Read an Excerpt
Your Sex Thermometer
IF YOU OFTEN THINK ABOUT HAVING SEX, you'll be happy to know that's exactly what you should be doing. When you think about having sex, you're indirectly thinking about your health, and that's always a good thing. Although you may not always be conscious of it, having sex requires many parts of your body to work well, both on their own and with each other. If sex is less desired, experienced with less frequency, or just isn't very good, your health most likely isn't very good, either.
Put another way, your penis is the thermometer for your overall health.
Charlie M.'s "thermometer" hadn't been rising much for 4 years when he came to see me in the summer of 2003. At 56 years old, Charlie was a successful, self-made investment banker who had overcome humble beginnings in the Bronx, New York. He referred to himself as a perfectionist. Until his erectile dysfunction (ED) showed up, he thought he had it all. He began to relate his story.
"I get up at 6 a.m. every day, work 70 or 80 hours a week without a problem. Except for my erection trouble, I feel fine." He went on to tell me that ED had been occurring more frequently. He had seen a urologist who prescribed a PDE-5 inhibitor (Viagra), but Charlie said that didn't help him much. His doctor then prescribed the other oral medications, Levitra and Cialis, but the results were still inconsistent.
"I'm only 56 years old. I don't want to take drugs for the rest of my life, even if they do work." Charlie looked me straight in the eye, years of frustration and shame evident on his face. "Why the hell do I have ED, doctor?" Why, indeed.
I started by reviewing Charlie's statistics: He was 5 feet 8 inches tall and 248 £ds, with a 48-inch waist, followed no regular exercise program, admitted to moderate-to-heavy alcohol consumption, and smoked a pack and a half per day. Diagnostic tests then confirmed that Charlie was, in fact, "perfect"--a perfect example of millions of other men who have the underlying metabolic disorder known as syndrome X.
His total cholesterol of 245 was above normal, with a high LDL of 159 and a low HDL of 29. Triglycerides were well above acceptable at 280. His blood pressure was borderline high at 145/90. Fasting glucose was normal, so diabetes wasn't a concern--yet. In addition to Charlie's abnormal metabolic indices, he had diminished bloodflow to his penis as revealed by duplex Doppler ultrasound. The connection between the two is not coincidental; hence, Charlie's erection problems.
You might be wondering how someone carrying around 70 excess £ds, who had poor cardiovascular markers, could feel "fine." Simple. The syndrome that Charlie had is typically silent, with overt symptoms taking years to reveal themselves. The decline of health is so subtle, each incremental slip so small, that most of us who are too busy with our perfect lives fail to notice it. But Charlie couldn't ignore his thermometer.
SEXUAL PHYSIOLOGY
Erections are only the tip of the sexual health iceberg. Sexual function involves complex psychological, anatomical, and physiological elements that work together in what Masters and Johnson, the famed gynecologist and psychologist, respectively,* termed the sexual response cycle--Desire, Arousal/Erection, Orgasm/Ejaculation, and Resolution. A lot of doctors and scientists have added substantially to their pioneering work, quantifying what happens during each phase.
DESIRE: In healthy men, this is a continuous state that is satisfied intermittently, like hunger and thirst. The default position is that it is always there--you have to do something to suppress it. Sexual desire is temporarily satisfied every time you have sex, but after a while, like with eating and drinking, you want more.
Frequency of desire is a separate issue. The healthier you are, the more sex you want. Although there are questionnaires that try to quantify sexual thoughts, stimulation, and activity, there is no absolute measure for what is healthy interest in sexual activity. For some, twice a month is perfectly fine; for others, once a day is just right. But like the Supreme Court justice who couldn't define pornography but knew it when he saw it, we know that little or no desire at all is a sure sign that at least one area in the body is not functioning properly.
The brain is the seat of desire. It responds to various stimuli-- sights, sounds, smells, touch--and triggers sexual thoughts. Testosterone, which is produced by the testicles, and the neurotransmitters (brain chemicals) dopamine, serotonin, oxytocin, and norepinephrine provide the fuel that powers and regulates desire.
Testosterone, which you'll learn much about in this book, plays a critical role in both sexual and general health. It decreases gradually after age 30, and decreases markedly in certain diseases such as type 2 diabetes, metabolic syndrome, chronic kidney failure, and chronic alcoholism.
