The three most common sexual health problems men experience are erectile dysfunction, low sex drive, and premature ejaculation. This article will cover erectile dysfunction and low sex drive, as the two are often related and it’s important to discuss how they interact. For solutions to premature ejaculation, see my article devoted to it here.
I’ve been able to help many men improve their sexual health and function using the powerful tools of Chinese herbal medicine. In this article I’m going to explain the pathophysiology of erectile dysfunction from both a modern medical and TCM perspective, and share how using the best herbs for erectile dysfunction can help you improve your sex life.
It's important to note that this article is as much about improving sexual performance as it is about treating sexual dysfunction. Sexual function is a spectrum, and we use erectile dysfunction, or ED, as a term to define the more severe end of that spectrum. Whether you are dealing with severe ED, or you’re just wanting to improve erection hardness or sex drive - you can benefit from reading this article. In most cases, normal healthy erections could still be better and the same treatment strategies that can take you from bad to great, can also take you from good to great.
I highly recommend reading through to the end of this article; gaining an understanding of why your body is doing what it’s doing can greatly help inform the path forward to better sexual health.
That being said, if you are ready to jump right in and start working with me to improve your sexual function you can get started with treatment through my online herbal clinic. Our process is easy, fast, and discreet. Just take a few minutes to complete our online intake, and get customized herbal medicine delivered to your door. Interested? Visit the Chinese Medicine page to learn more about the treatment process, and get started by filling out our New Patient Herbal Intake.
We’ll start with erectile dysfunction, or ED. Erectile dysfunction is the inability to achieve or maintain penile erection sufficient for satisfactory sexual performance.
Blood Flow
The single most important factor in erectile function is blood flow. An erection begins with arterial dilation where blood flows into the elastic smooth muscle of the penis, the corpus cavernosum. The blood is then trapped by venous occlusion, which increases pressure in the corpus cavernosum and results in a rigid, erect, penis.
Erectile function decreases with aging of the cardiovascular system. The cardiovascular system is made up of the heart and blood vessels; it’s how blood travels through our body. As the cardiovascular system ages, the smallest blood vessels are affected first. The blood flow to small capillaries can become restricted, or blocked completely. The strength of the heart’s pumping action can become weaker, so it becomes harder for blood to move through the body. One of the first places people notice the effects of the aging cardiovascular system is with cold feet, resulting from poor blood circulation to the feet. For men, changes in erection strength and hardness will often be the first sign that brings the issue to attention.
Erection strength and hardness typically declines gradually with age, and the point at which it becomes problematic for a satisfying sex life is different for everyone. Sometimes this threshold can feel like a sudden change, other times it feels more gradual. This can happen in your 20s, 30s, 40s, all the way up to your 80s.
If you look to modern medicine for solutions to ED, the answer is also all about blood flow. Phosphodiesterase 5 (PDE5) inhibitors like sildenfil (aka Viagra), taladafil, and vardenafil etc all work by increasing blood flow to the penis. These medications work for 60-70% of men with ED. This confirms that the majority of ED is strictly related to problems with blood flow to the penis.
PDE5 drugs do have problems though, which is why 50% of men stop taking them within a year. Some of these problems are logistical annoyances and inconveniences, and other problems are side effects and legitimate health risks. This is where Chinese herbal medicine comes in; we can address the problem in a holistic way without causing the logistical problems or the side effects and health risks. If you want to read more about the problems with PDE5 drugs like sildenafil, you’ll find that section at the end of this article.
If you’re dealing with significant ED or if your erections just aren’t as hard as they used to be, improving blood flow and cardiovascular health is the most important aspect to address. This is more obvious if you have high cholesterol, high blood pressure, or a family history of heart disease, but it’s also true if you have none of these. Even if you run, workout regularly, and eat healthy - improving blood flow is still the most important aspect of improving sexual function. I have worked with lots of young men in their 30s and 40s who are usually incredulous that their cardiovascular function could be affecting their erections, but when they take my herbal formulas and their sexual function improves (sometimes dramatically) they are happy with the results. I’m not sure if they end up believing that’s why the treatment works or if they don’t actually care. Either way, I’m happy that they’re happy.
To help men with ED, low sex drive, and other forms of sexual dysfunction I provide individualized treatment through my online herbal clinic. I assess each person’s specific needs, and provide intensive Chinese herbal medicine treatment. Each formula is composed of roughly 12-18 herbs that are specifically chosen to fit the needs of each individual, whether that’s focused on improving cardiovascular function, increasing the production of sex hormones, regulating stress, or any other aspect that needs to be addressed.
In my herbal clinic we use more than 400 individual herbs, and there are many to choose from for improving cardiovascular health and blood flow. Some of my favorites include Dan Shen, Wang Bu Liu Xing, San Leng, and E Zhu.
