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Abstract on Sexual Health and Healing


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Abstract on Sexual Health and Healing

  1. 1. Abstract on Sexual Health and Healing By Nick Delgado PhD, CHT Overview of Female sexual health, orgasmic response, Testosterone Therapy, Estrogen clearance, Male Erectile Dysfunction, STD- Mind, Fitness, Diet, and biochemistry Physiologic balancing I. Sexual Pharmacology 1. Sexual dysfunction is highly prevalent in both sexes. Considerable progress has been made in the development of new pharmacological treatments since the approval of sildenafil in 1998. A variety of oral erectogenic agents are available or are in late-phase development, including centrally active dopamine agonists (e.g., sublingual apomorphine), peripheral nonselective alpha-blockers (e.g., oral phentolamine), and other phosphodiesterase type-5 inhibitors (e.g., vardenafil). 2. FEMALES: Despite the importance of sexuality for both men and women of all ages, only in the last few years’ extensive research has been carried out into female sexual problems. It has been discovered that sexual problems affect a considerable number of women each year, and this indicates the validity and necessity of further medical studies. Estimates of the number of women who have sexual dysfunction range from 19% to 50% in "normal" outpatient populations67-69 and increase to 68% to 75% when sexual dissatisfaction or problems (not dysfunctional in nature) are included.68-70 Currently, there are six major pharmaceutical therapeutic paths being pursued for treatment of female sexual disorders and/or postmenopausal symptoms. These include dopaminergic agonists and related substances, melanocortin- stimulating hormones, adrenoceptor antagonists, nitric oxide delivery systems, prostaglandins, and androgens. These drugs have recently been evaluated for the treatment of female sexual arousal disorder, although results to date have been inconclusive. We know that female genital sexual response is a combination of vasocongestive and neuromuscular events in the genital tract and pelvic floor, which are controlled in part by specific neurotransmitters. Other pelvi-perineal genital structures undergo vasculogenic changes, namely the labia, periurethral glands, urethra and the Halban's fascia, but much less attention has been paid to the role of these tissues in sexual response compared to the clitoris and the vagina. The most common etiologies of female sexual dysfunction are vasculogenic, neurogenic, hormonal/endocrine and muscologenic. The increasing various problems of female sexual dysfunction and the interest in the matter and the subsequent research are factors that keep the scientific community involved constantly active.
  2. 2. Device Assists Women to Reach Orgasm The FDA has approved the Eros Clitoral Therapy Device, a mechanical pump that draws blood to the clitoris to cause engorgement. Trials of the device in women with female sexual-arousal disorder resulted with 80% of the subjects able to achieve sexual satisfaction, with 55% of the subjects reporting they were able to reach orgasm more easily. SOURCE/REFERENCE: reported by Time 5/15/00 Vibrators –Hitachi, etc Help For Female Impotence The U.S. Food and Drug Administration has approved a device for treating female sexual arousal disorder, a condition characterized by the inability to reach orgasm, vaginal dryness, lack of clitoral sensation or diminished interest in sex. Previously, estrogen therapy and vaginal lubricants to relieve dryness were the main treatments available, but now UroMetrics Inc.'s Eros is the first FDA-approved product to address clitoral dysfunction. The device consists of a soft suction cup that is placed over the clitoris. The cup is attached via a tube to a handheld battery-operated vacuum. Women can turn the vacuum suction up or down as needed until the clitoris feels engorged, and then remove the device. In a study of 15 women with female sexual arousal disorder, 80 percent reported increased sexual satisfaction or orgasms after using Eros. However, the FDA cautions that the device will not work for every woman. It is approved to be sold by prescription only. SOURCE/REFERENCE: 5/6/00 Viagra Effective For Women With Sexual Dysfunction Related to Antidepressant Therapy Results of a study conducted by Detroit psychiatrist Dr. Albert Bayer, M.D., show unequivocally that the drug Viagra (sildenafil) is effective in treating women with sexual dysfunction related to antidepressant therapy. Although Viagra is commonly prescribed for erectile dysfunction in males, scientific evidence supporting its use for the management of antidepressant-induced sexual dysfunction in women has been relatively non-existent. In this unique study, 21 adult female patients with major depression were given ten 50 mg samples of Viagra and instructed to take one tablet sixty to ninety minutes prior to initiating sexual activity. After 90 days, the women demonstrated statistically improvement of both sexual dysfunction and depressive symptoms. Many of the women who participated reported sexual functioning in terms of arousal and intensity of orgasm as far greater than they had experienced at any prior time in their lives. Besides two women experiencing mild facial flushing and a third woman reported mild nasal congestion, no other adverse events were described. Furthermore, none of the subjects wished to discontinue Viagra due to adverse effects. SOURCE/REFERENCE: reported by , 5/9/00 Menopause Makes Women Eat More Results of a recent study may help to explain why many women put on weight after the menopause. Judy Cameron and colleagues at Oregon Health & Science University induced menopause in monkeys by removing the ovaries, and thus cutting off the animals' supply of the female hormone estrogen. Results showed that removing the ovaries made the animals' food intake increase by 67% and caused them to gain 5% of their body weight within weeks. The researchers say that the findings suggest that estrogen may affect the metabolism, or play a role in appetite control. SOURCE/REFERENCE: Reported by on the 13th November 2003.
