Women lead stressful lives. They do home management, do trouble shooting, manage kids, and cater to in-laws and relatives. This lifestyle hardly leaves room for them to think about themselves. A married life is equivalent to never ending series of duties. This leaves them with stressed out mind and body.
Studies show that if the woman is content in her marital life, her husband is happy with life in general. It definitely pays men with a happy life scenario when they keep their wives satisfied in marriage. Women need care and attentive listening apart from the financial and social security. So all you men should keep your spouse happy to make your own life happier!Alok adds : There will be some who can not be satisfied or made happy but above will work for most women.
Read the study in detail at Tasnimnews.com
Thursday, February 12, 2015
Wednesday, February 4, 2015
Vitaros may come to India which is a better alternative to Viagra
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8:01 PM (16 hours ago)
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Dear Alokji
Good news for the ED topical cream alternative which can become OTS and will fetch good revenue; useful for diabetic and heart patients without major side effects.
currently we chemist cannot dispense sildenafil formulations without prescription.
Regards
Anil
On Wed, Feb 4, 2015 at 6:49 PM, Alok Tholiya <atholiya@gmail.com> wrote:
Apricus Biosciences Expands Exclusive License Agreement With an Existing Partner to Market Vitaros(R) in Select Asia-Pacific CountriesApricus Eligible to Receive an Additional Upfront, Milestone Payment and a Double-Digit Royalty on Net SalesFebruary 03, 2015: 04:05 PM ETSAN DIEGO, Feb. 3, 2015 (GLOBE NEWSWIRE) -- Apricus Biosciences, Inc. (Nasdaq:APRI), a biopharmaceutical company advancing innovative medicines in urology and rheumatology, today announced that it has further expanded its exclusive license agreement with Hexal AG, an affiliate within the Sandoz Division of the Novartis Group of Companies ("Sandoz"), for the commercialization of Vitaros®, Apricus' novel topical on-demand treatment for erectile dysfunction ("ED"). This amendment is in addition to the in-place collaboration established with Hexal AG in Germany in 2012, and the expansion of the cooperation in 2013 to include Austria, Belgium, Denmark, Finland, Iceland, Luxembourg, the Netherlands, Norway, Sweden and Switzerland. This expanded agreement includes Malaysia, Indonesia, the Philippines, Thailand, Taiwan, Vietnam, Hong Kong and Singapore (the "New Territory").In combination with the terms of the previously signed license agreements with Sandoz, Apricus is eligible to receive up to approximately $63.5 million in combined upfront, regulatory and sales milestone payments, which includes up to a total of $6.4 million in upfront and pre-commercialization payments, and a double-digit royalty rate for Vitaros."Leveraging our strong working relationships and expanding our existing Vitaros agreements with our collaboration partners is an on-going key initiative within Apricus," said Richard Pascoe, Chief Executive Officer of Apricus. "Having recently introduced Vitaros in Germany, Belgium and Sweden, Sandoz has set an impressive pace with their launch performance to date, and as such, we are very pleased that they have elected to increase their commitment to Vitaros in these important markets outside of Europe." Mr. Pascoe continued, "Moreover, we will continue to seek value creating partnerships in other available territories in an effort to bring this novel ED treatment to physicians and patients throughout the world."Vitaros is an exciting new entrant into the ED treatment market, offering a range of clear benefits that make it ideal for virtually any ED patient. Vitaros is a topical cream ED medication that delivers rapid onset (generally 5-15 minutes), a treatment duration of approximately 1 hour and an excellent safety profile. Vitaros' local delivery provides a very attractive alternative for all patients, but particularly those with complications that preclude them from using the orally delivered systemic treatments or who prefer to not use the injectable forms of alprostadil.According to the most recent estimates, the global ED market in 2013 was in excess of $5.5 billion annually. Vitaros has the potential to generate for Apricus over $215 million in future milestone payments, as well as additional potential royalty revenue on net product sales based upon double-digit royalty rates through its existing commercial partnerships. In addition, Apricus intends to leverage Vitaros through additional licensing efforts in key markets such a Japan and China in Asia and throughout Latin America.About Apricus Biosciences, Inc.Apricus Biosciences, Inc. (APRI) is a biopharmaceutical company advancing innovative medicines in urology and rheumatology. Apricus' lead product, Vitaros®, for the treatment of erectile dysfunction, is approved in Europe and Canada and is being commercialized in several countries in Europe. Apricus' marketing partners for Vitaros include Abbott Laboratories Limited, Takeda Pharmaceuticals International GmbH, Hexal AG (Sandoz), Recordati Ireland