Thanks, Hollywood, for making sex look so easy. In real bedrooms, the rest of us must wrangle with some not-so-sexy issues: unsatisfactory erections, untimely ejaculation, pain, low libido, and more. Yet tending to a problem might save not only a relationship but also your life. "Sexual health problems are very often the first sign of underlying serious medical issues," says Michael Krychman, medical director of sexual medicine at Hoag Memorial Hospital Presbyterian in Newport Beach, Calif.
In women, for example, dulled desire may signal thyroid dysfunction or other hormonal troubles; painful sex could even be an early symptom of pelvic cancer. And erectile dysfunction is now recognized as an early whiff of looming cardiovascular disease. "Your problems shouldn't be ignored," he says.
Of course, they are ignored, jammed deeply into back corners of brains, denied. Patients and doctors, it's clear, have trouble talking sex. Many adults would like to discuss sexual problems, research indicates, but don't--for fear that doctors will dismiss their concerns, or worse. Women appear especially likely to stay mum, says Anita Clayton, a professor of psychiatry at the University of Virginia and coauthor of Satisfaction: Women, Sex, and the Quest for Intimacy. "Everyone has the right to a satisfying sex life."
Satisfying sex has been linked to increased longevity, better immunity, better stress-coping abilities, and enhanced connectivity with a partner, says Krychman. So, if you're sinking, not sailing, between the sheets, help can come in many forms, from sex therapy to various pharmacological options. Most important, if you're not getting the answers that you're looking for, "keep seeking," says Irwin Goldstein, director of sexual medicine at San Diego's Alvarado Hospital. Your sex life--and health--will thank you. Here are a few places to start:
More Than Just an Erectile Problem
Men, you may not realize it, but you've got a canary in your pants. Doctors now recognize that the penis functions as an exquisitely simple gauge for detecting impending heart problems. That's one reason flagging erections, which affect more than a third of men over the age of 40, should not be ignored. Another: Drugs like Viagra, which celebrated its 10th birthday this year, are just one set--among several--of time-tested treatments.
A decade into the medical revolution that turned erectile dysfunction into a household term, a shift in thinking is afoot. There's ample evidence that Viagra, Levitra, and Cialis can revitalize a man's sex life; in trials, Viagra enabled 83 percent of men struggling with ED to have intercourse at least once compared with 45 percent of those taking a placebo. Still, other drugs may be necessary to deal with vascular disease or diabetes, which often accompany ED. And long-impotent men may want to consider options like penile implants because, as vascular disease progresses, the usefulness of Viagra and its kin often wanes.
ED heralds heart trouble because arteries in the penis have about a quarter the diameter of coronary arteries. When plaque builds up, the slender vessels reach the strangling point first--but cardiac problems are often just around the corner. "In many cases, erectile dysfunction is quite literally vascular disease under the belt," says Randy Fagin, a urologist and director of the Prostate Center of Austin. Symptoms often occur three to four years before cardiac problems, such as chest pain or heart attack, begin to crop up, says Robert Kloner, a cardiologist at the University of Southern California. New guidelines in 2006 advised physicians to consider a man with erectile dysfunction and no cardiac symptoms a cardiac patient until proved otherwise.
In addition to any treatment they may need for vascular disease or diabetes, men have options for fixing ED. Eating better and exercising regularly can not only stave off plaque buildup in arteries but reverse it, research has shown. A 2004 study of obese men with erectile dysfunction found, for example, that erectile function improved in a third of men who adopted healthful behaviors and lost about 30 pounds.
Among medical options, doctors say, one of the best is to inject a medication such as alprostadil into the base or side of the penis. A quick, relatively painless shot, which can produce an erection within 10 minutes, costs about twice as much as a dose of an oral ED drug.
Other ED fixes are made to last. Vacuum pumps put negative pressure on the penis, creating an erection that can be maintained for about 30 minutes by placing an elastic band around its base. Studies report success rates of 70 to 94 percent with the devices, but side effects can include pain, numbness, bruising, and obstructed ejaculation. Surgical implants are pricier but have upsides. Men can inflate the implants at will, using a pump placed in the scrotum. Satisfaction rates are high.
Yet despite the availability of solutions, many harried doctors are not as aggressive as they could be about sleuthing out sexual problems. That puts the burden of speaking up on men.
Is premature ejaculation the most common form of male sexual dysfunction? The answer is debated, but one thing is clear: For men who have the problem, it can be a showstopper. "I see young guys who simply cannot establish a relationship with a woman because of this," says Ira Sharlip, a spokesperson for the American Urological Association.
