Ageing and Sexual Dysfunction


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Ageing and Sexual Dysfunction

  1. 1. Ageing & Sexual Dysfunction 1 PG Student- Dr. Sagar Gaikwad PG Guide-Dr. Arun Humne Department of Preventive and Social Medicine Govt. Medical College Nagpur,Maharashtra
  2. 2. Scope • Introduction • Historical Theories of Developments • Sexuality and Sexual Health • Ageing theories • Sexuality through life- cycle • Sexual functioning • Sexual disorders • Sexual dysfunction in male • Sexual dysfunction in female • Andropause & Menopause • References 2
  3. 3. Introduction Sex- Is not mere physiological transaction but implies - Love and love making Forms nucleus of family and marriage institutions Pervades art and produces its spells and magic Throughout the history of mankind Sex is supposed to contribute events of major impact and even Rise and Fall of Civilizations or Empires. Thus Sex remains Sociological and Cultural force. 3
  4. 4. Introduction contd.. Perspective of Sex Personal Perspective of sex comes from A) Private- Personal experiences Public social sources B) Society - Religions Philosophies Judicial system C) Historical perspective These perspectives help to study sex from Biological, Psychological, Behavioral, Clinical and Cultural dimensions. 4 Shape sexual behaviour by establishing Values &Taboos
  5. 5. Historical Developments in Sexology The first imminent personality who described central importance of sexuality into Human Existence is Sigmund Freud. Through his Psycho-analytical methods, described Sexuality as a Primary force in motivation. Also Freud was first who introduced principal of Childhood Sexuality and aberrations into development leading to various types of Neurosis. Although his work is criticized much and other theories of development, states more than one element apart from sexuality only has pivotal roles in development, still Psycho-analysis remains major form of diagnosis for Psychological illness. 5
  6. 6. Freud’s Psychosexual Development Theory Stage Age Range Erogeno us Zone Consequences of Psychological Fixation Oral Birth – 1 Year Mouth Aggressive: Chewing gums & ends of pencils etc. Passive: Smoking, Eating, Oral sexual practices Anal 1-3 Years Bowel & Bladder Retentive: Obsessively organized or excessively neat Expulsive: Reckless, Careless, Defiant, Disorganized, Phallic 3-6 Years Genitalia Oedipus Complex Electra Complex Latency 6- puberty Dormant Sexual Feelings Sexual unfulfillment Genital Puberty -Death Sexual Interests Mature Frigidity, Impotence, Unsatisfactory Relationships 6 EGO Develop SUPER EGO Develop Various Para-philias , aversions were proposed to occur due to level Psycho-sexual fixation
  7. 7. Historical Development Theories contd.. 7
  8. 8. Historical Development Theories contd.. Malinowski - Postulates Sociological and Cultural dimensions of Sexuality. Henry Miller–Made Philosophical statements about Sexuality in his works. Gestalt Psychologists– Thought Mind as a Whole component encompassing all aspects of development through complete interactions between body, mind and social determinants. Thus there are many preponderant theories regarding development of human and sexuality …. 8
  9. 9. What is Sexuality? Sexuality: “Encompasses Sex, Gender Identities & Roles, Sexual Orientation, Eroticism, Pleasure, Intimacy, Reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships” (WHO, 2006)
  10. 10. Sexual Health • According to the current working definition, sexual health is: “…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (WHO, 2006) 10
  11. 11. Theories of Ageing Senescence - state or process of ageing Aging has been associated with Physiological and Psychological changes that lead gradual dysfunction at cellular level including those of Reproductive System. Theories of Aging Biological – Design DNA Damage Wear and Tear Non Biological- Activity Disengagement 11
  12. 12. Reproductive – Cell Cycle Theory of Aging…. ʘ Chemical reactions that regulate cell growth, development, and death, are believed to control ageing. ʘ Cellular changes are directed by reproductive hormones of the hypothalamic-pituitary-gonadal axis. ʘ HPG axis hormones normally promote growth and development of the organism early in life in order to achieve reproduction. ʘ When the HPG axis becomes unbalanced, cellular growth and development is disregulated, and cell death and dysfunction can occur, both of which can initiate senescence. 12
