Treating erectile dysfunction (a.k.a. ED; I always wonder how guys named Ed feel about this acronym) is challenging on several fronts.
First, the ED supplement category is the most recalled or penalized area of dietary supplements in FDA history; this is due to lack of testing and good quality control. I tried to shake up the industry a few years ago and force quality- control testing, but to no avail. (Some of the world’s most legitimate, nonbiased quality-control testing agencies did not want to test well-researched ED supplements because they were too worried about how it would appear!) It’s completely insane and shameful, and I am still crazy upset about this. Unfortunately, most people just assume that ED supplements don’t work or are dangerous.
Another challenge is that the stereotype of ED drugs—let’s call it the “Hugh Hefner phenomenon”—clouds the fact that ED is a legitimate medical condition. If more physicians treated it as such, I believe couples would have access to better, higher-quality dietary supplement options.
Finally, the current cost of prescription ED drugs is ridiculously high at $10 to $25 a pill, which makes it the most overpriced drug and the most egregious case of drug price gouging that I have ever come across in my career! The average per pill cost of a prescription ED drug is 20 to 40 times that of an effective supplement, plus these drugs often come with numerous minor toxicities and some serious ones. As a result, according to research done by the pharmaceutical companies themselves, only one-third to one-half of first-time users refill their prescriptions!
What is Erectile Dysfunction?
ED is the inability to achieve or maintain an erection sufficient for intercourse or for other sexual activity. Any heart-unhealthy condition (high bad cholesterol, excess weight, low good cholesterol, inactivity) can contribute to ED, but there are also many other potential causes, including hormonal, neurological, psychological, vascular/cardiovascular, extrinsic (a medication or surgical procedure), disease-related (liver disease, kidney problems, etc.), structural (such as fractures or curvature of the penis), or any combination of these.
ED is very complex and does not just include issues related to erectile function; it also encompasses orgasm and sex drive (libido). Some dietary supplements help more with erectile function while others help more with libido, but ED prescription drugs only address erectile function.
So is ED in the big head or the little head? Just a decade or two ago, experts thought that most cases of ED were caused by psychogenic/psychological factors, but now we know that this is false (only 20 percent of cases are psychogenic). The remaining 80 percent are due to an organic cause (some kind of underlying physical medical condition) or a mix of organic and psychological factors.
The question to work out with your doctor before deciding on a dietary supplement—or any intervention— is whether your ED is mild, moderate, severe, or very severe. This is important because I believe that men with mild to moderate ED have the most to gain from dietary supplements. Men with moderate to very severe ED generally don’t respond as well to supplements and need more aggressive conventional medicines, devices, or procedures.
Home Remedies For Erectile Dysfunction
1. (tie) L-citrulline (free form) 1,500 to 6,000 milligrams a day maximum
Citrulline is derived from the Latin word for watermelon (Citrullus vulgaris). It’s primarily found in watermelon rind, but it’s virtually impossible to get sufficient amounts through diet, unless you like to eat watermelon rind all day long (perhaps after reading this section you might!). It increases nitric oxide levels, which boosts bloodflow to the penis, improving erectile function, especially hardness. Research continues to show that it’s hardness—not size— that matters to partners when it comes to sexual satisfaction. Keep in mind that L-citrulline improves erections but rarely impacts libido and the most tested dose is 1,500 milligrams a day.
Nitric oxide may have antiplatelet effects, which means it acts as a blood thinner, so be careful when combining this with other blood-thinning drugs, like warfarin. It also may cause a slight reduction in blood pressure in some individuals, so check with your doctor about combining this medicine with prescription ED drugs that can significantly drop blood pressure. (You need to have adequate kidney function for this product to work well because the kidneys facilitate the conversion of L-citrulline into nitric oxide by way of L-arginine.)
Although there hasn’t been any research yet looking into combining L- citrulline with prescription ED medicine in general, it seems promising; ED drugs work best when there is a sufficient amount of nitric oxide available, and Viagra works by helping nitric oxide stick around and function better.
