Latest / The Dr Louise Newson Podcast / 296 - Viagra: is it time to rethink the little blue pill for future health?

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296 - Viagra: is it time to rethink the little blue pill for future health? · The Dr Louise Newson Podcast

0:11
Hello, I'm Doctor Louise Newson, I'm AGP and menopause specialist
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and I'm also the founder of the Newson Health Menopause and
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well-being Centre here in Stratford upon Avon.
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I'm also the founder of the free Balance app.
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Each week on my podcast, join me and my special guests where we
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discuss all things perimenopause and menopause.
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We talk about the latest research, bus myths on menopause
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symptoms and treatments and often share moving and always
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inspirational personal stories. This podcast is brought to you
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by the Newsome Health Group, which has clinics across the UK
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dedicated to providing individualised perimenopause and
0:52
menopause care for all women. So today on my podcast, I've got
1:04
someone I do know very well and I have met in real life, unlike
1:07
some of my other podcasts. And I've got Professor Mike
1:10
Kirby, who is an inspiration. He's a real mentor and more of a
1:16
mentor than he realises actually for a lot of my work, but I've
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known him for many years. He is also, like me, very
1:22
interested in cardiology, cardiovascular disease, disease
1:26
prevention, keeping healthy, and really interested in looking at
1:34
people as a whole. He does a lot more maybe with
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men than women, but he still borders on that line with
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Women's Health as well and works with the British Society of
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Sexual Medicine, who I've had the privilege of lecturing for
1:47
many times and lecturing alongside Mike.
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So I've been lecturing about the role of female hormones and he's
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been lecturing a lot about the role of testosterone and men's
1:58
health. And there is so much crossover.
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So I'm very honoured to have him here in the podcast.
2:04
So welcome, Mike today. I'm delighted to be here,
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Louise. We're a great fan of yours, so I
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would never say no to you. Oh, very good.
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I've got that on the record now. So that's great.
2:15
So it's really interesting because there's so much
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misperceptions in medicine where people have been told something
2:24
and then there's something else actually, and then they're not
2:28
really sure and then they don't want to believe.
2:30
So even if we start with just testosterone, when you talk
2:34
about testosterone, people think about male bodybuilders.
2:37
And that's probably what people will really think.
2:41
And most of us as clinicians haven't been trained at all
2:45
about hormones, let alone testosterone in women, which I
2:49
have talked about quite a lot on previous podcasts, but in men as
2:52
well. And I remember the first time
2:54
hearing you lecture, coming to one of the BSSM meetings and
2:59
thinking, why didn't I know this?
3:01
Like, why did we not understand the importance of testosterone
3:05
to improve cardiometabolic health, to reduce risk of heart
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disease and dementia and osteoporosis in men?
3:12
And it's still something that's really not spoken about enough,
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is it? No, there have been a lot of
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barriers put up to people using testosterone because in America
3:25
it was used inappropriately. It was being prescribed there
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without checking blood levels, just on the basis of a history,
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and it was being prescribed for bodybuilding.
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That really got at a very bad reputation.
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So we tried to overcome that by producing a evidence based
3:43
guideline. And the key thing is that it's
3:46
actually very common to have a low testosterone and that is
3:51
driven by the fact that people are changing their lifestyles.
3:55
So there's more people who are overweight, more men with
3:58
diabetes. And if you gain central body
4:02
fat, essentially it produces cytokines or hormones that
4:08
switch off the control of testosterone in the body.
4:12
So for example, men with type 2 diabetes, about 40% of them, if
4:17
you look, we'll have a low testosterone.
4:20
That's a lot, isn't it, 40%? That's a lot.
4:24
Because I remember years ago when I was quite a newly
4:26
qualified GP, we were asking men with type 2 diabetes and we were
4:32
actually measuring their testosterone levels.
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So we were asking them if they had any symptoms suggestive of
4:37
testosterone deficiency and measuring their levels.
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And they mostly, in fact, I think it's probably more than
4:42
40% came back low and then we were told to stop doing it
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because it was so common and the system wouldn't actually cope
4:50
with all the testosterone that needed prescribing.
4:52
And that was about 20 years ago. Yes, yeah.
4:55
So takes a long time for evidence to get into practice in
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medicine. The other problem is that the
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reference ranges are wrong because when the GPS get the
5:07
result, there's a very wide reference range from 6 to 30.
