About 25% of all erectile dysfunction (ED) cases are linked to medications. Of the 12 most commonly prescribed drugs in the US, eight list ED as a potential side effect.

Leslie SW, Sooriyamoorthy T. Erectile Dysfunction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; January 9, 2024.

One such group of drugs is antihypertensives.

 

 

The burden of sexual dysfunction 

 

A review from Vascular Health and Risk Management notes that ED is twice as prevalent in hypertensive men as in those with normal blood pressure, affecting 30%–60% of them.

Lou IX, Chen J, Ali K, et al. Relationship between hypertension, antihypertensive drugs and sexual dysfunction in men and women: a literature review. Vasc Health Risk Manag. 2023;19:691–705.

 

 

On the other hand, female sexual dysfunction (FSD), affecting 20%–50% of women, is understudied and lacks effective treatments. Hypertension can impair clitoral and vaginal blood flow, leading to vasculogenic FSD.

Kumar N, Khan SI, Versha FNU, et al. Comparison of effect of nebivolol and bisoprolol on sexual function of hypertensive female patients. Cureus. 2021;13(5):e15062.

 

 

This issue extends beyond the physical symptoms, affecting treatment adherence and, by extension, the patients’ cardiovascular health. The culprit drugs include beta-blockers, thiazide diuretics, and loop diuretics.

 

Management with beta-blockers

 

Beta-blockers are essential for managing hypertension and reducing mortality post-myocardial infarction, but their influence on sexual health—especially with older nonselective beta-blockers like propranolol and beta-1 selective blockers—cannot be overlooked.

For instance, a study from Frontiers in Cardiovascular Medicine found that beta-blockers significantly impact ED, especially in patients with early-onset coronary artery disease (EOCAD).

Dai Y, Mei Z, Zhang S, et al. Sexual dysfunction and the impact of beta-blockers in young males with coronary artery disease. Front Cardiovasc Med. 2021;8:708200.

The study reported the following:

 

• 57.8% of EOCAD patients on beta-blockers experienced ED vs 31.1% of controls.

• Post-coronary revascularization, ED scores improved in patients not on beta-blockers but remained unchanged in those on them.

Similar effects are observed in females, report authors of a review in Medicina:

Zhong Q, Anderson Y. Management of hypertension with female sexual dysfunction. Medicina (Kaunas). 2022;58(5):637.

 

• Research shows that 69.2% of women on beta-blockers experience sexual dysfunction, significantly higher than the 42.7% of those not on these medications.

• In a study of postmenopausal hypertensive women, atenolol decreased libido, whereas valsartan increased it. 

• In another report, felodipine-metoprolol was associated with lower sexual function scores, while felodipine-irbesartan showed improvements.

 

Furthermore, the sedative effects of this group of drugs reduce libido.

 

Diuretics

 

The Current Heart Failure Reports authors also discussed how diuretics like thiazides, spironolactone, and loop diuretics disrupt sexual function. These drugs can induce hypovolemia, cause electrolyte imbalances, and activate the renin-angiotensin-aldosterone system. By lowering testosterone production and elevating prolactin levels, these drugs can affect hormonal regulation of sexual function. 

 

However, the impact on women remains unclear. The Medicina authors stated that studies have failed to establish a link between diuretics and FSD.

 

The Hawthorne effect

 

There is another interesting aspect of this relationship that may be more psychological than physiological. A 2023 report attributes many cases of ED related to treatment with beta-blockers to the Hawthorne effect, suggesting that the mere anticipation of this side effect from beta-blocker therapy could psychologically induce ED.

Zhao C, Feng JL, Deng S, et al. Genetically predicted hypertension, antihypertensive drugs, and risk of erectile dysfunction: a Mendelian randomization study. Front Cardiovasc Med. 2023;10:1157467.

 

 

Researchers publishing in the journal Cardiology illustrated this phenomenon.

Cocco G. Erectile dysfunction after therapy with metoprolol: the Hawthorne effect. Cardiology. 2009;112(3):174–177.

In their study, men newly diagnosed with hypertension but without ED were started on metoprolol, but only some were told about the possibility of ED.

 

 

Clinical insights

 

History of pre-existing sexual dysfunction should be taken from every patient before starting any new treatment for cardiovascular diseases. Cardiologists should discuss potential side effects when prescribing medications and emphasize that not every patient experiences these effects. 

For patients complaining of sexual dysfunction, consider switching to antihypertensives less likely to impact sexual health. The Vascular Health and Risk Management authors suggest angiotensin-converting enzyme inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers favorable medications for hypertensive patients who have sexual dysfunction. 

For example, valsartan has been linked to improvements in erectile dysfunction, orgasms, sexual desire, frequency of intercourse, and sexual satisfaction. The Medicina review found that ARBs improve endothelial function and vascular dilatation in the genitalia, decreasing female genital tissue fibrosis.

 

In men, PDE5 inhibitors like sildenafil, vardenafil, and tadalafil (effective for both ED and pulmonary hypertension) have been found to improve cardiac function and pulmonary pressures.

Karedath J, Dar H, Ganipineni VDP, et al. Effect of phosphodiesterase-5 (PDE-5) inhibitors on clinical outcomes in patients with pulmonary hypertension: a meta-analysis of randomized control trials. Cureus. 2023;15(1):e33363.

In women, apart from nebivolol, alpha-blockers and clonidine are viable options, per the Medicina review.

 

Thus, the management of hypertension with consideration for sexual function involves a careful selection of antihypertensive agents and patient education to minimize anxiety and psychological impacts.