Pomegranates are a fruit known not only for their well-regarded taste but also their health benefits (Figure 27-2). In historical times the pomegranate was linked with fertility due to its abundance of seeds and it was used for many other medicinal purposes [19]. Pomegranate extract has been shown to benefit individuals suffering from a wide array of illnesses, including coronary artery disease, peripheral vascular disease, benign prostatic hypertrophy, and even infertility in men [20–22]. Atherosclerotic plaques can, over time, lead to reduced ability to deliver blood flow to areas of the body more distal to the heart, including the limbs in the case of peripheral arterial disease and the sex organs as in erectile dysfunction (ED). Pomegranate’s ability to prevent arterial plaques occurs via several mechanisms. First, it blocks the expression of NF-kB, thus reducing inflammation that plays a key role in plaque development. Second, it lowers the activity of serum angiotensin-converting enzyme , reducing blood pressure that can lead to damaging of arterial intima. Third, it is a potent antioxidant due to high concentrations of tannins and flavonoids found in the peel that prevent peroxidation of lipids that lead to plaque development [20, 21].

Although it might not seem that these aspects of pomegranate make them a true aphrodisiac, cardiovascular health is essential in maintaining a healthy sexual drive, hormone production, and the ability to both attain and maintain erections in men. Indeed men and women who look after their cardiovascular health have much healthier sex lives into their older ages via improved ability and mood than those who neglect this aspect of their health [23]. Turk et al. noted in a rat study that groups of rats receiving medium and high doses of pomegranate nutrients had statistically significant increases in sperm concentration, and the high dose group had significant decreases in the production of abnormal sperm [19, 24].

Like pomegranate , other foods that are reputed to have sexually enhancing properties likely act through improving cardiovascular health. Foods rich in antioxidants such as avocados, various nuts, olive oil, figs, arugula, and cherries are thought to enhance sexual desire and function [25–30]. Red wine has also been popularly associated with enhanced sexual desire. Recent research has revealed red wine to be rich in a potent antioxidant called resveratrol that like other antioxidants promoted cardiovascular health [31]. This potent health benefit in combination with the subjective increase in sexual desire experienced under the influence of alcohol likely contributes to the erotic reputation of red wine [32].

Similar to antioxidants, omega-3 fatty acids have strong anti-inflammatory effects that help reduce atherosclerotic plaques and improve cardiovascular health. Not surprisingly foods rich in omega-3 such as salmon and walnuts have been thought to promote sexual health [33–35].

Cinnamon and coriander are also known to have anti-inflammatory properties and along with cinnamon containing chai tea drinks might promote sexual health [36–38]. It is likely similar mechanisms of enhancing cardiovascular health lie behind these purported benefits.

Foods such as basil, cardamom, and garlic have been used for their aphrodisiac potential in various cultures. They also all have been documented to have blood pressure lowering effects. In a study by Tabassum and Ahmad, Ocimum basilicum (basil) caused a fall in mean arterial pressure (MAP), systolic, and diastolic blood pressure. The active ingredient in basal is thought to be eugenol [39]. Cardamon seed also has antihypertensive and antioxidant activity. In a study of 20, Stage 1 hypertensive individuals cardamom significantly lowered systolic, diastolic, and MAP [40].

Garlic is appreciated for many health benefits including its blood pressure lowering ingredient allicin (Figure 27-3). Allicin has been show to both increase blood flow in post-ischemic conditions and lower blood pressure in rat models [41, 42].

Watermelon has been reputed to have sexual enhancing properties due to its high content of l-citrulline (it is mostly in the rind, not the flesh) (Figure 27-4). l-citrulline is a precursor to l-arginine, the key source of nitrogenous substrate for the production of nitric oxide (NO) which in turn plays a central role in penile erection [43, 44].

Cormio et al. studied the effects of l-citrulline supplementation on erection strength in men and found that subjects on the supplement achieved a stronger erection. However, it was noted that the effect was not as great as PDE-5 inhibitors [45]. One additional health benefit of l-arginine is its ability to lower blood pressure [46].

