Natural Aphrodisiacs—A Review of Selected Sexual Enhancers

Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading?

INTRODUCTION

Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern.

AREAS COVERED

The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs.

EXPERT OPINION

Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.

Nootropics as Cognitive Enhancers: Types, Dosage and Side Effects of Smart Drugs

Nootropics, also known as “smart drugs” are a diverse group of medicinal substances whose action improves human thinking, learning, and memory, especially in cases where these functions are impaired. This review provides an up-to-date overview of the potential effectiveness and importance of nootropics. Based on their nature and their effects, this heterogeneous group of drugs has been divided into four subgroups: classical nootropic compounds, substances increasing brain metabolism, cholinergic, and plants and their extracts with nootropic effects. Each subgroup of nootropics contains several main representatives, and for each one, its uses, indications, experimental treatments, dosage, and possible side effects and contraindications are discussed. For the nootropic plant extracts, there is also a brief description of each plant representative, its occurrence, history, and chemical composition of the medicinal part. Lastly, specific recommendations regarding the use of nootropics by both ill and healthy individuals are summarized.

Belief traps: Tackling the inertia of harmful beliefs

Beliefs are a key element of healthy cognition. Yet overly rigid beliefs are the basis of societal problems including prejudices, psychiatric disorders, and conspiracy theories. Recent findings from neurobiology, psychiatry, and social sciences show how resilience of beliefs is boosted by stressful conditions. This implies the possibility of self-propelled societal deterioration where rigid beliefs harm the quality of personal and political decisions, evoking more-stressful conditions that further rigidify beliefs. Measures reducing social stress, including economic policies such as universal base income, may be the most effective ways to counteract this vicious cycle.

Beliefs can be highly resilient in the sense that they are not easily abandoned in the face of counterevidence. This has the advantage of guiding consistent behavior and judgments but may also have destructive consequences for individuals, nature, and society. For instance, pathological beliefs can sustain psychiatric disorders, the belief that rhinoceros horn is an aphrodisiac may drive a species extinct, beliefs about gender or race may fuel discrimination, and belief in conspiracy theories can undermine democracy. Here, we present a unifying framework of how self-amplifying feedbacks shape the inertia of beliefs on levels ranging from neuronal networks to social systems. Sustained exposure to counterevidence can destabilize rigid beliefs but requires organized rational override as in cognitive behavioral therapy for pathological beliefs or institutional control of discrimination to reduce racial biases. Black-and-white thinking is a major risk factor for the formation of resilient beliefs associated with psychiatric disorders as well as prejudices and conspiracy thinking. Such dichotomous thinking is characteristic of a lack of cognitive resources, which may be exacerbated by stress. This could help explain why conspiracy thinking and psychiatric disorders tend to peak during crises. A corollary is that addressing social factors such as poverty, social cleavage, and lack of education may be the most effective way to prevent the emergence of rigid beliefs, and thus of problems ranging from psychiatric disorders to prejudices, conspiracy theories, and posttruth politics.

Diet, herbs and erectile function: A good friendship!

Plants and plant materials have been used for thousands of years to treat and control erectile dysfunction in men. This practice has spanned many cultures and traditions around the world, with the therapeutic effects of many plants attributed to their phytochemical constituents. This review explains how polyphenols (including phenolic acids, flavonoids, terpenoids, carotenoids, alkaloids and polyunsaturated fatty acids) in plants and plant food products interact with key enzymes (phosphodiesterase-5 [PDE-5], angiotensin-converting enzyme [ACE], acetylcholinesterase [AChE], adenosine deaminase [ADA] and arginase) associated with erectile dysfunction. By modulating or altering the activity of these physiologically important enzymes, various bioactive compounds from plants or plant products can synergistically or additively provide tremendous protection against male erectile problems.

A preliminary study of the efficacy of the polyherbal preparation Sao Thong Tai for erectile dysfunction among elderly men: a double-blind, randomized controlled trial

Background

The traditional Thai polyherbal formulation “Sao Thong Tai” (STT) contains four medicinal plants, namely Boesenbergia rotunda (L.) Mansf., Sida acuta Burm.f., Dactyloctenium aegyptium (L.) Willd., and Oryza sativa L. and it is considered an aphrodisiac and remedy for the effective treatment of decreased male libido in Thai traditional medicine and it may ameliorate erectile function. This pilot study was carried out to investigate the efficacy and safety of the polyherbal STT for mild to moderate erectile dysfunction in a small group of elderly men in Thailand in a double-blind, randomized controlled trial.

