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Report Author: Simran Sharma

Report Date: May 8, 2025

Table of Contents

Introduction

Andropause, often called male menopause, is characterized by a gradual decline in testosterone levels in aging men. This condition, also known as Androgen Decline in the Aging Male (ADAM), is associated with a range of physical and psychological symptoms that can significantly impact the quality of life. A variety of symptoms include diminished libido (sex drive), erectile dysfunction (ED), fatigue, depression, cognitive decline, anemia, and mood alterations. Physical changes, such as progressive loss of muscle mass and strength, as well as osteoporosis (bone weakness), are also common.¹ Understanding its causes, health impacts, and treatment options is crucial for effective management and improving patient outcomes. The causes of andropause include aging, medical conditions, and lifestyle choices. Lifestyle factors that can cause andropause include smoking, alcohol consumption, unhealthy food habits, psychological factors, and lack of exercise.² The treatment options for andropause include testosterone replacement therapy (TRT), lifestyle modifications (healthy diet, exercise, adequate sleep, and stress management), and herbal supplements.³ TRT is a medical treatment that involves administering testosterone to men who have low testosterone levels; however, it may have potential side effects, such as the increased risk of hair loss, prostate cancer, blood clots, or heart disease.⁴ Lifestyle modifications take time but are safe and effective options that can help with andropause. 

Diet is an essential factor that can positively or negatively impact sexual health. A healthy diet supports hormone balance, improves blood flow to sex organs, and promotes a positive mood. Scientific studies have indicated that specific nutrients in the diet (vitamins, minerals, and antioxidants) help manage andropause symptoms. This literature review comprehensively examines the interactions between diet and andropause management. It also explores the factors causing andropause and considers the evidence supporting the positive effects of dietary nutrients and natural herbs on andropause management, as well as their benefits, dosage, drawbacks, and concerns.

To start, the possible causes of andropause are explored. This is followed by a detailed exploration of dietary nutrients and herbs, focusing on their mechanisms of action and scientific evidence supporting their effectiveness in treating andropause. Specific topics include dosage recommendations, natural food sources rich in these nutrients, potential side effects, interactions with common medications, and essential safety precautions to ensure proper use. Conclusively, the positions and views of worldwide governmental medical and health organizations, leading experts, and social platforms addressing the issue of andropause are also discussed.

Significance of the Topic

Menopause is a natural physiological process that marks the end of a woman’s reproductive years with the permanent cessation of her monthly menstrual periods.⁵ Only in recent years has menopause been discussed more openly among women and the media. However, ‘andropause,’ or the so-called ‘male menopause’ is less frequently discussed, though it is of equal importance. Andropause has been used to describe decreasing testosterone levels related to aging, associated with various physical, psychological, and sexual symptoms. In today’s time, men’s health and well-being are taking center stage more than ever, making it imperative to shed light on andropause. More effective strategies should be discussed to manage andropause and promote optimal sexual health and well-being.⁶

Testosterone levels generally decline steadily by approximately 1% per year with age after age 30. The signs and symptoms suggestive of andropause include lower sexual desire and activity, low enthusiasm and energy levels, increased body fat (particularly around the abdomen and chest, like “man boobs”), decreased spontaneous erections or erectile dysfunction, infertility, weakness of bones or osteoporosis, loss of muscle mass, hot flashes or night sweats, depression or anxiety, mood swings, difficulty concentrating and remembering or sleep disturbances. Libido naturally declines with aging.⁷ An early study revealed that libido in middle-aged men (40–60 years) was three times lower than in younger men (18–29 years).⁸

According to available research, the global prevalence of andropause is estimated to affect a significant portion of men over 40, with studies reporting that over 70% of men in this age group experience some degree of andropause symptoms. According to global statistics, over 480,000 older men (over 40 years) annually experience andropause, which gradually increases in severity and frequency.⁹ The prevalence of andropause symptoms varies widely across different regions and populations, influenced by social, health, and lifestyle factors. These symptoms can significantly impact the quality of life, particularly in terms of sexual and psychological well-being. Understanding these variations and factors is crucial for better management and support for men experiencing andropause. Factors such as obesity, chronic diseases, occupational stress, marital satisfaction, and lifestyle choices like smoking and alcohol consumption can exacerbate andropause symptoms.¹⁰

Healthy lifestyle changes can make a big difference in andropause management. A healthy diet provides the raw materials and nutrients required for the body’s metabolic processes, including maintaining hormone balance, elevating mood and sexual desire, enhancing erectile function, providing energy to combat fatigue, managing weight gain, reducing the risk of ED, and promoting overall health.¹¹ The present review summarizes the evidence on the role of specific dietary components in managing andropause symptoms.

Potential Cause of Andropause

Andropause in men can have many causes, including:

Natural Aging and Testosterone Decline

A healthy reproductive system requires a balanced hormone level. The pituitary gland regulates the production of hormones like testosterone.¹² Testosterone is the most important androgen (sex hormone) associated with maintaining sexual health, muscle mass, and bone density, signaling the body to produce red blood cells and regulating fat distribution in men.¹³

A hormone imbalance occurs when the hormone level rises above or drops below normal levels in the bloodstream. The normal testosterone level for adult men is 300-1000 nanograms (ng) per deciliter (dL). Elderly males (over 40) should optimally reach testosterone levels between 500 and 800 ng/dL, while young adults should expect levels between 600 and 900 ng/dL. Not enough production of testosterone by the testicles causes male hypogonadism. In elder men, age-related hypogonadism is called andropause, a condition in which the body, especially a man’s sex glands (gonads), does not produce enough of the testosterone hormone. Hypogonadism is usually diagnosed when the morning serum testosterone level is less than 300 ng/dL.¹⁴

A gradual natural decline in testosterone levels with aging leads to andropause in males. The andropause age is between 40-50 years, but it slowly starts to show its effect as one crosses 30 years. After the age of 30, there is a small decline (around 1%) in testosterone levels with each passing year. The main cause of hormonal imbalance leading to andropause is mainly natural aging. However, lifestyle factors that hasten its occurrence include lack of exercise, stress, medications, medical conditions, and unhealthy food habits.¹⁵

Medications

Taking certain medications, including opioids, corticosteroids, some tranquilizers, and chemotherapy/radiation therapy, can cause low testosterone levels, potentially leading to andropause. Medications that can potentially lead to andropause if used long-term include opioids for pain (e.g., Vicodin), corticosteroids, tranquilizers, such as benzodiazepines (e.g., Xanax), and barbiturates (e.g., Luminal and Nembutal). Some therapies, including cancer treatment (chemotherapy), may lead to andropause.¹⁶

Medical conditions

Medical conditions that directly impact testosterone production include testicular cancer, surgical removal of testes (orchiectomy), and late-onset hypogonadism. Late-onset hypogonadism is a condition in which the testes produce insufficient testosterone. This condition can develop later in life, particularly in men who are obese or have type 2 diabetes.¹⁷

Obesity and type 2 diabetes can contribute to lower testosterone levels. ¹⁸ Obesity is a critical factor that accelerates the reduction of testosterone levels, thereby exacerbating andropause symptoms. A study found that 60% of men with andropause had a body mass index (BMI) classified as obesity. On the other hand, 66.7% had central obesity (accumulation of excessive fat around the abdominal area) based on waist circumference measurements. This suggests a strong link between obesity and the severity of andropause symptoms. Central obesity is linked to unhealthy dietary patterns.¹⁹

Chronic illness or conditions like cirrhosis of the liver, kidney disease, or HIV/AIDS can disrupt testosterone hormone production by their effect on the hypothalamus and pituitary gland. The hypothalamus and pituitary gland (parts of the brain) signal the testicles to produce testosterone and chronic illnesses interfere with these signals.²⁰ Certain inflammatory diseases, such as sarcoidosis, histiocytosis, and tuberculosis, can affect the hypothalamus and pituitary gland, and thus testosterone production. Prostate cancer treatment, like anti-testosterone therapy, can also cause low testosterone levels, leading to andropause.²¹

Psychological factors

Emotional health issues like depression, anxiety, and chronic stress can potentially accelerate the decline in testosterone levels and exacerbate andropause symptoms.²² 

A little stress is part of life and unavoidable, and it can help combat difficult situations. However, too much stress and anxiety can negatively impact overall health, including sexual health. Long-term or chronic stress causes mental exhaustion that accelerates the secretion of cortisol (a stress hormone) and reduces testosterone levels, potentially worsening the effects of andropause.²³ Stress management techniques, such as practicing relaxation exercises (breathing, meditation, yoga, or tai-chi), eating healthy, sleeping adequately, talking with loved ones, enjoying what you like (e.g., listening to music), avoiding smoking, alcoholism, and drugs, and having a therapist session, may help reduce stress.²⁴

Smoking and Alcoholism

Smoking is consistently associated with an earlier onset of andropause symptoms. The toxins in vapes or cigarette smoke, such as nicotine, cadmium, carbon monoxide, cancer-causing metals, and free radicals, cause oxidative stress, high blood pressure, damage to blood vessels, hamper blood circulation to private parts, and reduce testosterone production. Oxidative stress happens when harmful reactive oxygen species (ROS), also known as free radicals, build up to levels that the body’s natural antioxidant defenses cannot effectively manage. Studies indicate that smoking more than 10 cigarettes a day can lead to an earlier onset of symptoms, reducing the age of onset to below 50 years. Additionally, smoking is linked to increased muscle weakness and powerlessness among middle-aged men experiencing andropause.²⁵

Vaping may negatively impact men’s testosterone levels. For instance, men who incorporate vaping into their daily routine, typically for an hour or more, may experience a notable decrease in testosterone levels (around 30% less) in comparison to non-vapers. ²⁶ Some studies have shown that nicotine in vapes may disrupt the hormonal balance and affect testosterone production.²⁷ E-cigarettes, even those that are nicotine-free, contain many harmful substances (formaldehyde, acetaldehyde, methylglyoxal, acrolein, acetone, benzaldehyde) that disturb hormonal balance and testosterone production.²⁸

The relationship between alcohol consumption and andropause is less clear. While some studies do not find a direct association between alcohol and the onset of andropause, alcohol consumption is noted to exacerbate symptoms such as powerlessness.²⁹ However, other studies suggest that alcohol consumption does not significantly correlate with the incidence of andropause.²⁵

Exercise

Regular physical activity promotes hormonal balance, leading to increased testosterone levels, proper blood flow to the genital area, and reduced stress.³⁰ Exercise may help in combating andropause symptoms such as decreased muscle mass, increased body fat, fatigue, lower energy levels, and mood swings. While exercise may not prevent or reverse andropause, it can help improve testosterone levels naturally, especially through strength training or resistance exercise. Strength training is crucial for maintaining muscle mass, which can decline during andropause.³¹

Unhealthy Food Habits

Diet exerts a profound positive or negative influence on testosterone levels, which are crucial for male health and well-being. Diets high in unhealthy foods (mostly highly processed food or junk food), such as those rich in unhealthy fats, sugars, salt and preservatives, are associated with lower testosterone levels.³² Conversely, weight loss through low-fat, low-calorie diets can improve testosterone levels and alleviate some symptoms of andropause. Highly processed food consumption is associated with increased risks of obesity, chronic diseases (such as cardiovascular diseases and type 2 diabetes), and higher body mass index in adult men that lead to the early onset of andropause and worsen the symptoms of andropause.³³

Food processing is transforming raw agricultural products into food or converting one form of food into another. A food classification system, NOVA (not an acronym), is used to categorize all foods according to the nature, extent, and purposes of the industrial processes they undergo. It divides foods into four groups: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods.³⁴ NOVA food classification is discussed in detail in Table 1.

