Tori Hudson.Pdf

WOMEN’S ENCYCLOPEDIA of NATURAL MEDICINE

A lternative T herapies and Integrative Medicine for Total Health and Wellness

TORI HUDSON, N.D.

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DOI: 10.1036/0071464735 To: The women who have sought my advice as a naturopathic physician and lent me their trust and conﬁdence The women in medicine The women who have made a difference in my life This page intentionally left blank For more information about this title, click here

CONTENTS

Foreword ...... ix Acknowledgments ...... xi Contributors...... xv Introduction ...... xvii

1 Abnormal Uterine Bleeding ...... 1 2 Amenorrhea ...... 15 3 Cervical Dysplasia ...... 31 4 Contraception ...... 51 5 Cystitis ...... 65 6 Endometriosis ...... 75 7 Fibrocystic Breasts...... 89 8 Genital Herpes ...... 99 9 Heart Disease ...... 109 10 Infertililty ...... 155 11 Interstitial Cystitis ...... 167 12 Menopause ...... 175 13 Menstrual Cramps ...... 225 14 Osteoporosis ...... 237 15 Pelvic Inﬂammatory Disease ...... 267 16 Pregnancy ...... 275 17 Premenstrual Syndrome ...... 301 18 Sexually Transmitted Infections ...... 317 19 Uterine Fibroids ...... 327 20 Vaginitis ...... 341

Appendix A: General Exercise Program ...... 359 Appendix B: Body Mass Index ...... 365 Appendix C: Hormone Replacement Therapy Prescriptions ...... 367 Appendix D: Procedures and Practices ...... 373 Appendix E: Recommended Screening Tests and Immunizations ...... 375 Resources ...... 381 References ...... 391 Index ...... 481 vii This page intentionally left blank FOREWORD

’ve long been a fan of the work of Dr. Tori solutions to her health problems on her own, IHudson, the foremost national leader in natur- along with guidance about when she needs to opathic and botanical medicine specifically for seek professional help. Many of these solutions women. And unbeknownst to her, Dr. Hudson are available at your local natural food store. has been a guiding light for me in using botanical Some are even available in your own kitchen. and naturopathic approaches to women’s health Many naturopathic approaches stand alone as problems for many years. Long before herbal a viable, safe, and effective treatment option. medicine enjoyed its current mainstream accept- Others can be used in an integrative approach ance, my patients who were interested in natural along with conventional medicine. Some women approaches to their gynecologic problems brought and situations will require the most conventional me copies of Dr. Hudson’s articles and even the of medical treatments. Dr. Hudson’s book helps text that she wrote for her students to fill in the to sort through these options. In general, the information gap about gynecology and natural naturopathic treatments outlined in this book medicines that existed in the naturopathic training offer safer and gentler solutions to many women’s program where she teaches. In this text, entitled health problems that can be applied to help Gynecology and Naturopathic Medicine: A Treat- rebalance the body and restore it to health long ment Manual, Dr. Hudson set down natural treat- before more serious conditions develop. ment protocols that she had used effectively for Women have used the healing power of plants years to treat the kind of women’s health problems since the beginning of time. Now Dr. Hudson that I was seeing every day, ranging from irregular brings her years of scientific and clinical expertise periods and menstrual cramps to hot flashes. As to the field of natural, plant-based healing and a conventionally trained allopathic gynecologist, I helps make it safer and more effective for women was gratified to learn about and help my patients than ever before. This is a book that should be in apply some of Dr. Hudson’s gentle, natural, and every woman’s health library and every alternative plant-based approaches. They were an excellent practitioner’s library, and it is a resource for the complement to the standard gynecologic care I new breed of conventional practitioners open to a was already practicing. more integrative health-care system. So when Dr. Hudson called and told me about her new book, I was delighted. Here in one —Christiane Northrup, M.D., author of volume is everything a woman needs to know to Women’s Bodies, Women’s Wisdom and begin applying gentle, natural, naturopathic The Wisdom of Menopause

hroughout the course of writing the origi- My family has been very supportive through- Tnal book, and now the second edition, I out my entire career. My mother, Pat Lawrence, have had overwhelming moments of gratitude has provided me with lifelong love, support, and for all the people that have helped. trust and has always made it clear that I am worthy I have reflected on those who helped me with and special. She’s also the one that keeps me in the first edition: Norman Goldfind, the original touch with what the media are communicating publisher. Dr. Susanna Reid, who worked with about alternative medicine. Not everyone has me from almost the very beginning when she was her own clipping service from all the popular mag- still a student at the National College of Naturo- azines and regular updates on what’s happening pathic Medicine. If it were not for her, I would on “Oprah,” “20/20,” and the rest. Her husband, not have learned to use a computer. Thanks to Dick, who has now passed on, was my special proj- her weekly tutoring, I finally achieved at least a ect man. All the things I haven’t had time for— functional level of competence. Susanna was crit- hanging the Christmas lights, cleaning the gutters, ically involved in the research of information for staining the deck—what a guy! My real father, Ken the first edition of the book and in planning its Guenther, made it possible for me to go back to organization and format. I also want to thank Dr. school and receive an education in naturopathic Sandoval Melin for his expertise in the area of medicine, and I thank him for providing the sup- exercise. Sandoval has elevated the role of exercise port and resources that allowed me to pursue a therapeutics in the first edition of the book and career as a naturopathic physician. My stepdad, is responsible for its inclusion. Jack Hudson, who passed away at too young an I would also like to thank my editor of the age, gave me the gift of learning and doing all the second edition, Deborah Brody. She graciously things normally reserved for boys. My niece, Jana, accommodated my need for additional time and delights me with her spirit and resilience. distinctly improved the feel and readability of Sometimes I cannot believe my good fortune each chapter. to have Doug Stapf in my life—trusted business Dr. Elizabeth Newhall generously gave of her partner at Vitanica, easygoing Texan friend, time and expertise as an obstetrician and gyne- fellow basketball fan, the most excellent of men cologist for the first edition. If it were not for her one could hope to know and work with. generous sharing of her conventional medical Having become a naturopathic physician in knowledge over the last 14 years, my expertise in 1984, I am honored to be an alumna and faculty women’s health would not have been complete. member of the National College of Naturopathic I am fortunate to have a very talented and Medicine (NCNM) these last 24 years. The supportive sister, Karen Hudson. Not many National College of Naturopathic Medicine is women have the good fortune to have a sister the oldest college of naturopathic medicine in that knows everything they do not know. Being the United States, and the expertise and experi- in business together at our clinic, A Woman’s ence of its faculty in the field of natural medicine Time, is the perfect blend of what we each do are exceeded by no other college in the country. I best. Our joint commitment of delivering health- honor the faculty, administration, and employees care options to women is our work and our play. of NCNM for their commitment and vision. xi

Copyright © 2008 by Tori Hudson. Click here for terms of use. xii ACKNOWLEDGMENTS My naturopathic colleagues as a whole, and Karen Hudson, M.P., H.C.; Theresa Baisley, particularly the members of the American LMT; and Mari Greenly, L.Ac. Association of Naturopathic Physicians, are an I would also like to thank our clinic staff, a incredible community of individuals with an formidable group of fine women who extend extraordinary commitment to living on this their skill, compassion, ethics, and care of planet in a respectful, mindful way and healing patients and coworkers on a daily basis: Tamara, the humans of this planet in gentle ways that uti- Kim, Whitney, Susan, Renee, and Audra. lize the medicines of Mother Nature. In order to practice an integrative medicine I could not have succeeded in the generation approach, I have had the guidance and support of and manifestation of two important projects (the many conventional practitioners in the Portland Institute of Women’s Health and Integrative community. I can’t possibly list them all, but here Medicine and the Naturopathic Education and is an important beginning list: Mike McClung, Residency Consortium) without the years of sup- M.D.; Trish Burford, M.D.; Nathalie Johnson, port, trust, and guidance from three individuals M.D.; Jane Harrison-Hohner, N.P.; Katherine and companies: Wally Simons, R.Ph., of Women’s Hill, N.P.; Nina Davis, M.D.; Renee Edwards, International Pharmacy; David Shefrin, N.D., of M.D.; Kim Surianno, M.D.; Sandra Emmons, Bezwecken; and Sharon McFarland of Transitions M.D.; Lisa McCluskey, M.D.; Michael Lewis, for Health/Emerita. M.D.; Kim Suriano, M.D.; Brenda Kehoe, M.D.; Several other people have lent their profes- Sally Holtzman, M.D.; Pillippa Ribbink, M.D.; sional, business, academic, and personal support Liz Newhall, M.D.; Randi Ledbetter, M.D.; Tom and extended themselves in various ways: Michael Johnson, M.D.; Paul Kucera, M.D.; Rodney Murray, N.D., of Natural Factors; Don West, Pommier, M.D.; Jeff Jensen, M.D.; Laura Green- R.Ph., of Lloyd Center Pharmacy; Rick Liva, N.D., berg, M.D.; Dan Gruenberg, M.D.; Kasra and Jackie Germain, N.D., of Vital Nutrients; Karamlov, M.D.; Maureen Goldring, M.D.; Cyn- Ronnie Boyer, M.D., of The Center for Education thia Ferrier, M.D.; Kip Kemple, M.D.; Wesley and Development in Homeopathy; Riley Liv- Lewis, M.D.; and many more. I thank them for ingston; David Hanning of Biogenesis; Jon Thore- their open-mindedness and fierce commitment to son and Nigel Plummer, Ph.D., of Pharmax; Kyle their patients and medicine. Bliffert of Nordic Naturals; Ken Koenig, D.C., of When things are up and things are down, or Wise Woman Herbals; Michael Schaeffer of Well- even just content, my trusted friend, playmate, ness Naturals; Steve Wickham of Metametrix; and confident Dee Packard is one of those special Brehan Griswold of Emerson Ecologics; and Shane beings the universe has brought into my life. I McCamey of Boiron. consider myself fortunate to have the loving I have a special place in my heart for the daily friendship and committed support of Eileen privilege I have in working with my associates at Stretch, Cindy Phillips, Holly Lucille, Nirala A Woman’s Time. This group of women practi- Jacobi, Kate Krider, Patti Kohler, Tracy Waters, tioners are extraordinary in their work and truly Laurel Haroon, Steve Austin, Kathy Hitchcock, an incredible pleasure to work with. I am grate- and Sidney Henry. I also thank my special ful for their camaraderie and collaboration in all friends Lupita and Jon McClanahan who teach that we do together: Barbara McDonald, N.D., and share with me the “beauty way” of the L.Ac.; Stephanie Kaplan, N.D.; Leigh Kochan, Navajo people. To K. C. Snellgrove, D.C., I N.D., L.Ac.; Wendy Vannoy, N.D.; Moira Fitz- thank you for keeping my body going, despite patrick, Ph.D., N.D.; Michelle Rogers, N.D.; long hours at my desk, and I thank her able ACKNOWLEDGMENTS xiii coworker, Lucille Gouge, who always seems to fit teacher, better physician, and better person me into the schedule for a treatment. because of you. To Bette Joram, Ph.D., I thank you for your For those with whom I’ve played, worked, intellect and remarkable insights, your contain- nourished, and loved, you have brought about ment, your support, and your trustworthiness. my evolution as a human being. And to Ann Kafoury, L.P.C., I thank you for Finally, we all owe our gratitude to the your skill, your grace and compassion, your trust women who seek safe, effective, respectful medi- in me and trustworthy ways, and your commit- cine and choices in their health care. You have ment to me and my own healing. changed history on more than one occasion and I also want to thank all the women I have protected our humanness. treated over these last 24-plus years. I am a better This page intentionally left blank CONTRIBUTORS

he second edition of Women’s Encyclopedia My gratitude and appreciation for the contri- Tof Natural Medicine would not have been butions of Dr. Leigh Kochan and Dr. Randi Led- possible without the studious help of two col- better are immense and will extend long into the leagues in particular: Leigh Kochan, N.D., L.Ac., future. Without their knowledge and assistance, and Randi Ledbetter, M.D. Dr. Kochan is a this would have been a much longer and more former resident and now an associate at our clinic, arduous process. A Woman’s Time, in Portland, Oregon. She has The following additional practitioners have spent countless weeks and months assisting me in made selected contributions in different sections compiling the scientiﬁc literature of the last seven of the book, reviewing, editing, and contributing years, particularly for updated research in herbal their expertise: and nutritional therapies. Her efforts have kept me from feeling overwhelmed and made this Sandoval Melin, N.D., Ph.D. Exercise daunting project of updating the book a real therapeutics possibility. Dr. Randi Ledbetter is a gynecologist Elizabeth Newhall, M.D. Obstetrics, practicing in Portland, Oregon, at The Meno- gynecology pause Clinic. She has generously offered her gyne- Nina Davis, M.D. Urology cological expertise to me and other alternative Katherine Hill, N.P. Infertility practitioners these past many years and now has Susanna Reid, Ph.D., N.D. First edition extended that to helping me to rewrite and update research assistant the sections on conventional medicine. I consider Judy Fulop, N.D. First edition these sections of the book vital in the education of research assistant, patients and fellow practitioners. endometriosis

’ve spent the last 28 years studying, practic- bloodletting therapies and toxic mercury dosing Iing, teaching, and evolving as a naturopathic and replaced them with more effective and less physician. Two themes have been consistent: toxic treatments. With therapies more acceptable natural medicine and the health care of women. to the public, subsidies from wealthy foundations, Alternative medicine has come to be the the support of the developing pharmaceutical popular term used to distinguish natural, nonin- industry, and political savvy and legislation in its vasive therapies from conventional medicine. favor, conventional medicine was able to restrict Whether the terms alternative medicine, comple- the use of unorthodox doctors, midwives, herbal- mentary medicine, natural medicine, or holistic ists, and others and gain a virtual monopoly on medicine are used, they all reflect the transforma- the health-care system. tion that is occurring in health care: a focus on Fortunately, alternative medicine and naturo- disease prevention, the promotion of healthy pathic medicine have seen a rebirth in the last 15 lifestyle habits, and the treatment of disease with to 20 years, and especially in the last 5. A public natural, nontoxic, and less invasive therapies. At hungry for choices in their health care, an the center of this transformation is a distinct increased awareness about the role of diet and system called naturopathic medicine. lifestyle in cancer and chronic disease, the aging of The roots of naturopathic medicine are seen the baby boomer generation, and the failures of in the healing traditions of Egypt, India, China, certain aspects of modern conventional medicine Greece, Germany, South and Central America, and the health insurance industry to deal with Africa, and native North America. The European people and their health problems respectfully, hydrotherapy tradition had a strong influence on carefully, fairly, and effectively have been responsi- the development of naturopathy, and by the end ble for this resurgence. Conventional medicine has of the nineteenth century, Benedict Lust, a physi- brought great insights, successes, and miracles of cian trained in the water-cure methods of Europe, what human intelligence can accomplish. Natural came to America and began using the term natur- medicine has matured, particularly in the areas opathy to describe an eclectic combination of nat- of scientific research, educational institutions, ural healing principles and methods. number of licensed practitioners, and profession- The first college of naturopathic medicine alism and is now poised to serve those who seek its in the United States opened in New York City gentle ways. in 1902. It taught a system of medicine that Naturopathic medicine is its own distinct included nutritional therapy, natural dietetics, healing art and is best defined by its principles herbal medicine, homeopathy, manipulation, ex- and therapies. Simply put in modern terms, ercise therapy, hydrotherapy, electrotherapy, and naturopathic physicians are primary health-care stress reduction techniques. providers, family physicians who specialize in Naturopathic medicine grew and flourished natural medicine. The following seven principles from the early 1900s until the mid-1930s. At that are the foundation for naturopathic medicine: point in history, the conventional medical profession began to influence the health-care system in 1. The healing power of nature (vis medica- several ways. It abandoned some of its barbaric trix naturae). The body has the inherent ability xvii

Copyright © 2008 by Tori Hudson. Click here for terms of use. xviii INTRODUCTION to establish, maintain, and restore health. The 6. Prevention is the best cure. The ultimate physician’s role is to facilitate and augment this goal of naturopathic medicine is prevention. process with the aid of natural, nontoxic thera- This is accomplished through education and pies; to act to identify and remove obstacles to promotion of lifestyle habits and through natu- health and recovery; and to support the creation ral therapeutic recommendations. The emphasis of a healthy internal and external environment. is on building health rather than on fighting 2. First, do no harm (primum no nocere). disease. Naturopathic physicians seek to do no harm 7. Establish health and wellness. The pri- with medical treatment by employing safe, mary goals of naturopathic physicians are to effective, less invasive, and natural therapies. establish and maintain optimum health and to 3. Identify and treat the cause (tolle promote wellness. They strive to increase the causam). Naturopathic physicians are not only patient’s level of wellness, characterized by a trained to investigate and diagnose diseases, positive emotional state, regardless of the level they are also trained to view things more holisti- of health or disease. cally and look for an underlying cause, be it In addition to these seven principles, there are physical, mental, or emotional. Symptoms are two principles that I believe are fundamental not viewed as expressions of the body’s attempt to only to natural medicine, but to good medicine heal but are not the cause of disease. The physi- in general: the principle of resonance and the cian must evaluate fundamental underlying principle of choice. Let me explain. Resonance causes on all levels, using treatment that is basically an issue of compatibility. What includes addressing the root cause rather than approach, what therapy, what herb, or what of just suppressing symptoms. any substance is compatible with this particular 4. Treat the whole person. Health and disease patient in this particular moment and set of life are conditions of the whole organism, involving circumstances? The selection of the therapeutic a complex interaction of physical, spiritual, approach that is resonant with the individual is mental, emotional, genetic, environmental, and the therapy that will create the most healing social/cultural/economic factors. The physician momentum. Picture a child on a swing. You must treat the whole person by taking all of stand behind the child pushing her forward so these factors into account. Homeostasis and she can achieve the most momentum, and her harmony of functions of all aspects of the indi- swinging becomes effortless. If you push her at vidual are essential to recovery from disease, the right moment, your force is perfectly timed prevention of future health problems, and with her body motion and the rhythm of the maintenance of wellness. swing. The perfect timing sends her smoothly 5. Physician as teacher (docere). The naturo- and easily higher, and with the slightest effort she pathic physician’s major role is to educate, can keep swinging forever. If you push her at the empower, and motivate the patient to take wrong moment, the swinging becomes jerky, she responsibility for his or her own health. The loses speed and height, and the rhythm is dis- physician educates about risk factors, hereditary rupted. It then takes a great deal of effort to susceptibility, lifestyle habits, and preventive regain momentum. The perfect effortless swing measures and makes recommendations on how comes from the perfect timing and perfect force- to avoid or minimize future chronic health fulness of the “push.” This is resonance. The problems. A healthy attitude, diet, exercise, and person with the health problem is the child on other lifestyle habits serve as the cornerstone of the swing. The person who pushes the swing is our recommendations. INTRODUCTION xix the physician and the therapy she uses. Any med- will, desire, discipline, and motivation. Freedom icine, natural or pharmaceutical, can be resonant. of choice occurs in an environment of equality The art of medicine is to know when to use what, and respect between physician and patient. for whom, and for how long. I believe the most These two principles, resonance and choice, profound healing principle in the practice of are what motivates me toward the vision of an medicine is the principle of resonance, not integrative health-care model. I no longer believe whether the medicine is natural or synthetic, alter- in a fractionated approach to health and healing native or conventional, or a naturopathic philoso- where alternative medicine is on one side and phy versus conventional allopathic philosophy. conventional medicine is on the other. There is a The healing method is the medicine that is right spectrum of options that go from simple to com- for that person. The true goal of a physician is plex, from the least intervention to the most to perceive what is resonant with that individual. aggressive intervention, and from the most natu- Dr. John Bastyr was considered by most ral therapy to the most synthetic or technologi- naturopathic physicians to be the modern patri- cal. We need all of it. Human intelligence has arch of naturopathic medicine. A whole new created incredible tools and techniques. The generation of naturopaths looked to him for physician who is educated and aware of all the their wisdom as the holder of true naturopathic options and learns to understand how and when medicine. The story goes, a young naturopathic to best use all these choices on behalf of someone medical student asked Dr. Bastyr, “How are we who is ill and suffering is the true physician in supposed to know what therapy to choose my book. An integrative model incorporates the when there are so many different medicines and natural/naturopathic perspective and the con- systems to choose from?” Dr. Bastyr calmly and ventional perspective and knows the strengths quickly responded, “Choose what works.” and weaknesses of each in different circum- Another question was posed to Dr. Bastyr: “How stances. When we can do something effectively can you tell an excellent physician from a good and safely with nontoxic, natural medicines with physician?” Dr. Bastyr’s answer: “The results.” far fewer side effects, then what would stop us? If My second guiding principle is that of choice. we can’t, or it’s too risky to wait and find out, Each patient chooses what is right for her. The then let’s move up the ladder to more invasive, doctor’s role is to educate about the health prob- riskier medicines with more side effects that may lem, about the options, including their pros and work better or be a more appropriate choice cons, and to share resources. The goal is to provide because the risk of the disease is greater than the the context in which the patient can make an risks of the treatment. informed decision. The physician must be percep- Naturopathic and other alternative medicine tive and must listen, investigate, evaluate, educate, disciplines have their strengths and their weak- offer recommendations, and then create an envi- nesses. Conventional medicine has its strengths ronment where the individual can make a decision and its weaknesses. I encourage consumer and for herself. The individual seeking my help gets practitioner alike to advocate for practitioners of to choose. It may be black cohosh, or it may be all disciplines to integrate their intelligence, estrogen. It may be a rigorous naturopathic health experience, and energies to build cooperative regimen, or it may be surgery. It may be an inte- working relationships with each other so that grated combination, a “complementary” approach they can truly help people to choose what works using the best of two worlds. Choice is a powerful best for them. force—the force of individual responsibility, In addition to recommendations on lifestyle, empowerment, and self-direction. Choice fosters diet, and exercise, naturopathic physicians utilize xx INTRODUCTION a vast array of therapeutic tools to promote Women want safe, effective, affordable medi- health and treat illnesses. Naturopathic physi- cine. Women want to be educated about their cians are trained in what is called the eclectic tra- bodies and their health. Women want to make dition. They have a broad range of therapies and choices in their health care that they have deter- tend to use a selected mixture of these therapies mined are right for them. By philosophy, by when treating their patients. Naturopathic thera- design, and by commitment, alternative healing pies include dietary and lifestyle changes, clinical systems have the package to offer women what nutrition (nutritional supplementation), botanical they want. medicine (herbs), homeopathy, Chinese medicine Beginning with the AMA’s exclusion of and acupuncture, hydrotherapy, manipulation, women in the late 1800s, orthodox medicine’s physical therapies, psychotherapy, and minor sur- lack of respect for women both as healers and gery. We also recognize the judicious use of pre- patients has been all too obvious. Today, signifi- scription medications when the benefits exceed cantly more empowered women have come to the risks, integrated into a comprehensive naturo- reject the dictums of orthodox medicine in greater pathic health-care plan. Some naturopathic physi- numbers. Women intuit the limitations of the cians receive extra training and licensure to biomechanical model to completely explain phys- practice obstetrics and natural childbirth. iological processes. Despite the orthodox physi- And now for the second consistent theme in cian’s uniform advocacy for menopausal hormone my life: the delivery of health care to women. replacement therapy (HRT) for all, only a frac- Modern women are the first women in history to tion, less than 20 percent of women, comply; 90 enjoy the luxury of anticipating that their lives will percent of the women who begin HRT stop be healthy, long, and self-directed. This awareness within the first year of use. Partially a failure of of opportunities and choices is leading them today access, it is also a profound testimonial to their to seek the benefits of natural medicine in ever- lack of trust in conventional medicine’s safety, effi- increasing numbers. More dominant and discrim- cacy, and commitment to their well-being. inating consumers of health care than men or The creation of synthetic hormones in the children, and quicker to grasp the advantages of a 1950s and 1960s was unquestionably revolution- vitalistic, holistic healing art, their innate wisdom ary for women in that it suddenly allowed per- has already led to many significant changes in sonal life autonomy through successful fertility conventional medicine in recent years. Women control and the elimination of the hot flashes and insisted on natural childbirth, and now it is the mood swings of menopause. Women’s lives were goal of most pregnant women and available every- changed forever. However, with hormones where. They have too long felt the restrictions of coming as they did on the heels of the “miracle paternalistic conventional medicine with its uni- medicine era” in which antibiotics and vaccines formity and lack of individualization of healing led the general public to believe medicine could approaches and are therefore more than ready to do no wrong, the consequences of hormone embrace the natural principle of treating the indi- excess and side effects were not anticipated or vidual. Moreover, the success of natural treatments quickly recognized and dealt with. Up until in relieving disease and suffering has done much to 2002, most conventional practitioners recom- promote their popularity. The now well-recognized mended a postmenopausal lifetime on HRT. neglect of women in allopathic conventional This has recently changed, and the data have research and the failure to prioritize women’s begun to show that the risk of breast cancer health in general have left a profound gap in health increases after five years of use. Consequently, care that alternative medicine is well poised to fill. many women distrust and fear hormonal medi- INTRODUCTION xxi cine and their conventional physicians. Unfortu- In addition to practitioner-delivered natural nately, this fear and mistrust may lead to the health care, natural medicine offers safe and refusal of a medicine that in some cases may effective self-care options for many common achieve more benefit than risk. Here’s where the conditions such as vaginitis, PMS, fibrocystic integrated wisdom and approach come in. While breasts, menstrual cramps, menopause symp- clearly not a panacea, hormones are not all bad toms, bladder infections, and more, further and have important uses for selected individuals. expanding women’s health-care autonomy. We can also use hormones in a form that may I support the self-care approach to healing. enhance their benefits and minimize their risks, Much of the practice of medicine is not particu- or use a combination of a reduced dose of hor- larly difficult or complex. Education and mones along with soy and herbal medicines to resources can provide a lot of very practical infor- bring about the most benefit with the least risk. mation. One of the things I’ve tried to do in this Women today are insisting on participating book is not only to provide some self-care treat- in their health-care decisions in a way conven- ments for common female disorders but also to tional medicine is just beginning to recognize. provide guidelines about when self-care is not I believe that the baby boomer menopausal appropriate. Health care is a team approach: the woman is having and will continue to have a patient, the practitioner, the therapies. The team more significant impact on our health-care can include both the alternative and the conven- model than any other previous group of health- tional practitioner—and, better still, those that care consumers. Menopausal women today reject talk to each other on behalf of the patient. the notion of a single therapeutic modality being Choice in doctors and medical approaches, essential for all women undergoing a natural involvement in the health-care process, healthy process. They reject the notion of taking a drug lifestyles, and safer, nontoxic natural therapies are for the rest of their lives, especially if they have recognized by today’s women as essential to health other options, especially if they can do other and well-being. Women highly value the longer things to help prevent osteoporosis and heart dis- time spent in discussion with their alternative ease, and especially if that drug increases their provider as well as the careful, complete, and risk of a life-threatening disease. respectful collection of their history. They value Women are the biggest consumers of health processing their options thoroughly and individu- care in America. A menopause supplement to ally. This unique quality of alternative health-care OB-GYN, the journal of the American College systems is rare in conventional medicine and is one of Ob-Gyn, states, “Focus groups, involving of the chief reasons women seek alternative care. women age 40 to 60, reveal that women know Naturopathic physicians and other providers more about herbal medicines than about estro- of alternative medicine must seek to verify the gen.” That seems an impressive testimonial to the “scientific” truth of their medicines whenever power of alternative medicine in its alliance with possible—by research and by modifying the the natural wisdom of women to define their own mechanistic model when necessary to suit their health-care standards. It is an invitation to alterna- vitalistic philosophy. They must continue to tive medicine to continue to provide women with stand by their tradition of resonance between the wider, healthier options they seek. Fifty per- patient and therapy, ever seeking the resonance cent of American women will be menopausal by for a particular woman with a particular problem the year 2015, and they will provide alternative at a particular time in her life. medicine the greatest opportunity yet to serve our Last, alternative medicine must recognize that communities. conventional medicine, while inadequate alone, is xxii INTRODUCTION here to stay and offers important options and life- selecting from all options, both naturopathic and saving measures. Likewise, conventional medicine conventional. A combined, well-thought-out coop- must recognize that natural therapies are a funda- erative and integrative approach is often the best mental healing tradition of all cultures and that that medicine has to offer. Our open-mindedness modern alternative medicine is also here to stay. will be rewarded manyfold by the improved health The more practitioners make themselves aware of of women and their increased satisfaction and trust these options, the better they can guide women in in their health-care providers. WOMEN’S ENCYCLOPEDIA of NATURAL MEDICINE ABNORMAL CHAPTER 1 UTERINE BLEEDING

OVERVIEW Benign Abnormal Bleeding Changes in the amount of menstrual blood flow, The causes of abnormal bleeding can be benign, duration, and pattern are among the most premalignant, or malignant. Benign causes can common health concerns that women face. be further subdivided as either organic or hor- Although these changes cause a lot of anxiety for monal. Organic disorders are all benign causes women and do warrant a medical evaluation, of bleeding that are not hormonal. This may most cases of abnormal bleeding are due to include systemic health problems, abnormal benign and easily addressed conditions. Whether pregnancy, foreign bodies, trauma, infections, alternative or conventional treatments are used and growths. for intervention, prompt evaluation is highly Systemic diseases that are associated with recommended. problems in how the blood clots are called coag- There are many causes of abnormal bleeding, ulopathies and can cause heavy vaginal bleeding. but our main purpose in this chapter is to discuss Heavy bleeding in a teenage girl may be caused a benign hormonal cause of bleeding called dys- by a coagulopathy called von Willebrand’s dis- functional uterine bleeding (DUB), abnormal ease. In fact, 20 percent of teenage girls with uterine bleeding without any demonstrable severe menorrhagia have a significant coagulation organic cause. First, we need a little background problem. A decrease in the number of blood and overview on abnormal bleeding in general. platelets (thrombocytopenia) can also cause A wide variety of clinical disorders can mani- abnormal bleeding. Other systemic diseases, such fest as abnormal bleeding from the vagina. What as hypothyroidism and severe liver diseases, can is considered abnormal bleeding depends on the also cause prolonged menses, heavy menses, or age of the patient. The bleeding can take many intermenstrual bleeding. forms, including heavy and/or prolonged menses An abnormal pregnancy is the most common (menorrhagia), intermenstrual bleeding (metror- cause of abnormal vaginal bleeding in women rhagia), frequent menses (polymenorrhea), infre- who are of reproductive age. Any type of mis- quent menses (oligomenorrhea), heavy and carriage can present with abnormal bleeding irregular intermenstrual bleeding (menometror- that is also often associated with cramping pains. rhagia), or postmenopausal bleeding. Normal Women with an ectopic pregnancy (a pregnancy menses are defined as vaginal bleeding that occurs in the fallopian tubes rather than the uterus) can approximately every 28 days (with a range of 21 present with abnormal bleeding, as can those to 35 days) and lasts for 4 to 7 days. Abnormal with a molar pregnancy (an abnormality of the bleeding is bleeding that occurs more frequently placenta caused by a problem when the egg and than every 21 days, less frequently than every 35 sperm join together at fertilization). days, lasts more than 7 days, is unusually heavy or Abnormal bleeding in children can be caused light, or occurs after menopause. In addition, by foreign bodies that they may have placed in vaginal bleeding is considered heavy if a woman their vaginas while playing. The most common loses more than 80 ml of blood per cycle (normal foreign body in women of reproductive age is is 30 to 35 ml). an IUD, or intrauterine birth control device. 1

Copyright © 2008 by Tori Hudson. Click here for terms of use. 2 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Women with IUDs will tend to have heavier the female genital tract. Eighty-five percent menses and sometimes intermenstrual bleeding. of the primary vaginal cancers are squamous cell Trauma during intercourse can cause vaginal (a particular cell type) carcinoma. The most bleeding, for example in postmenopausal women common symptoms of invasive squamous cell who may have a dry vagina with thinning vaginal cancer include vaginal bleeding or foul-smelling tissue. Just the friction of normal vaginal penetra- discharge. Pain is usually a late symptom. tion during sex may be traumatic to this sensitive The tragedy of another cancer, cervical tissue. Trauma may also be experienced in a violent cancer, is that it is a preventable disease. It is pre- situation such as sexual abuse and rape. In children ceded by a prolonged precancerous state in or adolescents, sexual abuse must be considered in almost all cases and can be detected at its early cases of traumatic vaginal bleeding. Traumatic precancerous states by annual Pap smears. These bleeding may also occur after gynecological proce- earlier states of abnormal cells and cervical dys- dures such as biopsies and instrumentation. plasias are easily treatable conditions. Cervical Occasionally, a uterine infection called cancer accounts for approximately 18 percent of chronic endometritis can present with abnormal female genital cancer in the United States. The vaginal bleeding or spotting. Other symptoms peak incidence of cervical cancer is from 35 to 39 often associated with this infection include a and 60 to 64 years of age. Vaginal bleeding after vaginal discharge, fever, abdominal/pelvic pain, vaginal sexual activity is the most common or lower back pain. symptom occurring in cancer of the cervix. In Of the most common causes of abnormal women with advanced disease, a foul-smelling bleeding are growths known as myomas, more discharge may be present. commonly referred to as uterine fibroids. These Endometrial hyperplasia is an increased growth tend to be more common in women over the age of the lining of the uterus (endometrium) and a of 30, particularly women in their 40s. Different subsequent thickening. Most cases of endometrial kinds of fibroids are discussed in Chapter 19, but hyperplasia revert to normal, either spontaneously submucous fibroids tend to be the most trouble- or with hormonal treatment. Some may persist, some in terms of heavy bleeding. Fortunately, they and others can progress to endometrial cancer. represent only about 5 to 10 percent of all fibroids. Endometrial hyperplasia may occur in any age Endometrial polyps can also cause abnormal group but is most commonly seen in older women. bleeding, but the bleeding is usually not heavy. Chronic lack of ovulation, as seen in the teenage Adenomyosis, a variant of endometriosis, may years, after menopause, and as a result of polycystic result in very heavy bleeding associated with men- ovary disease, is a condition where we may see strual cramping. Endometriosis itself can cause endometrial hyperplasia. Endometrial hyperplasia irregular changes in the menstrual cycle, but not can be simple or complex, and either atypical, typically heavy menses. Finally, bleeding may which is precancerous, or without atypia. These result from cervical polyps or a simple inflamma- distinctions are very important when it comes to tion of the cervix called cervicitis. Cervical polyps treatment and management and can best be made and cervicitis tend to present with intermenstrual with a procedure called an endometrial biopsy. bleeding or spotting after intercourse. Pelvic ultrasound has improved to the point where it can detect thickening of the endometrium. Once Malignant Abnormal Bleeding thickening is observed, a biopsy will probably be Now let us look at the premalignant and malig- recommended to further evaluate the situation. nant causes of uterine bleeding. Vaginal cancer Some endometrial hyperplasias will progress accounts for only 2 percent of malignancies of to cancer of the endometrium, i.e., uterine ABNORMAL UTERINE BLEEDING 3 cancer. As in cervical dysplasia and cervical result of polycystic ovarian syndrome, elevated cancer, endometrial hyperplasia is the precancer- prolactin levels, emotional stress, obesity, weight ous state; its adequate treatment will prevent the loss due to anorexia, or athletic training. development of endometrial cancer. Endometrial The actual cause of DUB is not completely cancer is the most common malignancy of the clear. One theory is that the fluctuating estrogen female genital tract and accounts for approxi- levels seen in chronic lack of ovulation can cause mately 7 percent of all cancers in women. The intermittent estrogen withdrawal bleeding. average age of patients with endometrial cancer Another theory is that the continuous estrogen is 59 years; the highest range for the incidence is stimulation leads to a thickening of the endo- age 50 to 59 years in postmenopausal women. metrium, which needs more estrogen in order to The most common symptom associated with maintain itself. Eventually, the need for estrogen endometrial cancer is abnormal uterine bleeding. surpasses the production and breakthrough Typically, the bleeding is in the form of spotting, bleeding results. Another theory is that some especially in postmenopausal women. areas of the endometrium outgrow their blood supply, and subsequent bleeding occurs because Dysfunctional Uterine Bleeding (DUB) of the lack of progesterone. DUB can occur at any age but is most common There are also cases of DUB that are not due at either end of the reproductive age span. One to anovulation but rather occur even though uses the term DUB when other causes for abnor- there is regular monthly ovulation. Ovulatory mal bleeding have been excluded (fibroids, DUB is defined as heavy menses in women who polyps, and endocrine or other disorders). Ado- ovulate and who do not have a coagulopathy or lescents account for about 20 percent of DUB any uterine abnormality. The cause of this form cases after the first menstrual cycle. These cases of DUB is not clear. are due to the immature endocrine system, particularly the immature function of the hypothal- DIAGNOSIS amus. Perimenopausal women account for The key to accurate diagnosis of abnormal bleed- approximately 50 percent of DUB cases due to ing is the woman’s medical history. Several perti- waning ovarian function. As the ovary ages, it nent pieces of information will facilitate diagnosis: becomes less efficient in completing the ovula- • Previous menstrual patterns for the last three tory process. Initially there is a decrease in prog- months esterone production, which causes shorter cycles. • The presence or absence of pain along with As the aging process progresses, ovulation the bleeding becomes less frequent, resulting in a variable • Heaviness of the flow (number of pads or length of the menstrual cycle and a variation in tampons per day and how often they are the duration of the flow. Eventually, the lack of changed when saturated) ovulation puts women in an estrogen-dominant • Contraceptive methods, if any state in the presence of too little progesterone • Symptoms of pregnancy because ovulation must occur in order to pro- • Dates and histories of past pregnancies duce progesterone. Women who are in a state of • Premenstrual symptoms chronic anovulation tend to have an excess of • Recent abdominal, pelvic, or vaginal trauma estrogen in the body. This excess estrogen is what • Clotting problems disrupts the normal pattern of menstruation. • Easy bruising or bleeding The remaining 30 percent of cases of DUB • Symptoms of systemic diseases occur among women age 20 to 40, generally as a 4 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE • History of taking estrogens without ade- a lack of ovulation. Tests such as saline infusion quate progesterone/progestins sonohysterography (SIS—an ultrasound proce- • History of sexually transmitted diseases dure that gives a three-dimensional view so as not • Past gynecologic history to miss any portion of the uterine cavity), hysteroscopy (a procedure that involves dilating the A physical exam will involve visualizing the cervix so that a small lighted scope can be inserted cervix, feeling the contour and size of the uterus, to visualize the intrauterine cavity), or a dilation and general palpation of the pelvic area. Labora- and curettage (D&C) may be recommended in tory testing may include: addition to or instead of the pelvic ultrasound and • Pap smear the pipelle biopsy in selected cases to improve • Thyroid function tests accuracy of the results. • Pregnancy test KEY CONCEPTS • Complete blood count to rule out anemia • Follicle-stimulating hormone • Seek and utilize a health-care practitioner who (FSH)/luteinizing hormone (LH) will distinguish DUB from benign, premalignant, • Liver function tests and malignant causes. If benign, is the cause • Prolactin levels organic or hormonal? • Adrenal function studies • Workup will include a medical history and may • Pelvic ultrasound to identify uterine fibroids include a physical exam and further laboratory or measure endometrial thickness tests, pelvic imaging, and/or endometrial • Pelvic saline infusion sonohystogram biopsy. • Do not self-treat unless assured that the cause • Testing for sexually transmitted diseases is DUB. • Endometrial biopsy • Practitioners can often presume a diagnosis of An endometrial biopsy may be recommended DUB temporarily and recommend a further workup depending on response to the treatment. to test the tissue itself. This is a simple procedure done in the practitioner’s office in which the clinician inserts a small narrow plastic instrument PREVENTION called a pipelle into the uterine cavity to extract a small sample of tissue. It only takes about 30 to 60 • Reduce stress. seconds, but women can experience mild to signif- • Avoid taking any form of estrogen without ade- icant cramping during that time. A local anesthetic quate progesterone or progestins. is usually not required, and the cramping generally • Engage in healthy lifestyle habits. subsides very quickly once the procedure is over. • Protect yourself against sexually transmitted Endometrial pipelle biopsies can determine the diseases. • Use well-tolerated forms of contraception. presence of endometrial hyperplasia, uterine • Have regular medical visits, including an annual cancer, infection (endometritis), a disrupted hor- physical exam. monal effect, a lack of estrogen as is seen in post- • Maintain optimal body weight. menopausal women, or a uterine polyp. If an endometrial biopsy is done at the right time, it can also be used to verify ovulation. If the OVERVIEW OF biopsy shows that the endometrium has prolifer- ALTERNATIVE TREATMENTS ated, when the woman’s next bleeding episode The goals of alternative treatment for DUB are the occurs within 10 to 12 days, it generally indicates same as the goals of conventional treatment: con- ABNORMAL UTERINE BLEEDING 5 trol the bleeding, prevent and treat anemia, restore for their ability to bring about ovulation and an acceptable menstrual pattern, and prevent orderly stimulation of ovarian function, and endometrial hyperplasia/endometrial cancer. herbs for their tonifying and astringent effects. Repeated episodes of heavier and prolonged The concept of tissue tonification is a key fea- bleeding should be distinguished from acute ture of the philosophy of herbal medicine. It is hemorrhage. My general guidelines are as follows: thought that gynecological conditions associated If a woman is saturating a super tampon or heavy with bleeding may occur as a result of poor tissue pad every hour for six to eight hours or more she tone of the mucous membranes, poor uterine will often need some form of prescription hor- tone, and a constitutional weakness of the tissues mone intervention. Herbal/nutritional interven- that presents as generalized lack of tissue tions can be tried, but if there is no change within integrity, in this case the uterus. The astringents two to four hours, then hormonal therapies (herbs that slow the loss of body fluids, i.e., men- should be utilized. Even heavier bleeding (i.e., sat- strual bleeding) are the herbs most likely to affect urating pads every half hour or less) will most tissue tone, while the uterine tonics and the likely require surgical intervention. Monitoring emmenagogues (herbs to promote menses) are physical symptoms, blood pressure, pulse, and most likely to affect uterine tone. Traditionally, hemoglobin and hematocrit levels will help to the ability of an astringent herb to stop bleeding determine management of these more semi- has been attributed to the tannin content of the urgent and urgent cases. Use of high-dose oral bio- plants. Uterine tone is related to the ability of the identical estrogens (estradiol) and bio-identical uterus to function as a smooth muscle. When the progesterone (oral micronized progesterone) may uterine tone is normal, there is a normalization be substituted in some cases of heavier semi-acute of menstrual flow. A hypertonic uterus can be bleeding, although the net effect is the same as associated with a delayed menses and cramping when using conventional hormones. In most uterine pains. A hypotonic uterus is frequently states, licensed naturopathic physicians can pre- accompanied by heavy bleeding and a feeling of scribe bio-identical hormones and conventional pelvic congestion. hormones. They would approach these dramatic Stress reduction has an underappreciated but situations with the same high degree of concern significant influence on irregular menses and and astuteness as would a conventional practi- DUB. A disruption in the messages between the tioner and may integrate acute antihemorrhagic hypothalamus (which produces gonadotropin- botanicals or nutrients in combination with the releasing hormones) and the anterior pituitary hormonal therapies. (which releases FSH and LH, follicle-stimulating Less dramatic cases that still involve heavy and luteinizing hormones) brings about a mis- menstrual flow will be best managed with both timing of the release of these hormones and a an immediate plan for the semi-acute bleeding subsequent lack of ovulation and/or estrogen and episode, which should slow down within a few progesterone production by the ovaries. The hours to 48 hours, and a comprehensive plan timing of the release of these pituitary hormones, that should bring results with no further episodes as well as of estrogen and progesterone, is what in one to four months. A comprehensive plan determines a normal, regular menstrual cycle. may include the use of soy and flax products to This timing can be adversely affected by stress, regulate the menstrual cycle, herbal extracts to and by the same token, the timing can be address immediate bleeding episodes, nutrients improved by stress reduction. A third hormone such as bioflavonoids and bromelain for their produced by the pituitary, prolactin, also plays an natural anti-inflammatory effect, herbal extracts important role in the menstrual cycle. Increased 6 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE production of prolactin can inhibit the matura- Two foods stand out in their ability to regulate tion of ovarian follicles and induce menstrual the menstrual cycle: flaxseed and soy protein. abnormalities and sterility. Prolactin release is Flaxseed contains a group of phytoestrogens often stress related. called lignans that have been shown to have weakly estrogenic and antiestrogenic properties. Nutrition Two specific lignans, enterodiol and enterolac- Consume a whole foods diet rich in whole grains, tone, are absorbed after formation in the intes- fruits, vegetables, legumes, quality cooking oils tinal tract from plant precursors particularly (canola and olive), nuts, and seeds. Emphasize abundant in flaxseed. fish high in omega-3 oils (salmon, tuna, sardines, The ingestion of flaxseed powder and its effect halibut, mackerel, herring) and reduce saturated on the menstrual cycle was studied in 18 normally animal fats (beef, chicken, butter, cheese) to pro- cycling women.1 Each woman consumed her mote the preferred prostaglandin pathways that usual omnivorous, low-fiber diet for three cycles are discussed in Chapters 9 and 13 (in the discus- and her usual diet supplemented with 10 grams sions of heart disease and menstrual cramps). per day of flaxseed for another three cycles. All These preferred prostaglandins will reduce women were instructed to avoid soy foods. The inflammation and may thereby help to reduce second and third flax cycles were compared to the heavy and profuse menstrual flows. second and third control diet cycles. Three Foods high in iron in particular should be nonovulatory cycles occurred among the 18 incorporated into the general diet when heavy women during the control diet (36 total cycles) blood loss persists on a monthly basis. Refined compared to none during the 36 flaxseed cycles. breads and cereals are the single greatest nutri- The ovulatory flax cycles were consistently associ- tional contributor to iron-deficiency anemia. ated with about one more day in the luteal phase Although we do have iron “enriched” flour, it has (second half of the cycle) when compared to the only about one-third the iron content of whole ovulatory non-flax cycles. Only one day longer wheat flour. Brewer’s yeast and wheat germ are before you bleed and a slight increase in the both excellent sources of iron, supplying about number of ovulations may not seem like much. 18 and 8 mg respectively per half cup. Blackstrap However, over a period of months and years, the molasses is not only one of the richest sources of cumulative effect not only has implications for iron but also of many other minerals. It supplies regulating the menstrual cycle but may also play a about 9 mg of iron per tablespoon; dark unre- positive role in reducing the risk of breast and fined molasses contains 1.5 mg of iron per table- other hormonally dependent cancers. spoon, and sugar, none. Single foods high in iron The influence of a diet containing soy protein probably cannot surpass the amount found in on the length of the menstrual cycle in pre- liver and kidneys. However, I do not recommend menopausal women has also been studied.2 Sixty these because it is very difficult to get organic grams of soy protein containing 45 mg of products, and these organs accumulate many isoflavones (a phytoestrogen compound found in metabolic wastes. Apricots and eggs are also high amounts in soy; see Table 1.1) was given rather high in iron. We often think of dark green daily for one month in a study lasting nine leafy vegetables as high in iron, but iron is diffi- months. A significant increase in the length of cult to absorb in this form. Foods such as yogurt the follicular phase (first half of the menstrual that contain Lactobacillus acidophilus and sour cycle) by an average of 2.5 days and/or delayed fruits and citrus juices aid in the absorption of menstruation was observed in the six women iron because of their high vitamin C content. who consumed the soy protein. Again, as with ABNORMAL UTERINE BLEEDING 7 therapy showed that 92.5 percent of the 40 cases Table 1.1 Isoflavone Content of Soybeans of menorrhagia were cured or alleviated. Serving Isoflavones It is important to understand that 60,000 IU Food Size (mg) of vitamin A given for long periods of time could lead to vitamin A toxicity, but generally this Textured soy protein would only occur if doses in excess of 50,000 IU granules 1⁄4 cup 62 were used for several years. Smaller doses may Nutlettes breakfast cereal 1⁄4 cup 61 produce toxicity symptoms if there are problems 1 Roasted soy nuts ⁄4 cup 60 in storage and transport of vitamin A. These Tempeh 1⁄2 cup 35 problems are generally found only in people with Tofu, low-fat and regular 1⁄2 cup 35 cirrhosis of the liver, hepatitis, or malnutrition Soy beverage powders and in children and adolescents. However, for a (varies with manufacturer) 1–2 scoops 20–50 period of only one month, as in this study, vita- Regular soy milk 1 cup 30 min A toxicity is of virtually no concern, and I would not hesitate to use it for this amount of Low-fat soy milk 1 cup 20 time, or up to three months. Using lower doses Roasted soy butter 2 tbsp 17 of 25,000 IU for longer periods of time should be considered in those cases where ongoing treat- flaxseed, soy protein has a role not only in con- ment is necessary to control menorrhagia. tributing to the regularity and lengthening of the menstrual cycle, but adding 2.5 days per month Vitamin A and lengthening the number of days from one 60,000 IU per day for 1–3 months menses to another may in part contribute to a 10,000–25,000 IU ongoing, if necessary, but be aware lower incidence of breast cancer.3 of potential increase in urinary calcium loss

Nutritional Supplements Note: Vitamin E improves vitamin A storage Vitamin A. A deficiency of vitamin A may and utilization, and zinc is required to mobilize contribute to menorrhagia in adult women. Vit- vitamin A. A deficiency of zinc, vitamin C, pro- amin A deficiency impairs enzyme activity and tein, or thyroid hormone may impair the conver- hormone production in the ovaries of animals,4 sion of carotenes to vitamin A. Provitamin A and serum levels of vitamin A have been found carotenes such as beta-carotene require these to be lower in women with menorrhagia than in nutrients for their conversion to vitamin A. healthy women.5 In the latter study, vitamin A was used as a treatment in 40 women who had B Complex. There may be a correlation diagnosed menorrhagia as a result of a diverse between a nutritional deficiency of vitamin B array of causes. In the group who received complex and menorrhagia and metrorrhagia. It 60,000 IU of vitamin A for 35 days, menstrua- has been shown that the liver loses its ability to tion returned to normal in 23 women (57.5 per- inactivate estrogen in vitamin B-complex defi- cent) for a period of at least three months. A ciency. We know that some cases of heavy menses significant decrease in the amount of blood or a and intermenstrual bleeding are due to an excess reduction in the duration of the menses or both of estrogen. Therefore, supplementing with a was obtained in 14 women (35 percent). The complex of B vitamins may restore the proper vitamin A was ineffective in 3 of the 40 women metabolism of estrogen and thus have a role in (7.5 percent). The overall result with vitamin A treating DUB. A study done over 50 years ago 8 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE was undertaken to determine if the B-complex Bioflavonoids. Like vitamin C, bioflavonoids vitamins were effective in the treatment of these have demonstrated a significant ability to reduce menstrual conditions. Although the study, done heavy menstrual bleeding by strengthening the in the 1940s, was not up to today’s scientific vessel walls of the capillaries in women with men- standards, a series of consecutive cases showed orrhagia.8 Bioflavonoids also can have an anti- that a B-complex preparation was effective in estrogen effect on the uterus by occupying the “prompt” improvement in both menorrhagia and estrogen receptor sites and thus limiting the metrorrhagia.6 The B-complex preparations used estrogen-stimulating effect on the endometrium. orally in the study were usually given in daily This can help to reduce bleeding. Just as conven- doses providing 3 to 9 mg of thiamin, 4.5 to 9 tional medicine prescribes nonsteroidal anti- mg of riboflavin, and up to 60 mg of niacin. inflammatories to reduce heavy bleeding, alternative medicine has natural anti-inflammatories such Vitamin B-100 Complex as bioflavonoids that can be used for the same pur- 1–2 capsules daily of a B-100 combination pose. Foods high in bioflavonoids (and vitamin C) include grape skins, cherries, blackberries, blueber- Vitamin K. Vitamin K deficiency is pretty ries, and the pulp and white rind of citrus fruits. rare, but its role in the manufacture of clotting fac- Bioflavonoids tors like prothrombin and clotting factors VII, IX, and X has obvious implications for women with 1,000–2,000 mg per day heavy or prolonged menses.7 Even when the cause of the excessive bleeding is not a clotting disorder, it may be prudent to use vitamin K as part of a Botanicals comprehensive treatment plan. Fat-soluble chloro- Chaste Tree (Vitex Agnus Castus). Chaste phyll is a good source of vitamin K and is found in tree is probably the best-known herb in all of fresh green juices. Consider increasing the intake Europe for hormonal imbalances in women. of green leafy vegetables and/or supplementing Since at least the time of the Greeks, chaste tree with 150 to 500 mcg per day of vitamin K. has been used for the full scope of menstrual disorders: heavy menses, lack of ovulation, frequent Vitamin K and infrequent menses, irregular menses, and a 150–500 mcg per day complete lack of menses. Chaste tree has been repeatedly studied in Germany. Although the Vitamin C. Vitamin C helps to reduce heavy fruit was used traditionally, it is the seeds that are bleeding by strengthening the capillaries. In at mainly used for medicine in Europe and in this least one study, vitamin C was able to reduce country. Consequently, most of the testing has heavy bleeding in 87 percent of the women.8 Vit- been done on the seeds. Chaste tree acts on the amin C also is an important supplement for hypothalamus and pituitary glands. It increases women who have acquired iron-deficiency anemia LH production and mildly inhibits the release of from menstrual blood loss. It helps to increase iron FSH. The result is a shift in the ratio of estrogen absorption and can be used to prevent anemia as to progesterone and consequently a “progesterone- well as to treat it. like” effect.9 The ability of chaste tree to raise progesterone levels is an indirect effect and not a Vitamin C direct hormonal action.10 Chaste tree has also 2,000–4,000 mg per day been shown to inhibit prolactin release by the pituitary gland, particularly under stress.11 ABNORMAL UTERINE BLEEDING 9 The first major study on chaste tree was pub- contraindication, and women should not worry if lished in 1954,12 proving the herb’s effectiveness they become pregnant while taking chaste tree for for patients with cystic hyperplasia (excessive pro- the first trimester. Chaste tree is completely safe liferation of the endometrium). Although this during lactation, and there are no known interac- condition is not technically DUB, it is impressive tions with other drugs, but theoretically, it might that chaste tree was able to bring about enough of interfere with dopaminergic antagonists. Mini- a progesterone effect to reduce the hyperplasia. In mal, reversible side effects have included itching, a separate study, 126 women with menstrual dis- occasional rash, nausea, headache, gastrointestinal orders took 15 drops of a chaste tree liquid extract disturbance, menstrual disorders, acne, and possi- three times daily over several menstrual cycles.13 In bly a lowered libido.16 33 women who had frequent menses (polymenor- Note: Aucubin and agnuside are different rhea), the duration between periods lengthened marker compounds found in chaste tree, used to from an average of 20.1 days to 26.3 days. In 58 standardize the product to assure an effective dose. patients with excessive bleeding (menorrhagia), the number of heavy bleeding days was decreased. Chaste Tree As mentioned earlier, chaste tree has an ability 30–60 drops liquid extract or 215 mg .6% aucubin to inhibit prolactin production. A double-blind, standardized extract or 175 mg .75% agnuside stan- placebo-controlled study done in 2005 was able to dardized extract per day examine the effect of a chaste tree preparation on 52 women with luteal phase defects due to Ginger (Zingiber Officinale). Ginger has elevated prolactin levels.14 The dose given was been shown to inhibit prostaglandin synthetase17 20 mg chaste tree extract daily for three months. and cyclooxygenase-2 (COX-2)18 enzymes believed After three months of treatment, prolactin release to be related to the altered prostaglandin-2 ratio was significantly reduced in those taking chaste associated with excessive menstrual loss.19 Pro- tree. The shortened luteal phase was normalized staglandins are hormone-like substances, and an as was the decrease in progesterone production. excess of prostaglandin 2s can cause increased pain In another study examining the pharmacology and inflammation. The most potent constituent of vitex (another term for chaste tree), serum appears to be gingerol, the pungent ingredient in prolactin levels were reduced via vitex’s natural the ginger. Inhibition of prostaglandin and prolactin-suppressive compounds, namely diter- leukotriene formation could explain ginger’s tradi- penes. These diterpenes have dopaminergic prop- tional use as an anti-inflammatory agent, and anti- erties and bind to the DA2-receptor protein, inflammatories are effective in reducing the flow which, in turn, suppressed prolactin release.15 from heavy and protracted menses. Chaste tree is the most important herb to normalize and regulate the menstrual cycle. Chaste Ginger tree is not a fast-acting herb; do not hesitate to use 1–4 g dry powder per day for semi-acute blood loss or it over a long period of time. In fact, results may ginger root extract (5%) gingerols 100 mg per day not be achieved until after four to six months. It is not an herb to be relied on for immediate relief, Dietary Kelp or Bladderwrack (Fucus and it will not be effective in reducing semi-acute Vesiculosus). A very small study of three women bleeding episodes. Human and animal studies demonstrated that dietary kelp may be effective in have determined chaste tree to be safe for most normalizing DUB by decreasing 17 beta-estradiol menstruating women. It is not recommended (one of the estrogens the body naturally produces) during pregnancy, although this is not an absolute and increasing progesterone. These pilot data sug- 10 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE gest that dietary bladderwrack may prolong the a good choice for both semi-acute situations and length of the menstrual cycle and exert anti- chronic recurring episodes of DUB. 20 estrogenic effects in premenopausal women. Uterine Tonics. In traditional herbal medi- Traditional Astringent Herbs. Astringent cine, uterine tone determines the ease of menstrual herbs form a large category of tannin-containing flow. If the uterus is hypertonic, then it may be dif- plants that are used to reduce blood loss from ficult to initiate menses in a timely manner. If the the reproductive tract as well as from the bowel, uterus is hypotonic, there may be heavy bleeding. stomach, respiratory tract, and skin. In the repro- In either case, improving uterine tone will tend to ductive tract, the astringent herbs are used to normalize and regulate menstrual bleeding. Two correct uterine or cervical bleeding. The astrin- categories of herbs are said to have the most effect gents most effective in uterine blood loss are on uterine tone and therefore bleeding. often high in tannins, but other constituents also Tonics That Regulate Uterine Tone. The fol- explain their mechanism of action. The following lowing are uterine tonics or amphoterics that reg- herbs are the major astringent and hemostatic ulate tone (both reduce excess tone and increase herbs used in gynecological problems: tone in states of laxity): With Tannins • Dong quai (Angelica sinensis): potent antico- • Yarrow (Achillea millefolium) agulant and hemostatic effects via platelet • Ladies’ mantle (Alchemilla vulgaris) aggregation23 • Cranesbill (Geranium maculatum) • Blue cohosh (Caulophyllum thalictroides) • Beth root (Trillium erectum) • Helonias (Chamaelirium luteum) • Greater periwinkle (Vinca major) • Squaw vine (Mitchella repens) Cranesbill. This astringent herb, high in • Raspberry leaves (Rubus idaeus) tannic acid, was relied on by early American Indi- • Life root (Senecio aureus) ans to treat diarrhea, dysentery, leukorrhea, and Life root, also known as ragwort, is a time- chronic menorrhagia, especially cases of prolonged honored “female regulator” that has been used bleeding. Cranesbill was used by early practition- consistently in traditional herbal medicine for ers of natural medicine (the eclectic physicians) to menstrual cramps, menorrhagia, suppressed men- achieve prompt and predictable results in cases of struation, and other disturbances of the reproduc- menorrhagia without any unpleasant side effects. tive tract. It is a classic uterine tonic that has been Without Tannins used to tonify a soft, less-than-firm uterus, includ- • Horsetail (Equisetum arvense) ing laxity of the uterine ligaments. It adds tone • Goldenseal (Hydrastis canadensis) and structure to the nervous and muscular struc- • Shepherd’s purse (Capsella bursa-pastoris) tures of the reproductive female organs and regulates the quantity of the monthly flow. Shepherd’s Purse. Shepherd’s purse is a mild Tonics That Stimulate Menstrual Flow. The astringent that contains saponins, choline, acetyl- following are uterine stimulants or emmenagogues choline, and tyramine, all likely to be helpful in (agents that stimulate menstrual flow) that female reproductive health.21 Chemical analysis increase tone or muscular activity and serve to ini- shows that it can coagulate blood.22 Its best use is tiate the onset of menses: in combination with other astringent and hemostatic herbs for uterine bleeding, particularly when • Squaw vine (Mitchella repens) there is extremely heavy flow. Shepherd’s purse is • Yarrow (Achillea millefolium) ABNORMAL UTERINE BLEEDING 11

• Chaste tree (Vitex agnus castus) Dosage for Botanicals • Pennyroyal* (Mentha pulegium) • Mugwort (Artemisia vulgaris) The herbs listed in the text with an asterisk (*) may • Blue cohosh (Caulophyllum thalictroides) be toxic if given in inappropriate doses, so correct dosing is very important. Use a botanical reference to Blue cohosh is a perennial herb that grows assure safe dosage. all over the United States, and it is the root or rhizome that is used medicinally. The chemical Essential oil of cinnamon: 1–5 drops every 3–4 constituents include alkaloids, saponins, phyto- hours Other herbs: Do not exceed 20 drops every 2 hours sterols, and many minerals. As an emmenagogue or 1 capsule every 4 hours if using a single herb. that promotes the onset of menstrual flow, it Several herbs may be used in combination, and in would seem odd to use it as a treatment for men- these cases it is important to consult a reference orrhagia. Yet, traditionally, blue cohosh, when book or an herbal practitioner to know the dose used with other astringent herbs, acts as a uterine limitations. tonic and in fact helps to regulate the menses and the amount of flow. Astringent and uterine tonic herbs can be Natural Progesterone. Cyclic bio-identical used in combination formulations and used for or natural progesterone that is given 12 days out weeks to several months. Use as a tea, liquid of the month (usually day 15 of the cycle to day extract, or powdered capsule. 26) can be used to correct infrequent menses, heavy menses, and sometimes intermenstrual Traditional Herbs for Semi-Acute bleeding. This therapy substitutes for what the and Acute Blood Loss body is not producing due to the lack of ovula- • Cinnamon* (Cinnamomum verum) tion. A woman must ovulate in order to produce • Life root (Senecio aureus) adequate levels of progesterone. Because natural • Canadian fleabane* (Erigeron canadensis) progesterone is biochemically identical to human • Greater periwinkle (Vinca major) • Shepherd’s purse (Capsella bursa-pastoris) Natural Bio-Identical Progesterone • Yarrow (Achillea millefolium) • Savin (Sabina officinalis) A dose of 200 mg is thought to be adequate to regulate abnormal bleeding. Natural progesterone is sev- Bio-Identical Hormones eral times less potent than a progestin (a synthetic Bio-identical hormones are made in a manufactur- substance). Even 400 mg per day of oral micronized ing laboratory and are derived from a compound progesterone may not work as well as 10 mg of found in either Mexican wild yam root or soy- medroxyprogesterone acetate (Provera). beans. The diosgenin plant compound from Mex- Oral dosage: 100–200 mg twice daily, given 7 to 12 ican wild yam or beta-sitosterol from soybeans is days per month for infrequent menses, menorrha- extracted from the plant and then used to make a gia, and, occasionally, intermenstrual bleeding Cream dosage: (product that contains at least 400 hormone, in this case progesterone, that is bio- mg progesterone per ounce) 1⁄4–1⁄2 tsp twice daily chemically identical to the progesterone in a for 12 to 21 days per month for cases of mild men- woman’s body. Sometimes these are called natural orrhagia, infrequent menses, and, occasionally, hormones, and other times they are called bio- intermenstrual bleeding identical hormones. Sublingual tablets: 50–75 mg twice daily for 12 to 21 days per month for cases of mild menorrhagia *May be toxic if given in inappropriate doses. See the dosage guidelines in this section. 12 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plans for Abnormal Uterine Bleeding

See the Resources section for formulation sources. • Oral micronized progesterone: 200–400 mg per day for 7–12 days, followed by a cyclic hor- Chronic Recurring Menorrhagia mone product for 21 days on and 7 days off • Bioflavonoids: 1,000 mg twice per day • If there is no change in 24 to 48 hours, high- • Vitamin A: 60,000 IU per day up to 3 months dose estrogens may be needed to stop the • Chaste tree (standardized extract): 175 mg per immediate bleeding, followed by a proges- day, or 1 tsp daily terone regimen. • Combination herbal product using astringents and uterine tonics; sample herbal tincture: Oligomenorrhea (Infrequent Menses) Yarrow: 2 oz • Chaste tree: .6–.75% standardized extract, one Helonias: 2 oz 175–215 mg capsule daily; or liquid extract, 1 Squaw vine: 2 oz Life root: 2 oz tsp daily 1 tsp twice daily • Combination herbal emmenagogue: Squaw vine: 11⁄2 oz • Consider natural progesterone cream, 1⁄4–1⁄2 tsp Yarrow: 1 oz twice daily, days 15–26 (day 1 is the first day Blue cohosh: 1 oz of your menses) Pennyroyal: 1⁄2 oz 20 drops every 2–3 hours Semi-Acute Menorrhagia • Natural progesterone cream • Bioflavonoids: 1,000 mg 2–3 times daily Apply 1⁄4 tsp 1–2 times daily, days 7–14 of cycle • Combination herbal products using astringents Apply 1⁄2 tsp 1–2 times daily, days 15–26 and uterine tonics; sample herbal tincture: Yarrow: 2 oz Polymenorrhea (Frequent Menses) Greater periwinkle: 2 oz Shepherd’s purse: 2 oz • Chaste tree: .6–.75% standardized extract, Life root: 2 oz one 175–215 mg capsule daily; or liquid 20–30 drops every 2–3 hours extract, 1 tsp daily • Natural progesterone cream: 1⁄4–1⁄2 tsp twice If you choose to use one of the more toxic daily, 21 days on, 7 days off (during menstrual herbs, such as cinnamon or beth root, be sure flow) not to exceed recommended doses. • Some cases may require higher doses of oral • Essential oil of cinnamon: 1–5 drops every 3–4 micronized progesterone. hours • Some cases may require a natural estrogen/natural progesterone formulation that requires more individualized dosing.

progesterone, it is generally very well tolerated by viable alternative therapy in premenopausal women. One study found that while traditional bleeding disorders.24 You may want to read much progestin treatments such as norethindrone can more on bio-identical hormones in Chapter 12. decrease estradiol, follicle-stimulating hormone, The disadvantages to the natural hormone luteinizing hormone, sex-hormone-binding include a short half-life (three to six hours) that globulin, and high-density lipoprotein choles- requires giving it two to three times a day. Natural terol, bio-identical progesterone offers the hor- progesterone can be delivered by injection, sub- monal benefits without these side effects and is a lingual tablets, rectal or vaginal suppositories, oral ABNORMAL UTERINE BLEEDING 13 capsules or tablets, and topical creams. Dosing is Oral contraceptives containing estrogen and dependent on the delivery system and the charac- progestin are also used to stop acute bleeding, teristic bleeding problems. When treating women although they may not be as effective as the high with DUB, the amount of progesterone given doses of estrogen alone. Three tablets of an oral must be adequate to convert the endometrium for contraceptive containing a progestin plus 35 mcg complete sloughing to avoid endometrial hyper- of estrogen taken every 24 hours (one tablet plasia. Continuous progesterone can be effective every eight hours) will usually provide sufficient in controlling menorrhagia. estrogen to stop acute bleeding while simultaneously providing progestin. Treatment is contin- Natural Estradiol. To control an acute bleed- ued for at least one week after the bleeding stops. ing episode, the use of natural estradiol should be The practitioner can choose from a variety of just as effective as one of the dosing regimens of equally effective treatment regimens. conjugated estrogens. These hormones are pre- The treatment of choice for chronic, stable scription items and should be administered by a anovulatory bleeding is a progestogen medication. practitioner qualified to use them. One high-dose Use either MPA or norethindrone (NE) in doses regimen would be 2 mg of estradiol every four of 5 to 10 mg daily or oral micronized proges- hours for 24 hours, a single daily dose for 7 to 10 terone (either compounded or Prometrium) 200 days, followed by oral micronized progesterone, to 400 mg daily for 14 days starting on day 14 of 200 mg per day for 7 to 12 days. the menstrual cycle. The patient can stop the med- CONVENTIONAL ications if she has begun menstruating before the MEDICINE APPROACH end of her progestogen. Nonsteroidal anti-inflammatory drugs The goals of conventional treatment for abnor- (NSAIDs) are also used to reduce blood loss, mal uterine bleeding are to control bleeding, pre- especially in women who have DUB but still have vent endometrial hyperplasia or cancer, prevent normal ovulation. When NSAIDs are taken during or treat anemia, and restore quality of life. When the episode of menorrhagia, the effect is a 20 to 50 the diagnosis is definitely DUB, it is preferable to percent reduction in blood loss. The following use medical, not surgical, treatments. anti-inflammatories are usually given for the first To control an acute bleeding episode, 10 mg of three days of menses, or throughout the menstrual oral conjugated estrogens (or the equivalent) flow, and seem to have similar effects: administered daily as 2.5 mg four times per day are usually effective. If bleeding is not controlled 1. Ibuprofen: 600 mg every 6–8 hours within the first 24 hours, higher doses (20 mg) may 2. Naproxen sodium: 550 mg every 6–8 hours be effective. Once the bleeding has stopped, oral 3. Mefenamic acid: 500 mg first dose, then estrogen therapy is continued at the same dosage 250 mg every 8 hours for a total of 21 days; the addition of a progestin, 4. Meclofenamate sodium: 100 mg every 8 such as medroxyprogesterone acetate (MPA), 10 hours mg daily, should be added for the last 7 to 10 days 5. Naproxen: 500 mg every 12 hours of those 21 days. Alternatively, 200 to 400 mg daily of progesterone may be substituted for the NSAIDs may be used alone in some cases or MPA. At the end of 21 days, both hormones are combined with an oral contraceptive or proges- stopped, at which time the patient should expect a togen. Other, more sophisticated medical regi- light “withdrawal” bleed. At this time, a strategy for mens may be used to intervene, including GnRH long-term management should be developed. agonists (Lupron), androgenic steroids (danazol), 14 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE or an antifibrinolytic agent. However, these because of the pain of the procedure. Ablation options have significant side effects, and their use technology continues to advance with the hopes is limited to women who fail to respond to other of developing a procedure that can be done in methods of drug management and who do not the office. want surgery. 3. Hysterectomy, surgical removal of the Progesterone-releasing IUDs (Mirena) are uterus, should be reserved for the woman with gaining interest because of their lack of systemic other indications for hysterectomy such as uter- side effects, duration of action of five years, and ine fibroids, uterine prolapse, or atypical hyper- 60 to 80 percent reduction in menstrual blood plasia. When a hysterectomy is done for flow. They also can suppress the growth of the bleeding problems there is usually no need to endometrium in oligo-ovulatory patients, thereby remove the ovaries. preventing hyperplasia or uterine cancer. There are basically three surgical options that SEEING A LICENSED PRIMARY may be considered in individual cases: dilation HEALTH-CARE PRACTITIONER and curettage (D&C), endometrial ablation, or (N.D., M.D., D.O., N.P., P.A.) hysterectomy. Changes in the pattern or amount of menstrual blood flow is one of the most common health con- 1. Dilation and curettage (D&C) can be both cerns of women. Even though many of these cases diagnostic and therapeutic. A D&C is the are of no serious concern, a woman with abnormal quickest way to stop bleeding; therefore, it is a bleeding distinctly different from her familiar his- treatment of choice in women with DUB who tory should do the cautious thing and be seen by suffer from anemia due to heavy menstrual a licensed health-care practitioner such as a natur- blood loss or who are acutely unstable. The opathic doctor (N.D.), medical doctor (M.D.), problem with a D&C is that it is only tempo- osteopathic doctor (D.O.), nurse-practitioner rary in most cases and does not cure the prob- (N.P.), or physician’s assistant (P.A.). After a thor- lem the majority of the time. One advantage, ough medical history is taken, a physical exam though, is that it can give the doctor tissue for and further laboratory testing and imaging may diagnosis. be requested not only to adequately diagnose the 2. Endometrial ablation is a procedure to cause of the problem but also to determine if destroy the endometrial tissue. It is highly pop- excessive blood loss has caused an anemic state. ular because of the ease of treatment, the suc- The most worrisome situation is an acute cess, and the low incidence of complications. bleeding episode. As stated earlier, bleeding that There are several types of ablations now: the meets or exceeds saturation of a super tampon or original roller ball or loop unipolar resection, a heavy pad every hour for six to eight hours or bipolar electrical vaporization method, a bipolar more requires medical intervention. Bleeding electrical mesh, a balloon filled with dextrose that is even more severe will require immediate water that is heated to 200 degrees Fahrenheit, medical attention to assess the need for a surgical free-flowing hot water, and a microwave and intervention and management of the dangers of cryo probe technology as well. The method acute blood loss. used depends on practitioner preference and A licensed naturopathic physician may work select uterine characteristics. All ablations in tandem with conventional medical colleagues require IV sedation or general anesthesia and to cooperate on an integrated approach to opti- may not be well tolerated in an office setting mize the patient outcome. AMENORRHEA CHAPTER 2

OVERVIEW rhea caused by low levels of estrogen, or hypo- Tr a ditionally, amenorrhea (absence of menstrual estrogenic amenorrhea, is associated with loss of bleeding) has been classified as either primary or bone mineral density and an increased risk later secondary. Primary amenorrhea means that no in life of osteoporosis and fractures. Lipid levels vaginal bleeding has ever occurred by the time of in the bloodstream are also negatively affected by expected initial onset (usually age 16). Secondary prolonged hypoestrogenic states, and this is asso- amenorrhea means that vaginal bleeding has pre- ciated with an increased risk of cardiovascular viously occurred but has now ceased—for three disease. Amenorrhea without ovulation is associ- months in a woman with a history of regular ated with an increased risk of endometrial hyper- cyclic bleeding or for six months in a woman plasia and uterine cancer because of the lack of with a history of irregular periods. In the United progesterone and the presence of what is called States, females normally experience the onset of an “unopposed” estrogen state. Polycystic ovarian their first menstrual period between the ages of syndrome (PCOS) is an example of this type 9 and 18. It has been estimated that the prevalence of amenorrhea. Characteristics of PCOS include of amenorrhea in the general U.S. female popula- obesity, hirsutism (abnormal hair growth), acne, tion during the reproductive years is 1.8 to 3 infertility, hypertension, and diabetes. percent, the prevalence in college-aged women is Evaluating and managing amenorrhea is best 2.6 to 5 percent, and amenorrhea may be seen in addressed with the medical knowledge of a quali- 20 percent of women reporting infertility. fied primary care practitioner. Sometimes a spe- Determining the cause of amenorrhea is one of cialist in endocrinology is necessary, to rule out or the most challenging tasks in gynecology. Causes consider an array of potential diseases and disor- of amenorrhea can be organized into four classifi- ders of the hypothalamus, pituitary gland, ovaries, cations: disorders of the vagina or uterus, disorders thyroid, and/or uterus. of the ovary, disorders of the anterior pituitary gland, and disorders of the central nervous system. THE NORMAL MENSTRUAL CYCLE The causes of primary amenorrhea are often very Normal menstruation results from a complex chain complex, and approximately 40 percent of all cases of events initiated in the central nervous system: are due to a chromosomal defect. Absence of a vagina is the second-most-common cause, fol- 1. The hypothalamus secretes gonadotropin- lowed by testicular feminization syndrome. Other releasing hormone (GnRH) that regulates causes of primary and secondary amenorrhea are pituitary function. often overlapping. 2. The anterior pituitary produces luteinizing The majority of amenorrheic young women hormone (LH) and follicle-stimulating hor- have very low levels of estrogen, and a minority mone (FSH) that govern ovarian function. will have subnormal, noncyclic estrogen levels The main action of LH is to stimulate syn- without progesterone due to a lack of ovulation. thesis of androgens by the theca cells in the This distinction is important in considering the ovary and progesterone synthesis by the long-term implications of amenorrhea. Amenor- corpus luteum. LH also induces ovulation, 15

Copyright © 2008 by Tori Hudson. Click here for terms of use. 16 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE which leaves behind the corpus luteum. The 2. Proliferative (follicular) phase: days 6–14 primary action of FSH is to stimulate the • Regrowth of endometrial tissue granulosa cells in the ovary to produce estro- • Secretion of FSH by the pituitary gland gen. Both the theca cells and the granulosa • Development in ovary of a mature cells are sources of androgens (such as testos- graafian follicle containing a mature egg terone) and estrogen. • Secretion of increasing amounts of estro- 3. The ovaries respond to these gonadotropins gen by graafian follicle by synthesizing the steroid hormones estradiol • Suppression of FSH when estrogen level and progesterone that affect uterine function. becomes high, leading to secretion of LH 4. The uterus has a cavity capable of endome- by pituitary gland trial thickening and shedding according to 3. Secretory (luteal) phase: days 15–28 the levels of ovarian hormones in the blood • Rupture of graafian follicle releasing egg (estrogen and progesterone), and an outflow (ovulation) starts the secretory phase tract (vagina) to allow the emptying of men- • Movement of egg through fallopian tube strual flow. to uterus • Formation of corpus luteum at site of rup- Phases of the Menstrual Cycle tured follicle The menstrual cycle can best be broken into • Production of progesterone by corpus three phases. luteum • Stimulation by progesterone of endome- 1. Menstrual phase (menstruation): days 1–5 trial cell growth • Estrogen and progesterone withdrawn • Significant decrease in progesterone level if before onset of menstrual flow implantation does not occur; menstrual • Shedding of endometrial lining phase then begins again

Figure 2.1 Normal Menstrual Cycle

FSH & Progesterone LH Estradiol 17-OHP IU/L pg/nl ng/ml 20 500 10 18 9 16 400 8 LH Progesterone FSH 14 7 12 300 6 10 5 8 200 4 63 4 100 2 21Estradiol 17-OH Progesterone 000 246810121416182022242628

Menses Ovulation AMENORRHEA 17

DIAGNOSING AND PREVENTION EVALUATING AMENORRHEA A good history is the most important part of the • Have adequate calories in the diet. medical evaluation to diagnose amenorrhea. The • Include adequate levels of dietary fat. • Keep regular daily eating habits. history will include evaluating for pregnancy, men- • Avoid being underweight. strual history, emotional stress, weight gain or • Avoid obesity. loss, alcohol use or abuse, dietary habits, exercise • Avoid excessive exercise. habits, medications, narcotics, drug abuse, acute or • Practice stress reduction and management. chronic illnesses, accidents or injuries, infertility, • Women with hypoestrogenic amenorrhea must be metabolic disease, immune system abnormalities, vigilant about prevention of osteoporosis and tuberculosis, hot flashes, breast discharge, head- coronary artery disease. aches, and family history. • Women with anovulatory amenorrhea must be A physical and pelvic exam will confirm the monitored for endometrial thickening and the most likely causes as suggested by the history. development of endometrial hyperplasia, a precancerous state, and endometrial cancer. During the pelvic exam, the practitioner will • Women who have been diagnosed with polycys- attempt to determine if there is an adequate estro- tic ovarian syndrome (PCOS), the normogo- gen effect on the cervix and vagina, check for the nadotropic anovulation state, must not only be size of the ovaries, assure the normalcy of the treated for current problems related to the PCOS, uterus and vagina, and observe for the presence or but they need assertive prevention for diseases absence of secondary sex characteristics (such as for which they are at higher risk, including breasts and pubic hair). The thyroid gland will also type 2 diabetes, high blood pressure, heart be checked, and laboratory tests will be chosen disease, endometrial cancer, and possibly breast selectively to document the suspected diagnosis. cancer. Due to the complexity of amenorrhea and the diverse array of causes, it is impossible to address each potential cause in this chapter. The guiding rule in the management of amenorrhea is to diag- KEY CONCEPTS nose before treating. The appropriate management depends not only on the diagnosis but also • Successful management of amenorrhea depends on the presenting problem. Each woman must on an accurate diagnosis. then be treated according to the specific causative • Amenorrhea is a symptom, not a diagnosis. factors involved. Consequently, in the discussion • The absence of menses in itself has no deleteri- of alternative treatment, we will largely focus on ous effect on health, but it may be a presenting four of the most common causes of amenorrhea: symptom of an underlying disorder that requires treatment. 1. Hypergonadotropic hypogonadism. The • A licensed primary health-care practitioner is pituitary secretes elevated amounts of its hor- needed to conduct a careful history, examina- mones, but the ovary does not respond. Exam- tion, and indicated tests. ple: premature ovarian failure. • The most common cause of secondary amenorrhea is pregnancy. 2. Hyperprolactinemia. The pituitary secretes • Prolonged amenorrhea that is hypoestrogenic too much prolactin. Examples: certain drugs, (hypergonadotropic hypogonadism or hypogo- pituitary tumors, hypothyroid disease. nadotropic hypogonadism) prior to menopause is 3. Hypogonadotropic hypogonadism. a risk factor for osteoporosis. Reduced secretion of FSH and LH that results in failure of the ovarian follicle to develop and, 18 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE hence, a lack of secretion of estradiol by the meticulous medical approach employing mind- ovaries. Examples: psychological stress, weight body-oriented perspectives. Specific dietary loss, genetic diseases. counseling may be warranted, and practitioners 4. Normogonadotropic anovulation. Normal may find themselves in the unusual position of FSH and LH, but the cyclic nature of the advocating an increase in cholesterol and other pulsed secretions is disrupted. The ovarian folli- fats in the diet and counseling patients to gain cles develop and estrogen is produced, but at weight or exercise less. Because stress disrupts the some stage the follicles do not fully mature. menstrual cycle, it is also important to provide Thus, there is no ovulation but there is no sign guidance about stress reduction. of estrogen deficiency; rather, there is a proges- The goal of a natural therapeutic treatment terone deficiency. Example: polycystic ovary plan for amenorrhea is to address the specific syndrome. underlying cause as would conventional medicine, while also taking a more constitutional and OVERVIEW OF holistic approach to treatment. Even in cases ALTERNATIVE TREATMENTS where something specific such as an elevated pro- A licensed alternative primary care practitioner lactin level may be the cause, the practitioner such as a naturopathic physician must first make would want to address the mental and emotional an accurate diagnosis as to the cause of the amen- component, support the digestion, provide toni- orrhea, utilizing a medical history, physical exam, fying and nutritive support to the reproductive and possible laboratory testing. Naturopathic system in general, and more. This organ-specific physicians often see patients who are on extreme as well as constitutional approach is a common diets due to some other health concern; sometimes theme in many alternative medicine disciplines, these diets are inappropriate for that individual and especially naturopathic medicine. and are the cause of the amenorrhea. Insufficient The natural therapies presented in this chap- calories and insufficient dietary fat and cholesterol ter deal with these four general states: may be the culprit in some of these cases. Other 1. Premature ovarian failure (See Chapter 12 health-conscious individuals may have become for more in-depth information and treat- too thin with a combination of diet and exercise, ment.) and they may have acquired amenorrhea because 2. Hyperprolactinemia they have too little body fat. It is unlikely that 3. Inadequate estrogen production overexercise alone will cause amenorrhea; it usu- 4. Chronic lack of ovulation, including poly- ally takes a combination of low body fat and heavy cystic ovary syndrome (PCOS) exercise to induce amenorrhea. In other cases such as polycystic ovarian syn- Keep in mind that causes such as thyroid disor- drome (PCOS), about 50 to 60 percent of women ders, tumors, systemic diseases, genetic disorders, will be overweight. In these cases, a 10 percent and others will require therapies to specifically weight loss can lead to ovulation and also decrease address those underlying problems, which are insulin resistance. A diet lower in starchy carbs and beyond the scope of this book. higher in healthy protein is an important strategy for women with PCOS, whether they are over- Nutrition weight or not. Both weight loss and obesity can be associated A holistic approach to treatment requires with amenorrhea. A range of weight-loss prob- exploring the mental, spiritual, emotional, and lems are associated with amenorrhea, including physical aspects of the patient integrated with a crash diets, malnutrition, and life-threatening AMENORRHEA 19 anorexia nervosa. Anorexia nervosa occurs pri- insulin, and glucose intolerance, conditions that marily in young white middle- to upper-class often co-occur with obesity and polycystic ovar- women under age 25, yet has also been known to ian syndrome, are associated with amenorrhea occur in young men and middle-aged women. and oligomenorrhea (infrequent menses).2, 3 The family situation of a young woman with Usually, oligomenorrhea and chronic anovula- anorexia is very often success-achievement- tion caused by hormonal abnormalities is the appearance oriented. The pattern usually starts cause of the menstrual irregularity in women with a diet to control weight and a fear of excess with significant amounts of excess body fat.2 A weight when in fact the weight being gained is reduction in body weight by reducing calories, due to normal maturing. There is often a preoc- increasing physical exercise, and possibly other cupation with food that may manifest itself by weight-management interventions will result in large intakes of lettuce, raw vegetables, and other beneficial changes in the hormonal profile, low-calorie foods. Other manifestations may be including a marked reduction of androgenic hor- chaotic eating habits and eating times, radical mones and their effects.1 A reduction of weight diets, missed meals, and bingeing episodes. by even as little as 5 to 10 percent can not only Bulimia is a syndrome of episodic and secre- restore regular menses, but also improve fertility.4 tive binge eating followed by self-induced vomit- Some women may have low body weight ing, fasting, or the use of laxatives and diuretics. but do not have an eating disorder or exercise- Bulimic behavior is frequently seen in about half induced amenorrhea. This may be a metabolism of women with anorexia nervosa. Body weight in issue, a hereditary factor, or a diet that is ex- “pure” bulimics fluctuates but does not fall to the tremely low in fat although not low in calories. low levels seen in anorexics. Women who take in insufficient calories, such as Teenagers with low body weight, amenorrhea, strict vegetarians who eat no animal products or and overachievement (excellent grades and many others with extreme diets, may have insufficient extracurricular activities) need astute evaluation dietary fat and low cholesterol. Adequate choles- for an eating disorder. Psychological counseling, terol is needed to manufacture hormones. If no consistent support, and monitoring for calorie cholesterol is found in the diet and the liver is intake will be needed to break the established pat- not manufacturing adequate cholesterol, these terns. The earlier the recognition of the problem, women may have amenorrhea due to insufficient the more successful the intervention. Family hormone levels. Measuring the cholesterol level members, friends, and health-care practitioners can be telling in such cases. If cholesterol is low should pay particular attention to weight and diet (below 120), a change in vegetarian philosophy in young women with amenorrhea. will probably be necessary so that some animal Obese women exhibit several abnormalities products can be included in the diet in order to in their hormone profile. Elevated serum concen- raise the cholesterol levels. trations of androstenedione, testosterone, and Sometimes it is difficult to find the best nutri- DHEA-sulfate are associated more closely with tional program for one’s body type and lifestyle. the pattern of fat distribution (abdominal vs. In these cases, nutritional counseling and nutri- hips, in particular) than to the body fat mass.1 tional analysis with a qualified practitioner can High levels of these hormones, called androgens, be very helpful. No one diet plan is right for are known to be a cause of menstrual irregulari- everyone. Not everyone needs to eat from all the ties including amenorrhea, hirsutism (abnormal food groups, not everyone can be a vegetarian, body hair growth), and other metabolic distur- and not everyone responds well to a high-protein bances. In addition, type 2 diabetes, elevated or high–complex carbohydrate diet. 20 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE In addition to proper food choices, another orrhea in long-distance runners was associated basic general principle for good nutrition is reg- with hypercarotenemia, but that association was ularity. Just as going to bed and rising at regular disproved, and no difference in carotene levels times with a certain amount of sleep assures ade- was observed.11 quate energy and vitality, regular mealtimes and I found no reference to amenorrhea or men- consistency in eating habits lead to good diges- strual irregularities associated with taking carotene tion and absorption of nutrients necessary for supplements, and, as of this writing, I don’t believe normal physiology. amenorrhea has been reported as a side effect of Not all advice on nutritional habits for beta-carotene ingestion. However, I will probably women with amenorrhea is related to dietary encourage women who are experiencing signifi- fat, calories, body weight, or eating disorders. cant weight loss and amenorrhea to eat lesser Some nutritional guidance is relevant to the pre- amounts of carotene foods for the time being. I vention of osteoporosis, a potential consequence would also be inclined to reduce their vitamin A of amenorrhea. Please see Chapter 14 for more and carotene supplementation if they were on information on preventing osteoporosis. high doses for some other medical reason.

Supplements Calcium. One of the serious long-term consequences of amenorrhea due to premature ovar- Vitamin A and the Carotenes. Carotenemia, ian failure or lower production of estrogen an abnormal elevation of plasma carotene levels, (hypothalamic amenorrhea) is a lower bone den- may result from an excessive ingestion of carotene- sity and an increased risk for osteoporosis and rich vegetables, anorexia, and impaired ability of fractures later in life. Even when calcium intake the body to metabolize carotenes.5–7 Carotenemia is the same between amenorrheic women and has been linked with menstrual dysfunction and women who menstruate normally, there is a amenorrhea in some women, generally in associa- decrease in calcium absorption and an increase in tion with weight loss. In 1968, elevated carotene calcium excretion in estrogen-deficient women. levels were observed in 9 of 12 women with There is ample evidence that a lack of estrogen anorexia nervosa who did not ingest excessive increases the daily calcium requirement.12 As a amounts of carotenes.8 An additional study also result, I recommend a higher-than-normal daily found that patients with amenorrhea and weight intake (1,200 to 1,500 mg per day) of either cal- loss had carotenemia.9 Another group of re- cium carbonate or calcium citrate to maintain searchers found elevated serum carotene levels in calcium balance in low-estrogen states in women women with anorexia nervosa, but not in women of reproductive age. (For more information on with normal or abnormal menstrual function.7 It osteoporosis, please see Chapter 14.) is thought that mobilization of fat stores secondary to weight loss might be responsible for hypercarotenemia in women with anorexia nervosa. Calcium Carbonate or Calcium Citrate or Combination In 1971, a small study examined six women with elevated serum carotene levels who had 1,200–1,500 mg per day excessive intake of carrots or pumpkins.10 The researcher described what he called “golden Additional Vitamins and Minerals. Many ovaries” and noted that amenorrhea developed in other minerals and nutrients affect bone density the two younger patients and irregular menstrual and are relevant to the prevention of osteoporo- bleeding in the four older patients. For some sis in amenorrheic women. Magnesium, man- time it was thought that exercise-induced amen- ganese, zinc, copper, boron, vitamin K, vitamin AMENORRHEA 21 D, and other nutrients determine bone health, increased, and FSH values either did not change each in their own way. In Chapter 14, I discuss or decreased slightly. this in detail. Chaste tree also inhibits prolactin release by the pituitary gland, particularly when elevated Botanicals prolactin is caused by stress, by binding dopa- Chaste Tree (Vitex Agnus Castus). Chaste mine receptors and then inhibiting prolactin tree is probably the best-known herb in all of release in the pituitary.17, 18 Since elevated pro- Europe for hormonal imbalances in women. Since lactin levels cause some cases of amenorrhea, at least the time of the Greeks, chaste tree has been chaste tree is also indicated for these cases. A used for the full scope of menstrual disorders, double-blind, placebo-controlled study examined including amenorrhea. Chaste tree acts on the the effect of a chaste tree (vitex) preparation on 52 hypothalamus and pituitary glands by increasing women with luteal phase defects due to hyperpro- LH production and mildly inhibiting the release lactinemia (elevated prolactin levels).19 The daily of FSH. The result is a shift in the ratio of estro- dose of the extract was 20 mg, and the study gen to progesterone, in favor of progesterone.13 lasted for three months. Prolactin release was sig- Chaste tree stimulates ovulation, which in turn nificantly reduced in the vitex group. The short produces progesterone. Thus, chaste tree indi- luteal phase (second half of the cycle) was normal- rectly raises progesterone levels,14 an effective ized, and the decreased progesterone production treatment for some cases of amenorrhea. was normalized. No side effects were noted, and If we were to give progesterone hormone for two women became pregnant. several days, stop, and then a menses occurs, this When using chaste tree, don’t expect immedi- indicates an intact reproductive system that lacks ate results. It’s not the same as giving proges- cyclicity and ovulation, or at least regular cyclic terone, even natural progesterone. Chaste tree is ovulation. It suggests that the body is producing more of a medium-range plan; usually it begins enough FSH to stimulate the ovaries and that the to take effect after three or four months when ovaries can develop follicles. Furthermore, it given daily. indicates that follicular production of estrogen is sufficient to cause the lining of the uterus (endo- Chaste Tree metrium) to grow and that the sloughed endo- 40 drops tincture or 175 mg .6% aucubin standardized metrium is able to pass through the cervical extract per day opening and the vagina. This tells us that the problem most likely is a dysfunction in the hypo- Black Cohosh (Cimifuga Racemosa). Black thalamus or pituitary. The ability of chaste tree to cohosh has become one of the most significant modulate the hypothalamus or pituitary then women’s herbs in all of botanical medicine. Also makes this herb an obvious choice. known as snakeroot or rattleroot, this plant The first major study on chaste tree was belongs to the buttercup family and is indigenous published in 1954.15 Subsequent studies have to the eastern part of North America. The native continued to prove its effectiveness. In a study peoples of Canada and America used black cohosh published in 1990, 20 women with secondary for many different indications, such as uterine amenorrhea were admitted to a six-month study pains during menses and childbirth, rheumatism, using chaste tree liquid extract at 40 drops rattlesnake bites, and general malaise. Black daily.16 At the end of the six-month study, 10 out cohosh was introduced to Western gynecology in of the 15 women had menstrual cycles. Testing the middle of the eighteenth century in the treat- showed that values for progesterone and LH ment of menopausal symptoms.20 22 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE The exact mechanism of how black cohosh ance to high altitude sickness, fatigue, depres- works has yet to be elucidated. We attribute most sion, anemia, impotence, gastrointestinal ail- of its gynecological effects to its “estrogen-like” ments, infections, and disorders of the nervous action, yet recent research has shown that black system. The folklore surrounding rhodiola led to cohosh does not contain phytoestrogens, nor does the first investigations in its phytochemistry in it change hormone levels such as estradiol, LH, the early 1960s, when scientists identified adap- FSH or prolactin.21–23 The primary constituents in togenic compounds in its roots. These adapto- black cohosh extract are glycosides, particularly gens, believed to help the body adapt to stress by the triterpene glycosides, mainly cimicifugoside supporting the adrenal glands and endocrine and actein, which are assumed to interfere with system, as well as the antioxidant and stimulating pituitary gland receptors and the hypothalamus. compounds that were later discovered in rhodi- Other characteristic constituents are the flavo- ola, are responsible for its medicinal properties. noids, resins, volatile oils, fatty acids, tannins, Animal studies looking at the effect of rhodi- alkaloids, cimicifugin, and salicylic acid. Although ola on thyroid function, adrenal function, and the constituents in black cohosh may be able to ovarian egg maturation have raised interest in bind to receptors in the pituitary or hypothala- rhodiola for endocrine problems in humans. mus, these constituents do not seem to be able Forty women suffering from amenorrhea (loss of to bind to receptors in target organs. Older menstrual cycles) were given 100 mg of rhodiola research showed the effects of a black cohosh twice daily for two weeks or an injection for 10 preparation on LH and FSH secretion in meno- days. Remarkably, normal menses were restored pausal women. After a treatment of two months, in 25 women, 11 of whom became pregnant.28 LH (but not FSH) levels were significantly Physicians have reported cases of women who reduced in the black cohosh–treated group.24 had failed to conceive with standard fertility There have been many studies using black drugs, who then became pregnant within several cohosh preparations in menopausal women. months of beginning Rhodiola rosea extract. For These studies and the further use of this plant in treatment, look for extracts that are standardized menopausal women will be discussed in much to contain 3 percent rosavin. detail in Chapter 12. For women who have amenorrhea due to hypoestrogenic states, a state similar Rhodiola (3% Rosavin) to menopause, black cohosh will be important in 200 mg per day (or 100 mg twice daily) relieving some symptoms. Recent studies even indicate that black cohosh may decrease risk fac- Maca (Lepidium Peruvianum). Maca is a tors associated with menopause such as osteoporo- root vegetable, in the same family as turnips and sis and cardiovascular disease and may even be broccoli, which grows at high elevations, native to effective in preventing bone loss.25–27 the high Andean plateaus of Peru. It has been used traditionally by native Peruvians as both a food Black Cohosh and medicine. It has historically been used for a 40–80 mg standardized extract twice daily variety of purposes, including hormone balancing, thyroid function, sexual function, PMS, meno- Rhodiola. Rhodiola, also called golden root, pause, and as a tonic for healthy aging. has enjoyed centuries of use in Eastern Europe, A recent study proved maca’s effectiveness in Scandinavia, and Asia. Traditionally, this herb treating women with amenorrhea due to hypo- was used in folk medicine to increase physical estrogenic states, and especially premature ovarian endurance, work productivity, longevity, resist- failure. In a study of 20 healthy menopausal AMENORRHEA 23 women in the early phase of their menopause, Phytoestrogens. Phytoestrogens are by and maca (2,000 mg per day) was given for up to large nonsteroidal hormone-like constituents eight months and was shown to lower follicle- found in over 300 medicinal and edible plants. stimulating hormone (FSH) (higher levels of With the currently available evidence, soybeans FSH are a measure of low estrogen production are probably the richest edible source of phyto- from the ovaries) and increase luteinizing hor- estrogens. Some plant compounds, such as lig- mone (LH) (elevated LH is necessary to stimu- nans, found in flaxseed, are not phytoestrogens late ovulation), resulting in increases in both but are converted to estrogens in the intestines. estrogen levels and progesterone levels.29 These There are many herbs that contain phytoestrogen results would seem to suggest that maca, depend- compounds and have a role in amenorrhea. They ing on the length of use, could act as a hormonal support the reproductive cycle and relieve meno- toner and stimulate the production of estrogen pausal symptoms in women who are appropri- and progesterone. ately menopausal (see Chapter 12) as well as women who are amenorrheic and prematurely Maca menopausal. These herbs include: Four 500-mg capsules (2,000 mg) per day • Alfalfa (Medicago sativa) • Dong quai (Angelica sinensis) Traditional Herbs • Flaxseed (Linum usitatissimum) • Ginseng (Panax ginseng) Uterine Stimulants. Uterine stimulants or • Hops (Humulus lupulus) emmenagogues increase tone or muscular activ- • Licorice (Glycyrrhiza glabra) ity and serve to initiate the onset of menses and • Red clover (Trifolium pratense) stimulate reproductive function. Most important are the herbs that cause shedding of the endo- Progesterone Precursors. Diosgenin and metrium and stimulate normal menstrual cycles sarsasapogenin can be converted in the labora- in the absence of pregnancy. tory to various hormones, including progesterone, which in turn can be converted to adrenal • Squaw vine/partridgeberry (Mitchella repens) steroids and then to testosterone or estrogens. • Yarrow (Achillea millefolium) Even though diosgenin from plants is used by • Chaste tree (Vitex agnus castus) pharmaceutical companies to synthesize various • Pennyroyal* (Mentha pulegium) hormones, there is very little scientific informa- • Mugwort (Artemisia vulgaris) tion on diosgenin-containing plants and their • Water pepper (Polygonum hydropiper) relationship to human metabolism. A number of Water Pepper.30 In a medical journal of 1846, herbs contain diosgenin or sarsasapogenin: Dr. Thomas Ogier, a surgeon and obstetrician, • Bloodroot (Sanguinaria canadensis) 31 published an herbal approach for amenorrhea. • Blue cohosh (Caulophyllum thalictroides) He maintained that administering a tincture of • Fenugreek (Trigonella foenumgraecum) water pepper successfully treated a case of obsti- • Sarsaparilla (Smilax officinalis) nate amenorrhea. Exactly how the water pepper • Wild yam (Dioscorea spp) works is not known. • Yucca (Yucca spp) Special Herbal and Supplemental Consid- *Important caution: Do not use essential oil of pennyroyal erations for Polycystic Ovarian Syndrome. internally in any situation. For PCOS, include herbs that will increase 24 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE sex-hormone-binding globulin. This will bind up will induce complete secretory changes in the some of the excess androgens secreted by the endometrium and induce a menses in a woman ovarian follicles. whose uterus has been adequately stimulated by estrogen. Lack of vaginal bleeding after the prog- • Nettle root esterone challenge suggests either inadequate • Green tea priming of the endometrial lining, absence of an •Soy endometrial cavity, or some kind of obstruction. • Flaxseed If no withdrawal bleeding occurs after the Other herbs and nutrients can improve insulin progesterone challenge, then it is important to use sensitivity and PCOS: a birth control pill—generally one that contains at least 30 mcg of ethinyl estradiol, for 21 days. At • Chromium the end of these 21 days, withdrawal bleeding • Fenugreek powder should occur within 14 days; even spotting is suf- • Vitamin C ficient to count as withdrawal bleeding. Absence • Bitter melon of uterine bleeding under these circumstances indicates uterine end-organ failure that may result Licorice can lower serum testosterone in women from congenital malformation of the uterus and and saw palmetto can inhibit the conversion of vagina or from distortion of the endometrial cavity testosterone to dihydrotestosterone (a stronger by intrauterine adhesions due to tuberculous form of testosterone). By inhibiting this conver- endometritis, also called Asherman’s syndrome. If sion, we can maybe modestly decrease testosterone- bleeding does occur after the oral contraceptive induced hair loss and acne. pill, then the likely diagnosis is hypothalamic • Licorice amenorrhea, after excluding a pituitary tumor. • Saw palmetto The woman who is hypoestrogenic and is not a candidate for induction of ovulation requires Bio-Identical Hormones hormone replacement therapy. In young women, Bio-identical, also known as natural, proges- especially those in their 20s and 30s, the best terone can be used for both diagnosis and treat- approach is most likely to take oral contracep- ment of amenorrhea. Progesterone-induced tives (OCs). Hormone replacement therapy, menses indicates that there are adequate estrogen whether bio-identical hormones or conventional levels and that anatomical problems causing hormone replacement, could potentially be used obstruction of the outflow of blood are not pres- in the usual doses for normal-aged menopausal ent. In these instances, the progesterone chal- women. However, these doses are considerably lenge is an effective means of diagnosis. lower than the body’s normal level in a young The progesterone challenge test is considered reproductive-aged woman and considerably positive if uterine bleeding (even a few days of lower than the dose of hormones in oral contra- spotting) occurs and correlates with a serum ceptives. As these lower doses may not be ade- estradiol level of 40 g/mL or higher. Onset of quate for bone protection at this young age, my menstruation after intramuscular injection of recommendation is to use a 20 to 30 mcg oral 150 mg of progesterone in oil suggests that contraceptive pill for women in their 20s and 30s anovulation is the most likely explanation of the who have hypothalamic amenorrhea or prema- amenorrhea. Oral micronized progesterone ture ovarian failure. (Smokers older than 35 will (OMP) (also called oral natural progesterone) need to consider other options, most preferably administered for seven days at 400 mg per day to stop smoking.) AMENORRHEA 25 Younger women who insist on using alterna- tional therapies that induce ovulation such as tive medicine need to fully understand their risks chaste tree extract. in premature states of insufficient hormone production. If the herbal, nutritional, and lifestyle Exercise interventions are not sufficient to stimulate the Amenorrhea in the female athlete is associated menstrual cycle, they must understand that bone with reduced caloric intake and strenuous exer- loss in amenorrheic women shows the same pat- cise, which leads to low estrogen and is associated tern over time as that seen in postmenopausal with stress fractures, osteoporosis, and a potential women.32 The loss is most rapid in the first few increase in the risk of premature cardiovascular years, emphasizing the need for early treatment. disease.33 If bio-identical hormones are your choice as Most cross-sectional studies suggest that an alternative to OCs, then the following pre- female competitive athletes, whether runners34–39 scription, called bi-est (for bi-estrogen), would or bodybuilders,40, 41 have increased incidence be considered a higher-than-average hormone of menstrual cycle disturbance, shorter luteal replacement dose for menopausal women: estriol phases, and amenorrhea than do sedentary con- 2 mg/estradiol 0.5mg/progesterone 100 mg; one trols. Because of subject self-selection and conse- pill twice daily, for three weeks on and one week quent oversampling, results of these studies must off. Beginning medication on the first of every be interpreted with caution.42 Prospective studies month establishes an easily remembered routine. have found no hormonal changes in women fol- Some practitioners use a tri-estrogen formulation lowing one year of endurance training43 and, up instead of the bi-estrogen formulation. In this to 1994, had not detected induction of second- case, the formula would be estriol 2 mg/estradiol ary amenorrhea by exercise alone.42 0.250 mg/estrone 0.250 mg/progesterone 100 In her excellent review, Bonen states that sec- mg; one pill twice daily, for three weeks on and ondary amenorrhea “is difficult to induce by exer- one week off. cise alone.”42 She concludes that some of the factors Menstruation generally occurs within three thought to be associated with exercise-induced days after the last pills, the 28th day of each amenorrhea—type, duration, intensity of exercise, month. Bleeding that occurs at any other time age of menarche, training before menarche, and may indicate that the body’s own function has training history—remain speculative and that, in returned. The natural hormone replacement pro- fact, little is known about the true incidence of gram should then be discontinued and the secondary amenorrhea in athletic populations. patient monitored for the return of ovulation. The higher incidence of secondary amenorrhea Natural progesterone creams may be used in detected in competitive athletes appears related to selected cases to help maintain a monthly cycle metabolic factors. In weight lifters and body- in women with anovulatory amenorrhea. Some builders, the appearance of luteal-phase distur- women only need this monthly lower-dose bances and oligo- or amenorrhea is directly related hormone support during the second half of a to drastic reduction in caloric intake prior to com- monthly cycle. The typical dosing recommenda- petition combined with increases in strenuous tions are from one-quarter to one-half teaspoon exercise. For example, Sandoval found that female applied to the palms, inner forearms, and chest bodybuilders, examined for a period of 48 hours twice daily from day 15 to day 26. This cycle can before competition, achieved a degree of leanness be repeated. In the event that menstruation does similar to their male counterparts.44 Kleiner found not occur, it may be necessary to return to the in female bodybuilders, competing at the 1988 estrogen/progesterone plan and/or herbal/nutri- National Physique Committee’s Junior USA 26 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Bodybuilding Championships, a 9.8 percent body The hypoestrogenic state that predisposes fat (males, 6.0 percent).45 In a group of female postmenopausal women to cardiovascular disease bodybuilders studied for one month pre- and post- is similar to that of the amenorrheic athlete and, competition, Walberg-Rankin detected a twofold therefore, so is the cardiovascular risk. Specifi- increase in caloric intake and a tenfold increase in cally, amenorrheic athletes have been shown to fat intake postevent as compared to pre-event.41 have elevated LDL and total cholesterol, Furthermore, these unhealthy practices are fol- impaired endothelial function, and increased lowed by college-age women who compete in lipid peroxidation.54, 55 Though this phenome- bodybuilding events.46 In this context, it is not non warrants further study, present data suggests surprising that in Walberg’s study, 86 percent of that the risk of premature cardiovascular disease female competitive bodybuilders not on birth deserves attention in monitoring and treatment control pills reported menstrual dysfunction, and of these women. in Kleiner’s, 81 percent of female elite body- Finally, as shown by Bonen, menstrual distur- builders had contest-related amenorrhea for one or bances are quite common in the general popula- two months precontest. tion of sedentary women. Different factors— The picture is similar for competitive female weight change, starvation, crowding, travel, com- runners whose caloric intake is inadequate or munal living, exercise, and severe stress of any falls below the constant energy demanded by kind—have been implicated in altered menstrual their sports. Time and again, menstrual cycle dis- cyclicity.42 Ronkainen and colleagues found turbances in these populations have been shown increased abnormalities in the menstrual cycles to be related to inadequate caloric intake com- of women during the short sunlight days of bined with strenuous, abrupt increases in run- fall.56 Thus, amenorrhea appears to have multiple ning distances.34, 42, 47–49 Amenorrhea usually is etiologic relationships. Inappropriate exercise is not seen in athletes with a high percentage of only one of them. body fat.49 Since the cause of amenorrhea and Exercise Recommendations. If a woman has other menstrual disturbances is linked to energy documented secondary amenorrhea not due to deficiency, there is no justification for fears that pregnancy, a careful history of eating and exercis- exercise itself is unhealthy for women.50 ing habits is critical. In addition, her body weight As mentioned earlier, amenorrheic athletes and percentage body fat should be ascertained show dangerous reductions in mean trabecular and compared to the normal ranges for her body bone density as compared to eumenorrheic coun- build and age. For those women with amenor- terparts (42 percent).51 Exercise may intensify rhea due to hypoestrogenic states, a bone densit- these effects48 as well as low calorie intake itself. ometry test, called a DEXA scan, particularly of The effects of insufficient caloric intake on bone the lumbar spine and proximal femur, is highly mineral density likely represents an estrogen- desirable. independent mechanism for bone loss; exercise- In cases where the history and tests recom- associated amenorrhea alters additional hormones mended indicate inadequate calorie consump- that play an important role in modulating bone tion, a bone mass density below normal range, turnover and bone mineral density in these and body fat less than 15 percent, the recom- women.52 A study of amenorrheic ballet dancers mended course is as follows: treated with estrogen plus progesterone replacement demonstrated that there was no significant • Adapt diet to individual needs; particularly improvement in bone mineral density even in those emphasize protein, calcium, magnesium, that resumed menses.53 vitamin D, zinc, copper, and chromium.57 AMENORRHEA 27 • Reduce or stop intensive training, particu- five hours per week is necessary to improve larly running, until cycling resumes. insulin resistance and lose weight. • Modify type of exercise. Instead of running, do moderate walking (30 minutes per day) CONVENTIONAL and add a regular program of moderate MEDICINE APPROACH weight lifting for 30 minutes, three times Successful management of amenorrhea depends on per week. an accurate diagnosis. A careful history and exami- • Avoid competition in sports, on the job, and nation and simple laboratory investigations will elsewhere. most likely yield a diagnosis that allows one to offer appropriate treatment in the majority of cases. A For those women who have PCOS and are physical exam should assess the signs of secondary overweight, regular and preferably almost daily sexual characteristics (such as breast development aerobic exercise in the range of two and a half to and the presence or absence of normal or abnormal

Sample Treatment Plans for Amenorrhea

See the Resources section for formulation sources. roid, adrenal, and ovarian tissue. (Each woman is unique and requires an individualized approach.) Premature Ovarian Failure Hyperprolactinemia Diet: A whole foods diet using plenty of grains, beans (especially soybeans), fruits, vegetables Diet: A whole foods diet using plenty of grains, (especially dark leafy greens), nuts and seeds beans (especially soybeans), fruits, vegetables (especially flaxseed), and fish (salmon, tuna, hal- (especially dark leafy greens), nuts and seeds ibut, sardines) (especially flaxseed), and fish (salmon, tuna, hal- Exercise: Regular aerobic and weight-bearing exer- ibut, sardines) cise 30 to 60 minutes, 4 to 7 days per week; Exercise: Moderate exercise 150 minutes per week weight/strength training 2 days per week Chaste tree extract: 40 drops or 175 mg .6% aucu- Mineral supplementation: Calcium/magnesium/ bin standardized extract per day boron/vitamin D/other trace minerals and nutrients (see Chapter 14) Hypoestrogenic States (Hypothalamic Consider oral contraceptives with 30 mcg of Amenorrhea) ethinyl estradiol: Estriol 2 mg/estradiol 0.5 mg/ These states are often associated with weight loss, OMP 200 mg; 1 pill twice daily, 3 weeks on and 1 psychological states, and anorexia nervosa. week off Diet: Consider bio-identical hormones: Estriol 2 mg/ estradiol 0.5 mg/progesterone 100 mg; 1 pill twice Increase calories, dietary protein, fat, and daily, 3 weeks on and 1 week off carbohydrates. Consider short-term trial (less than 6 months): Consume regular meals using whole foods. Avoid extreme dieting. Black cohosh extract: standardized extract, Increase soy foods and flaxseed. 40–80 mg twice daily Maca: 2,000 mg per day Lifestyle: Rhodiola: 3% rosavin, 200 mg per day Counseling (for eating disorders) Polyglandular products: To stimulate the hypothala- Stress management counseling and practices mus/pituitary/ovarian feedback mechanisms, use Reduce exercise from excessive to moderate bovine extracts of combinations of pituitary, thy- (continued) 28 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plans for Amenorrhea (continued )

Mineral supplementation: Calcium/magnesium/ ful in this situation to reduce the hyperinsulinemia boron/vitamin D/other trace minerals and nutrients and provide better weight management. Increase (see Chapter 14) soy foods and flaxseed. Emphasize whole grains, Oral contraceptives with 30 mcg of ethinyl fruits, vegetables, nuts, seeds, fish (salmon, estradiol tuna, sardines, halibut), organic low-fat meats Consider bio-identical hormones: Estriol 2 mg/ (chicken, turkey, beef, buffalo, elk, deer), low-fat estradiol 0.5 mg/OMP 100 mg (not 200 mg); 1 pill dairy products, eggs, and beans. twice daily, 3 weeks on and 1 week off Chaste tree extract: 40 drops or 175 mg .6% aucu- Consider short-term trial (less than 6 months): bin standardized extract per day Black cohosh extract: standardized extract, Rhodiola: 3% rosavin, 200 mg per day 40–80 mg twice daily Green tea extract: 500 mg per day Maca: 2,000 mg per day Nettles root: 600 mg per day Rhodiola: 3% rosavin, 200 mg per day Saw palmetto extract: 400 mg per day Soy isoflavones: 50–100 mg per day Polyglandular products: To stimulate the hypothala- Flaxseed: 1–2 tbsp per day mus/pituitary/ovarian feedback mechanisms, use Chromium: 500–1,000 mcg per day bovine extracts of combinations of pituitary, thy- Fenugreek powder: 24 g per day roid, adrenal, and ovarian tissue. (Each woman is Oral micronized natural progesterone: 200–400 mg unique and requires an individualized approach.) per day for 12 days per month 1 Chronic Anovulation Due to PCOS Natural progesterone cream (20 mg per ⁄4 tsp): 1⁄4–1⁄2 tsp twice daily, days 16–25. Or 1⁄4 tsp 1 or Diet: Reduce carbohydrates (80 g per day) and 2 times daily, days 7–14; 1⁄4–1⁄2 tsp twice daily, increase protein in the diet (60 mg or more per days 15–26 day). Diets such as the Zone Diet can be very help-

body hair). Pelvic ultrasound might be helpful in medications and regimens are discussed earlier in determining whether the ovaries are enlarged with this chapter and also in Chapter 12. Oral contra- small, peripherally located follicular cysts indicative ceptives may also be used and may even be an of polycystic ovary syndrome (PCOS). Blood tests optimal choice because of the higher dose of to measure FSH, LH, prolactin, estradiol, testos- estrogen for relieving symptoms, ease and cost, or terone, and thyroid function may be used to help coverage for contraception in case the amenor- determine the diagnosis. rhea is temporary and the women wants preg- On the basis of this information, women nancy protection. with amenorrhea can be classified into the four 2. Hyperprolactinemia. Treatment with dopa- groups mentioned earlier in this chapter, with mine agonists (bromocriptine, cabergoline, treatments as follows: quinagolide) leads to reduction in prolactin secretion by the pituitary gland. When prolactin 1. Hypergonadotropic hypogonadism. Hor- is elevated, a CT or MRI should be done to dis- mone therapy with estrogen will induce second- tinguish between overactive pituitary produc- ary sexual characteristics in girls with primary tion by a microadenoma versus an actual tumor amenorrhea. Estrogen in combination with cyclic (macroadenoma). The large tumor can be asso- progestins will prevent osteoporosis, endometrial ciated with headaches or vision changes and hyperplasia, or cancer. The hormone therapy requires surgical resection, but it is very rare. AMENORRHEA 29 Once a tumor is excluded, medical therapy to by the continuous estrogen can cause endome- decrease prolactin is mainly used to achieve trial hyperplasia or cancer. pregnancy, and it is not required in an asympto- Polycystic ovary syndrome is associated with matic patient who is not seeking fertility. clinical symptoms such as obesity, hirsutism, 3. Hypogonadotropic hypogonadism. In the anovulation, and irregular bleeding. The range majority of women with this classification, no of problems that women with polycystic ovary organic disease can be identified in the hypothala- syndrome have varies greatly from woman to mus, anterior pituitary, or ovary. Management of woman. There are significant differences in hypothalamic amenorrhea associated with weight terms of the amount of acne, hair growth, men- loss must focus primarily on trying to correct the strual irregularity, infertility, hypertension, and underlying cause of the weight loss. Amenorrhea diabetes. There is no current known treatment from anorexia, bulimia, and exercise-induced for the disease, so treatment by conventional weight loss requires prompt diagnosis and treat- medicine is aimed at individual patient goals and ment. Some women will require hospitalization in symptom relief. Obviously, the health concerns a controlled environment for their malnutrition. of hypertension, hyperlipidemia, and diabetes Dietary counseling, psychological counseling, and need to be addressed in terms of lifestyle changes advice about exercise could all help to correct the and periodic monitoring of blood pressure, problem and restore ovarian function. lipids, and blood sugar. For the woman who has If amenorrhea persists for more than 12 very infrequent menses, the prevention of uter- months, then osteoporosis should be excluded ine hyperplasia or cancer is most important. with bone density testing, or some form of However, most women with PCOS have estrogen therapy should be considered to pre- uncomfortable side effects that can be improved. vent bone loss. Women with hypothalamic amenorrhea who wish to become pregnant are If a woman has very infrequent menstruation, treated by administering GnRH medications in she should either use birth control pills for regular a pulsatile manner via a portable programmable menstrual withdrawal or at least quarterly pro- pump that releases the medication every one to gestogens that cause withdrawal bleeding. The two hours, simulating the body’s pulsatile secre- progestogens that have been used include Provera tions. Women with rare disorders such as the or Cycrin (medroxyprogesterone), 10 mg daily for pituitary disease Sheehan’s syndrome are given seven days; Prometrium (oral micronized proges- hormones FSH and LH. terone) or compounded oral micronized proges- 4. Chronic anovulation and polycystic ovary terone, 400 mg daily for seven days; Aygestin syndrome. About 30 percent of women with (norethindrone acetate), 5 mg daily for seven days; secondary amenorrhea have concentrations of and Megace (megestrol), 20 mg daily for seven FSH, LH, and estrogen within the normal days. Most of the progestogens have similar symp- range. Polycystic ovarian syndrome is a toms of nausea, bloating, moodiness, and oily skin common cause of this type of amenorrhea. in varying degrees, but they are usually tolerable Many women with this type of amenorrhea for a few days or a week. actually present with irregular menstrual pat- Hirsutism can be with treated topically with terns more often than amenorrhea. These Vaniqa, which reduces the transformation of women do not have estrogen deficiency, but testosterone to dihydrotesterone at the hair folli- rather experience problems related to continued cle, reducing the growth, or at least the size and exposure to estrogen unopposed by proges- color, of the hair. This product needs to be terone. The buildup of the uterine lining caused applied once to twice daily in the areas of hair 30 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE growth and works while it is being used. There is tility specialist. Sometimes metformin is added no permanent effect, so it has to be used daily. to help aid clomiphene in induction of ovula- Also, electrolysis and laser hair removal are very tion, or the patient is given more intense ovula- effective permanent hair removal treatment. tion induction medications such as Pergonal. Spironolactone, an antiandrogen medication Probably the most important treatment of with minimal side effects, can reduce acne and polycystic ovary syndrome is recognition of the hair growth. The recommended does is 50 to 200 problem. When counseling the patient, the focus mg once daily. There has been some concern of should be on the management of her lifelong very rare cases of hyperkalemia (abnormally high symptoms. We need to inform women that this potassium levels) with this product, so patients disease comes in all shades and that there will be need to be warned of cardiac arrhythmias and different treatment regimens for different women muscle cramping. rather than one treatment for all. Metformin, an insulin-receptor-improving medication used for diabetes, has been touted to SEEING A LICENSED PRIMARY decrease weight gain and stimulate ovulation in HEALTH-CARE PRACTITIONER women with PCOS. However, many studies (N.D., M.D., D.O., N.P., P.A.) have shown minimal effect on weight gain, and it All women with amenorrhea should be evaluated has significant side effects of nausea, vomiting, by a licensed primary care practitioner (naturo- and diarrhea, as well as uncommon but serious pathic doctor, medical doctor, osteopathic doctor, liver enzyme problems. Most practitioners use nurse-practitioner, or physician’s assistant) because only it for treatment of diabetes or as an adjunct of the diverse array of potential diseases and disor- in infertility. Metformin usage, along with clomi- ders. Some of these conditions are rare, such as phene and/or Pergonal, seems to improve ovary Asherman’s syndrome, Cushing’s disease, Sheehan’s receptiveness and ovulation. Encouraging weight syndrome, and pituitary-secreting tumors. Other loss can help the situation tremendously, but causes are more common but can be complex, such women with polycystic ovary syndrome and obe- as malnutrition, anorexia nervosa, hyperthy- sity seem to be very resistant to standard weight- roidism, polycystic ovary syndrome, and pituitary loss programs. It is possible to lose weight, but disorders. Other causes are rather straightforward; they need to be persistent and have a good sup- for example, hypothyroidism, strenuous exercise, port system, possibly even some help from pregnancy, and stress-related amenorrhea. bariatric medicine (obesity doctors). Fortunately, most women with amenorrhea The treatment that achieves the best symp- have relatively simple problems that can be man- tom control is oral contraceptives. Oral contra- aged easily by primary care physicians, whether ceptives can reduce hair growth, reduce acne, they are alternative medicine practitioners, con- cause regular menstrual sloughing, suppress ventional practitioners, or a team approach using luteinizing hormone (LH) and ovarian cyst pro- the best choices of each. After an evaluation has duction, and are very widely prescribed for been done and a cause diagnosed, natural thera- women who also need contraception. pies can be administered as the primary therapy Antiestrogens such as clomiphene are some- or integrated with the conventional treatment. times given to induce ovulation and may restore Conventional treatments may be necessary in fertility in women seeking pregnancy. However, many cases of amenorrhea, but dosing regimens PCOS can be resistant to normal ovulation may be lower when natural therapies are used as induction and often requires the help of an infer- part of an integrated plan. CERVICAL CHAPTER 3 DYSPLASIA

OVERVIEW 1988, of low- and high-grade (precancerous) Over the past four decades, cervical cancer rates lesions or, more specifically, low-grade squamous have dropped dramatically in most developed intraepithelial lesions (SIL) and high-grade SIL, countries. This improvement in our health is also referred to as LSIL and HSIL, respectively. attributable to the commonly available Pap In the new terminology, low-grade SIL replaces smear, whereby early premalignant lesions can be the former terms mild dysplasia and CIN 1 (cer- found and treated, most often with fairly simple vical intraepithelial neoplasia) and includes office techniques. Cervical cancer presently ranks changes of simple infection with the human third in cancer deaths of American women, papillomavirus. High-grade SIL includes moder- although it remains the leading cause of death ate and severe dysplasia, formerly classified as from cancer among women in developing coun- CIN 2 and CIN 3. Both the newer and tradi- tries who do not enjoy the same access to diagno- tional terms are used in this chapter and in the sis and early treatment.1 In the United States, medical literature. approximately 9,710 cases of cervical cancer were What exactly is dysplasia? The mucous mem- diagnosed in 2006 and about 3,700 women died brane that covers the cervix changes in adolescence from it. Worldwide, human papilloma infection from more bumpy columnar cells, like those that causes almost 500,000 cases of cervical cancer also line the uterus, to squamous cells, like those and 280,000 deaths each year. that line the mouth, through a normal process Squamous cell cervical cancer is virtually called metaplasia. Squamous cells make up all of always preceded by cervical dysplasia, which is our external body surfaces that are characteristi- 100 percent treatable in its noninvasive stage. cally smooth, like our skin, for example. Where (Cervical cancer of the glandular cells, adenocar- these two types of cells meet is called the squamo- cinoma, is more problematic and requires more columnar junction—and it is here that our cells aggressive treatment.) Human papillomavirus are most susceptible to premalignant transforma- (HPV) is the most common sexually transmitted tion. The Pap smear samples cells from this area to infection in the United States,2 and about 75 examine microscopically. percent of the U.S. adult population has been The very bottom layer of squamous cells are exposed to HPV.3 Fortunately, the majority of called basal cells. They are the largest and round- genital HPV infections don’t cause any symp- est with the biggest nuclei. As the cells progress toms and go away on their own. The others go toward the surface, they become smaller, flatter, on to cause abnormal cells, including cervical and ultimately lose their nuclei before they get to dysplasia and/or cervical cancer. the top. In mild dysplasia, the basal cell layer is Cervical cancer and dysplasia, genital warts, thicker, up to one-third the total thickness of the and condyloma are caused by the human papillo- tissue; in moderate dysplasia, they occupy the mavirus, which is sexually transmitted. Virtually bottom and into the middle third; in severe dys- 100 percent of cervical dysplasias and cervical plasia, they extend to the top third. Carcinoma cancer is caused by HPV. This association is “in situ” is not an invasive malignancy, but rather reflected in a simple rating system, in use since the extension of the immature basal cells to the 31

Copyright © 2008 by Tori Hudson. Click here for terms of use. 32 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE very top of the tissue thickness. While it does forms, thanks to our well-functioning immune carry a higher risk of conversion to true cancer, it systems. Spontaneous regression of CIN 1 and too is completely treatable. CIN 2 has been documented to be as high as 50 The possibility of progression to cervical percent to 40 percent respectively, with numbers cancer increases with the severity of the dysplasia. improving the longer women are followed (usu- Mostly, though, it is a slow process, occurring over ally one to three years). Almost 70 percent reso- about 10 to 15 years in most women who are lution of HPV alone was observed.6 untreated. Currently, more than 100 HPV sub- Other studies confirm this, and the majority of types have been identified, numbered, and catego- untreated mild dysplasias were shown to regress to rized. More than 30 types can infect the genital normal within two years. A critical review of the area. The progression of dysplasia to cancer varies literature on the natural history of CIN was done according to which HPV subtype one is infected over a span of over 40 years.7 The author con- with. The low-risk types (6 and 11) are generally cluded that approximately 60 percent of CIN 1 associated with external genital warts but do not regressed to normal, 30 percent persisted, 10 per- cause cervical cancer. The most aggressive or cent progressed to CIN 3 (a high-grade lesion), high-risk types are HPV 16, 18, 26, 31, 33, 35, and only about 1 percent progressed to cervical 39, 45, 51, 51, 56, 58, 59, 66, 68, 73, and 82. cancer. CIN 2 regressed in 40 percent of the cases, These can transform susceptible tissue into cancer persisted in 40 percent, progressed to CIN 3 in 20 in about 18 months, but this is the exception percent, and progressed to cervical cancer in less rather than the norm, and dysplasia typically takes than 5 percent of cases. CIN 3 regressed in 33 per- more than 10 years to progress to cervical cancer. cent of the cases and progressed to cervical cancer In the United States, HPV 16 accounts for more in more than 12 percent. than 50 to 60 percent of cervical cancer cases, fol- A recent study demonstrates that the risk of lowed by HPV 18 (10 to 12 percent) and HPV 31 progression from mild to severe dysplasia or and 45 (4 to 5 percent each). frank cervical cancer was only 1 percent per year, A recent study confirmed that lesions of the but the risk of progression from moderate dys- cervix persist longer and progress more quickly in plasia was 16 percent within two years and 25 women with the aforementioned oncogenic HPV percent within five years.8 types, known as the higher risk types, than in Mild dysplasia is detected in about 1 percent women with nononcogenic types or without of women visiting their private gynecologist and HPV.4 However, it is important to remember that about 14 percent of women who visited desig- most women with the human papillomavirus nated sexually transmitted disease clinics.6 never get dysplasia at all. On the other hand, some Besides HPV, other risks include early age at first women with normal Pap smears, but showing intercourse, giving birth before age 22, cigarette inflammation, may indeed harbor the oncogenic smoking, low socioeconomic status, number of HPV types 16 and 18,5 suggesting women with lifetime partners, and possibly, although not con- chronic inflammation may benefit from high-risk clusively, oral contraceptive use. Women with HPV screening. Some estimate that as many as 70 five or fewer lifetime heterosexual partners had percent of women are or have been infected in higher rates of regression of untreated CIN 1 and their lifetime. On the other hand, only about 10 CIN 2 than did women with more than five part- women per 100,000 get cervical cancer. ners, independent of barrier contraception In addition to eliminating dysplasia through method use (condoms or diaphragms).9 It is dif- treatment, there can be a significant amount of ficult to separate out the effects of sexual activity spontaneous regression of even the most severe without barrier protection from that conferred CERVICAL DYSPLASIA 33 by ingesting hormonal contraception. For what- Fortunately, there are benign changes that ever reason, women who used these barrier meth- result in an AGUS Pap smear. These include ods had less dysplasia. In fact, condom use was chronic endocervicitis, microglandular hyperpla- associated with higher rates of CIN regression sia of the endocervix, or ciliated cell metaplasia of and clearance of cervical HPV infection in the endocervix, which is often seen in women women as well as protection from genital warts who have IUDs. Some women with AGUS have and invasive cervical cancer.10–12 high-grade (precancerous) squamous cells. The Evaluation of an abnormal Pap smear result is complicating problem is that AGUS cells may done by a method called colposcopy, which is a also come from the upper genital tract, such as lot like using binoculars to view the cervix. The tubal or ovarian cells, or even metastasis from colposcope magnifies the cervix, and white vine- the pelvis. gar is applied to make the abnormal areas show up. Tiny biopsies are taken of these areas, a few Risk Factors for Cervical millimeters at most. These are examined by the Dysplasia and Cervical Cancer pathologist and graded into mild, moderate, or severe as described previously. • Smoking. Women who smoke are about twice as One of the most important points I am sure likely to develop cervical cancer. to explain to my clients is that cervical cancer is • Human immunodeficiency virus (HIV) infection. a sexually transmitted disease, greatly promoted Immunocompromise results in increased risk for by smoking, but one that usually grows slowly HPV infections. over years from its precursor, dysplasia, and is • Chlamydia infection. Recent or past positive test treatable in all of its earliest forms. results for chlamydia may lead to greater risk for cervical cancer. Atypia • Poor nutrition. Diets low in fruits and vegetables may increase the risk for cervical cancer. Another possible Pap smear result is atypia—which • Multiple heterosexual partners. Having three or is really a kind of fence-sitting cell. The cells are not more partners in a lifetime increases risk of cervi- changed enough to warrant being labeled as abnor- cal cancer. mal, but they are not quite normal either. Usually • Obesity. Overweight women are more likely to atypia is either an early abnormal change or evi- develop cervical cancer. dence of tissue repairing itself, for example follow- • Oral contraceptives. Although the research is ing a birth or vaginal infection. These Pap tests are mixed, long-term use of oral contraceptives may usually just repeated, but if atypia persists, the increase the risk of cervical cancer. woman should be evaluated. • Low socioeconomic status. Poor access to adequate health care, including Pap tests and treat- Atypical Glandular Cells of Undetermined ment of precancerous lesions, leads to higher risk Significance (AGUS). AGUS may be the most for cervical cancer. difficult diagnostic challenge of all the Pap smear • Family history of cervical cancer. Recent studies abnormalities. AGUS represents a significantly suggest that women with a mother or sister with greater risk of cervical cancer than atypical squa- cervical cancer are at higher risk for developing cervical cancer. mous cells of undetermined significance (ASC- • First intercourse. Women at highest risk of test- US, discussed later in this chapter) or low-grade ing positive for HPV are those in the first few squamous intraepithelial lesions. The good news is years after first intercourse. that AGUS is not a common diagnosis and only • Age. HPV risk prevalence declines with age. represents 0.13 to 0.8 percent of all Pap smears. 34 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE When the report says AGUS “favor neopla- • ASC-US: atypical squamous cells of unde- sia,” this is of great concern, because 50 to 100 termined significance. This is considered a percent of patients with this test result have a mild abnormality. ASC-US is often then significant cervical lesion. These could include a tested for HPV types. high-grade CIN, adenoma carcinoma in situ, or • ASC-H: atypical squamous cells, cannot rule adenocarcinoma. Even though more than 50 per- out high-grade (precancerous) lesions. cent of women with AGUS will be found to be Women with ASC-H are at greater risk for normal, we cannot predict this, and a normal CIN 2 or CIN 3. For this reason, and follow-up Pap smear may be falsely normal, or because detection of high-risk types of HPV what is called a false negative. Therefore, a prac- is much more common with ASC-H, the titioner must carefully evaluate AGUS. recommendation is that these women get Evaluation may include colposcopy, biopsy, colposcopy and biopsies. endocervical curettage and endometrial biopsy, • LSIL: low-grade squamous intraepithelial in some cases dilation and curettage or hys- lesion—early changes in the size, shape, and teroscopy, and in some cases a conization. If number of abnormal cells. Lesion refers to there is adenomacarcinoma in situ on biopsy, a an area of abnormal tissue, and intraepithe- cervical conization is recommended. Cervical lial means that the abnormal cells are pres- conization for any woman with AGUS “favor ent in the surface layer of cells, not the neoplasia,” adenocarcinoma in situ, or adenocar- deeper glandular layer. This is considered a cinoma is recommended for most women. If mild abnormality. Colposcopy and biopsies there is frank invasion detected by biopsy, more are recommended. extensive surgery is recommended. • HSIL: high-grade squamous intraepithelial lesions. There may be a few, or there may be A Note About New Technologies many. This is obviously more severe and Most women are familiar with the Pap smear. Cells serious and has a higher likelihood of pro- are scraped from the cervix and placed on a slide for gressing to cervical cancer. Colposcopy and examination in a laboratory. There is now a new biopsies are recommended. liquid-based technique in which the cervical cells • ASC-US and ASC-H: HPV testing is collected by scraping the cervix are placed in liquid. recommended. In the laboratory much of the mucus, blood, and • LSIL and HSIL: These are generally not inflammatory cells are removed from the cell tested for HPV typing, as it does not alter sample. Liquid-based methods are more expensive the course of treatment. than conventional Pap tests but have a higher sensitivity for detection of lower-grade squamous cell If the results of the Pap smear are ASC-H, lesions and can be used to test for HPV types in LSIL, or HSIL, the clinician should perform or women with atypical squamous cells of undeter- recommend a colposcopy and biopsies. This is the mined significance (ASC-US) Pap results. The FDA only certain way to evaluate the abnormal cells and has approved two liquid-based cytology methods: determine the appropriate course of treatment. the Sure-Path system and the ThinPrep Pap test. OVERVIEW OF Reporting of Abnormal Pap Results ALTERNATIVE TREATMENTS About 5 to 10 percent of Pap tests performed Cervical dysplasia is an excellent example of what in the United States each year are abnormal. preventive medicine can accomplish because, in Abnormal cells include the following: almost all cases, it is a preventable disease. Through CERVICAL DYSPLASIA 35

Recommendations for Pap Smear Testing PREVENTION

• For women up to age 29: annual Pap with con- • Annual Pap smears are the single most impor- ventional smear, or every two years using tant factor in preventing cervical cancer and in liquid-based smear detecting earlier grades of cervical dysplasia. • For women 30 years and older: if three consec- • The use of condoms during intercourse is a sig- utive normal Paps, may go to every two to niﬁcant tool in preventing exposure to HPV, three years unless history of DES or HIV or reducing the risk of chlamydia and HIV, and immunocompromised reducing the risk of cervical dysplasia. • Reduce sexual risk factors: multiple partners, Note: Despite these recommendations, consider that sexual exposure to men who have genital warts, all women should have annual Paps; this is to ensure sexual exposure to men sexually exposed to that they also get an annual exam. Begin Pap smear women with genital warts or cervical dysplasia, testing approximately three years after onset of vagi- and intercourse prior to age 18. nal intercourse, no later than 21 years of age. • Avoid smoking. • Stop screening: for women 70 years or older • Eat a healthy whole foods diet rich in green, who have had three or more consecutive yellow, orange vegetables and lignans. normal Paps after age 60 • Use folic acid supplementation if using oral • Women with ASC-US and ASC-H can receive contraceptives. HPV testing to determine low-risk or high-risk • HIV-positive women and women who are HPV subtypes immunosuppressed because of kidney dialysis or • Women with ASC-H, LSIL, and HSIL should get immunosuppressive medications are at higher a colposcopy and biopsies risk for cervical dysplasia and cervical cancer and need more frequent screening. • Consider contraceptive options other than oral KEY CONCEPTS contraceptives.

• Cervical dysplasia is a sexually transmitted disease transmitted through skin-to-skin contact. lifestyle habits, dietary factors, nutritional supple- Condoms do not fully protect because HPV mentation, and regular Pap smears, most cases of extends onto skin beyond the condom, but they cervical dysplasia and its consequence, cervical may impart some protection and may enhance cancer, could be avoided. possibility of regression of low-grade lesions to Natural medicine perspectives on cervical dys- normal. plasia are consistent with conventional medicine’s • The human papillomavirus (HPV) causes virtually understanding that the human papillomavirus all cases of cervical dysplasia, although most causes virtually all cases and that this virus is sexu- women exposed to HPV actually never get dysplasia. ally transmitted. Many cofactors serve as cocar- • Cervical dysplasia is classified as either low-grade cinogens in the development of cervical dysplasia, or high-grade and, if left untreated or if the body including smoking, nutrient deficiencies, immune is not able to reverse it on its own, can progress deficiency, and possibly oral contraceptives. Where to cervical cancer, especially if a person is natural medicine diverges in its approach is in infected with the oncogenic strains of HPV. advising patients what they can do about these • Cervical cancer of squamous cells is a preventable cofactors. In addition, there are nutrients that can disease. be used in supplement form both to prevent the • Pap smears are screening tests, not diagnostic progression of cervical dysplasia to cervical cancer tests. and to reverse some cases of dysplasia. 36 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Cervical dysplasia is both a local problem in- increased consumption of vegetables, yellow- volving the cervical tissue immunity and health orange vegetables, fruits, or legumes.21 Nonethe- and a systemic problem involving general less, there is enough evidence to support a diet rich immune health and resistance to viral exposure. in beneficial vegetables. The overriding goals of natural treatments are to Phytoestrogens may also play a role in lowering reduce exposure to the human papillomavirus, premalignancies of the cervix. A recent study reduce cofactors, correct nutrient insufficiencies, demonstrated that plasma levels of equol and improve local immune response, strengthen gen- enterodiol, two isoflavonoids, were positively asso- eral immune health, and prevent the progression ciated with a lower cervical dysplasia risk, and in to cervical cancer. addition found a nonsignificant positive association with enterolactone, a lignan. Consistent with NUTRITION these results, dietary sources of lignans, including Cervical cancer has been studied in relationship garlic, onions, grapefruit, seeds, seaweed, and taro, to many dietary factors. In general, diets high were positively associated with lowered CIN risk.22 in vitamin C, carotenoids, vitamin E, selenium, Indole-3-carbinol, found in cruciferous veg- and other substances found in fruits and vegetables etables such as broccoli, cabbage, brussels sprouts, have been found to be protective in at least some cauliflower, and kale, has the potential to prevent studies.13–17 A recent study found that higher levels and treat several cancers. Eating these foods alters of vegetable consumption were associated with a estrogen metabolism in such a way as to reduce 54 percent decrease in risk of HPV persistence. the carcinogenic metabolites of estrogen metabo- Also, a 56 percent reduction in the persistence of lism. Women with CIN 1 or 2 have altered estro- the virus was observed in women with the highest gen metabolism and have higher 16-alpha plasma cis-lycopene concentrations compared hydroxyestrone, a potent carcinogen, and fewer 2- with women with the lowest plasma cis-lycopene hydroxyestrogen metabolites than women with no concentrations. These results suggest that veg- abnormal cells of the cervix.23 etable consumption and circulating cis-lycopene may be protective against HPV persistence.18 Nutritional Supplements Another report revealed that the risk of chronic Carotenes. Carotenes include beta-carotene, HPV infection was lower among women reporting alpha-carotene, cryptoxanthin, gamma-carotene, higher intake of the following foods: carotenes zeaxanthin, lutein, and lycopene. Studies have such as beta-cryptoxanthin (found in eggs, yellow shown that beta-carotene deficiency in the cervi- and orange fruits and vegetables), lutein and zeax- cal cells plays an etiologic role in the develop- anthin (eggs, dark green vegetables), vitamin C, ment of cervical dysplasia.24 In addition, a and, specifically, papaya.19 significant decrease in plasma beta-carotene In the treatment sections of this chapter, I levels is found in women with either cervical dys- emphasize a vegetarian diet, one that is high in plasia or cancer of the cervix.25 fruits and vegetables, especially yellow-orange ones It has been suspected that carotenes like like carrots, yellow squash, cantaloupe, peaches, lycopene, found in tomatoes, are more responsi- and corn. In China, consumption of both animal ble for an improvement in dysplasia than is beta- foods (including meat, eggs, and fish) and green carotene or the other carotenes.26 In fact, recent vegetables was significantly correlated with a lower studies have found that high serum levels of death rate from cervical cancer.20 One study lycopene and alpha-carotene are associated with a among white women showed that risk of cervical decreased risk of cervical dysplasia,27 and increas- dysplasia and cervical cancer was not affected by ing serum levels of lycopene alone was found to CERVICAL DYSPLASIA 37 increase clearance of oncogenic HPV infections higher intake of these nutrients.32–34 Another by over 50 percent.28, 29 study showed that the rate of progression from My own research study investigating natural dysplasia to cervical cancer was nearly five times treatment methods for cervical atypia, cervical higher in women with lower serum retinol levels dysplasias, and carcinoma in situ of the cervix than those with higher serum retinol levels35 and used beta-carotene supplementation as one part of that diets rich in vitamin A and high-retinol foods a multifactorial supplementation and local treat- may reduce risk of in-situ and invasive cervical ment protocol. I found a high success rate using this cancer.36 In addition, in vitro studies confirm that combination protocol. Most of the women were vitamin A and its analogues inhibit the prolifera- given supplements of 150,000 units of mixed natu- tion of HPV infection through apoptosis (cell ral carotenes daily for a minimum of three months. death) and inhibition of cell growth rates. Such Of 43 women studied, 38 patients returned to therapy is promising in decreasing the progression normal, 3 patients had partial improvement, of early cervical lesions to cancer.37–39 2 stayed the same, and none of the patients pro- Topical vitamin A is an important form of treat- gressed to a worse state of dysplasia during the ment as well. In one study of 301 women, topical course of the natural treatment protocol.30, 31 vitamin A (retinoic acid) increased the complete The full treatment protocols for each degree of regression rate of moderate dysplasia from 27 per- dysplasia are described in the treatment plans in cent in the placebo group to 43 percent in the treat- this chapter. Overall, my approach has been to rec- ment group. Women with severe dysplasia failed to ommend increased sources of carotenes in the diet respond.40 An earlier, well-known study on topical as well as supplementation. There are potential vitamin A and dysplasia on the exocervix (external concerns about using beta-carotene by itself, espe- surface of the cervix) at the University of Arizona cially in women who are at higher risk for lung had comparable results, eliminating the disease in cancer. As a precaution, I avoid beta-carotene sup- 10 of the 20 women. Five of the 10 had mild dys- plementation in women at high risk for lung plasia, and 5 had moderate dysplasia.41 Too few cancer (smokers), and for everyone else, I only rec- patients had severe dysplasia to evaluate. This find- ommend products that have mixed carotenes and ing was replicated recently in a study of three differ- natural carotenes. Careful label reading is essential. ent doses of topical retinoic acid in women with If the label doesn’t say “natural,” then the product CIN 1 and 2.42 In my own research, vitamin A sup- has synthetic beta-carotene. positories were applied topically as part of a multi- Do not be alarmed if your skin turns an orange factorial systemic and local treatment plan. (The tint when supplementing with high amounts of protocol is described later in this chapter.) carotenes. It is merely a pigment and is not a sign of liver toxicity. Carotenes are not toxic. Vitamin E. Low levels of serum vitamin E have been associated with an increased risk of all Carotenes stages of CIN and cervical cancer and high levels Mixed, natural carotenes, 75,000 IU twice daily associated with a decreased risk.43–46 Low levels of 25,000–50,000 IU for prevention (see treatment plans) vitamin E combined with deficient levels of vitamin A have been associated with an increased risk Vitamin A. Studies have shown that dietary of oncogenic HPV infection.47 One study demon- vitamin A protects against cervical cancer. Women strated a greater than 50 percent inhibition of with lower serum levels and dietary intakes of total proliferation of HPV-infected cells in vitro.48 In vitamin A are significantly more likely to have addition, vitamin E is a potent antioxidant and, dysplasia or carcinoma in situ than women with a therefore, may mitigate the oxidative damage asso- 38 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE ciated with cervical dysplasia and cancer.49 In a abnormalities) and low blood levels of folic acid recent study, women with CIN or cervical cancer have been associated with a moderately increased were found to have low levels of vitamin E and risk of invasive cervical cancer.57, 58 Deficiency has other antioxidants—like glutathione, vitamin C, been observed more often in women who are and CoQ10—were found to be low, while mark- taking oral contraceptives. In another study, ers of lipid peroxidation were found to be high, women taking 10 mg of folic acid daily for three both corresponding to severity of disease stage.50–52 weeks (while continuing oral contraceptives) Vitamin E can help in the treatment of cervi- showed a striking reversion of the megaloblastic cal cancer as well by improving the efficacy of changes toward the normal,59 with a regression-to- radiation therapy and enhancing tumor response normal rate of 20 percent in this study and 100 and chromosomal damage of cancer cells while percent in another.60 Folic acid supplementation concurrently protecting normal cells.53 may be effective in preventing dysplasia from pro- Vitamin C. The possible role of vitamin C in gressing as well. Theoretically, folic acid may act preventing cervical dysplasia is of special interest by decreasing homocysteine, which, when ele- because vitamin C is involved in collagen synthe- vated, has been associated with an increased risk sis, detoxifies chemical carcinogens, interferes with of cervical cancer.61, 62 It should be noted that a the formation of chemical carcinogens, and mod- recent study demonstrated the difficulty of getting ulates the immune system. It has been demon- adequate folate via diet and, therefore, additional strated in more than one study that there is a supplementation is warranted.63 significant decrease in vitamin C intake as well as When doses as high as 10 mg of folic acid per plasma levels of vitamin C in patients with cervi- day are given, two points must be kept in mind. cal dysplasia.54, 55 Vitamin C supplementation has The first is that most retail natural foods stores not been studied by itself as a treatment for cervi- have folic acid available only in capsules up to cal dysplasia. It was a part of the comprehensive 800 mcg (less than 1 mg, which is equal to 1,000 treatment protocol in my research study. mcg). Higher doses of folic acid are available only by prescription from your medical doctor or Vitamin C licensed alternative practitioner. A prescription 2,000–6,000 mg per day liquid form is available for which one drop is 1,000–2,000 mg per day for prevention (see treatment equal to 5 mg, which is very cost effective. The plans) second issue is that high doses of folic acid can mask a vitamin B12 anemia. To avoid this, take Folic Acid. There have been several studies either a multiple vitamin-mineral, B-complex, or using folic acid supplementation in women with B12 supplement along with the daily folic acid. mild and moderate cervical dysplasia, with conflicting results. In one study, women with mild or Folic Acid moderate dysplasia received 10 mg daily of folic 2.5–10 mg per day acid supplementation or placebo for three 800–2,400 mcg per day for prevention (see treatment months. All of these women had used oral con- plans) traceptives for at least six months and continued to do so. The results showed significant improve- B Vitamins. B vitamins, specifically ribo- ment or normalization of Pap smears and biop- flavin, thiamine, and B12, have an inverse corre- sies at the end of the treatment period.56 lation with risk for CIN, leading some In patients with folic acid deficiency, changes researchers to promote the protective role they in the cells of the cervix (called megaloblastic may play in cervical cancer, reducing the risk by CERVICAL DYSPLASIA 39 as much as 50 to 90 percent for the upper limits pounds including diindolylmethane (DIM). It has of intake.64 Women with the highest levels of been suggested that I3C can act in several ways to serum B12 were less likely to have a persistent prevent abnormal cell growth and prevent tumor 65 infection. Serum B12 levels should be evaluated progression. Recent studies indicate that I3C has and deficiency corrected. As with folic acid, B12 the ability to prevent and maybe even treat some may act by decreasing homocysteine, which, common cancers, especially those that are estrogen when elevated, has been associated with an related,71 by altering the pathway of estrogen increased risk of cervical cancer.66, 67 metabolism.72–74 Women with CIN 2 and 3 have altered estro- Vitamin B12 gen metabolism; higher 16-alpha hydroxyestrone, 1,000 mcg per day a potent carcinogen; and fewer 2-hydroxyestrogen metabolites than normal.75 One therapeutic goal of treatment, then, is to increase the Botanicals 2-hydroxylation of estrogen and decrease the 16 Green Tea. One of the most exciting advances alpha-hydroxylation. In one double-blind, placebo- in the treatment of cervical dysplasia is the controlled study of 30 women with CIN 2 or research that has been published on green tea. In CIN 3,76 4 of 8 patients in the 200 mg group and both laboratory and clinical studies, constituents 4 of 9 in the 400 mg group had complete regres- of green tea, namely polyphenol E (poly E) and sion of their CIN compared to none of the epigallocatechin-3-gallate (EGCG), have been placebo group. A laboratory study of human cer- effective against HPV-infected cervical cells and vical cancer cells determined that I3C and DIM lesions. The mechanisms involved appear to be could induce apoptosis (cell death) of human cer- apoptosis, cell cycle arrest, modification of gene vical cancer cells and HPV-16-infected cervical 77 expression, and antitumor effects.68, 69 A clinical cells of mice. It appears DIM is preferred over study confirms these findings in patients through I3C due to increased bioavailability and the fact the use of either topical application via a poly E that it increases the protective 2-hydroxyestrogen ointment and/or oral ingestion via a poly E or an without increasing another harmful metabolite, EGCG capsule. All treatment groups improved the 4-hydroxyestrogens. compared to placebo (50 to 75 percent versus 10 Diindolylmethane (DIM) percent), but the topical treatment groups improved the most significantly compared to oral 200–400 mg per day alone (75 percent versus 50 to 60 percent).70 Additional Botanicals. Traditional herbal Green Tea medicine includes the use of many plants for Green tea extract (95% polyphenols, 80% catechins, systemic immune support. No plants (except 55% EGCG, 10% caffeine): 300 mg per day orally green tea) have been studied by themselves in Green tea suppositories: insert one twice weekly (see relationship to the human papillomavirus and treatment plans) cervical dysplasia that I am aware of, although many plants are known both to act as immune Indole-3-Carbinol/Diindolylmethane (DIM). modulators and to be antiviral in their activity. Indole-3-carbinol (I3C) is a phytochemical found This concept of immune support is an in cruciferous vegetables, including cabbage, broc- important part of preventive medicine as well as coli, Brussels sprouts, cauliflower, and kale. I3C is in reversing and preventing the progression of converted in the stomach to a variety of com- cervical dysplasia. Since up to 80 percent of the 40 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE U.S. sexually active adult population carries the of a systemic botanical formula including thuja, human papillomavirus and less than 5 percent echinacea, ligusticum, and goldenseal. You will have a visible lesion or abnormal Pap smears, it is also notice herbal suppositories containing many common sense that most people’s bodies have the traditional herbs for immune support, antiviral ability to prevent the virus from causing an actual activity, and squamous cell repair. These include diseased state. Specifically, their immune systems myrrh, echinacea, usnea, goldenseal, marshmallow are doing a better job at keeping them healthy. root, geranium, and yarrow. This is true for women both systemically and in Recent evidence supports the use of cur- the vagina. There is local immune tissue in the cumin in the prevention of cervical cancer due to cervical epithelium, and the immune status of its ability to inhibit lipid peroxidation and down- this tissue is in part responsible for resistance to regulate HPV virus.78–80 the virus. This is the background logic for both systemic Curcumin immune support and local immune support. As 350–500 mg once to twice daily part of the research protocol, you will see the use

Criteria and Guidelines for Treatment Selection

Note: Not all of the treatments described in this 7. Low-grade squamous intraepithelial neoplasia: chapter are appropriate for self-care. Some, such as endocervical curettage is positive with a satis- the escharotic treatment, need to be administered factory colposcopy, but the patient is at low risk by a licensed health-care practitioner trained in for more serious disease or has low-risk HPV women’s health. In addition, not all cases of cervi- typing, or at the discretion of the practitioner. 8. High-grade squamous intraepithelial neoplasia: cal dysplasia are appropriate for the natural treat- endocervical curettage is positive with a satis- ment protocols. Licensed practitioners familiar with factory colposcopy, but the patient is at low diagnosing and treating cervical dysplasias should risk, or at the discretion of the practitioner and be consulted to assist in making appropriate and considered carefully after colposcopy, biopsies, safe decisions. For practitioners reading this book, and careful follow-up. the following criteria may be helpful in determining 9. It is possible to treat carcinoma in situ in the appropriate treatment: selected cases, but this is deﬁnitely a judgment call and should be considered very carefully after Criteria for Naturopathic Protocol colposcopy, biopsies, and careful follow-up. 1. ASC-US. Referrals for Colposcopy with Biopsies 2. ASC-US with documented HPV. 3. ASC-H: endocervical curettage is negative or 1. ASC-US if HPV DNA testing is positive for high- positive with a satisfactory colposcopy. risk HPV; if no HPV testing is done, then repeat 4. Low-grade squamous intraepithelial neoplasia: the Pap twice at 4 to 6 month intervals. If HPV endocervical curettage is negative with a satis- typing is negative for high-risk types, then factory colposcopy. repeat Pap in 12 months. 5. High-grade squamous intraepithelial neoplasia: 2. ASC-H. endocervical curettage is negative with a satis- 3. Low-grade squamous intraepithelial lesions. factory colposcopy. 4. High-grade squamous intraepithelial lesions. 6. ASC-H: endocervical curettage is positive with a 5. AGUS (atypical glandular cells of undetermined satisfactory colposcopy, but the patient is at low signiﬁcance); need endometrial biopsy as well. risk for more serious disease or has low-risk HPV 6. Adenocarcinoma in situ (AIS): need endometrial typing, or at the discretion of the practitioner. biopsy as well. (continued) CERVICAL DYSPLASIA 41

Criteria and Guidelines for Treatment Selection (continued)

7. Pap smear diagnosis of microinvasion or frank 4. The patient may not be a good candidate for more invasion. ongoing treatments and the closer follow-up 8. Endometrial cells present in a postmenopausal required by alternative treatments. woman even if the cells are benign; also needs an 5. No improvement in pathology using the initial endometrial biopsy. naturopathic plan or repeated alternate plan. 9. A patient that may not follow through with the 6. If AGUS on Pap smear and no detection of disease recommended follow-up Pap smear after an abnor- on colposcopy, biopsies, and endocervical curettage. mal Pap result. 7. If AIS on Pap smear and no detection of disease 10. Visible unknown cervical lesion, regardless of the on colposcopy, biopsies, and endocervical Pap smear test result. curettage 11. Initial exam of a DES daughter. Practitioner and patient discretions: 12. Unexplained or persistent cervical bleeding. 13. Vulvar condyloma with abnormal Pap smear test 8. Positive endocervical curettage with any degree result. of squamous intraepithelial lesions. A more 14. To be used for follow-up after treatment plan is assertive approach is recommended. completed, especially in high-grade squamous 9. High-risk patients: the last Pap test was more intraepithelial lesions. than one year previous, a history of genital warts, a history of cervical dysplasia, smokers, Referrals for Conization or LEEP multiple sexual partners with lack of safe sex practices. In these cases, a more proactive and 1. Pap smear results that are more than one grade of assertive approach is recommended. dysplasia different than that seen on colposcopy or reported on in the biopsy. Referrals for Probable Hysterectomy 2. Biopsy squamous intraepithelial lesions with three to four quadrants involved. 1. Microinvasive cervical cancer. 3. Unsatisfactory colposcopy with any degree of 2. Frank invasive cervical cancer. squamous intraepithelial lesions on biopsy. 3. Adenocarcinoma.

