Fear and anxiety are normal emotions and most people will experience them to some degree as a normal response to stress. Fear is an emotional, physical and behavioral response to an immediately recognizable threat (eg. intruder, car spinning on ice) while anxiety is a distressing, unpleasant emotional state of nervousness and uneasiness with less clear causes. Anxiety is less tied to the exact timing of a threat, it can be anticipatory before a threat, persist after a threat has passed or occur without a threat.
Biomedicine Pathology, Etiology & Treatment
Anxiety becomes pathological when it repeatedly interferes with daily life, is irrational, excessively prolonged or out of proportion with the cause. There are subjective as well as objective manifestations. Subjective manifestations range from heightened awareness to deep fear of impending disaster or death. The objective manifestations, which occur with activation of the sympathetic cascade through the hypothalamic-pituitary-adrenal axis (HTPA), include restlessness, sweating, palpitations, increase in heart rate and blood pressure, dry mouth and a desire to run and escape. Anxiety is the most prevalent of the psychiatric disorders and affects 28.8% of all individuals, women more than men. According to the DSM IV classification system anxiety is subdivided into five types, depending on clinical characteristics and response to pharmacologic agents:
- Panic disorder – the experience of intense fear with neurologic (dizziness, lightheadedness, paresthesias, fainting), cardiac (tachycardia, chest pain, palpitations), respiratory (shortness of breath, feeling of smothering or choking) and psychological symptoms (feeling of impending doom, fear of dying and a sense of unreality). Panic attacks usually last for 15 to 30 minutes. Depression can co-exist in 40% to 80% of patients and substance abuse disorders are common. Neurophysiologic studies suggest that the attacks may result from an abnormally sensitive ‘fear network’ that is centered in the amygdala and involves interactions with the hypothalamus and prefrontal cortex. Panic attack patients have lower serotonin levels than normal. Treatment usually involves behavioral, psychological and drug therapies (antidepressants, SSRIs)
- Post-traumatic stress disorder (PTSD) – chronic activation of a stress response as a result of experiencing a significant traumatic event – symptoms include intrusions (flashbacks), avoidance (emotional numbing), depression, hyperarousal (increased irritability, difficulty concentrating, exaggerated startle effect, increased vigilance and concern over safety), memory problems, sleep disturbances and excessive anxiety. Research is needed to determine the mechanisms by which the disorder develops so that treatment methods can be developed. Currently, debriefing following the traumatic event and psychotherapy are the prevailing biomedicine treatment options.
- Generalized anxiety disorder (GAD) – excessive chronic uncontrollable worry for more than 6 months. Muscle tension, autonomic hyperactivity, vigilance, and scanning. Treatment by benzodiazepines (eg diazepam), buspirone, SSRIs (which support normalization of limbic, paralimbic and frontal hyperactivity), tricyclic and atypical antidepressants and beta-adrenergic blockers (which just block the symptoms).
- Social phobia – intense fear reaction to social interaction – the fear must not be related to any physiologic effects of a substance and must be present for at least 6 months. It is a fairly common disorder with a lifetime prevalence of 12%. 50% of persons with social phobia also have a drug or alcohol problem. Treatment includes behavioral and cognitive therapies and medications (SSRIs, benzodiazepines and MAO inhibitors, beta-adrenergic blockers)
- Obsessive-compulsive disorder (OCD) – repetitive thoughts (obsessions) and actions – these behaviors are time-consuming (like washing hands too often, praying, counting, repeating) and distressing to the individual. Between 2% and 3% of the world population has OCD and OCD is the 10th most disabling disease worldwide. Diagnosis is based on history and clinical observation and treatment include behavioral therapy, cognitive therapy and drugs (60% of patients “respond” to SSRIs).
(please note that the more recent DSM V lists more anxiety disorder categories: Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Social Anxiety Disorder (Social Phobia), Panic Disorder, Panic Attack Specifier, Agoraphobia, Generalized Anxiety Disorder, Substance/Medication-Induced Anxiety Disorder, Anxiety Disorder Due to Another Medical Condition, Other Specified Anxiety Disorder, Unspecified Anxiety Disorder – ICD10 seems to reflect categories consistent with DSM V.)
