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Medical hair restoration in the literal sense includes the hair loss treatment which depends upon the use of medicines. Unusual hair loss both in men and women is caused by the alterations in the androgen metabolism. Androgen is a male hormone which has a major role to play in regulation of hair growth or hair loss. The dermal papilla is the most important structure in a hair follicle which is responsible for hair-growth. It is the dermal papilla, the cell of which divides and differentiates to give rise to a new hair follicle. The dermal papilla is in direct contact with blood capillaries in the skin to derive the nutrients for the growing hair follicle. Research has shown that dermal papilla got many receptors for androgens and there are studies which have confirmed that males have more androgenic receptors in dermal papilla of their follicles as compared to females. The metabolism of androgen involves an enzyme called 5 alpha reductase which combines with the hormone androgen(testosterone) to form the DHT (Dihydro-testosterone). DHT is a natural metabolite of our body which is the root cause of hair loss. Proper nutrition is critical for the maintenance of the hair. When DHT gets into the hair follicles and roots (dermal papilla), it prevents necessary proteins, vitamins and minerals from providing nourishment needed to sustain life in the hairs of those follicles. Consequently, hair follicles are reproduced at a much slower rate. This shortens their growing stage (anagen phase) and or lengthens their resting stage (telogen phase) of the follicle. DHT also causes hair follicle to shrink and get progressively smaller and finer. This process is known as miniaturization and causes the hair to ultimately fall. DHT is responsible for 95% of hair loss. Some individuals both men and women are genetically pre-disposed to produce more DHT than the normal individuals. DHT also creates a wax-like substance around the hair roots. It is this accumulation of DHT inside the hair follicles and roots which is one of the primary causes of male and female pattern hair loss. Blocking the synthesis of DHT at molecular level forms the basis for the treatment of MPHL ( male pattern hair loss) and FPHL female pattern hair loss). There are many natural DHT blockers and a number of drugs which are used for medical hair restoration. Let us see the main drugs which are available for medical hair restoration in men and women. Minoxidil Minoxidil has the distinction of the first drug being used for promoting the hair restoration. This medical hair restoration treatment drug was used earlier as an oral antihypertensive drug, but after its hypertrichosis (excessive body hair) effects were noticed, a topical solution of the drug was tested for its hair growing potential. Minoxidil was then approved as medical hair restoration treatment drug for men by the US Food and Drug Administration (FDA) in 1988 as a 2% solution, followed by 5% solution in 1997. For women, the 2% solution was approved in 1991. Though 5% solution is not approved for women, it is used as a medical hair restoration treatment by many dermatologists worldwide. Both solutions are available without a prescription in the US. Mechanism of action Minoxidil is thought to have a direct mitogenic effect on epidermal cells, as has been observed both in vitro in vivo. Though the mechanism of its action for causing cell proliferation is not very clear, minoxidil is thought to prevent intracellular calcium entry. Calcium normally enhances epidermal growth factors to inhibit hair growth, and Minoxidil by getting converted to minoxidil sulfate acts as a potassium channel agonist and enhances potassium ion permeability to prevent calcium ions from entering into cells. Thought the exact action of minoxidil preventing the formation of DHT has not been shown but the drug has been shown to have a stabilizing effect on the hair loss. The result of the drug takes about few months time to be evident since it is the time which is necessary for restoring the normal growth cycle of hair fibers. Use of Minoxidil has approved by FDA for men (Norwood II-V) and women (Ludwig I-II ) older than 18 years. It is used as a medical hair restoration treatment either for frontal or vertex scalp thinning. It brings about an increase in density which is mostly caused by conversion of miniaturized hairs into terminal hairs rather than a stimulated de novo re-growth. The hair loss becomes stabilized after continued use of drug, which takes about a year’s time for the medical hair restoration treatment to show its complete results. Hair loss restoration treatment with 0.05% betamethasone dipropionate and 5% topical minoxidil are found to be superior to minoxidil alone. Topical minoxidil is very well tolerated and adverse effects are mainly dermatologic. The most frequent adverse effect is an irritant contact dermatitis. Though minnoxidil does not have any effect on blood pressure, it should be used with caution in patient with cardiovascular diseases. It is