Women s Encyclopedia of Natural Medicine (PDF)

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					      WO M E N’S
   o f N AT U R A L

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      WO M E N’S
   o f N AT U R A L


A lternative T herapies a nd I ntegrative
Medicine for Total H ealth a nd Wellness


  New York Chicago San Francisco Lisbon London Madrid Mexico City
     Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2008 by Tori Hudson. All rights reserved. Manufactured in the United States of America. Except as permitted under the
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DOI: 10.1036/0071464735

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The women who have sought my advice as a naturopathic
    physician and lent me their trust and confidence
                The women in medicine
   The women who have made a difference in my life
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Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

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

Appendix A: General Exercise Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Appendix B: Body Mass Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Appendix C: Hormone Replacement Therapy Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Appendix D: Procedures and Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Appendix E: Recommended Screening Tests and Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . 375
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
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I  ’ve long been a fan of the work of Dr. Tori
   Hudson, the foremost national leader in natur-
opathic and botanical medicine specifically for
                                                                solutions to her health problems on her own,
                                                                along with guidance about when she needs to
                                                                seek professional help. Many of these solutions
women. And unbeknownst to her, Dr. Hudson                       are available at your local natural food store.
has been a guiding light for me in using botanical              Some are even available in your own kitchen.
and naturopathic approaches to women’s health                   Many naturopathic approaches stand alone as
problems for many years. Long before herbal                     a viable, safe, and effective treatment option.
medicine enjoyed its current mainstream accept-                 Others can be used in an integrative approach
ance, my patients who were interested in natural                along with conventional medicine. Some women
approaches to their gynecologic problems brought                and situations will require the most conventional
me copies of Dr. Hudson’s articles and even the                 of medical treatments. Dr. Hudson’s book helps
text that she wrote for her students to fill in the              to sort through these options. In general, the
information gap about gynecology and natural                    naturopathic treatments outlined in this book
medicines that existed in the naturopathic training             offer safer and gentler solutions to many women’s
program where she teaches. In this text, entitled               health problems that can be applied to help
Gynecology and Naturopathic Medicine: A Treat-                  rebalance the body and restore it to health long
ment Manual, Dr. Hudson set down natural treat-                 before more serious conditions develop.
ment protocols that she had used effectively for                    Women have used the healing power of plants
years to treat the kind of women’s health problems              since the beginning of time. Now Dr. Hudson
that I was seeing every day, ranging from irregular             brings her years of scientific and clinical expertise
periods and menstrual cramps to hot flashes. As                  to the field of natural, plant-based healing and
a conventionally trained allopathic gynecologist, I             helps make it safer and more effective for women
was gratified to learn about and help my patients                than ever before. This is a book that should be in
apply some of Dr. Hudson’s gentle, natural, and                 every woman’s health library and every alternative
plant-based approaches. They were an excellent                  practitioner’s library, and it is a resource for the
complement to the standard gynecologic care I                   new breed of conventional practitioners open to a
was already practicing.                                         more integrative health-care system.
    So when Dr. Hudson called and told me
about her new book, I was delighted. Here in one                   —Christiane Northrup, M.D., author of
volume is everything a woman needs to know to                       Women’s Bodies, Women’s Wisdom and
begin applying gentle, natural, naturopathic                        The Wisdom of Menopause

Copyright © 2008 by Tori Hudson. Click here for terms of use.
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T        hroughout the course of writing the origi-
         nal book, and now the second edition, I
have had overwhelming moments of gratitude
                                                                    My family has been very supportive through-
                                                                out my entire career. My mother, Pat Lawrence,
                                                                has provided me with lifelong love, support, and
for all the people that have helped.                            trust and has always made it clear that I am worthy
     I have reflected on those who helped me with                and special. She’s also the one that keeps me in
the first edition: Norman Goldfind, the original                  touch with what the media are communicating
publisher. Dr. Susanna Reid, who worked with                    about alternative medicine. Not everyone has
me from almost the very beginning when she was                  her own clipping service from all the popular mag-
still a student at the National College of Naturo-              azines and regular updates on what’s happening
pathic Medicine. If it were not for her, I would                on “Oprah,” “20/20,” and the rest. Her husband,
not have learned to use a computer. Thanks to                   Dick, who has now passed on, was my special proj-
her weekly tutoring, I finally achieved at least a               ect man. All the things I haven’t had time for—
functional level of competence. Susanna was crit-               hanging the Christmas lights, cleaning the gutters,
ically involved in the research of information for              staining the deck—what a guy! My real father, Ken
the first edition of the book and in planning its                Guenther, made it possible for me to go back to
organization and format. I also want to thank Dr.               school and receive an education in naturopathic
Sandoval Melin for his expertise in the area of                 medicine, and I thank him for providing the sup-
exercise. Sandoval has elevated the role of exercise            port and resources that allowed me to pursue a
therapeutics in the first edition of the book and                career as a naturopathic physician. My stepdad,
is responsible for its inclusion.                               Jack Hudson, who passed away at too young an
     I would also like to thank my editor of the                age, gave me the gift of learning and doing all the
second edition, Deborah Brody. She graciously                   things normally reserved for boys. My niece, Jana,
accommodated my need for additional time and                    delights me with her spirit and resilience.
distinctly improved the feel and readability of                     Sometimes I cannot believe my good fortune
each chapter.                                                   to have Doug Stapf in my life—trusted business
     Dr. Elizabeth Newhall generously gave of her               partner at Vitanica, easygoing Texan friend,
time and expertise as an obstetrician and gyne-                 fellow basketball fan, the most excellent of men
cologist for the first edition. If it were not for her           one could hope to know and work with.
generous sharing of her conventional medical                        Having become a naturopathic physician in
knowledge over the last 14 years, my expertise in               1984, I am honored to be an alumna and faculty
women’s health would not have been complete.                    member of the National College of Naturopathic
     I am fortunate to have a very talented and                 Medicine (NCNM) these last 24 years. The
supportive sister, Karen Hudson. Not many                       National College of Naturopathic Medicine is
women have the good fortune to have a sister                    the oldest college of naturopathic medicine in
that knows everything they do not know. Being                   the United States, and the expertise and experi-
in business together at our clinic, A Woman’s                   ence of its faculty in the field of natural medicine
Time, is the perfect blend of what we each do                   are exceeded by no other college in the country. I
best. Our joint commitment of delivering health-                honor the faculty, administration, and employees
care options to women is our work and our play.                 of NCNM for their commitment and vision.
Copyright © 2008 by Tori Hudson. Click here for terms of use.

          My naturopathic colleagues as a whole, and         Karen Hudson, M.P., H.C.; Theresa Baisley,
      particularly the members of the American               LMT; and Mari Greenly, L.Ac.
      Association of Naturopathic Physicians, are an             I would also like to thank our clinic staff, a
      incredible community of individuals with an            formidable group of fine women who extend
      extraordinary commitment to living on this             their skill, compassion, ethics, and care of
      planet in a respectful, mindful way and healing        patients and coworkers on a daily basis: Tamara,
      the humans of this planet in gentle ways that uti-     Kim, Whitney, Susan, Renee, and Audra.
      lize the medicines of Mother Nature.                       In order to practice an integrative medicine
          I could not have succeeded in the generation       approach, I have had the guidance and support of
      and manifestation of two important projects (the       many conventional practitioners in the Portland
      Institute of Women’s Health and Integrative            community. I can’t possibly list them all, but here
      Medicine and the Naturopathic Education and            is an important beginning list: Mike McClung,
      Residency Consortium) without the years of sup-        M.D.; Trish Burford, M.D.; Nathalie Johnson,
      port, trust, and guidance from three individuals       M.D.; Jane Harrison-Hohner, N.P.; Katherine
      and companies: Wally Simons, R.Ph., of Women’s         Hill, N.P.; Nina Davis, M.D.; Renee Edwards,
      International Pharmacy; David Shefrin, N.D., of        M.D.; Kim Surianno, M.D.; Sandra Emmons,
      Bezwecken; and Sharon McFarland of Transitions         M.D.; Lisa McCluskey, M.D.; Michael Lewis,
      for Health/Emerita.                                    M.D.; Kim Suriano, M.D.; Brenda Kehoe, M.D.;
          Several other people have lent their profes-       Sally Holtzman, M.D.; Pillippa Ribbink, M.D.;
      sional, business, academic, and personal support       Liz Newhall, M.D.; Randi Ledbetter, M.D.; Tom
      and extended themselves in various ways: Michael       Johnson, M.D.; Paul Kucera, M.D.; Rodney
      Murray, N.D., of Natural Factors; Don West,            Pommier, M.D.; Jeff Jensen, M.D.; Laura Green-
      R.Ph., of Lloyd Center Pharmacy; Rick Liva, N.D.,      berg, M.D.; Dan Gruenberg, M.D.; Kasra
      and Jackie Germain, N.D., of Vital Nutrients;          Karamlov, M.D.; Maureen Goldring, M.D.; Cyn-
      Ronnie Boyer, M.D., of The Center for Education        thia Ferrier, M.D.; Kip Kemple, M.D.; Wesley
      and Development in Homeopathy; Riley Liv-              Lewis, M.D.; and many more. I thank them for
      ingston; David Hanning of Biogenesis; Jon Thore-       their open-mindedness and fierce commitment to
      son and Nigel Plummer, Ph.D., of Pharmax; Kyle         their patients and medicine.
      Bliffert of Nordic Naturals; Ken Koenig, D.C., of          When things are up and things are down, or
      Wise Woman Herbals; Michael Schaeffer of Well-         even just content, my trusted friend, playmate,
      ness Naturals; Steve Wickham of Metametrix;            and confident Dee Packard is one of those special
      Brehan Griswold of Emerson Ecologics; and Shane        beings the universe has brought into my life. I
      McCamey of Boiron.                                     consider myself fortunate to have the loving
          I have a special place in my heart for the daily   friendship and committed support of Eileen
      privilege I have in working with my associates at      Stretch, Cindy Phillips, Holly Lucille, Nirala
      A Woman’s Time. This group of women practi-            Jacobi, Kate Krider, Patti Kohler, Tracy Waters,
      tioners are extraordinary in their work and truly      Laurel Haroon, Steve Austin, Kathy Hitchcock,
      an incredible pleasure to work with. I am grate-       and Sidney Henry. I also thank my special
      ful for their camaraderie and collaboration in all     friends Lupita and Jon McClanahan who teach
      that we do together: Barbara McDonald, N.D.,           and share with me the “beauty way” of the
      L.Ac.; Stephanie Kaplan, N.D.; Leigh Kochan,           Navajo people. To K. C. Snellgrove, D.C., I
      N.D., L.Ac.; Wendy Vannoy, N.D.; Moira Fitz-           thank you for keeping my body going, despite
      patrick, Ph.D., N.D.; Michelle Rogers, N.D.;           long hours at my desk, and I thank her able
                                                                                  ACKNOWLEDGMENTS         xiii
coworker, Lucille Gouge, who always seems to fit        teacher, better physician, and better person
me into the schedule for a treatment.                  because of you.
    To Bette Joram, Ph.D., I thank you for your            For those with whom I’ve played, worked,
intellect and remarkable insights, your contain-       nourished, and loved, you have brought about
ment, your support, and your trustworthiness.          my evolution as a human being.
    And to Ann Kafoury, L.P.C., I thank you for            Finally, we all owe our gratitude to the
your skill, your grace and compassion, your trust      women who seek safe, effective, respectful medi-
in me and trustworthy ways, and your commit-           cine and choices in their health care. You have
ment to me and my own healing.                         changed history on more than one occasion and
    I also want to thank all the women I have          protected our humanness.
treated over these last 24-plus years. I am a better
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T      he second edition of Women’s Encyclopedia
       of Natural Medicine would not have been
possible without the studious help of two col-
                                                                    My gratitude and appreciation for the contri-
                                                                butions of Dr. Leigh Kochan and Dr. Randi Led-
                                                                better are immense and will extend long into the
leagues in particular: Leigh Kochan, N.D., L.Ac.,               future. Without their knowledge and assistance,
and Randi Ledbetter, M.D. Dr. Kochan is a                       this would have been a much longer and more
former resident and now an associate at our clinic,             arduous process.
A Woman’s Time, in Portland, Oregon. She has                        The following additional practitioners have
spent countless weeks and months assisting me in                made selected contributions in different sections
compiling the scientific literature of the last seven            of the book, reviewing, editing, and contributing
years, particularly for updated research in herbal              their expertise:
and nutritional therapies. Her efforts have kept
me from feeling overwhelmed and made this                       Sandoval Melin, N.D., Ph.D. Exercise
daunting project of updating the book a real                                                therapeutics
possibility. Dr. Randi Ledbetter is a gynecologist              Elizabeth Newhall, M.D.     Obstetrics,
practicing in Portland, Oregon, at The Meno-                                                gynecology
pause Clinic. She has generously offered her gyne-              Nina Davis, M.D.            Urology
cological expertise to me and other alternative                 Katherine Hill, N.P.        Infertility
practitioners these past many years and now has                 Susanna Reid, Ph.D., N.D.   First edition
extended that to helping me to rewrite and update                                           research assistant
the sections on conventional medicine. I consider               Judy Fulop, N.D.            First edition
these sections of the book vital in the education of                                        research assistant,
patients and fellow practitioners.                                                          endometriosis

Copyright © 2008 by Tori Hudson. Click here for terms of use.
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I   ’ve spent the last 28 years studying, practic-
    ing, teaching, and evolving as a naturopathic
physician. Two themes have been consistent:
                                                                bloodletting therapies and toxic mercury dosing
                                                                and replaced them with more effective and less
                                                                toxic treatments. With therapies more acceptable
natural medicine and the health care of women.                  to the public, subsidies from wealthy foundations,
     Alternative medicine has come to be the                    the support of the developing pharmaceutical
popular term used to distinguish natural, nonin-                industry, and political savvy and legislation in its
vasive therapies from conventional medicine.                    favor, conventional medicine was able to restrict
Whether the terms alternative medicine, comple-                 the use of unorthodox doctors, midwives, herbal-
mentary medicine, natural medicine, or holistic                 ists, and others and gain a virtual monopoly on
medicine are used, they all reflect the transforma-              the health-care system.
tion that is occurring in health care: a focus on                    Fortunately, alternative medicine and naturo-
disease prevention, the promotion of healthy                    pathic medicine have seen a rebirth in the last 15
lifestyle habits, and the treatment of disease with             to 20 years, and especially in the last 5. A public
natural, nontoxic, and less invasive therapies. At              hungry for choices in their health care, an
the center of this transformation is a distinct                 increased awareness about the role of diet and
system called naturopathic medicine.                            lifestyle in cancer and chronic disease, the aging of
     The roots of naturopathic medicine are seen                the baby boomer generation, and the failures of
in the healing traditions of Egypt, India, China,               certain aspects of modern conventional medicine
Greece, Germany, South and Central America,                     and the health insurance industry to deal with
Africa, and native North America. The European                  people and their health problems respectfully,
hydrotherapy tradition had a strong influence on                 carefully, fairly, and effectively have been responsi-
the development of naturopathy, and by the end                  ble for this resurgence. Conventional medicine has
of the nineteenth century, Benedict Lust, a physi-              brought great insights, successes, and miracles of
cian trained in the water-cure methods of Europe,               what human intelligence can accomplish. Natural
came to America and began using the term natur-                 medicine has matured, particularly in the areas
opathy to describe an eclectic combination of nat-              of scientific research, educational institutions,
ural healing principles and methods.                            number of licensed practitioners, and profession-
     The first college of naturopathic medicine                  alism and is now poised to serve those who seek its
in the United States opened in New York City                    gentle ways.
in 1902. It taught a system of medicine that                         Naturopathic medicine is its own distinct
included nutritional therapy, natural dietetics,                healing art and is best defined by its principles
herbal medicine, homeopathy, manipulation, ex-                  and therapies. Simply put in modern terms,
ercise therapy, hydrotherapy, electrotherapy, and               naturopathic physicians are primary health-care
stress reduction techniques.                                    providers, family physicians who specialize in
     Naturopathic medicine grew and flourished                   natural medicine. The following seven principles
from the early 1900s until the mid-1930s. At that               are the foundation for naturopathic medicine:
point in history, the conventional medical profes-
sion began to influence the health-care system in                 1. The healing power of nature (vis medica-
several ways. It abandoned some of its barbaric                 trix naturae). The body has the inherent ability
Copyright © 2008 by Tori Hudson. Click here for terms of use.

        to establish, maintain, and restore health. The       6. Prevention is the best cure. The ultimate
        physician’s role is to facilitate and augment this   goal of naturopathic medicine is prevention.
        process with the aid of natural, nontoxic thera-     This is accomplished through education and
        pies; to act to identify and remove obstacles to     promotion of lifestyle habits and through natu-
        health and recovery; and to support the creation     ral therapeutic recommendations. The emphasis
        of a healthy internal and external environment.      is on building health rather than on fighting
         2. First, do no harm (primum no nocere).            disease.
        Naturopathic physicians seek to do no harm            7. Establish health and wellness. The pri-
        with medical treatment by employing safe,            mary goals of naturopathic physicians are to
        effective, less invasive, and natural therapies.     establish and maintain optimum health and to
         3. Identify and treat the cause (tolle              promote wellness. They strive to increase the
        causam). Naturopathic physicians are not only        patient’s level of wellness, characterized by a
        trained to investigate and diagnose diseases,        positive emotional state, regardless of the level
        they are also trained to view things more holisti-   of health or disease.
        cally and look for an underlying cause, be it
                                                                 In addition to these seven principles, there are
        physical, mental, or emotional. Symptoms are
                                                             two principles that I believe are fundamental not
        viewed as expressions of the body’s attempt to
                                                             only to natural medicine, but to good medicine
        heal but are not the cause of disease. The physi-
                                                             in general: the principle of resonance and the
        cian must evaluate fundamental underlying
                                                             principle of choice. Let me explain. Resonance
        causes on all levels, using treatment that
                                                             is basically an issue of compatibility. What
        includes addressing the root cause rather than
                                                             approach, what therapy, what herb, or what of
        just suppressing symptoms.
                                                             any substance is compatible with this particular
         4. Treat the whole person. Health and disease
                                                             patient in this particular moment and set of life
        are conditions of the whole organism, involving
                                                             circumstances? The selection of the therapeutic
        a complex interaction of physical, spiritual,
                                                             approach that is resonant with the individual is
        mental, emotional, genetic, environmental, and
                                                             the therapy that will create the most healing
        social/cultural/economic factors. The physician
                                                             momentum. Picture a child on a swing. You
        must treat the whole person by taking all of
                                                             stand behind the child pushing her forward so
        these factors into account. Homeostasis and
                                                             she can achieve the most momentum, and her
        harmony of functions of all aspects of the indi-
                                                             swinging becomes effortless. If you push her at
        vidual are essential to recovery from disease,
                                                             the right moment, your force is perfectly timed
        prevention of future health problems, and
                                                             with her body motion and the rhythm of the
        maintenance of wellness.
                                                             swing. The perfect timing sends her smoothly
         5. Physician as teacher (docere). The naturo-
                                                             and easily higher, and with the slightest effort she
        pathic physician’s major role is to educate,
                                                             can keep swinging forever. If you push her at the
        empower, and motivate the patient to take
                                                             wrong moment, the swinging becomes jerky, she
        responsibility for his or her own health. The
                                                             loses speed and height, and the rhythm is dis-
        physician educates about risk factors, hereditary
                                                             rupted. It then takes a great deal of effort to
        susceptibility, lifestyle habits, and preventive
                                                             regain momentum. The perfect effortless swing
        measures and makes recommendations on how
                                                             comes from the perfect timing and perfect force-
        to avoid or minimize future chronic health
                                                             fulness of the “push.” This is resonance. The
        problems. A healthy attitude, diet, exercise, and
                                                             person with the health problem is the child on
        other lifestyle habits serve as the cornerstone of
                                                             the swing. The person who pushes the swing is
        our recommendations.
                                                                                           INTRODUCTION       xix
the physician and the therapy she uses. Any med-        will, desire, discipline, and motivation. Freedom
icine, natural or pharmaceutical, can be resonant.      of choice occurs in an environment of equality
The art of medicine is to know when to use what,        and respect between physician and patient.
for whom, and for how long. I believe the most              These two principles, resonance and choice,
profound healing principle in the practice of           are what motivates me toward the vision of an
medicine is the principle of resonance, not             integrative health-care model. I no longer believe
whether the medicine is natural or synthetic, alter-    in a fractionated approach to health and healing
native or conventional, or a naturopathic philoso-      where alternative medicine is on one side and
phy versus conventional allopathic philosophy.          conventional medicine is on the other. There is a
The healing method is the medicine that is right        spectrum of options that go from simple to com-
for that person. The true goal of a physician is        plex, from the least intervention to the most
to perceive what is resonant with that individual.      aggressive intervention, and from the most natu-
    Dr. John Bastyr was considered by most              ral therapy to the most synthetic or technologi-
naturopathic physicians to be the modern patri-         cal. We need all of it. Human intelligence has
arch of naturopathic medicine. A whole new              created incredible tools and techniques. The
generation of naturopaths looked to him for             physician who is educated and aware of all the
their wisdom as the holder of true naturopathic         options and learns to understand how and when
medicine. The story goes, a young naturopathic          to best use all these choices on behalf of someone
medical student asked Dr. Bastyr, “How are we           who is ill and suffering is the true physician in
supposed to know what therapy to choose                 my book. An integrative model incorporates the
when there are so many different medicines and          natural/naturopathic perspective and the con-
systems to choose from?” Dr. Bastyr calmly and          ventional perspective and knows the strengths
quickly responded, “Choose what works.”                 and weaknesses of each in different circum-
Another question was posed to Dr. Bastyr: “How          stances. When we can do something effectively
can you tell an excellent physician from a good         and safely with nontoxic, natural medicines with
physician?” Dr. Bastyr’s answer: “The results.”         far fewer side effects, then what would stop us? If
    My second guiding principle is that of choice.      we can’t, or it’s too risky to wait and find out,
Each patient chooses what is right for her. The         then let’s move up the ladder to more invasive,
doctor’s role is to educate about the health prob-      riskier medicines with more side effects that may
lem, about the options, including their pros and        work better or be a more appropriate choice
cons, and to share resources. The goal is to provide    because the risk of the disease is greater than the
the context in which the patient can make an            risks of the treatment.
informed decision. The physician must be percep-            Naturopathic and other alternative medicine
tive and must listen, investigate, evaluate, educate,   disciplines have their strengths and their weak-
offer recommendations, and then create an envi-         nesses. Conventional medicine has its strengths
ronment where the individual can make a decision        and its weaknesses. I encourage consumer and
for herself. The individual seeking my help gets        practitioner alike to advocate for practitioners of
to choose. It may be black cohosh, or it may be         all disciplines to integrate their intelligence,
estrogen. It may be a rigorous naturopathic health      experience, and energies to build cooperative
regimen, or it may be surgery. It may be an inte-       working relationships with each other so that
grated combination, a “complementary” approach          they can truly help people to choose what works
using the best of two worlds. Choice is a powerful      best for them.
force—the force of individual responsibility,               In addition to recommendations on lifestyle,
empowerment, and self-direction. Choice fosters         diet, and exercise, naturopathic physicians utilize

