Today online pharmacy shopping is one of the most demanded online spheres. It is because online pharmacy can be called “problem free” shopping comparing to offline drugstores.

You can ask why we need online pharmacy when there are so many pharmacy stores next to your house. But there are many pros with online pharmacy shopping.

First of all you do not need any medical prescription to buy something from online pharmacy. It does not matter, do you have a head ache or some sexual problems or you want to lose your weight… you can find any kind of pills in the online pharmacy store. So, now you can save hundred dollars on doctors visiting to get some prescription.

Also you can save much more money with online pharmacy because all prices in the online stores are at least twice cheaper than in your local pharmacy stores. If you do not trust us, just visit your local pharmacy and compare their prices to our online pharmacy prices. Now you can pay only for the pills itself, no extra cost added when you buy with online pharmacy. All your favorite pharmacy brands at discount prices in one online pharmacy store.

One more great advantage that you can get with online pharmacy shopping – is confidentiality!!! Many people prefer not to tell about their health problems to their friend, relatives, neighbors… but when you visit local pharmacy to get some medicines you can meet some friends… but when you order with online pharmacy you’ll get the package and nobody will know what is inside: Viagra, other pills that prevent erectile dysfunction, some medicine that helps to lose weight, some medicine for your hemorrhoids…

Our online pharmacy store offers any kind of products, such as health, beauty, wellness, personal care and pharmacy products. Online pharmacy also gives you an opportunity to enjoy your favorite brands and special medicine even when you abroad and can not find special medicine in the local stores. Just visit our online pharmacy store and in a few days or less you’ll get medicine that you need. 

Online pharmacy shopping is very easy because we offer different payment and delivery methods to our clients. One more online pharmacy shopping advantage is its working time; our online pharmacy always opened 24/7.

The only thing that you should always remember buying from online pharmacy is that you have to read medical descriptions carefully to make sure that this or that medicine is exactly what you need. You can check some other customers’ reviews about drugs and about companies that produce these or that drugs, so you can choose the best one. It should be mentioned that our online pharmacy store cooperate only with reliable suppliers, so all our medicines are high quality only.

NOLVADEX is effective in the treatment of metastatic breast cancer in women and men. In premenopausal women with metastatic breast cancer, NOLVADEX is an alternative to ovarian irradiation. Available evidence indicated that patients whose tumors are estrogen receptor positive arc more likely to benefit from NOLVADEX therapy. Adjuvant Treatment of Breast Cancer: NOLVADEX is indicated for the treatment of node-positive breast cancer in postmenopausal women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation. NOLVADEX is also indicated for the treatment of axillary node-negative breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation. In addition, NOLVADEX reduces the occurrence of contralateral breast cancer in patients receiving adjuvant therapy with NOLVADEX for breast cancer. Ductal Carcinoma in Situ (DCIS): In women with DCIS, following breast surgery and radiation, NOLVADEX is indicated to reduce the risk of invasive breast cancer. (See BOXED WARNING at the beginning of full prescribing information.) Reduction in Breast Cancer Incidence in High-Risk Women: NOLVADEX is indicated to reduce the incidence of breast cancer in women at high risk for breast cancer. NOLVADEX is indicated only for high-risk women. "High risk" is defined as women at least 35 years of age with a 5-year predicted risk of breast cancer a 1.67%, as calculated by the Gail Model. (See BOXED WARNING at the beginning of enclosed full prescribing information.)

Today, diabetes is one of the most widely-spread diseases that affect the life of millions of people nationwide. In actuality, diabetes is considered to be a chronic disease which needs the effective treatment and maintenance of the health of patients. At the same time, patients with diabetes are always vulnerable to the consistent deterioration of their health under the impact of the disease because the existing technologies and methods of diagnosis and treatment do not always allow health care professionals to forecast the consistent deterioration of the patient’s health. In such a situation, patients with diabetes should be very careful and follow recommendations of health care professionals to maximize the effectiveness of the treatment and to minimize the negative impact of the disease on health of patients.

Definition of the disease

In actuality, diabetes is one of the most widely-spread diseases. Traditionally, specialists (Rother 2007) define diabetes as a set of metabolic diseases related to incapability of human body to regulate the amount of sugar, specifically glucose, in blood. Basically, all types of diabetes are treatable but diabetes type one and two last for the lifetime of patients. the type one diabetes implies that the body fails to produce the sufficient amount of insulin, whereas type two diabetes means that the body stops to produce insulin at all. At the same time, often pregnant women may also suffer from diabetes, which is known as gestational diabetes. This type of diabetes normally occurs in the second half of the pregnancy and may be treated successfully. As a rule, the gestational diabetes goes away after the delivery.

