Section: Medicine

IRWIN GOLDSTEIN COULD HARDLY WAIT for the FDA to approve Viagra. The renowned Boston University urologist is so excited about last month’s approval of the first-ever impotence pill for men that he is opening a new sexual-dysfunction clinic, and will soon begin prescribing the drug-for women.

As doctors learn more about the causes of impotence, they’re becoming increasingly convinced that the underlying mechanisms of male and female sexual dysfunction may not be so far apart. And if that’s the case, it’s entirely possible that the same pharmacological science that restores sexual function to men can work similar magic in women.

Viagra trials in women are already under way in Europe. This month the FDA is holding an invitation-only meeting of scientists and pharmaceutical executives to discuss possible testing and use of the drug in women in the U. S . And in June leading sex researchers will devote their annual meeting in Cape Cod to discussing how a range of impotence drugs might be tested in female p atients. If the medications prove effective, they could offer women a safer alternative to the current best weapon against female sexual dysfunction, hormone-replacement therapy, which carries a slightly increased risk of cancer. Meanwhile, with the approval of Viagra (release date: mid April) as an impotence treatment, doctors will be able to prescribe it “off-label” for women too. “We intend to use it in women once it’s released for men,” Goldstein says. “Not even a question.”

Viagra’s effects on the hydraulics of male sexuality are pretty straightforward. Originally developed as a heart medication, the drug works directly on the blood vessels, blocking an enzyme called phosphodiesterase. This enzyme prevents the release of certain neurotransmitters-most notably one called cyclic GMP-that cause the smooth muscles surrounding the arteries to relax, a llowing the arteries to expand. When this occurs in penile arteries, it leads to engorgement, which leads to erection.

While Viagra doesn’t work for every impotent man, it does work for up to 80% of them. “There appears to be no group that has been tested that has a zero response,” says urologist Dr. Harin Padma-Nathan of the University of Southern California. Even men with the most severe forms of impotence-spinal-injury victims, diabetics, those who have undergone prostate-cancer surgery–have responded.

Such results ought to mean good things for women too. Female genitals fill with blood during sexual stimulation just as male genitals do, resulting in engorgement of the clitoris and lubrication of the vagina. As women age, they experience some of the same genital problems men do, as a number of ailments-particularly atherosclerosis and diabetes-impair blood flow; this leads to vaginal dryness, pain during intercourse and problems in achieving orgasm. Indeed, according to one study, more than a th ird of women in the 18-to-59 age group experience sexual dysfunction, compared with just 10% of men. “Male sexuality has always been viewed as more important, says Julia Heiman, a psychologist at the University of Washington and one of America’s leading experts on female sexual dysfunction. “A man needs an erection to have intercourse, so it’s easy to regard a man’s sexuality as important and interesting pastime.”

How effective Viagra is come of the tests. The FDA and Pfizer, the manufacturer, do not encourage women to use it. “We strongly recommend against women taking their husband’s pills or physicians using it off-label,” says Raymond Rosen, professor of psychiatry at the Robert Wood Johnson, who will chair the Cape Cod.