Finally, it should also be noted that anxiety can be secondary to other pathologies and caused by drug use:
- Biomedical Causes of Anxiety – hyperthyroidism, pheochromocytoma, temporal lobe epilepsy, hypoglycemia, depression, neurosis, menopausal syndrome, premenstrual syndrome, stress.
- Drugs causing anxiety – withdrawal from or dependence on benzodiazepine, alcohol and other drugs of addiction, amphetamines, bronchodilators, caffeine excess, ephedrine, levodopa, thyroxine.
OM Pathology, Etiology & Treatment
In contrast to biomedicine, Oriental Medicine (OM) takes a different approach to anxiety and in some cases, it is challenging to establish a direct correspondence with biomedicine classification (especially as it become more and more segmented with each DSM revision).
In OM, anxiety is the emotion most frequently associated with disorders of the Heart and instability of the shen. The shen is easily agitated by Heat and easily destabilized if Heart Qi, yin or Blood are weak. Anxiety can also occur in the presence of Phlegm Heat. Treatment focuses on calming the shen and nourishing yin and blood and tonifying Heart Qi. Herbs are effective at replenishing yin and Blood and providing a better anchor for the shen. It is also important to remember that patients might need to be progressively weaned out from anxiolytic drugs and also that their condition might be the result of those drugs or other substances (eg appetite suppressants). Finally, excessive use of caffeine (coffee, chocolate, cola drinks) can also be a cause of anxiety.
OM Patterns & Treatments
Heart Qi Deficiency
Heart Qi is most easily damaged by prolonged or excessive sadness, depression or grief. Heart Qi deficiency may also develop over time if the Spleen fails to produce adequate Qi for the body’s needs. Insufficient Heart Qi fails to protect the shen which becomes vulnerable, disoriented and unstable and this results in feelings of anxiety, unease, and apprehension.
In some individuals, excessive coffee consumption will also damage Heart Qi. This is due to the dispersing action of the bitter flavor of coffee. Also, profuse sweating due to fever, high environmental temperature or excessive diaphoresis can damage Heart Qi (and yang, yin, and Blood), as sweat is the fluid of the Heart.
- Anxiety, apprehension, constant worry
- Palpitations, poor concentration, fitful sleep, insomnia
- Shortness of breath, dizziness, mental and physical fatigue, pale complexion
- T: pale with a thin white coat
- P: thready and weak
- Tonify and nourish Heart Qi
- Calm the shen
- Avoiding stress is important – this includes avoiding watching violent images on TV or movies. Also, coffee and other stimulants should be avoided.
- Encourage the active pursuit of relaxation (Tai Chi, meditation, yoga, walking, running or swimming) in order to calm the mind and build Qi
Heart Blood & Spleen Qi Deficiency
Heart Blood deficiency may develop in much the same way as Heart Qi deficiency – through prolonged or intense emotions or through inadequate production of Blood by the Spleen. In addition, any deficiency of Liver Blood will lead to Heart Blood Deficiency via the 5 elements generative cycle. Significant blood loss can also cause Heart Blood Deficiency particularly if the bleeding is from the uterus (the Bao Mai links the Heart and the uterus directly). And as with the previous pattern, significant loss of fluid as sweat can damage Heart Blood.
Heart (and yin) anchors and grounds the shen and Spleen Qi supports and manufactures Heart Blood, so when the Heart and Spleen become deficient the shen is unanchored and becomes unstable. Clinically the mixture of deficiency can be equally shared or tend toward either Spleen or Heart. In all cases supporting Spleen function in addition to tonifying Blood is essential so the Spleen can continue to manufacture Blood. The anxiety in this pattern can be associated with thrombocytopenia and anemia (Blood deficiencies).
Associated with this pattern there is also the Zang Zuo syndrome, a type of emotional disorder associated with Heart and Spleen deficiency that can be characterized by anxiety and other shen disturbances. It is most common in women and frequently associated with hormonal changes. However, it can be applied to any situation where emotional or physical trauma has led to emotional instability.
- Anxiety, phobias, panic attacks, palpitations
- Insomnia with difficulty falling asleep or dream disturbed sleep
- Forgetfulness, poor memory and concentration
- Postural dizziness, blurring vision, spots in the visual field
- Fatigue, weakness and poor appetite, abdominal distention after eating
- Sallow complexion, easy bruising or heavy or prolonged menstrual periods
- T: Pale with a thin white coat
- P: Thready and weak
- Strengthen and nourish Heart and Spleen
- Tonify Qi and Blood and calm the shen
- As with all patterns avoid violent images and stimulants such as coffee
- Stress the importance of a strictly regular bedtime routine
- In women who lose blood through heavy periods, Blood tonics and Blood replenishing foods should be taken after each period.