Causes

On analyzing causes of diabetes, it is worth mentioning the fact that diabetes is mainly provoked by the lifestyle and genetics of patients. What is meant here is the fact that some patients are predisposed to the development of diabetes genetically because their ancestors suffered from diabetes that increases the risk of the development of diabetes consistently. At the same time, the lifestyle of an individual can provoke the fast development of diabetes along with genetic factors. In this respect, it is worth mentioning the fact that the sedative lifestyle contributes consistently to the development of diabetes. In addition, such negative factors as alcohol consumption, smoking, drug abuse, low physical activities and other negative factors can contribute to the development of diabetes.

Furthermore, along with genetics and lifestyle, it is necessary to take into consideration some diseases and complications associated with diseases that may lead to the development of diabetes. As the matter of fact, it is mainly type one diabetes that may derive from complications of other diseases. For instance, Coxsackie B4 virus can provoke the development of diabetes. At this point, it is worth mentioning the fact that the understand of causes of diabetes can help to develop the effective treatment of the disease.

Detection

Today, it is extremely important to identify diabetes at the early stage of the development of the disease because the earlier the disease is identified the more effective the treatment of the disease will be. At this point, it should be said that the main way to diagnose diabetes is the glucose tolerance test. Basically, people suffering from diabetes have recurrent or persistent hyperglycernia. The disease is diagnosed when the patient demonstrates the poor glucose tolerance and cannot regulate the level of sugar in blood. The analysis of the blood of patients and the regular observation of patients by health care professionals help to identify the disease and diagnose which type of the disease patients suffer from.

Treatment

The treatment of insulin can help patients to maintain their health in a relatively stable state. At the same time, it is important to place emphasis on the fact that there is still no common cure to the disease and diabetes lasts for the lifetime of patients. As a rule, the treatment of diabetes implies that patients receive regular insulin injections. In addition, patients should do certain physical exercises and follow the special diet developed by specialists. As for type two diabetes, this type of diabetes may be treated with the help of medicaments, special diet and exercises. In addition, insulin injections can be used.

Anyway, the treatment of diabetes is essential because the ignorance of the development of diabetes may lead to the development of complications, which may threaten to the life of patients to the extent that in the most severe cases patients can die. Therefore, the treatment of diabetes should start at the possibly earlier stage of the development of the disease to prevent the consistent and irrevocable changes in human body.

Current status and emerging issues

In actuality, diabetes is a serious challenge to the public health, especially taking into consideration the development of the disease and the current lifestyle of people. At this point, it is possible to refer to the statistics concerning diabetes in the US presented in Table 1 below:

Table 1. Diabetes Statistics

17.9m people are diagnosed with diabetes

5.7m people are undiagnosed with diabetes
57m people have pre-diabetes
186,300 (0.22%) people under 20 have diabetes
1 in every 400 to 600 under 20-year olds have Type 1 diabetes
2m adolescents have pre-diabetes
23.5m (10.7%) of those over 20 have diabetes
12.2m of those over 60 have diabetes
12m men (11.2%) have diabetes
11.5m women (10.2%) have diabetes

Source: Lawrence JM, Contreras R, Chen W, Sacks DA (May 2008). "Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999–2005". Diabetes Care 31 (5): 899–904.

Today, the risk of the development of diabetes increases because of the sedative lifestyle of people, the high level of smokers in the society, the risk of the  negative impact of alcohol consumption and drug addiction, and other risk factors that can contribute to the development of diabetes in patients. At the same time, in spite of the progress of the modern science and pharmaceutical industry, there is still no common cure for diabetes.

Conclusion

Thus, taking into account all above mentioned, it is important to place emphasis on the fact that the development of diabetes represents a serious threat to the life and health of patients because diabetes can provoke complications that may lead to the death of patients. Therefore, the diagnosing and treatment of diabetes is essential.

WHAT ARE THE PROS AND CONS OF PROPECIA?

Propecia and the newer Proscar are brand names for the medication finasteride. The only difference between them is the dosage: Propecia is 1 milligram of finasteride, Proscar is 5. Because Propecia is expensive, some men buy Proscar and cut the pills into smaller doses—not recommended. Proscar is prescribed to treat prostate enlargement, not hair loss.

Finasteride works by blocking the conversion of testosterone into dihydrotestosterone, or DHT. High DHT levels are associated with baldness, so by preventing testosterone from converting into DHT, finasteride allows hair follicles that have become inactive to produce hairs again. In two twenty-four-month studies of men age 18 to 41, finasteride was shown to be fairly successful in treating hair loss. About 80 percent of the men studied maintained their base hair count, and 66 percent grew new hair. It usually takes about twelve months to see results from finasteride.