also contraindicated in pregnant and nursing mothers. Finasteride The drug finasteride was earlier used as treatment for prostate enlargement, under the medical name Proscar. But in 1998, it was approved by FDA for the Medical hair loss restoration in MPHL. Mechanism of Action Medical hair restoration treatments with Finasteride depends upon its specific action as an inhibitor of type II 5α-reductase, the intracellular enzyme that converts male hormone androgen into DHT (Dihydro Testosterone). Its action results in significant decrease in serum and tissue DHT levels in even in concentration as low as 0.2mg. Finnasteride is able to stabilize hair loss in 80% of patient with Vertex hair loss and in 70% of patients with frontal hair loss. Most of these patients are able to grow more hair or retain the ones they have. The peculiar thing about Propecia is that its effect is more pronounced in crown area than in the front. The hair that grow after the medical hair restoration treatments are better in texture and are thicker, more like the terminal hair. The best thing about medical hair restoration treatment with the finnasteride is that it is well tolerated and has minimal side effects. Sexual dysfunction (decreased sex drive, erectile dysfunction, and decreased semen volume) are observed in about 3.8% of cases. But these side-effects subside within few months of Medical hair restoration treatments or disappear within a week’s time as soon as the treatment is stopped. It generally requires about 6 to 12 months for the m edical hair restoration treatment to be apparent but the side effects appear earlier. So even after the medicine is stopped, there is no possibility of loosing the hair that has been gained, but the side effects are sure to disappear. Many hair restoration surgeons find Propecia (finasteride) to act as an excellent adjunct to the surgical hair restoration. There are several benefits of this kind of combination therapy. As the Medical hair restoration with Propecia brings about a hair re-growth in the crown area, it has a complementary action; it allows the surgeon to have more donor hair to be available for frontal hair transplant and design the hairline at his own will. Since finasteride has no effect in the frontal area of the scalp, it does not have any interference with the surgical hair restoration. Combination Therapy There are reports which say that use of finasteride and topical minoxidil combination therapy as a Medical hair restoration treatment is of more advantage in cases of mild to moderate MPHL. Further studies are in progress. Many hair restoration doctors have already started the use of combination therapy in order to obtain better hair growth. Anti Androgen Therapy For women with hyperandrogonism( with increased levels of androgen) who do not respond well to minoxidil, antiandrogen therapy is another option of Medical hair restoration. In UK the most commonly used anti-androgen for women is CPA (cyproterone acetate), which is used in combination with ethinyl-estradiol. However, in United States, where CPA is not available, the aldosterone antagonist spironolactone is the alternative choice of hair restoration doctors. Flutamide Medical hair restoration with flutamide has shown improvement as hair loss restoration treatment in women with hirsutism. For hyperandrogenic premenopausal women, flutamide is a better medical hair restoration agent than both the CPA or finestride. Hair loss restoration management is a structured process which depends upon many factors along with the medical hair restoration. 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A plumber came round to my house today. This in itself was all well and good. He was a lovely guy by the name of Dennis, clearly very experienced, and he got the job done in an unexpectedly short couple of hours. I'd been bracing myself for a hot-water-free weekend, so it was a very pleasant surprise to have the problem fixed so quickly. In order to assist Dennis in finding the information he needed to mend my water heater, I looked up the manufacturer's details on the Internet, with Dennis looking over my shoulder, helping. Within a few minutes, Dennis had called his boss, who called the manufacturer, who explained the solution to Dennis's boss, who explained the solution to Dennis, who fixed the problem. Presto. Dennis and I were quite pleased with ourselves, and congratulated each other profusely on our combined ingenuity. After Dennis had left, I got back to my laptop to find that the two websites that I'd been editing before he arrived had been clearly on view throughout his visit. These websites were, let's just say, 'in the experimental stages', and were designed to draw a large number of hits, thereby generating a bit of advertising revenue for this pauper of a writer. One was called 'Living Sober - Without AA'. The other was called 'Free Penis Enlarger'.* I'm not embarrassed about it though. It's a simple mistake which anybody could make. * I feel obliged to add, for the sake of my own self-esteem, that this site was in fact devoted to images of beautiful women! buy penile enlargment pills cheap penis enlarement penile enlargement photo free pennis enlargement tip natural penis enlarement exercise pennis enlargement pic free penile enlargement technique penis elargement system pennis enlargement without pills