Methods

This research is a preliminary study. Fifty-four elderly males aged 50-69 years who had been diagnosed with mild to moderate ED were randomized into two groups of equal size: an STT group (n=27) and a placebo control group (n=27). The patients received either an 800 mg dose of STT extract or a lactose placebo twice a day for the eight-week treatment period, after which they were followed up for four weeks. Erectile function, sexual activity, self-reported attitudes toward sexual dysfunction, and partner-reported sexual dysfunction were investigated to confirm the efficacy of the polyherbal preparation. The International Index of Erectile Function (IIEF-5) and the Scale for Quality of Sexual Function (QSF) were used for primary outcome assessment.

Results

The IIEF-5 scores of the STT group were significantly increased compared with those of the placebo group (p<0.001). The severity of ED decreased from "mild" or "mild to moderate" to normal in 88.9% of the STT group vs. 0% of the placebo group, and the QSF score increased in the STT group (p<0.001). Sexual activity, self-reported views of sexual dysfunction, and partners’ views of sexual dysfunction showed significant improvement in the STT group, and there was no significant difference in psychosomatic quality of life. No adverse events were observed in either group.

Conclusion

Compared with a placebo, an oral aqueous extract of STT taken daily at a dose of 1,600 mg for eight weeks can effectively treat mild to moderate ED in elderly men. The preparation was also shown to be safe with respect to all parameters assessed. This finding demonstrates that STT can be used for the effective treatment of decreased male libido in Thai traditional medicine and may ameliorate ED.

Trial registration

TCTR/20180126001 033/2560. Registered 16 January 2018, Thai Clinical Trials Registry http://www.thaiclinicaltrials.org/

Beneficial effects of natural products on female sexual dysfunction: A systematic review and meta-analysis

BACKGROUND

Female sexual dysfunction (FSD) includes female orgasmic disorder, female sexual interest or arousal disorder, and genito-pelvic pain or penetration disorder. FSD affects 40% of women worldwide, but it is understudied and likely undertreated. Natural products are frequently used by women to treat FSD, but scientific evidence of their efficacy is lacking.

OBJECTIVE

This systematic review and meta-analysis focused on the study of the efficacy of natural products on FSD.

STUDY DESIGN

Systematic review and meta-analysis of existing studies on natural products in the treatment of FSD.

METHODS

The literature search included MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trial databases for studies published from January 2000 to February 2020. The quality and the level of evidence of the studies were assessed. The association between natural products and FSD was summarized using standardized mean differences (SMD) with a 95% confidence interval (CI).

RESULTS

A total of 536 studies were identified, with 20 of them meeting the criteria. According to this meta-analysis, Tribulus terrestris showed a significant positive effect in improving overall female sexual function (SMD = 1.12, 95% CI = 0.46 - 1.79, p = 0.001) and individual sexual arousal (SMD = 1.03, 95% CI = 0.22 - 1.84, p = 0.013), sexual desire (SMD = 1.08, 95% CI = 0.52 - 1.63, p ≤ 0.001) and sexual orgasm (SMD = 0.51, 95% CI = 0.02 - 1.00, p = 0.040) domains compared to placebo. Panax ginseng was found to be effective in treating sexual arousal (SMD = 0.54, 95% CI = 0.11 - 0.97, p = 0.014) and sexual desire (SMD = 0.59, 95% CI = 0.27 - 0.90, p < 0.001) compared to placebo. Meanwhile, other natural products reviewed in this study, such as Trifolium pretense, did not differ significantly from placebo in terms of improving FSD.

CONCLUSION

Preliminary evidence suggests that Tribulus terrestris and Panax ginseng may be effective as alternative treatments for FSD in a clinical setting.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

Ginseng for erectile dysfunction

BACKGROUND

Dietary supplements with ginseng, or ginseng alone, are widely used for a broad range of conditions, including erectile dysfunction. Ginseng is particularly popular in Asian countries. Individual studies assessing its effects are mostly small, of uneven methodological quality and have unclear results.

OBJECTIVES

To assess the effects of ginseng on erectile dysfunction.

