Medicinal Plants for Female Sexual Dysfunction

A recent article in The Journal of Sexual Medicine identifies and describes the popular and clinical uses of medicinal plants for Female Sexual Dysfunction (FSD) in climacteric (menopausal) women. Although there is very little evidence from the literature to recommend the use of medicinal plants for treating FSD, Mazaro-Costa, et al, list those plants that are currently used for female reproductive disturbances, most notably the climacteric state to correct aspects of female sexual dysfunction. More research is needed before strong recommendations can be made.

Black cohosh – Cimicifuga racemosa

Current use: Menopausal therapy for hot flashes, profuse sweating and vaginal complaints

Active Ingredients: triterpene glycosides, phenolic acids, flavonoids, volatile oils, tannins

Standardization: 2.5% triterpene glycosides

Research: was not statistically significant in treating hot flashes after 16 weeks; does improve the vaginal maturity index in postmenopausal women; approaches significance in treating vaginal dryness; statistically significant in treating anxiety

Mechanism: SERM (does not affect ERα or ERβ but does have an effect on ERϒ), high affinity for various serotonin receptors

Safety: Relatively safe; however, case reports about liver toxicity. Because of unknown MOA and potential estrogenic effect it should be avoided during pregnancy and lactation and in children under 12.

Ginkgo - Ginkgo biloba

Current use: asthma, fatigue, tinnitus, memory improvement

Active Ingredients: flavonol, glycosides, terpene lactones, bilobalide

Standardization: 6% terpene lactone sna 24% flavones glycosides

Research: 300 mg improved physiological sexual arousal but no subjective sexual arousal; when combined with sex therapy increased sexual desire and contentment; effective in alleviating antidepressant-induced sexual symptoms in 84% of cases

Mechanism: Relaxes smooth muscle, facilitates peripheral blood flow, has NO-scavenging abilities

Safety: Side effects are rare and limited to mild, transient and reversible; drug interactions with warfarin, aspirin, lithium; safety in pregnancy and breastfeeding has not been established

Maca – Lepidium meyenii

Current use: Andean aphrodisiac an/or fertility-enhancing, menopausal therapy

Active Ingredients: sterols which possess phytoestrogen activity

Standardization: Unknown

Research: RDBPCT decreased psychological symptoms including anxiety, depression and sexual dysfunction and did not affect estradiol, FSH, LH or SHBG levels.

Mechanism: Unknown

Safety: Unknown

Puncture vine – Tribulus terristris

Current and traditional use: ancient aphrodisiac, UTI treatment, inflammation, edema and TCM sexual dysfunction

Active Ingredients: Steroidal saponins (tribestane, vitanone and protodioscin)

Standardization: 16.4% protodioscin

Research: 49/50 women experienced improvement in all or some menopausal symptoms (hot flashes, depression, genital discomfort, libido) however, may lack validity due to conflict of interest

Mechanism: increase endogenous androgen production by increasing LH release from the pituitary gland; increases NO release

Safety: Phototoxic reactions; safety during pregnancy and lactation has not been established

Red clover – Trifolium pretense

Current use: Menopausal therapy for hot flashes, profuse sweating and vaginal complaints

Active Ingredients: phytoestrogens such as genistein, formononetin, daidzein and biochanin A

Standardization: 9-15% isoflavones

Research: meta-analysis showed a marginal effect for treating hot flashes with 40-82 mg/day; significant beneficial effect on vaginal and sexual health in postmenopausal women

Mechanism: SERM (does not affect ERα or ERβ but does have an effect on ERϒ), high affinity for various serotonin receptors

Safety: Safe and well-tolerated in women with one first degree relative with breast cancer; supplements containing these isoflavones did not adversely affect breast density, skeletal strength or cardiovascular status; none of the CCT have reported adverse effects at doses upt to 160 mg of isoflavones per day.

