phosphodiesterase inhibitor alone is like a morning erection… not necessarily caused by heightened sexual awareness.

Compared to solving problems associated with penile plumbing, sexual wiring seems more complex. And while there are several, albeit sometimes not particularly popular alternatives to phosphodiesterase inhibitor for fixing the plumbing (e.g. alprostadil penile injections, penis pumps), the search for a wiring fix has been rather elusive.

The best prospects lay with dopaminergic drugs, though their common side effect of causing nausea is a clear minus.

But new dopaminergic drugs with a better side-effect profile are constantly developed, and particularly one, Dostinex, looks quite promising.

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Sex reassignment surgery

Sex reassignment surgery from male to female involves reshaping the male genitals into a form with the appearance of and, as far as possible, the function of female genitalia. Prior to any surgeries, transwomen usually undergo hormone replacement therapy and facial hair removal. Other surgeries undergone by transwomen may include facial feminization surgery and various other procedures.

For changing anatomical sex from male to female, the testicles are removed and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951) to form a fully sensate vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hair follicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.

In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty). These linings may not provide the same sensate qualities as results from the penile inversion method, but the vaginal opening is identical, and the degree of sensation is approximately the same as that of most women so pleasure should not be less.

Surgeon's requirements, procedures and recommendations in the days before and after, and the months following these procedures vary enormously.

Plastic surgery, since it involves skin, is never an exact art, and cosmetic refining to the outer vulva is sometimes required. Some surgeons prefer to do most of the crafting of the outer vulva as a second surgery, when other tissues, blood and nerve supplies have recovered from the first surgery. This relatively minor surgery, which is usually performed only under local anaesthetic, is called labiaplasty.

The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is especially affected by smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage. However, in the best cases, when recovery from surgery is complete, it is often very difficult for anyone, including gynecologists, to detect women who have undergone vaginoplasty.

Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. However, many post-op trans women report that the skin used to line their vaginas develops mucosal qualities from months to years post-op (http://www.gendercare.com/italiano_paper1.html). For others, lubrication is needed when having sex and occasional douching is advised so that bacteria does not start to grow and give off odors.

Because the human body treats the new vagina as a wound, any current technique of vaginoplasty requires some long-term maintenance of volume (vaginal dilation), by the patient, using medical graduated dilators, dildos, or suitable substitutes, to keep the vagina open. It is very important to note that sexual intercourse is not always an adequate method of performing dilation.

Regular application of estrogen into the vagina, for which there are several standard products, may help but this must be calculated into total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually or, in extreme cases, under anaesthetic.

With current procedures, transwomen do not have ovaries or uteruses. This means that they are unable to bear children or menstruate, and that they will need to remain on hormone therapy after their surgery to maintain female hormonal status.

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Dopamine agonistsl

Version 1.3, December 2004

Dopamine agonists have been around for many decades, and their pro-libido effect is well established. Apart from Dostinex, the assortment of dopamine agonists includes bromocriptine, pergolide, pramipexole, lisuride, apomorphine, and a few more.

Actually, apomorphine (brand name: Uprima) is sold in Europe as a medication for erectile dysfunction. But it's wrong marketing. Dopamine agonists don't work for erections as reliably as phosphodiesterase inhibitors. They work on libido. Therefore, Uprima typically is a disappointment for men whose problems are primarily vascular. I assume that Uprima is sold as a medication for erectile dysfunction mainly because erectile dysfunction meanwhile is an accepted medical condition, while low libido is not.

I have been using dopamine agonists for sexual enhancement for several years. And not only dopamine agonists.

To summarize my observation: while sildenafil citrate and yohimbine work on erections, and while elevating testosterone levels only is of a pro-sexual nature if it is done with tongkat ali extract, dopamine agonists are the agent of choice for enhancing sexual excitement, orgasm, and ejaculation.

Because dopamine agonists suppress the hormone prolactin, which in turn suppresses testosterone, dopamine agonists can, in people with elevated prolactin levels, function in the same way as a testosterone replacement therapy would. This most clearly happens in patients with pituitary cancer, which typically expresses itself in strongly elevated prolactin levels. Those afflicted by the disease have very low testosterone levels. Thus, for them, Dostinex and other dopaminergic agents work as hormonal therapy. The hormonal effects of Dostinex are less extreme in healthy subjects.