     a vast array of therapeutic tools to promote                 Women want safe, effective, affordable medi-
     health and treat illnesses. Naturopathic physi-          cine. Women want to be educated about their
     cians are trained in what is called the eclectic tra-    bodies and their health. Women want to make
     dition. They have a broad range of therapies and         choices in their health care that they have deter-
     tend to use a selected mixture of these therapies        mined are right for them. By philosophy, by
     when treating their patients. Naturopathic thera-        design, and by commitment, alternative healing
     pies include dietary and lifestyle changes, clinical     systems have the package to offer women what
     nutrition (nutritional supplementation), botanical       they want.
     medicine (herbs), homeopathy, Chinese medicine               Beginning with the AMA’s exclusion of
     and acupuncture, hydrotherapy, manipulation,             women in the late 1800s, orthodox medicine’s
     physical therapies, psychotherapy, and minor sur-        lack of respect for women both as healers and
     gery. We also recognize the judicious use of pre-        patients has been all too obvious. Today, signifi-
     scription medications when the benefits exceed            cantly more empowered women have come to
     the risks, integrated into a comprehensive naturo-       reject the dictums of orthodox medicine in greater
     pathic health-care plan. Some naturopathic physi-        numbers. Women intuit the limitations of the
     cians receive extra training and licensure to            biomechanical model to completely explain phys-
     practice obstetrics and natural childbirth.              iological processes. Despite the orthodox physi-
         And now for the second consistent theme in           cian’s uniform advocacy for menopausal hormone
     my life: the delivery of health care to women.           replacement therapy (HRT) for all, only a frac-
     Modern women are the first women in history to            tion, less than 20 percent of women, comply; 90
     enjoy the luxury of anticipating that their lives will   percent of the women who begin HRT stop
     be healthy, long, and self-directed. This awareness      within the first year of use. Partially a failure of
     of opportunities and choices is leading them today       access, it is also a profound testimonial to their
     to seek the benefits of natural medicine in ever-         lack of trust in conventional medicine’s safety, effi-
     increasing numbers. More dominant and discrim-           cacy, and commitment to their well-being.
     inating consumers of health care than men or                 The creation of synthetic hormones in the
     children, and quicker to grasp the advantages of a       1950s and 1960s was unquestionably revolution-
     vitalistic, holistic healing art, their innate wisdom    ary for women in that it suddenly allowed per-
     has already led to many significant changes in            sonal life autonomy through successful fertility
     conventional medicine in recent years. Women             control and the elimination of the hot flashes and
     insisted on natural childbirth, and now it is the        mood swings of menopause. Women’s lives were
     goal of most pregnant women and available every-         changed forever. However, with hormones
     where. They have too long felt the restrictions of       coming as they did on the heels of the “miracle
     paternalistic conventional medicine with its uni-        medicine era” in which antibiotics and vaccines
     formity and lack of individualization of healing         led the general public to believe medicine could
     approaches and are therefore more than ready to          do no wrong, the consequences of hormone
     embrace the natural principle of treating the indi-      excess and side effects were not anticipated or
     vidual. Moreover, the success of natural treatments      quickly recognized and dealt with. Up until
     in relieving disease and suffering has done much to      2002, most conventional practitioners recom-
     promote their popularity. The now well-recognized        mended a postmenopausal lifetime on HRT.
     neglect of women in allopathic conventional              This has recently changed, and the data have
     research and the failure to prioritize women’s           begun to show that the risk of breast cancer
     health in general have left a profound gap in health     increases after five years of use. Consequently,
     care that alternative medicine is well poised to fill.    many women distrust and fear hormonal medi-
                                                                                             INTRODUCTION        xxi
cine and their conventional physicians. Unfortu-              In addition to practitioner-delivered natural
nately, this fear and mistrust may lead to the           health care, natural medicine offers safe and
refusal of a medicine that in some cases may             effective self-care options for many common
achieve more benefit than risk. Here’s where the          conditions such as vaginitis, PMS, fibrocystic
integrated wisdom and approach come in. While            breasts, menstrual cramps, menopause symp-
clearly not a panacea, hormones are not all bad          toms, bladder infections, and more, further
and have important uses for selected individuals.        expanding women’s health-care autonomy.
We can also use hormones in a form that may                   I support the self-care approach to healing.
enhance their benefits and minimize their risks,          Much of the practice of medicine is not particu-
or use a combination of a reduced dose of hor-           larly difficult or complex. Education and
mones along with soy and herbal medicines to             resources can provide a lot of very practical infor-
bring about the most benefit with the least risk.         mation. One of the things I’ve tried to do in this
    Women today are insisting on participating           book is not only to provide some self-care treat-
in their health-care decisions in a way conven-          ments for common female disorders but also to
tional medicine is just beginning to recognize.          provide guidelines about when self-care is not
I believe that the baby boomer menopausal                appropriate. Health care is a team approach: the
woman is having and will continue to have a              patient, the practitioner, the therapies. The team
more significant impact on our health-care                can include both the alternative and the conven-
model than any other previous group of health-           tional practitioner—and, better still, those that
care consumers. Menopausal women today reject            talk to each other on behalf of the patient.
the notion of a single therapeutic modality being             Choice in doctors and medical approaches,
essential for all women undergoing a natural             involvement in the health-care process, healthy
process. They reject the notion of taking a drug         lifestyles, and safer, nontoxic natural therapies are
for the rest of their lives, especially if they have     recognized by today’s women as essential to health
other options, especially if they can do other           and well-being. Women highly value the longer
things to help prevent osteoporosis and heart dis-       time spent in discussion with their alternative
ease, and especially if that drug increases their        provider as well as the careful, complete, and
risk of a life-threatening disease.                      respectful collection of their history. They value
    Women are the biggest consumers of health            processing their options thoroughly and individu-
care in America. A menopause supplement to               ally. This unique quality of alternative health-care
OB-GYN, the journal of the American College              systems is rare in conventional medicine and is one
of Ob-Gyn, states, “Focus groups, involving              of the chief reasons women seek alternative care.
women age 40 to 60, reveal that women know                    Naturopathic physicians and other providers
more about herbal medicines than about estro-            of alternative medicine must seek to verify the
gen.” That seems an impressive testimonial to the        “scientific” truth of their medicines whenever
power of alternative medicine in its alliance with       possible—by research and by modifying the
the natural wisdom of women to define their own           mechanistic model when necessary to suit their
health-care standards. It is an invitation to alterna-   vitalistic philosophy. They must continue to
tive medicine to continue to provide women with          stand by their tradition of resonance between
the wider, healthier options they seek. Fifty per-       patient and therapy, ever seeking the resonance
cent of American women will be menopausal by             for a particular woman with a particular problem
the year 2015, and they will provide alternative         at a particular time in her life.
medicine the greatest opportunity yet to serve our            Last, alternative medicine must recognize that
communities.                                             conventional medicine, while inadequate alone, is

       here to stay and offers important options and life-   selecting from all options, both naturopathic and
       saving measures. Likewise, conventional medicine      conventional. A combined, well-thought-out coop-
       must recognize that natural therapies are a funda-    erative and integrative approach is often the best
       mental healing tradition of all cultures and that     that medicine has to offer. Our open-mindedness
       modern alternative medicine is also here to stay.     will be rewarded manyfold by the improved health
       The more practitioners make themselves aware of       of women and their increased satisfaction and trust
       these options, the better they can guide women in     in their health-care providers.
      WO M E N’S
   o f N AT U R A L

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                                 UTERINE BLEEDING

OV E RV I E W                                                   Benign Abnormal Bleeding
Changes in the amount of menstrual blood flow,                   The causes of abnormal bleeding can be benign,
duration, and pattern are among the most                        premalignant, or malignant. Benign causes can
common health concerns that women face.                         be further subdivided as either organic or hor-
Although these changes cause a lot of anxiety for               monal. Organic disorders are all benign causes
women and do warrant a medical evaluation,                      of bleeding that are not hormonal. This may
most cases of abnormal bleeding are due to                      include systemic health problems, abnormal
benign and easily addressed conditions. Whether                 pregnancy, foreign bodies, trauma, infections,
alternative or conventional treatments are used                 and growths.
for intervention, prompt evaluation is highly                       Systemic diseases that are associated with
recommended.                                                    problems in how the blood clots are called coag-
    There are many causes of abnormal bleeding,                 ulopathies and can cause heavy vaginal bleeding.
but our main purpose in this chapter is to discuss              Heavy bleeding in a teenage girl may be caused
a benign hormonal cause of bleeding called dys-                 by a coagulopathy called von Willebrand’s dis-
functional uterine bleeding (DUB), abnormal                     ease. In fact, 20 percent of teenage girls with
uterine bleeding without any demonstrable                       severe menorrhagia have a significant coagulation
organic cause. First, we need a little background               problem. A decrease in the number of blood
and overview on abnormal bleeding in general.                   platelets (thrombocytopenia) can also cause
    A wide variety of clinical disorders can mani-              abnormal bleeding. Other systemic diseases, such
fest as abnormal bleeding from the vagina. What                 as hypothyroidism and severe liver diseases, can
is considered abnormal bleeding depends on the                  also cause prolonged menses, heavy menses, or
age of the patient. The bleeding can take many                  intermenstrual bleeding.
forms, including heavy and/or prolonged menses                      An abnormal pregnancy is the most common
(menorrhagia), intermenstrual bleeding (metror-                 cause of abnormal vaginal bleeding in women
rhagia), frequent menses (polymenorrhea), infre-                who are of reproductive age. Any type of mis-
quent menses (oligomenorrhea), heavy and                        carriage can present with abnormal bleeding
irregular intermenstrual bleeding (menometror-                  that is also often associated with cramping pains.
rhagia), or postmenopausal bleeding. Normal                     Women with an ectopic pregnancy (a pregnancy
menses are defined as vaginal bleeding that occurs               in the fallopian tubes rather than the uterus) can
approximately every 28 days (with a range of 21                 present with abnormal bleeding, as can those
to 35 days) and lasts for 4 to 7 days. Abnormal                 with a molar pregnancy (an abnormality of the
bleeding is bleeding that occurs more frequently                placenta caused by a problem when the egg and
than every 21 days, less frequently than every 35               sperm join together at fertilization).
days, lasts more than 7 days, is unusually heavy or                 Abnormal bleeding in children can be caused
light, or occurs after menopause. In addition,                  by foreign bodies that they may have placed in
vaginal bleeding is considered heavy if a woman                 their vaginas while playing. The most common
loses more than 80 ml of blood per cycle (normal                foreign body in women of reproductive age is
is 30 to 35 ml).                                                an IUD, or intrauterine birth control device.
Copyright © 2008 by Tori Hudson. Click here for terms of use.
2   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

    Women with IUDs will tend to have heavier                                the female genital tract. Eighty-five percent
    menses and sometimes intermenstrual bleeding.                            of the primary vaginal cancers are squamous cell
        Trauma during intercourse can cause vaginal                          (a particular cell type) carcinoma. The most
    bleeding, for example in postmenopausal women                            common symptoms of invasive squamous cell
    who may have a dry vagina with thinning vaginal                          cancer include vaginal bleeding or foul-smelling
    tissue. Just the friction of normal vaginal penetra-                     discharge. Pain is usually a late symptom.
    tion during sex may be traumatic to this sensitive                            The tragedy of another cancer, cervical
    tissue. Trauma may also be experienced in a violent                      cancer, is that it is a preventable disease. It is pre-
    situation such as sexual abuse and rape. In children                     ceded by a prolonged precancerous state in
    or adolescents, sexual abuse must be considered in                       almost all cases and can be detected at its early
    cases of traumatic vaginal bleeding. Traumatic                           precancerous states by annual Pap smears. These
    bleeding may also occur after gynecological proce-                       earlier states of abnormal cells and cervical dys-
    dures such as biopsies and instrumentation.                              plasias are easily treatable conditions. Cervical
        Occasionally, a uterine infection called                             cancer accounts for approximately 18 percent of
    chronic endometritis can present with abnormal                           female genital cancer in the United States. The
    vaginal bleeding or spotting. Other symptoms                             peak incidence of cervical cancer is from 35 to 39
    often associated with this infection include a                           and 60 to 64 years of age. Vaginal bleeding after
    vaginal discharge, fever, abdominal/pelvic pain,                         vaginal sexual activity is the most common
    or lower back pain.                                                      symptom occurring in cancer of the cervix. In
        Of the most common causes of abnormal                                women with advanced disease, a foul-smelling
    bleeding are growths known as myomas, more                               discharge may be present.
    commonly referred to as uterine fibroids. These                                Endometrial hyperplasia is an increased growth
    tend to be more common in women over the age                             of the lining of the uterus (endometrium) and a
    of 30, particularly women in their 40s. Different                        subsequent thickening. Most cases of endometrial
    kinds of fibroids are discussed in Chapter 19, but                        hyperplasia revert to normal, either spontaneously
    submucous fibroids tend to be the most trouble-                           or with hormonal treatment. Some may persist,
    some in terms of heavy bleeding. Fortunately, they                       and others can progress to endometrial cancer.
    represent only about 5 to 10 percent of all fibroids.                     Endometrial hyperplasia may occur in any age
        Endometrial polyps can also cause abnormal                           group but is most commonly seen in older women.
    bleeding, but the bleeding is usually not heavy.                         Chronic lack of ovulation, as seen in the teenage
    Adenomyosis, a variant of endometriosis, may                             years, after menopause, and as a result of polycystic
    result in very heavy bleeding associated with men-                       ovary disease, is a condition where we may see
    strual cramping. Endometriosis itself can cause                          endometrial hyperplasia. Endometrial hyperplasia
    irregular changes in the menstrual cycle, but not                        can be simple or complex, and either atypical,
    typically heavy menses. Finally, bleeding may                            which is precancerous, or without atypia. These
    result from cervical polyps or a simple inflamma-                         distinctions are very important when it comes to
    tion of the cervix called cervicitis. Cervical polyps                    treatment and management and can best be made
    and cervicitis tend to present with intermenstrual                       with a procedure called an endometrial biopsy.
    bleeding or spotting after intercourse.                                  Pelvic ultrasound has improved to the point where
                                                                             it can detect thickening of the endometrium. Once
    Malignant Abnormal Bleeding                                              thickening is observed, a biopsy will probably be
    Now let us look at the premalignant and malig-                           recommended to further evaluate the situation.
    nant causes of uterine bleeding. Vaginal cancer                               Some endometrial hyperplasias will progress
    accounts for only 2 percent of malignancies of                           to cancer of the endometrium, i.e., uterine
                                                                          ABNORMAL UTERINE BLEEDING            3
cancer. As in cervical dysplasia and cervical          result of polycystic ovarian syndrome, elevated
cancer, endometrial hyperplasia is the precancer-      prolactin levels, emotional stress, obesity, weight
ous state; its adequate treatment will prevent the     loss due to anorexia, or athletic training.
development of endometrial cancer. Endometrial             The actual cause of DUB is not completely
cancer is the most common malignancy of the            clear. One theory is that the fluctuating estrogen
female genital tract and accounts for approxi-         levels seen in chronic lack of ovulation can cause
mately 7 percent of all cancers in women. The          intermittent estrogen withdrawal bleeding.
average age of patients with endometrial cancer        Another theory is that the continuous estrogen
is 59 years; the highest range for the incidence is    stimulation leads to a thickening of the endo-
age 50 to 59 years in postmenopausal women.            metrium, which needs more estrogen in order to
The most common symptom associated with                maintain itself. Eventually, the need for estrogen
endometrial cancer is abnormal uterine bleeding.       surpasses the production and breakthrough
Typically, the bleeding is in the form of spotting,    bleeding results. Another theory is that some
especially in postmenopausal women.                    areas of the endometrium outgrow their blood
                                                       supply, and subsequent bleeding occurs because
Dysfunctional Uterine Bleeding (DUB)                   of the lack of progesterone.
DUB can occur at any age but is most common                There are also cases of DUB that are not due
at either end of the reproductive age span. One        to anovulation but rather occur even though
uses the term DUB when other causes for abnor-         there is regular monthly ovulation. Ovulatory
mal bleeding have been excluded (fibroids,              DUB is defined as heavy menses in women who
polyps, and endocrine or other disorders). Ado-        ovulate and who do not have a coagulopathy or
lescents account for about 20 percent of DUB           any uterine abnormality. The cause of this form
cases after the first menstrual cycle. These cases      of DUB is not clear.
are due to the immature endocrine system, par-
ticularly the immature function of the hypothal-       D I AG N O S I S
amus. Perimenopausal women account for                 The key to accurate diagnosis of abnormal bleed-
approximately 50 percent of DUB cases due to           ing is the woman’s medical history. Several perti-
waning ovarian function. As the ovary ages, it         nent pieces of information will facilitate diagnosis:
becomes less efficient in completing the ovula-
                                                        • Previous menstrual patterns for the last three
tory process. Initially there is a decrease in prog-
esterone production, which causes shorter cycles.
                                                        • The presence or absence of pain along with
As the aging process progresses, ovulation
                                                          the bleeding
becomes less frequent, resulting in a variable
                                                        • Heaviness of the flow (number of pads or
length of the menstrual cycle and a variation in
                                                          tampons per day and how often they are
the duration of the flow. Eventually, the lack of
                                                          changed when saturated)
ovulation puts women in an estrogen-dominant
                                                        • Contraceptive methods, if any
state in the presence of too little progesterone
                                                        • Symptoms of pregnancy
because ovulation must occur in order to pro-
                                                        • Dates and histories of past pregnancies
duce progesterone. Women who are in a state of
                                                        • Premenstrual symptoms
chronic anovulation tend to have an excess of
                                                        • Recent abdominal, pelvic, or vaginal trauma
estrogen in the body. This excess estrogen is what
                                                        • Clotting problems
disrupts the normal pattern of menstruation.
                                                        • Easy bruising or bleeding
    The remaining 30 percent of cases of DUB
                                                        • Symptoms of systemic diseases
occur among women age 20 to 40, generally as a
4   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     • History of taking estrogens without ade-                              a lack of ovulation. Tests such as saline infusion
       quate progesterone/progestins                                         sonohysterography (SIS—an ultrasound proce-
     • History of sexually transmitted diseases                              dure that gives a three-dimensional view so as not
     • Past gynecologic history                                              to miss any portion of the uterine cavity), hys-
                                                                             teroscopy (a procedure that involves dilating the
        A physical exam will involve visualizing the                         cervix so that a small lighted scope can be inserted
    cervix, feeling the contour and size of the uterus,                      to visualize the intrauterine cavity), or a dilation
    and general palpation of the pelvic area. Labora-                        and curettage (D&C) may be recommended in
    tory testing may include:                                                addition to or instead of the pelvic ultrasound and
     •   Pap smear                                                           the pipelle biopsy in selected cases to improve
     •   Thyroid function tests                                              accuracy of the results.
     •   Pregnancy test
                                                                              KEY CONCEPTS
     •   Complete blood count to rule out anemia
     •   Follicle-stimulating hormone                                         • Seek and utilize a health-care practitioner who
         (FSH)/luteinizing hormone (LH)                                         will distinguish DUB from benign, premalignant,
     •   Liver function tests                                                   and malignant causes. If benign, is the cause
     •   Prolactin levels                                                       organic or hormonal?
     •   Adrenal function studies                                             • Workup will include a medical history and may
     •   Pelvic ultrasound to identify uterine fibroids                          include a physical exam and further laboratory
         or measure endometrial thickness                                       tests, pelvic imaging, and/or endometrial
     •   Pelvic saline infusion sonohystogram
                                                                              • Do not self-treat unless assured that the cause
     •   Testing for sexually transmitted diseases
                                                                                is DUB.
     •   Endometrial biopsy                                                   • Practitioners can often presume a diagnosis of
                                                                                DUB temporarily and recommend a further
        An endometrial biopsy may be recommended
                                                                                workup depending on response to the treatment.
    to test the tissue itself. This is a simple procedure
    done in the practitioner’s office in which the clini-
    cian inserts a small narrow plastic instrument                            PREVENTION
    called a pipelle into the uterine cavity to extract a
    small sample of tissue. It only takes about 30 to 60                      • Reduce stress.
    seconds, but women can experience mild to signif-                         • Avoid taking any form of estrogen without ade-
    icant cramping during that time. A local anesthetic                         quate progesterone or progestins.
    is usually not required, and the cramping generally                       • Engage in healthy lifestyle habits.
    subsides very quickly once the procedure is over.                         • Protect yourself against sexually transmitted
    Endometrial pipelle biopsies can determine the
                                                                              • Use well-tolerated forms of contraception.
    presence of endometrial hyperplasia, uterine
                                                                              • Have regular medical visits, including an annual
    cancer, infection (endometritis), a disrupted hor-                          physical exam.
    monal effect, a lack of estrogen as is seen in post-                      • Maintain optimal body weight.
    menopausal women, or a uterine polyp.
        If an endometrial biopsy is done at the right
    time, it can also be used to verify ovulation. If the                    OV E RV I E W O F
    biopsy shows that the endometrium has prolifer-                          A LT E R NAT I V E T R E AT M E N T S
    ated, when the woman’s next bleeding episode                             The goals of alternative treatment for DUB are the
    occurs within 10 to 12 days, it generally indicates                      same as the goals of conventional treatment: con-
                                                                          ABNORMAL UTERINE BLEEDING             5
trol the bleeding, prevent and treat anemia, restore    for their ability to bring about ovulation and
an acceptable menstrual pattern, and prevent            orderly stimulation of ovarian function, and
endometrial hyperplasia/endometrial cancer.             herbs for their tonifying and astringent effects.
    Repeated episodes of heavier and prolonged              The concept of tissue tonification is a key fea-
bleeding should be distinguished from acute             ture of the philosophy of herbal medicine. It is
hemorrhage. My general guidelines are as follows:       thought that gynecological conditions associated
If a woman is saturating a super tampon or heavy        with bleeding may occur as a result of poor tissue
pad every hour for six to eight hours or more she       tone of the mucous membranes, poor uterine
will often need some form of prescription hor-          tone, and a constitutional weakness of the tissues
mone intervention. Herbal/nutritional interven-         that presents as generalized lack of tissue
tions can be tried, but if there is no change within    integrity, in this case the uterus. The astringents
two to four hours, then hormonal therapies              (herbs that slow the loss of body fluids, i.e., men-
should be utilized. Even heavier bleeding (i.e., sat-   strual bleeding) are the herbs most likely to affect
urating pads every half hour or less) will most         tissue tone, while the uterine tonics and the
likely require surgical intervention. Monitoring        emmenagogues (herbs to promote menses) are
physical symptoms, blood pressure, pulse, and           most likely to affect uterine tone. Traditionally,
hemoglobin and hematocrit levels will help to           the ability of an astringent herb to stop bleeding
determine management of these more semi-                has been attributed to the tannin content of the
urgent and urgent cases. Use of high-dose oral bio-     plants. Uterine tone is related to the ability of the
identical estrogens (estradiol) and bio-identical       uterus to function as a smooth muscle. When the
progesterone (oral micronized progesterone) may         uterine tone is normal, there is a normalization
be substituted in some cases of heavier semi-acute      of menstrual flow. A hypertonic uterus can be
bleeding, although the net effect is the same as        associated with a delayed menses and cramping
when using conventional hormones. In most               uterine pains. A hypotonic uterus is frequently
states, licensed naturopathic physicians can pre-       accompanied by heavy bleeding and a feeling of
scribe bio-identical hormones and conventional          pelvic congestion.
hormones. They would approach these dramatic                Stress reduction has an underappreciated but
situations with the same high degree of concern         significant influence on irregular menses and
and astuteness as would a conventional practi-          DUB. A disruption in the messages between the
tioner and may integrate acute antihemorrhagic          hypothalamus (which produces gonadotropin-
botanicals or nutrients in combination with the         releasing hormones) and the anterior pituitary
hormonal therapies.                                     (which releases FSH and LH, follicle-stimulating
    Less dramatic cases that still involve heavy        and luteinizing hormones) brings about a mis-
menstrual flow will be best managed with both            timing of the release of these hormones and a
an immediate plan for the semi-acute bleeding           subsequent lack of ovulation and/or estrogen and
episode, which should slow down within a few            progesterone production by the ovaries. The
hours to 48 hours, and a comprehensive plan             timing of the release of these pituitary hormones,
that should bring results with no further episodes      as well as of estrogen and progesterone, is what
in one to four months. A comprehensive plan             determines a normal, regular menstrual cycle.
may include the use of soy and flax products to          This timing can be adversely affected by stress,
regulate the menstrual cycle, herbal extracts to        and by the same token, the timing can be
address immediate bleeding episodes, nutrients          improved by stress reduction. A third hormone
such as bioflavonoids and bromelain for their            produced by the pituitary, prolactin, also plays an
natural anti-inflammatory effect, herbal extracts        important role in the menstrual cycle. Increased
6   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

