Medicines and Your Performance In the Bedroom

There are hundreds of medicines, some commonly used drugs, that can affect a man’s sex life and sexual performance.  Many of these drugs are necessary for treatment of depression and hypertension and shouldn’t be stopped.  This blog will discuss the causes of medications and deterioration of sex drive and sexual performance.

How can medicines affect sexual function?

The mechanism of sexual function involves a complex coordination of hormones, chemical messengers in the brain (neurotransmitters such as dopamine and serotonin) and the sexual organs. In general:

• dopamine increases sexual function
• serotonin inhibits sexual function
• the hormone testosterone is important, as are the blood vessels supplying the penis are also involved in producing an erection.

A medicine can therefore affect sexual function in several ways.

Libido or sex drive

Sex drive is influenced by reproductive hormones, particularly testosterone, which is required for sexual arousal.

Medicines that reduce the testosterone level or block its effects are likely to reduce sex drive.

Libido is also affected by your general emotional and physical health. Medicines that affect any of these aspects, even indirectly by causing drowsiness, lethargy, weight gain or confusion, have the potential to reduce your sex drive.

An erection is the result of coordination between nerves, hormones, blood vessels and psychological factors. This means there are many areas where things can go wrong.

Medicines that have a physical effect on the blood vessels in the penis, those drugs that act on the brain or interfere with hormone levels (particularly testosterone) or affect the transmission of nerve messages, can all cause impotence.

Ejaculation is a complex reflex process that involves the activation of alpha receptors in the prostate gland and seminal vesicles.

Medicines that block alpha-receptors can interfere with ejaculation.

During ejaculation, increased alpha-receptor activation closes the bladder neck, facilitating the normal flow of semen out of the penis.

If this mechanism is disrupted, it results in retrograde ejaculation, with semen flowing along the path of least resistance from the urethra up into the bladder.

Various chemicals in the brain are also involved in orgasm and ejaculation, and medicines that affect these chemicals can also cause ejaculatory disturbances.

The most widely prescribed centrally acting agents that affect ejaculation are selective serotonin re-uptake inhibitor (SSRI) antidepressants.

Antidepressants are the medicines most frequently implicated in causing sexual dysfunction. This is because they work by altering levels of chemicals in the brain. In particular, SSRIs increase serotonin levels, which inhibits sexual function.

Blood pressure lowering (antihypertensive) medicines are also implicated, although the mechanism by which they cause sexual problems will vary from medicine to medicine.

The table of medicines below lists the sexual side effects that some people have reported during their use.

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Antidepressants	Main use	Possible effect on sexual function
MAOI antidepressants (eg moclobemide, phenelzine)	Depression	Decreased sex drive, impotence, delayed orgasm, ejaculatory disturbances
SSRI antidepressants (eg fluoxetine)	Depression	Decreased sex drive, impotence, delayed or absent orgasm, ejaculatory disturbances
Tricyclic antidepressants (eg amitryptiline)	Depression	Decreased sex drive, impotence, delayed or absent orgasm, ejaculatory disturbances
Antiepileptics	Main use	Possible effect on sexual function
Carbamazepine	Epilepsy	Impotence
Antihypertensives	Main use	Possible effect on sexual function
ACE inhibitors (eg enalapril, lisinopril)	High blood pressure, heart failure	Impotence
Alpha-blockers (eg prazosin, doxazosin)	High blood pressure, enlarged prostate	Impotence, ejaculatory disturbances
Beta-blockers (eg atenolol, propranolol and including timolol eye drops)	High blood pressure, angina, glaucoma	Impotence
Calcium channel blockers (eg verapamil, nifedipine)	High blood pressure, angina	Impotence
Clonidine	High blood pressure	Impotence, decreased sex drive, delayed or failure of ejaculation
Methyldopa	High blood pressure	Impotence, decreased sex drive, ejaculatory failure
Thiazide diuretics (eg bendroflumethiazide)	High blood pressure	Impotence
Antipsychotics	Main use	Possible effect on sexual function
Phenothiazines (eg chlorpromazine, thioridazine)	Psychotic illness	Ejaculatory disturbances, decreased sex drive, impotence
Risperidone	Psychotic illness	Impotence, ejaculatory disturbances
Cholesterol lowering medicines	Main use	Possible effect on sexual function
Fibrates (eg clofibrate, gemfibrozil)	High cholesterol	Impotence
Statins (eg simvastatin)	High cholesterol	Impotence
Other	Main use	Possible effect on sexual function
Benzodiazepines	Anxiety and insomnia	Decreased sex drive
Cimetidine	Peptic ulcers, acid reflux disease	Decreased sex drive, impotence
Cyproterone acetate	Prostate cancer	Decreased libido, impotence, reduced volume of ejaculation
Disulfiram	Alcohol withdrawal	Decreased sex drive
Finasteride	Enlarged prostate	Impotence, decreased sex drive, ejaculation disorders, reduced volume of ejaculation
Metoclopramide	Nausea and vomiting	Decreased sex drive, impotence
Omeprazole	Peptic ulcers, acid reflux disease	Impotence
Opioid painkillers (eg morphine)	Severe pain	Decreased sex drive, impotence
Prochlorperazine	Nausea and vomiting	Impotence
Propantheline	Gut spasm	Impotence
Spironolactone	Heart failure, fluid retention	Impotence, decreased sex drive

