Impotence, or erectile dysfunction, is the inability to achieve an erection. Impotence may occur for any of at least 15 possible causes, including diabetes, drug side effects, pituitary tumors, hardening of the arteries, hormonal imbalances, and psychological factors. A few of these conditions respond to specific treatment. For example, if a blood pressure drug is causing impotence, the best approach is to change drugs. If a pituitary tumor is secreting the hormone prolactin, treating that tumor may result in immediate improvement. However, in most cases, conventional treatment of impotence is nonspecific.
The drugs Viagra and Cialis have revolutionized treatment for erectile dysfunction. These medications work by increasing tissue sensitivity to the blood-vessel-dilating substance nitric oxide (NO) in the penis. Older methods include mechanical devices that utilize a vacuum to produce an erection, drugs for self-injection, and implantation of penile prostheses.
In the better of the two trials, 45 participants received either placebo or Korean red ginseng at a dose of 900 mg 3 times daily for 8 weeks.14 After a 1-week period of no treatment, the two groups were switched. The results indicate that while using Korean red ginseng men experienced significantly better sexual function than while they were taking placebo.
In an analysis combining the results of 6 controlled trials, researchers found some evidence for the benefits of Korean red ginseng. However, the small size and generally low quality of the studies left some doubt about this conclusion.37
For more information, including safety issues, see the full Ginseng article.
The substance nitric oxide (NO) plays a role in the development of an erection. Drugs like Viagra increase the body's sensitivity to the natural rise in NO that occurs with sexual stimulation. A simpler approach might be to raise NO levels, and one way to accomplish this involves use of the amino acid L-arginine. Oral arginine supplements may increase nitric oxide levels in the penis and elsewhere. Based on this, L-arginine has been advertised as "natural Viagra." However, there is as yet little evidence that it works. Drugs based on raising nitric oxide levels in the penis have not worked out for pharmaceutical developers; the body seems to simply adjust to the higher levels and maintain the same level of response.
The main support for the use of arginine in erectile dysfunction comes from a small double-blind trial in which 50 men with erectile dysfunction received either 5 g of L-arginine or placebo daily for 6 weeks.2 More men in the treated group experienced improvement in sexual performance than in the placebo group.
A double-blind crossover study of 32 men found no benefit with 1,500 mg of arginine given daily for 17 days;11 the much smaller dose and shorter course of treatment may explain the discrepancy between these two trials.
L-arginine has also been evaluated in combination with other products. For example, a double-blind, placebo-controlled trial of 45 men found that one-time use of L-arginine plus the drug yohimbine (made from the herb yohimbe) 1-2 hours before intercourse improved erectile function, especially in those with only moderate erectile dysfunction scores. Arginine and yohimbine were both taken at a dose of 6 g.
Note: Do not use the drug yohimbine (or the herb yohimbe) except under physician supervision, as it presents a number of safety risks.
Researchers have also studied a formulation of L-arginine and pine bark extract (pycnogenol). In a randomized study involving 124 men with moderate erectile dysfunction, those that were in the treatment group had an improvement in their symptoms.38
For more information, including dosage and safety issues, see the full L-arginine article.
In a 6-month, double-blind trial of 120 men, average age 66, carnitine (propionyl-l-carnitine 2 g/day plus acetyl-l-carnitine 2 g/day) and testosterone (testosterone undecanoate 160 mg/day) were separately compared to placebo.22 The results indicated that both carnitine and testosterone improve erectile function; however, while testosterone significantly increased prostate volume, carnitine did not.
Another double-blind, placebo-controlled study found that propionyl-l-carnitine at 2 g/day enhanced the effectiveness of sildenafil (Viagra) in 40 men with diabetes who had previously failed to respond to sildenafil on at least eight occasions.23
In another double-blind study, a combination of the propionyl and acetyl forms of carnitine enhanced the effectiveness of Viagra in men who suffered from erectile dysfunction caused by prostate surgery.31
Carnitine has also shown promise for treating male infertility. For more information, including dosage and safety issues, see the full Carnitine article.
