AP2-Lesson10

Applied Phytotherapeutics II Human Flower: Reproduction By Terry Willard ClH, PhD; Todd Caldecott ClH Lesson 10

The Human Flower Part One: Human Reproduction

Introduction The area of reproductive health provides a large divergence between Western bio-medicine and modern herbal practice. From a bio-medicine point of view the reproductive system (especially female) is one of the most challenging areas. With complex physiology and constant hormone fluxes, Western medicine finds this area hard to treat. This is very apparent in the use of birth control pills and hormone replacement therapy (HRT), where instead of continuous fluctuations, a constant level of hormones is delivered. This is like making all the hormones, receptor sites and tissues march to the same drummer, instead of a naturally continuous dance of harmony, with the natural ebbs and flow of an inner rhythm.

On the other hand historically a very large percentage of herbalists have been women, making up the wise-women, midwives and local rural practitioner of the past. They, of course, focused much of their attention on matters of reproduction, fertility, childbirth and child rearing. In modern bio-medicine treatment solutions are not satisfactory; with surgery, and hormone ‘bullying’ being the major options. Repeated use of antibiotics is often used to treat infection and inflammation.

The main characteristic of the female reproductive system is that of mobility and changeability. This makes it quite complex to understand from a bio-medical model and thus dysfunctions seem hard to treat. On the other hand from an herbalist’s point of view it is usually simply a matter of strengthening the underlying tissue and restoring rhythm. You will therefore notice many of the herbal treatments protocols are the same for what appear to be different health issues (e.g. the same herbs are used for no menstruation, excessive menstruation, menstrual cramps or other menstrual irregularities). This concept of self-organization is almost foreign to modern bio-medicine, but quite prominent in herbal programs. By taking away stresses on the system, feeding the proper nutrients and supporting the underlying

tissue, most rhythmic conditions will fix themselves. This is very true of many of the reproductive issues dealt with in this lesson.

The reproductive system often only requires a ‘herbal nudge’ to encourage the underlying hormone systems and tissue to regain a state of health.

There is a long list of botanicals that have an effect on female or male reproductive tissues. A list of these can be found in the appendix of this lesson. Most practitioners will rely on just a few favourites to accomplish the desired effect. For the female system the herbs most used at Wild Rose are Dong quai (Angelica sinensis), Black Cohosh (Cimicifuga racemosa), Blue Cohosh (Caulphyllum thalictroides), squaw vine (Mitchella repens) and Chaste berry (Vitex agnus- castus). For male issues Saw Palmetto (Serenoa repens), Buchu (Agathosma betulina), Nettle roots (Urtica dioica) and pumpkin seeds (Cucurbita pepo).

In this lesson we will deal with the area of:

Female: • irregular menstruation • painful menstruation • heavy menstruation • Premenstrual syndrome • menopause • ovarian cysts • vaginal infections • fibroids • endometriosis • pelvic inflammatory disease

Male: • Inguinal and scrotal inflammation • Prostatic infection and inflammation • Hormonal dysfunction and male infertility •

Female Reproductive system

The female reproductive organs can be divided into external organs, including the vulva and the breasts, and internal organs such as the ovaries, uterus and fallopian tubes.

Female external anatomy More information can be found in previous courses you have taken, or in your mandatory text: Principles of Anatomy & Physiology by Tortora and Grabowski.

The term vulva refers to the mons pubis, labia minora, labia majora, the clitoris, and the vestibule. The mons pubis is an elevation of adipose tissue covered in pubic hair, located anterior to the vaginal and urethral openings,

and helps to cushion the pubic symphysis during sexual activity. The labia majora are large fleshy folds of skin and adipose tissue that encompass the inner structure of the vulva. Pubic hair grows on the external surfaces of the labia majora, and its inner surfaces are lined with mucus membranes, sudoriferous (sweat) and sebaceous (oil) glands that help to lubricate the vagina during sexual activity. The labia minora are contained within the labia majora and are joined at the top to form the clitoral hood or prepuce, and encompass the vaginal and urethral openings. The labia minora is typically devoid of hair and fat tissue, and contains fewer sudoriferous glands. The clitoris is a small, cylindrical mass of erectile and nervous tissue. The exposed portion of the clitoris is the glans, is capable of enlargement during tactile stimulation, and plays a role in sexual excitement in the female. The vestibule is the cleft between the labia minora, containing the hymen (if present), the vaginal orifice, the urethral orifice and the openings of several glands. The bulb of the vestibule is two elongated masses of erectile tissue deep to the labia on either side of the vaginal opening. During sexual arousal the bulb becomes engorged with blood, narrowing the vaginal opening. Anterior to the vaginal opening and posterior to the clitoris is the external urethral orifice. It is surrounded by the paraurethral glands that secrete mucus. On either side of the vaginal opening are the Bartholin’s glands that secrete mucus to lubricate the vagina during sexual activity.

The breasts contain modified sudoriferous (sweat) glands called mammary glands that produce milk. They are paired and lie over the pectoral region of the chest. Internally, each mammary gland consists of lobes that are separated by adipose tissue. The size of the breasts is determined by the presence of adipose tissue, but fat tissue has nothing to do with milk production itself. Each lobe is divided into smaller lobules, which in turn are composed of clusters of milk-secreting glands called alveoli. Arranged in grape-like clusters, the alveoli convey the produced milk into secondary tubules and then into mammary ducts. As these ducts approach the nipple they expand to form sinuses called lactiferous sinuses, where the milk is typically stored if it is being produced. The sinuses contain lactiferous ducts that terminate in a pigmented projection called the nipple. Surrounding each nipple is circular pigmented area called the areola that has a roughened appearance due to the many modified sebaceous glands contained within it.

Female internal anatomy The internal organs of the female reproductive system are composed of the uterus and endometrium, fallopian tubes, cervix, ovaries, and vagina. The uterus is a powerful muscular organ, considered to be one of the strongest in the body. It is about the size and shape of a slightly flattened pear, but can stretch to accommodate a developing fetus and rhythmically contract during childbirth. The shape of the uterus is affected by polyps, fibroids, as well as current and repeated pregnancies. The lining of the uterus, called the endometrium, is shed every three to four weeks as menstrual fluid. It is divided into two layers, the basal layer that always covers the uterine muscle and is unchanging, and the functional layer that changes with hormonal activity, becoming glandular

and developing microscopic spiral arteries that supply it with nutrition. The functional endometrium develops under the influence of the ovarian hormones estrogen and progesterone. It is thinnest during the first part of the cycle after menstruation, and estrogen initiates its development. If and when ovulation occurs, progesterone is produced in increasing amounts, thickening the endometrium and promoting glandular changes. Although the regular shedding of the endometrium is an indication of hormonal change, it does not necessarily indicate ovulation.

The fallopian tubes are paired muscular organs lined with microscopic hair-like projections called cilia. The fallopian tubes are on average about 10 cm long and end in small finger-like projections called fimbria (pl. fimbriae). The fimbriae are funnel-shaped, wide at the ovarian end and narrow at the uterine end, about the width of a needle. The regular contraction of the fallopian tubes conveys the expelled ovum during ovulation into the uterus, preventing the back flow of menstrual fluid and the infection of the pelvic cavity. The cilia function to sweep the released ovum along the fallopian tube from the ovaries to the uterus, and are enhanced by the influence of estrogen. The fimbriae act like tiny fingers, constantly in motion, sweeping the expelled ovum into the end of the fallopian tubes, where the cilia and the rhythmic contraction of the tubes take over. If one fimbria is damaged from surgery, infection, or endometriosis, the other can actually cause the ovum released by the opposite ovary to be drawn toward it.

The ovaries are the paired, oval-shaped gonads of the female reproductive tract, about the size of a small, slightly flattened egg. The ovaries are not attached to the end of the fallopian tubes, but to the uterus by the ovarian ligament. A suspensory ligament attaches each ovary to the side wall of the pelvis, containing blood vessels, nervous and lymphatic tissues that supply the ovaries. The ovaries and entire pelvic cavity are covered by the peritoneum, two thin layers of tissue lying over the posterior and anterior surfaces of the pelvic cavity, with the organs, blood vessels and ligaments lying in between. An infection or hemorrhaging in the reproductive tract can cause the inflammation of the peritoneum, called peritonitis.

The cervix makes up the lower third of the uterus, or the neck of the womb, half of which protrudes into the vagina. The cervical opening is normally tightly closed except during childbirth, during the passing of menstrual fluid, and during sexual activity to facilitate the entry of sperm. The cervix is prone to cancerous changes and can become infected, inflamed and sometimes bleed. These changes are detected by a speculum examination, a swab to check for bacteria, and a Pap smear.

The vagina is situated between rectum and urethra, and is the structure through which menstrual fluids are shed and the penis enters during sexual intercourse. The vagina is highly muscular and elastic to accommodate childbirth. The upper and lower portions of the vagina that surround the cervix are an arch-like space termed the anterior and posterior fornices (sing. fornix), respectively. The posterior fornix, or pouch of Douglas, is longer than the anterior fornix, and is a vulnerable site in infection and endometriosis.

Female Reproductive Physiology

Menstruation and the Menstrual Cycle On average, a woman will spend 3 years of their entire lives menstruating, which is about 10 times more often than our Neolithic ancestors. Recently, a link has been made between the incidence of some common reproductive diseases, such as breast cancer, and the frequency of menstruation. In cultures where women are pregnant and lactate more often the incidence of many reproductive diseases such as breast cancer and endometriosis is dramatically lower than in the West, most likely due to the diminished influence and cyclical variations of estrogen over a lifetime.

The term amenorrhea describes the absence of menstruation.

The term oogenesis is used to describe the formation of gametes in the ovaries. At birth there are between 200,000 to 2,000,000 oogonia and oocytes, many of which undergo a degenerative process called atresia, resulting in only about 40,000 at puberty. As a women ages the number of

oocytes declines until menopause, when the estrus cycle ceases due to ovarian degeneration.

During a woman’s reproductive life the microscopic structures of the ovary are constantly changing. At some point during a woman’s cycle, between 10 and 20 primordial follicles, or eggs-in-waiting, begin developing simultaneously. By day 8-12 however, one follicle has become the primary follicle (Graafian follicle) and the others are reabsorbed before reaching maturity in a process called follicular atresia. It is this primary follicle that then produces the ovum. By day 13 or 14 the membrane of the follicle ruptures and the ovum is expelled into the pelvic cavity. The structure left behind is called the corpus luteum, or yellow body, which secretes estrogen and progesterone into the bloodstream. If fertilization does not occur, after about 14 days the corpus luteum dies and becomes scar tissue known as the corpus albicans, or white body. If we were able to examine the healthy ovary of a mature woman, we would see many of these scars, indicating a history of ovulation. As the woman ages the follicles are less responsive to hormonal stimulation and the ovary has fewer primordial follicles left.

The menstrual cycle can be divided into three phases: the proliferative phase, the secretory phase, and the menstrual phase. The proliferative phase or follicular phase of the ovarian cycle represents the period during which the ovum is maturing and the ovaries secrete estrogen to stimulate the proliferation of the endometrium. Within two days of the end of menstruation, or by about day 8, rapidly growing endometrial cells have completely resurfaced the uterine wall. During the remaining 4 days or so before ovulation the endometrium thickens from about 1 mm to 6 mm by ovulation. This thickening is marked by an increased sponginess of the stromal or supportive tissue, and the development of glandular tissue within the stroma that secretes mucus and glycogen to assist in the development of the fertilized ovum. Blood vessels also begin to grow into the endometrium to provide nutrition to the developing tissues.

The secretory phase or luteal phase begins with ovulation and the development of the corpus luteum, which then starts to produce large amounts of progesterone. The combined effect of progesterone with the already circulating estrogen causes the endometrium to become secretory. The glandular structures become larger and more convoluted, and begin to produce and secrete larger amounts of glycogen. The arteries begin to take on a characteristic spiral shape indicative of progesterogenic activity. The veins also increase in size and the supportive stromal layer thickens and becomes even spongier, up to 8 mm. At this point, the uterus provides an optimal environment for a fertilized ovum to embed in the glycogen-rich tissues and begin to develop.

If fertilization does not occur the corpus luteum degenerates into the corpus albicans and the level of progesterone and estrogen in the blood begins to decline. The developing endometrium, deprived of the proliferating influence of these hormones, becomes fragile and begins to fall apart. The sponginess of stroma is lost and the endometrium collapses upon itself, cutting off its blood supply. The activity of locally acting prostaglandins gradually increases during the secretory stage, and

stimulates the uterus to contract. As uterine contractions become stronger and more frequent, the prostaglandins also cause the endometrial blood vessels to constrict, shutting of blood supply. Uterine contractions also assist in the expulsion of the functional layer of the endometrium through the cervical opening, shed as menstrual fluid. As mentioned, this marks the first day of the estrus cycle, or the menstrual phase.

Hormonal control of Menstrual Cycle During a woman’s reproductive years the secretion of the various hormones does not usually fall beyond a certain baseline level. It is the hormonal variability above this baseline that is responsible for cyclical variability that characterizes the menstrual cycle. The endocrine glands responsible for hormone production and cyclic regulation are the hypothalamus, pituitary and ovaries. The regulation of hormonal secretion begins with the hypothalamus that produces gonadotropin-releasing hormone (GnRH). This hormone then activates the pituitary gland to secrete lutenizing hormone (LH) and follicle stimulating hormone (FSH), which in turn activates the ovaries to secrete estrogen and progesterone. Any fluctuations in the production of hormones from each of these endocrine glands signals the next gland in the chain to vary its hormone production, called a feedback loop. The hypothalamus responds to both high and low levels of estrogen and progesterone. The declining levels of estrogen during the menstrual phase results in the secretion of GnRH, which in turn signals the pituitary gland to release FSH, which then stimulates follicular growth in the ovary. While the follicles are developing they produce increasing levels of estrogen, which in turn stimulates the endometrium to develop. Under the influence of estrogen the vaginal secretions become rich with glycogen, which in turn is acted upon by commensal bacterium to produce lactic acid that makes vaginal secretions acidic. The high levels of estrogen just before ovulation cause the cervical mucus to become “egg-white” in color and consistency, and promote a softening of the muscle tissue, indicating fertility.

The increasing levels of estrogen from the maturing follicles gradually increases the frequency of GnRH and LH secretion in a positive feedback cycle, and at its height,

signals the pituitary gland to release a sudden surge of LH. FSH also surges at this time, but whereas both estrogens and GnRH stimulate LH secretion from the pituitary directly, FSH secretion is only regulated by GnRH stimulation. This surge of LH and FSH is thought to trigger the release of the ovum from the ovary. After ovulation the follicle that contained the ovum collapses and forms a blood clot called the corpus hemorrhagicum, which is then reabsorbed by the other follicles. Under the influence of high levels of LH the follicular cells enlarge to form the corpus luteum. As the corpus luteum begins to secrete progesterone, the levels of LH begin to decline. Both FSH and the levels of estrogen decline as well, but estrogen levels eventually climb back up and maintain a constant level in the blood until just before menstruation. If fertilization doesn’t occur, all the hormonal levels eventually drop to baseline, thereby initiating menstruation. Consistently low levels of estrogen then stimulate the release of GnRH and in turn, FSH, to initiate the whole process over again.

Using the analogy of a theatre company, one can liken the activities the various hormones to all the different components needed to get a production on stage, with different managers, directors, and actors. The managers of the production are GnRH and the catecholamine neurotransmitter dopamine, both of which are secreted by the hypothalamus. GnRH is pulsed from the hypothalamus about every 60 to 90 minutes to stimulate the pituitary gland to secrete LH and FSH, and increases in frequency during mid-cycle to stimulate ovulation. Dopamine is secreted to inhibit the release of prolactin, a hormone that stimulates breast milk production.

The directors of the show are LH, FSH and prolactin. LH levels slowly increase in response to low estrogen levels during the early follicular phase, but just prior to mid cycle there is a dramatic surge in LH, as well as in estrogen and FSH, to initiate the rupture of the mature follicle. The main job of LH is to stimulate both estrogen and progesterone production in the ovary, and it is the progesterone secretions of the corpus luteum that causes LH levels to decline. FSH, on the other hand, stimulates the growth and development of the ovarian follicle and the number of estrogen producing cells in the developing follicle. The

hormone prolactin affects breast growth and milk production, and levels are typically low in non-pregnant women, but slightly increase during the luteal phase of menstruation, and at night time and with stress. The breast tenderness that can occur prior to menstruation is due to a slight elevation in prolactin levels.

Estrogen The actors in the production are the estrogens, progesterone, androgens and carrier proteins. Estrogens have growth enhancing effects that stimulate puberty in young women, and are responsible for the deposition of fat around the abdomen, hips and breasts. Estrogens also stimulate the growth of the endometrium, and maintain the structure of skin, blood vessels and bones. Estrogens stimulate the development of cells that have estrogen receptors, and also the number estrogen receptors on each cell. This activity leads to an escalating ability of estrogens to stimulate cell growth, and an increased number of places for estrogen to interact with cells. Estrogens are of three types: estradiol, estrone and estriol. Each cycle the ovaries begin to produce estradiol just after menstruation. Some of the estradiol is then converted into a relatively weaker estrogen called estrone. Both estradiol and estrone are then released into the blood stream and travel to estrogen sensitive cells to stimulate proliferation. The levels of ovarian estrogen reaches a peak just prior to ovulation, dips slightly after ovulation, creeps back up to maintain a relatively consistent level in the blood, and then falls just prior to menstruation.

Another site of estrogen production is in muscle and fatty tissue, where androgens produced by the adrenal glands are acted upon by the aromatase enzyme to produce estrone. This is called peripheral conversion, and is the major source of estrogen after menopause, when the ovaries shut down estrogen production. Thin women who are perimenopausal may suffer from the adverse effects of not having enough peripheral sites for estrogen production, and may suffer from intense hot flashes and vaginal dryness. Estradiol is the most powerful of the estrogens, and is further converted into either 2-hydroxyestrone (the “good” estrogen) or 16-hydroxyestrone (the “bad” estrogen). When examining the blood levels of estrogen in breast cancer patients, researchers have found that the levels of

16-hydroxyestrone are elevated. It has been determined that 16-hydroxyestrone has a strong growth promoting potential and may even damage DNA. Further, synthetic chemicals called xenoestrogens have been found to mimic or potentiate the effects of 16-hydroxyestrone. Xenoestrogens include a large and diverse range of compounds found in such items as pesticides, PCBs, soft plastics (food wrap, plastic containers) and lacquers used to coat metal cans for preserved food. They are soluble in fat and accumulate in fatty tissue, and are thus likely to be concentrated in animal products. Xenoestrogenic compounds in combination with each other are thought to have effects as much as thousands of times more potent than a single chemical. Perhaps even more worrisome is that xenoestrogens can accumulate during fetal development and may persist in the body for decades, altering hormonal balance.

Xenoestrogens appear to be an underlying cause of many health issues like obesity, infertility, fibroids, premature menses, and cancers; the list is still accumulating.

All estrogens eventually pass through the liver where they are conjugated (deactivated) and eliminated into the small intestine through bile secretion. At this point estrogens may be acted upon by an enzyme called beta-glucuronidase that is produced by intestinal bacteria, or may be eliminated in conjugated form. If the bacterial enzymes are present in sufficient amounts, much of the conjugated estrogen may become de-conjugated back into its active form and be reabsorbed back into the bloodstream. Factors that enhance bacterial activity include a diet high in saturated fat, whereas a high fiber intake binds estrogens and enhances elimination.

Circulating estrogens also pass through the kidneys where they are changed into the weak estrogen estriol for elimination. The activity of estriol is about 80 times weaker than estradiol, and is on par with many of the plant hormones called phytoestrogens that are used therapeutically. Both phytoestrogens and xenoestrogens have an ability to connect to estrogen receptor sites, and if the fit between the hormone and the receptor is perfect the estrogenic effects will be potent. Many xenoestrogens appear to resemble estradiol and fit perfectly in estrogenic receptors sites, stimulating a powerful estrogenic effect. If,

on the other hand, the fit is less than perfect, as is the case with phytoestrogens, the estrogenic effect is weaker. A phytoestrogenic compound may act in different ways dependent upon whether or not a woman is pre or post menopausal. In premenopausal women phytoestrogens bind to estrogen receptors and thereby block the effects of more potent estradiol and xenoestrogens, stimulating weaker effects. Thus, in conditions like fibroids and endometriosis in which the tissues are responsive to estrogen, phytoestrogens can have a positive benefit. Conversely, phytoestrogens in postmenopausal women have a relatively potent estrogenic effect because of the general lack of endogenously produced estrogen. Thus, phytoestrogens appear to play an important role throughout a woman’s life.

Progesterone Progesterone is an important hormone in both men and women, and is a precursor to many other steroid hormones including the glucocorticoids, estrogen and testosterone. In women progesterone stimulates tissues sensitive to progesterone such as the breasts and uterus to become secretory. In the endometrium progesterone stimulates blood vessel development and the production and secretion of glycogen. In the breasts progesterone facilitates changes to these tissues so they can become capable of secreting milk. Progesterone also helps to regulate the level of circulating androgens, and when progesterone levels are high the level of circulating androgens are low. In postmenopausal woman a deficiency of progesterone may facilitate androgenic changes such as alopecia (hair loss) and hirsutism (facial hair and male pattern hair growth). Progesterone has several beneficial activities in the body such as increasing bone density, elevating mood, and balancing the activity of estrogen thereby helping to prevent breast and uterine cancer. The starting molecule for progesterone is cholesterol, and in either the ovary or adrenal gland, it is converted successively into pregnenolone and then into progesterone. Once progesterone is manufactured, and dependent upon need, it may be converted into estradiol, estrone, testosterone or cortisone. Progesterone circulates through the bloodstream and is active until it is conjugated by the liver, and excreted in the bile.

Androgens Androgens are masculinizing hormones that in women are an important source of estrogen after menopause, but can also produce undesirable secondary male sexual characteristics. High levels of androgens, as are found in conditions such as polycystic ovarian disease, can produce abnormalities of the estrus cycle, male pattern hair growth, alopecia, deepening of the voice, loss of female body contour, and a decrease in breast size. The most abundant and potent androgen is testosterone, about 25% originating from the ovary, 25% from the adrenal gland, and the remaining 50% from the conversion of other adrenal or ovarian hormones.

The biological precursor to testosterone is androstenedione, an increasingly common drug taken by athletes to enhance testosterone and the resultant anabolic effects on muscle mass. Androstenedione is transformed in the liver, fat and skin into testosterone. Dihydro- testosterone is produced from both androstenedione and testosterone and when present in excess, can promote prostate issues in men, and masculinization, acne, and clitoral hypertrophy in woman. Some testosterone is derived from the adrenal hormones dehydro- epiandosterone (DHEA) and DHEA sulfate. These hormones have been shown to decline with age, and some believe that supplementing with these hormones can prevent aging. The level of DHEA is easily measured, and is an indicator for evaluating abnormal adrenal androgen levels.

Carrier proteins As steroid hormones are made from cholesterol, and cholesterol is a fat that is repelled by the watery solution of the blood, they need to be bound with special carrier proteins, such as albumin and globulin. The most common carrier proteins include sex hormone binding globulin (SHBG) and cortisol binding hormone (CBG). When bound to carrier proteins, steroidal hormones are less able to act upon target tissues, and will not be deactivated by the liver. Sex hormone binding globulin (SHBG) controls estrogenic activity by reducing the amount of free estrogen

in circulation. It is synthesized in the liver; estrogen and an excess of thyroid hormone both increase its production. Factors that lower SHBG are obesity, excessive testosterone levels, acromegaly, thyroid hormone deficiency, exogenous progesterone, and corticoids. Cortisol binding hormone (CBG), or transcortin, is the carrier protein for both progesterone and cortisol, and thus regulates the amounts of available progesterone.

Male Reproductive system

Male Reproductive anatomy Unlike the female, much of the male reproductive system lies external to the body. Additionally, the mechanism involved in controlling male reproductive physiology is not quite as complex as it is in women. For this reason we can map the various facets of the male reproductive system by following the production and path of sperm cells, beginning with the scrotum.

The scrotum is a cutaneous outpouching of the abdomen, consisting of loose skin and superficial fascia. Containing the testes and accessory structures, its location and muscular activity helps to regulate the temperature of the testes, ideally about 3 degrees lower than body temperature. Internally, a vertical septum divides the scrotum into two sacs, each containing a testicle. The cremaster muscle is an extension of the internal oblique muscle that elevates the testes during sexual arousal and exposure to cold. If exposed to warmth however, the muscle relaxes. The scrotum is the male equivalent of the labia majus, derived from the same embryonic tissue.

The testes are paired oval-shaped glands almost identical in size and shape to the ovaries, measuring about 5 cm in length, 2.5 cm in width, each weighing between 10 – 15 g. They are covered by a serous membrane called the tunica vaginalis. Internal to the tunica vaginalis is a dense white fibrous capsule called the tunica albuginea that divides each testis into a series of internal compartments called lobules. Contained within each one of the 200-300 lobules are 1-3 tightly coiled seminiferous tubules, the site of spermatogenesis, or sperm production. The developing sperm, called spermatogonia, lie next to the basement membrane of the seminiferous tubule. As they develop the spermatogonia gradually move away from the sides of the tubule to become spermatozoa (sing. spermatozoon). At this point the spermatozoa begin to move through a series of ducts.

Sertoli or sustentacular cells form tight junctions in the tubules and act as a blood-testis barrier, keeping spermatozoa safely away from the immune system that recognizes the sperm cell as a foreign antigen. The Sertoli cells also support and nourish the developing sperm cells, and mediate the effects of testosterone and FSH on spermatogenesis. They also secrete a fluid for sperm transport, secrete androgen-binding hormone and release a hormone called inhibin that helps to regulate sperm production by inhibiting FSH. Between the seminiferous tubules are the Leydig or interstitial cells that secrete testosterone, the most potent of the male androgens. In the fetus the testes are located roughly in the same location as the ovaries, but descend after birth to facilitate sperm production. There remains however, some kind of nervous connection with this area, witnessed by the referred pain felt in the lower abdomen if there is a blow to the testes.