Heart & Kidney Yin Deficiency
The relationship between the Heart and Kidney is one of the fundamental relationships of the body and mind. The relationship functions on both a physical and mental level. On the physical level Kidney Water (yin) keeps Heart Fire in check, preventing a runaway blaze and overheating. On the other hand, Heart Fire catalyzes Kidney Water, preventing stagnation and accumulation of fluids. On the mental level, the Fire of the shen arises from a stable base of Kidney Jing. Jing and shen rely on each other for a clear expression of mental consciousness.
If Kidney yin is damaged (overwork, excess sexual activity, insufficient rest and sleep, aging, etc) there may be a breakdown in relationships between the Heart and Kidney (via the 5 elements controlling cycle) whereby Kidney Water no longer keeps Heart Fire in check. The uncontrolled blazing of Heart Fire causes agitation of the shen and the resulting anxiety can be severe. If Heart Fire remains unchecked Heart Yin will be damaged. The shen then has no anchor because of Heart yin depletion and becomes ungrounded and agitated into an anxiety state that can become chronic. Heart yin may also be damaged by stimulant and recreational drugs (including coffee) or excessive mental stress.
From a biomedicine standpoint, the anxiety of this pattern can be associated with hyperthyroidism, menopausal, post-traumatic shock syndrome, anxiety neurosis, post febrile disease and the pattern often emerges during the withdrawal phase of long term sedative or anxiolytic drug use.
- Anxiety or panic attacks with palpitations
- Insomnia, often waking to anxiety or panic or sleep with nightmares
- Restlessness, irritability, “Five Palms Heat” and night sweats
- Dry mouth and throat, dizziness and lightheadedness, tinnitus, forgetfulness
- Lower backache
- T: Red and dry with little or no coat
- P: thready and rapid
- Nourish Heart yin, calm the shen
- Clear Heat
- Important also to avoid violent images and drugs and stick to a regular bedtime routine.
- Also avoid excessive sexual activity, excessive lifting and standing, and dehydration
- As in other patterns active relaxation should be encouraged (tai chi, meditation, swimming, walking, etc)
Heart & Gallbladder Deficiency
Heart and Gallbladder Qi deficiency describes a personality type which may be congenital or acquired. When congenital it may be due to a significant shock that damaged the developing fetal shen during the mother’s pregnancy. The pattern may be acquired easily in children (the shen is unstable when young) who are brought up in an abusive or fearful environment, or in adults or children who experience a violent or extreme shock or fright. It may also sometimes follow other debilitating illnesses that consume Qi.
The involvement of the Gallbladder refers to the timidity and “lack of gall” (fearfulness) which characterizes people with this pattern. In the Chinese language and also in English there is an implicit understanding of the relationship between the Gallbladder and courage. In Chinese to be bold and courageous is to have a big gallbladder5. In French, people who worry are described as “making bile” (“Se faire de la bile”) which is the western function of the Gallbladder.
Acute anxiety and frequent panic attacks are a key feature of Heart and Gallbladder Qi deficiency. This pattern represents a deep-seated or constitutional shen instability combined with Heart Qi deficiency. It may also be precipitated by severe shock and trauma. Finally, this type of anxiety may be associated with mental disorders, neurosis and postnatal depression.
- Frequent severe anxiety, panic attacks, apprehension, fearfulness, inappropriate worry, easily frightened, timidity and phobias
- Insomnia, nightmares, waking terrified, restlessness, forgetfulness
- T: normal or with a pale body and a thin white coat – in congenital or long-standing cases there may be a deep narrow crack to the tip
- P: weak, thready and rapid. Or thready and wiry
- Calm the shen
- Nourish and tranquilize the Heart
- Prolonged therapy is usually necessary. If the pattern is congenital a combination of TCM treatment and psychotherapy of some sort can be beneficial.
