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Mood Killers: Hormones, Menopause, and Erectile Dysfunction. Stacy Higgins, MD, FACP Emory University School of Medicine. Menopause. Definition. The permanent cessation of menses because of loss of ovarian follicular function A natural biologic process, not a disease!.

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mood killers hormones menopause and erectile dysfunction

Mood Killers: Hormones, Menopause, and Erectile Dysfunction

Stacy Higgins, MD, FACP

Emory University School of Medicine

definition
Definition
  • The permanent cessation of menses because of loss of ovarian follicular function
  • A natural biologic process, not a disease!
why does it happen
Why does it happen?
  • Aging of the female reproductive system starts at birth
  • Steady loss of eggs from either ovulation or atresia
  • Once last egg is depleted- menopause
why so much attention
Why so much attention?
  • Menopause affects every woman
  • Aging of the population means more women are postmenopausal than ever before
  • More postmenopausal women living beyond 65
terminology
Terminology
  • Pre-menopause
  • Peri-menopause
  • Post-menopause
  • Premature menopause
    • Premature ovarian failure
    • Induced menopause
age at menopause
Age at Menopause
  • Average age: 51.4
  • (40-58)
  • Peri-menopause:47.5
  • Lasts on average 4 years
  • No change in average age
when will it happen
When will it happen?
  • Later than average:
    • Multiparous
    • Increased BMI
  • Earlier than average:
    • Nulliparous
    • Medically treated depression
    • Seizure disorder
    • Smoking
hormonal
Hormonal
  • Irregular menses
  • Decreased fertility
  • Osteoporosis
vasomotor
Vasomotor
  • Hot Flashes
  • Night Sweats
  • Sleep Disturbances
urogenital atrophy
Urogenital Atrophy
  • Itching
  • Dryness
  • Bleeding
  • Urinary frequency and urgency
  • Urinary Incontinence
skin changes
Skin Changes
  • Breast Atrophy
  • Skin Thinning
  • Decreased Elasticity
  • Thinning Hair
psychological
Psychological
  • Mood disturbance
  • Irritability
  • Fatigue
  • Memory loss
  • Depression
sexual
Sexual
  • Decreased Libido
  • Vaginal Dryness
  • Problems reaching orgasm
  • Dyspareunia
diagnosis
Diagnosis
  • Usually clinical diagnosis
    • FSH
  • Home Testing
  • What else might it be?
    • Pregnancy!!
    • Thyroid problems
complications
Complications
  • Cardiovascular Disease
  • Osteoporosis
  • Urinary Incontinence
  • Weight Gain
self care1
Self-Care
  • Cool hot flashes
  • Decrease vaginal discomforts
  • Optimize your sleep
  • Strengthen your pelvic muscles
  • Eat well
  • Don’t smoke
  • Exercise regularly
  • Get regular checkups
medical symptom management
Medical Symptom Management
  • Estrogen
  • Low-dose Antidepressants
  • Clonidine
  • Complementary Medicines
systemic estrogen
Systemic Estrogen
  • Most effective treatment option for relieving menopausal hot flashes
  • Take lowest dose needed to provide symptom relief
  • Weigh risk vs. benefit
  • Protects against osteoporosis
  • Increased risk of breast cancer, heart disease, stroke, and blood clots
antidepressants
Antidepressants
  • Venlafaxine (Effexor)- selective serotonin reuptake inhibitor (SSRIs)
  • Shown to decrease menopausal hot flashes
  • Other helpful SSRIs- fluoxetine (Prozac/Sarafem), paroxetine (Paxil), citalopram (Celexa) and sertraline (Zoloft)
clonidine
Clonidine
  • Available as a pill or patch
  • Typically used to treat high blood pressure
  • May significantly reduce the frequency of hot flashes
  • Unpleasant side effects are common
vaginal estrogen
Vaginal Estrogen
  • Relieves vaginal dryness
  • Can be administered using a vaginal tablet, ring or cream
  • Releases just a small amount of estrogen, which is absorbed by the vaginal tissue
  • Also helps relieve discomfort with intercourse and some urinary symptoms
phytoestrogens
Phytoestrogens
  • Two main types of phytoestrogens
    • Isoflavones: found in soybeans, chickpeas and other legumes
    • Lignans:occur in flaxseed, whole grains and some fruits and vegetables
  • Most studies have found them ineffective
  • Isoflavones have some weak estrogen-like effects
black cohosh
Black Cohosh
  • Used to treat hot flashes, night sweats, vaginal dryness, and other symptoms
  • Study results are mixed on whether black cohosh effectively relieves menopausal symptoms
  • Studies to date have been less than 6 months long, so long-term safety data are not currently available
  • Can cause headaches and stomach discomfort
erectile dysfunction1
Erectile Dysfunction
  • Inability to attain or maintain erection sufficiently firm to permit satisfactory sexual performance
  • Impotence is a broad term including problems of libido, erection and orgasm
how common is it
How common is it?
  • Prevalence of 5% in men <40 years
  • Prevalence of 55-75% in men 75-80 years
  • Approximately 600,000 new cases of ED each year
types of dysfunction
Types of Dysfunction
  • Ability to obtain a full erection at some times (e.g. when asleep)
  • Obtaining erections which are either not rigid or full or lost rapidly
physiology
Physiology
  • Penis innervated by nerves
  • Blood vessels bring blood to the penis
  • Brain provides stimulation
how does an erection happen
How Does an Erection Happen?
  • Stimulation causes the brain to release chemicals
  • Chemicals bring message to nerves in the penis
  • Nerves tell penile blood vessels to relax
  • Blood flows into the penis
  • Pressure traps the blood, sustaining an erection
causes
Causes
  • Physiologic
