Newsletter – Vol. 2, No. 4

November 1, 2003

The Institute for Sexual Medicine, composed of the Center for Sexual Medicine and Laboratory for Sexual Medicine Research, is dedicated to the diagnosis and treatment of patients with sexual health problems. This is achieved through the pursuit of multidisciplinary basic science and clinical research, training and education of health care professionals, and the promotion of the exchange of scientific information.

Message from our Center Director
Dr. Irwin Goldstein

This is an exciting time as we celebrate our 25th year as a sexual dysfunction clinic. The month of October marked our third visiting professor, Dr. Tom Lue, Professor and Vice Chair of Urology at University of California, San Francisco and Medical Director of the Knuppe Molecular Urology Laboratory.

I would like to welcome several new people to our Institute family. In the Laboratory for Sexual Research we have a gynecologist who has joined the lab, Miljan Stankovic, investigating nerves and blood vessels to the clitoris and vagina. Our new nurse in the Center for Sexual Medicine, Aija Dennis started in October. She joins Terry Payton in providing quality nursing care for our patients as well as running clinical trials. Working alongside Stan Ducharme we have a doctoral candidate helping to provide sex therapy for our patients, Julie Johnson, MA. Also new to the Center is Lisa Scepkowski, MA who is doing research for her doctoral thesis.

Please check out our new look. Depending upon the timing of your next visit, you may either see our interim room layout or our refurbished facility. We are excited about our facelift, as we will be able to offer state of the art facilities to go along with the state of the art medical care we believe we are providing. As part of the process of redoing our space Boston Medical Center offers naming opportunities for any patients or friends interested in making appropriate gifts.

Message from our Laboratory Assistant Director
Dr. Noel Kim

This autumn brings an interesting milestone to the Laboratory for Sexual Medicine Research. While we have a lengthy history of training and collaboration with urologists in the laboratory, Miljan Stankovic, MD, PhD is the first person with a gynecology background to join our research team. Dr. Stankovic also has particular expertise in non-invasive technologies to measure blood flow beneath the surface of the skin. Having recently completed his residency training in obstetrics and gynecology in New York, Dr. Stankovic is engaged in a 12 month basic science research fellowship. During this time, he will investigate the role of steroid hormones on the physiology of the vagina, continuing the studies that were begun by Drs. Kweonsik Min and Soo Woong Kim – 2 visiting urologists from Korea.

Dr. Stankovic will also begin to investigate the effects of diabetes on vaginal function. The general adverse effects of diabetes on the cardiovascular system have been well-defined in animal studies and widely recognized by the scientific and medical community for numerous years. The link between diabetes and vascular health provides a very compelling
reason to study this disease and how it affects sexual function in women. Interestingly, hardly any laboratory research has been conducted on female sexual dysfunction in the context of a disease state. Such work will be invaluable in adding to our knowledge of both healthy and pathological states.

Even as we venture out into new directions of research, we continue to study male sexual dysfunction. We are currently investigating some of the molecular mechanisms that may lead to scarring (fibrosis) of the erectile tissue within the penis. This type of disease process inhibits the erectile tissue from expanding properly during sexual arousal and makes it difficult or impossible to achieve a rigid erection. We are also continuing to study the biochemical regulation of phosphodiesterase type 5, the molecular target of Viagra and Levitra.

This has proven to be a time of remarkable productivity. In this calendar year alone, our research group has generated 9 peer-reviewed articles with 4 more scheduled to appear in journals over the next several months. We remain grateful for your continued support of our work and the overall mission of the Institute.

Upcoming Events

The Institute for Sexual Medicine is pleased to announce its first public seminar. Female Sexual Dysfunction: Symptoms and Solutions will be held on November 23, 2003 from 1:00-5:00 PM at the Holiday Inn, 399 Grove St in Newton Lower Falls, near the junctions of Routes 90 and 95. Dr. Goldstein will present an educational lecture about sexual dysfunction in women. A patient panel of women wiho had different symptoms and different reasons for their FSD will share their stories and solutions. This will be followed by an “Ask the Expert” pane; including faculty from the Center for Sexual Medicine and Center consultants Holly Herman and Dr. Michael Krychman from the Memorial Sloan-Kettering Cancer Center. Registration is free and pre-registration is recommended. For more information about this program and registration, pick up a brochure in our office or go to .

Tips from a Sex Therapist….part 2
Dr. Stanley Ducharme

For many people, sexual functioning is often an issue associated with anxiety and a focus on performance. For most of us, satisfying and pleasing one’s partner is a high priority. However, what sexually arouses a man is very different than what arouses a woman. Too often, such an obvious fact gets ignored!

In this second brief article, I’d like to highlight a few more of the subtle differences between men and women. Often, paying attention to these differences can make a man a better lover. At other times, paying attention to these simple distinctions can make a significant change in the quality of a sexual encounter.

