Content uploaded by Rajendra Persad
Author content
All content in this area was uploaded by Rajendra Persad on Mar 26, 2014
Content may be subject to copyright.
Internet websites selling herbal treatments for erectile dysfunction
R Thurairaja
1
*, B Barrass
1
and R Persad
1
1
Department of Urology, Bristol Royal Infirmary, Bristol, UK
The objective of the study was to investigate the safety and reliability of internet websites selling and
providing medical information regarding herbal substitutes for Viagra. Using keywords ‘Herbal’
and ‘Viagra’, websites selling and providing medical information regarding herbal substitutes were
identified. The top 50 sequential sites were assessed for safety and reliability against the Health on
the Net (HON) criteria. Medically trained staff provided information in only 21% of the sites yet just
24% stated that the information was not a replacement for medical advice. No sites warned patients
about erectile dysfunction (ED)-associated cardiovascular disease. In all, 88 and 70% of sites
indicated drug efficacy and ingredients but only 36 and 21% provided contraindications and side
effects, respectively. All sites fell short of the HON requirements. In conclusion, acquiring medical
information and herbal substitutes for ED from the internet is convenient and easy. However,
patients should be cautious as safety and reliability of this approach is poor.
International Journal of Impotence Research (2005) 17, 196–200. doi:10.1038/sj.ijir.3901282
Published online 28 October 2004
Keywords: herbal treatments; internet; erectile dysfunction
Introduction
Erectile dysfunction (ED) is a common and distres-
sing condition affecting an increasing number of
men.
1
It is estimated that almost 30 million men
in the US and two to three million men in the UK
suffer from ED.
2
According to the American Urolo-
gical Association clinical guidelines, ED is defined
as ‘the inability to achieve or maintain an erection
sufficient for satisfactory sexual intercourse’.
3
The
growing incidence of ED is related primarily to a
growing ageing population worldwide, a rise in the
prevalence of risk factors (such as diabetes and
cardiovascular disease) and an increase in treatment
for prostate cancer. Prostate cancer is now the most
commonly diagnosed cancer among Western men
and, ED is a common side effect of treatment.
4
Despite this, it is estimated that close to 90% of ED
sufferers are still reluctant to visit their family
doctors because of embarrassment.
2
Furthermore,
the National Health and Social Life Survey (NHSLS)
concluded that although 31% of American men aged
18–59 y suffered sexual dysfunction, only 10% of
the men (or 3% of the men surveyed) sought medical
advice while the postsildenafil survey for the Pfizer
Global Study of Sexual Attitudes and Behaviours
found that only 19% of men reporting sexual
problems actively sought medical advice in the past
year.
5,6
The internet is now one of the most readily
accessible and comprehensive methods for acces-
sing medical information and treatments by the
public. Studies have shown that more than half the
population of North America has access to the
internet and up to 62% of users were seeking health
or medical information.
7,8
Many websites address
health and medical issues in conjunction with the
sale of products that may alleviate health problems
and diseases, including prescription and nonpre-
scription drugs and health supplements. In the US,
from 1990 to 1997, there was a 380% increase in the
use of herbal remedies and in 2001 over half the
population of America were regularly taking herbal
supplements.
8
Herbal treatments are health supplements that are
chemically rich in plant or plant parts containing
single or multiple ingredients in the form of tablets,
capsules, creams or tinctures.
9
Since Viagra (silde-
nafil) was first introduced as an effective tablet
treatment for ED by Pfizer in 1998, there has been a
rise in the sale of herbal substitutes of Viagra on the
Received 27 April 2004; revised 29 September 2004;
accepted 29 September 2004
*Correspondence: R Thurairaja, Department of Urology,
Bristol Royal Infirmary, Marlborough Street, Bristol BS2
8HW, UK.
E-mail: rthurairaja@doctors.org.uk
International Journal of Impotence Research (2005) 17, 196–200
&
2005 Nature Publishing Group All rights reserved 0955-9930/05 $30.00
www.nature.com/ijir
internet.