    production of prolactin can inhibit the matura-                          Two foods stand out in their ability to regulate
    tion of ovarian follicles and induce menstrual                           the menstrual cycle: flaxseed and soy protein.
    abnormalities and sterility. Prolactin release is                        Flaxseed contains a group of phytoestrogens
    often stress related.                                                    called lignans that have been shown to have
                                                                             weakly estrogenic and antiestrogenic properties.
    Nutrition                                                                Two specific lignans, enterodiol and enterolac-
    Consume a whole foods diet rich in whole grains,                         tone, are absorbed after formation in the intes-
    fruits, vegetables, legumes, quality cooking oils                        tinal tract from plant precursors particularly
    (canola and olive), nuts, and seeds. Emphasize                           abundant in flaxseed.
    fish high in omega-3 oils (salmon, tuna, sardines,                            The ingestion of flaxseed powder and its effect
    halibut, mackerel, herring) and reduce saturated                         on the menstrual cycle was studied in 18 normally
    animal fats (beef, chicken, butter, cheese) to pro-                      cycling women.1 Each woman consumed her
    mote the preferred prostaglandin pathways that                           usual omnivorous, low-fiber diet for three cycles
    are discussed in Chapters 9 and 13 (in the discus-                       and her usual diet supplemented with 10 grams
    sions of heart disease and menstrual cramps).                            per day of flaxseed for another three cycles. All
    These preferred prostaglandins will reduce                               women were instructed to avoid soy foods. The
    inflammation and may thereby help to reduce                               second and third flax cycles were compared to the
    heavy and profuse menstrual flows.                                        second and third control diet cycles. Three
        Foods high in iron in particular should be                           nonovulatory cycles occurred among the 18
    incorporated into the general diet when heavy                            women during the control diet (36 total cycles)
    blood loss persists on a monthly basis. Refined                           compared to none during the 36 flaxseed cycles.
    breads and cereals are the single greatest nutri-                        The ovulatory flax cycles were consistently associ-
    tional contributor to iron-deficiency anemia.                             ated with about one more day in the luteal phase
    Although we do have iron “enriched” flour, it has                         (second half of the cycle) when compared to the
    only about one-third the iron content of whole                           ovulatory non-flax cycles. Only one day longer
    wheat flour. Brewer’s yeast and wheat germ are                            before you bleed and a slight increase in the
    both excellent sources of iron, supplying about                          number of ovulations may not seem like much.
    18 and 8 mg respectively per half cup. Blackstrap                        However, over a period of months and years, the
    molasses is not only one of the richest sources of                       cumulative effect not only has implications for
    iron but also of many other minerals. It supplies                        regulating the menstrual cycle but may also play a
    about 9 mg of iron per tablespoon; dark unre-                            positive role in reducing the risk of breast and
    fined molasses contains 1.5 mg of iron per table-                         other hormonally dependent cancers.
    spoon, and sugar, none. Single foods high in iron                            The influence of a diet containing soy protein
    probably cannot surpass the amount found in                              on the length of the menstrual cycle in pre-
    liver and kidneys. However, I do not recommend                           menopausal women has also been studied.2 Sixty
    these because it is very difficult to get organic                         grams of soy protein containing 45 mg of
    products, and these organs accumulate many                               isoflavones (a phytoestrogen compound found in
    metabolic wastes. Apricots and eggs are also                             high amounts in soy; see Table 1.1) was given
    rather high in iron. We often think of dark green                        daily for one month in a study lasting nine
    leafy vegetables as high in iron, but iron is diffi-                      months. A significant increase in the length of
    cult to absorb in this form. Foods such as yogurt                        the follicular phase (first half of the menstrual
    that contain Lactobacillus acidophilus and sour                          cycle) by an average of 2.5 days and/or delayed
    fruits and citrus juices aid in the absorption of                        menstruation was observed in the six women
    iron because of their high vitamin C content.                            who consumed the soy protein. Again, as with
                                                                          ABNORMAL UTERINE BLEEDING             7
                                                        therapy showed that 92.5 percent of the 40 cases
 Table 1.1     Isoflavone Content of Soybeans
                                                        of menorrhagia were cured or alleviated.
                              Serving      Isoflavones       It is important to understand that 60,000 IU
 Food                          Size           (mg)      of vitamin A given for long periods of time could
                                                        lead to vitamin A toxicity, but generally this
 Textured soy protein
   granules                   1⁄4    cup       62
                                                        would only occur if doses in excess of 50,000 IU
                                                        were used for several years. Smaller doses may
 Nutlettes breakfast cereal          cup       61
                                                        produce toxicity symptoms if there are problems
 Roasted soy nuts             1⁄4    cup       60       in storage and transport of vitamin A. These
 Tempeh                       1⁄ 2   cup       35       problems are generally found only in people with
 Tofu, low-fat and regular    1⁄ 2   cup       35       cirrhosis of the liver, hepatitis, or malnutrition
 Soy beverage powders                                   and in children and adolescents. However, for a
  (varies with manufacturer) 1–2 scoops        20–50    period of only one month, as in this study, vita-
 Regular soy milk             1 cup            30       min A toxicity is of virtually no concern, and I
                                                        would not hesitate to use it for this amount of
 Low-fat soy milk             1 cup            20
                                                        time, or up to three months. Using lower doses
 Roasted soy butter           2 tbsp           17       of 25,000 IU for longer periods of time should
                                                        be considered in those cases where ongoing treat-
flaxseed, soy protein has a role not only in con-        ment is necessary to control menorrhagia.
tributing to the regularity and lengthening of the
menstrual cycle, but adding 2.5 days per month           Vitamin A
and lengthening the number of days from one              60,000 IU per day for 1–3 months
menses to another may in part contribute to a            10,000–25,000 IU ongoing, if necessary, but be aware
lower incidence of breast cancer.3                        of potential increase in urinary calcium loss

Nutritional Supplements                                     Note: Vitamin E improves vitamin A storage
    Vitamin A. A deficiency of vitamin A may             and utilization, and zinc is required to mobilize
contribute to menorrhagia in adult women. Vit-          vitamin A. A deficiency of zinc, vitamin C, pro-
amin A deficiency impairs enzyme activity and            tein, or thyroid hormone may impair the conver-
hormone production in the ovaries of animals,4          sion of carotenes to vitamin A. Provitamin A
and serum levels of vitamin A have been found           carotenes such as beta-carotene require these
to be lower in women with menorrhagia than in           nutrients for their conversion to vitamin A.
healthy women.5 In the latter study, vitamin A
was used as a treatment in 40 women who had                 B Complex. There may be a correlation
diagnosed menorrhagia as a result of a diverse          between a nutritional deficiency of vitamin B
array of causes. In the group who received              complex and menorrhagia and metrorrhagia. It
60,000 IU of vitamin A for 35 days, menstrua-           has been shown that the liver loses its ability to
tion returned to normal in 23 women (57.5 per-          inactivate estrogen in vitamin B-complex defi-
cent) for a period of at least three months. A          ciency. We know that some cases of heavy menses
significant decrease in the amount of blood or a         and intermenstrual bleeding are due to an excess
reduction in the duration of the menses or both         of estrogen. Therefore, supplementing with a
was obtained in 14 women (35 percent). The              complex of B vitamins may restore the proper
vitamin A was ineffective in 3 of the 40 women          metabolism of estrogen and thus have a role in
(7.5 percent). The overall result with vitamin A        treating DUB. A study done over 50 years ago
8   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

    was undertaken to determine if the B-complex                                 Bioflavonoids. Like vitamin C, bioflavonoids
    vitamins were effective in the treatment of these                        have demonstrated a significant ability to reduce
    menstrual conditions. Although the study, done                           heavy menstrual bleeding by strengthening the
    in the 1940s, was not up to today’s scientific                            vessel walls of the capillaries in women with men-
    standards, a series of consecutive cases showed                          orrhagia.8 Bioflavonoids also can have an anti-
    that a B-complex preparation was effective in                            estrogen effect on the uterus by occupying the
    “prompt” improvement in both menorrhagia and                             estrogen receptor sites and thus limiting the
    metrorrhagia.6 The B-complex preparations used                           estrogen-stimulating effect on the endometrium.
    orally in the study were usually given in daily                          This can help to reduce bleeding. Just as conven-
    doses providing 3 to 9 mg of thiamin, 4.5 to 9                           tional medicine prescribes nonsteroidal anti-
    mg of riboflavin, and up to 60 mg of niacin.                              inflammatories to reduce heavy bleeding, alterna-
                                                                             tive medicine has natural anti-inflammatories such
     Vitamin B-100 Complex                                                   as bioflavonoids that can be used for the same pur-
     1–2 capsules daily of a B-100 combination                               pose. Foods high in bioflavonoids (and vitamin C)
                                                                             include grape skins, cherries, blackberries, blueber-
        Vitamin K. Vitamin K deficiency is pretty                             ries, and the pulp and white rind of citrus fruits.
    rare, but its role in the manufacture of clotting fac-
    tors like prothrombin and clotting factors VII, IX,
    and X has obvious implications for women with                             1,000–2,000 mg per day
    heavy or prolonged menses.7 Even when the cause
    of the excessive bleeding is not a clotting disorder,
    it may be prudent to use vitamin K as part of a                          Botanicals
    comprehensive treatment plan. Fat-soluble chloro-                            Chaste Tree (Vitex Agnus Castus). Chaste
    phyll is a good source of vitamin K and is found in                      tree is probably the best-known herb in all of
    fresh green juices. Consider increasing the intake                       Europe for hormonal imbalances in women.
    of green leafy vegetables and/or supplementing                           Since at least the time of the Greeks, chaste tree
    with 150 to 500 mcg per day of vitamin K.                                has been used for the full scope of menstrual dis-
                                                                             orders: heavy menses, lack of ovulation, frequent
     Vitamin K                                                               and infrequent menses, irregular menses, and a
     150–500 mcg per day                                                     complete lack of menses. Chaste tree has been
                                                                             repeatedly studied in Germany. Although the
        Vitamin C. Vitamin C helps to reduce heavy                           fruit was used traditionally, it is the seeds that are
    bleeding by strengthening the capillaries. In at                         mainly used for medicine in Europe and in this
    least one study, vitamin C was able to reduce                            country. Consequently, most of the testing has
    heavy bleeding in 87 percent of the women.8 Vit-                         been done on the seeds. Chaste tree acts on the
    amin C also is an important supplement for                               hypothalamus and pituitary glands. It increases
    women who have acquired iron-deficiency anemia                            LH production and mildly inhibits the release of
    from menstrual blood loss. It helps to increase iron                     FSH. The result is a shift in the ratio of estrogen
    absorption and can be used to prevent anemia as                          to progesterone and consequently a “progesterone-
    well as to treat it.                                                     like” effect.9 The ability of chaste tree to raise
                                                                             progesterone levels is an indirect effect and not a
     Vitamin C                                                               direct hormonal action.10 Chaste tree has also
     2,000–4,000 mg per day                                                  been shown to inhibit prolactin release by the
                                                                             pituitary gland, particularly under stress.11
                                                                           ABNORMAL UTERINE BLEEDING              9
     The first major study on chaste tree was pub-        contraindication, and women should not worry if
lished in 1954,12 proving the herb’s effectiveness       they become pregnant while taking chaste tree for
for patients with cystic hyperplasia (excessive pro-     the first trimester. Chaste tree is completely safe
liferation of the endometrium). Although this            during lactation, and there are no known interac-
condition is not technically DUB, it is impressive       tions with other drugs, but theoretically, it might
that chaste tree was able to bring about enough of       interfere with dopaminergic antagonists. Mini-
a progesterone effect to reduce the hyperplasia. In      mal, reversible side effects have included itching,
a separate study, 126 women with menstrual dis-          occasional rash, nausea, headache, gastrointestinal
orders took 15 drops of a chaste tree liquid extract     disturbance, menstrual disorders, acne, and possi-
three times daily over several menstrual cycles.13 In    bly a lowered libido.16
33 women who had frequent menses (polymenor-                 Note: Aucubin and agnuside are different
rhea), the duration between periods lengthened           marker compounds found in chaste tree, used to
from an average of 20.1 days to 26.3 days. In 58         standardize the product to assure an effective dose.
patients with excessive bleeding (menorrhagia),
the number of heavy bleeding days was decreased.          Chaste Tree
     As mentioned earlier, chaste tree has an ability     30–60 drops liquid extract or 215 mg .6% aucubin
to inhibit prolactin production. A double-blind,           standardized extract or 175 mg .75% agnuside stan-
placebo-controlled study done in 2005 was able to          dardized extract per day
examine the effect of a chaste tree preparation on
52 women with luteal phase defects due to                    Ginger (Zingiber Officinale). Ginger has
elevated prolactin levels.14 The dose given was          been shown to inhibit prostaglandin synthetase17
20 mg chaste tree extract daily for three months.        and cyclooxygenase-2 (COX-2)18 enzymes believed
After three months of treatment, prolactin release       to be related to the altered prostaglandin-2 ratio
was significantly reduced in those taking chaste          associated with excessive menstrual loss.19 Pro-
tree. The shortened luteal phase was normalized          staglandins are hormone-like substances, and an
as was the decrease in progesterone production.          excess of prostaglandin 2s can cause increased pain
In another study examining the pharmacology              and inflammation. The most potent constituent
of vitex (another term for chaste tree), serum           appears to be gingerol, the pungent ingredient in
prolactin levels were reduced via vitex’s natural        the ginger. Inhibition of prostaglandin and
prolactin-suppressive compounds, namely diter-           leukotriene formation could explain ginger’s tradi-
penes. These diterpenes have dopaminergic prop-          tional use as an anti-inflammatory agent, and anti-
erties and bind to the DA2-receptor protein,             inflammatories are effective in reducing the flow
which, in turn, suppressed prolactin release.15          from heavy and protracted menses.
     Chaste tree is the most important herb to nor-
malize and regulate the menstrual cycle. Chaste           Ginger
tree is not a fast-acting herb; do not hesitate to use    1–4 g dry powder per day for semi-acute blood loss or
it over a long period of time. In fact, results may        ginger root extract (5%) gingerols 100 mg per day
not be achieved until after four to six months. It is
not an herb to be relied on for immediate relief,           Dietary Kelp or Bladderwrack (Fucus
and it will not be effective in reducing semi-acute      Vesiculosus). A very small study of three women
bleeding episodes. Human and animal studies              demonstrated that dietary kelp may be effective in
have determined chaste tree to be safe for most          normalizing DUB by decreasing 17 beta-estradiol
menstruating women. It is not recommended                (one of the estrogens the body naturally produces)
during pregnancy, although this is not an absolute       and increasing progesterone. These pilot data sug-
10   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     gest that dietary bladderwrack may prolong the                           a good choice for both semi-acute situations and
     length of the menstrual cycle and exert anti-                            chronic recurring episodes of DUB.
     estrogenic effects in premenopausal women.20                                 Uterine Tonics. In traditional herbal medi-
         Traditional Astringent Herbs. Astringent                             cine, uterine tone determines the ease of menstrual
     herbs form a large category of tannin-containing                         flow. If the uterus is hypertonic, then it may be dif-
     plants that are used to reduce blood loss from                           ficult to initiate menses in a timely manner. If the
     the reproductive tract as well as from the bowel,                        uterus is hypotonic, there may be heavy bleeding.
     stomach, respiratory tract, and skin. In the repro-                      In either case, improving uterine tone will tend to
     ductive tract, the astringent herbs are used to                          normalize and regulate menstrual bleeding. Two
     correct uterine or cervical bleeding. The astrin-                        categories of herbs are said to have the most effect
     gents most effective in uterine blood loss are                           on uterine tone and therefore bleeding.
     often high in tannins, but other constituents also
                                                                                  Tonics That Regulate Uterine Tone. The fol-
     explain their mechanism of action. The following
                                                                              lowing are uterine tonics or amphoterics that reg-
     herbs are the major astringent and hemostatic
                                                                              ulate tone (both reduce excess tone and increase
     herbs used in gynecological problems:
                                                                              tone in states of laxity):
      With Tannins
                                                                               • Dong quai (Angelica sinensis): potent antico-
      • Yarrow (Achillea millefolium)
                                                                                 agulant and hemostatic effects via platelet
      • Ladies’ mantle (Alchemilla vulgaris)
      • Cranesbill (Geranium maculatum)
                                                                               • Blue cohosh (Caulophyllum thalictroides)
      • Beth root (Trillium erectum)
                                                                               • Helonias (Chamaelirium luteum)
      • Greater periwinkle (Vinca major)
                                                                               • Squaw vine (Mitchella repens)
         Cranesbill. This astringent herb, high in                             • Raspberry leaves (Rubus idaeus)
     tannic acid, was relied on by early American Indi-                        • Life root (Senecio aureus)
     ans to treat diarrhea, dysentery, leukorrhea, and                            Life root, also known as ragwort, is a time-
     chronic menorrhagia, especially cases of prolonged                       honored “female regulator” that has been used
     bleeding. Cranesbill was used by early practition-                       consistently in traditional herbal medicine for
     ers of natural medicine (the eclectic physicians) to                     menstrual cramps, menorrhagia, suppressed men-
     achieve prompt and predictable results in cases of                       struation, and other disturbances of the reproduc-
     menorrhagia without any unpleasant side effects.                         tive tract. It is a classic uterine tonic that has been
      Without Tannins                                                         used to tonify a soft, less-than-firm uterus, includ-
      • Horsetail (Equisetum arvense)                                         ing laxity of the uterine ligaments. It adds tone
      • Goldenseal (Hydrastis canadensis)                                     and structure to the nervous and muscular struc-
      • Shepherd’s purse (Capsella bursa-pastoris)                            tures of the reproductive female organs and regu-
                                                                              lates the quantity of the monthly flow.
         Shepherd’s Purse. Shepherd’s purse is a mild
                                                                                  Tonics That Stimulate Menstrual Flow. The
     astringent that contains saponins, choline, acetyl-
                                                                              following are uterine stimulants or emmenagogues
     choline, and tyramine, all likely to be helpful in
                                                                              (agents that stimulate menstrual flow) that
     female reproductive health.21 Chemical analysis
                                                                              increase tone or muscular activity and serve to ini-
     shows that it can coagulate blood.22 Its best use is
                                                                              tiate the onset of menses:
     in combination with other astringent and hemo-
     static herbs for uterine bleeding, particularly when                      • Squaw vine (Mitchella repens)
     there is extremely heavy flow. Shepherd’s purse is                         • Yarrow (Achillea millefolium)
                                                                                   ABNORMAL UTERINE BLEEDING              11
 •   Chaste tree (Vitex agnus castus)                            Dosage for Botanicals
 •   Pennyroyal* (Mentha pulegium)
 •   Mugwort (Artemisia vulgaris)                                The herbs listed in the text with an asterisk (*) may
 •   Blue cohosh (Caulophyllum thalictroides)                    be toxic if given in inappropriate doses, so correct
                                                                 dosing is very important. Use a botanical reference to
    Blue cohosh is a perennial herb that grows                   assure safe dosage.
all over the United States, and it is the root or
rhizome that is used medicinally. The chemical                    Essential oil of cinnamon: 1–5 drops every 3–4
constituents include alkaloids, saponins, phyto-                   hours
                                                                  Other herbs: Do not exceed 20 drops every 2 hours
sterols, and many minerals. As an emmenagogue
                                                                   or 1 capsule every 4 hours if using a single herb.
that promotes the onset of menstrual flow, it                       Several herbs may be used in combination, and in
would seem odd to use it as a treatment for men-                   these cases it is important to consult a reference
orrhagia. Yet, traditionally, blue cohosh, when                    book or an herbal practitioner to know the dose
used with other astringent herbs, acts as a uterine                limitations.
tonic and in fact helps to regulate the menses and
the amount of flow.
    Astringent and uterine tonic herbs can be                       Natural Progesterone. Cyclic bio-identical
used in combination formulations and used for                   or natural progesterone that is given 12 days out
weeks to several months. Use as a tea, liquid                   of the month (usually day 15 of the cycle to day
extract, or powdered capsule.                                   26) can be used to correct infrequent menses,
                                                                heavy menses, and sometimes intermenstrual
 Traditional Herbs for Semi-Acute                               bleeding. This therapy substitutes for what the
 and Acute Blood Loss                                           body is not producing due to the lack of ovula-
 • Cinnamon* (Cinnamomum verum)                                 tion. A woman must ovulate in order to produce
 • Life root (Senecio aureus)                                   adequate levels of progesterone. Because natural
 • Canadian fleabane* (Erigeron canadensis)                      progesterone is biochemically identical to human
 • Greater periwinkle (Vinca major)
 • Shepherd’s purse (Capsella bursa-pastoris)
                                                                 Natural Bio-Identical Progesterone
 • Yarrow (Achillea millefolium)
 • Savin (Sabina officinalis)                                     A dose of 200 mg is thought to be adequate to regu-
                                                                 late abnormal bleeding. Natural progesterone is sev-
Bio-Identical Hormones                                           eral times less potent than a progestin (a synthetic
Bio-identical hormones are made in a manufactur-                 substance). Even 400 mg per day of oral micronized
ing laboratory and are derived from a compound                   progesterone may not work as well as 10 mg of
                                                                 medroxyprogesterone acetate (Provera).
found in either Mexican wild yam root or soy-
beans. The diosgenin plant compound from Mex-                     Oral dosage: 100–200 mg twice daily, given 7 to 12
ican wild yam or beta-sitosterol from soybeans is                   days per month for infrequent menses, menorrha-
                                                                    gia, and, occasionally, intermenstrual bleeding
extracted from the plant and then used to make a
                                                                  Cream dosage: (product that contains at least 400
hormone, in this case progesterone, that is bio-
                                                                    mg progesterone per ounce) 1⁄4–1⁄ 2 tsp twice daily
chemically identical to the progesterone in a                       for 12 to 21 days per month for cases of mild men-
woman’s body. Sometimes these are called natural                    orrhagia, infrequent menses, and, occasionally,
hormones, and other times they are called bio-                      intermenstrual bleeding
identical hormones.                                               Sublingual tablets: 50–75 mg twice daily for 12 to
                                                                    21 days per month for cases of mild menorrhagia
*May be toxic if given in inappropriate doses. See the dosage
guidelines in this section.
12   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      Sample Treatment Plans for Abnormal Uterine Bleeding

