Natural Aphrodisiacs

39REVIEW Natural Aphrodisiacs jsm_1521 39..49 Rany Shamloul, MD Queen’s University—Pharmacology, Kingston, Ontario, Canada; Cairo University—Andrology and Sexology department, Cairo, Egypt DOI: 10.1111/j.1743-6109.2009.01521.x ABSTRACT Introduction. The search for a remedy or a prescription that can enhance sexual function and/or treat male erectile dysfunction has been an obsession throughout known history. Whether it was an Eastern civilization or a Western one, religious or atheist, man’s aspiration for a better or best “manhood” has been a history-time goal. Aim. This review will discuss the current research done on the most popular natural aphrodisiacs and examine the weight of evidence to support or discourage the use of any of these substances to enhance sexual desire and/or function. Methods. Review of the current evidence on the use of natural substances as aphrodisiacs. Main Outcome Measures. Efficacy of natural aphrodisiacs in enhancing sexual function in men and women. Results. There is little evidence from literature to recommend the usage of natural aphrodisiacs for the enhancement of sexual desire and/or performance. Data on yohimbine’s efficacy does not support the wide use of the drug, which has only mild effects in the treatment of psychogenic ED. Although there’s a positive trend towards recommending ginseng as an effective aphrodisiac, however, more in depth studies involving large number of subjects and its mechanism of action are needed before definite conclusions could be reached. Data on the use of natural aphrodisiacs in women is limited. Conclusions. The current body of objective evidence does not support the use of any natural aphrodisiac as an effective treatment for male or female sexual dysfunctions. Potent men and men with ED will continue the search for natural aphrodisiacs despite the current disappointing data on their effectiveness. Care should be taken regarding the fraud addition of sildenafil analogues to natural aphrodisiacs. Shamloul R. Natural aphrodisiacs. J Sex Med 2010;7:39–49. Key Words. Natural Aphrodisiacs; Ginseng; Yohimbine Introduction A s a sexual medicine specialist whether you were in a bar in downtown New York or in a downtown Cairo cafe you probably might have been asked about natural substances that can enhance libido and/or performance. By scientific terms, these substances are called aphrodisiacs. Aphrodisiacs take their name from Aphrodite, the Greek goddess of love and beauty. According to Greek poet Hesiod, she was born when Uranus was castrated by his son Cronus. Cronus threw his severed genitals into the sea, and from the aphros (sea foam) arose Aphrodite. © 2009 International Society for Sexual Medicine The search for a remedy or a prescription that can enhance sexual function and/or treat male erectile dysfunction (ED) has been an obsession throughout known history. Whether it was an Eastern civilization or a Western one, religious or atheist, man’s aspiration for a better or best “manhood” has been a history-time goal. In a review by Shah, different civilizations’ thoughts and reactions concerning this goal is eloquently discussed [1]. For example, poems from the Hindu civilization dating back to 3,000 to 4,000 years are the earliest recordings of the human eternal search for substances that can enhance sexual experiences lead to the much unknown, “supersex,” and/or treat J Sex Med 2010;7:39–49 Because of their huge diversity of chemical content. Cantharides are excreted in urine and can irritate the urethral passages. Intracavernosal. However. No mechanism is known regarding its popular aphrodisiac effects but it is assumed that it may have central stimulatory actions because of its hallucinogenic properties [8]. perfumes and even spices that can enhance man’s sexual abilities [1]. J Sex Med 2010. Cantharides have very limited clinical uses. Plant-Related Natural Aphrodisiacs Yohimbine Yohimbine is an indole alkaloid extracted from the bark of West African yohim trees. and watermelon [4.40 ED [2]. In recent history. a remedy consisting of 22 ingredients is described to the contemporary emperor who drank it and was able to “mount 1. This may be because of the fact that the discovery of very successful therapies of ED may have led to increased expectations of finding a natural substance that may have similar effects to PDEs without their known side-effects. Spanish Fly The Spanish fly is an emerald-green beetle in the family Meloidae. One of these poems describes natural high nutritional value treatments. Side effects.200 women and