Still, some physicians see potential benefits in careful, off-label use of the new drug. Goldstein plans to test female patients-mostly postmenopausal women- for impaired blood flow and give Viagra to those he thinks it can help. He has already received E-mail from women eager to try it. Other doctors are bracing for the same. “The Viagra avalanche is about to begin,” says Rosen. “Where the oral contraceptive was liberating for younger people, Viagra may be the sexual-liberation pill of older adults.” This time both men and women will be getting in line.

~~~~~~~~

By ARNOLD MANN

Viagra (chemical name: sildenafil): Relaxes muscle cells to enhance blood flow. Early female trials under way in Europe: U.S. female trials will be discussed at an FDA meeting later this month

Vasomax (phentolamine): Oral version of an approved injectable drug. Dilates blood vessels to increase flow. Male trials are near completion in the U.S.; female trials are planned

Spontane (apomorphine): Works through the central nervous system. Male trials are nearing completion; female trials are planned

Prostaglandin creams: Applied to the surface of the genitals to stimulate blood flow. Male trials are under way; female trials are planned

ILLUSTRATION

Section: Love, Sex & Health

MEN

PRESCRIPTION THERAPIES

• Viagra, Levitra and Cialis: All these drugs work the same way, by relaxing smooth-muscle cells and widening blood vessels, primarily in the penis. Cialis stands out as particularly long-acting–up to 36 hours, compared with four or five hours for the others

• Testosterone: For men who don’t produce enough, patches (Androderm, Testoderm) and gels (Androgel) deliver extra hormone through the skin

• Alprostadil: This vasodilating drug can be self-administered as an injection (Caverject) in the penis, or inserted into the urethra as a suppository (MUSE)

WOMEN

PRESCRIPTION THERAPIES

• Testosterone: Doctors prescribe the hormone in lower doses than typically used for men, though it’s not approved for this use by the FDA. Women can also take under-the-tongue drops specially formulated by pharmacies or use patches and gels

• Estrogen: Tablets (Vagifem), creams (Estrace, Premarin) and a silicone ring (FemRing) inserted into the vagina release estrogen to alleviate such symptoms of menopause as vaginal dryness

• Viagra and Levitra: Initial trials are disappointing, but the drugs appear to work for some women

MEN

NONPRESCRIPTION THERAPIES

• Ginkgo biloba: Better known as a memory enhancer, this herb is believed by some to improve blood flow to the body, including the penis. Conclusive scientific proof is lacking

• Ginseng: In the lab, ginseng has been shown to release nitric oxide, but there’s no evidence to suggest that it improves erectile function

• L-arginine: This naturally occurring amino acid is a precursor to nitric oxide and is believed to improve the flow of blood to the genitals

WOMEN

NONPRESCRIPTION THERAPIES

• Avlimil: The pill contains various plant leaves and roots and is touted as the female Viagra, but experts question its effectiveness

• Zestra: A botanical-oil lotion applied to the genitals can create a tingling sensation and enhance orgasm (breath mints or a few drops of Binaca on your partner’s tongue during oral sex do the same)

• XZITE: A daily capsule, manufactured in Marina del Rey, Calif., containing Chinese plant bark, flowers and roots, which doctors at UCLA’s Female Sexual Medicine Center say works for many of their patients

MEN

DEVICES

• Penile prostheses: These surgically implanted devices are still used by men who, for medical or physical reasons, don’t respond to drugs

WOMEN

DEVICES

• Slightest Touch: UCLA doctors express high hopes for this device, which uses a set of electrodes to stimulate nerve pathways

~~~~~~~~

By Sora Song

Section: Men’s Health Special Report

Life without erections is like rock and roll without guitar solos: It’s doable, but a lot less entertaining. Think it can’t happen to you? Think again.

“The best study we have shows erectile problems in 52% of men ages 40 to 70,” says Ira Sharlip, MD, spokesperson for the American Urological Association in Baltimore and president of the Sexual Medicine Society of North America in Schaumberg, IL. That translates to an estimated 20 to 30 million men who can’t get the erections they want. It’s an alarming statistic, but don’t panic. The truth is, there are more options than ever for reviving a penis that’s lying down on the job.

On any given day (or night), there may be obvious reasons why a man has trouble summoning an erection: stress, fatigue, anxiety, the baby crying in the next room. But if the problem persists, it crosses the line from occasional disappointment to a medical condition called erectile dysfunction (ED). “We usually say that if the problem lasts 3 months or more, you have ED,” says Dr. Sharlip.

The defining symptom of ED is the inability to achieve and maintain an erection sufficient for satisfactory sexual function. While erectile dysfunction is not an uncommon problem among men as they get older, says Dr. Sharlip, neither is it an automatic consequence of aging.

To know why erections stop reporting for duty, you have to understand how they get there in the first place. Many a man has been accused of thinking with his penis, but in fact the opposite is true: Men have erections with their brains. Whatever the triggerevery erection is a sequence of events that begins in your head, says Tom Lue, MD, professor of urology at the University of California, San Francisco and spokesperson for the American Foundation for Urologic Disease in Baltimore.