SEARCH METHODS

We conducted systematic searches on multiple electronic databases, including CENTRAL, MEDLINE, Embase, CINAHL, AMED, and loco-regional databases of east Asia, from their inceptions to 30 January 2021 without restrictions on language and publication status. Handsearches included conference proceedings.

SELECTION CRITERIA

We included randomized or quasi-randomized controlled trials that evaluated the use of any type of ginseng as a treatment for erectile dysfunction compared to placebo or conventional treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently classified studies and three authors independently extracted data and assessed risk of bias in the included studies. We rated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

We included nine studies with 587 men with mild to moderate erectile dysfunction, aged from 20 to 70 years old. The studies all compared ginseng to placebo. We found only short-term follow-up data (up to 12 weeks).  Primary outcomes Ginseng appears to have a trivial effect on erectile dysfunction when compared to placebo based on the Erectile Function Domain of the International Index of Erectile Function (IIEF)-15 instrument (scale: 1 to 30, higher scores imply better function; mean difference [MD] 3.52, 95% confidence interval [CI] 1.79 to 5.25; I² = 0%; 3 studies; low certainty evidence) assuming a minimal clinically important difference (MCID) of 4.  Ginseng probably also has a trivial effect on erectile function when compared to placebo based on the IIEF-5 instrument (scale: 1 to 25, higher scores imply better function; MD 2.39, 95% CI 0.89 to 3.88; I² = 0%; 3 studies; moderate certainty evidence) assuming a MCID of 5. Ginseng may have little to no effect on adverse events compared to placebo (risk ratio [RR] 1.45, 95% CI 0.69 to 3.03; I² = 0%; 7 studies; low certainty evidence). Based on 86 adverse events per 1000 men in the placebo group, this would correspond to 39 more adverse events per 1000 (95% CI 27 fewer to 174 more). Secondary outcomes Ginseng may improve men's self-reported ability to have intercourse (RR 2.55, 95% CI 1.76 to 3.69; I² = 23%; 6 studies; low certainty evidence). Based on 207 per 1000 men self-reporting the ability to have intercourse in the placebo group, this would correspond to 321 more men (95% CI 158 more to 558 more) per 1000 self-reporting the ability to have intercourse. Ginseng may have a trivial effect on men's satisfaction with intercourse based on the Intercourse Satisfaction Domain of the IIEF-15 (scale: 0 to 15, higher scores imply greater satisfaction; MD 1.19, 95% CI 0.41 to 1.97; I²=0%; 3 studies; low certainty evidence) based on a MCID of 25% improvement from baseline. It may also have a trivial effect on men's satisfaction with intercourse based on item 5 of the IIEF-5 (scale: 0 to 5, higher scores imply more satisfaction; MD 0.60, 95% CI 0.02 to 1.18; 1 study; low certainty evidence) based on a MCID of 25% improvement from baseline. No study reported quality of life as an outcome. We found no trial evidence to inform comparisons to other treatments for erectile dysfunction, such as phosphodiesterase-5 inhibitors. We were unable to conduct any predefined subgroup analyses.

AUTHORS' CONCLUSIONS

Based on mostly low certainty evidence, ginseng may only have trivial effects on erectile function or satisfaction with intercourse compared to placebo when assessed using validated instruments. Ginseng may improve men's self-reported ability to have intercourse. It may have little to no effect on adverse events. We found no trial evidence comparing ginseng to other agents with a more established role in treating erectile dysfunction, such as phosphodiesterase-5 inhibitors.

Systematic Review of l-Arginine for the Treatment of Hypoactive Sexual Desire Disorder and Related Conditions in Women

This systematic review evaluates the efficacy and safety of l-arginine alone or in combination for the treatment of women with hypoactive sexual desire disorder (HSDD) or related conditions, such as female sexual interest/arousal disorder and female sexual arousal disorder. Medline, Embase, International Pharmaceutical Abstracts, Science Direct, and the Cumulative Index to Nursing and Allied Health Literature were searched using keywords “arginine”, “Lady Prelox”, “ArginMax”, “Stronvivo”, “Ristela”, “hypoactive sexual desire disorder”, “female sexual interest arousal disorder”, “female sexual arousal disorder”, “sexual dysfunction”, “sexual behavior”, “dyspareunia”, “libido”, and permutations thereof. Relevant records were retained if they were primary literature, conducted in women with HSDD or related conditions, and published as full text in English. Five randomized controlled trials and two nonrandomized studies met eligibility criteria. Six of the seven studies reported either an increase in the total mean Female Sexual Function Index score or significant increases in multiple domains therein. One study assessed vaginal pulse amplitude and found a statistically significant increase in a combination treatment group compared to placebo. No significant side effects were reported. Four of seven studies had potential risk-of-bias concerns per Cochrane assessments. This systematic review found that combination products containing l-arginine in the form of ArginMax or Lady Prelox may be considered for the treatment of HSDD and related conditions in women regardless of age.

