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Dr. Abraham Morgentaler on Treating Sexual Dysfunction in Men
Abraham Morgentaler, M.D.
Associate Clinical Professor of Urology,
Harvard Medical School
Author, The Viagra Myth
Dr. Morgentaler has disclosed that he is a member of the speakers bureau of Pfizer, Lilly/ICOS, Solvay, and Auxilium, that he is on the medical advisory boards of Solvay and Auxilium, and that he has a funded fellowship from Auxilium. Dr. Morgentaler has disclosed that testosterone has not been approved by the U.S. Food and Drug Administration for use in the treatment of depression. Please consult product labeling for the approved usage. TCR: Dr. Morgentaler, as a urologist with particular expertise in male sexual dysfunction, what kind of advice might you have for psychiatrists in terms of helping us to differentiate psychogenic from organic sexual problems?
Dr. Morgentaler: This can be a very confusing issue. If you look at most men who are having erectile dysfunction (ED), most of them will have some sort of psychological manifestation of this, even if the origin of the problem is mainly organic. If a man is having trouble with erections, he generally will lose some of his interest in sex and avoid it. Nevertheless, there are some questions in the medical history that are useful in distinguishing psychogenic ED from organic or physical ED. Some of those questions have to do with whether or not the onset was sudden or gradual, with sudden being more suggestive of psychological issues. If the symptoms have been progressive, a lot of men will say, "You know, the rigidity has been reduced over time and now it is getting worse and worse." Whereas the psychological tends to be abrupt and complete, or it may wax and wane a bit, but you don't get a history of gradual worsening. Another important question is, when the man first noticed the problem, was there anything special happening around that time? And this may not be obvious for men so it is worth probing. Because if the stressful event was nonsexual, the man may not associate it with the sexual problem. So, for example, you might hear that a man had put his mother in a nursing home around when the problem started, or that there were some financial stressors. And once guys have had one failed sexual experience, whatever the cause, they are very aware of it after that. It's like when somebody says, "Don't think of a pink elephant." Once it is there, men start to observe themselves while having sex, which takes them away from their ability to have normal erections. And if they failed a few times in a row, sex is no longer an exciting, sexy activity; it is a performance activity, and sex is one of the few endeavors in human life where trying harder doesn't work!
TCR: So how can we help men get out of this bind?
Dr. Morgentaler: I find that it is often useful to go back to the original failed event, and to inquire whether there was anything at all going on in the man's life at that time; struggles with wife, conflicts, visits to the doctor, concerns about a new medical diagnosis, or anything like that. Ask really concrete questions like, "Were there any new medications prescribed around that time? Any new medical events?" Other questions that are really critical are, "Is the man ever able to get a full erection under any circumstances?" There are usually three main circumstances under which men get erections, and if they can get a good one under any of them, then the physical aspects of the erection are probably normal. And those three are: sex, masturbation, and nocturnal erections. Sex itself can even be broken up into two categories. One is sexual activity that doesn't involve insertion of the penis and the other is intercourse. There is no real performance pressure if a man is engaged in sexual activity with his clothes on. And a lot of men may be aware that their erections are normal then. But there are sort of two moments of truth: putting the condom on and putting the penis inside. The guy is going to get anxious around that time. So if a guy has great erections during kissing or petting but not during intercourse, then it suggests psychogenic etiology.
TCR: You've done a lot research and writing on testosterone therapy for hypogonadism. How would we recognize this as a hidden cause of sexual dysfunction, and how is it treated?
Dr. Morgentaler: To begin with the basics, testosterone is a hormone that is made by the testicles. It has a wide variety of actions in men, but one of its main actions is as a brain hormone, where it has remarkable effects on the sexual sensor of the brain, located in the preoptic area and anterior hypothalamus. In men, the testosterone level declines as we age, and when men have low testosterone levels, basically the pump is not primed properly and so the classic symptom is diminished libido. And often, men may not be aware of the libido problem because it may have progressed gradually over the years and they just think it is normal for them. But once we replace their testosterone they come back and say, "Wow, I forgot what this felt like."
TCR: Of course, psychiatrists will see a lot of men with low libido due to depression or medication effects.
Dr. Morgentaler: That's right, it can be a complicated differential because low testosterone leads to other problems that can be confused with depression, such as poor energy and an overall sense of reduced vitality, and in fact it can lead to frank depression. There is nice evidence from a placebo-controlled study from McLean Hospital a couple of years ago that men with depression and low testosterone who had failed SSRI treatment improved with testosterone therapy. In making the diagnosis, it may be helpful to know that in addition to causing diminished desire, low testosterone can cause a few other sexual symptoms, including erectile dysfunction, a diminished intensity of the orgasm, difficulty coming to the point of an orgasm, and diminished sensation in the penis.
TCR: What are the basic studies to diagnose the problem?
Dr. Morgentaler: The basic study is a blood test for testosterone, and there are two that are generally available: one is total testosterone, the other is free testosterone. If men are low or lowish on either one, then a trial of testosterone therapy may be reasonable.
