Just say NO: What’s Good For the Gander Is Probably Good For the Goose header

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Just say NO: What’s Good For the Gander Is Probably Good For the Goose

By George Gillson MD PhD CCFP

When I was starting out as a Family Doctor, I learned several key nuggets of wisdom that I never forgot, from working with/talking to a couple of practitioners with decades of experience. One was to always shake the hand of your new patients as a gauge of their musculature, bone density, and brain health. Perhaps this is more accurate in males than females, as the hearty handshake is the human male equivalent of peeing on a fencepost.

Dog peeing on a fencepost.

The other nugget of wisdom was to always ask men about their erections, as erectile dysfunction (ED) is a gauge of the overall health of the cardiovascular tree.

These are still great pieces of advice but the problem with the erection nugget is that it is male-centric. I was talking to my wife, Jeanette, who incidentally also happens to be the owner of EvolveWell clinic, about what to write for this post. I commented that we recognize the connection that ED has to cardiac health in males but nobody says a word about cardiac health and the possible effects on perfusion of female genitalia.

Jeanette said, “Oh my gosh,” and began typing busily at the keyboard of her computer.  Seconds later, this appeared in my inbox:

The link led to a paper by Nascimento et al, entitled: Sexual dysfunction and cardiovascular diseases: a systematic review of prevalence.

The paper summarized a meta-analysis of the literature on the impact of cardiovascular disease (typically post-heart attack) on males and females. The impacts were assessed by a wide variety of survey instruments such as the FSFI (Female Sexual Function Index), the RSS (Relationship Sexuality Scale) and the WDWDIAMH (Why Don’t We Do It Any More Honey).

Happily, of the twenty-three best papers found, twelve included data on females.

The results were very consistent, indicating that cardiovascular disease takes the same significant toll on all aspects of the sex life of women as it does for men. The effects include diminishment of the frequency and intensity of the following: desire, frequency of sexual interactions, arousal, sensitivity of relevant tissues, satisfaction, and confidence. Depression is also an issue.

Heart disease is caused by clogged arteries and the root of the clogging is damage to the endothelium or lining of the arteries. The disease also shows up in the smaller blood vessels in the peripheral tissues. “Fingers, toes, penis, nose” is the old saying from Med School listing important peripheral tissues that need a good blood supply. There is no reason why the clitoris should not have been included in that saying. Erectile dysfunction is not restricted to males, in my book.

There are many aspects to sexual response/function and there’s no way I can address all of them so I’m going to take a very simplified approach and focus on the plumbing. (We never think about plumbing until the toilet is plugged.)

This brings me to Viagra. And beets. And arginine

How does Viagra work? Well, nitric oxide (NO) is a soluble gas molecule that is made in healthy vascular endothelium. (NO can also be made from dietary sources of nitrate NO32-.) NO is a vasodilator, i.e. it increases blood flow to tissues by triggering a cascade of biochemical signals that opens up the blood vessels.

Viagra doesn’t increase NO but it prolongs the downstream effects of NO by prolonging the signals generated by it. The result is that you get more bang for your NO buck to paraphrase the old saying.

Another way to get more NO signaling is to eat foods that contain nitrate.  Beets happen to be one of those foods. In fact, beets have a reputation for enhancing sexual health dating back to antiquity, although they confer many other benefits.  This article lists 18 health benefits of beets: https://www.stylecraze.com/articles/top-10-health-benefits-of-beetroot/

Leafy greens including Arugula, Spinach and Parsley also contain high levels of nitrate but nowhere near what is in beets!

A third way to boost NO is to take the amino acid arginine, which can be used by the liver to form NO.  At least one reputable nutritional supplement company makes an arginine product specifically for this purpose.

The bottom line is that a good supply of NO and healthy endothelial linings are crucial for erectile tissue. Another reason to have lots of NO on hand is to promote lubrication (Diedrich). Lubrication is impaired if the lubricant-producing tissue don`t have an ample blood supply. For example, the saliva glands are an example of a tissue that needs tremendous blood flow to keep oral mucosal tissues well-lubricated. (Remember that blood is basically half water.)

