Hormonal Methods of Birth Control

Hormonal Methods of Birth Control

Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel Jr., MD, FACP, FACR

• Introduction to birth control
• Hormonal methods of contraception
• Oral hormones: the pill
• Injection: depot medroxyprogesterone acetate (DMPA)
• Contraceptive patch: Ortho-Evra
• Vaginal ring: NuvaRing
• Contraceptive implants
• Find a local Obstetrician-Gynecologist in your town

Introduction to birth control

If a woman is sexually active and she is fertile, meaning that she is physically able to become pregnant, she needs to ask herself, "Do I want to become pregnant now?" If her answer is "No," she must use some method of birth control (contraception).

Terminology for "birth control" includes contraception, pregnancy prevention, fertility control, and family planning. But no matter what the process is called, sexually active people can choose from a plethora of methods to reduce the possibility of their becoming pregnant. Nevertheless, no method of birth control available today offers perfect protection against sexually transmitted infections (sexually transmitted diseases, or STDs), except abstinence.

In simple terms, all methods of birth control are based on either preventing a man's sperm from reaching and entering a woman's egg (fertilization) or preventing the fertilized egg from implanting in the woman's uterus (her womb) and starting to grow. New methods of birth control are being developed and tested all the time. And what is appropriate for a couple at one point may change with time and circumstances.

Unfortunately, no birth-control method, except abstinence, is considered to be 100% effective.

Hormonal methods of contraception

There are several different hormonal methods of birth control. The differences among them involve

• the type of hormone,
• the amount of hormone, and
• the way the hormone enters a woman's body.

The hormones can be estrogen and/or progesterone. These hormones may be taken orally (taken by mouth), implanted into body tissue, injected under the skin, absorbed from a patch on the skin, or placed in the vagina. The mode of delivery determines whether the hormonal exposure is continuous or intermittent.

The different hormonal types of birth control are comparable in that they are all highly effective and all are reversible. However, none of the horm

Oral contraceptives: the pill

The pill for women is an oral contraceptive made from synthetic hormones. The pill is considered to be 97%-99% effective if used properly. The pill is also fully reversible. The pill has been available since 1960, and it is estimated that more than 10 million American women currently use birth-control pills.

There are two types of birth-control pills available:

• the combination pill and
• the minipill.

The combination pill

The combination pill contains the hormones estrogen and progestin, a form of progesterone. When a woman uses the combination pill, the eggs in her ovaries do not mature and she does not ovulate. She doesn't become pregnant because no egg is available to be fertilized by a sperm.

The traditional combination pill comes in 21-day packs or 28-day packs depending on the manufacturer. The 21-pill pack has pills for 21 "on" days and no pills for the seven "off" days that follow. The 28-pill pack has active pills for the first 21 "on" days and seven inactive (placebo) or reminder pills for the following seven "off" days.

New preparations have been developed that allow for extended or continuous use of combination pills. These products allow for a reduction in the number of menstrual periods a woman experiences.

The minipill

The minipill only contains one hormone, progestin. Progestin thickens the cervical mucus, making it more difficult for sperm to pass through the cervix. It also makes the lining of the uterus less receptive to the implantation of a fertilized egg. The progesterone-only pill is sometimes recommended for women who have medical reasons for which they must avoid taking estrogen hormones. (These reasons can include liver disease, certain types of blood clots in the veins, breast cancer, and uterine cancer.) In addition, it is often recommended in nursing mothers because it has no adverse affects on breastfeeding. Indeed, extended breastfeeding, as well as delay in the need for formula supplementation has been observed in breastfeeding users of the minipill.

The minipill is taken every day. There are no "on" or "off" days with the minipill.

No matter which type of birth-control pill a woman uses, she should take it every day at the same time in order to establish a routine. The woman needs to minimize the chance she will forget to take the pill, which is not an uncommon occurrence. This is especially critical in the case of the progestin-only pill (minipill). Forgetting to take the minipill, or taking it at varying times of the day, can significantly impair its effectiveness in contraception. This is due to the low dose of the minipill causing its effects to wear off rapidly if the pill is missed.

When a woman begins taking the pill, she may not protected from pregnancy until she has been taking the pill for 10 consecutive days in a row. If a woman forgets to take a pill after she has started, she may be at risk for getting pregnant.

If she only misses one pill, she should take it as soon as she remembers, even if it means taking two pills in the same day. If she misses two pills, she should take both of them as soon as she remembers, plus the pill for that day at her regular time. If she misses three pills, she should discontinue use of the pill for four more days to complete one week and then begin taking a new pack of birth control pills, whether she has a menstrual period or not. She must use an alternate form of birth control or abstain from sexual activity during the week that she stops taking her pills. If a woman continually forgets to take her pills, perhaps she should consider a different method of birth control.

