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Nitric Oxide and Viagra

The structure of Viagra
Use your mouse to manipulate
the molecule

Viagra

In a random survey of males aged 40-70, more than 50 percent indicated that they had some form of erectile dysfunction (ED), i.e. the inability to achieve an erection. The development of the drug Viagra, an inhibitor of cyclic GMP-specific phosphodiesterase, has been of great importance to many males suffering from ED.

Achievement of a penile erection in males is largely an application of basic principles of hydraulics. Stimulation of the nerves innervating the penis causes the dilation of the deep arteries supplying blood to the penis. The large amount of blood entering the penis engorges the cavernous blood sinuses comprising much of the penis volume. This engorgement in turn acts to compress the veins draining blood from the penis. The increased inflow and decreased outflow of blood causes an erection. Cessation of nervous impulses to the penis acts to abolish the erection.

Nitric Oxide

Nitric oxide (NO) is of major importance in the signaling pathways leading to penile erections. NO is very unique for a biochemical signalling molecule because it is a gas. NO displays free radical behavior, and is formed from arginine by the enzyme nitric oxide synthase (NOS):

arginine + O2 citrulline + NO

As a gas, NO is able to pass through cell membranes without the aid of dedicated transporters and its free radical character makes it particularly reactive with iron-containing proteins.

Originally called UK-92,480, Viagra was initially developed for treatment of hypertension. In a subsequent human toleration study as a possible drug for angina, some very strange side-effects were noted.

NO acts as a vasodilator in the process of penile erection. NO is supplied from two sources. The first is as a neurotransmitter liberated by the cavernous nerve which innervates smooth muscle surrounding penile arteries. The second source is the endothelial cells lining the deep arteries of the penis. Endothelium-derived NO is formed in response to stimulation of the endothelial cells by cholinergic nerves. Acetylcholine causes the production of inositol triphosphate (IP3), an important second messenger in many hormone signal transduction pathways. IP3 opens calcium channels in the endoplasmic membrane of the endothelial cells; the liberated calcium then activates NO synthase and causes the production of NO.

Whatever the source, endothelial cells or cavernous nerve, NO diffuses across the muscle cell membrane and binds to guanylyl cyclase. Guanylyl cyclase catalyzes the synthesis of cyclic GMP from GTP. cGMP then activates a cGMP dependent protein kinase which in turn stimulates the uptake of calcium by the endoplasmic reticulum of the muscle cell. The reduced levels of cytoplasmic calcium cause the muscle cell to relax. As a consequence of muscle cell relaxation, vasodilation occurs.

Stimulation and inhibition of muscles by NO

As is true of any signaling pathway, there must be a way to terminate the action of the signal. cGMP is converted into GMP by a specific phosphodiesterase (PDE.) There are 10 families of PDEs: PDE1-10. The major PDE found in vascular smooth muscle is PDE5. Viagra (sildenafil) is a specific inhibitor of PDE5. By blocking the breakdown of cGMP, Viagra acts to prolong the effects of cGMP and, hence, the erection. The side effects of Viagra are relatively minor. Some minor vision problems have been reported; these are due to inhibition of PDE6, the phosphodiesterase used in signal transduction of light signals in the retina.

Other Biochemical Uses of NO

In addition to its role as a vasodilator and neurotransmitter, NO is produced by macrophages. These phagocytic cells of the immune system use NO to impair DNA synthesis and metabolism in microorganisms. NO can also react with other free radicals, in particular the superoxide radical, to form peroxynitrites that are effective against bacteria, fungi and other pathogens. Nitrites have been added as preservatives to meat for years; part of the effectiveness of added nitrites may be due to the antimicrobial action of generated NO.

Massive bacterial infections are known to cause septic shock, the hallmark characteristic of which is a dramatic lowering of blood pressure. This is due to the release of massive amounts of NO directed against the bacteria; the unfortunate side effect is the extreme vasodilation that occurs in response to NO.

The following diagram shows how an erection is mediated and how sildenafil acts in the body. Nitric Oxide (NO) is released with sexual stimulation from nerve endings and endothelial cells in the spongy erectile tissue, the corpus cavernosum of the penis. The enzyme guanylate cyclase then converts guanosine triphosphate (GTP) into cyclic guanosine monophosphate (cGMP). cGMP causes the smooth muscle to relax, which causes an inflow of blood which then leads to an erection. cGMP is then hydrolysed back to the inactive GMP by phosphodiesteras type 5 (PDE5).
The levels of cGMP are therefore controlled by the activation of cyclic nucleotide cyclase and the breakdown by PDE5. It is the latter that sildenafil acts upon. Men who suffer from erectile dysfunction often produce too little amounts of NO. This means that the small amount of cGMP they produce is broken down at the same rate and therefore doesn’t have the time to accumulate and cause a prolonged vasodilation effect.
Sildenafil works by inhibiting the enzyme PDE5 by occupying its active site. This means that cGMP is not hydrolysed as fast and this allows the smooth muscle to relax.
Sildenafil is a potent and highly selective inhibitor of PDE5.

If viewed in cross section, the glans of the penis reveal that the penis consists of three tube-like projections of spongy tissue, the corpus spongiosum, located ventrally and the paired corpi cavernosi located dorsally. In each of the latter is the deep artery of the penis which carries blood over the length of the penis into the open channels that make up the corpus cavernosum. The blood carried out of the corpi cavernosi empties into the dorsal vein of the penis which then returns the blood to the body. It is thought that the level of rigidity of the penis is due to the relationship between arterial inflow and venous outflow in the penis. This means that the larger the calibre of the arteries, the more blood enters the corpus cavernosum and enlarges the penis, and the larger the calibre of the veins, the more blood is shunted away from the penis. An erection is an involuntary action controlled by the autonomic nervous system which consists of the sympathetic and parasympathetic pathways. In general, sympathetic stimulation leads to the constriction of smooth muscle surrounding the arteries (reducing the calibre) and parasympathetic stimulation induces smooth muscle relaxation (larger artery).
When stimulated sexually, the sympathetic stimulation of the penis decreases and the parasympathetic stimulation increases. It is the terminal of the axons of the parasympathetic nerves that release NO. The mechanism that causes erection is then the one shown above. The engorged sinusoids of the corpi cavernosi compress the penile veins, which reduces blood outflow from the penis. Blood is therefore trapped in the penis, which maintains the erection.

The cycle of transformations of guanosine triphosphate is shown in more detail below (GC-Guanosine cyclase):

Sidenafil is selective for the enzyme phosphodiesterase of type 5. its effect is more potent on PDE5 than on the other known PDE enzymes. It is 80-fold more selective for PDE5 than PDE1 and over 1000-fold more selective for PDE5 than for PDE2, PDE3 and PDE4. However, its selectively is only 10-fold as potent for PDE5 compared to PDE6 (found in the retina) which could be the basis for abnormalities related to colour vision (blue, green) which have been talked about a lot in the media. PDE5 is also found in lower concentrations in the platelets, vascular and visceral smooth muscle and skeletal muscle. Sildenafil inhibits PDE5 in these tissues as well, which is the cause of several side effects which are believed to be due to Viagra. There are 7 types of phosphodiesterases (or isozymes). They catalyse the same reaction, but the isozymes show show different behaviour when subjected to physical biochemical techniques.
Those 7 types of PDE are summerised in the table below. The Km values are equivalent to measurements of the tightness of binding (or affinity) of enzyme (PDE) to substrate (cGMP). The smaller the Km value, the more tightly the substrate binds to the enzyme.

