April 16, 2001 -- One in four American adults has high blood pressure, putting them at risk for heart attack and stroke. Nearly one in 10 suffers from a depressive illness. Luckily, an expanding array of prescription drugs is available to help treat and control both conditions.
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The bad news? As these drugs lower blood pressure and lift mood, they can also mess up normal sexual functioning. So while a given medicine might restore physical and mental health, it can also spark erectile dysfunction, lack of interest in sex, and the potential destruction of a relationship.
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The key, say doctors who have studied drugs for hypertension and depression, is to seek help from a physician who is up to date on what treatments are out there and who is willing to work to find the best ones for you . Together, you can choose one that will keep you as healthy as possible while doing the least damage -- or perhaps none at all -- to your sex life.
Lowering pressure
The search for what doctors call "high-yield, low-risk" treatment of high blood pressure has been going on for decades, writes Peter Rudd, MD, a professor of medicine and chief of the division of general internal medicine at Stanford (California) University Medical Center, in an editorial published in the April 1, 2000, issue of the American Journal of Medicine.
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In recent years, the old standbys -- thiazide diuretics (such as HCTZ, Maxide) and the beta-blocker drugs (such as Lopressor) have been joined by a tongue-twisting litany of other drug classes. You will likely hear your doctor refer to other types of blood pressure-lowering drugs known as alpha-blockers (Regitine, Dibenzyline), calcium antagonists (Cardizem, Plendil), angiotensin-converting enzyme (ACE) inhibitors (Lotensin), angiotensin II receptor antagonists (Cozaar), and direct vasodilators (Minoxidil, Apresoline). Each works differently to lower pressure.
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And despite that smorgasbord of drugs, Rudd tells WebMD, the truth is there is much yet to be learned about the effects of blood pressure-lowering drugs on sexual functioning.
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And in women, that goes double, as the "data about female dysfunction is scant," he says.
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Physicians do have a good idea of how some of the blood pressure-lowering drugs affect some sexual functioning. Beta-blockers, for instance, can reduce stimulation to the erection center.
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Studies have yielded mixed results about which antihypertensive drugs to avoid if you want to keep some romance in your life. Several have shown, for instance that diuretics and beta-blockers are associated with more sexual side effects, according to Rudd.
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Despite that, he says, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure continues to recommend those drugs first.
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"Those two drugs classes have been shown to reduce heart attack, stroke, and other major end points of high blood pressure," Rudd adds. But it can be a tradeoff.
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For instance, he says, ACE inhibitors, shown in some studies to be less likely to cause sexual problems, are also more expensive.
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Not all of the studies paint a bleak picture of the old standby drugs, however. For instance, a study published in the same issue of American Journal of Medicine that carried Rudd's editorial found no difference in sexual function between 312 men and women randomly placed on either the beta-blocker Inderal or an inactive placebo drug.
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It's difficult to predict who will and won't notice an effect on sexual functioning after beginning blood pressure-lowering drugs, Rudd says. But one study published in the May 1999 issue of Pharmacotherapy found that nearly every first-line antihypertensive treatment (which includes diuretics and beta-blockers) has been reported to cause some degree of erectile dysfunction. But sexual problems can also increase with age and as other diseases set in, so it's even more difficult to pinpoint exactly what percent of problems can be blamed on the drugs.
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A physician should mention the possibility of side effects when prescribing a blood pressure-lowering drug, Rudd says, but encourage a patient to try it before dismissing it because of potential effects. "The only way to be sure," he tells patients, "is to take a trial of it."
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If sex life is affected, doctors can consider many options: reduce the dose, switch to another drug, or suggest lifestyle modifications such as exercise, which could help lower blood pressure and reduce the need for medication.
Lifting mood
For physicians, treating patients with depression and sexual problems can be frustrating. For one thing, sexual problems can be both a symptom of the depression and a side effect of the medication that treats the depression, according to James M. Ferguson, MD, a psychiatrist who is founder and director of the Pharmacology Research Clinic in Salt Lake City and clinical professor of psychiatry at the University of Utah School of Medicine.
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Most people suffering from depression would like to be sexually active, but about half experience a decrease in desire or performance, he writes in a review of the topic in the March 2001 issue of the Journal of Clinical Psychiatry. Antidepressants often interfere with several parts of the sexual response, he says, including an inability to achieve orgasm.
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With the introduction of a new class of antidepressant medicine called selective serotonin reuptake inhibitors or SSRIs (including Prozac, Zoloft, and Paxil), many doctors thought they were associated with less impact on sexual function. But as the drugs began to be prescribed in greater numbers, reports found that nearly half of patients on SSRIs had libido or orgasm problems.
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The side effects vary in terms of severity, Ferguson tells WebMD. In the review article he notes that the greatest negative effects on sex lives have been reported with Paxil and the least with Prozac -- but this comes from anecdotal reports, not careful, scientific studies, he says.
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But even if an antidepressant that is associated with sexual side effects is deemed the best course of treatment, there are ways to cope, Ferguson says. For instance, a patient on Zoloft, under his doctor's supervision, might skip a dose or two before a romantic evening. Because this drug stays active for a relatively short time, this may be enough to restore normal sexual function, he says.
Other considerations
Physicians who treat hypertension and depression say they don't rule out the use of Viagra for all patients on blood pressure-lowering or antidepressant drugs. But they do select these patients very carefully and rule out certain patients. Those taking nitrate drugs, for instance, such as nitroglycerine (such as Nitrol or Nitro-Bid) for chest pain, are warned by the manufacturer, Pfizer, not to take Viagra. Others are cautioned to tell their physician about other drugs they are taking.
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Doctors say they decide on a case-by-case basis, weighing the risks against the benefits.
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Whether you need medication to lower blood pressure or lift your mood, find a doctor you can communicate with, agree Ferguson and Rudd.
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"Get a good doctor who will work with you to find the best drug," advises Ferguson. A physician should listen to your concerns about a medication's effect on your sex life, consider switching you to another drug if possible, or reduce the dose.
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If your doctor does none of the above, experts agree, it's time to doctor-shop.
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Kathleen Doheny is a Los Angeles-based health journalist and regular contributor to WebMD. Her work also appears in the Los Angeles Times, Shape, Modern Maturity, and other publications.
