This meeting and this conference is about men’s health, about male aging. The question is, does men’s health, does male aging have a portal, have an entry point. Is there a way we can get to the minds and hearts of men out there? What can health care professionals such (as) us do to attract the attention of men out there to attend to their health? I would like to share with you a journey that will show us that maybe sexual health is the portal to men’s health. Maybe it is the secret that we can use to access the minds and the hearts of men out there so that they can improve their health and improve their lives and enjoy their life.
The question is, why did we choose sexual health to be the portal to men’s health? I would like to say that we have ten reasons to make this statement. On this slide we have five of them. The pathophysiology of sexual function involves multiple organ systems and involves the integrity of multi-organ systems, such as any failure in one of these organ systems, which can happen with many diseases, can contribute to reduction in overall health, and reduction in sexual health. The epidemiology in studies, cross-sectional, longitudinal, many different studies have confirmed a strong association of erectile dysfunction with cardiovascular disease, a strong association of hypogonadism, with the metabolic syndrome and diabetes. Furthermore, erectile dysfunction has found to be a marker of cardiovascular complications of hypertension. Erectile dysfunction is a predictor in longitudinal studies of the metabolic syndrome.
The other five reasons include hypogonadism as a predictor years in advance of development of diabetes type II, not only on the observational side, but also on interventional. In interventional studies we can see that treatment of obesity, which is a major public health issue, improves erectile dysfunction. Treatment of erectile dysfunction on the other hand has been shown in well-controlled studies to improve co-morbid depression, and we all know the morbidity of depression to the overall health. And most exciting, recent research showing that we can create calculators. We can do it both ways. We can calculate erectile dysfunction risk from overall health, or, we can calculate overall men’s health risks from erectile dysfunction. These are the ten reasons to believe that sexual health is important to men’s health, and let’s go through the journey of each item of this one by one.
First the pathophysiology involving multiple organs; involving the nerves, involving the vessels, involving the hormones. This major involvement of sexual function makes it very logical that if we have any disease that interferes with the central or peripheral nervous system, any disease that interferes with the endothelial functions, smooth muscle function, vascular disease, will end up having a sexual health impact. Not only that, hormonal disturbances will also affect sexual function. This title here of the slide was voted upon by my medical students in Columbia University as the best description of erectile physiology. They said erection is a neur0-vascular reflex, which is a very sophisticated complex reflex involving inhibitory and facilitatory factors but that reflex functions in a hormonal, androgenic milieu.
If we look further at the path of physiology at the epidemiology, cross-sectional studies, longitudinal studies have confirmed the association of erectile dysfunction with aging. As we see in this presentation from the Massachusetts Male Aging Study not only the prevalence of erectile dysfunction is associated and increasing with age, the severity of erectile dysfunction increases with aging.
We can see that not only in the Massachusetts Male Aging study in the United States, this cross-national survey on men’s health looked at six countries; Unites States, France, Germany, Italy, Spain and the United Kingdom, confirming a strong association of erectile dysfunction with aging.
In the same study subjects, there were about 30 000 subjects in these six countries, were asked one simple question, “How would you rate your own health”? They were given four choices: excellent, good, fair and poor. Ladies and gentlemen, think with me this one single, simple question to rate overall health in 30 000 men, as we see here about a quarter to a third of men answered excellent. So, only a quarter to a third would rate themselves as being in excellent, overall health. One would wonder what this would do to sexual function and erectile function if you rate yourself as excellent versus good.
Here is what it looks like if you look at the odds ratio of having erectile dysfunction if you rate your overall health as good versus excellent you double your chance of having erectile dysfunction. If you rate your health as fair compared to excellent you triple your chance of erectile dysfunction, and if you think your health is poor, then your chance of having erectile dysfunction is five times higher such an intimate relationship of erectile dysfunction and the person’s perception of overall health. Keep in mind that the study was done in doctors’ waiting rooms. These were 30 000 men who were accessed in doctors’ waiting rooms and they were given a questionnaire. They could have been in the doctors’ waiting room for any reason. The age range of these men is 20 to 75, which is an important thing because we, the healthcare profession, should be interested in the younger men, we should be interested in the middle-age men because those are the ones that are aging and that is where preventative medicine could play a major role.
In the same study we took the data and looked at the presence or prevalence of, major men’s health issues such as hypertension, hyperlipidemia, heart disease, diabetes, depression, and we looked at the data divided by either having mild erectile dysfunction, mild to moderate, moderate or severe, according to the international index of erectile function, the IIEF. As you see here, in every single category of men’s health problems, the severity of ED determines the prevalence of cardiovascular disease and other men’s health problems increases with the severity of erectile dysfunction. So it is not only yes or no, you have erectile dysfunction, how severe your erectile dysfunction will determine your chance of having men’s health problems.
