You are on blood pressure medication. Now your erections are not what they used to be. So is it the drug or is it the blood pressure itself?
It is a fair question and it is one a lot of men quietly Google instead of asking their doctor. The answer is usually both but not equally. Uncontrolled high blood pressure damages the blood vessels that create an erection in the first place. Some blood pressure drugs make that worse. Others do not touch erectile function at all and a couple may actually help.
In this guide, DirectMeds will provide you with everything you need to know about which classes of blood pressure medication are linked to erectile dysfunction (ED) and what the research actually shows so that you know which drugs are actually the cause and what to raise with your doctor instead of just stopping a medication you need.
The Short Answer, Upfront
Not every blood pressure medication poses the same danger. Among medications with higher ED risks are:
- thiazide diuretics and older beta-blockers (e.g. atenolol, metoprolol, bisoprolol)
- calcium channel blockers (CCBs), with neutral risk
- ACE inhibitors and angiotensin receptor blockers (ARBs) along with newer beta-blocker nebivolol, with neutral to potentially protective risk
If you are taking a diuretic or older beta-blocker and have encountered changes in your erections, then you should discuss it with your doctor and look for alternatives instead of stopping the medication yourself.
How High Blood Pressure Itself Causes ED
Before blaming the medication, one should consider that hypertension is one of the main causes of ED. Getting an erection requires healthy blood vessels to relax and fill the penis with blood. Chronic high blood pressure harms the endothelial lining of blood vessels and hardens the artery walls, thus causing heart disease and stroke as a result.
The evidence in support of this is as follows:
- A meta-evaluation of 18 studies conducted among 41,943 males concluded that high blood pressure increased the incidence of erectile dysfunction by 84% (summary odds ratio: 1.84, 95% confidence interval: 1.58-2.14).
- Another systematic review of 40 studies including 121,641 subjects concluded that hypertension increased the incidence of erectile issues by 74%.
- The findings of a national cohort study showed that 41.2% of men suffering from erectile dysfunction have high blood pressure, while only 19.2% of men in the control cohort have such diseases.
- According to estimates made in Australia, the AIHW reported that 39% of people (around 7.2 million individuals) suffering from high blood pressure are men and women almost equally (40% and 39% respectively). Besides, one in four Australian males suffers from untreated high blood pressure.
Thus, the starting position matters because right at the very beginning, any man suffering from high blood pressure has a higher risk of erectile dysfunction before any class of medicine that affects hypertension is discussed.
Which Blood Pressure Drugs Actually Cause ED
This is where the topic becomes very particular. Various blood pressure medications work differently and influence erectile function in different ways.
Thiazide Diuretics: The Original Suspect
Thiazide diuretics (hydrochlorothiazide, chlortalidone, indapamide) represent the first-line treatment against hypertension all over the world and in Australian PBS prescribing guidelines. They are also one of the two drug classes that are most influentially associated with erectile dysfunction.
- The notable Medical Research Council (MRC) trial demonstrated that 22.6% of men using bendrofluazide (a thiazide) reported impotence as opposed to 10.1% of men using placebo.
- The review of diuretic therapy showed that men who suffered from moderate-to-severe erectile dysfunction were 2.5 times more likely to be using diuretics than those who did not have erectile dysfunction.
Thiazides probably influence erectile dysfunction because they restrict blood flow to the penis and because long-term usage of thiazides may lead to lower testosterone levels.
Beta-Blockers: Highly Dependent on Which One
There are different types of beta-blockers (such as atenolol, metoprolol, bisoprolol and carvedilol) that have been known to decrease heart rate and cardiac output, especially the older beta-blockers.
- A systematic review and meta-analysis has demonstrated that the chances of ED with each type of beta-blocker differed significantly: whereas atenolol gave rise to ED in 17.8% of patients, with bisoprolol, carvedilol and metoprolol the figures were 31.1%, 10.8%, and 9.8% respectively.
- While conducting a crossover study, it has been revealed that more than 65% of the patients on atenolol, metoprolol or bisoprolol experienced ED compared to only 31% on nebivolol, thus demonstrating the significant improvement on discontinuing the older generation beta-blockers.
This implies that the statement ‘I’m taking a beta-blocker’ is misleading: different beta-blockers do exert somewhat different effects because of their differing abilities to promote the release of nitrites in the body, the release of which is the mechanism of action of PDE5 inhibitors.
ACE Inhibitors and ARBs: Neutral, and Possibly Protective
ACE (angiotensin converting enzyme) inhibitors (perindopril, ramipril and lisinopril) as well as angiotensin receptor blockers (ARBs) such as irbesartan, telmisartan and candesartan act on the renin-angiotensin system.
Interestingly, unlike other medications that increased cardiac output or blood volume.
There is more than one report of erectile dysfunction (ED) in patients taking ACE inhibitors.
- In one of the studies with the ARB losartan, it was shown that the level of sexual satisfaction increased – out of 100% of participants at the beginning of the study only 7% were sexually satisfied. In contrast, those who had been examined after 12 weeks were satisfied at the level of 58%.
- The comparison of ARB and beta-blocker over 16 weeks showed that men using ARB reported an increase in the frequency of their sexual activity (from about 8 to 10 times a month whereas the group of men who used beta-blocker experienced a drop in their sexual activity from about 8 to 4 times a month) even though both groups were equal in blood pressure control.
