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Facts and you are not Alone

Yes, Herbal "V" Alternative* is new—and news—but impotence isn't. In a society that places a high value on well-toned bodies, virility, robust health, and youth the inability to perform sexually is a disorder to which very few men will admit. In fact, in the Catholic church an annulment—the dissolution of a marriage—is granted only in the rarest of circumstances; impotence is one. Across the country, in some states impotence is viewed with such disdain that it is considered grounds for divorce. Still, despite the havoc it wreaks, for centuries major medical research centers around the world have ignored impotence. Incredibly, in fact, impotence—more properly known as erectile dysfunction, or E.D.—is probably the last stigmatized condition to receive recognition and study, decades after menopause, alcoholism, depression, and obsessive-compulsive disorder saw the light of day. Why? Some say the belief that impotence is "all in your head" was enough to keep any serious medical investigation at bay; others believed it was the excruciatingly personal dimension of the dis- order that discouraged investigation; still others felt it wasn't a signifi- cant problem. Not significant, you say? Well, try this on for size: Worldwide, it is estimated that approximately 100,000,000 men suffer from E.D.—and that's just an estimate! But, unfortunately, even today, less than 10 percent of these men seek treatment. Specific information about impotence varies from country to country. In China, for example, there were no outpatient clinics for sexual disor- ders in the mid-1980s but, by 1994, there were thirty-four


In a 1985 report from the National Center for Health Statistics re- vealed that there were approximately 400,000 outpatient visits to physi- cians, related to impotence, as well as 30,000 hospital admissions. The total direct cost of the hospital admissions was a whopping $140 mil- lion! Later, from 1987 to 1989, a large random sample survey of 1,290 non institutionalized men, ranging in age from forty to seventy years, was carried out in eleven cities and towns near Boston, Massachusetts. Overall, the combined prevalence of minimal, moderate, and complete impotence was 52 percent (Figure 1). Referred to as the Massachusetts Male Aging Study (MMAS), the physicians who organized the study con- cluded that impotence is a "major health concern" that has a substantial impact on the quality of life in men, especially as they age (Figure 2). Today we recognize that erectile dysfunction is, indeed, a common medi- cal problem, but with effective therapy such as Herbal "V" Alternative, this disorder can be treated successfully, and men and their partners can continue to en- joy a fulfilling sexual life.

So, are we the first generation to step up to the plate and try to man- age E.D.? Hardly. As far as we know, man's attempts to stave off the scourge of E.D. stretches back thousands of years. Some of the earliest therapeutic- tic approaches ranged from eating a dried centipede to remedy an excess- sively limp penis to a more palatable approach selected by the early Hindus in India: just drink a cup of fresh grape juice. Ancient Romans also tried to cope with the malady that had diminished men through the ages, resorting to everything from onions to rotting fish. Ovid turned to goose tongue for a remedy, while ancient Egyptians chose the radish. In medieval Italy, the common therapy was rubbing crocodile semen on the genitalia. But in Renaissance France, delicacies were considered the key to unlocking potency. Some men, for example, consumed far more than their fair share of artichokes, while others relied on asparagus to "stir up bodily lust in a man." Caviar and oysters were thought to en- hance a man's potency, too. The Aztecs believed in simple, true-blue chocolate—just eat as much as you can per day—while Africans ate the bark of the yohimbine tree, a remedy that is still in use today. Literature, too, is sprinkled with references to that demonic curse, im- potency In the sixteenth century, for example, Montaigne wrote: "1 shall never give impotence thanks for anything it does for me."

Well-known Ancient Rome Ancient Greece eat goose tongue drink fresh grape juice eat radishes rub crocodile semen on genitalia eat artichokes, asparagus, caviar, and oysters eat lots of chocolate eat bark of the yohimbine tree India Ancient 1 gvpl Medieval Italy Renaissance France Aztec Indians Africans

