NMT150 BOT Wk13 ED Lecture Material (1) PDF

The use of Botanicals in ED Chris Pickrell, ND, Herbalist, TCM Practitioner Key Actions: Adaptogen, Alterative, Cardiotonic, Vascular tonic, Differentiate between physical and mental/emotional causes Differentiate between...

The use of Botanicals in ED Chris Pickrell, ND, Herbalist, TCM Practitioner Key Actions: Adaptogen, Alterative, Cardiotonic, Vascular tonic, Differentiate between physical and mental/emotional causes Differentiate between challenges with arousal vs challenges with performance The primary interventions of nutrition, physical activity, and stress Key treatment reduction will yield best results principles: Botanical best results are usually seen in one of two approaches: Adaptogens: favour herbs that are warm and drying. Alteratives: use hepatics and laxatives to restore liver function and elimination Try framing the case from a TCM perspective: Look for: 1. Kidney Yang deficiency leading to Damp accumulation, Phlegm, Pro tip: and Cold affecting the lower burner 2. Liver Qi and Blood stagnation with stagnant Heat  Botanicals in ED Panax ginseng (Korean Red Ginseng) FEATURED HERBS IN THIS SECTION Rhodiola (Rhodiola rosea) Epimedium grandiflorum (Horny goat weed) Chocolate (Theobroma cacao) Lepidium meyenii (Maca) Ashwagandha (Withania somnifera) Pausinystalia yohimbe (Yohimbe) Cinnamon (Cinnamomum zeylanicum) Pygeum africanum (Pygeum) Serenoa repens (Saw palmetto) Damiana (Turnera diffusa) Smilax officinalis (Sarsaparilla) Rhodiola (Rhodiola rosea) Tribulus terrestris (Puncture vine He shou wu (Polygonum multiflorum) Nettle root (Urtica dioica) Korean red ginseng (Panax ginseng) Cayenne (Capsicum frutescens) Sarsaparilla (Smilax officinalis)  Botanicals in ED CASE PRESENTATION – ED A 58 year-old male presents with decreased libido and decreased performance. He reports a healthy, uncomplicated relationship. Sexual frequency is twice a month, and sex is unsatisfying. He reports that occasionally he is unable to maintain a firm erection and often climaxes too quickly or not at all. He would like to be able to engage in satisfying intercourse twice a week. OUTCOME MEASURES Improve frequency of arousal Improve ability to sustain and maintain an erection RELEVANT BOTANICAL ACTIONS TO CONSIDER PRIMARY SECONDARY or OTHERS TO CONSIDER SUPPORTIVE Adaptogen Cardiotonic Specific libido or testosterone Alterative Vascular tonic improving herbs Circulatory tonic Nervine  Botanicals in ED Saw palmetto (Serenoa repens) FEATURED HERBS BY BOTANICAL ACTION Actions Herbs Adaptogen Ashwagandha (Withania somnifera) Rhodiola (Rhodiola rosea) Korean red ginseng (Panax He shou wu (Polygonum multiflorum) ginseng)  Botanicals in ED Lepidium meyenii (Maca) Sarsaparilla (Smilax officinalis) Alterative Arctium lappa Sarsaparilla (Smilax officinalis) Berberis vulgaris Ceanothus americanus (Red root) Vascular Hawthorn (Crataegus oxyacantha) Linden (Tilia cordata) tonic Hibiscus (Hibiscus sabdariffa) Gingko (Gingko biloba) Motherwort (Leonurus cardiaca) Circulatory Prickly ash (Zanthoxylum tonic americanum) Cayenne (Capsicum frutescens) Gingko (Gingko biloba) Nervine Passionflower (Passiflora Valerian (Valeriana officinalis) incarnata) (Sedative) Lavendula officinalis HERB SELECTION Rhodiola (Rhodiola rosea) 20 Korean ginseng (Panax ginseng) 15 He shou wu (Polygonum multiflorum 15 Sarsaparilla (Smilax officinalis) 15 Damiana (Turnera diffusa) 10 Formula Nettle root (Urtica dioica) 10 Cinnamon (Cinnamomum zeylanicum) 10 Cayenne (Capsicum frutescens) 5 100mL Dosage Tincture: Two tbsp (15mL), twice a day between meals. Can also be used acutely. Duration Six weeks, possibly ongoing as needed.  Botanicals in ED Expectations This combo should moderately improve libido and performance. This combo will work best when stress and exhaustion are the main causes. If the cause is anxiety or performance anxiety, results will be less. Cautions, Panax ginseng, and this combo in general may elevate blood pressure – Contraindication caution in hypertensive patients. s and Potential Because this combo is generally stimulating, dizziness, feeling light Side Effects headed, or feelings of heat in the head and face may occur. Relevant Herb- Generally safe with medications. Drug Can have additive effects with erectile-performance medications. Interactions Other Effective Dietary and lifestyle modifications: regular exercise; do not smoke; Therapies consume plenty of vegetables, fruits, and fiber; avoid battered and fried foods; consume healthy oils and fats; minimize refined sugars, preservatives, and alcohol Specific counselling regarding performance anxiety In many cases, relationship counselling is helpful. Damiana, as a strong tea, works well as a nervine for performance anxiety. Passiflora can be combined with Damian for increased effect (and add a pinch of lavender