JSMPatient Highlights

Information about sexual health issues & treatments © 2014 International Society for Sexual Medicine

How Does Yohimbine Work? Yohimbine is an indole alkaloid extracted from the bark of West African yohim trees. It has been used through oral capsules to improve erection in men with ED. Yohimbine can cause an increase in the chemicals at the genital levels helping in increasing the nerve signals specifically to these areas and indirectly leading to an increased genital blood flow.

How Does Red Ginseng Work? Ginseng is an extract of plants from the genus Panax, a group of slow-growing perennial plants with fleshy roots in the family Araliaceae. Two species of ginseng widely studied with respect to their medicinal benefits are Panax ginseng (Asian ginseng) and Panax quinquefolium. We do not know how it works, but potential mechanisms may include relaxation in the smooth muscles of the genital organs leading to increased blood flow and increased sexual response.

I Heard that Horny Goat Weed Has Icariin in It. What’s That?

Complementary and Alternative Medicine (CAM) for Sexual Dysfunction

The scientific name for the genus of plants called horny goat weed is Epimedium. There are many species of horny goat weed (e.g., Epimedium brevicornum, Epimedium sagitattum, etc.) that have been used as an energy and erectile-enhancing drug in TCM for centuries. Icariin is an active natural substance found in horny goat weed. Recent studies have shown that icariin can relax the smooth muscles of the male genital organs and increase its internal pressure leading to better erections. However, these findings have not been confirmed in human studies.

Can Terribulus Terristrus Increase Sex Drive?

What Is Complementary and Alternative Medicine (CAM)?

C

AM is any practice that is put forward as having the healing effects of medicine but is not based on evidence gathered using the standard scientific methods. Examples of alternative medicine include traditional Chinese medicine (TCM), homeopathy, naturopathy, chiropractic, nutritional supplements, and acupuncture. In the United States, CAM therapies are available without a doctor’s prescription. The U.S. Food and Drug Administration (FDA) mandates that CAM therapies cannot claim to treat a specific medical condition but can make general health claims; in other words, a CAM therapy cannot claim to treat erectile dysfunction (ED), but it can claim to “promote sexual health” or “enhance penis function.” Laws regulating CAM therapies vary around the world. The most popular forms are herbal aphrodisiacs and sex enhancers, although there is also a growing interest in acupuncture. Aphrodisiacs are any substance (typically natural) that are purported to enhance sexual desire and/or performance.

What Kind of Herbal Medicines Are Available and How Do They Work? Many herbal medications originate in Asia and Africa where the use of CAM and traditional medicine is very popular. There are many more folk remedies than can be easily listed here. Some of the most famous herbs used for sexual effects include yohim, ginseng, maca, horny goat weed, muira puama, Tongkat Ali and Tribulus Terrestris, and Spanish fly. In some parts of the world, these herbs/plants may be used in teas, potions, or in raw form. In Western nations, most herbal CAM therapies are available as pills rather than as raw extracts. The active ingredients are extracted from the source plants using a variety of biochemical methods. Different techniques are needed for different herbals. It is important to recognize that how the extraction is performed, and how the resulting substance is stored may have important effects on the active ingredients.

Does CAM Therapy for Sexual Problems Actually Work? In most cases, we actually do not know if CAM works or not. The vast majority of these herbs has not undergone valid scientific experiments to determine their efficacy, and most of their reputation

Tribulus terristrus (TT) is a perennial creeping herb with a worldwide distribution. Some animal studies have shown that TT can, in fact, increase some sexual desire parameters in male animals. These studies have shown an increase in the blood levels of testosterone in animals after intake of TT. There have been no human clinical studies done on TT.

What Is Maca? Lepidium meyenii or Lepidium peruvianum (Maca) is an Andean cultivated root that belongs to the brassica (mustard) family. Dried Maca root is rich in amino acids, iodine, iron, and magnesium. Maca has been used as an old remedy for sexual problems, but scientific data on its use are sparse.

What Is Spanish Fly? The Spanish fly is an emerald green beetle in the family Meloidae, Lytta vesicatoria. The beetle contains up to 5% cantharidin that irritates animal tissues. The cantharidin in the crushed beetle powder may enhance blood flow to the genital areas; this may theoretically lead to increased sexual arousal. It should be borne in mind that increased genital blood flow does not necessarily mean sexual arousal. Contrary to popular beliefs, cantharides’ actions are not specific to females, developing equally in men and women.

JSMPatient Highlights

Information about sexual health issues & treatments

in enhancing sexual ability comes from popular culture. Two partial exceptions to this include yohimbine and ginseng. These herbals have been studied adequately enough for scientists to comment on their sexual-enhancing abilities. Yohimbine is a drug approved by the FDA and has been used with some success in men with ED because of psychological issues. Red ginseng has also undergone extensive scientific scrutiny with the majority of scientific evidence backing its use as valid treatment option for ED in men.

