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From the Townsend Letter
December 2018

Erectile Dysfunction:
An Integrative Approach to Making it Work

by Dr. Geo Espinosa, ND, LAc, IFMCP, CNS
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Botanical and Natural Support for ED
Adaptogens are nontoxic agents that increase resistance to stressors and prevent fatigue. There are well-documented adverse effects of stress on libido and sexual function to suggest that adaptogens might have a role in counteracting stress-induced sexual dysfunction. In my clinical experience, adaptogens are the primary botanical approach in treating ED.
Panax or Asian ginseng
(also known as Korean or Chinese ginseng) is considered a "heating" or stimulating herb in Chinese traditional medicine, though the degree to which it is energizing vs. calming (as a result of counteracting the harmful effects of stress) appears to have been lost in translation as Asian ginseng moved from traditional Chinese medicine to being a Western commodity, according to Dr. Eric Yarnell in the book, Integrative Sexual Health.16
A meta-analysis of seven clinical trials using steamed, dried roots of four-year-old Asian ginseng roots (known as red ginseng or hóng shēn) in men with ED of various types found that overall red ginseng was effective compared to placebo. Doses ranged from 1,000 mg daily to 600 mg tid.16
Withania somnifera
(ashwagandha) root, a member of the Solanaceae family, also has a long history of use and would be considered an adaptogen. As its Latin binomial suggests (somnifera coming from the Latin word for sleep), it is more clearly a calming or relaxing agent. It has a strong history of use as a sexual tonic, particularly for men, despite the fact that in a randomized, single-blind trial, crude root powder 2 g tid was not superior to placebo at improving psychogenic ED in 86 men, The short duration of this trial of 60 days was probably a major limiting factor as adaptogens typically take more than three months to start to have noticeable effects.17 A good dose ranges from 500 mg two times a day to 2 grams three times a day for at least three months.
Rhodiola rosea
, like ginseng, is another popular research-supported adaptogen used for centuries to increase physical endurance and longevity, as well as to manage fatigue, depression, and impotence.  A multitude of published clinical studies supports rhodiola's well-known and established benefits to energy levels, stress management, immune function, and cellular health, as well as its role as a potent antioxidant. Given the strong connection between stress and increased sexual dissatisfaction, supplementation with this botanical becomes all the more important.
In one study, rhodiola was given to 56 young physicians on night call, when there is typically a significant decrease in physical and mental performance. At the conclusion of the study, the researchers found a statistically significant reduction of stress-induced fatigue after just two weeks of supplementation with rhodiola. No side effects of rhodiola were reported.18
Another well-designed study evaluated the one-time use of the same rhodiola in 161 male military cadets undergoing sleep deprivation and stress. The results showed that rhodiola was more effective than placebo in fighting the effects of fatigue.19
The dose for rhodiola is 500 mg once to two times a day.
BDNF EssentialsEpimedium or Horny goat weed
and icarrin, a flavonoid found in it, have been repeatedly shown in preclinical trials to act as phosphodiesterase-5 inhibitors with similar mechanisms of action to the pharmaceuticals sildenafil, tadalafil, and vardenafil.20

Epimedium should be considered a long-term tonic medicine for men with erectile dysfunction and low libido. It takes one to three months to start to take effect and gets stronger with long-term use in most cases. A typical dose would be 1-2 g three times daily.
(L-Cit) is known to increase nitric oxide (NO) production via the increase of L-arginine (L-Arg) concentration in the blood and improve endothelial dysfunction in cardiovascular diseases. A small study of 24 patients reported improvement in the erection hardness score in the L-citrulline group compared to the placebo arm. All patients reporting an erection hardness score improvement from 3 to 4 reported being very satisfied.21 The dosage for L-citrulline is 750 mg, once to two times a day.
is a natural antioxidant with benefits for a variety of age-related challenges, including circulatory and sexual health concerns. Studies indicate that resveratrol supplementation may help to ward off atherosclerotic changes associated with imbalanced cholesterol while enhancing nitric oxide circulation, erection quality, blood testosterone levels, and sperm count and motility. The result is safe support for superior erectile function and endothelial health.22
. The analysis shows that pomegranate is abundant in the antioxidant anthocyanin, a flavonoid that enhances erection-stimulating nitric oxide bioavailability while promoting arterial health and optimal penile blood flow. As a result, controlled trials have revealed that supplementation with pomegranate may be able to facilitate firm erections and enhanced sexual performance in men with both cardiovascular and erectile function concerns – two challenges that often present simultaneously.23 The dosage for pomegranate extract is 300 mg once or twice a day.
Dehydroepiandrosterone (DHEA).
In a randomized clinical trial, men in the DHEA arm experienced significant improvement compared to placebo participants whose results were unchanged or worse. There was no change in testosterone or the serum biomarker PSA. Mean prostate size decreased slightly in the DHEA arm and increased in placebo.24 The dosage for DHEA is 50 to 100 mg once a day.


