What is Ginkgo Biloba ?
Also known as Ginkgoaceae contain a number of identified flavonol, glycosides, terpene lactones, and bilobalide which are associated with perceived health benefits (Rimmer 2007; Meton 2008). It has been shown to facilitate peripheral blood flow and it is thought that this is the mechanism that promotes sexual arousal through nitric oxide scavenging abilities and relaxant effect on smooth muscle tissue (Auguet 1983; Marocci 1994).
What do the studies suggest about Ginkgo Biloba supplementation in libido improvement?
A study by Meston evaluated it’s effects on subjective and physiological (using vaginal photoplethysmography) measure of sexual function in women with sexual arousal disorder and found that there was a small but significant facilitatory effect on physiological sexual arousal compared to placebo but no effect on subjective sexual arousal.
A study that compared placebo, ginkgo biloba extract, sex therapy or sex therapy plus ginkgo biloba found that when combined with sex therapy, but not alone, long term therapy increased sexual desire and contentment beyond placebo, however, sex therapy alone improved sexual desire and contentment when compared to placebo.
In a study of women taking antidepressant induced sexual dysfunction herbal treatment was effective in alleviating antidepressant-induced sexual symptoms in 91% of women. The authors concluded that it could increase vascular flow to the genitals through the inhibition of platelet activating factors due to the enhancement of cerebral perfusion (Cohen 1998). There was also a case report of a 37-year old woman who reported improvement in sexual function with daily gingko extract (Ellison 1998).
What is the appropriate dose of Ginkgo Biloba?
A dose of 300mg/day of Gingko biloba seems to be the most common dose used.
What are potential side effects?
There is a concern that it may cause prolonged bleeding time and risk for hemorrhage through antiplatelet activity and risk of intracranial bleeding. Interactions with other anticoagulants would be of concern – so anyone taking such medications as warfarin, aspirin or lithium would not be candidates for ginkgo biloba.
Who might be helped by Ginkgo biloba?
It really seems that the only suggested benefit may be for women with sexual function issues secondary to taking anti-depressant use.
Auguet M, Clostre F. Effects of an extract of Ginkgo biloba and diverse substances on the phasic and tonic components of the contractions of an isolated rabbit aorta. Gen Pharmcol 1983;14:277-80.
Cohen AJ, Bartlik B. Binkgo biloba for antidepressant induced sexual dysfunction. J Sex Marital Ther 1998;4:139-43 .
Ellison JM, DeLuca P. Fluoxetine induced genital anesthesia reliebed by Ginkgo biloba extract. J. Clin Psychiatry 1998;59:199-200.
Kang BJ, LeeSJ, Kim MD, Cho MJ. A placebo controlled, double-blind trial of Ginkgo biloba for antidepresaant induced sexual dysfunction. Hum Psychopharmcol 2002;17:279-84.
Marocci L, Maguire JJ, Droy-Lefaix MT, Packer L. The nitric oxide-scavenging properaties of Ginkgo biloba extract EGb 761. Biochem Biophys Res Commun 1994; 201:748-55.
Meston CM, Rellini Ah, Telch MJ. Short and long-term effects of Ginkgo biloba extraction on sexual dysfunction in women. Arch Sex Behav 2008;37:530-47.
Rimmer CA, Howerton SB, Shrpless KE, Sander LC, Long SE, Murphy KE, Porter BJ, Putzbach K, Rearich MS, Wise SA, Wood LH, Ziesler R, Hancock DK, Yen JH, Betz JM, Nguyenpho A, Yang L, Scriver C, Willie S, Sturgeon R, Schaneberg B, Nelsonm C, Skamarack J, Pan M, Levanseler K, Gray D, Waysek EH, Blatter A Reich E. Characterization of a suite of ginkgo –containing standard reference materials. Anal Bioanal Chem 2007; 389:179-96.
When the “pink pill” for women came to market late this past year I had a number of women asking me for it. This reminded me to look into the different options for libido. Without going into too much about the new medication, it is only approved for use in premenopausal women and most of the requests came from my postmenopausal patients. Overall, the literature also seems to suggest it carries a number of significant risks with minimal gain. Maybe I’ll do a little reassessment of this drug in the future but for now trying to see if any more “natural” remedies were available to suggest my patients. So, one of the first things on my topic list is to evaluate is DHEA.
What is DHEA ?
Keeping it simple – DHEA, also known as dehydroepiandrosterone (but we’ll just stick with DHEA), is a steroid. It is primarily made the adrenal gland but also is produced in small amounts in the brain (Strous 2006). As part of the cholesterol biochemical pathway, DHEA goes through multiple transformations leading to increased levels of testosterone and estrogen. (Callahan et al, 2004).