A sperm cell is comprised of a head, body and a tail. The head contains the nucleus of the sperm cell, and coating the outside of it is the acrosome, a granular tissue that contains hyaluronidase and proteases that function to digest the membrane of the ovum during fertilization. The body of the sperm cell contains many mitochondria that produce the energy needed to feed the tail that propels the sperm cell.

When the spermatozoa leave the testes they enter into efferent ducts call the epidiymides (sing. epididymis), tightly coiled structures containing branching microvilli called stereocilia that increase the surface area for the reabsorption of degenerated sperm. The surface area of one epididymidis is more than 6 metres in length, by 1 mm in width. It is within the epididymides that the spermatozoa mature over a 10-14 day period, and can be stored for at least a month before being reabsorbed. In many ways the epidiymides are homologous, or similar to, the fimbriae of the female fallopian tubes, collecting the sperm from the testicle, and propelling it towards the urethra through its muscular contraction and the wave like action of the stereocilia.

The seminal ducts are long winding tube-like structures that connect to each of the epididymides, and carry the sperm to the urethra. Each ascends along the posterior border of the epididymis, penetrating the inguinal canal, and entering into the pelvic cavity. The seminal ducts then loop over the side and down the posterior surface of the bladder and end at the ejaculatory duct. The seminal ducts are homologous to the fallopian tubes, propelling mature sperm to the urethra by peristalsis.

A vasectomy is a surgical procedure in which a portion of both seminal ducts is removed to sterilize the male. It is a highly effective procedure that can be performed in a physician’s office, but as the ducts can grow back together, it is not considered a success until two sperm-free ejaculates have been obtained. Although sperm are still produced after a vasectomy, they cannot reach the exterior and are destroyed by the immune system. In about 5% of cases a hematoma may ensue, and less often, an inflammatory immune response to the leaking spermatozoa. If the vasectomized man wishes to become fertile again, there is 45 – 60% chance of regaining fertility with corrective surgery.

The seminal vesicles are convoluted pouch-like structures lying posterior to the base of the urinary bladder, in front of the rectum. They secrete an alkaline viscous fluid containing fructose, prostaglandins and fibrinogen that make up about 60% of the fluid volume of semen. Its alkaline pH helps to neutralize the acidic vaginal pH.The sperm use the fructose to produce ATP. The prostaglandins enhance sperm motility, and fibrinogen, when activated, coagulates the semen to keep all the sperm cells from dispersing immediately after ejaculation.

The prostate gland is a chestnut sized, doughnut-shaped gland, inferior to the urinary bladder, surrounding the superior portion of the urethra. It secretes a milky, slightly acidic fluid that contains citric acid and several enzymes, making up about 25% of the total semen volume. Prostatic fluid contains clotting enzymes that cause the fibrinogen secreted by the seminal vesicle to clot. Fibrolysin acts later to break down the clotting factors about 5 – 20 minutes after ejaculation, so the sperm can begin their migration to the uterus. The prostate gland is an endocrine-dependent organ, and the absence of testosterone will cause it to atrophy. Some commentators equate it with the uterus, and although it does not display cyclical changes, it does function to nourish and protect the sperm cells. One theory suggests that the outer mass of prostatic tissue is responsive to androgens, whereas the inner mass is responsive to estrogen. Thus prostate diseases can be related to either an excess of testosterone or an excess of estrogen.

The bulbourethral glands are paired glands about the size of a pea that lie beneath the prostate on either side of the membranous urethra. It secretes an alkaline substance to protect semen from the slightly acidic pH of the urethral environment and lubricates the end of penis during sexual activity.

The urethra is the terminal duct of the male reproductive organ, passing through the prostate, urogenital diaphragm and penis. It is the passageway of both semen and urine.

The penis is the cylindrical shaped sexual organ that is used to deposit spermatozoa into the vagina. It consists of three parts: a body, root and glans. The body is composed of three cylindrical masses of tissue, each bound by a layer of fibrous tissue. The two dorsolateral masses are the corpus cavernosa, and the smaller midventral mass is the corpus spongiosum. All three layers are enclosed by fascia and skin, and consist of erectile tissue that is permeated by blood sinuses. With tactile, visual, auditory, olfactory or imaginative stimulation, the arteries of the penis dilate and large quantities of blood enter the sinuses. This expansion compresses venous flow so the blood becomes trapped, resulting in an erection. When the arteries constrict the penis returns to its normal, flacid state. Ejaculation is the propulsion of semen from the ejaculatory duct through glans to the exterior. The smooth muscle at the base of the urinary bladder simultaneously closes during ejaculation to prevent urine expulsion.

The root of the penis is divided into the bulb and crus, the former attaching to the interior surface of the urogenital diaphragm and enclosed by the bulbocavernous muscle, and the latter to the ischial and inferior pubic rami.

The distal end of the corpus cavernosum is a slightly enlarged acorn shaped area called glans. The margin that separates the glans of the penis from the body is called the corona. The external opening in the glans is the urethral orifice. In men who have not been circumcised the covering of the glans is the prepuce or foreskin. During embryonic development, the penis and the clitoris are derived from homologous tissue, each with a glans and a prepuce. One could think of the penis as an elongated shaft with a clitoris on top. Under the influence of testosterone these tissues

develop into male reproductive organs, and under the influence of estrogen they develop into female reproductive organs. The glans penis, like the clitoris, contains many nerves endings that provide a high degree of tactile pleasure. The prepuce covers the glans to protect and nourish these tissues, producing a complex mixture of sebum and mucus called smegma. The removal of the foreskin causes the glans to dry out, becoming progressively more and more keratinized, leading to nerve destruction and a significant loss of sensation.

Male Reproductive Physiology As in females, men normally produce haploid (n) gametes that are capable of fertilization in a process called spermatogenesis. The process of spermatogenesis occurs with the testes with the onset of puberty. Diploid (2n) stems cells called spermatogonia arise from the basement membrane of the semeniferous tubules. Some of these cells break away from the basement membrane and differentiate into a diploid primary spermatophyte. These cells then undergo meiosis, creating four haploid daughter cells called spermatids that are genetically different from one another. Spermatids then mature further into sperm cells when they break away from the Sertoli cells to make their way to the ducts of the testes.

At the onset of male puberty the anterior pituitary secretes FSH and LH in response to GnRH secretion by the hypothalamus. FSH initiates spermatogenesis by stimulating the Sertoli cells, and LH stimulates the Leydig cells to secrete testosterone, created from cholesterol in the testes. Like women, the hypothalamus pulses GnRH about every 60 to 90 minutes, and if testosterone levels drop a negative feedback loop enhances the secretion of GnRH, FSH and LH.

Testosterone is the primary male androgen, but some tissues aren’t responsive to it until it becomes metabolized into dihydrotestosterone by the enzyme 5-alpha-reductase. Thus, testosterone is both a hormone and a hormone precursor. Testosterone is the most potent of the androgens; responsible for primary and secondary male sexual development, the initiation of the sex drive, and aggressiveness, it also promotes protein synthesis. Other

important androgens include androstenedione and DHEA, already discussed.

Inhibin is a hormone secreted by the Sertoli cells that acts directly upon the anterior pituitary gland and upon the hypothalamus to inhibit the secretion of FSH. It is released when the required amount of sperm is produced for sexual activity, inhibiting spermatogenesis in a negative feedback cycle. If spermatogenesis occurs too slowly inhibin declines and FSH is released in greater volumes.

Semen is the mixture of sperm and the secretions of the seminal vesicles, prostate and bulbourethral gland. On average the volume of sperm is between 2.5 and 5 mL, containing about 50 to 150 million sperm per mL. If the level of spermatozoa falls below 20 million per mL the male is likely to be infertile. An incredibly large number of sperm are required for reproduction because only a few are ever likely to reach the ovum. Further, the act of fertilization requires the combined enzymatic activity of several spermatozoa to digest the material that covers the ovum. Semen has an alkaline pH of between 7.2 and 7.6 that protects it from the acidic environment of urine and the vagina. The secretions of the prostate give it a milky appearance and the bulbourethral and seminal vesicle secretions give it a mucoid consistency, all providing protection and nutrients to the spermatozoa. Semen also contains an antibiotic called seminalplasmin that has the ability to destroy certain bacteria that may be present in the vagina, and could interfere with fertility.

Part Two: Sexual Response, Orgasm and Aphrodisiacs

The initial stage of the sexual response is called arousal. In women, arousal is usually dependent upon both tactile and psychological responses. Under appropriate conditions the tactile stimulation of the breasts and especially the clitoris results in widespread sexual arousal. Indications of arousal include the erection of the nipples and clitoris, the vascular engorgement of the vagina, and an increase in vaginal and cervical secretions. In men, arousal is identified with an

enlargement and stiffening of the penis, stimulated by psychological stimuli and especially the tactile stimulation of the penis. In both women and men arousal is mediated by parasympathetic impulses sent from the sacral spinal cord to the external genitalia. In men, this causes the release of nitric oxide that relaxes the vascular smooth muscle of the penis, allowing it to become engorged with blood. The bulbourethral glands then begin to secrete a small amount of mucus, discharged through the urethral orifice for lubrication during sexual activity. The parasympathetic reflex of the sacral spinal cord in women initiates vascular engorgement as well as lubrication, stimulating the cervix and Bartholin’s glands to secrete mucus.

The climax, or orgasm, is mediated by sympathetic impulses from the first and second lumbar vertebrae when stimulation reaches a maximum intensity. Just prior to orgasm in women, the breasts and clitoris become highly engorged with blood, muscle tension increases, and heart and respiratory rates become rapid. In men, the erectile tissue of the penis reaches maximum engorgement, and there is a complementary increase in muscle tension, heart rate and respiration. With orgasm, the rhythmic sympathetic impulses released by the spinal cord cause peristaltic contractions within the ducts in the testes, epididymides and seminal ducts, propelling the spermatozoa into the urethra. Simultaneous contractions of the prostate and seminal vesicles expel prostatic and seminal fluid into the urethra with the arriving spermatozoa, and these fluids mix with the bulbourethral secretions before being ejaculated by peristaltic contractions of the urethra.

The rhythmic sympathetic impulses of orgasm in women cause the perineal muscles to contract rhythmically, accompanied by the rhythmic contractions of the uterus and cervix. During orgasm, the cervix has been observed to rhythmically contract, opening and dipping down into the vaginal cavity several times, thereby enhancing the entry of sperm into the uterus. With orgasm, both men and women experience sensations of pleasure throughout the body, but these sensations typically decline after several seconds. With continued stimulation however some women can experience multiple orgasms. Men however are stated to

experience a period of time just after ejaculation called the refractory period in which a second orgasm and ejaculation cannot be experienced, which can vary from a few minutes to several hours in different individuals. Recent research has indicated however that some men do not experience a refractory period at all, which is a challenge to the assumption that it is physically impossible for a man to have multiple orgasms (Whipple and Komisaruk 1998). An ancient oriental technique used to prolong the sexual experience in men requires the clenching of the PC muscle just prior to ejaculation, inhibiting ejaculation but allowing men to continue the pleasurable sensations of sexual activity. While not exactly a multi-orgasmic experience, some advocates feel that when properly practiced this technique can allow a man to experience several “99%” orgasms without experiencing a refractory period.

Similar to men, some women appear to be able to ejaculate. Although long considered by the medical establishment to be a of kind urinary stress incontinence, recent research has shown that this is a totally normal response in some women. There is a series of intraurethral glands called Skene’s glands that encircle the urethra, and can release a clear or milky, non-viscous fluid upon orgasm (Zaviacic et al 2000). The tactile stimulation of the anterior vaginal wall in an area called the G-crest (‘G-spot’) and/or the clitoris, can relax the urethral sphincter and stimulate the Skene’s glands. The Skene’s glands appear to be homologous to the male prostate, and can eject a similar fluid. Female ejaculate however, has also been found to contain certain components of urine, even though the bladders of test subjects were drained prior to experimentation. This suggests that during orgasm in some women there is an alteration in urine excretion in the kidneys and the secretion of fluids from the bladder wall.

Aphrodisiacs

Aphrodisiacs, by definition, are substances that arouse the spirit of Aphrodite, the Greek goddess of love and sensuality. They are by nature, or rather because of human nature, a most varied collection of pleasing and sexually stimulating sense objects that appeal to each person in a

unique fashion. From sexy clothing to sensual fragrances, the function by which an aphrodisiac works is often a matter of association rather than the direct stimulation of libido. Aromatherapy is great way to set the mood, and essential oils such as Sandalwood, Musk, Ylang, Vanilla, Jasmine, Cinnamon, Patchouli, Rosewood, Nutmeg and Allspice are all considered to be aphrodisiac scents.

Aphrodisiacs, however, have a broader definition in Asian culture, the criteria encompassing therapies that support genitourinary, endocrine and nervous function. According to these systems of traditional healing, sexual function is an expression of overall vitality, just as the fruiting of a plant is dependent upon the strength of the plant to reproduce itself. If the health of the organism is weak sexual function is thus impaired. In these traditional systems of medicine, a healthy sexuality is synonymous with overall vitality. There are many complex systems of sexual healing in the Asian tradition, in which sex is engaged in not just for pleasure but as a way of healing disease.

Aphrodisiac therapy in herbal medicine borrows heavily form the Asian ideas of vitality. Thus, any herb that benefits the body by enhancing energy, dispelling fatigue, stimulating mental function and relaxing the body is, in one way or another, an aphrodisiac. In Ayurvedic medicine these medications are vajikarana rasayanas, supporting the function of the Shukla (men) and Artava (women) dhatus, and supporting the status of ojas. In Chinese medicine aphrodisiac herbs are usually those that support the Kidney Yin (women) and Yang (men). In some cases these herbs need to be combined with some kind of carrier (as in the concept of anupana in Ayurveda, such as milk or ghee), or are combined with other herbs to ensure they are properly assimilated (e.g. dipanapachana herbs to enhance digestion such as Jatiphala (Myristica fragrans) and Ela (Elettaria cardamomum)). This is especially the case for Yin supporting herbs in Chinese medicine, which are used therapeutically to reduce heat, and can adversely affect the Spleen Qi. In contrast, Yang restoratives are excessively warming, and may be contraindicated in cases of heat and inflammation. Both vajikarana rasayanas and Kidney restoratives are contraindicated in symptoms of congestion and autotoxicity, as they can feed these processes instead of the tissues they are being used to restore. Thus prior to the

implementation of any kind of aphrodisiac therapy a course of eliminative therapies are undertaken, along with therapies to enhance and strengthen the digestion (i.e. agni in Ayurveda, Spleen and Stomach in Chinese medicine).

Female aphrodisiacs Female aphrodisiacs in Chinese medicine are those that are orientated towards supporting the feminine or Yin essence of the body; although medicaments that support the Yang may also be used in a supportive role, they do not typically dominate as they may injure the feminine essence. Among the components of Yin in the body is Blood, which in women of reproductive age can naturally become deficient through the dynamics of regular menstruation. Thus Blood nourishing herbs are an important part of supporting female fertility, including Shu Di Huang (Rehmannia glutinosa), Dang Gui (Angelica sinensis), Dong Chong Xia Cao (Cordyceps), Bai Shao (Paeonia lactiflora), and Gou Qi Zi (Fructus lycium). Important botanicals that support the Yin of the Kidneys include Xi Yang Shen (Panax quinquefolium), Tian Men Dong (Asparagus cochinchinensis), Shi Hu (Dendrobium nobile), and Nu Zhen Zi (Ligustrum lucidum). Yang restoratives may also be used, but as mentioned only in a supportive role, or in conditions where a Yang deficiency syndrome predominates, including weakness of the lower back, coldness of the body and depression.

Female restoratives in Ayurvedic medicine are similar in many respects to those in Chinese medicine, but there is less of a distinction between those that support male and female reproductive function. Thus the nature of the aphrodisiac therapy undertaken is based on the specific symptoms and signs of the patient. Among the most celebrated female vajikarana rasayanas is Shatavari (Asparagus racemosa), another species in the Asparagus genus, and probably identical in effect to the Chinese species Asparagus cochinchinensis, which is used as a Yin restorative. In Sanskrit the name ‘Shatavari’ can be translated to mean “100 husbands,” referring to the sexual potency this herb is said to bring to women. Typically, the freshly powdered dried root is taken, 10-15 g decocted in milk with 2-3 g of Pippali (Piper longum) for 15-20 minutes, mixed with a teaspoon of ghee and a teaspoon of

jaggery, taken before meals at dawn and at dusk. Both Ayurveda and Chinese medicine counsel that both Shatavari and Tien Men Dong are very cooling herbs and are thus contraindicated in mucus congestion and poor digestion. Shatavari can be used to treat a variety of female reproductive disorders including infertility, cervical dysplasia, menorrhagia, gonorrhea, menopause, and breast milk insufficiency. It is also used in men as well to enhance sperm production, and improve sperm motility and morphology. Other applications for this herb include rheumatism, diarrhea, chronic fever, dry coughs, lung abscess, and dehydration. Other botanicals mentioned in Ayurvedic texts such as the Chakradatta and the Bhavaprakasha used in the treatment of female infertility include Bala (Sida cordifolia), Atibala (Abutilon indicum), Madhuka (Glycyrrhiza glabra), Nagakeshara (Mesua ferrea), Ashwagandha (Withania somnifera), Kumari (Aloe vera juice), Kurantaka (Barleria prionitis), and Kumudam (Nymphaea alba).

Another esteemed female aphrodisiac is Damiana (Turnera diffusa, T. aphrodisiaca), native to the southern U.S., Mexico, and Central America. Author Diana De Luca states in her book Botanica Erotica that Damiana was esteemed by the ancient Aztecs, considered to be second only to xocolatl (chocolate seed) for its health giving properties (1998, 29-30). If taken in fairly large amounts it has marked aphrodisiac properties in women and in some people can provoke a very mild marijuana-like euphoria that lasts about an hour or so. It is used in Western herbal medicine to treat frigidity, depression and sexual anxiety in women, and more generally in the treatment of atonic constipation, renal catarrh and bronchial congestion. Traditionally, Damiana was prepared by the Guaycura tribe of the Baja desert as a ritual herb, but according to legend, it had such profound aphrodisiac property that a Guaycura chief had to prohibit its usage (De Luca 1998, 30). Today a cordial prepared from the herb can be found in shops all over Mexico, where it is often packaged in bottles shaped like a pregnant woman, and marketed as an aphrodisiac.

A reasonable facsimile of the commercially produced cordial can be made as follows:

375 ml brandy 100 g fresh dried Damiana leaves 375 ml spring water 250 ml honey 10 ml Vanilla extract

Macerate Damiana in the Brandy for two weeks, and when complete press out marc, collect the tincture and soak the marc in the water for 3 days. Strain, discard the leaves from the water and combine the tincture with the water, mixing in the honey and vanilla extract. Pour into a clean bottle and let sit for 1 month in a dark cool location. Dose is one small sherry glass.

Another renowned aphrodisiac for women is chocolate (Theobroma cacao), which contains small amounts of N- oleolethanolamine and N-linoleoylethanolamine which inhibit anandamide hydrolysis in the brain, and act as cannabinoid mimics (Tytgat et al 2000). Researchers have also isolated other neuroactive chemicals in chocolate including tetrahydro-β-carbolines, serotonin and tryptamine biogenic amines (Herraiz 2000). Further evidence of the mood-altering effects of chocolate can be found in the epidemiological evidence, in which the consumption of chocolate is correlated with lower rates of suicide and violent crimes in populations that eat it on a regular basis. The Aztecs believed that chocolate was brought from paradise, and that great wisdom and power came from eating the fruit of the Cacao tree. The seeds of this tree are shaped similar to lima beans and are intensely bitter. Unfortunately, this useful herb is most often consumed with milk, lots of sugar, and a plethora of additives such as soy lecithin and artificial sweeteners that ends up making chocolate a rather unhealthy choice. As an alternative to these unhealthy products, chocoholics can make their own chocolate tea, prepared by mixing one heaping teaspoon of cocoa powder in a cup of hot water, with a ½ teaspoon of brown sugar or honey, a little cinnamon, and a 1/4 teaspoon of vanilla extract. There are now several companies that produce a 70% or higher content of cocao. Chocolate is also a good source of magnesium, and thus premenstrual cravings for chocolate can be indicative of a deficiency of this important mineral (Planells et al 1999). The antioxidant

effect of pure cacao is also quite good. There is presently a movement to use raw cacao seeds as a therapy.

Male aphrodisiacs Aphrodisiac therapy for men is a much more comprehensive subject in the Asian medical literature than is aphrodisiac therapy for women, primarily because of the way the ancients viewed the differences between male and female physiology. When ejaculation is too frequent this robs men of the vital energy needed to maintain the normal function of the body, and can result in deficiency diseases.

In both Chinese and Ayurvedic medicine there are many herbs and therapies recommended which enhance male sexual function. Both medical systems however maintain that men should avoid frequent ejaculatory sex. In the text the Qianjin Yifang, written by the great Chinese physician Sun Simiao, there are rules for the frequency of sexual intercourse. Sun Simiao states that between the ages of 20 and 29, men can engage in ejaculatory sex once every four days; between the ages of 30 and 39, once every eight days; between the ages of 40 and 49, once every 16 days; between the ages of 50 and 59, once every 20 days; and after the age of 60 no more than once each month. Ayurvedic medicine states that sexual activity should be limited during the summer and fall, but can be experienced with greater frequency during the winter and spring. It is probably wise however to never completely prohibit ejaculation, which has been shown to be a key component in maintaining proper prostatic health.

In Chinese medicine male aphrodisiacs are mostly derived from those that nourish and protect the Kidney Yang and Jing, including Lu Rong (Deer antler, deer antler velvet), Ge Jie (Gecko), Dong Chong Xia Cao (Cordyceps), Yin Yang Huo (Epimedium grandiflorum), Ba Ji Tian (Morinda officinalis), Bu Gu Zhi (Psoralea coryfolia), Yi Zhi Ren (Alpinia oxyphylla), and Du Zhong (Eucommia ulmoides). A variety of other perhaps more questionable Yang restoratives include Hai Gou Shen (Walrus genitals), Hai Ma (Seahorse) and Hai Shen (Sea cucumber), not because they are not efficacious, but because of issues of ecological

sustainability. Herbs that nourish the Kidney Yang might be combined with those that nourish Kidney Yin described under female aphrodisiacs, depending upon the indications.

In Ayurvedic medicine medicaments that support male sexual function are those that restore and support the Shukla dhatu and invigorate ojas. Beyond specific mediations however, texts such as the Bhavaprakasha recommend a variety of other activities conducive to promoting the sexual response, including certain foods, wine, music, massage, moonlight, and flower garlands. Among the different botanicals that are recommended are Ashwagandha (Withania somnifera), Kapikachu (Mucuna pruriens), Tila (Sesamum indicum), Amalaki (Emblica officinalis), Gokshura (Tribulus terrestris), Shatavari (Asparagus racemosa), Jatamamsi (Nardostachys jatamansi), Kushmanda (Benincasa hispida), Bala (Sida cordifolia), Atibala (Abutilon indicum), and Madhuka (Glycyrrhiza glabra). Other substances used to enhance male sexuality include Shilajitu (Mineral pitch), goat testicles, and tortoise eggs. Among the various Ayurvedic remedies Ashvagandha is among the best, its name meaning “smell of the horse,” indicating the sexual potency of a stallion. Dosage is between 10-15 grams of the freshly powdered root decocted in milk and taken with ghee and jaggery, twice daily. Although sometimes referred to as the “Indian Ginseng” Ashvagandha is a mild sedative and has a relaxing effect, making it particularly suitable to relax the body for extended periods of lovemaking. It is important to remember that sexual arousal is mediated by parasympathetic responses, and thus in conditions of emotional or mental stress the arousal state may be inhibited. Thus Ashvagandha is a useful treatment for both performance anxiety such as impotence and premature ejaculation.

In Western herbal medicine the concept of aphrodisiacs is underdeveloped, perhaps due to the relatively recent cultural understanding that sex was somehow “dirty,” and thus extensive commentaries on the subject were limited. Among the few herbs that have been discussed, perhaps none stands out like Milky Oats (Avena sativa), which should be distinguished from oatmeal or even oatstraw, referring specifically to the fresh milky seeds. The genus name for Oats is Avena, who, as Susun Weed recounts in

her book Healing Wise, was the daughter of Demeter, the goddess of fertility, and Poseidon, the God of the Sea. Within the English language there are many references to Oats in regard to sexual function, such as “feeling your oats,” or “sowing your oats,” and it appears that these references have their basis in fact. For improving libido the fresh milky seed tincture is best, 60 drops twice to three times daily. Milky Oat is also useful in any kind of nervous exhaustion, fatigue and to ameliorate withdrawal from addictive substances. It nourishes the entire body, enhances sexuality, improves memory, and builds endurance.

Another reputed male aphrodisiac in Western herbal medicine is Saw Palmetto (Serenoa serrulata); some practitioners believe that its aphrodisiac properties are suggested by the shape of the dried fruit, which rather resembles a testicle. Rather than a simple reproductive restorative, Saw Palmetto is a regulator of androgen synthesis, balancing testosterone production in both men and women. Thus, it is used in men to enhance testosterone production and improve sexual function. It also inhibits the synthesis of dihydrotestosterone which has been implicated in benign prostatic hypertrophy. In women, Saw Palmetto lowers androgen levels, making it a useful treatment for the symptoms of androgen excess such as male pattern hair growth, and for treating polycystic ovarian disease. Saw palmetto is an excellent remedy for many kinds of urinary problems in men, improving flow and relieving spasm. As this herb contains many sterols and fatty acids it is important to get fresh plant extracts to avoid rancidity. The dose for Saw Palmetto is between 2 and 4 mL of a 1:2 fresh plant or recently dried plant tincture.

