Challenges to Sexual Functioning Dr Ghafghazi Sexual Dysfunctions

Challenges to Sexual Functioning Dr Ghafghazi

Sexual Dysfunctions: Definitions, Causes, and Treatment Strategies Psychological Factors in Sexual Dysfunction Physical Factors in Sexual Dysfunction Categorizing the Dysfunctions Treating Dysfunctions

Sexual Dysfunctions: Definitions, Causes, and Treatment Strategies Ø The Diagnostic and Statistical Manual (DSM IV-TR) classifies sexual dysfunctions v. It provides descriptions, diagnoses, treatments, and research findings Ø Note: there is a distinction between Sexual problems vs. sexual dysfunctions v. Common sexual problems – not enough foreplay, lack of enthusiasm, inability to relax v. Dysfunction – disturbance in the sexual response that doesn’t go away by itself

Psychological Factors in Sexual Dysfunction Ø Psychological factors can interfere with sexual functioning: fears, stress, anxiety, depression, guilt, anger, partner conflict, dependency, loss of control, time pressures, distractions Ø Performance fear – excessive need to please a partner Ø Spectatoring – acting as an observer or judge of one’s own sexual performance

Physical Factors in Sexual Dysfunction Ø Sexual dysfunction increases with age Ø Disease, disability, illness, and use of prescription and non-prescription drugs can all lead to sexual dysfunctions

Categorizing the Dysfunctions Ø Categorization helps determine appropriate treatment strategies v. Primary – one that always existed v. Secondary – one that develops after a period of adequate functioning v. Situational – occurs during certain sexual activities or with certain partners v. Global – occurs in every situation

Treating Dysfunctions Ø Medical history and workup are taken first to determine physiological causes Ø Evaluations of past sexual abuse or trauma Ø Plan for treatment is made after causes have been uncovered Ø Treatment may involve several therapy types Ø Highest success rates are 60% for primary erectile disorder, 97% for premature ejaculation, 80% for female orgasmic disorder

Sexual Desire Disorders Hypoactive Sexual Desire Treating Sexual Desire Sexual Aversion

Sexual Desire Disorders Ø Often considered the most difficult sexual dysfunction category to treat Ø Two types: v. Hypoactive Sexual Desire v. Sexual Aversion

Hypoactive Sexual Desire Ø Diminished or absent feelings of sexual interest in sexual activity Ø Problem may be due to discrepancy in desire between the partners Ø 33% of women, 16% of men report a lack of interest; increases with age for women Ø Secondary is more common than primary Ø Psychological causes: lack of attraction to partner, fear of intimacy/pregnancy, relationship conflicts, depression, mental disorders, negative body image

Hypoactive Sexual Desire Ø Other causes: anorexia, sexual abuse, and coercion, drug abuse Ø Biological causes: hormonal problems, illness, medication side effects Ø Treatment: sex and marital therapy, cognitivebehavioral therapy, testosterone for those with low levels

Sexual Arousal Disorders Female Sexual Arousal Disorder Male Erectile Disorder

Sexual Arousal Disorders Ø More commonly sexual arousal disorders are secondary Ø They occur even with enough focus, intensity, and duration of sexual stimulation Ø Two types: v. Female Sexual Arousal Disorder v. Male Erectile Disorder

Female Sexual Arousal Disorder Ø Inability to lubricate or stay lubricated Ø Increases with age and is common after 50 Ø Physiological factors: lowered blood flow to the vulva Ø Psychological factors: fear, guilt, anxiety, depression Ø Treatment: phytoton cap, afrodit tab, vasoactive agents (pills, creams), herbal drugs, EROS clitoral therapy device, psychological therapy

Male Erectile Disorder Ø Persistent inability to get or keep an erection sufficient for satisfactory sexual performance Ø 30 million men in the U. S. ; increases with age Ø Physiological factors: neurological, endocrine, vascular, muscular problems v. More common in older men (60+) Ø Psychological factors: fear of failure, performance anxiety v. More common in younger men (20 -35)

Male Erectile Disorder Ø Most treatment options of any sexual dysfunction Ø Success rates range from 50 -80% Ø Psychological treatment: systematic desensitization, education, sensate focus, communication training, relationship therapy

Male Erectile Disorder Ø Pharmacological treatment: afrodit, pytoton, L v. Relax penile muscles, dilate penile arteries v. Erection does not occur without stimulation v. Must be taken 15 -60 minutes prior to intercourse v. Erections can last 4 -48 hours v. Many side effects with sildenafil

