Tolle Totum

Carrie Decker, ND

Through the years and many stages in a woman’s life, factors contributing to sexual dysfunction can vary vastly. In younger years, insecurities with one’s body and sexual ability may prevail¹; in the middle years, stressors of career and/or children (or lack thereof) affect not only time for intimacy, but libido as well^2,3; and in later years, changes in hormones and the vaginal tissues, and typical age-related increases in medical problems, render sexual function mediocre at best for many.⁴ Through each of these stages, historic traumas, relational stresses, cultural influences, and mental health are also major factors impacting sexual function.^5,6 Given all of these possibilities (and many other factors not mentioned), it is no wonder that sexual problems are reported by more than 40% of women aged 18 years or older in the United States.⁷ 

While the general guidelines for male sexual dysfunction (MSD) provided by clinical resources such as UpToDate® are overly simplistic (improve libido and erection, reduce premature ejaculation)^8,9 and primarily detail the various medications available for these purposes, there really are no standard guidelines for the management of female sexual dysfunction (FSD). For the management of FSD and female orgasmic disorder, a commonly recommended approach includes setting clear, feasible treatment goals, reminding the patient that sexual issues do not have an easy or immediate treatment, and ensuring the patient’s mood and psychosocial functioning are stable. Although these points are undeniably important, it is interesting to note that they do not have equal emphasis with regards to MSD. Following this, a complex breakdown of management per potential problem is often given (including discussion of weight loss surgery for body image issues, and recommendation against the use of any herbal supplement); this results in most physicians referring patients out to a sex therapist – a service that many insurance plans won’t cover. For the holistic provider or feminists reading this content, the contrast in approach and these other suggestions are difficult to digest without one’s blood pressure rising…

Clearly, there is a great need for improved holistic management of the factors contributing to FSD, one which we as holistic providers are well poised to offer. Hence, herein we will discuss some of the natural therapeutics – with evidence backing their use – for the treatment of FSD as well as its potential underlying etiology.

Ashwagandha: Stress Mediator and More

Ashwagandha (Withania somnifera) is a well-known botanical for improving many aspects of the body’s response to stress: in randomized, double-blind, placebo-controlled trials (RDBPCTs), ashwagandha has been shown to reduce perceived stress and stress assessment scores, decrease anxiety and symptoms of obsessive compulsive disorder, improve happiness, and curb food cravings, even reducing body weight.^10-13 Biochemically, treatment with the herb has been shown in humans to reduce levels of cortisol, C-reactive protein (CRP), and fasting blood sugar, as well as improve cholesterol profiles.^14,15 Additionally, in a RDBPCT, ashwagandha was shown to improve subclinical hypothyroidism,¹⁶ which, although not an established risk factor for FSD, has been shown to be associated with higher rates of sexual dysfunction and depression.¹⁷

In addition to impacting the stress response, there are several mechanisms via which this herb may directly impact female sexual function. In humans with type 2 diabetes, ashwagandha has been shown to improve endothelial function, including increasing levels of nitric oxide.¹⁸ Although healthy blood vessel dilation is often only thought of as a mediator of male sexual response, it plays a very important role in arousal, lubrication, and orgasm in females as well.^19,20 In animals, ashwagandha has been shown to significantly increase testosterone and progesterone compared to controls, while in the animals with diabetes, it partially attenuated the adverse effects of diabetes on progesterone, as well as increasing it.²¹ In aging overweight men, supplementation of ashwagandha for 8 weeks significantly increased both dehydroepiandrosterone-sulfate (DHEA-S) and testosterone compared to placebo.²²

The effects of ashwagandha on sexual function have also been studied clinically. Fifty women with sexual dysfunction and arousal disorder, ages 21 to 50, were randomized to treatment with 300 mg of ashwagandha or placebo twice daily for a period of 8 weeks.²³ Physician interviews indicated that many of the women experienced stress associated with social demands, child rearing, and their husbands’ expectations despite living in affluent households with domestic help. After 8 weeks of ashwagandha supplementation, significant improvements in Female Sexual Function Index scores related to lubrication, arousal, orgasm, and satisfaction; an increase in number of successful sexual encounters; and a decrease in Female Sexual Distress Scale scores were seen, with most parameters having a p-value of less than 0.001 compared to placebo. No adverse effects were experienced, and the therapy was well tolerated. Ashwagandha has also been shown to be of therapeutic value for male sexual health, significantly improving hormone levels and sperm count as well as other semen parameters in men with oligospermia.²⁴

Saffron: Antidote to Depression & SSRI-related Sexual Dysfunction?