The pill may partially lose its effectiveness if a woman vomits or has diarrhea for any reason. Some medications, including certain sedatives and some antibiotics such as penicillin and tetracycline, may reduce the effectiveness of the pill. Research in this area is ongoing. A woman should ask her health-care professional about these matters and the necessity of using a backup method of birth control if any of these conditions exist.

Some women experience temporary symptoms of spotting or light vaginal bleeding, breast tenderness, and nausea during the first one to three months of taking the pill. Nausea can be helped if the pill is taken after a meal. While women sometimes fear weight gain with oral contraceptives, studies of the low-dose preparations demonstrate that there is no significant weight gain with oral contraception and no major difference in weight change comparing various contraception products. Negative mood changes, such as depression, and pigmented patches of skin on the face (melasma) may occur with oral-contraceptive use. Because the progesterone in women can cause thinning of the lining of the uterus, some women may experience loss of menstrual periods (amenorrhea). Oral contraceptive-induced amenorrhea happens in about 1% of women in the first year of use. As long as the woman is properly taking her pills, amenorrhea is not harmful and it does not signal any loss of effectiveness of the pills. Most side effects from the combination pill or the minipill decrease after two to three months of use. It is important to remember that because most side effects of oral contraceptives decrease in the first two to three months of use, women should try to avoid switching pills prior to an adequate trial. Trying to stick with any given product for two to three months may be necessary to really determine whether or not it will be tolerated over time. Switching too early to another brand may only needlessly subject the woman to the possibility of similar side effects starting all over again with the new pill.

There is no increased risk of birth defects in babies born to women who have taken the pill, but a woman should not use either type of pill if she is pregnant. A woman who is breastfeeding should not use the combination pill because it can reduce the amount of her breast milk and the concentration of proteins and fat in her breast milk. Additionally, her breast milk will contain traces of the hormones from the pill. However, in contrast to the combination pill, the minipill is routinely used in lactating women.

Women who smoke and take the pill are at increased risk of heart disease and stroke. There is no increased risk of heart attack or stroke among healthy nonsmoking women who use the pill. Blood clots in the legs and elsewhere are slightly more frequent with low-dose oral contraceptives, but the risk is very low, and lower than the increased risk of clotting that occurs with pregnancy. Nevertheless, oral contraceptives are not recommended for women with clotting tendencies (such as cardiolipin antibody associated clotting), known coronary heart disease, stroke, unevaluated breast lumps, vaginal bleeding, or breast cancer. Smokers over 35 years of age should not use oral contraceptives, nor should women with a significant liver disorder.

A woman should contact her health-care professional immediately if she experiences any of these side effects while taking the pill:

• severe headache;
• leg cramps;
• change in vision, including blurred vision, vision loss, or flashing lights;
• abdominal pain;
• chest pain;
• shortness of breath;
• coughing up blood; or
• leg swelling or pain.

There are a number of benefits to taking the pill. Both the combination pill and the minipill can regularize a woman's menstrual cycle and reduce her menstrual flow andmenstrual cramps. There is evidence that the pill protects against cancer of the ovary and uterus as well as pelvic inflammatory disease (PID) and iron deficiency anemia. The combination pill can reduce acne (although maximal acne reduction may take six months to occur), the risk of an ectopic pregnancy, noncancerous breast cysts, andovarian cysts. According to a large study, the combination pill confers no long-term risk of breast cancer. In addition, a woman who has taken the pill is less likely to develop rheumatoid arthritis and osteoporosis. Users of oral contraceptives have experienced significant decreases in excessive menstrual flow and in occurrence and severity of menstrual cramps.

A woman's menstrual periods should begin again within about six months of stopping the oral-contraceptive pill. However, the length of delay before a woman's period returns after stopping the pill varies from woman to woman. Oral contraceptives are about 97% effective in preventing pregnancy. The pill does not protect a woman against sexually transmitted infections.

Injected contraceptive: depot medroxyprogesterone acetate

Depot medroxyprogesterone acetate (DMPA) is a synthetic long-acting form of the hormone progesterone. DMPA is similar to the birth-control minipill in that it does not contain estrogen. Like other progesterone-based contraceptives, DMPA acts by preventing the release of the egg from the ovary (ovulation) and by promoting thick cervical mucus that impedes the sperm's progress. Its effectiveness in preventing pregnancy is close to 100%.