Assessment of Reproductive Toxicity of Hydroethanolic Root Extracts of Caesalpinia benthamiana, Sphenocentrum jollyanum, and Paullinia pinnata

Purpose

Male sexual dysfunction negatively affects an individual's quality of life and thus its of prime public concern, hence the need to boost reproductive abilities in such individuals. This study assessed the effect of hydroethanolic root extracts of Caesalpinia benthamiana (CBRE), Sphenocentrum jollyanum (SJRE), and Paullinia pinnata (PPRE), commonly used as aphrodisiacs in Ghana, using male Sprague-Dawley rats.

Methods

Plasma testosterone, follicle-stimulating hormone, and luteinizing hormone were assayed in grouped rats treated orally with 1 mL/kg normal saline, 50 mg/kg monosodium glutamate (MSG), and 100, 300, or 1000 mg/kg CBRE, SJRE, and PPRE, respectively, for 60 days. Epididymis and testis weights were determined. Semen was assessed on spermatozoa count, motility, and morphology. Malonyladehyde formation in lipid-peroxidation assay and histological examinations were performed to assess pathological changes in testes. Testicular testosterone was also assayed.

Results

While MSG, CBRE, SJRE, and PPRE treatments did not result in significant reduction (p>0.05) in plasma testosterone, there was significant reduction (p≤0.05 -0.0001) in plasma luteinizing hormone, and follicle-stimulating hormone. The combined mean wet weights of epididymides and testes of all treated groups did not vary significantly (p>0.05) from the control. There was significant reduction (p≤0.0001) in sperm motility and count, with significant morphological changes (p≤0.05-0.001), ie, bent necks, tails, and midpieces, and multiple anomalies in the spermatozoa in extract and MSG-treated groups. There was also significant (p≤0.0001) reduction in testicular testosterone among all treatment groups.

Conclusion

Hydroethanolic CBRE, SJRE, and PPRE were found to have detrimental effects on reproductive function with prolonged usage and thus may not be safe to use in healthy males who intend to reproduce.

Pharmacology of Herbal Sexual Enhancers: A Review of Psychiatric and Neurological Adverse Effects

Sexual enhancers increase sexual potency, sexual pleasure, or libido. Substances increasing libido alter the concentrations of specific neurotransmitters or sex hormones in the central nervous system. Interestingly, the same pathways are involved in the mechanisms underlying many psychiatric and neurological disorders, and adverse reactions associated with the use of aphrodisiacs are strongly expected. However, sexual enhancers of plant origin have gained popularity over recent years, as natural substances are often regarded as a safer alternative to modern medications and are easily acquired without prescription. We reviewed the psychiatric and neurological adverse effects associated with the consumption of herbal aphrodisiacs Areca catechu L., Argemone Mexicana L., Citrus aurantium L., Eurycoma longifolia Jack., Lepidium meyenii Walp., Mitragyna speciosa Korth., Panax ginseng C. A. Mey, Panax quinquefolius L., Pausinystalia johimbe (K. Schum.) Pierre ex Beille, Piper methysticum G. Forst., Ptychopetalum olacoides Benth., Sceletium tortuosum (L.) N. E. Brown, Turnera diffusa Willd. ex. Schult., Voacanga africana Stapf ex Scott-Elliot, and Withania somnifera (L.) Dunal. A literature search was conducted on the PubMed, Scopus, and Web of Science databases with the aim of identifying all the relevant articles published on the issue up to June 2020. Most of the selected sexual enhancers appeared to be safe at therapeutic doses, although mild to severe adverse effects may occur in cases of overdosing or self-medication with unstandardized products. Drug interactions are more concerning, considering that herbal aphrodisiacs are likely used together with other plant extracts and/or pharmaceuticals. However, few data are available on the side effects of several plants included in this review, and more clinical studies with controlled administrations should be conducted to address this issue.

