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Sexual Performance & Sexual Health (Erectile Dysfunction, Low Desire & Pain)

Trouble with erections, desire, arousal, ejaculation or pain during sex is common, treatable and nothing to be ashamed of. These problems can have physical, medicine, emotional and relationship causes, and erection problems can be an early sign of heart and blood vessel disease, so they are worth raising with a clinician. This guide explains the urgent warning signs, the safety rules for prescription pills and unregulated “enhancement” products, and what is known about each approach.

Get medical care right away if you:

  • Have an erection that lasts longer than 4 hours (priapism). NIDDK lists this as a side effect of erection medicines taken by mouth, by injection or as a suppository, and says to call your health care professional right away (NIDDK). The drug label says to seek immediate medical help, because untreated priapism can cause penile tissue damage and permanent loss of potency (FDA-approved label). The NHS in the UK says to call 999 or go to A&E at 3 to 4 hours, or after just 1 hour if you have sickle cell disease, and not to apply ice (NHS).
  • Have chest pain, dizziness or nausea during sexual activity. MedlinePlus says to call your doctor immediately and avoid sexual activity until your doctor tells you otherwise (MedlinePlus). MBHA suggests calling 911 if chest pain is severe or does not settle quickly.
  • Lose vision suddenly, or lose hearing suddenly, after taking an erection medicine. Stop the medicine and seek prompt medical attention (FDA-approved label, NIDDK).
  • Have severe pelvic or lower belly pain. The NHS says to call 999 or go straight to A&E for pelvic pain that is severe or getting worse, a sharp, sudden and intense pain in the lower belly, or pelvic pain with heavy vaginal bleeding; pelvic inflammatory disease is one cause (NHS). Pain in a testicle also needs medical attention (MedlinePlus).

Never combine an erection pill with a nitrate medicine (such as the nitroglycerin used for chest pain) or with nitrate “poppers.” The sildenafil label contraindicates nitrates because the combination can lower blood pressure, and the FDA gives the same warning for tadalafil (FDA-approved label, MedlinePlus, FDA notice). Do not delay urgent care to try a chiropractic, acupuncture or massage visit, an herb or a supplement first.

You are not alone, and it is not a character flaw

Sexual health is part of overall health. NIDDK puts it plainly: you may find it uncomfortable to talk about erectile dysfunction, but a healthy sex life is part of healthy living (NIDDK). MedlinePlus describes common problems in men as erectile dysfunction, reduced or lost interest in sex, ejaculation problems and low testosterone, and in women as lack of desire, inability to become aroused, lack of orgasm and painful intercourse (MedlinePlus, MedlinePlus). Occasional problems are common. MedlinePlus advises seeing a provider if problems last more than a few months or cause distress for you or your partner (MedlinePlus, MedlinePlus).

This guide is for people of every gender. Many sources describe the body parts involved (the NHS says vaginismus can affect “anyone with a vagina”), so where a source speaks only about men or women, we say so (NHS vaginismus page).

Erectile dysfunction: how common and why it matters

Erectile dysfunction (ED) means being unable to get or keep an erection that is firm enough for sex. Symptoms include getting an erection only sometimes, getting one that does not last long enough for sex, or being unable to get one at all (NIDDK causes page). Research cited by NIDDK suggests 30 million to 50 million men in the United States have ED, about 40% of men at age 40 and about 70% by age 70, yet NIDDK and MedlinePlus both stress that ED is not a routine part of aging (NIDDK, MedlinePlus).

An early warning sign for the heart

MedlinePlus says ED can be a sign of health problems: it may mean blood vessels are clogged, or that diabetes has damaged nerves, and without a visit those problems go untreated (MedlinePlus). A meta-analysis of 14 follow-up studies (92,757 participants, average follow-up 6.1 years) found men with ED had a higher risk of cardiovascular events (pooled relative risk 1.44), heart attack (1.62), stroke and other cerebrovascular events (1.39) and death from any cause (1.25) than men without ED. The link was stronger in younger men and in men at intermediate cardiovascular risk (Vlachopoulos et al., 2013). These are group averages, not a prediction for any one man, but new ED is a good reason to ask about blood pressure, blood sugar, cholesterol and heart health. See our heart, blood pressure and diabetes guides.

