Frequently Asked Questions

As a man I’m supposed to think about sex all the time and I don’t–is that okay?

While the majority of men have sexual desire much of the time, some men have minimal desire. The condition of hypoactive sexual desire disorder (HSDD) in a man is characterized as a lack or absence of sexual fantasies and desire for sexual activity for at least 6 months that causes marked distress or interpersonal difficulties and is not be better accounted for by another mental disorder such as depression, a legal or illegal drug, or some other medical condition. Hypoactive sexual desire disorder can be general (general lack of sexual desire) or situational (still has sexual desire, but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or life-long (the person has always had no/low sexual desire). The cause of lifelong/generalized hypoactive sexual desire disorder is unknown. In the case of acquired/generalized hypoactive sexual desire disorder, possible causes include various medical/health problems, psychiatric problems, and hormone problems such as low levels of testosterone. Low sexual desire can also be a side effect of various medications, especially SSRI antidepressants. In the case of acquired/situational hypoactive sexual desire disorder, possible causes include intimacy difficulty, relationship problems, sexual addiction, and chronic illness of the man’s partner. If you have low desire and personal distress, there are both psychologic and biologic strategies that can help restore a degree of sexual interest that does not result personal distress or interpersonal difficulties.

Is erectile dysfunction a normal part of aging?

No. Many aging men can have excellent ability to obtain a sufficiently rigid and sustained erection for satisfactory sexual activity as they enter the 60’s, 70’s, 80’s and beyond. Erectile dysfunction (ED, impotence) does not have to be a part of getting older. While erectile dysfunction can occur at any age in a man, erection problems are uncommon in young men (except bicycler riders or young men in blunt pelvic or perineal accidents) and more common in the aging man. Erectile dysfunction, does vary in severity. Some men have “mild erection problems” and can sustain an erection for less duration that they used to. Some men have “moderate erectile problems” and have an inconsistent ability to achieve and maintain a sufficiently rigid erection. Some men have “complete erectile problems” and have a total inability to achieve an erection. According to the Massachusetts Male Aging Study, the combined prevalence of minimal (17%), moderate (25%) and complete (10%) erection problems was 52%. In one study, a man’s age was the variable most strongly associated with erectile dysfunction. By the time they reached 70, men were three times more likely to experience complete erection problems (15% prevalence at age 70 vs. 5% at age 40) and twice as likely to have moderate ED (34% prevalence at age 70 vs. 17% at age 40) compared with their 40 year old counterparts. An estimated 60% of men were free from erection problems at age 40. This fell to 33% at age 70 years. Similar findings were found by another study, the National Health and Social Life Survey (NHSLS) in the USA. Here, men aged 50-59 were more than three times as likely to suffer from erectile problems and low sexual desire as men aged 18-29 years. In another study, there was an age-related increase in erection problems from 2.3 to 53.4% (men aged 30-80 years). The increase was linear in the age groups 30 to 59 years while the age groups aged 60 years and over showed an exponential increase in prevalence. Another study – the Prevalence of ED in Northern South America (DENSA) – examined the prevalence of ED in 1946 men aged over 40 years (mean: 54.9) and found that in the 60-69 year group the increase in risk for ED was three times higher than at age 40 years while it was six times higher than age 40 for those men aged over 70 years. While aging may worsen erectile function, that doesn’t mean your erectile function shouldn’t or can’t be safely and effectively treated.

Is it possible to cure erectile dysfunction?

