Upcoming Issue Highlights

Sexual Health for Women

Phase 2

Nutraceutical products for men’s sexual health have significantly more than their fair share of representation, with sales estimations to be in the range of $517 million, and recent annual increases of 5.4 percent, according to 2012 figures from Nutrition Business Journal. Likewise, articles and books on the topic abound.

The same, however, cannot be said for women’s sexual health. This is problematic since research1 suggests that sexual dysfunctions affect 20 percent to even more than 40 percent of all women. The reason for this may be there are a greater number of factors influencing the female libido.

According to the Mayo Clinic: A woman’s desire for sex is based on a complex interaction of many components affecting intimacy, including physical well-being, emotional wellbeing, experiences, beliefs, lifestyle and current relationship. If you’re experiencing a problem in any of these areas, it can affect your sexual desire.2

With this article I will focus on two issues that probably account for a significant percentage of sexual health issues for women: stress and menopause.


It is well established that female sexual dysfunctions and low desire, in particular, are frequently associated with an elevated level of psychological stress.3,4 Consequently, anything that can be done to promote relaxation and reduce the effects of stress may be able to help. The amino acid L-theanine fits this description.


Asian cultures have often used teas for relaxation effects. The relaxing effect is, at least in part, caused by the presence of a neurologically active amino acid, L-theanine (gamma-ethyl-amino- L-glutamic acid). In the brain, L-theanine increases both serotonin and dopamine production5, and possibly GABA as well.6 Evidence from human electroencephalograph (EEG) studies show that it also significantly increases brain activity in the alpha frequency band which indicates that it relaxes the mind without inducing drowsiness.7

According to Mason, two small human studies8 showed that within 30- 40 minutes of consuming 50 or 200 mg of L-theanine there is an increase of alpha wave activity/electrical signals produced by the brain. The perceived relaxation effect in the subjects coincided with the detection of alpha waves. This shows that L-theanine fosters a state of alert relaxation, which is Consistent with the fact that anxious people have fewer or smaller alpha waves. Other studies have shown similar benefits.6,9,10


Most authors agree that female sexual dysfunctions are age-related.1 Research suggests that some sexual functions are significantly impaired in postmenopausal compared to perimenopausal women11, and other research suggest that sexual dysfunctions affect about 50 percent of postmenopausal women.12 While the reasons for this may be multifactorial, there is at least one physiological reason: the lining of the vagina changes around menopause. It usually becomes thinner and drier, so sex can be uncomfortable, especially if the vagina is not lubricated well enough through arousal.13 Of course, other menopausal symptoms such as hot flashes are not particularly conducive to feelings of intimacy either. Maca root extract, black cohosh root extract and hop cone extract may help.

Maca Root Extract

The herbal medicine maca has a history of use for women’s sexual function. Maca’s fertility-enhancing properties and also its stimulant effect were first described in 1653.14 Field researchers have since reported that, in Peru, maca has been used for medicinal purposes and as a source for energy, stamina and endurance, and has been used as an aphrodisiac and tonic for postmenopausal problems.15 In 1964, Leon16 reported that Maca was currently eaten by Indian and white women who want to have children, and is sold in the market for this purpose.