Do androgens matter for libido?
Studies have shown that women need a certain amount of estrogen and testosterone to maintain libido and sexual response (Clayton 2010, Davis 2005) and women with supplemented hormones show improvement in sexual functioning (Davis 2008). In premenopausal women with low scores of sexual response and arousal, lower DHEA levels were found (Turna 2005) but correlation doesn’t necessarily mean a cause.
My next question is:
What do the studies suggest about DHEA supplementation in libido improvement?
There are only a handful of studies that reviewed DHEA specifically and the results are mixed. Two small studies with higher DHEA doses [100mg] administered showed improvement in sexual function (Hackert & Heiman 2002; Schmidt 2005) but other studies with lower doses of DHEA [50mg] and more women included didn’t show a difference (Kritz-Silverstein 2008; Panjari et al 2009). A more recent study (Bloch 2013) conducted a randomized, double blind trial of 100mg DHEA supplementation for postmenopausal women. After 6 weeks the women supplemented with DHEA showed improvement in sexual arousal and satisfaction.
So, while the results are mixed and there are only a few studies, this may be something that could potentially help some of my patients.
What is the appropriate dose of DHEA?
This is a good question. Most supplements suggest 25mg daily, however, the studies used a minimum of 50mg and many of those that noted significant effects used more, 100mg. It is possible that for some women the smallest amount would be effective but with increasing doses come increasing side effects and risks.
Who should avoid DHEA?
As with any medications or supplements, there are potential side effects and risks. Individuals with any contraindication to other steroids should avoid DHEA. For instance, women with any estrogen positive cancers, individuals with liver dysfunction, insulin resistance could be worsened for those with diabetes and it may have central nervous system effects so those with psychiatric disorders may want to avoid DHEA. It also seems that women with elevated testosterone as a result of polycystic ovary syndrome would be harmed more than helped by DHEA. Those already on any hormone replacement should avoid additional hormones.
What are potential side effects?
As with any increasing androgens, the potential side effects are oily skin, acne, hot flashes and increased hair growth in a male pattern. In high enough doses or potentially if someone is very sensitive other significant risks are deepening of the voice, clitoral enlargement, and breast size reduction to name a few. Interestingly enough, in the Bloch et al (2013) paper the side effects were similar in the DHEA as in the placebo groups with short-term use.
Who might be helped by DHEA?
The studies seem to suggest that postmenopausal and potentially peri-menopausal woman, or any woman with low hormone levels as the cause of low libido, could benefit by DHEA supplementation.
Bloch M, Meiboom H, Zaig I, Schreiber S, Abramov L (2012). The use of dehydroepiandrosterone in the treatment of hypoactive sexual desire disorder: A report of gender differences. European Neuropharmcology, 1-9.
Callahan T., Caughey A., Heffner L (2004) Blueprints, Obstetrics and Gynecology. Pages 202-204.
Clayton AH, (2010). The pathophysiology of hypoactive sexual desire disorder in women. Int J. Gynecol.Obstet. 110, 7-11.
Davis SR, Davison SL, Donath S, Bell RJ et al (2005). Circulating androgen levels and self-reported sexual function in women. JAMA 294, 91-96.
Davis SR, Moreau M, Kroll R, Bouchard, C, Panay N, Gass M, Braunstein et al (2008). Testosterone for low libido in postmenopausal women not taking estrogen. NEJM. 359, 2005-2017.
Genazzani AR, Stomati M, Valentino V, Pluchino N, Poti E, Casarosa e, Merlini S, Giannini A, Luisi M. (2011). Effect of 1-year, low dose DHEA therapy on climacteric symptoms and female sexuality. Climacteric 14, 661-668.
Hackert L, Heiman JR (2002). Acute dehydroepiandrosterone (DHEA) effects on sexual arousal in postmenopausal women. J Womens Health Gender Based Medicine 11, 155-162.
Kritz-Silverstein D, Von Muhlen D, Laughlin GA, Bettencourt R (2008). Effects of dehydroepiandrosterone supplementation on cognitive funtion and quality of life: The DHEA and wellness (DAWN) trial. J Am Geriatric Society 56, 1292-1298.
Morales AJ, Haubrich RH, Hwang JY, Asakura H, Yen SSC (1998). The effect of six months treatment with a 100mg daily dose of dehydroepiandrosterone (DHEA) on circulating sex steroids, body composition and muscle screnght in age-advanced men and women. Clin Endocrinol. (Oxf), 49, 421-432.
