Efficacy of Tribulus terrestris for the treatment of hypoactive sexual desire disorder in postmenopausal women: a randomized, double-blinded, placebo-controlled trial

Phytotherapic approach in menopause: light and darkness

INTRODUCTION

Menopause is a critical period of the woman life, characterized by a peculiar modification in estrogens concentration and accompanied by different signs and symptoms. To prevent and contrast unfavorable consequences of menopause, different therapeutic approaches could be evaluated. The hormone replacement therapy (HRT) is the most known, but it has several contraindications. The increasing interest in phytotherapy introduces the necessity for endocrinologist involved in menopause to suggest different therapeutic approaches, considering the state of health of patient and the real efficacy of the drugs. We aim to outline the main phytotherapy treatments to choose in menopause.

EVIDENCE ACQUISITION

This review is based on focused research of the current literature on PubMed and Scopus such as research databases. We selected 4120 papers through these keywords: "MENOPAUSE" AND "phytotherapy," "natural therapy," "phytoterapy drugs." Then, the literature was scanned selecting English papers of last 10 years (last research on October 1, 2021), excluding reviews. Separately, two researchers MGT and CP examined and read 212 full selected papers. We included clinical trials and randomized clinical trials written in English and excluded duplicates, animal studies and studies with lack of group of interest, non-relevant outcomes, inappropriate methodology. Retrospective studies, case reports, case series, original articles, brief communications, and letter to the editor were included in our research. We furthermore completed our research by the examination of every study's bibliography.

EVIDENCE SYNTHESIS

Phytotherapy involves the use of plants or plant extracts for the treatment of diseases thanks to the activities of their compounds and metabolites. In particular, many of them have an estrogen-like activity and are identified as phytoestrogens, because thanks to their chemical structure are able to bind the estrogen receptors and carry out biological estrogenic or antiestrogenic activities. The supplementing diet with these compounds can ensure an advantage on various aspects of the climacteric syndrome and some of them also have a beneficial impact on cardiovascular risk, bone health and sleep complaint. These substances can be used with safety due to their good tolerability and low rate of side effects. There are no known serious adverse events associated with their consumption, but as a precaution, its use is not recommended during pregnancy and in association with hormonal therapies or in women with hormone responsive cancers.

CONCLUSIONS

Phytotherapy must be considered an interesting tool in the treatment of signs and symptoms in selected menopause woman.

Efficacy of Hormonal and Nonhormonal Approaches to Vaginal Atrophy and Sexual Dysfunctions in Postmenopausal Women: A Systematic Review

OBJECTIVE

 To evaluate the efficacy of the hormonal and nonhormonal approaches to symptoms of sexual dysfunction and vaginal atrophy in postmenopausal women.

DATA SOURCES

 We conducted a search on the PubMed, Embase, Scopus, Web of Science, SciELO, the Cochrane Central Register of Controlled Trials (CENTRAL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, as well as on clinical trial databases. We analyzed studies published between 1996 and May 30, 2020. No language restrictions were applied.

SELECTION OF STUDIES

 We selected randomized clinical trials that evaluated the treatment of sexual dysfunction in postmenopausal women.

DATA COLLECTION

 Three authors (ACAS, APFC, and JL) reviewed each article based on its title and abstract. Relevant data were subsequently taken from the full-text article. Any discrepancies during the review were resolved by consensus between all the listed authors.

DATA SYNTHESIS

 A total of 55 studies were included in the systematic review. The approaches tested to treat sexual dysfunction were as follows: lubricants and moisturizers (18 studies); phytoestrogens (14 studies); dehydroepiandrosterone (DHEA; 8 studies); ospemifene (5 studies); vaginal testosterone (4 studies); pelvic floor muscle exercises (2 studies); oxytocin (2 studies); vaginal CO₂ laser (2 studies); lidocaine (1 study); and vitamin E vaginal suppository (1 study).

CONCLUSION

 We identified literature that lacks coherence in terms of the proposed treatments and selected outcome measures. Despite the great diversity in treatment modalities and outcome measures, the present systematic review can shed light on potential targets for the treatment, which is deemed necessary for sexual dysfunction, assuming that most randomized trials were evaluated with a low risk of bias according to the Cochrane Collaboration risk of bias tool. The present review is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100488).

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.

