Sexual Dysfunction in Patients with Hypertension: Implications for Therapy

Carlos M. Ferrario, MD, Pavel Levy, MD

In This Article

Types of Antihypertensive Therapy Associated with Sexual Dysfunction

Several widely prescribed antihypertensive agents, including diuretics, methyldopa, clonidine, guanethidine, and blockers (especially those that are nonselective), are known to cause sexual problems or exacerbate existing problems ( Table II and Table III ).[6,29,30] However, not all classes of antihypertensive agents share the same risk of inducing sexual problems, and certain classes of antihypertensive agents tend to be associated with a higher prevalence of sexual dysfunction than others.[6,12] As summarized in Table II , differences among the various classes of antihypertensive agents have been noted in men with respect to erectile dysfunction, decreased libido, impaired ejaculation, gynecomastia, and priapism. Conclusions regarding an association between antihypertensive therapy and sexual dysfunction are limited by the fact that several of the studies denoted in Table III were poorly controlled and results were based on questionnaires. This is one of the factors responsible for the lack of recognition of sexual dysfunction as a component of the hypertensive process rather than as a consequence of antihypertensive medications.

Compared with placebo or other classes of antihypertensive agents, a higher prevalence of male sexual dysfunction has been reported in some studies of diuretics, including spironolactone, which inhibits dihydrotestosterone binding, and thiazide diuretics (e.g., chlorthalidone), as well as blockers ( Table III ).[9,12,19,22,31,32,33] Beta blockers (e.g., atenolol and propranolol) may potentially impact sexual functioning through a variety of mechanisms, including a reduction in central sympathetic outflow, impairment of vasodilation of the corpora cavernosa, effects on luteinizing hormone and testosterone secretion, and a tendency to produce sedation or depression, thereby causing a loss of libido.[12,31] However, as noted, deleterious effects of diuretics and blockers on sexual function have not been consistently found, and several controlled studies, including TOMHS and a combined analysis of six randomized, blinded, prospective trials, have found little or no evidence for a greater risk of occurrence of adverse sexual sequelae between these agents and other antihypertensive medications.[23,34,35] Variations in the design of the studies, the inclusion of a placebo control arm, and the characteristic of the population under investigation are factors adding to the difficulties in recognizing the nature of the mechanisms that associate sexual dysfunction with hypertension and its medications.

Centrally acting antiadrenergic agents, such as methyldopa and clonidine, also give rise to male sexual dysfunction, possibly by decreasing sympathetic outflow as well as diminishing libido and ejaculation. Direct vasodilators, including hydralazine and minoxidil, may produce erectile dysfunction and priapism, but this appears to be uncommon.[36] There is little evidence to suggest that calcium channel blockers (CCBs) result in erectile dysfunction, although impotence associated with verapamil has been described,[37] and in our study, CCBs were second to angiotensin-converting enzyme (ACE) inhibitors in their association with erectile dysfunction.[11] Moreover, gynecomastia and problems with ejaculation have been reported with CCB therapy.[31,38]