Munarriz R, Talakoub L, Flaherty E, Giola M, Hoag L, Kim NN, Traish A, Goldstein I, Guay A, Spark R (2002). Androgen replacement therapy with dehydroepiandrosterone for androgen insufficiency and female sexual dysfunction: Androgen insufficiency and female sexual dysfunction: Androgen and questionnaire results. J Sex Marital Ther 28, 165-173.
Panjari M, Bell RJ, Jane F, Wolfe R, Adams J, Morrow C, Davis SR (2009). A randomized trial of oral DHEA treatment for sexual function, well-being and menopausal symptoms in postmenopsual women with low libido. J Sex Med 6, 2579-2590.
Schmidt PJ, Daly RC, Bloch M, Smith MJ, Danaceau MA, Simpson St Clair L, Murphy JH, Haq N, Rubinow DR (2005). Dehydroepiandrosterone manotherapy in midlife onset major and minor depression. Arch Gen Psychiatry 62, 154-162.
Shifren JL, Baunstein GD, Simon JA, Casson PR, Buster JE, Redmond GP, Burki RE, Ginsburg ES, Rosen RC, Leiblum SR, Caramelli KE, Jones KP, Daugherty CA, Mazer NA (2000). Transdermal testosterone treatment in women with impaired sexual function after oophorectomy. NEJM 343, 682-688.
Simon J, Braunstein G, Nachtigall L, Utian W, Katz M, Miller S, Waldbaum A, Bouchard C, Derzko C, Buch A, Rodenberg C, Lucas J, Davis S (2005). Testosterone patch increases sexual activity and desire in surgically menopsual women with hypoactive sexual desire disorder. J Clin Endocrinol Met 90, 5226-5233.
Strous RD, Maayan R, Weizman A (2006). The relevance of neurosteroids to clinical psychiatry: from the laboratory to the bedside. Eur Neuropsychopharmacol. 16, 155-169.
Turna B, Apaydin E, Semerci B, Altay B, Cikili N, Nazli O (2005). Women with low libido: Correlation of decreased androgen levels with female sexual function index. Int J Impot Res 17, 148-153.
*You should consult with a qualified healthcare provider regarding your specific health risks/benefits before making decisions about therapies and/or health conditions.
The recent Bangladesh garment factory tragedy reminded me once again how much our lives impact the lives of others thousands of miles away. In our daily lives, we simply walk in a store and purchase items at low cost without any thought to the cost imposed on others.
While the owner’s of this facility were aware that cracks were forming, they used fear tactics, threatening job loss, if employees didn’t come to work that fateful day. Greed caused, as of a report today (NPR, 05/13/13), more than 1,127 people to lose their lives. At least charges were brought against the owner but that isn’t any condolence to the families who lost love one’s.
We, as in the collective Western World ‘WE’ can’t continue to distance ourselves and plead ignorance. The companies that manufacture products under poor conditions can’t say “we didn’t know what was taking place in these factories”. I’m sorry, but if your products are manufactured somewhere you need to know the circumstances under which it is produced, you are ultimately responsible. Corporations need to stop treating people as expendable.
However, as consumers we are ultimately responsible. We can refuse to spend our money on items that cause undue suffering anywhere along the supply chain. We can demand that others are treated fairly and provided fair wages and standards of working conditions. We need to be willing to pay a little more for items that are produced under more just conditions. We can seek out locally produced and sourced items to our best ability and we can voice our desire for information about the conditions that our fellow humans exist. Some of these work circumstances are essentially slavery. In fact, we all have any number of slaves working for us depending on how extravagantly we live. You can calculate your own number of slaves at http://slaveryfootprint.org/. I have 29.
Admittedly, even when you try, it is difficult. I have tried not to buy anything new, choosing to purchase from used clothing stores. Around the Tri-valley I frequent any number of thrift stores for various causes as well as Picket Fences in Livermore and Savvy Seconds in Pleasanton. Sometimes though I would like to purchase new items made in a responsible and sustainable manner. From what I’m finding though, well, it’s hard to find!
I’ve started trying to search out shops with clothing made local or made by collectives internationally who benefit directly from the clothing, and if at all possible also sustainably produced. One I like for children’s clothes is Tomat. They are made in the US with organic cotton and it’s a business operated by a mom. Certainly this route is a fair bit more costly than buying from your local big box retailer, but you can purchase them in good conscience and that to me is priceless.
Have been trying to find other potential places to purchase items for myself. Searching Etsy I found a few clothes designers who sew special order sizes. I’ve also found a few potential on-line companies with some interesting finds:
If you have any retailers to add, please don’t hesitate to let me know about them, I am always on the lookout.
…to hormone replacement therapy and anti-depressants
Exploring our local health food store yesterday, Van’s, reminded me to complete and post this article I’ve been working on way too long. It also reminded me how many “natural” products are out there that tout miracles for menopausal symptoms.