DMPA must be injected by a health-care professional every three months (12 weeks). Preparations are available both as intramuscular or subcutaneous (beneath the skin) injections. The injection must be administered within the first five days of a woman's menstrual period. She is then protected from pregnancy within 24 hours of receiving the injection.

A woman may stop having periods altogether after using DMPA for one year. After two years of use, 70% of women will have no menstrual bleeding. Menstrual periods stop because the DMPA causes the ovaries to go into a "resting" state. When the ovaries do not release an egg every month, the regular growth of the lining of the uterus does not occur and no uterine lining is shed during the subsequent menstrual cycle.

A woman's menstrual periods should begin again within six to 18 months after she stops taking the injections. A woman can also become pregnant, usually within 12 to 18 months, once she stops using DMPA. If a new mother does not breastfeed her baby, she can resume the injections right after childbirth. Mothers who are breastfeeding can safely begin the injections six weeks after childbirth. The injections do not reduce the flow of her breast milk, and no harmful effects on the baby have been noted.

The most common side effects of DMPA injections are irregular menstrual cycles, cessation of menstrual periods, and weight gain. Other side effects may include nervousness, dizziness, stomach discomfort, headaches, fatigue, or breast tenderness. It is important that a woman realize that once she has been injected with DMPA, any side effects she may experience cannot be neutralized or eliminated. She has to tolerate these side effects until the medication wears off, typically three months later.

DMPA has also been shown to have a negative effect on bone mineral density, especially with longer-term use; however, studies have shown that her previous bone density is usually restored when the drug is discontinued.

Women may be able to use DMPA when avoidance of estrogen is prudent for medical reasons (see oral contraceptives). A qualified health-care provider should be able to help make the proper distinction. DMPA should not be used by women who have a history of breast cancer, blood clots, liver disease, unexplained vaginal bleeding, or stroke. A woman on DMPA should contact her health-care professional if she experiences a heavy menstrual flow, severe abdominal pain, headaches, or depression.

DMPA injections are over 99% effective if the injections are received according to the correct schedule. A woman using injection contraceptives has the advantage of being capable of becoming pregnant at a later time, if desired, simply by discontinuing use. DMPA does not increase a woman's risk of cancer, including breast cancer, and greatly reduces her risk of developing uterine cancer.

Injectable hormonal contraceptives do not protect against sexually transmitted infections.

Contraceptive patch: Ortho-Evra

An adhesive patch has been developed that provides hormonal contraception through the skin, which is known as a transdermal (through the skin) delivery system. The patch is about the size of a half-dollar and can be worn on the arm, abdomen, or buttocks. A woman wears the patch for a week and then replaces it with a new patch.

These patches, called Ortho-Evra (ethinyl estradiol/norelgestromin patch-topical), are similar to the pill in that they contain both estrogen and progesterone. Ortho-Evra should be just as effective in preventing pregnancy as the pill. Ortho-Evra is similar to the pill in that it suppresses ovulation and has the advantage of improved compliance and convenience due to weekly administration. A woman only needs to remember to replace the patch once a week instead of being required to remember taking a pill every day. However, some studies have shown that the contraceptive patch may be associated with a greater risk of negative side effects, such as blood-clotting problems, than oral contraceptive pills.

Women who have medical reasons why oral contraceptives are not recommended (such as already having an underlying tendency toward blood clotting) may find that their prescribing physician also recommends against Ortho-Evra because of the similarity in the hormone ingredients of both types of contraceptives.

It is important to ensure that the patch makes good contact with the skin. The patch could be a problem for those women who sweat a lot and/or take frequent showers because moisture can interfere with the patch's contact with the skin. Some women may also experience skin irritation at the site of the patch. Furthermore, contraceptive failure may be a risk in heavier women (those who weight over 198.4 pounds, or 90 kilograms).

As with all other hormonal methods of birth control, the patch will not protect a woman against sexually transmitted infections.

Vaginal ring (NuvaRing)

A ring-shaped device that contains the hormones estradiol and etonogetrel (a progestin) can be placed in the vagina. It remains in place for three weeks continuously, then it is removed for one week to allow for a menstrual period. It continuously releases low levels of the hormone into the bloodstream for the entire three weeks.

There is currently one brand available in the U.S., NuvaRing (etonogestrel/ethinyl estradiol-vaginal ring). It is about 99% effective in preventing pregnancy, having the same high effectiveness as the other hormonal methods of contraception. The incidence of hormone-related side effects is similar to those seen with other hormonal contraceptive methods such as the pill and the patch. Vaginal discharge can sometimes occur as a side effect of the ring preparation.