  13. 13. Sexuality in Infancy Sexual reflexes operate at the very start of infancy and probably before birth USG studies provided some evidence that reflex erections occur in developing baby boys several months before birth.. Many newborn baby boys have erections in the first few minutes after birth, even before umbilical cord is cut. Similarly newborn baby girls have vaginal lubrications and clitoral erections in their first twenty four hours. By 3 to 4 months genital stimulation accompanied by smiling and cooing. Sensuous closeness of parents through holding, clinging and cuddling forms important phase of infantile sexuality. A child who is deprived of warm, close bonding during infancy may experience later difficulties forming intimate relationships or being comfortable in his/her sexuality. 13
  14. 14. Sexuality in Childhood  2 to 3 Years Solitary ,In-pair or Group sexual play. If parent give negative messages that it dirty Children take literal meaning of “Dirtiness” paving to later life sexual difficulties.  4 Years Has vague and magical notations about child birth. Ask many questions .  5 Years Fascinated with learning words about sex parts and; jokes about sex and genital functions, although do not understand.  6 to 7 Years Have clear anatomical differences between sexes. Become modest to show body to others. Sex plays in two thirds occurs, also involving siblings. 14
  15. 15. Sexuality in Childhood contd..  8 to 9 Years Has knowledge of erotic element in sex plays. Sexual fantasies, falling in love occurs. Learn to relate others leading to development of adult psycho-sexual adjustment.  Up to 12 Years – Indulge infrequently (and less important in meaning)  many types of sexual activities like masturbation, Hetero or Homosexual activities. Few also has sexual activities including Animal or Object, Sometimes Oral or Anal sex  Why we do not remember ??  Ernest Borneman – Puberty characterized by a special amnesia “Blocked Memories” about prior sexual experiences. 15
  16. 16. Sexuality in Puberty  Sexual fantasies and dreams are common, often accompanied by masturbation.  Fantasy add pleasure of sexual activity- a substitute to real but unavailable experience, that induce arousal or orgasm and provide form of mental rehearsal for later life real sexual experience and provide a safe, controlled un- embarrassing means of sexual experimentations.  It also paves path for later sexual existence & confidence.  Patterns of Sexual behaviour Masturbation Petting Intercourse Homosexuality ( Generally isolated or transient episodes) 16
  17. 17. Early Adulthood (20 to 40 Years) Sexuality  More driven by internal need to become more sexually knowledgeable and has more sexual opportunities.  Conflicts may arise due to attitude of sexual guilt carried over from earlier age.  Coming out for Homosexuals – associated with marked dysfunction.  Pregnancy : sexual desire may vary between individuals. Ist Trimester : Nausea, Vomiting and fatigue –Aversion IInd Trimester: Increase in Desire & Physical response in 80% IIIrd Trimester: Drop in in frequency of intercourse  In married couple Integration between burden of needs and responsibility may fail leading to sexual dysfunction. Extramarital affairs may sprout and divorces may arise due to sexual dysfunction. 17
  18. 18. Middle Adulthood(40 to 60 Years)Sexuality Midlife Crisis:-for most-life must be reappraised in terms of Goals, accomplishments and experiences-as a result midlife crisis begins to take shape.  Male – more vulnerable and are at “over the hill” position. Once start questioning about sexual capabilities, the odds are that he will experience difficulty getting or keeping an erection.  Female – Those who remain mothers mostly, children attain independence leading to “empty nest syndrome”. These changes causing depression and listlessness that may coincide with menopause .  However leaving children gives couples a chance to their own interactions and opportunities for freer more relaxed sex.  Sexual Burnout – Stems from tedium and satiation with same sexual routines, marked by sense of depletion, emotional emptiness and negative self-concept. Although most recover over time, 10% remain sexually inactive. 18
  19. 19. Late Adulthood ( 60 + Years) Sexuality Biological Considerations in Male Sexual organ atrophy Diminished testosterone level Delay in attaining erection Erection of poor quality Longer delay in achieving and maintaining erection Decline in intensity of orgasm Reduced desire 19
