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Sexual dysfunction in men and women
Erectile dysfunction is often an early sign of vascular disease, so it is a gateway to cardiovascular risk assessment; low desire — in men and in women — calls for a search for medicines, depression, relationship problems and hormonal deficiency.
Why it matters in the exam
The exam presents a 67-year-old man with a gradual decline in erections including morning erections (organic, vascular cause), a young man who gained weight and lost desire (testosterone and prolactin work-up), a man looking for an antidepressant with fewer sexual side effects, and a postmenopausal woman with low desire. It asks about work-up and treatment.
The key warning: PDE5 inhibitors are forbidden with nitrates (severe hypotension), and a painful erection lasting over 4 hours is an emergency.
Many patients will not raise the subject themselves, so an open, respectful question from the family doctor — especially in patients with diabetes, heart disease or depression — is often the only way to identify the problem.
In a man whose desire fell and who gained weight, prolactin is checked too, because a pituitary tumour can present this way. Another question describes a postmenopausal woman with painful intercourse — here the treatment is local vaginal oestrogen.
Key points
- Erectile dysfunction — an early sign of vascular disease.
- Morning erections preserved — psychogenic; lost — organic.
- PDE5 inhibitors — first line; forbidden with nitrates.
- Low desire — morning testosterone twice, then LH, FSH and prolactin.
- SSRIs impair sexual function; bupropion and mirtazapine less so.
Summary table
| Condition | Clues | Work-up | Treatment |
|---|---|---|---|
| Organic erectile dysfunction | Gradual, morning erections also lost; diabetes, smoking, hypertension | Glucose, lipids, blood pressure, cardiovascular risk assessment; morning testosterone when desire is low | Lifestyle, PDE5 inhibitors (sildenafil, tadalafil) |
| Psychogenic erectile dysfunction | Sudden, situational, morning erections preserved | Conversation, assessment of anxiety and depression | Sex or couples therapy; PDE5 inhibitors as needed |
| Medicines | Thiazides, beta-blockers, SSRIs, antiandrogens, 5-alpha-reductase inhibitors, opioids | Drug review | Switch where possible; bupropion or mirtazapine instead of an SSRI |
| Testosterone deficiency | Low desire, fatigue, weight gain | Morning total testosterone twice; if low — LH, FSH, prolactin | Treat the cause; testosterone when deficiency is confirmed |
| Low desire in a woman (HSDD) | Low desire causing distress | Relationship, depression, drugs, vaginal dryness after menopause | Sex therapy; treat contributors; transdermal testosterone after menopause in selected cases |
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Sources
- American Urological Association, 2018 (amended 2024) — Erectile dysfunction guideline
- International Society for the Study of Women's Sexual Health, 2017–2019 — Process of care for hypoactive sexual desire disorder; Global consensus position statement on testosterone therapy for women
- Goroll AH, Mulley AG. Primary Care Medicine, 8th edition (2020) — Evaluation and management of sexual dysfunction in men and women
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.