NuvaRing does not protect against sexually transmitted infections.

Contraceptive implants (Implanon)

A contraceptive implant known as Implanon is available in the U.S. Implanon provides contraception by the slow release of the progestin etonogestrel over a period of three years. Implanon is a thin rod that is inserted in the upper arm under local anesthesia. Protection from pregnancy occurs within 24 hours of insertion of the rod. One advantage of the Implanon rod is that fertility rapidly returns after removal of the rod.

Preliminary studies of the product showed that it was generally well tolerated and effective in preventing pregnancy. However, these studies showed that irregular bleeding is a possible side effect of the product.

As with all other hormonal methods of birth control, Implanon will not protect a woman against sexually transmitted infections.

Medications

• Birth Control Pills (Oral Contraceptives)
• medroxyprogesterone, Provera, Depo-Provera, Depo-Sub Q Provera 104
• norethindrone-oral contraceptive, Micronor, Nor-Q-D

Sexual Dysfunction in Men (Introduction·Decreased Libido· Erectile Dysfunction (ED)· Inability to Ejaculate· Premature Ejaculation· Retrograde Ejaculation)

INTRODUCTION

In men, sexual dysfunction refers to difficulties engaging in sexual intercourse. Sexual dysfunction encompasses a variety of disorders that affect sex drive (libido), the ability to achieve or maintain an erection (erectile dysfunction, or impotence), ejaculation, and the ability to achieve orgasm.

Sexual dysfunction may result from either physical or psychologic factors. Many sexual problems result from a combination of physical and psychologic factors. A physical problem may lead to psychologic problems (such as anxiety, fear, or stress), which can in turn aggravate the physical problem. Men sometimes pressure themselves or feel pressured by a partner to perform well sexually and become distressed when they cannot (performance anxiety). Performance anxiety can be troublesome and further worsen a man's ability to enjoy sexual relations.

Did You Know... Sexual dysfunction may affect the sex drive or the ability to have an erection, to ejaculate, or to have an orgasm. How much of sexual dysfunction is due to physical factors and how much is due to psychologic factors can be difficult or impossible to discern.

Erectile dysfunction is the most common sexual dysfunction in men. Decreased libido also affects some men. Problems with ejaculation include uncontrolled ejaculation before or shortly after penetrating the vagina (premature ejaculation), ejaculation into the bladder (retrograde ejaculation), and inability to ejaculate (anejaculation).

Psychologic Causes of Sexual Dysfunction Anger toward a partner Anxiety Depression Discord or boredom with a partner Fear of pregnancy, dependence on another person, or losing control Feelings of detachment from sexual activities or one's partner Guilt Inhibitions or ignorance about sexual behavior Performance anxiety (worrying about performance during intercourse) Previous traumatic sexual experiences (for example, rape, incest, sexual abuse, or previous sexual dysfunction)

Normal Sexual Function

Normal sexual function is a complex interaction involving both the mind (thoughts, memories, and emotions) and the body. The nervous, circulatory, and endocrine (hormonal) systems all interact with the mind to produce a sexual response. A delicate and balanced interplay among all parts of the nervous system controls the sexual response in men.

Desire (also called sex drive or libido) is the wish to engage in sexual activity. It may be triggered by thoughts, words, sights, smell, or touch. Desire leads to the first stage of the sexual response cycle, excitement. Excitement is sexual arousal. During excitement, the brain sends nerve signals through the spinal cord to the penis. The arteries supplying blood to the erectile tissues (corpora cavernosa and corpus spongiosum) respond by widening (dilating). The widened arteries dramatically increase blood flow to these areas, which become engorged with blood and expand. Muscles tighten around the veins that normally drain blood from the penis, slowing the outflow of blood and elevating blood pressure in the penis. This elevated blood pressure causes the penis to increase in length and diameter, producing an erection. Also, muscle tension increases throughout the body.

In the plateau stage, excitement and muscle tension are maintained or intensified. Orgasm is the peak or climax of sexual excitement. At orgasm, muscle tension throughout the body further increases. The man experiences contractions of the pelvic muscles followed by a release of muscle tension. Semen is usually, but not always, ejaculated from the penis. Ejaculation results when nerves stimulate muscle contractions in the male reproductive organs such as the seminal vesicles, prostate, and the ducts of the epididymis and vas deferens. These contractions force semen into the urethra. Contraction of the muscles around the urethra further propels the semen through and out of the penis. The neck of the bladder also constricts to keep semen from flowing backward into the bladder.