Promising role of medicinal plants in the regulation and management of male erectile dysfunction

Male erectile dysfunction (ED) refers to incompetency to reaching and retaining adequate penile tumescence for sexual intercourse. Over 152 million men globally suffer from ED and by 2025, the number of affected individuals is anticipated to be around 322 million. Pharmacological and nonpharmacological therapies such as phosphodiesterase (PDE) inhibitors, alprostadil, penile prosthesis surgery, and hormonal replacement are available for management and recuperation of ED. Nevertheless, such therapies are reported to have adverse effects as well as life-threatening. Accordingly, diversity of medicinal plant species and bioactive active compounds are preferred as therapeutic options because they are natural, abundant, available, low-cost and cause fewer or no side effects. This current review will emphasise the aetiology, risk factors, mechanisms underlying the pathophysiology of ED, treatments of ED as well as their side effects. It also provides medicinal plants that are proven effective in vivo and in vitro for the mitigation and treatment of male ED. This knowledge could be used in the future in drug discovery for the development of more natural drugs with no side effects.

Efficacy of Herbal Based Syrup on male sexual experiences: A double-blind randomized clinical trial

Background and aim

An Aphrodisiac includes any drug and food that arouses sexual instinct, induces venereal desire, and increases pleasure and performance. The present study was designed to clinically evaluate efficacy and safety of Herbal Based Syrup (HBS) composed of Tribulus terrestris L., Panax ginseng C.A. Meyer., Zingiber officinale Rosc, Ceratonia siliqua L., Papaver rhoeas L., and Palm tree pollen on sexual experience of men.

Experimental procedure

The study was designed as a double-blind randomized clinical trial. The main outcome measures were the responses obtained from using the Arizona Sexual Experience Scale (ASEX). The ASEX was completed by 100 married and seemingly healthy men before and after taking one dose of HBS or placebo and at least one sexual intercourse. In addition, possible side effects were observed. A split-plot ANOVA (SPANOVA) design was used for statistical analysis.

Results

Results of analysis of data for each variable of the ASEX showed significantly lower scores in HBS-treated group compared to the placebo (control) group in items of desire, arousal, erection, orgasm and satisfaction (p < 0.05). No drug-related serious adverse events were observed.

Conclusion

Results of this study indicated a significant improvement in sexual experience of men following consumption of HBS. Due to various complications reported about the use of chemical sexual drive enhancers, HBS can be introduced as an alternative with fewer side effects.

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The syrup enhances sexual desire, arousal, erection, orgasm and satisfaction.

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The syrup may be a useful supplement to improve sexual experience of healthy men.

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The syrup was stable more than 1 year in room temperature.

Korean red ginseng promotes hippocampal neurogenesis in mice

Neurogenesis in the adult hippocampus plays a major role in cognitive ability of animals including learning and memory. Korean red ginseng (KRG) has long been known as a medicinal herb with the potential to improve learning and memory; however, the mechanisms are still elusive. Therefore, we evaluated whether KRG can promote cognitive function and enhance neurogenesis in the hippocampus. Eight-week-old male C57BL/6 mice received 50 mg/kg of 5-bromo-2'-deoxyuridine (BrdU) intraperitoneally and 100 mg/kg of KRG or vehicle orally once a day for 14 days. Pole, Rotarod and Morris water maze tests were performed and the brains were collected after the last behavioral test. Changes in the numbers of BrdU- and BrdU/doublecortin (DCX; a marker for neuronal precursor cells and immature neurons)-positive cells in the dentate gyrus and the gene expression of proliferating cell nuclear antigen (a marker for cell differentiation), cerebral dopamine neurotrophic factor and ciliary neurotrophic factor in the hippocampus were then investigated. KRG-treated mice came down the pole significantly faster and stood on the rotarod longer than vehicle-treated mice. The Morris water maze test showed that KRG administration enhanced the learning and memory abilities significantly. KRG also significantly increased BrdU- and BrdU/DCX-positive cells in the dentate gyrus as well as the proliferating cell nuclear antigen, cerebral dopamine neurotrophic factor and ciliary neurotrophic factor mRNA expression levels in the hippocampus compared to vehicle. Administration of KRG promotes learning and memory abilities, possibly by enhancing hippocampal neurogenesis. This study was approved by the Pusan National University Institutional Animal Care and Use Committee (approval No. PNU-2016-1071) on January 19, 2016.

