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Dietary Supplements for Male Sexual Enhancement

Gayle Nicholas Scott, PharmD DISCLOSURES October 26, 2015

Question

"Herbal Viagra" has been in the news recently. Are these products safe and/or effective? Gayle Nicholas Scott, PharmD Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia

Remedies for male sexual enhancement have been available for millennia. The Ebers Papyrus, dating back to around 1600 BC, recommended topical application of baby crocodile hearts mixed with wood oil. A Sanskrit text written six centuries earlier suggested a man could visit 100 women after consuming a mixture of goat testes boiled in milk, sesame seeds, and the lard of a porpoise. Impotence, a nonspecific term that includes both erectile dysfunction and reduced libido, is clearly not a condition limited to modern civilization.

Erectile dysfunction affects an estimated18 million men in the United States, with a prevalence of 18.4% in men aged 20 years and older. Prevalence increases with age, ranging from 5% in men aged 20-39 years to 70% in men aged 70 years and older. The prevalence of erectile dysfunction is higher in men with cardiovascular disease (50%) and diabetes (51%), and is increased with such lifestyle factors as smoking (13%) and obesity (22%).

Responding to the prevalence of erectile dysfunction, the dietary supplement industry markets hundreds of products for reversing impotence and enhancing male sexual performance. Legally, dietary supplement labels cannot make medical claims, such as "for treatment of erectile dysfunction"; however, such claims as "to enhance sexual function" are permissible. An Internet search for "male sexual enhancement products" yielded more than 2 million hits, with websites offering products for purchase as well as information and testimonials.

Labeled Ingredients

Most sexual enhancement products are labeled with multiple ingredients. Commonly listed ingredients on male enhancement products include Butea superba (red kwao krua), Chlorophytum borivilianum (safed musli), Crocus sativus (saffron), dehydroepiandrosterone (DHEA), Epimedium grandiflorum (epimedium, horny goat weed), Eurycoma longifolia (tongkat ali, pasak bumi), Fadogia agrestis (fadogia), Ginkgo biloba, Lepidium meyenii (maca), Muira puama (potency wood), Panax ginseng, Pausinystalia yohimbe (yohimbe bark, not to be confused with the prescription drug yohimbine), Pinus pinaster (pycnogenol, pine bark), Serenoa repens (saw palmetto), Turnera aphrodisiaca (damiana), and Tribulus terrestris (devil's weed, goathead). Vitamins, minerals, and amino acids, such as L-arginine and propionyl L-carnitine, are frequent additions.

Many of these products have been studied only in male rats, but the few studies in men have been small or poorly designed, limiting conclusions about efficacy and safety.

Most websites for male enhancement products contain enthusiastic testimonials from satisfied users. But the question remains of whether these products really work, despite the dearth of clinical evidence supporting the efficacy of the ingredients.

Unlabeled Ingredients

Some products for sexual enhancement augment sexual activity, but the labeled ingredients may not be the source of the effect. Of the 232 drug recalls by the US Food and Drug Administration (FDA) between 2007 and 2012—all for unlabeled drug ingredients—51% were dietary supplements. Of the dietary supplement products recalled, sexual enhancement products were the most commonly recalled (40%), followed by bodybuilding (31%) and weight-loss products (27%).[7] Of the 1560 Health Safety Alerts for dietary supplements issued by the FDA MedWatch and Health Canada between 2005 and 2013, 33% were for sexual enhancement products.

Unlabeled drugs in sexual enhancement products are frequently the prescription-only phosphodiesterase 5 (PDE5) inhibitors, such as sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Stendra®). With increasing frequency, the unlabeled drugs may be analogues of PDE5 inhibitors that have been modified slightly from the parent structures. These derivatives are not detected by routine laboratory screening, which reduces the risk for both detection by the FDA and lawsuits for patent infringement.

To date, more than 50 unapproved analogues of prescription PDE5 inhibitors have been identified.

Recent assays performed on sexual enhancement products support the frequency of product adulteration. Of 91 products analyzed, 74 (81%) contained PDE5 inhibitors, including tadalafil and/or sildenafil (n = 40) or PDE5-inhibitor analogues (n = 34). Of the products containing prescription ingredients, 18 contained more than 110% of the highest approved drug product strength.

Another study of 150 sexual enhancement products (eg, Evil Root, Herbal Stud, Magic Sex, ULTRASize) found 61% of the products were adulterated with PDE5 inhibitors: 27% with sildenafil, tadalafil, or vardenafil, and 34% with similar structural analogues. Among the adulterated products, 64% contained only one PDE5 inhibitor and 36% contained mixtures of two to four PDE5 drugs or analogues. The amounts of PDE5 inhibitor prescription medicines were higher than the maximum recommended dose in 25% of products.[8] Unlabeled yohimbine, flibanserin (Addyi™, which was recently approved by the FDA for female sexual dysfunction), phentolamine, DHEA, and testosterone also were found in some supplements.

Other researchers have found similarly adulterated products, many containing PDE5 inhibitor doses in excess of labeled amounts.