  3. 3. 3. MALES. Pharmacological therapies have also been proposed for the treatment of premature ejaculation and hypoactive sexual desire disorder. Strong evidence exists for the value of serotonergic drugs (e.g., selective serotonin reuptake inhibitors) in the treatment of premature ejaculation. Further research is needed, particularly on the effects of these drugs on female sexual dysfunction. 4. Erection is basically a spinal reflex that can be initiated by recruitment of penile afferents, but also by visual, olfactory, and imaginary stimuli. The reflex involves both autonomic and somatic efferent and is modulated by supraspinal influences. Several central transmitters involved in the erectile control have been identified. Dopamine, acetylcholine, nitric oxide (NO) and peptides, such as oxytocin and adrenocorticotropic/alpha-melanocyte- stimulating hormone, seem to have a facilitatory role. Whereas, serotonin may be either facilitatory or inhibitory, and enkephalins are inhibitory. Peripherally, the balance between contractant and relaxant factors controls the degree of contraction of the smooth muscle of the corpora cavernosa and determines the functional state of the penis. Noradrenaline contracts both corpus cavernosum and penile vessels via stimulation of alpha(1)- adrenoceptors. Neurogenic NO is considered the most important factor for relaxation of penile vessels and corpus cavernosum. The role of other mediators released from nerves or endothelium has not been definitely established. ED may be due to inability of penile smooth muscles to relax. This inability can have multiple causes. However, patients with ED respond well to the pharmacological treatments that are currently available. The drugs used are able to substitute, partially or completely, the malfunctioning endogenous mechanisms that control penile erection. Most drugs have a direct action on penile tissue facilitating penile smooth muscle relaxation, including prostaglandin E (1), NO donors, phosphodiesterase inhibitors, and alpha-adrenoceptor antagonists. Dopamine receptors in central nervous centers participating in the initiation of erection have been targeted for the treatment of ED. Apomorphine, administered sublingually, is the first of such drugs. Uprima: a New Drug Treatment for Male Impotence A Food and Drug Administration advisory panel this week recommended approval of a new drug, Uprima, for male impotence. The drug, however, can have some serious side effects. Uprima takes a neurological approach to treating erectile dysfunction (ED); it works by raising levels of the neurochemical dopamine in a part of the brain that is believed to be important for male erections, and for this reason, it might not be effective for all forms of ED. The drug is supposed to be taken about half an hour before sex. It is placed under the tongue and allowed to dissolve into the mouth tissue. In month-long studies of 3,000 men, a 4- mg dose was effective 56 percent of the time, according to TAP Pharmaceuticals, manufacturers of prima. The 4-mg dose caused seriously low blood pressure and even fainting in one of every 30 men who took it. Five percent of the men also experienced nausea, vomiting, dizziness, sweating or sleepiness, and in some cases these side effects led to injuries from falling or, in one case, a car wreck involving a man who was driving when he became dizzy from the drug. The FDA panel is concerned because of the potential for cardiac patients and people with low blood pressure to be prescribed the medication. SOURCE/REFERENCE: Reported by 4/15/00 1. Testosterone
  4. 4. GENERAL DESCRIPTION: Although the decline in testosterone production as men age ("andropause") is not as dramatic as the drop in women’s estrogen production with the onset of menopause, testosterone decline is a serious issue for many older men. Among other problems, declining testosterone production is strongly associated with impotency and libido problems. ROLE FOR ANTI-AGING: Anti-aging benefits that have been associated with testosterone replacement therapy may include increased libido and sexual potency; improved erectile function; improved mood and increased feelings of well-being; decreased fatigue; increased red blood cell count; reduction of LDL cholesterol and overall cholesterol levels and strengthening of the bones. Results of research published in 2002 revealed that men who have higher levels of "bioavailable" testosterone - testosterone that is not bound to protein - appear to perform better on tests of mental performance than men with lower levels of the hormone. DEFICIENCY SYMPTOMS: Symptoms of testosterone deficiency include: reduced libido, fatigue or a decrease