But, more often than not, this confuses cause and effect. Most of the time we have a condition that is slowly reducing our mobility. In everyday life, we go about our business without any awareness until there is a single twist or turn that brings the problem to our attention. This is not to deny that some people do have traffic accidents in which their necks and spine are damaged, or play sports and pick up injuries. But, most people have a moment when the minor problem becomes more obvious. It is easy to link the cause of the pain with the event and not recognize that the pain has been slowly creeping up on us for months.

What happens then? Well, a lot of money has been spent to convince people that pain is a serious problem. No, really. Even though you might think it is obvious, pharmaceutical companies have to teach you that you solve the problem of pain by buying a medication like ultram. Wherever you look, advertisements sell the idea of science as the best treatment for pain. And there is a lot of science that backs up this idea. Thousands of people have been through clinical trials for medications like ultram and have reported reductions in pain with few side effects. This is all intended to reassure the public. “Look”, it says, “you don’t have to walk around like you’re treading on eggshells. We know pain is terrible but you don’t have to be afraid anymore. Just take this pill.”

But what used to happen in the “good old days”? Well, when the pain got bad enough, a lot of people used to take opiates like laudanum - a tincture of opium. It was notoriously addictive and many would only consider using it when there were no alternatives. The rest of the time, people lived with the pain. This is not what modern capitalism wants us to remember. The pharmaceutical industry needs us to keep refilling the medicine cabinet. But pain management was as much art as science. It varied from relaxation techniques to reduce tension in the muscles and to control fear (when you anticipate pain, fear magnifies the slightest twinge), to religious groups like the Christian Scientists who believed you can transcend pain through prayer.

Now let us be clear. There are some painful conditions like arthritis which so disrupt life that using ultram or an equivalent is entirely appropriate. However, the more quickly you reach for the pills, the less effect they will have over time. Tolerance reduces the effectiveness of almost every medication. So looking at alternatives to painkillers is a good idea if you know that you condition is chronic, i.e. likely to last for some time.

The usual blood pressure test has come and gone, and now the doctor is gently telling you to drop your trousers. This is one of those moments you’ve been dreading and all those questions about Viagra are suddenly less important.

Let’s be clear what’s going on and why. Although your doctor can tell a lot from your medical records and the answers to all those questions, a physical examination is a necessary part of the process. No matter what you may have said or how you may have described your problems, you are not the best person to make a physical examination of your genitals because, quite simply, you don’t know what you’re looking for. There are a number of possible physical causes of erectile dysfunction that can quickly be eliminated by an examination. This means a full examination of your abdomen, front and, sometimes, back.

What? That means I have to take off most of my clothes?

Sadly, yes. Many men are reluctant to take off their boxers, but the doctor really does need full access and, just this once, you have no choice but to allow it. As it happens, this first examination is always fairly nominal. It only gets really invasive if further tests are indicated. Let’s hope for the best.

So, he’s examined your abdomen, prostate, penis and testicles. Some doctors will also do a rectal examination as well. One of the things that must be tested is whether there is nerve damage. This not only means testing your more obvious reflexes, but also checking your sense of touch. So do not be surprised if he prods you with something less than blunt or rubs your skin with something smooth.

This is all in a good cause (particularly, if you can feel every embarrassing touch - that means your nervous system is working as it should).

And, for most men in your position (which can now be a man in motion getting dressed again), that will be that. Only if there is something in your medical records or there has been some cause for concern in the physical examination will there be a need for further tests. Most men do not have a major physical illness or disease. For thoroughness, there can be tests of your blood or urine to make sure that you don’t have diabetes, and in a urine sample, tests for protein to eliminate problems with your kidneys. It is also possible to test your levels of testosterone, but this will not usually be done so long as your testicles are the expected size.

So, it should be good news time. If there’s nothing obviously wrong with your general health and your penis and testicles in particular appear normal, there’s no reason why your erectile dysfunction cannot be treated quite simply.

