Viagra: is it time to rethink the little blue pill for future health?

In this week’s episode, Dr Louise Newson talks to Professor Mike Kirby, president of the British Society for Sexual Medicine and author of more than 450 clinical papers and 32 books. He was previously director of the Hertfordshire Primary Care Research Network, visiting professor to the Faculty of Health and Human Sciences at the University of Hertfordshire, and was attending physician to the Prostate Centre, London, where he dealt with complex medical problems until 2020.

Dr Newson and Professor Kirby discuss the importance of hormone health for both men and women, including testosterone. They also explore the benefits of phosphodiesterase inhibitors – which include Viagra – in treating not only erectile dysfunction, but their potential to reduce risk of cardiovascular disease, urinary symptoms, dementia, and even cancer.

Professor Kirby is one of the speakers at the upcoming Newson Conference: The Hormone Blueprint, which will be held in London on 21 March. An event for healthcare professionals, the conference will delve into the far-reaching impact of hormones on the body. For more information and to book your place, click here.

Click here to find out more about Newson Health.

Transcript

Dr Louise Newson: [00:00:11] Hello. I’m Dr Louise Newson. I’m a GP and menopause specialist and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on my podcast, I’ve got someone I do know very well and I have met in real life, unlike some of my other podcasts. And I’ve got Professor Mike Kirby, who is an inspiration. He’s a real mentor and more of a mentor than he realises actually for lot of my work. But I’ve known him for many years. He is also, like me, very interested in cardiology, cardiovascular disease, disease prevention, keeping healthy and really interested in looking at people as a whole. He does a lot more maybe with men than women, but he still borders on that line with women’s health as well, and works with the British Society of Sexual Medicine, who I’ve had the privilege of lecturing for many times and lecturing alongside Mike. So I’ve been lecturing about the role of female hormones. And he’s been lecturing a lot about the role of testosterone and men’s health. And there is so much crossover. So I’m very honoured to have him here in the podcast. So welcome, Mike, today. [00:02:05][114.2]

Professor Mike Kirby: [00:02:06] I’m delighted to be here, louise. I’m a great fan of yours, so I would never say no to you. [00:02:11][5.3]

Dr Louise Newson: [00:02:13] Very good, I’ve got that on record now, so that’s great. So it’s really interesting because there’s so much misperceptions in medicine where people have been told something and then there’s something else actually and then they’re not really sure and then they don’t want to believe. So even if we start with just testosterone. When you talk about testosterone, people think about male bodybuilders. And that’s probably what people will really think. And most of us as clinicians haven’t been trained at all about hormones, let alone testosterone in women, which I have talked about quite a lot on previous podcasts, but in men as well. And I remember the first time hearing you lecture, coming to one of the BSSM meetings and thinking, Why didn’t I know this? Like, why did we not understand the importance of testosterone to improve cardiometabolic health, to reduce risk of heart disease and dementia and osteoporosis in men. And it’s still something that’s really not spoken about enough, is it? [00:03:16][63.2]

Professor Mike Kirby: [00:03:16] No. There have been a lot of barriers put up to people using testosterone because in America it was used inappropriately, it was being prescribed there without checking blood level, just on the basis of the history, and it was being prescribed for bodybuilding that really got it a very bad reputation. So we tried to overcome that by producing an evidence-based guideline. And the key thing is that it’s actually very common to have a low testosterone, and that is driven by the fact that people are changing their lifestyles. So there’s more people who are overweight, more men with diabetes. And if you gain central body fat, essentially it produces cytokines or hormones that switch off the control of testosterone in the body. So, for example, men with type two diabetes, about 40% of them, if you look, will have a low testosterone. [00:04:19][62.6]

Dr Louise Newson: [00:04:20] And that’s a lot, isn’t it? 40%. [00:04:21][1.6]

Professor Mike Kirby: [00:04:23] It’s a lot. [00:04:23][0.0]