10
Viagra is now well established as a brand
name, which the public associate with effective and
safe relief from erectile failure. Websites therefore
use the Viagra brand to promote their products and
may even advertise herbal treatments for ED as
‘Herbal Viagra’. Such websites frequently describe
their products as being efficacious, safe and contain-
ing only natural products with no side effects. The
internet therefore provides an easy and confidential
method obtaining nonprescription herbal treatments
for ED, which will be perceived as being both safe
and effective.
However, the safety of herbal treatments pur-
chased from the internet is unclear. In addition, the
quality and reliability of medical information pro-
vided by websites providing herbal treatments for
ED is unknown. A survey of internet sites selling
herbal supplements for ED was therefore conducted
in order to investigate their safety and reliability
against set criteria.
Materials and methods
In July 2003, an internet search using the key
words ‘Herbal’ and ‘Viagra’ was conducted with
the world’s largest internet search engine (www.
Google.com). The first 50 sites were identified and
sequentially investigated. Safety and reliability were
assessed against the validated and well-established
Code of Conduct (COC) requirements (Table 1)
provided by the Health on the Net (HON) Founda-
tion.
11
The HON Foundation is a medical and health
website accreditation body that is supported by the
World Health Organisation (WHO). It recommends
standards that websites providing medical and
health information should adhere to. Although there
are a number of professional and national criteria for
assessing the quality of medical information on the
internet, the HON criterion was identified as an
ideal tool for assessment since it has been used in
similar studies previously.
12–15
In addition, it was
noted whether sites provided specific advice regard-
ing the assessment of occult cardiovascular disease,
which is known to be associated with ED.
2
The
information provided by websites in terms of the
drugs they advertised (ingredients, efficacy, side
effects and contraindications) was also recorded.
Results
A total of 160 000 websites were identified from the
search. Of the 50 sites reviewed, 33 were new and
independent sites, whereas the remaining 17 sites
were hyperlinks to one of the other 33 sites.
Medically trained personnel provided the infor-
mation in 21% of sites, 24% clearly stated that their
information was not to replace doctors’ advice, 18%
had referenced information and 33% provided
disclaimers (Figure 1). No sites specifically advised
Table 1 HON guidelines
Guidelines from HON code of conduct for medical and health websites
Principle 1—Authority
Any medical or health advice provided and hosted on this site will only be given by medically trained and qualified professionals
unless a clear statement is made that a piece of advice offered is from a nonmedically qualified individual or organization
Principle 2—Complementarity
The information provided on this site is designed to support, not replace, the relationship that exists between a patient/site visitor and
his/her existing physician
Principle 3—Confidentiality
Confidentiality of data relating to individual patients and visitors to a medical/health website, including their identity, is respected by
this website. The website owners undertake to honour or exceed the legal requirements of medical/health information privacy that apply
in the country and state where the website and mirror sites are located
Principle 4—Attribution
Where appropriate, information contained on this site will be supported by clear references to source data and, where possible, have
specific HTML links to that data. The data when a clinical page was last modified will be clearly displayed (eg, at the bottom of the page)
Principle 5—Justifiability
Any claims relating to the benefits/performance of a specific treatment, commercial product or service will be supported by
appropriate, balanced evidence in the manner outlined in Principle 4
Principle 6—Transparency of Authorship
The designers of this website will seek to provide information in the clearest possible manner and provide contact addresses for
visitors who seek further information or support. The Webmaster will display his/her E-mail address clearly throughout the website
Principle 7—Transparency of Sponsorship
Support for this website will be clearly identified, including the identities of commercial and noncommercial organisations that have
contributed funding, services or material for the site
Principle 8—Honesty in Advertising and Editorial Policy
If advertising is a source of funding, it will be clearly stated. A brief description of the advertising policy adopted by the website
owners will be displayed on the site. Advertising and other promotional material will be presented to viewers in a manner and context
that facilitate differentiation between it and the original material created by the institution operating the site
The eight HON criteria that websites providing medical and health information on the internet are recommended to fulfil.