5:12
Because you know, if you take blood on 1000 men, some will be
5:17
6, some will be 30. But that doesn't mean that's
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normal. So we've tried to overcome that
5:23
by producing action levels. So if the testosterone is 12 and
5:28
above, that's normal. If it's between 8:00 and 12:00,
5:32
it needs to be repeated and probably those people might
5:35
benefit from replacement. If it's less than 8, then they
5:39
definitely would benefit because they will be suffering the
5:43
complications of having low testosterone, which is increased
5:47
heart disease risk, increased risk of diabetes, loss of
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muscle, brain fog, et cetera. So there's a lot of good things
5:57
you can do and all we're suggesting is simply replace
6:01
this hormone back to the normal level.
6:04
It should be in that man. There's nothing special about
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it. But women need each students
6:09
stay healthy. Men need testosterone, but they
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don't need more than normal. They don't need less than
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normal. They need about right.
6:17
And it's similar between men and women that, you know, we do need
6:22
to get together and sing from the same hymn sheet.
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It's exactly the same. I mean, we see lots of women,
6:28
obviously with estrogen, progesterone and testosterone
6:31
deficiency. And I also think about how many
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men are estrogen and progesterone deficient as well,
6:37
because that's another conversation.
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But certainly testosterone deficiency is very common.
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But a lot of people think they can only take it if they want to
6:44
build their muscles, like you say, and become somebodybuilder.
6:47
They don't see it as a treatment that helps reduce risk of
6:51
diseases. And you know, like you might,
6:53
I'm very keen to think about longevity.
6:56
I want to keep my patients living well and disease free for
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as long as possible. And it's more important than it
7:03
was even, you know, half a century or a century ago because
7:07
we're living so much longer. But we only need to look at the
7:10
rates of osteoporosis, heart disease, diabetes, dementia.
7:14
They're going off the scale because we're living so much
7:16
longer and we have quite inflammatory diets and
7:20
lifestyles that perhaps we didn't have 40-50 years ago.
7:24
So that's compounding. But also, when you think about
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how many people have low hormones, it's quite staggering,
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isn't it? No, it really is.
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And I suppose because we're living longer, it's exaggerated.
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So for women, you know from mid 40s to 80 or 90, you're hormone
7:43
deficient. In men, about 75% of men will
7:47
maintain their testosterone at normal level, about 1/4 will
7:51
become deficient. So it's, it's not the same in
7:54
men, but it's the same risk on their well-being really, because
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you know, having low testosterone level and having a
8:04
low issue level really effects well-being, effects sexual
8:07
function really badly and loss of muscle, osteoporosis,
8:12
etcetera. And it's a big issue.
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And it's such a simple test to do and it's a very simple
8:18
treatment to replace. And there's just been a, a
8:22
large, a randomised controlled trial which has shown that
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testosterone replacement is perfectly safe from the heart
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and from the prostate. And those were two barriers that
8:33
people put out saying it causes heart disease and it causes
8:37
prostate cancer. The Traverse trial published
8:40
fairly recently barriers that it is safe for the heart and it is
8:45
safe for the prostate, full stop.
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Which actually makes sense, doesn't it?
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Because it's a natural hormone. Yeah.
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So it'd be very weird to think that it was dangerous in people
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when you're replacing at physiological levels.
8:57
Which indeed is what happens when you give it to men, isn't
9:00
it? Yeah, yes, yes.
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We monitor the blood level and we try and get it in the middle
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of the normal range. Not too much, not too little.
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MMM. It's not difficult medicine, no.
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So the other area that I've learnt more and more from you
9:14
from the British Society of Sexual Medicine, but also from
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my husband, as you know, Paul who's a urologist is about
9:20
phosphodiesterase inhibitors. So a lot of people will have
9:23
heard, I think probably everyone has heard of Viagra, but there
9:26
are other types as well. And I remember again as quite a
9:30
young GP when it first came out. And it's really interesting the
9:36
whole, and we can talk about what's happened with Viagra now
9:39
being available over the counter, how commonly prescribed
9:43
it is. And it's always thought about a
9:46
drug that's just for erectile dysfunction that men and only
9:49
men take for erectile dysfunction.
9:52
When I talk to people about, hang on, it wasn't actually
9:55
designed as a drug for erectile dysfunction.
9:58
Yeah, a lot of people don't realise that.
