What supplements have evidence for improving libido in otherwise healthy adult men and women?

Supplements for Libido: Limited Evidence and Better Alternatives

For libido concerns, I do not recommend supplements as first-line therapy—the evidence is weak, inconsistent, and far inferior to addressing underlying hormonal deficiencies (particularly testosterone) or using FDA-approved medications for erectile dysfunction when appropriate. 1, 2

Why Supplements Are Not Recommended

Poor Quality Evidence

• Only 17% of human studies on popular supplement ingredients (ginseng, horny goat weed, L-arginine, tongkat ali, tribulus) showed any improvement in erectile function, and these studies were generally of low quality 3
• A systematic analysis of supplements marketed in Italy found that 80% had no expected efficacy based on ingredient dosing, with only 8% meeting criteria for higher expected efficacy 4
• Most supplements contain negligible doses of active ingredients or combine multiple substances without evidence supporting the specific formulations 4, 5

Misleading Marketing

• Analysis of online reviews revealed that after filtering disingenuous comments, there was a 77% decrease in reports of improved erection strength, 83% decrease in maintained erections, and 89% decrease in erection confidence 3
• Products often contain up to 33 different ingredients in a single formulation, making it impossible to determine what (if anything) is providing benefit 5

The Only Supplement with Modest Evidence: Ginseng

If a patient insists on trying a supplement, ginseng (Panax ginseng) is the only option with any meaningful evidence, though it remains far inferior to standard medical therapy. 2

• Meta-analysis showed ginseng significantly improved IIEF-5 scores compared to placebo (SMD 0.43; 95% CI 0.15-0.70; P < 0.01) 2
• However, this evidence comes from only 5 trials with 399 patients total, and the clinical significance of this improvement is modest 2

Other Supplements with Insufficient Evidence

• Tribulus terrestris: Mixed results, no consistent benefit 4, 2
• L-arginine: Included in many formulations but limited evidence as monotherapy 3, 5
• Saffron: Mixed results in small studies 2
• DHEA: No convincing evidence for libido improvement in healthy postmenopausal women; only potential benefit seen in women with adrenal insufficiency 6
• Horny goat weed, maca, fenugreek, yohimbine: Popular ingredients but low-quality evidence 5

What Actually Works: Address the Real Problem

For Men with Low Libido

Check testosterone levels first—this is the most common reversible cause of low libido and responds to proven therapy. 7

• Measure total testosterone, free testosterone, and SHBG 7
• Target mid- to upper-normal testosterone range with testosterone replacement (gel 50-100 mg daily or injection 100-200 mg every 2 weeks) 7
• Monitor PSA, hematocrit, and symptomatic response at 3-6 month intervals 7

For Men with Erectile Dysfunction (Not Just Libido)

PDE-5 inhibitors (sildenafil, tadalafil) are first-line therapy with high-quality evidence showing 69% success rates versus 33% with placebo. 1, 8

• Start with either sildenafil or tadalafil based on patient preference for timing (tadalafil lasts 36 hours, allowing spontaneity) 8, 9
• Ensure adequate trial: at least 5 attempts at maximum tolerated dose with proper sexual stimulation before declaring failure 8
• Critical safety check: Absolutely contraindicated with nitrates due to fatal hypotension risk 8

For Men with Both Low Testosterone and ED

Combination therapy with testosterone replacement plus PDE-5 inhibitor is more effective than either alone. 7

• Men with testosterone deficiency respond less robustly to PDE-5 inhibitors alone 8, 7
• Optimize testosterone levels first, then add tadalafil 5 mg daily (FDA-approved for both ED and BPH) 7

Critical Counseling Points

• Supplements lack regulation for purity, dosage, and ingredient accuracy 5
• No safety data exists for long-term supplement use 6
• Patients using supplements should be counseled about the availability of FDA-approved therapies with proven efficacy and safety profiles 3
• Heavy alcohol use, relationship issues, and inadequate sexual stimulation are modifiable factors that must be addressed regardless of treatment choice 8