A Systematic Literature Review of Health-related Quality of Life Measures for Women with Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder

INTRODUCTION

Hypoactive Sexual Desire Disorder (HSDD) / Female Sexual Interest/Arousal Disorder (FSIAD) impacts health-related quality of life (HRQoL) of women and their partners, yet existing measures fail to adequately capture relevant concepts (ie, what is essential to measure including symptoms/impacts) important to women with HSDD/FSIAD.

OBJECTIVES

To identify HRQoL tools used to assess women with HSDD/FSIAD, and to evaluate their psychometric properties (ie, reliability, validity, and responsiveness).

METHODS

We conducted searches in PubMed, Embase and PsychINFO from June 5, 1989 to September 30, 2020 for studies in women with HSDD/FSIAD and psychometric analyses (English only). Principles of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias Checklist and other psychometric criteria were applied. Based on this search, 56 papers were evaluated including 15 randomized-controlled trials, 11 observational/single arm/open label studies, and 30 psychometric studies.

RESULTS

Of the 18 measures identified, the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) were included in most studies (> 50%). General HRQoL instruments were not used in any of the clinical trials; the SF-12, SF-36 and EQ-5D-5L were reported in two observational studies. No instruments achieved positive quality ratings across all psychometric criteria. The FSFI, FSDS-R, Sexual Event Diary (SED) and the Sexual Desire Relationship Distress Scale (SDRDS), were the only measures to receive a positive rating for content validity.

CONCLUSION

Reliable and valid HRQoL measures that include sexual desire and distress are needed to provide a more systematic and comprehensive assessment of HRQoL and treatment benefits in women with HSDD/FSIAD. While inferences about HRQoL are limited due to the lack of uniformity in concepts assessed and limited psychometric evaluation of these measures in women with HSDD/FSIAD, opportunities exist for the development of reliable and validated tools that comprehensively measure the most relevant and important concepts in women with HSDD/FSIAD. Lim-Watson MZ, Hays RD, Kingsberg S, et al. A systematic literature review of health-related quality of life measures for women with Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder. Sex Med Rev 2021;XX:XXX-XXX.

Effect of Tribulus Terrestris in the Treatment of Female Sexual Dysfunction and Clitoral Vascularization. Results of a Randomized Study Comparing Two Different Dosage Regimes

We evaluated the efficacy of Tribulus terrestris in two different dosage regimes for the treatment of sexual dysfunction in pre and postmenopausal women and its effect on the vascular resistance of the clitoral artery using Power Doppler. A total of 104 women were randomly assigned to receive 94mg, three times/day (TT3) or 280mg once/day for 90 days (TT1). Evaluation was performed using FSFI and QS-F questionnaires, serum levels of prolactin, TSH, total testosterone and SHBG, and clitoral artery assessment with Power Doppler ultrasound. FSFI results demonstrated an improvement in all domains in both groups (P < 0.05) except for the "Satisfaction" in the TT3 premenopausal group. QS-F results showed a significant improvement in the mean total score in women of both reproductive phases, for both groups. Postmenopausal patients improved in all sexual domains, except for "orgasm" in the TT1 group. PI of the clitoral artery showed no difference in both reproductive phases, in both groups. We conclude that TTerrestris can be a safe alternative for the treatment of sexual dysfunction in pre and postmenopausal women as it is effective in reducing the symptoms with no side effects. Moreover, its use, increased total, free and bioavailable testosterone.

Tribulus terrestris and female reproductive system health: A comprehensive review

BACKGROUND

Tribulus terrestris L. (T. terrestris) positive performance on the male sexual system has been confirmed, but little is known about its effects on the female reproductive system.

PURPOSE

This review discussed in detail the beneficial impact of T. terrestris and its secondary metabolites on the female reproductive system.

STUDY DESIGN AND METHODS

In this review, the scientific Databases of Science direct, Pubmed, Web of Science, Google, Google Scholar, Researchgate, EMBASE, Scientific Information (SID), and Elsevier were searched profoundly. Studies about the pharmacological activities of T. terrestris on the female reproductive system in each aspect of investigations: human, in vivo, and in vitro studies, in the period from 1998 to 2020 were admitted. Our study was not limited by the language of publications.

RESULTS

23 articles about the effects of T. terrestris on the female reproductive system were found. These studies approved the T. terrestris efficacy on improvements in histological features of the ovary and uterus of polycystic ovary syndrome patients as well as the well-working of normal ovaries, enhancements in the sexual desire of postmenopausal syndrome, improve ovarian and breast cancers.