“Basically, when a man is sexually stimulated, a signal is transmitted from the brain down the spinal cord and reaches the penis,” he explains. Then the stimulated nerves in the penis release a chemical called a neurotransmitter. This chemical signal causes blood vessels in the penis to open up. Blood is pumped into spongy tissues in the penis, causing it to swell and stiffen like a water balloon. And there’s your erection. A problem at any step in this process can cause the erection to be weakened or prevent it altogether, and all the Victoria’s Secret catalogs in the world won’t help then.

Here are the known erection killers.

Low hormone levels. No matter how romantic the setting, unless you have enough sex hormones (primarily testosterone), the brain-to-penis transmission just won’t happen, because you simply won’t be aroused. (It’s normal for a man’s testosterone levels to decrease with age, but such changes usually happen gradually and don’t completely erase the libido.)

Psychological problems. A brain overwhelmed by stress, anxiety, fatigue, or other mental concerns is less likely to send out the “Let’s party!” signal.

Nerve damage. Injury to the brain, spinal cord, or nerves in the pelvic area can prevent the erection signal from reaching its destination. Nerve damage can be caused by uncontrolled diabetes, surgery, or cancer therapy.

Blocked vessels. If the arteries that bring blood into the erection chamber are blocked, the erection will be weak or even nonexistent.

Damage to the penis. Scar tissue or other structural damage can prevent the erection from occurring.

Medication. Certain medicines have side effects that inhibit erections. Your doctor will know if any of your medications fall into this category.

It may seem like there’s a lot of things that can go wrong. But low hormone levels, long-term psychological problems, nerve damage, and penis injury are relatively rare causes of ED. The problem that most men should be concerned about is blocked arteries. “High blood pressure, high cholesterol, coronary artery disease: People with these conditions will also have trouble pumping blood into the penis,” says Dr. Lue. It’s the same process that leads to heart disease: Arteries become gunked up, and the narrowed channels can’t bring in enough blood to do the job.

In a study of 50 men experiencing impotence , 40% had significant blockages in their coronary arteries, though they had no other symptoms of vascular disease. That makes ED an early warning signal of heart disease and stroke.

When you take your erection problems to your family doctor, odds are you’ll come away with a prescription for sildenafil citrate, known to comedians everywhere as Viagra. Why? All the hype and late-night talk show jokes aside, because it’s actually a very effective medication. “It works for two-thirds of the men who try it,” Dr. Sharlip says. “It’s the first-line treatment for ED.”

Viagra does its job by causing the chemical messenger that stimulates erections to persist in your body longer than it normally would. This keeps narrowed blood vessels allowing an erection to occur. This medicine doesn’t produce erections; rather, it sets to occur naturally. “You still need some sort of sexual stimulation for an erection to happen,” says Dr. Lue. Your doctor will typically instruct you to take Viagra 1 hour before sex.

Because Viagra works so well, there’s a danger of forgetting that it’s medication, not a magic trick. And like all medications, it comes with cautions. For some men, particularly those with serious heart conditions or those taking certain other medicines, Viagra can be deadly.

“People can die if they take Viagra with the wrong combination of drugs,” warns Dr. Lue. Any drug containing nitrate, notably nitroglycerin (used to treat angina symptoms), can be a lethal mix with Viagra. Tell your doctor what drugs you’re taking.

Borrowing Viagra from a friend, ordering it on the Internet, or taking it without your doctor’s supervision is a stupid and possibly suicidal move. Not only are you risking dangerous side effects, you’re cheating yourself of a doctor’s visit that could turn up serious health problems, such as heart disease or diabetes, that are contributing to ED.

What happens when Viagra doesn’t work? Then it’s time to see a specialist, says Dr. Lue. “Your doctor will refer you to a urologist who will do a more specialized examination,” he explains. Depending on the cause of your erectile dysfunction, there are a number of other options for treatment. (See “Your Options for Treating Erectile Dysfunction” at left.)

The bottom line: “A man who’s willing to do whatever is necessary has a 90 to 95% chance of having satisfactory sexual functioning for the rest of his life,” says Dr. Sharlip.