Table 1 NOVA food classification system

Highly processed food or drinks are stripped of nutrients and fiber and are high in salt, sugar, bad fat (saturated fat, cholesterol, and trans-fat), harmful preservatives, and additives (artificial color and flavor) that have no nutritional value and can negatively impact overall health. These foods increase oxidative stress and inflammation in the body, resulting in metabolic disorders that damage reproductive and immune systems, imbalanced hormones, and sexual dysfunction and disinterest.³⁵ High saturated fat, salt, sugar, and cholesterol increase blood pressure and cause the narrowing of arteries that carry blood to sexual organs. That hampered blood flow to sex organs contributes to ED and interferes with the sex drive.³⁶

However, not every type of processed food is necessarily bad for our health. For example, minimally processed food should be preferred over processed food.³⁷

Specific Nutrient: Vitamins

What is it

Vitamins are micronutrients required in small quantities for good health. This is due to the antioxidant capacity of vitamins and the role of some vitamins in various biological or metabolic processes as cofactors. Specifically, vitamins D, E, B9 (folic acid), and C may help in managing andropause by supporting testosterone levels and overall health.

How it Works

Vitamin D is a crucial precursor for testosterone production in the testes and is associated with healthy testosterone levels in men. Research suggests that there is a correlation between adequate levels of vitamin D and adequate levels of testosterone. Vitamin D deficiency can worsen andropause symptoms like fatigue, mood swings, and muscle loss.³⁸ During andropause, there is a gradual decline in testosterone levels that can impact erectile function. This decline can lead to symptoms like reduced sex drive and difficulty achieving or maintaining an erection. Vitamin D regulates endothelial function, which is important for maintaining erectile function. Vitamin D also protects endothelial cells from oxidative stress and maintains vascular thickness, which can boost erections. Endothelial function refers to the health and proper functioning of the endothelial cells lining blood vessels. They play a crucial role in regulating blood flow, particularly in the penis, and therefore markedly impacting erectile function. Essentially, good endothelial function is necessary for a healthy libido and the ability to achieve an erection, while impaired endothelial function can contribute to ED.³⁹

Vitamin C is an antioxidant that may help regulate the production of cortisol (a stress hormone), which can negatively impact testosterone levels. Vitamin C reduces cortisol levels and increases testosterone levels, oxytocin release, nitric oxide production, and blood flow by vasodilation, i.e., opening of blood vessels. Hence, improves mood, erectile function, and intercourse frequency, all of which can be affected by andropause.⁴⁰ Testosterone plays a crucial role in muscle growth and maintenance. As testosterone levels decline during andropause, men may experience a decrease in lean body mass, leading to muscle loss. Vitamin C has physiological relevance to skeletal muscles and may protect them during aging. Vitamin C is involved in collagen and carnitine production (a structural component of muscle), both of which are important for muscle structure and function. Also, its antioxidant property protects muscle cells from damage caused by free radicals.⁴¹ 

Vitamin E is an antioxidant that acts as a free radical scavenger, reducing oxidative stress and boosting testosterone production.⁴² Vitamin E does not directly increase testosterone, but it can help maintain healthy testosterone levels by addressing oxidative stress, which can negatively impact hormone production. An animal study suggests that vitamin E may protect Leydig cells, which are responsible for producing testosterone, from oxidative damage and improve their function.⁴³

Folic acid (Vitamin B9) is essential for overall reproductive health, sperm development, libido, erectile function, and positive mood. However, there is limited evidence to suggest a direct, significant impact of folic acid on testosterone levels in men. Research suggests that folic acid helps in erectile function by protecting endothelial cells and playing a role in nitric oxide production that maintains proper blood flow to the penis by opening or dilation of the blood vessel.⁴⁴ Nitric oxide is a neurotransmitter and vasodilator that relaxes the muscles in blood vessels, thereby widening them to facilitate proper blood flow and lower blood pressure. Increased blood flow to sexual organs is required for penile erection.

The decline in testosterone levels in andropause can negatively impact serotonin production, which leads to low sex drive and mood changes, including depression, anxiety, irritability, and difficulty concentrating. ⁴⁵Folic acid also boosts serotonin production. Serotonin is a neurotransmitter made up of tryptophan (an essential amino acid).⁴⁶  

What the Research is Telling us

Many studies have found a significant association between vitamin D deficiency and testosterone levels. For instance, a study conducted on 102 male patients (age 36-64) with vitamin D deficiency (vitamin D levels less than 30 ng/ml in the blood) demonstrated that vitamin D treatment [vitamin D oral dose of 600000 International unit (IU) once a month] for 1-year improved testosterone levels and erectile function in middle-aged men. The dose of vitamin D changes as per the patient’s serum vitamin D level. When serum vitamin D level reached ≥ 30 ng/ml, the dose was switched to 600000 IU/2 months. The target vitamin D serum level range was 30-80 ng/ml during the study. If any level reached nearly 80 ng/ml during the monitoring, the dose was decreased to 600 000 IU/3 months (by increasing the time interval between doses) to prevent any vitamin D toxicity.⁴⁷ Another study of 50 patients affected by ED reported that patients with vitamin D deficiency (vitamin D levels less than 20 ng/ml in the blood) had more severe/complete ED than those in the group with optimum vitamin D levels (more than 20 ng/ml).⁴⁸ The normal range of vitamin D levels in the blood for adult men is 30 nanograms/ml or more; levels below 20 ng/ml are associated with a higher risk of ED. Moreover, to sustain or improve endothelial and erectile function, which is maintaining vitamin D above 30 ng/ml in blood, male adults need to take at least 1500-2000 IU/day of supplemental vitamin D.⁴⁹  

There is a significant association between vitamin D deficiency and mood in aging men. For instance, a study conducted on 80 aged males with vitamin D deficiency (vitamin D levels less than 30 ng/ml in the blood) demonstrated that vitamin D deficiency was associated with low mood.⁵⁰ A vitamin D deficiency may also adversely affect mood by disrupting the body’s production of serotonin, a chemical that helps regulate mood. In a 2-month study, vitamin D supplementation (50000 IU once per week) helped in reducing depression score (from 9.25 to 7.48) in 78 older men (aged over 60 years) suffering from moderate to severe depression with vitamin D deficiency (less than 23 ng/ml). The serum vitamin D level increased to ~43 ng/ml by supplementation. The depression score was measured by the geriatric depression scale-15 (GDS-15) questionnaire. GDS-15 is a self-report questionnaire used to assess depression in older adults. A score of 0-4 on the GDS-15 is generally considered normal, while a score of 5-8 indicates mild depression, 9-11 indicates moderate depression, above 12 or higher may suggest severe depression.⁵¹

Research indicates that vitamin C supplementation can lead to an increase in testosterone levels, libido, and muscle mass. An animal-based study conducted on male Wistar rats showed a significant rise in testosterone levels when supplemented with vitamin C compared to the control group. This suggests that vitamin C may play a role in enhancing male reproductive hormones.⁵² A 14-day study has shown that a high-dose vitamin C supplement (3000 mg/day) increased intercourse frequency and improved mood in 42 adult men. The vitamin C supplement helped in decreasing depression scores in the study population, as measured by the Beck Depression Inventory. ⁵³ In another study, dietary vitamin C intake (with a diet rich in vitamin C) helped in reducing age-related muscle loss in 13000 elderly men and women (42-82 years of age). The fat-free mass (a measure of skeletal muscle mass) was higher in individuals having sufficient plasma vitamin C levels (more than 50 μmol/L).⁵⁴ However, more robust, randomized controlled trials on large sample sizes are needed on the human population to conclusively determine the effect of vitamin C on testosterone levels and in managing andropause.

Animal-based studies (in male rabbits and rats) have associated supplementation with vitamin E with increased testosterone levels.⁵⁵ When male Wistar rats were subjected to excessive exercise in one study, vitamin E supplementation increased the number of Leydig cells (by 2.6 times) and demonstrated a 2.3 times increase in testosterone levels, indicating its potential to counteract exercise-induced oxidative stress and support testosterone production. This suggests a potential role for vitamin E in supporting testosterone production, which helps in andropause. However, its direct impact on libido in humans requires further investigation.⁵⁶ Vitamin E has been studied for its potential effects on low libido and erectile dysfunction, the symptoms most associated with andropause. An International Index of erectile function (IIEF) questionnaire-based study on 52 patients (ages 18-60 years) with ED revealed significant improvement in erectile function (based on IIEF score) when given a daily supplement of vitamin E (100 IU or 67 mg) and ginseng (67 mg Korean ginseng and 40 mg Siberian ginseng) for 6 weeks. However, further trials with longer follow-up times and a bigger population are still suggested.⁵⁷

To differentiate between mild, moderate, and severe ED, healthcare professionals typically use a scoring system based on the International Index of Erectile Function (IIEF) questionnaire, where a higher score indicates less severe ED. The International Index of erectile function (IIEF) questionnaire is a self-administered, 15-question tool used to assess male sexual function, specifically focusing on erectile function, by evaluating different domains like sexual desire, orgasmic function, intercourse satisfaction, and overall satisfaction, allowing healthcare professionals to diagnose and monitor the severity of ED in a patient. According to the classification by the IIEF, scores ranging from 5 to 7 indicate severe ED, 8-11 indicate moderate ED, 12-16 indicate mild-moderate ED, and 17-21 indicate mild ED, whereas scores above 21 are considered normal.⁵⁸

Direct studies on folic acid and testosterone levels and andropause, especially on human populations, are limited. In various animal studies, folic acid supplementation has been shown to improve reproductive functions. For instance, in rams, a combination of zinc sulfate and folic acid improved testicular volume, serum testosterone levels, and semen quality under heat stress conditions, indicating a positive effect on reproductive health.⁵⁹ In a study on rats, oxidative stress was induced by administration of a toxic methomyl (a pesticide) that causes testicular damage and hinders testosterone production. This study observed that folic acid supplementation mitigated the negative impact of oxidative stress on testosterone levels and sperm quality, suggesting its protective effects on testicular cells.⁶⁰ Several studies have explored the relationship between folic acid levels and erectile dysfunction. Studies have found a significant association between low serum folic acid levels and increased severity of ED. Patients with ED tend to have lower folic acid levels compared to healthy controls, and these levels decrease as the severity of ED increases. For instance, a decreased serum folic acid level (approximately 7.61-8.84 ng/ml) was observed in 67 patients suffering from ED in comparison to 30 healthy men (approximately 12.23 ng/ml folic acid level). This suggests that folic acid deficiency might be an independent risk factor for ED.⁶¹ The normal serum level of folic acid for adult men is between 2.5 and 20 nanograms per milliliter (ng/ml).⁶² A study conducted on 22 Egyptian male patients (ages between 30-60 years) with vasculogenic ED,  a type of ED caused by damage to the blood vessels in the penis that supply it with blood, showed that daily consumption of folic acid (500 µg/day) for 3 months significantly improved erectile function. The IIEF score increased from approximately 6.4 (indicating severe ED) to 15.5 (indicating mild-moderate ED), after supplementation.

Dosage Recommendation Based on Research

Recommended dietary allowances (RDA) or minimum daily recommended intake of different vitamins for adult men (age more than 14 years) according to the National Institutes of Health (NIH) include vitamin D [15 micrograms (µg)/day or 600 IU]; vitamin C (90 mg/day); vitamin E (15 mg/day), and vitamin B9 or folic acid (400 µg/day).⁶³

Recommended dosages of different vitamins for specific sexual functions include vitamin D (1500-2000 IU) for erectile function; vitamin C (1000 mg/day) for improving libido⁶⁴; vitamin E (67 mg/day) for enhancing erectile function; and vitamin B9 or folic acid (500 µg/day) for improving erectile function.

