While hormone balance, autonomic nervous system function, anatomic and other factors are necessary aspects of case management for erectile dysfunction, the capacity of the local vascular system to regulate blood delivery to the tissues of interest is as important for sexual as it is for cardiac function. No wonder a paper just published in the Archives of Internal Medicine provides evidence that lifestyle modification of cardiovascular function improves erectile dysfunction. The authors state:

“Erectile dysfunction (ED) shares similar modifiable risks factors with coronary artery disease (CAD). Lifestyle modification that targets CAD risk factors may also lead to improvement in ED. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating the effect of lifestyle interventions and pharmacotherapy for cardiovascular (CV) risk factors on the severity of ED.”

They examined multiple electronic databases from randomized controlled clinical trials with follow-up of at least 6 weeks of lifestyle modification intervention or pharmacotherapy for cardiovascular risk factor reduction. Their main outcome measure was differences in the International Index of Erectile Dysfunction (IIEF-5) score. Their data demonstrated significant effectiveness:

“A total of 740 participants from 6 clinical trials in 4 countries were identified. Lifestyle modifications and pharmacotherapy for CV risk factors were associated with statistically significant improvement in sexual function (IIEF-5 score): weighted mean difference, 2.66. If the trials with statin intervention (n = 143) are excluded, the remaining 4 trials of lifestyle modification interventions (n = 597) demonstrate statistically significant improvement in sexual function: weighted mean difference, 2.40.”

Readers may wish to search this site for several reports on the cautions and limitations associated with statin use. There are, however, no risks associated with skillful lifestyle modification of CV risk factors. The authors conclude:

“The results of our study further strengthen the evidence that lifestyle modification and pharmacotherapy for CV risk factors are effective in improving sexual function in men with ED.”

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A study just published in The Journal of Sexual Medicine documents the persistent sexual side effects of finasteride (Propecia, Proscar), a medication commonly used for both male pattern baldness and prostate hyperplasia, that too often are not discussed when prescribed. The authors observe:

“Finasteride has been associated with reversible adverse sexual side effects in multiple randomized, controlled trials for the treatment of male pattern hair loss (MPHL). The Medicines and Healthcare Products Regulatory Agency of the United Kingdom and the Swedish Medical Products Agency have both updated their patient information leaflets to include a statement that “persistence of erectile dysfunction after discontinuation of treatment with Propecia has been reported in post-marketing use.””

They set out to…

“…characterize the types and duration of persistent sexual side effects in otherwise healthy men who took finasteride for MPHL,”…

…by investigating the new onset of sexual side effects lasting for at least 3 months despite discontinuing finasteride. What did their data show?

“Subjects reported new-onset persistent sexual dysfunction associated with the use of finasteride: 94% developed low libido, 92% developed erectile dysfunction, 92% developed decreased arousal, and 69% developed problems with orgasm…The mean duration of finasteride use was 28 months and the mean duration of persistent sexual side effects was 40 months from the time of finasteride cessation to the interview date.”

The authors admonished practitioners in their conclusion to offer patients the courtesy of full disclosure:

“Physicians treating MPHL should discuss the potential risk of persistent sexual side effects associated with finasteride.”

This report follows a study published earlier this year on persistent sexual side effects from finasteride and another 5α-reductase inhibitor (5α-RI), dutasteride, when used to treat urinary tract symptoms caused by prostate enlargement. They also stated:

“Prolonged adverse effects on sexual function such as erectile dysfunction and diminished libido are reported by a subset of men, raising the possibility of a causal relationship…We suggest discussion with patients on the potential sexual side effects of 5α-RIs before commencing therapy. Alternative therapies may be considered in the discussion, especially when treating androgenetic alopecia.”