Food as an aphrodisiac Certain foods have long been associated with sexual intimacy. The pomegranate for example, is considered in many cultures to be a symbol of fertility, and has been found to have estrogenic properties. With its sweet sticky juice dribbling down your chin just eating a pomegranate is a sensual experience! Another food that has long been associated with sex is Garlic. Garlic, of course, has many other properties, and has been shown to lower cholesterol and enhance immunity; but its ability to “heat” the genitalia has long been an established fact in many cultures. In Asia

for example, Garlic is a forbidden food for those engaged in disciplined meditative practices because it enhances the sexual drive and draws the mind away from more lofty pursuits. The same could be said for almost all of the onion family, including Jiu Zi (Allium tuberosum), an important Chinese remedy to fortify the Yang.

Certain kinds of animal products have long been associated with virility, and especially the genitalia of various animals. Although this might sound weird, it is important to remember that it wasn’t too long ago that our ancestors would eat every part of the animal that was killed, and not just the muscle tissue. Thus, the testicles and penis of beef, pork, goat, walrus and even dog are still consumed even today in various parts of the world as a regular part of the diet and to treat sexual dysfunction. Some aphrodisiac animal products are taken from animals that are endangered however, such as the rhinoceros and the sea horse, and should be avoided.

Oysters have long been considered an aphrodisiac food, perhaps because of their slippery texture and resemblance to the female genitalia. Geoducks are very popular among the Asian community as an aphrodisiac food, once again, probably because this bivalve resembles a penis. The velvet from deer antler has long been used as a Yang restorative in Chinese medicine, and has been shown to have some very interesting effects on immune and endocrine function, and is being used by athletes to enhance physical performance. The Gecko lizard is a premier sexual restorative in Chinese medicine and is included in many formulas used to treat male sexual dysfunction. Goat meat is considered to be a sexual restorative and “warming” to the genitalia, as is cock (eg, rooster), partridge, caviar, and salmon row. Even the humble legume has been considered to be an aphrodisiac! According to the ancient Ayurvedic text the Charaka Samhita, if a man consumes curried black gram (a type of legume) and basmati rice he “remains awake for the whole night with the urge for sexual intercourse.”

The following are some recipes that either have an aphrodisiac property, or by their sensual and delicious tastes, can help to put one “in the mood.” For more recipes please consult Diana De Luca’s sumptuous offerings in her

book Botanica Erotica, from which some of these recipes are derived or modified.

Savory foods

Ensalata- Tomato salad Sliced ripe tomatoes, laid on a plate with bocinccini cheese, dressed with olive oil, balsamic vinegar thinly sliced garlic and fresh crushed sweet basil. Serve with fresh baked Italian bread.

Pasta putanesca “Prostitute’s” pasta (called such because it was a quick meal that a woman could throw together between “business”) Spaghetti cooked to al dente, tossed with extra virgin olive oil, crushed red chilies and grated fresh parmesan cheese.

Tandoori chicken There are several good brands of tandoori paste on the market, and I suggest you buy these from your local gourmet shop rather than try to prepare this complex sauce yourself. In a large mixing bowl mix the tandoori paste with a few dollops of yogurt and a little water until the mixture is like a thick soup. Skin the chicken and marinate in the tandoori paste for 20 minutes. Barbecue over a low heat until tender. Serve with artichokes and garlic butter, saffron basmati rice and a nice Indian pale ale.

Steamed Chinese oysters On the half shell, cover the oysters with chopped green onions and cilantro, a little grated ginger, and a few drops each of toasted sesame oil and tamari. Place oysters face up in a vegetable steamer, and steam covered for a few minutes, or until the edges start to curl. Serve with warm sake.

Steamed Mussels For this dish to be good you have to use fresh mussels, bought on the day from your local fishmonger. Put them in the fridge when you get home and only take them out when you are ready to cook. Bring a large pot of salted water to boil and dump in the mussels. They are ready when all the shells have opened, in about six to eight minutes. Serve on the shell with garlic butter, fresh French bread and a nice Chardonnay.

Desserts

Parvati’s Delight 6 oz (squares) of unsweetened chocolate 1/4 cup tahini 1/2 cup honey 2 tbsp. clarified butter 2 tbsp. Ashvagandha powder, finely sieved 2 tbsp Shatavari powder, finely sieved 2 tsp. cinnamon powder, finely sieved

2 tsp. cardamom powder, finely sieved 1 tsp. nutmeg powder, finely sieved 1 tsp. clove powder, finely sieved 1 tsp. black pepper powder, finely sieved

Melt chocolate and clarified butter together. Add powders of Ashvagandha, Shatavari, cinnamon, cardamom, nutmeg, clove and black pepper, mix into chocolate/butter combination and simmer over a low heat for 10 minutes. Cool in pan until warm. Pour over honey in a separate bowl and mix well. Add tahini and mix. Place in well-greased ice cube trays and place in freezer for an hour. Using a knife, pry chocolates from the tray and cut each in half, rolling in powdered sugar. Place in tin, lined with wax paper and keep in fridge. Dose, 1-2 chocolates before love-making, with a small glass of red wine.

Crystal Flowers Egg white, beaten until foamy 7.5 ml water Edible flowers (Violet, Rose, Nasturtium, Vervain, Borage, Rose geranium, Fuschia)

Gather the flowers on a dry, sunny day. Gently clean off any dirt or insects with a water colour brush. Beat an egg until foamy and add the water. Moisten flower petals with the egg white mixture. Dust the blossoms with super fine granulated sugar. Shake off excess sugar and place the petals on waxed paper in a warm location to dry. Decorate your partner’s body with them and nibble them off.

Chocolate Cordial 125 ml brandy 250 ml cocoa syrup 5 ml vanilla extract

Mix well and let sit for 7 to 10 days. Serve over ice cream, dribbled over fresh strawberries, or use during foreplay.

Part Three: Seven Habits of Highly Infertile People

Modeled after the popular book by Stephen Covey, The Seven Habits of Highly Effective People, the following is an overview of seven important behaviours and lifestyle issues that can inhibit fertility.

Bad habits

Women Pregnant women have long been told that alcohol can affect the fetus, but now it appears that alcohol is just plain bad for women. Even moderate consumption, or 1-2 glasses of wine per week can increase prolactin levels and suppress ovulation (Emanuele et al 2002). The elevation of prolactin also occurs with the usage of antidepressants, analgesics, hallucinogens, and marijuana. Tobacco too, poses problems for women, and although no one knows the exact link, female smokers generally have decreased estrogen levels, poor cervical mucus, a higher risk of pelvic infection, and an increased incidence of ectopic pregnancy and miscarriage (Zavos 1989). Additionally, nicotine appears to be toxic to sperm, and thus smoking can interfere with fertility. Coffee is another vice, and women who consume one cup of brewed coffee a day are half as likely to conceive. Caffeine is also implicated in cyclic breast pain and fibrocystic breast disease.

Men Although moderate alcohol consumption appears not to pose any great risks for a man’s reproductive health, excessive alcohol consumption, the equivalent of 2-3 pints of beer per day can lead to poor sperm motility and poor libido. The ensuing damage to liver function also causes estrogen levels to rise and antagonize the activity of testosterone. Tobacco also poses certain risks, and about two-thirds of impotent men are smokers. Nicotine inhibits blood flow to the penis, and only 1-2 cigarettes will cause an immediate impairment of circulation (Zavos 1989). In men who smoke marijuana frequently there are typically lower testosterone levels, and poor sperm motility (De Celis et al 1996). Other drugs, such as cocaine and amphetamines inhibit parasympathetic activity and can result in premature ejaculation.

Stress In both men and women, stress can negatively affect sexual performance and fertility (Sheiner et al, 2002, 2003). With stress the activity of the hypothalamus is decreased,

resulting in diminished GnRH, FSH and LH secretion, and decreased levels of the gonadotropins such as estrogen, progesterone, and testosterone. Statistics suggest that about 5-10% of infertility is stress related. This problem obviously becomes compounded if drugs and alcohol are used as a coping mechanism.

Diet

Women Due to the unrealistic representation of feminine beauty in the media, eating disorders are gaining an increasing prevalence in our society. Most women, for example, consider their ideal weight about 10 lbs. under their actual ideal weight. These unrealistic expectations can result in anorexia nervosa and bulimia. Further, the effects of fad dieting and the resulting labile weight levels disrupt the delicate hormonal balance. Nutritional deficiency, common in many fad diets, may result in amenorrhea and anovulation. Whatever their size, a woman should ideally have no less than 25% body fat. This becomes especially important after menopause when the fat tissue becomes a major source of estrogen, preventing bone loss and ensuring the skin and mucus membranes stay healthy. That said, obesity is not any better either, and obese women are more likely to suffer from the effects of excess androgens, leading to male pattern hair growth and polycystic ovarian disease.

Men Men typically scoff at dieting and tend to do the opposite and eat way too much, especially animal fats and proteins, which leads to obesity. As mentioned already, fat cells are a site of estrogen synthesis, and excess fat can convert stored testosterone into estrogen, leading to gynecomastia (an increase in breast size) and a diminishment of male secondary sexual characteristics. Obesity can also interfere with the sexual act, creating discomfort for the partner, inhibiting suitable penetration and sufficient stimulation. Underweight men, however, are more likely to experience a decrease in libido and decreased sperm counts.

In both men and women, there are several factors in the diet that can negatively affect fertility. Hormones in animal products can interfere with hormonal balance, and pesticides and herbicides found on fruit and vegetables can place a strain on liver detoxification, and are a source of endocrinal disrupters such as xenoestrogens. Plastic bottles are a common source of these xenoestrogens and are now considered a big cause for many health issues. Phosphates, commonly found in soft drinks, can also inhibit fertility. And, even though regular garden peas are a good food they contain a chemical called m-xylohydroquinone that has a weak contraceptive activity when consumed in excess (Farnsworth et al 1975).

Exercise

Women Exercise is certainly an important and healthful regimen for everyone at all ages, but in some circumstances can negatively impact reproductive function. Women who exercise vigorously during menstruation have a higher risk of endometriosis, possibly because of retrograde flow enhanced by aerobic exercise, and are more likely to experience delayed menstruation, amenorrhea, and erratic ovulation. In joggers, menstrual disorders increase proportionally with the distance run, and women who run more than 80 km a week have a higher incidence of menstrual irregularities. Further, because excessive exercise places stress upon the bones as well, such women are more likely to experience low bone density and stress fractures due to insufficient hormone secretion. In many respects, anaerobic exercise coupled with a moderate or light aerobic workout, is the best recipe for health.

Men There appears to be little problem with men and exercise, except with the use of anabolic steroids. The regular use of such compounds leads to long term male infertility by inhibiting GnRH secretion.

Personal Hygiene

Women “Cleanliness is next to godliness” the saying goes, but some kinds of hygiene can negatively affect fertility. Women who douche regularly for example, end up disrupting the delicate ecology of the vagina, leading to an increased risk of infection and inflammation. Some factors, such as clothing, can also enhance the risk of infection. Synthetic fibers for example, as well as tight clothing around the vagina, facilitate the growth of Candida, leading to yeast infections. Vinyl seats too can facilitate this, and women who are driving long distances or sit on vinyl seats at work would do well to sit on a towel to encourage air circulation and absorb moisture.

Sexual intercourse without sufficient lubrication can lead to abrasion and thereby facilitate yeast growth. Thus it is recommended that high quality food grade oils such as olive, coconut and almond oil be used as sexual lubricants (although these should be avoided with condom use as they can impair the integrity of the latex). The retention of urine before or after sex can increase the likelihood of bacterial or yeast infection. Even with lubricants the urethra may get aggravated during sexual intercourse and urinating before and after sex washes out the urethra and decreases the likelihood of infection.

Tampons, although a convenient method of absorbingmenstrual flow, can pose some serious health risks. In some tampons there may be toxic residues from organochlorines and dioxins used in the bleaching process, and other toxic compounds such as heavy metals, surfactants, waxes and hydrocarbons have been found. Toxic shock syndrome (TSS) is an infection from Staphylococcus aureus, and is more likely to be a factor in tampons made from synthetic fibers, or super absorbent tampons that are left in more than 12 hours. Further, there is a link between long term usage of tampons and endometriosis. Women should at least use natural fiber tampons for a maximum of 4-6 hours, and not for the entire duration of menstruation.

Toilet habits, things we thought we learned before kindergarten, can also affect reproductive health. It is most

important that women do not wipe from back to front after a bowel movement, as this can lead to bacterial infection from fecal contamination. Further, the anal region should be cleaned thoroughly, preferably with water, after bowel movements to avoid cross contamination.

Men The testicles are contained within the scrotum outside the pelvic cavity in order to maintain a lower temperature than the body, and any increase in temperature will have a negative impact upon sperm production. Things that increase scrotal temperature include tight underwear or pants, sitting for extended periods of time, crossing one’s legs, hot baths, and saunas. Also, laptops, especially the newer ones with their faster processor speeds tend to get quite warm and should be used in conjunction with some kind of insulating surface if used on one’s lap.

Anal intercourse poses another risk for men, and although the urethra within the penis is longer than a females and resists infection, fecal material can become lodged in the urethra and promote infection. Thus, condoms should always be used, for this reason as well as to prevent sexually transmitted diseases.

In men that are not circumcised care should be taken to clean the glans every so often, gently pulling back the foreskin. The yellowish creamy material that can be found under the foreskin, called smegma, is not an indication of infection, but a natural mucosal secretion that nourishes and protects the glans. An alternate method to cleanse the glans in non circumcised men, especially if there is any kind of infection or inflammation, is to do a penis soak, in which the penis is immersed in a decoction of an antimicrobial herb such as Echinacea (Echinacea angustifolia root) or Goldenseal (Hydrastis canadensis root), best facilitated by using a glass or a jar.

Sexual Habits

While oral sex is certainly an important aspect of some couples sexual experience, a few guidelines should be followed in order to maximize fertility. First, the ingestion of the partner’s sperm by the woman may allow for the production of antibodies to the sperm, a kind of vaccination that should be avoided if child bearing is desired. Folklore states that this is a form of birth control that sectors of some cultures employed as a form of birth control. It is not considered a reliable form of birth control. The antibody issue may also happen with semen that is deposited rectally.

Men should avoid cunnilingus after intercourse to prevent autoimmune reactions to their own sperm by accidentally swallowing semen.

There are many sexual lubricants on the market, and almost all are made from petroleum products. It appears that many lubricants can interfere with the sperm’s survival and the cervical mucus. Thus one should use pure, edible oils such as olive oil, clarified butter and unrefined sesame oil, if needed. The use of such oils is reflected in Ayurvedic medicine in which the genitalia of both men and women should be massaged with nourishing oils both before and after sexual intercourse. Using natural oils, unfortunately, is not recommended with synthetic condoms as they can interfere with the integrity of the condom.

Ejaculation frequency is a subject that is perhaps unfamiliar in the West, but guidelines for ejaculation frequency are an important part of Eastern sexology. At the least, it is important for a man to ejaculate once a month if he is not following a strict spiritual discipline that can transmute the energy contained within the semen and use it for spiritual purposes. But perhaps more importantly, are limitations on how often a man ejaculates. A general rule is that a man should not ejaculate more than every other day in order to maintain maximum potency, as it takes at least 48 hours for the sperm to be completely regenerated. Again this has been employed as a method of birth control in some cultures.

The traditional sexual practices of China and India advocate semen retention, complexed with certain spiritual techniques. This technique requires that just prior to orgasm the man stops and contracts the perineum rapidly and holds his breath, squeezing the Jing or ojas up to higher energy centers. When done correctly a rushing sensation that travels up the spine may be felt, accompanied by a sensation of flashing of light in the head. Using this technique a man can have several “99% orgasms” all night long without actually ejaculating, thereby ensuring that his partner is completely satisfied. There are many books on this subject, such as Stephen Chang’s The Tao of Sex and Mantak Chia’s Taoist Secrets of Love: Cultivating Male Sexual Energy. Traditional Chinese medicine suggests that a man should ejaculate according to his age. The desired ejaculation frequency is determined multiplying a man’s age by 0.2. Thus, a 30 year old man may ejaculate every 6 days. Men should also avoid masturbating to the point of ejaculation to maintain maximum virility – nonetheless, habitual arousal (e.g. pornography) without release will likely cause other problems, including testicular and glandular congestion (see chronic nonbacterial prostatitis, below). In regard to the frequency of female orgasm however there appears to be no limitations according to the traditional literature, but there are still many exercises and techniques that can be utilized to enhance female sexuality, as described in Mantak and Maneewan Chia’s Healing Love Through the Tao: Cultivating Female Sexual Energy.

If we recall the activity of the cervix during the female orgasm, fertility is best served if the man can time his orgasm with the woman’s. This will result in the deposited sperm being ‘scooped up’ into the uterus by the descending contractions of the cervix. Sexual positions that are traditionally considered to be the best for promoting conception are those in which the man is in the superior position. Post coital routines such as the woman lying with her knees up or doing the bicycle are probably of little effectiveness, and the best technique to enhance conception is relaxation and sleep.

The traditional Asian literature also suggests there are specific methods than can be used to secure the sex of the child. One Ayurvedic technique for example, requires the woman to use the fresh juice of the Banyan tree (Ficus

religiosa), and apply it as a nasya (nasal administration) to the nostril that corresponds with the desired sex of the child, i.e. the right nostril for boys, and the left nostril for girls (please refer to the course entitled Traditional Ayurvedic Medicine). Alternately, while the man and woman are making love they can position themselves (face to face), so that the nostrils of the desired sex are open, and the other nostrils that correlate to the undesired sex are closed. Thus if a female child is desired, the man and woman are face to face with their noses together while making love up until and just after the point of orgasm, the man pressing the right side of his nose up against the woman’s right nostril, thereby blocking the right nostrils in both, and leaving them with only the left nostrils open. The activation of the left nostril awakens the flow of prana within the ida nadi, the psychospiritual channel that corresponds to the feminine, which promotes the chances of conceiving a female child. For a male child, the procedure would be reversed.

Arousal techniques, specifically those that involve alcohol or marijuana may negatively affect fertility and should be avoided. Flavoured jellies as well inhibit fertility, interfering with sperm motility and cervical secretions. Sexual intercourse in water, such as in a hot tub or shower is not suggested, as the water may dilute the semen and the heat of these environments will negatively affect sperm production.

Work Habits

For the most part, workaholics are admired in our society. They are the achievers, the go-getters and the perfectionists. Unfortunately, the high stress of living such a life can decrease libido by suppressing the parasympathetic response. Maximum virility involves leading a balanced lifestyle, and experiencing the difference between work and play.

There are also occupational hazards in the workplace that can negatively affect fertility such as the exposure to chemicals. To date, over 60,000 different industrial pollutants have been found to exist in the environment, and

these are often concentrated in the work place. Only three of these however, have been absolutely linked with infertility, including lead (still found in some fuels), dibromochloropropane (DCBP, a pesticide), and ethyl oxide (a pharmaceutical solvent). Other chemicals that have been established as agents that impair fertility include mercury, chlordecone (a pesticide), vinyl chloride, benzene (found in a variety of petroleum-based solvents, paints, stains and varnishes, as well as in many household and personal care products), manganese (used in steel, glass, ink, ceramics, paints, welding rods, rubber and wood preservatives), and hormones used in the agricultural industry. The bulk of these pollutants have not undergone adequate testing, and nor have they been tested in combination. Thus we are in the process of conducting a huge experiment upon ourselves that is spinning rapidly out of control. Female healthcare workers, and especially dentists, dental hygienists and dental assistants are at particular risk by being exposed to nitrous oxide and heavy metals such as mercury. Statistically, these workers have been found to have a 60% drop in conception rates, and at least 50% of them have an increased risk of miscarriage. Other negative factors in the workplace are video display terminals, and frequent users have a suspected increase in risk of miscarriage.

Part Four: Female Sexual Dysfunction and Holistic Treatment

Menorrhagia

Menorrhagia refers to excessive menstrual bleeding, and can be of two types: functional, which is heavy bleeding during an otherwise normal menstrual cycle; and secondary, which is heavy bleeding due to some other clinically identifiable cause, usually the result of uterine fibroids. Analyzing the case history, and performing pulse, tongue, and iris examination however should investigate any kind of irregular bleeding. If no cause is ascertained a laparoscopy, D&C (dilatation and curettage), or

hysteroscopy may be required to determine the nature of the bleeding.

It is important to note that a practitioner can not rely completely on asking the patient if they feel their menstrual flow is heavy or light. This is a very subjective assessment. It has been shown that 40% of women with excessive menstruation feel it is normal, moderate or even scanty; while 14% of those with low menstruation feel they are heavy.1

Functional menorrhagia is in some way related to a prostaglandin imbalance, usually PGI2, leading to reduced clotting and dilated blood vessels during menstruation. It is often related to relative estrogen excess and/or a diet high in saturated fat (which facilitates the growth of bacteria in the lumen of the intestine that deconjugates conjugated estrogens in the bile). The diagnosis of functional menorrhagia requires that hormonal causes are weeded out, best assessed by using a symptothermal chart to assess for ovulation, or any other method, such salivary testing. Using such a chart a woman records her basal body temperature first thing in the morning, before she gets out of bed. When ovulation occurs during mid-cycle there should be a noticeable rise in body temperature, and if there isn’t, this Female Formula may indicate that ovulation has not occurred, suggesting a Dong Quai Angelica sinensis progesterone deficiency. (Trickey 1998, 174-79; Berkow 172mg 1805-06) Blue Cohosh Caulophyllum thalictroides 57mg Black Cohosh Cimicifuga Using botanicals, the treatment of menorrhagia involves the racemosa 57mg use of astringents to check hemorrhaging and uterine tonics Blessed Thistle Centaurea to promote the tone of the uterus. benedicta 57mg Cramp Bark Viburnum opulus 57mg Useful hemostatics include Beth root (Trillium erectum), Yarrow (Achillea millefolium), Tienchi Ginseng (Panax Dosage 2 - 3 Tablets; bid-tid notoginseng), Shepherd’s Purse (Capsella bursa pastoris), Lady’s Mantle (Alchemilla vulgaris), and Cranesbill (Geranium maculatum).

Important uterine tonics include Dang gui (Angelica sinensis), False Unicorn root (Chamaelirium luteum), Raspberry leaf (Rubus spp.), Blue Cohosh (Caulophyllum

1 Hallberg L, Hogdahl AM, Nilsson L, Rybo G. Menstrual blood loss-a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966;45:320-351.

thalictroides), Squaw Vine (Mitchella repens), and True Unicorn root (Aletris farinosa).

Hepatics, or ‘liver’ herbs are also an important adjunct, helping to relieving the pelvic congestion that often underlies this condition, as well the conjugation and elimination of excess estrogen. Hepatics include Oregon Grape root (Mahonia aquifolium), Barberry (Berberis vulgaris), Yellowdock root (Rumex crispus), Dandelion root (Taraxacum officinalis), and Stone root (Collinsonia canadensis).

Important nutritional supplements include iron (20 mg/day), vitamin A (30,000 IU/daily), oils rich in EPA (3-5 g daily) as they will compete with PGI production, vitamin Suggested Program 2 C (to bowel tolerance), and bioflavonoids such as quercitin. Femaherb: 2 tab – bid Cinnamon Homaccord (Heel): Useful foods to emphasize in the diet are fermented 8 – 10 drops bid or as needed legumes, leafy green vegetables, increased fiber (to for bleeding when menstruating improve estrogen clearance), and organic, free-range up to every 15 min. BEVC 2 tablets bid animal products. Due to PGI2 interaction it is suggested to Fish or Krill Oil keep archhidonic acid low in diet (as found in red meat fat and shell fish), while increasing levels of fish oils. If iron is Iron if needed low of course heme iron as found in red meat is easiest source for absorption.

If bowel function appears to be impaired the addition of Lactobaccilus and Bifido bacteria to the regimen may be of benefit, as are herbs containing long-chain polysaccharides that are fermented by beneficial bacteria, such as Burdock root (Arctium lappa), Elecampane root (Inula helenium), and Slippery Elm bark (Ulmus fulva).

Homeopathic Cinnamon is quite useful to reduce excessive bleeding. If fibroids are involved Cordyceps is beneficial.

Metrorrhagia

Metrorrhagia or dysfunctional uterine bleeding (DUB), can be the result of several causes. Endometrial hyperplasia is a possible cause, the result of excessive estrogen and deficient progesterone secretion, resulting in an excessive

stimulation of endometrial cells. Uterine cancer is a more common cause of DUB in postmenopausal women over 40. The aggravation of cervical or endometrial polyps after sexual intercourse or medical examination is another cause of DUB. Cervical dysplasia may also be the cause of metrorrhagia, and is a precancerous change in the cervical tissue, with bleeding indicative of a progression of dysplastic changes. Cervicitis is another possible cause of DUB, and is often secondary to chronic pelvic inflammation. Sometimes the bleeding is the result of cervical abnormalities such as cervical eversion, which can be congenital or the result of chronic infections. Other possible causes include ovarian cysts, oral contraceptive use, and excessive exercise. (Trickey 1998, 192-97; Berkow 1807-08)

If the above causes have been ruled out, the treatment of DUB is similar to menorrhagia. In many cases of metrorrhagia ovulation is sporadic or absent, suggesting a progesterone deficiency. Progesterone and estrogen maintain the delicate balance of the menstrual cycle, and when progesterone is deficient there is nothing to counter the estrogenic effects. Without the progesterogenic effects the endometrium proliferates, impairing circulation within the endometrium and resulting in endometrial fragility.

The holistic treatment for metrorrhagia is similar to that of menorrhagia. Besides using the therapies already mentioned to astringe the tissues, tone the uterus and enhance liver function, the treatment for DUB involves ovulatory support, often with a focus to treat underlying issues of emotional stress common to this condition. Thus, progesterogenics such as Chasteberry (Vitex agnus castus) and White Peony (Paeonia lactiflora) are taken throughout the cycle, including menstruation. Additional support includes the use of relaxing nervines such as Ashvagandha (Withania somnifera), St. John’s Wort (Hypericum perforatum), Vervain (Verbena officinalis), and Motherwort (Leonorus cardiaca).