  20. 20. Late Adulthood( 60 + Years) Sexuality Biological Considerations in Female Loss of elasticity in breast tissue and loss of breast dimensions Cervix and uterus shrink in size Walls of the vaginal canal atrophy Vaginal length and width decrease Decrease in vaginal lubrication Sex steroid starvation may indirectly affect sex drive 20
  21. 21. Causes of Sexual Dysfunction in Late Adulthood Numerous factors contribute to a varied and complex aetiology.  Biological Changes Of Ageing,  Negative Cultural Expectations,  Medical Or Surgical Problems  Effects Of Drugs  Mental Illnesses -Depression, Psychosis, Dementia  Availability of Partner 21
  22. 22. Physiology of Coitus Excitement Plateau Orgasm Resolution 22 All show Age related Changes
  23. 23. The human sexual response cycle
  24. 24. Definition Sexual Dysfunction- Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. Sexual response is a psychosomatic process and both psychological and somatic processes are usually involved in the causation of sexual dysfunction. Male Sexual Dysfunction  Erectile Dysfunction or Impotence  Premature Ejaculation  Ejaculatory Incompetence Female Sexual Dysfunction  Vaginismus  Anorgasmia  Dyspareunia 24
  25. 25. Erectile Dysfunction Erectile dysfunction or impotence- Is the inability to have or maintain an erection that is firm enough for coitus. Classification  Primary ED- Never been able to have intercourse  Secondary ED – Has succeeded to have intercourse before dysfunction began  ED can occur at any age.  Total absent of erection is infrequent  Partial erection - that weak for vaginal insertions  Firm erections - that quickly disappear if intercourse is attempted ED with normal erections – Changed partner, Changed sexual pattern(Intercourse/ Masturbation) 25
  26. 26. Erectile Dysfunction contd..  Isolated episodes of having no erections or loosing an erection at an inappropriate time are so common that they are universal occurrence among men.  So Masters and Johnson classified a man as secondarily impotent only if his erection problems occurred in at least 25 percent of his sexual intercourse.  Isolated episodes may be due to -  Fatigue  Distraction  Inebriation ( drunken )  Acute illness  Transient anxiety  Lack of privacy 26
  27. 27. Erectile Dysfunction contd.. • Fears of sexual performance- – Will I loose my erection? – Will I satisfy my partner? Are likely to dampen sexual arousal and cause of loss of erection. The stronger and more insistent such fears become the man will experience an actual inability to get and keep an erection. On long term basis, it will lead to-  Avoidance of sex,  Loss of self-esteem,  Anxiety to overcome ED– sex becomes performance 27
  28. 28. Erectile Dysfunction Cycle Erectile Dysfunction Performance Fear Spectator Role Distraction Loss of Erection 28
  29. 29. Etiology of ED Anatomical causes Congenital Deformities Testicular Fibrosis Cardio-Respiratory causes Coronary or pulmonary insufficiency, MI Drugs Alcohol, Beta blockers Anti-depressants, Amphetamines Antiandrogens , Monoamine oxidase inhibitors Nicotine, Narcotics Barbiturates Cimetidine, Clonidine Endocrine Causes Diabetes Age related decline in T Hyperprolacteinemia Genitourinary causes Phimosis, Priapism Hematological Causes Sickle cell anemia Acute and chronic Leukemia's Infectious cause Elephantiasis, Urethritis Mumps Genital TB Neurologic Causes Cerebral Palsy Spinal cord transection or tumors Multiple sclerosis PID Vascular causes Thrombotic obstruction Aneurysm Arteritis Impaired blood flow Miscellaneous causes CRF, Cirrhosis, Obesity 29
  30. 30. Psychogenic ED Developmental Factors Maternal or paternal dominance Conflicted parent-child relationship Severe negative family attitude toward sex Child abuse Traumatic coital experience Gender identity conflict Cognitional factors Acceptance of cultural myths Paraphilias Affective actors Anxiety- performance and size Guilt Depression Poor self esteem Hypochondria Fear of VD Interpersonal factors Poor communication Hostility toward partner Lack of physical attraction to partner 30
  31. 31. 31 History & Physical Examination Eliminate Causes (drugs, alcohol, diabetes, thyroid disease) & Reassess Improved Not ImprovedLikely to be Organic Likely to be Psychogenic Refer for Psychotherapy Not Improved Improved Organic impotence etiology? Measure Testosterone level Further Evaluation? Measure LH & Prolactine Level Low Normal LH & Prolactine Endocrinology referral for HPG axis LH & Prolactine Normal Testosterone Improved Refer Urologist No NPT Test Abnormal PBI vascular testing ;Neurologic testing Vascular or Neurologic ED Normal Consider surgery : prosthesis or revascularization