Ltd. (Recordati S.p.A.), Bracco S.p.A. and Laboratoires Majorelle. Apricus' second-generation Vitaros Room Temperature Device is under development and is expected to enhance the product's commercial value. The Vitaros trademark is registered or has pending applications for registration in certain countries and jurisdictions around the world. The mark is not registered in all of the countries mentioned above. Apricus recently commenced a Phase 2a trial for RayVa™, its product candidate for the treatment of the circulatory disorder Raynaud's phenomenon. Additionally, Apricus plans to initiate a Phase 2b trial for fispemifene, a selective estrogen receptor modulator for the treatment of male secondary hypogonadism, chronic prostatitis and lower urinary tract symptoms. Apricus is currently seeking a strategic partner to fund development of Femprox®, a product candidate for the treatment of female sexual interest/arousal disorder that completed an approximately 400-subject proof-of-concept study.For further information on Apricus, visit http://www.apricusbio.com. Forward-Looking StatementsThis press release contains forward-looking statements within the meaning of the Private Securities Litigation Reform Act, as amended. Statements in this press release that are not purely historical are forward-looking statements. Such forward-looking statements include, among other things: references to the planned launches of Vitaros® in various countries by Sandoz; the potential for the product to achieve commercial success generally or in any specific territory; the size of the commercial opportunity for the product; and the timing of Phase 2 clinical trials for fispemifene. Actual results could differ from those projected in any forward-looking statements due to a variety of reasons that are outside the control of Apricus, including, but not limited to: its ability to further develop its product Vitaros for the treatment of erectile dysfunction, such as the room temperature version of Vitaros, and its product candidates RayVa for the treatment of Raynaud's phenomenon and fispemifene for the treatment of secondary hypogonadism, chronic prostatitis and lower urinary tract symptoms in men, as well as the timing of such events; Apricus' ability to carry out clinical studies for RayVa and fispemifene, as well as the timing and success of the results of such studies; potential adverse side effects or other safety risks associated with fispemifene and RayVa that could delay or preclude approval; Apricus' dependence on its commercial partners to increase sales of Vitaros in various territories, and the potential for delays in the timing of commercial launches in additional countries; competition in the erectile dysfunction market and other markets in which Apricus and its partners operate; Apricus' ability to obtain license partners for Vitaros; Apricus' ability to obtain and maintain intellectual property protection for Vitaros, RayVa, fispemifene or any other product candidates; Apricus' ability to raise additional funding that it may need to continue to pursue its commercial and business development plans; Apricus' ability to obtain the requisite governmental approval for Vitaros in the New Territory; and market conditions. These forward-looking statements are made as of the date of this press release, and Apricus assumes no obligation to update the forward-looking statements, or to update the reasons why actual results could differ from those projected in the forward-looking statements. Readers are urged to read the risk factors set forth in Apricus' most recent annual report on Form 10-K, subsequent quarterly reports filed on Form 10-Q, and other filings made with the SEC. Copies of these reports are available from the SEC's website at www.sec.gov or without charge from Apricus.CONTACT: Institutional Investors: Angeli Kolhatkar angeli@areciaadvisors.com Arecia Advisors (917) 387-44770 Retail Investors: Chris Eddy, David Collins apri@catalyst-ir.com Catalyst Global (212) 924-9800
Arginex or Arginin or Gyargin or L-Arginine benefits
Arginin Formel activated muscle build up and maximizes the pump during workout
Nitric Oxide's effects on athletic performance have been the foremost discovery in the sports nutrition sector since Creatine took the world by storm. This molecule, produced inside our bodies, gives the muscles a direct growth signal. And that is merely one of Nitric Oxide's advantages - 3 scientists involved in its discovery have already received the Nobel prize for medicine in 1998.
Arginex activates muscle growth around the clock
The name Nitric Oxide might sound like powerful rocket fuel. In reality, it is a molecule produced inside our body that possesses a veritable plethora of advantages for our health and performance. Scientists have been both baffled and excited by Nitric Oxide. Many at first refused to believe that a single molecule can be responsible for so many functions inside the body. It took Dr. Ferid Murad's, Dr. Robert F. Furchgott's and Dr. Louis Ignarro's winning the Nobel Prize for Medicine in 1998, based on their discovery of Nitric Oxide's signal effect in the body, for its functions to finally be validated and recognized.
