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EDITORIAL Prevention, Not Cure “An ounce of prevention is worth a pound of cure” [1]. Franklin may have coined this phrase in 1736, but it is nonetheless just as true today. Unfortunately, this good advice, originally written for fire prevention, continues to be ignored by most of society. So how can we apply this in medicine, and more specifically to sexual medicine? Let us think of the preventative measures we have already explored. Finding the right bicycle seat might prevent various sexual dysfunctions in men and women, as does correct fit [2–4]. Choosing a method of contraception that does not have negative sexual side effects is another obvious preventative measure [5–8]. However, lifestyle choices go well beyond simple decisions about bicycle riding and contraception. Lifestyle choices may involve hormone use in aging. One practical strategy for the use of hormones in aging women and men is designed to return the sex steroid hormone milieu to the lowest values that still provide consistent physiologic benefit [9,10]. Hormone deprivation states in men and women are associated with sexual dysfunction as well and many other health issues such as failing memory and cognition, loss of bone density, and resulting fractures [11–14]. Specifically for aging women, approximately 10 years from menopause, data from the Women’s Health Initiative study showed that treatment with conjugated equine estrogens/medroxyprogesterone acetate vs. placebo resulted in higher chances of breast cancer. Such data caused great fear in all aging women, even in those far earlier in their menopause, or even in late perimenopause, and even among those using other forms of estradiol replacement including biologically identical estradiol for which there are no such breast cancer risk data. Many women stopped using hormones abruptly, and others who might have benefited from their use in menopause never even started any hormone treatment [15]. A recent article showed that over a 10-year period between 2002 and 2011, a minimum of approximately 18,000 and as many as approximately 91,000 postmenopausal women died prematurely because of the avoidance of estrogen therapy [16]. © 2013 International Society for Sexual Medicine
Lifestyle choices, however, that I want to focus on in this editorial are the ones associated with diet and exercise. These lifestyle choices are lifetime choices that we all make consciously or subconsciously. Our decisions about diet and exercise can really affect our sexual function [17–22]—there are growing diet and exercise literature on this topic. But have you ever thought that lifestyle choices regarding diet and exercise can really affect our chances for getting a cancer? When men and women are diagnosed with cancer, everything else in their world seemingly stops. In most cases, the oncologist or surgeon does not discuss in great detail the sexual side effects of cancer treatment, whether that be hormone ablation, surgical removal of gonads or ovaries, critical autonomic nerve damage, or any other oncologic treatment side effects. Even if these issues were brought into the discussion, they would likely fade into the background. From the moment the patient hears the word cancer, nothing else matters—understandably so. Outside of watchful waiting, sometimes recommended for men with low-grade prostate cancer, more often than not, there will be sexual consequences to cancer treatments. It is our job as sexual medicine providers to help pick up those pieces once the cancer has been treated and the patient wants to return to a more normal sexual lifestyle [23,24]. So where am I going with this? What I am saying, instead, is that an ounce of prevention is worth a pound of cure. That prevention may mean concomitant treatments that will help a more positive sexual outcome from the cancer treatment. However, more fundamentally, I am advocating prevention of cancer, in addition to the better recognized association with heart disease and metabolic syndrome and obesity and hypercholesterolemia and hypertension, through changes in diet and exercise. I can see your smirk while you are reading this editorial. Sure, this is what everyone wants. No one chooses to get cancer or other life-threatening diseases. But what is it we do choose? We choose our lifestyle. We choose to eat foods that are highly processed or filled with chemicals that our bodies do not recognize. We choose foods we J Sex Med 2013;10:2613–2615
