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Addyi: Information for Healthcare Providers

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New Penile Implant Type Could Benefit Men with ED

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Testosterone Replacement Therapy Rarely Prescribed for Hypogonadal Men

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Delayed Ejaculation: Could Anandamide Help?

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Defining and Treating Premature Ejaculation

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Suicide Risk among Genitourinary Cancer Patients

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Testosterone Controversy Continues

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Vaginal Electrical Stimulation

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Understanding Diabetic Neuropathy and Erectile Dysfunction

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Restless Genital Syndrome and Restless Leg Syndrome

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Making Pelvic Examinations Easier For Women

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Estrogen, Metabolic Syndrome, and Erectile Function

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Seed Brachytherapy and Erectile Function

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Peyronie’s Disease and Erectile Dysfunction

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ED Drugs Before and After Prostate Cancer Diagnosis

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Erection Hardness Score

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Motivations for Labial Reduction Surgery

Motivations for Labial Reduction SurgeryJackie took a deep breath and told her gynecologist that she wasn’t happy with her labia.

“They’re not normal,” she said. “They hang down too far and my boyfriend is grossed out. And I don’t go swimming anymore because when I wear a bathing suit, you can totally tell.”

Her doctor examined the area and explained that there are lots of variations in women’s labia. Some are just bigger than others.

“Yeah, but aren’t mine too big? Don’t you think I should have that surgery?”

The surgery Jackie is referring to is labial reduction surgery or labiaplasty, a procedure that has become more popular in recent years. While some women want smaller labia, the surgery can also involve reshaping them or making one labium symmetrical with the other.

What compels women to have this delicate, intimate surgery? A recent study in Sexual Medicine investigated women’s motivations.

Dr. Sandra Zwier of the University of Amsterdam reviewed four online communities of British, Dutch, and American women who discussed reduction of the labia minora – the inner “lips” of the labia. She also examined the websites of 40 providers of labiaplasty

She found that women were more likely to discuss emotional reasons for wanting the surgery when sharing with the online communities. Some said they felt “freakish.” For example, one woman remarked, “I hate mine, hate, hate it! It's like a tongue sticking out for heaven’s sake!”

Some online community members said they felt ashamed of their labia and worried that they would be ridiculed or rejected by a sexual partner. Others noted that they would feel better with more attractive labia and that having the surgery would help them enjoy sex more on an emotional level.

Providers’ websites were more likely to report functional reasons for having labiaplasty. Some women with larger labia had pain during sex or while exercising. Others had discomfort when their labia rubbed against clothing.

Both emotional and functional reasons were recently expressed in messages left on the website of “Embarrassing Bodies,” a British television program. This reality show focuses on medical conditions that might be awkward to discuss. (This website and these messages were not part of Dr. Zwier’s research.)

My labia is very large and dangles down. Every 2 months without fail I get a cut on my labia due to constant rubbing. It is very painful when i have to go for a wee. I literally have to use plastic disposable gloves and pee on my hand. I have recently been to my doctor to speak about this cause it constantly gets me down. (Charmaine, May 1, 2014)

I'm a 14 year old girl in the U.S. My labias are fairly large and hang too ever since I was little. I'm very self-conscious about it and worry in gym while changing. (Colette, April 29, 2014)

I'm 13 and I have this problem, I get asked to send pics a lot and never once have I because I'm afraid they'll make fun of me. I tried to get the surgery not only for confidence but for pain when peeing and the lady at the hospital was very rude about it, on my way out I heard her laughing at me :( (Juliet, May 6, 2014)

Should your patients have labial reduction surgery? Before answering that question, consider their motivations. Do larger labia affect their sexual function? Their physical comfort? Their self-confidence? Do they feel that smaller labia are “normal” or “ideal”? What expectations do they have of surgery? Are they realistic?

Considering these questions, along with guidance from their gynecologist and/or therapist, can help patients with this important decision.

Print this article or view it as a PDF file here: Motivations for Labial Reduction Surgery


ABC News

Moisse, Katie

“ ‘The Doctors’ Feature Labia Reduction Surgery”

(November 21, 2011)

British Society for Paediatric & Adolescent Gynaecology

“Labial Reduction Surgery (Labiaplasty) On Adolescents”

(Position Statement. October 2013)

Embarrassing Bodies - (UK)

“Enlarged Labia”


Beasley, Deena

“U.S. gynecologists alarmed by plastic surgery trend”

(August 25, 2012)

Sexual Medicine

Zwier, Sandra, PhD

“ ‘What Motivates Her’: Motivations for Considering Labial Reduction Surgery as Recounted on Women’s Online Communities and Surgeons’ Websites”

(Full-text. First published online: January 25, 2014)


“Vaginoplasty and Labiaplasty”

(Reviewed: March 26, 2013)

Possible Causes of Early Onset Erectile Dysfunction (ED)

Possible Causes of Early Onset EDWe often associate erectile dysfunction (ED) with older men and for logical reasons. After all, erection problems become more common as men age, especially as they develop age-related conditions like diabetes and cardiovascular disease.

However, younger men develop ED, too. And the causes for this population might be different from those affecting their older counterparts.

To understand such causes, it’s helpful to review the physiology of erection. When a man is sexually stimulated, smooth muscle tissue relaxes and arteries expand, allowing the penis to fill with blood. Once this occurs, smooth muscle tissue works to trap the blood in the penis until the stimulation ends or the man ejaculates. This “trapping” is called veno-occulsion.

Some men develop ED because they have problems with the arterial inflow. For example, the may have atherosclerosis, or hardening of the arteries, which impairs the flow of blood in to the penis.

Over the last decade or so, endothelial dysfunction, considered a precursor to atherosclerosis, has been linked to ED. Endothelial dysfunction involves the endothelium – the lining of blood vessels. Problems with the endothelium can also restrict blood flow to the penis.

But do younger men with ED tend to have arterial inflow problems and endothelial dysfunction? Scientists from UCLA decided to take a closer look at this question and published their results last fall in the International Journal of Impotence Research.

Their study involved 23 patients between the ages of 18 and 49. All of the men had had ED for at least six months. Their average age was 33 years. Each man had a duplex ultrasound scan of his penis.

The researchers found abnormal arterial responses in just 4 – 13% of the men, depending on the criteria used. Based on these data, they suggested that most cases of ED in younger men are not the result of problems with penile arteries.

They added that when their patients described their erectile difficulties, most said they had trouble keeping an erection after it started. “This inability to maintain an erection once the erection has occurred is clinically very suggestive of [cavernosal veno-occlusive dysfunction (CVOD)] rather than an arterial inflow issue.” Another term for CVOD is “venous leakage.”

“The conclusion from these observations is that the arterial system does not seem to be severely impacted in young men who present with ED, and as such does not appear to be the primary cause of ED in this age group,” they wrote, adding that their data suggest “that if there is going to be a vascular component in this age group, it is most likely going to reside on the veno-occlusive side.”

Why might this happen? It could be related to aging, the researchers said. It might also be explained by genetics.

They suggested that clinicians should not be so quick to blame ED on endothelial dysfunction. Past research has usually involved men over age 50 and men with hypertension and diabetes, which makes the connection to endothelial dysfunction more prominent. But for men younger than 50, the role of corporal smooth muscle tissue should be considered as well, the authors noted.

Print this article or view it as a PDF file here: Possible Causes of Early Onset ED


International Journal of Impotence Research

Rajfer, J., et al.

“Early onset erectile dysfunction is usually not associated with abnormal cavernosal arterial inflow”

(Full-text. November/December 2013)

Ospemifene for Vulvar and Vaginal Atrophy

Ospemifene for Vulvar and Vaginal AtrophyJust over a year ago, the U.S. Food and Drug Administration (FDA) approved ospemifene, marketed under the name Osphena, for postmenopausal women experiencing moderate to severe dyspareunia (painful intercourse).

When a woman’s estrogen levels drop at menopause, cellular changes occur in her vulvar and vaginal tissues. This can lead to a condition called vulvar and vaginal atrophy (VVA). VVA is estimated to affect about 60% of women.

For women with VVA, vaginal tissues become drier and less flexible. There may be an increase in vaginal pH. The vagina can also narrow and shorten, especially if a woman doesn’t have sex regularly.

The result can be irritation, burning sensations, and vaginal discharge. Intercourse may become painful, as there is less vaginal lubrication and greater risk of tearing and bleeding.  

VVA symptoms usually do not get better without treatment. Typical therapies include systemic hormone therapy, vaginal estrogen products, and nonhormonal lubricants and moisturizers that can be purchased over the counter. However, some women cannot take estrogen-based products or prefer not to.

Ospemifene offers postmenopausal women an alternative to estrogen treatments for VVA. Taken as a pill once daily with food, the drug acts like estrogen to keep vaginal tissues healthy and elastic.

Last fall, Chinese researchers published a study in the Journal of Sexual Medicine that examined the efficacy and safety of ospemifene in treating painful sex in postmenopausal women with VVA. Today, we’ll take a closer look at this research.

The Study

The researchers performed a meta-analysis of six randomized controlled trials that compared ospemifene with a placebo. Taken together, the studies involved almost 1,800 postmenopausal women. Three studies were considered short-term, lasting for twelve weeks. The other three were long-term, covering a 12-month period.

Studies were rated as A, B, and C according to their quality, as deemed by the researchers. Studies labeled A were considered the highest quality, with those labeled C considered poorer quality. The studies analyzed here were classified as A or B.

The researchers found that when compared to placebo, ospemifene significantly decreased vaginal pH levels and reduced vaginal pain during intercourse. In the short term studies, women taking ospemifene reported more adverse effects, but these did not appear to affect discontinuation rates.

Endometrial Concerns

Both short-term and long-term studies found greater increases in endometrial thickness for women taking ospemifene compared to those taking the placebo, although the authors called these increases “negligible.”

Still, this concern has been addressed by the FDA, which issued a “boxed warning” with the drug’s approval.

The endometrium refers to the lining of the uterus. In menstruating women, the endometrium naturally thickens once a month to prepare for a possible pregnancy. If no pregnancy occurs, the endometrium “sheds” and leaves the body during a woman’s period.

In postmenopausal women, it is not normal for the endometrium to thicken. Women taking ospemifene should see their healthcare professionals if they have any unusual bleeding, as this can be a sign of endometrial cancer.

Ospemifene may also increase the risk of strokes and blood clots.

Is Ospemifene Right For Your Patients?

The study authors concluded, “This meta-analysis indicates ospemifene to be an effective and safe treatment for dyspareunia associated with postmenopausal VVA.” But is it right for your patients?

It could be. Before recommending any medication, it’s important to assess a woman’s overall health and consult prescribing information.

However, it’s very possible that ospemifene could help make sex more comfortable for postmenopausal patients suffering from VVA.

Print this article or view it as a PDF file here: Ospemifene for Vulvar and Vaginal Atrophy


The Journal of Sexual Medicine

Cui, Yuanshan, MD, et al.

“The Efficacy and Safety of Ospemifene in Treating Dyspareunia Associated with Postmenopausal Vulvar and Vaginal Atrophy: A Systematic Review and Meta-Analysis”

(Full-text. First published online: November 23, 2013)

The North American Menopause Society

“Changes in the Vagina and Vulva” (Shionogi Inc.)

“Important Safety Information”

Sexual Medicine Society of North America

“Osphena Approved to Treat Painful Sex”

(April 9, 2013)

“Vulvar and Vaginal Atrophy”

(June 26, 2013)

U.S. Food and Drug Administration

“FDA approves Osphena for postmenopausal women experiencing pain during sex”

(News release. February 26, 2013)

Testosterone Concerns

As a healthcare professional, you’ve no doubt heard the buzz about testosterone and “low T.”

Testosterone ConcernsIt’s normal for men’s testosterone levels to decline as they age. This decline leaves some men feeling run down and depressed. They may lose interest in sex and develop erectile problems.

It may be easy to suggest that low testosterone is the culprit. Testosterone is widely marketed and often touted as an elixir that can return youth and vitality to the middle-aged man.

Certainly there are benefits to testosterone therapy. It can improve muscle power and bone mineral density. For some men, mood, libido, and erectile function get better as well.

But testosterone therapy is not appropriate for every man. If your patients are thinking about taking testosterone, several concerns should be addressed:

  • Testosterone therapy may not be needed. Symptoms such as fatigue, decreased sex drive, depression, and erectile dysfunction could very well signal testosterone deficiency. But these symptoms might be explained by other conditions, too. It’s important for patients to have a thorough examination before testosterone is prescribed. Also, some symptoms may be alleviated through lifestyle changes, like improved diet and exercise, making testosterone treatment unnecessary.
  • Testosterone therapy may have risks. At the end of January 2014, the U.S. Food and Drug Administration (FDA) announced its plans to investigate the safety of FDA-approved testosterone products. This decision came after two studies raised the agency’s concern. The first study, published in the Journal of the American Medical Association (JAMA) in November 2013, found increased risk of heart attack, stroke and death among men who took testosterone after coronary angiography. The second, which appeared two months later in PLOS One, found that heart attack risk increased for men aged 65 and older and for men younger than 65 with a history of heart disease. (Younger men with no history of heart disease were not at increased risk.)
  • Study funding may skew results, making them difficult to interpret. In a Medscape slideshow presentation, Dr. Charles Vega of the University of California, Irvine points out that half of the clinical trials examining cardiovascular events and testosterone have been sponsored by the pharmaceutical industry. In sponsored trials, the rate of cardiovascular events is 4%. In non-sponsored trials, the rate is 8%.
  • Men may try over-the-counter testosterone products, which can be risky. Some men feel embarrassed to discuss their symptoms with a physician, especially if they’re having sexual problems. They may see advertisements for testosterone products or hear about them from friends. Ordering such products online or picking them up at the drugstore may seem like a good way to avoid going to the doctor. But over-the-counter products are not always what they seem. They may include ingredients that aren’t listed on the label. These ingredients may cause dangerous interactions with drugs the man is already taking. Over-the-counter supplements are not regulated by the FDA. In the United States, testosterone is a controlled substance and illegal to sell without a prescription. (For more details on the risks of over-the-counter testosterone supplements, please click here.)

So who should take testosterone and how should therapy be managed?

Dr. Vega makes the following suggestions:

Only symptomatic men should be evaluated for possible [testosterone deficiency], and [testosterone deficiency] should not be diagnosed without 2 morning testosterone levels that are unequivocally low. Serum testosterone levels should be reevaluated 3-6 months after the initiation of testosterone treatment, with the goal of achieving serum testosterone levels in the mid-normal range. [Testosterone therapy] should be prescribed only for men who truly need it, and these men require close follow-up to ensure that treatment goals are met and to avoid overtreatment. Caution is warranted in recommending [testosterone therapy] to men at high [cardiovascular] risk.