Safety Concerns

Although dietary supplements are marketed as "all natural" with implied safety, the available research suggests caution. A recent survey indicates that cardiac symptoms were a frequent cause of emergency department visits among men aged 20-39 years taking sexual enhancement products.[14] The actual prevalence may be higher, because the presence of unlabeled PDE5 inhibitors may easily go unrecognized by clinicians. Common adverse effects of PDE5 inhibitors, such as flushing, lightheadedness, or dyspepsia, may be attributed to niacin and yohimbe, ingredients often found in sexual enhancement products. Profound hypoglycemia after ingestion of sexual enhancement products containing sildenafil and glyburide (Micronase® and others) also has been reported.

The covert addition of analogues of PDE5 inhibitors, which are not readily detectable by chemical screens, is particularly concerning. Although these chemical cousins of PDE5 inhibitors may retain the desired pharmacologic effect, none have been clinically tested for safety and toxicologic effects.

Obtaining dietary supplement products for sexual enhancement products has several perceived advantages. The purchase can be made discreetly, conveniently, and without a visit to a prescriber. Unlike drugs, dietary supplements are not required to be labeled with adverse effect or drug interaction information. Men taking prescription drugs, such as nitrates, may perceive dietary supplements for sexual enhancement as safe alternatives to contraindicated PDE5 inhibitors.

Clinicians should maintain a high degree of awareness for the potential for adverse effects of sexual enhancement products in men with unexplained cardiovascular symptoms. Patients who express interest in sexual enhancement supplements should be referred to their healthcare provider. Explain that even though a PDE5 inhibitor is not on the label, the supplement may have these ingredients added illegally without regard to patient safety. Patients should be warned of possible changes in vision and decreases in blood pressure, and the potentially dangerous combination of PDE5 inhibitors and nitrates that require medical advice. PDE5 inhibitors are substrates of cytochrome P450 3A4 (CYP3A4). Monitoring is required to avoid an interaction with CYP3A4 inhibitor drugs, such as erythromycin, which may result in high PDE5 levels.

In summary, advise patients that dietary supplements for sexual enhancement fall into one of two categories: those that might be safe but do not work, and those that might work but are not safe.

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Sciencists say penises are getting bigger (and we're here for it)

If you're partial to a large penis, we may have some good news for you. Yup, scientists have announced the average size has gone up. Bendy penises, tattooed penises, small penises, they're all great in their own unique way and we're here for them all. And of course while we all know size does not matter, some people just genuinely prefer a monster cock and that's okay too.

The Mirror reports SKYN, who make condoms, worked with King's College in London to measure over 15,000 penises last year. They found the average, when erect, was 5.16 inches in all its glory.

This year though, it turns out the average for millennials has shot up to 6.1 inches. Don't go celebrating too quickly though because when you delve deeper it all sounds a bit suspicious, doesn't it? This time around, participants were left to their own devices and allowed to enter their own length via an online form. Anyone else see a glaring error here?

So only like 3,000 men participated this time and obviously could exaggerate slightly about their size. Not saying they all lied, but we're guessing a fair number of them added an inch or two, which is to be expected, right?

Pressure is heaped on guys from all angles 24/7 to have the biggest, meatiest cocks and to give their sexual partner super orgasms that'll blow their bits off. When really, we all know most people who are interested in penises sexually give zero fucks about how big they are.

It's kind of a shame that this research is so fallible though, because millennials could really do with some positive news right now. It's bad enough we'll never get on the property ladder and will be working until we're 100. This could have been our tiny glimmer of hope.

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It is the secret dream of every Swedish or German woman to marry a black men, or at least have sex with a black man. Every smart young African man should migrate to Europe. Free money, nice house, good sex! ---

'I'm scared that my vagina smells. Will other people have noticed?'

You’re not alone. A lot of people are worried about how their genitals smell and look. And I’m glad you asked the question. This remains a taboo area, so people who are anxious about their bodies may feel unable to ask for advice. Or are unaware there are things they can do to help themselves.

This reply hopefully includes information that is directly useful to you, but may also help other people worried about body odour.

We all smell

At the risk of stating the obvious, everyone’s genitals smell. They all have a natural scent and may also sometimes smell of pee, poo or sweat. Or blood if you’ve got your period, or have recently given birth (or experienced pregnancy loss), or had genital surgery.

You may notice more of a smell from your genitals during or after sex. Women may notice at different times in the month their genitals smell more strongly, and that may also be the case during pregnancy.

But we’re led to believe by our media, self-help industry, peers and some cosmetic manufacturers that genitals should not smell. Or rather if they do, it should only be of soap or perfume.

That means if you can smell your body you may be embarrassed, or assume you are dirty, or there’s something wrong with you.

This is reinforced through jokes or shaming – suggesting women whose genitals smell must be promiscuous, diseased or unclean. This can prevent women accessing healthcare, especially if they are young or unmarried or living in cultures or communities where virginity is highly valued and pre-marital sex frowned upon.