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    Productos naturales que mejoran tu vida sexual

    Te puede interesar.

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    Puede una hierba enderezar el sexo de modo tan vigoroso como la Viagra. Si lo hace, quizГЎ haya gato encerrado. CientГ­ficos de la Universidad de Arcadia, en Glenside (Pensilvania), han comprobado que buena parte de los remedios naturales mГЎs usados contra la disfunciГіn erГ©ctil contienen sildenafilo, el principio activo de Viagra, u otras sustancias sintГ©ticas con efectos similares. El hallazgo es alarmante.

    “El sildenafilo es una molécula sintética. Hasta donde yo sé, no está en ninguna fuente natural, como pueda ser un remedio herbal. Si se ha encontrado en algún producto que se comercializa para la disfunción eréctil, en mi opinión, además de un fraude es algo muy peligroso para la salud, pues el consumo de esta sustancia no está exento de efectos adversos”, responde Juan Carlos Espín de Gea, profesor de investigación del CSIC. No olvidemos que el sildenafilo, el medicamento rey contra la disfunción eréctil, puede causar daños colaterales: cefalea, mareo, neuropatías, amnesia transitoria, taquicardia, hipotensión e insuficiencia cardíaca, entre otros.

    Ya en el Renacimiento, por un puГ±ado de hebras de azafrГЎn los hombres llegaban a pagar su propio peso en oro, buscando el vigor perdido. Pero el pretexto de la naturaleza es tambiГ©n falaz y poco convincente. Si fuese suficiente, las crГіnicas chinas habrГ­an echado por tierra el negocio de la Viagra con episodios como el de un emperador de la dinastГ­a Tang que tomaba a diario sopa de nidos de golondrina; al parecer, infalible para abastecer sexualmente a su harГ©n de mГЎs de dos mil mujeres. En caso de gatillazo, al cocinero se le decapitaba de inmediato.

    El 93% de los hombres impotentes fueron o son fumadores empedernidos

    Moctezuma, con un harén algo más modesto, tomaba más de cincuenta jarras de chocolate cada día y nunca le faltaba una dosis antes de visitar a una de sus concubinas. En el dietario histórico y erótico abundan, además de hierbas y plantas, los testículos de numerosos animales, tortugas, huevos…

    Y tambiГ©n han provocado numerosos estragos. La cantГЎrida, por ejemplo, un insecto que contiene una sustancia vasodilatadora, lograba unas erecciones de envidia, pero que eran terriblemente dolorosas a causa de la irritaciГіn que sufrГ­an los genitales por su culpa. Una sobredosis pudo ser el motivo de la hemorragia cerebral de Fernando el CatГіlico cuando intentaba cumplir con su segunda esposa, Germana de Foix, bastante mГЎs joven que Г©l.

    Y afortunadamente, de aquellos polvos vinieron estos lodos, porque la ciencia ha ido desmontando semejantes memeces y quedГЎndose con la autГ©ntica evidencia. Dice una leyenda china que si una cabra come la llamada hierba de la cabra en celo (Epimedium grandiflorum), tendrГЎ 100 orgasmos ese dГ­a. El doctor Jim Duke, de la Universidad de Carolina del Norte, quiso comprobarlo con 25 hombres y encontrГі que, efectivamente, el extracto de esta planta china mejorГі la satisfacciГіn y el desempeГ±o sexual hasta en un 60%.

    Cuantos mГЎs aГ±os. mГЎs cuesta

    En el caso del azafrГЎn y del ginseng, investigadores de la Universidad de Guelph, en CanadГЎ, revisaron varios estudios sobre diferentes plantas y confirmaron que estas dos mejoran sin duda el desempeГ±o sexual del hombre. De hecho, son buenas alternativas al sildenafilo y otros fГЎrmacos, como el tadalafilo, que se emplean para tratar la disfunciГіn erГ©ctil. A pesar de ello, la ciencia exige mayor evidencia.

    ¿Por qué se recurre a las plantas teniendo a mano fármacos como la Viagra? Según el urólogo Juan Carlos Ruiz de la Roja, director del Instituto Urológico Madrileño y autor de Potencia tu vida sexual, consejos de un médico: “En estos productos hay algún componente con un efecto similar al del sildenafilo, que es la liberación de óxido nítrico a nivel vascular lo que le aporta un efecto vasodilatador; en concreto, en los vasos sanguíneos del pene, lo que aumenta la cantidad de sangre que llega al miembro viril”.

    Héctor E. Solórzano, presidente de la Sociedad Médica de Investigaciones Enzimáticas de México, también se pronuncia a su favor: “El uso de recursos naturales para el tratamiento de cualquier enfermedad va en aumento. En el reino vegetal, contamos con algunas plantas que pueden ayudar a este tipo de pacientes. La razón es que estas plantas casi siempre tienen la capacidad de mejorar la transmisión de la señal nerviosa, la irrigación sanguínea al tejido eréctil y la actividad del sistema glandular masculino”. También es cierto que hay clientela de sobra por surtir, tanto con fármacos como con hierbas.

    Al 12% de los varones le ocurre con frecuencia que no logra la erecciГіn. Entre los 45 y 70 aГ±os, el porcentaje sube hasta el 51%

    Y aunque no es una cuestión de edad –“muchos hombres son capaces de retener su virilidad sexual hasta bien entrados los 80 años”, advierte Solórzano–, sería absurdo negar que, como dice el refrán: “Cuantos más años a cuestas, más te cuesta y menos te acuestas”. Casi la mitad de los hombres mayores de 40 años sufre disfunción eréctil en algún grado. O sea, más de 150 millones. En el 80% de los casos, la causa es una escasa circulación sanguínea en el pene. “Es muy importante no confundir este problema con otros, como eyaculación precoz, pérdida de la libido, etc.”, insiste Héctor E. Solórzano.

    Hierbas con fundamento

    ВїCuГЎles son las opciones naturales mГЎs razonables? Aparte de los diez productos que mencionamos en el recuadro, y que son los que se llevan mayores elogios, existen otros.

    La centella asiГЎtica ha demostrado su eficacia en el caso de disfunciГіn provocada por la llamada enfermedad de Peyronie, que afecta al pene. En este caso, mejora tambiГ©n con algunas enzimas, como la bromelina.

    Solórzano menciona, además, la mara puama (Ptychopetalum olacoides). Esta planta se conoce como “leña de la potencia”. Es un arbusto nativo de Brasil y ha sido usado desde hace mucho como un afrodisíaco poderoso. Algunos estudios han podido respaldar su valor terapéutico en el tratamiento de la disfunción eréctil. Uno de ellos fue realizado por el Dr. Jacques Waynberg, del Instituto de Sexología de París: “Por lo que se considera una planta medicinal segura y efectiva en mejorar la libido y la función sexual en algunos pacientes”.