A proprietary combination therapy containing arginine along with Ginkgo biloba, ginseng, and vitamins and minerals has shown some promise in an unpublished study.32
In a 3-week, double-blind, placebo-controlled trial, 20 men with erectile dysfunction received either placebo or a special form of magnet therapy called pulsed electromagnetic field therapy (PEMF).18 PEMF was administered by means of a small box worn near the genital area and kept in place as continuously as possible over the study period; neither participants nor observers knew whether the device was actually activated or not. The results showed that use of PEMF significantly improved sexual function compared to placebo.
A double-blind, placebo-controlled study enrolled 40 men with difficulty achieving or maintaining an erection who also had low measured levels of dehydroepiandrosterone (DHEA).1 The results showed that DHEA at a dose of 50 mg daily improved sexual performance; however, the authors failed to provide a statistical analysis of the results, making the meaningfulness of this study impossible to determine.
Severe zinc deficiency is known to negatively affect sexual function. Since marginal zinc deficiency is relatively common, it is logical to suppose that supplementation with zinc may be helpful for some men. However, this hypothesis has only been studied in men receiving kidney dialysis.16,17 The results were promising.
The herb Butea superba has shown some promise for erectile dysfunction, according to a 3-month randomized, double-blind study performed in Thailand.24
Based on exceedingly preliminary evidence, the herb maca ( Lepidium meyenii) has been advertised as "herbal Viagra." In one study in rats, use of maca enhanced male sexual function.33 There is one published human trial as well. In this small, 12-week, double-blind, placebo-controlled study, use of maca at 1,500 mg or 3,000 mg increased male libido.34 While this was an interesting finding, the study did not report benefits in male sexual function—just in desire. Since loss of sexual function is a more common problem in men than loss of sexual desire, these results do not justify the herbal Viagra claim. Contrary to some reports, maca does not appear to affect testosterone levels.19
Many other herbs are also reputed to improve sexual function in men , including ashwagandha, Avena sativa (oat straw), catuaba, cordyceps, damiana, diindolylmethane (DIM), eleutherococcus (so-called “Siberian ginseng”), L-citrulline, Macuna pruriens, molybdenum, muira puama (potency wood), pygeum, Polypodium vulgare, Rhodiola rosea, saw palmetto, schisandra, suma, traditional Chinese herbal medicine, and Tribulus terrestris. However, there is as yet no real evidence that they offer any benefits.
Numerous case reports and uncontrolled studies had indicated that the herb Ginkgo biloba offers dramatic benefits for male (and female) sexual problems caused by antidepressants.3-8 However, as always, double-blind, placebo-controlled studies are necessary to truly establish efficacy. (For the reasons why, see Why Does This Database Rely on Double-blind Studies?) When studies of this type were performed, it became clear that people had been misled about ginkgo’s efficacy by the power of suggestion: ginkgo failed to improve sexual function to any greater extent than placebo.20,27
In a small single-blind study, acupuncture proved superior to fake acupuncture for treatment of erectile dysfunction.28 However, because the treating practitioners administrating the control treatment were aware that they were providing sham acupuncture, it is quite likely that they unconsciously communicated lack of confidence as they provided it; this is an inherent limitation of single-blind studies.
The US Food and Drug Administration (FDA) warned consumers not to purchase or consume a several brands of dietary supplements after samples were found adulterated with the prescription drug tadalafil (Cialis), an analogue of sildenafil (Viagra). The products named in the warning are SIGRA, STAMINA Rx, STAMINA Rx for Women, Y-Y, Spontane ES, and Uroprin (all manufactured by NVE, Inc., and distributed by Hi-Tech). For more information, see the FDA's Public Health Advisory on this subject.
The herb yohimbe is the source of the drug yohimbine, which has been shown to be modestly better than placebo for impotence. However, due to many drug interactions and other risks, we do not recommend using yohimbine except under the supervision of a physician. Because there is no agency regulating herbal product quality and labeling, the herb yohimbe presents even more risks, such as unpredictable yohimbine content.
Soy or soy isoflavones,21 as well as the herb licorice,10 may reduce testosterone levels in men. For this reason, men with impotence, infertility, or decreased libido may want to avoid these natural products.
One report claims that both tea tree oil and lavender oil have estrogenic (estrogen-like) and antiandrogenic (testosterone-blocking) effects.35 If this were true, men with erectile dysfunction would be advised to avoid use of these herbs. However, a literature search failed to find any other published reports that corroborate this claim.
