Archive for Questions & Answers

Androstenedione (Steroids) & Sex Drive

Q. I’m 32, and for six years I’ve had a continuing loss of libido. In the last two years, I don’t think of sex or get an erection without serious coaxing from my partner. A hormone level test came back normal. My doctor gave me Viagra, which gives me an erection, but what’s the use when I have no urge to use it? Some time ago, when I lifted weights, I tried androstenedione and noticed that it increased my libido dramatically. I stopped taking it for health concerns, but lately I’ve tried it again to see if I could reproduce the side effect — and it worked! Now I’m weighing my (and my partner’s) sexual well-being against the long-term health concerns of this supplement. Is there anything else I should consider before continuing with androstenedione? Is it possible that although my testosterone levels test normal, my body isn’t using it efficiently?

A. Androstenedione is a precursor to testosterone, the male sex hormone responsible for our sexual drive and desire. Normally, androstenedione is made in the adrenal glands and released into the bloodstream. In the testicles, the androstenedione is converted into testosterone. As a category, these hormones are called anabolic steroids.

When a young man takes anabolic steroids as supplements, it can cause his testicles to lose their function. That is because the extra hormones lead his body to turn off its own hormone production. The hormones are produced in the testicles, so to turn off production, the body has to turn off the testicles. Sometimes this leads to permanent damage, resulting in low testosterone levels.

Most experts would agree that to identify a person with a hormone deficiency, you need to check testosterone levels at three separate time intervals. Usually, I will get morning testosterone levels once a week for three weeks before I say the patient has normal levels or not. If the levels are low, then I will give the person a prescription for testosterone patches to wear on a daily basis. These are safe and legal. Also, the dosage can be adjusted safely. I suggest you stop the steroids and let your doctor identify your hormone deficiency so it can be treated correctly and safely.

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Diet, Lifestyle & Impotence

Q. My boyfriend is 46, and over the last few years he’s started having trouble maintaining an erection. His doctor says there’s nothing medically wrong and has prescribed Viagra, but he’s nervous about using it. Are there any diet or lifestyle changes he could make that might make the drug less necessary?

A. Yes. When I was in medical school, I was taught that the major cause of impotence is psychological. We now know that it is mostly physiological. For many men, it’s not in their head, it’s in their arteries. The arteries in your heart aren’t the only ones that get clogged over time — it happens throughout your body, in men and in women. For men, the ability to get and maintain an erection is a direct function of blood flow to the penis, so anything that increases blood flow improves an erection, and anything that decreases blood flow makes it more difficult to have and maintain an erection. Approximately one-half of men over age 40 have problems at times with erectile dysfunction. Most men are embarrassed and don’t talk about it with their friends, or even their physicians, so they don’t realize how common it is — which often makes them feel even worse. No wonder Viagra is the biggest-selling drug of all time. Viagra works by stimulating nitric oxide, which dilates blood vessels and increases blood flow. (The Nobel Prize in medicine in 1998 went to the researchers who identified the role of nitric oxide in the cardiovascular system.) One of life’s ironies is that the very things our culture tells us are sexy and signs of the “good life” are also leading causes of impotence: A high-fat diet, alcohol, tobacco use, chronic stress, cocaine and many prescription drugs all reduce blood flow by constricting blood vessels, causing blood to clot, or promoting plaque buildup in your arteries. The good news is that when you change these behaviors, blood flow — and sexual function — can improve relatively fast. Your body also makes more nitric oxide — natural Viagra. For many people, improving sexual function is a more powerful motivator for lifestyle improvements than the prospect of living a little longer.

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Erection & Urination Problems

Q. Local doctors don’t seem to take my problem seriously, and I don’t know who else to ask. For the last year or so I’ve had erection problems. I seldom wake up with an erection. This affects my social life because I’m afraid I won’t be able to perform. I also have no force behind my stream when I urinate. If I pee outside, I barely miss my shoes! And when I am done urinating, I have to shake and dance a great deal to get it all out, and it still leaves a spot in my pants! Sometimes I even smell like urine. This scares me. I’m only 33, 165 pounds at five feet seven inches. I never miss work due to illness, and I see a doctor only for emergencies. I smoke, drink and drink coffee. I need help and I don’t have a lot of money. Is there any inexpensive treatment or over-the-counter medication I can use?