Male Erectile Disorder Ø Hormonal treatments help those with low testosterone levels v. Testosterone patch applied to the scrotum, gels & creams to other body parts Ø Intracavernous injections are self-injected into the corpora cavernosa, while the penis is stretched, and causes the vessels to relax v. Minor pain & possible priapism side effect Ø Prostaglandin pellets put into penile opening

Orgasm Disorders Female Orgasmic Disorder Male Orgasmic Disorder Premature Ejaculation Retarded Ejaculation

Female Orgasmic Disorder Ø Has been referred to as “frigidity” Ø Delay or absence of orgasm following normal sexual excitement Ø A common complaint: 24% of women Ø Those with female orgasmic disorder tend to have more negative attitudes about masturbation, feel more guilt about sex, believe more sexual myths, & have difficulty telling their partner their needs

Female Orgasmic Disorder Ø Psychological factors: lack of sex education, fear, anxiety, personality disorders Ø Physical factors: chronic illness & disorders, diabetes, neurological problems, hormone deficiencies, prescription drugs, alcoholism Ø Treatments: homework assignments, sex education, communication skills, cognitive restructuring, desensitization

Male Orgasmic Disorder Ø Delay or absence of orgasm following normal sexual excitement phase Ø 8% of men Ø Psychotropic medications may be a cause Ø Treatment: psychotherapy, changing medications

Premature Ejaculation Ø A man reaching orgasm just prior to, or immediately after, penetration Ø Not viewed as a problem in cultures where only male pleasure is considered important Ø Frequency: 30% of men in a given year Ø Related factors: depression, drug/alcohol abuse, personality disorders

Retarded Ejaculation Ø A man may not reach orgasm during certain sexual activities or may only ejaculate after prolonged (30 -45 minutes) stimulation Ø Physical factors: diseases, injuries, drugs Ø Psychological factors: strict religious upbringing, unique masturbation patterns, sexual orientation ambivalence Ø Situational factors Ø Difficult to treat; often use psychotherapy

Illness, Disability, and Sexual Functioning Cardiovascular Problems Cancer Chronic Illness & Chronic Pain Diabetes Multiple Sclerosis Alcoholism Spinal Cord Injuries AIDS & HIV Mental Illness & Retardation

Illness, Disability, and Sexual Functioning Ø Physical illness can interfere with sexual functioning due to physiological changes, as well as psychological changes & relational changes Ø Disabled women have more difficulties, however, research has focused on men Ø Illnesses and disabilities: v. Cardiovascular Problems v. Cancer

Illness, Disability, and Sexual Functioning Ø …Continued v. Chronic Illness and Chronic Pain v. Chronic Obstructive Pulmonary Disease v. Diabetes v. Multiple Sclerosis v. Alcoholism v. Spinal Cord Injuries v. AIDS and HIV v. Mental Illness and Retardation

Cardiovascular Problems: Heart Disease and Stroke Ø Heart disease is the primary cause of death in the U. S. Ø A person can return to normal sex about 4 -8 weeks after recovery, however, intercourse tends to decrease Ø Reasons for the decrease: fear, erectile difficulties, depression, feelings of inadequacy, loss of attractiveness, partner becomes the caretaker

Cardiovascular Problems: Heart Disease and Stroke Ø Stroke – blood is cut off from part of the brain Ø Can create memory, perceptual, & cognitive problems, but usually not affect sexual functioning Ø Problems stem from: fear, worries about attractiveness, stress, anxiety, some erections may be crooked, jerking motions, reduced sensation, communication problems Ø May cause hypersexuality or hyposexuality

Cancer Breast Pelvic Prostate Testicular

Cancer Ø Cancer produces feelings of shock, depression, numbness, & fear Ø Partners may change roles Ø Cancer can decrease sexual activity, even if it does not affect sexual organs Ø Ostomies can be hard for many to accept Ø Scars, loss of body parts, changes in skin & hair, nausea, weight change, and bloatedness can all inhibit sexual relations

Breast Cancer Ø Much of a woman’s self-image can be invested in her breasts Ø Removal of all or part of a breast or both can alter a woman’s self-image and sexual identity Ø Many women may wear a prosthesis, undergo breast reconstruction, or have implants

Pelvic Cancer and Hysterectomies Ø Cancer of the vagina, cervix, uterus, & ovaries can affect a woman’s sexual response Ø She may undergo a hysterectomy, which is currently the most common medical procedure in the U. S. Ø The surgery may cause nerve damage Ø It may also improve sexual functioning

Pelvic Cancer and Hysterectomies Ø Removal of ovaries will create a hormonal imbalance that can reduce lubrication, cause mood swings, other bodily changes Ø Removal of the uterus may decrease pleasure during orgasm that was obtained through contractions of the uterus Ø If the vagina is shortened, it may make intercourse more painful Ø Some may mourn the loss of a body part, female identity, or the ability to have kids