in physical stamina, difficulty in maintaining erections, memory impairment, weight gain, depression and anxiety, increased risk of heart disease, and decreased muscle mass THERAPEUTIC DAILY AMOUNT: Testosterone replacement needs to be managed by a physician to ensure that a patient receives only enough of the hormone to replenish lost levels. Many forms of administering testosterone have been developed, including intramuscular injections, suppositories, transdermal patches, attached to the midriff, thigh, or arm, as well as to the scrotum, oral micronized capsules, and sublingual lozenges. Oral administrations seem to be the least effective method. MAXIMUM SAFE LEVEL: Testosterone should only be supplemented under medical guidance. SIDE EFFECTS/CONTRAINDICTIONS: If testosterone replacement is administered to men with normal or near-normal levels of the hormone, any number of dangerous side effects may occur. Most notably, excess doses of testosterone may inhibit the body’s ability to produce testosterone. Testosterone replacement carries with it the risk of stimulating both benign and malignant prostate tumor growth. In addition, because it can reduce HDL cholesterol levels, testosterone replacement may be associated with an increased risk of coronary artery disease. Bright Light May Help to Boost Testosterone Levels Bright light could help men to boost their testosterone levels, a new study has found. Dr Daniel F Kripke, of the University of California at San Diego and colleagues found that exposing men to an hour of bright light before dawn led to increases in levels of luteinizing hormone (LH), which in turn boosts testosterone levels. For the study, Kripke studied 11 healthy men aged between 19 and 30. For the first part of the study all participants were woken at five am and exposed to either a bright light, or a low-wattage red light. For the second part, the groups were switched, so that the men who were exposed to bright light in the first part were then exposed to low light, and vice versa. Results showed that exposure to the bright light for just one hour led to a staggering 69% increase in LH levels. The researchers believe that the light treatment could be of benefit to men suffering from depression, and those with sexual dysfunctions caused by depression. SOURCE/REFERENCE: Neuroscience Letters 2003;341:25-28.
  5. 5. Male Sex Hormone Levels Show Seasonal Variation New research has revealed that sex hormone levels in men rise and fall with the seasons. Dr Anna-Maria Andersson and colleagues at Copenhagen University Hospital in Denmark, found that the levels of testosterone and luteinizing hormone (LH), the hormone that stimulates production of testosterone, peak in the heat of June and July and fall along with the temperature during winter and early spring. Whether or not seasonal changes in testosterone affect fertility or men's behavior remains unclear, however previous research has shown that people are more likely to conceive in June and August, and least likely to do so from January through March. SOURCE/REFERENCE: The Journal of Clinical Endocrinology & Metabolism 2003;88:932-937 High Levels of "Free" Testosterone Linked to Better Cognitive Performance Elderly men with higher levels of "free" or bioavailable testosterone in their blood score higher at tests of verbal and visual recall, and perform spatial tasks better than men with lower levels of the male hormone, according to researchers from the National Institute of Aging. Study co-author, Susan Resnick, Ph.D, concluded: "Based on our results, testosterone levels are associated with selective and very specific effects on some aspects of cognition, including memory." The findings suggest that "free" testosterone could be used to protect men with deficient levels of the hormone against cognitive decline later on in life. Data suggests that as many as 68% of men aged 70 and over have low levels of "free" testosterone. SOURCE/REFERENCE: Reported by the National Institute on Aging on the 4th November 2002 II. Overview of drugs currently available in the U.S. 1. Sildenafil – Viagra The most distributed oral agent worldwide. Shows a high efficacy safety profile with success rates for all etiologies between 50% to 80%. a. Advantages: First drug in this category as a PDE5 inhibitor with the longest track record of safety. b. Side Effects include headaches, flushing, dyspepsia (stomach indigestion), rhinitis (runny nose) and visual disturbances (seeing blue-green aura, changes in brightness and inability to discriminate color). It may also lower blood pressure too much if combined with other nitrate heart medications. Viagra Found to be Safe for Many A new, small