By Stephanie Prendergast

Last week, Gwyneth Paltrow’s popular newsletter featured an article on pelvic floor muscles, which prompted numerous emails and tweets in my direction. Apparently this is a topic that makes my friends and colleagues think of me. While pondering why everyone, except for me,  seems to be reading Goop,  I took a look. I am glad to see the pelvic floor muscles are getting increasing amounts of attention but I’m going to take this opportunity to expand on a great conversation started by the authors.

Goop says:

The Secrets of the Pelvic Floor (click here for the original article)

“If you’ve never had your pelvic floor released, consider hunting down an integrative structural specialist: It’s a weird sensation, for sure, and generally reveals a shocking revelation. While you might assume that this muscle web that acts as a “hammock” for your undercarriage would be stretched out (particularly if you’ve had kids), it’s generally the opposite. “The pelvic floor is one of the body’s primary stress containers,” explains Lauren Roxburgh, our go-to fascia and structural integrative specialist. “That pit in the base of your stomach is your pelvic floor in permanent clutch.” Because so many of us have lost our connection to this web of muscles, we’ve also lost the ability to mindfully relax the area—and so over the years, it loses range of motion, tone, and flexibility. Getting reconnected is essential: “Adore your pelvic floor,” Roxburgh ads: “It’s the key to great sex, a flat tummy, and the key to never laying in a supply of Depends.”

PHRC says:

Ms. Roxburgh explains “That pit in the base of your stomach is your pelvic floor in permanent clutch.” She is describing a unique aspect of pelvic floor physiology: The pelvic floor muscles are under autonomic AND voluntary control. They always have some tone, or ‘permanent’ tone, which keep us from leaking urine or stool. Similar to breathing, this happens without us thinking about it but we can choose to override its normal function if we want to. For example, we can do a Kegel or bear down, just like we can hold our breath or purposely breathe at a rapid rate. The pelvic floor muscles are responsible for urinary, bowel, and sexual functioning. They are involved in and affected by childbirth, age-related and hormonal changes. Generally speaking, these muscles can become too tight, or they can become over-lengthened or weak. Improving your awareness about these muscles and how they work can be very beneficial.

“Q

 So what exactly is the pelvic floor?

A

We’ve all probably once said: “I laughed so hard I nearly peed myself.” Well, for many women that isn’t a joke; it’s reality. According to the Agency for Healthcare Research and Quality, about 25 to 45% of women suffered from urinary incontinence (also known as leakage) at least once in the past year.

There are a number of reasons for this. It can be caused by urinary tract infections or certain medicines, but the most common type of incontinence is called ‘stress incontinence,’ and happens when you laugh, cough, sneeze, jog, or do something that puts pressure on your bladder. The culprit? A little-known group of muscles called the pelvic floor.

The pelvic floor is a group of muscles that attaches to the bones at the bottom of your pelvis. These muscles effectively form a hammock across the base of your pelvis that supports the internal organs above it. Having strong pelvic floor muscles gives you proper control over our bladder and bowels, but that’s not their only role. Strong pelvic floor muscles also improve sexual performance and orgasm, help stabilize the hip joints, and act as a lymphatic pump for the pelvis. You get the picture: They’re important.

There’s actually a pretty simple reason why so many women have issues with incontinence, low back pain, and not so much fun in the bedroom. It’s a lack of connection to the deep core muscles, thanks to the fact that the pelvic floor gets stuck, disconnected, weak, and loses tone because it is an area where we hold stress and tension. In Eastern traditions, the pelvic floor is known as the root chakra—it’s where we tend to literally “hold” fears, specifically fears around primary instincts such as our health, our family’s safety, and our financial security. It is a “stress container,” in that it’s where we process the emotion and house our fight or flight reactions. You know that feeling when you get cut off by someone while driving, get bad news, or are about to go into a high stress situation? This can cause you to clench your pelvic floor (i.e., it feels like a pit in your stomach).

When we lose the connection to those deep muscles, it becomes difficult to relax the area, meaning the pelvic floor becomes perma-flexed. Imagine flexing your bicep constantly and never fully letting go and you get the idea: After a while, this would cause your arm to lose flexibility, strength, and the ability to relax. That’s more or less what happens to the pelvic floor until you become aware of the stress and tension and do some work to alleviate it. Part of this is willfully relaxing and unclenching these muscles—and then directing energy to build strength.”