Phlegm Heat can be generated in several ways. First, the presence of Phlegm or Dampness due to Spleen weakness or overconsumption of Phlegm producing foods causes stagnation and Heat. Second, overconsumption of Phlegm Heat foods (rich, greasy, sweet, spicy food and alcohol) can directly cause Phlegm heat build-up. Finally, any pre-existing Heat in the body, due to Liver Qi stagnation with stagnant Heat or Fire, yin deficiency or external invasion can congeal fluids into Phlegm and subsequently Phlegm Heat. This pattern can also occur in the aftermath of a serious disease or febrile illness that has concentrated Fluids into Phlegm Heat.
The Heart is subject to mists of unsubstantial phlegm that obscure reason and consciousness. The Heart associated with this pattern can agitate the shen causing anxiety. Phlegm type anxiety can be a chronic response to Phlegm Heat in the body (usually from diet) but can also be more acute, occurring in the convalescent stage of a febrile disease that has congealed Fluids into Phlegm.
- Anxiety, nervousness, irritability, and restlessness
- Palpitations, dizziness, and vertigo
- Insomnia, with waking in the early hours of the morning (typically around 4 am) unable to fall back asleep
- Nausea, vomiting or indeterminate gnawing hunger, belching, acid reflux, bitter taste in the mouth, abdominal distention
- T: yellow greasy coat
- P: rapid and slippery or wiry
- Clear Heat and transform phlegm
- Harmonize the Stomach, calm the shen
- Important also to avoid violent images and drugs and stick to a regular bedtime routine.
- As in other patterns, active relaxation should be encouraged (tai chi, meditation, swimming, walking, etc)
Combined Pattern – Heart Qi & yin deficiency
Here the cause of anxiety is a combination of Qi deficiency and yin (Blood) deficiency. The shen is both vulnerable and ungrounded and may, in addition, be agitated by deficient Fire. The most distinctive feature of this pattern is the pulse – typically irregular. From a biomedicine standpoint, the anxiety in this pattern may be associated with disorders such as neurasthenia, hyperthyroidism, cardiac arrhythmia, and sick sinus syndrome.
- Anxiety accompanied by palpitations, insomnia, and irritability, shortness of breath
- Dry stools or constipation, dry mouth, and throat
- T: depending on the balance of Qi or yin deficiency: pale pink or red and swollen with surface cracks and little or no coat.
- P: knotted, intermittent or irregular pulse, particularly if Qi deficiency is prominent
- Nourish yin and Blood
- Tonify Qi
- Calm the shen
- As in all anxiety patterns, it is important to avoid violent and disturbing images as well as stimulants like coffee. A strictly regular bedtime routine should also be adhered to.
- Also, a relaxation practice should be encouraged (tai chi, walking, swimming, meditation, etc)
Note about anxiolytic drugs
Conventional drugs used to treat anxiety disorders are widely used (also for other disorders) and they often create dependence and become a source of the problem they are designed to solve. Anxiety is often overmedicated or mistreated by practitioners who don’t have the time or skills to address the root feelings, traumas or emotions behind the anxiety (the root of the problem). Overprescribing and abuse of tranquilizers and anxiolytic agents (mostly benzodiazepines) have created its own problems. Prolonged use brings dependence and withdrawal syndromes. Their bitter cool nature damages Heart and Kidney yin, weakens the spleen, congests the Liver and further destabilizes the shen. Depending on the clinical presentation, withdrawal syndromes from these drugs can be alleviated with herbal formulas, supplements, and acupuncture.
While modern drug therapy and to some extent psychotherapies have been somewhat successful in treating patients suffering from anxiety disorders they often fail to address the roots of the anxiety and eventually just become a band-aid or a quick fix for the disorder. Oriental Medicine and herbal medicine in particular (in combination with or without other treatments such as psychotherapy and mindfulness practices) can offer a natural path toward anxiety and worry-free life for many patients. It should be noted that we are likely to encounter patients with patterns more complex and intertwined than the ones presented here which could lead to combining more patent medicines or writing custom formulas.
One condition always brings men to the clinic: when their penis isn’t working. Erectile dysfunction (ED) is the inability to attain or sustain a penile erection satisfactory for sexual intercourse. ED affects up to 20 to 25 million men in the US. The prevalence of partial or complete ED is > 50% in men aged 40 to 70 and prevalence increases with aging. In this article, we examine ED in the context of Oriental Medicine (OM) and explore treatment principles.