Testosterone therapy can do a lot of good. But it’s important to consider it in full context.

Print this article or view it as a PDF file here: Testosterone Concerns



Black, Henry, MD

“When Men Want Testosterone, Show Them the Evidence”

(January 24, 2014)

Vega, Charles P., MD

“Putting the ‘T’rouble in Testosterone Therapy?”

(January 30, 2014)

Vega, Charles P., MD

“‘T’errific or ‘T’errible? A Review of Testosterone Deficiency”

(Slideshow. February 18, 2014)

Sexual Medicine Society of North America

“FDA to Review Safety of Testosterone Therapy”

(February 12, 2014)

“Marketing Low Testosterone”

(May 29, 2013)

“Risks and Realities of OTC Testosterone Supplements”

(April 9, 2013)

Testosterone Gel and BMI

If your patients or clients include older men, it’s likely that some have low testosterone (also called hypogonadism). Testosterone is an important hormone for men. It’s responsible for secondary sex characteristics like facial hair and a deepening voice. It also contributes much to a man’s sex life.

Testosterone levels naturally decline as men age. Some experts call this andropause and liken it to the estrogen decreases associated with female menopause, although this comparison is not entirely accurate. Testosterone declines for men tend to be more subtle than the estrogen declines in women.

Still, low testosterone can be troublesome. Men may feel fatigued and weak. They may lose muscle mass and gain body fat. And they often develop sexual problems, such as low sex drive and erectile dysfunction.

Some men replenish their testosterone through a prescription testosterone 2% gel. However, the effects of body mass index (BMI) on this type of therapy have not been widely studied.

New Research

In November 2013, the Journal of Sexual Medicine published a study by American researchers who examined the issue. They worked with 149 men between the ages of 18 and 75 who had baseline testosterone levels below 250/300 ng/dL. (According to the U.S. National Institutes of Health, a range of 300 – 1,000 ng/dL is considered normal.)

The men were divided into three groups based on their baseline BMIs. Tertile 1 included men with BMIs less than or equal to 29.1 kg/m2. The BMIs of men in Tertile 2 ranged from 29.2 to 32.4 kg/m2. Men in Tertile 3 had BMIs greater than 32.4 kg/m2).  The mean ages for the men in Tertiles 1, 2, and 3 were 52.9, 54.0, and 54.2, respectively.

Each man used a testosterone 2% gel for 90 days. The gel was applied to the front and inner thigh. If needed, the dosage could be adjusted at specified points during the study.

After 90 days, the researchers found that 79.1% of the men in Tertile 1, 79.5% of the men in Tertile 2, and 73.8% of the men in Tertile 3 had testosterone levels in the normal range. Men with BMIs greater than 32.4 kg/m2 needed higher doses of testosterone to reach this goal, however.

The researchers found that the treatment was generally well tolerated, even for men who had increased doses. The most common adverse events were skin reactions, upper respiratory infections, and sinusitis.

Using Testosterone With Care

If you have a patient considering testosterone gel therapy, here are a few points to keep in mind:

·         Therapy should be conducted under a doctor’s care. Only a qualified physician can determine the proper dose of testosterone for that individual patient. A doctor can also do a thorough examination to determine whether a man’s symptoms are indeed cause by low testosterone or whether other factors are involved.

·         Men should be cautioned about over-the-counter testosterone supplements, which are widely marketed. Again, testosterone therapy should be done under a physician’s guidance. Over-the-counter preparations can be risky. (Click here to learn more about these risks.)

·         Men using a testosterone gel should follow the doctor’s instructions carefully and read the accompanying medication guide. The application area should be covered to avoid transferring the gel to others, especially women and children. This guide, provided by the U.S. Food and Drug Administration, provides more information on the proper use of testosterone gel.

For More Information

We provide comprehensive information on low testosterone here. Your colleagues and managers may also provide details relevant to your particular clinical site.

Print this article or view it as a PDF file here: Testosterone Gel and BMI


The Journal of Sexual Medicine

Dobs, Adrian, MD, et al.

“Testosterone 2% Gel Can Normalize Testosterone Concentrations in Men with Low Testosterone Regardless of Body Mass Index”

(Full-text. First published online: November 28, 2013)

Medline Plus


(Page updated: March 22, 2012)

Sexual Medicine Society of North America

“Risks and Realities of OTC Testosterone Supplements”

(April 9, 2013)

U.S. Food and Drug Administration

“Testosterone Gel”

(Medication guide. February 2012)

Traction Therapy for Peyronie’s Disease

Do you work with men who have Peyronie’s disease? If so, they might be considering non-surgical treatment options. One is traction therapy and a recent Journal of Sexual Medicine study has shown some encouraging results.

Peyronie’s Disease – Some Basics

First, however, let’s go over some basics about Peyronie’s disease. It’s thought to stem from a penile injury that does not heal properly. Such an injury could happen during sports or vigorous intercourse, but sometimes, a man doesn’t even know that he has injured his penis.

For men with Peyronie’s disease, areas of hardened scar tissue called plaques form below the skin’s surface. These plaques cause the penis to lose some of its flexibility and bend.

Peyronie’s disease occurs in two stages. In the acute phase (the first 6 to 18 months), the plaques form and the penis curves. Many men experience pain, erectile dysfunction (ED), and penile shortening. Intercourse may become difficult.

In the chronic stage, the disease becomes more stable. Usually, the curve doesn’t worsen, but men still can still have problems with ED and intercourse.

Significant emotional distress can also occur during each stage.

Treatment for Peyronie’s disease depends on its severity. For some men, the situation resolves on its own or the curve is not bothersome. For others, the curve is so severe that they cannot have intercourse at all. These men may consider surgical treatment once the disease reaches the chronic stage.

What is Traction Therapy?

Men who undergo traction therapy for Peyronie’s disease wear a medical device specifically designed to gently pull the penis in the opposite direction of the curve.

A recent study by Spanish researchers found that this technique had good results for men in the acute stage of Peyronie’s disease.

Fifty-five patients (mean age 50) underwent traction therapy using the Andropeyronie device, a commonly used brand. A control group of 41 patients (mean age 48) had no intervention. All of the men had acute-state Peyronie’s disease.

The men receiving traction therapy were instructed to wear the device for at least six hours a day, but no longer than nine hours. Patients were also told to remove the device for at least 30 minutes every two hours to avoid glans ischemia. This group also had penile sonography to evaluate the status of their plaques.

After six months of treatment, the men in the traction therapy group saw a number of improvements:

·         Mean penile curvature at erection was reduced from 33 degrees at baseline to 15 degrees.

·         Mean penile length increased from 12.4 centimeters at baseline to 13.7 centimeters.

·         The men reported less pain and improved erectile function and hardness.

·         More men were able to penetrate a partner.

·         Sonographic plaques disappeared in 48% of the patients.

·         The need for surgery was reduced in 40% of the patients. Among the men who did need surgery, about one third were able to have simpler procedures.

·         These results were maintained at a 9-month follow-up point.

In contrast, the men who received no intervention did not fare so well:

·         After six months, their mean degree of curvature increased from 29 degrees at baseline to 51 degrees after six months.

·         Mean penile length decreased from 14.5 centimeters at baseline to 12.1 centimeters.

·         They reported more pain and poorer erectile function and hardness.

·         Fewer men were able to penetrate a partner.

·         After nine months, there were no significant improvements.

Compliance with treatment was an important factor for the traction therapy group. The men wore the device for a mean of 4.6 hours a day. However, those who wore it for more than six hours a day generally had better results.

Overall, the researchers concluded that penile traction therapy “seems an effective treatment” for men in the acute stage of Peyronie’s disease, as pain, curvature, and sexual function improved in their study group.

Is penile traction therapy right for your patients? It could be, especially if they are motivated to wear the device for the recommended amount of time. However, only a urologist can answer this question for certain. Clinicians are encouraged to refer their patients with Peyronie’s disease to the appropriate specialists.

Print this article or view it as a PDF file here: Traction Therapy for Peyronie’s Disease


Andromedical Corp./Andropeyronie

“FAQ – Method and Instructions”

The Journal of Sexual Medicine

Martínez-Salamanca, Juan I., MD, PhD, et al.

“Acute Phase Peyronie's Disease Management with Traction Device: A Nonrandomized Prospective Controlled Trial with Ultrasound Correlation”
(Full-text. First published online: November 22, 2013)

Sexual Medicine Society of North America

“Peyronie’s Disease”

Urology Care Foundation

“Peyronie’s Disease”

(Last updated: March 2013)


If you work with women, you have probably met patients coping with endometriosis, one of the most common female health issues. According to the American College of Obstetricians and Gynecologists, endometriosis occurs in about 10% of women of reproductive age. Because of the pain and discomfort involved, endometriosis can interfere with all aspects of a woman’s life. Today, we’ll talk a bit about how endometriosis affects a woman sexually.

Endometriosis – Some Basics

Endometriosis involves the endometrium – the lining of the uterus. Women with endometriosis have this tissue outside of the uterus as well. It might be found on the ovaries, Fallopian tubes, or peritoneum. It can also develop on the bladder, ureters, and rectum.

Even though the tissue is outside the uterus, it still responds to changes in estrogen, especially around the time of a woman’s menstrual period. This can cause the affected areas to become inflamed, swell, bleed. The tissue can grow to eventually cover the ovaries or block the Fallopian tubes. Some women develop cysts, scar tissue, and adhesions.

The most common symptom of endometriosis is pain in the pelvis, abdomen, and lower back. Pain may become worse during menstrual periods, bowel movements or urination. Sex can also be painful.

Depending on the severity, endometriosis may be treated with medications, hormonal therapy, or surgery. Some women with endometriosis become infertile.

Endometriosis and Sex

There are many ways endometriosis can interfere with sex. Most stem from pain and emotional/psychological issues.

  • Pain. A woman with endometriosis may experience severe pain during intercourse. This pain may be caused by pressure on the pelvis, penetration, or thrusting during intercourse. Anticipating pain can make the situation worse. Knowing that sex could be painful can make a woman tense. Because she can’t relax and enjoy herself, the pain intensifies. Women may find relief by trying different sexual positions or finding other ways to be intimate with their partner, such as kissing, cuddling, and caressing. Women may also time sex around their menstrual periods. It might be more comfortable to have sex when the growths are less likely to be inflamed.
  • Emotional/psychological issues. Endometriosis can affect a woman emotionally and psychologically, too. In turn, such issues can cause problems in the bedroom and in a relationship. Constant pain can be exhausting and fatigue can make a woman lose interest in sex. She might feel anxious about how endometriosis is affecting her day-to-day life. For example, if she has had to miss work because of the pain, she might feel stressed about her job and income. Not surprisingly, depression is common in women with endometriosis. They may feel that the pain will never go away and worry that life will never get back to normal. A woman may also worry about how her endometriosis is affecting her relationship. She may feel insecure about sexually pleasing her partner or guilty about the changes in their sex life. Many couples aren’t comfortable discussing sex, leading them to drift apart. In these cases, counseling is often suggested. A mental health professional can help a woman cope with depression and anxiety. With therapy, couples can learn how to communicate with each other and repair their relationship, if necessary. A sex therapist may be able to suggest changes to the couple’s sexual routine to make intimacy more comfortable and enjoyable.

If you have a patient or client struggling with endometriosis, talk with her about how she’s managing it. What treatments has she tried? Are they effective? Is her sex life or relationship suffering? If so, would it help for her to see a sexual healthcare provider? Might she benefit from a support group?

It’s not easy coping with a chronic condition like endometriosis. Being aware of the physical, emotional, and sexual implications of endometriosis can help clinicians understand the challenges of their female patients affected by it.

Print this article or view it as a PDF file here: Professional Audience Announcement – Endometriosis


The American College of Obstetricians and Gynecologists


(October 2012)

Davis, Julie

“Why Sex Hurts With Endometriosis”

(Last updated: May 21, 2010)

The Journal of Sexual Medicine

Montanari, Giulia, MD, et al.

“Women with Deep Infiltrating Endometriosis: Sexual Satisfaction, Desire, Orgasm, and Pelvic Problem Interference with Sex”

(Full-text. First published online: April 3, 2013)

“Endometriosis Fact Sheet”

(Last updated: July 16, 2012)


STAGE Technique for Congenital Penile Curvature

In your practice, you might meet patients with congenital penile curvature. Men with this condition were born with a distinct curve in their penis, the result of a problem in fetal development.

Congenital penile curvature can cause a number of issues for men, including difficulties with vaginal penetration, erectile dysfunction, and problems with sexual confidence and self-esteem.

Surgery can correct the curvature. However, there can be complications, such as shortening of the penis, loss of sensation, and erectile pain.

Dr. Paulo H. Egydio and Dr. Franklin E. Kuehhas, both from the Advanced Center for Penile Curve Treatment located in Brazil and Austria, developed a new procedure designed to treat congenital penile curvature.

Called the STAGE (Superficial Tunica Albuginea Geometric-Based Excision) technique, the procedure uses geometric principles to straighten the penis. According to the doctors, the STAGE technique has a 98.6% success rate and improves sexual function and satisfaction.

Today, we’ll take a closer look at the STAGE technique and the outcomes that have been reported.

The STAGE Technique: Four Steps

To prepare for the surgery, the patient is sedated and given local anesthesia. The penis is then degloved, a process that involves peeling back the skin to expose the internal tissue.

At this point, the STAGE technique is a four step process:

1.   Using geometric principles, surgeons examine the convex side of the bent penis and locate the area where it curves the most.

2.   Surgeons move the neurovascular bundle – the layer of tissue that holds the penile sensibility nerves. This allows access to the outer layer of the tunica albuginea, the sheath surrounding the tissue inside. Three small excisions (3 mm each) are then made at the point of maximum curvature found in Step 1.

3.   The excisions are closed with absorbable sutures.

4.   Steps 1, 2, and 3 are repeated until the penis is straight.

For three to six months after surgery, penile physical therapy and regular stretching are recommended.

STAGE Technique Outcomes

In October 2013, Drs. Egydio and Kuehhas published a study on the STAGE technique online in the Journal of Sexual Medicine. In their report, they discussed the effectiveness and safety of the procedure based on their retrospective analysis of 145 patients.