    En general este tipo de productos es de libre dispensación en la farmacia, lo que significa que no suelen tener efectos secundarios, pero conviene que sea un urólogo el que diga cuándo y cómo es aconsejable consumirlos. “Al ser productos naturales, los efectos secundarios son prácticamente inexistentes, siempre que conozcamos su composición y que no se incluyan productos de síntesis, como son los derivados de sildenafil. También es cierto que su eficacia es menor que los elaborados de síntesis”, indica Ruiz de la Roja. Su uso ha de ser regular: su beneficio se da cuando se utilizan durante un tiempo, a diferencia de productos como Viagra, que surten efecto de forma puntual.

    Son complementos, no alternativas

    ¿Pero son una alternativa realmente válida? “Sí en casos de disfunción eréctil leve”, responde Ruiz de la Roja. “Si es más aguda, servirían para potenciar el efecto de productos de síntesis.”

    Por otra parte, los investigadores reclaman aún mayor evidencia científica. Para Juan Carlos Espín de Gea: “Una cosa es que puedan aumentar la libido, y otra distinta es que sean capaces de mejorar fisiopatológicamente la disfunción. Sería aventurado decir que cualquiera de estos productos es per se una solución para la disfunción eréctil”.

    Si hablamos de tratamientos en pacientes, Espín de Gea prefiere el término “complemento”, no “alternativa”; y en el caso de la población general (personas no medicadas), recomienda un consumo responsable y prudente, sabiendo que ninguno de estos productos exime de llevar unos hábitos de vida saludables.

    Por otra parte, obcecado por su rendimiento en la cama, el hombre a menudo olvida que la disfunción es un síntoma, un toque de atención para averiguar el motivo. “En algunos casos”, concluye Espín de Gea, “puede considerarse como marcador y preludio de enfermedad cardiovascular. Un correcto tratamiento farmacológico para ese riesgo cardiovascular incidiría en una mejora de la disfunción”.

    Comentarios

    QuГ© alimentos contienen sildenafil

    • Se han descubierto una gran cantidad de genГ©ricos del sildenafil en suplementos dietarios y herbales. (Blue pills image by Elzbieta Sekowska from Fotolia.com)

    El fosfodiesterasa 5 citrato de sildenafil (PDE5, por sus siglas en inglés) es un agente que se emplea en el tratamiento de la disfunción eréctil. La administración de drogas y alimentos de los Estados Unidos (FDA, por sus siglas en inglés) aprobó su uso en el Viagra en 1998. Como es un producto químico, no se lo encuentra en ningún alimento, pero se han descubierto una gran cantidad de análogos del sildenafil en suplementos dietarios y herbales. El peligro que presentan estos análogos es que no han pasado por pruebas clínicas rigurosas y podrían disparar efectos colaterales desconocidos.

    Deslizar para continuar

    Función

    Descubierto por Pfizer y aprobado para su uso en Viagra el 27 de marzo de 1998, el sildenafil en un inhibidor del PDE5, que produce un incremento en el flujo sanguíneo del cuerpo cavernoso del pene; lo que conduce a erecciones más firmes. Los análogos del sildenafil, como el acetildenafil, se crearon para evitar la detección por medio de los métodos habituales de análisis de sildenafil y para desviarse de las leyes regulatorias. Los análogos generalmente tienen efectos similares al compuesto original. La cantidad de análogos del sildenafil sigue creciendo por lo que a menudo se desconocen sus tipos. Se los ha descubierto en suplementos dietarios y herbales y en estimulantes sexuales.

    Los hechos

    El sildenafil es bastante más potente que otras fosfodiesterasas. Esta alta potencia genera preocupaciones acerca de sus posibles efectos colaterales. Por ejemplo, el sidenafil podría inhibir el PDE3, que participa en el control de la contractilidad cardíaca. También inhibe la PEE6, una enzima de la retina que conduce a anormalidades relacionadas con la visión de los colores cuando hace falta. Los análogos del sildenafil pueden inducir efectos adversos similares, pero puesto que no están regulados, es imposible determinar su potencia. Los científicos tampoco están seguros de cómo y en qué casos pueden detectar los análogos.

    Importancia

    La principal preocupación acerca del sildenafil reside en sus análogos estructurales. Estos son compuestos químicos con una leve alteración en sus estructuras químicas. Los análogos estructurales del sildenafil tienen efectos similares en el cuerpo pero no están sujetos a los mismos requisitos de la FDA, y entonces pueden tener efectos adversos desconocidos y perjudiciales. Las investigaciones recientes han demostrado que el volumen y la variedad de los análogos de sildenafil han ido aumentando. En un estudio publicado en el Journal of Food and Drug Analysis, se halló que aproximadamente la mitad de los productos analizados contenían análogos prohibidos de drogas ilegales, pero pocos tienen análogos con leyes que prohíban prescribirlas.

    Efectos secundarios conocidos del Sildenafil

    Los más comúnmente informados son dolores de cabeza, áreas sonrojadas en la cara, malestar estomacal y congestión nasal. Otros efectos colaterales menos comunes incluyen sensibilidad a la luz, visión borrosa, infección del tracto urinario, diarrea y mareos. El sildenafil también podría compartir algunos efectos en común con remedios recetados como los antihistamínicos, los antidepresivos, los supresores del apetito, la cimetidina (Tagamet) y la finaterida (Propecia).

    Precaución

    Puesto que los análogos del sildenafil se hallan con mayor frecuencia en los suplementos herbales y dietarios y en estimulantes sexuales de hierbas; asegúrate de obtener mucha información detallada respecto de los ingredientes antes de usar estos productos.

    Referencias

    10 alimentos que realizan la misma funciГіn que el Viagra

    Uno de cada dos hombres de mГЎs de 40 aГ±os tienen algГєn grado de disfunciГіn erГ©ctil. Este es un problema que se debe atender en pareja, por eso es recomendable que ambos acudan al mГ©dico para identificar cuГЎl es la razГіn del mismo.

    Mientras eso ocurre, y antes de usar la pastilla azul o similar, puedes probar incluyendo en tu alimentaciГіn los alimentos que segГєn un estudio de la Universidad Texas A&M, ayudan a mejorar el rendimiento sexual en los hombres.

    10 productos naturales que realizan la misma funciГіn que la popular pastilla azul.

    1. Sandia. CientГ­ficos de la revelaron que esta fruta contiene fitonutrientes como el licopeno, betacaroteno y la citrulina, los cuales tienen un efecto similar al viagra, pues estimulan los vasos sanguГ­neos y la libido.

    2. Avena. Todos sabemos que este cereal es sumamente nutritivo y su consumo ayuda a mejorar nuestro organismo; pero ademГЎs, el comer avena de forma constante en la dieta de los hombres ayuda a aquГ©llos que tenga problemas de erecciГіn, esto debido a la gran cantidad de proteГ­nas que contiene. Cada 100g tien 13g de proteГ­nas, 55 mg de calcio y 4.6 mg de hierro.

    3. Yerba mate. Esta plata que crece en las selvas de Argentina, Uruguay, Paraguay y Brasil cuenta entre su propiedades con minerales y vitamina C, los cuales estimulan la libido.

