Sept. 6, 2000 — Sex — It’s everywhere you look: on television, in the movies, magazine ads, and in news articles. But what if you want to jump on the bandwagon, but just can’t? Sexual dysfunction among men has begun to get more attention, and the same is becoming true for women. The days of “Honey, I have a headache” may soon only be used by a woman when she really does have a headache.

Sexual dysfunction, especially in women, is little understood. However, it is known that there can be certain physical problems associated with a loss of sexual desire — menopause for one.

The mechanical problems associated with menopause — vaginal dryness, loss of elasticity, hot flashes, irritability, and loss of bladder control — are often thought to be due to the abrupt loss of natural estrogen. For women who can take hormone replacement therapy (HRT), these problems are often easily addressed. Even without HRT, use of an estrogen cream or ring placed in the vagina can help.

However, lack of arousal, desire, and less intense orgasms are often overlooked and not helped by HRT alone. Currently, interest has turned to women’s replacing testosterone levels, which is associated with sexual arousal and desire.

Menopause occurs naturally, but it also can be brought on by surgery. Abrupt changes in sexual response often occur after a woman’s ovaries are removed, causing profound changes in testosterone and estrogen levels.

A study reported in the Sept. 7 issue of TheNew England Journal of Medicine looked at a group of women who had both ovaries removed and who were on HRT. Their average age was 48, and they all reported a less than satisfying sex life.

The study, which was led by researchers from Massachusetts General Hospital in Boston, tested two testosterone patches against a placebo patch containing no hormones. The researchers found that the low dose and the placebo patch gave about the same results of improved sexual functioning, leading them to conclude that there was a psychological impact of simply giving attention to the women’s sexual dysfunction. However, when the women were put on the high-dose patch, there was a twofold to threefold increase in sexual activity, which included desire, arousal, activity, and pleasure.

“The significant finding of the study was that the higher testosterone dose, which importantly was still within the normal range for tadalafil cialis from india women, did result in significant increases in frequency of sexual activity and ratings of pleasure,” study author Jan Shifren, MD tells WebMD.

Shifren, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School in Boston, and a reproductive endocrinologist at the Vincent OB/GYN Service at Massachusetts General Hospital, says an additional highlight of the study was that the women reported a better sense of overall well-being.

Barbara Bartlik, MD, a psychiatrist and sex therapist at New York Weill Cornell Medical Center in New York City, has patients use a testosterone cream applied to the inner thighs or vaginally that she claims is effective.

Testosterone is very important, she says. “You take a woman who is low in testosterone and her orgasms are like a little sneeze, a little blip, and these are women who used to experience all-encompassing, total-body orgasms,” Bartlik tells WebMD.

While Bartlik calls it an generic cialis 10mg that more study isn’t being done on women’s sexuality and sexual functioning, she says there are some other advances in female sexual medicine. Among the top 10, she listed:

• oral medications, such as the use of Viagra for women,
• topical medications to enhance stimulation,
• the ERO-CTD — a flexible cup that stimulates the clitoris and improves arousal,
• erotic and educational videos written, produced, and directed by women, and
• improvements in sexual lubricants and vibrators.

However, testosterone tops Bartlik’s list. While stating that it still is not commonly used in clinical practice and has not yet received FDA approval for this purpose, studies such as Shifren’s should begin to shed light on this important hormone, she says.

There are questions of using supplemental testosterone akin to those of using estrogen replacement — will it cause hormone-activated cancers, will it cause women to lose the heart protective aspects of estrogen? Bartlik says there is not enough research to begin to even offer answers. Some research in men suggests that testosterone protects against heart disease in them just as estrogen protects women. It’s a new frontier for research.

Two known side effects of too much testosterone — acne and unwanted hair growth — were not found to be a problem in Shifren’s study.

Bartlik says testosterone replacement makes sense because “if we’re losing estrogen and losing testosterone, why are we only replacing estrogen?”

So who would most benefit from this skin patch therapy?

Shifren and other experts agree that if a woman had a very good sexual relationship prior to menopause or a complete herbal remedy for erectile dysfunction and is no longer citrate generic sildenafil viagra those same responses, she would benefit from such therapy.

And none too soon, according to Carole Altman, PhD, a sex therapist who says attention needs to be paid to more than just menopausal women. Addressing female sexual dysfunction is difficult, because often there is not one cause to address. Relationship issues, psychological problems, as well as physical conditions all go hand in hand. But they need to be faced: “There is such a sexual anorexia in this country,” Altman tells WebMD.

