LET'S TALK ABOUT SEX
Sexual problems often go untreated because older people avoid talk of such intensely personal matters, even with their physicians. by Jon NalickAfter undergoing bladder cancer treatments that included the surgical removal of his prostate, Elliott Fuss, 72, was dismayed to learn the operation eliminated his ability to have sex.
"I was so frustrated after the surgery and chemotherapy. I never told my wife how upsetting it was, but it really took away so much. To me, sex is life. It's a very important part of being human," he says.
While it is impossible to say exactly how many American men and women suffer from sexual dysfunction, a recent University of Chicago study revealed that 31 percent of men and 43 percent of women regularly suffer from some form. Further, older Americans suffer from a disproportionate percentage of sexual dysfunction, usually resulting from medical conditions-or, as in Fuss's case, from the side effects of medical treatment.
Until recently, sexual problems often went untreated because older people avoided talk of such intensely personal matters, even with their physicians. In addition, many physicians are themselves uncomfortable talking about the subject, says Loren Lipson, M.D., chief of geriatric medicine in the USC Department of Medicine.
With the advent of Viagra, however, the subject became, if not an easy one to discuss, less of a taboo, Lipson says.
"There is this acceptance that it's OK, it's all right to talk about it," Lipson says. "The bottom line is, we know more about sexual dysfunction in seniors than ever before. Most patients can be helped."
Fuss says that, for him, help arrived in the form of a penile implant that fully restored his sexual function, and adds: "Talking to my doctor about it was the smartest thing I ever did.
"Anyone reluctant to talk about sexual problems with their doctor is living in the dark ages. Why would anybody deny themselves the happiness of a normal sex life at any age?" Fuss asked.
Lipson notes that many elderly people mistakenly believe that loss of sexual function is an inevitable consequence of age and therefore often resign themselves to suffering with conditions that are actually easily treated.
He says that hundreds of thousands of people suffer from sexual dysfunction caused by the side effects of various medications.
For example, he recalls a 68-year-old man who came to him for diabetic care. While interviewing the patient, Lipson asked whether he was suffering from impotence.
The patient said he had, in fact, been impotent since he was 43, when he began taking blood pressure medicine. Lipson replaced his blood pressure medicine with a placebo for a short period of time and the man regained his potency. After that, a simple change to a new blood pressure medication solved the problem for good.
Lipson, a nationally recognized expert on sexual dysfunction among seniors, lectures frequently on the subject at nursing homes, senior centers and community centers. Each year, right before Valentine's Day, he gives a lecture he dubs "Sex Over 60" to physicians and health care providers. The outreach effort, which uses gentle humor to make some serious points, is an important and useful way of enhancing physician sensitivity to older patients' needs.
Treating sexual dysfunction in seniors traditionally has been difficult.
"People unwittingly accepted that men would lose their ability to have erections at 60 or 70," says Stuart Boyd, M.D., professor and chief of urology at USC University Hospital and the director of the Male Sexual Dysfunction Clinic at USC,, "which couldn't be further from the truth."
Seniors' traditional reticence when it comes to sexual topics can partly be explained by a prevailing attitude among many older people that private matters should remain private. But sexual subjects are especially taboo to many seniors because we are an "ageist" society that refuses to acknowledge that seniors have sexual feelings, Lipson says.
"We're the generation where youth is worshipped instead of age being respected," Lipson says. "We denigrate seniors basically on their ability to function as human beings. Yet we are sexual beings from the time of puberty until the time we die."
Physicians, too, have traditionally been uncomfortable discussing the subject, Lipson says. "So it's hard for us to be inquisitors and guides to the people we're supposed to be counseling."
Sexual dysfunction is caused both by physical and psychological factors, Lipson says.
"Every case I've ever seen has psychological overtones," he notes. "However, only 20 percent of people who have sexual dysfunction have a principally psychological basis."
Physical causes include: medications, especially those used to treat high blood pressure; reduced hormone levels due to aging; chronic disease; arthritis of the back, hips and knees; alcohol use, and physical trauma. Psychological causes include: depression; anxiety and fear of performance failure; marital strife; fear stemming from strokes or heart attacks, and dementia.
Erika Banks, M.D., assistant professor of obstetrics and gynecology, says the most common sexual problems for women over 60 include vaginal dryness and loss of libido-symptoms usually triggered by the onset of menopause.