There are possible side effects with this drug, the most famous being loss of libido. The irony is obvious, as most men are concerned about hair loss because they fear it makes them less attractive. (Propecia cannot be taken by women, and pregnant women shouldn't even touch the pills, because doing so may cause birth defects.) The Propecia Web site has a patient product information page that lists sexual side effects, including "less desire for sex, difficulty in achieving an erection; and, a decrease in the amount of semen." The site goes on to say, "Each of these side effects occurred in less than 2% of men. These side effects went away in men who stopped taking PROPECIA. They also disappeared in most men who continued taking PROPECIA."

That reassurance was enough to persuade millions of men to take Propecia. Not all of them are convinced the side effects are rare or temporary Their comments can be read on a number of forums, including propeciasideffects.com and askapatient.com. In February 2006, 87 men on askapatient .com described their experiences with the drug. Nearly all concluded that it grows hair superbly, but 35 of the men reported loss of sexual desire. Fifteen reported a change in their semen or erectile function, 11 reported testicular pain, and 9 reported breast enlargement. A few complained that their penis had developed a curvature. Their anguish comes through loud and clear. Wrote one man, "From looking at these forums, the 98% no side effects is a big lie. It annoys me that the FDA would approve something so destructive to our bodies." Another offered, "As far as preventing hair loss it worked like a charm. But now I've stopped taking it for almost a year, a lot of hair has fallen out (although it turns out it still looks fine overall), but I've got little man boobs THAT WONT GO AWAY. I'm embarrassed to take my shirt off in public. Anyone up for suing Merck?"

Perhaps most disturbing, 22 of the 87 men reported experiencing depression, anxiety, and panic attacks while taking Propecia. Merck's site mentions nothing at all about these side effects. "I experienced my first panic attack that lasted for hours," reported one user. "Since then I have had horrible anxiety, shortness of breath, shaking, mood swings, and loss of appetite. It did not occur to me that Propecia may be causing these problems because Propecia's web site does not list these side effects. Thanks Propecia." Several men also claimed that Propecia made it more difficult for them to concentrate. Others lamented that the side effects did not decrease after they stopped taking the drug.

However, some men were ecstatic about the results. Some had increased sexual capacity with no side effects whatsoever. A man who had been on Propecia for eight months declared,

"The negative experiences people have written about on this site astound me. ... I have had great success with Propecia and now enjoy a thicker head of hair than I've had in the last two years. More than anything, it has greatly soothed my anxiety about losing my hair and allowed me to focus on the important things in my life."

These online forums are not scientific surveys, to be sure. But if you are contemplating taking Propecia, it would be worth your while to look through the comments. You could get lucky and enjoy years of thick hair, or you could end up like the tormented soul who wrote, "I used this shit for 11 months and now, 28 months later 1 still have side effects. I wonder if I'll ever get to normal. ... I wish I could go back in time just to shave my head and avoid this poison."

Advantages

• Having satisfying sex should not be denied to older men. Viagra has been shown to help problems with ED in this group. Mild to moderate side effects seem to be similar in older and younger age groups, and your GP will be able to discuss these with you.

• Ability to penetrate partners is significantly increased from a few times to most times for patients receiving 100 mg Viagra.

• Ability to maintain an erection after you have penetrated your partner should significantly increase.

• Viagra restores erections to a level almost that of men without ED, but it doesn't have any effect on sexual desire. So, although Viagra will help you to gain an erection with sexual stimulation, it may not have any effect on sexual desire (libido) if other things, such as relationship problems, are affecting that desire.

• Studies have shown that about 85% of attempts at sexual intercourse are successful following Viagra.

• The effect of Viagra does not appear to wear off the more you use it.

• Viagra can significantly improve the erectile response in patients with ED of no known physical cause. One study showed improvement in nearly 90% of men.

• When men's partners were questioned on partner satisfaction, it seems that Viagra significantly improves satisfaction with their sex life.

• Viagra has been on the market for some years now. So far it has shown a good safety record. Only 1 % of men have discontinued taking Viagra because of side effects (see Viagra side effects).

• If you are trying for a baby, there has been no suggestion in any of the extensive studies on Viagra that it does any harm either to a man's partner, or to a resultant pregnancy, or to the baby.

Disadvantages

• It must not be taken by people taking nitrates.

• If you have had liver failure, eye disorders and certain other illnesses, you must discuss the suitability of Viagra for you.

• Its effects are slower than the injected type of drugs.

How can take Viagra, how to buy Sildenafil (Viagra) online?