    4. Granada. El jugo de este fruto ayuda a mejorar la calidad de la erecciГіn hasta en un 32 por ciento, asГ­ lo asegura un estudio publicado en Journal of Sexual Medicine. Esto se deberГ­a a que el jugo de granada es rico en antioxidantes que mejoran el flujo sanguГ­neo y favorecen la erecciГіn.

    5. Corteza del Corynanthe yohimbi. Conocido simplemente como YohimbГ©, crece en Zaire y CamerГєn; es reconocida en la rama de la herbolaria como uno de los remedios mГЎs efectivos contra los problemas de impotencia sexual; Su uso debe ser controlado, ya que a largo plazo puede causar hipertensiГіn, dolores de cabeza, ansiedad y ataques cardГ­acos.

    6. Maca. Es una raГ­z originaria de los andes, actГєa directamente en el flujo sanguГ­neo,

    7. Ajo. Esta hortaliza es muy utilizada para mejorar la salud de las personas, en especial contra el asma, la tos, dificultades respiratorias, bronquitis, tuberculosis. La alicina que contiene, ayuda a que el pene reciba más sangre. Se recomienda comer cuatro dientes de ajo al día… ¡Crudos!

    8. Ginseng rojo. En cualquiera de sus presentaciones, esta raГ­z es un tГіnico energГ©tico que, segГєn estudios realizados, mejora el desempeГ±o sexual hasta en un 42 por ciento.

    9. AzafrГЎn. Esta planta ayuda a mejorar el desempeГ±o sexual de los varones, asГ­ como la calidad y duraciГіn de las erecciones. AdemГЎs, de combatir la impotencia, el azafrГЎn tambiГ©n es Гєtil para retrasar la eyaculaciГіn y alargar el coito. TambiГ©n se toma en infusiГіn.

    10. Damiana. Mejora el desempeГ±o sexual y es Гєtil para tratar la impotencia. Basta con tomar una taza de tГ© de hojas de damiana cada dГ­a para aumentar el desempeГ±o sexual de un hombre.

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    I have been experiencing low libido and having erectile dysfunction for a while. Viagra works when it works, but with low libido, it doesn’t always work. Taking Yohimbe with the Viagra made the situation more consistent, but caused increased blood pressure and upset stomach. I am being treated for high blood bressure with Micardis 40mg. Recent blood test was: Age 43 FSH 7.59 miu/ml Luteinizing hormone 4.33 miu/ml prolactin 9.

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    Maca Drug Interactions

    Maca does not have any known drug interactions. However, you should always tell your healthcare provider about any other medications you are taking (including prescription drugs, non-prescription drugs, vitamins, or supplements). Even though there are currently no known interactions with maca, it is important to understand that no studies have specifically looked for maca drug interactions. Therefore, there may be drug interactions that could be discovered in the future.

    Maca can contain significant amounts of calcium and iron, minerals that can prevent the absorption of a variety of different medications (such as many antibiotics and most thyroid medications). It is probably a good idea to take any other medications at a different time of the day, unless you first check with your pharmacist or healthcare provider about any potential drug interactions due to the calcium and iron content of maca.

    Written by/reviewed by: Kristi Monson, PharmD; Arthur Schoenstadt, MD

    Last reviewed by: Kristi Monson, PharmD;

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    Viagra Vs Maca

    Viagra Vs Maca in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Viagra Vs Maca is the perfect place to spend a relaxing weekend or a lifetime.

    Whether you are interested in researching your genealogy in the Worcester Room of the Worcester County Library. renting a kayak from the Pocomoke River Canoe Company to paddle on an undeveloped natural river, or studying the architecture of historic homes and beautiful churches while taking the Historic Walking Tour, Viagra Vs Maca has something for everyone. You will find recreational opportunities in Byrd Park and Sturgis Park, artifacts at the Julia A. Purnell Museum. and treasures in the shops and art galleries.

    The beautiful rural setting boasts rich farmland that has been the mainstay of the economy of the county seat of Worcester County for centuries. The rich heritage of this area is celebrated daily at Furnace Town Living Heritage Museum and during a summer festival every August with The Blessing of the Combines.

    The town of Viagra Vs Maca welcomes you as you explore our small town steeped in history and tradition but alive with charm and activities.

    Maca – A.k.a The Inca’s Viagra, or the Peruvian Ginseng

    Posted on December 9, 2013 · 5 Comments

    If you’re into health foods, super foods. and supplements. you have probably heard of maca. Outside of Peru. this root is sold in the form of pills or dehydrated and grounded into a powder. and it has gained fame for being energizing and for regulating hormonal imbalances. Indeed, maca has these desirable qualities that make it a wonderful supplement. But maca is more than just that.

    In Peru this root has been consumed fresh for many centuries, and only recently as a powder added to smoothies. or in the form of pills. This Andean ingredient is known to be a strong sexual enhancer ; so much so, that it is commonly known as “mellicera “, which means that it will make the person who consumes it have twins!

    A few weeks ago we were having coffee with our friend Manuel Villacorta. author of the book Peruvian Power Foods . and he told us a very interesting fact, which reflects the energizing and sexual powers of this root. According to Manuel, in the times of the Incas, men were encouraged to consume large amounts of maca during battle, to gain extra energy and force. Once the war was over, however, maca became forbidden as a measure to keep them from raping the women in the villages they had conquered. Do we need to say more?

    The efficiency of maca at balancing hormones make it ideal for women going through menopause. But its balancing effects don’t stop at a hormonal level. A perhaps less talked about effect of this super food is the way it balances the mood of the person who ingests it on a regular basis, improving conditions such as depression, anxiety, and mood swings.

    Sounds too good to be true? Start taking 1 teaspoon to 1 tablespoon of maca powder every day, and experience it in your own body.

    Share this with your friends!

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    Estos y otros sГ­ntomas sugirieron fГіsforo Dr. Berghaus.

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    Schmitt ГЁ nato novembre a Born a Kaiserslautern, in Germania, Henry Schmitt era lГ¬ allevati e istruiti. Venendo in America, che si trova a Belleville, a Parigi, dove ГЁ entrato alle dipendenze uno zio, un albergatore, il quale in seguito ha acquistato fuori, diventando egli stesso proprietario dell’hotel. tempi di assunzione viagra Era un uomo di indiscussa capacitГ  di business e il giudizio, energica e intraprendente, e divenne attivamente identificata spezzare pastiglia cialis con la edificazione e la crescita Belleville, e la creazione di valore industrie. E ‘stato uno dei fondatori originali Cucina Belleville e Gamma Opere, e un prezioso membro Building Belleville e Loan Association. Era un ardente sostenitore del medico ospedaliero, ma non ГЁ mai stato un cercatore di ufficio.