The men had STAGE surgery between June 2006 and March 2012. Their mean age was 23.8 years. Before surgery, their penile curvature ranged from 45 to 90 degrees, with a mean of 65 degrees. About 35% of them had trouble with vaginal penetration and 43% of them had pain with intercourse (dyspareunia).  

After surgery, none of the men had a significant recurrence. Nine of them still had a residual curve of up to 20 degrees, but were still satisfied with their results and did not ask for a second operation. Two men had residual curves over 30 degrees. These men did have follow-up surgery.

Dyspareunia – for both men and their partners – went away within six months of the procedure.

Penile shortening was slight, with a mean of 0.7 centimeters. There were no significant complications during the procedure or recovery period.

Many men reported improved libido, greater sexual and relationship satisfaction, and increased sexual confidence after surgery.

Benefits of the STAGE Technique

On their website, Drs. Egydio and Kuehhas compared the STAGE technique to alternative methods. They noted that compared to the Nesbit procedure (a common technique), STAGE patients lost less penile length and had reduced risk for hematoma and erectile dysfunction. Sutures could not be seen or felt and had little potential for bleeding, rupture, or irritation. Patients undergoing STAGE were also less likely to lose penile sensation.

The STAGE technique offers men with congenital penile curvature another surgical treatment option. If your patients are interested in this technique, they should discuss it with a urologist.

Print this article or view it as a PDF file here: STAGE Technique for Congenital Penile Curvature


Advanced Center for Penile Curvature Treatment

“STAGE : ​Superficial Tunica Albugina Geometric-based Exicison (sic) for the correction of Congenital Penile Curvature”!stage-technique-curved-penis/c1qiu

The Journal of Sexual Medicine

Kuehhas, Franklin Emmanuel, MD and Paulo Henrique Egydio, MD, PhD

“The STAGE Technique (Superficial Tunica Albuginea Geometric-Based Excision) for the Correction of Biplanar Congenital Penile Curvature”

(Full-text. First published online: October 24, 2013)

Natural Orifice Transluminal Endoscopic Surgery (NOTES)

As a healthcare provider, you’ve likely worked with patients who are considering some form of surgery. Whether it’s a routine appendectomy or an unexpected mastectomy, the anticipation of a hospital stay, anesthesia, and complicated incisions can make anyone nervous.

This can be especially true if the type of surgery is relatively new. Today we’re going to talk a bit about natural orifice transluminal endoscopic surgery (NOTES), a technique that has been developed in the past decade or so. More specifically, we’ll look at a study that examines transvaginal organ extraction using NOTES and how it affects women.

What is NOTES?

NOTES involves conducting surgery through a natural orifice – a natural opening in the body - such as the mouth or the vagina. NOTES is getting more attention lately for it use in cholecystectomy (gallbladder removal), appendectomies, and sleeve gastrectomies (weight-loss surgery that removes part of the stomach).

Some of the advantages of NOTES include less scarring, reduced chances for infection, and decreased recovery time compared to more traditional surgery. Some patients also report less pain.

However, women considering NOTES through the vagina may be concerned about how such a procedure might affect sexual function and childbirth.

Researchers from the Center for the Future of Surgery at the UC San Diego School of Medicine examined this issue and presented their findings at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, held in Baltimore in April 2013.

How might NOTES affect women?

The research team analyzed data from 34 women who ranged in age from 23 to 63 (with a mean age of 40 years) and had undergone NOTES. Their surgeons had used a hybrid natural orifice approach that involved conventional laparoscopic surgery with transvaginal organ extraction at the end of the operation. The surgeries included cholecystectomy, appendectomy, and sleeve gastrectomy.

The researchers found that:

  • None of the surgeries had to be converted to open operations.
  • There were no intraoperative complications.
  • The mean hospital stay for all the women was 2 days.

The patients were followed for a mean of 24 months. In that time, there were no long-term complications. Six of the women had some spotting or heavy menstrual periods shortly after the surgery, but these issues were taken care of conservatively.

Two pregnancies and two successful vaginal deliveries also occurred during this time period.

The study authors concluded, “This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications.”

What’s next?

More research is needed to further evaluate NOTES and provide long-term follow up. However, this study may put some of your female patients at ease, if they are considering transvaginal organ extraction. Of course, their surgeon can best address their specific concerns.


General Surgery News

Smith, Monica J.

“In Study, Transvaginal NOTES Causes No Sexual Dysfunction”

(September 2013)

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

Barajas-Gamboa, Juan S., MD, et al.

“Trans-Vaginal Organ Extraction: Potential for Broad Clinical Application”

(Abstract S104. Presented at SAGES 2013, April 17-20, 2013, Baltimore, MD)

Yale School of Medicine

“Scarless Surgery”

(WTNH – New Haven, Connecticut - video broadcast on December 24, 2009. No longer available on or Accessed via Yale School of Medicine website.)

“Scarless Surgery/NOTES”

PSA Test and Hypogonadism

Can a test used to screen for prostate cancer be used to confirm hypogonadism in men with sexual dysfunction? It’s possible, according to new research published in the Journal of Sexual Medicine in July 2013.

What is Hypogonadism?

Hypogonadism occurs when a man’s body doesn’t produce enough – or any - testosterone. The problem may stem from a problem with the testes, which produce the hormone. Or, it may result from problems in the brain, specifically the hypothalamus or pituitary gland, both of which play a role in testosterone production.

Testosterone is important to men’s health. It has a huge effect on sex drive and is involved with erectile function. It gives men their secondary sex characteristics, like facial hair and a deeper voice. It’s also involved with sperm production, strength, and muscle mass.

When men have hypogonadism, they often feel weaker, fatigued, and moody. Their sex drive decreases and they may have trouble getting erections. Their testicles may get smaller; their breasts may get larger. Low testosterone levels also put them at higher risk for osteoporosis.

It’s natural for men’s testosterone levels to gradually decline as they age. Testosterone therapy may help, but should be done under a doctor’s care.

What is the PSA Test?

PSA stands for prostate-specific antigen. Produced by the prostate gland, PSA is a protein that helps liquefy semen. The PSA test is a common, though controversial, screening tool for prostate cancer. A PSA reading above 4.0 ng/mL usually prompts more screening. However, such readings do not always indicate cancer.

What is the connection between PSA and Hypogonadism?

In this study, Italian researchers were interested in late onset hypogonadism. They noted that past research on the relationship between PSA and testosterone levels was “controversial” and set out to investigate whether PSA could be a useful marker for low testosterone in men with sexual problems.

Their study involved almost 3,000 men seeking treatment for sexual dysfunction. None of the men had had prostate disease before the study. Men with PSA levels above 4 ng/mL were excluded. The participants ranged in age from 18 to 85 years (mean age 52.5).

In addition to taking a variety of measurements, such as waist circumference, total testosterone, testis volume, blood pressure, and HDL cholesterol, the researchers interviewed the men and had them complete questionnaires designed to assess hypogonadism.

The researchers found that after adjusting for age, lower PSA levels were linked to conditions associated with hypogonadism, including delayed puberty, lower testis volume, metabolic syndrome, type 2 diabetes, and cardiovascular disease. Men with lower PSA levels were also more likely to have problems with erections.

While these results did show that low PSA might help confirm a hypogonadism diagnosis, the study authors said the efficacy of PSA testing for this purpose was “modest.”

They explained that the relationship between PSA levels and testosterone was more evident when men’s testosterone levels were below average. The link was not as strong for men with normal testosterone levels. In the research, PSA levels did not rise when testosterone readings were above 8 nmol/L.

Also, the findings were more accurate in younger patients. When men are over a certain age, other factors are more likely to affect PSA. In these cases, using PSA to confirm hypogonadism could be less reliable.

With these points in mind, however, PSA testing could still help clinicians evaluate symptoms of hypogonadism in men with sexual dysfunction.


International Society for Sexual Medicine

“Serum PSA and Testosterone Levels”

(September 2013)

The Journal of Sexual Medicine

Rastrelli, Giulia, MD, et al.

“Serum PSA as a Predictor of Testosterone Deficiency”

(Full-text. First published online: July 16, 2013)

National Cancer Institute

“Prostate-Specific Antigen (PSA) Test”

Sexual Medicine Society of North America

“Conditions – Low Testosterone”

“Diagnosing Low Testosterone”

“Overview – Low Testosterone”

“Prostate Cancer – PSA Test Revisited”

(November 11, 2011)

Romantic Partners’ Reponses to Entry Dyspareunia

Dyspareunia – painful intercourse for women – can be devastating for couples who want to have a happy intimate relationship.

Some causes of dyspareunia might be easier to pinpoint than others. Poor lubrication, certain medical conditions (such as ovarian cysts or pelvic inflammatory disease), allergies, and poorly-fitting birth control devices are examples.

Other times, the causes are more elusive. A woman’s body may be responding to emotional problems or trouble in the relationship. She might not be able to articulate that to her partner. She might have vaginismus - involuntary spasms of the pelvic muscles that can make intercourse impossible. But she might not know why these spasms occur and feel guilty about her inability to control them.

Dyspareunia can be difficult for male partners to understand, too. Men may feel frustrated, wondering why something that should be so natural has become so difficult. They may also feel depressed about the relationship, as if the woman is rejecting them. They could feel anxious about intercourse itself, knowing that they induce this pain. Some men are patient and supportive; others pull away from the relationship or become hostile.

Research has shown that partner response can affect pain intensity for women with dyspareunia. Today, we’ll look at a recent study published in the Journal of Sexual Medicine. In particular, this study looks at two types of men’s cognitions: catastrophizing and self-efficacy.

The Study

A Canadian research team collected data from 179 heterosexual couples who were dealing with entry dyspareunia, pain caused by vaginal penetration. The women’s mean age was 31 years; for men, it was 33. The couples had been together for a mean of six years. The women had been having pain for a mean of six years, too.

Using a variety of questionnaires, the researchers assessed the women’s pain intensity, sexual functioning, and sexual satisfaction.  They also measured levels of catastrophizing and self-efficacy for both men and women.

Catastrophizing was defined as “an exaggerated and negative set of cognitions during real or anticipated painful experiences.” Put another way, catastrophizing involves expectations of a negative outcome and the belief that that outcome would be a catastrophe. For example, a man may expect penetration to be difficult in one sexual encounter, then catastrophize, believing that the couple will never have vaginal intercourse.

Self-efficacy was defined as “the confidence an individual has in his or her ability to perform a specific task.” In this study, researchers focused on the way a male partner perceived his female partner’s self-efficacy. A man with a high level of partner-perceived self-efficacy would believe that his partner had confidence that she could have painless intercourse.

After controlling for the women’s catastrophizing and self-efficacy, the researchers found that women’s pain was less intense when their partners catastrophized less and had higher levels of partner-perceived self-efficacy. In other words, pain was less severe when the men did not expect a catastrophic outcome and highly believed in his partner’s confidence about intercourse.

Why did this happen? The researchers suggested that the men’s cognitions might have made the women more aware of their pain. Heightened awareness could have made the pain more intense.

Implications for Practice

The study results give us a lot to think about as healthcare providers. Having a man consider his reactions to his partner’s pain – and how that reaction might affect the intensity of her pain – is one starting point. It may help for him to think about her point of view.

Clinicians can also benefit from viewing dyspareunia as the couple’s problem, not just the woman’s. While it’s the woman that feels the pain, both partners feel the tension and frustration. Couple-oriented therapies can help both partners learn to communicate about what’s happening and keep their relationship strong as they struggle to overcome painful sex.


The Journal of Sexual Medicine

Lemieux, Ashley J., MA, et al.

“Do Romantic Partners' Responses to Entry Dyspareunia Affect Women's Experience of Pain? The Roles of Catastrophizing and Self-Efficacy”

(Full-text. First published online: June 27, 2013)


Grohol, John M., PsyD

“What is Catastrophizing?”

(Last reviewed: January 30, 2013)

Sexual Medicine Society of North America

“Pain During Sex – Vaginismus”

“Painful Intercourse for Women”

Men with Infertility

Tony just didn’t know what to do anymore. He and his wife Rebecca had always planned to have a family, a large one. But after a year of trying, they were losing hope that they’d ever conceive a child. They were confused about their next steps. Should they give up? Keep trying? Try in vitro fertilization? Adopt?

Making matters worse, Tony was starting to have some problems in the bedroom. He’d never had trouble getting an erection before, but now he couldn’t count on being able to perform. And since this ability was crucial for starting a pregnancy, he felt like a failure. Rebecca tried to understand, but deep down, Tony knew she was as frustrated and disappointed as he was. Lately, they had started avoiding the subject of sex altogether and he knew that wasn’t good for their relationship. He missed the intimacy they shared.

There are lots of men like Tony. Infertility takes a huge toll on couples, emotionally and sexually.

Unfortunately, it’s fairly common for infertile men to develop sexual problems. Some have erectile dysfunction (ED), the inability to achieve and maintain an erection suitable for intercourse. Others may have premature ejaculation (PE), which occurs when a man ejaculates before he and his partner wish it to happen.

Depression and anxiety often accompany sexual problems. In Tony’s case, he missed the intimacy he once had with his wife. He might feel anxious about pleasing her. The fact that they’re trying to conceive adds even more pressure.

Today, we’ll take a closer look at the extent of sexual problems affecting men with infertility. We’ll also discuss some ways that we, as professionals, might help them.

Recent Research

A study published online in May in theJournal of Sexual Medicine has shed some light on the incidence of sexual and psychological problems among infertile men in China.

Researchers collected data from 1,468 infertile men and 942 fertile men who ranged in age from 23 to 45.

They found that the infertile men had higher rates of erectile dysfunction, premature ejaculation, depression, and anxiety than the fertile men. These rates were as follows:



Infertile Men

Fertile Men

Premature Ejaculation



Erectile Dysfunction









As you can see, infertile men were almost twice as likely to have premature ejaculation when compared to the fertile men. And they were more than twice as likely to have erectile dysfunction.

The study authors noted that their results coincide with the results of other studies that have found higher incidence of sexual and psychological problems among infertile men. However, they also pointed out that cultural and religious factors should be considered when comparing Chinese and Western patient populations. What may be true in one part of the world may not necessarily apply to another.

How Can Practitioners Help?

Still, the results are a worthwhile reminder of issues our patients and clients could be struggling with. So how can healthcare providers help men like Tony?