In addition, modern, human clinical research has also shown benefits. In a randomized, double-blind, placebo-controlled, crossover study17, postmenopausal women received 3.5 g of powdered maca root or placebo daily for six weeks. The results were that maca supplementation reduced psychological symptoms, including anxiety and depression, and lowered measures of sexual dysfunction. Another randomized, double-blind, parallel group dose-finding study18 examined the effect of maca supplementation on sexual dysfunction caused by SSRI (anti-depressant) drugs. Doses of 1.5 g and 3 g per day were compared. The results were that libido improved significantly (P<0.05) in the group receiving 3 g of maca. Other placebo-controlled studies have shown similar benefits in sexual interest and function when maca was supplemented to postmenopausal women.19,20 Note: Since 3-3.5 g is probably a significant amount of maca root to supplement with for many women, the use of 270 mg of maca root extract standardized for 0.6 percent macamides and macaenes will provide equivalent activity in a more manageable daily dose.21-24 Black Cohosh Root Extract While many are aware that black cohosh is well established as an effective herb for the treatment of menopausal symptoms, not everyone is also aware that those symptoms include menopause-related sexual disorders. For example, a recent randomized, double-blind, placebo-controlled, multicenter, clinical study25 demonstrated that black cohosh extract was significantly more effective than placebo In improving the menopause rating scale subscore (P=0.012) associated with vaginal dryness, sexual disorders and urinary complaints. Earlier randomized, multicenter, double-blind, clinical studies26,27 with black cohosh extract demonstrated virtually identical results. In addition, a prospective observational study28 demonstrated that black cohosh extract significantly improved quality of life in the sexuality domain among postmenopausal women. The daily doses typically used were 40-80 mg of black cohosh root extract standardized to 2.5 percent triterpene glycosides. Furthermore, numerous studies have demonstrated that black cohosh root extract significantly reduces menopause-related hot flashes, night sweats, nervousness, moodiness, sleeplessness.25-27,29-39 It would seem logical that a reduction of these symptoms would also play a positive role in helping to remove additional roadblocks to healthy sexual activity. Hop Cone Extract Although best known for its role in brewing beer, the hop cone has also been studied for its effect in relieving hot flashes during menopause. In a 16- week, randomized, double-blind, placebo-controlled, cross-over study40, a daily dose of 85 mg hop cone extract (standardized for 100 mcg 8-prenylnaringenin) or placebo was given to menopausal women. The results were that the hop cone extract was superior in reducing hot flashes. In another 12- week, prospective, randomized, double- blind, placebo-controlled study41, menopausal women received 80 mg of hop cone extract (standardized for 100 mcg 8-prenylnaringenin) or a placebo. The results were that the hop cone extract exerted favorable effects on hot flashes and other menopausal discomforts. Note: Hop extract contains plant estrogens that may bind to primary estrogen receptors in the female reproductive system, and may help smooth out some of the rough spots as estrogen declines during menopausal years.42,43 Black cohosh does not contain plant estrogens that bind to primary estrogen receptors44, but rather works with neurotransmitters or by other support mechanisms.45,46 Given these distinctly different mechanisms, I like to recommend the use of both herbs concurrently for the relief of menopausal symptoms. Conclusion As previously indicated, there are a number of factors influencing the female libido, and the nutraceuticals discussed in this article do not address all of them. Nevertheless, there is a good chance that they will help address two of the most frequent contributors to sexual health issues for women: stress and menopause. References: 1 Przybylski M, Spaczynski M. [Hypoactive sexual desire disorder]. Ginekol Pol. 2009 Jul;80(7):518-22. 2 Low sex drive in women. ©1998-2013 Mayo Foundation for Medical Education and Research. Retrieved November 26, 2013 from www.mayoclinic.com/health/low-sex-drive-inwomen/ DS01043/DSECTION=causes. 3 Hartmann U, Heiser K, Rüffer-Hesse C, Kloth G. Female sexual desire disorders: subtypes, classification, personality factors and new directions for treatment. World J Urol. 2002 Jun;20(2):79-88. 