Treatments for erectile dysfunction
R Thurairaja et al
197
International Journal of Impotence Research
patients with ED to seek assessment of occult
cardiovascular disease.
Of the sites reviewed, 88% outlined the effective-
ness of drugs and 70% stated drug ingredients.
However, only 36% provided contraindications
and 21% indicated drug side effects (Figure 2).
The commonest listed ingredients were yohimbine,
ginseng and gingko biloba.
In summary, all 33 new and independent sites
reviewed fell short of fulfilling the HON criteria and
the majority of sites provided inadequate informa-
tion regarding the side effects and contraindications
of the treatments they supplied.
Discussion
As a result of the massive expansion in internet use
during the last decade, health information is now
readily available to the public and the number of
websites providing medical advice or selling treat-
ments is steadily rising.
8
However, studies have
demonstrated that, without any regulations, the
quality of health-related websites varies consider-
ably and frequently falls short of conventional
medical advice.
16–19
For example, Impicciatore
demonstrated the information provided by websites
concerning the management of fever in children to
be highly inconsistent.
20
When Eysenbach reviewed
79 studies evaluating the quality of health informa-
tion provided by internet websites, it was concluded
that the information quality was equivocal.
21
Although regulatory bodies such as HON exist to
assess and accredit the quality of medical and
health-related websites, most sites choose not to be
reviewed.
Despite significant advances in the pharmacolo-
gical treatment of ED in recent years, there is still a
growing interest and demand for herbal treatments
for ED.
22
This may be attributed to the easy purchase
of nonprescription products and the lower costs
compared to some prescription drugs. The internet
provides an easy and confidential method of
acquiring health information and treatments for
ED. However, there are many uncertainties with
respect to the quality of health information as
described above and the efficacy and safety of these
products is not well established. In the present
study, less than a quarter of sites clearly stated that
their information was provided by medically trained
personnel or provided referenced information. Most
of these sites produced anecdotal evidence and third
party testimonials instead of scientific data to
support their products.
Most sites (88%) made claims about the effective-
ness of their products in treating ED but almost a
0%
10%
20%
30%
40%
Sites with
information
provided by
Medically Trained
Personnel
Sites with
Referenced
Information
Sites warning to
seek Medical
Advice
Sites with
Disclaimers
Sites fulfilling HON criteria (% total)
Figure 1 Details of site information. Percentage of websites
reviewed that fulfilled four specific guidelines from HON criteria
(authority, attribution, complementarity and disclaimers).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Drug
In
g
redients
Drug
Effectiveness
Drug Side-
Effects
Drug Contra-
indications
Sites providing drug Information (% total number sites)
Figure 2 Details of drug information. Percentage of websites
reviewed that described the herbal treatment being sold in terms
of efficacy, ingredients, side effects and contraindications.
Treatments for erectile dysfunction
R Thurairaja et al
198
International Journal of Impotence Research
third (30%) failed to clearly state the ingredients
making up the treatments. This has concerning
implications since it has previously been reported
that treatments marketed as entirely natural dietary
supplements have subsequently been found to
contain significant levels of active pharmaceutical
compounds. For example, in April 2003, in the
United States, the Food and Drug Administration
(FDA) discovered that tablets marketed as all-natural
herbal products to enhance sexual experience for
men and women (Vinarol) contained a type-5
phosphodiesterase (PDE5) inhibitor (sildenafil).
23
Likewise in Canada, the Chinese herbal preparation
‘Hua Fo’ was also found to contain a compound
similar to sildenafil.
24
Patients taking these prepara-
tions would unwittingly be putting themselves at
risk from the potentially dangerous adverse effects
of a prescription-only PDE5 inhibitor (such as life-
threatening hypotension if taken concurrently with
nitrates). For this reason, Vinarol and ‘Hua Fo’ were
subsequently recalled. However, it is unknown how
many other treatments for ED marketed as ‘Herbal’
supplements actually contain active and potentially
dangerous compounds.
