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Saturday, April 7, 2012


When a man has problems in bed, it is hard to determine if the issue is hormonal, anatomic, or low desire…. And what if it is a problem with LOVE??? ….

When discussing sexual problems in men, premature ejaculation is the most common sexual dysfunction according to the Journal of the American Medical Association. Erectile dysfunction is also very common, and men surely don’t have a problem talking about it. Even a former presidential candidate has discussed this issue in detail on national television. Low sex drive, low libido, or low "mojo," as Austin Powers would put it, for men on the contrary is one of the biggest issues for men.

Men who have a reduced sex drive don’t want to talk about it, and their partners have a hard time talking about it as well. A recent telephone survey of 1,000 American adults (18 years of age or older) reveals that just 50 percent of men polled would contact their doctor if they experienced a diminished sex drive. Men usually are embarrassed by this issue and rather not address it at all. In men, low libido makes them unhappy about the rest of their lives more so than it does to women. According to Dr. Edward Laumann, co-author of The Social Organization of Sexuality: Sexual Practices in the United States, only 23% of men with loss of libido say they still feel very happy about life in general versus 46% of women with loss of libido.

Women are afraid if they say much about their spouse’s issue, it may put in question their relationship, the love they have for each other and even their partner’s sexuality. When women were asked how their partners would react to diminished sex drive, only a third believed their partners would contact their doctors.

Overall, low libido in men is a much more common complaint than our popular culture would seem to indicate. The causes of this complex problem range from the physical and medical to the psychological and social. And keep in mind, quick fixes don't solve everything.


Impotence and loss of libido are two very separate things. However, men who experience impotence commonly experience a decrease in libido over time.

Impotence is also called erectile dysfunction (ED) and is characterized by the regular or repeated inability to develop or maintain an erection of the penis during sexual performance. ED can also be evident when it is difficult to obtain full erections early in the morning or when asleep – these are times when the mind and psychological issues, if any, are less present. It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. ED has been associated with aging. Only 7% of young men report being unable to keep an erection, and then it becomes 12% by age 40, 18% for ages 50-59; and then a sharp rise by age 60 to 25% to 30%. (Laumann)


Libido is a more complicated problem. What defines a low libido for any person, and more specifically for men, is subjective and depends upon many variables. Physical health and mental health are key factors that play a role in libido, yet this issue has also been associated with aging. Low desire is defined by the person who has it. A man has to ‘perceive’ his libido as low when compared to his previous activities and desires, and he has to identify it as a problem that is distressing to him. A partner may have a vote in the matter and may have brought up the issue, but it is really a very personal thing. In general terms, low libido is defined as a lack of interest in sex for several months over the past year as compared to your normal interest.

There is no pre-defined number of times a couples needs to have sex in order to have a good sex life, and for that matter a good and healthy intimate relationship. It is about communication and compatibility as well as communication and understanding of each other’s needs. For some couples, sex is not a high priority, and they have more enjoyment laying together, hugging, and enjoying each other’s embrace. For other couples, sex is a very important part of their relationship and can clearly notice when there is a change.

Loss of libido in men, or inhibited sexual desire, stresses a marriage more than any other sexual dysfunction. Losing interest in sex may not be as common an occurrence for men as it is for women: It affects about 15% to 16% of men, and at 30-40% of women. In men, losing their ‘mojo’ or interest in sex has been described as being very threatening.

There is no national average for sex drives for either men or women. Assigning a number to normal frequency of sex is nearly impossible just because the premise by which sex is initiated is a very personal one, and varies from individual to individual and couple to couple. What is MOST important is that the couple is HAPPY and in LOVE. It does not matter what the Jones’ are doing…..

Low libido is one of several symptoms of low testosterone. The U.S. Food and Drug Administration (FDA) estimates that four to five million American men may suffer from low testosterone, but only five percent are treated. Low testosterone is characterized by conditions, such as diminished interest in sex, erectile dysfunction, reduced muscle mass and strength, osteoporosis, depression, and fatigue. When testosterone levels dip below the normal range, men may begin to experience these symptoms. In my next blog, I will more specifically discuss the problems with low testosterone in men.


How do you know if you have a problem with loss of libido or erectile dysfunction?

