Conference session urges doctors to wait to prescribe meds and first discuss possible ED causes such as stress, hypertension, obesity, smoking, high cholesterol, and diabetes with their patients.
The age of the men in the Viagra ads has dropped a good 30 years since Senator Bob Dole became the poster boy for erectile dysfunction. Now they usually feature a fit-looking 40ish man along with the message: "Ask your doctor." Presumably, everyone knows what Viagra is for and the biggest hurdle, according to the doctors who addressed a recent conference, is to get men to ask for a prescription. Erectile dysfunction, which used to be called impotence, is defined as the inability to maintain an erection long enough for vaginal intercourse.
Though the ads have become increasingly pervasive in the five years since Viagra was approved, the drug simply isn't prescribed enough, several doctors told the science writer's conference on Sexual Dysfunction, held last month in New York and funded by several drug companies (Viagra's maker, Pfizer, was not among them). Erectile dysfunction affects about 30% of all men, reporters were informed, and less than 1% are getting Viagra.
But things can be more complicated than the prescription of a costly ($10) pill. Erectile dysfunction could be caused by hypertension, obesity, smoking, high cholesterol, and diabetes, said Irwin Goldstein, MD, director of Boston University's Institute of Sexual Medicine. He, and other physicians who addressed the conference, advised doctors to see erectile dysfunction as an opportunity to review these conditions in their patients who report the problem. Erectile dysfunction can also occur in men who spend three hours or more a week bicycle riding, especially if they ride leaning forward on the bike saddle's narrow front.
Though lip service was paid to the idea of working with patients about potentially reversible causes of erectile dysfunction, no study has been conducted to determine whether or how often doctors encourage men to address these issues before reaching for the prescription pad. In response to a reporter's question, Dr. Goldstein said that there are no data regarding whether changing a risk factor, for example, weight reduction or getting blood pressure under control, can reverse erectile dysfunction.
Primary care physicians account for 82% of Viagra precriptions, though they are uneducated about erectile dysfunction, said John Mulcahy, MD, of Indiana University. Like most of the conference speakers, Dr. Mulcahy is an urologist. They bemoaned the fact that medical schools do not have a department of sexual medicine. At this conference, which was cosponsored by the American Foundation for Urologic Disease, it would appear that urologists want to be the go-to guys for sexual difficulties. When women's needs were addressed in the afternoon sessions, Sandra Leiblum, PhD, said, "Gynecologists show a complete lack of interest in female sexual dysfunction."
Oral drugs are clearly the preferred treatment for erectile dysfunction (as opposed to drugs injected into the penis), but Viagra is not the answer for many men. "As wonderful as the drug is," said Dr. Goldstein, "it hasn't solved every man's issues." The dropout rate among men who have tried Viagra is 50%, he said, which explains why more drugs are needed. Two in the same drug class as Viagra are under FDA review: vardenafil and tadalafil. The former seems to work faster and last longer. "These drugs won't change your relationship with your partner," warned Dr. Goldstein, suggesting the need to look at the big picture where it concerns sexual difficulties. Attempts to treat erectile dysfunction with hormones have not been successful. For example, testosterone is important to desire and sperm production but not to erectile dysfunction.
That sexual dysfunction can be the side effect of a broad range of commonly prescribed drugs came up indirectly. Tranquilizers like Librium and Valium cause decreased libido; Zoloft and other antidepressants inhibit ejaculation; antihistamines and many antihypertensives, among them the ACE inhibitors (some brand names: Lotensin, Captopril, Vaseretic) cause erectile dysfunction. People are resistant to controlling hypertension, despite a range of effective treatments, observed a doctor in the audience, expressing skepticism about whether men would want to get their high blood pressure under control before moving on to Viagra. And the standard antihypertensive drug regimen itself causes sexual problems, he said, "You have a hypertensive patient on a diuretic and a beta blocker, add an ACE inhibitor and then you're in sexual hell."
If men with erectile dysfunction are likely to be overweight, hypertensive, and diabetic, then they are likely to be taking several other prescription drugs on a regular basis. When the question of drug interactions came up, reporters were assured that Viagra appears to be safe, though its interactions with other drugs have not been assessed longer than two years. It has been known that Viagra should not be taken with nitrates. Dr. Goldstein said that the only new information about interactions concerns men who are taking the anti-hypertensive drug Cardura (sold under multiple other brand names, including Apo-Doxazosin and Doxaloc). Combining Viagra with Cardura causes a similar effect when paired with nitrates: extremely low blood pressure.
"There will never be a one size fits all treatment for women," said Dr. Sandra Leiblum, who led off the session on female sexual dysfunction. "Women are very different. They look for romance, pleasure, hope for ecstasy, and they want intimacy. Orgasm is important but not the be all or end all," said Dr. Leiblum, professor of psychiatry and director of the Center for Sexual & Marital Health at the Robert Wood Johnson Medical School in Princeton, NJ. Women tend to have more sexual complaints than men, citing a survey that found 43% with sexual dysfunction. But, Dr. Leiblum cautioned, one-third are not complaining about lack of orgasm. "It's about lack of interest, though not always about sexual performance, and more about the quality of the sex and the satisfaction they derive from sex."
That said, drugs dominated the rest of the session about the treatment of female sexual dysfunction. Androgen, the hormone of desire, declines slowly in women after age 30. In a healthy young woman, half the androgen is produced by the ovaries and half by the adrenal gland. Replacement therapy with Andro-Gel, a topical testosterone product proven safe and effective only for men, was discussed by Dr. Goldstein, who has identified something in women called "androgen insufficiency."
Though Dr. Leiblum cited some nasty side effects, such as facial hair, deepened voice, and acne, they can be decreased by reducing the dose, according to Dr. Goldstein. "It is not a magic bullet for desire," said Dr. Leiblum, who also dismissed all hopes for the experimental topical drugs for women with sexual arousal problems. As with Viagra, which increases the blood flow to the penis, these topical creams currently in the testing phase bring blood to the genital area without much benefit to women with sexual dysfunction, according to Dr. Leiblum.
Viagra has been tested in women and after citing a few studies with disappointing results, Dr. Goldstein concluded, "The ideal female candidate for Viagra has not yet been defined. And it has no role for the treatment of women with low sexual desire. We have a long way to go in this field."