In the third grade I was told I could write a paper on any topic for an English homework assignment. I chose the subject of scurvy as it affected sailors who were away at sea for long periods of time and the resulting discovery of Vitamin C as its cure. I remember the paper well for I was literally transcended from ignorance to a place of awe at the intricacies of the human body and its response to nutrients. Today, antioxidants are the word on the street. They are used to boost energy (forget caffeine - this stuff rocks!) and these antioxidants fight infection, and address a whole range of health issues. Before XanGo, Tahitian Noni, Fruta Vida, (containing, respectively, mangosteen, goji, and acai) and now Amigo Juice (a marriage of all three super foods), we had Vitamin C, E, and A. For many of us, it was all about drinking that cup of orange juice at breakfast or taking a vitamin supplement. But today, we are not talking about just a punch but a real blow to sickness and disease, taking the form of antioxidant rich health beverages that many consumers swear by in their quest for wellness. Living in today's very toxic world, antioxidants deserve a special place in the area of nutritional supplements and are certainly worth examining closer to see what they are all about and learn how we can implement them into our daily routine. Quite simply put, at the molecular and cellular levels, antioxidants serve to deactivate certain particles called free radicals. In humans, free radicals usually come in the form of O2, the oxygen molecule. The oxygen molecule desires to be oxidized, and this oxidation process can sometimes be carcinogenic. Free radicals are the natural by-products of many processes within and among cells. They are also created by exposure to various environmental factors, tobacco smoke and radiation. Of course, this certainly includes air quality and all the junk we put into our bodies that our immune system is forced to combat. If allowed to run amok, these free radicals can cause damage to cell walls, cell structures, and genetic material within the cell. They are the bully on the playground and need to be dealt a firm hand for the resulting damage can eventually lead to disease and ultimately death. Antioxidants play a key role in cleaning up the destruction caused by these free radicals. They clean house before free radicals get a chance to harm the body. Researchers have determined that antioxidants are useful in the prevention of carcinogenic effects of oxidation. To that end, a variety of health companies, most notably in the form of multi-level marketing, have cropped up offering antioxidant rich health drinks, as captured in the "pericarp," "hull," "pulp," "rind," basically the whole fruit, the kitchen and its sink, ground and mixed and served up in tasty 1 oz. servings. Not to mention the mangosteen fruit has introduced an entirely new classification of antioxidants, called Xanthones with professed health benefits too numerous to list, many years of research, and centuries of positive use. These antioxidant rich drinks created three distinct camps. One decided the mangosteen is their drink of choice, goji has its determined followers, and there is also acai (pronounced ah-sigh-ee). It became difficult to navigate through hype and look for substance. According to numerous reports by customers, they all have their benefits. However, in March of this year, one product was introduced, integrating all three important fruits into one single product in a dried formula, omitting any need for pasteurization, cutting back on the cost of shipping, and providing the most bang for the buck. Most importantly, each of the three super foods had very distinct benefits. Now we have a marriage of all three fruits in one drink in Amigo Juice. THE BIG THREE SUPER FOODS The following is a look at the three fruits: acai, mangosteen, and goji. ACAI: The Acai berry, or Acai Fruit grows on majestic palm trees in the Amazon Rainforest and looks like a purple marble or grape. Acai contains high levels of Antioxidants, Omega Fatty Acids (healthy fats), Iron, Amino Acids, Fiber, and many other vitamins and minerals. The people living in the Amazon region in Northern Brazil, have consumed Acai for hundreds of years and its healing and sustaining powers are legendary. Acai Berry is known to harness the following properties: Antioxidant, Antibacterial, Anti-inflammatory, Antimutagenic, Cardiovascular System. Acai berries contain very high amounts of essential fatty acids and omegas proven to lower LDL and maintain HDL cholesterol levels. They also contain a remarkable concentration of antioxidants to help combat premature aging. Acai Berry is a dense source of a particular class of flavonoids called anthocyanins. The ORAC value of