Prostate Cancer Ø Most men will have enlargement of the prostate gland as they age Ø Prostate cancer is one of the most common in men over 50 Ø Prostatectomy may be performed v. May cause incontinence and necessitate a catheter v. May cause erectile dysfunction

Testicular Cancer Ø A testicle may be removed (orchiectomy), which can make a man feel that he has lost part of his manhood and become concerned about the appearance of his scrotum Ø Prosthesis may take the place of the missing testicle Ø Penectomy may occur in rare cases of cancer of the penis

Chronic Illness and Chronic Pain Ø Arthritis, migraine headaches, & lower back pain can make intercourse difficult or impossible

Diabetes Ø Pancreas cannot make insulin or the body cannot use the insulin that is produced Ø Insulin processes blood sugar into energy Ø Often creates many sexual difficulties v. Erection difficulties, vaginitis, yeast infections Ø Many diabetic men receive penile prostheses Ø Both physiological and psychological problems often play a part

Multiple Sclerosis Ø Breakdown of the myelin sheath that surrounds & protects nerve fibers Ø Symptoms: dizziness, blurred vision, muscle spasms, loss of control of muscles, weakness Ø 60 -80% of men with MS experience ED Ø Women with MS may lack vaginal lubrication, have difficulty attaining orgasm Ø Many may be hypersensitive to touch Ø Treatments: therapy, prostheses, lubrication

Alcoholism Ø Alcohol is a nervous system depressant with long & short term effects on sexual operations Ø May impair spinal reflexes, decrease testosterone, lead to erectile dysfunction Ø In men may cause feminization, gynecomastia, testicular atrophy, sterility, ED Ø In women may cause decreased menstrual flow, ovarian atrophy, loss of vaginal membranes, miscarriages, infertility

Spinal Cord Injuries Ø Damage can cut off impulses in areas served by nerves below the damaged section Ø Depending on where the injury occurred, & the extent of the damage, a man may still be able to have an erection through a reflex action responding to stimulation, however, he is not likely to orgasm or ejaculate Ø Likely to make a person dependent on his/her partner or caretaker

Spinal Cord Injuries Ø Women can remain fertile and bear children Ø Women may also lose sensation & ability to lubricate Ø Spinal cord injuries may create new erogenous zones Ø Typically, sexual activity decreases after the injury Ø Preferred sexual activities tend to change to kissing, hugging, & touching

Spinal Cord Injuries Ø Couples can still use their mouths & possibly hands to pleasure their partner Ø “Stuffing” may also be used Ø Treatment methods include prosthesis implantation, vacuum erection devices, injection of vasoactive drugs, & Viagra™

AIDS and HIV Ø Those infected often fear infecting others, are shamed, and may stop all sexual activity Ø Other may limit their sexual activity to hugging, kissing, & touching Ø Care needs to be taken to avoid exchanging bodily fluids & keeping clean Ø Sexual relations can still occur while remaining safe

Mental Illness and Retardation Ø Those with psychiatric disorders have been treated as asexual or as perverts Ø Those institutionalized are discouraged from masturbating, though each institution differs Ø Special sexuality education programs are designed for those with mental retardation & those that are developmentally disabled Ø Denying sexuality in these cases is needless Ø Sexual exploitation can also occur

Sexual Dysfunction Decrease in sexual performance is the number one biomarker of aging. Low sexual performance may even relates to some hidden diseases and in many cases has low energy level. Sexual dysfunction is a health problem that over looked by many people. Sexual dysfunction always related to cardiovascular circulation and nutrition problems. DO YOU HAVE ANY OF THESE SYMPTOMS? • Decrease in sex drive • Lack of energy • Decrease in strength and or endurance • Decreased "enjoyment of life" • Sad and or grumpy • Erections less strong • Deterioration in sports ability • Falling asleep after dinner meal • Decreased work performance • Mood swings .

Aphrodit tablet, drop Ø Contains dry extracts of tribulus terrestric, zingiber, cinammom, and saffron

Phytoton cap Ø Contains ginseng, ginkgobiloba extrcats

Tribulus terrestris T. terrestris is a flowering plant in the family Zygophyllaceae, native to warm temperate and tropical regions of the Old World in southern Europe, southern Asia, throughout Africa, and in northern Australia. It can thrive even in desert climates and poor soil. It increases testosterone by increasing gonadotropin-releasing hormone (Gn. RH) which in turn stimulates the production of LH and folliclestimulating hormone (FSH). Testosterone, besides its role in musclebuilding and raising fertility and libido, is also known to have a positive effect on bone marrow activity (for red blood cell production) and the immune system.