      See the Resources section for formulation sources.                         • Oral micronized progesterone: 200–400 mg per
                                                                                   day for 7–12 days, followed by a cyclic hor-
      Chronic Recurring Menorrhagia
                                                                                   mone product for 21 days on and 7 days off
         • Bioflavonoids: 1,000 mg twice per day                                  • If there is no change in 24 to 48 hours, high-
         • Vitamin A: 60,000 IU per day up to 3 months                             dose estrogens may be needed to stop the
         • Chaste tree (standardized extract): 175 mg per                          immediate bleeding, followed by a proges-
           day, or 1 tsp daily                                                     terone regimen.
         • Combination herbal product using astringents
           and uterine tonics; sample herbal tincture:                         Oligomenorrhea (Infrequent Menses)
             Yarrow: 2 oz
                                                                                 • Chaste tree: .6–.75% standardized extract, one
             Helonias: 2 oz
                                                                                   175–215 mg capsule daily; or liquid extract, 1
             Squaw vine: 2 oz
             Life root: 2 oz                                                       tsp daily
             1 tsp twice daily                                                   • Combination herbal emmenagogue:

         • Consider natural progesterone cream, 1⁄4–1⁄ 2 tsp                         Squaw vine: 11⁄ 2 oz
                                                                                     Yarrow: 1 oz
           twice daily, days 15–26 (day 1 is the first day
                                                                                     Blue cohosh: 1 oz
           of your menses)
                                                                                     Pennyroyal: 1⁄ 2 oz
                                                                                     20 drops every 2–3 hours
      Semi-Acute Menorrhagia
                                                                                 • Natural progesterone cream
         • Bioflavonoids: 1,000 mg 2–3 times daily
                                                                                     Apply 1⁄4 tsp 1–2 times daily, days 7–14 of cycle
         • Combination herbal products using astringents                             Apply 1⁄ 2 tsp 1–2 times daily, days 15–26
           and uterine tonics; sample herbal tincture:
             Yarrow: 2 oz                                                      Polymenorrhea (Frequent Menses)
             Greater periwinkle: 2 oz
             Shepherd’s purse: 2 oz                                              • Chaste tree: .6–.75% standardized extract,
             Life root: 2 oz                                                       one 175–215 mg capsule daily; or liquid
             20–30 drops every 2–3 hours                                           extract, 1 tsp daily
                                                                                 • Natural progesterone cream: 1⁄4–1⁄ 2 tsp twice
             If you choose to use one of the more toxic
                                                                                   daily, 21 days on, 7 days off (during menstrual
             herbs, such as cinnamon or beth root, be sure
             not to exceed recommended doses.
                                                                                 • Some cases may require higher doses of oral
         • Essential oil of cinnamon: 1–5 drops every 3–4                          micronized progesterone.
           hours                                                                 • Some cases may require a natural
                                                                                   estrogen/natural progesterone formulation that
                                                                                   requires more individualized dosing.

     progesterone, it is generally very well tolerated by                     viable alternative therapy in premenopausal
     women. One study found that while traditional                            bleeding disorders.24 You may want to read much
     progestin treatments such as norethindrone can                           more on bio-identical hormones in Chapter 12.
     decrease estradiol, follicle-stimulating hormone,                            The disadvantages to the natural hormone
     luteinizing hormone, sex-hormone-binding                                 include a short half-life (three to six hours) that
     globulin, and high-density lipoprotein choles-                           requires giving it two to three times a day. Natural
     terol, bio-identical progesterone offers the hor-                        progesterone can be delivered by injection, sub-
     monal benefits without these side effects and is a                        lingual tablets, rectal or vaginal suppositories, oral
                                                                          ABNORMAL UTERINE BLEEDING             13
capsules or tablets, and topical creams. Dosing is           Oral contraceptives containing estrogen and
dependent on the delivery system and the charac-         progestin are also used to stop acute bleeding,
teristic bleeding problems. When treating women          although they may not be as effective as the high
with DUB, the amount of progesterone given               doses of estrogen alone. Three tablets of an oral
must be adequate to convert the endometrium for          contraceptive containing a progestin plus 35 mcg
complete sloughing to avoid endometrial hyper-           of estrogen taken every 24 hours (one tablet
plasia. Continuous progesterone can be effective         every eight hours) will usually provide sufficient
in controlling menorrhagia.                              estrogen to stop acute bleeding while simultane-
                                                         ously providing progestin. Treatment is contin-
    Natural Estradiol. To control an acute bleed-
                                                         ued for at least one week after the bleeding stops.
ing episode, the use of natural estradiol should be
                                                         The practitioner can choose from a variety of
just as effective as one of the dosing regimens of
                                                         equally effective treatment regimens.
conjugated estrogens. These hormones are pre-
                                                             The treatment of choice for chronic, stable
scription items and should be administered by a
                                                         anovulatory bleeding is a progestogen medication.
practitioner qualified to use them. One high-dose
                                                         Use either MPA or norethindrone (NE) in doses
regimen would be 2 mg of estradiol every four
                                                         of 5 to 10 mg daily or oral micronized proges-
hours for 24 hours, a single daily dose for 7 to 10
                                                         terone (either compounded or Prometrium) 200
days, followed by oral micronized progesterone,
                                                         to 400 mg daily for 14 days starting on day 14 of
200 mg per day for 7 to 12 days.
                                                         the menstrual cycle. The patient can stop the med-
C O N V E N T I O NA L                                   ications if she has begun menstruating before the
M E D I C I N E A P P R OAC H                            end of her progestogen.
                                                             Nonsteroidal anti-inflammatory drugs
The goals of conventional treatment for abnor-
                                                         (NSAIDs) are also used to reduce blood loss,
mal uterine bleeding are to control bleeding, pre-
                                                         especially in women who have DUB but still have
vent endometrial hyperplasia or cancer, prevent
                                                         normal ovulation. When NSAIDs are taken during
or treat anemia, and restore quality of life. When
                                                         the episode of menorrhagia, the effect is a 20 to 50
the diagnosis is definitely DUB, it is preferable to
                                                         percent reduction in blood loss. The following
use medical, not surgical, treatments.
                                                         anti-inflammatories are usually given for the first
    To control an acute bleeding episode, 10 mg of
                                                         three days of menses, or throughout the menstrual
oral conjugated estrogens (or the equivalent)
                                                         flow, and seem to have similar effects:
administered daily as 2.5 mg four times per day are
usually effective. If bleeding is not controlled         1. Ibuprofen: 600 mg every 6–8 hours
within the first 24 hours, higher doses (20 mg) may       2. Naproxen sodium: 550 mg every 6–8 hours
be effective. Once the bleeding has stopped, oral        3. Mefenamic acid: 500 mg first dose, then
estrogen therapy is continued at the same dosage            250 mg every 8 hours
for a total of 21 days; the addition of a progestin,     4. Meclofenamate sodium: 100 mg every 8
such as medroxyprogesterone acetate (MPA), 10               hours
mg daily, should be added for the last 7 to 10 days      5. Naproxen: 500 mg every 12 hours
of those 21 days. Alternatively, 200 to 400 mg
daily of progesterone may be substituted for the            NSAIDs may be used alone in some cases or
MPA. At the end of 21 days, both hormones are            combined with an oral contraceptive or proges-
stopped, at which time the patient should expect a       togen. Other, more sophisticated medical regi-
light “withdrawal” bleed. At this time, a strategy for   mens may be used to intervene, including GnRH
long-term management should be developed.                agonists (Lupron), androgenic steroids (danazol),
14   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     or an antifibrinolytic agent. However, these                              because of the pain of the procedure. Ablation
     options have significant side effects, and their use                      technology continues to advance with the hopes
     is limited to women who fail to respond to other                         of developing a procedure that can be done in
     methods of drug management and who do not                                the office.
     want surgery.                                                             3. Hysterectomy, surgical removal of the
          Progesterone-releasing IUDs (Mirena) are                            uterus, should be reserved for the woman with
     gaining interest because of their lack of systemic                       other indications for hysterectomy such as uter-
     side effects, duration of action of five years, and                       ine fibroids, uterine prolapse, or atypical hyper-
     60 to 80 percent reduction in menstrual blood                            plasia. When a hysterectomy is done for
     flow. They also can suppress the growth of the                            bleeding problems there is usually no need to
     endometrium in oligo-ovulatory patients, thereby                         remove the ovaries.
     preventing hyperplasia or uterine cancer.
          There are basically three surgical options that                     S E E I N G A L I C E N S E D P R I M A RY
     may be considered in individual cases: dilation                          H E A LT H - CA R E P R AC T I T I O N E R
     and curettage (D&C), endometrial ablation, or                            ( N . D. , M . D. , D. O . , N . P. , P. A . )
     hysterectomy.                                                            Changes in the pattern or amount of menstrual
                                                                              blood flow is one of the most common health con-
      1. Dilation and curettage (D&C) can be both                             cerns of women. Even though many of these cases
     diagnostic and therapeutic. A D&C is the                                 are of no serious concern, a woman with abnormal
     quickest way to stop bleeding; therefore, it is a                        bleeding distinctly different from her familiar his-
     treatment of choice in women with DUB who                                tory should do the cautious thing and be seen by
     suffer from anemia due to heavy menstrual                                a licensed health-care practitioner such as a natur-
     blood loss or who are acutely unstable. The                              opathic doctor (N.D.), medical doctor (M.D.),
     problem with a D&C is that it is only tempo-                             osteopathic doctor (D.O.), nurse-practitioner
     rary in most cases and does not cure the prob-                           (N.P.), or physician’s assistant (P.A.). After a thor-
     lem the majority of the time. One advantage,                             ough medical history is taken, a physical exam
     though, is that it can give the doctor tissue for                        and further laboratory testing and imaging may
     diagnosis.                                                               be requested not only to adequately diagnose the
      2. Endometrial ablation is a procedure to                               cause of the problem but also to determine if
     destroy the endometrial tissue. It is highly pop-                        excessive blood loss has caused an anemic state.
     ular because of the ease of treatment, the suc-                               The most worrisome situation is an acute
     cess, and the low incidence of complications.                            bleeding episode. As stated earlier, bleeding that
     There are several types of ablations now: the                            meets or exceeds saturation of a super tampon or
     original roller ball or loop unipolar resection, a                       heavy pad every hour for six to eight hours or
     bipolar electrical vaporization method, a bipolar                        more requires medical intervention. Bleeding
     electrical mesh, a balloon filled with dextrose                           that is even more severe will require immediate
     water that is heated to 200 degrees Fahrenheit,                          medical attention to assess the need for a surgical
     free-flowing hot water, and a microwave and                               intervention and management of the dangers of
     cryo probe technology as well. The method                                acute blood loss.
     used depends on practitioner preference and                                   A licensed naturopathic physician may work
     select uterine characteristics. All ablations                            in tandem with conventional medical colleagues
     require IV sedation or general anesthesia and                            to cooperate on an integrated approach to opti-
     may not be well tolerated in an office setting                            mize the patient outcome.
                                        AMENORRHEA                                                  CHAPTER

OV E RV I E W                                                   rhea caused by low levels of estrogen, or hypo-
Traditionally, amenorrhea (absence of menstrual                 estrogenic amenorrhea, is associated with loss of
bleeding) has been classified as either primary or               bone mineral density and an increased risk later
secondary. Primary amenorrhea means that no                     in life of osteoporosis and fractures. Lipid levels
vaginal bleeding has ever occurred by the time of               in the bloodstream are also negatively affected by
expected initial onset (usually age 16). Secondary              prolonged hypoestrogenic states, and this is asso-
amenorrhea means that vaginal bleeding has pre-                 ciated with an increased risk of cardiovascular
viously occurred but has now ceased—for three                   disease. Amenorrhea without ovulation is associ-
months in a woman with a history of regular                     ated with an increased risk of endometrial hyper-
cyclic bleeding or for six months in a woman                    plasia and uterine cancer because of the lack of
with a history of irregular periods. In the United              progesterone and the presence of what is called
States, females normally experience the onset of                an “unopposed” estrogen state. Polycystic ovarian
their first menstrual period between the ages of                 syndrome (PCOS) is an example of this type
9 and 18. It has been estimated that the prevalence             of amenorrhea. Characteristics of PCOS include
of amenorrhea in the general U.S. female popula-                obesity, hirsutism (abnormal hair growth), acne,
tion during the reproductive years is 1.8 to 3                  infertility, hypertension, and diabetes.
percent, the prevalence in college-aged women is                    Evaluating and managing amenorrhea is best
2.6 to 5 percent, and amenorrhea may be seen in                 addressed with the medical knowledge of a quali-
20 percent of women reporting infertility.                      fied primary care practitioner. Sometimes a spe-
    Determining the cause of amenorrhea is one of               cialist in endocrinology is necessary, to rule out or
the most challenging tasks in gynecology. Causes                consider an array of potential diseases and disor-
of amenorrhea can be organized into four classifi-               ders of the hypothalamus, pituitary gland, ovaries,
cations: disorders of the vagina or uterus, disorders           thyroid, and/or uterus.
of the ovary, disorders of the anterior pituitary
gland, and disorders of the central nervous system.             T H E N O R M A L M E N S T R UA L C Y C L E
The causes of primary amenorrhea are often very                 Normal menstruation results from a complex chain
complex, and approximately 40 percent of all cases              of events initiated in the central nervous system:
are due to a chromosomal defect. Absence of a
vagina is the second-most-common cause, fol-                    1. The hypothalamus secretes gonadotropin-
lowed by testicular feminization syndrome. Other                   releasing hormone (GnRH) that regulates
causes of primary and secondary amenorrhea are                     pituitary function.
often overlapping.                                              2. The anterior pituitary produces luteinizing
    The majority of amenorrheic young women                        hormone (LH) and follicle-stimulating hor-
have very low levels of estrogen, and a minority                   mone (FSH) that govern ovarian function.
will have subnormal, noncyclic estrogen levels                     The main action of LH is to stimulate syn-
without progesterone due to a lack of ovulation.                   thesis of androgens by the theca cells in the
This distinction is important in considering the                   ovary and progesterone synthesis by the
long-term implications of amenorrhea. Amenor-                      corpus luteum. LH also induces ovulation,
Copyright © 2008 by Tori Hudson. Click here for terms of use.
16   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

      Figure 2.1              Normal Menstrual Cycle

           FSH &                   Progesterone
           LH          Estradiol   17-OHP
           IU/L        pg/nl       ng/ml

           20          500         10
           18                       9
                                                                                        LH                                   Progesterone
           16          400          8
           14                       7
           12          300          6
           10                       5
            8          200          4
            6                       3
            4          100          2
            2                       1       Estradiol                                              17-OH Progesterone

            0             0         0
                                            2           4   6   8    10       12   14         16         18   20        22   24       26    28

