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ED signals are needed to manage 'manopause'.

ST. LOUIS -- Managing the "manopause" involves pills, psychology, and patience, Dr. Arshag D. Mooradian said at the annual symposium of the Kilo Diabetes and Vascular Research Foundation.

Aging men experience a process somewhat analogous to the female menopause, involving dysfunction, hypogonadism, and emotional changes. Unlike the estrogen-deficient state in women, the manopause has no single etiology, noted Dr. Mooradian, director of the Division of Endocrinology, Diabetes, and Metabolism at St. Louis University.

In older men, androgen (testosterone) deficiency may cause symptoms such as low libido, fatigue, irritability, depressed mood, and even hot flashes.

Physical signs include decreases in muscle mass, bone mass, and testis size, along with visceral adiposity, gynecomastia, and anemia, said Dr. Mooradian, who is on the speakers' bureau for Bayer Corp., the maker of Levitra.

Of course, erectile dysfunction (ED) is what leads many men to seek medical care. The first step is to address underlying conditions such as hypertension, hyperlipidemia, peripheral vascular disease, diabetes, and depression. "Individuals with ED are very likely to have a severe underlying systemic vascular disease. They need to be worked up aggressively," he said.

Various questionnaires--such as the International Index of Erectile Dysfunction and the Sexual Health Inventory for Men--are available as first steps in assessing the problem, but simply asking the patient to describe his symptoms typically elicits the clinically relevant information.

Psychogenic ED and organic ED often overlap, with one having led to the other. Organic ED tends to develop gradually, leading to a lack of early morning erections that persists even during the most stimulating circumstances.

Psychogenic ED tends to occur suddenly and completely; the patient still has some erections in the morning, and the dysfunction tends to come and go, depending on partner and circumstantial factors.

Failure to initiate an erection may be neurogenic or psychogenic in origin, while failure to fill is probably arteriogenic. Failure to maintain an erection may indicate venous leak. Suspected vasculogenic disease can be evaluated via Doppler ultrasound, or occasionally pudendal arteriography for patients who are being considered for vascular surgery.

First-line treatments for ED include phosphodiesterase type 5 (PDE5) inhibitors, vacuum tumescence pumps, and sex therapy. Intracavernosal injections are second line (for obvious reasons), and surgical prosthesis is a distant third.

Three PDE5 inhibitors--sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)--are available. All are metabolized by the liver via the CYP3A4 pathway; vardenafil and sildenafil have alternative metabolic pathways, but tadalafil does not. The half-life of tadalafil (17.5 hours) is much longer than that of the other two (4.6 hours for vardenafil, 3.8 hours for sildenafil).

Patients who can perform light to moderate exertion (such as brisk walking) without chest pain are candidates for PDE5 therapy.

The drugs should not be used in patients taking nitrates or [alpha]-blockers (except for Flomax 0.4 mg), due to the risk for hypotension.

A PDE5 inhibitor can be started prior to measurement of the bioavailable testosterone level, which should be done in the morning.

If testosterone is low, measure luteinizing hormone (LH) and prolactin levels. If LH is elevated, the primary hypogonadism should be treated with testosterone.

If LH is normal or low and prolactin is elevated, the patient should be referred to an endocrinologist for evaluation of the pituitary.


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Title Annotation:Across Specialties
Author:Tucker, Miriam E.
Publication:Clinical Psychiatry News
Date:Feb 1, 2004
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