2614 know are harmful to our cardiovascular system. We choose to sit on the couch and watch television or play Wii and consider that our exercise for the day. We choose to allow stress to take over our lives, day after day, worrying about our jobs, our families, our incomes, politics, keeping up with the Joneses—whatever it is that we do get stressed about. It is chronic stress, poor diet, and lack of exercise that systematically adversely affect our immune system that is designed to protect us from disease. This is the twenty-first century. We have all sorts of modern conveniences available to us, but not one of them will replace reducing stress, eating right, and moving our bodies regularly. Not one will keep us from being at risk for metabolic syndrome or heart disease—only we can do that. Stress triggers the endothelial dysfunction that first becomes the heart attack of the penis (erectile dysfunction) and ultimately the myocardial infarction. Stress triggers those cancer cells to start replicating in our bodies rather than lying dormant, unchecked by our weakened immune system that can no longer serve its intended function of seeking out and destroying any abnormal growths. However, we know so little about this in reality. We spend millions of dollars researching cures for various disease states and, in particular, the most common cancers. How much funding does the government supply toward development of guidelines for prevention of cancers? Should not that be a direction for the future? How much easier, cheaper, and less painful would it be to stop disease before tumors are growing throughout the body and the only options are life-threatening themselves. A year and a half ago, my daughter Lauren switched her family from a typical American diet to a vegan, organic, nongenetically modified diet of predominantly fruit and vegetables. She did this because she was very concerned about the effect of this diet on the welfare of type 1 diabetics. Her husband had been diagnosed with type 1 diabetes 15 years earlier. At this point in time, he no longer needs as much insulin and eliminated his need to wear an insulin pump. The family is eating essentially pure foods, as did our forefathers. As siblings often do, Lauren introduced this new way of eating to the rest of the family. Although Sue and I are not vegan, we are essentially vegetarian in our home and buy only organic, nongenetically modified fruits and vegetables. We do not eat processed foods or fast food, and we both feel (and look) so much better for that decision. My son J Sex Med 2013;10:2613–2615
Editorial Bryan’s family has certainly decreased their intake of carbohydrates and processed food, choosing to focus more on fruits and vegetables with small portions of meat or pasta at meals. However, my son Andrew has gone a step further. His family are now vegans, but this has inspired a change not only in his lifestyle but in his research work content—he is the inspiration for this editorial. He has redirected his basic science research from seeking the genetic basis of prostate cancer [25,26] to examining the effect of food on the development of prostate cancer. Can he prove scientifically that eating a healthy diet will prevent prostate cancer? He already has shown preliminary evidence that diet does indeed change gene expression. In addition, we already know the effect of diet and exercise on metabolic syndrome and cardiovascular disease. Ultimately, a decrease in cancer prevalence will also mean prevention of all the negative side effects from cancer treatments. In my ideal world, I would teach everyone how to prevent sexual health problems rather than treat those problems after they occur. You may call me altruistic—or a little crazy—maybe I am both. I believe there will always be a role for sexual health providers. However, I prefer to live in a world where the ounce of prevention weighs in against the pound of cure, where people take responsibility for their own health and where our governments and health insurance companies support prophylaxis through deed, not word alone. We only need a cure if we continue to have the disease. Let us focus on staying healthy, becoming more healthy, including sexually healthy. Help keep your journal healthy as well. Continue to read The Journal of Sexual Medicine, cite it, review for it, and write for it. As we come close to the end of 2013 and start thinking of resolutions for 2014, resolve to change diet and exercise habits and prevent health, including sexual health, problems from happening in the first place. Irwin Goldstein, MD Editor-in-Chief