  32. 32. Treatment of ED Penile prosthesis • Noninflatable, semi rigid devices • Inflatable devices Drug treatment • Yohimbine • Oral phentolamine • Apomorphine sublingual tablets • Intracaversonal injection of vasoactive drugs • Intraurethral insertion of prostaglandin • Use of vasoactive cream • Sildenafil Citrate, Tadalafil, Vardenafil 32
  33. 33. Treatment of psychogenic ED Sex therapy is indicated if counseling attempts have not reversed the dysfunction. Sex therapy ideally includes both the impotent man and partner, since therapeutic cooperation of the wife appears determinant of the outcome of therapy. Patterns of communication within the relationship as well as related behavior occurring between therapy sessions. Psychotherapy 1. lt is not useful to blame one's partner or oneself for the occurrence of dysfunction. 2.There is no such thing as an uninvolved partner when sexual difficulties 3.Sexual dysfunctions are common problems and do not usually psychopathology always. is not always possible to be certain of the precise origin of a sexual dysfunction, but treatment can frequently proceed successfully even when knowledge is lacking. 5.ln general, cultural stereotypes about how men and women should behave or function sexually are misleading and counterproductive. 33
  34. 34. Treatment of psychogenic ED contd.. 6. Sex is not something a man does to a woman or for a woman; something a man and a woman do together. 7. Sex does not only mean intercourse, apart from procreative purposes; is nothing inherent in coitus that makes it always more exciting, or more valuable than other forms of physical contact. 8. Sex can be a form.of interpersonal communication at a high intimate ; when sexual communications are not satisfactory, it often indicates aspects of the relationship might benefit from enhanced communication as well. 9. Using past feelings or behaviors to predict the present is not likely helpful, since such predictions tend to become self-fulfilling freedom to change. l0. Developing awareness of one's feelings and the ability to communicate feelings and needs to ones partner sets the stage for effective sexual interaction. 11.Assuming responsibility for oneself rather than delegating this responsibility to one's partner is often an effective means of improving the sexual relationship. 34
  35. 35. Premature Ejaculation  Although premature ejaculation is a common sexual dysfunction, there is no precise definition of this problem that is clinically satisfactory at present; partly because of the relative nature of the timing of ejaculation in the context of the female partner's sexual response cycle.  Masters and Johnson not consider it a problem, unless it occurs 50% or more of the times coitus is attempted.  If the man's rapid ejaculation limits his partner's ability to reach high level of sexual arousal or orgasm, then a problematic situation do exist.  Male who persistently ejaculates unintentionally during non coital sexual play or while trying to enter his partner has a greater problem(10%) 35
  36. 36. Premature Ejaculation contd… Etiology-  Ejaculation is a reflex phenomenon regulated by neurologic and possibly endocrine pathways.  Common historical cause - First coital experiences under circumstances of fear or being encouragement for rapid ejaculation from a prostitute  In effect, the man became conditioned to fast ejaculation and in subsequent sexual encounters he was often unable to alter the pattern that has been established.  Thus primarily it is psycho physiologic disorder.  Some authors have suggested that; relationship problems, unconscious hostility toward or fear of women, or hidden female sexual arousal problems are all processes underlying premature ejaculation. But these dynamics appear infrequently in couples seen by Masters and Johnson. 36