achieved immortality” [3]. salt. Natural Aphrodisiacs Nonplant Natural Aphrodisiacs Ambrein Ambrein a major constituent of Ambra grisea is used in Arab countries [6. a working classification can be designed to term aphrodisiacs made from natural sources as natural aphrodisiacs whereas others made of synthetic compounds are called non-natural aphrodisiacs. inducing vascular congestion and inflammation and thus may lead to sexual arousal [8].7]. developing equally in men and women. the search for the ultimate aphrodisiac did not stop with hundreds and hundreds of natural and unnatural substances tried. Another important reason is that it seems that some men seeking aphrodisiacs are normal and potent but just looking for an unrealistic heightened sexual satisfaction that they couldn’t attain using PDEs. which cannot be treated with PDEs. In an old Chinese text (2697 to 2595 BC). including renal toxicity and gastrointestinal hemorrhages. Also. and improvement of sexual performance. cantharides exhibit their actions by inhibition of phosphodiesterase and protein phosphatase activity and stimulation of b-receptors. and oral PDEs drugs used for the treatment of ED and synthetic androgens can all be classified as non-natural aphrodisiacs. causing inflammation in the genitals [11]. intra-urethral. rheumatism. It was expected that the advent of phosphodiesterase type 5 inhibitors (PDE5s) and other evidencebased successful oral pharmacotherapy for ED will lead to less interest in aphrodisiacs. However. ranging from treatment of headache. a net increase of 59%. Lytta vesicatoria. the reverse occurred and a simple Medline search using the term “aphrodisiac” between 2000 and 2009 yielded more than 146 citations compared with that 86 articles between 1990 and 1999. The beetle contains up to 5% cantharidin that irritates animal tissues. Bufo Toad The skin and glands of this toad contain bufotenine. It is the active ingredient in West Indian “love stone” and the Chinese medication chan su [10]. It is a prescrip- . It is found in the gut of sperm whales.5]. Only animal studies were conducted to investigate the sexual enhancing properties of this substance showing that it can stimulate pituitary secretion of luteinizing hormone (LH) leading to increased serum testosterone [8]. Moving on in history the Romans and Chinese shared the same aphrodisiac concept (or truly. It has been also shown to antagonize the effects of noradrenalin and other vasoconstricting agents on smooth muscles [5]. The ancient Egyptians had their share of aphrodisiacs with several papyri describing many medications for ED including local penile application of oiled baby crocodile hearts. it may be that men requesting aphrodisiacs are suffering from a mild form of decreased libido. However. misconception) that consuming the animal genitals can enhance men’s sexual function [1].7:39–49 Shamloul This review will discuss the current research done on the most popular natural aphrodisiacs and examine the weight of evidence to support or discourage the use of any of them to enhance sexual desire and/or function. Natural aphrodisiacs can be further classified into plant aphrodisiacs and nonplant aphrodisiacs. ingestion of pine. Orally. there appears to be no known universal classification of aphrodisiacs. contrary to popular beliefs cantharides’ actions are not specific to females. a putative hallucinogen congener of serotonin [9]. and its use in folk medicine is wide. which only work on men with various degrees of ED and normal libido. are a major limitation due the human use of Spanish fly [8]. exactly how TT increases testosterone levels is still unclear. steamed and dried) [34]. Saw Palmetto This is a small palm-like plant native to southeastern North America. Also. These studies on Larginine/yohimbine are preliminary and should not be considered definitive until they are confirmed by larger. Several randomizedcontrolled trials reported various efficacy rates of yohimbine ranging from 34% to 73% [9–15]. no clinical studies have been performed to date and recommendation for the usage of TT in ED would be very premature. randomized placebo-controlled studies are recommended to further confirm the sexual enhancing effects of this herb. This plant has been used for a long time as a traditional sexual stimulant. It is expected 41 that future clinical studies will delineate whether or not Epimedii Herba is a successful natural aphrodisiac. Also 50% of men initially with poor erection reported a beneficial effect of the herb on their erectile function [26]. Ginseng cultivated in