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Gender Issues
Gender-related issues in multiple sclerosis (MS) include the clinical observations that men are less susceptible to the disease than women. There is also the fact that disease activity in MS decreases during late pregnancy. This section reviews mechanisms underlying each of these clinical observations and looks at the role of sex hormones play in each. We look at the protective role of testosterone in younger men and the protective role of the pregnancy hormone estriol in pregnant women.

Gender has become a dominant factor in MS during the last couple decades. With a ratio of around 2 to 1 in years past and now around 3 to 1, MS is gradually changing into a disease predominantly among women. The ratio increase can either be that more women now have MS or there's an increase in women actually diagnosed with MS. Since genetic factors can be ruled out as a cause of this gender related increase, a great deal of scientific attention is on environmental factors that may increase MS risk in women exclusively. Many feel that the most likely environmental factors include smoking, viral infections, Vitamin D deficiency, hygiene changes and dietary factors.


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Sex Hormones and MS
Both testosterone and estriol, an estrogen hormone that is produced during late pregnancy, have been shown to have a beneficial effect in experimental allergic encephalomyelitis (EAE), the animal model of MS.

Testosterone is a steroid hormone from the androgen group. Testosterone is primarily secreted in the testes of males and the ovaries of females, with small amounts being secreted by the adrenal glands. It's the principal male sex hormone and an anabolic steroid. The pituitary gland controls the level of testosterone in the body. When the testosterone level is low, the pituitary gland releases a hormone called luteinizing hormone (LH). This hormone in men tells the testicles to make more testosterone.

The level of testosterone is the highest around age 40, and then gradually becomes less in older men. On average, an adult human male body produces about forty to sixty times more testosterone than an adult female body, but females are, from a behavioral perspective (rather than from an anatomical or biological perspective), more sensitive to the hormone.

In women, the ovaries account for half of the testosterone produced in the body. The amount of testosterone in their bodies compared to men is significantly less. But testosterone plays an important role throughout the body in both men and women. It affects the brain, bone and muscle mass, fat distribution, the vascular system, energy levels, genital tissues, and sexual functioning.

The three major naturally occurring estrogens in women are estrone, estradiol, and estriol. Estradiol is the predominate form in nonpregnant females, estrone is produced during menopause, and estriol is the primary estrogen of pregnancy. These are all produced from androgens through actions of enzymes.

Now estriol is one of the three main estrogens produced by the human body. It's only produced in significant amounts during pregnancy since it's made by the fetal liver from 16-OHDHEAS, an androgen steroid made in the fetal adrenal glands.

Studies are suggesting that one year of treatment with a skin gel containing the sex hormone testosterone to men with relapsing-remitting MS (RRMS) results in significant improvements in cognitive function and in slowing brain tissue loss.

There have been no large-scale studies of the effects of oral contraceptives or hormone replacement therapy in women with MS who are post-menopausal. Since this is the case, the effects of such hormonal therapies on MS are unknown. One study has suggested that the use of oral contraceptives by women has no effect on the expected rate of developing MS.
Sexual Difficulties
Intimacy with a loved one is an important component of a healthy, contended life. It doesn't have to disappear from the lives of couples when one partner has MS.

MS can affect the experience of intimacy in a variety of ways. Some people report changes in sexual function or feel disinterested in sexual contact. Some women report a lack of sensation or loss of sexual desire, some men report erectile dysfunction as being the most common problem with sexual function. Changes in sexual function can be either a direct result of the neurologic changes, symptomatic (spasticity or bladder problems) or can be a result of psychological problems (not feeling sexually attractive due to a disability).

Sexual arousal begins in the central nervous system (CNS), as the brain sends messages to the sexual organs along the nerve pathway in the spinal cord. MS-related changes to these nerve pathways can directly or indirectly impair sexual functioning.

MS can interfere either directly or indirectly with orgasm. "Primary orgasmic dysfunction" is caused from lesions in the spinal cord or brain that directly interfere with having an orgasm. Sensation and orgasmic response can be diminished if lesions disrupt the pathway. Indirect symptoms such as sensory numbness or pain can also interfere with achieving an orgasm.

Treatment of orgasmic loss depends on an understanding of the factors that are contributing to the loss. Having difficulty achieving an orgasm is something to discuss with your doctor.

It's not surprising that many people with MS report a decline in sexual desire. What with the fatigue, muscle spasms, and bladder control problems, who would want to think about sex? But, there are steps that can be taken to improve sexual function and intimacy, despite MS.

