BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 3. - Sexual Problems
RADIO 4
TUESDAY 11/09/07 2100-2130
PRESENTER:
MARK PORTER
REPORTER: LESLEY HILTON
CONTRIBUTORS:
JOHN DEAN
SUSAN QUILLIAM
SALLY OUSBY
JUNE RAINE
NICK PANAY
PRODUCER:
HELENA SELBY
NOT CHECKED AS BROADCAST
PORTER
Hello and welcome to a Case Notes special on sexual problems - part of Radio 4's Sex Lives of Us season. If the quality of your sex life isn't quite living up to expectations - yours, or your partner's - then this is the programme for you.
Over the next half hour we'll be looking at a new initiative designed to make it easier for British men to buy Viagra without a doctor's prescription. That's proper Viagra, from a proper pharmacy, not the dubious stuff all too often peddled on the internet.
CLIP
There's lots of availability of this particular tablet that you can never be certain as to exactly what medicine you're getting there so I knew I could speak to someone to make sure it was the right medicine for me and actually get the genuine supply.
PORTER
From Viagra for men, to Intrinsa - the new testosterone patch for treating low sex drive in women.
CLIP
My husband says that I'm much more aggressive but whether that's really aggression or whether it's just the fact that I'm now interested in life and I've got more bounce or energy, whatever, I'm not quite sure but anyway I have to try and get a balance now on not being too aggressive but still having the same energy and the same interest in life.
PORTER
Dubbed the "love patch", I'll be separating fact from fiction and finding out if Intrinsa lives up to the media hype.
And I'll also be looking at the latest management of a range of common sexual difficulties - from premature ejaculation in men, to women who struggle to reach orgasm at all. So be warned, the programme is likely to contain some pretty graphic sexual content.
I am joined by two experts this week - Dr John Dean and Susan Quilliam. John is a sexual physician and President Elect of the International Society for Sexual Medicine.
And Susan is a psychologist with a special interest in relationship and sexual problems.
John, you run an NHS clinic in Devon - what actually happens when people come to see to you, what do you do to them?
DEAN
I think most people are very worried about what I'm going to do them when they're coming to see someone who describes themselves as a sexual physician. But really talking is the key, listening to the concerns that they have, how they are affecting their enjoyment of sex and then seeking solutions to help them overcome them. And these are not all medical, they can be behavioural as well.
PORTER
Susan, that's an ideal opportunity to bring you in. I suppose if we're talking about people in steady relationship, as long as both parties are happy it doesn't really matter how long, how big, how fast, how often does it?
QUILLIAM
It absolutely doesn't matter. That said in my post bag and about 25,000 letters a year there are an awful lot of sexual problems out there. And one of the things that people tell me is that there is often disagreement. But you know if you have a couple - I mean for example if you have a couple where he takes 20 minutes to climax and she wants longer and he's worried about it then they design themselves as having premature ejaculation. Another couple where he takes two minutes to climax and she's perfectly happy with that and so is he do not have a problem and do not turn up to see people like John or write to people like me.
PORTER
Well let's stick with premature ejaculation - when should a man start to worry about how long he lasts? I mean John you must see quite a few people with this problem?
DEAN
Yes it's the most commonly experienced sexual concern of men although probably a minority of those affected come along and seek help. It's care is hampered by the lack of a universally agreed definition of what exactly premature ejaculation is. But to answer your question men should come along and seek advice when their lack of ejaculatory control bothers them or their partner, starts to cause them interpersonal difficulty.
PORTER
And who's most likely to suffer and why?
DEAN
Well it can affect men of all ages, it's a myth that it's something that particularly afflicts younger men. I see quite a lot of men in mid life and into their 70s and beyond affected by premature ejaculation and it is a source of equal bother whatever the man's age.
PORTER
Susan, what can we actually do to help these people?