2. Energy Reserves
Now, because you’re reading a Chinese Medicine blog you might think I would use the word “energy” in an esoteric or metaphysical way, but I generally do not. I use it in the common or scientific sense of the word.
en·er·gy
/ˈenərjē/
a. the strength and vitality required for sustained physical or mental activity.
The primary biological purpose of sexual function is to enable us to reproduce. The dopamine and oxytocin driven pleasure that humans experience during sexual activity is a trait that evolved presumably to make sure that we keep having sex and keep reproducing to pass on our genes. But in the bigger picture of our body’s needs, reproduction is an accessory function. When our body has adequate resources, nourishment, and energy to sustain our health, our body can divert extra energy towards reproductive function.
If we do not have adequate energy reserves to maintain our own health, our body will treat sexual function as an unnecessary function. It’s not essential to our survival, and when our energy reserves are low, it will shut down reproductive function and divert all power to life support.
Chronic stress, overwork, overexertion, and lack of good quality sleep are common factors that will drain our energy reserves. All of these issues also negatively impact cardiovascular health and function so they can be a double whammy to knock down erectile function.
Some of my favorite herbs to improve energy reserves in treating ED are Ren Shen, Wu Jia Shen, Hong Jing Tian, and Ba Ji Tian.
3. Nerve Function
Sensation and sensitivity in the penis is governed by the pudendal nerve, which is a branch of the sacral spinal nerves S2-S4. These nerves branch out from the spinal cord at the sacrum, a triangular shaped bone just below the lumbar vertebrae. The nerve carries messages back and forth from the brain to the penis. Sexual arousal can begin from the top down (brain first) or bottom up (sexual stimulus first) and generally it’s a complicated back and forth between the two. Arousal in the brain sends signals down the spinal cord, through the pudendal nerve, to the penis to initiate blood flow into the penis to create an erection. The nerves in the penis sense sexual stimulus and can signal the body to send blood to the penis.
Problems with pudendal nerve function can diminish sensitivity to stimulus and interrupt the signaling from the brain to the penis, resulting in erectile dysfunction. There are two common ways that the sacral spinal nerves and pudendal nerve branch can be injured.
The first is through physical injury to the low back and sacrum. Low back injury can cause compression of the sacral spinal nerves. If there are two things us men like to be proud of, it’s hard erections and our ability to lift heavy objects beyond our actual abilities. I’m joking, but this is also very real. The question is not “can you lift it?” The question is “can you lift it without causing long term damage to your back which can cause very real problems with getting hard erections in the future?” But damage to the sacral spinal nerves doesn’t only happen from irresponsible heavy lifting. Long term strain on the low back from manual labor, repetitive stress, or even excessive sitting can all cause structural damage to the sacral spinal nerves.
The second means of damage to the sacral spinal nerves is from…you guessed it, lack of blood flow. Nerves rely on both exogenous and endogenous blood supply to function normally, meaning that the nerve is fed by both blood supply from the small arteries and vessels in the tissue surrounding the nerve, and by epineurial vessels within the nerve tracts. So decreased blood flow as a result of cardiovascular aging will also negatively affect the nerve’s ability to function normally, affecting both sensation and sensitivity of the penis and normal signaling between the sexual stimulus, the brain, and initiating erections.
For repairing nerve function in ED, the primary treatment I use is herbal medicine but this is one aspect of ED where orthopedic acupuncture treatment of the low back and sacrum can be very helpful. Please note: acupuncture for ED does not involve needles in or around the genitals.
Some of my favorite herbs to use for this aspect of ED include Huang Qi, Dang Gui, and Chuan Xiong.
Ok, so here’s where the terminology gets a little esoteric. My practice is completely based in Chinese Medicine, but I do my best to explain concepts with modern terminology and avoid using TCM terminology whenever possible - because if you don’t speak Chinese and you don’t practice Chinese Medicine, most of the terms we use are going to be more confusing than educational. But when it comes to Jing - translated as essence - I’m just not sure there’s an equivalent concept in modern medicine.
Semen is the Latin word for seed. In the study of plants, we know that plants devote a huge amount of resources to developing seeds to pass on their genetic material. If a plant is lacking adequate water or nutrients, it may not produce any seeds (aka fruit) at all. Of course humans are different from plants, but maybe not as different as we think.
The seed or semen is the essence of the plant or human. And I mean this in the literal sense that it contains the genetic material of that person, the blueprint to create a whole new person. But the TCM concept of Jing is more than just the semen, it also represents the overall quality of vital substances in our body. We don’t tend to think our body is doing anything special by producing semen, since it does so without our thinking about it. In fact, it devotes a good deal of energy and material resources to that task so that we can reproduce. Producing semen is dependent on our body having adequate energy, and being well nourished with adequate nutrition.