Altman, the author of You Can Be Your Own Sex Therapist and 101 Ways To make Love Happen, says sex is our built-in health care system. “When you have an orgasm or an ejaculation, your blood pressure improves, your muscles become toned, your immune system increases, your sense of self and well-being increases, and there’s a euphoria that comes over the body which is very important.”

Altman says there are simple ways to address what she considers as important an aspect of everyday life as eating and breathing. “Touching, fantasizing, sexual games, focusing, bathing together, and brushing each other’s hair,” are among the various ways Altman says couples can initiate intimacy.

She also tells women to do the Kegel exercise. By learning to control the vaginal muscles through this technique of contracting and relaxing them, women can increase lubrication. “When they feel the lubrication start to come, they’ll feel sexual again, and if they don’t feel sexual per se, they’ll feel female.”

“We’re really neglecting ourselves, we’re body building, popping vitamins, yet we’re not doing the one thing God gave us — man and woman merging with each other,” Altman says. “We’re neglecting a very important aspect of our health, mental and spiritual well-being, and the ability to feel love.”

As for testosterone, it is not yet FDA-approved for use in female sexual dysfunction. Bartlik says

many doctors will not feel comfortable using non-FDA approved therapies, but women can find qualified medical sex therapists by checking with the American Association of Sex Educators, Counselors, and Therapists or the American Board of Sexology, both of whom certify therapists. Also, some gynecologists and urologists have a particular interest in female sexuality and may be amenable to helping with various therapies.

Altman sums it up: “We have to get back to having intercourse, kissing, hugging, and loving each other, she says. Quoting Wilhelm Reich, a pioneer in sexuality and orgasm research, Altman says “[orgasm] is the only singular moment in all of your life where you’re totally relaxed.”

Shifren and her colleagues currently are doing more study on the testosterone patch. Women who want to take part in the new trial can call (877) 54WOMEN to see if they qualify.

June 2, 2000 — My friend April, a 24-year-old graduate student from
Pittsburgh, began taking the popular anxiety cialis soft treatment viagra Zoloft in February, and
says the drug is fabulous. April’s calmer and much less anxious — although
when she pauses to think about it, the 50-milligram blue tablet she takes every
morning seems to be causing her all kinds of anxiety.

“My sex drive is still there and the arousal is the same. But when I
have intercourse, it takes way longer for me to have an orgasm, or I don’t have
one at all. That never happened to me before,” says tall, willowy April
who, like others in this story, has been given a pseudonym.

April’s drug-induced frigidity is causing her enough anxiety to consider
taking an additional drug to relax her. “I’m afraid my partner will ask me
to go off the Zoloft, but I feel too good on it. I’m starting to think I’m
going to have to fake it, and I don’t want to do that, but I don’t really know
what else to do.”

April is not alone. The antidepressant she is taking is an SSRI (selective
serotonin reuptake inhibitor) and, like other drugs in the same family (Prozac,
Paxil, Luvox, Effexor, and Celexa), they clobber sex drive in up to 60% of
those who take them. But SSRIs are so awesomely effective that, for most people
who take them, the pleasures of sex take a back seat to a sense of calm and
serenity that the drugs create.

SSRIs are the current drugs of choice for treating depression, and the most
popular still is Prozac. At $2.6 billion, Prozac, which costs about $90 a
month, has the third-best annual sales of any pharmaceutical sold in the United
States, according to market research firm IMS Health.

Such drugs may be great for prisoners, priests, and recovering
nymphomaniacs. But what about the rest of us?

Claire, a 46-year-old writer from Detroit, is a case in point. Before Claire
got married 20 years ago, she prided herself on her libertine ways. At any
given moment, Claire would have three or four lovers stashed away. Sex was
Claire’s middle name.

Because of health-related problems and difficulties at her job, Claire
started taking Paxil four years ago. “I was totally stressed out. I was in
tears every day. Everything seemed too much to handle. No small thing was too
small to set me off. I felt I was in a tornado continually sucking me down. If
I snagged my sweater on barbed wire, I’d be unable to get free. I’d stay snared
for days or weeks. Paxil was terrific. But no one warned me about the side
effects — although, really, it didn’t matter because suddenly there was peace,
some days I wasn’t in tears. And soon, I never felt the need to cry.”

The cost: Claire’s libido — which had been such a central part of her life
– diminished and then dried up. She and her husband, with whom she was still
deeply in love, ceased to have sex with any regularity. They had become their
parents; sex was reserved for special occasions, like their anniversary
night.