Foods rich in magnesium, such as oysters, okra, and pumpkin seeds, have been thought to enhance sexual drive and ability [47–49]. Several studies have attempted to shed light on this belief by evaluating the effects of magnesium on the production of testosterone . One study comparing Taekwondo athletes to a sedentary control group showed that supplementation with magnesium was associated with higher levels of free testosterone in both groups [50]. Maggio et al. studied the ability of magnesium supplements to increase free testosterone in older men who generally suffer from declining sex hormone production. The study found that magnesium levels were strongly and positively and independently associated with total testosterone levels. It was theorized that the possible mechanism behind this observation is that there is increased reactive oxygen species (ROS) production in magnesium deficiency, therefore low magnesium levels create a pro-inflammatory state [51]. Demirbag et al. found that testosterone production is strongly associated with the antioxidant capacity of hormone producing cells. Testosterone itself is thought to play a chief role in the libido of both men and women. Declines in libido in men have been associated with the decline in testosterone production that comes with age. Conversely, in women the decline in estrogen production with age leads to a higher relative level of testosterone and purported increase in libido [52, 53]. Thus, the positive association between testosterone and magnesium provides a plausible explanation for the potential aphrodisiac effects of magnesium rich foods.

Zinc containing foods, such as pine nuts, chickpeas, and cashews (Figure 27-5), are occasionally mentioned as a food with aphrodisiac potential in the popular literature. The scientific literature has found that zinc deficiency is associated with male hypogonadism [54]. In a rat study the aphrodisiac-like qualities of zinc were validated. Male rats given 5 mg/day of zinc supplements exhibited a significantly increased ejaculatory latency and increased penile thrusting. One possible explanation is that zinc supplementation increases serum testosterone levels in both unhealthy and healthy adult men. Jalalj et al. studied 100 males with end stage renal disease and found supplementation with zinc significantly increased serum testosterone levels.

Similarly, in a healthy population Prasad et al. found that serum testosterone increased significantly from 8.3 ± 6.3 to 16.0 ± 4.4 nmol/L with the administration of zinc [54, 55]. Given the central role of testosterone in both male and female libido, it is plausible that eating foods high in zinc could increase sex drive.

Celery is a vegetable that has been valued throughout history for its aphrodisiac qualities, with the Romans dedicating celery to Pluto. Celery is high not only in fiber but also hormones the androstenol and androsterone [56]. These two hormones are pheromones and are thought to play a role in human olfactory communication in regard to sexual attraction. In a study rating the subjective attractiveness of men it was found that women’s rating on men in the areas of warmth, goodness, and masculinity were significantly and positively associated with androsterone levels measured in the male subject [57].

Artichokes have been used since Roman times as a sexual stimulant. The mechanism of action seems to be related to improved endothelial function [63]. However, research studies still need to be performed to establish their exact effects on sexual functioning.

This natural product is found in the gut of the sperm whale (Figure 27-7) and is used in the Arab world as an aphrodisiac . Ambrein increases the concentration of several anterior pituitary hormones and serum testosterone as well as facilitation noradrenergic transmission and dopamine synthesis [64].

Arthropods such as lobster, Arizona bark scorpion, deathstalker, banana spider, Mediterranean black widow, Burmeister’s triatoma, giant water bug, diving-beetle, Korean bug, diaclina, flannel moth, Spanish fly, migratory locust, red wood ant, and honeybee, were reviewed in 2012 by Pajovic and colleagues for their use as aphrodisiacs [65]. Although they have been used for this purpose for centuries, research is still needed to establish their effectiveness.

The skin and glands of the Bufo toad contain bufotenine, related to serotonin (as well as the “love stone” from the Caribbean and Chan su from China), which has been reported historically to improve sexual performance [64]. However, research evidence is needed to establish the effectiveness of this food element.

A 3-week uncontrolled trial of 17 patients with a 12-month diagnosis of ED involved taking took 100 g pistachio nuts daily for 3 weeks. All five domains of the International Index of Erectile Function (IIEF) as well as penile color Doppler ultrasound parameters significantly improved [66].