Bottom Line: This blog makes the connection between medications and sexual performance.  The next blog will discuss how to

approach your physician and what options are available for men who have sexual side effects from medications.

Don’t Let Your Medicines Make You Sick

Most middle aged Americans are taking 2-5 medications. These medications if not used properly, can add to your illness rather than improve your health. It is estimated that 1.5 million Americans are sickened, injured or killed each year as a result of errors in prescribing, dispensing and taking medications. Here are a few tips that you might consider regarding your medications that will lead to be better health.

Start by storing your medicines properly. Your bathroom is hot and humid and may cause your medications to deteriorate or loose their potency. It is best to store your medications in the kitchen or nightstand in the bedroom.

Inaccurate dosing. If the medications is a liquid and you are advised to take a teaspoon of medication and use a teaspoon from the kitchen drawer, the volume may vary from 2.5 ml to 7.3 ml. Therefore, it is advised that you use an accurate medication spoon which is available at every pharmacy.

Skip rope not doses. Take your medications as prescribed by your doctor and don’t skip doses or discontinue the medication as soon as your symptoms subside. This is particularly true for antibiotics and patients who have infections and stop their medications as soon as the symptoms are gone may find that they develop a worse infection because the bacteria develop resistance.

Storing your medications in one bottle is to be avoided. If you are like most Americans and have multiple medications, you can get confused if they are all in one container and take the wrong medication at the wrong time of day. I suggest that you keep the prescriptions in their original bottles with the labels placed on the bottles by the pharmacist.

Shop until you drop may happen if you are getting your medications from multiple sources. Instead of picking up medications at the neighborhood pharmacy and then filling another prescription at a pharmacy near work, may result in receiving medications that may interact and not have the desired effect or have the potential for side effects, I suggest that you obtain your medications from a single pharmacist who will have a log of your medications and will caution you about conflicting medications.

Final suggestion: Keep a record of your medical encounters and carry them in a folder to each doctor you see. This avoids duplicating tests, having drugs prescribed that cause an allergic reaction or a medication interaction. Also, carry this folder with you when you travel in case you need to see a doctor out of town or go to an emergency room that doesn’t have access to your medical records.

Bottom Line: Medications do make us better if used properly and taken as prescribed by our doctors. Be prudent about your medications and you will get well!

This blog was inspired and excerpted from an article, Avoid Common Medication Mistakes, by Jodi Helmer and appeared in June 2013 Costco Connection.

How Often Do You Need To See Me?

You may wonder how the decision is made to making the next appointment for a patient. Is there a book, or now a website with guidelines, that guide physicians on when to make the patients’ next appointments? No, there is not. It is not something we learn in medical school but is something that is part of the art of medicine. Some patients really need to be seen in a few days or a few weeks such as the patient with a urinary tract infection where the urine has to be checked to be sure the infection has cleared even after the symptoms have subsided. Then there is the asymptomatic patient who is on no medications and probably needs to be seen only for a screening annual or even a biannual exam. Then there is the majority that fall somewhere in the middle of those two extremes.

What if you had diabetes, coronary disease, hypertension, high cholesterol, and sleep apnea, but no symptoms to indicate any acute problems? You’d probably see your primary doctor fairly routinely (mostly for management of diabetes) and maybe your cardiologist every six months or so.

Here’s the big question: When you’re coasting along pretty well with no actively changing symptoms but with chronic medical problems, how often do you need to see your doctors? Let’s take the example above: with those particular problems, should you see your cardiologist yearly, biannually, quarterly, monthly, or what? In the non-hypothetical world a patient’s follow-up is likely to be dictated by the doctor and set at the end of each appointment. “Okay, Mrs. X, it looks like you’re doing well. Let’s plan to see you again in 6 months.”