QUILLIAM
Well once you've ruled out medical problems and medicational problems you're usually down to a man not knowing when the signals come through that he's going to climax and the standard sexual therapy technique is a thing called sensate focus or a thing called the stop start technique where you are training him first by helping himself, then by introducing a partner, to recognise those signals and to be relaxed enough to notice them. And that's the key and it's a straightforward not all that long procedure but it has to be introduced and monitored by a therapist.
PORTER
John, we'd sometimes use medication for this area don't we.
DEAN
Yes indeed although I would always use medication as part of an integrated care package involving behavioural techniques, as Susan's described. At present there are no licensed medications for the treatment of premature ejaculation within Europe. We sometimes make use of what might be considered an unwanted side effect of antidepressant medication which can delay organism and ejaculation on an unlicensed basis and also sometimes topical anaesthetics are used as well to help reduce penile sensitivity. There's a lot of research going on in this area and there are new treatments in development though.
PORTER
I want to move on to another common problem now - erectile dysfunction or impotence. Not a new problem, but one that was brought very much to the fore following the launch of Viagra 10 years ago. A drug that - along with competitors like Cialis and Levitra - has revolutionised the outlook for men with erection difficulties. Nearly every man can now be helped to some degree, although under current NHS rules most have to pay for the drug privately.
A hurdle that - along with the embarrassment of consulting their doctor - drives some men to purchase the drug over the internet - where they risk being fleeced. One solution might be to allow high street pharmacists to dispense Viagra without a doctor's prescription. And that is exactly what is being tried, for the first time, at a Boot's store in Manchester. We sent Lesley Hilton to see if the experiment is proving popular.
PHARMACIST AT BOOTS
Thank you for that personal information. Now what I'll do is we'll talk a little bit about the problem that's brought you to come and see us today and from that then we'll look at your medical history and also talk a little bit about how Viagra works and how to get the best out of the medicine. And looking at the questionnaire and the different responses you've given me there obviously for you the main problem is that you're getting an erection to start with and then as soon as you start to penetrate with your partner you're finding it's just going altogether for you.
PATIENT
Absolutely, that's exactly what's happening.
PHARMACIST
How long is it since you first noticed that you've had some problems?
PATIENT
I think it's over the last couple of years really. We've been having some problems for a little while now that have been gradually developing over the last few years I'd say, it started to have an effect on my relationship etc., so I felt it was time to do something about it and seek some treatment.
HILTON
And why have you come here to Boots as opposed to going to your GP or a clinic?
PATIENT
The main reason was ease of access really, I work in Central Manchester so it was very easy to come in and make an appointment to see the pharmacist here. I knew I was going to get a genuine medicine, there's lots of availability of this particular tablet, but I thought I'd get the genuine supply.
HILTON
Have you thought about buying it on the internet or anything like that?
PATIENT
I have, I know friends that have bought it but you can never be certain as to exactly what medicine you're getting.
OUSBY
My name's Sally Ousby, consultant pharmacist.
HILTON
What sort of people have been coming to you?
OUSBY
We've had a wide variety of gentlemen coming to see us to access the Viagra through our programme. A lot of men, when we talk to them, have said I've been meaning to do something about this for ages and I've just never got round to it, typical guy response really. And eventually they think well I really do need to do something about it now, it's not going away and once they've sat down and had a chat they feel just so much better, they've actually talked about their problem, they've all said how easy it is to talk to us and how - what they were concerned about, about being embarrassed, has not been an issue at all.
HILTON
What do you think is the barrier then that stops them going to their GP?
OUSBY
I think very often people don't want to go and see their GP because they feel it's not the GP's job, it's not that they're ill, it's more a matter of how healthy you feel and health to different people is different things and feeling comfortable in your relationship and comfortable in your social life is very important to people but they don't feel it is very often the GP's job, they feel that their GP has seen them when they've been really ill or seen their wife and of having babies, different things, and some of them just don't feel comfortable going to talk to somebody that they often know quite well. And I think coming to talk to somebody who is - doesn't know their background, doesn't know anything about their previous history, sometimes is a bit easier to talk about very personal problems.
