Dear Dr G,

I am a sixty-year-old man who is reaching an age where it is harder to “stand up and be counted for”, especially when I have had a bit too much to drink.

I understand that Erectile Dysfunction (ED) is also likely to be related to my diabetes, hypertension and high cholesterol.

As issues around erectile dysfunction become less taboo, I am tempted to welcome the “blue pills” to the rescue.

My wife knows I am a careful chap and will not take any medication without considering the risks.

Therefore, she really wants to weigh out the pros and cons before treatment.

Because of the embarrassment of seeing a doctor about my condition and worries about cost, I would like to put Dr G on the spot for some clarification.

Firstly, can you please tell me what the track record of the “blue pills” is?

How exactly do these pills work?

How common is the use of the pills globally, and how effective are they?

I also hear horror stories about side effects such as heartburn and headaches. Will these lead to heart attack, stroke or sudden death?

Are there any individuals who are unsuitable to take the medications?

Lastly, do you think I should surrender to a sexless life with Erectile Dysfunction, or embrace these Hard Pills to swallow?

These are difficult decisions to make.

Regards

Hard Henry

The discovery of “blue pills” is one of the most famous examples of accidental success in modern pharmaceutical history. The drug’s active compound, sildenafil citrate, was developed in the early 1990s by researchers at Pfizer in the United Kingdom. At the time, the company was investigating new treatments for hypertension. Sildenafil is a phosphodiesterase type 5 (PDE5) inhibitor initially intended as a cardiovascular medication.

However, during these trials, researchers observed improved erectile function, which prompted Pfizer to redirect development toward the treatment of erectile dysfunction. Sildenafil was approved for erectile dysfunction in 1998, becoming the first widely available oral medication for this condition and transforming both clinical practice and public discussion of sexual health.

Erectile dysfunction is common, particularly with increasing age and in people with conditions such as diabetes, hypertension, and cardiovascular disease. As awareness increased and stigma gradually decreased, use of sildenafil expanded rapidly. Sildenafil has become widely used worldwide. Over time, tens of millions of men globally have used the medication, and its availability increased further once patent protection expired and lower-cost generic versions entered the market. Usage varies significantly by region, influenced by cultural attitudes and healthcare access.

Sildenafil has been shown in numerous randomised controlled trials to be effective for many causes of erectile dysfunction. By inhibiting PDE5, the drug enhances the effects of nitric oxide in penile tissue, leading to relaxation of smooth muscle and increased blood flow during sexual stimulation. Clinical studies consistently demonstrate that sildenafil improves the ability to achieve and maintain erections up to 80%. The medication does not cause spontaneous erections or increase sexual desire; sexual stimulation is still required for it to be effective.

Common adverse effects include headache, facial flushing, nasal congestion, and indigestion, all of which result from vasodilation in different parts of the body. Some users experience visual disturbances, such as increased light sensitivity or a bluish tinge to vision, because sildenafil has a mild effect on the enzyme PDE6, which is involved in retinal photoreceptor signalling. These visual symptoms are usually temporary and reversible. Less commonly, sildenafil can cause dizziness, low blood pressure, or muscle aches. Reports of heart attacks and sudden cardiac death occurring after sildenafil use prompted regulatory warnings and further investigation. Extensive clinical trials and pooled safety analyses, however, have not shown an

increased rate of myocardial infarction or cardiovascular death in patients taking sildenafil.

Contraindications to sildenafil are therefore essential to its safe use. The most important absolute contraindication is concurrent use of nitrates or nitric oxide donors, commonly prescribed for angina, because the combination can cause a severe and potentially life-threatening drop in blood pressure. Sildenafil is also contraindicated in patients taking certain medications that strongly interact with its metabolic pathway, as well as in those with the rare eye condition Retinitis Pigmentosa. Caution or avoidance is recommended in individuals with a recent heart attack or stroke, unstable angina, severe heart failure, very low blood pressure, or conditions in which sexual activity itself is medically inadvisable.

The “blue pills” journey from an unsuccessful heart drug to a revolutionary treatment for erectile dysfunction highlights the role of observation and adaptability in medical discovery. Its widespread global use reflects both its effectiveness and the prevalence of erectile dysfunction. When used appropriately, sildenafil is highly efficacious and generally safe, with side effects that are usually mild and predictable based on its mechanism of action. Serious risks, including cardiovascular events, are uncommon and largely related to improper use or underlying disease rather than the medication itself. Careful attention to contraindications and patient selection remains crucial to ensuring its benefits outweigh its risks. Famous American novelist G. Michael Hopf once said, “Hard times create strong men, strong men create good times.” Men coming to terms with the weakening erection and contemplating swallowing the hard pills often put Dr G on the spot for some advice. His view is: “After careful assessment by the doctors, hard pills create strong men, strong men definitely will enjoy good times!”