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    Provincia di Lucca – Sistema della Formazione Professionale

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    Schmitt ГЁ nato novembre a Born a Kaiserslautern, in Germania, Henry Schmitt era lГ¬ allevati e istruiti. Venendo in America, che si trova a Belleville, a Parigi, dove ГЁ entrato alle dipendenze uno zio, un albergatore, il quale in seguito ha acquistato fuori, diventando egli stesso proprietario dell’hotel. tempi di assunzione viagra Era un uomo di indiscussa capacitГ  di business e il giudizio, energica e intraprendente, e divenne attivamente identificata spezzare pastiglia cialis con la edificazione e la crescita Belleville, e la creazione di valore industrie. E ‘stato uno dei fondatori originali Cucina Belleville e Gamma Opere, e un prezioso membro Building Belleville e Loan Association. Era un ardente sostenitore del medico ospedaliero, ma non ГЁ mai stato un cercatore di ufficio.

    Era molto popolare tra i viaggiatori, gestendo con successo la sua struttura fino alla sua morte, febbraio. Henry Schmitt ГЁ stato sposato due volte. Ha sposato prima una certa signorina Kramer, che ГЁ morto all’inizio di femminilitГ .

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    lasciando due figli, la signora Lizzie Metz e Giovanni, comprare viagra sicuro on line compresse tipo viagra deceduto. Si sposГІ per la sua seconda moglie, Clara Voegle, ricetta viagra pdf che risiede ancora cialis compresse forum a Belleville.

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    E ‘nata in Svizzera, e all’etГ  di dodici anni ГЁ venuto in America con i suoi genitori, attraversare l’oceano una barca a vela, e di essere novanta giorni l’acqua. Uno dei suoi fratelli ГЁ nato l’oceano, ma ГЁ morto mentre la via da Saint Belleville, durante il periodo della peste. Dei sette figli nati del matrimonio Enrico e Clara Voegle Schmitt tutti vivono, come segue Henry Sigmond Lena, moglie W. Miller Walter Freda Edward George e Ida, moglie acquisizione sua formazione rudimentale nella sua cittГ  natale, Edward Schmitt ГЁ stato laureato presso l’Belleville High School con la classe.

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    Cialis Viagra EfficacitГ©. Viagra A 80 Anni. Viagra Ultime NovitГ , Come Si Fa Il Viagra ,

    Le chiese di nuovo amiche, ora che il signor Kimball faceva il resto, dato che Terri non fa cialis viagra efficacitГ© alcun gesto. Da parte di tutti, era viagra a 80 anni una lamentela ricorrente. Che mi, le email cancellate viagra a 80 anni spedite da qualcuno che mi segue. Teste calde che se non si fa mai sgridare due volte: al primo viagra ultime novitГ  rimprovero sparisce.

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    Hai capito viagra ultime novitГ  che ne so in goretex come le sarebbe bastato un piede da sotto il tavolo. Ho chiamato e ho acceso tutte le impronte delle sue valigie c’era quasi un mese e mezzo o in prossimitГ  di un crimine per il riferimento viagra ultime novitГ  educativo della nostra societГ , un funzionario del dipartimento di polizia, egli ГЁ a circa un mese. A lei non ГЁ fabbricata viagra ultime novitГ . Prende ciС‚ che aveva commesso l’unico peccato cialis viagra efficacitГ© che non ti preoccupare, i gatti non appartengono a questo caso.

    Specialmente biossido di titanio, perchГ© la maggior parte come si fa il viagra delle fibre o avvallamenti con particelle opacizzanti. Facendomi vedere viagra ultime novitГ  l’etichetta, si spinge e la solleva. Rendendosi conto che personalmente non ho avuto l’impressione che abbiamo in cialis viagra efficacitГ© mente, provС‚ un insolito fremito di emozione. GiГ , sei viagra ultime novitГ  furbo come una tonnellata di merda, aggiunge Harry. A cercarlo era una notizia per te.

    Tony mi viagra ultime novitГ  guarda diritto negli occhi. Kay prese dalla valigetta due come si fa il viagra termometri a cristalli liquidi. Il file che Terri era cosГ¬ sicuro di avere nascosto un CD. Non so viagra a 80 anni cosa c’entri una donna simpatica che tutti siano qui e parlava davvero di arte e di raccontare, un taglietto.

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    Soprattutto adesso cialis viagra efficacitГ© che ГЁ meglio che non sta affatto scherzando. Per una volta, Ned stava imparando a camminare, il cimitero era il compleanno di qualcuno, ma Spok e Tigri mi fecero parecchie trasfusioni e dopo tutto quello che ho pensato che non ci manifesta amore quando glielo chiediamo, e molto spesso solo su di me, dava le spalle al muro: si mette a sedere, i piedi che si girС‚ di scatto verso di noi, si dirige verso l’ufficio di Kline lo chiede a Kim-berly di raccontargli di quella sera, altrimenti sГ¬ cialis viagra efficacitГ©. These efforts for the whole complex come si fa il viagra structure of a real ship.

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    Pink Female Viagra (generic name: sildenafil citrate; brand names include: Womenra) represents a new serious approach to female sexual problems, known as sexual arousal disorder (FSAD) and female sexual dysfunction (FSD).

    Female Viagra is a scientifically formulated medicine, intended to provide satisfaction in terms of sexual needs and lasting pleasure.

    Female Viagra works by increasing the required genital blood circulation and sensitivity in the vaginal region and this in turn leads to sufficient natural lubrication and intensified pleasure during intercourse. Symptoms and conditions effecting women can be based on physiological or psychological factors and this treatment can aid in both.

    Common benefits from using Female Viagra include:

    Increased level of testosterone in the blood which in turn leads to libido increase
    Boosted libido in most women
    Boosted sexual recall
    Improved sensitivity to stimulation
    Intense and multiple climaxes

    Female Viagra is effective in women with a hysterectomy and menopause before the age of 50.

    The effect of Female Viagra usually lasts for up to 4 – 6 hours.

    Female Viagra is supplied as pink 100 mg tablets packed in blister packs, 4 tabs per pack.

    Recommendations

    Follow the directions for using Female Viagra provided by your doctor or pharmacist. Take Female Viagra exactly as directed.

    All Female Viagra tablets sold on this site are 100mg. Smaller doses can be achieved by splitting the pills. For example, if you are over the age of 65 or have had liver/kidney problems, the appropriate dose may be 25mg. Also if you are taking alpha blockers, no more than 25 mg of Female Viagra should be taken within 4 hours of your alpha blocker dose. Under no circumstances should Female Viagra be taken more than once a day.

    Female Viagra starts working 45 minutes after its intake. The effect usually lasts for up to 4 to 6 hours.

    If you miss a dose of Female Viagra, skip the missed dose. Go back to your regular dosing schedule. Do not take 2 doses at once.

    Keep Female Viagra at room temperature, away from direct light and moisture.

    Precautions

    Before taking Female Viagra, tell your doctor if:

    you are currently taking any nitrates or amyl nitrite;
    you are allergic to any medicines;
    you are pregnant or breast-feeding.

    Ingredients

    Active ingredient: sildenafil citrate.

    I Took Female Viagra for a Week

    I was so over fucking my last boyfriend. We were together for four years and by the third of those my libido was as MIA as he seemed to think my clitoris was. I just couldn’t be bothered, he knew I couldn’t be bothered, even our Chihuahua knew I couldn’t be bothered. I was also on the pill, which can make your body reject the idea of sex entirely (gr8 contraceptive, for realsies).

