Intimacy Throughout Life

Julian Whitaker, MD

“How often did you think about sex? How would you rate your level of sexual desire? How satisfied have you been with your overall sexual life? How frequently did you awaken with a full erection? Were you able to get and keep an erection which would be good enough for sexual intercourse?”

These are some of the questions asked of 3,369 middle-aged men in the European Male Aging Study. Their responses, which were recently reported in the New England Journal of Medicine, established clear relationships between testosterone deficiency, sexual dysfunction, and what these researchers call “late-onset hypogonadism,” also known as male menopause.

While some physicians scoff at the concept of male menopause, there is no question that testosterone production slows down around age 40 and steadily declines thereafter. There is also no doubt that this is a primary reason why many older men lose interest in sex and, along with other factors, have problems with sexual performance.

Testosterone Benefits and Risks

The European Male Aging Study defined “late-onset hypogonadism” as reduced sex drive, erectile dysfunction (ED), and decreased frequency of morning erections, coupled with a total testosterone level of less than 11 nmol/L (3.2 ng/mL) and free testosterone of less than 220 pmol/L (64 pg/mL)—a description that fit just 63 of the men in the study (2.1 percent), most of them over age 70. The researchers concluded, “The application of these new criteria can guard against the excessive diagnosis of hypogonadism and curb the injudicious use of testosterone therapy in older men.”

This is absolute nonsense. What parasitic brain infestation caused these researchers to conclude the opposite of their own data? Testosterone replacement is not being used “injudiciously”—it isn’t being used enough! I’ve been seeing patients for more than 35 years, at least half of them men and most of them over age 50. And believe me, far more than 2 percent have signs of age-related testosterone deficiency. To limit testosterone replacement only to those with the lowest of low levels, as this study suggests, does a disservice to millions of men who could derive tremendous benefits from this therapy.

When patients of mine complain of sexual problems or other manifestations of testosterone deficiency, I give them a trial of bioidentical testosterone replacement, even if their levels are in the low-normal range. The results are predictable. In addition to pronounced effects on sex, testosterone replacement therapy improves bone density, muscle mass, body composition, mood, energy, cognitive function, cardiovascular health, and quality of life. Furthermore, it reduces risk of diabetes and heart disease.

Despite its spotty reputation, testosterone therapy is quite safe. Liver toxicity is only an issue with oral testosterone, which I do not recommend. And virtually all experts agree that the most serious concern—that testosterone could cause prostate cancer—is unfounded.

Vascular Problems Affect Erectile Function

Because testosterone is the driver of sexual desire, low levels of this hormone are intimately linked with loss of libido. However, it is not the primary cause of ED. More often than not, this vexing problem is related to vascular disease.

Erections occur when nitric oxide (NO), a messenger molecule in the endothelial cells lining the arteries, signals the smooth muscles of the penile arteries to dilate, which engorges the penis with blood. If blood flow is compromised—as it is in individuals with heart disease, hypertension, peripheral artery disease, and diabetes—you’re obviously more likely to have problems. In fact, Australian researchers recently discovered that ED is strongly predictive of future heart attacks and other cardiovascular events, especially when it occurs in younger men.

Many prescription drugs make matters worse. For example, beta blockers and diuretics, often given to men with hypertension, can make it difficult to achieve an erection, and SSRI antidepressants cause ED in up to one-quarter of men who take them. Other popular drugs that impair sexual function include statins, antihistamines, and tranquilizers.

Getting a handle on health challenges and replacing side-effect-riddled drugs with natural therapies will improve not only your sex life but every aspect of your well-being.

Lifestyle, CPAP, and EECP for Lovers

How you live affects your sexual function as well. Smoking is associated with a 50 percent increase in ED, and kicking the habit often gets things back on track. A Mediterranean diet is linked with improvements in erectile function. Vegetables, fish, and other healthful foods stimulate NO release and enhance vascular health, while excess fat, sugar, and refined carbohydrates actually reduce production. Other lifestyle measures that boost NO synthesis include regular exercise and maintenance of normal weight.