Primary Sexual Effects - Neurologic Impact

These symptoms can occur as a direct result of myelin breakdown in the spinal cord or brain:
• Decreased sex drive
• Altered genital sensations (numbness, pain, increased sensitivity)
• Difficulty or inability to maintain erection
• Decreased vaginal lubrication
• Decreased vaginal muscle tone
• Difficulty to ejaculate
• Problems having an orgasm

Secondary Sexual Effects - Neurologic Impact

These symptoms can arise as a consequence of MS, physical changes or treatments:
• Fatigue can suppress sexual desire
• Spasticity can interfere with sexual positioning or cause pain
• Bladder or bowel problems are closely related with sexual dysfunction because the nerve pathways are nearby or shared
• Sensory changes can make physical contact uncomfortable
• Pain

Tertiary Sexual Effects - Psychological Impact

These symptoms result from psychological or social issues that interfere with sexual feelings and/or response:
• Depression
• Performance anxiety
• Changes in self-image or body image

Men

MS can affect a man's ability to achieve or maintain an erection suitable for intercourse. Fatigue, pain and numbness can also create sexual problems for men living with MS. An estimated 85 to 90% of men will experience some degree of sexual dysfunction.

Men with MS may experience the following sexual problems:
• Loss of libido or interest in sex
• Reduced sensitivity in the penis
• Difficulty getting and/or keeping an erection
• Difficulty having orgasms
• Difficulty with ejaculation or dry orgasms
• Fatigue
• Difficulty with the movements/positions involved in sex due to pain or muscle spasms

The mechanics of achieving an erection are probably not thought about very much until a problem occurs and something makes achieving or maintaining an erection more difficult than it used to be. Erections rely on nerves functioning properly and MS impairs nerve functioning, making erectile dysfunction one of the most common symptoms of MS reported by men.

Now depending on where in the brain or spinal cord the man has inflammation or demyelination, he may find that he is able to achieve erections in response to physical stimulation, but not foreplay or erotic situations (or vice versa). While erectile dysfunction is defined broadly as the inability to achieve or maintain an erection which is adequate for sexual intercourse, it also can have the following characteristics:
• Inconsistent ability to achieve an erection
• Dissatisfaction with size or rigidity of erection
• Having erections of short duration
• Requiring excessive time and/or stimulation to achieve erection

Erectile dysfunction is extremely common, with as many as 70 to 85% of men with MS experiencing problems with their erections. These typically are not the first MS symptoms that a man experiences, but happen some years after the onset of symptoms or diagnosis.

Women

Women may experience impaired sensation, numbness or tingling in the genital area. Fatigue and pain can also create sexual problems for women living with MS, or it can also be a side effect of many medications. An estimated 72% of women with MS experience some degree of sexual dysfunction at some point.

Add lubricant to assist with vaginal dryness, which is a common symptom of MS and use as much as you need so if feels like it should.

Women with MS may experience a range of sexual problems, including:
• Vaginal dryness
• Loss of libido or interest in sex
• Difficulty having orgasms
• Reduced sensation in the vaginal area
• Exaggerated sensitivity of the vagina
• Fatigue
• Pain and/or muscle spasms causing sexual positions to be difficult
• Difficulty with the movements/positions involved in sex due to pain or muscle spasms

Improving Sex With Communication

Most of these symptoms can be identified and medications or other therapies may be helpful. The most important way of dealing with sexual difficulties is to discuss your feelings with your loved one. Talk is the main way we come to feel close to another person. When MS problems begin affecting your sexual desire, then avoiding talking can easily lead to avoiding sex. Sensory changes can make things that used to bring pleasure now bring pain and discomfort. Telling your partner what feels good and what doesn't is essential for an intimate relationship.

Confiding in your partner deepens intimacy and may help in resolving fears of sexual intimacy. Keep your sex life exciting, playful, and fun. The key is to take the time to find out what's important to you and your partner. Also, it's important to keep a sense of humor about it all, because if you are healthy enough to try and have sex, then MS hasn't claimed everything.

You and your partner should figure out what feels good, what doesn't, and what hurts. This way you know what your limits, challenges, and things to avoid should be when that "special time" presents itself. Most importantly, find out what feels good and tell your partner. It's important to talk to them about this since they may have been nervous or worried about accidentally hurting you.

If you always wanted to spice things up, this may be a good time start. You can use this as an opportunity to try different things in bed. Try new positions because your old standbys may be uncomfortable now. You can use pillows or rolled-up towels to support the parts of your body that may now need it.

You may want to try and focus more on the experience and less on checking off the boxes. Sex doesn't mean you have to have intercourse. You and your partner don't have to do everything you have done in the past and it doesn't have to last for hours. You can still have an intimate experience with taking your time and enjoying each other.

It's a good idea to remember that sex doesn't have to be spontaneous. MS can put a halt to the way things used to be, but if you plan ahead and maybe decide on a day and time, then the anticipation might build your excitement. Pick a time of day when you feel best, or when you may have more energy.

The biggest key to a healthy sex life is the same as with all couples, and that's to have open and honest communication.

Talking With Your Doctor

You can make intimacy a part of your health care visit either with your primary care physician or your MS specialist. If you have symptoms that are interfering with sexual function, tell your health care team. If you are uncomfortable with talking about your sexual symptoms, then write them down and give the list to your physician or nurse. Many problems associated with neurologic changes or symptomatic problems of MS can be medically managed.