Yes. There is a saying that many sexual medicine health care providers like to use with frustrated patient with erectile dysfunction who feel that nothing can be done for them. If a man with erectile dysfunction has a penis of sufficient length and girth, then we as sexual medicine health care providers can always provide that patient with a functional penile erection. We believe that erectile dysfunction can virtually always either be cured or treated depending upon the cause of the problem. Most men with erectile dysfunction are surprised at all the options available for curing or treating erectile dysfunction. Starting at the least invasive, least costly and most reversible is lifestyle change. Good choice diet and exercise strategies have been shown to improve erectile function. The Mediterranean diet, especially in conjunction with daily exercise has been shown to increase validated outcome measures of erectile functioning. The one caveat is that some exercise forms have been shown to be deleterious to erectile function. These exercise forms, such as bicycle riding, involve placing high levels of compressive pressures against the nerve and artery to the erectile tissues of the penis. A second non-invasive treatment option is sex therapy. This time-honored strategy may be provided to the patient with erectile dysfunction alone, the partner alone or ideally with both the patient and the partner as a couple. Sex therapy addresses specific psychological or interpersonal factors that are likely to enhance sexual functioning. Factors that frequently interfere with sexual satisfaction are relationship distress, sexual performance concerns, and dysfunctional communication patterns. Sex therapy can be used in conjunction with biologic treatments such as oral phosphodiesterase type 5 inhibitors, constriction devices or other medical/surgical treatments. Sex therapy can address the psychological reactions to the medical treatment, which may be perceived as an unnatural or unacceptable means of achieving sexual gratification. Biologic options include oral phosphodiesterase type 5 inhibitors, such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). These medications have been FDA approved for the treatment of erectile dysfunction and are very widely used as safe and effective strategies. These medications are administered on demand in appropriate dosages and are effective in facilitating the initiation and maintenance of erections following sexual stimulation shortly after administration. Vacuum construction device therapy is a well-established, non-invasive therapy that is FDA approved for over-the-counter distribution. Vacuum constriction device therapy may represent an attractive treatment alternative if you do not desire the use of medications, such as oral phosphodiesterase type 5 inhibitors. The vacuum constriction device applies a negative pressure to the penis, thus drawing venous blood into the penis. The blood is then retained by the application of an elastic constriction band at the base of the penis. Testosterone therapy should be pursued, especially if you have consistently documented on blood testing low values of “free” or “unbound” testosterone in conjunction with symptoms of low testosterone such as low sexual interest, poor erection, diminished orgasm intensity, reduced physical performance, feeling sad, blue or grumpy, gaining weight, increased waist circumference, high blood pressure, abnormal lipids, reduced short-term memory, and falling asleep after meals. Often, using testosterone therapy will improve the effects of the PDE 5 inhibitors in facilitating, initiating, and maintaining erections. Intraurethral administration of alprostadil is another FDA approved therapy option for erectile dysfunction. The alprostadil is in the form of a semi-solid pellet that is placed in the male urethra with a special inserter device prior to sexual activity. Approximately 50% of men achieve successful intercourse with this system in the home situation. Penile self-injection therapy uses the FDA-approved drug prostaglandin E1 injected directly into the side of the penis into the erection chamber prior to sexual activity, using a small gauge insulin-like needle and syringe. You will need to be trained by a sexual medicine health care provider as to the correct techniques for self-administration. In general, penile self-injection therapy with alprostadil is effective in 70%-80% of patients, although discontinuation rates are very high in most studies. Surgical implantation of a semi-rigid or inflatable penile prosthesis is highly invasive and associated with high rates of sexual satisfaction for both you and your partner. The inflatable penile prosthesis provides a more aesthetic erection and better concealment than the semi-rigid prosthesis. Penile microsurgical revascularization surgery may correct erectile dysfunction, particularly in young men (aged <40-45 years) with a history of pelvic and/or perineal trauma. If a localized arterial blockage is determined to exist, a revascularization procedure employing a new artery source (e.g. the inferior epigastric artery) to deliver blood to the erection artery of the penis is a treatment option. Penile revascularization is associated with a 60-70% long-term (5-year) success rate and few complications. In some men whose pelvic arteries are the source of the artery blockage, drug-eluting vascular stents amy be placed in the artery to diminish the blockage and increase blood flow delivery to the erection chambers. There are new drugs and treatments for men with erectile dysfunction. So, at the end of the day, sexual medicine health care providers believe that erectile dysfunction can virtually always either be cured or treated depending upon the cause of the problem.

My testosterone is low—why should I take testosterone and for how long do I need to take this?