HILTON
In what circumstances would you say that they should go to their GP or that you would not suggest that they take it?
OUSBY
There obviously are many conditions where it isn't suitable for people to take Viagra. We look at what medicines they're already taking from their GP and that will obviously be sometimes a reason for not being able to supply them. We're obviously very cautious with people who have cardiovascular disease of any sort and also people who have any anatomical problems of their penis or genitals we would want to make sure that was checked out further and we would refer them to their GP for further advice. If we talk to people and we find that maybe erectile dysfunction is not the bottom line and there is some other sexual dysfunction we will refer them to a specialist for further advice through their GP.
HILTON
What proportion of people coming to you would you then refer to a GP?
OUSBY
Well if you're in the consultation we'll measure people's blood pressure and their blood glucose and their cholesterol level and very often these are indicators of possibly early detection of some other condition and we've actually referred about 89% of our customers over the three stores to the GP for further investigation of results which have laid outside a normal range.
PORTER
Lesley Hilton visiting the pharmacist in Manchester. Dr June Raine is Director of Vigilance and Risk Management at the Medicines and Healthcare products Regulatory Agency, and I asked her to explain how Boots can sell Viagra without a prescription.
RAINE
The special arrangements put in place to enable wider access in Boots in Manchester are under what's called a Patient Group Direction or a PGD and this is within the law, a special set of arrangements where a specific group of access to a medicine under a protocol or set of written directions approved and signed off by a senior doctor and a pharmacist. So it's a special arrangement.
PORTER
And presumably from your point of view this gradual introduction, if you like, this pilot that's going on in Manchester, is a good way to see how easing restrictions for them might work across the whole country.
RAINE
There's absolutely no reason why if the write evidence of safety is gathered that a medicine that is subject to a PGD might not be made available as a pharmacy medicine in future. That decision depends on having evidence of safety in use. In fact in Manchester there was a Patient Group Direction for emergency contraception and then, as you know, that was switched to over-the-counter availability and has been a very safe medicine in over-the-counter use.
PORTER
One of the other concerns raised in our package was that of giving the right drug, the reason why the man went there was to get the product that he knew was genuine. What's your stance on that sort of grey area 'twixt the two where you can go online to sometimes a UK based company and you can have an online consultation with a doctor, so you've never actually met him or her, and he or she then issues a prescription and gets round the rules that way and you can have your Viagra sent to you - is that legal?
RAINE
It is legitimate. We understand why people are tempted to go this route - to get Viagra from the internet - what we would say to our listeners today is if you're going in this direction please check for a UK address, look the price is in UK sterling, names and phone numbers of the head pharmacist - are they in the register of the RPSGV. So steer towards the legitimate pharmacies, keep away from those that are not.
PORTER
And presumably the danger of going to one that may not be registered in this country you really don't know what you're getting?
RAINE
You absolutely are taking a risk, we strongly advise against people going this way. It's quite impossible to be sure of the quality, of the effectiveness of medicines brought in this way.
PORTER
Dr June Raine talking to me earlier. You are listening to Case Notes. I'm Dr Mark Porter and I am discussing sexual problems with my guests sexual physician Dr John Dean and psychologist Susan Quilliam.
John, the pharmacist in Manchester raised an important issue when she said she had referred 9 out 10 men who'd come in asking for Viagra to their GP because they had raised blood pressure, signs of diabetes or high cholesterol levels. It's not just your sex life that might suffer if you bury your head in the sand?
DEAN
Absolute. Erectile dysfunction is sometimes called the barometer of men's health and there is an association between ED and diabetes, high blood pressure, coronary heart disease. Men who are affected by erectile dysfunction should be screened for conditions which might be causing it.
PORTER
It may be the first sign of serious underlying damage.