The past few years have brought a surge of interest from pharmaceutical researchers aiming to relieve the problem with a pill. So far, no medication has been approved for the purpose; the Food and Drug Administration turned down a drug called dapoxetine in 2005. Yet doctors can and often do prescribe drugs that are approved for other conditions, such as the antidepressants paroxetine (Paxil) and fluoxetine (Prozac), which have been shown to lengthen intercourse by a few minutes. Potential downsides, experts say, include diminished intensity of a man's orgasm and libido and a hampered ability to maintain an erection.
Creams and gels that numb the sensitivity of the penis are another option. They usually contain lidocaine or prilocaine. Studies have shown them to be effective, but some couples find them difficult to use. They generally involve a messy application within a condom and can numb a partner.
A man's mind-set can play a role. "It's pretty unusual to see premature ejaculation without some degree of psychological component," says Fagin, the Prostate Center of Austin urologist. Therapists can work with men to address anxiety, stress, guilt, and depression--and can impart techniques like the "stop and go" method or the "squeeze" method to help men slow down. Honest partner-to-partner communication is also critical, says Barry McCarthy, coauthor of Coping With Premature Ejaculation. For example, he says, some women simply can't achieve orgasm through vaginal penetration, yet a partner might blame himself unless the couple discusses how the woman can reach a climax.
More often than not, the only real problem may be outsize hopes. In various surveys, between 20 and 40 percent of men complain about the short duration of intercourse. But fewer than 5 percent have a sustained disorder in which they consistently ejaculate in a minute or less, estimates Marcel Waldinger, associate professor in sexual psychopharmacology at the Hague Leyenburg Hospital in the Netherlands.
"Nobody really knows how long is normal. It's very subjective," says Martin Miner, a clinical assistant professor of family medicine at Brown University Medical School. In a recent survey, sex therapists typically said satisfactory intercourse should last three to 13 minutes. That's a far cry from the 30-plus minutes that many men say they want.
Overcoming an Anticlimax
It begins as a swelling of excitement and tension. Then, it's like falling off a cliff. That's how Linda Banner, 59, describes an orgasm, the delicious sensation that she couldn't experience for the first decade of her sex life.
Orgasm eludes many women; upwards of 10 percent have never sexually climaxed, and many others do so erratically. Often, women just need some education about how their bodies work or professional counseling to address anxiety or inhibitions, says Sheryl Kingsberg, a psychologist at University Hospitals Case Medical Center in Cleveland. "You have to kick out every nun, rabbi, parent, and grandmother that's in your head," she explains. "Get them all out of the bedroom first."
Banner, whose experience isn't atypical, pins the root of her "anorgasmia" on a jumble of "goofy" ideas--like rigid notions that sex is for keeping men satisfied and that women shouldn't touch their nether regions. Things finally clicked for the Californian when she learned to grant herself license to relax, explore, and enjoy her sensuality.
Of course, medical factors can mute or kill orgasms in women who once felt them, and such cases may require treatment. Medications are big offenders, especially antidepressants that boost serotonin in the brain. Diabetes, neurological diseases like Parkinson's, and conditions that cause clitoral scarring or numbing can also affect orgasm. So, too, can sexual pain problems or anything that may lower libido, such as a hormonal imbalance. But medicine might fix what medicine has caused: The Journal of the American Medical Association recently reported that Viagra may counteract antidepressant-related orgasm problems.
Research suggests that women can learn to intensify their orgasms, giving hope to those who don't normally experience them. By studying the brains of those who can climax just by thinking about it, behavioral neuroscientist Barry Komisaruk and his Rutgers University team found that both physical stimulation and thoughts of physical stimulation activate many of the same brain areas. He is now showing anorgasmic women real-time scans of their brain activity as they self-stimulate, aiming to see if they can teach themselves to climax.
Even some women who can orgasm don't experience all three known types: vaginal, cervical, and clitoral. In fact, only a minority of women can reliably orgasm through penetration alone; most require clitoral stimulation, as by oral sex or touching. A long-standing theory suggests that if a woman's clitoris is more than an inch from her vagina, penetrative sex is less likely to produce a climax, says Kim Wallen, a neuroscientist in Emory University's psychology department. No matter, he says. "For many women, a helping hand works just fine."
