Anti-aging medicine seeks to prevent, slow down or compensate for the inevitable changes of aging. As we age, sex does not inevitably wane, though it certainly changes. There are two ways to stave off the effects of aging on one's sex life. First, is to maximize one's mental and physical health. The second step is summed up by the adage, "Use it or lose it." I will discuss some of the options for preventing or correcting sexual problems, but physicians should be aware that there is little real science to support their use.
Popular magazines often publish articles suggesting everything from sharing your fantasies, to incorporating "sex toys," to experimenting with new locations. By the number of articles and the frequency with which these articles appear, the problem must be widespread and the solutions less than effective.
Clinical sexologists generally believe the adage, "Use it or lose it." Of course, if a problem develops that prevents one from engaging in sex, non-use becomes a self-fulfilling prophecy. It also is true that the physiological causes of sexual dysfunction have psychological ramifications, and the psychological causes of sexual dysfunction have physiological ramifications.
Staying in good physical and psychological health may be the best insurance to ensure that sex remains vital. Changes in sexual function are often the first symptoms of a new disease, and prompt intervention can limit the disease progress and its sequela. Maximizing one's health in all areas maximizes the body's resources that can be directed toward sex rather than healing or compensating for another problem.
Unfortunately, the incidence and prevalence of most disease increases with age, and these diseases — along with their treatments — often affect sexual functioning negatively. Even if the change in a patient's sexual functioning is due to the disease process, his or her sex life is never over until the patient chooses for it to end.
Perhaps the most common aspect of sex affected by age is the change in the importance of sex in one's life. For some, having sex is fun, incredibly enjoyable and a wonderful form of exercise. Having sex can be a transformative event eagerly sought out and terribly missed when unavailable. Although there are people who are happy that their sexuality no longer drives them, others still want to see and feel the world in sexual terms. This paper is directed towards patients for whom sex is a vital, integral part of their being.
Sex does not start mystically at age 18 and end with retirement. Healthy sexuality starts at birth and needs to be nurtured throughout life. Sex is not easily turned off and on again. The secret to having good sex throughout your life is to have good sex throughout your life. Many of us work crazy hours, are stressed out much of the time. We put other responsibilities ahead of our sexual play. Sex will not just happen unless the time and place is made for it to happen. Patients should not sacrifice sex while working on other life goals; it may not be there when they want it to be.
Too many of our patients erroneously believe that they cannot be sexual if the "plumbing" is not working correctly. Healthy, wonderful sex can and does occur without erections, lubrication, orgasms and even genitals. When the focus is on what feels good, even old, tired genitals often respond. Possibly the worst way to get an erection is to look down and say up. Similarly, it is an error for a woman to judge her receptivity by how lubricated she is. The use of fingers, tongues and inanimate objects is not a sign of problems. It is a way to give pleasure and participate in what is most likely to produce adequate functioning. Patients should be encouraged to enjoy, experiment and explore to maximize their sexual potential.
An active fantasy life also is important. Too often sex becomes boring, stale or perfunctory, rather than new and innovative. It is important to add new stimuli and create new fantasies. Quite often it's inappropriate to notice sexual cues in our environment but difficult to respond when it is appropriate. I suggest allowing one's erotic imagination to run wild.
Although some people have moral or religious objections to masturbation, it is a powerful method to learn about one's own body. Masturbation allows us to discover what really feels good and to experiment with new techniques without chancing failure. It also helps to avoid performance anxiety. Masturbation does not require a partner, but it can become a partnered activity as well. It complements partnered sex but does not replace it. Many sexologists believe that sexual dysfunctions are relatively rare among those who masturbate regularly. Masturbation cannot be recommended too highly to your patients.
Just treating a symptom is often inadequate; a more holistic approach to healthy sexuality is needed. An estimated more than 50 percent of men for whom sildenafil (Viagra®) is successful in producing erections, never ask for a second prescription. Other erection treatments have significant dropout rates. The importance of relationship counseling in the maintenance of an active sex life cannot be overestimated and is highly encouraged.
Lack of a partner can be the easiest or the most difficult to fix. Having no partner can mean more than just being alone. It can indicate that a patient's partner is unwilling, unable or unavailable. Finding a partner can be difficult enough, but finding a partner that desires sex and desires the same type and frequency of sex as your patient, can be even more difficult. Relationship, individual and sex therapy can be an essential part of maintaining a healthy sex life.
What's a physician to do? Here are a few comments about the usual medical "cures" for sexual aging after other medical and psychiatric causes have been ruled out.
Menopause, naturally or surgically, often causes thinning of the vaginal lining, atrophy of the vaginal barrel and painful intercourse. These symptoms can be treated with exogenous estrogens, but new data raises concerns about a possible increase in stroke, heart disease and breast cancer. Care should be taken. There is little information that phytoestrogens or other menopausal treatments are effective and nothing to indicate they are safer.
Decreased sexual desire in both men and women has been treated with testosterone, but its use is controversial. In men, exogenous testosterone may accelerate the growth of an otherwise dormant prostate carcinoma. In women, it can cause hair loss (male pattern baldness), abnormal hair growth, voice changes, irritability and acne. Additionally, testosterone is converted into estrogen by the body, raising the possibility that it can aggravate or cause the same problems as hormone replacement therapy.
Growth hormone is a supposed fountain of youth, but little is known about its use as an anti-aging medication. Depending on the dose, growth hormone can cause both increased and decreased androgen levels. Increased levels would have the same effect as testosterone, and decreased levels could decrease libido.
Phosphodiesterase type 5 (PDE5) inhibitors include sildenafil and two newer agents (vardenafil and taldenafil) expected to be released soon. These agents prevent the degradation of (please spell out) cGMP, which causes corpora cavernosa smooth muscle relaxation resulting in erection. There is some evidence that sildenafil enhances sexual functioning in men without erectile dysfunction. Healthy men report a decrease in the time before they can obtain another erection, as well as a decreased need for tactile stimulation to maintain an erection. Its use in women is still quite controversial.
There also are other medications, which work directly on relaxation of the smooth muscle. These can be given by intracavernosal injection, by intraurethral suppositories and topically — still in development — to increase the ability to get and maintain erections.
This is an area of intense research. Drugs to heighten sexual desire, control the timing and intensity of orgasm, increase stamina, promote lubrication and erections by affecting brain chemistry all are being actively sought at the present time. Drugs specifically aimed at women are a high priority. Pfizer reportedly has a super secret drug, code-named "Pink Viagra."
Dr. Moser is a board certified internist, a member of the SFMS board of
directors and a member of the editorial board of