  37. 37. Premature Ejaculation contd… Although the precise neurophysiologic events that trigger ejaculation in the male are not known, a program of reconditioning the ejaculatory reflex response can be easily undertaken. Couple therapy 1) Discuss physiology of ejaculation. 2) Squeeze Technique- When genital touching is begun the women puts her thumb on the frenulum of the penis and places her first and second fingers just above and below the coronal ridge on the opposite side of the penis. A firm grasping pressure is applied for four seconds and then abruptly released. Pressure is given from back to front never from side to side. Use pads of fingers and thumbs and avoid pinching the penis or scratching with nails. 37
  38. 38. Premature Ejaculation contd…  For unknown reasons the squeeze technique reduces the urgency to ejaculate (and it also may cause temporary partial loss of erection).  It should not be used at the moment of Ejaculatory inevitability.  Can be used whether penis is erect or flaccid.  When couple begins having intercourse the women is asked to use the squeeze three to six times before attempting insertion. Once the penis is fully inside her she should hold still for fifteen to thirty second period with neither partner thrusting and then move off the penis apply squeeze again and reinsert. This time slow thrusting pattern can begin. 38
  39. 39. Premature Ejaculation contd…  Once the man improves his ejaculatory control both partners are taught the “Basilar squeeze”, so that the intercourse need not be interrupted by repeated dismounting to apply squeeze.  Kegel exercises is to improve muscle tone by strengthening the Pubococcygeus muscle of the pelvic and aid in reducing premature ejaculation in men.  Drugs that increase serotonin signaling in the brain slow ejaculation and have been used successfully to treat PE.  These include selective serotonin reuptake inhibitors (SSRIs), Paroxetine and Clomipramine. 39
  40. 40. Ejaculatory incompetence • Infrequent, generally below age of 35. • Primary-Never been able to ejaculate in vagina. • Secondary-men who have lost the ability to ejaculate intra vaginaly or who do so infrequently after prior history of normal coital ejaculation. • In 85 % ejaculation is possible by masturbation or by non coital partner stimulation. (50%) • In 15% ejaculation occurred only in nocturnal emissions. • It may be partner relative. • Ej. Incompetence may be source of pleasure as it permits prolonged periods of coitus. • Women may feel their partner do not find her attractive or withholding of orgasm is sign of selfishness. • In Procreational sex – it can be frustrating. • Only in 5% drug use and neurological disorders can be attributed. 40
  41. 41. Ejaculatory incompetence Theropy • In depth attention to underlying psychological components combined with sensate focus experiences that seek to lead the man through a sequence of 1) Ejaculating by masturbation while alone 2) Ejaculating by masturbation in presence of his partner 3) Ejaculating by manual stimulation received from his partner 4) Having the partner stimulate the penis vigorously to the point of ejaculatory inevitability ad then quickly inserting in the vagina. • With ejaculating once or twice intra vaginally, fears or inhibitions about this act disappear completely. • Where sequence has not worked it may helpful to have the man ejaculate externally onto women's genitals. After he becomes used to seeing his semen in genital contact with his partner, intravaginal ejaculation may occur more easily. 41
  42. 42. Retarded ejaculation • Seen in all groups, 2 to 3 times common than Ejaculatory Incompetence. • It may be source of sexual enjoyment but prolonged periods of coital thrusting required to bring about ejaculation are uncomfortable both physically and mentally. • Women may become resentful • However both Ejaculatory Incompetence and retarded ejaculation may be isolated. And causes may be fatigue, tension, illness, too much sex in short time, effects of alcohol or other drugs, or when man do not like partner but he feels its expected from him. 42
  43. 43. Sexual dysfunction in Rape Masters and Johnson has reported a fascinating study of 101 rapist.  Of these Erectile dysfunction occurred in 27 men.  Premature ejaculation occurred in 5 men.  Ejaculatory incompetence was seen in 26 cases. • Thus rape is not primarily an act of sexual desire. • 58 % of the rapist in this study were sexually dysfunctional.  Ejaculatory incompetence high rates signifies there preoccupation with expressing power in rapist or anger inhibits their sexual responsiveness.  Second point- Absence of semen in rape victim is not required?? So those acquitted on this ground can be prosecuted and also others, those who prematurely ejaculated. 43
