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

Episode Date: February 18, 2025

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.

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-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. and always inspirational personal stories. This podcast is brought to you by the Newsome 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 realizes actually, for a 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 a 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 honored to have him here in the podcast. So welcome Mike today. I'm delighted to be here, Louise. We're a great fan of yours. So I would never say no to you. Oh, very good. I've got that on record now. 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? 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 levels just on the basis of a history and it was being prescribed for bodybuilding that

really got a very bad reputation. So we tried to overcome that by producing a 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 lifestyle. 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, For example, men with type 2 diabetes, about 40% of them, if you'd look, will have a low testosterone. That's a lot, isn't it? 40%. That's a lot.

Because I remember years ago when I was quite a newly qualified GP, we were asking men with type 2 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 probably 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. 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 on a thousand men, some will be six, some will be 30, but 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 8 and 12, it needs to be repeated. Probably those people might benefit from replacement.

if it's less than eight, then 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 estrogen 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. It's similar between men and women that, you know, we do need to get together and sing from the same hymn sheet. It's exactly the same. I mean, we see lots of women, obviously, with estrogen, progesterone and testosterone deficiency and I also think about how many men are estrogen and pedestrian 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 bodybuilder. They don't see it as a treatment that helps reduce risk of diseases. And, you know, like you might, 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? No, it really is. And I suppose because we're living longer, it's exaggerated. So for women, you know, from mid-40s to 80 or 90, 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 well-being. really because having low testosterone level and having a low estrogen level really affects well-being and 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 randomized controlled trial which is showing that testosterone replacement is perfectly safe from the heart and from the prostate. And those were two barriers that people are who are 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 being more prostate. 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? 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. 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 phosphodiasterase inhibitors.

So a lot of people will have heard, and 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. drug for erectile dysfunction. A lot of people don't realize 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 phosphoryosterone's 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. I don't think this blog is low enough to talk about all the things. It's a PD5 inhibitors because they are tremendous. It was interesting because with my cardiological hat on,

I got very interested in this trial 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 the back and in all other studies, men always gave the pills back so they could count see what's 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, often 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 drug, as did Lily with Tadalufiel, as did Bayer with Levita. So we had three companies all doing research studies on erection problems, all showing very positive, very

effective drug, securing ereation 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 to 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 people, taking PD5 inhibitors compared to people who don't. And we published a study where we looked at a very big general practice database of the men who had diabetes.

And we looked at those men in that practice having PD5 inhibitors compared them with the same age group of men not taking PD5 inhibitors. And it was about a 30% reduction in cardiovascular death in the men taking them. Quite staggering. That is a lot. 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 told anybody about it. and they've 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 artery 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 swelieu, where they did the same thing with men with heart disease.

Those men with heart disease taking a PD5 inhibitor 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 PD5 inhibitor. Wow. So three years, I mean, that's better than statins and blood pressure-lowering drugs, isn't it? Yes, better.

Much much much better. And interestingly enough, the more of PD5 inhibits the better the protection. So if you take it once every couple of weeks compared with taking it every day, then you didn't do so well. So you're best off taking every day? Yes, best to take it regularly.

Because it is a cardiovascular drug, actually the end of the day, because it improves the lining of the blood vessels, called the endothelium. Yes. The vascular endothelium. So ED equals ED. Direction dysfunction equals endothelial dysfunction.

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 burying of the arteries, if you like, but you get this buildup 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. So that's often why people get eye changes before they have blood pressure changes, for example. So that's why ophthalmologists or the optician spent a long time looking at the back of our eyes, because it's a window into our heart system as well. And actually the phosphory diastroids inhibitors will help with something called nitric oxide as well, won't they? 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? Yes, it's very good for blood pressure.

I mean, there's a very large metronanasis where they showed that PD5 inhibitors were protective on cardiovascular health, but also they had beneficial effects on bones, the urogenital tract, the brain. It had benefits on the metabolic profile of the patients take it and cardiovascular. It's massive, is it? These drugs actually have widespread implications. The problem is that in the early days, a lot of the studies were pre-clinical. 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.

But we do that's a lot in medicine, don't we? We prescribe a lot of, you know, my daughter has, as you know, chronic migraine, and she's been given anti-epileptic drug. She's been given different antidepressants for her migraines. Well, you do it a lot in medicine. Yes. But it's still people often don't realize, but sorry, carry on. Well, I think for women, you see, women have used for ibupil since 2009

because they get treated for pulmonary hypertension. They use a very high dose in pulmonary hypertension, 40 milligrams. 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's a study using it in lower unit 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 program, both men and women, if they were taking a PD5 inhibitor,

they did better. So I think, you know, for women, I think particularly for sexual function, there's two large randomized control trials showing that women using PD5 inhibitors get benefit with increased arousal, increased ability to orgasm, and I think probably most importantly, more enjoyment to have 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 emissory veins, so the blood can't get out.