Sildenafil (Viagra)

Viagra was a major breakthrough for patients and doctors living with and managing erectile dysfunction, but it does not suit or help everyone with erection problems. When there is sexual stimulation, be that by touch, or sight, or smell, or whatever turns a man on, this is perceived by a certain area in the brain and then a cascade of chemical 'messengers' is sent out, which leads to the blood vessels supplying the penis opening up. One of these messengers is called 'cyclic GMP', and it is broken down by an enzyme called 'phosphodiesterase'. The medications such as Viagra, Levitra or Cialis work by blocking this phosphodiesterase and thus leading to an increased period where the blood vessels will be dilated. The way the drug works is very important for men regarding how it is used. It is only effective when there is sexual stimulation! The drug will not be successful if there is no stimulation, i.e. a man takes the medication and then awaits an erection before attempting any sort of sexual contact Many men claim that Viagra has failed for them because they have either taken it at too lower a dose, or not often enough, or they have taken it without any sexual stimulation.

At present Viagra is taken orally (by mouth) and, because of the relatively slow digestive process, it may be an hour or two before the drug produces its effects - certainly an issue in planning for sex. It affects not just the penis, but potentially could affect other parts of the body. As with most drugs, not everyone will benefit, although Viagra has been found to produce firmer, more frequent and longer lasting erections in the majority of men who have taken it Doses are 25,50 and 100 mg, taken 1 hour before sexual foreplay, and its effect lasts for 2-3 hours. Oral therapy is now prescribed in over 90% people with ED, and studies are showing that 70% of these achieve satisfaction. In one study of couples, where 87% of the men rated Viagra as 'somewhat satisfactory to very satisfactory', nearly 30% of their partners considered the treatment 'unsatisfactory', mostly because of their own lack of sexual interest

We get many questions about this drug. Some of its attributes are listed in the box.

All the junk email I get on my email account tells me that I can buy stuff from the USA that will work straight away. Is there an immediate-acting tablet?

At present, no there is not. Tablets that are taken under the tongue, or potentially in the future by nasal spray, will get into the bloodstream and act faster than tablets that are taken by mouth and swallowed, which need to be absorbed into your bloodstream to work.

All of the tablets that are presently licensed and indeed will be licensed in the near future require you to be sexually stimulated to work. The gap phase between taking a tablet and an erection developing would therefore be valuable for you and your partner to engage in the sort of foreplay that makes you both ready to enjoy making love.

Viagra sounds the perfect solution to my problems, which have affected my relationship with my new partner. How often can I use Viagra?

The recommended frequency of taking tablets is not more than once every 24 hours. There is no restriction on how many times a week you could use Viagra, but if you are getting it on the NHS, most GPs will limit their prescribing to one tablet per week as this is the recommendation in Schedule 11. You might find that, after using Viagra successfully to help you get an erection, your erections can also be better the following day. This could be a direct effect of the drug, but could also be due to the tissues in your penis being enlivened by getting a good supply of oxygenated blood in them.

I like to go out to dinner with my wife on Friday nights and have a Chinese meal. Can I take Viagra after a large meal? Would this be safe or sensible?

Taking Viagra after a large meal will slow the absorption of Viagra. What this means is that you may find that the Viagra does not work at all for you, or that it works much slower than it would have done had you taken it on an empty stomach, or after a light meal. In other words, it is safe in that it will have no harmful effects, but it is not sensible!

I am keen to get my love life as good as it was before we had kids, but do not want to go mad, as I have a demanding job. What dose of Viagra will I need?

The effect of Viagra does seem to improve the higher the dosage taken. The maximum dose is 100 mg. You might find that the dose of Viagra you need is dependent on other factors present at the time of intercourse, such as tiredness and stress. If you are unhappy with the first dose you are prescribed, visit your doctor again to discuss whether you could try a higher one.

I have seen the effect of Viagra on my husband, but do not feel stimulated myself. Could I try one of his Viagra tablets. Could women benefit from Viagra as well?

During foreplay and intercourse there are some very similar processes happening in women to those in men, so in theory Viagra could help to enhance sexual response, but so far there have been few studies of women while taking the drug. Women might feel that this shows a very particular gender bias in the testing of such drugs, but at the moment it is not licensed for women!

Viagra appears to improve the blood supply to the whole genital area. With sexual stimulation, this will lead to blood flowing into your clitoris and vulva and potentially make your vagina more slippery (better lubricated). This allows some women to enjoy sexual activity more; however, the majority of women with desire or libido problems don't appear to be helped. Further research in this area is going on and new results become available all the time. If you are interested in the treatment of Viagra in women, discuss this with your doctor or nurse.

There have been other reports of successful pregnancies in women taking Viagra, who were previously unable to have babies. Viagra may cause the lining of the womb to thicken from better nourishment from the bloodstream.

I am not well off, but should like to try Viagra to see if it will help our relationship. Will I have to pay for a private prescription?