4 Steiner M. Female-specific mood disorders. Clin Obstet Gynecol. 1992 Sep;35(3):599-611. 5 L-Theanine monograph. Alternative Medicine Review 2005;10(2):136-8. 6 Lu K, Gray MA, Oliver C, et al. The acute effects of Ltheanine in comparison with alprazolam on anticipatory anxiety in humans. Hum Psychopharmacol Clin Exp. 2004;19:457–65. 7 Nobre AC, Rao A, Owen GN. L-theanine, a natural constituent in tea, and its effect on mental state. Asia Pac J Clin Nutr. 2008;17 Suppl 1:167-8. 8 Mason,R. 200 mg of Zen. Alternative & Complementary Therapies. 2001; 7(2):91-95. 9 Kimura K, Ozeki M, Juneja LR, Ohira H. L-Theanine reduces psychological and physiological stress responses. Biol Psychol. 2007;74(1):39-45. 10 Higashyama A, Htay HH, Ozeki M, Juneja LR, Kapoor MP. Effects of l-theanine on attention and reaction time response. Journal of Functional Foods. 2011;3(3):171–178. 11 Pongsatha S, Morakot N, Chaovisitsaree S. Sexual in menopausal women comparing perimenopausal and postmenopausal women. J Med Assoc Thai. 2012 Dec;95(12):1489-94. 12 Chervenak JL. Reproductive aging, sexuality and symptoms. Semin Reprod Med. 2010 Sep;28(5):380-7. 13 Overview: Menopause. Created: February 14, 2006; Last Update: September 12, 2013. Institute for Quality and Efficiency in Health Care. Retrieved November 26, 2013 from www.ncbi.nlm.nih.gov/pubmedhealth/ PMH0060468/. 14 Gonzales GF. Ethnobiology and Ethnopharmacology of Lepidium meyenii (Maca), a Plant from the Peruvian Highlands. Evid Based Complement Alternat Med. 2012; 2012: 193496. 15 Balick MJ, Lee R. Maca: from traditional food crop to energy and libido stimulant. Altern Ther Health Med. 2002 Mar-Apr;8(2):96-8. 16 Leon J. The “Maca” (Lepidium meyenii), a little known food plant of Peru. Econ Botany. 1964;18:122-127. 17 Brooks NA, Wilcox G, Walker KZ, Ashton JF, Cox MB, Stojanovska L. Beneficial effects of Lepidium meyenii (Maca) on psychological symptoms and measures of sexual dysfunction in postmenopausal women are not related to estrogen or androgen content. Menopause. 2008 Nov-Dec;15(6):1157-62. 18 Dording CM, Fisher L, Papakostas G, Farabaugh A, Sonawalla S, Fava M, Mischoulon D. A double-blind, randomized, pilot dose-finding study of maca root (L. Meyenii) for the management of SSRI-induced sexual dysfunction. CNS Neurosci Ther. 2008 Fall;14(3):182-91. 19 Meissner HO, Kapczynski W, Mscisz A, Lutomski J. Use of gelatinized maca (Lepidium peruvianum) in early postmenopausal women. Int J Biomed Sci. 2005 Jun;1(1):33-45. 20 Meissner HO, Mscisz A, Reich-Bilinska H, Kapczynski W, Mrozikiewicz P, Bobkiewicz-Kozlowska T, Kedzia B, Lowicka A, Barchia I. Hormone-Balancing Effect of Pre-Gelatinized Organic Maca (Lepidium peruvianum Chacon): (II) Physiological and Symptomatic Responses of Early-Postmenopausal Women to Standardized doses of Maca in Double Blind, Randomized, Placebo-Controlled, Multi-Centre Clinical Study. Int J Biomed Sci. 2006 Dec;2(4):360-74. 21 “USP Safety Review of Maca.” USP Dietary Supplements Compendium. The United States Pharmacopeial Convention; 2009: 4 pgs. 22 Clément C, Diaz Grados DA, Avula B, Khan IA, Mayer AC, Ponce Aguirre DD, Manrique I, Kreuzer M. Influence of colour type and previous cultivation on secondary metabolites in hypocotyls and leaves of maca (Lepidium meyenii Walpers). J Sci Food Agric. 2010 Apr 15;90(5):861-9. 23 Melnikovova I, Havlik J, Fernandez Cusimamani E, Milella L. Macamides and fatty acids content comparison in maca cultivated plant under field conditions and greenhouse. 2012 Boletín Latinoamericano y del Caribe de Plantas Medicinales y Aromáticas. 2012;11(5):420-427. 24 Ganzera M, Zhao J, Muhammad I, Khan IA. Chemical profiling and standardization of Lepidium meyenii (Maca) by reversed phase high performance liquid chromatography. Chem Pharm Bull. (Tokyo). 2002 Jul;50(7):988-91. 25 Ross SM. Menopause: a standardized isopropanolic black cohosh extract (remifemin) is found to be safe and effective for menopausal symptoms. Holist Nurs Pract. 2012 Jan-Feb;26(1):58-61. 26 Osmers R, Friede M, Liske E, Schnitker J, Freudenstein J, Henneicke-von Zepelin HH. Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms. Obstet Gynecol. 2005;105(5 Pt 1) :1074-83. 27 Wuttke W, Seidlová-Wuttke D, Gorkow C. The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers. Maturitas. 2003;44 Suppl 1:S67-77. 28 Juliá Mollá MD, García-Sánchez Y, Romeu Sarri A, Pérez-lópez FR. Cimicifuga racemosa treatment and health related quality of life in post-menopausal Spanish women. Gynecol Endocrinol. 