  44. 44. Vaginismus  Vaginismus is a condition in which the muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration.  Less that 10% of female dysfunction cases.  Occurs at any ages and severity varies.  Less severe but considerable distressing is- pelvic pain  In milder form women may have intercourse but only with some discomfort.  Most women do have little or no difficulty with arousal.  Vaginal lubrication occurs normally, non coital play may be pleasurable and satisfying, orgasms may be unaffected. 44
  45. 45. Vaginismus contd..  Effects- Male partner thinks he is hurting her Becomes more passive, ED may develop Procreative sex not possible.  Causes-Mainly psychosocial problem However any of the organic cause of dyspareunia can condition a women into vaginismus, as a natural protective reflex.  Even when underlying organic problem is treated vaginismus may remain ,particularly when it has been present for a long period of time. 45
  46. 46. Vaginismus contd.. Treatment- Explain the nature of involuntary reflex muscle spasm to couple and demonstrating the reflex in carefully conducted pelvic examination with male partner and women urged to watch by use of mirror. Techniques for relaxing muscles around vagina- First deliberate tightening and simply let go. Various sized plastic dilators are used. First physician insert smallest dilator. Women is shown how to insert the dilator herself using plenty of sterile lubricating jelly and advised to practice this at home several times a day, keeping the dilators in place for ten to fifteen minutes at a time. Most women can use largest dilator by end of 5-6 days, that is of erect penis thickness. 46
  47. 47. Anorgasmia • Primary anorgasmia –women who were never had an orgasm. • Secondary anorgasmic women who were regularly orgasmic at one time but no longer are. • Situational anorgasmia- women who have had orgasms on one more occasions but only under certain circumstances-may orgasmic during masturbation but not when stimulated by partner. • Coital anorgasmia- Women who have orgasm in other that coital act • Random anorgasmia- Women who have experienced orgasms in different types of sexual activity but only on an infrequent basis 47
  48. 48. Anorgasmia contnd.. • Some anorgasmic women get little pleasure out of sex and see it as an obligation of marriage or a means of maintaining a relationship. • Other anorgasmic women find that sex is stimulating and satisfying. • Not having orgasm can create fears of performance that propel women into spectator role, dampening her overall sexual responsiveness. • Anorgasmia also leads to less self esteem, depression and sense of futility. • The male partner may feel threatened as they may assume that it is their responsibility to make their partner orgasmic. 48
  49. 49. Anorgasmia contnd.. • Treatment of anorgasmia depend greatly upon nature of dysfunction • A women with poor body image may be helped to find various ways of regarding her body more positively. • A women who is distracted from high levels of arousal by disturbing fantasies might be taught though blocking. • Women who can not go beyond plateau be encouraged to experiment with fantasies. • Dealing with performance issue with partner to curtail spectator role Reducing inhibitions. that limit the women's arousal or orgasm. • Masturbation or stimulation by partner. • Bridging technique – stimulation of clitoris. 49
  50. 50. Other approaches to sex therapy • Stop-start Method- by James seman • Manual penile stimulation-stopped as man reaches to ejaculation rapidly so the sense of ejaculatory urgency disappears. Stimulation then begins again. • Behavioural Theorpy 50
  51. 51. Andropause Greek ; “Andras” =human male “Pause” = cessation Other Names Male Menopause Male Climacteric Androclise Androgen Decline in the Ageing Male (ADAM) Partial Androgen Deficiency in Ageing Male (PADAM) Ageing Male Syndrome (AMS) Late Onset Hypo-gonadism • A syndrome in which the changes accompanying ageing are associated with the signs and symptoms of androgen deficiency in the older male (traditionally age >50). • Signs and symptoms are accompanied by a low serum testosterone level.
  52. 52. Testosterone levels with Age Hypogonadism in aging men. Total testosterone less than 11.3 nmol/L (325 ng/dL) (shaded bars). Total testosterone/SHBG (free T index) less than 0.153 nmol/Ls (striped bars). Numbers above each pair of bars indicate the number of men who were studied.
