and does not exercise. He does not take any medications.

We looked over to his wife and made sure that she is supportive and that she herself does not experience sexual issues. She thinks that their sexual relationship is very important and besides a slight decrease in libido she has no issues. She explains that once she and her husband get going, she does well.

We then focused on lifestyle changes for Joe, what he can do on his part to help his erectile function and prevent further deterioration. We then discussed all his options, from first line therapies (medications, intraurethral systems), second line therapies (injection, vacuum devices, surgeries). We discussed the pros and cons of each therapy, the side effects and possible complications (there is no free ride, no matter what we’d like to think, in medicine), and the benefits of one therapy versus another.

We outlined all of these and made certain recommendations depending on what he would use consistently, and something he and his wife can be comfortable with and incorporate into their sexual activity.

We also offered our sex therapist for sexual counseling (not marital counseling, a point that was important to make) to give them tips and educate them about their sensuality and sexuality. This could also potentially address other issues that we did not address from a medical standpoint. As I always point out — the brain is still the biggest sex organ (as much as Joe would like to think the penis is THE sex organ).

And I reminded them to be careful about what they see and hear in ads. Please do not use any herbal or supplement "medications" advertised on TV.  And yes, there are no guarantees. If there were, don't you think legitimate physicians would be using it already?

The biggest lesson Joe and his wife learned was that this was more about erectile dysfunction. It involved sexual health, a couple’s sexual function, and a myriad of therapies that he can choose from.

Kyle and Linda came to the clinic for an appointment. They are a young, attractive couple and the problem they have is actually a relatively common one.

Dr.: How can I help you guys?

Kyle: I can’t please her sexually.

Dr.: Are your erections good.

K.: Yes.

Dr.: Hard, and they last as long as you want?

K.: Well, it goes away after I ejaculate.

Dr.: That’s normal.

Linda then interjects: But he comes too fast. Whoop ... we’re done.

Dr.: Within what time frame?

L.: 30 seconds. I looked it up on the Internet (because women look things up in the Internet) and I think he has premature ejaculation. Is it something I’m doing? Is it me?

Dr.: OK. Kyle, were you able to hold it longer with other partners?

K.: No, not really. Maybe I could go a minute at most.

Dr.: That time period still falls under premature ejaculation. You have what is called lifelong premature ejaculation. It is a fairly common condition occurring between 5 percent and 40 percent of sexually active men (Int J of Psychitr Med 1992). We think that there is actually a higher incidence in adolescents and young adults.

L.: Kyle has been my only partner. What is considered normal?

Dr.: One study that included five countries, using a stopwatch, showed most men ejaculate within 5.5 minutes. This is what we call IELT or intravaginal ejaculation latency time. Most men with PE ejaculate within a minute (0.9 min actually). And, Linda, it is not your fault, there is nothing you are doing that is causing this. The best thing you can do as a partner is be supportive as Kyle works through this.

K.: Is there something we can do?

Dr.: A standard approach is making sure you don’t have any physical and medical issues and also participating in cognitive and behavioral therapy. I will give you a name of a sex therapist and we will check and make sure you don’t have an underlying condition that may be the cause or contributing to this. And recently there have been some medications that we can try to see if we can work on prolonging your IELT. Let’s begin …

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Andrew R. McCullough, MD, director of Male Sexual Health, Fertility and Microsurgery at the NYU Medical Center showed that men classified with probable premature ejaculation self-reported:

• poor control over ejaculation (50%)
• low satisfaction with sexual intercourse (23%)
• low satisfaction with sexual relationship (30%)
• low interest in actually having sexual intercourse (28%)
• difficulty in becoming sexually aroused (34%)
• difficulty relaxing during intercourse (31%)

Joe and his wife came to the our clinic, somewhat reluctantly. They have been having some issues in the bedroom.

Do you still get erections? I asked.

Yes!! Joe answered quickly. Then he turned to his wife, Don’t I?

Yeeeeeahhhhhhh? She answered.

Well….

I then asked the questions which let me know better whether he really is getting erections.

Do you get morning erections?