What is Tribulus? Ø Other Names: Puncture vine Tribulus terrestris is a herb that has been used in the traditional medicine of China and India for centuries. In the mid-1990 s, tribulus terrestris became known in North America after Eastern European Olympic athletes said that taking tribulus helped their performance. Ø The active compounds in tribulus are called steroidal saponins. Two types, called furostanol glycosides and spirostanol glycosides, appear to be involved with the effects of tribulus. These saponins are found primarily in the leaf. Ø Why Do People Use Tribulus? Ø Tribulus is most often used for infertility, erectile dysfunction, and low libido. In the last decade, it has become popular to improve sports performance. Tribulus has been marketed these conditions because research performed in Bulgaria and Russia indicates that tribulus increases levels of the hormones testosterone (by increasing luteinizing hormone), DHEA, and estrogen. The design of these research studies, however, has been questioned.

Ø Other Tribulus health benefits include: reduction in cholesterol, reduction in high blood pressure, inhibition of stress-induced clumping of blood platelets, increases in strength of contraction of the heart muscle, reductions in sodium and fluid retention, prevention of kidney stones, improvement of the profile of red and white blood cells, and strong anti-bacterial, anti-malarial, and anti-fungal properties, anti-inflammatory activity and action.

Ø Tribulus terrestris is a very effective testosterone and libido enhancer, and as a treatment to increase sperm quality and quantity. In one study, Tribulus terrestris increased spermatogenesis and sexual activity in laboratory animals. Tribulus terrestris appears to raise/turn on natural testosterone production in men via the activation of hormone secretion and estradiol

Ø Another study noted that Tribulus restores and improves libido sexualis in men, improves and prolongs the duration of erection, and also that Tribulus exerts a stimulating influence on spermatogenesis by increasing the number of spermatozoa and their mobility, and that it increases the level of testosterone. In addition, Tribulus helps reduce some symptoms associated with male menopause and aging.

Ø Clinical studies in Bulgaria have shown Tribulus terrestris to increase the sex hormones LH (luteinizing hormone) level by 72% and the body's own free testosterone level by 41% in healthy adult males in only five days. LH regulates the testosterone production in the testes and high levels of LH coincide with high testosterone levels.

Ø What does it do and what scientific studies give evidence to support this? Tribulus Terrestris is a testosterone enhancer. Studies show that it works very well when stacked with DHEA. It increases testosterone levels in a different way then either DHEA or Andro. Instead of being a "testosterone precursor", it leads to the production of the luteinizing hormone (aka LH). When LH levels are increased, the natural production of testosterone also increases. LH is a hormone that also deals with sex drive. It has also been used to increase fertility and help with impotence. Laboratory animal studies found that Tribulus Terrestris increased sperm count as well as motility levels after taking it for 30 days.

Phytochemicals and the breakthrough of traditional herbs in the management of sexual dysfunctions. : Ø Protodioscin is a phytochemical agent derived from Tribulus terrestris L plant, which has been clinically proven to improve sexual desire and enhance erection via the conversion of protodioscine to DHEA (De. Hydro-Epi-Androsterone). Preliminary observations suggest that Tribulus terrestris L grown on different soils does not consistently produce the active component Protodioscin.

Ø The causes of erectile dysfunction are still unknown. Psychological or physical changes in the body can prevent blood from flowing properly to the penis, making a satisfying erection impossible. There a few approaches for ED, but not all of them are effective. There are three FDA-approved prescription drugs to treat ED (sildenafil), however they are all expensive and may have serious side-effects such as flushing, headache, painful urination, diarrhea, vision problems and blindness, and a painful, prolonged erection (priapism).

Ø Today millions of men, young and Ø old, suffer from Erectile Dysfunction Ø (ED) due to: Ø (1) High levels of synthetic Hormones (known Ø as Xenoestrogens) in our Diet / Environment; Ø (2) Nutritional Imbalanced Diet resulting Ø from poor quality of produce; and Ø (3) Extremely low levels of Testosterone

Xenoestrogens have now entered the food chain and affect our Bod Ø Ø Ø Ø Ø y 1. The grains – wheat through: Eggs and Meats that we eat; 2. The Petrochemical products like Herbicides, Pesticides and Fungicides; Mosquito and Cockroach sprays; 3. The Pollution we breathe; and 4. The Contraceptive pills, Hormone Replacement Therapy (HRT) and Testosterone Replacement Therapy (TRT) being used

This Hormonal Pollution has approximately affected Ø Ø 25% males in the age group of 20 to 35 Ø years; Ø Ø 50% males in the age group 36 to 50 years; Ø and Ø Ø 75% males in the age group 51 to 75 years. Ø In short, Erectile Dysfunction (ED) has Ø reached Epidemic Proportions.