TCR: Is it reasonable for a psychiatrist to initiate that treatment, or is that something that patients should see their primary care doctor about?
Dr. Morgentaler: That’s a controversial issue. Psychiatrists can initiate treatment, but they may prefer to send these patients to their primary care doctor, because these men need to be monitored for the possible development of elevated hematocrit. In addition, some in the medical community fear that testosterone may increase the risk of prostate cancer, and while there is no actual data in support of this, men on testosterone should have their prostates monitored.
TCR: You've recently published a fascinating book, The Viagra Myth: The Surprising Impact on Love and Relationships (Jossey-Bass, 2003). What do you mean by the "Viagra Myth"? Are we overusing PDE-5 inhibitors?
Dr. Morgentaler: The title really refers to the fact that Viagra has become bigger than life and there is a lot of mythology around it. For example, Viagra does nothing for desire directly. Now, whenever I say that, there is always somebody who says, "Oh I knew somebody and he really didn't have much desire and he took Viagra and it worked and all of a sudden he's interested in sex again." And that does happen because men who are frustrated sexually by their inability to function develop an aversion to sex, and when they regain the ability, yes, their libido can come back.
TCR: Meaning that if the diminished libido is a response to erectile dysfunction, then Viagra can appear to increase desire?
Dr. Morgentaler: Right, but Viagra doesn't work on the brain, so it has nothing to do with desire directly. This reminds me of a man who was referred to me a couple of years ago. He was telling me how well Viagra was working for him, and I said, "So what are you here to see me for?" He said, "Well, I don't have much desire, and when I have sex now with Viagra, it is okay. My penis gets hard. I put it into my wife, but halfway through, I am going, "Why the heck am I doing this?" The point is that it is desire that makes sex pleasurable and Viagra as a rule doesn't help with that.
TCR: And a prescription of Viagra may end up as a smokescreen obscuring the true problem, which may be a relationship issue leading to low sexual desire.
Dr. Morgentaler: Right. And yet, in my practice, I find it surprisingly difficult to find men who are willing to follow up on a referral to a therapist, even though the population of men with libido issues have a great opportunity to try and figure out what is going on and to try and come up with a solution that could be life-long in its benefit.
TCR: Which would not necessarily involve a PDE-5 inhibitor?
Dr. Morgentaler: Exactly. And my main concern is that men take the medicine and somehow feel that this is what they need in order to be adequate. I'm especially concerned with the young men just entering into the sexual arena, or men who are recently separated or divorced. They may have no idea what Viagra does, and they may be completely normal sexually, but they turn to these medications and somehow feel like it gives them an advantage. But people enter into relationships ultimately to be loved and accepted exactly for who they are. And I think it is too easy for men to feel like they need to be pharmacologically enhanced in order to be acceptable.
TCR: Thank you Dr. Morgentaler.
General PsychiatryDr. Morgentaler: This can be a very confusing issue. If you look at most men who are having erectile dysfunction (ED), most of them will have some sort of psychological manifestation of this, even if the origin of the problem is mainly organic. If a man is having trouble with erections, he generally will lose some of his interest in sex and avoid it. Nevertheless, there are some questions in the medical history that are useful in distinguishing psychogenic ED from organic or physical ED. Some of those questions have to do with whether or not the onset was sudden or gradual, with sudden being more suggestive of psychological issues. If the symptoms have been progressive, a lot of men will say, "You know, the rigidity has been reduced over time and now it is getting worse and worse." Whereas the psychological tends to be abrupt and complete, or it may wax and wane a bit, but you don't get a history of gradual worsening. Another important question is, when the man first noticed the problem, was there anything special happening around that time? And this may not be obvious for men so it is worth probing. Because if the stressful event was nonsexual, the man may not associate it with the sexual problem. So, for example, you might hear that a man had put his mother in a nursing home around when the problem started, or that there were some financial stressors. And once guys have had one failed sexual experience, whatever the cause, they are very aware of it after that. It's like when somebody says, "Don't think of a pink elephant." Once it is there, men start to observe themselves while having sex, which takes them away from their ability to have normal erections. And if they failed a few times in a row, sex is no longer an exciting, sexy activity; it is a performance activity, and sex is one of the few endeavors in human life where trying harder doesn't work!
TCR: So how can we help men get out of this bind?
Dr. Morgentaler: I find that it is often useful to go back to the original failed event, and to inquire whether there was anything at all going on in the man's life at that time; struggles with wife, conflicts, visits to the doctor, concerns about a new medical diagnosis, or anything like that. Ask really concrete questions like, "Were there any new medications prescribed around that time? Any new medical events?" Other questions that are really critical are, "Is the man ever able to get a full erection under any circumstances?" There are usually three main circumstances under which men get erections, and if they can get a good one under any of them, then the physical aspects of the erection are probably normal. And those three are: sex, masturbation, and nocturnal erections. Sex itself can even be broken up into two categories. One is sexual activity that doesn't involve insertion of the penis and the other is intercourse. There is no real performance pressure if a man is engaged in sexual activity with his clothes on. And a lot of men may be aware that their erections are normal then. But there are sort of two moments of truth: putting the condom on and putting the penis inside. The guy is going to get anxious around that time. So if a guy has great erections during kissing or petting but not during intercourse, then it suggests psychogenic etiology.