In addition to the impact of stress on sexual function and overall well-being, mental health conditions can have a dramatic impact on sexual function.²⁵ Rather than improving with pharmaceutical treatment, sexual function is often worsened by many anti-anxiety and antidepressant medications.²⁶ With an estimated 21.4% of US adults experiencing a mood disorder at some point in their lives,²⁷ and the risk of diagnosis with depression in menopause being 2.5 times that of depression during the premenopausal years,²⁸ a considerable number of women will experience these challenges. A population survey of antidepressant use in the United States, from 2011 to 2014, found that more than 20% of women age 40 and older had taken an antidepressant within the last month – almost twice the rate of male use at a corresponding age.²⁹ Clearly, mental health challenges and even their treatment will often be a factor in FSD.

Saffron (Crocus sativus), a valuable herb commonly used in the Mediterranean and surrounding regions for more than 3000 years as a flavoring, coloring, and even perfume,³⁰ also has substantial evidence backing its medicinal use. Its brilliant yellow hue and characteristic taste are due to the high concentration of carotenoids and their degradation products found within it. The primary bioactive compounds found in saffron are crocin, crocetin, safranal, and picrocrocin, although trace amounts of lycopene, alpha- and beta-carotene, and zeaxanthin also may exist.^31,32 In addition to this botanical’s antioxidant,³³ anti-inflammatory,³⁴ digestive,³⁵ cardioprotective,³⁶ and anticarcinogenic³⁷ properties, it also been shown to improve depression as well as antidepressant-related sexual dysfunction.

In numerous RDBPCTs, treatment with saffron has been shown to significantly improve symptoms of anxiety and depression.^38-40 Studies suggest that the active constituents found in saffron interact with the GABAergic system and modulate levels of serotonin, dopamine, and norepinephrine.^41-43 A 2013 meta-analysis of the randomized controlled trials assessing the use of saffron for treatment of depression found a large effect size with supplementation of saffron compared to placebo, whereas when compared to various pharmaceutical antidepressants the effect size was null, indicating the treatments were similarly effective.⁴⁴ Daily supplementation of a saffron extract has also been observed to significantly improve mood and overall symptoms in women with premenstrual syndrome.⁴⁵

RDBPCTs have also assessed the impact of saffron on sexual function in women and men with antidepressant-related dysfunction. In women ages 18 to 45 who experienced sexual dysfunction after beginning treatment with fluoxetine for major depression, supplementation with 15 mg of an extract of saffron twice daily for 4 weeks significantly improved total sexual function index scores compared to placebo.⁴⁶ To be eligible for this study, the women were required to have normal sexual function prior to beginning treatment with fluoxetine, and to be stable on 40 mg of fluoxetine daily for 6 weeks or more with at least 50% improvement in their depression symptoms. Significant improvements were observed in scores related to arousal, lubrication, and pain compared to placebo, although desire, satisfaction, and orgasm were not significantly improved. A similar study looked at the impact of the same therapeutic regime on MSD related to antidepressant treatment, also finding improvements in total scores compared to placebo, with the primary benefits attributed to improved erectile function.⁴⁷