                                   Menses                                                    Ovulation
                                                                                                AMENORRHEA      17
D I AG N O S I N G A N D                                  PREVENTION
A good history is the most important part of the          • Have adequate calories in the diet.
                                                          • Include adequate levels of dietary fat.
medical evaluation to diagnose amenorrhea. The
                                                          • Keep regular daily eating habits.
history will include evaluating for pregnancy, men-
                                                          • Avoid being underweight.
strual history, emotional stress, weight gain or          • Avoid obesity.
loss, alcohol use or abuse, dietary habits, exercise      • Avoid excessive exercise.
habits, medications, narcotics, drug abuse, acute or      • Practice stress reduction and management.
chronic illnesses, accidents or injuries, infertility,    • Women with hypoestrogenic amenorrhea must be
metabolic disease, immune system abnormalities,             vigilant about prevention of osteoporosis and
tuberculosis, hot flashes, breast discharge, head-           coronary artery disease.
aches, and family history.                                • Women with anovulatory amenorrhea must be
    A physical and pelvic exam will confirm the              monitored for endometrial thickening and the
                                                            development of endometrial hyperplasia, a
most likely causes as suggested by the history.
                                                            precancerous state, and endometrial cancer.
During the pelvic exam, the practitioner will
                                                          • Women who have been diagnosed with polycys-
attempt to determine if there is an adequate estro-         tic ovarian syndrome (PCOS), the normogo-
gen effect on the cervix and vagina, check for the          nadotropic anovulation state, must not only be
size of the ovaries, assure the normalcy of the             treated for current problems related to the PCOS,
uterus and vagina, and observe for the presence or          but they need assertive prevention for diseases
absence of secondary sex characteristics (such as           for which they are at higher risk, including
breasts and pubic hair). The thyroid gland will also        type 2 diabetes, high blood pressure, heart
be checked, and laboratory tests will be chosen             disease, endometrial cancer, and possibly breast
selectively to document the suspected diagnosis.            cancer.
    Due to the complexity of amenorrhea and the
diverse array of causes, it is impossible to address     each potential cause in this chapter. The guiding
                                                         rule in the management of amenorrhea is to diag-
 KEY CONCEPTS                                            nose before treating. The appropriate manage-
                                                         ment depends not only on the diagnosis but also
 • Successful management of amenorrhea depends           on the presenting problem. Each woman must
   on an accurate diagnosis.                             then be treated according to the specific causative
 • Amenorrhea is a symptom, not a diagnosis.             factors involved. Consequently, in the discussion
 • The absence of menses in itself has no deleteri-
                                                         of alternative treatment, we will largely focus on
   ous effect on health, but it may be a presenting
                                                         four of the most common causes of amenorrhea:
   symptom of an underlying disorder that requires
   treatment.                                             1. Hypergonadotropic hypogonadism. The
 • A licensed primary health-care practitioner is        pituitary secretes elevated amounts of its hor-
   needed to conduct a careful history, examina-         mones, but the ovary does not respond. Exam-
   tion, and indicated tests.
                                                         ple: premature ovarian failure.
 • The most common cause of secondary amenor-
   rhea is pregnancy.
                                                          2. Hyperprolactinemia. The pituitary secretes
 • Prolonged amenorrhea that is hypoestrogenic           too much prolactin. Examples: certain drugs,
   (hypergonadotropic hypogonadism or hypogo-            pituitary tumors, hypothyroid disease.
   nadotropic hypogonadism) prior to menopause is         3. Hypogonadotropic hypogonadism.
   a risk factor for osteoporosis.                       Reduced secretion of FSH and LH that results
                                                         in failure of the ovarian follicle to develop and,
18   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     hence, a lack of secretion of estradiol by the                           meticulous medical approach employing mind-
     ovaries. Examples: psychological stress, weight                          body-oriented perspectives. Specific dietary
     loss, genetic diseases.                                                  counseling may be warranted, and practitioners
      4. Normogonadotropic anovulation. Normal                                may find themselves in the unusual position of
     FSH and LH, but the cyclic nature of the                                 advocating an increase in cholesterol and other
     pulsed secretions is disrupted. The ovarian folli-                       fats in the diet and counseling patients to gain
     cles develop and estrogen is produced, but at                            weight or exercise less. Because stress disrupts the
     some stage the follicles do not fully mature.                            menstrual cycle, it is also important to provide
     Thus, there is no ovulation but there is no sign                         guidance about stress reduction.
     of estrogen deficiency; rather, there is a proges-                            The goal of a natural therapeutic treatment
     terone deficiency. Example: polycystic ovary                              plan for amenorrhea is to address the specific
     syndrome.                                                                underlying cause as would conventional medi-
                                                                              cine, while also taking a more constitutional and
     OV E RV I E W O F                                                        holistic approach to treatment. Even in cases
     A LT E R NAT I V E T R E AT M E N T S                                    where something specific such as an elevated pro-
     A licensed alternative primary care practitioner                         lactin level may be the cause, the practitioner
     such as a naturopathic physician must first make                          would want to address the mental and emotional
     an accurate diagnosis as to the cause of the amen-                       component, support the digestion, provide toni-
     orrhea, utilizing a medical history, physical exam,                      fying and nutritive support to the reproductive
     and possible laboratory testing. Naturopathic                            system in general, and more. This organ-specific
     physicians often see patients who are on extreme                         as well as constitutional approach is a common
     diets due to some other health concern; sometimes                        theme in many alternative medicine disciplines,
     these diets are inappropriate for that individual                        and especially naturopathic medicine.
     and are the cause of the amenorrhea. Insufficient                             The natural therapies presented in this chap-
     calories and insufficient dietary fat and cholesterol                     ter deal with these four general states:
     may be the culprit in some of these cases. Other
                                                                              1. Premature ovarian failure (See Chapter 12
     health-conscious individuals may have become
                                                                                 for more in-depth information and treat-
     too thin with a combination of diet and exercise,
     and they may have acquired amenorrhea because
                                                                              2. Hyperprolactinemia
     they have too little body fat. It is unlikely that
                                                                              3. Inadequate estrogen production
     overexercise alone will cause amenorrhea; it usu-
                                                                              4. Chronic lack of ovulation, including poly-
     ally takes a combination of low body fat and heavy
                                                                                 cystic ovary syndrome (PCOS)
     exercise to induce amenorrhea.
         In other cases such as polycystic ovarian syn-                       Keep in mind that causes such as thyroid disor-
     drome (PCOS), about 50 to 60 percent of women                            ders, tumors, systemic diseases, genetic disorders,
     will be overweight. In these cases, a 10 percent                         and others will require therapies to specifically
     weight loss can lead to ovulation and also decrease                      address those underlying problems, which are
     insulin resistance. A diet lower in starchy carbs and                    beyond the scope of this book.
     higher in healthy protein is an important strategy
     for women with PCOS, whether they are over-                              Nutrition
     weight or not.                                                           Both weight loss and obesity can be associated
         A holistic approach to treatment requires                            with amenorrhea. A range of weight-loss prob-
     exploring the mental, spiritual, emotional, and                          lems are associated with amenorrhea, including
     physical aspects of the patient integrated with a                        crash diets, malnutrition, and life-threatening
                                                                                            AMENORRHEA        19
anorexia nervosa. Anorexia nervosa occurs pri-         insulin, and glucose intolerance, conditions that
marily in young white middle- to upper-class           often co-occur with obesity and polycystic ovar-
women under age 25, yet has also been known to         ian syndrome, are associated with amenorrhea
occur in young men and middle-aged women.              and oligomenorrhea (infrequent menses).2, 3
The family situation of a young woman with             Usually, oligomenorrhea and chronic anovula-
anorexia is very often success-achievement-            tion caused by hormonal abnormalities is the
appearance oriented. The pattern usually starts        cause of the menstrual irregularity in women
with a diet to control weight and a fear of excess     with significant amounts of excess body fat.2 A
weight when in fact the weight being gained is         reduction in body weight by reducing calories,
due to normal maturing. There is often a preoc-        increasing physical exercise, and possibly other
cupation with food that may manifest itself by         weight-management interventions will result in
large intakes of lettuce, raw vegetables, and other    beneficial changes in the hormonal profile,
low-calorie foods. Other manifestations may be         including a marked reduction of androgenic hor-
chaotic eating habits and eating times, radical        mones and their effects.1 A reduction of weight
diets, missed meals, and bingeing episodes.            by even as little as 5 to 10 percent can not only
    Bulimia is a syndrome of episodic and secre-       restore regular menses, but also improve fertility.4
tive binge eating followed by self-induced vomit-          Some women may have low body weight
ing, fasting, or the use of laxatives and diuretics.   but do not have an eating disorder or exercise-
Bulimic behavior is frequently seen in about half      induced amenorrhea. This may be a metabolism
of women with anorexia nervosa. Body weight in         issue, a hereditary factor, or a diet that is ex-
“pure” bulimics fluctuates but does not fall to the     tremely low in fat although not low in calories.
low levels seen in anorexics.                          Women who take in insufficient calories, such as
    Teenagers with low body weight, amenorrhea,        strict vegetarians who eat no animal products or
and overachievement (excellent grades and many         others with extreme diets, may have insufficient
extracurricular activities) need astute evaluation     dietary fat and low cholesterol. Adequate choles-
for an eating disorder. Psychological counseling,      terol is needed to manufacture hormones. If no
consistent support, and monitoring for calorie         cholesterol is found in the diet and the liver is
intake will be needed to break the established pat-    not manufacturing adequate cholesterol, these
terns. The earlier the recognition of the problem,     women may have amenorrhea due to insufficient
the more successful the intervention. Family           hormone levels. Measuring the cholesterol level
members, friends, and health-care practitioners        can be telling in such cases. If cholesterol is low
should pay particular attention to weight and diet     (below 120), a change in vegetarian philosophy
in young women with amenorrhea.                        will probably be necessary so that some animal
    Obese women exhibit several abnormalities          products can be included in the diet in order to
in their hormone profile. Elevated serum concen-        raise the cholesterol levels.
trations of androstenedione, testosterone, and             Sometimes it is difficult to find the best nutri-
DHEA-sulfate are associated more closely with          tional program for one’s body type and lifestyle.
the pattern of fat distribution (abdominal vs.         In these cases, nutritional counseling and nutri-
hips, in particular) than to the body fat mass.1       tional analysis with a qualified practitioner can
High levels of these hormones, called androgens,       be very helpful. No one diet plan is right for
are known to be a cause of menstrual irregulari-       everyone. Not everyone needs to eat from all the
ties including amenorrhea, hirsutism (abnormal         food groups, not everyone can be a vegetarian,
body hair growth), and other metabolic distur-         and not everyone responds well to a high-protein
bances. In addition, type 2 diabetes, elevated         or high–complex carbohydrate diet.
20   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         In addition to proper food choices, another                          orrhea in long-distance runners was associated
     basic general principle for good nutrition is reg-                       with hypercarotenemia, but that association was
     ularity. Just as going to bed and rising at regular                      disproved, and no difference in carotene levels
     times with a certain amount of sleep assures ade-                        was observed.11
     quate energy and vitality, regular mealtimes and                             I found no reference to amenorrhea or men-
     consistency in eating habits lead to good diges-                         strual irregularities associated with taking carotene
     tion and absorption of nutrients necessary for                           supplements, and, as of this writing, I don’t believe
     normal physiology.                                                       amenorrhea has been reported as a side effect of
         Not all advice on nutritional habits for                             beta-carotene ingestion. However, I will probably
     women with amenorrhea is related to dietary                              encourage women who are experiencing signifi-
     fat, calories, body weight, or eating disorders.                         cant weight loss and amenorrhea to eat lesser
     Some nutritional guidance is relevant to the pre-                        amounts of carotene foods for the time being. I
     vention of osteoporosis, a potential consequence                         would also be inclined to reduce their vitamin A
     of amenorrhea. Please see Chapter 14 for more                            and carotene supplementation if they were on
     information on preventing osteoporosis.                                  high doses for some other medical reason.

     Supplements                                                                  Calcium. One of the serious long-term con-
                                                                              sequences of amenorrhea due to premature ovar-
         Vitamin A and the Carotenes. Carotenemia,
                                                                              ian failure or lower production of estrogen
     an abnormal elevation of plasma carotene levels,
                                                                              (hypothalamic amenorrhea) is a lower bone den-
     may result from an excessive ingestion of carotene-
                                                                              sity and an increased risk for osteoporosis and
     rich vegetables, anorexia, and impaired ability of
                                                                              fractures later in life. Even when calcium intake
     the body to metabolize carotenes.5–7 Carotenemia
                                                                              is the same between amenorrheic women and
     has been linked with menstrual dysfunction and
                                                                              women who menstruate normally, there is a
     amenorrhea in some women, generally in associa-
                                                                              decrease in calcium absorption and an increase in
     tion with weight loss. In 1968, elevated carotene
                                                                              calcium excretion in estrogen-deficient women.
     levels were observed in 9 of 12 women with
                                                                              There is ample evidence that a lack of estrogen
     anorexia nervosa who did not ingest excessive
                                                                              increases the daily calcium requirement.12 As a
     amounts of carotenes.8 An additional study also
                                                                              result, I recommend a higher-than-normal daily
     found that patients with amenorrhea and weight
                                                                              intake (1,200 to 1,500 mg per day) of either cal-
     loss had carotenemia.9 Another group of re-
                                                                              cium carbonate or calcium citrate to maintain
     searchers found elevated serum carotene levels in
                                                                              calcium balance in low-estrogen states in women
     women with anorexia nervosa, but not in women
                                                                              of reproductive age. (For more information on
     with normal or abnormal menstrual function.7 It
                                                                              osteoporosis, please see Chapter 14.)
     is thought that mobilization of fat stores second-
     ary to weight loss might be responsible for hyper-
                                                                               Calcium Carbonate or Calcium Citrate or
     carotenemia in women with anorexia nervosa.
         In 1971, a small study examined six women
     with elevated serum carotene levels who had                               1,200–1,500 mg per day
     excessive intake of carrots or pumpkins.10 The
     researcher described what he called “golden                                  Additional Vitamins and Minerals. Many
     ovaries” and noted that amenorrhea developed in                          other minerals and nutrients affect bone density
     the two younger patients and irregular menstrual                         and are relevant to the prevention of osteoporo-
     bleeding in the four older patients. For some                            sis in amenorrheic women. Magnesium, man-
     time it was thought that exercise-induced amen-                          ganese, zinc, copper, boron, vitamin K, vitamin
                                                                                               AMENORRHEA       21
D, and other nutrients determine bone health,           increased, and FSH values either did not change
each in their own way. In Chapter 14, I discuss         or decreased slightly.
this in detail.                                             Chaste tree also inhibits prolactin release by
                                                        the pituitary gland, particularly when elevated
Botanicals                                              prolactin is caused by stress, by binding dopa-
     Chaste Tree (Vitex Agnus Castus). Chaste           mine receptors and then inhibiting prolactin
tree is probably the best-known herb in all of          release in the pituitary.17, 18 Since elevated pro-
Europe for hormonal imbalances in women. Since          lactin levels cause some cases of amenorrhea,
at least the time of the Greeks, chaste tree has been   chaste tree is also indicated for these cases. A
used for the full scope of menstrual disorders,         double-blind, placebo-controlled study examined
including amenorrhea. Chaste tree acts on the           the effect of a chaste tree (vitex) preparation on 52
hypothalamus and pituitary glands by increasing         women with luteal phase defects due to hyperpro-
LH production and mildly inhibiting the release         lactinemia (elevated prolactin levels).19 The daily
of FSH. The result is a shift in the ratio of estro-    dose of the extract was 20 mg, and the study
gen to progesterone, in favor of progesterone.13        lasted for three months. Prolactin release was sig-
Chaste tree stimulates ovulation, which in turn         nificantly reduced in the vitex group. The short
produces progesterone. Thus, chaste tree indi-          luteal phase (second half of the cycle) was normal-
rectly raises progesterone levels,14 an effective       ized, and the decreased progesterone production
treatment for some cases of amenorrhea.                 was normalized. No side effects were noted, and
     If we were to give progesterone hormone for        two women became pregnant.
several days, stop, and then a menses occurs, this          When using chaste tree, don’t expect immedi-
indicates an intact reproductive system that lacks      ate results. It’s not the same as giving proges-
cyclicity and ovulation, or at least regular cyclic     terone, even natural progesterone. Chaste tree is
ovulation. It suggests that the body is producing       more of a medium-range plan; usually it begins
enough FSH to stimulate the ovaries and that the        to take effect after three or four months when
ovaries can develop follicles. Furthermore, it          given daily.
indicates that follicular production of estrogen is
sufficient to cause the lining of the uterus (endo-       Chaste Tree
metrium) to grow and that the sloughed endo-             40 drops tincture or 175 mg .6% aucubin standardized
metrium is able to pass through the cervical              extract per day
opening and the vagina. This tells us that the
problem most likely is a dysfunction in the hypo-           Black Cohosh (Cimifuga Racemosa). Black
thalamus or pituitary. The ability of chaste tree to    cohosh has become one of the most significant
modulate the hypothalamus or pituitary then             women’s herbs in all of botanical medicine. Also
makes this herb an obvious choice.                      known as snakeroot or rattleroot, this plant
     The first major study on chaste tree was            belongs to the buttercup family and is indigenous
published in 1954.15 Subsequent studies have            to the eastern part of North America. The native
continued to prove its effectiveness. In a study        peoples of Canada and America used black cohosh
published in 1990, 20 women with secondary              for many different indications, such as uterine
amenorrhea were admitted to a six-month study           pains during menses and childbirth, rheumatism,
using chaste tree liquid extract at 40 drops            rattlesnake bites, and general malaise. Black
daily.16 At the end of the six-month study, 10 out      cohosh was introduced to Western gynecology in
of the 15 women had menstrual cycles. Testing           the middle of the eighteenth century in the treat-
showed that values for progesterone and LH              ment of menopausal symptoms.20
22   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         The exact mechanism of how black cohosh                              ance to high altitude sickness, fatigue, depres-
     works has yet to be elucidated. We attribute most                        sion, anemia, impotence, gastrointestinal ail-
     of its gynecological effects to its “estrogen-like”                      ments, infections, and disorders of the nervous
     action, yet recent research has shown that black                         system. The folklore surrounding rhodiola led to
     cohosh does not contain phytoestrogens, nor does                         the first investigations in its phytochemistry in
     it change hormone levels such as estradiol, LH,                          the early 1960s, when scientists identified adap-
     FSH or prolactin.21–23 The primary constituents in                       togenic compounds in its roots. These adapto-
     black cohosh extract are glycosides, particularly                        gens, believed to help the body adapt to stress by
     the triterpene glycosides, mainly cimicifugoside                         supporting the adrenal glands and endocrine
     and actein, which are assumed to interfere with                          system, as well as the antioxidant and stimulating
     pituitary gland receptors and the hypothalamus.                          compounds that were later discovered in rhodi-
     Other characteristic constituents are the flavo-                          ola, are responsible for its medicinal properties.
     noids, resins, volatile oils, fatty acids, tannins,                          Animal studies looking at the effect of rhodi-
     alkaloids, cimicifugin, and salicylic acid. Although                     ola on thyroid function, adrenal function, and
     the constituents in black cohosh may be able to                          ovarian egg maturation have raised interest in
     bind to receptors in the pituitary or hypothala-                         rhodiola for endocrine problems in humans.
     mus, these constituents do not seem to be able                           Forty women suffering from amenorrhea (loss of
     to bind to receptors in target organs. Older                             menstrual cycles) were given 100 mg of rhodiola
     research showed the effects of a black cohosh                            twice daily for two weeks or an injection for 10
     preparation on LH and FSH secretion in meno-                             days. Remarkably, normal menses were restored
     pausal women. After a treatment of two months,                           in 25 women, 11 of whom became pregnant.28
     LH (but not FSH) levels were significantly                                Physicians have reported cases of women who
     reduced in the black cohosh–treated group.24                             had failed to conceive with standard fertility
         There have been many studies using black                             drugs, who then became pregnant within several
     cohosh preparations in menopausal women.                                 months of beginning Rhodiola rosea extract. For
     These studies and the further use of this plant in                       treatment, look for extracts that are standardized
     menopausal women will be discussed in much                               to contain 3 percent rosavin.
     detail in Chapter 12. For women who have amen-
     orrhea due to hypoestrogenic states, a state similar                      Rhodiola (3% Rosavin)
     to menopause, black cohosh will be important in                           200 mg per day (or 100 mg twice daily)
     relieving some symptoms. Recent studies even
     indicate that black cohosh may decrease risk fac-                            Maca (Lepidium Peruvianum). Maca is a
     tors associated with menopause such as osteoporo-                        root vegetable, in the same family as turnips and
     sis and cardiovascular disease and may even be                           broccoli, which grows at high elevations, native to
     effective in preventing bone loss.25–27                                  the high Andean plateaus of Peru. It has been used
                                                                              traditionally by native Peruvians as both a food
      Black Cohosh
                                                                              and medicine. It has historically been used for a
      40–80 mg standardized extract twice daily                               variety of purposes, including hormone balancing,
                                                                              thyroid function, sexual function, PMS, meno-
        Rhodiola. Rhodiola, also called golden root,                          pause, and as a tonic for healthy aging.
     has enjoyed centuries of use in Eastern Europe,                              A recent study proved maca’s effectiveness in
     Scandinavia, and Asia. Traditionally, this herb                          treating women with amenorrhea due to hypo-
     was used in folk medicine to increase physical                           estrogenic states, and especially premature ovarian
     endurance, work productivity, longevity, resist-                         failure. In a study of 20 healthy menopausal
                                                                                                    AMENORRHEA   23
women in the early phase of their menopause,                     Phytoestrogens. Phytoestrogens are by and
maca (2,000 mg per day) was given for up to                  large nonsteroidal hormone-like constituents
eight months and was shown to lower follicle-                found in over 300 medicinal and edible plants.
stimulating hormone (FSH) (higher levels of                  With the currently available evidence, soybeans
FSH are a measure of low estrogen production                 are probably the richest edible source of phyto-
from the ovaries) and increase luteinizing hor-              estrogens. Some plant compounds, such as lig-
mone (LH) (elevated LH is necessary to stimu-                nans, found in flaxseed, are not phytoestrogens
late ovulation), resulting in increases in both              but are converted to estrogens in the intestines.
estrogen levels and progesterone levels.29 These             There are many herbs that contain phytoestrogen
results would seem to suggest that maca, depend-             compounds and have a role in amenorrhea. They
ing on the length of use, could act as a hormonal            support the reproductive cycle and relieve meno-
toner and stimulate the production of estrogen               pausal symptoms in women who are appropri-
and progesterone.                                            ately menopausal (see Chapter 12) as well as
                                                             women who are amenorrheic and prematurely
 Maca                                                        menopausal. These herbs include:
 Four 500-mg capsules (2,000 mg) per day
                                                              •   Alfalfa (Medicago sativa)
                                                              •   Dong quai (Angelica sinensis)
Traditional Herbs                                             •   Flaxseed (Linum usitatissimum)
                                                              •   Ginseng (Panax ginseng)
    Uterine Stimulants. Uterine stimulants or                 •   Hops (Humulus lupulus)
emmenagogues increase tone or muscular activ-                 •   Licorice (Glycyrrhiza glabra)
ity and serve to initiate the onset of menses and             •   Red clover (Trifolium pratense)
stimulate reproductive function. Most important
are the herbs that cause shedding of the endo-                   Progesterone Precursors. Diosgenin and
metrium and stimulate normal menstrual cycles                sarsasapogenin can be converted in the labora-
in the absence of pregnancy.                                 tory to various hormones, including proges-
                                                             terone, which in turn can be converted to adrenal
 •   Squaw vine/partridgeberry (Mitchella repens)            steroids and then to testosterone or estrogens.
 •   Yarrow (Achillea millefolium)                           Even though diosgenin from plants is used by
 •   Chaste tree (Vitex agnus castus)                        pharmaceutical companies to synthesize various
 •   Pennyroyal* (Mentha pulegium)                           hormones, there is very little scientific informa-
 •   Mugwort (Artemisia vulgaris)                            tion on diosgenin-containing plants and their
 •   Water pepper (Polygonum hydropiper)                     relationship to human metabolism. A number of
   Water Pepper.30 In a medical journal of 1846,             herbs contain diosgenin or sarsasapogenin:
Dr. Thomas Ogier, a surgeon and obstetrician,                 •   Bloodroot (Sanguinaria canadensis)
published an herbal approach for amenorrhea.31                •   Blue cohosh (Caulophyllum thalictroides)
He maintained that administering a tincture of                •   Fenugreek (Trigonella foenumgraecum)
water pepper successfully treated a case of obsti-            •   Sarsaparilla (Smilax officinalis)
nate amenorrhea. Exactly how the water pepper                 •   Wild yam (Dioscorea spp)
works is not known.                                           •   Yucca (Yucca spp)
                                                                Special Herbal and Supplemental Consid-
*Important caution: Do not use essential oil of pennyroyal   erations for Polycystic Ovarian Syndrome.
internally in any situation.                                 For PCOS, include herbs that will increase
24   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     sex-hormone-binding globulin. This will bind up                          will induce complete secretory changes in the
     some of the excess androgens secreted by the                             endometrium and induce a menses in a woman
     ovarian follicles.                                                       whose uterus has been adequately stimulated by
                                                                              estrogen. Lack of vaginal bleeding after the prog-
      •   Nettle root                                                         esterone challenge suggests either inadequate
      •   Green tea                                                           priming of the endometrial lining, absence of an
      •   Soy                                                                 endometrial cavity, or some kind of obstruction.
      •   Flaxseed                                                                 If no withdrawal bleeding occurs after the
     Other herbs and nutrients can improve insulin                            progesterone challenge, then it is important to use
     sensitivity and PCOS:                                                    a birth control pill—generally one that contains at
                                                                              least 30 mcg of ethinyl estradiol, for 21 days. At
      •   Chromium                                                            the end of these 21 days, withdrawal bleeding
      •   Fenugreek powder                                                    should occur within 14 days; even spotting is suf-
      •   Vitamin C                                                           ficient to count as withdrawal bleeding. Absence
      •   Bitter melon                                                        of uterine bleeding under these circumstances
                                                                              indicates uterine end-organ failure that may result
     Licorice can lower serum testosterone in women
                                                                              from congenital malformation of the uterus and
     and saw palmetto can inhibit the conversion of
                                                                              vagina or from distortion of the endometrial cavity
     testosterone to dihydrotestosterone (a stronger
                                                                              by intrauterine adhesions due to tuberculous
     form of testosterone). By inhibiting this conver-
                                                                              endometritis, also called Asherman’s syndrome. If
     sion, we can maybe modestly decrease testosterone-
                                                                              bleeding does occur after the oral contraceptive
     induced hair loss and acne.
                                                                              pill, then the likely diagnosis is hypothalamic
      • Licorice                                                              amenorrhea, after excluding a pituitary tumor.
      • Saw palmetto                                                               The woman who is hypoestrogenic and is not
                                                                              a candidate for induction of ovulation requires
     Bio-Identical Hormones                                                   hormone replacement therapy. In young women,
     Bio-identical, also known as natural, proges-                            especially those in their 20s and 30s, the best
     terone can be used for both diagnosis and treat-                         approach is most likely to take oral contracep-
     ment of amenorrhea. Progesterone-induced                                 tives (OCs). Hormone replacement therapy,
     menses indicates that there are adequate estrogen                        whether bio-identical hormones or conventional
     levels and that anatomical problems causing                              hormone replacement, could potentially be used
     obstruction of the outflow of blood are not pres-                         in the usual doses for normal-aged menopausal
     ent. In these instances, the progesterone chal-                          women. However, these doses are considerably
     lenge is an effective means of diagnosis.                                lower than the body’s normal level in a young
         The progesterone challenge test is considered                        reproductive-aged woman and considerably
     positive if uterine bleeding (even a few days of                         lower than the dose of hormones in oral contra-
     spotting) occurs and correlates with a serum                             ceptives. As these lower doses may not be ade-
     estradiol level of 40 g/mL or higher. Onset of                           quate for bone protection at this young age, my
     menstruation after intramuscular injection of                            recommendation is to use a 20 to 30 mcg oral
     150 mg of progesterone in oil suggests that                              contraceptive pill for women in their 20s and 30s
     anovulation is the most likely explanation of the                        who have hypothalamic amenorrhea or prema-
     amenorrhea. Oral micronized progesterone                                 ture ovarian failure. (Smokers older than 35 will
     (OMP) (also called oral natural progesterone)                            need to consider other options, most preferably
     administered for seven days at 400 mg per day                            to stop smoking.)
                                                                                          AMENORRHEA         25
    Younger women who insist on using alterna-       tional therapies that induce ovulation such as
tive medicine need to fully understand their risks   chaste tree extract.
in premature states of insufficient hormone pro-
duction. If the herbal, nutritional, and lifestyle   Exercise
interventions are not sufficient to stimulate the     Amenorrhea in the female athlete is associated
menstrual cycle, they must understand that bone      with reduced caloric intake and strenuous exer-
loss in amenorrheic women shows the same pat-        cise, which leads to low estrogen and is associated
tern over time as that seen in postmenopausal        with stress fractures, osteoporosis, and a potential
women.32 The loss is most rapid in the first few      increase in the risk of premature cardiovascular
years, emphasizing the need for early treatment.     disease.33
    If bio-identical hormones are your choice as         Most cross-sectional studies suggest that
an alternative to OCs, then the following pre-       female competitive athletes, whether runners34–39
scription, called bi-est (for bi-estrogen), would    or bodybuilders,40, 41 have increased incidence
be considered a higher-than-average hormone          of menstrual cycle disturbance, shorter luteal
replacement dose for menopausal women: estriol       phases, and amenorrhea than do sedentary con-
2 mg/estradiol 0.5mg/progesterone 100 mg; one        trols. Because of subject self-selection and conse-
pill twice daily, for three weeks on and one week    quent oversampling, results of these studies must
off. Beginning medication on the first of every       be interpreted with caution.42 Prospective studies
month establishes an easily remembered routine.      have found no hormonal changes in women fol-
Some practitioners use a tri-estrogen formulation    lowing one year of endurance training43 and, up
instead of the bi-estrogen formulation. In this      to 1994, had not detected induction of second-
case, the formula would be estriol 2 mg/estradiol    ary amenorrhea by exercise alone.42
0.250 mg/estrone 0.250 mg/progesterone 100               In her excellent review, Bonen states that sec-
mg; one pill twice daily, for three weeks on and     ondary amenorrhea “is difficult to induce by exer-
one week off.                                        cise alone.”42 She concludes that some of the factors
    Menstruation generally occurs within three       thought to be associated with exercise-induced
days after the last pills, the 28th day of each      amenorrhea—type, duration, intensity of exercise,
month. Bleeding that occurs at any other time        age of menarche, training before menarche, and
may indicate that the body’s own function has        training history—remain speculative and that, in
returned. The natural hormone replacement pro-       fact, little is known about the true incidence of
gram should then be discontinued and the             secondary amenorrhea in athletic populations.
patient monitored for the return of ovulation.           The higher incidence of secondary amenorrhea
    Natural progesterone creams may be used in       detected in competitive athletes appears related to
selected cases to help maintain a monthly cycle      metabolic factors. In weight lifters and body-
in women with anovulatory amenorrhea. Some           builders, the appearance of luteal-phase distur-
women only need this monthly lower-dose              bances and oligo- or amenorrhea is directly related
hormone support during the second half of a          to drastic reduction in caloric intake prior to com-
monthly cycle. The typical dosing recommenda-        petition combined with increases in strenuous
tions are from one-quarter to one-half teaspoon      exercise. For example, Sandoval found that female
applied to the palms, inner forearms, and chest      bodybuilders, examined for a period of 48 hours
twice daily from day 15 to day 26. This cycle can    before competition, achieved a degree of leanness
be repeated. In the event that menstruation does     similar to their male counterparts.44 Kleiner found
not occur, it may be necessary to return to the      in female bodybuilders, competing at the 1988
estrogen/progesterone plan and/or herbal/nutri-      National Physique Committee’s Junior USA
26   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     Bodybuilding Championships, a 9.8 percent body                                The hypoestrogenic state that predisposes
     fat (males, 6.0 percent).45 In a group of female                         postmenopausal women to cardiovascular disease
     bodybuilders studied for one month pre- and post-                        is similar to that of the amenorrheic athlete and,
     competition, Walberg-Rankin detected a twofold                           therefore, so is the cardiovascular risk. Specifi-
     increase in caloric intake and a tenfold increase in                     cally, amenorrheic athletes have been shown to
     fat intake postevent as compared to pre-event.41                         have elevated LDL and total cholesterol,
     Furthermore, these unhealthy practices are fol-                          impaired endothelial function, and increased
     lowed by college-age women who compete in                                lipid peroxidation.54, 55 Though this phenome-
     bodybuilding events.46 In this context, it is not                        non warrants further study, present data suggests
     surprising that in Walberg’s study, 86 percent of                        that the risk of premature cardiovascular disease
     female competitive bodybuilders not on birth                             deserves attention in monitoring and treatment
     control pills reported menstrual dysfunction, and                        of these women.
     in Kleiner’s, 81 percent of female elite body-                                Finally, as shown by Bonen, menstrual distur-
     builders had contest-related amenorrhea for one or                       bances are quite common in the general popula-
     two months precontest.                                                   tion of sedentary women. Different factors—
          The picture is similar for competitive female                       weight change, starvation, crowding, travel, com-
     runners whose caloric intake is inadequate or                            munal living, exercise, and severe stress of any
     falls below the constant energy demanded by                              kind—have been implicated in altered menstrual
     their sports. Time and again, menstrual cycle dis-                       cyclicity.42 Ronkainen and colleagues found
     turbances in these populations have been shown                           increased abnormalities in the menstrual cycles
     to be related to inadequate caloric intake com-                          of women during the short sunlight days of
     bined with strenuous, abrupt increases in run-                           fall.56 Thus, amenorrhea appears to have multiple
     ning distances.34, 42, 47–49 Amenorrhea usually is                       etiologic relationships. Inappropriate exercise is
     not seen in athletes with a high percentage of                           only one of them.
     body fat.49 Since the cause of amenorrhea and                                 Exercise Recommendations. If a woman has
     other menstrual disturbances is linked to energy                         documented secondary amenorrhea not due to
     deficiency, there is no justification for fears that                       pregnancy, a careful history of eating and exercis-
     exercise itself is unhealthy for women.50                                ing habits is critical. In addition, her body weight
          As mentioned earlier, amenorrheic athletes                          and percentage body fat should be ascertained
     show dangerous reductions in mean trabecular                             and compared to the normal ranges for her body
     bone density as compared to eumenorrheic coun-                           build and age. For those women with amenor-
     terparts (42 percent).51 Exercise may intensify                          rhea due to hypoestrogenic states, a bone densit-
     these effects48 as well as low calorie intake itself.                    ometry test, called a DEXA scan, particularly of
     The effects of insufficient caloric intake on bone                        the lumbar spine and proximal femur, is highly
     mineral density likely represents an estrogen-                           desirable.
     independent mechanism for bone loss; exercise-                                In cases where the history and tests recom-
     associated amenorrhea alters additional hormones                         mended indicate inadequate calorie consump-
     that play an important role in modulating bone                           tion, a bone mass density below normal range,
     turnover and bone mineral density in these                               and body fat less than 15 percent, the recom-
     women.52 A study of amenorrheic ballet dancers                           mended course is as follows:
     treated with estrogen plus progesterone replace-
     ment demonstrated that there was no significant                            • Adapt diet to individual needs; particularly
     improvement in bone mineral density even in those                           emphasize protein, calcium, magnesium,
     that resumed menses.53                                                      vitamin D, zinc, copper, and chromium.57
                                                                                                 AMENORRHEA      27
 • Reduce or stop intensive training, particu-          five hours per week is necessary to improve
   larly running, until cycling resumes.                insulin resistance and lose weight.
 • Modify type of exercise. Instead of running,
   do moderate walking (30 minutes per day)             C O N V E N T I O NA L
   and add a regular program of moderate                M E D I C I N E A P P R OAC H
   weight lifting for 30 minutes, three times           Successful management of amenorrhea depends on
   per week.                                            an accurate diagnosis. A careful history and exami-
 • Avoid competition in sports, on the job, and         nation and simple laboratory investigations will
   elsewhere.                                           most likely yield a diagnosis that allows one to offer
                                                        appropriate treatment in the majority of cases. A
   For those women who have PCOS and are                physical exam should assess the signs of secondary
overweight, regular and preferably almost daily         sexual characteristics (such as breast development
aerobic exercise in the range of two and a half to      and the presence or absence of normal or abnormal