  53. 53. Signs and Symptoms of the Andropause Endocrine • Erectile dysfunction • Reduced erectile quality • Diminished nocturnal erections Somatic • Decreased vigor • Easily fatigued • Poor exercise tolerance • Diminished strength and muscle mass • Decrease in bone mineral density Sexual • Decreased Libido • Decreased Sexual Activity • Limited Quality Of Orgasm • Reduced Ejaculate Strength • Reduced Ejaculate Volume Psychological. • Mood changes • Poor concentration • Loss of motivation • Reduced initiative • Memory impairment • Anxiety, Depression, Irritability, Insomnia
  54. 54. Diagnosis of Late Onset Hypogonadism  Screening beginning age 50 or 55  Exclude -Sexual dysfunction is due to psychological or local pathology  If total testosterone (T) <200ng/dL - hypogonadism is present regardless of age  If total T 200ng/dL to 400ng/dL, obtain free T  Once T deficiency is established, obtain LH and prolactin
  55. 55. Medications and low T Decrease Leydig Cell T Production Corticosteroids Ethanol Ketoconazole Bind to the Androgen Receptor Spironolactone Flutamide Cimetidine Decrease Gonadotropin Secretion Corticosteroids Ethanol Estrogens Progestins Rx That Raise Prolactin (Opiates, metoclopramide, s) Decreases Conversion of T to DHT Finasteride
  56. 56. Available T Preparations a) Oral preparation that is available in capsule form. It needs to be given one to three capsules daily. b) Transdermal Testosterone given as testosterone gel preparations. It need to be applied any part of skin once a day. c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses. d) Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective. e) Local application of D.H.T. gel available as Andractim gel is a new preparation for male hormone replacement. f) Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days. g) Long acting testosterone as testosterone bucilate given once in 4 months. h) Testosterones implants are now available which once injected remain effective for up to six months.
  57. 57. Menopause • Menopause - permanent cessation of menstruation resulting from loss of ovarian follicular activity. • Perimenopause (climacteric) – The period immediately prior to the menopause (when the endocrinological, biological and clinical features of approaching menopause commence) and at least the first year after the menopause. • Postmenopause - dates from the menopause, although it cannot be determined until after period of 12 months of spontaneous amenorrhea has been observed. 57
  58. 58. 58
  59. 59. Age • Usual age 45 to 50 yrs average being 47yrs. • Premature menopause - before 40 yrs • Late menopause – menstruation beyond 52 yrs • Delayed menopause – Due to good health and better nutrition. – Also seen in women with uterine fibroids . – Also in women with high risk of endometrial cancer • Menopausal age is directly associated with smoking and genetic disposition. • Smoking induces premature menopause 59
  60. 60. Pathophysiology • During climacteric, ovarian activity declines. • Initially, ovulation fails, no corpus luteum forms and no progesterone is secreted by the ovary. • Later, graffian follicle fails to develop, estrogenic activity decreases and endometrial atrophy leading to amenorrhea. • Increased secretion of FSH and LH by anterior pituitary. • Other Causes • Surgical menopause or radiation. • Chemotherapy esp. alkylating agents. • smoking., caffeine, alcohol. • Drugs related such as GnRH, heparin, corticosteroids and clomiphene(anti- estrogen) when given over prolonged period can cause estrogen deficiency. 60
  61. 61. 61 Hormonal changes over age in female
  62. 62. 62
  63. 63. • Anatomical changes SITE CHANGES Genital organs Atrophy and regression Ovary Shrink, surfaces: grooved , furrowed Plain muscle in fallopian tube: Atrophy Cilia Disappear Uterus Smaller Endometrium As basal layer: deeply stained stroma and a few glands 63
  64. 64. SITE CHANGES Cervix Smaller Vaginal fornices Disappears Vagina Narrow Epithelium Pale, thin, and dry: senile vaginitis Vulva Atrophy (+narrow vagina: dyspareunia) Skin of labia minora and vestibule Pale, thin, dry Labia majora Reduction in fat Pubic hair Reduced and grey Breast More pendulous(fat dep) Glandular tissue <5% Pelvic cellular tissue Becomes lax Ligaments supporting the uterus and vagina Lose their tone: prolapse of genital organs, stress incontinence of urine, and fecal incontinence 64