For this purpose, oral medications such as Viagra, Cialis or Levitra are usually discussed and recommended. Finally, your chance has come to ask all those questions about access to these medications whether with or without prescription. No doubt your doctor will have a view on the reliability of online pharmacies as against your neighbourhood pharmacies. You can explain how you feel about going into a local store to pick up this medication, that you would prefer to buy Levitra online where there is greater privacy. You can hear what your doctor says and make an informed choice.

At the outset, I will warn that attempting to self-medicate with Viagra, Cialis or Levitra when your erections are already painful could be very dangerous. Whenever you have pain whether in urination or an erection, this should be a signal to visit a physician immediately.

I will simply state the fact - cancer of the prostate is the most common form of malignant cancer diagnosed in men. To give you an insight into the scale of the problem in the USA, about 317,000 cases were diagnosed in 2006, and about 41,000 men died. But, only about 15% of the new cases were in men aged less than 65 years. It almost never appears in men under the age of 55 years.

So what is the true scale of the risk?

The answer, as always, is slightly complicated. Globally, about 3% of deaths are, in part, attributable to prostate cancer. But elderly men also have other diseases and conditions that will contribute to the risk of dying, so separating out the cause and effect of each contributing factor is problematic. But, looking from the other end of the telescope, there is a 90% success rate from treatment for all cases of cancer diagnosed early through prostatectomy, beam radiation therapy and other therapies. This treatment will not necessarily cure the ED. It may in fact make treatment of the ED more difficult in the short term despite the availability of Viagra, Cialis and Levitra.

Diagnosis of the cancer depends on the indicators of age, cultural and racial grouping, and whether prostate cancer runs in your family. It is an unfortunate fact that men from the African American community are 60% more likely to get this cancer and twice as likely to die than equivalent white men of the same age and educational background. Similarly, men with a full-blood relative who have had this cancer are twice as likely to get it themselves. Recent clinical studies into the incidence of prostate cancer also appear to be proving an increase in the risk among men with a diet high in red meat and dairy products as opposed a diet of lean meat and low fat products.

Although the mortality rate for cancer has declined by about 4% over the last decade, it is still greater than it was in the 1970s. At the same time, the diagnosis rate has been steadily increasing. Interestingly, the geographical areas with the highest early detection rates do not have the best survival rates. In other words, the survival rates are not determined by when the cancer is first detected. There may also be a problem because earlier post mortem statements of the cause of death may not have consistently identified prostate cancer even though it was the principal cause of death. The bad news is that men who get an earlier diagnosis simply live with the knowledge longer without any guarantee that the treatment outcome rates are improving.

There are two ways in which the cancer can be detected. One is by rectal examination whether physical or digital. The other is the PSA blood test. These tests are poor indicators in the earliest stages of the disease and only become more reliable as the condition progresses. Unfortunately, screening throws up a significant number of false-positive results. This causes what proves to be unnecessary anxiety and forces men to have biopsies taken which is an additional expense. It is therefore uncertain whether the benefits of a more general screening program outweigh the disadvantages. Nevertheless, the tests do remain useful where the medical history and other indicators suggest a greater risk. Even though the blood test may produce false positives or disclose risks that do not manifest themselves in any tumor for ten or more years, the negative results are a relief to those patients.

The available treatments include:

• surgery to remove some or all of the prostate;
• external beam radiation therapy;
• brachytherapy, i.e. radioactive material sealed in seeds is placed next to a tumor;
• testosterone suppression;
• cryotherapy; and
• waiting to see how the disease progresses.

It will be most important to consider your age and whether you have any other conditions affecting your ability to survive surgery and/or radiation therapy. Counselling is of fundamental importance at this time, particularly because the incidence of ED is higher following surgery. In such cases, the standard remedies of Viagra, Cialis and Levitra will not necessarily help so it may be better to defer surgery in the short term.