So the first thing is to work out is the smell normal for you and your body? Does it even exist? Or are you anxious about your genitals because you’ve learned that anything not covered up with a spray or fragrance is disgusting?

If so you may be able to reassure yourself nothing is wrong with you and note what you have been taught about your genitals is unhelpful. Alternatively, if you are noticing an ongoing unpleasant smell - particularly if it you haven’t had it in the past; or if it’s associated with pain, unexplained bleeding, or discharge - this should certainly be investigated further.

Check for yourself

As you aren’t certain if you do smell, it’s useful to do some personal detective work.

Can you recall when you first noticed the problem? What reduces the odour, or makes it stronger?

Keep a diary for the next week. Notice if the smell is present all the time or at specific times of day.

Does wearing particular clothing trigger it? Is it relieved by washing or does that make no difference (or even seem to make it worse)? If you sniff your underwear, jeans, tights etc after wearing them for a few hours do they smell bad?

More than just an odour

Although it isn’t always the case, genitals that are very smelly may often be accompanied by a discharge. As with genital smells, genital discharge is also normal and this guide from Scarleteen explains what this looks like.

However, you should be concerned if you notice a smell that is fishy, yeasty or cheesy AND…

• An unusual discharge that may be green, yellow or grey; have blood in it; or be frothy or very thick

• Stinging or burning sensations when you pee, or pain/discomfort inside your vagina, or stomach/low back pain

• If you are running a temperature and feeling feverish.

What could be the cause?

There are a number of reasons that might be causing your genitals to smell. Although it may be necessary to see the doctor, you may first want to try the following to see if it clears things up.

• Stop using vaginal deodorants, heavily scented soaps or other products that may aggravate your genitals. If you’re washing frequently because you are worried that you might have body odour this may be making things worse. Washing with water may be more soothing and this guide on genital hygiene may be useful.

• Check if any washing powder/fabric softener could be causing irritations and switch to non-allergenic brands.

• If you are worried about the smell being caused by a lack of hygiene, then washing regularly and wearing clean underwear should resolve the problem.

• Tight clothing – underwear, tights, trousers and so on, can aggravate the genital area. So looser clothes, or time without underwear on may help.

• If you use tampons, a Mooncup, contraceptive cap or diaphragm, then ensure these aren’t still inside you.

Some antibiotics and other medications can cause problems like thrush, which in turn can lead to genital itching and possible smell. Similarly health conditions, including diabetes, can lead to vaginal irritation.

Alert your doctor if you think this might be the cause of your odour problem.

Other possible reasons

The contraceptive pill can also lead to a change in discharge or a smell. Ask whoever supplies your contraceptives (family planning clinic/doctor) if you are experiencing problematic side effects and perhaps discuss other contraception choices.

Alternatively if you have a coil there may be a chance of an infection from that, which is leading to smell, discharge or other symptoms (see above) - in which case you should seek immediate medical advice.

Women with a disability that affects mobility or who have a catheter may experience genital irritation, soreness and smell. For those with support packages and PAs (personal assistants) there may be some concern over discussing genital issues and body odour, particularly for younger people. Considerations around dignity, respect and hygiene are vital however this does not mean the only response to noticing genital odour is washing (more on this later).

Trans Women may have concerns about vaginal odour that may or may not be related to infection. Noticing odour following surgery or when using dilators should be checked out, even if there are no other symptoms. There is more information below if stigma, shame or possible negative previous experience with healthcare staff makes you feel anxious about seeking help.

During and after the menopause changes within the body can lead to irritation, infection and smell. Some peri and postmenopausal women avoid seeking help due to embarrassment, fear of examinations being painful, or believing they no longer need genital care.

How to spot an infection

All people with vaginas can be affected by what’s covered by the term ‘vaginitis’. This refers to swelling and discomfort around and in the vagina and can include things like thrush or bacterial vaginosis.

These are not sexually transmitted infections, but they may be aggravated by having sex. More often they often occur with no sexual contact and can cause bad odours as well as discharge, itching and (sometimes, but not always) pain.

Although you aren’t in a relationship, if you have had sexual partners in the past it may be the smell you’ve noticed is caused by a sexually transmitted infection (STI). This guide gives you more information on how to spot if you might have an infection and where you could go for confidential testing and treatment.

Unexplained bleeding, pain, discharge or a recurring bad odour problem should be given medical attention, regardless of whether you are in a sexual relationship or not.

When and where to seek help

If you believe you have an infection then it is wise to seek help promptly. For things like thrush or bacterial vaginosis you could speak to your pharmacist in confidence, or see your GP.

If you think the problem is related to contraception then you can ask your doctor or family planning clinic for advice, using somewhere like Brook if you are under 25.

For those who’ve recently had a baby and think they may have an infection, ask your midwife, practice nurse or GP for help.

It’s understandable to be worried about seeing the doctor, not least if you feel ashamed or embarrassed – or perhaps if you are uncertain if a bad smell is reason enough to seek medical assistance. But if you haven’t been able to solve the problem yourself and if the symptoms aren’t going away or are getting worse, you should always seek medical advice.

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