Healthy sex: When to use sex-enhancing drugs

Can Viagra, testosterone, or other drugs really restore your love life?

Published: February 2009

Poor health can put a crimp in your love life. But the reverse is true, too: Good sex may help keep you healthy.

"A satisfying sex life can foster good emotional health, which in turn can promote good physical health," says Julia Heiman, Ph.D., director of The Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University. Moreover, sex itself may have direct health benefits. For example, orgasm or any loving touch may cause the body to release substances that ease pain, bolster immunity, or elevate mood long after the immediate pleasure passes. Indeed, people who have strong, intimate relationships tend to have fewer chronic diseases and to live longer, some research suggests. So there can be good reasons beyond just pleasure to address any significant loss of sexual appetite or activity, regardless of your age.

The introduction of sildenafil (Viagra) a decade ago has graphically demonstrated that some sexual problems can be eased. But it has also fed the misconception that every sexual difficulty can—and should—be cured by popping a pill. More and more doctors, with little supporting evidence, are now prescribing sildenafil and related drugs not only to men but women too, as well as the hormone testosterone, in an effort to boost libido. And many consumers are buying DHEA (see caution) a potent hormone sold as a dietary supplement that the body converts to both testosterone and estrogen, with hopes of improving their sex drive and performance.

However, psychological issues, not physical ones, are usually the major culprits in the two most common sexual problems—lack of desire in women and premature ejaculation in men. Even with largely physical problems, such as vaginal dryness or erectile difficulties, certain nondrug steps may be worth trying. Furthermore, not everyone who experiences changes in sexual desire and function as they age is bothered by those changes, and shouldn't be made to feel either abnormal or in need of a cure.

This report will help you talk intelligently with your doctor about when sex-enhancing drugs may be appropriate and when other steps-including leaving well enough alone-are enough.

Boosting low libido

Despite the increasing use of testosterone to stoke waning sexual desire, our consultants say that it's rarely worthwhile, for several reasons. There is little or no correlation between libido, sexual performance, and the normal age-related decline in testosterone. There's little evidence of the therapy's long-term efficacy and safety. And many other factors—from stress and lack of sleep to changed feelings about a partner—can contribute to decreased sex drive.

When low testosterone levels are well below normal, sexuality and performance may be affected. But those declines often stem from correctable health problems, notably pituitary or testicular disorders.

Even when those causes have been ruled out, taking testosterone is still a gamble. In men, while it can boost libido in those who have clearly low levels, side effects include breast enlargement and decreased sperm production. And it may speed the growth of prostate cancer and increase the risk of blood clots.

In women, some research suggests that restoring testosterone to a high normal level can increase sexual desire, at least temporarily. But it can also cause hair growth and acne, and may raise the risk of breast cancer. And other possible risks are largely unknown because of lack of long-term studies.

Moreover, the only testosterone product (EstraTest) approved for women in this country uses a combination that can reduce HDL (good) cholesterol. And while some doctors and pharmacists now compound special testosterone formulations for women, or use creams or gels intended for men, the safety and efficacy of such products or such use is even less well understood.

The reservations about testosterone apply doubly to DHEA, which is still allowed to be sold as a dietary supplement. That's because there's even less evidence of its safety and benefits and because it may increase both estrogen and testosterone levels. Further, dietary supplements are largely unregulated, so you don't know if what's on the label is in the bottle. And your use of this potentially potent hormone is unlikely to be monitored by a physician.

What to do: Our consultants advise avoiding DHEA entirely, and taking testosterone only after evaluation by an endocrinologist, a specialist in hormone therapy. Even then it should be used with extreme caution. (See "Testosterone Treatment in Men and Women," below).

Other measures—treating underlying disorders, adjusting drug dosages, reducing stress, or addressing problems in your relationship with your partner, with a therapist's help if necessary—should generally be tried first. The therapist could be a traditional one, a marriage counselor, or a sex therapist who focuses on negative sexual attitudes or beliefs. And remember that a lack of sexual desire is only a problem if you think it is. A recent study published in the November 2008 issue of Obstetrics & Gynecology found, for example, that while 43 percent of women report sexual problems, most commonly reduced libido, only about 12 percent were actually bothered by it.

Testosterone treatment in men and women
Despite its increasing use, testosterone should be prescribed only in very limited circumstances, described below.
  Men Women Comments
Consider testosterone replacement therapy if… You have signs of testosterone deficiency, notably bothersome decline in libido and potency, enlarged breasts, loss of body or facial hair, or osteoporosis, particularly before age 65.
Tests show you have low testosterone.
Other causes of low testosterone or the associated problems have been ruled out or addressed.
You understand that long-term risks, especially for men with moderately low levels, are largely unknown.
You have bothersome decline in libido starting after ovary removal or possibly after menopause.
Other causes of low testosterone or reduced libido have been ruled out or addressed.
You understand that long-term risks are unknown.
· Measuring testosterone may not help determine women's need for therapy since tests aren’t accurate for women and normal levels have not been determined.
· Women should avoid testosterone if they've had breast or uterine cancer or liver or heart disease.
· Men should avoid it if they've had breast or prostate cancer or have high prostate or breast-cancer risk, major prostate enlargement, or elevated red-blood-cell count.
Treatment options include… Injections (Delatestryl, Depo-Testosterone, Testro-La), patches (Androderm, Striant, Testoderm), or gels (AndroGel, Testim). Estrogen-testosterone combination (Estratest). · Estratest may lower HDL (good) cholesterol.
· For women, some doctors use low doses of men's creams or gels or create special formulas, though their safety is unknown.

