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'Sex Ed' for adults
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We often read about the pros and cons of sexual education in grade school. When is too early/late? How much should be taught?, etc. When I went to medical school, this was not part of the curriculum, although it is now included in most medical school curricula.
My first clinical encounter that involved "sex ed" involved a 68-year-old woman with multiple vertebral fractures related to her osteoporosis. She and her husband had enjoyed 45 years of marriage, but he was now very concerned about even giving his wife a hug for fear of injuring her. Somehow we managed to work through this together, with the couple leading the discussion. It was educational for me, and they reported that the options we discussed removed any concerns. She continued as my patient for the next several years, and their care and concern for each other was evident at each visit.
Over the last five years or so, the encounters mainly involve men who sought medical advice for erectile dysfunction and who were referred because the work-up by the primary care physician uncovered testosterone levels below or close to the lower limit of normal. This surprised me at first because male hypogonadism is often associated with decreased libido and concerns about ED would on the surface be less of an issue. ED in large part has a vascular etiology — not a hormonal one — and it is essential that the patient understands that correction of the hypogonadism may have no effect on the ED or in fact might make it more of an issue.
Then there are the men referred for evaluation and management of osteoporosis and in whom hypogonadism as a treatable secondary cause of bone loss needs to be evaluated. Again, this is often a husband-and-wife encounter and obtaining a history related to hypogonadism may be met with strong denial from the patient, fully supported by his wife. That does preclude doing the appropriate exam (WNL should not mean “We never looked”!), ordering labs for testosterone and gonadotropins, as well as other studies looking for secondary causes of bone loss. When the data confirms hypogonadism, it is not uncommon for the couple to open up about their intimacy and apologize for misleading me a few weeks earlier.
After all these years of on-the-job learning, a couple I saw some months ago underscored the importance of this topic and the need for each of us to be comfortable discussing intimacy. Both were 39, quite shy and shared little background history of having a boyfriend or girlfriend. They had “met” on an online dating service and been married for a year. At age 39, they were anxious to have a child as soon as possible, but their activity was plagued by his ED. They paid close attention to her menstrual cycle and attempted intercourse when they felt she was most likely to conceive. Frustratingly, every month he was unable to sustain an erection. When they spontaneously had intercourse while he was using a condom they never had a problem. His testosterone level was toward the low end of normal as were his gonadotropins. Testicular volume was a bit low at 15 cc, but the consistency was normal. The hypogonadism was confirmed on repeat testing, serum prolactin was normal as was the MRI of the pituitary.
Now what? A sperm count is indicated, but he needed some convincing that this was an OK clinical study. The result would make a difference to the treatment options for hypogonadism as sperm production might decrease with testosterone replacement.
They desperately wanted a child, and they also needed reassurance that at her age she was not at increased risk for miscarriage or fetal abnormality as an “elderly primip.” The most appropriate option was a referral to a reproductive endocrinologist, and after careful evaluation and discussion of the options open to them, they elected for adoption and delayed treatment of his hypogonadism. ED was no longer an issue, and the joy on their faces when they brought young Ian in to see me was a delight. The husband has now started on testosterone replacement and hopefully they will live happily ever after.