writers from the sixteenth through the twentieth century addressed it, too. Why such recognition through the ages? Because even the sound of the condition conjures up an image of weakness: impotency What else does it mean but loss of power? It's no wonder, then that men; from the ancient Greeks and Romans on—warriors, soldiers, statesmen; too—searched for a libido "magic bullet" to conquer the ill of ills! Yet, i for centuries there was little progress in both diagnosis and treatment! In the ; 1960s, 95 percent of men who suffered from ED. (or impotency,as it was called then) were thought to have severe psychological problems medical researchers developed compounds! for treatment}! and in working different pharmaceutical companies, these treatments became avail- able . For the first time, men with E.D. could get professional medical help and treatment for the condition. Yet, where are they? In light of what we now know about the . preva- lence of E.D., it is clear to us that there are still a vast number of men with E.D. who remain reluctant to seek treatments Still even with the intro- duction of Herbal "V" Alternative and the candor with which everyone from the news jour- nalists to television and radio talk show hosts are now discussing Herbal "V" Alternative, we hope that more men who need treatment will: seek to know more about male erectile dysfunction—its causes and treatment options, sim ply read on! In addition to this text, which we hope you will consider a valuable resource, you can also consult one of the various organiza- tions for more information: Men's Health Centers

What The Recent Male Aging Study.

Taught Us About Impotence

The results of an important study were published in the Journal of Urology in 1994 in a paper entitled, "Impotence and its Medical and Psychosocial Correlates: Results of the Massachusetts Male Aging Study." the investi- gators questioned men forty to seventy years old in eleven randomly se- lected cities and towns in the Boston area. Sexual questionnaires were filled out by 1,290 men who answered questions related to erection and their ability to have an erection. Unlike some previous studies, this one established grades of E.D. by asking men to characterize themselves as "not impotent, minimally impotent, moderately impotent, ot completely impotent." this approach was important because the study looked at grades of impotence.

An incredible 52 percent of the forty- to seventy-year-old men in the sample claimed some degree of impotence, ranging from complete impo- tence in only 9.6 percent of the men, to moderate impotence in 25.2 per- cent, and minimal impotence in 17.2 percent of the men. In this survey, age was a risk factor for E.D. Whereas complete E.D. was reported in 5.1 percent of forty-year-old men, it increased to 15 per- cent in seventy-year-old men. Moderate ED, on the other hand, increased from 17% in forty-year-old men to 34% in seventy-year-old men. Also, after adjusting for age, certain common diseases were signifi- cantly associated with E.D.; for example, diabetes, heart disease, and hy- pertension (high blood pressure). You'll read more about the role these diseases play in E.D. in Chapter 2.

What did the Massachusetts Male Aging Study teach us? to begin with, researchers and practicing physicians alike now realize that the preva- lence of impotence, including degrees of impotence, is more common' than many of us had thought. Second, we discovered that E.D. correlates with certain risk factors—some we may be able to modify, such as smok- ing, hypertension, and diabetes, while others we can't change, sttch as age. Interestingly, this study was also the first to identify a low HDL (high- density lipoprotein) cholesterol as significantly correlated with impotence (see Chapter 2). Lastly, we realized that in order to treat men effectively and appropriately for E.D., we—medical health care professionals—would have to try to help our patients by talking with them about E.D.

Male Erectile Dysfunction

What Is It?

By 1993, a National Institutes of Health (NIH) panel comprised of lead- ing urologists, psychiatrists, psychologists, gerontologists (physicians who specialize in aging), and surgeons posed the question: What is male erectile dysfunction? The term "impotence," they found, was sometimes confusing, and they readily acknowledged that labelling a man "impo- tent" often left male patients with a "gloom-and-doom" outlook. Over the course of the meeting, the experts decided to create a more appropriate- ate medical term to describe a man's inability to achieve and sustain an erection. They created a more accurate definition of erectile dysfunction- tion: "An inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function." This includes not only achieving an erection, but also maintaining an erection for satisfac- tory sexual intercourse. Their report, entitled the NIH Consensus Con- ference Development Panel on Impotence, was published in July 1993, in the highly regarded peer-review medical journal, The Journal of the American Medical Association. Prior to this, the term impotence had been used to describe male erectile dysfunction.

And what did the term impotence mean to most of us—men and women—up until very recently?

