Many women typically experience a significant reduction in sexual desire during the late perimenopausal and early postmenopausal stages, with the biggest decline in sexual desire occurring from three years prior to two years after the final menstrual period. Despite being a prevalent female complaint, currently no standard treatment for low sexual desire exists. Herbal medicines have been used therapeutically all around the world, and are an important component of Traditional and Complementary Medicine. There have been numerous trials and pharmacological studies of specific herbal preparations related to the treatment of low sexual desire.
Low sexual desire, or decreased libido, is one of the most prevalent sexual complaints in menopausal females. Many women find that their interest in sex as well as the intensity of their sexual desire gradually decrease with age. This is attributed to hormonal and physical changes, as well as sociopsychological factors. Indeed, menopause is often associated with a variety of distressing symptoms such as irregular or heavier menses, hot flushes, night sweats, anxiety, depression, insomnia, fatigue, vaginal dryness, and urinary symptoms, all of which can contribute to low libido. In some cases, the decrease or loss of sexual desire can be very distressing, yet currently there is no standard treatment for low sexual desire in females. Available treatment options include psychological therapy and pharmacological drugs, but their efficacy remains to be proven. In addition, for many women, the risks associated with pharmacological treatments often outweigh the benefits. A systematic review on the use of complementary medicines (CMs) found that 50.5% of women worldwide reported that they used CMs specifically for their menopausal symptoms, with herbal medicines being the most popular. A large number of aphrodisiac herbal medicines have been studied with regards to male sexuality, yet there is still a need for a review evaluating the efficacy of herbal medicines specifically for low sexual desire in menopausal women.
Female sexuality and menopause
Menopause is a time of biological, social, and psychological change, which may impact on various phases of the sexual response cycle and can lead to sexual dysfunction. Low sexual desire is one of four defined components of female sexual dysfunction, and is the most prevalent complaint related to sexual function in women. Although there are currently no South African statistics, one study has found that between 68% and 86.5% of menopausal women in the United States are affected.
Low sexual desire may be associated with feelings of low selfesteem, discontent, anger, and depression. One European study found that clinicians are reluctant to discuss female sexual dysfunction, as they felt it might shift the focus of the consultation to a problem for which they had almost no useful treatment options. These findings emphasise the frustration experienced by both clinicians and patients and further highlight the need for safe and effective treatment options for female sexual dysfunction.
Causes of low sexual desire in menopausal women
The most frequently reported causes include both physical and psychological factors. Some of these factors will be addressed below, but it is important to note that separation between these factors is somewhat artificial, as they are usually interrelated.
– Physical causes
Perimenopause is initially associated with large fluctuations in oestrogen levels, which are largely responsible for the myriad of symptoms seen. When menses cease due to ovarian failure, oestradiol levels drop, and oestrone becomes the principal form of oestrogen. Decreasing oestrogen levels lead to vaginal dryness and thinning of the mucosa, resulting in an increased risk of atrophic vaginitis and dyspareunia. Physiological and anatomical changes in the bladder and pelvic floor also occur, and many women experience a variety of urinary symptoms, which further exacerbate sexual dysfunction. During menopause, androgen (testosterone, androstenedione, dihydrotestosterone, and dehydroepiandrosterone) levels decline gradually to approximately half of premenopausal levels. Androgens are important for the maintenance of the female sex organs, and testosterone in particular has an effect on sexual desire; decreased levels of these hormones results in dramatic alterations in genital tissue structure and function. Other physical factors contributing to low sexual desire include sleep disturbances, chronic illness, and certain medications.
– Psychological factors
Depression affects as many as 70 – 90% of women, an d a bi-directional association exists between depression and sexual dysfunction. The pathophysiology can be directly attributed to the changes in neurotransmitter levels that occur, particularly brain dopamine, which forms the core of the sexual excitatory pathway. Indirect mechanisms such as sleep disturbances and low self-image also contribute to the prevalence of low sexual desire. In addition, low sexual desire is a recognised side-effect of certain antidepressant medications, namely SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs). The use of SSRIs leads to increased levels of cortisol, prolactin, and serotonin, which negatively impact sexual function. Research suggests that bupropion and other newer antidepressants exhibit a more favourable sexual dysfunction profile. Other psychological factors associated with low libido include anxiety, chronic daily stress, negative body image, and a history of sexual abuse. Relationship factors also remain an important contributor to libido.
Herbal medicine for low sexual desire
Numerous studies have been conducted on the use of herbal medicines for menopausal symptoms. However, only limited studies could be found evaluating their efficacy for the treatment of low libido specifically.