A. I would recommend seeing a urologist to evaluate your condition. You may well have diabetes or another condition that affects either the nerve supply or blood supply to the penis. Swelling of the prostate gland can impede the flow of urine, lessening the force of the stream. Until a diagnosis is made, there is no treatment that can be recommended. As untreated diabetes can have serious life-threatening complications, you would do best to see a physician and undergo evaluation.

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Erection Problems with Diabetes

Q. I am 26 and was recently diagnosed with diabetes. I am having a hard time maintaining an erection or reaching orgasm. Can anything be done to correct this problem?

A. Diabetes is not just a sugar problem. Unfortunately, while researchers and doctors can develop effective medicines to control blood sugar, other manifestations of the disease can still occur.

For instance, long after the original diagnosis — typically 10-20 years — some of the body’s autonomic nerves (which control the bladder, bowel and erectile function) may start to fail. This is called diabetic neuropathy. Symptoms could be the inability to urinate, severe constipation and loss of erections. This can happen even in patients with good sugar control, and researchers still aren’t sure why. We do know that neuropathies occur much more quickly in people who do not control their sugar levels, so please keep your blood sugar under control.

Also, diabetes can destroy small arteries in the body; this leads to poor tissue blood supply. This also takes years, and it usually occurs in the feet. The same poor circulation can affect the penis, and you can lose your erection. But again, this usually happens to older men, around age 50.

So, at this point, you are at risk of developing these problems because of your diabetes. But I am not sure the diabetes is responsible for your difficulty in erections now — at least not physically.

However, dealing with your new condition may be having an effect on your mood as a whole, which can in turn affect your sexual response. Someone who is diagnosed with a severe medical condition typically goes through several stages. Usually there is some degree of denial, followed by anger. Eventually the person must learn to accept the problem and go on with life. Once there is acceptance, the person then begins to deal with major lifestyle changes. Your doctor will tell you what to eat and how much to weigh, and every time you go to the doctor there is often more bad news. With this much stress, it is not uncommon for a person, no matter how strong, to get a little depressed.

I am very pleased you are willing to take get help for your erections, because there are several options. First, your urologist can offer support — and Viagra. The Viagra can increase blood flow to the penis and strengthen your erection. Second, look up a diabetic support group — in your community or online — where you can talk to others living with your problem who share common stresses. There you can vent and get reinforcement and encouragement. I believe that a healthy mind leads to a healthy erection.

Don’t forget, also, that there are other causes of erectile difficulty you may wish to explore with your doctor. For more information on erection problems, see my earlier column, Can’t Get Full, Lasting Erection.

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Impotence From Blood Leak

Q. I am 32 and can’t sustain a rigid erection for a long period of time. I’ve been to one doctor, two urologists, an impotence center and a psychologist and the only answer I have is a prescription of Viagra. The impotence center did thorough testing and determined I had a blood leak. An electrode rigid meter verified I did not have normal erections during sleep. I obtained two semi-erections, about 50 percent of normal. With Viagra I feel like I did when I was younger. However, I don’t want to depend on drugs the rest of my life. The alternatives seem to be a pump, MUSE or Caverject injections, which I find unacceptable. What do they do for blood leaks? Is there surgery to correct this?

A. I understand completely — I would not want lifelong medication either. I would like to give your urologists some credit because they at least did a complete workup and determined the cause of your problem.

A venous leak means that blood does not stay stored in the penis. An erection only stays hard as long as the penis stays full. Think of a car tire — when there is a small leak, it slowly loses pressure and goes flat. But you can fix the problem either by patching the leak or putting in air faster than it leaks out. Your doctor is doing the same thing to your penis.

MUSE (alprostadile) suppositories or Caverject (alprostadile) injections are both prostaglandin E1 derivatives that dilate the arteries and thus increase blood flow to the penis, overcoming the leak. These help you get an erection; unfortunately, it is not your own, nor is it as good.

The other option is to fix the leak with surgery. This to can be accomplished by a urologist who specializes in microsurgery of the penis. Such specialists can perform studies that will localize the exact leak point, and they may be able to perform surgery to tie off the leak. There are many in the United States; you should ask your doctor for a referral to one of them.