There is an Erection Hardness Scale:

0 — no erections at all
1 — some penile swelling
2 — gets hard, but not enough for penetration
3 — gets hard, and enough for penetration
4 — gets very hard

What number are you?
Does your erection last as long as you and your wife want it to?

He also filled out a SHIM questionnaire — a five item questionnaire that quantifies sexual function.

Here's a definition:
www.prostate-cancer.org/resource/gloss_s.html

And here's a link to the test:
http://www.urologychannel.com/HealthProfiler/healthpro_ed.shtml


A score of 21 or less means that erectile dysfunction (ED) needs to be addressed.

Joe’s score was 19.

Joe has ED.

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

It is my practice to measure testosterone levels on all my patients presenting with erectile dysfunction. We know that testosterone is needed for all sexual function from libido to erection to orgasm. Here I present evidence on the role of testosterone on erectile function. I will also address the claims that testosterone does not affect mood or energy levels or their bodies.

According to the article:

“... there is so little evidence to back up the claim that supplements … help men 45 and older buck up their sex lives, moods, energy levels or bodies.”

Here are some studies for you to consider.

Testosterone and sex lives:

Erectile dysfunction and testosterone deficiency.
Blute M, Hakimian P, Kashanian J, Shteynshluyger A, Lee M, Shabsigh R
Frontiers of Hormone Research. 37:108-22, 2009

Testosterone replacement alone in hypogonadal men can restore erectile function. A significant proportion of men who fail to respond to a PDE5 inhibitor are testosterone deficient. Testosterone replacement therapy can convert over half of these men into phosphodiesterase type 5 responders. It is now recommended that testosterone levels should be assessed in all patients with erectile dysfunction.

Endothelial effects of drugs designed to treat erectile dysfunction.
Aversa A, Caprio M, Rosano GM, Spera G
Current Pharmaceutical Design. 14(35):3768-78, 2008

… endothelial dysfunction is present in testosterone deficiency syndromes and replacement therapy is able to revert ED and to improve endothelial function.

Testosterone and mood

Effects of Testosterone Replacement in Middle-Aged Men With Dysthymia: A Randomized, Placebo-Controlled Clinical Trial
Seidman, Stuart N. MD; Orr, Guy MD; Raviv, Gil MD; Levi, Rachel BA; Roose, Steven P. MD; Kravitz, Efrat BSc; Amiaz, Revital MD; Weiser, Mark MD
Journal of Clinical Psychopharmacology
Issue: Volume 29(3), June 2009, pp 216-221

Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Comparison of long-acting testosterone undecanoate formulation versus testosterone enanthate on sexual function and mood in hypogonadal men.
Jockenhovel F., Minnemann T., Schubert M., Freude S., Hubler D., Schumann C., Christoph A., Ernst M.
European Journal of Endocrinology. 160(5):815-9, 2009 May.

Among the 12 items of subjective mood assessment, agitation, self-confidence, activation, good mood and concentration showed a significant improvement during the treatment and further significant improvement during follow-up with TU treatment. The other items, i.e. sociability, listlessness, dizziness, depression, fatigue, anxiety, and aggressivity, improved too, but not significantly. This tendency was the same during the follow-up with treatment with TU.

Partial androgen deficiency, depression and testosterone treatment in aging men.
Amore M, Scarlatti F, Quarta AL, Tagariello P
Aging-Clinical & Experimental Research. 21(1):1-8, 2009 Feb

Abstract: This study provides a critical review of the literature on depressive symptoms of partial androgen deficiency (PADAM) and their treatment with Testosterone (T). PADAM in aging males is responsible for a variety of behavioral symptoms, such as weakness, decreased libido and erectile dysfunction, lower psychological vitality, depressive mood, anxiety, insomnia, difficulty in concentrating, and memory impairment. The psychological and behavioural aspects of PADAM may overlap with signs and symptoms of major depression. Evidence of the relationship between androgen deficiency and male depression comes from studies that have assessed depression in hypogonadal subjects, the association between low T level and male depressive illness, and the antidepressant action of androgen replacement.

Although data derived from androgen treatment trials and androgen replacement do not support T treatment or replacement as more efficacious than placebo for major depressive disorder (MDD), the clinical impression is that, in some sub-threshold depressive syndromes, T may lead to antidepressant benefits.

