Introduction to Integrative Sexual Medicine

1. Introductionto Integrative Sexual Medicine Marissa Kummerling, MSIV Albert Einstein College of Medicine AMSA Sexual Health Scholars Program 2011-2012 A case-based approach to complementary treatments and aphrodisiacs

2. Objectives • To identify and apply the use of various herbs for both the treatment of sexual health complaints and the enhancement of sexual pleasure in those without complaints. • To understand how to counsel patients on the use of these methods.

3. What is Integrative Medicine? • Integrative Medicine • The blending of practices in conventional medicine with treatment methods in alternative, or complementary medicine • Complementary practices are rooted in the knowledge of traditional medicine of various cultures • A very limited list of practices: • Acupuncture • Herbal remedies • Bioelectromagnetic • Massage/Yoga • Energy therapies (Reiki) Sandroni P. Aphrodisiacs past and present: A historical review.Clinical Autonomic Research . 2001; 11:303-307

4. What is an aphrodisiac? • Aphrodisiac: a food, drink, or drug that stimulates sexual desire • Classified based on mode of action: • Libido: sexual desire • Potency: ability to develop and maintain an erection • Sexual pleasure Sandroni P. Aphrodisiacs past and present: A historical review.Clinical Autonomic Research . 2001; 11:303-307

5. Approach to Integrative Sexual Health • Sexual health complaints should be evaluated like other medical complaints: • History • Physical Exam • Laboratory Evaluation • Discuss the patient’s preferences for treatment • Conventional medical approach • Integrative medical approach (using alternative medicine practices)

6. Case One • A 50 year old man who has not been to a doctor for over 10 years presents with complaints of being unable to maintain an erection.

7. Erectile Dysfunction • History: • When start? How long? Persistent or intermittent? • Ever able to obtain an erection, even momentarily? Nocturnal or morning erections? • Able to achieve orgasm/ejaculation? Pain or discomfort with ejaculation? Is penile curvature a problem? • How frequent is sexual activity? Is it spontaneous or planned? What is your preferred frequency for intercourse? • Have you tried any treatments? • Assess surgical history and pertinent medical history (i.e., cardiovascular risk factors – HTN, DM, obesity, dyslipidemia, family history cardiac disease; current medications • Assess psychological history: depression, stress, problems with sexual relationship, history of abuse Adapted from medscape: Kim ED. History Taking in the Erectile Dysfunction Patient. Medscape Reference. Last updated May 24, 2011. Accessed on Feb 1, 2012. http://emedicine.medscape.com/article/1980342-overview. Accessed on Feb 1, 2012.

8. Erectile Dysfunction • Physical: • Focused physical on pertinent systems: vascular, neurological, genitourinary • Vascular: Blood pressure, peripheral pulses • Neurological: Sensation • Genitourinary: Status of genitalia and prostate, size and texture of the testes, presence of epididymis/vas deferens, abnormalities of penis (Peyronie plaques) Adapted from: Kim ED. Erectile Dysfunction Clinical Presentation. Medscape Reference. Last updated Oct 21, 2001. http://emedicine. medscape.com/ article/ 444220-clinical#a0256. Accessed on Feb 1, 2012.

9. Erectile Dysfunction • Labs: • Fasting glucose, lipids • BMP • PSA • CBC • testosterone Adapted from: Kim ED. Erectile Dysfunction Clinical Presentation. Medscape Reference. Last updated Oct 21, 2001. http://emedicine. medscape.c om/ article/ 444220-clinical#a0256. Accessed on Feb 1, 2012.