CONCLUSION

These studies showed that the positive effect of T. terrestris on the female reproductive system was due to the presence of a secondary metabolite called protodioscin; a steroidal saponin compound, as the dominant active component of this plant.

Medicinal plants/herbal supplements as female aphrodisiacs: Does any evidence exist to support their inclusion or potential in the treatment of FSD?

ETHNOPHARMACOLOGICAL RELEVANCE

Female Sexual Dysfunction is a complex condition with biopsychosocial origins. Plants traditionally used as aphrodisiacs may be promising as routes to develop therapeutic options which are lacking.

AIM

To distinguish the plants commonly used in (AP) on the market in the United States, and to evaluate their ethnobotanical and clinical evidence as a basis for their inclusion.

METHODS

This study is a narrative review of 53 species commonly found in AP on the market in the United States. Most species listed have anecdotal use as aphrodisiacs throughout history; therefore, a systematic search was done for clinical evidence. The primary outcome assessed is the clinical efficacy of plants in the treatment of libido desire disorders.

RESULTS

There is little to no evidence from the literature to substantiate claims of plants currently on the market as AP for female libido desire disorders.

CONCLUSIONS

The biggest problem in the literature is the lack of botanical verification and consistency in material across studies. Any botanical, commercial or otherwise must be tested for chemical markers exhibited by individual species; however, if no markers exist, work must first be done to determine these. Appropriate analytical techniques for this would include high pressure liquid chromatography, and mass spectroscopy. It would also be sufficient to taxonomically authenticate species provided the plant material. Further research should aim to standardize plant material and extraction methods utilized in order to compare studies effectively and allow for reproducibility to draw conclusions. While clear interest into investigation the aphrodisiac potential of plants exists, a translatable in vivo animal model does not. Clinical trials rely on patient reported outcomes to determine efficacy but cost and length of such trials deem a necessity for development of an animal model to first screen botanicals. We suggest development of screening tools utilizing the evident neurobiological underpinnings of FSD as the first step. In general, studies of plants currently used as ingredients for AP are severely lacking, and even so the evidence that exists is weak.

Chemical Constituents, Biological Properties, and Uses of Tribulus terrestris: A Review

Tribulus terrestris L. (TT) (puncturevine) is a common weed that grows in many countries worldwide and in some places is considered as a noxious weed. The plant has been used in traditional Chinese and Indian medicines and is now considered as one of the most popular aphrodisiacs. It is known for its healing properties for sexual difficulties, impotence, and human and animal hormonal imbalance. It is also used as a sexual booster. Because of the plant’s active substances that can be used for curing sexual and other disorders, interest in it is increasing, and it is currently one of the most studied medicinal plants. The products and preparations manufactured from the aboveground plant parts are especially popular among athletes and people with health issues and diseases such as hormonal imbalance, sexual problems, heart problems, and various kidney and skin diseases. The aim of this review is a comprehensive and critical assessment of the scientific publications involving TT, with special reference to its chemical constituents and biological properties that may facilitate current understanding and future studies of this fascinating plant species. The objectives of this review were (1) to find knowledge gaps, (2) to discuss critically relevant publications and issues with materials and methods that may be prerequisites for contradictory results, and (3) to identify research and development areas. It was found that some of the studies on TT extracts as aphrodisiacs are controversial. A significant number of research publications claim that TT extracts and nutritional supplements containing TT improve muscle tone, have a common biostimulating effect, and improve spermogenesis. However, there are a growing number of publications that dispute these claims, as there are no empirical data on commonly accepted mechanisms of action. The main biologically active substances in TT are steroidal saponins, flavonoids, alkaloids, and lignan amides, the most studied being the steroidal saponins. Multiyear data on the metabolic profile of the species are generally lacking. There are a variety of methods used for extracting plant material, differences in methodologies and saponin analyses, and scientific instruments that were used. Lack of common standards could be a reason for differences in the pharmacological activity and composition of the TT preparations. Development of standard procedures and methods for collection of plant material and analyses are recommended. Selection and breeding efforts and agronomic studies of promising clones of TT would need to be conducted in order to develop TT as a new crop. This will provide consistency of supply and quality of the feedstock for the pharmaceutical industry and could provide a new cash crop for growers.

