|Article Type:||Case study|
Impotence (Health aspects)
Impotence (Risk factors)
Cardiovascular diseases (Risk factors)
Hypertension (Complications and side effects)
Smoking (Health aspects)
|Publication:||Name: Australian Journal of Medical Herbalism Publisher: National Herbalists Association of Australia Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 National Herbalists Association of Australia ISSN: 1033-8330|
|Issue:||Date: Spring, 2009 Source Volume: 21 Source Issue: 1|
|Geographic:||Geographic Scope: Australia Geographic Code: 8AUST Australia|
Impotence, according to Miller and Keane (1997), is the inability
to maintain an erection of sufficient rigidity to perform sexual
intercourse. Otherwise known as erectile dysfunction, it requires
interference with the co-ordination of one or more of vascular,
neurologic, hormonal and psychological factors (Brock 2002), with
vascular being responsible in about 70% of cases. Brock (2002) points
out that where erectile dysfunction has previously been an accepted
consequence of aging, it is now recognised that organic causes play a
much more significant etiological role. As a result it becomes a
condition requiring a multifactorial approach that would include
androgen deficiency, lowered vitality, anxiety/stress levels,
circulatory considerations as well as smoking habits, age, pelvic
surgery and the presence of additional endothelial
dysfunction-associated medical conditions (Barada 2004).
With this current patient, there are further complications surrounding his heart attack eighteen months previous, his poor sleep quality and constant tiredness and the possibility that any or all of his cardiovascular medications are causing the erectile dysfunction.
He is in the age bracket for erectile dysfunction, in that after 50 years the prevalence of erectile dysfunction is greater than 50% (Porth 2002), with the added burden of his stressful work environment making him a prime candidate. Hartmann (1998) gave 751 patients with erectile dysfunction and 55 with no dysfunction a multidimensional questionnaire to categorise the prevalence of stress as a causative factor and found that there was a high existence of depression and an extreme extent of performance anxiety in the patient group. Using the Mood and Sexuality Questionnaire, Bancroft et. al. (2003) investigated what happened to sexual interest and response when a) depressed and b) anxious/stressed. They found a 42% decrease in sexual interest when depressed and a 28% decrease when anxious/stressed.
Morbidity factors for endothelial dysfunction are coronary heart disease, hypertension, diabetes and depression (Barada 2004). While we have no indication for whether diabetes is a risk factor, we do know about the others. In fact while these are indeed risk factors, we could also consider erectile dysfunction as a risk marker for these conditions and take the necessary precautions. Brock (2002) uses a case of 2,476 Spanish men who showed a significant positive correlation of erectile dysfunction with diabetes, hypertension, hypercholesterolemia, peripheral vascular disease and cardiac problems that were unrelated to medications, smoking or alcohol.
There have been numerous studies linking erectile dysfunction and cardiovascular disease (Russell 2004. Barrett-Connor 2004, Hooi 2001), with Kim et al (2001) stating that most patients with erectile dysfunction are known to have at least one significant cardiovascular risk factor. Associated with this is the finding by Saltzman et al (2004) that treating hypocholesterolemia may improve erectile dysfunction while promoting cardiac prevention.
By making an assumption that this patient has progressive ischemic heart disease, a further assumption could be that he is also experiencing sleep apnea which is making him hypoxic. Mansfield et al (2004) found that sleep apnea is highly prevalent among patients with heart failure and may contribute to a progression of cardiac dysfunction via hypoxia and hypertension. Li et al (2004) also found that sleep apnea hypoxia contributed to an elevation of endothelin-1 levels in patients with hypertension. This could in turn further aggravate the cardiovascular system dysfunction and therefore his erectile dysfunction. If this patient smoked he would be adding a further risk factor for erectile dysfunction in that there is a significant dose response risk for erectile dysfunction as measured by the pack-a-day and cumulative exposure over many years (Barada 2004).
A further issue to consider with this patient's medical history is his use of medications. He could quite conceivably be on medication for both his heart condition and his hypertension and some of these have sexual dysfunction as a side effect. The May 2004 MIMS CD has given the following side effects for the following three antihypertensives/cardiac agents: a) Felodur: fatigue, depression, cardiovascular effects, impotence/sexual dysfunction; b) Karvea: fatigue, sleep disturbances, arrythmias, depression, anxiety/ nervousness, sexual dysfunction/libido change; c) Avapro: sleep disturbances, depression, cardiovascular symptoms, anxiety/nervousness, depression, sexual dysfunction and stress related disorders. With this knowledge, a thorough assessment of his symptoms in relation to his medication history would be essential.
