Dr. Ronald Lewis Couples' treatment for sexual problems on the agenda for sexual medicine experts

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"We are gaining a more comprehensive perspective on the causes, effects and potential treatment of sexual dysfunction," says Dr. Lewis who is organizing the society's spring scientific meeting.

Evidence is mounting, for example, that if one partner has problems, it's likely the other does as well. However Dr. Lewis says treatments focused mostly on men, and rarely on women or couples, hinders effectiveness.

Couples' treatment is a win-win, he says, because it explores problems that may exist in the relationship beyond the man's physical ability to have an erection, such as whether there is adequate foreplay to create a more satisfying experience, or whether pushback from partners is impacting their desire and, ultimately, ability to have sex, Dr. Lewis says.

Such problems create a classic cause-and-effect scenario. "The man says, 'I can't please her, I am not a man anymore.' The woman says, 'He doesn't love me any more because he is not paying attention to me.' It gets to be a real bad situation."

The reality could be low estrogen levels are causing her vaginal dryness and painful intercourse and lower testosterone levels are decreasing the firmness of his erection, hurting his confidence, even before she pushes away. Not unlike the old adage, 'use it or lose it,' chemicals that are supposed to cause the erection can retool, so the man begins to have less sexual thought and erectile activity, "essentially a situational cause for real end-organ disease," Dr. Lewis says.

The focus on treating the disease - regional sexual medicine society's across the world use to be dubbed erectile dysfunction societies - actually helped illustrate the need for a broader perspective. Erection treatments - first shots, then pills - made men instantly technically ready for sex but did nothing for their partners' issues, Dr. Lewis says. "A lot of women would say, 'You may be fixed but it has not fixed our relationship.'"

A good place for partners to initiate a fix is talking about sex - with each other and their doctor, he says.

Many problems, such as vaginal dryness, already are treatable, and new options such as pills that turn on sexual centers in the brain and Viagra-like drugs for women are on the horizon. In fact, an MCG research team led by Dr. R. Clinton Webb recently showed these phosphodiesterase Type 5 inhibitors, which block an enzyme responsible for breaking down an erection, show promise in female rats at least, although they work differently than they do in the males. The MCG scientists and Dr. Lewis agree that is more evidence as well that sex for females is different and likely more complex.

While scientists explore new options for women, they also are taking a closer look at how low testosterone levels affect men. Testosterone therapy already is used to improve libido and erection but physicians likely need to put an emphasis on keeping tabs on testosterone levels to ensure bone health as well.

"In treating prostate cancer, for example, we actually have made a group of men more likely to have bone problems because we give them medication to block testosterone because prostate cancer depends on it," says Dr. Lewis.

Now urologists and others are "waking up" to the fact that low levels, natural or otherwise, contribute to osteoporosis and that hormone replacement therapy can even be given safely to a select number of men who have recovered from their cancer, as measured by a prostate specific antigen level of zero.

In fact, the thrust of last year's research meeting of the Sexual Medicine Society of North America focused on how there is little evidence to indict testosterone as an instigator of prostate cancer although patients with untreated prostate cancer shouldn't take it because the prostate cancer cells have receptors that feed off the hormone. Dr. Lewis has hand picked a number of recovered prostate cancer patients in his practice for testosterone therapy along with extremely close follow up.

As the need for hormone replacement therapy in men appears to be expanding, so are the delivery options. Near term, shots that last three months and pellets placed under the arm or in the abdomen that deliver six months of therapy likely will prove better options than older approaches such as a topical cream that is effective to the point that men have to wait until it dries to have casual contact with a woman and are advised to wear a shirt during sex even after it dries.

The increasing obesity epidemic is affecting sexual health as well. In men, for example, fat converts testosterone to estrogen. It's also becoming clear that the inability to get an erection can be one of the most visible signs of cardiovascular disease. "We tell people who see us for erectile dysfunction it's probably a good idea to get your heart vessels checked," Dr. Lewis says.

While sexual problems may not be lethal, they can be very impactful on general well being, Dr. Lewis notes. "If there is something breaking down between you and your partner of 20 years, you take it to work with you. It probably produces more absenteeism. It probably has more impact on us and our environment than we think."

Dr. Lewis is historian, charter member and former president of the International Society for Sexual Medicine (formerly known as the International Society for Impotence Research). He is a member of the Program Abstract Review Committee of the American Urological Association.

Medical College of Georgia