10:00
Yeah. They just know the little blue
10:01
drug that you can buy very easily if you want to have sex.
10:04
But it's. Can we just unpick some of that?
10:07
Because I think the phosphodiesterase inhibitors are
10:11
as undervalued generally as hormones, and people don't
10:16
understand what they are and the potential of how much benefit
10:20
they could give to people. I don't think this blog is low
10:24
enough to talk about all the benefits of PD5 inhibitors
10:27
because they are tremendous. It was interesting because with
10:32
my cardiological hat on, I got very interested in this trial
10:35
because it was originally used to treat both men and women with
10:41
coronary artery disease. And it was at the end of the
10:44
trial that the men refused to give the tablets back so
10:49
research nurse could count them to see how many they'd taken,
10:53
whereas the women were handing them back.
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And in all other studies, men always gave the pills back so
10:59
they could count and see what's done.
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And it turned out these men were getting better erections.
11:05
And because these were patients with underlying cardiovascular
11:09
disease, about 60 to 70% of those men would have had
11:14
problems getting in erection. And that really got Pfizer, who
11:19
were producing Viagra, off on the hunt of the opportunity to
11:23
make money, is a very good drug and a very safe drug for
11:27
treating erection problems in men.
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And they forgot that they had a cardiac drug, as did Lily with
11:35
Tadanaphil, as did Bayer with Levitra.
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So we had three companies all doing research studies on
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erection problems, all showing very positive, very effective
11:48
drugs at curing erection problems.
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And they completely forgot. And it was a really missed
11:54
opportunity. They do work extremely well
11:58
because they work by relaxing the blood vessels to allow blood
12:03
to flow effectively into the penis, but they also relax blood
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vessels everywhere else like the heart, the legs, the brain,
12:12
importantly. So what has happened over the
12:16
last few years? We have found more and more
12:19
benefits by looking at databases of people taking PB5 inhibitors
12:25
compared to people who don't. And we published a study where
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we looked at a very big general practice database of men who had
12:33
diabetes. And we looked at those men in
12:37
that practice having PD5 inhibitors, compared them with
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the same age group of men not taking PD5 inhibitors.
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And there's about a 30% reduction in cardiovascular
12:49
death in the men taking them, quite staggering.
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It is because the men with erection problems, theoretically
12:59
we're at the highest risk of dying from heart disease.
13:02
If you can't get an erection, your heart is headed in the
13:05
wrong direction. And another study that we did,
13:08
we went to cardiac rehab units and asked the men if they had
13:13
erection problems and 75% did, but less than 1/4 had told
13:19
anybody about it. And they've had erection
13:21
problems for five years before their heart attack.
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So by asking about sexual function, you have an
13:29
opportunity to prevent a heart attack five years down the line
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because it tells you they've got artery problems.
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And you give them a statin, treat their blood pressure,
13:39
treat their diabetes, and you prevent a heart attack.
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And interestingly enough, a year after we published that diabetes
13:48
study, there was a group in Sweden where they did the same
13:51
thing with men with heart disease, those men with heart
13:55
disease taking a PD5 inhibitor versus those men without 50,000
14:00
patients in this study. It's big.
14:01
And they're finding almost exactly the same figure, about
14:05
1/3 reduction in cardiovascular mortality within three years of
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starting to take a PD5 inhibitor.
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So three years? I mean, that's better than
14:17
statins and blood pressure lowering drugs, isn't it?
14:20
Yes, better. And interestingly enough, the
14:24
more of PD5 an image that they took, the better the protection.
14:28
So if you take it once every couple of weeks compared with
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taking every day, then you didn't do so well.
14:36
So you're best off taking every day.
14:38
Yeah, it's best to take it regularly because it is a
14:41
cardiovascular drug. Actually the end of the day,
14:44
because it improves the lining of the blood vessels called the
14:47
endothelium, the vascular endothelium.
14:50
So Ed equals Ed erection dysfunction equals endothelial
14:57
dysfunction. Yeah.
14:58
And it's interesting because I've talked about endothelium
15:00
before, which is the lining of our blood vessels, but it's very
15:04
biologically active, isn't it? And any inflammation in our body
15:09
will often be reflected in the endothelium.
15:11
So you get this firing of the arteries if you like, but you
15:14
get this build up of atheroma plaque and that's what happens.
