Sexual wellness care that looks for the cause

What changes in midlife

Sexual function draws on hormones, blood flow, nerves, mood, sleep, medications and relationships at the same time. In midlife several of these can shift together. Falling estrogen in perimenopause and menopause can thin vaginal tissue and reduce natural lubrication. Testosterone declines gradually in men. Blood vessel health, which underlies erections and genital arousal in both sexes, often reflects blood pressure, cholesterol and blood sugar.

Common medications, including some antidepressants and blood pressure drugs, can lower desire or affect erections. Stress, poor sleep and low mood play a large role too. That is why a good evaluation looks at the whole picture.

For women: comfort, arousal and desire

Vaginal dryness, irritation and pain with sex are part of genitourinary syndrome of menopause, and they tend to persist without treatment. Low-dose vaginal estrogen, such as compounded estriol vaginal cream included in our hormone therapy plan, treats the tissue directly with minimal absorption into the rest of the body. Systemic hormone therapy may help when hot flashes, sleep disruption and mood changes are also affecting intimacy.

Low desire that causes distress is a recognized condition. An FDA-approved medication, bremelanotide (Vyleesi), is approved only for premenopausal women with acquired, generalized hypoactive sexual desire disorder; it is not approved for postmenopausal women. Its most common side effect is nausea, and it temporarily raises blood pressure.

For men: erections, drive and confidence

Erectile changes are common with age, but they are not just aging. Erectile dysfunction can be an early sign of blood vessel disease, diabetes or high blood pressure, and it can come from medications or psychological factors. Your clinician will ask about heart health before prescribing.

Tadalafil Daily (from $99/month) is an FDA-approved PDE5 inhibitor. For once-daily use in erectile dysfunction, the label starting dose is 2.5 mg, which may be increased to 5 mg; 5 mg daily is also approved for urinary symptoms of an enlarged prostate. If low testosterone is suspected, labs and a review through our testosterone program come first. Propranolol and other beta blockers ($149) are sometimes prescribed off-label for performance anxiety.

The Triple Action Blend

The Triple Action Blend (from $149/month) is a compounded preparation combining tadalafil, oxytocin and PT-141 (bremelanotide). It is not FDA-approved, has not been studied as a combination in clinical trials, and is not equivalent to Cialis or Vyleesi. Your clinician will explain why they think it may suit you and what alternatives exist.

Safety points that apply to everyone

• Never combine tadalafil with nitrate medications such as nitroglycerin or isosorbide, or with recreational amyl nitrite. The combination can drop blood pressure dangerously.
• Tell your clinician about any heart disease, uncontrolled blood pressure or recent chest pain.
• Bremelanotide raises blood pressure temporarily and commonly causes nausea.
• Seek urgent care for an erection lasting more than four hours or sudden vision or hearing loss.
• Treatments here are for adults and are not for use during pregnancy.

When the cause is not hormonal

Many sexual concerns are not solved by a prescription alone. Relationship strain, stress, depression, anxiety about performance, pain from another condition and side effects of other medications all play a part. A clinician may suggest adjusting a medication with the doctor who prescribed it, treating an underlying condition such as sleep apnea or diabetes, or working with a sex therapist or pelvic floor physical therapist.

If an antidepressant seems to be affecting desire or orgasm, do not stop it on your own. Talk with your prescriber about options, since stopping suddenly can cause withdrawal symptoms and a return of depression.

Erectile changes and heart health

Because erections depend on healthy blood vessels, erectile dysfunction can appear before other signs of cardiovascular disease. If you have new erectile problems, especially with risk factors such as high blood pressure, diabetes, smoking or high cholesterol, your clinician may recommend checking blood pressure, lipids and blood sugar, and following up with your primary care clinician. Treating the erection without looking at the heart misses an opportunity.

How HealifyMD approaches sexual wellness

Your clinician starts with a confidential history covering symptoms, medications, health conditions and what you want to change. Labs are ordered when they could change the plan, such as testosterone in men or blood sugar and lipids when vascular risk is a concern. Treatment is chosen to match the likely cause, and you can adjust or stop it at follow-up.