Testosterone is vital for sexual desire and for erections, for a general feeling of well-being, as well as for preservation of lean body mass, maintenance of adequate bone minerals, muscle strength, mood, and energy-- all of which contribute to healthy and enjoyable sex.
Desire heats the thermometer bulb. Imbalances in testosterone or in any of the above neurotransmitters can lower it. Depression, medications, stress, negative sexual experiences, and partner issues, which will be discussed later, might also cool your desire for sex.
AROUSAL/ERECTION: An erection results when smooth muscles in the penis relax, allowing blood vessels there to fill up. These swollen vessels apply pressure to surrounding veins that trap the blood in the penis, thus maintaining the erection. This is known as the venous occluding mechanism. Erections are not firm or long-lasting when that mechanism fails. It's like trying to fill a tub with an open drain.
As an exercise, I had my medical students draft one sentence that explains the physiology of an erection. The majority voted for the following: An erection is a neurovascular reflex in a testosterone environment.
Those 10 words say an awful lot. Global components must work in concert to produce a healthy erection. The brain's desire is activated by sensory stimulation, and motor signals are transmitted through the central nervous system via the spinal cord to peripheral nerves and blood vessels in the penis. It is this action that causes the erectile response. Once again, testosterone comes to the fore here, bathing the nerves and blood vessels and stimulating the production of nitric oxide (NO) in the nerve endings and in the endothelium, the layer that lines all arteries. NO is the critical neurotransmitter involved in the penis's smooth muscle relaxation that facilitates vessel dilation so that it can fill with blood. That is the reflex. Something is done (stimulation from the senses) and there is a response (erection). Sensory stimulation can result from seeing, hearing, smelling, and touching. Touching can be genital and nongenital. In addition to this sensory stimulation, mental fantasy can also induce an erection. It's important to allow enough time for this phase. Foreplay is "fore sex." It conditions your body for the experience and heightens the pleasure and enjoyment of it. Rushed sex shortchanges you and your partner, and it can lead to performance anxiety and relationship problems, which are discussed later on.
An erection involves nerves, vessels, and testosterone, and it's a reflex-- not a primitive one like the Achilles tendon reflex or the knee jerk reflex. An erection is a sophisticated, cultivated reflex that has a number of inhibitive and facilitative influences. Someone next door, children down the hall, in-laws sleeping over, a ringing phone, and fatigue are a few of the many factors that can cause you to lose an erection. Conversely, privacy, being well rested or refreshed, and creating a pleasant ambience can help to get a rise out of you.
It's important to note that you need more stimulation as you age. When you are young, all it takes to trigger the reflex is to close your eyes and think of a girl you know or saw. When you're 50, it takes more effort. When you're 70, it takes real work. This is important to remember, especially in long-term monogamous relationships. The threshold for response gets higher. This is partly because of deterioration in the neuronal networks, but mostly because of something called habituation--nerves become "dulled" to the same old, same old, and require different stimulation. Bedroom boredom is a reality, but it's not just related to having the same partner for a long time. There's a real physiologic aspect to it as well. We'll discuss ways to overcome boredom in Step 5: Two to Tango.
ORGASM/EJACULATION: The timely collaboration of multiple elements culminates in a few seconds of sublime pleasure. Serotonin and norepinephrine neurotransmitters, testosterone, the central nervous system, pelvic muscles, testicles, and the prostate work in concert to produce the desired crescendo. If I conducted another writing exercise with my med students, they would likely settle on:
Orgasm/ejaculation is a neuropsychological event, enhanced by testosterone.
With continuous stimulation of the penis, pleasurable sensations build up in the mind, initiating brain chemical reactions that create electrical signals that bolt down the spinal cord. These messages terminate in the pelvic region, where muscles there receive the instructions to contract rhythmically until orgasm/ejaculation occurs.
The mechanism whereby your nervous system processes sexual stimulation is unique, and different from how the body reacts to other sensations. For example, you don't get an orgasm from stroking your arm. The spinal cord interprets that as rubbing; it does not transmit information to a group of muscles to eject fluid. With orgasm/ejaculation, the neuronal pathways are wired through the spinal switchboard in a highly specialized manner. When these pathways are short-circuited, premature ejaculation, delayed orgasm, or inability to achieve orgasm occurs. These events are addressed in Step 6: Sexual Medicine.