Korea is classified into three types. sexual fantasies and the ability to reach orgasm in 65% of women with prior sexual dysfunctions [27]. Several reports demonstrated that. Current research is only limited to animal studies that have shown significant increases in erectile function after oral administration of the plant extract [19. in the family Araliaceae. Jang et al conducted a detailed systematic review on the effects of red ginseng on the treatment of ED and reported that out of 28 published articles only seven satisfied their strict criteria of being double-blind and placeboJ Sex Med 2010. Interestingly. Also. Ginseng Ginseng refers to species within Panax. which might be the underlying mechanism for its erectileenhancing ability [19–21]. TT is able to increase endogenous testosterone levels. and red ginseng (6 years old. Animal studies reported significant increase in intracavernosal pressure following administration of icariin [23–25]. Epimedii Herba (Horny Goat Weed) Epimedii herba has been used as an energy and erectile-enhancing drug in traditional Chinese medicine for centuries. Two species of ginseng widely studied with respect to their medicinal benefits are Panax ginseng (Asian ginseng) and Panax quinquefolium (American ginseng) [33]. Also. only two clinical studies and no animal studies examined the prosexual effects of Muira Puama [26. In general. yohimbine was one of the few oral pharmacological agents prescribed for the treatment of ED. Despite its documented effects in improvement of lower urinary tract symptoms and benign prostatic hyperplasia. further reducing the herb’s potential to be a successful aphrodisiac [29–32]. To date. Sideeffects related to yohimbine include hypertension. Muira Puama (Potency Wood) This herb grows primarily in Brazil with many folk observations that it can promote sexual activities especially in old men. more rigorous studies. a genus of 11 species of slow-growing perennial plants with fleshy roots. it is unknown if TT has nonandrogenic effects that might contribute to its erectogenic actions. No mechanism is still known for these prosexual effects of Muira Puama and. The other study demonstrated that Muira Puama can improve sexual desire. This was also coupled to significant increase in the expression levels of inducible and neuronal nitric oxide synthases in the corpus cavernosum [25]. definitely. no study reported a direct effect of Saw Palmetto on sexual performance [28]. In one study. More recent studies reported that a combination therapy of Larginine/yohimbine may yield improvement of erectile function [17. The principle active constituents in ginseng are ginsenosides. Tribulus Terrestris Tribulus terristrus (TT) is a perennial creeping herb with a worldwide distribution. However. anxiety and palpitations. Prior to the advent of the PDE5s. white ginseng (4–6 years old). it is thought that different methods of assessment of the degree of ED in these trials may have impacted the results.20].18]. A meta-analysis of these trials commented that this large variability of success rates may be caused by the difference in the patients’ ages and the etiology of ED. yohimbine may be effective but primarily in patients with psychogenic ED [16]. Icariin has been determined to be the main active component of Epimedii herba [22]. 60% of men with initial low libido reported increase in their sexual desire following intake of the herb. depending on how it is processed: fresh ginseng (<4 years old). urological actions of Saw Palmetto have been attributed to its antiandrogenic effects. Red ginseng is the type of ginseng with mostly reported aphrodisiac effects [35]. saponin glycosides unique to the Panax species. and owing to its central action as an a-2 adrenergic antagonist.7:39–49 .Natural Aphrodisiacs tion drug approved by the Food and Drug Administration (FDA) as a mydriatic.27]. indeed. 42 controlled trials [36].54]. Scene 3. Using several female sexual function questionnaires they reported a positive trend of higher scores (and therefore better sexual function) in women consuming daily chocolate vs. Andean Maca is one of the most commonly cited natural drugs on internet as sexual dysfunction improvers. The seven trials differed regarding the duration of ED (1–30 years). has been located in several regions of the female genital tract in both animals and J Sex Med 2010. Alcohol is a central nervous system depressant that acts by increasing the levels of the inhibitory neurotransmitter. however. Watts sexual function questionnaire in one study and the global efficacy question