1. Mood Killers: Hormones, Menopause, and Erectile Dysfunction Stacy Higgins, MD, FACP Emory University School of Medicine

2. Menopause

3. Definition The permanent cessation of menses because of loss of ovarian follicular function A natural biologic process, not a disease!

5. Normal Menstrual Cycle

6. 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

8. 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

9. Terminology Pre-menopause Peri-menopause Post-menopause Premature menopause Premature ovarian failure Induced menopause

10. Age at Menopause Average age: 51.4 (40-58) Peri-menopause:47.5 Lasts on average 4 years No change in average age

11. When will it happen? Later than average: Multiparous Increased BMI Earlier than average: Nulliparous Medically treated depression Seizure disorder Smoking

12. Signs and Symptoms

14. Hormonal Irregular menses Decreased fertility Osteoporosis

15. Vasomotor Hot Flashes Night Sweats Sleep Disturbances

16. Urogenital Atrophy Itching Dryness Bleeding Urinary frequency and urgency Urinary Incontinence

17. Skin Changes Breast Atrophy Skin Thinning Decreased Elasticity Thinning Hair

18. Psychological Mood disturbance Irritability Fatigue Memory loss Depression

19. Sexual Decreased Libido Vaginal Dryness Problems reaching orgasm Dyspareunia

21. Diagnosis Usually clinical diagnosis FSH Home Testing What else might it be? Pregnancy!! Thyroid problems

22. Complications Cardiovascular Disease Osteoporosis Urinary Incontinence Weight Gain

25. Self-Care

26. Cool hot flashes Decrease vaginal discomforts Optimize your sleep Strengthen your pelvic muscles Eat well Don’t smoke Exercise regularly Get regular checkups

28. Medical Symptom Management Estrogen Low-dose Antidepressants Clonidine Complementary Medicines

30. 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

32. 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)

33. 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

34. 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

35. 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

36. 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

38. Erectile Dysfunction

40. 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

41. 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

42. 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

44. Physiology Penis innervated by nerves Blood vessels bring blood to the penis Brain provides stimulation

45. 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

46. 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

47. Risk Factors Vascular Disease is most common Atherosclerosis Diabetes Hypertension Cigarette smoking Hypercholesterolemia

48. 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

49. Risk Factors Medications Antihypertensives (B-blockers, ACEI, Ca ch blockers, diuretics) Antidepressants (TCAs, SSRIs) Antipsychotics Anticonvulsants H2 receptor blockers Statins and fibrates

50. Risk Factors Endocrine Abnormalities Hypogonadotropic hypogonadism Hyperthyroidism Hypothyroidism Hyperprolactinemia

51. Risk Factors- other Renal disease Pelvic injury Spinal cord injury Drug abuse Psychogenic abnormalities

52. 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)

53. 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?

54. 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

55. 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

56. Labs Serum chemistries Glucose, renal function Lipids Testosterone Normal values decline with age Normal range is based on morning values Prolactin Duplex Ultrasound

57. Treatment

58. Lifestyle Changes Quit smoking Exercise regularly Reduce stress Minimize alcohol use Eliminate drugs

59. Modify reversible causes Prescription and nonprescription drug use Psychosocial issues Specific endocrinologic conditions

61. 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

62. 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

63. Treatment- PDEIs Side Effects: flushing, headaches, GI disturbances, nasal congestion and transient color blindness Contraindicated in those using nitrate preparations or alpha blockers

64. 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

65. 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

68. 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

71. 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

74. On the Horizon

75. Topiglan: Topical Gel applied directly to the penis Avanafil: Newer PDEI that can be taken twice daily

76. 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

77. Counseling Being sexual is different than having an erection Focus more on intimacy and pleasure rather than achievement and performance Communicate with partners

78. 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