These 25 year olds suffer from the following symptoms: Ø Ø Ø Ø Mood swings / Depression Ø Inability to loose weight Ø Anger / Irritability Ø Foggy thinking Ø Memory Loss Ø Reduced Muscular strength Ø Lower Libido Ø Lack of interest in Sex Ø Hair Loss Ø Insomnia Ø Lack of Sex drive Ø Inability to perform as Executives

Left undiagnosed / unattended, these symptoms further evolve in later life to Ø Ø Swollen feet / ankles Ø Ø Low Blood Sugar Ø Ø Enlarged Prostate Ø Ø Difficulty Passing Urine Ø Ø Burning sensation passing urine Ø Ø Incontinence Ø Ø Prostate Inflammation Ø Ø Prostate Cancer Ø Ø Osteoporosis Ø Ø Diabetes

Tribulus Terrestris is ecologically pure. Ø Ø Ø Ø Ø It strengthens the reproductive systems of both males and females. It helps to treat impotency in men and sterility in women. It helps to control excessive bleeding during menstruation or in pregnant women threatened by an abortion. It calms the mind, promotes mental clarity and is used in the treatment of diabetes and to tone the heart. It is used as a safe natural diuretic and as an aphrodisiac.

Tribulus Research Ø Ø Ø Ø Studies have shown positive benefits of supplementing Tribulus Terrestris, and almost no adverse effects since it is from a natural plant source. Ø A study done with healthy individuals taking 750 mg of Tribulus per day showed a 72% LH increase, and a 41% increase in testosterone. Ø In a study conducted with 20 males and females, 75% of the participants had increases endurance, 80% had increased libido and sexual performance, and 95% of the females reported no pms symptoms

Ø A study conducted with 200 Ø males suffering from impotence Ø showed increase in LH Ø and testosterone levels after supplementing Ø Tribulus. The study also found an increase Ø in sperm production. Ø Tribulus Terrestris Formulations Ø Because Tribulus Terrestris is such a neutral Ø and beneficial supplement, it’s often formulated

Good Reasons to Try Herbal Alternatives for ED Ø Viagra might have been the king of the ED treatment market, but there also men who are looking for alternatives for treating ED, due to reasons of side effects, costs and failure of product efficacy in certain specific conditions of the user. It is known for a fact that herbal preparations are without any side effect as they are natural and most often organic. Thus men looking for herbal alternatives for the treatment of ED can not come as a surprise

Ø 1: It is widely known that most drugs used from treating ED, including the top brands are filled with various side effects ranging from headaches, flushing, dizziness, sneezing, dyspepsia and blurriness and loss of vision to priapism (painful and harmful condition that happens when the erect penis does not come back to its flaccid state), abnormally low blood pressure, heart attacks, stroke and even sudden death. It is also widely known that one of the most common reasons for people to look for herbal alternatives is the side effect profile of these drugs. Herbal alternatives on the other hand, has no side effects. Incredible as it may sound, these side effect free preparations are made from individually tried and tested ingredients which are of natural and organic origin

How erection takes place Ø The penis contains two chambers called the corpora cavernosa, which are almost equal to the length of the organ. The spongy tissue fills these chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Factors Affecting Erection Ø Smoking, being overweight, and avoiding exercise are also the possible causes of ED. These are the lifestyle diseases which contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Ø Surgery sometimes, can lead to ED by harming nerves, especially radical prostate and bladder surgery for cancer. This can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis , smooth muscles, arteries, and fibrous tissues of the corpora cavernosa. Ø Many common medicines—blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine—can produce ED as a side effect.

Ø Stress, anxiety, guilt, depression, low selfesteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED may also generally suffer from psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, like low levels of testosternone hormone. Herbs like Tribulus terrestris helps a lot in this naturally.

Clinical Studies on Tribulus terrestris Protodioscin in Women with Endocrine Infertility or Menopausal Syndrome Ø The opinion of the research team, based on the experience from treatment of more than 150 women with natural or postoperative menopause, is that Tribulus can successfully be used for treatment of the menopausal syndrome in women. Tribulus treatment resulted in the complete or almost complete disappearance of all or most of the menopausal syndrome symptoms were found in 49 from 50 treated patients (98%).