Although ejaculation and orgasm often occur nearly simultaneously, they are separate events. Ejaculation can occur without orgasm. Also, orgasm can occur in the absence of ejaculation, especially before puberty, or with the use of certain drugs (such as some antidepressants) or after surgery (such as removal of the prostate gland). Most men find orgasm highly pleasurable.

In resolution, a man returns to an unaroused state. Once ejaculation takes place or orgasm occurs, penile arteries constrict and the veins relax, reducing blood inflow, increasing blood outflow and causing the penis to become limp (detumescence). After orgasm, erection cannot be obtained for a period of time (refractory period), often as short as 20 minutes or less in young men but longer in older men. The time between erections generally increases as men age.

Decreased Libido Decreased libido is a reduction in sex drive. Possible causes include psychologic factors (such as depression, anxiety, or relationship problems), drugs, and low levels of testosterone. Depending on the cause, doctors may suggest psychologic therapy, prescribe a different drug, or prescribe supplemental testosterone. Sex drive (libido) varies greatly among men. And different men find different degrees of libido satisfactory. Libido may be decreased temporarily by conditions such as fatigue or anxiety. Libido also tends to gradually decrease as a man ages. Persistent low libido may cause a man and his sex partner distress. Occasionally, libido can be low throughout a man's life. Lifelong low libido can result from traumatic childhood sexual experiences or from learned suppression of sexual thoughts. Most often, however, low libido develops after years of normal sexual desire. Psychologic factors, such as depression, anxiety, and relationship problems, are often the cause. Some drugs (such as those used to treat high blood pressure, depression, anxiety, or widespread prostate cancer) and decreased levels of testosterone can also lower libido. A man with decreased libido thinks less about sex. He loses interest in sexual fantasy and masturbation and also in sexual activity. Even sexual stimulation, by sights, words, or touch, may fail to provoke interest. The man often retains the capacity for sexual function. Some men continue to engage in sexual activity to satisfy their partner. A blood test can measure the level of testosterone in the blood. However, the diagnosis is usually based on the man's description of his symptoms. If the cause is psychologic, various psychologic therapies, including behavioral therapies, such as the sensate focus technique (see Sexual Dysfunction in Women: Treatment), can help. Counseling can help address relationship issues. Men should also understand the role of stress and its impact on physical function. If the testosterone level is low,testosterone  can be given, usually as a patch or gel applied to the skin or as an injection (see Biology of the Male Reproductive System: Testosterone Replacement Therapy). If a drug appears to be the cause, a doctor can often try treating the man with a different drug.