Libido loss doesn't usually happen suddenly - It is usually a gradual process. If you're not happy about your loss of desire, researchers agree that it is best to try to address these problems before they get worse. Here are some questions that can help you identify the early warning signs. Answer them in a range of 10 if this happens often, and 0 of this does not happen at all.

1. In the last 3 months intimate touching ‘only’ takes place in the bedroom.

2. In the last 3 months you have not felt that sex gives you feelings of connection and sharing.

3. In the last 3 months your partner has always been the initiator

4. In the last 3 months you have felt pressured to have sex

5. In the last 3 months you have not looked forward to sex

6. In the past 3 months you have felt sex is mechanical and routine

7. In the past 3 months you have not had sexual thoughts or fantasies about your spouse

8. In the past 3 months you have at most had sex once or twice

If you answered between 60 and 80 you have a significant problem and it would be beneficial to discuss it with your partner, and consider visiting your health care provider. If you answered between 40 and 60 it would be healthy to start a conversation try to devote more time to the relationship and promote opportunities to communicate openly and intimately. If you answered 40 or less, you may be in a group that is not necessarily having a problem. Again, this is a very personal issue and a simple questionnaire like this is merely a guide to generate awareness.

Given that erectile dysfunction may lead to low libido, and on the other hand, when libido drops there may be some effects on potency, it is important to start by understanding ED. There are no formal tests to diagnose erectile dysfunction, but tests can be run to exclude underlying disease processes that can make ED worse, such as diabetes, cardiovascular disease, peripheral vascular disease, low testosterone (Hypogonadism), prolactinoma, poor physical health, poor dietary habits, obesity and substance abuse such as illicit drugs and alcohol among others.

The first and hardest step is to try to determine if the problem is physical or psychological, yet it is almost always a mix of both. There are tests that can be done to determine an anatomical reason to the ED, and if this is the case, then proper interventions can be put in place which include proper medications.

Tests that can determine if ED is a purely anatomical / biologic problem:

1. Blood tests: Comprehensive Metabolic Testing to measure sugar levels, liver and kidney function, HbA1c, Luteinizing Hormone (LH), Follicular Stimulating Hormone (FSH), Prolactin (PRL), Free and Total Testosterone, DHEA-s, are some of the blood tests that need to be considered when there is an ED-Libido problem.

2. Complete history and physical, which includes a penile and testicular exam.

3. There are several neurologic tests that can be performed to determine if a person has ED: the most popular one is the bulbocavernosus reflex test. This test is used to determine if there is sufficient nerve sensation in the penis. This test is done when the doctor squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. If it takes a while for the anus to contract, there may be a problem.

4. Duplex ultrasound: After the injection of prostaglandin, a hormone-like stimulator that induces erection, ultrasound is then used to see vascular dilation and measure penile blood pressure. Arterial and venous blood flow is measured, and signs of atherosclerosis, scarring or calcification of the erectile tissue are determined.

5. Nocturnal penile tumescence (NPT): This test measures the changes in penile rigidity and circumference during nocturnal erection.

6. Penile biothesiometry: This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis.

7. Dynamic infusion cavernosometry (DICC): During this test, fluid is pumped into the penis at a known rate and pressure, giving as a result, a measurement of the vascular pressure in the penis during an erection.

8. Magnetic resonance angiography (MRA): This is similar to magnetic resonance imaging, but in this case, the magnetic fields and radio waves provide detailed images of the blood vessels by injecting a "contrast agent" into the patient's bloodstream that makes the vascular tissues more visible allowing the evaluation of vascular abnormalities.

When these tests are not available, or you are more interested in determining if low desire is the issue consider this:

1. Performance Anxiety: Men report two major problems -- climaxing too early and anxiety about performance. Almost one in three men report premature ejaculation, and about one in five men are worried about performance. Many loving, and conscientious husbands feel they have not truly "performed" unless their partners climax during sex, too. This is a problem, as only 26% of women report that they always experience orgasm during sex, compared with 75% of men- and performing under pressure can cause loss of libido.

2. Any medical problem or chronic physical condition can reduce a man's sex drive; even minor illnesses can diminish a man's sexual interest. Diabetes, cardiovascular disease, high blood pressure, pituitary disease, testicular disease, thyroid disease and depression are definitely the worst offenders.