There are limited data from randomised con-
trolled trials to support efficacy and safety of the
commonest stated ingredients in the herbal treat-
ments identified in this study (yohimbine, ginseng
and Gingko biloba) for the treatment of ED. However,
despite the fact that only 21 and 36% of websites
investigated provided side effects and contraindica-
tions for their treatments, respectively, yohimbine,
ginseng and Gingko biloba have all been reported to
have clinically significant adverse effects and con-
traindications.
For example, yohimbine, a herb derived from a
tree native to Africa, has been shown to improve
male erections, but is contraindicated in patients
with cardiovascular and neurological disease and
causes several side effects including headaches,
sweating and hypertension.
25–27
These cardiac ef-
fects are likely to have particularly important
implications, given the high prevalence of cardio-
vascular disease in men with ED.
2
To date, most
studies investigating the efficacy of ginseng in the
treatment of ED have been performed in animals
where it has been shown to relax cavernosal smooth
muscle in rabbits and decrease time to ejaculation in
rats.
22,28
Recently, two clinical studies have demon-
strated ginseng’s effectiveness in improving para-
meters of erectile function such as penile rigidity
and duration of erection.
29,30
Documented adverse
effects of ginseng include gastrointestinal distur-
bances and dermatitis, and it is contraindicated in
patients with acute inflammatory disease and
bronchitis.
22
Gingko biloba has been shown to relax
vascular smooth muscle and this mechanism of
action is thought to contribute to an improvement in
ED.
31
However, a number of side effects including
diarrhoea, vomiting, headaches and allergic skin
reactions following consumption of Gingko biloba
have been reported.
22
It is also concerning that
Gingko biloba can potentiate the action of anti-
coagulants such as aspirin or warfarin to cause
bleeding disorders.
22
It is therefore contraindicated
in patients receiving anticoagulants to treat cardio-
vascular and cerebrovascular disorders.
Less than a quarter (24%) of the sites reviewed in
this study encouraged patients to seek medical
advice. ED is known to be associated with general-
ised disease in the vascular endothelium and the
onset of ED may be the first presentation of treatable
but potentially life-threatening cardiovascular dis-
ease.
2
By self-treating ED with herbal products
purchased from the internet, occult ED-associated
cardiovascular disease would go undiagnosed and
untreated, which could result in irreversible com-
plications and even death.
In conclusion, acquiring medical information
regarding ED and purchasing treatments such as
‘Herbal Viagra’ from the internet is convenient and
easy; however, the safety and reliability of such
websites and treatments is poor. Occult ED-asso-
ciated cardiovascular disease will go undiagnosed
and untreated among patients using this approach
and patients taking herbal treatments without
knowing their composition and effects are at risk
from potentially harmful adverse effects. Until more
stringent regulations are implemented, patients
should be cautious when acquiring information
and ‘Herbal’ treatment for ED from the internet.
References
1 Feldman HA et al. Impotence and its medical and psychoso-
cial correlates: results of the Massachusetts Male Aging Study.
J Urol 1994; 151: 54–61.
2 Matfin G. New treatments for erectile dysfunction. Sexuality
Reprod Menopause 2003; 1: 40–45.
3 NIH Consensus Development Panel on Impotence. NIH
Consensus Conference. Impotence. J Am Med Assoc 1993;
270: 83–90.
4 Jemal A, Thomas A, Murray T. Cancer statistics. CA Cancer
J Clin 2002; 52: 23–47.
5 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the
United States: prevalence and predictors. J Am Med Assoc
1999; 281: 537–544.
6 Pfizer Global Study of Sexual Attitudes and Behaviours. Pfizer
Sexual Health Summit, London, February 20, 2002, http://
www.pfizerglobalstudy.com/.
7 Pew Internet and American Life Project. The Online Health
Care Revolution: How the Web helps Americans take Better
Care of Themselves, 2001, http://www.pewinternet.org.
8 Morris CA. Internet marketing of herbal products. JAMA 2003;
290: 1505–1509.
