Herbal Medicines and Women's Health

1. Herbal Medicines and Women's Health British Pharmaceutical Conference 2005 Elizabeth M Williamson

2. Scope of talk • General overview of the most important herbs used by women (excluding those covered earlier in more detail), where available for self-medication or to purchase OTC • Assessment of evidence available • Any problems reported or anticipated when taken with conventional drugs

3. Issues of particular importance to women – and not always for health reasons! • Hormonal: premenstrual syndrome (PMS), dysmenorrhoea, menorrhagia • Menopausal symptoms, including osteoporosis • Child-birth, pregnancy and lactation • Life-style: stress, memory loss (which may be linked with hormonal changes) • Appearance: weight-loss, cosmetic issues (again linked to causes above)

4. Herbs used in hormonal conditions • PMS: evening primrose oil, St John’s wort, agnus castus • Dysmenorrhoea: dong quai, raspberry leaf, cramp bark • Menorrhagia (refer to GP or specialist): agnus castus, horsetail etc. Check iron levels. • Menopause: phytoestrogens, black cohosh, agnus castus, dong quai, St John’s wort (for depression), sage (for flushing and sweating)

5. Herbs and products: for PMS, menorrhagia and menopause

6. Herbs used during pregnancy and lactation • Pregnancy; for morning sickness: ginger* • Late pregnancy; to prepare for child-birth: raspberry leaf* • Lactation; to enhance: shatavari (wild asparagus*), agnus castus, fennel, fenugreek • Lactation; to suppress: sage, peppermint *will be further discussed

7. Herbs and products:pregnancy and lactation

8. Herbs used to treat varicose veins • To increase venous tone and strengthen blood vessels: horse-chestnut*, butcher’s broom* • To promote blood flow: red vine leaf*, bilberry, ginkgo, yarrow and hawthorn • To soothe itching: topically applied calendula, witch hazel etc

9. Herbs and products: varicose veins

10. Herbs used to slow memory loss! • General memory and cognition enhancement: sage*, lemon balm*, ginkgo* • Shown to help in post-menopausal memory problems: soya*, ginseng*, ginkgo*

11. Herbs and products: memory and cognition

12. Life-style issues: weight loss • Boldo: traditionally used – no mechanism of action postulated • Kelp: to ‘speed up’ metabolism and provide nutrients (e.g. iodine) • Ephedra*: for appetite suppression and to speed up metabolism • ‘Detox’ mixtures

13. Herbs and products: ‘helping’ with weight loss

14. Herbs ‘suitable’ for self-medication? • Women usually look after the health needs of the family • Many herbal products are purchased OTC, as opposed to consulting a general practitioner, pharmacist or medical herbalist • Pharmacist ideally placed to advise… • …..if they know about herbal medicines! • NB: medical herbalists use many more on an individual basis

15. A closer look at some of these • Some work! • Some don’t! • ….and some are dangerous….

16. Pregnancy: ginger (Zingiber officinalis) for morning sickness? • Contains: gingerols and shogaols (phenolics) • Evidence for efficacy? Yes, but limited. • Safe? Current thinking is that up to 5 days can be recommended, and doses limited (1-2g daily, in divided doses) • Concerns about possible mutagenicity, but no clinical evidence in support • Some authorities suggest only up to normal food levels (approx 1g daily)

17. Childbirth – is Raspberry leaf (Rubus idaeus) useful? • Contains: flavonoids, unknown actives • Raspberry leaf widely available • Evidence for efficacy? Very limited – conflicting reports from 2 Australian studies • But how do you measure it?! • Pharmacological studies show weak uterotonic effect • Safety???

18. Herbs used in lactation • No clinical evidence for any, but traditional usage by herbalists widespread for all • For shatavari (Asparagus racemosus) some pharmacological studies in rats and er… buffaloes - showed increase in milk flow • Remember constituents may pass into breast milk

19. Varicose veins and ‘heavy legs’: saponin-containing herbs • Horse Chestnut (Aesculus hippocastanum) and Butcher’s Broom (Ruscus aculeatus), both used internally and externally • Evidence: good! (Internal use in pregnancy not recommended due to absence of research, but a small study of horse-chestnut reported no adverse events after 2 weeks) • Safety: no clinical reports of toxicity

20. Varicose veins: flavonoid and anthocyanin-containing herbs • Red Vine (Vitis vinifera)– leaf extract, both internally and externally. Contains flavonoids and anthocyanins. Evidence: reasonable –several clinical studies to support • Bilberry, hawthorn, ginkgo: little evidence in varicose veins, but some rationale for use • Safety: no reports as yet of interactions • Internal use in pregnancy not recommended due to absence of research

21. Memory enhancement • Evidence available for ginkgo (Ginkgo biloba), soya (Glycine max), ginseng (Panax ginseng) in menopausal women – but the extent of their usefulness is not yet established • May be related to various types of activity – e.g. oestrogenicity, increase in cerebral blood flow, stimulant effects etc

22. Weight loss • No clinical evidence for any, except ephedra, (Ephedra sinica, Ma Huang) • Contains ephedrine, a sympathomimetic (amphetamine-like) biogenic amine • Banned in the US • Responsible for some deaths • Detox mixtures usually diuretic herbs with extra nutrients or minerals

23. Relevant herb-drug interactions 1 • Agnus castus: theoretical possibility of interacting with dopaminergic receptors • Bilberry – none reported, none expected • Boldo: report (unproven) of interaction with warfarin • Butcher’s Broom: none reported • Dong quai: 1 case with warfarin (reduced prothrombin time) • Evening Primrose oil: inhibits CYP3A4, 1A2, 2C9, 2D6 and 2C19 in vitro – however, similar fatty acids are common in many foods • Ginger: inhibits CYP3A4, 1A2, 2C9 and 2D9 in vitro – but no clinical reports

24. Relevant herb-drug interactions 2 • Ginseng: conflicting reports on CYP enzymes; weak inhibition of P-glycoprotein; avoid with MAOIs, warfarin, nifedipine and cancer chemotherapy • Horse chestnut: none reported • Raspberry leaf: none reported • Red Vine: none reported • St John’s wort: oral contraceptives, • Sage: none reported • Soya: conflicting reports, but avoid with oestrogens and anti-oestrogens for obvious reasons

25. Conclusions • Women are very likely to take herbal medicines • Only a few are well researched (see previous presentations) • Some are effective, some not • Most appear to be safe • The interaction profile of most is favourable – although St John’s wort has the usual caveats • Unfortunately slimming herbs don’t work!

26. Reference sources • Principles and practice of Phytotherapy. Mills S and Bone K, Churchill Livingstone, UK, 2000 • Potter's Cyclopedia of Herbal Medicines, E M Williamson, C W Daniels, UK. 2003 • Interactions between Herbal and Conventional Medicines. E M Williamson (2005) Expert Opinion in Drug Safety 4 (2) 355-378 • Major Herbs of Ayurveda. Dabur Research Foundation. Ed: E M Williamson; Elsevier 2002 • Herbal Medicines 2nd Edition. Barnes, Anderson and Phillipson. Pharmaceutical Press 2002 • Natural Standard Herb and Supplement Reference.Evidence-Based Clinical Reviews. Mosby 2005