INTRODUCTION
Epidemiological studies indicate that the prevalence of sexual dysfunction in women ranges from 8% to 78%. With the advancement of sexual information and the improvement of quality of life, therapeutic interventions for sexual dysfunction have been increasingly improved. Interest in therapeutic approaches for sexual dysfunction, including psychotherapy, behavioral therapy, pharmacotherapy, acupuncture, physical exercise, and gene therapy, has increased in recent years (3). Pilates has been shown to have beneficial effects on both physical and mental health, and it positively impacts quality of life in various dimensions. However, there are no clinical trials on the effect of Pilates exercises on quality of life, especially sexual function, in postmenopausal women (7). One of the herbs that has been introduced to improve sexual performance is Tribulus terrestris. Therefore, taking pills containing Tribulus terrestris for three months is effective in treating sexual problems in menopausal women and leads to improved libido (11). Given that providing health care services during menopause can provide a better quality of life for women, and given that therapeutic interventions usually include a combination of procedures, in the present study, for the first time, we seek to evaluate the simultaneous effect of the herb Tribulus terrestris and Pilates exercise on the sexual function of menopausal women.

METHODS
In this quasi-experimental study with a pre-test-post-test design, 28 postmenopausal women (48.90 years old) were selected by simple random sampling in Arak city, Iran, in 2023, and after obtaining informed consent, they were divided into the following groups: Tribulus terrestris supplement (T), Pilates + Tribulus terrestris (PT+T), and control (C). The PT+T group performed three 60-minute Pilates sessions per week for eight weeks and received one Tribulus terrestris (450 mg) orally every day, while the T group consumed only Tribulus terrestris once a day for the entire 8-week period. Participants in the control group received no exercise intervention and were asked to maintain their current lifestyle. Participants in the exercise intervention group performed moderate-intensity Pilates exercises for 50 minutes (excluding 10-minute warm-up and stretching periods) three times a week (on non-consecutive days) for 8 weeks. Groups T and PT+T received capsules containing dried extract powder of the plant Tribulus terrestris once a day after dinner for two months. Tribulus terrestris extract was purchased from Mazraa Morvarid Company (Iran, licensed by the Deputy of Food and Drug Administration of the Ministry of Health), and after approval by an herbalist, it was placed in edible gelatin capsules (Attarchian Company, Iran). Each capsule contained 450 mg of dried extract of Tribulus terrestris. Two days (48 hours) before and after the exercise intervention, sexual function (assessed by the FSFI questionnaire), body composition, and muscle strength (measured by hand grip) were evaluated. Data were analyzed using the SPSS (version 24) software, as well as the analysis of covariance and Bonferroni tests.

RESULTS
It was observed that muscle mass and strength in the intervention groups (T and PT+T) increased significantly compared to group C (P=0.001). We found that Tribulus terrestris was associated with improvements in five dimensions of desire, psychological arousal, wetness, orgasm, and sexual satisfaction compared to group C (P=0.01). In addition, the results indicated that Tribulus terrestris, along with Pilates training, had a positive effect on the sexual function of postmenopausal women in six dimensions of desire, psychological arousal, wetness, orgasm, satisfaction, and sexual pain compared to groups C and T (P=0.01).

CONCLUSION
In the present study, which was conducted to investigate the effect of hydroalcoholic extract of Tribulus terrestris on sexual function in menopausal women, consumption of Tribulus terrestris had a positive effect on increasing sexual function in menopausal women, and this difference was statistically significant. In addition, when Pilates training was combined with Tribulus terrestris intake, the desired effects were doubled. Our results support the notion that in middle-aged (postmenopausal) women, the intake of Tribulus terrestris is significantly associated with improved sexual function. Furthermore, when Tribulus terrestris supplementation is combined with Pilates exercise training, menopausal complications, including decreased sexual function, are doubly improved.

Ethical Considerations
Compliance with ethical guidelines
Code of Ethics No. IR.ARAKU.REC.1402.047 was obtained for this study. It should also be noted that the principles of the Declaration of Helsinki, including obtaining informed consent from participants and maintaining the confidentiality of their information, have been adhered to.

Funding
There is no funding support.
Authors' Contributions
The authors have contributed equally to this work.
Conflict of Interest
The authors declared no conflict of interest.
Acknowledgments
We would like to express our sincere gratitude to the esteemed research assistant of the university, the students, and all the dear ones who helped us conduct this project.