3. Alcohol even in moderate to low use can damper libido. Alcoholism is known to have an effect both psychologically and anatomically with negative effects on libido and potency associated with low testosterone.

4. Many prescription drugs can cause a decrease in libido, and these are mostly prescription antidepressants, tranquilizers and blood pressure medications.

5. Illicit substances, such as heroin, cocaine, and marijuana, when used heavily and chronically will definitely affect libido.

6. Stress, stress and stress some more: any kind of serious stress -- whether related to work, relationships, or any other area of life -- is going to diminish your sex drive. Being angry, hurt, and scared will surely compromise your desire to be intimate.

7. Fatigue: Being tired is an all-encompassing nemesis of sex.

8. Decreased communication: couples often don’t talk about sex, what turns them on, what time it takes to get there, and what they have as prior expectations of each other at the encounter. Couples not always know the issues at hand and when introducing the conversation, it is like a heavy weight is lifted, and then the work of intimacy can start. The meaning of sex can be very different for each partner and it can change over time in a relationship.

9. Marital anger: For couples that have been together for a long period of time, anger can stand in the way of sexual desire. The paradox of sex is that you have to ‘totally’ become yourself. But it also leaves you naked, and safety is a big factor when trust may be an issue.

10. Self-esteem issues: If a man’s self-worth is challenged or he feels he is not achieving his goals or is feeling unchallenged, he often may numb his sexual desires as a form of non-deserving behavior.


Every marriage has its ups and downs, and it is when the marriage is down that risks need to be taken in order to save the marriage. When couples hit a rough spot where do you turn? Not everyone is open to marriage counseling, and even then, every marriage is different and what works for one couple may be quite well what drives another right into the arms of divorce. Loss of libido is not something you have to live with. There is much you can do to regain your sex drive and your happy outlook on life. The advice needs to be centered into understanding that more is not necessarily better, but quality is paramount. Feelings count, and an individual needs to feel good before, during and after the encounter.

1. Provide the opportunity for renewal as a couple, intimacy and private time. Make the time for pleasure and intimacy on a routine basis.

2. Talk about what you like: Talking is hard in the best of times, but even harder if you have been avoiding sex. If talking is difficult, there are plenty of excellent books and blogs (including this one) that can be read together. As you let your partner know that you are interested and gently open without judgment, it can open a door to intimacy and love.

3. Start a healthy diet and exercise program: Get physical and start a cardiovascular routine, consider dancing and doing activities as a couple.

4. Keeping expectations real: Probably only about 40% to 50% of sexual events can be mutually satisfying (McCarthy). Take the pressure off the performance and embrace the moment as intimate and pure.

5. Use Imagination to fight loss of libido: Explore your mutual fantasies, talk about them and start making new ones together.

6. Planning time out- As spontaneity is more difficult with the pressures of daily life, make the time and plan it out. The anticipation of the date, the pleasure of the details such as a gift, new lingerie, a gift for your partner, get your favorite CD, turn off the phones and even get a sitter can light the fire and avoid interruptions.

7. Take time for the big picture: For men, focusing only on one body part, can be stressful, but if on the other hand, focusing on the entire body, discovering new erogenous zones, may allow for the encounter to be pleasure oriented and not ‘goal’ oriented.

8. Go out with together with and without friends, but try not to isolate. You get to dress up and look desirable, and so does your partner. Desire feeds on newness. Look at how other partners interact. You remember why you were attracted to each other in the first place.

9. Visit your doctor together, consider talking with a couple’s therapist, speak out, help is out there…..

In summary, it is hard to determine what the problem is when there are issues in the bedroom. But it is even harder to suffer in silence. Erectile dysfunction as well as low libido in men can be treated, either individually or together with lifestyle changes and medications. Treatment can also be geared to improved couple communication and understanding. Medical issues can be addressed, learning about the problem and even reading about how others have overcome it allows for hope, and working on how a person as well as the couple is dealing with it can be the light at the end of the tunnel for many suffering in loneliness and insecurity. Before you decide to continue without doing anything, and even considering a break up or divorce, give yourself a chance and get the facts, and get the help that you well deserve…..

Thank you for reading,

Margarita Ochoa-Maya, MD

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