15:18
And like you say, it happens in the penis earlier because the
15:21
blood supply, the blood vessels are so much thinner than the
15:24
vessels to the heart. So if you've got the damage to
15:27
the endothelium, it will always pick off the finer arteries
15:30
first. And that's often why people get
15:31
eye changes before they have blood pressure changes, for
15:34
example. So that's why ophthalmologists
15:36
or the opticians been a long time looking at the back of our
15:39
eyes, because it's a window into our heart system as well.
15:42
Yeah. And actually, the
15:43
phosphodiesterase inhibitors will help with something called
15:46
nitric oxide as well, won't they, which is a vasodilator.
15:49
It opens up the blood vessels and helps to reduce this
15:53
inflammation as well, which is good for blood pressure as well,
15:56
isn't it? Yes, it's very good for blood
15:58
pressure. I mean, there's a very large
16:01
metro analysis where they showed that PD5 inhibitors were
16:05
protective on cardiovascular health, but also they had
16:09
beneficial effects on bones, the urogenital tract, the brain.
16:14
They had benefits on the metabolic profile of the
16:17
patients. Take it and cardiovascular so
16:21
these drugs actually widespread implications.
16:25
The problem is that in the early days a lot of the studies were
16:28
preclinical and of course these are all off label indications.
16:34
So if you want to use them but those indications, then the
16:39
doctor is prescribing off label. But we do that a lot in
16:42
medicine, don't we? We prescribe a lot of, you know,
16:45
my daughter has, as you know, chronic migraine and she's been
16:47
given antiepileptic drugs, She's been given different
16:51
antidepressants for her migraines.
16:53
We do it a lot in medicine, yes, but it's still, people often
16:57
don't realise. But sorry, carry on.
16:59
Well, I think for women you see women have are used Viagra,
17:04
sildenafil since 2009 because they get treated for pulmonary
17:09
hypertension. They use a very high dose in
17:12
pulmonary hypertension 40 milligrams and women of course
17:16
are 7 times more likely to get pulmonary hypertension.
17:20
So, you know, women can take it perfectly safely and actually
17:26
there's no reason why women shouldn't get all the same
17:29
benefits as the men. For example, in 2022, there's a
17:34
study using it in lower unit tract symptoms and bladder pain
17:39
in women. It's very interesting that
17:42
during the COVID-19 pandemic, the people who were seriously
17:46
ill with COVID before the vaccination programme, both men
17:51
and women, if they're taking a PD5 inhibitor, they did better.
17:56
So I think, you know, for women, I think particularly for sexual
17:58
function, there's two large randomized controlled trials
18:02
showing that women using PD5 inhibitors get benefit with
18:07
increased arousal, increased ability to orgasm, and I think
18:13
probably most importantly, more enjoyment to have sex.
18:17
And you know, the clitoris of course, is equally affected by
18:22
poor blood flow as the penis. You see, with men, when the
18:27
penis fills with blood, the blood that goes in stays in
18:31
because it the pressure within the penis blocks off the
18:35
emissary veins, so the blood can't get out.
18:38
But for women in the clitoris, they don't have that mechanism.
18:41
It's a constant inflow of blood the whole time.
18:44
So in fact, women actually need a better pelvic blood flow than
18:48
men to some extent. And by improving endothelial
18:53
function in the clitoral vessels, you improve the
18:57
profusion of the clitoris and makes sex much more fun.
19:02
Which is not a bad thing. And it's something we were
19:05
talking before started recording about how few doctors actually
19:08
talk about sex to patients who often want to.
19:13
And it's really, really important.
19:15
But with this drug, it's more than, I say, just an inverted
19:18
Commons because I'm not very little in sex, but it's more
19:20
than that. You've already said it reduces
19:23
risk of diseases. And we said at the beginning how
19:25
common these diseases are as we get older.
19:28
I spent a lot of time in the 90s and early 2000 as a medical
19:32
doctor prescribing aspirin for people to reduce risk of heart
19:36
disease and, you know, especially if they've had a
19:37
heart attack. And people with diabetes,
19:40
everybody with type 2 diabetes used to be put on an aspirin as
19:43
well. And then we realised there were
19:45
bleeding effects, there were side effects of aspirin.