Jing is closely related to energy as discussed above, and could be placed under its umbrella. But there are a few aspects that are not covered by the discussion of energy reserve. Like cardiovascular function, essence declines over time. We think about this like a deep well that our body draws from and slowly uses up. In men, Jing also relates to ejaculation and the refractory period. Even though erections are formed by increased blood flow to the penis, our body’s biological presumption is that this will ultimately serve to deliver essence to serve for reproduction. So even if there is adequate blood flow to the penis, if there is not adequate Jing there may be no erection - because your body's biological drive doesn't see the point if your erection won't be able to deliver a good dose of genetic material.
The refractory period in men is the period of time after ejaculation during which they are not sexually responsive. This period of time increases with age, as the reserve of Jing diminishes. So if it only took 5 minutes before you were ready to go again when you were 18, at 40 it might be 30 minutes before you are ready to go again, and at 70 the refractory period can be 24 hours or longer. The refractory period varies from person to person, but it does increase with aging. Lifestyle factors like excessive ejaculation or overuse of certain drugs can drain the essence reserve faster. On the flip side, the Jing reserve can also be replenished by using the right herbal medicine, food, and lifestyle.
Some of my favorite herbs to use for nourishing Jing include Tu Si Zi, Wu Wei Zi, Lu Rong (Deer Antler), and Yang Shen (Goat testes and kidney).
Love Pearls is an encapsulated herbal formula excellent for nourishing essence. I frequently recommend it to men who don’t have notable erection problems, but would like to improve erectile function, sex drive, and just overall to have more fun in the bedroom. Like most practitioner-grade Chinese herbs, Love pearls is only available directly from TCM practitioners. You can contact me to see if it’s a good fit to benefit your sex life.
Performance anxiety is a common contributor to poor sexual performance. In performance anxiety, the body enters a sympathetic nervous system state in response to some form of stress. In this state, known more commonly as the "fight or flight" response, the body is prioritizing blood flow to deal with potential dangers, and one place it's not sending blood is to the penis. Performance anxiety can cause problems all on its own, but it frequently happens concurrently with other physical causes of ED.
The nervous system has two primary modes, the sympathetic state and parasympathetic state. The sympathetic state — “fight or flight” — evolved to help us deal with danger and conflict. In this state our body is gearing up to generate maximum power to our large muscle groups to run for our lives or strike, kick, or claw our way out. The adrenal glands release cortisol, our body converts glycogen stores into glucose to spike blood sugar, and blood pressure rises. All things that are helpful for surviving physical danger, but not at all helpful for creating and maintaining an erection.
Then there’s the parasympathetic state, commonly known as “rest and digest”. This is the state where we relax, where our body heals, recovers, and digests. In the parasympathetic state, the smooth muscle of the corpus cavernosum can relax and blood vessels can dilate to more easily create an erection.
For millions of years, our hominid ancestors dealt with very physical and life-threatening dangers and our “fight or flight” response developed to help us deal with them and it made sense. But today, even though most people don’t encounter that type of danger, our “fight or flight” response still comes out to play, only now it can be in response to the stress of a mean email, a work deadline, a verbal conflict, or being nervous about performing — whether it’s on stage or in the bedroom.
While performance anxiety can be the sole contributor to erectile dysfunction, it's much more common for other physical causes of ED to start reducing sexual performance, which initiates performance anxiety about the change in performance, and then this feedback worsens ED further. So in my clinical practice I have found it most effective to use herbal medicines to help the man feel more relaxed while simultaneously using herbs that address the physical causes of ED and improve erection hardness and strength.
Here is an example of the most common way performance anxiety manifests.
It starts with the man experiencing loss of erection strength and hardness or complete inability to sustain an erection resulting from a physical origin - cardiovascular aging, lack of energy, nerve injury, and/or essence exhaustion. It could be as simple as trying to have sex after a long week of work and just being too tired.
This results in a disappointing sexual experience, whether that’s experienced just by the man or also by his sexual partner.
The mental and emotional stress related to expectations not being met, feeling bad, etc create a feedback loop, and the man begins to experience performance anxiety around sexual activity, which further limits the amount of blood going to the penis and worsens the erectile function even more.
My approach is to focus treatment on the root of the problem — which again, in the majority of men is all about blood flow. This approach works very well. We basically blast so much healthy blood flow into the penis that the man starts getting consistently good erections.At the same time we include herbs that help reduce stress and feelings of anxiety. It’s hard for the brain to keep up the mental pattern of performance anxiety when the feedback it’s getting is consistently good erections and sexual function.
Some of my favorite herbs for helping men with performance anxiety to feel more relaxed include Bai Shao, Xiang Fu, and He Huan Pi.
Now let’s get into low sex drive or low libido.