The supplement androstenedione, often taken for male sexual dysfunction in the belief that it increases testosterone levels, actually appears to increase estrogen levels in men, and might therefore increase problems with erectile function.
A small study involving 21 men with erectile dysfunction found that those who took pine bark extract (120 mg/day for 3 months) experienced an improvement in their symptoms compared to placebo.39
Reiter WJ, Pycha A, Schatzl G, et al. Dehydroepiandrosterone in the treatment of erectile dysfunction: a prospective double-blind, randomized, placebo-controlled study. Urology. 1999;53:590-595.
Chen J, Wollman Y, Chernichovsky T, et al. Effect of oral administration of high-dose nitric oxide donor L-arginine in men with organic erectile dysfunction: results of a double-blind, randomized placebo-controlled study. BJU Int. 1999;83:269-273.
Sikora R, Sohn M, Deutz FJ, et al. Ginkgo biloba extract in the therapy of erectile dysfunction. J Urol. 1989;142:188A.
Cohen AJ, Bartlik B. Ginkgo biloba for antidepressant-induced sexual dysfunction. J Sex Marital Ther. 1998;24:139-143.
McCann B. Botanical could improve sex lives of patients on SSRIs. Drug Topics. 1997;141:33.
Cohen A. Treatment of antidepressant-induced sexual dysfunction with Ginkgo biloba extract [abstract #716]. Presented at: Annual Meeting of the American Psychiatric Association, 1996.
Cohen A, Bartlik B. Treatment of sexual dysfunction with Ginkgo biloba extract [scientific reports]. Paper session from: American Psychiatric Association Annual Meeting, 1997.
Cohen A. Long-term safety and efficacy of Ginkgo biloba extract in the treatment of antidepressant-induced sexual dysfunction. Priory Medical Journals website. Available at: http://www.priory.com/pharmol/gingko. Accessed 1997.
Drago F, Busa' L. Acute low doses of melatonin restore full sexual activity in impotent male rats. Brain Res. 2000;878:98-104.
Armanini D, Palermo M. Reduction of serum testosterone in men by licorice. N Engl J Med. 1999;341:1158.
Klotz T, Mathers MJ, Braun M, et al. Effectiveness of oral L-arginine in first-line treatment of erectile dysfunction in a controlled crossover study. Urol Int. 1999;63:220-223.
Ashton AK, Ahrens K, Gupta S, et al. Antidepressant-induced sexual dysfunction and Ginkgo biloba [letter]. Am J Psychiatry. 2000;157:836-837.
Choi HK, et al. Clinical efficacy of Korean red ginseng for erectile dysfunction. Int. J Impotence Res. 1995;7:181-186.
Hong B, Ji YH, Hong JH, et al. A double-blind crossover study evaluating the efficacy of Korean red ginseng in patients with erectile dysfunction: a preliminary report. J Urol. 2002;168:2070-2073.
Lebret T, Herve JM, Gorny P, et al. Efficacy and safety of a novel combination of L-arginine glutamate and yohimbine hydrochloride: a new oral therapy for erectile dysfunction. Eur Urol. 2002;41:608-613.
Mahajan SK, Abbasi AA, Prasad AS, et al. Effect of oral zinc therapy on gonadal function in hemodialysis patients. A double-blind study. Ann Intern Med. 1982;97:357-361.
Brook AC, Johnston DG, Ward MK, et al. Absence of a therapeutic effect of zinc in the sexual dysfunction of hemodialysed patients. Lancet. 1980;2:618-620.
Pelka RB, Jaenicke C, Gruenwald J. Impulse magnetic-field therapy for erectile dysfunction: a double-blind, placebo-controlled study. Adv Ther. 2002;19:53-60.
Gonzales GF, Cordova A, Vega K, Effect of Lepidium meyenii (Maca), a root with aphrodisiac and fertility-enhancing properties, on serum reproductive hormone levels in adult healthy men. J Endocrinol. 2003;176:163-168.
Kang BH, Lee SJ, Kim MD, et al. A placebo-controlled, double-blind trial of Ginkgo bilboa for antidepressant-induced sexual dysfunction. Hum Psychopharmacol Clin Exp. 2002;17:279-284.