Table 2 Dosage Recommendation of Vitamins for Adult Men (age more than 30 years)

Food Sources

Plant sources that provide Vitamin D include:⁶⁵

• Mushroom: 2300 IU/100 gram, 383% of the Daily Recommended Value (DV)

• Orange juice: 100 IU per cup, 16% of DV

• Soy Milk: 107-117 IU per cup, 19% of DV

• Fortified cereal: 85-145 IU per cup, 11-18% of DV

• Fortified orange juice: 100 IU per cup, 12% of DV

Animal sources that provide Vitamin D include:

• Tofu: 100 IU/100 gram, 16% of DV

• Canned sardines: 193 IU/100 gram, 32% of DV

• Cheese: 24 IU/100 gram, 4% of DV

• Cod liver oil: 450 IU/teaspoon, 50% of DV

Plant sources with the highest amount of vitamin C include:⁶⁶

• Guava: 125 mg per fruit, 138% of DV

• Kiwi: 56 mg per fruit, 62% of DV

• Orange: 83 mg per fruit, 92% of DV

• Raw kale: 93 mg of Vitamin C per 100 g, 103% of DV

• Black currants: 102 mg per half cup (56 g), 113% of DV

• Yellow Bell pepper(chopped): 342 mg per cup, 342% of DV

Animal sources with the highest amount of vitamin C are:

• Raw Chicken liver: 17.9 mg per 100g, 19.8% of DV

• Beef Lungs: 32.7 mg per 100 g, 36.3% of DV

Plant sources providing a good amount of vitamin E include:⁶⁷

• Wheat germ oil: 150 mg/100 g, 1000% of DV

• Almond:15 mg/100 g, 100% of DV

• Dried apricot: 4 mg/100 g, 26% of DV

• Sunflower seed: 35 mg/100 g, 233% of DV

• Avocado: 3.1 mg per fruit, 20% of DV

Animal sources providing a good amount of vitamin E include:

• Goose meat: 1.7 mg/100 g, 11% of DV

• Cod: 0.8 mg/100 g, 5% of DV

• Abalone: 3.4 mg/100 g, 23% of DV

• Goose meat: 2.4 mg/100 g, 16% of DV

Plant sources that provide Vitamin B9 or folic acid include:⁶⁸

• Kidney beans (cooked): 131 µg per cup, 32% of DV

• Asparagus (cooked): 134 µg per half cup, 33% of DV

• Brussels sprouts (cooked): 47 µg per half cup, 11% of DV

• Broccoli (cooked): 84 µg per half cup, 21% of DV

• Raw spinach: 58.2 µg/30g, 15% of DV

Animal sources that provide Vitamin B9 or folic acid include:

• Beef liver (cooked): 212 µg per half cup, 53% of DV

• Egg: 22 µg per egg, 6% of DV

Supplemental Sources

Vitamin D supplements, available as D2 (ergocalciferol) or D3 (cholecalciferol), can be found in multivitamin/mineral supplements or as standalone vitamin D supplements available in a variety of forms, such as tablets, capsules, powders, and gummies. Vitamin D can also be found in supplements that combine it with other nutrients, such as calcium or omega-3 fatty acids. Many foods, such as milk, cereals, and orange juice, are fortified with vitamin D, providing an alternative to supplements. 

Vitamin C supplements are available in a variety of forms, such as tablets, capsules, powders, and gummies. It is most often sold in its pure form as ascorbic acid, which is highly bioavailable (the extent to which a nutrient is absorbed and utilized by the body), but it can also be found in buffered form for sensitive stomachs, or in various formulations that are thought to increase absorption or bioavailability. No difference in bioavailability has been observed for ascorbic acid from natural sources such as kiwi as compared to supplemental sources.

Vitamin E supplements are most commonly available as softgels or capsules but can also be found in the form of liquid drops or powders. Natural vitamin E (d-alpha-tocopherol) generally has better bioavailability than synthetic varieties, which may be particularly important for those seeking optimal benefits.

Folic acid supplements are most commonly available as tablets, softgels, or capsules, having more bioavailability than the naturally occurring form, with about 85% of supplemental folic acid absorbed when taken with food and 100% when taken on an empty stomach. 

While vitamins in supplement form and raw food sources are available, prioritizing raw foods offers the benefits of a whole food approach, including other essential nutrients and antioxidants. In contrast, supplements can provide a concentrated dose and can be helpful for people who have trouble meeting their daily needs through food alone. Some supplements are made from real food sources, while others are synthetic. Although synthetic and food-derived vitamin supplements appear equally bioavailable in humans, ingesting vitamins as part of a whole food is preferable. In conclusion, for efficient vitamin intake, prioritizing whole, raw sources of vitamins from foods is generally considered the most effective approach, as opposed to solely relying on supplements

Side Effects

Common side effects: Vitamins are generally well-tolerated and safe for most adults. However, at very high doses, they can cause side effects.

Taking too much (more than 4000 IU) vitamin D supplements daily can cause side effects like itchy skin, sore eyes, stomach pain, diarrhea, or vomiting.⁶⁹

Side effects of high doses of vitamin C (more than 2000 mg/day) include diarrhea, stomach cramps, and nausea.⁷⁰

High doses (1000 mg/day) of vitamin E may cause side effects like headaches, nausea, fatigue, and bleeding.⁷¹

Side effects of folic acid are uncommon but may include allergic reactions like rash, itching, and redness.⁷²

Drug interaction: Vitamin D supplements may interact with medications like diuretics, antiarrhythmic drugs, blood pressure regulators, laxatives, and corticosteroids. Vitamin C supplements might interfere with cancer treatments, such as chemotherapy and radiation therapy. Vitamin E may interact with blood thinners (e.g., warfarin, aspirin). Folic acid supplements may interact with alcohol and medications such as antibiotics and anticonvulsants.

Safety precautions: Nutrients in the form of dietary supplements should be taken after consulting a doctor or other healthcare professional for safety. Supplements can interact with other supplements or medications, so a healthcare provider’s help is required to decide what supplement is right for you. Always remember that supplements cannot replace a well-balanced, healthy diet.

Legal Status and Availability

Vitamins D, C, E, and B9 are generally widely available as over the counter (OTC) supplements; however, physicians may prescribe higher-dose supplements for therapeutic use. Because dietary supplements are not subject to the same regulations as pharmaceuticals, there may be a variation between the true ingested dose and the product labeling. This may be due to intentional oversaturation by the manufacturer to ensure continued potency by the expiration date or degradation of the product over time. The FDA does not t approve dietary supplements like vitamin D, E, C, or B9 for safety and effectiveness before they are marketed, but it does regulate them by inspecting manufacturing facilities and reviewing product labels. These vitamins are easily accessible to buy online as a supplement in capsule, tablet, or powder form.

Bottom Line

Strength of recommendation: Adequate intake or supplementation of vitamins D, E, and folic acid may play a beneficial role in improving andropause symptoms, specifically erectile dysfunction. Vitamin C has also shown promise in improving libido and erectile function.

Specific Nutrient: Minerals

What is it

Minerals are required in small quantities for the variety of metabolic processes in the body. The body cannot produce minerals on its own; hence, they must be obtained through food or supplements. Minerals like zinc, magnesium, and selenium may play a vital role in supporting healthy hormone levels and overall health during andropause.

How it works

Zinc may play a role in managing andropause by influencing testosterone production. Some studies suggest that zinc, along with other nutrients like selenium and magnesium, can potentially help support healthy testosterone production.⁷³

 Zinc is the second most abundant trace element in the human body after iron. Zinc has high antioxidant potential. Zinc is an essential mineral that plays a role as a cofactor for enzymes involved in cell division, required for hormone balance, testosterone production, and blood flow to the genitals. It can reduce anxiety and depression by increasing serotonin levels and the expression of the brain-derived neurotrophic factor (BDNF), which is thought to be useful in treating depression. Serotonin helps regulate mood and stress response and enhances relaxation and sensualness.⁷⁴ Zinc deficiency can also be a factor in andropause, as zinc is essential for regulating testosterone levels and other aspects of male reproductive health. A lack of zinc can lead to low testosterone, impacting libido, muscle mass, and overall energy. A zinc deficiency hinders penile erection and sexual function. Zinc deficiency (serum zinc level below 70 μg/dL) can arise due to high oxidative stress and smoking. ⁷⁵

Selenium is an essential trace element that acts as a cofactor for the antioxidant enzymes that are involved in testosterone production, which is needed for both sexual and overall health in aging males.⁷⁶

Magnesium is essential to produce testosterone. Deficiencies in magnesium can lead to a decline in these hormones, which are vital for male sexual function, fertility, and physical performance. Magnesium also plays a role in the relaxation of penile blood vessels, nitric oxide metabolism, and erectile function.⁷⁷

What the Research is Telling us

Studies have shown that dietary zinc restriction leads to a significant decrease in serum testosterone concentrations.⁷⁸ Due to its antioxidant properties, zinc helps mitigate oxidative stress, which can impair sexual function. In lead-exposed rats, zinc supplementation improved sexual performance and erectile function by reducing oxidative injury and increasing testosterone levels. This suggests that zinc’s antioxidant properties contribute to its beneficial effects on testosterone and sexual health.⁷⁹

Magnesium plays a crucial role in various physiological processes, including the regulation of testosterone levels. In a 4-week human study, supplementation with magnesium (10 mg per kilogram body weight of the individual) was found to increase testosterone levels in sedentary individuals and athletes.⁸⁰

Selenium has been shown to positively influence testosterone levels. In a study involving sheep’s Leydig cells, selenium treatment increased testosterone production by increasing the proliferation of Leydig cells and regulating cellular oxidative stress.⁸¹ In mice, selenium mitigated the negative effects of toxins like aflatoxin B1 and cadmium on testosterone synthesis, highlighting its protective role against environmental stressors that could be due to its antioxidant property and ability to stimulate the expression of proteins and enzymes involved in testosterone synthesis.⁸²

Erectile dysfunction is a prevalent condition affecting aging men. A survey by the National Health and Nutrition Examination Survey (NHANES) on 3745 men (≥ 20 years of age) concluded that the increasing dietary intake of minerals [magnesium (300 mg/day), zinc (30 mg/day), and selenium (300 μg/day)] had a positive impact on reducing the prevalence of ED. The dietary intake range of magnesium was 100-300 mg/day, zinc was 10-30 mg/day, and selenium was 100-300 μg/day.⁸³ An animal-based study also revealed an association between a combination of zinc, magnesium, and selenium supplementation with increased production of the testosterone hormone by 105% in male Wistar rats.⁸⁴

Animal studies and a few human studies provide valuable insights into the role of zinc, selenium, and magnesium in improving testosterone levels and reducing the prevalence of ED. However, there is a lack of studies on the direct impact of these minerals on andropause. Further research, particularly in humans, is needed to fully understand the therapeutic potential and optimal dosages of these minerals for treating andropause.

Dosage Recommendation Based on Research

According to the National Institutes of Health (NIH), dietary allowances (RDA) or minimum daily recommended intake for adult men (age more than 14 years) for zinc is 11 mg/day, magnesium is 400-420 mg/day, and selenium is 55 µg/day.

Recommended dosages of minerals for reducing ED prevalence include zinc (30 mg/day), magnesium (300 mg/day), and selenium (300 μg/day).

Table 3 Dosage Recommendation of Certain Minerals for Adult Men (age more than 30 years)

Food Sources

Plant sources with the most zinc are:⁸⁵

• Pumpkin seeds: 8.4 mg per half cup, 57% of DV

• Cashews: 6 mg/100 g, 54% of DV

• Hemp seeds: 3 mg/30 g, 27% of DV

Animal sources with the most zinc are:

• Lobster: 4 mg/100 g of meat, 36% of DV

• Beef chuck: 8.47 mg/100 g, 77% of DV

• Lamb shank: 8.67 mg/100 g, 78% of DV

• Raw ground beef: 4.79 mg/100 g, 44% of DV

• Alaska king crab: 7.62 mg/100 g, 69% of DV

Plant sources with the most magnesium are:⁸⁶

• Cashews: 292 mg/100g, 73% of DV

• Sesame seeds: 351 mg/100g, 87% of DV

• Spinach: 79 mg/100g, 19% of DV

• Black beans: 180 mg/100g, 45% of DV

• Wholegrain bread: 76.6 mg/100g, 19% of DV

• Dark chocolate (70-85% cocoa solids): 228 mg per 100g, 57% of DV

• Avocado: 29 mg/100g, 7% of DV

• Almond butter: 270 mg/100g, 67% of DV

Animal sources with the most magnesium are:⁸⁷

• Salmon: 95 mg/100g, 23% of DV

• Mackerel: 60 mg/100g, 15% of DV

• Powdered egg white: 88 mg/100g, 22% of DV

• Whey protein powder: 195 mg/100g, 48.8% of DV

Plant sources high in selenium include:⁸⁸

• Brazil nut: 68-91 μg per nut, 165% of DV

• Firm tofu: 17.4 μg/100 g, 31% of DV

• Whole wheat pasta (cooked): 36.3 μg per cup, 53% of DV

• Cottage cheese: 20 μg per cup, 36% of DV

• Cooked brown rice: 19 μg per cup, 35% of DV

Animal sources high in selenium include:

• Lean pork chops: 47.4 μg/100 g

• Roasted beefsteak: 33 μg/85 g, 47% of DV

• Roasted turkey: 31 μg/85 g, 44% of DV

• Beef liver (pan-fried): 28 μg/85 g, 40% of DV

• Cooked Tuna: 92 μg/85 g, 131% of DV

Supplemental Sources

Zinc, selenium, and magnesium supplements are available in a variety of forms, such as tablets, capsules, powders, and gummies.

