Q&A with Dr. Peter Stahl
Did you know that erectile dysfunction (ED) is incredibly common? According to large national and multinational studies, ED affects up to 30% of young men and more than 50% of men aged 40–70. With so many men experiencing this condition, we know it’s important but not always easy to talk about. Below we are sharing common questions about seeking care for ED through the Hims platform, with responses crafted by our SVP of Men’s Sexual Health/Urology, Dr. Peter Stahl, who has conducted years of research and has years of clinical/medical experience on the topic. It’s our hope that you find this Q&A helpful in case you are or ever want to seek care for issues related to ED.
Q: What are the symptoms of ED?
A: Erectile dysfunction very specifically refers to the condition when a man sometimes or often experiences difficulty achieving or maintaining an erection. Other sexual dysfunctions like premature ejaculation or loss of sexual desire often coexist with ED, but they are distinct and separate conditions.
Q: What age groups deal with ED?
A: All age groups of men are affected by ED, but there are definite differences in ED prevalence and pathophysiology when you break up the population by age. In general, ED is less prevalent in younger men than in older men. That’s because vascular, connective tissue, and nerve problems that impair penile function usually develop slowly over time as men age. These common causes of ED are therefore relatively uncommon in younger men, in whom ED is more likely to result from psychological factors or hormonal disorders.
Q: Is premature ejaculation related to ED?
A: Premature ejaculation (PE) is a different, distinct clinical condition that is also very common. It often gets confused with ED. PE specifically refers to the condition in which a man ejaculates very quickly and has a sense that he lacks the control to delay ejaculation. There is a normal refractory period after ejaculation during which it is difficult to achieve an erection, and so struggling to regain an erection after ejaculation is not ED.
Q: At what point should someone see a physician about issues they are having that may be related to ED?
A: Everyone can have a bad day. Single or rare isolated instances of failing to get or maintain an erection are normal, and can occur for a variety of reasons (stress, lack of sleep, too much alcohol, etc.). That said, anyone struggling with ED on a consistent or repetitive basis should consult with a physician sooner rather than later. ED can sometimes be the presenting sign of hidden health-relevant conditions like vascular disease or testosterone deficiency. ED can also become more difficult to treat if it goes unaddressed for a long time. Repetitive intimacy failures or avoidance of partnered sexual activity can exacerbate any psychological contributions to sexual dysfunction.
Q: Is it important for someone who is, for the first time, seeking treatment for ED to visit a medical professional in-person? Why or why not?
A: We are learning every day about what conditions can appropriately be managed with virtual care outside of conventional in-person visits. As a fellowship-trained and experienced expert in male sexual health that has treated a lot of men, I’ve come to strongly believe that ED can be safely and effectively treated without an in-person visit in most cases. In fact, I think virtual care has many advantages over in-person care for the initial treatment and evaluation of ED. Barriers to care like embarrassment or needing to take time off from work are alleviated — that makes care for sensitive issues like sexual dysfunction much more accessible and approachable. The technology embedded into each virtual ED visit also enhances quality and safety by ensuring that each patient provides a full and detailed clinical history, and that each treating provider has the information that they need to make evidence-based, personalized treatment decisions. Overall, virtual care is a great way to initiate evaluation and treatment for ED.
Q: Can ED be cured, or is it something that someone struggles with throughout their life?
A: Some variants of ED are curable, and others are not (at least not yet!). ED that results from psychological factors (psychogenic ED) or hormonal insufficiency (endocrinologic ED) can sometimes be cured by addressing those underlying factors. Unfortunately, at the present time there are no clinically proven cures for erection problems that result from nerve disorders (neurogenic ED) or vascular disorders (vasculogenic ED). Fortunately, we do have great and effective medical and surgical treatments for all of these conditions that can allow affected men to have a great sexual quality of life.
Q: Can any non-Rx treatment help those struggling ED?
A: There are some non-prescription interventions that can help with ED. Sleeping enough, eating well, and avoiding behaviors like smoking cigarettes that impair sexual function are great first steps. Weight loss in overweight or obese men can improve sexual performance. Sex therapy can be important for men in whom ED results from psychological factors like anxiety about sexual performance. Certain dietary supplements may help with erectile function, though improvement in sexual function is much smaller than improvement seen with prescription ED medication. Tongkat ali, horny goat weed, arginine, and Korean ginseng are the supplements that are most supported by clinical data. Mechanical devices like vacuum erection devices or penile constriction bands are also helpful in certain cases.
Q: At what point, or for what reasons, do healthcare providers feel it’s recommended to prescribe ED medication?
A: The decision to start ED medication is a highly personalized, shared decision between a patient and their healthcare provider. Since the available ED medications are effective and generally low risk, my personal opinion is that they should be strongly considered for any man of any age who is consistently or episodically struggling to achieve or maintain a rigid erection. Treatment with oral medication is appropriate for all causes of ED.
Q: What are the most common ED medications prescribed?
A: Sildenafil and tadalafil are the most common ED medications prescribed. Sildenafil is the active ingredient in Viagra. It is taken “on demand” — which means that it should be taken in anticipation of planned sexual activity. Tadalafil is the active ingredient in Cialis. It differs from sildenafil in that it takes a little longer to become fully active (2 hours vs. 1 hour) but is eliminated much more slowly from the body. Tadalafil can be taken “on demand” just like sildenafil, but its slow elimination from your body also allows for it to be taken once a day at smaller doses. After a few days of daily use, a steady blood level of tadalafil is achieved that remains relatively constant. This eliminates the need to plan sexual activity, which can restore spontaneity and have a very positive impact.
Q: What types of ED treatment can someone obtain from visiting with a healthcare provider through Hims? Are these treatments safe?
A: Hims offers access to on demand ED treatment with sildenafil, tadalafil, branded Viagra, and Stendra (a name brand drug similar to sildenafil that acts a little more quickly). Hims also offers access to daily treatment for ED with tadalafil and branded Cialis. These are the same oral medications that would be offered during in-person care for ED. All of these treatments have been extensively studied in large scale clinical trials that have demonstrated their efficacy and safety.
Q: What can someone expect from a virtual visit about ED via Hims?
A: Hims provides a safe and secure platform through which patients can share their personal health information with medical providers. The visit consists of answering questions about both general health and ED. The process is designed to collect all of the clinical information needed to inform high quality medical decision making in an efficient way. After answering all of the questions, each patient has the opportunity to request a specific medication from a list of recommended and available treatments that is generated based on the answers they have provided. After that, the patient’s clinical information is reviewed by a healthcare provider. The patient and provider have the opportunity to communicate back and forth to provide any necessary clarifications. If treatment is indicated, the provider can write a prescription and treatment will be delivered directly to the patient within a few days.
Q: Why should people trust medical professionals providing care through the Hims platform to safely diagnose and treat ED?
A: The healthcare providers that the Hims platform connects to patients are carefully vetted and fully credentialed US licensed healthcare providers. Each provider undergoes additional training in any condition that they are treating through our platform. In addition, Hims has leveraged expert physicians (like me!) to develop clinical guideline statements and reference documents that are readily accessible to guide clinical care. We also have a highly structured quality and audit program that is very similar to quality programs found in large brick and mortar healthcare organizations. All of these factors allow us to monitor and maintain high standards of care for all of the conditions that are treated through our platform.
Q: If someone is embarrassed about their ED, do they need to be worried about privacy issues in seeking help for it via a healthcare provider online?
A: No — definitely not. The Hims platform was designed by some very talented people to safeguard personal medical information. Hims handles and protects personal medical information in accordance with relevant laws that govern how medical information must be handled.