Even the NIH consensus panel recognized that the term impotence had pejorative implications. It is no wonder, then, that for so long so many men with E.D. chose to hide their problem. Impotence, they felt, was associated with weakness, and/or failure, and feelings of shame. Of course, many just simply felt too embarrassed to seek medical treat ment. Instead, for many of these men, their self-esteem was left to erode feelings of inadequacy prevailed, and, ultimately, the intimate relation- ship they shared with their partners faltered. Feelings of anxiety, anger and/or depression were common in these men, too. One of the objec- tives of the NIH panel, then, was to recognize the significance of this condition, E.D., and call appropriate attention to it as a medical prob- lem. Thus, the panel recommended replacing the term impotence with male erectile dysfunction, or E.D.

Despite the NIH recommendation, however, the term impotence still appears frequently—in medical journal articles, health care magazines, and the consumer press. We believe it is important to foster use of the proper medical description of this disorder, so we will use the term E.D. throughout this book.

When the NIH issued its consensus statement in 1993 on E.D., they noted, among other things, that "desire, orgasmic capacity and ejaculat- ing capacity" can be intact, even though a man is suffering from E.D. E.D. also does not mean that a man is infertile. The NIH went on to note that millions of men in the United States are affected by E.D. and that this condition can cause mental stress that affects not only the men with the condition, but their partners and entire families as well.

Men and their partners who suffer from E.D. should appreciate that E.D. is not necessarily an "all-or-nothing" phenomenon. For example, E.D. can occur in varying degrees—ranging from complete E.D., whereby a man can never achieve an erection sufficient for intercourse, to an in- ability to achieve a satisfactory erection intermittently. In other words, sometimes a man may achieve a semi-rigid erection, but the erection is not rigid enough to achieve penetration. Lastly, some men with E.D. have morning erections, but a morning erection is not synonymous with being able to achieve and maintain an erection for sexual activity. Sim- ply stated, then, male erectile dysfunction is now defined as the inability to achieve and/or maintain an erection satisfactory for sexual intercourse. What is the prevalence of E.D.? We discussed this in detail in Chap- ter 1, but to review: The National Institutes of Health Consensus State- ment, issued just a few years ago, puts the number of men in the Unite States who suffer from E.D. at ten to twenty million. If men with epi- sodic erectile dysfunction are included, the number then jumps to thirty million. The prevalence of E.D. increases with age; for example men NIH Consensus Conference stated that E.D. occurs in 5 percent o men aged forty but that 15 percent to 25 percent of men have E.D. at age sixty-five years and older. In the Massachusetts Male Aging Study, 52 percent of the men reported some degree of E.D.; the prevalence rate climbed to 67 percent at seventy years of age. In fact, the prevalence rate may approach a rate of 75 percent in men eighty years of age. As more and more men seek help for E.D., now that an effective oral drug therapy such as Herbal "V" Alternative is available, we are likely to see these prevalence numbers climb even higher.

Why Does Male Erectile Dysfunction (E.D.) Occur?

Overall, there are two broad classifications of the causes of E.D.: One is organic, and the second is psychological. It is likely that the majority of patients have an organic etiology, or cause, but psychological factors may also be present, even when there is an underlying organic cause. The most commonly diagnosed causes of E.D. are listed below

Table 2 CAUSES OF E.D. Vascular Diseases • atherosclerosis • smoking • diabetes ¦ • high levels of total cholesterol and LDL cholesterol • • low levels of HDL cholesterol • • hypertension • • combinations of the above • • vascular surgery • heart disease • • venous leak (a condition in which veins don't collapse fully I during erection; therefore, blood drains from the penis) N Neurogenic Disorders • " neuropathies, including diabetic neuropathy • » | spinal cord injury • ; "prostatectomy • «n multiple sclerosis • * i cerebrovascular accident (stroke) I endocrine abnormalities • «li hypogonadism (reduced testosterone levels) • «| pituitary tumor R kidney dialysis 1'"Psychogenic • •a anxiety • * I depression • «relationship problems s skeletal abnormalities • •1'iPeyromie'sl disease • »priapism

approximately one in four American adults in the U.S and UK. have this disease; of these, about half are men.