Beyond tribulus (Tribulus terrestris L.): The effects of phytotherapics on testosterone, sperm and prostate parameters

ETHNO-PHARMACOLOGICAL RELEVANCE

Phytotherapeutic approaches have been widely proposed to improve male health. Despite the well-touted effects of tribulus (Tribulus terrestris L) on men's health, an optimal phytotherapy remains an elusive challenge.

AIM OF THE REVIEW

We sought to critically analyze the evidence in the phytotherapic literature beyond the effects of tribulus on testosterone (T) concentration and sperm analysis to also include indications for prostate health.

MATERIALS AND METHODS

A focused literature search was conducted to include studies published in Cochrane, Pubmed, and Web of Science databases between the years 2002 and 2018.

RESULTS

The use of tribulus and maca (Lepidium meyenii Walp, Brassicaceae) were not scientifically supported to improve serum T levels in men. Moderate evidence supports the use of long Jack (Eurycoma longifolia Jack, Simaroubaceae), mucuna (Mucuna pruriens (L.) DC., Fabaceae), ashwagandha (Withania somnifera (L.) Dunal, Solanaceae), fenugreek (Trigonella foenum-graceum L., Fabaceae), and black seeds (Nigella sativa L., Ranunculaceae) to increase total T and improve seminal parameters. Data suggests an increase in total T with the use of 5000 mg/d of powdered mucuna seed and ashwagandha root (151 and 143 ng/dL, respectively) over a 12-week period in patients with oligozoospermia. The use of mucuna was supported for patients with oligozoospermia to improve sperm parameters, with an increase of 83.3 million/mL observed after use of 5000 mg/d of powdered mucuna seed over a 12-week period. Evidence supporting the use of saw palmetto (Serenoa repens, (W.Bartram) Small, Arecaceae) to improve prostate health remains equivocal; whereas, evidence supporting the use of Pygeum africanum Hook.f., Rosaceae, Urtica dioica L., Urticaceae, beta-sitosterols, pollen extract, onion, garlic, and tomato, appears favorable and promising.

CONCLUSION

Scientific evidence supports the use of mucuna and ashwagandha as phytotherapics for improving serum T concentrations and semen parameters. Despite inconclusive evidence for use of tribulus as a T booster, it may provide advantageous effects on sperm parameters in men with idiopathic infertility. Nutraceutical strategies and some phytotherapics may also be effective to promote prostate health. Popular foodstuffs (onion, garlic, and tomato), nutraceutical agents (pollen extract and beta-sitosterols), and herbal medicines (Pygeum africanum and Urtica dioica) are rational approaches.

Effect of a multi-ingredient based food supplement on sexual function in women with low sexual desire

Background

Studies have demonstrated that women with low desire and low excitement have negative feelings regarding their physical and emotional satisfaction, as well as their happiness. In this study, we evaluate the efficacy of Libicare® - a multi-ingredient food supplement - to improve sexual function in postmenopausal women.

Methods

This was an exploratory, prospective, non-controlled, observational study. Postmenopausal women aged 45–65 with a risk of sexual dysfunction (Female Sexual Function Index (FSFI) < 25.83) were included during routine clinical visits and treated with 2 tablets of Libicare® daily for 2 months. Libicare® is an oral food supplement containing Trigonella foenum graecum, Turnera diffusa, Tribulus terrestris, and Ginkgo biloba dry extracts. Primary endpoint: change vs. baseline in FSFI score. Secondary endpoints: 1) changes in testosterone and serum steroid levels of free testosterone and sex hormone-binding globulin (SHBG) levels and 2) tolerability.

Results

A total of 29 patients (mean age: 54.69 years) were included. FSFI mean (SD) score showed a significant increase: 20.15 (4.48) vs 25.03 (6.94), baseline vs final; p = 0.0011, paired t-test. Most patients (86.2%) increased their FSFI score. All FSFI domains, except dyspareunia, showed significant increases. The highest increase was observed in the desire domain (p = 0.0004). Testosterone and SHBG levels were assessed in 21 patients. A significant increase in testosterone level was observed: 0.41 (0.26) vs. 0.50 (0.34) pg/mL, baseline vs. final; p = 0.038, Wilcoxon test. 52.4% of patients increased their testosterone levels. Finally, a significant decrease was observed in SHBG level: 85 (32.9) vs. 73 (26.8) nmol/L, baseline vs. final; p = 0.0001; paired t-test. 95.2% of patients decreased their SHBG levels.