  • Have compassion. Sexual problems and infertility are difficult enough on their own and can put tremendous strain on relationships. Adding the two together creates an even tougher situation. Keep this in mind when talking to your patient or client.
  • Ask. A lot of men are reluctant to discuss sexual problems with a clinician. Try giving them the opportunity to do so. For example, you might say, “A lot of men dealing with infertility develop sexual problems. Fortunately, there are treatments available. Is this something you’d like to talk about?”
  • Be prepared to make referrals. If sexual problems and infertility are outside your area of expertise, have a list of referrals ready. Men may benefit from counseling, either by themselves or with their partner. Urologists may be able to help with erectile dysfunction. Sex therapists can offer strategies for dealing with premature ejaculation. If these specialists are not part of your practice, ask your colleagues for recommendations.

Even if our patients don’t volunteer much information, being aware of the sexual implications of infertility can help us understand the deeper struggles that may be part of their relationships.


The Journal of Sexual Medicine

Gao, Jingjing, MM, et al.

“Relationship between Sexual Dysfunction and Psychological Burden in Men with Infertility: A Large Observational Study in China”

(Full-text. First published online: May 20, 2013)

Sexual Function in Childhood Cancer Survivors/Project REACH

When adults have cancer, it’s reasonable to consider how treatment will affect their sex lives. For example, men who have a radical prostatectomy may contend with erectile dysfunction. Women recovering from gynecological cancers may deal with the sexual side effects of surgical menopause.

But what happens when cancer occurs during childhood? How does pediatric cancer and its treatment affect the sex lives of those patients when they grow up?

Researchers from the Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School set out to learn more about that question. Their study, published online last month in The Journal of Sexual Medicine, has some interesting results.

Today, we’ll take a closer look at this study and its implications for healthcare providers.

Project REACH

Project REACH (Research Evaluating After Cancer Health) is a cohort study that assesses health outcomes in cancer survivors. Participants complete an annual survey along with some additional surveys as needed.

Two hundred ninety-one Project REACH survivors of childhood cancer were involved with this sexual health study. They ranged in age from 18 to 57 with an average age of 27. Fifty-two percent were women. The most common cancer diagnoses in the group were brain tumors, lymphoma, leukemia, and sarcoma. Treatment types included chemotherapy, radiation, surgery, and transplant procedures.

After analyzing data provided by the participants in three questionnaires, the researchers found the following:

  • 29% of the 291 young adult survivors of childhood cancer surveyed had two or more symptoms of sexual dysfunction.
  • When compared to adults under age 40 in the general population, childhood cancer survivors were three times more likely to have sexual problems.
  • The women in the study population were twice as likely as the men to have sexual dysfunction.
  • Survivors with sexual dysfunction tended to be older than those with normal function. They were also more likely to experience depression and anxiety.
  • Sexual dysfunction was not associated with type of childhood cancer treatment.


As mentioned above, women in this study were twice as likely as men to have sexual dysfunction. Several hypotheses have been proposed to explain this:

  • Women may feel more stress and anxiety about relationship and sexual difficulties.
  • They may be more vulnerable to some of the physical, emotional, and cognitive late-effects of treatment.
  • They might be at risk for posttraumatic stress symptoms.
  • They may have negative feelings about their body because of treatment.
  • Their treatment might have induced menopause, which can lead to sexual problems.

The authors noted that while none of these hypotheses were supported by their study, their work does emphasize sexual concerns for female childhood cancer survivors.


In this study, the average age of survivors with significant sexual dysfunction was 30. These survivors tended to be older than their counterparts with no sexual problems.

The researchers did not think this was due sexual changes that come with normal aging, however. Instead, they suggested that late-effects of treatment, those that wouldn’t be known when cancer treatment ended in childhood, were a factor. Such effects could interfere with heart, lung, hormonal, and neurological function.

Type of Cancer Treatment

One result that surprised the authors concerned the type of cancer treatment patients received as children. The researchers expected to see types of dysfunction related to types of treatment, as they often are in adults, but instead they found no association.

It’s possible, the authors suggest, that cancer treatment affects children and adults differently. Because children are still growing, treatment might impact their sexual development. Also, treatments that wouldn’t appear to affect sexual health could affect overall organ systems.

Implications for Healthcare Providers

“Our results underscore the stark reality that a significant number of young adult survivors of childhood cancer report the presence of multiple sexual problems and need effective intervention,” the authors wrote.  How can clinicians help?

  • Consider sexual health in broad terms. Remember that the treatment patients received in childhood may have affected their sexual health in ways that might not be obvious. Late-effects may take time to develop.
  • Watch for signs of depression and anxiety, which may be linked to sexual problems.
  • Work through the barriers that may exist when discussing sexual health with this population.
  • If you think your patient has a sexual health issue that is beyond your expertise, ask a colleague for guidance or support.

Of course, we might not know if our patients are survivors of childhood cancer. But if we do, it’s important to keep their sexual health in mind.


The Journal of Sexual Medicine

Bober, Sharon L., PhD, et al.

“Sexual Function in Childhood Cancer Survivors: A Report from Project REACH”

(Full-text. First published online: May 16, 2013)

Men’s Adherence to Erectile Dysfunction (ED) Drugs

It’s been fifteen years since the FDA approved sildenafil (Viagra) as the first drug to treat erectile dysfunction (ED). Since then, other drugs such as tadalafil (Cialis) and vardenafil (Levitra), have been developed. Together, these drugs often serve as first-line therapy for men with ED and generally work well in that role.

Sildenafil, tadalafil, and vardenafil are all phosphodiesterase type 5 inhibitors and work in similar ways to enhance blood flow to the penis so a man with ED can get an erection firm enough for sex.

Given the success of these drugs for men who can take them, we may think that men would be eager to comply with therapy. But this is not always the case. The drugs aren’t effective for every man and their length of effectiveness can vary. Some men are dissatisfied with their results or have unrealistic expectations.

How can we help patients adhere to their medication plan? To answer this question, it’s helpful to consider reasons why they don’t.

Men’s Adherence Study

In a recent study published in The Journal of Sexual Medicine, European scientists examined men’s adherence to three different types of ED medication regimens: tadalafil taken once daily, tadalafil taken on demand, and sildenafil taken on demand. (Vardenafil was not included in this study.)

Seven hundred seventy patients were randomly assigned to one of the three treatment plans. For eight weeks, the patients took their designated medication with no changes, except for adjustments in dosage when necessary. After this period, the men were allowed to continue their current treatment, switch to another regimen, or stop treatment completely.

Men who took tadalafil (once a day or on demand) tended to stay with their treatment plan longer than the men taking sildenafil. Overall, 44% of the men continued with their assigned plan. Forty-two percent switched plans at least once.

Why? Efficacy played a role in the two most common reasons. Men either felt that their erections were not hard enough or did not last long enough. Some men did not like taking a pill every day; others did not like taking medication on demand.

Helping Patients Choose an ED Drug

When choosing an ED drug, much depends on a man’s preferences. Some helpful questions to ask include the following:

·         How do you feel about taking an ED drug? Some men in the above study cited “feel medication controls my sexual life” as their reason for switching or discontinuing a regimen. Men with this concern may want to choose a different approach to treating ED.

·         How do you prefer to take this drug? Some men prefer once a day because it’s easier to remember. Others may not like the idea of taking a daily pill and choose the on-demand route.

·         How important is spontaneity? In some regimens, the drug must be taken 30-60 minutes before sex. But often, a couple may not know when they’ll feel inspired. They may prefer to take advantage of unplanned moments, which might make another regimen more suitable for them.

·         How important is length of effectiveness?  Each drug is effective for a different amount of time. According to the Mayo Clinic, sildenafil and vardenafil may be effective for up to 5 hours. Tadalafil may last up to 36 hours. This can be an important factor.

Being Realistic About Adherence and Usage

Advertising often portrays happy couples whose sexual problems are solved by a pill. But patients need to know that the situation can be more complicated than that.

Sometimes, adjustments are needed. The dose may need to be increased or decreased. Or the drug itself may need to be changed because of side effects. What works for one man may not work for another. It can take some time to find the right fit.

Helping patients and their partners understand their options is just one step. They may also need to think about their relationship and talk openly about their expectations. It often takes time, effort, patience, and understanding to work through ED.


The Journal of Sexual Medicine

Buvat, Jacques, MD, et al.

“Adherence to Initial PDE-5 Inhibitor Treatment: Randomized Open-Label Study Comparing Tadalafil Once a Day, Tadalafil on Demand, and Sildenafil on Demand in Patients with Erectile Dysfunction”

(Full-text. First published online: April 2, 2013)

Mayo Clinic

“Erectile dysfunction: Viagra and other oral medications”

(June 6, 2012)

Tadalafil and Sexual Problems that Accompany BPH/LUTS

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Biology and Psychology of Erectile Dysfunction

If you work with male patients, especially older ones, you might find some of them dealing with erectile dysfunction (ED). When a man has ED, he’s unable to achieve an erection that’s firm enough for intercourse. ED is a frustrating condition that often causes problems in relationships and diminished self-esteem. Many ED patients feel like they’re “less of a man” because they can’t perform sexually the way they used to.

What causes ED? There are a number of potential causes, some biological, some psychological. In this post, we’ll discuss some of the more common causes.

Biological Causes

To understand the biological causes of erectile dysfunction, it helps to understand the physiological process of erection.

A man can be sexually aroused by a variety of stimuli, such as the touch of his partner, the sight of someone attractive on television, or a fantasy he thinks over in his mind. Once this happens, signals in the brain trigger activity in the penis. Soft tissue in the penis relaxes and arteries expand to allow increased blood flow. This additional blood makes the penis erect. Veins constrict so that the blood stays in the penis until the sexual stimulation ends or until the man ejaculates. At that point, the veins open again, allowing blood to flow back into the body.

Medical conditions that interfere with this communication and blood flow process are often linked to ED. Here are some common culprits:

·         Diabetes

·         Cardiovascular disease

·         Obesity

·         High blood pressure

·         High cholesterol

·         Low testosterone

·         Kidney disease

·         Stroke

·         Multiple sclerosis

Men with diabetes may develop ED because of neuropathy – nerve damage that, in this case, prevents the transmission of signals from the brain to the penis. Men who have had a stroke may have similar problems with nerves, as can men with multiple sclerosis.

Men recovering from prostate surgery are prone to erection dysfunction as well. The prostate is surrounded by nerves essential for erectile function. Surgeons try to spare as many nerves as they can, but in many cases, patients still have erectile problems. Penile rehabilitation can help in this situation.

Atherosclerosis – hardening of the arteries – can happen to men with heart disease, diabetes, and high cholesterol. When atherosclerosis occurs, the arterial pathways into the penis are narrowed or blocked. With less blood flowing into the penis, a man may not be able to get an erection rigid enough for sex. Or, he might not be able to get an erection at all.

Often, ED can be treated by targeting the underlying medical condition that causes it. Medications and devices are other helpful options.

Psychological Causes

Psychology may also play a role in the development of erectile dysfunction. Depression, anxiety, and stress are all possible triggers. A man may be having financial problems or a conflict with his employer. He may have performance anxiety and be so concerned about satisfying his partner that he cannot get an erection.

Problems in a relationship can affect erectile function as well. Unhappiness, anger, and communication breakdowns may fuel the frustration and depression associated with ED.

Another angle to consider is past sexual experiences. A man who has been sexually abused in the past may need to work through feelings of fear, humiliation, or guilt before he can have satisfactory erection.

A man whose ED stems from psychological causes may find counseling or sex therapy helpful. He may choose to take these routes on his own or with his partner.

It’s possible that a man’s ED may have both biological and psychological causes.

Assurance and Understanding

Many men are reluctant to admit they’re having sexual problems. They may feel nervous about bringing it up and awkward about describing their feelings.

If you suspect that your patient has ED, assure him that it’s a common and treatable condition and that getting help will benefit not only his sex life but his overall health and well-being.


Sexual Medicine Society of North America

“Common Causes – Erectile Dysfunction”

“ED as an Indicator”

“Questions to Ask Your Health Care Provider about Erectile Dysfunction (ED)”

Prostate Removal and Continued Sexual Satisfaction

Feelings of anxiety, depression, and sexual dissatisfaction are common among men who have been surgically treated for prostate cancer, even a year after treatment, according to recent research from the Mayo Clinic.

More specifically, the study found that higher levels of anxiety were associated with depression and low sexual satisfaction and suggests that counseling may improve the quality of life for these men.

“The 10-year survival for a man undergoing surgery to remove localized prostate cancer is greater than 95 percent,” said researcher Alexander Parker, PhD in a press release. “Given that the majority of men who undergo prostatectomy for prostate cancer will not die from their disease, we are concerned about what life will be like for these patients decades after diagnosis and treatment.”

Dr. Parker added, “What is interesting from a sexual health standpoint is we observed that anxiety was not linked to poor erectile function per se but was linked to low levels of sexual satisfaction. If our results can be confirmed by other investigators, it would suggest that anxiety is not affecting some men’s ability to perform sexually but perhaps more their ability to enjoy their sex life.”

Erectile dysfunction is a common sexual complaint after prostate cancer surgery. This is because the prostate gland is surrounded by nerves and blood vessels that are critical for erections. Surgeons try their best to spare as many nerves as possible, but there are no guarantees that complete sexual function will be maintained. For some men, sexual problems are temporary and penile rehabilitation may help. For others, the issues are long-term. Either way, the adjustment can be frustrating, affect men’s self-esteem, and be a challenge for partners as well.

Treatments for Erectile Dysfunction Related to Prostate Removal

Treatments exist for erectile dysfunction and a man’s urologist can help determine which is best for him. But how can we help our patients with anxiety? Here are some steps we can encourage to start the process.

  • Counseling. Chances are, your patient’s cancer care team includes a counselor or therapist who specializes in issues facing cancer patients. If he is not already taking advantage of these services, encourage him to do so. Assure him that all conversations are confidential and that there’s nothing wrong with seeking some extra help.
  • Sex therapy. While a counselor can help with cancer-related anxiety, a sex therapist may be able to help with specific sexual adjustment issues. For example, a man might need some help in discussing his sexual difficulties with his partner.
  • Support groups. Some cancer centers offer support groups where a man can open up with like-minded individuals who are having similar experiences. In a support group, men can vent their frustrations and offer each other practical solutions, all in a safe community.
  • Involving the partner. It’s important to keep the partner in the loop and help her or him understand what is happening with the patient. Explain that the patient may feel like his manhood has been compromised because of erectile dysfunction or that he may be anxious about his ability to satisfy his partner. Some couples find it helpful to attend counseling sessions together or to use online counseling services.
  • Communication and social activity. Many men withdraw from their friends, families, and partners during and after cancer treatment. They may not want to discuss how they’re feeling or feel too overwhelmed. They may also worry about how those close to them will react. However, staying in touch with loved ones and engaging in social activity can help a man see his support network. It can also get his mind off of his problems, even if it’s just for a few hours.
  • Exercise. Staying physically active can do wonders for relieving anxiety and depression. Any exercise program should be started under a doctor’s guidance, however.
  • Sexual adjustments. A man may feel that that he’s a sexual failure if he can’t have erections like he used to. Help him remember that there is more to sex and intimacy and that by keeping an open mind and making adjustments, he and his partner can still have a satisfying sex life. This is another area where communication is crucial. Partners need to tell each other what works and what doesn’t. A sex therapist may be able to offer further suggestions.