Yes, if you don't conform to Schedule 11. A private prescription means that you will have to pay for the cost of the drug, plus whatever sort of percentage increase the pharmacy will put on the medication. Prices charged by retail pharmacies can vary greatly and it would be worthwhile asking your doctor if they know where the cheapest pharmacy is, or ringing round yourself, including the big retail chains. The prescription from the doctor won't cost you anything - the cost for the chemist lies in getting the drug privately rather than on the NHS.

I have a spinal cord injury and I am experiencing difficulty in achieving and maintaining an erection because of the effects of my injury. Will Viagra help improve my erections?

Viagra has been reported as being well tolerated and is effective in 45-60% of men suffering from spinal cord injury (SCI). As long as you are not taking any nitrates, there is no reason why you cannot take Viagra, but discuss treatment options with your GP. The side effects of taking Viagra are the same as for men who don't have a SCI (see section below). You may find that the results from Viagra are not as good as other treatments, such as injection therapy, for improving your erections, but this will dependant on your SCI.

Since having a spinal cord injury, I have had poor erections and Viagra didn't help improve them. Are there any other medications that will help?

Don't despair - there are other drugs available to treat ED such as Cialis, Levitra, Uprima (discussed in the following sections), MUSE, injections and vacuum therapy devices.

I had a car accident, which damaged my back and I'm now in a wheelchair. Could Viagra help me?

Yes. There have been a few studies of Viagra in people with nerve damage. In people with spinal cord injury, the majority had improved erections and preferred Viagra to 'placebo' (where there was no active-ingredient tablet taken). In a study of people with MS, Viagra improved the erection and side effects were mild to moderate. They felt that sex life was considerably better. So, yes, in your case, you should try consulting your GP, who may well prescribe it for you, and see if it improves your sex life.

I am 25 and have MS. I've read in the MS magazine about Viagra for men's impotence recently. Could that help me sexually?

There has been an enormous amount of publicity about Viagra in recent months, and the ways in which it may transform men's sex lives. Fortunately for many men with erection problems, caused by nervous system damage in MS, it may indeed offer some help.

Essentially Viagra acts on blood supply problems in MS and other similar conditions, by helping the penis to fill with blood. Even where nervous system damage is substantial and where erections are very difficult to obtain and sustain, Viagra might be able to help. As many men with MS are younger than those in which side effects with Viagra have happened, there should be fewer problems amongst your age group.

Note that, because of the cost of the drug, and the anticipated large demand for it, the Department of Health has been extremely circumspect about those for whom it can be prescribed via the NHS (see question in Chapter 5 on Schedule 11). However, MS is now one of the designated medical conditions - but there may still be local variations in supply, in addition to clinical reasons for its non-prescription.

Always get advice from your doctor and do not buy it on the internet. Viagra is a very safe and effective treatment, provided that you are guided medically - do not experiment without a medical opinion.

I had heart by-pass surgery 18 months ago. Can I take Viagra?

If this operation was successful and you now have no chest pain, then there is no reason for you not to be having sex, or be treated for any sexual dysfunction. If, however, you are still having chest pain, particularly at rest, then this needs to be sorted out before you embark on any physical activity, including having sex. If you are taking nitrates, you must not take Viagra.

Can I take Viagra? I had a stroke a year ago and worry that I might have another, which is not good for my self-confidence with my girlfriend.

The answer to this question is yes, in the vast majority of cases. Strokes can be either due to bleeding into the brain or to the brain not getting enough blood flow because of a blockage in the arteries. Viagra will open up the arteries flowing to the brain, and this results in some men getting a mild headache and a feeling of fullness in the head, following a Viagra tablet You will need to discuss the safety issue with your GP, but there is no reason why you should not try having sex again after having had a stroke.

I am on tablets for my depression. Could Viagra actually help my depression as well as my sex life?

Depression and sexual dysfunction can be very much a 'chicken and egg' situation because some ED problems could actually cause anxiety and depression, but, in long-standing depression, Viagra is successful in helping people have intercourse. We have discussed psychological problems in Chapter 2.

There is increasing evidence that men who are on anti-depressive treatment, when treated with Viagra, can, in some cases, decrease the amount of antidepressant therapy that they are taking.

If you are on medication called SSRIs (selective serotonin reuptake inhibitors), you should get better erections with Viagra.

I have had diabetes for the past 15 years (I'm 39) and rind it very difficult to make love to my wife nowadays because I cant sustain an erection. Would Viagra help me?

It could well do. In one study, Viagra helped over 50% of men with diabetes and ED. The effects did not seem to be affected by age, or how long they had had ED or diabetes. Although the response to Viagra was somewhat less than that seen in other groups, people with diabetes do often have many other problems, such as vascular disease or diabetic neuropathy.

The majority of side effects (see next section) seen with Viagra (e.g. headache, feeling of acidity, congestion in your nose) are not severe and don't last long, so these should not prevent you from trying Viagra.