Zinc supplements are available in various forms, including zinc gluconate, zinc citrate, zinc sulfate, zinc picolinate, and zinc acetate. Among these, picolinate and citrate are generally better absorbed. Long-term use above the recommended daily intake can lead to copper deficiency due to interference with absorption.

Selenium supplements are available in various forms, with common sources including selenomethionine, selenium-enriched yeast, sodium selenite, and sodium selenate, often found in multivitamin/mineral supplements or as standalone supplements. 

Magnesium supplements are also available in different forms, with magnesium citrate, glycinate, and malate typically offering the best absorption. A multimineral supplement may be recommended for enhanced benefits, as their synergistic effects can optimize nutrient absorption and utilization.

Side Effects

Common side effects: Taking very high doses of zinc (more than 40 mg) may cause side effects like stomach pain, diarrhea, or vomiting.⁸⁹ Magnesium intake of less than 350 mg daily is safe for most adults. However, it may cause stomach upset, nausea, vomiting, diarrhea, and other side effects in some people. Large doses (more than 350 mg/day) might cause serious side effects such as irregular heartbeat, confusion, breathing problems, low blood pressure, coma, and death.⁹⁰

Common side effects of high doses (more than 400 μg) of selenium are nausea, bad breath, hair loss, tiredness, and fever.⁹¹

Drug interaction: Zinc may interfere with medications such as antibiotics, non-steroidal anti-inflammatory drugs, blood pressure regulators, and immunosuppressants. Magnesium may interfere with medications such as levodopa/carbidopa (sinemet) used for Parkinson’s disease, aminoglycoside antibiotics, tetracycline antibiotics, quinolone antibiotics, blood pressure regulators, muscle relaxants, diuretics, anti-coagulants, digoxin, anti-diabetics, antacids, gabapentin, ketalar, sevelamer, and bisphosphates.

Selenium may interact with medications such as sedatives, immunosuppressants, anticoagulants, or antiplatelet drugs.

Safety Precautions: Check with your healthcare provider or dietitian before taking any supplements.

Legal Status and Availability

Magnesium, selenium, and zinc supplements are commonly available as over the counter (OTC) dietary supplements in many countries. While standard doses can typically be purchased without a prescription, higher-dose formulations may require a prescription. These supplements are easily accessible at pharmacies, grocery stores, and online retailers, with strict regulations in place to ensure safety and accurate labeling.

Bottom Line

Strength of recommendation: Overall, magnesium, zinc, and selenium are essential for maintaining male sexual health, particularly in preventing and managing ED, a common symptom of andropause. Ensuring adequate intake of these minerals can support hormonal balance and reduce oxidative stress. However, further research on human subjects is needed to confirm these effects.

Specific Nutrient: Antioxidant

What is it

Antioxidants are compounds in food that scavenge and neutralize free radicals, or ROS, from the body’s cells and protect from damage caused by oxidation. Certain nutrients possess antioxidant properties, such as L-carnitine and coenzyme Q (CoQ10). L-carnitine or 3-aminobutyric acid is a naturally occurring amino acid derivative or a semi-essential vitamin that acts as a cofactor in bioenergetic processes and transports long-chain fatty acids from cytosol to mitochondria for energy production from fat.⁹² CoQ10, also known as ubiquinone, is a naturally occurring antioxidant and cofactor (co-enzyme) that participates in bioenergetic processes and converts food into energy. It is usually naturally produced by the human body.⁹³

How it Works

L-carnitine supplementation has been found to significantly increase serum testosterone levels in both animal and human studies. L-carnitine has antioxidant properties that help reduce oxidative stress and inflammation. Low testosterone levels in older men have been associated with increased oxidative stress, inflammation, and endothelial dysfunction. Oxidative stress can damage Leydig cells, which are responsible for producing testosterone. L-carnitine is believed to improve endothelial function, which is crucial for erectile function. L-carnitine has been shown to positively affect hormone levels, such as increasing testosterone, which can contribute to improving metabolic health, mood, libido, erectile function, and overall health in older men.⁹⁴

The beneficial effects of CoQ10 on testosterone levels and reproductive health are attributed to its antioxidant properties, which help reduce oxidative stress and inflammation. CoQ10 is known for its significant role in cellular energy production and protection against oxidative damage. CoQ10 levels naturally decrease in some tissues as humans age, which may contribute to increased oxidative stress and associated aging processes.⁹⁵ By enhancing the activity of antioxidant enzymes, CoQ10 helps mitigate oxidative stress, potentially improving erectile function and overall health in aging men.⁹⁶

What the Research is Telling us

L-carnitine supplementation significantly impacts serum testosterone levels. There are many studies supporting the efficacy of L-carnitine, vitamin E, and CoQ10 in improving male fertility. However, there was a lack of studies comparing the effectiveness of L-carnitine with vitamin E, and CoQ10 combination on testosterone level and other sperm parameters. However, in a study on 73 infertile men, L-carnitine was compared with CoQ10 and vitamin E. Interestingly, L-carnitine (15 g/day) was found to significantly improve testosterone levels by ~33% alongside sperm motility and morphology by ~40%, outperforming the other supplement combination (100 mg vitamin E supplement and 10 mg coenzyme Q). Vitamin E and CoQ10 are often combined because they have a synergistic effect, meaning their combined antioxidant action is greater than the sum of their individual antioxidant effects. When combined, vitamin E and CoQ10 work together to enhance their antioxidant activity. CoQ10 helps in regenerating vitamin E, which has been oxidized, mainly extending its antioxidant capacity. ⁹⁷Similarly, an animal study reported that L-carnitine supplementation led to increased testosterone levels in diabetic rats.⁹⁸

L-carnitine was found to be effective for managing symptoms associated with male aging, such as metabolic health, mood, and erectile function. In andropause, a decline in testosterone levels may lead to reduced muscle mass and increased body fat in aging men. During exercise, fat oxidation (conversion of fat into energy) increases. Similarly, L-carnitine plays an essential role in fat oxidation, causing an increase in muscle mass and metabolic health. Studies have shown that an increase in muscle carnitine content through supplementation can potentially boost fat oxidation during exercise. In a 25-week study on 14 healthy older men (mean age 69 years), L-carnitine supplementation (4.5 g) along with exercise was shown to improve metabolic health by an increase of 20% in total muscle carnitine content and fat oxidation. Also, led to an increased expression of genes involved in fat metabolism. That is particularly beneficial as it improves lipid metabolism, which is often impaired with age. During L-carnitine supplementation, participants performed twice-weekly cycling sessions of 1 hour.⁹⁹

According to research, L-carnitine supplement (2,000 mg/day) for 6 months was found to be more effective than testosterone therapy in improving mood, sexual satisfaction, and erectile function (based on IIEF score) in the aging male group (120 patients, aged 60-74). The IIEF score of erectile function increased from approximately 8 to 24, whereas sexual satisfaction and desire increased from 4% to 7%, after supplementation.¹⁰⁰ Testosterone therapy is a medical treatment that involves administering testosterone to men facing the problem of low libido and ED due to low testosterone levels. It is considered for patients having low testosterone levels due to aging or testicular injury, mostly recommended for men aged more than 65 years. However, testosterone replacement therapy can have side effects, such as infertility, sleep apnea, enlarged breasts, blood clots, and an increased risk of prostate cancer. Further, the long-term risks aren’t known.¹⁰¹

A study on 54 males (age 35 to 75) with ED showed significant improvement in erectile function in 40% of men and partial improvement in the remaining cases when given L-carnitine, niacin, and L-arginine supplements for 3 months. L-carnitine may be a more effective and safer option for managing sexual dysfunction, depressed mood, and fatigue related to male aging. L-carnitine can improve erectile function and mood without the potential side effects of prostate enlargement associated with testosterone therapy.¹⁰²

Research indicates that CoQ10 supplementation can lead to increased testosterone levels. In an animal study involving male mice with chronic kidney disease, CoQ10 treatment significantly elevated testosterone levels by 10% and improved testicular function by its antioxidant activity, and elevating the protein expression of enzymes related to testosterone biosynthesis.¹⁰³ CoQ10 has been shown to improve erectile function in certain populations. A study was conducted in the cardiology unit of Hayatabad Medical Complex Hospital, Peshawar, Pakistan, from March 2020 to March 2021, on 230 male patients (average age 51) with hypertension and mild to moderate ED. A notable improvement in ED (measured by IIEF score) was observed in patients when treated with CoQ10 oral supplements (200 g/day) for 3 months alongside their current antihypertensive therapy. Around 20.1% of participants scored more than 17 (indicating mild ED) in the IIEF. ¹⁰⁴ In this study, the reason for this high dose of CoQ10 has not been explained. However, larger clinical trials on the male population are necessary to confirm the efficacy of CoQ10 in improving male libido and erectile function.

In a three-month animal study on aged male mice, oral administration of CoQ10 helped in lowering the immunosenescence incidence in aging males by shielding against reactive oxygen species and reducing oxidative stress by ~300%. Immunosenescence refers to the age-related decline in the immune system’s function, leading to a weakened ability to respond to infections and vaccines and increased susceptibility to age-related diseases.¹⁰⁵

Dosage Recommendation Based on Research

A daily dose of 2 g of L-carnitine is safe for up to 12 months but may have mild side effects like heartburn and indigestion.¹⁰⁶ Standard dosages for CoQ10 supplements range between 60 and 500 milligrams daily for 3 months.¹⁰⁷

Table 5 Dosage Recommendation of Certain Antioxidants for Adult Men (age more than 14 years)

Food Sources

Plant sources rich in L-carnitine are:¹⁰⁸

• Cooked asparagus: 0.1 mg per half cup, 0.02% of DV

• Avocado: 2 mg per medium-sized avocado

Animal sources rich in L-carnitine are:

• Cooked beef steak: 56-162 mg/113g, 11.2% to 32% of DV

• Cooked ground beef: 65-74 mg/85g, 13% to 15% of DV

• Cooked pork meat: 42 mg/113g, 8.4% of DV

• Milk: 8-12 mg/240 ml, 2% of DV

• Hard cheese: 3 mg/100g, 0.6% of DV

• Cooked chicken breast: 2-4 mg/85g, 0.4-0.8% of DV

Plant sources abundant in CoQ10 are:

• Boiled soybean: 1.2 mg/100g

• Pistachio: 2 mg/100g

• Peanut: 2.6 mg/100g

• Broccoli: 0.6-0.86 mg/100g

• Sesame seeds: 1.7 mg/100g

• Strawberries: 0.1 mg/100g

• Oranges: 0.3 mg per medium size orange

Animal sources abundant in CoQ10 are:

• Beef: 3.1 mg/100g

• Mackerel fish: 6.75 mg/100g

• Trout: 0.85mg/100g

• Chicken:1.4 mg/100g

• Pork:2.4 mg/100g

Supplemental Sources

L-carnitine and CoQ10 supplements are available in a variety of forms, such as tablets, capsules, powders, and gummies.