What can cause or worsen sexual problems

Causes are often mixed. NIDDK describes four groups of causes for ED (NIDDK causes page):

  • Diseases and conditions: diabetes; chronic kidney disease, obesity and chronic lung disease; heart and blood vessel disease, high blood pressure and stroke; low testosterone and thyroid imbalance; nerve damage (multiple sclerosis, spinal cord injury, pelvic surgery); and an enlarged prostate or Peyronie’s disease.
  • Medicines: many prescription and over-the-counter medicines can cause ED, including antidepressants, antihistamines, blood pressure medicines and water pills, chemotherapy and hormone medicines, some pain relievers and sedatives.
  • Mental and emotional issues: anxiety, depression, stress, loneliness, low self-esteem, lack of confidence and negative body image.
  • Lifestyle: too little physical activity, too much alcohol, smoking and recreational or illicit drugs.

The NHS adds that occasional trouble with erections is usually caused by stress, tiredness or too much alcohol (NHS). For low desire it lists relationship problems; stress, anxiety or depression; pregnancy and new parenthood; lower hormone levels, especially at menopause; certain medicines including hormonal contraception; heavy drinking; and long-term conditions such as heart disease, diabetes, an underactive thyroid or cancer (NHS). MedlinePlus adds that for some women past sexual trauma plays a part (MedlinePlus). See also our depression, anxiety, prostate, spinal cord injury, multiple sclerosis and cancer guides.

How to start the conversation: a clinician has heard it before. The NHS says a doctor or nurse seeing someone about ED may ask about lifestyle, relationships and any other problems and do basic checks such as blood pressure (NHS). For vaginal or vulval pain, the NHS says you can ask for a female GP and bring someone you trust (NHS vulvodynia page). Bring a list of every medicine and supplement you take (NIDDK diagnosis page). See our medication safety guide.

Side by side

Six approaches compared

For every condition we look at the same six approaches: what each involves, what it typically costs, and what a patient can realistically expect.

ApproachWhat it involves Estimated costWhat to expect
Conventional medicine (AMA) Evaluation by a primary care clinician, urologist, gynecologist or sex therapist: history, exam, and sometimes blood tests. Treatment aims at the cause first: medicine changes, lifestyle changes, counseling, then prescription classes (PDE5 inhibitors, injections, suppositories, testosterone when levels are truly low, medicines for low desire in some women), vacuum devices, pelvic floor therapy or surgery. Cost estimate being researched. Many people improve once a cause such as a medicine, blood sugar, stress or pain is addressed. Never mix erection pills with nitrates, and never buy pills from an unverified website.
Chiropractic No established role in treating sexual dysfunction. We found little research: one case report. Its safest role is to notice red flags and refer. About $55 to $100 per follow-up visit paying cash, per The Pricer. Medicare covers only spinal adjustments for a subluxation. A single case report describes an older man whose sexual symptoms resolved after spinal manipulation, but one case cannot show it works in general. Sexual symptoms deserve a medical check first.
Acupuncture Fine needles at specific points, studied for erectile dysfunction, premature ejaculation and low desire. About $90 to $185 per follow-up visit paying cash, per The Pricer. Medicare covers acupuncture only for chronic low back pain. Reviews find some improvement in erectile function scores, but the certainty is low, so no firm conclusion yet. Research for premature ejaculation and desire is also limited.
Herbal medicine Many “enhancement” products are sold. Ginseng and L-arginine have the most research; yohimbe is risky. Cost estimate being researched. A Cochrane review found ginseng has trivial effects on erection scores. Products sold for sexual enhancement are often contaminated with hidden prescription drugs, per FDA.
Massage therapy General massage is not a treatment for sexual dysfunction. Pelvic floor physical therapy, which includes hands-on techniques, is the better-studied option. One national chain: about $70 to $90 a month on a 12-month membership, per The Pricer. Medicare Part B covers medically necessary outpatient physical therapy (20% after the deductible). Reviews report pelvic floor muscle training helped erection problems and premature ejaculation, and physical therapy helped pain with sex, though study quality is modest.
MBHA Wellness Coach Everyday habits that support sexual health: movement, weight, alcohol and smoking, sleep and stress, communication with a partner, relaxation and pelvic floor exercises, plus help preparing for a clinician visit. Cost estimate being researched. Exercise and weight loss improved erection scores in trials. Supports, never replaces, medical evaluation.