PHRC says:

As the author mentions, Stress Urinary Incontinence (SUI) is a prevalent problem in the United States. Because the symptoms are so common, many women think that leaking urine is normal and sadly the majority of them do not actually seek help. What they do not realize is that leaking urine is NOT normal, and is actually a treatable problem¹.

The pelvic floor muscles and supporting connective tissues of the pelvic organs work together to keep us from leaking. Pregnancies, age-related changes, and hormonal factors influence the connective tissues and muscles. As women approach perimenopause they may notice increasing episodes of SUI. While we cannot restore connective tissue integrity, appropriate pelvic floor and girdle muscle strengthening and motor control exercises can help the muscles counteract the connective tissue changes and restore continence. In some cases, pessaries and surgery may be necessary.

In addition to SUI, a host of other symptoms can arise when the pelvic floor muscles become dysfunctional. On the opposite end of the spectrum, 1 in 4 women develop high-tone or ‘too tight’ pelvic floor muscles. When this occurs, the muscles need to be relaxed and lengthened instead of strengthened. Symptoms of high-tone muscles can include:

• Dyspareunia (pain with intercourse)
• Urinary urgency, frequency, burning (in the absence of infection)
• Difficulty/delayed painful orgasm
• Vulvar, clitoral , or perineal pain
• anal pain
• constipation
• genital pain with sitting, tight clothing, and exercise

And may be associated with diagnoses such as Vulvodynia, Painful Bladder Syndrome/Interstitial Cystitis.

Whether someone has a low-tone disorder such as SUI or a high-tone disorder such as a pelvic pain syndrome, pelvic floor physical and occupational therapistss can help. Here is a useful recent media post. 

“Q

How can you tell if you’re clutching your pelvic floor?

A

Here’s a way to do a quick alignment reboot. First, slightly squeeze your pelvic floor and take a few steps: Notice how this locks up your jaw and hips? Next, do a kegel, and the release the kegel. Stand down through your feet and notice how much more relaxed your face, jaw, and pelvis are…now take a few steps and feel how much more relaxed and calm you are! Also, watch how others walk, and notice if they look uptight. Another trick? As you drive, mindfully relax the pelvic floor every time you encounter a stop sign or stop light—locate it by concentrating on your lower gut. You’ll quickly become aware of the fact that you might keep it clenched all the time.”

PHRC says:

The majority of people cannot relax or contract their pelvic floors on verbal instruction alone . As I previously mentioned, women with tight muscles need to relax them and women with weak muscles need to strengthen, both groups need to improve their motor control function, or ability to voluntarily control their pelvic floor muscles. These three articles explain this concept further. Ending Kegel Confusion and Why Kegels are Bad for your Tight pelvic Floor sheds light on why people struggle with pelvic floor exercises. A pelvic floor drop is an exercise that is helpful for women with tight pelvic floors to help them relax the muscles. You can read about this exercise here.

It is very hard for people to determine on their own if their pelvic floor muscles are tight, over-lengthened, or weak. If you answer yes to following questions (Quick Screening) it is possible that you have a pelvic floor disorder and may benefit from the help of a pelvic floor physical and occupational therapists. To find a pelvic floor PT in your area click here.

“Q

How does having a baby impact the pelvic floor?

A

Let’s face it: Pregnancy and the process of actually giving birth to that beautiful baby does a number on your body, and for many it can lead to incontinence problems, back aches, pain during sex, and even a pooched belly.

During pregnancy, you are awash in hormones and carrying considerable extra weight. Your body supports this extra burden by arching your spine, which tilts the pelvis forward. This anterior tilt and the extra weight and pressure downward stretch the muscles of the pelvic floor, and giving birth stretches them even more. After you have the baby, most healing will happen naturally. Being patient and aware of your body will help you get back to balance.

Give your body at least six weeks to heal. Once you get cleared by your doc or midwife, it’s important to start reconnecting to the base of your core.

