Sexual Dysfunction and Aging: Building a Bridge between Genders
The sexual health of aging men and women has long been an area that physicians have not adequately addressed. In recent years, however, more open attitudes from patients and the availability of pharmacologic therapy and psychological counseling have allowed for successful management of older patients with an interest in remaining sexually active. In this article, we present two case studies to illustrate the modern-day concerns of older men and women about their sexuality, and to demonstrate how physicians can best manage issues of sexual dysfunction in this age group.
Case Study 1
A 75-year-old man with a 35-year history of moderately well-controlled hypertension has been referred to a new physician following a change in health care coverage. He comes to the office for a general check-up and blood pressure management. Currently, the patient’s blood pressure is controlled on a regimen of hydrochlorothiazide and atenolol that were prescribed by his previous physician. His physical is unremarkable with a blood pressure of 130/80 mm Hg; the laboratory tests reveal a low-density lipoprotein (LDL) of 130 mg/dL and a high-density lipoprotein (HDL) of 30 mg/dL with normal triglycerides.
Over the last 5-6 years, the patient has been progressively developing benign prostate hypertrophy (BPH) and has periodically taken terazosin for treatment; as of the last 2 years, he has neither morning erections nor libido. In spite of this, he never voiced his concerns to his former physician, partly out of fear and the perception that his physician would be indifferent to his specific concerns. However, the recent acquaintance with a woman served as the catalyst for further examination of his problems. After 2 months of dating, he is reticent about being emotionally and physically intimate, largely out of fears of inadequacy in light of his erectile dysfunction (ED) and diminished libido.
Hearing of new treatments through advertisements, the patient asks whether the physician can help and/or counsel him regarding his sexual drive and ED. This case clearly illustrates several important points. First, the patient may be under the impression that his physician is uninterested in discussion of sexual matters. Indeed, some physicians may be unaware or unwilling to discuss sexuality, partly because they have not resolved their own issues regarding sexuality, or due to general discomfort with this issue. Physicians may also have the preconceived idea that older persons are no longer sexual beings, thereby barring further discourse on the topic. Alternatively, the patient may project his own insecurities and fears regarding sexuality onto the physician, further inhibiting development of dialogue on the topic. Complicating matters, the patient is taking anti- hypertensive medications such as diuretics (hydrochlorothiazide) and beta blockers (atenolol) that may themselves cause ED. Therefore, an initial approach with this patient would be to obtain a targeted history and physical. Gonadal hormone levels could be indirectly assessed with a testicular exam and elicitation of signs of gynecomastia. Additionally, a focused neurologic exam and vascular exam with peripheral pulses should be performed. In the initial examination, laboratory tests such as free and total testosterone and prostate-specific antigen (PSA) are recommended.
Other frequently ordered tests such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH) may be ordered, but with low yield. Additional laboratory tests reveal low free and total testosterone The patient’s free and total testosterone levels are indicative of hypogonadism. The goal will be to prescribe testosterone. Given that testosterone tablets are contraindicated due to hepatotoxicity, testosterone gel can be used for this patient at a dose of 5 g per day; the gel is commonly applied to the torso with alternation of the site so as not to produce a rash. Concomitantly, a 5-phosphodiesterase (PDE5) inhibitor may be administered along with an explanation of its correct use and the variety of choices available. Moreover, it is of utmost importance to emphasize the contraindication of concurrent PDE5 inhibitor use with nitrates or alpha-adrenergic blockers such as terazosin; instead, terazosin may be replaced with another alpha blocker such as tamsulosin while on a PDE5 inhibitor. Tamsulosin is the only alpha-adrenergic blocker that can safely be used with some PDE5 inhibitors such tadalafil and sildenafil, although still contraindicated with others like vardenafil. As in other medical conditions, while evaluating efficacy of treatment, the importance of follow-ups cannot be overemphasized. In subsequent visits, the physician can re-evaluate the management and correct it accordingly, if necessary.
