Newsletter – Vol. 3 No. 3

September 1, 2004

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

Summer is passing and we have seen a group of medical students and masters students graduate, some of whom were my advisees, and a new group of graduate students have suddenly appeared. I am pleased that sexual medicine is making inroads in the medical school and graduate school curriculum. A rotation through the Center for Sexual Medicine has recently been accepted as a clinical elective for fourth year medical students. Residents from specialties including Gynecology and Family Practice will continue to spend time in our center, but residents in Internal Medicine will now be spending regular time observing our physicians treating patients. In the end, these opportunities for students and young physicians will help future patients with sexual health concerns. The Masters of Medical Sciences program will now offer a concentration in sexual medicine. Perhaps some of these young students will go on to become sexual medicine physicians after completing their medical training.

Along with the students who have changed, we have a new addition to the Center for Sexual Medicine as well as to the Laboratory for Sexual Medicine. In the Center we have our first Endocrinology fellow, Dr. Claudia Panzer. She is learning all about sexual health and teaching us more about endocrinology. You will find her bright and enthusiastic and warm and charming. Also spending some time in the clinic is Dr. Dongwoo Kang from Korea who is on a research scholar exchange. Please say hello when you come into the clinic. In the lab the new face belongs to Dr. Abdullah Armagan, who is a Turkish urologist doing a research scholar exchange studying testosterone and erection.

Upcoming Events

Plans are currently underway for CME courses in Female Sexual Dysfunction for health care providers. Updated information about the seminar will be posted on our website as soon as it is available.

Sexual Medicine Information Sessions

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 from 7:00-9:00 pm. Upcoming programs include a session on September 14 titled The Implant Story: Men Surviving ED, Sexual Pain in Women on October 5, 2004, and Sexual Dysfunction in Men scheduled for November 16, 2004, all from 7:00-9:00 pm.

Dr. Munarriz addressed a crowd on Sexual Dysfunction in Men in May. Community based epidemiologic studies reveal that more than 50% of men age 40-70 have erectile dysfunction. Recognized risk factors include age, high cholesterol and low HDL, hypertension, diabetes, cigarette smoking, coronary artery disease, myocardial infarction and obesity. Several new studies involving approaching 30,000 subjects have shown that daily exercise burning 200 calories/day lowers the risk of erectile dysfunction. Contemporary thinking about erectile dysfunction is that is it strongly predicted by factors that affect the health of the lining of the blood vessels (the endothelial cells). Should the process of atherosclerosis occur in the arteries of the body, one of the earliest signs of artery blockage even before the occurrence of a heart attack is the condition of erectile dysfunction.

Management of patients with erectile dysfunction is traditionally divided into first line, second line and third line therapies based on reversibility and cost and degree of invasiveness. First line therapies include sex therapy, vacuum constriction device therapy, and oral vasodilator agents such as Viagra, Levitra and Cialis. New head-to-head scientific trials have been performed with these 3 agents in placebo-controlled double-blind trials in PDE5 naïve patients. The bottom line of these studies is that not all patients with erectile dysfunction should choose a single drug in all situations; certain patients prefer one drug over another. Second line therapies include intraurethral or self-injection therapies with vasoactive drugs. Such therapies are used frequently when the underlying pathology is venous leakage or where impotence follows radical prostatectomy surgery. Third line therapies include penile prosthesis insertion or microvascular surgery, especially for young patients who have impotence after blunt trauma such as following bicycle riding.

Finally, androgen therapy is indicated for men with erectile dysfunction who have hypogonadism, defined by blood test values either below or in the lower quartile of the reference range. Such patients commonly have other symptoms including low interest, low energy, less efficient performance at work, fall asleep after dinner, and are sad and grumpy. Men who have erectile dysfunction have many management options and should seek professional consultation, especially with physicians who are knowledgeable in sexual medicine.

The session on Restoring Sexual Function after Lupron/Zoladex or Cancer Treatment was attended by men who were prostate cancer survivors and women who had been given Lupron/Zoladex for infertility treatment.

Prostate cancer is a highly prevalent disease afflicting one in five American men. It is the most commonly diagnosed cancer in men and the second leading cause of cancer death after lung cancer. Treatments for localized prostate cancer include observation, surgery and radiation therapy with and without androgen ablation. Treatments for advanced prostate cancer are androgen ablation and chemotherapy. The great majority of men who survive prostate cancer DO NOT achieve a return to functional sexual activity in the years after treatment.

Surgery and radiation therapy are associated with erectile dysfunction in 5% to 100% of cases. Surgery can lead to nerve damage to the erection nerve, erection arterial damage and erection tissue scar (fibrosis) damage which leads to venous leakage. Radiation therapy can also lead to ED. The major difference is that radiation does not damage the erection nerve. Radiation therapy may induce erection arterial damage and erectile tissue scar (fibrosis) damage which leads to venous leakage. Androgen deprivation therapy (Lupron/Zoladex) is associated with: erectile dysfunction smooth muscle dysfunction and /or erectile tissue fibrosis damage which leads to venous leakage; hypoactive sexual desire disorder which means no libido/interest; and orgasmic dysfunction.