Clinicians reading this will know that 5α-reductase inhibitors block the conversion of testosterone to dihydrotestosterone (DHT). DHT is 10 times stronger in conferring androgen stimulation on tissues—the loss of male hormone effects is more precipitous with smaller reductions of DHT. It is important to note that the hormone measurements were not done for these patients. Other factors, and other hormones, including estrogen and insulin, also affect the prostate. In the functional approach to MPHL and prostate hyperplasia the bioactive free fractions of testosterone, DHT and estrogen, along with other analytes are always measured to determine (1) if DHT is actually too high (not always the case), and (2) if a natural or synthetic 5α-reductase inhibitor is used, to make sure that DHT is not reduced too much (by follow-up tests). Excessive reduction of testosterone receptor stimulation is a risk not only for sexual side effects but also depression, cardiovascular disease, sarcopenia (loss of muscle mass), osteoporosis and other ailments.

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The standard bicycle seat can deliver a significant insult to the nerve and blood vessel supply to the male genitalia. There have been numerous studies investigating the relationship between bicycle riding and erectile dysfunction. The authors of a paper published a while back in The Journal of Sexual Medicine that reviewed the science set out to:

“…summarize accumulating data on the safety of bicycle riding based on medical evidence categorized by levels of evidence, including case reports, observational studies, case control studies, mechanistic studies, and population-based epidemiologic investigations. The secondary aim was to address the concerns of bicyclists and propose measures to minimize the risk of ED associated with bicycle riding.”

The mass of data revealed a clear picture and yielded specific recommendations:

“Bicycle riding more than 3 hours per week was an independent relative risk for moderate to severe ED. Therefore, bicycle riders should take precautionary measures to minimize the risk of ED associated with bicycle riding: change the bicycle saddle with a protruding nose to a noseless seat, change the posture to a more upright/reclining position, change the material of the saddle (GEL), and tilt the saddle/seat downwards.”

The authors note in their conclusion:

“Straddling bicycle saddles with a nose extension is associated with suprasystolic perineal compression pressures, temporarily occluding penile perfusion and potentially inducing endothelial injury and vasculogenic ED.”

In a subsequent paper published in the same journal this year the authors revisit the problem and begin by noting:

“For many years, reports in the literature have implicated bicycle riding as causing increased risk of erectile dysfunction (ED). Perineal compression during cycling has been associated with the development of sexual complications.”

They conducted a comprehensive review of the scientific literature and found that further studies had firmly established the risk of cycling-related sexual dysfunction and extended it to females:

“There is a significant relationship between cycling-induced perineal compression leading to vascular, endothelial, and neurogenic dysfunction in men and the development of ED. Research on female bicyclists is very limited but indicates the same impairment as in male bicyclists.”

The authors of a review published earlier in European Urology caution practitioners to be aware of this widespread phenomenon. They report that a range of problems have been documented:

“The most common bicycling associated urogenital problems are nerve entrapment syndromes presenting as genitalia numbness, which is reported in 50–91% of the cyclists, followed by erectile dysfunction reported in 13–24%. Other less common symptoms include priapism, penile thrombosis, infertility, hematuria, torsion of spermatic cord, prostatitis, perineal nodular induration and elevated serum PSA, which are reported only sporadically.”

They conclude by exhorting practitioners to be alert:

“Urologists should be aware that bicycling is a potential and not an infrequent cause of a variety of urological and andrological disorders caused by overuse injuries affecting the genitourinary system.”

Perhaps this could contribute, at least to some degree, occurrences of ‘cyclist road rage’. Are there any remedies or recommendations for cyclists to follow? Another study in The Journal of Sexual Medicine investigated the condition in police officers:

“The average bicycle police officer spends 24 hours a week on his bicycle and previous studies have shown riding a bicycle with a traditional (nosed) saddle has been associated with urogenital paresthesia and sexual dysfunction.”