We got you through the door as a straightforward patient suffering from erectile dysfunction (ED). In the light of the question and answer session and your medical history, we gave you the basic physical and, having found nothing to indicate more serious medical conditions, we discussed which of the three medications, Viagra, Cialis and Levitra, would work best for you. We also considered whether you should buy Levitra or any of the other medications online, looking at privacy vs confidence that you would get the medication you paid for.

But this leaves unanswered the question of what other tests might have been applied. We have all this laboratory space and skilled technicians standing by to do a range of tests. So, rather than leaving them standing around unemployed, let’s run through a few of their tests.

We’ll start with the sex hormones. We can test to see whether there are abnormalities in the levels of testosterone and/or prolactin in the blood. A low level of testosterone can make you less interested in sex and cause an erection problem. Research has shown that men with high blood pressure, diabetes or excessive body weight are twice as likely to have low testosterone levels. The body also produces less testosterone as it ages. This decline usually begins about the age of 40 years and slowly progresses over the next twenty years. It is sometimes referred to as the “male menopause” or “andropause”, but the comparison with women is not justified. When women experience their menopause, ovulation ceases and oestrogen production falls rapidly over a relatively period of time.

For the majority of men, the testosterone levels decline naturally over time, but those levels remain within the “normal” range until death, causing no significant problems. In about 20% of men aged sixty and older, the testosterone levels fall below the normal range and produce testosterone deficiency (TD). In addition to growing older, TD can be caused by damage through injury or disease to the hypothalamus or pituitary gland. If the testicles are damaged, this can slow or stop hormone secretion and testosterone production. This latter condition is known as hypogonadism. TD can have a number of different effects:

• a general sense of tiredness and loss of energy;
• a loss of muscle mass and physical strength;
• a loss of libido or impotence;
• a decline in general awareness, memory and thinking processes; or
• anxiety or depression.

But it is important to recognise that other medical conditions such as liver disease, hypothyroidism and depression can cause these symptoms. Similarly, these symptoms may be the side effects of some painkillers, beta blockers and the medications used to treat anxiety and depression. Further, some men who are generally healthy experience one or more of these symptoms because of declining hormones other than testosterone.

For example a high level of prolactin (hyperprolactinemia) can be evidence of an adenoma (a small benign tumor on one of the glands in the brain). These small growths can affect other hormone levels in the body so that libido falls, ED emerges and infertility may result. When this problem occurs in women, a change in the menstrual cycle is a reliable signal of a problem, but many men are not aware of the problem until they have headaches or eye problems caused by the adenoma on the pituitary gland pressing against the optic nerves. So, if ED is reported, testing for prolactin can represent a test to eliminate a less common cause.

Returning to testosterone, there are a number of products on the market as “testosterone therapy”. Sales are growing quite strongly. In 2004, pharmacies in the USA supplied 2.4m prescriptions for testosterone, doubling the number filled in 2000. No-one knows whether men or women are buying these medications, nor for what purpose. This is a controversial area because there is no scientific view on whether a slow decline in testosterone levels is an entirely natural effect of growing older or it represents a threat to health that must be treated.

Still wearing my physician’s hat, it’s time to reach a conclusion or two. There’s clinical evidence to show that when younger men suffer any serious reduction in their level of testosterone, low sexual desire, fewer nocturnal erections and low ejaculate volume result. All of these problems are reduced with testosterone therapy. So, I am prepared to offer supplementation alongside Viagra, Cialis or Levitra in this kind of case.

But I prefer not to treat declining levels of testosterone in the average older man. There is no clinical evidence to link the age-dependent decline in testosterone production to any precise sexual symptoms, and when supplementation has been given in clinical trials, it has not produced any relief of sexual problems. Thus, if one of my patients has problems of ED and one of the factors is TD, I will prescribe Viagra, Cialis or Levitra, or recommend where to buy Viagra online as a temporary expedient while exploring other treatment options. But I see no reason to hurry to offer any other form of treatment for the TD unless the testosterone levels have fallen well below the norm for men of that age and body weight.