 Sample Treatment Plans for Amenorrhea

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

      Sample Treatment Plans for Amenorrhea (continued )

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

     body hair). Pelvic ultrasound might be helpful in                        medications and regimens are discussed earlier in
     determining whether the ovaries are enlarged with                        this chapter and also in Chapter 12. Oral contra-
     small, peripherally located follicular cysts indicative                  ceptives may also be used and may even be an
     of polycystic ovary syndrome (PCOS). Blood tests                         optimal choice because of the higher dose of
     to measure FSH, LH, prolactin, estradiol, testos-                        estrogen for relieving symptoms, ease and cost, or
     terone, and thyroid function may be used to help                         coverage for contraception in case the amenor-
     determine the diagnosis.                                                 rhea is temporary and the women wants preg-
         On the basis of this information, women                              nancy protection.
     with amenorrhea can be classified into the four                            2. Hyperprolactinemia. Treatment with dopa-
     groups mentioned earlier in this chapter, with                           mine agonists (bromocriptine, cabergoline,
     treatments as follows:                                                   quinagolide) leads to reduction in prolactin
                                                                              secretion by the pituitary gland. When prolactin
      1. Hypergonadotropic hypogonadism. Hor-                                 is elevated, a CT or MRI should be done to dis-
     mone therapy with estrogen will induce second-                           tinguish between overactive pituitary produc-
     ary sexual characteristics in girls with primary                         tion by a microadenoma versus an actual tumor
     amenorrhea. Estrogen in combination with cyclic                          (macroadenoma). The large tumor can be asso-
     progestins will prevent osteoporosis, endometrial                        ciated with headaches or vision changes and
     hyperplasia, or cancer. The hormone therapy                              requires surgical resection, but it is very rare.
                                                                                           AMENORRHEA         29
Once a tumor is excluded, medical therapy to          by the continuous estrogen can cause endome-
decrease prolactin is mainly used to achieve          trial hyperplasia or cancer.
pregnancy, and it is not required in an asympto-           Polycystic ovary syndrome is associated with
matic patient who is not seeking fertility.           clinical symptoms such as obesity, hirsutism,
 3. Hypogonadotropic hypogonadism. In the             anovulation, and irregular bleeding. The range
majority of women with this classification, no         of problems that women with polycystic ovary
organic disease can be identified in the hypothala-    syndrome have varies greatly from woman to
mus, anterior pituitary, or ovary. Management of      woman. There are significant differences in
hypothalamic amenorrhea associated with weight        terms of the amount of acne, hair growth, men-
loss must focus primarily on trying to correct the    strual irregularity, infertility, hypertension, and
underlying cause of the weight loss. Amenorrhea       diabetes. There is no current known treatment
from anorexia, bulimia, and exercise-induced          for the disease, so treatment by conventional
weight loss requires prompt diagnosis and treat-      medicine is aimed at individual patient goals and
ment. Some women will require hospitalization in      symptom relief. Obviously, the health concerns
a controlled environment for their malnutrition.      of hypertension, hyperlipidemia, and diabetes
Dietary counseling, psychological counseling, and     need to be addressed in terms of lifestyle changes
advice about exercise could all help to correct the   and periodic monitoring of blood pressure,
problem and restore ovarian function.                 lipids, and blood sugar. For the woman who has
    If amenorrhea persists for more than 12           very infrequent menses, the prevention of uter-
months, then osteoporosis should be excluded          ine hyperplasia or cancer is most important.
with bone density testing, or some form of            However, most women with PCOS have
estrogen therapy should be considered to pre-         uncomfortable side effects that can be improved.
vent bone loss. Women with hypothalamic
amenorrhea who wish to become pregnant are                If a woman has very infrequent menstruation,
treated by administering GnRH medications in          she should either use birth control pills for regular
a pulsatile manner via a portable programmable        menstrual withdrawal or at least quarterly pro-
pump that releases the medication every one to        gestogens that cause withdrawal bleeding. The
two hours, simulating the body’s pulsatile secre-     progestogens that have been used include Provera
tions. Women with rare disorders such as the          or Cycrin (medroxyprogesterone), 10 mg daily for
pituitary disease Sheehan’s syndrome are given        seven days; Prometrium (oral micronized proges-
hormones FSH and LH.                                  terone) or compounded oral micronized proges-
 4. Chronic anovulation and polycystic ovary          terone, 400 mg daily for seven days; Aygestin
syndrome. About 30 percent of women with              (norethindrone acetate), 5 mg daily for seven days;
secondary amenorrhea have concentrations of           and Megace (megestrol), 20 mg daily for seven
FSH, LH, and estrogen within the normal               days. Most of the progestogens have similar symp-
range. Polycystic ovarian syndrome is a               toms of nausea, bloating, moodiness, and oily skin
common cause of this type of amenorrhea.              in varying degrees, but they are usually tolerable
Many women with this type of amenorrhea               for a few days or a week.
actually present with irregular menstrual pat-            Hirsutism can be with treated topically with
terns more often than amenorrhea. These               Vaniqa, which reduces the transformation of
women do not have estrogen deficiency, but             testosterone to dihydrotesterone at the hair folli-
rather experience problems related to continued       cle, reducing the growth, or at least the size and
exposure to estrogen unopposed by proges-             color, of the hair. This product needs to be
terone. The buildup of the uterine lining caused      applied once to twice daily in the areas of hair
30   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     growth and works while it is being used. There is                        tility specialist. Sometimes metformin is added
     no permanent effect, so it has to be used daily.                         to help aid clomiphene in induction of ovula-
     Also, electrolysis and laser hair removal are very                       tion, or the patient is given more intense ovula-
     effective permanent hair removal treatment.                              tion induction medications such as Pergonal.
         Spironolactone, an antiandrogen medication                                Probably the most important treatment of
     with minimal side effects, can reduce acne and                           polycystic ovary syndrome is recognition of the
     hair growth. The recommended does is 50 to 200                           problem. When counseling the patient, the focus
     mg once daily. There has been some concern of                            should be on the management of her lifelong
     very rare cases of hyperkalemia (abnormally high                         symptoms. We need to inform women that this
     potassium levels) with this product, so patients                         disease comes in all shades and that there will be
     need to be warned of cardiac arrhythmias and                             different treatment regimens for different women
     muscle cramping.                                                         rather than one treatment for all.
         Metformin, an insulin-receptor-improving
     medication used for diabetes, has been touted to                         S E E I N G A L I C E N S E D P R I M A RY
     decrease weight gain and stimulate ovulation in                          H E A LT H - CA R E P R AC T I T I O N E R
     women with PCOS. However, many studies                                   ( N . D. , M . D. , D. O . , N . P. , P. A . )
     have shown minimal effect on weight gain, and it                         All women with amenorrhea should be evaluated
     has significant side effects of nausea, vomiting,                         by a licensed primary care practitioner (naturo-
     and diarrhea, as well as uncommon but serious                            pathic doctor, medical doctor, osteopathic doctor,
     liver enzyme problems. Most practitioners use                            nurse-practitioner, or physician’s assistant) because
     only it for treatment of diabetes or as an adjunct                       of the diverse array of potential diseases and disor-
     in infertility. Metformin usage, along with clomi-                       ders. Some of these conditions are rare, such as
     phene and/or Pergonal, seems to improve ovary                            Asherman’s syndrome, Cushing’s disease, Sheehan’s
     receptiveness and ovulation. Encouraging weight                          syndrome, and pituitary-secreting tumors. Other
     loss can help the situation tremendously, but                            causes are more common but can be complex, such
     women with polycystic ovary syndrome and obe-                            as malnutrition, anorexia nervosa, hyperthy-
     sity seem to be very resistant to standard weight-                       roidism, polycystic ovary syndrome, and pituitary
     loss programs. It is possible to lose weight, but                        disorders. Other causes are rather straightforward;
     they need to be persistent and have a good sup-                          for example, hypothyroidism, strenuous exercise,
     port system, possibly even some help from                                pregnancy, and stress-related amenorrhea.
     bariatric medicine (obesity doctors).                                        Fortunately, most women with amenorrhea
         The treatment that achieves the best symp-                           have relatively simple problems that can be man-
     tom control is oral contraceptives. Oral contra-                         aged easily by primary care physicians, whether
     ceptives can reduce hair growth, reduce acne,                            they are alternative medicine practitioners, con-
     cause regular menstrual sloughing, suppress                              ventional practitioners, or a team approach using
     luteinizing hormone (LH) and ovarian cyst pro-                           the best choices of each. After an evaluation has
     duction, and are very widely prescribed for                              been done and a cause diagnosed, natural thera-
     women who also need contraception.                                       pies can be administered as the primary therapy
         Antiestrogens such as clomiphene are some-                           or integrated with the conventional treatment.
     times given to induce ovulation and may restore                          Conventional treatments may be necessary in
     fertility in women seeking pregnancy. However,                           many cases of amenorrhea, but dosing regimens
     PCOS can be resistant to normal ovulation                                may be lower when natural therapies are used as
     induction and often requires the help of an infer-                       part of an integrated plan.
                                            DYSPL ASIA