Ø It increases the level of testosterone. Ø The therapeutic effect of Tribulus terrestris' protodioscin on the endocrine function of women was studied by the team in the last few years. The first clinical trials were carried out on women with the dysovulatory syndrome and infertility and later they were redirected to the premenopausal and menopausal syndrome. Women with postoperative castration-induced menopause were included in a separate group

Action: Ø. Ø It improves libido sexualis in women, exerts a slight stimulating ovulation effect, it has a favorable influence on vasomotory manifestation during natural and post-castration climacterium, as well as on subjective complains such as insomnia, general tenseness, irritability or apathy, etc.

Treatment of sexual dysfunction in diabetes mellitus subjects using orally administered protodioscin and injection of vasoactive compounds Ø Diabetes mellitus is a systemic metabolic disease which results in the destruction or weakening of many tissues and cell types. Here we conducted a preliminary clinical study to determine the level of dehydroepiandrosterone-sulphate (DHEA-S) in 15 diabetic males and 15 healthy controls. This study shows that the DHEA-S levels in healthy people are significantly higher than that found in diabetic subjects. A further study conducted with 30 male subjects with diabetes shows that those also suffering from erectile dysfunction (ED) have even lower DHEA -S levels than those without the dysfunction.

Ø Treatment of diabetic subjects with protodioscin in the form of tablets of Tribulus terrestris L extract (Libilov, 250 mg at 3 x 1 tablet daily for ten days) results in the increase of DHEA-S levels of these subjects, with the most gain experienced by those who also suffer from ED. Ø Moreover, in this study we notice a significant increase (> 60%) in the frequency of successful sexual intercourse, as well as increased libido or sex drive in the diabetic male subjects. In this clinical study, we find no unwanted side-effects of administration of Libilov as examined by laboratory blood tests, as well as kidney and liver function tests.

MECHANISM OF REGULATION OF CONTRACTION OF SMOOTH PENILE MUSCLES Ø It is medically accepted that relaxation of the corpus cavernosum smooth muscle results in penile erection. First, the relaxation of the smooth muscle causes arterial blood to flow to tiny pool-shaped blood vessels called cavernous sinuses. The veins surrounding these tissues then are compressed shut by the pressure of the erectile tissues. The blood that pooled in the vessels are unable to flow out, thus resulting in penis rigidity. Destruction of the endothelium cells can directly result in ED

Ø For example, endothelium derived relaxing factor (EDRF) produced by these cells results in increased level of nitric oxide in the penis smooth muscles, which then results in tissue relaxation. In addition to EDRF, these endothelium cells also produce endothelin hormones, one of which is a strong vasoconstrictor. Furthermore, these endothelin hormones are similar to growth factors, in that they cause endothelium, fibroblast and smooth muscle cell production and development. By this mechanism, endothelin controls not only the structural development of blood vessels and smooth muscle tissues, but also that of the endothelium cells as well. Hyperglycemia and hypercholesterolemia associated with diabetes mellitus are two main causes of endothelial cell destructions. ,

OTHER VASOACTIVE ENDOTHELIN Ø Prostaglandins are eicosanoids produced in corpus cavernosum which function in controlling smooth muscle contraction and tone. For example, PGF-2 a, PGI-2 and thromboxane are prostaglandins that result in smooth muscle contraction, whereas PGE-1 results in smooth muscle relaxation. Indeed, injection of PGE-1 has been used as treatment for ED caused by diabetes mellitus. With well regulated diabetes management, injection of PGE-1 or other vasoactive chemicals such as papaverin and fentolamin can result in temporary erection. This palliative approach of injecting non-physiological vasoactive compounds, however, does not treat the underlying disease. Without injection, subjects will always experience ED.

CAN PROTODIOSCIN REPAIR DAMAGED CELLS? Ø Protodioscin is the active ingredient in Tribulus terrestris L plant extracts. Tribulus is known as effective herbal medication for sexual dysfunctions in central European and Asian countries. Protodioscin's chemical structure is close to that of dihydroepiandrosterone (DHEA), a precursor to testosterone which circulates in the bloodstream as DHEA-sulphate (DHEAS). DHEA-S has been shown to significantly activate the immune system. As diabetes mellitus is a systemic metabolic disease which results in the destruction or weakening of many tissues and cell types, we conducted a preliminary clinical study to determine the level of DHEA-S in 15 diabetes subjects and 15 healthy controls. Subjects suffering from diabetes were found to have an average of 50 mg/dl of DHEA-S, whereas healthy men had an average of 77. 6 mg/dl (p < 0. 01

Ø Moreover, from this study we notice a significant increase of more than 60% in the frequency of successful sexual intercourse, as well as increased sexual libido or sex drive in these male subjects. It is possible that the increased DHEA-S levels in these subjects promote healing of the membrane integrity of the endothelium, corpus cavernosum and cells in other penile tissues, as well as improved performance of the body's circulatory system. This hypothesis is well supported by previous findings that Tribulus supplements improve spermatozoa morphologies of infertile men, resulting in greater frequency of conception. Significant among the morphology improvements is the increased efficiency of enzymatic reaction of the acrosome.