and bit of vanilla to go all the way). TCM INTEGRATION – Lowered Libido A lowered libido is reliably a sign of Kidney yang deficiency. The treatment principle is therefore to nourish Kidney yang, but the difficulty in treatment lies in addressing the causes of Kidney yang deficiency. If Kidney Yang deficiency is treated only with kidney yang tonics, then this will injure and consume the yin, leading to a worsening progression. A balanced approach, in which Qi, yin, and blood are also proportionally supported is best. TCM INTEGRATION – Performance Challenges The two primary organs involved in sexual performance are the Kidneys and the Liver. Successful treatment will depend on identification of the underlying imbalance. Look primarily for deficiency of the Kidneys (likely of Qi, Yin, and Yang) and deficiency of Liver Blood.  Botanicals in ED In patterns of Excess, such as might be seen in hypertension, cardiovascular disease, diabetes, fatty liver, and obesity, the primary focus will be to restore proper smooth flow of the Liver and to clear Heat and Damp as needed. Real Sample Case  Botanicals in ED SELECTED MONOGRAPHS Capsicum frutescens (Cayenne) Primary Actions: Stimulant, circulatory tonic, rubefacient, sialagogue, libido tonic Constituents: Capsaicinoids (capsaicin), steroidal saponins Indications: Circulatory deficiencies, arthritic conditions, pain relief, depression Cautions/Contraindications: Non-toxic, but large doses will cause sweating and possible syncope. Safety rating during pregnancy and lactation not established. Extra Information: Acts as pain relief via local topical substance-P depletion. Excellent in salves for arthritis. Avoid contact with mucus membranes; internal use effective, but must be used in low doses. Part Used: Dried or powdered fruit Daily Therapeutic Dose Tincture: 1–5 mL (1:5 in 25%) Daily Therapeutic Dose Infusion or Decoction: 1–2 g powder (potency of starting material can vary considerably) Pairs Well With: Zanthoxylum americanum as warming circulatory tonic. Closest Substitute: Zingiber officinalis Ceanothus americanus (Red root) Primary Actions: Lymphatic, alterative, decongestant, antimicrobial, astringent Constituents: Alkaloids, tannins Indications: URTIs, enlarged spleen, palpable lymph nodes, edema, circulatory congestion, lethargy and melancholy, GI bleeding and loose stools Cautions/Contraindications: Considered safe, has been used as a tea substitute. Safety in pregnancy and lactation not established. Extra Information: An effective lymphatic used especially where there is confirmed enlargement or induration of lymph nodes, particularly during acute infections. Part Used: Root, root bark, twigs Daily Therapeutic Dose Tincture: 9–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 4–6 g dried root Pairs Well With: Salvia officinalis and Rosmarinus officinalis in acute URTIs with congestion and swollen lymph nodes Closest Substitute: Phytolacca americana  Botanicals in ED Cinnamomum zeylanicum (Cinnamon) Primary Actions: Diaphoretic, astringent, antimicrobial, antispasmodic, carminative, endocrine modulator (diabetes) Constituents: Cinnamyl acetaldehyde and ester (only bark), phellandrene (only leaf) Indications: Uterine hemorrhage, diarrhea, nausea, vomiting, URTI Cautions/Contraindications: Considered safe as spice used in food in doses less than 5 g. Generally CI in pregnancy and lactation. Extra Information: An excellent warming carminative, but can be too spicy for some individuals. In TCM, warms the individual, increases flow through the meridians, removes obstructions to the flow of Qi, and reinforces yang. A related (and sweeter tasting) species Cinnamomum cassia has recently been associated with some hepatotoxicity in large amounts, so C. zeylanicum is generally favored for medicinal use. Part Used: Bark, twig, occ leaf Daily Therapeutic Dose Tincture: 6–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 5–20 g dried bark or powder Pairs Well With: Arctium lappa for warming weak digestion – loose stools. Ginkgo biloba in circulatory formulas. Closest Substitute: Zingiber officinalis Crataegus oxyacantha (Hawthorn) Primary Actions: Cardiotonic, hypotensive, vascular tonic, nutritive Constituents: Flavonoids Indications: Hypertension, CHF, any cardiovascular conditions Cautions/Contraindications: Considered safe and nutritious, berries may be consumed as food. Extra Information: Positive inotropic, improves coronary contractility and circulation. Ripe berries are delicious and make a tasty therapeutic jam. Part Used: Berry, leaf Daily Therapeutic Dose Tincture: 8-12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 5–15 g dried fruit Pairs Well With: Convallaria majalis for hypertension and CHF.  