Acai Berry is higher than any other edible berry in the world. Acai Berry is also an excellent source of dietary fiber. Acai is extremely rich in organic vegetable protein which does not generate cholesterol during its digestion and is more easily processed and transported to your muscles than animal protein (such as what is found in milk or meat). Besides its outstanding content of protein and unsaturated lipids, Acai is also rich in carbohydrates, providing your body with the necessary energy while working or practicing any kind of sport. There is also an amazingly high concentration of antioxidants useful in combating premature aging. The proanthocyanidine contents in Acai Berries contain 10 to 30 times the anthocyanins (these are the purple colored antioxidants) of red wine per volume. Although the French consume a high fat diet, they have a low incidence of cardiovascular disease compared to the western countries. They contribute this factor to their consumption of red wine. Acai Berries can help promote a healthier cardiovascular system and digestive tract, because of its synergy of monounsaturated fats (these are the healthy fats), dietary fiber, and phytosterols. They provide the body with an excellent source of fiber. Fiber promotes a healthy digestive system. Research studies suggest soluble fibers may help lower blood cholesterol. The insoluble fiber may help to reduce the risk of developing certain types of cancers. Essential amino acid complex along with trace minerals, which are vital for proper muscle contraction and regeneration. MANGOSTEEN: The mangosteen (Garcinia mangostana) is a tropical evergreen tree, believed to have originated in the Sunda Islands and the Moluccas. The tree grows from 7 to 25 meters tall. The edible fruit is deep reddish purple when ripe. In Asia, the mangosteen fruit is known as the "Queen of Fruits." The outer shell of the fruit (pericarp) is rather hard, typically 4-6 cm in diameter, resembling a spherical, black cartoon bomb. Health benefits: Mangosteen has compounds with antioxidant, anti-bacterial, anti-fungal, and anti-tumor activity. Laboratory testing thus far indicates that extracts of mangosteen have activity against several cancer cell lines including breast, liver, and leukemia. Mangosteen also appears to have anti-histamine and anti-inflammatory properties. Most notably, the mangosteen provides powerful anti-inflammatory benefits which play an important role in numerous health conditions. For hundreds of years, the people of Southeast Asia have used the mangosteen, especially the rind, to ward off and treat infections, reduce pain or control fever, and treat various other ailments. Most of the studies with mangosteen have focused on the pericarp, or the dark, woody rind as opposed to the fruit inside the woody rind. The pericarp contains the active xanthone compounds. The fruit itself probably has some beneficial compounds but the compounds within the mangosteen fruit have not been studied as well as the mangosteen rind. Several compounds in mangosteen appear to be active, particularly xanthones. Some of these xanthones include mangostin, mangostenol, mangostenone A, mangostenone B, trapezifolixanthone, tovophyllin B, alpha- and beta-mangostins, garcinone B, mangostinone, mangostanol, and the flavonoid epicatechin. There are numerous studies available for review at www.pubmed.com. Just enter the word "mangosteen" to access a list. GOJI Goji berries have the highest concentration of beta-carotene among all foods on earth. Beta-carotene can be transformed into vitamin A under the influence of human liver enzymes. Therefore, vitamin A ultimately plays a major influence in Lycium's actions. Lycium's function on the eyes is related to this factor. Lycium's vitamin B1 and B2 contents are significant and the vitamin C content of freeze-dried Lycium has been measured to be 73 mg/100 grams. The fruit also contains vitamin C, beta-sitosterol (an anti-inflammatory agent), linoleic acid (a fatty acid), sesquiterpenoids (cyperone, solavetivone), tetraterpenoids (zeaxanthin, physalin), and betaine (0.1%). Lycium contains 18 kinds of amino acids, of which 8 are indispensable amino acids for the human body (such as isoleucine and tryptophan). 50% of Lycium's amino acids are free amino acid. Lycium contains numerous trace elements, of which the main ones are zinc, iron and copper. Mature fruits contain about 11 mg. of iron per 100 grams. Ning Xia Lycium contains 45% glucose, 7% fructose and 5.5% glucose. HEALTH BENEFITS: Goji Berries have been used in Tibet for at least 1,700 years. Tibetan medicine includes these berries in the treatment of kidney and liver problems. They are also used in Tibet to lower cholesterol, lower blood pressure, and cleanse the blood. Goji Berries have a long history of use in the treatment of eye problems, skin rashes, psoriasis, allergies, insomnia, chronic liver disease, diabetes and tuberculosis. Goji Berries are used by the people of Tibet to increase longevity and as a general health strengthening tonic. Science has shown that this bright