The officers manifested the typical problems, but also demonstrated some improvement when using a ‘no-nose saddle’:

“(i) With few exceptions, bicycle police officers were able to effectively use no-nose saddles in their police work. (ii) Use of no-nose saddles reduced most perineal pressure. (iii) Penile health improved after 6 month using no-nose saddles as measured by biothesiometry and IIEF. There was no improvement in Rigiscan® [nocturnal erection] measure after 6 months of using no nose saddles, suggesting that a longer recovery time may be needed.”

It only makes anatomical sense that insult to the nerves and blood vessels that supply the genitalia could cause sexual dysfunction in both males and females.

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Two papers recently published in the Journal of Sexual Medicine document the benefit of the low glycemic Mediterranean diet for sexual function in both women and men. The authors of Adherence to Mediterranean Diet and Sexual Function in Women with Type 2 Diabetes evaluated how well they stuck to the diet and correlated it with sexual function…

“The Female Sexual Function Index (FSFI) was used for assessing the key dimensions of female sexual function.”

What did the data show?

“Diabetic women with the highest scores (of adherence to the diet) had lower BMI, waist circumference, and waist-to-hip ratio, a lower prevalence of depression, obesity and metabolic syndrome, a higher level of physical activity, and better glucose and lipid profiles…The proportion of sexually active women showed a significant increase…of adherence to Mediterranean diet…women with the highest score of adherence had a lower prevalence of sexual dysfunction…These associations remained significant after adjustment for many potential confounders.”

The authors of Adherence to Mediterranean Diet and Erectile Dysfunction in Men with Type 2 Diabetes conducted a similar investigation for men. This time the International Index of Erectile Function-5 was used as a metric for sexual function. Here’s what the data showed:

“The proportion of sexually active men showed a significant increase…of adherence to Mediterranean diet. Moreover, men with the highest score of adherence were more likely to have a lower prevalence of global ED and severe ED as compared with low adherers.”

No surprise, right? Low glycemic vegetables and fruits, lots of olive oil, nuts, a little wine, etc: the Mediterranean Diet.

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Readers of these posts know about the profound impact of insulin resistance on glandular and metabolic function; as the authors of this study just published in the International Journal of Obesity note…

“Abdominal obesity and type 2 diabetes mellitus are associated with erectile and urinary dysfunction in men.”

The investigators set out to determine the extent to which weight loss would impact overall sexual function and lower urinary tract symptoms by measuring the effects of an 8 week low-calorie diet using meal replacements* on insulin sensitivity, testosterone, erectile function, sexual desire, prostate symptoms, abdominal obesity and waist circumference. What did their data show?

“Weight loss of ~10% was significantly associated with increased insulin sensitivity, plasma testosterone levels, IIEF-5 (erectile function) and SDI (sexual desire) scores, as well as reduced WC (waist circumference) and IPSS (prostate) scores, in diabetic as well as nondiabetic men.”

They further observed that…

“The degree of weight loss was significantly associated with improvements in plasma testosterone levels, erectile function and LUTS. Reduction in LUTS was significantly associated with increased plasma testosterone, erectile function and sexual desire.”

Hence their clear-cut conclusion:

“Diet-induced weight loss significantly and rapidly improves sexual function, and reduces LUTS, in obese middle-aged men with or without diabetes.”

This is a compelling illustration of the link between insulin resistance and male sexual function.

* Although effective in this study (at 800 calories per day) there are better meal replacement products available for weight loss than this one loaded with fructose, milk protein, and low grade minerals and fish oil.

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Here’s one more paper for now in the ‘series’ on erectile dysfunction, testosterone, cardiovascular disease and insulin resistance, this one published recently in the Journal of Clinical Endocrinology & Metabolism.

“The objective of the study was to examine whether male sex hormones are independently associated with AAA or increased abdominal aortic diameter.”

AAA (abdominal aortic aneurysm) is a swelling of the aorta in the abdomen; a rupture means sudden death. They measured abdominal aortic diameter, total testosterone, SHBG (sex hormone binding globulin), and LH (luteinizing hormone). Free testosterone was calculated. This is what they found:

“Lower free testosterone and higher LH levels are independently associated with AAA in older men. Impaired gonadal function may be involved in arterial dilatation as well as occlusive vascular disease in older men.”