I have had a kidney transplant and am on medication. Can I take Viagra?

Yes you can. There is no reason why the drugs normally taken after a transplant operation will interact with Viagra. (The only drug that you cannot take with Viagra is the class of drugs called nitrates, which are given to people for their heart pain.)

I had cancer some months ago, which left me rather incapacitated -1 now have trouble having sex with my partner. Would Viagra help me?

You do not say what your disability is, but there are various choices open to you. Tablets would still be your first choice: Viagra, Levitra or Cialis, or Uprima (see the following main sections), depending on what medication you are currently taking. However, you could also try other treatments such as injections, MUSE or a vacuum device (see Chapters 8 and 9), if drugs like Viagra do not work for you.

I've had an operation on my prostate and other treatment for cancer. My doctor was very negative about me having Viagra. Was he right to be so?

We know that men who have undergone surgery or radiotherapy for prostate cancer have taken Viagra successfully. Although the best response was seen in men with less severe ED, over half with complete ED were pleased with the effect Viagra had. So you doctor may well be over-pessimistic about it.

The success of Viagra has interested many pharmaceutical companies and there are now two new drugs, which are the same type of therapy as Viagra. They are called vardenafil (Levitra), marketed by Bayer and GlaxoSmithKline; and tadalafil (Cialis), developed by a technology company called ICOS and marketed on a worldwide basis by Eli Lilly.
Levitra and Cialis have the same advantages and disadvantages as Viagra, discussed previously, so the rest of this chapter will try to explain some of the differences between the three therapies.

Now there are other treatments like Viagra on the market perhaps I should try one of the others? Which one should I start on?
As you would expect with second-generation drugs, they do have advantages over Viagra. However, Viagra works and has no significant side effects for most men. Therefore, you will only find out which treatment is best for you by trying them and seeing which one works best
Each of the three treatments has its own strengths and weaknesses and your doctor or nurse will be able to discuss these with you. The balance will be an individual one between the potential advantages of the newer medications (Cialis and Levitra) compared with the great clinical experience that doctors now have with Viagra.

Do Cialis and Levitra work in the same way as Viagra?
Yes. Cialis and Levitra act in the same way as Viagra by blocking an enzyme called phosphodiesterase-5 (PDE5). This helps the smooth muscles in the penis relax and widen, allowing more blood to enter. Also similar to Viagra, there needs to be sexual stimulation for the drug to be effective. They are 'facilitators' of sexual activity not 'initiators', i.e. they are not aphrodisiacs.

Do Cialis and Levitra work in the same way as Viagra?
Yes. Cialis and Levitra act in the same way as Viagra by blocking an enzyme called phosphodiesterase-5 (PDE5). This helps the smooth muscles in the penis relax and widen, allowing more blood to enter. Also similar to Viagra, there needs to be sexual stimulation for the drug to be effective. They are 'facilitators' of sexual activity not 'initiators', i.e. they are not aphrodisiacs.

Is any one of these drags better than the others?
Some effort has been made by reviewers and by pharmaceutical companies to compare data from different clinical trials (with different patient populations) and conclude that Drug A is superior to Drug B for a given population. Such a conclusion must be treated with some reservation until direct comparative studies are done.
At present all that can be said conclusively is that Viagra, Cialis and Levitra are all very effective and very safe drugs for men with ED.

I have been taking Viagra for some time now. Should I change from Viagra to one of the new tablets?
The answer to this question is one that will be different for each man individually. For some, if Viagra has been successful and they are having no serious side effects, they will see no reason to change their medication. However, for others, there will be the urge to experiment and to try the newer compounds to see if they are better.

Do you think the effects of Viagra could be enhanced by taking Cialis or Levitra in combination?
There have been no clinical trials so far looking at the safely or the effectiveness of such combinations, and therefore it cannot be recommended that you try these drugs in combination at this stage. Take your doctor's advice - don't experiment with medicines!
I know that Viagra has been used by some women. Would Levitra or Cialis help female sexual problems?
It is very likely that these drugs will help some women with sexual problems, as Viagra has done. However, at this stage there have been no research trials reported of women taking these drugs, so as yet we cannot recommend that they are taken for women.

What side effects can I expect from Levitra?
Levitra is generally well tolerated, although some men will experience side effects. These are due to effects of Levitra on other parts of the body apart from the penis and the most common ones are headache, facial flushing, indigestion and a stuffy or runny nose. Similar side effects are seen with drugs that act in the same way as Levitra.
Side effects with Levitra are rarely unpleasant enough to make men stop taking it and it is often found that, with continued use, the side effects tend to disappear. If you are bothered by side effects, then you should discuss these with your doctor.