study funded by the maker of Viagra, the blockbuster anti-impotence pill, has found the drug appears to be safe in men with existing heart disease. Dr. Howard C. Herrmann and colleagues at the University of Pennsylvania Medical Center in Philadelphia studied the heart rate, blood flow, blood pressure and other vital signs in 14 men, average age 61, before and after they ingested Viagra. All study participants had heart disease, showed severe narrowing of the arteries, and were referred to the hospital for angioplasty. The team reports that Viagra is safe for men with heart disease who are not taking medications containing nitrates (which have been linked to Viagra-related deaths). However, Dr. Herrmann points out this study did not look at whether Viagra and sexual activity are safe for men with unstable angina, who have had a heart attack, or have congestive heart failure. SOURCE/REFERENCE: The New England Journal of Medicine, June 1, 2000 2. Vardenafil – Another selective PDE-5 inhibitor with potentially higher selectivity and efficacy compared to sildenafil. Data from clinical trials show the same adverse events and success rates as sildenafil. a. Advantages: The percentage of successful intercourses was between 71% and 75% for the three-vardenafil doses. For the 20 mg dose,
  6. 6. 80% of the patients experienced improved erections (GAQ) compared to 30% for placebo. b. Side Effects: headache (7-15%), flushing (10-11%) and up to 7% for dyspepsia or rhinitis. 3. Tadalafil – “Cialis” Amplifies erectile function for up to 24 hours, allowing patients to engage in sexual activity for this period. Adverse events and success rates resemble those of the other two substances. Eli Lilly. Now approved by FDA in USA. a. Advantages: Faster action, last longer (up to 36 hours) without food or alcohol restriction and more selective to sex and vision, etc. than Viagra. b. Side effects: Headaches were the main complaint in those using tadalafil, affecting 5% to 11% of 149 patients. Other side effects included back pain (4%), nasal congestion (4%), myalgia/body pain (4%), flushing (4%) and dyspepsia or indigestion (7%). 4. Comparison of PDE-5 Inhibitors – Since the introduction of the PDE-5 inhibitor sildenafil four years ago, there has been a fundamental change in the treatment of ED. Intracavernosal or intraurethral injections of vasoactive substances or penile implants as mechanical aids now play hardly any part in it. The development of the PDE-5 inhibitors vardenafil and tadalafil prompts the question of whether and how these three substances differ in terms of their efficacy and adverse effects. Sildenafil has proven to be a very effective medicinal product. Studies with a follow-up period of up to 6 years have been conducted. The success rate of sildenafil varies in the group of ED patients with an organic underlying disease from 43% in patients who have undergone radical prostatectomy to 85% in patients with a neurological underlying disease, and amounts to an average 82% (range 43-85%, 100mg). In an evaluation of spontaneous reports of deaths associated with sildenafil, the FDA concluded that there was no deducible evidence of an increase in the mortality rate among sildenafil users compared to the general population. In fact, fewer deaths associated in time with the ingestion of sildenafil were reported than might have been expected purely statistically on the basis of the normal mortality rate for men in this age group. According to the initial studies conducted, vardenafil and tadalafil demonstrate efficacy data approximately comparable to those of sildenafil. As of yet, insufficient data are available to evaluate the adverse effects of vardenafil and tadalafil, particularly their long-term use and use in high-risk groups. Sildenafil has already been used by over 20 million men in over 110 countries and is one of the best-studied pharmacological substances available. This advantage in terms of knowledge and safety data makes sildenafil a safe and reliable treatment for patients with ED. 5. Penile Self-Injection Vasoactive drugs such as alprostadil (PGE1) are injected directly into the side of the penis or inserted by suppository directly into the urethral opening
