Catherine B. Johannes

Incidence of erectile dysfunction in men 40 to 69 years old : Longitudinal results from the Massachusetts male aging study

PURPOSE We estimated the incidence of erectile dysfunction in men 40 to 69 years old at study entry during an average 8.8-year followup, and determined how risk varied with age, socioeconomic status and medical conditions. MATERIALS AND METHODS Data from a randomly sampled population based longitudinal study of Massachusetts men were analyzed. A total of 1,709 men completed the baseline interview during 1987 to 1989 and 1,156 survivors completed followup from 1995 to 1997. The analysis sample consisted of 847 men without erectile dysfunction at baseline and with complete followup information. Erectile dysfunction was assessed by discriminant analysis of 13 questions from a self-administered sexual function questionnaire and a single global self-rating question. RESULTS The crude incidence rate for erectile dysfunction was 25.9 cases per 1,000 man-years (95% confidence interval [CI] 22.5 to 29.9). The annual incidence rate increased with each decade of age and was 12.4 cases per 1,000 man-years (95% CI 9.0 to 16.9), 29.8 (24.0 to 37.0) and 46.4 (36.9 to 58.4) for men 40 to 49, 50 to 59 and 60 to 69 years old, respectively. The age adjusted risk of erectile dysfunction was higher for men with lower education, diabetes, heart disease and hypertension. Population projections for men 40 to 69 years old suggest that 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the United States (white males only) are expected annually. CONCLUSIONS Although prevalence estimates and cross-sectional correlates of erectile dysfunction have recently been established, incidence estimates were lacking. Incidence is necessary to assess risk, and plan treatment and prevention strategies. The risk of erectile dysfunction was about 26 cases per 1,000 men annually, and increased with age, lower education, diabetes, heart disease and hypertension.

Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? ☆

OBJECTIVES To prospectively examine whether changes in smoking, heavy alcohol consumption, sedentary lifestyle, and obesity are associated with the risk of erectile dysfunction. METHODS Data were collected as part of a cohort study of a random sample of men 40 to 70 years old, selected from street listings in the Boston Metropolitan Area, Massachusetts. In-home interviews were completed by 1709 men at baseline in 1987 to 1989 and 1156 men at follow-up in 1995 to 1997 (average follow-up 8.8 years). Analyses included 593 men without erectile dysfunction at baseline, who were free of prostate cancer, and had not been treated for heart disease or diabetes. The incidence of moderate to complete erectile dysfunction was determined by discriminant analysis of responses to a self-administered sexual function questionnaire. RESULTS Obesity status was associated with erectile dysfunction (P = 0.006), with baseline obesity predicting a higher risk regardless of follow-up weight loss. Physical activity status was associated with erectile dysfunction (P = 0.01), with the highest risk among men who remained sedentary and the lowest among those who remained active or initiated physical activity. Changes in smoking and alcohol consumption were not associated with the incidence of erectile dysfunction (P >0.3). CONCLUSIONS Midlife changes may be too late to reverse the effects of smoking, obesity, and alcohol consumption on erectile dysfunction. In contrast, physical activity may reduce the risk of erectile dysfunction even if initiated in midlife. Early adoption of healthy lifestyles may be the best approach to reducing the burden of erectile dysfunction on the health and well-being of older men.

Sexual functioning and practices in a multi‐ethnic study of midlife women: Baseline results from swan

This study examined the sexual practices and function of midlife women by ethnicity (African American, Caucasian, Chinese, Hispanic, Japanese) and menopausal status. Sexual behavior was compared in 3,262 women in the baseline cohort of SWAN. Participants were 42 to 52 years old, premenopausal or early perimenopausal, and not hysterectomized or using hormones. Analysis used multivariate proportional odds regression. In our sample, 79% had engaged in sex with a partner in the last 6 months, and a third considered sex to be very important. Common reasons for no sex (n = 676) were lack of partner (67%), lack of interest (33%), and fatigue (16%). Compared with Caucasians, Japanese and Chinese women were less likely, and African Americans more likely, to report sex as very important (p < 0.005). Significant ethnic differences were found for frequency of all practices. Perimenopause status was associated only with higher frequencies of masturbation and pain during intercourse.