Still, Claire was feeling so great on the antidepressant that in the summer
of 1998, she thought she could go it alone (”A little voice inside me said
I didn’t need to rely on a drug any longer …”), so she started cutting
back on the Paxil and within weeks her libido kicked back in. This was the old
Claire.

Alas, by late winter, Claire was back to weeping every day, not sleeping,
not eating. “My sex drive may have come back, but in that condition I
wasn’t interested. I didn’t want to go on Paxil again. It had caused me to have
night sweats and my heart would race. So, when I returned to my psychiatrist,
he suggested Celexa, but warned me about the sexual side effects.”

” ‘Start me on whatever is going to work the fastest,’ I told him, and
my husband (who was in the waiting room) agreed.”

Unlike Paxil, Celexa didn’t cause the weird side effects in Claire. Her
outlook on life became rosy again. But, again, the drug did a number on
Claire’s libido — and still does. “It’s not as though I don’t want to
cuddle or kiss. It’s just that my genitalia aren’t aroused — but with the
drug, nothing is easily aroused. We probably have sex once or twice a week. But
I don’t initiate it. I initiate it intellectually and psychologically, but for
me it always can wait. I love my husband and I want to connect, but it always
can wait till tomorrow.”

To jump-start their sex life, Claire and her husband started using a
vibrator, and now routinely rely on it whenever they get intimate. “It was
taking a long, long time, and I would get frustrated. So this [the vibrator]
seems to work. It’s very participatory on the part of my husband, and it’s made
my orgasms very intense. I used to define myself by my sexuality, and I don’t
any more. Nowadays, all my orgasms are vibrator-orgasms,” Claire says in a
wistful tone.

Still, she says that going off Celexa would be too much of a gamble.
“Now, when I snag myself, I can untangle myself quickly and move
on.”

Another friend of mine, Holly, a viagra soft divorced Atlanta housewife
with two teenage children, started taking Prozac in 1989 when her gynecologist
prescribed it for anxiety. “I had two small children at the time, was
working full time, and I had just too much to juggle. I noticed a slow but very
dramatic change in everything once I was on the Prozac. In one sense, nothing
changes, but your reaction to everything changes. I could be stopped in
traffic, late to pick up my kids from day care, and in the past, that would
cause me a lot of stress; but with the Prozac, I’d just accept the reality and
was much, much calmer. You roll with everything. You observe things
differently. I’d have a peaceful response to things that in the past would
cause me to freak.”

But as with Claire, the drug nailed her sex life. “I remember initially
on Prozac I had little interest in sex. It really was a nasty side effect. But
it was a trade-off: Everything functioned so much more smoothly that I never
got too concerned about what it was doing to my sex drive.”

With Holly — who is 48, works out with a personal trainer every week, and
is engaged to remarry in the fall — her libido gradually returned after about
a year on the drug. Psychiatrists say some people neutralize the effect the
drug has on their sex drive, but it can take months, sometimes years.

Holly noticed something else about the Prozac, something commonly known as
“Prozac poop-out.” The longer she took the drug, the less effective it
seemed to become. In 1992, her gynecologist switched her to Paxil, but that
seemed to deaden her much more than the Prozac did — and not just her sex
drive. “My emotions, reactions, feelings, were numbed with the Paxil.
Again, though, my sex drive came back but it took time, maybe a year.”

Finally, two years ago, Holly went to a psychiatrist who prescribed Celexa.
“For the first three weeks, I felt euphoric, almost giddy. Then I came down
a little, but I don’t feel deadened. I have my emotions back. It still has a
negative effect on my sex drive, but at least it’s the least of the three
drugs.”

Everywhere I turned, I heard the same story. The drugs were great, so great
that they were worth giving up great sex for. Cassie, a pixieish,
freckle-faced, 33-year-old web site developer from San Francisco, told me that
a crushing, traumatic divorce two years ago sent her crashing into a downward
spiral, and Prozac was the only way out. She credits Prozac with saving her
life. For the first year on the drug, her sex drive was minimal, but “who
wants to have sex when you’re trying to climb back to being yourself
again?” In the last year, she said, her body seems to have compensated for
the Prozac and her libido appears to be coming back, although she can’t say for
sure because she’s not currently in a relationship.

When I canvassed my male friends on antidepressants about their sex lives, I
got a different story. Either these guys are super studs and nothing can deaden
their ardor — or maybe it was an Arnold Schwarzenegger macho-guy thing.