Dr Louise Newson: [00:04:24] Because I remember years ago when I was quite a newly qualified GP, we were asking men with type two diabetes and we were actually measuring their testosterone levels. So we were asking them if they had any symptoms suggestive of testosterone deficiency and measuring their levels. And they mostly, in fact I think it’s really more than 40% came back low. And then we were told to stop doing it because it was so common and the system wouldn’t actually cope with all the testosterone that needed prescribing. And that was about 20 years ago. [00:04:54][29.9]

Professor Mike Kirby: [00:04:54] Yes. Yeah so it takes a long time for evidence to get into practice in medicine. The other problem is that the reference ranges are wrong because when the GPs get the result, there’s a very wide reference range from six to 30 because, you know, if you take blood of 1,000 men, some will be six, some will be 30. That doesn’t mean that’s normal. So we’ve tried to overcome that by producing action levels. So if the testosterone is 12 and above, that’s normal. If it’s between eight and 12, it needs to be repeated, probably, those people might benefit from a replacement. If it’s less than eight, and they definitely would benefit because they will be suffering the complications of having low testosterone, which is increased heart disease risk, increased risk of diabetes, loss of muscle, brain fog, etc.. So there’s a lot of good things you can do. And all we’re suggesting is simply replace this hormone back to the normal level, it should be in that man. There’s nothing special about it. But women need oestrogen to stay healthy. Men need testosterone, but they don’t need more than normal. They don’t need less than normal. They need about right. And it’s similar between men and women that we know we do need to get together and sing from the same hymn sheet. [00:06:24][89.8]

Dr Louise Newson: [00:06:25] It’s exactly the same. I mean, we see lots of women, obviously with oestrogen, progesterone and testosterone deficiency. And I also think about how many men are oestrogen and progesterone deficient as well, because that’s another conversation. But certainly testosterone deficiency is very common. But a lot of people think they can only take it if they want to build their muscles, like you say, and become some body builder. They don’t see it as a treatment that helps reduce risk of diseases. And, you know, like you Mike, I’m very keen to think about longevity. I want to keep my patients living well and disease free for as long as possible. And it’s more important than it was even, you know, half a century or a century ago because we’re living so much longer. But we only need to look at the rates of osteoporosis, heart disease, diabetes, dementia. They’re going off the scale because we’re living so much longer and we have quite inflammatory diets and lifestyles that perhaps we didn’t have 40, 50 years ago. So that’s compounding but also, when you think about how many people have low hormones, it’s quite staggering, isn’t it? [00:07:31][66.1]

Professor Mike Kirby: [00:07:31] It really is. And I suppose because we’re living longer, it’s exaggerated. So for women in their mid-40s to 80 or 90 year you’re hormone deficient. In men, about 75% of men will maintain their testosterone at normal level. About a quarter will become deficient. So it’s not the same in men, but it’s the same risk on their wellbeing really, because, you know, having a low testosterone level and having a oestrogen level really affects wellbeing, it affects sexual function really badly and loss of muscle, osteoporosis, etc.. It’s a big issue and it’s such a simple test to do and it’s a very simple treatment to replace. And there’s just been a large randomised controlled trial which has shown that testosterone replacement is perfectly safe from the heart and from the prostate. And those were two barriers that people had put up saying it causes heart disease and it causes prostate cancer. The TRAVERSE trial published fairly recently, buries that. It is safe for the heart and it is safe for the prostate full stop. [00:08:47][75.3]

Dr Louise Newson: [00:08:47] Which actually makes sense, doesn’t it? Because it’s a natural hormone. So it would be very weird to think that it was dangerous in people when you’re replacing at physiological levels, which indeed is what happens when you give it to men, isn’t it? [00:09:00][12.5]

Professor Mike Kirby: [00:09:00] Yes, Yes. We monitor the blood level and we try and get it in the middle of the normal range. Not too much. Not too little. [00:09:07][6.8]