Iridoids and Amino Acid Derivatives from the Paraguayan Crude Drug Adenocalymma marginatum (ysypó hû)

The crude drug ysypó hû (Adenocalymma marginatum DC., Bignoniaceae) is used traditionally by the Guarani of Eastern Paraguayan as a male sexual enhancer. The aim of the present study was to identify the main constituents of the crude drug and to evaluate the in vitro inhibitory activity towards the enzyme phosphodiesterase-5 (PDE-5). The main compounds were isolated by counter-current chromatography (CCC). The metabolites were identified by spectroscopic and spectrometric means. The chemical profiling of the extracts was assessed by high-performance liquid chromatography coupled to mass spectrometry (HPLC-MS/MS). The crude extract and main isolated compounds were tested for their PDE-5 inhibitory activity using commercial kits. The iridoid theviridoside and 4-hydroxy-1-methylproline were isolated as the main constituent of the crude drug. Four chlortheviridoside hexoside derivatives were detected for the first time as natural products. Chemical profiling by HPLC-MS/MS led to the tentative identification of nine iridoids, six phenolics, and five amino acids. The crude extracts and main compounds were inactive towards PDE-5 at concentrations up to 500 µg/mL. Iridoids and amino acid derivatives were the main compounds occurring in the Paraguayan crude drug. The potential of ysypó hû as a male sexual enhancer cannot be discarded, since other mechanisms may be involved.

A Patented Blend Consisting of a Combination of Vitex agnus-castus Extract, Lepidium meyenii (Maca) Extract and Active Folate, a Nutritional Supplement for Improving Fertility in Women

Background:Statistics from recent years have shown that 40% of infertile couples have a female etiological factor, 40% a male etiology and the remaining 20% a combination of female and male factors. For fertile couples, the chance of getting pregnant is 57% in three months of attempts, 75% in six months, 90% in one year, and 95% in two years. One-third of infertile couples have more than one cause involved in their inability to conceive. In 10-20% of cases, the reason for infertility cannot be determined. Approximately 25% of infertile women have ovulatory dysfunction. Objectives:This research investigates improvements on the fertility of couples following treatment with a daily tablet of the patented blend consisting in a combination of Vitex agnus-castus (Vitex) extract, Lepidium meyenii (Maca) extract and active folate alone or with a gel capsule of vitamin, minerals, oligo-elements plus DHA and EPA Omega 3 fatty acids. Materials and methods:Multicenter prospective interventional study with a duration of 18 months, conducted between June 2016 and December 2017. A total of 189 women were enrolled in the study. Participants were assigned to two treatment groups: group A, consisting of 103 patients who received a daily tablet of the patented blend consisting in a combination of Vitex extract, Maca extract and active folate, and group B, consisting of 86 patients who were given a daily tablet of the patented blend also administered to Group A and a gel capsule of vitamins, minerals, oligo-elements plus DHA and EPA omega 3 fatty acids. Paraclinical tests were conducted upon inclusion in the study and six months after treatment initiation in case of non-pregnancy. Every patient received ovulation kits and ovulation tests were performed on day 14 of the menstrual cycle. Outcomes:Average age of the women was 31.18 years (SD 5.18 years). There was a successful pregnancy rate of 37%, with no difference between the two arms of the study. The number of new pregnancies was relatively constant through the study duration. The number of women with ovulation increased from 10% to 42.9% by the end of the study. During the six-month-period of the study, there were no side effects reported between patients of the two groups. Conclusions:The supplement may be used by women trying to conceive. The patented blend consisting of a combination of Vitex, Maca and active folate regulates the menstrual cycle, stimulates ovulation and increases the likelihood of getting pregnant.

Sexual Performance Anxiety

INTRODUCTION

Sexual performance anxiety (SPA) is one of the most prevalent sexual complaints; yet, no diagnosis is recognized for either gender. Thus, research into treatment has been minimal.

AIM

Review the prevalence of SPA and its relation to sexual dysfunctions and anxiety disorders. Compare SPA to (non-sexual) performance anxiety and social anxiety (PA/SA). Apply pharmacologic principles to the known properties of drugs and phytotherapies to hypothesize treatments for SPA.