Greg, a 48-year-old television producer (and marathon runner) in Los
Angeles, went on Prozac for depression in 1990, but developed chronic insomnia
(a common side effect), so he switched to Zoloft a year later. Greg says he
doesn’t really know whether the SSRI has done anything to his sex drive. Now
married and the father of a 2-year-old daughter, he says his interest in sex
hasn’t dampened, but his frequency is off from what it used to be. “I’m not
prowling around as I did when I was 29.” Still, Greg says he has no problem
getting and keeping an erection, masturbating, and fantasizing. That also might
have something to do with his wife’s travel schedule: She’s away on business
for up to two weeks at a time.

Another friend, Todd, a 41-year-old Manhattan media executive who is a
drop-dead double for actor/playwright Sam Shepard, underwent a debilitating
bout of depression while living overseas two years ago, so bad that he thought
he’d have to be hospitalized. His psychiatrist prescribed Effexor, which
gradually seemed to lift the dark clouds. Todd isn’t sure about what sexual
side effects the drug had on him. “I was so depressed, I didn’t want to
have sex. And with the Effexor, my mood got better, the depression eased, so I
think, in that way, the drug probably helped me sexually.” Todd weaned
himself off the drug and now takes no antidepressants, and he says he hasn’t
had a relapse.

Welcome to the New Millennium, where the dot-com generation happily chats
about IPOs, their nifty Palm VII handhelds, and their accessory-dripping
Lincoln Navigator SUVs. RAM size is what’s important. Bandwidth is one’s
calling card. But mention orgasms, and the lattes go cold.

I’m not making light of depression. Surveys variously indicate that as many
as one out of three women and one out of eight men will, sometime during their
lives, be classified as clinically depressed. And the World Health Organization
says that by 2020, depression will top the list of health-related maladies in
the developed world, and that severe depression will be the second-greatest
cause of disability. It is a real disease; a crushing feeling that the world is
closing in on you, that a thick black curtain is crashing down on your
life.

Considering the enormous popularity of antidepressant drugs like Prozac,
Paxil, and Zoloft, and the drug culture that spawned them and now adores them,
it makes sense that modern-day pharmacology has perfected such an effective and
profitable pharmaceutical that can pinpoint with awesome accuracy the
neurotransmitters and receptor sites that cause depression.

The world’s first SSRI, Prozac, was launched in 1986 in Belgium and approved
a year later for use in the United States. Since then, about 17 million
Americans have taken the cream-and-lettuce-colored capsule. Prozac is the most
widely prescribed antidepressant in the world.

Since its introduction, other drugs with similar properties have come down
the pike: The most widely known include Paxil, Zoloft, Luvox, Effexor, and
Celexa. Each is slightly different in its formulation and, therefore, affects
users differently. Effexor, for instance, is not a straight SSRI; it blocks
reuptake of not just serotonin, but also erectile dysfunction natural herbs and dopamine.

A very short chemistry lesson on how SSRIs work and why they can massacre
your sex drive: Higher levels of serotonin in the brain generally lead to
enhanced moods. Prozac and its family of drugs increase the level of serotonin
by preventing its uptake in receptor nerve cells, thereby assisting brain cells
to communicate better with one another. For reasons not completely understood,
the rush of serotonin causes in many people an effect that restores confidence,
eases anxiety, and improves self-esteem. The downside is that while the
serotonin is doing all this great stuff, another chemical in the brain,
dopamine — known to increase sexual desire — is suppressed.

Alas, the proposition was too good to be true. There is no free lunch. No
rights to sexy morning reveries or sweet-dream dalliances that provide a
(legally) drug-induced feeling that makes you happy. If you want to be
chemically induced confident and serene (or, at least, no longer depressed),
you may have to kiss off such sexual luxuries once thought to be absolute
generational rights.

As far as physicians can determine, there are four kinds of sexual
dysfunction when it comes to SSRIs: loss of sexual desire, difficulty getting
aroused (in men, erectile flaccidity; in women, lack of lubrication and similar
lack of engorgement), duration of time from arousal to orgasm, and intensity
and length of orgasm. Both women and men report about the same incidence of
dysfunction when they take SSRIs.

But the incidence of dysfunction while on SSRIs probably is even greater
than reported. The underlying problem is that physicians and patients often
don’t talk about the sexual side effects of antidepressants. Some patients are
too embarrassed to ‘fess up. Many are so happy that they’re not depressed any
longer that the dip in their sex lives becomes secondary to their spectacularly
upturned mood. It’s a price, but one that most SSRI-users happily pay.