DEAN
Most certainly it can be and I think one of the important things about the patient group direction programme is that the right questions are asked by the pharmacist before medication is dispensed.
PORTER
Susan, does it worry you that doctors are perhaps being too quick to turn to drugs like Viagra?
QUILLIAM
I think people may be being too quick to turn drugs like Viagra, not only because sometimes there are psychological underpinnings to the problem ...
PORTER
But there often are I suppose.
QUILLIAM
Not as much as we thought even 10 years ago, we're now seeing that a very high proportion are medical. But I get a lot of letters from women saying it's all because he doesn't love me anymore, actually it usually isn't because he doesn't love me anymore. However, actually taking Viagra or one of the equivalence can have an impact on a relationship. If you've had a sex life without an erection for several years and maybe that's meant that foreplay's increased, might have meant that the woman is getting more organisms, man pops along gets his Viagra, pops back again, all of sudden their sex life is penetrative and I've seen a lot of letters coming in saying my man's got Viagra and I'm not getting orgasms anymore.
PORTER
It was a backward step.
QUILLIAM
It was a backward step.
PORTER
I want to pick up orgasms, is where I want to move on to next and I suppose this is diametrically opposed to what we started the programme with which is premature ejaculation in men, I want to move on to lack of orgasm in women.
My perception is that that's another common problem.
QUILLIAM
Very common in my post bag, a lot of my letters come from women, a lot of my letters come from women who are either worried because they've never had an orgasm or more likely don't get an orgasm through penetration, which is absolutely par for the course and just involves some knowledge - I mean maybe from a self-help book, maybe from the answer I give, maybe from reading round about it's not just penetrative, you need to involve the clitoris. So knowledge, self-knowledge, practise, practise with and without a partner can very often help that. And then of course if it doesn't a sex therapist will be able to help.
PORTER
Is anxiety an issue in these people?
QUILLIAM
Well it's the equivalent of performance anxiety for a man, a man doesn't get an erection, worries about, so doesn't get an erection. A woman doesn't get an orgasm and so worries about it and guess what - she doesn't get an orgasm.
PORTER
John, there can be medical reasons for people having difficulty getting an orgasm, not least the medication that we mentioned earlier.
DEAN
Yes I think medication's the commonest biomedical cause of orgasm problems and the most common culprit are antidepressants, both tricyclic antidepressants and the more modern SSRI Prosac-like antidepressants. But orgasm problems are often part of a more complex pattern of sexual difficulty. A woman who has difficulty with an orgasm may be having trouble with desire and may have trouble becoming aroused - getting vaginal lubrication, the swelling, with sexual excitement. All of these things interact to affect sexual satisfaction and the aim of treatment of all sexual problems is not to provide earth shattering orgasms or rock hard erections but to allow the couple to share together an enjoyable satisfying sexual experience.
PORTER
Well let's move on to another of the problems in this field - low sex drive, you mentioned it there - a problem potentially for both sexes. There are numerous factors that can influence a person's sex drive - including stress, ill health, and well simply not fancying your partner anymore. But hormones like testosterone play a role too, particularly in women.
It may come as surprise to learn that women produce the male hormone testosterone at all, but they do, and falling levels occurring around the menopause can affect a woman's sex drive. Especially if that fall is rapid, as happens when ovaries are surgically removed during hysterectomy.
Intrinsa is a new form of testosterone replacement designed to help boost sex drive in women who have lost their ovaries. Consultant gynaecologist Mr Nick Panay explains how it works.
PANAY
The patch is a transthermal sticky flat patch which contains the hormone within the adhesive. The patch is applied usually to the lower part of the tummy, some women choose to wear it on the bottom so that it's not visible and it lasts for three to four days and women can usually have a shower, swim, it doesn't come off and delivers hormone that lasts for three to four days and then the patch requires changing.
PORTER
So it would be two patches a week and therapy is continual. How long would it be before a woman would notice a difference and what sort of difference might she notice?