MS affects both the central and the peripheral nervous system. It therefore can produce a wide range of different symptoms. Treating them can make you feel more comfortable even though it will not stop the disease from developing. Some symptoms can be managed by changing your diet, and introducing more physical exercise and other changes of habit. Medications are available for each kind of symptom. Managing your condition involves deciding whether to treat any given symptom as needed or regularly, depending on how inconvenient or painful it is. The symptoms include:

• insomnia and fatigue;
• muscle spasms, stiffness and tremors;
• constipation and frequent urination;
• pain and abnormal sensations;
• depression; and
• erectile dysfunction.

There is an emerging consensus on how to treat MS. There is evidence that long-term treatment with interferon beta and glatiramer acetate can reduce or delay disability if started early enough. It seems that permanent damage to the nervous system is caused during the first phase of the disease. Early treatment can therefore improve the quality of life for those with relapsing-remitting MS. But some people whose initial symptoms are mild prefer not to begin interferon therapy, which causes flu-like side effects, until their condition worsens.

The treatment for the associated ED covers the full spectrum of remedies. The PDE-5 inhibitors, Viagra, Cialis and Levitra have good general effectiveness but, to date, only Viagra has been through clinical tests with MS sufferers. Nevertheless, since they all work in the same way, there is every reason to suppose that all three would help those with MS. But since none of these medications affects libido and depression with MS is quite common, counselling is almost certainly necessary to help couples resume intimacy. Since testosterone deficiency is not associated with MS, it is not helpful to prescribe a testosterone supplement. You should also note that the FDA has specifically warned against the use of Yohimbe for ED without prescription. Apomorphine hydrochloride sold under the brand name Uprima is used in the USA but, after a large scale study in the UK, its use there was discontinued in 2006.

Penile injections or suppositories that are inserted into the urethra are available. You can administer them yourself or your partner can do it for you. For those with MS, there can sometimes be a slight but transient ache from the injections. The resulting erection lasts for about one hour. There are three medications used for this purpose:

• prostaglandin E1 is sold under the names Alprostadil, Muse, Caverject and Edex - this has the best outcomes with the fewest side effects and is the only medication approved by the FDA for this purpose;
• Papaverine is an opium alkaloid used as a smooth muscle relaxant but it has a greater risk of causing priapism and so has not been approved by the FDA for this purpose;
• Phentolamine sold under the brand name Regitine is a vasodilator sometimes used in conjunction with either of the two other medications to improve blood flow.

As an alternative to drug therapy, you can also try the vacuum device which is placed over the penis. When air is pumped out, blood enters the penis and causes an erection. A small band is placed to prevent the blood from draining out and the erection is safe for about 20 minutes. If you have not responded to oral or injected medication, and have found counselling of little use, you may consider a surgically-implanted prosthesis whether semi-rigid or inflatable.

There can be associated problems with stiffness in the legs which make it difficult to maintain the necessary motion or to stay comfortable. Drugs, physiotherapy and experiment with different sexual positions may help. Similar management problems can occur if bladder control is not properly maintained. Again medications are available to keep the problem under control. Other problems of maintaining concentration and inhibition control can be addressed through counselling and behavioural therapy. Otherwise, different symptoms associated with depression and physical causes can be controlled but your physician must be involved at all times to ensure a proper and safe balance between the medications and your sexual needs.

In balancing cost-effectiveness against your safety, there’s one thing we never overlook. Assuming we can rule out heart disease or another condition where it might be dangerous for you to resume full sexual activity, we will always look to relieve your immediate erectile dysfunction (ED) by prescribing one of Viagra, Cialis or Levitra. Your own emotional health and the quality of your relationship with your partner should be protected wherever possible. If you’re alarmed by the prospect of going into your neighborhood pharmacy to collect a prescription, we can look at how to buy Levitra online with reasonable safety.