  7. 7. just prior to sex to achieve an erection. Some people may experience painful erections, hematoma (bruising) and local fibrotic complications do occur in 4% to 12% of the patients. The use of a mixture of papverine and phentolamine or moxisylyte reduces the likelihood of painful erections. However, the incidence of fibrotic complications is higher than alprostadil at nearly 30% of patients. This type of therapy has a very high drop out rate of between 55% to 78% after 2 to 5 years. Nearly 10% of these people stopped injections because of the partner’s lack of satisfaction associated with having to plan sexual encounters and feeling that injecting was unnatural. III. Other medical treatments available (nonpharmacologic options) a. Penile implants – completely imitate the physiologic erection. b. Vacuum constriction device – safe and effective option for well-selected patients, however, 58% to 81% of people discontinued using the vacuum because of pain or discomfort from the constriction ring. Another reason for stopping was that women disliked the feel of a cold penis in the vagina due to hypoxemic (entrapped blood). Nearly 50% of the men had difficulty using the device. c. Infection rates and mechanical failures have been minimized due to recent research. d. Well accepted by the patients and their partners. IV. HERBS in the Treatment of Sexual Performance Despite the increasing availability of effective conventional medical treatments, plant-derived and herbal remedies continue to provide a popular alternative for men and women seeking to improve their sex life. Nevertheless, the efficacy of most herbal agents in treating sexual problems remains uncertain. Therapists and consumers alike would benefit from an increased understanding of commonly used herbal agents on the market, their purported or supported effects, and their potential side effects. To this end, we cataloged the major prosexual herbal agents currently sold in several representative health food stores. We also specify the sexual problem purported ameliorated by each herbal agent. Finally, we evaluate eight herbal agents commonly promoted for the treatment of sexual problems. This evaluation includes a review of the research supporting the use, efficacy, dose, adverse effects, contraindications, and possible mechanism of action of each. We conclude by commenting on the quality of current research, pointing out gaps in our knowledge, and noting the need for rigorous research and product control to adequately address questions regarding the efficacy of these agents. 1. Over-the-Counter Products: Updated herbal studies (transdermal and oral)
  8. 8. 2. Herbal remedies that are most desired-combine capsules of multiple herbs, transdermal cream for hormone therapy (Strength Energy liposome cream) and a PDE5 inhibitor. The herbs found to be most effective undergo multi- fractionation, which makes them more potent than any other herbal enhancer. The Kudzu herb increases NO-Nitric Oxide for the filling of blood to the male or female sex organs. The Epimedium increase libido, drive and interest in sex. The herbs are not denatured as typically occurs from traditional processing. The bio-identical hormones (DHEA, Pregnenolone, Androstendiol added liposome Cream, Strength Energy combined will raise free testosterone (aphrodisiac like effect increasing libido). It is suggested to take a low dose PDE5 inhibitor that clears enzymes to prevent the loss of erection. 3. Why they work: Transdermal cream Strength Energy with DHEA, Pregnenolone and prohormones from the Scottish Pine-Androstendiol and phytochemicals (DIM, Chrysin) increase testosterone and remove estrogen binding and blocking of receptor sites. See 3-26 reference below. 4. Multiple hormones, peptides and neurotransmitters that enhance the sexual experience. DHEA, Pregnenolone from Wild Yam Root, Androstendiol from Scottish Pine build the experience. Other factors such as Serotonin, Dopamine also play a role in response. See reference 38 thru 51 below. 5. Why most herbal products don’t work (denatured processing methods). The process of extraction is a sophisticated science perfected by Ultimate Medical researchers. Most extraction companies use outdated methods that literally destroy the key active ingredients. 6. Legal issues, high incidence of drug doping of herb products in Europe sold over $6 million, several million sold in the USA, were found to have Cialis (Eli Lilly Tadalafil- the equivalent of Viagra). One lab found 8 out of 10 herbal products tested and sold over the internet were found to have Sildenafil – Viagra. Some of these companies official line is that others tampered with their product. FDA Public Health Advisory: FDA Warns Consumers Against Taking the Following Dietary Supplements Today, the Food and Drug Administration (FDA) is warning consumers not to purchase or consume the following products: SIGRA, STAMINA Rx and STAMINA Rx for Women, Y-Y, Spontane ES and Uroprin, manufactured by NVE, Inc., in Newton, N.J. and distributed by Hi-Tech in Norcross, Ga. These products, which are being marketed as dietary supplements, actually contain a prescription drug ingredient that poses possible health risks. The products are being sold over-the-counter and are claiming to increase stamina, confidence and performance. FDA has determined that the products actually contain the prescription-strength drug ingredient, tadalafil. Tadalafil is the active ingredient in Cialis, an Eli Lilly product approved in Europe to treat male erectile dysfunction. An interaction between certain prescription drugs containing nitrates (such as nitroglycerin) and tadalafil may cause a drastic lowering of blood pressure. There is real danger that this product may be taken by patients taking nitrates since erectile dysfunction is