Dr Louise Newson: [00:09:08] It’s not difficult medicine. So the other area that I’ve learnt more and more from you, from the British Society of Sexual Medicine, but also from my husband, as you know, Paul, who’s a urologist, is about phosphodiesterase inhibitors, so lots of people will have heard of, probably everyone has heard of Viagra, but there are other types as well. And I remember again as quite a young GP when it first came out and it’s really interesting the whole and we can talk about what’s happened with Viagra now being available over the counter, how commonly prescribed it is. And it’s always thought about a drug that’s just for erectile dysfunction that men and only men take for erectile dysfunction. When I talk to people about, ‘Hang on, it wasn’t actually designed as a drug for erectile dysfunction”. A lot of people don’t realise that. They just know the little blue drug that you can buy very easily if you want to have sex. But it’s… Can we just unpick some of that? Because I think phosphodiesterase inhibitors are as undervalued generally as hormones and people don’t understand what they are and the potential of how much benefit they could give to people. [00:10:21][72.3]

Professor Mike Kirby: [00:10:22] I don’t think this blog is long enough to talk about all the benefits of PDE5 inhibitors because they are tremendous. It was interesting because with my cardiological hat on I got very interested in this drug because it was originally used to treat both men and women with coronary artery disease. And it was at the end of the trial that the men refused to give the tablets back so the research nurse could count them to see how many they’d taken, whereas the women were handing them back. And in all other studies, men always gave the pills back so that they could count and see what was done. And it turned out these men were getting better erections. And because these were patients with underlying cardiovascular disease, about 60 to 70% of those men would have had problems getting an erection. And that really got Pfizer, who were producing Viagra, off on the hunt of the opportunity to make money as a very good drug and a very safe drug for treating erection problems in men. And they forgot that they had a cardiac their drug. As did Lilly with Tadalafil, as did Bayer with Levitra. So we had three companies all doing research studies on erection problems, all showing very positive, very effective drugs at curing erection problems. And they completely forgot. And it was a really missed opportunity. They do work extremely well because they work by relaxing the blood vessels to allow blood flow effectively into the penis. But they also relax blood vessels everywhere else, like the heart, the legs, the brain, importantly. So what has happened over the last few years, we have found more and more benefits by looking at databases of people taking PDE5 inhibitors compared to people who don’t. And we published a study where we looked at a very big general practice database of men who had diabetes. And we looked at those men in that practice having PDE5 inhibitors compared them with the same age group of men not taking PDE5 inhibitors, and there’s about a 30% reduction in cardiovascular death in the men taking them. Quite staggering. [00:12:53][151.1]

Dr Louise Newson: [00:12:53] That’s a lot. [00:12:54][0.1]

Professor Mike Kirby: [00:12:54] It is because the men with erection problems theoretically were at the highest risk of dying from heart disease. If you can’t get an erection, your heart is headed in the wrong direction. And another study that we did, we went to cardiac rehab units and asked the men if they had erection problems and 75% did. But less than a quarter had told anybody about it. And they’d had erection problems for five years before their heart attack. So by asking about sexual function, you have an opportunity to prevent a heart attack five years down the line because it tells you they’ve got atery problems and you give them a statin, treat their blood pressure, treat their diabetes, and you prevent a heart attack. And interestingly enough, a year after we published that diabetes study, there was a group in Sweden where they did the same thing with men with heart disease. Those men with heart disease taking PDE5 inhibitors versus those men without, 50,000 patients in this study, it’s big. And they found almost exactly the same figure, about a third reduction in cardiovascular mortality within three years of starting to take a PDE5 inhibitor. Wow. [00:14:14][79.6]

Dr Louise Newson: [00:14:15] Gosh so three years. I mean, that’s better than statins and blood pressure lowering drugs, isn’t it? [00:14:20][4.4]

Professor Mike Kirby: [00:14:21] Much better, much much better. And interestingly enough, the more of PDE5 inhibitors that they took, the better the protection. So if you’re taking it once every couple of weeks compared with taking every day, then you didn’t do so well. [00:14:35][14.4]

Dr Louise Newson: [00:14:36] So your best off taking every day? [00:14:38][1.8]

Professor Mike Kirby: [00:14:38] Yes, best to take it regularly because it is a cardiovascular drug, actually at the end of the day, because it improves the lining of the blood vessels called the endothelium, the vascular endothelium, so ed equals ed: erection dysfunction equals endothelial dysfunction. [00:14:57][18.7]