There doesn’t seem to be a “best” way to take this supplement, so you can decide whether to down it with or without food or in divided doses during the day. The higher doses can get pricey, so you’ll want to do some comparison shopping to find the best deal. And make sure to give it 1 to 4 weeks to see a difference. Finally, make sure you look for L-citrulline by itself (free form) and not the malate form, which is used for exercise enhancement but has no data yet for ED.
2. (tie) Panax ginseng (or, ideally, Korean red ginseng) 1,800 to 3,000 milligrams a day in divided doses, depending on ginsenoside content
This famous herb improves libido, but it also improves erectile function. Ginsenosides (also known as ginseng saponins or glycosylated steroidal saponins), which are unique to the Panax species, are the primary active ingredients in ginseng, and more than 30 different ginsenosides have been isolated from the root of Panax ginseng. They appear to improve the enzyme reaction that converts L-arginine to nitric oxide in the body, which allows for adequate bloodflow into the penis.
A study published in the Korean Journal of Urology provides some of the best clinical research to date for this supplement: A multicenter, randomized, double- blind, placebo-controlled study of 69 men used a highly concentrated ginsenoside but low-dose overall ginseng product (800 milligrams per day).
After 8 weeks, every single sexual health parameter was significantly improved by Korean ginseng compared with a placebo, including erec-tile function (primary endpoint), sexual desire, orgasmic function, intercourse satisfaction, and overall satisfaction. Furthermore, every single question on the medically validated ED questionnaire (which tracks patients’ subjective assessments of their problems) was improved.
Additionally, there were no significant differences in adverse events reported for ginseng compared with a placebo. The results of this trial should strengthen the clinical evidence for ginseng and the evidence that concentrated ginsenosides are the active or effective ingredients in ginseng when it comes to treating ED.
Here is the catch! This clinical trial used a specialized formulation that was a 50-50 combination of an almost 100 percent concentrated ginsenoside product and a standard extract of more than 8 percent ginsenosides. And it’s not easy to get this kind of product from Korea or China without paying a lot of money for it.
This is the Holy Grail of ginseng! Now all that consumers need is a ginseng supplement like this at a reasonable price. Here’s the dosage that I recommend: 1,800 to 3,000 milligrams per day for a ginsenoside content of 4 to 8.5 percent. For a ginsenoside content of 16 percent or higher, take 600 to 1,500 milligrams per day. Divide whatever amount you opt for into two or three daily doses with or without food and take it for at least 4 weeks .
Some laboratory studies have suggested that ginseng may increase testosterone, but I disagree because this has not been observed in clinical trials, and I have not seen this in any patients. A fascinating mechanism of action of ginseng that I have witnessed is its effect on the brain, and we all know how important your noggin’ is when it comes to sex. By binding to areas that can promote relaxation, improve mood, and impact dopamine receptors, it may stimulate sex drive. (The doctors I’ve been able to convince to try ginseng have called it the “happy pill,” regardless of whether it affected their erections.)
Ginseng also improves energy levels, which can impact libido and erectile function. That stimulant effect may increase blood pressure (it has not been seen in the clinical studies), so anyone with high blood pressure should be vigilant. Conversely, it’s also being studied to help lower blood pressure—go figure! Regardless, it’s important to be aware of this potential side effect. Also, there have been rare drug interactions with an older drug class known as MAO (monoamine oxidase) inhibitors (a type of antidepressant), and the research is controversial on whether it interacts with the blood thinner warfarin. Personally, I would not take this product if I were on warfarin, even if the overall research suggests it is probably safe.
One last word of warning: There are serious quality control and contamination issues with Panax ginseng, so once you’ve found a company whose products you’re interested in, make sure it has verified the ginsenoside content and checked its supplement for heavy metal contaminants.
3. (tie) L-arginine aspartate 2,800 milligrams a day and Pycnogenol 80 milligrams a day
L-arginine is the intermediary step between L-citrulline and nitric oxide, which increases bloodflow and possibly erectile function. The kidneys convert L- citrulline to L-arginine, which is then converted to nitric oxide. But you’d really need to take megadoses of L-arginine as a dietary supplement to see an impact on erectile function.
That’s because the liver and intestines remove huge quantities of L-arginine when the supplement is taken and very little ends up being converted to nitric oxide (your organs take a more hands-off approach, if you will, with L-citrulline, allowing more to be converted to nitric oxide).