What are the main benefits of Nitric Oxide ?
How can you provide your body with more Nitric Oxide?
Many studies show that the body's Nitric Oxide levels can be naturally and safely increased by the correct intake of the amino acid L-Arginine. Based on this research the powerful Nitric Oxide activator Arginex has been developed. Arginex contains the identical 100% free-form L-Arginine used in scientific studies to increase Nitric oxide production. To guarantee L-Arginine's maximum effectiveness, its formula also provides all critical co-factors for the activation of Nitric Oxide.
Arginex activates muscle growth
As has been proven, Nitric Oxide sends a growth signal to the muscle cells. This follows a simple rule: the higher the Nitric Oxide, the more powerful the muscle cells training-induced growth. Regular supplementation with Arginex will lift your Nitric Oxide level and allow you to gain more lean, hard muscle mass along with power, endurance and performance than has ever been thought possible.
Maximizes muscle pump during exercise
Arginex is also a powerful natural vasodilator. This means it expands blood vessels, thus promoting blood flow and enabling an extreme muscle pump during exercise. A high Nitric Oxide level lets you feel this pump not just during workouts but, to some extent, throughout the day. This is a sign that the muscles are continuously flushed with nutrients, allowing them to grow 24/7. This also reduces the muscles' recovery periods and permits maximum performance for the next workout or competition.
Increases growth hormone level
Growth hormone, often abbreviated as hGH, is the human body's foremost anti-aging hormone. It keeps us young, enhances fat-burning and promotes muscle growth. Arginex's L-Arginine is one of the amino acids which can stimulate the natural release of growth hormone. This lets you benefit from all of growth hormone's anti-aging effects without the need for injecting overpriced synthetic hGH.
Enhances potency
It is actually Nitric Oxide that signals the penis blood vessels to expand and fill with blood. The more Nitric Oxide, the stronger the erection. Arginex promotes potency in an all-natural fashion by delivering the building materials to release Nitric Oxide into the penis. Arginex does not immediately develop its full effectiveness but does so only after about a week of regular use. But it is free of side effects and allows you to benefit from all its other health- and performance-related functions. Arginex not only enhances potency, but also the quality of sperm. Studies have demonstrated that L-Arginine improves both sperm-count and -mobility.
Who should not use Arginex?
L-Arginine is known to promote the onset of cold sores (Herpes Simplex). Arginex therefore contains vital elements shown to suppress Herpes. If you are among those people who often suffer from Herpes Simplex, you should test your reaction to Arginex by using small dosages at first and then increasing them slowly. Should you still develop cold sores, you should discontinue Arginex usage. While the amino acid L-Lysine is known to avoid the onset of Herpes Simplex in many people, it is not contained in Arginex as it is a natural antagonist to L-Arginine and renders it ineffective. If you take L-Lysine, never do so at the same time as Arginex but choose a different time of day.
Benefits of Arginex:
Arginex's effectiveness is definitely dependent on its dosage. The more you take, the more Nitric Oxide is produced inside the body. The mentioned dosage should suffice to achieve optimal results. Should you find this not to be the case, the dosage can be increased up to twice that. Studies tested subjects onL-Arginine up to 30 grams. The only side effects were soft stools and iron erections.
How quickly can results be noticed?
After just 5 to 7 days you will feel a powerful pump while working out. Your muscles will feel fully engorged. This pump will not, as normally, disappear about 30 minutes after exercise but continue, to a certain extent, throughout the day. After an additional 2 to 3 days, you will feel increased power and endurance. You will experience a healthy tension in your muscles and notice an increase in solid muscle mass.
Combine Arginex with PowerCreatine for even better results
To maximize muscle growth, Arginex can be combined with PowerCreatine. These two products enhance each other and thus lead to an explosive gain in muscle mass and power. Arginex and PowerCreatine can even be taken at the same time.
Arginex activates muscle growth around the clock
The name Nitric Oxide might sound like powerful rocket fuel. In reality, it is a molecule produced inside our body that possesses a veritable plethora of advantages for our health and performance. Scientists have been both baffled and excited by Nitric Oxide. Many at first refused to believe that a single molecule can be responsible for so many functions inside the body. It took Dr. Ferid Murad's, Dr. Robert F. Furchgott's and Dr. Louis Ignarro's winning the Nobel Prize for Medicine in 1998, based on their discovery of Nitric Oxide's signal effect in the body, for its functions to finally be validated and recognized.