Two steroid hormones: estradiol and testosterone are important for blood flow to tissues. Note that these can be applied directly to the vulvovaginal tissues!

Per the diagram below, estradiol is where it’s at when we talk about NO in both men and women. Estradiol promotes the synthesis of eNOS or endothelial nitric oxide synthase, an enzyme that makes NO. Repeat after me: “No NO, poor blood flow.”

In both women and men, estradiol is made from testosterone via an enzyme called aromatase. Women make estradiol from testosterone within their ovaries whereas men make estradiol from testosterone in body fat. Drugs called aromatase inhibitors can therefore block the formation of estradiol in both women and men and impair NO formation. Statin drugs which lower cholesterol can also reduce the levels of both testosterone and estradiol since these are both made from cholesterol, along with the rest of the hormones in the steroid hormone family.

If you are on these medications you need to discuss them with your Integrative Health practitioner if vaginal health is a concern.

NO aside, the following figure depicts the effect of estradiol on the formation of blood vessel loops in vaginal mucosa with (A) being an illustration of healthy vaginal tissue and (B) illustrating atrophic vaginal tissue and the absence of capillary loops. The loops increase the thickness and resiliency of the vaginal tissues.

From Diedrich 2019

While there are specific technologies available to improve vaginal health, attention has to be paid to overall vascular health. You`re now up to speed on NO and should discuss NO support at your next visit with your Integrative Medicine practitioner. At a minimum, EAT MORE BEETS! You may also wish to try several different beetroot powders as nitrate levels vary from product to product.

Doing all the things you would do if you were told that you had heart disease will also improve your vaginal health. This means testing for and reducing inflammation and insulin resistance, ensuring adequate magnesium intake, doing resistance training, assessment of hormone levels and remediation of deficiencies which may include vulvovaginal application of hormones if needed.

One thing I neglected to mention last month is that since the Enfemme 360 stimulates collagen production through gentle warming of tissue, supplements to support collagen synthesis are in order! These include my favorite, Designs For Health Whole Body Collagen along with Vitamin C supplementation.

Get going.  Valentine`s Day is coming!

George Gillson MD PhD

Author: George Gillson, MD, PHD, CCFP
EvolveWell Medical Director


Arazi H, Eghbali E. Possible Effects of Beetroot Supplementation on Physical Performance Through Metabolic, Neuroendocrine, and Antioxidant Mechanisms: A Narrative Review of the Literature. Front Nutr. 2021 May 13;8:660150. doi: 10.3389/fnut.2021.660150. PMID: 34055855; PMCID: PMC8155490.

Diedrich CM, Kastelein AW, Verri FM et al. Effects of topical estrogen therapy on the vaginal microcirculation in women with vulvovaginal atrophy. Neurourol Urodyn. 2019 Jun;38(5):1298-1304. doi: 10.1002/nau.23977. Epub 2019 Apr 4. PMID: 30947367; PMCID: PMC6850718.

Karpuzoglu E, Ahmed SA. Estrogen regulation of nitric oxide and inducible nitric oxide synthase (iNOS) in immune cells: implications for immunity, autoimmune diseases, and apoptosis. Nitric Oxide. 2006 Nov;15(3):177-86. doi: 10.1016/j.niox.2006.03.009. Epub 2006 May 2. PMID: 16647869.

Nascimento ER, Maia AC, Pereira V et al. Sexual dysfunction and cardiovascular diseases: a systematic review of prevalence. Clinics (Sao Paulo). 2013 Nov;68(11):1462-8. doi: 10.6061/clinics/2013(11)13. PMID: 24270960; PMCID: PMC3812559.

Nappi R, Salonia A, Munarriz R, Montorsi F. Vascular aetiology of female sexual arousal disorder (FSAD) in women: Evidence and diagnostic approach. Urodinamica. 2004;14(2):94-8

Szymański JK, Słabuszewska-Jóźwiak A, Jakiel G. Vaginal Aging-What We Know and What We Do Not Know. Int J Environ Res Public Health. 2021 May 6;18(9):4935. doi: 10.3390/ijerph18094935. PMID: 34066357; PMCID: PMC8125346.