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Hepatitis, Cirrhosis & Erection Problems

Q. My fiance is 49 and has liver cirrhosis and is positive for the hepatitis C virus. His erection is short-lived and very weak, and it is not easy for me to get orgasm with him. He was a heavy alcoholic, but he stopped drinking completely six months ago. Do you think there is a possibility of improvement in his case? What medication or advice can you suggest? I am shy about telling him my problem with this, as he thinks he is perfect.

A. From what you are describing, your fiance has a very serious problem. First, hepatitis C is permanent, incurable and contagious. If you are not already infected, then please realize that unprotected sex puts you at risk for getting this dangerous virus. Hepatitis C causes end-stage liver failure requiring a transplant in up to 50 percent of the people it infects.

Secondly, cirrhosis damages the liver. Unfortunately, liver failure changes a person’s hormone metabolism. The liver controls the conversion of testosterone (the male hormone) to estrogen (the female hormone). A man with liver failure experiences excess estrogen and less sexual drive. Also, his body fills with toxins that affect cell metabolism throughout the body, not just in the liver. Unless and until his liver problem is corrected, there is no medication that will help his sexual function.

For cases such as this, some men use a vacuum erection device. The man puts this on the penis when he wants a erection. The device draws blood into the penis, allowing it to become hard. Once it is hard, a constriction band is released at the base of the penis that squeezes it tight to keep the blood in it. This not only provides erection, it can also help for some playful foreplay.

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Impotence in Teenager

Q. My boyfriend is only 17 and cannot get an erection. I thought only older men had this problem. What could possibly be causing this? I fear that I am not attractive to him, or perhaps he is cheating on me. Am I the cause of the impotence? Is there anything I can do? I try to talk to him about it, but he just gets quiet or frustrated.

A. You must be patient. At 17, there are few medical reasons for erectile dysfunction. In fact, I don’t think I have ever treated or seen a healthy 17-year-old with this problem. However, it is possible to have a problem with the penis if he has ever had injury or surgery to the penis. Also, there can be hormonal reasons for erection problems, such as testicular failure. Still, if a boy goes through puberty with normal pubic hair and body growth, and if he has sexual desires, then there is little to no chance that he has a hormonal imbalance.

It is possible that he might be suffering from psychological issues. As pleasurable as sex can be, for many people the first time (or the first time with a new partner) can be very stressful — stressful enough to cause a person to distance himself or avoid situations that might lead to intimacy, out of fear that he might not be able to perform to another’s expectations. This is called performance anxiety. Another common condition is called fear of failure, in which the person is so scared he won’t get an erection that, in fact, he doesn’t.

I can assure that you almost certainly are quite attractive to him and that he is not cheating on you. I know it is frustrating, but you might try to avoid putting any further pressure on him, and let him know that it is OK to not have sex. Many men perform well when they feel there is no pressure to perform at all. If he has any doubts, then he might want to see a counselor or his doctor.

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Injury, Illness & Alcoholism Can Cause Impotence

Q. My 52-year-old husband has been having a lot of problems. First, he wasn’t able to get an erection and was having pain in his lower abdomen. His doctor treated him for prostatitis. It helped relieve the pain, but then he got worse. He went to a urologist and was put on Flomax. He has been able to get erections, but they are painful, especially at the tip.

After taking this medicine for about a month, he began experiencing a curved penis. He went back to the urologist who told him he had Peyronie’s disease and said there was nothing he could do and handed him a brochure.

He used to take meds for hypertension and high blood pressure. He drinks two or three glasses of Scotch every night. He is now taking two vitamin E pills a day. Please send us any information you can.

A. Your husband certainly has more than his share of problems. I hope I can provide some useful information on what are two different but associated problems.

Erectile dysfunction or impotence is defined medically as the inability to achieve or sustain an erection of sufficient rigidity to permit sexual intercourse. Impotence is thought to affect 10 million American men, and it is age-related.

While some cases of impotence are psychological in origin, especially in younger men, most impotence is associated with medical or physical problems.

Because blood flow to the penis is critical to erection, vascular disorders such as atherosclerosis can cause impotence. Damage to nerves to and from the penis can also produce impotence. Such damage may be due to injury, diabetes, stroke and alcoholism.