Toxicity studies prove its safety up to 8,000 similar protocols were used including the mg per day by mouth for up to three months as escharotic treatment with some of the more well as its efﬁcacy in chemoprevention in cancer, severe cases. I discussed this in more detail in the including cervical cancer. section of this chapter on carotenes. Indications The Escharotic Treatment. The escharotic and directions for use of the escharotic treatment treatment is a topical caustic treatment of the are given later in this chapter. cervix used to remove abnormal cells. It involves the use of zinc chloride mixed with a botanical, Botanical Formula I Sanguinaria canadensis (bloodroot). I have used Red clover: 1 oz the escharotic treatment for more than 24 years, Dandelion root: 11⁄2 oz and at one time I conducted a small study using Licorice root: 1 oz 1 it as a treatment along with suppositories and Goldenseal: ⁄2 oz herbal/nutritional supplementation in seven Botanical Formula II 30 women with carcinoma in situ of the cervix. Thuja: 1 oz After one year, four of the women remained dis- Echinacea: 11⁄2 oz ease free, one woman improved to atypia and Goldenseal root: 1⁄2 oz then reverted to mild dysplasia, and two women Ligusticum: 1 oz had partial improvement. In a follow-up study, 42 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plan for ASC-US

See the Resources section for information on the con- Week 4: herbal vaginal suppository nightly for 6 tents of and resources for the suppositories and other nights, Vag Pack suppository 1 night per week products included in these treatment plans. Weeks 5–12: green tea suppository twice per week

Initial Naturopathic Plan Systemic Vitamin C: 6 g daily Topical Beta-carotene: 150,000 IU daily Week 1: vitamin A suppository nightly for 6 nights Folic acid: 10 mg daily Week 2: herbal vaginal suppository nightly for 6 Multiple vitamin/mineral: follow label directions nights Green tea capsules: 1 capsule daily Week 3: vitamin A suppository nightly for 6 nights Botanical Formula I: 1⁄2 tsp twice daily Week 4: herbal vaginal suppository nightly for 6 Use systemic treatment for 3 months until follow-up. nights Week 5–12: green tea suppository 2 nights per week Constitutional Systemic Vegetarian diet for 3 months until follow-up

Folic acid: 10 mg daily Additional Therapies to Consider Vitamin C: 6 g daily Beta-carotene: 150,000 IU daily Zinc: 30 mg daily Multiple vitamin/mineral: follow label directions Vitamin E: 400 IU daily Green tea capsules: 1 capsule daily Selenium: 400 mcg daily Botanical Formula I: 1⁄2 tsp, twice daily Green tea suppository: twice per week DIM: 200 mg daily Use systemic treatment for 3 months until follow-up. Comments: A follow-up Pap smear in 3 to 6 months Constitutional that is still abnormal warrants colposcopy and biopsies. Vegetarian diet for 3 months until follow-up Maintenance Plan for 3 Months Alternative Naturopathic Plan (After Normal Pap Smear) Topical Vitamin C: 2 g daily Week 1: vitamin A suppository nightly for 6 nights, Beta-carotene: 150,000 IU daily Vag Pack suppository 1 night per week Folic acid: 2.5 mg daily Week 2: herbal vaginal suppository nightly for 6 Multiple vitamin/mineral: follow label directions nights, Vag Pack suppository 1 night per week Green tea capsules: 1 capsule daily Week 3: vitamin A suppository nightly for 6 nights, Vegetarian diet Vag Pack suppository 1 night per week

LIFESTYLE HABITS involve HPV, women can best protect themselves by using condoms during intercourse. Even if a Sexuality male partner does not have visible genital warts, Early age at ﬁrst intercourse (before age 18) with he can have nonvisible genital warts and can also unprotected sex and/or multiple heterosexual carry the virus. partners with unprotected sex are associated with If the partner is female, it is more difﬁcult to an increased risk of cervical dysplasia and cervical contract the virus and cervical dysplasia, but not cancer. As nearly all cases of cervical dysplasia impossible. Avoiding genital-to-genital contact CERVICAL DYSPLASIA 43

Sample Treatment for Mild Dysplasia (CIN 1, Low-Grade SIL)

See the Resources section for information on the con- Week 1: vitamin A suppository nightly for 6 nights tents of and resources for the suppositories and other Week 2: herbal vaginal suppository nightly for 6 products included in these treatment plans. nights Week 3: vitamin A suppository (Vital-A) nightly for 6 Initial Naturopathic Plan nights Week 4: herbal vaginal suppository nightly for 6 Topical nights Week 1: vitamin A (Vital-A) suppository nightly for 6 Weeks 5–12: green tea suppository twice per week nights, Vag Pack suppository for 1 night Week 2: herbal vaginal suppository nightly for 6 Systemic nights, Vag Pack suppository for 1 night Vitamin C: 6 g daily Week 3: vitamin A suppository nightly for 6 nights, Beta-carotene: 200,000 IU daily Vag Pack suppository for 1 night Folic acid: 10 mg daily Week 4: herbal vaginal suppository (Herbal-C) nightly Multiple vitamin/mineral: follow label directions for 6 nights, Vag Pack suppository for 1 night Green tea capsules: 1 capsule daily Weeks 5–12: green tea suppository twice per week Botanical Formula I: 1⁄2 tsp twice daily Selenium: 400 mcg daily Systemic Use systemic treatment for 3 months until follow-up. Vitamin C: 6 g daily Beta-carotene: 150,000 IU daily Constitutional Folic acid: 10 mg daily Vegetarian diet for 3 months until follow-up Multiple vitamin/mineral: follow label directions Green tea capsules: 1 capsule daily Additional Therapies to Consider Botanical Formula I: 1⁄2 tsp twice daily Use systemic treatment for 3 months until follow-up. Zinc: 30 mg daily Vitamin E: 800 IU daily Constitutional Selenium: 400 mcg daily DIM: 200–400 mg daily Vegetarian diet for 3 months until follow-up Maintenance Plan for 6–12 Months Alternate Naturopathic Plan Vitamin C: 2 g daily Topical Beta-carotene: 150,000 IU daily Escharotic treatment (described later in this chapter) Folic acid: 2.5 mg daily twice per week for 3 weeks Multiple vitamin/mineral: follow label directions After the last escharotic treatment: Green tea capsules: 1 capsule daily Vegetarian diet or practicing safer sex if the partner has known ically possible, and there are conditions when the genital warts may be advisable. It is considered HPV virus may lodge in the larynx and oral very low risk for the virus alone to be transmitted cavity. However, these cases are extremely rare, between women, although it is theoretically pos- and so it is left to each person to make that judg- sible. Both heterosexual and homosexual women ment on her own. If one of the partners is ask about the risk of transmitting or contracting immunocompromised (HIV-positive, a trans- the virus through oral sex. Again, this is theoret- plant patient, or has chronic hepatitis), then she 44 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment for Moderate Dysplasia (CIN 2, High-Grade SIL)

See the Resources section for information on the con- Alternate Naturopathic Plan tents of and resources for the suppositories and other Topical products included in these treatment plans. Escharotic treatment twice per week for 4 weeks Initial Naturopathic Plan After the last escharotic treatment: Topical Week 1: vitamin A suppository nightly for 6 nights Week 2: papilloma suppository nightly for 6 nights Week 1: vitamin A suppository nightly for 6 nights, Week 3: vitamin A suppository nightly for 6 nights 2 Vag Pack suppositories for 1 night Week 4: papilloma suppository nightly for 6 nights Week 2: herbal vaginal suppository nightly for 6 Weeks 5–12: green tea suppository twice per week nights, 2 Vag Pack suppositories for 1 night Week 3: vitamin A suppository nightly for 6 nights, Systemic 2 Vag Pack suppositories for 1 night Folic acid: 10 mg daily Week 4: herbal vaginal suppository nightly for 6 Vitamin C: 6 g daily nights, 2 Vag Pack suppositories for 1 night Multiple vitamin/mineral: follow label directions Week 5: vitamin A suppository nightly for 6 nights, Beta-carotene: 150,000 IU daily 2 Vag Pack suppositories for 1 night Green tea capsules: 1 capsule daily Week 6: herbal vaginal suppository nightly for 6 Botanical Formula I: 1⁄2 tsp twice daily nights, 2 Vag Pack suppositories for 1 night Weeks 7–12: green tea suppository twice per week Use systemic treatment for 3 months until follow-up.

Systemic Constitutional Vitamin C: 6 g daily Vegetarian diet for 3 months until follow-up Beta-carotene: 200,000 IU daily Folic acid: 10 mg daily for 3 months Additional Therapies to Consider Selenium: 400 mcg daily Zinc: 30 mg daily Multiple vitamin/mineral: follow label directions Vitamin E: 800 IU daily Green tea capsules: 1 capsule daily Selenium: 400 mcg daily Carotene: 150,000 IU daily DIM: 200–400 mg daily Botanical Formula II: 1⁄2 tsp twice daily Use systemic treatment for 3 months until follow-up. Maintenance Plan for 1 Year Vitamin C: 3 g daily Constitutional Beta-carotene: 150,000 IU daily Vegetarian diet for 3 months until follow-up Folic acid: 2.5 mg daily Multiple vitamin/mineral: follow label directions Green tea capsules: 1 capsule daily Vegetarian diet

is more vulnerable to contracting HPV, and precancer is smoking. Smokers have a two- to threefold cautions are deﬁnitely warranted. increase in the incidence of cervical dysplasia.81 Some studies indicate that the incidence compared Smoking to nonsmokers is even greater than that. Nicotine is Probably the single most important cofactor in actually concentrated in the glands of the cervix, the development of cervical dysplasia and cervical where it then acts as a carcinogenic compound. CERVICAL DYSPLASIA 45

Sample Treatment for Severe Dysplasia (CIN 3, High-Grade SIL)

See the Resources section for information on the con- Week 4: papilloma suppository nightly for 6 nights tents of and resources for the suppositories and other Weeks 5–12: green tea suppository twice per week products included in these treatment plans. Systemic Initial Naturopathic Plan Vitamin C: 6 g daily Beta-carotene: 200,000 IU daily Topical Folic acid: 10 mg daily Escharotic treatment twice per week for 5 weeks Selenium: 400 mcg daily After the last escharotic treatment: Multiple vitamin/mineral: follow label directions Green tea capsules: 1 capsule daily Week 1: vitamin A suppository nightly for 6 nights DIM: 200–400 mg daily Week 2: herbal vaginal suppository nightly for 6 Botanical Formula II: 1⁄2 tsp twice daily nights Week 3: vitamin A suppository nightly for 6 nights Use systemic treatment for 3 months until follow-up. Week 4: herbal vaginal suppository nightly for 6 nights Constitutional Weeks 5–12: green tea suppository twice per week Vegetarian diet for 3 months until follow-up

Systemic Additional Therapies to Consider Folic acid: 10 mg daily Zinc: 30 mg daily Vitamin C: 6 g daily Vitamin E: 800 IU daily Beta-carotene: 150,000 IU daily Selenium: 400 mcg daily Multiple vitamin/mineral: follow label directions Pyridoxine: 50 mg 3 times daily Green tea capsules: 1 capsule daily Botanical Formula II: 1⁄2 tsp twice daily Maintenance Plan for 1 Year Use systemic treatment for 3 months until follow-up. Vitamin C: 3 g daily Beta-carotene: 150,000 IU daily Constitutional Folic acid: 2.5 mg daily Vegetarian diet for 3 months until follow-up Vitamin E: 400 IU daily Multiple vitamin/mineral: follow label directions Alternate Naturopathic Plan Green tea capsules: 1 capsule daily Topical Botanical Formula II: alternate 1 month on, 1 month off Escharotic treatment twice per week for 8 weeks Vegetarian diet After the last escharotic treatment: Week 1: vitamin A suppository nightly for 6 nights Week 2: papilloma suppository nightly for 6 nights Week 3: vitamin A suppository nightly for 6 nights

Smoking may also alter immune function Oral Contraceptives and affects the levels and distribution of ascorbic Earlier studies suggested that oral contraceptive acid. Ascorbic acid in the cells of the cervix and (OC) use increased the risk of cervical neoplasia, the vagina and plasma levels of ascorbic acid are both invasive and precancerous cervical dysplasias.83 reduced in smokers.82 Recently, however, studies that are controlled for 46 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment for Carcinoma In Situ (CIN 3, High-Grade SIL)

See the Resources section for information on the con- Week 3: vitamin A suppository nightly for 6 nights tents of and resources for the suppositories and other Week 4: papilloma suppository nightly for 6 nights products included in these treatment plans. Weeks 5–12: green tea suppository twice per week

Initial Naturopathic Plan Systemic Vitamin C: 10 g daily Topical Beta-carotene: 200,000 IU daily Escharotic treatment twice per week for 5 weeks Folic acid: 10 mg daily After the last escharotic treatment: Selenium: 400 mcg daily Week 1: vitamin A suppository nightly for 6 nights Multiple vitamin/mineral: follow label directions Week 2: herbal vaginal suppository nightly for 6 Green tea capsules: 1 capsule daily nights DIM: 200–400 mg daily 1 Week 3: vitamin A suppository nightly for 6 nights Botanical Formula II: ⁄2 tsp 3–4 times a day Week 4: herbal vaginal suppository nightly for 6 Use systemic treatment for 3 months until follow-up. nights Weeks 5–12: green tea suppository twice per week Constitutional Vegetarian diet for 3 months until follow-up Systemic Folic acid: 10 mg daily Additional Therapies to Consider Vitamin C: 6 g daily Zinc: 30 mg daily Beta-carotene: 180,000 IU daily Vitamin E: 800 IU daily Selenium: 400 mcg daily Selenium: 400 mcg daily Multiple vitamin/mineral: follow label directions Pyridoxine: 50 mg 3 times a day Green tea capsules: 1 capsule daily Lomatium isolate: 5 drops twice daily Botanical Formula II: 1⁄2 tsp twice daily Alternating sitz baths twice weekly for 4 weeks dur- Use systemic treatment for 3 months until follow-up. ing suppository routine

Constitutional Maintenance Plan for 1 Year Vegetarian diet for 3 months until follow-up Vitamin C: 3 g daily Alternate Naturopathic Plan Beta-carotene: 150,000 IU daily Folic acid: 2.5 mg daily Topical Multiple vitamin/mineral: follow label directions Escharotic treatment twice per week for 8 weeks Vitamin E: 400 IU daily Botanical Formula I: alternate 1 month on, After the last escharotic treatment: 1 month off Week 1: vitamin A suppository nightly for 6 nights Vegetarian diet Week 2: papilloma suppository nightly for 6 nights

sexual history have been reassuring. In addition, no Three large, well-controlled studies looked at form of hormonal contraception, be it oral or injec- invasive cervical cancer and OC use and did not tion, was found to be associated with an increased find statistically significant associations compared risk for developing dysplasia.84 While hormonal with women who never used OCs.85–87 There was contraception is not implicated in HPV-related dys- no overall change in risk of invasive cervical plasia, condoms should still be used concurrently. cancer. However, one of the three studies did find CERVICAL DYSPLASIA 47

Sample Treatment Plan After style, pessimism, a high degree of social alien- LEEP, Conization, or Cryotherapy ation, high anxiety states, and feeling threatened.91, 92 Life stressors with negative impact over Wait for 3 weeks after the procedure (described later the previous six months showed a direct, positive in this chapter), and then begin the following plan. association with level of dysplasia, while coping See the Resources section for information on the con- style showed a less prominent effect. tents of and resources for the suppositories and other products used. CONVENTIONAL Week 1: vitamin A suppository nightly for 6 nights MEDICINE APPROACH Week 2: herbal suppository nightly for 6 nights The degree of aggression used to combat simple Week 3: vitamin A suppository nightly for 6 nights human papillomavirus waxes and wanes through Week 4: herbal suppository nightly for 6 nights the years and from provider to provider. While Systemic and constitutional treatment plans are the HPV can be dormant for decades, recurrence is same as is described for the degree of lesion in the always possible. Some practitioners recommend other corresponding treatment plans. observation alone through the acute viral phase of cervical infection in low-risk patients. We have a modestly increased risk in long-term OC users.85 seen this work at least as often as not. Many doc- The other two studies failed to find a significantly tors give patients the option, considering their increased risk of invasive cervical cancer even with lifestyle, other risk factors, prior history, and long-term OC use. The definition of long-term immune system status. use is not always consistent, but some define it as Most everyone in the conventional medical more than five years of use. Two other recent stud- community agrees on how to manage moderate ies assessed OC use and risk of cervical dysplasia, and severe dysplasia: remove it. There is some and neither of these found any statistically signifi- ongoing controversy about the treatment of mild cant associations.88, 89 dysplasia. Since recent studies have shown that 70 One disturbing finding with OC use is an to 80 percent of mild dysplasia will revert to association with an increase in the incidence of a normal tissue before one year, there is an equally rare cancer of the cervix called adenocarcinoma, a compelling recommendation to just repeat the Pap variant of squamous cervical cancer. The incidence smear in one year and avoid further treatment of this disease has increased over the past several unless the condition progresses. If it is still mild decades, while the incidence of invasive squamous dysplasia at 12 months, then repeat the colposcopy cervical cancer has decreased since the pill was and biopsies to exclude more significant lesions. In introduced. Two recent studies86, 90 found a modest other words, mild dysplasia can be observed even but statistically significant increased risk of inva- longer, as long as close follow-up occurs. sive cervical adenocarcinoma in OC users with When treatment is needed, the procedures over 12 years of use. However, it is important to generally used are cryotherapy; a conization with remember that the cause of cervical cancer is the a scalpel or laser; laser ablation; or loop electro- sexually transmitted human papillomavirus. surgical excision procedure, referred to as LEEP. All of them remove the dysplastic cells and allow PSYCHOLOGICAL FACTORS new cells to replace the old. They all work The association between psychosocial factors and upward of 90 percent of the time when used cor- cervical dysplasia has been the subject of several rectly. Cryotherapy is reserved for mild dysplasia investigations. Significant life stressors were (CIN 1), because of the lesser depth of penetra- found to be correlated, including low coping tion. The other procedures are recommended for 48 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Cervical Escharotic Treatment

The escharotic treatment is especially indicated for 4. Leave the bromelain on the cervix and in the moderate dysplasia and severe dysplasia, both high- endocervical canal for 15 minutes. Place a GYN grade lesions, but only when there is a satisfactory lamp facing the vagina to provide gentle heat colposcopy performed by a clinician. In addition, the during this portion of the treatment. use of the escharotic treatment, rather than a LEEP or 5. Now remove the bromelain by placing a large conization, needs to fall within the guidelines as out- cotton swab in the calendula succus and then applying it to the cervix, thus washing off the lined in the criteria for naturopathic protocol. Please bromelain. Repeat with a small cotton tip appli- also read the section in this chapter clarifying when cator to the endocervical canal. Be liberal; a conization or LEEP is a more appropriate treatment. repeat washing two to four times. Take a dry The escharotic treatment is best done twice a large swab and absorb the washings that have week with two full days between treatments. The zinc pooled in the vagina. chloride (ZnCl) solution will have to be made by a 6. Now soak a large swab in the ZnCl2/sanguinaria compounding pharmacist, by prescription. mixture that you prepared earlier. Apply this to the cervix once. Repeat this procedure with a Instructions for the Practitioner small cotton tip applicator inserted in the endocervical canal. Leave on for one minute. If this Before beginning the treatment, you will need the causes pain, wash the cervix with a small following items: amount of distilled water. Avoid contact of the ZnCl /sanguinaria mixture with the vaginal wall. • 1 cup distilled water 2 7. Wash off the ZnCl /sanguinaria mixture with • A cup containing 2 powdered bromelain cap- 2 swabs of calendula succus. Wash the endocervi- sules or tablets. Remove the powder from the cal canal as well with a cotton tip applicator. capsules or crush the tablets to powder. Absorb the liquid that has pooled in the vagina 1 • ⁄4 tsp ZnCl2 solution (90 g ZnCl/60 ml sterlized with a dry cotton swab. water) mixed in a bottle with 3⁄4 tsp sanguinaria 8. Insert two Vag Pack suppositories. Instruct the tincture patient to leave the suppositories in place for • 1⁄3 cup calendula succus 24 hours, using a sanitary napkin as needed for leakage. 1. Insert speculum and visualize the cervix. 9. After the last escharotic treatment, use the fol- 2. Blot the cervix dry with large cotton swab or lowing treatment plan: cotton ball on the end of a ring forceps. 3. Dip a large cotton swab into the distilled water Week 1: vitamin A suppository nightly for 6 and then squeeze out the water. Place the damp nights swab into the bromelain and thickly cover the Week 2: herbal vaginal suppository nightly for 6 face of the cervix with the powder, repeating as nights, or in cases with HPV, use condyloma needed to cover the cervix completely. Apply suppository the powder in the endocervical canal using Week 3: vitamin A suppository nightly for 6 small, dampened cotton tip applicators (use a nights new applicator each time). Week 4: herbal vaginal or papilloma suppository nightly for 6 nights

moderate and severe dysplasias (CIN 2, CIN 3). inadequate prior treatment with residual cells Tissue destruction beyond the dysplastic lesions that then persist and regrow. occurs in all of these procedures to varying Cryotherapy is the oldest and cheapest of these degrees to help prevent recurrences. Recurrences procedures and is a simple office procedure per- are usually due to new infection, reactivation of formed with a blunt probe applied to the cervix the virus because of immune system changes, or and tubing that supplies concentrated nitrous CERVICAL DYSPLASIA 49 oxide to cause the probe to get very cold. Tissue opening to the cervix. The advantage of LEEP is penetration is several millimeters. This procedure that it can be done in the office, is well tolerated, takes approximately two to three minutes and is and is minimally expensive. associated with cramping at the time, which These techniques are all relatively safe and resolves quickly and is rarely present for more than effective for preventing future cervical cancer. a day. The devitalized tissue is sloughed as a watery However, their effects on future fertility and preg- discharge over the next 10 to 14 days. The cervix nancy outcomes are unclear. Some say that done is usually well healed within a month. properly, none of these procedures affects fertility, Conization is employed primarily for endo- sexuality, or pregnancy. There is no adequate data cervical dysplasia. A cold-knife procedure is per- from randomized controlled trials to evaluate formed in the operating room under anesthesia these potential effects. In one analysis of 27 obser- and employs a scalpel to remove a cone-shaped vational trials comparing the fertility and preg- piece of cervix and cervical canal. Conization has nancy of women who underwent ablation or the advantage of more clearly evaluating the mar- excision of CIN lesions to women who were not gins, because there is no thermal artifact. Laser treated with these therapies, LEEP and cold-knife ablation of the transformation zone can be per- conizations were both associated with significantly formed in the operating room or the office and increased risk for preterm delivery. LEEP was asso- allows for precise management of lesions but ciated with an increased risk for preterm rupture does not provide tissue for pathology. Laser of membranes, and the cold-knife cone was asso- conization obtains tissue similar to the cold-knife ciated with an increased risk for cesarean section. cone procedure, with some thermal destruction The laser cone and the laser ablation had no asso- at the margins, and is significantly more expen- ciation with any significant change for any of the sive than LEEP. outcomes. None of the treatments had any signif- The most common current treatment of icant association with perinatal mortality, compli- endocervical or cervical dysplasia of moderate- cation for the infant, or fertility. to-severe degree is a LEEP procedure, which is Follow-up recommendations may vary depend- generally performed in the office with cervical ing on your overall case history and your practi- anesthetic and is usually well tolerated and very tioner’s perspective. Some patients treated with any cost effective. LEEP can be used to remove the of these conventional treatments are advised to endocervical canal and/or the transformation have three-month Pap smears for the first year and zone. It also has thermal degradation at the mar- six-month Pap smears for the next year. Others will gins. When LEEP or laser is used, the tissue have the recommendation of annual Pap smears beyond the cut margin is heated and destroyed following the conventional treatment. for another 1 to 2 mm of penetration. Even when the dysplasia is seen all the way to the margin of Prevention: The HPV Vaccine the biopsy, there is still usually complete treat- The newest approach to conventional medical ment of the lesion because the heat destruction treatment of dysplasia is prevention. After a clini- penetrates into the tissue beyond the surgical site. cal trial done in 2002 initially showed that an Women treated by LEEP are more likely to HPV-16 vaccine reduced the incidence of both convert to HPV-negative status within one to two HPV-16 infection and HPV-16 cervical dyspla- years after the procedure and do so significantly sia,93 continued research has lead to the reality of sooner than those who are merely watched with- an HPV vaccine to reduce the incidence of cervi- out treatment. The LEEP can reduce cervical cal cancer. The FDA approved a quadrivalent vac- mucus and can occasionally cause a stenosis of the cine in June 2006. It vaccinates women against 50 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE strains 6 and 11, which cause venereal warts, and are not diagnostic; they are screening tests. When 16 and 18, which are the most common strains your licensed practitioner (naturopathic doctor, found in cervical cancer. The intended recipients medical doctor, osteopathic doctor, nurse- of this vaccine will be pubertal girls who have not practitioner, or physician’s assistant) recommends yet had intercourse. However, the vaccine has been that you need a colposcopy and biopsy, this is recommended up to age 26, because it will also good advice. They are not recommending treat- help prevent venereal warts in women who are ment; they are recommending accurate diagnosis. currently sexually active. Decisions regarding treatments such as a In one study young women without histories LEEP, cone biopsy, or cryotherapy versus one of of HPV infection or abnormal Pap smears who the natural treatment protocols require a medical were given the type 16 and 18 vaccine were sig- history, Pap smear report, colposcopy report, nificantly less likely to develop HPV type 16 or biopsy/pathology report, and a working knowl- 18 infections or abnormal cervical cells during edge of the advantages and disadvantages of each the two-plus years of follow-up.94 In another of the treatments. If your conventional practi- study, the 6, 11, 16, and 18 vaccine decreased the tioner is not aware of the research on the natural incidence of infection by 90 percent in young treatment protocols or is biased without knowl- women compared to placebo.95 edge, then he or she may not be the most appropriate person to help you make the right SEEING A LICENSED PRIMARY decision. Likewise, if your alternative practi- HEALTH-CARE PRACTITIONER tioner is not aware of the clinical indications for (N.D., M.D., D.O., N.P., P.A.) the conventional treatments as distinguished Accurate and adequate diagnosis and evaluation from the clinical indications for the safety and is the key to knowing which is the most appro- efficacy of the alternative treatment plan or is priate treatment for your case. Colposcopy (mag- biased without knowledge, then he or she too nification) and cervical biopsies are the specific may not be the most appropriate person to help diagnostic methods for evaluation. Pap smears you make the right decision. CONTRACEPTION CHAPTER 4

OVERVIEW ning or fertility awareness methods (often Around the same time suffragettes were securing described as the rhythm method), there are three the right to vote, other women, most notably general categories—hormonal contraception, bar- Margaret Sanger, desperately sought to provide rier contraception and the intrauterine devices, women a means of “family limitation,”1 later and abortion—that complete the list of birth con- called birth control. The political struggle to trol methods. Sterilization, the most common legitimize contraception and bring it into the method of fertility control, is a safe surgical proce- medical arena was long and fierce. Sanger was dure for either men or women. This method is jailed on obscenity charges more than once and used by about 20 percent3 of couples; yet it, too, finally fled the country rather than face a trial she has a failure rate of about 1 in 400. ultimately won years later. Any public discussion of reproduction was judged obscene under the KEY CONCEPTS prevailing Comstock Law. Although women frequently died in childbirth or struggled to feed • Consult your health-care practitioner to deter- families of six to ten or more, they were forbid- mine the effectiveness, health benefits, and den information concerning fertility regulation health risks of each contraceptive method. • Consult your health-care practitioner about cau- that was literally lifesaving. Although diaphragms tions and contraindications for each method. and condoms gradually became more readily • Smokers older than 35 should not use hormonal available (the first diaphragms in use in America contraceptive methods. were smuggled from Europe through Canada by • The choice of contraception method is based on Sanger and her husband), it was not until the benefits, risks, effectiveness, cost, side effects, Supreme Court decision Griswald v. Connecticut ease of use, and personal choice. in 1966 that married women’s rights to access • The key to the contraceptive benefit is proper birth control became assured. use and compliance with the chosen method. While we modern women lament the absence • Pregnancy itself carries considerable health of a perfect fertility control option, the mere fact risks. These must also be considered when choosing a method of contraception. that the birthrate has fallen so drastically these past • Regular annual health exams are required for 50 years illustrates both women’s desire to have users of hormonal contraception. fewer children and the efficacy of the combined • Report any side effects that you think are methods in achieving that goal. Nevertheless, even related to your method of contraception to your with the current availability of contraception, fully health-care practitioner. 57 percent of American pregnancies today are unintended.2 Perhaps our difficulty with the issue relates to our prudish roots. Safe, effective birth FERTILITY AWARENESS control does exist, although failures, whether Many couples successfully rely on this drug-free human or methodological, occur with each. The and device-free method that depends on identi- best we can do is choose wisely and minimize fying a woman’s fertile periods and abstaining human error. In addition to natural family plan- from intercourse during those times. However, to 51

Copyright © 2008 by Tori Hudson. Click here for terms of use. 52 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE achieve the lowest failure rates of 1 to 10 percent tion—days 11 through 17 at least, and optimally requires relatively long periods of abstinence each seven days before and at least four days after. If a month—at least 10 and up to 20 days—depend- woman’s cycle is not this regular, another ing on cycle length and predictability. The calendar method is useful that takes into account average pregnancy rate with most who use this cycle variance. First gather information about method is 20 percent, clearly less than the 85 cycle length over enough time to figure out how percent rate experienced with no method at all. wide the range is. You must know the longest and More pregnancies result from taking chances the shortest cycle length you experience—day 1 during fertile times than from difficulty deci- being the first day of menses and the last day phering the methods.4 These methods work best being the one just before menses resumes. Sub- when women have a predictable cycle length. tract 20 from the shortest cycle to get the first Ovulation is then predicted most accurately, and fertile day (day 4 in a 24-day cycle). Subtract 10 intercourse is restricted for the least amount of from the longest cycle (day 22 in a 32-day cycle) time. Barrier methods can be combined with the to get the last fertile day. Thus, a woman with calendar method pretty effectively during the cycles ranging from 25 to 30 days avoids inter- restricted time, but spermicide can obscure the course days 5 through 20 (25 Ϫ 20 ϭ 5 and cervical mucus method. All variations of this 30 Ϫ 10 ϭ 20). (Read through this paragraph two method assume that an ovulated egg can be fer- or three times to make sure you understand it.) tilized for up to 24 hours and that sperm can survive in the female reproductive tract for about Cervical Mucus three but possibly up to seven days.4 Amazingly, This method uses the recognition of “fertile one might become pregnant up to a week after mucus” to predict ovulation. It depends on the the last intercourse! So much for romantically physiological fact of the presence of slippery thin planning conception location or dating a preg- mucus at the cervical orifice around ovulation. nancy simply from the timing of sex. You can easily learn to discern fertile mucus by Combining all the methods somewhat prob- experimenting with egg white, which resembles ably works the best; for example, many women fertile mucus. Use your index finger to gather are quite good at predicting when they ovulate mucus from as close to the uterine opening as from a variety of symptoms (such as pelvic pain possible. Fertile mucus stretches between thumb or mittelschmerz), but this is only something you and index fingers as they are separated, just like notice after the fact. To successfully avoid preg- raw egg white, without breaking in the middle. nancy, you have to be able to predict ovulation Nonfertile mucus is tackier and breaks apart about five to seven days in advance or else avoid easily at short distances between the fingers. exposure completely during the first half of the Experiment with an egg white, then try room- cycle. Obviously noncoital activities are permissi- temperature butter—you will see the difference. ble at all times; this method does not require Imagine the sperm swimming easily between actual abstinence, just avoidance of intercourse. long slippery parallel strands of mucus around ovulation, which is thought to ease transport into Calendar Methods the uterus and may also modify the sperm so that Rhythm, the oldest of birth control schemes, it is capable of fertilizing the egg. Ovulation usu- relies on a woman having a regular 28-day cycle, ally occurs in the middle or toward the end of the with ovulation occurring on day 14—exactly fertile mucus time; thus it is best to determine midcycle. Intercourse must be avoided for at least your length of fertility in advance a few cycles three days before and three days after ovula- before relying on this method. Obviously semen, CONTRACEPTION 53 spermicides, vaginal creams, or lubricants can transmission of these diseases between humans. adulterate the mucus and make this assessment Because some organisms, such as HIV, are intra- unreliable. Experiment. cellular, they may not get exposed to the spermicide during sexual intercourse, and therefore Basal Body Temperature protection may be compromised. In fact, Basal body temperature is measured by taking nonoxynol-9 is rather irritating to some, and the one’s temperature the very first thing in the irritation may result in vaginal mucosa (the morning before getting out of bed and before any lining of the vagina) that is more susceptible to activity at all. Wake up, reach over, take the tem- the AIDS virus. It is safe to use nonoxynol-9 perature, record. Plotting these numbers daily unless it irritates you; in that case, don’t. over a few months will show a nice pattern of Condoms should obviously be used with any ovulation. The temperature may drop a bit (usu- new sexual partner to protect against many, but ally around half a degree) just before ovulation, not all, sexually transmitted diseases. Alone as a and then goes up about a degree from there (now method of birth control, they can be reasonably half a degree over baseline) just after ovulation. effective. If used consistently and properly, fail- Release of the egg probably occurs the day before ure rates are reputed to be as low as 3 percent, the elevation,3 which persists until menses. Ele- although actual use failure rates are closer to 10 vation longer than the expected 12 to 14 days to 14 percent. Using condoms with an intravagi- usually indicates pregnancy. A digital thermome- nal spermicide provides about 96 percent safety ter will help you demonstrate this rise more accu- from pregnancy with typical use. This combina- rately, but you can use any thermometer if you tion is the best over-the-counter method. are willing to precisely plot the points. Healthy noninfected couples that choose condoms may prefer the comfort of lambskin BARRIER METHODS condoms; the pores of these condoms are too Barrier methods include anything that imposes big to protect well against viral-size organisms, a barrier between egg and sperm and include but they do just fine in keeping out sperm. Con- condoms, diaphragm, cervical cap, and any of doms, a very old tried-and-true method, are the spermicides. Only the condom physically enjoying a surge in popularity. prevents sperm from reaching the egg. The Caps and diaphragms work similarly; both diaphragm and the previously available cervical cover the cervix and hold spermicide either cap are both methods of holding spermicide against the cervix or facing the entrance to the against the cervix; they don’t really keep the egg vagina. The suction-based cervical cap is cur- from meeting sperm. The new FemCap does rently not available in the United States due to a cover the cervix but doesn’t hold the spermicide business decision by the European manufacturer. against the cervix. Rather, it contains a groove This had nothing to do with safety or effective- facing the vaginal opening to store and deliver ness. What is now available, perhaps the newest spermicide or any microbicide. Without spermi- method of birth control, is the FemCap. The cide, these methods are not highly effective. FemCap is made of nonallergenic, latex-free Most condoms are impregnated with spermicide material and is designed to cover the cervix. It these days, because of the presumed protection has a groove facing the vaginal opening that nonoxynol-9 provides against sexually transmit- stores and delivers spermicide. It is available by ted diseases. Nonoxynol-9 kills gonorrhea, prescription only but does not require a technical herpes, trichomonas, syphilis, and HIV in vitro,4 fitting session and measurement by the health- which may or may not translate into reduced care provider. A FemCap must be applied before 54 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE arousal and should be kept in place for at least dates, IUDs are simple, cheap, highly effective, six hours after the last intercourse. A backup reversible, and have a minimal impact on underly- method is recommended while you are learning ing physiological processes. to use it. FemCaps have the advantage of being Modern IUDs became popular with the able to be left in with ongoing efficacy for as introduction of the Lippes Loop in the early long as 48 hours. A FemCap comes with an 1960s, when as many as 10 percent of women instructional video. (Information is available at who used contraceptives chose this method. The www.femcap.com.) failure rate was about 2 percent, although the A diaphragm is a latex shield that covers the expulsion rate (coming out with the menstrual cervix. Diaphragms come in several sizes, and the flow) was reported to be as high as 12 to 20 per- correct size must be determined as part of a pelvic cent.3 Lippes Loops are still available and in use exam by a health-care practitioner. Spermicide around the world, although not available in the must be placed in the diaphragm, which is then United States. placed up against the cervix. The diaphragm must IUDs are used much more commonly in be left in for at least six hours after intercourse, Europe than in the United States, largely because and any additional intercourse during that six of the persistent fear American women and hours must be preceded by the addition of an providers still harbor from the Dalkon Shield applicator of spermicide. Diaphragms with sper- debacle during the 1970s. Unfortunately, this micide have an effectiveness rate of approximately device traumatized the cervix on insertion, and 94 percent. the string was made of a material that was a The contraceptive sponge was originally perfect conduit for bacteria to ascend into the introduced in 1983 and remained on the market uterus. An infection called pelvic inflammatory until January 1995. It was taken off the market disease (PID) increased dramatically in Dalkon because the manufacturer chose not to modern- Shield users, essentially due to the prevalence of ize the manufacturing and hygiene standards. In sexually transmitted diseases that ascended into 2005, the Today sponge returned to the market- the uterus and/or fallopian tubes; many women place with a new manufacturer. The sponge is a acquired serious infections and in many, infertil- convenient, disposable, one-size-fits-all vaginal ity resulted. Yet the company did not recall the contraceptive that can be purchased over the device for 10 years—at least 5 years after the counter at most drugstores. It is used with a sper- problems were known. The reputation of the micide and offers an 82 to 92 percent effective- IUD was tarnished forever, and a good contra- ness rate. ceptive method is all but lost to women who might well benefit from it today. INTRAUTERINE DEVICES There are presently very few IUDs in the Intrauterine devices are in a contraceptive class all United States because manufacturers don’t want to by themselves, and they may arguably be the least take a chance on a device that has become so invasive and highest efficacy form of birth control. unpopular. Copper was added to IUDs to increase Rumors persist that Cleopatra had a gold ring in effectiveness in the 1980s, which allowed smaller her uterus that prevented pregnancy and allowed a and better-tolerated devices to be used. The Para- healthy, active love life. And the camel drivers in gard copper T fails less than 1 percent of the the same era are said to have put small rocks in time4 and lasts for at least 10 years. Fertility is their camels’ uteruses to prevent pregnancy on the unchanged over baseline in women who do not long roads they traveled. These may just be good contract sexually transmitted diseases. The device stories, but for those women who are good candi- comes in only one size, and so is better tolerated in CONTRACEPTION 55 a uterus that has carried a pregnancy. It can be put otic can be utilized to prevent infection. If you in during nursing for excellent carefree contracep- do become pregnant, the IUD should be tion that will not interfere with lactation. The removed. Pregnancies will be interrupted by the mechanism of action is now fairly well docu- IUD, and a miscarriage can occur about half the mented as a inflammatory response in the uterine time. If desired, ultrasound can be used to iden- cavity. It is not felt to be an abortifacient (a sub- tify the IUD before removal to minimize disrup- stance that induces abortion). tion of a wanted pregnancy. IUDS can make menstrual flow heavier and with more cramping. For those women with mod- BIRTH CONTROL PILLS (BCPS) erate or light menses, however, it is a method Never has there been a more perfect love/hate that requires no mess or loss of spontaneity, and relationship than that between women and IUDs can be used for years without loss of efficacy. hormonal contraception or birth control pills Even at a cost of $600 to $700, this is a minimal (BCPs), also called oral contraceptives (OCs). In expense if used over a 10-year period. 1951, Margaret Sanger is credited with convinc- Women who are in monogamous relation- ing Gregory Pincus (who ultimately synthesized ships, have given birth, and are not at risk for the first oral contraceptive) that his research in sexually transmitted infections are perfect candi- fertilization could be used to create an oral dates for IUD use, if their periods are normal. contraceptive. Available for the first time in the Again, though, IUDs can increase the amount of 1960s, oral contraceptives were truly a revolu- the menstrual flow and increase cramping. The tionary medical option for women. Women exception is the newer IUD called Mirena. It readily embraced the option of having fewer contains a progestin (Levonorgestrel) on the children, and the dramatically lower birthrate stem, which shrinks the endometrium and that resulted has persisted, undoubtedly due to decreases menstrual flow and cramping. It can the pill’s continued widespread use. Women’s reduce the normal flow by 80 percent and causes maternal burden was lifted for the first time in a lack of menses in 15 percent of patients. The history. That’s the good news. Mirena lasts 5 years, and the progestin stays Unfortunately, the hormonal content of early active inside the uterus. It is thought that in the birth control pills—estrogen and progesterone— majority of women and in the majority of the was much higher than today’s pills, and more time, the progestin is confined to the uterus women smoked then. Both factors affected what without systemic absorption. However, clinicians is always the course of any new medicine—the will report cases of patients who appear to have downside became obvious only with mass use. It had systemic progestin side effects from the soon became apparent that cardiovascular dis- Mirena. The Mirena is an important option in ease, including heart attacks, strokes, blood clots, contraception—a method that provides 99 per- and pulmonary emboli, was more frequent in cent protection and decreases menstrual pain and women who used birth control pills. But even heavy flows. though “more frequent,” these diseases are still Insertion of an IUD must be done in a prac- exceedingly rare in the healthy population of titioner’s office. Most women report nothing young women who are the usual pill takers. It is more than light cramping. STI testing for also true that these risks are dose related and have chlamydia and gonorrhea should precede inser- fallen measurably as the estrogen and progestin tion. Infections caused by the insertion itself are content of pills has fallen 4 and 10 times respec- rare and may occur approximately 1 percent of tively since their initial use. The FDA-approved the time, within 30 days of insertion. An antibi- package insert states the following: 56 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE The information contained in this package one-fifth that of pregnancy. If we can manage to insert is principally based on studies carried avoid pregnancy in other ways, presumably they out in patients who used oral contraceptives are safer than the pills. with formulations containing 0.05 mg [50 There are some significant health benefits mcg] or higher of estrogen. The effects of attributable to the pill—for example, an 80 per- long-term use with lower-dose formulations cent reduction in ovarian cancer and a 50 percent of both estrogens and progestogens remain reduction in uterine cancer with about a decade to be determined. of use.3 Assessing an individual’s risk/benefit ratio requires individualization based on health The birth control pills in common use today status, family history, and so forth. If one’s risk of have 20 to 35 mcg of estrogen, and only one or cardiovascular disease doubles with use (it does), two formulations containing 50 mcg are even that sounds worrisome. But if doubling one’s risk available. Moreover, the studies documenting means going from a risk of 1 in 10,000 to 2 in these higher risks in the earlier days did not con- 10,000, that doesn’t sound so bad. This is just trol for other risk factors such as smoking, high another way of looking at the same fact. Inciden- blood pressure, obesity, and so forth—all known tally, this risk is not even close to the risk we take to independently increase a woman’s risk of car- driving our car to work or school. diovascular disease. I like the way the late Dr. Smokers older than 35, however, should not Felicia Stewart, who dedicated much of her life use the birth control pill. Most other women at and career to designing research and policies that higher risk of heart disease, like those with dia- make safe, effective contraception and abortion betes, hypertension, or elevated cholesterol, 4 accessible to women, describes pill risk: should consider other options as well—but even If you were to draw a line 215 meters high in these conditions, pills are usually safer than an (the height of a 70-story building) to repre- undesired pregnancy. Blood pressure needs to be sent 100,000 young nonsmoking pill users, followed in all pill takers, and, if elevated signifi- and then draw a line beside it to represent cantly by use, another birth control method must the number of pill users in the United States be chosen. who die each year from complications relat- Breast Cancer and the Pill ed to higher-dose pills, that second line would be about 0.5 centimeters high [about Much attention has been given to the relation- one-fifth of an inch]. In comparison, the ship between the pill and breast cancer, and line representing the number of U.S. slowly some answers emerge. The Centers for women who would die of pregnancy-related Disease Control (CDC) conducted a study in the problems would be just under 2.5 centime- 1980s called the “Cancer and Steroid Hormone ters high [about an inch]. A line represent- Study” that looked at nearly 5,000 cases of breast ing maternal mortality in developing coun- cancer and 5,000 healthy control women and tries would be 25 centimeters to 1.5 meters concluded that there was no increased risk of 3 tall [10 inches to just under five feet]. breast cancer in women who had used the pill. Another significant study evaluated a pooled Risks attendant to birth control use must be analysis from 54 studies involving 53,297 measured against the risk of the pregnancies they women with breast cancer and over 100,000 prevent. We are fortunate to live in the time of controls and concluded that there is a slight but the lowest maternal mortality ever—and still the measurable increase in the relative risk of breast risk of oral contraception we all worry about is cancer for current BCP users that declines CONTRACEPTION 57 shortly after stopping the pill and disappears The cancers in former users are generally of a within 10 years.5 By age 50, there is no difference less advanced stage than the cancers of nonusers, in the risk of breast cancer in women who have and benign breast disease (cysts, fibrosis, breast ever used oral contraceptives versus those who pain, swelling) is generally improved by BCP use. have never used them. Also, the increase in risk Overall, there appears to be no evidence of any during use (1.24 relative risk) translates differ- significant increase in the lifetime risk of getting ently in a 20-year-old woman versus a 40-year- breast cancer among women who have used oral old woman. If the risk of breast cancer at 20 is 1 contraceptives. in 5,000 (or less), then a relative risk of 1.24 Before deciding for or against BCPs, consider increases it to 1 in 4,000. However, if a woman your risk for breast cancer (although most is 40 and the risk of breast cancer is about 1 in women who get breast cancer are not at risk, and 250, a relative risk of 1.24 increases her risk to 1 most at risk don’t get it),6 whether pregnancy in 200. Thus, the increase is clearly more signifi- poses a risk, and any other health risks and ben- cant in an older woman. In this age group, of efits related to BCP use. 1,000 40-year-old women who take the pill, one will contract breast cancer as a consequence. Other Health Benefits Only about 15 percent of breast cancers occur in of Birth Control Pills women younger than age 45,6 which is when Several years ago, the FDA began to require that, most of us take oral contraceptives. in addition to risks, pill manufacturers list bene- A very recent meta-analysis that revisited oral fits, because they are so significant. Some women contraceptives and the risk of breast cancer, pub- actually take birth control pills for the health lished in October 2006, concluded that oral con- benefits they offer. Oral contraceptives protect traceptives do increase the risk of premenopausal from uterine and ovarian cancers in the general breast cancer.7 Thirty-four case-control studies of population, but we aren’t sure yet about those in oral contraceptives and premenopausal breast families with a higher incidence. They protect cancer during or after 1980 were identified. Analy- from pregnancy nearly 100 percent of the time, sis of the data from these studies showed that the although even with perfect use, there is still risk of breast cancer was slightly increased for both about 1 pregnancy in 1,000 women per year, and nulliparous (having never given birth) and parous with common human error, a 2 percent failure (having birthed one or more times) women. In rate is more accurate. As a bonus, they reduce nulliparous women, the longer duration of use of heavy, painful periods in everyone. the pill did not significantly affect risk. In parous About 80 to 90 percent of functional ovarian women, the increased risk was more substantial cysts (those related to ovulation, the most when the oral contraceptives were used before the common type) are eliminated in women who first-full term pregnancy. The risk was highest in take birth control pills.4 Those who suffer from parous women who had used the pill for four or endometriosis can frequently reduce their ongo- more years before their first full-term pregnancy. ing pain by suppressing the disease with oral There are many limitations of this kind of review contraceptives. Women with polycystic ovary because there are so many variables, including race, syndrome and abnormal male pattern hair possible recall bias, difference in the age of first growth can decrease hair growth with oral con- using the pill, and poor information on when the traceptives because they measurably reduce the pills were last used. Taking oral contraceptives male hormones known as androgens in these must be decided based ultimately on the benefits women. Interestingly, because of the thickening compared to the risks for each woman. in cervical mucus that birth control pills induce, 58 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE it is less likely that women who take them will be that OCs interfere with gastrointestinal get pelvic inflammatory disease if they are absorption or with metabolism or binding. There unlucky enough to get gonorrhea or chlamydia seems to be general consensus in the literature in the cervix. Fertility is spared in this way. that consumption of oral contraceptives con- 9 Several recent studies have shown that a seven- tributes to pyridoxine (vitamin B6 deficiency). It day hormone-free interval causes more of a rise in has been estimated that the majority of women follicle-stimulating hormone (FSH), which causes on OCs for longer than six months manifest ovulation. Continuous daily regimens or shorter abnormal tryptophan metabolism. Vitamin B6 drug-free intervals (three or four days only) pre- can normalize tryptophan metabolism. vent ovulation. Suppression of ovulation reduces Although not consistent, some research has the cyclic symptoms some women have on the shown that OCs disturb folate metabolism. typical 21 days on and 7 days off pill regimens. Anemia, the gastrointestinal and genital tracts, There is also less breakthrough bleeding and a bone and heart health, and mental function are decrease in pregnancy rates with these shorter all affected by folic acid deficiencies. For this time-off regimens. More and more women are reason, folate is an important nutrient to supple- using their birth control daily, or for three months ment for women taking the pill. Oral contracep- at a time. Many oral contraceptives are being tion users have also been reported to have 9 repackaged with only three or four days of hor- reduced levels of vitamin B12. This may be mone-free pills, and we will likely see more of this related to malabsorption, increased renal excre- in the future. tion, and enhanced tissue acidity. A woman may or may not acquire an anemia associated with a Nutritional Supplements for Pill Users B12 deficiency, but long-term use of the pill may Apart from their hormonal effect, the hormones lead to this, or at least may compromise nerve in birth control pills have been shown to affect function, mood, mental function, and the health metabolic and nutritional factors. Women on oral of the digestive system. Carotenoids are also contraceptives may want to take nutritional sup- included in this formula to protect the cervix. plementation to adjust for some of the biochemi- Oral contraceptives have shown mixed results in cal alterations caused by the pill. Women on BCPs increasing abnormal changes in the cervix that have a higher requirement for folate,8 and this may can lead to cervical cancer. Beta-carotene defi- be especially true for women who have had cervi- ciency in the cervical cells may be a cofactor in cal dysplasia (precancerous abnormal cells of the the development of cervical dysplasia,10 and cervix). The frequent ingestion of the steroids decreases in plasma beta-carotene levels is found found in BCPs have been shown to depress levels in women with either cervical dysplasia or cancer 11 of riboflavin, pyridoxine, vitamin B12, ascorbic of the cervix. acid, and zinc.9 Hormones can also affect breast Reduced levels of ascorbic acid have also been tenderness, increase risk of blood clots, and induce observed in those who take oral contraceptives.9 an array of side effects in some women, and they It is possible that the steroids of oral contracep- are metabolized in the liver. Providing selective tives increase the breakdown of ascorbic acid, nutritional support, supporting breast health, and decrease absorption, and/or change tissue distri- enhancing hormonal metabolism and detoxifica- bution. Limited research in animals has shown tion pathways may optimize the experience of that oral contraceptives lower blood levels of vita- using hormonal contraception. min E.9 Vitamin E is the premier antioxidant for Riboflavin deficiency may occur with long lipids, protects structures against toxic com- periods of oral contraceptive (OC) use.9 It may pounds, and is important in immune function. CONTRACEPTION 59 Most investigations have shown a reduction in vaginal ecology by taking lactobacillus in the form plasma zinc levels following the administration of a nutritional supplement. of OCs.9 Decreased absorption, increased uri- Additional considerations may include liver nary excretion, and a decrease in albumin, an support to aid in the metabolism of the steroids. important carrier of zinc, may account for this. There are many options here, including a Zinc is essential to good health and is involved in lipotropic supplement and herbs such as dande- many enzyme and body functions. Immune lion root, burdock root, and milk thistle. function; wound healing; the nervous system; Little information is available about any maintenance of vision, taste, and smell; and skin interactions between botanicals and birth control health are dependent on adequate levels of zinc. pills. For now, my only real caution is with Saint- Zinc competes with copper for absorption, there- John’s-wort. A few case reports, as well as two fore adding a small amount of copper is also sug- controlled clinical trials, indicate that Saint- gested to avoid any problems. John’s-wort can cause breakthrough bleeding and Borage seed oil is high in gamma linolenic interferes with the metabolism of the hormones acid (GLA), which is important in maintaining in the pill. These observations lead me to think pain-free breasts. GLA decreases abnormal sensi- that the effectiveness of oral contraceptives may tivity of breast tissue to normal hormone levels. be reduced when taken in conjunction with The proposed mechanism of GLA’s action is that Saint-John’s-wort.16–18 Other speculations have it normalizes the balance of fatty acids contained been made about the possibility of other herbs within the cell membranes. The steroid receptors and nutrients interfering with the effectiveness of in the breasts then have a reduced affinity for birth control pills. However, hypotheses about estrogen, dramatically reducing breast sensitivity. chaste tree, indole-3-carbinole, soy, dong quai, Oral contraceptives can increase the risk of and others have no documentation to support blood clots, although this risk has been consider- these concerns. ably reduced since the lower-dose pills have become the norm. However, these concerns still Side Effects deserve our attention. Bromelain has a very favor- Many women prefer not to take birth control able effect on inflammation of a vein. In research, pills because they see them as an unnatural form bromelain has been shown to reduce all the symp- of birth control. Others are concerned, rightly so, toms of inflammation in those who had developed about some of the issues that have been raised acute thrombophlebitis.12 Garlic preparations here, but some women just plain don’t feel good have been shown to promote fibrinolysis, which on them. Some women have bloating, breast ten- can offer benefit in prevention of strokes and other derness or pain, headaches, mood swings, depres- clotting events.13, 14 Excessive clumping together sion, weight gain, nausea, lowered libido, and of platelets is linked to heart disease and strokes. breakthrough bleeding. Other women may expe- Garlic and its volatile oils can inhibit platelet rience significant, more serious side effects such aggregation and thereby improve circulation.15 as complete hair loss, blood clots, high blood Finally, women taking hormonal contracep- pressure, heart attack, and elevated liver enzymes. tives can experience changes in vaginal pH, which There are many kinds of birth control pills can lead to changes in the balance of organisms in today, and fortunately they are significantly lower the vagina. Lactobacillus species are fundamental in dose and cause far fewer side effects than in the to maintaining a healthy ecological vaginal envi- past. The pills vary in their estrogen and progestin ronment, which helps to prevent yeast and vaginal dosages and contain different kinds of estrogens infections. It may be possible to favorably alter this and progestins. A woman may tolerate one pill 60 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

poorly and another very well. If you struggle with Emergency Contraception feeling good on “the pill,” you should work with a health-care provider who knows the products well. Take 4 of one of the following pills within 72 hours Many side effects come from the progestin, and after unprotected sex, and take 4 more pills 12 hours there are currently six different progestins found in later: various birth control pills. Merely switching to a Cryselle pill with a different progestin can result in feeling Levlen normal while on the pill. There are pills with dif- Levora ferent estrogen doses as well. Lo/Ovral Overall, women need to assess how they feel Another option: take 5 of one of the following pills on oral hormonal contraceptives. Some women within 72 hours after unprotected sex and take 5 are moody, some are less so. Some women love more pills 12 hours later: the regularity of their periods and their reduced Alesse pain; others feel nauseous and bloated. Some love Aviane that their acne improves; others fret about breast Lessina cancer. Some women feel great and have low Levlite risks for most diseases; for them, the hormones Low-Ogestrel Nordette can fit into a healthy life. Portia The pill is not a natural form of birth control, Seasonale but for some women the benefits outweigh the downside. If you do choose to use birth control pills, remember that one of the advantages to appears to result primarily from an inhibition or barrier methods of contraception (diaphragm, delay of ovulation and does not disrupt an FemCap, condoms) is the reduced incidence of already established pregnancy. sexually transmitted infections (STIs), especially It is also possible to use more pills of a birth pelvic inflammatory disease. Oral contraceptives control pill that you might already have on hand do not significantly protect against most STIs. for emergency contraception. Condoms are the best method of contraception that also offers a “safer sex” method. Diaphragms OTHER FORMS OF and caps do not provide for safer sex, but they HORMONAL CONTRACEPTION may help stop sexually transmitted infections There are other hormonal contraceptive options from ascending into the uterus and pelvic region. available, in addition to the familiar estrogen/ These are important considerations when choos- progestin pills. There are progestin-only hormone ing your method of contraception. preparations—pills, injections, and implants. These options can have many of the same nui- Emergency Contraception sance side effects of combination pills—weight Emergency contraception refers to using birth gain, irritability, and depression. Progestin-only control pill hormones to prevent pregnancy after birth control pills are used by women who are intercourse has occurred. The only emergency breast-feeding or who have a contraindication to contraceptive pill (ECP) that is currently avail- estrogen, such as hypertension. The injection able is a progestin-only pill called Plan B. Two (Depo-Provera) and the new implant (Implanon) pills, taken 12 hours apart, reduce the risk of have a lower failure rate because compliance is not pregnancy by 75 percent if initiated within 72 required on a daily basis—only once every three hours after unprotected intercourse. The effect months for the Depo-Provera shot and every three CONTRACEPTION 61 years for the Implanon. Both work by suppressing estrogen levels can expose women to a higher risk ovulation to an extent, neither as completely as the of clotting. Clearly, this issue needs to be dis- combination birth control pill, but this mecha- cussed with your health-care practitioner. nism is augmented by even thicker cervical mucus that impedes the sperm at the cervix. They aren’t STERILIZATION as good for cyst suppression because of the incom- Sterilization for men and women is still a widely plete suppression of ovulation. Implanon boasts used form of birth control. For men, this is a vasec- the lowest systemic hormone dose of any hor- tomy. For women, there is now an alternative to a monal method because it is released at such a tubal ligation, called Essure. Tiny springs are steady low dose by the implant. As a consequence, inserted into the openings of the fallopian tubes menses are irregular in up to 40 percent of from the cavity of the uterus, so no surgery is done. women. This tends to improve over time and is It can be provided in an outpatient setting. A tolerated better by some than others. doctor uses a speculum, dilates the cervix, inserts a Depo-Provera, on the other hand, suppresses flexible fiber optic scope to see inside the uterus, menses entirely by one year of use, and it can take then threads the springs into the tubes. 5 to 18 months for fertility to return. There is con- You must have a tubal dye x-ray test three cern that inadequate estrogen will be available for months after insertion to check that tissue grew bone density protection as a consequence of the into the springs and blocked the tubes, indicat- estrogen suppression. There is reversible bone loss ing a successful sterilization. over time on Depo-Provera, and the FDA has required the company to do a prospective study of ABORTION bone density in users. Because both the shot and Unfortunately, all methods of birth control can the implant cannot be immediately reversed once fail. Humans make mistakes. Women have sex they start, I encourage women to try the pill first, against their wills. For all these reasons and more, unless they can’t remember to take a daily pill or abortion will always be with us, and it bears a can’t tolerate the estrogen. There is also a vaginal mention in a discussion of fertility control. ring, Nuvaring, that contains both estrogen and Women practiced abortion long before they prac- progestin and lasts three weeks, which is popular ticed birth control, because that’s what was avail- with women who forget their daily pill. able to them. The last measurable drop in Transdermal combined estrogen/progestin maternal mortality in the United States occurred can be delivered in a contraceptive patch and is with the legalization of abortion in 1973. Abor- available as Ortho Evra. It was approved by the tion has never been safer, with mortality at 0.25 FDA in 2002 and delivers 20 mcg of ethinyl deaths per 100,000 women—about 20 times safer estradiol and 150 mcg of norelgestromin, an than childbirth.19 Unfortunately, the political active metabolite of norgestimate. The regimen is fracas around abortion—and the real risk to work- to apply a patch once weekly for three consecu- ers and patients of clinic violence—has made tive weeks, followed by a patch-free week. It has access to abortion more rather than less difficult in a side effect profile similar to the oral contracep- recent times. We must recall that the battle for tives, although recent concerns have been raised birth control was nearly as emotional; perhaps about higher blood levels of estrogen in women someday we will see this struggle resolved as well. on the patch than on the birth control pill. The In the interim, if you choose an abortion, con- newer estrogen patch is associated with about 60 sult your regular provider first. Gynecologists and percent higher blood levels of estrogen than the family doctors need to realize how many women equivalent version in an oral pill. This increase in (1.5 million per year) in all walks of life need this 62 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE service and how judged they feel—most obviously Rather than a surgical abortion, medical abor- by “pro-life” practitioners, but also by their pro- tion with a drug called mifepristone (Ru-486) is a choice doctors who send them across town to a good option for early pregnancies, and it offers a clinic just because it’s easier for that doctor. If your method of abortion that aligns much more natu- gynecologist won’t help, go to one of the wonder- rally with our bodies. The medical abortion is just ful women-run and supported clinics that provide like a miscarriage. There is more bleeding and the service out of love and respect for women. cramping than a period, but it occurs within a 4- Their doctors are very experienced, with extremely to 24-hour period, and 98 percent of the time low complication rates. Emergency contraception avoids surgery altogether. The infection rate is can be obtained at most clinics as well, although lower, and the chance of significant uterine injury, emergency contraception is now available over the already miniscule, is further lowered. Many counter for women over the age of 18. women are quite pleased with this method.

Summary of Contraceptive Choices

Birth Control Pills Side effects such as weight change, irregular bleeding Advantages Continuous contraceptive protection when taken Effectiveness correctly 99 percent or greater Reversible Other possible health beneﬁts Tubal Ligation

Disadvantages Advantages Has to be taken daily Continuous contraceptive protection Increases the risk of blood clots, heart attack, and Disadvantages stroke, especially in smokers over age 35 Side effects such as nausea, weight gain, headaches Permanent A surgical procedure Effectiveness Effectiveness 99 percent or greater 99 percent or greater Depo-Provera Injections Essure Advantages Advantages Continuous contraceptive protection for up to 5 years Continuous contraceptive protection Reversible Insertion through vagina and uterus; no surgery is Don’t need to remember to take a daily pill or use a needed device Disadvantages Disadvantages Permanent

Requires a visit to a practitioner for quarterly Effectiveness injections Delayed fertility after stopping the injections 99 percent or greater (continued ) CONTRACEPTION 63

Summary of Contraceptive Choices (continued )

Intrauterine Device (Copper IUD) Condoms may break Male partner must agree Advantages Continuous contraceptive protection for up to 10 years Effectiveness Don’t need to remember to take a daily pill or use a 88 to 98 percent device Reversible Diaphragm (with Spermicide)

Disadvantages Advantages May be expelled by the uterus; may perforate the Insert up to 6 hours before intercourse uterus Noninvasive method Increases the risk for PID Inexpensive May cause heavier bleeding and menstrual cramps Disadvantages Effectiveness Must leave in for at least 8 hours after intercourse 97 to 99 percent Must reapply spermicide for repeat intercourse Discomfort Intrauterine Device (Progestin IUD) Must be able to insert by oneself Increases the risk of urinary tract infections Advantages Continuous contraceptive protection for at least 5 Effectiveness years 82 to 94 percent Don’t need to remember to take a daily pill or use a device FemCap May decrease menstrual cramps and heavy bleeding Advantages Reversible Insertion before sexual arousal Disadvantages Easy ﬁttings May be expelled by the uterus; may perforate the Inexpensive uterus Disadvantages Increases the risk for PID Must leave in for 6 to 8 hours after intercourse Effectiveness Vaginal odor and discharge 97 to 99 percent May be uncomfortable to insert Effectiveness Condom (Alone) 82 to 94 percent Advantages Easily obtained Spermicide (Alone) Inexpensive Advantages Best method for protection against STIs Better results when used with a spermicide Easy to obtain and use Good results when used with cervical caps, condoms, Disadvantages or diaphragms May reduce sexual sensation Inexpensive Less sexual spontaneity (continued ) 64 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Summary of Contraceptive Choices (continued )

Disadvantages Allergies in some people May increase the risk of urinary tract infections, Must be inserted within half hour prior to especially with diaphragms intercourse Reapplication necessary for repeated intercourse Effectiveness May be messy 79 to 97 percent CYSTITIS CHAPTER 5

OVERVIEW • Recent use of antibiotics Ten to twenty percent of all women have some • Symptoms that have lasted longer than kind of urinary discomfort or infection at least seven days once a year. Acute uncomplicated cystitis (infec- • Diabetes tion of the bladder) and recurrent cystitis are two • Immunosuppression (HIV, immunosuppres- important categories of urinary tract infections sive medications) in adults. Distinguishing between uncomplicated Simple, short-duration therapies may not be and complicated urinary tract infections (UTIs) appropriate for these situations. is important because they may require different It is reassuring that most of the acute UTIs that evaluation tests and procedures, as well as different occur are uncomplicated. Health-care practitioners types and duration of treatment plans. A compli- can generally assume that a premenopausal, sexu- cated infection is associated with a condition that ally active woman who is not pregnant, has not increases the risk of urinary tract infections or is been recently treated with antibiotics, and does associated with an increased likelihood of treat- not have a history of a genitourinary tract abnor- ment failure such as HIV, diabetes, or having a mality has uncomplicated cystitis if she presents catheter. An uncomplicated infection is one that with dysuria (painful or difﬁcult urination), fre- lasts less than one week, is unaccompanied by a quent urination, or urgency. It is even likely that fever, and presents itself in low-risk individuals, most postmenopausal women who do not have a such as nonpregnant, otherwise healthy women. genitourinary tract abnormality have uncompli- Symptoms of uncomplicated cystitis include cated UTIs. painful and frequent urination, the urge to uri- A narrow spectrum of microbes are responsible nate even though the bladder may be nearly for the infections in young women with acute empty, and pressure and pain in the pelvic area. uncomplicated cystitis: Escherichia coli (80 per- Acute cystitis is generally uncomplicated but may cent), Staphylococcus saprophyticus (5 to 15 per- be complicated if the individual has a catheter or cent), and occasionally Klebsiella species, Proteus also has a stone in the bladder. It is not always mirabilis, or other microorganisms. Bacteriuria possibly to classify someone as having a compli- (bacteria in the urine) is more common in women cated or uncomplicated UTI based on urinary who are sexually active, and certain forms of contract symptoms alone. However, there are factors traception are associated with urinary tract infec- that suggest the presence of a complicated UTI tions. Sexual intercourse, diaphragm use with in women. These include: spermicide, spermicides used alone, oral contraceptives, delayed postcoital urination, and a history of • Being elderly or young a recent urinary tract infection all increase the risk • Having a hospital-acquired infection of initial and recurrent infection. Sexual inter- • Pregnancy course is the strongest risk factor for UTIs, inde- • Having a urinary catheter pendent of contraception inﬂuences. As many as • Having had a recent procedure involving 30 percent of women with cystitis symptoms may urinary tract instrumentation have subclinical upper urinary tract involvement. 65

Copyright © 2008 by Tori Hudson. Click here for terms of use. 66 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Young women who present with acute pain Diagnosis of a bladder infection can be based with urination or difficult urination usually have on symptoms and physical exam alone, a urine either acute cystitis or acute urethritis due to dipstick, urinalysis, and/or a urine culture. Basing Chlamydia trachomatis, Neisseria gonorrhoeae, or the diagnosis on symptoms alone is considered herpes simplex virus. Vaginitis due to candida or reliable when the episodes are infrequent or occur trichomonas can also involve dysuria. These prob- less than three times per year. The urine dipstick lems can usually be differentiated on the basis of test is a simple test performed in the practitioner’s symptoms, physical exam, and urinalysis. A urine office that uses a dipstick of the urine to test for culture and vaginal cultures may also be needed. leukocyte esterase with or without urinary nitrite Pregnancy is also a risk factor for UTI. The and pyuria (the presence of pus in the urine). American College of Obstetricians and Gynecolo- There are problems with the sensitivity and speci- gists (ACOG) recommends that all pregnant ficity of the test, and it may be incorrectly negative women be screened for bacteriuria, even without if bladder bacteria have not had enough time symptoms. However, not all major authorities rec- to produce a sufficient amount of nitrite to be ommend this. Screening involves an initial urine detectable. The accuracy of the test is also altered culture in all women who are pregnant. If a preg- if the individual is eating a vegetable-free diet or is nant woman has classic symptoms of an acute and using a diuretic. The nitrite tests on the urine dip uncomplicated cystitis and no previous history of are frequently negative, even in the presence of bacteria in the urine without symptoms, some cli- two bacteria, S. saprophyticus and Enterococcus nicians would go ahead and treat for cystitis, while species. The leukocyte esterase test is more accu- others would do a urine culture before treating. rate than the nitrite test. Recurrent infections, defined as more than The urinalysis is a macroscopic and micro- three infections in six months or six to seven scopic analysis of urine performed at the practi- infections in a year, occur in about 20 percent of tioner’s office or the lab. The urine is examined for young women that have experienced a previous color and cloudiness, then examined under the episode of cystitis. Over 90 percent of recur- microscope for white blood cells, red blood cells, rences in young women are episodes of reinfec- epithelial cells (looking especially for an increased tion from exogenous sources that typically occur number or some sloughing down from the kid- months apart. Recurrences due to a persistent neys), bacteria, yeast, and crystals. The urine dip- focus of infection in the urinary tract or to stick test is also done in a complete urinalysis. anatomical or functional abnormalities are less A urine culture is often done after a history and common. Cases of recurrent cystitis should be physical exam suggests something other than an cultured and documented at least once. Some acute, uncomplicated UTI. If a recent UTI has just women may need not only treatment but also been treated and now the symptoms are recurring, continuous prophylaxis (preventive measures) or a culture would identify the possibility of a resist- postcoital prophylaxis. ant pathogen. Worrisome symptoms such as fever, Postmenopausal women may also have fre- malaise, and back pain over the kidney region quent reinfections, which are often due to resid- suggest that the infection may have ascended the ual urine retention after voiding or to a lack of urinary tract and warrant a urine culture. estrogen, which can cause marked changes in the Other diagnostic evaluations of UTI such as a vaginal and bladder microflora, including loss of cystourethroscopy, ultrasound, or intravenous lactobacilli and increased colonization by E. coli. pyelogram should be considered in women who Vaginal estrogen treatments are a key in restoring have recurrent UTIs. Even though these more normal vaginal and bladder flora. sophisticated studies should be considered, it is also CYSTITIS 67

KEY CONCEPTS PREVENTION

• UTIs are most commonly caused by the organism • Increase fluid intake. E. coli. • Urinate when you have the urge. • UTIs are most common in young heterosexually • Maintain bathroom hygiene. active women. • Wear cotton undergarments. • Sexual intercourse is the strongest risk factor for • Urinate after intercourse. a UTI. • Consider a different contraceptive method if you • Spermicides, diaphragms, and hormonal contra- are getting recurring UTIs. ception all increase the risk for UTIs. • Drink fresh juices, especially berry juices includ- • Pregnant women and postmenopausal women ing cranberry and blueberry. are also at risk for UTIs due to the effect of • Eat fermented milk products containing probi- hormones on the flora of the vagina, urethra, otic bacteria. and bladder. • Reduce dietary bladder irritants such as alcohol, • Common diagnostic tests include the urine chocolate, citrus fruits, coffee, black tea, toma- dipstick and the urine culture. toes, vinegar, and sugar. important to realize that some women may report quantity of liquids. Water and herbal teas related symptoms that may sound like an infection, but to the treatment goals are the most logical are actually symptoms from an overactive bladder, choices. Sixty-four ounces of liquids per day is interstitial cystitis, or a pelvic-floor problem such as the common recommendation. Urinating after a cystocele or uterine prolapse. Keep in mind that intercourse is also an important bladder hygiene some recurrent UTIs are caused by anatomic fac- practice that can prevent recurring UTIs. tors such as a shorter urethra-to-anus length or The lactobacilli species are an especially effec- birth defects in the urinary tract. tive means of alternative treatment for a couple of reasons. For one, they defend against E. coli, which OVERVIEW OF causes the majority of urinary infections. A healthy ALTERNATIVE TREATMENTS vaginal ecology is dominated by lactobacilli For most bladder infections, a natural approach is species,1 bacteria that defend against both UTIs usually very effective and the infection resolves and infectious vaginitis. Studies have shown that quickly without recurrence or complications. The women who have recurrent UTIs have a prepon- primary goals of a natural therapeutics approach derance of uropathogens on the introitus and in are to: the vagina.2 Lactobacilli adhere to the uroepithelial cells and inhibit the adherence of pathogenic • Enhance the individual’s internal defenses organisms such as E. coli to the cells, thereby pre- against the infection by providing immune venting proliferation. In addition, the H O - support 2 2 producing lactobacilli that are most commonly • Restore vaginal and bladder microflora, found in the normal bladder flora (Lactobacillus enhancing the flow of urine crispatus and Lactobacillus jensenii ) can help to • Promote a proper pH by acidifying the urine keep the bladder in its preferred acidic state.3 • Prevent bacteria from adhering to the bladder lining Nutrition Simple goals, such as increasing the urinary Since most UTIs are caused by E. coli, and this flow, are easily accomplished by increasing the resides predominantly in the gastrointestinal tract, 68 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE it seems reasonable that the risk for infection shown that cranberries and cranberry juice are might be altered by dietary influences and diges- effective in women with active urinary tract tive health. In fact, the risk for infection changes infections.8–9 In a large randomized, controlled with dietary modifications.4 The dietary and study, 300 ml (10 ounces) of cranberry juice was lifestyle habits of 139 women university students given to 153 elderly women with confirmed bac- with a diagnosis of an acute UTI were compared teruria.10 The level of bacteria in the urine and with those of 185 age-matched women with no the frequency of recurring infections was dramat- UTIs in the last five years. It was found that fre- ically decreased. In another study, 500 ml per quent consumption of fresh juices, especially berry day (17 ounces) of cranberry juice was shown to juices, and fermented milk products containing be helpful in 73 percent of the individuals with probiotics was associated with a decreased risk active UTIs.11 In an older study, 16 ounces of of recurring UTIs. Consuming fermented milk cranberry juice daily was effective in 73 percent products three or more times per week was better of individuals with an active infection. than less than one time per week. In this same This effectiveness is commonly attributed to study, frequency of intercourse was associated with cranberry juice’s hippuric acid content, antibac- increased risk of UTI as well. terial effect, and acidity. However, studies have Common probiotic-containing fermented shown that components in cranberry juice milk products include lactobacillus acidophilus reduce the ability of E. coli to adhere to the lining and kefir. Increasing garlic and onions in the diet of the bladder and urethra.12–15 may also be helpful due to their antimicrobial Often, women prefer cranberry extracts activity. They have been shown to inhibit the instead of cranberry juice as unsweetened cran- growth of E. coli, Proteus, Klebsiella pneumonia, berry juice is unpalatable and sweetened cranberry Staphylococcus, and Streptococcus.5–7 is more challenging to the immune system. Cran- Other logical dietary considerations for berry extracts are available in capsule form and women with recurring infections are to avoid have been studied for prevention of UTIs. Cran- excess sugar consumption, assess and avoid food berry extracts were compared with cranberry juice allergens, and eat a diet that promotes healthy in a one-year randomized, controlled trial in 150 digestive function, including complex carbohy- sexually active women of diverse ages.16 One tablet drates, high fiber, fermented dairy products, and was given twice daily to women in one group, and healthy oils such as olive oil, nuts, and seeds. 250 ml of cranberry juice was given three times Large amounts of fluids are highly recom- per day to the other group. Both decreased the mended for preventing UTIs, as they literally number of individuals who had at least one infec- flush out the urinary tract and dilute the concen- tion per year. Antibiotics were also used less in tration of disease-causing bacteria. Drink approxi- both the extract and the juice group, compared mately 64 ounces (two liters) per day, including with the placebo group. 16 ounces (500 ml) of unsweetened cranberry Cranberry extracts are less expensive than juice (see section on cranberry) and 8 ounces of cranberry juice. Another advantage of the blueberry juice (250 ml) daily. extracts is the concern that the oxalates in cranberry juice could contribute to kidney stone Nutritional Supplements formation. While logical, no studies have yet Cranberry. No natural approach to cystitis demonstrated an increase in kidney stones after would be complete without mention of cran- drinking cranberry juice. berry. Women have used cranberry juice as a Cranberry extracts can also be found in home remedy for decades. Several studies have numerous combination herbal/nutritional for- CYSTITIS 69 mulations along with uva-ursi, pipsissewa, weekly.18 Each patient had infection-free periods Oregon grape root, marshmallow root, buchu, ranging from four weeks to six months. vitamin C, and others. Cranberry is safe for preg- Lactobacilli species are safe for pregnant and nant and lactating women. lactating women.

Cranberry Extract Vitamin C. The beneficial effects and functions Acute infections: 400 mg 3 times daily or more of vitamin C are numerous and critical to optimal Chronic, recurring infections: 400 mg 1–2 times health. Vitamin C is involved in the manufacture daily of collagen, the main protein substance in the body, which results in its role in wound repair, connective Lactobacilli. Probiotics, especially lacto- tissue structures, vascular wall integrity, skin elastic- bacilli, are commonly used by alternative ity, healthy gums, and more. It is also critical to providers to prevent UTIs. Lactobacilli species immune function, the absorption and utilization of predominate the vaginal and urinary tracts of other nutrients, and the manufacture of numerous healthy premenopausal women. Women who hormones and nerve conduction substances, and it have recurring UTIs have an imbalance of their is an antioxidant. As early as the 1960s, ascorbic flora, and if we restored the flora, we could go a acid (vitamin C) was shown to be an effective long way to prevent the infection-causing organ- urinary acidifying agent,19 a successful means of isms from dominating. treating urethra and bladder infections. A recent review was done of all studies on the While some of these functions help maintain role of lactobacilli and UTIs in 2006.17 From normal tissue health of the bladder and urethra, the studies that are available, probiotics appear vitamin C has some additional effects when it to be beneficial for preventing recurrent UTIs in comes to treating UTIs. During a UTI, nitrates women. The Lactobacillus rhamnosus and reuteri are often generated by bacteria in the urine. (previously called L. fermentum) strains were found Acidifying nitrite forms nitric oxide along with to be the most effective. other reactive nitrogen oxides that are toxic to a The hydrogen peroxide–producing lactobacilli host of organisms, including cystitis-causing bac- are critical in maintaining acidity and inhibiting teria. A study examining the effects of ascorbic pathogenic bacteria from adhering to both the acid on nitrite in the urine and bacterial growth vaginal and bladder walls. In addition to consum- found that acidifying the urine, even mildly, gen- ing fermented dairy products with lactobacilli, erated large amounts of nitrous oxide, which was vaginal suppositories and oral supplementation increased by larger amounts of ascorbic acid. As are good means of administering lactobacilli. In a a result, the growth of three common bladder small study, women with recurrent urinary tract pathogens, E. coli, Pseudomonas aeruginosa, and infections were treated with Lactobacillus casei Staphylococcus saprophyticus were significantly species topically and via suppository twice inhibited.20 These results provide a good ration-

Lactobacilli Species Vitamin C Acute infections: 24 billion organisms or more per Acute infections: 500–2,000 mg every 2 hours for 2 day for active treatment days, then 500–2,000 mg 3 times daily for 5–10 Chronic, recurring infections: 8–16 billion organisms days per day Chronic, recurring infections: 1,000–3,000 mg daily Prevention: 2–8 billion organisms daily Prevention: 500–1,000 mg daily 70 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE ale for the beneficial effects of vitamin C for both branes, uva-ursi is best used in combination with prevention and treatment of UTIs. other botanicals. It is not safe for use by pregnant Vitamin C is likely safe for pregnant and lactat- women and unknown whether or not it is safe ing women in controlled amounts: up to 2,000 mg for lactating women. per day in women over age 19 and up to 1,800 mg per day for women 14 to 18. Uva-Ursi D-Mannose. D-mannose is a naturally occur- Acute infections: 1–11⁄2 tsp tincture or 300 mg dried 1 ring simple sugar contained in cranberry juice that herb capsule every 3 hours for 2 days, then 1–1 ⁄2 is helpful in treatment of UTIs. D-mannose adheres tsp 3 times daily for 7 days Chronic, recurring infections: best not to use more to the bladder epithelium, interfering with the abil- than 5 or 6 times per year; use in combination with 21 ity of the E. coli to adhere and cause infection. It soothing botanicals such as marshmallow is likely safe for pregnant and lactating women. Prevention: best not to use daily for long term Mannose Powder Pipsissewa (Chimaphila umbellata). Pipsis- 1 Acute infections: ⁄2–1 tsp 3 times daily sewa, a native plant of the Pacific Northwest and Chronic, recurring infections: 1 tsp or more daily also known as chimaphila, bitter wintergreen, or Prevention: 1⁄2–1 tsp daily ground holly, is a traditional remedy for urinary infections. As with uva-ursi, its antiseptic/mildly Botanicals antimicrobial effects are attributed to its arbutin Uva-Ursi (Arctostaphylos Uva-Ursi ). One content. It has mildly diuretic, astringent, and anti- of the most useful herbs for bladder infection spasmodic properties as well, all important mecha- is uva-ursi (Arctostaphylos uva-ursi), also known nisms in treating UTIs. Due to its arbutin content, as bearberry or upland cranberry. Uva-ursi has this herb is best used for shorter-term use, or occa- antiseptic, antibacterial, and astringent properties, sional use (up to four or five times per year), as for largely due to its arbutin content. Uva-ursi is espe- uva-ursi. It is unknown whether or not pipsissewa cially active against E. coli and has diuretic proper- is safe for pregnant and lactating women. ties. Uva-ursi has also been used with recurrent Pipsissewa bladder infections and was proven effective in a double-blind study of 57 women.22 After one year, Dried root: 1–2 g per day 1 5 out of 27 women in the placebo group had a Tincture: 1–1 ⁄2 tsp per day recurrence of cystitis, while none of 30 women Best used in combination with other botanicals, for had a recurrence in the uva-ursi group. both acute and chronic recurring infections Historically, many herbalists have taught that herbs with arbutin work best in an alkaline Goldenseal (Hydrastis Canadensis) and environment. That would appear to present a Oregon Grape Root (Berberis Aquifolium). problem given that acidifying the urine is a funda- Goldenseal and Oregon grape root are two of the mental concept in the successful treatment of most important herbs for bladder infections due to UTIs. This potential issue has not been a factor in their antimicrobial properties. Berberine, an alka- the great success I’ve witnessed in treating UTIs by loid constituent found in the rhizome and root of acidifying the urine with vitamin C while simulta- these plants, has demonstrated antibacterial activ- neously using uva-ursi and other botanicals. ity against E. coli species, Klebsiella species, Staphy- Because of its potential irritating and inflam- lococcus, and Pseudomonas species.23, 24 Berberine is matory effects on the urinary tract mucous mem- effective against many bacteria and is also able to CYSTITIS 71 fight infections by inhibiting the bacteria from cooling effect on the urinary tract; marshmallow adhering to the host cell.25 It is unsafe for pregnant root due to its content of mucilage, which can women and best not used by lactating women. form a protective layer on the lining of the bladder; and even plantain leaf with its high percent- Goldenseal age of mucilage and allantoin. Freeze-dried root: 500–1,000 mg Additional antimicrobial herbs for the bladder Dried root: 1–2 g per day include bucchu, myrrh, propolis, and juniper berry. Tincture: 1–11⁄2 tsp per day Numerous immune stimulants may be helpful, including echinacea, osha, and wild indigo root. Additional Botanicals. Other botanicals Bladder tonics stimulate the flow of blood and have been traditionally used for bladder infec- nutrients to the urinary tract and may be useful tions with positive effect. The water-soluble adjunct herbs. These herbs include nettle leaves, mucilage herbs are known to be soothing to the goldenrod, kava, and horsetail. Dandelion leaf, irritated uroepithelium and reduce inflamma- bucchu, and parsley root have diuretic effects and tion. These include corn silk for its soothing and increase the flow of urine to help flush the bacteria.

Sample Treatment Plans

See the Resources section for sources of herbal Oral probiotics: 8–16 billion organisms daily products. Mannose: 1⁄2–1 tsp daily; more if needed

Acute UTI Postmenopausal Women • Cranberry juice: 16 oz daily • Urinate upon urge and after intercourse. • Increase water: 8 or more 8-oz glasses daily • Use condoms for intercourse. • Vitamin C: 2,000 mg every 2 hours for 2 days, • Increase fluids. then 2 g 3 times daily for 7–10 days • Take the following supplements: • Combination herbal product such as cranberry, Combination herbal product: 1–2 capsules Oregon grape root, bucchu, uva-ursi, pipsissewa, daily marshmallow root: 2 capsules every 2 hours for 2 Cranberry extract: 400 mg twice daily days, then 2 capsules 3 times daily for 5–10 Cranberry juice: 8–16 oz daily days Oral probiotics: 8–16 billion organisms per day Mannose: 1⁄2–1 tsp daily; more if needed • D-mannose: 1⁄2–1 tsp 3 times daily for 5–10 Intravaginal estriol (1 mg/g): insert 1 g twice days daily for 2 weeks, then twice weekly as maintenance dose; or estriol suppositories Chronic, Recurring UTI (3- to 6-Month Plan) (1 mg): insert 1 daily for 2 weeks, then Premenopausal Women twice weekly as maintenance dose • Urinate upon urge and after intercourse. • Consider oral hormone therapy. • Use condoms for intercourse. With these prevention and treatment strategies, it • Increase fluids. will rarely be necessary to use antibiotics for • Take the following supplements: acute, chronic, or recurring UTIs. Please consult Combination herbal product: 1–2 capsules daily with your practitioners about use of these products Cranberry extract: 400 mg twice daily in pregnancy and lactation or if you are taking Cranberry juice: 8–16 oz daily medications. 72 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Intravaginal Estriol. In postmenopausal three days of therapy does not result in resolution women, other influences are important to con- of symptoms, a culture is recommended and the sider for chronic recurring UTIs. Lower estrogen antibiotic changed pending sensitivities. Most states result in fewer lactobacilli in the vagina and practitioners, in such a circumstance, will treat for bladder. Fortunately, vaginal estrogens are a a longer period, usually seven days. very safe and effective solution. Intravaginal Recurrent uncomplicated urinary tract infec- estriol effectively treats recurring UTIs in post- tions, particularly in young, sexually active menopausal women26 by restoring the normal women, may require what is called prophylactic vaginal flora and reducing the risk of vaginal E. (prevention) therapy to allow the bladder’s coli colonization. Other, more commercially depleted defenses to regenerate. This involves available vaginal estrogens are also used for this either a single dose of antibiotic daily, a single same purpose. dose of antibiotic following intercourse, or one or two doses of antibiotic at the onset of early Intravaginal Estriol symptoms prior to a full-blown UTI. For chronic, recurring infections and for prevention: Women who have structural or functional intravaginal compounded estriol: 1 mg/g, insert urinary tract abnormalities or who are immuno- 1 g twice daily, long term compromised develop complicated UTIs and This is a prescription item. Discuss the issue of using require more aggressive evaluation and treat- a progestational agent with your licensed primary ment. The workup will depend on the nature of care practitioner, although most women will not need the symptoms and the clinical situation. such an agent when using this low dose of vaginal Generally, complicated infections are treated estriol. for 7 to 21 days. A “test-of-cure” culture should be done approximately 5 to 7 days after completing therapy. In rare cases, when the response to the CONVENTIONAL antibiotic does not occur, surgery may be required MEDICAL APPROACH to drain or remove the focus of infection. The diagnosis of UTI in conventional practice Conventional medicine has also borrowed is the same as that for alternative medicine. freely from the naturopathic community, com- Conventional treatment, however, relies prima- monly employing prophylactic regimens of cran- rily on antibiotic therapy. For uncomplicated berry preparations and acidophilus. Blueberries urinary tract infections, especially those follow- also have abundant proanthocyanidins and are, ing sexual intercourse, culture and sensitivity therefore, recommended as well. Current litera- testing are not mandatory, and any antibiotic ture discourages the use of vitamin C, as it has except penicillin will likely be effective. (Most not proven to be of benefit. In the postmeno- gram-negative bacterial isolates are resistant to pausal population, topical estrogen therapy has penicillin.) The most commonly used agents are also been shown to prevent infection. nitrofurantoin macrocrystals (100 mg twice a Due to the prevalence of UTI among day), trimepthoprim-sulfamethoxazole double- women, there is a great impetus to develop new, strength (twice a day), or a fluoroquinolone such non-antimicrobial preventative therapies. The as ciprofloxacin (500 mg twice a day). most promising current work involves vaccines Cephalexin (500 mg three or four times a day) delivered transvaginally. Multiple applications of is another reasonable choice, but the dosing sched- the vaccine are required to confer resistance to ule may be onerous for most patients. The current infection. In the recent past, bacteriophages, recommendation is for three days of oral therapy. If viruses that invade bacteria, were developed by CYSTITIS 73 the Russians to treat resistant pathogens. This Women who have recurring infections should technology was brought to the United States and probably be evaluated for underlying causes as well tested briefly, but further development was as more sophisticated treatments. In addition, if tabled because the bacteria rapidly became resist- you have symptoms of a bladder infection, plus a ant to the treatment. Scientists therefore con- fever, this warrants a practitioner visit right away, as tinue to seek more ideal means of preventing and it may indicate that the infection has traveled to eradicating infection. In the meantime, we the kidneys. Blood in the urine is another sign are barely able to keep one step ahead of the when one should see a practitioner. bacteria. It is important to keep in mind that sexually transmitted infections due to chlamydia, gonor- SEEING A LICENSED PRIMARY rhea, or herpes simplex cause similar symptoms HEALTH-CARE PRACTITIONER to bladder infections, as do yeast or bacterial (N.D., M.D., D.O., N.P., P.A.) vaginal infections. Making an accurate diagnosis There are some definite situations as to when a is a key to successful treatment. A thorough his- licensed practitioner should be consulted. Cer- tory, physical, and laboratory test are the main tainly, this list includes women with urinary symp- ways a practitioner can diagnose UTIs. Whether toms who are pregnant, have catheters, have it’s alternative or conventional treatment, self- had symptoms for longer than seven days, are care should be limited to simple, uncomplicated, immunocompromised (immunosuppressive drugs, acute bladder infections that occur only once or HIV), or have chronic kidney disease or diabetes. twice per year. This page intentionally left blank ENDOMETRIOSIS CHAPTER 6

OVERVIEW the unruptured follicle, rather than a result.2 Endometriosis, one of the most common yet Whether endometriosis causes infertility or infer- misunderstood diseases, affects 10 to 15 percent tility causes endometriosis, tubal scarring, adhe- of menstruating women between the ages of sions, and unruptured follicles are common with 24 and 40 years. In some cases, symptoms women having endometriosis and infertility begin with the onset of menstruation. In others, problems. symptoms begin later and progressively become The main risk factor for endometriosis is worse until menopause. The triad of symptoms heredity. The likelihood for a woman who has a includes dysmenorrhea (pain with menses), dys- ﬁrst-degree relative with severe endometriosis pareunia (pain with vaginal intercourse), and having endometriosis is six times higher than infertility. Acute pain occurs before menses and that for relatives of women without the disease.3 can last for a day or two during menses or Women with menstrual cycles that are shorter in throughout the month. This pain can be a lifetime between cycles and longer in length have disrupting experience, affecting a woman’s social been found to be at higher risk for endometri- relationships, work, school, and well-being. For osis.4 Increased or altered estrogen levels, lack of some women, vomiting, diarrhea, and fainting exercise from early age, a high-fat diet, and use of can occur along with intense labor-like pains. intrauterine devices have also been found to be Other pain is described as chronic bearing-down risk factors. Even natural red hair color was pain and pressure on the lower back and pelvis, found in one study to be a factor in the develop- sometimes radiating down the legs. Other less ment of endometriosis.5 common complaints include pain with urination Baboons who developed endometriosis in cap- and bowel movements and bleeding from the tivity were found to have higher stress levels and a nose, bladder, and/or bowels. Endometriomas, decreased ability to react to stress compared to enlarged areas of ectopic endometrial involve- those in the wild, suggesting a stress factor.6 Indi- ment on the ovaries, are found in two out of viduals who exercised consistently from an early three patients with endometriosis.1 age reported a decreased risk for endometriosis, Early research as to the source of infertility while those who began an exercise program later initially led to the concept that endometriosis on experienced less painful periods. Although not was a “working woman’s disease.” Women who all women with endometriosis have a childhood delayed pregnancy until later in life and were history of abuse, a greater number of individuals found to have endometriosis were told to “just with adhesions and/or endometriosis have get pregnant.” Current research does not support reported abuse in their history.7 Additional possi- this concept. However, research as to altered ble risk factors include prenatal exposure to high immune action within the pelvic cavity and the levels of estrogen and pelvic contamination with possibility of antibody reactions to sperm has menstrual products, although these issues are prompted recognition of an immunological basis largely theory and research is needed. for endometriosis. Other studies suggest that Physical examination reveals one or more of infertility is a cause of endometriosis, due to the following: tenderness of the pelvic area 75

Copyright © 2008 by Tori Hudson. Click here for terms of use. 76 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE and/or cul-de-sac (a deep pouch anterior to the uals, the implants have their own cycle, with an rectum, separating the uterus from the large ebb and flow that differ from the estrogen bind- intestine); enlarged or tender ovaries; a uterus ing during the menstrual cycle.10 that tips backward and lacks mobility; fixed Although the most commonly accepted theo- pelvic structures; and adhesions. Endometrial ries of origin today vary and sometimes seem tissue can be found on surgical scar tissue, in the contradictory, they all have their place in holistic vagina, and on the cervix. Physical examination approaches to the treatment of endometriosis. during the first or second day of menses high- The predominant theory first proposed by Dr. lights tender areas in the septum between the John Albertson Sampson in 1927 is the theory of rectum and vagina, most likely correlated with retrograde flow—that during menses, blood deeply infiltrating endometriosis.8 flows backward and becomes seeds of implants in An ultrasound study can determine the con- the pelvic cavity.11 This theory and research sistency of the endometriomas (areas of cystic showing that over 90 percent of menstruating endometriosis within the ovary). Evidence of women without endometriosis have retrograde endometriosis other than on the ovaries cannot flow have raised questions as to the biochemical be seen on the ultrasound. Although magnetic and immunological differences causing implan- resonance imaging (MRI) can detect endometri- tation within the pelvic environment.12 Endome- omas, cost prevents widespread use. A blood test trial implants from women with endometriosis called a CA-125 can have positive results in compared with normal women have been found endometriosis. The problem is that a high CA- to be biochemically different.13 Other studies 125 cannot completely differentiate endometri- suggest that cells may only implant in women osis from uterine fibroids, cancerous growths, with altered cell immunity.14 As implants are and normal tissue. High levels of CA-125 have found in the nose, lungs, and other organs far been found in stages III and IV of endometriosis, from the uterus, transportation through lym- which are the diagnoses for more advanced endo- phatic channels and blood vessels has been sug- metriosis.9 The CA-125 test may, however, help gested. Still other researchers believe the implants in monitoring treatment and progression once to be of embryological origin, pieces of the uterus endometriosis has been confirmed. However, this left behind during development, which, when test is not used by many practitioners. activated, secrete a chemical causing the nearby Definitive diagnosis of endometriosis can only capillaries to bleed.15 Research on baboons with be accomplished with a biopsy using either of the endometriosis suggests activation by environ- following two surgical procedures. A laparoscopy mental toxins that mimic estrogens.16 is a surgical procedure in which the surgeon inserts Whether implants are caused by retrograde a scope through one of two very small pelvic inci- flow, decreased immune function, genetic fac- sions. More invasive, a laparotomy consists of tors, environmental influences, or embryological major pelvic and/or abdominal surgery. development or are stimulated by high estrogen Endometrial implants or lesions are known to levels from the environment or within the body, have similarities to uterine tissue—featuring the worsening of symptoms prompts individuals endometrial glands, endometrial stroma, and to seek medical help. There is not necessarily a hemorrhage into adjacent tissue. Growth of this correlation between pain and the extent of the tissue may be stimulated by estrogen. Therapeu- disease. Women with fixed ovaries and large tic treatment aimed at manipulating the body’s endometriomas may only report mild discom- own level of hormones as in menopause or preg- fort, while those with visibly smaller lesions may nancy has had a positive effect. In some individ- report severe and chronic pain. Upon surgery, ENDOMETRIOSIS 77 these lesions are found to extend more deeply; Belgium, which also has the highest incidence of they are possibly more influenced by circulating severe endometriosis.27 In two studies since, estrogens.17 Research has found that the severity however, one in Belgium found no significantly of symptoms is correlated with the depth of the increased risk with dioxins or polychlorinated lesions rather than the number of lesions.18 biphenyls,28 and in Italy, no significantly in- The abnormalities found in women with creased risk of endometriosis was seen in women endometriosis and the conditions that may pre- who had high levels of dioxin in their blood.29 dispose them to it are complex. Some discussion, Currently, there is no epidemiological study however, will help guide us toward more effective definitively linking any one class of chemicals to management and a better understanding of treat- the risk of endometriosis, although there appears ment options. to be some suggestion of a link with estrogen-like compounds in the environment30 called xeno- Genetic Factors estrogens, which can disrupt estrogen and estro- Groupings of endometriosis within families has gen metabolism. Substances that have been been found in clinical studies,3, 19 populations- shown to have estrogenic effects in the body based studies,20 and even studies of twins.21–23 include polychlorinated biphenyls (PCBs), weed Several analyses of the locations on the genes that killers, substances that line cans, plastics, deter- are shared by siblings indicate abnormalities in gents, and household cleaners.31 detoxification enzymes. This would lead to sus- Despite this lack of identification of a defini- ceptibilities to environmental exposures to sub- tive link between chemical exposures and endo- stances that could then lead to the increase in the metriosis, we do know that women are exposed disease. Other insights have included that the to a multitude of chemicals in utero, in child- genes involved are associated with tumor sup- hood, peripubertally (the time around the pressor genes. If these tumor suppressor genes are appearance of secondary sex characteristics such affected, there is susceptibility to abnormal tissue as pubic hair), and as adults. We can identify growth, such as the endometriosis. Aberrantly chemicals in cosmetics, nail polish, plastics, expressed genes can also occur during the time of household cleaners, dry cleaning, and foods. A implantation, which may be an explanation for survey by the Centers for Disease Control and some of the cases of endometriosis-associated Prevention (the National Report on Human infertility. Other genetic errors may occur in Exposure to Environmental Chemicals) is cur- multistep fashion involving both the develop- rently underway, which monitors 145 chemicals ment and the progression of the disease.24 in 2,500 people in the United States.32 I would assert that the roles of toxic chemicals Environmental Factors in reproductive health should not be underesti- Information about environmental influences on mated, and that scientific investigations that endometriosis in humans has been gleaned by “suggest a correlation” should be motivation observing the negative effects of environmental enough to reduce the toxic exposure to chemical exposures to rhesus monkeys. Radiation exposure estrogen-like compounds that disrupt our own and dioxin exposure have lead to higher fre- bodies’ hormone-receptive tissues. quency of developing endometriosis in monkeys.25, 26 It would seem plausible to extend this The Immune Connection consideration to environmental effects on Increasingly, we are finding evidence that a lack women, especially when it was reported that the of proper surveillance by the immune system in highest dioxin pollution in the world was in the pelvic area is the cause of endometriosis, and 78 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE alterations in other aspects of the immune system Numerous changes in the makeup of the are involved in the progression of the disease.33 peritoneal fluid are also evident in women with In studies on the immunological functions of endometriosis. Immune cells that mediate the baboons with spontaneous (noninduced) endo- inflammatory reaction such as cytokines, macro- metriosis, researchers have found a correlation phages, T lymphocytes, and tumor necrosis factors between suppressed immunity and a higher have all been found to be increased in concentra- number and greater area of lesions.34 Both types tion in the peritoneal fluid in women with endo- of immunity, cell mediated and humoral, have metriosis,44–46 and their increase correlates with been implicated in endometriosis, with immuno- the severity of the disease. Growth factors, angio- logical defects present even in the mildest forms genic factors (increasing blood supply to areas of of the disease.35 Macrophages (a kind of white endometriosis tissue), and lipid peroxidation in blood cell) that scavenge other microbes, debris, the peritoneal fluid may stimulate the endometrial and aberrant tissue are found in greater numbers cell growth. Targeting these proinflammatory in the early stages of endometriosis.36 This compounds and blocking their action with antiox- increase in macrophage activity may correlate idants and other compounds provide a good with decreased fertility and possible reaction to rationale for new treatment strategies, both con- sperm perceived by the woman’s body as for- ventional and with natural compounds. eign.37 In the peritoneal fluid (fluid aspirated As mentioned earlier, irregular cycles are from the area behind the membrane lining the common among women with endometriosis. abdominopelvic wall) of women with severe Anovulatory cycles (lack of ovulation), premen- endometriosis, natural killer cell activity has been strual spotting (very light bleeding before the found to be suppressed.38, 39 Natural killer cells onset of the menstrual flow), luteal phase defects release cell toxins and thus help keep tumor and (abnormal length of the second half of the men- other abnormal cells in check. By a decrease in strual cycle), and salivary progesterone secretion natural killer cells, the immune defense against are altered in women with endometriosis.47 Since the growth of tissue is decreased. Interestingly, higher estrogen levels are implicated in endome- studies suggest a correlation between high estra- triosis, it is not surprising that heavy smokers diol levels and decreased killer cell activity.40 have a decreased risk for endometriosis if they Humoral immunity is the component of the began smoking earlier in life, as smoking is immune system that produces antibodies, more known to decrease estrogen levels.48 In addition, specifically immunoglobulins, which are pro- an increased body fat placement indicative of duced by B lymphocytes. These immunoglobu- increased estrogen levels was also found to be lins provide protection to the body by their correlated with a higher incidence of endometri- attachment to foreign substances called antigens. osis.49 Since estrogens are known to stimulate Patients with endometriosis have been found to endometrial implants, women on hormone have high levels of immunoglobulins IgG and replacement therapy have been known to experi- IgM when compared with normal controls.41 ence a recurrence of endometriosis.50 Higher than normal amounts of immunoglobulins cause destruction of the body’s own tissue, as The Role of the Liver and seen in autoimmune conditions. Evidence of the Gut in Hormone Metabolism high levels of autoantibodies against ovarian and The liver has the enormous task of breaking down endometrial cells is consistent with the finding of estrogen and secreting metabolites through the individuals who have both endometriosis and bile into the large intestine. Whether hormones autoimmune diseases.42, 43 are produced naturally within the body, are pro- ENDOMETRIOSIS 79 vided through medication, or enter the body as OVERVIEW OF substances from the environment that mimic ALTERNATIVE TREATMENTS estrogen, optimal functioning of the liver is imper- While analgesics, anti-inflammatories and estrogen- 51 ative in maintaining a healthy balance. Inappro- blockers temporarily relieve symptoms, the need priate breakdown of estrogen can result in local for a long-term definitive treatment that involves liver damage, continual recycling of estrogens, and removal of the cause is imperative. A systemic alterations in immune function. Since the liver is approach to treatment that takes into considera- involved in breaking down 80 to 90 percent of the tion a multifaceted cause with long-term and hormones in the body, it follows that optimal liver acute symptomatic relief is the goal of alternative function can be of benefit in treatment. therapy. While late-stage endometriosis may The large intestine, which contains different only be addressed by radical surgery, early treat- types of microflora or gut organisms, has a unique ment, in the form of stimulation of the body’s role in the excretion and recycling of estrogen. The inherent ability to heal through enhancing the liver inactivates estrogen by attaching a bond immune system, restoring proper inflammatory between glucuronic acid and the estrogen molecule responses, balancing hormones, and aiding in the and excreting this substance with the bile. Some “unfriendly” bacteria in the large intestine, how- KEY CONCEPTS ever, secrete an enzyme called beta-glucaronidase that breaks down these bonds, releasing a strong • A gynecological checkup is imperative with any estrogen that is then recycled back through the type of pelvic pain to rule out any pelvic or body. In order to produce this enzyme, these bac- abdominal abnormality. teria feed on fat taken in by the body. However, • Provide symptom relief for acute pain. the balance can be restored by greater numbers • Provide removal of cause (endocrine, immune, environmental, liver). of the “friendly” bacteria that feed on fiber • Create a plan for treatment of the chronic and crowd out the “unfriendly” bacteria. With a problem. balance of the “friendly” bacteria in the large • Optimize nutritional intake and avoid environ- intestine, a higher amount of inactivated estrogen mental toxins. metabolites leave the body through the large intestine, preventing their reactivation and movement back through the body.52 PREVENTION Endometriosis is a complex disease with a variety of interconnecting influences. Enhancing • Eat nutritious whole foods. Include foods known the immune system, the endocrine system, and to reduce inflammation such as fish, curries, and the liver’s detoxification of hormones; reducing garlic and high amounts of fruits and vegeta- and blocking proinflammatory chemicals pro- bles, whole grains, and legumes. Reduce red meat, especially grain-fed meat. duced by the body; and providing optimal health • Get regular exercise. in the large intestine represent innovative and • Avoid pesticides, chemicals, solvents, and heavy effective approaches to the treatment of endome- metals. triosis. Considering the long-term consequences • Eat organic foods. of endometriosis—pain, disability, and disrup- • Drink purified water. tion in personal, family, and work activities— • Maintain good digestion and regular bowel innovative approaches that treat the whole body habits. and remove the cause promise a light at the end • Avoid alcohol. of the tunnel. 80 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE liver’s ability to break down environmental and Foods high in fiber are associated with opti- naturally occurring estrogen, is worthy of consid- mal transit time in the intestines and an optimal eration. balance of friendly microorganisms within the Certain foods and supplements aid in enhanc- large intestine.56 These microorganisms, better ing the body’s ability to mount a natural immune known as gut flora, crowd out the other types of response. Optimal liver function involves enhanc- flora that play a role in metabolizing estrogen. ing the liver’s ability to detoxify hormones, excess Studies suggest that an intake of less protein and medicines, and toxins through two main phases, high fiber or a vegetarian diet lead to a decrease called phase I and phase II detoxification. Individ- of biologically active estrogens in blood plasma.54 uals who have decreased function of the first path- While higher protein diets are found to provide way continue to recycle hormones, toxins, and enzymes for the detoxification pathways of estra- other products harmful to the body. If the second diol,57 vegetarian diets are of greater value due to detoxification pathway is dysfunctional, the meta- their lower fat content. Animal protein diets, bolic products of the first pathway build up and especially egg yolks, poultry, and red meat, con- can become even more toxic, decreasing immune tain large amounts of arachidonic acid, which response and accumulating as oxygen free radicals. promotes inflammatory prostaglandins and thus These metabolites can cause tissue injury and for- inflammation and pain. By enhancing your diet mation of adhesions.53 Healthy elimination of with vegetable protein, soy, almond and other these metabolites assures that the body doesn’t get nut butters, and salmon, you tip the inflamma- a chance to reabsorb them. tory pathway toward anti-inflammatory pro- Nutrition, exercise, and healthy lifestyle prac- staglandins that inhibit tumor growth—and tices play a preventive role in providing immune possibly endometrial growth. Interestingly, a support and a healthy body’s response to added recent study in Japan demonstrated that moder- stressors and imbalances of hormones. Women ate isoflavone intake from soy was significantly who exercise and eat less fat and sugar produce less associated with a decreased risk of premeno- estrogen. Vegetarian women excrete two to three pausal hysterectomy. This data led the authors to times more estrogen in their feces and have half as conclude that moderate soy intake may decrease much estrogen in their blood as meat-eaters.54 the risk for diseases like endometriosis, which Additional approaches in the area of mind-body commonly precipitate premenopausal hysterec- medicine recognize that belief systems and emo- tomies.58 Another study of 50 women with endo- tional health affect optimal physical health. metriosis examined the effect of dietary changes, specifically the reduction of glycemic carbohy- Nutrition drates, the addition of omega-3 and omega-9 The goods news is that there are numerous nutri- fatty acids, and the elimination of foods with tional influences related to endometriosis. This caffeine and tyramine, and found a significant means we can take an active part in prevention reduction in symptoms after eight weeks.59 and management of the condition. By increasing intake of vegetables, specifically A recent retrospective study of over 500 those that enhance liver function, the buildup of women with endometriosis concluded that there toxins and metabolites that produce cell damage was a significant decrease in risk of developing is prevented. Liver-friendly foods to increase are endometriosis with a greater consumption of carrots, kale, and the cabbage family vegetables green vegetables and fresh fruit, and an increase due to their known help in phase II of the liver’s in risk was associated with high intake of beef detoxification pathway. Indole-3-carbinol (I3C), and other red meat.55 found in broccoli, brussels sprouts, cabbage, and ENDOMETRIOSIS 81 cauliflower, favors the less active form of estro- Dietary Recommendations gen.60 Other liver-cleansing foods include beets, carrots, artichokes, lemons, dandelion greens, • Eat a high-fiber diet. watercress, and burdock root. Onions, garlic, and • Eat a high-protein vegetarian diet. leeks contain organosulfur compounds that • Increase intake of vegetables, nuts, and seeds. enhance the immune system and induce enzymes • Use turmeric, ginger, milk thistle, and flaxseeds. that detoxify the liver. In addition, they contain • Omit or decrease alcohol, dairy, red meat, the bioflavonoid quercitin, which is known to sugar, and caffeine. stimulate the immune response, protect against • Eat cold water fish (salmon, tuna, sardines, oxidation, block the inflammatory response, and mackerel, herring) 2 or 3 times per week. inhibit tumor growth.61 By eating as many of your • Eat organic foods. vegetables as possible in an organic form, you cut down on your intake of pesticides that may also mimic estrogen. pathway to be tipped toward prostaglandins and Use seasonings such as turmeric (curcumin) leukotrienes that cause inflammation, smooth that protect against environmental carcinogens, muscle contraction, and vascular constriction. decrease inflammation, and increase bile secretion. Alcohol use depletes stores of B vitamins in the Ginger is helpful with many types of inflamma- liver and also has estrogenic effects on the body. tion—and helps with liver detoxification. Adding a Nutritional Supplements tablespoon of soaked and ground milk thistle seeds each day can also help with liver function. Grind a Before beginning the discussion on nutritional tablespoon of fresh flaxseeds and place on cereals or supplements, it is important to explain the con- salads. The increase in lignans from these seeds aids cepts of free radicals, antioxidants, and free radi- in providing fiber as well as an oil that helps in the cal scavengers. There are several ways to define a anti-inflammatory pathway. Seasoning with fucus free radical, but a definition I like is, “an atom or (a seaweed) helps stimulate T cell production and group of atoms that has at least one unpaired absorb toxins.62 electron and is therefore unstable and highly Foods to omit or decrease include sugar, reactive.” Antioxidants such as vitamins C and E, caffeine, egg yolks, poultry, red meat, and alco- selenium, carotenes, and others are molecules hol. Sugar is known to increase estrogen levels that defend the body from cellular damage by in men; presumably the effect is similar in ending the free radical chain reaction before vital women.63 Endometriosis is found to be corre- molecules are harmed. These are often referred to lated with caffeine consumption. Women con- as “free radical scavengers.” suming 5,000 to 7,000 mg of caffeine per month Vitamin C. Studies using vitamin C show had a 1.2 times greater incidence of endometri- increase in cellular immunity and decreases in osis, while those consuming over 7,000 mg per month had a 1.6 times increase.64 One cup of coffee contains 120 mg of caffeine; one cup Vitamin C of black tea contains 60 mg; one cup of decaf- Take 6–10 g in divided doses daily, starting with feinated contains about 2 mg of caffeine. 1,000 mg a day, then add 1,000 mg every 4 or 5 days The Environmental Protection Agency esti- until the stools become loose. At this point, back mates that 90 percent of human dioxin exposure is down to the previous dose of vitamin C so that the through food, primarily meat and dairy prod- stools are normal in consistency. ucts.65 Egg yolks, meat, and poultry cause the lipid 82 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE autoimmune progression and fatigue.66 In addi- haps through the inhibition of the arachidonic tion, vitamin C enhances immunity and decreases lipid pathway. Inhibiting the arachidonic path- capillary fragility and tumor growth, all of which way helps prevent the release of chemicals that are involved at various levels in endometriosis. would normally cause edema, inflammation, and Studies on autoimmune progression indicate the smooth muscle contraction. effectiveness of high levels of vitamin C.67 Vitamin E Beta-Carotene. Beta-carotene helps enhance 400–800 IU daily immunity. Recent research shows that retinoids can help decrease IL-6, an inflammatory mediator, which has been implicated in endometri- Essential Fatty Acids. Gamma-linolenic acid osis.68 In addition, studies show that use of (borage, black currant, and evening primrose oils) beta-carotene increased T cell levels after seven and alpha-linolenic acid (flaxseed, canola, pump- days.69 Beta-carotene was also shown to be pro- kin seed, soy, and walnut oils) help decrease the tective against early stages of tumor growth.70 inflammatory response on the tissue level through Impairment of phagocytosis (the engulfing of pathways that produce prostaglandins in the body. microorganisms, other cells, and foreign particles Depending on one of three main pathways of by white blood cells) is seen in vitamin A– prostaglandin production, the effects can be help- deficient states.71 Although vitamin A was used in ful or harmful to the body. Animal fats produce a this study, one-third of beta-carotene is converted pathway of prostaglandin products that increase to the active form of vitamin A, retinol. Additional inflammation, muscle constriction, and edema. studies suggest that immune function is due to However, gamma-linolenic acid and alpha- carotenoids rather than vitamin A.72 linolenic acid produce the opposite effects. These fatty acids taken in supplemental form can pro- Beta-Carotene duce the prostaglandins that are involved in 50,000–150,000 IU daily inhibiting tumor growth, dilating smooth muscle, and decreasing inflammation.77 Since endometriosis tissue, called implants, are thought to secrete Vitamin E. Recent research demonstrates chemicals that cause leakage from nearby capillary that free radicals may contribute to the inflam- beds, decreasing the permeability of these vessels mation and excessive growth of endometrial could help control the tissue destruction and tissue seen in endometriosis, and in these circum- adhesions, decreasing irritation in the pelvis. stances, antioxidants such as vitamin E and Recent research demonstrates that having a higher N-acetyl cysteine can act to inhibit this abnormal omega-3 to omega-6 fatty acid ratio may have a proliferation.73, 74 suppressive effect on the in vitro survival of Vitamin E also helps to correct abnormal endometrial cells, leading the authors to conclude progesterone/estradiol ratios in patients with that omega-3 fatty acids may be useful in the man- mammary dysplasia (increased growth of cells).75 agement of endometriosis by decreasing inflam- Since parallels have been found between abnormal tumor growth in cancer and abnormal Essential Fatty Acids growth of lesions in endometriosis, vitamin E Eicosapentaenoic acid: 1,080 mg daily supplementation may be advantageous. While Docahexaenoic acid: 720 mg daily secondary dysmenorrhea is usually involved with Alpha-linolenic or gamma-linolenic acid: 300 mg endometriosis, studies on the use of vitamin E daily with primary dysmenorrhea76 show benefit per- ENDOMETRIOSIS 83 mation.78 In an animal model, fish oils were found Japanese herbal formulas of peony and licorice to decrease prostaglandin production and inhibit (Shakuyaku-kanzo-to) and peony and dong quai the growth of endometrial implants.79 (Toki-shakuyaku-san) was found to decrease endometrial pain in all patients studied and was B Vitamins. B vitamins help the liver to inac- even reported to promote ovulation.84 Another tivate estrogen. Studies suggest that supplemen- study reported both hormonal and inflammatory tation of B vitamins may cause the liver to modulation that led to decreased volume of become more efficient in processing estrogen.80 endometrial implants in an animal model of B Vitamins endometriosis through the use of Tripterygium wilfordii, another Chinese herb.85 50–100 mg B-vitamin complex; B6 should not exceed 200 mg daily Traditional Herbal Therapies Chaste Tree (Vitex Agnus Castus). Chaste Selenium. Selenium aids in the synthesis of tree has traditionally been used as a treatment for antioxidant enzymes responsible for detoxifica- hormone imbalances in women. Through action tion reactions within the liver. In addition, sele- on the pituitary gland, chaste tree has a proges- nium stimulates white blood cells and thymus terone effect by increasing luteinizing hormone function.81 Individuals with decreased selenium (LH). Useful for fibroids, premenstrual syn- levels have suboptimal cell-mediated immunity, drome, perimenopause, and various menstrual decreased numbers of T cells, and associated cycle disorders, it also has an indication in endo- inflammation.82 metriosis, perhaps because less estrogen is avail- Selenium able to stimulate endometrial tissue.86 200–400 mcg daily Dandelion Root (Taraxacum Officinale). Dandelion root is one of nature’s most detoxifying herbs. It works principally on the liver and Lipotropics. Lipotropics aid in promoting gallbladder to help remove waste products. By liver function and detoxification reactions. Sup- supporting the liver, excessive estrogens and plements that contain choline (a B vitamin), toxins can be deactivated. Researchers in Japan betaine, and methionine promote the flow of fat have found a link between dandelion and antitu- and bile (containing estrogen metabolites) from mor activity.87 In addition, dandelion leaf con- the liver out through the large intestine.83 tains vitamins A, C, and K and calcium, as well Lipotropics as choline, a lipotropic substance. 1,000 mg choline and 1,000 mg methionine or cys- Prickly Ash ( Xanthoxylum Americanum). teine 3 times a day Prickly ash is known for its specific action on capillary engorgement and sluggish circulation. Through its stimulation of blood flow through- Botanicals out the body, prickly ash helps enhance the trans- Herbal Medicines for Pain Relief. The port of oxygen and nutrients and the removal of herbs appropriate for acute pain relief in endo- cellular waste products. For women with pelvic metriosis are the same herbs used for menstrual congestion, this herb enhances circulation cramps. Valerian, crampbark, black cohosh, and throughout the pelvis. other helpful herbs are discussed in Chapter 13. Motherwort ( Leonurus Cardiaca). Mother- A recent study of a cyclic administration of two wort is antispasmodic and gently soothes the 84 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE nerves. As women with endometriosis generally similarities of cancer to cell growth found in the experience uterine cramps and pain, motherwort pelvis. This formula contains monkshood (Aconite is useful in promoting relaxation during times of napellus), yellow jessamine (Gelsemium semper- extreme “bearing-down” pain in the uterus and virens), bryony (Bryonia alba), and poke root (Phy- other regions.88 As a mild sedative, motherwort tolacca americana). Monkshood and yellow helps with the needed rest during menstrual jessamine contain alkaloids that have been known cramps. to disrupt the assembly of microtubules that eventually help in the formation of cells that differen- Herbal Tincture for Chronic Treatment tiate and give rise to connective tissues, blood, Chaste tree, dandelion, prickly ash, motherwort combi- lymphatics, bone, and cartilage. Quite possibly, nation: 1⁄2 tsp 3 times daily for 3 months these herbal alkaloids interfere with the induction of abnormal ectopic lesions within the pelvis (con- Turska’s Formula. Turska’s formula is a sistent with the theory of cells left behind in favorite old naturopathic treatment for decreasing embryonic development). Bryonia is also known aberrant cancer cell growth. A tincture of this for- to provide antitumor effects. Poke root contains mula is useful in treating endometriosis due to the glycoproteins known to stimulate lymphocyte

Sample Treatment Plan for Endometriosis

Nutrition • Lipotropics: 2–4 capsules • Flax oil, evening primrose oil, or borage oil: • Increase the following in your diet: 2 to 4 capsules per day Vegetables (especially cauliflower, brussels sprouts, and carrots) Botanicals Protein (tofu, beans, salmon, soy nuts, and small amounts of turkey and chicken) • Acute tincture: Fiber (whole-grain breads, rice, raw vegetables, Black cohosh: 1 oz and flaxseed) Wild yam: 1 oz Omega-3 oils (especially cold water fish: salmon, Cramp bark: 1 oz tuna, sardines, mackerel, and herring) Valerian: 1 oz • Decrease or eliminate the following: 1⁄2–1 tsp every 2–4 hours for acute pelvic pain All saturated animal fats • Chronic tincture: All foods containing sugar, caffeine, chocolate, or Chaste tree: 1 oz alcohol Dandelion: 1 oz • Avoid pesticides and heating food in plastic Prickly ash: 1 oz containers. Motherwort: 1 oz 1 • Drink purified water. ⁄2 tsp 3 times a day • Turska’s formula: 5 drops 3 times daily Daily Supplements • Progesterone cream: • Vitamin C: 6–10 g Option 1: days 1–6, no cream; days 7–26, 1 1 • Vitamin E: 400–800 IU ⁄4– ⁄2 tsp twice a day • Fish oils: 1,080 mg EPA and 720 mg DHA Option 2: days 1–14, no cream; days 15–26, 1⁄4–1⁄2 tsp twice a day • Beta-carotene: 50,000–150,000 IU Option 3: days 1–20, no cream; days 21–27, • Selenium: 200–400 mcg 1⁄4–1⁄2 tsp twice a day ENDOMETRIOSIS 85 transformation for immune enhancement. Poke ultrasound or CAT scan, laparoscopy (a surgical root also has anti-inflammatory properties. Due to procedure to view the interior of the abdomen its potential toxicity, however, this tincture can be and pelvis) remains the standard for diagnosis. provided only by a licensed health professional. Studies have repeatedly shown that 78 to 82 percent of women with chronic pelvic pain of more Turska’s Formula than six months’ duration that does not respond 5 drops 3 times daily to nonsteroidal anti-inflammatories or oral con- See Resources section for sources. traceptives have endometriosis. A recent development in the treatment of endometriosis is treatment of presumptive disease without laparoscopic proof. Some physicians now offer this Natural Progesterone option, and if no response is seen in six months, Progesterone has been known to modify the they then proceed with laparoscopy. action of estradiol by decreasing the retention of Often, women with chronic painful periods receptors, causing a fall in serum estradiol levels. or pelvic pain are initially treated with non- Women without enough progesterone are unable steroidal anti-inflammatory medication such as to balance out estrogen, leading to problems ibuprofen, naproxen, or meclofenamate. As that result from a relative excess of estrogen. In symptoms progress, patients usually resort to addition, progesterone has the effect of sedating prescription analgesics and/or hormones. Since painful uterine contractions. Chapter 13 dis- estrogen is known to stimulate the growth of cusses in more detail how progesterone inhibits endometriosis, treatment is aimed at suppression uterine contractions and reduces pain. It is possi- of estrogen synthesis. By achieving states of ble that this uterine sedative effect extends to pseudopregnancy (through birth control pills) or pain relief in the pelvic region in general. I have pseudomenopause (through cessation of the not used natural progesterone alone as a treat- body’s own production of estrogen and proges- ment for endometriosis, but it has been my terone), women have found significant symptom observation that progesterone is an important relief. Benefit from birth control pills is thought part of a comprehensive treatment plan. to be due to reduced menstrual bleeding, anovu- Natural progesterone creams can be applied lation, and lesion regression. However, stimula- in various regimens. For some women I recom- tion of a lesion does occur, possibly due to a mend 1⁄4 teaspoon two times a day for three decrease in concentration of progesterone recep- weeks on and the week of menses off, or apply tor sites and lesions. twice daily from day 15 of the cycle to day 26. In the past, danazol was regarded as a highly Other women just need to use it the week before effective drug because of its suppression of the their menses is due. Still other cases require pituitary and inhibition of estrogen and adrenal higher doses of natural oral micronized proges- hormone production. Relief quite possibly is due terone in a cyclic dosing pattern. to reduction of endometriosis associated with autoimmune abnormalities. However, male pat- CONVENTIONAL tern hair growth, irreversible low voice, hot MEDICINE APPROACH flashes, depression, weight gain, acne, reduced Conventional medical treatment for endometri- breast size, muscle cramps, fatigue, and other osis usually involves diagnosis plus medical or symptoms related to the medication have caused surgical treatment. Because one cannot feel danazol to become a less popular alternative, and endometriosis most of the time or detect it by it has mostly fallen out of use. 86 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Prescription drugs called gonadotropin- tion, laparoscopy allows for a shorter recuperation releasing hormone agonists (GnRH agonists), time when compared to a laparotomy. During a such as Lupron, Synarel, and goserelin, are used to laparotomy, the surgeon makes a larger incision in produce a menopausal state. Upon stimulation of the abdomen, allowing for larger endometriomas the receptors of the brain by these hormones, a or adhesions to be excised. decrease in production of LH (luteinizing hor- Surgery has produced cure for some individ- mone) and FSH (follicle-stimulating hormone) uals, while it has proved to be disappointing is achieved and causes the individual to have a to others. Whether laparotomy or laparoscopy, low estrogen state. This causes dramatic relief surgical treatment varies as to type of surgery, of symptoms within two to three months. Side technique, and surgeon experience. Conservative effects due to low estrogen, similar to those surgery removes superficial endometriosis lesions accompanying natural menopause (insomnia, and/or endometriomas while leaving the uterus hot flashes, vaginal dryness, and osteoporosis) do and ovaries intact. Recurrence rates vary from 5 occur. Current add-back therapy with low-dose to 20 percent per year, with a rate of 40 percent estrogen or a progestin reduces symptoms after five years. Differences in recurrence rates without reducing effectiveness. Higher doses of with surgery may be due to the method of endo- hormone therapy such as oral contraceptives metriosis implant removal and the skill of the may make the lesions grow, so very low doses of surgeon. Laser surgery is able to penetrate deeply, hormones are recommended. After the GnRH but without the possibility of biopsy (proving agonist is discontinued, recurrence of endometri- endometriosis), while excision by electrocautery, osis frequently occurs, so ovarian suppression which allows for meticulous biopsy, takes time regimens like oral contraceptives or Depo- and additional effort. The knowledge and experi- Provera injections are commonly used following ence of the surgeon are important in the identifi- GnRH therapy. cation of the implants, since color, consistency, Treatment with progestins helps endometrial appearance, and location of the implants can be tissue to atrophy. However, side effects include variable. In addition, some surgeons remove the nausea, weight gain, fluid retention, breakthrough clear peritoneal covering, as they believe that bleeding, and sometimes depression. endometrial implants reside in this tissue. Combinations of estrogen and progestin such The disease frequently recurs unless a woman as those found in low-dose birth control pills sup- has had a hysterectomy with bilateral salpingo- press FSH and LH. Mild-to-moderate pain relief is oophorectomy (removal of uterus and both achieved because the body’s own estrogen produc- ovaries and fallopian tubes). Aggressive surgery tion is decreased. In addition, since the volume of consists of removing implants, ovaries, and menstrual flow is also decreased, less blood is theo- uterus, and sometimes, even more aggressive sur- retically available for reflux into the pelvic cavity. gery involves removing the peritoneum as well. Current research shows promising results in While surgery removes implants that adhere to the use of the antiprogesterone Ru-486 due to the ovaries, uterus, and other pelvic organs, the the regression of endometriosis and possible min- effects of ovary removal and the resulting abrupt imal side effects. Clinical trials are underway. Use cessation of hormone production have to be of medications that enhance the immune system taken into consideration. While beneficial for are also being studied. some individuals, medical or surgical manage- Laparoscopic surgery has the advantage of ment is not effective in all circumstances. extensive use of microscopic imaging so that sur- Physicians have seen an increase in endo- geons can view lesions in greater detail. In addi- metrioid cancer in endometriosis implants. And ENDOMETRIOSIS 87 endometriosis can grow into bowels or cause lower back pain; or pain with urination, bowel bowel obstruction or fistulas. Therefore, finding movements, and vaginal intercourse should be a health-care provider who is very experienced brought to the attention of your health-care with endometriosis treatment is very important. practitioner, who will listen to your symptoms, take a medical history, and do a pelvic exam. This SEEING A LICENSED PRIMARY physical exam is valuable in determining whether HEALTH-CARE PRACTITIONER there are masses, areas of sensitivity, or abnormal (N.D., M.D., D.O., N.P., P.A.) findings suggestive of endometriosis. Depending As with any pain of unknown origin, a licensed on the exam, an ultrasound, MRI, and/or blood primary health-care practitioner should be con- work may be recommended. In addition, sulted to rule out other causes of pain before depending on these results, further recommenda- extensive use of analgesic medications, botanical tions may be made (such as a laparoscopy that formulas, or supplements. The cultural bias that can diagnose and potentially treat the endometri- menstrual periods are supposed to be painful—as osis at the same time). well as a reluctance to seek help due to past abuse, If you are reluctant to seek out help due to trauma, or fear—can be a detriment to healing. past trauma or just a feeling of discomfort, it is Although the norm is changing, in the past many essential that you find a health-care practitioner women with endometriosis were told that the you can trust. Have a friend (or even therapist) pain was “in their head” or psychosomatic. An come with you to the office and even to the increased understanding of the pain, pattern of exam room to hold your hand, ask questions, symptoms, and loss of quality of life for those who and be there for you. Since the key to prevention experience endometriosis has drawn attention and of further pain is early diagnosis, prompt med- research to this disruptive problem. ical intervention can lead to more effective assis- Abnormal bleeding, pain that increases in tance in supporting your body’s own ability to intensity, continued pain with or without menses; heal itself. This page intentionally left blank FIBROCYSTIC BREASTS CHAPTER 7

OVERVIEW related fluid retention. Most of us tolerate this well Virtually all knowledgeable health-care providers enough once reassured it is normal, and the symp- agree that the terms fibrocystic breast disease or fibro- toms always resolve with menses. Women who take cystic breast condition should be abandoned in favor exogenous estrogen, such as oral contraceptives or of a more accurate, physiologically based descrip- estrogen replacement therapy during menopause, tion. First of all, the benign breast conditions that may be similarly affected. are present in almost all of us to some degree should never have been given the “disease” label in the first Mastalgia place.1 Moreover, the widespread misconception Mastalgia refers to any breast pain severe enough that women with painful or lumpy breasts are at to interfere with the quality of a woman’s life, increased risk of breast cancer borders on the tragic. causing her to seek treatment. Physiological, Unfortunately, our health-care system requires a cyclical mastalgia is this severe about 15 percent diagnostic code to reimburse services, and “fibro- of the time and comprises the bulk of this group. cystic breast disease” has one, even though the med- Women who suffer from noncyclical pain are ical literature is replete with reasons why it more rare, and the pain is less likely to be hor- shouldn’t. This reinforces misinformation and fear monal in cause. Pain may be due to old trauma, and obscures the safe and simple means that exist acute infection, or sometimes something related for obtaining relief and reassurance. to the chest wall. In contrast, breast cancer occurs Tender or lumpy breasts are one of the most as a unilateral painful firm lump only about 5 common reasons why women consult their gyne- percent of the time. Painful swellings that flux cologists for assessment and treatment. Since with the cycle and do not change over time are painful breasts are not always lumpy, and lumpy not worrisome as cancer signals. breasts are not always painful (and neither situation is usually abnormal), it is useful to create Breast Nodularity or Diffuse Lumpiness descriptive categories of symptoms and condi- Breast lumpiness—the most worrisome category tions to replace the generic term fibrocystic. in most women’s minds—may be either cyclic or noncyclic, and might or might not include pain. Physiological, Cyclical The distinction between these and normal Pain and Swelling breasts is often simply a matter of degree. Many women notice painful or sensitive breasts Normal breasts are irregularly textured because just prior to menstruation. This has been attributed the tissue they are made of is not homogeneous. to a more prominent estrogen than progesterone It is a mix of glands, fat, and connective tissue. effect on breast tissue at this time. Sometimes less Glands can be more or less prominent and more progesterone is made late in the cycle, as in irregu- or less obscured by fat or fluid, so all breasts feel lar ovulation (inadequate luteal phase). Other different. Symmetry is important; finding a women may have average amounts of progesterone mirror-image thickening in the opposite breast but increased tissue sensitivity to estrogen with indicates a normal condition. 89

Copyright © 2008 by Tori Hudson. Click here for terms of use. 90 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Nondominant Masses Dominant Masses Even densities that are not symmetrical are These outright noncyclical unilateral lesions are largely due to benign nonprogressive causes, but clearly distinct on all sides from the surrounding they do require careful distinction from domi- breast tissue. They persist over time, and except nant masses. When careful palpation around the in the very young demand some kind of assess- edges of a nonsymmetrical lump reveals that the ment. Most commonly they are either fibroade- density merges in one or more places with the nomas or gross (obvious) cysts. A fibroadenoma surrounding breast tissue, it is considered non- is a rubbery, smooth, benign fibrous tumor dominant and may be comfortably observed for common in younger women. In women under change over time. When these lesions are biop- age 25, it can be observed over time. Fibroadeno- sied or, preferably, a sample of cells is taken in the mas generally do not grow bigger. Large cysts are office using a needle to be looked at microscopi- more common in women aged 25 to 50—an age cally (fine-needle aspiration), some 70 percent group when cancer just begins to appear. They will show nonproliferative changes (adenosis, are softer, usually squishier, and can be made to fibrosis, microcysts, mild hyperplasia, and more); disappear by draining them through a needle in some 20 percent will show proliferative changes the office; unless they recur frequently, no further without atypia—mostly epithelial hyperplasia. treatment is necessary. Recurrent large cysts have None of these conditions places one at increased been shown to slightly increase cancer risk in risk for cancer, and all are self-limited. Only a some studies but not in others;3, 4 fibroadenomas fraction, roughly the 5 percent that show atypi- do not. Unfortunately, noncyclical unilateral cal hyperplasia, carry a significantly increased risk dominant masses can sometimes be cancerous. of breast cancer (relative risk at 4 percent), especially when coupled with a positive family his- OVERVIEW OF tory (relative risk at 9 percent).2 It was this tiny ALTERNATIVE TREATMENTS subgroup that led to the original cancer scare Women with fibrocystic tissue causing breast pain, attached to fibrocystic breasts. discomfort, and lumpiness will find comfort in an The most useful tool a woman can bring to alternative perspective on their situation. Given her own breast health is her knowledge of and that this condition is not really a disease, a woman familiarity with the architecture of her own can direct her energies toward relieving symptoms breasts, particularly as it varies over time. Noth- and optimizing breast health, as well as increasing ing is more helpful in avoiding an unnecessary her motivation toward general health practices biopsy than a self-knowledgeable woman who and self-care. has observed the monthly variation in her own breasts and knows which tissue thickens cycli- KEY CONCEPTS cally. Think of the self-exam as a familiarization process, not a diagnostic one. The majority of • Practice monthly breast self-exams; know your breasts; be able to detect new and unusual breast cancer occurs in women over age 60, and changes, thickenings, and lumps. most women don’t get breast cancer at all. We all • Have a yearly breast exam by a licensed have plenty of time to learn our textures so that physician. our own hands are the most sensitive to any • Relieve symptoms of pain and tenderness. changes that may occur. This will occur effort- • Have changes, if any, evaluated by a physician. lessly over time with regular self-exams. FIBROCYSTIC BREASTS 91

The liver is the primary site for estrogen clear- PREVENTION ance or estrogen metabolism. Compromised liver function can lead to a state of estrogen domi- • Avoid caffeine (black tea, coffee, decaffeinated nance, contributing to texture and density changes coffee, cola, chocolate, and medications with in the breast. To assure that estrogens are being caffeine). Even decaffeinated coffee has other metabolized properly, it may be necessary to pro- methylxanthines, caffeine-like chemical vide nutritional and herbal support for the liver. compounds. Digestion and elimination are fundamental fac- • Assure regular, daily bowel movements. • Eat a diet high in fruits, vegetables, soy foods, tors involved in hormone-related health problems. and whole grains. Women having fewer than three bowel movements • Decrease dietary fats, especially saturated fats. per week have a risk of fibrocystic breasts four to five times greater than women having at least one movement per day.5 The longer it takes food to breast activity on scintigraphy; and a significant move through the colon, the more waste products reduction in the variability of tissue activity.7 pass into the bloodstream, creating a potentially Maybe somewhat surprisingly, another study toxic physiological environment. Bacterial flora in showed a decrease in benign breast changes with the large intestine, such as Lactobacillus acidophilus, alcohol consumption.8 Since alcohol slows down improve the transit time of bowel toxins, as well as the metabolism of estrogen, it is not clear why this improving the excretion and detoxification of estro- study demonstrated these results. gens. Women on a vegetarian diet excrete two to Avoid Methylxanthines (Caffeine). Removal three times more detoxified estrogens than women of caffeine from the diet, an idea that originated on an omnivorous diet. with Ohio surgeon Dr. John Minton, is probably the most well-known alternative treatment for Nutrition fibrocystic breasts. Of the 20 uncomfortable Epidemiological evidence supports a diet rich in women who followed his advice to stop all caffeine whole fruits and vegetables in the prevention of intake, 13 said their breasts felt better as a result.9 fibrocystic breast conditions. A recent study Dr. Virginia Ernster conducted the first ran- demonstrated that a reduced risk of proliferative domized study of a larger number of women, in and atypical breast lesions was associated with which for four months 158 women eliminated consumption of fresh fruits and vegetables, caffeine (coffee, tea, cola, and chocolate) from whereas a small but significant reduction of risk their diets as well as caffeinated medications was associated with soy consumption, possibly by (theophylline and theobromine). She found a decreasing cellular proliferation in the breast significant reduction in clinically palpable breast tissue.6 Another study examined the effect soy findings in the abstaining group compared with consumption has on breast tissue via direct imag- the control group, although the absolute change ing using breast enhanced scintigraphy (a nuclear in the breast lumps was quite minor and consid- medicine diagnostic imaging test). After one year ered to be of little clinical significance.10 of daily soy consumption, the researchers reported Several other studies have been done, leaving a number of promising subjective and objective us with mixed reports: three studies show no results: patients and their physicians reported a association between caffeine or other methylxan- reduction in both breast tenderness and fibrocys- thines and benign breast disease,11–13 and two tic changes; a small but statistically nonsignificant studies show a correlation with caffeine con- decrease in both the average and maximal count sumption.14, 15 Such is the way of science. 92 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Caffeine Content of Common Items Dietary Recommendations