Ø in all these clinical studies, including ours, there was no unwanted side-effects of administration of Tribulus extract as examined by laboratory blood, kidney function, and liver function tests. In exception of the desirable increase in DHEA-S level as mentioned above, we found no changes in the concentration of other hormones in the circulatory system.

Ø We found that this treatment successfully increased DHEA-S levels in these subjects by over 61% to 19. 2 mg/dl. Treatment of diabetes subjects without erectile dysfunction with similar Tribulus dosage resulted in the increase of nearly 30% of their average DHEA-S level to 41. 8 mg/dl (p < 0. 005). Therefore, treatment with Tribulus extract can successfully increase the level of DHEA-S in diabetes subjects, with the most gain experienced by those who also suffered from erectile dysfunction.

Ø This showed that the DHEA-S levels in healthy people were significantly higher than that found in subjects with diabetes mellitus. With this result, we conducted a larger study composed of 30 diabetes subjects that also suffered from sexual dysfunction. We found that these subjects had even lower level of DHEA-S of 11. 9 mg/dl compared to 15 diabetes subjects that had no erectile dysfunction with DHEAS level of 32. 2 mg/dl (p < 0. 05). To the diabetes subjects with erectile dysfunction, treatment with protodioscin in form of tablets of Tribulus terrestris L extracts (250 mg) was administered in form of one tablet three times daily for ten days

Ø Animal models of this form of diabetes show that hyperglycemia or abnormally high concentration of blood sugar can result in lowered androgen production, and lowered amounts of Leydig cells and Luteinizing hormone (LH) receptors. At first, insulin can successfully treat these deficiencies, suggesting that the lack of insulin is responsible for the sexual dysfunction of male diabetes mellitus subjects. This turns out not to be true, as later research revealed that insulin cannot successfully treat ED in these subjects.

Ø Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Performance Ø Erectile Dysfunction Preliminary animal studies found that tribulus heightened sexual behavior and increased intracavernous pressure. This was attributed to increases in testosterone. There haven't been any well-designed human studies to confirm these early findings. Ø Body Composition and Exercise Performance Although tribulus has become popular as a sports performance aid, one small but well-designed study found it has no effect on body composition or exercise performance. Fifteen subjects were randomly assigned to tribulus (3. 21 mg per kg body weight daily) or a placebo. After eight weeks with resistance training, there were no changes in body weight, percentage fat, dietary intake, or mood in either group. What was surprising was that muscle endurance actually improved more in the placebo group. Muscle endurance (determined by the maximum number of repetitions at 100 to 200% of body weight) increased for the bench and leg presses in the placebo group. The tribulus group experienced an increase in leg press strength only. Ø Dosage Ø Tribulus terrestris is often taken at a dose between 85 to 250 mg three times daily, with meals.

–Osteoporosis- some improvement in women over 70 but not in younger (Baulieu et al. PNAS 2000; 97: 4279 -4284) –Adrenal insufficiency: some improvement –Improving sexual functioning in women over 70 (but not younger women or men); another study showed increased sexual arousal in postmenopausal women (J Womens Health Gender Based Med 2002; 11: 155 -62) –Improving erectile dysfunction: N=40 Reiter et al. Urology 1999; 53: 590 -595. Benefit in small controlled study –Athletic performance: mostly negative results –Risks –unknown; stimulates hormone responsive breast tissue in vitro. Stimulates prostate cancer cell growth in vitro. Adverse effects on cholesterol pattern, acne and hirsutism increased

Ginger Ø Zingiber officinale Ø History-long used for food and medicine Ø Pharmacology vdigestive aid vflavor vnausea and vomiting treatment-effect is on the stomach not on the CNS v. For pain Ø Chemistry vvolatile compounds vnon volatile compounds Fgingerol Fshogaol

Ginger • Efficacy Studies • post operative nausea –studies are not in agreement on efficacy • motion sickness • most studies “in the field” show benefit but those in a spinning chair are equivocal

Ginger Summary Ø possibly worthwhile in preventing motion sickness Ø possibly worthwhile in treating and preventing nausea Ø must weigh risk vs. benefit in treating nausea of pregnancy Ø products and doses v 0. 5 -1 g one hour before travel v 2 g/d in divided doses for nausea vdried powdered ginger capsules are OK

Ginseng

What is Ginseng? Ø “Low-growing, shade-loving perennial herb of the Aralianceae family” (http: //www. bccancer. bc. ca/PPI/Unconventional. Therapies/Ginseng. htm) Ø Latin name= Panax Ø The scientific names v. Panax Ginseng v. Derived from the Greek word for cure-all, related to the word Panacea.