Useful supplements include vitamin C (to bowel tolerance), and vitamin B6 (50-150 mg b.i.d., 7-10 days before the period, taken with vitamin B complex, 100 mg daily). Iron (20 mg daily) is also important, as are the inclusion of lipotropic factors such as inositol and

phosphatidyl choline to enhance the hepatic clearance of estrogens.

Amenorrhea

Amenorrhea refers to the absence of menstruation and is of two types: primary amenorrhea, in which menstruation has not begun by late puberty, even if other signs of physical maturation are present; and secondary amenorrhea, which is the cessation of menstruation for more than 3 cycles in a post-pubescent woman. There are many possible causes of amenorrhea, including:

• intrauterine adhesions • cervical stenosis (narrowing) • obstruction of menstrual flow • hypothalamic dysfunction • GnRH inhibition • weight loss • rigorous exercise • severe chronic illness • drugs such as the phenothiazines (antiemetics), antihypertensives and antipsychotics • after using oral contraceptives • polycystic ovarian disease • breast feeding • hypothyroid conditions (leads to decreased SHBG and thus increased estrogen) • hyperthyroid (conversion of androgens to estrogens) • excessive glucocorticoids (e.g. Cushing's syndrome) • premature ovarian failure (perhaps an autoimmune disease) • ovarian damage or destruction (from ischemia) (Trickey 1998, 209-212; Berkow 1992, 1798, 1802)

The most common causes of amenorrhea are hyperprolactinemia, and a relative androgen excess. Hyperprolactinemia is a condition in which there are increased levels of prolactin in the bloodstream. The signs and symptoms include galactorrhea (breast milk production), menstrual irregularities, decreased GnRH and LH levels, elevated androgens (with decreased 5-alpha- reductase activity), decreased SHBG, and decreased bone

density. Possible causes of hyperprolactinemia include pituitary tumors, hypothyroidism, prolonged stress, excessive breast stimulation (Chinese "Deer" exercises), excessive exercise, drugs (phenothiazines, dopamine antagonists, antihypertensives, antiulcer drugs, estrogen oral contraceptives, opiates, cocaine) and alcohol (especially beer because of the Hops, which is a galactagogue). (Trickey 1998, 213-216)

The primary treatment of hyperprolactinemia involves the usage of progesterogenic botanicals such as Chasteberry (Vitex agnus castus), which has a dopaminergic activity, and other herbs to support the hypothalamic-pituitary axis such as Peony root (Paeonia lactiflora), Rehmannia (Rehmannia glutinosa), and Licorice root (Glycyrrhiza glabra).

The supplementation of zinc and vitamin B6 are useful as both are cofactors in dopamine synthesis and can be included in the treatment. Important also is weeding through the various medications that could be causing this condition, as well as eliminating alcohol from the diet. Other lifestyle regimens that need to be addressed are stress management skills and physical exercise.

Androgen excess is another possible cause of amenorrhea, and describes a condition in which there are higher than normal levels of circulating androgens. Possible causes include PCOD (polycystic ovarian disease), an androgen- secreting adenocarcinoma of the adrenal gland, adrenal hyperplasia, steroidal drugs (synthetic progesterone, cortisone), post-menopause, and obesity. The signs and symptoms of androgenization include hirsutism, alopecia, Amenorrhea with Hormonal acne, and elevated blood pressure. Other, rarer symptoms Issues include the deepening of the voice, clitoral enlargement, Caulophyllum 2 prts and decreased breast size. Laboratory evidence will Artemisia vulgaris 2 prts typically show elevated serum testosterone and DHEA. Vitex agnus-castus 1 prt Some cases of androgenization are the result of an increased sensitivity to androgens rather than an androgen Dosage: 2 ml; TID until start of Menses excess, and thus will not show up with lab tests. (Trickey 1998, 217-219; Berkow 1992, 1800)

The treatment of androgenization is difficult, and the primary thrust of the treatment is symptomatic, with the attention being placed upon the cause or causes. Important

botanicals are those that nurture and enhance the “feminine essence” such as Peony root (Paeonia lactiflora) and Licorice (Glycyrrhiza glabra), both of which have been shown to increase the enzymatic conversion of testosterone to less potent androgens. Phytoestrogens too, such as Red Clover blossoms (Trifolium pratense), True Unicorn root (Aletris farinosa), and Black Cohosh (Cimicifuga racemosa) are important as they increase the levels of SHBG that deactivate androgens. Especially important are herbs that have the ability to competitively inhibit androgenic activity, such as Damiana (Turnera diffusa), Saw Palmetto (Serenoa serrulata), and Sarsaparilla (Smilax spp.).

At Wild Rose Clinic we usually use Femaherb 2-3 tablets, BID.

Diet: animal products and saturated fat should be decreased, replaced by increased fiber, fermented legumes, and whole foods. Additionally, the importance of treating obesity should not be underestimated. The treatment of this condition is truly a challenge, complexed with the fact that herbal therapies are slow to take effect in androgenization. The treatment of androgenization is also addressed later in this section under ovarian cysts.

Dysmenorrhea

Dysmenorrhea refers to the uncoordinated contractions of the uterus just before and during menstruation, resulting in Suggested Program a decreased volume of blood flow through the uterus and Femaherb: 2 tab – bid - tid the resultant pain and cramping. Typically the pain BEVC 2 tablets bid experienced is dull, with a sense of pelvic heaviness or Krill Oil: 1 cap bid congestion. There may also be symptoms of fatigue, bowel Cal/mag : 300 mg/150 mg bid irregularity, shivering, sweating, leg pain, nausea and Ginger root tea Tissue salt Mag phos tid vomiting, faintness, and mood swings. 3 yin point: finger pressure daily during month for 2 – 5 Primary dysmenorrhea is common in young women and min and several times daily rare after childbirth, whereas the usual onset of secondary during cramps dysmenorrhea is in the 30's, or after childbirth. The most common cause for primary dysmenorrhea is an eicosanoid imbalance, with excessively high levels of PGE2 and PGF2, and in severe cases, high levels of the leukotrienes LTC4

and LTD4. The usage of oral contraceptives seems to reduce the symptoms, which suggests a relative estrogen excess and a progesterone deficiency. Secondary dysmenorrhea is most often associated with other gynecological conditions such as uterine inflammation, fibroids, endometriosis, pelvic inflammatory disease (PID), and occurs with premenstrual syndrome (PMS). In secondary dysmenorrhea, the underlying cause for the pain, such as fibroids or PID, must be resolved. (Trickey 1998, 223-26; Berkow 1992, 1792-93)

The treatment for both primary and secondary dysmenorrhea is essentially the same: relaxing the uterine muscle, altering the eicosanoid imbalance and reducing the inflammatory cascade, enhancing uterine circulation, regulating hormonal imbalance, and correcting liver function.

Uterine tonics are herbs that regulate the muscular activity of the uterus, making the contractions more regular and efficient. Examples of uterine tonics include False Unicorn root (Chamaelirium luteum), True Unicorn root (Aletris farinosa), Blue Cohosh (Caulophyllum thalictroides), Dang gui (Angelica sinensis), and Raspberry leaf (Rubus idaeus).

Antispasmodics are used before or at the first signs of pain, taken several days before the beginning of the period. Useful antispasmodics include Black Cohosh (Cimicifuga 3 Yin point is an acupuncture point, 4 finger width up from racemosa), Cramp bark (Viburnum opulus), Wild Yam inside ankle on both sides (Dioscorea villosa), and Parsley root (Petroselenum crispum).

Emmenagogues are herbs that increase the strength of uterine contractions, especially indicated in cases of pelvic congestion, dull cramping pain and a slow starting period. Examples of emmenagogues include Mugwort (Artemisia vulgaris), Rue (Ruta graveolens), Tansy (Tanacetum vulgare), Cotton root (Gossypium herbaceum), and Pennyroyal (Mentha pulegium).

Circulatory stimulants are an important aspect in the treatment of dysmenorrhea to enhance uterine circulation. Circulatory stimulants include Ginger root (Zingiber officinalis), Prickly Ash (Zanthoxylum americanum), Cinnamon bark (Cinnamomum cassia), and Cayenne pods

(Capsicum spp.). Circulatory stimulants are often included in a formula simply to enhance the activity of the other herbs in the formula.

Relaxing nervines can be an important aspect of treatment, especially if anxiety or emotional lability is part of the symptom picture. Useful relaxing nervines include Valerian (Valeriana officinalis), Vervain (Verbena officinalis), and Chamomile (Matricaria recutita). For more severe symptoms as well as pain, the use of anodynes and sedatives such as Pasque flower (Anenome occidentalis), Jamaican Dogwood (Piscidia erythrina), and California Poppy (Eschscholzia californica) may be necessary.

Hormonal amphoterics are botancials that appear to act upon the hypothalamic-pituitary axis or otherwise regulate hormonal levels. Some herbs such as Peony root (Paeonia lactiflora) and Chasteberry (Vitex agnus castus) appear to enhance progesterone levels, whereas herbs such as Red Clover (Trifolium pratense) compete with estrogen- binding, leading to a down-regulation in estrogenic activity. Vervain (Verbena officinalis) has a relaxing nervine property, is a bitter cholagogue and displays an amphoteric activity upon hormonal levels similar to Paeonia and Vitex.

Liver support is an important aspect in treatment, and is especially indicated in pelvic congestion, as well as premenstrual depression and irritability. Although the mechanism of action is not entirely clear, using hepatics such as Barberry (Berberis vulgaris) and Yellowdock root (Rumex crispus), as well as pelvic decongestants such as Yarrow (Achillea millefolium) and White Dead Nettle (Lamium album), relieve symptoms of pelvic heaviness and pain, perhaps by increasing the metabolism and elimination of estrogens, as well as relieving portal congestion. Although cholagogues that enhance bile synthesis and secretion can relieve the constipation that can accompany dysmenorrhea, sometimes the additional usage of aperients such as the Triphala, Rheum and Rhamnus is helpful.

One formula particularly useful in the symptomatic treatment of dysmenorrhea is Hayden’s Viburnum Compound:

Black Haw (Viburnum prunifolium) 6 parts Cramp Bark (Viburnum opulus) 4 parts Beth root (Trillium erectum) 4 parts Clove (Eugenia caryophyllus) 4 parts Cinnamon bark (Cinnamomum cassia) 3 parts Orange peel (Citrus reticulata) 2 parts Wild Yam (Dioscorea villosa) 2 parts Skullcap (Scutellaria lateriflora) 1 parts

Coarsely grind herbs, mix together, and add enough alcohol to make a 1:4 tincture, macerating for 2 weeks, or making a percolation. Add 1 part simple syrup to the strained tincture to bring the strength to 1:5. Dosage is 5-15 mL, taken 3-4 times daily for severe cramping.

Useful supplements to inhibit the inflammatory cascade includes oils rich in GLA such as evening primrose oil, black currant oil, borage oil, flax oil, and hemp oil, and oils rich in EPA such as salmon and halibut oil. There are some herbs as well that can help to inhibit inflammation, including Turmeric (Curcuma longa) and Feverfew (Tanacetum parthenium). Calcium and magnesium supplementation are also useful treatments to relieve uterine spasm, 800-1000 mg of each, on a daily basis.

Dietary changes are an important aspect in the treatment of dysmenorrhea, with an emphasis upon whole grains, cold water fish, and leafy green vegetables, and the avoidance of cold and heavy foods such as dairy, flour, and sweets. Topically, castor can be rubbed into the lower abdomen and back, followed by the application of heat using an electric blanket, hot water bottle, or hot shower. Massage can be helpful too, and some women find that orgasm seems to help to relieve the pain of dysmenorrhea, perhaps by coordinating uterine contraction.

Leucorrhea and vaginitis

Leucorrhea is a whitish-yellow creamy discharge that can be a symptom of non-specific vaginitis (inflammation of the vagina), trichomoniasis, yeast infections, gardnerella, gonorrhea, or chlamydia. Not all whitish or creamy discharges are indicative of a problem however, and the ‘egg-white’ secretions that occur during the ovulatory phase are an indication of fertility. Changes that occur to

the normal secretions of the vagina, including the consistency, colour and odour, may indicate uterine irritation, inflammation, or infection.

Vaginitis refers to a non-specific irritation and inflammation of the vagina with burning and irritation, sometimes with discharge, in which no specific pathogenic agent can be identified. The underlying mechanism is often a deficiency of the bacteria that act upon the vaginal secretions to make the vagina slightly acidic. The intensity of vaginal secretions typically reaches a peak during ovulation, and gradually decreases during the luteal phase and during menopause. Thus, the susceptibility to vaginitis increases late in the luteal phase just before menstruation, and also during menopause when vaginal secretions naturally diminish.

Other factors can negatively affect the pH of the vagina, including antibiotics, diabetes, pregnancy, frequent douching, and a diet high in refined carbohydrates. Factors that promote the irritation of the vagina include sensitivities or allergies to sexual lubricants, topical contraceptives and scented hygiene products, as well as frequent or unlubricated sexual intercourse. Hygiene is an important issue, Synthetic fibers, tight clothing around the vagina and sitting for long periods on vinyl seats (as in a long car trip) all can facilitate the growth of micro-organisms such as Candida, leading to yeast infections and vaginitis. Poor toilet habits (i.e. wiping back to front after a BM) can also lead to vaginal infection.

Candida NSV Trichomonas Gonorrhea Herpes Clamydia Keynote Itching Odor Odor and itching Asymptomatic Vesicles or Asymptomatic symptom(s) or cervicitis ulcers Discharge pH <4.5 >4.5 >5.0 <4.5 <4.5 <4.5 Odor None Fishy/amines May be fishy None None None Appearance Curdy, Gray, Greenish yellow, Mucopurulent None None adherent, scant homogeneous frothy cervicitis to thick Pelvic Adherent Unremarkable May show Cervical Small, multiple Unremarkable or examination white patches petechial lesions discharge; may vesicles or may show signs with an on cervix or have adenexal ulcers on cervix of pelvic erythematous vagina mucosa; tenderness inflammatory border a "strawberry disease cervix" Microscopic Mycelia (10% "Clue cells"; Motile, Many WBCs Unremarkable Unremarkable examination KOH) few white blood flagellated with gram- cells (WBCs) organisms; few negative WBCs intracellular diplococci Culture Sauerbaud CNAF Diamond Thayer-Martin Live cell Live cell or media antibody test

NSV, Nonspecific vaginitis.

Diagnostic differentiation of common causes of infectious vaginitis

Trichomoniasis Trichomoniasis is caused by Trichomonas vaginalis, a protozoon found in roughly 65% of women, and is responsible for up to 30% of all cases of vaginitis. Characteristic symptoms include itching, burning and a thin pale yellow to greenish malodorous discharge. With acute inflammation there may be “strawberry” colored spots in the mucosa. Symptoms often appear after menses. As many women are asymptomatic carriers for this protozoa, the manifestation of symptoms are often related to other causes, such as a secondary vaginal infection, emotional stress, and lowered resistance and immunity. Sexual partners may also be affected and thus treatment should be to both the woman and her partner to avoid a cycle of reinfection. (Berkow 1992, 1786-88)

Vaginal candidiasis Vaginal candidiasis, or a yeast infection, is an overgrowth of the fungus Candida albicans, a naturally occurring microbe in the vagina. The infection may be localized in the vagina, but is commonly a reflection of a systemic yeast infection. Both within the vagina and in the gut Candida is kept in check by the Lactobacillus bacteria, and in the vagina specifically by the relatively low pH. The symptoms of a yeast infection can range from mild chronic irritation to a thick white (cottage cheese) discharge with a strong smell, intense itching, inflammation, and burning upon urination. Candida infection is more common among women who have diabetes, who use IUDs, who have recently used an antibiotic (e.g. tetracycline for acne), who use corticosteroids regularly, or who are immunodeficient. (Berkow 1992, 1786-88)

Gardnerella Gardnerella is caused by Gardnerella vaginalis, a gram- negative bacterium and a frequent cause of vaginal infection. Although it is classified as a sexually transmitted disease, it is a normal constituent of the vaginal flora.Its manifestation is linked with recurrent vaginal irritation, alterations in vaginal pH, emotional stress, and lowered resistance and immunity. The primary symptom of gardnerella is a thin, grayish discharge with a ‘fishy’ odour. (Berkow 1992, 1786-88)

Chlamydia The bacteria of the genus Chlamydia, a unique bacterium that acts like a virus by invading a host cell in order to reproduce, causes chlamydia. Chlamydia trachomatis is found in humans, and lives in the conjunctiva of the eye, and in the urethra and cervix. In poor countries such as Nepal, chlamydia is the primary cause of blindness. Chlamydia is thought to affect up to half of all sexually active women, although as many as 60% of these women are not bothered by symptoms. As a result, chlamydia often goes untreated and can result in a low grade chronic inflammation that negatively affects fertility. When symptoms do manifest they may include a yellowish or greenish discharge from the cervix, bleeding of the cervix from a Pap smear, irregular vaginal bleeding, lower

abdominal pain, and pain upon urination. It is difficult to diagnose chlamydia as it is hard to culture it from vaginal swabs and urine samples, and as a result there is probably a high false negative rate of diagnosis. Women who are at risk for chlamydia are under the age of 24, have multiple sexual partners, and are not using barrier methods of contraception (i.e. condoms). The use of oral contraceptives enhances the likelihood of chlamydia infection, as do many surgical procedures that artificially dilate the uterus such as a fitting for an intrauterine device (IUD), abortion, dilatation and curettage (D&C), and fetal monitoring. (Berkow 1992, 1786-88)

The treatment of vaginitis and leucorrhea, whether non- specific or caused by a specific agent, is essentially the same, although certain aspects of the treatment are modified in each condition. A watery discharge with blood may indicate malignancy and thus it is important that the patient should have a medical diagnosis to rule out cancer.

Topical remedies are an important aspect in the treatment of vaginitis and leucorrhea, and include creams, salves, and douching. Creams, salves and fresh plant juices (succus) are easily customized to relieve individual symptoms. Tinctures of herbs that have antimicrobial, anti- inflammatory, astringent, and trophorestorative properties can be added to a base such as a hypoallergenic Calendula flower (Calendula officinalis) cream, Calendula salve or Calendula succus. Useful antimicrobials include Echinacea root (Echinacea angustifolia), Goldenseal root (Hydrastis canadensis), Myrrh (Commiphora mukul), Western Red Cedar (Thuja plicata), and Wild Indigo (Baptisia tinctoria). Anti-inflammatory herbs include Curcuma longa and soothing mucilaginous herbs such as Plantain (Plantago lanceolata) and Comfrey root (Symphytum officinalis). The use of astringent herbs is helpful to enhance tissue repair and examples includes White Oak bark (Quercus alba), Witch Hazel bark (Hamamelis virginiana), and Bayberry bark (Myrica cerifera). Essential oils too may be included in the cream, such as Lavender, Tea tree, Cajeput, Rosemary, Juniper and Geranium, to enhance tissue repair and antimicrobial activity.

Using such an approach, we might construct the following cream:

Quercus alba 5 mL Hydrastis canadensis 5 mL Echinacea angustifolia 5 mL Plantago lanceolata 5 mL 20 mL, (i.e. 30% v/v) Lavender E.O. 10 drops Calendula cream 60 g

Such a cream should be applied twice daily, covering the entire vulva and just inside the vagina. Ideally, the Simple Ointment application of the cream should be preceded with a herbal sitz bath. A sitz bath is a procedure by which the entire Take plain natural pelvic region is immersed in a specially prepared solution, Yogurt right out of the best implemented by using a shallow tub, placed in the refrigerator and apply bathtub. The sitz bath can be prepared with similar herbs, using them as an infusion, or as a diluted tincture, 15 mL of the tincture formula per 250 mL of water. Infusions and decoctions are an obvious choice for sitz baths, including a decoction of Pau D’arco (Tabebiua spp.), which has potent antifungal properties. An apple cider vinegar sitz bath has also been stated to be helpful in Candida infection (1 cup per gallon of water), as is topical application and douching with live, natural yogurt.

Apart from external therapies, herbs that enhance immunity, have antimicrobial activity, provide analgesic and antispasmodic activity, and are trophorestorative to the genitourinary tract are important. In the treatment of Candida it is often wise to include antifungals as well.

Important immunomodulants include Ashvagandha (Withania somnifera), Codonopsis (Codonopsis pillosa), Fo Ti (Polygonatum multiflorum), Astragalus root (Astragalus membranaceus), and Reishi mushroom (Ganoderma lucidum).

Herbs that have a general antimicrobial activity include Echinacea (Echinacea angustifolia), Goldenthread root (Coptis spp.), Myrrh (Commiphora mukul), Neem (Azadirachta indica), Isatis (Isatis tinctoria), Manjishta (Rubia cordifolia), Sandalwood (Santalum album), Japanese Honeysuckle (Lonicera japonica) and Goldenseal root (Hydrastis canadensis).

Botanicals that have a specific antimicrobial activity in the genitourinary tract, include Cubeb (Piper cubeba), Gokshura (Tribulus terrestris), Pipsissewa (Chimaphila umbellata), and Bearberry (Arctostaphylos uva-ursi).

Useful analgesics and anodynes include Kava (Piper methysticum) and Pasqueflower (Anenome occidentalis), with the rather toxic but effective Henbane (Hyocyamus niger) used when nothing else works.

Important trophorestoratives in the genitourinary tract include fresh Corn Silk (Zea mays), Couch Grass (Agropyron repens), and Marshmallow root (Althaea officinalis).

Antifungals to include in a general anti-candida regimen are Echinacea (Echinacea angustifolia), Garlic (Allium sativum), Pau D’Arco (Tabebuia spp.), Chaparral (Larrea tridentata), Sweet Annie (Artemisia annua), Reishi mushroom (Ganoderma lucidum), Barberry (Berberis vulgaris), and Myrrh (Commiphora mukul).

Boric Acid: Capsules of boric acid have been used as suppositories to treat candidiasis with success rates equal to or better than those for nystatin. A vaginal suppository (capsule), containing 600 mg boric acid twice a day for 2 or 4 weeks. Effective in curing 98% of the women with failure of response to the most commonly used antifungal agents. This treatment offers an inexpensive, easily accessible therapy for vaginal yeast infections.

Dietary considerations are important in the treatment of vaginitis and leucorrhea, with the reduction of refined carbohydrates and the emphasis of proteins to acidify the urine and vaginal secretions. Food rich in the Lactobacillus bacteria should be consumed frequently, such as live yoghurt, kefir, and unpasteurized sauerkraut. Useful supplements include vitamin C to bowel tolerance, vitamin B complex (50-200 mg daily), vitamin A (10,000-25,000 IU daily for a maximum of a month), vitamin E (400 IU daily), and zinc citrate (50 mg daily). In cases of Candida a course of Lactobacillus and Bifido bacteria is helpful to re- establish a healthy gut flora, as is the regular consumption of herbs rich in fructo-oligosaccharides such as Slippery

Elm (Ulmus fulva) that are exclusively fermented by these bacterium. Homeopathic Candida 30X (which is actually a nosode, and not a homeopathic per se), 5-10 drops may also be helpful.

Premenstrual syndrome

Premenstrual syndrome (PMS) refers to the different kinds of symptoms experienced by some women during the luteal and menstrual phase of the estrus cycle. It affects upwards of 75% of all women of menstruating age in varying degrees. The most common physical symptoms of PMS are abdominal distension, breast swelling and tenderness, headaches, changes in appetite, food cravings, fatigue, dizziness, weight gain, fluid retention, joint pain, pelvic congestion, poor immunity, constipation or diarrhea, herpes outbreak, and acne. Psychological symptoms might include insomnia, poor memory, grief, irritability, anger, anxiety, poor concentration, and confusion. Such symptoms, when recognized by the physicians of the middle ages, gave rise to all kinds of interesting ideas, such as the concept of a “wondering womb” that searched the body looking for a baby, and in its journey caused the myriad symptoms that we now define as PMS. The modern medical approach to this condition is little better however, and the prevailing notion is that PMS is nothing but a kind of female nervous tension best treated by sedation. (Trickey 1998 35-37; Berkow 1992, 1791)

Although the causes of PMS are varied, in her book Women, Hormones and the Menstrual Cycle, author Ruth Trickey illustrates some common themes, all of which are related to neuroendocrine control:

Estrogen: Elevated levels of estrogen relative to progesterone 5 – 10 days prior menses is thought to cause feelings of irritability and aggression by elevating norepinepherine in the brain.

Progesterone: A relative deficiency of progesterone 5 – 10 days prior to menstruation allows for the elevation of aldosterone, enhancing sodium retention and the resulting edema. The progesterogenic effects of the luteal phase are

also inhibited by elevated norepinepherine from emotional stress and elevated estrogen.

Aldosterone: Aldosterone is a cause of premenstrual fluid retention, and is enhanced with stress, low progesterone, high estrogen, and a deficiency of magnesium.

Prolactin: Women with PMS are thought to have an excessive sensitivity to, or mildly elevated levels of, prolactin. Prolactin is normally secreted in high levels during lactation, and prolactin is implicated in the increased breast sensitivity and swelling of some forms of PMS.

Endorphins: Endorphins are natural opiates that elevate mood, and when decreased, can give rise to symptoms of depression. Additionally, endorphins appear to regulate the secretion of the gonadotropins.

Dopamine: Dopamine is a prolactin antagonist, and is decreased under the influence of estrogen and a deficiency of magnesium and vitamin B6. Dopamine also appears to regulate mood, and a deficiency is implicated in anxiety, irritability, and emotional lability. (Trickey 1998, 109-118)

Other factors in PMS include a prostaglandin imbalance Suggested Program (for all types of PMS with additions if and the overgrowth of Candida albicans, the latter of which needed) is linked to a relative estrogen excess. A deficiency of Breakfast vitamin B6 is often implicated in PMS, and treatment with Femaherb (2-3 tab) this nutrient may provide relief from depression and Essential Fatty Acids (2-3 anxiety. The breast swelling and tenderness associated with capsules) BEVC (2 tablets) elevated prolactin levels may be relieved by Lunch supplementation of vitamin B6 through the enhanced Vitamin C (1,000 mg) synthesis of dopamine. Vitamin B6 is also a cofactor in the Vitamin B6 (100 mg) production of series 1 prostaglandins and can normalize Supper Same as breakfast cellular magnesium levels. Magnesium too is a factor in Consider Flower Essences dopamine synthesis, and a deficiency can lead to depression, anxiety, and cyclic breast pain. (Trickey 1998, 109-118)

There are five different subcategories of PMS, first devised by G.E. Abraham, and each of these subtypes has a unique set of symptoms and metabolic abnormalities associated with them. The following chart describes these subtypes and the mechanisms that could cause them. It is important

to note that a woman with PMS may experience more than one subtype.