PANAY
The trials suggest to us that the average length of time for effectiveness to kick in is four to eight weeks. Some individuals may notice a benefit sooner than that, usually within a week or two if that's going to happen quickly but others may notice that they don't have an improvement until 8 to 12 weeks have passed.
PORTER
I know the patch is only currently licensed for use in women who've had a surgical menopause but presumably it has implications for any woman who's been through the menopause whether natural or not?
PANAY
Work has also been done in women who've had a natural menopause using testosterone with oestrogen and also in women using testosterone alone and benefits have been shown in both these groups of women. You're quite right the licence has only as yet been applied for, for women who've had a surgical menopause but we hope that in the future a licence might be obtained for these other groups of women. It's a more difficult situation with a natural menopause because the fall in testosterone levels are less pronounced and in fact testosterone levels start to decline from late 20s onwards. So it's difficult to say a finite event has actually occurred whereby testosterone is required. Individuals may present in their 20s or 30s or may present in their 60s and 70s complaining of the same symptoms. So seeing the wood for the trees can be difficult in those situations.
PORTER
What about side effects, besides obviously improving their sex drive, can the patch cause problems in some women?
PANAY
This is a commonly asked question - is there a problem for women to use what is regarded as being a male hormone? - in fact if you use an appropriate dosage of what is in fact a female hormone and keep testosterones within the natural range, what we call the physiological range, the incidence of side effects is extremely low and in fact in the studies that have been conducted no different placebo to dummy treatment. The common concern is that there would be an excess of hair growth, for instance, either on the body or on the face, my patients say to me I'm going to come back with a beard if I put this patch on. In fact that doesn't happen. Yes in a very small group of women who have hormone levels, testosterone levels, at the upper end there maybe a little bit of increase of body hair growth but this is entirely reversible and really, as I say, is not a significant problem.
PORTER
And how effective is it in your experience in the right selected, carefully selected, patients, what sort of response rate do you get?
PANAY
The studies that have been conducted suggest a response rate of an increase in sexual frequency by about 75% compared to baseline and a reduction in distress by around 60-70%, the distress caused to the relationship or the individual due to low libido. My own personal experience - some women do extremely well with it, come back and they are transformed, their relationships are transformed and others, admittedly the minority, don't find any difference at all.
PATIENT
Before I used Intrinsa my sexual desire was at a real low ebb, I just wasn't interested at all in it, I was just always too tired and I never had the energy and it didn't really even occur to me actually, it's just not something I really thought about. My relationship with my husband was always affected really by being in the menopause anyway and being very tired and never having any energy but then when you're also not interested in sex as well at the same time it obviously doesn't help but my husband always tried to be understanding and sympathetic but it's - over a long period of time it's not a good thing for any relationship. So after I would say four or five weeks on Intrinsa I just suddenly had so much energy and I just felt a completely different person and well everything in life became much more interesting to me - everything I did - and obviously sex and my relationship with my husband was a big part of that, that suddenly I just became interested again and just like I used to be really before my hysterectomy and before my menopause.
PORTER
One of Mr Nick Panay's patients sharing her experiences of testosterone therapy.
Susan, it seems to have worked for that lady but boosting hormone levels won't help all women will it.
QUILLIAM
Absolutely not, I mean I'm a great fan of medicalisation where appropriate but if I get a letter from somebody who says you know my relationship is awful, he abuses me, he does this, he does that, I'm not in love with him and by the way I haven't got a sex drive then hormones are the last thing she needs. She needs counselling, they need couple counselling, they need to take a long hard look at the way they're running the relationship. But given that you're in a good relationship and particularly if there's a physical cause for the lack of desire then I'm sure Intrinsa will be wonderful.
PORTER
What about boredom, I briefly want to touch on this issue because even in a very happy loving relationship I mean it can be become sexually less exciting than it was?
