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Improving Erectile Health – Part 2 of 2

Improving Erectile Health – Part 2 of 2

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Nitric oxide support for sexual health

In Part 1 of this series, we looked at the physiology of a type of erectile dysfunction (ED) known as endothelial ED and explained the importance of blood vessel health on male sexual function. This week, we will explore some natural strategies, that have good scientific evidence for improving vascular (and erectile) integrity.

Although not all men with ED have endothelial ED, many of them do. Nevertheless, just about everyone can likely benefit from these suggestions:

Eat vegetables – especially beets

Diets rich in vegetables have been shown to support overall heart health,[1],[2] lowering the risks of high blood pressure, heart attack, and stroke.[3],[4],[5] If you’re not eating vegetables – it’s never too late to start!

Make at least half of your plate at every meal greens (spinach, kale, chard, etc.) and/or brightly colored vegetables like purple cabbage, tomatoes, purple onions, carrots, and peppers. Beets (beetroot) are particularly effective in increasing nitric oxide (NO) levels, as they’re rich in nitrates, antioxidants, and phenolic compounds important for cardiovascular health.[6] Beets have been observed to increase NO levels and lower blood pressure readings in both men and women of various ages.[7],[8],[9]

Beets have been observed to increase NO levels and lower blood pressure readings in both men and women of various ages.

A powdered greens and/or powdered beetroot supplement (organic whenever possible!) can be a quick and easy way to consume more dietary nitrates.

Enjoy berries

Rich in flavonoids and antioxidants, blueberries, cherries, goji berries, and other berries are excellent for vascular health. Organic green tea, and dark chocolate can also fight oxidative stress, reverse endothelial dysfunction, and stave off cardiovascular diseases.[10]

Nix commercial mouthwash and stomach-reducing medicines

The brilliant human body converts the nutrients found in vegetables into NO. This conversion requires the presence of the right kind of bacteria in the mouth and enough stomach acid.[11]

Because most commercial mouthwashes kill both the good and the bad bacteria in the mouth, they may be contributing to endothelial ED and vascular diseases.

I also typically advise my clients to stay away from calcium carbonate tablets, omeprazole, and other medications that dampen stomach acid production.[12],[13],[14] (If you have acid reflux and think you need acid-reducing drugs, read this.)


The amino acid L-arginine is the raw material from which the body produces NO.[15] Low blood levels of L-arginine have unsurprisingly been correlated with poor NO production, and a significant percentage of ED patients have low levels of L-arginine and/or its precursor, L-citrulline.[16]

A significant percentage of ED patients have low levels of L-arginine and/or its precursor, L-citrulline.

L-arginine supplements may improve NO levels and erectile health – but with limited efficacy, as L-arginine only stays in the circulation for milliseconds at a time.[17] This may be why a review of L-arginine’s efficacy in the treatment of ED reports that a minimum dosage of 3 grams daily is necessary to achieve outcomes, and some studies have even dosed the amino acid at 5 grams.[18]

Thankfully, there is evidence that L-arginine may work significantly well when supplemented along with glutathione (GSH),[19] vitamin C,[20] pine bark extract,[21],[22] and/or L-arginine’s precursor, L-citrulline.


L-citrulline is named for the watermelon, or Citrullus vulgaris, from which it is derived.[23] Unlike L-arginine, L-citrulline skips pre-systemic metabolism and effectively increases circulating NO levels.[24],[25] This might make L-citrulline a more advantageous nutritional supplement than L-arginine in the treatment of ED, hypertension, and related vascular conditions.[26],[27] It has also been shown to be an effective adjuvant to treatment with pharmaceutical PDE5 inhibitors (drugs like Sildenafil).[28]

What may be even more effective than L-arginine or L-citrulline monotherapy, however, is taking the two amino acids concurrently: Simultaneous oral supplementation of 1 gram of L-arginine and 1 gram of L-citrulline was shown to increase plasma L-arginine levels more than 2 g of either alone in a 2017 study.[29]

Caution: Because many viruses – including herpes simplex virus (HSV) – are dependent upon arginine for replication, L-arginine and L-citrulline supplements may be poorly tolerated by patients with frequent HSV outbreaks.[30]

French maritime pine bark extract

A standardized pine bark extract (SPBE) from the bark of the French maritime pine, Pinus pinaster – or Pycnogenol®, as it’s known in the U.S.A. by its patent name – has been shown to improve erectile function both as a standalone treatment and in combination with L-arginine.[31],[32]

SPBE has been observed to support the production and release of NO from the cells lining the blood vessels, improving forearm blood flow in humans in one study.[33]