What are the main benefits of Nitric Oxide ?
- The list of Nitric Oxide's functions on the body is a long one. Among its foremost tasks in the areas of sports, muscle growth and health are:
- activates muscle growth
- maximizes muscle pump
- enhances energy, power and performance
- accelerates regeneration
- normalizes blood pressure
- protects heart and cariovascular system
- relaxes blood vessels
- optimizes sensitivity to Insulin
- enhances erectile function
How can you provide your body with more Nitric Oxide?
Many studies show that the body's Nitric Oxide levels can be naturally and safely increased by the correct intake of the amino acid L-Arginine. Based on this research the powerful Nitric Oxide activator Arginex has been developed. Arginex contains the identical 100% free-form L-Arginine used in scientific studies to increase Nitric oxide production. To guarantee L-Arginine's maximum effectiveness, its formula also provides all critical co-factors for the activation of Nitric Oxide.
Arginex activates muscle growth
As has been proven, Nitric Oxide sends a growth signal to the muscle cells. This follows a simple rule: the higher the Nitric Oxide, the more powerful the muscle cells training-induced growth. Regular supplementation with Arginex will lift your Nitric Oxide level and allow you to gain more lean, hard muscle mass along with power, endurance and performance than has ever been thought possible.
Maximizes muscle pump during exercise
Arginex is also a powerful natural vasodilator. This means it expands blood vessels, thus promoting blood flow and enabling an extreme muscle pump during exercise. A high Nitric Oxide level lets you feel this pump not just during workouts but, to some extent, throughout the day. This is a sign that the muscles are continuously flushed with nutrients, allowing them to grow 24/7. This also reduces the muscles' recovery periods and permits maximum performance for the next workout or competition.
Increases growth hormone level
Growth hormone, often abbreviated as hGH, is the human body's foremost anti-aging hormone. It keeps us young, enhances fat-burning and promotes muscle growth. Arginex's L-Arginine is one of the amino acids which can stimulate the natural release of growth hormone. This lets you benefit from all of growth hormone's anti-aging effects without the need for injecting overpriced synthetic hGH.
Enhances potency
It is actually Nitric Oxide that signals the penis blood vessels to expand and fill with blood. The more Nitric Oxide, the stronger the erection. Arginex promotes potency in an all-natural fashion by delivering the building materials to release Nitric Oxide into the penis. Arginex does not immediately develop its full effectiveness but does so only after about a week of regular use. But it is free of side effects and allows you to benefit from all its other health- and performance-related functions. Arginex not only enhances potency, but also the quality of sperm. Studies have demonstrated that L-Arginine improves both sperm-count and -mobility.
Who should not use Arginex?
L-Arginine is known to promote the onset of cold sores (Herpes Simplex). Arginex therefore contains vital elements shown to suppress Herpes. If you are among those people who often suffer from Herpes Simplex, you should test your reaction to Arginex by using small dosages at first and then increasing them slowly. Should you still develop cold sores, you should discontinue Arginex usage. While the amino acid L-Lysine is known to avoid the onset of Herpes Simplex in many people, it is not contained in Arginex as it is a natural antagonist to L-Arginine and renders it ineffective. If you take L-Lysine, never do so at the same time as Arginex but choose a different time of day.
Benefits of Arginex:
- more lean muscle mass
- activates fat-burning
- more power and elasticity
- more endurance and performance
- faster regeneration
- extreme muscle pump
- enhances virility
Arginex's effectiveness is definitely dependent on its dosage. The more you take, the more Nitric Oxide is produced inside the body. The mentioned dosage should suffice to achieve optimal results. Should you find this not to be the case, the dosage can be increased up to twice that. Studies tested subjects onL-Arginine up to 30 grams. The only side effects were soft stools and iron erections.
How quickly can results be noticed?
After just 5 to 7 days you will feel a powerful pump while working out. Your muscles will feel fully engorged. This pump will not, as normally, disappear about 30 minutes after exercise but continue, to a certain extent, throughout the day. After an additional 2 to 3 days, you will feel increased power and endurance. You will experience a healthy tension in your muscles and notice an increase in solid muscle mass.
Combine Arginex with PowerCreatine for even better results
To maximize muscle growth, Arginex can be combined with PowerCreatine. These two products enhance each other and thus lead to an explosive gain in muscle mass and power. Arginex and PowerCreatine can even be taken at the same time.