Sleep apnea is now recognized as an independent risk factor for ED. When German researchers tested more than 400 men with overnight sleep studies, they found that 69 percent of those who were diagnosed with sleep apnea had ED, compared to 34 percent who had normal sleep patterns. If you snore or exhibit other signs of sleep apnea, get tested—and get treated. CPAP and APAP, the most effective treatments, may improve erectile function.

I also want to mention enhanced external counterpulsation (EECP). The effects of EECP on ED were discovered serendipitously when men undergoing this therapy for heart disease had unexpected improvements in erectile function. This outcome, which has since been confirmed in clinical studies, makes perfect sense—EECP increases NO levels, improves blood flow, and stimulates the formation of new blood vessels. Although I wouldn’t recommend a course of EECP strictly for this problem, it’s a nice side benefit for those receiving treatment for cardiovascular disease.

Effective Drugs and Supplements

It may take some time to see results with disease control and lifestyle changes. So while you’re waiting, I suggest you talk to your doctor about Viagra, Cialis, or Levitra. These drugs, which enhance the activity of NO, are pretty good medications. They improve erectile function in the majority of men who take them, and as long as contraindications such as concurrent use of nitroglycerin and other nitrate drugs are observed, they’re safe and well tolerated. I do, however, take exception to ads that recommend Cialis for daily use, so “you can be ready anytime the moment is right.” Who are they trying to fool?

Nonprescription options are also available. One of my favorites is the amino acid L-arginine, which is the direct precursor to NO. Although results aren’t as predictable as with the drugs, supplemental arginine has been shown in several clinical trials to improve erectile function.

Traditional healers have long relied on medicinal herbs to boost male sexual function, and I do believe these herbs are beneficial. After all, nothing can endure for thousands of years without some degree of efficacy. Among the most popular are Panax ginseng, an ingredient in many traditional Chinese remedies for men; maca, a South African herb purported to improve both desire and function; Ginkgo biloba and Epimedium (horny goat weed), which support blood flow; Tribulus terrestris, an herb that boosts testosterone levels,; and yohimbe, an extract from an African tree that has been used as a drug (yohimbine hydrochloride) to treat ED for more than 75 years.

I recognize that sexual problems are a sensitive area, and there’s no single solution that works for everyone. The good news is, you do have several options. I believe the most important first step is testosterone replacement. And anything you can do to increase NO production and improve blood flow is a good thing, especially if your problems are of vascular origin.

I sincerely hope that one, or a combination of, these suggestions will help you and your partner enjoy a lifetime of intimacy.

Recommendations

• Talk to your doctor about testing your total and free testosterone levels. If they’re in the low-normal range or below, consider a trial of injected or topical bioidentical testosterone.
• To receive bioidentical testosterone, EECP, and other therapies offered at the Whitaker Wellness Institute, call (866) 944-8253.
• The suggested dose of L-arginine is 1–2 g three times a day, taken on an empty stomach. (Do not take with Viagra, nitroglycerine, or related drugs or if you have herpes or migraines.) Look for this and other male supplements in your health food store or call (800) 810-6655. Use as directed.
• Although yohimbe is available in health food stores, this is one case in which I prefer the prescription form (yohimbine hydrochloride). This herb can cause anxiety if taken in too high a dose, and the drug delivers standardized levels. The usual dose is 5.4 mg three times a day. It should not be taken by men who have hypertension or are taking tricyclic antidepressants.

References

• Bassil N, et al. The benefits and risks of testosterone replacement therapy: a review. Ther Clin Risk Manag. 2009;5:427–448.
• Budweiser S, et al. Sleep apnea is an independent correlate of erectile and sexual dysfunction. J Sex Med. 2009 Nov;6(11):3147–57. Epub 2009 Jun 29.
• Chew KK, et al. Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: findings from a linked-data study. J Sex Med. 2010 Jan;7(1 Pt 1):192–202.
• Esposito k, et al. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med. 2010 May 4. [Epub ahead of print]
• MacKay D. Nutrients and botanicals for erectile dysfunction: examining the evidence. Altern Med Rev. 2004;9(1):4–16
• Wu FC, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. 2010 Jun 16. [Epub ahead of print]

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