Why Do Some People Sometimes Report Better Sexual Performance When They Use Some of CAM? There are a number of potential reasons why people might feel that CAM helps them. It may be that the active ingredients actually do have a positive effect on sexual function (i.e., the pills work). Alternatively, the effect of these treatments may be just a placebo with false perception of better sexual performance attributed to taking a pill. In studies of drugs to help with erections, it is typical to see as many as one-third of men saying that a placebo (sugar pill) helped them get and keep erections, so the “placebo effect” is very real. Another explanation is that many of these herbal supplements contain high protein content and other ingredients that boost overall body performance and increase energy levels, and sexual activity is part of that. Most concerning, some of these supplements may, illegally, contain synthetic chemicals (similar to what is found in prescription pills for ED) that can boost sexual performance. This may predispose users to some risks from their “natural” supplement.

Are There Any Health Hazards Associated with the Use of These Herbs? There is little regulation of the CAM market. Means of extraction and preservation are not standardized between manufacturers; hence, there may be a great variability in the amount and quality of active ingredient present in a given CAM preparation. Because strong scientific experiments have not been done on the majority of these herbs, there are limited data on their side effects. However, common side effects of yohimbine include high blood pressure, anxiety, and irregular heartbeats. The use of Spanish fly can result in kidney problems and gastrointestinal bleeding. In addition to the very limited data we have on their safety and extraction processes, additional risks regarding herbal medicine consumption come from the manufacturers’ integrity. A whole industry is built on manufacturing natural aphrodisiacs. Unfortunately, some medicinal drug manufacturers, realizing the huge demand, go ahead and deceive the public concerning the natural aphrodisiac products they market. In 2002, researchers found that sildenafil (the active ingredient of Viagra) or drugs like it was found in a number of “herbal” aphrodisiacs. In 2009, several scientific studies employed a new technique to detect the newly developed sildenafil-like drugs and reported the presence of sildenafil-like drugs in at least 10 herbal supplements marketed as “natural aphrodisiacs.” This means that some of these so-called natural products are not natural at all or are mixed with chemicals similar to Viagra that can produce erections. This not only implies dishonesty from the manufacturer but unknowingly exposes its users to the hazards and side effects of Viagra and its substitutes. For example, a patient taking a drug containing nitrates must not take Viagra or its analogues at the same time as the combined drugs can cause a big drop in blood pressure that may be fatal. If the same patient takes some of these “natural” supplements assuming they are safe while they actually contain Viagra or similar drugs, he may be taking a substantial risk. Therefore, patients should be very careful when they decide to purchase natural aphrodisiacs.

I Don’t Mind Taking a Risk; Where Can I Get These Herbal Medicines? These medicines are generally sold over the counter in many drug and convenience stores. Each country has its own regulations concerning the sale and distribution of herbal medicines. Please check with your local health authorities; it is also worthwhile to investigate the source as this may help you judge whether the people manufacturing and selling the therapy are trustworthy. An alternative way that some people use to obtain these medicines is to buy them online. However, safeguards to prevent fraud and ensure quality are much more difficult to enforce online so caution is advised.

Conclusions The general benefits of CAM in the area of sexual medicine are largely unclear. Many herbal medicines are present in the market and are available for trial. However, there have been relatively few studies to characterize these compounds and report on effectiveness and potential hazards. It is strongly advised that individuals interested in CAM exercise caution and due diligence before using either CAM or conventional medical treatments for sexual issues. Rany Shamloul, MD*†¶ and Anthony Bella, MD FRCSC‡§ *The Ottawa Hospital Research Institute, Ottawa, Canada, K1Z8M6; †Department of Andrology, Cairo University, Cairo, Egypt; ‡Greta and John Hansen Chair in Men’s Health Research; § Department of Surgery; ¶Department of Neuroscience, University of Ottawa

© 2014 International Society for Sexual Medicine

Can Alcohol Increase Sexual Performance? There are contradictory data to either refute or support the aphrodisiac properties of alcohol. Some people find that small quantities of alcohol help them relax and engage in sexual activity. Higher consumption of alcohol (more than eight drinks per week) has been associated with decreased sexual performance in men. Unfortunately, very little data are available examining the effects of alcohol on women’s sexual activity.

Is Marijuana Really an Aphrodisiac? Up until a few years ago, there was a tendency in the scientific community to believe that marijuana can, in fact, increase sexual desire in men. However, recent studies have shown a harmful effect of marijuana on sexual performance in men and women. Interestingly, a recent scientific report has established that marijuana can act on specific proteins in the man’s penis muscle tissue that may lead to its contraction (i.e., inhibition of erectile response).

How About Acupuncture and Sexual Performance? Most of the studies examining the effects of acupuncture on sexual performance focused mainly on the male side. Just like with natural aphrodisiacs, there is very little scientific evidence to support the use of acupuncture in the treatment of male and female sexual problems. Acupuncture may be of some utility and has a generally low risk when performed by a licensed and experienced acupuncturist. Side effects of acupuncture are somewhat common but are generally minor, typically mild pain and bleeding.

Complementary and alternative medicine (CAM) for sexual dysfunction.

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