The Mayo Clinic’s findings were presented at the World Meeting on Sexual Medicine in Chicago last August. The study was partially funded by a grant from the Sexual Medicine Society of North America.


American Cancer Society

Simon, Stacy

“Sex Counseling After Prostate Treatment Helps Couples”

(October 12, 2011)

“Sexuality for the Man with Cancer”

(Last medical review and revision: October 28, 2011)

Harvard Health Publications

“Penile rehabilitation after prostate cancer surgery”,N0111b

Mayo Clinic

“Prostate Cancer Surgery Can Lead to Anxiety, Depression, Quality of Life Issues”

(Press release. September 24, 2012)

Sexual Medicine Society of North America

“Nerve-sparing Prostate Surgery & Orgasms”

(March 16, 2012)

AAP Recommendations on Circumcision

Among the many considerations new parents must make for their newborn sons, one is circumcision.

Simply put, circumcision is the removal of foreskin from the penis and is done for a variety of reasons. For some families, it’s part of their culture or religion. Others believe that the procedure offers health benefits.

But circumcision is by no means universal. In 2006, the World Health Organization (WHO) estimated that about 30% of men worldwide – about 665 million men – are circumcised. The practice is widespread in Africa and the Middle East, fairly common in North America, and not as common in Europe and Asia. In the United States, it’s estimated that that between 20% and 80% of males are circumcised, usually when they are newborns.

Some parents choose not to circumcise, feeling that the procedure isn’t medically necessary and isn’t fair to perform on a child who can’t provide informed consent.

American Academy of Pediatrics (AAP) Revises Policy on Circumcision

On August 27, 2012, the American Academy of Pediatrics (AAP) revised its 1999 policy on circumcision, stating that “the health benefits of newborn male circumcision outweigh the risks” and that parents who choose circumcision for their sons should have access to the procedure. The AAP did not go as far as to recommend circumcision, but did make recommendations about it, based on a comprehensive review of medical literature conducted by a task force of representatives from the AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the U.S. Centers for Disease Control and Prevention.

Today, we’ll take a closer look at the revised policy.

Benefits of Circumcision

In reviewing the literature, the AAP task force found that circumcision has the following benefits:

  • Protection from STIs, including HIV.  Circumcision is associated with a lower prevalence of infections from human papillomavirus (HPV), herpes simplex virus 2 (HSV-2), and bacterial vaginosis (BV) in female partners. It is also believed to reduce the risk of acquiring HIV, the virus that causes AIDS. How does circumcision protect against these infections? An intact foreskin is more likely to develop microtears and abrasions – areas through which pathogens can enter the body. It is also an area where “trapped” pathogens can survive and grow. A circumcised penis, on the other hand, has no foreskin and less area for pathogens to enter the body, grow, and spread.
  • Reduced risk of urinary tract infections (UTIs). UTIs are infections that affect the kidneys, ureters, bladder, or urethra. They are quite common in males up to age 1. The AAP reports that data consistently show an association between circumcision and reduced likelihood of UTIs. This may be because the foreskin on uncircumcised males provides an environment for bacteria to grow.

Risks of Circumcision

Complications of circumcision are not common. However, the AAP reports that the following problems could occur with the circumcision of newborns:

Acute Complications

  • Bleeding
  • Infection
  • Inflammation
  • Imperfect amount of tissue removed
  • Penile injury

Late Complications

  • Adhesions
  • Skin bridges
  • Meatal stenosis (a narrowing of the opening of the urethra)
  • Phimosis (an inability to pull back the foreskin)
  • Epithelial inclusion cysts

Major complications, such as glans or penile amputation and transmission of herpes simplex virus, are considered rare.

Boys circumcised between the ages of 1 and 10 are more likely to have complications than newborns, but these complications are still rare in the United States. In this age group, general anesthesia is necessary, which adds risk.

The AAP stresses that newborns should undergo circumcision only if they are stable and healthy. Only trained clinicians should perform the procedure, which should be done in a sterile environment with proper pain management.

Education on Circumcision

The AAP policy states that parents should learn about circumcision early – even before conception, if possible – so that they can take their time making their decision. They should receive factual, accurate, non-biased information about the procedure, its benefits, and its risks. And they should be instructed in the care of their son’s penis, whether he is circumcised or not.

The AAP makes educational recommendations for healthcare providers as well. Clinicians performing circumcisions should be properly trained in the procedure and in analgesic techniques during post-graduate training programs. The AAP also calls for training materials that will help practitioners discuss circumcision with parents.

Parental Choice About Circumcision

Ultimately, the decision to circumcise is up to the parents. The AAP recommendations state, “Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.”

Learn More

You can access the AAP’s complete report on circumcision, which outlines all of the recommendations and the rationales behind them.


Medline Plus

“Circumcision – series”

(Last update: November 7, 2011)

“Meatal stenosis”

(Last update: September 3, 2010)

MedPage Today

Fiore, Kristina

“Circumcision is a Matter of Parental Choice”

(August 27, 2012)

Pediatrics – American Academy of Pediatrics

Task Force on Circumcision

“Circumcision Policy Statement”

(August 27, 2012)

Task Force on Circumcision

“Male Circumcision”

(Originally published online: August 27, 2012)

World Health Organization

“The Global Prevalence of Male Circumcision”


Good Vibrations Sex Summit

In this space, we talk about aspects of sexual health and how they affect our patients. While this includes clinical conditions, such as diabetes or an enlarged prostate, it also includes communication. Sex isn’t always easy to talk about and it takes practice to get the conversations going.

These discussions don’t happen in a vacuum, of course. We need to put them in the context of our current culture. But how can we get our bearings on the sexual climate around us?

Targeting that question, the Good Vibrations Sex Summit was recently held in San Francisco. Presented by Good Vibrations, a California-based retailer of sex products and education materials, the conference featured a number of speakers and educators to “explore our sexual state of the union.”

While we were unable to attend the conference, we wanted to highlight the planned panel discussions, as we think they offer some excellent jumping-off points for putting sexuality in a broader context.

Below, we share the panel descriptions from the conference press release and offer questions to consider for our own patients. Please keep in mind that our discussion is our own and that these questions were not necessarily brought up during the panels themselves.

“Regulating Pleasure: Sex, Politics, and Censorship”

“Sex is regarded differently from other elements of life and is arguably regulated more than anything else, whether it’s restrictions on sex education, limited definitions of relationships, censorship of sexual images, laws against certain kinds of sexual expression, or circumscribed civil liberties. The opening panel will explore some of the causes and effects of this social bias, including trends in censorship and sexual politics, and how some people are bringing a more sex-positive slant to this anti-sex playing field.”

How might these issues apply to your patients and practice? Your patients may include the following:

  • an adolescent boy who wants to learn how to use condoms correctly, but has no sex education at school and feels he can’t talk to his parents
  • a mother angry that her daughter’s English class is reading a “sexually-explicit” book
  • a man who wants to marry his same-sex partner but is facing legal challenges on partner benefits
  • a couple who wants to try an open relationship, but is unsure of what parameters to set and how to explain their arrangement to their families and friends

Can you think of other ways sex regulation impacts your patients?

“Outspoken/Unsaid: Sex & Media”

“How does the use of sex to sell products affect sexual attitudes? When movies and TV become substitutes for sex education, what happens to our relationships? Why does porn get blamed for becoming more explicit, while sexy images elsewhere get a pass? Our media experts will explore these and other questions and discuss what they see happening on our screens and in our publications.”

Your patients are likely bombarded with sexual messages. To what extent do you think they’re influenced by what they see and hear about sex?

  • Do your patients believe that buying a certain car or using a certain hair care product will attract a sexual partner? Is that true?
  • Do your patients believe that safe sex practices are important if they don’t see movie and TV characters following them?
  • What are your patients’ thoughts on “adult” fashions for young girls? Do they buy them? Why or why not?
  • Are sexual images and storylines in the media realistic?
  • What becomes the reality and how do patients reconcile what they see with what they feel and believe?

What are some other ways patients may be swayed by sex in the media?

“Pills, Profits & Pleasures: Sexual Health & Pharmaceuticals”

“The increase in pharmaceutical and medical treatments for sexual concerns has shifted the definition of “sexual health” even further towards a performance model. But for all of the challenges that sexual medicine creates, it also can have the potential to change lives and improve sexual experiences. This panel will explore how our sexual lives are shaped by the medicalization of the erotic body and the workings of the medical industry, what benefits and challenges medical science can offer, and how alternative perspectives can contextualize the pharmacological point of view.”

Here at, we often cover medical treatments for sexual problems and always hope our readers benefit. However, we know that such medical treatments are not without risks and concerns. Here are some questions your patients might be thinking about:

  • If my husband takes medication for erectile dysfunction, will it increase his libido? Will I be able to satisfy him? Will he have affairs?
  • How will my partner react to my penile prosthesis? Do I have to tell her or him? What is the best way to do that?
  • If I’m not interested in sex, is there something wrong with me? Do I need treatment?
  • Intercourse has always been difficult for me because of pain. How can I explain this to my new partner? Will he end the relationship?

What are some other questions your patients might ask in light of treatments for sexual problems?

“Sexual Stargazing: Sex and Popular Culture”

“Cultural attitudes about sex are changing faster than ever before and popular culture, fueled by technological changes, help create these shifts. This panel asks, what is it about celebrities that makes us so interested in their sex lives? Do we really want them to serve as role models? How can we use the contemporary folkways of mass culture to create different representations of sex?”

  • Why do celebrities and their sex lives make headlines?
  • Why do people care about who is cheating on whom?
  • Do celebrities’ sexual issues make us feel better or worse about our own?
  • Do we compare our lives to theirs?
  • Do their actions lead to acceptance and become the new norm?

While these might not be questions we’d ask our patients directly, it helps to consider them. Changes in cultural attitudes can play a large role in how our patients approach sex.

The Big Picture

We may work with our patients on the smaller aspects of sexual health. But even the smallest of issues are part of a big picture, shaped by culture. Keeping an eye on the wider context can help us better serve our patients and clients.


Good Vibrations

“About Good Vibrations”

 “Good Vibrations 2012 Sex Summit”

“Good Vibrations: Making the World a More Pleasurable Place”

PRWeb via San Francisco Chronicle

“Sex and Media, Medicine, Politics and Pop Culture Get their Due at Good Vibrations’ 2012 Sex Summit Conference”

(Press release. October 4, 2012)

Addressing Fertility and Sex Health Issues for Veterans

An Army doctor tends to a simulated wounded soldier in a training exercise.Many of our patients dream of having a family. When fertility problems interfere, the effect can be devastating. Couples face difficult decisions about adoption, surrogacy, and in vitro fertilization (IVF). Their attempts at having a family might not even work, adding more anxiety and frustration.

When one member of the couple is a wounded veteran, the situation can take another turn.

Many veterans struggle with injuries to their genital and pelvic areas, which can make conceiving a child difficult. Men with testicular damage may have problems producing sperm. Those with spinal cord injuries may have problems with ejaculatory and erectile function. Women may have damage to the uterus.

The Department of Veterans Affairs (VA) has provided limited access to certain reproductive services, such as IVF. For example, the VA has covered the retrieval of sperm from a male veteran, but not covered the rest of the IVF process, which includes forming embryos, transferring them to the mother’s uterus, and accompanying hormone injections. Not all trials result in a pregnancy and sometimes this cycle is repeated multiple times, costing thousands of dollars that the couple must pay out of pocket.

However, a bill before Congress may provide some help. On September 12, the Senate Committee on Veterans Affairs approved the Women Veterans and Other Health Care Improvement Act of 2012, designed to improve access to fertility and reproductive healthcare for veterans.

Washington Senator Patty Murray, Chairman of the Veterans Affairs Committee, introduced the bill in June. In a press release, Senator Murray said,

“Reproductive injuries are some of the most impactful and serious wounds of these wars. VA has an obligation to care for the combat wounded. For those with such catastrophic injuries, that includes access to the fertility care they need. Veterans and their spouses are specifically barred from accessing In Vitro Fertilization services at the VA and often times have to spend tens of thousands of dollars in the private sector to get the advanced reproductive treatments they need to start a family. These veterans deserve far more.”

Specifically, the legislation would provide the following:

  • Enhanced reproductive treatment and care for severely wounded veterans, including access to IVF, which is currently excluded from the VA’s medical benefits package. This would also include surrogacy. For example, if a female veteran’s uterus is injured and she cannot carry a child, one of her fertilized embryos may be implanted into a surrogate’s uterus.
  • Fertility treatment for an eligible family member or surrogate of a severely wounded veteran, at the same level of the veteran’s eligibility. For example, if a veteran’s sperm is retrieved and an embryo is implanted, his spouse would receive fertility treatment.
  • More research on the long-term reproductive healthcare needs for veterans, including infections specific to men and women and reproductive and urinary tract trauma sustained in battle.
  • A childcare program for veterans receiving readjustment counseling at VA’s Vet Centers.
  • Improved outreach to women veterans, ensuring that they are aware of and can access VA health care and benefits.

The Women Veterans and Other Health Care Improvement Act has been sent to the House and Senate for consideration. The time frame for further action is unknown, but as practitioners, it’s worthwhile to follow this bill and determine how it would affect our current patients.

Do you serve many veterans in your practice? What are your thoughts on the proposed legislation? Feel free to share your views by leaving us a comment.