These exercises will not only help with incontinence issues, but they’ll also bring back the balance and tone to make sex more enjoyable—for both partners! Doing these exercises also activates the deep abdominal muscles more efficiently which pulls the baby-belly back in and re-aligns the spine, alleviating back pain that is so common post-pregnancy. But whether you’ve had a baby or not, getting your pelvic floor back in shape has a ton of benefits.

Here are a few simple things you can do to help build awareness, tone, and strength in this magical little pelvic hammock!”

PHRC says:

Having a baby is like running a marathon with your pelvic floor muscles, which are only as thick as five sheets of paper! Common postpartum issues include:

• pain at perineal or C-section scars
• urinary, bowel, gas incontinence
• pelvic girdle pain
• Diastasis Recti
• pain with intercouse

The general rule is that it is safe to exercise and return to sex at 12 weeks postpartum. The reality is many of our friends and patients confess that they ‘just don’t feel like themselves’ or that they actually ‘cannot perform the exercises right’, even after the 12 week rule-of-thumb.  We understand the frustration and can often explain why this is the case.

1. If a Diastasis Recti is present, the entire musculoskeletal system is compromised: https://pelvicpainrehab.com/pelvic-floor-physical-therapy/2306/fix-diastasis-recti/
2. Painful scars, myofascial trigger points, and pelvic girdle pain can be treated effectively with pelvic floor physical and occupational therapy before initiating an exercise program
3. Pelvic floor muscle re-training may be necessary before more complex exercises can be started

While postpartum pelvic floor physical and occupational therapy is mandatory in other countries, it is not in the United States. Pelvic floor physical and occupational therapistss are well-positioned to help moms with their postpartum concerns and other great resources are also available to ease the musculoskeletal transition.

1. Mu Tu: https://mutusystem.com/
2. Marianne Ryan: http://www.babybodbook.com/
3. Julie Wiebe’s Pelvic floor DVD: http://www.juliewiebept.com/product/the-pelvic-floor-piston-foundation-for-fitness/

Adore Your Pelvic Floor!

I think it is safe to say that the majority of people in the United States have not had their pelvic floor ‘released’, as Ms. Roxburgh mentioned at the beginning of the article. We as pelvic floor physical and occupational therapistss deploy techniques to decrease tight pelvic floor muscles and use strategies to improve strength and motor control in cases of weak pelvic floor muscles. While we generally do not recommend ‘pelvic floor release’ for everyone, I hope this article shows you why you should adore your pelvic floor!

All my best,

Stephanie Prendergast, MPT

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical and occupational therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie (Abbie is a daily fixture at PHRC Los Angeles). For adventure, she gets her fix from scuba diving and global travel.

1. Curr Urol Rep. 2013 Aug;14(4):298-308. doi: 10.1007/s11934-013-0344-7.Urinary disorders and female sexual function.Chen J1, Sweet G, Shindel A.

If you’ve ever said the following:
“It feels like there’s a wall there.”
“I can’t insert a tampon.”
“I can’t have penetrative sex with my husband.”
“I was told I need to drink a glass of wine right before sex, but that still doesn’t help.”

You might be experiencing vaginismus symptoms.

DEFINITION

What exactly is vaginismus? Vaginismus, pronounced vaj-uh-niz-muhs, is characterized by involuntary contractions of the pelvic floor muscles, particularly the muscles surrounding the vaginal opening, interfering with vaginal penetration. While these muscle spasms cause unexplained sexual pain and penetration difficulties, they are not to be confused with dyspareunia, which is simply pain with sex. Vaginismus is often revealed during penetration attempts such as those made by inserting a finger, a tampon, or a speculum during a gynecological exam. Women report a feeling of having a “wall” at their vaginal opening, and are unable to go past this “wall”. Research has shown that around 5-17% of women are affected by vaginismus (1).

There are 2 main classifications of vaginismus, primary and secondary. Primary vaginismus is when a woman has never been able to have pain-free penetration. It is commonly discovered during her first attempt at inserting a tampon or with her first attempt at sexual intercourse. Women with primary vaginismus tend to report they have never been able to use a tampon or have a pain-free PAP test. They may also report never having been able to have sex with their partners.