How does Levitra compare with Cialis over Viagra?
In laboratory research conditions, Levitra is the most powerful of the presently available phosphodiesterases (compared with Cialis and Viagra). The question is whether then this equates to a superiority in a 'clinical* setting where healthy and difficult-to-treat groups, such as men with diabetes, are taking it. Up to now there have been no head-to-head data published, so for now we cannot answer the question as to which drug is 'better' or indeed which drug men prefer. At this stage, what can be said confidently is that this is another highly effective drug offering another choice for men with ED.

Can I get Levitra on the NHS?
The NHS has restricted the types of patients with ED who can get treatments paid for by the NHS and this includes Levitra. Your doctor will know whether you come into one of these categories, which are discussed above under Viagra, but generally you have to have some other disease, such as diabetes or spinal cord injury. If this is the case, then, unless you are normally exempt, you will still have to pay a prescription charge for Levitra.
If you are eligible to be prescribed Levitra on the NHS, then your doctor will write the letters 'SLS' (standing for Selected List Scheme) next to the drug name on the prescription. If these letters are not on the prescription, the pharmacist will ask you to pay for Levitra.
You may also be able to get Levitra on the NHS if you are diagnosed as suffering severe distress as a result of your ED. This diagnosis may have to be made by a hospital specialist rather than by your own GP.
The majority of patients have to pay for their ED treatments (although the consultation with the doctor is still free), but a prescription from your doctor is still needed. It is not possible to buy Levitra 'over the counter' from a pharmacist.

Side effects of Viagra

I have been prescribed Viagra but I am nervous about taking it as I don't like pills. What are the side effects?

When Viagra was first released there were several sensationalist newspaper headlines about men dying after taking the medication. These headlines have given many people the impression that Viagra is potentially a dangerous medication. This is not true. As men get older their blood vessels narrow and become hardened and inflexible (atherosclerotic). This is the reason that older men (and women) suffer from cardiovascular disease, which leads to, amongst other problems, heart attacks and strokes. It is the same disease process that stops the blood flowing into the penis, and it is therefore logical that people who are having problems with their erections because of this decreased blood flow might also have decreased blood flow to both their hearts and their brains.

In very extensive studies, both before and after Viagra had been launched ('licensed'), there was no suggestion of Viagra causing death. The one exception to this statement is that simultaneous taking of nitrates, which are drugs taken to stop angina (heart pain), or taken close to the time when Viagra is taken, can be extremely dangerous. This is because the Viagra and the nitrates work in the same way, i.e. by opening up the blood vessels. If taken together, the blood vessels can open too much causing the blood pressure to fall dangerously - in some cases this has led to serious problems, including death. However, if we exclude those people who have taken this combination of drugs, there is no sign of any increase in serious problems in people taking Viagra. Indeed, studies in Britain suggest that there may be fewer serious cardiovascular problems in people taking Viagra, compared with those men who are not taking the medication.

The danger therefore for men taking Viagra, as long they are not taking nitrates as well, is not to do with the drug itself, but with the level of energy expended in sexual activity. This level of energy expenditure is about the same as doing light housework, or walking 1 mile in 20 minutes on the level.

My older brother (I'm 59) had a heart attack recently and I'm worried that, if I take Viagra, I could be in danger too - at the moment I take water tablets for my high blood pressure.

Men who are having treatment for heart conditions, such as nitrates, run the risk of a dangerous further drop in blood pressure if they take Viagra. Older men, perhaps with an underlying undiagnosed cardiac problem, who may not have undertaken any exercise for several years, could find themselves in difficulty with vigorous sexual activity, so it is important that you discuss things fully with your doctor.

People with heart problems, including coronary heart disease, may benefit from Viagra because heart disease, rather than the drugs used to treat it, is the most common cause of ED.

Viagra does not cause heart attacks, any more than might occur by chance. Before trying it, have a check-up at the doctor's.

My doctor has given me a small pill to put under my tongue if I get breathless and my chest starts to hurt. I'd like to try Viagra. Is there a problem taking both tablets?

Yes, Viagra reacts with nitrates. You have been given nitrates and you most not take Viagra at the same time. There are alternative forms of therapy for ED, such as the new oral tablet Uprima (see below), injections into the penis, or MUSE.

Alternatively, you can talk to your doctor about changing to different treatments. Nitrates are for relatively weak angina (chest pain), and have no proven benefit in preventing heart attacks or sudden death. They are used only to help relieve pain and breathlessness. Heart specialists estimate that up to 90% of patients using nitrate therapy could be treated with other drugs, for example felodipine or amlodipine. Once the change has proved successful (2 weeks should be enough time), you can then try Viagra.