To learn more about problems that may face your male patients with spinal cord injuries, please click on the following links:

Spinal Cord Injury
Retrograde Ejaculation
Spinal Cord Injury and Ejaculation

For information on sexuality for women with spinal cord injury, this link may be helpful:

Women and Spinal Cord Injury

This link provides information on sexuality for both men and women with spinal cord injury:

Adjusting to Spinal Cord Injury



Associated Press via ABC News
Tucker, Eric
“Senate Panel OKs Veterans Infertility Bill”
(September 12, 2012)

Associated Press via the Huffington Post
Tucker, Eric
“Veteran Fertility Coverage Could Be Expanded Thanks To New Bill”
(August 18, 2012)
“S. 3313: Women Veterans and Other Health Care Improvement Act of 2012”
(Status check of bill. Accessed September 18, 2012)

United States Senator Patty Murray
“Chairman Murray Introduces Bill to Provide Veterans with Genital and Reproductive Wounds with Access to In Vitro Fertilization through the VA”
(Press release. June 19, 2012)

“Women Veterans and Other Health Care Improvement Act of 2012”


Col. Lionel M. Nelson assists Soldiers during a Mass Casualty training exercise.
Public Domain
Wikipedia Commons

Performance-Enhancing Drugs and Sexual Health

It’s not hard to miss stories about “doping” – using performance-enhancing drugs or PEDs – in the news these days.

In July, several athletes were suspended from competition in the London Olympics after failing drug tests. And 16-year-old Chinese swimmer Ye Shiwen sparked controversy after her stunning victory in the 400-meter individual medley. (The swimmer has denied using PEDs and, according to The Guardian, was deemed “clean” by Colin Moynihan, chairman of the British Olympic Association.)

This month, Major League Baseball suspended San Francisco Giants left-fielder Melky Cabrera for 50 games after he tested positive for testosterone use. And Lance Armstrong was stripped of his seven Tour titles after he declined to contest a case against him for blood doping

We often associate PEDs with famous athletes. But such drug use isn’t confined to the sports world. Some of our own patients may be using them, including men, women, and teenagers.

PEDs have a wide range of side effects and health risks, from acne to heart problems. Today, we’re going to talk about how one type of PED – anabolic steroids - affects sexual health.

What are Anabolic Steroids?

Anabolic steroids, sometimes called anabolic-androgenic steroids, are based on the male sex hormone testosterone or a synthetic form of it. Testosterone is important for building muscles and for the development of male sex characteristics, such as a deeper voice.

These drugs are sometimes prescribed for conditions stemming from testosterone deficiency, such as delayed puberty. They may also be prescribed to people who have lost significant muscle mass from diseases like AIDS and cancer.

However, some people take anabolic steroids to enhance their physical appearance or build strength and performance. Some find that the added aggression brought on by anabolic steroids gives them a competitive edge.

The Mayo Clinic explains, “Besides making muscles bigger, anabolic steroids may help athletes recover from a hard workout more quickly by reducing the muscle damage that occurs during the session. This enables athletes to work out harder and more frequently without overtraining.”

Anabolic steroids can be taken orally or by injecting them into the muscles. They may also come in the form of a gel or cream applied to the skin.

Sexual Problems Caused By Anabolic Steroids

Anabolic steroids are associated with a number of sexual problems. In men, common issues are:

  •  Testicular atrophy - a shrinking of the testicles
  • Gynecomastia - the development of noticeable breasts
  • Reduced sperm count or infertility
  • Enlargement of the prostate gland
  • Decrease in natural testosterone production
  • Erectile dysfunction
  • Common issues for women include:
  • Enlargement of the clitoris
  • Changes in menstrual cycle
  • Hormonal issues

Anabolic steroids have also been linked to:

  • Elevated blood sugar, which may lead to diabetes and, in turn, erectile dysfunction.
  • Increased aggression (“roid rage”) or depression, which may affect personal relationships, including intimate ones.
  • Risk of HIV and hepatitis transmission, if users inject the drugs.
  • Increased cholesterol, which may interfere with blood flow to the genitals. In men, this increases risk for erectile dysfunction
  • Changes in body appearance, such as breast development in men or facial hair in women. This may lower one’s sexual self-confidence.

Other Risks With Anabolic Steroids

Other risks associated with anabolic steroids are:

  • Dosage. Anabolic steroid users often take 10 to 100 times more than what is safely prescribed by doctors for medical uses.
  • “Stacking.” Some users use anabolic steroids in conjunction with other performance-enhancing drugs or dietary supplements in a risky process called “stacking” because they think they’ll achieve better effects.
  • Black market. Because anabolic steroids are only available by prescription in the United States, many users buy them on the black market. As such, there is no guarantee of the drugs’ safety, purity, or accurate labeling.
  • “Designer drugs.” These types of synthetic anabolic steroids are designed to help users pass drug tests, as they are undetectable. Unlike prescription anabolic steroids, these drugs are not approved for medical use. They are also not approved by the U.S. Food and Drug Administration (FDA).
  • Illegality. Non-prescription steroid use and production is illegal in the United States. Most major sports organizations prohibit them. Users may find themselves in legal trouble and/or banned from playing sports.

Are Your Patients Using Anabolic Steroids?

If you suspect one of your patients is abusing anabolic steroids (for example, if you see a patient with unusually large muscles), ask about it. While patients may not volunteer this information, it’s helpful to remind them that their honesty helps you help them. Reassure them of confidentiality and provide a trusting environment.

If they reveal anabolic steroid abuse – or any drug abuse – to you, don’t be judgmental. Calmly discuss the situation, the repercussions of continued use, and referrals to a drug treatment program, as appropriate.


BBC News
Heald, Claire
“London 2012 Olympics: Q & A on Drug Testing”
(July 31, 2012)

The Guardian
Addley, Esther
Ye Shiwen calmly takes another gold as drug claim storm rages around her
(July 31, 2012)

Mail Online
Moroccan, Belarusian and Colombian athletes suspended after failing drugs tests
(August 4, 2012) -athletes-suspended-failed-drugs-tests.html

Mayo Clinic
Performance-enhancing drugs: Know the risks
(December 23, 2010)

McKesson Health Solutions / RelayClinical Education (accessed via Agawam Public Library databases
Rouzier, Pierre.
“Anabolic steroids.”
RelayClinical Education. Vol. 2011.
McKesson Health Solutions LLC, 2011. 
Health Reference Center Academic
Web. 21 August 2012.
Haft, Chris “Melky banned 50 games for testosterone use
(August 15, 2012)

National Institute on Drug Abuse 
DrugFacts: Anabolic Steroids
(Last updated: July 2012)

NSW Health
Anabolic Steroids – Let’s Get the Facts Right
(1999, 2002)
Hecht, Mitchell Ask Dr. H: Harm steroids, other drugs can do to athletes
(August 7, 2012)

Steroid Abuse
(Last updated: June 30, 2011)


flickr user Andres Rueda, cc-by

The Looming Crisis in Sexual Health Education

Think back on your training as a healthcare professional. How much of your formal education focused on sexual health? Did you take courses specifically in sexual health or were sexual health topics mixed in with other content? Were any courses in sexual health mandatory? Were they offered as electives?        

Now that you’re working in the healthcare field, do you feel well-trained to respond to sexual issues with your patients or clients?

It might be true that your practice doesn’t focus much on sexual health or that these issues just don’t come up that often. However, given that sexual health is an important part of overall health, it’s worthwhile to consider how much time medical schools devote to sexual health education.

There is some sobering news.

The Situation

In 2010, Galletly et al. reported in Academic Psychiatry (citing previous research) that less than half of American medical schools have formal sexual health curricula. Physicians don’t feel prepared to address sexual issues with patients, who are becoming less confident in their physicians’ abilities to help them with sexual complaints.

Galletly et al. found that there is little consensus among American medical schools on what sexual health information students should be expected to master. Many schools focus on only a few areas, usually sexually-transmitted infections and the effects of illness and medications on sexual function.

However, topics concerning healthy sexual function are not commonly addressed. The authors also noted that medical schools could offer strategies for conducting sexual health screenings during busy, time-compressed office visits.

In the case of content related to lesbian, gay, bisexual, and transgender (LGBT) patients, the news could be better. In a 2011 study published in the Journal of the American Medical Association, Obedin-Maliver et al. found that among 132 U.S. and Canadian medical schools, a median of just 5 instructional hours was devoted to LGBT topics.

“Our understanding of LGBT health issues is poor,” lead author Dr. Juno Obedin-Maliver told Shots, the health blog of NPR. “We don’t ask patients about it and we don’t perform research on it. We know little bits about some populations in certain settings, but it remains a hidden population and therefore a hidden health demographic.”

Dr. Obedin-Maliver is a resident physician in obstetrics and gynecology at the University of California, San Francisco.

What Can Be Done?

Colleagues at the Program in Human Sexuality at the University of Minnesota Medical School have suggested a sexual health education summit for medical school educators.

The summit’s goals would include:

·       Assessing the current state of sexual health education in U.S. and Canadian medical schools

·       Discussing strategies for improving sexual health education, such as determining how much training is necessary and which content areas are essential

·       Making recommendations for curricula that will properly prepare medical students to address their patients’ sexual concerns

·       Recommending a “comprehensive and integrated” sexual health curriculum that every U.S. and Canadian medical school can follow

At this time, a date for the summit has not been set.  Interested parties may contact Eli Coleman at the University of Minnesota at

What Can Individual Practitioners Do?

Even if you’re finished with medical school, there are still a variety of ways to learn more about sexual health.

·       Participate in continuing medical education (CME) programs and courses.

·       Attend conferences and seminars related to sexual health.

·       Join professional organizations or check their websites for informational materials geared to healthcare providers.

·       Stay up to date on sexual health news and research by reading peer-reviewed journals, such as the Journal of Sexual Medicine.

·       Talk to your colleagues. How have they handled sexual medicine topics in the past? What are they doing to learn more?

Over time, we can ensure a complete sexual health education for current medical students as well as practitioners already in the field.


Academic Psychiatry
Galletly, Carol, PhD, et al.
“Sexual Health Curricula in U.S. Medical Schools: Current Educational Objectives”
(September-October 2010)

Journal of the American Medical Association

Obedin-Maliver, Juno, MD, MPH, et al.
“Lesbian, Gay, Bisexual, and Transgender-Related Content in Undergraduate Medical Education”
(September 7, 2011)

Sexual Medicine Society of North America
“Summit on Medical School Education in Sexual Health”

Shots (NPR)
Barclay, Eliza
“Med Schools Fall Short on LGBT Education”
(September 7, 2011)

Summit on Medical School Education in Sexual Health

Sponsored by
Program in Human Sexuality
Department of Family Medicine and Community Health
Medical School
University of Minnesota

Supported by the Joycelyn Elders Chair in Sexual Health Education

The Problem:  A Crisis in Medical School Education in Sexual Health

In 1997, Marian Dunn completed a survey on trends in sexuality education in United States and Canadian medical schools and reported a cautious but encouraging trend.
In a more recent study in 2003, Solursh et al reported a more sobering report that most medical schools provide only 3–10 hours of instruction. Of 101 medical schools who responded to their survey, human sexuality was taught as a course in only 31 schools and was required by 26 of them. Most schools did not provide specific clinical programs or continuing medical education.
I fear that if a survey was conducted today – that the number of courses has declined.
In a study in 2010, Gallety et al  reported that in examining sexual health curricula, there was no consensus about many of the attitudinal objectives and some of the skills medical students should acquire in sexual health. There was less consensus on the sexuality-related information student physicians need to master. The few common informational objectives focused narrowly on diagnosing sexual dysfunction and disease. They concluded that the model sexual health curricula, licensing exams, and guidelines from professional organizations mainly focus on the pathological aspects of sexuality. They recommended that student physicians should master fundamental information on healthy sexual function and become familiar with the roles of practitioners in various therapeutic disciplines in addressing sexual concerns and enhancing patients’ sexual functioning and well-being. Instruction should also address ways to incorporate this important topic in time-limited interactions with patients. Abstract Teaser
Most recently, in a study published in 2011 in JAMA, Obedin-Maliver et al reported that the median reported time dedicated to LGBT-related content in medical school in 2009-2010 was 5 hours, but the number of hours in the required curriculum, as well as number of LGBT-related topics covered, varied widely. In many schools, deans of medical education endorsed dissatisfaction with their institutions’ coverage of LGBT-related topics and provided potential strategies for increasing curricular content.  
Recently, there has been a push for more sexual diversity training – albeit insufficient – but general training in sexual health may have suffered even more.
Meanwhile there are major shifts occurring in overall medical school curricula today. There is a move away from stand-alone courses and a push for more integrated learning.  This puts whatever sexual health education at risk at most medical schools and my anecdotal observation is that we are losing ground.  There is more opportunity for integrating sexual health into the mainstream courses – yet there is a need for a model for doing so and major faculty development efforts are needed.
At the same time, the need for preparation of medical students to be able to attend to the myriad of sexual health problems faced by their patients is very clear.  We have a public health imperative to address these problems.
There are many questions:
  • Is there still a need for a stand alone course in human sexuality?
  • How much training is needed?
  • What are the best methods for teaching this type of course?
  • Beyond sexual history taking, what are the essential content areas?
  • What should be required and what should be elective?
  • Recognizing that sexual health should be taught in an integrated and longitudinal fashion, what is the best model for delivering that curriculum?
In this shifting climate of sexual health curricula, no model of how to fit sexual health into the “new” curricula has been established. 
Summit Purpose:
This sexual health education summit will gather key US and Canadian medical school educators in sexual health education, medical school educators, and interested parties at the federal level (CDC, HRSA) to examine the situation, discuss the challenges and opportunities, share lessons learned, and make recommendations for insuring that physicians are properly trained to address the sexual health needs of their patients when they go out in practice.  This will involve recommending a comprehensive and integrated sexual health curriculum that should be put into place in every US and Canadian medical school.  This summit and meeting report will serve as a catalyst for re-invigorating the necessary sexual health curriculum to meet the needs of physicians of the future.  
Format:  1 ½ days.  Leaders will be invited to review a commissioned background paper on the state of sexual health education in the US and Canada and recommended curriculum changes.  Each of the invited speakers will share their perspectives in a think-tank format with brief presentation followed by extensive discussion.  Interested parties will be invited as observers and will be permitted to ask questions and make comments at certain intervals of the process.  A meeting report will be prepared and disseminated to interested parties and key stakeholders.  
If interested, contact Eli Coleman at

Discussing Sex with Female Patients

To what extent do clinicians discuss sex with their female patients? The results of one study may surprise you.

Researchers from the University of Chicago Medicine recently reported that OB/GYNs don’t talk about sex nearly enough.

After surveying over 1,100 American OB/GYNs, the researchers found that while 63% did discuss sexual activities, many left the conversation at that. Only 40% asked patients if they had any sexual problems.

Fewer still asked about sexual satisfaction and pleasure. Most did not ask about a patient’s sexual orientation or identity. And about a quarter of the participants expressed disapproval of their patients’ sexual habits.