Approach 1 of 6

Conventional medicine (AMA)

NIDDK says clinicians treat the underlying cause of ED when possible, and otherwise focus on improving sexual function. Choosing a treatment is a personal decision, and couples may want to talk about options together (NIDDK).

Who to see and what to expect

NIDDK says clinicians, including urologists, diagnose ED with a medical, sexual and mental health history, a physical exam, and lab or other tests (NIDDK diagnosis page).. Tests can include blood tests (including thyroid and prostate tests), an ultrasound of blood flow or a nighttime erection test. For vulval pain the NHS says care often involves more than one specialist, such as a gynecologist, physiotherapist, psychologist or pain specialist (NHS vulvodynia page).

Review your medicines first

NIDDK says your clinician may review your medicines and suggest a different one. Do not stop any medicine on your own; talk with your clinician first (NIDDK).

Treatment options by category

  • Lifestyle changes: quitting smoking, limiting or stopping alcohol, more physical activity, a healthy weight and diet, and stopping recreational drugs (NIDDK).
  • Counseling and sex therapy when stress, anxiety or emotional issues play a part (see the counseling section below).
  • Prescription medicines, including PDE5 inhibitors, injections, suppositories and, in specific cases, testosterone (see the medicines section below).
  • Vacuum erectile devices: a tube, pump and elastic ring that pull blood into the penis. NIDDK says they can feel cold or numb, may leave bruising that fades in a few days, and can weaken ejaculation without affecting the pleasure of orgasm. The NHS says they work for most men (NIDDK, NHS).
  • Surgery is rarely needed. NIDDK says most people with ED do not need it; options include a penile implant or repairing arteries, which works best for younger men (NIDDK).

What it costs

Cost estimate being researched.

Find a medical doctor in our directory

Approach 2 of 6

Chiropractic

Chiropractic care is not an established treatment for erectile dysfunction, low desire, premature ejaculation or pain with sex. We found little research: in our search the only relevant item was one case report.

What the case report says

A 2023 case report describes a 72-year-old man with cardiovascular disease, depression and anxiety who had a six-year history of anorgasmia (no orgasm), anejaculation (no ejaculation) and ED, plus episodic low back pain. He had lumbar spinal stenosis, and earlier counseling and penile injections had not helped. After a month of lumbar manipulation, he reported that the anorgasmia and anejaculation resolved and stayed resolved over three months. The authors say further research is needed (Trager et al., 2023). One case, in a man with a back condition, cannot tell us whether chiropractic care helps sexual function in general.

The safety take-away

Because ED can signal blood vessel disease or diabetes (MedlinePlus), MBHA suggests that new sexual symptoms get a medical check, not only an adjustment. NCCIH notes that serious side effects of spinal manipulation are very rare, and that practitioners should assess patients thoroughly and patients should share their health conditions and medications (NCCIH).

What it costs

The Pricer lists about $55 to $100 for a self-pay follow-up visit and $90 to $200 for a first appointment (The Pricer). Medicare covers only spinal adjustments by a chiropractor to correct a subluxation, and does not cover other services or tests a chiropractor orders (Medicare.gov).

Find a chiropractor in our directory

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Acupuncture

Acupuncture has been studied for erection problems, premature ejaculation and sexual function in general. The overall picture: some benefits are reported, but the studies are mostly small or low quality, so we cannot say it works. It also cannot replace a medical evaluation.