The American Heart Association suggests that it is unsafe to take a nitrate within 24 hours of a Viagra dose. You will be advised, if you are taking Viagra, that you should not keep nitrates in the house, to avoid accidentally taking both of these drugs together. If you do take Viagra and have sex, and then experience chest pain, you should stop the sexual activity and either sit or stand while the symptoms ease. If your chest pain does not ease with this rest, then get medical help immediately.

I am 74 years old and still very active. For the last 5 years I have been prescribed various medications for high blood pressure and cholesterol levels, and also for the mild angina from which I occasionally suffer: simvastatin (Zocor) or atorvastatin (Lipitor) for cholesterol, nicorandil (Ikorel) for angina, felodipine (Plendil) and perindopril (Goversyl) for blood pressure, plus baby aspirins. At the same time as starting these drugs I have suffered from ED, although a number of doctors have said that the treatment I am receiving should not have that effect. When I ask if I can take Viagra, I am told by more than one member of the cardiac department in our local hospital that they do not recommend it for anyone with a heart condition such as mine, the reason being, apparently, that they believe Viagra can constrict the blood vessels to the heart and bring on a heart attack. I appreciate that Viagra should not be taken as well as a nitrate medication and would naturally avoid this, but I have never read that it should be banned to everyone with a common heart condition. It would seem to be just a policy decision by our local cardiologist. What do you think?

If you are not on nitrates, and are a fit active man, then there is no reason why you can't take Viagra. There is an oral therapy, Uprima (see next section), which is suitable for men who are taking nitrates. It is similar in one respect to Viagra, i.e. it needs sexual stimulation to work. It is a tablet that is placed underneath the tongue to dissolve and then takes about 20 minutes to work.

As with all treatments it is not a 100% success, but there are other treatment choices. Talk to your doctor about other forms of treatment for ED. Vacuum therapy devices, injections and MUSE are all suitable alternatives for you.

A friend of mine had a heart attack after taking Viagra - it seems dangerous to me. Are the media reports wrong?

There is no increased risk of a heart attack from Viagra - in fact there were fewer cases of heart attack when Viagra was compared with a placebo (this is where people are given a tablet with no active ingredients in it, but they feel that it has had an effect - a 'placebo effect’)- Newspapers like headlines. The many millions of people who have taken Viagra safely seem to disprove this unfounded fear.

I'm really terrified of these chest pains that I sometimes get. It really puts me off taking Viagra.

Do not use a nitrate tablet or spray at the same time as Viagra. Stop your activity and sit or stand up. The pain should gradually settle. A glass of whisky or brandy might be helpful. Do not try to have sex again until you have discussed what happened with your doctor. There are other options available to you that your GP can tell you about.

I am in my late 60s and had a mild heart attack about 7 years ago. My doctor prescribed atenolol and atorvas­tatin (Lipitor). I started to have ED about 2 years ago. The doctor changed my tablets from atenolol to what he called an ACE inhibitor but I am still having problems. Injections have not helped. I gather Viagra should not be used. Are there alternatives?

This is a very interesting question which raises several important issues. As has been stressed repeatedly in this book, erections are all about getting blood in to the penis. In this case, the same disease process that has blocked the arteries supplying your heart and caused your heart attack has blocked the arteries supplying the blood to the penis. Many people associate their treatment for high blood pressure with ED. The GP in this case was quite correct in changing the medication, as the older drugs, such as thiazide diuretics and beta blockers, are associated with a higher incidence of ED than the newer ones, such as ACE inhibitors and calcium channel blockers. Also, the only reason not to take Viagra is if you are taking nitrates, either in long-acting form or in the form of tablets that go under your tongue to relieve angina. This is because nitrates plus the Viagra (or the newer drugs, Levitra and Cialis, which are similar to Viagra - see the next section), if taken together, can cause your blood pressure to drop very significantly and hence be very dangerous. In your case, you are taking a lipid-lowering agent and an ACE inhibitor, so there is no reason why Viagra should not be used.

If Viagra is not successful, taking apomorphine under the tongue can be tried.

Although you say that the injections have not worked, it would be worthwhile reconsidering how the injections were used and what dose was given, as most people will respond to injection therapy if the correct dose is administered correctly.

Would taking Valium before using Viagra interfere with Viagra's effects?

The effect of Valium is to calm the nervous system in the body and to make people feel less apprehensive. There is no reason that taking Valium should stop Viagra working. However, regarding your sexual performance, Valium and other drugs used to decrease anxiety can slow down the time taken to ejaculate. Indeed these drugs are used to treat people who have rapid ejaculation. So if you take a normal time to ejaculate and are taking these drugs, you may find that you are slower to ejaculate, or even find it impossible to ejaculate. This does not happen in most men and, if it does happen to you, then you need to discuss it with your GP - do not stop taking your Valium without discussing the problem first