Banks says that the use of water-soluble lubricants offers some relief for the problem of vaginal dryness. More significantly, the inevitable drop of estrogen in the body with menopause and the common sexual problems that can result from this drop can usually be reversed with hormone replacement therapy.
"We can replace those hormones and help people feel normal again. A lot of women underestimate the effects of estrogen deprivation on sexual function. I think that hormone replacement therapy does make a big difference," she says.
Banks emphasizes that loss of libido and other changes in sexual function are only considered a problem when they interfere with the normal enjoyment of life. For example, an elderly woman who has lost her partner may find the loss of interest in sex non-problematic.
But for those in a healthy relationship, change in libido can be devastating-especially if it is a sudden change.
Banks recently treated a woman in her 30s who had undergone radiation treatment to her abdomen for cancer.
"She came in complaining of hot flashes, vaginal dryness and decreased libido, not realizing that the radiation had affected her ovaries and had triggered menopause. She felt tremendous relief that the problems were treatable because they had caused distressing relationship problems and made her feel abnormal," she says.
According to Banks, more and more women are actively fighting the loss of sexual function today than in years past because they see it as something that is no longer inevitable.
"I think women today feel younger at menopause than they used to. They're exercising and taking good care of themselves. So they feel that it's not normal for them to be less sexually active when they're still active in so many other ways," Banks says.
For men, the most common problem involves the inability to achieve or maintain an erection.
"Probably 100 percent of the cases can be treated," Boyd says. "It just depends on how many hoops you're willing to jump through, how many options you're willing to try."
Today, Viagra is the most common treatment for sexual dysfunction among men, says Boyd.
Other treatments include psychological counseling, sex therapy, eliminating alcohol, warm baths or medicine for arthritis and changing blood pressure medications. In some cases, penile problems can be treated with microsurgery, medications, injections, commercial preparations, vacuum erectile devices and implantable prostheses.
For Elliott Fuss, beating cancer was only part of the battle to regain a sense of normalcy in his life-it was not until he regained his sexual function that he felt whole again.
The lesson he says he learned is that there are few sexual problems that cannot be alleviated by treatment.
"People need to know that just because they have a problem, it doesn't mean it's all over for them. When someone with the kind of problem I had asks me if they should see a doctor, I tell them, "Don't be reticent. For God's sakes, go!" n
For more information about the research and treatment of sexual dysfunction in seniors, or to learn about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).
THAT LITTLE BLUE PILL
Viagra has earned a well-deserved reputation for restoring sexual function, but experts warn that it is a powerful drug with potentially dangerous side effects, especially for older men taking certain kinds of heart and ulcer medications.
Bradley Williams, Pharm.D., associate professor of clinical pharmacy and clinical gerontology, says that although the drug is considered safe and effective, several deaths have been associated with its use.
Most commonly, fatal reactions occurred in men taking nitrate-based medications for angina, or chest pain, and in men taking other drugs that interfere with the body's ability to metabolize Viagra.
"Anyone taking long-acting nitrate-based drugs, or nitroglycerine for angina, should not take Viagra," he says.
Viagra works in part by dilating blood vessels and when combined with other vasodilators the additive effect can cause plummeting blood pressure, heart attacks or strokes.
Similar reactions can be triggered by ulcer medications such as Tagamet, cardiac medications including diltiazem and verapamil, and the antibiotic erythromycin -all of which can interfere with the body's ability to metabolize Viagra.
Typically, men taking Viagra start with a 50 mg dose, not more than once per day. However, men with histories of heart attacks, heart disease or diabetes should start out at 25 mg, Williams says.
He also emphasizes that men considering taking the drug first discuss it with their partner. Post-menopausal women often experience vaginal dryness that can make intercourse painful, especially if they have not had sex in some time.
While the media is filled with stories about Viagra, Williams stresses that no one should feel an obligation to use it. Still, "if a man feels it can enhance his relationship, he should be encouraged to talk to his physician about it." In addition, men should be cautious about the so-called "Viagra clinics" and other programs advertised in the media. "There is no substitute for the personal knowledge that exists between a patient and a trusted health care professional," says Williams.
In any event, Williams says most men can take Viagra without any consequence, but it is important to consult a physician or pharmacist before taking it-and not only because of potential side effects. In many instances, medications used to treat high blood pressure, anxiety and depression and those used in chemotherapy can cause impotence. Sometimes simply switching to a different form of a medication can restore sexual function and eliminate the need for Viagra.
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