Phytoestrogens are nonsteroidal plant compounds that have a weak oestrogenic activity, and are a commonly used alternative to HRT. In the low oestrogen setting encountered in peri and postmenopause, phytoestrogens act as selective oestrogen receptor modulators (SERMs). They appear to have a greater affinity for beta oestrogen receptors, exerting their effects on skin, bone, and blood vessels and on the central nervous system without stimulating breast or uterine tissue, thereby reducing the undesired effect oestrogen can have on these body systems.
– Red clover (Trifolium pratense)
Red clover is a phytoestrogen that contains dadzein, irilone, and genistein; however, it is also rich in methylized precursors (biochanin A, formononetin, prunetin, and glycitein). Clinical research supports the positive effects of red clover isoflavones in menopausal women on vasomotor symptoms, as well as vaginal and sexual health. The isoflavones in red clover are deemed safe for women to use and do not promote the growth of cancer cells.
– Hops (Humulus lupulus)
Hops is a commonly used supplement for insomnia and menopausal symptoms. It contains various bio-active compounds such as 6-prenylnarigenin (6-PN) and 8-prenylnarigenin (8-PN), the latter being considered a powerful phytoestrogen. Hops is non-toxic and appears to play a protective role against breast cancer by modulating oestrogen metabolism as well the chemical oestrogen carcinogenesis pathway. While animal studies have shown hops to have aphrodisiac effects, there are very few clinical studies conducted on the use of hops for sexual disorders. According to one study conducted on postmenopausal women, topical application of a gel containing hops extract, hyaluronic acid, liposomes, and Vitamin E proved effective in reducing vaginal dryness and atrophic vaginitis. Sparavigna conducted a similar study on the same gel and found its moisturising effects to be quick-acting and long-lasting. The authors of a review on medicinal plants for female sexual dysfunction suggest that hops may help with desire disorders; however, there is a need for further clinical studies to be conducted.
– Maca (Lepidium meyenii)
Maca, a plant of the mustard family, has been shown to reduce vasomotor menopausal symptoms by increasing oestrogen production while simultaneously lowering cortisol levels. Several in vivo studies have shown that maca may improve sexual behaviour and enhance androgen-like effects in rats. A systematic review conducted by Shin found only limited evidence available, and only one study relating to sexual dysfunction in postmenopausal women. This study revealed maca to be effective in improving sexual desire as well as psychological symptoms of anxiety and depression after six weeks of use. Maca has also been shown to be helpful in alleviating SSRI related sexual dysfunction; however, this result appears to be a dose related effect. Further large scale studies need to be conducted to confirm these findings.
– Black cohosh (Cimicifuga racemosa)
Black cohosh is one of the most commonly used herbal treatments for symptoms associated with menopause. Its effects are thought to be due to a variety of compounds, in particular triterpene glycosides that have serotoninergic, noradrenergic, dopaminergic, and GABAergic actions on the hypothalamus. Extracts from the rhizome do not appear to have an oestrogenic effect; in fact, use is associated with a reduced risk of developing breast cancer. This herb is therefore thought to be safe for use in breast cancer patients. Efficacy studies on black cohosh for menopausal symptoms have produced mixed results. Remifemin, a standardised pharmaceutical preparation of black cohosh, has shown efficacy for menopausal symptoms in at least four RCTs, one of which showed equivalence with an oestradiol HRT patch. However, only one RCT could be found that specifically evaluated sexual symptoms, and showed that black cohosh use over an eight week period produced significant improvements in this sphere, amongst others. Black cohosh appears to be well tolerated and is generally considered safe. Minor side effects such as nausea, vomiting, and headaches, and dizziness have occasionally been reported.
– Maritime pine bark (Pycnogenol®)
Pycnogenol® is produced from the outer bark of Pinus pinaster Aiton subsp. atlantica. It has strong antioxidant and anti inflammatory properties and has been found to significantly reduce vasomotor symptoms and improve the quality of life of menopausal females. Pycnogenol® contains more than 40 functional components, including bioflavonoids. Based on its constituents, it is unlikely that Pycnogenol® exerts a hormonal effect by acting as a phytoestrogen, and the positive results observed are rather thought to be due to the beneficial effect it has on neurons and blood vessels, as well as its antioxidant effects. The active compounds stimulate endothelial NO production, which increases genital blood flow. Their study showed that Pycnogenol® ameliorated all symptoms associate d with menopause, including sexual symptoms, in a group of perimenopausal females. Pycnogenol® has GRAS (generally recognized as safe) status, based on data obtained from 70 clinical studies (Oliff, n.d.).
– Tribulus (Tribulus terrestris)
Tribulus has shown beneficial aphrodisiac effects in a number of animal and human studies. The chemical substance protodioscin, derived from this plant, is converted into the androgen dehydroepiandrosterone (DHEA). Evidence shows that improvement in sexual symptoms is accompanied by a significant increase in DHEA levels, without causing an increase in testosterone levels. One recent three month RCT was conducted on the effects of Tribulus in postmenopausal women with sexual dysfunction. The herb produced a statistically significant improvement in a variety of sexual problems, including sexual desire, with no significant adverse effects reported. Other studies conducted in premenopausal women with HSDD also showed efficacy. Tribulus extract is reported to be safe and effective in the treatment of female sexual dysfunction. Possible side effects include mild gastrointestinal symptoms.
