Does Viagra work for women?

This is a deliberately provocative title. A more accurate heading would be: Does improving a man's erectile dysfunction improve his partner's sexual satisfaction?

The intuitive response is that it should. If a man's problem is reduced, confidence, frequency and performance could be expected to improve, resulting in the couple's greater enjoyment of sex and the woman being more satisfied with this aspect of their relationship.

But sexual function does not work in straight lines. For example, when a man experiences erectile dysfunction (ED), he may be embarrassed or fear ridicule and withdraw, starting a series of events in his partner's mind about self-blame or being unattractive which can reduce her confidence or may arouse suspicions of unfaithfulness. Because the age at which men seek aid for ED is about 58 years and their partners' age about 54 years, these events are likely to coincide with her menopause with its attendant loss of libido and physical symptoms.

For these reasons, research is complex in the field of women's satisfaction from sildenafil (Viagra ® - Pfizer) treatment of men. However, Heiman et al (BJOG 2007;114:437-47) were able to carry out such a study comparing sildenafil with placebo and measuring the woman's perception of outcomes. Unsurprisingly, provided the woman had no dysfunction herself, her satisfaction with their sexual relationship improved significantly if he received sildenafil compared with those whose partners received the placebo. The scores were better for overall satisfaction as well as more detailed questions probing erectile function, orgasmic function, libido, arousal and intercourse satisfaction.

Side effects in the men were infrequent and mild to moderate. Maybe the manufacturers can add another side-effect - increased partner satisfaction?

Simple health tips - salt

Adult women and men, who reduce their salt intake, reduce their blood pressure. This effect is independent of age, race, baseline blood pressure or body mass. Such information has been around for years but a study by Cook et al (BMJ 2007;334:885-8) now shows that this leads to a long-term reduction in cardiovascular events.

We should restrict our daily intake to 5g per day, or less. We can reduce what we add to our food and support the profession's efforts to have salt levels on foods labeled. Legislation would help and the new data will add weight to the arguments encouraging less salt in prepared foods and declaring how much there is, so prudent purchasing is possible.

HRT and breast cancer

Breast cancer risk is not increased in estrogen-only HRT but when estrogens are combined with progestins, there is a raised risk that is cumulative. However, there is no evidence of increased mortality and after quitting HRT risk ratios return to normal.

If these data are correct, and if there is a causal or unmasking effect of hormonal therapy on breast cancer, then the rapid reduction in HRT use in America following the Women Health Initiative trial results would have led to a concomitant reduction in cancers detected.

Ravdin et al (NEJM 2007;356:1670-4) report that such a drop in estrogen-receptor-positive breast cancers did occur in 2002-2003 as the number of prescriptions fell from about 50 million to 25 million. This change occurred in postmenopausal women only, strongly implying an association with hormone therapy. The change was of the order of 7% relative risk and the incidence levelled off thereafter.

These findings support a link between combined hormone therapy and breast cancer, but the interpretation should be cautious. The observations concern a particular set of products, a particular age group and a particular type of breast cancer.

The absolute risk of breast cancer for any woman considering hormonal therapy in America remains around 0.30% per annum and this changes to 0.36% per annum on HRT and the effects are cumulative.

This sort of evidence moves our collective wisdom forward but does not answer other questions, such as will these incidences start to rise as the occult cancers reveal themselves later? Or will other forms of hormonal therapy remain free of breast cancer “encouragement”?


So where is the evidence that taking HRT for 10 years after the menopause is harmful?

Is this another example of medicine discovering a magic bullet that is first hailed, then discredited and then, finally, finds its appropriate niche?

JASS certainly believes that the notion of “feminine forever” was a grossly optimistic concept but, equally, there has been an over-reaction to the harmful effects of HRT because of inappropriate hormones given to women long past their menopause - and who were not in the best of health.

Perhaps the pendulum is reaching sanity and hormonal therapy will be useful in the treatment of menopausal symptoms AND offer protection against chronic conditions if used appropriately in terms of initiation, dose, mode of delivery and duration which may well turn out to be 10 years.

The bottom line in 2007 is that starting therapy at the menopause and continuing for a number of years carries little, if any, risk in healthy women. The experts appear in equipoise so it is up to women and their advisors to decide.

It seems clear that initiating combined HRT in women 10 years or more after their menopause does not turn back the clock and probably, on balance, does harm.