Erectile dysfunction

While anxiety sometimes causes erectile dysfunction, that disorder usually stems from physical problems, often the same ones that cause heart disease.

Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) can help improve men's potency by dilating blood vessels in the penis, to allow for the increased blood flow necessary for an erection. However, such drugs should be used cautiously, since they can cause potentially serious side effects. Those risks may include an increased chance of heart attack or stroke among men already at risk of such events-including those with coronary disease-as well as fertility problems and worsened sleep apnea. In some men, the drugs may also cause temporary vision or hearing problems. And they can interact with many medications, most notably nitrates (used to relieve angina) and certain herbs, including St. John's wort.

What to do: Addressing coronary risk factors—reducing blood pressure, cholesterol levels, and weight, stopping smoking, exercising more, and rigorously treating diabetes—may help correct erectile dysfunction. Therapy or counseling might also help some people. Pelvic-muscle exercises called Kegels—where you tightly tense the muscles that interrupt the flow of urine or passage of gas—may be worth trying as well.

If reducing risk factors and performing Kegels don't help, men could consider erection-boosting medication. Tadalafil, which lasts for about 36 hours compared with 4 hours for the other two drugs, may be a good choice for men who value spontaneity, though side effects may also be prolonged. Men considering any impotence drug should first have a doctor assess their risk of heart disease and review all of their medications for possible interactions.

Dryness, insensitivity

Reduced vaginal lubrication and clitoral sensitivity may sometimes stem from the same cardiovascular problems that can cause erectile dysfunction. But more often those problems stem from declining estrogen levels after menopause.

Sildenafil (Viagra) and related drugs may improve sexual function in some women, including those who experience side effects from antidepressant drugs such as fluoxetine (Prozacand generic), paroxetine (Paxil and generic), and sertraline (Zoloft and generic), according to preliminary research. Supplemental estrogen can also help relieve that problem as well as vaginal dryness. But both treatments pose risks, so should be used cautiously.

What to do: In theory, reducing coronary risk factors may improve sexual function in women as it does in men. Extended foreplay and nonpetroleum lubricants like K-Y Jelly and Replens can usually provide sufficient moisture. Staying sexually active may also help keep the vagina moist and responsive. Those steps, combined if necessary with treatment of a partner's sexual problems or of issues that impair libido, may improve a woman's ability to achieve orgasm as well.

Women who want to try estrogen for dryness or possibly insensitivity can use creams (Estrace, Premarin) or vaginal inserts (Estring), which allow you to use smaller doses that are less likely to increase the risk of breast cancer and heart disease. If those don't help, consider short-term use of low-dose estrogen pills or patches, provided you're not at high risk of those diseases.

Women with antidepressant-related sexual problems should try other measures before talking with their doctor about possibly trying sildenafil. For example, they could try a lower dose or switch to generic bupropion, since some research suggests it's less likely to interfere with your sex life than are other antidepressants.

Curbing early orgasm

There are currently no drugs approved for treating premature ejaculation, the most common form of sexual dysfunction in men. But some doctors do prescribe antidepressants such as fluoxetine (Prozac and generic), paroxetine (Paxil and generic), and sertraline (Zoloft and generic) for premature ejaculation, since one of their common side effects is to inhibit orgasm.

Unfortunately, they probably have to be taken daily, not just before sex, and can cause a number of side effects. Some other doctors prescribe topical anesthetics, such as lidocaine, but the evidence for such use is sparse. So it's generally best to try nondrug steps first.

What to do: You may be able to ease the anxiety and overexcitement that often underlie premature ejaculation by having sex more often, prolonging foreplay, and trying not to worry during or after sex, regardless of the outcome. Or talk with a sex therapist about other approaches that may train men to gain physical control over ejaculation.

Drugs and diseases that can hurt your sex life

Before resorting to medication or hormones to treat sexual problems, you and your doctor should first consider whether the problem stems from an underlying disorder or a medication you take. In some cases your doctor could ease or eliminate the problem by changing the prescription or treating the disorder.

Note that some side effects listed here may be only theoretical, particularly in women, or based on limited evidence, and that the list may not be complete. If you experience a sexual side effect soon after starting any new medication, ask your doctor if the drug could be contributing to the problem. Note that many of the brand-name drugs listed below are also available as generics.

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