Tuesday, January 27, 2015
Protect Your Erection: 11 Tips....By David Freeman
The last but not least is Stress: To protect erections one must not do anything in vocation which can give stress. Also wife, children and bosses must not give stress. .....Alok
Protect Your Erection: 11 Tips
How to avoid erectile dysfunction and protect your potency.
By David Freeman
WebMD Feature
WebMD Feature
Reviewed by David T. Derrer, MD
Erectile dysfunction (ED) becomes more common as men age. But it is not necessarily a normal part of aging. How can you avoid ED? Here's what experts told WebMD.
1. Watch what you eat.
A diet that's bad for a man's heart is also not good for his ability to have erections.
Research has shown that the same eating patterns that can cause heart attacks due to restricted blood flow in the coronary arteries can also impede blood flow to and within the penis. The blood flow is needed for the penis to become erect. Diets that include very few fruits and vegetables along with lots of fatty, fried, and processed foods can contribute to decreased blood circulation throughout the body.
Anything that is bad for a man's heart is also bad for his penis, says Andrew McCullough, MD, associate professor of clinical urology and director of the male sexual health program at New York University Langone Medical Center.
Recent studies show that ED is relatively uncommon among men who eat a traditional Mediterranean diet, which includes fruits, vegetables, whole grains, heart-healthy fats including nuts and olive oil, fish.
"The link between the Mediterranean diet and improved sexual function has been scientifically established," says Irwin Goldstein, MD, director of sexual medicine at Alvarado Hospital in San Diego.
2. Maintain a healthy weight.
Being overweight can bring many health problems, including type 2 diabetes, which can cause nerve damage throughout the body. If the diabetes affects the nerves that supply the penis, ED can result.
3. Avoid high blood pressure and high cholesterol.
High cholesterol or high blood pressure can damage blood vessels, including those that bring blood to the penis. Eventually, this may lead to ED.
Make sure your doctor checks your cholesterol levels and blood pressure. You might also want to check your blood pressure between doctor visits. Some stores and fire stations offer free screenings. Blood pressure monitors are also sold for home use.
If your cholesterol or blood pressure is out of whack, get it treated.
Blood pressure drugs can make it hard to get an erection. But doctors say many cases of ED that get blamed on these drugs are actually caused by arterial damage resulting from high blood pressure (also called hypertension).
4. Drink alcohol in moderation or not at all.
There is no evidence that mild or even moderate alcohol consumption is bad for erectile function, says Ira Sharlip, MD, a urology professor at the University of California San Francisco School of Medicine. But chronic heavy drinking can cause liver damage, nerve damage, and other conditions -- such as interfering with the normal balance of male sex hormone levels -- that can lead to ED.
5. Exercise regularly.
Strong evidence links a sedentary lifestyle to erectile dysfunction.Running, swimming, and other forms of aerobic exercise have been shown to help prevent ED.
Watch out for any form of exercise that puts excessive pressure on the perineum, which is the area between the scrotum and anus. Both the blood vessels and the nerves that supply the penis can be adversely affected from excessive pressure in this area. Goldstein says bicycle riding, in particular, can cause ED.
An occasional short ride is unlikely to cause trouble. But men who spend a lot of time biking should make sure their bike fits them properly, wear padded cycling pants, and stand up frequently while pedaling.
"No-nose" bike seats protect against genital numbness and sexual dysfunction, according to the National Institute for Occupational Safety and Health.
6. Don't rely on Kegels.
One form of exercise that doesn't seem helpful is Kegel exercises, which involve repeatedly contracting and relaxing the muscles in the pelvis. Kegels can be helpful for men and women suffering from incontinence. But there's no evidence that they prevent erectile dysfunction.
7. Keep tabs on testosterone.
Even in healthy men, testosterone levels often begin falling sharply around age 50. Every year after age 40, a man's testosterone level typically falls about 1.3%.
Symptoms like a low sex drive, moodiness, lack of stamina, or trouble making decisions suggest a testosterone deficiency, as do lackluster erections. Your doctor can check on that.
8. Avoid anabolic steroids.
These drugs, which are often abused by athletes and bodybuilders, can shrink the testicles and sap their ability to make testosterone.
9. If you smoke, stop.
Smoking cigarettes can harm blood vessels and curb blood flow to the penis. And nicotine makes blood vessels contract, which can hamper blood flow to the penis.