– Gingko (Ginkgo biloba)
Gingko has been used for thousands of years for its medicinal properties, and is widely available. Ginkgo biloba extract (GBE) enhances blood flow and NO production, and also promotes smooth muscle relaxation, all of which are important components of proper female sexual function. Studies investigating the effect of GBE on female sexual desire have, however, produced conflicting results. The clinical trial conducted by Pebdani showed that GBE significantly improves sexual desire in menopausal women. The authors concluded that GBE has weak oestrogenic properties, and suggested that it can be considered a safe means of improving sexual function in menopausal women.
– Korean red ginseng (Panax ginseng)
Korean red ginseng (KRG) is an herb of the Araliaceae family and contains triterpene saponins called ginsenosides, which are believed to be responsible for its various pharmacological effects, including those on sexual function. Animal studies have reported that KRG has a relaxing effect on the clitoral cavernosal muscle and vaginal smooth muscles, and may have phytoestrogenic effects. Kim conducted a systematic review on the use of ginseng for managing menopausal symptoms. The review only identified a small number of relevant RCTs. KRG extracts induce a statistically significant improvement in sexual arousal, with no severe adverse events reported. The authors of the review did, however, conclude that there are an insufficient number of trials from which to draw definitive conclusions.
Herbal medicines are reported to be the most commonly used CM modality amongst menopausal women. Those women who made use of herbal medicines experienced a significant improvement in menopausal symptoms, including libido. This study offers supportive evidence for herbal medicine as a possible treatment choice.
Although certain herbs are widely used and commonly self prescribed, herbal medicines should fulfil the basic requirements of being safe and effective before being recommended for use. Currently, the general public, and even medical practitioners, may have a poor understanding of the effects of herbal medicines. Indeed, while herbal medicines are often considered safer alternatives, they also may produce adverse effects and potentially cause drug interactions. Herbal medicines made by reputable companies that ensure good manufacturing procedures (GMP) are thus recommended, and their use should be monitored by a qualified practitioner.
Clinical trials related to herbal medicines for sexual desire in menopausal women are limited. The majority of studies available relate to the vasomotor symptoms of menopause, rather than sexual symptoms specifically. A variety of symptom rating scales are used, and an aspect of sexual function is usually included as a small subsection in these scales. Future studies should thus make use of standardised scales to evaluate sexual function, such as the Female Sexual Function Index (FSFI). There are also many considerations when reviewing research related to herbal medicines. It is difficult to conduct meta analysis on these studies due to heterogeneity not only of the studies themselves, but also of the preparation methods and dosages. From the limited evidence available, phytoestrogens (red clover, hops, maca), black cohosh and Pycnogenol® appear to have beneficial effects not only on vasomotor symptoms, but on libido as well. Gingko, tribulus and Korean red ginseng show promising results in the treatment of low sexual desire, but the evidence is limited. Further studies need to be conducted before any definitive conclusions can be made regarding the use of these herbs for treating low sexual desire in menopausal women.
Low sexual desire is a common complaint amongst menopausal women, and this can have a significant impact on quality of life. There are very few conventional treatment options for low sexual desire, and the pharmacological options are associated with adverse effects. Many women turn to herbal medicines as a therapeutic alternative. This review highlights the clinical evidence related to the most commonly used herbal medicines indicated for low sexual desire. Tribulus, black cohosh, Gingko biloba, Pycnogenol®, Korean red ginseng, and the phytoestrogens red clover, hops, and maca all show positive benefits for low sexual desire, yet there is limited evidence available to definitively recommend their use for treating low sexual desire. Further clinical RCTs should be conducted to evaluate the safety and efficacy of these herbal medicines.
Low sexual desire can be defined as a loss of interest in sexual activity over a period of months.
Sexual arousal is described as “a feeling that includes both physi cal and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication, or muscle contractions”.
Perimenopause includes the following stages: early menopausal transition (characterised by variability in the menstrual cycle); late menopausal transition (characterised by frequent anovulation and irregular menses); and the first 12 months of early postmenopause.
Menopause is defined as the physiological termination of menses due to a decrease in ovarian function.
Herbal medicine is the use of medicinal plants to prevent and treat diseases (Mosby’s Medical Dictionary, n.d.), and makes use of herbs, herbal materials, preparations, and products that contain as active ingredients parts of plants, or other plant materials, or combinations thereof.
Herbal medicine for low sexual desire in menopausal women: A clinical review by Janice Pellow and Linda McGrath.