  65. 65. Symptoms • 60-70% women go through menopausal period without problems • Rest needs guidance and treatment 65 Treatment – 1) Counseling 2)Mild Tranquillizers 3)HRT
  66. 66. Hormone replacement therapy Not all women require HRT. 70-85% of women remain healthy need only good nutrition and healthy life style. Indications of HRT 1) Women having climacteric symptoms  Vasomotor symptoms  Urinary symptoms  Sexual dysfunction  Established osteoporosis 2) All asymptomatic high-risk women having  Premature menopause  Family history of osteoporosis  Poor diet, excess alcohol  CVD, Alzheimer's disease, colonic cancer  Corticosteroid & other medications  Low plasma estradiol 
  67. 67. Estrogen therapy Short term estrogen therapy 1) To relieve symptoms like; hot flush, night sweats, palpitations, disturbed sleep In smallest effective dose for 3-6 months Ethinyl estradiol(0.01mg),Evalon(1-2mg), Combined hormone therapy(femet). 2mg 17-β- estrodiol & 1mg of norethisterone acetate. 2) for dyspareunia, urethral syndrome and senile vaginitis Local estrogen cream(oestriol: 1/2g-everyday-10-12 days each month for- 3-6 months) Estring(vaginal ringreleases 5-10microgram 3 months) • Long term therapy: – For delaying osteoporosis – Reduce the risk of CV disease – Beyond 8-10 yr
  68. 68. Preparations of estrogen • Oral: - – Conjugated equine estrogen (CEE): 0.625 mg daily – Ethinyl estradiol : 0.01mg – Micronized estrogen : 1-2g • Transdermal (estradiol): - – Patches: contains: 3-4mg; releases 50 micro gm / 24 hour twice weekly. – Gel :for improving collagen in skin 75 micro gm / 24 hours daily. • Sub cutaneous implant (estradiol): - – 25 / 50 / 100 mg. 6 monthly.
  69. 69. THE RISKS OF HRT • Vaginal bleeding • Thromboembolism • Endometrial cancer if E2 is taken alone • Brest cancer due to progestogen if HRT is taken over 5yrs. • CHD in a women with CVD.
  70. 70. Progesterone • Role in HRT • Prevents endometrial hyperplasia. • Implant may replace oestrogen, where estrogen is c/I or sensitive • Prevents breast cancer • Improves bone mineral density – Primolut-N 2.5mg , – Medroxyprogestrone & duphaston – Mirena IUCD- levonorgestrel
  71. 71. PREMATURE MENOPAUSE • Def: ovarian failure occurring 2 SD in year before the mean menopausal age in the population. • Clinically: sec. amenorrhea for at least 3 months with raised FSH/LH & low E2 level in a women under 40 year of age. • Inc. 1% -be. 30yr-1:1000 • -at 35yr-1:250 • -be.40yr-1%
  72. 72. LATE MENOPAUSE • Def: cond. in which menstruation cond. beyond 52 year. • Late menopause occurs in women with fibroids and is seen in women who develop endometrial cancer. Often it is constitutional. Beyond 52 yr , endometrial biopsy is required to rule out endometrial pathology.
  73. 73. References 1) Human Sexual Response- William Masters & Virginia E. Johnson. Ishi press International,1664 Davidson Avenue, Suite 1B,Bronx NY 10453-7877,Reprint 2010. 2) acceseed on 28/05/2014. 3) A General Introduction to Psychoanalysis ,BY PROF. SIGMUND FREUD, LL.D. AUTHORIZED TRANSLATION WITH A PREFACE BY G. STANLEY HALL PRESIDENT, CLARK UNIVERSITY HORACE LIVERIGHT PUBLISHER, NEW YORK Published, 1920, by Horace Liveright, Inc. Printed in the United States of America. 4) THREE CONTRIBUTIONS TO THE THEORY OF SEX SECOND REPRINTING BY PROF. SIGMUND FREUD, LL.D. VIENNA AUTHORIZED TRANSLATION BY A.A. BRILL, PH.B., M.D. CLINICAL ASSISTANT, DEPARTMENT OF PSYCHIATRY AND NEUROLOGY, COLUMBIA UNIVERSITY; ASSISTANT IN MENTAL DISEASES, BELLEVUE HOSPITAL; ASSISTANT VISITING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES WITH INTRODUCTION BY JAMES J. PUTNAM, M.D. NERVOUS AND MENTAL DISEASE PUBLISHING CO. NEW YORK AND WASHINGTON 1920. 5) Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.Walker HK, Hall WD, Hurst JW, editors. Boston: Butterworths; 1990. 6) Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. J Clin Endocrinal Metab 2001;86:724–31; 73
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