Male Sexual Dysfunction
Male sexual dysfunction is a multidimensional entity encompassing several organ systems including the nervous, vascular, and genitourinary systems. Of the different complaints expressed by men regarding sexual dysfunction, ED is one of the most common and well studied. Briefly, ED is defined as the inability to achieve and maintain an erection for satisfactory sexual intercourse. Indeed, results from the Massachusetts Male Aging Study1 showed that in men 40-69 years of age, combined prevalence of minimal, moderate, and complete ED was 52%, with 5-15% experiencing complete ED. Furthermore, more recent analysis of the data from this landmark study found that the incidence rate of ED was 25.9 cases per 1000 man-years, with increases for every decade of life. By age 40, men have an incidence rate of 46.4 cases per 1000 man-years, demonstrating that a major risk factor for ED is aging.2
However, while age is an important risk factor, it is not the only one; factors such as atherosclerosis, diabetes, mental health, and levels of gonadal hormone secretion must also be taken into account. Interestingly, as men age, they may experience decreases in gonadal hormone secretion resulting in decreased libido, muscle mass, and ED in a process termed “male menopause.”3 Other causes of sexual dysfunction include psychiatric illness (such as major depression and dysthymia), cardiovascular diseases, diabetes mellitus, and iatrogenic causes (selective serotonin reuptake inhibitors [SSRIs], antipsychotics, thiazides, and beta blockers). In establishing a more meaningful understanding of ED, the study of the physiology and biochemistry associated with erection has been critical. Erection lies at the nexus of the vascular and the nervous systems, and dysfunction of either arm will potentially cause ED.
Studies from the last 15 years have shed increasing light on the molecular mechanisms of erection. The principal molecular mediator of penile erection, nitric oxide (NO), is generated by nitric oxide synthase (NOS) within the endothelium.4,5 The end result is production of cyclic guanosine monophosphate (cGMP), causing vasodilation that facilitates penile engorgement and subsequent erection. Conversely, the enzyme PDE5 degrades cGMP to cause vasoconstriction and the loss of erection. The understanding of this mechanism made PDE5 a natural target for inhibition by a new class of selective and competitive PDE5-inhibitor drugs including sildenafil, tadalafil, and vardenafil. Studies have found that in contrast to earlier ED treatments such as vacuum pumps, urethral suppositories, or intracavernous injections, most patients prefer oral therapy (currently with the PDE5 inhibitors).6
Oral therapy offers patients increased convenience and flexibility with the net result of potentially less embarrassment in discussing ED with physicians and partners.7,8 Ultimately, treatment with the PDE5 inhibitors has resulted in increases in the quality of life.9 Yet, despite these advances, as many as 70% of men with ED remain untreated, perhaps indicating disconnects between patient and physician and/or partner.10 Therefore, what can physicians do to effectively address the concerns of aging patients with ED and treat their problem? The most effective work-up of ED includes a focused history and physical with laboratory tests (examining abnormalities in the endocrine, neurologic, vascular, or gonadal sources). The link between psychogenic and organic causes of ED is increasingly concrete, demonstrating their interconnectedness. Moreover, ED is a disorder that not only affects the male but also his partner. Therefore, during follow-up visits it is incumbent on the treating physician to involve the partner in the management of ED.
Case Study 2
With some prompting from the physician for couples counseling regarding his ED, the patient brings his new partner to a follow-up visit for a meeting between the patient, his partner, and the physician. During the course of the visit, the patient’s partner discloses her own recent medical/sexual history. The partner is a woman 70 years of age, widowed in the past 2 years, with a 30-year history of postsurgical menopause, status/post–radical mastectomy for breast cancer (25 years ago). She has been on an SSRI for the past 5 years secondary to depression. The partner states that she was the primary caregiver for her late husband who suffered a 10-year course of Alzheimer’s disease until his death.
On taking her history, the partner reveals that she has been sexually abstinent for the last 8 years and admits to ignorance regarding masturbation. Although she had been relatively sexually satisfied with her late husband in spite of her surgical history, his worsening illness extinguished her sexual desire. Following his death, the partner became depressed and sought medical treatment; she was started on fluoxetine and responded adequately. Although she expresses little sexual desire to date, the partner recently began seeing the patient at her senior center and has been emotionally intimate with him for the past 2 months. She feels she is ready for sexual intimacy but worries about issues such as her own lack of libido, vaginal dryness, self-image, the possibility of sexually transmitted diseases, and the fact that her beau mentioned having sexual dysfunction himself.
Female Sexual Dysfunction
Similar to male sexual dysfunction, female sexual dysfunction is multifactorial. However, unlike aging men, aging women may be much less forthcoming with their sexual problems, particularly when seen by a physician of the opposite sex. Causes of female sexual dysfunction can be categorized into organic/medical, social, and psychological sources with frequent interplay between the different etiologies. This case illustrates many of the issues facing aging women in similar circumstances.
