Viagra has been the most-talked-about prescription drug since the birth-control pill.
And with this week's U.S. debut of rival impotence drug Levitra - and with another competitor on the horizon - the talk is only going to get louder.
Levitra's makers, Bayer AG and Glaxo Smith Kline Plc., have promised lots of advertising. They have signed a three-year sponsorship deal with the National Football League and hired Mike Ditka, the former Chicago Bears coach, as a Levitra spokesman.
'You couldn't ask for a better audience,' said Michael Fleming, Glaxo Smith Kline's director of product communications. 'You want to reach out to men where they are. One hundred twenty million people watch the games every week - that's 100 million men.'
Another Viagra rival is just months away from store shelves. Like Levitra, Cialis (made by Eli Lilly & Co. and Icos Corp.) made its European debut months ago. Cialis is expected to gain FDA approval by the end of this year. Paul Newman has been mentioned as a potential spokesman.
A loud, chest-thumping contest seems inevitable as the rivals put forward competing claims about the three drugs' relative benefits. GlaxoSmithKline and Bayer assert that Levitra acts more quickly than Viagra, which Pfizer disputes.
Lilly says Cialis is effective for 36 hours, instead of four to five hours for Viagra and Levitra. In Europe, it's called 'the weekend pill' because a Friday-night dose lasts until Sunday.
The stakes of the ad battle will be huge. Despite Viagra's success (sales were $1.7 billion last year), nine of 10 men with erectile dysfunction don't get treatment.
In the United States, an estimated 32 million men (about half of men over 40) are affected, and many of them are still too embarrassed to bring up the subject with a doctor.
But although many men may not want to talk about it, they'll be hearing about it. A lot. Think Viagra advertising times three.
So far, Viagra ads have tried to break through men's reluctance to address the issue by using celebrity spokesmen who embody respectability (Bob Dole); athleticism (NASCAR driver Mark Martin, Brazilian soccer star Pele and Texas Rangers baseball player Rafael Palmeiro); and virility (Hugh Hefner).
Altogether, Pfizer has spent more than $100 million on endorsements, television advertising, online marketing and sports event sponsorship.
The celebrities encourage men to fix the problem - as they would fix heartburn with Nexium or arthritis with Celebrex.
The campaign has earned Viagra brand-name recognition approaching that of Coca-Cola and has led to a saturation of Viagra jokes and spam e-mails.
(At online marketing firm Opt In Real Big, one of Viagra's marketers, CEO Scott Richter estimates that online pharmacies collectively spend from $200,000 to $300,000 per week on mass e-mails for Viagra.)
Men are getting the message
'It comes up for refills, it comes up for new prescriptions. It is a daily event,' said West Palm Beach urologist Murray G. Goldberg. 'Some people come in asking for Viagra; other people come in for what seems like an unrelated thing, then they say, 'Oh, by the way....' You come back and say, 'Is that the reason you came in?' And they say, 'Yeah.' '
A sexual and social landmark
Viagra's prevalence also has created a shift in the way we view men's sexuality.
Start with the change in terminology. The issue is no longer 'impotence,' and it's no longer shameful.
It's 'erectile dysfunction' or 'ED.' It's nobody's fault. And it's treatable.
'Obviously (Viagra) is a relief for a lot of men; it really gives the man confidence,' says Palm Beach Gardens certified sex therapist Nicholas S. Aradi. 'It has been a very positive thing that has brought a lot of couples together. It has been very effective.'
But not every problem can be fixed with a pill. And if men take the drug for the wrong reason, a relationship can suffer.
'It has made sex more goal-oriented,' Aradi said. 'For women in particular, they prefer more intimacy, communication. And the man is thinking he's going to take the pill an hour before bed and - boom.'
Without communication, he said, the drugs can introduce even more tension into a relationship. And there's a wide-ranging mis perception that Viagra will increase a man's libido.
'If the interest is not there, Viagra is not going to bring it about. The most powerful sex organ is between our ears, not between our legs.'
Miriam Davis, a West Palm Beach-based sex therapist and licensed mental health counselor, says Viagra is helpful in cases where there is a clear medical problem - and when asking about it is a joint decision. But she worries that some couples use it as a way to avoid dealing with important issues.
'If anything, I think it's made people think we don't need to solve any problems, that it's OK not to bridge the intimacy problems,' she said. 'For a lot of women, it makes it nice and quick and it's done. It doesn't put any pressure on them.'
Another concern: Although Viagra can make sex physically successful, it can't guarantee emotional satisfaction. Some couples who have solved the erectile dysfunction problem with Viagra suddenly find themselves facing other challenges in the bedroom.
'A lot of people forget that just getting an erection is not enough to have satisfying sex,' Davis said. 'It's no magic bullet. It's not going to bridge emotional distance.'
With new drugs that work faster and last longer than Viagra, she added, it will be even easier to lose sight of that distinction. 'You have this medication that bypasses all the communication. It has made it easier for people not to interact.'
The challengers' claims
The competitors, which are getting a positive response in Europe, each claim their own edge over Viagra -and in both cases it's an edge with emotional appeal.
Levitra takes effect in about half the time, making it more spontaneous -- a plus for couples who dislike the hour-in-advance planning Viagra requires. Cialis, which lasts for 36 hours, might appeal to men who feel hurried with Viagra.
'Men tell us that, when they take other pills, they feel like they're on a stopwatch, and that adds to the pressure they already feel,' Carole Copeland, a spokeswoman for Cialis-maker Eli Lilly, told The New York Times. 'They would like a treatment that would disconnect taking a tablet from intimacy.'
(As with Viagra, sexual stimulation is also necessary for both drugs to work).
Glaxo Smith Kline will place its Levitra ads inside a larger education program called 'Tackling Men's Health,' said communication director Fleming.
Although the ads will target football fans, some see the fans' wives as key. Women are much more likely than men to go to the doctor and seek treatment. Might they be important in urging men to get help?
'Women do have a critical role in motivating their partners,' Fleming acknowledged, but there won't be any ads in women's magazines or on Lifetime. At least, not yet.
Meanwhile, 'there are a lot of women who do watch football,' he pointed out. No matter what the advertising venue, the new drugs face a tough battle against Viagra's established name and familiar faces.
But they'll have the luxury of appealing to a public already inured to frank talk about a subject that was taboo just five years ago.
Adrienne Merrill, communications director for the Sexuality Information and Education Council of the United States, notes a different side to the new treatments.
From a women's health and family planning perspective, she said, the publicity around Viagra has been an unexpected boon.
When Viagra was approved, health insurers were quick to include it in their prescription drug coverage. 'It set off a firestorm. Even the Defense Department was covering Viagra,' she said.
But many of the same insurers didn't cover contraceptives for women -- and the discrepancy created an outcry. As a result, 21 states have since passed legislation requiring health insurers to include birth control in their prescription drug coverage.
Gonorrhea
Genital warts (condyloma) are caused by the human papillomavirus (HPV) and look much like other warts. They usually occur near the tip of the penis in men. In women, the warts appear on the vulva, in the vagina, on the cervix of the uterus, or near the anus.
There are several types of HPV. Some types can cause precancerous cell changes in the tissues of a woman's vulva, anus, cervix, or vagina. An invasive cervical cancer can be fatal, which is why women with genital warts should have a Pap test at least once a year.