SUPPORTThe Townsend Letter is dedicated to examining and reporting on functional and integrative medicine. Our editorial content depends on support from readers like you, and we would appreciate your help to keep this content forthcoming. Please take this opportunity to contribute $50, or choose one of the other amounts listed on the next page, and ensure that our independent voices keep up the good fight against the skeptics, who would like to silence us and eliminate your medical freedoms.

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10.    Morales A, et al. Clinical safety of oral sildenafil citrate (VIAGRA) in the treatment of erectile dysfunction.
Int J Impot Res. 1998;10(2):69-73; discussion 73-4.
11.    Padma-Nathan H. Efficacy and tolerability of tadalafil, a novel phosphodiesterase 5 inhibitor, in treatment of erectile dysfunction.
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J Am Coll Cardiol. 2011;58:1378-1385
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J Endocrin Investigation. June 2009;32(6):542-545.
15.    Esposito K, et al. Effects of intensive lifestyle changes on erectile dysfunction in men.
J Sex Med. 2009 Jan;6(1):243-50.
16.    Bartlik B, Espinosa G, Mindes J (eds.).
Integrative Sexual Health. Oxford University Press. 2018.
17.    Mamidi P, Thakar AB. Efficacy of ashwagandha (Withania somnifera Dunal Linn) in the management of psychogenic erectile dysfunction.
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20.    Chiu JH, et al. Epimedium brevicornum Maxim extract relaxes rabbit corpus cavernosum through multitargets on nitric oxide/cyclic guanosine monophosphate signaling pathway.
Int J Impot Res. 2006;18:335-342.
21.    Cormio L, et al. Oral L-citrulline supplementation improves erection hardness in men with mild erectile dysfunction.
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22.    Fukuhara S et al. Vardenafil and resveratrol synergistically enhance the nitric oxide/cyclic guanosine monophosphate pathway in corpus cavernosal smooth muscle cells and its therapeutic potential for erectile dysfunction in the streptozotocin-induced diabetic rat: preliminary findings.
J Sex Med. 2011 Apr;8(4):1061-71.
23.    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 Nov-Dec;19(6):564-7.
24.    Reiter WJ, et al. Dehydroepiandrosterone in the treatment of erectile dysfunction: a prospective, double-blind, randomized, placebo-controlled study.
Urology. 1999 Mar;53(3):590-4; discussion 594-5.

Dr. Geo Espinosa is a naturopathic doctor, licensed acupuncturist and certified functional medicine practitioner recognized as an authority in holistic urology and men's health. He is faculty and holistic clinician in Urology at New York University Langone Medical Center and faculty at the Institute for Functional Medicine (IFM). As an avid researcher and writer, Dr. Geo has authored numerous scientific papers and books including co-editing the Integrative Sexual Health book, Oxford University Press, and author of the best selling prostate cancer book: Thrive, Don't Only Survive. Dr. Geo is the Chief Medical Officer (CMO) and formulator at XY Wellness, LLC and lectures internationally on the application of science-based holistic treatments in urological clinics. On his free time, he enjoys writing on his popular blog,, spending time with his wife and three kids and practicing the Israeli martial art, Krav Maga.

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