Botanicals in ED Closest Substitute: Hibiscus sabdariffa Gingko biloba (Gingko) Primary Actions: Circulatory tonic, vasodilator, anti-inflammatory, anticoagulant (as an antiplatelet activator factor [PAF]) nootropic, mild astringent. Constituents: Flavonoid glycosides, terpene lactones (gingkolides) Indications: Poor perfusion of tissues, especially cerebral; inflammation, clot formation, cognitive decline, erectile dysfunction, BPH. Cautions/Contraindications: Though not toxic, may cause stomach discomfort or cramping. Extra Information: At 200 million years old, Gingko trees are the most ancient species of tree on the planet and the only remaining member of their genus. They are also thought to be the hardiest tree species and are among the most resilient trees in urban environments. Gingko trees have a distinct male and female. The females produce a characteristically unpleasant smelling, but edible fruit. Part Used: Leaf and fruit Daily Therapeutic Dose Tincture: 3–9 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 4–10 g dried leaf Pairs Well With: Actaea racemosa and Hydrastis canadensis for vertigo. Capsicum frutescens in formulas for improved circulation. Centella asiatica for enhancing cognitive performance. Closest Substitute: Centella asiatica Lepidium meyenii (Maca) Primary Actions: Endocrine modulator (testosterone), adaptogen, anti-inflammatory Constituents: Carbohydrates, proteins, sterols, linoleic and oleic acid, micronutrients including zinc glucosinolates Indications: Debility, lowered libido, convalescence Cautions/Contraindications: Considered safe, consumed as food. Safety in pregnancy and lactation not established. Extra Information: Consumption of maca does appear to have benefit as a fortifying adaptogen showing improvement in physical and sexual performance. Though the exact mechanism of action is not known, it is likely that the rich nutritional profile of maca contributes broadly rather than specifically to performance. It is of note that the majority of the research suggesting benefit from maca comes from studying locals consuming it regularly as food in amounts similar to cereal grains. Maca has a characteristic nutty flavor that is not entirely pleasant to everyone.  Botanicals in ED Part Used: Root Daily Therapeutic Dose Tincture: Likely ineffective as tincture. 8–12 mL (1:5 in 40%). Daily Therapeutic Dose Infusion or Decoction: 6–25 g dried root Pairs Well With: As powder, Withania somnifera and Panax quinquefolius for physical stamina Closest Substitute: Inonotus obliquus Panax ginseng (Korean red ginseng) Primary Actions: Stimulating adaptogen, immune stimulant, libido stimulant, cardiotonic Constituents: Triterpene glycosides (ginsenosides), steroidal saponins Indications: Debility and convalescence (low dose), depression, end-of-life care Cautions/Contraindications: Non-toxic, but can be overstimulating to some individuals, particularly where yin has been weakened through excessive use of stimulants. CI in hypertension and other heat conditions. Extra Information: An excellent herb, often underused out of fear of its stimulating properties or overused because of its stimulating properties. A truly fortifying and whole-system adaptogen when used appropriately (by matching dose to condition and vitality), especially in combo with other herbs. Traditionally used in TCM to mobilize the essence of an elder near death so that the family would have time to gather for farewells. Part Used: Root. Red ginseng is the steamed root, while white ginseng is the unprepared root of the same species. The steamed red root is preferred. Daily Therapeutic Dose Tincture: 2–10 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 3–10 g dried root Pairs Well With: Astragalus membranaceus and Rehmannia glutinosa for convalescence after blood loss. Ganoderma lucidum for depression. Centella asiatica for mental clarity and focus. Closest Substitute: Rhodiola rosea Passiflora incarnata (Passionflower) Primary Actions: Sedative, nervine, hypotensive, antispasmodic, anti-inflammatory Constituents: Alkaloids, flavonoids Indications: Insomnia, general anxiety and restlessness, hypertension, neuralgia Cautions/Contraindications: Considered safe. May potentiate other anxiolytics.  