References 1 Independence Hall Association. The electric Ben Franklin, ushistory.org. 1995. Available at: http://www.ushistory.org/ franklin/info/ (accessed September 7, 2013). 2 Sommer F, Goldstein I, Korda JB. Bicycle riding and erectile dysfunction: A review. J Sex Med 2010;7:2346–58. 3 Guess MK, Partin SN, Schrader S, Lowe B, LaCombe J, Reutman S, Wang A, Toennis C, Melman A, Mikhail M,
Editorial
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5
6
7
8
9 10
11
12 13
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Connell KA. Women’s bike seats: A pressing matter for competitive female cyclists. J Sex Med 2011;8:3144–53. Partin SN, Connell KA, Schrader S, LaCombe J, Lowe B, Sweeney A, Reutman S, Wang A, Toennis C, Melman A, Mikhail M, Guess MK. The bar sinister: Does handlebar level damage the pelvic floor in female cyclists? J Sex Med 2012;9: 1367–73. Burrows LJ, Basha M, Goldstein AT. The effects of hormonal contraceptives on female sexuality: A review. J Sex Med 2012;9:2213–23. Enzlin P, Weyers S, Janssens D, Poppe W, Eelen C, Pazmany E, Elaut E, Amy J-J. Sexual functioning in women using levonorgestrel-releasing intrauterine systems as compared to copper intrauterine devices. J Sex Med 2012;9:1065–73. Caruso S, Iraci Sareri M, Agnello C, Romano M, Lo Presti L, Malandrino C, Cianci A. Conventional versus extended-cycle oral contraceptives on the quality of sexual life: Comparison between two regimens containing 3 mg drospirenone and 20 μg ethinyl estradiol. J Sex Med 2011;8:1478–85. Panzer C, Wise S, Fantini G, Kang D, Munarriz R, Guay A, Goldstein I. Impact of oral contraceptives on sex hormonebinding globulin and androgen levels: A retrospective study in women with sexual dysfunction. J Sex Med 2006;3:104–13. Corona G, Rastrelli G, Forti G, Maggi M. Update in testosterone therapy for men. J Sex Med 2011;8:639–54. Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women. J Sex Med 2005; 2(3 suppl):154–65. Corona G, Gacci M, Baldi E, Mancina R, Forti G, Maggi M. Androgen deprivation therapy in prostate cancer: Focusing on sexual side effects. J Sex Med 2012;9:887–902. Davis SR. Androgen therapy in women, beyond libido. Climacteric 2013;16(1 suppl):18–24. Davison SL, Bell RJ, Gavrilescu M, Searle K, Maruff P, Gogos A, Rossell SL, Adams J, Egan GF, Davis SR. Testosterone improves verbal learning and memory in postmenopausal women: Results from a pilot study. Maturitas 2011;70:307–11. Davis SR. Cardiovascular and cancer safety of testosterone in women. Curr Opin Endocrinol Diabetes Obes 2011;18:198– 203.
2615 15 Goldstein I. The effects of the Women’s Health Initiative on is 10th year anniversary. J Sex Med 2012;9:2479–82. 16 Sarrel PM, Njike VY, Vinante V, Katz DL. The mortality toll of estrogen avoidance: An analysis of excess deaths among hysterectomized women aged 50 to 59 years. Am J Public Health 2013;103:1583–8. 17 Giugliano F, Maiorino MI, Di Palo C, Autorino R, De Sio M, Giugliano D, Esposito K. Adherence to Mediterranean diet and sexual function in women with type 2 diabetes. J Sex Med 2010;7:1883–90. 18 Giugliano F, Maiorino MI, Bellastella G, Autorino R, De Sio M, Giugliano D, Esposito K. Adherence to Mediterranean diet and erectile dysfunction in men with type 2 diabetes. J Sex Med 2010;7:1911–7. 19 Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med 2010;7:2338–45. 20 Azadzoi KM, Schulman RN, Aviram M, Siroky MB. Oxidative stress in arteriogenic erectile dysfunction: Prophylactic role of antioxidants. J Urol 2005;174:386–93. 21 Forest CP, Padma-Nathan H, Liker HR. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: A randomized, placebo-controlled, double-blind, crossover study. Int J Impot Res 2007;19:564–7. 22 Miner M, Esposito K, Guay A, Montorsi P, Goldstein I. Cardiometabolic risk and female sexual health: The Princeton III summary. J Sex Med 2012;9:641–51. 23 Krychman ML, Katz A. Breast cancer and sexuality: Multimodal treatment options. J Sex Med 2012;9:5–13. 24 Incrocci L. Talking about sex to oncologists and cancer to sexologists. J Sex Med 2011;8:3251–3. 25 Goldstein AS, Huang J, Guo C, Garraway IP, Witte ON. Identification of a cell of origin for human prostate cancer. Science 2010;329:568–71. 26 Zong Y, Xin L, Goldstein AS, Lawson DA, Teitell MA, Witte ON. ETS family transcription factors collaborate with alternative signaling pathways to induce carcinoma from adult murine prostate cells. Proc Natl Acad Sci U S A 2009;106: 12465–70.