Beverage Caffeine (mg) • Avoid caffeine. Coffee, drip (8 oz) 150 • Decrease dietary fat to 20 percent of calories. Coffee, perk (8 oz) 60–120 • Increase dietary fiber (whole grains, legumes, Coffee, instant (8 oz) 70 fruits, and vegetables). Coffee, decaffeinated (8 oz) 2–5 • Increase seafood and seaweed. Tea, black, 5-minute steep (8 oz) 60–100 • Increase soy foods. Tea, green (8 oz) 20 Hot cocoa (5 oz) 2–10 ing the actual breast swelling and nodularity in Coca-Cola (12 oz) 34 some women.16 Reducing the dietary fat intake Food Caffeine (mg) to 20 percent of total calories results in signifi- Milk chocolate (1 oz) 1–15 cant decreases in circulating estrogens in women Bittersweet chocolate (1 oz) 5–35 with benign breast disease.17 Chocolate cake (1 slice) 20–30 Since fibrocystic breasts are a result of estro- Over-the-Counter Drugs Caffeine (mg) gen dominance, it is logical that decreasing estro- Anacin, Empirin, or Midol (2) 64 gen in the body or its influence on breast tissue Excedrin (2) 130 would improve the symptoms of breast pain and NoDoz (2) 200 swelling. However, a slight reduction in fat Aqua-Ban (2) 200 intake has repeatedly showed very little, if any, Dexatrim (1) 200 effect on breast problems, including breast cancer. A more rigorous approach to lowering the amount of fat in the diet is clearly needed. In clinical practice, I always recommend The simplest way to accomplish the necessary avoiding caffeine for women with painful/lumpy levels of fat reduction is to avoid animal fats in all breasts. Many women gain mild to dramatic forms; a vegan diet (vegetarian, without any results with this simple approach, and some animal products at all, including dairy or eggs) is women receive no benefit. A fair experiment naturally a very low-fat diet. Of course, vegetari- would be to completely abstain for three months ans, and even strict vegans, can succumb to fat in and observe any changes in the pain, swelling, other forms like french fries, potato chips, and and discomfort. A decrease in the nodularity will other greasy fried foods. A vegan diet rich in whole generally take longer, as long as eight months of grains, legumes, fruits, vegetables, seeds, nuts, complete abstention. olives, and seaweed that is enriched with oils for Dietary Fat. How dietary fat affects the stir-frying and in salad dressings results in a diet human breast is still controversial, although some that derives about 15 to 20 percent of its calories research has looked at low-fat diets in women from fat. with fibrocystic breasts and at how low-fat diets affect the hormone levels in these women. Nutritional Supplements Reducing the fat content of the diet to 16 per- Vitamin E. For more than 35 years, clinicians cent of total calories (in contrast to the average have used vitamin E in the medical management American diet of 40 percent fat), while increasing of benign breast disease. This practice was initially complex carbohydrate consumption, has been based on positive reports from small numbers of shown to reduce the severity of premenstrual patients as far back as 1965 and from subsequent breast tenderness and swelling, as well as reduc- studies in 1971, 1978, and 1982.18–21 When larger FIBROCYSTIC BREASTS 93 numbers of women were studied, vitamin E did seed oil and its essential fatty acid content that not fare so well, showing no significant effects holds the most interest today in maintaining either subjectively or objectively,22, 23 and the ear- health and preventing disease. lier results have never been duplicated. Evening primrose oil is rich in essential fatty However, this is not to say that some women acids—polyunsaturated fats that are as essential don’t find symptom relief from taking vitamin E. as vitamins and minerals for the maintenance of Two studies demonstrated that vitamin E is clin- good health. The oil contains 74 percent linoleic ically useful in relieving pain and tenderness, acid (LA) and 9 percent gamma linolenic acid whether cyclical or noncyclical.21, 24 The studies (GLA). Although other oils such as borage oil have been done with varying dosages: 150, 300, and black currant oil contain higher amounts of or 600 IU daily. In clinical practice, practitioners GLA, evening primrose oil is by far the most generally recommend from 400 to 800 IU of D- popular and familiar source of this fatty acid. alpha tocopherol with a minimum trial period of Evening primrose oil also contains 11 percent two months. Since vitamin E in these dosages is oleic acid, 6 percent palmitic acid, and 2 percent completely safe to use, this is a simple and appro- stearic acid. priate self-treatment method for a benign breast Under ideal conditions, the body uses LA to condition. produce GLA. In turn, GLA is used to produce beneficial hormone-like compounds called pro- Vitamin E (Natural) staglandins. Specifically, GLA is used to produce 400–800 IU daily series one prostaglandins such as prostaglandin E1 (PGE1). Omega-6 Fatty Acids. The pain and tender- Prostaglandins affect the function of virtually ness of benign breast disease associated with cyclic every system in the body. These molecules are mastalgia have been alleviated with evening prim- used in the regulation of inflammation, pain, rose (Oenothera biennis) oil, the only one of the blood pressure, fluid balance, and blood clotting. many essential fatty acids to be scientifically stud- Prostaglandins also affect hormone production ied in relation to fibrocystic breasts. and function. The evening primrose plant has been com- The key to understanding the important monly known as tree primrose and sun drop. need for supplementing with oils rich in GLA, Evening primrose can be found in many parts such as evening primrose oil, is that many of us of North American and is native in the North cannot convert LA to GLA efficiently. Dietary Temperate Zone, especially at high altitudes. The deficiencies, disease conditions, processed oils, native peoples of North America, as well as the trans-fatty acids, heated oils, alcohol, aging, viral English and Pilgrims, were well aware of the heal- infections, and sugar consumption block, slow ing properties of the leaves and bark as an astrin- down, or interfere with the enzyme that catalyzes gent, nervine (an herb that affects the nerves and the conversion of LA to GLA. The result is that includes relaxants, tonics, and even stimulants), virtually all North Americans are deficient in and sedative. It was often used for stomach and GLA. Supplementing with evening primrose oil liver complaints, coughs, and female reproductive can enrich the body’s GLA supply and restore the problems. Even the roots were eaten as a veg- production of beneficial prostaglandins derived etable. The seeds were recommended as a coffee from GLA. Research completed over the last 20 substitute in wartime and have a strong flavor years has confirmed that supplementation with similar to poppy seed oil. The therapeutic value of evening primrose oil has beneficial effects in the seed oil is a more recent discovery. It is this numerous diseases and conditions. Benefits for 94 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE health problems supported and/or suggested by oil contain higher amounts of GLA, so poten- scientific trials using evening primrose oil include tially, one could take fewer capsules to achieve the premenstrual syndrome, fibrocystic breast pain, same benefit. For example, borage oil contains 23 eczema, rheumatoid arthritis, diabetes, heart dis- percent GLA versus only 9 percent in the evening ease, osteoporosis, and ulcerative colitis. Other primrose oil. That would mean instead of the 6 conditions for which it may provide benefit capules of evening primrose oil it would take to include menopause and pregnancy. achieve the 3,000 mg of evening primrose oil that The pain and tenderness of benign breast dis- was used in the study, you could conceivably use ease associated with premenstrual breast pain and at half as many capsules of borage oil. fibrocystic breasts has been alleviated with evening primrose oil in more than one scientific Evening Primrose Oil (Omega-6 Fatty Acids) study. In 1985, when 291 women took three 1,500 mg twice daily grams per day of evening primrose oil for three to six months, almost half of the 92 women with Vitamin A. Basic science research supports cyclic breast pain experienced improvement com- the use of vitamin A by demonstrating the pres- pared with one-fifth of the patients who received ence of specific retinoid receptors in breast tissue the placebo. For those women who experienced that can modulate our genetic predisposition, breast pain throughout the month, 27 percent thereby decreasing the risk for both benign and (just over one-fourth of the 33 women) responded malignant breast changes.27 positively to the evening primrose oil, compared In a study of patients with fibrocystic breast to 9 percent on the placebo.25 Another 73 women disease, 12 women were treated with 150,000 IU with breast pain with or without lumpiness ran- of vitamin A daily for three months, and 5 of the domly received three grams per day of evening 9 women who completed the study showed com- primrose oil or placebo. After three months, plete or partial response.28 Some of the patients pain and tenderness were significantly reduced in experienced mild side effects of vitamin A toxic- both cyclical and noncyclical groups, while the ity, including dryness of the skin and mouth. women who took the placebo did not significantly Although the potential toxicity of vitamin A in improve.26 In the course of treatment, it has been doses this high makes it an impractical approach to detected that women with breast pain have unusu- fibrocystic breast disease, it is possible that beta- ally low concentrations of GLA and metabolites carotene could be substituted, since it has a similar from GLA. When patients receive supplements of activity without the side effects of vitamin A, or a evening primrose oil, the concentration of GLA diet high in yellow and orange fruits and vegetables. metabolites increases and the concentration of saturated fats in the breast decreases. This may also Beta-Carotene have long-term implications for prevention of 50,000–150,000 IU daily breast diseases such as breast cancer. Although symptom relief can be achieved Iodine/Thyroid Hormone. It has been through the use of evening primrose oil, it should known for a long time that for the thyroid gland not be relied on to actually reduce the number of to secrete thyroxine (its hormone), it requires developing cysts. iodine. Prescription thyroid hormone replacement Other omega-6 fatty acids that may have ben- with low or even normal thyroid function may eficial effects but have not been studied in relation result in improvement of fibrocystic breasts.29, 30 to fibrocystic breasts are flaxseed oil, black currant These results suggest that iodine deficiency may be oil, and borage oil. Borage oil and black currant a causative factor in fibrocystic breasts. FIBROCYSTIC BREASTS 95 Although the exact mechanisms of action on Aqueous Iodine breast tissue are not known, the breast has an affinity for both thyroid hormone and iodine. 3–6 mg daily (prescription item) The only areas of the breast in which iodine can be found are in the terminal and interlobular duct cells, which are also the areas primarily Additional Supplements involved in cystic changes. Without iodine, the • B-complex: 10 times the recommended breast tissue becomes more sensitive to estrogenic daily dietary allowance stimulation, which in turn produces microcysts • Methionine: 1 g per day high in potassium. The potassium is believed to • Choline: 1 g per day be an irritant that produces fibrosis and eventu- • Lactobacillus acidophilus: 1 tsp 3 times ally cyst isolation. per day Four types of iodine have been studied in the • Flaxseed oil: 1 tbs per day treatment of fibrocystic breasts, only one of which has been truly effective and free of side Botanicals effects on the thyroid gland. According to Herbal therapies for addressing the symptoms of research by Dr. William Ghent, although all breast pain, swelling, and cystic nodules in the forms of iodine relieve subjective clinical symp- breast are largely arrived at from traditional uses toms, the fibrocystic breast reacts differently to of herbal medicines and from observational expe- these different forms of iodine: sodium iodide rience in clinical practice. Herbal diuretics are (Lugol’s solution), potassium iodide, caseinated useful in decreasing breast swelling and the dis- iodine (protein-bound), and aqueous (diatomic) comfort associated with it. The most effective of iodine. Symptom relief varied a great deal with these is dandelion leaf (Taraxacum officinale). the different iodines, but only the aqueous or Unlike synthetic diuretics, dandelion leaf does diatomic iodine achieved both symptom relief in not deplete potassium; instead, it actually con- 74 percent of the women and also objective tains a high percentage of potassium. However, reduction in nodules and resolution of fibrosis in since potassium is possibly implicated in fibrosis 65 percent of the patients, without adverse and potential cyst isolation, dandelion may not effects on the thyroid gland.31 be the ideal diuretic to use. Diuretics considered Women get different amounts of iodine in to be effective for fibrocystic breasts include their diet, depending on the iodine content of cleavers (Galium aparine), yarrow (Achillea mille- the soil and water, as well as the types of food folium), and uva ursi (Arctostaphylos uva-ursi). they prefer to eat. Plant foods grown in the so- Additionally, poke root (Phytolacca ameri- called goiter belt areas of the country (the Great cana), an herb used in traditional naturopathic Lakes region, the Midwest, and the Intermoun- medical practices, can be applied as an oil to the tain states) lack iodine because the soil and water breasts and rubbed in like a lotion, reducing are iodine deficient. Today, iodine deficiency is painful lumpiness and nodularity. considered rare in the United States due to the Herbal support for the liver improves how widespread distribution of foods from areas of the liver metabolizes hormones. In this case, our the country sufficient in iodine and due to the goal is to encourage the normal pathways for the availability of iodized salt. Certain foods, such as metabolism, excretion, and recirculation of estro- seafood and seaweeds, are naturally high in gens. Traditional herbs that support the liver iodine and might be used to supplement a diet include burdock root, dandelion root (not leaf), low in iodine. milk thistle, celandine, fringe tree, and beet root. 96 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Herbal Recommendation I cannot conﬁrm the effectiveness or safety of this practice, and the research is not yet clear on • Yarrow leaf capsules: 2–6 per day; or yarrow the safety of long-term natural progesterone and leaf liquid tincture or extract: 1⁄4–1 tsp per day breast health. There is more information about • Phytolacca oil: apply to breasts nightly for 2 this in Chapter 12. weeks, then reduce to 3 times per week Natural Progesterone Cream

1 1 Additional Natural Therapies ⁄4– ⁄2 tsp applied to breasts and palms twice a day from ovulation to menses Natural Progesterone. Once we agree that fibrocystic breasts are, at least in part, due to a high-estrogen/low-progesterone problem, then CONVENTIONAL it is logical to use progesterone therapy as a MEDICINE APPROACH treatment. Specifically, many practitioners and Conventional medical literature has tended to women patients have experienced that the appli- focus more on pathologic descriptions of disease cation of natural progesterone in a cream or gel and on verifying or disproving related cancer risk form routinely resolves the problem. Dr. John rather than on exploring therapeutic options for Lee, the leader in the use of natural progesterone, symptom relief. In spite of conflicting data in the states that he cannot recall a single case in his 1980s, many women added vitamin E and elim- own practice in which the results were not posi- inated coffee from their diets with noticeable 32 tive. Lee suggests using the natural proges- subjective improvement and no side effects other terone cream or gel as prescribed by a health-care than those imparted by caffeine withdrawal. practitioner until the cysts are gone and then Low-fat, high complex carbohydrate diets can reducing the dose to the smallest amount that is reduce cyclical pain, and the results of studies still effective, to be continued monthly as needed with evening primrose oil have been mixed. through menopause. Cyclic breast pain and swelling are felt to be hormonal, so treatment is aimed at hormonal Sample Treatment Plan manipulation, usually by suppression. More often for Fibrocystic Breasts than not, oral contraceptives help to relieve mild or severe premenstrual pain, although for smaller Three-Month Period numbers of women the pain is worsened by this • Avoid caffeine and other sources of treatment. This paradox is explained by the fact methylxanthines. that oral contraceptives suppress ovarian produc- • Lower dietary fat to 20 percent and increase tion of hormones and replace this with an average dietary fiber (whole grains, legumes, fruits, synthetic dose of both estrogens and progesterone. vegetables, and soy foods); increase seafood and seaweed (for the natural iodine). If the replacement level is higher than the natural • Vitamin E: 400 IU twice per day one, sore breasts may result; usually, the replaced • Evening primrose oil: 1,500 mg twice per day level is lower, and then the pain is relieved. Con- If there is no change after three menstrual cycles, tinuous oral contraceptives (no placebo break) then incorporate a more assertive approach utilizing seem to help better than cyclic regimens. some of the other therapies listed, or see a naturo- Many so-called effective conventional treat- pathic physician for individualized recommendations ments cause such serious side effects that it is hard and, especially, prescription aqueous iodine. to imagine any cases that would warrant their use. Danazol, which interrupts LH and FSH secretion FIBROCYSTIC BREASTS 97 from the pituitary gland, was once touted as the The side effects of most of the expensive most effective breast pain reliever. However, it is a drugs used to eliminate breast pain and lumpi- male hormone and can cause facial hair, voice ness are probably too extreme to warrant their deepening, and other androgenic changes, quite use for most women until the simpler remedies unacceptable side effects for most women, and it have proven inadequate. If elimination of caf- can cost more than $200 per month. It is no feine, adding vitamin E, and switching to a low- longer used to treat fibrocystic breasts. fat, high complex carbohydrate diet do not bring Similarly, GnRH agonists work at the hypo- results, the next logical step for a conventional thalamic level to eradicate estrogen via a tem- practitioner would most likely be a trial of oral porarily induced menopausal condition. This contraceptives. class of drugs may make danazol obsolete, but they again do not present a good long-term solu- SEEING A LICENSED PRIMARY tion due to the side effects, including reversible HEALTH-CARE PRACTITIONER bone loss, and they cost even more money. (N.D., M.D., D.O., N.P., P.A.) Tamoxifen, an antiestrogen, has been used to A woman might decide to see a licensed health- treat breast cancer and can help cyclic breast care practitioner because she needs a breast exam pain, up to a 90 percent reduction in pain. How- or wants to determine the exact nature of her ever, it causes menopausal side effects, its long- breast pain/tenderness or lumps. The practi- term effects are unknown, and it increases the tioner will ask about her symptoms as well as incidence of endometrial cancer. On the other other pertinent factors in her medical history and hand, it has been shown to reduce breast cancer will perform a physical examination. risk in women who are at higher risk, including If the practitioner considers it necessary, she those women who have atypical hyperplasia of or he might recommend a mammogram and/or the breast, which is determined only by a biopsy. ultrasound to determine the nature of a specific For benign breast disease, it is difficult to imag- lump and may encourage aspiration of a mass to ine a situation where the benefits of tamoxifen determine whether it is cystic or solid. The prac- would outweigh the risks and side effects. titioner will no doubt recommend that highly Bromocriptine is a nonhormonal drug ther- suspicious lumps be surgically biopsied. apy that lessens the levels of prolactin, the hor- A lump that is new or one that is increasing in mone that manages lactation changes, and seems size, or a lump that does not change over the course to work well, although it is often not tolerated of the menstrual cycle, are all causes for concern because of nausea or dizziness. and might lead to a professional evaluation. This page intentionally left blank GENITAL HERPES CHAPTER 8

OVERVIEW with their first episodes of genital herpes are 18 Genital herpes is the most prevalent sexually trans- to 36 years of age. The highest annual incidence mitted infection (STI) in the United States.1–3 of genital herpes among women occurs at 20 to Data about the prevalence of genital herpes in the 24 years of age and is estimated to be 210 per United States has been collected from the 100,000 women. National Health and Nutrition Examination Sur- The diagnosis of typical genital herpes is veys between 1976 and 1980 (NHANES II) and fairly straightforward most of the time but from 1988 to 1994 (NHANES III). According to involves local and systemic signs. There are three NHANES III, 45 million Americans over the age distinct syndromes: primary herpes, first-episode of 12 are infected with Herpes simplex 2 (HSV-2 or nonprimary herpes, and recurrent herpes. There genital herpes). The prevalence increased 30 per- are, however, atypical manifestations, and these cent between 1988 and 1994, with the greatest are the ones that are not so straightforward. increase among teenagers, and quintupled among The severity of symptoms varies in extent and white teenagers and doubled among whites in duration according to whether the episode is their twenties. Some 25.6 percent of women and the patient’s first infection with either HSV-2 or 17.8 percent of men test positive for the virus in HSV-1, called primary herpes; initial genital infec- their blood, and blacks have a higher prevalence tion in a woman who has already had an infection (45.9 percent) than do whites (17.6 percent).4 with the other HSV type (initial, or first-episode Testing positive in the blood is different than nonprimary herpes); or a recurrence of a genital having a genital herpes eruption history. In fact, infection with either type. A woman’s first episode only 10 to 20 percent of seropositive individuals of genital herpes (primary herpes) is usually the have had a genital herpes lesion, showing us that most severe form of the disease. Symptoms usually the majority of cases are subclinical or undetected. start appearing within a week after infection, if There are six members of the herpesvirus they are going to appear at all. However, symp- family that are known to infect humans: HSV toms can start one day and up to 26 days after type 1 (HSV-1) and HSV type 2 (HSV-2), vari- exposure to the virus. Typically, infection is char- cella zoster virus, human cytomegalovirus, acterized by extensive, multiple clusters of painful Epstein-Barr virus, and herpesvirus type 6. lesions involving the genitals, anus, perineum, or Today, HSV-2 is the leading cause of genital surrounding areas. Symptoms and lesions of pri- ulcer disease in the United States. As many as one mary genital herpes vary in severity, extent, and in five Americans is believed to be infected with duration. Initial symptomatic episodes of HSV HSV-2—the virus type more closely associated not only tend to be more severe but are followed with genital herpes. Another virus type, HSV-1— within the first year of a greater likelihood of clin- the type more closely associated with infections ical recurrences as well as shedding of the virus of the mouth, lips, pharynx, and eyes earlier in without any symptoms (also known as subclinical life through oral/genital contact—is believed to shedding, when the outer layer of the skin or tissue be responsible for 10 to 50 percent of new cases harbors the virus without symptoms and then of genital herpes.5 About 80 percent of people sheds, transmitting the virus). These subsequent 99

Copyright © 2008 by Tori Hudson. Click here for terms of use. 100 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE episodes of HSV-2 are usually associated with ting. Swollen lymph nodes in the groin area are more symptoms and more frequent outbreaks also common. Discomfort with urination is also than HSV-1 of the genital area and occur about common, sometimes as a result of herpes in the four to five times a year in about one-third of urethra and in other cases because the urine women who have symptomatic outbreaks. comes into contact with lesions on the labia. Both HSV-1 and HSV-2 infect the skin and/or mucosal tissue of the genital area and the Diagnosis mouth, and once this occurs, the virus infects the A practitioner can best make a diagnosis of sensory and autonomic nerves and then ascends herpes based on the medical history, inspection to the nerve ganglia in the spinal cord where it of the area, and a laboratory test to provide con- establishes a lifelong home where it can be peri- firmation. The focus of the history is the onset odically reactivated. With this episodic reactiva- and clinical course of the genital lesions. Even tion, the virus migrates from the ganglia along though very personal, it is important that the the sensory nerves to the target site, which results practitioner know the following details of the in either an actual outbreak or a shedding with- woman’s sexual history: out an outbreak or with atypical symptoms, 1. Pregnancy history called subclinical shedding.1, 3 In fact, the major- 2. Currently sexually active or not ity of primary infections with HSV-1 and HSV-2 3. Sexually active with men, women, or both are subclinical. This presents a great difficulty in 4. If birth control is used, what kind sexual transmission, because the virus can be 5. Knowledge about partner or partners’ sexual transmitted to another, even when you do not history know you are infected or have ever been infected. 6. Condom use for protection from sexually Men are more likely to have asymptomatic HSV-2 transmitted infections infections than women.6 7. Types of sexual activity: oral sex with part- The classic herpes lesion begins as a red ner, mutual oral sex, penile/vaginal sex, papule, evolving within two to three days to a penile/anal sex vesicle containing clear fluid, and then progressing to a pustule. When the surface breaks open, The practitioner also needs to know whether the a tender ulceration occurs that may explain the lesions started as blisters or pimples and whether symptomatic burning pain. Lesions ulcerate or not they were painful. Knowledge about any more rapidly in moist areas than on dry skin, so systemic symptoms of both partners is important that painful genital ulcerations are more apt to as well. occur on the external vulva area. Several succes- The physical examination involves inspecting sive lesions may appear in the first three to four the lesions, examining the genital area thor- weeks of primary herpes. The lesions of primary oughly, including the anal area and the inguinal herpes may heal in one to six weeks. lymph nodes (those in the groin). Inspecting the In more than two-thirds of women, primary vaginal area with a speculum requires careful herpes is accompanied by systemic symptoms exam of the vaginal wall and the cervix. If sys- that may include fever, malaise, body aches, temic symptoms such as fever, headache, or neu- headaches, and nausea. Meningitis-like symp- rologia symptoms are present, a more thorough toms, such as stiffness of the neck and sensitivity neurological examination needs to be performed. to light, are also common. Nearly three-quarters The information gleaned from a good history of women will also suffer from herpetic cervicitis, and physical help to distinguish a genital HSV with vaginal discharge and intermenstrual spot- infection from other possible problems, includ- GENITAL HERPES 101 ing vaginal candida, herpes zoster, syphilis, chan- pregnant mother to her newborn child. Consulta- croid, allergic contact dermatitis, trauma, Behçet’s tion with a health-care practitioner during the syndrome, a heat rash, a rash from shaving the pregnancy is advisable both in women with recur- pubic area, a drug reaction, or a secondary infec- rent genital herpes and in women who may tion from something like scabies. uncommonly acquire their primary infection Laboratory testing to confirm the diagnosis is during pregnancy. Viral cultures late in the preg- indicated for most people who are having their nancy may be advised, and consultations about a initial genital eruption, even in women with a delivery by cesarean section may be justified. typical clinical symptom picture. Some lesions Other complications for the infant include menin- are classic in appearance, and perhaps a clinician will make a judgment that a laboratory test is not KEY CONCEPTS necessary. However, viral cultures are the most • Genital herpes is most commonly associated sensitive test for confirming the diagnosis of gen- with HSV-2. ital herpes. Determining the virus type has value • Risk factors for HSV-2: female, African-American, for future considerations. For example, individu- Mexican-American, older, low education level, als with genital HSV-1 (as many as 30 percent of poverty, cocaine use, a history of two to four or women with primary herpes) have a much lower more lifetime sexual partners, unprotected sex, risk of symptomatic recurring outbreaks. In addi- having a sexual partner with genital herpes, tion, women with primary genital herpes are at living in the southeastern United States (higher increased risk for other STIs and should possibly rate of seropositive individuals). be tested for chlamydia, gonorrhea, syphilis, and • The majority of primary genital herpes infections are asymptomatic or unnoticed. HIV infection. • All HSV infections establish latency and are con- The 2002 STD guidelines from the Centers sidered incurable. The present infection may for Disease Control (CDC) state that isolation actually be a recurrence of an asymptomatic of HSV in a cell culture and then immuno- infection acquired some time in the past. fluorescent staining can differentiate HSV-1 • Systemic symptoms are more common with pri- from HSV-2 and is the preferred viral test in mary infections, and symptoms are generally women who have an active genital lesion. There more severe in women than in men. are a few problems with these tests: transporting • Seek the advice of a health-care practitioner in a cell culture can be difficult, the sensitivity of diagnosing an initial genital lesion; differentiate the tests declines as lesions heal, and the test is far herpes from other causes of genital ulceration. • Recurring eruptions are common and are gener- more accurate for initial episodes than for recur- ally less severe than initial episodes. ring lesions. If the cell culture is used, then test- • Treating acute episodes can reduce symptoms 1–3 ing the blood is used to confirm the results. and shorten the duration of the eruption. Other testing methods include direct immuno- • Immune supportive therapy and antiviral therapy fluorescent antibody (DFA) test, direct enzyme- can reduce the frequency of recurrences and can linked immunosorbent assay (ELISA), and reduce symptoms in acute episodes. antigen detection tests. Only the DFA antigen test • The individual with herpes, the sexual partner, can distinguish HSV-1 infection from HSV-2. and the health-care practitioner all need to real- The most useful tests for HSV genital infection ize that genital herpes is a sensitive issue. Open detection are type-specific serologic assays for the communication, trust, and respect are essential for an informative dialogue and effective man- HSV antibodies. agement of genital herpes. The most serious and feared complication of genital herpes is the transmission from an infected 102 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

PREVENTION the disease to others. Disruption of one’s sexual life can also manifest as signiﬁcantly reduced sexual • Genital herpes is a sexually transmitted disease. pleasure and a strong sense of sexual inhibition. Education about recognizing the disease and its Many people also worry that they will be rejected prodromal symptoms of itching, numbness, and by future partners and are pessimistic about the tingling and protection during sexual contact or possibility of establishing normal sexual relation- abstaining during outbreaks are important in ships. Since many people become emotionally preventing transmission. upset upon learning of the diagnosis, a health-care • The virus can shed; thus, transmission of the provider can be extremely valuable in helping to disease to another individual is possible even without symptoms. The use of barrier methods is deal with anger, guilt, or anxiety. Education and recommended for any person who has evidence counseling include information about the nature of prior infection with HSV-2. of HSV infection, most importantly prevention • The safest method of protecting yourself and a of its transmission. It is important that patients sexual partner is to use some sort of barrier also understand that the primary infection may method to prevent contact. The use of male con- have been asymptomatic and that even an initial doms, female condoms, dental dams, or house- outbreak may be a reactivation of an infection hold plastic wrap are all recommended options. acquired months or even years previously. • Informing one’s sexual partner of a history of herpes is the responsible thing to do. Before OVERVIEW OF having sexual contact with a new partner, ask ALTERNATIVE TREATMENTS questions about his or her past sexual history, history of sexually transmitted infections, and A susceptible host plus exposure to the herpes past habits and lifestyle that may have exposed simplex virus add up to acquiring the disease. the partner to the virus and other sexually Improving the health of the host and enhance- transmitted infections. ment of the immune system is essential in pre- • A willingness to practice “safer sex” techniques venting and controlling herpes. There is some is an important health issue to discuss with a evidence that a defect in the immune system is sexual partner. One should understand that HSV present even in otherwise healthy individuals infection can be spread by oral-genital contact who have recurrent HSV infection. Support of as well as genital-genital sexual contact. the immune system, dietary factors, stressors, • Transmission from one body site to another is possible, and infected areas should be patted, skin health, and preventing and treating other rather than wiped, dry. Be especially careful non-herpes infections are all avenues for using about transmitting the infection from another natural therapies in reducing the likelihood of part of the body to the eye. contracting herpes and in reducing the frequency • Enhance the immune system. and intensity of recurrent herpes infections. • Some individuals may need to consider prophylactic suppressive antiviral medication. Nutrition A health-supportive diet is fundamental to good gitis, urinary or rectal dysfunction, infection in the health and an optimal immune system. Although eye, and erythema multiforme (a skin disease). biochemical differences may require that some of The impact of genital herpes on a person’s us eat more of some foods and less of others, psychological and sexual health can be quite intru- health-supportive diets are based on the guide- sive and profound. Many people withdraw from lines listed below. interpersonal relationships because of stress related A dietary approach for preventing recurring to their infection or because of fear of spreading herpes outbreaks that reduces high-arginine foods GENITAL HERPES 103

Dietary Recommendations After six months, the treatment was rated as effective or very effective by 74 percent of those receiv- • Maximize your intake of vegetables, whole ing the lysine, compared to 28 percent of those grains, legumes, and fruit. receiving placebo. The mean number of herpes • Drink 4 to 8 glasses of water daily. outbreaks was 3.1 in the lysine group compared • Reduce fat intake. to 4.2 in the placebo group, and lysine-treated • Eliminate refined sugar and chocolate. patients reported milder symptoms. No signifi- • Avoid food additives, coloring agents, pesti- cant side effects were reported in either group.10 cides, and herbicides. • Reduce salt and alcohol intake. Another experimental study was done with 41 • Reduce or avoid almonds, cashews, sunflower patients who took a daily dose of 1,248 mg of seeds, and peanuts. lysine. This demonstrated a decreased recurrence rate and a decreased severity of symptoms during recurrences, but not a reduced healing time.11 and increases high-lysine foods has become quite For people who want to rely on lysine supple- popular. This concept arose out of two findings. mentation alone, my recommendation is to take First, we know that the replication of the herpes one gram daily for maintenance and one gram simplex virus requires the manufacture of proteins three times daily during acute outbreaks. Lysine rich in arginine, and arginine itself may be a stim- can also be found in topical ointments to be ulator of HSV replication. Second, laboratory applied directly to herpes eruptions. These may be research has shown that lysine has antiviral activity helpful in reducing symptoms but have not been that blocks arginine7 and that an arginine-deficient adequately studied to prove their effectiveness. environment suppresses HSV replication.8 Thus, theoretically, reducing one’s intake of Lysine arginine and increasing one’s intake of lysine Acute: 1 g 3 times daily should be effective in reducing HSV replication. Maintenance: 1 g daily In fact, many people do observe an increased susceptibility to outbreaks if they eat chocolate Vitamin C and Bioflavonoids. Supplementa- or peanuts, foods that are high in arginine. Other tion with vitamin C may have therapeutic value in high-arginine foods include almonds, cashews, the treatment of recurrent external genital herpes and sunflower seeds. Foods high in lysine include eruptions. Using 600 mg of vitamin C and 600 most vegetables, beans, fish, turkey, and chicken. mg of bioflavonoids three times daily for three days after the initial onset of symptoms (in the Nutritional Supplements prodromal phase) was found to be the optimal L-Lysine. Scientific studies on the effective- dosage for the most rapid disappearance of symp- ness of lysine supplementation have not shown toms.12 In addition, in vitro evidence supports the consistent results, and a least one study cites use of ascorbate in combination with copper to dietary variability of lysine and arginine intake as inactivate HSV-2.13 In women with active lesions, a possible confounding factor that is often diffi- a randomized double-bind, placebo-controlled cult to control and is not often assessed in stud- clinical trial was done on the topical use of a ies.9 One study that did show positive results water-based solution of Ascoxal, an ascorbic was done in 52 patients with recurrent infections acid–containing formulation, in the treatment of (oral, genital, or both). Test subjects received recurrent mucocutaneous herpes. A solution- L-lysine (one gram three times daily) or a placebo. soaked cotton pad was applied to the lesion three They also avoided nuts, chocolate, and gelatin. times for two minutes with 30-minute intervals 104 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE on the first day only. Both subjective and objective Zinc and Vitamin C accounts demonstrated decreased symptoms and healing time. In addition, viral culture after the 25 mg zinc with 250 mg vitamin C twice daily for 6 first day yielded HSV significantly less frequently weeks when compared to placebo.14

Vitamin C and Bioflavonoids Botanicals Prodromal period: 600 mg vitamin C with 600 mg Lemon Balm (Melissa Officinalis). Lemon bioflavonoids 3 times daily for 3 days balm ointments have been used topically in Ger- many for oral cold sores, and products are now Vitamin E. Applying topical vitamin E to a available in the United States. Laboratory evi- lesion may provide pain relief.15 Although clinical dence demonstrates the anti-HSV-2 activity of observations have been made of only four pub- Melissa at nontoxic concentrations in vitro.22, 23 lished cases (in oral primary herpes, not genital), it The German cream Lomaherpan is a concentrate would seem logical that vitamin E applied to gen- of 70:1 lemon balm extract. Several clinical stud- ital eruptions may provide a similar benefit. Dry ies have shown impressive results. One study the area around the lesion with warm air and demonstrated that when the lemon balm cream apply vitamin E oil with a cotton swab. Leave in was used on patients with an initial oral herpes place for 15 minutes. After the 15 minutes, pain infection, or cold sore, not a single recurrence relief should be evident. Repeat as needed. occurred. Not one patient using the cream devel- Further evidence for the use of vitamin E was oped another cold sore. The cream was also found in an animal study that employed a patented shown to be effective in reducing the healing combination antioxidant cream including vitamin time in cases of genital herpes.24 E, sodium pyruvate, and membrane-stabilizing Another study, a double-blind, placebo- fatty acids. It demonstrated that the ingredients controlled, randomized trial, used a standardized worked synergistically to reduce genital HSV topical cream (active ingredient: 1 percent Lo- lesion development, duration, and severity signifi- 701—dried extract from Melissa officinalis L. cantly when compared to placebo or acyclovir.16 leaves) in 66 patients with a history of recurrent herpes labialis of at least four episodes per year. Vitamin E With applications four or five times a day, subjects Apply vitamin E oil to dry area around lesion; leave in noted shortening of the healing period, prevention place for 15 minutes. Repeat as needed. of infection spreading, and rapid relief of the typical symptoms of herpes. The authors also con- Zinc. A number of zinc salts have been cluded that the intervals between the periods with shown to have antiviral activity against HSV. In herpes might be prolonged with this treatment.25 vitro17 and animal studies have supported use of The cream should be applied two to four zinc topically with genital infection.18–20 Supple- times a day during an active eruption. No side mentation with zinc has been observed to reduce effects have been observed. the frequency, duration, and severity of genital Lemon Balm herpes eruptions. A compound of zinc (25 mg) and vitamin C (250 mg) was given twice daily for Apply topically 2 to 4 times a day. six weeks. In some cases, the eruption was completely suppressed, and in others the eruptions Licorice (Glycyrrhiza Glabra). Licorice has disappeared within 24 hours of their onset.21 traditionally been used by naturopathic physi- GENITAL HERPES 105 cians, herbalists, and other health-care practi- plants with waxes and glandular secretions. They tioners to support the body’s immune system and use this resin for the construction and repair of to defend against the effects of disease-causing their hives. It is also placed at the entrance to the viral infections. Laboratory studies demonstrate a hive where the worker bees brush up against it as component of Glycyrrhiza glabra root, gly- they enter the hive. This sterilizes the bees from cyrrhetinic acid, is active against viruses, specifi- infection. The composition of propolis varies cally in HSV where it inhibits the growth, depending on the plants in the area that the bees activity, and ability to replicate, irreversibly inac- visit. Some propolis may be higher in flavonoids, tivating the herpes simplex virus.26 In clinical other propolis may be higher in diterpene com- practice, I have observed that topical prepara- pounds. Historically, propolis has been used for tions of licorice containing glycyrrhetinic acid its antibacterial, antifungal, antiviral, antiproto- have helped to reduce both healing time and zoan, antitumor, anti-inflammatory, immunomo- uncomfortable symptoms associated with genital dulatory, and antioxidant activities. In vitro data herpes. Apply the ointment or gel several times suggests propolis has both antibacterial and daily. If used daily over several weeks or months, antiviral properties against a variety of microor- licorice may cause fluid retention and thereby ganisms, including HSV.28–30 raise blood pressure in certain individuals. Two of my favorite natural topical therapies for herpes lesions are honey and bee propolis. A small Licorice study comparing topical application of honey Apply ointment or gel several times daily. versus acyclovir cream found a statistically significant shorter duration of episodes and faster healing Siberian Ginseng (Eleutherococcus Sentico- time when using honey compared to acyclovir.31 sus). A randomized double-blind, placebo- Another larger, randomized, single-blind study controlled trial of a standardized extract of eleuthe- showed that more subjects’ lesions healed after 10 rococcus showed a decrease in severity, duration, days of treatment with a 3 percent propolis oint- and frequency of outbreaks when used for at least ment than with placebo or acyclovir.32 three consecutive months. Although not com- Bee Propolis monly used by alternative practitioners for the treatment of herpes, this study supports eleuthero’s Apply 3% bee propolis ointment several times per day. role in suppression of herpes outbreaks.27 Aloe Vera. Aloe vera is a cactus, and the gelat- Siberian Ginseng inous substance inside the leaf is known to have • Dried root: 500–3,000 mg dried root capsules many beneficial properties. It’s not surprising that • Tincture (herb and alcohol or herb, alcohol, some research shows some effects for the herpes and water): 1 tsp 3 times per day virus, and mucosal epithelial tissue appears to be • Fluid extract: 1⁄2–1 tsp 2–3 times per day a good site for the medicinal effects of aloe. In • Extract (33% alcohol extract): 40–120 drops vitro data suggests that chemical constituents of 1–3 times per day aloe vera inactivate HSV-2 both alone and syner- • Solid extracts made from dried, powdered root gistically with acyclovir.33, 34 Human clinical trials (at least 1% eleutheroside F): 100–200 mg 3 on men support its use topically as a 0.5 percent times per day Aloe Vera Bee Propolis. Propolis is a resinous substance 0.5% cream, apply 2–4 times daily that bees make by combining substances from 106 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE hydrophilic cream, but not as a gel, to shorten binding to the virus, thereby preventing the healing time and decrease symptoms.35, 36 infection of the host cells.39 Echinacea has shown in vitro antiviral activ- Myrrh (Commiphora Myrrha) and Gold- ity against HSV-1,40 but a human study did not enseal (Hydrastis Canadensis). I am not aware demonstrate any statistically significant reduc- of any research studies using myrrh and gold- tion in recurrent genital herpes.41 enseal for genital herpes eruptions, but the tradi- Viracea, a proprietary blend of benzalkonium tional use of both of these herbs is longstanding. chloride and derivatives from Echinacea pur- As an antiseptic and as an anti-inflammatory for purea, was found to have anti-HSV-1 and inflammations and sores of the mucous mem- -2 activity in vitro, even on strains that were branes, these two herbs have been very reliable resistant to acyclovir.42 and may go a long way not only toward improv- Chapparal (Larrea tridentate), specifically its ing the health of the epithelial tissue of the leaf resins, have been shown to have significant mouth and genital region but also stimulating an antiviral activity. The natural ingredients in the immune response locally in that tissue. leaf resin appear to the inhibit replication of the Myrrh virus.43 Preparations are available in either cap- Oral tincture: 10–30 drops 3 times per day Sample Treatment Plan for Genital Herpes Goldenseal See the Resources section for formulation sources. Oral tincture: 10–30 drops 3 times per day During an Acute Episode Additional Botanicals. Many botanicals • Apply ice, preferably during the prodrome stage have the ability to provide immune support during symptoms of itching, numbness, or tin- through various mechanisms. Other plants have gling or even after the eruption has appeared, very specific antiviral properties as well. for 10-minute applications several times during The antiviral activity of Saint-John’s-wort the day. This limits the discomfort and swelling (Hypericum perforatum) has been demonstrated. and can keep an outbreak from fully erupting. Laboratory studies have shown that two con- • Apply lemon balm ointment several times per stituents in Saint-John’s-wort, hypericin and day. • Apply licorice gel (glycyrrhetinic acid) twice pseudohypericin, exhibit strong antiviral activity per day. against herpes simplex virus 1 and 2 as well as • Lysine: 1,000 mg 3 times per day influenza types A and B, in addition to a virus in • Vitamin C: 600–800 mg with 600–800 mg bio- the mouth that causes vesicular stomatitis.37 flavonoids 3 times per day Momordica charantia, or bitter melon, has been • Zinc: 25 mg per day shown to have antiviral activity against both HSV 1 and 2 such that its effectiveness in vitro is Prevention not only greater than acyclovir, but it is also • Follow a diet that is high in lysine foods (veg- effective against acyclovir-resistant strains.38 etables, beans, fish, turkey, and chicken) and Medicinal mushrooms are known for their avoid foods high in arginine (chocolate, all antimicrobial activity against a number of nuts and seeds). microorganisms. Recent in vitro evidence sug- • Lysine: 1,000 mg per day gests that fungal beta-glucans extracted from • Safe sex protection Pleurotus tuber-regium exerts its antiviral effect by GENITAL HERPES 107 sules or a topical lotion. One or two capsules commonly prescribed are acyclovir, valacyclovir, daily of the leaf resin may reduce the frequency and famciclovir. Acyclovir (Zovirax) was the first of outbreaks, and the topical lotion, when FDA-approved drug for treatment of herpes and applied at the first sign of a tingling sensation, is available as capsules, tablets, oral suspension, may prevent the outbreak from occurring. topical ointment and cream, and sterile powder Botanicals such as thuja (Thuja occidentalis), for IV infusion. Valacyclovir (Valtrex) comes in lomatium (Lomatium disectum), and astragalus 500 and 1000 mg caplets, famciclovir (Famvir) (Astragalus spp.) have been traditionally used by in 125 mg, 250 mg, or 500 mg tablets. The side naturopathic physicians, herbalists, and other effect profile of all of these meds is the same. The health-care practitioners to support the body’s side effects are uncommon, but those reported immune system and to defend against the effects are nausea, vomiting, and headache. They seem of disease-causing viral infections. These herbs to be dose-dependent. There does not appear to are typically administered in liquid extracts, cap- be any long-term harm with the use of these sules or tablets, or teas. Lomatium may cause a meds, and there are few, if any, drug interactions. temporary skin rash if used in an improper dose. Essentially, this is a very safe medication class. These meds are used for episodic treatment and for prevention. We now know that 5 to 10 percent CONVENTIONAL of people are asymptomatic herpes shedders, so MEDICINE APPROACH suppressive daily therapy is recommended for: Many patients prefer to use antiviral therapy to 1. A person with an initial herpes outbreak suppress infections and to reduce recurrent 2. A person who is known to be an asympto- episodes. The primary goals of antiviral therapy matic shedder are to limit the severity of the infection and to 3. Patients with oral or genital herpes who have give the patient a sense of control over the disease more than four episodes a year process. Antiviral therapy is offered to normal immunocompetent patients with either primary The recommendation is for a year or more, or nonprimary genital herpes. In the vast major- depending on the patient’s interest. The usual ity of cases, oral antiviral therapy is sufficient, recommendation is for a year following the first although more severe cases may require hospital- episode of herpes, and longer if there are other ization and intravenous acyclovir. cofactors. Episodic therapy appears to work best for The dosing has also changed from the origi- women who have a clearly identifiable prodrome. nal recommendations. Acyclovir, which is avail- Patients who desire continuous suppressive therapy able generically, is recommended as follows: need to discuss with their physician the advantages Ointment for genital topical therapy used several and disadvantages of this regimen. Medical consid- times a day until the lesions have resolved and erations, psychosocial needs, and cost are all factors cream for oral lesions with the same dosing. influencing the wisdom of such a regimen. Orally, it is now 400 mg twice daily for 10 days The advent of herpes viral testing accuracy for an initial episode, then 400 mg twice daily for and knowledge of the asymptomatic carrier has 5 days for recurrences. 400 mg once daily is the led to an increase in the use of antiviral herpes suppression dose. treatments. The meds used to treat the virus are Valacyclovir has a variety of dosing recom- essentially the same as they have been for the past mendations: For an initial outbreak of genital 10 to 20 years, but recommendations for usage herpes, use 1,000 mg three times a day for 10 and dosing have changed. The three meds most days. For recurrent outbreaks, use 500 mg twice 108 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE daily for 5 days. For suppression, use 500 mg per treatment but also a key to determining sexual day. For oral herpes, the recommendation is 2 g behavior and habits with sexual partners. Labora- in the morning and 2 g in the evening on one day tory testing using viral cultures and blood tests for only. For recurrent outbreaks, many practitioners antibodies are the most common methods that prescribe the 1,000 mg caplet and suggest that may be recommended by your practitioner. patients cut it in half for economic reasons and A qualified health-care practitioner can be take one half caplet twice daily. extremely helpful in providing education and Famvir is dosed at 125 to 250 mg twice daily counseling to the person who has newly acquired for 10 days for the initial episode and 125 to herpes. Education includes information about the 250 mg twice daily for 5 days for the recurrent nature of HSV infection, various treatment episodes. The suppression dose is 250 mg once options, effect on pregnancy, and prevention of daily. It is interesting that with this product, the transmission. Counseling includes helping patients suppression dosing is greater than the active to deal with fears, shame, guilt, and feelings of treatment dosing, because the drug is more rap- social isolation as well as developing strategies for idly taken up by the virus when it is in its active communicating with present and future sexual replication phase. Hence, more drug is needed partners. for suppression than for active treatment. Women who are pregnant need to inform The drugs are eliminated through the kidneys, their practitioner of their history of herpes. Any so one may need to reconsider dosing in patients outbreaks during the pregnancy should be with renal impairment. The drugs are approved recorded and reported so that appropriate testing, throughout all ages of pediatric use, and they treatment, and management can be done during would need to be specifically dosed by a pediatri- the pregnancy and delivery. Whether your practi- cian. So far, no resistant strains are reported. tioner is a midwife, alternative practitioner quali- The most important treatment remains pre- fied to perform home births, obstetrician, or vention. Condoms do not prevent the spread of family physician, she or he needs to know your HSV genitally. Health practitioners continue to infection status to make appropriate recommen- suggest that patients refrain from sexual activity, dations for your health and your baby’s. including oral sex and kissing, when an active Women with recurrent genital herpes infec- lesion is present. We now recognize that 5 to 10 tions may need to seek more aggressive or indi- percent of people with a history of herpes do vidualized care from an alternative practitioner shed virus without an active lesion. Talking to than the therapies discussed in this chapter. your partner about his or her sexual history and Homeopathy, additional herbal/nutritional com- safe sex practices are probably the most important bination products, or Chinese herbal medicine steps in dealing with herpes. may be more effective in an individual case. Some women may choose to use conven- SEEING A LICENSED PRIMARY tional pharmaceutical antiviral therapy, although HEALTH-CARE PRACTITIONER this is not usually medically necessary. There are (N.D., M.D., D.O., N.P., P.A.) cases of primary or nonprimary genital herpes, The most appropriate method for accurate diagno- however, when antiviral therapy is indicated for sis of a genital lesion is to see a licensed health-care immunocompromised individuals. Cases where practitioner qualified to perform a gynecological symptoms and complications are severe enough exam. Accurate diagnosis of genital lesions is not to warrant hospitalization may require intravenous only an important key to effective and appropriate antiviral therapy. HEART DISEASE CHAPTER 9

OVERVIEW Abdominal obesity also increases the risk of Most of us are aware that heart disease is a pri- high blood pressure and diabetes and may lower mary afﬂiction for men, but cardiovascular the HDL (good) cholesterol level and raise the disease (CVD) is also the leading cause of death triglyceride level. A desirable waist-to-hip ratio in women. More than 500,000 women die of for middle-aged women is less than 0.8. To get cardiovascular-related causes annually in the your waist-to-hip ratio, measure your abdomen United States.1 Taking into account other athero- at the largest point and divide it by your hip sclerotic disorders resulting from damaged and measurement. narrowed arteries, such as strokes, almost 4 of Overall weight, usually calculated in terms of every 10 women will die of these diseases, body mass index (BMI), is also an important tool approximately 100,000 prematurely (before the for assessing one’s risk for coronary artery disease. age of 65).2 Starting at age 50, more women die To calculate your body mass index, divide your of cardiovascular diseases than of any other con- weight in kilograms by the square of your height dition,3 and women younger than 55 years old in meters. You can also refer to the height and who have a heart attack have a worse prognosis weight chart in Appendix B to help you to deter- and higher incidence of heart attack–related mine your body mass index. A desirable body death than do men of the same age who have a mass index is less than 25. The Nurses’ Health heart attack, as well as a greater chance of having Study found that women with a BMI of 29 or another heart attack.4, 5 Cardiovascular disease is more had triple the risk of coronary artery disease also a major cause of disability in older women. compared with women who were lean and with For black women, the risk of heart-related death is a BMI of less than 21.10 Women with a BMI of twice as high as for white women.6 25 to 28.9 had almost double the risk. As many Even though heart disease is the leading cause as one-third of white women and one-half of of death in both men and women, the rates of black women are 20 percent or more over their coronary disease (but not necessarily death) at desirable body weight. virtually every age are higher in men than in Between the ages of 30 and 60, and in each of women.7 When women are in their thirties and the decades in this age group, women who have forties, the difference between men and women is had either surgical or natural menopause have four- to ﬁvefold. After that, the difference shrinks twice the rate of CAD compared to women in with increasing age. Coronary artery disease their age group who still have premenopausal (CAD) is less common in premenopausal women, ovarian function.11 Women who have had both and the incidence of CAD tends to be about 10 to ovaries removed have a higher rate of CAD at an 15 years later than men, until the age of 70.8 earlier age than women who undergo natural Overweight women and those with the apple menopause.12 The explanations for this are multi- fat distribution (with abdominal fat) are at ple, but the estrogen produced by the ovaries greater risk for developing coronary artery dis- helps to maintain higher HDL levels, which pro- ease than are slim women and those with the tect the cardiovascular system, keep the LDL levels pear fat pattern (fat stored around the hips).9 low, and slow the aging of the arteries. Whether 109

Copyright © 2008 by Tori Hudson. Click here for terms of use. 110 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE women still have their ovaries or not, the rate of increases high-density lipoprotein (HDL) choles- cardiovascular disease increases with age13 and terol, decreases low-density lipoprotein (LDL) increases significantly after the age of 70.14 cholesterol, reduces oxidation of LDL choles- One of the largest and most controversial terol, lowers uptake of LDL in blood vessels, debates in modern medicine revolves around hor- binds to vascular estrogen receptors, reduces mone replacement therapy (HRT or HT). For vascular tone, preserves endothelial function, more than thirty years, observational research increases prostacyclin release, decreases throm- studies on HRT consistently reported signifi- boxane A2 formation, decreases fibrinogen, cantly reduced rates of cardiovascular disease in reduces plasminogen activator inhibitor, and women who used either estrogen alone or estro- decreases fasting blood glucose and insulin.23 gen plus progestins,15 and HRT was routinely As you can see, the last 9 or 10 years in par- prescribed for primary prevention of cardiovascu- ticular have seen a flurry of trials on the subject lar disease. Then, in 1998, the Heart and Estro- of HRT and heart disease, and with all of these gen/Progestin Replacement Study (HERS)16 studies, commentaries, confusions, contradic- found that the hormones did not protect women tions, controversies, questions, and opinions who already had evidence of cardiovascular dis- abound. Despite the more recent reassuring news ease from heart attacks, and moreover, that more about the effects of HRT when given early, women treated with HRT died of heart disease in women and their physicians are still left with no the first year of the study than those given a consistent clear message or guide as to what to placebo. This study was followed soon after, in think regarding HRT and cardiovascular disease. 2002, with one called the Women’s Health Initia- Because of this inconsistency, it is important to tive,17 which found that conventional HRT (Pre- assess each woman individually to determine marin and Provera) was not associated with a whether HRT is right for her. In addition, physi- decrease in heart disease, but actually with a slight cian advisory organizations no longer recom- increase. It was also associated with a slight mend that HRT be used to reduce the risk of increase in strokes and clots. As researchers con- heart disease. tinued to study the women in the estrogen-only The question really is, does hormone replace- group (Premarin), they did not find an increase in ment therapy benefit women, and, if so, which the risk of heart disease, but still did find a slight hormones, in what form, in what dose, and in increase in strokes and clots.18 In addition to the whom is it beneficial? estrogen plus progestin HERS study and the In determining the best plan of action, it is estrogen-only WHI study, numerous other ran- important that each woman is individually domized controlled trials have been done since assessed for her heart disease risk. Utilizing a the HERS trial. No beneficial effects of estrogen comprehensive medical history, physical exami- on heart disease risk were observed in either the nation, and selected laboratory and heart func- estrogen in the prevention of reinfarction trail tion testing, it is possible to assess a woman’s risk (ESPRIT)19 or in the women in the Papworth for coronary artery disease and the risk of heart HRT atherosclerosis study (PHASE).20 attacks. Based on this assessment, a strategy can Most recently, studies show that HRT might be put in place utilizing lifestyle changes, nutri- in fact be beneficial if taken during peri- tional and botanical supplements, and in some menopause or very early menopause,21, 22 offer- cases prescription medications to prevent and ing a window of cardioprotection if started in the treat cardiovascular disease. To assess each early menopausal years. Estrogen has favorable woman individually and comprehensively and effects on several heart disease risk factors: HRT use a holistic integrative therapeutic plan is a HEART DISEASE 111 long overdue approach in the management of discuss testing and management with your prac- heart disease in women. titioner as well as all available options, including exercise, weight management, dietary changes, What Is Heart Disease? aspirin, drug treatment, and nutritional supple- Before we go too far, let’s clarify what we mean ment interventions. by cardiovascular disease. Generally, when we Triglycerides are an important risk factor for refer to the risk of heart disease in menopausal cardiovascular disease in women, but especially women we mean coronary artery disease, includ- when increased triglycerides are present in associ- ing coronary artery atherosclerosis, myocardial ation with low HDL levels. If the triglyceride infarction (MI), acute coronary syndromes, and level is greater than 400 mg/dL and HDL choles- angina. These conditions are intimately related terol is less than 50 mg/dL, the risk of heart dis- to hypertension and hyperlipidemia. The term ease is significantly increased.24 Patients with heart disease is most often used to describe coro- elevated triglycerides and a family history for nary atherosclerosis, hardening of and deposition heart disease most likely have familial hyperlipi- of plaque in the arteries of the blood vessels that demia. Triglyceride levels from 200 to 400 supply the heart. Other forms of heart disease mg/dL are considered elevated but borderline. include congestive heart failure, arrhythmias, Weight loss alone can return elevated triglyceride mitral valve prolapse, and cardiomyopathy, but levels to normal. Smoking, dietary simple carbo- these are unrelated to issues of menopause and hydrates, obesity, and lack of exercise are all hormones. The focus of this chapter is the pre- related to elevated triglycerides. vention and treatment of coronary artery disease When determining one’s risk for heart disease, (CAD) and atherosclerosis, hypertension, hyper- there are some critical things to look for. Women lipidemia, and myocardial infarction. whose father had a heart attack or stroke before age 50, or mother before age 65 (unrelated to cig- Risk Factors for Heart Disease arette smoking), are at a genetic disadvantage. It’s Major risk factors for coronary artery disease important for these women to work harder in the (CAD) include high blood pressure, abnormal areas of prevention because they are at increased cholesterol profile (dyslipidemia), and diabetes. risk just by virtue of their family history. Optimal levels of lipids and lipoproteins for Hypertension is the most common chronic women are LDL cholesterol (LDL-C) less than disease in older women and a significant risk 100 mg/dL, triglycerides less than 150 mg/dL, factor for stroke, congestive heart disease, and non-high-density lipoprotein cholesterol less kidney disease. Beginning at age 50, hyperten- than 130 mg/dL, and HDL cholesterol (HDL-C) sion is more common in women than in men over 50 mg/dL. Updated guidelines from the and even more so in black women. See Table 9.1 2001 National Cholesterol Education Program for new blood pressure guidelines set in 2003. (NCEP III) expert panel on detection, evalua- Isolated systolic hypertension (systolic BP of 160 tion, and treatment of high blood cholesterol in mm Hg or greater) or combined hypertension adults (called the adult treatment panel, or ATP (systolic BP of 160 or greater and diastolic BP of III) are more complex than just this and empha- 90 or greater) is directly related to increased size more aggressive lowering of elevated LDL death rates from cardiovascular disease. levels, especially in women with higher risk fac- Impaired tolerance to glucose is another risk tors for heart disease. If you have peripheral vas- factor for heart disease. Women with higher than cular disease, coronary artery disease, abdominal normal blood sugar or who are clinically diabetic aortic aneurysm, diabetes, or metabolic syndrome, are at increased risk. The diabetic woman has three 112 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Table 9.1 Blood Pressure Guidelines

Blood Pressure Systolic Pressure Diastolic Pressure Category (mm Hg) (mm Hg)

Normal less than 120 less than 80 Prehypertension 120–139 80–89 Stage 1 hypertension 140–159 90–99 Stage 2 hypertension 160 or higher 100 or higher

to seven times the risk of cardiovascular disease percent of the nondiabetic population. As many as and of dying prematurely from atherosclerosis 50 percent of individuals with high blood pressure than a nondiabetic woman.25 Diabetes is a may have syndrome X.30 Overweight individuals stronger predictor of cardiovascular disease in are more susceptible to this condition, but as women than in men.26 Women are more prone to many as 50 percent of hyperinsulinemic patients suffer unrecognized or “silent” events related to may be of normal weight.31 Individuals who have ischemia. glucose intolerance and hyperinsulinemia should In addition to these risk factors, there are two eat a diet lower in carbohydrates, whether simple syndromes, both called syndrome X, associated or complex. A diet that is 40 percent carbohy- with heart disease risk. The first one was named by drates, 30 percent fat, and 30 percent protein may Dr. Harvey Kemp of Harvard in 1967 to describe help to correct the hyperinsulinemia. women with normal coronary angiograms who The diagnosis of coronary artery disease and had angina-like chest pain with or without posi- evaluation of the potential for risk of cardiovas- tive treadmill tests.27 Some of these women turned cular disease (CVD) are fundamental steps to out to have abnormal circulation in the small improve women’s health and decrease their risk of coronary arteries, and their coronary flow didn’t acquiring and dying from cardiovascular disease. adjust itself appropriately. Screening tests, noninvasive diagnostic testing, The second syndrome X, also called Reaven’s and testing to help determine risk and prognosis syndrome or metabolic syndrome,28 was coined in offer the opportunity to identify women at 1988 by Dr. Gerald Reaven of Stanford Univer- increased risk, begin proactive prevention strate- sity. It is a syndrome of increased truncal (midsec- gies, and provide the basis for treatment options. tion) obesity—a waist-to-hip ratio greater than For women who do not have symptoms of 1:1—and is defined as a cluster of symptoms that CAD, the goal is to identify risk factors for devel- appear to occur secondarily to cellular resistance to oping CAD. Risk prediction charts are available, insulin. Individuals who secrete larger amounts of and one risk chart, the Framingham risk score insulin because the normal insulin action is (FRS), includes traditional risk factors for CAD, impaired are predisposed to glucose intolerance, including age, smoking history, blood pressure, hyperinsulinemia, dyslipidemia, and hyperten- obesity, sedentary lifestyle, and cholesterol sion. The relationship between resistance to values.32 From this score, it is determined if the insulin, non-insulin-dependent diabetes mellitus, risk is low, intermediate, or high. This is then cor- hypertension, and cardiovascular disease has been related with expected rates of death or heart extensively documented.29 Evidence suggests that attack. Prevention strategies are then determined hyperinsulinemia may be seen in as many as 25 for each woman. In general, the risk of heart dis- HEART DISEASE 113 ease and heart events are low in premenopausal with an increased risk of future cardiac events in women and therefore screening is less important women, and a normal test is associated with a until menopause. Important exceptions to this are low risk of cardiac events. Even in symptom-free women who have diabetes, women with periph- women who are suspect for CAD, stress echo- eral arterial disease, and overweight women with cardiography is a cost-efficient and better test polycystic ovarian syndrome. than an exercise ECG, particularly in women The U.S. Preventive Services Task Force who are at intermediate risk for coronary artery (USPSTF) recommends against routine screen- disease. ing in adults who are low risk for CAD.33 For Cardiac imaging tests include what is called those at higher risk (a history of a nonfatal heart gated myocardial perfusion single-photon emis- attack, older age, high blood pressure, smoker, sion computed tomography (SPECT), a nuclear- abnormal cholesterol levels, diabetes, obesity, and based technique. SPECT imaging is currently being sedentary), appropriate testing is very the most commonly performed stress imaging important to prevent future cardiac events. It is test in the United States. However, it may have important to make a distinction between routine limitations in women, possibly due to their screening and tests done for individuals who are smaller heart and the interference of the breast symptomatic or who are suspected to have CAD. tissue. Different nuclear isotopes and pharma- For women who have a normal resting electro- ceuticals can be used to enhance the diagnostic cardiogram (ECG) and who have good exercise value of the SPECT test. Whichever SPECT tolerance, a routine exercise treadmill test with technique is used, these tests are able to further ECG is recommended as the initial test to evalu- evaluate and/or predict cardiac disease, and this ate suspected CAD. For women who have an information can be used to determine the extent undetermined or intermediate risk exercise ECG of the treatment intervention that is needed to test, cardiac imaging is recommended. Again, dia- improve their symptoms and future health. betic women merit special attention and will need Several new imaging technologies have to be evaluated more assertively due to their eight- emerged in the detection of subclinical CAD: fold higher risk of cardiovascular death compared computed tomography (CT), magnetic reso- to women who are not diabetic. nance imaging (MRI), and carotid intima-media For women who are symptomatic—for thickness (IMT). Consultation with a cardiolo- example with angina pains—and are intermedi- gist is important in determining the value or ate or high risk, noninvasive cardiovascular risk need for such tests. screening, including exercise ECG testing, stress Increasingly, blood tests for cardiovascular echocardiography (an ultrasound imaging of biomarkers, which may serve as markers for the heart called echocardiogram, done while CVD, are being done in healthy women. Tests exercising), and cardiac imaging looking for ath- for lipoprotein (a), C-reactive protein, fibrino- erosclorosis are recommended. Stress echocardio- gen, homocysteine, and subfractions of HDL-C graphy can provide important information about and LDL-C are a few of the more frequently the function of the left ventricle of the heart, used. It is difficult to say with certainty, at this valvular disease, and any stress-induced ischemia time, in whom and how often these should be or previous infarction. This particular test has done. Currently, the scientific community has become an important tool in testing women, not agreed on guidelines for their use or whether because it is more specific and accurate than stan- such testing ultimately does a better job than the dard exercise ECG in women. An abnormal exer- traditional physical exam with cholesterol panels cise stress echocardiography test is associated and blood glucose testing. In my practice, for 114 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Risk Factors for Coronary Artery Disease cular disease, risk factors such as cigarette smoking, exercise, dietary habits, and stress can be mod- Medical Conditions ified to reduce a person’s risk. In fact, a recent Hypertension study found that the following factors are to be Diabetes mellitus correlated to increased hypertension: excessive Hyperlipidemia/lipid abnormalities sodium intake, low potassium intake, physical Syndrome X (insulin resistance) inactivity, low intake of fish oil, low calcium Obesity and/or excess abdominal and upper body fat intake, low magnesium intake, excessive coffee (apple shape) consumption, and excessive alcohol intake.34 Dietary and lifestyle changes are the founda- Lifestyle tions of heart disease prevention and treatment. Sedentary lifestyle Dr. Dean Ornish and his team of researchers High-fat diet conducted the first significant clinical trial to Cigarette smoking determine whether comprehensive lifestyle Alcohol—more than two drinks per day changes affect coronary atherosclerosis. Dr. Dean Stress Ornish’s landmark study, called the Lifestyle Family History Heart Trial, published in 1990, found that lifestyle changes (a low-fat vegetarian diet, mod- Coronary artery disease erate aerobic exercise, stress management, smoking cessation, and group support)35 changed women who have had one regular lipid panel serum lipids as much as cholesterol-lowering with abnormalities, I am inclined to order these drugs. After one year in the program, patients additional, more sophisticated blood tests. The also showed significant overall regression of their more risk factors they have, such as obesity, coronary atherosclerosis. These results have been diabetes, and others, the more eager I am to eval- replicated in several recent studies.36–38 It is inter- uate them in as comprehensive a manner as pos- esting to note that patients who made less com- sible. These additional blood tests can be easily prehensive changes in lifestyle showed significant done to serve that purpose. progression of their atherosclerosis, suggesting There are heart disease risk factors unique to that the conventional 30 percent–fat diet recom- women. These include oral contraceptive use, mendation made to patients with cardiovascular pregnancy, having had both ovaries removed, and disease is not low enough. See the nutrition and premature menopause. Additional risk factors not dietary factors section for more about the Dean related to gender include increased body fat, espe- Ornish low-fat diet. cially if it is in the abdominal area; history of smok- Smoking is the most important risk factor for ing; being sedentary; diabetes mellitus; high blood cardiovascular disease and heart attacks, even in pressure; poor lipid ratios; and family history. premenopausal women. Smokers have three to five times the risk of coronary artery disease as OVERVIEW OF nonsmokers, and smoking accounts for one-fifth ALTERNATIVE TREATMENTS of CVD deaths.39, 40 Even smoking only one to Conventional and alternative medicine practition- four cigarettes a day doubles a woman’s risk of ers agree that, in most cases, atherosclerosis and CVD. Smoking a pack or more per day may cardiovascular disease are directly related to diet double to quadruple that.41 Tobacco smoke con- and lifestyle. While family history and genetic tains chemicals that damage the lining of the predisposition play an important role in cardiovas- arteries, raise the cholesterol level, promote the HEART DISEASE 115

KEY CONCEPTS reduces blood pressure, helps to inhibit blood clots, reduces overall body fat, and minimizes • Determine your individual risk for cardiovascular damage from stress. disease; make an appointment with a knowl- In many women, stress is the major cause of edgeable health-care practitioner for medical their high blood pressure. Relaxation techniques history, physical exams, and tests. such as deep breathing, biofeedback, meditation, • Monitor blood pressure regularly. yoga, progressive muscle relaxation, and hypnosis • Monitor fasting levels of total cholesterol, HDL have all been shown to have some value in lower- cholesterol, LDL cholesterol, cholesterol/HDL ing blood pressure.43 Many recent studies on var- ratio, triglycerides, and blood glucose. Consult with your health-care provider regarding at what ious stress reduction techniques have also shown age to start and how frequently ECGs, stress improvement in blood pressure and other meas- ECGs, stress echocardiograms, and cardiac or carotid artery imaging may be needed on an PREVENTION individual basis depending on symptoms and suspicion of CVD. Prevention of Heart Disease • More sophisticated testing as needed or desired: • Get regular aerobic exercise for 30 minutes, 5–7 homocysteine, alpha-lipoprotein (a), fibrinogen, days per week. C-reactive protein, HDL subfractions, LDL • Increase fish, whole grains, fruits, vegetables, subfractions. legumes, olive oil, and nuts and seeds intake. • Heart disease, and especially heart disease ear- • Eat lean meats and poultry without the skin. lier in life, is a preventable disease; appropriate • Eat low-fat or fat-free dairy (preferably organic). diet and exercise, emotional balance and stress • Decrease consumption of foods high in saturated management, and herbal and nutritional supple- fats, cholesterol, sugar, and simple mentation may substantially reduce CVD risk. carbohydrates. • Benefits and risks of hormone replacement ther- • Work toward or maintain a healthy body weight. apy need to be discussed with a health-care • Do not drink more than one alcoholic beverage provider familiar with up-to-date research on per day. this topic. • Stop smoking and avoid secondhand cigarette smoke. ability of platelets to clump together, elevate Prevention of Hypertension levels of fibrinogen (a clot-forming protein), and elevate the blood pressure. Smoking is especially • Limit sodium intake to less than 2,400 mg per problematic in women who use oral contracep- day. tives. This combination increases the risk of • Practice stress management techniques. • Work toward or maintain a healthy body weight. CVD by up to 39 times due to blood clots.42 The • Exercise daily for 30 minutes or more. good news is that women who stop smoking can reduce their risk of CVD to that of a nonsmoker Prevention of Hyperlipidemia within two years of quitting. • Decrease consumption of saturated fats and Exercise is a vital part of a lifestyle routine high-cholesterol foods. that can have lifelong benefits in preventing heart • Increase consumption of fruits, vegetables, and disease and strokes. Regular exercise lowers cho- whole grains. lesterol levels, improves the blood supply and • Exercise daily for 30 minutes or more. therefore the oxygen delivered to the heart, • Increase consumption of olive oil, nuts, and increases the strength of the heart muscle and seeds. thus improves the volume of blood it can move, 116 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE ures of CVD, including decreased mortality and as reduction of breast, ovarian, and uterine oxidative stress.44–49 cancer risk. A fundamental tenant of alternative medicine In addition to amount of fat, the type of fat is that lifestyle changes that include smoking is also important. Understanding the harmful cessation, appropriate exercise, diet, and the use effects of some fats and the beneficial effects of of dietary ingredients, nutritional supplements, others can be confusing. A little explanation of and herbal extracts can prevent or reduce risks terms and concepts may go a long way in clarify- and treat cardiovascular disease. Considerable ing the issue. Fats are the most concentrated scientific research exists that demonstrates the source of food energy. Each gram of fat provides effect of these natural therapies and interventions 9 calories, compared with only 4 calories per in lowering cholesterol, improving blood lipid gram for carbohydrates or protein. All fats are ratios, lowering blood pressure, preventing clots made from carbon, oxygen, and hydrogen. These and strokes, inhibiting fibrinogen, lowering elements are arranged in molecules called fatty homocysteine levels, strengthening the cardiac acids. The three major classes of dietary lipids are muscle, and preventing the oxidative damage to triglycerides, phospholipids, and sterols (such as vessel walls, all of which are implicated in cardio- cholesterol). Ninety-five percent of the dietary vascular disease risk. Ingredients such as fiber, fats are triglycerides. A triglyceride is a glycerol soy, antioxidants, folic acid, vitamins B6 and B12, molecule with three fat molecules attached. magnesium, fish oils and flax oil, garlic, haw- These fat molecules are called fatty acids. Lipase thorn berry, and others are just some of the many enzymes, found in our bile, break apart the natural therapies that give alternative practition- triglyceride molecules. The triglyceride is con- ers a great deal of confidence in their ability to verted into a monoglyceride, which the body can help women to prevent and treat heart disease. then absorb, along with the individual fatty acids Most alternative practitioners employ a diverse, and the glycerol. holistic health plan in their approach to prevent- Fatty acids and monoglycerides are absorbed ing and treating CVD. Recent research supports and transported by lipoproteins. These lipopro- the use of supplements like fish oil, oat bran, and teins are the very low-density lipoproteins plant sterols in combination with diet and exer- (VLDL), low-density lipoproteins (LDL), and cise interventions as a way to favorably effect all high-density lipoproteins (HDL) that we have lipid parameters,50 and diets focused on decreas- discussed earlier in the chapter. VLDL and LDL ing cholesterol have long-term success on par transport the fats from the liver to the cells in the with statin therapy.51 body, and HDL returns the fats to the liver. Ele- vations of LDL or VLDL are associated with an Nutrition and Dietary Factors increased risk for atherosclerosis (narrowing of Dietary habits are a fundamental area where we the arteries), which compromises blood flow to can exert a great deal of influence on our heart the heart, which can cause a heart attack, and health. creates an artery prone to releasing a blood clot, which can lead to a stroke. Elevation of the HDL Fats. Lowering the level of dietary fat has is protective and is associated with a lower risk of been in the news for a long time now. The Amer- heart attacks. ican Heart Association says that 30 percent or less of our total calories should be from fat. Many Types of Fatty Acids. A distinction should be alternative practitioners advise even lower intakes made between different types of fatty acids. Sat- because of some of the additional benefits, such urated fatty acids are solid at room temperature HEART DISEASE 117 and are typically animal fats (found in beef, either PUFAs or saturated fats. Of all the types lamb, butter, cheese, and lard). Saturated fats in of fat, monounsaturated is the healthiest for general are not good for the heart; they con- your heart. tribute to LDL cholesterol and should be eaten An omega-9 oil, such as oleic acid (found in in sparse amounts for a heart-healthy diet. A olive oil), is a monounsaturated fat that has the triglyceride is a saturated fat when the carbon unsaturated bond at the ninth carbon molecule molecules in the fatty acids are saturated with on the chain. Monounsaturated oils like canola hydrogen molecules and can’t carry any more. and olive are ideal for cooking as they are made When some of the hydrogen molecules are chiefly of oleic acid that is more resistant to removed, what remains is an unsaturated fatty damage from the heat from cooking and light acid, or unsaturated fat. Unsaturated fats are from storage. The high content of oleic acid liquid at room temperature and, therefore, are make these two oils far superior to the highly called oils. Most vegetable oils contain mainly polyunsaturated oils like corn, safflower, and soy unsaturated fats. These are not as bad for you as that are easily damaged by heat and light and saturated fats, and they contain healthy essential aren’t as heart-healthy. The fatty acids in these fatty acids (discussed later), but they aren’t less desirable oils are changed to lipid peroxides healthy in large quantities. Polyunsaturated fatty with cooking, which have a toxic effect on the acids contain more than one double bond along inside of the arteries. In a healthy cardiovascular the fatty acid chain. Replacing saturated fatty prevention regime, one would, therefore, prefer- acids in the diet with polyunsaturated fatty acids entially eat the seeds and fruits that contain (PUFAs) from vegetable oils will lower both total monounsaturated oils; use canola, sesame, and cholesterol and LDL levels and decrease blood olive oil for cooking; and leave the rest of the oils pressure.52 However, it may also lower HDL. on the supermarket shelves. (See Table 9.2 for the The third general type of fat is monounsatu- fatty acid composition of different dietary oils).53 rated fat. These fats contain one double bond. We don’t hear a lot about sesame oil, but a Monounsaturated fatty acids, as found in olive number of studies have proven its cardiovascular oil, show either no effect on HDL or an increase benefits. One study showed a significant decrease in HDL, thereby promoting a better effect than in blood pressure measures in patients after 45

Table 9.2 Fatty Acid Composition of Various Dietary Oils

% GLA % LA % ALA % Oleic % Saturated Oil (Omega-6) (Omega-6) (Omega-3) (Omega-9) Fat

Flax 0 14 55 20 9 Safﬂower 0 75 0 13 12 Soy 0 50 9 26 15 Olive* 0 8 0 76 16 Coconut 0 3 0 6 91 Corn 0 59 0 24 17 Canola 0 30 7 49 7

*Is especially high in the preferential monounsaturated fat, oleic acid. 118 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE days of using sesame oil and an increase in meas- are made during the process of hydrogenating oils ures when patients reverted back to other oils. In by chemically modifying a natural oil in a process addition, sesame oil decreased weight, body mass that converts some of the cis unsaturated fatty index, waist and hip measurements, blood sugar, acids to the trans form. When we metabolize trans hemoglobin A1c, total cholesterol, LDL, and tri- fat, it behaves similar to saturated fat, leading to a glycerides.54 Another study found that sesame oil higher risk of heart disease and other chronic dis- was superior to sunflower and nut oils in its abil- eases. Trans fats have adverse effects on HDL-C ity to decrease oxidation of lipids, improve lipid and LDL-C. Trans fatty acids also have an adverse parameters, and decrease blood pressure.55 effect on cell membranes, making them stiffer, and Olive oil, with a monounsaturated fatty acid in general are associated with increased inflamma- rich in oleic acid, is especially heart-healthy. Most tory and oxidative damage. of the beneficial effects of olive oil, especially the Trans fatty acid levels are determined by the richer virgin olive oil, are attributed to its high amount of hydrogenated oils in a food. Foods monounsaturated fatty acid content. However, it such as doughnuts, french fries, margarine, most also has other components that may help explain cookies, and any food that contains “partially its cardiovascular benefits. Virgin olive oils have hydrogenated oils” contain trans fats. Soybean more phenols, which appear to provide the great- oils, corn oils, and safflower oils contain rela- est benefits by increasing HDL cholesterol levels tively high amounts of oleic and linoleic acids, and reducing the oxidative damage on lipids. Phe- which can convert to elaidic acid during the nols are a class of naturally occurring compounds hydrogenation process. Elaidic acid is the most found in fruits, vegetables, tea, red wine, and common form of trans fatty acids because of its grape juice that are in essence antioxidants. These production by hydrogenation of our most cardioprotective phenols included flavonoids, common dietary oils. Elaidic acid is found in resveratrol, and curcumin. A daily 25 ml dose of amounts as high as 60 percent in hard margarine. any type of olive oil has been shown to reduce Being armed with a bit of knowledge about trans lipid cardiovascular risk factors56 by decreasing fats and the foods that contain them and know- oxidative damage on lipids, increasing HDL cho- ing what to look for on labels will help you to lesterol levels, and improving the glutathione bal- steer clear of the damaging effects of trans fats. ance that protects against oxidative stress. Many women are fearful of eating more nuts Hydrogenated oils (an unsaturated oil that due to their fat and calorie content, but nuts actu- has been made into a saturated fat) should be ally contain healthy fats, as does olive oil. Higher avoided for cardiovascular health. Hydrogenated amounts of nuts are associated with cardioprotec- oil raises LDL, lowers the protective effects of tive effects. Increased intake of walnuts in particu- HDL, and can in fact increase the incidence of lar, with their alpha-linolenic acid content, heart disease. Foods such as margarine, cakes, appears to have a triglyceride-lowering effect.57 In cookies, candies, and doughnuts often contain addition, beneficial oils in nuts help to decrease partially or totally hydrogenated oils. This is also inflammatory markers associated with CVD risk, true of many oils sold in supermarkets; in order such as C-reactive protein (CRP).58 Nuts and to prolong their shelf life, hydrogenated fats are seeds to increase in the diet in addition to walnuts used in many so-called cooking oils. include almonds, filberts, sesame seeds, pumpkin Another important fat classification, and one seeds, and flaxseed. that’s come under a good bit of scrutiny lately for Cholesterol. Cholesterol is a waxy substance being especially unhealthy, is trans fats. Trans fats found in animal tissue. It is produced by the liver HEART DISEASE 119 (about 1,000 mg per day) and is a component of all equal amounts of omega-6 and omega-3 essential cell walls. Blood-circulating cholesterol is supplied fatty acids. In the modern industrialized coun- by the liver and the intake of animal foods. Diets tries, most people eat from 10:1 to as high as that are high in cholesterol and saturated fats (beef, 30:1 omega-6 to omega-3. Based on the research pork, lamb, butter, cheese, palm oil, coconut oil) of Yeluda and Carasso,64 many modern alterna- contribute to poor lipid ratios and elevated choles- tive practitioners recommend a ratio of 4:1. This terol. Lowering the cholesterol in the diet will lower ratio of fatty acids will produce a favorable the blood cholesterol in most individuals.59 production of the friendly prostaglandins, series Essential Fatty Acids. The body can make most 1 and series 3, and a limited amount of the of the fatty acids it needs from the carbon, hydro- unfriendly series 2 prostaglandins. Overall, we gen, and oxygen provided by food. These have want to reduce omega-6 fats and increase omega- been arbitrarily classified as nonessential fatty acids. 3 fats in our diet. Increasing dietary fish, flaxseed, (This is a most unfortunate classification. It tends and walnuts and decreasing saturated fats will to mask the fact that the so-called “nonessential” help to improve this ratio. fatty acids are as critical to cellular life and metab- The eicosanoids from eicosapentaenoic acid olism as are the so-called “essential.” The nonessen- are also associated with cardioprotective effects. tial fatty acids are manufactured by the cells from EPA has been shown, in particular, to decrease raw materials. The others must be supplied by systolic blood pressure, in part due to its effects food. We cannot survive without both.) Essential on intracellular sodium transport,65 while doca- fatty acids (EFAs) are polyunsaturated fats that hexaenoic acid has been shown to increase must be obtained from foods. The two essential HDL.66 In animal studies, dietary fish oil has fatty acids are linoleic acid and alpha-linolenic acid. been shown to improve vascular function and Linoleic acid is the main omega-6 fatty acid. decrease oxidative stress.67 Alpha-linolenic acid is the main omega-3 fatty Fish oils contain EPA and DHA. Cold-water acid, which the body can convert to eicosapen- fish such as salmon, tuna, mackerel, herring, and taenoic acid (EPA) and docahexaenoic acid halibut in particular are excellent sources of (DHA). Linolenic acid has been found to decrease omega-3 fatty acids. Fish oils prevent clots, atherosclerotic plaques, systolic blood pressure, and inhibit inflammation in the vessel walls, cause related mortality in that high dietary consumption vasodilation, and promote a regular cardiac is related to low incidence of atherosclerosis.60–63 rhythm. Similar to aspirin, fish oils block the The body uses the omega fatty acids to create production of thromboxane A2, which is a eicosanoids. One of the most important classes of potent vasoconstrictor and promoter of the stick- eicosanoids is the prostaglandins. Prostaglandins iness of blood.68 Fish oils may also lower blood exert a local hormone-like effect on target cells pressure and triglycerides, but they may raise and tissues. For example, in the cardiovascular LDL.69–71 Other studies show that fish oils lower system, they affect dilation or constriction of total cholesterol, LDL and triglycerides, while blood vessels and clot formation. increasing HDL.72 In a large study of male physi- The omega-6 and omega-3 fatty acid groups cians, those who ate fish at least once per week each produce separate, distinct prostaglandins. had a 52 percent lower risk of sudden cardiac Both types of fatty acids are needed, but in the death.73 Fish oils with a seed oil of alpha- right ratio. There is some disagreement as to the linolenic acid and vitamin E have also been right ratio between omega-6 and omega-3 fatty shown to reduce the inflammatory marker C- acids. Our early ancestors probably ate roughly reactive protein (CRP), associated with cardio- 120 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Five Omega-6 and Omega-3 in arachidonic acid and high in omega-3 fatty 82 Fatty Acids to Remember acid. Fish consumption not only improves laboratory values but also decreases evidence of car- LA: Linoleic acid. An omega-6 fatty acid found in diovascular disease at the blood vessel level in vegetable oils, nuts, and seeds. Given the proper terms of stenosis and other markers of atheroscle- conditions, the body converts LA to GLA and rosis in postmenopausal women who consumed eventually into prostaglandin 1. two or more servings of fish per week.83 GLA: Gamma-linolenic acid. LA gets converted to GLA by enzymes in the body. Certain foods, habits, Fiber. Increasing the fiber in the diet is and events (saturated fat, partially hydrogenated another vitally important nutritional habit to oils, stress, aging, drinking alcohol) disrupt this acquire. Fiber sources that form a gel such as psyl- conversion so that only 5 to 10 percent of LA gets lium seed or oat bran bind bile and cholesterol in converted to GLA. It may be better to get GLA the intestines and promote their excretion. This directly from evening primrose oil, black currant action improves the cholesterol by decreasing LDL oil, or borage oil supplements. levels while increasing HDL levels.84 A diet high ALA: Alpha-linolenic acid. This is an omega-3 fatty acid not commonly found in foods. Seven seed oils in whole grains, fruits, vegetables, and legumes is contain some ALA, with flaxseed oil being the the optimal high-fiber diet. Soluble fibers such as richest natural source. Through several biochemical pectin or oat bran have the most consistent bene- steps, the body converts ALA to EPA and then to ficial effects on cholesterol levels.85 Most studies prostaglandin 3. on fiber have shown rather impressive lipid reduc- EPA and DHA: Eicosapentaenoic acid and doca- tions, with the higher the initial cholesterol, the hexaenoic acid. These two omega-3 fatty acids are greater the benefit. One of the ways fiber helps to found in cold-water fish oils. EPA is a building lower cholesterol is to increase the rate at which block for the body to make prostaglandin 3; DHA food passes through the digestive tract, thereby is important for the brain, nervous system, and increasing the loss of cholesterol in the stool. A vision. review of 20 scientific trials on the effect of oat products on cholesterol demonstrates that a vascular disease.74–79 Norwegian researchers con- modest reduction in blood cholesterol can be cluded that eating fish like mackerel, herring, and achieved by eating oat products daily.86 Eating one salmon will significantly reduce the risk of heart bowl of oat bran cereal or oatmeal daily (3 grams disease. As little as one serving of 300 grams of fish of oat fiber) lowers the total cholesterol by 8 to 23 per week will provide the benefit. They suggested percent. These results have been achieved in as that the minimal dietary requirement for EPA and little as three weeks. DHA should be about 200 mg per day.80 A more recent study showed that dietary fiber Keep in mind that fish oil has anticoagulation intake is inversely correlated with several cardio- effects that may act synergistically with medica- vascular disease risk factors. The highest total tions like warfarin, and therefore caution should dietary fiber and nonsoluble dietary fiber (more be exercised in supplementing with fish oil in than soluble) intakes from fruit, vegetables, and people who are taking these medications.81 cereals were significantly associated with a Lipid-lowering medication was found to decrease decrease in a number of cardiovascular risk beneficial omega-3 fatty acids and increase path- factors including overweight, hypertension, lipid ogenic arachidonic acid after only three months markers, and homocysteine.87 Part of fiber’s of use, leading the authors to conclude that these effect on lipids is because these higher fiber medications should be combined with diets low diets are in fact diets low in cholesterol intake.88 HEART DISEASE 121 Another study found that soluble fiber added even worse if you eat high-fructose corn syrup, a simply as a breakfast bread source was found to very common sweetener used in packaged foods. significantly decrease blood pressure and triglyc- Fructose increases LDL and does not improve eride and cholesterol levels in diabetic patients.89 HDL. A recent study showed that foods with a Increased fiber intake (more than 3 grams of high glycemic index have a negative effect on cereal fiber daily or more than six servings of HDL levels.98 whole grains per week) is also associated with If you have elevated triglycerides, you can eat decreased progression of coronary atherosclerosis all the whole grains that you want, although in postmenopausal women.90 some diets, such as the popular Zone diet, pres- A number of large, recent epidemiological ent some provocative, controversial ideas that studies published in medicine’s most respected may be contrary to this. journals found that overall, increased intake of One of the best ways to achieve a high-fiber dietary fiber is associated with decreased cardiovas- and low-fat diet is the vegan diet. This is a vege- cular disease in adults91, 92 and menopausal tarian diet in which absolutely no animal prod- women.93, 94 Another study looked at the combi- ucts are consumed. Strict vegan diets, which are nation of 10 mg of simvastatin and 15 grams of typically very low in saturated fat and dietary psyllium (Metamucil) and found that the combi- cholesterol and high in fiber, can help maintain nation decreased LDL cholesterol better than the or achieve desirable blood levels by especially same dose of medication alone and found reduc- lowering the total cholesterol and the LDL tions comparable to 20 mg of simvastatin after cholesterol.99 four to eight weeks of treatment without signifi- Specific fruits or vegetables may also have a par- cant changes in HDL or triglycerides.95 One study ticular positive effect on serum lipids. Raw carrots of a very low saturated fat diet plus a cholesterol- may have a more potent effect on lowering choles- lowering drug, compared to a diet high in plant terol than do oat products. Eating a raw carrot at sterols, including soy foods and high-fiber whole breakfast every day for three weeks has been shown grains, concluded that dietary intervention may be to reduce serum cholesterol by 11 percent and as effective as the medication.96 Continuing to eat increase fat excretion by 50 percent.100 a diet higher in fiber as we age also provides car- Evidence also exists demonstrating that dioprotection. A large study found that increasing people with a low intake of fruits and vegetables fiber later in life can decrease risk of cardiovascular have an increased risk for heart disease.101 disease in the elderly.97 Numerous studies have continued to show that a Research has also shown that the sugars in diet high in carotenes and flavonoids found in fruit (fructose) significantly raise blood triglyc- fruits and vegetables reduces the risk of heart dis- eride and cholesterol levels. If your triglycerides ease and strokes.102 It is thought that the antiox- are above 150 mg/dL, or if you have additional idants (C, E, carotenes, and flavonoids) found in significant risk factors for heart disease such as fruits and vegetables reduce the risk of cardiovas- elevated blood pressure or diabetes, avoid too cular disease by scavenging free radical species. much fruit, fruit juice, and other simple sugars. The antioxidants protect the unsaturated fatty Limit them to one serving per day. Sugar can be acids from peroxidation, thus preventing athero- eaten in small amounts only if your triglyceride sclerosis. Lipid peroxide concentrations are in level is below 150 mg/dl. All sugars can increase fact higher in individuals with atherosclerosis.103 triglycerides, but a high amount of fructose, esp- Good dietary sources of carotenes as well as vita- cially fructose added as a sweetener, is actually mins C and E are green leafy vegetables, yellow- more damaging than sucrose and glucose. It gets orange fruits and vegetables, red and purple 122 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE fruits and vegetables, legumes, grains, and seeds. studies published from 1966 to 2005 found that Good dietary sources of flavonoids are citrus soy protein intake was significantly related to fruits, berries, onions, parsley, legumes, green tea, decreased total and LDL cholesterol and trigly- and red wine. cerides and increased HDL.106 Other studies of pre- and postmenopausal women found that soy Soy. Soy foods contain a group of non- is beneficial for improving lipid parameters,107, 108 steroidal plant chemicals called phytoestrogens. with even more favorable effects in type 2 These compounds are similar in their chemical diabetic women with hyperlipidemia,109 decreas- structure to estradiol, and to equol, a phytoestro- ing lipid peroxidation better than estrogen,110 gen metabolite, but they are not actually estro- improving platelet function,111 decreasing homo- gens. Phytoestrogens are categorized into three cysteine,112 and working synergistically with main classes: isoflavones, lignans, and coumes- statins to achieve favorable cholesterol levels.113 tans. Isoflavones contribute significantly to our New research states consuming 25 grams of soy dietary phytoestrogen intake. Isoflavones are protein (containing 50 mg of isoflavonoids) daily found in legumes and are highest in soybeans. for five weeks may decrease systolic blood pres- These isoflavones are associated with the protein sure by nearly 6 percent.114 part of the soybeans and are not found in soy oils There are many other positive soy studies, or soy lecithin. too numerous to list here, but to be fair, let’s talk One potential dietary influence for a choles- about those soy studies that have not showed lipid- terol-lowering strategy is to consume more soy lowering effects. A recent study looked at daily soy protein. This is perhaps my favorite recommenda- consumption in the form of a 50-mg isoflavone bar tion to women because soy also offers many other and found no significant change in lipids, except potential benefits, including mild reduction of an increase in HDL, when consumed for eight menopausal symptoms and potentially reduction weeks. The isoflavone-enriched bar did improve in the risk of breast cancer and uterine cancer. C-reactive protein (CRP), a marker of inflamma- Observations in large Asian populations, whose tion that mediates the initiation and progression diet includes soybeans as a basic food group, show of atherosclerotic plaque lesions, but had no sig- a lower incidence of CVD than in populations nificant effect on other plasma inflammatory 104 who consume a traditional Western diet. markers.115 A controlled trial of 202 healthy post- Much research has been done on soy and its menopausal women aged 60 to 75 concluded that relationship to blood pressure, cholesterol, and the use of a soy protein supplement containing even some inflammatory biomarkers of cardio- isoflavones did not improve plasma lipids when vascular disease. In general, the studies are varied, started at age 60 or older.116 A 2006 review article with some showing clear benefit and some not concluded that the evidence for soy lowering showing any. Perhaps the best evidence comes cholesterol was not overwhelmingly impressive.117 from a review of 38 scientific studies. This meta- Interestingly, when soy intake (30 grams of analysis concluded that consumption of soy pro- soy, including 4 grams of phytosterols) was stud- tein rather than animal protein significantly ied in the setting of a low glycemic index diet decreased serum concentrations of total choles- (a diet that does not raise blood sugar levels terol, LDL cholesterol, and triglycerides.105 quickly), it demonstrated more improvement in The use of soy for menopausal symptoms and lipid parameters than the standard American heart disease protection continues to receive Heart Association Diet.118 It may in fact be that great interest from women, practitioners, and sci- soy is most effective as part of an overall healthy entists. Most recently, a large meta-analysis of diet and lifestyle plan. Substituting soy protein HEART DISEASE 123 for animal protein increases the variety of nutri- food containing refined carbohydrates. Decreas- ent intake and adds fiber, monounsaturated fats, ing the total carbohydrate intake in favor of minerals, and antioxidants while avoiding the increased protein may be advisable as well. A saturated fats found in animal protein. Other recent study of women found that weight loss of studies have found that supplementing the diet as little as 5 percent with a plan that included with a soy protein and soy fiber lowers LDL and decreased carbohydrates and increased exercise total cholesterol119 and that eating any legumes, lead to a decrease in the ability of LDL choles- including soy, at least four times per week can terol to cause atherosclerosis.126 Of course, this lower the risk of cardiovascular disease.120 would presume the carbohydrates left in the diet Despite the lack of effect in some studies to be complex and not refined. on soy and lipids, when we look at the role of soy If your triglycerides are above 150 mg/dL, or if in other aspects important to women’s health— you have additional significant risk factors for heart reducing the incidence and severity of hot disease such as elevated blood pressure or diabetes, flashes, loss of bone mass, vaginal dryness, and limit fruit, fruit juice, and other simple sugars to female-related cancers—the most convincing one serving per day. Sugar can be eaten in small effects of soy are in fact in the area of its action amounts only if your triglyceride level is below 150 on lipids. The North American Menopause Soci- mg/dl. All sugars can increase triglycerides, but ety seems to agree with this perspective in a 2000 fructose is actually more damaging than sucrose consensus opinion.121 and glucose. It gets even worse if you eat high-fruc- With many good reasons for women to eat tose corn syrup, a very common sweetener used in soy, blood pressure may be another area of bene- packaged foods. Fructose increases LDL and does fit. New research states that consuming about 25 not improve HDL. A recent study showed that grams per day of soy protein can decrease blood foods with a high glycemic index have a negative pressure.114, 122–124 effect on HDL levels.98 Foods with a high glycemic index are those Good Carbs, Bad Carbs. It seems we all love foods that raise blood sugar levels quickly. These carbohydrates. Complex carbohydrates, such as foods include items such as white bread, refined found in brown rice, whole wheat, rye, oats, cereals, white rice, and white flour pasta. These barley, millet, whole fruits, and vegetables are foods greatly stress blood sugar control and cause a high in both fiber and vitamin content and there- rapid rise in blood sugar. In response, the body fore the preferred form of carbohydrates. Refined secretes insulin from the pancreas. Over time, too carbohydrates, on the other hand, must be placed much insulin is secreted, called hyperinsulinemia, in the group of unhealthy foods. Sugar, a refined and the body tissues become resistant to the carbohydrate, is a significant factor in the devel- insulin. These two consequences of a high glycemic opment of atherosclerosis.125 index diet can promote the growth of cancer and High-sugar diets lead to elevations in trigly- increase the risk of heart disease and diabetes. cerides and cholesterol and also to an increase in Reading labels on packaged foods is a good insulin production. Elevations in insulin levels strategy for reducing intake of refined sugars. Any are associated with risk of cardiovascular disease label that says sucrose, glucose, maltose, lactose, by increasing cholesterol, triglycerides, and blood fructose, sugar, corn syrup, or white grape juice pressure. The prudent woman would decrease all concentrate is a source of added dietary sugar. sources of refined sugar in the diet by avoiding candies, pastries, and desserts; she would also Salt. With all this talk of lowering cholesterol avoid sweetened cereals, white breads, or any and improving the cholesterol ratios, it is easy to 124 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE forget how important it is to balance the blood more dietary saturated fats and cholesterol, are pressure and how foods may have a positive or a more likely to be smokers, and are less likely to negative effect on this. For example, a diet low in be current exercisers.130 potassium and high in sodium is associated with I encourage all my patients to decrease their high blood pressure. By contrast, a diet high in coffee intake to not more than one regular coffee potassium and low in sodium can protect against drink per day. Using any stimulant to falsely raise elevation of blood pressure.127, 128 It has become energy and obscure the fact that we are tired or common knowledge that too much salt in our stressed or just plain doing too much in our lives diet may contribute to high blood pressure. Not does not seem consistent with respecting our so commonly known is that high blood pressure bodies’ normal rhythms. For women who have is also related to too little potassium in our diet. elevated cholesterol, elevated blood pressure, or In fact, restricting salt alone may not be enough generally higher risks for heart disease, the to lower the blood pressure. Potassium must be number of studies that do show a connection increased. Most Americans ingest twice as much between coffee and hyperlipidemia, hyperten- sodium as potassium. Nutrition researchers rec- sion, and coronary heart disease seem to deliver ommend a 5:1 potassium-to-sodium ratio that is an obvious message: just say no. easily accomplished by a diet high in fresh fruits In hypertensive individuals, the use of caf- and vegetables, which are rich in potassium. feinated beverages is questionable. Two studies Dietary recommendations in the treatment showed slight elevations in blood pressure or a of hypertension were evaluated by the federal potentiation of the stress-related rise in blood government in the Dietary Approaches to Stop pressure in hypertension-prone males. In a third Hypertension (DASH) studies. The DASH diet study, caffeine (75 mg per day) had no effect on is high in fruits, vegetables, and low-fat dairy the blood pressure of young, healthy subjects.131 foods and low in saturated and total fats. It is In a recent study, caffeine consumption was not also low in cholesterol but high in fiber, potas- found to be related to the incidence of hyperten- sium, calcium, and magnesium. The DASH sion but consumption of cola was.132 diet, along with a sodium intake of less than Caffeine also appears to have adverse effects 2,400 mg per day, results in significantly lower on serum lipid profiles. In men, coffee intake blood pressures—systolic pressure that is 7 induced higher levels of cholesterol.133, 134 More- points lower in patients without hypertension over, when men with elevated cholesterol levels and 11.5 points lower in those with hyperten- refrained from coffee for five weeks, their serum sion.129 The characteristics of the DASH diet are cholesterol dropped by 10 percent. Those who described in Table 9.3. continued to abstain from coffee showed a 13 Caffeine. The peer pressure to become a percent average drop at ten weeks, and those who coffee drinker is no greater than the conflicting returned to coffee gradually reached prestudy evidence around the health impact of coffee. levels of total cholesterol.135 In women, choles- Some studies say it raises cholesterol; some do terol levels increased with increasing amounts of not. Some say caffeinated coffee is the problem coffee with a low of 214 mg/dL at one-half to but decaffeinated is not; others show no differ- one cup per day and a high of 234 mg/dL at four ence between the two. There is no one consistent cups per day.136 Almost all of the difference was answer on the effect of coffee on heart disease. due to an increase in low-density lipoprotein What does seem to be true is that caffeinated cholesterol. Cholesterol was not affected by coffee drinkers also drink more alcohol, consume decaffeinated coffee in this study. HEART DISEASE 125

Table 9.3 The DASH Diet—Basic Components (2,000 calories per day)

Food Daily Serving Signiﬁcance Group Servings Sizes Examples of Food

Grains and 7–8 1 slice bread Whole wheat bread, Sources of energy grain products 1⁄2 cup dry cereal whole-grain cereal, and fiber 1⁄2 cup cooked rice, oats, grits pasta, or cereal Vegetables 4–5 1 cup raw leafy Tomatoes, potatoes, Sources of vegetables carrots, peas, squash, potassium, 1⁄2 cup cooked broccoli, turnip greens, magnesium, vegetables collards, kale, spinach, fiber, flavonoids, 6 oz veggie juice artichokes, beans, antioxidants sweet potatoes Fruits 4–5 6 oz fruit juice Apricots, bananas, Sources 1 medium fruit dates, oranges or juice, of potassium, 1⁄2 cup dried fruit grapefruit or juice, magnesium, fiber, 1⁄2 cup fresh, frozen, mangoes, melons, flavonoids, or canned fruit peaches, pineapples, antioxidants prunes, rasisins, strawberries, tangerines Low-fat or 2–3 8 oz milk Skim or 1% milk; Sources of nonfat 1 cup yogurt nonfat or low-fat calcium, protein dairy foods 1.5 oz cheese yogurt, buttermilk, and cheese; part-skim mozzarella cheese Meat, including 2 or 3 oz cooked meat, Select lean; trim away Sources of poultry and fish fewer poultry, or fish visible fats; broil, roast, protein and or boil instead of frying; magnesium remove skin from poultry Nuts, seeds, 4–5 1.5 oz or 1⁄3 cup nuts Almonds, filberts, Sources of energy, legumes per 1⁄2 oz or 2 tbs seeds mixed nuts, peanuts, protein, fiber, week 1⁄2 cup cooked walnuts, sunflower magnesium, protein legumes seeds, kidney beans, lentils

There are multiple reasons that coffee has this and possibly kahweol in unfiltered coffee. effect on serum cholesterol. Unfiltered coffee in Another explanation came to light in a recently particular137, 138 increases coronary artery disease published Norwegian study140 that indicated a risk and mortality in men and women.138, 139 dose-response between coffee consumption and This effect is possibly explained by the presence blood homocysteine levels: the larger the coffee of the diterpines (removed by filtering), cafestol, intake, the greater the homocysteine levels. 126 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Homocysteine is formed during the breakdown liquor, and beer. However, researchers have of certain amino acids and is known to increase observed the “French paradox”: in France, satu- the risk of heart disease when it accumulates in rated fat intake and mean cholesterol levels are the blood. high, but heart disease mortality is low. Wide publicity about this paradox has asserted that Alcohol. Many sweeping statements have been red wine consumption in France is high and is made about the benefits of alcohol in preventing responsible for the unexpected results. As a con- heart disease. If we look at the connections be- sequence, a general perception exists that red tween heart disease and alcohol more closely, we wine is especially beneficial. Nonalcoholic ingre- find that these general statements are in fact para- dients in the red wine may in fact be responsible doxical and can be misleading. Heavy use of alco- for this benefit, including antioxidants and flavo- hol causes damage to the heart muscle and is also noids, namely the antioxidants in red grapes that related to high blood pressure, strokes, and ar- prevent the oxidation of LDL cholesterol. rhythmias (irregular heartbeats). On the other Alcohol ingestion, however, harbors potential hand, people who abstain from alcohol, when dangers that may outweigh its alleged benefits. compared to those who drink, are at greater risk of In my opinion, daily ingestion of alcohol cannot major heart disease events such as heart attacks. To be responsibly recommended to women. Well- understand the alcohol-heart connection, it is im- documented evidence indicates that alcohol may portant to distinguish between light, moderate, or increase serum estradiol by 300 percent in post- heavy alcohol use. A working definition is helpful: menopausal women who take hormone replace- Heavy use is three or more drinks per day. One to ment.145 Alcohol also increases the incidence two drinks per day is low to moderate, and light of breast cancer,146–148 osteoporosis,149 depres- would be something less than one daily drink. sion,150 pancreatitis, liver cirrhosis, gastritis, degen- There is now strong evidence that light to erative nervous system conditions, fetus damage, moderate alcohol consumption protects against substance abuse, and cancers of the mouth, phar- heart disease. Low to moderate alcohol intake, ynx, larynx, esophagus, and liver.151 These, and the one drink per day, may reduce the risk of cardio- harmful cardiovascular consequences of heavy vascular disease.141 In the Nurse’s Health Study, drinking, add up to considerable increase in disease one drink per day reduced the risk of heart dis- and death. ease by 40 percent.141, 142 Another study reported From a medical perspective, all heavy that women who had one drink per day had a 30 drinkers should reduce their intake. It is my to 40 percent lower risk of all cardiovascular opinion that moderate drinkers should also diseases as well as a lower death rate than heavy reduce to light intake, and in individual cases, drinkers and very light drinkers.143 And more abstinence (those with breast cancer, those with a recently, consumption of 15 grams (one drink) to history of substance abuse, possibly those taking 30 grams (two drinks) of alcohol per day by post- hormone replacement therapy, and maybe menopausal women was shown to improve lipid others). Daily alcohol probably does not belong profiles and therefore decreased their cardiovas- in a healthful life. Stick to the occasional celebra- cular disease risk.144 Alcohol tends to raise HDL tions, and utilize other methods of reducing your cholesterol, which likely contributes to its cardio- risk of cardiovascular disease. protectiveness. Alcohol also has a beneficial effect on decreasing blood clotting. Chocolate. It has been hypothesized for It is not clear whether there are any signifi- some time that chocolate can reduce the risk of cant differences between red wine, white wine, cardiovascular disease. High levels of antioxi- HEART DISEASE 127 dants, including stearic acid and flavonoids reduce the risk of cardiovascular disease by focusing called procyanidins, catechins, and epicatechins, on reducing elevated cholesterol levels. are found not only in chocolate but also in tea, The Step 1 diet advises to reduce total fat red wine, and various fruits and vegetables. intake to less than 30 percent of daily calories, Cocoa is particularly rich in these flavonoids. It is with 8 to 10 percent of calories coming from sat- thought that the flavonoids reduce leukotrienes, urated fats. Polyunsaturated fats should comprise potent vasoconstrictors, and contain prostacy- less than 10 percent of daily calories. Monoun- clins that vasodilate and inhibit blood stickiness. saturated fats (olive oil, avocados, soy) should be This benefit is only found in dark chocolate, limited to less than 15 percent of total calories. however. Milk chocolate binds to the antioxi- The intake of cholesterol should be less than 300 dants in chocolate and makes them unavailable. mg per day. Protein should be about 15 percent It is also higher in fat content. Dark chocolate, of total calories, and total calorie intake should with 70 percent cocoa or more, also known as be determined based on what amount would bittersweet or semisweet chocolate, contains little help to maintain normal body weight. or no added sugar and is made from cocoa butter, The stricter Step 2 diet requires greater disci- which has a neutral or even beneficial effect on pline and perhaps the guidance of a dietician/ cholesterol. Dark chocolate is also made without nutritionist. Step 2 differs from Step 1 in that less the use of hydrogenated or partially hydro- than 7 percent of daily calories comes from satu- genated oils, which have a negative impact on rated fats and cholesterol intake is limited to less cholesterol. than 200 mg. Dark chocolate decreases LDL cholesterol oxi- If you have a diet that differs from the Step 1 dation, reduces the risk of blood clots, increases diet, and you have hyperlipidemia, then start blood flow in arteries, and may even lower blood with this diet. If you are already following the pressure. It may or may not have a beneficial effect Step 1 diet, or a similar diet, and your cholesterol on cholesterol levels. According to laboratory is still abnormal, especially an elevated LDL, experiments and randomized trials, the suggestion then you should start the Step 2 diet. In either is that the flavonoids in chocolate are likely protec- case, a lipid panel test should be done after three 152 tive against death from cardiovascular disease. It months of the diet. is thought that eating 50 grams (about one two- In general, a Step 1 diet typically reduces the ounce bar) of dark chocolate per day may reduce total cholesterol by 5 to 7 percent. The Step 2 diet one’s risk of CVD by 10.5 percent.153 typically drops the level of LDL another 3 to 7 per- Heart-Healthy Diets. There are a number of cent. The dietary changes, along with an exercise diet recommendations that utilize nutritional program designed to reduce weight, should be done benefits to improve and maintain cardiovascular in women who are overweight. Even a small weight health. The following are some of the most loss of 5 to 10 pounds has been associated with a respected, well-known, and effective cardiovascu- greater reduction in LDL cholesterol than just the lar diets. Step 1 diet and no weight loss. Weight loss also results in raising HDL-cholesterol levels, lowering The Step 1 and Step 2 Cholesterol-Lowering triglycerides levels, and lowering blood pressure.154 Diets. The Step 1 and Step 2 diets were created by the National Heart, Lung, and Blood Association’s The TLC Diet. In 2001, the National Choles- National Cholesterol Education Program (NCEP) terol Education Program released new guidelines and have been endorsed by the American Heart for the management of cholesterol in the “Third Association (AHA). These diets were designed to Report of the Expert Panel on Detection, Evalu- 128 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

ation, and Treatment of High Blood Cholesterol Therapeutic Lifestyle Changes (TLC) Diet in Adults, Adult Treatment Panel III (ATP).” The American Heart Association has adopted the Limits for LDL-Raising Nutrients NCEP III guidelines, calling for more intensive Saturated fats Less than 7% of total life-habit interventions to lower cholesterol and calories reduce the risk for heart disease and of heart Trans fats Minimal or none attacks. They call this the Therapeutic Lifestyle Dietary cholesterol Less than 200 mg per day Changes (TLC) diet. Its target is to lower LDL cholesterol. See the following sidebar for the rec- Therapeutic Options for Lowering LDL ommendations of the TLC diet. Plant stanols/sterols 2 g per day Soluble fiber 10–25 g per day AHA Recommendations. The American Heart Total calories Adjust total calorie intake Association dietary recommendations are designed to maintain desirable to reduce high cholesterol, high blood pressure, body weight and excess weight. These are the dietary guidelines: Physical activity Include enough moderate exercise to expend at least • Eat a variety of fruits and vegetables. Choose 200 calories per day five or more servings per day. • Eat a variety of grain products, including Recommendations for Nutrient Intake whole grains. Choose six or more servings Percentage of per day. Nutrient Total Calories • Include fat-free and low-fat milk products, fish, legumes (beans), skinless poultry, and Total fat 25–35%* Saturated fat Less than 7% lean meats. Polyunsaturated fat Up to 10% • Choose fats with 2 grams or less of saturated Monounsaturated fat Up to 20% fat per serving, such as liquid and tub mar- Carbohydrates** 50–60% garines, canola oil, and olive oil. Protein Approximately 15% • Balance the number of calories you eat with (including soy protein) the number you use each day. (To find that number, multiply the number of pounds *Range of percentages for total fat allows for increased you weigh now by 15 calories. This repre- intake of unsaturated fat in place of carbohydrates in people sents the average number of calories used in with metabolic syndrome or diabetes. one day if you’re moderately active. If you **Carbohydrates should be mainly from foods rich in complex carbohydrates and fiber, including whole grains, legumes, get very little exercise, multiply your weight fruits, and vegetables. by 13 instead of 15. Less-active people burn fewer calories.) • Maintain a level of physical activity that keeps you fit and matches the number of • Limit foods high in saturated fat, trans fat, calories you eat. Walk or do other activities and/or cholesterol, such as full-fat milk for at least 30 minutes on most days. To lose products, fatty meats, tropical oils, partially weight, do enough activity to use up more hydrogenated vegetable oils, and egg yolks. calories than you eat every day. Instead choose foods low in saturated fat, • Limit your intake of foods high in calories trans fat, and cholesterol. or low in nutrition, including foods like soft • Eat less than 6 grams of salt per day (2,400 drinks and candy that have a lot of sugars. mg of sodium). HEART DISEASE 129 • Have no more than one alcoholic drink per Heart Disease. What is now known as the Ornish day. Lifestyle Modification Program is based on the following four components: Not all low-fat diets have provided cardiovas- 1. A very low-fat, high complex carbohydrate cular prevention. In the Women’s Health Initiative diet rich in fruits, vegetables, whole grains, dietary modification trial, 48,835 postmenopausal beans, and legumes women aged 50 to 79 years were randomly 2. Regular exercise assigned to an intervention of intensive behavior 3. Stress management modification to reduce total fat intake to 20 per- 4. Family/community support systems to cent of calories and increase intakes of vegetables maintain healthy behavior and fruits to five servings per day and grains to at least six servings per day.155 After an average of 8.1 The main focus is a plant food–based diet years, this diet did not significantly reduce the risk containing whole fruits and vegetables, whole of CAD, stroke, or CVD in postmenopausal grains (brown rice, whole wheat breads, whole- women and achieved very modest effects on CVD grain cereals, whole wheat pasta), dried beans risk factors. What this tells me is that an even and legumes, soy products, lean poultry, fish, egg more rigorous diet and lifestyle changes need to be whites, and nonfat dairy. Plant oils are to be used achieved in order to improve risk factors and only lightly, and red meat, butter, and animal fats reduce CVD risk. are to be avoided, as are processed foods, high-fat foods, sweets, and caffeinated drinks. Alcohol The Mediterranean Diet. The Mediterranean and salt are to be consumed in moderation. The diet, perhaps one of the healthiest diets in the Ornish Lifestyle Modification Program claims to world, emphasizes increased fiber, olive oil, fruits, promote weight loss, improve cardiovascular vegetables, grains, and legumes and decreased health, help to regulate blood sugar and insulin, refined cereals, meat products, eggs, and saturated and lower cholesterol levels. fats. This diet has been shown to have a beneficial Whether it is the TLC diet, the Step 1 or Step effect on cardiovascular health in a number of 2 diet, the Mediterranean diet, or the Ornish large studies.156 The Mediterranean diet has also diet, they all offer a great step toward reducing been shown to have beneficial effects on risk fac- the risk of heart disease. One might be more tors for cardiovascular disease and may even suited to you over the other. Consider reading exceed that of the low-fat diet. Compared with a more about each, experimenting, or speaking low-fat diet, three months on a Mediterranean with your health-care practitioner and/or a qual- diet that included olive oil (one liter per week) or ified nutritionist to determine which approach is packets of walnuts, hazelnuts, and almonds best for you. decreased cardiovascular risk factors.157 Both of these diets were associated with significant reduc- Nutritional Supplements tions in blood pressure, lower fasting glucose Although dietary changes alone can have a pow- levels, lower insulin levels in those without dia- erful effect in reducing the incidence of heart betes, lower triglycerides, increased HDL-C, and disease, they may not be enough for everyone. lower C-reactive protein levels. Lowering cholesterol, lowering blood pressure, Ornish Lifestyle Modification Program. The inhibiting blood clots, preventing oxidative low-fat diet has been promoted by Dr. Dean damage to the vessel walls, and several other Ornish since the publication of his bestselling mechanisms are all effects that can be achieved book Dr. Dean Ornish’s Program for Reversing with the therapeutic use of nutritional/herbal 130 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE supplements. This is an exciting and successful surgery), or the rate of cardiovascular events three area for alternative medicine to make an impact years later.163–165 on a large segment of the population. Given that Major clinical trials of antioxidant use for the heart disease is the number-one cause of death in primary (initial) prevention of CVD are cur- men and women in America, these concepts rently underway and include tens of thousands of deserve the attention and respect of individuals participants. In the near future, with an adequate and practitioners of all disciplines and all schools amount of high-quality scientific data, we hope of thought. to gain greater clarity as to the impact of antioxidant combination products and multivitamin Antioxidant Combinations. Combination combinations on cardiovascular disease. nutritional supplements are difficult to evaluate because of the multi-ingredient combinations and Vitamin E. In the past, I went so far as to say the different doses of each single ingredient from that of all the vitamins or minerals, vitamin E may one product to another. Numerous observational offer the greatest protection for women against studies have, however, evaluated the effect of heart disease because of its ability to be easily antioxidant combinations on cardiovascular incorporated into the LDL-cholesterol molecule events.158–161 In one study, vitamins C and E and prevent free radical damage and, as a result, reduced coronary death and death due to all causes prevent atherosclerosis and CAD.166 A number of in elderly patients.158 In another, an antioxidant clinical trials have shown that vitamin E supple- supplement significantly lowered risk for myocar- mentation (alone or in combination with other dial infarction (heart attack) in men and women antioxidants) leads to increased resistance of LDL over 55.159 A Finnish study showed no significant to oxidative damage.167, 168 Doses between 500 effect of an antioxidant supplement on death due and 1,500 IU have shown significant reduction in to coronary artery events;161 however, only 3 per- LDL oxidation.169 Women who took vitamin E cent of the people actually used an antioxidant sup- supplements for more than two years had about plement. In the very large U.S. observational study half the risk of CVD.170 A recent study evaluating of more than 1 million men and women,160 there childhood and adulthood dietary intake of vita- were modest reductions in CVD deaths among min E found that people who consumed the most women using antioxidants supplements who had vitamin E in their diet had a decreased risk of no previous history of CVD. hypertension.171 Prevention trials with antioxidant combina- The New England Journal of Medicine pub- tions have unfortunately not produced hoped-for lished a report showing that women who took at results. In the Heart Protection Study, a combina- least 100 IU of vitamin E per day for several years tion of vitamin C, vitamin E, and beta-carotene had 40 percent decreased likelihood of having appeared to cause no difference in either death a coronary event when compared with non- rates due to any cause, heart disease–related vitamin E users.172 Continued research has now deaths, heart disease events, or vascular events of demonstrated that doses between 400 and 800 any kind.162 Other quality studies of an antioxi- IU per day dramatically reduce the risk of nonfa- dant supplement for secondary prevention of tal heart attacks, but do not reduce the number CVD (people who already had evidence of heart of deaths from CAD.173 Doses of 400 to 1,000 disease or had a previous cardiac event) showed no IU per day provide additional cardiovascular significant effects on the rate of return of narrow- benefit by inhibiting platelet aggregation, ing of a coronary artery, the rate of restenosis (a increasing HDL-cholesterol, and stimulating the return of narrowing of the coronary artery after breakdown of fibrin (a clot-forming protein). HEART DISEASE 131 Levels of vitamin E in the blood may be more more) may increase death rates, at least in those directly related to the development of a heart people with chronic illnesses.180 It is important attack or stroke than are total cholesterol levels. to point out that this type of analysis has serious Whereas high blood pressure was predictive of a flaws. To summarize an insightful commentary heart attack 25 percent of the time, and high written by a well-known clinician, Allan Gaby, cholesterol 29 percent of the time, low blood M.D., for the Emerson Ecologics website (emer levels of vitamin E was predictive almost 70 per- sonecologics.com), in these different studies, cent of the time.174 patients were randomly assigned to take vitamin There are, though, negative studies on vita- E, in doses ranging from 16.5 to 2,000 IU per min E’s effect in cardiovascular disease. Although day, or a placebo for at least one year. Most of the vitamin E was shown in animal studies to be patients had one or more chronic diseases includ- beneficial for hypertension,175, 176 a human trial ing heart disease, diabetes, Parkinson’s disease, found that relatively modest doses, 500 IU Alzheimer’s disease, or kidney failure. Others mixed tocopherols per day for six weeks, led to were at high risk of developing heart disease. an increase in blood pressure and heart rate in When all 19 studies were combined, the risk of diabetic patients.177 A very large study, called the what is called all-cause mortality, or death due to HOPE trial, had a significant influence in dimin- any cause, did not differ significantly between ishing the role of vitamin E for cardioprotection people assigned to vitamin E supplementation in the minds of many consumers and practition- and those who were in the placebo group. In ers. In women and men, 55 years of age or older, studies using doses of vitamin E less than 400 IU who were at high risk for cardiovascular disease, per day, the vitamin E supplementation was treatment with 400 IU vitamin E per day for an associated with a small although not statistically average of 4.5 years had no apparent effect on significant reduction in the death rate. In the 11 cardiovascular outcomes.178 The HOPE-TOO studies using more than 400 IU per day, vitamin trial was extended for another four years and E supplementation increased the risk of death by studied men and women at least 55 years old 4 percent. who had vascular disease or diabetes.179 Again, A number of other influences may have there were no differences in the main cardiovas- affected this small but statistically significant cular outcome between those who took vitamin increase, including additional nutrient supple- E and those who took the placebo. In essence, mentation, serum cholesterol levels, and the high there was no significant effect of vitamin E on percentage of participants with significant health myocardial infarction (MI), stroke, cardiovascu- problems such as high blood pressure, diabetes, lar death, unstable angina, or total death rate. In cigarette smoking, and severe coronary artery dis- fact, investigators observed an increase in heart ease. There may have also been a problem in the failure rates in patients assigned to the vitamin E. type of vitamin E used. (There are four different It is not known whether this was due to chance types of vitamin E: alpha-, beta-, gamma-, and or whether the alpha-tocopherol form of vitamin delta-tocopherol, and gamma-tocopherol is the E became a pro-oxidant in these patients with most effective as an antioxidant.) significant disease. With these flaws, and in contrast to the large One of the most damaging reports on vita- body of scientific evidence that shows the bene- min E was a meta-analysis on high-dosage vita- fits of vitamin E in slowing the progression of min E that compiled the results of 19 studies Alzheimer’s disease, treating intermittent claudi- from 1966 through August 2004 to conclude cation, fibrocystic breast disease, premenstrual that large doses of vitamin E (400 IU per day or syndrome, osteoarthritis, and more, I continue 132 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE to advise the use of vitamin E supplementation. ated with decreased cardiovascular disease in a While controversial, I am not willing to give retrospective study of over 85,000 women.189 up on the potential benefits of vitamin E and Recent long-term studies of vitamin C do not cardioprotection. support its use in hypertension, however. A study of 500 mg daily for over five years was shown to Vitamin E have no effect in a group of over 400 subjects.190 400–1,000 IU per day Coenzyme Q10. CoQ10 can be used for high blood pressure control, atherosclerosis, Vitamin C. Vitamin C is probably not a angina, mitral valve prolapse, congestive heart major player in blood pressure, hyperlipidemia, failure, and cardiomyopathy. As an antioxidant, or other influences on cardiovascular disease. CoQ10 protects against atherosclerosis by pre- However, vitamin C has a positive effect on the venting the oxidation of LDL. In a recent study, cardiovascular system and, along with folic 150 mg CoQ10 in combination with the lipid- acid and zinc, has been found to be low in the lowering medication fenofibrate worked better blood of hypertensive patients.181 Vitamin C than drug therapy alone in improving total cho- protects LDL cholesterol from oxidation,182 lesterol, triglycerides, and blood pressure.191 A raises HDL cholesterol, and lowers total choles- large review study showed that CoQ10 adminis- terol triglycerides.183 In one recent study, 500 mg tration led to decreases in systolic and diastolic of vitamin C for 10 weeks led to significant blood pressure of 16 and 10 mmHg respec- decreases in total cholesterol and apoB, a bio- tively.192 A study using 60 mg CoQ10 twice daily marker for cardiovascular risk.184 But a combina- for 12 weeks led to an average decrease in systolic tion product that included 500 mg vitamin C, blood pressure readings of nearly 18 percent.193 160 mg bioflavonoids, 600 mg magnesium, and These findings were similar to a previous study 900 mg vitamin B complex led to decreased clot looking at 60 mg CoQ10 twice daily for eight formation in adults with hyperlipidemia.185 In a weeks in patients already receiving conventional recent study, 36 IU vitamin E and 250 mg vita- cardiovascular treatments.194 This study also min C two times per day dramatically decreased found decreases in blood sugar, insulin, and tri- atherosclerosis in hypercholesterolemic patients glycerides and increases in HDL. CoQ10 may be at both three and six years.186 Despite these coadministered with conventional medication to encouraging results, a long-term study of 500 mg increase duration of antihypertensive effect up to vitamin C daily did not significantly affect any twice as long.195 Other studies of up to 600 mg lipid measures except triglycerides in women per day allowed patients to decrease the dose or who had high triglycerides.187 discontinue the conventional medication while Smokers may gain a particular advantage dramatically improving cardiovascular function- with vitamin C. Nicotine has been known to ing196, 197 and decreasing subsequent cardiovascu- reduce blood vitamin C levels. An increased lar events and mortality by nearly half in patients intake of dietary vitamin C has been associated with a prior history of MI.198 CoQ10 also works with decreased risk of cardiovascular disease in together with vitamin E in preventing damage to smokers,188 who are typically deficient, and lipids and to the vessels.199 intake of vitamin C supplementation was associ- It may be that CoQ10 can benefit those Vitamin C women who choose to take HRT and are con- 1,000 mg or more per day cerned about the potential for increased risk of heart disease. A recent study showed that the HEART DISEASE 133 common dose of Prempro led to a decrease in with more significant increases in HDL.213 Cal- CoQ10 and vitamin E levels in the blood, cium carbonate 400 mg three times daily can thereby increasing menopausal cardiovascular reduce cholesterol and LDL cholesterol by about 4 risk factors in women who use HRT.200 Use of percent and increase HDL by 4 percent.214 statins to treat high cholesterol has been associ- While reducing cholesterol and blood pres- ated with muscle pain and decreased exercise tol- sure may not be calcium’s strong suits, the bene- erance that has been correlated with a reduction fits to bone health, tooth retention, weight loss, in CoQ10.201–204 PMS, and reduction in the risk of colorectal cancer make it one of our most important dietary CoQ10 nutrients and nutritional supplements. 50–150 mg per day Calcium Calcium. Calcium is most well known for 400–1,200 mg per day calcium carbonate or other its effects on bone health, but it can also be used form to treat elevated cholesterol and hypertension. Calcium supplementation may produce modest Magnesium. Many scientists and health reductions in blood pressure, usually only 1 or 2 practitioners believe that magnesium is one of points. But in those whose blood pressure is very the most important nutrients for cardiovascular sensitive to salt intake or whose dietary intake of protection and treatment. Drs. Burton and Bella calcium is low, supplementation may be more Altura of NY Health Science Center have done effective. Calcium has been related to decreases some of the most consistent research in magne- in systolic blood pressure,205, 206 and an analysis sium over the last 30 years. They, and others, of 40 well-controlled studies found that calcium assert that magnesium contributes to the lowers blood pressure measurements.207 Another strength of contraction of heart muscle,215 large review of studies of calcium for hyperten- increases HDL levels,216 inhibits platelet aggrega- sion in pregnancy found that higher calcium tion and prolongs the clotting time,217–219 intakes were correlated to decreased blood pres- decreasing the risk of heart disease, strokes, for- sure, as well as resultant preeclampsia and mation of atherosclerotic plaque, and blood clots death208 and that the combination of calcium that can result in heart attack or stroke. and linoleic acid decreases pregnancy-induced At least 10 independent clinical studies show hypertension as well.209, 210 that patients with hypertension exhibit serum Not all studies have shown benefit, and a large and/or tissue hypomagnesemia. On the average, review of three randomized controlled trials inves- patients with long-term hypertension have at tigating the combinations of magnesium, potas- least a 15 percent deficit in total magnesium.220 sium, and calcium found no evidence that these A recent review of studies showed that supple- supplements improved blood pressure or mortal- mentation with magnesium appears to modestly ity.211 Calcium probably has only a small role in decrease blood pressure,221 yet another large lowering cholesterol, but a recent randomized con- review showed no effect at all.222 Magnesium may trolled trial suggests that calcium may have a role be more effective in decreasing blood pressure and in decreasing cholesterol via its ability to improve improving arterial function when combined with the function of bile in the liver, thereby increasing potassium.223 Evidence from both animals and cholesterol excretion,212 and another study on 223 humans suggests that magnesium levels in diet menopausal women showed that calcium supple- and blood may affect blood lipids; the lower the mentation did decrease cholesterol slightly and magnesium intake, the higher the serum lipid 134 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE levels. In addition, a recent study showed that Niacin has been compared to several conven- supplementation of 600 mg daily for 12 weeks tional pharmaceutical drugs used to reduce choles- produced improvements in all lipid parameters in terol levels. A study published in 1994 compared both type 1 and 2 diabetics.224, 225 There is strong niacin and lovastatin over a period of 26 weeks in evidence suggesting a relationship between 136 patients who were at high risk for coronary uncontrolled type 1 and type 2 diabetes and mag- heart disease.233 Lovastatin produced a greater nesium deficiency,220 thus magnesium deficiency effect on reducing LDL cholesterol, but niacin pro- may predispose diabetic patients to an increased vided better overall results. Niacin far exceeded incidence of cardiovascular disease and death. lovastatin in increasing HDL cholesterol, which is Magnesium also improves cardiac perform- a more significant indicator in reducing the risk for ance by enhancing blood flow in the coronary heart disease, and some estimates suggest that it arteries. It also prevents oxidation of lipoproteins can raise HDL by as much as 35 percent.234 Niacin and subsequent atherosclerosis. has also been found to decrease inflammatory markers like C-reactive protein235 and increase Magnesium adiponectin, a hormone that not only decreases 400–1,200 mg per day in divided doses atherosclerosis but improves glucose tolerance, body mass index, and fatty liver disease.236, 237 In a Niacin. Niacin (nicotinic acid) has been shown study of patients with previous history of heart to favorably affect all lipids and lipoproteins, and it attack, niacin was found to decrease the risk of can be used either alone or in combination with repeat MI and death in patients with and without other lipid-lowering agents.226 We’re not sure metabolic syndrome.238 exactly how it works, although it likely inhibits Conventional practitioners and alternative mobilization of free fatty acids from peripheral fat practitioners alike acknowledge that several tissue to the liver. As a result, niacin reduces hepatic grams of niacin per day will lower total choles- synthesis of very low-density lipoprotein (VLDL) terol and LDL cholesterol, raise HDL,239 and and triglyceride levels. Because there is less VLDL decrease atherosclerosis both alone and when available, LDL levels decrease.227 used with conventional treatments like statins. The Coronary Drug Project was the first trial The niacin and statins seem to act synergistically to study the effect of niacin on cardiovascular to improve lipid parameters at lower doses, in a endpoints.228 Niacin therapy in men with prior shorter amount of time, and more effectively MI reduced the five-year incidence of nonfatal than when either is used alone.240–242 reinfarction by 27 percent. In addition, after a The major problem with the therapeutic mean follow-up of 15 years all-cause mortality dosage (1.5 to 3 grams per day) has to do with was 11 percent lower in niacin-treated men com- side effects. Flushing responses are common. pared with placebo-treated patients.229 Anecdotally, some clinicians decrease the effects Niacin—specifically nicotinic acid—may be of niacin’s flushing by having the patient start used to reduce total cholesterol, TG, and LDL with a low dose, like 500 mg per day, increasing levels and to raise HDL values. It is currently the the dose weekly to achieve the desired dose, and best treatment to raise HDL levels,227 and it can taking the dose before bed or coadministering reduce the risk of nonfatal MI.230 Niacin lowers with 81 mg baby aspirin. More seriously, liver LDL levels by about 5 to 25 percent, TG by 20 to function findings can become abnormal, and 50 percent, lipoprotein(a) by 34 percent,231 and the individuals with liver disease should not take total cholesterol/HDL ratio by 27 percent226 while niacin. Immediate-release niacin is recom- increasing HDL levels by 15 to 35 percent.232 mended, as sustained-release niacin has been HEART DISEASE 135 associated with severe liver toxicity in doses of cial in people over age 65 who often do not more than 2 grams per day. Niacin can also exac- respond well to antihypertensive drugs. erbate elevated serum glucose levels in diabetics Potassium supplements are available by pre- and can worsen gout. Niacin in doses of more scription and over the counter. The FDA restricts than 1 gram per day are best taken under the the potassium over-the-counter dose per tablet to guidance of a physician, with monitoring of 99 mg due to potential problems with nausea, liver-function tests. vomiting, diarrhea, and ulcers that may result from higher doses of the mineral. The frequency and Niacin (Nicotinic Acid) severity of side effects associated with potassium 500 mg 1–3 times per day supplementation are negligible when compared with the frequency and severity of side effects asso- Pantethine. Pantethine is the activated form ciated with conventional antihypertensives. of vitamin B5 (pantothenic acid) and a key com- Potassium dosing should be based on individ- ponent of coenzyme A (CoA). CoA plays a sig- ualized need and potassium level in the blood. nificant role in lipid metabolism and is involved The common dose for treating hypertension is in the transport of fats. The cells of our body 48 to 90 mEquivalents daily. Drug/potassium need CoA to utilize fats in the form of energy. interactions are possible, and a consultation with Pantethine, at the typical dose of 300 mg three your health-care provider should occur if you are times per day, has been shown to significantly taking ACE inhibitors, angiotensin receptor reduce serum triglycerides, total cholesterol, and blockers, or potassium-sparing diuretics. In addi- LDL cholesterol, while also increasing HDL cho- tion, certain drugs influence the nutrient levels lesterol.243, 244 This same dose was found to be and depletion of potassium. effective at decreasing adverse lipid parameters in Decreasing sodium and increasing potassium postmenopausal women. intake helps prevent heart disease, high blood pressure, and strokes. The standard American diet Pantethine has a poor potassium/sodium ratio; the ideal 300 mg 3 times per day potassium-to-sodium ratio is greater than 5:1. A diet rich in fruits and vegetables can produce a Potassium. The role of potassium in the more beneficial ratio because most of these foods body crosses over into many physiological events have significantly greater potassium than sodium. that include nerve transmission, muscle contrac- Amongst the highest are bananas, apples, carrots, tion, enzymatic reactions, carbohydrate synthe- oranges, lima beans, and potatoes. sis, basic cell functions, and acid-base balance. Inadequate potassium intake in the diet might Potassium play a role in the development of high blood 99 mg–2.5 g per day pressure, stroke, and cardiovascular disease. In addition to increasing the potassium foods in our L-Arginine. L-arginine is an amino acid diet, several studies now show that potassium involved in many areas of our physiology, includ- supplementation can reduce blood pressure. It ing the production of nitric oxide, an important has been shown that potassium supplementation messenger in the regulation of our blood vessels. of 2.5 grams per day can lower the systolic blood We synthesize arginine from other substances, pressure an average of 12 points and diastolic but dietary intake is the primary source of our blood pressure an average of 16 points.222 Potas- arginine levels. Arginine is the precursor of nitric sium supplementation may be even more benefi- oxide, a gaseous molecule involved in relaxation 136 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE of the smooth muscles of our vessels, which terol in individuals with hyperlipidemia251 and results in vessel dilation (vasodilation) and inhi- also decreased triglycerides in those with high bition of blood platelets clumping together. blood pressure.252 Lipoprotein(a) levels, an inde- The key to arginine’s cardiovascular benefits is pendent biomarker of cardiovascular disease risk, its ability to induce endothelial nitrous oxide pro- have also been reduced with 2 grams per day of duction whereby an enzyme in the endothelium L-carnitine, even in those with type 2 diabetes.253 (lining) of the blood vessel, nitric oxide xynthase, In addition, some preliminary evidence suggests catalyzes a reaction that produces nitrous oxide carnitine may be able to attenuate the muscular and ornithine. The nitric oxide diffuses into the side effects of statin therapy.254 underlying muscle of the vessel and causes relax- Numerous other cardiovascular effects of L- ation and dilation. Nitric oxide also helps to pre- carnitine are beyond the scope of this chapter, vent atherosclerosis in the vessels, along with its but improvement in exercise tolerance, func- dilation and clot prevention effects. tional improvement in angina, peripheral vascu- Supplementation with arginine has been lar disease, treatment of heart failure, and shown to increase artery dilation in normal people, reduced death rates from heart attacks are all people with hyperlipidemia, and in those with areas of clinical effectiveness of L-carnitine. hypertension;245, 246 significantly improve blood flow and function in patients with congestive heart L-Carnitine failure;247, 248 and in some, but not all trials, 2–3 g per day improve blood flow, vasodilation, exercise toler- 249, 250 ance, and quality of life in those with angina. Folic Acid, Vitamin B6, Vitamin B12. Much Therapeutic doses for cardiovascular effects seem to research over the years has shown that elevated range from 6 to 12 grams per day. L-arginine is a plasma levels of homocysteine are associated very safe supplement and has been associated with with significant increases in coronary artery only minor problems lasting a few days, including disease,255–257 myocardial infarction,258, 259 periph- diarrhea, bloating, abdominal pain, or allergic reac- eral occlusive disease, cerebral occlusive dis- tions. The exceptions are those patients with kidney ease,260, 261 dementia, and Alzheimer’s disease.262 failure or liver disease. For these patients, supple- Two recent meta-analyses of observational studies mental arginine may not be able to be metabolized concluded that a 25 percent reduction in plasma or excreted as well and should be monitored. homocysteine concentration was associated with decreases of 11 to 16 percent in the risk of L-Arginine ischemic heart disease and 19 to 22 percent 6–12 g per day in divided doses, 3 g at a time reduction in the risk of stroke.263, 264 Folate, vitamin B12, and vitamin B6 are inversely related to L-Carnitine. L-carnitine is an amino acid homocysteine levels, and anyone with a nutri- found naturally in the body. We obtain some tional deficiency that leads to low concentrations L-carnitine from the diet in foods such as red meats of either one or more of these nutrients is at and dairy products, but our bodies also synthesize increased risk for elevated homocysteine levels. carnitines from two other amino acids, methionine Testing for homocysteine levels is available and lysine. L-carnitine has a key role in the energy through commonly available simple blood tests. production within our cells and is required to The first meta-analysis of the Homocysteine transport long-chain fatty acids into our cells. Lowering Trialists’ Collaboration concluded that Two to three grams per day of L-carnitine has folic acid supplementation lowered homocysteine resulted in reductions in total and LDL choles- levels by about 25 percent.265 The second meta- HEART DISEASE 137 analysis found a 23 percent reduction in homo- Besides changes in diet, supplementation of var- cysteine concentration was the maximum observed ious oils is also warranted for many individuals. with 800 mcg per day of folic acid.266 A 20 percent The daily consumption of fish oils can signifi- reduction was seen with 400 mcg and 13 percent cantly lower blood pressure in people with hyper- with 200 mcg per day. Due to folic acid fortifica- tension, and low consumption may increase the tion of foods in the United States, our plasma incidence of hypertension, especially in diets folate concentration has increased, and subse- with a low fish intake.270 quently our homocysteine levels have decreased. A group of researchers at the Johns Hopkins For those of us who eat a diet fortified with folic Medical School evaluated the results of 17 clinical acid in some of the foods, folic acid supplementa- trials using fish oil supplementation and found tion is likely to lower homocysteine concentrations that consuming 3 grams or more per day of fish oil by only about 15 percent. led to reductions in blood pressure of individuals Women are more responsive to the with hypertension,271 lowered systolic pressure by homocysteine-lowering effects of folic acid than an average of 5.5 mm Hg, and lowered diastolic are men, and the Women’s Health Initiative pressure by 3.5 mm Hg. The effect was found demonstrated that the risk of vascular disease was to be greater at higher blood pressures. A meta- stronger than the association observed in males in analysis of 36 trials of fish oil supplementation and the Physician’s Health Study.267 High consump- blood pressure, with an average dose of 3.6 grams tion of foods containing folate and vitamin B6 per day, showed that fish oil had a small effect in may reduce the risk of heart attack268 in women by lowering blood pressure, especially in older people nearly 50 percent.269 A study of 80,000 female with hypertension.272 Another meta-analysis of 31 nurses showed a direct link between the ingestion trials also showed a small but statistically signifi- of these two B vitamins and reduced coronary dis- cant drop in blood pressures of about 3 points /1.6 ease. The results suggested that eating more fruits, points at 3.3 to 7 grams per day.273 Granted, these vegetables, and whole grains or obtaining these are small decreases, but fish oils in conjunction vitamins through supplementation may be as with other nutrients, botanicals, and lifestyle important as quitting smoking, lowering choles- changes can be used as part of a comprehensive terol, or controlling high blood pressure in lower- treatment plan to achieve a reduction in blood ing heart disease risk. Folic acid and the lowering pressure, stroke, and risk of coronary events. of homocysteine has recently been less impressive There are numerous studies on the effect of as a heart disease prevention strategy. omega-3 fish oils and triglycerides. In a review of human trials, about 4 grams per day of omega-3 Folic Acid fatty acids from fish oil decreased serum triglyc- 400 mcg–2.5 mg per day eride levels by 25 to 30 percent.274 Both the EPA content and the DHA content of fish oils have Vitamin B6 the triglyceride-lowering effects. Among post- 10–25 mg per day menopausal women, fish oil supplementation of 2.4 g EPA and 1.6 g DHA per day not only Vitamin B 12 lowered triglycerides by 26 percent but also 400–1,000 mcg per day improved the triglyceride/HDL ratio.275 Another issue pertinent to women is that for Essential Fatty Acids. As I discussed in the those who are on hormone replacement therapy, nutrition section, a diet rich in omega-3 oils C-reactive protein (CRP) and triglycerides levels results in a much lower risk of heart disease. can be higher. A recent clinical trial of 30 women 138 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE on HRT showed that 7 grams per day of fish oil rant seed oil dose of 3 grams per day was shown supplementation significantly decreased CRP to decrease LDL more than fish oil.282 A more and triglyceride levels.78 recent commercially available product, hemp It may be most effective to supplement fish oils seed and hemp seed oil, may also prove to be with statin medications for lowering cholesterol. beneficial in the lowering of lipids, homo- In one clinical controlled trial, 59 patients who cysteine, CRP, and others. Evening primrose oil already had coronary heart disease and hyper- rich in gamma-linolenic acid (GLA) may also triglyceridemia who were taking statins were able have a role in prevention of heart disease283 by to significantly lower their levels of triglycerides decreasing LDL cholesterol. and very low density lipoprotein (VLDL) when taking the fish oil and the statin.276 Fish Oil Another drug/fish oil study showed that 3.36 1 g per day of EPA and DHA grams per day of fish oils were able to further 2–4 g per day of EPA plus DHA may be useful in decrease the triglycerides, total cholesterol, and patients with elevated triglycerides apolipoprotein E than just the statin alone.277 Wild salmon ranges from 1.0–1.5 g EPA plus DHA per The most compelling reason to give fish oils is if 3 oz serving, with a little more DHA than EPA. Differ- it in fact lowers heart disease. We have evidence ent species range in their EPA and DHA content. Wild for this from 15 large studies of more than sockeye salmon has approximately 600 mg DHA and 60,000 individuals where a decrease in deaths 430 mg EPA per 3 oz serving. from ischemic heart disease was observed in Flaxseed Oil those who consumed fatty fish or omega-3 fatty acids.278 In one of these studies, 1 gram per 1 tbs per day day of omega-3 EFAs was associated with a 20 Evening Primrose Oil percent decrease in total deaths, a 30 percent decrease in cardiovascular deaths, and a 45 per- 3–4 g per day cent decrease in sudden deaths.279 All supplemental oils should be taken with meals. Flaxseed oil, nature’s richest source of omega-3 fatty acids, is the vegetable alternative to fish oil. It contains twice as many omega-3s and is usually less Botanicals expensive. Flaxseed oil provides the body with Flavonoids. Flavonoids are a group of com- alpha-linolenic acid (ALA), which it uses to make pounds found in many fruits, vegetables, nuts EPA, whereas fish oil provides EPA directly. There and seeds, and numerous medicinal plants. Over is some concern that humans do not readily con- 4,000 different flavonoids have been identified in vert ALA to the EPA and DHA, and therefore foods and plants. Quercetin, rutin, catechin, and flaxseed oil would be a less efficient method of hesperidin are the most frequently used in medi- gaining EPA and DHA. However, there are studies cine. Flavonoids inhibit the peroxidation of on supplementation with flaxseed oil that suggest lipids by acting as free radical scavengers.284 protective effects against cardiovascular disease by Quercetin specifically has been shown to inhibit inhibiting the excessive clotting of blood.280 A LDL oxidation.285 In addition to these direct recent study of flaxseed’s effect on cholesterol in antioxidant effects, flavonoids inhibit platelet postmenopausal women found decreases in LDL, aggregation, protect vitamin E from oxidation, triglycerides, and other lipid parameters.281 and chelate iron. In numerous dietary studies, Other seed oils may also provide some posi- flavonoids have been shown to reduce cardiovas- tive effects on lipids. For example, a black cur- cular disease.286, 287 HEART DISEASE 139 Green, oolong, and black tea are made from had a 16 percent lower risk of all-cause and CVD the leaves of the Camellia sinensis plant and are mortality during 11 years of follow-up. rich in cardioprotective flavonoids. Green tea is Several studies have examined the potential especially rich in the flavonoids called catechins. effects of tea on blood pressure. While there may These include catechin, epicatechin, epicatechin be transient increases in blood pressure due to gallate, epigallocatechin gallate, and proantho- the caffeine, regular use appears to be associated cyanidins. Epigallocatechin gallate is considered with lower blood pressures.293 Both green tea and the most significant active component of green oolong tea intake of 120 mL /day or more can tea. Theaflavins are the pigments found in black significantly reduce hypertension.294 In the large tea, formed from the catechins during the fermen- population-based Rotterdam Study of Dutch tation of green tea to form black tea. Green tea men and women, the risk of heart attacks was catechins have been studied fairly extensively as lower in those who drank more than 375 ml (one preventive agents for cardiovascular disease.288–290 and a half cups) per day.295 Two recent significant studies prove the car- Garlic (Allium Sativum). Garlic is popular diovascular benefits of green tea. Taking a as a lipid-lowering agent, but it has a modest flavonoid-rich green tea extract (375mg) for three effect. While analyses have demonstrated that months along with a low-fat diet decreased total garlic can reduce total cholesterol levels by 5 to cholesterol by 11.3 percent and LDL by 16.4 per- 12 percent, recent reports suggest these studies cent in men and women with mild to moderate may have been too brief to draw conclu- hypercholesterolemia.291 Another study, the sions.296–298 There is great variability in research Ohsaki study,292 found that green tea consump- results, which may in part be due to the great tion was inversely associated with mortality due to variation in the potency of and the extracts of all causes and inversely associated with cardiovas- garlic used. Even the studies showing a positive cular disease. Compared with individuals who effect lack long-term follow-up, standardized lab- consumed less than one cup per day of green tea, oratory measurements, and adequate dietary those who consumed five or more cups per day controls. While evidence supports at least a Flavonoids short-term benefit, the effect is typically a small but statistically significant decrease in lipid levels. Quercetin Since 1975, over 32 human studies have been 200–400 mg 3 times per day published demonstrating the lipid-lowering effects of garlic.299 Two meta-analyses of these Citrus Bioflavonoids studies indicate that one to three months of 1,000–6,000 mg per day treatment using 600 to 900 mg of garlic powder tablets reduced total serum cholesterol an average Green Tea of 9 to 12 percent and triglycerides from 8 to 27 300, 301 More than 1 cup per day, and especially more than 5 percent. A recent study of 30 patients who cups per day or consumed 5 grams of raw garlic for 42 days found 1 capsule or more per day of green tea catechin significant decreases in total and LDL cholesterol extract and increased HDL cholesterol. These benefits were reversed after 42 days of no garlic.302 Black Tea Garlic has also been shown to lower blood More than 11⁄2 cups per day pressure slightly,303 inhibit clotting,304 and regulate heart rhythms.305, 306 Garlic is not as aggressive at 140 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE lowering serum cholesterol and triglycerides as some lipid-lowering activity. One clinical trial some of the newer pharmaceuticals, but it also used 1,800 mg of artichoke extract versus does not have any of their side effects. For women placebo for six weeks for the treatment of high with a modest elevation of cholesterol, it will pro- cholesterol levels.315 The decrease in total choles- vide a safer and effective alternative. For women terol values was 18.5 percent in the artichoke with severe hypercholesterolemia, appropriate group versus 8.6 percent in the placebo group. drugs may be used and later replaced by garlic Also, LDL values fell by 22.9 percent. For when the desired drug effect is complete. patients with gallstones or other bile-duct Garlic is not contraindicated during preg- obstructions, globe artichoke supplementation nancy and lactation, and 800 mg per day was should be avoided due to the choleretic activity found to be a safe and effective way to decrease of the extract. This product is currently available gestational hypertension.307 as a nutritional supplement in the United States. Problems with ingestion of garlic are usually minor. In sensitive individuals they may include Globe Artichoke heartburn and flatulence. Some people do not 600 mg 3 times per day appreciate the odor or taste of garlic. Odor-free or enteric-coated products may avert these unde- Procyanidolic Oligomers (PCO). Extracts sirable effects. Individuals are rarely allergic to from grape seeds and the bark of the maritime garlic. However, people taking anticoagulant pine tree are high in a group of flavonoids called drugs should take garlic with caution and be proanthocyanidins, also called procyanidins. monitored by a health-care practitioner. Mixtures of proanthocyanidin molecules are referred to as procyanidolic oligomers (PCO). Garlic These commercially prepared extracts of grape 1 fresh raw clove of garlic per day or seeds and pine bark, or PCO extracts, possess Garlic pill providing a minimum of 4,000 mcg allicin potent antioxidant activity that is far stronger daily than even vitamin E or vitamin C. In animal studies, PCO extracts have been shown to pre- Ginger (Zingiber Officinale). The same vent damage to the arterial lining, lower blood ginger that is used in cooking and ginger ale cholesterol levels, and shrink cholesterol deposits has been shown to inhibit platelet aggregation in the arteries.316, 317 Human studies have con- (blood platelets sticking together),308 lower firmed these findings in smokers,318 and a combi- cholesterol,309–312 inhibit atherosclerosis,313 and nation of 100 mg grape seed extract and 200 mcg decrease blood pressure.314 Ginger stimulates chromium two times daily was found to signifi- the conversion of cholesterol to bile acids and cantly decrease total and LDL cholesterol up to increases bile secretion, thereby lowering choles- 20 percent.319 terol by promoting its excretion and impairing its absorption. Most research studies have used one PCO gram of dry powdered ginger root. 50–300 mg per day

Ginger Gugulipid (Commiphora Mukul ). The 1 g per day powdered ginger root mukul myrrh tree, native to India, Pakistan, and Afghanistan, is the source of standardized Globe Artichoke (Cynara Scolymus). The gugulipid extract. The extract is further concen- leaf extract of the artichoke has been found to have trated to isolate compounds known as guggul- HEART DISEASE 141 sterones. The two guggulsterones important Hawthorn in the management of hyperlipidemia are Z-guggulsterone and E-guggulsterone. Gugulipid Choose one of the following: appears to prevent the oxidation of LDL and may Tincture (1 part herb to 5 parts alcohol): 405 ml regulate the level of bile acids, helping the body to per day excrete cholesterol. Guggulsterones are thought to Freeze-dried berries: 1.0–1.5 g per day be the main active constituents responsible for Flower extract (1.8 percent vitexin or 20 percent these effects. Studies have shown that gugulipid procyanidins): 100–250 mg per day can decrease total cholesterol levels by 11.7 per- Berries or flowers (dried as a tea): 3–5 g of dried cent, LDL by 12.5 percent, and TG by 12.0 per- herb per day cent, with no change in HDL values.320 Most commercial extracts are standardized to 5 percent Plant Sterols/Stanols. Plant sterols are natu- guggulsterone content, and the typical treatment rally occurring cholesterol derivatives from veg- dose is 500 mg (providing 25 mg of guggul- etable oils, nuts, soy, corn, woods, and beans. sterones) three times per day.321 The hydrogenation of plant sterols produces A comprehensive review of available research stanols. Sterols and stanols are often referred to on gugulipid suggests conflicting evidence at this generically by the term phytosterols. Phytosterols time.322 When using the standardized extract have a chemical structure similar to cholesterol, preparations, only mild abdominal discomfort is and the consumption of these plant sterols reported in a small number of people. reduces the absorption of cholesterol and thus reduces circulating cholesterol levels. Even Gugulipid modest additions have been found to lower total 500 mg with 25 mg guggulsterones, 3 times per day blood cholesterol and LDL cholesterol by about 10 percent.328 Sterols and stanols from a dietary Hawthorn (Crataegus Oxyacantha). Haw- intake of plant sterols in the range of 1.5 to 2.5 thorn leaves, berries, and blossoms contain flavo- grams per day reduce LDL cholesterol by 8.5 to noids. One of these, proanthocyanidin, has 10 percent.329 A recent study found that dietary especially good cardiovascular effect. Hawthorn intervention with plant sterols could reduce cho- preparations are modestly effective in reducing lesterol levels by about 30 percent, or approxi- blood pressure,323 in the prevention and treat- mately the same extent as one of the statin drugs, ment of atherosclerosis, lowering cholesterol, and levostatin.330 Most studies have found no effect preventing the oxidation of LDL.324 Hawthorn of these sterols on triglyceride levels, but some preparations improve the blood supply to the individuals have shown effects in recent stud- heart by dilating the coronary arteries, increase ies.331–333 Sterols do not seem to lower HDL the force of contraction of the heart muscle, and levels. regulate cardiac rhythm.323 A very recent study of Sterols and stanols are often added to selected 79 diabetic hypertensive patients who received brands of margarines, semisolid food spreads, 1,200 mg hawthorn versus placebo for 16 weeks and salad dressings. As of 2000, the FDA author- found significant reductions in diastolic meas- ized sterol-containing products to state that they ures, no drug-herb interactions, and only few reduce the risk of heart disease. The lowest effec- mild side effects.325 Two randomized control trial tive dose for such a claim is 1.3 grams per day. found decreases in both systolic and diastolic Sterols and stanols are also available in dietary measures when treatment was administered for supplements. The supplement forms of phyto- about three months.326, 327 sterols are advantageous in that they do not 142 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE require refrigeration, are convenient to take, and flicting evidence, I still recommend policosanol in are largely calorie free. my clinical practice due to the results I witness. Dietary sterols include sitosterol, campe- Red Yeast Rice. Red yeast rice is made from sterol, and stigmasterol. Soybean oil is the prin- cooked white rice fermented by the yeast cipal source of sterol esters, followed by canola, Monascus purpureus, which is then sterilized and sunflower, and corn oils. Sterols reduce total cho- dried. Red yeast rice has been used as a dietary lesterol levels and LDL cholesterol because they staple, to make rice wine, and as a food preserva- are natural competitors of cholesterol absorption tive and is a cholesterol-lowering agent. The and resorption. main active ingredient in red yeast rice is mona- Plant Sterols and Stanols colin K (lovastatin),338 which inhibits the enzyme that initiates the synthesis of cholesterol. Average dose of 3.4 g per day Omega-3 fatty acids, isoflavones, and plant NCEP III recommends 2 g per day sterols in red yeast rice are likely also responsible for its beneficial effects on lipids. In one of the Policosanol. Policosanol is a mixture of alco- early studies on red yeast rice (using 2.4 g/d hols extracted from sugar cane, wheat germ, rice Cholestin), after 8 weeks cholesterol levels were bran, or beeswax. Policosanol has been used to lowered in men and women by 17 percent, LDL reduce total cholesterol, LDL cholesterol, and by 22 percent, and triglycerides by 12 percent, triglycerides and to increase HDL cholesterol with HDL values unchanged.339 based on over 10 years of critical trials and 30 However, there is significant variability in qual- or so positive clinical trials. One recent meta- ity and potency of commercial red yeast rice prod- analysis of natural interventions for abnormal ucts. In addition, the lovastatin content in dietary and elevated lipids concluded that policosanol is supplements of red yeast rice was lowered due to 334 more effective than plant sterols. challenges by the FDA and others. Due to legal However, evidence to the benefits of poli- issues, Cholestin is no longer available. There are, cosanol is conflicting. In May of 2006, a random- however, other effective red yeast rice products. ized controlled trial studied four different doses of policosanol compared to each other and a placebo Red Yeast Rice 335 group. None of the treatment groups had a 2.4 g per day decrease of LDL cholesterol of more than 10 percent, and no statistically significant difference Additional Botanical Therapies. A vast occurred between policosanol and placebo. It may range of herbs have been used for decades, or be that combining policosanol with other lipid- even centuries, to treat heart and vascular system lowering natural agents, and especially fish oils, conditions. Some of these herbs are categorized will offer the most effect. Animal and human here according to their dominant action: studies that combined 5 or 10 mg policosanol with 1 gram omega-3 fatty acids showed a Diuretics: dandelion leaf, lily of the valley, decrease in total cholesterol, triglycerides, and parsley LDL and an increase in HDL greater than when Heart tonics: broom, bugleweed, figwort, haw- fish oils alone were used.336, 337 Despite this con- thorn, lily of the valley, motherwort, night- blooming cereus Policosanol Aids to circulation: broom, cayenne, ginger, 10–80 mg per day hawthorn, horse chestnut, lime flowers, mistletoe, yarrow HEART DISEASE 143 Nervines (reduce anxiety and stress): lemon performed 12 resistance exercises for one hour, balm, hops, lime flowers, motherwort, pas- three times per week. After five months of exercise, sionflower, skullcap, valerian they showed decreases of 13 and 14 points in total Antihypertensives: rauwolfia, hawthorn, mistle- cholesterol and low-density lipoprotein cholesterol toe, garlic, yarrow, crampbark (LDL), respectively, from baseline values. Another Anti-atherosclerosis: lime flowers, hawthorn, study noted that previously hypertensive adoles- mistletoe, yarrow cents who reduced their blood pressure by aerobic exercise were able to maintain blood pressure con- Exercise trol by taking weight-lifting exercise after discontinuing aerobic exercise. These results are even Numerous studies show the great heart-health more surprising when one considers the lack of benefits of exercise.340–371 Physical exercise is effect noted for aerobic exercise in plasma total and associated with a reduction in obesity, improved LDL and triglycerides in women. body fat distribution, a reduced risk of type 2 The type of exercise chosen appears less signif- diabetes, reduced blood pressure, and reduced icant than its intensity or duration on its effects on cholesterol levels. In women of all ages, exercise CVD risk factors. Exercise recommendations have has been shown to reduce the risk for cardiovas- changed over the years and will likely continue to cular disease by altering CVD risk factors. In change with time. Public health recommendations addition, it diminishes the stiffness of arteries vary by organization. I recommend engaging in and decreases damaging plaque in blood vessels. 40 to 60 minutes of moderate-intensity physical Finally, exercise reduces the risk of arrhythmias, activity such as brisk walking on most days of the normalizes blood lipids, and increases insulin week or at a vigorous intensity for 20 minutes per sensitivity. A recent study suggests that exercise day. It should be noted here that the effects of and modest diet changes can decrease cholesterol exercise on CVD risk factors are not permanent. and resultant atherosclerosis comparable to cer- Code and colleagues found that, in both men and tain statins. Most important, by staying active women, the effects of exercise on blood pressure with moderate levels of physical activity, we can disappeared within weeks after the return to a prevent cardiovascular disease independent of sedentary lifestyle. other risk factors and improve our life expectancy. Aerobic exercise in particular is known to raise Benefits of Exercise HDL cholesterol levels, and in women, HDL may be the most important cholesterol issue in Exercise: predicting coronary artery disease. Williams 1. Normalizes blood lipids found an average 0.13 mg/dL plasma HDL 2. Elevates protective HDL levels in dose-response increase for each additional kilometer run by fashion female runners per week. Similarly, other studies 3. Significantly reduces LDL 4. Reduces and stabilizes blood pressure have reported modest to significant increases in 5. Increases insulin sensitivity HDL cholesterol following aerobic training. In 6. Stabilizes weight and decreases fat mass and BMI one of these studies, the increase in HDL was 7. Is beneficial in congestive heart failure measured at 7.6 mg/dL when exercise was com- 8. Reduces CVD mortality bined with smoking cessation in women. 9. Is an essential in rehabilitation after heart attack, stroke, or bypass surgery In addition to aerobic exercise, strength train- 10. Alleviates stress ing has been found to reduce CVD risk factors as well. In one study, previously sedentary women 144 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Exercise Recommendations studied 60 older patients (41 men and 19 women) who had had previous MI or bypass surgery and Prevention of Cardiovascular Disease participated in a rehab program that included Follow the exercise guidelines outlined in Appendix A. treadmill running for 25 minutes, stationary biking for 15 minutes, and machine rowing for Treatment of Existing Cardiovascular Disease 10 minutes for three and twelve months.371 The 1. Consult a health-care provider before beginning results showed improved fitness and increased a new exercise program. number and size of capillaries in the thighs. 2. Use caution and moderation. Note that in men Women should be encouraged to gradually who seldom exercise, cardiac arrest is 56 times increase their exercise and engage in an exercise more likely during vigorous exercise than at rest. In men who exercise frequently, the risk is 5 program that is safe, convenient, and hopefully times greater.372 satisfying and even fun, at least at times. There is 3. Walking program for heart patients:373 no single best exercise but rather what’s best for you. Regular, lifelong exercise offers women Distance Time more CVD benefits than any one drug, nutrient, Weeks (miles) (min/mile) or herbal intervention. 1–2 1 20 3–4 1 17–20 Stress Management 5–6 1 15 Women’s hearts appear more vulnerable to stress 7–8 1.5 15 than men’s. Arnold suggests that negative stres- 9–10 1.5 14 sors such as lack of social support and perceived lack of control contribute to CAD risk.375 A sim- To maintain the conditioning effect, exercise 20 ilar inference can be made from the data to 30 minutes three to five times a week. If you stop obtained by Blumenthal and colleagues.376 In exercise for more than two weeks, start again at a patients with CAD or ischemia, these authors lower level and gradually build back up to your original program. found that a stress management program was approximately three times more effective at Examples of Moderate Exercise for Mild CAD374 reducing cardiac events than exercise. • 30 minutes of brisk walking each day Many simple techniques can be effective in • 10 minutes of brisk walking 3 times a day managing stress and reducing its baleful influ- • Swimming, biking, or working out on an exercise ence. Techniques such as deep-breathing exer- machine such as a treadmill, stair-climbing cises, biofeedback, transcendental meditation, machine, rowing machine, or stationary cycle at yoga, progressive muscle relaxation, and hypnosis moderate intensity for 30 minutes daily have all been shown to reduce stress and lower Begin slowly and increase speed gradually over time. blood pressure.377 The antihypertensive effect of If you have never exercised before, start with a few these techniques is not dramatic. However, they minutes each day and increase time gradually every week until you reach 30 minutes per day. constitute an important factor in a holistic program to lower blood pressure and treat and prevent heart disease. For several decades, exercise has been advo- cated for the treatment of men who have had a Natural (Bio-Identical) Hormone heart attack or stroke. Recent encouraging results Replacement Therapy suggest that it should also be prescribed for Whether a woman should go through the meno- women in similar situations. Ades and colleagues pausal years without hormone therapy or HEART DISEASE 145 whether she should use bio-identical or conven- more important, because it is biochemically tional hormone therapy is a complex decision. identical to the progesterone produced by the The decision is especially difficult when one con- human ovary. Natural progesterone is biochemi- siders the many unanswered questions about cally different than progestin, which is com- menopause, cardiovascular disease, and natural monly misstated as progesterone. The most and conventional hormones. The method I common progestin used for menopausal women follow is to systematically evaluate each woman is medroxyprogesterone acetate (MPA), better with a thorough medical history, physical exam, known as Provera. and laboratory testing. Based on these tests and There are few studies on natural proges- the patient’s preferences and concerns, the prac- terone. However, the development of oral titioner and patient can together develop a per- micronized progesterone (OMP) in the last 10 to sonalized plan that is right for the patient. 15 years, together with the few side effects and A woman’s risk for cardiovascular disease popularity of natural progesterone, have encour- changes over time. The plan needs to change aged scientific research and medical interest in accordingly to carefully balance the benefits versus this natural hormone. For more information on the risks of therapy. Both practitioner and patient the indications and effects of natural proges- need to be open-minded so that informed and terone, please refer to Chapter 12. appropriate decisions are reached. To date, unfortunately, very few studies have Conventional HRT may be appropriate addressed the possible cardiovascular effects of for some women. When it is appropriate, it these preparations in postmenopausal women. behooves physicians to advise the use of the least The study with the biggest impact on the percep- objectionable options. Phytoestrogens and bio- tion of natural progesterone was the Postmeno- identical hormone therapy are perhaps the most pausal Estrogen/Progestin Interventions (PEPI) appropriate for some women, and I would assert, trial.378 Although the postmenopausal women in most women. No single protocol or approach is this study were also given estrogen, the PEPI trial equally appropriate for all women. Determining demonstrated similar lipid changes for estrogen if my patient is at low, medium, or high risk for and progesterone that are known to occur with CAD has been a critical tool in the path to the administration of estrogen alone, except for HDL, recommendations I finally make. (See the which was significantly reduced. Perhaps what overview section at the beginning of this chapter merits reflection here is that, despite its other for more about issues pertinent to HRT and car- undesirable effects, estrogen alone has the most diovascular disease.) favorable effect on lipids. When estrogen is combined with natural progesterone, HDL cholesterol Natural (Bio-Identical) Progesterone does not improve quite as much, and when given The use of natural or bio-identical progesterone with progestin, HDL improves even less. creams and oral micronized natural progesterone A recent study compared the effects of natu- has grown in popularity over the last several ral progesterone and synthetic progestin (in the years. However, only recently have natural prog- form of conjugated equine estrogen) and found esterone creams been shown to have biological the following: the conjugated equine estrogen activity. Progesterone is synthesized from dios- (CEE) group had an increase in HDL levels of genin or stigmasterol found in Mexican wild 14.4 percent after six months; the estrogen plus yams and soybeans. This hormone end product progestin had an increase in HDL of 4.58 per- has come to be known as natural or bio-identical cent; and the estrogen plus natural progesterone progesterone both because it is plant derived and, had an increase in HDL of 5.44 percent.379 Total 146 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE cholesterol levels were significantly decreased timing of when a woman starts HRT may affect only in the estrogen plus progestin group; triglyc- the risks and the benefits, see the overview sec- eride levels were increased only in the estrogen tion of this chapter. plus natural progesterone group; and the micronized progesterone was not superior to Natural (Bio-Identical) Estrogens medroxyprogesterone acetate. Natural estrogens are what we have come to call There is evidence showing that oral plant-derived bio-identical hormones. They micronized progesterone (OMP) may lower include estradiol, estrone, and estriol. Mexican blood pressure. In fact, OMP administered in wild yam contains diosgenin and soy contains stig- doses of 200, 400, and 600 mg per day to hyper- masterol that can be converted into an estrogen tensive postmenopausal women and older men biochemically identical to that produced by our significantly reduced systolic blood pressure as ovaries. Bio-identical estradiol and estrone in a compared to placebo in a two-week treatment patented delivery system and in premanufactured trial.380 With the maximum dose, systolic blood dosages are available by prescription from pressure was decreased approximately 19.7 mm a regular pharmacy. Bio-identical estradiol, estrone, Hg and diastolic blood pressure about 9.6 mm and estriol can also be compounded in customized, Hg. At the lower doses, the decreases in systolic individualized dosages of any strength, any combi- blood pressure were less significant. Both OMP nation, and in many different delivery systems and progestins can cause fluid retention, although including lozenges, sublingual tablets, creams, gels, natural progesterone to a lesser extent. capsules, and even injections. The distinctions Studies demonstrate that synthetic progestins between bio-identical estrogens and other forms of and natural progesterone have markedly different HRT are presented in Chapter 12. This section effects on the coronary vessels381 and on their will focus on their effect on the cardiovascular smooth wall muscle cells.382 The results of these system. two studies indicate that synthetic progestins Theoretically, if we have a dose of a bio- may induce spasm of the coronary arteries, identical estrogen that is equivalent in strength to whereas estrogen and/or natural progesterone the dose of the conventional estrogen, the cardio- promoted dilation. vascular benefit or risk should be the same. Although many women are presently using Nonetheless, any hormone therapy that is consid- natural progesterone creams as an alternative to ered to be an alternative to the leading form of ther- conventional HRT, relatively little research has apy (conjugated equine estrogens, i.e., Premarin) been done on these products—with little infor- must at some point be compared in order to prove mation about their impact on cardiovascular risk its worthiness and acceptability among patients and factors. For more information on the use of nat- health-care practitioners. A few studies have looked ural progesterone alone or in combination with at oral micronized estradiol alone or in combina- different estrogens in menopause, please refer to tion with bio-identical progesterone and compared Chapter 12. it to conjugated equine estrogens (CEE) plus Perhaps most interesting is that in the medroxyprogesterone acetate (MPA) to evaluate Women’s Health Initiative, women who were on possible effects on CAD. Ten menopausal women, estrogen only did not have an increased inci- administered the natural estrogen/progesterone dence of cardiovascular disease but did have an combination, experienced a decrease in total cho- increased risk of stroke,383 differing from the first lesterol. In contrast, this parameter did not change WHI study estrogen and progestin group.17 For significantly at 12 months over the initial choles- a discussion on other research and how the terol readings in the five women who were given HEART DISEASE 147

Sample Treatment Plan for Cardiovascular Disease or Hyperlipidemia

See the Resources section for formulation sources. Daily Supplements for Cardiovascular • The National Cholesterol Education Program Disease (NCEP) recommends that dietary therapy begin Plant sterols/stanols: 2.0–3.4 g per day with reducing dietary saturated fat by minimizing Vitamin E: 400–800 IU per day or eliminating beef, pork, lamb, cheese, butter, Garlic: 1 capsule per day containing 4,000–5,000 milk, chocolate, and fried foods. mcg allicin • Consider the Mediterranean diet: increase Green tea: 1 capsule extract or 3–5 cups tea per intake of fruits; vegetables; whole grains; day legumes, especially soybean products; nuts; CoQ10: 100 mg per day seeds; olive oil; and fish. EPA/DHA fish oil: 1 g per day • Reduce sodium to less than 2,500 mg per day. Folic acid: 800 mcg per day • Quit smoking. • Do not exceed one alcoholic beverage (5 oz) Daily Supplements for Hyperlipidemia per day. Policosanol: 20–40 mg per day • Practice regular aerobic exercise (30 minutes or Niacin (nicotinic acid): 500–1,500 mg per day more, 5–7 times per week)—e.g., a brisk walk. Plant sterols/stanols: 2.0–3.4 g per day • Reduce or eliminate coffee (both caffeinated EPA/DHA fish oil: 2–4 g per day if triglycerides are and decaffeinated). elevated • Strive for healthy body weight. Pantethine: 300 mg 3 times per day • Practice stress management such as meditation Other supplements based on specific situation or relaxation exercise 15 minutes each day.

