What's Healthy, and What's Not, in Bed
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What's Healthy, and What's Not, in Bed

Few subjects are more emotionally charged than a man's diminished sex drive. And yet, the reasons might be completely physical.

Erectile Dysfunction

A few years ago, many of us had never even heard of "erectile dysfunction" (ED). Now it seems as if we hear about it daily. But for all the talk, the big question remains: If it happens to your man on a regular basis, should you worry? And how on earth do you talk about it with him?

While most men may experience erectile dysfunction at one time or another, it is estimated that for as many as 30 million men, ED is a chronic problem. Still, until five years ago, when Bob Dole and Viagra brought male sexual function out from under the covers, physicians say patients rarely brought up the topic. And doctors didn't ask patients about how they were faring in that department, either, largely because there wasn't a good way of treating erectile problems. But now that Viagra has become mainstream, and two new, heavily advertised ED drugs, Levitra and Cialis, have come on the market, all that has changed. Doctors say that men have become much more open about discussing ED with them -- and are willing to undergo treatment. Because women are usually the ones responsible for getting men to the doctor in the first place, doctors agree it's important for them to understand the issues surrounding ED and the possible treatments. Here, Harvey B. Simon, MD, associate professor of medicine at Harvard Medical School, in Boston, and editor of the Harvard Men's Health Watch (www.health.harvard.edu), helps answer some of your questions on this touchy topic.

Is It Erectile Dysfunction?

Q. My husband is 42, and we've had a very satisfying sex life. But all of a sudden, he's unable to get an erection at all. It's been two weeks now, and still nothing. Is this ED -- or could it be a sign of a more serious problem?

A. Usually ED begins gradually. But since your husband seems to have become impotent overnight and has remained that way, he should get a medical evaluation to check for a urological or prostate problem. Diabetes can also cause ED, as can many medications, such as tranquilizers, antidepressants, and those for lowering blood pressure or cholesterol. ED can also be a sign, especially in men 50 and older, of atherosclerosis, or hardening of the arteries. The arteries to the penis are like the arteries to the brain or heart and are subject to the same problems caused by high cholesterol, high blood pressure, obesity, lack of exercise, smoking, etc.

A study published in the Journal of the American College of Cardiology found that most men in their mid 40s who had ED but no known health problems had subtle abnormalities in the smooth muscles of their artery walls. The finding suggests that men with ED should be evaluated and treated more aggressively for such conditions as high blood pressure or high cholesterol, which are risk factors for cardiovascular disease.

Viagra and Other ED Drugs

Q. My husband has high blood pressure and occasional ED. Can he take Viagra or another of the drugs I've been hearing so much about? What are the differences, and are they equally safe?

A. There are three similar drugs for ED on the market now: Viagra, Levitra, and Cialis. They are all quite safe for healthy men. They are even safe for men with high blood pressure or heart disease, provided they are not taking any nitrate medication (often prescribed for chest pain, or angina) -- the combination can cause a rapid drop in blood pressure and lead to a loss of consciousness or even a heart attack or stroke. These drugs may also interact with other medications, too. About 70 percent of men with ED respond well to Viagra, Levitra, or Cialis. For diabetics the response rate is closer to 50 percent.

All three drugs basically increase blood flow to the penis. They do not create erections, but they improve the erectile response to sexual stimulation. The man still needs to be stimulated in whatever way works for him before he will get an erection. They are prescription drugs, they're expensive and there are side effects, such as headaches, facial flushing, stomach upset, blue-tinged vision, or even an erection that will not subside. (An erection that lasts longer than four hours is a serious medical emergency.)

Viagra, as the first to become available, is being promoted as the drug with the longest proven record of safety and effectiveness. Levitra's active ingredient is more potent than Viagra's, so it tends to produce similar results at a smaller dose, and it acts a little more quickly. Cialis's major selling point is that it is effective for about a day and a half, so some men prefer it to the other two, the effects of which generally disappear after four to six hours. Because of that perceived advantage, Cialis has earned the nickname "the weekender." The hitch is that it takes longer to kick in, and the drug's side effects can also last significantly longer.

Is It Stress or Me?

Q. Do men's erections tend to be less firm as they age? That seems to be the case with my husband. He attributes the problem to stress, but I worry that he doesn't find me attractive anymore.

A. Most people, as they grow older, experience gradual changes in their sexuality. Starting in their 40s, men may have a decrease in desire, may take longer to become aroused, their erections may be a little less firm, their orgasms a little less intense, and it may take longer before they're ready to do it all over again. That's all normal, and it also parallels changes in women's desire and sexual response. It doesn't mean your husband doesn't find you attractive or that you can't have satisfactory intimacy and sex. But if it bothers either of you, he should talk to his doctor.

When Viagra Doesn't Work

Q. My husband has diabetes, and Viagra and the other ED pills don't work for him. Are there other options he could try?

A. There are treatments that act directly on the arteries in the penis, increasing blood flow to produce an erection without requiring sexual stimulation to work. One, Caverject, uses a drug called alprostadil that is self-injected right into the penis using a very fine-gauge needle. It's not as difficult or painful as it sounds, and once men are instructed in how to do it, the treatment has a success rate of 80 to 90 percent. The side effects are pretty minimal, mostly bruising and brief discomfort. The same medication is available in pellets that a man can insert in his urethra -- also not as bad as it sounds. Another treatment that's really effective with no side effects is a simple vacuum pump, available over the counter without a prescription. It draws blood into the penis, thereby producing an erection. But although there are a number of good alternatives, there are also some bad choices. For example, don't waste your money on ineffective herbal "remedies."

Discussing Erection Problems with Your Husband

Q. Any advice on how I can talk to my husband about erection problems? It's such a sensitive issue.

A. Make sure he knows that you are bringing this subject up out of concern for his health and because you want to improve sex and intimacy for both of you. Offer him warmth and support; don't seem frustrated or accusatory. Remind him that sexual problems are normal and usually mild, and that there are good treatments available.

Originally published in Ladies' Home Journal magazine, June 2004.