Saffron and its extracts have been shown to improve sexual function outside of this setting as well. In women ages 18 to 39 with complaints of sexual dysfunction not related to antidepressant use, supplementation with 15 mg of a saffron extract twice daily led to a significant increase in excitement and desire by 4 weeks, with all aspects of sexual dysfunction except lubrication and dyspareunia significantly improved vs placebo by 8 weeks.⁴⁸ The constituent crocin was shown in animals to mediate saffron’s aphrodisiac effects.⁴⁹ Other animal studies have shown the whole herb or its extract to improve endothelial function and activate nitric oxide synthase,^50,51 which may be another means by which it improves sexual response. These and other mechanisms of action may translate to enhanced erectile function, which daily supplementation of saffron has been demonstrated to improve in men.⁵² Improvements in semen parameters have also been observed with regular saffron supplementation, making it worthy of consideration for infertility issues as well.⁵³

Given the potential adverse effects of antidepressant medications on sexual health, and the observed benefits with saffron supplementation on both mood and sexual function, this botanical is at the top of the list for consideration when addressing mood as well as sexual health.

The Health of the Vadge Still Counts

Any woman that has experienced the discomfort of vaginal dryness or altered vaginal flora is well aware of how these changes can impact her sexual experience. From the embarrassment of having a discharge or altered odor to the considerable pain that can comes with penetration or even the application of a lubricant, vaginal health clearly plays a role in sexual wellness. Increasingly with age, dyspareunia occurs due to changes in the vaginal tissues and microbiome.⁵⁴ Although the shifts in the vaginal microbiome are mediated by hormonal changes,⁵⁵ the atrophy the tissue experiences also is associated with a low relative abundance of Lactobacillus.⁵⁶

Comparisons between postmenopausal women taking hormone replacement therapy (HRT) and those not taking HRT have shown that in women on HRT (in this case conjugated equine estrogens), the dominant flora is lactobacilli.⁵⁷ Not surprisingly, lower levels of potentially pathogenic bacteria were found in the women on HRT, which also translated to a significantly lower incidence of bacterial vaginosis (5.6% versus 31%). In premenopausal women, as well as postmenopausal women on HRT, the bacterial community is frequently dominated by Lactobacillus crispatus or L iners.^56,58 L crispatus, considered a biomarker of a healthy vaginal tract,⁵⁹ helps protect against genitourinary tract infections beyond just bacterial vaginosis involving Escherichia coli, Chlamydia trachomatis, and Neisseria gonorrhoeae.^60-62 Lower levels of Lactobacillus spp, along with a notable absence of L crispatus, also have been shown in women who experience vulvodynia.^63,64

In line with these findings, low doses of oral estrogen have been shown to improve symptoms of atrophic vaginitis in postmenopausal women, as well as dramatically increase the abundance of vaginal Lactobacillus spp and reduce levels of Gardnerella vaginalis and Atopobium vaginae, both of which were associated with genital symptoms.⁶⁵ As HRT is contraindicated in many women with hormone-sensitive cancers, a non-hormonal therapy (such as probiotics) that efficaciously resolves vaginal atrophy and related infections in the menopausal period would be ideal. Encouragingly, oral administration of a combination of Lactobacillus spp including L cristpatus to a population of postmenopausal women undergoing chemotherapy for breast cancer was shown to positively influence the vaginal microbiota and improve Nugent scores compared to placebo.⁶⁶ Additionally, vaginal administration of ultra-low doses of estriol (0.03 mg) in combination with L acidophilus daily has been shown to normalize the vaginal ecosystem and improve symptoms of vaginal atrophy,⁶⁷ while only slightly increasing serum levels of estriol and having no effect on estrone and estradiol levels.⁶⁸

Conclusion

The impact that each of these natural interventions may have on female sexual health as well as the many factors that contribute to its decline is well supported by clinical research. Given the low risk of adverse effects with each of these therapies, they are worthy of consideration when addressing sexual dysfunction in the many women that experience this challenge.

References:

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Carrie Decker, ND, graduated with honors from the National College of Natural Medicine (now the National University of Natural Medicine) in Portland, OR. Prior to becoming a naturopathic physician, Dr Decker was an engineer and obtained graduate degrees in biomedical and mechanical engineering from the University of Wisconsin-Madison and University of Illinois at Urbana-Champaign, respectively. She continues to enjoy academic research and writing and uses these skills to support integrative medicine education as a writer and contributor to various resources. Dr Decker supports Allergy Research Group as a member of their education and product development team.