METHODS

Review SPA and PA/SA through PubMed searches for relevant literature from 2000 to 2018.

MAIN OUTCOME MEASURE

Prevalence was estimated using population-representative surveys. For treatment results, controlled clinical trial results were prioritized over open-label trial results.

RESULTS

SPA affects 9-25% of men and contributes to premature ejaculation and psychogenic erectile dysfunction (ED). SPA affects 6-16% of women and severely inhibits sexual desire. Cognitive behavior therapy and mindfulness meditation training have been proven effective for PA/SA and are recommended for SPA, but controlled studies are lacking. Phosphodiesterase type 5 inhibitors are effective for psychogenic ED and premature ejaculation, both of which include SPA as a major element. Drugs proven for PA/SA have adverse sexual and sedative effects, but serotonergic anxiolytics with prosexual effects (buspirone ± testosterone, trazodone ± bupropion) may have potential, and sage, passionflower, l-theanine, and bitter orange are anxiolytic. Nitric oxide boosters (l-citrulline, l-arginine, Panax ginseng) have the potential for increasing genital tumescence and lubrication, and plant-based alpha-adrenergic antagonists may aid sexual arousal (yohimbine/yohimbe, Citrus aurantium/p-synephrine).

CONCLUSION

SPA causes or maintains most common sexual dysfunction. No treatments are well proven, although cognitive behavior therapy, mindfulness meditation training, and serotonergic anxiolytics (buspirone, trazodone, gepirone) have potential, and phosphodiesterase type 5 inhibitors are effective for psychogenic ED and premature ejaculation. Several phytotherapies also appear to have potential. Pyke RE. Sexual Performance Anxiety. J Sex Med 2020;8:183-190.

Natural phosphodiesterase 5 (PDE5) inhibitors: a computational approach

In 1998, sildenafil was marketed as the first FDA-approved oral drug for the treatment of erectile dysfunction (ED). During the last two decades, the commercialization of other synthetic phosphodiesterase 5 (PDE5) inhibitors has been paralleled by the rise of remedies based on natural molecules from different chemical classes (flavonoids, polyphenols and alkaloids in general). In this work, a set of in silico tools were applied to study a panel of 30 natural compounds claimed to be effective against ED in the scientific literature or in folk medicine. First, pharmacokinetic properties were analysed to exclude the compounds lacking in specific drug-like features. Estimated binding energy for PDE5 and selectivity towards other PDE isoforms were then considered to highlight some promising molecules. Finally, a detailed structural investigation of the interaction pattern with PDE in comparison with sildenafil was conducted for the best performing compound of the set.

Toward a Scientific Nutritional Supplement Combination for Prostatism and Erectile Dysfunction I: From Known Pharmacology to Clinical Testing

Prostatism and erectile dysfunction (ED) are highly prevalent and closely comorbid. Prescription treatments are limitingly expensive but robust in mechanisms of action (MoA). Nutritional supplements (NS) are low-cost but inadequately supported by evidence. Do any NS use robust MoA? Could their efficacy be amplified via dosing, concentration of active principles, and/or use in combination? The goal is to develop an effective NS for prostatism and ED using the MoA of prescription treatments. Literature reviews were conducted on dietary supplements for prostatism or ED and MoA of relevant drugs. The most promising NS employing these MoA were chosen. A pilot study of a prototype combination was conducted. A protocol was created for an adequate dose-response trial to test the NS combination in men with ED and prostatism. The main measures were response rates, International Prostate Symptom Score, and International Index of Erectile Function. For drugs, the MoAs best proven for prostatism and ED were nitric oxide augmentation, mild androgen inhibition, and anti-inflammatory effects. The following NS best simulate these MoA and are best supported for efficacy; for prostatism: beta sitosterol; for ED: panax ginseng, arginine, and citrulline. Pilot clinical data provided support. A plan for a formal dose-response clinical trial was approved by a central institutional review board. NS using effective MoA might suffice for prostatism and ED. Pilot testing of a combination NS with the best-supported MoA supported further development. A dose-response trial should be conducted using adequate doses of L-citrulline, beta-sitosterol, ginseng, and vitamin D3.