CEE and MPA. Both groups experienced an not in middle-aged postmenopausal women (age increase in HDL cholesterol.384 Another study 50 to 65).386 The other study followed post- reported the results of a combination pill contain- menopausal women using estriol and found an ing 2 mg of oral micronized estradiol, 1 mg of increase in their cardiac function and improved estriol, and 1 mg of a synthetic progestin in 265 blood flow in the extremities.387 Even so, I would women, who were followed for over four years; not currently consider estriol a viable approach serum cholesterol and triglyceride levels decreased for treating or preventing heart disease. significantly, but HDL levels were not measured.385 When it comes to cardiovascular disease, I con- Estriol is the other natural estrogen that can tend that ethically, practitioners using bio-identical be used either alone or in combination with hormone therapy must have the same benefit-risk estradiol (called bi-est) or with estradiol and conversation with patients as a conventional prac- estrone (called tri-est). Estriol is used for a variety titioner who prescribes the typical Premarin/ of treatments and is discussed in more detail in Provera would have. That said, in my opinion, Chapter 12. Little is known about what estriol there is enough evidence at this point that oral may or may not do with regard to CVD. How- micronized progesterone is more cardiac friendly ever, two studies indicate positive effects of on lipids and coronary arteries than are the syn- estriol administration on lipid profiles and car- thetic progestogens or progestin (such as Provera). diac function. Japanese researchers found that 2 Other than this point, I would advocate for fol- mg per day of estriol was effective in decreasing lowing the current guidelines from the North total cholesterol and triglycerides and increasing American Menopause Society and their Position HDL levels in elderly women (age 70 to 84), but Statement on HRT in Menopausal Women:388 148 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plan for Hypertension

See the Resources section for formulation sources. Daily Supplementation • Consider the DASH diet or Mediterranean diet: Dandelion leaf capsules: 2 capsules daily increase intake of fruits; vegetables; whole Garlic: 1 capsule containing 4,000–5,000 mcg grains; legumes, especially soybean products; allicin, twice per day nuts; seeds; olive oil; and fish. Coenzyme Q10: 100 mg per day • Consider avoiding all sodium; at the least, Potassium: 99 mg–2.5 g per day reduce sodium to less than 2,500 mg per day. Herbal tincture: • Quit smoking. Motherwort: 2 oz • Do not exceed one alcoholic beverage (5 oz) Passionflower: 2 oz per day. Rauwolfia (available through health-care • Practice regular aerobic exercise (30 minutes or practitioner—not to exceed .3 mg of more, 5–7 times per week)—e.g., a brisk walk. reserpine per day) • Reduce or eliminate coffee (both caffeinated Hawthorne: 2 oz and decaffeinated). Dose: 1 tsp twice daily • Strive for ideal body weight. • Practice stress management such as meditation or relaxation exercise 15 minutes each day.

• “Data from studies such as the WHI and the the biologic activity of component ingredi- Heart and Estrogen/progestin Replacement ents. There is some evidence that transder- Study (HERS) should be extrapolated only mal 17 beta-estradiol does not increase the with caution to women younger than 50 level of C-reactive protein, and also that it years of age who initiate HT. The data should may be associated with lower risk of deep not be extrapolated to women experiencing venous thrombosis than oral estrogen.” premature menopause (under 40 years of age) • “The effect of ET on CHD and stroke is not and initiating HT at that time.” yet clear. ET does not have a significant effect • “Premature menopause and premature ovar- on stroke risk in postmenopausal women ian failure are conditions associated with with known ischemic cerebrovascular disease, earlier onset of CHD [coronary heart dis- but for healthy older women, effects of ET ease], but there are no clear data as to on stroke risk are not clear. However, unless whether ET [estrogen therapy] or EPT confirming data become available, ET should [estrogen/progestogen therapy] will reduce not be used for primary or secondary preven- morbidity or mortality from these condition of these conditions.” tions. The benefit-risk ratio may be more favorable for younger women.” CONVENTIONAL • “Nonoral routes of administration of MEDICINE APPROACH ET/EPT may offer advantages and disadvan- There is still much that is unknown about car- tages, but the long-term benefit-risk ratio diovascular disease, hormone replacement, and has not been demonstrated. Differences the aging process in women. The results of the would be related to the role of the first-pass Women’s Health Initiative (WHI) have dramati- hepatic effect, the hormone concentrations cally changed how HRT has been prescribed in in the blood achieved by a given route, and this country. It is no longer routinely prescribed HEART DISEASE 149 to reduce the risk of cardiovascular disease, as it events except in women who were 65 years or was for over 30 years. The approach now is much older. In that age group, aspirin therapy did more individualized, and there is still lack of agree- reduce overall cardiovascular disease by 26 per- ment if the timing of when HRT is started cent and the risk of MI by 34 percent. impacts its influence on cardiovascular disease. As The U.S. Preventive Services Task Force with all therapies, HRT must be examined against (USPSTF) has found good evidence that aspirin the backdrop of benefit versus risk. The nagging decreases the incidence of heart disease in adults questions for women continue to be, “Should I or who are at increased risk. However, they also shouldn’t I?” and “Are the risks greater than the acknowledge that aspirin increases gastrointesti- benefits?” Further discussion of these concerns is nal bleeding episodes and that it may also presented in Chapter 12. increase the incidence of hemorrhagic (bleeding) Conventional practitioners are as eager to strokes. Their conclusion is that for those indi- educate their patients on the importance of pre- viduals who are at high risk for heart disease, the venting heart disease as holistic care providers benefits outweigh the risks. The American Dia- are. For several years now, patients have been betes Association has also concluded that clini- encouraged by their conventional physicians to cians should consider aspirin for primary stop smoking, increase exercise, lower their prevention of heart disease in diabetic patients dietary fat, increase fruits and vegetables, lose who are older than 30 or have risk factors for car- weight, and reduce their stress. It has become diovascular disease and no contraindications to much more common to recommend diet and aspirin. The American Heart Association recom- lifestyle changes as a first line of treatment for mends aspirin for “patients who’ve had a myocar- mild hyperlipidemia and mild hypertension. dial infarction (heart attack), unstable angina, Those individuals who are at increased risk ischemic stroke (caused by blood clot) or tran- for heart disease should discuss the potential sient ischemic attacks (TIAs or ‘little strokes’), if benefits and harms of aspirin therapy with their not contraindicated.” You should not start practitioner. Low-dose aspirin is a foundation of aspirin therapy without first consulting your heart disease secondary prevention, due to its practitioner. Also inform your practitioner if you ability to inhibit platelet aggregation. Recur- are taking aspirin and must have a simple surgi- rence rates for heart attacks are also consistently cal procedure, even a dental extraction, as it lower in women (and men) who already have increases the risk of excessive bleeding. coronary disease when they are treated with a When treating hyperlipidemia, most conven- low dose of aspirin.389 In a meta-analysis of four tional practitioners will follow the NCEP, ATP large primary prevention trials using low-dose III guidelines. Step 1 involves identifying the aspirin, a 15 percent reduction was seen in car- lipid levels with blood testing; step 2 is to iden- diovascular events and a 30 percent reduction tify the presence of any atherosclerotic disease was observed in MI rates.390 More recently, a that confers a high risk for heart disease events. large randomized placebo-controlled trial of Step 3 is to determine the presence of major risk low-dose aspirin was done in the Women’s factors other than an LDL level above 160. These Health Study (WHS).391 In 39,876 women who major risk factors include: did not have coronary disease, a 24 percent • Cigarette smoking reduction was observed in the risk of ischemic • Blood pressure of 140/90 or higher or some- strokes, compared with those women who did one on high blood pressure medication not take aspirin. Unfortunately, there was no • Low HDL, less than 40 mg/dL overall reduction in MI or total cardiovascular 150 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Table 9.4 ATP Guidelines for Drug Therapy

Risk Category LDL Goal LDL Level for TLC LDL for Drug Therapy

CHD or 10-year < 100 mg/dL >_ 100 mg/dL >_ 130 mg/dL risk > 20% (100–129 mg/dL: optional) 2ϩ risk factors < 130 mg/dL >_ 130 mg/dL 10-year risk 10–20%: (10-year risk –< 20%) >_ 130 mg/dL; >_ 160 mg/dL 0–1 risk factors < 160 mg/dL >_ 160 mg/dL >_ 190 mg/dL (160–189 mg/dL: optional)

• A family history of premature heart disease tatin. They each come in several strengths. Bile (before age 55 in father, brother, or son; acid sequestrants decrease LDL and increase HDL before age 65 in mother, sister, or daughter) but do not lower triglycerides. These include • Age (men 45 and older and women 55 and cholestyramine, colestipol, and colesevelam. Nico- older) tinic acid is used in three different forms: the immediate-release nicotinic acid (1.5–3 grams per Step 4 is to determine a woman’s 10-year day), the extended-release form (Niaspan, 1–2 heart disease risk according to Framingham grams), or the sustained-release form (nicotinic tables of greater than 20 percent risk, 10 to 20 acid, 1–2 grams). Nicotinic acid lowers LDL, percent risk, or less than 10 percent risk; Step 5 although not as much as some of the newer is to determine the risk category. At this point, statins; raises HDL better than all the statins; and your practitioner will initiate advice. Initiating lowers triglycerides as much or better than the the Therapeutic Lifestyle Changes (TLC) is the statins. Finally, fibric acids are drugs that are used first attempt at lowering your lipids, if your LDL primarily to lower triglycerides. These include is already at its goal. The specifics of the TLC are gemfibrozil, fenofibrate, and clofibrate. described in the nutrition section. Per the ATP The treatment of high blood pressure is III guidelines, drug therapy is advised, according responsible for more primary care visits than any to the scheme shown in Table 9.4. other chronic medical condition. However, Ideally, drugs will be advised simultaneously approximately 75 percent of treated hyperten- with TLC for women whose 10-year risk is greater sion patients are receiving inadequate care, as than 20 percent. For those in lower risk categories, defined by their inability to achieve and maintain drugs may be added after a three-month trial of their target blood pressure. just the therapeutic lifestyle changes. The American Heart Association (AHA) offers There are many drug or quasi-drug treatments 10 ways to control your high blood pressure: that your conventional practitioner may consider. The major classes of lipid-lowering agents used in 1. Know your blood pressure and have it conventional medicine include HMG-CoA reduc- checked regularly. tase inhibitors (statins), bile acid sequestrants, 2. Maintain a healthy weight. fibric acid derivatives, and nicotinic acid. 3. Avoid using salt in cooking or the salting of The group of drugs called the statins lower your foods. Avoid packaged salty foods. LDL and triglycerides, and some may raise HDL. 4. Eat a diet low in saturated fat according to Currently, these include lovastatin, pravastatin, the AHA recommendations (see nutrition simvastatin, fluvastatin, atorvastatin, and cerivas- section). HEART DISEASE 151 5. Limit your alcohol intake to one drink per different medications to see not only which works day. best, but which works best with the fewest side 6. If you are taking any medication, take it as effects. An additional reminder, though: Don’t prescribed. Do not make any changes with- just stop your medication on your own if you out consulting your prescribing practitioner. get discouraged or are experiencing side effects. 7. Make regular follow-up appointments with Call your medical office. The following sidebar your practitioner. contains a list of some of the drugs used to treat 8. Follow exercise advice. high blood pressure. This is not a complete list, as 9. Advise your immediate relatives to have there are many and new ones all the time. their blood pressure checked. The use of pharmacologic agents to lower 10. Manage stress optimally. lipids and/or blood pressure is an appropriate regimen for patients who have not responded to There are many different medications to a rigorous lifestyle modification program and lower high blood pressure, called antihyperten- nutritional and/or herbal supplementation. It is sives. Diuretics rid the body of excess fluids, and important to recognize, however, that despite even sodium, and are often used as the initial the effectiveness of alternative therapies, not all therapy. Beta-blockers reduce the heart rate and patients are able to make the necessary changes the amount of blood the heart pumps. Sympa- or comply with the supplementation regimen. A thetic nerve inhibitors reduce the blood pressure minority of patients have conditions that will by inhibiting the nerves that cause blood vessel resist their own and their physician’s best efforts. constriction. Vasodilators cause the muscle walls in the blood vessels to relax, and therefore allow SEEING A LICENSED PRIMARY them to dilate and widen. Angiotensin-convert- HEALTH-CARE PRACTITIONER ing enzyme (ACE) inhibitors work to lower blood (N.D., M.D., N.P., P.A., D.O.) pressure by interfering with the body’s production The signs and symptoms of coronary artery of angiotensin, a chemical that causes the arteries disease in women can be different from those to constrict. The angiotensin II receptor blockers found in men. Women more often have cases block the effects of angiotensin, and the calcium of silent myocardial infarction, have chest pain channel blockers are calcium antagonists that can while having normal coronary vessels, and have reduce the heart rate and relax the blood vessels. a higher incidence of mortality with their first Some individuals will need only short-term treat- incidence of chest pain due to coronary artery ment or may be able to reduce their dose after a spasm. Diagnostic testing in women may not be year or more of normal blood pressure. Others as reliable either. Exercise stress testing is less may need to be on blood pressure medications predictive, and angiograms reveal less extensive indefinitely. Keep in mind that reducing weight, disease in women than in men. eating healthier, exercising regularly, reducing One’s risk of heart disease changes with time, sodium, and reducing or managing stressors may and risk must be assessed periodically. For meno- keep you from having to take blood pressure pausal women, it starts with the annual physical medications or enable you to decrease or discon- exam, which should include a thorough medical tinue them. When drug treatments are needed, history, physical exam, blood pressure and pulse as you can see, there are many to choose from, check, weight, listening to heart and lungs, and and it takes knowledge, skill, and experience for other physical findings. Lipid panels checking your practitioner to offer the best medication for for total cholesterol, HDL, LDL, triglycerides, you. You may need to go through trial periods on and the cholesterol/HDL ratio and thyroid and 152 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Drugs Used to Treat High Blood Pressure

Diuretics Propranolol hydrochloride Alpha Blockers Hlorthalidone Timolol maleate Doxazosin mesylate Furosemide ACE Inhibitors Prazosin hydrochloride Hydrochlorothiazide Terazosin hydrochloride Ndapamide Benazepril hydrochloride Metolazone Captopril Combined Alpha and Beta- Enalapril maleate Blockers Potassium-Sparing Diurectics Fosinopril sodium Carvedilol Amiloride hydrochloride Lisinopril Labetalol hydrochloride Spironolactone Moexipril Triamterene Quinapril hydrochloride Central Agonists Ramipril Alpha-methyldopa Combination Diuretics Trandolapril Clonidine hydrochloride Amiloride hydrochloride plus Angiotensin II Receptor Guanabenz acetate hydrochlorothiazide Blockers Guanfacine hydrochloride Spironolactone plus hydrochlorothiazide Candesartan Peripheral Adrenergic Irbesartan Inhibitors Beta-Blockers Losartan potassium Guanadrel Acebutolol Valsartan Guanethidine monosulfate Atenolol Calcium Channel Blockers Reserpine Betaxolol Bisoprolol fumarate Amlodipine besylate Blood Vessel Dilators Carteolol hydrochloride Diltiazem hydrochloride Hydralazine hydrochloride Metoprolol tartrate Felodipine Minoxidil (use in severe cases or Metoprolol succinate Isradipine in conjuction with treatment of Nadolol Nicardipine kidney failure) Penbutolol sulfate Nifedipine Pindolol Nisoldipine Verapamil hydrochloride

glucose testing are done at different frequencies For women with abnormal findings, it is depending on health status and risk factors. While important to seek the advice of someone who can annual routine screening may be more often than help determine if therapeutic doses of some of most practitioners will recommend for women the natural therapies discussed in this chapter are aged 50 and older, I do in fact prefer that approach suitable and sufficient for success. A treatment to optimize the preventive medicine approach. If plan can be agreed on; then, with follow-up eval- deemed necessary, biomarkers of cardiovascular uation and testing after an appropriate interval, risk, EKG, stress EKG test, and stress echocardio- the next step in the process can be determined. grams may also be recommended. The results of Some women may need to take cholesterol- or these tests will help determine the most appropri- blood-pressure-lowering pharmaceutical agents if ate next step, whether it is a more aggressive diag- an aggressive natural treatment plan has not nostic test and/or treatment intervention. brought adequate results, at least on an interim HEART DISEASE 153 basis, and with appropriate monitoring and medications, for whatever reason, and want to follow-up. The determination of whether to use use the natural supplements for your blood pres- natural or conventional HRT and its dosage can sure or cholesterol. There are some significant best be made by a practitioner who appreciates drug/herb/nutrient interactions that are impor- the role and value of each and the benefits and tant to be aware of, and in a few circumstances risks of HRT. there are herbs and nutritional supplements that Another reason to see a licensed health-care are contraindicated with select medications. An practitioner (naturopathic doctor, medical alternative practitioner in particular can assure doctor, osteopathic doctor, nurse-practitioner, or the safest method of taking natural supplements physician’s assistant) is if you are on prescription with pharmaceutical medications. This page intentionally left blank INFERTILITY CHAPTER 10

OVERVIEW reproductive therapies for infertile couples who Impaired fertility affects over 6 million women wish to have a child. Many ob-gyns, primary care in the United States alone, and recent estimates physicians, and complementary care providers suggest that approximately 10 million couples may do couples a disservice by waiting too long to have sought infertility services. Infertility is con- make these referrals. sidered a common condition and affects 10 to If pregnancy has not been achieved within 15 percent of reproductive age couples. Female one year in a woman less than 35 years old, eval- infertility accounts for about 50 percent of the uation of both partners should be initiated. cases, 19 percent are due to male factor infertil- Women who are 35 years old or older; women ity, 17.6 percent are due to a combination, and who have a history of irregular menses, pelvic about 10.5 percent of the cases are caused by pain, or dyspareunia (pain with intercourse); and unknown factors.1 Female infertility most often women with a previous pelvic surgery, PID, or is due to tubal and pelvic disease (40 percent) or endometriosis should be evaluated earlier. from a previous pelvic inflammatory infection, A detailed medical history is necessary to asymptomatic chlamydia or gonorrhea, or ovula- determine many things that are pertinent to tory dysfunction (40 percent). Endometriosis, a fertility: diminished number of oocytes in the ovary, uterine • Previous pregnancy history and outcome abnormalities, immunologic factors, chromoso- • Menstrual cycle details mal abnormalities, environmental chemicals and • Contraception history toxins, and cancer chemotherapy or radiation • Duration of time without contraception can also cause infertility. • Coital frequency Infertility is defined as a failure to conceive • Surgeries, hospitalizations, illnesses, PID, after 12 months of frequent intercourse without STIs, Pap smear history contraception in women under 35 years of age or • A review of other systems and history of any failure to conceive after six months of intercourse thyroid problems, nipple discharge, acne, without contraception in women 35 years of age facial hair, or hair loss or older. Infertility is further broken down into • Medications, allergies two types: primary infertility is in women with • Family history of serious illnesses, congenital no history of prior pregnancy, and secondary birth defects, and reproductive health infertility is with a history of prior pregnancy. problems Eighty-five percent of couples will conceive • Lifestyle factors: smoking history, alcohol after the first year of trying, with an increase to use, exercise 93 percent after two years. Most spontaneous pregnancies occur within three years, and there is A physical evaluation should include height a poor prognosis for success without treatment and weight, observation for signs of excess andro- after that. This final point underscores the gens (facial hair, acne, and hair loss), abdominal importance of timely specialty referrals to repro- hip and waist circumference, and breast, thyroid, ductive endocrinologists for evaluation for assisted abdominal, and pelvic exam. 155

Causes of Infertility in Couples

Pelvic or Structural Factors (35%) • Genitourinary infection or sexually transmitted disease • Infection: pelvic inflammatory disease, sexually • Postpubertal mumps transmitted disease, septic abortion, • Hypogonadism endometritis, pelvic tuberculosis • Genital radiation or chemotherapy • Surgical history: dilation and curettage, rup- • Hypospadias tured appendicitis, adnexal surgery, leiomyoma • Testicular cancer (less than 0.1% of cases) (fibroids) • Retrograde ejaculation or other dysfunction • Contraception and pregnancy history: prior • Development abnormalities: vas deferens intrauterine device use, DES exposure in utero, absence (related to cystic fibrosis), impaired ectopic pregnancy, frequent abortion testicular function (chromosome abnormality) • Endometriosis • Exposure to excessive heat (hot tubs, saunas), Ovulatory or Hormonal Factors (15%) toxic chemicals, pesticides • Medication or drug use (gonadotoxins): med- • Secondary amenorrhea ications including allopurinol, colchicine, • Abnormal uterine bleeding chemotherapy, cimetidine, cyclosporine, eryth- • Obesity romycin, gentamicin, neomycin, nitrofurantoin, • Luteal phase defect (short luteal phase) tetracycline, spironolactone, and sulfasalazine; • Decreased ovarian reserve drugs including nicotine (first- or secondhand), • Premature ovarian failure (early menopause) alcohol, cocaine, steroids, and marijuana • Polycystic ovary syndrome • Elevated prolactin Unexplained (10%) • Elevated TSH • Depression • Prior use of antiestrogens (Lupron, Depo- Provera, danazol) Unusual Problems (5%) Male Causes (35%) • Immunologic

• Varicocele (42% of cases) Rare Causes • Unexplained (22% of cases) • Obstructive azoospermia (14% of cases) • Substance use (alcohol, marijuana, caffeine, • Cryptorchidism (3%) tobacco) • Testicular surgeries or injury

Laboratory testing can be extremely complex, semen. Other tests may be indicated such as and the order of what is done may vary depending androgen levels, blood sugar, insulin levels, or on the medical history and physical exam. Initial glucose tolerance testing. Pelvic and transvaginal exams often include thyroid testing, prolactin ultrasound (TVUS) looks for uterine fibroids, levels (for those with irregular cycles or symp- ovarian cysts, and ovarian follicles, and a saline toms), mentrual cycle day 3 follicle-stimulating sonohystogram (SHG) is useful in evaluating hormone (FSH) and possibly estradiol levels to the uterus for polyps, intrauterine adhesions, assess ovarian reserve, a mid-luteal phase proges- and submucosal fibroids. Some women who have terone test to confirm ovulation, hysterosalpin- a history of pelvic adhesions, tubal disease, or gography (HSG) to assess the fallopian tubes and endometriosis may need to have a laparoscopic any abnormalities of the uterus, and analysis of surgical evaluation. INFERTILITY 157

KEY CONCEPTS PREVENTION

• Female infertility is most often due to a previous • Prevent pelvic inflammatory disease by practic- pelvic inflammatory disease, asymptomatic ing safer sex and avoiding sexually transmitted chlamydia or gonorrhea, or ovulatory dysfunction. infections. • Other causes of infertility include endometriosis, • Avoid environmental toxins. diminished oocytes in the ovary, uterine abnor- • Reduce stressors. malities, immunologic factors, chromosomal abnor- • Avoid smoking and excess alcohol and reduce malities, environmental chemicals and toxins, caffeine. cancer chemotherapy, and cancer radiation. • Maintain optimal weight. • Maintain optimal weight. • Minimize exposure to environmental chemicals • Manage stress. and toxins. • Support fertility with a healthy diet. • Treat any underlying medical conditions related • Natural methods for infertility are most effective to infertility (exometriosis/endometriosis, poly- in anovulatory dysfunction. cystic ovarian dysfunction) • Acupuncture can increase pregnancy rates in women undergoing fertility treatment. • The decision to pursue conventional fertility nologist. After a detailed history and physical treatments depends on age, the duration and including pertinent lab work, treatment can be cause of the infertility, the results of ovarian- targeted to address any identified underlying reserve testing, finances, other health issues, emotional well-being, and thoughts and emo- causes. Unfortunately, in many cases, no cause tions about adoption or surrogate options. can be determined. In these causes of unex- • Seek a fertility specialist if considering conven- plained infertility, the first step is to address basic tional fertility treatments. issues of diet and lifestyle.

Environmental and Lifestyle Factors A day 3 FSH level (or day 3 and day 10 levels Both overweight and underweight women have if doing a full clomiphene citrate challenge test) is increased rates of infertility. Women who are important and helpful information in predicting overweight are more likely to experience prob- if a woman is less likely to become pregnant lems with ovulation and miscarriages. An in- beyond what would be predicted by age alone. An crease in abdominal fat decreases insulin elevated FSH level on cycle day 3 (or day 10) of sensitivity, which is related to ovulation dysfunc- greater than 11 to 12 IU/L is associated with poor tion. Women who are underweight have infre- chance of conception and poor results with in quent or even lack of ovulation. This is vitro fertilization. A FSH test that is 25 IU/L or compounded when combined with an eating dis- more or an age of 43 years or more are each asso- order or excessive exercise. In a woman with a ciated with a chance of pregnancy that is close to body mass index (BMI) less than 25, weight loss zero even with attempts at ovulation induction or of as little as 5 percent can be significant in help- with assisted reproductive technologies. ing to normalize menses and ovulation, especially in cases of polycystic ovary syndrome.2–4 Weight OVERVIEW OF gain in an underweight woman is important as ALTERNATIVE TREATMENTS well. Overall, the preponderance of evidence sug- Complementary medicine has a role in the man- gests that a normal body weight increases the agement of infertility both before and after a success of assisted reproductive therapies such as referral has been made to a reproductive endocri- in vitro fertilization. 158 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Focusing on daily exercise and a whole foods Stress can both contribute to infertility and be a diet free of processed foods, alcohol, and caffeine consequence of difficulty in conceiving. Many is important to help normalize weight as well as women and couples decide to discontinue their blood sugar. However, a very recent study sug- fertility treatments because of too much stress gests that vigorous exercise of greater than four and upset. In addition, research suggests that hours per week may interfere with the success of past or current stress and mental illness, especially in vitro fertilization (IVF) and that nonexercisers depression, may be the cause of many cases of may have more success with IVF than exercisers.5 unexplained infertility. This can be especially Moderate regular exercise is probably indicated problematic because continued inability to get for most individuals. In addition, in cases of pregnant often fuels depression, leading to a exercise-related reproductive dysfunction, most vicious cycle of emotional upset and a veritable of the evidence suggests that it isn’t the intensity roller coaster of monthly hopes and letdowns. of the exercise but the lack of adequate nutrition, Higher levels of premenstrual tension and specifically total calories and protein, that causes stress are associated with lower pregnancy rates.15 the fertility issues.6, 7 Stress hormones have inhibitory effects on the Smoking, caffeine (even decaf), and alcohol reproductive system, and, therefore, stress needs have been linked to decreased fertility, so avoid- to be addressed in anyone receiving fertility serv- ance is important in both partners in couples ices. In addition, it appears that stress decreases with fertility issues. Nicotine is toxic to the antioxidants, which are often low in both part- reproductive system. Smoking has been shown to ners in an infertile couple. Any treatment of cause both primary and secondary infertility in infertility should probably start with stress assess- women.8, 9 One study demonstrated that 38 per- ment and reduction techniques for both part- cent of nonsmokers conceived in their first cycle ners. Psychological counseling and a variety of attempt compared to only 28 percent for smok- relaxation techniques including biofeedback, ers. Smokers were over three times as likely to yoga, tai chi, Qi gong, and meditation can be take over one year to conceive versus nonsmok- helpful aspects of the treatment plan for anyone ers. Heavy smokers are affected more than light with past or present stress or depression. smokers.10 Smoking has also been shown to In the last few years, there has been a lot of decrease success of fertility treatments.11 In one public health information available on the report, female smokers had lower ovarian reserves importance of avoiding alcohol while pregnant, and required more drug intervention to induce but when it comes to the influence of alcohol ovulation than did the nonsmokers.12 consumption on female fertility, mild to moder- Other considerations are the genetic damage ate alcohol use has not been well studied. It seems, and chromosomal errors caused by smoking. however, that alcohol does reduce conception Cadmium, nicotine, and some of the nicotine rates with a dose-related connection. Research metabolites have been identified in the ovaries demonstrated that female alcohol intake was (and testes) and genital fluids of smokers. Cells associated with two to three times the risk of within the ovaries are affected by one particular spontaneous abortion, and alcohol intake during nicotine metabolite, cotinine, which causes the week of conception increased the risk of early oxidative damage and developmental problems pregnancy loss.16 In another study, there was a of the follicles.13, 14 greater than 50 percent reduction in the proba- Psychological stressors deserve to be addressed bility of conception during a menstrual cycle as well since the process of dealing with infertility in which women consumed alcohol. In this same can be very stressful and emotionally taxing. study, caffeine consumption did not independently INFERTILITY 159 affect conception rates, but it may enhance the formation, sperm viability, ovulation, egg viability, negative effect of alcohol.17 and hormone levels. Caffeinated beverages have been associated with decreased fertility, increased miscarriages, and Nutrition lower birth weights.18 More than five cups of coffee In addition to the issues related to weight, caf- per day, or more than 500 mg of caffeine per day, feine, and alcohol mentioned previously, there are is associated with a delayed time to conception, some specific nutritional influences on fertility in although we don’t really understand the mecha- women. In women who have a short menstrual nism. One possibility is that caffeine may impair cycle, increasing soy in the diet or taking soy estrogen production or the metabolism of estro- isoflavone supplements may increase the length of gens.19 Substances other than caffeine in coffee, the follicular phase and delay ovulation.22 Some- tea, and other beverages may also be responsible for thing as simple as flaxseed can lengthen the luteal reduced fertility. Numerous caffeinated beverages, phase of the cycle (the second half) and increase including coffee, soft drinks, black and green tea, the frequency of ovulatory menstrual cycles in and even decaffeinated coffee, contain tannins, women who don’t ovulate regularly.23 and some contain even more tannins than regular As far as weight loss is concerned, one can get coffee. In animal experiments, tannins have seriously confused these days about the value of reduced fertility in mice and hens.20, 21 carbohydrate versus protein diets. When it comes Increasingly, environmental pollution and to fertility, one study demonstrated that it did exposure to heavy metals, pesticides, estrogen-like not matter whether the diet was high-carbohydrate substances, and other chemicals are implicated in or high-protein: both groups who stuck to low- cases of infertility in men and women. Depending calorie diets lost weight and had improved men- on the specific exposure, duration, and load, dif- strual cycles and fertility.24, 25 ferent aspects of fertility can be affected. These It is, of course, important to limit certain kinds toxic exposures may affect sperm count, sperm of fish that have a higher mercury content in pregnancy, but evidence indicates it may be wise to do the same in cases of infertility. Studies show Caffeine Content that infertile couples consumed more fish and had Item Caffeine (mg) higher levels of mercury in their blood than fertile 26 Coffee, brewed (8 oz) 60–120 couples. Consumption of biphenyl-contaminated 27 Coffee, instant (8 oz) 70 fish also has an adverse effect on fertility. Substi- Coffee, decaffeinated (8 oz) 2–5 tuting fish oils from a reliable manufacturer for Double espresso (2 oz) 45–100 fish consumption is a good way to keep omega-3 Tea, black, 5-minute fatty acids in the diet. Prior to pregnancy, a mini- steep (8 oz) 60–100 mum daily intake of eicosapentaenoic acid (EPA) Tea, green (8 oz) 20 and docahexaenoic acid (DHA), found in fish and Barq’s Root Beer (12 oz) 22 fish oils, is about 650 mg of each. Coca-Cola (12 oz) 34 Wild salmon ranges from 1.0 to 1.5 grams Pepsi (12 oz) 38 Chocolate milk (8 oz) 4 per three-ounce serving, with a little more DHA Milk chocolate (1 oz) 1–15 than EPA. The different species of salmon (sock- Dark chocolate (1 oz) 20 eye, chinook, coho) range in EPA and DHA, and Ben & Jerry’s Coffee Fudge wild sockeye contains approximately 600 mg Frozen Yogurt (4 oz) 42 DHA and 430 mg EPA per three-ounce serving. Whether you take fish oil supplements daily or 160 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE eat fish several times per week, try to average cadmium and lead that can adversely affect about 650 mg of EPA and DHA per day. Specific sperm development. Selenium mostly affects needs for DHA increase during pregnancy (see male fertility by maximizing sperm formation, Chapter 16). (During pregnancy, cod liver oil optimizing testosterone production, and increas- may be a questionable choice due to the high ing sperm count. (For more information on male content of vitamin A, a teratogen, in fish liver.28) fertility, see the section titled “Male Fertility” later in this chapter.) Nutritional Supplements Vitamin E. Some simple vitamin and min- Selenium eral supplementation may be key to fertility in 100–200 mcg daily selected women, and because oxidative stress affects the female reproductive system and conse- Zinc. The most widely studied nutritional quently fertility, antioxidants are important con- supplement for fertility in both men and women siderations in enhancing fertility. Vitamin E is a is zinc. Zinc plays a vital role in cell division, and powerful antioxidant, combating free radical deficiencies are associated with reduced fertility, damage, and can play a beneficial role in female increased miscarriages, and chromosome damage. fertility. Most of the research on vitamin E is per- Less than optimal zinc levels not only reduce con- tinent to male fertility, such as making sperm ception rates, but babies have lower birth weights, more fertile. In one study, vitamin E was given to more birth defects, and can have a less developed both men and women and resulted in a signifi- brain and nervous system.31 Zinc deficiency is cant increase in fertility, and also assisted the especially important for sperm development. achievement and maintenance of pregnancy in women with repeated miscarriages.29 Other stud- Zinc ies show that adding antioxidants, including vitamins C and E, to the diet of animals significantly 30 mg per day reduced the decline of regular ovulation related to aging.30 This may have importance for women L-Arginine. L-arginine is an amino acid nec- in their 40s, who begin to experience reduced essary for the synthesis of protein and is found fertility due to diminished ovarian reserve. naturally in numerous animal protein foods. Arginine supplementation of 16 grams per day Vitamin E has been shown to improve uterine blood flow 400–800 IU per day and fertilization rates in women who had previously failed in vitro fertilization.32 Additional Selenium. The mineral selenium is another effects for enhancing sperm count and sperm antioxidant that protects from free radical quality are discussed in the male fertility section. damage. Free radicals are created when normal L-Arginine biochemical reactions cause oxygen molecules to become unstable. They are also formed by smok- 16 g per day ing, barbecuing, and deep-frying food, and more. Selenium can protect normal tissue from Para-Aminobenzoic Acid (PABA). PABA is oxidative damage caused by the free radicals, a part of the folic acid molecule and is found in including preventing chromosome damage. Sele- eggs, milk, meat, and several grains. The role of nium may also be able to provide protection PABA produced by the body is not really known, from exposure to toxic heavy metals including but as an oral supplement it is FDA-approved for INFERTILITY 161 difficult conditions such as scleroderma, vitiligo, Black Cohosh pemphigus, and dermatomyositis. It is approved for use as a sunscreen because it acts as a filter to 20–40 mg standardized extract twice daily block out ultraviolet radiation. In fertility, PABA supplementation of 100 mg four times daily Rhodiola (Rhodiola Rosea). Rhodiola may resulted in pregnancies in 12 of 16 women with enhance fertility. It has been shown to enhance a history of infertility.33 thyroid function without causing hyperthyroidism in animals, and egg maturation was PABA enhanced as well. These and other preclinical 100 mg 4 times per day research led to treating 40 women with amenorrhea and infertility with rhodiola (100 mg) twice Multiple Vitamin-Mineral. A double-blind daily for two weeks. Normal menses were restored trial found that taking a multivitamin-mineral in 25 women, 11 of whom became pregnant.43, 44 supplement increased female fertility.34 A multivit- Additional Botanicals. Numerous plants amin and mineral in the form of a prenatal prepa- have been used in traditional herbal medicine for ration has much of what is needed, but women their ability to regulate the tone of the uterus. In who are deficient in vitamins like folic acid and cases of infertility of undetermined cause, these 35–37 B12 and minerals like magnesium and sele- uterine tonics are thought to prepare the uterus nium38 may need additional supplementation. for implantation of a fertilized egg. These herbs include dong quai (Angelica sinensis), blue cohosh Botanicals (Caulophyllum thalictroides), crampbark (Viber- Chaste Tree (Vitex Agnus Castus). Chaste num opulus), false unicorn or helonias (Chamae- tree stimulates the release of luteinizing hormone lerium luteum), and squaw vine (Mitchella repens). (LH) from the pituitary gland and mildly inhibits Dong quai can tonify a weakened uterus by FSH. The result is an indirect ability to raise or improving the metabolism within the uterus45 as modulate progesterone levels.39 Chaste tree also well as regulating hormonal control and improv- modulates the secretion of prolactin from the ing the timing of the menstrual cycle.46 Blue pituitary gland, and in one study prolactin was sig- cohosh can improve the muscular tone of a hypo- nificantly reduced while shortened luteal phases tonic uterus and thereby was thought by early and progesterone deficits were normalized.40 traditional herbalists to improve fertility. Cramp- bark has been used more in cases of miscarriage Chaste Tree rather than actual infertility. It has been used tra- Liquid extract 1 tsp per day or 0.6–0.75% standard- ditionally both as a uterine sedative and a uterine ized extract, 175–215 mg per day tonic. False unicorn or helonias has been used to improve uterine tone and decrease what has been Black Cohosh (Cimicifuga Racemosa). called pelvic congestion. This herb also tends to Similar to chaste tree, black cohosh can also stim- be used more for women who have a history of ulate pituitary secretion of LH and therefore lead miscarriage or abnormal bleeding during the to ovulation and subsequent production of prog- pregnancy rather than true infertility. Squaw vine esterone by the corpus luteum.41, 42 Black cohosh is a uterine tonic that increases the circulation to may be especially valuable for women in their and in the uterus, thereby also reducing uterine 40s whose FSH levels may be starting to increase congestion. It can both sedate a hypertonic uterus as the ovary ages. as well as tonify a hypotonic uterus. 162 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

A Note About Acupuncture Polycystic ovary syndrome (PCOS), also known as chronic anovulatory syndrome, is the Acupuncture has been shown to improve pregnancy association of hyperandrogenism with chronic rates in women undergoing fertility treatment. Pelvic anovulation in women without specific underly- ultrasound studies have confirmed that acupuncture ing diseases of the adrenal or pituitary glands. treatments can improve pelvic blood flow, and this One of the characteristics is infertility, although may account for its effectiveness. Another possible mechanism for the ability of acupuncture to improve some PCOS patients may randomly ovulate and female fertility is a favorable effect on gonadotropin- are fertile that month. PCOS is a complicated releasing hormone, and therefore on the secretion of disorder that takes a very comprehensive, multi- gonadotropins and improved thickening of the lining factorial approach. Several herbs may have a role. of the uterus (the endometrium). In addition, Flaxseed, nettles, and green tea stimulate sex- acupuncture can also be helpful in improving sperm hormone-binding globulin, which can lower the count, menstrual cycle regulation, ovulation induc- elevated estrogens and androgens. Saw palmetto tion, and decreasing stress and depression. Acupunc- can inhibit 5-alpha reductase, which then inhibits ture, as with many complementary therapies, is best the conversion of testosterone to dihydrotestos- when combined with conventional treatment when terone, and smilax and sanguinaria may be able to indicated. Research studies thus far have had small sample sizes and difficulty in providing proper con- produce a progesterone effect. All of these mech- trol, so the results should not be overemphasized anisms—plus modifying insulin resistance and/or until further studies can be done. Acupuncture by a lowering a hypersecretion of insulin, treating the licensed professional with experience working with underlying endocrine problem, and inducing fertility issues appears to be safe and well tolerated. ovulation—are the keys to treating PCOS.

Additional Therapies Ginseng species are an important considera- Recent research also supports the use of manual tion in infertility due to their ability to enhance soft-tissue therapy for pelvic adhesions, which overall health, vitality, stamina, and endurance. may be implicated in some cases of infertility Siberian ginseng may be able to promote regula- where there has been a history of surgery, infection of reproductive hormones, thereby regulat- tion, inflammation, or trauma. Adhesions form ing the timing of ovulation.47 as a result of the natural healing process but cause Phytoestrogens can be particularly useful in the problems by attaching to internal structures and IVF fertility treatments by improving implanta- affecting normal anatomy, mobility, and function, pregnancy, and delivery rates.48 In addition, tion. The manual therapy can improve tissue phytoestrogens may also reverse the antiestrogen mobility and restore function by breaking the effects of clomiphene citrate, a medication fre- collagen cross-links that have formed during the quently used in the treatment of infertility.49 healing process. The specific technique studied is A plant that many are not familiar with, the Mojzisova method, which combines both tribulus (Tribulus terrestris), has been studied as soft-tissue and osseous manipulation and is usu- an ovarian stimulant. A study of women taking ally performed by specially trained physical tribulus every day has demonstrated the ability of therapists.51 tribulus to normalize ovulation, whereby some of Celiac disease, which may cause deficiencies the women also became pregnant.50 When using in a number of nutrients, requires special consid- the tribulus simultaneously with an ovulation- eration for appropriate diagnosis and manage- induction drug, the results with the combined ment. Gluten avoidance has been shown to use were better than the drug by itself. improve fertility rates in sensitive patients.52–54 INFERTILITY 163

Sample Treatment Plan for plaints, decreased intake of fruits and vegetables, Infertility Due to Lack of Ovulation family history of female fertility disorders, and 57 or Infrequent Ovulation Cycles nicotine and caffeine intake. Therefore, it seems prudent when dealing with a couple who See the Resources section for formulation sources. want to improve their fertility that these factors be addressed promptly, especially in patients who Diet have demonstrated sperm abnormalities. Whole foods diet high in vegetables, whole grains, Supplements nuts and seeds, fruits, low-fat organic dairy Protein: 60 g daily A number of supplements can improve sperm Soy foods: 1 serving daily quality and quantity, including vitamins C, B12, Flaxseed: 2 tbs per day and E; L-arginine; L-carnitine; selenium; zinc; Fish: 2–3 times per week and folic acid.58 Vitamins C and E. Vitamin C and other Lifestyle antioxidants can decrease sperm DNA damage Avoid caffeine, alcohol, and smoking. that can interfere with fertility.59 Vitamin C defi- Seek optimal body weight. ciency has been linked with significant decreases Nutritional Supplements in sperm count, motility, and vitality and with an increase in morphologically abnormal sperm.60 Vitamin E: 400 IU per day Vitamin E and selenium have been shown to Vitamin C: 2,000 mg per day reduce lipid peroxidation and, therefore, improve Zinc: 30 mg per day sperm quality. One study looked at men who had Selenium: 100 mcg per day Prenatal vitamins: 2 per day normal sperm counts, but low rates of fertilization during in vitro fertilization treatments. After one Botanicals month of daily vitamin E supplementation, the Chaste tree (0.6% aucubin extract capsule): 215 mg fertilization rates increased from 19 percent to per day 29 percent, suggesting that the antioxidant effects 61 Rhodiola: 200 mg per day of vitamin E may make the sperm more fertile. The combination of oral vitamin C and vitamin E (one gram of each), administered to male Celiac disease may lead to decreased absorption patients with DNA damage who had previously of fat-soluble vitamins, thereby causing deficien- failed fertility treatments for two months, was cies that may impair male fertility as well. shown to decrease DNA-fragmented sperm, and Topical or vaginal progesterone may help a second fertility treatment led to improvement normalize menstrual cycles, improve implanta- of clinical pregnancy and implantation rates.62 tion rates, and maintain pregnancies in women with history of repeated miscarriages but should Vitamin C only be used under the care of a physician.55, 56 500–3,000 mg 3 times daily

MALE FERTILITY Vitamin E Low sperm counts have been attributed to a 500–1,000 IU per day number of factors, including exposure to pesticides, welding, antibiotic and other medication L-Carnitine. The amino acid L-carnitine is use, a history of mumps, gastrointestinal com- essential for normal functioning of sperm. It seems 164 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE that the higher the levels of L-carnitine in sperm Three main types of medication are used to cells, the higher the sperm count and the more induce ovulation. Clomiphene citrate is the most motile the sperm. L-carnitine given as a supple- common, but aromatase inhibitors (AI) and ment helped to increase the sperm count and the injectable gonadotropins are also used when there number of normal sperm after four months.63 is no response to other treatments. Clomiphene citrate is not only the most commonly used med- L-Carnitine ication, but it is also the most effective, inexpen- 3,000 mg daily sive, and easiest to use and requires less monitoring than the other medications. Clomiphene citrate

B12. A deficiency of B12 leads to reduced is primarily used to induce ovulation in women sperm counts and reduced sperm mobility. In with abnormal ovulation patterns, in women with men who had sperm counts under 20 million/ml, a luteal phase defect (abnormal length of the 1,000 mcg of vitamin B12 per day led to an second half of the cycle), or in women who have increase to 100 million/ml.64 In another study of unexplained infertility. It is also used to assess ovar- men with low sperm counts, 6,000 mcg of vita- ian reserve. It is not generally effective in women min B12 per day showed improvements in the who have amenorrhea due to low estrogenic states sperm counts of 57 percent of them.66 such as hypothalamic amenorrhea. Clomiphene citrate is well tolerated most of CONVENTIONAL the time and does not often have any serious side MEDICINE APPROACH effects. However, because it depletes estrogen It is important to be aware of the latest conven- receptors, side effects include hot flashes, nausea tional treatment options for infertility and to and vomiting, breast discomfort, and headaches. gain insight into when is it timely to seek special- It can also have detrimental effects on cervical ized fertility care. The decision to pursue conven- mucus and the endometrial lining. Severe side tional modes of infertility treatment depends on effects occur in less than 2 percent of women age, the duration and cause of the infertility, the using it. CC can lead to an increase in multiple results of the ovarian-reserve assessment/testing, gestations at a rate of about 6 to 10 percent. finances, other health issues, emotional stamina, Most of these tend to be twins; less than 1 per- and thoughts and feelings about adoption or cent are triplets or higher-order multiples. Past surrogate options. Treatment options include concern about increasing the risk of ovarian intrauterine insemination (IUI) in the natural cancer has faded with recent research showing no menstrual cycle, ovulation induction using increased risk. About 80 percent of women using clomiphene citrate or gonadotropins (with or CC will ovulate, but only 50 percent of those will without IUI), and in vitro fertilization. conceive. Over the course of using CC for six to Intrauterine insemination involves introduc- nine cycles, the rate of pregnancy goes up to ing a concentrated suspension of washed sperm about 70 to 75 percent in those who begin to into the upper uterine cavity. The success of IUI ovulate while on CC. Obesity, elevated androgen varies depending on the cause of infertility. IUI states, and late reproductive age diminish the alone, without ovulation induction medications, response to CC. increases the chance of fertility in a natural cycle Inducing ovulation with gonadotropins is by only 1 to 2 percent in couples with unexplained indicated in women who fail to ovulate with CC, infertility. When clomiphene citrate (CC) is added don’t conceive on CC despite ovulatory cycles, in these couples, the fertility rate increases to 8 to have endometriosis, have unexplained infertility, 10 percent. or are of advanced reproductive age, or if CC is INFERTILITY 165 contraindicated. Gonadotropin therapy involves intercourse without contraception in women 35 injecting either FSH and LH, or FSH alone. years of age or older. At age 35, and especially after FSH stimulates the development of multiple fol- age 40, time becomes of the essence, so it is a good licles and therefore carries a higher risk of multi- idea to seek the advice of a practitioner promptly if ple birth than does CC use. Overstimulation a desired pregnancy is delayed. (hyperstimulation) of the ovaries is also a risk. A practitioner with expertise in fertility can These cycles require close monitoring with serial proceed with a methodical evaluation, treat any estradiol levels and ultrasounds. This therapy is abnormalities that are found, provide education usually combined with IUI. about the reproductive system, offer advice about Aromatase inhibitors (AIs) are best known for your fertility potential, provide counsel regarding the treatment of breast cancer, but they’ve been all options, and provide clinical and emotional used more recently to induce ovulation. By using support. AIs in the follicular phase of the menstrual cycle Infertility in women lends itself to an integra- (the first half, before ovulation), estradiol levels tive approach using conventional therapies along are reduced and the hypothalamus and pituitary with natural therapies. A health-care team of don’t receive their normal feedback message. diverse practitioners—including a reproductive This results in increased secretion of the pituitary endocrinologist, a naturopathic physician, and gonadotropins, which can stimulate ovulation. perhaps an acupuncturist specializing in women’s AIs are usually given at a dose of 2.5 to 5 mg per health and/or a psychotherapist—who are com- day on days 3 to 7 of the cycle. AIs are indicated fortable working collaboratively provides an opti- for women with infrequent or no ovulation and mal environment for patient care. for unexplained infertility. Other drugs that are used on a selective RESOURCES FOR PATIENTS basis and along with other therapies include A number of excellent resources are available to gonadotropin-releasing hormone agonists, couples that are having difficulty conceiving. gonadotropin-releasing hormone antagonists, and human chorionic gonadotropin. RESOLVE. An informational clearinghouse for infertile couples: offers educational materi- SEEING A LICENSED PRIMARY als, a medical call-in hour, help line, physi- HEALTH-CARE PRACTITIONER cian referrals, member-to-member support (N.D., M.D., D.O., N.P., P.A.) system, local chapters and support groups. It’s important to remember that a significant Website: resolve.org/main/national/index number of pregnancies occur in previously infertile .jsp?name=hom. couples without any treatment at all. The main Preserving Fertility pamphlet. Available at reason to see a health-care provider is to pursue a resolve.org/main/national/niaw/presfert thorough investigation of the reasons for your .pdf. infertility. Remember, infertility is defined as a fail- Conquering Infertility by Alice D. Domar, ure to conceive after 12 months of frequent inter- Ph.D. (Penguin, 2004). A mind/body course without contraception in women under 35 guide to enhancing fertility and coping with years of age or failure to conceive after 6 months of infertility. This page intentionally left blank INTERSTITIAL CYSTITIS CHAPTER 11

OVERVIEW then cytology tests should be done. Vaginal and cer- Interstitial cystitis (IC) is a multifactorial syn- vical cultures are done if the practitioner suspects a drome whose diagnosis and cause remain elusive. sexually transmitted disease. Some urology experts, Poorly understood, IC remains a significant especially urogynecologists, may choose to recom- women’s health problem. About 90 percent of IC mend a potassium sensitivity test, which instills patients are female.1 IC typically begins in young potassium into the bladder, to see if the bladder has or middle-aged women. increased in permeability. If the usual pain gets IC is characterized by pelvic and/or perineal worse, the test is considered positive for IC. pain, urinary urgency, urination at night, pain On cystoscopy, bladder ulcers called Hunner’s increased by holding urine (which leads to fre- ulcers and reduced bladder capacity are detected in quency), and a constant urge to urinate. The pain less than 10 percent of individuals with IC. If these of IC can range from a mild burning or discomfort ulcers are seen, this is considered definitive for IC. to severe debilitating pain in the bladder, lower More commonly, IC is characterized by petechial abdomen, perineum, pelvis, vagina, low back, and bladder mucosal hemorrhages, inflammation, and thighs. Menstruation and sexual intercourse aggra- no ulcerations. vate symptoms in as many as 75 percent of IC is more common in patients with irritable women. There are often flare-ups and remissions. bowel syndrome, spastic colon, abdominal When a woman has the classic symptoms of cramping, hysterectomy, rheumatoid arthritis, urinary urgency, frequency (more than eight times fibromyalgia, hay fever, asthma, and allergies to per day), bladder pain, and urinating at night foods and medications. (more than twice); has no evidence of a urinary Drug and surgical interventions have been tract infection; and reports continuous pain or pain used to treat this condition with limited success with menstrual flow, then other pelvic diseases such and potential side effects. Despite continued as endometriosis should be given some considera- research on IC, safe, noninvasive treatment tion. If urinary leakage (incontinence) is present, an options are lacking. evaluation for the cause of the incontinence should Several causes have been proposed for IC, be done. Painful or difficult urination (dysuria) although none have been proven. The contribut- may indicate a urinary tract or vaginal infection or ing factors fall into two main categories: bladder a structural problem in the urinary tract. epithelial permeability and inflammation. The Diagnostic tests for IC are mostly done to rule exact causes are difficult to distinguish and are out other causes. Keeping a daily diary of when you likely to be interrelated in any one patient. feel the need to urinate may be useful. Your health- Because of this, a variety of treatment options may care practitioner may use the O’Leary-Sant Index, be used. These include vitamin A (as palmitate), which measures pain, voiding symptoms, and qual- bioflavonoids (from citrus), L-arginine, quercetin, ity of life. A physical exam can help to rule out N-acetyl glucosamine, corn silk, kava root, and other diseases and pelvic pathology. Urinalysis and Oregon grape root. urine cultures are normal in patients with IC. If Although the cause of IC is unknown, it is blood is visible in the urine under a microscope, important to consider the possible causes to 167

KEY CONCEPTS urine levels of these mast cell mediators. Some IC bladder biopsy samples contain mast cells, but it • IC is a noninfectious chronic condition charac- is known that these cells are not specific to IC terized by pelvic and/or perineal pain, urinary and can also be found in other bladder disorders. urgency, urinary frequency, bladder pain, and • Autoimmune causes. Autoimmune theories urination at night. are based on detecting antinuclear antibodies, • IC is difficult to diagnose with any test; tests increased urinary excretion of eosinophilic are mostly done to rule out other causes of the cationic protein, and the tendency of IC to affect symptoms. women. Other evidence includes IgM in the • There is no proven cause, but bladder permeability and inflammation direct the variety of treat- uroepithelium, immune deposits in vessel walls, ment options available. and T and B cell nodules in patients with IC. • Inflammation. Most biopsies of IC bladders show mild chronic inflammation to significant PREVENTION infiltration of T cells, B cells, plasma cells, neu- trophils, eosinophils, and mast cells. Inflammatory • No specific prevention strategies have been mediators such as interleukin-6 are also increased. established, but minimizing bladder irritants • Infection. The possibility of an infectious seems logical. Classic offenders are coffee, cause has been suggested by the presence of chocolate, alcohol, carbonated drinks, citrus microorganisms embedded in the bladder wall fruits, and tomatoes. of patients with IC and bacterial ribosomal mRNA in tissues of bladder biopsies. understand the therapeutic basis for natural • Reflex sympathetic dystrophy. Bladder treatments. Because IC is a multifactorial syn- sympathetic innervation may be interrupted by drome, it is likely that several of these factors may injury to peripheral nerves from prior UTIs, be true in your case. Short descriptions of possi- hysterectomy, or childbirth. This may lead to an ble factors in IC follow: increased transmission of pain impulses from the bladder and reduced circulation, facilitating • Bladder epithelial permeability. One of inflammatory cell infiltration and leading to the more recent theories for IC is that the bladder ulceration, fibrosis, and atrophy. bladder epithelium is abnormally permeable, allowing components of urine to penetrate and Each of these theories has supportive and irritate the bladder. The most common explana- detractive evidence. As stated earlier, the cause of tion of the permeability is that the bladder IC may vary in different people, or multiple fac- epithelium is deficient in glycoproteins and tors may be in operation. glycosaminoglycans (GAG). Several studies have shown that IC patients had decreased levels of OVERVIEW OF glycoproteins and GAG in both the bladder and ALTERNATIVE TREATMENTS the urine. Therapeutic options, both conventional and • Mast cell activation. This theory proposes alternative, are as varied as the theories on the that bladder mast cells are activated and release cause of IC. Almost no studies have been done to histamine, prostaglandins, leukotrienes, and help practitioners identify which patients would other substances that affect bladder smooth likely respond best to which treatments. Treat- muscle and sensory nerve terminals. Several stud- ment choices are made individually for each ies have shown that IC patients have increased patient, and in most cases, several treatments INTERSTITIAL CYSTITIS 169 should be used concurrently until symptom relief Foods to Avoid occurs. After that, a careful, gradual process of reducing dosages or simplifying the treatment Alcohol Lentils Apples interventions is appropriate. Lima beans Aspartame Limes The most commonly used treatment by both Avocados Mayonnaise Bananas conventional and alternative practitioners is Nuts* Cantaloupes Onions Carbonated drinks Oranges Cheese** dietary changes. Patients with IC will often Peaches Chicken livers Pickled herring report that certain foods increase their symp- Chilies/spicy foods Pineapple Chocolate toms. Classic offenders are coffee, chocolate, Plums Citrus fruits Prunes alcohol, carbonated drinks, citrus fruits, and Coffee Raisins Corned beef tomatoes. Acid or potassium content is often sus- Rye bread Cranberries Saccharine pected as the mechanism. Responses to these Grapefruit Sour cream Grapes foods is hugely variable, and there is no consis- Soy sauce Tomatoes Guava tent diet that works for all IC patients. Strawberries Vinegar Lemons The following natural treatment plan may Tea Yogurt seem complex, but consider that the average *Except almonds, peanuts, and pine nuts patient with IC has symptoms three to four years **Except American, cottage, ricotta, and cream cheese prior to diagnosis. In my experience with treating Source: K. Whitmore2 IC patients over a one-year period with this protocol, significant improvements are usually seen within the first three months. Continued improve- Glycosaminoglycans and Bladder Epithe- ment (75 percent better or greater) is seen after six lial Permeability. The bladder epithelial perme- months while maintaining the same doses. Within ability hypothesis is a compelling and active area the second six months and beyond, gradual reduc- of research. This theory asserts that the bladder tion of dosage can be done on an individual basis. epithelium is abnormally permeable in IC, so I have found that IC patients are so thrilled with urine components penetrate and irritate the their improvement that they hesitate to reduce the bladder. Several lines of indirect evidence sup- supplements and do so carefully. With this natural port this hypothesis: medicine approach, IC patients can proceed with optimism and be reassured that there is likely help 1. Some IC patients have increased pain after for their very chronic condition. eating foods such as citrus fruits and tomatoes that are acidic and high in potassium. Nutrition 2. Some IC patients have pain when potassium Some foods and beverages seem to exacerbate chloride is instilled into the bladder, while symptoms for many women. Although not fully most healthy controls do not.3, 4 investigated, about 53 percent of patients with 3. Taking fluorescein orally yields higher blood IC associate a flare-up of their symptoms with fluorescein levels in IC patients than in con- dietary influences, especially citrus fruits and trols, attributed to increased fluorescein other acidic foods and beverages.2 Many women reabsorption across the bladder wall.5 find it helpful to avoid certain foods. If you avoid 4. In one of the only direct bladder permeability these foods for two weeks and your symptoms studies, radio-labeled diethylenetriamine pen- improve, this is good news for the bladder. taacetic acid (DTPA) was instilled in the blad- Making these dietary changes is a good self-help der and blood samples showed that IC strategy in managing this condition. patients had higher blood levels of DTPA than 170 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE healthy controls, although the small study of cases.22, 27, 28 Vitamin A also plays an essential role 10 IC patients and 9 controls was not able to in maintaining and protecting epithelial integrity demonstrate statistical significance.6 and mucosal surfaces and their secretions, 5. Glycosaminoglycans (GAGs) normally line including those of the bladder.26, 29 the epithelium and are thought to con- Vitamin A may also be of benefit in the man- tribute to the permeability barrier. Several agement of IC as it is essential to proper immune studies have shown that IC patients have function30, 31 and stimulates epithelial repair and decreased levels of GAGs in both the blad- growth.30, 32, 33 Vitamin A increases immune der and urine.7–12 response mainly due to its effect on T-helper cells.34 In addition, evidence supports the theory that GAG supplementation is used to treat IC Vitamin A may also attend to the GAG repair.35 based on the rationale that the GAG may supplement or replace the deficient epithelial GAGs. Vitamin A The GAG studies with published trials include 5,000 IU per day PPS (pentosan polysulfate sodium) Elmiron,13–19 heparin,20 and hyaluronic acid (Cystostat).21 These L-Arginine and Inflammation. Nitric oxide studies showed treatment efficacy over placebo (NO) may play an important role in the patho- for each of these treatments. No studies have genesis of IC in that it activates the cyclooxyge- been published on over-the-counter preparations nase (COX) enzymes, leading to production of of chondroitin sulfates and glucosamine prepara- proinflammatory prostaglandins that exacerbate tions; however, a link has been established between the inflammatory response.36 NO also plays a chondroitin and IC.22 A GAG in the form of role in IC in the regulation of smooth muscle N-acetyl glucosamine or glucosamine sulfate can relaxation, immunological responses, and blad- be used as part of a multifactorial approach to der neurotransmission and blood flow.37, 38 repair the bladder epithelium. Luminal nitric oxide is elevated in IC, correspon- Glucosamine Sulfate ding to symptom severity, and can be used as a marker for mucosal inflammation in such 750 mg twice daily cases.39–41 Nutrients such as arginine (a precursor N-Acetyl Glucosamine to NO synthase) and antioxidants like vitamin A help to elevate urinary nitric oxide levels and 500 mg twice daily may play an important role in the management of interstitial cystitis.36, 40, 42, 43 Oral supplemen- Vitamin A. Vitamin A has been shown to tation with arginine changes urine levels of inhibit mast cell growth and proliferation, and NO,44 and three studies demonstrated symptom deficiency may aggravate the clinical manifesta- improvement over placebo.40, 45, 46 Another tions of inflammatory reactions due to mastocy- study reported that a six-month course of oral 23–26 tosis. Vitamin A also helps to elevate urinary L-arginine increased nitric oxide–related enzymes nitric oxide levels. (See the section on L-arginine and metabolites in the urine of patients with IC. and inflammation for more information on the This result was correlated with a decrease in IC role of nitric oxide in IC.) In addition, vitamin A symptoms.37 deficiency has been linked to a higher level of tissue damage due to inflammation, both as an L-Arginine etiological and aggravating factor, and supple- 500 mg twice daily mentation may decrease inflammation in these INTERSTITIAL CYSTITIS 171 Calcium Glycerophosphate (Prelief). Cal- has been reported to be aggravated by stress49, 50 cium glycerophosphate has been shown to help and associated with panic disorder,51 two condi- reduce bladder pain and urinary urgency in IC tions that may be ameliorated by kava.52 patients when it is used with acidic foods and beverages. Calcium glycerophosphate, sold under Kava Extract the trade name Prelief, is a food-grade mineral, Kavalactones: 70 mg 3 times daily available in granulated form. When added to acidic foods and beverages, it removes the acid Quercetin. Another proinflammatory culprit and helps to reduce bladder pain and urinary in IC is the mast cell, an immune modulatory cell urgency associated with these foods. that secretes its damaging contents in a process However, from a naturopathic medicine called degranulation in response to factors such as standpoint, this should be done sparingly. This is stress and toxins. Mast cells can directly damage like taking a heartburn medicine but still eating the bladder mucosa, leading to bladder inflamma- spicy Polish sausages. The food is still aggravating tion. Some researchers speculate that treatment you, you are just temporarily protected from the of IC must include mast cell stabilizers.45, 53, 54 immediate bodily response. The fact that these Quercetin and other bioflavonoids may be helpful foods are causing symptoms means that they are in mast cell stabilization, inhibiting degranulation causing irritation and inflammation. and the release of damaging mediators.55–59 Quercetin and other bioflavonoids also con- Calcium Glycerophosphate (Prelief) tribute in other ways to mitigate the inflammatory 2 packets 3 times daily with meals process. Quercetin may be beneficial to connective Add 2 packets of powder to a serving of acidic food tissue by limiting inflammation and associated or beverage. (It will not dissolve in alcoholic drinks.) tissue degradation, improving circulation, and Also take 2 packets at bedtime if desired. You can use promoting a strong collagen matrix.60, 61 Quercetin more if needed. also plays a part in modulation of the inflammatory response, at least in part by modulating pros- 62 Botanicals taglandin synthesis and cytokine production. Kava (Kava Methysticum). A permeable or Quercetin “leaky” bladder may allow chronic diffusion of 500–1,000 mg twice daily urinary potassium, leading to sensory symptoms and tissue damage. This appears to be a major Bioflavonoids factor in the pathogenesis of interstitial cystitis.47 500–1,000 mg twice daily Kava is known historically as a urinary antispasmodic, and recent reports support its use as a Oregon Grape Root (Berberis Aquifolium). smooth muscle relaxer, likely through inhibition Oregon grape root, a berberine-containing of calcium channels.48 In addition, kava blocks botanical, is an immune modulator, specifically sodium and calcium ion channels in neural tissue in mucosal membranes, and, like vitamin A, may and thereby alters potassium potentials.47 Abnor- be effective in treating allergic and inflammatory mally elevated potassium levels may induce conditions like IC due to its effect on T-helper heightened nervous and electrical sensitivity and cells.63, 64 In addition, evidence suggests that increase mucosal sensitivity in patients with IC. berberine may also decrease inflammation by Kava may help to reduce this effect by altering inhibiting arachidonic acid metabolism in the potassium channel activity. In addition, IC endothelial cells.65 172 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plan

See the Resources section for formulation sources. If the preceding list is too strict, avoid the following: Nutrition Tomatoes Coffee Avoid the following foods: Chocolate Alcohol Lentils Apples Alcohol Lima beans Aspartame Limes Avocados Mayonnaise Bananas Supplements Nuts* Cantaloupes Onions N-acetyl glucosamine: 500 mg 3 times daily; or Carbonated drinks Oranges Cheese** glucosamine sulfate: 750 mg 2 times daily Peaches Chicken livers Pickled herring L-arginine: 500 mg 3 times daily Chilies/spicy foods Pineapple Chocolate Quercetin: 500–1,000 mg twice daily Plums Citrus fruits Prunes Vitamin C (buffered, noncitrus source): Coffee Raisins Corned beef 1,000–2,000 mg daily Rye bread Cranberries Saccharine Corn silk: 300 mg 3 times daily Grapefruit Sour cream Grapes Kava extract: 1 capsule 3 times daily Soy sauce Tomatoes Guava Vitamin A: 5,000 IU daily Strawberries Vinegar Lemons Tea Yogurt

*Except almonds, peanuts, and pine nuts **Except American, cottage, ricotta, and cream cheese

Oregon Grape Root slippery elm (Ulmus fulva), marshmallow (Althea officinalis), oat seed (Avena sativa), and comfrey 500 mg per day (Symphytum officinale). It can be crucial to use herbs that provide Corn Silk (Zea Mays). Another botanical, pain relief while the other therapies attempt to corn silk, has been found to be a potent inhibitor repair the lining of the bladder. Common choices of proinflammatory cytokines as well.66 Corn silk would be kava (Piper methysticum), crampbark also has historical evidence for its application in a (Viburnum opulus), wild yam (Dioscorea villosa), variety of urinary conditions and may be helpful in and valerian (Valeriana officinalis). the treatment of IC due to its demulcent effects.67 CONVENTIONAL Corn Silk MEDICINE APPROACH 300 mg 3 times daily The most likely conventional IC expert will be the urogynecologist. Dietary modifications are Additional Botanicals. Other botanicals standard recommendations. A diet low in acidic might be considered for their anti-inflammatory foods and avoidance of beverages such as coffee, properties, such as licorice (Glycerrhiza glabra) tea, and carbonated and/or alcoholic drinks can and feverfew (Tanacetum parthenium). Botanicals be helpful in reducing symptoms. The practitioner with demulcent properties allow for mucosal also will often recommend Prelief, a nutritional protection and soothing. These include licorice, supplement discussed earlier in this chapter. INTERSTITIAL CYSTITIS 173 The only oral medication approved for IC SEEING A LICENSED PRIMARY by the FDA is pentosan polysulfate sodium HEALTH-CARE PRACTITIONER (PPS, Elmiron). Other oral medications include (N.D., M.D., D.O., N.P., P.A.) amitriptyline, imipramine (used for pain), hydrox- The symptoms of IC can range in severity from yzine, antispasmodics, muscle relaxants, and mild and intermittent to chronic and very severe. numerous pain medications. PPS is the most stud- The main reason to see a licensed health-care ied conventional medicine for IC. Unfortunately, practitioner is to diagnose the cause of the symp- it only shows about a 30 percent efficacy rate. toms. That is easier said than done, and often Medicine can also be instilled into the bladder. IC symptoms are misdiagnosed as a urinary tract Until PPS, DMSO was the only approved med- infection, endometriosis, a sexually transmitted ication for IC. The medication is placed directly infection, or a vaginal infection. On the other into the bladder through a catheter weekly or hand, sometimes these, rather than IC, are the biweekly. Another intravesicular (within the blad- cause of the symptoms. Rarely, bladder cancer der) therapy is Bacillus Calmette-Guerin (BCG). may be the cause if blood in the urine is present. The mechanism is unknown, but the solution The diagnosis of IC is based upon the pre- may modulate the immune response in the blad- senting signs and symptoms. A good medical der. Intravesical heparin, hyaluronic acid, and history, physical exam, and tests are done to intravesical PPS are other options. determine the cause of the symptoms. A cys- Experimental therapies are being explored, toscopy or intravesical potassium sensitivity test including electrical nerve stimulation to activate may be recommended. Once the diagnosis of IC the inhibitory circuits and decrease the sensation has been made, either with certainty or as a pos- of pain, intravesical injection of botulinium toxin, sibility, treatment can proceed. IC is a condition gene therapy, and nerve growth-factor inhibitors. that lends itself well to alternative therapies—not Surgical interventions are currently considered a only because they typically work as well or better last resort. These include surgical removal of visi- than the conventional options, but also because ble ulcers, laser denervation, or removing a part of there is no medical danger if conventional treat- the colon and attaching it to the bladder to ment options are declined. Whether alternative increase bladder capacity. These surgical proce- or conventional medicine or an integration of the dures are still associated with a high rate of relapse, two is used, symptom improvement is the ulti- persistent pain, permanent or intermittent need mate measure of success. for catheterization, and additional surgeries. This page intentionally left blank MENOPAUSE CHAPTER 12

OVERVIEW no pregnancy, toxic chemical exposures, treat- There are currently 43 million American women ment of childhood cancers with chemotherapy who are postmenopausal, and their numbers are and radiation, epilepsy, and cognitive scores in expected to increase to 60 million by the year childhood (the higher the score, the later the 2020. By the year 2015, nearly 50 percent of the menopause). There appears to be no link women in the United States will be menopausal. between age of menopause and history of hor- This rapid expansion in the menopausal popula- monal contraception, socioeconomic or marital tion is related both to an increase in longevity (to status, race, or age of first menstrual cycle. an average life expectancy of approximately 84 Premenopause refers to the period of life from years) and to the maturation of the baby boomer the first menstrual period up to the final men- generation into the menopausal age group. strual period, but this term is often used incor- Understanding the terminology and defini- rectly. To avoid confusion, it’s probably best to tions can be helpful in understanding the natural not even use this term. Perimenopause is the biological process of aging. The term menopause period immediately before menopause. Peri- is derived from meno (month, menses) plus pausis menopause starts with changes in the menstrual (pause, cessation); in other words, it is a pause in cycle and ends 12 months after the final men- menstruation. A spontaneous or natural meno- strual period. In the early stage of peri- pause is the permanent cessation of menstruation menopause, the menstrual cycle length begins to following the loss of ovarian activity and is vary by as much as 7 days from the normal cycle. strictly defined as the point after 12 consecutive So, rather than having a 28-day cycle, maybe the months of no menses following the final men- cycle begins to be a 20- to 21-day cycle from day strual period. The average age of menopause has 1 of the menses to the next day 1. In the later been estimated to be between 50 and 52. In the stage of perimenopause, we start to see two or Massachusetts Women’s Health Study, the largest more missed menses in a year, and the cycle and most comprehensive study of middle-aged being 60 days or more. Some people call peri- women, the median age for menopause was 51.3 menopause the menopause transition or the years.1 The range is generally from age 40 to 58 climacteric. The average age of onset of the peri- years of age, although some women reach meno- menopause or menopause transition is age 47.5. pause prematurely in their thirties and a few as For most women, this transition lasts about four late as in their sixties. Despite our aging popula- years. Only a very small number of women stop tion and greater life expectancy, the age of meno- having their menses abruptly. Most of us experi- pause has not changed in the last few centuries. ence the irregular pattern of bleeding. Three important factors influence the age of Postmenopause begins after the time of the menopause: current smoking, familial factors, final menstrual period, whether it was a natural and genetic factors involving the estrogen recep- or medically induced menopause, and continues tors. Other influences may also affect the timing until the end of life. It is defined as stage ϩ1 of menopause: increased body mass index (being (early postmenopause) and stage ϩ2 (late post- overweight), more than one pregnancy, history of menopause). The early postmenopause stage is 175

Copyright © 2008 by Tori Hudson. Click here for terms of use. 176 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE five years, which includes the first year since the The term induced menopause is used when final menstrual period and the next four years. the menses ceases after surgical removal of both Menopause should be regarded as a normal, ovaries. This is referred to as ovariectomy or natural event of aging except when it is brought bilateral oophorectomy and may or may not about by surgery, medications, or radiation. As we include the removal of the uterus (hysterectomy). discuss problems that can be associated with meno- A hysterectomy is actually only the surgical pause for some women, it can quickly be viewed as removal of the uterus. These surgeries can be a disease process and a sign of pending fragility, dis- done separately or together. The incidence of ability, and even death. It is important to appreciate hysterectomy and oophorectomy in the United that menopause is or can be the beginning of a States is substantial. Women who undergo a new phase of life, with fewer family obligations, bilateral oophorectomy have an increased risk of new options, new learning opportunities, and new developing osteoporosis, coronary artery disease, adventures. With a proper understanding of peri- and/or atrophy of the genital area at a younger menopause and menopause, and an adequately age. Probably the most dramatic entry into informed and respectful health-care practitioner, menopause is to have both ovaries removed. the majority of menopausal women can be healthy From 1994 through 1999, an estimated and happy and use this time period as an opportu- 3,525,237 hysterectomies were performed among nity to foster a preventive health-care plan and U.S. women aged 15 years or older.4 During lifestyle as well as an opportunity to assess their life. this time, the overall hysterectomy rate for U.S. Women can enter menopause by several dif- women was 5.5 per 1,000 women. The hysterec- ferent routes and pass through more than one tomy rates for women living in the South (6.5 per phase. Premature menopause (also called prema- 1,000) is significantly higher than those in the ture ovarian failure, or POF) is a combination of Northeast (4.3) or West (4.8). For women living secondary amenorrhea, menopausal symptoms, in the Midwest, it was 5.4 per 1,000. About 55 and a persistent elevation in follicle-stimulating percent of women who had a hysterectomy had a hormone (FSH) levels greater than 20 IU/L bilateral oophorectomy (both ovaries removed). before 40 years of age. One in 100 women Uterine fibroids, endometriosis, and prolapse of between the ages of 15 and 40 will spontaneously the uterus are the most frequent reasons for these develop premature menopause.2 In two-thirds of surgeries in women aged 15 years and older. With cases, no apparent cause for the premature ovar- new laparoscopic-assisted hysterectomies, ovaries ian failure will be found.3 These cases are called are removed more easily (and this is unfortunate if idiopathic. In one-third of cases, causes of prema- the ovaries are healthy) and removal of the ovaries ture menopause include metabolic and systemic has increased significantly, from 20.4 percent in disease, chromosome abnormalities, immunologic 1994 to 42.5 percent in 1999. disorders, infections, lack of blood supply to the When the ovaries are removed, the onset of ovaries, cigarette smoking, ovariectomy or bilateral menopause is immediate. The sudden onset of oophorectomy (both ovaries removed), pelvic irra- hot flashes, mood changes, sleep disturbances, diation, and chemotherapy. and loss of sexual arousal is accompanied by a Some women may experience a temporary slower onset of fatigue, headaches, dry skin, bone menopause in which normal ovarian function is and joint pain, loss of vaginal lubrication, and interrupted temporarily and the menses stops (for painful vaginal sex. This overwhelming barrage 12 months or more). Some medications that are of symptoms results from the sudden drop in used to treat conditions such as endometriosis or hormone production—estrogen, progesterone, certain cancers may cause this. and testosterone. MENOPAUSE 177 Women who have had a hysterectomy but words, the ovaries and the adrenal glands are still retain one or both ovaries will go through responsible for producing all of a woman’s testos- menopause more naturally most of the time, terone, either directly or indirectly. The adrenal although sometimes earlier than they would have glands also produce androstenedione. Andro- otherwise. Without the uterus and the monthly stenedione is converted to estrogen (estrone) in bleeding, it may be harder to know when meno- the body fat and to a lesser degree in some other pause arrives. All the typical symptoms can tissues and organs including the muscle and skin. occur, though. If you are fortunate to not have For some women, this source of estrogen is ade- any of the overt menopausal symptoms, you can quate to counter some of the menopausal symp- estimate that you’ll have gone through meno- toms, and they have an easier time. pause somewhere between ages 48 and 53. The Although this adrenal source of hormonal sup- FSH blood test may be used to determine meno- port is a blessing, the adrenal glands produce their pausal status. maximal amount of androgens in the presence of Other methods of inducing menopause fully functioning ovaries. The function of the include chemotherapy, medications, or pelvic cortex of the adrenal glands is linked to the func- radiation therapy, which causes the ablation of tions of the ovaries due to their shared original ovarian function. Women who have been treated group of cells in the developing embryo. If you with chemotherapy may go into menopause either don’t have your ovaries, then the adrenal glands temporarily or permanently. About 30 percent of will not produce their potential amount of andro- these women will have a return of their menses gens. In natural menopause, the ovaries continue sometime within the first year. Irradiation of the producing androgens (typically referred to as male pelvic or abdominal area can also induce meno- hormones) that help maintain the potential for pause. Tamoxifen, another cancer drug used sexual arousal.5 Several studies have shown that mostly for women who have breast cancer, can surgically induced menopausal women have lower either induce menopause in premenopausal sexual desires and subjective arousal compared to women or increase menopause symptoms in post- women who have retained their ovaries; treating menopausal women. these post-oophorectomy women with estrogen Several drugs can induce menopause that is and androgens results in a greater sexual response reversible once the drugs are discontinued. These than treatment with estrogen alone.6 Surgical include Lupron and Synarel, which are usually menopause may also have a psychological impact given to suppress menses in the case of endome- on women. Not only is this related to the sudden triosis and to shrink fibroids before surgery. change in hormone status, but the severity of Menopausal symptoms tend to be not as severe as depression that may develop can often be corre- in surgical menopause but worse than natural lated to body image, sexual identity, cultural back- physiologic menopause. ground, and family issues.7 Fortunately, all of the sex hormones are not The natural transition from the reproductive lost with menopause or even with surgical meno- years to the postmenopausal years is not necessar- pause. For example, about 50 percent of our ily a smooth one, even though it is a normal testosterone comes from the ovaries and adrenal process of aging. Though not a disease, there can glands; the other 50 percent comes from many be health problems associated with menopause. different parts of the body, including the liver, the For many women, symptoms of these hormonal skin, and the brain. These tissues manufacture changes occur intermittently for a number of testosterone from precursor hormones that are years. Dr. Susan Love calls this period “puberty made in the ovaries and the adrenals. In other in reverse.” Just as the hormonal highs and lows 178 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE of puberty brought sleepiness, acne, mood uterine lining, and there is not enough tissue swings, and unpredictable menses, this end of to produce a menses. the spectrum with its own hormonal fluctuations • The specific reason why menopause occurs may bring hot flashes, insomnia, mood swings, is the ultimate loss of follicles in the ovaries. acne, poor concentration and memory, and This leads to the loss of progesterone pro- unpredictable menses again. duction and declining estrogen influence. No two women’s menopause transition is alike. This coincides with an increase in FSH and Many women begin to experience an array of LH (luteinizing hormone). physical, mental, and emotional symptoms long The symptoms of decreased hormone levels before they meet the definition of menopause. and perimenopause are varied, unpredictable, During perimenopause, several biological and often go unrecognized as perimenopausal changes occur: symptoms. The signs and symptoms of peri- • The number of ovarian eggs (oocytes) menopause can include menstrual irregularities, reaches very low levels hot flashes, vaginal dryness and thinning, skin • The menstrual cycle begins to vary, usually changes, fatigue, decreased libido, mood swings, shortening from one menses to the next. depression, changes in memory and cognition, • The levels of FSH in the body increase. This sleep disturbance, hair loss on the head, hair rise is one of the first signs of an aging repro- growth and acne on the face, heart palpitations, ductive system. Health-care practitioners often nausea, headaches, urinary tract infections, joint measure FSH levels to determine if one’s pains, and the beginning stages of osteoporosis symptoms are related to menopause. There are and heart disease. two problems with this test, however: varying patterns of FSH may occur even in the same Menopausal Symptoms woman, and the FSH is often normal even in The transition to menopause usually begins a perimenopausal woman. sometime in a woman’s 40s. Symptoms tend to • Ovarian production of estradiol, proges- begin and increase over a span of months and can terone, and testosterone decreases with the last about four to seven years. Seventy-five to 90 onset of true menopause. percent of women will have transient symptoms • Although hormone levels will eventually that resolve within this time period and stop decrease, lower estrogen levels aren’t experi- without any treatment. Maybe 10 to 25 percent enced until six months to one year before will have symptoms that persist. Vaginal dryness true menopause. It’s only in the last year of and thinning and problems related to this tend perimenopause that estrogen levels begin to not to be transient and in fact tend to get worse decrease. Near menopause, estrogen levels with time. rise very high and then drop very rapidly. The changes associated with menopause can Declining progesterone levels precede be mild, moderate, or severe. Some women may declining estrogen levels. Some of the peri- have no significant menopausal symptoms, and menopause symptoms may in fact be due to others will have symptoms that are progressive lowered progesterone levels or a relative and problematic for many years. The most change in the relationship of estrogen to common prevalent symptoms are vasomotor progesterone. symptoms (hot flashes and night sweats), sleep • Eventually, the lower levels of estrogen are disturbances, and vaginal dryness. A comprehen- no longer adequate to cause a buildup of the sive list of symptoms includes the following: MENOPAUSE 179 • Decline in fertility (perimenopause) ronments, alcohol, and caffeine are the most • Irregular bleeding (perimenopause) common triggers. Hot flashes are sudden, tran- • Vasomotor symptoms sient episodes ranging from just feeling warm or • Sleep disturbances overheated to intense heat and perspiration. • Urinary problems (urinary leakage, urinary Women tend to describe a wavelike sensation over urgency, urinary frequency, infection, pelvic the body, particularly of the upper torso, face, and relaxation) head. If the hot flashes occur at night and are asso- • Vulvovaginal changes (dryness, irritation, ciated with what can be drenching perspiration, discomfort during sexual activity, discharge, they are called night sweats. itching, inflammation, infection) The number of women in the United States • Headaches who are affected by hot flashes is remarkable. • Mood swings About 75 percent of women will experience hot • Depression and anxiety flashes, and 15 percent are severely affected.9 The • Memory changes occurrence of hot flashes is highest in the first • Sexual function effects two years postmenopause, although information • Body aches is scanty on the total time over which hot flashes • Skin, mouth, eye dryness are experienced. Women with surgically induced • Fatigue menopause often report particularly persistent, more intense, and more frequent hot flashes. It More rare symptoms might include voice impair- has been determined by one large study that for ment, shoulder problems, and sometimes strange, most women hot flashes last about 2 years, rare, and peculiar symptoms that don’t seem to be although some women experience them for 5 to related to anything else but are due to hormonal 10 years.9 As many as 15 percent of women may changes. These might include numbness and still report hot flashes 16 years after menopause. tingling sensations, dizziness, and nerve pain, to Hot flash frequency is particularly variable and name a few. ranges anywhere from several episodes in a year Hot Flashes, Night Sweats. Hot flashes and to every hour throughout each day. night sweats in perimenopausal and menopausal Not all cultures report the same incidence of women are often referred to clinically as vasomo- hot flashes or other menopausal symptoms. For tor symptoms. The traditional vasomotor symp- example, Japanese and Indonesian women report toms, commonly referred to as hot flashes and far fewer hot flashes than do women from Western reported by about 85 percent of menopausal societies.10 Mayan women in the Yucatan do not Western women, are related to the decline in ovar- report any symptoms at menopause other than ian function.8 Hot flashes are the most common menstrual cycle irregularity.11 Many researchers symptom associated with the menopausal period have attributed these differences to biological, and second to irregular menses during the peri- psychological, social, and cultural factors. menopausal period. We still do not understand The clearest explanation for hot flashes is that the physiology of hot flashes, the mechanism of they appear to be the body’s response to a sudden lowered estrogen levels and hot flashes, the average but transient downward resetting of the body’s age of onset, triggers, duration, frequency, or why thermostat, which is located in the hypothala- they are prominent in some cultures and absent in mus.12 This temporary alteration of the set point others. A few triggers may affect the frequency would cause the sensation of intense heat and and/or severity of hot flashes in some women. flushing. What we don’t know is what triggers Stress, hot or spicy foods, hot drinks, warm envi- this event. A logical correlation between low 180 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE estrogen levels and hot flashes exists. Estrogen bleeding needs to be evaluated by a licensed levels have been found to be lower in premeno- health-care practitioner. Fortunately, in the vast pausal women with hot flashes than in those majority of cases there is nothing serious, and the without hot flashes.13 However, not all studies solutions are straightforward and effective. At are consistent, and some women never have hot times, the bleeding can become too chaotic, and, flashes, while others have persistent ones, and of course, there are other causes of abnormal yet others have them only sporadically. Prior to bleeding other than perimenopause such as a puberty, girls have low estrogen levels, but not uterine polyp, hypothyroid, uterine fibroids, and hot flashes. Also, hot flashes are reported during endometriosis, to name a few. Chapter 1, on pregnancy, when the estrogen level is high. Some abnormal bleeding, is an important chapter to researchers believe that hot flashes are due to an read to help understand these distinctions. imbalance in beta-endorphins and other opiates Normal menstrual blood loss is approximately 40 in the brain that in turn may influence the tem- mL. Blood loss greater than 80 mL is considered perature regulation center.14 Estrogen and prog- heavy, especially if there are blood clots or if you esterone may alter the activity of these naturally become anemic. If the bleeding is prolonged, occurring opiates, and it is possible that lower longer than seven days, and/or the cycle is now levels of estrogen and progesterone cause a with- shorter than 21 days, and/or bleeding or spotting drawal of opioids, triggering a hot flash. occurs between menses or after sexual activity, What may seem like a hot flash due to peri- then these symptoms require investigation by a menopause or menopause may in rare cases be health-care practitioner and effective treatments. caused by another condition such as thyroid Although perimenopausal women are at risk disease, epilepsy, infection, insulin-producing for endometrial hyperplasia (a thickening of the tumors, pheochromocytoma, carcinoid syn- lining of the uterus), the majority with abnormal dromes, leukemia, pancreatic tumors, autoim- perimenopausal bleeding do not have hyperplasia. mune disorders, or allergic disorders. In postmenopausal women who bleed and who Irregular Uterine Bleeding. In the transition are not taking HRT, the bleeding is generally due phase of menopause, changes in the amount of to atrophy (thinning of the lining of the uterus). flow and the frequency of the flow are the main Any uterine bleeding that occurs after the actual signs of perimenopause. These changes and irregu- menopause (12 consecutive months since the last larities in the cycle are due to decreased frequency menstrual period) should be reported to your of ovulation and unpredictable fluctuating levels of practitioner. In women on HRT, abnormal bleed- the ovarian hormones, estrogen and progesterone. ing can be due to too little estrogen, too much The menses can become lighter or heavier, bleed- estrogen, too little progesterone, or too much ing for fewer days, even less than two, or more days progesterone. It is important to see your licensed than your usual length. The cycles can become health-care practitioner in order to determine the shorter by at least a week, as well as longer than the correct hormonal solution and also to determine if pattern you have become accustomed to. At some further testing with a pelvic ultrasound and/or point, most women will just skip one or more uterine biopsy is necessary. These issues are dis- menstrual cycles. Basically, changes can occur any cussed further in Chapter 1. which way, and each woman will have to identify Fertility Changes. The decline in fertility what is an irregular bleeding pattern for her. during perimenopause is related to several factors, Even though these hormonal changes are including that word we don’t want to hear, “aging” normal, the woman with abnormal uterine of the ovaries and the uterus. Other specific MENOPAUSE 181 changes are going on as well: rising levels of follicle- awakenings are also signs of depression and anx- stimulating hormone (FSH) and changes in the iety. These emotional changes are also associated feedback mechanism that regulates the menstrual with menopause for some women. cycle. This increase in FSH is a reflection of the In addition to the direct influence of hor- lower number of follicles within the ovaries and the monal changes and hot flashes on insomnia, this less viable quality of the follicles. Fewer follicles, time in a woman’s life, quaintly called midlife, poor quality, and irregular or lack of ovulation con- can also be a time of significant life changes tribute to this decline in fertility. The blood level of and challenges. Job stress, relationship loss, child FSH on day 3 of the menstrual cycle is a good indi- care, parent care, or medical problems can alter cator of infertility related to aging ovaries. brain chemistry and sleep patterns. Insomnia can On the other hand, some women mistakenly also be a result of sleep-related disordered breath- think that if they are in their mid- to late 40s or ing due to snoring or apnea, chronic pain such as early 50s, having some perimenopause symptoms, arthritis or fibromyalgia, thyroid conditions, rest- and haven’t menstruated for a few months, they less leg syndrome, asthma, or medications. cannot become pregnant. On the contrary, Mood Swings, Depression, and Anxiety. unplanned pregnancies are common during this The psychological conditions associated with time period. If pregnancy is not desired, contracep- menopause have been a source of conflicting tion must be used until you have not had a menses scientific data and controversy. Even though the for 12 consecutive months, or until levels of FSH relationship between menopause and depression are consistently above 30 IU/L. has been extensively studied, the results have Insomnia/Sleep Disturbances. Sleep prob- been inconsistent. Some studies have shown lems are especially common in perimenopausal more frequent depressive moods among peri- women, increasing after age 40 and plateauing by and postmenopausal women compared to pre- age 50. Sleep problems also contribute to fatigue, menopausal women, while other studies have poor concentration, low motivation, irritability, not. It may be that the psychosocial and cultural depression, and anxiety. Insomnia comes in many factors that influence variations in moods affect sizes and shapes, including difficulty falling asleep, women more at the time of menopause.15 difficulty staying asleep, restless sleep, and waking The Massachusetts Women’s Health Study early and not being able to go back to sleep. These concluded that women who were depressed pre- problems may last only a few days or a few weeks menopausally had higher rates of depression in or become chronic with persistent problems more perimenopause; for the women who were not than three nights per week. The longer or more depressed during the premenopause years, the frequent the insomnia, the more it leads to poor rate of depression was slightly increased during coping skills, fatigue, and depression. perimenopause and was highest for women who A primary problem for many women with remained perimenopausal for at least 27 months.16 hot flashes and nighttime sweats is sleep disrup- Researchers observed that the rate of depression tion. Some women are awakened during sleep begins to decrease as women move from peri- to due to a night sweat, but sleep disturbances are postmenopause and is lowest for those women not always a result of hot flashes, and not all hot who have been postmenopausal for at least 27 flashes disrupt sleep. Most nighttime hot flashes months. These results show that depression is are associated with waking up, but almost half moderately associated with perimenopause and the time a waking episode is not associated with that the depression is transient and will decline hot flashes. Sleep disturbances and early morning about two years after menopause. 182 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE A 1997 study was able to demonstrate that matic after childbirth or after bilateral oophorec- depression and anxiety were higher in post- than tomy (both ovaries being removed). Short-term in perimenopausal women,17 although not all memory impairment is also a common cognitive studies confirm this. This study also showed that change in women with natural menopause. Diffi- depression and anxiety scores were reduced to culty concentrating, difficulty with previously values below those of perimenopausal women simple technical tasks, decrease in memory, and when the women took hormone replacement lack of mental clarity are typical states that can therapy (HRT). Women who take estrogen alone then be worsened by difficulty sleeping and sleep seem to do best mood-wise, compared to women interruptions. who take estrogen plus synthetic progestogens, An evaluation of significant cognitive impair- called progestins.18 ment may be necessary to assess for a thyroid Mood changes may not be as prominent as imbalance, medication problems, overuse of seda- depression or anxiety. Many women are plagued tives or alcohol, and dementia. Alzheimer’s disease by irritability, melancholy, weepiness, short (AD) is the most common cause of dementia and temper, feeling overwhelmed, and a lower toler- affects 1.5 to 3 times more women than men.19 ance of stressors. Up to 10 percent of peri- For women on hormone therapy, adjustments in menopausal women experience mood changes. the dose may improve mental function. Some of these mood changes are due to sleep Vaginal Dryness and Thinning. Vaginal deprivation with or without night sweats. In dryness, vaginal thinning, and what is called these circumstances, successful treatment for the atrophy are very common problems for meno- moods requires treatment of the night sweats pausal women but usually do not become trou- and/or insomnia. blesome until several years after menopause. Decreased Memory and Concentration. Estrogen is responsible for the thickened, elastic, Trouble concentrating, planning, and learning lubricated tissue of the vagina and vulva (external new things and difficulty remembering names, genital area). When estrogen levels decline, the words, or what you went into the kitchen to vulva loses its collagen, fat, and water-retaining retrieve are common changes experienced by ability. As a result, it becomes flattened, thin, and women in the menopause and menopause transi- dry and loses tone. With estrogen loss, the vagina tion. Many of us experience some degree of also shortens and narrows, and the vaginal walls change in memory and concentration and clarity become thinner, less elastic, and pale in color. of thinking as we age, but there are also specific Problems of vaginal dryness, vaginal discharge, cognitive changes that occur when estrogen, and pain with vaginal sex are reported by two out progesterone, and androgens are rapidly with- of three women at the age of 75.20 The change drawn from the system, most commonly short- that is usually noticed first is a feeling of dryness term memory loss. The relatively rapid transition of the vagina. The cause is atrophy of the mucus- from the menstruating/reproductive years to producing glands of the vaginal wall. With a loss menopause appears to be a factor in these cogni- in lubrication and a thinning of the tissue, the tive changes, and related to these hormonal vagina is more prone to infections and mechani- declines, especially in estrogen. Estrogen affects cal injury from vaginal penetration. Small pin- numerous neurotransmitters in our brain, includ- point bleeding, itching, and burning can result. ing acetylcholine, serotonin, noradrenalin, and Other tissue in the same area also becomes thin dopamine. All of these have influences on concen- and atrophied. The urethral tissue (exit route for tration, learning, and memory. This is most dra- urine), the labia (the “lips” of the external genital MENOPAUSE 183 region), and the vaginal wall can all atrophy. According to at least one large study, as many These changes can result in increased bladder as 30 percent of women have low sexual desire, infections, involuntary loss of urine (inconti- and about 50 percent of these feel distressed nence), and prolapse of the bladder, rectum, or about it.21 Not all sexual problems come in the uterus. As the atrophy progresses, women may form of low desire. Female sexual disorder (FSD) experience an increase in urinary urgency or dif- is defined in four main categories: desire disor- ficulty holding the urine. ders, arousal disorder, orgasmic disorders, and pain disorders. Sexual desire disorders include Urinary Problems. Urinary incontinence hypoactive sexual desire disorder (HSDD), and recurring urinary tract infections become which is a recurrent consistent deficiency or more common in postmenopausal women. Uri- absence of sexual thoughts, fantasies and/or nary incontinence (recurring involuntary leakage interest in sexual activity, and sexual aversion of urine) is common and affects from 10 to 30 disorder, a persistent or recurrent aversion to percent of women between the ages of 50 and and/or avoidance of sexual contact with a part- 64. Urge incontinence occurs when there is a ner. HSDD increases with age and is more sudden strong desire to urinate, and stress incon- common in women after age 60. In fact, it is tinence is urinary leakage with coughing, laugh- thought that HSDD is more related to age than ing, sneezing, or lifting. Stress incontinence is to menopause.22, 23 Sexual arousal disorder is more common during perimenopause and does defined as the inability to attain or maintain not tend to increase over time, whereas urge sexual excitement and a lack of response to sexual incontinence tends to increase with time. stimulation such as lubrication. Orgasmic disor- Other urinary changes include increased uri- der is difficult, delayed, or absent orgasm after nary frequency, sudden urges to urinate even adequate sexual stimulation and arousal. Sexual when the bladder is not full, frequent nighttime pain disorders include dyspareunia, genital pain urination (nocturia), and increased frequency of associated with vaginal penetration; vaginismus, urinary tract infections. As estrogen levels involuntary spasm of the musculature of the decline, the end of the urethra, where we urinate, entrance to the vagina that interferes with pene- becomes shorter, and this reduces our defense tration; and sexual pain related to sexual stimula- against the bacteria that cause urinary tract infection other than intercourse. tions (UTI). Lower estrogen levels also cause our Numerous variables affect sexual function, vagina, urethra, and bladder to become more including emotional and psychological factors, alkaline, which also leaves these areas prone to medical problems causing fatigue and/or pain, infections. Vaginal estrogen therapy is an impor- certain medications (see the following sidebar), tant option in restoring the acidic environment and hormonal influences. of the vagina and the bladder. Testosterone is necessary for a normal sex Changes in Sexual Response and Sex drive in women and men, helping to determine Drive. Changes in sexual response and libido are desire, arousal, and sexual sensation. During per- common throughout life, can be due to a host imenopause, estrogen levels are fluctuating but of influences, and tend to increase with aging. ultimately are declining, and testosterone pro- With an increasing number of menopausal duction is also declining. The hormonal issues women, an aging population, and an increased influencing sexual function in women aren’t openness about the topic of sexuality, women are totally understood, but fluctuating testosterone increasingly coming to their health-care practi- levels have been associated with a decrease in tioners wanting help in this area. libido (desire).24, 25 Most, but not all, sexual 184 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Selected Medications That A woman’s total estrogen production decreases Can Affect Sexual Function by 70 to 80 percent in menopause, while androgen production decreases by about 50 percent. If Reduction in Sexual Desire one has a surgical menopause, the plasma levels Antipsychotics of testosterone are decreased significantly more 27 Barbiturates than in women in natural menopause, and this Selective serotonin reuptake inhibitors (SSRIs) can result in an even greater incidence of sexual Tricyclic antidepressants dysfunction than in women who went through a Beta blockers natural physiologic menopause. Digoxin Spironolactone Acne, Facial Hair, and Hair Loss. Many Oral contraceptives peri- and postmenopausal women have problems Histamine H2-receptor blockers related to the change in the ratio of estrogen to testosterone. Even though both hormones have Reduction in Arousal declined, there is a relative increase in testos- Antihistamines terone because there is less estrogen to block its Antihypertensives effects. In addition, women have individual sen- SSRIs sitivities to androgens. Some women only react Tricyclic antidepressants to very high levels, while others are especially sensitive to what are considered normal androgen Reduction in Orgasmic Response levels. In addition, women have different kinds Amphetamines of receptor site and tissue sensitivity. Some will Antipsychotics develop acne, some thinning hair, and some Narcotics excess body and/or facial hair. SSRIs Excessive hair growth occurs in areas where Trazodone hair follicles are the most androgen-sensitive. Tricyclic antidepressants These include the face, chin, skin under the jaw- bone, upper lip, sideburn area, and cheeks. Other problems in postmenopausal women are related sensitive areas include the area below the belly to estrogen loss to the genitals. Decreased estro- button, the lateral pubic area, midline of the gen levels are responsible for most of the changes chest, around the nipple area, and the low back and decrease in lubrication during sexual arousal, over the sacrum. Hirsutism (excess body hair) is vaginal tone, vaginal elasticity, and genital most notably correlated with elevated free testos- engorgement. This can manifest as a lack of ade- terone, but testosterone must be converted by an quate vaginal lubrication with sexual arousal, enzyme in the skin to be fully active in the skin. bleeding after vaginal sex, and pain with vaginal This enzyme is probably higher in women who sex. Vaginal dryness is not only associated with have excess body and facial hair. These enzyme painful vaginal sex, but also with a decrease in levels may change in postmenopausal women, or sexual desire.26 It is not hard to understand why the hair follicle may become more sensitive to the anticipation of painful sex would dampen one’s activated testosterone in some postmenopausal desire for sex. With a loss of estrogen, relaxation women. of vaginal tissue and decreased muscle tone Hair thinning and hair loss are often trau- also occur, which leads to a decrease in sexual matic for women and cause a great deal of anxi- response. ety. Androgenic alopecia (hair loss) is the most MENOPAUSE 185 common alopecia in humans and is genetically Skin, Eye, and Dental Changes. We already determined. Androgens modulate hair growth. talked about how hormone changes can be The follicle responds to the androgens and is related to acne. Specifically, acne can be the effect dependent on the amount present and the pres- of excess testosterone on the glandular secretions ence and number of androgen receptors. The in the skin. Estrogen also has important func- thinning of hair that can be seen in menopausal tions in the skin. It determines the skin collagen, women is more likely to be diffuse but is most skin thickness, and texture. Collagen, a major common on the top of the head (the vertex) protein in the skin, is dependent on estrogen, and next most common at the crown. Some and 30 percent of skin collagen is lost during the women have a receding hairline and thinning at first few years after menopause. As time goes on, the temples. more collagen is lost, resulting in increasing Weight Gain. One of the more troubling laxity of the skin, wrinkling, and loss of elasticity. changes to women during the menopause transi- The skin also becomes dry more easily. tion is weight gain, which is often about five A variety of changes occur in the eye relative pounds. We don’t understand very clearly if or to hormonal status. Postmenopausal women how a drop in hormones, and if or how prescrib- report dry eyes, burning, pressure, light and tem- ing hormones, affects weight. What we do know perature sensitivity, blurring, tearing, eye fatigue, is that aging itself and lifestyle are associated with swollen eyelids, and a feeling of scratchiness. Dry weight gain. Lean body mass, muscle mass, and eye syndrome can, oddly enough, cause excess the metabolic rate decrease with age, which tearing, and it appears to also be affected by means we burn fewer calories. These changes, drops in testosterone levels. combined with being more sedentary as we age, Fluctuations in hormones during peri- can easily lead to weight gain. Hormonal changes menopause and lower levels in menopause are in menopausal women are probably associated involved in inflammation of the gums, sensitivity with an increase in insulin resistance, leading to of the teeth, tooth loss, and a burning sensation increased fat storage, increased abdominal fat, in the mouth and tongue. These symptoms may and weight gain. be a sign of more serious problems as well. Tooth loss may be associated with low bone density and Headaches. Hormonal changes may play a osteoporosis. Burning sensations in the mouth role in headaches, especially in perimenopause can be a symptom of diabetes or anemia, and and especially in women with migraine head- gum inflammation may be related to an aches. Migraine headaches tend to be worse on increased risk of cardiovascular disease. one side of the head and worse with light and noise, can be associated with nausea and vomit- Heart Palpitations. A palpitation can feel ing, and tend to be moderate to severe. The hor- like a rapid heart rate, missed heartbeats, or irreg- monal changes associated with the menopause ular heartbeats. Not all heart palpitations are transition can increase the frequency and inten- related to a decrease in estrogen levels but may be sity of headaches, especially for those women a symptom of anxiety, panic disorder, fears, or who have a history of menstrual-related head- depression. Fortunately, women in their 40s and aches. During times of more stable estrogen early 50s, during the most common time of the levels, such as during pregnancy, or once meno- menopause transition, are not likely to have a pause has been reached, most women will expe- serious cardiac problem. Nonetheless, these rience a resolution of their headache patterns, symptoms should be evaluated, especially if they especially migraine headaches. occur with exercise, are associated with shortness 186 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE of breath or chest pain, or if you have a family pause). The follicle stimulating hormone (FSH) history of early heart disease or heart attack (men test is not as accurate as we would like, but if it is less than age 50 and women less than age 60). consistently elevated above 30 mIU/mL, a diagnosis of menopause can be established. The diffi- Joint Pains. Another symptom commonly culty with FSH tests is that they can fluctuate reported during menopause is joint pain and/or immensely, especially in perimenopause. The body aches. This is not currently well under- other problem is that FSH tests are frequently stood, but it is likely there is a connection normal in perimenopausal women. It can also be between hormones, immune function, and very difficult to use the FSH test if women are on inflammation in the joints. Osteoarthritis, specif- hormonal contraceptives or hormone replace- ically, is a common joint disease that increases ment therapy (HRT or HT). with age and affects women more than men. There is a recent popular notion that saliva or Osteoporosis and Cardiovascular Disease. serum testing can be done to determine estrogen, While the symptoms of hot flashes, mood swings, progesterone, and testosterone levels or individ- insomnia, sexual dysfunction, and the rest are ual estrogen levels including estriol, estrone, and annoying at best, and can significantly impact estradiol. However, saliva testing has yet to be quality of life, the most significant changes proven accurate for the testing of these hor- associated with menopause are osteoporosis and mones, although the FDA has approved saliva cardiovascular disease. These conditions can dra- tests for cortisol and DHEA levels. I will focus matically alter and even shorten one’s life. For a my comments on blood serum testing. comprehensive discussion on osteoporosis, refer to For the perimenopausal woman, it is difficult Chapter 14, and for heart disease, refer to Chapter to gather conclusions on test results when the 9. Prevalence, risk factors, evaluation, and alterna- hormones are in such a fluctuating state. There tive and conventional approaches and treatments are so many peaks and valleys and so much are covered in these chapters. erratic hormone activity that testing offers little value in most situations. For the women taking Menopause Evaluation HRT, it is tempting to think that we could test The onset of perimenopause is an important the blood to determine what dose to take. This is time for a comprehensive health and lifestyle a popular recommendation in some consumer evaluation. A thorough medical history, com- menopause books. However, I would point out plete physical exam, and selected tests depending that there is no mathematical grid comparing on your age, your symptoms, and other medical values of estrogen or progesterone or of testos- problems should be done by a licensed health- terone levels in the blood and how that would care practitioner. equate with a certain dose of the comparable hor- While it may seem surprising, there is no one mone. There are reference ranges for these hor- test for menopause. Tests to determine ovarian mones, but practitioners don’t know exactly what function are not routinely done because the diag- dose to give to keep a woman in the reference nosis of perimenopause or menopause is largely range. Women absorb and metabolize hormones able to be made based on the medical history. differently. The form of hormones and the deliv- Practitioners can use hormone testing on an indi- ery method—oral, transdermal, sublingual, or vidual basis, mostly to differentiate menopause injection—also behave differently from woman from thyroid problems, abnormal causes of a lack to woman. In selective cases, testing may be a of menses such as elevated prolactin levels, or helpful guide. These are generally cases in which premature ovarian failure (premature meno- a woman is on HRT and not doing well, and MENOPAUSE 187 despite the practitioner’s best efforts with a good when a fasting plasma glucose test is 126 mg/dL or medical history and adjusting the dose, she still greater on two or more occasions or the blood glu- does not feel well. But clearly, the majority of the cose is 200 mg/dL or greater two hours after a dose time, it requires the practitioner’s experience and of glucose is ingested. menopause expertise and time to listen to the Other important situations also warrant test- patient to know what dose, what dosing adjusting and are discussed in the appropriate chapters ments, and what forms and deliveries of hor- in this book. To name a few, abnormal uterine mones may work best. Even if testing is done, the bleeding may need thyroid blood tests, pelvic decision basically comes down to good clinical ultrasound, or endometrial biopsy. Urinary tract judgment and the willingness of the woman and infections can be tested with urinalysis and urine her practitioner to try various approaches. cultures. Cervical cancer can be screened for Testing can be done to facilitate assessing a with Pap smears. Breast cancer can be screened woman’s risk for diabetes, heart disease, and osteo- for with mammograms. porosis. Risk assessment for heart disease is discussed in Chapter 9 and for osteoporosis, Chapter OVERVIEW OF 14. Diabetes risk assessment is a combination of ALTERNATIVE TREATMENTS history and physical exam, glucose screening, and The fundamental goals of an alternative lipid panel testing. Diabetes mellitus is diagnosed approach to menopause are to provide relief from common menopausal symptoms and to prevent KEY CONCEPTS and/or treat osteoporosis, heart disease, and other diseases of aging. The goal is to do this with • Find a good menopause practitioner to work methods that do not increase the risk of life- with. Seek the advice of practitioners who can threatening diseases such as breast cancer, blood inform you about the spectrum of options. clots, and strokes. • Seek out an initial comprehensive evaluation. In order to accomplish these fundamental • Managing menopause symptoms is distinct from goals, the menopausal woman and her practi- prevention of significant diseases such as heart tioner must embrace an individualized approach. disease and osteoporosis. • Attempt to determine individual risks for signifi- An alternative and comprehensive approach is cant diseases—osteoporosis, heart disease, distinct in that the evaluation of each woman breast cancer, and diabetes. lends a great deal of attention not only to indi- • Hormone testing is not routinely recommended vidual symptoms, but also to her individual risks and offers limited help in knowing how to for future diseases. This requires a comprehensive manage your menopause symptoms. health history; judicious use of tests to assess risks • Be well informed about the process of for osteoporosis and heart disease; an apprecia- menopause. tion of risk factors for breast cancer, diabetes, and • Be well informed about the spectrum of alterna- Alzheimer’s disease; a willingness to individualize tive and conventional treatment options. the treatment very carefully; and an ability to uti- • Realize that menopause and aging are processes that evolve over time. lize the whole spectrum of interventions, includ- • What you decide today is not permanent; you ing diet, exercise, stress management, nutritional can change your treatment decisions based on supplements, herbal therapies, all available hor- your changing health, changes in medical under- mone options, and prescription and over-the- standing and research, and newly available counter pharmaceuticals. treatment options. Although more and more conventional HRT regimens are becoming available and new non- 188 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE hormonal drugs are being developed, a practi- The Naturopathic Approach tioner who has an understanding of the whole In the naturopathic approach to menopause, spectrum of options from the most natural to the therapeutic intervention is determined following most conventional is in the ideal position to a comprehensive assessment of symptom severity properly advise and prescribe a customized opti- and scope and an evaluation of risk factors for mal treatment and prevention plan. A licensed osteoporosis, heart disease, Alzheimer’s, diabetes, naturopathic physician is currently the only pri- and breast cancer. A determination of low, mary health-care provider trained in all these medium, or high risk, especially for osteoporosis options, although he or she may have to refer for and heart disease, is especially directive in provid- some selected expertise in osteoporosis, heart dis- ing choices regarding alternative and/or conven- ease, gynecology, or endocrinology. In the past, tional therapies. Once the symptoms have been conventional medicine largely approached the pinpointed and the risks have been assessed, then situation as “HRT for all and forever.” Since treatments are recommended. Treatment consid- 2002 and the first Women’s Health Initiative erations include a spectrum of options. The seven 28 research results, women and many of their doc- treatment categories are: tors abandoned HRT almost overnight. At the other extreme is an absolute fear and 1. Diet, exercise, lifestyle, and stress bias against using HRT for any reason or for any management amount of time. The use of nonhormonal natu- 2. Nutritional supplementation ral therapies has thrived in this environment, 3. Botanical supplementation both in the form of women treating themselves 4. Compounded bio-identical hormones and for those seeking advice from licensed alter- 5. “Friendlier” conventional HRT native practitioners. In either case, caution 6. “Less friendly” conventional HRT should be exercised in presuming that just treat- 7. Nonhormonal prescription medications ing the symptoms of menopause is adequate. You may be surprised to see the inclusion of Keep in mind our fundamental goals: symptom conventional hormone replacement therapy in relief, disease prevention, and disease treatment. my list of options. Choosing to use hormones, While there are many effective nonprescription whether compounded bio-identical or conven- natural therapies for symptom relief, this does tional pharmaceutical preparations, is a matter of not adequately address greater long-term con- weighing the benefits and the risks. Hormonal cerns such as bone density, blood pressure, cho- therapies should be utilized in the lowest dose, lesterol levels, breast health, or vaginal tissue shortest duration, and safest way possible that health. The identification of disease risks may not meets the goals that have been identified. These be very important in the early perimenopausal issues are addressed in the section on hormones. years, but it acquires increasing importance as the Diet/exercise/lifestyle and/or nutritional sup- postmenopause years accumulate. This is why I plements and/or botanical therapies will be effec- recommend that women seek the advice of a tive for the management of menopause symptoms licensed naturopathic physician with a strong in the majority of women. When these are not experience in women’s health, and menopause in adequate, individualized formulations of bio- particular. identical hormone options should be used. If In this section on natural medicine, we will these are not adequate, then “friendlier” hor- focus on symptom relief. See the chapters on mone therapy (also bio-identical) is preferred heart disease and osteoporosis for prevention and over “less friendly” (synthetic and semisynthetic treatment of those diseases. MENOPAUSE 189 and not bio-identical) HRT. (The distinctions well as an antiestrogen effect, depending on the between the different kinds of hormones are dis- tissue involved and the dose consumed. cussed in the hormone section.) Determining the There are hundreds of studies on soy and treatment approach is a combination of subjec- dozens on hot flashes, some showing effect and tive and objective findings resulting from the others not, making it difficult to make conclu- medical history, physical exam, any lab or diag- sions. For now, I’d like to pass on the results of nostic imaging tests, and the personal perspective two systematic reviews of isoflavones and meno- and values of each woman. The specifics of these pausal symptoms and one consensus opinion options and therapies will be expanded on as we from the North American Menopause Society discuss nutrition, exercise, nutritional supple- that offer a good summary of the research. The mentation, botanicals, bio-identical hormones, first systematic study was a review of the literature conventional HRT, and nonhormonal drugs. for the randomized controlled clinical trials on soy and perimenopausal symptoms.29 Ten trials Nutrition were evaluated, and only four were positive and showed benefit for perimenopausal symptoms. An alternative approach to menopause isn’t com- There were no serious safety concerns with soy plete without proper nutrition. This includes gen- products for the treatment periods, which were eral considerations such as a diet rich in whole up to six months. In the second systematic review, natural and unprocessed foods, with an emphasis 25 trials involving approximately 2,300 women on fruits, vegetables, whole grains, beans, seeds, met the study criteria.30 Soy and red clover nuts, and healthy fats, and low in saturated fats, isoflavones were evaluated in this review, includ- fried foods, white flour, alcohol, sugar, and salt. ing soy foods, beverages, or powders; soy extracts; The Value of Soy. One of the important and red clover extracts, for a total of 25 studies. dietary recommendations for all menopausal Only one soy food trial and two soy extract trials women may be to increase foods that are high in showed the ability to reduce hot flushes. phytoestrogens, although their benefits may be The final report comes from a consensus more for preventing osteoporosis, heart disease, opinion of the North American Menopause Soci- and even breast cancer than for the relief of ety,31 which acknowledges that some data does menopause symptoms such as hot flashes. support the efficacy of isoflavones in reducing A large number of plants, especially legumes, the incidence and severity of hot flashes but that contain compounds called phytoestrogens. many studies have not found any difference. It Phytoestrogens are mainly, but not exclusively, also concluded that there was not adequate data nonsteroidal in structure and are either of plant to evaluate the effect of isoflavones on breast and origin or derived from the body’s metabolism of other cancers, bone mass, and vaginal dryness precursors present in dietary components. The but that there were convincing health benefits of most important dietary phytoestrogens are the isoflavones and lipids in reducing low-density phenolic phytoestrogens, which include the lipoproteins and triglycerides and increasing isoflavones and the lignans. Soybeans are the high-density lipoproteins. Perhaps the best evi- richest food source of isoflavones, containing 1 dence that soy lowers cholesterol comes from a to 2 mg of isoflavones per gram of soy protein. review of 38 scientific studies. This meta-analysis The two main isoflavones of soy are genistein concluded that consumption of soy protein rather and daidzein. Isoflavones have a unique ability to than animal protein significantly decreased serum weakly bind to estrogen receptors in the body concentrations of total cholesterol, LDL choles- and seem to have both a weak estrogen effect as terol, and triglycerides.32 190 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE In terms of menopause symptoms and hot ative comments and concerns about soy are in flashes in particular, I’m sure the three reviews are some cases incorrect and in other cases highly disappointing news for advocates of soy. It’s exaggerated. Some have pointed out problems important to appreciate, though, that statistical with thyroid function, inhibition of mineral and significance is not the same as clinical signifi- protein absorption, and concerns about hor- cance for any one person. For some women, and monal effects. this has been borne out in some studies, soy pro- Some of the controversy about soy lies not tein and soy isoflavones can be helpful in reduc- only in its ability to bind to estrogen receptors ing the frequency and severity of hot flashes. For but in its content of phytates and trypsin the specifics in regard to bone effects and cardio- inhibitors, interference with thyroid function, vascular effects, please refer to the osteoporosis and difficult digestibility for some individuals. and heart disease chapters. Soy foods, especially cooked soybeans, are diffi- If you choose to increase soy foods or take cult for some people to digest, causing gas and soy beverages, powders, or supplements, a word stomach upset. Soy’s content of trypsin inhibitors about dosages and addressing some of the highly can block the enzymes needed for protein diges- publicized controversies about soy is important. tion. When the protein is improperly digested, A reasonable approach would be to ingest a daily fermentation and gas production ensues. How- level of isoflavones that does not exceed the ever, many researchers believe that so few trypsin amount consumed in ethnic diets that contain inhibitors are left behind after processing the soy high amounts of isoflavones. From a review of food that for most people, their digestion is not those diets, it appears that this amount is some- affected. where between 50 to 150 mg of isoflavones per The phytate content in soybeans has been day for adults. The isoflavone content of soy another cause for concern with soy foods. Phy- foods varies with the form. A listing of the tates are compounds found in grains and legumes isoflavone content of some of these soy foods will that can compete with the uptake of minerals offer some help in calculating your daily intake such as calcium, magnesium, iron, and zinc. (see Table 12.1). Although the phytate content of soybeans is There have been some controversies about higher than that of other grains or legumes, the soy, and based on the actual research, these neg- mineral-blocking effect of phytates is reduced

Table 12.1 Isoﬂavone Content of Soybeans

Soy Food Amount Isoﬂavones (mg)

Textured soy protein granules 1⁄4 cup 62 Roasted soy nuts 1⁄4 cup 60 Tofu, low-fat and regular 1⁄2 cup 35 Tempeh 1⁄2 cup 35 Soy beverage powders 1–2 scoops 20–50 (varies with manufacturer) Regular soy milk 1 cup 30 Low-fat soy milk 1 cup 20 Roasted soy butter 2 tbs 17 Cooked soybeans 1⁄2 cup 35 MENOPAUSE 191 when eaten with meat or fish. If you eat soy from a paper citing over 280 references.36 In products in the context of a healthy, varied diet, reviewing animal, laboratory, and human studies, you should get adequate minerals. Phytates are the study’s authors conclude that while there is also reduced in fermented products such as some conflicting data as to whether soy is protec- tempeh and miso. tive against breast cancer or is safe or harmful for The genistein and daidzein in soy can also breast cancer patients, it is clear from reading this inhibit thyroid hormone synthesis. High- research that the data significantly favors safety soybean diets have been implicated in diet- and even protection if consumed from a young induced goiter. This problem is not likely to age. The authors concluded that moderation in occur with an average amount of soy in the diet intake is probably wise and should mimic the and again in the context of a healthy, varied diet, Asian soy intake of one to two servings per day. especially a diet that is adequate in iodine, which Doubts as to the significance of the breast cancer is now mostly the case in this country. In some protective effects of soy and the safety of soy will susceptible individuals, or in some who take very remain until there has been a prospective study high doses of nutritional supplementation of soy on soy comparing women on a high-soy diet isoflavones (above 200 mg per day) or have an with women on a low-soy diet over the span of extreme diet low in other nutrients and high in many years with identical risk factors in other soy, it is prudent to be aware of potential but areas. One specific word of caution to breast extremely rare problems with soy ingestion. cancer patients undergoing treatment with One of the greatest fears for women contem- tamoxifen: until it has been determined if soy is plating menopause treatment options is the con- beneficial in addition to tamoxifen or if it inter- cern about estrogen replacement therapy and feres with tamoxifen, I would recommend breast cancer. Although we will be addressing against daily soy ingestion while on tamoxifen. this in the hormone and conventional medicine For the most part and in most individuals, sections of this chapter, there are several lines of soy foods will not interfere with thyroid func- evidence and logic that support the conclusion tion, protein digestion, or the uptake of minerals, that not only is soy safe, but there is actually a and they are more associated with reducing the relationship between increased soy intake and risk of hormone-dependent cancers than with breast cancer prevention. Several studies con- increasing it. Any potential negatives with soy are cluded that Asian women who consume a tradi- not likely to occur with one to two servings of tional low-fat, high-soy diet have a four- to soy foods daily, with adequate iodine in the diet, sixfold lower risk of developing breast cancer.33 using soy in the context of a healthy, varied diet The constituents in soy are remarkable in their and focusing on organic sources. Organically activities against a variety of cancers via several grown soybeans are grown without pesticides and different mechanisms. Dietary phytoestrogens are not from genetically modified seeds. This is also inhibit cancer cell growth by competing with an important issue for soy foods in particular, as estradiol for the type II estrogen binding sites.34 genetically modified soy crops have increasingly Even more convincing evidence for the breast dominated in the agriculture business. Fortu- cancer protection benefit of soy comes from nately, there are farmers and manufacturers who animal studies.35 Soy supplementation has are committed to raising and producing organic reduced the number and size of tumors induced soy products. with a carcinogenic substance. The optimal use of soy would be to start early The most comprehensive review of the litera- in life and eat a diverse array of soy foods with a ture on soy and its effects on the breast comes total dietary intake of 50 to 150 mg of soy 192 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

isoflavones per day. If you don’t like soy foods, take Dietary Recommendations a high-quality soy protein powder or capsule. Reduce saturated fats (cheese, butter, beef, pork). Flaxseed. Another significant dietary source Avoid trans fats (deep fried foods, margarine, par- of phytoestrogens to consider is flaxseed. tially hydrogenated oils). Flaxseed contains lignans, two of which, Reduce refined grains and flours, sugar, and salt. matairesinol and secoisolariciresinol, are known Use only a modest amount of low-fat dairy products. to have estrogenic activity. Other lignans are Increase fruits, vegetables, legumes (especially soy), modified by intestinal bacteria to form estrogenic whole grains, nuts and seeds, olive oil, and cold- compounds. Lignans from plants such as flaxseed water fish (salmon, tuna, mackerel, herring, hal- are absorbed in the circulation and have both ibut, and sardines). estrogenic and antiestrogenic activity37 much like soy, although to a lesser degree. necessary dietary changes have a significant advan- Flaxseed flour and its defatted meal (flaxseed tage in being able to age healthfully and reduce the meal) are the highest plant producers of lignans. risk of heart disease. Lowering the level of trans fats The lignan content of flaxseed meal is 75 times and saturated fats while increasing omega-3 fats higher than that of seaweeds (the second highest and monounsaturated fats from olive oil are keys to lignan-containing group) and 804 times higher a nutritional preventive approach to heart disease. than that of fruits (the lowest lignan-containing Diets that are high in cholesterol and saturated fats group).37 (beef, pork, lamb, butter, cheese, palm oil, and The evidence that lignans can reduce the risk coconut oil) contribute to poor fat ratios and ele- for cancer is still unclear, although the biologic vated cholesterol. Even though total fat intake properties of lignans and data from various cul- should be reduced, switching from saturated fats to tures suggest that they do. Many lignans have vegetable oils will lower total cholesterol levels. antitumor, antioxidant, weak estrogenic, and Olive oil is your best choice for salads and cooking. antiestrogenic characteristics.38–42 Adding to the Increasing fiber in the diet with whole grains, evidence, urinary excretion of lignans has been fruits, vegetables, and legumes is the optimal found to be lower in nonvegetarians and in post- high-fiber diet. Soluble fiber such as the pectin in menopausal women with breast cancer as com- apples or oat bran has the most consistent bene- pared with healthy women.43–45 ficial effect on cholesterol levels.46 Specific fruits Foods for Bone Health. Several dietary factors or vegetables can also have a positive effect on affect bone health and are involved in the develop- blood levels of fat. Raw carrots, for example, may ment of osteoporosis: insufficient calcium intake, have a more potent effect in lowering cholesterol vitamin D deficiency, low calcium and high phos- than oat products.47 People with a low intake of phorus intake, low fatty acid intake, insufficient fruits and vegetables have an increased risk for dark leafy greens, a high-protein diet, excess salt heart disease.48 See Chapter 9 for dietary and intake, and excess alcohol. See Chapter 14 for lifestyle factors, supplements, herbs, hormones, dietary and lifestyle factors, supplements, herbs, and other conventional medications for preven- hormones, and other conventional medications for tion and treatment of heart disease. prevention and treatment of bone loss. Foods for Heart Health. Heart disease is the Nutritional Supplements other major concern in the postmenopausal years. Following are the nutritional supplements that are The prevention of heart disease is largely deter- used to treat some of the symptoms of menopause. mined by diet and lifestyle. Women who make the For an in-depth look at some of the nutritional MENOPAUSE 193 supplements used to treat and prevent heart dis- the problem in the past. Results of research and ease and osteoporosis, consult Chapters 9 and 14. clinical trials have consistently shown that EPO is Bioflavonoids. Bioflavonoids, such as rutin, effective in relieving breast pain and premenstrual hesperidin, and quercetin, are usually known for cyclic breast pain.54–56 (See Chapter 7 for more their antioxidant and anti-inflammatory proper- information about this and other treatments for ties and their ability to strengthen capillaries. painful and lumpy breasts.) Some evidence exists to show that giving bio- Evening Primrose Oil flavonoids in combination with vitamin C will help to relieve menopausal hot flashes.49 1,500–3,000 mg per day

Bioﬂavonoids Gamma-Oryzanol. Gamma-oryzanol is a 1,000 mg per day plus 1,000–1,500 mg vitamin C substance found in grains and is isolated from rice bran oil. This ferulic acid compound is pres-