Erectile dysfunction

  • An early review (2009) found only four studies; one randomized trial favored real over sham acupuncture and another found no effect. The authors judged the evidence insufficient (Lee et al., 2009).
  • A 2019 review of 22 randomized trials, 14 involving psychogenic ED (ED mainly from psychological causes), found most had high or unclear risk of bias. It reported low-quality evidence of benefit as an add-on treatment, mainly for psychogenic ED, and said safety was insufficiently reported (Lai et al., 2019).
  • A 2026 review of 21 randomized trials found acupuncture improved erectile function scores (mean difference 3.28 on the IIEF-5 questionnaire), but certainty of evidence ranged from very low to moderate; the authors said the weak evidence precludes definitive conclusions (Yan et al., 2026).

Premature ejaculation and desire

A 2023 review of seven trials (603 men) found acupuncture beat sham acupuncture on ejaculation time and symptom scores, and the authors urged caution because of the quality of the trials (Zhang et al., 2023). An earlier review found preliminary evidence of benefit from acupuncture, with unclear study quality (Cooper et al., 2017). A 2023 review of 13 papers on male and female sexual dysfunction reported improvements in desire, libido and erection, with few serious side effects, but said high-quality evidence is lacking (Abdi et al., 2023).

Safety

NCCIH says that when not delivered properly acupuncture can cause serious problems, including infections and punctured organs (NCCIH). MBHA suggests choosing a licensed practitioner who uses sterile, single-use needles, and telling them about any sexual symptoms and medicines.

What it costs

The Pricer lists about $90 to $185 per follow-up visit and up to about $230 for a first private appointment, with community acupuncture around $50 to $90 (The Pricer). Medicare covers acupuncture only for chronic low back pain (Medicare.gov).

Find an acupuncturist in our directory

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Herbal medicine

Shelves and websites are full of products that promise better sex. Federal sources urge caution: most are unproven, and some are contaminated with hidden drugs (see the supplement warning section below). NIDDK says some people report that alternative medicines help, but for safety reasons you should talk with a health care professional before using dietary supplements or any complementary approach, because medicines and supplements can affect how other medicines work (NIDDK). NCCIH reminds us that dietary supplements are not approved by the FDA before they are sold, and that “natural” does not always mean “safe” (NCCIH).

Asian (Panax) ginseng

NCCIH says some research shows oral Asian ginseng seems to improve sexual function in people with ED. Short-term use (up to 6 months) appears safe for most people; insomnia is the most common side effect, and it may interfere with blood clotting, lower blood sugar and interact with medicines (NCCIH). A 2021 Cochrane review included nine placebo-controlled studies of 587 men with mild to moderate ED, with follow-up of up to 12 weeks. It concluded ginseng may have only trivial effects on erectile function scores compared with placebo (mostly low-certainty evidence), may improve men’s self-reported ability to have intercourse, and may have little to no effect on adverse events. No trial compared ginseng with PDE5 inhibitors (Lee et al., 2021).

L-arginine and other supplements

A 2024 network meta-analysis of 15 randomized trials (1,000 men) found that, against a background of general ineffectiveness of most nutraceuticals, L-arginine and a mix of two carnitine forms appeared to be of some use, especially combined with PDE5 inhibitors in ED with a physical cause (Barbonetti et al., 2024). In that analysis L-arginine alone ranked below the prescription drugs sildenafil and tadalafil. Ask your clinician before combining any supplement with a prescription medicine (NIDDK).

Yohimbe

NCCIH says there is very little research in people on yohimbe, and not enough evidence to say it helps ED. It is illegal in the United States to market an over-the-counter product containing yohimbine as a treatment for ED without FDA approval. Yohimbine has been associated with irregular heartbeat, blood pressure problems, heart attacks and seizures; supplement labels often do not say how much yohimbine they contain (NCCIH). MBHA suggests avoiding it.

Premature ejaculation and low desire

For premature ejaculation, a review found preliminary evidence for some Chinese herbal medicine, Ayurvedic herbal medicine and a topical cream, but the studies were of unclear quality with sparse safety data (Cooper et al., 2017). We found little research on herbs for low desire in women.