Is there an association between menopause status and sexual functioning

Objective: The purpose of this study was to address whether: (1) there is an association between menopause status and various aspects of sexual functioning, and (2) the relative contributions of menopause status and other variables to various aspects of sexual functioning. Design: Analyses are based on 200 women from the Massachusetts Womens Health Study II, a population‐based sample of women transitioning through the menopause who were not HRT users, who had not had a surgical menopause, and who had partners. The women were classified as pre‐, peri‐, or postmenopausal according to menstrual cycle characteristics. Estradiol, estrone, and follicle‐stimulating hormone were also measured. Sexual functioning was measured in terms of satisfaction, desire, frequency of sexual intercourse, belief that interest declines with age, arousal compared with a younger age, difficulty reaching orgasm, and pain. Predictor variables included sociodemographics, health, vasomotor symptoms, psychological variables, partner variables, and lifestyle behaviors. Results: Menopause status was significantly related to lower sexual desire, a belief that interest in sexual activity declines with age, and womens reports of decreased arousal compared with when in their 40s. Menopause status was unrelated to other aspects of sexual functioning in either unadjusted or multiple regression analyses. In analyses in which log estradiol (E2) was included in addition to menopause status, log E2 was only related to pain. In multiple regression analyses, other factors such as health, marital status (or new partner), mental health, and smoking had a greater impact on womens sexual functioning than menopause status. Conclusions: Menopause status, but not E2, is related to some, but not all, aspects of sexual functioning. This may be due to menopause per se or other factors associated with menopause and aging (e.g., increased sexual dysfunction among aging men). Menopause status has a smaller impact on sexual functioning than health or other factors. (Menopause 2000;7:297‐309.

Correlates of sexual function among multi-ethnic middle-aged women: results from the Study of Women's Health Across the Nation (SWAN)

Objective:To examine sexual function in a cohort of Baby Boomer women of diverse racial/ethnic backgrounds; to compare differences between pre-and early perimenopausal women; and to identify sociodemographic, health-related, and psychosocial (including psychological, behavioral, and relationship) factors related to sexual function. Design:Six domains of sexual function were studied in 3,167 women in the baseline cohort of the Study of Womens Health Across the Nation (SWAN). Participants were 42 to 52 years old, pre-or early perimenopausal, and not using hormones. The study sample included non-Hispanic white, African American, Hispanic, Chinese, and Japanese women. Results:Early perimenopausal women reported greater pain with intercourse than premenopausal women (P = 0.01), but the two groups did not differ in frequency of sexual intercourse, desire, arousal, or physical or emotional satisfaction. Variables having the greatest association across all outcomes were relationship factors, the perceived importance of sex, attitudes toward aging, and vaginal dryness. Despite controlling for a wide range of variables, we still found ethnic differences for arousal (P < 0.0001), pain (P = 0.03), desire (P < 0.0001), and frequency of sexual intercourse (P = 0.0003). African American women reported higher frequency of sexual intercourse than white women; Hispanic women reported lower physical pleasure and arousal. Chinese women reported more pain and less desire and arousal than the white women, as did the Japanese women, although the only significant difference was for arousal. Conclusions:Relationship variables, attitudes toward sex and aging, vaginal dryness, and cultural background have a greater impact on most aspects of sexual function than the transition to early perimenopause.

Measurement of erectile dysfunction in population-based studies : the use of a single question self-assessment in the Massachusetts Male Aging Study

A concise, reliable means of assessing erectile dysfunction (ED) in large, multidisciplinary population-based studies is needed. A single, direct question for self-assessed ED was assessed in the population-based sample of the Massachusetts Male Aging Study (MMAS). Of the 1156 respondents to the 1995–97 MMAS follow-up evaluation, 505 were randomly selected to complete either the International Index of Erectile Function (IIEF) (n=254), or the Brief Male Sexual Function Inventory (BMSFI) (n=251), in addition to the single question self-assessment. The proportion not classified due to missing data was MMAS–9%, BMSFI–8%, and IIEF–18%. The single question correlated well with these other measures (r=0.71–0.78, P<0.001). Prevalence was similar to that based on the IIEF, agreement was moderate (kappa=0.56–0.58), and associations with previously identified risk factors were similar for each classification. Thus, the MMAS single question may be a practical tool for population-based studies where detailed clinical measures of ED are impractical.