Secondary vaginismus is when a woman used to be comfortable with penetration, but then  something happened to cause the vaginal muscles to go into involuntary contraction, causing painful penetration. An example would be hypersensitivity along the vestibule (an area at the vaginal opening) due to frequent yeast infections. The hypersensitivity and pain felt along the vestibule with penetration can lead towards involuntary muscle contractions and eventually an inability to allow any penetration at all: vaginismus. Another example of a cause of secondary vaginismus could be some sort of traumatic event, such as childbirth. Childbirth can be quite traumatic due to natural tearing of the vaginal opening, an episiotomy, and/or bruising around the vagina. The pain and discomfort associated with a traumatic birth can cause muscle guarding and involuntary muscle spasms to protect the area. These involuntary pelvic floor muscle spasms can develop into vaginismus.

There are different severities of vaginismus: “situational” and “complete.” Situational vaginismus is an ability to tolerate certain forms of penetration, such as using a tampon, and an inability to tolerate other forms of penetration, such as sexual intercourse. Complete vaginismus is an inability to tolerate any form of penetration.

The cause of vaginismus varies. It may be due to an emotional response, such as rigid upbringing, sexual assault/rape, or negative feelings. It can be brought on as a physical response too (for example, yeast/urinary infections, childbirth, or hormonal changes, such as those occurring during menopause). There may also be no identifiable cause at all.

Fear and anxiety are commonly associated with vaginismus, as they feed into the pain cycle. The pain cycle, in this case,  starts with a woman anticipating pain with penetration. When this happens, the body involuntarily contracts the pelvic floor muscles to guard from potential pain, which tightens the muscles making penetration painful. The pain felt during penetration further induces the pelvic floor to guard and spasm, which actually creates more pain. The woman may start to avoid sexual intimacy and develop fear and anxiety around it. The fear and anxiety feed into the anticipation of pain, and the whole cycle starts all over again.

DIAGNOSIS

Vaginismus is typically diagnosed from a patient’s medical and psycho-sexual history and a gynecological exam to rule out other conditions, such as vulvodynia. Some medical practitioners use questionnaires, such as the Female Sexual Function Index or the Vaginal Penetration Cognition Questionnaire (1), to help diagnose vaginismus. It is important for practitioners to rule out other conditions and to understand the severity of the pain and anxiety associated with vaginismus. This will help determine the prognosis and the treatment plan.

TERMINOLOGY CONTROVERSY

The field of pelvic floor dysfunction is in its adolescence. As a result, many pelvic pain diagnoses have undergone change as our understanding of the disorder improves. For example, “Interstitial Cystitis” has become “Painful Bladder Syndrome” and “Chronic Prostatitis” has become “Chronic Pelvic Pain Syndrome”. The term “vaginismus” is being debated and may be replaced with more specific terminology in the near future. To read more about this, please read our blog post “Is Vaginismus an outdated, useless, term?”

TREATMENT

Treatment does not consist of a glass of wine right before sex… despite the number of practitioners offering this advice! However, pelvic floor physical and occupational therapy is very effective. Physical therapy consists of manual therapy to release the muscle spasms throughout the pelvic floor, abdomen, buttocks, lower back and legs; training on how to voluntarily relax the pelvic floor muscles (fondly known as the pelvic floor drop); and initiation of an individualized home program involving stretches and dilators. We see the best results when the patient is treated by a multidisciplinary team including( as well as a physical and occupational therapists): a psychologist, a sex therapist, and/or a medical doctor (who can administer trigger point or Botox injections, if necessary). The psychologist and/or sex therapist will help with addressing fear and anxiety, as well as any emotional disturbances associated with the pain of vaginismus. Trigger point injections and dry needling can be helpful with releasing trigger points throughout the pelvic floor and larger muscle groups contributing towards pelvic floor tightness. Botox injections can also be helpful with relaxing muscle tightness in the pelvic floor, particularly the muscles surrounding the vaginal opening. To read about one woman’s successful treatment, click here.

Relaxation of the pelvic floor musculature is key to treating vaginismus. This means that kegel exercises are not appropriate! Kegels contract the pelvic floor and when you have something already tight, you do not want to tighten it even further and cause more spasming. It is best to hold off on kegel exercises and to seek an evaluation with a pelvic floor physical and occupational therapists.