Sex drive and libido are synonyms for sexual desire and interest in sex. Going forward I will primarily use the term sex drive. Sex drive and erectile function interact in important ways, but they are separate things. You can have healthy erections and no sex drive, and you can have high sex drive with erectile dysfunction. It’s common for men to refer to sex drive or libido when they are actually having a problem with erections because there is less stigma with reduced sex drive than with ED.
Sex drive is complex, and involves sex hormones, mental patterns, energy reserve, and essence. Erectile dysfunction interacts with sex drive in a similar way to how it can cause performance anxiety. Loss of erection strength and hardness can reduce sex drive as a result of the mental feedback. In this case, improving erectile function can improve sex drive but the converse is generally not true. For example, increasing sex drive without addressing the problems causing ED will not generally resolve the ED. This is where many of the common herbal aphrodisiac strategies fail to help men with ED. There are many herbs that help stimulate sex drive and desire for sex, but do nothing to help the blood flow to the penis. Some herbs are good at doing both. Most herbal supplements that are sold to enhance sexual performance are focused on increasing sex drive, not on improving erectile function.
When I am working with a man to help improve sex drive, I use herbal medicines to improve energy reserves, supplement essence, and when appropriate, to support the production of sex hormones (like testosterone).
Some of my favorite herbs I use to help increase sex drive include Yin Yang Huo, Xian Mao, as well as some of the same herbs I use to nourish essence like Lu Rong (deer antler).
The problem with sildenafil (and other PDE5 inhibitors)
There are both logistical and safety problems with PDE5 inhibitors, so while they work to treat ED in the majority of men, they have some significant downsides which I’ll cover here.
Logistical problems. Sildenafil takes about 30-60 minutes to start working so the typical recommendation will be to take it one hour before sex. Now, for a lot of people timing sex doesn’t work like that. Maybe you’re on a date and you don’t think sex is on the table, turns out it is, but you didn’t plan ahead. Or maybe you do plan ahead, but sex is actually not on the table, and now you’re dealing with some of the side effects like headache, dizziness, nasal congestion, and a potentially awkward erection. Taladafil is longer acting, so it can help with some of the complications around timing sex, but it doesn’t get around the side effects.
PDE5 inhibitors cause aggressive vasodilation (opening of the blood vessels) and can lower blood pressure, so if you’re a person with normal or low blood pressure, PDE5 inhibitors can cause dizziness or even fainting - generally not the sexiest way to present yourself.
PDE5 inhibitors also act on the blood vessels in the lungs, and on the erectile tissue in the nasal passages which can result in side effects like chest pressure, headaches, and stuffy nose. Aggressive vasodilation of blood vessels in the digestive tract can cause symptoms like nausea and it can worsen existing ulcers.
Safety problems. Some of the side effects that are logistical problems or inconveniences also point to the health risks with PDE5 inhibitors. The root cause of the majority of ED, and especially the type of ED that responds well to PDE5 inhibitors is lack of good blood flow to the penis. This lack of good blood flow is caused by problems in the cardiovascular system. And yet, patients have to be screened for cardiovascular disease before being put on drugs like sildenafil. This is because these drugs have the potential to worsen cardiovascular disease and increase risk of cardiovascular events.
Now, if you google that you’ll find nothing but studies that suggest PDE5 inhibitors actually improve cardiovascular outcomes. I’m generally not one for bandying medical conspiracies, but sildenafil is one of the most successful drugs in modern history, and when it first came out it was abundantly clear that it could increase risk of cardiovascular events like heart attack. It happened to enough people in real life that it became a commonplace event in movies. The classic movie scene is the older male politician taking a little blue pill to have sex with his younger secretary, then dying of a heart attack on the conference table. Today there is almost no information anywhere that indicates these risks, except for the fact that doctors are required to screen for signs of cardiovascular disease before prescribing PDE5 inhibitors. The little blue pill lobby even has so much power that you legally cannot advertise any alternative medicines for ED almost anywhere on the internet; they own advertising rights on Google, Facebook, and Instagram.
Simply put, in cases of ED the heart and blood vessel system isn’t up to the task of supplying blood to the penis. The drug forces the body to prioritize blood to the penis, effectively robbing the heart and other parts of the body of blood which may be needed elsewhere. Like the old saying goes "don't let your dick write a check that your heart can't cash."
It may sound like I’m real down on PDE5 inhibitors. In fact I think they can be very important medicines when used in the right context. I just think that clinical herbal medicine treatment is safer, more convenient, and can address all the aspects that contribute to sexual dysfunction in a much more comprehensive and holistic way. With herbal medicine treatment through my clinic, you don't have to worry about awkwardly timing sex, headaches, lightheadedness, chest tightness, etc.
I hope you found this article helpful in understanding the factors involved in male sexual function. If you're ready to radically improve your sex life with the power of clinical Chinese herbal medicine, you can get started at my online herbal clinic. Check it out here.
Get into it! - Sean Dugan L.Ac.
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