Mood Killers: Hormones, Menopause, and Erectile Dysfunction

1. Mood Killers: Hormones, Menopause, and Erectile Dysfunction Stacy Higgins, MD, FACP Emory University School of Medicine

2. Menopause

3. Definition • The permanent cessation of menses because of loss of ovarian follicular function • A natural biologic process, not a disease!

5. Normal Menstrual Cycle

6. Why does it happen? • Aging of the female reproductive system starts at birth • Steady loss of eggs from either ovulation or atresia • Once last egg is depleted- menopause

8. Why so much attention? • Menopause affects every woman • Aging of the population means more women are postmenopausal than ever before • More postmenopausal women living beyond 65

9. Terminology • Pre-menopause • Peri-menopause • Post-menopause • Premature menopause • Premature ovarian failure • Induced menopause

10. Age at Menopause • Average age: 51.4 • (40-58) • Peri-menopause:47.5 • Lasts on average 4 years • No change in average age

11. When will it happen? • Later than average: • Multiparous • Increased BMI • Earlier than average: • Nulliparous • Medically treated depression • Seizure disorder • Smoking

12. Signs and Symptoms

14. Hormonal • Irregular menses • Decreased fertility • Osteoporosis

15. Vasomotor • Hot Flashes • Night Sweats • Sleep Disturbances

16. Urogenital Atrophy • Itching • Dryness • Bleeding • Urinary frequency and urgency • Urinary Incontinence

17. Skin Changes • Breast Atrophy • Skin Thinning • Decreased Elasticity • Thinning Hair

18. Psychological • Mood disturbance • Irritability • Fatigue • Memory loss • Depression

19. Sexual • Decreased Libido • Vaginal Dryness • Problems reaching orgasm • Dyspareunia

21. Diagnosis • Usually clinical diagnosis • FSH • Home Testing • What else might it be? • Pregnancy!! • Thyroid problems

22. Complications • Cardiovascular Disease • Osteoporosis • Urinary Incontinence • Weight Gain

25. Self-Care

26. Self-Care • Cool hot flashes • Decrease vaginal discomforts • Optimize your sleep • Strengthen your pelvic muscles • Eat well • Don’t smoke • Exercise regularly • Get regular checkups

28. Medical Symptom Management • Estrogen • Low-dose Antidepressants • Clonidine • Complementary Medicines

30. Systemic Estrogen • Most effective treatment option for relieving menopausal hot flashes • Take lowest dose needed to provide symptom relief • Weigh risk vs. benefit • Protects against osteoporosis • Increased risk of breast cancer, heart disease, stroke, and blood clots

32. Antidepressants • Venlafaxine (Effexor)- selective serotonin reuptake inhibitor (SSRIs) • Shown to decrease menopausal hot flashes • Other helpful SSRIs- fluoxetine (Prozac/Sarafem), paroxetine (Paxil), citalopram (Celexa) and sertraline (Zoloft)

33. Clonidine • Available as a pill or patch • Typically used to treat high blood pressure • May significantly reduce the frequency of hot flashes • Unpleasant side effects are common

34. Vaginal Estrogen • Relieves vaginal dryness • Can be administered using a vaginal tablet, ring or cream • Releases just a small amount of estrogen, which is absorbed by the vaginal tissue • Also helps relieve discomfort with intercourse and some urinary symptoms

35. Phytoestrogens • Two main types of phytoestrogens • Isoflavones: found in soybeans, chickpeas and other legumes • Lignans:occur in flaxseed, whole grains and some fruits and vegetables • Most studies have found them ineffective • Isoflavones have some weak estrogen-like effects

36. Black Cohosh • Used to treat hot flashes, night sweats, vaginal dryness, and other symptoms • Study results are mixed on whether black cohosh effectively relieves menopausal symptoms • Studies to date have been less than 6 months long, so long-term safety data are not currently available • Can cause headaches and stomach discomfort

38. Erectile Dysfunction

40. Erectile Dysfunction • Inability to attain or maintain erection sufficiently firm to permit satisfactory sexual performance • Impotence is a broad term including problems of libido, erection and orgasm

41. How common is it? • Prevalence of 5% in men <40 years • Prevalence of 55-75% in men 75-80 years • Approximately 600,000 new cases of ED each year

42. Types of Dysfunction • Ability to obtain a full erection at some times (e.g. when asleep) • Obtaining erections which are either not rigid or full or lost rapidly

44. Physiology • Penis innervated by nerves • Blood vessels bring blood to the penis • Brain provides stimulation

45. How Does an Erection Happen? • Stimulation causes the brain to release chemicals • Chemicals bring message to nerves in the penis • Nerves tell penile blood vessels to relax • Blood flows into the penis • Pressure traps the blood, sustaining an erection

46. Causes • Physiologic • Impedence of blood entering and being retained in the penis • Psychologic • Erection or penetration fails due to thoughts or feelings rather than physical impossibility

47. Risk Factors • Vascular Disease is most common • Atherosclerosis • Diabetes • Hypertension • Cigarette smoking • Hypercholesterolemia

48. Risk Factors • Age • More time or more physical stimulation to achieve erection • More control over ejaculation, but flow is reduced • Tend not to be as hard, and the refractory period is prolonged • More likely to take medication that contributes to erectile dysfunction

49. Risk Factors • Medications • Antihypertensives (B-blockers, ACEI, Ca ch blockers, diuretics) • Antidepressants (TCAs, SSRIs) • Antipsychotics • Anticonvulsants • H2 receptor blockers • Statins and fibrates

50. Risk Factors • Endocrine Abnormalities • Hypogonadotropic hypogonadism • Hyperthyroidism • Hypothyroidism • Hyperprolactinemia