Asparagus has been reported for centuries to improve sexual performance. Through activating NO release, asparagus could potentially improve arousal and erection [67]. More studies would need to be performed to examine on the impact of asparagus on sexual functioning.

Chocolate has historically been thought to exert several effects on sexuality including acting as an aphrodisiac and enhancing sexual pleasure, especially in women [67] (Figure 27-8). Salonia et al. addressed this question in a study of 163 women that completed anonymous semi-structured interviews on their sexual function, sexual distress, and depression. The study found that women who consumed chocolate daily had a statistically significant higher score on sexual desire and total sexual function section the interview; however this difference was eliminated once adjusted for age [68].

One possible explanation for the effects of chocolate on human sexuality is its ability to have a significant impact on overall mood [69]. It is thought that the appeal of chocolate and its positive effect on mood are due its fat and sugar content along with its pleasant aroma [70–72]. At a biochemical level chocolate contains high levels of phenylethylamine, a compound that is detected at higher levels among people in love [72]. Additionally, chocolate has been associated with serotonin release that acts to produce arousal in women [67, 72]. Despite feasible mechanisms at a biochemical level there are no studies showing a significant association between chocolate consumption and libido.

Nutmeg or Myristica fragrans is a dried kernel that is native to India and has historically been used as a medicine for stomach ailments and several other illnesses, and as a tonic, nerve stimulant, and aphrodisiac [73–76]. The aphrodisiac potential of nutmeg has been studied in animal models, though further testing is required in order to apply these results to humans and provide a plausible biological mechanism.

Saffron or Crocus sativus is a plant from the Middle East and South Asia traditionally ascribed with medicinal value including aphrodisiac potential [77, 78]. In a study of male rats Hosseinzadeh et al. that found intraperitoneally injected crocin, a saffron extract constituent, produced increased frequency of mounting, intromission, and erection relative to controls [78]. To determine is these findings are applicable to humans Safarinejad et al. evaluated the ability of saffron to benefit patients suffering from ED in an open label, randomized crossover study [79]. Patients were given on demand sildenafil for 12 weeks followed by twice daily saffron for an additional 12 weeks. When compared to sildenafil, saffron did not exhibit satisfactory benefit in men with ED [79]. Saffron does show potential for enhancing sexual drive in mammals but no evidence to date indicates its usefulness in humans.

Caffeine is found in a variety of foods. Caffeine is a central nervous system stimulant, with peak plasma concentration occurring at 1–2 h, with an approximate half-life of 5 h. It is broadly consumed and often associated with withdrawal effects [80]. Approximately 80% of caffeine is metabolized to paraxanthine. Caffeine and paraxanthine are known increase diastolic blood pressure, plasma epinephrine levels, and free fatty acids [81]. It is anxiogenic, especially for those who consume it in large quantities. Caffeine has does not increase alertness in non- or low-consuming individuals, and with consistent consumption, tolerance develops to its anxiogenic effect [82]. A recent study investigated the effect of on-demand caffeine consumption in treating patients with PE [83]. The caffeine group, comprised of 40 healthy males, was treated with 100 mg of encapsulated caffeine 2 h prior to intercourse for 3 weeks, 2 h prior to each occurrence of sexual intercourse . There was a highly significant correlation between caffeine treatment and improvements in intravaginal ejaculation latency time, as well as index of sexual satisfaction [83].

l-arginine , an amino acid available over the counter, is the substrate for nitric oxide synthase (NOS) and is converted into NO [85]. This pathway affects the smooth muscle relaxation that is needed for sexual functioning [86]. NO relaxes blood vessel walls, thus improving circulation throughout the body, including in erectile tissue. l-arginine also increases elasticity of arteries, potentially decreasing blood pressure and improving the capacity of erectile tissue [87].