Why SSRIs dampen sexual ardor is still under research. Three physicians at
the University of G?teborg in Sweden (J. Matuszcyk Vega, K. Larsson, and E.
Eriksson) injected a male rat with fluoxetine (the chemical compound of Prozac)
and found that the rodent couldn’t ejaculate when he frequented a female rat
nearby.

Fellows at the department of psychiatry and neurosexology concocted another
pioneering study at The Hague’s Leyenburg Hospital. While having sex with their
partners, volunteers equipped with stopwatches timed how long it took them to
ejaculate while on SSRIs. The doctors concluded that the men’s ejaculations
were dramatically slowed, and in some cases, stopped by the SSRIs. Off the
SSRIs, the men performed fine.

For those on SSRIs, don’t despair. There are a host of legal drugs and herbs
that may help restore your libido and return your orgasms. But as in
prescribing SSRIs, it’s a hit-and-miss proposition. Some drugs and herbs work
to bring back libido; others fail.

Before you mainline yet another dose of a potent herb or drug (which, too,
may carry side effects), most psychiatrists suggest one of the following
strategies to help stoke your libido. Don’t try the following at home until you
discuss it with your physician.

• Talk to your doctor about a drug-free holiday. For example, go off your
  SSRI Thursday through Sunday and then attempt sex (even wild sex!) on Sunday
  night. This may work with Paxil, Zoloft, Celexa, or Effexor, but it won’t if
  you’re taking Prozac, which stays in your system for a longer time than the
  other drugs. Drug half-life is the time it takes for the pharmaceutical to
  decrease by half of its original dose in your blood stream. Prozac’s half-life
  is about a week; Paxil and Zoloft take about a day. The drug-free holiday
  strategy is a gamble. Many users don’t want to risk being off their SSRI, even
  for a day.

• Ask your doctor about lowering your dosage. The standard daily dose of
  Prozac, for instance, is 20 milligrams. Reduce it to 10 milligrams, by either
  getting a new prescription or (the less expensive way) by taking a 20-milligram
  capsule once every other day. This works especially well with Prozac, precisely
  because its half-life is so long; results with other SSRIs may be mixed.

• Switch antidepressants. Wellbutrin, Remeron, Effexor, Luvox, Celexa,
  Serzone, and Desyrel may be less likely to destroy libido but, for many, aren’t
  as effective in combating depression as Prozac, Paxil, or Zoloft.
  (Interestingly, the smoking-cessation drug, Zyban, is the exact same formula as
  Wellbutrin in a smaller dose.)

• Wait. Give your body time to compensate for the rush of serotonin that
  bathes the delicate receptor tissues of the brain. Some or most of your sex
  drive may eventually return. Some people, like Holly, develop tolerance to the
  sexual side effects and eventually bounce back.

If you are able to maintain your composure and return to your sexual
equilibrium after trying the above, read no further. If not, some additional
gambits: The drug yohimbine has shown to reverse the sexual side effects of
SSRIs, says M.J. Gitlin, a psychiatrist at UCLA. Yohimb?, an African bark, is
available over the counter; your physician will have to write a prescription
for yohimbine, a pharmaceutical agent. It is a non-hormonal drug, in pill form,
designed to decrease the outflow of blood from the penile tissue. Yohimb?
chewing gum is available in some health food stores.

Some physicians suggest taking a half-tab to one tab (5.4 milligrams each)
of the pill an hour or so before the “event.” Beware, though, yohimbine
can produce insomnia, already a side effect for many people on SSRIs.

The herb ginkgo biloba may also work. Alan Jay Cohen, a psychiatrist at the
University of California at San Francisco, did a study on ginkgo-tree leaf
extracts in which he reported that 86% of patients who took two 60- to
120-milligram capsules twice a day reported substantial improvement in their
sexual function, with no side effects. Cohen says that ginkgo biloba restored
the blood flow to the genitalia often blocked by the serotonin-enhancing drugs.
The popular prescription drug, Viagra, does much of the same.

If all else fails, here’s another idea: Three psychiatrists wrote in the
Journal of Clinical Psychiatry that granisetron (a sexual stimulant in
rats) works great in men and women, if taken one hour before sex. But the drug,
available as Kytril (and labeled for chemotherapy-related nausea control),
costs $50 a pill. That means it would have to be a very hot date.

Stephen G. Bloom teaches medical reporting at the University
of Iowa.