Can ashwagandha (Withania somnifera) be used to treat low libido (hypoactive sexual desire disorder)?

Ashwagandha for Low Libido

Ashwagandha is not recommended for the treatment of low libido based on current clinical guidelines, which explicitly state that herbal therapies lack sufficient evidence from repeated, randomized controlled trials with independent data monitoring to support their use for sexual dysfunction. 1

Guideline-Based Recommendations

What Guidelines Say About Herbal Therapies

• The American Urological Association explicitly recommends against herbal therapies for erectile dysfunction and sexual dysfunction, citing insufficient documentation of mechanisms of action, effectiveness, and safety in repeated, randomized clinical trials with independent data monitoring 1

• Major quality and safety concerns exist with herbal products, including disparities in raw materials, variations in manufacturing procedures, poor identification of active agents, and inconsistent product potency both within and between brands 1

• Contamination is a documented problem, with one study finding therapeutic levels of PDE5 inhibitors in some herbal products, raising serious safety and efficacy interpretation concerns 1

Evidence-Based Treatment Options for Low Libido

For women with hypoactive sexual desire disorder (HSDD):

• Flibanserin (100 mg daily at bedtime) is the first-line FDA-approved treatment for premenopausal women, though efficacy is modest with approximately 1 additional satisfying sexual event every 2 months compared to placebo 2, 3, 4

• Bremelanotide (subcutaneous injection as needed) is an alternative FDA-approved option for premenopausal women with HSDD 2, 4

• Off-label options include bupropion and buspirone, though these have limited safety and efficacy data 2, 4

For men with low libido:

• Testosterone therapy is indicated only for men with documented low testosterone levels and reduced sexual desire, not for those with normal testosterone 1

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line for erectile dysfunction, though they primarily address erectile function rather than libido per se 1

Research Evidence on Ashwagandha

Conflicting Study Results

The limited research on ashwagandha shows contradictory findings:

• One 2022 study in healthy women (n=80) showed statistically significant improvement in Female Sexual Function Index scores from 14.20 at baseline to 22.62 at 8 weeks with ashwagandha 300mg twice daily versus 14.17 to 19.25 with placebo (p<0.0001), with improvements in desire, arousal, lubrication, orgasm, satisfaction, and pain subscales 5

• However, a 2011 study in men with psychogenic erectile dysfunction (n=86) found no clinically meaningful benefit, with only 12.6% improvement in the ashwagandha group versus 19.11% in placebo, and no significant difference between groups (p>0.05), concluding that both ashwagandha and placebo provided no relief (<25% improvement) 6

• Animal studies in stressed male rats showed improvements in sexual behavior and erectile function through modulation of neurotransmitters and the NO/cGMP/PDE5α pathway, but animal data cannot be directly extrapolated to human clinical practice 7

Traditional Use Claims

• Traditional Ayurvedic texts describe ashwagandha as "Brusya" (sexual performance enhancer), "vajikari" (spermatogenic), and "Kamarupini" (libido-enhancing), but these historical claims have not been validated through rigorous modern clinical trials 8, 9

Critical Clinical Considerations

Why Guidelines Recommend Against Herbal Therapies

The lack of regulatory oversight creates multiple problems:

• No standardization of active ingredients means different products may contain vastly different amounts of potentially active compounds 1

• Manufacturing variability prevents reliable dosing and reproducible effects 1

• Potential drug interactions and contamination pose safety risks that are not adequately studied 1

Common Pitfalls to Avoid

• Do not recommend ashwagandha as a substitute for FDA-approved treatments when evidence-based options like flibanserin or bremelanotide are available for women with HSDD 2, 3, 4

• Do not assume that "natural" or "traditional" means safe or effective – the absence of regulation means quality and safety cannot be assured 1

• Do not ignore underlying medical or psychological factors contributing to low libido, including medications (SSRIs, narcotics, hormonal therapies), relationship distress, depression, anxiety, or vaginal symptoms 2, 4

Recommended Clinical Approach

For patients presenting with low libido:

• Screen for reversible contributing factors first: medications impairing libido (SSRIs, narcotics, hormonal therapies), psychological issues (anxiety, depression, relationship distress), vaginal symptoms (dryness, dyspareunia), and traditional risk factors (cardiovascular disease, diabetes, obesity, smoking, alcohol abuse) 4

• Consider non-pharmacological interventions: cognitive behavioral therapy, psychoeducational support, sexual counseling, couples therapy, lifestyle modifications (increased physical activity, smoking cessation, weight loss, limiting alcohol), and mechanical devices (vibrators, clitoral stimulatory devices) 2, 4

• Use FDA-approved pharmacological treatments when appropriate: flibanserin or bremelanotide for premenopausal women with HSDD, testosterone therapy for men with documented hypogonadism 1, 2, 3, 4