SPBE has also been shown to improve erectile function, both as a standalone treatment and in combination with L-arginine.[34],[35] In one trial, for example, supplementation with SPBE (120 mg daily for three months) significantly reduced patients’ ED severity from moderate to mild.[36] The Pycnogenol group in this study was also observed to have increased plasma antioxidant activity and reduced total cholesterol and LDL-cholesterol levels as compared to the placebo group. These findings suggest that SPBE may not only treat ED, but also improve overall cardiovascular health.[37]

In another study of 40 males 25 to 45 years of age, a combination of L-arginine and Pycnogenol significantly outperformed Pycnogenol alone, helping 80% of men (and, after another month of the study, 92.5% of men) achieve a normal erection – as compared to only 5% of men who benefitted from Pycnogenol alone. Pycnogenol was given at a dose of 40 mg one to three times daily, with L-arginine at a dose of 1.7 g daily.[38]

A combination of L-arginine and Pycnogenol significantly outperformed Pycnogenol alone, helping 80% to 92.5% of men achieve a normal erection.

In a similar trial of 50 males, L-arginine (3 g per day) plus pycnogenol (80 mg per day day) restored normal erectile function after just one month of supplementation. Sperm quality improved in the men who took this combination and their testosterone levels increased significantly, thus suggesting enhanced fertility. The men also reported a doubling in their sexual intercourse frequency.[39]

Glutathione and other antioxidants

As the master antioxidant of the body, glutathione (GSH) strongly protects against the oxidative stress associated with endothelial dysfunction. GSH and other antioxidants may thus prevent oxidative stress, ameliorate vascular endothelial dysfunction, and stave off cardiovascular disease (among other chronic ailments).[40]

Supplementation with L-citrulline and GSH has also been shown to synergistically increase NO levels.[41]


The steroid hormone precursor dehydroepiandrosterone (DHEA) enhances sex hormone production and positively effects NO levels, thus supporting endothelial health.[42]

A systematic review of 38 trials found that DHEA improves various aspects of sexual health.

A systematic review of 38 trials found that DHEA improves various aspects of sexual health in both males and females, including sexual interest, sexual frequency, lubrication, arousal, pain, and orgasm.[43] DHEA can also help with brain health.[44]

Avoid refined sugars and refined carbohydrates

Foods like breads, pastas, commercial pastries, candy bars, so-called “sports” drinks, sodas, most juices, cereals, crackers, and potato chips all increase blood glucose (sugar) levels and drive inflammation in the blood vessels. It’s no coincidence that men with diabetes and pre-diabetes are more likely to have ED than other guys.[45],[46]

Quit smoking and drinking

You know that smoking and drinking alcohol are harmful for your health, as does everybody else under the sun! These habits also create very high levels of inflammation and oxidative stress in the body, thus wreaking havoc on the circulatory system.[47],[48] ED may be a sign that it’s time to make some healthy lifestyle changes.

Mindfulness practice

NO helps with more than just the dilation of blood vessels: it also supports immune function, balances the nervous system,[49] and protects against various types of dementia.[50] NO helps us feel more relaxed, in turn supporting further NO production.[51] In fact, experienced meditators were found to have higher levels of NO precursors in their blood than non-meditators, in one study.[52]

Move your body

A sedentary lifestyle is a significant risk factor for ED and other cardiovascular diseases. Exercise is the number one lifestyle factor most strongly correlated with erectile health.[53]

Exercise is the number one lifestyle factor most strongly correlated with erectile health.

A review of ten studies found that moderate to vigorous aerobic exercise (four times weekly for six months) improved erectile function in men with ED caused by sedentary lifestyle, obesity, high blood pressure, cardiovascular disease, and/or metabolic syndrome.[54]

Physical activity is an effective way to prevent – and likely treat – ED because it increases NO levels, improves vascular function,[55] and increases testosterone.[56] Considering that exercise helps with a wide array of other health conditions, physical activity should be a part of just about every person’s day. (Too busy to move? Read our tips for fitting exercise into your day.)


During male sexual arousal, nitric oxide (NO) delivers blood to the penis, resulting in erection. Erectile dysfunction may therefore sometimes be a symptom of poor circulatory health, high vascular inflammation, and/or low nitric oxide (NO) levels – all of which can predispose a man to more serious problems like high blood pressure, angina, heart attack, and stroke. ED can therefore serve as an important warning signal of bigger problems to come.

Thankfully, some simple, natural strategies can make all the difference.


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The information provided is for educational purposes only. Consult your physician or healthcare provider if you have specific questions before instituting any changes in your daily lifestyle including changes in diet, exercise, and supplement use.

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