Sexual Dysfunction in Patients with Hypertension: Implications for Therapy

Carlos M. Ferrario, MD, Pavel Levy, MD

Disclosures
In This Article

Abstract and Introduction

Sexual dysfunction associated with hypertension or antihypertensive therapies may impact the ability of patients to stay on therapy and lead to deterioration in patients' quality of life. Therefore, it is important for practitioners to become familiar with the wide variation in sexual side effects produced by antihypertensive agents and to discuss the potential occurrence of these side effects with their patients. In many cases, a change in the patient's drug regimen may help patients overcome specific sexual side effects experienced with certain treatments. Practitioners should consider selecting an antihypertensive therapy that is highly effective in lowering blood pressure but preserves patients' quality of life. The effect of medications on sexual function remains controversial. Some blinded trials report little difference between placebo and specific medications, whereas other studies indicate that antihypertensive medications increase sexual dysfunction, which has an impact on quality of life. Recent evidence suggests that losartan, an angiotensin II antagonist, is not typically associated with development of sexual dysfunction and may actually positively impact several indices of sexual function (erectile function, sexual satisfaction, and frequency of sexual activity) as well as perceived quality of life. Thus, angiotensin II antagonists may offer a therapeutic option to prevent or correct erectile dysfunction in patients with hypertension. The favorable effects of these agents on sexual function may be related, in part, to their ability to block angiotensin II, which has recently become recognized as an important mediator of detumescence and possibly erectile dysfunction.

Despite the well known benefits of effective long-term antihypertensive drug therapy in reducing cardiovascular risk, almost three quarters of US adults with hypertension fail to achieve adequate blood pressure control.[1] This statistic is, in part, attributable to the rate of discontinuation of antihypertensive medications due to the occurrence of troublesome side effects. Appearance of treatment-related side effects may actually make patients feel worse than they did before beginning antihypertensive therapy, particularly since most patients with hypertension are asymptomatic.[2] As many as 70% of hypertensive patients who experience side effects are noncompliant with their antihypertensive medication, and patients experiencing a negative impact on their quality of life have a 40%-60% higher rate of therapy discontinuation than patients whose quality of life is unaffected.[3,4] On the other hand, blood pressure control may be associated with quality of life improvement (patients feeling better). The inability of patients to stay on therapy in the long term may be one of the factors contributing to the development of hypertension-related complications and higher overall health care expenditures.[5]

Sexual dysfunction induced by antihypertensive medications is one of the poorly recognized side effects impacting the patient's ability to stay on therapy. Moreover, this side effect of antihypertensive medications is strongly associated with an impaired quality of life.[6,7,8] Many commonly prescribed antihypertensive medications may give rise to sexual dysfunction, which often presents in men as a decrease in libido, difficulty attaining or maintaining an erection, and ejaculation problems, and, in women, as a delay in orgasm.[9,10] Not all classes of antihypertensive agents share the same risk of inducing sexual problems; certain types of antihypertensive medications are generally associated with a lower risk of sexual dysfunction than others.[6] In fact, recent studies suggest that angiotensin II antagonists (AIIAs) may actually improve erectile function and sexual activity in male hypertensive patients.[11,12] The favorable effects of AIIAs on sexual function may be related to their ability to block angiotensin II (ANG II), which has been shown to terminate spontaneous erections when administered exogenously in an experimental model of penile function.[13]

In view of these observations, it is important for practitioners to be aware of the sexual side effects produced by antihypertensive agents so that the selected therapy may provide an optimum balance between antihypertensive efficacy and quality of life.[6,12] In the present review, we will 1) discuss the frequency of sexual dysfunction in hypertensive men and women; 2) summarize the spectrum of sexual problems associated with various classes of antihypertensive therapies; 3) assess the impact of sexual dysfunction on quality of life and the patients' ability to stay on therapy; 4) explore the emerging role of ANG II as an important factor in sexual dysfunction; and, finally, 5) describe the potential clinical benefits of AIIAs in treating patients with hypertension and sexual dysfunction.

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