Gardner-Thorpe D, O'Hagen C, Young I, et al. Dietary supplements of soya flour lower serum testosterone concentrations and improve markers of oxidative stress in men. Eur J Clin Nutr. 2003;57:100-106.
Cavallini G, Caracciolo S, Vitali G, et al. Carnitine versus androgen administration in the treatment of sexual dysfunction, depressed mood, and fatigue associated with male aging. Urology. 2004;63:641-646.
Gentile V, Vicini P, Prigiotti G, et al. Preliminary observations on the use of propionyl-L-carnitine in combination with sildenafil in patients with erectile dysfunction and diabetes. Curr Med Res Opin. 2004;20:1377-1384.
Cherdshewasart W, Nimsakul N. Clinical trial of Butea superba, an alternative herbal treatment for erectile dysfunction. Asian J Androl. 2003;5:243-246.
Durackova Z, Trebaticky B, Novotny V, et al. Lipid metabolism and erectile function improvement by pycnogenol extract from the bark of Pinus pinaster in patients suffering from erectile dysfunction-a pilot study. Nutr Res. 2003;23:1189-1198.
Stanislavov R, Nikolova V. Treatment of erectile dysfunction with pycnogenol and L-arginine. J Sex Marital Ther. 2003;29:207-213.
Wheatley D. Triple-blind, placebo-controlled trial of Ginkgo biloba in sexual dysfunction due to antidepressant drugs. Hum Psychopharmacol. 2004 Sep 20. [Epub ahead of print]
Engelhardt PF, Daha LK, Zils T, et al. Acupuncture in the treatment of psychogenic erectile dysfunction: first results of a prospective randomized placebo-controlled study. Int J Impot Res. 2003;15:343-346.
Conaglen HM, Suttie JM, Conaglen JV. Effect of deer velvet on sexual function in men and their partners: a double-blind, placebo-controlled study. Arch Sex Behav. 2003;32:271-278.
Partin JF, Pushkin YP. Tachyarrhythmia and hypomania with horny goat weed. Psychosomatics. 2004;45:536-537.
Cavallini G, Modenini F, Vitali G, et al. Acetyl-L-carnitine plus propionyl-L-carnitine improve efficacy of sildenafil in treatment of erectile dysfunction after bilateral nerve-sparing radical retropubic prostatectomy. Urology. 2005;66:1080-1085.
Ito T, Kawahara K, Das A. A double-blind placebo-controlled study on the effects of ArginMax, a natural nutritional supplement for enhancement of male sexual function. ArginMax website. Available at: http://www.arginmax.com/html/abstract.htm. Accessed October 5, 2005.
Cicero AF, Piacente S, Plaza A, et al. Hexanic Maca extract improves rat sexual performance more effectively than methanolic and chloroformic Maca extracts. Andrologia. 2002;34:177-179.
Gonzales GF, Cordova A, Vega K, et al. Effect of Lepidium meyenii (Maca) on sexual desire and its absent relationship with serum testosterone levels in adult healthy men. Andrologia. 2002;34:367-95.
Henley DV, Lipson N, Korach KS, Bloch CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356:479-485.
Forest CP, Padma-Nathan H, Liker HR. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: a randomized, placebo-controlled, double-blind, crossover study. Int J Impot Res. 2007 Jun 14. [Epub ahead of print]
Jang DJ, Lee MS, Shin BC, et al. Red ginseng for treating erectile dysfunction: a systematic review. Br J Clin Pharmacol. 2008 Jun 9.
Ledda A, Belcaro G, Cesarone MR, Dugall M, Schönlau F. Investigation of a complex plant extract for mild to moderate erectile dysfunction in a randomized, double-blind, placebo-controlled, parallel-arm study. BJU Int. 2010;106(7):1030-1033.
Durackova Z, Trebaticky B, Novotny V, Zitnanova I, Breza J. Lipid metabolism and erectile function improvement by pycnogenol, extract from the bark of pinus pinaster in patients suffering from erectile dysfunction-a pilot study. 2003;23(9):1189-1198.
Last reviewed September 2014 by EBSCO CAM Review Board
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.