What it costs

Cost estimate being researched.

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Massage therapy

Ordinary relaxation massage is not a treatment for sexual dysfunction, and we found little research on it for these problems. What is better studied is pelvic floor physical therapy, delivered by a trained physical therapist, which can include exercises and hands-on techniques.

Pelvic floor therapy for erection problems and premature ejaculation

A 2019 review of ten trials of pelvic floor muscle training in men with ED or premature ejaculation found improvement in all ED trials and in most premature ejaculation trials, but the studies were of low to moderate quality, protocols varied widely and no best routine was identified (Myers et al., 2019). A separate meta-analysis of exercise trials in men with ED included pelvic floor routines (see the coaching section).

Physical therapy for pain with sex

A 2023 review and meta-analysis of 19 studies of physical therapy for dyspareunia (pain during or after intercourse) included multimodal programs, electrotherapy, Thiele massage and pelvic floor training. Electrotherapy, alone or with pelvic floor training, significantly improved pain and quality of life but not sexual function scores; the authors concluded that strengthening the pelvic floor muscles, nerve stimulation, trigger point release and Thiele massage help reduce pain (Fernandez-Perez et al., 2023). NHS lists pelvic floor exercises among treatments for vaginismus and vulvodynia (NHS vaginismus page, NHS vulvodynia page).

Safety

NCCIH says the risk of harm from massage appears low, but rare serious problems such as a blood clot, nerve injury or bone fracture have been reported, some after vigorous deep-tissue work (NCCIH). MBHA suggests looking for a physical therapist trained in pelvic floor care rather than a spa massage, and avoiding anyone who offers sexual services under the name of massage.

What it costs

One national chain’s membership runs about $70 to $90 a month on a 12-month term (The Pricer). Medicare Part B helps pay for medically necessary outpatient physical therapy certified by your provider; after the deductible you pay 20% of the Medicare-approved amount (Medicare.gov).

Find a massage therapist in our directory

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MBHA Wellness Coach

An MBHA Wellness Coach can help you build everyday habits that support sexual health and prepare you to get the most from medical visits — alongside, never instead of, evaluation and treatment. A coach is not a licensed sex therapist or physician.

Movement

NIDDK says physical activity increases blood flow, including to the penis, and cites the guideline of at least 150 minutes of moderate-intensity activity a week (NIDDK). A meta-analysis of seven trials (478 men with ED) found exercise improved erection scores, particularly aerobic exercise of moderate to vigorous intensity, although risk of bias in the trials was moderate to high (Silva et al., 2017).

Weight and eating

In a randomized trial of 110 obese men with ED, those who received detailed advice on losing weight and increasing activity lost more weight and became more active over two years, and their erectile function scores improved; 17 of 55 in the intervention group, versus 3 of 55 in the control group, reported scores of 22 or higher (the study defined ED as a score of 21 or lower) (Esposito et al., 2004). NIDDK says a healthy diet can lower the risk of ED or improve symptoms, and that diets such as the Mediterranean diet help; it suggests vegetables, fruits, legumes, nuts, seeds, fatty fish and whole grains, and limiting saturated fats, refined carbohydrates, sodium, added sugars and alcohol (NIDDK diet page). See our weight control guide.

Alcohol, smoking and drugs

NIDDK says smoking is linked to heart and blood vessel disease, which can lead to ED, and that illicit drugs and too much alcohol can prevent arousal or mask other causes (NIDDK). The NHS advises staying within 14 units of alcohol a week, and taking a break from cycling if you cycle more than 3 hours a week (NHS). A coach can help you set realistic goals and keep track.

Stress, mood and sleep

NIDDK says caring for your mental and emotional health can help prevent ED, and suggests relaxation techniques such as deep breathing (NIDDK). A coach can help build routines for sleep, relaxation and movement. See our sleep problems guide.

Relationship and communication

NIDDK suggests partners talk together about treatments that work for them as a couple, and that counselors may invite the partner to sessions (NIDDK). The NHS lists “sensate focus” — exercises to help with relaxation during sex — as part of treatment for vaginismus, along with relaxation and breathing exercises (NHS). A coach can help you plan conversations and prepare questions for visits.