l-arginine appears to impact two desire and arousal stages of the sexual response cycle and has been explored as an intervention in both premenopausal and postmenopausal women. Two studies of a mixture that includes l-arginine suggested improvements in female sexual function, including desire, frequency of intercourse, and orgasm [88, 89]. Another study, assessed the effects on sexual function in healthy, postmenopausal women, this time using a mixture containing the dietary supplement pycnogenol and l-arginine, found that there were significant subjective improvements after 4 and 8 weeks in domains related to desire, arousal, lubrication, and orgasm [90]. l-arginine’s effect on sexual function of healthy women of reproductive age with moderate sexual dysfunction was examined using a mixture containing pycnogenol and l-arginine, along with a management program of lifestyle, diet, exercise, and stress control. The results revealed significantly improved desire, arousal, lubrication, orgasm, satisfaction, and pain [91]. Some studies of l-arginine also have focused on its physiological impact. In one such study a mixture of oral l-arginine glutamate and yohimbine significantly increased vaginal pulse amplitude in response to an erotic film in postmenopausal women with female sexual arousal disorder [92].

In one study of 50 men with organic ED, of the 29 who took l-arginine, nine indicated subjective improvements in sexual function. Of note, all nine of these men had low levels of NO excretion or production [93]. l-arginine as an intervention for ED has been investigated primarily in combination with a variety of other agents. A combination of pycnogenol and l-arginine was tested in 40 men over 3 months. After 1 month of l-arginine treatment, there was no change in the percent of men who experienced normal erection, but after adding pycnogenol during the second month there was a significant improvement. After 3 months of treatment with the combination, successful erections were elicited in 92.5% of participants [94]. Another study of 50 men with moderate ED, treatment with a mixture including pycnogenol and l-arginine restored erectile function to normal over 1 month [95]. These results were replicated in the treatment of mild to moderate ED in Japanese men [96]. Prelox^® Blue is an example of a commercially available product containing this combination of l-arginine and pycnogenol with the addition of l-taurine and aspartic acid. A combination of l-arginine and adenosine monophosphate one to 2 h prior to sexual intercourse showed gains in erectile function and in intercourse satisfaction [97]. Side effects of l-arginine include abdominal pain, bloating, diarrhea, gout, blood abnormalities, allergies, airway inflammation, asthma exacerbation, and hypotension. Doses for treatment of ED are about 5 g PO daily over 6 weeks [98]. For postmenopausal women with sexual arousal disorder, the dose is 6 g PO daily 1 h prior to intercourse [94].

l-carnitine acts as a vasodilator by activating prostaglandin synthesis [93]. Cavallini et al. compared androgen supplementation to l-carnitine (propionyl-l-carnitine 2 g/day plus acetyl-l-carnitine 2 g/day) and placebo for 6 months, and showed that l-carnitine was superior to androgen supplement in terms of nocturnal penile tumescence and IIEF [99].

DHEA occurs naturally as a weak steroid hormone produced by the adrenal glands and by the brain. Its uses in the body are myriad, one herein significant being the improvement of sexual function. It leads to the production of androgens and estrogens, but its levels decline with age, more quickly in women than in men. DHEA is converted to androstenedione, testosterone, and dihydrotestosterone, and aromatized to estrogen. As DHEA, testosterone, and estrogen decrease over time, the employment of DHEA has not been limited to treatment of primary adrenal insufficiency, building the immune system, slowing the aging process, providing increased energy, improving memory and mood, and building bone and muscle strength [100]. Prasterone is a formulation of DHEA used, off label, to treat sexual dysfunction in postmenopausal women. It can be applied intravaginally as a cream [101]. Alternatively, low-dose DHEA therapy for sexual dysfunction in postmenopausal women is available in oral form [102]. DHEA also can be used orally in men for the ED off label.