But for women in the clitoris, they don't have that mechanism. It's a constant influx 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 clitorial vessels, you improve the perfusion of the clitoris and makes sex much more fun. Which is not a bad thing. And it's something we were talking before, started recording about how few doctors, 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 better to 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 2000 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 2 diabetes, used to be put on an aspirin as well. And then we realized there were bleeding effects,

there were side effects of aspirin. So it's not done as much. But I often think of everyday osphroidiris inhibitor like Taldanophil as a new aspirin really without the risks. Is that a fair way to think about it, Mike? Or am I being a bit overzealous, do you think? Well, aspirin works by stopping the plate that's being so sticky, whereas, you know,

it's down a world works by making the blood vessels more healthy. But I'm thinking about just not the mechanism, but they're just reducing risk of disease. Certainly in women, there was an Italian study where they used it in ladies with type 2 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 Well, if 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 PD5 inhibits work by making the endothelium more healthy and reducing the inflammation.

So I think there's lots of data now in prevention of dementia. How important is that? Jeff and I are just trying to get a randomized control trial to Dallafel 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 a PD5 inhibitors reduces your risk of dementia. That's a bit of an added bonus, isn't it? Less heart disease, less serious, less dementia, better diabetes control, less renalose disease, and actually there's good evidence for reduction in colon cancer as well,

because PD5 inhibitors are anti-prolifitive. So it begs the question, doesn't it? Why are more people not taking them for these reasons? Because anything we can do to reduce risk of diseases will help that individual, but also when you're talking about population health and drain on, NHS resources but healthcare systems in any country, we've got to be thinking about keeping people healthy. These drugs are actually quite cheap. They're very low risk. So why are we not prescribing the MoMAI? Because they're off licence for all those indications and 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. You've got very much associated. with sexual problems. I was reading at the weekend, you probably know this, but one of the ways they wanted to market it when they realized it had this rectal dysfunction benefit was they got a 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, 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. It's harder to monitor, of course, but people still think, of course it can be taken for when people want sex,

but this is taken as a lower dose often about every single day. And that's the shift that I think people haven't realized that it can be taken every day. It doesn't usually interfere with medication for most. people don't have contraindications that can be used. And I do think about all the other medications that are prescribed like the anti-hypertensives like statins that don't necessarily have the same long-term benefits that you're describing in very good studies. I think so. I think the fact it's over-the-counter is 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 their GP will be embarrassed.

and see they'd rather be independent and just talk to a pharmacist in a private room. So Vycra is over the counter, Tadalafil is over the counter, that's a dose of 10 milligrams. Vikra is 25 or 50. And I think I flew to Australia for two days to advise the Australian government

about having Vyker over the counter about 15 years ago. It didn't become available in Australia, actually. But it's been available across Europe over the count of a while now, 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 that the wife was saying, well, I think he doesn't love me anymore.

I'm not attractive anymore because things are 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. There are very few men that 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 improves 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. 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 Tildanafel or Saldanafel, you know,

one of the phosphodiasetriis 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.

No, you're right. We need to keep talking about it and waving the flag and showing all the data on safety and efficacy. I mean, for men with lower urinary tract symptoms, they often get prescribed venesteride to shrink the prostate, and that has awful sexual side effects. Absolutely.

They get prescribed alpha blockers, which make them dizzy, and actually to take Delia to Dalafel has virtually no side effects and she most of those men also have erection problems and you're giving them cardiovascular benefit for the same time so it's quids in re-dict but I think we have a problem getting DEPs to prescribe it for men but you have a huge problem getting DEP to prescribe it for women and you're absolutely right looking at the lower unary tract symptoms in women as well a lot of women

are given oxybutinin, 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 listening to this podcast, whether they're male or female,

Should know more about phosphodustrade's inhibitors. Okay, well, they're cheap and safe. They reduce the risk of cardiovascular disease. They are probably one of the most effective treatments of 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. Amazing.

Amazing. So, well, I hope this has got people thinking and thinking about Viagra and Viagra-like medication, so phosphodiaspherase inhibitors in a different way. So I'm very grateful for your time and thank you so much. It's a pleasure. Thank you for asking me. You can find out more about Newsome Health Group by visiting www.com.com. Health.co.uk.

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