If we look further, at hypertension for example, this elegant study from the Francois Giuliano lab in Paris, France, showed that if you looked at laboratory animals, such as there mice that naturally develop hypertension you will find that the magnitude of erectile dysfunction is significantly higher than control animals. You will see also that the onset of erectile dysfunction precedes hypertension. These are laboratory animals that are destined to become hypertensive but erectile dysfunction in these laboratory animals precedes hypertension with proven histological changes in the erectile vascular tissue, including changes in the collagen. So, erectile dysfunction could be an early warning sign of hypertension.
In this study on coronary artery disease, two groups of men, one with ED and one without ED were investigated with calculation of their risk for coronary artery disease in ten years. The study showed that there was an increased ten-year coronary artery disease risk in men with erectile dysfunction. And those who had erectile dysfunction had a 56% chance of having coronary artery disease in ten years versus 32% in those that had no erectile dysfunction. The two groups were matched for age, diabetes, hypertension, angina, depression and BMI. So, erectile dysfunction stood out by itself to be a predictor of their coronary artery disease.
Looking at very large databases, for example this study that was presented at the American Society of Andrology looking at data from health insurance and health care panels, including 28 million members and choosing an ED cohort of 285,000 men, and a non-ED cohort for comparison of 1.5 million men. It was possible to do a multiple regression analysis to calculate the predictor power of erectile dysfunction of having diabetes.
It was possible to plot the odds ratios of having diabetes in these men with erectile dysfunction over the years. An interesting thing is that the odds ratio went down to around 1.0 after age 50, which is very understandable because after age 50 the mathematical effect of aging was great. It wipes out the effect of erectile dysfunction. But we are interested, as I said, in capturing these disease processes early. If you look in men age 20 to 50 you will see a very respectable odds ratio of developing future diabetes if you have erectile dysfunction. As a matter of fact, about age 30 – 35 the chance of having diabetes if you have erectile dysfunction is about 3.0. So this is a very respectable predictive value of erectile dysfunction, of sexual health predicting overall men’s health and sexual health being a portal to men’s health.
One of the issues of men’s health is prostate problems, prostate symptoms, or what we call lower urinary tract symptoms – LUTS. And here we can see in a number of studies repeatedly, that the chance of having erectile dysfunction is almost doubled if you have lower urinary tract symptoms.
Not only on the physical side, but also on mental health side, erectile dysfunction is associated with depressive symptoms. This is a population of clinic patients that came to our urology department complaining of ED only, benign prostatic hyperplasia symptoms only, or both. If we surveyed them for depressive symptoms, we can see that depressive symptoms were doubled if you had erectile dysfunction.
This association of depressive symptoms and erectile dysfunction was re-confirmed also in the Massachusetts Male Aging study not only at the prevalence level, but also at the severity level. The more severe erectile dysfunction -- the more severe the depressive symptoms.
So here we are starting to see from the epidemiology an emerging association of sexual health issues, such as erectile dysfunction, and hypogonadism with major morbid conditions of men’s heath, including diabetes, cardiovascular disease, depression and BPH.
And hypogonadism, ladies and gentlemen, has been significantly associated with the metabolic syndrome, which as we know, is a major public health issue, and is a pathway to disease. The metabolic syndrome will end up in the future with diabetes, will end up in the future with cardiovascular disease and ultimately with cardiovascular events, such as heart attacks and strokes. After adjusting for age, men with hypogonadism have a 2.3 – fold increase of insulin resistance and diabetes.
This is an excellent presentation from the Massachusetts Male Aging study showing that a reduction in the free testosterone of one standard deviation increases the chance of having future, this is a longitudinal study, of having in the future diabetes type II by 58%.
In our clinic at Columbia University we looked at men who presented with hypertension and surveyed them for erectile dysfunction. We found that the majority of them, 68 percent had ED. The majority of those who had ED had mild to severe ED, but more interestingly we found that men with hypertension plus ED had more complications of their hypertension, meaning MI and stroke, than men with hypertension and no ED.
A recently conducted study in collaboration with the Massachusetts Male Aging study and the New England Research Institute that was presented last year at the AUA meeting in the United States showed that erectile dysfunction was longitudinally a predictor of the development of the metabolic syndrome, especially in men with low BMI. And why low BMI? If you have a high BMI you are destined to have a high risk of the metabolic syndrome anyway. So, it is not a big discovery. But if you have a low BMI maybe erectile dysfunction is an early warning sign of the other ED. You know we have two EDs, erectile dysfunction and endothelial dysfunction.