Types of Ginseng True Ginseng: Ø American Ginseng v (Panax Quinquefolium) Ø Korean, Chinese or Japanese Ginseng v (Panax Ginseng)

History Ø Ginseng root has been used for over 2000 years Ø Has traditionally used for treatment of a number of disorders in China and Korea Ø Crossed to Western by the eighteenth century Ø US expoted $20. 9 million worth of ginseng last year (NYtimes, 2005)

Active Components v Ginsenosides or Panaxosides Major ginsenosides: Rg 1, Re, Rf, Rb 1, Rc, Rg 2, Rb v Panaxans v Ginsenans

Clinical efficacy of Korean red ginseng for erectile dysfunction Ø To investigate the efficacy in treating erectile dysfunction and to develop a natural drug without complications, the results of ginseng treatments are compared to placebo and other drug. A total of 90 patients with 30 patients in each group were closely followed.

Ø The overall therapeutic efficacies on erectile dysfunction were 60% for ginseng group and 30% for placebo and trazodone treated groups, statistically confirming the effect of ginseng (p < 0. 05). No complete remission of erectile dysfunction was noted, but partial responses were reported.

Dosage vusually provide 100 mg to 400 mg of dried extract F(equivalent to 0. 5 g to 2 g of ginseng root. )

Marketing Claims F “Heart tonic” F “Energy and mood booster” F “Healthy glucose metabolism formula” F “Helps normalize imbalances in the body’s energy in different disease status” F “Sex drive” F “Immune support” F “Stress management” F “Menopausal control”

Traditional and modern uses F Improving the health of people recovering form illness F Increasing a sense of well-being and stamina, and improving both mental and physical performance.

Current Research Area v v v v Ginseng vs. Exercise performance Mood and cognitive function Cardiovascular disease Sexual function Diabetes Obesity Cancer

Diabetes vs. Ginseng Ø Ø Ø Historically used to treat type-2 diabetes. No. 6 th commonly suggested herbal medicine to improve glycemic control by Italian herbalists Many studies support its antihyperglycemic activity.

Theoretical Basis Ø Ginsenosides alter blood glucose levels by vstimulating the biosynthesis of insulin by the pancreas vinducing the production of a glucose transporter in the liver Ø The polysaccharides in ginseng lower blood glucose by veither decreasing the production of glucose by the liver vincreasing the use of glucose by tissues

THE MARKET FOR MALE SEXUAL HEALTH PRODUCTS IS EXTREMELY CROWDED …. WITH MOST PRODUCTS NOT MEETING EXPECTATIONS Ø A majority of products are not clinically proven or the studies are not conducted by qualified professionals Ø They do not address all the main components of male sexual function (libido, erection, ejaculation, orgasm) Ø Drugs like Sildenafil though very widely used are beneficial only in Erectile Dysfunction. They are contraindicated in patients with cardiac disorders & also cause other side effects such as headache, flushing & dyspepsia Ø One has to be exceptionally cautious of formulations that do not have sufficient scientific backup , are unethical , do not match quality standards & may cause untoward side effects In contrast… Ø Carefully selected phytoconstituents with proven activity offer multiple actions & are not only useful in treating the problem of male sexual dysfunction but also address other health conditions that might otherwise inhibit sex eg. problems of impotence, prostate problems , andropause , arthritis , diabetes , lack of energy

Cinnamomum zeylanicum (cinnamon) Ø Parts used- oil & bark Ø Evergreen tree native to India & Sri Lanka; in Laurel family Ø Properties- Astringent, stimulant, antiinfective, anti-fungal, digestive aid Ø One of the oldest and most valuable spices Ø Related spice, called cassia, from C. cassia.

Crocus sativus (saffron) Ø Ø Ø Member of “Iris” family From ‘zafaran’ in Arabic From 3 -parted Stigma of flower Dried by slow roasting Imparts delicate & distinct taste & color Ø Used in French, Spanish, Middle Eastern & Indian cooking Ø Each saffron crocus flower has 3 stigmas v Ca. 80, 000 flowers (240, 000) stigmas to make a pound of saffron v 12 days to pick v cost is > $250 per ounce v (so most costly spice) v 1444: any merchant caught selling adulterated saffron in Bavaria was burned alive