10. Steer clear of risky sex.
Believe it or not, some cases of erectile dysfunction stem from penile injuries that occur during sex. Taking your time and avoiding certain positions can help. It may be uncomfortable, but consider talking to your doctor about what to do and, more importantly, what not to do.
11. Curb stress.
Psychological stress boosts levels of the hormone adrenaline, which makes blood vessels contract. That can be bad news for an erection. Anything a man can do to ease tension and feel better emotionally is likely to give his sex life a big boost.
Friday, November 21, 2014
Hyperprolactinemia and Erectile Dysfunction
Hyperprolactinemia and Erectile Dysfunction
Hyperprolactinemia can also cause visual field defect............Alok
Rev Urol. 2000 Winter; 2(1): 39–42.
PMCID: PMC1476085
Hyperprolactinemia and Erectile Dysfunction
Scott I Zeitlin, MD and Jacob Rajfer, MD
This article has been cited by other articles in PMC.
Abstract
Hyperprolactinemia from a pituitary adenoma is a rare cause of erectile dysfunction. Men with erectile dysfunction who are found to have a low testosterone level should have a measurement of their prolactin level. Treatment consists of lowering the prolactin level by medication or surgery, or both. Bromocriptine, a dopamine agonist, is efficacious in lowering elevated prolactin levels and can simultaneously shrink these pituitary tumors. With large tumors, transphenoidal surgery may be used to debulk/remove the tumor. Post-treatment prolactin levels can be used to monitor the efficacy of treatment.
Key words: Erectile dysfunction, Hyperprolactinemia, Impotence, Pituitary neoplasms, Prolactin, Magnetic resonance imaging (MRI)
A 40-year-old obese man presented with a complaint of erectile dysfunction throughout the previous 6 years. He was unable to attain and maintain a rigid erection, yet his libido was normal. Mammography, performed recently for a breast lump, was negative for malignancy. The patient had a history of sleep apnea but did not have any neurologic or visual complaints. He was not on any medications. There was also a question of whether he fathered a child in the past.
On physical examination, the patient was markedly obese (1,575.5 kg, or 347 lb) with normal vital signs. Pertinent physical findings included bilateral gynecomastia and a large abdominal pannus. The penis did not have any palpable plaques. Total serum testosterone level was 123 ng/dL (normal, 280 to 1,250 ng/dL), the free testosterone level was 3.1 pg/mL (normal, 12 to 40 pg/mL), and the prolactin level was 396 ng/mL (normal, less than 13 ng/mL). An MRI of the pituitary gland revealed a pituitary macroadenoma with minimal involvement of the right cavernous sinus (Figure 1A – Figure 1D). The optic chiasm was not involved. Because of the large size of the tumor, a transsphenoidal hypophysectomy of the pituitary adenoma was elected. Following surgery, the patient’s prolactin levels dropped to about 90 ng/mL, which indicated subtotal resection of the adenoma. Postoperative medical therapy with a dopamine agonist would be required to lower the prolactin level to normal range.
Discussion
In the evaluation of patients with erectile dysfunction, an endocrinopathy is the rarest of causes.1,2 However, when an endocrinopathy does affect erectile function, it is almost always caused by hypogonadism.1–3 Obtaining a serum testosterone (T) level is the most cost-effective way of screening for an endocrinopathy as the cause of erectile dysfunction.2,3 If the serum T level is abnormally low, then additional evaluation should include obtaining serum luteinizing hormone, free T, and prolactin levels.2 If the serum T is elevated, then a thyroid evaluation may be indicated.2
In our patient, hypogonadism as well as an elevated prolactin level (prolactin was emanating from the lesion within the pituitary gland) were found. Hyperprolactinemia induces hypogonadism by interfering with the secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus (Figure 2).4,5 The resulting decrease in serum T is believed to be the cause of the erectile dysfunction, although there may be an end-organ effect of prolactin on the penis.4 Surprisingly, not everyone with hyperprolactinemia has a low serum T level or complains of erectile dysfunction.6,7 However, when the serum prolactin is corrected in patients with an elevated prolactin level and a low serum T level, the serum T level usually returns to a normal value, and erectile function is usually restored (if erectile dysfunction was present).2 Simply treating the patient with exogenous T does not usually correct the erectile dysfunction (unless the prolactin levels are returned to normal).