J Sex Med 2013;10:2613–2615
EDITORIAL Prevention, Not Cure “An ounce of prevention is worth a pound of cure” [1]. Franklin may have coined this phrase in 1736, but it is nonetheless just as true today. Unfortunately, this good advice, originally written for fire prevention, continues to be ignored by most of society. So how can we apply this in medicine, and more specifically to sexual medicine? Let us think of the preventative measures we have already explored. Finding the right bicycle seat might prevent various sexual dysfunctions in men and women, as does correct fit [2–4]. Choosing a method of contraception that does not have negative sexual side effects is another obvious preventative measure [5–8]. However, lifestyle choices go well beyond simple decisions about bicycle riding and contraception. Lifestyle choices may involve hormone use in aging. One practical strategy for the use of hormones in aging women and men is designed to return the sex steroid hormone milieu to the lowest values that still provide consistent physiologic benefit [9,10]. Hormone deprivation states in men and women are associated with sexual dysfunction as well and many other health issues such as failing memory and cognition, loss of bone density, and resulting fractures [11–14]. Specifically for aging women, approximately 10 years from menopause, data from the Women’s Health Initiative study showed that treatment with conjugated equine estrogens/medroxyprogesterone acetate vs. placebo resulted in higher chances of breast cancer. Such data caused great fear in all aging women, even in those far earlier in their menopause, or even in late perimenopause, and even among those using other forms of estradiol replacement including biologically identical estradiol for which there are no such breast cancer risk data. Many women stopped using hormones abruptly, and others who might have benefited from their use in menopause never even started any hormone treatment [15]. A recent article showed that over a 10-year period between 2002 and 2011, a minimum of approximately 18,000 and as many as approximately 91,000 postmenopausal women died prematurely because of the avoidance of estrogen therapy [16]. © 2013 International Society for Sexual Medicine
Lifestyle choices, however, that I want to focus on in this editorial are the ones associated with diet and exercise. These lifestyle choices are lifetime choices that we all make consciously or subconsciously. Our decisions about diet and exercise can really affect our sexual function [17–22]—there are growing diet and exercise literature on this topic. But have you ever thought that lifestyle choices regarding diet and exercise can really affect our chances for getting a cancer? When men and women are diagnosed with cancer, everything else in their world seemingly stops. In most cases, the oncologist or surgeon does not discuss in great detail the sexual side effects of cancer treatment, whether that be hormone ablation, surgical removal of gonads or ovaries, critical autonomic nerve damage, or any other oncologic treatment side effects. Even if these issues were brought into the discussion, they would likely fade into the background. From the moment the patient hears the word cancer, nothing else matters—understandably so. Outside of watchful waiting, sometimes recommended for men with low-grade prostate cancer, more often than not, there will be sexual consequences to cancer treatments. It is our job as sexual medicine providers to help pick up those pieces once the cancer has been treated and the patient wants to return to a more normal sexual lifestyle [23,24]. So where am I going with this? What I am saying, instead, is that an ounce of prevention is worth a pound of cure. That prevention may mean concomitant treatments that will help a more positive sexual outcome from the cancer treatment. However, more fundamentally, I am advocating prevention of cancer, in addition to the better recognized association with heart disease and metabolic syndrome and obesity and hypercholesterolemia and hypertension, through changes in diet and exercise. I can see your smirk while you are reading this editorial. Sure, this is what everyone wants. No one chooses to get cancer or other life-threatening diseases. But what is it we do choose? We choose our lifestyle. We choose to eat foods that are highly processed or filled with chemicals that our bodies do not recognize. We choose foods we J Sex Med 2013;10:2613–2615
