Viagra: The Little Blue Pill That Could

Medical Author: Benjamin Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stöppler, MD

Once upon a time, there was a little blue pill. Its inventors were trying to treat heart disease and prevent heart attacks and found that the little blue pill could dilate blood vessels. The theory was that angina or chest pain could be decreased when more red blood cells carrying oxygen were delivered to heart muscle cells through the dilated coronary vessels. Though good in theory, since it works for nitroglycerin, clinically, the little blue pill wasn't very effective.

The little blue pill wasn't very specific as to where it dilated blood vessels. Not only were heart vessels dilated, but so were blood vessels in other places, and this side effect became its claim to fame. Viagra hit the market as the first treatment for erectile dysfunction and was a superstar.

It was also becoming a superstar in the athletic world. Studies with cyclists and mountain climbers found that at high altitude, the little blue pill dilated blood vessels in the lung and allowed more oxygen to be extracted from the air, increasing the oxygen concentration in the bloodstream. This translated into faster and stronger training. All of a sudden, the little blue pill moved from the bedroom to the playing field...please insert your own performance-enhancing joke here.

And so we have the latest revelation that baseball players are loading up on Viagra. No big surprise, since Viagra has been a hit on the pro cycling tour for a while, and baseball usually lags behind by a couple of years. History reminds us of anabolic steroids and growth hormone.

The theory is simple. Aerobic metabolism needs oxygen and glucose to occur. During training and competition, if more oxygen can be delivered to a muscle, then it can maintain a higher level of activity before switching over to anaerobic metabolism (when the oxygen supply runs out). Lactic acid, the byproduct of anaerobic metabolism, is a death sentence for performance. The acid-base balance within the muscle cells is upset, and muscle contraction stops. Recovery time is needed to flush out the acid and restore normalcy to the cell and to the muscle as a whole.

There are a variety of ways of increasing oxygen delivery to cells, and most have to do with increasing the number of red blood cells in the body. The more red cells, the more oxygen molecules that can be delivered to a muscle with each heartbeat. But one should be wary of too many red cells, since they can cause sludging in the blood vessels and lead to bad things like stroke and heart attack.

The legal way to increase the number of red blood cells in the bloodstream is to move to a high altitude. The body recognizes the lower oxygen concentration in the air and stimulates the bone marrow to produce more red cells. Instead of moving, you could sleep in a tent with lower oxygen levels. (Nike has a built a whole house for some of their athletes.)

Less than legal ways to increase red blood cell numbers include blood doping, in which blood transfusions are used to increase the blood count or injecting erythropoietin, the hormone in the body that stimulates the bone marrow.

When winning is dependent on a tenth of a second, or a fraction of an inch, the athlete will look for an extra edge. Sometimes that extra edge is needed to remain on the roster instead of being cut or demoted to the minor leagues. Some athletes look for that little extra within themselves by working harder or training longer. Others look for that edge with performance-enhancing drugs.

Viagra has more than a few side effects, but those who choose to go the route of drug enhancement have already made their own deal with their conscience; a few minor or major side effects won't deter them. Even death is an acceptable risk. Ask a potential Olympian whether they would trade years of their life for a gold medal. Researchers have asked, and the answer, of course, is yes. The only question left was...how many years?