red berry not only contains extremely high levels of antioxidants, vitamins, and minerals, but also contains many unique phytochemicals, polysaccharides, and complex compounds that scientists are only beginning to understand. Goji Berries contain the following complex compounds: Betaine, which is used by the liver to produce choline, a compound that calms nervousness, enhances memory, promotes muscle growth, and protects against fatty liver disease. Physalin, which is active against all major types of leukemia. It has also been used as a treatment for hepatitis B. Solavetivone, a powerful anti-fungal and anti-bacterial compound. Beta-Sitoserol, an anti-inflammatory agent. It has been used to treat sexual impotence and prostate enlargement. It also lowers cholesterol. Cyperone, a sesquiterpene that benefits the heart and blood pressure. It has also been used in the treatment of cervical cancer. These compounds as found in the Goji Berry are used in the following manner: Betaine, which is used by the liver to produce choline, a compound that calms nervousness, enhances memory, promotes muscle growth, and protects against fatty liver disease. Physalin, which is active against all major types of leukemia. It has also been used as a treatment for hepatitis B. Solavetivone, a powerful anti-fungal and anti-bacterial compound. Beta-Sitoserol, an anti-inflammatory agent. It has been used to treat sexual impotence and prostate enlargement. It also lowers cholesterol. Cyperone, a sesquiterpene that benefits the heart and blood pressure. It has also been used in the treatment of cervical cancer. When navigating through the myriad of choices in determining which product to choose in today's antioxidant saturated market, it is important to consider the following criteria: quality of product; quantity and source of ingredient; reputation of manufacturing company; and cost. At one time, health products did a little bit of this and a little bit of that. As someone who used to pop about 30 different pills each day to get what I felt my body needed for good health, it is exciting to see a number of products offering profound results. These results are allowing individuals to drop their pharmaceutical drug habit, or at the very least drop the dose, giving the body what it craves most, all things natural. 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The internet was just born and already it has 6 billion websites, one for every person on Earth today. Human beings are obsessed with writing and even more obsessed with Paris Hilton, the number one search on the internet. Lets get to know a little about our modern day Aphrodite aka Venus, the Goddess of Love, Beauty and Sex worshipped by the Greek and Roman people 4 thousand years ago. Paris Hilton proves once again that sex sells both hamburgers and religion. The Greek Goddess Aphrodite Festival is called the Aphrodisiac, which was celebrated all over Greece especially in Athens and Corinth. Christina Onassis was the heiress of Aristotle Onassis the Greek shipping billionaire. We are talking real money here. Christina was Aristotle’s only living child, a real heiress, like Jennifer Gates, 9, and Phoebe Gates, 3, the two daughters of the world’s richest man, send me the Bill Gates, at $51 billion dollars and counting. Bill and Melinda French of Dallas Texas have given so much money to charity that they have completely eradicated poverty in Africa. Paris Hilton, if she is lucky enough to make it into her grandfather’s will will be lucky to inherit one million dollars. The One with the money, Paris’ great grandfather Conrad Hilton, (whose son Nicky was the first husband of Elizabeth Taylor), left the grand total of nothing to his 4 children. He married his third wife at 87 and then left his entire fortune to the Catholic Church. Paris’ grandfather Barron Hilton went to court to contest the will and he won, becoming the first person ever to defeat the Vatican in court, walking away with a few hundred million. He has 8 kids. They have kids. Paris’ slice of the pie could be $200,000, walking around money for the Sultan of Brunei, whose oil fields America is now spending its blood to protect. That is hot – not. Being an heiress is normally a mirage, as Christina Onassis can testify to. Have you ever noticed how many pop icons cash in on Jesus’ story right in their names? It’s like people’s minds are like search engines responding either positively or negatively to certain keywords like Paris Hilton. Madonna, the Virgin Mary, Christ Ina Aguilera, Britney Spears, I have a pain in my side, said Jesus. Is that a spear in my ribcage or are you just happy to see me? Jesus Christ was a Jewish Rabbi painted by the Greek New Testament writers with the Godlike qualities of the Greek Goddess Eurynome and Bellerophon and his flying horse Pegasus and several other Greek deities. You can read all about it at The Temple of Love. 20 million Christian and Jewish children lost their lives in WW2 aka The War Against the Jews because according to stories which God of Mount Sinai aka Jesus aka Allah