Drugs are implicated in as much as 25 percent of impotence. Drugs known to have an impact include antihypertensives, antidepressants, sedatives and alcohol. Even pain, such as from prostatitis, can cause impotence.

Flomax (tamsulosin) is given to improve urinary flow and reduce the symptoms of benign prostatic hyperplasia, the increased growth of the prostate. The side effects of tamsulosin include decreased sexual urge.

Your husband’s medical history and the drugs he’s taking, including alcohol, may be implicated in his erectile dysfunction problems. The first step is to work with the urologist to find the cause or causes and deal with them.

Your husband’s second problem, Peyronie‘s disease, is a medically and psychologically traumatic disorder in which a fibrous plaque forms in the covering around the spongy erectile tissue of the penis. This plaque, similar to scar tissue, causes a curvature of the erect penis that may make sexual intercourse difficult, painful or impossible. Peyronie’s disease can lead to erectile dysfunction.

The cause of Peyronie’s disease is unknown, but it’s thought to be congenital or initiated by genital trauma. Some investigators see an association between Peyronie’s disease and hypertension and high cholesterol, among other conditions.

For milder cases, a number of nonsurgical therapies are available, but all of them appear only partially successful. Vitamin E and potassium para-aminobenzoate have long been suggested as treatment for Peyronie’s disease.

Injection of the calcium channel blocker, verapamil, directly into the plaque has been shown to be effective in some cases. Effective surgical procedures for this condition include incision of the fibrous material and venous patch grafting.

The other good news on Peyronie’s disease is that it often goes away by itself.

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Just a Little Viagra

Q. I am 51, and I have a problem with keeping an erection for more then 10 minutes. I think it is a blood circulation problem, because my feet always feel cold and my balls feel cool to the touch. If only I could stay erect for another 10 minutes I would be satisfied. My doctor gave me a prescription for Viagra. He says I don’t need to use the whole pill, but to cut it in half and see how that works. What would it do if I cut it in quarters? Would that help me out for another 10 minutes? I don’t want to take the whole pill because I’m afraid of side effects.

A. At 51 years old, a 10-minute erection is excellent. In fact, studies have shown that most men ejaculate within 90 seconds of penetration.

I don’t think that you have a circulation problem, since most men with atherosclerosis (clogged arteries) don’t get any erection at all. Furthermore, cold feet and testicles are not signs of a circulation problem. Instead, circulation problems usually first appear as pain in the calves or buttocks when walking.

Nonetheless, Viagra is a common and safe way to increase rigidity and blood flow into the penis. The medication works by relaxing the arteries in the penis to increase the blood flow and in turn strengthen the erection. The standard dosages are 25mg, 50mg and 100mg. Many doctors will prescribe the maximum dose of 100 mg and instruct the patient to break the pill in half. The logic is that all doses are the same price, so by breaking a pill in half you get twice the uses for the same price. In my practice, I only prescribe 100mg, since very few patients respond to the lower dosages.

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New Sexual Enhancers

Q. I have tried Viagra for erectile difficulty, but it gives me headaches. I’ve heard there are some other sexual enhancers available or in testing. What can you tell me about these?

A. One potential competitor for Viagra is a pill called Vasomax. This is a new application of the established drug phentolamine, which used to be injected directly into the penis. It works by blocking blood-vessel constriction, making it easier for the blood vessels to expand. When taken orally, it affects the whole body. Trials showed that 42 percent of men with mild erectile dysfunction develop better erections with this drug. Its effects in men with severe erectile dysfunction are less satisfying. Side effects include headaches, low blood pressure, fast heartbeat and nasal congestion. As of this writing in mid-2000, this agent is working its way through trials required in the FDA approval process.

Another promising agent is Uprima, or oral apomorphine, which should be released soon. The mechanism of action appears to be located in brain centers that enhance the erection and sexual experience. This fast-acting drug might be used in combination with others like Viagra. Known side effects are limited to nausea, which might go away after the first few uses.

Bayer Pharmeceuticals also has a new agent in drug studies; this is a selective phosphodiesterase inhibitor that should have effects similar to Viagra, but hopefully with fewer side effects. However, it is expected to achieve a response only in about 30 percent of the men who use it.

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