Sex is often hard to talk about. For many – providers and patients alike – it’s embarrassing, awkward, or even an invasion of privacy.

But it’s important. Sexual health and overall health are connected on so many levels. Sometimes sexual problems are signs of underlying physical conditions, like diabetes or cardiovascular disease. Sexual problems can also lead to strained relationships, anxiety, and depression – all issues that can interfere with a patient’s quality of life.

Today, we’ll share some tips on how to have sexual conversations with female patients. (Many of these tips apply to male patients, too.)

Explain why you’re starting the discussion.

Let patients know how assessing sexual health helps you help them. Explain that you ask similar questions to all your patients and that doing so is part of a routine medical exam.

If you can give specific examples to explain why you’re asking certain questions, do so. For example, you might say, “Many menopausal women find that their sex drive decreases. Is this a concern for you?”

Ensure comfort and confidentiality

Make sure the patient knows that the conversation is between the two of you (unless she has allowed you to share information with others). If you cannot ensure that the conversation will be confidential, explain this before you get started.

Consider the 5 Ps

The Centers for Disease Control and Prevention (CDC) has outlined the “5 Ps” of sexual health, which can guide the content of a conversation. The 5 Ps are:

·         Partners. Is the patient sexually active now? How many partners has she had in the last few months? Does she have sex with men, women, or both?

·         Practices. What kinds of sex does the patient current have (vaginal, anal, or oral)? What kinds has she had in the past?

·         Protection from STDs. What kind of protection does the patient and her partner(s) use? Do they use this protection consistently? If they don’t use protection, is she willing to tell you why?

·         Past history of STDs. Has the patient ever had an STD diagnosis? How was the STD treated? Would she like to be tested for HIV or other STDs? How about her partners? What is their STD status? Have they had STDs in the past?

·         Prevention of pregnancy. Is the patient currently trying to conceive? Is she using birth control? What kind?

Of course, these questions are only suggestions. You can adjust them to fit your own patients’ needs.

The answers, however, should yield some important information and “jumping off points” that can help direct your next steps. Does the patient need STD testing? What kind? Does she need a referral to counseling for relationship issues? Should you refer to her to a specialist? Does she need more guidance and education about safer sex practices? Can you suggest resources to help her?

Don’t judge.

Imagine you have a female patient who has had many sexual partners over the last year and does not always use protection. You’re concerned about her risky behavior, the possibility of STDs, and the risk of unplanned pregnancy. You wonder if her relationships are healthy ones and how her decisions affect her mental health.

Your first instinct may be to shake your head and say, “In this day and age, why aren’t you using protection? You should know better!”

Consider her angle. Revealing this information was probably difficult and scary for her. A judgmental response could make her less likely to follow through with testing and treatment.

Instead, be encouraging. Kindly suggest appropriate testing, safer sex, or other referrals, as appropriate. Let the patient know that you’re there to help.

Use inclusive language

Don’t assume that your patient is heterosexual. Some women have sex with only men; some have sex with only women. Some have sex with both men and women. So be careful not to alienate your patient or breach the trust she has placed in you by making assumptions.

Try using inclusive language. For example, instead of asking, “Do you have a boyfriend?” ask “Are you dating anyone?” You could also ask if your patient is in an intimate relationship and, if so, how monogamous that relationship is.

Ask if the patient has any questions

In this dialogue, the patient should have multiple opportunities to ask questions. It takes time to build rapport and trust, and she might not feel comfortable bringing up certain topics until later in the conversation. Or, something else might occur to her during your discussion.

Also let her know that you and your staff are available to answer any questions she may have after the visit.

Ask colleagues for help if you need it

If you’re nervous about taking a sexual history, ask a colleague for guidance. You might consider role-playing for practice. Keep up to date with sexual health news and research, especially the topics that most affect the populations you serve.

The more confident you are in discussing sex with your patients, the more confident they will be in sharing their experiences with you. Help them see that this conversation is an opportunity to work together toward healthy outcomes.

Taking a Look at BPH

How To Help

If you suspect that a patient or client has an enlarged prostate, encourage him to see a urologist. Assure him that this is common for men as they get older. Your patient may feel that he should just accept the symptoms. Let him know that there are treatments available and many are routine. He should not let the symptoms interfere with his quality of life.

Also, assure him that an enlarged prostate is not the same as cancer, but emphasize that it is still important to have prostate cancer screenings. A urologist can advise on the best screening intervals.

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Recommending sources of info

At the American Academy of Pediatrics national conference last month, Dr. Purvi Shroff presented findings on parents’ Internet usage before taking a child to the emergency room. She noted that 11.8 percent of the 262 parents and guardians interviewed sought online medical information about the child’s problem within 24 hours prior to the ER visit. The majority of the Internet users said they were likely to visit sites recommended by a doctor.

How about your patients and clients? How often do they access health information? Do you recommend certain resources to them?

Health information is plentiful. Patients can access it through a variety of media, not just the Internet. TV, radio, newspapers, and magazines are all full of information.

But not all of that information is reliable. If patients are likely to look at resources we recommend, we need to make sure that information is the best it can be. We also need to be sure that the resources we recommend are appropriate for the audience.

Evaluating Resources

When you consider recommending particular resources, ask yourself the following questions:

·         Who is putting out the information? Does it come from an association or colleague your respect and trust? What are the credentials of those involved? Are authors listed?

·         If the information is compiled by a lay person, is it reviewed by trusted professionals before distribution?

·         Who is promoting the information? Does it come from a company selling a product? Does it come from a group that aims to change public opinion or policy?

·         How current is the information? Does it incorporate the latest research?

·         Is the information based on large, well-designed studies or is it based on anecdotal evidence or opinion?

·         How objective is the information? Does it discuss the pros and cons of the subject, if applicable?

·         What sources were used to substantiate the information? Were the sources peer-reviewed?

Audience Appropriateness

While the reliability of the materials you recommend is important, you also need to consider the patients who are receiving the information. Resources aren’t valuable if they’re not reaching their audience. Here are some ideas to think about regarding your patients:

Age / Phase in Life. Imagine two patients – we’ll call them Janet and Alicia. Janet is in her 50s, just starting to date again after ending her 25 year marriage. Alicia is 17 and thinking about becoming sexually active. Both are interested in learning more about STDs. Will you recommend the same resources?

Probably not. The tone that reaches a middle-aged woman will not always reach a 17-year-old.

But even if patients are closer in age, they might not be in the same phase of life. Kathy may be 20, in a stable relationship, and concerned about how her past experience with chlamydia might affect her pregnancy. Even though Alicia and Kathy might be closer in age, they still need resources that are tailored to them.

Literacy or Education Level. You might not know the literacy levels of your patients or clients, but during office visits, you might get a glimpse of their education levels. Be sure that the materials your recommend match what they can handle. This is not to say that materials should be dumbed down – far from that. But be sure that materials are in language they can understand. For example, a patient may be more likely to understand “enlarged prostate” than “benign prostatic hyperplasia.”

Language and Culture. Do you serve non-native English speakers? Recommending properly translated and culturally-appropriate materials can help this population.

Accessibility. Do your patients or clients have special needs? What accommodations can you make for those who are vision or hearing impaired?

Presentation. Some people prefer certain formats when receiving information. Some are visual learners; others retain more when they hear or see something. DVDs, podcasts, and online interactive tutorials are all viable options to consider.

Orientation. Your patient may not disclose sexual orientation to you. However, you should be able to recommend resources to people of all orientations.

Recommending appropriate materials makes it more likely that your patients will engage with them, understand them, and ask questions about them.

When recommending information, you might not have every kind of resource at your fingertips. You might not even be aware of new resources that are out. So it helps to have your eyes and ears open. Ask your colleagues what resources they recommend and seek feedback from patients.

Health information is always changing. Considering the information and the audience can help us recommend resources with confidence.

Talking to Patients About Marijuana Use

It’s not uncommon for healthcare providers to discuss sensitive subjects with their patients.  But handling two or more sensitive subjects at once, like sexual health and marijuana use, can be a challenge.  Both topics are entwined with a patient’s  overall well-being along with cultural norms and expectations. 

Discussing them together can be delicate.  You don’t want to alienate your patient, but you do want to make sure he or she gets proper care.

Many practitioners do not want to pry into a patient’s drug use or sexual health, but since drug use can have a huge impact on sexual health, it’s important to know how to talk about them.

The pointers below refer to marijuana use, but can be adapted to other drugs. 

Understand Marijuana

According to 2009 statistics from the National Institute on Drug Abuse, over 28 million Americans over the age of 12 said they had abused marijuana in the previous year.  About 4.3 million were deemed addicted using DSM-IV criteria.  Almost 1 out of 11 people who try marijuana become addicted.  And for people who use marijuana daily, the addiction rate is 25% to 50%.

How does marijuana affect the brain?  Its primary active ingredient is called tetrahydrocannabinol, or THC.  When THC enters the human body, it attaches itself to proteins called cannabinoid receptors.  In the brain, these receptors are prominent in areas that affect pleasure, memory, and pain, among other functions.

Understand How Marijuana Affects Sexual Health

Some patients may tell you that marijuana enhances their sexual experience.  But marijuana use can have serious consequences for sexual health, including:

  • High-risk behaviors.  Marijuana affects judgment and decision-making.  People under its influence may be more likely to engage in unsafe sex, increasing the risk of getting or passing along sexually-transmitted infections (STIs).  Unintended pregnancies are also a concern, as are unwanted emotional issues, either during the act or after.
  • Orgasm issues.  Research has suggested that men who use marijuana daily are more likely to have problems reaching orgasm than non-users.  They are also more likely to experience premature ejaculation.
  • Erectile dysfunction.  A recent study in the Journal of Sexual Medicine reported that cannabinoid receptors are found in penile tissue.  The authors suggest that when THC attaches to these particular receptors, erectile dysfunction can result.
  • Testicular cancer.  Research has shown that men with testicular cancer were 70% more likely to be marijuana users.  This may be because cannabinoid receptors are also found in the testes.
  • Fertility.  Sperm cells exposed to THC are more likely to tire themselves out as they swim to an egg cell.  Some do not reach the egg at all. And if they do, they are less likely to fertilize it, since THC hinders the release of enzymes needed to penetrate the egg wall.

Women who use marijuana can also have fertility issues.  THC can travel to the uterus, cervix, vagina, and vaginal fluids, giving the sperm cells more opportunities for THC exposure.

Reserve Your Judgment

Even in the best of circumstances, it can be difficult for patients to open up about drug use or their sexual lives.  If they are worried about being judged, they may not want to give you their whole story.  Any details they omit could be critical to their care.

Remember that your goal is better health for your patient.  If you discuss these issues in an open, non-judgmental way, your patient may be more likely to be honest with you.  Make them feel comfortable about asking you questions as well. 

Be Aware of Resources

Sometimes, the severity of a patient’s drug use falls outside your expertise.  Know what resources are available in your local area and make referrals when necessary. 

Educate Yourself

Drug use and sexual health permeate many aspects of healthcare. Find out what issues are especially important for the population you serve.  Participate in workshops and trainings and stay on top of different trends.  If you are unsure which resources are most reliable, check with a colleague.

Keep the Lines of Communication Open

Let your patients know that you and your colleagues are always available to help.  If they are not ready to open up with you at first, they may do so later.

Discussing Sex with the Elderly

“One way to think about aging is that older people are younger people later in life.”

This observation is from Dr. Stacy Tessler Lindau, a University of Chicago researcher and lead author of a 2007 study of sexuality and older Americans. And it provides us with a good starting point for discussing sex with the elderly.

There seems to be a disconnect between sex and the older generations, an assumption that the elderly don’t have sex or aren’t interested in it.

But people can enjoy healthy sex lives well into their 70s and even their 80s. Sometimes they need to make some modifications, but overall there’s no reason to believe people’s sexuality changes just because they get older.

Here are some issues to consider as you discuss sex with elderly patients.

Attitudes – Yours and Theirs

Some find the idea of elderly people having sex distasteful, perhaps because sex is almost always depicted in the media as something for the young. A lot of people can’t imagine their parents having sex, never mind their aunts, uncles, or grandparents.

However, if we go back to Dr. Lindau’s quote above, it makes total sense that older people have sex. It’s an idea we need to embrace, if we haven’t already.

Still, older people come with their own attitudes toward sex. Much depends on culture, upbringing, and the social mores in place when they came of age, especially for women. Before the “Sexual Revolution” of the 1960s and 1970s, many women were taught that it wasn’t normal for them to have sexual desire. And if they acted on a human need for sex, they were considered “loose” or “damaged goods.”

This might make it difficult for some patients to open up about what they want or need. Interestingly, as baby boomers – people who did experience the Sexual Revolution – age, they bring a different set of attitudes and may be more forthcoming.

No matter who you’re treating, try to understand where they’re coming from. They might feel reluctant about discussing sex, afraid they’ll be ridiculed. Reassure them that sex is a normal part of life for all ages.

Physical Limitations and Concerns

While sexual interest might be there, for many older people, the “equipment” just doesn’t function the way it used to. For example, most women have problems with lubrication after menopause. Many men find that their erections aren’t as firm as they used to be and may develop erectile dysfunction. Both men and women might need more time to become aroused or reach orgasm.

Diseases and medications may also have an impact. Arthritis may make some positions painful. Some people with coronary artery disease experience chest pain when having sex and might be afraid of a heart attack. Others may have had surgeries, such as a mastectomy, that make them self-conscious in front of their partner. Medications can cause problems with sex drive and performance as well.

If physical limitations are an issue, modifications can be made. Patients should first talk to their physicians. Lubricants can help women. Some men may be able to take erectile dysfunction drugs. Couples can also experiment with different positions so that sex is not painful.

Reassure the elderly that while sex might take more time and more adjustments, they can still enjoy the journey and find intimacy.

Sexually Transmitted Infections

Sexually transmitted infections and diseases are on the rise among older populations. According to the U.S. National Institute on Aging, 25% of people with HIV/AIDS are age 50 and older.

For many older people, the dating world isn’t the same. Many people might be dating again for the first time in decades, after long, committed marriages. While sexually transmitted diseases like herpes, syphilis, and gonorrhea existed many decades ago, HIV is newer.

And some older people are naïve about safe sex, thinking STDs can’t happen to them. Therefore, men who find condoms uncomfortable forgo them. Some women might feel awkward about asking a partner to use one. They may feel it’s not necessary, since after menopause, pregnancy is not a worry. Both men and women may feel uncomfortable asking about a partner’s sexual history, that doing so is rude or intrusive.