Socioeconomic factors and incidence of erectile dysfunction: findings of the longitudinal Massachussetts Male Aging Study

Despite the well-documented relationship of socioeconomic factors (SEF) to various health problems, the relationship of SEF to erectile dysfunction (ED) is not well understood. As such, the goals of this paper are: (1) to determine whether incident ED is more likely to occur among men with low SEF; and (2) to determine whether incident ED varies by SEF after taking into consideration other well-established ED risk factors that are also associated with SEF such as smoking, diabetes, and high blood pressure. We used data from 797 participants in the longitudinal population-based Massachusetts Male Aging Study (baseline 1987-1989, follow-up 1995-1997) who were free of ED at baseline and had complete data on ED and all risk factors. ED was determined by a self-administered questionnaire and its relationship to SEF was assessed using logistic regression. We first analyzed the age-adjusted relationship of education, income, and occupation to incidence of ED. The results show that men with low education (O.R. = 1.46, 95% C.I. = 1.02-2.08) or men in blue-collar occupations (O.R. = 1.68, 95% C.I. = 1.16-2.43) are significantly more likely to develop ED. For the multivariate model, due to multicollinearity among education, income, and occupation, we ran three separate models. After taking into consideration all the other risk factors--age, lifestyle and medical conditions--the effect of occupation remained significant. Men who worked in blue-collar occupations were one and a half times more likely to develop ED compared to men in white-collar occupations (O.R. = 1.55, 95% C.I. = 1.06-2.28).

Relation of Dehydroepiandrosterone and Dehydroepiandrosterone Sulfate with Cardiovascular Disease Risk Factors in Women: Longitudinal Results from the Massachusetts Women's Health Study

Low circulating levels of the adrenal steroids dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) are thought to be associated with increased risk of cardiovascular disease (CVD) in men. In women, either a positive or null association with CVD has been found. The nature of the relation between DHEAS and CVD risk factors in women is unclear and is based on cross-sectional data. We present results from a longitudinal investigation of serum DHEA and DHEAS and cardiovascular disease risk factors in 236 women, initially 50-60 years old, from a population-based prospective (1986-1995) study of the menopausal transition. We used generalized estimating equations to model the relation of serum DHEA and DHEAS to systolic and diastolic blood pressure and serum levels of total cholesterol, high density lipoprotein cholesterol, and apolipoproteins A and B, adjusting for other factors related to CVD. Both DHEA and DHEAS were positively related to diastolic and systolic blood pressure, and DHEAS was negatively related to apolipoprotein A. DHEA and DHEAS were also positively related to smoking, alcohol use, estrone, and estradiol levels, and inversely related to age. Our results suggest that higher levels of DHEA and DHEAS in middle-aged women may indicate increased CVD risk.

A New Surrogate Variable for Erectile Dysfunction Status in the Massachusetts Male Aging Study

Erectile dysfunction (ED) is the subject of a vast clinical literature, but little information has been gathered from random samples of the general public. The Massachusetts Male Aging Study (MMAS) addressed this important aspect of mens health. The MMAS was conducted in two waves, with baseline data collection in 1987-1989 and follow-up in 1995-1997. Subsequent to the baseline MMAS survey, a consensus developed that subjective measures are optimal for defining ED. Unfortunately, the baseline questionnaire did not ask subjects directly about their erectile functioning. Thus, we previously assigned the MMAS subjects a degree of impotence at baseline using a series of related questions, employing a discriminant formula constructed from a separate sample of urology clinic patients. At follow-up the men classified themselves directly in addition to answering the original series of related questions. In the present article, we report the results of a new discriminant function, based on the MMAS men at follow-up. We also compare the two methods and discuss our reasons for preferring the internally calibrated method.

Does collecting repeated blood samples from each subject improve the precision of estimated steroid hormone levels

Measuring levels of steroid hormones in epidemiologic studies is difficult because pulsatile release can cause the levels of many hormones to vary markedly over short intervals, leading to a loss of precision in between-subject comparisons. Clinicians often control this variation by collecting several samples from each subject at defined intervals and pooling these samples for assay. The number of samples per subject that would adequately control such variation in an epidemiologic study has not been fully investigated. This study examines the effects of collecting 1, 2, or 3 samples per subject on the variances of 11 hormones and sex hormone binding globulin in men and 6 hormones in women. Three samples were collected at 30-minute intervals from each of 20 men and 59 women and were assayed separately. Variances that would be obtained in studies collecting one, two, or three samples per subject were then estimated. Collecting more than one sample substantially reduced the variances of several hormones in men but not in women.