in three studies) [37–43]. However. However.40]. doses of ginseng used (600–1. lechery. Chocolate (Cacao) Chocolate is made originally from the Cacao beans after fermentation and multiple processing. when the data was adjusted to age. it provokes the desire.7:39–49 Shamloul humans. In Shakespeare’s Macbeth Act 2. Most clinical studies done on the aphrodisiac properties of Maca are small and did not employ reliable measures of sexual function [55]. The meta-analysis reached the conclusion that ginseng improved sexual performance more than placebo. and side effects reported are usually mild gastrointestinal upset [39. three times daily). There is no known effective dose of red ginseng. These results are confirmatory to previously reported data suggesting that Maca’s aphrodisiac effects are mainly because of its nutritional properties being rich in essential amino acids and minerals [56]. some did not report power calculation and some did not describe baseline comparisons of ED symptoms between the two arms (drug vs. and unprovokes. This claim is supported by animal studies [53. all these studies focused completely on male sexual dysfunction and ignored female sexual dysfunctions further undermining the ability to accurately assess the aphrodisiac effects of red ginseng. the most commonly used recreational drug. The mechanism of action of red ginseng is largely unknown. Finding an association between chocolate and sexual health is very tempting. However. Chocolate often is considered the food with the greatest impact on mood [44. the principle active constituents of red ginseng. Also. Dried Maca root is rich in amino acids. no significant difference in terms of International Index of Erectile Function (IIEF) scores between men who consumed Maca and those who used placebo [55]. women who do not. Alcohol Alcohol. reported recently. which may act both as a vasoconstrictor and vasodilator. resulting in muscle relaxation [37. Thus. duration of treatment (4–12 weeks). purely organic in 1 study and mixed in the remaining three studies).47]. and the method of erectile function assessment (IIEF in three studies. . probably through its effect on cardio- . gamma amino butyric acid [57]. but it takes away the performance”. Interestingly. alcohol causes disinhibition and thus can potentiate sexual desire.45] and it has shown a potential impact on overall human health [46. Serotonin. iodine. there is some scientific evidence backing these historical claims. All in all the seven studies evaluated 363 men aged from 24 to 70 years old. Chocolate contains a wide range of chemical compounds that are pharmacologically active such as methylxanthines and Narachidonoylethanolamine (a brain lipid that can mimic the psychoactive effects of cannabinoids [48]. Recently.50]. drawing definitive conclusions of the aphrodisiac effects of ginseng is very difficult [36]. placebo-controlled study. in a double-blinded.38]. it provokes. . . Zenico et al. iron and magnesium. Maca roots have been used in the Andean region for their supposed aphrodisiac and/or fertility enhancing properties [52]. placebo) or obtain sufficient ethical approval. Traditionally. etiology of ED (purely psychogenic in three studies. Lepidium Meyenii (Maca) Lepidium meyenii (Maca) is an Andean cultivated root that belongs to the brassica (mustard) family. several studies did confirm the potential harmful effects chronic alcohol drinking has on male and female sexual functions. with some animal studies reporting that ginsenosides. has been associated with sexuality for a long time. several studies reported that some chocolate constituents (especially serotonin and flavinoids) may be involved in modulating women’s genital sexual functioning [49. it should be taken into account that some of these seven studies did not report the nature of placebo used. can lead to an increased release of nitric oxide from the smooth muscles of the cavernous tissue. Salonia and colleagues tried to examine the effects of chocolate on women’s sexual health [51]. On the other hand. we read “What three things does drink especially provoke. further in-depth studies should be conducted before a solid conclusion could be reached [51]. sir. this difference was lost. the overall sense of well being was significantly higher in the Maca group. Also.000 mg. Indeed. Southeast Asia Fruits. India Potentiates penile erection *Animal [78] Eurycoma longifolia Jack (Tongkat Ali) Ferula harmonis. and Srilanka Evergreen shrub or a tree. vascular functions [58–60]. kebob (barbequed beef) is considered as a strong aphrodisiac by