Beside these five types of PMS, intestinal flora issues, most commonly Candida albicans, makes up a six type of PMS. It is not uncommon for a woman to have a cross over, or a combination of more than one of these types at a time. In general we use one standard program (see text box insert) as soon as we start treatment and then start collecting data to determine which type(s) is most present. After 1 – 2 months of treatment we decide if we need to add additional treatment dependenting on which type(s) are still prominent.

It is not unusual for a woman to display different symptoms in different months, as she will typically ovulate from one side one month and the other side the next. This might be confusing at first, with some women feeling they are regressing in one month when they had reduced symptoms the month before.

Subgroup Symptoms Mechanisms PMS A Anxiety Estrogen excess A = anxiety Nervousness Progesterone deficiency Mood Swings Liver congestion Nervous tension PMS C Craving for sweets Hypoglycemia C = craving Increased appetite Magnesium deficiency Palpitations Prostaglandin imbalance Fatigue Often occurs in association with PMS A Dizziness Headaches PMS H Breast tenderness Elevated aldosterone H= hydration Bloating Estrogen excess Weight gain Progesterone deficiency Edema Elevated prolactin PMS D Depression Estrogen deficiency D= depression Poor memory Grief Confusion Insomnia PMS P Lower back pain Estrogen excess P= pain Abdominal pain Prostaglandin imbalance Joint pain Headaches (Trickey 1998, 118-121)

Treatment of PMS A The primary treatment of PMS A is to enhance progesterone levels, best accomplished with Chasteberry (Vitex agnus castus), 40 drops of a 1:3 extract taken every morning for at least 6 months. Vitamin B6, at a dose between 100-600 mg daily, taken with 50-100 mg of a full spectrum B-complex, is best used 10-14 days prior menses. Magnesium is an important supplement as well, taken at a dosage between 200-800 mg throughout the cycle. Botanicals that reduce anxiety and pain, as well as promote a feeling of well-being are an important aspect of treatment, and include relaxing nervines such as Valerian (Valeriana officinalis), Skullcap (Scutellaria lateriflora), Passionflower (Passiflora incarnata), Vervain (Verbena officinalis), and anodynes such as Kava (Piper methysticum) and Pasqueflower (Anenome occidentalis). Adaptogens are particularly indicated in anxiety with exhaustion, including Ashvagandha (Withania somnifera), Shatavari (Asparagus racemosa), Dang gui (Angelica sinensis), Peony root (Paeonia lactiflora), and Siberian Ginseng (Eleuthrococcus senticosus). Hepatics can be useful to enhance the excretion of conjugated estrogens, and include Buplerum (Buplerum chinensis), Barberry (Berberis vulgaris), and Dandelion root (Taraxacum officinalis). Phytoestrogenic herbs that compete for estrogen-binding sites are useful, such as Red Clover (Trifolium pratense), as well as phytoestrogen-containing foods such as fermented and sprouted legumes. Fiber intake should be enhanced, and saturated fat and refined carbohydrate intake should be curtailed. In particularly recalcitrant cases, natural progesterone creams can be used to enhance serum progesterone levels, 1/4 tsp applied over the extremities once daily before bedtime.

With forms of PMS it often helps to repetorize for the relavent Flower Essence.

Treatment of PMS C The primary treatment of PMC C is to regulate blood sugar levels, best accomplished by enhancing protein intake, especially in the morning, and decreasing refined carbohydrate intake throughout the day. Smaller, more frequent meals can help, as will the elimination of methylxanthine-containing beverages such as coffee and

tea that promote labile blood sugar levels. Supplementation with magnesium is useful (800-1000 mg daily), as is chromium (250 mcg t.i.d., with meals). To correct the prostaglandin imbalance that can accompany this condition, supplementing with Black Currant seed oil, Borage seed oil or cold water fish or Krill oil is very useful, 5 g daily taken mid cycle until menstruation, or throughout the cycle on a daily basis Additionally, vitamin B6 (100- 300 mg daily, taken with a B-complex), vitamin E (200 - 600 IU daily), and zinc citrate (50 mg daily) can facilitate the production of PGE1.

Treatment of PMS H The treatment of PMS H is essentially the same as it is for PMS A, with the addition of treatments to correct aldosterone levels and the sodium-potassium balance. To this end botanicals that are rich in potassium such as Dandelion leaf (Taraxacum officinalis), Catnip (Nepeta cataria), and Skullcap (Scutellaria lateriflora) are helpful when taken as an infusion, as are potassium-rich foods such as kelp, raisins, avocados, apricots, potato skins, cantaloupe, and broccoli. Although the treatment for PMS- H is similar to that of PMS A, the use of Licorice root (Glycyrrhiza glabra) as a phytoestrogen is contraindicated because of its aldosterone-like activity.

Treatment of PMS D As PMS D relates to a relative estrogen deficiency, therapies that enhance estrogen production or facilitate the cellular activities of estrogen are all helpful. It appears that lead, found in some fuels, paints, and other household products can accumulate in the body and interfere with the activity of estrogen receptors, and thus agents that decrease lead absorption and retention such as magnesium, iron, copper, and zinc. A diet high in fiber can promote the excessive excretion of estrogen and thus fiber intake should be reduced. Foods high in phytoestrogens should be emphasized in the diet, as well as botanicals such as Red Clover (Trifolium pratense), Wild Yam (Dioscorea villosa), False Unicorn root (Chamaelirium luteum), and True Unicorn root (Aletris farinosa). And, just as for PMS A, botanicals that reduce anxiety and pain, as well as promote a feeling of well-being are important aspects of

treatment. For severe pain, follow the recommendations under PMS P. Serotonergic foods such as those high in tryptophan (e.g. turkey and hard cheeses) can also be taken to enhance serotonin levels, or with severe depression the biological precursor to serotonin, 5-HTP (100-300 mg daily).

Treatment of PMS P PMS P relates to an increased sensitivity to pain, perceived to be an imbalance of the proinflammatory and pain- promoting prostaglandins, facilitated by elevated estrogen and the excessive consumption of saturated animal fat. Once again magnesium appears to be an effective agent to reduce pain sensitivity, as is vitamin B6 and zinc, all taken at dosages previously mentioned. The therapeutic usage of GLA and EPA are both important here, 5-10 g daily. The addition of herbs that have a phytoestrogenic property is helpful, as is increasing dietary fiber. Herbs that inhibit the inflammatory cascade include Feverfew (Tanacetum parthenium), Turmeric (Curcuma longa), Devil’s Claw (Harpagophytum procumbens), and Baical Skullcap (Scutellaria baicalensis). Botanicals that have potent analgesic and anodyne properties are Kava (Piper methysticum), Wild Lettuce root (Lactuca virosa), Jamaican Dogwood (Piscidia erythrina), White Willow bark (Salix alba), California Poppy (Eschscholzia californica), and Pasqueflower (Anenome occidentalis).

Fibrocystic breast disease

Fibrocystic breast disease (FBD) is a common benign condition of premenopausal women that may or may not occur with the variance in hormonal levels experienced during the estrus cycle. Although many women display areas of relatively indistinct breast lumpiness, FBD refers to small benign tumors that are well-circumscribed and feel like a slippery marble to the touch. The primary symptoms of FBD are irregularly lumpy and swollen breasts that feel heavy, aching and sore. In most cases the pain is

worst just prior to menstruation and as such can be considered to be a form of PMS (see PMS A and PMS H). In other cases however, the pain is ongoing with no cyclical change. It is important to get an accurate diagnosis as some of the symptoms resemble that of breast cancer. (Trickey 1998, 123-26; Berkow 1992, 1814-15; Rubin 2001, 540-42)

The exact cause of FBD still eludes researchers, but it appears it is aggravated by a relative estrogen excess. During the follicular phase of the estrus cycle estrogen stimulates the production of lactiferous glands and the supporting stromal layers of the breast. After ovulation, when progesterone is elevated, prolactin levels begin to increase to trigger glandular changes in the breast. If implantation does not occur however, the newly formed breast apparatus begins to break down. It is thought that in FBD however, the growth and development of new tissues in the breast is faster than the process of degeneration and resorption. Small pockets of cellular debris and trapped secretions are formed, and these may coalesce to form fluid-filled cysts. Although the cysts can be surgically excised, they frequently reappear, and thus little treatment is offered. Women who have FBD however, have 4 times Suggested Program the risk of developing breast cancer, and thus some form of preventative treatment is appropriate. Further, women with Breakfast Femaherb (2-3 low thyroid function have a greater incidence of FBD as capsules), BEVC (1-2 tablets), well as breast cancer. (Trickey 1998, 123-26; Berkow Essential Fatty Acids (1,000 - 1992, 1814-15; Rubin 2001, 540-42) 3,000 mg), Kelp (500-1000 mg), B complex (25 mg), Vit. E 400I.U. The holistic treatment of fibrocystic breast disease is Snack Vitamin C (1,000 mg). similar to that of PMS A and PMS H. Foods and beverages Lunch Essential Fatty Acids rich in methylxanthines such as coffee, tea, colas, and (1,000 - 2,000 mg), Vitamin C chocolate should be completely eliminated as the regular (1,000 mg), Vitamin E (400 IU). consumption of these compounds are implicated in the Snack Vitamin C (1,000 mg). development of FBD. Organic iodine (0.25 mg daily), best Supper Same as breakfast. taken in sea vegetables such as Kelp, is another important treatment if hypothyroidism is suspected, as is the The suggested diet is listed. elimination of cruciferous vegetables such as broccoli and Apply poultice if needed. Homeopathic tissue salts such cabbage, and legumes such as soy that have thyrostatic as Nat. Sulph. and Nat. Mur. activity. The primary treatment of FBD is to reduce the 12X can be very beneficial in relative estrogen excess by increasing fiber intake, and these cases. enhance the hepatic conjugation of estrogens with the use of cholagogues. The latter approach is particularly appropriate as women who have less than three bowel movements per week have 4.5 times the risk of suffering

from breast disorders including FBD and breast cancer. Important topical remedies include a poultice of Verbena (Verbena officinalis) or a fomentation of astringent herbs such as Witch Hazel (Hamamelis virginiana) and Oak bark (Quercus spp.). An infused castor oil or cream made with Poke root (Phytolacca decandra) (20% v/v) is very effective when applied topically over the affected areas on a daily basis. Important nutritional supplements to include are beta carotene (50,000 IU twice daily), vitamin E (800 IU daily), and GLA and EPA-rich oils (5-10 g daily) to inhibit inflammatory prostaglandin synthesis.

Uterine fibroids

Uterine fibroids (syn. Leiomyomas) are non-cancerous tumors of the uterus, affecting 20 – 25% of the female population over the age of 35. It increases up to 50% by time of menopause. African women experience a higher rate of fibroids. Fibroids can vary in size, shape, position and number, some causing symptoms of pressure and uteral enlargement, while others are small and discrete. They are composed of dense muscular fibers arranged in circular layers, and encapsulated in a layer of smooth muscle. Fibroids may be located within the uterus (intrauterine), in the wall of the uterus (myometrial), or outside of the uterus (extrauterine). Intrauterine fibroids can inhibit fertility by interfering with implantation. Myometrial fibroids can place pressure on adjacent organs, and in some cases, can affect renal function by placing pressure upon the ureters. Extrauterine fibroids are located under the serous membrane of the uterus, and can be on or near the fallopian tubes and can inhibit fertility. (Trickey 1998, 184-87; Berkow 1992, 1807)

Fibroids are of two basic types. They can be discrete, fibrous, encapsulated and roughly spherical in shape, or can be large pendunculated fibroids. The former are usually of little concern, and although they should be monitored, do not present any problems. Preventative measures, such as the use of phytoestrogens, should be encouraged however. Large pendunculated fibroids are of concern due to the likelihood of torsion. Such an event is very painful and may require immediate surgery. Such fibroids are also associated with an increased risk of sarcoma. Although the specific causes of fibroids remain elusive, it is known that they are dependent upon estrogen for their growth. They are rare before menarche (the first period) and typically resolve with menopause. Fibroids have also been found to contain higher amounts of DDT than other uterine tissues, which as a xenoestrogen could promote their growth. Some herbalists have speculated that fibroids act as a kind of “second liver” within the uterus, walling off toxic compounds from the rest of the uterus. (Trickey 1998, 184- 87; Berkow 1992, 1807)

The most prominent symptoms of uterine fibroids are menorrhagia, sensation of abdominal pressure and pelvic congestion, urinary frequency, abdominal enlargement, lower back pain, and dysmenorrhea. The primary risk factors for fibroids include obesity, with a slight risk associated with oral contraceptive use. The risk of fibroids declines with repeated pregnancies, and the incidence is lower in smokers. (Trickey 1998, 184-187; Berkow 1992, 1807; Rubin 2001, 523)

The primary treatment of fibroids is to check hemorrhaging, tone the uterus, and lower the relative estrogen excess. The therapies outlined for PMS A may be used to inhibit estrogen and enhance elimination, and the Suggested Program treatment methods for menorrhagia are used to check Femaherb: 2 tab – bid hemorrhaging and tone the uterus. Adjunct treatments Cordyceps: 2 caps or 1 tsp. – include the use of hepatics, pelvic decongestants, uterine bid circulatory stimulants, and anodynes listed under Chaga mushroom ½ tsp of dysmenorrhea. Topical treatments include castor oil packs powder made into tea, bid Homeopathic cinnamon for infused with Poke root (Phytolacca decandra) tincture, excessive bleeding 20% v/v. The medicated oil is liberally rubbed over the Essential fatty acid: 2 caps - entire uterine area before bed, the lower torso being bid wrapped with plastic wrap or wax paper to prevent soiling the bed sheets. Cordyceps has been found quite useful in

this condition both to act as a tonic and to aid in clearing the fibroids. Useful supplements include vitamin B6 (100- 600 mg daily, with a B complex, 100 mg/daily), vitamin E (600 IU daily), vitamin C (to bowel tolerance), bioflavonoids (3-5 g daily), iron (20 mg daily) and lipotropic factors such as inositol and phosphatidyl choline to aid in the hepatic clearance of estrogen. Dietary changes should reflect an increase in whole foods and a decrease in saturated fats and alcohol.

Pelvic inflammatory disease

Pelvic Inflammatory isease (PID) or salpingitis are general terms for inflammation of the pelvic organs, and are given different names according to the location of inflammation, such as endometritis (endometrium), oophoritis (ovaries), and peritonitis (peritoneum). The primary cause of PID is bacterial infiltration from the vagina, more common after childbirth, miscarriage, abortion, IUD insertion, and D&C. The most common pathogenic factors include Chylamydia and Trichomonas, but Neisseria gonorrhoeae (i.e. gonorrhea) and Ureaplasma urealyticum (mycoplasma) can also promote PID. The signs and symptoms of PID include a dull ache or acute pain in the lumbar region, pain after intercourse, cramping, fever, abnormal vaginal discharge, dysuria, pain upon defecation, inguinal lymphadenopathy, nausea and vomiting, metrorrhagia and/or menorrhagia, and pain upon ovulation (mittleschmerz). Not all of these symptoms may be present and what symptoms there are may come and go over a period of years in a cycle of exacerbation and remission. Abscesses may develop in the fallopian tubes, ovaries and pelvis during the inflammatory stage. (Trickey 1998; Berkow 1992, 1789-90; Rubin 2001, 524)

The treatment of PID is essentially the same as it is for vaginitis and leucorrhea, but with the use of powerful alteratives, immunostimulants, uterine tonics, antispasmodics, and anodynes, as well as topical therapies. Particularly indicated are a class of botanicals called pelvic decongestants that relieve portal congestion and the symptoms of pelvic heaviness, including Stone root (Collinsonia canadensis), Yarrow (Achillea millefolium),

and White Dead Nettle (Lamium album). Among the more useful alteratives in PID is Blood root (Sanguinarea canadensis), but others such as Echinacea (Echinacea angustifolia), Wild Indigo (Baptisia tinctoria), Goldenseal (Hydrastis canadensis), Sarsaparilla (Smilax spp.), and Nettle (Urtica dioica) may prove to be useful. Examples of uterine tonics are Dang gui (Angelica sinensis), Raspberry leaf (Rubus spp.), False Unicorn root (Chamaelirium luteum), and True Unicorn root (Aletris farinosa). Useful antispasmodics include Cramp bark (Viburnum opulus), Wild Yam (Dioscorea villosa), Black Cohosh (Cimicifuga racemosa), and Kava (Piper methysticum). For the severe pain of exacerbation powerful anodynes such as Pasqueflower (Anenome occidentalis) and Yellow Jessamine (Gelsemium sempervirens) are indicated in small doses. The treatment of adhesions is covered under Endometriosis. Useful supplements include vitamin C (to bowel tolerance), zinc citrate (50 mg daily), acidophilus, and GLA or EPA/DHA (5-10 g daily). The diet should be rich in green vegetables, fresh vegetable juices, as well as fermented and sprouted legumes. During exacerbation care should be taken to reduce iron-containing foods such as beef and eggs in order to inhibit bacterial growth.

Endometriosis

Endometriosis refers to the growth of endometrial tissue outside of the uterine cavity or into the uterine wall. The cyclic variations of the estrus cycle cause this misplaced endometrial tissue to undergo both proliferative and secretory stages, but without elimination during menstruation. The cyclical hemorrhaging of extrauterine (ectopic) endometrial tissue can give rise to a variety of symptoms, and with repeated hemorrhaging the implanted endometrial tissue begins to enlarge. Endometriosis is a disease of women of reproductive age and regresses with artificially induced or natural menopause. It is believed to affect upwards of 10% of women, and is slightly more common in women in their late 20's to mid 30's. It has been estimated that 25-50% of infertile women have endometriosis. The sites most commonly affected, in order of decreasing frequency, are the ovaries, fallopian tubes, uterus, pouch of Douglas, uterosacral ligaments, urinary bladder, ureters, vagina, lower gastrointestinal tract, and

rarely, in distant areas such as the lungs, pleura, and extremities. (Trickey 1998, 239-249; Berkow 1992, 1809- 12; Rubin 2001, 518-19)

Although the etiology is unclear, there are four possible causes of endometriosis considered by bio-medicine:

• the retrograde flow of menstrual fluid into the pelvic cavity; • relative estrogen excess, increasing the number of cells and sites receptive to estrogen; • immunological and inflammatory factors; • fetal developmental of ectopic endometrial tissue.

The first possible cause of endometriosis is the retrograde flow of menstrual fluid into the pelvic cavity, in which foci of the menstrual tissues regurgitate into the fallopian tubes and become implanted upon the various pelvic organs. Factors that can enhance the retrograde flow of menstrual fluid include cervical stenosis, uterine or cervical adhesions, imperforate hymen, exercise during menstruation, and excessive uterine spasm and fallopian dilation during menstruation, mediated by excessive PGE2. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)

The second and third causes are somewhat related, with elevated levels of estrogen having a negative effect upon immune activity that might otherwise 'clean up' the regurgitated tissues. Further, women exposed to high levels of estrogen are more likely to develop endometriosis. Women now menstruate far more often then our forebears, and complexed with the influence of xenoestrogens and oral contraceptives, women are generally overexposed to estrogen. The immune response too can have a negative impact upon the situation, and an enhanced localized immune response promotes inflammation, and can result in macrophage-induced infertility during the initial stages of endometriosis. Note as well that a high level of circulating estrogen facilitates the production of the anti-inflammatory prostaglandins. With the progression of the disease the immune response declines, but the scarring from inflammation remains and inhibits fertility. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)

The fourth possible cause of endometriosis is linked to fetal development. All reproductive tissues develop from the same embryonic tissue. During embryonic development the tissues may fail to differentiate properly, giving rise to an ectopic endometrium. The risk factors for endometriosis are numerous, including lifestyle, familial and dietary aspects. As mentioned already, women who menstruate early, and/or who never have children or lactate, have a higher incidence of endometriosis due to the negative effects of excessive estrogen. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)

Sexual intercourse during menstruation is also thought to increase the retrograde flow of endometrial fluids, and many cultures for this and other reasons prohibit sexual intercourse during menses. There also appears to be a familial link, and immediate family members of a woman who has endometriosis are seven times more likely to develop it. Additionally, daughters of mothers with endometriosis have an increased risk of endometriosis. The use of an intrauterine device (IUD) is associated with an increased risk of endometriosis, possibly because the device enhances retrograde flow, as do tampons. Women taking oral contraceptives appear to have a negligible risk for endometriosis, but former OC users are at a higher risk of developing endometriosis than women who have never taken the Pill. Other risk factors include the regular use of caffeine and alcohol in the diet. Factors that appear to decrease the risk of endometriosis include pregnancy and lactation, with the risk of endometriosis decreasing with each successive pregnancy. Exercise too appears to have a beneficial effect because it can reduce estrogen production, but strenuous exercise, and in particular aerobic exercise, is though to enhance retrograde flow. (Trickey 1998, 239- 249; Berkow 1992, 1809-12; Rubin 2001, 518-19)

Holistic practitioners have found a clear link between systemic Candida yeast problems and endometriosis. One should check to see if this is the major cause or a co-factor. Since Candida can cause micro-perforations in the female area, literately farming the ovaries, it can be a strong factor in endometriosis.

There are two primary forms of endometriosis: adenomyosis, and extrauterine or ectopic endometriosis.

Adenomyosis is the growth of endometrial tissue into the muscular wall of the uterus. It is more likely to occur in women over the age of 35 and in women who have carried more than one full term pregnancy. In 50% of cases it is associated with fibroids. When the uterus is palpated it feels hard, large and may have an irregular shape. The symptoms of adenomyosis include severe dysmenorrhea (related to implants of ectopic endometrium on the uterosacral ligaments that swell just before menstruation), infertility, menorrhagia, increased frequency of menstruation, and uteral enlargement. Extra-uterine or ectopic endometriosis is the growth of endometrial tissue outside the uterine cavity. If implanted upon the ovaries it can lead to the development of ovarian cysts, which occurs in about 60% of all cases. The formation of the cyst is due to the ovary trying to contain endometrial growth by encapsulating it. These endometrial cysts are called endometriomas, and are filled with clotted dark brown blood that gives rise to their more common name of chocolate cysts. The size of an endometrioma varies from a small cyst that has a tendency to rupture at each period, to large cysts, which do not rupture, but only get larger, upwards of 20 cm in diameter. When large cysts rupture there is acute abdominal pain and shock, and immediate surgery is required. Small rupturing cysts on the other hand cause chronic irritation, inflammation, and pain within the pelvic cavity. Other sites of implanted endometrial tissue often include the fallopian tubes, pouch of Douglas, the uterosacral ligaments, and other pelvic organs such as the bowel, urinary bladder, ureters, and urethra. The implanted tissue forms raspberry-like clusters of endometrial tissue that are in various stages of development. Typically the implanted endometrial tissue may bleed for a few months, Suggested program and then be replaced by fibrous tissue called adhesions. Endometriomas that occur peripherally may manifest as Femaherb: 2 – 3 tab bid-tid bluish swellings under the skin that become increasingly BEVC: 2 tab – bid painful and may even bleed as menstruation approaches. EFA: 1 – 2000; bid The symptoms of extrauterine endometriosis includes Candida program when severe dysmenorrhea, infertility, pain with sexual activity, indicated. increasing pain as luteal phase progresses, pain at Liver support if needed ovulation, one sided pelvic pain, pelvic heaviness, and irritable bowel syndrome. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)

The treatment of endometriosis utilizes a broad array of medicinal herbs. Phytoestrogens such as Red Clover (Trifolium pratense) and Black Cohosh (Cimicifuga racemosa) are an important part of treatment, to reduce the negative effects of excessive estrogenic stimulation. The primary treatment of endometriosis involves improving uterine tone to promote orderly contraction and the proper elimination of menstrual fluid, to relieve excessive or abnormal uterine spasm, and to regulate eicosanoid synthesis. Uterine tonics that regulate contraction of the uterus include Dang gui (Angelica sinensis), Raspberry leaf (Rubus idaeus), Blue Cohosh (Caulophyllum thalictroides), and False Unicorn root (Chamaelirium luteum). Emmenagogues such as Mugwort (Artemisia vulgaris), Pennyroyal (Mentha pulegium), and Rue (Ruta graveolens) are used just prior to menstruation to facilitate the elimination of menstrual fluid, particularly with menstruation that is slow to start, accompanied by pelvic heaviness and cramping. Antispasmodics such as Cramp bark (Viburnum opulus) and Wild Yam (Dioscorea villosa) can be used to alleviate excessive uterine spasm that is uncoordinated and painful. Regulators of prostaglandin synthesis in the uterus are an important aspect of treatment to improve uterine tone, and are chosen based on the underlying symptoms of the patient. For feelings of heat and irritability the cooling properties of Feverfew (Tanacetum parthenium) is a better choice, whereas symptoms of coldness and depression are best resolved by using warming and stimulating botanicals such as Ginger (Zingiber officinalis). Another regulator of prostaglandin synthesis is Curcuma longa, which is neutral in energy.

A general treatment for many female reproductive ailments and no less for endometriosis are pelvic decongestants. This class of botanicals helps to relieve symptoms of pelvic congestion by relieving portal vein congestion, enhancing lymphatic drainage, and promoting liver metabolism. Included in this category are White Dead Nettle (Lamium album), Yarrow (Achillea millefolium), Stone root (Collinsonia canadensis), and Ocotillo (Fouquieria splendens). Additional treatments for endometriosis may resemble those for PMS, such as the use of hormonal regulators such as Peony root (Paeonia lactiflora) and Chasteberry (Vitex agnus castus), and mood-elevating botanicals such as St. John’s Wort (Hypericum

perforatum), Skullcap (Scutellaria lateriflora), Passionflower (Passiflora incarnata), Vervain (Verbena officinalis), and Kava (Piper methysticum).