L-carnitine supplements come in various forms, including L-carnitine, acetyl-L-carnitine, and propionyl-L-carnitine, with L-carnitine being the most common and least expensive. The human body absorbs carnitine from food much better than it absorbs carnitine from dietary supplements. 

CoQ10 supplements, often in synthetic forms, are produced through chemical synthesis or microbial fermentation, with the latter being more common due to the ability to produce a pure, high-yield product. While both synthetic and natural CoQ10 supplements are available, the synthetic form, ubiquinone, generally exhibits lower bioavailability than the natural form, ubiquinol, due to its poor solubility and lipophilic nature. 

Side Effects

Common side effects: A daily dose of 2 g of L-carnitine is safe but may have mild side effects like heartburn and indigestion.

CoQ10 may cause side effects like nausea, diarrhea, heartburn, and abdominal pain.

Drug interaction: L-carnitine may interfere with medications such as anticoagulants and thyroid medication. CoQ10 may interfere with medications such as anticoagulants, antidiabetics, and thyroid medication.

Safety Precautions: Talk to your doctor before adding supplements to your diet.

Legal Status and Availability

L-carnitine and CoQ10 supplements are commonly available as over the counter (OTC) dietary supplements in many countries. While standard doses can typically be purchased without a prescription, higher-dose formulations may require one. These supplements are easily accessible at pharmacies, grocery stores, and online retailers, with strict regulations in place to ensure safety and accurate labeling.

Bottom Line

Strength of recommendation: Both L-carnitine and CoQ10 supplementation have beneficial effects on erectile function in aging men. However, further research on human subjects is needed to establish their effects on other andropause symptoms.

Specific Nutrient: Amino acids

What is it

Amino acids are organic compounds involved in protein synthesis essential for producing reproductive hormones (e.g., testosterone).

L-arginine is a conditionally essential amino acid that plays a crucial role in various physiological processes such as protein buildup, immune response, nitric oxide production, testosterone synthesis and blood circulation.¹⁰⁹

L-citrulline is an amino acid that is made naturally in your body. It is found in watermelon. Its name is derived from citrullus, the Latin word for watermelon. It has antioxidant and vasodilating properties.¹¹⁰

How it Works

L-citrulline and L-arginine amino acids may potentially benefit men during andropause by supporting testosterone levels and improving erectile dysfunction (ED) symptoms. The beneficial effects of L-citrulline and L-arginine on testosterone levels are likely due to their role in enhancing antioxidant activities. L-arginine also influences the expression of steroidogenesis-related genes and the activity of enzymes critical for testosterone synthesis.¹¹¹

L-citrulline and L-arginine also help in improving erectile function in aging males. L-citrulline is converted into L-arginine in the body. L-arginine is a natural precursor of nitric oxide. It induces the synthesis and release of nitric oxide, leading to higher testicular blood flow and improved testosterone production by the testes. Nitric oxide relaxes penile muscles and increases blood flow to the penis required for maintaining erection and male sexual arousal.¹¹²

What the Research is Telling us

L-arginine administration has been shown to enhance testosterone levels in various animal models. In heat-stressed rams, intramuscular L-arginine (5mg/kg) administration significantly increased plasma testosterone concentrations and nitric oxide levels compared to controls, which led to enhanced testicular blood flow and reproductive capacity in rams in hot season (non-breeding season).¹¹³ In aged broiler breeder roosters, dietary L-arginine supplementation (0.68%) resulted in higher plasma testosterone levels, indicating a positive effect on testosterone production.¹¹⁴ L-arginine has been shown to significantly improve erectile function in men with mild to moderate ED. In a study on 51 patients with mild to moderate vasculogenic ED, L-arginine supplement (6 g/day) for 3 months helped in restoring erectile function by 30% (as measured by IIEF score). The IIEF score increased from approximately ~12-16 (indicating mild to moderate ED) to ~17-21 (indicating mild ED). However, for patients with severe vasculogenic ED, no significant improvement was observed.¹¹³

Research indicates that L-citrulline supplementation can have a positive impact on testosterone levels, particularly in conditions where oxidative stress is a factor. This is achieved through its antioxidant properties, which help to mitigate the damage caused by oxidative stress. In an animal study involving male rats, L-citrulline was shown to reverse the negative effects of lead acetate-induced testicular toxicity and improve testosterone hormone levels. Lead exposure decreases antioxidant enzyme activity and nitric oxide levels and increases oxidative stress. L-citrulline supplementation restored antioxidant enzyme activity and nitric oxide levels, indicating reduced oxidative damage. ¹¹⁵ 

 During andropause, men may experience various health challenges, including muscle loss and erectile dysfunction. In animal studies, L-citrulline supplementation has been shown to favorably modulate body composition by increasing lean body mass and reducing fat mass, as well as protecting against lipid oxidation, suggesting potential benefits for metabolic health in aging populations.¹¹⁶ A human study on 24 males (mean age 56) with mild ED showed significant improvement in erection hardness score from 3 (mild ED) to 4 (normal erectile function) and an increase in intercourse frequency by 17% in 50% of men when given L-citrulline supplements (1.5 g/day) for 1 month. This is attributed to L-arginine’s ability to improve nitric oxide-mediated vasodilation and endothelial function.¹¹⁷

Dosage Recommendation Based on Research

For improving erectile function, the recommended dose of L-arginine is between 1 to 6 grams daily for up to 3 months, and L-citrulline is 1.5 g/day for 2 months.

Table 6 Dosage Recommendation of Certain Amino acids for Adult Men (age more than 14 years)

Food Sources

Plant sources rich in L-citrulline are:¹¹⁸

• Watermelon: 3.16–3.79 mg/100 grams

• Amaranth: 1.73–16.48 mg/100 grams

• Kales: 1.73–16.48 mg/100 grams

• Button mushroom: 0.65–19.41 mg/100 grams

• Cucumber: 0.65–19.41 mg/100 grams

• Pumpkin: 0.65–19.41 mg/100 grams

• Avocado: 474 mg per fruit.

• Nectarine: 886 mg per fruit

• Asparagus: 500 mg per half cup of cooked asparagus

Plant sources that are naturally rich in L-arginine are:¹¹⁹

• Peanut: 3.35 g/100g

• Pumpkin seed: 5.35 g/100g

• Soy protein concentrate: 4.64 g/100g

• Walnut: 3.62 g/100g

• Sesame: 3.25 g /100g

• Tofu: 3.19 g/100g

Animal sources that are naturally rich in L-arginine are:

• One cooked turkey breast:16 g of L-arginine

• One cooked chicken breast: 9 g of L-arginine

Supplemental Sources

L-citrulline and L-arginine supplements are available in a variety of forms, such as tablets, capsules, powders, and gummies.

L-arginine is commercially produced through fermentation using glucose as a carbon source or by hydrolyzing various protein sources, such as gelatin.

L-citrulline is available in various forms, including L-citrulline malate, which is a combination of L-citrulline and malic acid. L-citrulline malate is often used in sports supplements as it may enhance absorption and bioavailability. L-citrulline supplements, whether synthetic or from sources like watermelon, are generally considered to have good bioavailability, meaning the body readily absorbs and utilizes them. 

Side Effects

Common side effects: L-arginine supplements can cause some side effects, such as stomach pain, diarrhea, low blood pressure, and bloating.¹²⁰ L-citrulline is possibly safe in doses of 1.5-5 g for up to 2 months. It is usually well-tolerated. Some people might experience stomach discomfort or heartburn.¹²¹

Drug interaction: L-arginine may interfere with medications such as diuretics, antidiabetics, sildenafil, blood pressure regulators, and anticoagulants. L-citrulline may interfere with antihypertensive drugs.

Safety Precautions: L-citrulline and L-arginine might affect blood pressure. They might interfere with blood pressure control during and after surgery. It is important to stop taking L-citrulline and L-arginine at least two weeks before a scheduled surgery. Seek advice from a healthcare provider before taking supplements.

Legal Status and Availability

L-citrulline and L-arginine supplements are commonly available as over the counter (OTC) dietary supplements in many countries. While standard doses can typically be purchased without a prescription, higher-dose formulations may require one from a health care provider. These supplements are easily accessible at pharmacies, grocery stores, and online retailers, with strict regulations in place to ensure safety and accurate labeling.

Bottom Line

Strength of recommendation: If you are experiencing mild or moderate ED due to andropause, taking L-citrulline and L-arginine supplements can possibly help improve blood flow. However, research on L-citrulline and L-arginine for ED and libido is limited and more research is needed to determine its effects on humans. Always consult a healthcare professional for advice before starting any new supplements.

Specific Nutrient: Tongkat ali

What is it

Tongkat ali (Eurycoma longifolia), commonly called pasak bumi or longjack, or Malaysian ginseng, is a flowering shrub native to Southeast Asia, including Indonesia, Malaysia, Vietnam, Cambodia, Myanmar, Laos, and Thailand. It is an integral part of indigenous medicine.¹²² It has gained attention for its potential benefits in addressing symptoms of andropause like low libido and energy and erectile dysfunction.

How it Works

Tongkat ali contains bioactive compounds such as eurycomanone and canthin, which promote testosterone production, balance hormones, and increase libido and erectile function. Eurycomanone inhibits the aromatase enzyme and prevents the conversion of testosterone to estrogen, thus maintaining higher levels of free testosterone required for overall health in aging males.¹²³

What the Research is Telling us

Research indicates that tongkat ali supplementation can significantly improve symptoms of andropause. In a study involving 76 patients with this condition, a 200 mg standardized water-soluble extract of tongkat ali improved the Ageing Males’ Symptoms (AMS) score and increased serum testosterone levels to the normal range. This suggests that tongkat ali may be effective in managing symptoms of andropause, such as reduced libido and energy levels.¹²⁴

The AMS (Aging Males’ Symptoms) scale is a questionnaire used to assess symptoms in aging men. Total scores range from 17 to 85, where higher scores indicate more severe symptoms. According to the classification, a score of more than 50 indicates severe aging symptoms, 37-49 indicates moderate symptoms, 27-36 indicates mild symptoms, and 17-26 indicates non-significant symptoms.¹²⁵

Another study has reported a positive impact of tongkat ali supplement (200 mg/day) for 6 months on erectile function and testosterone levels of 45 male patients (mean age 47 years) suffering from androgen deficiency in aging males (ADAM).¹²⁶ Additionally, a one-month study exhibited the potential of tongkat ali root (hot water extract) in improving mood and reducing stress by ~11-15% in 32 men, which can indirectly enhance libido and sexual performance. There was a significant decrease in cortisol levels of 16% and an increase in testosterone levels of 37%.¹²⁷

While the current findings are promising, more comprehensive human studies are required to validate these preliminary results and to explore the long-term benefits and potential side effects of tongkat ali. 

Dosage Recommendation Based on Research

The standard dosage of tongkat ali in managing symptoms of andropause is 200-400 mg/day.

Table 11 Dosage Recommendation for Tongkat ali

Supplemental Sources

Tongkat ali root is available as an herbal supplement in powder, softgel, capsule, tablet, or liquid extract form. Capsules are generally considered the most convenient and standardized option, while dry root powder can be a good choice for those who prefer a more natural approach. Powder form provides flexibility in dosage but requires careful measurement. Powder can be added to juice, drinks, smoothies, or other foods to mask its bitter taste.

Side Effects

Common Side Effects: The common side effects of tongkat ali may include insomnia, irritability, and restlessness. Tongkat ali supplements may contain mercury or lead. An overdose might lead to mercury or lead poisoning or other side effects.¹²⁸

Drug Interaction: It may interact with medications that control blood sugar (metformin, glipizide, and miglitol), immunosuppressants, and beta-blockers (propranolol).¹²⁹

Tongkat ali can be combined with other herbs, e.g., ashwagandha which may offer complementary benefits. Both herbs are stressbusters and energy boosters, making them a dynamic duo. This combo might improve physical and mental performance and could be especially helpful for sexual health and hormone balance.¹³⁰ The same applies to tongkat ali and maca. Many fitness and health enthusiasts find that combining these two may enhance their overall benefits. However, it is advisable to start with smaller doses to see how the body responds before fully integrating that combination into your health regimen.¹³¹

Safety Precautions: While supplements, especially herbs, have been used safely in traditional cultures for centuries, individual effects vary depending upon each person’s genetic makeup. Speak with your healthcare provider before taking herbal supplements.