OV E RV I E W                                                   1988, of low- and high-grade (precancerous)
Over the past four decades, cervical cancer rates               lesions or, more specifically, low-grade squamous
have dropped dramatically in most developed                     intraepithelial lesions (SIL) and high-grade SIL,
countries. This improvement in our health is                    also referred to as LSIL and HSIL, respectively.
attributable to the commonly available Pap                      In the new terminology, low-grade SIL replaces
smear, whereby early premalignant lesions can be                the former terms mild dysplasia and CIN 1 (cer-
found and treated, most often with fairly simple                vical intraepithelial neoplasia) and includes
office techniques. Cervical cancer presently ranks               changes of simple infection with the human
third in cancer deaths of American women,                       papillomavirus. High-grade SIL includes moder-
although it remains the leading cause of death                  ate and severe dysplasia, formerly classified as
from cancer among women in developing coun-                     CIN 2 and CIN 3. Both the newer and tradi-
tries who do not enjoy the same access to diagno-               tional terms are used in this chapter and in the
sis and early treatment.1 In the United States,                 medical literature.
approximately 9,710 cases of cervical cancer were                   What exactly is dysplasia? The mucous mem-
diagnosed in 2006 and about 3,700 women died                    brane that covers the cervix changes in adolescence
from it. Worldwide, human papilloma infection                   from more bumpy columnar cells, like those that
causes almost 500,000 cases of cervical cancer                  also line the uterus, to squamous cells, like those
and 280,000 deaths each year.                                   that line the mouth, through a normal process
    Squamous cell cervical cancer is virtually                  called metaplasia. Squamous cells make up all of
always preceded by cervical dysplasia, which is                 our external body surfaces that are characteristi-
100 percent treatable in its noninvasive stage.                 cally smooth, like our skin, for example. Where
(Cervical cancer of the glandular cells, adenocar-              these two types of cells meet is called the squamo-
cinoma, is more problematic and requires more                   columnar junction—and it is here that our cells
aggressive treatment.) Human papillomavirus                     are most susceptible to premalignant transforma-
(HPV) is the most common sexually transmitted                   tion. The Pap smear samples cells from this area to
infection in the United States,2 and about 75                   examine microscopically.
percent of the U.S. adult population has been                       The very bottom layer of squamous cells are
exposed to HPV.3 Fortunately, the majority of                   called basal cells. They are the largest and round-
genital HPV infections don’t cause any symp-                    est with the biggest nuclei. As the cells progress
toms and go away on their own. The others go                    toward the surface, they become smaller, flatter,
on to cause abnormal cells, including cervical                  and ultimately lose their nuclei before they get to
dysplasia and/or cervical cancer.                               the top. In mild dysplasia, the basal cell layer is
    Cervical cancer and dysplasia, genital warts,               thicker, up to one-third the total thickness of the
and condyloma are caused by the human papillo-                  tissue; in moderate dysplasia, they occupy the
mavirus, which is sexually transmitted. Virtually               bottom and into the middle third; in severe dys-
100 percent of cervical dysplasias and cervical                 plasia, they extend to the top third. Carcinoma
cancer is caused by HPV. This association is                    “in situ” is not an invasive malignancy, but rather
reflected in a simple rating system, in use since                the extension of the immature basal cells to the
Copyright © 2008 by Tori Hudson. Click here for terms of use.
32   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     very top of the tissue thickness. While it does                          forms, thanks to our well-functioning immune
     carry a higher risk of conversion to true cancer, it                     systems. Spontaneous regression of CIN 1 and
     too is completely treatable.                                             CIN 2 has been documented to be as high as 50
         The possibility of progression to cervical                           percent to 40 percent respectively, with numbers
     cancer increases with the severity of the dysplasia.                     improving the longer women are followed (usu-
     Mostly, though, it is a slow process, occurring over                     ally one to three years). Almost 70 percent reso-
     about 10 to 15 years in most women who are                               lution of HPV alone was observed.6
     untreated. Currently, more than 100 HPV sub-                                  Other studies confirm this, and the majority of
     types have been identified, numbered, and catego-                         untreated mild dysplasias were shown to regress to
     rized. More than 30 types can infect the genital                         normal within two years. A critical review of the
     area. The progression of dysplasia to cancer varies                      literature on the natural history of CIN was done
     according to which HPV subtype one is infected                           over a span of over 40 years.7 The author con-
     with. The low-risk types (6 and 11) are generally                        cluded that approximately 60 percent of CIN 1
     associated with external genital warts but do not                        regressed to normal, 30 percent persisted, 10 per-
     cause cervical cancer. The most aggressive or                            cent progressed to CIN 3 (a high-grade lesion),
     high-risk types are HPV 16, 18, 26, 31, 33, 35,                          and only about 1 percent progressed to cervical
     39, 45, 51, 51, 56, 58, 59, 66, 68, 73, and 82.                          cancer. CIN 2 regressed in 40 percent of the cases,
     These can transform susceptible tissue into cancer                       persisted in 40 percent, progressed to CIN 3 in 20
     in about 18 months, but this is the exception                            percent, and progressed to cervical cancer in less
     rather than the norm, and dysplasia typically takes                      than 5 percent of cases. CIN 3 regressed in 33 per-
     more than 10 years to progress to cervical cancer.                       cent of the cases and progressed to cervical cancer
     In the United States, HPV 16 accounts for more                           in more than 12 percent.
     than 50 to 60 percent of cervical cancer cases, fol-                          A recent study demonstrates that the risk of
     lowed by HPV 18 (10 to 12 percent) and HPV 31                            progression from mild to severe dysplasia or
     and 45 (4 to 5 percent each).                                            frank cervical cancer was only 1 percent per year,
         A recent study confirmed that lesions of the                          but the risk of progression from moderate dys-
     cervix persist longer and progress more quickly in                       plasia was 16 percent within two years and 25
     women with the aforementioned oncogenic HPV                              percent within five years.8
     types, known as the higher risk types, than in                                Mild dysplasia is detected in about 1 percent
     women with nononcogenic types or without                                 of women visiting their private gynecologist and
     HPV.4 However, it is important to remember that                          about 14 percent of women who visited desig-
     most women with the human papillomavirus                                 nated sexually transmitted disease clinics.6
     never get dysplasia at all. On the other hand, some                      Besides HPV, other risks include early age at first
     women with normal Pap smears, but showing                                intercourse, giving birth before age 22, cigarette
     inflammation, may indeed harbor the oncogenic                             smoking, low socioeconomic status, number of
     HPV types 16 and 18,5 suggesting women with                              lifetime partners, and possibly, although not con-
     chronic inflammation may benefit from high-risk                            clusively, oral contraceptive use. Women with
     HPV screening. Some estimate that as many as 70                          five or fewer lifetime heterosexual partners had
     percent of women are or have been infected in                            higher rates of regression of untreated CIN 1 and
     their lifetime. On the other hand, only about 10                         CIN 2 than did women with more than five part-
     women per 100,000 get cervical cancer.                                   ners, independent of barrier contraception
         In addition to eliminating dysplasia through                         method use (condoms or diaphragms).9 It is dif-
     treatment, there can be a significant amount of                           ficult to separate out the effects of sexual activity
     spontaneous regression of even the most severe                           without barrier protection from that conferred
                                                                                          CERVICAL DYSPLASIA         33
by ingesting hormonal contraception. For what-                  Fortunately, there are benign changes that
ever reason, women who used these barrier meth-             result in an AGUS Pap smear. These include
ods had less dysplasia. In fact, condom use was             chronic endocervicitis, microglandular hyperpla-
associated with higher rates of CIN regression              sia of the endocervix, or ciliated cell metaplasia of
and clearance of cervical HPV infection in                  the endocervix, which is often seen in women
women as well as protection from genital warts              who have IUDs. Some women with AGUS have
and invasive cervical cancer.10–12                          high-grade (precancerous) squamous cells. The
    Evaluation of an abnormal Pap smear result is           complicating problem is that AGUS cells may
done by a method called colposcopy, which is a              also come from the upper genital tract, such as
lot like using binoculars to view the cervix. The           tubal or ovarian cells, or even metastasis from
colposcope magnifies the cervix, and white vine-             the pelvis.
gar is applied to make the abnormal areas show
up. Tiny biopsies are taken of these areas, a few
                                                             Risk Factors for Cervical
millimeters at most. These are examined by the
                                                             Dysplasia and Cervical Cancer
pathologist and graded into mild, moderate, or
severe as described previously.                             • Smoking. Women who smoke are about twice as
    One of the most important points I am sure                likely to develop cervical cancer.
to explain to my clients is that cervical cancer is         • Human immunodeficiency virus (HIV) infection.
a sexually transmitted disease, greatly promoted              Immunocompromise results in increased risk for
by smoking, but one that usually grows slowly                 HPV infections.
over years from its precursor, dysplasia, and is            • Chlamydia infection. Recent or past positive test
treatable in all of its earliest forms.                       results for chlamydia may lead to greater risk for
                                                              cervical cancer.
Atypia                                                      • Poor nutrition. Diets low in fruits and vegetables
                                                              may increase the risk for cervical cancer.
Another possible Pap smear result is atypia—which
                                                            • Multiple heterosexual partners. Having three or
is really a kind of fence-sitting cell. The cells are not     more partners in a lifetime increases risk of cervi-
changed enough to warrant being labeled as abnor-             cal cancer.
mal, but they are not quite normal either. Usually          • Obesity. Overweight women are more likely to
atypia is either an early abnormal change or evi-             develop cervical cancer.
dence of tissue repairing itself, for example follow-       • Oral contraceptives. Although the research is
ing a birth or vaginal infection. These Pap tests are         mixed, long-term use of oral contraceptives may
usually just repeated, but if atypia persists, the            increase the risk of cervical cancer.
woman should be evaluated.                                  • Low socioeconomic status. Poor access to ade-
                                                              quate health care, including Pap tests and treat-
    Atypical Glandular Cells of Undetermined                  ment of precancerous lesions, leads to higher risk
Significance (AGUS). AGUS may be the most                      for cervical cancer.
difficult diagnostic challenge of all the Pap smear          • Family history of cervical cancer. Recent studies
abnormalities. AGUS represents a significantly                 suggest that women with a mother or sister with
                                                              cervical cancer are at higher risk for developing
greater risk of cervical cancer than atypical squa-
                                                              cervical cancer.
mous cells of undetermined significance (ASC-
                                                            • First intercourse. Women at highest risk of test-
US, discussed later in this chapter) or low-grade             ing positive for HPV are those in the first few
squamous intraepithelial lesions. The good news is            years after first intercourse.
that AGUS is not a common diagnosis and only                • Age. HPV risk prevalence declines with age.
represents 0.13 to 0.8 percent of all Pap smears.
34   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         When the report says AGUS “favor neopla-                              • ASC-US: atypical squamous cells of unde-
     sia,” this is of great concern, because 50 to 100                           termined significance. This is considered a
     percent of patients with this test result have a                            mild abnormality. ASC-US is often then
     significant cervical lesion. These could include a                           tested for HPV types.
     high-grade CIN, adenoma carcinoma in situ, or                             • ASC-H: atypical squamous cells, cannot rule
     adenocarcinoma. Even though more than 50 per-                               out high-grade (precancerous) lesions.
     cent of women with AGUS will be found to be                                 Women with ASC-H are at greater risk for
     normal, we cannot predict this, and a normal                                CIN 2 or CIN 3. For this reason, and
     follow-up Pap smear may be falsely normal, or                               because detection of high-risk types of HPV
     what is called a false negative. Therefore, a prac-                         is much more common with ASC-H, the
     titioner must carefully evaluate AGUS.                                      recommendation is that these women get
         Evaluation may include colposcopy, biopsy,                              colposcopy and biopsies.
     endocervical curettage and endometrial biopsy,                            • LSIL: low-grade squamous intraepithelial
     in some cases dilation and curettage or hys-                                lesion—early changes in the size, shape, and
     teroscopy, and in some cases a conization. If                               number of abnormal cells. Lesion refers to
     there is adenomacarcinoma in situ on biopsy, a                              an area of abnormal tissue, and intraepithe-
     cervical conization is recommended. Cervical                                lial means that the abnormal cells are pres-
     conization for any woman with AGUS “favor                                   ent in the surface layer of cells, not the
     neoplasia,” adenocarcinoma in situ, or adenocar-                            deeper glandular layer. This is considered a
     cinoma is recommended for most women. If                                    mild abnormality. Colposcopy and biopsies
     there is frank invasion detected by biopsy, more                            are recommended.
     extensive surgery is recommended.                                         • HSIL: high-grade squamous intraepithelial
                                                                                 lesions. There may be a few, or there may be
     A Note About New Technologies                                               many. This is obviously more severe and
     Most women are familiar with the Pap smear. Cells                           serious and has a higher likelihood of pro-
     are scraped from the cervix and placed on a slide for                       gressing to cervical cancer. Colposcopy and
     examination in a laboratory. There is now a new                             biopsies are recommended.
     liquid-based technique in which the cervical cells                        • ASC-US and ASC-H: HPV testing is
     collected by scraping the cervix are placed in liquid.                      recommended.
     In the laboratory much of the mucus, blood, and                           • LSIL and HSIL: These are generally not
     inflammatory cells are removed from the cell                                 tested for HPV typing, as it does not alter
     sample. Liquid-based methods are more expensive                             the course of treatment.
     than conventional Pap tests but have a higher sensi-
     tivity for detection of lower-grade squamous cell                            If the results of the Pap smear are ASC-H,
     lesions and can be used to test for HPV types in                         LSIL, or HSIL, the clinician should perform or
     women with atypical squamous cells of undeter-                           recommend a colposcopy and biopsies. This is the
     mined significance (ASC-US) Pap results. The FDA                          only certain way to evaluate the abnormal cells and
     has approved two liquid-based cytology methods:                          determine the appropriate course of treatment.
     the Sure-Path system and the ThinPrep Pap test.
                                                                              OV E RV I E W O F
     Reporting of Abnormal Pap Results                                        A LT E R NAT I V E T R E AT M E N T S
     About 5 to 10 percent of Pap tests performed                             Cervical dysplasia is an excellent example of what
     in the United States each year are abnormal.                             preventive medicine can accomplish because, in
     Abnormal cells include the following:                                    almost all cases, it is a preventable disease. Through
                                                                                       CERVICAL DYSPLASIA          35
Recommendations for Pap Smear Testing                     PREVENTION

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

• Cervical dysplasia is a sexually transmitted dis-
  ease transmitted through skin-to-skin contact.         lifestyle habits, dietary factors, nutritional supple-
  Condoms do not fully protect because HPV               mentation, and regular Pap smears, most cases of
  extends onto skin beyond the condom, but they          cervical dysplasia and its consequence, cervical
  may impart some protection and may enhance             cancer, could be avoided.
  possibility of regression of low-grade lesions to           Natural medicine perspectives on cervical dys-
  normal.                                                plasia are consistent with conventional medicine’s
• The human papillomavirus (HPV) causes virtually        understanding that the human papillomavirus
  all cases of cervical dysplasia, although most
                                                         causes virtually all cases and that this virus is sexu-
  women exposed to HPV actually never get
                                                         ally transmitted. Many cofactors serve as cocar-
• Cervical dysplasia is classified as either low-grade    cinogens in the development of cervical dysplasia,
  or high-grade and, if left untreated or if the body    including smoking, nutrient deficiencies, immune
  is not able to reverse it on its own, can progress     deficiency, and possibly oral contraceptives. Where
  to cervical cancer, especially if a person is          natural medicine diverges in its approach is in
  infected with the oncogenic strains of HPV.            advising patients what they can do about these
• Cervical cancer of squamous cells is a preventable     cofactors. In addition, there are nutrients that can
  disease.                                               be used in supplement form both to prevent the
• Pap smears are screening tests, not diagnostic         progression of cervical dysplasia to cervical cancer
                                                         and to reverse some cases of dysplasia.
36   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         Cervical dysplasia is both a local problem in-                       increased consumption of vegetables, yellow-
     volving the cervical tissue immunity and health                          orange vegetables, fruits, or legumes.21 Nonethe-
     and a systemic problem involving general                                 less, there is enough evidence to support a diet rich
     immune health and resistance to viral exposure.                          in beneficial vegetables.
     The overriding goals of natural treatments are to                            Phytoestrogens may also play a role in lowering
     reduce exposure to the human papillomavirus,                             premalignancies of the cervix. A recent study
     reduce cofactors, correct nutrient insufficiencies,                       demonstrated that plasma levels of equol and
     improve local immune response, strengthen gen-                           enterodiol, two isoflavonoids, were positively asso-
     eral immune health, and prevent the progression                          ciated with a lower cervical dysplasia risk, and in
     to cervical cancer.                                                      addition found a nonsignificant positive associa-
                                                                              tion with enterolactone, a lignan. Consistent with
     NUTRITION                                                                these results, dietary sources of lignans, including
     Cervical cancer has been studied in relationship                         garlic, onions, grapefruit, seeds, seaweed, and taro,
     to many dietary factors. In general, diets high                          were positively associated with lowered CIN risk.22
     in vitamin C, carotenoids, vitamin E, selenium,                              Indole-3-carbinol, found in cruciferous veg-
     and other substances found in fruits and vegetables                      etables such as broccoli, cabbage, brussels sprouts,
     have been found to be protective in at least some                        cauliflower, and kale, has the potential to prevent
     studies.13–17 A recent study found that higher levels                    and treat several cancers. Eating these foods alters
     of vegetable consumption were associated with a                          estrogen metabolism in such a way as to reduce
     54 percent decrease in risk of HPV persistence.                          the carcinogenic metabolites of estrogen metabo-
     Also, a 56 percent reduction in the persistence of                       lism. Women with CIN 1 or 2 have altered estro-
     the virus was observed in women with the highest                         gen metabolism and have higher 16-alpha
     plasma cis-lycopene concentrations compared                              hydroxyestrone, a potent carcinogen, and fewer 2-
     with women with the lowest plasma cis-lycopene                           hydroxyestrogen metabolites than women with no
     concentrations. These results suggest that veg-                          abnormal cells of the cervix.23
     etable consumption and circulating cis-lycopene
     may be protective against HPV persistence.18                             Nutritional Supplements
     Another report revealed that the risk of chronic                             Carotenes. Carotenes include beta-carotene,
     HPV infection was lower among women reporting                            alpha-carotene, cryptoxanthin, gamma-carotene,
     higher intake of the following foods: carotenes                          zeaxanthin, lutein, and lycopene. Studies have
     such as beta-cryptoxanthin (found in eggs, yellow                        shown that beta-carotene deficiency in the cervi-
     and orange fruits and vegetables), lutein and zeax-                      cal cells plays an etiologic role in the develop-
     anthin (eggs, dark green vegetables), vitamin C,                         ment of cervical dysplasia.24 In addition, a
     and, specifically, papaya.19                                              significant decrease in plasma beta-carotene
         In the treatment sections of this chapter, I                         levels is found in women with either cervical dys-
     emphasize a vegetarian diet, one that is high in                         plasia or cancer of the cervix.25
     fruits and vegetables, especially yellow-orange ones                         It has been suspected that carotenes like
     like carrots, yellow squash, cantaloupe, peaches,                        lycopene, found in tomatoes, are more responsi-
     and corn. In China, consumption of both animal                           ble for an improvement in dysplasia than is beta-
     foods (including meat, eggs, and fish) and green                          carotene or the other carotenes.26 In fact, recent
     vegetables was significantly correlated with a lower                      studies have found that high serum levels of
     death rate from cervical cancer.20 One study                             lycopene and alpha-carotene are associated with a
     among white women showed that risk of cervical                           decreased risk of cervical dysplasia,27 and increas-
     dysplasia and cervical cancer was not affected by                        ing serum levels of lycopene alone was found to
                                                                                       CERVICAL DYSPLASIA          37
increase clearance of oncogenic HPV infections           higher intake of these nutrients.32–34 Another
by over 50 percent.28, 29                                study showed that the rate of progression from
     My own research study investigating natural         dysplasia to cervical cancer was nearly five times
treatment methods for cervical atypia, cervical          higher in women with lower serum retinol levels
dysplasias, and carcinoma in situ of the cervix          than those with higher serum retinol levels35 and
used beta-carotene supplementation as one part of        that diets rich in vitamin A and high-retinol foods
a multifactorial supplementation and local treat-        may reduce risk of in-situ and invasive cervical
ment protocol. I found a high success rate using this    cancer.36 In addition, in vitro studies confirm that
combination protocol. Most of the women were             vitamin A and its analogues inhibit the prolifera-
given supplements of 150,000 units of mixed natu-        tion of HPV infection through apoptosis (cell
ral carotenes daily for a minimum of three months.       death) and inhibition of cell growth rates. Such
Of 43 women studied, 38 patients returned to             therapy is promising in decreasing the progression
normal, 3 patients had partial improvement,              of early cervical lesions to cancer.37–39
2 stayed the same, and none of the patients pro-             Topical vitamin A is an important form of treat-
gressed to a worse state of dysplasia during the         ment as well. In one study of 301 women, topical
course of the natural treatment protocol.30, 31          vitamin A (retinoic acid) increased the complete
     The full treatment protocols for each degree of     regression rate of moderate dysplasia from 27 per-
dysplasia are described in the treatment plans in        cent in the placebo group to 43 percent in the treat-
this chapter. Overall, my approach has been to rec-      ment group. Women with severe dysplasia failed to
ommend increased sources of carotenes in the diet        respond.40 An earlier, well-known study on topical
as well as supplementation. There are potential          vitamin A and dysplasia on the exocervix (external
concerns about using beta-carotene by itself, espe-      surface of the cervix) at the University of Arizona
cially in women who are at higher risk for lung          had comparable results, eliminating the disease in
cancer. As a precaution, I avoid beta-carotene sup-      10 of the 20 women. Five of the 10 had mild dys-
plementation in women at high risk for lung              plasia, and 5 had moderate dysplasia.41 Too few
cancer (smokers), and for everyone else, I only rec-     patients had severe dysplasia to evaluate. This find-
ommend products that have mixed carotenes and            ing was replicated recently in a study of three differ-
natural carotenes. Careful label reading is essential.   ent doses of topical retinoic acid in women with
If the label doesn’t say “natural,” then the product     CIN 1 and 2.42 In my own research, vitamin A sup-
has synthetic beta-carotene.                             positories were applied topically as part of a multi-
     Do not be alarmed if your skin turns an orange      factorial systemic and local treatment plan. (The
tint when supplementing with high amounts of             protocol is described later in this chapter.)
carotenes. It is merely a pigment and is not a sign
of liver toxicity. Carotenes are not toxic.                  Vitamin E. Low levels of serum vitamin E
                                                         have been associated with an increased risk of all
 Carotenes                                               stages of CIN and cervical cancer and high levels
 Mixed, natural carotenes, 75,000 IU twice daily         associated with a decreased risk.43–46 Low levels of
 25,000–50,000 IU for prevention (see treatment plans)   vitamin E combined with deficient levels of vita-
                                                         min A have been associated with an increased risk
    Vitamin A. Studies have shown that dietary           of oncogenic HPV infection.47 One study demon-
vitamin A protects against cervical cancer. Women        strated a greater than 50 percent inhibition of
with lower serum levels and dietary intakes of total     proliferation of HPV-infected cells in vitro.48 In
vitamin A are significantly more likely to have           addition, vitamin E is a potent antioxidant and,
dysplasia or carcinoma in situ than women with a         therefore, may mitigate the oxidative damage asso-
38   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     ciated with cervical dysplasia and cancer.49 In a                        abnormalities) and low blood levels of folic acid
     recent study, women with CIN or cervical cancer                          have been associated with a moderately increased
     were found to have low levels of vitamin E and                           risk of invasive cervical cancer.57, 58 Deficiency has
     other antioxidants—like glutathione, vitamin C,                          been observed more often in women who are
     and CoQ10—were found to be low, while mark-                              taking oral contraceptives. In another study,
     ers of lipid peroxidation were found to be high,                         women taking 10 mg of folic acid daily for three
     both corresponding to severity of disease stage.50–52                    weeks (while continuing oral contraceptives)
         Vitamin E can help in the treatment of cervi-                        showed a striking reversion of the megaloblastic
     cal cancer as well by improving the efficacy of                           changes toward the normal,59 with a regression-to-
     radiation therapy and enhancing tumor response                           normal rate of 20 percent in this study and 100
     and chromosomal damage of cancer cells while                             percent in another.60 Folic acid supplementation
     concurrently protecting normal cells.53                                  may be effective in preventing dysplasia from pro-
          Vitamin C. The possible role of vitamin C in                        gressing as well. Theoretically, folic acid may act
     preventing cervical dysplasia is of special interest                     by decreasing homocysteine, which, when ele-
     because vitamin C is involved in collagen synthe-                        vated, has been associated with an increased risk
     sis, detoxifies chemical carcinogens, interferes with                     of cervical cancer.61, 62 It should be noted that a
     the formation of chemical carcinogens, and mod-                          recent study demonstrated the difficulty of getting
     ulates the immune system. It has been demon-                             adequate folate via diet and, therefore, additional
     strated in more than one study that there is a                           supplementation is warranted.63
     significant decrease in vitamin C intake as well as                           When doses as high as 10 mg of folic acid per
     plasma levels of vitamin C in patients with cervi-                       day are given, two points must be kept in mind.
     cal dysplasia.54, 55 Vitamin C supplementation has                       The first is that most retail natural foods stores
     not been studied by itself as a treatment for cervi-                     have folic acid available only in capsules up to
     cal dysplasia. It was a part of the comprehensive                        800 mcg (less than 1 mg, which is equal to 1,000
     treatment protocol in my research study.                                 mcg). Higher doses of folic acid are available only
                                                                              by prescription from your medical doctor or
      Vitamin C                                                               licensed alternative practitioner. A prescription
      2,000–6,000 mg per day                                                  liquid form is available for which one drop is
      1,000–2,000 mg per day for prevention (see treatment                    equal to 5 mg, which is very cost effective. The
        plans)                                                                second issue is that high doses of folic acid can
                                                                              mask a vitamin B12 anemia. To avoid this, take
         Folic Acid. There have been several studies                          either a multiple vitamin-mineral, B-complex, or
     using folic acid supplementation in women with                           B12 supplement along with the daily folic acid.
     mild and moderate cervical dysplasia, with con-
                                                                               Folic Acid
     flicting results. In one study, women with mild or
     moderate dysplasia received 10 mg daily of folic                          2.5–10 mg per day
     acid supplementation or placebo for three                                 800–2,400 mcg per day for prevention (see treatment
     months. All of these women had used oral con-                               plans)
     traceptives for at least six months and continued
     to do so. The results showed significant improve-                             B Vitamins. B vitamins, specifically ribo-
     ment or normalization of Pap smears and biop-                            flavin, thiamine, and B12, have an inverse corre-
     sies at the end of the treatment period.56                               lation with risk for CIN, leading some
         In patients with folic acid deficiency, changes                       researchers to promote the protective role they
     in the cells of the cervix (called megaloblastic                         may play in cervical cancer, reducing the risk by
                                                                                    CERVICAL DYSPLASIA        39
as much as 50 to 90 percent for the upper limits         pounds including diindolylmethane (DIM). It has
of intake.64 Women with the highest levels of            been suggested that I3C can act in several ways to
serum B12 were less likely to have a persistent          prevent abnormal cell growth and prevent tumor
infection.65 Serum B12 levels should be evaluated        progression. Recent studies indicate that I3C has
and deficiency corrected. As with folic acid, B12         the ability to prevent and maybe even treat some
may act by decreasing homocysteine, which,               common cancers, especially those that are estrogen
when elevated, has been associated with an               related,71 by altering the pathway of estrogen
increased risk of cervical cancer.66, 67                 metabolism.72–74
                                                             Women with CIN 2 and 3 have altered estro-
 Vitamin B12                                             gen metabolism; higher 16-alpha hydroxyestrone,
 1,000 mcg per day                                       a potent carcinogen; and fewer 2-hydroxyestrogen
                                                         metabolites than normal.75 One therapeutic
                                                         goal of treatment, then, is to increase the
Botanicals                                               2-hydroxylation of estrogen and decrease the 16
    Green Tea. One of the most exciting advances         alpha-hydroxylation. In one double-blind, placebo-
in the treatment of cervical dysplasia is the            controlled study of 30 women with CIN 2 or
research that has been published on green tea. In        CIN 3,76 4 of 8 patients in the 200 mg group and
both laboratory and clinical studies, constituents       4 of 9 in the 400 mg group had complete regres-
of green tea, namely polyphenol E (poly E) and           sion of their CIN compared to none of the
epigallocatechin-3-gallate (EGCG), have been             placebo group. A laboratory study of human cer-
effective against HPV-infected cervical cells and        vical cancer cells determined that I3C and DIM
lesions. The mechanisms involved appear to be            could induce apoptosis (cell death) of human cer-
apoptosis, cell cycle arrest, modification of gene        vical cancer cells and HPV-16-infected cervical
expression, and antitumor effects.68, 69 A clinical      cells of mice.77 It appears DIM is preferred over
study confirms these findings in patients through          I3C due to increased bioavailability and the fact
the use of either topical application via a poly E       that it increases the protective 2-hydroxyestrogen
ointment and/or oral ingestion via a poly E or an        without increasing another harmful metabolite,
EGCG capsule. All treatment groups improved              the 4-hydroxyestrogens.
compared to placebo (50 to 75 percent versus 10           Diindolylmethane (DIM)
percent), but the topical treatment groups
improved the most significantly compared to oral           200–400 mg per day
alone (75 percent versus 50 to 60 percent).70
                                                             Additional Botanicals. Traditional herbal
 Green Tea                                               medicine includes the use of many plants for
 Green tea extract (95% polyphenols, 80% catechins,      systemic immune support. No plants (except
   55% EGCG, 10% caffeine): 300 mg per day orally        green tea) have been studied by themselves in
 Green tea suppositories: insert one twice weekly (see   relationship to the human papillomavirus and
   treatment plans)                                      cervical dysplasia that I am aware of, although
                                                         many plants are known both to act as immune
    Indole-3-Carbinol/Diindolylmethane (DIM).            modulators and to be antiviral in their activity.
Indole-3-carbinol (I3C) is a phytochemical found             This concept of immune support is an
in cruciferous vegetables, including cabbage, broc-      important part of preventive medicine as well as
coli, Brussels sprouts, cauliflower, and kale. I3C is     in reversing and preventing the progression of
converted in the stomach to a variety of com-            cervical dysplasia. Since up to 80 percent of the
40   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     U.S. sexually active adult population carries the                        of a systemic botanical formula including thuja,
     human papillomavirus and less than 5 percent                             echinacea, ligusticum, and goldenseal. You will
     have a visible lesion or abnormal Pap smears, it is                      also notice herbal suppositories containing many
     common sense that most people’s bodies have the                          traditional herbs for immune support, antiviral
     ability to prevent the virus from causing an actual                      activity, and squamous cell repair. These include
     diseased state. Specifically, their immune systems                        myrrh, echinacea, usnea, goldenseal, marshmallow
     are doing a better job at keeping them healthy.                          root, geranium, and yarrow.
     This is true for women both systemically and in                               Recent evidence supports the use of cur-
     the vagina. There is local immune tissue in the                          cumin in the prevention of cervical cancer due to
     cervical epithelium, and the immune status of                            its ability to inhibit lipid peroxidation and down-
     this tissue is in part responsible for resistance to                     regulate HPV virus.78–80
     the virus.
         This is the background logic for both systemic                        Curcumin
     immune support and local immune support. As                                350–500 mg once to twice daily
     part of the research protocol, you will see the use