Testosterone acts on androgen receptors to direct the synthesis of numerous critical proteins that are involved in the structure and function of many tissues. Testosterone receptors exist in brain, bone, skin, sweat glands, skeletal muscle, fat and genital tissues. Testosterone has been shown to affect sexual desire, penile erection following sexual stimulation, orgasmic function, bone density, muscle mass and strength, fat tissue distribution, mood, energy, and psychological well-being. Testosterone therapy has been used for men for almost 70 years for suspected testosterone deficiency states. It is well appreciated that when a man has low testosterone values, symptoms most often reported include: a diminished sense of well-being or unpleasant mood; persistent, unexplained fatigue; and sexual function changes, including decreased libido, sexual receptivity, and pleasure. Other potential symptoms of testosterone insufficiency include bone loss and decreased muscle strength, decreased physical performance and falling asleep after meals. The diagnosis of testosterone insuffciency or hypogonadism is made in men who have both clinical symptoms and low blood testosterone tests. Before starting testosterone replacement therapy, a clinical assessment should be performed by a physician. This evaluation should include a medical and psychosocial history, physical examination, and laboratory testing. This is relevant since testosterone insufficiency may be mimicked by other conditions such as a major life stress or relationship conficts, thyroid disease, major metabolic or nutritional disorders, other causes of chronic fatigue and psychiatric disorders. In multiple trials, the use of testosterone replacement has led to statistically significant and clinically meaningful improvements sexual interest, sexual function, sexual activity, and decrease in personal distress. Testosterone replacement treatment can occur with testosterone intramuscular injections, subcutaneous testosterone pellets, and topical testosterone therapy with gels. In most cases, testosterone is provided for as long as is needed. Drug holidays off testosterone can be made to see if discontinuing testosterone results in a return of clinical symptoms associated with deficiency. Testosterone blood tests should be performed at various intervals. In young men with low testosterone, the use of testosterone replacement is discouraged due to potential infertility concerns. In young men, a more rational strategy is to use clomiphene citrate, as this medication will increase gonadotropin release whereas exogenous testosterone will decrease gonadotropins.

Why is an erection longer than 4 hours dangerous?

Priapism is a full or partial erection that continues more than 4 hours beyond sexual stimulation and orgasm and is unrelated to sexual stimulation. The term priapism has its historical origin in reference to the Greek god Priapus, who was worshiped as a god of fertility. Priapus is memorialized in sculptures for his large fully erect phallus. There are several forms of priapism. The type called ischemic or low flow priapism occurs typically when the patient has a more than 4 hour penile erection that is rigid only in the erection chambers and the glans penis is soft. This priapistic erection is also quite painful painful. Ischemic or low flow priapism is characterized by little or no arterial in?ow perfusing the erection chambers despite the outside penile skin appearing completely normal. As a result of lack of arterial perfusion, there are progressive changes in the metabolic environment of the erection chambers in ischemic priapism with eventual low oxygen, elevated carbon dioxide and very acid blood levels. Under the microscope, at 12 hours of priapism, corporal specimens show tissue changes that eventually lead to death of muscle cells and replacement with scar tissue. Ischemic priapism is an emergency that if not treated early leads to permanent erectile dysfunction. There is another rare form of priapism called nonischemic or high flow arterial priapism. This occurs following blunt perineal trauma (falling onto a bicycle seat or bar) and results when the erection artery lacerates within the erection chamber causing unregulated arterial inflow to enter the erection chamber leading to penile erection. Patients with arterial priapism do not usually have pain and do not usually have a rigid erection. Nonischemic or high flow arterial priapism is not considered an emergency.

Are any of the tests or treatments different if I am gay?

There are no differences in tests or treatments between gay and straight women who have sexual health concerns.

I have low desire–is this just something that is in my head?

Low desire or hypoactive sexual desire disorder (HSDD) may be either biologic or psychologic or both, but the way to determine this is through a combined biologic and psychologic evaluation. Psychologic reasons for HSDD include life stage stressors such as childbirth, infertility, divorce or partner loss, unemployment, extra-relationship affairs, humiliating or traumatic sexual experiences, partner sexual inadequacy, and relationship discord. Biologic-based HSDD problems may result from hormonal conditions such as testosterone insufficiency, low estradiol (such as following bilateral oophorectomy or natural menopause) and/or hypothyroidism. Other biologic-based HSDD causes include use of medications such as antidepressants, and chronic medical problems. HSDD may be secondary to a brain imbalance of excitatory neurochemicals (noradrenaline, dopamine, oxytocin, melanocortins) and inhibitory neurochemicals (serotonin, prolactin, opioids and endocannabinoids). In this sense, HSDD may be both in your head and in your body.