Erectile Dysfunction (ED) Erectile dysfunction (impotence) is the inability to achieve or maintain an erection adequate for penetration. The cause may be a disorder that reduces blood flow or damages nerves to the penis, a hormonal disorder, use of certain drugs, or psychologic issues. In many men, sex drive (libido) also decreases. A physical examination (including blood pressure measurement), blood tests, erection testing during sleep, and sometimes ultrasonography may detect a disorder contributing to erectile dysfunction. Drugs, taken by mouth or inserted or injected into the penis, may help, as may constriction and vacuum devices and psychologic therapy. Every man is occasionally unable to achieve an erection, which is normal. Erectile dysfunction occurs when the problem is frequent or continual. Erectile dysfunction can range from mild to severe. A man with mild erectile dysfunction may occasionally achieve a full erection, but more often he achieves an erection that is inadequate for penetration or no erection at all. A man with severe erectile dysfunction is rarely able to achieve an erection. Erectile dysfunction becomes more common with age but is not part of the normal aging process. About half of men 65 years of age and three fourths of men 80 years of age have erectile dysfunction. Causes To achieve an erection, the penis needs an adequate inflow of blood, a slowing of blood outflow, and proper function of nerves leading to and from the penis. Disorders that narrow arteries and decrease blood inflow (such as atherosclerosis, diabetes, high blood pressure, and high blood cholesterol levels) or surgery affecting the blood vessels can cause erectile dysfunction. Also, abnormalities in the veins of the penis can sometimes drain blood back to the body so rapidly that erections cannot be sustained despite adequate blood inflow. Damage to the nerves that lead to or from the penis can produce erectile dysfunction. Such damage could result from pelvic or abdominal surgery (particularly prostate surgery), radiation therapy, spinal disease, diabetes, multiple sclerosis, or peripheral nerve disorders. Other risk factors include stroke, smoking, alcohol, and drugs. Drugs that commonly cause erectile dysfunction (particularly in older men) include antihypertensives, antidepressants, some sedatives, cimetidine  , digoxin  , some diuretics, antipsychotics, and illicit drugs. Occasionally, hormonal disturbances (such as abnormally low levels of testosterone) cause erectile dysfunction. Also, factors that decrease a man's energy level (such as illness, fatigue, and stress) can make it difficult to achieve an erection. Psychologic issues that can cause sexual dysfunction (see Sexual Dysfunction in Men: Psychologic Causes of Sexual Dysfunction) can impair the ability to achieve erections. Psychologic causes are more common in younger men. Any new stressful situation, such as a change of sex partners or problems with relationships or at work, can also contribute. Did You Know... Occasional inability to achieve an erection is normal and does not mean that a man has erectile dysfunction. About half of men older than 65 and one fourth of men older than 80 can usually have erections adequate for penetration. Low levels of testosterone tend to decrease sex drive rather than cause erectile dysfunction. Combinations of drugs injected into the penis and devices that constrict or apply suction to the penis are highly effective and lack many of the side effects of oral drugs. Psychologic therapies can help even when erectile dysfunction has a physical cause. Symptoms Sex drive (libido) often decreases in men with erectile dysfunction, although some men do maintain a normal libido. Regardless of whether libido changes, men with erectile dysfunction have difficulty engaging in intercourse either because the erect penis is not sufficiently hard, long, or elevated for penetration or because the erection cannot be sustained. Some men stop having erections during sleep or upon awakening. Others may attain strong erections sometimes but be unable to attain or maintain erections other times. When testosterone levels are low, the result is more likely to be a drop in libido than erectile dysfunction. In addition, low testosterone levels may lead to thinning of the bones, loss of energy, and loss of muscle mass. Diagnosis To diagnose the cause of erectile dysfunction, a doctor asks about diseases and conditions that may contribute to erectile dysfunction and drugs the man is taking. A general physical examination, including examination of the genital organs and prostate, is performed. The doctor may assess the function of nerves that supply the genitals. Measuring the blood pressure in the legs and assessing the pulses in the legs and feet may reveal a problem with the arteries that supply blood to the penis. A blood sample can be taken to measure the level of testosterone. Certain blood tests can help identify diseases that may lead to temporary or permanent erectile dysfunction, such as diabetes or infection. If a problem with the arteries or veins is suspected, specialized tests may be done. For example, a device can be used at home to measure erections during sleep (when they normally occur). If erections are present during sleep, the cause may be mostly psychologic, whereas if erections are absent during sleep, the cause may be mostly physical. Ultrasonography also can be used to measure blood flow to the penis. Treatment Measures that help prevent or control conditions that contribute to erectile dysfunction, such as high blood pressure, atherosclerosis, and diabetes, may also help improve erectile dysfunction, although the effect may be small. For example, losing excess weight, exercising, and stopping smoking may help. Some men and their partners may choose not to pursue any treatment for erectile dysfunction. Physical contact without an erection may satisfy their needs for intimacy and fulfillment. Sometimes, stopping use of a particular drug can improve erections. Several folk remedies for erectile dysfunction exist, but none have proven to be effective. For men who choose to pursue treatment, there are many choices. Drug Treatment: Many drugs are used to treat erectile dysfunction. Most drugs that are given to treat erectile dysfunction increase blood flow to the penis. Most of these drugs are given by mouth, but some drugs can be applied locally—by injection or insertion into the penis. Sildenafil  , vardenafil  , and tadalafil  are known as phosphodiesterase inhibitors. These are the drugs most frequently used to treat erectile dysfunction. They are effective in about 60 to 75% of men with erectile dysfunction. These drugs are taken by mouth about 1 hour before sexual activity. Tadalafil  is effective for about a day, longer thansildenafil  and vardenafil  , which are effective for about 4 to 6 hours. The drugs are effective only when the man is sexually aroused. Side effects of phosphodiesterase inhibitors include headache, flushing, stuffy nose, upset stomach, and vision problems. More serious side effects, including dangerously low blood pressure, can occur when phosphodiesterase inhibitors are taken with certain other drugs (such as nitroglycerin  or amyl nitrite). Because of this risk, men should not take phosphodiesterase inhibitors if they take nitroglycerin  . Rarely, men taking these drugs have experienced blindness, although it is possible that blindness had nothing to do with taking the drug. Phosphodiesterase inhibitors can cause painful, prolonged erections, but this occurs very rarely. Other oral drugs that have been used to treat erectile dysfunction are phentolamine  ,yohimbine  , and testosterone. They have only limited effectiveness and can have significant side effects. Drugs injected or inserted into the penis widen the arteries and increase blood flow to the penis. Men who cannot tolerate drugs taken by mouth can often be treated with these drugs. An example is alprostadil  , in the form of a pellet (suppository), which can be inserted into the penis through the urethra. It may cause light-headedness, a burning sensation of the penis, or, occasionally, a prolonged, painful erection (priapism—seePenile and Testicular Disorders: Priapism). Because these serious side effects occasionally occur, a man usually takes his first dose under observation in a doctor's office. A man can also induce an erection by injecting drugs (such as alprostadil  alone or a combination of alprostadil  , papaverine  , and phentolamine  ) into the shaft of his penis. Injection is one of the most effective ways to obtain an erection, producing erections in 80 to 90% of men with