Botanicals in ED Extra Information: Slightly spicy in flavour similar to Lobelia inflata or Nicotiana tabacum, but overall cooling. Effective nervine-sedative, used especially in conditions presenting with nervous anxiety. Part Used: Leaf Daily Therapeutic Dose Tincture: 3–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 1–4 g dried herb Pairs Well With: Agrimonia eupatoria and Avena sativa for nervous tension preventing sleep. Closest Substitute: Scutellaria lateriflora Pausinystalia yohimbe a.k.a. Coryanthes yohimbe (Yohimbe) Primary Actions: Endocrine modulator (testosterone), mild stimulant Constituents: Indole alkaloids (yohimbine, corynanthine) Indications: Lowered libido, improved sexual performance, possibly BPH Cautions/Contraindications: In larger doses, can cause flushing, dizziness, and elevated blood pressure. Priapism is uncommon but has been reported. CI in pregnancy. Extra Information: Used commonly as a performance enhancer for physical exertion and sexual performance. Effects are significant but transient and diminish with recurrent use. Best used acutely, and cautioned in individuals with tendency to fainting and dizziness. Also common in weight loss formulas, though the research suggests limited efficacy. Part Used: Bark Daily Therapeutic Dose Tincture: 4–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 4–9 g dried bark Pairs Well With: Tribulus terrestris and Serenoa repens in BPH Closest Substitute: Panax ginseng Serenoa repens (Saw palmetto) Primary Actions: Endocrine modulator (male), decongestant, diuretic, possible libido tonic Constituents: Volatile oils, fixed oils, fatty acids, sterols, saponins Indications: BPH, edema, PCOS with androgen dominance Cautions/Contraindications: Considered safe, berries have been eaten as food. May interact to enhance efficacy of other 5-a reductase inhibitors.  Botanicals in ED Extra Information: Thought of as a specific for BPH. Has a characteristic (and often unpleasant) taste. Research continues to debate the efficacy of Serenoa repens in generating improvement in non-infectious prostatic enlargement. Absorption is thought to be improved when taken with fat-containing meals. Part Used: Berry Daily Therapeutic Dose Tincture: 3–6 mL (1:5 in 50%) Daily Therapeutic Dose Infusion or Decoction: 2–4 g dried berry or powder Pairs Well With: Wolfiporia extensa in BPH formulas Closest Substitute: Tribulus terrestris Smilax officinalis (Sarsaparilla) Primary Actions: Adaptogen, alterative, anti-inflammatory Constituents: Saponins based on the aglycone sarsapogenin, sterols, volatile oils Indications: Eczema, psoriasis, BPH, waning libido, RA, gout Cautions/Contraindications: Considered safe. Safety rating during pregnancy and lactation not established. Extra Information: Excellent tonic, useful in cases of fatigue following intense physical activity, especially when associated with joint pain. One of the original roots in root beer. Part Used: Root and rhizomes Daily Therapeutic Dose Tincture: 3–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 6–12 g dried root Pairs Well With: Polygonum multiflorum and Urtica dioica root as a male tonic. Vanilla extract, soda water, and a tsp of honey as a pleasant fortifying beverage. Closest Substitute: Hemidesmus indicus, Rhodiola rosea Tribulus terrestris (Puncture vine) Primary Actions: Endocrine modulator (androgen) Constituents: Alkaloids (harmane and norharmane) Indications: Lowered libido, erectile function, fatigue and debility, BPH Cautions/Contraindications: May cause paresis in large doses. Perilous to bicycle tires. Extra Information: Current research remains ambivalent to the ability of Tribulus to boost circulating testosterone. In treating BPH, it is possible that Tribulus contributes to an improved profile between testosterone and dihydrotestosterone.  Botanicals in ED Part Used: Seed (or nut) Daily Therapeutic Dose Tincture: 4–9 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 3–9 g dried seed Pairs Well With: Serenoa repens and Wolfporia extensa in formulas for BPH Closest Substitute: Pausinystalia yohimbe Valeriana officinalis (Valerian) Primary Actions: Sedative, nervine, hypotensive, anodyne, antispasmodic, emmenagogue, decongestant, mild carminative. Constituents: Iridoids, valpotriates, baldrinals, essential oils, valerianic acid Indications: Deficient pattern anxiety and insomnia, sinus congestion, pain conditions. Cautions/Contraindications: Considered safe. May potentiate other anxiolytics, particularly benzodiazepines. Extra Information: Has an especially strong smell reminiscent of dirty socks. Effective sedative, may induce grogginess the next morning if used in high dose. Best prepared using a strong infusion (30+ min). Some individuals experience a “paradoxical reaction” in which valerian makes them feel restless and stimulated; this is seen especially in people with TCM heat/empty heat patterns. Valerian is generally considered a warm, dry herb. Notably useful in attenuating the symptoms of benzodiazepine withdrawal. Mexican valerian (Valeriana edulis) is considered interchangeable. Of note, valerian is considered safe in pregnancy, and it may be thought of as the treatment of choice in insomnia or anxiety during pregnancy. Part Used: Root Daily Therapeutic Dose Tincture: 8–18 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 6–9 g dried root Pairs Well With: Syzygium aromaticum for a warm, drying bedtime decongestant in cold- pattern URTIs. Any of the other sedatives for anxiety, insomnia, or pain relief. Closest Substitute: None