Male sexual enhancers from the Peruvian Amazon

ETHNOPHARMACOLOGICAL RELEVANCE

Selected Peruvian Amazon plants are macerated into sugar cane distillates to prepare alcoholic beverages used to improve male sexual performance. The tree bark from Campsiandra angustifolia Spruce ex Benth (Fabaceae), Swartzia polyphylla DC (Fabaceae), Minquartia guianensis Aubl. (Olacaceae) and Thynantus panurensis (Bureau) Sandwith (Bignoniaceae) usually are used as crude drugs in mixtures of several ingredients.

AIM OF STUDY

Describe the chemical composition of the most traded traditional male enhancer beverages, namely "Levántate Lazaro" and "Siete veces sin sacarla", and their single crude drug constituents, as well as their inhibitory activity towards the enzyme phosphodiesterase-5. The presence of pro-sexual drugs such as Sildenafil® and derivatives was assessed in the samples.

MATERIALS AND METHODS

Single plant constituents and the preparation mixtures were purchased in the Mercado Belen (Iquitos, Peru). Chemical profiling was carried out by HPLC-DAD-ESI-MS/MS. The extracts were assessed for phosphodiesterase-5 inhibition. The occurrence of pro-sexual drugs was determined by HPLC-DAD-ESI-MS/MS.

RESULTS

Chemical profiling allowed the identification of condensed tannins as the main constituents of C. angustifolia and S. polyphylla, hydrolysable tannins for M. guianensis, and C-glycosides for T. panurensis. The traditional preparations showed similar composition compared to the crude drugs. At 200 µg/mL, the traditional preparation "Levántate Lázaro" and "Siete veces sin sacarla" inhibited the phosphodiesterase-5 by 49.88% and 27.90%, respectively. No adulterations with pro-sexual drugs were found in the samples. From the crude drugs, low effect was found for the extracts of S. polyphylla and T. panurensis and high activity for C. angustifolia which inhibited the enzyme by 89.37% and 81.32% at 200 and 100 µg/mL, respectively.

CONCLUSION

The traditional preparations used to improve sexual performance in the Peruvian Amazon showed activity as phosphodiesterase-5 inhibitors. The most active ingredient of the traditional preparations was C. angustifolia, with some contribution from T. panurensis. These results encourage additional studies, including animal models to confirm the male enhancer effect of the preparations.

Exo-Clinical Trials of Nutritional Supplements for Sexual Dysfunction: Precedents, Principles, and Protocols

INTRODUCTION

Care-seeking for sexual dysfunction is limited by embarrassment, efficacy/safety concerns, and cost. Nutritional supplements (NSs) are low-cost but unproven.

AIM

To provide hypotheses on whether effective NS combinations for sexual dysfunction can be created following known pharmacology principles and tested with sufficient rigor in Internet-based "exo-clinical" trials (XCTs).

METHODS

PubMed and Google searches were conducted to review the feasibility of XCTs of NS combinations for sexual dysfunction. Findings were synthesized into recommendations for XCTs to treat the most common sexual problems.

MAIN OUTCOME MEASURE

The hierarchy of references used for making recommendations was controlled clinical trials over uncontrolled trials. The frequency of sexual dysfunction was determined in population-representative national surveys.

RESULTS

XCTs of cognitive behavioral therapy show conclusive efficacy for anxiety and depression. 5 small XCTs showed efficacy for female sexual dysfunction and erectile dysfunction (ED), and 2 XCTs of NS for other medical problems substantiated feasibility. To test the feasibility of XCTs for the most common forms of sexual dysfunction-ED, hypoactive sexual desire disorder (HSDD), and sexual performance anxiety-protocol outlines were generated for frugal XCTs; the total estimated subject time burden is ≤1 hour.

CONCLUSION

An XCT is a cost-effective method of evaluating new treatments, including sexual dysfunction and common mental disorders, if compliance is maintained by regular outreach while minimizing the time burden on subjects and handling consent and privacy issues appropriately. NS combinations might expand the opportunities for relief of sexual dysfunction if formulated with pharmacologically active doses of NS with already supported efficacy and safety. The feasibility of XCTs of NS combinations for sexual dysfunction might be tested most productively in men with ED, in women with HSDD, and in men and women with sexual performance anxiety. Pyke RE. Exo-Clinical Trials of Nutritional Supplements for Sexual Dysfunction: Precedents, Principles, and Protocols. Sex Med Rev 2019;7:251-258.

Ginseng for erectile dysfunction

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effects of ginseng on erectile dysfunction (ED).