HIV and Sexual Functioning: What's (Not) Up?
Many people living with HIV experience problems with sexual performance at times. There are three phases of sexual function: libido (sexual desire), arousal (erection in men and swelling and lubrication in women), and orgasm. It is necessary for all three phases to function for sexual performance. The causes of poor libido or desire include depression and other psychological factors, side effects of medication, and medical diseases. The causes of poor arousal include side effects of medications, diabetes, circulatory problems or improper function of the blood vessels, alcohol and other drugs, and low testosterone levels. The causes of failure to have an orgasm include psychological problems, side effects of medications, and use of alcohol and/or drugs.
The initial assessment should include a thorough history of sexual problems, a careful physical exam, determination of which phases of sexual performance are not functioning properly, a review of all current medications and their potential to interfere with sexual performance, and measurement of testosterone levels, both "total" and "free." While testosterone is critical to libido and sexual performance in both men and women, the range of normal values is better known for men than women. Testosterone replacement in women may be associated with undesirable masculinizing side effects, such as facial hair growth and deepening of the voice. In both men and women, testosterone or other steroid supplementation may increase cholesterol levels, or cause adverse effects on the liver or heart.
There are three good options to supplement testosterone: injections, skin patches (Androderm®), and a gel applied daily (Androgel®). Although there are many supplements on the market claiming to raise testosterone levels, buyers should be wary. Several herbs, however, have been studied for their ability to increase hormonal levels in both men and women. Of particular interest is the herb tribulus, which has been shown in recent studies to increase levels sex hormones in both men and women without any deleterious side effects. However, finding tribulus in local health food stores may still be difficult.
Many over-the-counter products to increase testosterone levels are currently on the market. Many of these contain testosterone precursors, such as androsterone and DHEA (dehydro-epiandrosterone). The scientific literature regarding the effectiveness of taking these precursory hormones remains mixed. However, taking any hormone can lead to suppression of the body's natural ability to produce it on its own. Before considering supplementation, consult a physician and request a blood test to measure serum levels. Just like free and total testosterone, serum levels of DHEA-sulfate and androsterone can be determined by testing. If levels are below normal levels, then supplementation could be considered. Other methods of increasing DHEA levels do exist. Several studies demonstrate the effectiveness of meditation, walking, and exercise in significantly raising DHEA levels.
The herb yohimbine has been used to increase libido in men only. Available in both herb and pill form (by prescription from your doctor), yohimbine is an alpha-adrenergic blocker and has been used for erectile dysfunction of both vascular (poor circulation) and psychological causes. In both cases, yohimibine was shown to improve libido and penile blood flow. Studies still have not demonstrated that yohimbine is useful in increasing testosterone levels, although it has been argued that this property exists.
The use of yohimbine for women with decreased libido is not advised. In addition, the warnings for yohimbine use are more severe for those on antiretrovirals. Yohimbine can lead to panic attacks and anxiety. Furthermore, it has been shown to elevate blood pressure and heart rate, induce headaches, and cause skin flushing (all signs that occur in anxiety). Finally, yohimbine should never be used by individuals with kidney disease.
Panax Ginseng has also been recommended to improve libido in men; however, not much evidence exists for its ability to increase testosterone levels. Still, ginseng has been used effectively for thousands of years as a tonic to combat fatigue and exhaustion and to aid concentration. With increased vitality and strength, sexual function can improve. Ginseng is a Chinese medicinal herb and its use is based on constitutional symptoms rather than simply one symptom alone, such as fatigue. For better insight as to its suitability, it is best to consult an acupuncturist or herbalist regarding its use.
A careful physical exam should also be conducted with special attention paid to the vascular system. Inadequate blood flow to the genital area can cause sexual dysfunction. Special studies can be done to measure penile blood flow. In the general population, it has been estimated that the majority of men over 50 years old who suffer from impotence have atheroscelerosis of the artery to the penis (JAMA 1993). Since elevated cholesterol and triglyceride levels lead to atherosclerosis of the penile artery, men currently on highly active antiretroviral therapy (HAART) would benefit from herbs and supplements that improve their overall circulation.
The herbal remedy gingko biloba is extremely useful in maintaining and improving the flow of blood throughout the entire vascular system. Studies comparing gingko biloba to papaverine injections showed significantly enhanced blood supply to the penis, resulting in improved erectile ability within 6 to 8 weeks for the gingko, and further improvement 6 months later. Gingko offers other benefits in addition to its usefulness in erectile dysfunction. Gingko has been effective for improving memory and concentration, reducing the frequency and severity of headaches, and eliminating dizziness and tinnitus. Use of gingko is relatively safe and has been recommended at a dosage of between 60 and 120 mg a day, standardized to contain approximately 24% gingkoflavonglycosides or gingkolides (the active constituents of gingko). The main caveat with gingko is for people taking blood thinners to prevent clots. Because gingko is a potent inhibitor of platelet-activating factor (which is responsible for forming clots), it is recommended that gingko not be taken with blood-thinning medication to avoid the danger of too much blood thinning.
Other herbs that have been known to decrease the risk of atherosclerosis, mainly by lowering the levels of lipids (cholesterol and triglycerides), are garlic, curcumin, fenugreek, artichoke, and ginger. Using herbs in foods rather than taking supplements in pill form can be an easy and healthy way to improve blood flow throughout the body. Essential fatty acids play a vital role in maintaining proper circulation as well, and should be considered in any plan for decreasing lipid levels (see "Ask Dr. Brad" in this issue).
It should be noted that several lifestyle factors also influence circulation throughout the body, and may have a direct effect on the blood supply to the penile artery. Smoking, excessive alcohol intake, lack of cardiovascular exercise, coffee consumption (both caffeinated and decaffeinated), and a diet high in saturated fat and cholesterol and low in high-fiber plant foods (such as vegetables, grains, fruits, nuts and seeds) are all factors in increasing cholesterol and triglycerides and decreasing blood flow.
Interestingly, exercise, both aerobic and weight resistance training, has been shown to increase libido in both men and women. Whether this is a result of increased circulation and decreased lipid levels or whether this is merely a positive side effect of mood enhancement is unknown. However, exercise consistently demonstrates a positive effect on mood and enhanced self-esteem. Because of these overall benefits, consider getting to the gym at least 3 times a week for both cardiovascular as well as weight training.
Other options to improve sexual performance include psychotherapy, when appropriate, changing of medications that may be interfering with sexual performance, and Viagra®. For many people, the association between sex and the risk of HIV transmission has a major dampening effect on sexual desire and performance. A cautionary note: protease inhibitors increase the blood levels of Viagra®, so people on protease inhibitors should use lower doses of Viagra®. Many people with HIV are reluctant to discuss their sexual problems with their healthcare providers. This may be due in part to the perception that their healthcare providers would not approve of them being sexually active. However, as long as people who are HIV-positive are using safer sex practices, they should not have to abstain from sex, or be afraid to discuss their sexual problems with their healthcare providers.
The role of testosterone supplementation and Viagra® in female sexual dysfunction has been largely ignored by research to date. Hopefully more attention will be paid to the treatment of sexual dysfunction in women.
One final note: As there are many manufacturers of nutritional supplements, choosing a reputable brand is paramount. Many brands claiming to contain the herb or hormone listed, in fact, do not. To ensure quality control, consult your M.D., naturopathic physician, acupuncturist, or herbalist. Many buyers clubs strive to ensure quality control as well.
This article was provided by Seattle Treatment Education Project. It is a part of the publication STEP Perspective.