Mindfulness

A 2019 review of 15 studies found mindfulness-based therapy improved arousal, desire and sexual satisfaction and reduced fear linked with sex in women, but did not significantly reduce pain during sex; only one study looked at men with ED. The authors noted small, limited studies (Jaderek and Lew-Starowicz, 2019).

What it costs

Cost estimate being researched.

Another approach

Prescription medicines and the nitrate warning

MBHA lists medicine classes and safety information only. Doses are for your prescriber to set.

PDE5 inhibitors

Phosphodiesterase type 5 (PDE5) inhibitors are pills that improve blood flow to the penis and may help you get and keep an erection (NIDDK). The NHS names sildenafil, tadalafil, vardenafil and avanafil as examples and says the main treatments for ED are these medicines (NHS). They work with sexual stimulation (MedlinePlus).

Safety rules from the FDA-approved sildenafil label

The label below is for sildenafil (Viagra). Ask your prescriber and pharmacist how each point applies to the specific medicine you are given; MedlinePlus says the vision and hearing warnings also apply to similar medicines such as tadalafil and vardenafil (MedlinePlus).

  • Nitrates are contraindicated. The label says sildenafil was shown to increase the blood pressure-lowering effect of nitrates, so use in anyone using organic nitrates or nitrites in any form, regularly or occasionally, is contraindicated. It adds that it is unknown when nitrates can safely be given after taking the medicine (FDA-approved label). MedlinePlus lists examples of nitrates for chest pain and says street drugs containing nitrates (“poppers”) are also a problem (MedlinePlus). Tell every prescriber and emergency team which pills you took.
  • Other blood pressure effects. Sildenafil should not be used with riociguat, and caution is advised with alpha-blockers and other blood pressure medicines because blood pressure can fall significantly, causing dizziness or fainting (FDA-approved label).
  • Heart health. Treatments for ED should not generally be used in men for whom sexual activity is inadvisable because of their cardiovascular condition (FDA-approved label). MedlinePlus says to tell your doctor if you have ever had chest pain during sexual activity (MedlinePlus).
  • Erection longer than 4 hours. Seek immediate medical help; use caution with Peyronie’s disease, penile deformity, and conditions such as sickle cell anemia, multiple myeloma or leukemia (FDA-approved label).
  • Sudden vision loss. Stop the medicine and seek medical care. This may be a sign of a rare eye condition called NAION, reported rarely after use of PDE5 inhibitors. The label says the reports do not establish that the medicines cause it (FDA-approved label).
  • Sudden hearing loss, sometimes with ringing in the ears or dizziness, also means stopping and getting prompt care (FDA-approved label).

Injections, suppositories and testosterone

NIDDK describes injectable medicines that cause an erection by increasing blood flow, and suppositories placed in the urethra; your clinician teaches you how to use either (NIDDK). If you have ED and low testosterone, NIDDK says a clinician may prescribe testosterone together with a PDE5 inhibitor (NIDDK). Low testosterone is a medical diagnosis. MedlinePlus says a testosterone test is done on a morning blood sample, that symptoms of low levels can include low sex drive and ED, that a test alone cannot diagnose a condition, and that it is normal for levels to decrease with age (MedlinePlus).

The FDA’s position (February 2025): testosterone is approved solely for men who lack or have low testosterone together with an associated medical condition. The FDA kept its “limitation of use” language for age-related low testosterone, removed boxed-warning language about cardiovascular risk after the TRAVERSE trial, and is adding blood pressure warnings to testosterone products, after studies confirmed that all of them raise blood pressure (FDA). In plain terms: testosterone is approved for low testosterone with an associated medical condition, not as a general “vitality” or “performance” product. Ask your clinician how a diagnosis would be confirmed.