Women want men who are fully in the present moment. Most men never think about how “present” they are during intimate moments with their partner or wife. Men can be caught up in their own private sexual fantasies or focused on their sexual performance. Some guys see nothing wrong with watching a game on TV while making love to their wife.

Men can easily be more concerned about the quality of their erection than whether their partner is feeling emotionally connected and cared for. Feeling uptight during sex, worrying about other matters or “observing” your performance can all take away from the romance of an intimate encounter. These thoughts are distractions and keep a man out of the “present”.

Emotional closeness can be uncomfortable for many men. Thus, strangely enough, the intimacy of the sexual act can easily be anxiety provoking. Often, men deal with these uncomfortable feelings by “emotionally pulling away”, focusing on performance or being angry and frustrated during sex. There is almost nothing that can improve a man’s ability to be a good lover more than by staying emotionally connected and caring during lovemaking. It is important to stay focused on what is happening in the present and share these moments together. Put on soft music rather than the TV.

Women get aroused by words and touch while men often get aroused by what they see. For men, seeing a beautiful woman or looking at erotic pictures is one of life’s greatest pleasures. Erotic pictures, magazines and videos do not serve the same purpose for women. Seeing a naked male body doesn’t turn a woman on in the same way that a naked female body arouses a man. Thus, while watching an x-rated video during sex may sound great for the guy, it can be a complete turn off for his partner.

Touch is another difference between men and women. Touching for the man is a means to an end. Men are only interested in being touched on the genitals or on erotic areas such as the nipples. Being touched anywhere else is a waste of time and energy.

Women are very different. Touch conveys a sense of caring, romance and affection. Most women enjoy being touched on any part of the body as long as it is done softly and affectionately. Often, women enjoy being touch in non-sexual areas even more than being touched on the breasts or genitals. This seems completely foreign to most guys! Again, it’s the romance and the emotional closeness conveyed by touch that is important for a woman. Being a better lover, for the man, means turning off the erotic video and spending the time touching and caressing whenever possible.

In summary, sex therapists tend to focus on bridging the differences and improving communication between men and women. Often for many couples, having a sexual dysfunction can reduce communication or make it nonexistent. By improving communication and trust, a couple can often achieve a new level of closeness and intimacy.

Sexual Medicine Information Sessions

Upcoming sexual medicine information sessions are open to patients, the public, health care professionals and interested persons. All programs are held at Boston Medical Center, 88 E. Newton St, Boston, usually in conference room C-D, from 7:00-9:00 pm. On December 2 Dr. Goldstein will be speaking on Considerations for a Healthy Sex Life after Breast Cancer. Please note this was originally scheduled for November. Dr. Munarriz and Dr. Ducharme will lecture on January 27, addressing the general topic of Sexual Dysfunction in Men. No registration is required

Dr. Goldstein presented the educational lecture on Improving Sexual Function with Androgen Therapy. Androgen therapy for men and women with sexual dysfunction has been successfully used to restore sexual function for over 80 years in an off-label setting. The FDA has not approved androgen therapy for treatment of male or female sexual dysfunction. It has approved testosterone use only for men with “male hypogonadism” including low interest, osteoporosis, depressed mood, low energy, etc. There are limited long term safety data for use of androgens in women.

All steroids are derived from enzyme breakdown of cholesterol. Androgens are sex steroids which structurally have 19 carbons. There are 7 total androgens: dehydroepiandrosterone (DHEA), delta 5 androstenediol, androsterone, delta 5 androstanediol, delta 4 androstendione, testosterone and dihydrotestosterone. The other sex steroids are estrogens with 18 carbons. Androgens are synthesized in the:gonad (ovary or testicle) from cholesterol; adrenal gland from cholesterol and periphery from DHEA. Androgens are as natural to women as are estrogens. Androgens have actions on multiple areas of the body including bone, muscle, skin, liver, kidney, brain, immune system, bone marrow and genital organs. Contemporary evidence is accumulating from animal/human studies that androgens are critical for male and female sexual function – desire, arousal, orgasm function. The exact mechanism of action of androgens on the body may involve synthesis of critical sex steroid dependent proteins or growth factors which act on the nerves, arteries, smooth muscles and connective tissue of the genitals maintaining structure and function.

Androgen values consistently decrease with age in both genders. By age 40 – 50, men and women have less than half of the DHEA and testosterone they had at age 20 years. Andorgen insufficiency: can be Gonadal (chemo- or radiation-therapy, oophorectomy), Adrenal (adrenal failure or insufficiency), Hypothalamic-Pituitary (hypopituitarism), Drug-Related (corticosteroids, anti-androgenic agents, oral contraceptive pill, oral estrogen therapies) and Idiopathic (age-related). It may indicate or be related to other medical, psychiatric or psychosocial factors such as (i) a major life stress or relationship conflict (ii) thyroid disease, (iii) major metabolic/nutritional disorders or other causes of chronic fatigue, psychiatric disorders such as major depressive disorder, or other conditions or factors. SHBG (sex hormone binding globulin) is elevated in many of these syndromes. Free testosterone is equal to the total testosterone divided by the free testosterone. In patients with elevated SHBG values, total testosterone values have to be elevated to even higher values, so that free testosterone values are adequate. Production of SHBG is highly estrogen sensitive: oral intake of estrogen results in a profound dose-dependant INCREASE in SHBG. Conditions in women where androgen values are associated with decreased activity of critical enzymes include sexual dysfunction after childbirth and sexual dysfunction associated with the transition and the menopause. Oral contraceptives are associated with decreased ovarian synthesis of testosterone and increased synthesis of SHBG. In women, estrogen medications are associated with increased synthesis of SHBG. In women, lupron, zoladex medications are associated with decreased ovarian synthesis of testosterone.