Dopamine from higher brain centers stimulates release of prolactin inhibitory factor (PIF), and prolactin (PRL) from the pituitary inhibits gonadotropin-releasing hormone (GnRH) secretion. Bromocriptine, a dopamine agonist, works to further increase production ...
Hyperprolactinemia is a very rare cause of impotence in a general population of men with impotence.8 However, men who have hyperprolactinemia have a high incidence of sexual dysfunction, and the erectile dysfunction appears more likely to resolve in patients with the most severe hyperprolactinemia once this glandular disorder is corrected.7
Many medications may also elevate prolactin levels, and this may interfere with erectile function (Table 1). Some of these medications belong to the dopamine antagonist group; this is not surprising, since the normal regulation of prolactin in man is primarily inhibitory (dopamine from the hypothalamus inhibits the secretion of prolactin from the pituitary gland by the inhibiting hormone prolactin inhibitory factor [PIF]). This forms the basis of medical treatment for hyperprolactinemia: dopamine agonists, such as bromocriptine, exert their antiprolactinemic effects by inhibiting the secretion of prolactin by the pituitary cells, which normally secrete prolactin. In hyperprolactinemia induced by exogenous medications, once the suspect medication is stopped, the prolactin and serum T levels and the erectile function (if the impotence is caused by elevated prolactin levels) usually return to normal.9,10 If erectile dysfunction is not corrected by lowered prolactin levels, then other causes of the dysfunction must be considered.
More than half of patients with hyperprolactinemia (Table 2) have no demonstrable pituitary lesion, and not every pituitary adenoma produces prolactin. It has been theorized that hyperprolactinemia can also be caused by interfering with PIF that is transported down the pituitary stalk (such as a craniopharyngioma or cystic enlargement within an empty sella that prevents the PIF from reaching its target in the pituitary gland). Whether this PIF is dopamine or some other chemical remains to be determined. Like other causes of erectile dysfunction from hyperprolactinemia, these nonpituitary causes may also lead to erectile dysfunction.
One of the predominant symptoms in men who are hyperprolactinemic is loss of libido.11 Johnson and Jarow1reported on a series of 330 consecutive patients who presented for evaluation of impotence; they found an endocrine etiology in 7 (2.1%). All 7 patients had either decreased libido or testicular atrophy; therefore, these investigators recommended that screening for endocrine disorders (as opposed to obtaining a serum T level) should only be done in those patients with clinical signs of hypogonadism. Routine prolactin measurements are not necessary in the evaluation of patients with erectile dysfunction.12,13
Other presenting symptoms of a pituitary adenoma, with or without hyperprolactinemia, are headaches and visual-field defects (Table 3). When hyperprolactinemia is managed with dopamine agonists, such as bromocriptine, not only will the prolactin levels be decreased, but also shrinkage of the tumors may be seen in about two thirds of patients with pituitary tumors. If present, headaches and visual-field defects may also improve with treatment, regardless of whether the treatment is medical or surgical.14,15 Recently, another synthetic dopamine agonist, cabergoline, has been found to be a potent inhibitor of prolactin secretion. Cabergoline is taken twice weekly and is an alternative for patients who are sensitive to bromocriptine.16
Conclusion
While pituitary tumors—specifically, prolactin-secreting adenomas—are seen rarely in patients presenting solely with impotence, when such tumors do occur, they can be successfully managed with surgery and/or medication. Most patients who present with erectile dysfunction caused by a prolactin-secreting adenoma will harbor a low serum T level. Therefore, the serum T appears to be an excellent screening test for these patients. Once the prolactin level is determined to be elevated, the pituitary/hypothalamic area is imaged either by MRI or by CT scan. Treatment of patients with hyperprolactinemia—whether by surgery, medication, or both—depends on the findings seen on radiologic scans, with most patients receiving a dopamine agonist initially. For those who undergo surgery and still have a postoperative elevated prolactin level, which suggests residual adenoma, medical therapy is instituted.17
Main Points
- The prolactin level should be measured in men presenting with a complaint of erectile dysfunction who have a low serum testosterone level.
- Hypogonadism is almost always the cause of an endocrinopathy that affects erectile function.
- In hyperprolactinemia, which induces hypogonadism, the excess prolactin interferes with secretion of gonadotropin-releasing hormone, resulting in decreased testosterone and erectile dysfunction.
- Hyperprolactinemia caused by a pituitary tumor can be managed with surgery and/or a dopamine agonist.
Wednesday, November 12, 2014
Sunday, October 26, 2014
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