Vaginismus is not a sentence to life behind a wall. It is a common impairment affecting millions of women worldwide. If you or a loved one has been diagnosed with vaginismus, please know that treatment is available. To find a pelvic floor physical and occupational therapists near you click here. To read Jackie’s story on vaginismus please click here.

 

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Are you unable to come see us in person? We offer virtual appointments!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical and occupational therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical and occupational therapistss committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical and occupational therapistss via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical and occupational therapistss, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical and occupational therapists who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

Reference:

1. Pacik, Peter. Understand and treating vaginismus: a multimodal approach. Int. Urogynecol J. 2014; 25:1613-1620.

“If you “play with sex steroid hormones” using finasteride (propecia) – the goal of finasteride (propecia) is to reduce the synthesis of the sex steroid hormone – dihydrotestosterone – then you will likely “play with your sex life” – as sexual function is very much related to sex steroid hormone levels”, says sexual medicine expert and urologist Dr. Irwin Goldtsein.

Propecia (aka finasteride) is the only FDA-approved oral drug on the market prescribed for treating androgenetic alopecia-more commonly called male pattern baldness (MPB). Unfortunately, many unsuspecting men concerned about hair loss do not know that using Propecia can result in side effects much more devastating than a bald spot. At PHRC, we are seeing increasing numbers of men with sexual dysfunction following Propecia use. If you are considering taking Propecia you need to read this article.

MPB is widespread.

According to the American Hair Loss Association, by age 35, 66% of all men have experienced some degree of hair loss and by age 50, approximately 85% of men have significantly thinner hair. Roughly 33 million men. This is a huge number! And, until the late ‘90s most men reported that they felt that physicians were dismissing their concerns about hair loss. For some men, hair loss can cause serious psychological distress. Researchers at Charité – Universitätsmedizin Berlin, one of the largest university hospitals in Europe, found that MPB can result in decreased self confidence, depression, anxiety, and impaired quality of life. This is a troublesome issue and the reality is that there are not that many affordable and/or effective options for people going through this.

So when Propecia was approved by the FDA to treat MPB in 1997, it was momentous. Millions of men began taking it since that time, with countless individuals having utilized it to combat hair loss. What’s more is that during the period it is being taken,  it actually works! But as always, there are side effects to consider. Thus, it is in situations like this that we need to ask ourselves, do the benefits outweigh the potential costs?

Before we go into the side effects of Propecia, let’s first discuss the mechanism of how this drug works:  it prevents the conversion of testosterone into dihydrotestosteorne (DHT) which is the active form of testosterone in hair follicles and in the prostate. What does that have to do with hair loss? While scientists have yet to fully understand the mechanism of MPB, they do know that it is largely genetic and those who have inherited this condition have hair follicles that are sensitive to DHT. As these hair follicles are exposed to DHT over time, they begin to shrink, decreasing the integrity and lifespan of these follicles until eventually they become dormant and stop producing hair. So when Propecia is introduced to our system, it stops testosterone from breaking down into DHT, which significantly reduces the amount of DHT in the body. Now the hair follicles that are present can thrive and produce hair–problem solved.

But there’s a hitch…

Although Propecia has been proven effective for treating MPB, our patients will tell you that the most common side effects greatly override any benefits. Propecia use can cause erectile dysfunction, decreased libido, and a decrease in semen production. A large percentage of men that take Propecia have reported these symptoms. The Journal of Sexual Medicine published a study that interviewed 71 men recruited from propeciahelp.com, ranging in age from 21 to 46 years. “Subjects reported new-onset persistent sexual dysfunction associated with the use of finasteride [Propecia]: 94% developed low libido, 92% developed erectile dysfunction, 92% developed decreased arousal, and 69% developed problems with orgasm.” The study also found that the average number of sexual episodes per month was lower and the “total sexual dysfunction score increased according to the Arizona Sexual Experience Scale (P < 0.0001 for both).” The average length of Propecia use was 28 months and the average duration of persistent sexual side effects was 40 months from the time of discontinuation.1

Obviously these side effects are a serious problem for men. Erectile dysfunction is known to be a major cause of decreased quality of life in men. A clinical series published in 2012, found that 89% of the sample size (n = 54) reported some degree of sexual dysfunction with the use of Propecia. 20% of subjects who had used Propecia to treat MPB reported persistent sexual dysfunction for ≥6 years. This same study found that most men who developed persistent sexual side effects lasting ≥3 months with the use of Propecia continued to experience erectile dysfunction for many months or years despite stopping the drug, which lead the researcher to suggest the possibility that the dysfunction may be permanent.2

