Posts Tagged ‘cardiovascular disease’

ED and Good Health

April 10, 2017

Many men are unaware of the relationship between ED (impotence) and their overall health.  ED not only include ability to engage in sexual intimacy but also includes problems with libido, and abnormal ejaculation.

ED is defined as the consistent inability to attain or maintain a penile erection of sufficient quality to permit satisfactory sexual intercourse.

The process of diagnosis and treatment begins with a careful sexual history.  Men with a sexual problem will probably be asked:

  • Are you currently having sexual relations?
  • With whom do you have these relations (men, women, or both, and how many partners)?
  • When was the last time you had intercourse?
  • Are you satisfied with the quality and frequency of your sexual experiences?

The answers will clarify what aspects of sexual dysfunction are occurring and inform the rest of the evaluation. If libido is intact but ED is a complaint, then what underlying medical conditions or medications may be contributing to the problem? If libido is affected, are there significant psychologic or emotional contributing factors that need to be addressed as well as measuring the serum testosterone level.

Although sexual problems are not necessarily caused by aging; it is true that aging is associated with an increase in sexual issues. As early as 40 years of age, up to 40% of men report some impaired sexual function.  Inability to attain or maintain an erection consistently for satisfactory intercourse was reported in 67% of males over 69 years of age in another study.  Testosterone decline is common with age. While this may play a hormonal role in sexual dysfunction, it is important to thoroughly evaluate all possible causes before initiating testosterone replacement therapy for sexual dysfunction alone.

Similarly as men age, interest in sex may decline due to lack of novelty as well as an increase in stress that often occurs in older men. Fatigue, lack of privacy in the family setting, and unresolved anger with a partner may all be determinants of sexual problems in the older male. More critically, loss of interest in sexual activity and loss of libido may be manifestations of depression.  Depression can cause sexual problems, but the reverse may also be true.

In addition to these factors, diabetes, blockage of the blood vessels, and adverse effects from medications, both prescribed and recreational (marijuana and cocaine) may all play roles in sexual functioning. Disease states such as hypertension, diabetes, heart disease, and obesity can affect the blood flow into the penis. Blockage in any of the major arteries feeding the blood supply to the penis can lead to inability to obtain and maintain an erection. Diabetes, for example, this can also affect the mechanism of erection and cause ejaculatory disorders such as backward ejaculation of the fluid to the bladder instead of out of the tip of the penis at the time of orgasm.

Medications that are often identified as causes of erectile disorder which include medications used to treat depression, blood pressure lowering medications, cholesterol medications, and drugs used to treat prostate cancer.  Excessive alcohol use is the most common substance that can lead to ED, though cocaine, heroin, and marijuana have all been linked as well.

Bottom Line:  ED is a common problem affecting millions of middle age and older American men.  The diagnosis can often be attributed to underlying disease states.  A careful history and physical examination will help to elucidate the problem and start you on the road to successful treatment.

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Testosterone and Its Impact On the Heart-Here’s the Good News

October 22, 2014

I am frequently queried by my patients about the safety of using testosterone and the risk of developing heart disease or a stroke. I would like to give you the evidence from the medical literature, and then help you make an informed decision if testosterone replacement is right for you.

Men have more than twice the risk of dying from coronary disease than women. It has been assumed that testosterone is deleterious to the male cardiovascular system and contributes to the risk of heart disease. In fact, there is little evidence that testosterone produced in body by the testicles is an adverse risk factor but the role of testosterone status and replacement therapy on male health is controversial.

High doses of anabolic steroids often used by body builders and athletes are undoubtedly associated with cardiac disease but these are doses much higher than what the body normally produces. Testosterone levels within the normal range do not appear to be harmful. Indeed, low rather than high testosterone levels in men are associated with several cardiovascular risk factors including an atherosclerosis or hardening of the arteries, insulin resistance, and obesity.

Let me give you information first from animal studies where the scientists can control the variables. Studies in male animals have shown that castration or induced hypogonadism increases atherosclerosis and testosterone replacement prevents this. In addition, testosterone has beneficial effects in men with cardiac disease. Testosterone is a potent coronary artery vasodilator. Testosterone therapy reduces total cholesterol, fat mass, waist circumference and pro-inflammatory cytokines associated with atherosclerosis, diabetes and the metabolic syndrome. Testosterone also improves functional capacity of the heart and insulin resistance in men with heart failure.

In an ageing male population low serumotal testosterone is common and has a prevalence of 30% in men over the age of 60 years. Testosterone deficiency may cause undesirable effects such as loss of bone and lean body mass, increased adiposity, low energy and impaired physical and sexual function. Until recently, these effects were viewed as the natural physiology of aging; however, four recent major studies have found low testosterone to be associated with increased all-cause mortality after controlling for baseline morbidity and age.

The effect of testosterone on mortality has demonstrated an increased risk of death due to cardiovascular diseases in men with low testosterone. One report found that mortality due to any cause and cardiovascular mortality was increased with a reduction in serum testosterone. Low testosterone status is therefore associated with mortality and vascular mortality, yet no study has specifically examined patients with established cardiovascular disease. This is important because men with manifest coronary artery disease are at a higher risk of cardiovascular mortality and represent a patient population prone to testosterone deficiency. In addition, those men with angina, chronic heart failure or diabetes may derive particular symptomatic benefit from androgen replacement therapy.