Biomedicine Pathology, Etiology & Treatment
According to the Merck Manual, most erectile dysfunction is related to vascular, neurologic, psychologic and hormonal disorders; drug use can also be a cause. Evaluation typically includes screening for underlying disorders and measuring testosterone levels. Treatment options include oral phosphodiesterase inhibitors, intraurethral or intracavernosal prostaglandins, vacuum erection devices, and surgical implants. The major causes of ED are:
- Vascular disorders – most common is atherosclerosis of cavernous arteries of the penis, often caused by smoking and/or diabetes.
- Neurologic disorders – stroke, partial seizures, multiple sclerosis, peripheral and autonomic neuropathies, and spinal cord injuries.
- Drugs – Anti-hypertensives, anti-psychotics, anti-depressants, sedatives, diuretics, steroids, alcohol, methadone, heroin, cannabis, and tobacco.
- Other – Aging, hyperprolactinemia, hypogonadism, hypothyroidism, hypopituitarism, orchitis, prostatitis, psychogenic (anxiety, loss of interest, boredom, depression, fear of sexual incompetence, marital discord or guilt over unconventional sexual impulses), excessive fatigue or stress.
Finally, any endocrinopathy associated with testosterone deficiency may decrease libido and cause ED. However erectile function only rarely improves with normalization of serum testosterone levels.
Oriental Medicine Pathology, Etiology & Treatment
In oriental medicine (OM) terms penile erectile function is connected to the Kidney and the Liver. Kidney Yang controls the functional aspect of an erection and Kidney Jing the ability to reproduce while the Liver channel passes through the external genitals. The weakness of the Kidney reduces the physiological “Fire of Desire” while the stagnation of Liver Qi reduces the physical ability.
Sexual function depends not only on sound physiological health but also on the psychological state. Thus the emotional aspects of the Heart, Liver and Kidney systems can all influence sexual ability. Mental stress can obstruct the flow of Liver Qi which can have a dismal effect on the functioning of the ‘Ancestral Tendon of the Liver’ (as the penis is sometimes known). Anxiety and extremes of emotion, which destabilize Heart and Shen can interfere with erectile function.
Another OM aspect of ED is related to Kidney dysfunction from fear or shock. In this case, severe fright damages the Zhi (willpower) and the Shen (spirit) profoundly, such that timidity and nervousness become constant personality traits. Such traits do not lend themselves to confident and effective sexual encounters.
Oriental Medicine Patterns & Treatments Principles
Liver Qi Stagnation
Frustration, anger, resentment, prolonged emotional turmoil and stress disrupt the circulation of Liver Qi and because the Liver channel passes through the penis, insufficient Qi arrives to enable an erection. This type of ED is often found in men stressed by overwork or facing the emotional conflicts of a midlife crisis and also seen in younger men overwrought with sexual anxiety or frustration.
- Inability to get/sustain an erection, loss of libido
- Tightness/fullness in the chest, hypochondriac discomfort or tightness, vague aches and pains, frequent sighing, dizziness, irritability, depression
- Abdominal distention, flatulence, alternating constipation and diarrhea
- The tongue is normal or dark, maybe with red edges and pulse is generally wiry
- Regulate and soothe Liver Qi
- Support Yang
The Damp Heat that causes ED is most commonly a disorder of overconsumption of alcohol and rich foods. It can also be generated in the lower jiao by any long term Heat in the system, such as Heat generated by yin deficiency, qi stagnation or by prolonged stagnation of Dampness. In some cases, it may be due to an unresolved or poorly treated external Damp-Heat pathogen. In this case, the Damp Heat often lingers in the lower jiao as low-grade infection (chronic prostatitis). In every case, Damp-Heat weakens and softens the tendons (which include the penis).
- Inability to get/sustain an erection
- Loose stools or alternating constipation/diarrhea, concentrated urine
- Heaviness and aching in lower limbs, lethargy, afternoon fatigue
- Possible excessive sweating in groin area and scrotum, itching or pain in genitals
- The tongue has a greasy yellow coat, especially over the root. Pulse is likely deep and slippery or soft and slippery – possibly rapid.
- Clear Dampness and Heat
Kidney deficiency is an important cause of ED. It can involve either Jing, Yang or Yin deficiency or a combination. It can be inherited or may develop as a result of overwork, age, chronic illness or excessive ejaculation.