Vitamin B6. Vitamin B6, or pyridoxine, plays ent in rice, wheat, barley, oats, tomatoes, aspara- a critical role in the manufacture of serotonin as gus, olives, berries, peas, citrus fruits, and other well as other amino acid neurotransmitters. Vita- foods. The concentrations are higher in whole min B6 levels are typically quite low in depressed grains than in refined grains and flours. patients, especially women taking birth control Gamma-oryzanol was initially shown to be pills or conjugated equine estrogens (Pre- effective in relieving menopausal hot flashes in the 50–52 57 marin). An insufficiency of vitamin B6 may early 1960s, and at least one additional study has also cause insomnia and irritability. Since depres- confirmed that finding.58 The typical dosage of sion, insomnia, and irritability are typical meno- gamma-oryzanol is 100 mg three times daily. pausal symptoms, this vitamin may be a helpful addition to a supplement program. Gamma-Oryzanol 100 mg 3 times per day Vitamin B6 50–200 mg per day Vitamin E. The considerable reputation of Warning: chronic intake of dosages greater than vitamin E as a remedy for hot flashes comes from 200 mg per day can be toxic over a period of many studies done as far back as 1945.59–62 The problem months or years. is that vitamin E has received very little scientific attention for this use since those early studies. Only Evening Primrose Oil. Currently, natural recently has there been renewed research interest, products for menopause often include evening largely born of the need to provide menopausal primrose oil (EPO) because it has a reputation breast cancer patients with safe and effective medi- for alleviating vasomotor symptoms such as hot cines for symptom relief.63 Patients received four flashes. However, a study on the effects of gamma weeks of vitamin E (800 IU per day), then four linolenic acid (GLA) from evening primrose oil weeks of an identical placebo, or vice versa. Hot found it to offer no benefit over placebo in treat- flash frequency decreased by 25 percent in the vita- ing menopausal flushing.53 min E group and 22 percent in the placebo group. Cyclic breast pain is a common symptom in Although this is considered a statistically significant menstruating women before their period. In peri- difference, the clinical impact of this reduction was menopausal women, this symptom can be exacer- marginal, and the patients did not particularly bated or can occur in women who have not had show a preference for vitamin E over placebo. 194 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE they preferentially express estrogenic effects in Vitamin E the central nervous system, blood vessels, bone, 400–800 IU per day and skin without causing stimulation of the breast or uterus, at least in typical doses.66 Botanical Medicines Dong Quai (Angelica Sinensis). Dong quai, Phytoestrogens. As discussed in the nutri- also known as tang-kuei, dang-gui, and Chinese tion section, phytoestrogens are plant-derived angelica, is an aromatic herb widely used through- substances that are able to activate the estrogen out Asia. In Asia, dong quai is to women’s health receptors in mammals. They are mainly, but not what ginseng is to men’s. It has predominantly exclusively, nonsteroidal in structure and are been used as a female remedy to treat menopausal either of plant origin or derived by the body’s hot flashes, menstrual cramps, lack of menstrua- metabolism of precursors present in dietary com- tion, or frequent menstruation and to promote ponents. Phytoestrogens are present in virtually a healthy pregnancy and easy delivery. The every plant in varying amounts. coumarins in dong quai are found largely in the Phytoestrogens are capable of exerting weak root. The potential estrogen-like activity of dong estrogenic effects in some parts of the body, and quai has been assumed because of its observed tra- they also have antiestrogenic effects due to their ditional uses and clinical effects, and evidence ability to occupy estrogen receptor sites and includes its ability to cause an initial increase in 67 block the estrogen produced by our own bodies uterine contraction, followed by relaxation and from binding. Since the phytoestrogens are so its effect in increasing uterine weight when given 68 much weaker than the body’s estrogen, the net to mice. These observations may be a partial effect is significantly less estrogenic stimulation explanation as to why dong quai may be useful in in the target organ. menopause, although clearly there is some benefit Phytoestrogens are found in many medicinal at least for issues related to missed menses or fre- herbs with a historical use in conditions that are quent menstruation. now treated by estrogens. The weak estrogenic In a 12-week study conducted by Kaiser Per- effects of phytoestrogen-containing herbs can manente, using dong quai as a solo agent for the provide some benefit in relieving menopause relief of menopausal symptoms such as hot 69 symptoms. One advantage of phytoestrogens is flashes and sweats did not prove to be effective. that they have not been associated with increas- More research is needed on use of dong quai in ing the risk of breast cancer. In fact, epidemio- combination with other herbal preparations. logic data and experimental studies in animals Dong quai may increase the flow of a period have demonstrated that phytoestrogens are or bring on a menses. In a perimenopausal woman extremely effective in inhibiting mammary who is either already having heavy flow problems tumors, not only because they occupy estrogen or may have missed a menses for several months, receptors but also through other unrelated anti- this may be alarming. In this case, dong quai is cancer mechanisms.64, 65 probably not the best herbal choice for your The common phytoestrogen compounds, the menopausal symptoms. isoflavones, have a similar structure to the body’s Dong Quai sex hormones. They have the ability to bind to estrogen receptors on human cells, and in Dry herb used in combination with other herbs in capsule form or women they have a preference for binding to the Tincture: 1⁄2–1 tsp 1–3 times per day beta form of the estrogen receptor. As a result, MENOPAUSE 195 Ginkgo (Ginkgo Biloba). Ginkgo is the Ginkgo Biloba world’s oldest living species of tree with fossil records as old as 200 million years. The leaves of 40–80 mg standardized extract capsules or 1⁄2–1 tsp young, cultivated trees are used in modern herbal tincture 3 times per day preparations. Two groups of active constituents— the terpene lactones and the ginkgo flavone glyco- Ginseng (Panax Ginseng). There are many sides—are the most critical compounds of types and grades of ginseng and ginseng extracts standardized herbal products. Many forms and that include related species. Panax ginseng, also methods of preparation of ginkgo are available, known as Korean or Chinese ginseng, is the most although a high quality of Ginkgo biloba extract is widely used. A standardized extract of ginseng typically standardized to 24 percent ginkgo has been shown to improve depression and well- flavone glycosides and 6 percent terpene lactones. being in 384 postmenopausal women.79 Another The actions of these constituents include improv- randomized controlled trial found that one ing blood flow to the brain70 and to the hands and month of Korean red ginseng increased energy feet.71, 72 Although ginkgo extract has not been and decreased insomnia and depression.80 specifically studied in menopausal women with Historically, ginseng has been used as a “tonic memory or cognition problems, it has been used for invigoration and fortification in times of to improve memory. fatigue and debility and for declining capacity for Clinical studies have demonstrated the efficacy work and concentration.”81 Ginseng can help in of Ginkgo biloba extract (GBE) for the treatment of reducing mental or physical fatigue,82–85 enhanc- memory loss, depression, and disorientation associ- ing the ability to cope with physical and mental ated with cerebrovascular insufficiency in geriatric stressors by supporting the adrenal glands,86 or patients.73–75 Two studies have shown gingko to be treating the atrophic vaginal changes due to lack effective for patients with mild to moderate pri- of estrogen.87 mary dementia of the Alzheimer’s type or multi- Panax Ginseng infarct dementia.76, 77 Patients who received ginkgo showed memory and attention improvements and Standardized extract capsules: 200 mg 5% ginseno- significant improvement in cognitive function tests sides or 100 mg 10% saponin ginsenoside per day and depression. Relative differences for dementia High-quality root: 4–6 g per day were not observed. I think it is important to include ginkgo for menopausal women because Licorice (Glycyrrhiza Glabra). The major changes in mental clarity, memory, and concentra- active constituent in licorice root is glycyrrhizin. tion are common, and it may be that ginkgo will Much of the attention on licorice root has cen- have an increasing role in improving these symp- tered on its anti-inflammatory, antibacterial, toms for this group of women. antiviral, and expectorant (promotion of the Another commonly reported change in peri- elimination of mucus from the lungs or bronchi) and postmenopausal women is a drop in their sex properties, but for menopausal symptom relief drive. Extract of ginkgo appears to be remarkably we are more interested in the estrogenic activity effective in reversing antidepressant-induced of some of its phytoestrogen components, includ- sexual dysfunction in women as well as men.78 ing beta-sitosterol, formononetin, coumarin, and Although the sexual dysfunction in this study others, in particular beta-sitosterol, which is was drug-induced rather than the result of 1⁄400th as active as estradiol.88 However, the gly- changing hormones, I recommend trying this coside of glycyrrehetinic acid has been shown to safe and simple approach. have an antiestrogen activity, inhibiting the effect 196 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE of estradiol on uterine growth in ovariectomized with the placebo group, the hot flashes were animals.89 It may be that licorice has both hor- reduced more rapidly in the group receiving 82 mone and antihormone effects, or it may in fact mg of isoflavones.95 lower estrogen levels while simultaneously raising Other effects of red clover also have implica- progesterone levels. This creates some confusion tion in menopausal women. One published in thinking about why and when to take it, and study showed that red clover isoflavones may at this time we cannot really clear up the confu- reduce the risk of coronary vascular disease by sion because there is insufficient research to increasing arterial elasticity, although it did not account for the use of licorice as a single meno- improve cholesterol levels.96 Red clover isoflavones pausal herb. Licorice may, however, be used in may also slow bone loss of the spine.97 combination with other herbs as part of an effec- There have been no significant adverse or tive formulation for symptom relief. intolerant reactions with red clover, no significant change in blood parameters used to measure Licorice toxicity, and no evidence of uterine bleeding or Dry form used in combination with other herbs in cap- increased endometrial thickness. In fact, an 80 sules or mg red clover extract did not increase the thick- Tincture: 1⁄2–1 tsp 1–3 times per day ness of the lining of the uterus in postmenopausal women, despite its high content of Red Clover (Trifolium Praetense). Red phytoestrogens.98 clover, a member of the legume family, has been I cannot offer women who have a history of used worldwide as a source of hay for cattle, breast cancer the same degree of reassurance about horses, and sheep, and the leaves and young using red clover as I can with black cohosh. I do sprouts have been used by humans as a source of not consider it definitely contraindicated, because protein. Historically, it has also been recognized in fact red clover has a rich history in herbal med- as a medicinal plant for humans and, more icine as a treatment for cancers of all kinds. One recently, as a menopausal herb. can see the logic of its use in cancer because of its At least six clinical trials have been conducted genistein and daidzein constituents, both known on the effect of red clover isoflavones on vasomo- inhibitors of tumor growth and cancer cell divi- tor symptoms. Three show benefit, and three do sion. However, the results of an experiment that not. The first two published studies on red clover compared the relative effects of several different and vasomotor symptoms showed no statistically herbs on estrogen-receptor positive breast cancer significant difference between the red clover stan- cells in vitro raised concern.99 Surprisingly, the dardized extract and the placebo.90, 91 Two other breast cancer cells in the laboratory responded the studies showed positive results in reducing hot same to red clover as they did to estradiol. The flashes.92, 93 The two most recent studies con- question of safety or concern with using red clover tinue the contradictions. In a 2002 study, 80 mg extracts in postmenopausal women with a history of isoflavones per day resulted in a significant of estrogen receptor positive breast cancer remains reduction in hot flashes as compared to base- unanswered. line.94 Another recent study, called the ICE study, compared two different doses of red clover Red Clover isoflavones with placebo. The reductions in the Standardized extract of 40 mg total isoflavones, mean daily hot flash count at 12 weeks were sim- 1 tablet 1–2 times per day or ilar for groups receiving 82 mg of isoflavones, 57 Dry herb capsule (500 mg): 1 per day mg, and the placebo. However, in comparison MENOPAUSE 197 Nonphytoestrogen Herbs In a double-blind, randomized, placebo- controlled study, a combination of black cohosh Black Cohosh (Cimicifuga Racemosa). Black and Saint John’s wort was studied.111 The Saint cohosh, Actaea racemosa or Cimicifuga racemosa, is John’s wort plus black cohosh group was signifi- a member of the buttercup family and is used for a cantly superior to the placebo group on scales variety of women’s health conditions. In the last 25 measuring menopause symptoms and depression. years, it has emerged as the most studied of the The average recommended dose of the stan- herbal alternatives to hormone replacement ther- dardized extract of black cohosh is 40 to 80 mg apy for menopause symptoms. Since the 1980s per day. The clinical studies performed prior to and up through 2005, numerous studies, including 1996 used doses of 40 to 140 mg of standardized several randomized controlled trials, have been car- extract. Although there is still some confusion ried out using a standardized extract of black about which dose of black cohosh may be most cohosh, with encouraging but mixed results.100–106 effective, the dosage used in most clinical trials to In one of the largest studies, 629 women with date is 20 to 40 mg of the standardized extract menopausal complaints received a liquid standard- twice daily. ized extract of black cohosh at 40 drops twice per Despite the two negative studies in 2006, the day for six to eight weeks. As early as four weeks collective study findings and clinical anecdotal after beginning the therapy, a clear improvement in evidence on black cohosh teach us that it is effec- the menopausal ailments was seen in approxi- tive for menopause symptoms of hot flashes, mately 80 percent of the women. After six to eight mood swings, sleep disorders, and body aches. weeks, complete disappearance of symptoms Left unanswered is, how does black cohosh occurred in approximately 50 percent.107 work? Early studies found it to have estrogenic In 2006, one study using a standardized activity,112 whereas other studies in the last few extract of black cohosh seemed to indicate bene- years have demonstrated no phytoestrogens in ficial effects on bone metabolism by stimulating black cohosh and no estrogen-like effects on LH bone-building cells and a weak effect on matura- or FSH. In addition, prolactin levels, estradiol, tion of vaginal cells,108 and another showed no and endometrial thickness were not affected by effect on menopausal symptoms.109 black cohosh.113, 114 Most recently, scientists In a third study, the Herbal Alternatives for from the University of Illinois have reported that Menopause (HALT) Study, five groups were constituents in black cohosh bind to opiate studied: black cohosh (160 mg/daily), a multi- receptors and activate responses, including core botanical herbal formula including black cohosh, temperature regulation.115 At the moment, the a multibotanical formula plus dietary soy, conju- mechanism of action is not clear, although some gated equine estrogen (0.625 mg/daily), and have postulated an effect on serotonin levels. placebo.110 Hot flash frequency and intensity did Over these same 25 years, safety and toxicity not differ between the herbal interventions and studies have also been conducted on black placebo at 3, 6, or 12 months with one excep- cohosh, and it has been subjected to increased tion. At 12 months, symptom intensity was sig- scrutiny, as has hormone replacement therapy. nificantly worse in the group that received the Two areas that receive the most attention are multibotanical formula plus dietary soy versus whether black cohosh is safe in breast cancer the placebo group. The unfortunate news here is patients and if there are any adverse effects on that black cohosh extract, in a higher dose than liver function. is generally used in clinical practice, did not show We don’t know with certainty that black benefit in the relief of hot flashes. cohosh is safe to use in breast cancer patients, but 198 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE we have compelling safety data that offers much cohosh preparations are causally associated with reassurance. There are two recent excellent reviews hepatotoxicity. No warning labels are required on of the literature on the safety of black cohosh.116, black cohosh products in the United States. In 117 The more comprehensive Low Dog paper the recent Osmers study, liver enzyme testing addresses safety in special populations, such as was done, and there was no adverse effect on liver breast cancer survivors. Recent studies find that function tests.103 Another recent long-term there is no estrogenic action of black cohosh, that observational study published in the journal it does not effect serum levels of estradiol, LH, Menopause in 2006 found no endometrial prolif- FSH, and prolactin.113, 114 In addition, in vitro eration, no negative effect on breast health, and no studies have shown that black cohosh did not hepatotoxicity after 52 weeks of 20 mg of black cause increase in proliferation of estrogen receptor cohosh extract in postmenopausal women.121 positive breast cancer cells, and it had an additive These facts, and a review of the scientific effect of inhibiting proliferation when given with literature, do not present a compelling case for the antiestrogen drug tamoxifen.118–120 A very concern.116, 117 The only true contraindication to recent study demonstrates that black cohosh black cohosh that I can point out is for the cancer inhibits the growth of human breast cancer cells.99 patient taking cisplatin. This is based on an in vitro The other area that has received a lot of atten- study in which black cohosh slightly protected tion in the last two years is whether black cohosh mouse mammary tumor cells from cisplatin.122 has adverse effects on liver function. Reports and Black cohosh did not alter the response of the cells human clinical trials including more than 2,800 to radiation or 4-HC and had an enhancing sensi- patients demonstrate the low incidence of adverse tizing effect for doxorubicin and docetaxel. Very events associated with black cohosh. The World occasional side effects have been reported that Health Organization (WHO) Collaborating include gastrointestinal discomfort, headache, Center for International Drug Monitoring data- nausea, vomiting, weight gain, and vertigo. base of adverse reactions to pharmaceutical and Standardized extracts of black cohosh continue herbal products revealed a total of 35 adverse to be one of the most reliable herbal approaches reactions to black cohosh as of July 31, 2000. The to treating a wide array of perimenopausal and reactions were primarily general and temporary menopausal symptoms. The most common symptoms and were not concentrated on a partic- dosage is 40 mg daily, but many achieve better ular organ system. This list did include one case results with 40 mg twice daily. One should expect of liver failure, one case of hepatitis, and one case results within four weeks. In my experience, about of elevated liver enzymes. These cases were related 85 percent of women will receive benefit, and to unspecified amounts of black cohosh and maybe 50 percent will achieve complete ameliora- unspecified products. Some studies on animals tion of their hot flashes and night sweats. Black reported increased liver weights associated with cohosh can also be safely and effectively used with very large doses over an extended period of time. hormone therapy. Lower doses of hormone ther- Australia, Canada, and selected European apy are often achieved by also using black cohosh countries have elected to require a warning label extract at the same time. on black cohosh about liver effects. In the United States, the National Institutes of Health (NIH) Black Cohosh concluded in 2004 that there was no competent Standardized extract capsules (40 mg per capsule): evidence to support concerns about safety in the 1–2 capsules twice per day use of black cohosh in breast cancer patients and Standardized liquid extract: 1⁄2–1 tsp twice per day that there is inadequate evidence that black MENOPAUSE 199 Chaste Tree (Vitex Agnus Castus). As an herb Saint John’s Wort (Hypericum Perfora- for the management of menopausal symptoms, I tum). Saint John’s wort is the most thoroughly believe chaste tree has been overpromoted. The researched natural antidepressant. The majority fruits of chaste tree contain essential oils, irridoids, of these studies have not been conducted on pseudoindicans, and flavonoids, and the effect of menopausal women, but in 37 of 39 clinical chaste tree is on the hypothalamus-hypophysis trials, Saint John’s wort was shown to be superior axis. It increases secretion of LH and also has an to the placebo or equal to the conventional pre- effect that favors progesterone.123–125 The result is scription antidepressant medications. In general, a shift in the ratio of estrogen to progesterone and studies have shown improvement in individuals consequently a “progesterone-like” effect. One of with mild to moderate depression.128 In a recent the most common changes that occurs in the review of studies, a total of 37 trials, including 26 menopause transition is irregular bleeding. comparisons with placebo and 14 comparisons Whether it be frequent or infrequent, heavy or with synthetic standard antidepressants, were light, ultimately a change and cessation will occur. evaluated. The authors concluded that “current In the process, some will experience significant evidence regarding hypericum extracts is incon- bleeding problems because of menses that are sistent and confusing. In patients who meet either too frequent or too heavy. These problems criteria for major depression, several recent are some of the most convincing indications for placebo-controlled trials suggest that the tested chaste tree. hypericum extracts have minimal beneficial The first major study on chaste tree was pub- effects while other trials suggest that hypericum lished in 1954.126 Although this study was pre- and standard antidepressants have similar benefi- dominantly treating women with amenorrhea cial effects.”129 (lack of menses), a dramatic improvement was One non-placebo-controlled clinical trial seen in 40 patients with cystic hyperplasia of the conducted in women with menopause symptoms endometrium (excessive thickening of the uterine found that 900 mg of Saint John’s wort for 12 lining). The impressive effect lends credence to its weeks significantly improved psychological and progesterone effect. Chaste tree was also studied in women with frequent menses and heavy menses, Sample Treatment Plan for Mild although they were not perimenopausal.127 In Depression, Irritability, and Mood Swings women who had frequent menses, the duration between periods was lengthened, and in women See the Resources section for formulation sources. with excessive bleeding, a shortening of the Diet: number of heavy bleeding days occurred. Reduce alcohol, avoid sugar and simple Chaste tree is the most important herb to carbohydrates. normalize and regulate the menstrual cycle. It is Eat whole grains, vegetables, nuts, seeds, adequate not a fast-acting herb, so do not hesitate to use it fish or low-fat dairy, proteins, and legumes. over a long period of time. Results may not be Eat regularly three meals per day. achieved until after three to six months. Lifestyle: Get 30–60 minutes of exercise daily. (See Appendix A.) Botanicals: Chaste Tree Black cohosh: 40 mg standardized extract twice Standardized extract capsules (175 mg of 75% agnu- daily side): 1 capsule per day Saint John’s wort standardized extract: 300 mg 3 Standardized liquid extract: 30–60 drops per day times per day 200 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE psychosomatic symptoms as well as a feeling of and similar reduction in depression and anxiety sexual well-being.130 in the two kava dosing groups compared with As mentioned earlier, in a double-blind, ran- the calcium alone control group, but not a clear domized, placebo-controlled study using a com- decline in general menopause symptoms scores. bination of black cohosh and Saint John’s wort, the study group was significantly superior to the Kava placebo group on both a general menopause Standardized extract (70% kavapyrones): 100–210 mg rating scale and a depression scale.111 per day

Saint John’s Wort Standardized extract of 3 percent hypericin: 300 mg 3 Additional Botanicals and Combination times per day Herbal Products for Menopause The natural food stores and drug stores are brim- Kava (Piper Methysticum). Kava is a plant ming with herbal menopause products these indigenous to Melanesia, Micronesia, and Polyne- days. You will find the herbs we have discussed in sia. Its properties have been most often associated most of them in one combination or another, with analgesic, sedative, anxiolytic, muscle relaxant, and perhaps in combination with nutritional and anticonvulsant effects. While kava is typically supplements, soy, or additional herbs that con- not often thought of as an herb for menopause, tain phytoestrogens or have some other thera- anxiety, irritability, tension, nervousness, and sleep peutic benefit specific to menopause. Most of disruption are common perimenopause and meno- these combination products have not been pause symptoms in which kava can offer some help. researched, even though individual ingredients Kava has been used as a social and ceremonial bev- have been. I am aware of only one herbal combi- erage for generations by the people of Fiji and other nation product that has been researched in a islands of the South Pacific, at least in part to create double-blind, placebo-controlled trial. I was one a relaxed, stress-free atmosphere. Kava has been of two principal investigators on this study, shown to have significant effects in reducing anxi- which set out to research the effects of a botani- ety in a number of studies.131 cal formulation containing phytoestrogens on Three randomized, controlled trials have menopausal symptoms, serum lipids, and some investigated the value of kava for menopausal of the hormone indicators of menopause.136 symptoms.132–134 The first two showed signifi- The treatment group took two capsules of cant reduction in anxiety and general menopause burdock root, licorice root, motherwort, dong symptoms and the third a reduction in the anxi- quai, and wild yam root three times per day. ety scale, with kava plus HRT showing the great- After three months, women receiving the herbal est improvement. product showed a greater response rate than In 2003, another valuable study evaluated the women in the placebo group. One hundred per- effects of kava on anxiety, depression, and meno- cent of women taking the botanical formula had pause symptoms in perimenopausal women for a reduction in their symptom severity, while only three months.135 Eighty women were random- 67 percent of women receiving the placebo ized to one of three groups. The control group showed a decrease. Seventy-one percent of knowingly received 1,000 mg of calcium per day, women taking the herbal formula reported a the second group received the calcium and 100 reduction in the total number of symptoms, while mg of kava, and the third group received the only 17 percent of the women taking the placebo calcium and 200 mg of kava. There was a clear reported a decrease in the total number of their MENOPAUSE 201 symptoms. The botanical formula was most effec- menopausal women aged 50 to 79.28 This study, tive in treating hot flashes, mood changes, and of 0.625 mg conjugated equine estrogens (Pre- insomnia. marin) and 2.5 mg medroxyprogesterone acetate Numerous other herbs can be helpful for (Provera) was halted prematurely after 5.2 years individual menopause symptoms. The German due to a slight increase in the risk of breast cancer Commission E (the German agency similar to in women receiving the HRT. Women in the our FDA) has approved hops for mood issues hormone group also appeared to have higher such as anxiety and restlessness and for sleep rates of strokes, heart attacks, and blood clots disruptions.137 Hops contain a group of non- than the placebo group. The HRT users also had steroidal phytoestrogens called prenylflavonoids. a reduced risk of colorectal cancer and fractures, In one study, 67 menopausal women were given but overall the risks outweighed the benefits. either a placebo or a 100 mcg or 250 mcg stan- This study marked a significant moment in his- dardized hop extract for 12 weeks.138 At 6 weeks, tory for HRT, and millions of women discontin- the 100 mcg dose was significantly superior to ued their HRT as a result of the findings. In the the placebo, but not after 12 weeks. Even so, five years since the WHI, many studies have been there was a more rapid decrease in menopause completed, shedding new light on why decades symptoms for both doses of hop extract, espe- of observational studies of postmenopausal cially the hot flash score. The higher dose was not women using HRT differed from the WHI study any better than the lower dose. and why there seems to be such disparity Valerian has been used for centuries by many amongst some of the key studies in the area of different cultures and has been used in modern memory, heart disease, and breast cancer in par- times, mostly for anxiety and insomnia. Three ticular. While reviewing each of these studies randomized clinical trials have showed improve- would be informative, I would like to summarize ment in sleep quality, although none of these stud- and utilize the 2007 position statement of the ies were specific to menopausal women.139–141 North American Menopause Society (NAMS) Motherwort is another plant that has been and its expert advisory panel of clinicians and used historically in situations that are relevant to experts in the field of women’s health.143 The pri- perimenopause and menopause. It can ease heart mary goal of understanding HRT research in palpitations and act as a calming agent, known peri- and postmenopausal women is to come to as a nervine. The German Commission E has some determination as to the risks and benefits of approved its use for nervous cardiac problems.142 estrogen therapy (ET) and estrogen-progestogen therapy (EPT) for symptom relief and disease OVERVIEW OF HORMONE prevention and treatment. For a more compre- REPLACEMENT THERAPY hensive discussion on osteoporosis and heart dis- Hormone replacement therapy (HRT), now ease, and on the benefits and risks of ET and often called HT as well, has been used since the EPT, I refer you to Chapters 14 and 9. 1950s to treat menopause symptoms and to pre- The NAMS panel offered two main categories vent osteoporosis and heart disease. Several key of recommendations: those where the panel was studies, of the last nine years in particular, have able to reach consensus and those where they were challenged previously held beliefs about the not. There are several factors involved in the lack of safety and efficacy of long-term HRT use. The consensus recommendations: the timing of when Women’s Health Initiative (WHI) was the most HRT was started in relation to perimenopause and famous of these studies and was a large-scale, menopause accounts for part of the difficulty. randomized, controlled clinical trial of 16,608 Starting HRT in early perimenopause has a differ- 202 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE ent risk-benefit profile than starting 5, 10, or even of these products is to provide protection to more years beyond the last menstrual period. In the lining of the uterus when estrogen is given. addition, the panel acknowledged that there is Postmenopausal women who have a uterus and insufficient scientific data on the risks of long-term who are given estrogen need an adequate dose of use of HRT for symptom control versus the long- a progestogen in order to prevent endometrial term use for reduction of risk of certain diseases cancer. For women who have no uterus, a proges- such as osteoporosis, heart disease, or even demen- togen is generally not prescribed with the tia. Another difficulty faced in drawing conclusions systemic estrogen. (Some practitioners, and espe- from the HRT research is that not all the groups of cially alternative-minded practitioners, believe women studied are comparable. Some groups have that giving a bio-identical progesterone can have more women on statins (drugs for high cholesterol) additional health benefits other than protecting and others have more overweight women, smokers, the uterus from the estrogen. A discussion on or previous users of HRT. These are just some of this is included in the section on bio-identical the significant variables involved in comparing one progesterone later in this chapter.) A progestogen study to the next. is generally not indicated when a low-dose vaginal estrogen is used for local vaginal effects. Recommendations for the Use of HRT Coronary Heart Disease. “The majority of The following summarizes the areas of consensus observational and preclinical studies support the recommendations for the use of HRT,143 along potential benefits of systemic ET/EPT in reduc- with some additional input for clarification and ing coronary heart disease (CHD) risk. Most discussion. randomized clinical trials do not. Emerging data Evaluation Prior to Starting HRT. All suggest that these disparities in findings may be women should have a complete health evalua- related to the timing of initiation of ET/EPT in tion, including a medical history and physical relation to the proximity of menopause. It is cur- examination and a mammogram within the pre- rently not clear if ET/EPT can prevent CHD in vious 12 months before HRT. Decisions on bone women who do not have evidence of CHD density testing are made based on each situation. (called primary prevention). There is current evidence that initiating ET/EPT in perimenopausal Hot Flashes. The primary indication for or early postmenopausal women may indeed using HRT is for the treatment of hot flashes and offer protection, but this needs further evalua- night sweats. tion. For women who already have evidence of Vaginal Symptoms. Most systemic and vagi- CHD, EPT does not provide prevention of nal ET and EPT products are approved for treat- future cardiovascular problems (called secondary ing symptoms of vulvar and vaginal atrophy. prevention). For the moment, the NAMS panel These symptoms include vaginal dryness, painful states that the use of ET/EPT is not recom- vaginal sexual activity, and atrophic vaginitis. If mended for the purpose of coronary heart disease one or more of these symptoms are the only prevention in women, no matter their age. It is menopause symptom, then a local vaginal estro- also important to note that in the WHI study of gen is recommended rather than products that estrogen only, there was no increased risk of deliver a systemic effect. CHD.144 Progestogens. Progestogens include bio- Venous Thromboembolism (Blood Clots). identical progesterone and progestins (which Postmenopausal women who use ET or EPT have are synthetic). The primary purpose for the use an increase in the risk of venous thromboem- MENOPAUSE 203 bolism (VTE). This tends to appear during the ference between women who use HRT daily and first one to two years after starting the hormones, those who cycle their hormones by going off for a and it tends to decrease over time. In the WHI, few days per month. In the ET arm of the WHI, there were 11 additional cases per 10,000 women there was no increase in the risk of breast cancer per year of using EPT and 2 additional cases per even after seven years of use, and in fact there were 10,000 per year in the ET-only women aged 50 to eight fewer cases of breast cancer per 10,000 59. It is thought that lower doses of estrogen may women per year of use of estrogen only.144 be safer, and possibly estrogen delivered transder- EPT increases the proliferation of breast cells, mally as well (creams, gels, and patches). breast pain, and density of mammograms. ET Stroke. Both ET and EPT appear to increase only does this to a lesser degree. In fact, it is pos- the risk of ischemic strokes (deficiency of blood sible that EPT may interfere with the radiologi- supply caused by a clot) in postmenopausal cal interpretation of mammograms. (Other women, although clinical trials have not been research has shown that women who take EPT consistent. There were 8 additional strokes per and acquire breast cancer get diagnosed earlier on 10,000 women per year in the WHI EPT group mammograms and have less invasive disease, and 12 additional strokes per 10,000 women per smaller tumors, and better outcomes.) year in the WHI ET only group. This is consid- Osteoporosis. Both ET and EPT reduce the ered rare for the EPT group and slightly above risk of osteoporotic fractures. For women who rare for the ET group. The risk is even lower in have osteoporosis or are at high risk for fractures, women who are 50 to 59 years old or within the ET/EPT is a treatment option. One should first five years of menopause. Women who weigh the benefits and the risks of this and other already have cardiovascular disease have a higher treatment options. risk of stroke even without the use of hormone Depression. Short-term ET may have anti- therapy. The panel concluded that no HRT regi- depressant activity in perimenopausal women men should be used for the primary or secondary but not in older postmenopausal women. The prevention of stroke, and HRT should be partic- panel did not support the use of ET or EPT for ularly avoided for women who have an elevated the treatment of depression. baseline risk of stroke. Dementia and Cognitive Decline. Starting Diabetes Mellitus. Large good studies sug- EPT after age 65 is not recommended for gest that HRT reduces the onset of diabetes mel- the prevention of dementia or cognitive decline. litus (DM). Women in the EPT group of the The Women’s Health Initiative memory study WHI had a 21 percent reduction in DM or what showed an increase in the risk of dementia resulted in 15 fewer cases per 10,000 women per during the five years in women 65 and older.145 year of hormone use. Even so, the panel does not It is not yet clear as to whether ET or EPT can recommend the use of EPT for the sole purpose prevent dementia when hormones are started of DM prevention. during perimenopause or early postmenopause. Breast Cancer. According to the WHI, breast Premature Menopause and Premature cancer risk slightly increases in women on EPT Ovarian Failure. Women who have the onset of after five years of use. This risk was rare, slightly menopause early, and especially prior to age 40, less than having a first-degree relative with breast have lower risks of breast cancer, but earlier onset cancer, but resulted in four to six additional breast of bone loss and CHD. It is not known if ET or cancers per 10,000 women per year in EPT users EPT affects these conditions in this population for five or more years. It is not clear if there is a dif- of women. It is logical to think that younger 204 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE women who start ET or EPT may experience want to make based on the benefits they receive more benefits, but this is not known. in relieving their menopause symptoms. These Risks and Benefits. An overriding perspec- benefits may outweigh the risks. Other women tive of ET and EPT use offered by the NAMS who may want to use HRT long term are women panel is that HRT should be used based on cer- with osteoporosis who also have moderate to tain goals and evaluating the benefits and risks severe menopause symptoms. Another group is for each individual woman. This should also take women who have low bone density for whom into account the cause of menopause (surgical, other nonhormonal therapies cause too many medications, normal physiology), time since side effects or do not work to slow bone loss. For menopause, and scope and severity of symptoms women who have been on HRT and decide to and their impact on quality of life, as well as the stop, symptoms have about a 50 percent chance underlying risk of cardiovascular disease, stroke, of recurring. clots, DM, dementia, and depression. The panel’s position on bio-identical hormones that are compounded for an individual by Dosing. Lower doses should be considered a special pharmacy is that any risk-benefit data and can provide adequate symptom relief in pertaining to other kinds of hormones also many women, while also being able to stabilize applies to these compounded hormones. They bone loss. Some women will not achieve ade- also expressed a concern as to quality control quate results with lower doses or may need an issues with some bio-identical compounded hor- additional vaginal estrogen for local vaginal mone prescriptions. (In my opinion and experi- symptoms. These lower ET and EPT doses are ence, quality control is not an issue with better tolerated in terms of less breast tenderness, compounding pharmacies that are operated by for example, and may have a better risk-benefit licensed pharmacists with oversight by state and profile, although this is not known for certain. federal agencies.) Non-Oral Hormones. There is some evi- There were only two areas where the panel did dence that transdermal estradiol supplied not reach consensus. How to discontinue HRT through patches, gels, or creams is less likely to was one area. Some clinicians recommend abrupt cause blood clots because it initially bypasses discontinuation of HRT, while others taper the metabolism by the liver, which has clotting fac- dose. In general, it doesn’t seem to affect the tors. There is no evidence that transdermal estro- return of menopause symptoms. In women who gens are any safer for the breast. have a history of severe symptoms, tapering the Additional Issues. Some additional guide- dose is a compelling approach, and I find it to be lines are offered by the advisory panel. The preferable. However, there is not current data to results of the WHI are relevant especially for suggest whether stopping abruptly or reducing women in their mid-60s but should be extrapo- gradually over time is better. The other area with lated with caution for perimenopausal women, lack of agreement is whether taking estrogen and women younger than 50 who use HRT, and for progestin every day has a different effect than women early in their menopause. Short-term cycling the estrogen and progestin or just cycling use (less than five years) in symptomatic peri- the progestin. There is some concern that daily menopausal and early menopausal women is progestin may be related to the adverse breast generally considered beneficial with very small cancer and cardiovascular effects, but the data is risks. conflicting on this topic. Long-term use of the lowest effective dose of The panel concluded that each woman will ET or EPT is a decision that many women may have to decide for herself based on her own goals MENOPAUSE 205 and her own concerns relevant to benefits and been the most commonly prescribed estrogen in risks of long-term HRT. An age of less than 60 and the United States. Conjugated estrogens are within the first four years of menopause are the derived from pregnant mares’ urine. In the 1970s more optimal times to use HRT. The potential it was believed that Premarin consisted of only risks are small, and even rare, except for stroke, 10 estrogens—17 beta-estradiol, 17 beta dihy- especially for women who use estrogen only. For droequilin, 17 beta dihydroequilenin, 17 alpha women younger than 50 and at low risk for CHD, dihydroequilin, 17 alpha estradiol, estrone, equi- stroke, osteoporosis, breast cancer, and colon lin, 17 alpha dihydroequilenin, delta 8-9 dehy- cancer, the risks or benefits for HRT are even droestrone sulfate, and equilenin. Since then, smaller than those described in the WHI. Again, advancements in technology have revealed that it is important to emphasize that each woman the original 10 estrogens make up less than 40 should have an evaluation prior to hormone use percent of the hormonal content of Premarin. and should be informed of potential risks. Using modern analytical techniques, today over 200 individual components have been identified, Bio-Identical or Natural Hormones including androgens and progestins.146 The com- One of the greatest areas of confusion in meno- position of Premarin is complex, and different pause medicine today is the subject of bio- estrogens produce various effects in different identical or natural hormones. The bio-identical tissues. Herein may lie a theoretical basis for a hormones include estradiol, estrone, estriol, potentially different effect of conjugated equine progesterone, testosterone, and dehydroepian- estrogens versus bio-identical estradiol. Dr. Joel drosterone (DHEA). These hormones are dis- Hargrove has shed some light on these distinc- tinct from many of the commercially available tions for years.147 His hypothesis is that a nonprescription hormones—some of which are syn- bio-identical hormone may act like an environ- thetic, while others may be derived from a natu- mental toxin to the genetic material within the cell ral substance but are still not bio-identical. because even though it can bind to the receptor Bio-identical hormones are made from either hormone complex, it is a foreign substance. beta-sitosterol extracted from the soybean or Besides the effect on the genes themselves, from diosgenin extracted from Mexican wild bio-identical hormones and non-bio-identical yam root. Those compounds are made into the hormones may very well leave what Dr. Hargrove desired hormone that is biochemically identical calls a “different metabolic footprint” on the rest to the hormone the body produces. By defini- of the body with different metabolic conse- tion, a “natural” hormone is plant derived and quences. They may be directly cytotoxic to bio-identical. The bio-identical estrogens include estrogen-sensitive tissues, bind differently to dif- estriol, estrone, and estradiol. By contrast, non- ferent kinds of estrogen receptors, alter binding bio-identical hormones are intentionally differ- of other hormones to those receptors, or alter the ent in chemical makeup from the body’s natural liver’s metabolism of carcinogens. It is this dis- hormones and include conjugated plant estro- tinction and potential difference in metabolic gens, conjugated equine estrogens, synthetic consequences, as well as the shorter half-life of estrogens, synthetic progestogens, called prog- bio-identical hormones, that motivates me to use estins, and synthetic testosterone. It is the chem- almost exclusively bio-identical hormones. ical structure of a hormone, not its source, that Bio-identical estrogens are available as either determines if a hormone is bio-identical or not. a patented conventional hormone prescription For the past 50 years, conjugated equine made by a pharmaceutical company and dis- estrogen, under the brand name Premarin, has pensed from a regular pharmacy with a prescrip- 206 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE tion, or in a nonpatented form from a specialty conjugated equine estrogens, or conjugated plant pharmacy called a compounding pharmacy, also estrogens. (There are, however, some clear and available only by prescription. There are a few potential advantages to bio-identical proges- key advantages to the compounded forms. First, terone over progestogens.) Much of the decision health-care providers can create customized as to which kind of hormone to take depends on dosing regimens and potencies to fit each indi- the woman. vidual woman, which can be adjusted in small Some would argue that the advantage of con- units to taper a woman onto or off of treatment. ventional pharmaceutical company HRT is that Second, the pharmaceutical company versions it has undergone years of scientific study. While have additives, binders, adhesives, or preserva- this is true, there has been little effort to make tives included in their formulations because they distinctions between different kinds of estrogens. patent one or more of those or the delivery tech- Also, as you will see, combining estriol with nology rather than the estrogen itself. As more estradiol, and the use of bio-identical proges- and more practitioners recognize, these chemical terone and testosterone with the estrogens, pro- substances can cause reactions and side effects in vide the potential maximum benefit and a more many individuals. These can include skin reac- individualized approach for each patient. tions, headaches, digestive problems, or others, only because of the chemical additive, not Bio-Identical Estrogens because of the estrogen itself. Estrogen is the major hormone that has been Third, bio-identical hormone formulations used to treat menopausal symptoms. There are have a vast array of delivery options to attend to three dominant estrogens in the body: estradiol, the specific individual needs of each patient. estrone, and estriol. Estradiol is the primary Capsules, sublingual lozenges or pellets, creams, estrogen produced by the ovaries. Estrone is gels, vaginal creams or gels or tablets, nasal formed from estradiol. Estriol is produced in sprays, and even pellets that are implanted under large amounts during pregnancy and is a break- the skin are available in an infinite array of down product of estradiol. Before menopause, dosing combinations. These exceed the limited estradiol is the body’s predominant estrogen; number of doses and deliveries that are available after menopause estradiol levels drop so that in either the pharmaceutical company bio- estrone becomes the predominant estrogen. Bio- identical hormone preparations or the synthetic identical estrogen preparations mirror these three and semisynthetic prescription items. naturally occurring estrogens in your body. Finally, bio-identical estrogens include estradiol, estriol, and estrone, as I mentioned earlier. Estriol. Naturally occurring estriol is pro- Bio-identical progesterone, testosterone, and duced by the body almost exclusively during DHEA are also available. Any combination of pregnancy. Practitioners of alternative medicine these hormones can be formulated in a com- primarily use estriol to treat menopausal symp- pounded hormone prescription: any dose, any toms because it is considered to be the safest combination, and the numerous delivery options. form of estrogen—it is thought to be less car- I am not suggesting that bio-identical hor- cinogenic than estradiol and estrone and is about mones are innately good and other hormones are one-fourth the potency. innately bad. I want to stress that there currently Several researchers have studied the use of is no scientific evidence that bio-identical estra- estriol on postmenopausal women. Symptoms diol has a better safety profile than the non- that were alleviated with estriol treatment bio-identical estrogens of synthetic estrogens, included hot flashes, insomnia, and vaginal dry- MENOPAUSE 207 ness and itching during intercourse. A common called endometrial hyperplasia, that can lead to problem associated with menopause is atrophic cancer), there have been mixed results. In typical vaginitis, a condition that occurs when estrogen is doses from 1 to 4 mg, there appears to be no lacking in the body. Symptoms may include vagi- thickening of the lining of the uterus. If I were nal dryness, pain with penetration, increased fre- prescribing higher doses, I would advise using quency of vaginal and urinary tract infections, estriol along with a proven progestational agent urinary incontinence, and urinary frequency and to protect the lining from this thickening effect. urgency. Estriol and Heart Disease Risk. Estriol has Estriol can be taken orally, in capsules or not been studied as extensively as conventional tablets, and intravaginally in a cream, gel, or sup- HRT in terms of its affect on the risk for heart pository to treat urinary incontinence, urgency, disease; however, a few studies indicate positive persistent urinary tract infections, and recurring effects of estriol, while others have found estriol vaginal infections. I often prescribe estriol vagi- to have no effect on blood cholesterol levels, a nal cream or suppositories for dry or itchy tissue precursor of heart disease.150 There is no clear related to low estrogen, vulvar/vaginal discom- risk or benefit related to estriol and heart disease. fort with sexual activity, urinary incontinence, and recurrent urinary tract and vaginal infections Estriol and Bone Density. Estriol also has in women who are peri- or postmenopausal. been minimally studied regarding its effects on These creams most likely work by restoring the bone density and loss; therefore, I do not use vaginal flora, which improves vaginal and blad- estriol to slow or prevent bone loss or to treat low der health, and increasing lubrication, elasticity, bone density. The research is just not convincing and thickness of the vaginal skin cells. enough at this point. However, estriol taken with Estriol cream is equal to the estradiol ring in calcium lactate supplements may help prevent decreasing vaginal dryness, decreasing atrophic bone loss that occurs during menopause. signs (signs of thinning), and decreasing the vagi- Estriol and Breast Cancer. Women often nal pH to a more preferred acidic environment. opt against conventional HRT because they are However, the estriol cream may not be quite as afraid that it might put them at risk for breast good at decreasing the itching.148 Estriol has also cancer. Many practitioners and researchers agree decreased the incidence of bladder infections.149 that there is a slight increased risk, and delivering A common prescription is 1 mg of estriol per the safest possible hormone options continues to gram of cream. One gram of cream is inserted in be a goal. This has led some to study and use the vagina daily for two weeks as a loading dose, estriol for reducing the risk of and treating breast then twice a week as a maintenance program. cancer. Henry Lemon, M.D., a leading researcher on Estriol estriol, has concluded that small doses of estriol Oral estriol: 1–4 mg per day given in a noncontinuous dosing or cyclic sched- Vaginal cream (1 mg/g): insert 1 g every night for 2 ule provides protection from breast cancer. weeks, then twice weekly as a maintenance dose Although his hypothesis and work is interesting and provides an appealing basis in which to use Estriol and Endometrial Cancer. Although estriol, his findings have not been followed up there has been a good deal of study as to the with rigorous clinical trials. The results of other effects of estriol therapy on the endometrial or research has not been promising.151 Estriol, uterine lining (conventional estrogen therapies estrone, and estradiol all stimulated human cause a thickening or overgrowth of the lining, breast cancer cells in tissue cultures. However, 208 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE estriol may reduce the negative effects of the diol and estrone. Currently, practitioners who cancer drug tamoxifen for women already diag- prescribe a triple-estrogen compound typically nosed with breast cancer.152 use a formula of 80 percent estriol, 10 percent estradiol, and 10 percent estrone. Progesterone is Prescribing Estriol. Estriol seems to be help- added to the formula at a minimum of 100 mg ful in treating many of the symptoms of meno- per day to protect the uterus from the potential pause such as hot flashes. However, the jury is still effects of the estrogen in thickening the lining of out as to whether estriol will protect you from the endometrium. Using estrogen only, without conditions such as osteoporosis and if it provides the proper dose of progesterone, in women with any heart disease protection or adverse cardiovas- a uterus might put them at risk for endometrial cular effects. Women who currently have breast hyperplasia or even endometrial (uterine) cancer. cancer or who are survivors must weigh the bene- I use a bi-estrogen formulation containing fits and risks after being provided with well- estriol and estradiol, which is increasingly popular balanced information. The prudent thing to do, because of concerns that estrone may be associated given current research, is for breast cancer sur- with more carcinogenic estrogen metabolites and vivors to avoid the use of oral estriol. Vaginal thus an increase in the risk of breast cancer. estriol for vaginal dryness, however, is a preferred form of vaginal estrogen for breast cancer sur- Bio-Identical or Natural Progesterone vivors. In a study of 11 postmenopausal women Many people make the mistake of using the term with vaginal atrophy who were treated for eight progesterone when they really mean its synthetic weeks with 0.5 mg/day of estriol vaginal cream counterpart, progestin. Progesterone is the other daily for three weeks then twice weekly for five natural hormone your ovaries make, other than weeks, there was no change in blood levels of estrogen, and its main function before meno- estradiol or estrone.153 In another study of 74 pause is to support pregnancy. Progestin is the postmenopausal women with vaginal atrophy term applied to the synthetic derivatives, which treated with vaginal estriol cream, while blood differ in biochemical structure from proges- estriol levels rose initially followed by a gradual terone. Progestins are the synthetic hormones decline, the levels of the stronger estrogens, used in conventional hormone replacement ther- estrone and estradiol, were unchanged.154 This is apy and birth control pills and are what often considered reassuring for breast cancer survivors. account for the side effects that some women feel A popular practice for prescribing com- when taking these medications such as irritabil- pounded natural estrogens is to combine the ity, depression, bloating, and mood swings. potentially safer estriol with small doses of estra- These side effects are due to the progestins’ ten- Tri-Estrogen and Bi-Estrogen dency to cause water retention, affect brain Formulation Dosages chemistry, and alter other steroid pathways. Pro- gestogen is a term applied to any substance pos- Tri-estrogen formulation (estriol 1 mg/estradiol .125 sessing progesterone qualities. It can refer to mg/estrone .125 mg/progesterone 50 mg): 1 cap- progesterone or a progestin. sule twice daily (equivalent to 0.625 mg Premarin During the perimenopausal phase, when a ϩ 2.5 mg Provera) woman may have months or years of irregular Bi-estrogen formulation (estriol 1 mg/estradiol .250 ovulation, her production of progesterone begins mg/progesterone 50 mg): 1 capsule twice daily to decline. Progesterone falls to almost zero in (equivalent to 0.625 mg Premarin or 2.5 mg Provera) the beginning of menopause, while estrogen levels decline to about 40 to 60 percent of pre- MENOPAUSE 209 menopausal levels. The progesterone deficiency may have a positive affect on cholesterol profiles explains many of the perimenopausal symptoms and help to keep the coronary arteries in the such as mood swings, hot flashes, vaginal dry- heart dilated. ness, and irregular menses. If you are taking estrogen and are one of the In treating perimenopause and menopause few women who cannot tolerate either the syn- symptoms, progesterone can be used for the relief thetic or natural progesterone, you must be mon- of symptoms and to balance the effects of estro- itored by a primary care practitioner to watch for gen on the uterus. It has a critical role in prevent- certain cancers such as uterine cancer. ing endometrial hyperplasia (an overgrowth or Progesterone is available with a prescription in thickening of the uterine lining) and uterine the form of an oral capsule, sublingual drops, sub- cancer. Progesterone is often touted in the natu- lingual pellets, lozenges, or transvaginal or rectal ral products marketplace as effective for the pre- suppositories; it also may be injected. Progesterone vention and treatment of osteoporosis, but is also available over the counter as a cream. clinical trials show that neither oral natural progesterone nor progesterone patches or creams can Progesterone Creams. The most popular slow, prevent, or reverse bone loss. form of progesterone is the topical cream. The I can’t stress enough that if you are peri- or goal of natural progesterone cream is to support postmenopausal and are taking any form of estro- the waning daily production of progesterone in gen, you must also take a proven form and dosage the body and keep progesterone at normal levels. of progesterone (or progestin) to protect your The goal is not to supply pharmacological levels uterus from hyperplasia and cancer. The excep- (higher doses), as is the case with oral progesterone. tion is women who have had a hysterectomy; they Unfortunately there is currently considerable con- do not need to take progesterone or progestins. fusion and misinformation about progesterone However, there are times when adding natural creams. There are two basic categories of creams: progesterone rather than increasing the dose of • Those that contain wild yam and no the estrogen, even in women without a uterus, progesterone may alleviate some menopausal symptoms. Some • Those that contain diosgenin extract (a phy- women’s insomnia, fatigue, mood swings, and toestrogen compound) from wild yam that other menopause symptoms may be more respon- is converted into natural progesterone in a sive to progesterone than to estrogen. laboratory It is important to note that all progestins (the synthetic progestogen) can have undesired The problem is that the creams that contain only side effects.155 Premenstrual symptoms such as wild yam are not effective as a progesterone agent increased breast tenderness, edema, irritability, because the body cannot convert the diosgenin and abdominal cramps are fairly frequent, caus- to progesterone. ing as much as 40 percent of women to not take The confusion is further exacerbated by the their prescriptions properly. More serious side varied strengths of the creams. The wild yam effects are rare and include high blood pressure, creams with bio-identical progesterone added blood clotting, and altered carbohydrate lipid come in a wide range of dosages. Some of these metabolism.156 If you try the synthetic progestins products have less than 2 mg of progesterone per and find you cannot tolerate them, bio-identical ounce of cream, some have between 2 and 15 mg progesterone is an excellent option. In fact, bio- per ounce, and some have as much as 400 mg per identical progesterone is a preferred option not ounce or more. It is important to know exactly only to minimize these symptoms, but it also what you are getting because the strength of the 210 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE cream will dictate how it is used and what symp- applied on a regular basis.157 This same study also toms it should be used for. demonstrated significant improvement in hot As a practitioner, when using the proges- flashes and night sweats. However, another study terone creams, I largely use the creams that have on transdermal progesterone cream delivering 32 at least 400 mg per ounce because they yield the mg daily did not show evidence that it supplied best results for most women suffering from PMS, sufficient hormone to enter the body to achieve a menopause symptoms, and irregular bleeding. In biologic or therapeutic effect on lipid levels or general, these doses of bio-identical progesterone bone mineral markers or to improve vasomotor in cream form tend to be effective for milder symptoms or moods.158 Bio-identical proges- symptoms of menopause. terone cream has yet to be adequately studied to In general, women tolerate bio-identical prog- show sufficient protection of the uterus when esterone cream extremely well, and most find it given with an oral estrogen or estrogen patch. effective for alleviating some menopausal symp- I do not recommend that progesterone toms. Very few women experience side effects creams be used to prevent heart disease, osteo- (reported as less than 4 percent by the manufac- porosis, breast cancer, endometrial hyperplasia, turing companies), but these may include breast or uterine cancer. There is continuing research tenderness, drowsiness, depressive moods, head- on the benefits of progesterone creams, but to aches, and irritability. In my experience as a clini- date there is insufficient evidence that they pro- cian, I have found very few side effects. tect women from any of these conditions. Bio-identical progesterone cream is typically Oral Micronized Progesterone (OMP). used for menopausal symptoms such as hot While bio-identical progesterone creams are pop- flashes, mood swings, sleep disruption, and irregular with women in menopause, only the oral, ular and/or heavy bleeding. Absorption of prog- injectable, and vaginal gel forms, available by esterone from the creams through the skin is prescription only, are available in high enough variable from person to person. A study evaluat- concentrations to protect against endometrial ing different concentrations of progesterone hyperplasia, a thickening of the uterus that can creams has demonstrated that the progesterone lead to cancer. can be measured in the blood if the cream is Studies demonstrate that oral micronized Natural Progesterone Cream progesterone (OMP) is effective in preventing endometrial hyperplasia associated with estrogen Apply natural progesterone cream (400 mg proges- use.159 It does not undermine estrogen’s bone loss terone per ounce) to the palms, inner upper arms, or benefits, nor does it improve bone density when inner thighs. it is added to estrogen replacement,160 and it does not appear to increase the risk of heart disease.161 Perimenopausal Women However, I can’t stress enough that if you are Days 1–7: do not use progesterone cream during peri- or postmenopausal with an intact uterus menses and taking any kind of estrogen, you must also Days 8–21: 1⁄4 tsp twice a day take a proven form and dosage of progesterone Days 22–28: 1⁄4–1⁄2 tsp twice a day (or progestin) to protect your uterus from hyperplasia and uterine cancer. If you do not tolerate Menopausal or Postmenopausal Women synthetic progestins, bio-identical progesterone 1⁄4 tsp twice daily continuously is an excellent option. If you are one of the small number of women who do not even tolerate bio- MENOPAUSE 211

Oral Micronized Progesterone (OMP) Sublingual Progesterone. Sublingual (under the tongue) progesterone has basically the same Perimenopausal woman taking continuous estrogen uses for menopause and premenstrual symptoms and/or a monthly menstrual cycle is desired: 100 mg as the creams and the oral progesterone. How- twice daily (or 200 mg once daily) 12 days per month ever, it is generally stronger than the creams and Perimenopausal woman taking estrogen and/or a weaker than the usual oral doses. Typically, the monthly menstrual cycle is desired: 1 mg estradiol tablets must remain under the tongue for 20 (or equivalent) plus 50 mg OMP twice daily (or 100 minutes while they dissolve before the proges- mg once daily) 3 weeks on and 1 week off (during menses) terone is fully absorbed. Postmenopausal woman taking continuous estrogen One advantage of sublingual tablets—as well and a monthly cycle is not desired: 1 mg estradiol as creams and vaginal and rectal suppositories— (or equivalent) plus 50 mg OMP twice daily (or is that they are not significantly metabolized by 100mg once daily) continuously the liver, as is the case with oral progesterone. In my experience, women have few side effects with This is thought to minimize side effects. However, OMP in doses of 200 mg or less. Higher doses, 400 there is very little information available as to mg per day, are sometimes prescribed for amenorrhea, how sublingual progesterone works and its possi- or lack of menstruation, in women who are not yet ble longer-term side effects, so I take care when truly menopausal, or to manage heavy acute uterine recommending this form of progesterone. The bleeding. However, in high doses OMP can cause side main issue is that sublingual progesterone and effects, including dizziness, abdominal cramping, progesterone creams have not yet been proven to headaches, breast pain, nausea, diarrhea, fatigue, irri- protect the uterus from the effects of estrogen tability, and abdominal bloating.162 replacement. Rectal administration of progesterone has not identical progesterone and you are taking an been well studied. Nasal sprays of progesterone estrogen, then you and your uterus must be reg- (in oil) produce relatively low serum levels, ularly monitored by a primary care practitioner. which are sustained for only a few hours.163 Even OMP is available by prescription from a com- though these levels are low, they can produce pounding natural pharmacy in any dose your some secretory changes in the endometrium and provider prescribes. It is also available from a may prove with further study to be sufficient to conventional pharmacy under the trade name reverse endometrial hyperplastic effects of estro- Prometrium. For perimenopausal women who gen replacement therapy. are taking estrogen every day, oral progesterone can be given at a dose of 100 mg per day every More About HRT and Breast Cancer. The day, or it can be given at 200 mg per day on days issue of progestogens and breast cancer is com- 15 to 26 of the cycle. plex and not very well understood. It is difficult These doses are based on an average dose of to come to a comfortable conclusion on this estrogen replacement or less. For higher doses of matter. One of the largest studies to date, the estrogen, the dose of progesterone will need to be Nurses’ Health Study, showed that adding a syn- increased as well, typically doubled. Progesterone thetic progestin to estrogen failed to reduce the is prescribed on a cyclical basis (as opposed to incidence of breast cancer and actually increased every day) for women who are still bleeding. This it.164 Women taking estrogen alone had a 36 per- cycling of the progesterone allows them to still cent increase in their risk of breast cancer; those have a monthly period, the onset of which occurs on estrogen plus progestin had a 50 percent within a few days of stopping the progesterone. increase; those on progestins alone had a 240 212 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE percent increase—although this number may be whether postmenopausal HRT increased the misleading because the number of women on risks for breast cancer and death from breast only progestins was very small. The Nurses’ cancer in women with a family history of breast Health Study also was able to report on duration cancer.168 There was no significant increase in the of use. For women who had been taking estrogen rate of breast cancer even in women with a family and progestin for five to ten years, there was a 46 history of breast cancer who were using HRT percent increase in their risk of breast cancer. At longer than five years. These results are consistent the end of 2000, the Nurses’ Health Study pub- with other reports that there is no additional risk lished its estimates of breast cancer risk associated in using HRT/ERT in women who have a first- with HRT in postmenopausal women.165 The degree relative with breast cancer. results were expressed as percentage increases in The latest analysis from the Iowa Women’s the cumulative risk of breast cancer and were Health Study, an 11-year follow-up, showed an frightening to many: the use of estrogen alone association between women who had ever used for 10 years leads to a 23 percent increase by age postmenopausal HRT and the risk of breast can- 70, and the use of estrogen plus progestin for 10 cers that were more localized and had a better years leads to a 67 percent increase by age 70. It prognosis.169 The study did not find an increased is important to realize that the result is not an risk of invasive ductal or lobular carcinoma in actual mathematical conclusion but the conclu- women who had used HRT either less than or sion of the model, the consequences of a small more than five years. A slight increased risk of difference in risk that gets magnified as the math breast cancer was observed in current users and is carried out into the future. Also, it is important those with less than five years of use; current to realize that risk estimates represent a projec- users with more than five years of use had no tion, not an actual measurement. increase in risk. These results are the opposite of Another study done in Seattle had contradic- those seen in the Nurses’ Health Study—women tory findings to the Nurses’ Health Study.166 This who are using HRT for more than five years study found no effect on the risk of breast cancer have the increase in risk.164 Two other recent from either estrogen alone or estrogen and prog- studies, the Carolina Breast Cancer Study170 and estins together. In the WHI group of estrogen analyses from the National Health and Nutrition plus progestin users, there was a slight increase Examination Survey (NHANES),171 found no in breast cancer after five years of use.28 In the increased risk with postmenopausal hormones. estrogen-only arm of the WHI, estrogen did not These recent studies perpetuate the inconsistency increase the risk of breast cancer, even after seven in research on this issue that has been true in the years of use.144 last 25 years. This provides some logic to the At the other end of the pendulum, investiga- point of view that if there is an increased risk of tions that have found no increased risk of breast breast cancer associated with ERT/HRT, the risk cancer with HRT or ERT use receive much less must be small because otherwise by now, after attention. The Iowa Women’s Health Study is this many years, we would have seen more con- prospectively following a cohort of women sistency in the data and the size of the risk esti- who were selected in 1985.167 After six years of mates would be large rather than slight. following these women, a statistically significant A reminder about duration of use offers some increase in the risk of breast cancer could not be reassurance amidst the confusion. No studies detected in women who had either ever used find an increased risk of breast cancer with short- HRT or who were currently using it. Another term use of HRT, and the conflicting results of report through eight years of follow-up looked at more than 60 studies demonstrate that if there is MENOPAUSE 213 an increased risk with long-term use, it is a slight estins that are not identical to a woman’s own estro- increase. gen or progesterone. Conjugated equine estrogens The effect of bio-identical progesterone on are derived from the urine of pregnant mares. the risk of breast cancer in menopausal women Esterified estrogens are in part estrone sulfate and who are taking bio-identical EPT is basically in part equilin sulfates. (See Appendix C for a chart unresolved. Some evidence does exist that bio- on current conventional hormone options.) identical progesterone might help to prevent breast cancer. In a 1995 study, women who were Androgens. The normal postmenopausal scheduled for breast reduction surgery applied ovary produces testosterone as well as andro- progesterone cream to their breasts for two weeks stenedione and small amounts of estrogen. Fol- before the surgery.172 The cells in the removed lowing menopause, a woman’s androgen (male breast tissue showed less cell division in the hormone) production decreases by as much as 50 women who used the progesterone cream, and percent. Ovarian androgen production stops the researchers concluded that progesterone abruptly with surgical menopause and more applied directly to the breast might even help gradually with natural menopause. A substantial prevent breast cancer. In perhaps the most com- number of menopausal women who are given pelling study to date, done in France, transder- estrogen replacement at standard dosages con- mal bio-identical estradiol plus oral micronized tinue to have menopause symptoms such as bio-identical progesterone was not associated hot flashes, night sweats, and insomnia. These with an increased risk of breast cancer whereas women may have enhanced symptom relief when transdermal estradiol with progestins did increase they are switched to estrogen plus androgen, the risk, similar to the WHI results.173 usually testosterone. Studies have shown that For women already at risk for breast cancer or testosterone increases the bioavailable estrogen, who have had breast cancer, no good studies exist both that produced by the body and that given on the effects of progestins or progesterone. in a pill.174 Estrogen and testosterone therapy has been Friendlier and Less-Friendly explored not only for its ability to improve vaso- Conventional HRT motor symptoms but also to improve sexual Friendlier conventional HRT includes all estro- desire and sexual satisfaction. For example, a gens manufactured by a pharmaceutical com- double-blind study of women who were dissatis- pany that are made with bio-identical estradiol fied with their HRT regimen showed that sexual or estrone. As stated previously, the differences desire, satisfaction, and frequency of sexual activ- are the binders, fillers, preservatives, adhesives, ity were increased when they used the estrogen/ and additives used in these products. Oral testosterone combination.175 Another study of capsules of 1 mg bio-identical hormones are early postmenopausal women, both natural and equivalent to 0.625 mg of conjugated equine surgical, were switched from estrogen alone to estrogens (CEE). Estrogen patches that contain estrogen/testosterone therapy.176 Overall symp- 0.05 mg of bio-identical estradiol are equivalent tom relief was greater with estrogen/testosterone to 0.625 mg CEE (Premarin) or to 1 mg of oral therapy than with estrogen-only therapy. Sexual bio-identical estradiol. Estradiol cream and gel drive and satisfaction increased. Results of other are also now manufactured by pharmaceutical studies have shown that the combination of 1.25 companies. mg of esterified estrogen and 2.5 mg of methyl- Less-friendly conventional HRT uses hor- testosterone given daily for two years signifi- mones that are composed of estrogens and prog- cantly reduced the intensity of hot flashes and 214 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE vaginal dryness in women with surgical meno- mulation, and the pills are taken one capsule pause.177 A study comparing the effects of estro- twice daily. Testosterone cream applied to the gen and an estrogen/testosterone combination genital region has received mass media attention on sex drive showed improvement in 50 percent on “The Oprah Winfrey Show.” It is used as an of women on estrogen alone, but 90 percent of alternate method of delivering the testosterone. women when testosterone was added.178 Common prescriptions are anywhere from 1 to 4 There have been some concerns about estro- mg per gram of cream. These are applied to the gen/testosterone therapy reversing the increased external genital region right before sexual activity HDL cholesterol achieved with estrogen alone. to enhance sensation to touch and orgasm. Use The combination of esterified estrogens and should not exceed twice per week to avert local methyltestosterone has been shown to decrease testosterone side effects such as enlargement of triglycerides, LDL, HDL, and total cholesterol the clitoris that can occur if testosterone cream is in postmenopausal women. However, a two-year used daily and in the stronger dosages. A good study of estrogen/testosterone therapy produced resource for both menopausal women and their no change in LDL levels but did show significant health-care practitioners is a book called The reductions in triglycerides and very low-density Hormone of Desire.179 lipoprotein, and also reduced HDL levels. So the The North American Menopause Society story is mixed, and further studies are needed to (NAMS) invited a panel of clinicians and determine the actual impact of these changes on researchers who were experts in the field of cardiovascular disease. If testosterone is used, it testosterone therapy to review the scientific evi- would be prudent to monitor blood lipid levels dence regarding the role of exogenous testos- for any adverse effects. terone in postmenopausal women.180 Their For treatment of osteoporosis, adding testos- conclusions were as follows: Postmenopausal terone to estrogen therapy appears to produce a women with decreased sexual desire with no greater increase in bone density compared with other cause other than being postmenopausal estrogen therapy alone. In a double-blind study, may be candidates for testosterone treatment. 66 surgically menopausal women without osteo- Because of lack of adequate evidence for testos- porosis received either 1.25 mg of esterified terone increasing sexual function, testosterone estrogen alone or 1.25 mg of esterified estrogen treatment without also giving estrogen therapy and 2.5 mg of methyltestosterone daily for two cannot be recommended. Other causes of low years. Both groups already had bone loss at the libido are to be ruled out and laboratory testing spine, hip, and wrist. Only the combination of of testosterone levels should be used only to estrogen with testosterone significantly increased monitor for supraphysiologic levels before and spinal bone density after one year and two years. during therapy, not for the purpose of diagnosing Standard formulations of CEE and methyltestosterone insufficiency. Monitoring would be testosterone combine either 0.625 or 1.25 mg included in an office visit follow-up to assess of CEE with 5 mg of methyltestosterone. Other changes in sexual function. Transdermal and top- formulations contain either 1.25 or 0.625 mg ical gels or creams are preferred over oral forms esterified estrogens, combined with 2.5 or 1.25 due to their minimal effect on the liver. Testos- mg of methyltestosterone, respectively. terone therapy is contraindicated in women with Through a compounding pharmacist, one breast or uterine cancer and in women with car- can obtain bio-identical testosterone. I generally diovascular or liver disease. Testosterone should use 1 to 3 mg of bio-identical testosterone for- be given at the lowest dose for the shortest time mulated into the bi-estrogen or tri-estrogen for- that meets treatment objectives. MENOPAUSE 215 mg and 100 mg daily.181 Few adverse effects have Bio-Identical Testosterone been reported with DHEA, although in women, Oral: 2–6 mg per day androgenic side effects such as facial hair growth Cream (1–4 mg/g): apply twice weekly to external and acne can occur with doses as low as 50 mg. genitalia before sexual activity A dose of 25 mg daily may be more appropriate.182 I typically give 5 to 20 mg per day to Dehydroepiandrosterone (DHEA). Dehy- women who are either low in DHEA according droepiandrosterone (DHEA) is another of the to test results or to women with fatigue, loss of androgens. It is the most abundant circulating vitality, and/or low sex drive. steroid in humans. DHEA is called a precursor hormone because it is produced in large amounts DHEA in the body and other steroid hormones are made 5–50 mg per day from it, including estrogen and testosterone. In a woman, 90 percent of DHEA comes from the adrenal glands; the remaining 10 percent is manu- Exercise factured by the ovaries. Our DHEA level peaks at The benefits of exercise for perimenopausal and age 25 and then declines gradually to only 15 to 20 postmenopausal women are wide and deep. percent of our maximum by the time we turn 70. Women can receive substantial reductions in car- Many claims have been made about DHEA’s diovascular disease,183 a reduced risk of breast effect on the immune system, and its anti-aging cancer,184 an increase in bone density,185 a lower- properties are said to include better memory, less fatigue, more energy, relaxation, and increased Sample Treatment Plan for ability to handle stress. It is also touted as having Hot Flash Symptom Relief positive effects on bone density and helping to prevent cancer and cardiovascular disease. How- Diet: ever, the exact effect DHEA has on the body’s Follow a whole foods diet high in fruits, vegeta- cells is unclear. I have seen DHEA increase bles, whole grains, and legumes. energy, improve stress response, improve muscle Emphasize soybean products and flaxseed. Reduce total fat, animal fats, and simple mass, and occasionally increase libido. carbohydrates. A daily oral intake of 50 mg of DHEA for a Eat modest amounts of organic low-fat dairy. postmenopausal woman may restore DHEA Exercise: Regular weight-bearing, strengthening, and levels to those of a young adult. At this dosage, aerobic exercise with light weight training DHEA is converted to other more potent andro- Herbal: Choose one of the following: gens, including testosterone. In pharmacological Black cohosh standardized extract capsules (40 doses of 1,600 mg, DHEA is converted to mg): 1–2 capsules 1–2 times per day estrone and estradiol. Unfortunately, there are Consider herbal combination formulations: dong only a handful of randomized placebo-controlled quai, licorice root, motherwort, burdock root, studies examining the effects of giving DHEA to hops, Saint John’s wort, red clover, maca Bio-identical progesterone cream (400 mg/oz or humans. Although animal studies are promising, more): apply 1⁄4 tsp twice daily 3 weeks on and we need more research on its particular effects on 1 week off if perimenopausal postmenopausal women. Bio-identical estrogens/progesterone (estriol 1 One of the most significant effects of DHEA mg/estradiol 0.25 mg/progesterone): 1 capsule (50 may be its ability to enhance a sense of general mg) twice daily (1 week off if perimenopausal) well-being. This effect was found at doses of 50 216 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

ing of body fat and body mass index, and an Sample Treatment Plan for Insomnia improved sense of well-being.186 The ability of exercise to reduce the incidence or severity of hot See the Resources section for formulation sources. flashes during menopause is not clear. It appears Diet: that for women who are not overweight, moder- Avoid stimulants, especially during the second half ate exercise may be beneficial for hot flashes and of the day (coffee, caffeinated tea, chocolate, more vigorous exercise may exacerbate them. caffeinated sodas). Have a protein snack before bed. Exercise Recommendations. Physical exer- Lifestyle: Get regular exercise, practice good sleep cise that includes strength, cardiac, and flexibility hygiene. modalities (see Appendix A) ensures a meno- Herbal: pause without exaggerated symptoms and pro- Black cohosh extract: 40 mg twice daily tects against heart disease and osteoporosis when Valerian: 1–2 capsules or 1–2 tsp liquid extract it is initiated early in life, is appropriate and before bed moderate, and lasts throughout life. Nutritional supplement: 2 mg melatonin before bed However, if you have reached menopause and For difficult cases: have been sedentary, start slowly and progress Add hormone prescription, with oral micronized progesterone taken right before bed. gradually. Consult an exercise consultant to learn Consider adding 5-HTP, higher doses of melatonin, the safest program both for aerobic and strength/ or other herbal combinations of hops, valerian, weight training. and passionflower. Solutions to Selected Problems Insomnia. In determining individualized maintain sleep through the night by regulating treatments for insomnia, it is imperative to iden- nighttime blood glucose levels. tify and address the underlying cause as well as Relaxation techniques such as biofeedback, provide options for short-term relief. The basics progressive muscular relaxation, meditation, and start with good sleep hygiene. This includes warm baths can help sedate some people. Sooth- going to bed at the same time each night and ing music may also reduce anxiety and stress. avoiding or reducing naps. A comfortable bed One study showed that after listening to music and room temperature along with low levels of while trying to go to sleep, the level of sleepiness light and noise contribute to better sleep was significantly increased and the time to sleep hygiene. It is often advised that the bedroom onset was much lower. The music became more should not be used for eating or television watch- effective each night of continued use.187 ing but rather only for sleep and intimacy. If you Some studies of insomnia in postmenopausal are not able to fall asleep after 20 to 30 minutes women demonstrate that HRT significantly in bed, get out of bed and engage in a quiet activ- improves sleep quality, shortens sleep onset, and ity and then return to bed when sleepy. reduces nighttime restlessness and awakenings.188 Nutritional practices may influence sleep. Sleep efficiency and time spent awake after sleep Caffeinated drinks may have to be avoided alto- onset appear to be significantly better when using gether or at least within 12 hours of sleep. Some oral micronized progesterone with estrogen individuals have nighttime hypoglycemia. A replacement therapy but not when using syn- drop in blood glucose level causes the release of thetic medroxyprogesterone acetate (MPA).189 chemicals that can stimulate the brain. Consum- Insomnia is not only a frequent medical ing complex carbohydrates with protein can help problem, but it’s also a difficult problem. Insom- MENOPAUSE 217 nia is usually a symptom of an underlying Other Botanicals. Numerous plants have seda- hormonal, nutritional, pharmacological, or tive actions and have been used historically to psychological problem. Some women may need promote sleep and improve sleep quality. These evaluation for sleep apnea, treatment of psycho- include hops, skullcap, chamomile, lemon balm, logical issues, or pharmacological treatment. oat straw, lavender, bitter orange, California Melatonin. One of the better-known natural poppy, and kava. Preparations can include pow- treatments for insomnia is melatonin. One dered capsules, tinctures, and teas. Most of these placebo-controlled trial on melatonin found that herbs are mild sedatives and are unlikely to suffice 0.5 mg of melatonin daily for two weeks short- alone, but are typically used in combinations. ened the amount of time it took to fall asleep but Sexual Function had no effect on sustaining sleep or improving the quality of the sleep.190 In another study, 2 mg Ginseng. The most well-known herb to im- of melatonin per day was effective in improving prove energy and stamina, as well as for sexual sleep efficiency.191 Melatonin has also been effec- rejuvenation, is ginseng. American ginseng has tive in patients with long-term insomnia who traditionally been used for weakness, loss of were using benzodiazepines.192 Most patients muscle tone, low endurance, loss of work efficiency, were able to decrease their benzodiazepines by 50 and decreased sexual function. The ginsenosides in percent during the second week of using 2 mg of American ginseng exert an estrogen-like action on melatonin nightly and discontinue it by the fifth the vaginal epithelium that improves the lubrica- or sixth week. It is thought that individuals who tion and elasticity of the vaginal tissue, contributing actually have a melatonin deficiency are most to sexual response and comfort. In animal stud- responsive to melatonin for insomnia. ies, ginseng increased testosterone levels in males.199 Given the potential influence of testos- 5-Hydroxytryptophan (5-HTP). 5-HTP is a terone on sexual function in women, this may form of tryptophan that has been reported in partly account for its effect in women as well. numerous double-blind studies to decrease the Therapeutic effects of ginseng on the reproduc- time required to get to sleep and to decrease the tive system of female animals also include accel- 193–196 number of night awakenings. The typical erating ovarian function, enhancing ovulation, dosage range of 5-HTP is 100 to 300 mg about and stimulating egg production.200 45 minutes before bed. (Enhancing pelvic and specifically genital cir- Valerian. This herb has been used for decades, culation is also a consideration for which one if not centuries, as a sedative, including as an aid might consider ginkgo. Ginkgo was also dis- for insomnia. Studies have confirmed the effec- cussed earlier in the botanicals section as an aid tiveness of valerian. In a double-blind study from to improve sexual function in women taking Switzerland, valerian improved sleep latency, antidepressants.78) reduced night awakenings, and improved sleep Several studies show the ability of ginseng quality, especially in women.197 Several trials have to battle fatigue and stress. One study of nurses looked at valerian in combination with other who took ginseng showed improved scores in job herbal sedatives such as passionflower and lemon competence, mood, and mental and physical balm. In one clinical trial, 33 percent of men and performance.84 women without insomnia who took valerian and Ginseng has also been shown to enhance the lemon balm 30 minutes before bed reported an ability to cope with various mental and physical improvement in sleep quality. Only 9 percent in stressors, largely due to its effect on the adrenal the placebo group reported improvement.198 glands, which are involved in maintaining our 218 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE hormonal balance. Finally, in a double-blind, Look for these herbs in popular combination placebo-controlled trial of 232 patients with products to enhance sexual desire as well as to fatigue, it was found that ginseng improved fatigue, address other menopause issues. anxiety, nervousness, and poor concentration.201 The Importance of Lubrication. The amount Damiana. All students of herbal medicine are of estrogen in the vagina is the main determinant probably familiar with damiana’s time-honored of vaginal health, including the pH, the balance reputation as an aphrodisiac. It is unclear how the of organisms, the integrity of the tissues, and the constituents of damiana bring about this effect, amount of lubrication. As estrogen levels decline and indeed no studies have proven this effect on with menopause, many changes can occur, women, but it has been shown to enhance sexual including thinning of the vaginal wall tissue, behavior in animals. A combination product that vaginal dryness, loss of vaginal tone, and suscep- included ginseng, damiana, and gingko was shown tibility to infections. Symptoms such as pain in a small placebo-controlled study to improve with vaginal sexual activity, itching and burning, sexual desire and satisfaction.202 Mexican Indians and even urinary leakage may result. For sexual and generations of herbalists have looked to dami- function and comfort with vaginal sexual activ- ana to improve sexual interest and response. ity, lubrication during sex not only is helpful for Ashwagandha. In cases of general debility, comfort, but for some is a necessity. There are nervous exhaustion, loss of muscle strength, and many over-the-counter lubricants, and in the that all-familiar “brain fog,” the ashwagandha context of natural medicine, we can look for plant that grows and is cultivated in India and lubricants that are less irritating due to a lack of even the Himalayas is well-known in folk medi- chemicals and hypoallergenic bases. Something cine of that region as a traditional treatment of as simple as vitamin E oil can be used as a lubri- these problems. This plant is regarded in India as cant. Products are available that contain vitamin a tonic and adaptogen, with properties similar to E oil and allantoin and are water based so they ginseng. In one study, physical endurance was are nondrying and nonirritating. Other natural doubled in participants given extracts of ashwa- vaginal moisturizers are oil based rather than gandha (Withania somnifera).203 water based. Common ingredients are mineral Rhodiola. Rhodiola, also known as golden oil, glycerin, yerba santa, castor oil, and more. It root or arctic root, has been used for centuries to is important to check to see which ones are increase physical endurance and exercise per- appropriate to use with condoms and to remem- formance204 and as a folk custom to ensure fertil- ber that lubricants do not contain spermicide ity. Effects on regulation of the menstrual cycle and so do not provide contraception. and the successful treatment of 25 of 40 women The most effective way to improve lubrication who had stopped having menses altogether sup- over the long term is prescription vaginal estrogens. port its use in matters related to hormones and Please refer to the section on hormones earlier in sexual function.205 this chapter for how to use vaginal estrogens for thinning, dryness, and pain of the vagina and Maca. Maca has been used in Peru for five problems related to these atrophic changes. thousand years. Alkaloids from the root of the plant act upon the two key glands in the brain, Topical Ingredients to Enhance Arousal. the hypothalamus and the pituitary, supporting Numerous botanical and nutrient topical products and boosting energy levels and encouraging the now exist to enhance female arousal and orgasm production of ovarian hormones such as estrogen when applied to the vulva (external female genital and testosterone.206 area). One such product is a feminine massage oil MENOPAUSE 219 that contains borage seed oil, evening primrose placed on hormone therapy, which was a mainstay oil, extracts of angelica and coleus, and several of conventional medicine for the preceding 40 to antioxidants. A randomized, double-blinded, 60 years, has changed. After the WHI report, the cross-over study was conducted to evaluate the effi- American College of OB/GYN (ACOG) and the cacy of this product in women who had been diag- North American Menopause Society (NAMS) nosed with female sexual arousal disorder. The convened panels of specialists to look at the infor- treatment resulted in increases in sexual pleasure in mation and make recommendations. These rec- more than 90 percent of women.207 ommendations are for the general patient, with Another over-the-counter topical cream that provisos that each individual woman should be supports female sexual arousal contains nitric counseled and her risk and goals assessed, and oxide, which is the chemical produced by the some deviation from these guidelines may be pos- body to promote the dilation of blood vessels in sible at the discretion of the practitioner and pa- the female genital tissues. L-phenylalanine and tient. There are three commonly agreed-upon uses L-tyrosine are amino acids that the body uses to for hormone therapy: produce neurotransmitters important in the initi- 1. Decrease of menopausal symptoms ation of blood vessel dilation. Niacin, also known 2. Prevention of osteoporosis in women who as vitamin B , is known for its ability to dilate 3 are intolerant of other medications used to blood vessels as well. In addition, oils such as treat osteoporosis L-menthol from mint oil, rosemary oil, and cinna- 3. Topical use of hormones for urogenital mon oil can increase local blood flow and have atrophy warming and stimulating effects when formulated in a cream and applied to the genital tissues. They also recommend that hormones be used As discussed earlier in the hormone section, at the lowest effective doses for the shortest effec- topical testosterone cream is also a valuable tool tive period of time. What this means is that the to enhance genital arousal and orgasm. provider should try different doses and find one that is most effective in the reduction of a CONVENTIONAL woman’s symptoms. That does not mean it has to MEDICINE APPROACH be the lowest dose possible. The shortest period Conventional medicine treatment of menopause of time means that women should periodically has changed fairly dramatically in the years follow- go off their hormones to see if their menopausal ing the initial publication of the Women’s Health symptoms have reduced or gone away. These Initiative (WHI) report in 2002. Many women recommendations are not applicable to women who were taking hormone therapy for prevention who are using hormones for treatment of osteo- of heart disease and osteoporosis were instructed porosis, which should be a lifetime treatment. to stop their hormones, because the WHI sug- Women with atrophic urogenital symptoms will gested that there might be a slight increase in need to use their hormones lifelong, but the top- breast cancer and strokes in asymptomatic women ical vulvovaginal estrogens pose no meaningful taking hormones. We have known that there is a risks. The lowest effective dose, in the shortest slight increase in deep venous thrombosis, which period of time, pertains primarily to a woman was confirmed by this study. The study also using hormones for menopausal symptoms. showed an improvement in prevention of osteo- They recommend that all women with an porosis and colon cancer, but these beneficial ef- intact uterus have a progestogen administered fects were considered not to be worth the risk. The along with the estrogen to prevent endometrial recommendation that all menopausal women be hyperplasia and uterine cancer. The regimens of 220 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE treatment with progestogens varies greatly but reports over the years that the use of estrogen are divided into two basic approaches: reduces the onset or severity of dementia, macu- lar degeneration, cataracts, tooth loss, and skin 1. Continuous daily therapy wrinkling, and many women choose to use hor- 2. Cyclic treatment, adding a progestogen 12 mones for these quality-of-life issues. This goes to 14 days per month, and recently there is a back to the decision to individualize each “long sequential cyclic” regimen of 14 days woman’s therapy based on her goals and risk every 3 months factors. Properly counseled about the risks of Woman who do not have a uterus are not hormone therapy, many women are continuing required to use a progestogen. Women who have a to use hormones for these issues. That choice is uterus and are progestogen intolerant can have the between the woman and her provider. option of annual uterine lining evaluation with A pharmaceutical company’s FDA application transvaginal ultrasound or an endometrial biopsy. information shows that 0.014 mg of transdermal When using transvaginal ultrasound, women with estradiol in the form of a weekly patch has been an endometrial thickness of 4 mm or less are con- shown to be effective for prevention of osteoporo- sidered not to have disease and do not need an sis, but it does not develop blood levels high endometrial biopsy unless there is persistent enough to increase or build an endometrial lining. abnormal bleeding or other medical reasons. Therefore, the FDA is allowing this medication to Women with more than 4 mm thickness may have be used as an unopposed estrogen in women with a normal lining but need an endometrial biopsy a uterus. The information in the package insert for and/or a saline sonohystogram. Or, instead of the this medication suggests a progestogen challenge two-step approach of ultrasound and then biopsy, test at 6- to 12-month intervals. Another contro- women may instead have an endometrial biopsy versial unopposed estrogen use is topical vaginal yearly to assess the lining tissue. products. Several studies suggest that there is min- Another alternative is the use of the proges- imal to no increase in blood estrogen levels with togen intrauterine system known as a Mirena the use of the vaginal ring, creams, and tablets. IUD. This is not an FDA-approved use of this Over the years, there have been suggestions that a device as of this writing. The Mirena IUD pro- woman with a uterus using these products be vides a large local progestogen environment for given a progestogen withdrawal challenge test on prevention of hyperplasia and cancer without an annual basis. These recommendations are vari- any significant systemic absorption. There is no ably applied. Again, discussion with the woman justification for the use of unopposed estrogens about her choices is probably the most important in a woman with a uterus unless she is doing reg- management suggestion. ular assessments of her uterine lining. There are So, what hormones are currently being used? only a few reasons why women without a uterus The delivery systems and types of hormones have are given progestogens along with estrogen: changed dramatically over the past 10 to 20 years. This discussion will provide some informa- 1. To increase menopause symptom relief tion on the most commonly prescribed products. 2. To reduce the risk of endometriosis in There are, however, two first important guiding women who had active disease during their principles for hormone therapy management surgery to remove the uterus and ovaries that should be discussed. The use of hormone therapy for other reasons First is the bioequivalence of oral and trans- is widespread, but is not approved by the FDA, dermal estrogen products. The following doses ACOG, or NAMS. There have been empiric of the different types of estrogen supposedly MENOPAUSE 221 provide the same blood levels after administra- generic forms. Estrogens also come in combination, and so they are considered biologically tion products containing an estrogen plus a pro- equivalent: gestogen and in transdermal patches, gels, and Oral conjugated estrogen: 0.625 mg creams, as well as in a vaginal ring that provides Oral estradiol: 1.0 mg transdermal systemic estrogen levels (Femring). Patch estradiol: 0.05 mg Even some conventional practitioners are Biest/Triest: 2.5 mg orally increasingly using compounded hormone ther- Estradiol gel (Estrogel): 2 squirts apy, which has the benefit of a variety of dosing Estradiol cream (Estrasorb): 2 packets forms and can be compounded as an oral capsule, a transdermal cream or gel, a vaginal tablet, A dosage higher than these amounts would give or a sublingual-dissolving medication. higher-than-average blood levels, and dosages 2. Combination products. The combinations lower than these amounts would give lower- of estrogen plus progestogen products are very than-average blood levels. It is acceptable to vary popular because the woman can take one med- the estrogen dosage to meet the woman’s symp- ication and get both hormones. These come in tom requirements. oral forms and in two patch brands. There is The second guiding principle is that there is also a combination estrogen plus progestogen a minimal acceptable dosage of progestogen that vaginal product called NuvaRing, which is a will prevent hyperplasia or uterine cancer. One low-dose birth control product that has been cannot go below the recommended amounts of used for perimenopausal symptom relief and progestogen or frequency intervals without the cycle control. And again, there are compounded risk of hyperplasia and uterine cancer, so the rec- hormone products from the compounding ommended progestogen dosages should not be pharmacies. varied. For information on the various types of 3. Progestogens. There are several commer- conventional estrogen products and the recom- cially available non-bio-identical progestins in mended progestogen dosages, see the North common usage today: Provera or Cycrin American Menopause Society website, meno- (medroxyprogesterone), Aygestin (norethin- pause.org. This site offers a menopause guide- drone acetate), the minipill Micronor (norethin- book that outlines all of the currently available drone), and Megace (megestrol). Bio-identical conventional estrogen and progestogen products progesterone is available in a product called as well as a 47-page committee consensus opin- Prometrium, in two dose forms. Compounding ion on progestogen usage. (See Appendix C for a pharmacies can compound bio-identical proges- list of conventional hormone preparations and terone in oral, sublingual, transdermal, or vagi- some details about dosing.) nal form. There is also a vaginal bio-identical For purposes of the summary discussion in progesterone, FDA approved for use in infertil- this chapter, these are the conventional hormone ity, that comes in a 4 percent and 8 percent gel guidelines: and can be used for vaginal application of sys- 1. Estrogens. The most commonly used estro- temic progesterone. gens are the oral forms, and they come as estra- 4. Vaginal estrogens. Vaginal estrogen prod- diol (by product name and generic), conjugated ucts that are used only for urogenital atrophic animal-source estrogens (Premarin), a mixture problems are very weak estrogens and are not of esterified vegetable estrogens (Enjuvia, Cen- likely to increase blood levels. For many years, estin, Menest), esterified estrogens with methyl vaginal creams have been available in either testosterone (Estratest and Syntest), and various estradiol or conjugated estrogens, but in the 222 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE past 10 years or more, we have also had the sweats and flushes in studies at 37.5 to 75 mg three-month indwelling vaginal ring estrogen and 10 to 20 mg daily, respectively. However, called Estring and vaginal tablets of estradiol SSRIs and SNRIs have been occasionally shown called Vagifem. Compounded vaginal estrogen to cause vasomotor symptoms in men and products in variable doses are also available. women. Bellergal Spacetabs, an ergot and bel- Conventional practitioners by and large do not ladonna combination, were used for many years use these and are particularly unaware of how to for vasomotor symptoms but are no longer made use vaginal estriol, as discussed in the alternative by its pharmaceutical company. Some com- medicine section on hormone therapy. pounding pharmacies supply it. There are no studies on it, but empirical reports have shown Nonhormonal medical options have in- mixed results. It is used one to two times daily. creased in popularity and understanding. For Sexual problems are commonly reported by low bone density, a bisphosphonate such as women in midlife, and the treatment is very Fosamax, Actonel, or Boniva or a selective estro- complex. Libido can be decreased because of gen receptor modulator (SERM) such as Evista estrogen deficiency, sudden surgical loss of testos- (raloxiphene) may be prescribed. Or for severe terone from an oophorectomy (not from natural osteoporosis, parathyroid hormone (Forteo)— ovarian aging), or the administration of an oral which works on the bone in an entirely different estrogen, which can lower serum testosterone. way than hormones, SERMs, or bisphospho- Libido can decrease because of pain with inter- nates—may be recommended. course, decreased skin sensation from loss of For insomnia, there are many different options estrogen, chronic medical problems, medica- depending on age, type of use (daily versus inter- tions, or most often from the woman’s psychoso- mittent), and abuse potential of the patient. cial environment. Sexual performance problems Most sleep aids are benzodiazepines, some are can have similar roots but are often the result of antihistamines, and a new one (Rozerem) works other diseases (hypertension, diabetes, athero- on melatonin receptors. Consult a physician well sclerosis) that affect clitoral and pelvic blood flow acquainted with the use of these medications. or from medications used to treat other diseases For anxiety and depression, there are the (notably antidepressants). A few studies have common SSRIs (Prozac, Paxil, Celexa, Zoloft), been done on the use of testosterone to improve newer SNRIs (Effexor, Cymbalta) and tricyclic sexual function and have shown conflicting antidepressants, and sedatives. results. The work done by Dr. David Archer For vasomotor symptoms, a blood pressure using testosterone patches (pending FDA med, a seizure drug, SSRIs, SNRIs, and ergots approval) shows improvement in women who can be prescribed. None of these medications’ had bilateral oophorectomy but not those who actions on relieving sweats and flushes are under- have undergone natural menopause. Testosterone stood—practitioners have just observed that is not well absorbed orally, and it has potential some women on some medications had signifi- health risks such as permanent voice change, hair cant improvement in their symptoms. Most of growth on the face or body, loss of head hair, the drugs are safe and easy to use, but some lipid elevations, acne/oily skin, and emotional are expensive. The blood pressure med used is side effects. More research is needed on the role Clonidine, usually 0.1 to 0.2 mg daily at bed- of hormones in sexual dysfunction in women. time. The anti-epileptic drug gabapentin (Neu- In summary, the conventional practitioner’s use rontin) is administered as 300 mg three times a of hormone therapy and the standard of practice day. Effexor and Paxil have shown a reduction in these days is limited to three areas of use: meno- MENOPAUSE 223 pausal symptoms, osteoporosis prevention or treat- My advice to all women is to at some ment, and vaginal or urogenital atrophic symp- time have a full evaluation by a practitioner who toms. The formulations of type, dose, and delivery is educated in all the natural, hormonal, and have significantly increased, and it is important to pharmaceutical nonhormonal options. The work with a provider who is capable and knowl- only primary care practitioners that are trained in edgeable about the various products. Most women the medical school setting about all of these will do well on most hormone products, but for options are licensed naturopathic physicians. those women whose symptoms do not respond The purpose of this evaluation, as discussed in easily to these products, a knowledgeable meno- the overview section and the overview of alterna- pause clinician can provide better guidance. It is tive medicine, is to conduct a medical history, important for a woman with a uterus to use a pro- physical exam, and necessary laboratory and gestogen along with estrogen replacement. Women imaging studies to determine the risk for osteo- who have had a hysterectomy do not typically need porosis and heart disease. After a determination progestogens. Hormone therapy is used for nonap- of whether you are at low risk, medium risk, or proved, nonstandard reasons, and the patient needs high risk for these conditions, a treatment plan to be counseled about risks and needs to define her will be recommended. goals. This is an acceptable practice as long as Using natural therapies versus using conven- proper counseling is provided. tional or bio-identical HRT or some combination of the these is a very personal decision. SEEING A LICENSED PRIMARY A well-informed patient who also has the good HEALTH-CARE PRACTITIONER fortune of having a well-informed, respectful, (N.D., M.D., D.O., N.P., P.A.) open-minded practitioner is in the best position Most women who are perimenopausal can feel to make appropriate decisions. Remember that comfortable starting on their own with the diet, any decision you make is reversible. Decisions exercise, herbs, nutritional supplements, and nat- can and do change over time. Menopause, aging, ural progesterone creams described in this chapter and our concerns about long-term health prob- for the relief of menopause symptoms. Women lems evolve over time, and balance is necessary. who do not find adequate relief from these thera- Naïveté is inappropriate, and over-medicalization pies will need to see a licensed primary care of menopause is also inappropriate. Menopause provider (naturopathic doctor, medical doctor, is a normal and natural event of aging. It can be osteopathic doctor, nurse-practitioner, or physi- a time of strength, empowerment, personal cian’s assistant) who preferably is educated in the growth, and positive, life-changing insights and range of options, not just conventional HRT. decisions. This page intentionally left blank MENSTRUAL CRAMPS CHAPTER 13

OVERVIEW this age group experience the most severe pain. Menstrual cramps are one of the most common Women older than 24 have less painful cramp- problems that women face, affecting over 50 per- ing, and the overall incidence of primary dys- cent of menstruating women. The term dysmen- menorrhea tends to decrease with age—more orrhea, derived from the Greek and meaning rapidly in married women than in unmarried “difficult monthly flow,” is commonly used to ones, possibly due to pregnancy and childbear- refer to painful menstruation. Dysmenorrhea is ing. Women who begin to menstruate at a best classified as primary or secondary. In pri- younger age and have longer menstrual periods mary dysmenorrhea, painful menstrual cramps have increased severity of pain and more days of occur that have nothing to do with any physical pain. In smokers, cramps tend to last longer. In abnormalities or identifiable pelvic disease. Sec- fact, a recent study showed that there is a definite ondary dysmenorrhea is painful menstrual relationship between the amount of cigarette cramps due to some specific pelvic or systemic smoke exposure and menstrual cramps.2 Being condition such as endometriosis, pelvic inflam- overweight is also an important risk factor for matory disease, adhesions, ovarian cysts, celiac menstrual cramps, and it doubles the odds of disease, thyroid conditions, congenital malfor- having a long painful episode.3 Conversely, being mations, narrowing of the cervical opening, underweight has also been shown to be an inde- polyps, or uterine fibroids. We will be focusing pendent risk factor for dysmenorrhea.4 on primary dysmenorrhea in this chapter, Primary dysmenorrhea usually appears within although the treatments in this chapter for acute 6 to 12 months after the first menstrual period. pain relief can be used in both primary and sec- The pain usually begins several hours before or ondary dysmenorrhea. just after the onset of menstruation and is often Treatment for secondary dysmenorrhea is the most severe the first or second day of men- directed to treating the underlying cause of the struation. It tends to be spasmodic and is condition, whether it is endometriosis, fibroids, strongest in the lower part of the abdomen above or another condition. Menstrual cramps are a the pubic hairline, although it can often radiate significant personal and public health problem to the back and along the inner aspects of the for women. Of the 50 percent of menstruating thighs. More than 50 percent of women with women who are affected by menstrual cramps, menstrual cramps also have additional symptoms about 10 percent have severe pain that renders including nausea and vomiting, fatigue, diarrhea, them incapacitated for one to three days each lower backache, and headache. Women with month.1 It is estimated that 600 million work severe cases may also become dizzy and even hours are lost in a year in the United States faint. The symptoms may last from a few hours because of untreated and incapacitating dysmen- to one day but seldom last longer than two to orrhea. Social and family life is also disrupted by three days. Some women have more congestive the painful episodes. symptoms that are characterized by a dull aching Primary dysmenorrhea occurs most com- in the low back and pelvis, bloating, and weight monly between the ages of 20 and 24. Women in gain, along with some systemic symptoms 225

Clinical Features of Dysmenorrhea of menses. Dysmenorrhea occurs only in cycles where ovulation has occurred. In cycles without • The initial onset is at or shortly after the first ovulation, there is no increase in progesterone menstrual period (menarche). If dysmenorrhea production in the second half of the cycle and starts two years or more after menarche, then then decline right before the onset of menses, as other causes and secondary dysmenorrhea in a normal cycle, and there is subsequently no should be considered. Endometriosis is difficult to distinguish from primary dysmenorrhea increase in the prostaglandin concentration in because they produce similar symptoms. One the lining of the uterus. These mechanisms form distinction is that endometriosis tends to get the basis for many of the therapies used, both worse with time. natural and conventional. • Duration of the pain is usually 48 to 72 hours, starting a few hours before or just after the OVERVIEW OF onset of the flow. Pain that starts several days ALTERNATIVE TREATMENTS before the menses is less likely to be primary An alternative approach to menstrual cramps due dysmenorrhea. to primary dysmenorrhea needs to provide effec- • The pain is cramping, or labor-like, although tive pain relief while at the same time correcting some women have more congestion and bloating. the underlying dysfunction that is creating the • Findings on pelvic exam are normal. pain. Because it is a functional problem and not a disease state that is causing the pain, we can truly focus on a holistic approach by looking for including breast tenderness, headaches, and irri- aggravating factors in the diet, lifestyle, environ- tability. ment, and emotional realm. Dietary principles Primary dysmenorrhea is diagnosed when emphasizing good nutritional habits—eliminat- other causes of pelvic pain have been excluded. ing junk foods, saturated fats, and trans fats; Certain characteristic clinical features distinguish increasing omega-3 oils from fish, hemp oil, and the diagnosis. flax oil; and increasing whole grains, fruits, and The cause of primary dysmenorrhea may be vegetables—provide a range of nutrients needed one of several factors, including behavioral and to prevent and treat menstrual cramps. Stress psychological factors; lack of blood flow, and reduction can help relieve tension in the lower therefore oxygen, to the uterus (ischemia); and back and pelvic area that can worsen cramps. increased production and release of uterine pro- Improvements in posture improve the position- staglandins. Increased prostaglandins, specifically ing of the spine and promote proper circulation PgF2-alpha and PgE2, cause uterine contractions and nerve stimulation to the pelvic organs. that lead to ischemia and pain. The levels of both Providing acute pain relief is one of the great- PgF2-alpha and PgE2 are low during the first est challenges for natural medicine, whether it is half of the menstrual cycle and the early part of pelvic pain, headaches, or musculoskeletal pain. the second half, then rise sharply and reach their Mild and moderate levels of pelvic pain are more highest levels shortly before and during the onset treatable with natural therapies than is severe of menses. Studies have found that women with pain, although some women with severe pain dysmenorrhea produce 8 to 13 times more PgF will experience relief from the therapies that than do women without dysmenorrhea.1 This follow. Even when acute pain relief is not accom- increase in prostaglandin production may be plished with alternative therapies, a treatment plan related to the decline in progesterone levels for the interim days of the month is important toward the end of the cycle just before the onset in order to reduce the severity of the recurring MENSTRUAL CRAMPS 227

KEY CONCEPTS PREVENTION

• Primary dysmenorrhea should be distinguished • Good posture and spinal alignment may decrease from secondary dysmenorrhea. the tendency toward menstrual cramps. • Typical menstrual cramps are due to primary • Stress reduction may help to relax the pelvic and dysmenorrhea. low back muscles. • Causes of secondary dysmenorrhea include endo- • Some women may find that their menstrual metriosis, pelvic inflammatory disease, adhesions, cramping is worsened when they use tampons; ovarian cysts, celiac disease, thyroid conditions, these women should switch to sanitary napkins. congenital malformations, narrowing of the cervi- • A copper IUD (Paraguard) for contraception cal opening, polyps, and uterine fibroids. may worsen spasmodic menstrual cramping. A • Seek adequate pain relief in addition to trying progestin-containing IUD (Mirena) and hormonal to correct the underlying mechanism that is contraception can improve chronic dysmenor- causing the problem. rhea. Barrier methods of contraception have no • About half of all women experience menstrual bearing on dysmenorrhea. cramps. • Maintain a healthy weight. • Avoid smoking. • Food allergies may contribute to water reten- menstrual cramp episodes over time. Having a tion, gas, and bloating, which may contribute to congestive menstrual pain. natural therapeutic treatment plan for the • An increase in exercise may improve blood flow chronic problem and using over-the-counter or to the uterus and create an optimal pelvic mus- prescription conventional medicines for acute culature that will tend to reduce the incidence pain relief can turn out to be the most effective of menstrual discomfort. plan. Over time, hopefully, the need for pain • Maintain optimal digestive function. Irregular medications will decrease. bowel habits may be correlated to primary Many alternative practitioners have experi- dysmenorrhea. ence with natural therapies not included in this • Reduce foods that may contribute to an excess book such as acupuncture, homeopathy, and of the prostaglandins that cause uterine con- hands-on techniques that may offer effective help tractions: dairy products, beef, pork, lamb, poultry, eggs, deep-fried foods, and trans fats found for many women with menstrual cramps. I often in potato chips, french fries, and partially encourage women to try an herbal or nutritional hydrogenated packaged foods. product for a couple of hours during acute pain. If no relief is accomplished within that amount of time, then switch to a pharmaceutical method cycle, especially among those women with a prior of pain control. As each successive month of history of painful menses.5 Psychotherapy can treating the chronic problem goes by, a measure help a woman gain insight into these influences of the success of that treatment will be a de- and learn how to reduce and manage stressors. creased need to use the pain relief medication. Research has shown that behavior therapy has It is important not to overlook the role of stres- been highly effective in reducing the symptoms of sors in our personal lives that can be at least part spasmodic dysmenorrhea.6 of the cause of our pain and can also affect our Biofeedback treatment with a relaxation prac- ability to deal with pain. A recent study of over tice has also proven to be significant in reducing 380 otherwise healthy women demonstrated that dysmenorrhea.7 After two months of biofeedback women who experienced high stress were twice as treatments, sufferers of menstrual cramps had likely to experience dysmenorrhea in the following dramatic declines in the severity and duration of 228 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE their symptoms as well as a decline in the the intake of milk, cheese, cottage cheese, butter, amount of medication they were taking. Medita- ice cream, and yogurt may be enough to have a tion, visualization, and relaxation techniques are significant impact for as many as one-third of used by many women both as a primary form of women with menstrual cramps. pain management and also in combination with Saturated fats from nondairy sources can also other therapies. My advice would be to seek the intensify menstrual cramps by stimulating the advice of a trained person to help you learn PgE2 series. Most of our saturated fats come which method may be most appropriate and from animal products, although a few are from effective for you. vegetable sources such as palm oil or coconut oil. Animal foods to reduce or avoid that contain sat- Nutrition urated fat include beef, pork, lamb, and even A healthy diet is fundamental to an effective chicken and turkey. Even though chicken and menstrual cramps treatment program. In fact, turkey are lower in saturated fat, they are actually something as simple as eating breakfast regularly higher in arachidonic acid than red meats. was found to be inversely related to the incidence Salt can be another aggravating factor for and severity of dysmenorrhea.8 Many women women with menstrual cramps. Too much dietary experience relief from cramps just by switching salt can increase fluid retention and worsen bloat- to good nutritional habits. There are two basic ing that contributes to the congestive symptoms of aspects to making changes in the diet. One is to menstrual cramps. Canned and frozen foods, fast decrease the intake of foods that may be con- foods, and processed/packaged foods are all sus- tributing to the condition, and the other is to pect for high amounts of salt. Read the labels care- increase the intake of foods that provide a wide fully. You may be surprised to find that some of range of important nutrients necessary to bring the things you thought were healthy, such as cer- about a functional change in the pelvic area. One tain salad dressings, are actually loaded with salt. study supports this theory by demonstrating that Even a bean burrito at a fast-food restaurant will dietary intake of fish, eggs, and fruit was associ- be high in salt. Look for “no salt” labels on your ated with less dysmenorrhea while wine intake packaged foods, and go light on the saltshaker in was associated with more dysmenorrhea.9 In the kitchen and at the table. addition, another study advocates a vegetarian Although sugar in the diet may not be directly diet as a way to increase sex-hormone-binding related to menstrual cramps, sugar does interfere globulin and decrease body weight and the sever- with the absorption and metabolism of some B ity and duration of menstrual cramps.10 vitamins and minerals. Deficiencies or less than The most important foods to avoid are those optimal amounts of some of these nutrients may that are high in arachidonic acid. This is the worsen muscle tension and increase the contractile polyunsaturated fatty acid that the body uses to nature of the uterus. High-sugar foods are often produce the series-2 prostaglandins (PgE2)—the the same foods that are high in saturated fats. ones that cause muscle and uterine contractions. Women with monthly menstrual cramps run Egg yolks, red meat, and poultry are the main the risk of overusing alcohol because of its seda- sources of arachidonic acid. tive and pain-relieving effects. This overuse may In addition, many people are allergic to dairy lead to other problems, including alcoholism and products or lack the enzymes to digest them. substance abuse. Nonaddictive pain relief med- Digestive problems such as bloating and gas can ications would be far preferable. Alcohol also intensify with menstrual cramps, adding to the depletes the nutrient status of many B vitamins overall discomfort. Reducing or even eliminating and minerals such as magnesium. These deficien- MENSTRUAL CRAMPS 229 cies and nutritional imbalances can lead to diffi- natural anti-inflammatory substances like bio- culty in regulating muscle function and worsen flavonoids and vitamin C. These nutrients not muscle spasms during menstruation. Alcohol may only strengthen the blood vessels that can aid cir- also interfere with the liver’s ability to metabolize culation to areas of muscle tension in the pelvis hormones effectively and efficiently. This may lead but also reduce the pain from menstrual cramps to heavier flows. A heavier amount of blood creates through their anti-inflammatory effect. more clots, and the passage of clots will trigger an increase in the uterine muscle spasms. Nutritional Supplements The best medicinal foods for menstrual Vitamin B1 (Thiamine). A large, well- cramps are those foods that increase the antispas- designed study found that 100 mg of thiamine modic prostaglandins, the PgE1 and PgE3 series. daily helped to alleviate dysmenorrhea com- Certain fish, including salmon, tuna, halibut, and pletely in 87 percent of study subjects, while only sardines, contain omega-3 oils, specifically eicos- 5 percent had no relief.13 apentaenoic acid (EPA), a fatty acid that helps to relax muscles by the production of PgE3.11 Many Vitamin B1 seeds and nuts are sources of linoleic acid and 100 mg daily linolenic acid, also precursors to these muscle- relaxing prostaglandins. The best sources of both Vitamin B3 (Niacin). Niacin or vitamin B3 of these fatty acids are flaxseed, hemp seeds, and has been shown in clinical research to be effective pumpkin seeds. Sesame seeds and sunflower seeds in 87.5 percent of women with menstrual are excellent sources of linoleic acid. The oils from cramps.14 Niacin was given in 100 mg doses the seeds of flax, hemp, pumpkin, sesame, and twice daily throughout the month, and then sunflower are the best oils to use in salad dressings. every two to three hours during the periods of Flax, hemp, and pumpkin oils should not be menstrual cramps. Although a sometimes heated, but sesame and sunflower are acceptable uncomfortable niacin flush could easily occur at cooking oils. In many cases the seeds, nuts, and the escalated dosing, none of the women in the fruits from which these oils are extracted are study stopped the medication due to the flush- healthy choices as well. ing. Interestingly, the women who received no To round out the healthy changes in the diet, relief of their menstrual cramps were frequently emphasize whole grains, legumes, vegetables, and the women who reported no flushing. The fruits. Whole grains such as brown rice, oats, vasodilating effect of niacin (which causes flush- millet, barley, rye, amaranth, and buckwheat pro- ing) may indeed be the main treatment effect. vide sources of magnesium, calcium, potassium, Vasospasm of the uterine arteries may be respon- fiber, vitamin E, B-complex vitamins, and protein. sible for the menstrual pain. Specifically, intake of dietary fiber has been shown to be inversely proportional to menstrual pain.12 Vitamin B3 (Niacin) Both calcium and magnesium reduce muscular 100 mg twice daily throughout the month tension, fiber helps to regulate the bowel function, 100 mg every 2–3 hours during episodes of menstrual and potassium has a diuretic effect that can aid in cramps reducing bloating. Beans are also good sources of calcium, magnesium, potassium, and protein. Vitamin C and Rutin. In a follow-up study, Many vegetables are high in the calcium, magne- the author of the niacin study also found that sium, and potassium that help to relieve and pre- rutin with ascorbic acid increased the effective- vent muscle spasms. Fruits are an excellent form of ness of niacin in the treatment of menstrual 230 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE cramps.15 In twice as many women as the niacin- self-care treatment for many years. Muscles need only study, the same dose of niacin (100 mg calcium to maintain their normal muscle tone; twice daily regularly and every two or three hours if they are deficient in calcium, they can more during menstrual cramps) was given while also easily cramp. This is true of the uterine muscle as adding 300 mg of vitamin C and 60 mg of rutin well. Low calcium intake is associated with men- daily. These additions slightly improved the strual water retention and greater pain during the response in up to 90 percent of the women. This menses.18 The typical American diet supplies increased effectiveness was thought to be due to about 450 to 550 mg of calcium per day, falling improving the permeability of the capillaries, short of the recommended daily allowance of thus potentiating the vasodilating effect of the 1,000 mg per day in menstruating women. niacin. In most cases, niacin was not effective unless it had been taken 7 to 10 days before the Calcium onset of the menstrual flow. Supplement the diet so that total calcium is 1,000 mg per day Vitamin C 300–3,000 mg per day Omega-3 Fatty Acids. Essential fatty acids Rutin are the raw materials from which prostaglandins, beneficial hormone-like substances, are made. 60–1,000 mg per day There are two essential fatty acids: linoleic acid (omega-6 family) and linolenic acid (omega-3 Vitamin E. Vitamin E was studied back in the family). Linoleic and linolenic acids cannot be 1950s for the treatment of spasmodic dysmenor- made by the body and must be supplied daily in rhea. It was used in doses of 150 IU ten days pre- the diet from either food or supplements. The menstrual and during the first four days of the typical American diet is often much higher in menstrual period. In approximately 70 percent of omega-6 oils than it is in omega-3 oils. As a result, the women tested, it helped to relieve menstrual many of us end up with the PgE2 prostaglandins discomfort within two menstrual cycles.16 A more that cause muscle contractions and pain. recent, large, well-designed study evaluated vita- Another problem is that our bodies need a min E at a dose of 200 IU two times per day certain amount of linoleic acid to convert to beginning two days before the start of menses and gamma linolenic acid (GLA), which leads to the continuing through the third day of the cycle and production of the PgE1 prostaglandins (the anti- found a significant decrease in dysmenorrhea and spasmodic and anti-inflammatory prostaglan- overall blood loss after two months.17 I generally dins). The conversion of linoleic acid to GLA recommend higher amounts of vitamin E because and the beneficial prostaglandins requires the there are so many other benefits for women, presence of magnesium, vitamin B6, zinc, vita- including relieving cyclic breast pain, raising ben- min C, and niacin. Women who are deficient in eficial HDL cholesterol, and providing antioxi- these nutrients won’t be able to make this conver- dant protection. sion adequately. Supplementation with flax oil (high in omega-3 fatty acids), hemp oil, borage Vitamin E oil, black current oil, and evening primrose oil 150–800 IU per day (all high in linoleic acid and GLA) is one way of favorably altering the synthesis of the beneficial Calcium. Calcium supplementation for prostaglandins; the end result likely will be fewer menstrual cramps has been used by women as a uterine contractions and less menstrual pain. MENSTRUAL CRAMPS 231 As mentioned earlier, after the rise of proges- Melatonin. I have no personal experience terone in the second half of the menstrual cycle prescribing melatonin for menstrual cramps, but followed by its decline right before menstruation, I think it has potential based on some of its omega-6 fatty acids, particularly arachidonic acid, known biochemical effects. It has been proposed are released. Subsequently, an increase in PgF2- that insufficient melatonin secretion during the alpha and PgE2 occurs, causing uterine contrac- second half of the menstrual cycle (the luteal tions leading to ischemia and pain. Instead of phase) is a factor in primary dysmenorrhea.20 inhibiting ovulation and therefore the proges- This hypothesis is based on several factors: (1) terone effect, or inhibiting the synthesis of pro- melatonin levels are low at ovulation and increase staglandins with nonsteroidal anti-inflammatory premenstrually three- to sixfold and reach their agents, the omega-3 fatty acids, eicosapentaenoic peak at menstruation;21 (2) melatonin decreases acid (EPA), and docahexaenoic acid (DHA) com- uterine contractility;22 (3) melatonin exerts anal- pete with omega-6 fatty acids and result in the gesic effects;23 (4) melatonin stimulates proges- production of the friendlier antispasmodic and terone secretion;24 and (5) melatonin inhibits anti-inflammatory prostaglandins, series 1 and 3. uterine prostaglandin synthesis and release.25 Based on these observations and mechanisms, Since melatonin has been shown to have all using fish oil containing omega-3 fatty acids as a these effects, supplementation in order to achieve supplement seems beneficial. Dietary supple- high concentrations during menstruation may mentation with fish oils was tested in 42 adoles- serve to oppose the effects of prostaglandins and cent girls with dysmenorrhea.11 The first group therefore prevent the occurrence of dysmenorrhea. of 21 girls received fish oil (1,080 mg EPA and 720 mg DHA) and 1.5 mg vitamin E daily Melatonin for two months, followed by a placebo for an 2.5 mg per day, taken 3–4 days prior to onset of menses additional two months. In the second group, 21 girls received a placebo for the first two months, followed by fish oil for two more months. Botanicals At the conclusion of the study, on a 7-point Rose. A recent study suggests that rose tea scale, a score of 4 being moderately effective and consumption helped to decrease both pain and a 7 meaning totally effective, 73 percent of the psychological distress of women during menses.26 girls rated the supplementation greater than or In addition, another study showed that abdominal equal to 4. Another, more recent study looked at massage of rose, lavender, or clary sage essential supplementation with krill oil in decreasing oil in a base of almond oil was more effective menstrual symptoms, including cramps com- than almond oil alone in decreasing the severity of pared to standard fish oil, and found the krill dysmenorrhea.27 oil to be superior in decreasing the severity of dysmenorrhea as evidenced by a decreased use of Valerian (Valeriana Officinalis). Valerian analgesics.19 traditionally has been used primarily as a sedative and antispasmodic for the treatment of anxiety Fish Oils disorders, sleep disorders, and a diverse array of 1,080 mg EPA and 720 mg DHA per day conditions associated with pain. Valerian contains an important class of compounds called Evening Primrose Oil (EPO) valepotriates and valeric acid, which are found 500–1,000 mg up to 3 times per day exclusively in this perennial plant native to North America and Europe. It is not difficult to see how 232 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE valerian would help to relieve pain, anxiety, and ine relaxants, one of which is scopoletin, which insomnia because both valepotriates and valeric has been historically used as a specific medicine acid are capable of binding to the same receptors for menstrual cramps with severe low back and in the brain as the pharmaceutical drug Valium.28 bearing-down pelvic pains. For menstrual pains Although valerian has not been scientifically associated with a profuse menstrual flow and studied for menstrual cramps, it has been shown intermittent severe pains, black haw would prob- to relax the spasmodic contractions of intestinal ably be a more specific choice than crampbark. muscles.29 Both the uterus and intestines contain American Indians used the root and/or stem for smooth muscles. In clinical practice, valerian is the treatment of painful menses, to prevent mis- usually a significant feature of an alternative medi- carriage, and as a postpartum antispasmodic. cine approach to painful menstruation. It is most practical to take valerian in tincture form or cap- Crampbark sules. Many people prefer valerian capsules because 1⁄2 tsp tincture or 1 capsule every 2–3 hours the tincture has a very bitter taste. Attempts to dis- Black Haw guise the taste can be made by placing the tincture 1 in a small amount of fruit juice and then following ⁄4 tsp tincture or 1 capsule every 2–4 hours that with several swallows of plain juice. Valerian Caution: Both viburnum species should be avoided may make you tired and sleepy, so it is advisable to during pregnancy except in the hands of an experienced herbal practitioner. stay home and rest or take a nap.

Valerian Ginger (Zingiber Officinale). Ginger is typ- 1 tsp tincture or 1–2 capsules every 3–4 hours or as ically known for its stimulatory effects on diges- needed for pain tion and easing the nausea of an upset stomach. The pungent constituents in ginger, shagaol and Crampbark (Viburnum Opulus) and Black gingerol, also have an inhibitory effect on inflam- Haw (Viburnum Prunifolium). Both of these matory and spasmodic prostaglandins. Although species of viburnum are mentioned repeatedly in ginger has not been studied specifically in rela- the traditional botanical reference books as uter- tion to menstrual cramps, it does have antispas- ine relaxants and general antispasmodics.30 They modic effects on the smooth muscle of the have been used mainly for menstrual cramps, intestines. Given that the uterus is also made up of bearing-down uterine pains, and chronic uterine smooth muscle, and ginger has a long history of and ovarian pains. Animal studies have con- traditional use for treating spasmodic dysmenor- firmed that both species have an antispasmodic rhea, I use it in clinical practice with great confi- effect on the uterus.31 Laboratory studies on dence in combination with other herbs. human uterine tissue also have confirmed that Ginger Viburnum prunifolium exhibits a relaxant effect on the uterine tissue.32 1–2 g of dried ginger powder 1–2 times daily When the menstrual pains are of either a congestive or spasmodic nature and include low Black Cohosh (Cimicifuga Racemosa). back pains, especially if the pains radiate down Black cohosh has gained increased attention in the thighs, there is no better herbal choice than the last few years largely as an herb for the relief crampbark. of menopause symptoms. However, when I was The root bark of black haw is reported to first studying botanical medicine, this herb was contain several active constituents that are uter- known more for its relaxant effect on the uterus MENSTRUAL CRAMPS 233 in dysmenorrhea, false labor pains, and threat- onset of blood flow. Natural progesterone may ened miscarriage. It can be helpful in both con- allow a slower decline or a delayed decline. Thus, gestive and spasmodic menstrual cramps of even some women do indeed find that a natural prog- a severe nature. If the menses is also associated esterone cream, applied topically for 3 to 12 days with PMS irritability and anxiety, delayed or prior to onset of menses, will reduce menstrual irregular menstrual cycles, or scanty flow, then cramps. black cohosh would be an even more indicated herbal choice for menstrual cramps. Natural Progesterone Cream Apply 1⁄4 tsp of cream (>400 mg/oz) 2 times per day Black Cohosh for 3–12 days before the expected onset of menses. 1⁄4–1⁄2 tsp tincture or 1–2 capsules every 2–4 hours Exercise Other Traditional Herbs to Consider. The effects of both special exercises33–35 and gen- Herbs such as false unicorn root (Chamaelirium eral regular physical exercise on primary dysmen- luteum), wild yam (Dioscorea villosa), passion- orrhea have been studied. No discrepancies exist flower (Passiflora incarnata), German chamomile in the results from the first group of studies— (Matricaria chamomilla), blue cohosh (Caulo- special exercises are reported consistently to phyllum thalictroides), and hops (Humulus lupu- reduce or eliminate menstrual pain. For example, lus) have an independent antispasmodic or one researcher found symptom reduction in 89.3 sedative effect on the uterus in their own right. percent of 129 dysmenorrheic women who They are often used in combination with each adhered to his program of special exercises. Sim- other or in formulations with some of the more ilarly, another researcher, investigating 141 dys- dominant choices such as crampbark, black haw, menorrheic girls 14 to 18 years of age from two valerian, and black cohosh. different high schools, found that 92 percent of Additional herbs may also be considered for participants in one of the schools were “cured” or their different actions. For example, herbs that improved after being given a set of specific exer- have an anti-inflammatory effect, such as white cises to reduce menstrual pain.36 (A girl was con- willow and ginger; diuretic herbs that decrease sidered cured “if she was free of pain for at least the pelvic congestion, such as parsley, dandelion three menstrual periods” following the perform- leaf, or horsetail; and herbs that promote circula- ance of the prescribed exercises.) The experiment tion, such as ginkgo, may also have a role in reduc- was conducted from mid-September 1956 to ing the pain experienced from dysmenorrhea. mid-June 1957. The results for the second school Natural Progesterone. As stated earlier, it is were 76 percent “cured.” believed that the drop in progesterone premen- The three studies on the effects of general reg- strually results in an increased production of ular physical exercise on dysmenorrhea offer arachidonic acid by the endometrium. This stim- conflicting results. One group of investigators37 ulates PgE2 release and uterine contractions. If conducted a 12-week experiment that compared we can temper or delay this drop in progesterone two groups of dysmenorrheic women who volun- premenstrually, then, in effect, natural proges- teered to either walk/jog or to act as sedentary terone can be used to inhibit the uterine contrac- controls. The experimental group reported signifi- tions, ischemia, and pain during menstruation. cantly less severe menstrual symptoms than the Remember, though, that some decline in controls. In contrast, another group of investiga- progesterone is necessary in order to trigger the tors reported a 30 percent increase in menstrual 234 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plan for Dysmenorrhea

Dietary Recommendations valerian, and black cohosh: 3 capsules every 3 hours during acute pain (see the • Increase salmon, tuna, halibut, sardines, her- Resources section for formulation sources) ring, fruits, vegetables, and whole grains. • Decrease dairy, salt, sugar, red meat, poultry, Use Throughout the Month and eggs. • Niacin: 100 mg twice daily For Acute Pain Management • Fish oils: 1,080 mg EPA and 720 mg DHA daily • Calcium carbonate: 1,000–1,500 mg during • Vitamin E: 200–400 IU daily pain • Crampbark and/or black haw and/or black • Valerian: 1 tsp tincture or 1–2 capsules every cohosh: 1–2 capsules daily 3–4 hours • Consider combination products containing • Crampbark and/or black haw: 2 capsules every niacin, borage, vitamin E, calcium, cramp- 3–4 hours bark, valerian, and black cohosh: 2 capsules • Relaxation techniques for daily pain (see the Resources section for • Consider combination products containing formulation sources) niacin, borage, vitamin E, calcium, crampbark,

symptoms in regularly exercising over sedentary regimen of oral contraceptive use may be even student nurses.38 However, a more recent, con- more effective. Reducing the pill-free interval to trolled study again validated the hypothesis that approximately four days reduces the volume of regular exercise decreases menstrual symptoms in menstrual bleeding beyond the usual reduction finding that “high exercisers experienced the great- seen in the seven-day pill-free interval and sup- est positive effect and sedentary women the least.”39 presses ovulation more effectively, further reducing the production of prostaglandins. Pain CONVENTIONAL control with oral contraceptives is probably the MEDICINE APPROACH result of reduced volume of menstrual fluid and Two groups of drugs are highly effective against suppression of ovulation, which reduces uterine dysmenorrhea: oral contraceptives and prostag- prostaglandin levels. landin synthetase inhibitors, also known as non- You may need to try several oral contracep- steroidal anti-inflammatory drugs (NSAIDs). The tives before you find one you are comfortable choice of medication depends on whether a with. The majority of oral contraceptive side woman needs oral contraceptives for birth control, effects come from the progestin. Use the medica- whether she has any allergies to aspirin or con- tions for several months before you decide traindications to oral contraceptives such as prior whether they are effective, rather than giving up deep venous thrombosis, whether she has a history after the first cycle, and be willing to try different of gastric ulcers, and her age. brands if necessary. Oral contraceptives, if suc- Women desiring birth control should proba- cessful, can be used throughout a woman’s entire bly use oral contraceptives as the first agent of reproductive cycle and into her early 50s. If dys- choice. Combination oral contraceptives reduce menorrhea is reduced but not significantly elim- prostaglandin levels and menstrual flow, and inated, an NSAID can also be added. approximately 80 percent of patients achieve For women who do not need contraception near-complete relief of dysmenorrhea. A newer or do not tolerate or choose to take oral contra- MENSTRUAL CRAMPS 235

Exercise Recommendations for Menstrual Cramps

If not exercising regularly, incorporate exercise into them, move pelvis away from wall and then your daily routine. (See Appendix A.) toward it until pelvis touches the wall. Try the following special exercises for moderate • Return to original position. to severe dysmenorrhea (adopted from Haman33 and • Repeat 5 times. Golub36). For mild menstrual pain, do only one or two of the exercises. Do these exercises twice a day for 10 Exercise 3 consecutive days before menses. • Stand with feet 12 inches apart and arms Exercise 1 raised to the side at shoulder level. • Keeping knees slightly flexed, to avoid • Stand at a right angle to the wall with left hyperextending them, twist trunk to the elbow on the wall on a level with the left right and bend forward, attempting to touch shoulder. the right ankle with the left hand. • Tilt pelvis forward. • Return to original position. • Keeping knees slightly flexed, to avoid hyper- • Repeat sequence in the opposite direction. extending them, move left hip until it touches • Repeat 5 times. wall. • Return to original position. Exercise 4 • Repeat 5 times. • Stand with feet a few inches apart and arms • Repeat sequence with right elbow on the wall. at the sides. Exercise 2 • Swing arms forward and upward, simultaneously raising the right leg backward. • Stand facing the wall with both elbows on wall • Return to the original position. on a level with shoulders. • Repeat with the left leg. • Without moving elbows or feet and keeping • Repeat 5 times. knees slightly flexed, to avoid hyperextending ceptives, prostaglandin synthetase inhibitors can has not been shown to be any more effective than be used. These nonsteroidal anti-inflammatory a placebo and is not generally used by women for drugs reduce menstrual fluid prostaglandins and menstrual cramps. However, aspirin in associa- their metabolites, resulting in decreased uterine tion with other proprietary agents in a combina- contractility and menstrual pain. They also tion medication such as Midol is reported by somewhat decrease the amount of menstrual patients to be effective. flow. They are most effective if given before Another category of NSAIDs includes meclofe- cramping begins and are usually only taken for namate (Meclomen) and mefenamic acid (Ponstel). two to three days per cycle. They have been available for more than 20 years There are several groups of prostaglandin syn- and have been highly effective. They are used when thetase inhibitors, including medications such as cramps begin. COX-II inhibitors such as Celebrex aspirin, ibuprofen, naproxen, and mefenamic have been very effective in the treatment of dys- acid. The aryl-propionic acid derivatives such as menorrhea. However, some head-to-head trials ibuprofen and naproxen are easily available over with the other NSAIDs have not shown them to be the counter and have been highly successful. more effective, and they are significantly more Patients achieve a significant reduction in dys- expensive and possibly have an increase in side menorrhea 60 to 90 percent of the time. Aspirin effects. Side effects of all prostaglandin synthetase 236 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE inhibitors can include headaches, stomach or intes- The levonorgestrel intrauterine system in the tinal upset (specifically gastritis or ulcers), and a Mirena IUD substantially reduces menstrual flow tendency to feel fatigued. Serious complications approximately 80 percent as a bonus to the excel- involve kidney damage and gastrointestinal bleed- lent contraception it provides. It has also been ing. Recommended doses for acute menstrual pain found to significantly reduce menstrual cramps and are as follows: might be a good option for women seeking both Ibuprofen: 600 mg every 6 to 8 hours contraception and treatment of menstrual cramps. Naproxen (Naprosyn): 500 mg every 12 hours Naproxen sodium (Aleve): two 220-mg tablets SEEING A LICENSED PRIMARY every 6 hours HEALTH-CARE PRACTITIONER Naproxen sodium (Anaprox DS): 550 mg every (N.D., M.D., D.O., N.P., P.A.) 6 to 8 hours We need to remember that primary dysmenorrhea Mefenamic acid (Ponstel): two 250-mg tablets is pain during menses that exists without any iden- at the onset of pain, followed by one tablet tifiable pelvic disease. You must be certain that every 8 hours your menstrual pain is indeed primary dysmenor- Meclofenamate (Meclomen): 100 mg every 8 rhea and not pain due to pelvic disease such as hours endometriosis, adenomyosis, uterine fibroids, Celebrex: 200 to 400 mg once daily pelvic infection, or an ovarian tumor. These condi- For those who do not respond to oral contra- tions need to be diagnosed by a licensed health-care ceptives or other medications, it is best to consider practitioner capable of ordering the tests necessary laparoscopy to rule out endometriosis or another to exclude these pelvic diseases if you are not pelvic disease. Usually, when the oral contracep- responding to simple treatments. tives or the NSAIDs work, the practitioner will If your pain is being well managed by con- consider that the patient has primary dysmenor- ventional treatments, but you are experiencing rhea, which is not associated with another pelvic some unwanted side effects, an alternative practi- disease. If the patient has a negative laparoscopy tioner can work collaboratively to reduce these and oral contraceptives or NSAIDs do not help side effects. Alternative practitioners may also be the dysmenorrhea, she may be carefully watched consulted for their expertise in using effective and administered intermittent narcotic medica- alternative therapies and higher doses of natural tions under the ongoing supervision of a physi- anti-inflammatories, herbs that may not be easily cian. Narcotic medications should be avoided accessible for self-treatment, or for a comprehen- when possible because of the potential for toler- sive treatment plant looking at the relationship of ance and abuse. They should be used only when the menstrual cramps to the whole system and other options and diseases have been excluded. whole person. OSTEOPOROSIS CHAPTER 14

OVERVIEW responsible for about 90 percent of all hip and As the U.S. population ages, certain diseases and spine fractures in white American women aged medical conditions more common among aging 65 to 84.5 The World Health Organization Americans are gaining greater public attention. (WHO) has defined osteoporosis as a bone min- Osteoporosis, a serious and disabling disease and eral density that is 2.5 standard deviations (SD) the most prevalent metabolic bone disease in below the mean peak value in young adults.6 Western societies, is one such condition. Fortu- This is called the T-score. A T-score that is nately, osteoporosis can and should be prevented between 1 and 2.5 SD below the mean is called and, when present, treated. Osteoporosis affects osteopenia. 75 million people in Europe, the United States, These definitions are useful because they pro- and Japan. In the United States alone, it affects vide objective criteria, but they have limitations 25 million people and causes 1.5 million frac- because they ignore the importance of other tures annually.1 determinants of bone strength. The definitions In the United States the rates of osteoporosis also ignore other risk factors for fractures in and fractures vary with ethnicity, with African- elderly women such as a maternal history of Americans having the highest bone mineral hip fracture, age, and poor balance. For example, density (BMD) and Asian-Americans having the most postmenopausal women with fractures do lowest. After adjusting for body weight, one large not have a bone density score that meets the study of postmenopausal women revealed that WHO osteoporosis criteria.7 The World Health white American women and Hispanic American Organization, the National Osteoporosis Foun- women had the highest risk of osteoporotic frac- dation, and other expert panels are in the process ture. This was followed by Native Americans, of releasing new guidelines to estimate a woman’s African-Americans, and Asian-Americans.2 So risk of an osteoporotic fracture, using a bone while Asian-Americans have the lowest BMD, density test along with these other risks. These they also have a lower fracture rate, which we new guidelines will provide better direction for think may be related to body size. treatment interventions. Most cases of osteoporosis occur in post- Although low bone mass, as measured by bone menopausal women, and the rates increase with density, is important in determining a person’s risk declining BMD and with age. Of white Ameri- of fracture, other risk factors are equally important. can women, 13 to 18 percent who are 50 years or These include maternal history of a hip fracture, older have osteoporosis of the hip.3 An additional previous vertebral fracture, previous hip fracture, 37 to 50 percent have low bone mass (osteope- high fall risk, and others.8 Assessing a person’s like- nia) of the hip, again increasing with age and lihood of a fall (use of sedative medications, inabil- worse in women age 80 and older. ity to stand unaided from a sitting position, poor Osteoporosis is defined as a skeletal disease vision, muscle weakness) is very important as well. characterized by low bone mass and a deteriora- Low bone mass may be due to osteoporosis and/or tion in bone microarchitecture leading to bone poor bone quality. Vitamin D deficiency and other fragility and susceptibility to fracture4 and is causes of hyperparathyroidism can lead to poor 237

Copyright © 2008 by Tori Hudson. Click here for terms of use. 238 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE bone quality as well. Clinically, the term osteoporo- of about 15 percent by age 80, but a peak inci- sis is used in reference to loss of bone associated dence about 20 to 25 years sooner. Each year, with relatively atraumatic fractures of the ribs, 172,000 wrist fractures occur that are the result of spine, wrist, and hips. moderate trauma and rapid postmenopausal bone Fractures associated with osteoporosis are dis- loss. The female to male ratio is 5:1. Wrist frac- tinguished by three characteristics:9 tures are rarely fatal and cause much less disability than do hip and spinal fractures.17, 18 • Greatly increased incidence with aging, with fractures occurring 2 to 100 times more How Osteoporosis Affects the Bone among adults over age 75 than among There are two types of bone: trabecular and cor- younger people tical. The skeleton is living tissue composed of • Greater incidence among women than men about 75 percent cortical bone and 25 percent • Associated with modest trauma trabecular bone. The trabecular bone is the inside The three most common fracture sites are the part of the bone where the bone marrow is. It is spine, hip, and forearm. For a 50-year-old Amer- comprised of a network of structural tissue that ican woman, the risk of having an osteoporotic prevents it from compressing with pressure (for fracture in her remaining years is estimated to example, from a fall). The cortical bone is the be 40 percent,10 and two-thirds of the fractures hard exterior of the bone that protects the bone occur after age 75. Osteoporosis-related fractures from external trauma. Vertebrae are made up of will develop in half of all women and one-fifth of 90 percent trabecular bone and only 10 percent all men older than 65 years.11 Hip fractures, with cortical bone; the hip is 50:50, and the extremi- a median age of 82, are particularly life altering. ties are 90 percent cortical bone. Trabecular bone Within the first year following a hip fracture, the is concentrated in the vertebrae, pelvis, other flat mortality rate is increased by up to 20 percent, as bones, and at the ends of long bones like the many as 25 percent of the survivors will be con- upper and lower leg. fined to long-term care facilities one year after Trabecular bone is metabolically much more the fracture, and 50 percent will have at least active and has a higher turnover rate than corti- some long-term loss of mobility.12 cal bone. To provide support for the body, bone Vertebral fractures (fractures of spinal verte- is continuously rebuilt to maintain an optimal brae) occur a little younger, on average in a structure. Any damage or fatigue effect is con- woman’s mid-70s. Multiple vertebral fractures, stantly repaired through a process of bone break- or one severe one, can cause severe pain, loss of down (resorption) and rebuilding (formation) height, and an exaggerated curvature of the mid- called bone remodeling. Bone formation and spine called thoracic kyphosis. These pains and resorption are interdependent processes; if one is deformities can restrict bending and reaching altered, it directly affects the other. The cells that and can greatly increase the risk of additional ver- cause bone resorption are called osteoclasts and tebral fractures.13, 14 Fractures of the thoracic stimulate the production of acid and enzymes spine can also restrict lung function, cause diges- that dissolve bone mineral and proteins. Bone tive problems, 15 lower self-esteem and body building cells, or osteoblasts, promote bone for- image, and result in depression.16 mation by creating a protein matrix, which con- Vertebral fractures are twice as common as sists primarily of collagen. This becomes calcified either hip fractures or distal radius (wrist) frac- and results in mineralized bone. tures. The incidence of wrist fractures starts to rise Normal bone remodeling is a process that is immediately after menopause, with an incidence balanced by bone resorption and bone formation. OSTEOPOROSIS 239 In childhood, bone formation far exceeds bone menstrual period, and this accelerated rate of remodeling, leading to longer, denser bones. loss ends three to four years after menopause. At During the adult years, bone resorption and the hip, bone loss has an age-related rate of bone formation are in balance, and total bone decline of about 0.5 percent per year. Over these mass remains relatively stable. As we age, the five to seven years, it totals approximately 10.5 osteoblasts and osteoclasts may no longer func- percent loss for the spine and 5.3 percent for the tion in a balanced fashion. When there is an hip.20 A slow and small amount of bone loss imbalance between bone resorption and bone for- occurs from then on. Women older than 70 face mation, bone loss occurs, bone mass decreases, other challenges that may accelerate their bone and fracture risk increases. loss again such as increasing age and secondary Bone loss can be osteoclast-mediated, as seen hyperparathyroidism due to a drop in calcium in osteoporosis, or osteoblast-mediated, as seen absorption. in bone cancers. In osteoporosis, osteoclast- In women who have premature menopause mediated bone loss outpaces the ability of (at or before age 40), whether spontaneous or by osteoblasts to fill in the empty spaces. Certain medical causes such as having both ovaries problems cause different types of bone loss. removed, chemotherapy, or pelvic radiation, Trabecular bone loss occurs with low estrogen there is a greater risk of low BMD compared to levels, steroid use, and immobilization. So, when other women their age who are not meno- women choose not to take estrogen after menopausal.21 By the age of 70, when risk of fracture pause, they are more likely to lose trabecular is greater in general, this issue of early premature bone and therefore may be at higher risk for ver- menopause becomes moot because no matter tebral and hip fractures. Cortical bone loss occurs how menopause was attained, women will have with calcium and vitamin D abnormalities such the same risk of low BMD or fractures. as vitamin D deficiency and leads to an increased risk of extremity fractures. An extreme form of The Role of Heredity, Nutrition, and this is rickets, which presents with bowing of the Lifestyle in Osteoporosis femurs that results from small microfractures of Genetic predisposition contributes significantly those bones. Because of the differences in cortical to bone mass and to the development of osteo- and trabecular bone, many practitioners prefer to porosis later in life. Heredity has the greatest measure both the hip and the spine when doing influence on a woman’s peak bone mass, and bone density testing. studies have suggested that 80 percent of the determinant of peak bone density is due to The Role of Menopause in Osteoporosis genetic factors.22, 23 Female children of women As we age, bone resorption increases. This in- who experienced an osteoporotic fracture were crease is worsened by a decrease in bone forma- found to have 3 to 7 percent lower bone mass tion in women after menopause. Within the first than would be expected for their age.24, 25 Addi- few years of menopause, there is rapid bone loss tional studies have shown that relatives of women due to lower levels of ovarian estrogen produc- with osteoporosis tend to have lower bone tion. With less estrogen in the body, bone resorp- mass.26 The racial differences observed in bone tion is no longer inhibited. This decline in mass also suggest the role of a genetic factor. estrogen is the most significant factor in the in- Dietary factors and nutrient deficiencies alter creased bone loss associated with menopause.19 bone growth and remodeling and may result in In the spine, bone loss of 2 percent per year lower bone mass. Girls or women with a dietary begins about two to three years before the last abnormality such as anorexia nervosa have signifi- 240 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE cantly lower bone mass than their healthy counter- adequate assessment of low bone mass, but rather parts.27 A balanced diet of plenty of vegetables, are important guides in the clinical assessment of especially dark green leafy vegetables, nuts, seeds, osteoporosis risks that contribute to optimal pre- whole grains, low-fat dairy, fish, and small amounts ventive management. Ultimately, an individual of animal meats play an important role in the woman’s risk of fracture is the most relevant development and maintenance of healthy bone. parameter for her future health care. Adequate calcium and vitamin D intake is needed It is important to distinguish between risk to achieve the genetically determined peak bone factors for osteoporosis as defined by BMD and mass, to maintain bone mass once this peak has risk factors for osteoporotic fractures. For osteo- been achieved, and to maintain the strength and porosis defined by BMD, major risk factors are: integrity of the skeleton throughout our lives.28 • Postmenopausal The intake of calcium is most important • Advanced age during the bone-building years of childhood • Genetics through adolescence and in old age. During • Lifestyle factors (low calcium, low vitamin puberty, calcium is required for bone growth and D intake, smoking) for the achievement of maximal calcification. • Thinness Postmenopausal women and men over 65 require a greater intake of calcium because absorption of The most common risk factors for osteo- calcium is less efficient, but the dietary intake of porotic fracture are female, advanced age, low calcium is usually lower because of intolerance to BMD, previous fracture as an adult (other than dairy products or elimination of dairy products the skull, facial bone, ankle, finger, and toe). A as part of a low-fat diet. more comprehensive list of risk factors for osteo- Lifestyle factors, such as the level of physical porotic fractures includes: activity, cigarette smoking, alcohol consumption, • Female and additional nutritional influences can pro- • Postmenopausal and advanced age foundly impact bones. We will expand on these • Previous fracture as an adult (other than in the overview of alternative treatments. skull, facial bone, ankle, finger, and toe) Assessing Osteoporosis Risk and • History of hip fracture in a mother or father Diagnosing Osteoporosis • Body weight less than 127 pounds or body mass index (BMI) less than 21 The evaluation of risk and diagnosis of osteo- • Characteristics: short, slender, fair-skinned, porosis is made by a careful medical history, a blonde, blue-eyed thorough physical examination, laboratory • Current smoking, of any amount analysis, and measuring bone density. • Low calcium or vitamin D intake No one test or risk factor, alone or in combi- • More than two alcoholic drinks per day nation, will accurately predict which patients will • Early menopause (physiologic, surgical, or or will not experience osteoporotic fractures. In drug-induced) general, the more risk factors present, the greater • Increased risk of falling (impaired vision, the potential for lower bone mass and the higher dementia, poor health or fragility, sedentary, the risk of fracture. However, predictions from history of recent falls) risk factors cannot pinpoint all persons who will be affected. Risk factors for osteoporosis account When trying to determine a woman’s risk of for only 20 to 40 percent of bone mass variance.29 low bone mass and risk of fracture, questions Therefore, risk factors alone do not provide should be asked to determine risk factors as OSTEOPOROSIS 241