erectile dysfunction. However, many men are unwilling to inject their penis. Also, the injection is sometimes painful and occasionally causes priapism, and repeated injections may eventually produce scar tissue. Testosterone  replacement therapy may help men whose erectile dysfunction is caused by abnormally low testosterone levels. Unlike other drugs, which work by increasing blood flow to the penis, testosterone works by correcting a hormonal deficiency. Testosterone can be taken in many forms, including patches, topical creams, and injections. Side effects can include liver dysfunction, increased red blood cell counts, and increased risk of stroke. Testosterone replacement alone is rarely adequate to restore erectile function. Whether testosterone increases risk of prostate cancer is unclear, but men taking testosterone should be closely monitored. Constriction (binding) and Vacuum Devices: Erectile dysfunction can often be managed with the use of a constriction device with or without a vacuum device. These devices enable a man to avoid the side effects that can occur with drug treatment. Constriction devices are among the least expensive treatments for erectile dysfunction. These devices (such as bands and rings made of metal, rubber, or leather) are placed at the base of the penis to slow the outflow of blood. These medically engineered devices can be purchased with a doctor's prescription in a pharmacy, but inexpensive versions (often called cock rings) can be purchased in stores that sell sexual paraphernalia. However, the devices are somewhat cumbersome and can cause penile pain, difficulty ejaculating, and bruising. Constriction devices should not be left on for longer than 30 minutes, or they may cause skin breakdown (ulceration). Vacuum devices (which consist of a hollow chamber attached to a source of suction) fit over the penis, creating a seal. Mechanical suction applied to the chamber draws blood into the penis, producing an erection. Many vacuum devices have a constriction device that attaches to the base of the penis. If not, a constriction device can be applied separately. Surgery: When erectile dysfunction does not respond to other treatments, a device that simulates an erection (prosthesis) can be surgically implanted in the penis. A variety of prostheses are available. One type consists of a pair of firm rods, one inserted into each of the corpora cavernosa to create a permanently hard penis. Another prosthesis type is an inflatable balloon that is inserted into the penis. Before having intercourse, the man inflates the balloon with a small internal pump. Surgical implantation of a penile prosthesis requires at least a brief hospital stay and a 6-week recovery before intercourse is attempted. Psychologic Therapy: Some types of psychologic therapy (which include behavior-modification techniques, such as the sensate focus technique—see Sexual Dysfunction in Women: Treatment) can improve the mental and emotional factors that contribute to erectile dysfunction. Psychologic therapy can even help when the erectile dysfunction has a physical cause, because psychologic factors often compound the problem. Specific therapies are selected based on the particular psychologic cause of the man's erectile dysfunction. For example, if the man is suffering from depression, psychotherapy may help with erectile dysfunction. Antidepressants may help erectile dysfunction by relieving depression, but antidepressants may themselves decrease libido and contribute to erectile dysfunction, so their effect may be difficult to predict. Sometimes psychotherapy can reduce anxiety about sexual performance in men with erectile dysfunction from any cause. Improvement may take a long time, and many sessions are usually required. A man, and often his partner, must be highly motivated for psychotherapy to work. Inability to Ejaculate Inability to ejaculate (anejaculation) is usually caused by inability to reach orgasm. It usually occurs as part of erectile dysfunction. Causes, diagnosis, and treatment are the same as for erectile dysfunction (see Sexual Dysfunction in Men: Erectile Dysfunction (ED)). Retrograde ejaculation can sometimes result in absence of visible semen. Premature Ejaculation Premature ejaculation is ejaculation that occurs too early, usually before, upon, or shortly after penetration. The cause is most likely to be anxiety, other psychologic factors, or very sensitive penile skin. Behavior modification therapy, including strategies to delay ejaculation, helps most men. Many males, especially adolescents, ejaculate sooner than they or their partners would like. Premature ejaculation is not just ejaculation that occurs before a man wants it to but rather ejaculation that occurs very soon—often within a minute or two—after penetration. Many experts believe that premature ejaculation almost always results from anxiety or other psychologic causes. Others think that unusually sensitive penile skin may be a cause. Having intercourse less frequently than desired may worsen the problem by making the man even more sensitive. Premature ejaculation is rarely caused by a disease, although inflammation of the prostate gland or a nervous system disorder can cause the condition. Premature ejaculation can distress a man and his partner. If the man ejaculates too early, the partner may be left unsatisfied sexually and may become resentful. Behavior modification therapy can help most men overcome premature ejaculation. A therapist provides reassurance, explains why premature ejaculation occurs, and teaches the man strategies for delaying ejaculation. Other methods that can help a man delay ejaculation include drug treatment (with a selective serotonin reuptake inhibitor, such as fluoxetine  , paroxetine  , or sertraline ), application of an anesthetic to the penis, and use of condoms, which tend to decrease sensation. Sometimes a combination of drug treatment and behavioral therapy enables a man to delay ejaculation even longer than he might be able to with only one of these treatments. When premature ejaculation is caused by more serious psychologic problems, psychologic therapy may help. Learning to Delay Ejaculation Two techniques are commonly used to treat premature ejaculation. They also help reduce the anxiety that often aggravates the problem. Each technique trains the man to experience high levels of excitement without ejaculating. Both involve self-stimulation of the penis (while masturbating) or stimulation by a partner until the man feels that he will soon ejaculate. When done with a partner, stimulation is at first by hand and later before or during intercourse. In the stop-and-start technique, stimulation is stopped. With the squeeze technique, the man or his partner squeezes for 10 to 20 seconds the part of the penis where the head (glans) meets the shaft, preventing ejaculation and decreasing the strength of the erection. In both techniques, stimulation can resume after about 30 seconds. With practice, more than 95% of men learn to delay ejaculation for 5 to 10 minutes or even longer. Retrograde Ejaculation Retrograde ejaculation is a condition in which semen is ejaculated backward into the bladder rather than out through the penis. In retrograde ejaculation, the part of the bladder that normally closes during ejaculation (the bladder neck) remains open, causing the semen to travel backward into the bladder. Common causes of retrograde ejaculation include diabetes, spinal cord injuries, certain drugs, and some surgical operations (including major abdominal or pelvic surgery—one of the most common causes is prostate surgery). Men with retrograde ejaculation can still have orgasms. However, retrograde ejaculation decreases the amount of semen ejaculated out of the penis. Sometimes, no semen comes out. The condition can cause infertility but is otherwise not harmful. Did You Know... Insemination may be possible if infertility is caused by retrograde ejaculation. A doctor makes the diagnosis of retrograde ejaculation by finding a large amount of sperm in a urine sample taken shortly after ejaculation. Men usually need no treatment unless infertility is an issue. About one third of men with retrograde ejaculation improve after treatment with drugs that close the bladder neck (such as pseudoephedrine  ,phenylephrine  , chlorpheniramine  , brompheniramine, orimipramine  ). However, most of these drugs can increase heart rate and blood pressure, which can be dangerous in men with high blood pressure or heart disease. If infertility requires treatment and drugs do not help, doctors can sometimes collect a man's sperm for insemination (see Infertility: Treatment).

