medical Andrology sexuality

1. HERBAL MEDICINES FOR SEXUAL
DYSFUNCTIONS: True but for how far
…!!
By
SHEDEED ASHOUR M.D,
Professor of Andrology, Sexology & STDs
Cairo University, CAIRO-EGYPT
Consultant Andrologist, Dr Erfan & Bagedo General Hospital
Jeddah, KSA
MESSM – CAIRO 2015

2. Sex, Diet and Herbs: Introduction
Sex is important, crucial and integral for the integrity.
If Men are asking for more of any thing it would be sex
Men love Sex and Food
So how if you eat for more sex
Many food stuff and natural supplements are well known
to improve sexual function. Desire, Erection , ejaculate
volume, orgasm and control.

3. Epidemiology
Massachusetts Male Aging Study, Feldman et al. J Urol 1994; 150:54-61
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 7

4. According to the most updated demography of KSA, It is estimated that there are >
1.5 M ED patients in KSA
ED is Wide spread in KSA

5. Initiator Conditioner
Central
Peripheral
Other
Apomorphine
Melanotan
Oxytocin
Trazodone
Sildenafil
Other PDE5I
Others
PGE1 (ICI, TU, TD)
Papaverine
VIP+Phen (ICI)
Counseling
Prosthesis
VED
Combinations
Testosterone
Matrix of treatment strategies MATS
Yohimbine
Serotonin
(5-HT1C & 2C)

6. Title • time and place of presentation • Page # 6
Non-Responders
The reported 62% prescription renewal rate
at three to four months of follow-up, which
dropped to around 30% by 6-12 months,
suggests that patients stop taking the drug
for reasons other than failure of treatment.1
Fagelman E, Fagelman A, Shabsigh R. Efficacy, safety, and use of sildenafil in urologic practice. Urology 2001;57:1141-4.

7. Title • time and place of presentation • Page # 7
Causes for Poor or No Response
The reasons for acute or delayed failure include:
•Severe erectile dysfunction at presentation,
•Worsening of endothelial dysfunction and
progression of penile atherosclerosis,
•Erectile dysfunction after radical prostatectomy,

8. Title • time and place of presentation • Page # 8
Causes for Poor or No Response
The reasons for acute or delayed failure include:
•Unrecognised hypogonadism, inadequate
Patient education and incorrect drug usage,
• The development of tachyphylaxis (drug
tolerance), and
•Psychosocial factors.

9. Dose optimization
Switching oral agents
Daily dosing with PDE5 inhibitors
Improvement in co-morbid conditions
Psychosexual therapy
Combinations……..
Testosterone for hypogonadal men
Strategies to salvage non- responders
To PDE5I
Pfizer Corporation. Viagra® (sildenafil HCl) tablets: prescribing information (online). http://pfizer.com/download/uspi_viagra.pdf
(accessed 6 Mar 2005).
Bayer AG. Levitra® (vardenafil HCl) tablets: prescribing information online). www.univgraph.com/bayer/inserts/levitra.pdf. (accessed 6 Mar
2005).
McMahon CG. High dose sildenafil citrate as salvage therapy for severe erectile dysfunction. Int J Impot Res 2002;14(6):533-8.

10. Medicines with Plant and Herbs origin: list of
plants that have been used as herbal medicine
 Atropine
 Digitalis
 Digoxin
 Opium Poppy
 Capsicum
 Garlic
 Celery
 Ginko
 Ginger
 Giensing
 Chamomile
 Clove
 Dandelion
 Eucalyptus
 Fenugreek
 Guava
 Horse chestnut
 Lavender
 Marigold
 Papaya
 St. Jhon’s wart
 Pippermint
 Sage
 Rosemary
 Thyme
 Saw Pallmetto
 Turmeric
 Valeriana Officialis
Elizabeth M. Manhã, Maria C. Silva, Maria G. C. Alves, Maurício B. Almeida, Maria G.
L. Brandão (October 3, 2008). "PLANT - A bibliographic database about medicinal
plants". Retrieved 2010-09-29.