Medications, Diseases, and Disorders That Increase the Risk of Osteoporosis

Medications Endocrine Disorders • Oral or intramuscular use of glucocorticoids for • Cortisol excess more than three months • Cushing’s syndrome • Excessive thyroid hormone • Gonadal insufficiency • Long-term use of the anticonvulsant phenytoin • Hyperthyroidism • Heparin • Type 1 diabetes • Cytotoxic drugs • Gonadotropin-releasing hormone Gastrointestinal Diseases • Intramuscular medroxyprogesterone contracep- • Cirrhosis tive agent • Malabsorption syndromes (celiac disease, • Immunosuppressive drugs (cyclosporine) Crohn’s disease) Genetic Disorders • Total gastrectomy (removal of the stomach) • Osteogenesis imperfecta Other Disorders and Conditions • Thalassemia • Multiple myeloma • Hemochromatosis • Lymphoma and leukemia • Hypophosphatasia • Systemic mastocytosis Calcium Balance Disorders • Anorexia nervosa • Rheumatoid arthritis • Elevated urinary calcium • Chronic renal disease • Vitamin D deficiency stated in the two preceding lists. There are also • Poor vision various medications, disease states, and genetic • Medications that affect balance and disorders that are secondary causes of bone loss. coordination This information should also be explored with a Physical exam should assess height, weight, site medical history. Most of these risks can be deter- of back pain and localized spinal muscle spasms, mined on a questionnaire. They don’t diagnose spinal contours and deformities, and dental health. osteoporosis, but identifying these risk factors A loss of height can be a sign of a fracture in the can help to determine causes of osteoporosis and vertebrae. Normal age-related height loss is up to help to guide the best treatment strategy. 1.0 to 1.5 inches. Height should be measured After menopause, the risk of falling should also yearly, and a loss of height that is greater than 1.5 be determined. Factors related to an increased risk inches increases the possibility that a vertebral frac- of falling include ture has occurred.30 Vertebral fractures also cause • A history of falls, fainting, or loss of acute or chronic back pain, especially in the consciousness middle part of the back, called the thoracic spine. • Muscle weakness If there are multiple vertebral fractures, called • Balance problems compression fractures, the most obvious sign is an • Dizziness abnormal curvature called kyphosis. If back pain, • Difficulty standing or walking height loss, and kyphosis are all present, this war- • Arthritis rants an x-ray of the spine to determine if there is 242 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE osteoporosis and/or vertebral fractures. Even exces- diagnose osteoporosis or determine future bone sive height loss without back pain warrants an loss or fracture rates. However, they can be used x-ray to confirm a spine fracture. Women who have to determine a response to treatment. These tests one vertebral fracture are at high risk for a subse- of bone turnover can be done prior to beginning quent fracture,31 which makes diagnosing a single a treatment for osteoporosis and then again in a vertebral fracture that much more important. few months to determine if the treatment is Body weight should also be recorded. A body working to slow bone turnover. Tests for bio- weight less than 127 pounds or a body mass chemical markers of bone turnover can be done index less than 21 kg/m2 is a risk factor for low more frequently than a bone density test and can BMD. Thinness is associated with low bone den- be done early, even within weeks after beginning sity and a twofold increased risk of fracture, espe- the treatment. The role of these tests in routine cially in older women.32 clinical practice has not been established, how- Laboratory Tests. Laboratory tests are ever, and therefore it is difficult to determine the important in determining the cause of the low scope of their usefulness. bone density or osteoporosis. Secondary causes It might be tempting to think that all meno- of bone loss should be identified because the pausal women should have a bone density test. I cause needs to be treated, not just the resulting would discourage that way of thinking because a effects, the bone loss. Laboratory studies and test is really only helpful if it influences the treat- biochemical markers are done on an individual ment. If a woman really wants the test, I have no basis. Some women may need some or all of objection to ordering it for her. However, I tend these tests initially because their risk is deter- to follow the recommendations for BMD testing mined to be high from the history and physical (described later) of the North American Meno- exam. Other women will want or need these tests pause Society: because their bone density is significantly low, • Postmenopausal women with medical causes and possible metabolic causes will be important of bone loss to determine. Tests may need to be repeated over • All postmenopausal women who are 65 time in order to monitor the effectiveness of the years or older treatments that have been employed. It’s impor- • Postmenopausal women younger than age tant to fully understand, however, that these tests 65 who have one or more of the following cannot diagnose osteoporosis, predict bone den- risk factors for fracture: sity, or determine fracture risk. Tests that should be routinely performed Fracture after menopause (other than skull, include a complete blood cell count, serum cal- facial bone, ankle, finger, and toe) cium, alkaline phosphatase, thyroid-stimulating Weight less than 127 pounds or BMI less hormone, albumin, and urinary calcium excre- than 21 tion to detect malabsorption of calcium or a Hip fracture in mother or father renal calcium leak. Selected cases warrant addi- Current smoker tional testing of 25-hydroxyvitamin D levels in Bone density testing can clarify an already diffi- the serum, parathyroid hormone, and serum cult decision and can optimize the use of both electrophoresis to determine the cause of the conventional and natural medicine therapies. excessive bone loss or fractures. There are some newer tests that are biochem- Imaging Techniques. Bone imaging tech- ical markers of bone turnover. Again, they do not niques include radiographic techniques and OSTEOPOROSIS 243 ultrasound of the heel. Radiographic techniques World Health Organization Definitions include dual energy x-ray absorptiometry (DXA), CT scan, x-rays, dual photon absorptiometry 1. Normal bone mineral density (BMD): Within (DPA), single-photon absorptiometry (SPA), and 1 standard deviation (SD) of young adult gender-matched means x-ray absorptiometry (SXA). DXA is the preferred 2. Osteopenia: BMD between 1 and 2.5 SD below test of the commonly used densitometry tech- young adult means niques and is more accurate in measuring bone 3. Osteoporosis: BMD more than 2.5 SD below density of the lumbar spine and proximal femur. young adult means DXA offers a lower dose of radiation and a 4. Severe osteoporosis: BMD more than 2.5 SD below young adult means and the presence of shorter examination time than other imaging one or more fragility fractures methods. Because of its enhanced precision and accuracy, DXA has become the gold standard for bone densitometry. The total hip, femoral neck, and estrogen therapy), a reduction in fracture risk and lumbar spine are the three most important occurs even if the bone density is not increased. measurements. The lowest score of the three is the On the other hand, if there is a decrease in the most important. Repeat tests in women who are DXA scan, while on proven osteoporosis treat- not receiving treatment generally do not need to ment medications, further testing should be done occur until three to five years later. For women to determine if there are any secondary causes of receiving treatment for osteoporosis, BMD test- bone loss. ing is typically done after two years, although selected cases may warrant testing at one year. OVERVIEW OF Ultrasound of the heel is less expensive, is ALTERNATIVE TREATMENTS easily administered, and uses no radiation. The Osteoporosis is far easier to prevent than to treat. heel bone is 100 percent trabecular bone, the same An osteoporosis prevention perspective needs to type of bone that makes up 90 percent of the ver- start in the teenage years. Education should tebrae and 50 percent of the hip. Ultrasound include several key areas: measurement of the heel bone may provide a less Medical problems, early in life and current, that expensive screening test for osteoporosis. Reviews can lead to osteoporosis have concluded that ultrasound of the heel was a Medications that can interfere with calcium good predictor of fractures of the spine.33 Its lim- metabolism iting factor is that the scans are not useful in The role of nutrition and exercise early in life detecting small changes in density over time and and their necessity in achieving peak bone therefore cannot be used to monitor the effective- density ness of treatment of osteoporosis. Women with Awareness of the long-term consequences for abnormal results would be referred for DXA test- bone health of anorexia ing to more precisely assess bone mineral density. Awareness of the negative effect of smoking and In women who are receiving treatment for excess alcohol osteoporosis, DXA scans are usually done after two years of treatment. It is important to realize For women in their 40s, 50s, and older who that even if there is no increase in BMD on the have just begun to think about osteoporosis, the DXA scan in the first two years, there may be time for reaching peak bone density at age 30 to significant increases in the third year, even on the 35 is already past. We all lose bone density as we same therapy. In addition, if proven fracture- age, and if you achieved 100 percent of maxi- reducing drugs are being used (bisphosphonates mum by 30 or 35 and you do not have a condi- 244 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

tion or genetics that cause rapid bone loss, then PREVENTION all is well usually. If your peak bone density was only 85 percent of maximum, then you can’t • Do not smoke. afford as much normal age-related bone loss • Reduce or avoid alcohol consumption and do not before your bone density becomes osteopenic exceed one drink per day. and then osteoporotic. • Do regular weight-bearing exercise, especially Several approaches are available to prevent comprehensive weight lifting throughout life. osteoporosis and to treat both those who are at • Ensure proper nutrition: organic low-fat dairy, soy foods, adequate calcium and vitamin D, high risk and those who have developed the condi- whole grains, dark leafy green vegetables, nuts, tion. Natural medicines are especially key in pre- seeds, healthy oils, and fish. vention and in helping women with mild low bone • Avoid being underweight. density. Once osteoporosis has been diagnosed, • Minimize caffeine intake. many of the natural interventions such as diet, • Reduce animal protein. exercise, nutritional supplementation, and herbal • Avoid falls and injuries. medicines could be used aggressively in milder • Get regular annual health checks; laboratory cases to slow bone loss and possibly improve bone testing and bone-density testing may be density, bone strength, bone architecture, and bone appropriate. health in general. In general, it is my position that • Consider hormone replacement therapy (bio- identical hormones or conventional hormones) if in cases of diagnosed osteoporosis, natural inter- you have several risk factors. vention should be used to supplement an antire- • Take nutritional supplements for bone health. sorptive therapy intended to stop or slow the rate of bone loss and reduce the rate of fractures. The most common proven antiresorptive therapies balanced diet, adequate calcium and vitamin D, include estrogens, bisphosphonates, and selective regular exercise, not smoking, low alcohol intake, estrogen receptor modulators (SERMS). and fall prevention are important steps for bone All postmenopausal women, no matter their health as well as other health benefits. risk for osteoporosis or bone density status, should Natural interventions for mildly low bone be encouraged to practice prevention strategies. A density and osteoporosis include dietary and lifestyle factors, exercise, nutritional supplemen- KEY CONCEPTS tation, the use of phytoestrogens, and natural (bio-identical) hormone replacement therapy. • Osteoporosis-related fractures will develop in Each of these areas deserves special attention. almost half of all women older than 65. • Osteoporosis is a serious and disabling disease Nutrition and is far easier to prevent than to treat. Several dietary factors affect bone health and are • Women with a family history of osteoporosis, and especially hip fractures, are at the highest involved in the development of osteoporosis: risk of developing the condition. Eighty to insufficient calcium and vitamin D intake, high ninety percent of the determination of the phosphorus intake, a high animal protein diet, development of osteoporosis is a family history excess salt intake, and other mineral deficiencies. of osteoporosis. A diet that maximizes consumption of fruits and • Fracture risk can be determined from a medical vegetables and minimizes dietary fats is beneficial history, physical exam, laboratory testing, and a for bone development. DXA bone density test. Women older than age 65 who do not eat enough and women who practice frequent dieting OSTEOPOROSIS 245 or have eating disorders are susceptible to insuf- a severe impact of soft drinks on calcium levels. ficient intake of vitamins and minerals and there- Fifty-seven children with low blood calcium levels fore may have insufficient bone mass. Elderly were compared to 171 children with normal cal- women are particularly vulnerable to the negative cium levels.42 Of the 57 children who had low effects of weight loss impacting their bone blood calcium levels, 66.7 percent drank more health. Weight loss in this group may lead to than four 12- to 16-ounce bottles of soft drinks per accelerated bone loss and a higher risk of frac- week. Only 28 percent of the 171 children with tures, particularly of the hip.34 normal serum calcium levels consumed that many Studies have shown that excessive animal pro- soft drinks per week. For all 228 children, a strong tein in the diet may promote bone loss. It particu- correlation was seen in the serum calcium level and larly causes an increase in urinary excretion of the number of bottles of soft drinks consumed calcium. Raising daily animal protein intake from each week. The more soft drinks consumed, the 47 to 142 grams doubles the excretion of calcium lower the calcium level in the blood. Due to the in the urine.35 Calcium is mobilized from the high intake of soft drinks in the United States, we bone to buffer the acidic breakdown products of can probably expect to see increased osteoporosis protein. In addition, the amino acid methionine, in the “Pepsi generation” for many years to come. highest in meat, dairy products, and eggs, is con- The American per-capita consumption of soft verted to homocysteine, which in high amounts drinks is about three quarts per week. may also cause bone loss. All of these mechanisms Other nutritional factors also accelerate cal- of a high animal protein diet contributing to calcium loss and may be implicated in osteoporosis. cium and bone loss should raise serious concern Refined sugar may raise the risk for osteoporosis about popular high animal protein diets. by increasing the loss of calcium from the body On the other hand, insufficient protein may and by causing a significant increase in fasting also be a problem, especially in women older serum cortisol levels. A serving of refined sugar than 75, and adequate protein intake may help increases the urinary excretion of calcium,43 and to minimize bone loss.36, 37 Protein supplementa- an excess of corticosteroids can cause osteoporosis. tion of 20 grams per day in older patients who High sodium intake can also cause an increase in have had a hip fracture have been shown to urinary excretion of calcium in some individu- decrease recovery time and result in lower rates of als.44 Refined grains and flours may also play a complications and a lower death rate the first part in the development of osteoporosis. Due to seven months after the fracture.38 their lack of nutrient-rich germ and bran, there is A vegetarian diet is associated with a lower a significant loss of vitamins and minerals in risk of osteoporosis,39 even though vegetarians do these foods. The refining process produces white not have greater bone mass in their 20s, 30s, and flour stripped of B6, folic acid, calcium, magne- 40s. Several studies have shown that vegetarians sium, manganese, copper, and zinc. do have significantly higher bone mass later in One of the best general dietary preventive life, which would indicate that vegetarians lose habits to acquire is to eat a lot of dark green leafy bone more slowly than nonvegetarians.40, 41 vegetables. Kale, collard greens, romaine, spinach, Many high-protein animal foods also contain Swiss chard, and other dark greens are a rich source high amounts of phosphorus, which mobilizes of vitamins and minerals, including calcium, vita- calcium from the bones in order to maintain min K, and boron. As you will learn in the nutri- homeostasis in the bloodstream. tional supplements section, vitamin K is involved High-phosphorus beverages are also implicated in the mineralization of bone, and boron decreases in osteoporosis. A study in children demonstrated the urinary excretion of calcium and magnesium. 246 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Soy foods appear to also have some role in Illinois found that menopausal women had an preventing or slowing bone loss. Soy contains a increase in mineral levels and density in their class of compounds called phytoestrogens. The lumbar spines after taking 55 to 90 mg of phytoestrogen especially high in soy foods is isoflavones for six months.47 The placebo group isoflavone. Phytoestrogens and isoflavones are showed the lowest bone density and the greatest discussed in more detail in Chapter 12; here we’ll bone loss, while the estrogen group showed the focus on their effect on bone health. Soybeans highest bone density and the slowest bone loss. contain phytoestrogens called isoflavones and a What was surprising was that the soybean pro- particular isoflavone called daidzein. Daidzein is tein diet was effective in preventing bone loss in similar to a semisynthetic product called Ipri- the fourth lumbar vertebra and, although less so, Flavone, which is used to treat osteoporosis. Soy in the right hip as well. Soybean protein seems to is the only dietary source of daidzein, which is a have more of an effect on trabecular bone (more nonsteroidal estrogen-like molecule. Soy also predominant in the spine) than on cortical bone increases the menstrual cycle length by one to (more predominant in the hip). The soybean five days, especially the follicular phase. This may protein did not show as great an ability to pre- have a positive effect on bone density due to vent bone loss as the estrogen group, but the pos- longer exposure to elevated estrogen levels. itive effect it showed is encouraging. Soy appears to have a proestrogen effect on The study of the relationship between soy bone in some experimental evaluations. The isoflavone intake and bone mineral density was bone density of ovariectomized rats for which conducted from the Study of Women’s Health soy replaced casein in the diet was compared to Across the Nation, a U.S. cohort study of women another group that received estrogen. The addi- aged 42 to 52 years.48 For African-American and tion of soy inhibited bone loss, although not to Caucasian women, median intakes of genistein the same extent as was achieved with estrogen were too low to pursue analyses. For Chinese treatment.45 Another study of ovariectomized women, no association between genistein and rats also reported a positive effect of the soy phy- bone mineral density was found. Premenopausal, toestrogen genistein in maintaining bone.46 but not perimenopausal, Japanese women whose These authors also reported that genistein sup- intakes were greater had a higher bone density of presses the bone resorption cells (osteoclasts) the spine and femoral neck. Mean spinal bone both in the test tube and in vivo. density of those women in the highest genistein Several human studies have provided further intake group was 7.7 percent greater than that insight into the possible role of soy in bone of women in the lowest group. Bone density of health. A study conducted at the University of the femoral neck was 12 percent greater in the highest intake group versus the lowest. Calcium Content of Selected Soy Foods Other positive studies on soy and bone density also give some credence to the role of soy Soy Product Calcium (mg) for bone health. In a study estimating the daily 1 Tofu, firm ( ⁄4 block) 553 intakes of soy isoflavones in the diets of 478 post- 1 Tofu, regular ( ⁄4 block) 406 menopausal Japanese women who reported soy Soy milk, calcium-fortified (1 cup) 80–300 consumption, high consumption of soy products Soy milk (1 cup) 7 49 Soybeans, roasted (1⁄4 cup) 119 was associated with increased bone mass. Soybeans, boiled (1⁄4 cup) 88 Soy is also a good source of calcium. A diet Tempeh (1⁄4 cup) 77 that includes greater amounts of soy products can account for a meaningful amount of calcium, OSTEOPOROSIS 247 and some soy foods can offer as much or more increasing linoleic acid in the diet significantly calcium than a serving of dairy products. reduce calcium in the stool, indicating that An adequate intake of calcium and vitamin D omega-6 essential fatty acids (EFAs) stimulate is fundamental for bone health and is an impor- calcium absorption.51 Calcium absorption will tant adjunct to drug treatments for osteoporosis. also be significantly increased when the diet is In fact, a review of almost three dozen clinical supplemented daily with fish oil, evening prim- trials found that bone mineral density of the hip rose oil, a mixture of both, or sunflower oil.52 increased more in the estrogen plus calcium Deficiencies of EFAs modify bone fatty acid group, compared with the estrogen group levels and have profound effects on the degree of alone.50 mineralization of the bone. This is observed in Most menopausal women look to calcium animals fed EFA-deficient diets, who develop supplementation to meet their calcium needs. osteoporosis. The role of EFAs is discussed in However, dietary sources of calcium should be much more detail in the nutritional supplement emphasized as part of a well-balanced diet to section of this chapter. ensure intake of other nutrients found in high- calcium foods. Dairy products are good sources Alcohol and Smoking. Consumption of of calcium. In addition, dairy products have a alcohol also appears to promote bone loss. Scien- high elemental calcium content and absorption tific evidence links consumption of alcohol (seven rate and are affordable. There are now many dairy ounces or more per week) with lower bone mass, product alternatives as well, such as calcium- increased bone loss, an increase risk of falls, and a fortified soy foods, calcium-fortified rice milk, higher incidence of hip fracture.53 A meta-analysis and others. showed that consuming two alcoholic drinks per Some foods can actually inhibit calcium day significantly increases the risk of fracture,54 absorption. I don’t advocate avoiding these and even heavier consumption has additional neg- foods, but it is important to be aware that the ative effects on bone density. The good news is oxalate contained in foods such as spinach and that a small amount of alcohol, one to two ounces the phytates found in whole grains can inhibit per week, is associated with a higher bone mineral calcium absorption. density in women age 65 years and older55 and a Foods high in calcium include kelp, Swiss decreased risk of hip fracture.56 and cheddar cheese, carob flour, dulse, collard The results of most studies show that smok- greens, turnip greens, molasses, almonds, ers lose bone more rapidly and have a lower bone brewer’s yeast, parsley, corn tortillas, dandelion mass than nonsmokers.57 Some research shows greens, Brazil nuts, watercress, goat’s milk, tofu, that postmenopausal women who smoke have a dried figs, buttermilk, sunflower seeds, yogurt, significantly higher fracture rate than women beet greens, wheat bran, whole milk, buckwheat, who don’t smoke.58 In female smokers, the risk sesame seeds, olives, broccoli, walnuts, cottage of hip fracture is increased by 1.5 to 2.5-fold.14 cheese, and spinach. Calcium and vitamin D are It’s not clear what mechanisms are involved in discussed in detail in the nutritional supplement the adverse effects of smoking on bone density section. and fracture. Some evidence suggests that smok- The influence of dietary fats on mineral ing may alter calcium absorption59, 60 and lower absorption is complex and only understood in estrogen levels.61 All in all, it appears that women part. Several key observations have been made, who smoke tend to lose bone more rapidly, have although many of the factors that influence lower bone mass, and reach menopause about absorption are still unknown. For example, two years earlier than nonsmokers.62–64 248 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Nutritional Supplements Recommendations for Calcium Intake Calcium. When women think about what they can do to prevent osteoporosis, most women National Academy of Sciences think of calcium supplementation. Calcium Recommendations improves bone health, increases bone mineral Age 31–50 1,000 mg/day density, and improves the effectiveness of osteo- Age 51 and older 1,200 mg/day porosis medications. Although most studies do National Institutes of Health not show a positive effect of calcium in reducing Recommendations fracture risk, in the Women’s Health Initiative (WHI) trial, hip fractures were significantly Premenopausal women reduced in older women on the calcium supple- aged 25–50 1,000 mg/day ment program.65 Calcium supplementation has Postmenopausal women under 65 using estrogen therapy 1,000 mg/day also been shown to decrease bone loss in post- Postmenopausal women not using 66 menopausal women. The effects of calcium sup- estrogen therapy 1,500 mg/day plementation have been greatest in women whose All women aged 65 and older 1,500 mg/day baseline calcium intake was low, in older women, and in women with osteoporosis.67 As women age, especially after menopause, that you get 250 mg per day, not counting any calcium requirements increase due to both dairy foods or calcium-fortified foods, if you eat reduced intestinal calcium absorption and less two or three meals per day. Most women take in efficient kidney conservation of calcium. Even an additional 300 mg per day in the form of one though these two mechanisms are in play, how- serving of dairy. If you take in more than one ever, the primary influence on calcium absorp- serving per day of dairy, add another 300 mg for tion is the amount of calcium that is ingested, each additional serving, as well as for each serv- via either diet or supplementation. Selected ing of a calcium-fortified soy food. If you drink populations of postmenopausal women may not one glass of milk per day and eat no soy foods or have adequate calcium intake, including older other calcium-fortified foods, for example, your women, women who are lactose intolerant (and average daily intake is 250 mg ϩ 300 mg ϭ 550 so must avoid dairy foods), vegans (who con- mg per day. So, if you are 55 and postmeno- sume no animal or dairy products), and women pausal, you need an additional 650 to 950 mg on poor diets in general. Even in the United per day to reach a total that falls within the rec- States, postmenopausal women have dietary ommendations of 1,200 to 1,500 mg per day for intakes of calcium of about 600 mg per day, postmenopausal women under 65. which is below the recommended amount. The There is a great deal of confusion and contro- National Academy of Sciences (NAS) recom- versy about which form of calcium is best. I dis- mendations68 (last revised in 1997) and the courage women from using either oyster shell or National Institutes of Health (NIH) recommen- bone meal calcium. These calcium supplements dations69 (last revised in 1994) are the two most may contain substantial amounts of lead. In well-accepted guidelines for calcium intake in 1981, the FDA cautioned the public to limit women (see the following sidebar). intake of calcium supplements made from either To determine how much calcium you should dolomite or bone meal because of the potentially take in a supplement, you must first estimate high lead levels. Unfortunately, even other what your dietary intake is. Start by assuming sources of calcium from various chelates may also OSTEOPOROSIS 249 contain minute amounts of lead. In a 1993 study promised zinc absorption, their possible mar- of lead content in calcium supplements, lead was ginal zinc status to begin with, and their high risk the highest in bone meal, unrefined calcium of osteoporosis. A zinc deficiency can result in carbonate, and dolomite and lowest in calcium skin changes, growth retardation, loss of appetite, chelate supplements and refined calcium carbon- changes in vision, decreased insulin function, ate.70 Calcium chelates are bound to citrate, dysfunction in prostaglandin synthesis, and fumarate, malate, succinate, and aspartate. immunologic abnormalities. Zinc is also essential When the calcium is taken on an empty for normal bone formation; it enhances the bio- stomach, calcium citrate is absorbed better than chemical actions of vitamin D, is required for the calcium carbonate. In addition, it may be that as formation of osteoblasts and osteoclasts, and is women age and have lower stomach acid produc- required for the synthesis of various proteins tion, lower fat absorption, and take in less vita- found in bone tissue. Zinc levels have been found min D due to less exposure to sunshine and to be low in the serum and bone of elderly people decreased fat absorption, calcium citrate may be with osteoporosis,74 and also in people with bone a better choice to combat these compromising loss at the alveolar ridge of the mandible.75 This effects on calcium absorption. In most women, negative interaction between calcium and zinc though, especially in perimenopausal women absorption raises concerns about how higher cal- and postmenopausal women up to age 65, there cium intakes may affect the absorption of other is no known best form. Calcium carbonate is minerals needed for bone health. absorbed well when taken with food. Calcium Another area of great disagreement is what citrate can be taken with food or on an empty ratio of calcium to magnesium is best. Some stomach, making it more flexible as to timing of researchers and clinicians recommend twice as your supplement regime. much calcium as magnesium; others recommend Calcium supplementation is extremely safe, equal parts calcium and magnesium; others rec- and even in amounts of total calcium intake up ommend 1.5 parts calcium and 1 part magne- to 1,500 mg per day there is no increase in the sium; and still others recommend twice as much risk of a kidney stone.71 However, in women magnesium as calcium. The most scientific with a history of kidney stones, calcium supple- research support exists for two parts calcium to ments are contraindicated except with medical one part magnesium. (See the section on magne- testing/assessment and supervision. Calcium sium later in this chapter.) intake greater than 2,500 mg per day, taking into The optimal time to take calcium supple- account diet and supplement, should be avoided. mentation is the last question to consider. The Some women become constipated or have nausea absorption of calcium is dependent on its and indigestion with calcium supplementation, becoming ionized in the intestines. Calcium especially calcium carbonate. In these cases, cal- carbonate has to be solubilized and ionized by cium citrate will less likely cause these problems. stomach acid in order to be absorbed. Many Another issue that makes it difficult to deter- people have insufficient stomach acid, and stom- mine the optimal dose of calcium is that higher ach acid secretion decreases with age. In studies doses of calcium may interfere with the absorp- of postmenopausal women, about 40 percent are tion of other nutrients. In two separate studies, found to be severely deficient in stomach acid.76 researchers have shown that a high dietary cal- For this reason, I recommend taking a form of cium intake adversely affects zinc absorption and calcium that is already in a soluble and ionized balance in humans.72, 73 This may be especially state, such as calcium citrate, calcium lactate, or important in elderly women due to their com- calcium gluconate. In these ionized products, 250 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE about 45 percent of the calcium is absorbed from Vitamin D enhances intestinal calcium absorp- calcium citrate in patients with reduced stomach tion, thereby contributing to a favorable calcium acid, as compared to 4 percent absorption for balance in the system. Increased calcium absorp- calcium carbonate.77 tion also reduces parathyroid hormone–mediated All of these issues make it difficult to choose bone resorption. In the United States, most infants from the myriad options of form and dosing in and young children have adequate vitamin D con- calcium supplementation. In general, I would sumption from fortified milk. During adolescence, follow the dosages of either the NIH or NAS. If however, the consumption of dairy products drops you don’t mind taking more pills, then I would off and inadequate vitamin D intake is more likely also recommend taking calcium citrate over cal- to adversely affect calcium absorption. cium carbonate, or at least a combination. (Cal- In general, calcium intake alone may have only cium citrate is much bulkier, and you have to a slight protective effect for bone mass and fracture take more pills to get adequate amounts of the risk, and it is more beneficial to supplement with elemental calcium.) Even though I can no longer a combination of calcium and vitamin D. Several argue for advantages in absorption in general of large studies of vitamin D (400 and 800 IU per citrate over carbonate, fewer digestive side day) plus calcium (1,000 mg per day) have not effects, the flexibility of taking the calcium with shown a significant effect on fracture risk.78, 79 or without meals, and the possibility of enhanced However, there are studies that do show a signifi- absorption as you age make a good case for cal- cant effect. One such study in people aged 65 cium citrate. In the end, though, the amount of years or older showed that both calcium and vita- your total calcium intake is far more important min D consumption can significantly reduce the than the kind of calcium. incidence of nonvertebral fractures.80 Another study of postmenopausal women undergoing hip Recommended Daily Calcium Intake replacement surgery showed that women with hip Women aged 25–50: 1,000 mg/day fractures were more likely to have a vitamin D Women aged 51 and older: 1,200–1,500 mg/day deficiency than those undergoing elective joint replacement.81 More recently, the NoNOF study Vitamin D. Vitamin D is the only vitamin of survivors of hip fractures demonstrated that that’s also a hormone, and it is the only vitamin vitamin D supplementation, either orally or by we don’t have to consume from our diet. Vitamin injection, suppresses parathyroid hormone, D is normally produced in the skin through increases bone mineral density, and reduces falls.82 ultraviolet exposure of a derivative of cholesterol The effects were more marked with cosupple- (7-dehydrochlesterol) to produce previtamin D, menting with 1,000 mg of calcium per day. which is then metabolized to 25-hydroxyvitamin Perhaps the most compelling study is a meta- D in the liver and then to 1-alpha dihydroxyvit- analysis of randomized clinical trials in post- amin D3 in the kidney, at which time it becomes menopausal women with a mean age of 71 to 85, functional. This hormone is now able to carry which found that 700 to 800 IU per day of vita- out its function, including calcium absorption, min D was associated with significant reduction phosphate absorption in the intestine, calcium in hip and wrist fractures83; 400 IU per day had mobilization in the bone, and calcium reabsorp- no effect. Finally, more recent results from the tion in the kidneys. Vitamin D also maintains Women’s Health Initiative found that 1,000 mg normal parathyroid status, is an important regu- per day of calcium plus 400 IU of vitamin D was lator of the immune system, and is important for associated with a small but significant 1 percent muscular strength. increase in bone mineral density of the hip.65 OSTEOPOROSIS 251

Experts have typically thought that the mod- Current Dietary erate protective effect of vitamin D on fracture Recommendations for Vitamin D risk is due primarily to bone mineral density changes. However, there is a good body of evi- Adequate Tolerable dence that vitamin D may also directly improve Age Intake Upper Limits muscle strength and, as a result, reduce fracture 0–50 200 IU/day 2,000 IU/day risk by preventing falls. While randomized con- 51–70 400–800 IU/day 2,000 IU/day trolled trials have found that vitamin D reduced Over 70 800 or more IU/day 2,000 IU/day fractures within two to three months84 and has Higher doses than those listed as adequate or even benefits in improving muscle strength,85–87 the upper limits will be needed by women who have had effect of vitamin D on falls has not been well their vitamin D levels tested and found to be low or established and results of randomized trials have low normal. Dosage for these women should be moni- been mixed. A meta-analysis in 2004 attempted tored with follow-up tests. to determine the overall efficacy of vitamin D in preventing falls in the elderly, especially women.88 which can exacerbate calcium loss and be associ- Based on five randomized clinical trials involving ated with low bone density. 1,237 individuals, vitamin D reduced the risk of falling by 22 percent, compared with individuals, Magnesium. The conventional scientific view but especially women, who received calcium is that magnesium is essential for parathyroid hor- or a placebo. A recent study on vitamin D sup- mone (PTH) production and release. PTH is plementation and fall prevention was done in essential for the activation of vitamin D and there- Australia89 in which 625 older residents of nurs- fore absorption of calcium across the gut wall. ing homes and assisted-living facilities (95 per- However, magnesium is an intracellular ion and cent women) were randomized to receive either difficult to measure. A magnesium level is a reflec- vitamin D (ergocalciferol; 10,000 IU weekly or tion of extracellular magnesium. There are several 1,000 IU daily) or a placebo. None of the partic- conditions that can lead to magnesium deficiency ipants had a vitamin D deficiency. All partici- and therefore hypoparathyroidism and vitamin D pants also received 600 mg of elemental calcium deficiency. These include diuretic use (urinary daily. During two years of follow-up, the inci- loss), alcohol abuse (nutritional deficiency), dia- dence of falls was significantly lower in the vita- betes (urinary loss), and chronic diarrhea (malab- min D group compared to the placebo group sorption). Otherwise, magnesium deficiency is (1.37 versus 1.86 falls per person/year). Those rare. From the conventional scientific viewpoint, who received vitamin D were also less likely to the main reason why magnesium is part of calcium sustain a fracture (8 percent versus 11 percent), supplements is that carbonates are constipating although this was not statistically significant. and magnesium has a laxative effect, and therefore How much vitamin D is enough? The the combination is usually better tolerated. requirements for vitamin D were last set in 1997 Even though calcium has received the most by the Food and Nutrition Board of the Institute attention, alternative medicine views the impor- of Medicine and may be inadequate (see sidebar). tance of magnesium in skeletal metabolism and A popular approach of using cod liver oil to calcium regulation in a little bit different and supplement vitamin D deserves awareness and a perhaps broader context. Magnesium influences bit of caution. One tablespoon of vitamin D– both matrix and mineral metabolism in bone. fortified cod liver oil supplies 1,400 IU of vita- Magnesium depletion causes cessation of bone min D but also contains high levels of vitamin A, growth, decreased osteoblastic and osteoclastic 252 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE activity, osteopenia, and bone fragility.90 Ade- in studies of calcium or hormone replacement quate serum magnesium levels are necessary for therapy taken either separately or together. proper calcium metabolism; adequate calcium However, in most studies on bone density or intake may not ensure proper bone health if osteoporosis-related fractures, the benefits of magnesium status is abnormal. calcium have been observed without magnesium Magnesium deficiency has been shown more supplementation. A study looking at calcium than once to be related to osteoporosis. Magnesium absorption found no benefit on calcium absorption status appears to have a major influence on the type in postmenopausal women taking magnesium.94 of calcium crystals present in the bones, and there- Continued research to elucidate magnesium’s role fore its deficiency is associated with abnormal calci- in bone metabolism and calcium-magnesium inter- fication of the bone.91 This may in part explain actions is needed as well as clinical treatment trials why some women who have reduced bone mineral that vigorously evaluate magnesium as a potential density do not have an increase in fracture rates. treatment for postmenopausal osteoporosis. These women may have a lowered bone mass, but Foods high in magnesium include kelp, wheat they have excellent structural calcification, due in bran, wheat germ, almonds, cashews, molasses, part to adequate levels of magnesium. brewer’s yeast, buckwheat, Brazil nuts, dulse, fil- In order to assess the effects of magnesium on berts, peanuts, millet, whole wheat, pecans, wal- bone density, a group of osteoporotic postmeno- nuts, rye, tofu, beet greens, and coconut. pausal women were given magnesium over a period of two years. At the end of the study, mag- Magnesium nesium therapy appeared to have prevented frac- 500–750 mg per day tures and resulted in a significant increase in bone mass density after the first year of treat- Manganese. Manganese may be one of the ment. There was, however, no change in density most important trace nutrients related to osteo- from then on to the end of the study.92 The find- porosis. Manganese deficiency causes a reduction ing that magnesium supplementation actually in the amount of calcium laid down in the bone caused an increase in bone density rather than and thereby an increased susceptibility to frac- just a stabilization of current bone density is ture. Manganese stimulates the production of significant. Other factors may have influenced mucopolysaccharides that provide a structure on the increase in bone density, but the results of which calcification takes place.95 this study warrant further investigation into the potential effect of magnesium on bone density. Manganese Dr. Guy Abraham published a study supporting the importance of magnesium above that of 15–30 mg per day calcium. His study demonstrated an 11 percent increase in bone density in the group that was Boron. Dr. Forrest Nielsen studied the effect given dietary advice, hormones, and nutritional of boron on bone loss in postmenopausal supplements (500 mg calcium citrate, 600 mg women. Published in 1988, his results indicated magnesium oxide, vitamin C, vitamin B-complex, that boron supplementation reduced the urinary vitamin D, zinc, copper, manganese, and boron). excretion of calcium by 44 percent, reduced The group that received the dietary advice plus the urinary magnesium excretion, and markedly hormones but no supplementation had an average increased the serum concentrations of 17 beta- increase of only 0.7 percent.93 An 11 percent estradiol and testosterone.96 These findings increase in bone density is greater than that found definitively implicate boron in calcium and mag- OSTEOPOROSIS 253 nesium metabolism, hormonal stabilization, and cysteine levels and BMD at either the femoral neck the subsequent prevention of bone loss. or the lumbar spine. Despite these associations, it is not yet clear that giving folic acid is a therapeu- Boron tic tool in preventing bone loss or fractures. For 3 mg per day now, it remains an interesting association, and folic acid is easy enough to include in a holistic bone Zinc. Zinc is essential for normal bone for- health approach and prevention program. mation,97 enhances the biochemical actions of Folic Acid vitamin D,98 and is required for the formation of osteoblasts and osteoclasts and for the synthesis 400–800 mcg per day of various proteins found in bone tissue. Zinc levels have been found to be low in the serum Vitamin B6. Vitamin B6 also plays a role in and bone of elderly people with osteoporosis.74 homocysteine metabolism. In genetic homocystinuria, B6 supplementation has been shown Zinc to reverse the elevated levels of homocysteine.102 15–20 mg per day Vitamin B6 has been studied and prescribed for its role in osteoporosis prevention in other capac- Copper. Copper deficiency may be a related ities as well. Animal studies have shown B6 defi- cause of osteoporosis. Copper deficiency is known ciencies to cause increased fracture healing to produce abnormal bone growth in growing chil- time,103 impaired growth of cartilage and defec- dren. Copper supplementation has been shown in tive bone formation,104 and more rapid develop- 105 laboratory studies to inhibit bone resorption.99 Its ment of osteoporosis. Vitamin B6 may also supplementation is deemed necessary in women stimulate the production of progesterone and, at risk for or with diagnosed osteoporosis. through this hormone’s activation of osteoblasts, have a distinct role in preventing osteoporosis. Copper Vitamin B6 1.5–3 mg per day 50–100 mg per day Folic Acid. Accelerated bone loss in menopausal women may in part be due to the increased Vitamin C. One of the actions of vitamin C levels of homocysteine, a breakdown product of is to promote the formation and cross-linking of methionine. Homocysteine has the potential to some of the structural proteins in bone. Animal promote osteoporosis if it is not eliminated studies have shown that vitamin C deficiency can adequately. Since folic acid is involved in the cause osteoporosis.106 Moreover, it has been breakdown of homocysteine, supplementing post- known for decades that scurvy, a disease caused menopausal women with this nutrient results in by vitamin C deficiency, is associated with abnor- significant reductions in homocysteine levels.100 malities of bone. This association of homocysteine levels and osteo- Vitamin C porosis was recently seen in a study showing that high homocysteine levels were associated with 500 mg or more per day almost twice the risk of nonvertebral osteoporotic fractures in women.101 However, in the same Vitamin K. Vitamin K has been thought for study, there was no association between homo- some time to be a contributing factor in the 254 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE prevention of bone loss. It is required for the pro- Vitamin K duction of osteocalcin, the protein matrix on 2 which mineralization occurs. Octeocalcin attracts 45 mg per day calcium to bone tissue, enabling calcium crystal formation to occur. Vitamin K also plays a key role in the formation, remodeling, and repair of bone Essential Fatty Acids by helping the calcium adhere to the site of this Essential fatty acids (EFAs) have not been talked protein matrix. Individuals with osteoporosis have about much in relationship to osteoporosis, but been found to have lower serum vitamin K levels there is a growing body of evidence and research to when compared to age-matched controls.107 The warrant attention. Most of the research and focus amount of vitamin K that is required for optimal on osteoporosis has been around the loss of calcium bone health appears to be greater than that needed from bone before and during osteoporosis, reduced for normal clotting of blood.108 bone strength, and increased risk of fractures. What Recently, a review and meta-analysis of 13 has received less attention is that osteoporosis may published clinical trials made an even stronger be a marker for other serious potential health prob- case for the role of vitamin K in osteoporosis.109 lems apart from fractures. Not only must we con- In 12 of the 13 clinical trials, this meta-analysis sider demineralization of bone, but ectopic concluded that supplementation with large doses calcification and the possible connection between of vitamin K can prevent bone loss of the hip and ectopic calcium deposits, particularly in the arteries vertebrae. (The one trial that showed no effect and kidneys, and bone decalcification. was a study of premenopausal athletic women Specifically, low bone density may be related to who were given 10 mg per day of vitamin K1.) vascular problems, and essential fatty acids and Even more impressively, fracture data was avail- their regulation of calcium metabolism may be a able in seven of the studies. The rates of hip key player in influencing the sites at which calcifi- fractures were reduced by 77 percent, other non- cation occurs. The role of essential fatty acids has vertebral fractures by 81 percent, and vertebral largely been ignored in relation to osteoporosis fractures by 60 percent.110 despite animal and human studies indicating that Most of the studies in this meta-analysis were EFAs enhance calcium absorption, enhance the of postmenopausal women, but some of the effects of vitamin D, reduce urinary calcium studies included patients who had diseases that excretion, increase bone calcium, reduce ectopic are associated with higher risk of osteoporosis, calcification elsewhere, and increase bone protein including patients with primary biliary cirrhosis synthesis and bone strength. and some on glucocorticoids. These results in The first published paper that clearly fracture reduction exceed those typically seen described the relevance of EFAs on calcium with alendronate (about 50 percent), and fewer showed that in EFA-deficient animals, the kid- side effects are associated with vitamin K com- neys became highly calcified, apparently because pared to the approximately 17 percent side effect of a shift of calcium from the bones.111 Other rate of reflux and esophagitis with bisphospho- early studies demonstrated that EFA deficiency nates. However, the longest study in this meta- in animals was associated with loss of normal col- analysis was only three years, which is a short lagen synthesis and of normal connective tissue amount of time in the world of bone density and in bone, loss of normal cartilage, demineraliza- fracture data, and further research is needed tion of bone, and bone weakness.112–114 before drawing conclusions on the comparative This early body of research established that value of vitamin K supplementation. EFA deficiency led to severe osteoporosis in ani- OSTEOPOROSIS 255 mals and that the osteoporosis was associated are also correlated with increased PgE2 and with significant ectopic calcification. Not until increased calcium excretion. Although the pre- the 1990s, however, did new observations lead to cise role of EFAs and prostaglandins in hypercal- renewed interest in EFAs and calcium. These ciuria is not understood, the balance of research observations indicated that prostaglandin (PG) demonstrates that excessive production of PGE formation could stimulate bone growth, that from arachidonic acid is a factor. renal calcium stones were rare among the Inuit If we could reduce urinary calcium excretion, (Eskimos) of the Arctic, seemingly due to their this could not only have a bone-preserving effect high intake of EFAs from fish oils, and that EFA but also reduce the formation of stones. Research metabolism might form a basis for the associa- in the early 1990s explored enhancing dietary tions between osteoporosis and coronary artery EPA with fish oils to protect against stone dis- disease, peripheral vascular disease, and stroke. ease. What was found was that the fish oils were Before we get too far along, it’s important to able to reduce urinary calcium excretion. This have some familiarity with the basics of EFA bio- work was preliminary and fundamental to chemistry. There are two families of EFAs of understanding how EFAs and prostaglandin import in this conversation, the omega-6 series metabolism could affect calcium excretion and and the omega-3 series. Linoleic acid (LA) is the reabsorption. Although the work was undertaken parent compound of the omega-6 series, and in an effort to prevent kidney disease and kidney alpha-linolenic acid (ALA) is the parent com- failure, it supports the idea that EFAs affect cal- pound of the omega-3 series. Each of these is cium metabolism and could be used to improve metabolized by a series of enzymatic reactions bone health and bone density. in which their metabolites play key roles within The influence of dietary fats on mineral the body. The most important metabolites are absorption is complex and only understood in probably dihomo-gamma-linoleic acid (DGLA) part. Several key observations have been made, and arachidonic acid (AA) of the omega-6 series although many of the factors that influence and eicosapentaenoic acid (EPA) and doca- absorption are still unknown. For example, hexaenoic acid (DHA) of the omega-3 series. increasing linoleic acid in the diet significantly Essential fatty acids are required constituents reduces calcium in the stool, indicating that of every membrane within the body. They are omega-6 EFAs stimulate calcium absorption.51 required for the normal functioning of every Calcium absorption will also significantly membrane and for the normal functioning of increase when the diet is supplemented with fish calcium release from storage. EFAs are also part oil, evening primrose oil, a mixture of both, or of most of the signaling systems within every cell. sunflower oil daily.52 How calcium is excreted and how much is Animal studies have revealed many mecha- excreted are major factors in the metabolism of nisms related to EFAs and calcium absorption. bone and the development of kidney stones, as Probably the largest body of work established well as the overall calcium balance in the body. that there is a significant relationship among Probably the major factor controlling calcium EFAs, the actions of vitamin D, the transport of excretion is calcium intake, but we also know calcium across the membrane, and an increase in that prostaglandins are involved in calcium reab- membrane fluidity followed by an increase in sorption and excretion. Significantly elevated calcium absorption. levels of urinary prostaglandin E2 (PgE2) are As mentioned earlier in the nutrition section, positively correlated with urinary calcium excre- deficiencies of EFAs modify bone fatty acid levels tion.115–117 Calcium stones forming in the urine and have profound effects on the degree of miner- 256 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE alization of the bone. Animals fed EFA-deficient lar weight-bearing exercise, and proper vitamin diets also develop osteoporosis. Evidence is also and mineral intake should be the hallmarks in building that prostaglandins have an influence on the prevention of osteoporosis, the information bone metabolism. Prudent use of EFAs may reduce and data on essential fatty acids should not only the degradation of bone matrix collagen, while also motivate us to improve sources of dietary fat, it increasing bone mineral content. Animal studies also suggests that EFA supplements are a viable using different ratios of evening primrose oil (high method of decreasing the risk of osteoporosis. in gamma-linolenic acid or GLA), fish oil (rich in EPA and DHA), sunflower oil, and flaxseed oil Essential Fatty Acids: Omega-3 and Omega-6 suggest that supplementation with high doses of Approximately 1 g per day of EPA and DHA evening primrose oil and fish oil is more effective in inhibiting bone loss than is supplementation with linoleic and alpha-linolenic acids.118 Botanical Medicine The relationship between osteoporosis and Red Clover (Trifolium Pratense). Red clover is cardiovascular disease has several correlations. a member of the legume family rich in flavonoids, One is that those individuals with osteoporosis glycosides, phytoestrogens, and other vitamins and and a subsequent hip fracture have an increased minerals. This native American herb was histori- risk of mortality due to strokes. Calcium is not cally used to treat whooping cough, gout, and simply lost from the bone in osteoporosis, but cancer. Some researchers speculate that red clover some of that calcium is deposited in the arteries may have an estrogenic effect on the bone. They and kidneys. The calcification process in athero- studied the effects of a special red clover extract, sclerosis is very similar to what occurs in bone. It Rimostil, containing Clovone, a specific blend of may be that metabolic issues that regulate calcifi- isoflavones (biochanin A, formononetin, genistein, cation are common to both diseases. Individuals and daidzein), on serum lipids, bone density, with osteoporosis frequently have ectopic calcifi- and endometrial thickness in postmenopausal cation in other tissues as well, especially the discs women.119 Fifty postmenopausal women were ran- between the vertebrae. domly assigned to receive either 28.5 mg, 57.0 mg, Loss of bone calcium with concomitant calci- or 85.5 mg of Rimostil for six months, followed by fication in the kidneys was observed as far back two months of a placebo. Bone density was meas- as 1931 in a study by Borland and Jackson where ured at baseline, three months, and six months an induced EFA deficiency elicited both prob- using a DXA scan. (Lipid levels and uterine lining lems.111 More recently, supplementation with thickness were also measured in this study.) All EPA and GLA was shown to prevent ectopic cal- three doses of Rimostil were associated with a 2.9 cification. This is better understood by looking at to 4 percent increase in bone density from zero to the role of EFAs in membrane health, calcium six months in the proximal radius and ulna (clos- absorption, calcium excretion, and bone mineral- est to the elbow). No significant change in bone ization. It is also worth speculating that since density occurred at the distal radius and ulna. deficits of long chain EFAs are important in Another placebo-controlled clinical trial cardiovascular disease, the associations between attempted to determine the effect of red clover osteoporosis and heart disease may be dependent isoflavones on bone density in women aged 49 to on a commonality of impaired EFA metabolism 65.120 One group received one tablet of a stan- and poor sources of dietary fat. dardized extract of red clover (26 mg biochanin While preventive measures of a well-balanced A, 16 mg formononetin, 1 mg genistein, and 0.5 diet, avoiding smoking and excess alcohol, regu- mg daidzein), and the other received a placebo. OSTEOPOROSIS 257 This trial lasted one year, and 86 women in the percent, these results provide yet another option red clover group and 91 in the placebo group for many women who cannot, will not, or do not completed the study. Dietary calcium and vita- need to take stronger, more effective conven- min D were similar in both groups. At the end of tional treatments. It remains to be seen whether 12 months, women in the red clover group had Ipriflavone can have a positive effect on the less bone loss of the lumbar spine than women in hip, a far greater concern. Although the effect on the placebo group. Bone density decreased by the spine and wrist is encouraging, these small 1.08 percent in the red clover group and by 1.86 increases in bone density do not necessarily mean percent in the placebo group. The differences in there is a reduced fracture rate, the true test of an the hip bone between the red clover and placebo effective treatment for the prevention and treat- groups were not significant. Two markers of bone ment of osteoporosis. formation were also tested in this study. For post- One well-publicized study in 2001 was not menopausal women in the study, there was an able to document any benefit for Ipriflavone in increase in these markers in the red clover group, women with significant bone loss and with and a decrease in one marker and a lower increase osteoporosis.122 It was also noted through blood in another marker in the placebo group. These tests that some of the women taking Ipriflavone results suggest that red clover isoflavones may be developed lower lymphocyte counts. For this able to slow bone loss in the lumbar spine. reason, I recommend Ipriflavone only for women with mild bone loss or for those who are at Red Clover Standardized Extract higher risk for bone loss, but not for women with 28–85 mg per day of red clover isoflavones significant bone loss. I also recommend getting a blood test, a complete blood count (CBC), every Ipriflavone. A synthetic derivative of six months to check the lymphocyte counts. isoflavones, Ipriflavone was only available in Italy In the studies that do show benefit, Ipri- and a handful of other countries until recently. flavone was given with a calcium supplement. It is now available over the counter in natural food stores or from alternative practitioners. Two Ipriflavone multicenter, two-year clinical trials evaluated 200 mg 3 times per day the efficacy and bioavailability of Ipriflavone in postmenopausal women with low bone mass.121 Herbs in High Mineral Content. Through- Women were randomly selected to receive either out the centuries of traditional herbal medicine, oral Ipriflavone (200 mg three times daily) or a many herbs have been known for their high min- placebo, plus 1 gram oral calcium daily. Both eral content. It is difficult to use herbs as a substi- studies were reported in the same paper. Study tute for mineral supplementation because we A showed a bone-sparing effect of 1.6 percent in know so little about the precise mineral content of the spine, and study B, 3.5 percent in the wrist a given herb. However, using these high-mineral after two years. A significant difference was herbs to augment mineral supplementation may found between the treatment groups and the not only improve one’s mineral status but also placebo groups in both studies. offers other health benefits. High-mineral herbs It seems as though Ipriflavone has a direct include nettles, oatstraw, red raspberry leaves, ability to inhibit the osteoclastic (bone-losing) chamomile, horsetail, and dandelion greens. cell activity, but how it does this is unknown. Although the effects on bone density using Ipri- Natural or Bio-Identical Progesterone. The flavone tend to be small, between 1.15 and 3.7 term natural progesterone, now more popularly 258 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE called bio-identical progesterone, refers to proges- women with the shortest luteal phases, and there- terone made from derivatives found in the Mex- fore with decreased progesterone production, ican wild yam or in soybeans. It is important to had the greatest decline in spinal bone density, realize that commercial bio-identical proges- losing 2 to 4 percent of bone per year. These terone is made in a manufacturing laboratory results have been cited as a strong suggestion that by extracting either diosgenin from Mexican wild the maintenance of peak bone density through- yam or beta-sitosterol from soybeans, then con- out a woman’s adult life requires normal ovarian verting the natural substance into progesterone production of progesterone as well as estrogen. through various enzymatic and biochemical reac- Dr. Prior and colleagues also studied the tions. This progesterone is biochemically identi- effects of synthetic progestin, medroxy- cal to the progesterone produced by a woman’s progesterone acetate (MPA, also called Provera), ovaries. Because of this, it is called bio-identical 10 mg for 10 days each month, in athletic or natural progesterone. This is distinctly differ- women who had stopped having a menstrual ent from synthetic progestational agents, properly cycle. The regimen led to significant increases in called progestins, the most common of which is spinal bone density.132 These studies indicate that medroxyprogesterone acetate (MPA). progesterone and MPA appear to have osteo- Accelerated bone loss has been shown to tropic (bone-building) effects. This is some of the occur after menopause, but evidence also exists research that alternative practitioners cite when indicating that normal menstruating women making a case for administering natural proges- begin to lose spinal bone prior to meno- terone for the treatment and prevention of pause.123–127 Evidence also exists that this bone osteoporosis. An error is often made when practi- loss prior to menopause is related to progesterone tioners assume that administering bio-identical deficiency and that progesterone, like estrogen, progesterone is the same as administering the plays an important role in bone metabo- synthetic analogue MPA, and this often occurs lism.128–130 Dr. Jerilyn Prior postulated a hypo- when advocates of bio-identical progesterone thetical relationship between phases of the bone attempt to make a case for its use in osteoporosis remodeling cycle and the normal menstrual management. cycle. Ovarian steroid levels are low at menstrua- There is good theoretical evidence from these tion, so increased bone resorption occurs at this studies and additional laboratory and animal time. As estrogen production increases before studies that the body’s progesterone and MPA ovulation, resorption begins to reverse. Finally, have a stimulatory effect on bone formation bone remodeling begins as progesterone levels and reduce bone turnover. What is not clear is peak in the mid part of the second half of the whether giving bio-identical progesterone in a menstrual cycle.131 pill or cream has similar effects. When it comes Dr. Prior and colleagues went on to study 66 to preventing or reversing osteoporosis, no other premenopausal women over one year.128 In these product has been the subject of as much contro- women, 29 percent of all menstrual cycles were versy as the use of topically applied bio-identical disturbed by a lack of ovulation or short luteal progesterone. A large segment of women seeking phase (number of days between ovulation and alternatives to conventional hormone replace- onset of menses), even though nearly all of these ment therapy and many alternative practitioners women continued to have regular 30-day cycles. have accepted the premise, most often promoted These subtle ovulatory disturbances did not by the late Dr. John Lee, that topically applied result in any symptoms, but they did correlate natural progesterone cream will not only prevent with decreases in spinal bone density. The osteoporosis but will actually increase bone min- OSTEOPOROSIS 259 eral density and prevent fractures. In his publica- 12). That said, too many women are inappropri- tions, Dr. Lee had become the strongest advocate ately selecting natural progesterone cream as of the role of progesterone in preventing and their main and possibly only treatment interven- reversing osteoporosis. He asserts that almost all tion for osteoporosis. A careful process of sifting women can successfully prevent and reverse through the benefits of alternative and conven- osteoporosis and improve their bone density by tional medicine and the weaknesses or downside as much as 15 percent with this cream and that of any natural or conventional therapy is espe- estrogen replacement therapy is very seldom a cially warranted when it comes to osteoporosis. necessary component. Another way to take bio-identical proges- Although I respect much of the groundbreak- terone is as oral micronized progesterone (OMP). ing work done by Dr. Lee, this particular prem- It is also often used in menopause management, ise is based almost exclusively on a hypothesis although it has not received the attention and that lacks adequate scientific evidence. Other commercial interests for general consumer use researchers have investigated the therapeutic because it is available only by prescription. effects of natural progesterone cream, including Results from the Postmenopausal Estrogen/ its effects on bone in menopausal women. One Progestin Interventions Trial (PEPI) have also randomized clinical trial compared the effect of a provided us with some insight on natural proges- transdermal natural progesterone cream (32 mg terone and bone density.137 Participants in the daily) with a placebo cream. Eighty postmeno- placebo group lost an average of 1.8 percent of pausal women in Australia were randomly spinal bone density and 1.7 percent of hip bone assigned to each group. Women were evaluated density by the 36-month visit, while those using the familiar Greene Climacteric Scale and assigned to one of the four treatment groups the Menopause Quality of Life Questionnaire, as gained bone density at both sites ranging from well as blood lipids and bone markers, over 12 3.5 to 5.0 percent and a total increase of 1.7 per- weeks.133 No detectable change was seen in vaso- cent bone density in the hip. Although the motor symptoms, moods, libido, lipids, or meta- changes in bone density were significantly greater bolic markers of bone turnover. There was a in the treatment groups when compared to slight elevation of blood levels of progesterone. placebo, the results among the treatment groups The authors concluded that the use of 32 mg of were not significantly different from each other. transdermal progesterone was not sufficiently Treatment groups were either (1) 0.625 mg absorbed into the bloodstream to achieve biolog- conjugated equine estrogens (CEE) daily alone; ical effects. (2) 0.625 mg CEE and 10 mg MPA per day for At least two studies, though, have shown that 12 days per month; (3) 0.625 mg CEE and 2.5 transdermal natural progesterone of 30 mg per mg MPA daily; or (4) 0.625 mg CEE and 200 day134 and 40 mg per day135 did modestly elevate mg OMP per day for 12 days per month. I am levels of progesterone in the blood after 15 days presenting this in some detail because, in this and 42 days respectively. A transdermal cream study, it appears that it was the estrogen therapy of 20 mg daily in a randomized clinical trial component that increased bone density and not resulted in statistically significant improvement the various progestogen regimens, either syn- in vasomotor symptoms, but no improvement in thetic or natural. mood or bone mineral content.136 So does natural progesterone alone, without Transdermal progesterone cream for vasomo- estrogen, either topically or orally, have an ability tor symptoms does have efficacy, which is dis- to increase bone density? From the data we have cussed in the chapter on menopause (Chapter so far, I would have to say no, it does not seem 260 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE to. Estrogen, not progesterone, is the main hor- combined options with estriol or estrone, and mone that provides benefits for the bone. numerous delivery methods depending on patient preference or tolerance. Natural or Bio-Identical Estrogens. Natural Whether it is compounded estrone/estradiol or bio-identical estrogens are made in the same or the commercial pharmaceutical company way as natural or bio-identical progesterone, form, these forms of estrogen have bone mineral except that the end product is either estrone, density effects similar to those of conventional estradiol, or estriol. Compounded estrone used conjugated equine estrogens (CEE). A study of by alternative practitioners is the same hormone 32 postmenopausal women compared 0.625 mg that is used in at least two prescription conven- CEE and 5.0 mg MPA with micronized 1.0 mg tional estrogens (Ogen and Ortho-est), with estradiol (considered to be an equivalent dose to the caveat that the prescription drug has fillers, 0.625 CEE) and 200 mg OMP, administered binders, preservatives, and/or excipients. These daily and continuously for 13 cycles.138 Lumbar are added in order for the particular product bone density improved by 5 percent in the to receive a patent; a particular individual may CEE/MPA group and 3.8 percent in the absorb and tolerate one form better than another. micronized estradiol/OMP group. Hipbone den- Bio-identical estrone is also available, by pre- sity improved by 2.6 percent in the CEE/MPA scription, from a compounding pharmacy. These group, and 3.1 percent in the micronized estra- pharmacies are able to formulate the dose re- diol/OMP group. Statistically, the numbers for quested by the practitioner and adjust the dosing the two groups are considered similar. Low-dose and the delivery method based on very individual estradiol (0.5 mg), equivalent to 0.3 mg of CEE, needs. Bio-identical estrogens are free of unneces- has also been shown to be effective in maintain- sary fillers and available in individualized doses ing vertebral mass.139 Although the authors of and delivery forms (capsules, tablets, sublingual this study were able to show that 0.5 mg of estra- tablets, lozenges, creams, gels), an important diol effectively preserved spinal bone density, advantage in using natural estrogens. In addition, more traditional (1.0 mg) and higher-dose (2.0 estrone can be used either alone or in combina- mg) estradiol actually increased spinal bone mass tion with estradiol and estriol as is appropriate to by 1.8 percent and 2.5 percent, respectively. each woman and each set of circumstances. Based on this information, it seems that 0.5 Bio-identical estradiol is also available from mg estradiol can be used to maintain bone mass, a compounding pharmacist and also individual- whereas 1.0 mg of micronized 17 beta-estradiol ized by dose and delivery for each woman. Bio- is considered the optimal dosing for enhance- identical estradiol is the same hormone as the ment of bone mass in postmenopausal women. estradiol that is used in many conventional pre- No significant differences were seen with using scription estrogens (Estrace, Gynediol, and all the synthetic progestin (MPA) compared with the current estrogen patches on the market such the natural progesterone (OMP). Even the new as Estraderm, Climara, Vivelle, Alora, and lowest dose transdermal patch, Menostar 14 mcg Menostar). Again, the difference in the com- patch (.014 mg), which delivers one-quarter of pounded bio-identical estradiol is that it is an average dose of estradiol, shows some ability devoid of the binders, fillers, preservatives, and to slow bone loss, although not to as great a adhesives found in the patented product. As with degree as the average-dose patches of .05 mg. compounded bio-identical estrone, compounded Most people have not heard much about bio-identical estradiol also carries with it the estriol, and I discuss it in more detail in Chapter extra advantage of very individualized dosing, 12. The question in this chapter is whether OSTEOPOROSIS 261 estriol will effectively prevent bone loss. A few When the load on bone exceeds the set point, studies done in the last couple of years in other more bone is deposited than removed. When the countries have been able to shed some light on load is below the set point, the opposite effect the effects of estriol on bone. Although not all takes place, and bone is lost.144, 145 estriol studies have shown positive results with This statement explains why swimming and bone mass, several Japanese studies have. Seventy- moderate walking generally do not lead to five postmenopausal women with bone densities increased bone mineral density (BMD),146 but at least 10 percent or more below peak bone den- weight lifting,147–149 jogging/running,150 gym- sity were given estriol, 2 mg/day, with 800 mg nastics,151, 152 and certain sports like basketball daily of calcium lactate. After 50 weeks, an average do. The set point theory of bone mass increase in increase in bone mineral density of 1.79 percent response to strain also explains why a few studies was seen on the routine DXA scan.140 showed no effect153 or a negative effect154 of exer- In another Japanese study, 17 women who cise on BMD—a load below the set point fails to were 10 years postmenopause were given estriol, trigger a response. 2 mg/day, and 2 g/day of calcium lactate for Regular physical exercise of appropriate one year. Another group was given only the intensity and duration that overloads the skeletal calcium lactate. Bone density was significantly system above its set point increases BMD in reduced after one year in the calcium-only group, women of all ages within the limits set by hered- while the estriol-plus-calcium group had a 1.66 itary factors, nutrition, and the hormonal status percent increase in bone density, using the DXA of the individual. In children and adolescents;155 scan again.141 A third Japanese study compared in college-age women;156, 157 in women in their 50- to 65-year-old women and elderly women 40s; and in young,158, 159 older,160, 161 and very who received either estriol, 2 mg/day, plus 1 old162 postmenopausal women, exercise has been g/day calcium lactate or 2 mg/day of estriol alone shown to be essential to the development and for 10 months.142 Increases of about 5 percent in maintenance of bone health. the lumbar spine were seen in both age groups of In sedentary women, trabecular bone loss women who took the estriol and the calcium. begins to occur in the third decade of life and Women of both age groups in the calcium-alone cortical bone loss in the sixth.163, 164 The 35 to 45 group had a decrease in bone mineral density of percent reduction in muscle strength observed in the lumbar spine. High doses of estriol, one at 4 women at 80 years of age parallels the observed to 6 mg/day and one as high as 12 mg/day, were bone loss at that same age.165 Conversely, the studied in Scotland, but they were not proved age-related loss of bone parallels decreased phys- protective against bone loss.143 ical activity.166 Moreover, women who exercise As with bio-identical progesterone, studies on retain bone mass throughout life,167 achieve estriol also leave us with a lack of sufficient con- greater peak bone mass that contributes to the firmation about its bone-protective benefits. consolidation and strength of bone following the end of linear growth,168 and have significantly Exercise lower risk of fractures in later life.154, 169 When bones are stressed by weight, the bone Furthermore, Recker and associates demon- cells (osteocytes) sense it. Osteocytes, in cooper- strated that, independent of calcium intake or ation with other bone cells, initiate a cascade of oral contraceptive use, the more college-age events leading to increased bone mass that limits women exercised, the greater BMD they the deformation to a predetermined set point achieved. These increases were highly significant (0.1 to 0.5 percent) in any given dimension. despite relatively small increments in exercise. A 262 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

1996 review of the literature on peak bone mass Exercise Recommendations and exercise confirms these results and adds that exercise can maintain normal bones sufficiently If you are not already exercising regularly, consult strong until very old age and can strengthen with your licensed health-care professional in cooper- weak bones when used in concert with adequate ation with a qualified exercise expert. Together with nutrition.170 The author of this review con- them establish: cludes—as is the case in many studies—that even • A schedule of exercise small increases in initial bone mass grow to a sub- • The types, intensity, and duration of exercise stantial difference if the increased bone mass is Consider the following guidelines: maintained by a lifetime of regular exercise. • Begin slowly. Exercises that involve weight training can • Increase intensity very gradually. increase the mass of bones if the exercise also • Train with weights for six weeks before intro- increases muscle mass and muscle strength. ducing intensive aerobic exercise (such as running or speed walking) into your program. Therapeutic Scheme for • Begin each exercise session with joint warming Management of Osteoporosis exercises (see Appendix A) for 5 minutes. • End each exercise session with 5 to 10 minutes • Determine risk for osteoporosis: mild, of stretching exercises. moderate, or severe. • Use caution and moderation throughout your • Be aware of seven levels of intervention that lifetime of exercise. cover the majority of clinical situations: Level 1: Diet, exercise, lifestyle, and stress Women who are in the early postmenopausal management Level 2: Nutritional supplementation years can achieve small but statistically significant Level 3: Botanicals benefits on bone mass from strength training.171 Level 4: Compounded bio-identical hormones A meta-analysis found that women who exer- Level 5: Pharmaceutical company bio- cised could increase their spinal BMD by identical hormones (Use with oral approximately 2 percent.172 Menopausal women micronized progesterone if uterus is still intact.) who use estrogen along with weight training have Level 6: Synthetic and semisynthetic non- better BMD increases than do women who use bio-identical hormones in cases that estrogen alone.173 do not respond to other medicines Strength or weight training can be done as little (Use with oral micronized proges- as twice a week to achieve these benefits and can be terone if uterus is still intact.) Level 7: Prescription bone-specific done on very inexpensive home equipment that medications includes as little as a chair, a bench, and some hand • Recommendations according to risk: weights. One word of caution is for women who already have osteoporosis. Heavy weight-bearing Level Mild Moderate Severe exercises and vigorous stretching and lifting can be 1. X X X enough to trigger a fracture of the spine. 2. X X X One of the more important aspects of physi- 3. X 4. X X cal activity, especially in women who are 75 and 5. X X older, is its role in reducing the risk of falls. 6. X X Muscle strengthening and exercises to improve 7. X X balance have been shown to reduce the risk of falls and related injuries by 75 percent.174 OSTEOPOROSIS 263

Sample Treatment Plan for Osteoporosis Prevention

See the conventional medicine section if you have a Nutritional Supplementation diagnosis of borderline osteoporosis or osteoporosis • Calcium: 1,200–1,500 mg per day or have already had a fracture postmenopause. The • Magnesium: 400–750 mg per day dietary and nutritional supplement recommendations • Vitamin D: 400–800 IU per day minimum for should then be used in combination with conven- women 51 to 70 and 800 IU per day for tional therapy. If you do not want to take or are women over 70; consider even higher amounts not able to take hormone therapy or conventional of 1,000–2,000 IU if you have been tested and osteoporosis-specific medications despite a diagnosis have a vitamin D deficiency of osteoporosis, this sample treatment plan may not • Trace minerals: boron (3 mg), zinc (15 mg), be adequate to prevent bone loss or reduce the risk chromium (100 mcg), manganese (15 mg), and of fracture. Continue to see a licensed health-care copper (1.5 mg) practitioner and monitor bone density. • Other nutritional cofactors such as vitamin K2, 45 mg per day Dietary Recommendations • Essential fatty acid supplement: 2–4 g fish oil • Soy foods: 1 to 2 servings per day or 4 g fish oil/evening primrose oil per day • Dark leafy greens: 1 to 3 servings per day • Women at low risk: recommended diet, regular • Low-fat dairy, especially low-fat cultured weight-bearing exercise, nutritional supple- yogurt: 1 serving per day mentation, no hormone therapy necessary • Decrease animal meats (except for fish) and • Women at medium risk: recommended diet, substitute vegetarian choices, but with ade- daily weight-bearing exercise, nutritional sup- quate vegetarian and/or fish protein plementation, natural hormones (estriol, estra- • Avoid alcohol, caffeine, and sugar diol, and progesterone or estriol, estrone, estradiol, and progesterone; dose equivalent to Regular Exercise 0.3 mg or 0.625 mg Premarin, depending on individual—see Appendix C), or conventional • Weight-bearing and aerobic exercise 150 min- HRT or bone-specific medications utes per week • Women at high risk: recommended diet, daily • Weight training twice per week weight-bearing exercise, nutritional supplemen- • Most important, keep finding ways to motivate tation, conventional estradiol (1 mg per day) yourself: and oral micronized progesterone (200 mg per Be moderate—avoid burnout. day for 12 days per month or 100 mg daily), or Form a circle of friends who also love to exercise. conventional HRT or bone-specific medications

Exercise throughout life is as critical as a life- branch out into the more comprehensive exercise time of adequate nutrition. The important ques- program described in Appendix A. tion for doctors is not to help their female If you are already exercising regularly, con- patients of any age decide whether or not to exer- sider introducing into your program: cise. It is rather to study ways to personalize the • Variations of speed in your aerobic exercises exercise prescription and motivate the patient to • Different exercise positions, particularly in begin and continue exercising for life. weight training, that challenge your bones Numerous books are now available that pro- from different angles vide an excellent introduction to your lifetime • Alternating practicing sports such as basket- of exercise. Use simple low-impact exercises and ball, volleyball, tennis, and so on with a reg- stretching for two or three months before you ular exercise routine 264 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE cies, and have had dental intervention. Dental CONVENTIONAL implant failures have also been seen in patients MEDICINE APPROACH receiving oral bisphosphonates for osteoporosis. It Once the diagnosis of osteoporosis has been could be, especially in those patients who have suf- made, the most frequently instituted medications fered necrosis after dental procedures, that there is are the bisphosphonates, nonhormonal in- compromised postoperative healing of the bone hibitors of bone resorption that act by decreasing due to the inhibition of bone turnover caused by osteoclast activity (the cells that destroy bone). the bisphosphonate. A nonhealing wound could These drugs have very poor gastrointestinal ab- then lead to osteomyelitis, and then necrosis. sorption and can cause esophageal ulcers, gastric Another mechanism may be that the bisphospho- ulcers, and possibly gastrointestinal bleeding. nates are decreasing the levels of vascular endothe- The instructions for the use of these medications lial growth factor. Assuring dental health and are very specific: the patient should take the med- dental status may be smart preventive advice prior ication immediately upon awakening and with to even oral bisphosphonate therapy, especially in an empty stomach, following the ingestion of the those patients who have metastatic cancer, for medication with a full glass of water. It is impor- whom oral or IV bisphosphonate therapy may tant that she remain upright for 30 to 45 minutes slow their disease progression in the bones. to prevent reflux and medication problems in the Estrogen and/or progestin therapy works in esophagus. Initially, these medications were used the same manner by decreasing the activity of the daily, and patient compliance was quite poor; cells (osteoclasts) that remove bone. Hormone being able to take these medications weekly or therapy was a mainstay for more than 40 years monthly has been one of the biggest advances in for prevention of bone loss, treatment of osteo- bisphosphonate therapy. porosis, and reduction of fracture risk. In the The medications that are most commonly aftermath of the Women’s Health Initiative study used these days are alendronate (Fosamax), a 70- in 2002, more women have changed to bisphos- mg tablet once weekly for treatment or a 35-mg phonate use due to fears about hormone therapy. tablet once weekly for prevention in patients who Currently, however, hormone therapy is FDA- are at very high risk for osteoporosis and have approved for treatment of osteoporosis in women rapid bone loss but have not actually been diag- who do not tolerate the bisphosphonates, such as nosed as having osteoporosis yet. The next in women who have had esophagitis, gastric ulcers, order of frequency of use is risedronate (Actonel), or GI bleeds and women whose bone density a 35-mg tablet once weekly. The newest is iban- doesn’t improve on bisphosphonates. Some dronate (Boniva), which is a 150-mg pill once women are changed to a selective estrogen recep- monthly. There are intravenous forms of bispho- tor modulator (SERM) also. sphonates that can be used on a quarterly basis, None of these agents will work optimally but because of their cost and the need for IV without the presence of an adequate amount of administration, they are not frequently used. calcium, and in order to absorb the calcium, one Concerns have been raised about bisphospho- needs an adequate amount of vitamin D. New nates causing osteonecrosis of the jaw. While a studies suggest that 400 units of vitamin D daily serious problem, it is incredibly rare. Approxi- are not adequate for calcium absorption and that mately 150 cases of osteonecrosis of the jaw asso- 800 to 1,000 units per day may be more effec- ciated with bisphosphonate therapy have now tive. Vitamin D deficiency is a leading cause of been reported. Most of these patients, but not all, osteoporosis. When women present with post- have received intravenous therapy, have malignan- menopausal osteoporosis, it is assumed that it is OSTEOPOROSIS 265 related to being female and postmenopausal with they have a proestrogen effect on certain tissues low estrogen, but it is also important, as discussed such as bone and endometrium and an anti- earlier, to rule out other causes of osteoporosis estrogen effect on other tissues such as breast such as parathyroid hormone problems, concomi- tissue. Clomiphene citrate used for infertility is tant steroid use, and vitamin D deficiency. essentially a SERM. Tamoxifen is probably the Calcium is also very important, and many most widely recommended SERM. It has been women do not tolerate the most common and used for many years in breast cancer treatment. It least expensive form of calcium, calcium carbon- improves skeletal bone density in the same way ate. All calciums appear to be absorbed equally that estrogen works, by decreasing osteoclast well when taken with food and in the presence of activity, but it does have a significant stimulatory vitamin D, but calcium carbonate seems to create effect on endometrium and has increased more gastrointestinal symptoms. When bloating, endometrial cancer in patients. constipation, diarrhea, or gas is present, the cit- The third and currently recommended osteo- rate variety is frequently substituted. The recom- porosis treatment SERM is raloxifene (Evista). It mended daily dosage of calcium between diet and differs from tamoxifen in that it has no activity on supplements remains 1,000 mg in women under the endometrium. It stimulates bone growth by 50 and 1,200 to 1,500 mg in women over 50. reducing the activity of the osteoclasts and reduces Androgens have had renewed interest as a serum lipids just like estrogen, but it does not therapy for osteoporosis. Tibolone, an anabolic stimulate the endometrium or the breast and has steroid, has been used in many years in Europe actually been shown in several studies to reduce for treatment of osteoporosis and is being studied lifetime risk of breast cancer by 50 to 74 percent. in the United States. There is concern about The side effects of raloxifene are vasomotor symp- effects on lipids and the endometrium, as well as toms, unexplained leg cramps, and a risk of deep basic side-effect profiles that present with andro- vein thrombosis (DVT) approximately equal to gens, such as acne, facial hair growth, and body that of estrogen. hair loss. Typically, androgens are not recom- The newest, but very limited, drug for osteo- mended for osteoporosis treatment. porosis treatment is parathyroid hormone. It is Calcitonin is a less well-known medication called teriparatide (Forteo), and it actually stim- that is primarily used for vertebral compression ulates osteoblast activity, the cells that build fracture pain. It is a peptide that inhibits bone bone. Its effect on the bone is uniquely different resorption and causes a modest increase in verte- from any of the other medications. It is a daily bral bone. Calcitonin does not seem to have any subcutaneous injectable medication that is mod- significant effect on trabecular bone. Initially, it erately expensive and used for severe osteoporosis was very difficult to obtain, but recombinant in patients who are not responding to the other DNA production of the medication has increased medications or are having a lot of fractures. The its availability. It is an intranasal medication used main side effects are dizziness, nausea, joint once daily, but its ability to treat general skeletal aches, and leg cramps. osteoporosis is limited. It has a very significant For perimenopausal and young postmeno- effect, however, on pain improvement in vertebral pausal women with osteopenia and a T-score not compression fractures. worse than Ϫ2.0, I would consider the use of any SERMs are selective estrogen receptor modu- of these conventional approaches overtreatment. lators. They have estrogen-like effects in select Other prevention strategies include dietary tissues while not actually being estrogen. They advice, exercise including strength training, vita- are called selective receptor modulators because min D, calcium, trace minerals and nutrients, 266 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE and low alcohol intake. The practitioner should status, and assessment of calcium metabolism monitor the bone density over time. For women and bone density provide the basis for determin- of this age who actually have osteoporosis, bis- ing what is appropriate for each woman. A phosphonates may be a good choice. Calcium licensed health-care practitioner who is educated and vitamin D have important but modest ben- about when to rule out secondary causes of bone efits in women who already have osteoporosis. loss and the importance of early identification, Older postmenopausal women (over 65) who prevention, and treatment, and who is also aware have either significant osteopenia or osteoporosis of the spectrum of alternative and conventional are more certain candidates for bisphosphonates options, is especially crucial for women who are and other conventional treatments, which are at higher risk or who already have osteoporosis. proven to reduce the risk of fracture by 50 percent. Your family physician, internist, or endocrinolo- Hopefully, research will determine the shortest gist is probably the cornerstone for medical ther- amount of time that is necessary to be treated and apy. Some gynecologists can provide advice and the lowest dose that is required to achieve this sig- treatment as well. Some licensed alternative prac- nificant benefit, which is not currently known for titioners may have expertise in osteoporosis man- some of these medications. Fortunately, there is no agement as well. rapid bone loss after discontinuing bisphosphonate Many physicians do not even discuss osteo- treatment, compared to the rapid loss that does porosis, and you may have to insist on a DXA scan occur after discontinuation of estrogen. to measure bone density. An ultrasound test of the Also in time, research on natural medicines heel, which is much less expensive, may be a help- can be expanded to include the role of nutrients ful screening test for some women. There is some not only in bone density, but in bone strength and evidence that a heel test is 85 to 90 percent accu- bone architecture. Some of these areas could be rate compared with the bone density of the hip on the use of significantly higher doses of vitamin D, a DXA scan. Many insurance companies do not as well as red clover isoflavones, soy isoflavones, cover routine osteoporosis screening for women manganese, boron, fish oils, and more. In this way, under 65 unless they have significant risk factors, natural therapies could play an increasingly but if you have a heel test that shows your bone important role in slowing bone loss and reducing density is below normal, this can be the stimulus fracture rates. for obtaining a DXA scan. Some practitioners recommend screening women with heel ultrasounds, SEEING A LICENSED PRIMARY but by and large the heel test is not yet considered HEALTH-CARE PRACTITIONER an accurate test to replace DXA scans for either (N.D., M.D., D.O., N.P., P.A.) early detection or monitoring. Osteoporosis is one of the most important age- The more risk factors you have for osteoporo- associated disorders and should be considered a sis, the greater the need to have laboratory and potentially disabling disease that warrants sub- bone density testing. Women are especially stantial preventive efforts and management inter- encouraged to seek a licensed health-care practi- ventions. Early identification of risk factors for tioner who is well educated in the diagnosis and osteoporosis, prevention strategies, vitamin D management of osteoporosis. PELVIC CHAPTER 15 INFLAMMATORY DISEASE

OVERVIEW spread of the organisms. Another possibility is Pelvic inflammatory disease (PID) includes a that the bacteria may be transferred into the spectrum of infections of the upper genital tract. fallopian tube due to the common occurrence of These include endometritis (infection of the retrograde menstruation. The pathogenic organ- lining of the uterus), salpingitis (infection of the isms may spread along with the blood, contribut- fallopian tubes), tubo-ovarian abscess, and pelvic ing to PID. peritonitis (infection of the serous membrane Once the pathogen ascends to the uterus or lining the abdominal and pelvic walls). More fallopian tubes, it adheres to mucus-secreting than one million women in the United States cells and then invades just below the epithelial develop PID each year, and one-fourth of them surface (the surface of the tissue lining the fallop- require hospitalization. ian tubes). An acute inflammatory response The infection typically results from the spread occurs, causing cell death and tissue damage, and of microorganisms that ascend from the endo- can result in scarring and tubal adhesions. cervix (the canal leading from the cervix into the One in four women diagnosed with PID may uterus) to the upper genital organs. The most develop complications, including ectopic preg- common organisms are Neisseria gonorrhoeae nancy, infertility, recurrent pelvic pain, and and Chlamydia trachomatis. Chlamydia causes recurrent PID. It is important to recognize the 50 percent of PID in Europe and 20 to 30 per- possibility of PID because of its potential for cent of cases in the United States, though the real developing into a lethal condition, a more com- incidence may be even higher. Gonorrhea remains plicated condition, or a condition with long- the single most frequent cause in the United term consequences. It is also important to be States. Additional organisms implicated in PID alert to possible surgical emergencies. Sometimes include bacterial vaginosis organisms (Mycoplasma PID can be elusive, and there is little clinical evi- spp., Peptostreptococcus spp., Prevotella spp.), dence to support a suspicion of PID, especially Haemophilus influenzae, Streptococcus pyogenes, when the symptoms are mild and insidious. The and Streptococcus pneumoniae. PID is considered a classic symptoms of lower abdominal pain and polymicrobial infection due to the many organ- tenderness with examination or motion of the isms involved. Bacterial vaginosis (BV) produces cervix occurs in only 20 to 25 percent of patients. enzymes that dissolve cervical mucous, and there- A much more common presentation is often a fore if you have BV, there is an increased risk of mild or subtle pelvic pain. Some women with endometritis (PID in the uterus), and women PID will have discomfort with urination and with the highest bacterial loads have increased urinary frequency as well as other urinary tract risk of PID of at least twofold. symptoms. An increased number of risk factors The problems associated with PID involve its for PID increases the suspicion. These may ability to ascend from the lower to the upper include the following: genital tract. How it ascends is not exactly clear. Uterine contractions may be responsible, and • Age 14 to 24 even sperm may play a role in enhancing the • Heterosexual and sexually active 267

Copyright © 2008 by Tori Hudson. Click here for terms of use. 268 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE • Multiple heterosexual sex partners PID by eliminating the sperm as the method in • New heterosexual sex partner which the STI can ascend. • Low socioeconomic status Intrauterine devices (IUDs) are associated • History of sexually transmitted disease with an increased risk of PID, particularly in the • History of PID first four months after insertion, but then risk • Oral contraceptive users have increased risk returns to normal at five months.2 The thinking of acquiring gonorrhea or chlamydia if is that microorganisms in the vagina and cervix exposed but a decreased risk of upper tract are introduced into the uterus during the IUD infection insertion. The incidence of PID in IUD users is • Use of IUD for contraception two to nine times that of nonusers in most pop- • Never having been pregnant ulations of women studied.1 If a woman with • Cigarette, alcohol, or illicit drug use suspected PID has an IUD, it must be removed. • Any instrumentation of the uterus—such as Oral contraceptives (OCs) have both a positive a uterine biopsy, diagnostic scope, or surgi- and a negative effect on the risk of PID. They can cal abortion increase the risk of chlamydia infecting the cervix • Pelvic or bowel surgery (mucopurulent cervicitis), but they are also associated with a decreased risk of symptomatic PID. Adolescents and young single heterosexual It is thought that the progestin component in the adults have the highest incidence of gonorrhea. OCs causes the cervical mucus to become thicker This organism is believed to be the cause in 33 to and the STI cannot penetrate this. OCs also 80 percent of the PID cases, although mixed gon- decrease the heaviness of the menstrual flow, and orrhea and chlamydial infections occur frequently. this decreased blood may result in less retrograde About 15 percent of endocervical gonorrhea infec- menstrual flow, making it harder for the bacteria tions result in PID. A diagnosis of PID in children to ascend and cause PID. If a woman using warrants an evaluation for child abuse. oral contraceptives does acquire PID, it is often PID symptoms more often occur during or milder or possibly even asymptomatic.3 within one week of menses because the opening Use of illicit drugs (especially crack cocaine), of the cervix is wider due to menstruation. alcohol, or cigarettes has been associated with an Microorganisms can then more easily ascend into increased risk of STDs and PID. Substance abuse the upper genital region and use the flow of also increases the potential for HIV infection. blood as nutrition for their growth. Women with HIV are far more likely to have PID. Women with new heterosexual partners within Vaginal douching may be associated with PID the last 30 to 60 days or multiple sex partners are and even ectopic pregnancy. In several studies, more likely to develop PID. If a woman’s partner women with PID are more likely to use douching is not monogamous, then she is also at increased than women without PID. One study found that risk. A history of a sexually transmitted infection douching within the previous two months was (STI) increases the likelihood of contracting sub- associated with a 70 percent increase in PID.4 sequent STIs, as does a history of PID. Diagnosis of PID starts with a combination Barrier contraceptive methods such as con- of a good medical history and physical exam. The doms, diaphragms, and cervical caps (FemCap) medical history should include a thorough sexual reduce the risk of STIs, PID, and infertility.1 history. Symptoms include but are not limited to Their protective benefit comes from decreasing vaginal discharge, fever, chills, urinary symp- the risk of acquiring a STI. In addition, the toms, heavy menstrual bleeding, intermenstrual condom may decrease the risk for developing bleeding, and lower abdominal/pelvic pain. A PELVIC INFLAMMATORY DISEASE 269

PREVENTION KEY CONCEPTS

• Use barrier methods of contraception. • Acute or chronic pelvic pain warrants a visit to • Avoid illicit drugs and cigarettes, and limit a qualified licensed health-care practitioner for alcohol. diagnosis. • Treat previous STIs with appropriate therapy and • PID must be differentiated from other causes of be certain of resolution. pelvic and abdominal pain. • Avoid douching. (It is possible that douching • PID should be treated primarily with antibiotic will cause a vaginal infection of GC, CT, or BV to therapy, while alternative medicine can offer ascend into the uterus and/or the fallopian supportive and adjunct therapies to conven- tubes.) tional treatment. • Know the sexual history of your partner. • Seek prompt medical attention if you have the • Heterosexual women who have multiple partners symptoms described in this chapter or suspect and do not use condoms, cervical caps, or you have PID. diaphragms are at higher risk for PID. • The sex partner must also be evaluated and • Women with HIV are at even higher risk and treated. Reinfection will almost certainly occur need to practice even greater caution. if the sex partner is not treated. physical exam includes taking the temperature; a department and report the disease if this organ- pelvic and abdominal exam with any tenderness ism has been cultured. Due to the potential com- of the uterus, fallopian tubes, or cervix serving as plications and seriousness of PID, in concert a red flag; observing the cervix and looking for with a lack of proven therapeutic results in using redness, swelling, and friability (easy bleeding) of natural treatments for this disorder, alternative the cervix; and evaluating genital tract secretions, therapies should be seen as secondary to conven- particularly for mucopurulent (green or yellow) tional treatment. Women who suffer from PID discharge. and have strong opinions about not being treated The vaginal secretions should be evaluated for with antibiotics should be fully educated and the presence of white blood cells during micro- informed so that their decision to decline antibi- scopy. Laboratory testing includes cervical samples otic therapy can be fully considered. A short for Neisseria gonorrhoeae (GC) or Chlamydia tra- course of antibiotic therapy is rarely detrimental chomatis (CT); a pelvic ultrasound showing thick- to one’s health. In this case, the benefit of the ened, fluid-filled tubes or tubo-ovarian mass; and therapy far outweighs the risk of its use. Like- acute and/or chronic endometritis on endometrial wise, alternative practitioners should understand biopsy. The gold standard in diagnosing PID is a that the integration of antibiotic therapy for the laparoscopy. During this surgical procedure, the benefit of the patient is not a failure of natural surgeon looks for swelling of the fallopian tubes, medicine. There are old texts that make reference tubal adhesions, tubal erythema (redness), tubal to treating PID with natural therapies, but they purulent or serous discharge, and/or a tubo-ovarian lack modern methods of evaluation and follow- mass. up. It could be that botanicals used in India, China, or elsewhere have a tradition substanti- OVERVIEW OF ated by modern confirmation testing, but I am ALTERNATIVE MEDICINE not aware of any confirmed treatments. Gonorrhea is a reportable disease. This means Using alternative therapies to support the that a practitioner must call the public health immune system, assist in managing pain and 270 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

discomfort, reduce inflammation, and counter- Sample Adjunct Treatment Plan act some of the side effects of the antibiotics are for Pelvic Inflammatory Disease the main priorities. Drinking plenty of water, getting rest, eating simple light foods, and avoid- This plan should be used as a complement to antibi- ing stimulants are basic guidelines during any otic therapy. acute infection, including pelvic infections. • Eat a light diet during acute infection: veg- General immune support to complement etable broths, steamed vegetables, salads, and conventional antibiotic treatment is just good fruits plain common sense. Nutritional and botanical • Acidophilus yogurt: 4–8 oz per day as a pre- support can stimulate white blood cells that ventive of yeast vaginitis engulf and destroy bacteria. Herbs and nutrients • Vitamin E: 400 units twice daily • Vitamin C: 1,000–2,000 mg 3 times daily can enhance the function of T cells, B cells, and • Vitamin A: 25,000 units per day and up to natural killer cells that support the immune 50,000 units for a maximum of 2 weeks system’s response to infection. Vitamin A, vita- • Zinc: 45–60 mg per day min C, the carotenes, vitamin E, zinc, and the B • Ice pack over the uterus with a hot footbath vitamins all play an important role in immune • Echinacea: 1⁄2 tsp liquid extract or 2 cap- enhancement. Increasing antibody response, sules/tablets every 3 hours during course of stimulating helper T cells, enhancing white infection blood cell response and function, and directly • High-dose allicin extract: 2 capsules 4 times killing the virus or bacteria are just some of the daily for the first 3–6 days, then 2 capsules ways in which these supplements can be helpful twice daily for 1 week, and then 2 capsules daily until infection is gone during an infection of any kind. Many herbs have also been shown to have antimicrobial and immunostimulating effects. eight ounces of unsweetened acidophilus yogurt Allicin extracts from garlic may hold the most or at least three capsules of Lactobacillus aci- promise for inhibiting bacterial infections. Gold- dophilus daily for two weeks may be able to pre- enseal and Oregon grape root also have the ability vent the overgrowth of vaginal yeast that often to inhibit the overgrowth of numerous organisms, occurs when taking antibiotics. Additional although this does not include BV and CT. The dietary advice, plus botanical and nutritional most commonly used herb for immune support therapies for the prevention and treatment of is echinacea. Echinacea can increase the produc- yeast vaginitis, is discussed in Chapter 20. tion of T cells, stimulate the white blood cells that Ice packs over the pelvic region can reduce engulf and destroy bacteria, stimulate natural inflammation and pain in cases of acute PID. killer cell activity, and increase the number of Cold or ice packs placed over the region of the circulating white blood cells in order to deal with uterus while putting the feet in a tub of hot water the infection.5 The end result is a strengthened can further assist in reducing the inflammation, immune system. Curcumin is one of the best congestion, and pain in the pelvic area. Alternat- herbs to reduce inflammation. ing hot and cold sitz baths can also be used to The best complement to counteract the side improve circulation in the pelvic area and effects of antibiotic use is to add or increase the improve the healing time from the infection. intake of Lactobacillus acidophilus to help prevent This is done by sitting in a bath of hot water, a vaginal yeast infection. This can be accom- with the water level just above the waist, for three plished by eating yogurt daily or by taking oral minutes, followed by sitting in a small second capsules of Lactobacillus acidophilus. Four to portable metal or plastic tub of ice cold water for PELVIC INFLAMMATORY DISEASE 271 one minute. This procedure is repeated three Regimen B times in succession, once or twice daily through- • Ceftriaxone (250 mg intramuscularly in a out the course of the pain and infection. single dose) plus doxycycline (100 mg orally twice a day for 14 days) or CONVENTIONAL • Cefoxitin (2 g intramuscularly in a single MEDICINE APPROACH dose) plus probenecid (1 g orally adminis- Conventional practitioners rely on their judg- tered concurrently in a single dose) plus ment in assessing the severity of the disease and doxycycline (100 mg orally twice a day for the ability of the patient to carry out the treat- 14 days) or ment successfully. It is essential for the practi- • Another parenteral third-generation cepha- tioner to educate the patient about the exact losporin (for example, ceftizoxime or cefo- treatment regimen. If she is able to comply with taxime) plus doxycycline (100 mg orally the recommendations, she may be a candidate twice a day for 14 days) for outpatient treatment. Infertility may be more These regimens can be used with or without successfully prevented by prompt administration metronidazole (500 mg orally twice a day for 14 of IV (intravenous) antibiotics, even if the days). The addition of metronidazole should be woman is not acutely ill. In the case of outpatient considered, as anaerobic organisms are suspected treatment, once antibiotics are administered, in the majority of PID cases. Metronidazole will the patient must have a follow-up visit within 72 also treat bacterial vaginosis, which is frequently hours. With the advent of home IV therapy, associated with PID and/or follows antibiotic sometimes IV antibiotic treatment can be therapy. received at home. It is important to realize how critical it is to PID therapy must provide broad-spectrum follow the practitioner’s directions and to com- coverage of the most likely offending organisms. plete the drug regimen as prescribed on the bottle. Although several antimicrobial regimens have There may be side effects about which the patient been effective in achieving cure in randomized should be informed to improve compliance. clinical trials, few studies have been done to There are certain criteria for hospitalization assess and compare elimination of infection of of a woman with PID that include but are not the lining of the uterus and the fallopian tubes or limited to: the incidence of long-term complications such as infertility and ectopic pregnancy. No single • Concern about the ability of the patient to antibiotic regimen has been established. Health- comply with treatment and to follow up care providers select treatment regimens based • A fever greater than 101 degrees on drug availability, cost, the patient’s tolerance • Signs of an acute abdomen (acute onset of of the drug, and other individuating factors. abdominal pain/tenderness/bloating, nausea, Most practitioners follow the Centers for Disease vomiting) Control treatment guidelines, which were • Lack of improvement within 72 hours updated in 2006: If hospitalization occurs, a more complex regi- Regimen A men is administered with several combinations • Levofloxacin (500 mg orally once daily for of IV antibiotics. After the patient leaves the hos- 14 days) or pital, two weeks of doxycycline is given. • Ofloxacin (400 mg orally once daily for 14 Intravenous treatment recommendations of days) PID are as follows: 272 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE • Levofloxacin (500 mg IV once daily) with or the importance of treating her male partners, if without metronidazole (500 mg IV every 8 applicable; and the importance of barrier contra- hours) or ceptives and other methods to reduce the risk of • Ofloxacin (400 mg IV every 12 hours) with STIs. To a patient not accustomed to dealing with or without metronidazole (500 mg IV every severe infections and the need for antibiotics, 8 hours) or some practitioners may seem overly aggressive in • Ampicillin/sulbactam (3 g IV every 6 hours) their recommendations and insistence. Although plus doxycycline (100 mg orally or IV every this may offend some women, it is important that 12 hours) they do not let a less-than-optimal bedside style distract their attention from the value of what These medications are used in the hospital until physicians know and have to offer. the patient’s fever has been absent for one or two days, her pelvic pain has dramatically reduced, SEEING A LICENSED PRIMARY she is taking oral food and able to get up and out HEALTH-CARE PRACTITIONER of bed and take care of herself, and any of the (N.D., M.D., D.O., N.P., P.A.) other criteria that a physician chooses to release Women with pelvic pain need to consider not the patient from the hospital. only PID but also other conditions that can Treatment of a tubal ovarian abscess, which is occur with similar discomfort. Ectopic preg- a common complication of PID, is more com- nancy, tubo-ovarian abscess, ruptured ovarian plex. If the patient has a fever, with an acute cysts, appendicitis, inflammatory colitis, pancre- abdomen, the first line of treatment is surgical atitis, cholecystitis (inflammation of the gallblad- drainage of the tubal ovarian abscess followed by der), cystitis (inflammation of the bladder), multiple IV antibiotics. Sometimes, if a patient diverticulitis (inflammation of a small pouch has minimal tenderness, does not have a fever, along the border of the colon), hepatitis, and a and is a good candidate for outpatient therapy, twisted fallopian tube are among the other she can be given oral medications for two to potentially serious disorders that require differen- three weeks and followed in the office. tiation from PID. Treatment of PID should eliminate signs and Women with PID typically describe pain that symptoms of the infection and eradicate the is sharp, localized, and on both sides of the body. microorganisms while minimizing the damage to They may also have an oral temperature above the fallopian tubes as well as long-term complica- 101 degrees. Ectopic pregnancy typically pres- tions. Follow-up for outpatient treatment is crit- ents with one-sided pain but no fever. ical within 72 hours to assure that the patient is If you have these symptoms, call your doctor taking the medicine accurately and to evaluate immediately. A licensed health-care practitioner the effectiveness of the treatment. (naturopathic doctor, medical doctor, osteopathic Pregnant women with suspected PID should doctor, nurse-practitioner, or physician’s assistant) be seen immediately and have an ectopic preg- will proceed with a history, physical examination, nancy ruled out. PID in pregnancy is uncom- and diagnostic testing, including blood work, cul- mon and is more likely to occur when HIV is tures, and possible pelvic ultrasound. An abdomi- present. Hospitalization and IV antimicrobial nal exam will be done to check for pain in various therapy are recommended. locations. A pelvic exam will check the external Conventional practitioners take great care in genital region; a speculum exam will check for educating the patient about the disease; the im- inflammation and discharge. A thick, transparent, portance of treatment; the possible consequences; yellow, gray, or brown discharge coming through PELVIC INFLAMMATORY DISEASE 273

Diagnostic Criteria for Pelvic They may be able to reveal a cyst, an ectopic preg- Inflammatory Disease nancy, an abscess, or an enlarged tube. Laparoscopy is considered to be the gold All three criteria must be present for a clinical diag- standard for diagnosing PID. Because diagnostic nosis (without the use of tests) of PID: laparoscopy is expensive and invasive, requires • Lower abdominal tenderness special training, and may not affect the decision • Bilateral adnexal tenderness to treat the patient for pelvic infection, it is not • Cervical motion tenderness routinely used in the emergency management of Additional criteria useful in diagnosis: patients with PID. A procedure called culdocen- tesis aspirates fluid that has collected behind the • Oral temperature greater than 101°F uterus. It is rarely used unless the diagnosis is • Mucopurulent cervical or vaginal discharge • Palpable pelvic mass uncertain or a complication is suspected. The • Elevated sedimentation rate or C-reactive presence of blood in the fluid sample suggests an protein—both markers of inflammation ectopic pregnancy or a ruptured ovarian cyst. • White blood cell count greater than 10,000 Cloudy or purulent fluid suggests an infection, • Evidence of cervical infection with Neisseria and the fluid is then tested with cultures for PID. gonorrhoeae or Chlamydia trachomatis About 25 percent of women with PID will • Tubo-ovarian abscess or fluid-filled tubes on require hospitalization. Criteria for hospitaliza- pelvic ultrasound tion have been established by the CDC. If your • Acute and/or chronic endometritis on endome- practitioner recommends that you be admitted trial biopsy to the hospital, I would urge you to entrust your- • Laparoscopic abnormalities consistent with PID self to his or her care. You can always use natural therapies to augment the treatment. The CDC criteria for hospitalization include: the cervix suggests a chlamydial or gonococcal infection. An internal exam will check for an • Adolescent patient enlarged uterus or pain and tenderness. Cultures • A surgical abdomen, a serious condition for the infectious agents require two to three days characterized by sudden onset of abdominal/ to process and are important in confirming a diag- pelvic pain, tenderness, and muscular rigid- nosis, but severe symptoms and the potentially ity (possibility of appendicitis) serious consequences of acute PID require imme- • HIV infection diate treatment even if confirmation has not yet • The diagnosis of PID is uncertain been obtained. • The patient has not responded to outpatient Since more than one organism can cause PID, treatment a negative culture result can be misleading. Newer • The patient has not been able to tolerate or and more accurate tests using antigen detection follow the outpatient regimen methods or fluorescence antibody marker tech- • A surgical emergency is possible niques are available for the rapid detection of • Pregnancy chlamydial infection. They can be especially useful • The patient has a septic appearance (fever, in detecting mild cases or cases that have no symp- chills, shaking, or other flu-like symptoms) toms. Pelvic ultrasound examinations are per- • Severe illness or nausea and vomiting formed when a pelvic mass or abscess is suspected. • Suspected pelvic abscess This page intentionally left blank PREGNANCY CHAPTER 16

OVERVIEW consider, the most important preventive medi- All women want to do everything they possibly cine is the mother’s relationship to her own body can to optimize the health and well-being of and her emotional and physical connection to themselves and their children. There is no other the child she is carrying. condition that inspires women to care for them- During pregnancy, hormone secretion changes selves as well as pregnancy. That said, Mother radically, causing the physical and emotional Nature’s talent in producing healthy babies is changes experienced by most women fairly early awesome indeed, and no matter the range of in the first trimester. Estrogen and progesterone one’s individual decisions regarding optimal levels are about 100 times higher than usual health care, most babies arrive intact and healthy. during pregnancy, dropping immediately after Women who receive prenatal care enjoy the birth to prepregnancy levels as prolactin (the lowest risk of maternal and infant mortality in pituitary hormone) is produced to stimulate the history. production of breast milk. Throughout preg- It is important to recognize those things we nancy, the placenta produces a hormone called have control over and those we don’t. While relaxin, which softens the connective tissues women should do their best to take excellent care and ligaments that support the uterus, allowing of themselves during pregnancy, they must not it to expand. The production of endorphins assume personal responsibility for vagaries of (morphine-like hormones that are the body’s natu- biology like miscarriages and rare abnormalities. ral painkillers and tranquilizers) is increased during Ninety-eight percent or more of babies are born pregnancy and continues to rise during labor, when healthy. Keep that number in mind as you read they reach peak levels.1 These hormonal changes through this information. Remember that fetuses can lead to the experience of morning sickness or are strong little creatures. They pull what they nausea in the first trimester, especially when there need from our bodies pretty effectively. It is the are nutritional deficiencies as well. woman carrying the child, in all but extreme cases, who suffers from any deficiencies in nutri- OVERVIEW OF ALTERNATIVE tion or health—the fetus gets preferential treat- MEDICINE CONSIDERATIONS ment. Welcome to motherhood! Nearly all pregnant women can benefit from nutri- Pregnancy and birthing are normal physio- tional and multivitamin supplementation one year logical processes that can be positively supported before and all during pregnancy, as well as through adequate rest, preventive nutrition, and throughout labor, delivery, and breast-feeding. The the avoidance of harmful substances. Minimizing effects of poor nutrition during pregnancy can be stress, getting plenty of low-impact exercise and seen in the increase of birth defects during times of fresh air, and sleeping well are important factors famine.2 But a standard Western diet (high in fats, leading to a positive overall experience of preg- salt, and sugar and low in complex carbohydrates) nancy and birth. The important thing to remem- also lacks essential vitamins and minerals needed ber is that each pregnancy is unique, and during pregnancy and breast-feeding, which can although there are certain universal factors to compromise your baby’s health.3 The appropriate 275

diet is well balanced and varied and includes fresh KEY CONCEPTS fruits, vegetables, whole grains, legumes, beans, and fish, with a limit on refined sugars, processed • Eat a healthy, whole foods diet, high in healthy foods, and saturated fats. Organically grown pro- oils (low-mercury fish high in omega-3 oils), duce, meats, and poultry are preferable, or inor- complex carbohydrates, fruits, vegetables, ganic produce that has been carefully washed to organic meats and dairy, legumes, and nuts and remove agricultural chemicals.4 seeds. In an observational study involving 76 healthy • Avoid situations that would increase risk of acute illness. pregnant women, 78 percent had “one or more • Manage medical problems safely and effectively, 5 glaring nutritional deficiencies.” Another study as necessary. showed an “overall apparent protective effect of • Have regular prenatal health checks. peri-conceptual multivitamin use” for prevention • Seek assistance from a qualified health-care of certain pregnancy-related illnesses and birth practitioner. defects.6 Of special importance are folate (folic acid) and calcium intake, since the requirement for both of these doubles during pregnancy. TO PREVENT COMPLICATIONS One study found that “The fetus, the neonate, and the pregnant woman have an • Avoid alcohol. increased requirement for folic acid and vitamin • Avoid nicotine. • Reduce exposure to mercury-containing foods. B12, and are more likely to suffer from a deficiency of these vitamins.”7 Nutrients such as folic • Avoid recreational drugs. acid and vitamins B and B have been corre- • Avoid over-the-counter drugs, prescription 6 12 drugs, and herbs that may adversely affect the lated with prevention of the more common preg- fetus. Consult with knowledgeable medical per- nancy complications, such as spontaneous sonnel about these choices. abortion, placental abruption, preterm delivery, • Exercise regularly; avoid injuries, falls, and high- low infant birth weight, and neural tube defects risk athletics. (such as spina bifida and anencephaly).8 Supple- mentation with calcium—the only mineral whose requirement doubles during pregnancy9— illicit drugs are more likely to have inadequate has been positively correlated with prevention of nutrition as well as birth abnormalities and pregnancy hypertension,10 preeclampsia,11, 12 developmental problems in the infant. preterm delivery,13 and low birth weight,14 as well as puerperal psychosis (postpartum depres- Nutrition sion).15 Magnesium supplementation has also During pregnancy, a woman’s physiology changes been shown to reduce the complications of preg- dramatically to allow for the development of a nancy and improve the health of the infant.16 healthy fetus. To support the rapidly growing In addition to taking nutritional supple- fetus, changes in metabolism, biochemistry, and ments, certain substances should be avoided in hormone status are needed to provide the environ- preparation for and during pregnancy. Smoking ment and energy required. Appropriate nutrition during pregnancy increases the incidence of pre- is important for both the mother and child during mature labor,17 low birth weight,18 and infant pregnancy and plays a pivotal role in a healthy complications.19 These complications may not pregnancy. Members of the health-care team assess be alleviated by increased maternal caloric intake. maternal nutritional risk, assign goals for weight In addition, women who abuse alcohol and use gain, and recommend dietary changes to achieve PREGNANCY 277 those goals. Prenatal evaluation and continued nutritional practices. Women with limited or health care are important to monitor the progress potentially imbalanced dietary habits (vegetari- of the pregnancy and intervene with corrective ans, vegans, anorexics, and women consuming changes when needed. macrobiotic, high-protein, weight-loss, high-fat, The nutritional assessment includes informa- or high–junk food diets) should receive special tion about diet, eating habits, daily activities, attention and be educated on the potential com- medical and medication history, and the use of plications and risks of these habits to both the tobacco, alcohol, and recreational drugs. An initial mother and the fetus. Women with a history of physical examination followed by ongoing exams anorexia, bulimia, obesity, diabetes, chronic is essential in assessing the mother’s body mass kidney disease, chronic gastrointestinal disease, or index (BMI) and appropriate weight gain and fetal extreme diets may need more individualized edu- growth. BMI relates weight to height and thus cation and nutritional therapy. Vegetarian, vegan, provides a better estimate of body fat distribution and macrobiotic diets are not necessarily inappro- than weight alone. The practitioner uses the BMI priate as long as certain parameters are monitored. to determine whether the mother is underweight, These include regular physical exams and prenatal normal weight, overweight, or obese. Weight is a checks, appropriate weight gain, and laboratory very important indicator of fetal health and testing. Even women that have done well or seem- requires precise and regular measurement. At each ingly well on these diets prior to pregnancy may visit with your prenatal health-care worker, you not do well when pregnant or nursing. should be weighed to assess your weight gain com- Other women may suffer from an inadequate pared to the target goals. caloric intake because of their fear of weight gain, Low prepregnant weight and inadequate inadequate education about pregnancy, or insuf- weight gain during pregnancy are dominant con- ficient money to purchase enough nutritious tributors to intrauterine growth retardation20 and food. For low-income pregnant and postpartum low birth weight.21 Maternal prepregnant weight lactating women, for infants, and for children up and weight gain in pregnancy also have an impact to the age of five years at nutritional risk, assis- on early infant death rates. For women who are tance is available through the federal Supplemen- underweight prior to pregnancy, the perinatal tal Food Program for Women, Infants and mortality risk at birth is lowest when their weight Children (WIC). Food stamp programs and Aid gain during pregnancy is greater than 37 pounds. to Families with Dependent Children may also For women who had normal weight prior to preg- be available for women. Other local, private, nancy, the lowest risk is with a weight gain of 30 church, county, and state organizations may also to 37 pounds.22 Women who are obese prior to be a source of assistance. pregnancy need to gain less weight for an optimal Some women are potentially at nutritional risk. fetal outcome. Significant risk occurs in obese These include women who have had several full- women if there is a greater than 25-pound weight term pregnancies, previous low birth weight deliv- gain during the pregnancy.23 Weight loss in obese eries, and short intervals between births. Women women is not recommended during pregnancy. with medical conditions such as diabetes, chronic Teenagers, especially, often need careful education renal disease, anemia, and phenylketonuria all about the importance of nutrition, nutritional require special attention to dietary counseling. Use choices, the importance of healthy weight gain, of prescribed medications, over-the-counter drugs, and guidance throughout the pregnancy. vitamin and mineral supplements, laxatives, and All pregnant women will benefit from prena- diet aids should all be reviewed by a qualified tal nutritional education that focuses on healthy health-care practitioner. 278 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE The average amount of weight gain is 28 porate healthy foods into your diet. If you already pounds. The maternal component of weight eat a very healthy diet, then it is important to accumulation starts in the first trimester and is ensure that you are eating adequate amounts of most prominent in the first half of the pregnancy. food. If you are on a restricted diet or follow a spe- The growth of the fetus is most rapid in the cific dietary system, I advise you to seek the advice second half of the pregnancy. In the last 12 of a health-care practitioner knowledgeable in the weeks, the weight of the fetus more than triples. area of nutrition. Generally this would be a licensed Optimal health during pregnancy not only naturopathic physician or a nutritionist/dietitian. helps to ensure a healthy baby but also helps to The following general guidelines for daily food ensure good health for the mother after the birth. servings have been proposed as the “daily dozen” in A strong nutritional foundation during pregnancy the book What to Eat When You’re Expecting.24 can provide mothers necessary support in the • Calories: plenty of healthy foods to ensure postpartum period, throughout breast-feeding, adequate calories (2,300 daily) and during the years to come when the demands • Protein: four servings (either vegetable or of raising young children are high. When contem- animal sources—74 g total) plating pregnancy, the first step a woman needs to • Calcium foods: four servings daily (dairy take is to commit to eat healthfully. Support of and nondairy sources) family and friends during days of not feeling well • Vitamin C–rich fruits and vegetables: two along with assistance with shopping and cooking servings can help in keeping that commitment. Almost • Green leafy vegetables and yellow fruits and every pregnant woman will experience cravings. vegetables: three servings The main problem with cravings arises when crav- • Other veggies and fruits: one or two servings ings for chocolate, sodas, sweets, and ice cream • Whole grains and other complex carbohy- become substitutes for nutritious foods. Cravings drates: four to six servings often can also be clues about specific nutritional • Iron-rich foods: one or more servings daily needs. A craving for ice cream may indicate an • High-fat foods: two servings increased need for protein, fat, or calcium. A crav- • Salt: in moderation, to taste ing for acidic foods like pickles may be a clue to • Fluids: at least six to eight glasses increased need for calcium or salt. A craving for • Supplements: nutritious herbs, highly con- sweets may indicate a need for more protein in the centrated food supplements (soy or green diet. Cravings for chips can indicate a need for drinks), and a prenatal vitamin-mineral more salt and fats. A continued effort should be supplement made to replace these junk foods with healthier nutritious choices. The Food and Nutrition Board of the Insti- The best way to ensure that you are eating well tute of Medicine has published recommended is to establish a balanced, wide variety of foods, dietary allowances (RDAs) periodically since including whole-grain cereals and breads, vegeta- 1943. The RDAs are listed by nutrient in the bles and fruits, nuts, seeds, legumes, and comple- nutritional supplement section that follows. mentary amounts of dairy products and meats, The question of how many calories per day to especially fish and poultry. If you are unfamiliar consume is dependent upon many variables. The with natural foods, try to find a nutritional practi- input portion of the energy equation includes tioner who can advise you and begin to make the consumed food plus the amount of stored fuel appropriate changes in your diet. Books on nutri- in the body. The output variable in the equation tion and cooking also can be of help as you incor- includes the metabolic rate, thermogenesis (heat PREGNANCY 279 production), and physical activity. The caloric con- According to one controlled study, women at tent of the diet required to supply daily energy high risk (having previously given birth to babies needs and achieve optimal weight gain can be esti- with neural tube defects) who were given folate mated by multiplying your optimal body weight in supplementation showed a 72 percent protective pounds by 15.9 and adding 300 to the total. (Al- effect compared to the placebo group.25 In one ternatively, you can multiply your optimal weight study, a group of pregnant women given folate in kilograms by 35 and add 300 to the total.) supplementation gave birth to infants with The postnatal period is another time when increased birth weight and Apgar scores and had the physiological demands of lactation and a decreased incidence of fetal growth retardation breast-feeding put additional nutritional strain on and maternal infections.26 the mother. Optimal milk production requires a Other studies also showed significant preven- total daily caloric intake of at least 1,800 calories. tion with supplementation.27–30 Because of The energy sources are fat stores and diet, which firmly established connections between deficien- need to supply an additional 500 calories per day. cies of folic acid and low–birth weight infants Intake of water, juice, and milk (this can be cow, and neural tube defects, the U.S. Public Health goat, almond, soy, oat, or rice milk) to satisfy thirst Service recommends that all women of child- is sufficient for breast milk production needs. bearing age take daily folic acid supplementation The well-balanced, varied whole foods diet to reduce the risk of congenital birth defects. that was consumed prenatally should be main- Dietary folic acid is a mixture of folates in the tained postnatally. The monthly loss of iron with form of polyglutamates, which are readily breast-feeding is about half that of regular men- destroyed by cooking. Higher levels of dietary struation, and because women do not menstruate folate intake has been shown in some cases to during breast-feeding, their iron stores are usu- decrease the incidence of neural tube defects, but ally replenished. Some vitamins and other miner- women hereditarily predisposed to such defects als, however, may be depleted during lactation. may need to take in more folic acid through Continued nutritional supplementation with a supplements in order to reach optimal levels.31 prenatal vitamin or, even better, a postnatal vita- Folic acid can be found in green leafy vegetables, min, can prevent deficiencies and is important nuts, whole grains, liver, watercress (avoid in first even if the diet is sufficient. trimester), parsley, and dandelion. With artificial After rapid weight loss in the first month, the supplementation, care must be taken, because lactating mother of normal weight may lose large doses of folic acid have been associated with weight at a rate of about two pounds a month a decrease in zinc absorption, a mineral required without affecting milk volume. For the obese for proper fetal growth and immunity,32 as well woman, losing four pounds a month is also safe. as with maternal infection and abnormally slow Intentional weight reduction diets or rapid fetal heart rate.33 weight loss during lactation are not advisable. At one year after delivery, a two-pound residual Folic Acid additional weight is considered average. Recommended dietary allowance (RDA): Nutritional Supplements Pregnant: 600 mcg per day Nursing: 500 mcg per day Folic Acid. Folate is the only vitamin whose Food sources: green leafy vegetables, nuts, whole requirement doubles in pregnancy.9 Deficiencies grains, liver, watercress (avoid in first trimester), of folic acid have been linked in studies to low parsley, dandelion birth weight infants and neural tube defects. 280 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Vitamin B3 (Niacin, Nicotinic Acid). Vitamin are green peas, bell peppers, and sunflower seeds. B3 (niacin) supplementation in the first trimester Herbal sources include alfalfa, dandelion, fenu- has been positively correlated in studies with higher greek, raspberry leaf, red clover, and seaweed. birth weight, longer length, and greater newborn head circumference, all signs of healthier infants.34 Vitamin B1 (Thiamine) Good food sources of niacin are wheat germ, fish, Recommended dietary allowance (RDA): and garlic. Herbal sources are alfalfa, burdock root Pregnant or nursing: 1.4 mg per day and seed, dandelion, and parsley. Food sources: bell peppers, green peas, sunflower seeds Vitamin B3 (Niacin) Herbal sources: alfalfa, dandelion, fenugreek, raspberry leaf, red clover, seaweed Recommended dietary allowance (RDA): Age 18 and younger, pregnant or nursing: 30 mg per day Vitamin B6 (Pyridoxine). Vitamin B6 is Age 19 and older, pregnant or nursing: 35 mg per “marginally deficient” in about 50 percent of day pregnant women.37 Supplementation has been Food sources: wheat germ, fish, garlic linked to relief of nausea and morning sickness, Herbal sources: alfalfa, burdock root and seed, dande- especially in extreme cases that include vomit- lion, parsley ing.38, 39 In one experimental study, 75 percent of women taking vitamin B6 experienced complete Vitamin B2 (Riboflavin). Studies show that relief from symptoms of morning sickness.40 vitamin B2 (riboflavin) depletion is common Higher doses were used for treatment of first during pregnancy (up to 40 percent less at term trimester morning sickness (25 to 200 mg three than nonpregnant women and men), so ribo- times daily), but are not recommended before flavin supplementation is recommended to pre- delivery, as higher doses may shut off breast milk vent metabolic disturbances.35 Good sources of in nursing mothers or cause the baby to have riboflavin are watercress (avoid in first trimester) withdrawal seizures if commercial formula is and brown rice. Herbal sources include rose hips, given that does not include enough pyridoxine parsley, saffron, dandelion, dulse (seaweed), kelp, 41, 42 (B6). However, when given during labor, and fenugreek. vitamin B6 may prevent many postnatal adapta- tion problems by increasing the oxygen-carrying Vitamin B2 (Riboflavin) capacity of the blood that supplies the fetus.43 Recommended dietary allowance (RDA): Pregnant: 1.4 mg per day Nursing: 1.6 mg per day Vitamin B6 (Pyridoxine) Food sources: watercress (avoid in first trimester), brown rice Recommended dietary allowance (RDA): Herbal sources: rose hips, parsley, saffron, dandelion, Pregnant: 1.9 mg per day dulse (seaweed), kelp, fenugreek Nursing: 2.0 mg per day Tolerable upper intake level (UL): Age 18 and younger, pregnant or nursing: 80 mg per Vitamin B (Thiamine). Direct correlation 1 day has been shown between supplementation of Age 19 and older, pregnant or nursing: 100 mg per vitamin B1 (thiamine) early in pregnancy and day higher infant birth weight and size.34 Thiamine Food sources: whole grains, wheat germ, egg yolk, depletion is common during pregnancy, and sup- peas, carrots plementation is recommended.36 Food sources PREGNANCY 281 Local application of B as a lozenge provided 6 Vitamin A women with protection from dental cavities, which are more common during pregnancy.44 Recommended dietary allowance (RDA): Supplementation may also prevent toxemia of Age 18 and younger, pregnant: 2,500 IU per day pregnancy (preeclampsia).45 Food sources are Age 18 and younger, nursing: 4,000 IU per day whole grains, wheat germ, egg yolks, peas, and Age 19 and older, pregnant: 2,600 IU per day Age 19 and older, nursing: 4,300 IU per day carrots. Tolerable upper intake level (UL): Age 18 and younger, pregnant or nursing: 9,000 IU Vitamin B12 (Cobalamin). The coenzyme per day form of vitamin B12 is a very complex molecule containing cobalt, designated in humans as Age 19 and older, pregnant or nursing: 10,000 IU per day cobalamin, which is required for proper homo- Beta-carotene: cysteine metabolism. At least 12 different inher- No recommended doses or insufficient reliable infor- ited inborn errors of metabolism related to mation. Consider UL to be 10,000 IU per day. cobalamin are known; low plasma vitamin B12 Anywhere between 10 IU and 10,000 IU per day is levels have been shown to be an independent risk an option. factor for neural tube defect in one study.46 Sup- Food sources: yellow and orange fruits and vegetables plementation is recommended and may also help Herbal sources: alfalfa, cayenne, comfrey, dandelion, prevent anemia. Food sources are cauliflower and elderberries, lamb’s quarters, seaweed broccoli. Herbal sources are alfalfa, comfrey, miso, seaweed, and catnip. min A in the blood have also been correlated with low birth weight.51 Vitamin B12 (Cobalamin) Preterm infants have been shown to be defi- Recommended dietary intake (RDA): cient in vitamin A, which may predispose them 52 Pregnant: 2.6 mcg per day to development of chronic lung disease. Nursing: 2.8 mcg per day Healthy pregnant women who developed pre- Food sources: cauliflower, broccoli eclampsia were shown to be deficient in vitamin Herbal sources: alfalfa, catnip, comfrey, miso, seaweed A (but not beta-carotene).53 Preeclampsia is a potentially dangerous condition characterized by Vitamin A. It is important to avoid oversup- high blood pressure, swelling, and/or protein plementation of vitamin A during pregnancy. spilling into the urine. Daily doses of 40,000 units or more of vitamin To avoid complications, supplementation A during pregnancy may be toxic,47 while doses with no more than 6,000 units of vitamin A is lower than 10,000 units appear to be safe.48 In a optimal and recommended.54 Beta-carotene, study of 22,000 pregnant women, those who which has the same positive effects as vitamin A, consumed more than 15,000 units of vitamin has not been associated with toxicity or terato- A per day from food and supplements, or 10,000 genicity in humans or animals.55 Plant sources of units as a supplement, showed a significant in- the nontoxic “provitamin A” beta-carotene are crease in birth defects associated with cranial- organic fruits and vegetables, especially yellow neural-crest tissue (several-fold higher incidence and orange ones; for example, one sweet potato of birth defects).49 Most of these women con- or one cup of carrot juice contains 25,000 IU sumed the vitamin A before the seventh week of of beta-carotene.56 Herbal sources are alfalfa, pregnancy. Rat studies show a possible link to cayenne, comfrey, dandelion, elderberries, lamb’s folic acid metabolism.50 Elevated levels of vita- quarters, and seaweed. 282 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Vitamin C. Vitamin C plays a vital role in Vitamin D the formation of collagen—a major protein 3 found in connective tissue, cartilage, and bone. It Adequate intake (AI): is essential to the nerves, healthy gums, and teeth Pregnant or nursing: 200 IU per day and prevents infection. Although one study Tolerable upper intake level (UL): showed that women who took 5,000 mg of vita- Pregnant or nursing: 2,000 IU per day Environmental source: sunshine min C daily during pregnancy delivered healthy Food sources: fish 57 infants who developed scurvy, this “rebound Herbal sources: alfalfa, nettles scurvy” is very rare, and the infant recovers quickly without treatment. Supplementation Vitamin E. Vitamin E declines during preg- with vitamin C may be as effective as calcium for nancy, creating deficiencies, and fetal vitamin E leg cramps during pregnancy.58 levels are usually low.59 Lower plasma levels in Food sources of vitamin C are fruits (particu- the mother may be associated with increased risk larly citrus), green chilies, tomatoes, honey, cab- of preeclampsia, as well as premature and bage, cucumbers, and prunes. Herbal sources low–birth weight infants.60 Supplementation has include elderberries, rose hips, parsley, dandelion been shown to be effective in preventing chronic greens, nettles, alfalfa, and cayenne. miscarriages.61 Good food sources are parsley, brown rice, and wheat germ. Herbal sources Vitamin C include alfalfa, rosehips, raspberry leaf, dande- Recommended dietary allowance (RDA): lion, and seaweed. Age 18 or younger, pregnant or nursing: 115 mg per day Vitamin E Age 19 and older, pregnant or nursing: 120 mg per day Recommended dietary allowance (RDA): Tolerable upper intake level (UL): Pregnant: 15 mg or 22 IU per day Age 18 or younger, pregnant or nursing: 1,800 mg Nursing: 19 mg or 28 IU per day per day Tolerable upper intake level (UL): Age 19 and older, pregnant or nursing: 2,000 mg per Pregnant or nursing: 400 IU per day and up to 900 day IU per day during the last two months of pregnancy Food sources: fruits (especially citrus), green chilies, Food sources: brown rice, parsley, wheat germ tomatoes, cabbage, cucumbers, and prunes Herbal sources: alfalfa, rosehips, raspberry leaf, dan- Herbal sources: elderberries, rose hips, parsley, dandelion, seaweed, watercress (avoid in first trimester) delion greens, nettles, alfalfa, and cayenne Vitamin K. Vitamin K is necessary for bone Vitamin D. The absorption of vitamin D (as metabolism. In most states it is required by law well as calcium, which vitamin D helps metabo- that vitamin K be given to newborns in the hos- lize) is enhanced during pregnancy, and since pital by injection in the foot immediately after vitamin D tends toward toxicity, supplementa- birth or a shot during labor to prevent hemolytic tion should be judicious to prevent excessive disease, which is characterized by anemia, jaun- amounts of it from spilling into the urine. Fish dice, enlargement of the liver and spleen, and oil and sunshine are good sources of natural vita- generalized edema. Naturopathic doctors recom- min D, which benefits the development of good mend checking the pregnant mother’s diet for teeth and bones. Herbal sources of vitamin D are vitamin K deficiency and adding oral supple- alfalfa and nettles. mentation of vitamin K in the last month of PREGNANCY 283 pregnancy, if needed, rather than automatically tablets, which have been found to be high in lead, giving the shots, which have been shown in some mercury, cadmium, and other toxic metals. studies to link with childhood cancer.62 Vitamin K (along with vitamin C) is effective Calcium in preventing the nausea and vomiting of early Adequate intake (AI): pregnancy, and it may reduce the risk of intraven- Age 18 or younger, pregnant or nursing: 1,300 mg tricular hemorrhage in premature infants.63 Some per day food sources are parsley and brown rice. Nettle or Age 19 and older, pregnant or nursing: 1,000 mg per day Food sources: parsley, watercress (avoid in first tri- alfalfa leaf infusion or tea taken throughout the mester), dairy products, dark green leafy vegetables, pregnancy will increase available vitamin K and asparagus, pumpkin seeds hemoglobin in the blood; kelp is also helpful. Herbal sources: raspberry leaf, nettles, horsetail

Vitamin K Chromium, Cobalt, and Copper. These Recommended dietary allowance (RDA): three trace minerals were positively associated in Pregnant or nursing: 65 mg per day studies with higher infant birth weights, and sup- Food sources: parsley, brown rice plementation is therefore recommended.68 Herbal sources: alfalfa, nettles, kelp Chromium Calcium. Calcium is the only mineral whose Adequate intake (AI): requirement doubles during pregnancy. Low Age 18 and younger, pregnant: 29 mcg per day dietary intake is associated with preeclampsia,64, 65 Age 18 and younger, nursing: 44 mcg per day a potentially dangerous (but preventable) condi- Age 19 and older, pregnant: 30 mcg per day tion characterized by high blood pressure (hyper- Age 19 and older, nursing: 45 mcg per day tension), swelling, and/or protein spilling into Cobalt the urine. Supplementation with calcium may Adequate intake (AI): reduce the risk of preterm delivery, often associ- Pregnant or nursing: presumably as part of B12, 2 ated with preeclampsia, and may also prevent the mcg per day, and sufficient if you are taking vita- hypertensive disorders of pregnancy.66 Calcium min B12 supplementation can also help to ease leg cramps during pregnancy.67 Copper Excessive levels of calcium in the body, how- Adequate intake (AI): ever, can result in spillage into the urine and an Pregnant or nursing: 2 mg per day increased possibility of kidney stones. Supplement with the form of calcium that does not cause you Iron. Some researchers have concluded that indigestion or constipation. And attention must iron supplementation is essential during preg- be paid to the relationship between calcium and nancy in order to maintain adequate maternal other minerals, such as magnesium and zinc. iron stores. However, because iron supplementa- Raspberry leaf infusion contains calcium in its tion can exacerbate zinc depletion, supplementa- most absorbable form, as do nettle infusions, fresh tion is only warranted if iron deficiency is parsley, and watercress. Other food sources of cal- detected and routine iron supplementation cium include milk products (although consump- during pregnancy is clearly indicated.69 tion of these can lead to allergies in the baby), dark If a woman gets sufficient iron in the first green leafy vegetables, asparagus, and pumpkin trimester of pregnancy, studies show a definite seeds. Avoid bone meal or oyster shell calcium positive association with infant birth weight and 284 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE size, although the same is not true for the second nancy and improve infant health.74 In studies, and third trimesters.34 Good food sources are magnesium-treated women had a 29.5 percent almonds, honey, beets (including greens), and reduction in the risk of hospitalization, as well as a high-quality protein foods like egg yolks and 37 percent reduction in days spent in the hospital. organ meats (liver, kidney, heart), preferably Food sources are honey, almonds, barley, dried organic. Herbs high in iron are nettles, dande- fruits, and potatoes. Herbs are dandelion, alfalfa, lion, and alfalfa, as well as kelp. and watercress (avoid in first trimester), as well as seaweed (also called dulse). Iron Potassium. Potassium levels may be deficient Recommended dietary allowance (RDA): in pregnancy, with the lowest concentrations in Pregnant: 27 mg per day women with preeclampsia.75 Supplementation is Age 18 and younger, nursing: 10 mg per day Age 19 and older, nursing: 9 mg per day recommended. Food sources are bananas, pota- Tolerable upper intake level (UL): toes (especially peels), olives, bran, and green Pregnant or nursing: 45 mg, if not iron deficient leafy vegetables. Herbs are nettles, dandelion, Food sources: almonds, beets (including greens), egg alfalfa, and chamomile. yolks, honey, organ meats (liver, kidney, heart) Herbal sources: alfalfa, dandelion, nettles, kelp Potassium Recommended dietary allowance (RDA): Magnesium. Magnesium deficiencies are asso- Pregnant or nursing: 99 mg per day; should not be ciated with preeclampsia70, 71 and preterm labor.72 taken unless prescribed by your practitioner Supplementation must be in the first trimester to Tolerable upper intake level (UL): positively affect birth weight and size. Researchers Pregnant or nursing: 99 mg per day; should not be taken unless prescribed by your practitioner think that magnesium may act by opposing Food sources: bananas, potatoes (especially peels), calcium-dependent arterial vasoconstriction and olives, bran, green leafy vegetables may also prevent cell damage and death, making Herbal sources: nettles, dandelion, alfalfa, magnesium sulfate the “drug of choice” in the chamomile treatment of preeclampsia.73 In general, supplementation may reduce the complications of preg- Zinc. Zinc is required for proper fetal growth and immunity. Plasma zinc levels decline about Magnesium 30 percent during pregnancy,76 and low zinc Recommended dietary allowance (RDA): intake is associated with spontaneous abortion Age 18 and younger, pregnant: 400 mg per day and premature delivery,77 as well as complica- Age 18 and younger, nursing: 360 mg per day tions and labor abnormalities.78 Low zinc was Age 19–30, pregnant: 350 mg per day also associated with the specific complication of Age 19–30, nursing: 310 mg per day fetal distress79 and may be associated with central Age 31–50, pregnant: 380 mg per day nervous system abnormalities in infants, includ- Age 31–50, nursing: 320 mg per day ing neural tube defects,80 81 as well as low birth Tolerable upper intake level (UL): weight infants82–84 and toxemia of pregnancy.85 Do not exceed 400 mg per day during pregnancy Supplementation, especially if zinc levels are low, Food sources: honey, almonds, barley, dried fruits, potatoes is recommended to reduce the risk of fetal and 86 Herbal sources: alfalfa, dandelion, seaweed (dulse), maternal complications. In one study, labor watercress (avoid in first trimester) complications (vaginal bleeding, fetal acidosis, uterine inertia) were improved.87 Another study PREGNANCY 285 showed a lower incidence of pregnancy-induced immune system have all been associated with ade- hypertension (which is associated with pre- quate intake of docahexaenoic acid (DHA) during eclampsia and preterm labor).88 Some food the development of the fetus. sources of zinc are oysters, beets, broccoli, wheat Essential fatty acids have a unique role during germ, wheat bran, fish, lentils, and watercress pregnancy because of the rapid cell growth and (avoid in the first trimester). Herbs are garlic, development of new tissues and new organ sys- ginger root, and parsley. tems in a developing fetus. Fetal development is associated with a high EFA requirement, and this Zinc supply is dependent on the amount and availability of EFAs from the mother. Infants born of Recommended dietary allowance (RDA): mothers with low DHA levels have shorter atten- Pregnant: 15 mg per day tion spans,91 and this may have long-term effects Nursing: 15 mg per day Tolerable upper intake level (UL): on future learning, development, and perform- Age 18 and younger, pregnant or nursing: 34 mg per ance. Children born to mothers who had taken day 10 ml per day of cod liver oil during their preg- Age 19 and older, pregnant or nursing: 40 mg per nancy and lactation had higher IQs at age four day compared to those born to mothers who had Food sources: beets, broccoli, fish, lentils, oysters, taken corn oil or placebo.92 wheat bran, and wheat germ Maternal levels of omega-3 fatty acids, espe- Herbal sources: garlic, ginger root, and parsley cially DHA, decrease during pregnancy.93 EFAs are components of breast milk, and maternal levels may be reduced further in nursing women. Bioflavonoids. Bioflavonoids are beneficial For the fetus, a deficiency of EFAs, particularly for women who have recurring miscarriages. eicosapentaenoic acid (EPA) and DHA, may lead When placed on citrus bioflavonoids daily as soon to a poorly developed central nervous system. as a period was missed, many stopped aborting.89 EFA deficiency may also lead to intrauterine One study demonstrated that previously Rh- growth retardation leading to a lower body immunized mothers treated with bioflavonoids weight and slower growth of the brain. Supple- during their pregnancy delivered babies who were mentation with a daily complex of essential fatty less erythroblastotic than expected.90 acids and fish oils during pregnancy provides Omega-3 and Other Fatty Acids (EFAs). vital nutrients that supply the necessary EFAs for There is a growing body of evidence about the the increased nutritional and metabolic demand importance of omega-3 fats for human health and throughout the nine months of gestation. Fish development, not the least of which starts with oil supplementation has been shown to improve infant exposure during fetal development. Doca- the DHA status of not only infants at birth but hexaenoic acid (DHA) is an important component mothers too.94 Other research has shown that of phospholipids in the central nervous system and supplementation with fish oils is a good means of is found in high amounts in the retina, about 25 improving omega-3s in pregnant women95 and percent. DHA makes up 12 to 20 percent of the of improving the DHA status in breast milk.96 fatty acids in the gray matter of the cortex of the Trials on omega-3 fatty acids conducted in brain and in the brain stem. Inadequate intake of pregnant women have shown a significant reduc- omega-3s has significant implications for both tion in the incidence of premature delivery.97 In mother and infant. The development of the central one such study, fish oil was investigated for its nervous system, the brain, the eyes, and the effects on pregnancy duration, birth weight, 286 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE intrauterine growth restriction, and pregnancy- induced hypertension105 (associated with pre- induced hypertension.98 Omega-3 fatty acid sup- eclampsia and preterm labor). plementation of 2.7 grams per day was compared There is some evidence that evening primrose to olive oil and/or no supplement. The fish oil (EPO), taken both orally and vaginally, can oil–supplemented pregnancies lasted four days be used to promote the preparation of the cervix longer and birth weight was 107 g greater. In for the birth (cervical ripening). Clinically, EPO another study, infants born of mothers who had supplementation during pregnancy has been been given cod liver oil had higher levels of DHA found by practitioners of natural childbirth to be in their umbilical cord, longer gestational length an efficacious method to stimulate cervical ripen- (longer to develop in the uterus), and more ing during labor, and the prostaglandin PgE1 is mature brain functioning measurements on the known to stimulate cervical ripening and hasten second day of life.99 Fish oil also appeared to be the progression of labor.106 Although practitioners related to a reduction in the risk of preterm deliv- using this supplement report no adverse effects, ery in those women who had had a previous a retrospective trial comparing the oil to no sup- preterm delivery. There was no effect of fish oil plement did not note a difference between groups, on intrauterine growth restriction or pregnancy- and there was a suggestion that there was an induced hypertension.100 In addition, this study increased incidence of premature rupture of mem- reported that preterm delivery and low birth branes, labor augmentation, and assisted vaginal weight of the infants occurs when little to no delivery in the evening primrose oil group.107 omega-3 fats from fish or fish oil are consumed. The main food sources of essential fatty acids A more recent study of pregnant women in are raw seeds and nuts or fish. Whole and ground Iceland showed that consuming liquid cod liver flaxseed and purified flaxseed oil are excellent oil in the first 15 weeks of pregnancy resulted in sources of the two essential oils, linoleic acid and babies with higher birth weight.101 Higher infant linolenic acid. Borage oil and black current oil birth weight is related to a lower prevalence of can be taken in capsule form as nutritional sup- cardiac disease, high hypertension, and glucose plements. It should be stated, though, that all intolerance in the future.102, 103 Additional good seed oils are not the same in their makeup of news was that the women did not gain more essential fatty acids, and substituting a seed oil weight, despite their consumption of increased does not necessarily give the same benefits as the calories and fat from the oil. fish oils and vice versa. Hormone-like substances called prostaglandins Although research clearly shows that moder- are also involved in the development and clinical ate EFA supplementation is beneficial and safe expression of preeclampsia. These prostaglandins for pregnant women, caution should be exercised are modulators of vascular smooth muscle tone when consuming large doses. Also, there may be and platelet aggregation (blood platelets sticking some caution about increased fish intake and together). Preeclampsia is characterized by environmental contamination. The U.S. Food increased vasoconstriction, frequently associated and Drug Administration and the Environmen- with increased platelet aggregation, reduced utero- tal Protection Agency advise that pregnant and placental blood flow, and premature delivery. In a nursing mothers and young children avoid certain placebo-controlled clinical trial, a group of preg- types of fish and shellfish and limit others. In nant women receiving a combination of evening part, this may be due to the methylmercury con- primrose oil and fish oil had a significantly lower tent in fish such as albacore tuna, shark, sword- incidence of edema.104 Evening primrose oil has fish, king mackerel, and tilefish. Methylmercury also been shown effective in preventing pregnancy- is a known neurotoxin. PREGNANCY 287 Supplementing with fish oils should be done Phosphatidylcholine (PC). PC is a primary with purified fish oil supplements, which can component of lecithin, sometimes referred to as reduce or practically eliminate exposure to mer- pure lecithin, from which dietary choline is cury, PCBs, dioxins, and pesticides. Due to how derived. Dietary choline, after absorption by the we have contaminated our ocean waters and the intestinal mucosa, is metabolized in the liver to wildlife that inhabits these waters, high-quality choline, a critical nutrient for brain and nerve fish oils supplements may in fact be a safer alter- development and function. In mammals, amni- native to fish in food form and enable us to gain otic fluid has a tenfold greater concentration of the benefits of omega-3s while reducing the risk choline than that in maternal blood,113 and at of toxicity.108, 109 birth, all mammals studied have plasma choline concentrations much higher than those found in Omega-3 Fatty Acids adults.114 When rats were supplemented with choline, the spatial memory of their offspring No recommendations have been established by the FDA but the International Society for the Study of was permanently enhanced, and they showed Fatty Acids and Lipids recommends 2.87 mg per day more accurate performance on both working and of omega-3 fatty acids with a minimal intake of 300 reference memory components of tasks. From mg per day of DHA for pregnancy or lactation. these studies,115 researchers believe that choline is Food sources: fish high in omega-3 fatty acids include critical for optimal brain development, and tuna, salmon, sardines, mackerel, and herring (see therefore supplementation is suggested. precautions in text); other sources include flaxseed, No recommended dose available. hemp seeds, sunflower seeds, walnuts, almonds, and filberts Lecithin. Lecithin, a derivative of the soybean, is needed by the brain to function properly and helps to break down fatty cholesterol Coenzyme Q10. Coenzyme Q10 is a fat- deposits in the body. Lecithin contains phospho- soluble quinone occurring in the mitochondria rus and stimulates the metabolism. Lecithin is of every cell that is a cofactor in the electron also found in fertile eggs, soy products, and, in transport chain on which most cellular functions small amounts, in all vegetables that have been rely, making it essential for the health of virtually vine ripened. all human tissues. Plasma levels of this enzyme No recommended dose available. rise during normal pregnancy, reaching highs of Taurine. Taurine is an amino acid found 50 percent above normal by the 36th week. widely distributed in foods of animal origin Decreased levels have been linked in studies to (but not milk or milk products). Taurine is spontaneous abortion and threatened abortion, biosynthesized from methionine or from cysteine particularly before 12 weeks.110 during the metabolic process, and disturbances No recommended dose available. in enzymatic reactions that take place in this Methionine (SAM). Methionine is a compo- process can lead to mental retardation. Vegetar- nent of many proteins, serving as a source of ian mothers who consume no meat products available sulfur for synthesizing both cysteine during their pregnancy, and therefore have a and taurine, crucial to cellular metabolism. Sup- low-taurine diet, as well as others on a protein-, plementation with methionine in mice reduced methionine-, or vitamin B6–deficient diet might neural tube defects by 47 percent111 and also pos- be at particular risk.116 itively affected birth weight and size.112 Although dietary deficiency of taurine has No recommended dose available. not been demonstrated to impact fetal develop- 288 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE ment in humans, researchers recommend that leaf. The root or the leaf can be taken as a tea, in vegetarian women who intend to have children capsule form, or as a liquid tincture (a mixture of optimize dietary levels of protein and vitamin B6, plant, alcohol, and water). It can be safely taken since there is no taurine present in plants and throughout pregnancy as a tonic or to address vegetables. Meat eaters are advised to eat only one of the indicated specific problems associated organic or “free-range” animals in order to avoid with pregnancy. the high concentrations of hormones and pesti- False Unicorn (Chamaelirium Luteum). cides found in animal products in industrialized False unicorn has traditionally been used as a countries. uterine tonic before, during, and after pregnancy, No recommended dose available. especially for women who have a history of miscarriage. Similar to dandelion, it is used to sup- Botanicals port liver and digestive function. Due to its bitter There are many herbs that can be used safely taste, this herb is probably best tolerated in cap- during pregnancy. Some herbs are characterized sule or tincture form rather than as a tea. as tonics, others are spices that improve taste and Ginger (Zingiber Officinale). Ginger is digestion, other herbs contain specific vitamins probably best known for its treatment of nausea and minerals that aid different organ systems, and vomiting, whether pregnant or not. There and still others can be used as medicines to inter- have been several good scientific studies on the vene and treat conditions or illnesses related to use of ginger in nausea of pregnancy and the the pregnancy. However, there are some herbs more severe state called hyperemesis gravidarum that are commonly contraindicated for use (severe nausea and vomiting during pregnancy). during pregnancy. Although some of these herbs In these studies, ginger brought about a signifi- may be used in very small amounts for specific cant reduction in both the severity of the nausea conditions, it is prudent to avoid them unless and the number of attacks of vomiting in the under the supervision of an expert in herbal majority of the patients. In all of these studies, medicine. Some of these contraindicated herbs there were no adverse effects on pregnancy and can be used safely late in the pregnancy or during pregnancy outcome. In fact, in the most recent labor with the guidance of an experienced practi- study of 70 women, there were three sponta- tioner (see the following sidebar). neous abortions in the placebo group and only The following herbs are some of the most one in the ginger group. More full-term pregnan- common medicinal plants used in traditional cies occurred in the ginger group than in the herbal practice for promoting and maintaining placebo group as well. No infants had any con- health during pregnancy. genital anomalies.118 Dandelion Leaf and Root (Taraxacum In a double-blind, randomized, crossover trial Officinale). Dandelion is a potent source of vita- that studied the effectiveness of ginger in hyper- mins and minerals, especially vitamin A, cal- emesis gravidarum, the most severe form of cium, potassium, and iron. Mildly diuretic and pregnancy-related nausea and vomiting, early in stimulating to bile flow, dandelion leaf helps with pregnancy, 250 mg of ginger root powder taken the inevitable digestive complaints of pregnancy, four times a day significantly reduced the severity and its root cleanses and tones the liver.117 In of the nausea and the number of attacks of vom- early pregnancy, dandelion can help to alleviate iting in 19 of 27 women.119 Ginger is safe to use nausea, upset stomach, and indigestion. As a at any time during pregnancy and is a welcome diuretic, the most active part of the plant is the alternative to some of the antinausea pharmaceu- PREGNANCY 289

Herbs Contraindicated During Pregnancy

The following herbs should not be Cascara sagrada (Rhamnus Mandrake (Podophyllum taken during pregnancy: purshiana) peltatum) Alder buckthorn (Rhamnus Coltsfoot (Tussilago farfara) Mistletoe (Viscum album) frangula) Cowslip (Primula veris) Mugwort (Artemesia vulgare) Aloe (Aloe vera) Damiana (Turnera aphrodisiaca) Nutmeg* (Carum petroselinum) Angelica (Angelica archangelica) Dong quai (Angelica sinensis) Pennyroyal (Mentha pulegium) Arnica (Arnica montana) Ephedra (Ma huang) (Ephedra vul- Periwinkle (Vinca spp.) Autumn crocus (Colchicum garis) Peruvian bark (Cinchona spp.) autumnale) Feverfew (Tanacetum Pleurisy root (Aesclepius tuberosa) Barberry (Berberis vulgaris) parthenium) Poke root (Phytolacca americana) Bethroot (Trillium spp.) Ginseng (Panax quinquefolium) Rhubarb (Rheum palmatum) Black cohosh (Cimicifuga Goat’s rue (Galega officinalis) Rue (Ruta graveolens) racemosa) Goldenseal (Hydrastis Sage* (Salvia officinalis) Blessed thistle (Carbenia canadensis) Sarsaparilla (Smilax officinale) benedicta) Gotu kola (Hydrocotyle asiatica) Senna (Cassia senna) Bloodroot (Sanguinaria Ipecac (Ipecac ipecacuanha) Shepherd’s purse (Capsella canadensis) Juniper berry (Juniperis bursa-pastoris) Blue cohosh (Caulophyllum communis) Stillingia (Stillingia sylvatica) thalictroides) Licorice (Glycyrrhiza glabra) Tansy (Tanacetum vulgare) Broom (Sarpthamnus scoparius) Lily of the valley (Convallaria Thuja (Thuja occidentalis) Butternut (Juglans canadensis) majalis) Wormwood (Artemesia Calamus (Acorus calamus) Lobelia (Lobelia inflata) absinthinum) Calendula (Calendula officinalis) Male fern (Dryopteris filix-mas) Yarrow (Achillea millefolium)