Is genital pain or discomfort at the opening to the vagina during (or after) sex normal?

Vulvodynia, a discomfort or burning pain at the opening to the vagina, is increasingly recognized as a cause of sexual pain and is not normal. Vulvodynia most likely represents several disorders without an identifiable cause in the majority of cases. Vestibulodynia is a common type of vulvodynia where the pain is localized only to the vestibule, the area just around the hymenal remnants extending to midway of the inner aspect of labia minora. Vestibulodynia is classified as primary (the pain has been present since the first tampon use or intercourse) or secondary (the pain developed after there was a period of painless tampon insertion or intercourse). Vestobulodynia was formerly called vulvar vestibulitis syndrome. The etiology of vulvodynia remains elusive, but it most likely occurs from a variety of sources and represents many different disease processes. Possible causes include embryologic factors, pelvic floor factors, genetic and/or immunologic factors, hormonal factors, peripheral and central neuropathic factors, dermatologic factors, psychologic factors, nerve entrapment factors, and infectious factors. Generalized, non-provoked vulvodynia may be thought of as a complex regional pain syndrome similar to ?bromyalgia and interstitial cystitis. The treatment of all patients with vulvodynia includes a comprehensive, systematic approach that not only employs various treatment options for the biological process of vulvodynia, but also addresses the psychosocial and sexual aspects of the disease with compassion. The management of women with vulvodynia requires a sensitive health care provider who can coordinate this multidisciplinary approach to care.

I’ve never had an orgasm–does that mean I never will?

Anorgasmia is a female sexual orgasmic disorder in which there is persistent and consistent inability to achieve orgasm, after adequate stimulation, that causes personal distress. Primary anorgasmia is used to define the condition of never having experienced orgasm while secondary anorgasmia is used to describe a woman who once experienced orgasm but lost the ability. Anorgasmia can be caused by psychologic problems. Anorgasmia also be caused by medical problems such as diabetic neuropathy, multiple sclerosis, genital mutilation or complications from spinal cord injury, genital surgery, total hysterectomy, pelvic trauma, hormonal issues such as low testosterone, low estrogen, low thyroid. A common cause of anorgasmia, in women, is the use of anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs). It is estimated that 15-35% of users of selective serotonin reuptake inhibitors are affected by anorgasmia. Very often anorgasmia is secondary to both psychologic and physiologic causes. If a woman has never had an orgasm it is important to have a biopsychosocial evaluation to determine the cause of the anorgasmia. Once the cause can be determined psychologic and biologic-based treatment options can be contemplated.

My doctor prescribed biologically identical hormones–how long do I have to take them?

When your doctor prescribed biologically identical hormones (exactly the same chemically to the hormones naturally synthesized in your own body), either dehydroepiandrosterone, testosterone, estradiol, progesterone or thyroid, it was because you had clinical symptoms related to the low hormone state, and the hormone values in your body were not felt to be in the appropriate range. For example, women with low testosterone may experience low sexual interest, sexual pain, muscle weakness, fatigue and easy exhaustion, and poor memory. For example, women with low estradiol may experience night sweats, hot flashes, and vaginal dryness. For example, women with low thyroid may experience include weight gain or increased difficulty losing weight, coarse, dry hair and dry, rough pale skin, hair loss, intolerance to cold and inability to tolerate cold, muscle cramps and frequent muscle aches, and constipation. Women with sexual health concerns who take biologically identical hormones should have clinical symptoms relating to the low hormone state, experience relief of the clinical symptoms with use of the hormones, and have hormone bloods values monitored to be in the appropriate value. Those women whose symptoms are improved by taking hormones and the hormones blood tests are in the appropriate range, may consider taking a drug (hormone) holiday and see if the clinical symptoms return and the hormone levels fall. Should the woman with sexual health concerns require hormones to be free of clinical symptoms, then long term use of hormones should be considered and frequent monitoring of hormone values should be performed by a health care provider.