Some phytotherapy experts recommend that herbs (e.g., tongkat ali, ashwagandha, ginseng, maca, and puncturevine) with adaptogenic (stress relieving) properties should not be combined but given separately. This allows for more easily discerning their effects on the body and the ability to track down the ‘culprit’ of any side effects.¹³²

Legal Status and Availability

The FDA does not regulate herbal supplements like tongkat ali, meaning it does not approve them for medical use. As such, consumers need to be aware of potential interactions and side effects and should consult with a healthcare provider before using them. It is easily accessible to buy online or at pharmacies as a supplement in capsule, tablet, or powder form. However, due to potential adulteration and contamination, careful sourcing of tongkat ali is crucial, as it can contain heavy metals like lead and mercury. Choose brands that have a good reputation and are known for quality control.¹³³ 

Bottom Line

Strength of recommendation: Tongkat ali shows potential as a natural remedy for managing symptoms of andropause in aging males, enhancing erectile function, and addressing male libido, but more rigorous clinical trials are needed to establish its efficacy and safety and fully understand its benefits and mechanisms.

Specific Nutrient: Unripe Black Raspberry

What is it

Rubus coreanus Miquel (R. coreanus) is a species of Rubus genus native to eastern Asia. Its common name is unripe black raspberry, which is referred to as “bokbunja” in Korean. The immature or unripe fruits of R. coreanus have greater health effects than fully ripe black raspberries due to their high phenolic content. It has been utilized in traditional medicine for centuries.¹³⁴

How it Works

In traditional Korean medicine, unripe black raspberry extract (BRE) is used for prostate and urological issues, and studies suggest it may have benefits for andropause symptoms, including improving voiding function (expelling urine from the urinary bladder) and potentially promoting testosterone production. During andropause, men may experience changes in voiding function due to hormonal shifts, prostate enlargement, and weakened pelvic floor muscles, leading to symptoms like urinary urgency (loss of bladder control), frequency, and difficulty emptying the bladder.¹³⁵ Ellagic acid is the major phenolic compound of black raspberry fruit and is known to have powerful antioxidant and anti-inflammatory properties. However, more research is needed to understand the mechanism behind the BRE effects on andropause fully.¹³⁵

What the Research is Telling us

Unripe black raspberry extract (BRE) has been studied for its potential benefits in managing symptoms associated with men experiencing andropause. Research on the effects of BRE extract on testosterone levels is limited. However, one study on diabetic male rats showed that raspberry extract (200 mg/kg) could reverse alterations in testosterone levels caused by diabetes, suggesting a potential protective effect on the male reproductive system due to its antioxidation property. The testosterone level increased by ~121%.¹³⁶ Research has supported BRE’s anti-inflammatory and antioxidant properties: a noted reduction in inflammation and oxidative stress was observed in various human cell models, contributing to its overall health benefits. ¹³⁷ In a study involving 30 middle-aged men experiencing andropause, after 3 months of treatment with BRE (4800 mg/day in two doses), a significant improvement in voiding function by ~36% and ~13% enhancement in lipid metabolism, and ~20% reduction in bad cholesterol levels were observed. That could be advantageous for cardiovascular health in men undergoing andropause.¹³⁶ While traditional and anecdotal evidence supports the use of BRE for male sexual health, particularly during andropause, there is a gap in understanding its effects on humans. More rigorous scientific studies are needed to substantiate these claims and explore their full therapeutic potential in andropause.

Dosage Recommendation Based on Research

BRE has been used in doses of up to 2500 mg daily for 8 weeks.

Table 12 Dosage Recommendation for Unripe black raspberry extract

Supplemental Sources

Unripe black raspberries are not currently available as a supplement.

Side Effects

Common Side Effects: Unripe black raspberries have been traditionally used for centuries in Korea. They are likely safe for most people. Unripe black raspberries might cause digestive upset or allergic reactions in some people. However, current research doesn’t indicate any significant side effects associated with unripe black raspberry extract consumption. Because the research on unripe black raspberry extract is limited, more studies are needed to fully understand its potential side effects.¹³⁸ 

Drug Interaction: Currently there is no information for unripe black raspberry interactions.

Safety Precautions: Speak with your healthcare provider before taking herbal supplements.

Legal Status and Availability

The FDA does not regulate herbal supplements like BRE, meaning it does not approve them for medical use. Thus, consumers should be aware of potential interactions and side effects and consult with a healthcare provider before using them.

Unripe black raspberries are not a common grocery store item and will likely need to be found at local farms or specialty stores. Look for farms or orchards that specialize in unusual or native fruits. Or, search for online retailers specializing in Korean or Asian produce but be aware of potential shipping costs and freshness concerns.

Bottom Line

Strength of recommendation: Unripe black raspberries are a popular natural remedy for male sexual health issues associated with andropause. As research continues, unripe black raspberries remain a promising herbal option for those seeking natural solutions to andropause. However, more robust, randomized controlled trials are needed, especially on the human population, to conclusively determine the efficacy of unripe black raspberries in improving andropause symptoms. That may help in increasing its commercial availability and ease of access.

Specific Nutrient: Ashwagandha

What is it

Ashwagandha (Withania somnifera), also known as Indian ginseng or Indian winter cherry, is an aphrodisiac and adaptogenic evergreen herb found in India, northern Africa, and the Middle East. It has been used for over 6,000 years in Ayurveda (one of the world’s oldest studies of natural healing, practiced in India) due to its powerful health benefits.¹³⁹ “Ashwagandha” is derived from the word “ashwa”, meaning horse, and “gandha” meaning smell. It is believed that after consuming the Ashwagandha root, one gains powers like a horse.¹⁴⁰

How it Works

The principal bioactive compounds of ashwagandha are triterpene lactones known as withanolides. Withanolides have antioxidant, adaptopgenic (antistress), and anti-inflammatory properties. It prevents male sexual dysfunction and improves libido by balancing hormones, reducing stress by lowering stress hormone (cortisol) levels, and increasing testosterone levels.¹⁴¹ This herb may also support deeper sleep, proper hormonal function, and increased energy, which are often impacted by andropause.¹⁴² 

What the Research is Telling us

Some studies have reported that ashwagandha may offer some benefits for men experiencing andropause, potentially boosting testosterone levels and muscle strength and reducing stress, which can improve energy, libido, and mood. For instance, in a 2-month study conducted on 57 overweight, aging men (aged between 40-70 years) experiencing andropause and mild fatigue, ashwagandha root extract (delivering 21 mg of withanolide glycosides a day) was given daily for eight weeks. Over time, ~14.7% greater increases in testosterone levels and improvements in fatigue, vigor, and sexual and psychological well-being were reported. ¹⁴³

Another 2-month study conducted on 57 men (aged between 18-50 years old) found that daily consumption of ashwagandha root extract (200 mg/day), in conjunction with resistance training, showed a significant ~4.7% increase in testosterone levels, ~74% muscle mass, and strength, and a ~3.5% decrease in body fat percentage. ¹⁴⁴

A recent randomized, controlled trial involved 50 overweight men struggling with low sex drive and metabolic issues associated with low testosterone levels. A significant increase in sexual desire by ~32% and a ~18% increase in testosterone levels were observed with the supplementation of ashwagandha root extract (300 mg/day in two doses) for 2 months.¹⁴⁵

Dosage Recommendation Based on Research

The recommended dosage for ashwagandha ranges from 200 mg to 600 mg/day for 1-2 months to enhance libido and testosterone levels.¹⁴⁶ With ashwagandha, a common approach is to use it for 6 to 12 weeks and then take a one to two-week break before resuming.

Table 7 Dosage Recommendation for Ashwagandha

Supplemental Sources

Ashwagandha root is available as herbal supplements in powder, softgel, capsule, tablet or liquid extract form. The number of active compounds in ashwagandha withanolides can vary depending on the form: liquid extracts have more concentrated withanolides than powder form. Hence, the ashwagandha liquid extract has higher potency, which results in more pronounced and faster effects after consumption than the powder form. On the other hand, ashwagandha in tablet or capsule form offers convenience and ease of use. You can also buy dried ashwagandha root to boil in water for tea. Capsules are generally considered the most convenient and standardized option, while dry root can be a good choice for those who prefer a more natural approach, and powder offers flexibility in dosage but requires careful measurement. Raw ashwagandha root can have a slightly earthy and bitter taste. Ashwagandha root powder can be added to drinks, smoothies, or other foods to mask its taste.

Side Effects

Common side effects: Side effects of ashwagandha may include diarrhea, headache, sedation, nausea, or liver problems.¹⁴⁷

Drug interaction: Ashwagandha may interact or interfere with medications such as antidiabetics, antihistamines, antihyperglycemic, contraceptives, thyroid hormone supplements, immunosuppressants, blood pressure regulators, and blood thinners.

Both maca and ashwagandha are renowned for improving testosterone production and sexual health. Thus, taking them together may potentially amplify the individual benefits of each herb and contribute to better testosterone production, stress management, vitality, and strength.¹⁴⁸

Safety Precautions: Seek an opinion from your doctor before taking herbal supplements.  

The National Sanitation Foundation (NSF), the American Botanical Council (ABC), and Good Manufacturing Practices (GMP) offer certification for dietary or herbal supplement products to ensure that supplements are manufactured, processed, and packaged according to strict quality standards, promoting safety and quality. To ensure that dietary or herbal supplements are produced in a quality manner and do not contain contaminants or impurities, the consumer should carefully read the product label or packaging and look for the quality certification.

Legal Status and Availability

The Food and Drug Administration (FDA) does not regulate herbal supplements like ashwagandha, meaning it does not approve them for medical use. Consumers should be aware of potential interactions and side effects and consult with a healthcare provider before using them. It is easily accessible to buy online or at pharmacies as a supplement in capsule, tablet, or powder form. It is important to note that some manufacturers may sell ashwagandha products that have not been tested for quality or safety. Consumers should always purchase ashwagandha products from reputable sources. 

Bottom Line

Strength of recommendation: Ashwagandha offers promising benefits for improving testosterone levels, physical performance, and libido and managing stress, which are relevant to addressing symptoms of andropause in males. 

Specific Nutrient: Maca

What is it

Maca (Lepidium meyenii), also known as Peruvian Ginseng or Ginseng Andin, is a biennial herbaceous plant that originated in Peru. Maca has a rich history of traditional use and is considered a valuable commodity by the Andean population. The Andean region is one of the world’s most densely populated mountain ranges and includes parts of Peru, Ecuador, Colombia, and Bolivia. Dried roots of maca can be preserved for years.

How it Works

Maca root is rich in a unique bioactive compound known as macamides that possess antioxidant, anti-inflammatory, and libido-enhancing properties. Macamides stimulate the production of neurotransmitters like dopamine, which plays a key role in sexual arousal and pleasure.¹⁴⁹

There is a positive association between maca root consumption and increased testosterone levels. However, the mechanism by which maca exerts its effect on testosterone levels is under study, especially in humans. In animal studies on rats, maca has been shown to enhance the steroidogenic (steroid hormone synthesis, e.g., testosterone hormone production) ability of Leydig cells, which are responsible for testosterone production.  However, further research is needed to understand its mechanisms of action.¹⁵⁰

What the Research is Telling us

Maca root has been studied for its potential to improve testosterone levels and reproductive health in men experiencing andropause. In a one-month animal study on aged male mice, oral administration of gelatinized maca root has been reported to improve muscle mass, testosterone levels (from ~2.4 to 2.5 ng/dL), and lipid metabolism.¹⁵¹ A case series sharing the experience of 2 men (age 38 and 44 years individually) taking a concentrated and gelatinized form of Maca (1500 mg Maca-OG™ daily) for 3 months led to increased testosterone levels (from ~435 to 680 ng/dL) and improved energy, mood, and sleep.¹⁵²

Maca root has been reported to improve sexual desire and libido in men; however, the evidence is limited due to the small number of studies with small sample sizes. A few studies have explored maca’s effects on sexual desire. For instance, a clinical study involving 57 men observed improvement in sexual desire (based on self-perception of individuals) by ~42.2% after 3 months of treatment with maca root supplementation (1.5 g or 3 g/day in three doses).¹⁵³

Research indicates that maca root may have a positive impact on erectile function, particularly in men with mild ED. A study involving 80 male patients (aged over 40 years) with andropause observed improvement in erectile function (measured by IIEF score) after 3 months of treatment with maca root (1 g/day in three doses). After supplementation, the IIEF score increased from approximately 6.3 (indicating severe ED) to 14 (indicating mild-moderate ED).¹⁵⁴ A similar study on 50 Caucasian males (men with origins in Europe, the Middle East, or North Africa) affected by mild ED observed a significant increase in erectile function after 3 months of treatment with maca root dry extract (2.4 g/day in three doses).¹⁵⁵

Dosage Recommendation Based on Research

The recommended daily dose of maca ranges from 1.5 to 3 g/day for 3 months for libido and 1g/day for 3 months to improve erectile function.