2614 know are harmful to our cardiovascular system. We choose to sit on the couch and watch television or play Wii and consider that our exercise for the day. We choose to allow stress to take over our lives, day after day, worrying about our jobs, our families, our incomes, politics, keeping up with the Joneses—whatever it is that we do get stressed about. It is chronic stress, poor diet, and lack of exercise that systematically adversely affect our immune system that is designed to protect us from disease. This is the twenty-first century. We have all sorts of modern conveniences available to us, but not one of them will replace reducing stress, eating right, and moving our bodies regularly. Not one will keep us from being at risk for metabolic syndrome or heart disease—only we can do that. Stress triggers the endothelial dysfunction that first becomes the heart attack of the penis (erectile dysfunction) and ultimately the myocardial infarction. Stress triggers those cancer cells to start replicating in our bodies rather than lying dormant, unchecked by our weakened immune system that can no longer serve its intended function of seeking out and destroying any abnormal growths. However, we know so little about this in reality. We spend millions of dollars researching cures for various disease states and, in particular, the most common cancers. How much funding does the government supply toward development of guidelines for prevention of cancers? Should not that be a direction for the future? How much easier, cheaper, and less painful would it be to stop disease before tumors are growing throughout the body and the only options are life-threatening themselves. A year and a half ago, my daughter Lauren switched her family from a typical American diet to a vegan, organic, nongenetically modified diet of predominantly fruit and vegetables. She did this because she was very concerned about the effect of this diet on the welfare of type 1 diabetics. Her husband had been diagnosed with type 1 diabetes 15 years earlier. At this point in time, he no longer needs as much insulin and eliminated his need to wear an insulin pump. The family is eating essentially pure foods, as did our forefathers. As siblings often do, Lauren introduced this new way of eating to the rest of the family. Although Sue and I are not vegan, we are essentially vegetarian in our home and buy only organic, nongenetically modified fruits and vegetables. We do not eat processed foods or fast food, and we both feel (and look) so much better for that decision. My son J Sex Med 2013;10:2613–2615
Editorial Bryan’s family has certainly decreased their intake of carbohydrates and processed food, choosing to focus more on fruits and vegetables with small portions of meat or pasta at meals. However, my son Andrew has gone a step further. His family are now vegans, but this has inspired a change not only in his lifestyle but in his research work content—he is the inspiration for this editorial. He has redirected his basic science research from seeking the genetic basis of prostate cancer [25,26] to examining the effect of food on the development of prostate cancer. Can he prove scientifically that eating a healthy diet will prevent prostate cancer? He already has shown preliminary evidence that diet does indeed change gene expression. In addition, we already know the effect of diet and exercise on metabolic syndrome and cardiovascular disease. Ultimately, a decrease in cancer prevalence will also mean prevention of all the negative side effects from cancer treatments. In my ideal world, I would teach everyone how to prevent sexual health problems rather than treat those problems after they occur. You may call me altruistic—or a little crazy—maybe I am both. I believe there will always be a role for sexual health providers. However, I prefer to live in a world where the ounce of prevention weighs in against the pound of cure, where people take responsibility for their own health and where our governments and health insurance companies support prophylaxis through deed, not word alone. We only need a cure if we continue to have the disease. Let us focus on staying healthy, becoming more healthy, including sexually healthy. Help keep your journal healthy as well. Continue to read The Journal of Sexual Medicine, cite it, review for it, and write for it. As we come close to the end of 2013 and start thinking of resolutions for 2014, resolve to change diet and exercise habits and prevent health, including sexual health, problems from happening in the first place. Irwin Goldstein, MD Editor-in-Chief