Testosterone and bodies:

Low bone density and high percentage of body fat among men who were treated with androgen deprivation therapy for prostate carcinoma.
Chen Z, Maricic M, Nguyen P, Ahmann FR, Bruhn R, Dalkin BL.
Cancer. 2002;95: 2136 –2144

Chen et al (2002) investigated the effect of androgen deprivation (removing testosterone) on total body fat mass after 1–5 years of treatment in 62 men with prostate cancer. There was a significant increase in total body fat mass and reduction in lean body mass.

Effects of Testosterone Administration on Fat Distribution, Insulin Sensitivity, and Atherosclerosis Progression
Shalender Bhasin
Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine Science, University of California — Los Angeles School of Medicine
Clinical Infectious Diseases 2003;37:S142–S149

In spite of the widespread belief that testosterone supplementation increases the risk of atherosclerotic heart disease, evidence to support this premise is lacking. Although supraphysiological doses of testosterone, such as those used by athletes and recreational body builders, decrease plasma high‐density lipoprotein (HDL) cholesterol concentrations, replacement doses of testosterone have had only a modest or no effect on plasma HDL in placebo‐controlled trials. In epidemiological studies, serum total and free testosterone concentrations have been inversely correlated with intra‐abdominal fat mass, risk of coronary artery disease, and type 2 diabetes mellitus. Testosterone administration to middle‐aged men is associated with decreased visceral fat and glucose concentrations and increased insulin sensitivity. Testosterone infusion increases coronary blood flow. Similarly, testosterone replacement retards atherogenesis in experimental models of atherosclerosis.

Testosterone and growth hormone improve body composition and muscle performance in older men.
Sattler FR., Castaneda-Sceppa C., Binder EF., Schroeder ET., Wang Y., Bhasin S., Kawakubo M., Stewart Y., Yarasheski KE., Ulloor J. Colletti P., Roubenoff R., Azen SP.
Journal of Clinical Endocrinology & Metabolism. 94(6):1991-2001, 2009 Jun.

Supplemental testosterone produced significant gains in total and appendicular lean mass, muscle strength, and aerobic endurance with significant reductions in whole-body and trunk fat.

The management of hypogonadism in aging male patients.
Sharma V, Perros P
Postgraduate Medicine. 121(1):113-21, 2009 Jan

Several studies indicate that testosterone replacement therapy may produce a wide range of benefits for men with hypogonadism, including improvement in libido, bone density, muscle mass, body composition, mood, and cognition.

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The Journal Sentinel's claims that "one key problem is that there is a lack of scientific evidence that men over the age of 45 benefit from taking testosterone" is simply untrue. I have presented numerous articles in these posts, all based on scientific and medical research and publications disclaiming their assertion. It is unfortunate that patients are misguided by these articles. Patients should be cautious of what they read in the newspapers and they should always consult their physicians regarding their care and what they read before acting on their own.

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The following is feedback received for this blog: Dr. K - Thanks for writing this rebuttal on that article. Do you know if middle-aged men can do something to increase T without having the actual hormone injections? Something "natural?" - Don Despite claims that the benefits of testosterone replacement therapy aren't supported by research, I have all the evidence I need. I use it myself and, believe me, it works. A daily dose of Testim 1% has significantly improved my sex drive and sexual function. It has given me a sense of mental clarity and accuity that many 50-something men seem to lack. It has dramatically raised my energy level and helped me to add lean muscle mass instead of fat. It may not be the fountain of youth, but it has improved the quality of my life, and that's good enough for me. - Kiernan B. Don, Yes, there have been studies that show increasing muscle mass can increase testosterone production. So start exercising and pumping iron! - Dr. Kressin

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html


So the article also claimed that

“concerns that it may increase … cardiovascular disease”

Here I present articles published (364 articles matched), most of them within the last 9 months disputing this point. I didn’t have to go beyond the first page of my medline search to get these:

Endogenous testosterone and the prospective association with carotid atherosclerosis in men: the Tromsø study
Vikan T. Johnsen SH. Schirmer H. Njolstad I. Svartberg J. European Journal of Epidemiology. 24(6):289-95, 2009.