2009;25(1):21-6. 29 Stoll W. Phytopharmacon influences atrophic vaginal epithelium: double blind study – cimicifuga vs. estrogenic substances. Therapeutikum. 1987;1:23-31. 30 Frei-Kleiner S, Schaffner W, Rahlfs VW, Bodmer Ch, Birkhäuser M. Cimicifuga racemosa dried ethanolic extract in menopausal disorders: a double-blind placebo- controlled clinical trial. Maturitas. 2005;51(4):397-404. 31 Oktem M, Eroglu D, Karahan HB, Taskintuna N, Kuscu E, Zeyneloglu HB. Black cohosh and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized trial. Adv Ther. 2007;24(2):448-61. 32 Bai W, Henneicke-von Zepelin HH, Wang S, Zheng S, Liu J, Zhang Z, Geng L, Hu L, Jiao C, Liske E. Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: a randomized, double blind, parallel- controlled study versus tibolone. Maturitas. 2007;58(1):31-41. 33 Nappi RE, Malavasi B, Brundu B, Facchinetti F. Efficacy of Cimicifuga racemosa on climacteric complaints: A randomized study versus low-dose transdermal estradiol. Gynecol Endocrinol. 2005;20(1):30-5. 34 Chandeying V, Sangthawan M. Efficacy Comparison of Pueraria mirifica (PM) against Conjugated Equine Estrogen (CEE) with/without Medroxyprogesterone Acetate (MPA) in the Treatment of Climacteric Symptoms in Perimenopausal Women: Phase III Study. J Med Assoc Thai. 2007; 90 (9): 1720-6. 35 Liske E, Hänggi W, Henneicke-von Zepelin HH, Boblitz N, Wüstenberg P, Rahlfs VW. Physiological investigation of a unique extract of black cohosh (Cimicifugae racemosae rhizoma): a 6-month clinical study demonstrates no systemic estrogenic effect. J Womens Health Gend Based Med. 2002 Mar;11(2):163-74. 36 Vermes G, Bánhidy F, Acs N. The effects of remifemin on subjective symptoms of menopause. Adv Ther. 2005;22(2):148-54. 37 Juliá Mollá MD, García-Sánchez Y, Romeu Sarri A, Pérez-lópez FR. Cimicifuga racemosa treatment and health related quality of life in post-menopausal Spanish women. Gynecol Endocrinol. 2009;25(1):21-6. 38 Briese V, Stammwitz U, Friede M, Henneicke-von Zepelin HH. Black cohosh with or without St. John's wort for symptom-specific climacteric treatment--results of a large-scale, controlled, observational study. Maturitas. 2007;57(4):405-14. 39 Pockaj BA, Loprinzi CL, Sloan JA, et al. Pilot evaluation of black cohosh for the treatment of hot flashes in women. Cancer Invest. 2004;22(4):515-21. 40 Erkkola R, Vervarcke S, Vansteelandt S, Rompotti P, De Keukeleire D, Heyerick A. A randomized, double-blind, placebo-controlled, cross-over pilot study on the use of a standardized hop extract to alleviate menopausal discomforts. Phytomedicine. 2010 May;17(6):389-96. 41 Heyerick A, Vervarcke S, Depypere H, Bracke M, De Keukeleire D. A first prospective, randomized, doubleblind, placebo-controlled study on the use of a standardized hop extract to alleviate menopausal discomforts. Maturitas. 2006 May 20;54(2):164-75. 42 Milligan SR, Kalita JC, Heyerick A, Rong H, De Cooman L, De Keukeleire D. Identification of a potent phytoestrogen in hops (Humulus lupulus L.) and beer. J Clin Endocrinol Metab. 1999;84:2249–52. 43 Milligan SR, Kalita JC, Pocock V, et al. The endocrine activities of 8-prenylnaringenin and related hop (Humulus lupulus L.) flavonoids. J Clin Endocrinol Metab. 2000;85:4912–5. 44 Wuttke W, Jarry H, Haunschild J, Stecher G, Schuh M, Seidlova-Wuttke D. The non-estrogenic alternative for the treatment of climacteric complaints: Black cohosh (Cimicifuga or Actaea racemosa). J Steroid Biochem Mol Biol. 2013 Feb 28. Pii: S0960-0760(13)00038-1. [Epub ahead of print]. 45 Nadaoka I, Yasue M, Kitagawa Y, Koga Y. Oral administration of Cimicifuga racemosa extract attenuates psychological and physiological stress responses. Biomed Res. 2012 Jun;33(3):145-52. 46 Ruhlen RL, Sun GY, Sauter ER. Black Cohosh: Insights into its Mechanism(s) of Action. Integr Med Insights. 2008; 3: 21–32. Gene Bruno, MS, MHS, the dean of academics for Huntington College of Health Sciences, is a nutritionist, herbalist, writer and educator. For more than 30 years he has educated and trained natural product retailers and health care professionals, has researched and formulated natural products for dozens of dietary supplement companies, and has written articles on nutrition, herbal medicine, nutraceuticals and integrative health issues for trade, consumer magazines and peer-reviewed publications. Field researchers have since reported that, in Peru, maca has been used for medicinal purposes and as a source for energy, stamina and endurance, and has been used as an aphrodisiac and tonic for postmenopausal problems.