Another approach

Low desire and arousal

Low desire is one of the most common sexual concerns, and the NHS says treating the cause should help (NHS). The NHS matches causes with treatments: relationship counseling for relationship problems; medicines or lubricants for problems such as ED or vaginal dryness; hormone replacement therapy for menopause; antidepressants or cognitive behavioral therapy for depression; and changing a medicine or type of contraception when that is the cause (NHS). The NHS lists a reduced sex drive and vaginal dryness among menopause symptoms (NHS menopause page).

Counseling and mindfulness-based therapy

A 2026 systematic review of 36 studies of treatments for desire, arousal and orgasm problems in women without pain conditions found that mindfulness-based cognitive behavioral therapy improved overall sexual function and the desire, arousal and orgasm scores, and mindfulness-based therapy, flibanserin and bremelanotide all reduced distress (Toledo et al., 2026). A review of sexual counseling programs for postmenopausal women (8 studies, 619 women, all within five years of menopause) found such programs improved overall sexual function compared with routine care (Santos Silva et al., 2022).

Prescription medicines for low desire (by name, no doses)

Two FDA-approved prescription products are labeled for a specific diagnosis called hypoactive sexual desire disorder (HSDD): low sexual desire that causes marked distress and is not due to a medical or psychiatric condition, relationship problems or a medicine or drug.

  • Flibanserin (Addyi) is a bedtime pill labeled for women under 65 with acquired, generalized HSDD. It carries a boxed warning: using it with alcohol close in time raises the risk of severe low blood pressure and fainting, and it is contraindicated with certain other medicines and in liver impairment. The label says it is not indicated in men and not indicated to enhance sexual performance (FDA-approved label).
  • Bremelanotide (Vyleesi) is an as-needed injection labeled for premenopausal women with acquired, generalized HSDD, not for postmenopausal women or men. The label reports temporary rises in blood pressure, nausea in 40% of patients in studies, and that it is not recommended for people at high risk of cardiovascular disease (FDA-approved label).

In the 2026 review, flibanserin improved desire and bremelanotide improved desire and arousal; no study compared these medicines with therapy (Toledo et al., 2026). Talk with a clinician about whether you fit the label, what else could explain low desire and what the risks are.

Low desire in men

MedlinePlus lists reduced or lost interest in sex and low testosterone among sexual problems in men (MedlinePlus); see the testosterone information above before pursuing hormone treatment.

Another approach

Pain with sex

Pain during sex is a medical symptom, not something to push through. Possible causes are many, and a clinician can help sort them out.

Common causes

  • Vaginal dryness. The NHS says it is common and can cause pain during sex. Causes include menopause, pregnancy or breastfeeding, some medicines such as hormonal contraceptives or antidepressants, cancer treatments, not being aroused, and perfumed soaps or douches. It suggests water-based lubricants, vaginal moisturizers and unperfumed washes, and seeing a GP if it persists (NHS).
  • Vaginismus. An automatic tightening of the vaginal muscles when something is inserted, which can cause burning or stinging pain. It may not affect arousal or other sexual touch. The NHS lists treatment as managing feelings about penetration and gradual exercises: psychosexual therapy, relaxation techniques, pelvic floor exercises, sensate focus and vaginal trainers, usually learned with a specialist therapist and practiced at home (NHS).
  • Vulvodynia. Pain in the vulva lasting at least 3 months with no specific cause. The NHS lists treatments including numbing creams, nerve-pain medicines, pelvic floor exercises, vaginal trainers, CBT or psychosexual therapy, and says no single treatment works for everyone (NHS).
  • Infections and other conditions. The NHS names thrush, sexually transmitted infections, menopause, pelvic inflammatory disease and endometriosis among other causes of pain during sex (NHS vaginismus page). See our endometriosis and women’s health problems guides.
  • Peyronie’s disease (penile curvature). NIDDK says scar tissue (plaque) can make the penis curve, making erections painful and sex painful, difficult or impossible; roughly 1 in 100 men in the U.S. have been diagnosed (NIDDK).

Emotions and history

The NHS lists anxiety or fear about sex, a painful sexual experience, sexual assault or abuse, a difficult medical examination or childbirth, and believing sex is shameful or wrong among the factors thought to contribute to vaginismus (NHS). If any of this is part of your story, you deserve a clinician who goes at your pace. You can ask for a female clinician and bring a support person (NHS vulvodynia page).