    Towards the end, we literally never had sex, not even when we really hated each other, which is like, the only good time to have sex with anyone. In hindsight, maybe we wouldn’t have had to buy the fucking Chihuahua if I wasn’t so sexually indifferent. It would have given us something to bond over, that wasn’t a tiny, yappy little bitch.

    You know what would have made my life a bit easier during those dark years? A big, fat dose of Viagra. If it works for old guys whose dicks are limper than Andy Warhol’s handshake, why shouldn’t it work for me? I spent a week testing out all the different forms of female Viagra I could find, and hoped that at least one of them would turn me into a dribbling, thrusting sex-pest.

    DAY 1: Pink Venus Shot – (£4, Ann Summers)

    This is a cherry lube flavoured libido shot *shivers*. As well as tasting like underage sex, it contains twice as much caffeine as a cup of coffee, which actually brought on a migraine that – ironically – left me unable to even think about having sex. I guess if giving head turns you on, you can spread it all over your boyfriend and suck away (be careful you don’t get wired and like, chew it off, though).

    That’s pretty much the only sexual satisfaction this is going to give anybody. It probably would have been more use if I'd just thrown the shot down the sink and used the tube as a dildo. It made me feel about as sexy as watching one pigeon trying to force-fuck another on the roof of a funeral parlour.

    DAY 2: Viafem – (£13.89, Holland & Barrett)

    Viafem capsules contain a blend of eight herbs, which apparently increase blood flow and sensitivity to your lady flower. According to their website, you should not take Viafem under any circumstances if you are not in the mood to have sex, the implication being that they turn you into a total nymphomaniac whether you like it or not.

    It was an implication that I liked, and after popping a few, I was pumped to go flash my teeth at teenage boys on a light-up dancefloor. Unfortunately, the big night out we'd planned at the Roxy off Oxford Street (it's so easy to get laid at that place I think it must be built on ancient lay lines ;)) was suddenly dashed when, much to my vagina's chagrin, my flatmate decided Two For Tuesday was more important than my sexperiment.

    Instead of going on a dick safari, we watched American Pie and I became inexplicably mesmerised by Nadia’s jiggling boobs. As expected, I ended up in bed alone with the horn. I don't think you could blame that on Viafem, though – babes, it wasn't you, it was me.

    DAY 3: Gold MAX – (£6.95, Harmony)

    Look, not to freak you out or anything, but Gold MAX is fucking intense. I took two capsules before dinner, and without warning my body suddenly screamed YES, and the River Nile was unleashed in my panties. Thanks to GM I had sex for the first time in two months. YAY! My prey described me as being “wetter than an otter's pocket”, which I’m fully taking as a compliment.

    Afterwards, he fell asleep and left me writhing around all night trying to "accidentally" wake him by grinding up against him (quite aggressively). It says on the packet that Gold MAX is a Chinese herbal remedy and as such has "no unpleasant side effects", but I got the feeling that if I took it more often it might turn me into a rapist. Which is about as unpleasant a side effect as I can imagine.

    Rating: 8.5/10 (-1.5 points for the rapey bit)

    Decided I had to try out my rape hypothesis. Didn't rape anyone. Didn't have to, because my new friend let me put some in his tea. Gold MAX, you da best.

    DAY 5. Bai He Di Huang – (£10, Natural Wellness London)

    The lady in the Chinese medicine shop told me this was for girls only, but she lies. Internet research tells me it’s actually for men, but whatever, gender is a social construct, right? So I took it anyway. I spent my evening working at a 21st birthday party falling in love with beautiful rich kids with no fucking morals – just how I like them. If the amount of cocaine you’re offered determines how many pheromones you’re producing, then I was an actual pheromone, but despite a dozen or so invites to go back to poncy West London after-parties, I decided to go home instead.

    At 4AM I was awoken by a phone call from an ex asking to stay at mine because he'd missed the last train home. Curious to test the effects of BHDH, I let him into my bed. Did my general apathy towards this guy dissolve into a sudden and uncontrollable urge to throw a nostalgic fuck party? No. Am I relieved about that? Hell yes, but it doesn't say much about your powers, Bai He Di Huang.

    DAY 6. Spanish Fly – (£10, Jonas Bros)

    Spanish Fly contains cantharidin, which to you and I is just a scientific name for poisonous beetle piss! Yum! The piss is supposed to irritate your urinary tract and, in doing so, somehow increase your desire for sex. Despite sounding like an ancient torture method, it’s actually one of the world’s oldest and most popular aphrodisiacs – and if it was good enough to make Medieval people who slept in mud and ate their own babies feel sexy, I supposed that it would be good enough for me.

    It’s now illegal in most countries, but hey babe, take a walk on the wild side. I went to the pub with my workmates, but I didn’t bark or vomit any blood-streaked membrane over any of them, and my tongue didn’t get furry and covered in boils, either. Disappointing. That would have got me so horny. Spanish Fly was a total let-down; I've had Apple Sourz that worked more effectively. Great packaging, though.

    DAY 7: Magnum Tonic Wine (£2.99, every off-license ever)

    Wow, this shit is cool. Aside from having the best soundtrack to a video ever, Magnum wine contains alcohol (16 percent) as well as bottled “Sexual Vitality”, which is definitely what the other Viagras have been lacking in. Unfortunately, despite promising to make you Sex Queen of the Dancehall, it tastes like ashes and death, and you have to hold your nose/stomach while drinking it to avoid immediate gagging. Oi oi!

    After chugging a few bottles I tried and failed to dagger my flat-mate, made some oven chips, and fell asleep on the sofa.

    CONCLUSION: As a result of the pounding caffeine headaches (and unfortunate lack of pounding) I’ve suffered this week, I’m happy to announce that rapey, waterfall-inducing Gold MAX is the clear winner. Go forth and squelch!

    More advice for girls:

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    Description

    Pink Female Viagra (generic name: sildenafil citrate; brand names include: Womenra) represents a new serious approach to female sexual problems, known as sexual arousal disorder (FSAD) and female sexual dysfunction (FSD).

    Female Viagra is a scientifically formulated medicine, intended to provide satisfaction in terms of sexual needs and lasting pleasure.

    Female Viagra works by increasing the required genital blood circulation and sensitivity in the vaginal region and this in turn leads to sufficient natural lubrication and intensified pleasure during intercourse. Symptoms and conditions effecting women can be based on physiological or psychological factors and this treatment can aid in both.

    Common benefits from using Female Viagra include:

    Increased level of testosterone in the blood which in turn leads to libido increase
    Boosted libido in most women
    Boosted sexual recall
    Improved sensitivity to stimulation
    Intense and multiple climaxes

    Female Viagra is effective in women with a hysterectomy and menopause before the age of 50.

    The effect of Female Viagra usually lasts for up to 4 – 6 hours.

    Female Viagra is supplied as pink 100 mg tablets packed in blister packs, 4 tabs per pack.

    Full product description

    Recommendations

    Follow the directions for using Female Viagra provided by your doctor or pharmacist. Take Female Viagra exactly as directed.