Endocrine disorders

So, in this article, we’re going to focus on one of the endocrine disorders. Most people know that diabetes can affect sexual performance and the ability to reproduce. But we’re going to look at thyroid dysfunction as a cause of erectile dysfunction. To give you an idea of its incidence, thyroid problems affect 2% of the total population, and about 10% of men over the age of 60 years. Because it’s relatively straightforward to treat, this makes the associated ED reasonably simple to “cure”.

Let’s start by clarifying the terminology. The “thyroid” describes the endocrine gland located near the bottom of your neck. The “parathyroids” to refer to the four to eight hormone-producing glands found behind and inside the thyroid gland itself.

An over-productive thyroid causes hyperthyroidism. An underproductive thyroid causes hypothyroidism. Both extremes cause ED. As we age, the thyroid gland often slows down and produces less than we need. Many men just think they are getting older, and so don’t ask for their thyroid function to be tested. Whether you’re young or old, thyroid dysfunction can upset the hormone balance between testosterone and the allied estradiol. This reduces sperm production, makes you less interested in sex and causes ED. The diagnosis of thyroid problems is not always straightforward. If you have any combination of these symptoms, it may indicate hypothyroidism:

• you feel tired most of the time no matter how much sleep you get;
• you begin to feel the cold more than usual;
• you find yourself increasingly constipated;
• you find that your thinking process are slowing down and you are growing a little forgetful;
• you find yourself waking at night with muscle cramps - this affects you during the day but less commonly;
• your libido falls and you begin to suffer from premature ejaculation and ED;
• your hair begins to thin and fall out; and
• you are depressed.

The following symptoms may indicate hyperthyroidism

• you eat more but lose weight - not always present in older men;
• you are full of energy, always busy and highly productive - you friends and colleagues may think you hyperactive;
• despite the level of mental activity, you can often feel physically weak;
• you feel warm even though those around you think it is quite cool;
• you often feel that your heart is racing even though you have not been physically exerting yourself;
• if you hold your hands out, you can see a slight trembling in the fingers, hands or arms;
• you find yourself more nervous and anxious, sometimes quite irritable;
• your libido is affected and you have problems of erectile dysfunction; and
• you have problems in getting to sleep or staying asleep for long periods of time.

All these symptoms can have many causes. Only a blood test can confirm the diagnosis. The simplest test relies on the fact that the thyroid regulates the balance of calcium and phosphorous in your blood stream. We therefore draw a little blood to look at both the calcium and thyroid hormone levels. If the test confirms a thyroid problem, there are relatively inexpensive medications available to correct the balance. In more serious cases of hyperthyroidism in younger men, surgery may be considered.

If you are older, the treatment to balance your hormone levels should be done gradually. Older hearts may find the changes stressful. The beats may temporarily grow irregular and you may experience chest pains. And to dismiss one other possibility that may be lurking in your mind, the incidence of thyroid cancer is rare and, even if you are unlucky, these tumors are often easier to treat successfully than other kinds of cancer.

Study

In a recent study* Italian researchers examined the relationship between thyroid problems and sexual performance.
The study looked at 48 adult men, 34 with hyperthyroidism and 14 with hypothyroidism. The majority experienced some sexual dysfunctions, most of which were reversed when the thyroid hormone levels were normalised. The most common dysfunction affected ejaculation. That almost all these problems were immediately resolved suggests that the thyroid hormones regulate the physiology of ejaculation and are closely associated with ED.

*The Journal of Clinical Endocrinology & Metabolism Vol. 90, No. 12 6472-6479

If you look at the roll call of celebrities who claim shyness as children, it may seem like an epidemic but it reflects a more serious truth. At some point or another, most children will feel shy. There are always going to be moments when they doubt their abilities to do something. If there is an audience, this performance anxiety can become more intense because, even as adults, we feel hurt when our best efforts are mocked by our peers. Which makes it all the more surprising that so many who have worked in the theatre or films were encouraged to overcome their shyness by performing in public. It feels “counterintuitive” until you consider the alternatives.

