I have taken medications like Viagra and Cialis without any results. What are the next steps to restore my sexual function?

ED is ultimately about the penis filling completely with blood. Any process that impairs or lessens penile blood flow can cause ED. Thus, ED and heart disease share common risk factors. What has been found in these men with comorbid disease states (those men with ED and high blood pressure, elevated lipids, or diabetes, etc.) is that the better the control of these medical conditions, the more likely the ED may improve or respond to medications like Viagra (sildenafil). Also, a man needs to be taking the ED meds correctly, and his testosterone should be in the normal range to optimize a response to oral therapy.

Any man with erectile dysfunction who does not respond to usual medical treatment for ED and wishes to have a normal spontaneous sex life may be a candidate for penile implant surgery.  An implant is a long term solution and typically lasts for 10-15 years. Penile implant surgery has the highest rate of satisfaction of any treatment for ED. There are several types of implants, and the inflatable 3-piece penile implant is the most popular.  It allows for a more natural erection. Consultation with a urologist Individuals must be healthy enough for surgery and medical conditions like diabetes and heart disease must be stable before surgery can be considered.

My doctor told me that I have metabolic syndrome. What is the definition of metabolic syndrome and how do I fix this? Does it affect my sexual function?

Metabolic syndrome is defined as having 3 of 5 criteria: A fasting blood sugar or glucose > 110 mg/dL or having a diagnosis of type 2 diabetes; a waist circumference > 40 inches or 102 cm [reflects belly obesity]; blood triglycerides of > 150 mg/dL; and HDL (good chol) < 40 mg/dL; and a BP > 130/90 mm Hg or on medication for hypertension. Each of these is a risk factor for heart disease or stroke. A man who has more than one of the risk factors is also at risk for the condition of testosterone deficiency. Testosterone deficiency is associated with erectile dysfunction and the loss of sexual desire, also known as a low libido.  Of even greater significance, low testosterone levels in a man are associated with a greater risk of heart attack and stroke, and a higher risk of death.

Men with metabolic syndrome should focus on the 4 main areas of healthy living to correct these negative attributes: diet, exercise; stress reduction and good sleep. While diet and exercise improve many consequences of obesity, most caloric-restricted diets are not manageable for the long-term. Thus, strategies that lead to fat loss while maintaining muscle mass and improving a man’s testosterone levels are needed.  Time-restricted feeding (TRF) may be an ideal dietary approach for reducing fat and heart disease risk, while diminishing the loss of muscle mass and strength associated with obesity and aging. TRF, also known as intermittent fasting, unlike continuous caloric restriction, does not require a restricted caloric consumption. Such eating requires individuals to consume calories within a set window of time during each day (for example, 8-10 hours) and include a fasting window of 14-16 hours/day. Many studies of men who follow both TRF in combination with both aerobic and resistance training have found an improvement of all facets of the metabolic syndrome and an overall lowering of cardiovascular risk factors and fat mass and improved muscle mass. It is believed that this type of eating, while healthier, reduces the incidence of diabetes and testosterone deficiency.

My wife and I have having trouble having children. Could I have Klinefelter Syndrome?

Klinefelter syndrome is the most common congenital (inborn or hereditary) abnormality causing dysfunction of the testicles. It is estimated that Klinefelter Syndrome affects 1 in 1,000 male births. Men with Klinefelter Syndrome often present with infertility and a low sperm count or absent sperm production. They also have low testosterone levels. Treatment for Klinefelter syndrome may involve advanced fertility techniques and testosterone therapy. Men with Klinefelter syndrome are at higher risk for other medical problems like osteoporosis and certain types of cancer. They should seek care with a clinician who has experience treating this condition.

“I have not been myself and I feel so tired. Sleep is not restorative. I have little desire to make love and I have lost my passion for work and my ability to concentrate. I don’t have patience and my wife tells me I am always irritable. My erections are not as hard. Should I be tested for low testosterone (T)?”

Do I need a medical evaluation for ED or can I just order medication online?

Erectile dysfunction can occur for many reasons, and it can affect men of all ages. When ED is due to poor circulation (vasculogenic) it is a marker for increased risk for heart disease. This association is strongest in younger middle-aged men in their 40’s and 50’s. High blood pressure, high cholesterol levels, high blood sugars and weight gain are all risks for erectile dysfunction, and men with ED should be screened for these conditions. A recent study published by Dr. Miner demonstrated that ED is an independent predictor of future cardiovascular events, and men with ED should have a thorough cardiovascular risk assessment before starting treatment for ED. (circulation.2018;138:540-542.)

I have not been myself and feeling quite tired. Should I be tested for low testosterone (T)?”