Dr Louise Newson: [00:14:58] Yeah, And it’s interesting because I’ve talked about endothelium before, which is the lining of our blood vessels, but it’s very biologically active, isn’t it? And any inflammation in our body will often be reflected in the endothelium. So you get this burning of the arteries if you like, but you get this build-up of atheroma plaque and that’s what happens. And like you say, it happens in the penis earlier because the blood supply, the blood vessels are so much thinner than the blood vessels to the heart. So if you’ve got the damage to the endothelium, it will always pick off the finer arteries first. And that’s often why people get eye changes before they have blood pressure changes, for example. So that’s why ophthalmologists or the opticians spend a long time looking at the back of our eyes because it’s a window into our heart system as well. And actually the phosphodiesterase inhibitors will help with something called nitric oxide as well, which is a vasodilator. It opens up the blood vessels and helps to reduce this inflammation as well, which is good for blood pressure as well, isn’t it? [00:15:56][58.6]

Professor Mike Kirby: [00:15:57] Yes, it’s very good for blood pressure. I mean, there’s a very large meta-analysis where they showed that PDE5 inhibitors were protective on cardiovascular health. But also they had beneficial effects on bones, The urogenital tract. The brain had benefits on the metabolic profile of the patients taking it and cardiovascular… [00:16:19][22.0]

Dr Louise Newson: [00:16:21] It’s massive. [00:16:21][0.0]

Professor Mike Kirby: [00:16:23] So these drugs have widespread implications. The problem is that in the early days, a lot of the studies were preclinical. And of course, these are all off label indications. So if you want to use them, but those indications, then the doctor is prescribing off label. [00:16:41][17.6]

Dr Louise Newson: [00:16:41] But we do that a lot in medicine, don’t we? We prescribe a lot of things. My daughter has, as you know, chronic migraine and she’s been given antiepileptic drugs. She’s been given different antidepressants for her migraines. We do it a lot in medicine, but it’s still…people often don’t realise, but sorry, carry on. [00:16:58][17.0]

Professor Mike Kirby: [00:16:59] Well, I think for women you see, women have used Viagra sildenafil, since 2009 because they get treated for pulmonary hypertension. They use a very high dose in pulmonary hypertension, 40mg. And women, of course, are seven times more likely to get pulmonary hypertension. So, you know, women can take it perfectly safely. And actually, there’s no reason why women shouldn’t get all the same benefits as the men. For example, in 2022, there was a study using it in lower urinary tract symptoms and bladder pain in women. It’s very interesting that during the COVID-19 pandemic, the people who were seriously ill with COVID before the vaccination programme, both men and women, if they were taking a PDE5 inhibitor, they did better. So I think, you know, for women, I think particularly for sexual function, there’s two large randomised controlled trials showing that women using PDE5 inhibitors can benefit with increased arousal, increased ability to orgasm. And I think probably most importantly, more enjoyment out of sex. And you know, the clitoris of course is equally affected by poor blood flow as the penis. You see with men, when the penis fills with blood, the blood that goes in stays in because the pressure within the penis blocks off the emissary veins so the blood can’t get out. But for women and the clitoris, they don’t have that mechanism. It’s a constant inflow of blood the whole time. So, in fact, women actually need a better pelvic blood flow than men to some extent. And by improving endothelial function in the clitoral vessels, you increase the perfusion of the clitoris and makes sex much more fun. [00:19:01][121.8]

Dr Louise Newson: [00:19:02] Which is not a bad thing. And it’s something we were talking before I started recording about how few doctors actually talk about sex to patients who often want to. And it’s really, really important. But with this drug, it’s more than I say, ‘just’ in inverted commas, because I’m not belitting sex. But it’s more than that. You’ve already said it reduces risk of diseases. And we said at the beginning how common these diseases are as we get older. I spent a lot of time in the 90s and early 2000s as a medical doctor prescribing aspirin for people to reduce risk of heart disease. And, you know, especially if they’ve had a heart attack and people with diabetes, everybody with type two diabetes used to be put on an aspirin as well. And then we realised there were bleeding effects, there were side effects of aspirin. So it’s not done as much. But I often think of every day phosphodiesterase inhibitor like Tadalafil as a new aspirin really without the risk. Is that a fair way to think about it, Mike? Am I being a bit overzealous, do you think? [00:20:02][59.9]