19:48
So it's not done as much. But I often think of everyday
19:52
phosphodiesterase inhibitor like tildanafil as a new aspirin
19:56
really without the risks. Is, is that, is that a fairway
19:59
to think about it Mike or am I being a bit overzealous do you
20:02
think? Well, that's been works by
20:03
stopping the platelets being so sticky, whereas yeah, Tabata
20:08
works by making the blood vessels more healthy.
20:11
But I'm thinking about just not the mechanism, but they're just
20:14
reducing risk of disease. Certainly in women.
20:17
There was an Italian study where they used it in ladies with type
20:21
2 diabetes and they got increased control of the
20:25
diabetes and it reduced the inflammatory markers.
20:29
So I think that's another side to the story is that
20:33
unfortunately our lifestyle, we gain weight, get diabetes, have
20:38
high blood pressure, we get inflammation of the blood
20:41
vessels. And that's I think one of the
20:44
ways in very much the same way that aspirin worked in heart
20:47
disease, that PD5 inhibitors work by making the endothelium
20:51
more healthy and reducing the inflammation.
20:56
So it's, I think there's lots of data now on prevention of
21:00
dementia. How important is that?
21:06
Jeff and I are just trying to get a randomized controlled
21:08
trial of tadalafil in patients with severe heart disease and to
21:15
look at the dementia data in those patients as well.
21:19
Because there's good evidence now that taking PD5 inhibitors
21:23
reduces your risk of dementia. That's a bit of an added bonus,
21:27
isn't it? Less heart disease, less
21:30
symptoms, less dementia, better diabetes control, less Renault's
21:35
disease, and actually there's good evidence for reduction in
21:39
colon cancer as well because PD5 inhibitors are anti
21:45
proliferative so. It begges the question, doesn't
21:51
it, Why are more people not taking them For these reasons?
21:55
Because anything we can do to reduce risk of diseases will
21:59
help that individual. But it also when you're talking
22:01
about population health and drain on NHS resources, but
22:06
healthcare systems in any country, we've got to be
22:09
thinking about keeping people healthy.
22:11
These drugs are actually quite cheap.
22:14
They're very low risk. So why are we not prescribing
22:17
them more, Mike? Because they're off licence for
22:20
all those indications and people are very resistant and nervous
22:24
about prescribing things. You know, I think Viagra got a
22:28
bit of a bad name really, because there's a lot of market
22:32
hype. You got very much associated
22:35
with sexual problems. I was reading at the weekend,
22:38
you, you probably know this, but one of the ways they wanted to
22:40
market it when they realised it had this erectile dysfunction
22:43
benefit was they got blessing from the Pope to say that it
22:48
would improve relationships in families and it will keep the
22:52
family unit together. And as soon as they got that
22:55
endorsement from the Pope, it just made it even easier to
22:59
market. And it has been one of the most
23:03
over, well, not over most prescribed drugs, as you know,
23:06
but then quite quickly it became available over the counter.
23:10
So it's a lot easier for people to get harder to monitor of
23:14
course, but people still think, of course it can be taken for
23:18
when people want sex, but this is taken as a lower dose often,
23:22
but every single day. And that's the shift that I
23:26
think people haven't realised that it can be taken every day.
23:30
It doesn't usually interfere with medication for most people
23:35
don't have contraindications, so it can be used.
23:38
And I do think about all the other medications that are
23:41
prescribed like the antihypertensives, like statins
23:44
that don't necessarily have the same long term benefits that
23:47
you're describing in very good. Studies I think so.
23:51
I think the fact it's over the counter is a good thing because
23:55
it's a very difficult to get to see AGP these days BA lot of
23:59
people feel embarrassed or their GP will be embarrassed and see
24:04
if they'd rather be independent and just talk to a pharmacist in
24:08
a private room. So Viagra is over the counter,
24:11
Tadalafil is over the counter. That's a dose of 10 milligrams.
24:16
The Viagra is 25 or 50 and I think I flew to Australia for
24:22
two days to advise the Australian government about
24:25
having biker over the counter about 15 years ago.
24:30
It didn't become available in Australia actually, but it's
24:34
been available across Europe over the counter what a while
24:37
now. Poland particularly, and I think
24:41
that's a good thing, particularly as we know that it
24:45
has all these other benefits. But and if it saves marriages, I
24:49
think the Pope was right when I was treating a lot of men, the
24:55
partner would come in and part of the problem was that the wife
24:57
would say, well, I think he doesn't love me anymore, I'm not
25:00
attractive anymore because things aren't working.