9 Barnes J. Quality, efficacy and safety of complementary
medicines: fashions, facts and the future. Part 1. Regulation
and quality. Br J Clin Pharmacol 2003; 55: 226–233.
10 Editorial. Viagra’s licence and the internet. Lancet 1998;
352: 751.
11 Health on the Net Foundation. http://www.hon.ch.
Treatments for erectile dysfunction
R Thurairaja et al
199
International Journal of Impotence Research
12 Mitretek Working Group—Criteria for Assessing Quality of
Health Information on the Internet, October 14, 1997, http://
www.hitiweb.mitretek.org/docs/criteria.html.
13 European Commission Information Society Directorate-
General Quality (ECISDQ) Criteria for Health Related
Websites—Draft Guidelines, 2002, http://www.europa.eu.int/
information_society/eeurope/ehealth/quality/draft_guidelines/
index_en.htm.
14 Bedell SE, Agrawal A, Petersen LE. A systematic critique of
diabetes on the World Wide Web for patients and physicians.
Int J Med Inform 2004; 73: 687–694.
15 Croft DR, Peterson MW. An evaluation of the quality and
contents of the asthma education on the World Wide Web.
Chest 2002; 121: 1301–1307.
16 Doupi P, Van der Lei J. R-x medication information for the
public and the WWW: quality issues. Med Inform Internet Med
1999; 24: 171–179.
17 Latthe M, Latthe PM, Charlton R. Quality of information on
emergency contraception on the Internet. Br J Fam Plann 2000;
26: 39–43.
18 Sandvik H. Health information and interaction on the internet:
a survey of female urinary incontinence. BMJ 1999; 319:
29–32.
19 Hellawell GO, Turner KJ, Monnier KJ, Brewster SF. Urology
and the internet: an evaluation of internet use by urology
patients and of information available on urological topics. Br J
Urol Int 2000; 86: 191–194.
20 Impicciatore P, Pandolfini C, Casella N, Bonati M. Reliability
of health information for the public on the World Wide Web:
systematic survey of advice on managing fever in children at
home. BMJ 1997; 314: 1875–1879.
21 Eysenbach G, Powell J, Kuss O, Sa E-R. Empirical studies
assessing the quality of health information for customers on
the World Wide Web: a systematic review. JAMA 2002; 289:
2786.
22 Rowland DL, Tai W. A review of plant-derived and herbal
approaches to the treatments of sexual dysfunctions. J Sex
Marital Therapy 2003; 29: 185–205.
23 Mitka M. FDA issues warning on ‘All-Natural’ herbal product
found to contain Viagra. JAMA 2003; 289: 2786.
24 Wooltorton E. Hua Fo tablets tainted with sildenafil-like
compound. CMAJ 2002; 166: 1568.
25 Ernst E, Pittler MH. Yohimbine for erectile dysfunction: a
systematic review and meta-analysis of randomized clinical
trials. J Urol 1998; 159: 433–436.
26 Riley AJ. Yohimbine in the treatment of erectile disorder. Br
J Clin Pract 1994; 48: 133–136.
27 Bratman S, Girman A. Mosby’s Handbook of Herbs and
Supplements and their Therapeutic Uses. Mosby Inc.:
St Louis, MO, 2003; 976–978.
28 Choi YD, Xin ZC, Choi HK. Effect of Korean red ginseng on the
rabbit corpus cavernosal smooth muscle. Int J Impot Res 1998;
10: 37–43.
29 Choi HK, Seong DH, Rha KH. Clinical efficacy of Korean
red ginseng for erectile dysfunction. Int J Impot Res 1995; 7:
181–186.
30 Hong B, et al. A double-blind crossover study evaluating the
efficacy of Korean red ginseng in patients with erectile
dysfunction: a preliminary report. JUrol2002; 168: 2070–2073.
31 Paick JS, Lee JH. An experimental study of the effect of Ginkgo
biloba extract on the human and rabbit corpus cavernosum
tissue. J Urol 1996; 156: 1876–1880.
Treatments for erectile dysfunction
R Thurairaja et al
200
International Journal of Impotence Research