On daily basis women with menopausal symptoms often ask me if there are any “natural” remedies for their hot flashes and mood issues. It seems lately that I’ve had more and more women asking this question. The only thing that I have to offer them is hormone replacement therapy, some women just aren’t the best candidates for this method, and anti-depressants have their own list of unpleasant side effects.
Especially for women who are just starting the menopausal transition or having milder symptoms, natural and/or herbal remedies may be an ideal option but I wasn’t familiar enough to recommend anything in particular. In an attempt to come up with some alternatives, I headed to the literature.
The least invasive and least risky are the behavioral therapies. Few studies have looked at these methods of managing symptoms but a couple studies show promise with a particular kind of breathing, paced respiration. This method of slow, deep breathing has been compared with progressive muscle relaxation, doing other relaxing leisure activities, and biofeedback. In all cases, the paced respiration group demonstrated decreases in hot flashes (Kronenberg et al, 2002). This is an easy practice that women can incorporate into daily life to help cope and reduce the hot flashes experienced in menopause, especially if mild severity.
While I am very much a believer in acupuncture for many things, its efficacy in menopause symptoms is still in question. There is one study that looked at acupuncture and one issue with the study is that the treatment and control groups may’ve been too much alike; one received standard acupuncture and the other a shallow acupuncture treatment, but at the same points. From pre-treatment to post-treatment, both groups showed a significant decrease in hot flashes but between the two there was not a difference (Kronenberg et al, 2002). Since both groups showed an improvement following treatment, this actually suggests that acupuncture or pressure may work to help alleviate the symptoms.
As mentioned previously, the only tools I have available are hormone replacement and anti-depressants, which have their issues. I was hoping a review of the literature would reveal more herbal options to offer but sadly it is still limited. While many things have been touted as working: black cohosh, dong quai, evening primrose, ginseng, red clover, vitamin E, chasteberry, soy, wild yam, and progesterone creams, there are limited remedies with proven evidence that they are beneficial.
It seems that only one really has any evidence, that being black cohosh, and another soy, has promising but mixed results. The others seem to have no clinical benefit, at least based on current literature. (Kronenberg et al, 2002; Low Dog, 2005) and while women using progesterone cream seemed to note “improvement”, it came with a risk of postmenopausal bleeding and subsequent endometrial biopsies (Leonetti et al., 1999). This finding suggests any estrogen or progesterone-containing product over the counter may influence the uterine lining. In women who still have a uterus, when physicians prescribe these medications, both are given in an amount to attempt and reduce the risk of uterine lining stimulation that can result in development of endometrial cancer. Therefore, I tend to caution my patients who are using over the counter products to avoid those that are basically hormones and carry those same risks.
Black cohosh, in the form of Remifemin, is relatively well studied and has the most support for its use. A review article found 5 controlled studies and all found that black cohosh reduced psychological symptoms, improved vaginal epithelium, and decreased measures of menopausal symptoms, particularly hot flashes and sweating (Low Dog, 2005). It does seem to be helpful for a multitude of symptoms but a concern I have is that no studies exist on long-term use regarding hormonal stimulation on breast or uterus, so women with a history of breast cancer or at risk for endometrial cancer I would advise use with caution.
Ironically, while working on reviewing the literature for this post our pharmacy department came out with a memo that addressed soy as a recommended “pharmaceutical” for reducing mild menopausal symptoms. The studies I found suggest only modest benefits, mostly for hot flashes, and the benefits by 6 weeks decreased. Interestingly, there was a 50-60% reduction in symptoms in both the soy and placebo groups in the studies. Foods containing soy certainly seem a safe addition and may help with mild symptoms so supplementing your diet with beans is a benign way to start. However, it is difficult to make a statement about high-dose isoflavones, with the most common doses being between 50-150mg daily and in women with a history of breast cancer it’s best avoided (Umland, 2008). Like most things, the lowest dose possible to help with the symptoms should be the guiding principle.
While less than I had hoped to offer patients with menopausal symptoms, at least this provides a few options to suggest to my patients with some confidence thanks to support from the research.
Kronenberg F and Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: A review of randomized controlled trials. Annals of Int Med. 2002;137:10:805-813.
Leonetti HB, Longo S, Anasti JN. Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstet Gynecol. 1994;94:225-8.
Low Dog T. Menopause: A reiew of botanical dietary supplements. Am J of Med. 2005;118:12B:98S-108S.
Umland EM. Treatment strategies for reducing the burden of menopause-associated vasomotor symptoms. Suppl to J Managed Care Pharm. 2008;14:3:S14-S19.