25:03
As would explain. It's not actually the fact he
25:06
doesn't love you anymore or you're not attractive.
25:09
The problem is that it's the mechanics of the penis are not
25:13
working because he's had high blood pressure and diabetes.
25:16
But we can sort this out out. There are very few men that we
25:20
couldn't find a solution to their erection problems.
25:24
So, you know, we shouldn't just be talking about men or women in
25:29
isolation. We should be talking about their
25:31
partnership and really supporting a loving
25:35
relationship. Because I gave a talk the other
25:39
day about the benefit of continuing to be able to have
25:43
sex for both men and women. And for women it gives them
25:47
about an extra six years of life, and for men about the
25:51
same. And that's probably related to
25:54
the fact that if you have a good, satisfying, enjoyable sex
25:58
life, then you're a lot calmer about everything else in your
26:02
life. And it's a very good form of
26:04
exercise. It produces oxytocin, which has
26:09
all sorts of cardiovascular benefits in itself.
26:14
It's a very under talked about hormone because it improves your
26:20
immune system, it improves blood flow to the brain, it improves
26:24
heart. So, you know, there are lots of
26:27
health benefits from being able to continue having a healthy,
26:31
loving sexual relationship. And unfortunately, a lot of
26:34
people are deprived of it because they can't get access to
26:37
the drugs, which is ridiculous because, as you say, they're
26:40
dead cheap and they're very, very, very safe.
26:46
And I often, I play mind games quite a lot, but I often think,
26:49
I wonder what the world would look like if people who needed
26:52
hormone replacement, men and women had the right doses and
26:55
types for them. And those people that wanted to
26:58
and were able to take tildanafil or sildanafil, you know, one of
27:02
the phosphodiesterase inhibitors daily as well, because I think
27:06
it would reduce a lot of other medications needing to be
27:09
prescribed. I think people would be happier.
27:12
Of course, we've talked about quality of life, but they would
27:14
be healthier as well. And and there'd be less long
27:17
term problems and diseases as well.
27:20
But we've got a long way to go. I'm quite impatient as you know.
27:23
But we have a long way to go before even that's accepted or
27:27
thought about in traditional medicine.
27:29
No, you're right. We need to keep talking about it
27:32
and waving the flag and sharing all the data on safety and
27:37
efficacy. I mean for men with lower unit
27:40
tract symptoms, they often get prescribed finasteride, they
27:46
shrink the prostate and that has awful sexual side effects.
27:50
They get prescribed alpha blockers which make them dizzy
27:54
and actually to take daily Cedarophyl has virtually no side
27:59
effects. I mean she most of those men
28:00
also have erection problems and you're giving them
28:04
cardiovascular benefit at the same time.
28:06
So it's quids in your but I think we have a problem getting
28:11
GPS to prescribe it for men. But you have a huge problem
28:14
getting TP to prescribe it for women.
28:18
And you're absolutely right, looking at the lower urinary
28:20
tract symptoms in women as well, a lot of women are given
28:24
oxybutynin which increases risk of dementia.
28:27
It's not really a nice drug and even some of the newer drugs
28:29
still have side effects. So we have a long way to go,
28:32
Mike, but you are amazing in the way that you educate and share
28:37
your phenomenal knowledge. So I'm very grateful for you
28:39
coming today. I always end the podcast with
28:43
three take home tips. So 3 reasons why people
28:48
listening to this podcast, whether they're male or female,
28:51
should know more about phosphodiesterase inhibitors.
28:55
OK, well, they're cheap and safe.
29:00
They reduce the risk of cardiovascular disease.
29:05
They are probably one of the most effective treatments of
29:09
sexual dysfunction in both men and women.
29:14
And for people with diabetes, they actually improve diabetes
29:19
control. And if you want an extra 1, we
29:23
could well prevent cancers as well.
29:25
Amazing, amazing. So, well, I hope this has got
29:29
people thinking and thinking about Viagra and Viagra like
29:34
medications, so phosphodiesterase inhibitors in
29:37
a different way. So I'm very grateful for your
29:40
time and thank you so much. It's a pleasure.
29:43
Thank you for asking me. You can find out more about
29:50
Newson Health Group by visiting www.newsonhealth.co.uk and you
29:57
can download the free Balance app on the App Store or Google
30:01
Play.