Middle Eastern people. Other recreational drugs that have been considered as natural aphrodisiacs include cannabis and its more popular derivative. but nonsignificant. dyspareunia and sexual dysfunction in a large study of 3004 men and women [67]. Some of these are very common and some are extremely difficult to find. Table 1 lists some of the most popular traditional plants and herbs used as aphrodisiacs and studies examining their effectiveness. Another common food thought to be a strong aphrodisiac is sea food.70] Unknown Delays ejaculation time *Animal [71] ↑Testosterone Potentiates penile erection *Animal [72. which examined their effects on male sexual function. physiological evidence to date demonstrates that cannabis and its derivatives inhibit libido and sexual function [66]. apart from th three studies on Tongkat Ali [80–82].7:39–49 . However. Also. who was born at sea [94]. Other Plant-Related Traditional Aphrodisiacs There are a huge number of folklore plants and herbs that are used by humans as aphrodisiacs. it is believed that this may be caused by its relation to Aphrodite. Further basic and clinical studies examining the nature of alcohol consumption. West Africa Potentiates penile erection *Animal [69. and its relationship to sexual function are needed [65]. ED was found to be a side effect in a randomized. It could be speculated that this may be true because of its very high protein content that increases body vitality as a whole and therefore increases energy to perform sex. It can be easily deducted from this list that the majority of these studies were done on animals. However. however. duration and type. especially Malaysia Shrub root. **References [75.73] Unknown Rhizomes. As a whole.63]. Also. West Africa Potentiates penile erection *Animal [76. “Zallouh Root” Shrub. Studies examining the effect of alcohol on female sexual function are very limited with inconclusive results [64]. More importantly. In their excellent meta-analysis Chew et al demonstrated that chronic alcohol significantly decreased odds of ED among alcohol drinkers in 7 of the 11 cross-sectional studies cited. marijuana. including amount. Lebanon Potentiates penile erection *Animal [79–86] ?↑eNOS ?Antioxidant ?↑Testosterone ?↑Brain dopamine Unknown Potentiates penile erection **Animal [87–93] Camellia sinensis Aframomum melegueta and Piper guineense Curculigo orchioides (Kali Musli) Microdesmis keayana ?Indirect LH secretion ↓Smooth muscle contraction Many toxic effects ↓Female sexual function *Males only. LH=luteinizing hormone. the use of marijuana was associated with inhibited orgasm. Furthermore. Southeast Asia. eNOS = endothelial nitric oxide synthase. recent reports have produced strong evidence to the contrary. Other Nonstudied Aphrodisiacs Currently.43 Natural Aphrodisiacs Table 1 Popular traditional aphrodisiacs plants and herbs Plant Nature and origin Effects *Type of studies Mechanism of action Myristica fragrans (nutmeg) India. For example some Eastern cultures consider tea as a good aphrodisiac. all mechanisms proposed for the effects of this group of aphrodisiacs are not evidencebased and are only hypotheses that need rigorous investigations. Whereas drinking less than eight drinks per week had the lowest. many beverages and foods are used popularly as aphrodisiacs.77] Mucuna pruriens Seeds. controlled study investigating the appetitive stimulatory effects of dronabinol (delta9-tetrahydrocannabinol) [68]. all other studies involved young animals (<20 weeks old).77] used female rats. Spicy food and chili are believed to be J Sex Med 2010. drinking more than eight standard drinks a week was associated with a statistically significant but with higher ED risk [61]. Indonesia. India Potentiates penile erection *Animal [74. contrary to the popular belief. Similar results were reported from other studies [62. these contradictory results from epidemiological studies are not sufficient to make a solid conclusion regarding the role of alcohol consumption as an aphrodisiac.75] ?