39 msfocusmagazine.org orgasm is most commonly reported, but decreased desire for sexual activity, difficulty with arousal (such as decreased lubrication) and pain during sexual activity also occur. MS can affect sexual function both directly and indirectly. Direct effects of MS include demyelinating lesions in the brain and spinal cord that cause sensory, motor or autonomic dysfunction such as difficulty achieving and maintaining an erection, vaginal lubrication, and orgasm. MS can also indirectly affect sexuality by decreasing energy, concentration, mobility, and by causing pain and spasticity. Some medications used to treat MS symptoms can affect sexuality as well. Finally, MS can effect psychosocial and emotional changes such as decreased self-esteem, mood, and body image. Depression, stress, and anxiety canalsoaffectsexuality,andsexualdysfunction itself can produce negative emotions such as fear of rejection by a partner or fear of being perceived as less masculine or feminine. In addition, some medications used to treat symptoms of MS can cause sexual side effects. Given the myriad influences on sexual function, it is important to be comprehensive in one’s approach to sexuality — this means enlistingthesupportofyourpartner,neurologist, and other physicians (urologist, primary care, etc.), psychologists, therapists, and others in yourcommunitywhomyoucantrustifneeded. Excellent communication with your partner and healthcare team is essential. Use the language with which you are comfortable and let your doctor know you want to discuss sexual health during the appointment, to make sure there is time in the visit. TIPS: Get the conversation going. Questions for your neurologist: • “I am concerned about howMS might affect my sex life. What should I look for and how can I plan for these changes?” • “I have some questions about how MS might be affecting my sexuality.” • “I’m not sure how to talk to my (new/ existing) partnerabout howMS has affected my sexuality. Where can I find resources to help?” Libido/erectile dysfunction: • Avoid illicit drugs and alcohol • Flibanserin can be used for decreased libido in women • Medications such as sildenafil, vardenafil, and tadalafil are highly effective for men with erectile dysfunction, but may be contraindicated for those with a history of heart disease or those taking nitrates • Penile suppositories, penile injections such as alprostadil can be helpful • Vacuum erection devices and prostheses can also be used Vaginal dryness: • Water-based lubricants • Discuss other options with gynecologist Difficulty achieving orgasm: • Communication! • Incorporate more flirting, fantasy, foreplay, or oral sex • New or different sexual positions • Incorporating sexual devices such as vibrators Pain during intercourse: • Vibrators and/or desensitizing lubricants may be helpful for women