The first step in the management of the patient’s partner should be to commend and validate her openness. Her depression by itself may be the primary precipitant for her lack of libido, but it may also be combined with the side effect of the SSRI used to treat her. One of the most common iatrogenic causes of sexual dysfunction is the use of SSRIs, creating such side effects as anorgasmia, delayed orgasm, or diminished libido. The possibility of an iatrogenic cause of her lack of libido related to her SSRI use may necessitate a referral to a psychiatrist or further management by the primary care provider with the idea of changing the antidepressant.
The partner’s depression may stem from several causes in her life. Coping with the illness and subsequent loss of her spouse may have acted as triggers for her depression. Additionally, surgeries such as mastectomies may compromise feminine—and specifically sexual—aspects of self-image, resulting in feelings of sexual inadequacy.11 Such feelings can either precipitate depression or exacerbate pre- existing depression, and can contribute to sexual dysfunction. Superimposed over these extrinsic causes is the observation that aging itself, with its related comorbidities, is a risk factor for depression in women.12 Given the high prevalence of vaginal dryness in women of the patient’s age group, the vaginal dryness is somewhat expected; after verifying the benign nature of this condition, a lubricant such as lanolin-mineral oil is prescribed.
To address the possibility of sexually transmitted diseases, our patient’s partner should be instructed no differently than a woman of a younger age group. In addition to these issues, a woman’s sexual dysfunction affects not only her but also her partner. Especially in light of her partner’s sexual dysfunction, as in the case of the male patient, further management may entail bringing her partner to subsequent visits for joint counseling and/or therapy. Often, establishing a rapport between both partners allows the physician to gain insight into problems related to sexual intimacy and psychosocial factors contributing to the sexual dysfunction that visits solely with the patient alone will not permit. Moreover, in the longer term, both the patient and partner may benefit from couples therapy with the primary physician if he or she so desires and is so trained, or from a sex therapist.
Overall, these cases help illustrate the many approaches that must be taken in fully evaluating and treating both patient and partner. Furthermore, the problems associated with sexual dysfunction in men and women are often complementary, requiring a multidisciplinary approach incorporating many different treatment modalities and philosophies. In the future, better awareness of sexual dysfunction on the parts of both physicians and patients will not only demystify this often frustrating disorder but also lead to more effective management and improved patient quality of life.
There has traditionally been a gender-specific disparity in the way physicians, and Western societies in general, have approached sexuality. Through the centuries, conceptions of female sexuality across the life- span were either not discussed or were full of misconceptions; for example, in many cultures women were either isolated or made to abstain from sexual intercourse during menstruation, as they were perceived as “unclean.”13 This lack of information extended to women’s issues during menopause and beyond. However, beginning in the 1960s with the introduction of modern oral contraceptives by Frank Colton and Carl Djerassi, the first “sexual revolution” was born. The advent of oral contraceptives, in turn, may have been the catalyst for the explosion in the understanding of women’s health and, in particular, about sexuality. No longer was sex relegated only to procreation in the mindset of many, but now it was also intended for purposes of pleasure—for women as much as for men. This paradigm shift was incorporated into the political credos of the youth movement and into the popular idiom, with phrases such as “Make love, not war.” These sentiments were later codified by the medical establishment through the popularization and use of the Masters and Johnson technique in treatment of sexual dysfunction.
The cohort coming of age in those turbulent times, termed “the baby boomer generation,” were convinced that physical strength, virility, and freedom (which included the capacity to choose partners and, for the first time, to attain a previously unknown level of control in planning pregnancy) would accompany them throughout aging. Currently, the baby boomers continue to maintain a certain economic freedom and, to a degree, social dominance, keeping an eye on their general health, including their sexuality. As discussed, although we still feel the seismic shifts of the first sexual revolution, a second sexual revolution has evolved around the watershed development of sildenafil citrate beginning in 1998. Termed “the blue pill,” sildenafil achieved near-instant household recognition; however, with this recognition it also rapidly acquired a number of popular misconceptions regarding its use and mechanism of action. For example, the notion that sildenafil’s mode of action is through enhancement of sexual energy rather than through its true mechanism of facilitation in obtaining and maintaining an erection has widely filtered through the public consciousness. Thus, based on its popularity, sildenafil and the pharmaceutical companies created a cultural phenomenon that transcends class lines, ages, and beliefs. As a consequence, entire populations have been inundated with advertisements and sexual messages, creating a certain degree of unrealistic expectations in many regarding its precise indication and use. In the context of this new environment, physicians have been made to confront their patients’ sexuality and learn how to diagnose and manage sexual dysfunction not only in their patient but also between partners. In years to come, increased awareness of issues related to sexual health in aging men and women among physicians and their patients will surely increase not only the quality of medical care but also quality of life in general.