Question: Hi Doctor,

I hope that you are doing well. I had consulted a doctor on your site for my problem but I just realised that he is a psychiatrist and not a sexologist.

I am attaching my email communication with him. Can you please advise.
_____________________________________________________________________________


I am 37 years old Indian man and lost my virginity a couple of month back. I had paid sex a couple of times with different women as I was embarrassed to have sex with my girlfriend, being a virgin. I used a condom both times but did not feel much. I could only feel a general warmth when I was inside.



I had unprotected sex without a condom after this with my girlfriend but it was the same situation. I did not feel any pleasure and could just feel a slight warmth when I entered her.

My problem is that I am 37 years old, lost my viriginity three months back, but can feel no sensation during sex other than a mild warmth.

I suffer from Osteomalacia for which I am taking Vitamin D supplements. I have also been on anti depressants for the past 15 years.

I have no problem is gaining an erection or with my self image. Staying a virgin for this long was a personal choice.

_________________________________________________________________
I have been on anti depressants for the past fifteen years and have been taking sertraline regularly along with other anti depressants.

Asked by Me , Tue, 8 May 2012     
Doctor's reply to your question above...
Hello,
Thanks for your query.

I appreciate your efforts for medical consultation in so much distress.

Important aspects of your query are:
• 37 year old male
• Known case of Depression
• On sertaline for 15 years.

From your query it appear that you are not having orgasm and not experiencing pleasure from sex.

Considering your case there are three possibilities for this problem:
-Side effect of sertaline as it causes delayed orgasm and no orgasm in several persons
-Residual depressive symptoms
-Thyroid hormone problem: Get Serum T3/T4 and TSH assay done on empty stomach.

If you do not have any depressive symptoms currently then you should visit your psychiatrist for following measures:
-Lowering the dose of sertaline
-Change anti depressants. Like Bupron which improve sexual functioning.
-Start brisk walk in morning to improve blood circulation
-Vitamin supplement like Revital.

Final message to you: Do not worry about symptoms, follow above advice, stop substance use if any and take multi vitamins.

Wish you good health.
Regards,
Replied by Dr. XXXXXXX Mittal , Tue, 8 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Dr.Mittal,

Thank you for your response. I would like to provide a few more details.

1. I have been totally depression free for the past five years and live a full active and very successful professional life

2. I have no issues of getting an erection when aroused and getting pleasure from mastrubation or coming to orgasm and ejaculating.

3. I also suffer from Osteomalacia which I know is very uncommon in males and am taking Vitamin supplements for this and getting my Vitamin D3 and PTH tested.

I have had my T3/T4 tested earlier but will do so again.

Do you think that there could be some other reason, other than the anti depressants as I have no problem in getting sexually aroused or getting pleasure out of masturbation. I usually masturbate around once in 3 days. I am also highly attracted to the opposite sex and don't have a problem getting hard when I see someone I like.

Could there be any other cause Doctor?
Asked by Me , Tue, 8 May 2012     
Doctor's reply to your question above...
Hello again,

Thanks for follow up,

With further information it is clear that you do not have any sexual dysfunction and you have proper orgasm. So, no issue with sertaline.

Can you specifically tell your current problem to understand and help you better.

Regards,
Replied by Dr. XXXXXXX Mittal , Tue, 8 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Dr.Mittal,

My specific problem is that I do not feel any pleasure during penetration and very little during oral sex. I can only feel a wetness and warmth when I am inside her but do not feel anything else. It has come to a stage where I feel that if this is it, it is hardly worth the trouble. There is no sensation of pleasure at all. However, strangely, masturbation has always felt good and at present feels way better than the sex act.

I also would like to point out that I have stayed a virgin for so long out of choice and am a good looking, smart and social guy who has had his opportunities to have sex earlier but has turned them down, so it is not a lack of self esteem issue.

Also though I am on medication for depression, I am totally depression free and it does not affect my life in any way.

I also think that it would be pertinent to point out that I have also been on Propecia(finasteride) for the past 7 years. Though initially it did seem to reduce my sex drive in the first couple of months, at least in terms of desire for sex, it does not seem to be affecting me. I cannot say whether it affects the sensation during sex, but it has certainly had no effect on sensation during masturbation.


Asked by Me , Tue, 8 May 2012     
Doctor's reply to your question above...
Hello again,

Thanks for follow up,

Your threshold for orgasm is appear to increase because following reasons: Regular masturbation and sertaline use as masturbation provide more physical stimulation to penis compare to natural sex.