This study had two aims: first to assess the impact of testosterone status on life expectancy in men with pre-existing coronary disease, and second to identify the prevalence of biochemical testosterone deficiency in men with coronary disease. Our hypothesis was that low serum testosterone would be associated with an adverse survival.

One excellent study that was peer reviewed showed that the prevalence of testosterone deficiency is common in men with coronary disease and is present in 25% of the men. The data have confirmed that low T is related to all-cause and vascular mortality in a coronary disease population. Therefore, the study also concluded that borderline low levels of T may also have an adverse impact on survival.

This study is entirely consistent with previous studies of low testosterone as a cause of decreased life expectancy.

What is the pathophysiology of low testosterone status and the apparent increased mortality of atherosclerotic disease? Animal data show that testosterone deficiency accelerates atheroma or atherosclerosis and replacement with testosterone prevents this. Human studies have shown an increased progression of atheroma in men with lower testosterone. These data therefore suggest that testosterone deficiency is associated with progressive atherosclerosis and replacement, in animals at least, prevents this progression of the heart disease.

We have demonstrated that testosterone deficiency is associated with premature death in male patients with vascular disease; many of these patients died and will continue to die from cardiovascular disease. There is scientific evidence and several documented trials showing benefit in terms of risk factor modification and symptoms. If androgen deficiency is part of the underlying pathophysiology of atherosclerotic disease in men, then the serum testosterone level could be viewed as a modifiable risk factor as men can increase the T level by testosterone replacement therapy. Physiological testosterone replacement is an inexpensive and well-tolerated therapy but does require careful monitoring.

Bottom Line: Testosterone deficiency is common in middle aged and older men. Low testosterone levels appear to cause men to be at an increased risk of cardiovascular disease and even increased risk of death. Hormone replacement therapy for men who are symptomatic may be protective of heart disease but these men require close follow up consisting of a PSA test, a digital rectal exam, and a blood count to check that there is not an increased production of red blood cells.

Recent Study Does Not Indicate Testosterone Use Doesn’t Increase Heart Risk

July 7, 2014

A few months ago an article appeared in the Journal of the American Medical Association (JAMA) that implicated testosterone as a cause of heart disease and stroke. But critics including several hundred physicians have attacked the study noting that among other things, the study including over 100 women among the 1,132 subjects studied. Over 25 international medical groups have demanded that JAMA retract the article.

A new study now points out that testosterone therapy didn’t increase the risk of heart attack, contrary to the JAMA study, and that it even lowered the risk of heart attack by about 30%.
In the latest study, published online in the Annals of Pharmacotherapy, researchers at the University of Texas Medical Branch used a national Medicare sample and compared the records of 6,355 men who had at least one testosterone injection between 1997 and 2005, with 19,065 non-testosterone users. The testosterone users were no more likely to have a myocardial infarction than the nonusers during the period, according to the study.

The researchers also ranked the subjects based on their predicted risk of heart attack for other reasons. For men in the quarter with the highest risk, the use of testosterone cut that risk by roughly 30%.

The latest study only at men receiving testosterone injections, not those using pills, patches or gels, and couldn’t assess what other medications the men were taking. Men typically lose testosterone as they age, and some conditions can cause a steep drop in levels earlier, leading to osteoporosis which increases the risk of hip and spine fractures, sexual dysfunction, loss of muscle tone, fatigue, diabetes and other health problems. Proponents say restoring normal levels can alleviate those issues.

Bottom Line: Testosterone deficiency or low T affects millions of American men. The diagnosis is easily made with a history of decreased libido, decreased sexual performance, loss of muscle mass and loss of energy or fatigue. The diagnosis is easily made with a simple blood test and can be helped with testosterone replacement therapy. For more information on testosterone deficiency speak to your doctor.

Erectile Dysfunction (Impotence)-a Dangling Stress Test

February 5, 2013

Erectile dysfunction (ED) or impotence may more than affect your relationship with your significant other. ED just may be a warning sign of impending heart disease.

Men with even mild erectile dysfunction — but no known heart problems — face a major extra risk of developing heart disease in the future. And as erectile dysfunction becomes more pronounced, signs of hidden heart disease and earlier death risk grow.

Not surprisingly, men already known to have a heart condition along with severe erectile dysfunction fare worst of all. Among men aged 45 and up without diagnosed heart disease, those with moderate or severe erectile dysfunction were up to 50 percent more likely to be hospitalized for heart problems. Erectile dysfunction boosted the risk for hospitalization with a diagnosis of heart disease.

Men with erectile dysfunction should take action by seeing a health professional and asking for a heart check.

An estimated 60 percent of men aged 70 and up suffer from moderate to severe erectile dysfunction. The condition can place major limits on sexual activity and require the use of drugs like Viagra, Levitra, or Cialis that can come with side effects.

A variety of causes can contribute to impotence, but it is widely acknowledged that erectile dysfunction is predominantly the result of underlying cardiovascular disease.

Doctors already believe that erectile dysfunction is an early warning sign of heart problems. The arteries of the penis are smaller than those of other parts of the body including the arteries to the heart and may be more likely to reveal problems when their lining deteriorates before heart symptoms occur.

Bottom Line: Men with severe erectile dysfunction, compared to those with no problem, were eight times more likely to have heart failure, 60 percent more likely to have heart disease and almost twice as likely to die of any cause.
 So before you ignore erectile dysfunction as occurring with age, think of your ED as a dangling stress test and see your doctor and get your heart checked out.