In the cross-sectional study, we found an inverse association between testosterone levels and total carotid plaque area (P < 0.05), after adjusting for age, systolic blood pressure, smoking and use of lipid-lowering drugs.

Androgens and cardiovascular disease.
Liu PY, Death AK, Handelsman DJ
Endocrine Reviews 2003 Jun;24(3):313-40

Observational studies show that blood testosterone concentrations are consistently lower among men with cardiovascular disease, suggesting a possible preventive role for testosterone therapy, which requires critical evaluation by further prospective studies. Short-term interventional studies show that testosterone produces a modest but consistent improvement in cardiac ischemia over placebo, comparable to the effects of existing antianginal drugs.

Reduced testosterone levels in males with lone atrial fibrillation.
Lai J, Zhou D, Xia S, Shang Y, Want L, Zheng L, Zhu J
Clinical Cardiology. 32(1):43-6, 2009 Jan

Mean levels of testosterone were significantly lower in subjects with lone atrial fibrillation when compared with controls (476 ng/dl versus 514 ng/dl, p = 0.005). CONCLUSION: Reduced testosterone levels may be associated with susceptibility to lone atrial fibrillation in men.

The dark side of testosterone deficiency: I. Metabolic syndrome and erectile dysfunction. [Review] [121 refs]
Traish AM. Guay A. Feeley R. Saad F.
Journal of Andrology. 30(1):10-22, 2009 Jan-Feb.

The metabolic syndrome (MetS) is considered the most important public health threat of the 21st century. This syndrome is characterized by a cluster of cardiovascular risk factors including increased central abdominal obesity, elevated triglycerides, reduced high-density lipoprotein, high blood pressure, increased fasting glucose, and hyperinsulinemia.

Central or abdominal obesity, measured as WC, is a classical feature of MetS and is associated with reduced total testosterone levels (Pasquali et al, 1997; Svartberg et al, 2004a,b, 2007; Osuna et al, 2006).

Other studies have confirmed the significant inverse correlation between total T and obesity (Pasquali et al, 1991; Laaksonen et al, 2003; Kalyani and Dobs, 2007). Therefore, men with visceral obesity are in a vicious cycle as T deficiency leads to reduced lipolysis, reduced metabolic rate, visceral fat deposition, and insulin resistance.

The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. [Review] [99 refs]
Traish AM. Saad F. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Low testosterone precedes elevated fasting insulin, glucose, and hemoglobin A1c (HbA1C) values and may even predict the onset of diabetes. Treatment of prostate cancer patients with surgical or medical castration exacerbates insulin resistance (IR) and glycemic control, strengthening the link between testosterone deficiency and onset of type 2 diabetes (T2D) and IR. Androgen therapy of hypogonadal men improves insulin sensitivity, fasting glucose, and HbA1c levels. We suggest that androgen deficiency is associated with IR, T2D, MetS, and with increased deposition of visceral fat, which serves as an endocrine organ, producing inflammatory cytokines and thus promoting endothelial dysfunction and vascular disease.

The dark side of testosterone deficiency: III. Cardiovascular disease. [Review] [99 refs]
Traish AM. Saad F. Feeley RJ. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Androgen deficiency is associated with increased levels of total cholesterol, low-density lipoprotein, increased production of proinflammatory factors, and increased thickness of the arterial wall and contributes to endothelial dysfunction. Testosterone supplementation restores arterial vasoreactivity; reduces proinflammatory cytokines, total cholesterol, and triglyceride levels; and improves endothelial function but also might reduce high-density lipoprotein levels.

And finally a few others in summary:

• Diaz-Arnjonilla, et al Intl J of Impot Res 2009 —
  
  • Low T in obese men
  • Lot T in men with metab syn and DM
  • BMI inv propor to serum total T
• Schandt et al Current Opinion in Urology 2009 — Link of androgen deprivation therapy in prostate cancer to development of metabolic syndrome
• Corona et al J of Sex Med 2008 — Low levels of androgens in men with erectile dysfunction and obesity
• Dandona P et al Postgrad Medicine 2009—
  • Hypogonadotropic hypogonad seen in DM2 is assoc with obesity but not duration of DM2
  • 1/3 of DM2 have low T