Conclusion

In this pilot study, a significant improvement in sexual function and related hormone levels was observed with Libicare®. Further studies must be conducted to confirm these exciting results.

Trial registration

Current Controlled Trial ISRCTN12928573. Date of registration: 28/March/2019. Retrospectively registered.

Efficacy of Tribulus Terrestris for the treatment of premenopausal women with hypoactive sexual desire disorder: a randomized double-blinded, placebo-controlled trial

Although hypoactive sexual desire disorder (HSDD) is the most common sexual complaint, there is no consensus for the ideal treatment. Our study aimed to evaluate the efficacy of treating premenopausal women with HSDD with Tribulus terrestris and its effect on the serum levels of testosterone. We performed a prospective, randomized, double-blind, placebo-controlled trial, with 40 premenopausal women reporting diminished libido, receiving T. terrestris or placebo. The questionnaires FSFI and the QS-F were used to evaluate sexual dysfunction before and after treatment. Patients treated with T. terrestris experienced improvement in total score of FSFI (p < .001) and domains "desire" (p < .001), "sexual arousal" (p = .005), "lubrication" (p = .001), "orgasm" (p <.001), "pain" (p = .030) and "satisfaction" (p = .001). Treatment with placebo did not improve the scores for the "lubrication" and "pain". QS-F scores showed that patients using T. terrestris had improvements in "desire" (p = .012), "sexual arousal/lubrication" (p = .002), "pain" (p = .031), "orgasm" (p = .004) and "satisfaction" (p = .001). Women treated with placebo did not score improvements. Women receiving T. terrestris had increased levels of free (p = .046) and bioavailable (p < .048) testosterone. T. terrestris might be a safe alternative for the treatment of premenopausal women with HSDD as it was effective in reducing the symptoms, probably due to an increase in the serum levels of free and bioavailable testosterone.

Evaluation and Management of Hypoactive Sexual Desire Disorder

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) often has a negative impact on the health and quality of life of women; however, many women do not mention-let alone discuss-this issue with their physicians. Providers of gynecologic services have the opportunity to address this subject with their patients.

AIM

To review the diagnosis and evidence-based treatment of low sexual desire in women with a focus on strategies that can be used efficiently and effectively in the clinic.

METHODS

The Medline database was searched for clinically relevant publications on the diagnosis and management of HSDD.

RESULTS

HSDD screening can be accomplished during an office visit with a few brief questions to determine whether further evaluation is warranted. Because women's sexual desire encompasses biological, psychological, social, and contextual components, a biopsychosocial approach to evaluating and treating patients with HSDD is recommended. Although individualized treatment plan development for patients requires independent medical judgment, a simple algorithm can assist in the screening, diagnosis, and management of HSDD. Once a diagnosis of HSDD has been made, interventions can begin with office-based counseling and progress to psychotherapy and/or pharmacotherapy. Flibanserin, a postsynaptic 5-hydroxytryptamine 1A agonist and 2A antagonist that decreases serotonin levels and increases dopamine and norepinephrine levels, is indicated for acquired, generalized HSDD in premenopausal women and is the only agent approved in the United States for the treatment of HSDD in women. Other strategies to treat HSDD include using medications indicated for other conditions (eg, transdermal testosterone, bupropion). Bremelanotide, a melanocortin receptor agonist, is in late-stage clinical development.

CONCLUSIONS

Providers of gynecologic care are uniquely positioned to screen, counsel, and refer patients with HSDD. Options for pharmacotherapy of HSDD are currently limited to flibanserin, approved by the US Food and Drug Administration, and off-label use of other agents. Clayton AH, Kingsberg SA, Goldstein I. Evaluation and Management of Hypoactive Sexual Desire Disorder. Sex Med 2018;6:59-74.

A review of traditional pharmacological uses, phytochemistry, and pharmacological activities of Tribulus terrestris

Tribulus terrestris L. (TT) is an annual plant of the family Zygophyllaceae that has been used for generations to energize, vitalize, and improve sexual function and physical performance in men. The fruits and roots of TT have been used as a folk medicine for thousands of years in China, India, Sudan, and Pakistan. Numerous bioactive phytochemicals, such as saponins and flavonoids, have been isolated and identified from TT that are responsible alone or in combination for various pharmacological activities. This review provides a comprehensive overview of the traditional applications, phytochemistry, pharmacology and overuse of TT and provides evidence for better medicinal usage of TT.