Should Viagra Be Available for Women?

An analysis of Viagra's use in female sexual interest/arousal disorder

Viagra.jpg
Getty Images

Ever since its popularization in the early aughts, female sexual dysfunction (FSD) has been a firebrand issue, with drug companies and certain medical professionals (think the Berman sisters) heralding and monetizing its cause. All this interest makes sense; way back in 2005, the market for FSD products was estimated at $1.7 billion.  

To date, there has been no pill approved by the FDA for the treatment of FSD.

But, believe me, no FDA approval is not for a lack of trying. First, Pfizer tried to prove that its juggernaut drug Viagra could help with FSD. Second, in 2004, P&G tried to sell the FDA on its testosterone patch, Intrinsa. The timing couldn't be worse. Fresh from the blow of Vioxx, a more circumspect FDA cited concerns about Intrinsa's clinical meaningfulness and safety. Most recently--and to no avail--Sprout Pharmaceuticals attempted to get its neurotransmitter-acting drug, flibanserin, approved.      

In an attempt to give a complete review of proposed treatments for FSD, I've needed to examine three interventions aimed at this condition in 3 separate articles.  This article examines Viagra's use by women, a second article examines the testosterone patch, and a third article examines flibanserin. Of note, despite P&G discontinuing its trials on Viagra in women in 2004, and the FDA shutting down Intrinsa that same year, some physicians still prescribe Viagra off-label and testosterone treatments to women with FSD.

Flibanserin, however, has yet to be approved.

How Does Viagra Work?

Viagra is a phosphodiesterase type 5 (PDE5) inhibitor.which enhances the production of guanosine monophosphate. Guanosine monophosphate relaxes smooth muscle cells and vasodilates and increases blood flow to the genitals. As we all know, in men, Viagra's effect is an erection.

 

However, PDE5 is also expressed in smooth muscle of the vagina, clitoris, and labia resulting in vaginal engorgement and clitoris erection. It's believed that in women with an organic cause of FSD, blood flow to the genitals is diminished.  On a related note, research shows that in some women with atherosclerosis, blood flow to the genitals is diminished.

Like all medications, Viagra has adverse effects including a headache, flushing, nausea, visual disturbance and so forth.  Furthermore, people taking nitrates for the treatment of angina should avoid Viagra for fear of hypotension or dangerously low blood pressure.

Female Sexual Dysfunction (FSD) Definitions

Currently, any female use of Viagra involves women with a specific type of FSD called female sexual interest/arousal disorder. This terminology is relatively new and introduced in the DSM-5. Female sexual interest/arousal disorder can be defined as the following:

  • Distressing lack of (or much reduced) sexual interest and arousal sensations involving sexual fantasy. sexual thoughts, interest in sex, physiological arousal, sex initiation and so forth;  
  • Lasting six or more months;
  • Not better explained by other diseases or conditions;
  • Either lifelong or acquired;
  • Either generalized or situational;
  • Of mild, moderate or severe severity.

As is sometimes the case with an emerging field of research, earlier discrepancies in definitions of sexual conditions obfuscated research results. Specifically, earlier studies involving female sex drugs went with earlier terminology which split problems with arousal and problems with desire into two different groups: female sexual arousal disorder and hypoactive sexual desire disorder respectively. 

On a related note, other types of FSD include female orgasmic disorder, genito-pelvic pain/penetration disorder, and substance/medication-induced sexual dysfunction.  (Evidently, the DSM loves slashes.)

Research on Viagra in Women

The most prominent study that suggests Viagra may benefit women with FSD was done by Dr. Jennifer Berman, a sex and relationship therapist, and Dr. Laura Berman,a sexual health expert and urologist, while they were still in academia. Results from their findings suggest that Viagra may improve sexual function in women with arousal problems but not women with desire issues. Moreover, results of this study were burdened by the heavy placebo effect.  

It should be noted that the Berman sisters definitely have their critics including Dr. Heather Hartley, a "public" and medical sociologist and women's health advocate who famously challenged the medicalization of sex. Sadly, Hartley died at age 39. (Hartley's was a life cut short.)

In a 2006 article titled "The 'Pinking' of Viagra," Hartley heavily criticizes the Berman sisters. She criticizes the sisters as "adept at using media to promote their own industry." Hartley also criticizes the Bermans' marked preference for medicine over therapy. Moreover, she claimed that the Berman sisters' "continued insistence on prescribing Viagra and other 'male' sex drugs off-label for women illustrates the departure from a science-based practice and the embrace of a retail Viagra culture."

Interestingly, Hartley also paints a picture of the Berman sisters as opportunists charging exorbitant prices at their highly commercial practices. Hartley claims that the Bermans' success is fueled by a combined media persipacity intent on cultivating "a sense of intimacy with their viewing public, as evidenced, for example, by the link on their web site to a 'medically explicit' video of Jennifer's elective cesarean birth, complete with her personal descriptions of her recovery process."

In recent years, the Berman sisters have enjoyed a ubiquitous media presence. Currently, Jennifer Berman is one of The Doctors, and Laura Berman is tight with Oprah and  Dr. Oz.

With the notable exception of the Berman study, other studies have shown Viagra to be ineffective in the treatment of arousal and desire issues. For example, one randomized-control trial performed by Basson and colleagues showed that Viagra caused no significant changes in physical response during sexual activity in both premenopausal and postmenopausal women. Another study showed that because of a lower concentration of PDE5 in the vagina and clitoris as compared with the penis, the effect of Viagra is markedly reduced in women.

If you or a loved one suffer from female sexual interest/arousal disorder as defined by the DSM-5, you may be wondering whether to take Viagra. With respect to this concern, I present you with the conclusion of a 2014 commentary by Lo Monte and colleagues from the journal Drug Design, Development and Therapy:

FSAD [female sexual interest/arousal disorder] is a complex disease, whose underlying cause is difficult to diagnose.  Preliminary evaluation of the sexual, psychological, and medical history is mandatory to exclude possible systemic diseases and to identify the type of FSAD.  Generalists should pursue a global approach to the patient with sexual difficulties, while non-hormonal treatment such as PDE5 inhibitors (eg, sildenafil citrate) [Viagra] should be kept as a last option.

In other words, you may want to consider Viagra only as a last-line treatment after a thorough and multifactorial review of your female sexual interest/arousal disorder by a primary care physician [or specialist].

Sources

Article titled "Safety and Efficacy of Sildenafil Citrate for the Treatment of Female Sexual Arousal Disorder: A Double-Blind, Placebo-Controlled Study" JR Berman, LA Berman at co-authors published in The Journal of Urology in 2003.  Accessed on 3/15/2015.

Article titled "The Pinking of Viagra Culture: Drug Industry Efforts to Create and Repackage Sex Drugs for Women" by Heather Hartley published in Sexualities in 2006.  Accessed on 3/15/2015.

Article titled "women taking the 'blue pill' (sildenafil citrate): such a big deal?" published in Drug Design, Development and Therapy in 2014.  Accessed on 3/15/2015.

Continue Reading