10. Erectile Dysfunction • Integrative Treatment Options: • Acupressure/shiatsu • Acupuncture • Arginine • Coleus • Cordyceps • Ginkgo • Ginseng • Horny goat weed • Hypnotherapy • L-carnitine • Maca • Muira puama • Pomegranate • Saffron • Vitamin D • Yohimbe • Zinc www.naturalstandard.com

11. Highlight: Cordyceps • Cordyceps sinensis • Genus of parasitic ascomycete fungi • Cordyceps grows on the back of a caterpillar found mainly in China, Nepal, and Tibet • Used therapeutically in a variety of conditions (asthma, respiratory disorders, drug-induced nephrotoxicity, hyperlipidemia) • CordyMax ® is a standardized form of dried extract that contains 525mg. Can take up to two capsules, 2-3 times per day. • Can also take 3-9g daily in a hot tea. www.naturalstandard.com

12. Highlight: Ginkgo • Ginkgo biloba • Animal and human models have demonstrated ginko’s vascular relaxant properties, which may act on the corpus cavernosum of the penis. • Effective in treatment of antidepressant-induced decreased libido and erectile dysfunction • Contraindicated in conjunction with warfarin. Stop 2-3 weeks before surgical procedures • Can be taken as pill, leaf extract, or tea • These forms available and nutrition or supplement stores • Beneficial effects may take 4-6 weeks • Gingko seeds are potentially toxic and should be avoided www.naturalstandard.com Cohen AJ, Bartlik B. Ginkgo biloba for antidepressant-induced sexual dysfunction. J Sex & Marital Therapy, 1998: 24(2); 139-143.

13. Case Two • A 35 year old woman with no previous medical history complains of inability to achieve orgasm during sexual intercourse with her male partner.

14. Female Anorgasmia • History • When start? How long? Persistent or intermittent? • Able to achieve orgasm through self stimulation? • How frequent is sexual activity? Is it spontaneous or planned? What is your preferred frequency for intercourse? • Have you tried any treatments? • Assess surgical history and pertinent medical history (i.e., cardiovascular risk factors – HTN, DM, obesity, dyslipidemia, family history cardiac disease; current medications • Assess psychological history: depression, stress, problems with sexual relationship, history of abuse

15. Female Anorgasmia • Physical • Focused physical on pertinent systems: vascular, neurological, pelvic • Vascular: Blood pressure, peripheral pulses • Neurological: Sensation • Pelvic: examine external genitalia, speculum exam, bimanual exam

16. Female Anorgasmia • Labs • Fasting glucose, lipids • BMP • CBC • Thyroid hormone (TSH, FT4) • B12/folate

17. Female Anorgasmia • Integrative Treatment Options: • Acupressure/shiatsu • Cordyceps • Damiana • Ginkgo • Ginseng • Horny goat week • Muira puama • Vitamin D • Yohimbe • Zinc www.naturalstandard.com

18. Highlight: Damiana • Turnera diffusa, Turnera aphrodisiaca, Turnera ulmifolia • Damiana used in traditional medicine as anti-cough, diuretic, and aphrodisiac. • Recent studies in rats support the use of Turnera diffusa as a sexual stimulant. • Unsafe in patients with psychiatric disorders as damiana may cause hallucinations and mood changes. May also affect blood sugar levels in patients with diabetes. • 2-4g dried leaf, steeped in 150 mL of boiling water for 5-10 minutes; taken 2-3 times daily • 2-4mL liquid damiana extract three times daily • Commercial preparations also available, often include other herbs/supplements. (Avlimil, Asotas, Libidol, and ArginMax) Estrada-Reyes R, Ortiz-Lopez P, Gutierrez-Ortiz J, Martinez-Mota L. Turnera diffusa Wild (Turneraceae) recovers sexual behavior in sexually exhausted males. J Ethnopharmacol. 2009. 123(3):423-9. . www.naturalstandard.com

19. Highlight: Ginseng • Panax ginseng • Used for more than 2000 years in Chinese medicine • Pharmacologically active constituents are ginsenosides, 25 of which have been identified • A combination of Panax ginseng, L-arginine, Ginkgo biloba, damiana, and multivitamin/minerals improved sexual arousal in women with decreased sex drives and menopausal women. • 100-200mg daily • 3g of chopped fresh root or 1.5g dried root powder in 5 oz. boiling water for 5-15 minutes, straining particulate; take 3-4 times daily for 3-4 weeks. • Avoid in people on warfarin, oral hypoglycemics, insulin, phenelzine www.naturalstandard.com

20. Case Three • A 35 year old woman without a previous medical history presents for her annual physical exam. During the visit, she asks what you know about aphrodisiacs as she is trying to find safe options for her and her partner to use. Neither her nor her partner have sexual health complaints.