It is not clear why are you started on finasteride by some physician but following steps will help you (as mentioned also in primary reply):
-Stop masturbation for few 2-3 months.
-Lowering the dose of sertaline
-Change anti depressants. Like Bupron which improve sexual functioning.
-Start brisk walk in morning to improve blood circulation
-Vitamin supplement like Revital.

Wish you good health.
Regards,
Replied by Dr. XXXXXXX Mittal , Wed, 9 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Doctor,

Sorry to keep asking you so many questions. I was given finasteride 1mg- once a day, by my skin specialist who is a qualified and reputed doctor, to prevent hair fall when I noticed that I was losing hair 7 years back.

I am taking the following drugs in a day- sertraline-200mg, etizolam-1.5mg,heloperidol-.5 mg.

Can you please suggest options for these and I will take it up with my doctor.

As I mentioned earlier, I have been on anti depressants for many years and have never felt any lack of longing for sex. Nor do I have any self image problems or problems with getting an erection, staying erect or coming to orgasm and ejaculating.
Asked by Me , Wed, 9 May 2012     
Doctor's reply to your question above...
Hello again,

With further treatment history, future guideline remain same as in last reply. Your current problem appear to only 'increase threshold for orgasm'.

Try to taper stop and stop etizolam as long term use may lead to dependence on it. Haloperidol may also associated with sexual dysfunction, but Bupron will take care of it. So, discuss these treatment options with your psychiatrist.

Wish you good health.
Regards,
Replied by Dr. XXXXXXX Mittal , Wed, 9 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Doctor,

Just a couple of more questions:

1. I don't have a problem in coming to orgasm either through masturbation of penetration.

2. Do you think that the anti-depressants are more likely to be causing the loss of penile sensation or is it finasteride more likely to be .

I will accordingly change/stop that set of medication after consulting with my doctor one at a time.
Asked by Me , Wed, 9 May 2012     
3. I read on the net that creams like "man1 man oil" help a lot. Should I try it and if so, can you tell me where it is available in India and if it is not available in India, which other oils can I try.

Asked by Me , Wed, 9 May 2012     
Doctor's reply to your question above...
Hello again,

1. Problem is increase threshold for orgasm. Do not confuse it with absent orgasm.

2. Sertaline more likely cause

3. Avoiding it will be better.

Wish you good health.
Regards,
Replied by Dr. XXXXXXX Mittal , Wed, 9 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Dear Doctor,

My physician has reduced the sertraline and etizolam and will gradually reduce the other medicines.

Can you please let me know in how many weeks, can I expect things to change and is their any way to know that things have turned around?
Asked by Me , Fri, 11 May 2012     
Doctor's reply to your question above...
Hello again,

Duration differ case to case.

Usually it take 1-2 months

Regards,
Replied by Dr. XXXXXXX Mittal , Sat, 12 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Dear Doctor,

I am following your advice as I mentioned to you earlier.

Could you tell me whether there is any way in which I can know whether the sensation has returned to my penis without intercourse.

What I find difficult to understand is why masturbation feels good and yet there is no sensation during sex.

Asked by Me , Sun, 13 May 2012     
Doctor's reply to your question above...
Hello again,

When things are apparent clinically, then no investigation is required in my view. Best is to keep patience for 1-2 month.

I am not aware for such investigation for penis. To, check sensation usually nerve conduction study done by neurologist in other part of body. You can contact them if such investigation can be done for penis.

Regards,
Replied by Dr. XXXXXXX Mittal , Mon, 14 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Thank you Doctor.

I also wanted to know what is the reason that masturbation feels good and yet there is no sensation during sex. Logically there should be no sensation in both the activities.
Asked by Me , Mon, 14 May 2012     
Doctor's reply to your question above...
Hello again,

Just go with previous answers for reply. It is discussed in detail there.

Sensation occur due to orgasm. Other time you feel only warm.

What sensation you have during masturbation, or while holding penis? Is it tingling or numbness or anything else?


Regards
Replied by Dr. XXXXXXX Mittal , Mon, 14 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
What I can describe it as a kind of sensation of the 'nerves' which gives a tingling sensation throughout the body.
Asked by Me , Mon, 14 May 2012     
Doctor's reply to your question above...
Hello again,

Then it is abnormal. Sensation like this occur only during orgasm, not by holding penis only. This sensation can occur due to vitamins deficiency.

Regards
Replied by Dr. XXXXXXX Mittal , Mon, 14 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Sorry doctor, I was describing the sensation during orgasm. I was somewhat under the impression that, that was what you were asking.

The sensation during masturbation I would say is localized to the penis and is one of pleasure- that is all that I can describe it as.