Lupron/Zoladex mimic the messages made by the hypothalamus to stimulate the pituitary. They are very effective agents stopping genital biosynthesis of testosterone, with blood levels of testosterone falling below the reference values. Sex steroid hormones, such as testosterone, induce protein synthesis in the genital tissues. These proteins cause the genitals to grow, become more sensitive and have more blood vessels. These proteins also act on the brain to have libido and also act on the bones, muscles, skin, mood, etc. Without sex steroids, genital tissues shrink/atrophy, become poorly sensitive and poorly engorge.

Therapies utilized for men who develop ED after treatment for prostate cancer are oral erectogenic agents (Viagra, Levitra or Cialis), MUSE/Intracavernosal therapy, Vacuum Constrictive Device or penile implant. If the cause of the ED is disrupted erection nerve integrity, treatment by oral erectogenic agents is often not effective. MUSE and Caverject are both FDA approved for ED treatment and are more likely to be effective if the cause of the ED is disrupted erection nerve integrity. Other intracavernosal agents may be used when Caverject is either not tolerated or not effective. Another option for ED management is the Vacuum Constrictive Device. Finally, if none of the above treatments are effective, consider insertion of the penile implant.

The Most Common Female Sexual Dysfunction: Low Interest was presented by Dr. Goldstein in July. Despite the heat wave and the time of year, it was well attended.

Female sexual dysfunctions are highly prevalent, multi-dimensional, interrelated, associated with personal distress. Symptoms include problems with desire, problems with arousal, problems with orgasm/ejaculation, problems with pain during intercourse. Female sexual dysfunction, especially low interest is associated with problems with mind and/or relationships (to be assessed by a mental health professional) and problems with brain, hormones, blood flow and/or nerves (to be assessed by a medical healthcare professional).

Sex steroid hormones are critical for genital (clitoris, labia, vagina) structure and function. Sex steroid hormones induce protein synthesis causing the genitals to grow, become more sensitive, have more blood vessels, act on the brain to have libido, act on the bones, muscles, skin, mood, etc. Without sex steroids, genital tissues shrink/atrophy, become poorly sensitive and poorly engorge. Conditions associated with reduced levels of sex steroid hormones in women with sexual dysfunction include combined oral contraceptive pills; infertility treatments with “lupron/zoladex”, childbirth; hysterectomy and bilateral oophorectomy; chemotherapy for cancer; hormone ablation therapy for endometriosis; eating disorders – bolemia, anorexia; transition and menopause; depression, major life stress, relationship conflicts; drug treatment for depression; drug treatment for epilepsy; thyroid disease; Lyme disease, HIV, diabetes mellitus, chronic fatigue syndrome, rheumatoid arthritis, systemic lupus erythematosis and HIV-AIDS; and major metabolic/nutritional disorders.

The women evaluated at the Institute for Sexual Medicine who have sexual dysfunction and low sex steroid hormone blood values have complaints of loss of desire, decreased frequency of sexual activity, painful intercourse, atrophy of genital tissues, diminished sexual responsiveness, difficulty achieving orgasm and decreased genital sensation. Other symptoms include decreased memory, sense of smell, taste and hearing, diminished vision, tiredness, fatigue, less energy, depressed mood and osteoporosis/osteopenia.

Double-blind, placebo-controlled, multi-institutional international trials in women with hysterectomy and bilateral oophorectomy have documented that androgen therapy in women with sexual dysfunction and androgen insufficiency (hypogonadism) can significantly improve sexual dysfunction during sexual activity compared to placebo with minimal side effects. Treatment with androgens is suggested if sex steroid blood test values fall either below or in the lower quartile of the reference range. Patients on treatment should have follow-up blood tests every 3 months. In our experience, 70% of women with low interest secondary, in part, to low sex steroid blood test values will experience restoration of sexual function with normalization of the sex steroid hormone milieu.

More detailed information about these and other programs from this year and previous years is available on line at www.bumc.bu.edu/sexualmedicine/informationsessions.

Treating the Couple

Sexual medicine physicians treat men and women with sexual health issues. Unfortunately sometimes when one person in a relationship has undergone diagnosis and treatment it is assumed that the process is complete. Often both partners have issues, even though they both assumed all the problems lay with the person who made the doctor’s appointment. If your doctor doesn’t ask you about your partner’s sexual function, offer to talk about it. If you bring your partner with you to your appointment, not only will he or she have an opportunity to learn firsthand about your problem but can answer your doctor’s questions about his or her sexual function. If, in fact, your partner has problems, they should be addressed along with yours for a healthier, more enjoyable sex life.

Sexual Medicine Meetings

Dr. Goldstein recently attended the annual meeting of the International Academy of Sex Research in Helsinki. He presented at a seminar on hormone therapy for female sexual dysfunction.

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.