But the news isn’t all bad. Multiple studies have shown that the combination of L- arginine aspartate and Pycnogenol can improve erectile function. The drawback is you have to take several pills a day and it’s not cheap, but there is always the option of trying fewer pills at first (this is true of any supplement). One of the best-selling products is called Prelox; another is EDOX. In fact, Prelox is one of the only dietary supplements for ED that was studied in a 6-month clinical trial against a placebo! The results (increased orgasmic function, sexual desire, intercourse, and overall satisfaction) were not dramatic, but it’s still one of the best-researched options on the market.
Just like with L-citrulline, you need to be careful about combining any supplement that increases nitric oxide levels with prescription ED drugs because both can cause a drop in blood pressure, so I would not combine them without your doctor’s approval.
4. Tongkat ali
Tongkat ali (Eurycoma longifolia) comes from a plant or a common shrub found along the slopes of hilly areas in the Malaysian rainforest, and there is preliminary human data showing that 200 milligrams per day might improve various aspects of male health, including sex drive, testosterone, and sperm quality and quantity.
The product that has the most research—and the only one with real clinical data—is the standardized water-soluble extract of Eurycoma longifolia root called Physta (from Biotropics Malaysia). Another study with Physta (300 milligrams per day for 12 weeks) showed improvement in erectile function and libido.
Maca (Lepidium meyenii) had early promising research, but it seems to have dropped off. I have always called maca the pride of Peru! It’s a plant that grows only at higher elevations in the central Peruvian Andes. There have been multiple clinical studies with maca, and about half have shown an improvement in sexual desire for men and sexual function for women. It has not been standardized in studies, so all I can tell you is that 1,500 milligrams worked as well as 3,000 milligrams in a study completed more than 10 years ago in Peru.
It has not been found to raise testosterone or estrogen, which means it probably works by some unidentified central (brain) activating mechanism, if it truly works. I definitely think it does something to slightly improve libido and sexual function, and it appears to be safe as maca is used widely in Peruvian culture. There is no research on whether it should be taken with or without food, and no serious drug interactions have been reported, but, again, it only has several preliminary clinical trials.
6. Horny goat weed
Horny goat weed (Epimedium sagittatum) is a tacky name, but the research on this supplement is increasing. Unfortunately, quality control is a major problem. There is a compound in this herb known as icariin that has been shown in laboratory studies to have a similar mechanism of action as prescription ED drugs (making nitric oxide stick around longer), but I don’t believe it’s anywhere near as effective. The other problem is that there still hasn’t been a good clinical study completed, but this will happen soon.
What Supplements Are Useless For Treating Erectile Dysfunction?
Yohimbine HCL is the active ingredient found in the bark of a West African tree. Many supplement manufacturers sell yohimbe, the bark that supposedly contains yohimbine HCL, but the products, in many cases, have little to no—or variable—quantities of yohimbine HCL in them. In other words, when you buy the supplement yohimbe, you may or may not be getting any active ingredient.
All of the positive data regarding yohimbine HCL came from studies that evaluated the active ingredient in drug form, not as a supplement. Yohimbine HCL works and can be tried in rare cases (Viagra and other drugs work 10 times better). I say in rare cases because it’s dangerous.
Most dietary supplements that claim to contain yohimbine HCL have serious quality-control problems and are just as dangerous. Side effects for both the drug and supplements include headache, sweating, nausea, dizziness, nervousness, tremors, sleeplessness, antidiuresis (can’t pee), and elevated blood pressure and heart rate. It should not be used by anyone who is taking anti-depressants or other mood-altering drugs or who has kidney disease or specific cardiovascular, neurological, or psychological issues. In short, I would never take this supplement or the drug!
This is the only official prohormone (a compound that gets converted in the body into a hormone, such as testosterone or estrogen) that’s allowed to be sold in supplement form. (Other prohormone supplements were banned by the FDA many years ago because of safety concerns.)
The thing about DHEA is that it can increase estrogen levels in men as much as it increases testosterone when taken at higher doses (100 milligrams or more). (Those athletes who were taking DHEA for athletic performance enhancement many years ago were probably getting more in touch with their feminine side!)