Add the previous two posts to this and connect the dots. Low testosterone, erectile dysfunction with cardiovascular disease, death from cardiovascular disease, aortic aneurysm (blood vessel damage), and insulin resistance are all connected. So what do you do?

Obviously life style factors and individually determined supplementation for healthy blood sugar and insulin are important. What about testosterone? Standard testosterone supplementation suppresses endogenous production after a brief ‘honeymoon’ period. This is why in my practice I always measure both free (biologically active) testosterone and free LH when evaluating male hormone function. (LH is produced by the pituitary gland. In men it stimulates the testicles to produce testosterone. When they are not responding adequately LH goes up, indicating that the problem is ‘hypogonadia‘, usually due to background inflammation. Supplementary testosterone suppresses LH and dulls the receptors over time. There is a better way….

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A study just published in the journal Circulation reports a result that is not too surprisingly if we consider the underlying biology of erectile dysfunction. The authors begin with this in mind:

“Although erectile dysfunction (ED) is associated with cardiovascular risk factors and atherosclerosis, it is not known whether the presence of ED is predictive of future events in individuals with cardiovascular disease. We evaluated whether ED is predictive of mortality and cardiovascular outcomes…”

After crunching the numbers on a study cohort of 1549 patients over more than two years, this is there clear-cut conclusion:

“ED is a potent predictor of all-cause death and the composite of cardiovascular death, myocardial infarction, stroke, and heart failure in men with cardiovascular disease.”

They also noted this about the medications used in their trial, Altace and Micardis…

“The study medications did not influence the course or development of ED.”

There is a lot more to the functional approach to ED than ACE inhibitors and angiotensin receptor antagonists. See the next two posts.

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Those of you interested in how brain function is significant for virtually all aspects of health will like this study just published in the medical journal Sleep. It’s also another example of the importance of healthy dopamine signalling. The investigators note that “Dopaminergic hypofunction in the central nervous system may contribute to restless legs syndrome (RLS) and erectile dysfunction (ED). We therefore examined whether men with RLS have higher prevalences of ED.” After analyzing the data on a group of 23,119 men they conclude: “Men with RLS had a higher likelihood of concurrent ED, and the magnitude of the observed association was increased with a higher frequency of RLS symptoms. These results suggest that ED and RLS share common determinants.” The take home message here is that dopamine function can play a role in both Restless Leg Syndrome and Erectile Dysfunction. This can be helped with a functional medicine approach to restoring dopamine regulation.

Coincidentally, a related paper has also just been published in the journal Sleep Medicine examining the role of dopaminergic dysfunction and treatment in Restless Leg Syndrome. Here the authors conclude their observations by stating: “Since dopaminergic treatment can reverse delayed facilitation in RLS, we hypothesized that cortical plasticity related to dopaminergic systems may play a crucial role in RLS pathophysiology.”

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Here is more evidence of the strong correlation between erectile dysfunction and insulin. This paper recently published in the Journal of Andrology clearly discerns  the “correlation between erectile function and IR and abdominal obesity.” [IR = insulin resistance. Waist circumference is a metric for abdominal obesity.] Moreover, “IR also appears to alter testosterone production.” Important: a careful reading of this paper also discloses what functional medicine practitioners and Lapis Light patients know: “a negative correlation [with erectile function] was shown only between BT (biologically active fraction) and abdominal obesity. (BT is also termed free-fraction testosterone, measured in our salivary profiles. Total testosterone is not a reliable indicator.)

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Metabolic syndrome and it’s associated hormonal, neurological and vascular effects is a major factor affecting sexual function for women too, as described in this recent paper: “The MS is strongly correlated with erectile dysfunction, hypogonadism (predictors of future development of MS), and female sexual dysfunction.” [Note: MS = metabolic syndrome]

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