A retrospective analysis using the the US Food and Drug Administration Adverse Event Reporting System data was published this month. Disturbingly, low-dose finasteride was associated with reports of sexual dysfunction that were more than expected. Among the reports of serious sexual dysfunction, 43% led to disability, 28% required medical intervention (including hospitalization) and 5% were life-threatening.3

We asked some of the nation’s leading specialists on sexual medicine to give us their take on prescribing Propecia as a treatment for MPB and here is what they had to say:

Dr. Seth Cohen, urologist and sexual medicine specialist in NYC stated: “Propecia is a scary drug that should be cautiously used after exhausting all other treatments for MPB. Propecia or 1mg of finasteride irreversibly binds to the enzyme 5 alpha reductase (the enzyme that converts testosterone to dihydrotestosterone) irreversibly turning the enzyme OFF causing DHT levels to plummet close to zero. Signs of Post Finasteride Syndrome (PFS) include mood swings, mental fog, depression, anxiety, erectile dysfunction, orgasm and ejaculation dysfunction. This is a scary drug and we have no idea who might be affected worse by it. Some men taking propecia for MPB seem to have little to no side-effects, whereas others suffer for years. In addition, many doctors don’t understand or even recognize PFS as a real disease and these patients will suffer alone. Luckily, social media and the internet have been able to provide a safe haven for these patients. Propeciahelp.com is a great resource for men suffering from PFS.”

Dr. Joshua Gonzalez, urologist and sexual medicine specialist in Los Angeles, states: “ I will not prescribe finasteride to young men with MPB because of the potential side effects. In my clinical experience, the length of time on the medication does not correlate with the severity or duration of the side effects. There are numerous hormonal and nonhormonal treatment options for men with PFS.”

Find Your Solution:

An individualized, interdisciplinary approach to treatment will result in the best outcome. First, find a physician with a particular interest in sexual medicine. The Sexual Medicine Society of North America offers a ‘Find a Provider’ link on their website: SexHealthMatters.

Pharmacologic treatment options  include hormonal regulation, antidepressants, and psychostimulants, all of which should be brought up with your physician.

Nonpharmacologic treatment options include psychotherapy, meditation, and pelvic floor physical and occupational therapy. We know that musculoskeletal health of the pelvic floor is necessary for erectile function and orgasm.  So, even if the primary cause of erectile dysfunction is due to hormonal changes caused by Propecia use, there is evidence to suggest that pelvic floor muscle strengthening can improve erectile function and orgasm intensity. A pelvic floor physical and occupational therapists can evaluate the musculoskeletal structures associated with sexual function and provide you with a treatment plan to address any and all areas that are impaired.

Finally, know that you are not alone. Many men are dealing with the adverse effects of taking Propecia and while the medical community is still working on perfecting the most effective plan for treating these issues, it may help to be able to connect with others that may be going through a similar situation. Online support groups are available at these websites: Post Finasteride Syndrome Foundation and Propeciahelp.com.

Each person will have a different combination of symptoms and treatment needs which will affect the prognoses. Stay persistent and work closely with your health care providers until you find the therapeutic combination that is right for you.

 

 

References:

1. Irwig, M. S. and Kolukula, S. (2011), Persistent Sexual Side Effects of Finasteride for Male Pattern Hair Loss. Journal of Sexual Medicine, 8: 1747–1753. doi:10.1111/j.1743-6109.2011.02255.x
2. Irwig, M. S. Persistent sexual side effects of finasteride: could they be permanent? J Sex Med. 2012 Nov;9(11):2927-32. doi: 10.1111/j.1743-6109.2012.02846.x. Epub 2012 Jul 12.
3. Ali AK et al Persistent Sexual Dysfunction and Suicidal Ideation in Young Men treated with Low-Dose Finasteride: A Pharmacovigilance Study, Pharmacotherapy, July 2015.
4. Laumann, E., Paik, A., et al. Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. 1999;281(6):537-544. doi:10.1001/jama.281.6.537.