Chasteberry fruit – Vitex agnus-castus

Current use: Premenstrual syndrome

Active Ingredients: triterpene glycosides, phenolic acids, flavonoids, volatile oils, tannins

Standardization: 0.05% agnuside and 0.08% casticin

Research: topical application - improvement in vaginal tone, thinning and lubrication with less dyspareunia; increased uterine weight, serum progesterone and estrogen levels in ovariectomized female rats; decreased LH and Prolactin

Mechanism: SERM (affects ERα or ERβ), decreases LH and prolactin; dopaminergic D2 receptor agonist; increases melatonin secretion

Safety: Relatively safe

Dong quai – Angelica sinensis

Current use: replenishing the blood, treating menstrual disorders and menopausal symptoms; when used in Traditional Chinese Medicine is used in conjunction with other herbs

Active Ingredients: ferulic acid and Z-ligustilide; has no phytoestrogens.

Standardization: ferulic acid 0.4-0.7%, 0.5-5.0% ligustilide

Research: When used alone has not effect in treating menopausal symptoms; has no estrogenic effect in humans but did in rat studies; when combined with Matricaria chamomilla demonstrated a reduction in hot flashes, improved sleep; when combined with Astragalus membranaceus helped decrease mild hot flashes; the improvement of sexual symptoms was not explored

Mechanism: not mentioned

Safety: few side effects including headache and potentiates anticoagulant therapy; do not use in children or adults with diarrhea, hemorrhagic diseases, hypermenorrhea, pregnancy or lactation; some concerns about liver toxicity

Zalloh – Ferula hermonis

Current use: native to Syria and Lebanon, used as a strong aphrodisiac for both sexes, treatment of frigidity and circulation enhancement

Active Ingredients: ferutinin has binding capacity for estrogen receptor α and β equivalent to about 1/10 of the binding affinity of estradiol

Standardization: not mentioned

Research: may be suggested for female sexual dysfunction associated with desire disorder

Mechanism: estrogenic effect, increased production of progesterone and therefore stimulate female sexual behavior

Safety: Unknown

Hops - Humulus lupulus

Current use: in Germany hops baths are used for treatment of gynecological disorders and hops extracts have been reported to reduce hot flashes in menopausal women

Active Ingredients: 8-prenylanaringenin; isoxanthohumol which can readily be converted to 8-prenylnaringenin by intestinal microbes; three flavonoids with estrogenic activity including: 6-prenylnaringenin, 8-geranylnaringenin and 6,8-diprenylnaringenin

Standardization: 0.11 + 0.01 mg of 8-prenylnaringenin/capsule

Research: RPCCO studies with 50 postmenopausal women over 16 weeks showed superiority over placebo for treating hot flashes; other studies have shown improvement in climacteric symptoms; topical application combined with hyaluronic acid, liposomes and Vitamin E showed significant improvement in vaginal dryness. Animal studies demonstrate an estrogenic effect on the uterus, vagina and mammary gland secretion however in vitro study did not confirm androgenic or progestogenic activity of the active ingredient.

Mechanism: may act as a SERM

Safety: safe alternative treatment for genital atrophy in postmenopausal women when HRT is not recommended; causes drowsiness; inhibits cytochrome P450; unknown safety during pregnancy and nursing.

Reference: J Sex Med 2010;7:3695-3714

PMS and Integrative Medicine (Part II): Botanicals

Chastetree, Black cohosh, Ginkgo biloba and Evening primrose are the most commonly used botanicals to treat premenstrual syndrome in the United States. Of those listed, Chastetree has been the most widely studied.

Some of the descriptions below refer to "The German Commission E". The German Commission E Monographs are a therapeutic guide to herbal medicine. There is an English translation by the American Botanical Council, with 380 monographs evaluating the safety and efficacy of herbs for licensed medical prescribing in Germany. Though the German Commission no longer exists, in Germany only those herbs with Commission E approved status are legally available.
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Chastetree Berry (Vitex agnus-castus) is the dried ripe fruit of the chaste tree. In a number of well conducted studies chastetree berry has been effective in reducing PMS symptoms, especially breast discomfort, when compared to placebo. The German Commission E has approved the use of chastetree berry for irregularities of the menstrual cycle, premenstrual symptoms and breast pain.