↑Testosterone Roots. risk for ED. all searched by man to find substance(s) that could heighten his sexual desire and performance. these serious concerns drastically undermine the clinical value of these aphrodisiacs and further confirm the 1989 decision by the FDA not to recommend the over-the-counter use of these substances [96]. maca. Obviously. this may be because of the gender differences between men and women regarding sexual behavior [99]. Despite the fact that many aphrodisiacs may be used by men and women alike. Also. Natural aphrodisiacs are used by men complaining of various degrees of ED and by normal potent men as well. There is little evidence from literature to recommend the usage of natural aphrodisiacs for the enhancement of sexual desire and/or performance. Maca’s aphrodisiac effects are through the enhancement of whole body vitality with no specific benefit on sexual function. surprising that normal potent men continue to use aphrodisiacs. However. recently.72. Mikami et al. at least until sufficient scientific evidence through robust randomized controlled trials [97] is presented. Furthermore. however. A whole industry is built on manufacturing natural aphrodisiacs. these studies (except few [80–82] using Tongkat Ali) were conducted on normal young (<20 weeks old) animals. Discussion Countless natural substances have been used by humans as aphrodisiacs. it is undoubtedly. Most sildenafil analogues found as adulterants have been modified in the piperazine portion of the molecule [103–107]. This may be because of misconceptions regarding sexual satisfaction. Moreover. realizing the huge demand towards natural aphrodisiacs.73. Unfortunately. Data on yohimbine’s efficacy does not support the wide use of the drug. it has only mild effects in the treatment of psychogenic ED. controversial [87. reported for the first time the discovery of sildenafil analogues in “herbal” aphrodisiacs [102]. and also may be because of unrealistic expectations of pleasure from sex.70. Although any substance may be claimed as a good aphrodisiac. rhinoceros horn and snakes are largely used because of their physical similarity to the genital organs. Recent scientific evidence regarding the use of alcohol as an aphrodisiac is potentially interesting. A reasonable explanation for this paucity is that scientific interest in exploring female sexual dysfunctions only began few decades ago [99–101] and more time may be needed to investigate women’s attitude towards aphrodisiacs. physical responses very similar to that a encountered during sexual intercourse [95]. for example. orgasm. burning. In 2002. herbal dietary supplements were found to contain sildenafil analogues developed by replacing a carbonyl group in . however. scientific data is needed to prove these claims. go ahead and deceive the public concerning the natural aphrodisiac products they market. side effects and toxic profile are largely unknown and may be hazardous [87. more in depth studies involving large number of subjects with elucidation of its mechanism of action(s) are needed before definite conclusions could be reached. Although the precise size of this industry is unknown. Current scientific body of literature refutes the claims that cannabis and marijuana have any aphrodisiac properties and provides evidence to the exact contrary [98].93]. the existence of controversial data necessitates extensive future investigations. Several other hard to find substances are still used as aphrodisiacs.89] or largely hypothetical [87–93] with no backup by solid scientific evidence. Also. J Sex Med 2010. there is a strong need to understand the effects of different aphrodisiacs on women sexual function.79– 86]. who were potent by nature. and distraction. most mechanisms of action to support the use of these substances as natural aphrodisiacs are either unknown [69. this may be because of the fact that their consumption lead to sweating. however. From plants to animal body parts to blood. dried tiger’s penises soup. Although there is a positive trend towards recommending red ginseng as an effective aphrodisiac. (ginseng. however. Although the quest for successful erectogenic drugs is understandable for men with ED or low desire. Collectively.44 aphrodisiacs. Other popular aphrodisiacs include oysters. snake blood. shark components. and even the melted fat of a camel hump and leeches [1]. some medicinal drug manufacturers. The vast majority of studies on natural aphrodisiacs were conducted on animals with very few clinical studies done mostly on red Ginseng [36]. a quick visit to any drug store and examination of the number of products being marketed as natural aphrodisiacs will give an idea on the huge amounts of money invested in this industry. tongkat ali) studies on the use of aphrodisiacs by women or female animals are extremely rare (Table 1). Ginseng and Maca are examples of the very limited number of natural aphrodisiacs that underwent rigorous scientific investigations to explore their aphrodisiac properties.7:39–49 Shamloul Yohimbine. Arch Int Pharmacodyn Ther 1995. 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