The treatment of adhesions may be a necessary aspect of treatment, and botanicals such as Plantain (Plantago lanceolata), Selfheal (Prunella vulgaris), St. John’s Wort (Hypericum perforatum), Astragalus (Astragalus membranaceus), Bilberry (Vaccinium myrtillus), and Calendula (Calendula officinalis) have all been used traditionally for their wound-healing properties. Vitamins A, C, E, and zinc are also important in this regard.

For the bowel related issues that often accompany endometriosis, a treatment for IBS may need to employed, described fully in modules The Fire Within: Digestive function and Botanical medicine and Herbal Immunity: Nonspecific resistance, Immunity and Botanical medicine. Phrased succinctly, it is important to ensure the correct function of the liver, the health of the gut flora, and the proper tone of the bowel wall in bowel-related issues in endometriosis.

Important supplements in the treatment of endometriosis include the use of oils rich in GLA and EPA and oligomeric proanthocyanidins such as pycnogenol (150 - 300 mg daily) to inhibit the inflammatory cascade and promote wound healing. Vitamin E at a dose between 500- 1000 IU may be helpful to reduce adhesions, as is the use of a castor oil pack. In regards to diet it is important to increase dietary fiber, reduce saturated fat intake, and increase phytoestrogenic foods.

Ovarian cysts

Ovarian cysts refer to the development of cysts within ovarian tissue, and can range from being otherwise benign to cancerous. Up to 20% of all women have some degree of cyst formation in their ovaries at some point, although the vast majority is symptom-free. Ovarian cysts are often discovered by routine examination, or from the investigation of abdominal pain, discomfort, or pain upon intercourse. An ultrasound will indicate the presence of an

ovarian cyst, but without performing a biopsy it is difficult to identify the kind of cyst. The most common forms of ovarian cysts are physiological cysts, as well as those associated with polycystic ovarian disease (PCOD). Other less common types of ovarian cysts include the cystadenomas, fibromas, dermoid cysts, and Brenner cysts. Most cysts are symptom free unless they rupture or twist upon their stalk (pedicle). Some cysts are malignant, and others, called functioning cysts, have the ability to produce hormones. (Berkow 1991, 1784; Trickey 1998, 258-269; Rubin 2001; 524-25)

Physiological cysts are simple cysts that do not produce hormones, and represent a deviation in the normal functioning of the ovary. Follicular cysts are formed due to a problem with the developing follicle, in which the mature follicle fails to release the ovum and continues to enlarge, or one of the developing follicles fails to disintegrate. The symptoms are minimal and require little in the way of treatment. Luteal cysts form during the luteal phase of the estrus cycle after the corpus luteum has formed. Typically the cysts are small and require no treatment, but sometimes the cysts will become quite large and be filled with blood. Luteal cysts may interfere with the normal cycle, delaying menstruation and can cause an alteration in blood loss during the period. Luteal cysts typically resolve after one cycle and require little in the way of treatment. (Trickey 1998, 258-269; Rubin 2001, 524-25)

If physiological cysts occur often however, the use of botanicals that regulate follicular growth and development such as Peony root (Paeonia lactiflora), True Unicorn root (Aletris farinosa), and False Unicorn root (Chamaelirium luteum) are indicated.

Polycystic ovarian disease The term 'polycystic' refers to the formation of many cysts within the ovaries. Polycystic ovarian disease (PCOD) represents a dysfunction of the endocrinal activities of the ovaries, with erratic ovulation and menstrual dysfunction in association with a tendency to excessive androgen secretion. The signs and symptoms of PCOD are ovulatory failure, infertility, hirsutism, obesity, and abnormal menstruation. A smaller percentage of women with PCOD

may also experience male pattern hair growth, a deepening of the voice, and a loss of feminine contour. Diagnostically, an ultrasound is used to detect ovarian cysts, and blood tests will reveal high levels of LH with relatively constant or low FSH. The differential diagnosis includes Cushing's syndrome, adrenal hyperplasia, adrenal adenocarcinoma, hyperprolactinemia, and thyroid dysfunction. (Trickey 1998, 264-269; Rubin 2001, 524-25)

The causes of PCOD relate to abnormal functioning of the ovaries, with the excessive production of androgens within the developing follicle. Obesity is recognized as an underlying factor, and about 40% of women with PCOD are obese. Chronically high estrogen levels are found in obese women. Excess fatty tissues increasing the conversion of ovarian androgens into estrone by the enzyme aromatase cause this. Obese women, and in particular those women with truncal or abdominal obesity, display a greater proclivity to insulin resistance, leading to elevated blood sugar levels, hyperinsulinemia, and a greater risk of cardiovascular disease and diabetes. Women with PCOD may also display abnormal adrenal function, with an excessive production of androgens that results in their conversion to estrone. A high level of estrone without the normal cyclic variation then stimulates excess LH production. This secretion of LH adds fuel to the fire by triggering ovarian androgen production. Further, the levels of FSH, due to the high levels of circulating estrogens, remain suppressed. Low FSH reduces the ability of cells in the ovarian follicle to convert androgen into estrogen. Although elevated levels of LH are generally accepted as being caused by androgen excess, some researchers have suggested that the cause may be abnormal hypothalamic function with the improper secretion of GnRH. This could lead to elevated LH levels, resulting in elevated androgens, which in turn, initiates LH secretion in a self-perpetuating cycle. Playing into this whole cycle of low ovarian estrogen, high peripheral estrogen, and excess androgen, is SHBG (sex hormone binding globulin). Normally, SHBG binds to both estrogens and androgens to reduce the bioactivity of these hormones. With obesity and elevated androgens however, the level of SHBG declines, and the masculinization effects of the excess androgens begins to be seen. (Trickey 1998, 264-269; Rubin 2001, 524-25; Berkow 1992)

Suggested Program There also seems to be a link between PCOD and Candida Femaherb: 2 – 3 bid Krill 1 cap bid yeast problems, essential fatty acid problems and/or BEVC: 2 tab – bid Syndrome X, and women presenting with PCOD should be Berberini if needed evaluated for these conditions and treated appropriately.

Candida and/or The treatment of PCOD consists of reducing androgenic Syndrome X program if virilism, stimulating ovulation, correcting menstruation, indicated. and protecting the uterus and breast tissue from the cancerous changes caused by consistently high estrogen levels. If obesity is an issue then this must be addressed as well, as must the effects of insulin resistance such as hyperlipidemia and hyperglycemia. Often there is a thyroid insufficiency behind the weight gain and this must be addressed simultaneously.

Botanicals that can be used to normalize ovulation and reduce androgenization include the ‘female restoratives’ such as Peony root (Paeonia lactiflora), Dang gui (Angelica sinensis), Shatavari (Asparagus racemosa), False Unicorn root (Chamaelirium luteum), and Wild Yam (Dioscorea villosa), all of which have been used historically to enhance female fertility. Chasteberry (Vitex agnus castus) may also be used to stimulate ovulation, taken every day first thing in the morning, and may also help to reduce the androgenization. Another herb that may be useful with androgenization is Saw Palmetto (Serenoa serrulata), normally considered a ‘male’ herb that inhibits the production of more potent androgens. Botanicals that can be used to normalize LH secretion can be introduced in conjunction with therapies that inhibit androgenization, which of itself, will promote normal LH levels. Of the botanicals that help to regulate LH secretion are Hops (Humulus lupus) and Black Cohosh (Cimicifuga racemosa).

The most important method to protect the uterus and breast tissue from consistently high levels of estrogens is the use of the phytoestrogens as competitive inhibitors. To protect the endometrium progesterogenic botanicals are emphasized, such as Chasteberry (Vitex agnus castus) and Peony root (Paeonia lactiflora) (see treatment for metrorrhagia). In case of infection Berberini (Coptis) is quite beneficial.

If obesity is an issue than an active weight loss regimen must be promoted, with an emphasis upon anaerobic exercise, the elimination of refined carbohydrates, and an increase of dietary fiber. The guidelines for the treatment of obesity and insulin resistance are covered in A Life in Balance: Metabolic Function and Botanical Medicine.

Menopause We can’t really call menopause a health issue, it is more of a transitional period in a women’s life. Menopause denotes the cessation of menstruation in a woman, which usually occurs at an average age of 51 years, although it can start anywhere between 35 and 60 years old. Twelve months in a row without a period is the commonly accepted rule for diagnosing menopause. The time prior to menopause is referred to as perimenopause. During the perimenopausal period, many women ovulate irregularly and therefore begin to have changes in the menstrual cycle, with or without other symptoms. The time after menopause is referred to as postmenopause.

By the year 2015, nearly 50% of the women in North America will be menopausal. Between 1990 and 2020, the menopausal population on the continent will double. This dramatic rise in the number of menopausal women is changing the way health practitioners work with women, and even changing medicine itself. At no other time in history have so many individuals been dealing with the same set of health care issues.

Menopause begins with a decline of endogenous estrogen; which in turn leads to multiple tissue and organ changes. In addition to the reproductive and urinary tracts, estrogen- sensitive tissues are skin, bone, vascular lining, teeth and gums, eyes, brain, and the central nervous system.

Fifty to eighty percent of menopausal women in North America report menopause-related hot flashes, night sweats, vaginal dryness, insomnia, mood swings and depression. During the first 5 to 10 years of menopause, vulvovaginal symptoms begin to appear. Later, as the other mucous membranes of the urogenital tract become affected, rates of incontinence and infections rise.

In recent years there has been much concern regarding hormone replacement (HRT) or estrogen replacement therapy (ERT). The following is a recommendation from the advisory panel on the subject:

Basic Recommendations from the Scientific Advisory Panel of the North American Menopause Society

1. Treatment of menopause symptoms remains the primary indication for HRT and ERT. 2. The only menopause-related indication for long-term use of progestogen appears to be endometrial protection from unopposed estrogen therapy. For all women with an intact uterus who are using estrogen therapy, clinicians are advised to prescribe adequate progestogen, whereas women without a uterus should not be prescribed a progestogen. 3. No HRT regimen should be used for primary or secondary prevention of coronary heart disease (CHD). Proven alternative cardioprotective regimens should be considered. The effect of ERT on CHD is not yet clear. Until confirming data are available, ERT should not be used for primary or secondary prevention of CHD. 4. WHI and HERS data cannot be directly extrapolated to symptomatic perimenopausal women or to women experiencing early menopause (i.e., 40 to 50 years) or premature menopause (i.e., <40 years). 5. Many HRT and ERT products are FDA-approved for the prevention of postmenopausal osteoporosis; however, because of the risks associated with these forms of therapy, alternatives should also be considered, with the risks and benefits of each being considered. 6. Use of HRT or ERT should be limited to the shortest duration consistent with treatment goals, benefits, and risks for the individual woman. 7. Lower-than-standard doses of HRT and ERT should be considered. The Women's Health, Osteoporosis, Progestin, Estrogen (HOPE) trial demonstrated that lower doses of HRT achieved equivalent symptom relief and preservation of bone density without an increase in endometrial hyperplasia.

8. Alternative routes of administration of HRT may offer advantages, but the long-term benefit/risk ratio has not been demonstrated. 9. An individual risk profile is essential for every woman contemplating any regimen of HRT or ERT. Women should be informed of known risks. 10. The risk of ERT may be different than the risk of HRT.

Holistic treatment of Menopause

There are three fundamental goals in the treatment of menopause: relief of symptoms, prevention of disease, and treatment of disease. Each woman must be assessed individually to determine the scope and severity of her symptoms and then evaluated subjectively and objectively as to her risks of osteoporosis, heart disease, breast cancer, Alzheimer's disease, and colorectal cancer as well as other chronic health problems.

Phytoestrogens

The most important dietary recommendation is to increase the consumption of plant foods, especially those high in phytoestrogens, while reducing the consumption of animal foods. Consumption of fruit and vegetables also confers a protective effect.

Foods that contain phytoestrogens are an important part of a menopause diet. Phytoestrogens are plant-derived substances that are able to weakly bind to the estrogen receptors in mammals and have a very weak, estrogen-like effect in some tissues and a weak anti-estrogen effect in other tissues. Phytoestrogens are classes of compounds that are mainly non-steroidal in structure, and are either of plant origin or derived by the body's metabolism of precursors present in dietary components. They are present in virtually all plants, from negligible amounts in some plants to particularly high levels in others.

Overall, phytoestrogens have only a fraction of the strength of endogenous or typically exogenous doses of estrogen.

Some estimates place them at 1/100th the strength, and others at 1/1000th the strength. The ability of phytoestrogens to act as both estrogen agonists and estrogen antagonists appears to depend on the target organ, the dose, the nature of the estrogen receptor (alpha or beta), the total estrogens in the body, and the kind of phytoestrogen.

Soybeans are thought to have the highest content of phytoestrogens of any edible food. Another significant source is flax seeds. Many other foods, such as apples, carrots, fennel, celery, parsley, and other legumes, contain small amounts of phytoestrogens. Dozens of medicinal plants contain phytoestrogens and are discussed in the botanicals section.

A high dietary intake of phytoestrogens seems to explain why hot flashes and other menopausal symptoms appear to occur less frequently in cultures consuming a predominantly plant-based diet. In addition, such a diet is promising for disease prevention, with some research showing a lower incidence of breast, colon, and prostate cancer in those consuming high-phytoestrogen diets. Unfortunately a high percentage of women with European decent become allergic to soy product rather easily.

Soybeans are the richest food source of isoflavones, (a family of phytoestrogens), containing 1 to 2 mg of isoflavones per gram of soy protein. The isoflavones of soy are genistein, daidzein, and glycitein. Unfortunately many people of Northern European descent have sensitivities or an allergy to soy products. We have seen this as high as 70% of these patients. The allergy level is quite low among Asians and people from India. Several cultures that ate a lot of legumes as part of their traditional diet have lower allergy levels.

Not all soy protein products contain phytoestrogens. Some soy protein isolates have been processed with an alcohol extraction that removes the phytoestrogens. This is not a concern when eating soy foods, but one should be cautious when choosing other type of soy products. When using a soy powder or soy capsule, be sure to look for the isoflavone content on the label. Soy protein that has not had the phytoestrogens removed usually contains about 1.2 mg

per gram of protein as genistein, 0.5 mg per gram of protein as daidzein, and small quantities of glycitein. Different soy products contain differing amounts of isoflavones. It is valuable to know the isoflavone content of the various soy foods and soy products in order to target the desired dose per day.

Genestein has a sixfold greater affinity for the beta estrogen receptor than for the alpha receptor. That is why it may act differently in different tissues, depending on the nature of the estrogen receptors in that tissue. It may act as a pro- estrogen in the bones but an anti-estrogen in the breast.

Table 189-1. Isoflavone content of soy foods Soy food Amount Isoflavones (mg) Textured soy ¼ cup 62 protein granules Roasted soy nuts ¼ cup 60 Tofu, low-fat and ½ cup 35 regular Tempeh ½ cup 35 Soy beverage 1-2 scoops 25-90 (varies with product) powders Regular soy milk 1 cup 30 Low fat soy milk 1 cup 20 Roasted soy butter 2 tbsp 17 Cooked soybeans ½cup 150 Soy isoflavone pills Varies with the Varies with the manufacturer; read label manufacturer; read label Fermented soy Will contain lower amount of isoflavone pills isoflavones but may be better absorbed

A menopause diet should have other considerations besides those that recommend soy and flax seeds. Symptom relief is important, but perhaps of greater concern is reducing the risk of illnesses that increase mortality and morbidity. Diets intended to prevent heart disease, osteoporosis, diabetes, and cancer prevention are clearly warranted, as these conditions are most common in aging women. Diets higher in fruits, vegetables, whole grains, vegetarian proteins, nuts, seeds, and legumes, as well as low in saturated fats,

trans-fats, simple carbohydrates, and fast foods are the foundation of disease prevention; although individual needs and physiologic differences are fundamental to the approach. For example, women with diabetes and/or insulin resistance may need a higher-protein and lower- carbohydrate approach.

Several nutrients have been shown to be effective in relieving hot flashes and atrophic vaginitis in clinical studies, including vitamin E, hesperidin in combination with vitamin C, and gamma-oryzanol.

Vitamin E

In the late 1940s, several clinical studies found vitamin E to be effective in relieving hot flashes and menopausal vaginal complaints compared with a placebo. Unfortunately, there have been no further clinical investigations. In one study, vitamin E supplementation was shown to improve not only the symptoms but also the blood supply to the vaginal wall when taken for at least 4 weeks. A follow-up study published in 1949 demonstrated that vitamin E (400 IU/day) was effective in about 50% of postmenopausal women with atrophic vaginitis.

Vitamin E oil, creams, ointments, or suppositories can be used topically to provide symptomatic relief of atrophic vaginitis. Vitamin E may be effective in relieving the dryness and irritation of atrophic vaginitis as well as other forms of vaginitis.

Hesperidin and Vitamin C Like many other flavonoids, hesperidin is known to improve vascular integrity and relieve capillary permeability. Combined with vitamin C, hesperidin and other citrus flavonoids, it may be effective in relieving hot flashes.

In one clinical study, 94 women suffering from hot flashes were given a formula containing 900 mg of hesperidin, 300 mg of hesperidin methyl chalcone (another citrus flavonoid), and 1200 mg of vitamin C daily. At the end of 1 month, symptoms of hot flashes were relieved in 53% of the patients and reduced in 34%. Improvements in nocturnal leg cramps, nose bleeds, and easy bruising were

also noted. The only side effect was a slightly offensive body odor with a tendency for the perspiration to discolor the clothing.

Gamma-Oryzanol Gamma-oryzanol (ferulic acid) is a growth-promoting substance found in grains and isolated from rice bran oil. It is also found in the Chinese herb Angelica sinensis (Dong Quai root). In the treatment of hot flashes, its primary action is to enhance pituitary function and promote endorphin release by the hypothalamus. Gamma-oryzanol was first shown to be effective in menopausal symptoms, including hot flashes, in the early 1960s. Subsequent studies have further documented its effectiveness.

Gamma-oryzanol is an extremely safe natural substance. No significant side effects have been produced in experimental and clinical studies. In addition to being helpful in improving the symptoms of menopause, gamma- oryzanol has also been shown to be quite effective in lowering blood cholesterol and triglyceride levels.

Botanical Medicines

Trifolium pratense (Red Clover), a member of the legume family, has also been recognized as a medicinal plant for humans and, more recently, as a menopausal herb. The principal substances of red clover are the flavonoid glycosides, coumestans, volatile oils, L-dopa caffeic acid Red Clover Isoflavone conjugates, polysaccharides, and some miscellaneous plus resins, fatty acids, hydrocarbons, alcohols, chlorophyll, minerals, and vitamins. Red Clover Standardized Extract Two studies using 40 mg standardized extract of red clover (40% isoflavones) 125mg produced a 75% reduction in hot flashes after 16 weeks in Isoflavones 50mg Vitex 150 mg 30 women. A similar study, evaluating 40 mg of red clover Dandelion root 100mg standardized isoflavones for 2 months in 23 Black Cohosh 50mg postmenopausal women, found that red clover users had a 54% reduction in hot flushes versus 30% in the placebo group. Other intriguing effects of red clover reported by these studies are as follows: no endometrial thickening, increase in HDL, and no abnormalities in liver function parameters, complete blood count, or estradiol determination. The two most recent studies continue the contradictions. In 2002, 80 mg of isoflavones per day

resulted in a significant reduction in hot flushes as compared with baseline. The other, called the ICE study, compared two different doses of red clover isoflavones with placebo for 12 weeks. One dose was 82 mg and the other was 57 mg/day. The reductions in mean daily hot flash count at 12 weeks were similar for the 82-mg group, the 57-mg group, and the placebo group. However, in comparison with the placebo group, the 82-mg isoflavone group reduced hot flashes more rapidly. Lastly, a published study showed that red clover isoflavones may reduce risk of coronary vascular disease by increasing arterial elasticity by 23%.

Angelica sinensis (Dong Quai root) Proven over the millennia to be one of the most functional female blood tonics, this herb is very useful during menopausal transition. It is the most popular botanical used in the Orient for menopause, often used in combination. One study conducted in China showed that a combination of A. Suggested Program sinensis, Paeonia lactiflora, Ligusticum monnieri, Red Clover Iso-flavones Plus Atractylodes chinensis, Sclerotium poriae, and Alisma (standardized to 50 mg orientalis was effective in roughly 70% of women Isoflavones; 1 cap 2 times a day) experiencing menopausal symptoms. Femaherb (2 tabs 2 times a day) Calcium Magnesium Chelazome At Wild Rose formulas with Angelica sinensis have had the (Amino Acid Chelate; 2 caps 2 times a day) most benefit for menopausal problems.

Cimicifuga racemosa (Black Cohosh) Black cohosh has emerged as one of the most commonly used herbs for the treatment of menopausal symptoms. There have been several studies showing its effectiveness. In one of the largest studies, 629 women with menopausal complaints were given a liquid standardized extract of black cohosh twice daily for 6 to 8 weeks. As early as 4 weeks, clear improvements in the menopausal ailments were seen in 80% of the women. Complete disappearance of symptoms occurred in approximately 50%. Symptoms included hot flashes, night sweats, headaches, insomnia, and mood swings. The other studies reported improvements in fatigue, irritability, hot flashes, and vaginal dryness.

A later study of black cohosh involved 85 women diagnosed with breast cancer who were experiencing hot flashes. Fifty-nine of them (70%) were taking tamoxifen during the trial. Participants took either black cohosh

standardized extract of 40 mg twice daily or placebo. Both the black cohosh and placebo groups had a decline in the number and intensity of hot flashes during the first month of about 27%. Women in the black cohosh group did report a greater reduction in sweating. Although the results of this study are not consistent with those of other studies showing benefit from black cohosh for menopausal symptoms, it is important to acknowledge that the results should take into account that black cohosh may not work in the presence of an anti-estrogen such as tamoxifen. Further weaknesses in the study are that the duration was only 2 months and there was a high dropout rate, with most of the women remaining in the black cohosh group taking the tamoxifen.

Lifestyle Factors

Exercise: The hypothesis that impaired endorphin activity within the hypothalamus is a major factor in provoking hot flashes led researchers in Sweden to design a study to determine the effect of regular physical exercise on the frequency of hot flashes. In the study, the frequency of moderate and severe hot flashes was investigated in 79 postmenopausal women who took part in physical exercise on a regular basis. They were compared with a control group of 866 postmenopausal women between 52 and 54 years old.

The study clearly demonstrated that regular physical exercise definitely reduced the frequency and severity of hot flashes. The women in the exercising group passed through a natural menopause without the use of HRT. The physically active women who had no hot flashes whatsoever spent an average of 3.5 hours/week exercising, whereas women who exercised less were more likely to have hot flashes. Similar results, including mood elevation in premenopausal, perimenopausal, and postmenopausal women who were exercising or sedentary have been reported in other studies. The benefits of exercise were experienced in women who did and did not take HRT.

Part Five: Male Sexual Dysfunction and Holistic Treatment

Male sexual dysfunctions can exist in three primary areas: the penis, the scrotum and groin, and within the accessory reproductive structures contained within the pelvic cavity, such as the prostate.

Inguinal and scrotal inflammation

A lump or swelling found in the groin or scrotum is among the most common clinical presentation in both boys and men. Most lumps are either hernias or enlarged inguinal nodes. Inguinal herniations are more common than femoral herniations by a ratio of 4:1 (Swash 1995, 100). Within the scrotum, lumps could be a varicocele, a hydrocele of the tunica vaginalis, a hydrocele of the spermatic cord (spermatocele), a lipoma of the spermatic cord, a cyst of the epididymis, inflammation of the epididymis, or an enlargement of the testes (orchitis). It is necessary to get an accurate medical diagnosis however, to rule out the possibility of testicular cancer, or to determine the nature of a pathogenic agent. Inguinal and femoral hernias usually need corrective surgery.

Lymphadenopathy Enlarged lymph nodes in the groin typically indicate a genitourinary tract infection such as prostatitis or urethritis, most often caused by gram negative bacteria such as a Escherichia coli, Staphylococcus saprophyticus, Klebsiella and Proteus. The treatment of inguinal lymphadenopathy is secondary to the treatment of the underlying pathogenic factor. In most cases the use of urinary tract disinfectants such as Pipsissewa (Chimaphila umbellata), Buchu (Barosma betulina), Bearberry (Arctostaphylos uva-ursi), and Cubeb (Piper cubeba), used along with urinary tract demulcents such as fresh Corn silk (Zea mays), Couch Grass (Agropyron repens), and Marshmallow root (Althaea

officinalis), will resolve the issue. To improve lymphatic circulation lymphagogues such as Red root (Ceanothus americanus), Cleavers (Galium aparine), and Poke root (Phytolacca decandra) may be called for. Additional measures include the use of non-specific stimulants to immune function such as Echinacea (Echinacea angustifolia), Katuka (Picrorrhiza kurroa) and Wild Indigo (Baptisia tinctoria). Topical applications include astringents such as Witch Hazel bark (Hamamelis virginiana) and lymphagogues such as Poke root (Phytolacca decandra), the latter applied as an infused oil (1:3, fresh root), and covered with a hot washcloth, or used as a fomentation.