References 1 Independence Hall Association. The electric Ben Franklin, ushistory.org. 1995. Available at: http://www.ushistory.org/ franklin/info/ (accessed September 7, 2013). 2 Sommer F, Goldstein I, Korda JB. Bicycle riding and erectile dysfunction: A review. J Sex Med 2010;7:2346–58. 3 Guess MK, Partin SN, Schrader S, Lowe B, LaCombe J, Reutman S, Wang A, Toennis C, Melman A, Mikhail M,
Editorial
4
5
6
7
8
9 10
11
12 13
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Connell KA. Women’s bike seats: A pressing matter for competitive female cyclists. J Sex Med 2011;8:3144–53. Partin SN, Connell KA, Schrader S, LaCombe J, Lowe B, Sweeney A, Reutman S, Wang A, Toennis C, Melman A, Mikhail M, Guess MK. The bar sinister: Does handlebar level damage the pelvic floor in female cyclists? J Sex Med 2012;9: 1367–73. Burrows LJ, Basha M, Goldstein AT. The effects of hormonal contraceptives on female sexuality: A review. J Sex Med 2012;9:2213–23. Enzlin P, Weyers S, Janssens D, Poppe W, Eelen C, Pazmany E, Elaut E, Amy J-J. Sexual functioning in women using levonorgestrel-releasing intrauterine systems as compared to copper intrauterine devices. J Sex Med 2012;9:1065–73. Caruso S, Iraci Sareri M, Agnello C, Romano M, Lo Presti L, Malandrino C, Cianci A. Conventional versus extended-cycle oral contraceptives on the quality of sexual life: Comparison between two regimens containing 3 mg drospirenone and 20 μg ethinyl estradiol. J Sex Med 2011;8:1478–85. Panzer C, Wise S, Fantini G, Kang D, Munarriz R, Guay A, Goldstein I. Impact of oral contraceptives on sex hormonebinding globulin and androgen levels: A retrospective study in women with sexual dysfunction. J Sex Med 2006;3:104–13. Corona G, Rastrelli G, Forti G, Maggi M. Update in testosterone therapy for men. J Sex Med 2011;8:639–54. Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women. J Sex Med 2005; 2(3 suppl):154–65. Corona G, Gacci M, Baldi E, Mancina R, Forti G, Maggi M. Androgen deprivation therapy in prostate cancer: Focusing on sexual side effects. J Sex Med 2012;9:887–902. Davis SR. Androgen therapy in women, beyond libido. Climacteric 2013;16(1 suppl):18–24. Davison SL, Bell RJ, Gavrilescu M, Searle K, Maruff P, Gogos A, Rossell SL, Adams J, Egan GF, Davis SR. Testosterone improves verbal learning and memory in postmenopausal women: Results from a pilot study. Maturitas 2011;70:307–11. Davis SR. Cardiovascular and cancer safety of testosterone in women. Curr Opin Endocrinol Diabetes Obes 2011;18:198– 203.
2615 15 Goldstein I. The effects of the Women’s Health Initiative on is 10th year anniversary. J Sex Med 2012;9:2479–82. 16 Sarrel PM, Njike VY, Vinante V, Katz DL. The mortality toll of estrogen avoidance: An analysis of excess deaths among hysterectomized women aged 50 to 59 years. Am J Public Health 2013;103:1583–8. 17 Giugliano F, Maiorino MI, Di Palo C, Autorino R, De Sio M, Giugliano D, Esposito K. Adherence to Mediterranean diet and sexual function in women with type 2 diabetes. J Sex Med 2010;7:1883–90. 18 Giugliano F, Maiorino MI, Bellastella G, Autorino R, De Sio M, Giugliano D, Esposito K. Adherence to Mediterranean diet and erectile dysfunction in men with type 2 diabetes. J Sex Med 2010;7:1911–7. 19 Esposito K, Giugliano F, Maiorino MI, Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med 2010;7:2338–45. 20 Azadzoi KM, Schulman RN, Aviram M, Siroky MB. Oxidative stress in arteriogenic erectile dysfunction: Prophylactic role of antioxidants. J Urol 2005;174:386–93. 21 Forest CP, Padma-Nathan H, Liker HR. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: A randomized, placebo-controlled, double-blind, crossover study. Int J Impot Res 2007;19:564–7. 22 Miner M, Esposito K, Guay A, Montorsi P, Goldstein I. Cardiometabolic risk and female sexual health: The Princeton III summary. J Sex Med 2012;9:641–51. 23 Krychman ML, Katz A. Breast cancer and sexuality: Multimodal treatment options. J Sex Med 2012;9:5–13. 24 Incrocci L. Talking about sex to oncologists and cancer to sexologists. J Sex Med 2011;8:3251–3. 25 Goldstein AS, Huang J, Guo C, Garraway IP, Witte ON. Identification of a cell of origin for human prostate cancer. Science 2010;329:568–71. 26 Zong Y, Xin L, Goldstein AS, Lawson DA, Teitell MA, Witte ON. ETS family transcription factors collaborate with alternative signaling pathways to induce carcinoma from adult murine prostate cells. Proc Natl Acad Sci U S A 2009;106: 12465–70.
J Sex Med 2013;10:2613–2615