Testosterone deficiency occurs in ~5-8% of all men. It is characterized by the presence of both low T and clinical signs or symptoms of T deficiency. Up to 12-30% of men may have low levels without any signs or symptoms. The most sensitive signs or symptoms of T deficiency are the sexual signs and symptoms: i.e. loss of sexual desire; loss of morning and other spontaneous erections; and erectile dysfunction (ED). Other less specific signs and symptoms include obesity, especially visceral obesity or increased belly fat; profound fatigue; loss of concentration; sadness or irritability or both; loss of exercise endurance; and loss of motivation. Although most guidelines do not advocate for generalized screening as men age, if a man has a common medical problem associated with T deficiency, such as type 2 diabetes, high blood pressure or elevated blood lipids, any chronic inflammatory disease, that man should have a baseline testosterone level and further tests if clinical signs and symptoms present. In the above case, if that man had no other explanation for his fatigue or if he has a medical problem associated with T deficiency, then he should have a screening Total Testosterone level done and repeated if low.

My doctor says I have low T and by using T for repletion, I might improve my sexual function. Yet my wife says that T therapy can cause an increase in blood clots or heart attacks or strokes. Is this true?

A randomized, double-blinded, placebo-controlled “safety” study of T therapy is presently underway. This is the first such study with excellent methods and should be highly educational, though the results will not be available for 4-6 years. Testosterone has been used to treat medical conditions since the 1930s. Men who have low levels of T are thought to be at higher risk for heart attacks and strokes. Men who are treated with testosterone therapy appear to have the same risk as men who have normal levels of T, with a 50% reduction of overall risk of heart disease, stroke and death. These relationships are known as associations and at this time we cannot say that “low T” causes an increased risk of heart attack and stroke. The reason is that these studies are cross-sectional (prospective [looking forward] or retrospective [examining the past] but not randomized with a placebo) and generally have too few participants and for too short a time to imply causality. Often things we read on the web or in the news are presented as “causal” but in truth, are associations and must be examined in a randomized, blinded, placebo-controlled trial to imply causality.

Yet the medical literature have corroborated this relationship -that low T is associated with increased cardiovascular risk and death- with publication of almost 75 studies in the past 15 years ranging from 1 to 18 years of length.

In 2013 and 2014, three studies were published that showed a potential increased risk of T therapy being associated with heart attacks or stroke. These studies were reported in the news and the inference was that the relationship was causal; however, given that they were cross-sectional studies we know this is not true. In addition, the FDA in its review agreed with many clinicians in this specialty that the design of these studies were seriously flawed and methods of analysis were inconsistent with good research design. One study’s original population included over 1000 women! But the FDA stated in 2015 that patients should be counselled on the possible risk of heart attack and stroke until the evidence is clarified. The American Urological Association in its testosterone guidelines state that this risk appears to be low and patients should be presently reassured that current evidence does not show an increased risk of events and death with the use of testosterone therapy.”

Is it true I lose my own production of Testosterone if I go on testosterone therapy?

At present, most forms of testosterone therapy (with the possible exception of nasal testosterone gel) do suppress testosterone production beginning at the level of the pituitary gland and ending with cessation of testosterone production in the testes. This does not tend to bother older men as most are done fathering children. Both testosterone and sperm (semen) are produced by the testes. Thus giving a man testosterone therapy is likely to make him infertile while he is using the therapy.

In younger men, or in men of any age who wish to remain fertile, with low testosterone levels and clinical symptoms we tend to use fertility medicines such as clomiphene citrate to boost their levels of T and not suppress their own production of T. These meds are safe and generally do not cause infertility or cessation of T production, but rather increase that man’s ability to make his own T.

Office Practices and Billing:

EVALUATIONS: Dr. Miner’s fee schedule is $1000 for the initial visit and $250 for f/u visits. The initial visit often takes up to 2 hours to conduct a thorough history and physical examination.

CONFIDENTIALITY: All communications between patients and myself are kept strictly confidential.

EMERGENCY PROCEDURE: If you need emergency assistance, contact me at 994-0898. If you are unable to reach me then call 911 or go to the nearest emergency room.

CANCELLATIONS: The appointment time has been reserved for the client. Subsequently, missed appointments and non-emergency last minute cancellations with less than 24 hours notice will be billed. 

COMMUNICATION: Please contact Loddie Mosley or 781-890-2133 for:
Appointment changes
Medication Refills (should be requested at least 24 hours in advance)

Billing questions
All forms, reports and paperwork requests

APPOINTMENTS AND FEES: The fee for the first 1-2 hour consultation is $1000. Ongoing follow-up sessions are billed at $250 per session. This includes all phone and email contact. Payments are to be made at the time of each session

VACATIONS: Unless previous arrangements have been made, I will not generally be answering texts, phone messages, or emails during vacations. I will respond to those messages upon my return.

INSURANCE: In some cases, health insurance plans will reimburse clients for a specified portion of the billed amount. I require that the client pay the entire bill and then be reimbursed by the insurance company. I will prepare a billing statement at the end of the session for you to attach to the insurance company claim form.

DELINQUENT ACCOUNT POLICY: Failure to pay your account in a timely manner will result in legal action or use of a collection agency. You will be charged for all costs incurred for this extra service.