I don't feel any particular pleasurable sensation while simply holding the penis without any stroking- only the touch of the hand on the penis, that is all.

I do suffer from a Vitamin D deficiency for which I am taking supplements and my Vitamin D and PTH which had become very low and very high respectively have been at normal levels for the past few years. I recently had the levels checked.

Asked by Me , Mon, 14 May 2012     
Doctor's reply to your question above...
Hello again,

Ok. Got serum B12 and serum folic acid (folate) level done. It will also help in management.

Regards
Replied by Dr. XXXXXXX Mittal , Mon, 14 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Doctor,

I got my tests done and the results are as follows:

Serum Vitamin B12-167.5pg/ml (Range 200-800 pg/ml)
Serum Folate -5.63 ng/ml Reference range(3.1-17.5 ng/ml)

Please note that I suffer from Osteomalacia and am currently on Shelcal -1500 mg and Rocaltrol-0.25 mcg per day. The blood tests for Vitamin D3 and PTH is normal. These were done around a month back. I have decreased my psychiatric medicines after consulting my doctor and discontinued propecia(finasteride).

Please do advise me on how to proceed. Thank you so much for your excellent diagnosis.
Asked by Me , Mon, 21 May 2012     
Doctor's reply to your question above...
Hello again,

Continue psychiatric medicine as advised by your psychiatrist in current doses. Start B12 preparation like: Cap Rejunex once in a day.

Please accept my answer in case there are no further queries and recommend our services to your friends too if you have found it helpful.

Wish you good health.
Regards.
Replied by Dr. XXXXXXX Mittal , Mon, 21 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Dear Doctor,

I will definitely refer you to my friends and family.

I spoke to my GP and he suggested the following. I would like your expert opinion on which treatment I should take ( the one given below or Rejunex):


methycobal - injection b12 alternate days 1000mcg intramuscular for 5 days
then once a week 1000 mcg for one month
then once a month for 3 months


Folic acid - 5mg -daily for three months

Asked by Me , Mon, 21 May 2012     
Doctor's reply to your question above...
Hello again,

In my opinion Rejunex and folic acid combination for 3 month is sufficient. Repeat B12 level after 1 month.

Take care
Replied by Dr. XXXXXXX Mittal , Mon, 21 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Ok Doctor. Do you think that I need to get my T3/T4 and TSH levels checked?

Should I get any other tests done for any other vitamin or other deficiencies?
Asked by Me , Tue, 22 May 2012     
Doctor's reply to your question above...
Hello again,

Checked t3 t4 and tsh if not done before.
You can have complete health check from some lab for reassurance and baseline values for future.

Regards,
Replied by Dr. XXXXXXX Mittal , Tue, 22 May 2012     
Disclaimer: The Expert's advice is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, as a complete assessment of an individual has not taken place. Please consult your nearest physician before acting on it. The advice is not valid for medico-legal purposes also.
Hi Doctor,

I hope that you are doing well.

I think that you would remember my case. I have taken(as suggested by my specialist):

methycobal - injection b12 alternate days 1000mcg intramuscular for 5 days
then once a week 1000 mcg for one month
Folic acid - 5mg -daily for one month

I don't find any sensation even now when I have sex. I just feel a mild warmth and no pleasure.

Can you please advise.

Hi Doctor,

Thank you so much for reading my mail so diligently and showing so much interest in my case.

I will follow up on your advice. I just wanted to know which is a better medicine for my condition- seduz or rejunex which the previous doctor had recommended.

Could you also throw light on what you mean by an orgasm disorder, as I am able to reach erection and come to orgasm/climax very easily but I do not feel any sensation of pleasure during the act of sex.

Hi Doctor,

I have one last question- how long do you think that it will take take to get completely cured from the condition if I follow all the steps which you have suggested?

Hi Doctor,

Thank you for being so supportive.

I wanted to understand which is the type of condom which is most suited to my condition.
I have bought Himcolin gel and have started applying it but Seduz capsule does not seem to be available in Delhi. Can you please suggest another brand.
I also have a couple of more questions Doctor. I am listing them out so that you can answer all the questions in one go:

1. Why does my condition come under erectile dysfunction as I have no problem is reaching and maintaining an erection and coming to climax.

2. Is seduz a generic form of Viagra?

Earlier questions:

3. Seduz does not seem to be avaialable in Delhi. Can you please suggest another brand name

4. Which is the condom type which is most suited to my condition.


Thank you once again.

Hi Doctor,

I have checked up at many places including drug stores which sell herbal medicines, but am not able to find Seduz.

Can you please suggest another brand name.