Last week, the New England Journal of Medicine (NEJM) published a review article on the treatment of erectile dysfunction. Before you read the article (the link is provided below), I'd like to make a few observations:
1. Just two days ago, I sat in my office while a man in his 40's told me, "Doc, I love this woman but I'm afraid to get too close to her because I don't think I can perform in bed."
Yesterday, a woman came to my office for weight loss, but as we spoke, she began to cry. "Doctor," she said, "my husband just can't have sex anymore. I'm going to leave him. He sleeps in another bedroom and won't even discuss the issue any more. Before I leave him, I want to lose about 15 pounds because I want to be more confident about undressing for another man."
Both of these discussions are common in my practice where I make it comfortable for people to talk to me about sexual problems. But here's the tragedy, the second paragraph of an article in the New England Journal of Medicine (just last week!) reads, "Erectile dysfunction was once considered to be psychogenic in origin and was frequently neglected by health care providers. More recently, there has been increased recognition of the many physiological causes of the condition and of the potential for therapy to improve a patient's quality of life, self-esteem, and ability to maintain intimate relationships."
I'm grateful for Dr. McVary's very elegant review of erectile dysfunction (the tragedy is not in Dr. McVary's heroic efforts to improve the treatment of ED); the tragedy is that in 2007 we're reading in the New England Journal that "recently" doctors are recognizing that having a good erection improves a man's life and ability to maintain intimate relationships.
"Recently" in 2007 doctors think
erections help people maintain intimate relationships?!
"Recently" in 2007 doctors think that there may be a physical reason (it's not all in your head) that can be treated with medication/hormones and the treatment actually works?!
In summary, until "recently" (to put it bluntly) men with erection problems were told that it's all in your head and there's not anything we can do for you. Now we know there are physical reasons that can be treated with improvement in erections and in life in general.
2. Still, there's an unspoken fear that if you give a man excellent sexual capacity that he will be out and about town leaving the poor wife at home. Such may be the case with some but more often in my practice I see strained relationships, depression, broken families, and broken children (because of the broken family) as a side effect of the father's inability to have an erection.
3. Also, there is the legitimate fear by doctors of losing their license for writing a prescription for testosterone. Now that it's controlled like a narcotic by the DEA, if you write a prescription for testosterone you open yourself for close scrutiny by the narcotics agencies. It's alright to do surgery on a woman and implant foreign bodies to help her have a lager bra size, it's alright to risk death so suck the fat from her thighs or lower her waist line, it's even alright to take a bothered man and do an operation to change him into a woman and give him hormones to help him grow breasts is he has homosexuality with gender identity problems-but give hormones to a man to help him to look more like a man (muscle enhancement) and you risk a jail sentence. I DO NOT WRITE PRESCRIPTIONS FOR MUSCLE ENHANCEMENT OR FOR ANTI-AGING. But, every time I write a prescription to a man for testosterone (especially if he also takes my advice and exercises by running and lifting weights) I risk being accused of practicing anti-aging medicine.
I have written in the past that I think it a tragedy that it has become taboo to try address aging directly. Doctors can practice prevention (for which they are not likely to get paid) and practice treatment of disease. Treating disease will likely make you feel younger. Most of my patients look and feel younger after I treat them; but, I do not ever give hormones except to treat disease.
All of these political issues (and continued mistaken belief that testosterone causes prostate cancer) prevents many physicians from addressing hormonal issues of erectile dysfunction.
4. Also, unfortunately, even with such articles in the New England Journal, I can testify first hand that if you are a physician that makes an art of being very good at helping people with sexual function you risk be labeled with many different labels that do not compliment.
As a physician who trained in the 1980's and early 1990's, I can testify first hand that I was taught that erectile dysfunction was mostly a psychological problem and it was considered not really a serious problem and frequently overlooked. I was severely criticized by more than one of my teachers (attending physicians while I was working as a resident) for suggesting that we measure testosterone levels in depressed men and treat those levels if low.
My book (Anytime...for as Long as You Want: Strength, Genius, Libido, & Erection by Integrative Sex Transmutation [A 15-Day Course for Men to Improve Sex & Life]) describes an over all approach to health that gives the benefit of improved erectile function. Finally, it's becoming more common to recognize the role that obesity, smoking, diabetes, and hypertension play in causing ED and how addressing these problems can improve erectile function. The NEJM article supports this strategy.
5. The article recognizes the role that elevated prolactin and that thyroid plays in the development of erectile dysfunction but recommends checking those levels only if testosterone levels are low. I think this practice would overlook many men with elevated prolactin levels. I have found men with elevated prolactin with normal testosterone levels and found that they regained wonderful sexual function and enhancement of erections by simply taking a tablet used to lower prolactin levels (and did not need Viagra or testosterone).
6. The article recommends testosterone be applied to the skin rather than by injection. Using testosterone by application to the skin raises dihydrotestosterone levels (which increases hair loss and prostate enlargement). Testosterone does not cause prostate cancer but DHT is riskier so I prefer injection or pellets to avoid the skin's transformation of testosterone into something less desirable.
7. I still think there's a place for prescription strength Yocon. There was a 21% response rate before we had Viagra (before Viagra, Yocon was the only prescription available for the specific erection enhancement) and it has the added benefit of increasing libido. The man must be monitored for elevated blood pressure and I've found that going on and off the drug gives less side effects of irritability. But, I still think it has a place in our therapy (and it's not included in this article).
So, with those observations, you may benefit by reading this article. Overall, it is elegant, clear, beautifully illustrated and written and offers a good overview of the problem: review (December 13, 2007) in the New England Journal of Medicine discussing the treatment of erectile dysfunction.
Click here to read a review of the hormonal treatment of erectile dysfunction that includes more specific ideas about the use of prolactin blockers and hormones in general.
Click here to read more about erection enhancement (as in increased size of the penis)
Also, be sure to pick up the best selling sex manual on Amazon.com, my 15-Day Course for men (which offers an overview of hormone replacement in men), Anytime...for as Long as You Want: Strength, Genius, Libido, & Erection by Integrative Sex Transmutation
Peace & Health,
Charles Runels, MD