*Small amounts of nutmeg and sage used in cooking are OK. Note: Some of the herbs listed may be recommended by a licensed practitioner with expertise in the use of botanicals during pregnancy and labor. ticals, which may be associated with teratogenic- pregnancy, nettle can help to improve energy, ity (physical defects in the fetus in utero). strengthen the blood vessels, reduce varicose veins, Information that has appeared in the writings alleviate leg cramps, prevent anemia, and decrease of traditional herbalists and the lay press or the likelihood of hemorrhage during childbirth. herbal resources about the danger of ginger This is an herb that can be taken in all forms, during pregnancy appears to be out of date and including freshly picked young leaves and as a leafy not based on scientific facts. Select sensitive indi- green addition to steamed vegetables or salads. viduals may get some stomach-burning sensa- Partridgeberry (Mitchella Repens). Par- tions when using ginger. Taking it with food will tridgeberry or squaw vine is considered one of most likely relieve that discomfort. the best uterine tonics. It should be taken for Nettle (Urtica Dioica). Nettle is one of the several weeks before the due date. Squaw vine is best herbs to use in pregnancy due to its appre- often used in combination with raspberry leaf. It ciable amounts of vitamins and minerals, includ- can be taken as a tea, in capsule form, or as a ing calcium and iron. Used throughout the tincture. 290 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Red Raspberry (Rubus Idaeus). Red rasp- betes, and herpes are all potentially teratogenic berry leaf is the most often mentioned traditional agents and able to cause loss of a pregnancy, birth herbal tonic for general support of pregnancy defects, or pregnancy complications. Pesticides and breast-feeding. Rich in vitamins C and E and other contaminants found in the environ- and minerals, especially high in naturally ment (including our food and water) can disrupt chelated iron (which is well assimilated), it tones the hormonal and chromosomal cycles, leading the uterus, increases the flow of milk, and to breaks in the DNA and a wide range of defor- restores the reproductive system after childbirth. mities and abnormalities in all animal species, Raspberry leaf contains fragrine, an alkaloid that including humans. gives tone to the muscles of the pelvic region, including the uterus itself. In addition to tonify- Alcohol ing the uterus, raspberry is used to prevent hem- Alcohol consumption during pregnancy is an orrhage. It deserves its reputation as a pregnancy established cause of serious birth defects and herb par excellence. developmental delay, described as fetal alcohol Wild Yam (Dioscorea Villosa and Bar- syndrome (FAS). FAS is caused by in utero basco). Wild yam can be used to help prevent alcohol-induced damages and results in mental miscarriage due to its calming and antispasmodic retardation. Infants born with FAS have facial action on the uterus. Even though wild yam has abnormalities and slow growth. They show acquired a considerable reputation as a “female impairment in their intellectual development herb,” perhaps its most traditional uses are as a and have difficulties in learning, memory, prob- digestive aid in treating nausea, as an antispas- lem solving, and attention span. They can also modic for intestinal and gallbladder colic, and as experience mental health problems and difficul- a liver herb. This herb is best used in capsule or ties with social behaviors.120 It is estimated that tincture form. To help prevent miscarriage, the prevalence of FAS in the United States higher doses of the tincture can be used (1⁄4 to 1⁄2 ranges between 0.3 to 2.2 per 1,000 live births. teaspoon every three to four hours). Much higher rates can occur in some communities. The focus should be on prevention and SUBSTANCES TO AVOID aggressively promoting no alcohol use during DURING PREGNANCY pregnancy. Besides supplementing with multivitamins, min- Even mild alcohol ingestion during pregnancy erals, and other appropriate nutrients, a pregnant is said to result in hyperactivity, short attention woman improves her chances for a complication- span, and emotional problems in children.121 free pregnancy and birth by avoiding harmful Alcohol consumption during pregnancy con- substances such as alcohol, caffeine, nicotine, tributes to birth abnormalities whether the mother and recreational and prescription drugs. Terato- drinks a little or a lot.122 There are two periods of gens are substances that cause birth defects, mis- pregnancy when the maternal consumption of carriage, or pregnancy complication when a alcohol is particularly threatening to the develop- pregnant woman is exposed to them, especially ment of the fetus: from the 12th to the 18th week in the early stages of pregnancy. Environmental and from the 24th to the 35th week. Three or four chemicals such as mercury and lead, many pre- beers or glasses of wine a day can cause any one or scription drugs such as Dilantin and Accutane, more of the following defects: mental retardation, recreational drugs including cocaine and alcohol, hyperactivity, a heart murmur, facial deformity and even some illnesses including rubella, dia- such as a small head, or low-set ears.123 PREGNANCY 291 Cigarettes The more a woman smokes, the greater the The sad news is that more than 20 percent of risk to her baby. However, if she stops smoking women in the United States smoke. The num- before the end of her first trimester, she is no more bers are similar in other developed countries and likely to have a lower birth weight baby than a only slightly lower in developing countries. nonsmoking woman. Even stopping by the third Unfortunately, many of these women also smoke trimester can improve the baby’s growth. during pregnancy—about 11 percent. Not only The good news is that it is possible to stop does smoking harm a woman’s long-term health, smoking and there are numerous resources to it can increase numerous complications and help you. The National Partnership to Help cause serious problems for newborn infants. Pregnant Smokers Quit provides information for According to statistics, we could reduce the rate women and resources for health-care profession- of stillbirths by 11 percent, and newborn deaths als. The American Legacy Foundation is another by 5 percent, if all pregnant women stopped organization that helps smokers quit. Smoke smoking.124 free.gov is an online resource for individuals who Cigarette smoke contains more than 2,500 want to stop smoking that is sponsored by the chemicals, and both nicotine and carbon monox- federal government. The American College of ide are thought to be related to adverse outcomes Obstetricians and Gynecologists provides good in pregnancy. Smoking nicotine has been associ- information for health-care providers to offer ated with several complications of pregnancy. It assistance to their patients. There are many other appears to double a woman’s risk of developing additional resources as well, and some may be placental problems,124 including placenta previa (a local to your community. low-lying placenta that covers part or all of the Caffeinated Beverages opening of the uterus), placental abruption (the placenta peels partially or completely away from A small amount of caffeine will probably not be the uterine wall prior to delivery), and premature harmful for most women and their infants. How- rupture of the membranes. Cigarette smoking is ever, there are some studies of concern. Caffeine known to cause lower birth weight and size; moth- has been shown to contribute to growth-retarded ers who smoke 13 or more high-tar cigarettes a or low–birth weight infants.128 Researchers have day have smaller babies in poorer condition than suggested that women limit their intake of caf- those of nonsmoking mothers.125 Smokers have a feine to approximately 300 mg per day during miscarriage rate twice as high as that of nonsmok- pregnancy, and since caffeine is known to enter ers,126 and babies born to mothers who smoke breast milk, that level might be appropriate for have more than double the risk of dying of sudden nursing mothers as well.129 One cup of regular infant death syndrome.127 coffee contains about 120 mg of caffeine. Even Women who smoke may experience more with this limited amount, the coffee or tea ectopic pregnancies (a potentially dangerous sit- should be organic in order to avoid the pesticides uation in which the fertilized egg attaches to, and used in agricultural processes. grows on, the fallopian tube outside the uterus). Children of smokers may have far more respira- Pesticides and Environmental Hazards tory illnesses (like asthma) than those of non- Environmental factors are becoming more and smokers. Even secondhand smoke is seriously more problematic to each generation of pregnant harmful to mother and baby and should be women, as many artificial compounds (such as avoided when possible. PCBs from plastics) build up in the environment 292 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE over time without degrading, become part of Over-the-Counter and the food chain, and are incorporated into our Prescription Drugs bodies. Theo Colburn’s groundbreaking study Seemingly harmless over-the-counter drugs like of the links between pesticides, PCBs, and other aspirin, taken by mothers in the first half of organochlorides in the food chain and hormonal the pregnancy, have been linked to lower-than- disruption and birth defects makes clear that average IQs in their offspring.136 Valium oil whatever an individual woman can do to avoid administered to egg-laying chickens induced these compounds in her food and water is well impaired muscle cell development, suggesting 130 worth doing. Because humans are high on the potential harm from the use of Valium in preg- food chain, the effects of these compounds on nancy.137 Medications such as lithium (used to human reproduction are potentially exponential treat bipolar disorder, formerly called manic and devastating. depression) and tetracycline (an antibiotic) can Hazardous substances such as pesticides, lead, harm the fetus; if at all possible, avoidance of and other chemicals brought home from the work these substances is recommended. Some anti- environment on a parent’s clothing can harm an seizure medications are folate antagonists and, as 131 unborn child. Also potentially harmful to the such, can increase the risk for fetal neural tube fetus are the mother’s exposure to x-rays during defects unless folic acid supplementation is pregnancy or the father’s preconception exposure implemented along with the medication.138, 139 to x-rays.132 One study showed that high amounts In addition to the products already men- of lead and barium in drinking water caused an tioned, herbalist Susun Weed provides the fol- increased risk of miscarriages.133 Elevated lead in lowing list of products to avoid: DES the body has also been linked to preeclampsia134 (diethylstilbestrol), laxatives, pHisoHex (or any- and lower birth weight. thing else containing hexachlorophene), hair Mercury has received perhaps the most atten- dyes, phenobarbital, barbiturates, tranquilizers, tion of any of the pesticides and heavy metals. epinephrine (adrenaline) shots, sulfa drugs, Methylmercury crosses the placenta and can antibiotics, vaccines, anesthetics, mercury vapors impair the development of the central nervous in dentists’ offices, steroids, hormones, and system in the fetus. As a result, the federal Accutane (an acne medication).140 government has issued guidelines regarding fish Your health-care practitioner can make avail- intake for pregnant women and for all age able a full list of over-the-counter and prescrip- groups. The intake of fish appears to be strongly tion medications rated in terms of safety and side correlated with the concentration of mercury in effects for the fetus during pregnancy and for the hair, and it has been observed that women in infant during lactation. Please ask your health- states with fish advisories who ate 20 or more care provider(s) before taking any over-the- servings of fish in a three-month time span had counter medication, prescription medication, or mercury concentrations in their hair that was herbal and nutritional supplements. sevenfold higher than those of women who ate no fish. The majority of these women exceeded the recommended limit for lead.135 Canned alba- Recreational Drugs core tuna (or white tuna) and tuna steaks are Before conception and during pregnancy, espe- generally considered to be higher in mercury cially the first trimester, it is important to avoid than light canned tuna. The USFDA currently using recreational drugs, even those that may recommends that pregnant women eat no more seem harmless at other times, as consequences to than six ounces of fish per week. a developing fetus may be serious. Genetic mate- PREGNANCY 293 rial can be damaged by marijuana, for example; COMMON COMPLAINTS AND in animals, it has been linked to an increase in DISORDERS OF PREGNANCY 141 fetal deaths and malformations. Cocaine may Most problems experienced during pregnancy are a decrease sperm concentration in semen, induce result of the immense hormonal changes, nutri- deformities in the shape of the sperm, and reduce tional deficiencies, and shift in weight distribution 142 the motility after ejaculation. Men’s precon- that happens as a result of sudden weight gain. ceptual use of cocaine has been linked to cases of Backache, digestive discomfort, fatigue, swelling, neurological damage in children. and mood changes are almost inevitable. With the judicious use of rest, exercise, and EXERCISE nutrition, most women can successfully weather The appropriate take-home message on exercise the hormonal roller coaster ride of pregnancy. during pregnancy is not that women should exer- Walking a mile a day is unanimously recom- cise during pregnancy but that they may. Too often, women have heard that maybe they should limit their exercise. It is not necessary to be so Safety Tips for Exercising While Pregnant restrictive in exercise during pregnancy, although 1. Drink enough water or other fluids during and certain precautions should be observed. Despite after exercise to prevent dehydration and conflicting opinions, information on exercise hypovolemia. and pregnancy is plentiful, and its message is 2. Wear clothing that allows for adequate ventila- clear: low-impact, moderate exercise is safe tion and prevention of hyperthermia while exercising. during pregnancy. 3. Your exercise regimen should emphasize low- In certain instances, exercise can prove bene- impact activities, such as stationary bicycling, ficial to the pregnant woman and her child. Exer- swimming, walking, and low-impact aerobics. cise can reduce the length of hospitalization, 4. Do not exercise if you have a fever. reduce the incidence of cesarean section, and 5. Supine exercise (exercises in which you lie on your back) should be avoided, especially in the result in a healthier baby with a higher birth third trimester, as they may reduce blood supply weight. The advantages also extend to the preg- to the fetus. nant mom to be. Women who exercise during 6. Exercises that require repetitive bouncing and pregnancy seem to do a better job at maintaining jerky movements and exercises requiring balance their ideal body weight after pregnancy and have should be avoided, especially in the third trimester. less discomfort during their pregnancy. 7. Activities that involve potential low-oxygen See the sidebars for some helpful guidelines states, such as scuba diving and mountain for exercising during pregnancy. climbing, are contraindicated. 8. Be sure to follow a diet that emphasizes com- Contraindications to plex carbohydrates to replace muscle glycogen Exercise During Pregnancy lost during exercise, thereby minimizing the risk of fetal ketosis (elevated ketones in the body There are instances when exercise should be tissues). avoided during pregnancy. These include: pre- 9. Participation in competitive team sports is eclampsia, pregnancy-induced hypertension, acceptable in the first 15 weeks of pregnancy, toxemia, preterm rupture of membranes, history although there are potential but unproved risks for fetal loss from pelvic trauma, abdominal of preterm labor, persistent second or third trauma, or both. trimester bleeding, incompetent cervix, or signs of 10. Avoid exercises such as weight lifting, especially intrauterine growth retardation. in the third trimester. 294 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Tips for Safe Weight Summary of Exercise Guidelines Training During Pregnancy 1. Regular frequency of exercise is preferable to 1. Do not compete, not even with yourself. sporadic physical activity. 2. Begin with very light weights. 2. Guidelines for exercising safely during pregnancy 3. Avoid holding your breath while lifting. Breathe should be followed. (See other sidebars in this in during relaxing part of exercise and breathe section.) out during effort part of exercise. 3. Intensity of exercise should be monitored 4. Rest between exercises. according to symptoms, and exhaustive exercise 5. Take a mouthful of pure water between should be avoided. exercises. 4. Adequate caloric and nutrient intake should be 6. Do not lift while lying on your back. Pregnant maintained. women should not lie on their backs while exer- 5. Adequate hydration, proper clothing, and avoid- cising, especially after the sixth month, because ance of hot, humid environments should aug- blood supply may be reduced to the fetus. ment heat dissipation, especially in the first 7. Stay cool. Exercise increases body temperature, trimester. which may threaten the health of the fetus. Keep your temperature below 100 degrees. Dress lightly in warm weather. although it may be linked to an increase in thy- 8. Warm up for three to five minutes before per- roid hormone (T4) effects on smooth muscle forming weight-lifting exercises. (See “Joint Warming Exercises” in Appendix A.) relaxation in the stomach. Physical exercise, espe- 9. Perform a few basic stretches of muscles used cially walking, is recommended for morning during the exercise session at the end of the sickness. Low blood sugar is implicated in the workout. (See Appendix A.) nausea of early pregnancy and can be regulated 10. See Appendix A for the “Speak Pregnancy by eating smaller meals more often, eating high- Exercises.” protein snacks before sleeping, and eating unsalted crackers or matzo before getting out of mended by researchers and birth supporters, as is bed in the morning. eating healthy (preferably organic) foods every Insufficient B vitamins may be associated day (including protein, whole grains, fruits, and with morning sickness; pregnant women are vegetables). I recommend that if a pregnant often deficient in B6 as well as folic acid (the need woman eats meat and/or dairy products, these for which increases during pregnancy). Foods should be “free range” and organic, or at least free rich in B vitamins—such as nutritional yeast, from the artificial hormones and pesticides used yogurt, bee pollen, spirulina, wheat germ, whole in the agricultural processes. Dairy products have grains, egg yolk, cabbage, and organic organ some of the highest concentration of estrogen- meats—might be sufficient to alleviate morning mimicking artificial compounds and growth hor- sickness; if not, a B-50 vitamin supplement may mones. Xenoestrogens from pesticides are also be needed during the first trimester. suspected of causing genetic damage. Anise, fennel, peppermint, chamomile, or spearmint teas are all helpful; raspberry leaf tea, Morning Sickness sipped before getting out of bed in the morning, One of the first and perhaps most annoying com- may help. Wild yam root, according to herbalist plaints of pregnancy is the nausea (and vomiting) Susun Weed, is “specific and powerful for nausea of “morning sickness,” which generally stops of pregnancy.”140 As we discussed earlier in this being a problem after the first trimester. No one chapter, studies have shown ginger root to be really knows what causes morning sickness, extremely effective in the treatment of the nausea PREGNANCY 295 and vomiting of severe morning sickness. Start Preeclampsia or Eclampsia (Toxemia) with 250 mg of ginger root powder four times Preeclampsia is a dangerous condition that may daily; increase if necessary. Fresh ginger root tea develop in the third trimester of pregnancy. It can be made by simmering slices of ginger root in includes hypertension (high blood pressure), boiling water for 15 minutes. Add honey to taste. edema, and protein in the urine. About 6 percent Chronic Miscarriage/Abortion of all pregnant women will develop preeclampsia sometime after completing 20 weeks of gesta- Ten percent of first trimester pregnancies end in tion; eclampsia occurs in 0.1 percent of cases.143 spontaneous abortion or miscarriage. Women Western medicine believes that there is no who miscarry always feel guilty; they often feel way to prevent preeclampsia but that it can be responsible for the miscarriage. The fact is, how- kept from progressing to eclampsia with good ever, that nature is not perfect; all conceptions prenatal care. Herbalist Susun Weed disagrees, are not destined to become a child. Having two calling preeclampsia “the result of malnutrition miscarriages—even in a row—is not necessarily during pregnancy,” and says it is easily prevented abnormal. The causes of miscarriage include by eating 60 to 80 grams of protein daily, getting unknown factors, stressors, environmental factors enough salt, foods high in calcium, adequate (toxic substances in food, water, and air and pollu- calories, and nourishing herbal supports like tants in the workplace), smoking, drinking alco- raspberry, nettle, and dandelion leaves through- hol, dietary deficiencies, and fetal abnormalities. out pregnancy.140 The Harvard Guide to Women’s As discussed earlier in the nutrition section, low Health links preeclampsia to very young or much zinc intake has been associated with spontaneous older women (over 45), women with underlying abortion and premature delivery, and vitamin E medical problems (high blood pressure, kidney supplementation and bioflavonoids may help to disorders, autoimmune disorders, and diabetes), prevent miscarriage. In addition, Susun Weed lists and multiple births.144 the following herbs as being used in traditional Once preeclampsia is diagnosed, a skilled 140 herbal medicine for preventing miscarriage: professional must be called in to help manage the treatment, since the condition is serious enough • Black haw root. This is especially effective. to threaten the mother’s life and damage the Drink one or two cups of tea or one-half fetus. Potassium levels must be increased (in cup of infusion daily as soon as pregnancy is addition to prescription potassium, eating potato known; use throughout entire pregnancy if peels and bananas helps; also mint, chicory, and desired. dandelion leaves). The sodium-potassium ratio • False unicorn root. This is recommended needs balancing (drink raw beet juice, up to four especially for women who have experienced ounces daily); supplement with B6 in conjunc- repeated miscarriages. Take three drops of tion with a high-potency B-complex vitamin; eat tincture four to five times daily from pre- spirulina; and add seaweed to your daily diet. conception through the first trimester. The Harvard Guide expresses the current allo- • Wild yam root. For threatened miscarriage, pathic medical perspective when it states unequiv- make a strong tea by steeping one teaspoon ocally: “The only definitive cure for preeclampsia of wild yam root in two cups hot water for is delivery of the baby.”144 However, women with 15 minutes; take two to four ounces every preeclampsia are generally sent to bedrest unless 30 minutes. The tincture is less effective and the diastolic blood pressure is greater than 100 may induce nausea or vomiting. with bedrest. If significantly preterm, efforts are 296 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE made to confirm fetal maturity or mature fetal Varicose Veins lungs medically before delivery. Usually the earlier Varicose veins can occur in the legs or in the anal in the pregnancy that pregnancy-induced hyper- or vulvar areas in pregnancy, due to hormonal tension occurs, the more severe it becomes. The softening of the muscular walls of the veins com- majority of cases at term are usually benign and bined with the extra weight of pregnancy. Simple easily managed. Catastrophic outcomes of tox- yoga and other nonstressful exercise can help by emia include seizures, strokes, and failure of the improving circulation from the lower body up to heart, liver, lungs, or kidneys. the trunk; it is also good to get your weight off Since preeclampsia is characterized by high your legs and put your feet up whenever possible. blood pressure, it stands to reason that yoga, A lack of nutritional elements in the diet, meditation, and stress reduction techniques especially vitamin C, rutin, and other bioflavo- would be a useful complement to nutritional, noids, combined with the extra stress on the cir- botanical, and conventional medications. culatory system, can cause the fragile capillaries Heartburn, Gas, and Constipation to break. A tendency toward varicose veins and hemorrhoids may also be inherited. Eat foods Hormonal imbalances during pregnancy may high in vitamin C and bioflavonoids, such as result in softening of the smooth muscle found in buckwheat, nettles, rose hips, oranges, lemons, the walls of the digestive tract. The consequent grapefruit, peppers, whole grains, hibiscus flow- reduction in peristaltic movement causes food to ers, and the white rinds of organically grown pass more slowly through the esophagus, stom- citrus fruits; also include garlic, onion, chives, ach, and small and large intestines to the rectum, and leeks. These help maintain elasticity in the inducing gas and constipation. Heartburn can be veins and capillaries. Lecithin, vitamin E, and caused by the softening of the muscular valve rutin supplements are also recommended for pre- between the esophagus and the stomach so that venting and repairing varicose veins. partially digested, acidic food may leak back up into the esophagus, causing a burning sensation in Backache the chest. Heartburn and constipation are gener- It may not be possible to find an herb that is safe ally experienced in the later stages of pregnancy. during pregnancy that is also a good treatment Susun Weed140 and Rosemary Gladstar145 for backache. Gentle yoga stretches; walking and emphasize eating small meals frequently, chewing swimming; chiropractic adjustments; physical food carefully, and avoiding acid-causing and therapy; sleeping with pillows to support the legs, greasy foods. Both recommend papaya (especially back, and belly; wearing flat heels; and getting raw, but also in tablets and papaya leaf) for the plenty of minerals can all help in easing backache. enzymes, as well as fennel and anise seeds; Glad- star also recommends cumin and dill seeds in Bladder Infections addition to the fennel and anise, suggesting an Blood volume increases 50 percent during preg- old-fashioned remedy for digestive disturbances: nancy, causing the kidneys to work harder and combine these four seeds and chew them before making the urinary system more vulnerable to and after meals. stress and infection. Especially in the last Be aware that coffee and cigarettes increase trimester, burning or frequent urination or heartburn by irritating the stomach, and remem- cramping in the abdomen may indicate a bladder ber that whole grains, fresh fruits, and vegetables infection. Many herbs and nutrients can be used combined with nonstressful exercise are the best to treat urinary tract infections, although not all solutions to constipation. of them are safe while pregnant. PREGNANCY 297 Uva ursi is safe and is one of the most effec- births are not equipped to handle complications tive herbs to prevent recurrent bladder infections such as profound fetal distress, prolapsed umbil- while also having antimicrobial activity in acute ical cords, and maternal hemorrhage. Moreover, infections. Used in leaf form, place the leaf in a these complications can be significantly wors- tea ball and place in water that has already come ened during emergency transport to the hospital. to a boil. Let it steep for five minutes, then drink Modern obstetrics was born after a time one cup every three hours for two days, then one when all births occurred at home, no matter cup three times a day for an additional week. what, and maternal mortality was substantially Vitamin C and unsweetened cranberry juice higher than now. Forceps—we now groan at can be used to acidify the urine and fight the their mention—were a lifesaving invention for infection by interfering with the ability of the mothers as well as their babies, because prior to bacteria to stick to the bladder wall. Take 1,000 their use, both mother and baby sometimes died mg of vitamin C three to four times per day of the “obstructed” pelvis, often after laboring for for up to one week. Eight to sixteen ounces of days. Life without cesarean sections was also life unsweetened cranberry juice per day is recom- with many more maternal deaths. mended. Mannose, the simple sugar contained in Where is the happy medium? How can we cranberries, is a very effective and safe treatment avail ourselves of the truly lifesaving aspects of during pregnancy. D-mannose adheres to the obstetrics and eliminate the excess? The best bladder epithelium and interferes with the ability answer I have is to be as educated as possible of infection-causing bacteria such as E. coli to about options and be open to the obstetrical real- adhere to the bladder wall.146 ity that things do not always go as we hope and Lactobacillus supplements are also safe in plan. Be flexible. If possible, have a relationship pregnancy. From the studies that are available, with a conventional provider that you see at least probiotics appear to be beneficial for preventing once during your pregnancy. recurrent bladder infections in women. See One good option is to consider hospital- Chapter 5 for further directions on treating blad- based midwife services. The midwives are very der infections. committed to natural childbirth and, unlike the typical hospital birth, are present and supportive CONVENTIONAL throughout your whole labor. They work with MEDICINE APPROACH a backup physician, someone presumably of Nothing would be better in the realm of child- their choosing. Even if the physician is called, the birth than for peace to be made between those midwife will continue to attend you as her pri- who endorse modern obstetrics and hospital mary patient and advocate for your wishes. The births and those who applaud the naturalness C-section rates for midwife-assisted births are of pregnancy and labor and prefer home birth low, their respect for the birthing process high. If when uncomplicated. There is merit in both you choose an out-of-hospital birth, be aware approaches. Like all options in health care, only that the main reasons women eventually come to the pregnant woman can decide which is right the hospital are for prolonged labor and/or for her—but with better cooperation between pain—not emergencies. Have a plan worked out the groups, her choice would be easier. for what you will do in that situation. When childbirth goes normally—which is Conventional obstetrics need not be as off- most of the time—it can be safely managed at putting as many assume. There are providers who home. Unfortunately, we have no way of know- support a woman’s wish to have her birth natu- ing if a low-risk birth will go awry, and home rally. They also support women who choose to 298 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE have their labor pains assuaged. Women are so often is to check their blood pressure. Most offered the choice of intravenous medication or women’s blood pressures goes way down in preg- epidural medication. When an epidural is given nancy. Women with chronic hypertension that at no sooner than 4 to 5 cm dilation in a woman does not stabilize at a safe level during pregnancy delivering her first child, the cesarean section rate have a higher risk of smaller, more at-risk babies. is not increased over the rate of those women The women themselves are at risk of developing who go without epidural anesthesia. the complications of hypertension, such as renal Cesarean section rates vary among physicians disease. Labor is sometimes induced at term— and institutions; it is reasonable to ask a provider 38 weeks or so—to lighten the load on mother for numbers. Around 15 percent is acceptable, and baby. although some will be as high as 20 percent; it Preeclampsia is a different hypertensive disor- depends somewhat on how “high-risk” the prac- der of pregnancy. It is most often a mild disease, tice is. Moms or babies at higher risk may need to characterized by the development of hyperten- be delivered more urgently, and therefore more sion toward the end of pregnancy. At its worst, it often by C-section. Most doctors do not take the can cause seizures or eclampsia and significant decision to operate lightly, and your doctor hematological abnormalities, including loss of should always discuss the issues with you clearly. the ability to clot blood. Kidney failure can Nothing will ever happen without your informed occur. Usually none of these things happen, but consent. You never need to have the drug Pitocin because the severity of disease does not predict to stimulate labor or any other adjunct to labor which women will have seizures, women with unless you are in agreement. I encourage women preeclampsia require protection against this risk to make their needs and wishes known in all with magnesium sulfate that is given during aspects of their health care. That is the only way labor and for 24 hours afterward. the system can become responsive to the evolving Mild forms of preeclampsia are treated with and varied needs of women. bedrest. Severe forms are treated with bedrest in the hospital. All efforts are made to avoid deliv- SEEING A LICENSED PRIMARY ering babies very prematurely. However, when HEALTH-CARE PRACTITIONER maternal health is significantly compromised, (N.D., M.D., D.O., N.P., P.A.) this measure may need to be taken. When severe, Healthy women with normal pregnancies have there is no cure for this disorder but delivery. It is the lowest risk of complications, so medical man- thought to be caused when the mother’s immune agement choices are largely personal. Most non- system is intolerant of the fetus’s foreign genetic M.D. providers use a list of criteria to determine makeup, and thus it is extremely rare to have a the low-risk or high-risk status of a pregnant second severe case in subsequent pregnancies woman. The criteria should address the mother’s with the same partner. blood pressure, the risk of bleeding, and the lie or position of the baby in the uterus, as explained in Bleeding the following sections. Bleeding is never normal in pregnancy. Although it doesn’t necessarily indicate a serious problem, Blood Pressure it must be assumed to do so until proven other- Hypertensive disorders are the most common wise. Placental abruption is a disorder in which disorder of pregnancy, affecting as many as 5 to the placenta pulls away from the uterus prema- 10 percent of pregnant women.147 One of the turely, causing bleeding and contractions that main reasons practitioners see pregnant women can be life threatening to both the woman and PREGNANCY 299 the fetus. Because the placenta is so large, a lot about half the time. Neither of these procedures can pull away before things are hugely compro- should be undertaken at home. mised, but an evaluation is in order. If the fetus measures significantly large or Placenta previa—in which the placenta small at any point, this should prompt at least an covers the opening to the cervical canal—can ultrasound. Fetal abnormalities associated with also cause significant hemorrhage and is classi- poor growth or too much or too little fluid can cally heralded by a small, otherwise insignificant present this way, and these are best prepared for “sentinel bleed.” Ultrasound can diagnose this in advance of delivery. Size discrepancy is often as easily. No pregnant woman should have a vaginal simple as an error in dating, but figuring out the exam in the third trimester without first using right due date is still very helpful. ultrasound to locate the placenta. Digital explo- The pregnancies of women with any major ration can cause significant blood loss in the case underlying health problem—such as diabetes or of placenta previa. heart or respiratory disorders significant enough to require ongoing surveillance in the nonpreg- Abnormal Lie nant state—should be managed with input from Many hospitals will support the vaginal birth of a licensed provider. So should those of women a healthy frank breech infant (butt first). with kidney disease or autoimmune disorders Footling breech—with the feet first—is unsafe like lupus or rheumatoid arthritis. All of these vaginally, because the feet can come down conditions can make a pregnancy much riskier through the partially dilated cervix—as can the for both mother and child. Ultrasound can be cord—before the entire infant will fit. An alter- invaluable in assessing fetal growth and well- native to delivering an infant in the frank breech being. Ongoing surveillance of the pregnancy position is to rotate the fetus, or rather coax the can alert the woman to any medical problems as fetus to rotate, from outside, which is successful early as possible. This page intentionally left blank PREMENSTRUAL CHAPTER 17 SYNDROME

OVERVIEW jeopardized. Most women who have symptoms When finally we understand premenstrual syn- do not seek medical care but instead self-treat, drome (PMS), we will have gone a long way making this an ideal arena for natural self-care. toward understanding the interplay between the Some 150 symptoms have been ascribed to cultural, physiologic, and emotional factors that PMS—most commonly feelings of anxiousness regularly affect women’s lives during the premen- (premenstrual tension was the first name given struum. A huge piece of work will have been to this syndrome), irritability, and anger or done toward improving women’s health. moods vacillating unpredictably among the Dr. Maria Gurevich has written, “The persist- three. Some women feel predominantly sad or ence of PMS as a medical category despite the self-deprecating, others simply fatigued and inconclusiveness of the research, suggests that lethargic. Physical changes include bloating, PMS is not simply a biomedical entity . . . it is also breast tenderness, food cravings, headache, and a complex, ideologically and culturally constructed gastric upset. No particular assortment of symp- category . . . predicated on a number of unarticu- toms is diagnostic; it is the regular recurrence lated, well-entrenched beliefs about the nature of of symptoms on a monthly basis, just before science, biology, health and femaleness.”1 the menstrual period, that matters. Symptoms Maintaining good health and attitude through usually last a few days to a week before menses, all phases of the menstrual cycle is just not as sometimes two weeks, beginning at midcycle simple as correcting female physiology gone awry with ovulation and lasting until the menses starts but also involves on some level transforming our or into the first few days of the flow. cultural image of women’s reproductive health, As important as the regular timing of the specifically menstruation, from negative (the arrival of these symptoms is the predictable relief “curse”) to positive. and complete resolution experienced with the However far-reaching these ideals, what we are onset of menses or within one to two days of the after is practical help for the woman who suffers menstrual flow beginning. PMS symptoms, premenstrually. While precisely defining PMS whatever they may be for a particular woman, go remains scientifically challenging, any woman can away completely just as regularly as they arrive. tell you what it is, and a great many will tell you Most who study this entity require that a woman that they have it. Defining terms carefully helps to be able to predict in advance for at least a couple extract “pure” PMS from an assortment of over- of cycles when symptoms will come and when lapping conditions. they will leave to warrant a diagnosis of PMS.3 Eighty percent of women experience premen- It is important to check for other possible strual emotional or physical changes, whereas sources of the symptoms that might indicate med- only about 20 to 40 percent of these women have ical conditions a woman may suffer from even difficulties as a result. A much smaller number, more dramatically in the premenstruum. Women about 2.5 to 5 percent,2 feel these changes have a who are afflicted with asthma, migraines, epilepsy, significantly negative impact on their lives to the herpes, or disordered eating,4 for example, often point where work, relationships, or home life are note a cyclic worsening, a premenstrual magnifica- 301

Copyright © 2008 by Tori Hudson. Click here for terms of use. 302 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE tion, if you will, but this is not considered to be by 75 percent.3 Blocking progesterone only using PMS. In addition, obesity has been found to be an Ru-486 did not have this effect, nor did it independent risk factor for PMS, and those with a worsen symptoms.8 It is likely that ovarian hor- body mass index of greater than 30 had a threefold mones affect the neurotransmitter, neuroen- increase in risk for PMS.5 Treatment for the under- docrine, and circadian systems that influence lying condition in these cases is more likely to mood and behavior differently in each of us. As eliminate the premenstrual aggravation than is research continues, we are learning more about treatment aimed solely at PMS. the role of neurotransmitters, neurophysiology, Among women self-presenting to PMS clin- and electrical conduction in the brain in the ics for medical care, fully 75 percent had another development, severity, and treatment of PMS. diagnosis that contributed significantly to their It is interesting to look at the work done on symptoms—major depressive or other mood dis- serotonin to appreciate the role our social envi- orders being most prominent.6 About 10 percent ronment may have on PMS. Anita Rapkin, M.D., had early menopausal symptoms, 10 percent studied serotonin levels in women with and with- were affected by hormonal contraceptives, and out PMS and found that serotonin levels fell after about 5 percent each were found to have eating ovulation in women with PMS.9 Those without disorders or substance abuse issues predominat- PMS had much higher levels of serotonin during ing. Anyone who considers her PMS to be signif- the last half of the menstrual cycle. Abnormal icantly bothersome might be wise to check with serotonin metabolism has long been linked to her practitioner should her efforts with self-care depression. Elevating serotonin levels is how the fail. There may be other, more effective treat- popular antidepressant Prozac works. ments, either for the PMS itself or for an under- There is evidence that estrogen levels affect lying condition. the serotonin system. More interesting, studies in Most women feel different emotionally and animals and humans have demonstrated how physically during the premenstruum. The term social interactions in groups can affect our sero- molimina refers to those changes women notice tonin levels. Dominant animals in groups have that let them know their menses is approaching: higher levels of serotonin, which then fall if they appetite changes, swelling, or menstrual-like are removed from their prominent position. cramps. A recurrent pattern of mild but noticeable Serotonin levels rise in the animals that replace changes provides evidence that cycles are ovulatory. them in dominance.9 Rapkin postulates that Some women enjoy positive changes: enhanced women without PMS may offset ovulation- creativity, heightened sexual desire, intellectual induced susceptibility to low serotonin and isola- clarity, and feelings of happiness and well-being.7 tion behavior through interacting more with It is difficult to identify cause in a condition “desirable others.” In other words, women able that overlaps so broadly with normal physiology, to manipulate their social environment success- affects so many, and has such a wide array of fully are less susceptible to the mood conse- symptoms. Many theories have been explored quences of low serotonin. and none found completely satisfying. Most One begins to see how our culture’s historical likely this is because there is such a complex attitude of embarrassment or distaste around men- interaction of factors both physiologic and social. struation might contribute to susceptible women’s While absolute levels of estrogen and proges- neurotransmitters being adversely affected at a terone are no different in PMS sufferers, we physiologically critical time, resulting in mood know that in women in whom both hormones swings, anger, and irritability. This is congruent are pharmaceutically blocked, PMS diminishes with the views of feminist writers who criticize the PREMENSTRUAL SYNDROME 303 medicalization of PMS symptoms as disease, argu- of women. PMDD includes a minimum of five ing that medicine has tended to pathologize specific symptoms that occur during the latter behaviors that do not conform to the unnatural part of the luteal phase of the menstrual cycle, yet pervasive female stereotype. Certainly, no right before the onset of menses.10 other named condition in women is so common According to the Diagnostic and Statistical and so little understood and yet contains so many Manual of Mental Disorders (DSM-IV), a woman significant pieces to our lives. would be diagnosed with PMDD if she experi- In the last few years, premenstrual dysphoric enced five or more of the following symptoms disorder (PMDD) has been proposed by some to during most of the week before her menses, they be a distinct entity clinically different from PMS. interfere significantly with daily life and relation- Many consider it a new psychiatric disorder. ships, and they have occurred in the last year. At Other experts believe that PMDD is simply least one of the first four symptoms must also be severe PMS with more impairment of normal life present to lead to a diagnosis of PMDD. functions. However it is classified, PMDD is 1. Significantly depressed mood, hopeless- more severe than PMS, and the diagnostic crite- ness, self-defeating thoughts ria for this severity are met by only 3 to 8 percent 2. Significant anxiety, tension, feeling KEY CONCEPTS irritable, uptight 3. Sudden mood changes of sadness, • PMS is characterized by cyclic symptoms during weepiness, or easily feeling rejected the second half of the menstrual cycle with a 4. Anger or irritability or increased conflict symptom-free phase during the first half of the with others cycle. 5. Lack of motivation for usual activities • Premenstrual magnification may manifest as an 6. Difficulty concentrating increase in chronic symptoms during the second 7. Lethargy, easily fatigued, low energy half of the cycle. 8. Changes in appetite, overeating, food • Premenstrual dysphoric disorder (PMDD) is cravings thought by some to be distinct from PMS, and by others to be a more severe form of PMS. The 9. Hypersomnia or insomnia hallmarks are when a woman experiences 5 or 10. Overwhelmed, feeling out of control more of 11 key symptoms. 11. Additional physical symptoms: breast • The best evaluation and determination of PMS is tenderness, swelling, headaches, joint or a symptom diary relating symptoms to the men- muscle pain, bloating, weight gain strual cycle. • Testing should be limited but should rule out PREVENTION thyroid problems and blood sugar problems in particular. • A whole foods diet with minimal intake of sugar, • Medical evaluation should be done to reveal refined carbohydrates, dairy products, caffeine, concurrent disorders of depression and anxiety. and saturated fats • Treatment should provide symptom relief while • Increase dietary fiber including whole grains also addressing any need for lifestyle changes • Increase essential fatty acids from nuts, seeds, and treating problems in the neuroendocrine and fish connections (central nervous system brain chem- • Stress management istry as it is affected by estrogen and proges- • Regular aerobic exercise terone in particular). • Weight loss 304 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE The specific cause of PMDD has not been deter- sion), or PMS-H (hyperhydration). Yes, women mined, but the dysregulation of serotonin ap- may have one or more of these symptoms char- pears to be a key feature.11 acterized in the particular classification, but treating women for the correlating hormonal OVERVIEW OF imbalance has not typically been productive in ALTERNATIVE TREATMENTS my experience. In the more difficult cases, it is Historically, conventional mainstream medicine often necessary to expand one’s thinking, how- has not been able to offer women a known cause ever, and it may occasionally be helpful to for PMS, nor has it been able to offer a manage- explore some of these theories. ment approach short of pharmaceuticals with as Another basic foundation for many alterna- many side effects as relief. Fortunately, new tive practitioners in treating PMS is the concept research has led to a better understanding of of the liver’s role in the detoxification process. If PMS and to new and more successful conven- the liver function is compromised, then estrogen tional and natural treatments. Self-care with nat- metabolism is inadequate, leading to excess estro- ural therapies is the dominant method women gen levels and what is often described as estrogen use to manage PMS. Women have clearly taken dominance. A “sluggish liver” is then addressed this familiar monthly problem into their own with various dietary, nutrient, and herbal inter- hands and more often than not have determined ventions. It is important to understand that this what works for them. Fortunately, PMS is a con- is a theory with much speculation and minimal dition for which inadequate self-treatment yields scientific support in its connection with PMS. dissatisfaction rather than dangerous side effects One cannot argue, however, about the central or progression of a serious disease. role of the liver and its varied metabolic processes In an attempt to offer women rationales for with subsequent influence on the biochemistry viable natural treatments for the relief of PMS, of hormone and enzymatic pathways. There may many theories have been offered. While comfort- in fact be a role for liver function in PMS, but ing in their attempts to analyze the syndrome, what that is remains unknown. On the other these theories are poorly confirmed in research hand, improving liver function pays off in other studies yet are still used as a basis for many natu- ways, like exercise does, with many positive ral therapies. Popular models such as hormonal- health benefits to numerous body systems. based therapeutics, including elevated estrogen Numerous natural alternative therapies are levels and reduced progesterone levels; elevated available, including lifestyle changes, vitamin and prolactin; and increased aldosterone are not ade- mineral supplementation, herbal medicines, and quately confirmed in research. Even though a natural hormones. Many of these have demon- given therapy may work for a number of women, strated their effectiveness in standard scientific its mechanism may still elude our true under- studies. But at least an equal number have either standing. These models are tidy and convenient shown no effect or an effect that was not signifi- for a logical train of thought, but, due to their cantly greater than the placebo effect. Herein lies limited ability to help many women, they distract one of the curiosities of medicine, elegantly por- us from potentially having a more accurate under- trayed with PMS: why do conventional scientific standing and more effective treatment options. studies fail to demonstrate success with many of Clinically, I have not usually found it useful these natural therapies that women consistently to use classification systems commonly used by rely on for successful monthly treatments? alternative practitioners like PMS-A (anxiety), Perhaps the answer is as simple as that statis- PMS-C (carbohydrate craving), PMS-D (depres- tically significant is not the same as clinically PREMENSTRUAL SYNDROME 305 relevant: what works for one person is different simple sugars and decreased consumption of pro- than what works for another. We are truly indi- tein. This study also showed that PMS sufferers viduals with our own unique physiology, stres- had a higher number of “eating incidences” than sors, and psychological makeup. Double-blind, women who did not meet the criteria for PMS.15 placebo-controlled scientific studies attempt to These increases in eating incidence and carbohy- find what works for as many people as possible, drate craving in general during PMS may be not what works best for an individual. due in part to a decrease in serotonin during the Even in studies where the placebo response is luteal phase in PMS sufferers, and it follows that given credit, perhaps the belief that the mind can serotonergic treatments like SSRIs or 5HTP may heal the body is the real explanation. The inter- be helpful in controlling not only mood changes action between neurotransmitters, neurophysiol- during this period but also food cravings.16 ogy, the body’s steroids, circadian systems, mood, It is these same food cravings that often serve and behavior plus plants and nutrients from to worsen PMS symptoms, leading to a vicious nature may remain scientifically elusive, but, to cycle of poor dietary choices and mood distur- the credit of women, we have instinctually come bance. It has been suggested, however, that upon safe and effective natural solutions. ingesting high amounts of carbohydrates may be One of the significant benefits of treating PMS a form of “self-medication” in that it leads to a naturally is that it serves as a touchstone to moti- transient increase in tryptophan, a precursor to vate women to make lifestyle changes that have a serotonin, and a resultant improvement in mood positive cascade effect on their general health. and energy.17 Choosing high-quality carbohydrates (including whole grains such as oatmeal, Nutrition brown rice, barley, rye, and whole wheat) Women who have PMS typically have dietary throughout the luteal phase may help decrease habits that are worse than the standard American PMS mood symptoms. diet. In a nutritional analysis published in 1983, Another nutritional factor in PMS is the Guy Abraham reported that PMS patients con- effect of refined sugars on the retention of sumed 62 percent more refined carbohydrates sodium. After a large intake of sugar, insulin than women who did not have PMS, 275 percent increases quickly, which causes sodium and water more refined sugar, 79 percent more dairy prod- retention. Symptoms such as swelling in the ucts, 78 percent more sodium, 53 percent less hands and feet, abdominal bloating, and breast iron, 77 percent less manganese, and 52 percent engorgement and tenderness result. Complex less zinc.12 A diet higher in dairy products can also carbohydrates are preferred over simple sugars contribute to PMS symptoms such as anxiety, irri- (white sugar, white flour, white rice, etc.) because tability, and nervous tension. A dietary survey of they stimulate insulin release much more slowly 39 patients with PMS and 14 women with no and in a more sustained manner, thereby pre- PMS found that the women with PMS consumed venting many of these water-retention symp- fivefold more dairy products and threefold more toms. In fact, one study found that consumption refined sugar than those women without PMS.13 of a low-fat, high complex carbohydrate diet alle- Dairy products and calcium interfere with magne- viated premenstrual breast tenderness.18 Many sium absorption, and refined sugar increases the other symptoms of PMS may be exacerbated by urinary excretion of magnesium.14 the intake of sugary foods and beverages.19 Further data confirm these findings by Excessive and incorrect prostaglandin (PG) showing that women with PMS have increased synthesis has been implicated in the pathogenesis consumption of dietary fat, carbohydrates, and of PMS, and a deficiency of prostaglandin E1 306 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

(PgE1) in the central nervous system has been Dietary Recommendations proposed to be involved in PMS.20 Many nutrients are important for the synthesis of PgE1. • Reduce the intake of alcohol, caffeine, salt, These include magnesium, linoleic acid (an sugar, refined carbohydrates, and dairy products. essential fatty acid), vitamin B6, zinc, vitamin C, • Increase the intake of fruits, vegetables, and vitamin B . On the other hand, arachidonic 3 legumes, nuts, seeds, fish, soy, and healthy acid is a precursor to PgE2, which has antagonis- oils such as fish, flaxseed, and olive oils. tic effects with regard to PgE1. Think of PgE1 as the good guy and PgE2 as the bad guy. Vegetable oils are rich sources of linoleic acid, and animal will especially benefit those with fluid-retention fats are the main dietary sources of arachidonic symptoms. (See Chapter 7 on fibrocystic breasts acid; therefore, patients with PMS would be wise for more information about the detrimental to decrease their consumption of animal fats and effects of caffeine.) increase their consumption of polyunsaturated It is estimated that there are two million alco- vegetable oils so that they have more of the good holic women in the reproductive age group in guy, PgE1. A diet high in the other nutrients the United States.22 Sixty-seven percent of these mentioned would also promote the synthesis of women relate their drinking to their menstrual PgE1. We will discuss these more in the nutri- cycles, and drinking bouts occur usually during tional supplement section. the premenstrual phase.23 Alcohol may also play A recent study showed that an increase in a role in the reactive hypoglycemia of PMS as C-reactive protein, a marker of inflammation, well as worsening a variety of other PMS-related was positively correlated with the severity of symptoms.24 both physical and psychological symptoms of Soy isoflavones may be beneficial for PMS in PMS,21 providing more support for the use of anti- addition to the other women’s health conditions inflammatory dietary choices for PMS sufferers. they seem to positively affect. A recent study sug- Foods that can stimulate inflammatory pathways gests that increased consumption of dietary soy include, among others, sugar, poultry, eggs, cheese, may be related to a reduction in PMS symp- milk, white flour, white rice, and partially hydro- toms.25 Another study compared the effect of genated oils. Foods that can reduce inflammation isolated soy protein containing 68 mg/day soy include fresh fruits and vegetables, fish, grass-fed isoflavones with a placebo in a double-blind fash- beef, nuts, seeds, curry powder, garlic, and onions. ion and found that the soy protein was effective Limiting the dietary intake of salt can be at reducing headache, breast tenderness, cramps, helpful to some women. Table salt enhances the and edema after two cycles of treatment.26 response to the ingestion of glucose, consequently increasing the insulin response. As men- Nutritional Supplements tioned earlier, an increase in insulin causes It has been hypothesized that women with PMS swelling through water retention. are deficient in certain nutrients. Nutritional Many women with breast symptoms in their profiles and biochemical and hematological eval- premenstrual phase benefit from avoiding caf- uations in 11 women with PMS showed that feine. Even though scientific studies are contro- they did indeed have various nutritional deficien- versial on this subject, the practical results speak cies.27 Other biochemical investigations have for themselves. Restricting the intake of coffee found no evidence that premenstrual symptoms (both caffeinated and decaffeinated), black tea, are caused by either absolute or relative nutri- chocolate, and caffeine-containing soft drinks tional deficiencies.28, 29 PREMENSTRUAL SYNDROME 307 Nutritional supplements are widely used in double-blind, randomized study of 44 women the treatment of PMS despite the inconsistent divided women with PMS into four subgroups evidence to support their use. Again we have a depending on their symptoms. Subjects were discrepancy between scientific information and randomly assigned to receive either placebo or 6 what a significant number of women report. A or 12 tablets of the supplement a day for three possible explanation for this discrepancy might menstrual cycles. All subjects had significant dif- be that vitamin and mineral levels in the periph- ferences in severity of symptoms between the fol- eral blood (which is measured in a laboratory) do licular and luteal phase of the control cycle. Two not parallel the levels in the central nervous PMS subgroups especially improved: PMS-A system (CNS). Researchers J. C. Chuong and (nervous tension, mood swings, irritability, anxi- E. B. Dawson state, “It is possible that the ety) and PMS-C (headaches, craving for sweets, bioavailability of vitamins and minerals in the increased appetite, heart pounding, fatigue). CNS, which is related to the activities of several Supplementation with six tablets of Optivite neurotransmitters (including serotonin), could daily was associated with significant reduction in change during the luteal phase in some patients all symptom categories, including those with with PMS. As a result, premenstrual symptoms PMS-D (depression, insomnia, forgetfulness, occur. However, these changes in vitamin and crying, and confusion). Those with PMS-H mineral levels in the CNS may not show up in the (premenstrual weight gain, breast tenderness, peripheral blood levels.”30 abdominal bloating, and swelling of the arms Positive results seen in some studies with and legs) did not receive any benefit. If 12 tablets nutritional supplementation most likely repre- were taken, then there were significant reduc- sent a pharmacological response to therapeutic tions of symptoms in all groups. doses of vitamins or minerals rather than revers- When selecting a multiple vitamin and min- ing an underlying deficiency. eral supplement, I recommend one that has been Multiple vitamin and mineral supplements formulated especially for women, as these take may be helpful for women with PMS. A study into account the special nutritional needs of was done in 1985 of Optivite, a rather typical women. multiple vitamin/mineral supplement. The quantities and proportions of vitamins and minerals Vitamin B6. A rational basis for the use of in this supplement either met or exceeded the rec- vitamin B6 (pyridoxine) in the treatment of PMS ommended daily allowances except for calcium was first indicated by the work of Adams and his and vitamin D. In a double-blind, placebo- colleagues in 1973,33 although it had been pre- controlled crossover study, 16 of 23 subjects scribed since the 1940s. They reported successful reported feeling better during the cycles in which treatment with vitamin B6 of patients complain- they took the supplement, and 7 reported feeling ing of depression associated with oral contracep- better during the placebo cycles.31 These tion. Since that time there have been over one researchers also classified the patients into four dozen studies on vitamin B6 and PMS. Some of different subgroups (PMS-A, PMS-C, PMS-D, these have shown no effect from vitamin B6, but PMS-H) and found that only two of the four sub- most of the studies have shown that there was a groups responded to this particular supplement. substantial and broad effect on the whole range A second study on the same product was of PMS symptoms. An overview of these studies done in 199132 to assess the effectiveness of a has been published in the British Journal of vitamin/mineral supplement in controlling Obstetrics and Gynaecology.34 The studies have symptoms of premenstrual syndrome. This used anywhere from 50 to 500 mg per day. 308 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Vitamin B6 is thought to be unique in its have demonstrated a reduction in premenstrual ability to increase the synthesis of several neuro- nervous tension, headache, fatigue, depression, transmitters in the brain. These neurotransmitters insomnia, and breast tenderness.12, 42 Aberrant include serotonin, dopamine, norepinephrine, prostaglandin (PG) synthesis has been implicated epinephrine, taurine, and histamine.35 Lower in PMS, and a deficiency of prostaglandin E1 levels of brain neurotransmitters such as serotonin (PgE1) has been proposed to be involved in PMS and dopamine have been implicated in the etiol- as well as an increase in another prostaglandin ogy of PMS.36 In fact, a double-blind crossover called PgF2-alpha. It has been hypothesized that trial demonstrated that 50 mg of B6 per day was vitamin E inhibits the negative prostaglandin effective at decreasing premenstrual depression, (PgF2) and increases the PgE1. Women continue fatigue, and irritability.37 In addition, another to use vitamin E to relieve the symptoms of breast study showed a synergistic effect of 50 mg of B6 tenderness before the period. Despite science that combined with 200 mg of magnesium in reducing does not confirm a statistically significant benefit, premenstrual anxiety.38 vitamin E remains an important part of self-care. Vitamin B6 supplementation is generally This is discussed more in Chapter 7. considered safe in dosages of 50 to 100 mg daily. When using dosages greater than 50 mg, it may Vitamin E be important to divide it into 50 mg dosages 400–800 IU per day throughout the day to assure appropriate utilization by the liver. One should not exceed 200 mg Essential Fatty Acids. The main strategy of total in one day in order to assure safety. Chronic supplementing with essential fatty acids is an intake of dosages greater than 500 mg per day can attempt to raise the body’s own formation of be toxic if taken daily for many months or years. PgE1. The most popular method of doing so has There are also a few rare reports of toxicity at been to supplement with evening primrose oil chronic long-term dosages of 150 mg per day.39 (EPO) products in order to supply increased levels of gamma linolenic acid. Although there Vitamin B 6 are several studies that show positive results, 50 mg 2–4 times per day some of the studies did not include a placebo group, and other studies did not show a statisti- Vitamin D. We don’t normally think of vita- cally significant difference between the treatment min D as a treatment for PMS. Recent research group and the placebo group.43–45 has shown, however, that increased intake of vita- Four double-blind, crossover, controlled trials min D in both dietary and supplement forms is of EPO have demonstrated a significant effect inversely related to PMS symptoms.40 A combi- over the placebo group.46–49 One of these studies nation of vitamin D and calcium decreased the used three grams of EPO per day; the others used frequency and severity of menstrual migraines four grams per day. EPO has been shown to be and other PMS symptoms.41 most effective for relieving clumsiness and headaches, although all symptoms, including depres- Vitamin D sion, irritability, bloating, and breast tenderness, Age 19–50: 200 IU per day showed a marked improvement. Other sources of Tolerable upper limit: 2,000 IU oils that contain gamma linolenic acid (GLA) and raise PgE1 levels include borage oil, black Vitamin E. Vitamin E is probably not a big currant oil, and canola oil. Hemp oil contains a player in PMS relief, although some studies very small amount of GLA. PREMENSTRUAL SYNDROME 309

Another study looked at krill oil and its effec- showed a synergistic effect of 50 mg of B6 com- tiveness at reducing symptoms of PMS. Krill oil is bined with 200 mg of magnesium in reducing pre- derived from plankton and is high in omega-3 fatty menstrual anxiety.38 In addition, another study acids, bioflavonoids, and vitamins E and A. This suggests that cyclical hormonal changes may cause study looked at two 1-gram capsules of krill oil a relative deficiency state that can exacerbate symp- versus fish oil in the management of PMS symptoms associated with PMS.55 toms and found it to be comparable at decreasing swelling, bloating, and weight gain and superior to Magnesium fish oil in decreasing analgesic use, breast tender- 300 mg 1–3 times per day ness, joint pain, dysmenorrhea, and emotional symptoms after 45 to 90 days of treatment.50 Calcium. Reports have suggested that problems in calcium regulation and frank calcium defi- Evening Primrose Oil ciency actually mimic many PMS symptoms56–58 3–4 g per day and may underlie some of the symptoms of PMS. Therefore, dietary and supplemental forms of cal- Krill Oil cium may have a therapeutic benefit.40, 59 2 g per day An important randomized, double-blind, placebo-controlled, multicenter clinical trial was Magnesium. Magnesium has shown some conducted to test this hypothesis. A group of 479 beneficial effect in the treatment of PMS. Mag- women were given either 1,200 mg of calcium nesium is depleted by changes in the female sex carbonate or a placebo for three menstrual hormones in the luteal phase leading to a variety cycles.60 During the luteal phase of the treatment of PMS symptoms, notably migraines and bloat- cycle (from ovulation to menses), a significantly ing.51 One study suggests that 200 mg of magne- lower symptom complex score was observed in sium daily may reduce premenstrual fluid the calcium group for both the second and third retention and resultant symptoms like breast dis- months. By the third month, calcium effectively tension, peripheral edema, and abdominal bloat- resulted in a 48 percent reduction in total symp- ing after two months of treatment.52 tom scores from baseline compared with a 30 In another study involving 32 women with percent reduction in the placebo group. All four PMS, 360 mg of magnesium three times daily symptom factors (negative mood affect, water was given from midcycle to the onset of men- retention, food cravings, and pain) were signifi- strual flow.53 In menstrual distress questionnaire cantly reduced by the third treatment cycle. scores, relief of premenstrual mood fluctuations In addition, as mentioned earlier in the nutri- and depression during magnesium treatment was tional supplement section, research suggests that significant. Although blood serum levels of mag- a combination of vitamin D and calcium may nesium are not found to be different between decrease the frequency and severity of menstrual women who have PMS and women who don’t, it migraines and other PMS symptoms with only seems there is a significant decrease in red blood two months of treatment.41 cell magnesium levels in PMS patients.54 The mechanism of magnesium and its possible Calcium role in PMS are not well understood, but we do 1,200 mg per day know that magnesium is involved in essential fatty acid metabolism and B6 activity. In fact, as men- Tryptophan. As alluded to previously, de- tioned in the section on vitamin B6, one study creased serotonin and its precursor tryptophan 310 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE may exacerbate PMS mood changes, including Older research led up to these more recent and depression, anxiety, and aggression.61, 62 In addi- rigorous studies. Two surveys were done covering tion, trials done in recent years to test the effec- 1,542 women with premenstrual syndrome who tiveness of supplementation of L-tryptophan in had been treated with a German liquid extract of reducing symptoms of PMS have shown promis- chaste tree for periods of up to 16 years. The mean ing results. These studies, which used daily doses duration of treatment was 166 days, and the of 6 grams for 17 days from ovulation to day 3 of average dose was 42 drops daily. Effectiveness as menses led to significant reductions in mood recorded by the patients’ doctors was either very swings, insomnia, carbohydrate craving, tension, good, good, or satisfactory in 92 percent of the irritability, and dysphoria.63, 64 cases.76 Only 2.1 percent of the women noted side effects during treatment, and 1.1 percent of them Tryptophan discontinued the medicine because of them. 6 g per day for 17 days, from ovulation to day 3 of Chaste tree has also been found to be safe for menses use with most patients, but caution should be exercised with those on medications that inhibit dopamine. A recent review of research found that Botanicals the most frequent adverse events reported were Chaste Tree (Vitex Agnus Castus). The headache, gastrointestinal disturbances, men- single most important plant for the treatment of strual disorders, acne, itching, and rash, and no premenstrual syndrome is Vitex agnus castus, also known drug interactions were reported.77 known as chaste tree. The fruits of chaste tree contain essential oils, irridoids, pseudoindicans, Chaste Tree (Vitex Agnus Castus) and flavonoids. The effect of chaste tree is on the 40 drops liquid or extract per day or hypothalamus-hypophysis axis. It increases secre- Capsules of standardized extract: 175 mg per day tion of luteinizing hormone (LH) and also has an effect that favors progesterone.65–67 Chaste tree Ginkgo (Ginkgo Biloba). We don’t normally has also been substantiated in its ability to inhibit think of ginkgo for PMS. But when you consider prolactin.68 Elevated prolactin levels may be a that some PMS symptoms have to do with conges- factor in PMS. Studies of chaste tree for cyclic tion, it makes sense that it might be useful. A breast tenderness confirm its effectiveness in this double-blind, placebo-controlled study was done disorder.69, 70 Chaste tree is also thought to posi- in 1993 to determine the effectiveness of ginkgo tively influence PMS symptoms by affecting extract on PMS symptoms. A group of 165 women opioid receptors in the brain.71 between the ages of 18 and 45 who had fluid reten- Three studies found that chaste tree reduced tion, breast tenderness, and vascular congestion a variety of premenstrual symptoms after three were studied. The patients were assigned to receive cycles of active treatment in a large number of either a ginkgo extract of 24 percent ginkgo women.72–74 An additional study looked at the flavonglycoside content at 80 mg twice daily or a effectiveness of chaste tree versus fluoxetine placebo from day 16 of their cycle to day 5 of the (Prozac) in decreasing PMS symptoms and next cycle. Based on symptom evaluation by both found the two treatments comparable, except that fluoxetine was more effective with psycho- Ginkgo (Ginkgo Biloba) logical symptoms and chaste tree was more effec- 80 mg standardized extract twice daily tive with physical symptoms.75 PREMENSTRUAL SYNDROME 311 patient and doctor, ginkgo extract was effective for anxiety, dandelion leaf for water weight gain, against the congestive symptoms of PMS, particu- valerian for sleep problems, and lemon balm for larly breast pain or tenderness.78 herpes eruptions. You will often find one or more Saint John’s Wort (Hypericum Perforatum). of these herbs in combination herbal and nutri- Saint John’s wort has shown promise in prelimi- tional products that have been specifically formu- nary studies of its effectiveness at alleviating lated for PMS symptom relief. PMS mood dysfunction, but more research is still needed.79–81 In one observational pilot study, Exercise Saint-John’s-wort standardized extract was given at Specific exercises are conspicuously absent from a dose of 300 mg three times daily.81 Nineteen scientific studies looking at the effects of exercise women with PMS underwent a preliminary on PMS. In contrast, although mechanisms of screening interview and completed a daily symp- action remain elusive, general regular physical tom rating for one cycle. After taking the Saint John’s exercise has been the subject of several controlled wort for two complete menstrual cycles, daily trials. In all of these, the results show that women symptoms were rated again. The degree of who exercise regularly have less strong or fewer improvement in overall premenstrual syndrome PMS symptoms. scores between baseline and the end of the trial was Aerobic training (walking, jogging, swim- 51 percent, with more than two-thirds of the ming, cycling) appears more effective at reducing sample demonstrating at least a 50 percent decrease PMS symptoms than strength training (weight in symptom severity. The mood subscale showed lifting).84 Frequency of exercise, but not inten- the most improvement (57 percent), and the sity, relates to decreased rating of selected men- symptoms with the greatest reductions in scores strual distress symptom clusters;85 gradual were crying (92 percent), depression (85 percent), increase in running distances correlates directly confusion (75 percent), feeling out of control (72 with greater reductions in PMS symptoms.86 percent), nervous tension (71 percent), anxiety (69 Regular exercisers show improvement in all PMS percent), and insomnia (69 percent). parameters, including concentration, affect, pain, hostility, fear, guilt, and sadness.87 Saint John’s Wort Regularly exercising women report a signifi- 300 mg 3 times daily cant decrease in anxiety following baseline relaxation but show greater increase in anxiety during Additional Herbs. Many other herbs that have a stress task than nonexercisers.88 not been subjected to scientific research have also Two reviews of the literature on exercise and been used successfully by women and practitioners PMS emphasize the obvious fact that controlled for decades. These include many species of wild trials of exercise training and PMS cannot be per- yam, licorice root, dong quai, black cohosh, and formed under double-blind conditions, making more. One study on black cohosh and PMS it difficult to formulate probable mechanisms for demonstrated that it was effective in improving the observed effects of regular training on PMS anxiety, tension, and depression.82 Currently, there symptoms. According to L. Gannon, exercise is some thought that black cohosh may act as a may reduce PMS symptoms by (1) decreasing mild serotonin reuptake inhibitor, which would estrogen levels, (2) improving glucose tolerance, make it an appealing option for PMS.83 (3) decreasing catecholamines, and (4) elevating Other plants are used because of their benefit endorphins.89 Gannon concludes, “If PMS with specific symptoms; for example, kava extract symptoms are caused or exacerbated by dramatic 312 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Exercise Recommendations original work with progesterone therapy is the historical root on which the use of natural pro- • Follow the “General Exercise Program” and gesterone is based today. Research scientists, and exercise instructions outlined in Appendix A. therefore the majority of the conventional med- • The key words in exercising are regularity and ical community, ultimately did not embrace Dr. diversity. Dalton’s conclusions about the efficacy of proges- • It is important to schedule exercise along with the other vital activities of the day—meals, terone therapy for PMS. This was largely based sleep, and rest. on what they thought to be inadequate scientific • Equally important is to enjoy the exercise you research studies, although it is also fair to specu- choose, remembering that best results are late that other matters of medical politics and the obtained from a combination of types of exer- business of medicine were at play here as well. cise—flexibility, stretching, strength, and car- Natural progesterone (also called bio-identical diovascular. progesterone) is a white crystalline powder derived from extracts of the Mexican wild yam or soybean. It requires laboratory manufacturing variations in endorphin levels, exercise may serve processes and is something altogether different to prevent exaggerated elevations and abrupt than what we know as botanical medicine. What declines and, ultimately, to reduce symptoms.” makes natural progesterone natural is not so Yoga postures are another form of exercise much the original plant material but rather that that appears to have benefit and may suit some the progesterone molecules that result are chem- women more. A study of 40 women was done for ically identical to the progesterone hormone pro- almost one year to investigate the effect of yoga duced by a woman’s own ovaries and adrenal in relieving premenstrual and menstrual prob- glands. lems.90 The women assigned to the treatment Confusion exists when people think that bio- group did yoga postures and meditation. At the identical progesterone is found in wild yam and end of the 10 months, there were significantly soybeans or that the human body can convert lower scores on the menstrual distress question- wild yam and soybean extracts to natural proges- naires for those in the yoga group compared to terone. Neither of these is true. Further confus- those in the control group. ing the issue is that many people mistakenly call Progressive muscle relaxation and deep synthetic progestogens or progestins proges- breathing can also significantly reduce the mood terone. Progestins are chemically different than symptoms associated with PMS.91 progesterone and also chemically different than bio-identical progesterone. Natural (or Bio-Identical) Progesterone Dr. Dalton reports that she has used natural Perhaps no other PMS therapy has been the progesterone via injections (25 to 100 mg daily), target of so much controversy as natural proges- vaginal and rectal suppositories (400 to 1,600 mg terone. This has as much to do with the lack of daily), and subcutaneous pellets (500 to 1,600 mg scientific research and agreement to support a every 3 to 12 months) with results as good as com- unified theory as to the cause of PMS as it has to plete relief of PMS symptoms in 83 percent of do with the efficacy of natural progesterone itself. women.92 There have been several studies that Raymond Green and Katharina Dalton advanced demonstrated a lack of efficacy of rectal and a theory in the 1950s that PMS was caused by vaginal suppositories in the treatment of PMS. unopposed estrogen during the luteal phase Sampson and Freeman found these forms of prog- (second half) of the menstrual cycle. Dr. Dalton’s esterone to be no better than placebo.93, 94 PREMENSTRUAL SYNDROME 313 Although the suppository method of deliver- progesterone per ounce of cream. For severe ing natural progesterone for PMS has not held PMS symptoms that have not responded to up to scientific scrutiny, oral micronized natural nutritional, botanical, and lifestyle changes, and progesterone has. A study by Dennerstein and for those whose symptoms start from a few days to colleagues in 1985 found an overall beneficial one week before the menses, I recommend apply- effect of using 300 mg per day (100 mg in the ing one-quarter teaspoon natural progesterone morning and 200 mg in the evening) for 10 days cream twice daily starting at midcycle and stop- of each menstrual cycle starting three days after ping the day before the menses is due. For women ovulation.95 After only one month of treatment, whose significant symptoms begin at ovulation, I those receiving progesterone could be clearly recommend one-quarter teaspoon per day from distinguished from those receiving placebo on day 8 to day 14 (do not use during days 1 to 7 measures of stress, anxiety, and concentration. while bleeding), and then one-quarter teaspoon Most other symptoms also continued to improve twice daily until the menses begins, as described with each menstrual cycle. The only premen- above. The best sites for rubbing in the cream strual complaint not consistently improved by include the palms, inner forearms, chest, and progesterone was arousal. A 1993 study also inner thighs. Also, it is best utilized when rotating reported successful use of progesterone in doses sites of application. Individual uses may vary of 300 mg oral micronized progesterone daily or depending on symptoms or menstrual pattern. 3 cc rectal solution twice daily.96 Since bio-identical progesterone is a hor- More recently, Dr. John Lee had become the mone, I think it is best to seek the advice of a most outspoken proponent of the use of natural qualified health-care practitioner who is experi- progesterone by using transdermal creams that enced with its use for those who use it long are applied to specified areas of the skin. He term. This assures proper usage and therefore reported significant success in his medical prac- maximum results. Oral micronized progesterone tice and has written about it in his treatise on and some of the other delivery methods of prog- natural progesterone.97 esterone are prescription items. These products The availability of natural progesterone in are used mainly by licensed naturopathic physi- transdermal creams in the retail over-the-counter cians but also by progressive medical doctors market has created perhaps the greatest confu- and a growing number of chiropractors and sion yet in the use of this valuable medicine. It is acupuncturists. important for the consumer and practitioner to understand the difference between wild yam and Natural (Bio-Identical) Progesterone Cream soy extracts versus natural progesterone products • If symptoms start from a few days to 1 week derived from these extracts. Wild yam extracts do before the menses, apply 1⁄4 tsp twice daily not contain natural progesterone unless they say beginning at midcycle (day 15) and stopping that natural progesterone has been added. Also, approximately day 26 or a day or two before different products contain different amounts of the menses is due. • If symptoms begin at ovulation, apply 14 tsp progesterone. The range is as little as 2 mg per ⁄ per day on days 8–14 (do not use during days ounce to more than 400 mg per ounce. The rule 1–7 while bleeding), and then 1⁄4 tsp twice is user beware and be educated. These products daily until the menses begins. all have their value, but not necessarily for the treatment of PMS. Oral Micronized Progesterone In my clinical practice, I largely use the trans- 50–200 mg per day on days 15–26 dermal creams that contain at least 400 mg 314 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Sample Treatment Plan for The first, and most important, step in treat- Premenstrual Syndrome ing PMS is recognizing it. The woman should undergo accurate assessment for other mental 3-Month Plan and physical diseases, and then do at least three • Reduce the intake of alcohol, caffeine, salt, months of symptom charting, possibly with help sugar, refined carbohydrates, and dairy from her partner. Once the diagnosis of PMS is products. made, then the therapy consists of the following: • Increase the intake of fruits, vegetables, 1. Lifestyle therapies. Nonpharmacological legumes, nuts, seeds, soy, fish, and flaxseed therapies are more effective in less severe oil. PMS/PMDD. The first is making lifestyle • Exercise regularly, focusing especially on aerobic exercise. changes that support the use of aerobic exercise • Take a combination nutritional/botanical PMS to maintain a normal BMI and possibly increase product (available at natural food stores or endorphins that may be lacking in the luteal alternative health practitioners). It should phase. Next are dietary modifications that include vitamin B6; magnesium; gamma include having small, frequent meals; reducing linolenic acid from borage, evening primrose, intake of caffeine, sugar, alcohol, artificial sweet- or black currant oil; chaste tree (vitex); eners, salt, red meat, saturated fat, and simple vitamin E; Saint John’s wort; and possibly carbohydrates; and increasing the intake of some traditional herbs for PMS, including complex carbohydrates; and foods that are rich dandelion leaf, dong quai, black cohosh, and in calcium and magnesium. A general multivita- wild yam. (See the Resources section for formulation sources.) min supplement is also recommended. • Take a multiple vitamin/mineral supplement, 2. Cognitive-behavioral therapy (CBT). 1 to 6 capsules per day. Cognitive-behavioral therapy is a short-term, • Take 1,000–1,200 mg of calcium per day. structured psychotherapeutic treatment that • If this plan doesn't relieve PMS after three helps emphasize the role of the patient’s current cycles, then use bio-identical progesterone thinking in determining behavior. The patient is creams with greater than 400 mg per ounce or taught behavioral techniques to help alter her prescription oral micronized progesterone. response to the premenstrual symptoms. CBT helps in stress management and in teaching the woman how to alter or cope with her lifestyle. 3. Pharmacological therapies. The most CONVENTIONAL common medication recommended for MEDICINE APPROACH PMS/PMDD of moderate to severe intensity is In perhaps no other diagnostic category has the an SSRI. These medications can be used just on advice of conventional physicians so overlapped the severe-symptom days each month. They are with that of their naturopathic colleagues. All are effective the day they are taken, which suggests searching! Basic lifestyle issues such as exercise, that SSRIs in this case are not helping by diet, nutritional supplements, and stress and mood increasing neurotransmitters. They seem to assessment have all been studied and are always the work in PMS by altering the neurophysiology starting point of treatment. Probably in part and electrical conduction in the brain. Several because we had no consistently effective therapy, SSRIs have been used. Suggested doses are flu- conventional physicians have borrowed eagerly oxetine (20 mg a day) or the once-weekly tablet from natural medicine, and enthusiastic interest in sertraline or paroxetine controlled-release (12.5 natural progesterone occurred in the early 1980s. to 25.0 mg per day). The biggest problem with PREMENSTRUAL SYNDROME 315 the use of these drugs is the high incidence of for extended periods of time and have a high side effects that can include nausea, headache, incidence of side effects. Add-back therapy with fatigue, hyperexcitability, and sexual dysfunction estradiol or a progestogen to reduce the side as well as weight gain. The new serotonin and effects also seems to reduce the effectiveness for norepinephrine reuptake inhibitor venlafaxine, treatment of PMS. with doses anywhere from 50 mg to 200 mg per Short-acting, water-soluble sedatives such as day, was shown to have a better effect than the alprazolam and lorazepam have also been useful placebo in reducing PMDD. either in a scheduled dosing (for example, a small dose three times daily from cycle day 20 until Spironolactone is an aldosterone antagonist, menses) or on an as-needed basis to reduce anxi- used as a diuretic. It has been successful in treat- ety and agitation. ing symptoms of irritability, depressed mood, Correction of PMS through surgical removal edema, breast tenderness, and food craving. of the ovaries has been done and remains a very Oral contraceptives are commonly prescribed high-risk, symptomatic (due to the abrupt loss of for PMS/PMDD and have reports of as many fail- estrogen), and expensive treatment for PMS. It is ures as successes. Probably the most significant done only in the most extreme circumstances problem with oral contraceptives is the current reg- after extensive consultations. imen of taking them 21 days on and 7 days off. The 7-day drug-free interval allows for less suppression SEEING A LICENSED PRIMARY of ovulation. During that 7-day pill-free interval, HEALTH-CARE PRACTITIONER follicle-stimulating hormone (FSH) rises, follicles (N.D., M.D., D.O., N.P., P.A.) begin to grow, and ovulation frequently occurs. PMS is an excellent condition for self-treatment Since PMS is only seen in ovulating women, this most of the time. Mild to moderate PMS is well lack of ovulation suppression may be the reason addressed by lifestyle changes and safe and effec- for the frequent failure of OCs in PMS. There are tive nutritional and botanical supplements most several new studies that show that a 4-day pill-free of the time. When these measures are not effec- interval reduces the FSH volumes by 50 percent, tive or when the symptoms are severe, a licensed helps suppress the development of new follicles, naturopathic physician can readily utilize natural and appears to significantly suppress ovulation. A progesterone therapy, more aggressive dosing shorter hormone-free interval may thus be more of nutritional and botanical supplements, or effective in treating PMS. There is also a birth selected nutrients that specifically and more control pill that contains drospirenone, which is assertively target serotonin and other neurotrans- derived from 17 alpha-spironolactone and has mitters and neurophysiology. antimineralocorticoid and antiandrogen effects. It Few conventional medical doctors are trained helps prevent fluid retention, and studies have in these therapies, although increasing numbers shown excellent efficacy in symptom relief of PMS. are integrating them into their practice. Severe Uncommonly prescribed medications for symptoms of depression, headaches, breast pain, PMS/PMDD are the GnRH agonists that sup- or others may require the use of pharmaceutical press ovulation and make women in effect tem- intervention, although this is rarely necessary. In porarily menopausal. The use of GnRH agonists these cases, temporary use of such drugs must be places women in a low estrogenic state that func- recommended judiciously, while the continued tions like a reversible medical removal of ovaries. use of natural medicines is integrated into the These agents have been shown to decrease symp- long-term plan. Only rarely will PMS not respond toms of severe PMS, but they cannot be used to a comprehensive natural medicine approach. This page intentionally left blank SEXUALLY CHAPTER 18 TRANSMITTED INFECTIONS

OVERVIEW Chlamydia Trachomatis Sexually transmitted infections (STIs) and their Chlamydia trachomatis infection is the most complications continue to infect women at epi- common STI causing a female pelvic infection in demic rates. Each year, more than 15 million the United States. The infection rate is consid- American men and women contract an STI.1 ered epidemic in women and is estimated at four Worldwide, the estimated incidence of STIs is million new cases each year. Chlamydia is evi- over 250 million cases per year. All women who dent in about 20 to 40 percent of sexually active are sexually active are at risk for acquiring infec- women in the United States.2 It can be deceptive tion and related reproductive tract problems, because as many as 80 percent of women with although heterosexual women are at substantially this infection do not exhibit symptoms.3 This is increased risk compared to lesbian women. Gon- of particular concern, because chlamydia can orrhea and chlamydial infections may produce progress to an asymptomatic pelvic infection urethritis, cervicitis, and pelvic inflammatory resulting in infertility. Women between the ages disease (PID) and are the two types of bacteria of 15 and 25 are at greatest risk of chlamydia, but that most frequently cause PID. Human papillo- all heterosexually active women are at risk.4, 5 The mavirus (HPV) is the cause of genital warts and rate of C. trachomatis pelvic infection among sex- cervical dysplasia. Syphilis is responsible for ually active women is from 5 to 20 percent.6 The myriad systemic and tissue abnormalities. Herpes chlamydia organism invades the columnar cells simplex virus (HSV) infection is associated with of the cervix, invades the immune system, and small blisterlike skin eruptions and ulcerations. can either lie in a latent state in the cervix for Scabies and pediculosis are fraught with itching months, create asymptomatic cervical infection, of the skin. As many as 60 percent of hepatitis B or ascend to the upper genital tract, where it can cases are sexually transmitted. HIV infection and also be asymptomatic or cause infections of the AIDS (the most advanced stage of HIV infection) fallopian tubes or uterus. When symptoms do are sexually transmitted diseases as well. Less occur, it commonly causes urethritis, cervicitis, common STIs, such as lymphogranuloma vener- and PID in women. Common symptoms that eum and chancroid, present as pimple-like or occur include uncomfortable urination, fre- ulcerative genital lesions. quency of urination, vaginal spotting, increased The purpose of this chapter is to discuss some discharge that may be yellowish, pelvic pain, and of the alternative approaches and conventional pain or spotting with intercourse. therapies used in the treatment of chlamydia and Due to the high incidence of chlamydia and gonorrhea. Please refer to Chapter 20 (vaginitis), the high rate of asymptomatic infections, it is rec- Chapter 3 (cervical dysplasia), Chapter 8 (genital ommended that all heterosexually active women herpes), and Chapter 15 (pelvic inflammatory between ages 15 and 25 be screened yearly. By disease) for further information and treatment screening regularly, the incidence of PID can be recommendations regarding other conditions reduced significantly. Chlamydia is diagnosed on that can be transmitted through sexual contact. physical examination, with a smear of the dis- 317

Copyright © 2008 by Tori Hudson. Click here for terms of use. 318 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE charge from the urethra and cervix viewed under a toms, many women go untreated. Unfortunately, microscope and with special tests and cultures of many of these women find out later that their fal- the same discharge. The rectum should also be lopian tubes have been scarred, which leads to examined for a purulent discharge. The vaginal infertility. discharge should also be tested for the presence of bacterial vaginosis, trichomoniasis, and gonorrhea. Neisseria Gonorrhoeae The cervix is also examined for hypertrophy Neisseria gonorrhoeae is the second most common (enlargement) of the endocervical epithelium (the STI causing a female pelvic infection. In 2003, cells in the cervical canal), looking for intense ery- the rate of reported cases in the United States was thema (redness) and friability (bleeds easily when 116.2 cases per 100,000 individuals. Rates have it is touched with a cotton-tipped applicator). The been decreasing each year since 1999, and we are presence of a mucopurulent discharge from the currently at our lowest reported rate. Approxi- cervix is a tip-off to a cervical infection. This mately 75 percent of the cases occur in women, yellow discharge is then tested for chlamydia and and the highest rate is among women aged 20 to gonorrhea. 24 years.7 The highest group at risk is heterosex- Being infected with chlamydia is of special ually active women aged 15 to 19.8 concern for the pregnant woman because it can The southern United States has the highest cause spontaneous abortion, premature rupture rates of gonorrhea, and the rates are 20 times of the membranes, premature labor and delivery, higher for African-Americans than for Cau- and postpartum endometritis (infection of the casians. Young women (and men) who are non- uterus). Due to the frequent asymptomatic white, unmarried, less educated, and who live in nature of chlamydia infection, examinations of urban settings are the group most commonly all women suspected of having an STI during affected.9 pregnancy should include testing for chlamydia Gonorrhea is most easily transmitted from and gonorrhea. About 60 to 70 percent of males to females assuming lack of condom use. untreated cases in pregnant women result in Oral gonorrhea occurs in about 20 percent of neonatal infection in the eyes or lungs.2 women who practice fellatio with males who Due to the ability of chlamydia infection to have an infection of their urethra. Transmission be asymptomatic, it is a particularly problematic between women is not impossible, but extremely pelvic infection. It can ascend to the upper rare. The incubation period of gonococcal infec- genital tract without detection and then cause tion averages 3 to 5 days, with a range of 1 to 14 significant damage to the reproductive tract days. The majority of women with gonorrhea affecting fertility. Lower abdominal or pelvic have no symptoms, but one-third of women pain in a heterosexually active woman may be a observe a vaginal discharge. Urethritis with symptom of pelvic inflammatory disease (PID), uncomfortable urination and frequency, cervici- especially when it occurs with cervical inflamma- tis, a puslike discharge, abdominal or pelvic pain, tion and vaginal and/or purulent endocervical vaginal spotting, and pain with intercourse are discharge. Pain and tenderness on the physical symptoms that warrant a suspicion of gonorrhea. exam in addition would be enough to have a Mucopurulent cervicitis is the most common clinical diagnosis of PID and should be followed STI pelvic infection in women. Cervicitis is usu- with appropriate testing. (See Chapter 15 for ally caused by gonorrhea, chlamydia, herpes more information on PID.) simplex, or a combination, with chlamydia infec- Because of the number of women who have tions being the most common cause. A vaginal contracted chlamydia and do not exhibit symp- infection along with cervicitis may be due to SEXUALLY TRANSMITTED INFECTIONS 319 candida or trichomonas, or the candida or are unmarried, are African-American, have a trichomonas may coexist along with the other prior history of STI, have new or multiple organisms. heterosexual partners, have cervical ectopy (a Symptoms often do not show up until PID change in the cervix exposing more colum- develops. Abdominal pelvic pain is generally an nar cells to potential infection), or show indication of endometritis, salpingitis, or an inconsistent use of barrier contraception abscess, and it generally develops a few days fol- Women who are treated for chlamydia should be lowing the onset of menses. The physical exam of rescreened three to four months after treatment. a woman with gonorrhea reveals a mucopurulent The optimum frequency of how often to discharge from the cervical opening, a swollen screen for chlamydia is uncertain. For women and friable cervix, and/or bleeding from the cer- who have previously tested negative during a vical canal. screening test, rescreening should occur if there is Infected mothers may transmit gonorrhea to a change in sexual partners. Once older than 25, their babies during pregnancy or at the time of or for women who are in a mutually monoga- delivery. It most commonly causes conjunctivitis mous relationship and have a history of negative in the baby and can also cause blindness in screening tests for chlamydia infection, screening newborns. Other complications can include can be much less frequent and based on clinical increased risks of spontaneous abortion, prema- judgment. Women who have a history of being ture labor, early rupture of the fetal membranes, previously infected need to be rescreened every 6 and perinatal infant mortality. to 12 months due to high rates of reinfection. As As many as 30 to 60 percent of women with stated earlier, women with positive infections gonorrhea are also infected with chlamydia,10 should be treated and retested after treatment. and therefore gonorrhea and chlamydia should According to the U.S. Preventive Services be tested together. Task Force (2005), the following women should Testing for Chlamydia and Gonorrhea be tested for gonorrhea: The U.S. Preventive Services Task Force (2001) • All sexually active women age 25 or younger and the Centers for Disease Control (CDC) • All women, especially pregnant women, who (2006) provide the following guidelines and are at higher risk, including women who are recommendations for who should be tested for unmarried, are African-American, have a chlamydia and gonorrhea. Their guidelines are prior history of STI, have new or multiple slightly different, so I have combined them heterosexual partners, are sex workers, use for optimal recommendations. The following drugs, have cervical ectopy (a change in the women should be tested for chlamydia: cervix exposing more columnar cells to potential infection), or show inconsistent • Women with mucopurulent cervicitis or use of barrier contraception PID • All pregnant women who are 25 years old or • All sexually active or pregnant women 25 younger or are at risk (screen at the first pre- years old or younger natal visit) • Any woman who is at risk, defined liberally • Women who live in communities with a as inconsistent condom use and having a higher prevalence of gonorrhea new partner or multiple partners • Pregnant women at increased risk for Using cultures to test for C. trachomatis and chlamydial infection, including women who N. gonorrhoeae has historically been the gold 320 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

KEY CONCEPTS PREVENTION

• All heterosexually active women age 25 or • Know the sexual disease history of your poten- younger should be screened annually for gonor- tial sexual partner. rhea and chlamydia. • The best protection against acquiring a sexually • Any sexual contact with a person with gonor- transmitted disease is for the male partner to rhea or chlamydia warrants a visit to the doctor use latex condoms. for a physical exam and tests. • All heterosexual women who engage in unpro- • Antibiotic treatment of chlamydia and gonorrhea tected sex with one or more men are at risk for should be considered the primary treatment, STIs. Women with frequent partners or multiple with alternative treatments used as partners have more STIs. complements. • Oral contraceptive use may predispose women to • Complications of gonorrhea and chlamydia can chlamydial infection.11 be serious and even life threatening, and a • Patients diagnosed with one STI should be pregnant woman can pass the infection to her screened for other common STIs. baby. • IV drug users should avoid sharing needles. • Symptoms of chlamydia and gonorrhea include • Health-care workers should be focused and care- cervical discharge, difficult or painful urination, ful and practice universal precautions in their bleeding between periods or after intercourse, workplace. pain in the pelvic area during sex, a swollen cervix and/or bleeding from the cervix, and acute or chronic pelvic pain. However, many (NAATs), that are significantly more sensitive women have no symptoms at all. than previous nonculture tests in detecting • Appropriate management of an STI includes DNA or RNA sequences. The Gen-Probe PACE seeing a health-care practitioner who can iden- 2 and the Digene Hybrid Capture II can detect tify the disease and treat the woman and her for both organisms in a single specimen. Rapid current sexual partner. in-office tests may be used by some clinics to test for chlamydia; liquid-based Pap smears and urine tests can also be used to detect chlamydia. standard and the reference against which all other tests have been compared. However, these Hepatitis B culture methods are more difficult and expensive, Hepatitis B (HBV) is a virus that infects more so new testing methods have been sought. The than 300,000 Americans annually. It is estimated first nonculture screening tests that were devel- that 1.5 million people in the United States are oped included enzyme immunoassays (EIAs), carriers of the disease but experience no symp- which detect specific chlamydial or gonococcal toms at all. Sexual contact, especially anal sex, is antigens, and direct immunofluorescent anti- the leading method of transmitting HBV. Other body (DFA) tests for C. trachomatis. Nucleic methods of transmission include the sharing of acid hybridization tests followed, which detect C. needles among drug users, exposure to infected trachomatis–specific or N. gonorrhoeae–specific body tissues or fluids through an open cut or deoxyribonucleic acid (DNA) or ribonucleic acid sore, and infected mothers who pass the virus on (RNA) sequences. The main disadvantage of to their babies. The most common early symp- these tests, especially for C. trachomatis, is that toms are flulike. Symptoms that arise later they aren’t able to detect a fair number of the include jaundice (yellowing of the skin and infections. This has led to a new generation of whites of the eyes), abdominal pain, and dark tests, called nucleic acid amplification tests and foamy urine. With treatment, most people SEXUALLY TRANSMITTED INFECTIONS 321 begin to feel better within two to three weeks and immune support is echinacea. Echinacea can recover within four to eight weeks. A very small increase the production of T cells, stimulate percentage of people who are chronic carriers of phagocytosis of bacteria, stimulate natural killer HBV will develop potentially severe and fatal cell activity, and multiply the number of white liver diseases such as active hepatitis, cirrhosis, or blood cells that circulate in order to deal with the cancer. Blood tests are used to diagnose both the infection.12 Many herbs have also been shown active form of HBV and the carrier state. Preg- to have antimicrobial and immunostimulating nant women can be screened for the virus during effects. Allicin extracts from garlic may hold the their prenatal care. most promise for inhibiting bacterial infections. Goldenseal and Oregon grape root also have the OVERVIEW OF ability to inhibit the overgrowth of numerous ALTERNATIVE MEDICINE organisms, although this does not include bacte- Due to potential infertility from the scarring of rial vaginosis or chlamydia. Curcumin is one of acute PID as well as some of the other complica- the best herbs to reduce inflammation. The end tions of chlamydial infection and gonorrhea, my result is a strengthened immune system. advice is to consider alternative medicine as an The best complement to counteract the side adjunct to conventional antibiotics rather than a effects of antibiotic use is to add or increase the primary treatment. Using alternative therapies to intake of Lactobacillus acidophilus to support support the immune system, to assist in manag- intestinal health and to help prevent a vaginal ing pain and discomfort, and to counteract some yeast infection. This can often be accomplished of the side effects of the antibiotics are the main by eating yogurt containing Lactobacillus aci- priorities. Drinking plenty of water, getting dophilus daily or by taking oral capsules of enough rest, eating simple light foods, and avoid- Lactobacillus acidophilus. Four to eight ounces of ing stimulants are basic guidelines during any unsweetened acidophilus yogurt or at least three acute infection, including pelvic infections. capsules of Lactobacillus acidophilus daily for two General immune support to complement weeks should prevent the overgrowth of vaginal conventional antibiotic treatment is just good yeast that often occurs when taking antibiotics. plain common sense. Nutritional and botanical In addition, Lactobacillus has been shown to support can stimulate the white blood cells that inhibit both gonorrhea and chlamydia and to be engulf and destroy bacteria and enhance the inversely related to PID.13–16 function of T cells, B cells, and natural killer cells Ice packs over the pelvic region can reduce that modulate the immune system in reaction to inflammation and pain in cases of acute PID. bacteria and viruses. Such supplements as vita- Cold or ice packs placed over the region of the min A, vitamin C, the carotenes, vitamin E, zinc, uterus while putting the feet in a tub of hot water and the B vitamins play an important role in can further assist in reducing the inflammation, immune enhancement. Increasing antibody congestion, and pain in the pelvic area. Alternat- response, stimulating helper T cells, enhancing ing hot and cold sitz baths can also be used to white blood cell response and function, and improve circulation in the pelvic area and directly killing the virus or bacteria are just some improve the healing time from the infection. of the ways in which these supplements can be This is done by sitting in a bath of hot water, helpful during an acute infection of any kind. with the water level just above the waist, for three Many herbs have also been shown to have minutes, followed by sitting in a small second antibacterial, antiviral, and immunostimulating portable metal or plastic tub of ice cold water for effects. The most commonly used herb for one minute. This procedure is repeated three 322 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE times in succession, once or twice daily through- you’re not used to fasting, I would not suggest out the course of the pain and infection. trying this approach for any longer than three days on your own. Drink plenty of water as well. Nutrition Better yet, you may want to seek advice from a The nutritional goals during an active STI are to knowledgeable practitioner about this approach. eat health-promoting and immune supportive If you are taking antibiotics, be sure to eat foods. Generally, this refers to a diet that is high eight ounces of unsweetened lactobacillus yogurt in fiber, plant-based foods, essential fatty acids, daily to help maintain intestinal health and to and antioxidant nutrients and low in saturated help prevent the possibility of a yeast vaginitis fat and refined sugar. infection caused by the antibiotics. The best dietary sources of antioxidants, and especially the carotenes, are green leafy vegetables Botanicals and yellow-orange fruits and vegetables such as An Indian study of Azadirachta indica (neem carrots, apricots, peaches, mangoes, yams, and seed oil), Sapindus mukerossi (reetha saponin squash. Beans, whole grains, and many seeds are extract), and quinine included 58 women who also good sources of carotenes. presented to a gynecology clinic in India with an Eliminating refined sugar and simple sugars (corn syrup, honey, fructose, maple syrup, white Sample Treatment Plan for grape juice concentrate, and others) will help to Chlamydia and Gonorrhea assure optimal immune function. Eliminating saturated fats such as red meat, butter, cheese, This plan should be used as a complement to and ice cream, even in the short run, will enable antibiotics. the body to utilize essential fatty acids such as the • Vitamin A: 50,000 IU per day for up to 1 week fats from olive oil, canola oil, and ocean fish. and 25,000 IU for 1 additional week (Do not These essential fatty acids are important in the exceed 6,000 IU if pregnant.) promotion of the anti-inflammatory prostaglan- • Vitamin C: 500 mg every 2 hours for 2 days followed by 1,000 mg 3 times daily for 2 weeks dins PgE1 and PgE3; reducing inflammation is a • Carotenoids: 50,000 IU per day for 2 weeks primary goal in healing a sexually transmitted • Zinc: 30 mg per day for 2 weeks infection. • Echinacea: 2 capsules every 2 hours for 2 days Keeping the digestion in order with regular followed by 2 capsules 3 times daily for 2 bowel habits and free of constipation can be weeks; or 1⁄4 tsp tincture every 2 hours for 2 accomplished with a high-fiber diet rich in whole days followed by 1⁄2 tsp 3 times daily for 2 grains, fruits, vegetables, and beans. This will not weeks only minimize digestive side effects if antibiotics • Lactobacillus: 4–8 oz Lactobacillus acidophilus are used in the STI treatment, but will also max- yogurt daily for 2 weeks or 24 billion or more imize the elimination of metabolic toxins that are Lactobacillus acidophilus organisms daily for 2 weeks increased during the infection. • High-dose allicin extract: 2 capsules 4 times Some naturopathic physicians advocate a very daily for the first 3 to 6 days, then 2 capsules light diet or even fasting during an active acute twice daily for 1 week, and then 2 capsules infection. The rationale is to minimize the daily until infection is gone burden on the body so that all of its resources can • Ice packs over the uterus with a hot footbath be utilized for an immune response to fight the or hot water bottle to the feet; repeat twice infection. Fasting is also presumably a more effi- daily as needed cient way of eliminating the metabolic toxins. If SEXUALLY TRANSMITTED INFECTIONS 323 abnormal discharge. They were tested and were the office or clinic. The sexual partner should be found to have chlamydia, candidiases, trichomo- tested if at all possible, but the partner should niasis, bacterial vaginosis, or mixed infections. also be treated with antibiotics, regardless of test- The women were randomized to receive either a ing. Current CDC recommendations are that cream containing neem seed oil, reetha saponin any partner exposure within 60 days should be extract, and quinine or a placebo cream. The evaluated and then treated. It is often the case creams were applied intravaginally at bedtime for that partner evaluation does not occur or is not 14 days. Ten of the 12 patients with chlamydia economically feasible, so many providers rou- who received the treatment cream recovered tinely treat the partner as well. The ability to test within two weeks. Ten of the 17 women with bac- for chlamydia and gonorrhea has significantly terial vaginosis who received the treatment cream improved and now can be done using vaginal, recovered within two weeks. There was no bene- cervical, or rectal swabs, as well as urine testing. fit in women with candidiasis or trichomoniasis. Some labs can now also test for chlamydia and There was no improvement in symptoms or lab gonorrhea on the liquid left over from a liquid test results in any of the women in the placebo Pap test. Pregnant women should always be group. Although there were not enough women screened for chlamydia and gonorrhea. to achieve statistical significance, the cream The CDC now recommends that all women showed encouraging results and should clearly be with positive chlamydia tests have a reevaluation investigated further. It would be very appropriate and testing at three months after their therapy to to try this cream in bacterial vaginosis. In chlamy- look for reinfection. This differs from the test-of- dia infection, it could be used as an adjunct treat- cure evaluations that have been done extensively ment along with antibiotics or following the in the past and are currently not recommended. antibiotics to help prevent recurrence.17 Repeating the test in three months to make sure that the patient is not reinfected is important for CONVENTIONAL preservation of future fertility and prevention of MEDICINE APPROACH tubo-ovarian abscesses. Treating infected patients Chlamydia is the most common reportable sexu- prevents transmission to sex partners. Also, treat- ally transmitted infection in the United States, ing pregnant women often prevents transmission with gonorrhea following second. Both of these of chlamydia to infants during birth. Treatment bacterial illnesses can be present without symp- of sex partners also helps to prevent reinfection of toms, and they are highly transmittable. Both are the initial patient and the infection of other part- very preventable with the use of a condom. The ners. Coinfection with chlamydia and gonorrhea current CDC guidelines (2006) recommend that occurs frequently, and patients should be treated all women under the age of 25 have annual for both diseases when one is found unless test- screenings for both chlamydia and gonorrhea, ing for the other is negative when tested for both. and then anytime a woman has a new partner, The standard antibiotic regimen for treat- screening is recommended. Return visits for a ment of chlamydia would include one of the repeat test for cure were recommended in the following: past, but now they are only done in the cases of • Azithromycin (1 g orally in a single dose) pregnant women. Single-dose therapy is highly • Doxycycline (100 mg orally twice a day for effective, especially when administered in the 7 days) provider’s office. It is thus recommended that, if possible, providers carry a supply of medications Alternative antibiotic regimens would include for administration to the patient before she leaves one of the following: 324 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE • Erythromycin base (500 mg orally 4 times a • Cefotaxime (500 mg administered once day for 7 days) intramuscularly) • Erythromycin ethylsuccinate (800 mg orally None of the injectable cephalosporins offers 4 times a day for 7 days) any advantage over ceftriaxone, which is more • Ofloxacin (300 mg orally twice a day for 7 commonly stocked in offices and clinics. days) Azithromycin (2 g orally) is effective against • Levofloxacin (500 mg orally once daily for 7 uncomplicated gonorrhea, but it is expensive days) and causes significant gastrointestinal distress Since doxycycline, ofloxacin, and levofloxacin are and therefore is not currently recommended contraindicated in pregnant women, azithromy- for treatment of gonorrhea. The gonorrhea cin is probably the drug of choice. in the United States is not adequately suscepti- The standard antibiotic treatment of uncom- ble to penicillins, tetracyclines, and macrolides plicated gonorrhea infections involves one of the (erythromycin) for these to be used in treat- following: ment. • Ceftizoxime (125 mg intramuscularly in a Again, a person being treated for gonorrhea single dose) would also be treated for chlamydia, unless tests • Cefixime (400 mg orally in a single dose) have shown that chlamydia is not present. • Ciprofloxacin (500 mg orally in a single dose) SEEING A LICENSED PRIMARY • Ofloxacin (400 mg orally in a single dose) HEALTH-CARE PRACTITIONER • Levofloxacin (250 mg orally in a single dose) (N.D., M.D., D.O., N.P., P.A.) Quinolone-resistant gonorrhea is on the rise, If you have unprotected sexual contact with and quinolones are not recommended for the someone who has chlamydia, gonorrhea, or hep- treatment of gonorrhea in regions where the rate atitis B, I strongly urge you to see a licensed prac- of resistant gonorrhea is high. The main areas in titioner (naturopathic doctor, medical doctor, the United States where quinolones use is not osteopathic doctor, nurse-practitioner, or physi- recommended are California and Hawaii. Some cian’s assistant) who is trained and qualified to inner-city areas and other regions also have these perform a physical exam and take samples for warnings, so it is important for the practitioner testing and also capable of administering or to be aware of regional resistance patterns. The making available prescription antibiotics and CDC recommends the following treatment for vaccine. This does not necessarily require a gyne- patients at high risk for quinolone resistance: cologist or other conventional practitioner. • Ceftriaxone (125 mg intramuscularly in a Licensed naturopathic physicians are trained to single dose) perform and provide these services. State law • Cefixime (400 mg orally in a single dose) determines which antibiotics naturopathic physicians may prescribe. If a practitioner cannot pre- Other antibiotic regimens for gonorrhea scribe a particular antibiotic, he or she can either treatment include single-dose injectable cepha- refer you to a conventional practitioner or work losporin regimens such as one of the following: in cooperation with a conventional practitioner • Ceftizoxime (500 mg intramuscularly) who can make a prescription available to you. • Cefoxitin (2 g IV) administered with Nutritional and herbal supplements can then be probenecid (1 g orally) used in addition to your conventional treatment. SEXUALLY TRANSMITTED INFECTIONS 325 A naturopathic physician can also provide natu- If you have severe liver disease due to hepati- ral therapies to augment your immune sup- tis B, I would strongly consider alternative treat- port, prevent side effects from the medications, ments as the primary treatment, with careful and help you to recover optimally from the monitoring of liver enzymes and liver biopsy infection. with the help of a specialist. This page intentionally left blank UTERINE FIBROIDS CHAPTER 19

OVERVIEW lining (endometrium). Although these findings Uterine fibroids (also known as leiomyomas or may help to explain why fibroids are sensitive to myomas) occur in 20 to 25 percent of women by estrogen, they have not been consistently sub- age 40,1 more than 50 percent of women overall. stantiated in other studies.7, 8 This higher con- They are the most common solid pelvic tumors centration of estrogen receptors may be due to in women and the most common indication for changes in estrogen metabolism within the fibroid major surgery in women, and they account for itself. Pollow and colleagues8 demonstrated a sig- approximately one-third of hysterectomies each nificantly lower conversion of estradiol into year.2 According to some studies, in African- estrone in fibroids than in the myometrium, sug- American women the incidence of fibroids is gesting that local, concentrated estradiol increases three to nine times higher and the fibroids’ rate within the fibroid may play a role in the cause and of growth is increased.3, 4 growth of fibroids. You would think for a condition as common The prevalence and size of fibroids are greater as this that we would have a good understanding in women who do not ovulate or who have of the cause and cure. Nevertheless, the cause of endometrial hyperplasia or a granulosa cell tumor fibroids remains poorly understood. Uterine of the ovary. Even though fibroids do not lead to fibroids are not actually fibrous but consist of cancer and are not a cause of uterine cancer, they muscle, probably uterine smooth-muscle cells are associated with a fourfold increase in the risk but possibly connective tissue or the smooth- of endometrial carcinoma. This is probably muscle cells of uterine arteries. The growth of because too much estrogen without any or enough fibroids may be stimulated by estrogen. The ten- progesterone (called unopposed estrogen) is a con- dency of fibroids to arise during the reproductive tributing factor in both conditions. years, grow during pregnancy, and regress post- Fibroids come in all sizes and shapes and usu- menopausally does implicate estrogen as one ally occur as multiple tumors, although each factor in the cause and growth of fibroid tumors. fibroid is discrete. Most discernible fibroids are A growth spurt in fibroids is frequently seen in between the size of a walnut and the size of an the perimenopausal period and is likely due to orange, but unusual tumors have been reported anovulatory cycles with a relative estrogen excess up to 100 pounds. Fibroids are classified accord- that commonly occur during this period. Preg- ing to their location. They are either submucosal nancy is a condition of elevated estrogen and (just under the endometrium), intramural (within progesterone, and even though progesterone is the uterine muscle wall), or subserosal (from the an antiestrogen, the increased blood supply outer wall of the uterus). They can also be during pregnancy leads to an overall stimulating intraligamentous (in the cervix between the two effect on the uterine fibroids.5 layers of the broad ligament), pedunculated and There have been reports that concentrations dangling from a stalk into the uterine cavity of estrogen receptors in fibroid tissue are higher (pedunculated submucous), or pedunculated on than in the surrounding uterine muscle tissue the outside of the uterine wall (pedunculated sub- (myometrium)6 but lower than in the uterine serous). The pedunculated submucous fibroids 327

Copyright © 2008 by Tori Hudson. Click here for terms of use. 328 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE can on occasion protrude through the cervix into although they may not be the cause or the only the vagina. Other pedunculated fibroids on a long cause of the pain.16, 17 stalk outside the uterus can be mistaken for an There may also be racial differences when it ovarian mass or attach to the bowel. comes to pelvic pain and uterine fibroids. One The majority of fibroids (an estimated 50 to study reported that 41 percent of white and 59 80 percent)9 don’t cause any symptoms, but when percent of black hysterectomy patients with a symptoms do occur they often begin as a vague presurgical diagnosis of fibroids reported severe feeling of discomfort and may include a feeling pelvic pain.18 Another study reported a series of of pressure, congestion, bloating, heaviness, pain studies in which pelvic pain and/or menstrual pain with vaginal sex, urinary frequency, backache, was experienced in 34 percent of patients with abdominal enlargement, and abnormal bleeding. fibroids.19 In a recent study, the first population- Abnormal bleeding occurs in only 30 percent of based study of gynecologic pain symptoms and women with fibroids. Heavy bleeding (menor- fibroids, dyspareunia (pain with vaginal sexual rhagia) results when intramural tumors enlarge activity) and noncyclic pelvic pain, but not dys- the endometrial cavity and increase the surface menorrhea (menstrual pain), increased in severity area of endometrium and blood supply to the with the presence of uterine fibroids.20 Pregnant uterus. Intermenstrual bleeding (metrorrhagia) women with fibroids also have reported pelvic results when submucous fibroids ulcerate through pain more frequently, and it seems that the pelvic the endometrial lining or cause congestion of the pain is related to the size of the fibroid(s) and their surrounding blood vessels. location.21, 22 Fibroids can undergo degenerative changes. So you might now be confused: do fibroids One type of degenerative change is when the con- cause pelvic pain or not? The majority of the tinued growth of the fibroid outgrows the blood time, uterine fibroids do not cause pelvic pain; supply. A more common type of degenerative however, if you have chronic pelvic pain, fibroids change is when there is a loss of cellular detail may in fact be a cause of that chronic pelvic pain, (hyaline degeneration) as a result of a decrease in especially if they can be palpated on the pelvic the vascularity of the tumor. Necrosis (cell death) exam. Some of the urinary complications that results in cystic degeneration, which lends itself to occur in 5 percent of fibroids are cause for con- a softer than usual consistency and can be concern because they may be due to compression of fused with an ovarian mass on exam or pelvic the ureter (outflow tract from kidney to bladder) ultrasound. Calcification can occur over time and that can cause enlargement of the kidneys and is usually seen in postmenopausal women. compromise of kidney function. The historical perspective has been that Fibroids are thought to be the cause of 2 to 10 fibroids are not usually associated with pain except percent of cases of infertility. There are several pos- when degeneration occurs or when the uterus sible reasons for this. The tumors may interfere contracts in its efforts to expel a submucous with implantation of the fertilized ovum, they may fibroid. Feelings of pressure pains may develop if cause compression on the fallopian tubes and inter- the uterus becomes excessively enlarged with fere with motility of sperm or egg, or they may fibroids, or if a single fibroid is larger than 5 cm at cause early miscarriage. They may also cause peri- its greatest diameter.10 However, if we look a little odic anovulation or abnormal uterine blood flow harder at some of the research, clinic-based studies and may obstruct sperm. Large fibroids may affect suggest that gynecologic pain is often related to pregnancy by interfering with the fetus growth, the presence of fibroids.11–15 Fibroids are com- leading to potential intrauterine growth retarda- monly found in women with chronic pelvic pain, tion, premature rupture of membranes, retained UTERINE FIBROIDS 329

KEY CONCEPTS PREVENTION

• Uterine fibroids are benign and common. • Ensure regular ovulation. • We do not know what causes fibroids. • Avoid situations that promote lack of ovulation, • Fibroids are estrogen dependent (some may even such as stress. be progesterone dependent). • Avoid estrogen-only medications. • The majority of the time there are no symptoms, • Dietary phytoestrogens (soy, flax, red clover) do but when there is pelvic pain, abnormal bleed- not appear to stimulate the growth of fibroids. ing, or infertility, uterine fibroids must be • Practice good nutritional habits with a diet that considered. is higher in complex carbohydrates, higher in • Abnormal bleeding may be caused by uterine fruits and vegetables, and low in saturated fats, fibroids. alcohol, sugar, or other foods that interfere with • Abnormal bleeding warrants a visit to your the liver’s role in metabolizing hormones. health-care practitioner. • Maintain a healthy weight. Obesity can lead to • There are several kinds of fibroids based on higher estrogen effects on the uterus. location. • An enlarged uterus or abnormal finding on a pelvic exam may require further testing to imaging test is able to identify fibroids and delin- determine the diagnosis. eate the size and to some degree the location, as • Less than 1 percent of fibroids are malignant, well as identify that the ovaries are normal in size. but rapidly growing fibroids warrant further exploration. The ultrasound detects the contours of the uterus, the fibroids (called hypechoic masses), compression of the ureters, any potential enlarge- placenta, postpartum hemorrhage, abnormal labor, ment of the kidneys caused by the compression, or an abnormal lie of the fetus. Not all practicing and, of course, the presence of an enlarged uterus. obstetricians would agree with these reports, and It is difficult for the ultrasound to detect fibroids their main observations with pregnant women and smaller than 2 cm. A magnetic resonance imaging large fibroids are an abnormal lie or postpartum (MRI) test is more accurate in assessing the hemorrhage. The incidence of miscarriage due to number, size, and location of fibroids, but it does fibroids is unknown but estimated to be two to not provide significant enough additional infor- three times greater than normal. mation to be worth the cost. A hysteroscopy can If a fibroid uterus is present, it can often be detect submucous tumors. An x-ray can diagnose felt during a pelvic examination. It usually feels calcified fibroids. firm but can vary from soft to rock-hard. The The main diagnostic consideration is differ- uterus can be irregularly shaped or irregularly entiating a possible fibroid from the following enlarged and often feels like it has protrusions. conditions: ovarian malignant tumor, an abscess Most of the time it is not painful during the in the fallopian tube/ovarian region, a diverticu- exam. Many times women don’t realize they have lum from the colon, a pelvic kidney (rare), endo- a fibroid until the practitioner finds it. This is not metriosis, adenomyosis (endometriosis within cause for alarm. Fibroids are benign growths the muscle wall of the uterus), congenital anom- most of the time. The worrisome fibroid is a rap- alies, adhesions in the pelvis, or a rare retroperi- idly growing one; the rare malignant uterine sar- toneal tumor. Not all of these considerations can coma may have to be considered in these cases. be distinguished from the medical history, phys- After the pelvic exam, a pelvic ultrasound is ical exam, and pelvic ultrasound. Surgery may be the most useful tool in diagnosing a fibroid. This required to distinguish one condition from the 330 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE other. Laparoscopy is the definitive method of some kind of conventional intervention. My excluding these other diagnoses from fibroids, main goals with women who have large fibroids even though laparoscopy is not typically done to are to (1) deal with problem symptoms, (2) try to diagnose fibroids. Only when there is great con- stabilize the situation and hold out until meno- cern or lack of clarity about the diagnosis will the pause, and (3) recognize the clinical situations procedure be warranted. when conventional treatment intervention is appropriate and reasonable. OVERVIEW OF One aspect of being a naturopathic physician ALTERNATIVE MEDICINE is to more fully educate patients about their Over the more than 23 years I have been in clin- health and health problems so that they can ical practice, not many health problems have make informed decisions about their health care. eluded successful treatment as consistently as With uterine fibroids, I have often been in the uterine fibroids. Women who are seeking an position of discussing surgical options or proce- alternative to drug or surgical treatment for uter- dures that not all gynecologists discussed with ine fibroids will not find an easy, reliable alterna- their patients. Educating the woman who is tive to shrink the tumors with natural medicine. faced with a possible hysterectomy and finding a Using the protocols in this book, we are usually surgeon or gynecologist who is skilled in these able to successfully resolve or improve most alternatives may be the most important service symptoms that relate to the fibroids such as an alternative provider can offer. There are many abnormal bleeding, pelvic pain or pressure, and new conventional therapies that can be alterna- backache. In addition, there are natural therapies tives to a hysterectomy in many cases. These that may be able to slow the growth of the new therapies include hysteroscopic resection, fibroids to avoid further problems. embolization, and laparoscopic surgery. How- When it comes to shrinking fibroids, espe- ever, not all cases of fibroids may be successfully cially the large ones, natural therapies can only treated with these methods. significantly shrink a small minority of cases. There are individual cases that report reduction Nutrition in size on pelvic ultrasound, disappearance of Even though diet changes alone are unlikely to symptoms, and even total disappearance of any shrink fibroids, good dietary habits are still evidence of fibroids. I myself can report cases important. Clinical observation has taught me where fibroid growth and the size of the uterus that all natural therapies work best in the context have been significantly reduced. The problem is of a healthy lifestyle. Improving one’s diet may that the results are very inconsistent. Often the help in small ways, to decrease heavy bleeding or cases that have shown the most dramatic the pain and discomfort caused by the fibroids. improvements are the women who are nearing Besides these potential benefits, dietary improve- menopause or postmenopausal whose fibroids ments will improve your general well-being. shrink because of the natural decrease in their Also, women with uterine fibroids may be at estrogen levels. higher risk for endometrial cancer due to the It may be possible to reduce uterine fibroids higher estrogen levels. A diet high in saturated through alternative means and avoid a surgery or fats is associated with higher blood levels of estro- drug treatment that your gynecologist has rec- gen, potentially exacerbating the problem. Low- ommended, but, more likely than not, large fiber diets are associated with elevated estrogen fibroids that are causing symptoms that have not levels and poor excretion of estrogen. Poor nutri- been successfully dealt with will indeed require tional habits can also lead to dysfunctional estrogen UTERINE FIBROIDS 331 metabolism and inhibit the body’s ability to some of the raw materials it needs to carry out its break down and excrete excess estrogen. metabolic processes and regulate estrogen levels. The tradition of naturopathic medicine holds A recent animal study suggests that lycopene sup- that the health and vitality of an individual plementation (high in yellow/orange fruits and depends on the health of the liver and the whole vegetables and especially high in tomatoes, digestive system. The liver’s basic functions are tomato sauce, and tomato juice) may decrease the vascular, secretory, and metabolic. As a vascular incidence and size of leiomyomas.23 Another organ, the liver is a major reservoir of blood study extolled the benefits of a vegetarian diet by and filters over one quart of blood per minute. finding that women who suffered from fibroids The liver removes bacteria, endotoxins, antigen- were more likely to have high consumption of red antibody complexes, and other particles from the meat and ham and have low consumption of circulatory system. The liver’s secretory functions fruits and green vegetables.24 are the synthesis and secretion of bile. The liver Whole grains such as brown rice, oats, buck- manufactures about one quart of bile daily. Bile wheat, millet, and rye are excellent sources of B is required for the absorption of fat-soluble sub- vitamins. Whole grains also help the body to stances, including some vitamins. The majority excrete estrogens through the bowel. The role of of the bile secreted from the liver into the intes- whole-grain fiber in lowering estrogen levels was tines is reabsorbed. The metabolic functions of first reported in 1982.25 This study found that the liver are involved in carbohydrate, fat, and vegetarian women who eat a high-fiber, low-fat protein metabolism; the storage of vitamins and diet have lower blood estrogen levels than minerals; the formation of numerous biochemi- omnivorous women with low-fiber diets. Once cal factors; and the detoxification or excretion again, we can see why a high-fiber diet might into the bile of hormones such as estrogen as well prevent and perhaps reduce uterine fibroids as histamines, drugs, and pesticides. through the estrogen connection. The liver not only has to process the foods A high-fiber diet may also help relieve some that we eat every day but also detoxifies harmful of the bloating and congestion associated with substances, both those we produce from normal fibroids. By bulking up the stool and regulating metabolism and those we are exposed to in our bowel movements, some of these symptoms may environment. In addition, it metabolizes and improve. Some women have a hard time tolerat- deactivates hormones. The liver metabolizes ing increased fiber in their diet because of com- estrogen so it can be eliminated from the body by promised digestive function. In these cases, it converting it to estrone and finally to estriol, a may be necessary to increase fiber slowly and weaker form of estrogen that has very little abil- include digestive support such as enzymes or ity to stimulate the uterus. If the liver cannot acidophilus. effectively metabolize estradiol, the uterus may Because there is an association between become overestrogenized and respond with having uterine fibroids and a fourfold increase in fibroid growths. the risk of endometrial cancer,1 three dietary rec- Saturated fats, sugar, caffeine, alcohol, and ommendations stand out above all else: increase junk foods are unhealthy and problematic for two fiber, decrease dietary fat, and increase soy prod- reasons: (1) they interfere with the body’s ability ucts and other legumes. Researchers at the to metabolize estradiol to estrone to estriol, and Cancer Research Center at the University of (2) some of these foods are deficient in B vitamins Hawaii published a case-controlled, multiethnic or interfere with B-vitamin metabolism. If B vita- (Japanese, Caucasian, Native Hawaiian, Filipino, mins are lacking in the diet, the liver is missing and Chinese) population study to examine the 332 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE role of dietary soy, fiber, and related foods and indicated that isoflavones are selectively estro- nutrients on the risk of endometrial cancer.26 genic and antiestrogenic; they have an estrogenic The diets of 300 women with endometrial effect on some tissues and organs and an anticancer were compared with women in the gen- estrogenic effect on others. Soy foods may be eral multiethnic population. The researchers analogous to a class of drugs called selective estro- found that high fat intake was positively associ- gen receptor modulators (SERMs). In the uterus, ated with endometrial cancer, whereas a diet rich soy isoflavones appear to have an antiestrogenic in fiber, soy, and other legumes reduced the risk effect, with the possible exception of when they are of endometrial cancer. The study concluded that used in high doses daily for a longer term. plant-based diets low in calories from fat, high in Long-term high-dose use of soy may be dif- fiber, and rich in legumes (especially soybeans), ferent than the usual average typical daily con- whole-grain foods, vegetables, and fruits reduce sumption of soy. In one study, one group of the risk of endometrial cancer. postmenopausal women were given soy tablets While I can’t say that lowering fat and containing 150 mg of soy isoflavones per day increasing soy and fiber intake will definitely pre- for five years.28 The second group received an vent or treat fibroids, these nutritional habits do identical placebo tablet for five years. Results of lower the risk of endometrial cancer. Since uter- endometrial biopsies were obtained at baseline, ine fibroids are associated with an increase in the 30 months, and five years after the beginning risk of endometrial cancer, it logically follows of the treatment. At the five-year endpoint, 70 that these diet recommendations could help with percent of the women on the 150 mg of soy fibroids. isoflavones had atrophic tissue versus 81 percent Some people have raised the concern that who received the placebo. After five years, the women with uterine fibroids should avoid soy incidence of endometrial hyperplasia was signifi- foods for their high content of phytoestrogens cantly higher in the isoflavone-treated group, (specifically isoflavones) because phytoestrogens 3.37 percent versus 0 percent. There were five may have a weak estrogenic effect. The answer cases of simple hyperplasia and one of complex appears to be that this is not necessary. Soy hyperplasia. No cases of atypical hyperplasia or phytoestrogens do not have an estrogenic effect endometrial cancer occurred during the five on the uterus, at least in the usual doses. This was years. This is the first study that raises concerns most recently confirmed in a Chinese study.27 about long-term, high-dose isoflavone supple- This population-based, case-controlled study mentation and its effects on the endometrium. It obtained detailed information from a food- would typically take three to five servings of soy frequency questionnaire on soy food intake over foods per day to achieve 150 mg. One serving five years. The participants were 832 women, per day of soy foods is only 25 to 60 mg per day, ages 30 to 69, who were diagnosed with endome- depending on the soy food item. trial cancer from 1997 to 2001. This group was Isoflavones appear to be able to act as a par- compared with 846 control-matched women tial agonist, binding to the estrogen receptor. selected from the Shanghai Residential Registry, Because the action of isoflavones is weaker than who had an average intake of 42.5 mg of soy- that of endogenous estrogens at low doses and for based isoflavones per day. short durations, these phytoestrogens seem to This study demonstrated that regular con- be antagonistic. They are able to counteract the sumption of soy foods, as either soy protein or effects of endogenous estrogens. When treatment soy isoflavones, was inversely associated with the is prolonged and at a higher dose, the agonist risk of endometrial cancer. Moreover, this study effects are more evident and the isoflavones have UTERINE FIBROIDS 333 an estrogenic effect. It is important to note that Pancreatic Enzymes. There are three cate- at 30 months there was no difference between gories of pancreatic enzymes: the isoflavone-treated group and the placebo • Lipases: enzymes that help digest fats along group. It was only after five years that the dose with bile. A deficiency of lipase results in of 150 mg per day produced an estrogenic effect malabsorption of fats and fat-soluble in a small number of women. vitamins. The subject of phytoestrogens is discussed in • Amylases: enzymes that break down starch more detail later in this chapter and in Chapter molecules into smaller sugars. 12 in the discussion of menopause. • Proteases: trypsin, chymotrypsin, and car- boxypeptidase break down protein molecules Nutritional Supplements into single amino acids. As mentioned earlier, many of the symptoms of Supplementation with pancreatic enzymes is enlarged fibroids can be effectively treated using usually done to treat pancreatic insufficiency. natural therapies. For abnormal bleeding and Pancreative insufficiency manifests itself in pelvic pain, refer to Chapters 1 and 13. In this symptoms of abdominal bloating, gas, indiges- section, I will largely be discussing the traditional tion, undigested food in the stool, malabsorp- naturopathic methods of trying to reduce the size tion, and nutrient deficiencies. Other clinical of uterine fibroids or to inhibit their growth. uses of pancreatic enzymes are for treatment of These recommendations are based more on tra- cystic fibrosis, rheumatoid arthritis, athletic dition, theory, logic, and clinical experience than injuries, and—one of the most controversial on scientific evidence. uses—the treatment of cancer. Lipotropic Factors. Supplements such as The logic for the treatment of uterine fibroids inositol and choline exert a lipotropic effect, is similar to the logic for the treatment of cancer. meaning they promote the removal of fat from Enzyme preparations have been used at the Con- the liver. Lipotropic supplements are usually a treras Clinic in Mexico and by Drs. William combination vitamin and herbal formulation Kelley and Nicholas Gonzalez as part of a cancer and sometimes an animal liver extract designed treatment protocol. There is little evidence in to support the liver’s function in removing fat, the scientific literature to support their use, but detoxifying the body’s wastes, detoxifying exter- the logic is that the pancreatic enzymes will nal harmful substances (pesticides, fossil fuels, digest the protein cell membrane surrounding etc.), and metabolizing and excreting estrogens. the malignant cells. By doing so, the immune These lipotropic products vary in their formula- cells will then be able to enter the cancer cells and tions depending on the manufacturer, but they alter the abnormal cell division of the cancer are all similar and have the same uses in mind. cells. In the case of uterine fibroids, the belief is Because the liver is the most important organ of that the pancreatic enzymes will help to digest metabolism, naturopathic physicians believe that the fibrous/smooth muscle tissue and dissolve the when the liver function improves, metabolism fibroids. When used for this purpose, the pancre- improves, making this treatment fundamental to atic enzyme supplement must be taken between the treatment of many chronic diseases. meals rather than with meals.

Lipotropic Factors Pancreatic Enzymes 1–4 tablets per day with meals 2–4 capsules 3 times per day between meals 334 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE

Botanical Medicines decreased fibroid growth in vitro.29–31 Other Traditional Herbs. Many plants have been botanicals used in traditional Chinese medicine used in traditional herbal medicines designed to that show some promise in treating fibroids in treat women with uterine fibroids. The plants vivo include poria and cinnamon.32 and herbal formulations talked about here are Traditional herbalists have developed various used to try to shrink uterine fibroids; herbs used botanical uterine fibroid protocols and report to deal with abnormal bleeding and uterine modest success in reducing the size and number cramping are discussed in Chapters 1 and 13. of uterine fibroids. I have used many herbs and Scutellaria barbata, commonly used in tradi- herbal formulations over the years in an attempt tional Chinese medicine for its purported antitu- to shrink fibroids, and I present the protocol mor properties, was shown to inhibit the below from one of the traditional herbalists, Rick proliferation of uterine smooth muscle cells and Scalzo, as an option for your consideration. (See act as an aromatase inhibitor contributing to the Resources for a listing of herbal companies.)

Scalzo’s Protocol

Scudder’s Alterative Goldenseal root (Hydrastis canadensis) Lobelia (Lobelia inflata) Corydalis tubers (Dicentra canadensis) Ginger root (Zingiber officinale) Black alder bark (Alnus serrulata) Mayapple root (Podophyllum peltatum) Add 30 drops to a small amount of warm water and Figwort flowering herb (Scrophularia nodosa) take 3 times daily. Yellow dock root (Rumex crispus) Add 30–40 drops to a small amount of warm water Turska Formula and take 3 times daily. Gelsemium root (Gelsemium sempervirens) Poke root (Phytolacca americana) Echinacea/Red Root Compound Aconite (Aconitum napellus) Echinacea (Echinacea spp) Bryonia root (Bryonia dioica) Red root (Ceanothus americanus) Add 5 drops to a small amount of warm water and Baptisia root (Baptisia tinctoria) take 3 times daily. Thuja leaf (Thuja occidentalis) Stillingia root (Stillingia sylvatica) Other Herbal Extracts to Consider Blue flag root (Iris versicolor) Prickly ash bark (Xanthoxylum clava-herculus) Chaste tree (Vitex agnus castus) Nettle (Urtica dioica) Add 30 drops to a small amount of warm water and Burdock root (Arctium lappa) take 3 times daily. Dandelion root (Taraxacum officinale) Oregon grape (Berberis aquifolium) Fraxinus/Ceonothus Compound Mountain ash bark (Fraxinus americanus) Topical Preparations Red root (Ceanothus americanus) Poke root oil: rub onto the belly over the uterus Life root (Senecio aureus) nightly before bed. Mayapple root (Podophyllum peltatum) Castor oil packs: apply over pelvis 3–5 times per Helonias root (Chamaelirium luteum) week. (See Appendix D for instructions.) UTERINE FIBROIDS 335 Herbal Phytoestrogens. There are three types if they have an estrogenic effect, they should be of naturally occurring estrogen-like substances avoided by women with uterine fibroids or called phytoestrogens found in plants: resorcylic endometrial cancer. We talked earlier about soy- acid lactones, steroids and sterols, and phenolics. beans and how they are actually associated with a Phytoestrogens are present in virtually every plant reduced incidence of uterine cancer.26 I do not in at least modest levels, with some plants having believe that eating a high soy diet is something to particularly high levels. Resorcylic acid lactones be concerned about; in fact I recommend are not true phytoestrogens but are mycotoxins increasing the soy foods in the diet in order to produced by soil-dwelling molds. Their presence reduce the estrogen burden in the body. in plants is the result of contamination with Most of the research on the effects of phyto- molds. Steroids are the classic steroidal estrogens estrogens on the uterus is found in relationship (estradiol and estrone) and are found in very to the agricultural industry and the health of minute amounts in a few plants such as apple seed, grazing animals. In the 1940s, it was reported date palm, and pomegranate seed in the range of that the red clover sheep grazed on in Australia one to ten parts per billion.26, 33, 34 Diosgenin is a was responsible for their infertility.37 A Finnish steroid derivative and is found in at least 20 plants, study of pasture legumes determined that red including wild yam species. Beta-sitosterol is the clover contained the highest concentrations of most common phytosterol and is distributed phytoestrogens38 and that abundant intake of red widely through the plant kingdom. It is found in clover resulted in fertility problems in cattle.39 plant oils such as wheat germ oil, cottonseed oil, In one study on the effects of phytoestrogens in and soybean oil. Beta-sitosterol is the dominant sheep, it was noted that both coumestans and phytosterol found in garlic and onions. Herbal isoflavones produce changes in the typical stimula- sources include licorice root, saw palmetto, and tion with steroidal hormones such as estradiol in red clover. Stigmasterol is closely related to beta- all of the target organs.40 Among these changes was sitosterol. Soybean oil is an important source of an increase in uterine weight. Other investigators stigmasterol and is a better source for laboratory have examined the binding of phytoestrogens to synthesis of progesterone than is beta-sitosterol. the uterus and vagina. Coumestrol has temporarily Some herbal sources include burdock, fennel, enhanced the uptake of estradiol by the uterus and licorice, alfalfa, anise, and sage. vagina only one hour after being injected into The phenolic phytoestrogens are members of mice.41 Researchers also noted that coumestrol the flavonoids, the largest single family of plant actually inhibited the uptake of estradiol by the substances, which has over 4,000 individual mem- uterus over the long term, and they postulated that bers. The term flavonoid derives from the Latin there was actually an inhibitory effect at the estra- flavus meaning “yellow” because the flavonoids are diol receptor sites. Other researchers have noted responsible for the yellow, red, white, and blue that coumestans and isoflavones compete with pigments in plants. Phenolics include isoflavones, estradiol for uterine receptor sites but have less which are higher in legumes and especially soy- affinity for them than estradiol.42 beans than any other plants; coumestans, with one Coumestrol has been found to increase uterine known estrogenic member (coumestrol) that is weight at a 100 mcg dose when given to rats at a approximately six times more estrogenic than the certain time in the development of glands.43 It isoflavones;35, 36 and lignans, high in grains and appears that the weak estrogenic effect of phyto- cereals and highest in flaxseed. estrogens is variable and can even be weakly anti- There has been some concern and contro- estrogenic. Variability is based on dose, target tissue, versy about how phytoestrogens affect the uterus; the woman’s hormonal environment, and more. 336 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Higher does of phytoestrogens have stimu- nance is a much greater problem than is recog- lated some concern. However, it is reassuring that nized by conventional medicine. “Since many in countries with a high intake of phytoestrogens women in their mid-thirties begin to have (Japan, Thailand, China), women do not have an nonovulating cycles, they are producing much increase in uterine fibroids. However, they do less progesterone than expected, but still produc- have a four- to sixfold lower incidence of breast ing normal (or more) estrogen. They retain water cancer44 (also an estradiol target tissue), although and salt, their breasts swell and become fibrocys- how a substance affects one tissue is not necessar- tic, they gain weight (especially around the hips ily translated to how it affects another. and torso), they become depressed and lose sex Again, though, I must come back to the drive, their bones suffer mineral loss, and they effects of soy on the endometrium, which may be develop fibroids. All are signs of estrogen domi- different than some of the other plants, most nance relative to a progesterone deficiency. When notably red clover. Like data on breast cancer, sufficient natural progesterone is replaced, data on women of different cultures support the fibroid tumors no longer grow in size (they gen- conclusion that soy phytoestrogens are not an erally decrease in size) and can be kept from estrogen stimulus for the endometrium. Rather, growing until menopause, after which they will they probably act as an estrogen antagonist and atrophy. This is the effect of reversing estrogen are associated with low rates of endometrial dominance.”50 The preferred form of natural cancer in countries where soy phytoestrogen progesterone for treating fibroids (unless heavy intake is high.45 bleeding is involved) is a topical cream with at Based on these studies, my recommendation least 400 mg of progesterone per ounce. to those with uterine fibroids is to eat a diet high Be advised, however, that there is a counter in soy products; however, my current cautionary theory about the relationship of progesterone to advice would be to avoid the use of red clover. uterine fibroids. Dr. Mitchell Rein and his col- In cases where conventional treatment with leagues at Brigham and Women’s Hospital pub- GnRH inhibitors is needed, thus causing a phar- lished a report in 1995 stating that not only is maceutically induced menopause, Ipriflavone (a there no evidence that estrogen directly stimu- semisynthetic soy derivative) supplementation lates myoma growth, but that it is actually prog- has been helpful at preventing side effects such as esterone and progestins that promote the growth bone loss and increased LDL.46, 47 of fibroids.51 The authors cite the biochemical, histologic, and clinical evidence that supports an Natural (Bio-Identical) Progesterone. His- important role for progesterone and progestins in torically, studies have suggested that proges- the growth of uterine myomas. Their compre- terone may inhibit growth of uterine fibroids. hensive hypothesis is based on an analysis of A. Lipschutz demonstrated that progesterone many different technical studies, which they con- administered to guinea pigs prevented formation clude suggest that the development and growth of tumors that had been induced by estrogen.48 of myomas involves a multistep chain of events. In 1946, A. Goodman reported six cases of clin- Since both of these schools of thought are ically diagnosed uterine fibroids that regressed theoretical, I encourage all women and their after using progesterone therapy.49 health-care practitioners to educate themselves so Dr. John Lee proposes that because uterine as to make the best individual decision. Fibroids fibroids are a result of estrogen stimulation and are generally not urgent or life threatening, so what he calls estrogen dominance, progesterone there is room for experimentation and observa- is the solution. He asserts that estrogen domi- tion to determine the best course of treatment. UTERINE FIBROIDS 337

Sample Treatment Plan for Uterine Fibroids

Diet Botanicals

• Eat a high-fiber, low-fat diet. See the Resources section for sources. • Eat a diet high in whole grains (brown rice, oats, buckwheat, millet, rye, whole wheat). • Scudder’s Alterative: 30 drops 3 times per • Eat a diet high in fruits and vegetables. day • Eat a diet high in flaxseed, particularly ground • Echinacea/Red Root Compound: 30 drops 3 flaxseed. times per day • Eat a diet high in legumes, especially soy • Fraxinus/Ceonothus Compound: 30 drops 3 products, 1 serving per day. times per day • Avoid saturated fats, sugar, caffeine, alcohol, • Gelsemium/Phytolacca Compound (Turska and junk foods. Formula): 5 drops 3 times per day See Chapter 1 for abnormal bleeding problems. See Nutritional Supplementation Chapter 13 for pelvic and menstrual pains. • Lipotropic factors: 1–2 tablets twice daily with meals • Pancreatic enzymes: 2–3 capsules 3 times per day between meals

In cases of fibroids where heavy bleeding exists, Natural (Bio-Identical) Progesterone Cream progestogens or estrogen is used to manage the 1⁄4 tsp of a cream containing at least 400 mg/oz 1 to 2 bleeding, and any anemia is treated with iron times daily for 1 week after menses; 1⁄4 to 1⁄2 tsp twice supplements. Treatment of fibroids with progesta- daily for the next 2 weeks. Discontinue for 1 week dur- tional agents (norethindrone, megestrol, medroxy- ing menses. Apply the cream to the inner arms, chest, progesterone acetate) has been used, but there is inner thighs, and/or palms. no consensus regarding the routine use of these drugs to shrink fibroids. The progestational agents produce a hypoestrogenic effect by inhibiting CONVENTIONAL gonadotropin secretion and suppressing ovarian MEDICINE APPROACH function. They may also have a direct antiestrogen Small fibroids that cause few symptoms require no effect. Even though estrogen and progestogens treatment, only observation of growth, which can may be necessary to control bleeding from be done with annual pelvic exams. If the patient fibroids, most practitioners do not consider them notices new symptoms, or the physician thinks useful in shrinking fibroids. When used to control there is a change in the fibroid, ultrasound can bleeding, there is always a concern about the pos- follow and assess the location and size of fibroids. sible effect on the increase in growth of the fibroid, Because there is some concern about estrogen’s so fibroids need to be periodically evaluated by role in promoting the growth of fibroids, use of physical exam and/or pelvic ultrasound. oral contraceptives in premenopausal women and Agents such as leuprolide acetate (Lupron) hormone therapy in postmenopausal women have been used to temporarily control bleeding, should be prescribed with care, close follow-up, correct anemia, and shrink tumors. This allows a and the lowest doses possible. large tumor to shrink to a more manageable size. 338 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE Lupron can be used to change the need for an tions of the vagina are maintained. With a vaginal abdominal hysterectomy to a vaginal or laparo- hysterectomy, the entire uterus, including the scopic type, which shortens patient recovery. cervix, is removed. In either case, the decision to Lupron suppresses ovarian estrogen secretion, leave the ovaries depends on the patient and her thereby causing temporary and reversible med- doctor. Most doctors would recommend leaving ical menopause. The use of GnRH analogs has ovaries in women under 45 and might recom- successfully reduced uterine and tumor size by mend removing them in women over 45 because 40 to 65 percent. Most reduction occurs within they will soon be menopausal, oftentimes to pre- 8 weeks, and maximum reduction occurs within vent ovarian cancer. However, we cannot remove about 12 weeks. After the treatment is discontin- all of our organs to reduce the risk of cancer. Since ued, the uterus and fibroids often return to their the lifetime risk of ovarian cancer is 1 in 70, original size within three months. On occasion, women with healthy ovaries should be encouraged the use of Lupron may make surgical treatment to leave them in place when possible. Special cir- unnecessary, but usually the solution is tempo- cumstances, such as a strong family history of rary and surgery is inevitable. ovarian cancer, might warrant their removal. One of the most significant disadvantages of Myomectomies are particularly appropriate Lupron is that it is expensive, costing approxi- for women who wish to retain their childbearing mately $600 per month. The other is that it puts option or in women with a small submucous the patient into an instant menopausal state with myoma that causes a bleeding problem. Most hot flashes and other side effects, which can be myomectomies for large intramural fibroids are controlled with very small add-back doses of done abdominally. Laparoscopic myomectomies either estrogen or a progestogen. The GnRH for intramural or subserosal fibroids are very rare, analogs cannot be used long-term (more than six and there are only a few physicians in the United months) because they can lead to irreversible States capable of performing them. Abdominal bone loss and elevated total cholesterol. myomectomies have many of the same risks asso- The standard surgical treatments for uterine ciated with a hysterectomy and can often be fibroids are a hysterectomy or a myomectomy. associated with more blood loss. Many women Hysterectomy, the removal of the uterus, is the feel much more comfortable with retaining their only approach that provides a permanent solution reproductive organs and should be encouraged for fibroids. Myomectomies are surgeries that to find a physician who is comfortable with remove the fibroids but leave the uterus. There are the concept of myomectomy when the patient two basic approaches: abdominal myomectomies, prefers that approach. which are used primarily for the removal of sub- Hysteroscopic myomectomies are done with serous, pedunculated, or intramural fibroids, and an instrument inserted through the vagina, up a hysteroscopic myomectomy, which is used for the cervical canal, and into the uterine cavity, removal of submucous myomas. providing a view of the interior of the uterus and Hysterectomies can be done with an abdomi- an instrument that can slice or cauterize the sub- nal incision, a vaginal incision, or by laparoscopy. mucous fibroid. Sometimes, when a woman is Except in vaginal hysterectomies, it is possible past childbearing age, an associated destruction to leave the cervix, removing the uterine fundus of the uterine lining tissue is performed at the (body) only, which contains the uterine fibroids. same time. This is called an ablation and further There is really no reason to remove either ovaries helps to reduce menstrual flow. or cervix to treat the symptoms of fibroids. By There are other treatments for fibroids, some leaving the cervix, the normal length and sensa- of which are gaining more popularity and some UTERINE FIBROIDS 339 of which are still experimental. Uterine artery in phase III trials. It is not known if this is a tem- embolization is designed to reduce fibroids by porary or permanent treatment. obstructing the blood supply that nourishes The other area of medical research involves them. The procedure is done by a radiologist in antifibrinolytic agents. There are other fibrin the x-ray department. It entails making a small deposition diseases such as keloids (excessive incision in the groin and threading a small growth of scar tissue) and pulmonary fibrosis catheter into the femoral artery. The doctor that serve as fibrin disease models. Researchers works the catheter up to the vessels that supply are beginning to look at medications that reduce the uterus under guidance with dye and x-rays. the growth and deposition of fibrin for treatment Microscopic plastic particles are injected to close of fibroids. There are no significant investiga- off the uterine vessels, temporarily creating a tional trials underway at the present time. condition of shock for the uterus. Because The newest nonmedical technique being used fibroids only have one blood supply, the shock is to treat fibroids is high-intensity focused ultra- often enough to cause them to begin to degener- sound. This is done in the radiology department ate (necrose). The uterus, however, has blood with MRI-guided high-intensity focused ultra- supply through the uterotubal ligaments and sound. The uterus is scanned for fibroids and vaginal arteries as well and recovers from the ini- divided into plains at different depths, and the tial loss of blood flow most of the time. ultrasound is directed in small increments into Embolizations have been done for about 10 the fibroid. It is completely noninvasive and is years, and now there is enough data to indicate just beginning to be used. The setups are very that there is a less than 1 percent chance that a expensive and the machines are few and far woman will need an emergency hysterectomy between at this point. because of uterine necrosis after an embolization. The thermal ablation treatment techniques There is a 1 to 5 percent chance that the patient that transfer laser, radio frequency, microwave, or could become menopausal because of a decrease cryotherapy through either a percutaneous or a in the blood supply to the ovaries occurring transvaginal probe (which were evaluated unintentionally at the time of the embolization. between 2000 and 2003) are largely outdated The patient can expect significant pain or cramp- now and are not thought to be an effective form ing for up to six months, treatable with pain of treatment. medications and anti-inflammatories, and most fibroids will reduce approximately 50 percent in SEEING A LICENSED PRIMARY their size. This is more successful for treatment of HEALTH-CARE PRACTITIONER pain from fibroids than bleeding, but it can (N.D., M.D., D.O., N.P., P.A.) improve bleeding. Four clinical problems that require special con- The new fibroid treatment that conventional sideration in fibroid cases are heavy, prolonged, medicine is investigating is selective progesterone or frequent bleeding; infertility; enlarged kid- receptor modulators (SPRMs). Ru-486, the only neys; and pregnancy complications. currently used SPRM, is in investigative trials for Menstrual flows that are longer than 7 days in treatment of fibroid pain and bleeding and helps duration, more frequent than every 21 days, by reducing the size of fibroids. Most of these involve intermenstrual spotting/bleeding or trials suggest that the medication is well tolerated excessive blood loss (more than 80 ml per cycle with minimal side effects. A second SPRM called compared to the normal average of 33 ml) asoprisnil has been shown to significantly shrink deserve a visit to your licensed primary care prac- fibroids with minimal side effects and is currently titioner. It is difficult to quantify the number of 340 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE pads or tampons used as a criterion for determin- women who have previously had a myomectomy, ing excessive blood loss. Bleeding that meets or the safety of a vaginal delivery is controversial. exceeds saturation of a super tampon or heavy One school of thought holds that if there has pad every hour for six to eight hours or more been an incision into the uterine cavity, the deliv- requires immediate intervention. Bleeding that ery must be by cesarean section. Other practi- exceeds this deserves an immediate phone call to tioners believe that if there was no infection after your practitioner and urgent management for the myomectomy, the incision into a nonpreg- hemorrhage. Some women tolerate excessive nant uterus is of no concern in subsequent vagi- blood loss better than others. If you are feeling nal deliveries. lightheaded, this is cause for concern. A hemo- Remember, the mere presence of uterine globin and hematocrit test can determine if you fibroids does not require treatment. If you have are anemic from blood loss. Additional tests may symptoms, they can most often be managed with be done to determine if your iron stores are low. alternative therapies, although excessive bleeding Infertile women who have uterine fibroids may require drug or surgical intervention. Even may need to consider the causal relationship. Even if you have no symptoms, a licensed primary though fibroids may be a cause of only a small per- health-care practitioner should examine you centage of infertility cases, if it is the cause, the every six months to rule out rapid enlargement. solutions aren’t particularly optimistic. It is This is especially true for women who are plan- reported that only a 16 percent pregnancy rate fol- ning pregnancies or approaching menopause. lows myomectomy for infertility. Postoperative Rapidly enlarging fibroids warrant special atten- adhesions and the low return question the value of tion because of the potential for malignancy. A myomectomy for this set of circumstances. young woman whose uterus is larger than a 12- Pregnancy in women with uterine fibroids is to 14-week pregnancy should carefully monitor generally problem-free, but each situation is differ- the fibroid growth and consider the need for sur- ent. Even though fibroids can grow during preg- gical intervention, because there are many more nancy, only a very few actually do have continued years for potential further growth and the bigger growth. Six weeks after delivery, many uterine the uterus and fibroids, the more technically dif- fibroids will decrease in size to become similar to ficult the surgery. the size it was prior to pregnancy. Women rarely need to rush to any decision That said, some complications can occur about surgical intervention, except in the case of during pregnancy. An enlarging fibroid during excessive bleeding problems, a rapidly enlarging pregnancy can degenerate and cause pain, infec- fibroid uterus, or prolonged or severe pain. If sur- tion, and fever. Though debatable, the presence gical intervention becomes appropriate, remem- of fibroids can also affect implantation of the fer- ber that you may have a number of surgical tilized egg with the potential for an early miscar- options and explore some of the newer tech- riage, bleeding later in the pregnancy, premature niques. If a hysterectomy is indeed the best rupture of membranes, and postpartum hemor- option, and sometimes it is, then be sure to dis- rhage. Other potential complications include a cuss with your surgeon whether you would like decrease in the ability of the uterus to contract to keep your ovaries; most of the time, there is no during labor or obstruction of the birth canal. In pressing medical need to remove them. VAGINITIS CHAPTER20

OVERVIEW result in more serious complications such as acute Vaginal infections are responsible for an estimated or chronic pelvic inflammatory disease (PID), 10 percent of all women’s visits to health-care chronic pelvic pain, and infertility. Vaginitis may practitioners. There are three general categories of also increase the transmission of other sexually vaginitis: hormonal, irritant, and infectious. Hor- transmitted infections like human immunodefi- monal vaginitis, also called atrophic vaginitis, is ciency virus (HIV) and genital herpes. usually found in postmenopausal or postpartum Vaginitis is most often a disorder of imbalance women, but occasionally in young girls before of the normal vaginal flora. Many of the organ- puberty. (Atrophic vaginitis in menopausal isms that are responsible for vaginitis, like gard- women is addressed in greater detail in Chapter nerella, mycoplasma, staph, E. coli, and candida 12.) Irritant vaginitis can be due to allergies to are naturally occurring in the healthy vagina. such substances as latex in condoms, spermicides, These organisms only become problematic when deodorants, soaps, perfumes, semen, or douches.1 the delicate balance of the beneficial bacterial, like Irritation may also be due to hot tubs, mechanical aerobic lactobacillus, is disrupted. There are a abrasion, sanitary napkins, tampons, toilet tissue, number of factors that may adversely affect this or topical medications. balance by reducing the lactobacilli population, However, most vaginitis is due to a vaginal such as lubricants, nonoxynal-9 (spermicide), oral infection. More than 90 percent of vaginitis in contraceptives (OCs), hormonal changes, and reproductive-age women is caused by bacterial antibiotics. vaginosis, candidiasis, or trichomoniasis. There are Though self-diagnosis is common, it is not other less common infectious causes of vaginitis recommended, because it is difficult to make an like gonorrhea, chlamydia, mycoplasma, campy- accurate diagnosis based on discharge, itching, lobacter, and even parasites like pinworms and and odor and because of the possibility of dual giardia. Among these, gonorrhea, chlamydia, and infection. To properly treat vaginitis and avoid trichomona are sexually transmitted. Women who potential treatment complications, it is essential have sexually transmitted vaginitis require treat- to know the exact diagnosis. ment with antibiotics to prevent pelvic inflammatory disorder; testing and treatment should be Bacterial Vaginosis offered to partners as well. To learn more about Bacterial vaginosis (BV) is the most common sexually transmitted infections, see Chapter 18. cause of vaginal infections and abnormal vaginal General symptoms of infectious vaginitis discharge and odor. Unfortunately, it can also be include a vaginal discharge, irritation, itching, and one of the infections most resistant to treatment. odor. Not all infectious causes of vaginitis have the BV consists of a significant polymicrobial over- same symptoms, but they all are associated with a growth. It is the result of alterations in the vagi- vaginal discharge. Though vaginitis is often easily nal ecosystem rather than an infection caused by treated, some women may experience chronic or any single microorganism. In BV, the ordinarily recurrent infections that may be resistant to usual lactobacilli-dominant vaginal environment is treatments. In addition, untreated vaginitis may overgrown with anaerobes (mainly Prevotella, 341