Chastree is considered safe. Possible side effects are mild and reversible. They include mild headache, diarrhea, abdominal cramps, decreased appetite, rash and itching. Possible drug interactions could include anti-psychotics, some antidepressants and estrogen-containing compounds. However all potential drug interactions are theoretical.

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Black Cohosh (Actaea racemosa) was used by American indigenous peoples for the treatment of respiratory complaints, muscuoskeletal pain and to aid in childbirth. It was most likely used for its anti-inflammatory and muscle relaxant properties.

Compounds in black cohosh bind to the 5-HT7 (serotonin) receptor which may explain its positive effect on depressive and anxiety symptoms in PMS. A study published by Dittmar in 1992 demonstrated a reduction of the PMS symptoms including anxiety, tension and depression. A number of studies show a benefit for various menopausal symptoms such as hot flashes, profuse sweating, sleep disturbance and depressed moods. Because these symptoms often exist in those suffering from PMS, many clinicians have recommended the use of black cohosh in this population, too. Black cohosh is approved by the German Commission E for use in women suffering from premenstrual symptoms, painful menstruation (i.e. dysmenorrhea) and menopause.

Side effects and drug interactions: Black cohosh is generally safe and well tolerated when used for 6 months; and has not been well-studied beyond 6 months duration. Caution should be exercised as there have been multiple case reports of liver damage while using black cohosh. As stated above, Black Cohosh has been studied as a therapy for menopausal symptoms, not PMS. At this time that there is insufficient evidence to support or refute the use of black cohosh for PMS.
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Ginkgo (Ginkgo biloba): Ginkgo is commonly used to sharpen mental focus and improve circulation. One well-done study suggests the ginkgo is more effective in decreasing psychological and congestive symptoms ( e.g. breast pain, breast tenderness and fluid retention) than placebo in PMS sufferers. More studies need to be conducted before strong recommendations can be made to support or refute the use of ginkgo for PMS.

Ginkgo is generally well tolerated and considered safe with similar side effect rates as placebo in several reviews. Ginkgo is thought to have a blood-thinning effect. Therefore, possible drug interactions can occur with anti-coagulants such as warfarin and aspirin.
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Evening Primrose Oil (Oenothera biennis): A systematic review of the literature published in 1996 included seven studies. Unfortunately, none of the studies found a beneficial effect of evening primrose oil for PMS symptoms; this included two well-designed, randomized, placebo-controlled trials that were adequately powered.

Potential side effects include headache, seizures among people with seizure disorder or taking anesthetics, nausea, vomiting, anorexia, diarrhea, hypersensitivity reactions, rash, inflammation and immunosuppression with long-term use. Possible drug interactions include anticoagulants, phenothiazines and other anti-seizure medication. In lite of the currently available information, EPO is not a recommended treatment for PMS.

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Other biologically based therapies: St. John’s Wort (Hypericum perforatum) is primarily used to alleviate depressive symptoms. Kava (Piper methysticum) has been proven effective for treating anxiety, though has a questionable safety profile. Valerian (Valeriana officinalis) is a common over-the-counter ingredient for sleep preparations and relaxants. Don Quai (Angelica sinensis) as a tonic for women with fatigue and low vitality. None have yet been adequately studied for the treatment of PMS.

References:
1. Daniele C, et al. Vitex agnus castus: a systematic review of adverse events. Drug Saf
2. Dittmar FW, et al. Premenstrual syndrome: treatment with a phytopharmaceutical. Therapiwoche Gynakol 1992;5:60-8.
3. Budeiri, D, Li Wan Po A, Doman JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clin Trials 1996;17:60-8.
4. Tamborini A, Taurelle R. Value of standardized Ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome. Rev Fr Gynecol Obstet
5. Blumental M, et al., eds. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine communications, 1998.
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