Androgen therapy demands a clear indication. No patient is too old if indicated. For men, digital rectal examination and PSA blood tests are mandatory if the patient is older than 40. In women, estrogen levels are indicated. Androgen therapy is contraindicated in men and women with breast and prostate cancer. In men androgen therapy is contraindicated in severe LUTS (lower urinary tract symptoms). In women, androgen therapy is contraindicated in pregnancy. All patients on androgen therapy should have quarterly follow-up in the first year to establish the best dosing regimen. Patients should be fully informed of potential risks and monitored for potential adverse reactions. Potential side effects of androgen therapy for women include acne, weight gain, excess facial and body hair, permanent lowering of the voice, and adverse lipid changes. Based on clinical trial data and experience at the Center for Sexual Medicine, side effects are infrequent if androgen levels are maintained within normal physiological ranges and androgen administration is via topical testosterone therapy. Potential virilization of a female fetus is a serious risk in reproductive-aged women. More research in the field of male and female sexual dysfunction is needed.

Treating Peyronie’s Disease was presented by Dr. Goldstein in Dr. Munarriz absence. Peyronie’s disease is considered to be a form of traumatic arthritis of the penis, especially the tunica albuginea of corpora cavernosa. The cause is likely a fracture in the tunica occurs during sexual activity. The fracture leads to healing which becomes excessive, leading to a fibrous scar which can cause pain, deformity and erectile dysfunction. Symptoms of Peyronie’s Disease in the early phase triad (up to 12 months) are plaque, painful erection and deformity (curvature or narrowing). Late phase triad symptoms (after 12 months) are harder plaque (1/3 calcified), stable deformity and erectile dysfunction (ED). Diagnosis of Peyronie’s Disease is made by history: trauma, Dupuytren’s, family history and physical examination: a lump in the penis, if rock hard–chronic phase, tenderness. Lab tests include an evaluation of the plaque by ultrasound, assessment of the deformity by penile injection and a photograph, and the vascular assessment is made by color duplex ultrasound, which must be done if surgery is planned.

There are no FDA-approved treatments for the management of Peyronie’s disease. There have been limited placebo-controlled, double-blind studies for the treatment of Peyronie’s disease. Most often the best treatment option for Peyronie’s disease is no treatment, or conservative treatments with limited risks. Medical therapies include Vitamin E, Potaba, Colchicine, Verapimil, Collagenase, Iontophoresis with 3 drugs and Shock Wave. Surgery is the last treatment option. Surgical options include plication surgery with no risk of ED, graft surgery with a risk of ED and penile prosthesis if ED already exists with Peyronie’s Disease.

Sexual Medicine Society Meetings

The month of October has been busy for the faculty at the Institute for Sexual Medicine. In one month Dr. Munarriz attended the Sexual Medicine Society of North America held in Denver Colorado, and Dr. Goldstein attended the International Society for the Study of Women’s Sexual Health in Amsterdam, The Netherlands. Despite their travel and respective presentations, they found time to prepare abstracts in sexual medicine for submission to the American Urological Association. At last year’s meeting they taught the first post graduate course ever offered there in sexual dysfunction in men and women, and have been asked to teach it again.

The Sexual Medicine Society focuses much of its time on erectile dysfunction, but includes in a portion of its program female sexual dysfunction. Dr. Goldstein chaired the inaugural scientific meeting for the society in Boston in 1999. At that time it was the Society for the Study of Impotence.

In 1998 Dr. Goldstein held a meeting named “New Perspectives in Female Sexual Dysfunction”, which became the Female Sexual Function Forum and eventually spawned the International Society for the Study of Women’s Sexual Health, of which Dr. Goldstein is secretary. This year’s meeting captivated the attendees with the quality presentations and diverse topics. This society is a multi-disciplinary organization open to all those working or studying in the field of sexual dysfunction in women.

Donations

Tax deductible gifts may be made to the Institute for Sexual Medicine. Please make check payable to Boston Medical Center/Irwin Goldstein, MD, write ‘ISM donation’ on the memo line and mail to Jerie McGrath, Boston Medical Center, Department of Urology W607, 700 Albany Street, Boston, Massachusetts 02118.