Professor Mike Kirby: [00:20:02] Well, aspirin works by stopping the platelets being so sticky, whereas Tadalafil works by making the blood vessels more healthy. [00:20:10][7.8]

Dr Louise Newson: [00:20:11] But I’m thinking about just not the mechanism, but the just reducing risk of disease. [00:20:15][4.6]

Professor Mike Kirby: [00:20:16] Certainly in women, there was an Italian study where they used it in ladies with type two diabetes and they got increased control of the diabetes and it reduced the inflammatory markers. So I think that’s another side to the story is that unfortunately, our lifestyle, we gain weight, get diabetes, have high blood pressure. We get inflammation of the blood vessels. And that’s, I think, one of the ways in very much the same way that aspirin worked in heart disease, that PDE5 inhibitors work by making the endothelium more healthy and reducing the inflammation. So it’s, I think it’s lots of data now on prevention of dementia. And how important is that? Geoff [Dr Geoff Hackett] and I are trying to get a randomised controlled trial of tadalafil in patients with severe heart disease. And to look at the dementia data in those patients as well. Because there’s good evidence now that taking PDE5 inhibitors reduces your risk of dementia. That’s a bit of an added bonus, isn’t it? Less heart disease, less urinary symptoms, less dementia, better diabetes control, less Raynaud’s disease. And actually there’s good evidence for reduction in colon cancer as well because PDE5 inhibitors are anti proliferative. [00:21:45][89.2]

Dr Louise Newson: [00:21:47] So I it begs the question, doesn’t it why aren’t more people not taking them for these reasons? Because anything we can do to reduce risk of diseases will help that individual. But it also when you’re talking about population health and drain on NHS resources, but health care systems in any country, we’ve got to be thinking about keeping people healthy. These drugs, they’re actually quite cheap. They’re very low risk. So why are we not prescribing them more Mike? [00:22:18][30.4]

Professor Mike Kirby: [00:22:18] Because they’re off licence programs for all those indications. People are very resistant and nervous about prescribing things. You know, I think Viagra got a bit of a bad name really, because there was a lot of market hype and it got very much associated with sexual problems. [00:22:35][17.5]

Dr Louise Newson: [00:22:36] I was reading at the weekend, you probably know this, but one of the ways they wanted to market it when they realised it had this erectile dysfunction benefit was they got blessing from the Pope to say that it would improve relationships in families and it will keep the family unit together. And as soon as they got that endorsement from the Pope, it just made it even easier to market. And it has been one of the most over, well not over, most prescribed drugs, as you know. But then quite quickly, it became available over the counter. So it’s a lot easier for people to get, harder to monitor, of course. But people still think and of course, it can be taken for when people want sex. But this is taken as a lower dose often but every single day, and that’s the shift that I think people haven’t realised that it can be taken every day. It doesn’t usually interfere with medication, for most people don’t have contraindications so it can be used. And I do think about all the other medications that are prescribed, like the antihypertensives, like statins, that don’t necessarily have the same long term benefits that you’re describing in very good studies. [00:23:48][71.6]