The prescription drug testosterone does everything DHEA can do—and more— and it’s safer and smarter. There’s a saying I trot out at lectures: “If you want to go to the Super Bowl, don’t try and sneak in the back door, just buy a ticket.” In other words, you’re better off just taking testosterone. Studies have also shown that DHEA can lower your good (HDL) cholesterol, which is not heart healthy (what’s good for the heart is good for the penis!).
Don’t mess around with this herbal DHEA copycat. Just get a prescription of testosterone. Manufacturers claim it increases testosterone, but human studies have failed to demonstrate that.
Again, human studies have failed to demonstrate that this herb/spice supplement increases testosterone consistently, contrary to manufacturers’ claims. In fact, in one study it actually significantly reduced levels of free testosterone! Some experts are pushing it as an ideal substitute for testosterone replacement therapy for men, but the studies are so weak. Now, if you buy fenugreek seeds (not concentrated pills) and just use them once in a while in your diet, they may slightly lower cholesterol because they have fiber in them.
This compound helps with energy production in the body, and it may also play a role in repairing injuries. There has been a lot of research with it in regard to reducing fatigue and improving sexual function, but most of the studies are in the area of male fertility.
However, although it has a good safety record, it’s very expensive and the required dose is huge. In one older clinical trial, it took 4,000 milligrams (that’s several pills a day) to get a questionable improvement in sexual response. L-carnitine, in my personal experience, rarely improves ED beyond what a placebo or lifestyle changes can accomplish.
The majority of the research on ginkgo and ED was done with individuals who were also on prescription antidepressants, which are a known cause of sexual dysfunction for many people. In one of the better studies, researchers saw no difference between ginkgo versus a placebo, and side effects included increased risk of bleeding and potentially increased blood sugar levels.
Zinc is commonly advertised for male sexual health because there are claims it can improve testosterone levels (sorry, this is only true in super-rare cases of profound zinc deficiencies). Some bone-headed experts recommend megadoses of zinc for ED (80 to 100 milligrams daily), but the evidence has demonstrated that such large amounts may lead to prostate-related problems, including benign prostatic hyperplasia and cancer.
It also may increase the risk of hospitalization for uri-nary tract infections and kidney stones. In fact, in one of the largest studies of zinc supplements in medicine (a Harvard study), researchers found a significantly higher risk of advanced prostate cancer in men consuming large amounts of zinc supplements.
In Canada and some other countries, there are now restrictions on dosages of over-the-counter zinc pills. In other words, this supplement does nothing for sexual health.
What Lifestyle Changes Can Help With Erectile Dysfunction?
Heart healthy = penis healthy!
Any time the risk of heart disease is reduced through lifestyle changes penis health is improved. In the official ED treatment guidelines for European doctors, published in the medical journal European Urology, lifestyle changes were considered the top evidence-based treatment for ED (they can be used along with conventional medicine or by themselves). When will this finally be recognized in the United States?
Cardiovascular disease is the number one killer of men and women and, of course, the number one cause of sexual dysfunction and reduced erections in men. Erectile or sexual dysfunction can be an indicator of a future life- threatening disease, especially in younger men.
After all, the same type of cells that line coronary blood vessels also line the penile artery. The artery itself is just 1 to 2 millimeters in diameter, about the same as a coffee stirrer; the blood vessels that supply the heart (coronary arteries) are 3 to 5 millimeters in diameter, similar to a regular straw, and the blood vessels that supply the brain (carotid arteries) are 4 to 6 millimeters in diameter, which is the size of two straws combined. Most research suggests that the penis runs into trouble before the heart does because the “pipes” that lead to it are smaller and more vulnerable to damage.
If a man has erectile issues early in life, there are many doctors who will refer that patient to a cardiologist, and I could not agree more. You will never look at a coffee stirrer the same way again, and you shouldn’t because it’s a vivid reminder of how easy it is to harm your sex life. Men, take care of the one and only coffee stirrer you’ve got!
Drink in moderation
Alcohol in excess is a sedative, which also makes a man’s penis soft and weak. However, a small amount (one to two drinks, maximum) of alcohol increases the release of nitric oxide in the blood vessels, which slightly improves bloodflow to the penis.