Another approach

Premature ejaculation

Premature ejaculation (PE) is commonly defined as ejaculation with minimal stimulation before, on or soon after penetration and before the person wishes it. It can be lifelong or can begin later (Cooper et al., 2015 (NIHR report)). A UK national health technology assessment reviewed 103 studies and found that several treatment classes lengthened the time to ejaculation compared with placebo: topical anesthetics, SSRI antidepressants (including dapoxetine), an antidepressant of the serotonin-noradrenaline type (duloxetine), a tricyclic antidepressant, PDE5 inhibitors and the opioid pain reliever tramadol. Behavioral therapies improved results over waiting lists, and behavioral therapy plus medicine was better than either alone. Most medicines had treatment-related side effects, and long-term data were lacking (Cooper et al., 2015 (NIHR report)).

Behavioral techniques

A review of ten randomized trials (521 men) of techniques such as squeeze and stop-start, sensate focus, devices and pelvic floor rehabilitation found limited evidence of improvement over waiting lists and better results when combined with medicine than with medicine alone, and no adverse effects were reported (safety data were limited) (Cooper et al., 2015). Pelvic floor training is covered in the massage section (Myers et al., 2019).

Complementary approaches

See the acupuncture and herbal sections: acupuncture and some herbal products show preliminary benefit in small, mixed-quality studies (Zhang et al., 2023, Cooper et al., 2017). The medicines above are prescription products; antidepressants should never be started or stopped on your own.

Another approach

Counseling and sex therapy

NIDDK says clinicians may suggest counseling when mental health or emotional issues are affecting ED. Counselors can help you lower anxiety and stress about sex, and may ask you to bring your partner for more support (NIDDK). The NHS says counseling and therapy can help if erection problems are linked to emotional or mental health problems, though NHS waits can be long; in the UK, sex therapists should belong to a professional body such as the College of Sexual and Relationship Therapists (NHS). In the U.S., ask any sex therapist about their license and training.

What the research says

A Cochrane review (2007) of 11 small trials in 398 men found that group psychotherapy reduced the number of men whose ED persisted compared with a waiting list, and that men who had group therapy plus sildenafil did better and were less likely to drop out than men on sildenafil alone. The review is older and the trials small (Melnik et al., 2007). For women, see the mindfulness and counseling findings in the desire section (Toledo et al., 2026).

Cost

Cost estimate being researched.

Another approach

Warning: “enhancement” supplements may hide drugs

The FDA warns that many products claiming to help with sexual enhancement or to treat sexual dysfunction — such as male enhancement supplements, ED treatments, male energy pills and stamina pills — are likely to be contaminated with dangerous hidden ingredients. They are sometimes falsely advertised as dietary supplements, food or all-natural treatments, often have many positive reviews or spread on social media, and are sold both online and in stores. The FDA says they pose a serious health risk, can lead to hospitalization, are not guaranteed to work, and that its list covers only a small fraction of such products: if a product is not on the list, that does not mean it is safe (FDA).

One 2026 FDA notice shows why: laboratory analysis found a product sold for male sexual enhancement contained two prescription ED drugs and testosterone propionate, none listed on the label. The FDA warned that such undeclared ingredients may interact with nitrates, such as nitroglycerin, and lower blood pressure to dangerous levels, and that people with diabetes, high blood pressure, high cholesterol or heart disease often take nitrates (FDA notice). NCCIH likewise warns that products marketed for sexual enhancement may contain prescription drugs that are not allowed in dietary supplements or other unlisted ingredients (NCCIH).

Buying prescription pills online

NIDDK says not to order an ED medicine online before talking with a health care professional, because medicines and supplements can affect how other medicines work (NIDDK). The NHS warns that many websites sell fake medicines and that ingredients can vary from pack to pack (NHS). If you have a bad reaction, MedlinePlus points to the FDA’s MedWatch reporting program (MedlinePlus).

Member stories

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