11. L-arginin.
Ginko Biloba
Panax Gensing
Yohimbine
Saw Palmetto
Maca Root Extract
Avena Sativa
HERBS that are known to improve Sex
Performance:
Gurana Extract
Tribulus Terrestris extract
Fenugreek Extract.
Tongat Ali
Horny Goat
Pumpkin seed extract

12. L-Arginine
 Effectiveness of Oral L-Arginine in first line treatment of Erectile Dysfunction in
a controlled crossover study.
 Klotz T, Mathers MJ, Braun M, Bloch W, Engelmann U. Urol. Intl., 1999; 63(4): 220-3.
 Effect of Oral Administration of high dose nitric oxide donor L-Arginine in men
with organic erectile dysfunction: results of a double-blind randomized placebo-
controlled study.
 Chen JI, Wollman Y, Chernichovsky T, Laina A, Sofer M, Matzkin H. BJU. Int.; 1999,
Feb.;83 (3): 269-73.
 Efficacy and safety of a novel combination of L-arginine and Yohimbine HCL: a
new oral therapy for erectile dysfunction.
 Lebret T, Herve` JM, Corny P, Worcel M, Bottoh H. Eur. Urol. 2002;41: (6):608-13.

13. Treatment of Erectile Dysfunction by Pycnogenol and
L-Arginine.
 The study included 40 men, aged 25-45 years, without confirmed organic erectile dysfunction.
During the 3 month duration of the trial, patients received 3 ampoules of Sargenor a day, a
drinkable solution of dipeptide arginyl aspartate equivalent to 1.7 g L-arginine per day. During
the second month patients were additionally supplemented with 40 mg. Pycnogenol two times
per day. During the third month, the dose was increased to 40mg three times a day.
 Sexual History questionnaire and a sexual activity diary from each patient.
 After one month of treatment with L-arginine, only 2 (5%) of patients experienced a normal
erectile function. The treatment by the combination during the second month and the increase
of dose the third, increased the number of patients with normalized erectile function to 80%
and 92.5 respectively.
 Conclusion: oral administration of L-arginine in combination with pycnogenol is highly
effective, restoring normal erection in men with ED, with no side effects reported.
.
Stanislavov R1, Nikolova V J Sex Marital Ther. 2003 May-Jun;29(3):207-13.

14. Improvement of erectile function with Prelox: a randomized,
double-blind, placebo-controlled, crossover trial.
 In a randomly allocated, double-blind, placebo-controlled, crossover design,
 50 patients with mild to moderate erectile dysfunction (ED) were treated for 1 month with
placebo or a combination of L-arginine aspartate and Pycnogenol (Prelox).
 Patients reported sexual function from diaries. Testosterone levels and endothelial NO
synthase (e-NOS) were monitored along with routine clinical chemistry.
 IPycnogenol for 1 month restored erectile function to normal. Intercourse frequency
doubled. e-NOS in spermatozoa and testosterone levels in blood increased significantly.
Cholesterol levels and blood pressure were lowered. No unwanted effects were reported.
 Prelox is a promising alternative to treat mild to moderate ED.
Stanislavov R, Nikolova V, Rohdewald P. Int J Impot Res. 2008 Mar-Apr;20(2):173-80.

15. Ginko Biloba
 Effect of Ginkgo biloba Extract (EGb-761) on Recovery
of ErectileDysfunction in Bilateral Cavernous Nerve Injury Rat Model.
 Wu YN1, Liao CH2, Chen KC3, Liu SP4, Chiang HS5. Urology. 2015 May;85(5):1214.e7-15.
 Noncontact erection is enhanced by Ginkgo biloba treatment in rats:
role of neuronal NOS in the paraventricular nucleus and sacral spinal
cord.
 Yeh KY1, Wu CH, Tsai YF. Psychopharmacology (Berl). 2012 Aug;222(3):439-46
 Ginkgo biloba extract enhances noncontact erection in rats: the role
of dopamine in the paraventricular nucleus and the mesolimbic
system.
 Yeh KY1, Wu CH, Tai MY, Tsai YF. Neuroscience. 2011 Aug 25;189:199-206.

16. Ginko Biloba
 Recent research suggests Ginkgo biloba can be used to ameliorate
antidepressant-induced sexual dysfunction.
 The notion that Ginkgo may benefit ED started with the observation that male
geriatric patients on Ginkgo for memory enhancement reported improved
erections.
Cohen AJ, Bartlik B. J Sex Marital Ther 1998;24:139-143.

17. Triple-blind, placebo-controlled trial of Ginkgo
biloba in sexual dysfunction due to antidepressant
drugs.
 A triple-blind (investigator, patient, statistician), randomized, placebo-controlled, trial
of Ginkgo biloba240 mg daily.
 Following a 1-week control, it was given to 24 patients with sexual impairment due to
antidepressant drugs.
 Efficacy analysis was carried out on eight males and five females on placebo and six males
and five females on Ginkgo, completing the full 12 weeks of treatment. A validated, sex
(gender)-orientated questionnaire was recorded at - 1, 0, 1, 3, 6, 9 and 12 weeks, and a
non-blind follow-up for a further 6-weeks on Ginkgo. Hamilton anxiety and depression
ratings were made at 0, 6 and 12 weeks and simple global assessments of alertness and
memory.
 There were some spectacular individual responses in both groups, but no statistically
significant differences, and no differences in side-effects.
Wheatley D. Hum Psychopharmacol. 2004 Dec;19(8):545-8.