Peptostreptococcus species, Eubacterium species, Diagnostic Criteria and Mobiluncus) and facultative bacteria (Myco- plasma species, Staphylococcus epidermidis, Strep- Three of the following criteria must be present to tococcus species, and Gardnerella vaginalis). This confirm a diagnosis of bacterial vaginosis. overgrowth results in the degradation of the 1. A thin, frothy, gray, odorous discharge mucus membrane and shedding of the vaginal 2. Vaginal pH greater than 4.5 with pH paper 3. A wet-mount lab sample that reveals clue cells epithelium, resulting in a discharge, and may 4. A positive whiff test (a fish odor detected when lead to potential complications in the uterus and 10 percent potassium hydroxide is added to the fallopian tubes. The destruction of these mucins discharge) exposes the epithelium to other organisms, with the subsequent appearance of clue cells (cells that line the vagina and now have clusters of bacteria More than 50 percent of women with BV are adhered to their surface).2 These are visualized asymptomatic. BV most often occurs among het- with microscopy and are unique to BV. erosexual, sexually active women, but is not con- BV is characterized by decreased or absent sidered a sexually transmitted disease.7, 8 Among Lactobacillus species and increased concentra- those who are heterosexually active, BV is more fre- tions of potentially pathogenic bacteria. Other quent in women who have had intercourse at an characteristic changes include elevated pH, early age, those with more sexual partners, and greater than 4.5; formation of clue cells; odor among women with concurrent or prior due to increased vaginal fluid concentrations sexually transmitted diseases.9 BV can also exist of diamines, polyamines, and organic acids;3–5 among sexually abused children and lesbian an upregulation of inflammatory cytokines such partners of women with bacterial vaginosis.10, 11 as interleukin (IL)-1beta, a noticeable absence or Several factors have been associated with the devel- rare presence of white blood cells in the vaginal opment of BV, such as cigarette smoking and racial discharge; and a decrease in naturally protective background. Hispanic women are 50 percent more molecules like secretory leukocyte protease likely than Caucasian women to develop BV, and inhibitor. Four diagnostic criteria, of which three African-American women are twice as likely as must be present, confirm a diagnosis of bacterial Caucasian women to have BV.12 The reasons for vaginosis. these differences are not clear but may be due to There are three main factors that are respon- less condom use in Hispanic women and increased sible for the decline of lactobacilli and conse- douching in African-American women. quential BV: The alterations in vaginal immune response and vaginal microflora associated with BV leave 1. Intercourse without condoms: sperm women more susceptible to other infections, alkalinizes the vagina, which depletes including HIV and gonorrhea.13–16 Women with lactobacilli. BV are also more likely to shed HIV, and there- 2. Douching, which also depletes lactobacilli. fore BV may increase the transmission of HIV.17 3. The absence of the kind of lactobacilli that There are some potential consequences of produce peroxide. Broad-spectrum antibi- untreated or undertreated BV.18 The bacteria can otics can also eliminate healthy vaginal migrate into the uterus and the upper genital lactobacilli.6 tract and cause pelvic inflammatory disease in a Bacterial vaginosis may be merely an acute or minority of women who have the infection. The episodic condition, may become persistent, or loss of lactobacilli and the resulting degradation may resolve itself spontaneously. of the mucin layer, as well as loss of the local VAGINITIS 343 immune response, may allow pathogens to it clears up the clue cells and amine fishy odor ascend to the uterus and fallopian tubes. In preg- and restores the vaginal flora to healthy levels nant women, BV can cause premature rupture of lactobacilli. Reexamination following treat- of membranes and premature labor, and it is ment is fundamental to assure that the pH has responsible for 70 to 80 percent of all perinatal decreased to less than 4.5. If it has not, then you deaths.19 BV is also responsible for approximately are at risk for developing a recurrence. If pH one-third of postpartum endometritis (infection remains greater than 4.5 following treatment, of the uterus).20 Additionally, women with sub- more aggressive use of lactobacillus and/or vagi- optimal vaginal flora are at increased risk for nal boric acid suppositories should be utilized. infections following gynecologic surgery. The first follow-up should occur after the desig- It has been estimated that about 30 percent of nated treatment time of usually 7 to 14 days, women experience a recurrence of symptomatic then again in one month. BV within 30 to 90 days of treatment, and 70 Treatment of BV in nonpregnant women will percent will have a recurrence within nine reduce vaginal symptoms, lower the risk of months.21 With BV, it may not be clear whether postabortion and posthysterectomy infectious the repeat episode is a reinfection or a relapse. complications, and may reduce transmission of Reinfection implies that the original problem and infection with other sexually transmitted was reversed and the patient was completely infections. Women should refrain from sexual asymptomatic before recurrence; relapse indicates that the symptoms and microbiology have Prevention of Bacterial Vaginosis never returned to normal even though there may have been improvement or a period of improve- • Practice safe sex, which is helpful in prevent- ment. Reinfection is a possibility due to exposure ing even infections not clearly considered to to the same factors that caused the first episode. be sexually transmitted, such as bacterial In heterosexual women not using condoms, rein- vaginosis. • Consider regular condom use to prevent fection may be due to the alkalinizing effect of vaginitis and maintain a normal pH. semen. This alkaline environment fosters over- • Use condoms until treatment regimen is com- growth of BV. The treatment for recurrent BV plete to prevent recurrence. should focus on preventing relapse, as this is the • Eat a diet rich in whole foods with little to no most common cause of recurrence. Possible rea- sugar or refined carbohydrates. sons for relapse include (1) lack of reestablishing • Determine possible allergies to food, pollen, the lactobacillus-dominant vaginal flora, (2) per- clothing detergent, and semen for recurrent sistent overgrowth of pathogenic bacteria, and cases. (3) some of the pathogens have sequestered them- • Determine possible infection with other organ- selves in inaccessible sites such as the endometrial isms for recurrent cases. • Increase intake of acidophilus yogurt and/or cavity. take supplemental lactobacillus supplements, A simple and useful method for monitoring especially when using antibiotics. patients during treatment for BV is pH paper. If • Vaginal estrogen may be necessary to maintain a woman has a vaginal pH of less than 4.5 (some an acidic vaginal environment in postmeno- say of less than or equal to 5.0), she has adequate pausal women. numbers of lactobacilli and does not have BV. • In cases of relapse, take boric acid and lacto- The goal of treatment is to restore the vaginal bacillus vaginally for 1 to 2 weeks, plus lacto- pH to less than 4.5 and reestablish normal vagi- bacillus orally for 2 to 6 months. nal ecology. Treatment is considered successful if 344 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE intercourse during the treatment period and until and, if necessary, a culture. The usual symptoms their vaginal ecology is normal. Women who have of VVC are acute itching and vaginal discharge. recurrent BV following intercourse may need to The discharge is typically described as cottage use condoms or consider having the sexual partner cheese–like in character, but it may actually vary treated at the same time. Unfortunately, BV can from watery to thick. Symptoms may also be the most difficult vaginal infection to treat sat- include vaginal soreness, irritation, vulvar burn- isfactorily with alternative treatments. However, ing, inflammation and swelling of both the inter- even conventional treatments can be insufficient nal and external genital tissue, redness, pain with without a lot of patience and time. vaginal sexual activity, and urinary discomfort. The symptoms are often worse the week preced- Candida Vaginitis ing the onset of menses with some relief after the Although vulvovaginal candidiasis (VVC), more menstrual flow. commonly known as a candida or yeast infection, Self-diagnosis of VVC is unreliable and often is often assumed to be the cause of vaginitis, only results in misdiagnosis. There is even a concern 33 percent of vaginitis cases are in fact VVC. that physicians are frequently inaccurate in diag- VVC is frequently misdiagnosed by both patients nosing vaginal infections.25 The most candida- and practitioners. It encompasses a broad range specific symptom is itching without discharge, of issues, ranging from those who have coloniza- and even this criterion correctly predicts VVC in tion of yeast but are asymptomatic to those only 38 percent of patients.26 who have frequent, recurrent, and symptomatic The greatest concern in self-diagnosing and episodes. It is estimated that 75 percent of all self-treating VVC is in women who have recur- women will have at least one VVC infection in rent VVC, defined as four or more candida- their life, 45 percent will have multiple episodes, confirmed episodes of symptomatic infection and 5 to 8 percent will have recurrent episodes within one year. This occurs in approximately (RVVC, defined as four or more episodes within 5 percent of women27 and can be dangerous, as one year).22 the underlying condition could go undiagnosed Studies throughout the world have shown because the woman is repeatedly treating what that Candida albicans is the most common cause she thinks are simple vaginal yeast infections. of VVC. It is the organism identified in 85 to 90 Recurrent VVC commonly affects women who percent of positive vaginal yeast cultures. How- are immunocompromised as the result of AIDS ever, there are infections with nonalbicans species or other predisposing conditions such as dia- such as C. glabrata, C. tropicallis, and C. krusei, betes, Cushing’s disease, Addison’s disease, hypo- which are becoming more prevalent in the or hyperthyroidism, or leukemia. There are other United States. Of the nonalbicans species, Can- predisposing factors in recurrent infections that dida glabrata is the most common. The number may also need to be addressed: high-estrogen of VVC cases that are due to nonalbicans species medication, antibiotics, hormones, contraceptive is increasing and rose from 9.9 percent in 1988 devices, cytotoxic drugs, immunosuppressive to 17.2 percent in 1995.23 It is thought that this drugs, radiotherapy or chemotherapy, tight increase is due at least in part to the increased use clothing, nylon underwear, pregnancy, and exces- of over-the-counter treatment medications and sive sugar in the diet. that nonalbicans species are becoming less and Reinfection may also come from extravaginal less susceptible to these agents.24 sources. Although the sexual transmission of can- A diagnosis of VVC is made by a combina- dida is still controversial, there is evidence that tion of history, clinical examination, microscopy, sexual transmission might be a likely source of VAGINITIS 345 recurrent infection. In one study, the researchers that yeast is in fact present for symptomatic found identical strains of candida in the male women with negative microscopic findings and sexual partners of 48 percent of women with to identify the genus and species. recurrent VVC.28, 29 Reservoirs of infection were It cannot be overemphasized how the health found in the oral cavities of 36 percent of 33 het- of the entire body affects the internal ecosystem erosexual couples, the rectums of 33 percent, and of the vagina. The vaginal pH and microflora, the ejaculate of 15 percent of the men.30 This the hormonal cycles, and the vaginal immune data suggests that oral-genital contact constitutes tissue are all influenced by our general health and a probable mode of sexual transmission. Many dietary habits, and this in turn determines our alternative practitioners treat the overgrowth of susceptibility to vaginitis. A healthy diet assures candida in the digestive track as well to address our body’s defense system. A diet low in sugars the possibility of migration from rectum to vagina. and refined carbohydrates is particularly impor- In fact, a 1977 study found that in 98 women tant in preventing candida vaginitis. In fact, a with recurrent VVC, candida was always found in recent study confirmed that women with the feces of women with current VVC and was not impaired glucose tolerance were at higher risk for found in women without VVC.31 Although recurrent vaginal candidiasis.33 In general, a well- numerous studies have failed to yield definitive balanced whole foods diet that is low in fat, results, it may provide a useful avenue of treat- sugars, refined foods, and alcohol is optimal in ment in especially chronic and resistant cases.32 preventing all infections. The first step in the physical evaluation is to Some women who have severe, stubborn determine if there is a vulvitis (inflammation of cases of chronic candida vaginitis may benefit the external genital tissue) and/or vaginitis. Some from stricter diets that avoid fermented foods. women may have vulvar hyperplasia (prolifera- However, many “anti-candida” diets can be rigor- tive cell growth), vestibulitis (inflammation of ous and unnecessarily stressful. Some of these the tissue surrounding the opening to the diets are so restricted that they actually cause vagina), genital ulcerations, lichen sclerosis, or other health problems. Women who have self- other dermatitis conditions. A thorough exami- diagnosed or who have been diagnosed with “sys- nation of the external genitalia involves looking temic candida” by an alternative practitioner for erythema, hypopigmentation, hyperpigmen- might want to make sure of this popular over- tation, fissures, vesicles, ulcerations, thinning, used diagnosis. Conventional medicine uses the and thickening. A woman with VVC will often term systemic candidiasis to describe the situation have vulvar and vaginal redness, swelling, and when candida contaminates the blood stream itching. A thick white discharge may be present, and spreads throughout the body, causing pro- but many women with VVC do not have a dis- found illness affecting a wide variety of organ sys- charge or do not have the typical thick and white tems. This state, according to this definition, discharge. only occurs in seriously immunocompromised The diagnosis can often be made in the prac- patients, such as HIV-positive individuals. In titioner’s office by using 10 percent potassium individuals who have no serious immune defi- hydroxide (KOH) and microscopy that demon- ciency, any exposed warm, moist part of the body strates features of yeast. Another diagnostic tool is susceptible to candida infection. Common is pH paper. A vaginal pH of less than 4.5 helps examples of this would include vulvovaginitis, to exclude bacterial vaginosis, trichomoniasis, oral thrush, conjunctivitis (infection of the inner atrophic vaginitis, or a mixed bacterial/yeast eyelid), diaper rash, and infections of the nail, infection. A vaginal culture may help to establish rectum, and other skin folds. In immuno- 346 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE compromised individuals, systemic illnesses such occur. Taking shortcuts in history, physical exam, as myocarditis (infection of the heart muscle), and testing can result in misdiagnosis, unneces- hepatosplenic abscess, pulmonary infection, cen- sary treatments, and delays in effective treatment. tral nervous system (CNS) infection, and chronic Most cases of VVC will be very effectively treated disease states may occur. with natural methods. When this does not Alternative medicine has used the term sys- work, there are various oral and vaginal regimens temic candidiasis to describe less intense situa- including butoconazole cream, clotrimazole tions, in an attempt to explain a multitude of cream or vaginal tablet, miconazole cream or general symptoms such as headache, fatigue, gas suppository, terconazole cream or suppository, and bloating, depression, and more. Perhaps a fluconazole oral medication, and nystatin vaginal better term for this would be systemic candida tablets. Treatment options for nonalbicans can- syndrome. Ruling out other causes of these gen- dida infections include more aggressive flucona- eral symptoms is important, and testing the stool zole and terconazole regimens, flucytosine and vaginal secretions for candida overgrowth vaginally, and boric acid vaginal capsules. and the blood for the candida antigen provides While VVC may seem trivial to many, for the best hope for accurately diagnosing true sys- some the discomfort, the chronicity, and the temic candida infections. health-care costs incurred are excessive. Treat- The main concepts of managing VVC are ment strategies for candida vaginitis with natural accurate diagnosis, management of other influ- therapies will focus on maintaining a normal ences, and being creative and persistent when vaginal pH, restoring normal ecology of the treatment does not provide relief or recurrences vagina, reducing inflammation, relieving symptoms, and using natural antifungal agents. Prevention of Candida Vaginitis Trichomonas Vaginalis Preventing infections is almost always easier than Trichomonas vaginalis is a motile, flagellate, anaer- treating them. Here are some simple strategies: obic protozoan and is a far more prevalent sexually • Avoid wearing tight clothing.34 transmitted infection than either Chlamydia • Avoid wearing pantyhose.35 trachomatis or Neisseria gonorrhoeae. About 6 per- • Consider using condoms to prevent all types of cent of all cases of a vaginal discharge are due to vaginitis and maintain a normal pH in the trichomoniasis, and about 5 million new cases vagina. appear annually.36, 37 The prevalence of disease • Eat a whole foods diet with very little to no varies widely by population. Multiple sexual part- sugar and refined carbohydrates. ners, African-American race, previous history of • Determine possible allergies to food, pollen, clothing detergent, and semen for recurrent sexually transmitted diseases, coexistent infection cases. with Neisseria gonorrhoeae, and nonuse of either • Determine possible infection with other organ- barrier or hormonal contraceptives are known isms for recurrent cases. risk factors for acquisition of trichomoniasis.38 • Increase intake of acidophilus yogurt and/or Trichomoniasis is associated with several signifi- take lactobacillus supplements, especially cant health consequences, including the transmis- when using antibiotics. sion of the human immunodeficiency virus • Vaginal estrogen may be necessary to maintain (HIV), infertility, atypical pelvic inflammatory an acidic vaginal environment in postmeno- disease (PID), increased risk of postoperative pausal women. infection, preterm births, and cervical dysplasia as well as adverse pregnancy outcomes such as VAGINITIS 347 preterm delivery, premature rupture of mem- vaginal discharge is that it can be done in the branes, and low–birth weight infants. practitioner’s office; it’s fast, easy, and low cost; The sexual transmission rates are higher from and an immediate diagnosis can be made. man to woman than from woman to man, and If the trichomonad was not seen, a culture is transmission is considered rare from woman to more sensitive for diagnosis. A culture in Dia- woman. Trichomoniasis is rarely transmitted to mond’s medium is both sensitive and specific. infants born to infected mothers, and although However, there is a diagnostic delay because of the trichomonas organism can survive for short the time it takes for the culture to detect the periods on moist objects (toilet seats, benches, organism. Pap smears are not very sensitive in towels) or exposed bodily fluids (urine, vaginal testing trichomoniasis, only 56 percent effective exudate, semen), no cases of transmission by in one study,43 and are therefore not a very reli- indirect or inanimate exposure have been docu- able method. mented. Prevalence of trichomoniasis is highest Newer tests are available now that increase among women with multiple sexual partners accuracy and ease diagnosis. A DNA-based test and in women with other sexually transmitted infections.39–41 KEY CONCEPTS The most common complaints associated with trichomoniasis are vaginal discharge and • Diagnosis is necessary to determine the cause of vulvovaginal irritation and itching. Discharge is the vaginal infection. present in 50 to 75 percent of infected women • Be aware of underlying metabolic or immune and is classically described as frothy or bubbly problems in chronic resistant cases of candida vaginitis. and yellow-green. Other associated symptoms • In recurrent cases of candida vaginitis and bac- include dyspareunia (pain with vaginal sexual terial vaginosis, consider the possibility of activity), dysuria (painful urination), and, in a sexual transmission, even though they are not small number of patients, some degree of lower typically considered STIs. abdominal pain. Vulvar redness is an uncommon • The sexual partner should be treated in all cases finding, but vaginal redness is noted in as many of trichomoniasis. as 75 percent of patients. A “strawberry cervix” is • Consider additional testing methods such as created by dilatation of capillaries on the cervix cultures and DNA probes in cases that elude with small hemorrhages and is seen through a diagnosis. magnification device called a colposcope in as • Self-diagnosis is usually inaccurate and can inhibit successful treatment. many as 90 percent of cases.42 With the naked eye it is seen in only 2 percent of cases, but when it is seen it is an almost sure sign of trichomoniasis. As these clinical signs and symptoms are not PREVENTION sensitive enough or specific enough to be used • Use condoms to prevent all types of vaginitis alone, it’s most important to somehow identify and maintain a normal vaginal pH. the organism. • Eat a whole foods diet with very little to no The time-honored method for diagnosing sugar and few refined carbohydrates. trichomonal infections has been microscopic • Determine possible infection with other organ- (wet prep) evaluation. The diagnosis is made isms for recurrent cases. by directly observing the motile parasite. This • Increase intake of acidophilus yogurt and/or procedure detects 60 to 80 percent of cases. The take lactobacillus supplements. advantage of the microscopic examination of the 348 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE called the Affirm VP system uses a probe inserted over-the-counter or prescription medications in the vagina that can detect trichomoniasis, bac- need to be used, the principles and methods of terial vaginosis, and candida species from a single the natural treatments can be an important part vaginal swab. Additional diagnostic methods of ensuring a healthy vaginal ecosystem and include polymerase chain reaction tests, but most immunity for the future. doctors’ offices do not yet use these. A new 10- The health of the ecosystem of the vagina is minute antigen test for trichomonas is also avail- the most important concept in treating vaginitis. able. Women who are found to have an infection While the vaginal flora and ecosystem is in a of T. vaginalis should also be tested for Neisseria variable state throughout a woman’s lifetime, gonorrhoeae (GC) and Chlamydia trachomatis (CT) largely affected by hormonal influences, nothing and, if positive for one or both, should then be is more key to this ecosystem than lactobacillus. screened for additional sexually transmitted infec- The vaginal microflora of healthy asymptomatic tions, including syphilis, hepatitis B and C, HIV, women consist of a wide variety of anaerobic and herpes type 2 virus, and human papillomavirus. aerobic bacteria dominated by lactobacillus. The treatment strategy is to kill the tri- The first extensive study of the human vaginal chomonads, reduce inflammation, support the microflora was published in 1892 by Doder- vaginal ecology and immune system, and prevent lein.44 Since then we have learned that a wide recurrence. variety of microorganisms are present in a healthy vaginal ecosystem. The range of bacterial OVERVIEW OF types is immense, including Staphylococcus ALTERNATIVE TREATMENTS species, Gardnerella vaginalis, Streptococcus An important aspect of treating vaginal infec- species, Bacteroides species, Lactobacillus species, tions is looking at the problem holistically and Mobiluncus, even Candida species, most com- systemically rather than just finding drug alterna- monly Candida albicans, and more. Yet the tives to kill unwanted organisms. To this end, predominant organisms are members of the we try to improve the vaginal immune system, Lactobacillus genus. support the systemic immune system, restore The body’s ability to control the vaginal the proper balance of normal microflora in the microflora is no easy feat. The normal vaginal vagina, restore the normal pH of the vagina, microflora defend against abnormal vaginal colo- decrease the inflammation and irritation of the nization. Factors controlling this defense system tissue itself, provide symptomatic relief, and, include the content of the vaginal tissue itself when necessary, curb the overgrowth of the (called the squamous epithelium), the domi- offending organism. nance of lactobacilli, the subsequent low or Although this approach sounds basic and log- acidic pH balance, hydrogen peroxide produc- ical, it is radically different than the conventional tion, and hormonal influences (over one’s approach, which is essentially to kill the over- lifetime as well as monthly cyclic changes). High growth of the causative organism. Although in or low estrogen states such as pregnancy or severe acute cases pharmaceutical antifungals menopause; hormonal medications such as con- may ultimately be necessary, organisms are traceptive devices, including OCs; feminine becoming resistant to these products due to their hygiene products; and vaginal sexual activity, overuse, and newer, stronger treatments are con- including friction, lubricants, and semen can all tinually developed to address these resistant create a challenge for the vaginal ecology to strains. Thus, even when the pharmaceutical maintain homeostasis. VAGINITIS 349 Nutrition vulvar tissue to relieve discomfort there. Vitamin I cannot overemphasize how the health of the E is especially useful in cases of allergic and entire body affects the internal ecosystem of the irritant-induced vaginitis because it is so soothing. vagina. The pH of the vagina, the microflora that Vitamin E live there, the hormonal cycles, and the immune tissue in the vagina are all influenced by our gen- Intravaginal suppository or gelatin capsule once or eral health and dietary habits, and this in turn twice daily for 7 or more days determines how susceptible we are to vaginitis. A generally healthy diet—well balanced, rich in Vitamin C. Vitamin C has long been touted whole foods, and low in fat, sugars, refined foods, for its beneficial effects on the immune system. and alcohol—is optimal in preventing infections. According to a recent study, administering 250 mg A diet low in sugars and refined carbohydrates is of vitamin C vaginally for six days significantly particularly important in preventing candida improves both subjective and objective parameters vaginitis. Some women who have severe, stub- of vaginitis, like eradicating bacteria and clue cells, 46 born cases of chronic candida vaginitis may ben- increasing lactobacilli, and lowering pH. efit from stricter diets that avoid fermented Vitamin C foods; however, most of the time these “anti- candida” diets are not necessary. Insert 250 mg vitamin C tablet in the vagina for 6 days Nutritional Supplements Vitamin E. We most often think of using Vitamin A and Beta-Carotene. Both vita- nutritional supplements orally, but in this case I min A and beta-carotene are necessary for the recommend the use of vitamin E intravaginally normal healthy growth of epithelial tissues that and topically. This use of vitamin E dates back at make up the vaginal mucosa. Vitamin A and least to 1954.45 As demonstrated then as well as beta-carotene enhance the immune response in in my practice, vitamin E provides a very sooth- epithelial tissues and thereby help mucous mem- ing effect. The tissue becomes less irritated with branes resist infection. Vitamin A and beta- a decrease in redness, swelling, and congestion. carotene can be used orally to enhance the Vitamin E usually relieves burning and itching immune response, and vitamin A can be used within one to three days. It can be administered intravaginally to stimulate the local immune as either a suppository or from a gelatin capsule tissue of the vaginal mucosa. Vitamin A in a cap- that is inserted into the vagina once or twice sule can suffice, but vitamin A suppositories are daily for seven or more days. Vitamin E oil or available in higher doses than a standard capsule. ointment can also be applied externally to the Vitamin A intravaginally is useful in cases of infectious vaginitis as well as allergic and irritant- Nutrition induced vaginitis. Daily use for up to one week is

• Avoid sugar, refined carbohydrates, fruit juice, Vitamin A and alcohol. • Reduce fats. Intravaginal suppository or gelatin capsule once daily • Eat 8 oz of unsweetened acidophilus yogurt for 7 days; use vitamin E, lactobacillus, or mixed daily. herbal suppository daily for 1 week before repeating • Increase garlic in the diet. this dosage. 350 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE typical. It can be repeated after one week without ability to affect both yeast and bacteria, these two suppositories or one week of some alternate like herbs would seem a logical choice in cases where vitamin E, lactobacillus, or a mixed herbal sup- multiple infectious agents are involved. pository to avoid any possible side effects. Goldenseal or Oregon Grape Root Botanicals Orally (capsules or liquid extracts) or intravaginally in Garlic (Allium Sativum). Garlic extracts have suppositories been shown to inhibit the growth of Candida albicans by blocking the lipid production.47, 48 Tea Tree (Melaleuca Alternifolia). Tea tree oil The major growth inhibitory component in has been studied for trichomoniasis, candidiasis, garlic extract is allicin, and garlic products that and other vaginal infections. Most of the evidence have the highest amount of allicin are the most supports its use against candida species.52–54 One desirable for treatment. Look specifically for study found tea tree effectively inhibited both products with high allicin and the stabilized form fluconazole-susceptible and fluconazole-resistant of allicin. Garlic is diverse in its uses for vaginitis cases of candidiasis in vitro and in animals.55, 56 because it is both antibacterial and antifungal.49, 50 Perhaps the most impressive study used an emulsi- I recommend garlic vaginal suppositories for fied 40 percent solution of Australian tea tree oil both candida (yeast) vaginitis and bacterial vagi- with 13 percent isopropyl alcohol. In the 96 cases nosis. A clove peeled carefully so as not to nick of trichomonal vaginitis, clinical cures were seen the garlic can be inserted into the vagina for 6 with the application of six treatments applied once to 8 hours. The garlic can be threaded like a weekly with a solution-saturated tampon left in necklace so that it can be easily removed like a place for 24 hours (see “Sample Treatment Plan for tampon. Garlic or garlic capsules can be inserted Trichomonas Vaginalis” sidebar later in this chapter intravaginally in the evening, and then lacto- for specifics).57 Various tea tree oil preparations bacillus capsules can be inserted in the morning have demonstrated antimicrobial activity against to inhibit growth of the offending organism and Staphylococcus aureus and Candida albicans, thereby repopulate the healthy microflora. showing its usefulness in diverse situations.58

Goldenseal (Hydrastis Canadensis) and Tea Tree Oil Oregon Grape Root (Berberis Vulgaris). Gold- enseal and Oregon grape root contain a sub- Emulsified 40 percent solution of Melaleuca alternifolia stance called berberine that acts both as an oil with 13 percent isopropyl alcohol: wash vaginal canal for 30 seconds once a week for 4 weeks, then antibacterial and as an immune enhancer. This use vaginal tampon saturated with solution for 24 immune effect is especially specific in epithelial hours following each washing. mucus membrane tissue as is found in the vagina, mouth, and even the stomach. Berberine has been shown to possess antimicrobial activity Other Therapeutic Agents against a wide variety of microorganisms, includ- Lactobacillus. Several species of lactobacillus ing those found in the vagina, such as Candida populate the vagina. Although we often think albicans, Escherichia coli, Staphylococcus aureus, of Lactobacillus acidophilus as being the most and others.51 Preparations of goldenseal and dominant, other species, such as L. crispatus, Oregon grape root have been used both orally in L. jensenii, L. fermentum, and L. gasseri are at teas, caps, and liquid extracts and intravaginally least as or more dominant than Lactobacillus in douches and suppositories. Because of their acidophilus. VAGINITIS 351 Several factors explain how and why lacto- because there are few clinical trials. When you bacillus does its remarkable job. Through its consider the logic, the safety, the affordability, production of lactic acid, lactobacilli contribute the lack of side effects, the ease, and the research to the low vaginal pH that is instrumental in that does confirm a benefit, continuing to pro- maintaining a healthy vaginal microflora. mote the use of L. acidophilus is a compelling Because vaginal infections are associated with a one. Lactobacillus therapy is quite popular both loss of lactobacilli, it seems logical and hopeful with alternative practitioners and with women that lactobacilli would make for a good treat- who seek simple self-treatment methods. ment.59 Lactobacilli thrive at an acidic pH of 3.5 A study was done in 1992 on the daily inges- to 4.5, levels that are found in the healthy, normal tion of yogurt containing Lactobacillus aci- vagina throughout the menstrual cycle. Lacto- dophilus in pregnant women with recurrent bacilli have also been shown to interfere with the candidal vaginitis. The women who ate eight adherence and colonization of pathogenic (disease- ounces daily of the yogurt had a threefold causing) bacteria.60 In addition, strains of lacto- decrease in infections when compared to the bacilli that inhabit the vagina produce hydrogen women who did not eat the yogurt.64 It is now peroxide (H2O2), another well-recognized antago- also popular to ingest Lactobacillus acidophilus nist to problematic bacterial populations. Lacto- supplements in oral form in place of or in addi- bacilli also act directly as antibacterials61 and may tion to eating yogurt or to apply lactobacilli function as a local immune stimulant in control- directly into the vagina. ling microbial levels in the vagina. A number of studies have supported the use of For these reasons, administering lactobacillus lactobacillus in preventing and treating vaginitis. orally and intravaginally is one of the most A recently published study on treating BV found important aspects of effectively treating and pre- that both vaginal administration and oral-plus- venting yeast and bacterial vaginitis, although the vaginal administration of lactobacilli were effective scientific literature has inconsistent results. at reducing the vaginal pH, treating the current Women who have hydrogen peroxide–producing infection, and preventing recurrence over the sub- lactobacilli in the vagina are less likely to have sequent three months.65 Another study examined bacterial vaginosis or candida vaginitis.62 These the effectiveness of weekly intravaginal Lacto- same lactobacilli are also toxic to Gardnerella bacillus acidophilus versus clotrimazole (antifun- vaginalis, the predominant organism in the gal) tablets in HIV-positive women, a group vagina of women with BV.63 In addition, the bac- highly susceptible to recurrent yeast vaginitis, and teria that cause bacterial vaginosis thrive in a found the two treatments to be similarly effective higher pH of 5.0 to 6.0 and cannot readily sur- at preventing candidiasis.66 After any conventional vive in the lower pH, more acid environment treatment with antibiotics, vaginal lactobacillus that lactobacilli promotes. can be restored by the coadministration of lacto- The concept that lactobacilli might be useful bacillus and low-dose vaginal estriol.67 This is when supplemented in the diet or administered especially important for preventing VVC after intravaginally dates back to the 1890s. While sci- conventional treatment of BV. entists have vacillated on the value of lactobacilli A review of lactobacillus treatments for VVC in prevention or in treatment, patients in need in 200368 found that vaginally administered or have not. It has been difficult to confirm the “ifs, orally ingested lactobacillus is able to colonize ands, or buts” in using L. acidophilus in the pre- the vaginal ecosystem and that most supplemen- vention and treatment of infectious vaginitis tation needed to continue for two to six months 352 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE in order to sustain continued colonization. The purchasing encapsulated products, it may be author also concluded that controlled trials are worth requesting product analysis information to encouraging but few, and that these trials had assure quality and choosing human strain lacto- small numbers of women, inadequate controls, bacillus to enhance adherence to the intestinal lack of blinding, high attrition rates, and were and vaginal mucosa. not consistent in the form of lactobacillus used. Vaginal Estrogen. One of my most reliable In addition, they had conflicting results. treatments for chronic or chronic recurring yeast Douching used to be a popular method of vaginitis or bacterial vaginosis is the use of administering lactobacillus, but research has vaginal estrogen. This is best seen in peri- and shown that douching may contribute to infertil- postmenopausal women, but it can be used for ity and pelvic infections. A safer and more con- difficult cases in younger women as well. Suffi- venient method is to administer lactobacillus cient estrogen promotes the growth of the lacto- capsules or tablets intravaginally.69 bacillus species that maintain the normal vaginal I believe that lactobacillus, alone or in combi- ecology. Using this concept as a treatment was nation with other vaginal or oral therapies, is the well illustrated in a randomized, placebo- key to establishing normal vaginal microflora and controlled study of 32 premenopausal women preventing recurring infections, as well as treat- with bacterial vaginosis71 that used hydrogen ing acute candida and bacterial infections of the peroxide–producing lactobacillus vaginal tablets vagina. A word to the wise, however, is buyer delivered with 0.03 mg of vaginal estriol (a Euro- beware. There is a great deal of variability in pean product called Gynoflor). The study found lactobacillus products. For yogurt, make sure the that estrogen enhances the acid production of the label lists lactobacillus, and choose a brand with- lactobacilli and assists in their proliferation, in out sweeteners. Some yogurts and encapsulated addition to helping maintain normal vaginal products make claims that they contain L. aci- tissue health. At two weeks, a 75 percent cure dophilus but, when tested,70 they did not; more- rate occurred in the treatment group compared over, they contained contaminants. When with a 25 percent cure rate in the placebo group. Lactobacillus At four weeks, there was an 88 percent cure rate versus a 22 percent placebo rate. Prevention Although this product is not available in the United States, vaginal estriol is available by pre- • Eat 8 oz unsweetened live-culture acidophilus scription from a compounding pharmacy. Your yogurt daily. • Oral Lactobacillus acidophilus or combination practitioner could either request that the phar- multispecies of probiotics daily. Doses may macy formulate an estriol/Lactobacillus acidophilus range from 2 to 10 billion organisms per day suppository or cream, or a vaginal estriol cream for as short as 2 weeks and as high as 24 to (0.03 mg/g; insert one gram daily for two weeks) 48 billion organisms per day for 2 to 6 months and L. acidophilus capsule or suppository (one to maintain vaginal colonization. daily for two weeks) could be inserted separately.

Treatment Boric Acid. The most successful natural treatment for VVC that I’ve encountered is boric • For acute infections: intravaginal tablet, gelatin capsule, or suppository once or twice daily acid suppositories. Laboratory tests and human for a few days to 2 weeks. trials support its use for both Candida glabrata and albicans, even in cases of resistance to antifungal prescription drugs.72, 73 Several studies VAGINITIS 353 conﬁrm its success, ranging from 64 to 98 per- pared boric acid with the more conventionally cent effective.74–76 In one study, 100 women with prescribed nystatin, the boric acid cured 92 per- chronic resistant yeast infections who had failed cent after 10 days and 72 percent after 30 days, extensive and prolonged conventional therapy compared to 64 percent and 50 percent, respec- were treated with 600 mg boric acid vaginal tively, of nystatin.78 suppositories twice a day for two or four weeks; the regimen was effective in curing 98 percent of Boric Acid the women.77 Once daily boric acid suppositories Acute: 600 mg vaginal suppositories twice a day for used for four days per month during the menses 3–7 days for four consecutive months was also clearly indi- Chronic: 600 mg vaginal suppositories twice a day for cated as the treatment of choice for preventing 2–4 weeks recurrence. Prevention: 600 mg vaginal suppositories 4 days per month during menses for 4 consecutive months Clinical effectiveness doesn’t really get any better than this. Boric acid works most of the time, it’s inexpensive, and it’s easy to use. The Arden’s Powder. A colleague of mine has only downside I have observed is that if the tissue been using a vaginal douche powder called has been irritated by the infection, the boric acid Arden’s Powder for over 20 years. She attributes may burn during urination. Using vitamin E oil, its antifungal properties to the essential oils of lanolin, or even Vaseline on the external genitalia eucalyptus, thyme, and boric acid powder. The protects the tissue from the boric acid and averts menthol crystals in the oils provide quick relief any signiﬁcant discomfort. In a study that com- from itching and burning even before the infec-

Sample Treatment Plan for Bacterial Vaginosis

Guidelines • Insert a more potent suppository containing a combination of thuja oil, tea tree oil, • Provide systemic and local immune bitter orange oil, and vitamin A (as palmi- enhancement. tate) 2 days per week for the same 2 weeks • Restore vaginal flora and normal vaginal pH. as the herbal suppositories. • Use natural antimicrobials. • Follow with vaginal lactobacillus supposi- • Relieve symptoms. tory: insert daily for 6 days. 2-Week Minimum Regimen • Oral lactobacillus: take 1 daily for 2 to 6 months to restore normal vaginal ecology. See the Resources section for natural products and • If there is a recurrence, add boric acid sup- formulations used in this regimen. positories; insert 1 daily for 2 weeks. • Avoid refined foods and simple carbohydrates. Other Considerations • Avoid vaginal sexual activity during course of treatment to avoid reinfection and reduce • Use boric acid suppositories (600 mg) to irritation. acidify the vagina either as a primary treat- • Insert one herbal suppository (containing ment or after antibiotic regimens. myrrh, echinacea, slippery elm, golden seal • Paint the cervix and vagina with povidone- root, marshmallow, geranium, and yarrow) into iodine twice each week. (A speculum exam vagina every evening, 5 days per week for 2 would be the most desirable method of weeks. doing this.) 354 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE tion is cleared. Although I have not been a strong use or even douching. In vitro research supports proponent of douching, this old-fashioned the effectiveness of propolis, cayenne, clove, approach can most likely be used safely for yeast and bergamot oil against a number of Candida vaginitis. species.79 Other in vitro evidence showed bergamot oil alone and in combination with boric Arden’s Powder acid to be effective against Candida species, sug- Mix 1 tsp Arden’s Powder in 1 pint warm water; douche gesting a potential role for topical treatment of with 2 applications daily for the first 2 days, then candida infections.80 reduce to 1 application daily for 5 more days. Avoid dur- Powdered herbal mixes of myrrh, echinacea, ing menstrual period or during pregnancy. usnea, goldenseal, marshmallow, geranium, yarrow, and calendula are often used by herbalists Herbal Combinations. Many different herbs and naturopathic physicians. Each herb has its can be prepared in combinations for suppository own special feature, whether antimicrobial,

Sample Treatment Plan for Candida Vaginitis

Guidelines • Boric acid powder capsules: insert morning and evening for 14 days; repeat for an addi- • Provide systemic and local immune enhance- tional 14 days if responding but not com- ment, especially in chronic cases. pletely resolved after the first 2 weeks. • Restore vaginal flora and maintain normal vaginal pH. Prophylaxis for Prevention of Recurrence • Natural antifungal agents will be effective in most cases. • Avoid sugars, refined carbohydrates, alcohol, • Relieve symptoms. and fermented foods. • Eat 8 oz. unsweetened acidophilus yogurt Acute Infection daily. • Lactobacillus species capsules: 8–48 billion Follow these guidelines for a minimum of 1 week: organisms per day. • Avoid sugars, refined carbohydrates, and • Boric acid powder capsules: insert 1 capsule alcohol. once daily at bedtime during menstruation • Eat 8 oz unsweetened acidophilus yogurt daily. only for 4 consecutive months. • Lactobacillus species capsules: 8 billion or more organisms per day. During Pregnancy • Boric acid powder capsules: insert morning and Avoid boric acid suppositories, herbal supposito- evening for 3–7 days in mild cases and up to ries, and garlic during pregnancy. Consult your 14 days for resistant cases. alternative and conventional medical practitioner Chronic Infection for safe options. The following guidelines are generally safe for pregnant women: • Avoid sugars, refined carbohydrates, alcohol, • Avoid sugars, refined carbohydrates, alcohol, and fermented foods. and fermented foods. • Eat 8 oz unsweetened acidophilus yogurt daily. • Eat 8 oz unsweetened acidophilus yogurt • Lactobacillus species capsules: 8–48 billion daily. organisms per day. • Lactobacillus species capsules: 8 to 48 bil- • Garlic (allicin) capsules: 1–2 capsules 2 to 4 lion organisms per day. times daily. VAGINITIS 355 immune enhancing, soothing to the membranes, improved, 3 percent had modest improvement, or antifungal. These suppositories can be made at and 7 percent showed no improvement. home with powdered herbs and cocoa butter or Gentian violet is available only by prescrip- can be purchased from a natural food store or tion in certain states. You may be able to find a alternative health-care practitioner. milder strength available without a prescription. Put a few drops of the over-the-counter concen- Gentian Violet. Most herbal suppositories, tration onto a tampon if you want to try using it including boric acid and tea tree oil, should be on your own. avoided during pregnancy. However, gentian violet is effective for the mother-to-be and safe Gentian Violet for the fetus. In the 1950s, this was the most commonly used and favorite treatment of gyne- See a licensed health-care practitioner for a prescription. Use 1 vaginal applicator daily at bedtime for cologists. It can be painted onto the cervix and 12 days. the vaginal wall, but leaves a disconcerting, sig- nature blue stain; moreover, it requires a speculum insertion to apply. A gentian violet gel made Iodine. Yeast and trichomonal vaginitis infec- up according to the following formula is more tions can often occur simultaneously. Moreover, desirable and appropriate for home use: 0.2 per- after treatment for trichomoniasis, a yeast infection cent gentian violet; 3.0 percent lactic acid; 1.0 may flare up. Local therapy that can treat both percent acetic acid; and polyethylene glycol base. would obviously be desirable. Iodine in the form of This preparation was proven effective in a 1950 povidone-iodine preparations is a logical solution. study.81 Of 191 cases studied, 78 percent were This is another example of an older successful treat- considered cured, 12 percent were significantly ment that got left behind in the face of more

Sample Treatment Plan for Trichomonas Vaginalis

Guidelines vulva and vagina with a 1% solution of the basic medication (i.e., 0.4% M. alternifolia • Provide systemic and local immune oil), using approximately 15 cc. Then insert enhancement. a tampon that has been saturated with the • Restore vaginal flora and normal vaginal pH. solution and keep it in place for 24 hours. • Use natural antimicrobials. • Douche daily for up to 7 weeks with a solu- • Relieve symptoms. tion of 1% of the basic M. alternifolia oil • Treat sexual partner(s). solution in 1 quart of water (0.4% oil). • Eat 8 oz unsweetened acidophilus yogurt Treatment daily for 1 month. • Avoid sugars, refined carbohydrates, and alcohol. • Lactobacillus species capsules: 8 to 48 bil- • Tea tree oil: 40% water-miscible emulsified lion organisms per day. solution with 40% M. alternifolia oil and 13% • Garlic (allicin) capsules: 1–2 capsules 2 to 4 isopropyl alcohol. times daily. • Repeat the following treatment once per week • Consider goldenseal, echinacea, garlic, for up to 6 weeks: Thoroughly wash the vulva licorice, and myrrh for systemic botanical and vagina with pHisoHex followed by a thor- immune support. ough water rinse. Dry the area and swab the 356 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE modern, mass-market pharmaceuticals. In addition The mainstay of therapy is metronidazole, to candidiasis and trichomoniasis, povidone-iodine either orally or in a vaginal gel. Other treatment has been proven effective against potentially patho- regimens involve clindamycin, either orally or in genic microorganisms like Gardnerella, Bacteroides, a vaginal cream. Tinidazole, FDA-approved for and Enterobacteria without adversely affecting the the treatment of trichomoniasis, has also been lactobacillus population.82, 83 used for treatment of BV in patients who have One study combined a povidone-iodine solu- failure of clindamycin and have nausea and vom- tion for swabbing, a povidone-iodine vaginal gel iting problems with metronidazole. This should for application at night, and a povidone-iodine not be used in people who are allergic to metron- douche for use in the morning in 93 courses idazole because they are members of the same of treatment in 87 patients with yeast or tri- class of drugs. Alcohol intake should be avoided chomonal vaginitis, or a combination of both. In while using metronidazole due to a drug interac- the yeast vaginitis cases, symptoms were cleared tion causing violent vomiting. in one to three weeks in all 74 courses of treat- Recurrent BV is common and is often associ- ment. In four of five patients with trichomonal ated with high levels of stress. Recommended vaginitis, symptoms were cleared within three prevention regimens include metronidazole weeks. In 14 courses for combined infections, (0.75 mg gel, or one full applicator) one to two symptoms were cleared within three weeks in 13 times per week for six months or metronidazole patients.84 Another study found that nearly 75 gel for 10 days on the initial treatment. There is percent of cases (trichomoniasis, candidiasis, and no need to treat the sexual partner. nonspecific vaginitis) had complete resolution with povidone-iodine treatment.85 Candida Vaginitis Uncomplicated, acute candidal infections can be Iodine treated with one of a variety of products. Cur- See licensed health-care practitioner for 6-day regimen rently, there are over 100 prescription and overusing povidone-iodine preparations. the-counter preparations that are marketed to

Treatment of Acute Bacterial Vaginosis CONVENTIONAL MEDICINE APPROACH Recommended Oral Medications The accurate diagnosis of vaginitis is critical. Oral metronidazole: 500 mg twice daily for 7 days Incorrect self-diagnosis or guesswork by the prac- Oral metronidazole: 250 mg 3 times daily for 7 days titioner can lead to unnecessary and ineffective Clindamycin: 300 mg orally twice a day for 7 days treatment, thus prolonging the symptoms. Recommended Vaginal Medications Bacterial Vaginosis Metronidazole gel (0.75%): 5 g vaginally once daily Bacterial vaginosis is more common than can- at bedtime for 5 days didiasis and is frequently overlooked or misdiag- Clindamycin cream (2%): 1 full applicator (5 g) nosed. The initial evaluation suggests candidiasis; intravaginally at bedtime for 7 days the candidiasis is treated and the bacterial vagi- Sustained-release clindamycin (2%): 1 full applicator nosis is overlooked, left untreated, and continues 1 time only (7-day duration) to provide a hospitable environment for candida Clindamycin ovules (100 g): intravaginally once at (yeast). Again, an accurate diagnosis is impor- bedtime for 3 days tant, and risk factors for BV should be discussed. VAGINITIS 357 deal with this problem. Despite the latest “third- oral fluconazole once weekly for six months. If generation” anticandidal preparations, women this treatment is not feasible, one can also use continue to be plagued by the occurrence and topical clotrimazole (200 mg twice a week) or recurrence of candidal vulvovaginal infections. once-weekly clotrimazole (500 mg) vaginal sup- While this is sometimes because of undiagnosed positories for six months. and untreated bacterial vaginosis, chronic yeast Emergence of azole-resistant candidiasis is infections do occur. The 2006 CDC recommen- increasing. For non-albicans candidiasis, the recur- dations for treatment of candidiasis are listed in rence treatment recommendation is 600 mg of Table 20.1. boric acid in a gelatin capsule vaginally once daily Topical azoles are more effective than nystatin for two weeks following the original oral or vaginal and provide for symptom relief and complete treatment. Sometimes adding oral Lactobacillus aci- treatment in 80 to 90 percent of patients who dophilus, especially for women who are using oral follow recommended treatment guidelines. contraceptives, daily or every other day helps to Creams and suppositories are oil-based and can reduce recurrences. This is discussed in more detail weaken latex condoms and diaphragms, however, in the alternative medicine section of this chapter. so it is important to be warned of this possibility. Instruction in proper hygiene (in terms of always For recurrent vulvovaginal candidiasis, extend wiping from front to back) is also helpful. There is the initial topical or oral therapy. The first treat- no need to treat the sexual partner. ment of recurrence would involve a longer 7- to 14-day topical therapy regimen or a dose of flu- Trichomoniasis conazole orally every three days for a total of The treatment of trichomoniasis has not changed three doses. If this does not work, then consider very much over time; it calls for treating the patient

Table 20.1 CDC Guidelines for Intravaginal Treatment of Yeast Vaginitis

Intravaginal Drug Regimen

Butoconazole 2% cream 5 g single intravaginal application Clotrimazole 1% cream (OTC) 5 g intravaginally for 7–14 days Clotrimazole 100-mg vaginal tablet 2 per day for 3 days Miconazole 2% cream (OTC) 5 g intravaginally for 7 days Miconazole 100-mg vaginal suppository (OTC) 1 per day for 7 days Miconazole 200-mg vaginal suppository (OTC) 1 per day for 3 days Miconazole 1200-mg vaginal suppository (OTC) 1 in a single dose Nystatin 100,000-unit vaginal tablet 1 per day for 14 days Tioconazole 6.5% ointment (OTC) 5 g intravaginally in a single application Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 80-mg vaginal suppository 1 per day for 3 days

Oral Drug Regimen

Fluconazole 150-mg oral tablet 1 in a single dose 358 WOMEN’S ENCYCLOPEDIA OF NATURAL MEDICINE and her partner with oral metronidazole. Recom- cian’s assistant) who is familiar with the clinical mended medications are metronidazole 2 g orally picture of various forms of vaginitis, can perform in a single dose; the new Tindamax (tinidazole) 2 g a physical exam, knows what to test for, and can orally in a single dose; or metronidazole 500 mg collect those samples during your exam. Accurate orally twice daily for seven days. For pregnant diagnosis is the most important key to efﬁcient women, metronidazole is the safe treatment of and appropriate treatment, whether the therapies choice with 2 g metronidazole in a single oral dose are natural or pharmaceutical. If you know what during pregnancy. Nursing women should with- kind of infection you currently have and choose hold breast-feeding for 12 to 24 hours after the self-treatment, it is essential to recognize when and dose of metronidazole. If you are taking Tindamax, if self-treatment isn’t working and to seek profes- practitioners recommend that you interrupt breast- sional care at that time. It is most important to feeding for three days after the dose. seek professional care when infections recur more than three times per year, if you have a chronic SEEING A LICENSED PRIMARY infection that doesn’t fully resolve, or when you HEALTH-CARE PRACTITIONER are pregnant. Speciﬁc testing can be done, but, (N.D., M.D., D.O., N.P., P.A.) more important, a licensed practitioner can help The most appropriate way to assure an accurate determine if underlying disorders are contributing diagnosis is to see a licensed health-care practi- to the vaginal infection. All the alternative thera- tioner (naturopathic doctor; medical doctor; pies discussed in this chapter are generally safe for osteopathic doctor; nurse-practitioner, or physi- home use, except for pregnant women. GENERAL APPENDIX A EXERCISE PROGRAM

here is strong and rapidly accumulating cent and 70 percent to get the bottom and Tevidence that muscular exertion reduces top of the range: cancer risk. The following recommendations are Bottom THR ϭ MHR ϫ .60 based on a review of recent scientific literature on physical exercise and cancer risk reduction: Top THR ϭ MHR ϫ .70 Otherwise, multiply MHR by 70 percent 1. To prevent injuries, begin each exercise ses- and 85 percent: sion with Joint Warming Exercises and end each exercise session with Basic Stretches Bottom THR ϭ MHR ϫ .70 (see the following pages). Top THR ϭ MHR ϫ .85 2. Exercise six days a week. Walk or do moderate hiking on your day off. Divide the results by 6 to calculate THR per 3. Alternate aerobic (cardiovascular) with 10 seconds. strength (weight lifting) exercises. As an example, let us calculate THR for 4. Take one day off each week: a 50-year-old woman who is beginning to exercise. • Forget about your work, your bills, your problems. Seek peace in the woods or MHR ϭ 220 Ϫ 50 ϭ 170 beats per mountains. minute • Refresh your being with pure air, pure Bottom THR ϭ 170 ϫ .60 ϭ 102 beats water, simple food, and communion with per minute nature. • Hike moderately, read a good book, lie Top THR ϭ 170 ϫ .70 ϭ 119 beats per down and look at the sky or the birds, or minute take a nap. To calculate THR per 10 seconds: • This is your day of recreation. Let nothing interfere with it. 102 Ϭ 6 ϭ 17 5. Calculate your training heart rate (THR) for 119 Ϭ 6 ϭ 20 aerobic exercise. THR is defined as the range THR range ϭ 17–20 beats per 10 seconds of heart rates that is safe for your heart and will strengthen it. To do this, first calculate For this example, the recommendation your maximum heart rate (MHR): would be, after three minutes of aerobic exercise, check your pulse for 10 seconds. If MHR ϭ 220 Ϫ your age (in years) it is less than 17, increase your pace. If more Next calculate your training heart rate than 20, reduce your pace. Repeat this pro- (THR) as a percentage of MHR. If you are cedure every three minutes or so throughout just beginning, multiply MHR by 60 per- your exercise session.

359

Copyright © 2008 by Tori Hudson. Click here for terms of use. 360 APPENDIX A JOINT WARMING EXERCISES the left leg, 20 times while standing on right The following exercises are designed to protect leg. the joints against injury from weight-bearing 8. Ankles exercise. These exercises should be performed Standing on left foot, rotate right ankle before any cardiovascular or strength workout. inward 10 times and then outward 10 times. Repeat exercise with left ankle while stand- 1. Neck ing on right foot. Rotate neck gently to left 5 times, then to right 5 times. BASIC STRETCHES 2. Shoulders Here are some general guidelines for stretching: Rotate shoulders forward 10 times, then backward 10 times. • Stretch at the end of the exercise session, 3. Elbows, Wrists, and Fingers when muscles are warm. Begin with arms bent, elbows against the • Hold stretch steadily—do not bounce. sides of body, hands forming a fist against • Accept a bit of discomfort but avoid pain— shoulders. Then extend arms fully, directly do not push. in front of you, while opening hands and 1. Calves, Hamstrings, Back, Neck extending fingers. Return to initial position. • Stand, feet apart about shoulder width, Repeat 10 times. toes pointing forward, knees straight. Repeat motion, but this time raise your • Let head and trunk fall forward and hands above your head. Don’t forget to open down. Let arms hang down. Allow gravity your hands and your extend fingers as you to push down your trunk so that your fin- extend your arms above your head. Repeat gertips will get closer and closer to your 10 times. toes, without forcing. 4. Trunk and Waist • Relax in this position for 30 seconds (over Bend your trunk at the waist from right to several weeks, increase gradually to 60 left and from left to right. Avoid stiffening seconds). your muscles or applying force as you do 2. Inner Thigh, Low Back this exercise. Perform the exercise as a gentle • Standing, separate feet as much as possi- rocking movement from side to side. Alter- ble, knees straight. nate right to left for 20 counts. • Bend trunk forward at the hips, let arms 5. Hips and head hang down comfortably. “Hula-hoop” exercise. Perform full circles • Relax in this position for 20 seconds. with your hips rotating clockwise 10 times. 3. Inner Thigh, Right Side of the Body, Left Repeat rotating counterclockwise 10 times. Hamstrings 6. Hips and Knees • Same position as in stretch 2. Rotate Bring right knee close to chest by using both trunk over left leg and let your trunk and hands around knee and gently pulling with arms hang along the left leg with hands your arms. Count to 20. Repeat with left trying to reach the left foot. knee. • Relax in this position for 20 seconds. 7. Knees • Repeat with trunk and arms hanging Standing on left leg, gently bend and extend along the right leg. the right leg 20 times. Repeat exercise with • Relax in this position for 20 seconds. GENERAL EXERCISE PROGRAM 361 4. Tibialis, Quadriceps, Abdominals, Chest, obic exertion. Five- to ten-minute transition Front of Neck periods between rest and exercise and then rest • Kneel on hands and knees, with thighs are important to help the metabolic, circulatory, and arms perpendicular to the floor. and neuromuscular systems adapt without • Keeping hands and knees in place and injury or trauma. A recommended warm-up is arms extended, move trunk forward until Joint Warming Exercises (see instructions). your abdomen touches the floor. Then 4. Proper equipment. Safety equipment and raise your head up and back so that you quality footwear are important for all sports. can see the ceiling. For the runner this may mean reflective tape • Hold this position for about 20 seconds. and $50 to $100 shoes; for the cycler, this • Keeping hands and knees in place and means a hard helmet; for the racquetball player, arms extended, move trunk backward goggles, etc. until your buttocks touch your heels. Let 5. Gradual progression. The number-one head down, forehead against the floor. cause of musculoskeletal problems is overuse— • Relax in this position for 20 seconds. too much, too fast, too soon. A conservative beginning, with gradual progression, is the most PREVENTING EXERCISE INJURIES important injury-prevention practice and is readily available. Many beginner exercisers are Prevention of exercise injuries revolves around overzealous initially and soon acquire injuries several guidelines: that thwart future exercise. 1. Stretching. Stretching exercises should be 6. Moderation. Avoid too much of any one engaged in after every exercise session, especially activity. Engaging in several different activities concentrating on the muscle groups that have can help prevent overspecialization and resulting been utilized during the exercise session. For walk- muscle imbalances and overcompulsion. ers and runners, this means concentrating on pos- 7. Responsibility of the individual. The indi- terior leg muscles, the lower back, and the front of vidual’s responsibility is to stay within the toler- the chest. For cyclers, this means the quadriceps, ance of her or his own musculoskeletal system. posterior leg muscles, and upper back. For swim- Individual judgment and common sense should mers, the shoulder joints especially should be be utilized to “listen” to one’s body, making stretched as well as the lower back and calves. adjustments when necessary. This can mean 2. Strengthening. Often muscle imbalances can avoiding that extra three miles of running or create injury problems. For knee problems in run- that extra set of squats, being regular in train- ners, for example, often the hamstrings are too ing, obtaining adequate rest and optimal nutri- strong and the quadriceps are too weak, so pro- tion, and seeking a balanced approach. gressive resistance exercises for the knee (exten- 8. Be willing to rest. An important equation sion) can be performed, both for prevention and in exercise is “Exercise plus rest equals fitness.” treatment. If the shin area is giving problems or In other words, it takes both exercise and ade- might potentially be a future problem, the ante- quate rest to build fitness. Either alone will not rior leg muscles can be strengthened through toe- do it. Often beginner exercisers will sacrifice raising resistive exercises (with stretching of the sleep time to get up and exercise. Chronic calf muscle, which is often too strong). fatigue may result, and the whole purpose of 3. Warming up and down. Slow aerobic exer- exercise—to feel better—is negated. It’s impor- cises should always precede and follow hard aer- tant to get both rest and exercise. 362 APPENDIX A 9. Exercise technique. Various aerobic activi- Strength Exercise ties require special techniques to avoid injury. Flexibility exercises demand stretching below Beginner the pain threshold. Regarding aerobic activities • Follow program of exercise planned for you such as running or jogging, it is important to by an exercise specialist. keep the body in an upright posture and the • Allow at least 8 weeks for conditioning of arms at a 90-degree angle, swinging from the your muscles and joints: exercise very mod- shoulder. The feet should land almost flat- erately and increase weight gradually every footed with the weight well back toward the week as you get stronger. heel. Only sprinters should run on their toes. Breathing should be through the mouth and More Advanced nose in a regular fashion. Overall, the body • For 6 weeks, do 10 reps, 2 sets. should be loose, natural, and poised. Each • Keep increasing weight every week, sport should be studied to ensure adequate gradually. technique. Advanced ABBREVIATED GENERAL EXERCISE PROGRAM • Divide workout into upper body exercises on alternate days. Aerobic Exercise • Do 10 reps, 3 sets of each exercise. Preventing Injury from Strength Training Beginner • Work with an exercise specialist who can • Allow at least 6 weeks for conditioning of show you the safe way to use weights. your heart: exercise very moderately. • Do not compete with anyone but yourself. • Exercise at a training heart rate (THR) that • Begin with very light weight, so that you is 60–70 percent of your maximum heart can perform 12–15 repetitions of the exer- rate (MHR). cise easily. Increase weight very gradually. • Walk for 15 minutes. Increase time of exer- • Avoid holding your breath while lifting. cise gradually to 30 minutes over the 6-week Breathe in during relaxing part of exercise period. and breathe out during effort part of More Advanced exercise. • Rest and take a mouthful of pure water • For 10 weeks, increase THR to 65–75 per- between exercises. cent of MHR. • Warm up for 3–5 minutes before weight lift- • Walk for 30–45 minutes. ing exercises and stretch the muscles used Advanced during the exercise session after the workout.

• Increase THR to 70–85 percent of MRH. SPEAK PREGNANCY EXERCISES • Walk for 45–60 minutes. These exercises for pregnant women are adapted • Introduce variations in program. For exam- from Health magazine (December 1993: 28–30). ple, do interval training: walk fast for 5 minutes and then jog for 30 seconds. Repeat 1. Cobbler’s Pose. This exercise helps the pelvic combination three times during workout. organs by promoting circulation of blood in this GENERAL EXERCISE PROGRAM 363 area. It also helps to assure the correct position of • Try a gently rocking movement, shifting the pelvis. This exercise can be done as often as your weight from your arms to your legs. you like and can be used in general as a sitting • Breathe deeply while trying to stay in this position. When sitting in this position, you position for a minute or longer, and then should be able to feel a stretch on the inside of come up and resume a normal sitting position. your thighs, vagina, and hip joints. You may also 3. Pelvic Floor Exercises. This exercise will feel stretching in your knees and ankles. help your pelvic floor muscles relax if you do it • Sit on the floor with your back straight and often enough. This will prove to be helpful in legs stretched out in front. You can sit the second stage of labor, and it may prevent a against a wall to support the lower back. tear when giving birth. This exercise should be • Bend your knees and let your knees relax done daily, especially in the third trimester. away from each other to each side, bringing • Stand with your feet about two feet apart. the bottom of your feet together. The soles Squat down and end up squatting on the of your feet should now be touching with balls of your feet. Lean forward onto your the outside ankle region resting on the floor. hands, keeping your arms and back straight, • Pull your pressed-together feet as close to and open your knees wide apart, pointing the opening of your vagina as possible. them to the outside. Open out your thighs and let your knees • Tighten your pelvic floor muscles, pulling lower toward the floor. Breathe deeply. them in as if you are trying to stop yourself from urinating. Hold for several seconds, and 2. Kneeling with Knees Apart. This position then slowly let go. Repeat three to five times. helps to alleviate low back pain and decrease • Repeat the exercise again, but this time let tension in the pelvis and pelvic joints. The go in four stages, a little at a time. pelvic joints open and the muscles are able to • Repeat the exercise again, and this time pic- relax and lengthen in the low back and pelvis. ture your baby’s head passing through your Stretch only as far as you can without bending pelvis during the second stage of labor. Each your back, and then hold this position while time you breathe out, imagine that your breathing deeply. You should be able to feel the baby is continuing to pass through your stretch in the vaginal region and in the knees vagina as you release your pelvic muscles. and ankles. 4. Pelvic Tuck-In. One of the health problems • Kneel on the floor with knees as wide apart as during pregnancy can be strain on the lower possible, the top of your feet on the floor, and back due to the extra weight. This exercise your toes pointing in toward each other. Try strengthens the buttocks muscles, increases sup- to sit between your feet with your buttocks port to the lower back, and stabilizes the pelvis, on the floor or sit on top of your heels. which can help prevent back pain. A gentle • Move slowly forward from the hips, keeping rocking movement added to the exercise can be your buttocks down as much as possible and good practice for labor and lessen pain and ease then lean forward and place your palms on the passage of the baby through the birth canal. the floor in front of you with both arms straight. Try resting on your arms, keeping • Position yourself on the floor on your hands your back straight. You should feel a stretch and knees. Your knees should be about one in the vagina. foot apart. 364 APPENDIX A

• Pull in and tighten your buttocks, pulling More Advanced Strength your pelvis so that your back arches like a Training: Weeks 9–16 cat’s back when it’s afraid or angry. Hold this for 10 to 15 seconds, and then let go. To continue with strength training, it is probably best • Repeat this at least six times, and then do to join a health club, ﬁtness club, gymnasium, or a the exercise a little bit faster, rocking your similar organization. pelvis gently up and down along with your Divide your workouts into body parts and do two back motion. sets per exercise. Begin each workout by warming up for 5 to 10 minutes and end each workout with 5 to Sample Conditioning 10 minutes of Basic Stretches. Exercise Program: 8 Weeks Exercise Aerobic (Sunday, Tuesday, and Thursday) Day Part (2 sets each) Reps Day 1 Chest Bench press 8–10 • Joint Warming Exercises (see instructions). Biceps Arm curl 8–10 • Walk briskly for 15 minutes. Gradually increase Abdominals Easy crunches 8–10 to 30, 45, or 60 minutes over a period of 4 to Day 2 Back Pull-down to chest 8–10 6 weeks. (Other possibilities: Jog, run, swim, Triceps Arm extension 8–10 cycle, row, play a sport such as tennis, skate, Abdominals Easy crunches 8–10 ski, or water exercise.) Day 3 Legs Squat or leg press 8–10 • Basic Stretches (see instructions). Calves Heel raise 8–10 • Friction entire body, from feet up (30 sec- Shoulders Press behind neck 8–10 onds), with dry washcloth. • Shower. Weight Lifting Guidelines Strength (Monday, Wednesday, and Friday) 1. Work out on alternate days. • Joint Warming Exercises (see instructions). 2. Take a mouthful of water between sets. • Walk briskly for 15 minutes. 3. For each repetition, breathe out during the effort phase of the repetition, breathe in during • Dumbbell exercises: the relaxation phase. Week 1: begin with a weight that allows you to 4. If, after a workout, the exercised muscles are do 10–12 repetitions (reps) of each exercise sore for more than 48 hours, reduce the weight easily. and/or the number of repetitions. Week 2: increase weight, 10 reps. 5. Most injuries from exercise result from doing Week 3: 10 reps, 2 sets per exercise. “too much, too fast, too soon.” Week 4: increase weight, 10 reps, 2 sets. 6. Warm up for 5 to 10 minutes before the work- Week 5: increase weight, 10 reps, 2 sets. out. Joint mobility exercises are excellent for Week 6: increase reps to 12, 2 sets. this purpose. Week 7: increase weight, 12 reps, 2 sets. 7. From week to week increase weight slightly so Week 8: increase weight, 12 reps, 2 sets. that you can continue to perform the same • Basic Stretches (see instructions). number of repetitions per exercise as in the pre- • Friction entire body, from feet up (30 sec- vious week. onds), with dry washcloth. 8. After 16 weeks of this conditioning program, you may • Shower. Increase the number of sets per exercise Rest (Saturday) Modify your routine to include other exercises • See item 4 on page 359. Concentrate on body areas that need extra work BODY MASS APPENDIX B INDEX

Healthy Weight Overweight Obese

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Ht (in) Body weight (lb)

58 91 95 100 105 110 114 119 124 129 133 138 143 148 152 157 162 167 172

59 94 99 104 109 114 119 124 129 134 139 144 149 154 159 164 169 174 179

60 97 102 107 112 117 122 127 132 138 143 148 153 158 163 168 173 178 183

61 101 106 111 117 122 127 132 138 143 148 154 159 164 169 175 180 185 191

62 103 109 114 120 125 130 136 141 147 152 158 163 168 174 179 185 190 196

63 107 113 119 124 130 135 141 147 152 158 164 169 175 181 186 192 198 203

64 111 117 123 129 135 141 146 152 158 164 170 176 182 187 193 199 205 211

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216

66 118 124 131 137 143 149 156 162 168 174 180 187 193 199 205 212 218 224

67 121 127 134 140 147 153 159 166 172 178 185 191 198 204 210 217 223 229

68 125 132 139 145 152 158 165 172 178 185 191 198 205 211 218 224 231 238

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243

70 133 140 147 154 161 168 175 182 189 196 203 210 217 224 231 237 237 244

71 136 143 150 157 164 171 179 186 193 200 207 214 221 229 236 243 250 257

72 140 148 155 162 170 177 185 192 199 207 214 221 229 236 244 251 258 266

73 143 151 158 166 174 181 189 196 204 211 219 226 234 241 249 257 264 272

74 148 156 164 171 179 187 195 203 210 218 226 234 242 249 257 265 273 281

75 151 159 167 175 183 191 199 207 215 223 231 239 247 255 263 271 279 287

76 156 164 172 181 189 197 205 214 222 230 238 246 255 263 271 279 287 296

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The following has been adapted from The 2004 tablet contains 1.5 mg estropipate; Guide to Hormone Therapy Products by Nayahmka 2.5 mg tablet contains 3 mg McGriff-Lee, Pharm.D., GlaxoSmithKline; and estropipate Karim Anton Calis, Pharm.D., M.P.H., Depart- 0.625 mg, 1.25 mg, 2.5 mg ment of Health and Human Services, National Ortho-Est Estropipate; 0.625 mg tablet con- Institutes of Health (Ob/Gyn Special Edition tains 0.75 mg estropipate; 1.25 mg Spring 2004: North American Menopause tablet contains 1.5 mg estropipate Society). 0.625 mg, 1.25 mg Premarin Conjugated equine estrogens; ORAL ESTROGENS 50–60% estrone sodium sulfate; Cenestin 9 synthetic plant-derived conjugated 20–35% equilin sodium sulfate and estrogens; slow-release tablet 17 beta-dihydroequilin; small 0.3 mg, 0.45 mg, 0.625 mg, 0.9 amounts of 17 beta-estradiol and mg, 1.25 mg equilenin; contains over 200 com- Enjuvia Synthetic conjugated estrogens pounds, including androgenic com- 0.3 mg, 0.45 mg, 0.625 mg, 1.25 pounds mg 0.3 mg, 0.45 mg, 0.625 mg, 0.9 Estratab Esteriﬁed estrogens mg, 1.25 mg 0.3 mg, 0.625 mg, 1.25 mg, 2.5 mg Indications Estrace 17 beta-estradiol; most active form Moderate to severe vasomotor symptoms of endogenous estrogen; up to 90% Vulvar and vaginal atrophy of the oral dose is converted to Osteoporosis prevention estrogen by the gut and liver 0.5 mg, 1.0 mg, 2.0 mg Note: Cenestin and Menest are not FDA- Femtrace Estradiol acetate approved for the prevention of osteoporosis; 0.45 mg, 0.9 mg, 1.8 mg Cenestin 0.3 mg is indicated only for vasomotor Gynediol 17 beta-estradiol; micronized for- symptoms; Menest is indicated for atrophic mulation; 2 mg tablet contains tar- vaginitis. trazine (dye) that may cause allergy in patients with a sensitivity to Adverse Effects aspirin Common: breakthrough bleeding, breast ten- 0.5 mg, 1.0 mg, 1.5 mg; 2.0 mg derness, nausea, bloating, abdominal cramps, Menest Esteriﬁed estrogens (synthetic vomiting, headache, dizziness, depression, plant-derived) peripheral edema, weight changes, rash, intoler- 0.3 mg, 0.625 mg, 1.25 mg, 2.5 mg ance to contact lenses, migraine, libido changes Ogen Estropipate; 0.625 mg tablet con- Rare: thromboembolism, stroke, endometrial tains 0.75 mg estropipate; 1.25 mg cancer, breast cancer (when used with a proges- 367

Copyright © 2008 by Tori Hudson. Click here for terms of use. 368 APPENDIX C togen), hepatic adenoma, gallbladder disease, Estrogel 17 beta-estradiol; nonaerosol, increased blood pressure, myocardial infarction metered-dose pump; gel dries in as little as 2–5 minutes Dosing 1.25 g (0.75 mg estradiol) Continuous or cyclic (21 days on, 7 days off ) 1x/day; 1 pump ϭ 0.05 patch Add a progestogen 10–14 days of month for FemPatch 17 beta-estradiol women with uterus. 0.025 mg (2x/week) Menostar 17 beta-estradiol Drug Interactions One patch provides 14 mcg Drugs affected by oral estrogens: cortico- of estradiol per day (1x/week) steroids (increased), levothyroxine (decrease), Vivelle or 17 beta-estradiol (2x/week); 0.05 theophylline (increase), warfarin (decrease), Vivelle-Dot mg/24-hour patch antibiotics (decrease), androgens (decrease), 0.025 mg, 0.0375, 0.05 mg, nicotine (eliminates more rapidly) 0.075 mg, 0.1 mg Drugs that affect oral estrogens: barbiturates (decrease), rifampin (decrease) Indications Moderate to severe vasomotor symptoms TRANSDERMAL ESTROGENS Vulvar and vaginal atrophy Alora 17 beta-estradiol (2x/week); 0.05 mg/24-hour patch Note: Alora and Vivelle-Dot are also indicated 0.025 mg, 0.05 mg, 0.075 mg, for the prevention of osteoporosis; Estrasorb is 0.1 mg indicated only for moderate to severe vasomotor Climara 17 beta-estradiol (1x/week); 0.05 symptoms. mg/24-hour patch 0.025 mg, 0.0375 mg, 0.05 mg, Adverse Effects 0.06 mg, 0.075, 0.1mg Common: Erythema and skin irritation occurs in Esclim 17 beta-estradiol (2x/week); 0.05 10–17% of patients using reservoir-type patches mg/24-hour patch compared to approximately 5% with newer 0.025 mg, 0.0375 mg, 0.05 mg, matrix-type patches, breakthrough bleeding, 0.075 mg, 0.1 mg breast tenderness, nausea, abdominal cramps, Estraderm 17 beta-estradiol (2x/week);0.05 headache, peripheral edema, migraine mg/24-hour patch Rare: rash, thromboembolism, stroke, endome- Includes a drug reservoir of trial cancer, breast cancer (when used with a estradiol and alcohol and a copoly- progestogen), increased blood pressure mer membrane that controls the rate of drug diffusion Dosing and Administration 0.05 mg, 0.1 mg Discontinue oral therapy for 1 week before ini- Estrasorb Topical emulsion of estradiol tiating transdermal estrogen. hemihydrate Patch should be applied to the trunk of the body. 1 g emulsion ϭ 2.5 mg estradiol; Avoid application on the breasts. each foil-laminated pouch contains Rotate application site weekly to minimize irri- 1.74 g (4.35 mg estradiol hemihy- tation. drate); nominal estradiol delivery Patch may be worn while showering or rate of 0.05 mg/day swimming. HORMONE REPLACEMENT THERAPY PRESCRIPTIONS 369 Drug Interactions Indications See oral estrogens (except antibiotics and Vulvar and vaginal atrophy nicotine). Note: Premarin and Vagifem are indicated for VAGINAL ESTROGENS atrophic vaginitis; Femring is also indicated for moderate to severe vasomotor symptoms. Estrace 17 beta-estradiol; 0.01% cream; cream 1 g 1–3x/week 0.1 mg per g Adverse Effects Consider starting with 2–4 g every Common: headache, nausea, vaginal discom- day intravaginally for 2–4 weeks, fort, vaginal candidiasis and then 1–2 g for 1–2 weeks; Rare: vaginal trauma from the applicator if maintenance dose usually 1 g patient has severe atrophy 1–3x/week Estring Alpha estradiol; biologically inert Dosing and Administration liquid polymer matrix with pure crystalline estradiol; releases 7.5 Daily dosing will achieve systemic mcg/24 hours over 90 days concentrations. 2 mg delivered over 90 days; Low dose, 1–3x/week, will achieve predomi- replace ring every 90 days nantly local effects. Femring Estradiol acetate; device contains Drug Interactions 12.4 mg or 24.8 mg estradiol acetate, which releases 0.05 mg/24 See oral estrogens (except antibiotics and nico- hours or 0.1 mg/24 hours; replace tine); interactions are based on extent of systemic every 3 months absorption. Ogen cream Estropipate; 2–4 g 1–3x/ week 1.5 mg per g of cream ORAL ESTROGEN-PROGESTIN Premarin Conjugated equine estrogens COMBINATIONS cream (CEE) Activella 1 mg 17 beta-estradiol/0.5 mg 0.625 mg per g of cream; 0.5–2 g norethindrone acetate 1–3x/week; applicator marked in Continuous combined regimen, 1 0.5 g intervals; absorbed slower pill daily than other estrogen preparations Angeliq 1 mg 17 beta-estradiol ϩ 0.5 mg and therefore a longer duration of drospirenone action Femhrt 5 mcg ethinyl estradiol/1 mg Vagifem Estradiol hemihydrate vaginal norethindrone acetate tablets; a gel forms when the Continuous combined regimen, 1 tablet comes in contact with the pill daily vagina; initial dose of 1 tablet Prefest 1 mg 17 beta-estradiol ϩ 1 mg 17 1x/day for 2 weeks, and then beta-estradiol/.09 mg norgestimate maintenance of 2x/week 3 days estradiol tablet, and then 3 25 mcg in single use applicator; 1 days norgestimate tablet, alternat- tablet 2x/week ing continuously; packaged as 2 separate tablets 370 APPENDIX C Premphase 0.625 conjugated equine estrogen ClimaraPro 0.045 estradio/0.015 mg lev- (CEE) days 1–14 days and a combo onorgestrel; 1 patch/week tablet of 0.625 mg CEE/5.0 mg medroxyprogesterone acetate Indications (MPA) days 15–28 Moderate to severe vasomotor symptoms Packaged as 2 separate tablets Prempro 0.625 mg CEE/2.5 mg MPA; or Note: CombiPatch is also indicated for vulvar 0.625 mg CEE/5.0 mg MPA; or and vaginal atrophy. 0.3 mg CEE/1.5 mg MPA; or Adverse Effects 0.45 mg CEE/1.5 mg MPA A single tablet contains one of the See transdermal estrogens and oral progestins. four dosing options; continuous Dosing and Administration combined regimen Complete the current cycle of therapy before Indications initiating combination transdermal therapy. Combination therapy is indicated for women Apply to lower abdomen. with an intact uterus Potential Drug Interactions Adverse Effects See oral estrogens (except antibiotics and nico- See oral estrogens and oral progestins. tine) and oral progestins.

Dosing and Administration ORAL PROGESTINS Addition of a progestin for at least 10–12 days Amen Medroxyprogesterone acetate per month protects against the increased risk of 5.0 mg, 10 mg endometrial hyperplasia that occurs with unop- Aygestin Norethindrone acetate posed estrogen use. 5 mg Continuous combined therapy is an alternative Cycrin Medroxyprogesterone acetate regimen that reduces and often eliminates with- 2.5 mg, 5 mg, 10 mg drawal bleeding when compared to a cyclic regi- Megace Megestrol acetate men. 20 mg, 40 mg Micronor Norethindrone acetate Potential Drug Interactions 5 mg See oral estrogens (except antibiotics and nico- Nor-QD Norethindrone tine) and oral progestins. .35 mg Ovrette Norgestrel 0.075 mg; 19-nor deriv- TRANSDERMAL ESTROGEN- ative of testosterone with progesto- PROGESTIN COMBINATIONS genic, estrogenic, androgenic, and CombiPatch .05 mg 17 beta-estradiol/0.14 mg antiestrogenic effects norethindrone acetate; 2 patches/ Provera Medroxyprogesterone acetate week 2.5 mg, 5 mg, 10 mg; usual main- .05 mg 17 beta-estradio/0.25 mg tenance dose of 5–10 mg daily for norethindrone acetate; 2 12–14 days per month patches/week HORMONE REPLACEMENT THERAPY PRESCRIPTIONS 371 Indications ESTROGEN/TESTOSTERONE To reduce the incidence of endometrial hyper- Estratest h.s. 0.625 esterified estrones/1.25 plasia in nonhysterectomized women receiving methyltestosterone estrogen Estratest 1.25 esterified estrones/2.5 methyltestosterone Adverse Effects Common: breast tenderness, nausea, irritability, TESTOSTERONE weight change, fluid retention, sleep disturbance Androgel 10 mg/g (formulated for men) Rare: thromboembolism, edema, rash; increased 1% gel risk of breast cancer when used with estrogens Testoderm 1 patch delivers 4 mg over 24 hours (formulated for men) Dosing and Administration 1 patch delivers 6 mg over 24 Use for 12–14 consecutive days. hours Start on day 16 or 21 of cycle when used in Androderm 1 patch delivers 2.5 mg over 24 combination with estrogen. hours (formulated for men) 1 patch delivers 5 mg over 24 Potential Drug Interactions hours Drugs affected by oral progestins: warfarin Female 300 mcg patch (not commer- (decrease), digoxin (decrease) testosterone cially available yet) Drugs that affect oral progestins: rifampin patch (decrease) Indications PROGESTERONE Treatment of vasomotor symptoms in patients Prometrium Oral micronized progesterone who do not respond to estrogen alone 100 mg, 200 mg; 200 mg daily Androgens may improve libido, energy, and for 12–14 days, or 100 mg overall well-being daily Prochieve 4% vaginal progesterone Adverse Effects Common: virilization, changes in libido Note: Progesterone is generally associated with (increased or decreased), nausea, abdominal less nuisance effects than progestins. It is unclear cramps, headache, breakthrough bleeding, if progesterone has a better safety profile for more breast tenderness, edema serious side effects. Natural progesterone may be Rare: increased liver function tests, poly- used as a sleep aid. cythemia, cholestatic hepatitis, jaundice, hypercalcemia, thromboembolism, stroke, INTRAUTERINE PROGESTINS endometrial cancer, breast cancer, hepatic ade- Mirena 20 mcg/day approximate noma, gallbladder disease, increased blood release rate pressure 52 mg IU has 5-year use Dosing and Administration VAGINAL PROGESTERONE GEL Cycle 21 days on, 7 off Prochieve 4% progesterone; 45-mg applicator Can be used continuously 372 APPENDIX C Potential Drug Interactions Drugs affected by oral estrogens-androgens: warfarin (increase), cyclosporine (increase) Drugs that affect oral estrogens-androgens: barbiturates, phenytoin PROCEDURES APPENDIX D AND PRACTICES

BREAST SELF-EXAM perature). Fill the other one half full with ice cold The breast self-exam should be done in three steps:* water. Sit in the hot water for three minutes and then quickly sit in the cold for 30 seconds. 1. The first step is a visual exam in front of a Repeat this three times in succession. Quickly get mirror: Look at your breasts with your arms at dressed or put on a robe or blankets so as not to your sides, then hold your arms overhead, clasp- become chilled. The room where you are doing ing your hands behind your head. Next place the treatment should be comfortable and warm. your hands on your hips, roll your shoulders forward, and bow forward slightly as you pull CASTOR OIL PACK your shoulders and elbows forward. Inspect Materials needed: both breasts for swelling, changes in skin (dim- pling, puckering, discoloration, or scaling of 1. Wool flannel cloth skin), or changes in your nipples, including 2. Plastic sheet (medium thickness) retraction or discharge. 3. Bath towel 2. The second step is to lie down and place a 4. Two safety pins small pillow or folded towel under your right 5. Bowl shoulder and your right arm behind your head. 6. Castor oil Press firmly with the pads of your fingers and 7. Plastic wrap move your left hand over all parts of your right 8. Baking soda breast in an up-and-down motion as if you are 9. Large resealable plastic bag tracking vertical lines in rows next to each Instructions other. Pay extra attention to the area between the breast and the armpit, including the armpit Fold a piece of wool or cotton flannel to make a itself. Gently squeeze the nipple to check for pack three layers thick and approximately 12 discharge. Check the left breast with your right inches square. This size is recommended for hand in the same way. abdominal and pelvic applications. Pour castor 3. The third step is standing. With your left arm oil into the bowl. Place the cloth in the bowl to behind your head, use your right hand to examine saturate the flannel; wring it out so it is not drip- your left breast. Move your fingers up and down ping. Place the plastic sheet on the bed where in vertical rows pressing firmly with the pads of you will be lying down. Apply the cloth to the your fingers. Repeat this on the right breast. designated bodily area and cover it with a piece of plastic wrap. Wrap a towel around the entire ALTERNATING SITZ BATHS area and fasten it with safety pins. Lie down and Obtain two large tubs that you are able to sit in. avoid becoming chilled. The pack should stay in Fill one half full with hot water (bath water tem- place for a minimum of one hour but may be worn longer. After removing the castor oil pack, *Adapted from the American Cancer Society, September clean the skin with soda water (two teaspoons of 2006, cancer.org. baking soda added to a quart of warm water). 373

Copyright © 2008 by Tori Hudson. Click here for terms of use. 374 APPENDIX D The castor oil pack may be saved in a reseal- weigh out one ounce of dry herbs. Add one pint able plastic bag or container for future use. It can (two cups) of boiling water to the herbs. Some be used repeatedly for a number of treatments. herbs will taste better if you use more than two cups of water. Steep the herbs for ten to twenty INFUSIONS minutes. Herbs that are steeped longer will become An infusion is a simple tea made with one or more stronger. Strain the tea through a metal-wire or herbs steeped in boiled water. To make an infusion, bamboo tea strainer. Drink throughout the day. RECOMMENDED SCREENING APPENDIX E TESTS AND IMMUNIZATIONS

The following charts list recommended screen- health-care needs. The charts are based on the ings and immunizations for women at average recommendations of the National Women’s risk for most diseases and for women with vari- Health Information Center, U.S. Department of ous risk factors. These are guidelines only. Your Health and Human Services, Ofﬁce on Women’s health-care provider will personalize the timing Health as of October 2006. of each test and immunization to best meet your

Recommended Screening Tests and Immunizations for Women at Average Risk

Screening Tests Ages 18–39 Ages 40–49 Ages 50–64 Ages 65 and Older

Full checkup, Discuss with your Discuss with your Discuss with your Discuss with your including weight doctor or nurse. doctor or nurse. doctor or nurse. doctor or nurse. and height Thyroid test Start at age 35, and Every 5 years Every 5 years Every 5 years (TSH) then every 5 years Blood pressure At least every At least every At least every At least every test 2 years 2 years 2 years 2 years Cholesterol test Start at age 20; discuss Discuss with your Discuss with your Discuss with your with your doctor or nurse. doctor or nurse. doctor or nurse. doctor or nurse. Bone mineral Discuss with your Discuss with your At least once; talk density test doctor or nurse. doctor or nurse. to your doctor or nurse about repeat testing. Blood glucose Discuss with your Start at age 45, and Every 3 years Every 3 years test doctor or nurse. then every 3 years Mammogram Every 1–2 years; Every 1–2 years; Every 1–2 years; discuss with your discuss with your discuss with your doctor or nurse. doctor or nurse. doctor or nurse. Pap test and Get this test if you have Every 1–3 years Every 1–3 years Discuss with your pelvic exam been sexually active doctor or nurse. or are older than 21. Chlamydia test Yearly until age 25 if Get this test if you Discuss with your Discuss with your sexually active; older have new or doctor or nurse. doctor or nurse. than age 25, get this multiple partners. test if you have new All pregnant women or multiple partner. should have this All pregnant women test. should have this test. (continued) 375

Recommended Screening Tests and Immunizations for Women at Average Risk (continued)

Screening Tests Ages 18–39 Ages 40–49 Ages 50–64 Ages 65 and Older

Sexually transmitted Both partners Both partners Both partners Both partners infection (STI) tests should get tested should get tested should get tested should get tested for STIs, including for STIs, including for STIs, including for STIs, including HIV, before HIV, before HIV, before HIV, before initiating sexual initiating sexual initiating sexual initiating sexual intercourse. intercourse. intercourse intercourse. Fecal occult blood test Yearly Yearly Flexible sigmoidoscopy Every 5 years Every 5 years (with fecal occult (if not having a (if not having a blood test) colonoscopy) colonoscopy) Double contrast Every 5–10 years Every 5–10 years barium enema (DCBE) (if not having a (if not having a colonoscopy or colonoscopy or sigmoidoscopy) sigmoidoscopy) Colonoscopy Every 10 years Every 10 years Rectal exam Discuss with your Discuss with your Every 5–10 years Every 5–10 years doctor or nurse. doctor or nurse. (with (with sigmoidoscopy, sigmoidoscopy, colonoscopy, colonoscopy, or DCBE) or DCBE) Eye exam Get your eyes Every 2–4 years Every 2–4 years Every 1–2 years checked if you have problems or visual changes. Hearing test Starting at age 18, Every 10 years Every 3 years Every 3 years and then every 10 years Mole exam Monthly mole Monthly mole Monthly mole Monthly mole self-exam; by a self-exam; by a self-exam; by a self-exam; by a doctor every 3 years, doctor every year doctor every year doctor every year starting at age 20 Dental exam One to two times One to two times One to two times One to two times every year every year every year every year Mental health Discuss with your Discuss with your Discuss with your Discuss with your screening doctor or nurse. doctor or nurse. doctor or nurse. doctor or nurse. RECOMMENDED SCREENING TESTS AND IMMUNIZATIONS 377

Immunizations Ages 18–39 Ages 40–49 Ages 50–64 Ages 65 and Older

Inﬂuenza vaccine Discuss with your Discuss with your Yearly Yearly doctor or nurse. doctor or nurse. Pneumococcal vaccine One time only Human papillomavirus Discuss with your Discuss with your Discuss with your vaccine (HPV) doctor or nurse. doctor or nurse. doctor or nurse. Meningococcal vaccine Discuss with your doctor or nurse if attending college. Tetanus-diphtheria Every 10 years Every 10 years Every 10 years Every 10 years booster vaccine

The following chart lists screenings or tests you might need more often or earlier due to having high-risk factors or things in your life that increase your chances of developing a condition or disease.

Recommended Screening Tests and Immunizations for Women with High-Risk Factors

Does your family history include? You may need these tests more often or at a younger age

High blood pressure Blood pressure test High cholesterol Cholesterol test Heart disease, premature heart disease, Blood pressure test, cholesterol test, exercise stress test or heart attack Diabetes Blood glucose test Breast cancer Mammogram, ovarian cancer tests Cervical, uterine, or vaginal cancer Pap test, pelvic exam, ovarian cancer tests, colon screening Ovarian cancer Pelvic exam, ovarian cancer tests, colon screening, clinical breast exam Osteoporosis, bone fracture in adulthood Bone mineral density test Thyroid disease or thyroid cancer Thyroid test and/or genetic counseling Gum (periodontal) disease Oral exam Are you? You may need these tests or vaccines more often or at a younger age

African-American Blood pressure test, cholesterol test, blood glucose test, vision exam, colonoscopy, genetic counseling for sickle cell anemia Alaska Native or Paciﬁc Islander Blood glucose test Ashkenazi Jewish descent Genetic counseling for Tay-Sachs disease if you want to become pregnant

(continued) 378 APPENDIX E

Recommended Screening Tests and Immunizations for Women with High-Risk Factors (continued)

Are you? You may need these tests or vaccines more often or at a younger age

Ashkenazi Jewish with family history Genetic counseling for possible BRCA1⁄2 mutation of breast or ovarian cancer Asian-American Blood glucose test Hispanic American Blood pressure test, cholesterol test, blood glucose test, colonoscopy Native American Blood glucose test Age 65 or older Bone mineral density test, flu vaccine, pneumococcal vaccine Between the ages of 60 and 64, Bone mineral density test weigh less than 154 lbs., and not taking estrogen College age MMR vaccine, varicella vaccine, human papillomavirus (HPV) vaccine, meningococcal vaccine Postmenopausal Bone mineral density test Pregnant Blood pressure test, blood glucose test, urine test, HIV test, STI tests, MMR vaccine, hepatitis B antigen test A nonpregnant woman of MMR vaccine, varicella vaccine childbearing age A smoker Blood pressure test, cholesterol test, bone mineral density test, oral exam, vision exam Overweight Blood pressure test, blood glucose test, weight checked Living in prison Tuberculosis (TB) test, HIV test, STI tests, hepatitis A and B vaccines Living in long-term care TB test, influenza vaccine, pneumococcal vaccine A health-care worker TB test, influenza vaccine, pneumococcal vaccine, MMR vaccine, varicella vaccine, hepatitis B vaccine with post-vaccination testing, HIV test, hepatitis test, hepatitis B vaccine if exposed to blood

Do you have or have you had? You may need these tests or vaccines more often or at a younger age

High blood pressure Blood pressure test, cholesterol test, blood glucose test High cholesterol Blood pressure test, cholesterol test, blood glucose test Heart disease Blood pressure test, cholesterol test, blood glucose test, inﬂuenza vaccine, pneumococcal vaccine Diabetes Blood pressure test, cholesterol test, blood glucose test, vision exam, urine sugar test Gestational diabetes Blood glucose test A baby weighing more than 9 lbs. Blood glucose test (continued) RECOMMENDED SCREENING TESTS AND IMMUNIZATIONS 379

Do you have or have you had? You may need these tests or vaccines more often or at a younger age

Breast cancer Mammogram, ovarian cancer tests Dense breasts Mammogram, clinical breast exam Cervical, uterine, vaginal cancer Pap test, pelvic exam, ovarian cancer tests, colon screening Ovarian cancer Pelvic exam, ovarian cancer tests, mammogram, colon screening Previous abnormal Pap tests Pap test, pelvic exam, human papillomavirus (HPV) vaccine Early menopause (natural or surgical), Bone mineral density test absent or infrequent menstrual periods, bone fracture in adulthood, low calcium intake, little physical activity, low body weight (under 154 lbs.), an eating disorder such as anorexia nervosa An autoimmune disease (lupus, Thyroid test, TB test, influenza vaccine, MMR vaccine, rheumatoid arthritis, scleroderma, pneumococcal vaccine, autoimmune screening test, bone mineral multiple sclerosis, psoriasis) density test Chronic lung disease Influenza vaccine, pneumococcal vaccine Chronic liver disease Hepatitis A and B vaccines Thyroid disease Thyroid test, influenza vaccine, pneumococcal vaccine, bone (if hyperthyroid) mineral density test Gum (periodontal) disease Oral exam Colon polyps or inflammatory Colonoscopy bowel disease A developmental delay Vision exam, hearing test Eye injury or disease Vision exam Ear injury or prolonged exposure Hearing test to loud noise HIV/AIDS Oral exam, vision exam, Pap test, pelvic exam, TB test, thyroid test, STI tests, influenza vaccine, pneumococcal vaccine, hepatitis screening, hepatitis A and B vaccines A blood transfusion or organ Hepatitis C test transplant before 1992 or received clotting factor concentrates made before 1987 A blood transfusion before 1985 HIV test Multiple sex partners or a partner who STI tests, HIV test, hepatitis B vaccine, Pap test, pelvic exam, has or has had multiple sex partners human papillomavirus (HPV) vaccine Alcoholism Pneumococcal vaccine, TB test, psychological screening, liver tests Injection drug use (IDU) or addiction Hepatitis A and B vaccines, hepatitis C test, TB test, STI tests, HIV test, psychological screening

(continued) 380 APPENDIX E

Recommended Screening Tests and Immunizations for Women with High-Risk Factors (continued)

Do you have or have you had? You may need these tests or vaccines more often or at a younger age

A sexually transmitted infection (STI) STI tests, HIV test, Pap test, pelvic exam, hepatitis B vaccine, human papillomavirus (HPV) vaccine Lived or worked with someone exposed TB test to tuberculosis (TB) A serious injury (cut or laceration) Tetanus-diphtheria booster vaccine A baby within the last few months Postpartum depression screening RESOURCES

HERBAL AND NUTRITIONAL Horse Chestnut Varicose veins, PRODUCTS lymphedema Vitanica Formulations HRT Companion Companion to HRT Developed by Dr. Tori Hudson IC Blend Interstitial cystitis Immune Symmetry Infections, immune Product Purpose support Iron Extra Iron-deficient anemia Adrenal Assist Adrenal support, Ipriflavone Bone support fatigue LactationBlend Breast-feeding support Black Cohosh Menopause symptoms Luminous Hair, skin, nails Breastblend Breast cancer Lysine Extra Herpes infections prevention Maternal Symmetry Prenatal multivitamin Butterbur Extra Migraine headaches Mindblend Memory, focus, CandidaStat Systemic candida concentration syndrome Nausea Ease Nausea—pregnancy Cardioblend Heart disease and other prevention OC Companion Companion to oral Chaste Tree Berry Abnormal uterine contraceptives bleeding Opti-Recovery Surgery support Cholestblend High cholesterol Osteoblend Osteoporosis CoQ10 Heart disease prevention Cramp Bark Extra Menstrual cramps OsteoDrink Osteoporosis CranStat Extra Urinary tract prevention infections PCOS Blend Polycystic ovarian Fem Rebalance Irregular menses, syndrome hormonal balance PhytoEstrogen Phytoestrogen powder Fibroblend Fibrocystic breasts Herbal GABA Ease Anxiety Pregnancy Prep Fertility enhancement Ginger Extract Plus Nausea, high choles- Red Clover Hot flashes terol, cramping Rhodiola Fatigue, memory, Gingko Extract Plus Memory stress Green Tea Breast health, immune Senior Symmetry Multiple vitamin- support mineral 65+ HBP Blend High blood pressure Sleepblend Insomnia HepaFem Liver support, liver Slow Flow Menstrual flow detox reduction Herbal Symmetry Multiherb daily Soy Choice Hot flashes, elevated Herpblend Herpes simplex cholesterol 381

Copyright © 2008 by Tori Hudson. Click here for terms of use. 382 RESOURCES St. John’s Wort Depression CLINICAL GUIDE TO Thyro Fem Hypothyroid VITANICA PRODUCT USAGE Uplift Depression Veinoblend Varicose veins Abnormal Uterine Bleeding: Woman’s Passage Menopause symptoms Heavy Bleeding support Slow Flow Acute: 3 caps every 3 hours Women’s Phase I Premenstrual during heavy flow syndrome Chronic recurring: 2 caps Women’s Phase II Menopause symptoms daily (up to 6 caps daily support for 3 months, and then 1 Women’s Symmetry Multiple vitamin- cap daily and/or Chaste mineral Tree Berry 1–2 caps/daily) Yeast Arrest Yeast vaginitis Abnormal Uterine Bleeding: Companion Products to Conventional Irregular Bleeding Cancer Treatments. The following Vitanica Chaste Tree Berry 1–2 caps daily products are available only through licensed practitioners: Amenorrhea AC Blend Rhodiola 100 mg 2 to 3 times daily TX Blend Chaste Tree Berry 1 cap daily R Blend Osteoblend 2 caps twice daily to Base Blend prevent osteoporosis Ipriflavone 1 cap 3 times daily to Environmental Products. The following prevent osteoporosis Vitanica products are available only through Anemia (Iron Deficiency) licensed practitioners: Iron Extra 1–4 caps daily Endocrine Disruptor Relief Neuro Disruptor Relief Anxiety Women’s Detox Co-Factors GABA Ease 2 caps twice daily Vaginal Suppositories. The following Vitan- Bladder Infections ica products are available only through licensed CranStat Extra Acute: 2 caps every 2 hours practitioners, except Yeast Arrest: for the first 2 days, and Green Tea then 2 caps 3–4 times Herbal-C daily for 7–14 days or Papillo until resolution; for best Vag Pak results, add 1,000 mg Vita-A vitamin C to each dose Yeast Arrest Chronic recurring: 2 caps daily RESOURCES 383 Breast-feeding Chronic health problem: 3–4 caps daily LactationBlend 1 to 2 caps twice daily Serious chronic health Breast Cancer Prevention problem, high stress, or heavy exerciser: 2 caps 3 Breastblend 2 caps twice daily times daily Green Tea 1–3 caps daily Senior Symmetry Same regimen as with PhytoEstrogen 1 tbs 1–2 times daily Women’s Symmetry Herbal Herbal Symmetry 2 caps daily Soy Choice 1–4 caps daily CoQ10 1 cap daily Hair, Skin, Nails Cholesterol Luminous 2–6 caps daily Cardioblend 2 caps twice daily Heart Disease Cholestblend 1 cap 3 times daily Cardioblend 2 caps twice daily for CoQ10 1 cap daily general prevention Ginger Extract Plus 1–2 caps daily CoQ10 1 cap daily PhytoEstrogen 1 tbs 1–2 times daily Ginger Extract Plus 1 cap twice daily Herbal Soy Choice 1–4 caps daily Soy Choice 1–4 caps daily Hemorrhoids Depression Horse Chestnut 1 cap twice daily Rhodiola 100 mg 1 to 3 times daily Herpes (Oral or Genital) St. John’s Wort 1 cap 3 times daily Lysine Extra Acute: 2 caps 2–3 times Uplift 1 cap 3 times daily daily for up to 10 days Detoxification Chronic: 2 caps per day Women’s Detox 4 caps twice daily High Blood Pressure Co-factors HBP Blend 1 cap 1–3 times daily Endocrine 2 caps twice daily CoQ10 1 cap daily Disruptor Relief Neuro 2 caps twice daily Hormonal Balance Disruptor Relief Fem Rebalance 2 caps daily Fibrocystic Breasts Infections Fibroblend 2–4 caps daily through- Immune Symmetry Acute infections: 2 caps out cycle; or 2 caps twice every 2 hours for 2 days, daily from day 15 until and then 2 caps 3 times onset of menstrual flow daily for 1–2 weeks General Health Chronic immune problems: 2 caps 1–3 times Women’s Symmetry General: 1–2 caps daily daily as needed 384 RESOURCES Infertility Menstrual Cramps Pregnancy Prep 2 caps daily Cramp Bark Extra Acute: 1–3 caps every 3 Chaste Tree Berry 1–2 caps daily hours up to 4 times daily Rhodiola 100–300 mg daily during menses To prevent recurring Insomnia cramps: 2 caps daily; Sleepblend 1–2 caps 30–60 minutes increase to 2 caps twice before bed daily the week before menses Interstitial Cystitis Ginger Extract Plus 1–3 caps daily, for acute IC Blend 3 caps 3 times daily or for prevention Liver Support Nausea HepaFem 2 caps daily Nausea Ease 1–2 caps daily Ginger Extract Plus 1–4 caps as needed Lymphedema throughout the day Horse Chestnut 1 cap twice daily Osteoarthritis Migraines Ginger Extract Plus 1–4 caps as needed Butterbur Extra 2 caps twice daily for 1–2 throughout the day months, and then 2 caps Osteoporosis daily Ipriflavone 1 cap 3 times daily Memory Osteoblend 2 caps twice daily Mindblend 2 caps daily OsteoDrink 1 scoop daily Ginkgo Extract Plus 1 cap 3 times daily PhytoEstrogen 1 tbs 1–2 times daily Rhodiola 100 mg 1 to 3 times Herbal daily Soy Choice 1–2 caps daily Menopause Symptoms PMS Black Cohosh 1–2 caps 1–2 times daily Ginkgo Extract Plus 1 cap 2–3 times daily PhytoEstrogen 1 tbs 1–2 times daily St. John’s Wort 1 cap 3 times daily Herbal Uplift 1 cap 3 times daily Red Clover 1 cap daily Chaste Tree Berry 1–2 caps daily Soy Choice 1–4 caps daily Women’s Phase I Mild symptoms: 2 caps Woman’s Passage 1 cap daily daily throughout cycle Women’s Phase II 2–6 caps daily Moderate to severe symptoms: 2 caps twice daily Also see Abnormal Uterine Bleeding, Depres- throughout cycle sion, Insomnia, and Memory. RESOURCES 385 Polycystic Ovarian Syndrome taxane family Base Blend 4 caps twice daily with Green Tea 1–3 caps daily any chemotherapeutic PCOS Blend 3–6 caps daily regimen PhytoEstrogen 1–2 tbs daily R Blend 3 caps twice daily with Herbal radiotherapy Pregnancy Environmental Medicine Maternal Symmetry 2–6 caps daily and Women’s Health Stress Women’s Detox 4 caps twice daily Co-Factors Rhodiola 100 mg 1–3 times daily Endocrine 2 caps twice daily Surgery Recovery Disruptor Relief Neuro 2 caps twice daily Opti-Recovery 1 cap twice daily Disruptor Relief Thyroid (Hypo) Suppositories for Infections, ThyroFem 2 caps daily ASCUS, Cervical Dysplasias, HPV Vaginitis (Yeast) All suppositories are to be inserted vaginally. For Yeast Arrest Acute: 1 suppository in use in escharotic treatments, insert two supposito- vagina morning and ries after each treatment. Can also be used for evening for 3–14 days vaginal infections and as part of an overall treat- Chronic: 1 cap twice daily ment plan for abnormal Pap smears. See clinical for 2–4 weeks, and then indications listed for each suppository in “Product 1 cap daily during Knowledge” manual for infections, condyloma, menses for 4 months cervical dysplasia, and ACUS; also see Encyclope- CandidaStat 2 caps 1–2 times daily dia of Natural Medicine by Tori Hudson, N.D. Suppositories may require use of panty liner due Varicose Veins to leakage when suppository dissolves. Veinoblend 1 cap 3 times daily Green Tea Horse Chestnut 1 cap twice daily Herbal-C Weight Loss Papillo Vag Pack Green Tea 2 caps with breakfast, Vita-A 2 caps with lunch Yeast Arrest

VITANICA SPECIALTY LINES MORE PRODUCT SOURCES FOR PROFESSIONALS ONLY Bio-Identical Cancer Support for Hormone Creams Company Cancer Adjunctive Care Progest Emerita/Transitions for AC Blend 4 caps twice daily with Health adriamycin/cytoxin Proganol Bezwecken (available TX Blend 5 caps twice daily with 386 RESOURCES through professionals) Uterine Fibroid Herbal Ostaderm Bezwecken (available Formulations from Gaia Herbs through professionals) Scudder’s Alterative Ostaderm V Bezwecken (available Echinacea/Red Root Compound through professionals) Fraxinus/Ceonothus Compound Compounded Women’s International Gelsemium/Phytolacca Compound hormones Pharmacy (Turska Formula) Fish Oils NUTRITIONAL AND Nordic Naturals HERBAL COMPANIES Greens Drink Vitanica (Dr. Tori Hudson’s women’s health product line) Wellness Naturals P.O. Box 1285 Homeopathic Medicines Sherwood, OR 97140 800-572-4712 Boiron vitanica.com Standardized Herbal Extracts by Vitanica Bezwecken Black Cohosh 15495 SW Millikan Way Chaste Tree Berry Beaverton, OR 97006 Ginger Extract Plus 800-743-2256 Gingko Extract Plus Green Tea Boiron USA Horse Chestnut 98c West Cochran Street Red Clover Simi Valley, CA 93065 Rhodiola 805-582-9091 St. John’s Wort Other Reputable Suppliers of Eclectic Institute Standardized Herbal Extracts 14385 SE Lusted Road Sandy, OR 97055 Enzymatic Therapies (Retail) 800-332-4372 Integrative Therapeutics (Professionals) Herbal Tinctures Emerita/Transitions for Health 621 SW Alder Eclectic Institute Portland, OR 97205 Herb Pharm 800-888-6814 Wise Woman Herbals emerita.com Probiotics Formulations Emerson Ecologics (distributor of professional Pharmax products) 7 Commerce Drive Bedford, NH 03110 603-656-9778 emersonecologics.com RESOURCES 387 Enzymatic Therapies Vital Nutrients (for professionals) 825 Challenger Drive 45 Kenneth Dooley Drive Greenbay, WI 54311 Middletown, CT 06457 800-783-2286 888-328-9992 enzymatictherapy.com vitalnutrients.com

Gaia Herbs Wise Woman 108 Island Ford Road P.O. Box 279 Brevard, NC 28712 Creswell, OR 97426 800-831-7780 800-532-5219

Herb Pharm COMPOUNDING PHARMACIES P.O. Box 116 International Academy of Compounding Williams, OR 97544 Pharmacists 800-599-2392 P.O. Box 1365 herb-pharm.com Sugarland, TX 77487 713-933-8400 Natural Factors 900-927-4227 1550 United Boulevard Coquitlam, BC V3K 6Y7 Women’s International Pharmacy Canada 12012 N. 111th Avenue 604-415-4155 Youngtown, AZ 85363 800-699-8143 Natural Partners (distributor of professional products) Lloyd Center Pharmacy 7949 E. Acoma, Suite 103 1302 Lloyd Center Scottsdale, AZ 85260 Portland, OR 97232 888-633-7620 800-358-8974 naturalpartners.com LABORATORY TESTING Nordic Naturals Metametrix Clinical Laboratory 94 Hangar Way 4855 Peachtree Industrial Boulevard Watsonville, CA 95076 Norcross, GA 30092 800-662-2544 800-221-4640, ext. 373 nordicnaturals.com Fax: 770-441-2237 metametrix.com Pharmax (for professionals) 1233 120th Avenue NE SKIN CARE PRODUCTS FOR Bellevue, WA 98005 WOMEN 800-538-8274 Emerita/Transitions for Health pharmaxllc.com 621 SW Alder Portland, OR 97205 800-888-6814 emerita.com 388 RESOURCES SPECIALTY FOODS National College of Naturopathic Medicine Hemp Seeds, Hemp Protein, Hemp Oil 049 SW Porter Portland, OR 97201 Living Harvest 503-499-4343 P.O. Box 4407 Portland, OR 97208 Bastyr University 503-274-0755 14500 Juanita Drive NE livingharvest.com Bothell, WA 98011 Organic Dairy Foods and Meats 425-602-3100 Organic Valley Southwest College of Naturopathic Medicine One Organic Way and Health Sciences La Rarge, WI 54639 2140 East Broadway 608-625-2666 Tempe, AZ 85282 organicvalley.coop 602-990-7424 Whole-Grain Breads Bridgeport University French Meadow Bakery 126 Park Avenue 2610 Lyndale Avenue South Bridgeport, CT 06601 Minneapolis, MN 55408 203-576-4552 612-870-4740

CLINICS, NATUROPATHIC Canadian College of Naturopathic Medicine COLLEGES, AND ORGANIZATIONS 2300 Yonge Street P.O. Box 2431 A Woman’s Time, P.C. Toronto, ON M4P1E4 Tori Hudson, N.D. 416-486-8584 2067 NW Lovejoy Portland, OR 97209 American Association of Naturopathic 503-222-2322 Physicians awomanstime.com 4435 Wisconsin Avenue NW, Suite 403 E-mail: [email protected] Washington, DC 20016 Blog: torihudson.com 202-895-1392

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Abortion, 61–62, 295 for infertility, 157–64 Abraham, Guy, 252 for interstitial cystitis (IC), 168–72 Acne, 184–85 for menopause, 187–219 Activella, 369. See also Hormone replacement for menstrual cramps, 226–34 therapy (HRT) for osteoporosis, 243–63 Acupuncture, 162 for pelvic inflammatory disease (PID), Adrenal Assist, 381 269–71 Adrenal glands, 177 for pregnancy, 275–90 Age factors for premenstrual syndrome (PMS), 304–13 bone density, 243 for sexually transmitted infections (STIs), cervical dysplasia, 33 321–23 menopause, 175–76 for uterine bleeding, 4–13 osteoporosis, 237, 238 for uterine fibroids, 330 screening tests for risk factors, 378 for vaginitis, 348–55 AIDS infection Amen, 370. See also Hormone replacement screening tests risk factors, 379 therapy (HRT) Alcohol, 126 Amenorrhea, 15–30, 382 infertility and, 158 alternative treatments, 18–27 osteoporosis and, 247 conventional treatment, 27–30 pelvic inflammatory disease (PID) and, 268 diagnosis, 17–18 pregnancy and, 290 licensed primary health-care practitioners screening tests risk factors, 380 and, 30 Alfalfa (Medicago sativa), 23 physical exercise and, 25–27 Allicin extract, 322 prevention, 17 Aloe vera, 105–6 sample treatment plans, 27–28 Alora, 368. See also Hormone replacement American College of OB/GYN (ACOG), therapy (HRT) 219 Alpha-linolenic acid (ALA), 120 American Heart Association recommendations, Alternative treatments, 388–89 128, 150–51 for amenorrhea, 18–27 Amylases, 333 for cervical dysplasia, 34–47 Androderm, 371. See also Hormone for cystitis, 67–72 replacement therapy (HRT) definitions, xvii Androgel, 371. See also Hormone replacement for endometriosis, 79–85 therapy (HRT) for fibrocystic breasts, 90–96 Androgens, 213–14 for genital herpes, 102–7 osteoporosis and, 265 for heart disease, 114–48 Anemia, 382 481

Copyright © 2008 by Tori Hudson. Click here for terms of use. 482 INDEX Angeliq, 369. See also Hormone replacement Bioflavonoids, 171, 193 therapy (HRT) for abnormal uterine bleeding, 8 Anorexia nervosa, 19 for genital herpes, 103–4 Anti-atherosclerosis, 143 for pregnancy, 285 Antibiotics Birth for pelvic inflammatory disease (PID), footling breech, 299 270 frank breech infant, 299 for sexually transmitted infections, screening tests risk factors, 379, 380 323–24 vaginal, 299 Antihypertensives, 143 Birth control pills (BCPs), 55–60, 62. See also Antioxidant combinations Oral contraceptives for heart disease, 130 Bisphosphonates, 266 Antiviral herpes treatments, 107 Bitter melon (Momordica charantia), 24, 106 Anxiety, 181–82, 382 Black cohosh (Cimicifuga racemosa), 197–98, Aqueous iodine, 95 232–33, 381, 384, 386 Archer, David, 222 for amenorrhea, 21–22 Arden’s powder, 353–54 for infertility, 161 Aromatase inhibitors (AI), 164–65 Black haw (Viburnum prunifolium), 232 Ashwagandha, 218 root, 295 Astringent herbs, 10 Black tea, 139 Atherosclerosis, 123 Bladder epithelial permeability, 168, 169 Atypia, 33 Bladder infection, 66, 296–97, 382. See also Atypical glandular cells of undetermined Cystitis significance (AGUS), 33–34, 385 Bladderwrack (Fucus vesiculosus), 9–10 Autoimmune disease, screening tests risk Blood clots, 202–3 factors, 379 Blood glucose test, 375 Autoimmune theories of interstitial cystitis Blood pressure, 150. See also High blood (IC), 168 pressure Aygestin, 370. See also Hormone replacement pregnancy and, 298–99 therapy (HRT) tests for, 375 Blood transfusion Backache, 296 screening tests risk factors, 379 Bacterial vaginosis (BV), 341–44, 356–57. See Bloodroot (Sanguinaria canadensis), 23 also Vaginitis Blue cohosh (Caulophyllum thalictroides), 23, Bastyr, John, xix 233 Bee propolis, 105 for infertility, 161 Beta-carotene Body weight, 242. See also Weight gain; for endometriosis, 82 Weight loss for fibrocystic breasts, 94 body mass index, 365 for vaginitis, 349 pregnancy and, 277, 294 Bio-identical testosterone, 215 screening tests for risk factors, 378 Biofeedback, 228 Boiron, 386 INDEX 483 Bone density, 222 Breasts, dense bone mineral density (BMD), 243, 375 screening tests risk factors, 379 estriol and, 207 Breasts, painful. See Fibrocystic breasts; osteoporosis, 237–66 Mastalgia peak ages, 243 Bromocriptine, 97 Bone health, 192 bone remodeling, 238–39 C-reactive protein, 306 osteoporosis, 237–66 Caffeine, 91–92, 124–25 Bone imaging, 242–43 content in foods, 159 Boniva, 264 infertility and, 158, 159 Boric acid, 353 pregnancy and, 291 Boron, 252–53 premenstrual syndrome (PMS) and, 306 Botanicals Calcitonin, 265 for amenorrhea, 21–24 Calcium, 133, 192 for cervical dysplasia, 39–41 for amenorrhea, 20 for cystitis, 70–72 excretion in urine, 245 for endometriosis, 83–85 for menstrual cramps, 230 for fibrocystic breasts, 95–96 for osteoporosis, 241, 245, 248–50, 265 for genital herpes, 104–7 for pregnancy, 283 for heart disease, 138–43 premenstrual syndrome (PMS) and, 309 for infertiliy, 161–62 recommendations of intake, 248 for interstitial cystitis (IC), 171–72 Calcium glycerophosphate (Prelief), 171 for menopause, 194–201 Canadian fleabane (Erigeron canadensis), for menstrual cramps, 231–33 11 for osteoporosis, 256–60 Cancer, 385. See also Specific types for pregnancy, 288–90 companion products, 382 for premenstrual syndrome (PMS), screening tests risk factors, 379 310–11 Cancer Research Center (University of for sexually transmitted infections (STIs), Hawaii), 331 322–23 Candida vaginitis, 344–46, 356–57. See also for uterine bleeding, 8–11 Vaginitis for uterine fibroids, 334–37 Canola oil, 117 for vaginitis, 350–56 Carbohydrates, 123 Breast cancer Cardiac imaging tests, 113 birth control pills and, 56–57 Cardiovascular disease (CVD). See Heart estriol and, 207–8 disease hormone replacement therapy (HRT) and, Carotenes, 20, 36–37, 121 203, 211–13 Carotenoids, 322 prevention, 383 Castor oil pack, 373–74 self-exam for, 373 Celiac disease, 162 Breast-feeding, 383 Cenestin, 367. See also Hormone replacement Breast nodularity, 89 therapy (HRT) 484 INDEX Centers for Disease Control (CDC) Circulation aids, 142 guidelines for treatment of yeast vaginitis, Citrus bioflavonoids, 139 357 Cleavers (Galium aparine), 95 Ceonothus compound, 334 Climara, 368. See also Hormone replacement Cervical cancer, 2, 31 therapy (HRT) Cervical cap, 53–54, 63 ClimaraPro, 370. See also Hormone Cervical dysplasia, 31–50, 385 replacement therapy (HRT) alternative treatments, 34–47 Clinics, 388 conventional medical treatments, 47–50 Clomiphene citrate (CC), 164 licensed primary health-care practitioners Cobalamin, 281 and, 50 Cobalt, 284 preventative medicine, 34–35 Coconut oil, 117 psychological factors, 47 Coenzyme Q10, 132–33, 287 risk factors, 33 Cognitive-behavioral therapy (CBT), sample treatment plans, 42, 43, 44, 45, 46, 314 48 Cognitive decline, 203 Chamomile, 217 Colon disease Chapparal (Larrea tridentate), 106 screening tests risk factors, 379 Chaste tree (Vitex agnus castus), 23, 199, 310, Colonoscopy, 376 334, 384 Colposcopy, 40 for amenorrhea, 21 CombiPatch, 370. See also Hormone berry, 381, 382, 384, 386 replacement therapy (HRT) for endometriosis, 83 Comfrey (Symphytum officinale), 172 for infertility, 161 Computed tomography (CT), 113 for uterine bleeding, 8–9 Concentration, 182. See also Memory Chlamydia trachomatis (CT), 269, 317–18, Condoms, 53–54, 63 322 Condyloma, 31 cervical dysplasia and, 33 Conization, 41, 47, 49 sample treatment plan, 322 Constipation, 296 test, 375 Contraception. See also Oral contraceptives Chocolate, 126–27 barrier methods, 53–54 Choice, xix basal body temperature, 53 Cholesterol, 118–19, 383. See also HDL birth control pills (BCPs), 55–60, 62 cholesterol; LDL cholesterol calendar methods, 52 caffeine and, 124 cervical mucus, 52–53 heart disease and, 111, 116 emergency, 60 screening tests, 378 fertility awareness, 51–53 test, 375 hormonal, 55–61 Choline, 95 patches, 61 Chromium, 24, 283 pelvic inflammatory disease (PID) and, Chronic anovulation, 29–30 268 Cinnamon (Cinnamomum verum), 11 for premenstrual syndrome (PMS), 315 INDEX 485 Conventional medical treatments, xxi–xxii licensed primary health-care practitioners for amenorrhea, 27–31 and, 73 for cervical dysplasia, 47–50 nutrition, 67–70 for cystitis, 73 sample treatment plans, 71 for endometriosis, 85–87 Cytology methods, 34 for fibrocystic breasts, 96–97 for genital herpes, 107–8 D-mannose, 69–70 for heart disease, 148–51 Dalton, Katharina, 312 for infertility, 164–65 Damiana, 218 for interstitial cystitis (IC), 172–73 Dandelion leaf, 95, 288–89 for menopause, 219–23 Dandelion root (Taraxacum officinale), 83, 288, for menstrual cramps, 234–36 334 for osteoporosis, 264–66 DASH diet, 124, 125 for pelvic inflammatory disease (PID), Deep vein thrombosis (DVT), 265 271–72 Dehydroepiandrosterone (DHEA), 215 for pregnancy, 297–98 Dementia, 203 for premenstrual syndrome (PMS), 314–15 Dental issues for sexually transmitted infections (STIs), changes with menopause, 185 323–24 exam, 376 for uterine bleeding, 13–14 Depo-Provera, 60–61, 86 for uterine fibroids, 337–40 Depression, 181–82, 383 for vaginitis, 356–58 sample treatment plan, 199 Copper, 253, 284 Detoxification, 383 Corn oil, 117 Developmental delay Corn silk (Zea mays), 172 screening tests risk factors, 379 Cortical bone, 238 Diabetes, 123 Coumestrol, 335 heart disease and, 111–12 Crampbark (Vibernum opulus), 172, 232 screening tests, 378–79 for infertility, 161 Diabetes mellitus Cranberry, 68–69 hormone replacement therapy (HRT) and, Cryotherapy, 47, 49 203 Curcumin, 40 Diagnostic and Statistical Manual of Mental for pelvic inflammatory disease (PID), 270 Disorders (DSM-IV), 303 Cuts Diaphragm, 53–54, 63 screening tests risk factors, 380 Diet Cycrin, 370. See also Hormone replacement for abnormal uterine bleeding, 6 therapy (HRT) cholesterol and, 119 Cystitis, 65–73 for cystitis, 68 alternative treatments, 67–72 DASH diet, 124, 125 botanicals, 70–72 for endometriosis, 80–81 diagnosis, 66–67 for fertility, 158, 159 diet, 68 fiber and, 120–22 486 INDEX for fibrocystic breasts, 91–92 Ectopic pregnancy, 267 genital herpes and, 102–3 Eicosapentanoic acid (EPA), 119, 120 heart and, 116–29 Electrocardiogram (ECG), 113 high-fiber, 331 Embolization, 338 for hypertension, 124 Endoctrine disorders for interstitial cystitis (IC), 169 osteoporosis and, 241 for menopause, 192 Endometrial ablation, 14 for menstrual cramps, 228–29 Endometrial cancer, 2–3, 330 for premenstrual syndrome (PMS), 306 estriol and, 207 vegan, 92, 248 Endometrial hyperplasia, 2–3 vegetarian, 245 Endometrial polyps, 2 Dietary fat, 92 Endometriosis, 75–87 Dilation and curettage (D&C), 14 alternative treatments, 79–85 Diuretics, 95, 142 botanicals, 83–85 Docahexaenoic acid (DHA), 120, 137, conventional medical treatments, 85–87 285–86 diet, 80–81 Dong quai (Angelica sinensis), 23, 194 environmental factors, 77 infertility and, 161 genetic factors, 77 Double contrast barium enema (DCBE), 376 hormone metabolism, 78–79 Drug use, illegal immune connection, 77–78 pelvic inflammatory disease (PID) and, 268 licensed primary health-care practitioners pregnancy and, 292–93 and, 87 screening tests risk factors, 380 nutrition, 80–83 Drugs, over-the-counter preventative medicine, 79 pregnancy and, 292 research, 75–77 Drugs, prescription sample treatment plan, 84 pregnancy and, 292 stress and, 75 Dysfunctional uterine bleeding (DUB), 1, Endometritis, 267 3–14 Enjuvia, 367. See also Hormone replacement alternative treatments, 4–14 therapy (HRT) diagnosis, 3–4 Environmental factors, 385 prevention, 4 endometriosis and, 77 sample treatment plans, 12 infertility and, 158–59 Dysmenorrhea, 225, 226. See also Menstrual pregnancy and, 290–91, 292 cramps Ernster, Virginia, 91 Dysuria, 167 Escharotic treatment, 41, 48 Esclim, 368. See also Hormone replacement Ear injury therapy (HRT) screening tests risk factors, 379 Essential fatty acids, 93–94 Echinacea, 106, 334 endometriosis and, 82–83 sexually transmitted infections (STIs), 322 heart disease and, 116–17, 119–20, 137–38 Eclampsia, 295–96 osteoporosis and, 254–56 INDEX 487 pregnancy and, 285–87 Ethnicity premenstrual syndrome (PMS) and, 308 screening tests for risk factors, 377–78 Essure, 61 Evening primrose oil, 94, 138, 193, 231, 287 Estrace, 367. See also Hormone replacement premenstrual syndrome (PMS) and, 308 therapy (HRT) Exercise. See Physical exercise Estrace cream, 369. See also Hormone Eye issues replacement therapy (HRT) changes with menopause, 185 Estraderm, 368. See also Hormone replacement exam, 376 therapy (HRT) screening tests risk factors for injury, 379 Estradiol, 13 Estrasorb, 368. See also Hormone replacement Facial hair, 184–85 therapy (HRT) Falling risks, 241 Estratab, 367. See also Hormone replacement False unicorn, 288 therapy (HRT) infertility, 161 Estratest, 371. See also Hormone replacement False unicorn root (Chamaelirium luteum), therapy (HRT) 233, 295 Estring. See Hormone replacement therapy Family history. See also Genetic factors (HRT) cervical dysplasia and, 33 Estriol, 206–7 screening tests for risk factors, 377 Estrogel, 368. See also Hormone replacement Fasting therapy (HRT) sexually transmitted infections (STIs), Estrogen, 13, 86, 220–21, 302 322 bio-identical, 146–49, 206–8, 260–61 Fats, 116–120. See also Essential fatty acids combination products, 221 monounsaturated, 117 conjugated equine estrogens (CEE), polyunsaturated fatty acids (PUFAs), 117 213 saturated, 117 natural, 146–49, 260–61 unsaturated, 117 oral, 367–68 Fatty acids. See Essential fatty acids for osteoporosis, 260–61 Fecal occult blood test, 376 selective estrogen receptor modulator Female testosterone patch, 371. See also (SERM), 264, 265 Hormone replacement therapy (HRT) transdermal, 368–69 FemCap. See Cervical cap vaginal, 221–22, 369 Femhrt, 369. See also Hormone replacement Estrogen dominance, 304 therapy (HRT) Estrogen-progestin FemPatch, 368. See also Hormone replacement oral combinations, 369–70 therapy (HRT) transdermal combinations, 370 Femring, 369. See also Hormone replacement Estrogen-progestogen therapy (EPT), therapy (HRT) 201 Femtrace, 367. See also Hormone replacement Estrogen/testosterone, 371 therapy (HRT) Estrogen therapy (ET), 201, 264. See also Fenugreek (Trigonella foenumgraecum), 23, Hormone replacement therapy (HRT) 24 488 INDEX Fertility. See also Infertility Gamma-linolenic acid (GLA), 93–94, 120 awareness, 51–53 premenstrual syndrome (PMS) and, 308 diet, 159 Gamma-oryzanol, 193 male, 163 Garlic (Allium sativum), 139–40 menopause and, 180–81 for pelvic inflammatory disease (PID), 270 nutrition, 159–62 for vaginitis, 350 Feverfew (Tanacetum parthenium), 172 Gas, 296 Fiber, 120–22 Gastrointestinal disease research and, 121 osteoporosis and, 241 Fibrins, 338 Genetic factors Fibrocystic breasts, 89–97, 383 endometriosis, 77 alternative treatments, 90–96 infertility, 158 botanicals, 95–96 osteoporosis, 239–40, 241 conventional medical treatments, 96–97 Genital herpes, 99–108 diet, 91–92 alternative treatments, 102–7 dominant masses, 90 botanicals, 104–7 licensed primary health-care practitioners conventional medical treatments, 107–8 and, 97 diagnosis, 99, 100–102 nondominant masses, 90 diet, 102–3 nutrition, 91–95 licensed primary health-care practitioners research, 91 and, 108 sample treatment plan, 96 nutrition, 102–4 Fish oil, 119, 120, 138, 159–60, 386. See also preventative medicine, 102, 108 Essential fatty acids research, 99, 101, 104 for menstrual cramps, 230–31 sample treatment plan, 106 5-hydroxytryptophan (5-HTP), 217 symptoms, 99–100 Flavonoids, 121, 138–39, 335–36 Genital warts, 31 Flax oil, 117 Gentian violet, 355 Flaxinus, 334 German chamomile (Matricaria chamomilla), Flaxseed (Linum usitatissimum), 23, 24, 233 192 Ghent, William, 95 oil, 95, 138 Ginger (Zingiber officinale), 140, 232, 288–89, powder, 6 381, 383, 386 Flexible sigmoidoscopy, 376 abnormal uterine bleeding and, 9 Folic acid root, 334 cervical dysplasia and, 38 Ginkgo (Ginko biloba), 195, 310–11, 381, heart disease and, 136 384, 386 osteoporosis and, 253 Ginseng (Panax ginseng), 23, 162, 195, pregnancy and, 279 217–18 Follicle-stimulating hormone (FSH), 176, 178, Globe artichoke (Cynara scolymus), 140 181 Glucosamine sulfate, 170 tests, 186 Glucose tolerance, 111 INDEX 489 Glycosaminoglycans (GAGs), 169–70 licensed primary health-care practitioners GnRH agonists, 86, 97 and, 151–53 Golden root. See Rhodiola lifestyle changes, 114–16 Goldenseal (Hydrastis canadensis), 70–71, 106, nutrition, 116–38 334, 350 obesity, 109 for pelvic inflammatory disease (PID), physical exercise, 143–44 270 risk factors, 109, 111–14, 149–50 root, 334 sample treatment plan, 147 Gonorrhea. See Neisseria gonorrhoeae (GC) screening, 113, 378 Gonzalez, Nicholas, 333 stress and, 144 Green, Raymond, 312 women compared to men, 109 Green leafy vegetables, 245 Heart palpitations Green tea, 24, 39, 139, 385, 386 menopause and, 185–86 Greens drink, 386 Heart tonics, 142 Gugulipid (Commiphora mukul), 140–41 Heartburn, 296 Gum disease Helonias (Chamaelerium luteum), 161 screening tests risk factors, 379 Hemorrhoids, 383 Gurevich, Maria, 301 Hepatitis B (HBV), 320–21 Gynediol, 367. See also Hormone replacement Herbs. See also Botanicals therapy (HRT) to avoid during pregnancy, 289 companies, 386–87 Hair, 383 high mineral herbs, 257 loss, 184–85 for menstrual cramps, 233 Hawthorn (Crataegus oxyacantha), 141 nonphytoestrogen, 197–200 HDL cholesterol, 111, 116, 119, 142 for pelvic inflammatory disease (PID), 270 fiber and, 120–21 for polycystic ovarian syndrome, 23–24 niacin and, 134 for premenstrual syndrome (PMS), 311 soy and, 122 products, 380–87 Headaches progesterone precursors, 23 menopause, 185 tinctures, 386 Hearing test, 376 uterine stimulants, 23 Heart disease, 109–53, 186, 192, 383 for vaginitis, 354–55 alternative treatments, 114–48 Herpes simplex 2 (HSV-2), 99–108, 383 botanicals, 138–43 HERS study, 148 conventional medical treatments, High blood pressure, 383 148–51 heart disease and, 111, 150–52 definitions, 111 screening tests, 378 diagnosis, 112–13 Hip fracture, 238 estriol, 207 HIV infection, 346 genetic factors, 111 cervical dysplasia and, 33 hormone replacement therapy (HRT), screening tests risk factors, 379 111–12, 138, 202 Homeopathic medicines, 386 490 INDEX Homocysteine levels, 125 Hypoestrogenic states, 27 Hops (Humulus lupulus), 23, 201, 217, 233 Hypogonadotropic hypogonadism, 17–18, 29 Hormonal changes, 275 Hypothalamic amenorrhea, 27–28 Hormone creams, 385–86 Hysterectomy, 14, 41, 176–77, 338 Hormone metabolism, 78–79 endometriosis and, 86 Hormone replacement therapy (HRT), 144–48, 186, 187–88, 201–15, 219–20 Ice packs, 321, 322 benefits of, 204 Immunity issues blood clots from, 202–3 endometriosis and, 77–78 breast cancer and, 203, 211–13 pelvic inflammatory disease (PID) and, 270 diabetes mellitus and, 203 Immunizations, 375–80 dosing of, 204 high risk factors, 377–80 evaluation of, 202 Implanon, 60–61 friendly versus less-friendly, 213–15 Incontinence, 167 heart disease and, 111–12, 138, 153, 202 Indole-3-carbinol/diindolylmethane (DIM), 39 hot flashes and, 202 Infections, 383 non-oral hormones and, 204 suppositories for, 385 prescriptions, 367–71 Infertility, 155–65, 340, 384 risks of, 204 alternative treatments, 157–64 stroke and, 203 botanicals, 161–62 studies of, 148 causes, 156 vaginal symptoms and, 202 conventional medical treatments, 164–65 Hormones, bio-identical, xx–xxi, 205–15 definition, 155 for abnormal uterine bleeding, 11–13 diet, 158 for amenorrhea, 24–25 laboratory testing, 156–57 Hormones, natural, 205–15 licensed primary health-care practitioners Horse chestnut, 386 and, 165 Hot flashes, 179–80 lifestyle factors, 157–59 hormone replacement therapy (HRT), 202 medical history, 155 symptom relief, 215 preventative medicine, 157 Human papillomavirus (HPV), 31, 35, 385 resources, 165 vaccine, 50, 377 sample treatment plan, 163 Hunner’s ulcers, 167 statistics, 155 Hydrogenated oils, 118 uterine fibroids and, 329 Hypergonadotropic hypogonadism, 17, 28 Influenza vaccine, 377 Hyperlipidemia, 147 Infusions, 374 Hyperparathyroidism, 237 Insomnia, 181, 222, 384 Hyperprolactinemia, 17, 27, 28–29 menopause and, 216–17 Hypertension Insulin, 123 diet, 124 Interstitial cystitis (IC), 167–73, 384 heart disease, 111 alternative treatments, 168–72 sample treatment plan, 148 botanicals, 171–72 INDEX 491 causes, 168 Laboratories, 387 diagnostic tests, 167 Lactobacilli, 69 diet, 169 Lactobacillus acidophilus, 69, 270, 321, 322 foods to avoid, 169 sexually transmitted infections (STIs) and, licensed primary health-care practitioners 322 and, 173 vaginitis and, 348, 350–53 nutrition, 169–71 Laparoscopic surgery, 86, 269, 330 preventative medicine, 168 LDL cholesterol, 111, 116, 119, 142 sample treatment plan, 172 alcohol and, 126 Intestine, hormone metabolism and, 78–79 fiber and, 120–21 Intima-media thickness (IMT), 113 niacin and, 134 Intrauterine devices (IUDs), 2, 54–55, 63 soy and, 122 Intrauterine insemination (IUI), 164 Lecithin, 287 Intravaginal estriol, 71–72 Lee, John, 336 Iodine, 355–56 LEEP, 41, 47, 49 fibrocystic breasts and, 94–95 Lemon balm (Melissa officinalis), 104, 217 Ipriflavones, 257, 382, 384 Leuprolide acetate, 337 Iron Licensed primary health-care practitioners for abnormal uterine bleeding, 6 for abnormal uterine bleeding, 14 deficiency, 382 for amenorrhea, 30 for pregnancy, 283–84 for cervical dysplasia, 50 Irritability, 199 for cystitis, 73 Isoflavones, 332–33 for endometriosis, 87 for fibrocystic breasts, 97 Joint pain, 186 for genital herpes, 108 for heart disease, 151–53 Kava (Piper methysticum), 171, 172, 200, 217 for infertility, 165 Kelley, William, 333 for interstitial cystitis (IC), 173 Keloids, 338 for menopause, 223 Kelp, dietary (Fucus vesiculosus), 9–10 for menstrual cramps, 236 Kemp, Harvey, 112 for osteoporosis, 266 Krill oil, 309 for pelvic inflammatory disease (PID), 272–73 L-arginine for pregnancy, 298–99 heart disease and, 135–36 for premenstrual syndrome (PMS), 315 infertility and, 160 for sexually transmitted infections (STIs), interstitial cystitis (IC) and, 170 324–25 L-carnitine for uterine fibroids, 339–40 heart disease and, 136 for vaginitis, 358 infertility and, 163–64 Licorice (Glycyrrhiza glabra), 23, 24, 104–5, L-lysine 172, 195–96 genital herpes and, 103 Life root (Senecio aureus), 11 492 INDEX Lifestyle. See also Preventative medicine Melatonin, 217, 231 cervical dysplasia and, 42–47 Memory, 182, 384 heart-healthy diets, 127–29 Menest, 367. See also Hormone replacement infertility and, 157–59 therapy (HRT) osteoporosis and, 239–40 Meningococcal vaccine, 377 premenstrual syndrome (PMS) and, 314 Menometrorrhagia, 1 Linoleic acid (LA), 120 Menopause, 175–223 Lipases, 333 alternative treatments, 187–219 Lipids, 123. See also Cholesterol; HDL botanicals, 194–201 cholesterol; LDL cholesterol conventional medical treatments, Lipotropics, 333 219–23 endometriosis and, 83 diet, 192 Liver, 331, 384 evaluation, 186–87 detoxification, 304 induced, 176–77 estrogen clearance, 91 licensed primary health-care practitioners hormone metabolism, 78–79 and, 223 screening tests risk factors for disease, naturopathic approach, 188–89 379 nutrition, 189–94 Love, Susan, 177 osteoporosis and, 239 Lung disease sample treatment plans, 199, 215, 216 screening tests risk factors, 379 screening tests risk factors, 379 Lupron, 337–38 stages, 175–76 Lymphedema, 384 statistics, 175–76 symptoms, 178–86, 384 Maca (Lepidium peruvianum), 218 temporary, 176 amenorrhea and, 22–23 transition, 177–78 Magnesium Menorrhagia, 1, 12 heart disease and, 133–34 Menostar, 368. See also Hormone replacement osteoporosis and, 250–52 therapy (HRT) pregnancy and, 284 Menstrual cramps, 225–36, 384 premenstrual syndrome (PMS) and, 309 alternative treatments, 226–34 Magnetic resonance imaging (MRI), 113 botanicals, 231–33 Mammogram, 375 conventional medical treatments, Manganese, 252 234–36 Manual soft-tissue therapy, 162 diet, 228–29 Marshmallow (Althea officinalis), 172 licensed primary health-care practitioners Mast cell activation, 168 and, 236 Mastalgia, 89 nutrition, 228–31 Meditation, 228 physical exercise, 233–34, 235 Mediterranean diet, 129 preventative medicine, 227–28 Megace, 370. See also Hormone replacement sample treatment plan, 234 therapy (HRT) stress and, 228 INDEX 493 Menstruation Naturopathic medicine. See also Alternative absence of menstrual bleeding (amenorrhea), treatments 15–30 college, xvii benign abnormal bleeding, 1 eclectic traditions of, xx normal cycle, 15–16 history of, xvii Mental health screening, 376 principles of, xvii–xviii Methionine (SAM), 95, 287 roots of, xvii Methylxanthines, 91 Naturopathic organizations, 388–89 Metrorrhagia, 1, 328 Nausea, 384 Micronor, 370. See also Hormone replacement Neisseria gonorrhoeae (GC), 269, 318–20, 322 therapy (HRT) quinolone-resistant gonorrhea, 324 Migraines, 384 Nervines, 143 Minerals Nettle (Urtica dioica), 289, 334 amenorrhea and, 20–21 root, 24 high mineral herbs, 257 Niacin, 134, 280 infertility and, 161 for menstrual cramps, 229 Minton, John, 91 Nicotinic acid, 280 Mirena IUD, 220, 371. See also Hormone Nielsen, Forrest, 252 replacement therapy (HRT) Night sweats, 179–80 Miscarriage, 295 Nitric oxide (NO), 170 Mojzisova method therapy, 162 Nonsteroidal anti-inflammatory drugs Mole exam, 376 (NSAIDs), 234–36 Molimina, 302 abnormal uterine bleeding and, 13–14 Monoglycerides, 116 Normogonadotropic anovulation, 18 Monounsaturated fats, 117 Nor-QD, 370. See also Hormone replacement Mood swings, 181 therapy (HRT) sample treatment plan, 199 North American Menopause Society (NAMS), Morning sickness, 294–95 201, 214, 219 Motherwort (Leonurus cardiaca), 83–84, Nurses’ Health Study, 212 201 Nutrition Mugwort (Artemisia vulgaris), amenorrhea and, 18–21 23 birth control pill users and, 58–59 Mushrooms, 106 cervical dysplasia and, 33, 36–39 Myomas, 2 cystitis and, 67–70 Myomectomies, 338 endometriosis and, 80–83 Myrrh, 106 fertility and, 159–62 fibrocystic breasts and, 91–95 Nails, 383 genital herpes and, 102–4 National Health and Nutrition Examination heart disease and, 116–38 Survey (NHANES), 212 interstitial cystitis (IC) and, 169–71 Nature, healing power of, xvii–xviii menopause and, 189–94 Naturopathic colleges, 388–89 menstrual cramps and, 228–31 494 INDEX osteoporosis and, 239–40, 241, 243–56 Organ transplant pregnancy and, 276–88 screening tests risk factors, 379 premenstrual syndrome (PMS) and, 305–10 Organic foods, 388 sexually transmitted infections (STIs) and, Ornish, Dean, 114, 129 322 Ornish Lifestyle Modification Program, 129 supplements, 129–38 Ortho-Est, 367. See also Hormone replacement uterine bleeding, abnormal, and, 5–8 therapy (HRT) uterine fibroids and, 330–33 Osteoarthritis, 384 vaginitis and, 349–50 Osteopenia Nuts, 118 definition, 243 Osteoporosis, 186, 237–66, 384 Oat (Avena sativa), 172 alternative treatments, 243–63 Oat straw, 217 assessing risk, 240–43 Obesity bone effects, 238–39 amenorrhea and, 18 botanicals, 256–60 cervical dysplasia and, 33 conventional medical treatments, 264–66 heart disease and, 109 definition, 237, 243 infertility and, 157 diagnosing, 240–43 Obstetrics, 298 fracture sites, 238 Ogen, 367. See also Hormone replacement heredity and, 239–40 therapy (HRT) hormone replacement therapy, 203 Ogen cream, 369. See also Hormone licensed primary health-care practitioners replacement therapy (HRT) and, 266 Oleic acid, 117 lifestyle and, 239–40 Oligomenorrhea, 1, 12 menopause and, 239 Olive oil, 117, 118 nutrition and, 239–40, 243–56 Omega-3 fatty acids, 120, 254–56 preventative medicine, 244, 263 menstrual cramps and, 230–31 sample treatment plan, 263 pregnancy and, 285–87 severe, 243 Omega-6 fatty acids, 93–94, 120, 254–56 statistics, 237 Omega-9 oil, 117 Ovarian abscess, 272 Oophorectomy, 176 Ovrette, 370. See also Hormone replacement Oral contraceptives, 55–60, 234. See also therapy (HRT) Contraception birth control pills (BCPs), 55–60, 62 Pancreatic enzymes, 333 cervical dysplasia and, 33, 45–47 Pantehine for premenstrual syndrome (PMS), 315 heart disease and, 135 Oral micronized progesterone (OMP), 211 Pap smears, 31, 33, 375 Oregon grape root (Berberis aquifolium), new technologies, 34 70–71, 171, 334, 350 recommendations, 35 for pelvic inflammatory disease (PID), reporting, 34 270 screening tests risk factors, 379 INDEX 495 Para-aminobenzoic acid (PABA) Phytosterols, 141–42 infertility and, 160–61 Placenta abruption, 299 Partridgeberry (Mitchella repens), 289 Placenta previa, 299 Passionflower (Passiflora incarnata), 233 Plant stanols, 141–42 Pelvic exam, 375 Plant sterols, 141–42 Pelvic inflammatory disease (PID), 267–73, Pneumococcal vaccine, 377 321, 346 Poke root (Phytolacca americana), 95 alternative medicine, 269–71 Policosanol, 142 conventional medical treatments, 271–72 Polycystic ovarian syndrome (PCOS), 23–24, diagnosis, 268–69, 273 28, 29–30, 162, 385 licensed primary health-care practitioners chronic anovulation and, 28 and, 272–73 Polymenorrhea, 1, 12 preventative medicine, 269 Polyunsaturated fatty acids (PUFAs), 117 risk factors, 267–68 Postmenopause urinary discomfort, 66 statistics, 267 Potassium, 123–24 types, 267 heart disease and, 135 vaginitis and, 341 pregnancy and, 284 Pelvic peritonitis, 267 Preeclampsia, 295–96, 299 Pennyroyal (Mentha pulegium), 23 Prefest, 369. See also Hormone replacement Perimenopause, 178 therapy (HRT) Periwinkle, greater (Vinca major), 11 Pregnancy, 275–99, 385 Pesticides abnormal uterine bleeding and, 1 pregnancy and, 291–92 alternative medicine, 275–90 Pharmacies, 387 bleeding and, 298–99 Phosphatidylcholine (PC), 287 botanicals, 288–90 Physical exercise, 359–64 common complaints, 293–97 amenorrhea and, 25–26 conventional medical treatments, 297–98 basic stretches, 360–61 ectopic, 267, 272, 291 conditioning, 364 genital herpes and, 108 endometriosis and, 80 hormonal changes, 275 heart disease and, 115, 143–44 licensed primary health-care practitioners infertility and, 158 and, 298–99 joint warming exercises, 360 nutrition, 276–88 menopause and, 215–16 physical exercise, 293–94, 362–64 menstrual cramps and, 233–34, 235 postnatal period, 279 osteoporosis and, 261–63 preventative medicine for complications, 276 pregnancy and, 293–94, 362–64 substances to avoid, 289, 290–93 premenstrual syndrome (PMS) and, 311–12 urinary discomfort and, 66 preventing injuries, 361–62 with uterine fibroids, 340 strength exercises, 362, 364 weight gain, 277–78, 293 Phytoestrogens, 23, 162, 189–92, 194 Premarin, 367. See also Hormone replacement herbal, 335–36 therapy (HRT) 496 INDEX Premarin cream, 369. See also Hormone for sexually transmitted infections (STIs), replacement therapy (HRT) 320 Premature ovarian failure (POF), 27, 176, for uterine fibroids, 329 203–4 for vaginitis, 343, 346, 347 Premenstrual dysphoric disorder (PMDD), Prickly ash (Xanthoxylum americanum), 83 303 Prochieve, 371. See also Hormone replacement Premenstrual syndrome (PMS), 301–15, therapy (HRT) 384 Procyanidolic oligomers (PCO), 140 alternative treatments, 304–13 Progesterone, 24–25, 219–20, 371 botanicals, 310–11 for abnormal uterine bleeding, 11–13 classifications systems, 303, 307 bio-identical, 145–46, 208–13, 257–60, conventional medicine approach, 314–15 312–13, 335–36 definition, 301 creams, 96, 209–10, 233, 313, 337 diet, 306 for endometriosis, 85 licensed primary health-care practitioners gel, 371 and, 315 natural, 85, 95, 145–46, 208–13, 233, lifestyle, 314 257–60, 312–13, 335–36 liver and, 303 oral, 210–11 medications, 314–15 oral micronized, 313 nutrition, 305–10 for osteoporosis, 257–60 physical exercise, 311–12 for premenstrual syndrome (PMS), 312–13 preventative medicine, 303 precursors, 23 sample treatment plan, 314 sublingual, 211 statistics, 301–2 Progestins, 86 symptoms, 301–2 intrauterine, 371 Premphase, 370. See also Hormone oral, 370–71 replacement therapy (HRT) therapy, 264 Prempro, 370. See also Hormone replacement Progestogens, 202, 221 therapy (HRT) combination products, 221 Preventative medicine Prometrium, 371. See also Hormone for cervical dysplasia, 34–35, 43–47 replacement therapy (HRT) for endometriosis, 79 Propolis, 105 for fibrocystic breasts, 91 Prostaglandin (PG) synthesis, 305–6 for genital herpes, 102, 108 Proteases, 333 for heart disease, 115 Protein, 245 for infertility, 157 Provera, 370. See also Hormone replacement for interstitial cystitis (IC), 168 therapy (HRT) for menstrual cramps, 227–28 Prozac, 302 for osteoporosis, 244, 263 Psychological factors for pelvic inflammatory disease (PID), 269 cervical dysplasia and, 47 for pregnancy complications, 276 infertility and, 158 for premenstrual syndrome (PMS), 303 Pyridoxine, 280 INDEX 497 Quercetin, 139, 171 Serotonin, 302 Sesame oil, 117 Rapkin, Anita, 302 Sexual practices, 217–19, 222 Reaven, Gerald, 112 cervical dysplasia and, 33, 42–44 Reaven’s syndrome, 112 female arousal, 218–19 Rectal exam, 376 genital herpes and, 108 Red clover (Trifolium pratense), 23, 196, 381, lubrication, 218 384, 386 menopause and, 183–84 for osteoporosis, 256–57 screening tests risk factors, 379 Red raspberry (Rubus idaeus), 290 trauma during intercourse, 2 Red root compound, 334 Sexually transmitted infections (STIs), 66, Red yeast rice, 142 315–25 Reflex sympathetic dystrophy, 168 alternative medicine, 321–22 Rein, Mitchell, 336 antibiotics, 323–24 Relaxation techniques, 228 botanicals, 322–23 Rhodiola (Rhodiola rosea), 218, 383, 384, 385, cervical dysplasia and, 35 386 Chlamydia trachomatis (CT), 269, 317–18 for amenorrhea, 22 conventional medical treatments, 323–24 for infertility, 161 genital herpes, 99–108 Riboflavin, 280 licensed primary health-care practitioners Rose, 231 and, 324–25 Rutin, 229–30 Neisseria gonorrhoeae (GC), 269, 318–20 nutrition, 322 Safflower oil, 117 pelvic inflammatory disease (PID) and, 267 Saint John’s wort (Hypericum perforatum), 106, preventative medicine, 320 199–200, 311, 382, 383, 384, 386 sample treatment plan, 322 Salpingitis, 267 screening tests risk factors, 380 Salt, 123–24 testing for, 319–20, 376 Sarsaparilla (Smilax officinalis), 23 vaginitis and, 341–58 Savin (Sabrina officinalis), 11 Shepherd’s purse (Capsella bursa-pastoris), 11 Saw palmetto, 24 Siberian ginseng (Eleutherococcus senticosus), Scalzo, Rick, 334 105 Screening tests, 375–80 Sitz baths, 373 high risk factors, 377–80 Skin, 383 Scudder’s Alterative, 334 changes during menopause, 185 Scutellaria barbata, 334 products for, 387 Selenium Skullcap, 217 for endometriosis, 83 Sleep disturbance, 181 for infertility, 160 Slippery elm (Ulmus fulva), 172 SERMS (selective estrogen receptor Smoking, 24 modulators), 332 cervical dysplasia and, 33, 44–45 osteoporosis and, 264, 265 heart disease and, 114–15 498 INDEX infertility and, 158 Testosterone, 371–72 organizations to help quit, 292 Tetanus-diphtheria booster vaccine, 377 osteoporosis and, 240, 247 Thermal ablation treatment techniques, 338 pelvic inflammatory disease (PID) and, 268 Thiamine, 229, 280 pregnancy and, 291 ThyroFem, 385 screening tests for risk factors, 378 Thyroid disease, 385 Socioeconomic status, cervical dysplasia and, screening tests risk factors, 379 33 Thyroid hormone Sodium, 123–24 fibrocystic breasts and, 94–95 Soy foods, 24, 122–23, 189–92, 383 Thyroid test, 375 for abnormal uterine bleeding, 6–7 Tissue tonification for osteoporosis, 246–47 uterine bleeding, abnormal, and, 5 for premenstrual syndrome (PMS), 306 TLC diet, 127–28 research, 122–23 Toxemia, 295–96 for uterine fibroids, 332 Trabecular bone, 238 Soy oil, 117 Trans fats, 118 Specialty food companies, 388 Transvaginal ultrasound, 156 Spermicides, 53–54, 63–64 Tribulus (Tribulus terrestris), 162 Squamous intraepithelial lesions (SIL), 31 Trichomonas vaginalis, 346–48, 357–58. See Squaw vine (Mitchella repens), 23 also Vaginitis for infertility, 161 Triglycerides, 111, 118 Sterilization, 61 niacin and, 134 Stress, 385 Tryptophan endometriosis and, 75 premenstrual syndrome (PMS) and, heart disease and, 115, 144 309–10 infertility and, 158 Tubal ligation, 61 menstrual cramps and, 228 Tuberculosis uterine bleeding, abnormal, and, 4, 5 screening tests risk factors, 380 Stroke, hormone replacement therapy (HRT) Tubo-ovarian abscess, 267 and, 203 Turska’s formula, 84–85, 334 Sugar, 123, 245, 305 Surgery recovery, 385 Ultrasound, 338 Syndrome X, 112 Underweight issues infertility and, 157 Tamoxifen, 97 Urinary problems, 183 Tannins, 10 urinary discomfort, 65, 267 Taurine, 287–88 urinary tract infection, 65–73 (See also Tea, 139. See also Green tea Cystitis) Tea tree (Melaleuca alternifolia), 350 Uterine bleeding, abnormal, 1–14, 339–40, oil, 350 382 Testoderm, 371. See also Hormone alternative treatments, 4–14 replacement therapy (HRT) benign, 1–2, 3–4 INDEX 499 in children, 1 Vaginitis, 341–58, 385 irregular menses, 180 alternative medicine, 348–56 licensed primary health-care practitioners botanicals, 350–56 and, 14 Centers for Disease Control (CDC) malignant, 2–3 guidelines, 357 menses and, 1 diagnosis, 341–48 nutrition, 5–8 herbs for, 354–55 during pregnancy, 1 licensed primary health-care practitioners sample treatment plans, 12 and, 358 during sexual intercourse, 2 nutrition, 349–50 Uterine fibroids, 2, 327–40 preventative medicine, 343, 346, 347 alternative medicine, 330 sample treatment plans, 353, 354, 355 bleeding, 339–40 symptoms, 341 botanicals, 334–37, 337 Vaginosis organisms, 267 diagnosis, 329–30 Valerian (Valeriana officinalis), 172, 201, 217, herbs for, 386 231–32 infertility and, 340 Varicose veins, 296, 385 licensed primary health-care practitioners Vasectomy, 61 and, 339–40 Vasomotor symptoms, 222 nutrition, 330–33 Venous thromboembolism, 202–3 pregnancy and, 339–40 Vertebral fracture, 238, 242 preventative medicine, 329 Viracea, 106 sample treatment plan, 337 Visualization, 228 statistics, 327 Vitamin A symptoms, 328–29 abnormal uterine bleeding and, 7 Uterine tonics amenorrhea and, 20 for abnormal uterine bleeding, 10–11 cervical dysplasia and, 37 Uva-ursi (Arctostaphylos uva-ursi), 70, fibrocystic breasts and, 94 95 interstitial cystitis (IC) and, 170 pregnancy and, 281 Vaccines. See Immunizations sexually transmitted infections (STIs) and, Vagifem, 369. See also Hormone replacement 322 therapy (HRT) vaginitis and, 349 Vaginal cancer, 2 Vitamin B complex Vaginal dryness, 182–83 abnormal uterine bleeding and, 7–8 Vaginal estrogen treatments, 66 fibrocystic breasts and, 95 Vaginal flora, 341, 348 Vitamin Bs, 193 Vaginal suppositories, 382 cervical dysplasia and, 38–39 Vaginal symptoms endometriosis and, 83 hormone replacement therapy (HRT) for, heart disease and, 136–37 202 menstrual cramps and, 229 Vaginal thinning, 182–83 osteoporosis and, 253 500 INDEX pregnancy and, 280–81 Vitamins. See also Specific types premenstrual syndrome (PMS) and, infertility and, 161 307–8 Vivelle, 368. See also Hormone replacement Vitamin C, 24 therapy (HRT) abnormal uterine bleeding and, 8 Vivelle-Dot, 368. See also Hormone cervical dysplasia and, 38 replacement therapy (HRT) cystitis and, 69–70 Von Willebrand’s disease, 1 endometriosis and, 81–82 Vulvovaginal candidiasis (VVC), 344–46, genital herpes and, 103–4 356–57. See also Vaginitis heart disease and, 129, 132 infertility and, 163 Water pepper (Polygonnum hydropiper), 23 menstrual cramps and, 229–30 Weight gain, 185. See also Body weight osteoporosis and, 253 pregnancy and, 277, 294 pregnancy and, 282 Weight loss, 159, 385. See also Body weight sexually transmitted infections (STIs) and, amenorrhea and, 18–19 322 WIC (supplemental food program), 277 vaginitis and, 349 Wild yam (Dioscorea villosa), 23, 172, 233, Vitamin D, 192 290 osteoporosis and, 237, 239, 241, 250–51, root, 295 265 Women, modern, xx pregnancy and, 282 choice, xix premenstrual syndrome (PMS) and, 308 as consumers of health care, xxi Vitamin E, 193–94 participation in health care, xxi abnormal uterine bleeding and, 7 Women’s Health Initiative (WHI), 148, 201, cervical dysplasia and, 37–38 213, 219 endometriosis and, 82 World Health Organization, 243 fibrocystic breasts and, 92–93 genital herpes and, 104 Yarrow (Achillea millefolium), 11, 23, 95 heart disease and, 130–32 Yeast infection, 385. See also Vaginitis infertility and, 160, 163 Yucca (Yucca spp), 23 menstrual cramps and, 230 pregnancy and, 282 Zinc premenstrual syndrome (PMS) and, genital herpes and, 104 308 infertility and, 160 vaginitis and, 349 osteoporosis and, 253 Vitamin K, 253–54 pregnancy and, 284–85 abnormal uterine bleeding and, 8 sexually transmitted infections (STIs) and, pregnancy and, 282–83 322