If you had to pick between your sanity and your sex life, which would you choose? Many women who have sought medical help for the treatment of depression, anxiety, or panic disorder are faced with this impossible dilemma. Drugs like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and other selective serotonin reuptake inhibitors (SSRIs) may make them feel better, but the side effects of these drugs can be upsetting in their own right. One of these side effects -- sexual dysfunction -- occurs at least 50 percent of the time. For women, symptoms can include decreased libido, delayed orgasm, inability to achieve orgasm, lack of lubrication, or pain during intercourse.

Simply put, if you choose sex over your sanity, you're not likely to be in the mood, and if you choose sanity over sex, you're not likely to care.

Women certainly have cause for concern when it comes to the side effects of antidepressants. The ratio of women with depression or panic disorder to men with the conditions is 2 to 1. The figures for female sexual dysfunction are pretty high as well. "National surveys indicate that one-third of women report a lack of interest in sex, and one in four say they are unable to achieve orgasm," reports Arthur Barnett, M.D., a leading researcher at Johns Hopkins University. "Right now, we don't understand all the causes because female sexual dysfunction is so woefully understudied."

One very small study out of the University of New Mexico last year, however, may have found a solution: sildenafil, better known by the trade name Viagra. Although Viagra is not widely used yet for female patients, this study showed that the high-profile drug might be as useful to women as it is to men. Nine study subjects, all female and all experiencing sexual dysfunction as a result of their use of antidepressants, were prescribed Viagra for use before sexual activity. According to the study's report, "The nine patients who took sildenafil (Viagra) reported a complete or very significant reversal of their sexual dysfunction." By reversal, the researchers mean a return of feelings of arousal and an ability to reach orgasm.

George Nurnberg, M.D., the lead physician in the study, became interested in trying Viagra on women after conducting a different study on the prevalence of patients who switch their antidepressants. "We found that somewhere around one-quarter of patients don't make it on the first drug and switch," he explains.

As with the birth-control pill, it's common for patients to try different SSRIs to find the one that suits them best. But it's also common for patients to experience sexual dysfunction, a side effect severe enough to drive patients away from effective antidepressant therapy, Dr. Nurnberg explains. "Less than 50 percent of patients stay on their antidepressants for more than 3 months. Less than 30 percent stay on for the standard full year of treatment," says Nurnberg. For people who stop taking the drugs because of the sexual side effects, he says, "Viagra could allow them to stay on their drugs for a full treatment."

Does Viagra work for women?

The major studies on Viagra, up to this point, have been conducted on men; therefore, the formal descriptions of how the drug works refer to male anatomy. According to the Food and Drug Administration's papers on the drug, "Viagra does not directly cause penile erections, but affects the response to sexual stimulation. The drug acts by enhancing the smooth muscle relaxant effects of nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, leading to an erection." As Dr. Nurnberg points out, however, the effect of the drug is similar for women, increasing blood flow to the genital area, prolonging sexual arousal, and increasing sensation -- all of which can lead to more pleasurable lovemaking. But you have to make the first move. "Viagra doesn't directly enhance sexual drive -- it is not an aphrodisiac," explains Dr. Nurnberg. Instead, he says, "by correcting sexual dysfunction [Viagra] can enable patients to secondarily restore their interest in sex."

The researchers might support Viagra use for women, but what about the practitioners? Dr. Gary Chinman, a psychiatrist at Brigham & Women's Hospital, in Boston, says that he has prescribed Viagra for female patients with sexual dysfunction from antidepressants. The results have been mixed, he explains, but when Viagra works, it works well.

"One of my patients is a relatively healthy 38-year-old, married public-relations consultant and mother of two. She has obsessive compulsive disorder, so I prescribed fluoxetine at 80 milligrams per day. Her compulsive symptoms were relieved ... but she also became anorgasmic and experienced pain during intercourse due to vaginal dryness." Dr. Chinman prescribed Viagra for this patient, with very good results. "Her sexual side effects from the fluoxetine were completely responsive to 50 milligrams of Viagra, about an hour before (but not more than two hours before) sexual activity. Her only side effect from the Viagra is a mild facial flushing about 45 minutes after taking it."

So far, the FDA has approved Viagra only for use with men. But with continued research on Viagra as a treatment for female sexual dysfunction, the drug may be approved by the FDA for use with women. Dr. Nurnberg's group is continuing studies, and Johns Hopkins University has an ongoing study of Viagra used for women. "Some people were astonished to learn that Viagra can benefit women as well as men," says Dr. Nurnberg. "But it's our contention that [Viagra] has a similar mechanism in both sexes, that is, in the arousal phase ... We were among the first to use Viagra for antidepressant-associated sexual dysfunction in women. Now there is worldwide interest in it."

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