When Sex Drive Dries Up
For years, Kate Johnson didn't know she had a sex drive. On the birth control pill since age 17, she participated without desire. Now, she uses a different contraceptive--and often makes the first advance with her husband. Ironic as it may seem, suppressed libido is a known side effect of the pill. "It was a relief to figure out that I was normal," says Johnson, 39, of Littleton, Colo., "as opposed to some sort of undersexed person."
Many women find themselves stalled by sluggish sex drives, and the pill isn't always the culprit. Hypoactive sexual desire disorder, the medical term, is recognized as the most prevalent sexual complaint among females. It can affect young and old alike, stemming from a complicated stew of factors from partner problems to medical issues, like depression (and some of its treatments) and waning hormones. Although no drug has been approved by the FDA, medical solutions do exist. "Something can be done," says Goldstein of Alvarado Hospital, though it usually requires a thorough medical and psychological evaluation.
For some women, especially those who are aging, low testosterone is the trouble. That hormone is linked to libido in both sexes, not just men. While deficiencies won't always create problems, specialists like Goldstein may use testosterone products that are approved for men to rekindle female desire. Of course, doses are scaled way back: Too much of the hormone can cause a collection of effects, like voice deepening, acne, and excessive hair growth. Testosterone replacement appears safe, says Goldstein, although some experts worry that its use in breast cancer survivors might trigger recurrence. Some also warn against using it in women who could become pregnant.
A nonhormonal option targets the hub of sexual desire: the brain. The antidepressant bupropion has been shown to lift libido in premenopausal women and may be helpful for others, too, says the University of Virginia's Clayton. She has studied its effects in research sponsored by the manufacturer of Wellbutrin, a brand name for bupropion.
One thing remains clear: As men have gotten pill after pill to combat a chief sexual problem, women who've lost their sexual appetite have been left hungry. Although pharmaceutical companies are racing to change that--drugs in the pipeline include a testosterone gel and a pill that reduces serotonin action in the brain--women will have to wait for their "pink Viagra." For now, treatment remains largely experimental and in the hands of a skilled few, agree Goldstein and Clayton, who have both done work for companies developing new medications. "We just don't have many options right now," says Clayton. "We're looking for equality."
When Sex Hurts
For Michele Gaymon, 38, pain with sex has been the norm from the very first encounter--and the burning discomfort that follows can last for hours or days afterward. "What is supposed to be pleasurable and fun is not," says the Somerset, N.J., woman. In relationships, Gaymon hasn't always disclosed her condition, choosing to bear the pain of intercourse silently. And while her most recent partner was understanding when she shared her condition, his fear of hurting her put a damper on their attempts.
While many women experience the itching or burning of a yeast infection from time to time, experts say that's nothing like the pain suffered by women with more serious conditions, which can range from endometriosis to an ovarian cyst to a disorder called vulvodynia. Millions of women experience pain associated with one or another of these conditions; vulvodynia alone may account for as many as 1 million new cases per year, according to a recent University of Michigan study.
Like many women, Gaymon saw multiple doctors in vain. Some initially told her to "relax, have a few drinks, calm down," recalls the senior account specialist at Merrill Lynch. Others misdiagnosed. "I was put on so many different yeast infection medications it was ridiculous," she says. Five gynecologists and two urologists later, she was finally diagnosed with vulvodynia, which made the entryway of her vagina become irritated with penetration.
The causes of vulvodynia, which can produce pain even when sex is not being attempted, are not well understood. Aside from the genitals, the nervous system is thought to be involved, says Jennifer Gunter, director of pelvic pain and vulvovaginal disorders at Kaiser Permanente San Francisco Medical Center. And because no medications are approved for the condition, she says, it's difficult for some to get treatments covered. Gunter and other experts retool therapies such as tricyclic antidepressants, antiseizure drugs, steroid and Botox injections, implantable devices to stimulate misfiring nerves, and surgery.
For Gaymon, relief has finally come with lidocaine cream, the drug Cymbalta, and physical therapy that involves techniques to pinpoint and relax muscle tension. She also found support in the National Vulvodynia Association. Getting help from multiple sources--including a sex therapist is often critical to treating the causes of painful intercourse, experts agree.
Gunter, who says Kaiser Permanente covers a full arsenal of treatments, estimates about 80 percent of her patients improve considerably. But patients who wait months or years let their pain become entrenched, complicating treatment. Says Gunter: "Pain begets pain; the more your nervous system is stimulated by pain, the more pain becomes your norm."
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