Dopamine agonists not only support sexual excitement; they also tend to enhance orgasm and make for a stronger ejaculation, though the ejaculation-enhancing effect is greater with tongkat ali, which can account for an additional half meter in ejaculatory range (and ejaculations on tongkat ali can feel like pellets, not fluid, moving through the urethra). Orgasms in general will be much more overwhelming.

But dopamine agonists also have their downsides. All the older ones can cause nausea. I myself cannot take L-dopa or lisuride. Nausea on these drugs is so severe that I want to see a nurse, rather than a girl, and only for medical purposes.

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Facial feminization surgery

Facial feminization surgery (FFS) refers to surgical procedures that alter the human face to bring its features closer in shape and size to those of an average female human. FFS includes various bony and soft tissue procedures (see below) though the term "FFS" is generally not regarded to include facial hair removal. FFS techniques are derived from maxillofacial and reconstructive surgery as well as general plastic and cosmetic surgery. Douglas Ousterhout pioneered what is now called FFS During the 1980s and 1990s in the U.S.A. There are only a small number of surgeons globally who specialise in FFS.

FFS has become increasingly sought after by transsexual women and many feel that it is just as important or even more important for them than sex reassignment surgery (SRS) because it helps them integrate socially as women. While most FFS patients are transsexual women, some non-transsexual women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by other transgender people such as cross-dressers and drag queens.

In males the hairline is often higher than in females and usually has receded corners above the temples that give it an “M” shape. The hairline can be moved forwards and given a more rounded shape either with a procedure called a “scalp advance” where the scalp is lifted and repositioned or with hair transplantation. Hair transplants can also be used to thicken up hair that has been thinned by male pattern baldness. If too much hair has been lost, it will not be possible to correct hairline problems.

Males tend to have a horizontal ridge of bone running across the forehead at eyebrow level called the brow ridge or “brow bossing” while female foreheads tend to smoother and flatter and have little or no bossing. The outer segments of the bossing that the eyebrows sit on are called the “supraorbital rims”. These are usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the glabella) sits over a hollow area called the frontal sinus and because it is hollow it can be more difficult to remove the bossing here. If the wall of bone sitting over the frontal sinus is thick enough the bossing can be removed by simply grinding down the bone, however if the wall of bone is thin it may not be possible to grind the bossing away completely without breaking through the wall into the frontal sinus. FFS surgeons have taken 3 main approaches to resolving this problem:

1. Most FFS surgeons can perform a procedure called a forehead reconstruction where the wall of bone is taken apart, thinned, re-shaped and put back together in the new feminine position with titanium wires or titanium screws and microplates.

2. Some surgeons grind down the wall of bone as far as possible without breaking through and then build up the area around the remaining bossing with bone cement. The bone cement smooths out any visible step between the remaining bossing and the rest of the forehead to give a smooth and feminine appearance. In these cases some additional reduction in the bossing can also be made by thinning the soft tissues that sit over it.

There is a great deal of heated debate in FFS circles about whether it is best to remove the bossing with a reconstruction or to use the build-up method to disguise it. Some feel that a reconstruction is too invasive and that disguising the bossing is just as good as removing it; others feel that disguising the bossing is an unacceptable compromise and that it can sometimes leave the forehead with an unnatural bulge - these patients would rather have the bossing completely removed with a reconstruction.

3. Some FFS surgeons now offer a compression technique in appropriate cases where the wall of bone is first weakened and then compressed into place. It then heals in the new position.

Male foreheads also often have various indented areas. For example, the centre of the forehead is often slightly indented. These areas can be filled with bone cement during surgery to smooth everything out.

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Restless legs syndrome: Treatment with dopaminergic agents.

Neurology, 58(4 Suppl 1): S87-92   2002

Restless legs syndrome (RLS) is a common neurologic disorder that affects 5 to 10% of the population and increases in prevalence with aging. The clinical hallmarks of RLS include dysesthesias or paresthesias in the legs and sometimes the arms, occurring primarily at rest, which are usually worse in the evening and are alleviated by movement. RLS can be a disabling disorder, causing sleep disturbance at night and excessive sleepiness during the day. Although treatment with levodopa alleviates symptoms, many RLS patients develop rebound (occurrence of symptoms during the night) or augmentation (occurrence of symptoms before levodopa dosing in the evening). Augmentation occurs in up to 82% of patients treated with levodopa, limiting the long-term usefulness of this agent. The direct dopamine receptor agonists are long-acting drugs often administered as a single dose at bedtime. Among these agents, pergolide, pramipexole, ropinirole, and cabergoline have all been shown to alleviate RLS symptoms in 70 to 100% of patients. The most common adverse effect is nausea. Augmentation, although it may be associated with chronic agonist use, is usually mild and responsive to additional dosing. The direct dopamine receptor agonists have largely replaced levodopa as the most effective treatment for RLS.<

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Cabergoline treatment rapidly improves gonadal function in hyperprolactinemic males: a comparison with bromocriptine.

