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!
Normal Menstrual Cycle
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?
Menopause affects every woman
Aging of the population means more
women are postmenopausal than ever
before
More postmenopausal women living
beyond 65
Terminology
Pre-menopause
Peri-menopause
Post-menopause
Premature menopause
Premature ovarian failure
Induced 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?
Later than average:
Multiparous
Increased BMI
Earlier than average:
Nulliparous
Medically treated depression
Seizure disorder
Smoking
Signs and Symptoms
Hormonal
Irregular menses
Decreased fertility
Osteoporosis
Vasomotor
Hot Flashes
Night Sweats
Sleep Disturbances
Urogenital Atrophy
Itching
Dryness
Bleeding
Urinary frequency and urgency
Urinary Incontinence
Skin Changes
Breast Atrophy
Skin Thinning
Decreased Elasticity
Thinning Hair
Psychological
Mood disturbance
Irritability
Fatigue
Memory loss
Depression
Sexual
Decreased Libido
Vaginal Dryness
Problems reaching orgasm
Dyspareunia
Diagnosis
Usually clinical diagnosis
FSH
Home Testing
What else might it be?
Pregnancy!!
Thyroid problems
Complications
Cardiovascular Disease
Osteoporosis
Urinary Incontinence
Weight Gain
Self-Care
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
Estrogen
Low-dose Antidepressants
Clonidine
Complementary Medicines
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
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
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
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
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
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 Dysfunction
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?
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
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
Penis innervated by nerves
Blood vessels bring blood to the penis
Brain provides stimulation
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
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
Vascular Disease is most common
Atherosclerosis
Diabetes
Hypertension
Cigarette smoking
Hypercholesterolemia
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 Factors
Medications
Antihypertensives (B-blockers, ACEI, Ca ch
blockers, diuretics)
Antidepressants (TCAs, SSRIs)
Antipsychotics
Anticonvulsants
H2 receptor blockers
Statins and fibrates
Risk Factors
Endocrine Abnormalities
Hypogonadotropic hypogonadism
Hyperthyroidism
Hypothyroidism
Hyperprolactinemia
Risk Factors- other
Renal disease
Pelvic injury
Spinal cord injury
Drug abuse
Psychogenic abnormalities
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- 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
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
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
Labs
Serum chemistries
Glucose, renal function
Lipids
Testosterone
Normal values decline with age
Normal range is based on morning values
Prolactin
Duplex Ultrasound
Treatment
Lifestyle Changes
Quit smoking
Exercise regularly
Reduce stress
Minimize alcohol use
Eliminate drugs
Modify reversible causes
Prescription and nonprescription drug
use
Psychosocial issues
Specific endocrinologic conditions
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
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
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
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 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
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
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 Horizon
On the Horizon
Topiglan: Topical Gel applied directly to
the penis
Avanafil: Newer PDEI that can be
taken twice daily
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
Being sexual is different than having an
erection
Focus more on intimacy and pleasure
rather than achievement and
performance
Communicate with partners
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