    • Impedence of blood entering and being retained in the penis
  • Psychologic
    • Erection or penetration fails due to thoughts or feelings rather than physical impossibility
risk factors
Risk Factors
  • Vascular Disease is most common
    • Atherosclerosis
    • Diabetes
    • Hypertension
    • Cigarette smoking
    • Hypercholesterolemia
risk factors1
Risk Factors
  • Age
    • More time or more physical stimulation to achieve erection
    • More control over ejaculation, but flow is reduced
    • Tend not to be as hard, and the refractory period is prolonged
    • More likely to take medication that contributes to erectile dysfunction
risk factors2
Risk Factors
  • Medications
    • Antihypertensives (B-blockers, ACEI, Ca ch blockers, diuretics)
    • Antidepressants (TCAs, SSRIs)
    • Antipsychotics
    • Anticonvulsants
    • H2 receptor blockers
    • Statins and fibrates
risk factors3
Risk Factors
  • Endocrine Abnormalities
    • Hypogonadotropic hypogonadism
    • Hyperthyroidism
    • Hypothyroidism
    • Hyperprolactinemia
risk factors other
Risk Factors- other
  • Renal disease
  • Pelvic injury
  • Spinal cord injury
  • Drug abuse
  • Psychogenic abnormalities
evaluation history
Evaluation- History
  • Establish a comfortable environment to take sexual history
  • Ask open ended questions
    • How is your sex life?
  • Get a description of the problem
    • Is there a problem with libido, erection or ejaculation
  • Review risk factors for organic disorder
  • Review medications
  • Assess for psychological disorders (depression)
evaluation history1
Evaluation- History
  • Do you experience erection problems?
  • How often?
  • What do you believe has caused the problem?
  • How long have you been having problems?
  • Do you ever wake up with an erection?
  • Can you achieve an erection with self stimulation?
  • Can you get an erection at any time, during any sexual activity, with any partner?
evaluation physical exam
Evaluation- Physical Exam
  • Search for signs of vascular disease
    • BP, cardiac exam, pulses, hair growth
  • Genitourinary exam
    • Testicles, penile plaques, genital exam
  • Digital rectal exam
    • Rectal tone, prostate exam
  • Neurological exam
    • Perineal sensation, rectal tone, cremasteric reflex
evaluation testing
Evaluation- testing
  • Expensive diagnostic testing often adds unnecessary cost to the diagnostic accuracy of the workup
  • Testing should be directed based on the history and physical findings
slide56
Labs
  • Serum chemistries
    • Glucose, renal function
  • Lipids
  • Testosterone
    • Normal values decline with age
    • Normal range is based on morning values
  • Prolactin
  • Duplex Ultrasound
lifestyle changes
Lifestyle Changes
  • Quit smoking
  • Exercise regularly
  • Reduce stress
  • Minimize alcohol use
  • Eliminate drugs
modify reversible causes
Modify reversible causes
  • Prescription and nonprescription drug use
  • Psychosocial issues
  • Specific endocrinologic conditions
treatment sildenafil viagra
Treatment- Sildenafil (Viagra)
  • Increases blood flow to the penis
  • Allows for an erection with stimulation
  • Take ~30 minutes prior to sexual activity
  • Dose 25-100mg (most 50mg)
  • Duration of action 4-6 hours
  • Effective in 50-90% of patients
  • Cost $10 per dose
cialis and levitra
Cialis and Levitra
  • Levitra takes about 30 minutes for effect
  • Lasts about 5 hours
  • Cialis takes about 15 minutes for effect
  • Can lasts up to 36 hours
treatment pdeis
Treatment- PDEIs
  • Side Effects: flushing, headaches, GI disturbances, nasal congestion and transient color blindness
  • Contraindicated in those using nitrate preparations or alpha blockers
treatment other oral therapy
Treatment- other oral therapy
  • Yohimbine
    • Alpha-adrenergic receptor antagonist
    • Acts on brain receptors associated with libido and penile erection
    • Greatest effect in men with nonorganic erectile dysfunction
vacuum constriction device
Vacuum Constriction Device
  • Vacuum device placed over the penis
  • Blood is drawn into the penis due to creation of vacuum pressure around the penis
  • Constriction band is then placed around the base of the penis to hold the blood in place
  • Complications: painful ejaculation and bruising
  • $300-500 per device
alprostadil
Alprostadil
  • Medication that causes blood vessels to expand
  • Suppository inserted via an applicator into the distal urethra 10-15 minutes before intercourse (MUSE)
  • Direct injection into the penis (Caverject)
  • Side effects: penile pain, syncope and urethral bleeding
implants
Implants
  • Used when medical treatment unlikely to work
  • Two types:
    • Malleable rods
    • Hydraulic
  • 90-95% success rate in producing an erection
  • 80-90% satisfaction rate
on the horizon1
On the Horizon
  • Topiglan: Topical Gel applied directly to the penis
  • Avanafil: Newer PDEI that can be taken twice daily
psychological effects
Psychological Effects
  • Tied closely to cultural notions of potency, success and masculinity
  • Can have devastating psychological consequences including feelings of shame, loss or inadequacy
  • Strong culture of silence and inability to discuss the matter
counseling
Counseling
  • Being sexual is different than having an erection
  • Focus more on intimacy and pleasure rather than achievement and performance
  • Communicate with partners
therapy
Therapy
  • Treatment of ED with medications often uncovers an underlying or concomitant hypoactive sexual desire or early ejaculation
  • Couples may have difficulty reinitiating sexual activity