Eur J Endocrinol, 138(3): 286-93 1998

This study evaluated the effects of chronic treatment with cabergoline (CAB), a new, potent and long-lasting ergoline-derived dopamine agonist, on seminal fluid parameters and sexual and gonadal function in hyperprolactinemic males in comparison with the effect of bromocriptine (BRC) treatment. Seventeen males with macroprolactinoma were treated with CAB at a dose of 0.5-1.5 mg/week (n = 7), or BRC at a dose of 5-15 mg/day (n = 10) for 6 months. Baseline prolactin (PRL) was 925.7 +/- 522.6 microg/l in the CAB-treated group and 1059.4 +/- 297.6 microg/l in the BRC-treated group. All the patients suffered from libido impairment, ten from reduced sexual potency, and six had infertility. In five patients provocative bilateral galactorrhea was found. Seminal fluid analysis, functional seminal tests and penis rigidity and tumescence, measured by nocturnal penile tumescence (NPT) using Rigiscan equipment, were assessed before and after 1, 3 and 6 months of CAB or BRC treatment. Hormone profiles were assessed before and after 15, 30, 60, 90 and 180 days of both treatments. Before treatment, all patients had a low sperm count with oligoasthenospermia, reduced motility and rapid progression with an abnormal morphology and decreased viability, and a low number of erections. After 1 month, serum PRL levels were significantly reduced in both groups of patients (20.6 +/- 6.6 microg/l during CAB and 256.3 +/- 115.1 microg/l during BRC treatment) and were normalized after 6 months in all patients (CAB: 7.9 +/- 2.2 microg/l; BRC: 16.7 +/- 1.8 microg/l). After 6 months, a significant increase of number, total motility, rapid progression and normal morphology was recorded in patients treated with both CAB and BRC. An increase in the number of erections during the first 3 months of both treatments was noted by NPT. However, the improvements in seminal fluid parameters and sexual function were more evident and rapid in patients treated with CAB. The number of erections was normalized after 6 months of treatment in all patients submitted to CAB treatment, and in all patients but one treated by BRC. In addition, a significant increase of serum testosterone (from 3.7 +/- 0.3 to 5.3 +/- 0.2 microg/l) and dihydrotestosterone (from 0.4 +/- 0.1 to 1.1 +/- 0.1 nmol/l) was recorded. At the beginning of treatment, mild side-effects were recorded in two patients after CAB and mild-to-moderate side-effects in five patients after BRC administration. The treatment with CAB normalized PRL levels, improving gonadal and sexual function and fertility in males with prolactinoma, earlier than did BRC treatment, providing good tolerability and excellent patient compliance to medical treatment.

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Schisandra chinensis

Is a deciduous woody vine hardy to USDA Zone 4 and is dioecious, meaning individual plants are either male or female, thus both male and female plants must be grown if seeds are desired. It is very tolerant to shade. Its Chinese name comes from the fact that its berries possess all five basic flavors: salty, sweet, sour, pungent (spicy), and bitter. Sometimes it is specifically called in Chinese (pinyin: b?i w? wèi zi, literally "northern five flavor berry") to distinguish it from another traditionally medicinal schisandraceous plant Kadsura japonica that grows only in subtropical areas.

Its berries are used in traditional Chinese medicine, where it is considered one of the 50 fundamental herbs. They are most often used in dried form, and boiled to make a tea.

Medicinally it is used as a tonic and restorative adaptogen with notable clinically documented liver protecting effects. The primary hepatoprotective (liver protecting) and immuno-modulating constituents are the lignans schizandrin, deoxyschizandrin, gomisins, and pregomisin, which are found in the seeds of the fruit. It should not be used by pregnant women.

In China, a wine is made from the berries.