aka Elohim Himself endlessly calls man made legends and fairy tales right in the Holy Bibles, the Jewish people killed this half real half fictitious character 2,000 years ago in Jerusalem. Humans have a problem separating fact from fiction. At least Paris Hilton is a real person. I’ve seen her. I’ve touched her. I’ve kissed her. Her lips are as candy. Her legs are as ladders. Sex sells. Paris Hilton was a nobody, an extra in a series of B movies until the videotape of her coiting Rick Salomon in “1 Night in Paris” showed up on the internet last year at the same time that The Simple Life debuted. People are fascinated by infamy. Did you know that the male cat’s penis has spines which point backwards? Upon withdrawal of the penis the spikes rake the walls of the female’s vagina. The female needs this stimulation for ovulation to begin. Paris Hilton, outraged over the release of the video, raked in $400,000 plus a percentage of the profits of the film which shot her to super stardom. Without that video Paris Hilton is serving cocktails at Studio 54 today instead of dancing on the bar topless with the world’s media murdering each other for a snapshot of Paris Hilton half nude. Paris Whitney Hilton was named after Whitney Houston because her name wasn’t famous enough. During the Aphrodite Festival, the Aphrodisiac, in Corinth Greece, the men had intercourse with the Priestesses of Aphrodite. This was considered a method of worshipping Aphrodite. What did you get for Christmas? In the Holy Temple in Jerusalem the Priests lured the people in with The Temple Prostitutes who lived in the Holy Temple in Jerusalem. King Solomon who built the Holy Temple had 900 wives, concubines and mistresses. Compared to him Jesus was a mere piker with his Mary Magdalene and a few of her girlfriends. Do you hear what I’m saying girlfriend? At least Paris Hilton is a real person. Aphrodite was born as an 18 year old Paris Hilton in the Sea off of Cyprus after Cronus cut off Uranus’ genitals and the elder God’s blood and semen dropped on the Sea where they began to foam. Aphrodite rose out of the foam in her 18 year old birthday suit. When did people become so prudish? Going wild over 1 Night in Paris? 4,000 years ago mating with hookers in the Temple was normal. In 1879 William-Adolphe Bouguereau painted the Birth of Venus, (Venus was Aphrodite’s Roman name), which showed the full face on nude 18 year old Aphrodite being born rising from the sea foam. How did Hugh Hefner get to be called risqué? And where did all the paintings and likenesses of Jesus come from? There isn’t one single word of description of Jesus in the Holy Bible or anywhere else. Sex sold religion then and it still sells it today. The Las Vegas Hilton boasts the world’s largest free standing sign, “Welcome Idiots”. The hijackers on 911 fully expected to hit the twin towers then immediately wake up in eternal paradise with 72 virgins and wine with no side effects, because they read it in their Bible. Lot, the only righteous man in sin city, (Tony the Ant came in second) Sodom and Gomorrah was saved by God and rewarded with wine and sex with his two virgin daughters. Oscar Goodman, the mayor of Las Vegas with 85% of the vote was the mob’s lawyer who represented Meyer Lansky, Ace Rosenthal, Tony the Ant and corrupt San Diego mayor Roger Hedgecock to get the job. He recently said on Television, “Those who deface freeways with graffiti should have their thumbs cut off on Television.” Violence sells too. At least Paris Hilton is real. vigrx for men penis enargement homemade pennis enlargement penis enlagement information free pnis enlargement truth about pennis enlargement penis enhancement before and after photo easy enlargement free pennis surgery way pennis enlargement without pills

Male sexual dysfunction is one of the most common health problems affecting men and is more common with increasing age. Chronic ED affects about 5% of men in their 40s and 15-25% of men by the age of 65. Transient ED and inadequate erection affect as many as 50% of men between the ages of 40 and 70. In around 95% of the cases, a suitable treatment can be found. Erectile dysfunction is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for erectile dysfunction. Viagra, Levitra and Cialis Currently, there are three oral medications approved by the Food and Drug Administration (FDA) for the treatment of erectile dysfunction: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). All these agents block the enzyme phosphodiesterase type 5 (PDE-5) and belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Viagra was the first and is probably the most famous of the three PDE-5 inhibitors used to treat erectile dysfunction. Viagra was approved as an effective agent for treating erectile dysfunction in March 27, 1998. Viagra is manufactured by Pfizer, Inc. Levitra was the second PDE-5 inhibitor to come to market in the United States, and it was approved by the FDA in August 19, 2003. Levitra is manufactured by Bayer Pharmaceuticals Corporation. Cialis was the third PDE-5 inhibitor to come to