  9. 9. often a common problem in people with diabetes, hypertension (high blood pressure), hyperlipidemia (high cholesterol), ischemic heart disease and in people who smoke. FDA's Office of Criminal Investigations, with assistance from FDA’s New Jersey and Atlanta Districts, executed concurrent federal search warrants in Georgia and New Jersey after finding these dietary supplements. Consumers who have used these products and have medical concerns should consult with their health care providers. All consumers should be aware of the risks associated with these products. V. Physiology of Arousal 1. Masters & Johnson-correct stimulus response techniques 2. Touch receptors 3. Possibilities and how they can be achieved/enhanced. See references 67 to 70. VI. The psychology of sex The psychology of sex is not to be overlooked since the power of the mind does influence several biochemical pathways in men and woman. Timeline therapy which is a form of biofeedback with guided imagery has proven to free on of excessive feelings of guilt and or trauma form past experiences. This freeing effect allows for future positive encounters and a greater degree of satisfaction. VII. STD- prevention Herpes, warts, Aids, Tests etc. Condoms, oral sex References: Section I and II 1. Delgado, Nick PhD, # 1 Way to Fitness "Grow Young and Slim" Lake Forest CA, Health Wellness Studios, 2003. 2. Collins, Joe ND, What’s Your Menopause Type? Roseville, CA, Prima Health, 1999. 3 Muti, Paola, et al., Estrogen metabolism and risk of breast cancer: A prospective study of the 2OHE: 16-alpha- Hydroxyestrone ratio in premenopausal and postmenopausal women. Epidemiology, Nov., 2000, Vol. 11 No. 6, 635-664. 4. Michnovicz JJ. Changes in levels of urinary estrogen metabolites after oral indole-3carbinol treatments in humans. J National Cancer Inst.89 (10): 718-23, 1997. 5. Michnovicz JJ. Increased estrogen 2-hydroxyation in obese women using oral indole-3-carbinol. Int J Obese Relat Metab Disorder 22(3): 227-9, 1998. 6. Kall MA, Effects of dietary broccoli on humans in vivo drug metabolizing enzymes: evaluation of caffeine, estrone. Carcinogenesis 17(4):793-9, 1996. 7. Bradlow HL, Telang NT, Sepkovic DW, et al., "2-hydroxyestrone: The ‘good’ estrogen," Journal of Endocrinology 150 Suppl (Sept. 1996):S259-S265. 8. Lemon HM, Reduced estriol excretion in patients with breast cancer prior to endocrine therapy. JAMA 196(no 3), 1966. 9. Ursin G, A pilot study of urinary estrogen metabolites 16 alpha hydroxyestrone (OHE1) and 2-OHE-1 in postmenopausal women with and without breast cancer. Environ. Health Perspect 105(suppl 3): 601-5, 1997. 10. Brandi ML. Natural and synthetic isoflavones on the prevention and treatment of chronic diseases. Calicif Tissue Int 61 (suppl 1): S5-S8, 1997. 11. Ghanadian, R. and Puah, C.M., "The clinical significance of steroid hormone measurements in the management of patients with prostatic cancer," World Journal of Urology, 1983; 1: 49-54. 12.Geller, J. et al., "DHT concentrations in human prostate cancer tissue," JCEM, 1978; 46:440-4 13. Gustafsson, O. et al., "Dihydrotestosterone and testosterone levels in men screened for prostate cancer: a study of a randomized population," British Journal of Urology, 1996;77:133-140. 14. Suzuki, K. et al., "Endocrine environment of benign prostatic hyperplasia: prostate size and volume are correlated with serum estrogen concentration," Scandinavian Journal of Urology and Nephrology, 1995; 29:65-68. 15. Gann, P.H. et al., "A prospective study of plasma hormone levels, nonhormonal factors, and development of benign prostate hyperplasia," The prostate, 1995; 26:40-49. 16. Kaiser, F. et al., "Impotence and aging: clinical and hormonal factors," Journal of the American Geriatric Society, 1988; 36: 511-519. 17 b. Feldman HA et al., Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urology 1994; 151:54-61. 18 c. Davidson J et al., Hormonal changes and sexual function in aging men. J Clin Endocrinology Metab. 1983; 57:71-77.
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