Varicocele A varicocele is the tortuous dilation of the pampiniform venous complex of the spermatic cord, forming a soft, elastic swelling that can cause pain but is more often asymptomatic. Essentially, a varicocele is a varicosity of the spermatic vein, in which the blood flows backwards to engorge the vein. Varicoceles are more common in the left testicle because the left testicular vein connects to the renal vein at a right angle, whereas the right testicular vein drains directly into the vena cava. Varicoceles of the right testicular vein however, may indicate an obstruction of the vena cava. In regard to examination, a varicocele is apparent upon standing rather than lying down, and feels like a "bag of worms" superior to the testicle. Varicoceles account for roughly 30 – 40% of male infertility cases, and occur in about 15 – 20% of the population. Although the cause of the infertility is unknown, it is thought that the increase in testicular temperature from the enhanced blood flow may inhibit spermatogenesis and sperm motility. Varicoceles can be diagnosed with examination, ultrasound, or venography (x-ray of testicles). (Swash 1995, 100-101; Berkow 1992, 1745; Junnila and Lassen 1998)

As varicoceles are essentially benign, it is worth treating them with holistic methods before using surgical methods. Further, holistic therapies can be used concurrently and after surgery to improve testicular circulation and prevent new varices from forming. The treatment of varicoceles is much the same as for the treatment of hemorrhoids and

varicose veins, but with some important modifications. Pelvic decongestants such as Stone root (Collinsonia canadensis) and White Dead Nettle (Lamium album) are an important part of treatment, as are venous astringents such as Horse Chestnut (Aesculus hippocastanum) and Witch Hazel (Hamamelis virgininica). Botanicals particularly rich in flavonoids such as Hawthorn (Crataegus oxycanthoides), Bilberry (Vaccinium myrtillus) Gotu Kola (Centella asiatica), Bhumy Amalaki (Phyllanthus amarus) and Arjuna (Terminalia arjuna) can also be considered to repair endothelial permeability and increase capillary resistance. In situations of impotence and sexual debility gonadal trophorestoratives such as Dang Gui (Angelica sinensis), Kapikachu (Mucuna pruriens), Cordyceps, Saw Palmetto (Serenoa repens), Yin Yang Huo (Epimedium grandiflorum), or Ashvagandha (Withania somnifera) can be included in formulation. To enhance the effectiveness of a formula, circulatory stimulants such as Rosemary (Rosmarinus officinalis) and Prickly Ash berry (Zanthoxylum americanum) should be included. Topical treatment involves the use of cold water sitz baths, and venous astringents such as Horse Chestnut (Aesculus hippocastanum) tincture, 15% v/v in a hypoallergenic cream base, applied over the affected area twice daily. Useful supplements include bioflavonoids and oligomeric proanthocyanidins such as pycnogenol, as well as vitamins A, C, E, and zinc. Dietary shifts should reflect an increase in whole foods and fiber, with an emphasis upon fruits such as blueberries and vegetables like carrots and kale to ensure an optimum intake of flavonoids and other supportive nutrients.

Hydrocele, hematocele and spermatocele A hydrocele is a common intrinsic swelling of the scrotum resulting from excessive accumulation of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis. In infants, a hydrocele is the result of persistence of the processus vaginalis, a diverticulum of the peritoneal membrane. This defect typically closes spontaneously within the first year of life and requires no specific therapy. In adults, a hydrocele may be due to a diminished resorptive capacity of the lymphatic and venous vessels, from

inflammation due to trauma or infection, or from testicular torsion or neoplasm. A hematocele is a solid mass of the tunica vaginalis comprised of blood, and is usually secondary to trauma. A spermatocele is a cyst of the epididymis or areas adjacent to the epididymis that contains dead sperm. Hydroceles and spermatoceles are easily distinguished from other scrotal masses by tensing the scrotal skin gently over the swelling and shining a bright light behind it. Both of these masses will transmit light, whereas a hematocele will not. The difference between a hydrocele and a spermatocele is that in the former the testis is not palpable separately from the swelling. In contrast, a spermatocele lies adjacent to the epididymis, superior and posterior to the testes, suggesting a "third testis." In very large spermatoceles however, it may be difficult to differentiate it from a hydrocele, in which case ultrasonography may help with the diagnosis. (Swash 1995, 100-101; Berkow 1992, 1745; Junnila and Lassen 1998)

Similar to varicoceles, hydroceles and spermatoceles are typically benign, and holistic methods may be utilized before surgery is resorted to. Many of the same methods of treatment utilized for a varicocele may be used in the management of hydrocele and spermatocele, but with the additional use of lymphagogues such as Red Root (Ceanothus americanus), Cleavers (Galium aparine) and Poke root (Phytolacca decandra). Serous tonics such as White Bryony (Bryonia dioica) may be of use, especially if there is some tenderness upon pressure. Gonadal restoratives such as Dang Gui (Angelica sinensis), Kapikachu (Mucuna pruriens), Cordyceps, Saw Palmetto (Serenoa repens), Yin Yang Huo (Epimedium grandiflorum) and Ashvagandha (Withania somnifera) are also indicated to restore proper function. Topically, a tincture of Poke root (Phytolacca decandra) infused in castor oil (10-20% v/v), or a Poke root castor oil infusion (1:3), with the addition of a few drops each of essential oils of Chamomile and Lavender, may be applied locally. The management of acute pain associated with hydrocele can be helped by preparing an ice pack and applying it topically.

Epididymitis Epididymitis is an acute or chronic inflammation of the epididymis, a complication resulting from sexually

transmitted diseases, ascending urinary tract infections, or prostatitis. It is the most common cause of scrotal swelling in postpubescent males. Pyuria, or leukocytes in the urine, is a laboratory feature of epididymitis, and the absence of pyuria makes the diagnosis of epididymitis unlikely. In males under the age of 35 the organism typically involved is Chlamydia trachomatis, but could be Neisseria gonorrhoeae. In prepubescent males and males over the age of 35, the most common cause of epididymitis is a bacterial infection of the urinary tract. Gram's stain and culture should be obtained however, in order to rule out a sexually transmitted disease. If the test is positive for an STD, the patient's sexual partner(s) should be treated as well. It should be pointed out that epididymitis can be tubercular in origin. Symptoms include difficult urination, fever, chills, groin pain, and a tender, swollen epididymis that may be difficult to distinguish from the testis. (Swash 1995, 100-101; Berkow 1992, 1745; Junnila and Lassen 1998)

The treatment of epididymitis resembles some of the components in the treatment of pelvic inflammatory disease in women, emphasizing antimicrobial and urinary antiseptics, as well as soothing diuretics and anodynes. Important antimicrobial agents include Goldenseal (Hydrastis canadensis), Echinacea (Echinacea angustifolia), Wild Indigo (Baptisia tinctoria) and Sarsaparilla (Smilax spp.). Useful urinary antiseptics to include if the epididymitis is secondary to a urinary tract infection are Pipsissewa (Chimaphila umbellata), Buchu (Barosma betulina), Bearberry (Arctostaphylos uva-ursi), and Cubeb (Piper cubeba), used along with urinary tract demulcents such as fresh Corn silk (Zea mays), Couch Grass (Agropyron repens), and Marshmallow root (Althaea officinalis). Important anodynes in the genitourinary tract include Kava (Piper methysticum), Pasqueflower (Anenome occidentalis), and Henbane (Hyocyamus niger). If the condition occurs with hemorrhoids, pelvic decongestants such as Stone root (Collinsonia canadensis) or Ocotillo (Fouquieria splendens) are called for. If the condition is more or less chronic in the absence of a urinary tract infection, the addition of gonadal restoratives such as Dang Gui (Angelica sinensis), Kapikachu (Mucuna pruriens), Cordyceps, Saw Palmetto (Serenoa repens), Yin Yang Huo (Epimedium grandiflorum), or Ashvagandha

(Withania somnifera)is useful. Topical measures include scrotal ice packs and scrotal elevation with adhesive strips. King’s American Dispensatory recommends the topical application of an infusion of Tobacco (Nicotiana tabacum) in epididymitis, applied as a compress to relieve pain. (Felter and Lloyd 1893)

Orchitis Orchitis is an acute inflammation of one or both testicles, presenting as a sudden onset of testicular pain, high fever, abdominal pain, and nausea and vomiting. The testis is enlarged (about 2 – 3 times larger), swollen, and tender upon palpation. The causes of acute orchitis must be clearly established before treatment, as both testicular trauma and torsion require immediate surgery to prevent permanent damage to the testis. Without such an indication, orchitis may be a complication of a urinary tract infection, a sequela to gonorrhea, syphilis or tuberculosis, a complication of prostate surgery, and most commonly, the result of viral parotitis (mumps). In some cases, orchitis may be an autoimmune response to spermatozoa, more common in older men and after a vasectomy. Orchitis as a complication of parotitis occurs in about 20% of postpubescent men, presenting as a unilateral swelling of the testes that accompanies or follows the inflammation of the salivary glands. Some degree of testicular atrophy may ensue, and in about 4% of cases inflammation of both testes results in a loss of spermatogenesis, although androgenic activity is maintained. The swelling typically resolves on its own in about 7 – 10 days, and if the testes appear smaller than before the swelling, atrophy is indicated. The medical treatment of orchitis is based upon the causative factor. Chlamydia trachomatis is most often the organism implicated in non-viral orchitis, and other diseases such as tuberculosis, syphilis, or mycotic (fungal) infections are now rare. (Swash 1995, 100-101; Berkow 1992, 1745; Junnila and Lassen 1998)

The holistic treatment of orchitis utilizes supportive therapies such as bed rest, scrotal support and ice packs, antimicrobial therapies if infection is suspected, as well as anti-inflammatory and analgesic therapies. The use of antimicrobials agents in herbal therapy is the same in orchitis as they are for a genitourinary tract infection,

discussed previously under epididymitis. Important botanicals that have anti-inflammatory and analgesic activity include Arnica (Arnica montana), White Bryony (Bryonia dioica), Kava (Piper methysticum), and Pasqueflower (Anenome pulsatilla), the latter in particular indicated in enlarged and painful testes, with no underlying major pathology (Moore 1990, 27). In cases of chronic orchitis in the aged, gonadal restoratives are also indicated, and if accompanied with biliary congestion, a sense of pelvic heaviness, or hemorrhoids, pelvic decongestants and cholagogues such as Stone root (Collinsonia canadensis), Ocotillo (Fouquieria splendens) and Dandelion root (Taraxacum officinalis) are indicated. In addition to scrotal ice packs and scrotal support, topical therapies include Arnica (Arnica spp.) as a lotion or liniment, containing the essential oils of Lavender and Roman Chamomile. Once again, Felter and Lloyd recommend an infusion of Nicotiana as a compress (1893).

Prostatic infection and inflammation

Prostatitis is the inflammation of the prostate gland, differentiated into an acute or chronic bacterial prostatitis, a chronic nonbacterial prostatitis, and benign prostatic hypertrophy.

Bacterial Prostatitis Acute bacterial prostatitis is an acute infection of the prostate gland, the patient presenting such symptoms as chills, fever, urinary frequency and urgency, burning upon urination, hematuria, and perineal and lumbar pain. Upon examination the prostate will feel swollen, tense, and warm to the touch, and laboratory investigation of the cultured prostatic secretions will yield a high bacterial count, most commonly enteric, gram-negative organisms. Chronic bacterial prostatitis is similar to the former, except the symptoms are less acute and display a greater degree of variability. The symptoms are distinguished by a relapsing urinary tract infection that can range from being asymptomatic except for bacilluria, to urinary frequency and urgency, burning upon urination, hematuria, and perineal and lumbar pain. With chronic infection, the

scrotal contents may become affected presenting as epididymitis and/or orchitis. Upon examination the prostate may be boggy or irregularly swollen and tense, and somewhat tender. (Berkow 1992, 1715)

The holistic treatment of bacterial prostatitis is once again similar to that mentioned in the treatment of epididymitis, with an emphasis upon urinary antiseptics, systemic antimicrobials, urinary tract demulcents, and anodynes. In chronic bacterial prostatitis dietary and lifestyle factors should be duly considered, with an emphasis upon stress reduction and management, the elimination of methylxanthine-containing beverages, and a diet without carbohydrates, which tend to increase truncal-abdominal obesity and thus promote pelvic congestion. Of course normal treatment for bacteria (especially in urinary tract) are used include Berberini (Coptis) Barberry (Berberis) or Goldenseal (Hydrastis).

Chronic nonbacterial prostatitis Chronic nonbacterial prostatitis is more common than bacterial prostatitis but is idiopathic. The symptoms resemble those of chronic bacterial prostatitis, and although laboratory investigation may show an elevation of leukocytes in the urine, cultures of the urine and prostatic secretions fail to indicate a pathogenic organism (Berkow 1992, 1716).

The medical approach to chronic nonbacterial prostatitis is limited in scope, with reliance upon topical measures such as sitz baths, anticholinergic drugs and prostatic massage. The holistic treatment, in contrast, views the issue somewhat differently, and takes into account several factors that are usually not addressed with a conventional approach. Chronic nonbacterial prostatitis is a congestive condition, and thus anything that promotes pelvic congestion may underlie the condition. Many men for example, spend much more time sitting than our forebears, such that it is not uncommon for men to sit for more than 8 hours a day, 5 days a week. Such inactivity, often complexed with dietary factors that inhibit liver and digestive function such as stress, a diet high in refined foods and saturated fats, as well as methylxanthine

containing beverages and a high carbohydrate diet promotes pelvic congestion.

What are Kegel Prostatic congestion can also be a symptom of non- exercises? ejaculatory sex and extended periods of arousal, both of Kegel exercises were originally which enhance prostatic circulation, but inhibit elimination. developed by gynecologist Arnold Kegel to help incontinent women. Some commentators, such as James Green in his book The The technique utilizes a series of Male Herbal, note that men are now exposed to overt isometric exercises to strengthen the sexual stimuli in an increasing fashion, from books and pubococcygeal (PC) muscle. Since magazines, to television and movies. Green suggests that then, the technique has been used such chronic stimuli congests sexual energy, promoting not only in the treatment of bladder control problems, but to enhance the prostatic enlargement and inflammation (1991, 113). tone of the entire genitourinary system in both men and women. There are other factors that may underlie prostatitis. Men The technique involves the familiar who bicycle frequently are at an increased risk of muscular action required to stop the prostatitis, and should be counseled to try many of the flow of urine while voiding. There are two parts to Kegel exercises, newly designed bicycle seats that take some of the pressure both of which are best performed in off of the perineal region. Excessive sexual activity may a supine position, with the knees also irritate prostate function, as might the habitual tucked into the chest: consumption of spicy foods that are traditionally said to 1. Slow clenching – contract and inhibit male sexual function. The regular excessive hold the PC muscle for a slow count of three, and then relax. consumption of alcohol, and especially beer, may also tax Repeat 9 times. the prostate through the distension of the urinary bladder 2. Fast clenching – rapidly and excessive diuresis. Another factor traditionally ascribed contract and relax the PC muscle to prostatic inflammation is the suppression of urination. thirty times, and then relax. The call to eliminate should never be ignored, and many Repeat twice. men can actually trace the cause of their prostatitis to an Both techniques should be repeated occasion in which the suppression of urination caused acute as much as five times a day, and can pain. Such an event is likely to cause permanent damage even be performed while at work. and chronic inflammation, and although the exact cause is Initially, there may be difficulty in unclear, it most likely stems from the acute distension of performing these exercises, but with practice the PC muscle will become the urinary tract and the retrograde flow of urine. stronger and contractions will become easier. Both Tai chi and The treatment of chronic nonbacterial prostatitis with Yoga utilize certain positions that botanicals rests upon the use of pelvic decongestants, also strengthen the PC muscle. urinary tract demulcents, anodynes, and gonadal restoratives. Additional measures include the use of botanicals that appear to have direct decongestant activity upon the prostate such as Fireweed root (Epilobium angustifolium), Nettle root (Urtica dioica), Saw Palmetto (Serenoa serrulata), Buchu (Barosma betulina), and Goldenrod (Solidago canadensis). Topical measures include the use of alternating hot and cold sitz baths (always ending with cold), a lotion blended with the essential oils of Lavender and Roman Chamomile (5% v/v)

rubbed into the perineal area, and rectal suppositories, such as the following:

1 part Echinacea (Echinacea angustifolia) tincture 1 part Saw Palmetto (Serenoa serrulata) tincture 3 parts Glycero-gelatin

Prepare the glycerol-gelatin base by mixing one part glycerin, one part gelatin, and one part water in a double boiler. When constituents have dissolved add in the tinctures. Pour in suppository molds, and add about 5% essential oils of Chamomile and Lavender before suppository has cooled. Insert 1-2 suppositories before bed.

Additional measures in the treatment of nonbacterial prostatitis include stress management, Kegel exercises, Tai chi, Hatha yoga, anaerobic exercises such as leg presses and squats, and regular ejaculation. Useful supplements include zinc citrate (50 mg daily), vitamin B complex (50- 100 mg daily), and EPA/DHA (1000 mg each daily). Other important dietary and lifestyle considerations include the elimination of excessive amounts of saturated fat, and the elimination of coffee, nicotine, marijuana, and alcohol. Helpful dietary measures include increasing fiber intake through the consumption of leafy green vegetables and whole grains. As previously stated, prostate problems often occur in association with the truncal-abdominal obesity pattern, and thus measures to correct the underlying problem of insulin resistance and hyperinsulinemia are recommended.

Benign Prostatic Hypertrophy Benign prostatic hypertrophy (BPH) refers to the adematous enlargement of the periurethral prostate gland, promoting obstruction of the urethra and bladder opening. It is a disease commonly seen in men over the age of 50; although the etiology is unclear, it may involve alterations in hormonal balance associated with aging. BPH is less common in the Orient and more frequent in the Western world, and within North America, has a higher frequency among blacks than whites. With aging however, the incidence of BPH increases in all populations, and by about 80 years of age, 90% of men have prostatic hypertrophy. (Berkow 1992, 1736; Rubin 2001, 501-02)

In the initial stages of the disease multiple nodules derived from epithelial, stromal and smooth muscle cells begin to occur in the periurethral region of the prostate. Five types of nodules have been found, with fibromyoadenomatous nodules being the most common. Histologically, the hyperplastic tissue is glandular, with varying amounts of stromal tissues interposed. Gradually, the progressive growth of these hyperplastic nodules begins to distort and compress the urethra, placing pressure upon the peripheral areas of the prostate. With progressive compression and urinary obstruction there is an increased risk of secondary infection and the development of urinary calculi. The bladder becomes distended, and the retrograde flow of urine can impair renal function and promote hydronephrosis. In the latter stages the flow of urine may become completely blocked, causing acute pyelonephritis, uremia, and death. In the vast majority of cases however, BPH rarely progresses beyond being an annoying chronic condition.

The symptoms of BPH are progressive frequency and urgency, difficulty initiating urination, decreased urine flow and force, and nocturia. Upon rectal examination the prostate is enlarged and has a rubbery consistency, and an abdominal exam may reveal a distended bladder that is palpable or percussible. The congestion of the superficial veins of the prostate and the trigone muscle of the bladder can cause hematuria if the patient strains while trying to void. Burning sensations and fever indicate secondary infection.

Although testosterone levels typically decline with aging, it is clear that testosterone plays a role in the pathogenesis of the hyperplasia. Specifically, it is the conversion of testosterone into 5-alpha-dihydrotestosterone by 5-alpha- reductase within the prostate that is thought to cause the hypertrophy. 5-alpha-dihydrotestosterone is about fives times more potent than testosterone and thus has a greater stimulatory effect. Additionally, with the declining levels of testosterone estrogen levels begin to increase. Some researchers have speculated that the prostate is divided into an inner and outer mass, the outer mass responsive to testosterone and the inner to estrogen. The relative increase of estrogen with aging, complexed with the ubiquitous influence of xenoestrogens from dietary and environmental

sources, causes the inner prostatic mass to enlarge. Cadmium has also been found to induce prostatic hyperplasia in animals, and has been found to be elevated in prostatic tissues in patients with BPH, proportional to the elevated levels of 5-alpha-dihydrotestosterone. (Berkow 1992, 1736-37; Rubin 2001 501-02; Green 1991, 104-05; Brys et al 1997; Hoffmann et al 1985; Habib et al 1976)

The treatment of BPH is essentially the same as it is for chronic nonbacterial prostatitis. Treatment strategies for secondary infection will resemble that of bacterial prostatitis. Saw Palmetto (Serenoa repens) is one botanical that has undergone extensive investigation in the treatment of BPH, and has been found to inhibit 5-α-reductase, reduce inflammation, lower androgenic activity, and prevent spasm (Newall et al 1996, 237). Two studies have thrown a kink in the use of Saw palmetto. One in which 257 patients where given a combination of 320 mg of S. repens and 240 mg of Urtica extracts per day or placebo. In this study there was a Suggested Program substantially higher group with symptom relief of excessive night urination and prostatic pain.2 In another study there Prostate formula 1 capsule 3 seemed to be no relief if Saw Palmetto was used by itself. BID or 30 drops of At Wild Rose we always use a combination formula with tincture BID good results. BEVC 2 tablets, BID Saw Palmetto is by no means the only herb for BPH and Essential Fatty Acids should not be relied upon exclusively. Pumpkin and squash 2,000 mg, BID seeds (Cucurbita spp.) have also been traditionally used in Eat tomato paste (3 BPH, and contain curcubitacin, as well as various tablespoons 2 -3 times a tocopherols and sterols, that have been shown to enhance week), a handful of bladder tone and promote prostatic decongestion (Weiss pumpkin seeds daily and 1988, 254). The seeds from fresh squash and pumpkin can eat fish 2-3 times a week be eaten straight or soaked overnight in cool water and then for 3-6 months. blended the next day to make a soothing diuretic. The use

of lycopene found in tomatoes has had great success. Other botanicals of benefit in relieving prostatic congestion are Fireweed root (Epilobium angustifolium) and Nettle root (Urtica dioica). Genitourinary trophorestoratives such as Ren Shen (Panax ginseng), Ashvagandha (Withania somnifera), and Cordyceps have long been used by elderly men to combat the effects of aging, and may be very

2 Lopatkin N, Sivkov A, Walther C et al: Long-term efficacy and safety of a combination of sabal and Urtica extract for lower urinary tract symptoms--a placebo-controlled, double-blind, multicenter trial. World J Urol 23:139-146, 2005 3 Bent S, Kane C, Shinohara K et al: saw palmetto for benign prostatic hyperplasia. N Engl J Med 354:557- 566, 2006.

important adjuncts in the treatment of BPH. Useful also are Prostate tincture botanicals typically reserved for women, such as the Saw Palmetto (Serenoa repens) 3 prt emmenagogue Cotton root (Gossypium herbaceum) Nettle Root (Urtica dioica) 2 prt indicated in both acute and chronic prostatitis, and the Buchu (Barosma betulina) 1 prt uterine tonic Dang gui (Angelica sinensis) as a gonadal Uva Ursi (Arctostaphylos uva-ursi) 1 prt Corn Silk Zea mays 1 prt restorative. Botanicals that are helpful in the elimination of urinary calculi, which can accompany BPH, are Gravel root Dosage: 30 drop bid (Eupatorium purpureum), Couch Grass (Agropyron repens), Hydrangea (Hydrangea arborescens), and Horsetail (Equisetum arvense). To strengthen the trigone muscle of the bladder and relieve venous stasis Michael Moore suggests the root of Mullein (Verbascum thapsus) may be helpful (1990, 16). To relieve the pain and spasm of BPH, Kava (Piper methysticum), Black Cohosh (Cimicifuga racemosa), or Trembling Aspen bark (Populus tremuloides) are indicated. Important nutritional supplements include zinc (50 mg daily) to inhibit 5-α- reductase activity and selenium (200 mcg daily) to counter cadmium-induced prostatic hypertrophy, as well as vitamin E (800 IU daily), vitamin B complex (25 - 50 mg daily), and EPA/DHA (1000 mg daily).

Diet has been shown to play a large role in relieving BPH. A low-fat, high-vegetable and high protein diet has shown to be effective in reducing BPH. In one study, 4770 men were followed for seven years. In it the above diet, especially if tomato paste (lycopene) and Vitamin D were included, resulted in a lower incident of BPH.4

Hormonal dysfunction and male infertility

Hormonal dysfunctions can have a variety of effects upon male fertility, and given the rising incidence of hormonal dysfunction and infertility in both men and women, new strategies are needed to counter these effects.

4 Kristal AR, Arnold KB, Schenk JM, et al: Dietary patterns, supplement use, and the risk of symptomatic benign prostatic hyperplasia: Results from the prostate cancer prevention trial. Am J Epidemiol 167(8):925- 934, 2008.

Hypothalamic-pituitary dysfunction Consistently high levels of FSH indicate dysfunctional Sertoli cells, and are usually accompanied by low LH and low testosterone levels. Such findings may indicate testicular failure, for which there is no medical treatment available. Holistic methods however, may make use of the rich repertoire of aphrodisiac and genitourinary trophorestorative botanicals used in both Chinese and Ayurvedic medicine. Among those used in Chinese medicine, the majority of them nourish and support the Kidney Yang, including Lu Rong (Deer antler, deer antler velvet), Ge Jie (Gecko), Dong Chong Xia Cao (Cordyceps), Yin Yang Huo (Epimedium grandiflorum), Ba Ji Tian (Morinda officinalis), Bu Gu Zhi (Psoralea coryfolia), Yi Zhi Ren (Alpinia oxyphylla), and Du Zhong (Eucommia ulmoides). Such kidney restoratives may also be used in conjunction with herbs that support the Kidney Yin and Blood, especially when symptoms of heat are present, including Shu Di Huang (Rehmannia glutinosa), Dang Gui (Angelica sinensis), Bai Shao (Paeonia lactiflora), Gou Qi Zi (Fructus lycium), Xi Yang Shen (Panax quinquefolium), Tian Men Dong (Asparagus cochinchinensis), Shi Hu (Dendrobium nobile), and Nu Zhen Zi (Ligustrum lucidum). In Ayurvedic medicine aphrodisiac remedies are called vajikarana rasayanas, meaning “to do like a horse,” and include Ashvagandha (Withania somnifera), Kapikachu (Mucuna pruriens), Tila (Sesamum indicum), Amalaki (Emblica officinalis), Gokshura (Tribulus terrestris), Shatavari (Asparagus racemosa), Jatamamsi (Nardostachys jatamansi), and Bala (Sida cordifolia). Other substances used in Ayurvedic medicine to enhance male sexuality include Shilajitu (Mineral pitch), goat testicles, and tortoise eggs.

