You might consider Evan R. Goldfischer, a board-certified urologist, the physician who's keeping a smile on the world's face.


Affiliated with Hudson Valley Urology since 1998, he's also its co-managing partner and director of research — as well as a pioneer in the field of female sexual dysfunction, or FSD.

He's recently spoken at the International Federation of Gynecology and Obstetrics at its annual conference in Cape Town, South Africa. He has lectured in Sweden, Italy and Amsterdam, too.

"The problem is universal," he says. "I've written many papers on the topic, and there aren't a whole lot of us doing so. So if there's a conference on sexual medicine, I'm often invited to speak."

Q. How did you become involved in researching and treating FSD?

A. The little blue pill that made its debut in 1998 — Viagra — changed male sexual dysfunction. What was previously called "impotence," which few men would own up to, was now a treatable physiologic condition known as "erectile dysfunction."

Before Viagra, all sexual dysfunction was left for the psychiatrists. Now that there was a cure, it was easier for men to step forward.

Because of my interest in research, I became the principal investigator for Levitra and Cialis, heading clinical trials and collecting data.

Although I was treating men, many times they brought their partners along. Soon I had all these women telling me they had issues, too. However, there was, and still is, no FDA-approved medication for FSD.

I began working with a psychologist, Ken Pollock, so that together we could address the physiological and psychological components of sexual dysfunction in women.

Q. What exactly is FSD?

A. Female sexual dysfunction includes disorders of desire, disorders of arousal, difficulty with orgasm or pain during intercourse. Obviously, female issues are far more complicated. There are women who have never achieved an orgasm.

With men, the lion's share of sexual dysfunction involves an inability to achieve an erection because of diminished blood flow. But even with men, until there was a treatment, impotence was regarded as psychological rather than physical.

It's not unlike depression. The previous standard course of treatment was years of intense therapy. Now, we understand there is a physiologic aspect in terms of brain chemistry that can be treated pharmaceutically.

When the pharmaceutical companies begin investing money in research, then FSD will be regarded as a treatable medical condition rather than something that's "just in her head."

Six years ago, a German company began studying Flibanserin's (a drug being researched and developed for women diagnosed with decreased sexual desire) claims of stimulating a woman's sexual desire, which I'm now the principal investigator for. There are some promising clinical trials under way in this country.

Q. About how many women are affected by FSD, and is there a common age group?

A. Somewhere between 1 in 5 and 1 in 6 women experience FSD. The critical question is whether it's causing the woman distress. Some post-menopausal women have written off sex, as have their husbands because of ED or other medical conditions. If both parties are satisfied with the new level their relationship is on, that's fine.

So most of the patients I see are working women in their late 30s or early 40s with one or two children. They used to have sex two times a week; now, it's down to maybe monthly — and planned at that. The marriages are stable; they're each still attracted to their respective partners. However, the women can take or leave sex, while the husbands are still very interested in recouping the old days. The disparity in desire is starting to put a strain on the relationship.

Q. How do you break the ice around this potentially embarrassing topic?

A. It's an incredibly common problem, and that's what I try to convey. I'll say something like: "Many women in your age group who are working and caring for children report a decrease in their sex drive. Has this happened to you?"

Incontinence is also a cause of FSD. Women are sometimes embarrassed to let their husbands know. If a woman presents for incontinence, I'll let her know that it's not uncommon to experience FSD as well and open the door to discussion.

Q. Don't most women discuss these issues with their gynecologist, rather than a urologist?

A. I get many of my referrals from gynecologists. They simply don't have the time it takes to delve into these issues. You can talk to a male patient and know within a few minutes what treatment will probably work. With a female patient, the conversation can go on for 45 minutes or longer.

I found there to be a huge problem in the Hudson Valley. Ten years ago, no one else was working with FSD in the region. Hudson Valley Urology was the first to address this need among women.

Q. How do you diagnose FSD?

A. It's always best when the partner is there. We'll talk, and I'll take a history. I'll perform an exam. Women who have had chemotherapy, for example, have a greatly diminished sensation — which they often don't know about until the exam. Blood is drawn for a hormone panel that will determine levels of testosterone and estrogens. Occasionally, imaging is required.

Q. Are there treatments?

A. Yes. Treatments include testosterone, Flibanserin, DHEA, lubricants, vaginal dilators, vibrators and psychotherapy.

Q. And there are no FDA-approved treatments?

A. The only FDA-approved treatment for FSD is an Eros device, which is a suction-cup device placed on the clitoris to promote arousal. Flibanserin is in the clinical-trial stage.

Testosterone, for example, is approved for male sexual dysfunction. Females, however, also need testosterone for a healthy sex drive — but in a much smaller amount. Once a drug is FDA-approved, it can be prescribed. However, if it is prescribed for an "off-label" use rather than the approved use, the insurance company will typically not cover it.

Q. Are there risks to prescribing testosterone to women?

A. Yes, which is why we weigh those risks against the distress caused by the FSD. Testosterone can affect the liver, kidneys, cause a thickening of the blood, decrease good cholesterol and increase bad cholesterol, as well as cause sleep apnea. The body can also change testosterone to estrogen, which might be a concern to a breast cancer survivor. A woman who's given testosterone should be under the supervision of her physician.

That's the problem with the supplement DHEA, which is available without a prescription. It comes with the same risks as testosterone, and women who are taking it are typically not being monitored.

Similarly, caution needs to be taken when researching on the Internet. There are a lot of products out there making claims that aren't backed up. It might appear to be the easier and less embarrassing route, but people need to be careful.

Q. So how is it that you now speak around the world?

A. Sexuality and sexual dysfunction have become medicalized in the United States, which I believe is a good thing. Today, medical students are learning to talk about sexual issues with patients. That wasn't even done in the early '90s when I was in school.

Right now, female sexual dysfunction is a wide open field with a huge need for investigative research. Clinical trials of FSD drugs are finally becoming more mainstream.

Because of my early research connections, the papers I have written, and my continued involvement in research, I have been privileged to speak at conferences around the world. I share the facts: The symptoms, research results, treatment options and patients' experiences. And I look ahead to the first FDA-approved drug that will elevate FSD to that of a treatable condition.

Q. Have you noted any differences between countries?

A. The cultural differences are vast. There are many progressive Third World countries wherein discussion of sexual issues is encouraged, and there are still many developing nations wherein sexual suppression is the norm.

In my recent trip to Cape Town, for example, I noted the cultural difference in sexual attitudes between countries. The same can be said of regions of Asia or Latin America.

When populations are more open to talking about sexual issues, women tend to have their first child at an older age and have fewer children. There are many people who still believe you can't get pregnant the first time. As one would expect, European countries tend to be more open. However, in Europe and other countries, there are more paramedical professionals — sex therapists without benefit of the most current technology or research — to whom people turn. In effect, they're doing their own thing with different degrees of success.

What has surprised me the most in my travels, however, is the amount of female mutilation that still occurs the world.

Q. What's your advice for Hudson Valley women?

A. I can't stress enough that this is a common problem and nothing to be embarrassed about. Women should talk to their primary-care physician or gynecologist and seek referral to the appropriate individual.