Sexual Activity and Heart Disease Sexual activity is generally less taxing than moderate to heavy physical activity and is therefore usually safe for men with heart disease. Although the risk of a heart attack is higher during sexual activity than it is during rest, the risk is still very low during sexual activity. Still, sexually active men with diseases of the heart and cardiovascular system (which include angina, high blood pressure, heart failure, abnormal rhythms of the heart, and blockage of the aortic valve [aortic stenosis]) need to consult their doctor. Usually, sexual activity is safe if the disease is mild, if it causes few symptoms, and if blood pressure is normal. If the disease is moderate in severity or if the man has other conditions that make a heart attack likely, testing may be necessary to determine how safe sexual activity is. If the disease is severe or if the man has an enlarged heart that blocks the flow of blood leaving the left ventricle (obstructive cardiomyopathy), sexual activity should be deferred until after treatment reduces the severity of the symptoms. Sexual activity should also be deferred until at least 2 to 6 weeks after a heart attack. Use of sildenafil  , vardenafil  , and tadalafil may be dangerous in men taking nitroglycerin  , who should not use these drugs. Most often, testing to determine the safety of sexual activity involves monitoring the heart for signs of poor blood supply while the man is exercising on a treadmill. If the blood supply is adequate during exercise, a heart attack during sexual activity is very unlikely.