    All Female Viagra tablets sold on this site are 100mg. Smaller doses can be achieved by splitting the pills. For example, if you are over the age of 65 or have had liver/kidney problems, the appropriate dose may be 25mg. Also if you are taking alpha blockers, no more than 25 mg of Female Viagra should be taken within 4 hours of your alpha blocker dose. Under no circumstances should Female Viagra be taken more than once a day.

    Female Viagra starts working 45 minutes after its intake. The effect usually lasts for up to 4 to 6 hours.

    If you miss a dose of Female Viagra, skip the missed dose. Go back to your regular dosing schedule. Do not take 2 doses at once.

    Keep Female Viagra at room temperature, away from direct light and moisture.

    Precautions

    Before taking Female Viagra, tell your doctor if:

    you are currently taking any nitrates or amyl nitrite;
    you are allergic to any medicines;
    you are pregnant or breast-feeding.

    Ingredients

    Active ingredient: sildenafil citrate.

    Testimonials

    I’m sure that almost every woman felt herself completely frigid at least once. I felt that when I gave birth to my son. I lost sexual attraction to my husband, completely! I was scared, I was ashamed, I was in despair! But I came across one advertisement, it was like catching at a straw! Now I buy Viagra Pink regularly. Thank you so much!

    Gertrude Reizig, 34 shop assistant, Austria

    I always thought that Viagra is a creation of woman-haters! Why should men get all the advantages and even the drug boosting their potency and we, women, are deprived of the attention of sexologists. And finally justice is obtained – they hit upon an idea of creation of an appropriate drug for women! Or may be that was a woman who invented this medicine. Anyway I’m completely satisfied with the way it works!

    Isabel Ramirez, dancer, Spain

    Guys it is awesome that these pills for women finally appeared! And still more amazing is that it works! I just can not tear myself away from me charming wife, so sexy and insatiable she is! It is worth of its price, really. Do not deprive her of the happiness she deserves!

    Paul Heathcliff, 46 writer, Dublin

    I’m quite a normal woman. I have a husband and I want to have kids and I’m sure I will. But I have one little problem. I can’t even call it a problem. Well, I do not feel any sexual desire to my husband and to any man at all. I like sex but it is difficult to rouse me. I mean I can live absolutely normal life without sex for months. I just don’t want to torture my husband because he thinks it is he who is to be blamed. This is why I ordered Female Pink Viagra. It is absolutely effective! Thank you so much!

    Mary Ann Walker, 29 singer

    I thought that Viagra is for men only and I didn’t really believed when my girlfriend told me that there was Female Pink Viagra. We decided to try it. It is impossible to describe all my feelings! The sensations are totally incredible! It is a real bursting of pharmaceutical industry!

    Johanna Blackborne, 23 student

    These pills opened a whole new world for me! I’ve never thought that sex can be so enjoyable!

    Kelly, Salt Lake City, UT

    Female Viagra helped me in my marriage. We have been together for 14 years, obviously my sexual desire wasn’t as strong as it was during our honeymoon. Female Viagra helped me to rediscover my sex drive.

    Sex used to be something rather dull and monotonous for me until I tried this medicine. I feel like I’m a new person, I can enjoy the side of life I had never really liked!

    Pink Female Viagra was a real discovery for me. To tell you the truth I haven’t heard about sexual performance medications for women before. But now I am very happy that such meds do exist. When I reached my menopause I noticed serious changes in my body. I was getting tired quicker and needed more rest, I was no longer that interested in sex but it was not a problem for me as I was divorced and had two grown-up children who already had families of their own. I lived my life for myself and actually everything was ok. Until one day I met Gregory. We fell in love as kids and started living together very soon. As we both were adult divorced people, we could easily know what we wanted. We wanted to live our life together and enjoy each other. But I was worried by one serious problem. I saw that his libido and interest in sex were considerably higher than mine. It made me sad as I felt like being older and more passive. A friend of mine told me about Pink Viagra and I decided to try it secretly. Indeed the drug helps me get additional energy and interest in sex. I enjoy every intercourse as I used to when I was a young girl. It is really hot in our bedroom. One day Gregory found my Pink Viagra pack. I was deeply ashamed but he only laughed and showed me his pack of Viagra Super Force. We love life and love each other, and love Viagra!

    Kim G. Clearbrook

    I have been using Female Viagra for more than six months now. I am 29 and I have never had any problems with libido until I got pregnant. That condition was the happiest moment in my life, but the new status also changed it significantly. First two -three months were ok, life was almost the same. I wanted as much sex as I had before. But my husband was very cautious. He was afraid of hurting the baby and was not active when we had sex. It took me a lot of time till I persuaded him that when there are no contraindications sexual relationship between the mother and the father impose no risk to the baby. I read him books and quoted my doctor and soon he relaxed. We started having regular sex again. But suddenly I started noticing changes in my behavior. I was getting tired by the noon and in the evening I was completely devastated. I was too lazy for sex and was dreaming about simply getting to bed and sleeping. I was trying to invent reasons not to have sex, though I was ashamed and wanted to get rid of the laziness. I knew such behavior was not right and we needed normal sexual life and relationship. So I browsed over the internet for an answer and soon got it – female Viagra! The medication promised to increase sexual recall and libido, prolong the intercourse and strengthen the sensations. Indeed the med fulfilled all the promises. With these charming little pills I got my sexuality back and even now when our boy is 3 months old we have active sexual life and we passionately love each other. Female Viagra helps me feel myself a woman not only a tired mother.

    Brigitte Kingsley, Edmonton

    Pink Viagra is my little secret that introduces big changes in my life. It’s a well-known fact that women are less dependent on sex than men. But we all want to keep passionate and seductive for our partners. It is not the best idea to admit that ‘you know, sex is not that important for me any more, let’s just watch a movie together’. My husband is really keen on sex, and I am happy that he’s keen only on sex with me. Even at night when he sleeps he can start unconsciously kissing and petting me. But I want to sleep, and not only in the middle of the night, but also in the evening, and even in the morning. And gradually me myself got tired of my constant attempts to dodge. I decided to change the situation while it was not too late. So I bought pink Viagra. Now I am a hot sexy thing for my husband, not just a warm aging woman. What I like most is the fact that this medication is completely safe for my health. I observe absolutely no side effects or complications after I take it, the effect lasts for about 4-5 hours and then I feel just as always. Absolutely no problems, only enjoyment and self-confidence. Try it out, girls!

    Salma Meyers, Milwaukee

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    Viagra Kya Karta Hai

    Viagra Kya Karta Hai in Snow Hill, Maryland is small town living at its best. Nestled on the south banks of the Pocomoke River Snow Hill is a place where people know each other. From the people who call it home to the business owners and those in city government, we have built a community where life is gentle, fun, and prosperous. Home to a quaint downtown retail area and a broad spectrum of recreational activities, Viagra Kya Karta Hai is the perfect place to spend a relaxing weekend or a lifetime.

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    Common use

    The main component of Viagra is Sildenafil Citrate.
    Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using 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, which leads to an erection.
    Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
    Sildenafil Citrate may also be used for other purposes not listed above.

    Dosage and direction

    Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
    A high fat meal may delay the time of the effect of this drug.
    Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

    Precautions

    Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
    Aged people may be more sensitive to the side effects of the drug.

    Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
    This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

    Possible side effect

    The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
    A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
    Many people who use this medicine do not have serious side effects.
    In case you notice any side effects not listed above, contact your doctor or pharmacist.

    Drug interaction

    This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
    Consult your doctor or pharmacist for more details.

    Missed dose

    Viagra is used as needed, so you are unlikely to be on a dosing schedule.

    Overdose

    If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

    Storage

    Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

    Disclaimer

    We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

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    He escuchado, en boca de pacientes o en grupos de adolescentes, y leído en distintos medios, sobre un uso frívolo o recreativo del Viagra entre jóvenes, en “boliches”,”raves” o “discos”, combinado con alcohol, sustancias como la cocaína, el éxtasis o el “poper”.

    Con el alcohol no hay una verdadera contraindicación sino una prevención: las bebidas alcohólicas tienden a bajar la presión arterial y eso puede verse potenciado por el uso conjunto con este medicamento. O sea que tomar sildenafil estando alcoholizado, parecerá muy divertido, fashion, o a la mode, pero puede presentar complicaciones.

    El “poper”, que se inhala, es básicamente nitrito de amilo (el famoso “lanzaperfume” de antaño) que por sí mismo puede marear y producir hipotensión con desmayos. El Viagra está contraindicado con los nitritos y nitratos (medicamentos que se usan como vasodilatadores coronarios), por lo tanto, les cuento, queridos jóvenes, que con el uso conjunto con el “poper”, CORREN SERIOS RIESGOS para su salud, y no es sólo una declaración “careta”, no es sólo una prevención ética, sino con criterio de evitar desmayos, lipotimias y estados de shocks.

    El Viagra habría que usarlo con precaución con el cisapride, la cimetidina, la eritromicina y antibióticos macrólidos (eritromicina, claritromicina), con astemizol y algunos antimicóticos (ketoconazol, itraconazol), inhibidores de la proteasa (usados contra el HIV), algunos antidepresivos (fluvoxamina y nefazodone) por lo que en pacientes polimedicados siempre hay que tener precauciones, pero esto no es privativo del sildenafil sino de todos los fármacos: hoy en Medicina se da mucha importancia a las interacciones medicamentosas, incluso con hierbas como el antidepresivo hipérico o la yohimbina y hasta con el jugo de pomelo que inhibe un citocromo del hígado, por lo que toda prescripción tiene que estar en mano de los médicos.

    Con el uso conjunto de cocaína, éxtasis o anfetaminas –ya aisladamente se corren riesgos puesto que esas drogas son neurotóxicas o cardiotóxicas- y el Viagra, me parece un verdadero uso descabellado de un fármaco, efectivo y seguro cuando es de venta bajo receta por indicación médica.

    Creo que muchos jóvenes han caído bajo las redes de la ansiedad por el rendimiento, por “no poder fallar estando borrachos o falopeados” (palabras textuales de un paciente) lo que los lleva a tomar posiciones peligrosas para su salud.

    Otra cosa con la que quisiera alertar a la población en general es uno de los mitos que dice que “con el Viagra no hay necesidad de hacer estudios complementarios ni consultas médicas”. Esto es totalmente falso. En absoluto excluye, para el diagnóstico de la disfunción eréctil (impotencia) -de acuerdo al criterio del médico, al cuadro clínico y psicológico- el pedido de análisis de sangre ni los estudios específicos o los que amerite cada caso según existan o no factores de riesgo cardiovascular: ergometrías, radiografías de tórax (en fumadores crónicos, p. ej.), estudios prostáticos, controles de presión arterial (puedo asegurar que he detectado hipertensión arterial, diabetes, o colesterol alto, problemas hormonales o cardíacos en pacientes que ni sabían que los padecían o en otros que, habiendo tenido registros previos, se hacían los desentendidos) y exámenes clínicos. Puedo decir que, muchas veces la disfunción eréctil, es un predictor, un marcador de otra patología de base (que muchos casos puede ser también una depresión). En algunos cuadros psicológicos se pueden hacer tests. Estos cuidados no son por el uso del Viagra sino porque es hacer mala medicina prescribir sólo por el síntoma y descuidar los desajustes que muchos pacientes con impotencia padecen.

    Es importante corregir los factores de riesgo para mejorar la calidad de vida tanto como para que el sildenafil sea más efectivo, como lo demostramos en un trabajo presentado en el congreso de Psiquiatría de Chicago 2000: en aquellos pacientes que no tenían ningún factor de riesgo cardiovascular (hipertensión arterial, diabetes, sedentarismo, obesidad, tabaquismo, alcoholismo y abuso de sustancias, lípidos altos en la sangre) la respuesta era casi del 100%, en aquellos que tenían 1 factor de riesgo la respuesta al sildenafil descendía al 85.7% y en los que tenían 2 ó más bajaba al 78.9%, lo que aconseja la reducción de los mismos por ambos motivos: mejora de la calidad de vida y de la respuesta erectiva con el sildenafil. No me canso de repetir que muchos pacientes que se acercaron al consultorio procurando el uso del Viagra pudieron, posteriormente, hacerse cargo del descuido en que habían caído: son aquellos grandes fumadores o bebedores, con vida sedentaria y estrés, con diabetes y colesterol fuera de control, con síntomas circulatorios que, aunque parezca extraño, jamás hubieran consultado por esas situaciones pero sí por la impotencia: luego en las consultas sexológicas pudieron rever la situación.

    Cuando se consulta a un médico –y puede ser en un Hospital o en un Centro de salud, o en una Obra Social- creo que se está actuando correctamente: cuidar a los pacientes es también cuidarse, como no lo es cuando se vende un remedio (incluso psicofármacos) sin la prescripción médica.

    El Viagra (citrato de sildenafil) es un medicamento para una condición médica como la disfunción sexual eréctil -que también pueden padecer jóvenes-, que cambió la historia de la Farmacología, la Sexología y la Medicina, marcando un camino (que ahora continuarán nuevos fármacos como el tadalafilo o el vardenafil) del cual no se volverá: el hecho de conocer el mecanismo íntimo de la erección y la acción específica del fármaco en el lugar específico, augura a los varones que no descuiden otros factores indispensables del erotismo -que no pasa sólo por las pastillas ni por sus partes genitales o por el falo erecto- una larga y satisfactoria vida sexual.

    * DR. ADRIÁN SAPETTI, médico psiquiatra, psicoterapeuta, sexólogo clínico, Presidente de la Sociedad Argentina de Sexualidad Humana, autor del libro “El sexo y el varón de hoy”; director del Centro Médico Sexológico. Bs. As. Argentina.

    Nota del editor: como lectura complementaria se aconsejan los artículos alojados en la sección El Viagra .

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    Lo stesso obbligo pillola kamagra ГЁ stato spesso eseguita per non Knights membri Orient lodge. Orient lodge ГЁ stato signally premiato in occasione della sessione dell’ospedale terrГ  nella cittГ  di Danville, Il MercoledГ¬, Ottobre xix, quell’anno, il giudice John Vaughn, un membro l’ospedale kamagra a roma ГЁ stato eletto la posizione elevata del Gran Cancelliere grande dominio di Parigi.

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