QUILLIAM
We're programmed in fact after three or four years for our sexual levels to drop with any one partner, you know this is what we now discover is the four year itch, rather than the seven year itch. But with loving communication and yeah you know self-help books or simply talking about it and building in the occasional weekend away or the occasional sex toy, for example, if you've got the communication, you've got the love then you can get the spark back.
PORTER
It requires a bit of investment. John, we talked about falling testosterone levels in women, does the same thing happen in men, presumably it does?
DEAN
Yes there's a gradual decline in testosterone production in men from around the age of 30, it drops by about 1% a year. And probably if you live long enough you will ultimately experience testosterone deficiency symptoms. Low sexual drive, problems with erection, are just some of the symptoms which are experienced, more worrying perhaps are problems with high cholesterol, increased cardiovascular risk, depression and osteoporosis.
PORTER
But is it a common problem, is it something you come across regularly?
DEAN
Yes I see it very regularly, I suspect that probably over a third of the men who I see over 60 are beginning to develop biochemical evidence of testosterone deficiency. That doesn't mean to say they all need treating but it's something that we need to look at.
PORTER
Talking about age and sex, there is a sort of feeling that it's inevitable as we get older, and I mean a lot older than 60 I would hope that everything eventually grinds to a halt but that's not necessarily the case.
DEAN
Not in my experience no, the oldest couple I recall treating were 92 and 86 ...
PORTER
Good on them.
DEAN
... and they were extremely keen for treatment and very satisfied with the outcome. Most couples are still sexually active on a regular basis at the age of 70, that might come as a surprise to many. One automatically assumes that one's parents don't do it and certainly one's grandparents and great grandparents don't do it but they do and they still enjoy it.
PORTER
And Susan one of the big problems in older women is vaginal dryness, it's a common symptom that affects most women to some degree, do you get many letters about that?
QUILLIAM
I do get letters about that, I mean some of it is down to lack of arousal, lack of foreplay, again as we were saying earlier down to lack of knowledge. But it can be biological and that can be helped as well.
PORTER
And John how would you go about helping that?
DEAN
I think that the first thing to do is to ensure that there is adequate arousal and excitement. Our sexual response gets a little slower as we get older but it's still there, so don't be in the same rush for penetration at 60 as you were in your 20s. For women who do have oestrogen deficiency related vaginal dryness which follows the menopause or removal of the ovaries then usually an oestrogen preparation and a topical oestrogen preparation - a little tablet or cream which is inserted in the vagina where you get little or not systemic absorption of oestrogen - can absolutely revolutionise their sexual responsiveness. And because there is so little absorption of this into the body minimal effects on breasts and cardiovascular system as well.
PORTER
And of course that sort of HRT's available from your GP. But how do people get to see you with more complex problems, there aren't many of you are there?
DEAN
No I think there are only four of us in the country who would describe ourselves as sexual physicians, although there are many urologists, genitourinary physicians and a few psychiatrists who provide sexual medicine services, more commonly for men than for women and there are a handful of gynaecologists who are interested in the subject as well.
PORTER
But are there - there can't be anything like enough to meet the demand?
DEAN
There's not enough physicians to meet the highly specialised needs of some patients but family physicians, GPs, can help the vast majority of women, they're very good at helping men and women with sexual difficulties and if they can't help them themselves they should be able to find out where to refer you on to.
PORTER
But we GPs are not clairvoyants, so if you need help you must ask for it.
Well that's all we have time for. Susan Quilliam and Dr John Dean, thank you very much. If you want anymore details on the issues we have covered today then do call our Action Line on 0800 044 044, or visit the website at bbc.co.uk/radio4 - where you can also listen to any part of the programme again.
Next week the Sex Lives of Us season continues with a special edition of Am I Normal. We may have lived through the sexual revolution but are we happier as a result? Or are we too busy comparing our sexual activities to what every one else is doing - or, at least, what they claim to be doing.
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