My doctor prescribed testosterone–isn’t this for men?

Men have 10 times the amount of testosterone as women, but all women synthesize testosterone. In fact the estradiol hormone of women is actually synthesized from their testosterone hormone. Testosterone is as natural and critical to women as is estradiol, progesterone and thyroid. The amount of testosterone in a woman decreases over time for various reasons such as aging, menopause, oophorectomy (surgical removal of ovaries) and in response to medications such as oral, patch or ring hormonal contraceptives, infertility and/or endometriosis treatments. Low testosterone may be associated with sexual heath clinical symptoms such as low sexual interest, poor arousal, reduced orgasm intensity or increased time to achieve an orgasm. In women with clinical symptoms who have blood test values not in the appropriate range, consideration should be made for testosterone therapy. The risks and benefits of testosterone therapy should be discussed.

What does the physical therapist do for tests regarding my sexual function?

Pelvic floor rehabilitation is a specialized field within the scope and practice of physical therapy. The pelvic floor muscles are active in female (and male) genital arousal and orgasm. Low tone pelvic floor muscle dysfunction may impact negatively on these phases of function. High tone pelvic floor dysfunction is a significant component of sexual pain disorders in women (and men). Furthermore, conditions related to low and high tone pelvic floor dysfunction, such as pelvic pain, pelvic organ prolapse, and lower urinary tract symptoms, are correlated with sexual dysfunction. The physical therapists’ evaluation of women with sexual dysfunction includes a detailed assessment of both strength and tone of the pelvic floor muscles. Pelvic floor physical therapists utilize a range of treatment tools, including manual therapy, therapeutic exercise, biofeedback, and electrical stimulation. The involvement of the pelvic floor in sexual function and dysfunction is better established and the role of pelvic floor rehabilitation in treatment of sexual dysfunction is an integral part of the multi-disciplinary process of management of women with sexual health problems.

What does the term biologically identical (bioidentical) mean?

Biologically identical (bioidentical) means chemically identical to what is naturally synthesized in your body. Biologically identical dehydroepiandrosterone, testosterone, estradiol, progesterone or thyroid is exactly the same chmecial structure as was synthesized in your own body. There is a misconception that biologically identical hormones need to be provided by a compounding pharmacy. This is not true. There was many Food and Drug Administration (FDA) approved biologically identical dehydroepiandrosterone, testosterone, estradiol, and progesterone hormones. The benefit to the patient of using FDA-approved biologically identical hormones is that the FDA has a very strict manufacturing inspection. There is confusion of the term synthetic versus natural. All chemicals, such as biologically identical hormones, need to be synthesized from some substrates. Synthesized biologically identical hormones are the same as natural biologically identical hormones. Biologically identical hormones, dehydroepiandrosterone, testosterone, estradiol, and progesterone, are to be distinguished from synthetic pharmaceutical hormones that are not biologically identical, such as methytestosterone, conjugated equine estrogens and medroxyoprogesterone.

Why isn’t persistent genital arousal disorder a good thing?

Persistent genital arousal disorder (PGAD) is genital arousal without accompanying sexual feelings. Persistent genital arousal disorder ranges from being distracting to destroying a woman’s ability to live her life normally. Persistent genital arousal disorder (PGAD), formerly known as persistent sexual arousal syndrome (PSAS), is associated with unrelenting, unwanted, persistent, intrusive, and spontaneous sensations such as pressure/discomfort, engorgement, pulsating, pounding and/or throbbing, in the genital tissues such as the clitoris, labia, vagina and/or in the perineum and/or anus in the absence of conscious thoughts of sexual desire or sexual interest. Persistent genital arousal disorder is often associated with significant personal bother and distress. Persistent genital arousal disorder is associated with spontaneous orgasms or feelings that orgasm is imminent or feelings that orgasmic release is needed to reduce the feelings of persistent arousal, but where symptoms are not consistently diminished by achieving orgasmic release. Persistent genital arousal disorder is an uncommonly reported women’s sexual health concern. Persistent genital arousal disorder may be classified into primary, lifelong if the PGAD is present throughout the person’s life or into secondary, acquired if the PGAD develops variably in later life.

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