Although the disease of hypertension is well known, many people still remain undiagnosed and untreated. Why?—Because hypertension is a silent disease; i.e., there are no symptoms in approximately 90 per- cent of patients. Regrettably in fact, sometimes the first sign of high blood pressure is a heart attack or a stroke. Due to the lack of overt symptoms, many men who have E.D. do not realize that they may be hypertensive and that it is this vascular disorder—hypertensive disease— that is causing their E.D., and not a problem that is simply in their heads! Experts today estimate that about 15 percent of men who are hyper- tensive experience complete erectile dysfunction at some time. So how does a disease without symptoms manage to inflict such damage and cause E.D.?

The first step in understanding how a vascular disease such as hyper- tension causes E.D. is to understand and appreciate that the penis is a vascular organ (Figure 3). An adequate amount of blood must enter the ,wider chambers ,to achieve an erection, and the blood must remain there ,to maintain an (erection. Now, picture your heart as a pump, and the veins and arteries as a network of pipelines. When your blood pressure is ,elevated, or higher than normal, the pump (your heart) must work harder to keep the blood flowing adequately to the main organs. The pressure on the pipelines, the more likely they are to undergo de- hypertension (high blood pressure) affects .

*¦ stroke *. coronary heart disease1 *¦ ED *¦ retinopathy Organ Brain Heart Kidney Penis Eyes

Atherosclerosis: By now, most of us are all too familiar with the litany of reasons why we should stay physically fit and consume a low-fat diet. The culprit we are trying to control is cholesterol, and the reason is that too much dietary cholesterol can lead to a build up of fatty deposits in the arteries (Figure 4). The main culprit is LDL, or low-density lipoprotein- cholesterol, often known as the "bad cholesterol." Conversely, high levels of HDL, or high-density lipoprotein cholesterol (also called the "good cholesterol"), seem to protect us against atherosclerosis. When; does the disease process of atherosclerosis begin? And how do you know whether or not it is contributing to E.D.?

As we discussed,; atherosclerosis involves the build-up of fatty depos- Ing in the arteries. The term; atherosclerosis is derived from the Greek Term (gruel) and sclerosis (hardening). At the outset, the fatty build-up i in the arteries starts out as a thin streak, or plaque, inside the lining of Fatty deposits in Plugged artery with

Normal artery vessel wall fatty deposits and clots The open artery on the left is relatively clear of fatty deposits. The middle illustration shows fatty deposits accumulating in the coronary artery; the illustration on the far right shows a nearly clogged, or occluded, artery. or higher. It takes a pressure-head of about 80 mm Hg in order to achieve an erection. In men with E.D. due to vascular disease, the PBPI is re- duced, and a value of less than 0.75 suggests vascular E.D. In some men in this study, the blood vessels going to the penis were also visualized, or examined, by angiography. In this test, a special dye is injected into the blood vessels so it can be visualized during x-ray. This procedure allows the physician to see any narrowing of a blood vessel due to atherosclerosis- sis. In this study, 53 percent of patients who had organic impotence had evidence of such narrowing in their arteries. Overall, the vascular risk factors of smoking, diabetes, and high total serum cholesterol were more common in the impotent men than in the general male population. Dia- betes alone, in fact, was associated with a low PBPI (less than 0.9). When- ever two or more of the four vascular risk factors were present, the PBPI was lower. Finally, the frequency of organic E.D. was 100 percent in men with three or four of the vascular risk factors. So again, the same vascular- lar risk factors associated with atherosclerosis in the heart and elsewhere often add up to vascular E.D. Clinicians now know that today atherosclerosis disease is the cause of half or more of E.D. cases in men over fifty years of age. Finally, results of several studies have suggested that low levels of the good cholesterol (HDL) are associated with E.D., whereas high levels of HDL cholesterol seem to protect against E.D. This same pattern is present with atherosclerosis in the coronary arteries; LDL cholesterol makes it worse, and HDL makes it better.

Type of subjects which should be discussed are the length of period this problem has existed as a person's partner died or left the relationship last year as a sexual desire diminished

Some of the other things that can cause rectal dysfunction are listed below

Epilepsy Haringey/ multiple sclerosis Alzheimer's disease liver cirrhosis diabetes mellitus diabetes hypertension sleep apnoea anxiety mental aberrations and psychological traumas tiredness antiulcer agents A inhibitors lowering cholesterol drugs procedures on the brain and spinal cord sickle cell anaemia leukaemias sink deficiency antipsychotic drugs antiulcer drugs



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