market and was approved by the FDA at the end of November 21, 2003. Cialis is manufactured by Lilly ICOS LLC. The major advantage of PDE-5 inhibitors is that they do not cause an erection at inappropriate times, because they act only in response to sexual stimulation. If there is no sexual stimulation drug remains in the background. All three are taken orally prior to planned sexual activity, acting to increase blood flow in the penis in response to sexual stimulation. However, there are important differences between the three, differences that could influence safety, specificity, duration of action, adverse effects, and ultimately, public acceptance within this class of drug. Mechanism of Action PDE-5 inhibitors do not directly cause an erection of the penis, but they alter the body's response to sexual stimulation by enhancing the effect of the nitric oxide, a chemical that is normally released during stimulation. Nitric oxide causes relaxation of the muscles in the penis, which allows for better blood flow to the penile area. Effectiveness of PDE-5 Inhibitors All 3 PDE-5 inhibitors have demonstrated excellent efficacy. Viagra, at 84%, is slightly more effective than Cialis at 81% and Levitra at 80%. Pharmaceutical Forms, Onset of Action and Duration of Effect Viagra and Levitra differ only minimally in terms of their structure, while Cialis differs markedly from Viagra and Levitra in terms of its molecular structure, which is also reflected in pharmacokinetic differences. Viagra: 25 mg, 50 mg 100 mg tablets Onset of action: 30 minutes (effect delayed if taken with food) Duration of action: 4 to 5 hours Levitra: 2.5 mg, 5 mg, 10 mg, 20 mg tablets Onset of action: 25 minutes (effect delayed by fatty meal) Duration of action: 4 to 5 hours Cialis: 5 mg, 10 mg, 20 mg tablets Onset of action: 16-45 minutes (effect NOT delayed by food) Duration of action: 36 hours All three drugs require sexual stimulation to be effective. Viagra should be taken on an empty stomach it works better if you do not eat a high-fat meal around the time you take it. Levitra may be slightly less effective if you eat a high-fat meal, but a moderate-fat meal does not reduce its effectiveness. Cialis works without regard to what you eat. Viagra and Levitra have similar half-lives, and onset and duration of action. Cialis has a slower onset of action and longer duration of action, which is attributed to its longer half-life. Patients who wish for spontaneity may opt for Cialis, which may allow for successful intercourse up to 36 hours postdose, even though it takes longer to reach peak effect. The considerably longer duration of effect for Cialis will likely allow less frequent dosing and greater impulsiveness between partners, but also could potentially prolong adverse effects. Dosage The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. Levitra is also available in a 2.5 mg dose. None of these PDE-5 inhibitors should be used more than once a day. Possible Side Effects Although all three drugs are generally well tolerated, side effects are still possible. Most common side effects: Viagra: facial flushing, headache, indigestion Levitra: facial flushing, headache Cialis: headache, indigestion Less Common Side Effects: Viagra: altered vision, dizziness, nasal, congestion Levitra: indigestion, nausea, dizziness, nasal congestion Cialis: back pain, muscle aches, nasal congestion, facial flushing, dizziness Precautions and Contraindications All PDE-5 inhibitors are absolutely contraindicated in persons who take organic nitrates. Alpha-blockers Viagra has precautionary labeling advising against taking 50 mg or 100 mg doses within four hours of taking a alpha-blocker. The 25 mg dose of Viagra has not been shown to significantly decrease blood pressure and in patients who take 25 mg of Viagra, use of any of the alpha-blockers is considered safe. Levitra is contraindicated in patients taking alpha-blockers. Cialis is contraindicated in patients taking alpha-blockers, except for tamsulosin (Flomax). Since both Viagra and Levitra have moderate vasodilatory and hypotensive effects, they should not be given in the presence of marked arterial or orthostatic hypotension, and should only be administered with caution in aortic stenosis or hypertrophic obstructive cardiomyopathy. Men who have had a heart attack or stroke within the past 6 months and those with certain medical conditions (e.g., uncontrolled high blood pressure, severe low blood pressure or liver disease, unstable angina) that make sexual activity inadvisable should not take Cialis. Dosages of the drug should be limited in patients with kidney or liver disorders. Conclusions The differences between the 3 drugs are not great. All appear to be effective and safe. Levitra has less side effects compared to Viagra and lasts about the same time as Viagra in the body. Cialis has few side effects and lasts longer in the body. This allows increased spontaneity and less frequent dosing than either Levitra or Viagra. However, the longer half-life of Cialis imposes increased risk for drug interactions.