DHEA was tested in 16 sexually functional postmenopausal women in whom sexual arousal was activated by erotic video. Subjective responses and physical sexual arousal increased significantly in the DHEA group versus the placebo group [103]. A time- and dose-dependent improvement in desire/interest, arousal, and orgasm was detected upon treatment with intravaginal DHEA in 216 postmenopausal women with moderate to severe symptoms of vaginal atrophy. Arousal/sensation improved by 68%, arousal/lubrication by 39%, orgasm by 75%, and dryness during intercourse by 57%, supporting the use of intravaginal DHEA in postmenopausal women with sexual dysfunction [101]. The treatment of dyspareunia, or pain with intercourse, was examined in one study of 114 postmenopausal women who were also treated with intravaginal DHEA. Intravaginal DHEA caused a rapid, efficient effect on dyspareunia [104]. The effect over 1 year of oral DHEA on sexual dysfunction in early postmenopausal women was also assessed. In 48 healthy postmenopausal women daily oral DHEA provided significant improvement in sexual function and in frequency of sexual intercourse [102]. One study significant for discerning DHEA treatment differences between sexes was undertaken. The premise was that outcome differences in dehydroepiandrosterone treatment in postmenopausal women and in men with HSDD were gender-based as a consequence of the peripheral conversion of DHEA to testosterone. Women, as opposed to, men had significant beneficial effect on arousal, suggesting that ongoing dosing with DHEA could be efficacious in the treatment of HSDD in women [105]. The Massachusetts Male Aging Study in 1994 reported an inverse correlation between DHEA and ED. A study to replace DHEA in men suffering from ED was therefore undertaken. Success was determined by the ability to maintain or achieve an erection sufficient for satisfactory sexual performance. Although the patient database was not large enough to perform meaningful statistical analysis, what was found was that DHEA treatment was associated with higher mean scores for the International Index of Erectile Function [106].

Side effects of DHEA include abdominal pain, acne, fatigue, alopecia, headache, hirsutism, hypertension, hypoglycemia, menstrual irregularities, nasal congestion, psychosis, voice changes [107]. DHEA is administered as a 10% vaginal cream to apply topically daily [108], and at 50–100 mg PO daily for ED [108, 109].

Zestra oil is an over the counter preparation that is applied to the clitoris and labia locally, and it leads to improved desire and arousal, and the effects are reported to start within 3–5 min and lasting up to 45 min [110, 111]. A 16-week randomized, placebo-controlled, double-blind study of 256 women, age 21–65, showed significant improvement in desire, arousal, and treatment satisfaction benefits. Zestra was well tolerated and the only significant safety finding was mild to moderate genital burning in 14.6% of patients [112].

SS cream contains extracts of plants and is used for the treatment of premature ejaculation. Placebo controlled studies showed that the mean ejaculatory latency time was nearly 11 min on the SS cream compared to nearly 2.5 min on placebo. Moreover, nearly 80% of SS cream patients had an ejaculatory latency time >2 min compared to 15% of placebo patients. Side effects of the SS cream included mild local burning and pain [113].

Ginkgo biloba leaves and extract are thought to stimulate NO production and on contribute to smooth muscle relaxation (Figure 27-9). Reports of improving sexual function led to more research to examine its effects. In a randomized placebo-controlled study, Meston et al. examined the effects of Ginkgo biloba 300 mg/day on women with sexual arousal disorder, compared to sex therapy or their combination, showing that Ginkgo biloba combined with sex therapy but not alone, increased sexual desire and contentment more than placebo with minimal side effects [114].

Vitamin B for sexual enhancement includes B1, B3, B6, B9, and B12. B1 (Thiamine) was reported to improve erectile dysfunction during treatment of alcoholism [115]. B3 (Niacin) has been reported to improve sexual function in hyperlipidemia and diabetes mellitus [116]. B6 is involved in homocysteine regulation, which is implicated in NO synthesis, and B6 has been reported to improve erection scores when combined with PDE5 inhibitors in diabetics [117]. B9 (Folate) is also involved in homocysteine regulation and its deficiency affects energy level [118]. B12 deficiency is associated with fatigue and depression, and therefore B12 supplementation could improve mood, energy, and sexual functioning [118].

Trace elements are important to maintain healthy metabolism and different body functions including sexual performance. Selenium daily intake for dose is 55 mcg. Zinc is very common element among men’s sexual enhancement products with doses ranging from 1 to 30 mg with 11 mg being the daily recommend dose [84]. Zinc deficiency is associated with decreased testosterone [55]. Magnesium has a positive effect on the production of testosterone [50–53]. Selenium is frequently encountered in men’s sexual health preparations [84], although no studies have linked its supplementation with sexual performance.