How does the doctor know when to see you next? There are a few ground rules to take into consideration. The pharmaceutical industry doesn’t allow us to write prescriptions with refills that extend past 12 months, and many clinics have a policy of not providing new prescriptions after the 12-month mark unless they’ve at least laid eyes on the patient (apparently to make sure the patient is indeed alive), and so most people with chronic problems will likely have to be seen at least once a year. It is amazing how many men using erectile dysfunction drugs will keep that annual appointment in order to obtain a refill of their medications! The other ground rule is common sense.

So, routine follow-up will most likely fall somewhere between “less often than weekly” and “at least once yearly or more frequently.” But within those limits, as a doctor I’m pretty much free to choose whatever I like.

I don’t know how other doctors do it, but I like to burden healthy patients with as few doctor visits as possible, so I mostly try to set my return appointments for a year. This works well for most people, but there are clearly exceptions. I see a lot of men with prostate cancer. Many of them are on medications to decrease the testosterone level and receive injections every 3-6 months. If it is possible, I try to convert these men to injections that can be given once a year. Most of the men with prostate cancer like the idea of getting a yearly injection and coming in every six months for a blood test, a PSA level. However, there are some men that want that more often and I allow them to make appointments to be seen more frequently. This, again, is where the art of medicine is used to guide how often a patient returns for an appointment.

There are patients with certain conditions like bladder cancer that should have a cystoscopy or look into their bladder with a lighted tube every 3 months. This guideline is written in all urologic textbooks and is good medicine to see these patients on a frequent basis.

I commonly ask certain patients to see me more frequently. Any patient who is on medications that is having side effects is asked to come back more frequently until I can get the dosage or the medication straightened out that provides them with the beneficial effect and with manageable side effects.

Bottom Line: How often should you be seeing your doctor? I have no clue. Between you and your doctor you’ll come up with some type of balance that works. Just understand that none of this is written in stone….i.e., a kidney stone!

This blog was inspired and modified from a blog by Dr. Eric Van de Graaf, which appeared in Patient on January 17, 2011.

When Medicines Make You Sick

Most middle age and older men and women take more than one medication on a regular basis. Unfortunately these medications can interact with each other and produce undesired effects; sometimes the side effects are worse than the disease or condition that the original medication was intended to treat. It is estimated that 4.5 million Americans will return to the doctor’s office or even have to go to the emergency room because of the side effects of medication. There are an estimated 2 million serious drug reactions each year and drug reactions are the fourth leading cause of hospital deaths exceeding only by heart disease, cancer and stroke.

Side effects can produce symptoms ranging from lethargy, insomnia, muscle aches, depression, dizziness, diarrhea, constipation, and even chest paid.

So what can you do to avoid side effects of medications? First be sure your doctor knows what medications you are currently taking. Ask if the drug he is prescribing has any interactions with the drugs you are currently taking. There are computer programs that are available that will alert the doctor of any possible drug interactions. One of the most popular programs is e-Pocrates where the doctor or nurse can write in the drug being prescribed and the drug(s) the patient is currently taking and will list any potential drug interactions. Most electronic medical record programs that are becoming so prevalent among physicians’ practices will notify the doctor of any potential drug interactions.
Also, you can go to the Internet and use one of the search engines such as Google and type in the name of the medication and the phrase “drug interactions” and you will learn what drugs should not be taken together. There are drug interaction checkers available online. One of the best is aarp.org/healthtools.

Next, ask the doctor what are the most common side effects and what is the likelihood of having any of the side effects. If the medical problem is not serious and not incapacitating, you may decide to forgo any new medications.

Also, ask your doctor if there are any lifestyle changes you can make as an alternative to taking medications. For example, if you have newly diagnosed high blood pressure, you can undergo a weight loss program and significantly reduce the salt in your diet, and you may avoid taking blood pressure lowering medications, which have side effects.

If you are taking multiple medications, you can ask your pharmacist to review all of your medications and the pharmacist will let you know which drugs are incompatible. Some pharmacists will charge you a few for this review but it is certainly worth it especially if you are older and if you take multiple medications. Also, if you are in a Medicare Advantage program, you may qualify for its medications therapy management services.

If you begin to experience a change or symptoms shortly after starting a new medication, you should contact the doctor’s office and speak to the doctor or nurse to find out if this is an expected side effect, how long it might last, or if the side effect is more serious and the drug should be discontinued.

It is also important to mention to your doctor any supplements, herbal medications, or vitamins that you routinely take as these may interact with your prescribed medications.

Final advice: Even if you are experiencing side effects due to medications, don’t stop taking the medication without calling your doctor first.

Bottom Line: For the most part drugs properly prescribed can be very helpful and will alleviate symptoms and treat your medical condition. However, all medications have side effects and you can minimize these side effects by being knowledgeable and informed about drugs and drug side effects.