The ordinary social situations should all become “safe” territory for us as we gain experience and advance into adulthood. But, so many of those who do feel more seriously anxious are being encouraged to accept the idea that their first reponse should be to take medication. There are three classes of possible “help”: beta blockers, one of the benzodiazepines like Xanax or one of the Selective Serotonin Reuptake Inhibitors like Paxil. These and other antidepressants are more likely to be covered under health insurance schemes in the United States whereas behavioural therapy and psychologists are not. Even the waiting times to see regular doctors are growing longer as fewer opt for general practice as against the higher status (better paid) world of hospitals. The consequence is that prescriptions following minimal consultations have become the norm. No more preventative medicine. Just a booming pharmaceuticals industry and hospitals when the people or the medications fail.

When time was cheaper, more might have tried therapy. Now it is try self-help. If that does not work, try Xanax. The problem is that no medication is without side effects, and it is often the case that once you start on a pill, it becomes a crutch that has to carry you for a long time. The question is going to be how badly your life is being affected by the current levels of shyness (which is nothing more than anxiety applied in social situations). Some doctors argue that starting you on Xanax early is better because it also relieves some of the symptoms that might develop into more serious depression. If you are less depressed, you may do better with self-help. In other words, Xanax does not cure your social problems for you, but it makes them more manageable so that you can do something about them through self-help or therapy.

When you start to take Xanax, you have to practice in social situations. The more you interact without problems, the more your self-confidence will grow and the more your social anxieties will ease. As role models, check out the list of Hollywood celebrites who overcame their problems by rehearsing and so learning how to act on stage. You can do the same on the stage of everyday life. Xanax is a means to this end. If you make Xanax the end, the likelihood is that you will become dependent on it and face all the personal, medical and legal problems that go with addiction as in the sad case of Heath Ledger, a celebrity who lost control of his addiction to Xanax.

Some worked with a registered dietitian. Jon S. says, "I got to a weight that was healthy and tried to adjust my lifestyle so my eating and exercise habits maintained my new weight. But it seemed that I kept losing weight. Eventually, I met with a dietitian to make sure I was able to find that [calorie] level to maintain while in my new lifestyle."
Some went by trial and error and used the scale as a guide. Wes G. says, "It was trial and error. I paid attention to what I was eating and weighed myself once a week. If I was up a little, I’d cut back. At that point, I was familiar enough with the foods I was eating to know where I was getting too many calories."

Some used the same strategies that they used to lose weight but ate a little more. Ally S. explains, "I started adding a little back to every meal. For example, I used to only have one serving of cereal with milk for breakfast. Now I have two servings of cereal and milk. Instead of just a yogurt and salad for lunch, I’ll now have yogurt, salad, and carrots with peanut butter."

Some learned more about the nutritional value of foods. To figure out what she could eat to maintain her slimmer weight, Margaret G. educated herself through magazines and sites. However, she says, "I think I might have taken it a bit far with learning things that were too specific, such as calorie counts and specific vitamins. I definitely don’t follow that now, but I’m aware of what I eat. I’m able to make healthier choices without over-obsessing on what I’m consuming."

Some took advantage of exercise. Stina B. had on her list of transition strategies, "And, of course, exercise, exercise, exercise!"

Phentermine is the best appetite suppressant

Some tuned in to their bodies. Amber M. emphasizes, "Being able to recognize biological hunger from psychological hunger is very important." She says it took her a long time to make the distinction. Aaron T. says of his transition, "I think that part of what happened was a reformation in the way I think about food. Now my body just knows what to eat and how much."

There’s some evidence that these strict diets do not have an advantage over diets that are less restrictive. In fact, Dr. James Anderson, who has conducted research on VLCDs in adults, feels that there is no advantage to having teens on such diets. "I think teens who need an intensive approach do as well when eating 1,000 to 1,200 calories per day, and I no longer use diets that are lower in calories than this," he says.

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