“When men fail sexually a few times in a row, sex is no longer an exciting, sexy activity; it is a performance activity, and sex is one of the few endeavors in human life where trying harder doesn't work!”
- Abraham Morgentaler, M.D.
TCR: You've done a lot research and writing on testosterone therapy for hypogonadism. How would we recognize this as a hidden cause of sexual dysfunction, and how is it treated?
Dr. Morgentaler: To begin with the basics, testosterone is a hormone that is made by the testicles. It has a wide variety of actions in men, but one of its main actions is as a brain hormone, where it has remarkable effects on the sexual sensor of the brain, located in the preoptic area and anterior hypothalamus. In men, the testosterone level declines as we age, and when men have low testosterone levels, basically the pump is not primed properly and so the classic symptom is diminished libido. And often, men may not be aware of the libido problem because it may have progressed gradually over the years and they just think it is normal for them. But once we replace their testosterone they come back and say, "Wow, I forgot what this felt like."
TCR: Of course, psychiatrists will see a lot of men with low libido due to depression or medication effects.
Dr. Morgentaler: That's right, it can be a complicated differential because low testosterone leads to other problems that can be confused with depression, such as poor energy and an overall sense of reduced vitality, and in fact it can lead to frank depression. There is nice evidence from a placebo-controlled study from McLean Hospital a couple of years ago that men with depression and low testosterone who had failed SSRI treatment improved with testosterone therapy. In making the diagnosis, it may be helpful to know that in addition to causing diminished desire, low testosterone can cause a few other sexual symptoms, including erectile dysfunction, a diminished intensity of the orgasm, difficulty coming to the point of an orgasm, and diminished sensation in the penis.
TCR: What are the basic studies to diagnose the problem?
Dr. Morgentaler: The basic study is a blood test for testosterone, and there are two that are generally available: one is total testosterone, the other is free testosterone. If men are low or lowish on either one, then a trial of testosterone therapy may be reasonable.
TCR: Is it reasonable for a psychiatrist to initiate that treatment, or is that something that patients should see their primary care doctor about?
Dr. Morgentaler: That’s a controversial issue. Psychiatrists can initiate treatment, but they may prefer to send these patients to their primary care doctor, because these men need to be monitored for the possible development of elevated hematocrit. In addition, some in the medical community fear that testosterone may increase the risk of prostate cancer, and while there is no actual data in support of this, men on testosterone should have their prostates monitored.
TCR: You've recently published a fascinating book, The Viagra Myth: The Surprising Impact on Love and Relationships (Jossey-Bass, 2003). What do you mean by the "Viagra Myth"? Are we overusing PDE-5 inhibitors?
Dr. Morgentaler: The title really refers to the fact that Viagra has become bigger than life and there is a lot of mythology around it. For example, Viagra does nothing for desire directly. Now, whenever I say that, there is always somebody who says, "Oh I knew somebody and he really didn't have much desire and he took Viagra and it worked and all of a sudden he's interested in sex again." And that does happen because men who are frustrated sexually by their inability to function develop an aversion to sex, and when they regain the ability, yes, their libido can come back.
TCR: Meaning that if the diminished libido is a response to erectile dysfunction, then Viagra can appear to increase desire?
Dr. Morgentaler: Right, but Viagra doesn't work on the brain, so it has nothing to do with desire directly. This reminds me of a man who was referred to me a couple of years ago. He was telling me how well Viagra was working for him, and I said, "So what are you here to see me for?" He said, "Well, I don't have much desire, and when I have sex now with Viagra, it is okay. My penis gets hard. I put it into my wife, but halfway through, I am going, "Why the heck am I doing this?" The point is that it is desire that makes sex pleasurable and Viagra as a rule doesn't help with that.
TCR: And a prescription of Viagra may end up as a smokescreen obscuring the true problem, which may be a relationship issue leading to low sexual desire.
Dr. Morgentaler: Right. And yet, in my practice, I find it surprisingly difficult to find men who are willing to follow up on a referral to a therapist, even though the population of men with libido issues have a great opportunity to try and figure out what is going on and to try and come up with a solution that could be life-long in its benefit.
TCR: Which would not necessarily involve a PDE-5 inhibitor?
Dr. Morgentaler: Exactly. And my main concern is that men take the medicine and somehow feel that this is what they need in order to be adequate. I'm especially concerned with the young men just entering into the sexual arena, or men who are recently separated or divorced. They may have no idea what Viagra does, and they may be completely normal sexually, but they turn to these medications and somehow feel like it gives them an advantage. But people enter into relationships ultimately to be loved and accepted exactly for who they are. And I think it is too easy for men to feel like they need to be pharmacologically enhanced in order to be acceptable.
TCR: Thank you Dr. Morgentaler.
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