- According to the results of a systematic review on ACE inhibitors and ARBs, ACE inhibitors and ARBs were shown to improve sexual function and sexual satisfaction in patients.
Calcium Channel Blockers: Largely Unaffected
Calcium channel blockers (amlodipine, felodipine) work by relaxing and widening blood vessels. Various reviews mention that the class is seldom responsible for ED and is often considered a substitute medication for men experiencing ED due to diuretics or beta-blockers.
Comparison at a Glance
Drug Class | Common Examples | Effect on ED | Key Stat |
Thiazide diuretics | Hydrochlorothiazide & chlortalidone | Increases risk | 22.6% reported impotence vs 10.1% on placebo (MRC trial) |
Older beta-blockers | Atenolol, metoprolol and bisoprolol | Increases risk | Up to 65.9% ED rate reported in crossover study |
Newer beta-blocker (nebivolol) | Nebivolol | Neutral / improves | Lowest ED risk ratio among beta-blockers (RR 0.87) |
ACE inhibitors | Perindopril, ramipril and lisinopril | Neutral | ED reported in <1% of patients |
ARBs | Losartan, irbesartan & telmisartan | Neutral / may improve | Sexual satisfaction rose from 7% to 58% at 12 weeks (losartan study) |
Calcium channel blockers | Amlodipine and felodipine | Largely neutral | Rarely associated with ED across reviews |
It is important to state that there is no claim that one product is better than another; how a certain hypertension medication affects a person is always unique, and it is only a doctor who can balance the benefits for the cardiovascular system with potential sexual side effects experienced by the patient.
Why This Happens: The Mechanism in Plain Terms
Erections happen due to nitric oxide, a molecule that helps relax the smooth muscle of the penis, letting blood vessels open wider and fill with blood. Different blood pressure medications influence this mechanism differently:
- Diminished blood flow: diuretics reduce blood volume with an effect on blood flow throughout the body, including the penis.
- Reduced cardiac output and effect on nervous system: old beta-blockers slow down heart rate.
- Effects on central hormone level: some antihypertensive medications lower testosterone.
- Nitric oxide mechanism: ACE inhibitors, ARBs, and nebivolol affect the nitric oxide mechanism in a more positive way compared to other blood pressure drugs which is presumably the reason why they do not pose a similar risk.
Another point to make is that some cases of ED related to a new medication may be caused by the fear of anticipating an unwanted side effect. In one expectation/anxiety study, the incidence of ED was stated to be 3.1% among individuals who were not informed about this side effect, which increased to 31.2% among men who knew that the medication has a strong correlation with ED. Expectation has an influence on the result which shows the necessity to consult with a professional rather than relying on the information from patient education materials in self-diagnosing the possible effects of a new drug.
What To Do If You Think Your Blood Pressure Medication Is Causing ED
- Do not discontinue the medication on your own. Quitting suddenly causes a dangerous spike in blood pressure, which is in itself a cause of ED, heart attack, and stroke.
- Know the timing. Mark down the date when ED began in relation to starting or changing your medications so that the doctor can establish if the medication is responsible or if it is the hypertension or some other factor (age, overweight, drinking, stress or other conditions).
- Ask for alternatives. If prescribed a thiazide diuretic or traditional beta-blocker, it is better to inquire with the doctor and work out if any medication from the ACE inhibitors, ARBs, or calcium blockers would suit the case.
- Get blood pressure properly controlled. Hypertension is an independent ED risk factor, blood pressure well controlled is part of the treatment not just the cause.
- Inquire about TGA-approved medications for ED. This way you will ensure that you will be safe to combine PDE5 inhibitors with blood pressure medications except for nitrates or riociguat, which may cause a serious drop in blood pressure.
Frequently Asked Questions
Can blood pressure medication cause permanent ED?
Erectile dysfunction from medications is reversible in most cases. Research into changing the type of beta-blocker has shown that erectile difficulties may improve in three months. Medication-related ED can usually be resolved by stopping or switching the drug, but ED that results from chronic vascular damage due to uncontrolled high blood pressure could take longer to resolve and possibly require additional treatment.
Which blood pressure medication is least likely to cause ED?
Currently there is evidence suggesting that ACE inhibitors, ARBs, calcium channel blockers, and the beta-blocker nebivolol are among the medications that lead to little risk of causing ED but the choice depends on the overall cardiovascular health of a patient, which can only be assessed by a doctor's examination.
Is it the high blood pressure or the medication causing my ED?
In most cases, it is probably both. Having hypertension by itself raises the risk for erectile dysfunction (OR 1.74 to 1.84) but certain medications will further increase the risk. A doctor can help you understand which factor is involved in your case by analyzing your blood pressure level and symptom timeline.
Should I stop taking my blood pressure medication because of ED?
No, except with the doctor's advice. Quickly stopping medication can cause a rapid rise in blood pressure. Try discussing switching to 'antihypertensives' instead.
Can I take Viagra or Cialis with blood pressure medication?
Generally PDE5 inhibitors can be used safely with other blood pressure medications, but not with nitrates and riociguat because of the risk for a sudden drop in blood pressure. Always verify your medications with the pharmacist.