Safe sex education applies to all generations. If your patients seem hesitant to talk about safe sex practices, let them know why it’s important. Let them know it’s okay to ask questions – of you or their partners – and be ready to give them more information if they need it.

Availability of Partners

Even though people are living longer than they did generations ago, many elderly people find themselves without partners. They might be coping with the death of a spouse or long-term partner. Or, they may be entering the dating scene again after a divorce. For many, the idea of finding a new partner fills them with anxiety.

Women, especially, tend to be without partners when they’re older. One reason is that women tend to live longer than men. Another is that many men in their age group have relationships with younger women.

If your elderly patients want to find new partners, be encouraging. Suggest ways that they can meet new people; senior centers, book groups, vacation tours, and even the Internet can provide plenty of opportunities. They might also ask their friends to introduce them to others. Even if new relationships don’t develop immediately, the new friendships they make can take the edge off any loneliness.


Getting older isn’t always easy. Sex for the elderly may have its obstacles, but it may also bring much pleasure and happiness. 

Treating Patients from Different Cultures

Discussing sex with patients can be awkward and uncomfortable even in the best of circumstances.  But if patients come from a culture different from your own, that can pose another challenge.  You want patients to be open with you so you can get accurate information.  However, not every culture treats sex the same way.  What can you do as a provider? 

One starting point is understanding.  Your perspectives and those of your patients aren’t always going to match.  Try to see where your patients are coming from. 

Remember that what’s “wrong” in your culture isn’t necessarily “wrong” in another.

Let’s look at female circumcision (often called female genital mutilation or FGM) as an example.  FGM is a cutting of young girls’ genitals for no medical reason.  It can have some serious health repercussions, including infections and infertility.  While the ritual is quite common in some African countries (such as Egypt, Ethiopia, Somalia, and Sudan), most western healthcare providers consider it unacceptable and a violation of human rights. 

Why are young girls cut in this way?  Many of these cultures place a high value on female virginity and believe that a woman’s libido can be controlled by FGM.  A girl who has been circumcised is often seen a more attractive marriage partner. For some girls, the ritual is a rite of passage and a time of celebration.

This does not mean that you have to accept FGM.  However, understanding its rationale can help you work with a patient who has undergone FGM or is considering it for a daughter.  You can then explain the western perspective, the serious risks and consequences, and the reasons it is not done here.

Respect modesty.  Assign same-sex providers when appropriate.

In some cultures, women must be covered at all times and cannot be seen by a male provider.  It is best to assign same-sex providers in these cases. 

Respect gender roles.

Men are the decision-makers in many societies, such as in Asia and the Middle East.  Some patients will only accept treatments or sign consent forms if a male family member gives approval.  Men may also answer questions for their wives or female family members.  Or, patients might only accept instructions from male physicians.  This situation may be contrary to what we know in the United States, but it can be respectfully handled by including men in the decision-making process.

Explain things as clearly as you can and check understanding.  Use an interpreter if necessary.

Words associated with sexual health may not translate directly from language to language.  For instance, Helen Osborne (2005) notes that there is no word for “cervix” in Vietnamese.  Be ready to explain what a body part is and how it works.  Keep in mind that in some cultures, girls get no sex education.

Watch body language.

For example, direct eye contact between males and females is considered a sexual invitation in some cultures.

Realize that not all cultures are open to discussing their problems with healthcare providers.

You might feel that sex therapy or couples counseling might benefit a patient.  But in some cultures, it’s unheard of to discuss personal issues with outsiders.  Those conversations are held only with family members or with members of a church.  You might need to find a different strategy or explain why talk therapy could help.

Any referral to counseling should be handled with care.  Some patients may see this as an suggestion of mental illness, which is highly stigmatized in some cultures.

Remember that even people who grew up in the same country can be of different cultures. 

Even if patient and therapist grew up in the same city, their experiences might be vastly different.  For example, Galanti (2008) explains that some African-American patients might not be open to therapy because many practitioners are white.  These therapists are not likely to relate to the African-American experience. 

Remember that you are still treating an individual. 

Be careful about over-generalizing.  Avoid stereotypes.  You might be treating a patient from another culture, but that does not mean that person follows every practice of that culture.  Keep an open mind.  For example, it’s inaccurate to think “All African women experience FGM” because that simply isn’t true.

Look for opportunities to learn more about cross-cultural communication and healthcare. 

See if your facility offers cross-cultural trainings.  If none are available, suggest some.  If your setting treats diverse populations, see what you can find out about the healthcare beliefs and practices of those groups.  Get to know people from these groups when you’re out and about in your community.

Treating patients from different cultures can be a challenge, especially for busy practitioners who are pressed for time.  But taking the time to understand where your patients are coming from can build trust and ease communication.  This should make the office visit go much more smoothly.

Understanding HSDD

Did you know that hypoactive sexual desire disorder (HSDD) affects about 1 in 10 women? 

It’s the most common of female sexual dysfunctions, but it’s underdiagnosed and undertreated.  Many practitioners aren’t sure of how to approach it with their patients.  Some clinicians feel uncomfortable discussing sex.  Others feel that they don’t have the expertise to handle HSDD complaints or that discussing sexual health will take up too much time during the office visit.

However, sexual health is important to overall general health.  And because HSDD can have medical and psychological implications, it’s best to keep it in mind when assessing your female patients or clients.

What is HSDD?

HSDD is a decrease or absence of sexual desire that causes a woman personal distress.  The “personal distress” aspect is critical.  Sexual desire varies from woman to woman. What might seem “normal” for one may not be “normal” for another.  If a woman is not bothered by her level of desire, then she probably does not have HSDD.   

HSDD is classified as generalized or situational.  In generalized cases, a woman lacks desire in most sexual circumstances.  When HSDD is situational, it only happens at certain times. 

HSDD can also be classified as acquired or lifelong.  Acquired HSDD happens after a woman has had normal functioning for some time.   

There are many possible causes for HSDD.  Common physical ones include diabetes, high blood pressure, and coronary artery disease. Certain medications, such as antidepressants, can affect sex drive.  And hormonal changes from pregnancy or menopause can play a role.

Psychological issues like stress, anxiety, depression, low self-esteem, and sexual abuse are other causes.  A woman might also lose her desire for sex if there are problems with her partner or relationship. 

Often, there is a combination of causes at work.  For example, a new mother might lose interest in sex because of hormonal changes and because she’s exhausted from caring for a newborn baby. 

HSDD can lead to, or worsen, poor self-esteem, anxiety, and problems with relationships. 

Patient/Provider Communication

Why is HSDD underdiagnosed and undertreated?

The problem may be communication – or lack of it.  Many healthcare providers don’t bring up the subject of sex.  It’s awkward sometimes.  There are cultural taboos.  Taking a sexual history may not be part of the everyday routine.  Some providers are afraid of offending their patients.  Or they might not feel confident in their abilities to handle sexual health issues.

Unfortunately, female patients are often just as – or even more – reluctant to bring up the subject.  Many women are brought up to believe that “nice girls” aren’t supposed to want to have sex or that their sexual needs aren’t important.  Some believe, or fear, that it’s all in their heads.

Also, many women simply don’t know about HSDD and that it’s a treatable condition.  A recent survey conducted by the Society for Women’s Health Research showed that women were 7 times more familiar with erectile dysfunction in men (ED) than with HSDD.  66% of the women surveyed knew about ED, but only 9% knew about HSDD. 

But remember, you and your patient are a team.  Your goal is to improve overall health and addressing sexual health concerns, when appropriate, is part of that goal.

So how can you approach the topic?

Establish rapport with your patient.  Help her understand the importance of sexual health and that it’s okay to discuss sexual matters.

For diagnosing HSDD, the Decreased Sexual Desire Screener (DSDS) is a helpful tool.  The DSDS is a five-point questionnaire that a woman can easily fill out during her office visit (click here to see the questions).  Provided instructions guide the practitioner in clarifying and evaluating the patient’s answers to determine if she does have HSDD.

After diagnosis, you can decide what next steps might be appropriate for your patient.  She may need to be screened for certain illnesses, have her hormone levels checked, or have medications changed.

She may also need a referral to a specialist, such as a sex therapist or counselor, to help her work through any psychological or relationship issues.

Learning More

You may not have received much sexual health training during your professional education.  But we encourage you to learn more about sexual health – and about HSDD in particular.  Find out what professional development opportunities are available for your clinical setting.  Read more about discussing sexual health with patients.  Talk to your colleagues about how they approach HSDD with patients and what strategies they use to discuss, diagnose, and treat it. 

Working together, healthcare providers can improve sexual health communication and get help for their patients with HSDD.

Treating Prostate Cancer: Will It Come Back?

If you work with prostate cancer patients, you’re probably familiar with the fear and anxiety they face.  Understandably, they want to know how serious their condition is and whether their cancer has metastasized.  What stage is their cancer in?  And, if treatment is successful, what is the likelihood that the cancer will recur? 

The last two questions can be difficult to answer.  And a recent study published in the November 22 online edition of Cancer, a peer-reviewed journal of the American Cancer Society, tells us stage and recurrence aren’t necessarily linked, at least not in men who have localized cancer (confined to the prostate) and who have had their prostates removed.

The study was conducted by researchers at the University of California at San Francisco.  Lead by Adam Reese, MD, the team studied data from 3,875 men with localized prostate cancer between 1995 and 2008.  “Localized” means that the cancer had not spread beyond the prostate.  The men also had their prostate glands removed in a procedure called a prostatectomy.

After analyzing the men’s data, the researchers concluded that the stage of cancer didn’t reliably predict whether cancer would come back. 

Typically, staging information is used to determine where a patient stands with an illness and whether the cancer is likely to recur after treatment.  

In the United States, prostate cancer is generally categorized into four stages.

  • Stage 1 - The cancer is located only in the prostate and the cells are microscopic.  Cancer at this stage can’t be discovered by a doctor’s digital rectal exam (DRE).

  • Stage 2 – The cancer remains within the prostate, but it has spread.  At this stage, doctors can detect the cancer with a DRE.

  • Stage 3 – The cancer has spread beyond the prostate to nearby tissues, but hasn’t reached the lymph nodes or other parts of the body.

  • Stage 4 – The cancer has spread to the lymph nodes and/or other areas, like the bladder or rectum.

It has been thought that patients in higher stages would be more likely to see recurrence, but, as this study shows, this isn’t always the case.

The University of California research team also discovered that 35.4% of the men had been staged incorrectly to begin with.  The main reasons for the staging errors were using biopsy results inappropriately and failing to consider transrectal ultrasound results. 

However, even when the researchers corrected these errors and staged the study subjects properly, the results were the same.  There was still no apparent link between stage of prostate cancer and the likelihood of recurrence.

Your patients may feel a bit unsettled by this news.  They might wonder what the point of staging is when it can’t tell them about their prognosis with any certainty.  They might also be concerned about proper staging.  What if their own doctors are misinterpreting or misapplying test data?  Could their cancer be in a different stage?  If their doctors are incorrect about their stage, what other mistakes could they be making?  And if they suspect that errors have been made, what should they do?

It’s important to remember that these study results applied only to a group of men who had been diagnosed with localized cancer and had had their prostate glands removed.  If your patients do not meet these criteria (for example, if their cancer has metastasized), the information does not necessarily apply to them.  

Your patients should feel free to discuss any questions or concerns with their doctors.   You can help them feel more comfortable doing so by reassuring them that their health care team is looking out for them and has their best interests at heart.     

Treating Diabetes: Talking about sex?

If you treat a man with diabetes, you might want to ask how his sex life is going.

That’s because there’s a strong link between diabetes and erectile dysfunction (ED). According to the American Diabetes Association, about half of men with diabetes experience ED at some point. And the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reports that diabetic men may experience ED ten to fifteen years earlier than men who don’t have diabetes.

Diabetes can damage the nerves and blood vessels needed for a man to sustain an erection. Normally, when a man is sexually aroused, a signal goes from his brain to his penis and starts the erection process. If there is nerve damage, this signal cannot be transmitted properly and the erection will either not happen or not be firm enough for sexual intercourse.

Similarly, in a healthy man, the sexual stimuli will cause the blood vessels in the penis to relax and expand, allowing the penis to fill with blood and become erect. But if there is blood vessel damage, this won’t happen the way it should.

In most cases, ED is caused by underlying physical problems. Diabetes is just one. Others include heart disease, high blood pressure, atherosclerosis, obesity, low testosterone, tobacco use, and alcoholism.

Fortunately, ED is treatable and a variety of options exist for men with diabetes. Common treatments include medication, injections, or devices like penis pumps. Sex therapy can also help men whose ED stems from psychological causes.

So it seems that treatment for ED would be the key to solving some of these issues. The problem is – a lot of men don’t want to discuss their sexual problems, even with their health care providers. Many don’t want to admit that they’re having trouble in the bedroom because it makes them feel “less of a man.” They may feel embarrassed and nervous or think that certain providers can’t help them.

Indeed, a recent poll of men and women over age 50, commissioned by LIFESPAN (manufacturer of 112 Degrees, a men’s sexual health supplement), indicated that roughly a third of men waited over a year before acting on their ED symptoms. In addition, while 100% of the men surveyed said they had symptoms of ED, only 32% of the women reported that there were ED experiences in their relationship.

Sexual performance is often tied closely to a man’s identity and self-esteem. Therefore, it’s not surprising that men with ED can be stressed and anxious about it. They may feel inadequate because they cannot please their partner and worry that their partner will go elsewhere for sexual satisfaction.

Relationship problems are a common complication of erectile dysfunction. Sexual issues aren’t always easy for a couple to talk about. They may isolate themselves and withdraw from the relationship. All of this can exacerbate the problem of ED. The more anxious a man feels about ED, his sexual performance, and his relationship, the worse the ED becomes.

Eventually, depression and anxiety can interfere with other aspects of his health, his other relationships, his job, and his overall well-being.

Communication about ED is important. But how do we get reluctant men talking?

Health care providers may need to start the conversation. If you suspect a man under your care has ED but isn’t seeking help, ask some questions. How is his relationship going? How are things at work? Has he been anxious or depressed?

Even if he doesn’t open up, you can still let him know that ED is common in diabetic men, that it’s nothing to be ashamed of, and that treatments are available. You can offer to refer him to a urologist or therapist. Or, he might decide to go on his own or discuss it with his partner.

No matter what happens, there’s no reason for a man to suffer in silence. It might be awkward, or outside your area of expertise, but just starting the dialogue may be all that’s needed for your client to move forward with treatment for his ED and on to a happier, healthier life.