Ginseng is a plant of the Panax genus of the family Araliaceae used as a food and herbal remedy renowned for its health benefits, especially in East Asia and the Indian subcontinent (Figure 27-10). It has been explored as an agent to increase energy, decrease blood sugar, lower cholesterol levels, reduce stress, promote relaxation, improve psychomotor performance, and treat sexual dysfunction [119]. Ginseng promotes NO release and relaxation of the smooth muscle of the corpora cavernosa [120].

Two Korean studies tested the sexual enhancing properties of ginseng root. Compared to placebo, men who took 3000 mg of ginseng daily showed improved erection rigidity and ability to penetrate [121]. A placebo-controlled trial, the oral administration of Korean red ginseng extracts improved sexual arousal in menopausal women [122]. The use of a mixture contained ginseng, along with l-arginine, ginkgo, and damiana for 4 weeks of treatment showed improved satisfaction with their overall sex life in 73.5% of patients compared to 37.2% on placebo [89]. Perimenopausal women exhibited significant improvements in frequency of intercourse and satisfaction with sexual relationship in a placebo-controlled trial using the same mixture [90]. A double-blind crossover study of 45 with ED were treated with Korean red ginseng over 8 weeks showed significantly improved erections [123]. A subsequent study of 119 men with mild-to-moderate ED demonstrated improvement in all domains of sexual function when compared to placebo [124]. A 60 person study of patients with mild to moderate ED administered 1000 mg three times daily of ginseng and found that ratings for penetration and maintenance were significantly higher than those found in the placebo group [125].

Side effects of ginseng include: skin hypersensitivity reaction, amenorrhea, appetite decreased, cerebral arteritis, cholestatic hepatitis, diarrhea, edema, ejaculation delay (topical use), euphoria, excitability, ginseng abuse syndrome, headache, hypertension, hyperpyrexia, hypotension, insomnia, irritability, libido increase, local burning/irritation (topical use), mastalgia, arthralgia/myalgia, palpitations, pruritus, restlessness, rose spots, skin eruptions, Stevens-Johnson syndrome, tachycardia, vaginal bleeding, and vertigo [126]. Ginseng dosing is not well established and depends on the type of ginseng used. The usual treatment course lasts 3 weeks to 3 months. There is a 2-week ginseng-free period that is encouraged between treatment courses. Tea is prepared with 3 g root per 150 mL water [127].

Chlorophytum borivilianum roots (vajikaran rasayana or safed musli) have been used in Ayurdedic medicine for its positive influence on sexual behavior [128]. In a comparative study comparing C. borivalinum to other traditional Indian herbs in a rat model, the group given C. borivalinum had the least hesitation time when initiating mating behavior in the presence of a female rat. Additionally the male rats had increased penile erection index which is a measure of NO activity [128]. The positive studies in rat models using C. borivilianum suggest that could be a source of promising research in regard to enhancing fertility and sexual drive in humans. Furthermore, there were no reports of serious side effects.

Monida whitei is a sub-Saharan plant that has been used as an aphrodisiac since ancient times [129]. In an in vitro study it enhanced total and progressive motility human spermatozoa in a time-dependent manner [129]. One possible explanation is that M. whitei increases serum and intratesticular testosterone levels [130]. A later study by the same group showed that M. whitei extract had an anti-alpha adrenergic effect on penile smooth muscle, possibly enhancing erectile function [131]. Based on these findings M. whitei might have potential therapeutic benefits in males suffering low sperm counts and might help enhance erectile function. However, without human trials it is difficult to determine the safety and effectiveness of this herb.

Tribulus terrestris is a plant native to tropical and warm regions and used in both Indian and Chinese traditional medicine for sexual enhancement of men [132] (Figure 27-11). Other studies have shown that active ingredients in T. terrestris, improve sperm production in human and animal trials and increases levels of testosterone, LH, and DHEA [133–135] Some studies suggest that endothelium and nitric oxide-dependent mechanisms underlie its aphrodisiac and pro-erectile activities [136, 137]. In preclinical studies Tribulus terrestris increases intracavernosal pressure, suggesting that pro-erectile properties might be the result of increased androgen levels and subsequent release of NO from nerve endings that innervate the corpus cavernosum [138].