RESOLUTION: Your brain and nervous system allow pleasure to dissipate and then all of your sexual mechanisms are turned off for a time--the refractory period--so that your body can be recharged for the next episode. This period becomes longer as you age. In your older years, if you attempt a second sexual episode shortly after the first, you'll need more stimulation not only to become aroused but to achieve orgasm. This is again attributable to how your nervous system is habituated, or conditioned. (It is interesting to note that women have almost no refractory period.)
The second point in this last phase is the memory of the event. Your memories may include not only the physical act and resulting pleasure, but what happens afterward between the partners, particularly in long-term relationships. The experiences are retained and feed into your desire for another encounter, which completes the circle in the sexual response cycle.
As you can see, there is a lot going on in a short amount of time! And although we certainly don't want to be thinking about clinical aspects when we're engaged in sexual activity, the point is that quite a bit has to happen physiologically in your body to engage in and enjoy intimate relations. If something is amiss, you'll miss out now on some of the pleasure associated with sex, and you might not be able to enjoy it at all later.
If you do have a performance problem, you have some options: You could choose to ignore it and suffer more serious consequences later; you could address the immediate issue and still have a bigger problem later; or you could choose to get to the root of the problem, and fix it permanently.
So what did I do about Charlie's problem?
I explained that his case involved a lot more than ED. He was a walking time bomb, with heart attack or stroke undoubtedly in his future. I told him if he wanted to get his erections back, he'd have to be totally committed to getting his health back. And if he wanted me to help him, he had to hand over his cigarettes before we got started. This was the moment of truth.
After hesitating for a tortured minute, he slid his pack across my desk and asked, "What's next?"
Charlie was given a diet and exercise regimen to lose weight and improve cardiovascular function. His alcohol consumption was restricted to one cocktail and one glass of wine no more than twice a week. I told him that it certainly wasn't going to be easy, but if he stayed away from cigarettes and followed my recommendations faithfully, it wouldn't be long before he saw positive results.
ERECTION PARTNERS
Brain
Nerves
Heart
Arteries
Veins
Testosterone
Nitric oxide
I saw Charlie periodically over the next year. By the summer of 2004, he had lost 43 £ds and had changed his blood chemistry significantly. By the time of his fall checkup that year, his weight was down to 195 and his blood tests were all within acceptable ranges. "I'm having intercourse about half the time without any oral medications, and the other half of the time successfully with Cialis," he told me then. In a little more than a year, the sexual dysfunction that had plagued Charlie for 4 years was well on its way to being completely reversed. Charlie had gotten the answer to his question about why he had ED. And he found out that the solution wasn't just about that small pill; it was about a large commitment to his overall health.
THE "HALLWAY" PRESCRIPTION
Here's a typical scenario: On the way out of the office, at the end of a visit for a separate health issue, a man hesitantly says, "By the way, doctor ... " and goes on to ask for a prescription for erection-assistance medication. Asking at the last minute like this preempts what many men consider to be an embarrassing discussion. But this "hallway" prescription, as I call it, negates the opportunity for me to perform a comprehensive examination that places the issue in its proper context, and this is a disservice to the patient.
The truth is that the majority of men do not see doctors regularly. Too many of them have to be sick for an extended period, critically injured, or the victim of their first cardiac episode before they cross the threshold of a medical facility. Even when something they took for granted their whole life, something that defines their very manhood-- sexual function-- slips, studies show that 50 percent still avoid a doctor visit! When I first encounter men who seek help for sexual dysfunction, I see a distinct opportunity ... and I seize it.
Men who have ED are all ears when they're in my office and I warn them about quick fixes. Then I probe to get to the source of the problem. "How is your health? Do you smoke? How much do you drink? How's your blood pressure? What about your weight? Do you have diabetes? Are you depressed? How are things with your wife or partner?" Having sex is vitally important to men. Healing them is vitally important to me. So men come in wanting better erections, but they leave on their way to improved health ... and a better life.
SEXUAL HEALTH AND GENERAL HEALTH: INTIMATELY RELATED