Kidney Yang Deficiency
Kidney Yang is the basis of sexual desire and also plays a role in the mechanics of getting and sustaining an erection.
- Low libido, inability to get/maintain an erection
- Listlessness and fatigue, pale complexion, cold intolerant, cold extremities, urinary frequency, nocturia or edema of lower limbs with scanty urine
- Weak, cold and sore lower back and knees
- The tongue is pale wet and swollen, the pulse is deep and thready or slow and weak
- Tonify the Kidneys
- Warm and support the Yang
Kidney Yin Deficiency
Kidney Yin is damaged through overwork (especially while under stress), late nights, shift work, insufficient sleep, febrile diseases, insufficient hydration and the use of some prescription, recreational and in this case, tonic drugs. Kidney Yin deficiency type ED is fairly common in young men (in their 30s and 40s) who consume large quantities of hot-natured yang tonic herbs like red ginseng and deer horn to increase sexual potency.
- ED or premature ejaculation worse when the patient is stressed or fatigued. Maybe frequent desire for sex but the inability to initiate or maintain an erection or there may be erotic dreams with spontaneous emission.
- Soreness or weakness of lower back and knees (possibly exacerbated by sex)
- Dry mouth and throat, insomnia, restlessness, facial flushing, molar flush, night sweats, five palm heat
- The tendency to dry stools and constipation
- The tongue is red and dry with little or no coat, the pulse is thready and rapid
- Nourish and Strengthen Kidney Yin
- This pattern can be constitutional or a complication of chronic Liver Qi stagnation that generates Heat, or lingering Damp Heat, both of which may consume Yin. It may develop in men who work long hours under significant pressure or in men who have a history of excessive sexual activity and drug use (Marijuana and cocaine are particularly dangerous to Kidney Yin).
- Also, drugs like Viagra or Cialis that enable men to have erections can prove counterproductive for patients in this category. The excessive sexual desire they experience combined with the drug-assisted ability to have frequent sexual intercourse can lead to further exhaustion of Yin.
Heart Blood & Spleen Qi Deficiency
Overwork, physical and mental exhaustion, worry, irregular diet, and too much raw or sweet food can damage the Spleen when then fails to generate sufficient Qi and Blood. Similarly, any situation that overwhelms the Spleen’s ability to replace Qi and Blood, like prolonged or severe illness, can lead to Qi and Blood deficiency. The primary weakness in this pattern is in the Spleen, which is unable to generate enough blood to nourish the Heart and stabilize the Shen. The instability of the Shen can then be the basis of ED with psychological components. Weakened or scattered Shen cannot lead Qi to the penis or if an erection occurs it can easily be lost.
- Inability to get or maintain an erection, possibly associated with performance anxiety; ED worse with fatigue – erections obtained during sleep or masturbation.
- Pale complexion, fatigue, low spirits, insomnia, dream disturbed sleep, forgetfulness, palpitations with or without anxiety, panic attacks.
- The tongue is pale with a thin white coat, the pulse is thready and weak
- Tonify and nourish Heart and Spleen
- Support Yang
Heart and Gallbladder Qi Deficiency
This pattern describes an anxious or timid personality type, traits that may be congenital or acquired. When congenital it can be the result of a significant shock or prolonged fearful situation experienced by the mother during pregnancy or weakness of the parental Kidney Jing. When acquired it is the result of some sudden and violent or extreme shock or fright. Other, more insidious events, like emotional or physical abuse during childhood, may contribute. It may also sometimes follow other debilitating illnesses that plunder Qi. This pattern also underlies the impotence of psychogenic origin.
- Inability to get/sustain an erection
- The patient is anxious, timid, shy, easily startled and may appear very nervous and maybe very uneasy about intimate relationships
- Palpitations and insomnia
- The tongue is thin with a greasy coat, the pulse is wiry and Thread
- Benefit the Heart, Gallbladder, and Kidney, calm the Shen
- Support Yang
While modern drug therapy claims good success in increasing the ability to achieve erections it does nothing to address the underlying causes of ED. Chinese medicine allows us to pinpoint the root causes of men’s sexual health issues. In addition to counseling and acupuncture, patent or customized herbal formulas can provide effective and convenient treatments so that patients can regain their potency in a natural way and enjoy an healthy sex life. Do not hesitate to contact us if you are concerned about your sexual health.