If we look at the predictive value this is the relative risk of having a future metabolic syndrome if you have erectile dysfunction. It is a double chance if you have erectile dysfunction that in eight years from now you will develop the metabolic syndrome.
This was an excellent study that was done by a group from Italy looking at obese men who lost weight in a well-organised program. In this study it shows that weight loss, this is one of the major issues in men’s health, results in improvement in sexual function. Here is the IIEF erectile function domain score in those who lost at lest ten percent of their body weight. Erectile function improved without pharmacological intervention on erectile dysfunction.
Improvement of sexual health and improvement in erectile dysfunction has been shown in two well-controlled randomised studies to be associated with improvement of co-morbid depression. In this randomised controlled trial on sildenafil, those that responded in the treatment of erectile dysfunction did improve their depressive symptoms in a number of measures.
A similar observation was also made in an excellent study randomised controlled trial of vardenafil in the treatment of men with erectile dysfunction and co-morbid depression.
Recently I had been thinking about sexual health being important to men’s health. What can we do with that? One day I was looking on the internet and I saw a number of calculators. You can calculate your home mortgage loan, you can calculate your retirement, these are calculators you enter data and they give you an output of some projections. And I thought we men, we deserve some calculator. We should have a calculator of our own health. Maybe sexual health would be one of the portals of this calculator. Then I looked further in the European Urology Journal we see this excellent paper looking at data from the Cologne survey, from the Berlin study and from the MALES study. They combined data from three studies and published this excellent paper on creating a men’s health calculator that calculates the risk of having erectile dysfunction.
The way this works, you enter your age, whether you had pelvic surgery, diabetes, arterial circulatory disorder, heart disease, smoking or hypertension and the output will calculate your chance of having erectile dysfunction.
And this is the way it looks, very simple. You have a point system. The point system which assigns a certain point to age, pelvic surgery, diabetes, etc. and then when you add your points you can calculate from this table your percentage chance of having erectile dysfunction.
Following this, I did some collaboration and work with the Bayer Health Care team and the GSK team on the MALES study. What is the MALES study? The MALES study was an excellent international survey that recruited men from eight countries. In phase I, which was in 2001, the study population was almost 28000, and it collected demographic information, prevalence of disease, and overall health.
Later, in phase II, those who reported erectile dysfunction were studied in-depth further about their erectile dysfunction. In 2004 a longitudinal database was created by studying the same population again. So I thought this created a great opportunity to look at the possibility of developing the other calculator. Maybe we can calculate men’s health based on sexual health.
So working with mathematicians and statisticians a scoring system, or calculation system, came about. Here you can see a simple question about your own perceived health status. Whether you have ED or not, whether you have a sexual partner, and your waist size. Here you see a beautiful marriage of sexual health issues, such as erectile dysfunction and major public health issues, and metabolic issues such as waist size. As we know abdominal obesity is one of the very important predictors, and one of the very important components, of the metabolic syndrome and hypogonadism. And here you see the mathematical value.
I would like to share with you a hypothetical man. This hypothetical man is a male aged 40 years with severe ED, not taking medications. He rates his own health as 1 on a scale of 1 to 7, which many men do by the way, many men live in denial, “I’m in excellent health of course”. He reported however, a waist size; whether he admitted it or not, it was measured at 40” and he had a sexual partner. Now this is a typical middle-aged man that we see in practice. Let’s put his numbers in the calculator, we will put his numbers and then do the values here, do the math, and we come up with a score of 3.
If we go further, we can see how the mathematicians recommended having a high risk, medium risk or a low risk of developing hypertension, or having hypertension, diabetes, coronary artery disease, or hyperlipidemia. And our man’s score was obviously a high risk. He is at high risk. If we go back, we can see his high risk came from two components: if you look at his health status and having a sexual partner mathematically wipe each other out. He has severe ED and abdominal obesity. Now if we think just to see the contribution of erectile dysfunction here, if this man did not have ED, his risk will go from high risk to medium risk. So here we see, truly, sexual health as the portal to men’s health.
I think after this journey in the ten reasons why sexual health is the portal to men’s health, we can all ask the question; how can sexual health not be the portal to men’s health? With a pathophysiology involving so many organ systems, cross-sectional and longitudinal epidemiological studies showing such association of erectile dysfunction and hypogonadism to overall health, erectile dysfunction being a marker of cardiovascular complications of hypertension, erectile dysfunction being a predictor of the metabolic syndrome.
Hypogonadism being a predictor of diabetes type II, treatment of obesity improving erectile function, treatment of ED improving co-morbid depression and finally, the ability to calculate sexual health from overall health and overall health from sexual health.
Thank you for your attention.
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