Table 8 Dosage Recommendation for Maca

Supplemental Sources

Maca root extract is available as herbal supplements in powder, softgel, capsule, tablet or liquid extract form. You can also buy dried maca root to boil in water for tea, but you need to grind the dried root into powder. Capsules are generally considered the most convenient and standardized option, while dry root can be a good choice for those who prefer a more natural approach, and powder offers flexibility in dosage but requires careful measurement. Raw maca can have a strong, bitter taste, but the benefits are likely the same as a capsule. Maca root powder can be added to drinks, smoothies, or other foods to mask in its taste.

Side Effects

Common side effects: It has mild side effects like headaches, stomach issues, insomnia, or jitteriness.¹⁵⁶

Drug interaction: People taking blood thinners, high blood pressure medicine, or having thyroid problems should take the advice of their healthcare provider.

Both maca and ashwagandha are renowned for improving testosterone production and sexual health. Hence, taking them together may potentially amplify the individual benefits of each herb and contribute to better testosterone production, stress management, vitality, and strength.¹⁵⁷

Safety Precautions: Seek an opinion from your doctor before taking herbal supplements.

Legal Status and Availability

The FDA does not regulate herbal supplements like maca, meaning it does not approve them for medical use. Consumers should be aware of potential interactions and side effects and consult with a healthcare provider before using them. It is easily accessible to buy online or at pharmacies as a supplement in capsule, tablet, or powder form.

Bottom Line

Strength of recommendation: While maca shows potential as a natural remedy for improving male libido and ED, more rigorous and large-scale studies are needed to explore its effect on other andropause symptoms.

Specific Nutrient: Korean Red Ginseng

What is it

Korean red ginseng (Panax ginseng), also known as Asian ginseng or Chinese ginseng, is a perennial plant that grows in the mountains of South Korea and China. Its roots have been used for ages in traditional Chinese medicine to increase alertness and potentially improve erectile dysfunction, a common issue during andropause.

How it Works

Korean red ginseng is one of the famous aphrodisiacs. It contains ginsenoside, a bioactive compound that has antioxidants and anti-inflammatory properties. Ginsenosides may impact the hypothalamus-pituitary-gonadal axis, stimulating the production of hormones like testosterone required for sexual and overall health in aging males.¹⁵⁸ Ginsenosides play a role in erectile function by stimulating the release of nitric oxide, which relaxes penile muscles and increases blood flow to the genitals, which is required for lengthier erections. It also stimulates oxytocin release associated with sexual desire.¹⁵⁹ Korean Red Ginseng appears to offer multiple benefits for aging males experiencing andropause. Its ability to mimic testosterone effects, improve metabolic health, rejuvenate testicular function, and provide antioxidant support makes it a promising natural remedy for managing symptoms associated with aging and testosterone deficiency. Korean red ginseng’s antioxidant properties play a crucial role in its anti-aging effects. It helps regulate oxidative stress by balancing oxidant and antioxidant levels, which is vital in addressing age-related male sexual impairments.¹⁶⁰

What the Research is Telling us

Korean red ginseng has shown promise in addressing testosterone deficiency-related issues, such as obesity and dyslipidemia (high cholesterol). In an animal study involving castrated (removed testicles) mice, Korean red ginseng was found to inhibit obesity and improve lipid metabolism by reducing body weight, adipose tissue mass, and serum lipid levels. These effects were comparable to those of testosterone, suggesting that Korean red ginseng may act similarly to testosterone in preventing obesity and related metabolic disorders in men with testosterone deficiency.¹⁶¹ Another animal study observed that Korean red ginseng helps rejuvenate testicular function in aged rats by improving the expression level of spermatogenesis-related key biomolecules (inhibin-α, nectin-2, and cyclic adenosine monophosphate) and sex hormone receptors, as well as enzymes regulating oxidation (antioxidant enzymes such as glutathione peroxidase). In andropause, testicular function gradually declines, leading to reduced testosterone production and sperm production. ¹⁶²

Many human studies have demonstrated that Korean red ginseng can significantly improve erectile function in men. Research on 60 male patients with mild to moderate ED reported that daily intake of Korean red ginseng (1 g/day) for 3 months enhanced erectile function. After supplementation, the IIEF score increased from approximately 16.4 (indicating mild to moderate ED) to 21 (indicating mild ED). ¹⁶³ Another study on 45 male patients (mean age 54 years) with clinically diagnosed ED demonstrated that daily intake of Korean red ginseng (900 mg/day) for 3 months significantly increased erectile function (increased IIEF score).¹⁶⁴

Animal studies on Korean red ginseng showed its potential in alleviating certain symptoms related to andropause. Additionally, a few human studies supported its effect on enhancing erectile function. However, more clinical trials on the human population are required to evaluate the effect of Korean red ginseng on managing other andropause symptoms.

Dosage Recommendation Based on Research

Korean red ginseng is safe for daily intake of 2 g for up to 4 months by healthy adults.¹⁶⁵ Korean red ginseng at a dosage of 1 g/day for 3 months can be taken to enhance erectile function.

Table 9 Dosage Recommendation for Korean Red Ginseng

Supplemental Sources

Korean red ginseng root extract is available as herbal supplements in powder, softgel, tablet or liquid extract form. You can also buy dried root to boil in water for tea. 

For Korean red ginseng, capsules are generally considered the most convenient and standardized option, while dry root can be a good choice for those who prefer a more natural approach, and powder offers flexibility in dosage but requires careful measurement. Powder can be added to drinks, smoothies, or other foods.

Side Effects

Common Side Effects: Side effects of Korean red ginseng may include diarrhea, headache, increased blood pressure, nausea, or insomnia.¹⁶⁶

Drug Interaction: Korean red ginseng may interact or interfere with medications such as antidiabetics, antidepressants, antihypertensives, diuretics, and blood thinners.

Maca and ginseng are a perfect blend to boost libido, vitality, and endurance. Because maca boosts energy, improves mood, and supports hormone regulation, and ginseng increases stamina and reduces stress, the two ingredients together promote overall physical and sexual health.¹⁶⁷

For other herbs in combination with Korean red ginseng, there’s limited information specifically about their combined use and potential interactions. It is always best to consult with a healthcare professional or qualified herbalist before combining any herbs.

Safety Precautions: Talk with your healthcare provider before taking herbal supplements.

Legal Status and Availability

The FDA does not regulate herbal supplements like Korean red ginseng, meaning it does not approve them for medical use. Consumers should be aware of potential interactions and side effects, and consult with a healthcare provider before using them. It is easily accessible to buy online or at pharmacies as a supplement in capsule, tablet, or powder form.

Bottom Line

Strength of recommendation: In conclusion, Korean red ginseng appears to be an effective and safe alternative treatment for ED, a common symptom associated with andropause. However, more comprehensive studies are necessary to establish its efficacy and safety profile. More rigorous, large-scale clinical trials are needed to confirm these findings and better understand Korean red ginseng’s active components and mechanisms. Further research could lead to breakthroughs in the management of andropause using active compounds extracted from Korean red ginseng.

Specific Nutrient: Puncturevine

What is it

Puncturevine (Tribulus terrestris), commonly called goathead, bindii or lawnweed is an annual herb native to Africa, Asia, Australia, and Europe. It is an integral part of indigenous/folk medicine used to improve libido in both men and women. 

How it Works

It contains strong phytochemical protodioscin (steroidal saponin). Protodioscin acts as a stimulator of testosterone production. It also enhances erectile function by influencing nitric oxide production, which is important for blood flow to the genital area.¹⁶⁸

What the Research is Telling us

Puncturevine has a history of traditional use as an aphrodisiac and for male health; however, scientific evidence supporting its efficacy for andropause or increasing testosterone in humans is limited. A few studies have reported improvements in testosterone levels, sexual desire, and satisfaction in men treated with puncturevine, suggesting a positive effect on andropause-associated symptoms. For instance, in a 3-month study, supplementation with puncturevine (750 mg/day, in three divided doses of 250 mg/day) led to a significant increase in testosterone levels, as well as improvements in erectile function in 30 aging male patients suffering from partial androgen deficiency in aging males (PADAM).¹⁶⁹

In another study, a significant enhancement of erectile function, sexual satisfaction, orgasmic function, sexual desire, and overall satisfaction was noted in a study involving 180 male patients (aged between 18 and 65 years) with mild to moderate ED after 3 months of treatment with puncturevine extract tablet (250 mg/day).¹⁷⁰ Another study observed a significant increase in erectile function (based on IIEF score) in 98 men with ED when given 500 mg of an herbal supplement tablet consisting of a combination of puncturevine, Korean red ginseng, and L-arginine for 3 months. The herbal tablet contained 100 mg of protodioscin, 35 mg of ginsenosides, and 250 mg of L-arginine. The IIEF score increased from approximately 10.75 (indicating moderate ED) to 13.97 (indicating mild to moderate ED). ¹⁷¹

Puncturevine is thought to influence sex hormones, which could contribute to its effects on sexual health. Studies have shown increases in testosterone and other sex hormones in animal models, which might explain its potential benefits in mild to moderate ED.¹⁷² However, these hormonal effects have not been consistently observed in human studies, and the evidence remains inconclusive.

Dosage Recommendation Based on Research

Puncturevine extract is possibly safe when taken at doses of 250 mg daily for up to 90 days.

Table 10 Dosage Recommendation for Puncturevine

Supplemental Sources

Puncturevine herb is available as herbal supplements in powder, softgel, capsule, tablet, or liquid extract form. Capsules are generally considered the most convenient and standardized option, while powder can be a good choice for those who prefer a more natural approach but require careful measurement.

Side Effects

Common Side Effects: The common side effects of puncturevine may include diarrhea, constipation, headache, increased blood pressure, nausea, or insomnia.¹⁷³

Drug Interaction: Puncturevine may interact with medications like antidiabetics, anti-hypertensives, diuretics, and blood thinners.

The pairing of puncturevine with ashwagandha has a synergistic effect and represents a thoughtful fusion of ingredients that have been valued for centuries in various herbal traditions.¹⁷⁴

Safety Precautions: Speak with your healthcare provider before taking herbal supplements.

Legal Status and Availability

The FDA does not regulate herbal supplements like puncturevine, meaning it does not approve them for medical use. Consumers should be aware of potential interactions and side effects and consult with a healthcare provider before using them. It is easily accessible to buy online or at pharmacies as a supplement in capsule, tablet, or powder form.

Bottom Line

Strength of recommendation: Puncturevine shows promise as a treatment for improving testosterone levels and erectile function in aging males with partial androgen deficiency. While the results are encouraging, further research is needed to fully understand the long-term safety and efficacy of this botanical medicine in managing symptoms of andropause.