Professor Mike Kirby: [00:23:50] I think so. I think the fact is, over the counter’s a good thing because it’s A: very difficult to get to see a GP these days. B: a lot of people feel embarrassed or they think their GP will be embarrassed and so they’d rather be independent and just talk to a pharmacist in a private room. So Viagra’s over-the-counter, Tadalafil is over-the-counter at a dose of ten milligrams, the Viagra’s 25 or 50. And I think, I flew to Australia for two days to advise the Australian Government about having Viagra over the counter about 15 years ago. It didn’t become available in Australia actually, but it’s been available across Europe over the counter for quite a while now, in Poland particularly. And I think that’s a good thing, particularly as we know that it has all these other benefits. And if it saves marriages, I think the Pope was right. When I was treating a lot of men, their partner would come in and part of the problem was the wife would say, well, I think he doesn’t love me anymore. I’m not attractive anymore because things aren’t working. I would explain it’s not actually the fact he doesn’t love you anymore or you’re not attractive. The problem is that it’s the mechanics of the penis are not working. Because he’s had high blood pressure and diabetes. But we can sort this out. And very few men where we couldn’t find a solution to their erection problems. So, you know, we shouldn’t just be talking about men or women in isolation. We should be talking about their partnership and really supporting a loving relationship. Because I gave a talk the other day about the benefit of continuing to be able to have sex for both men and women and for women it gives them about an extra six years of life and for men about the same. And that’s probably related to the fact that if you have a good, satisfying, enjoyable sex life, then you’re a lot calmer about everything else in your life. And it’s a very good form of exercise. It produces oxytocin, which has all sorts of cardiovascular benefits in itself. It’s a very under-talked about hormone because it improves your immune system. It improved blood flow to the brain. It improves heart. So, you know, there are lots of health benefits from being able to continue having a healthy, loving sexual relationship. And unfortunately, a lot of people are deprived of it because they can’t get access to the drugs, which is ridiculous because, as you say, they’re dead cheap and they’re very, very, very safe. [00:26:44][173.8]

Dr Louise Newson: [00:26:46] And I often. I play mind games quite a lot, but I often think I wonder what the world would look like if people who needed hormone replacement, men and women, had the right doses and types for them and those people that wanted to and were able to take Tadalafil or Sildenafil? you know one of the phosphodiesterase inhibitors, daily as well because I think it would reduce a lot of other medications needing to be prescribed. I think people would be happier. Of course we’ve talked about quality of life, but they would be healthier as well and there’d be less long term problems and diseases as well. But we’ve got a long way to go. I’m quite impatient, as you know, but we have a long way to go before even that’s accepted or thought about in traditional medicine. [00:27:29][42.8]

Professor Mike Kirby: [00:27:29] Well, you’re right. We need to keep talking about it and waving the flag and sharing all the data of safety and efficacy. I mean, for men with lower urinary tract symptoms, they often get prescribed finasteride to shrink the prostate. And that has awful sexual effects. They get prescribed alpha blockers, which make them dizzy. And actually to take daily Sildenafil has virtually no side effects. Actually, most of those men also have erection problems and you’re giving them cardiovascular benefit at the same time. So it’s quids in really, but I think we have a problem getting GPs prescribe it for men, but you have a huge problem getting GPs to prescribe it for women off licence. [00:28:16][46.5]

Dr Louise Newson: [00:28:18] And you’re absolutely right, looking at the lower urinary tract symptoms in women as well. And a lot of women are given oxybutynin which increases risk of dementia. It’s not really a nice drug and even some of the newer drugs still have side effects. So we have a long way to go, Mike, but you are amazing in the way that you educate and share your phenomenal knowledge. So I’m very grateful for you coming today. I always end the podcast with three take home tips. So three reasons why people listen to this podcast, whether they’re male or female, should know more about phosphodiesterase inhibitors. [00:28:54][35.8]

Professor Mike Kirby: [00:28:55] Okay, well, they’re cheap and safe. They reduce the risk of cardiovascular disease. They are probably one of the most effective treatments for sexual dysfunction in both men and women. And for people with diabetes, they actually improve diabetes control. And if you want an extra one, it could well prevent cancers as well. [00:29:25][29.8]

Dr Louise Newson: [00:29:25] Amazing. Amazing. So, well, I hope this has got people thinking and thinking about Viagra and Viagra-like medication, so, phosphodiesterase inhibitors in a different way. So I’m very grateful for your time and thank you so much. [00:29:41][16.0]

Professor Mike Kirby: [00:29:42] It’s a pleasure. Thank you for asking me. [00:29:44][1.4]

Dr Louise Newson: [00:29:49] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. 

ENDS