The priorities are:
Damiana (Turnera diffusa): used traditionally for sexual dysfunction and to enhance sexual activity (Braun 2005). It is considered to be specific in cases of anxiety and depression where there is a sexual factor (Hoffman 2001). Bone (2003) lists it for impotence, sexual inadequacy, nervousness, anxiety and depression.
Siberian ginseng (Eleutherococcus senticosus): according to Bisset (2001) is a prophylactic which increases the resistance to environmental influences and stimuli and reduces susceptibility to illness. According to Bone (2003) it will enhance stamina and minimise the effects of stress. Braun and Cohen (2005) explain that it appears to work by altering the levels of different neurotransmitters and hormones involved in the stress response and acts to increase the levels of noradrenaline and serotonin in the brain and adrenaline in the adrenal glands. In a study of 20 elderly hypertensive patients who on digitalis, Cicero et al (2004) confirmed that Eleutherococcus safely improved both mental health and social functioning after 4 weeks of therapy.
Withania (Withania somnifera): Bhattacharya and Muruganandam (2003) compared the effects of Withania and Panax ginseng and found that both had significant antistress adaptogenic activity, making Withania a viable option when Panax is contraindicated. Gupta et al (2004) studied the efficacy of Withania to limit myocardial injury after ischemia and improve mortality rates after myocardial infarction. They confirmed Withania's action as a cardioprotective agent which can reduce myocardial injury and also confirmed that it had a strong antioxidant effect. A double blind clinical trial of 101 healthy aging males found a 71.4% improvement in sexual performance after taking 3 g per day for one year (Kupparajan 1980). Bhattacharya (2000) explains that Withania is used to promote physical and mental health and to provide protection against disease.
Tribulus (Tribulus terrestris): according to Gauthaman et al (2003) has long been used to improve sexual function in men as well as provide more energy and vitality. Adimoelja (2000) reported that it has been clinically proven to improve sexual desire and enhance the erection. It has the added benefit of supporting coronary heart disease as Wang et al (1990) found when they observed 406 cases of angina treated with Tribulus. They reported an 82.3% rate of remission with a 52.7% rate of ECG improvement with no adverse reaction on the blood and hepatic and renal function if taken long term.
An appropriate formula would be:
Dose: 5 mL with water three times a day to be reviewed in 4 weeks.
Include MediHerb Tribestan as a supplement.
If on further investigation hormonal imbalances are confirmed, Vitex should be given every evening before bed at 2 mL of 1:2 extract: With hormonal imbalances, hyperprolactinemia is likely to be an issue and dopamine is the most important inhibitory factor (Porth 2002). Vitex has dopaminergic activity associated with the inhibition of prolactin synthesis and release in hyperprolactinaemia (Heinrich 2004). A study by Dericks-Tan et al (2003) using 120-480 mg per day of Vitex on males confirmed that the nocturnal release of melatonin makes it a valuable tool in the treatment of insomnia.
Lifestyle advice would include:
* Maintain a healthy body weight as obesity has been shown to be potential risk factors in a review of 1981 men between 51 and 88 years which showed that men with a waistline of 42 inches or more were more than twice as likely to experience erectile dysfunction compared with men whose waistline measured 32 inches or less (Brock 2002).
* If he is on cardiac or hypertensive medication, have a medication assessment done by his doctor and trial different options.
* Identify the main stressors in his life and discuss ways of dealing with them--suggest some holidays!
* Take a CoQ10 supplement as it has been proved to lower blood pressure. Wilburn et al (2004) found after a review of eight trials using CoQ10 for hypertension that there was some degree of reduction. They reported that a double blind trial using 60 mg CoQ10 twice daily on patients already on hypertensive medication, provided protection to pancreatic B cells, liver cells, arterial smooth muscle cells and endothelial cells through its antioxidant action.
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Carolyn Ward BHSc (CompMed) Post Grad Dip HM BEd Adv Dip HM Dip Irid MNHAA
Turnera diffusa 1:2 30 mL Eleuthrococcus senticosus 1:2 15 mL Ginkgo biloba 2:1 20 mL Withania somnifera 1:2 35 mL 100 mL
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