Consistently high levels of LH accompanied with low testosterone levels can indicate problems within the Leydig cells, whereas consistently low levels of both LH and FSH may indicate problems within the hypothalamic-pituitary axis. Both of these situations call for the use of botanicals high in steroidal saponins, such as vajikarana and Kidney Yin/Yang restoratives. Examples of these are Ashvagandha (Withania somniferum), Dang gui (Angelica sinensis), Ren Shen (Panax ginseng), Dong Chong Xia Cao

(Cordyceps) and Licorice root (Glycyrrhiza glabra). Any genitourinary trophorestorative therapy should be given for a sustained period of time, and should accompany major dietary and lifestyle changes such as stress reduction, the elimination of coffee, alcohol, nicotine and recreational drugs, and an adherence to a whole foods diet.

Gynecomastia Gynecomastia is the enlargement of the breast, most usually in pubescent males as a transient swelling of breast tissue under the areolae that appears as a hardened disk. Gynecomastia may also occur with aging, or may accompany hepatic disease, regular marijuana consumption, and with the use of various pharmaceutical drugs. Obesity is also a risk factor for gynecomastia, due to the conversion of androgens into estrogen by adipose tissue. (Berkow 1991, 1815; Rubin 2001, 549)

This problem is becoming more and more common. The presumed cause is xenoestrogens in our environment, especially plastic bottles, but there are many other sources.

The holistic treatment of gynecomastia depends upon the cause, and includes weight loss management or the use of botanicals such as Chasteberry (Vitex agnus castus) as a dopaminergic to counter elevated prolactin levels in a pituitary tumor. Additional therapies include hepatoregenerative and cholagogue botanicals such as Milk Thistle seed (Silybum marianum), Turmeric (Curcuma longa), and Wu wei zi (Schizandra chinensis), the symptomatic usage of phytoestrogens such as Red Clover (Trifolium pratense), and the use of reproductive trophorestoratives such as Ren Shen (Panax ginseng) and Ashvagandha (Withania somnifera).

Thyroid function Both the hyperfunction and hypofunction of the thyroid can alter sperm production and decrease libido. If hyperthyroidism is suspected or indicated by diagnostic tests the most important botanical to consider is Bugleweed (Lycopus virginicus), which contains lithospermic acid that acts as a competitive inhibitor of thyroid stimulating hormone (TSH). Additional measures to control

palpitations and nervous irritability include Motherwort (Leonorus cardiaca) and Night-blooming Cactus (Selenicerus grandiflorus). Hypothyroidism is best treated by using foods high in organic iodine such as sea weed, and botanicals that act as adaptogens such as Siberian Ginseng (Eleuthrococcus senticosus), Sarsaparilla root (Smilax spp.), and Ren Shen (Panax ginseng). Other botanicals that can be of use in hypothyroidism include Cayenne fruit (Capsicum spp.), Oregon Grape root (Mahonia aquifolium), and Guggulu (Commiphora mukul). The complete treatment of thyroid disorders is covered in A Life in Balance: Metabolic Function and Botanical Medicine.

Sperm dysfunction Male infertility is often linked with various forms of sperm dysfunction. Spermatogenesis and sperm morphology has already been discussed in Part Two, and factors that negatively affect male fertility are discussed in Part Four. Oligospermia is a low sperm count, which apart from anatomical issues, usually relates to hormonal deficiencies. The holistic treatment of oligospermia rests upon the use of herbs that enhance spermatogenesis, including Chasteberry (Vitex agnus castus), Ren Shen (Panax ginseng), Sarsaparilla (Smilax spp.), Dong Chong Xia Cao (Cordyceps), Ashvagandha (Withania somnifera), Epimedium (Epimedium macranthum), and Kapikachu (Mucana pruriens). Asthenospermia is poor sperm motility, and if it is the only factor is usually indicative of a genitourinary infection. Thus the treatment of asthenospermia requires the use of antimicrobials such as Buchu (Barosma betulina), Bearberry (Arctostaphylos uva-ursi), Pipsissewa (Chimaphila umbellata), Dong Chong Xia Cao (Cordyceps) and Myrrh (Commiphora mukul). Teratospermia is poor sperm morphology, which in association with poor motility often indicates an autoimmune reaction to the spermatozoa. Immunomodulants such as Ling Zhi (Ganoderma lucidum) and Huang Qi (Astragalus membranaceus,) Dong Chong Xia Cao (Cordyceps) are indicated, as well as a diet with a low level of immunogenicity (e.g. the Paleolithic diet). Other key strategies involve avoiding the ingestion of sperm, often from post-coital cunnilingus. Pyospermia is a

high white blood cell count in semen, and is indicative of a genitourinary infection, and should be treated accordingly.

The ubiquitous presence of xenoestrogens in the diet and environment may be responsible for a variety of effects upon male fertility. Reduced sperm counts, a rise in anatomical defects such as undescended testes, hermaphroditism, and a rise in reproductive cancers can all be correlated to the influence of xenoestrogens. The rates of male infertility have risen sharply since the early 1980’s, and over the last 50 years there has been a substantive decrease in the quality and quantity of sperm. In Britain, for example, the testicular cancer rate has more than doubled in the last 50 years, and is now the most common cancer in men under 30 (Moller and Evans 2003). Thus, measures should be taken to limit the effects of xenoestrogens by enhancing hepatic elimination with cholagogues and the use of phytoestrogens. Further, the diet should be comprised of organic whole foods, supported by a Danish study published in the Lancet that showed that male farmers who ate pesticide-free foods produced roughly double the average number of sperm (Abell et al 1994).

Erectile disorder Erectile dysfunction (ED), also called impotence or sexual arousal disorder, refers to the inability to attain or sustain an erection satisfactory for sexual intercourse. There are two primary forms of ED. Psychogenic ED is caused by psychological factors, such as an abnormal fear of the vagina, sexual guilt, fear of intimacy, or depression. Organic ED can result from vascular, nervous, or hormonal causes. At one time, psychogenic ED was thought to be the primary form of ED, but it is now recognized that organic ED accounts for up to 80% of all cases. In some situations however, psychogenic effects occur simultaneously with organic causes. (Berkow 1992, 1575; Brosman 2005)

There are many conditions associated with ED, including aging, chronic disease (cardiovascular disease, liver disease, renal disease), endocrine abnormalities (hypogonadism, hyperprolactinemia, hyper/hypothyroidism, hyperinsulinemia and diabetes), lifestyle habits, neurogenic causes (e.g. multiple sclerosis, spinal cord

injury, herniated disk), penile injuries, drugs, psychological issues, pelvic trauma or surgery, and pelvic radiation. The most common medical conditions associated with ED are those conditions in which there is an impairment of arterial flow to the erectile tissues, or disruption of the neuronal circuitry. Patients with diabetes mellitus have the highest rates of ED as a result of vascular disease and autonomic dysfunction. Up to 25% of ED cases are caused by medication, most commonly those used to treat hypertension (e.g. diuretics, beta-blockers, and sympatholytics) and psychiatric disorders (e.g. antipsychotics, anxiolytics, and antidepressants). Additionally, both the regular consumption of alcohol and smoking have been associated with an increased incidence of ED. With aging there is typically a diminution of spontaneous erectile function with erotic thoughts or activity. The easy to achieve erection that occurs in youth begins to become less a feature of male sexuality by about mid-life. Often, some form of consistent tactile stimulation is required to sustain an erection, and when achieved, may not be as hard as experienced in youth. With these changes, the man may become increasingly anxious about his sexuality, which may further exacerbate the condition. (Berkow 1992, 1575; Keene and Davies 1999; Brosman 2005)

In the recent past the success of medical treatments for ED were acknowledged to be ineffective, cumbersome, or invasive. Previously popular measures included vacuum devices used prior to sexual activity, the urethral insertion of a prostaglandin compound, and penile implant surgery. Oral medications consisted of testosterone, which has since been shown to be ineffective if the cause is not hormonal. The introduction of sildenafil (Viagra, Revatio) however, has largely replaced these measures, and has been shown to enhance erection during erotic stimulation without surgery or invasive procedures. Sildenafil acts by blocking the activity of phosphodiesterase V, an enzyme found primarily in the penis. The inhibition of this enzyme allows for corporal smooth muscle relaxation and the prolongation of penile engorgement and erectile enhancement. Adverse effects of sildenafil include headache, flushing, dyspepsia, and visual disturbance, the latter of which is most likely due to the weak inhibition of phosphodiesterase VI located in the retina. Severe adverse reactions and even fatalities

have been documented when sildenafil is taken with other medications. Thus, the American College of Cardiology recommends that patients taking multiple antihypertensive medications, who have a recent history of angina or myocardial infarction, have severe left ventricular dysfunction and low blood pressure, or are taking drugs that can inhibit the hepatic cytochrome P450 system, should avoid sildenafil.

The holistic treatment of ED is essentially the same as it is for sperm dysfunctions such as oligospermia, using dietary, lifestyle, nutritional, and botanical therapies to enhance male reproductive function and the overall “vital essence.” One botanical traditionally used in the treatment of ED and sexual dysfunction is the bitter tasting Yohimbe bark (Pausinystalia yohimbe), native to tropical West Africa and used traditionally by the Bantu people as a stimulant in mating rituals. It is a central nervous system stimulant and mild hallucinogen with cholinergic and adrenergic- blocking activities, increasing pelvic blood supply and affecting the spinal ganglia to promote erections. The dose of a 1:5 tincture is 5-30 gtt., and the effects last anywhere from 2 to 4 hours. Yohimbe however, is a monoamine oxidase inhibitor, and if taken with sedatives, tranquilizers, antihistamines, narcotics, or alcohol, may promote a severe hypotensive crisis. Taken with amphetamines, LSD, methylxanthines such as caffeine, or dairy products, Yohimbe may promote a hypertensive crisis. Like sildenafil, Yohimbe is contraindicated in cardiovascular disease and with antihypertensive medication.

Safer than Yohimbe is Yin Yang Huo (Epimedium grandiflorum), a Chinese botanical used to nourish the Kidney Yang, whose name translates as “Horny Goat Weed.” Bensky and Gamble report that it has been shown to enhance sexual activity, increase spermatogenesis, and stimulate sexual desire (1993, 342). It is often prepared in rice wine, but an ethanol extract may also be made (1:5 40% alcohol), dosed between 3-5 mL. Yin Yang Huo is contraindicated in dryness, thirst, and symptoms of heat and inflammation.

Another helpful botanical in ED that is used in Ayurvedic medicine is Kapikachu seed (Mucana pruriens), a slender climbing annual found throughout India. Apart from its use

in the treatment of ED, it is an important botanical in the treatment of Parkinsonism, and contains significantly high amounts of naturally occurring L-DOPA, up to 7.64% (St- Laurent et al 2002). The dose is 3-5 g of the powdered seed, or 3-10 mL of a 1:3 tincture (40-50% alcohol).

Although botanicals such as Yohimbe bark (Pausinystalia yohimbe) and Epimedium herb (Epimedium grandiflorum) can be successfully used to treat sexual dysfunction, they are, by their very natures, highly stimulating. If they are taken long term or used inappropriately they can lead to the depletion of the vital essence or have negative side-effects. Thus, these botanicals should be used in association with others that have a more generalized nutritive property, such as American Ginseng (Panax quinquefolium), Dang gui (Angelica sinensis), Cordyceps, Ashvagandha (Withania somnifera), Saw Palmetto (Serenoa serrulata), and Milky Oat seed (Avena sativa).

Relationship factors play an important part in ED, and if the man is in relationship, both partners will need to be part of the treatment strategy. Although sexuality is often heightened in the early stages of a relationship, over time sexual roles may take on an almost perfunctory nature. If this dynamic is apparent in the relationship the couple should be encouraged to examine new levels of intimacy and sensuality. Men with ED require more time to achieve an erection and thus extended sessions of foreplay prior to intercourse may be of benefit. Further, the use of sexual stimulants may enhance the patient’s sexual appetite, and the partner should be made aware of this possibility.

Lifestyle and dietary factors are essential to take into consideration. The parasympathetic nervous system, the rest and restorative aspect of autonomic function, mediates the sexual response. Thus, if the patient with ED is found to have a high level of emotional stress this could be the underlying cause of the condition. Other important habits include all those that enhance and rebuild the vital essence of the body such as the avoidance of nicotine, alcohol, caffeine, and marijuana, and limiting excessive exposure to solvents, cleaning agents, industrial chemicals, and electromagnetic radiation. Controlling weight gain is another aspect in the treatment of ED, and measures taken to improve self-image will go a long way to enhancing

sexuality. The diet should be comprised of organic, whole foods, with possible supplements that include vitamin B complex (50 mg daily), vitamin C (1,00 mg bid), selenium (200 mcg daily), and zinc (50 mg daily).

APPENDIX

Botanical classifications: Herbs for Women

Uterine tonics Hepatics Angelica sinensis (Dang gui root) Mahonia spp. (Oregon Grape) Caulophyllum thalictroides (Blue Cohosh root) Barberry (Barberry) Chamaelirium luteum (False Unicorn root) Taraxacum officinale (Dandelion) Aletris farinosa (True Unicorn root) Cynara scolymus (Artichoke) Mitchella repens (Squaw Vine) Erythraea centuarium (Centaury) Rubus spp. (Raspberry leaf) Anodynes Phytoprogesterogenics Anenome pulsatilla (Pasque Flower) Vitex agnus castus (Chaste berry) Piscidia erythrina (Jamaican Dogwood) Paeonia lactiflora (Peony root) Gelsemium sempervirens (Yellow Jasmine) Verbena officinalis (Vervain) Eschscholzia californica (California Poppy)

Antispasmodics Nervines Dioscorea villosa (Wild Yam root) Scutellaria lateriflora (Skullcap) Viburnum spp. (Cramp Bark root) Valeriana officinalis (Valerian) Cimicifuga racemosa (Black Cohosh root) Verbena hastata (Vervain) Hypericum perforatum (St. John’s Wort) Phytoestrogenics Leonorus cardiaca (Motherwort) Trifolium pratense (Red Clover) Piper methysticum (Kava) Cimicifuga racemosa (Black Cohosh root) Aletris farinosa (True Unicorn root) Adaptogens Salvia officinalis (Sage) Eleutherococcus senticosus (Siberian Ginseng) Humulus lupulus (Hops) Panax spp. (Ren Shen) Withania somnifera (Ashvagandha) Circulatory stimulants Glycyrrhiza glabra (Licorice) Zanthoxylum spp. (Prickly Ash) Zingiber officinale (Ginger) Galactagogues Cinnamomum cassia (Cinnamon) Galega officinalis (Goat’s Rue) Foeniculum officinalis (Fennel) Antiseptics/antimicrobials Cuminum cyminum (Cumin) Echinacea spp. (Coneflower) Asparagus racemosa (Shatavari) Baptisia tinctoria (Wild Indigo) Humulus lupulus (Hops) Hydrastis canadensis (Goldenseal) Thymus vulgaris (Thyme) Anti-galactagogues Thuja plicata (Red Cedar) Salvia officinalis (Sage) Commiphora mukul (Myrrh) Sanguinaria canadensis (Blood Root) Emmenagogues Smilax spp. (Sarsaparilla) Artemisia vulgaris (Mugwort) Ruta graveolens (Rue) Pelvic Decongestants Mentha pulegium (Pennywort) Achillea millefolium (Yarrow) Tanacetum vulgare (Tansy) Lamium album (White Dead Nettle) Collinsonia canadensis (Stone Root) Mucilaginous Diuretics Fouquieria splendens (Ocotillo) Agropyron repens (Couch Grass) Zea mays (Corn Silk) Althaea officinalis (Marshmallow)

Astringents Alchemilla vulgaris (Lady’s Mantle) Capsella bursa pastoris (Shepherd’s purse) Geum spp. (Alum) Geranium maculatum (Spotted Cranesbill) Panax notoginseng (San Qi) Trillium erectum (Beth Root) Hydrastis canadensis (Goldenseal)

Female Reproductive Trophorestoratives Turnera diffusa (Damiana) Asparagus racemosa (Shatavari) Cordyceps sinensis (Cordyceps mushroom) Vanilla planifolia (Vanilla) Theobroma cacao (Chocolate) Rehmannia glutinosa (Shu Di Huang) Paeonia lactiflora (Bai Shao) Fructus lycium (Gou Qi Zi) Angelica sinensis (Dang gui) Panax quinquefolium (Xi Yang Shen) Asparagus cochinchinensis (Tian Men Dong) Dendrobium nobile (Shi Hu) Ligustrum lucidum (Nu Zhen Zi) Sida cordifolia (Bala) Abutilon indicum (Atibala) Glycyrrhiza glabra (Licorice) Withania somnifera (Ashvagandha) Aloe vera (Kumari juice) Elettaria cardamomum (Cardamom) Cinnamomum cassia (Cinnamon) Myristica fragrans (Nutmeg) Eugenia caryophyllus (Cloves)

Botanical Classifications: Herbs for Men

Pelvic Decongestants Thymus vulgaris (Thyme) Epilobium spp. (Fireweed root) Thuja plicata (Red Cedar) Urtica dioica (Nettle root) Commiphora mukul (Myrrh) Serenoa serrulata (Saw Palmetto) Sanguinaria canadensis (Blood Root) Eupatorium graveolens (Gravel Root) Smilax spp. (Sarsaparilla) Collinsonia canadensis (Stone Root) Fouquieria splendens (Ocotillo) Male Reproductive Trophorestoratives Agathosma betulina (Buchu) Panax ginseng (Ren Shen) Piper cubeba (Cubeb) Angelica sinensis (Dang gui) Aesculus hippocastanum (Horse Chestnut) Mucana pruriens (Kapikachu) Chimaphila umbellata (Pipsissewa) Withania somniferum (Ashvagandha) Equisteum arvense (Horsetail) Serenoa serrulata (Saw Palmetto) Solidago spp. (Goldenrod) Withania somnifera (Ashvagandha) Deer antler (Lu Rong) Mucilaginous Diuretics Gecko (Ge Jie) Agropyron repens (Couch Grass) Cordyceps sinensis (Dong Chong Xia Cao) Zea mays (Corn Silk) Epimedium grandiflorum (Yin Yang Huo) Althaea officinalis (Marshmallow) Morinda officinalis (Ba Ji Tian) Psoralea coryfolia (Bu Gu Zhi) Hepatics Alpinia oxyphylla (Yi Zhi Ren) Mahonia spp. (Oregon Grape) Eucommia ulmoides (Du Zhong) Barberry (Barberry) Sesamum indicum (Tila, Sesame seed) Taraxacum officinale (Dandelion) Tribulus terrestris (Gokshura) Cynara scolymus (Artichoke) Asparagus racemosa (Shatavari) Erythraea centuarium (Centaury) Nardostachys jatamansi (Jatamamsi) Sida cordifolia (Bala) Anodynes Mineral pitch (Shilajitu) Anenome pulsatilla (Pasque Flower) Piper longum (Pippali) Piscidia erythrina (Jamaican Dogwood) Elettaria cardamomum (Cardamom) Gelsemium sempervirens (Yellow Jasmine) Cinnamomum cassia (Cinnamon) Eschscholzia californica (California Poppy) Myristica fragrans (Nutmeg) Eugenia caryophyllus (Cloves) Nervines Piper methysticum (Kava) Scutellaria lateriflora (Skullcap) Turnera diffusa (Damiana) Valeriana officinalis (Valerian) Pausinystalia yohimbe (Yohimbe) Verbena hastata (Vervain) Liriosma ovata (Muira Puama) Hypericum perforatum (St. John’s Wort) Epimedium grandiflorum (Epimedium) Leonorus cardiaca (Motherwort) Cuscuta japonica (Dodder seed) Piper methysticum (Kava) Psoralea corylifoliae (Psoralea)

Circulatory stimulants Zanthoxylum spp. (Prickly Ash) Zingiber officinale (Ginger) Cinnamomum cassia (Cinnamon)

Antiseptics/antimicrobials Echinacea spp. (Coneflower) Baptisia tinctoria (Wild Indigo) Hydrastis canadensis (Goldenseal)

References

Abell A, Ernst E, Bonde JP. 1994. High sperm density among members of organic farmers' association. Lancet. Jun 11;343(8911):1498. Anderson K., L. Anderson and W. Glanze. 1994. Mosby’s Medical, Nursing and Allied Health Dictionary. 4th ed. St. Louis: Mosby Bensky, D. and A. Gamble. 1993. Chinese Herbal Medicine Materia Medica. Revised edition. Seattle: Eastland Press. Bergner, Paul. 1997. The Healing Power of Minerals, Special Nutrients and Trace Elements. Rocklin, CA: Prima Publishing. Berkow, Robert ed. et al. 1992. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, NJ: Merck and Co. Brosman, Stanley. 2005. Erectile Dysfunction. Available from: http://www.emedicine.com/med/topic3023.htm Brys M, Nawrocka AD, Miekos E, Zydek C, Foksinski M, Barecki A, Krajewska WM. 1997. Zinc and cadmium analysis in human prostate neoplasms. Biol Trace Elem Res. Winter. 59(1-3):145-52. Cabrera, Chanchal. 1993. Gaiacology- Herbs and Reproductive Health. Vancouver: Wild Rose College of Natural Healing De Luca, Diana. 1998. Botanica Erotica. Rochester: Healing Arts. Green, James. 1991. The Male Herbal. Freedom, CA: The Crossing Press Haas, Elson. 1992. Staying Healthy with Nutrition: the complete guide to diet and nutritional medicine. Berkeley: Celestial. Habib FK, Hammond GL, Lee IR, Dawson JB, Mason MK, Smith PH, Stitch SR. 1976. Metal-androgen interrelationships in carcinoma and hyperplasia of the human prostate. J Endocrinol. Oct;71(1):133-41. Herraiz S. 2000. Tetrahydro-beta-carbolines, potential neuroactive alkaloids, in chocolate and cocoa . J Agric Food Chem. Oct;48(10):4900-4 Hoffmann L, Putzke HP, Kampehl HJ, Russbult R, Gase P, Simonn C, Erdmann T, Huckstorf C. 1985. Carcinogenic effects of cadmium on the prostate of the rat. J Cancer Res Clin Oncol. 109(3):193-9. Jensen TK, Giwercman A, Carlsen E, Scheike T, Skakkebaek NE. 1996. Semen quality among members of organic food associations in Zealand, Denmark. Lancet. Jun 29;347(9018):1844. Joffe M. 1996. Decreased fertility in Britain compared with Finland. Lancet. Jun 1;347(9014):1519-22. Junnila J, Lassen P. 1998. Testicular Masses. American Family Physician. Available from: http://www.aafp.org./afp/980215ap/junnila.html Keene LC, Davies PH. 1999. Drug-related erectile dysfunction. Adverse Drug React Toxicol Rev. Mar;18(1):5-24. Mills, Simon and Kerry Bone. 2000. Principles and Practice of Phytotherapy. London: Churchill Livingstone. Moller H, Evans H. 2003. Epidemiology of gonadal germ cell cancer in males and females. APMIS. 2003 Jan;111(1):43-8 Moore, Michael. 1993. Medicinal Plants of the Pacific West. Santa Fe: Red Crane. Moore, Michael. 1990. Herbal Repertory in Clinical Practice. Albuquerque: Southwest School of Botanical Medicine. Nadkarni, Dr. K.M. 1976. The Indian Materia Medica, with Ayurvedic, Unani and Home Remedies. Revised and enlarged by A.K. Nadkarni. 1954. Reprint. Bombay: Bombay Popular Prakashan PVP. Newall, C, L. Anderson, and J.D. Phillipson. 1996. Herbal Medicines: A Guide for Professionals. London: The Pharmaceutical Press. Planells E, Rivero M, Mataix J, Llopis J. 1999. Ability of a cocoa product to correct chronic Mg deficiency in rats. Int J Vitam Nutr Res. Jan; 69(1):52-60 Rubin, E. ed. 2001. Essential Pathology. 3rd ed. Philadelphia: J.B. Lippinocott. Swash, Michael. 1995. Hutchison’s Clinical Methods. 20th ed. London: W.B. Saunders Tortora, G. and S. Grabowski. 2003. Principles of Anatomy and Physiology. 10th ed. New York: Harper- Collins.

Applied Phytotherapeutics The Human Flower: Reproduction By Todd Caldecott and Terry Willard Lesson 10

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Applied Phytotherapeutics II Human Flower: Reproduction By Terry Willard ClH, PhD; Todd Caldecott ClH Lesson 10 Worksheet

The Human Flower

CHOOSE THE BEST ANSWER

1. Aphrodisiacs: a) enhance energy b) stimulate mental function c) relax the body d) all of the above

2. What aphrodisiac is used to treat frigidity, depression and sexual anxiety in women? a) Theobroma cacao b) Turnera diffusa c) Mucana pruiens d) Psoralia corylifoliae

3. In Sanskrit, the herb name ______can be translated to mean “100 husbands”. a) Damiana b) Ashvagandha c) Yohimbe d) Shatavari

4. What can alter sperm production and decrease libido? a) thyroid hyperfunction b) thyroid hypofunction c) both a and b d) none of the above

5. Which herb increases pelvic blood supply and affects the spinal ganglia to promote erections? a) Pausinystalia yohimbe b) Epimedium grandiflorum c) Mucana pruriens d) Piscidia erythrina

6. Which herb is a uterine tonic? a) Collinosa canadensis b) Tanacetum vulgare c) Chamaelirium luteum d) Turnera diffusa

7. What is NOT applicable to Saw Palmetto (Serenosa serrulata)? a) regulator of androgen synthesis b) contains N-linoleoylethanolamine c) implicated in benign hypertrophy d) treats polycystic ovarian disease

8. Which herb is a pelvic decongestant? a) Anenome occidentalis b) Lamium album c) Plantago major d) Azadirachta indica

9. The herb(s) used to eliminate urinary calculi that accompanies BPH: a) Eupatorium purpureum b) Agropyron repens c) Hydrangea arborescens d) all of the above

10. A male patient with chills, urinary frequency and urgency, burning upon urination, hematuria and perineal and lumbar pain is showing signs and symptoms of: a) Orchitis b) Benign Prostatic Hypertrophy c) Acute bacterial prostatitis d) Epididymitis