Who are the Experts

Several renowned researchers and experts in the field of andropause and its associated symptoms of low libido and ED have made significant contributions to understanding its causes and treatments. Some notable names include:

Alvin M. Matsumoto is a professor emeritus in the Department of Medicine, Division of Gerontology and Geriatric Medicine at the University of Washington School of Medicine and a clinical investigator at the Department of Veterans Affairs Puget Sound Health Care System (VAPSHS) in Seattle, Washington. Dr. Matsumoto has authored over 210 peer-reviewed research papers. His research has focused on the physiological and clinical endocrine and intracrine effects of testosterone and its active metabolites in aging men and the diagnosis and management of male hypogonadism and andropause.

Abstract of relevant published work:

Testosterone replacement in men with age-related low testosterone: what did we learn from the testosterone trials?¹⁷⁵ (Elsevier, June, 2019)

Testosterone treatment and mortality in men with low testosterone levels¹⁷⁶ (Oxford Academic, June 1, 2012)

Andropause: clinical implications of the decline in serum testosterone levels with aging in men¹⁷⁷ (Oxford Academic, February 1, 2002)

Dr. Tom F. Lue: Dr. Lue is an internationally recognized expert on the treatment of male sexual dysfunction. In 1983, he was one of the first urologists in the country to offer penile injections for ED. He is vice chair of the University of California, San Francisco (UCSF) Department of Urology and medical director of the Knuppe Molecular Urology Laboratory. Lue has won numerous honors, including the Gold Cystoscope Award from the American Urological Association and an award for most innovative research from the American Foundation of Urologic Disease. He has authored or co-authored more than 380 publications and 12 books on male sexual dysfunction.

Abstract of relevant published work:

Normal male sexual function: emphasis on orgasm and ejaculation¹⁷⁸ (Elsevier, November, 2015)

Evaluation and treatment of erectile dysfunction in the aging male: a mini-review¹⁷⁹

(Gerontology, September 7, 2011)

Summary of the recommendations on sexual dysfunctions in men¹⁸⁰ (Wiley, October 28, 2010)

Erectile and sexual dysfunction in the aging diabetic male ¹⁸¹ (Taylor & Francis, December 14, 2006)

 Dr. Mohit Khera: Dr. Khera is a Board-certified urologist specializing in andropause, male infertility, erectile dysfunction, premature ejaculation, and declining testosterone levels in aging men. He offers specialized treatments to restore sexual function. He is a professor in the Scott Department of Urology at Baylor College of Medicine and holds the F. Brantley Scott Chair in Urology. 

Abstract of relevant published work:

The Potential for Pharmacological Interventions for Low Sex Drive in Men¹⁸² (The Journal of Sexual Medicine, January 3, 2022)

Recent advances in the treatment of erectile dysfunction¹⁸³ (Postgraduate Medical Journal, July 27, 2017)

Effect of aerobic exercise on erectile function: systematic review and meta-analysis of randomized controlled trials¹⁸⁴ (The Journal of Sexual Medicine, October 9, 2023)

Professor Chiara Simonelli: Prof. Simonelli is a specialist in Sexology at the Sapienza University of Rome. She specializes in the physiology and psychopathology of sexual behaviors. She is a full Member of the International Academy of Sex Research.

Abstract of relevant published work:

The Sex Therapists’ Approach to the Evaluation and Management of Low Sex Drive in Men¹⁸⁵ (Oxford Academic, March 3, 2022)

Male Sexual Desire: An Overview of Biological, Psychological, Sexual, Relational, and Cultural Factors Influencing Desire¹⁸⁶ (Sexual Medicine Review, January 1, 2020)

Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile dysfunction (ED)¹⁸⁷ (International Journal of Impotence Research, March 1, 2006)

Which psychosocial variables affect drive the most? Analysis of sexual desire in a group of Italian men¹⁸⁸ (International Journal of Impotence Research, February 11, 2019)

Prof. Jin Ling Tang: Professor Tang is a trained epidemiologist and a Professor of Epidemiology in The Chinese University of Hong Kong, with a significant interest in evidence-based healthcare, traditional Chinese medicine, systematic reviews, and the appraisal of medical evidence.

Abstract of relevant published work:

Traditional Chinese medicine¹⁸⁹ (The Lancet, December 06, 2008)

Observational studies on evaluating the safety and adverse effects of traditional Chinese medicine¹⁹⁰ (Wiley, September 14, 2013)

Prof. Mradu Gupta: Dr. Gupta is a professor in Ayurveda at the Institute of Post Graduate Ayurvedic Education & Research, Kolkata, West Bengal, India. She is especially working on the evaluation of pharmacological activities and toxicities of evidence-based traditional Ayurvedic formulations along with clinical trials on human subjects and experimental work on animal models to prove their safety, efficacy and stability and toxicity, etc. 

Abstract of relevant published work:

Clinical evaluation of aphrodisiac activity of a novel ayurvedic formulation for treatment of male sexual disorders¹⁹¹ (International Journal of Research in Medical Sciences, May 30, 2020).

Pharmacological properties and traditional therapeutic uses of important Indian spices: A review¹⁹² (Taylor & Francis, November 11, 2008)

Positions and Views of Worldwide Governmental Medical and Health Organizations

The positions and views of governmental medical and health organizations on andropause, low libido, and ED in men vary by country but generally emphasize its importance as a public health issue, its association with underlying health problems, and the psychological and emotional burden it can place on individuals and couples. Here is a summary of some global perspectives on andropause, low libido, and ED in men:

• Positions from the Medical Community

  • Agency for Healthcare Research and Quality (AHRQ)

    • Erectile Dysfunction | Effective Health Care (EHC) Program (AHRQ 2015)¹⁹³

• Worldwide Governmental Websites on Male Infertility

  • NIH (USA)

    • Understanding How Testosterone Affects Men (NIH 2015)¹⁹⁴

    • Eating, Diet, & Nutrition for Erectile Dysfunction – NIDDK (NIH 2024)¹⁹⁵

    • Treatment for Erectile Dysfunction – NIDDK (NIH 2024)¹⁹⁶

    • Symptoms & Causes of Erectile Dysfunction – NIDDK (NIH 2024)¹⁹⁷

    • Sexuality and Intimacy in Older Adults – National Institute on Aging (NIH 2024)¹⁹⁸

    • Lifestyle Changes and Treatments for Managing Erectile Dysfunction (NIH 2024)¹⁹⁹

    • Preventing Erectile Dysfunction – NIDDK (NIH 2024)²⁰⁰

  • NHS (UK)

    • The ‘male menopause’ (NHS 2018)²⁰¹

    • Low sex drive (loss of libido) (NHS 2017)²⁰²

    • Erectile dysfunction (impotence)(NHS 2017)²⁰³

  • CDC.gov (USA)

    • Using No-nose (Noseless) Bicycle Saddles to Prevent Genital Numbness and Sexual Dysfunction (CDC 2009)²⁰⁴

Nonprofits and Private Organizations

Not many specific nonprofit and private organizations focus on male andropause, However, a few organizations work to raise awareness about male sexual dysfunctions like andropause, provide educational materials, and help individuals access treatment options through diet or medicines. Below is a list of some of these organizations:

• Nonprofit and Private Organizations:

  • American Society for Reproductive Medicine (ASRM)

    • Purpose/Mission statement: “ASRM’s mission is to lead the advancement of reproductive medicine through evidence-based ethical practice, education, research, and advocacy”. ASRM is a professional organization that includes resources about male sexual dysfunction, its causes, diagnosis, and treatment options. It provides educational materials and offers support for healthcare providers and patients alike. It provides a platform for male sexual problem specialists and patients to access the latest science, journals, courses, opinion documents, and networking opportunities. ASRM mission page.²⁰⁵

Website: asrm.org

• Social media accounts: Instagram: @asrm_org // LinkedIn: https://www.linkedin.com/company/american-society-for-reproductive-medicine/ //YouTube: www.youtube.com/@ASRMEducation //Facebook: https://www.facebook.com/ASRMFB/ //Twitter: @ASRM_org

• FertilityIQ

  • Purpose/Mission statement: “FertilityIQ’s goal is to deliver critical education to people when they need it most – so they can navigate life’s most complex inflection points”.²⁰⁶ They offer ratings and reviews of fertility clinics, including those that treat male sexual dysfunction. It provides a platform for men to research various treatments, clinics, and procedures related to male sexual dysfunctions like andropause, decreased libido, and low testosterone levels.

Website: fertilityiq.com

• Social media accounts: Instagram: @fertilityiq //Twitter: @FertilityIQ //Facebook: https://www.facebook.com/FertilityIQ/

• Canadian Andropause Society at Work

  • Purpose/Mission statement: “Its mission is to provide physicians and pharmacists with information and continuing education about andropause.” These education and awareness programs target the diagnosis, treatment, and monitoring of aging men experiencing the clinical manifestations of androgen deficiency.²⁰⁷ 

  • Website: https://www.pulsus.com/scholarly-articles/the-canadian-andropause-society-at-work.html

• The Sexual Medicine Society of North America (SMSNA)

  • Purpose/Mission statement: “To improve the quality of care and patient care outcomes by providing specialized training to increase knowledge and skills and support research and education to promote innovation and best practices in the field of sexual medicine” SMSNA mission page.²⁰⁸ Provides research, education, and treatment options for sexual dysfunction, including andropause, hosts annual conferences, and funds research.

Website: www.smsna.org

• Social media accounts: Twitter: @SMSNA_ORG

//Facebook: https://www.facebook.com/smsna.org/

• American Urological Association (AUA)

  • Purpose/Mission statement: “To promote the highest standards of urological clinical care through education, research, and the formulation of health care policy.” AUA mission page.²⁰⁹ Provides professional guidelines, research funding, and educational resources for both doctors and patients related to urological diseases and conditions, including andropause and male sexual issues.

Website: www.auanet.org

• Social media accounts: Instagram: @amerurological // Twitter: @AmerUrological// Facebook: https://www.facebook.com/AmerUrological//Linkedln: https://www.linkedin.com/company/american-urological-association// YouTube: https://www.youtube.com/user/AmerUrological

Social Media Contributors

Platforms that frequently discuss the topic of andropause and male sexual wellness are:

• NutritionFacts.org

  • It is a science-based nonprofit organization founded by Michael Greger, M.D. Fellow of the American College of Lifestyle Medicine (FACLM. It provides free updates on the latest research on male sexual function and its link to nutrition via bite-sized videos, blogs, podcasts, and infographics.

Website: nutritionfacts.org

• Social media accounts: Instagram (1.2M+ followers):www.youtube.com/@NutritionFactsOrg //YouTube (1.21M+ Subscribers):www.youtube.com/@NutritionFactsOrg //Facebook (881K+ Followers): facebook.com/NutritionFacts.org// Twitter (153.5K+ Followers):twitter.com/nutrition_fact

• Maze Men’s Sexual & Reproductive Health

  • A channel of Dr. Michael A. Werner, MD, a board-certified, fellowship-trained urologist. His social platforms provide information about andropause and its management, low testosterone symptoms, and lifestyle factors affecting testosterone levels.

Website: mazehealth.com

• Social media accounts: Instagram (20.3k+ followers)//YouTube (7.12k+ Subscribers): www.youtube.com/@mazewerner/videos //Facebook (7.9K+ Followers): facebook.com/MazeMensHealth// Twitter (1.1K+ Followers): twitter.com/mazemenshealth

• Rena Malik, M.D

  • Dr. Rena Malik is a Urologist & Pelvic Surgeon. On her channel, she posts weekly videos with education about male sexual wellness, optimization and boosting of testosterone levels naturally, and warning signs of low testosterone levels.

Website:renamalikmd.com

• Social media accounts: Instagram (100k+ followers): instagram.com/renamalikmd //YouTube (2.16M+ Subscribers): www.youtube.com/@RenaMalikMD// Twitter (15.8K+ Followers): twitter.com/RenaMalikMD

• Doctors’ Circle World’s Largest Health Platform

  • Doctors’ Circle is a platform where specialists provide free knowledge and updates on the optimization of male sexual function naturally with diet and lifestyle changes.

  • Social media accounts: YouTube (2.21M+ Subscribers): www.youtube.com/@doctors-circle

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