For some men, keeping their erection options open into their 70s isn’t a top priority. If you want your ability to have erections to outlast your ability to grow hair on your head, take steps now to ensure an active retirement-home sex life later. You want to keep those geriatric care nurses on their toes, don’t you? Here’s the plan.

Stop smoking. Amazingly, there are still men for whom the threat of an early death isn’t motivation enough to quit. So how about the threat of an early death after years without sex? Smoking is as bad for the arteries that support an erection as it is for the arteries that nourish your heart.

Stop eating like a pig. Or, since pigs generally prefer to eat grains and vegetables, start eating like one. A healthy diet will help you lose weight and lower your cholesterol, keeping you alive longer and, very possibly, keeping you erect longer.

Get your butt off the couch. Exercise to shed pounds, lower your blood pressure, and keep your blood vessels healthy, including those critical ones in the groin area.

Have sex regularly. Besides making you feel good and strengthening your relationship, having and using erections may help keep your penis in working order. Which, of course, allows you to keep having and using erections.

THERAPYDESCRIPTION 
	
ViagraThis pill allows erections to occur with
sexual stimulation. It's the first choice
for most ED cases. 
	
Injection TherapyMedication is self-injected directly into the
penis before sex to increase bloodflow and
produce an erection. 
	
SuppositoryAn alternative to injection therapy; the
medicine is delivered by a capsule that you
you insert into the tip of your penis. 
	
Vacuum DeviceThe penis is inserted into a cylinder, and air
Is pumped out, producing an erection. 
	
SurgeryIn certain situations, this can be done to bypass
 A blockage of bloodflow to the penis. 
	
ImplantA prosthetic device is implanted into the penis
To provide stiffness.

PHOTO (COLOR): Obsessing about your “problem” is the last thing you need to do in bed. Most erectile dysfunction is curable.

PHOTO (COLOR): What you don’t use, you lose.

PHOTO (COLOR): Exercise keeps all your blood vessels healthy.

~~~~~~~~

By Rick Chillot, Rick Chillot writes about health and other topics from his home in rural Pennsylvania.

Experts believe that most cases (some 70%) of erectile dysfunction (ED) have a physical, rather than mental, origin. But it’s also true that ED can produce emotional wounds that a pill won’t heal, says Gerald Weeks, PhD, chairman of the department of counseling at the University of Nevada-Las Vegas and author of several textbooks for doctors and sex therapists, including Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy, and Medical Treatment (W.W. Norton & Company, Inc., 2000).

“After the problem’s happened a few times, a man may try to have sex more often, thinking he can correct it by extra stimulation or force of will,” says Weeks. In such cases, sex becomes hyperfocused on the man getting an erection, with his partner’s needs given short shrift. When that strategy fails, the man will typically start avoiding sex, and his partner may feel that she’s no longer attractive to him.

In another common scenario, an older man whose penis has been revived by modern science may find that his wife isn’t celebrating the resurrection. “About one-third of all women lose interest in sex at some point in their life,” explains Dr. Weeks. “When they stop having sex because of the man’s erectile problems, it takes the pressure off her to summon sexual desire that she doesn’t have.”

If you’re facing these kinds of difficulties, a sex therapist can help. This sounds like a racy solution, but don’t get the wrong idea: The sexy stuff is actually done at home with your spouse, not during the office visits. “In a typical session, the therapist will ask the couple a series of detailed questions about what’s happening or not happening. Then he’ll give them behavior-oriented homework assignments,” Dr. Weeks explains.

Sex therapists, especially those who also do marital therapy, can make medical treatments more effective by helping couples deal with psychological issues that may be contributing to ED. They can also help couples get their sex lives back on track after a long dry spell and advise them on how to bring various medical therapies into the bedroom.

Sex therapy doesn’t mean signing up for years of analysis; most problems can be overcome in a matter of 10 to 15 1-hour sessions, says Dr. Weeks. To find a board-certified sex therapist, go to www.prevention.com/links for links to the American Board of Sexology and the American Association of Sex Educators, Counselors, and Therapists.