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But that widening can lower your blood pressure, and if you already have low blood pressure or you take medication to manage your blood pressure or blood clotting, these ingredients can be dangerous.27 Preliminary evaluation of the sexual, psychological, and medical history is mandatory to exclude possible systemic diseases and to identify the type of FSAD. The combination of testosterone and vardenafil caused an improvement in genital response (ie, vaginal pulse amplitude at vaginal photoplethysmography), especially in a group that initially had low attention for sexual cues.15 The efficacy of tadalafil was evaluated in 33 type 1 premenopausal diabetic women affected by sexual genital arousal disorder. Van der Made et al examined the efficacy of vardenafil alone or combined with testosterone in 28 women affected by FSADs and/or hypoactive sexual desire disorder. In fact, no significant changes in physical response during sexual activity were reported in either group of women.13 It should also be considered that sildenafil citrate is not devoid of side effects. Many “natural supplements” contain illicit PDE-5i, subjecting users to the same risks with even less warning. By bypassing the legitimate healthcare system, users of counterfeit PDE-5i bypass screening for concurrent medical comorbidities, as well as proper education and warnings of PDE-5i use. Unsuspecting patients often seek alternative treatments of ED due to embarrassment and lower cost, but also because of the perception that “all natural” products are somehow safer than synthetic medications. Even though 57 of 58 products were labeled as “all natural” and no sample claimed to include synthetic substances, 81% contained PDE-5i. In one study, the ingredients of 58 products available for the treatment of ED without a prescription were analyzed. 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