21. No Sexual Complaints • Abuta • Alizarin • Ambrette • Anise • Annatto • Apricot • Arnica • Arum • Ashwagandha • Asparagus • Avocado • Integrative Treatment Options: • Bael fruit • Bala • Beet • Burdock • Calamus • Cardamom • Carqueja • Chasteberry • Chives • Chocolate • Clove • Coriander • Damiana • Garlic • Ginger • Ginseng • Gotu kola • Guarana • Horny goat weed • Jasmine • Kava • Lavendar • Maca • Muira puama • Parsley • Passion flower • Poppy seed • Pygeum • Savory • Shiitake • Sundew • Sweet almond • Yohimbe www.naturalstandard.com

22. Highlight: Ambrette • Ambelmoschus moschatus • Ambrette seeds traditionally have been used to treat a wide variety of ailments (wound healing, dyspepsia, heart disease, intestinal disorders, diarrhea, vomiting) • Used in cosmetics, perfumes and to flavor food • Taken as tea or tincture, can also chew seeds • Purchased from herbalist or online-reputable source • Use with caution in diabetics on therapy as ambrette may lower glucose levels www.naturalstandard.com

23. Highlight: Maca • Lepidium meyenii • Vegetable cultivated as a root crop for 2000 years. Found in Peru, Bolivia, Paraguay, and Argentina. Grows easily at high altitudes, most commonly found in Peruvian highlands. • Highly nutritious (11% protein content) and can be eaten baked, roasted, or prepared as porridge. • In addition to acting as an aphrodisiac, may boost energy and enhance fertility. • Aphrodisiac properties: 1500-3000 mg per day for 8-12 weeks • 450mg taken twice daily of commercially prepared root • 2800mg root powder placed in 8 oz of water, taken up to 3 times per day www.naturalstandard.com

24. Conclusion • The integrative therapies discussed here should be used in conjunction with other forms of patient education about sexual functioning: • Male and female sexual response and anatomy • Identifying sexual expectations and communicating with partner • Diet, exercise, and stress reduction as important contributors to sexual health • Other methods to enhance sexual pleasure: • Fantasy, self stimulation • Referral to sex therapist

25. Resources • www.naturalstandard.com • Cohen AJ, Bartlik B. Ginkgo biloba for antidepressant-induced sexual dysfunction. J Sex & Marital Therapy, 1998: 24(2); 139-143. • Estrada-Reyes R, Ortiz-Lopez P, Gutierrez-Ortiz J, Martinez-Mota L. Turnera diffusa Wild (Turneraceae) recovers sexual behavior in sexually exhausted males. J Ethnopharmacol. 2009. 123(3):423-9. • Kim ED. History Taking in the Erectile Dysfunction Patient. Medscape Reference. Last updated May 24, 2011. Accessed on Feb 1, 2012. http://emedicine.medscape.com/article/1980342-overview • Malviya N, Jain S, Gupta VB, Vyas S. Recent studies on aphrodisiac herbs for the management of male sexual dysfunction: a review. Acta Poloniae Pharmaceutica Drug Research, 2011: 68(1): 3-8. • Sandroni P. Aphrodisiacs past and present: a historical review. Clinical Autonomic Research, 2001: 11; 303-307. • Zenico T, Cicero AFG, Valmorri L, Mercuriali M, Bercovich E. Subjective effects of Lepidium meyenii (Maca) extract on well-being and sexual performances in patients with mild erectile dysfunction: a randomised, double-blind clinical trial. Andrologia, 2009: 41; 95–99.