18. Panax ginseng
 Laboratory studies of Panax ginseng have shown it may improve
vascular endothelial abnormalities by increasing the production of
NO.
 Several studies suggest Panax ginseng possesses antioxidant
and organ-protective action associated with enhanced NO
synthesis in the endothelium of the lung, heart, kidney, and corpus
cavernosum.
Gillis CN. Biochem Pharmacol 1997;54:1-8. 44. Tamaoki J, Nakata J, Kawatani K,
et al. Br J Pharmacol 2000;130:1859-1864. 45.
Han SW, Kim H.. Int J Biochem Cell Biol 1996;28:573- 580

19. A double-blind crossover study evaluating the efficacy of
Korean red ginseng in patients with erectile dysfunction: a
preliminary report.
 Forty-five men diagnosed with ED were randomized and received
either 900 mg Panax ginseng or placebo (starch capsule with
ginseng flavor) three times daily for eight weeks.
 The first eight weeks of treatment were followed by a two week
washout period, after which the patients received crossover
treatment of placebo or Panax ginseng for another eight weeks.
 Treatment efficacy was determined based on changes observed in
indexes of erectile function, including the International Index of
Erectile Function (IIEF), RigiScan, serum testosterone levels, and
penile duplex ultrasonography with audiovisual sexual stimulation.
Hong B, Ji YH, Hong JH, et al. J Urol 2002;168:2070-2073

20. MACA Ginseng Péruvien
 Maca Nutrition Facts
 Maca root powder is comprised of approximately 18% protein, 76.5% carbohydrates, 5% fat, and 8.5% fiber
(indigestible carbohydrates). Maca provides a powerful source of nutrition, including:
 Over 20 amino acids, including 8 essential amino acids
 20 free-form fatty acids (such as lauric, linolenic, palmitic acid, oleic , and steric acid)
 Vitamins B-1, B-2, C and E
 Calcium
 Magnesium
 Potassium
 Copper
 Zinc
 Manganese
 Phosphorus
 Selenium
 Sulphur
 Sodium
 Iron
Cohen AJ, Bartlik B. J Sex Marital Ther 1998;24:139-143.

21. TOP 5 MACA BENEFITS
3. PMS,Menopause
2. Women’sHormones,Fertility,andSexualHealth
1. Male’sTestosteroneLevels and Fertility
4. Energy,MemoryandMood
5. AntioxidantBooster
21

22. Maca Clinical Trial
Lepidium meyenii (maca) improved semen parameters in adult men
 Aim: Does maca increase sperm count and volume?
 In total 12 men were originally involved, however 3 had to drop out
due to personal reasons. That left a total of 9 who finished; 3 single
and 6 married men. Their ages ranged from 22 to 44 years old and
were healthy with normal sexual vitality.
 After a 3 day abstinence, semen samples were collected. The same
was done after 4 months of receiving normal yellow maca
supplements at a dosage of 1,500 or 3,000 mg per day. Various
hormone levels were measured at both times, too.

23. RESULTS:

24. Maca (L. meyenii) for improving sexual function: a
systematic review
Four RCTs met all the inclusion criteria.
Two RCTs suggested a significant positive effect of maca
on sexual dysfunction or sexual desire in healthy
menopausal women or healthy adult men, respectively,
while the other RCT failed to show any effects in healthy
cyclists. The further RCT assessed the effects of maca in
patients with erectile dysfunction using the International
Index of Erectile Dysfunction-5 and showed significant
effects.
Byung-Cheul Shin,1 Myeong Soo Lee,,4 Eun Jin Yang,2 Hyun-Suk Lim,3 and Edzard Ernst4
BMC Complement Altern Med. 2010; 10: 44.

25. Conclusion
The results of this systematic review provide limited
evidence for the effectiveness of maca in improving sexual
function. However, the total number of trials, the total
sample size, and the average methodological quality of the
primary studies were too limited to draw firm conclusions.
More rigorous studies are warranted.

26. Final thoughts…
ED is common.
PDE5 I are the first line therapy
Despite their efficacy, still there are non responders.
There is no imperative ED treatment up to date.
Natural and alternative medicines can be tried for mild
to moderate cases, psychogenic cases and in
combination for the Moderate to severe cases.

27. Thank You