      Criteria and Guidelines for Treatment Selection

      Note: Not all of the treatments described in this                         7. Low-grade squamous intraepithelial neoplasia:
      chapter are appropriate for self-care. Some, such as                         endocervical curettage is positive with a satis-
      the escharotic treatment, need to be administered                            factory colposcopy, but the patient is at low risk
      by a licensed health-care practitioner trained in                            for more serious disease or has low-risk HPV
      women’s health. In addition, not all cases of cervi-                         typing, or at the discretion of the practitioner.
                                                                                8. High-grade squamous intraepithelial neoplasia:
      cal dysplasia are appropriate for the natural treat-
                                                                                   endocervical curettage is positive with a satis-
      ment protocols. Licensed practitioners familiar with
                                                                                   factory colposcopy, but the patient is at low
      diagnosing and treating cervical dysplasias should                           risk, or at the discretion of the practitioner and
      be consulted to assist in making appropriate and                             considered carefully after colposcopy, biopsies,
      safe decisions. For practitioners reading this book,                         and careful follow-up.
      the following criteria may be helpful in determining                      9. It is possible to treat carcinoma in situ in
      the appropriate treatment:                                                   selected cases, but this is definitely a judgment
                                                                                   call and should be considered very carefully after
      Criteria for Naturopathic Protocol                                           colposcopy, biopsies, and careful follow-up.

        1. ASC-US.                                                             Referrals for Colposcopy with Biopsies
        2. ASC-US with documented HPV.
        3. ASC-H: endocervical curettage is negative or                         1. ASC-US if HPV DNA testing is positive for high-
           positive with a satisfactory colposcopy.                                risk HPV; if no HPV testing is done, then repeat
        4. Low-grade squamous intraepithelial neoplasia:                           the Pap twice at 4 to 6 month intervals. If HPV
           endocervical curettage is negative with a satis-                        typing is negative for high-risk types, then
           factory colposcopy.                                                     repeat Pap in 12 months.
        5. High-grade squamous intraepithelial neoplasia:                       2. ASC-H.
           endocervical curettage is negative with a satis-                     3. Low-grade squamous intraepithelial lesions.
           factory colposcopy.                                                  4. High-grade squamous intraepithelial lesions.
        6. ASC-H: endocervical curettage is positive with a                     5. AGUS (atypical glandular cells of undetermined
           satisfactory colposcopy, but the patient is at low                      significance); need endometrial biopsy as well.
           risk for more serious disease or has low-risk HPV                    6. Adenocarcinoma in situ (AIS): need endometrial
           typing, or at the discretion of the practitioner.                       biopsy as well.
                                                                                         CERVICAL DYSPLASIA           41
 Criteria and Guidelines for Treatment Selection (continued )

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

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

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

      Initial Naturopathic Plan                                                Systemic
                                                                                 Vitamin C: 6 g daily
                                                                                 Beta-carotene: 150,000 IU daily
        Week 1: vitamin A suppository nightly for 6 nights                       Folic acid: 10 mg daily
        Week 2: herbal vaginal suppository nightly for 6                         Multiple vitamin/mineral: follow label directions
         nights                                                                  Green tea capsules: 1 capsule daily
        Week 3: vitamin A suppository nightly for 6 nights                       Botanical Formula I: 1⁄ 2 tsp twice daily
        Week 4: herbal vaginal suppository nightly for 6
                                                                               Use systemic treatment for 3 months until follow-up.
        Week 5–12: green tea suppository 2 nights per week                     Constitutional
      Systemic                                                                   Vegetarian diet for 3 months until follow-up
        Folic acid: 10 mg daily                                                Additional Therapies to Consider
        Vitamin C: 6 g daily
        Beta-carotene: 150,000 IU daily                                          Zinc: 30 mg daily
        Multiple vitamin/mineral: follow label directions                        Vitamin E: 400 IU daily
        Green tea capsules: 1 capsule daily                                      Selenium: 400 mcg daily
        Botanical Formula I: 1⁄ 2 tsp, twice daily                               Green tea suppository: twice per week
                                                                                 DIM: 200 mg daily
      Use systemic treatment for 3 months until follow-up.
                                                                               Comments: A follow-up Pap smear in 3 to 6 months
      Constitutional                                                           that is still abnormal warrants colposcopy and biopsies.
        Vegetarian diet for 3 months until follow-up
                                                                               Maintenance Plan for 3 Months
      Alternative Naturopathic Plan                                            (After Normal Pap Smear)
      Topical                                                                    Vitamin C: 2 g daily
        Week 1: vitamin A suppository nightly for 6 nights,                      Beta-carotene: 150,000 IU daily
         Vag Pack suppository 1 night per week                                   Folic acid: 2.5 mg daily
        Week 2: herbal vaginal suppository nightly for 6                         Multiple vitamin/mineral: follow label directions
         nights, Vag Pack suppository 1 night per week                           Green tea capsules: 1 capsule daily
        Week 3: vitamin A suppository nightly for 6 nights,                      Vegetarian diet
         Vag Pack suppository 1 night per week

     LIFESTYLE HABITS                                                         involve HPV, women can best protect themselves
                                                                              by using condoms during intercourse. Even if a
     Sexuality                                                                male partner does not have visible genital warts,
     Early age at first intercourse (before age 18) with                       he can have nonvisible genital warts and can also
     unprotected sex and/or multiple heterosexual                             carry the virus.
     partners with unprotected sex are associated with                            If the partner is female, it is more difficult to
     an increased risk of cervical dysplasia and cervical                     contract the virus and cervical dysplasia, but not
     cancer. As nearly all cases of cervical dysplasia                        impossible. Avoiding genital-to-genital contact
                                                                                          CERVICAL DYSPLASIA         43
 Sample Treatment for Mild Dysplasia (CIN 1, Low-Grade SIL)

 See the Resources section for information on the con-       Week 1: vitamin A suppository nightly for 6 nights
 tents of and resources for the suppositories and other      Week 2: herbal vaginal suppository nightly for 6
 products included in these treatment plans.                  nights
                                                             Week 3: vitamin A suppository (Vital-A) nightly for 6
 Initial Naturopathic Plan                                    nights
                                                             Week 4: herbal vaginal suppository nightly for 6
  Week 1: vitamin A (Vital-A) suppository nightly for 6      Weeks 5–12: green tea suppository twice per week
   nights, Vag Pack suppository for 1 night
  Week 2: herbal vaginal suppository nightly for 6          Systemic
   nights, Vag Pack suppository for 1 night                  Vitamin C: 6 g daily
  Week 3: vitamin A suppository nightly for 6 nights,        Beta-carotene: 200,000 IU daily
   Vag Pack suppository for 1 night                          Folic acid: 10 mg daily
  Week 4: herbal vaginal suppository (Herbal-C) nightly      Multiple vitamin/mineral: follow label directions
   for 6 nights, Vag Pack suppository for 1 night            Green tea capsules: 1 capsule daily
  Weeks 5–12: green tea suppository twice per week           Botanical Formula I: 1⁄ 2 tsp twice daily
                                                             Selenium: 400 mcg daily
                                                            Use systemic treatment for 3 months until follow-up.
  Vitamin C: 6 g daily
  Beta-carotene: 150,000 IU daily                           Constitutional
  Folic acid: 10 mg daily
                                                             Vegetarian diet for 3 months until follow-up
  Multiple vitamin/mineral: follow label directions
  Green tea capsules: 1 capsule daily
                                                            Additional Therapies to Consider
  Botanical Formula I: 1⁄ 2 tsp twice daily
 Use systemic treatment for 3 months until follow-up.        Zinc: 30 mg daily
                                                             Vitamin E: 800 IU daily
 Constitutional                                              Selenium: 400 mcg daily
                                                             DIM: 200–400 mg daily
  Vegetarian diet for 3 months until follow-up
                                                            Maintenance Plan for 6–12 Months
 Alternate Naturopathic Plan
                                                             Vitamin C: 2 g daily
                                                             Beta-carotene: 150,000 IU daily
  Escharotic treatment (described later in this chapter)     Folic acid: 2.5 mg daily
    twice per week for 3 weeks                               Multiple vitamin/mineral: follow label directions
 After the last escharotic treatment:                        Green tea capsules: 1 capsule daily
                                                             Vegetarian diet

or practicing safer sex if the partner has known           ically possible, and there are conditions when the
genital warts may be advisable. It is considered           HPV virus may lodge in the larynx and oral
very low risk for the virus alone to be transmitted        cavity. However, these cases are extremely rare,
between women, although it is theoretically pos-           and so it is left to each person to make that judg-
sible. Both heterosexual and homosexual women              ment on her own. If one of the partners is
ask about the risk of transmitting or contracting          immunocompromised (HIV-positive, a trans-
the virus through oral sex. Again, this is theoret-        plant patient, or has chronic hepatitis), then she
44   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

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

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

     is more vulnerable to contracting HPV, and pre-                          cancer is smoking. Smokers have a two- to threefold
     cautions are definitely warranted.                                        increase in the incidence of cervical dysplasia.81
                                                                              Some studies indicate that the incidence compared
     Smoking                                                                  to nonsmokers is even greater than that. Nicotine is
     Probably the single most important cofactor in                           actually concentrated in the glands of the cervix,
     the development of cervical dysplasia and cervical                       where it then acts as a carcinogenic compound.
                                                                                          CERVICAL DYSPLASIA      45
 Sample Treatment for Severe Dysplasia (CIN 3, High-Grade SIL)

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

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

    Smoking may also alter immune function                Oral Contraceptives
and affects the levels and distribution of ascorbic       Earlier studies suggested that oral contraceptive
acid. Ascorbic acid in the cells of the cervix and        (OC) use increased the risk of cervical neoplasia,
the vagina and plasma levels of ascorbic acid are         both invasive and precancerous cervical dysplasias.83
reduced in smokers.82                                     Recently, however, studies that are controlled for
46   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

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

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

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

     sexual history have been reassuring. In addition, no                        Three large, well-controlled studies looked at
     form of hormonal contraception, be it oral or injec-                     invasive cervical cancer and OC use and did not
     tion, was found to be associated with an increased                       find statistically significant associations compared
     risk for developing dysplasia.84 While hormonal                          with women who never used OCs.85–87 There was
     contraception is not implicated in HPV-related dys-                      no overall change in risk of invasive cervical
     plasia, condoms should still be used concurrently.                       cancer. However, one of the three studies did find
                                                                                      CERVICAL DYSPLASIA         47
 Sample Treatment Plan After                              style, pessimism, a high degree of social alien-
 LEEP, Conization, or Cryotherapy                         ation, high anxiety states, and feeling threat-
                                                          ened.91, 92 Life stressors with negative impact over
 Wait for 3 weeks after the procedure (described later    the previous six months showed a direct, positive
 in this chapter), and then begin the following plan.     association with level of dysplasia, while coping
 See the Resources section for information on the con-    style showed a less prominent effect.
 tents of and resources for the suppositories and other
 products used.                                           C O N V E N T I O NA L
   Week 1: vitamin A suppository nightly for 6 nights     M E D I C I N E A P P R OAC H
   Week 2: herbal suppository nightly for 6 nights        The degree of aggression used to combat simple
   Week 3: vitamin A suppository nightly for 6 nights     human papillomavirus waxes and wanes through
   Week 4: herbal suppository nightly for 6 nights
                                                          the years and from provider to provider. While
 Systemic and constitutional treatment plans are the      HPV can be dormant for decades, recurrence is
 same as is described for the degree of lesion in the
                                                          always possible. Some practitioners recommend
 other corresponding treatment plans.
                                                          observation alone through the acute viral phase
                                                          of cervical infection in low-risk patients. We have
a modestly increased risk in long-term OC users.85        seen this work at least as often as not. Many doc-
The other two studies failed to find a significantly        tors give patients the option, considering their
increased risk of invasive cervical cancer even with      lifestyle, other risk factors, prior history, and
long-term OC use. The definition of long-term              immune system status.
use is not always consistent, but some define it as             Most everyone in the conventional medical
more than five years of use. Two other recent stud-        community agrees on how to manage moderate
ies assessed OC use and risk of cervical dysplasia,       and severe dysplasia: remove it. There is some
and neither of these found any statistically signifi-      ongoing controversy about the treatment of mild
cant associations.88, 89                                  dysplasia. Since recent studies have shown that 70
    One disturbing finding with OC use is an               to 80 percent of mild dysplasia will revert to
association with an increase in the incidence of a        normal tissue before one year, there is an equally
rare cancer of the cervix called adenocarcinoma, a        compelling recommendation to just repeat the Pap
variant of squamous cervical cancer. The incidence        smear in one year and avoid further treatment
of this disease has increased over the past several       unless the condition progresses. If it is still mild
decades, while the incidence of invasive squamous         dysplasia at 12 months, then repeat the colposcopy
cervical cancer has decreased since the pill was          and biopsies to exclude more significant lesions. In
introduced. Two recent studies86, 90 found a modest       other words, mild dysplasia can be observed even
but statistically significant increased risk of inva-      longer, as long as close follow-up occurs.
sive cervical adenocarcinoma in OC users with                  When treatment is needed, the procedures
over 12 years of use. However, it is important to         generally used are cryotherapy; a conization with
remember that the cause of cervical cancer is the         a scalpel or laser; laser ablation; or loop electro-
sexually transmitted human papillomavirus.                surgical excision procedure, referred to as LEEP.
                                                          All of them remove the dysplastic cells and allow
P S Y C H O L O G I CA L FAC TO R S                       new cells to replace the old. They all work
The association between psychosocial factors and          upward of 90 percent of the time when used cor-
cervical dysplasia has been the subject of several        rectly. Cryotherapy is reserved for mild dysplasia
investigations. Significant life stressors were            (CIN 1), because of the lesser depth of penetra-
found to be correlated, including low coping              tion. The other procedures are recommended for
48   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      Cervical Escharotic Treatment

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

     moderate and severe dysplasias (CIN 2, CIN 3).                           inadequate prior treatment with residual cells
     Tissue destruction beyond the dysplastic lesions                         that then persist and regrow.
     occurs in all of these procedures to varying                                Cryotherapy is the oldest and cheapest of these
     degrees to help prevent recurrences. Recurrences                         procedures and is a simple office procedure per-
     are usually due to new infection, reactivation of                        formed with a blunt probe applied to the cervix
     the virus because of immune system changes, or                           and tubing that supplies concentrated nitrous
                                                                                    CERVICAL DYSPLASIA          49
oxide to cause the probe to get very cold. Tissue       opening to the cervix. The advantage of LEEP is
penetration is several millimeters. This procedure      that it can be done in the office, is well tolerated,
takes approximately two to three minutes and is         and is minimally expensive.
associated with cramping at the time, which                 These techniques are all relatively safe and
resolves quickly and is rarely present for more than    effective for preventing future cervical cancer.
a day. The devitalized tissue is sloughed as a watery   However, their effects on future fertility and preg-
discharge over the next 10 to 14 days. The cervix       nancy outcomes are unclear. Some say that done
is usually well healed within a month.                  properly, none of these procedures affects fertility,
    Conization is employed primarily for endo-          sexuality, or pregnancy. There is no adequate data
cervical dysplasia. A cold-knife procedure is per-      from randomized controlled trials to evaluate
formed in the operating room under anesthesia           these potential effects. In one analysis of 27 obser-
and employs a scalpel to remove a cone-shaped           vational trials comparing the fertility and preg-
piece of cervix and cervical canal. Conization has      nancy of women who underwent ablation or
the advantage of more clearly evaluating the mar-       excision of CIN lesions to women who were not
gins, because there is no thermal artifact. Laser       treated with these therapies, LEEP and cold-knife
ablation of the transformation zone can be per-         conizations were both associated with significantly
formed in the operating room or the office and           increased risk for preterm delivery. LEEP was asso-
allows for precise management of lesions but            ciated with an increased risk for preterm rupture
does not provide tissue for pathology. Laser            of membranes, and the cold-knife cone was asso-
conization obtains tissue similar to the cold-knife     ciated with an increased risk for cesarean section.
cone procedure, with some thermal destruction           The laser cone and the laser ablation had no asso-
at the margins, and is significantly more expen-         ciation with any significant change for any of the
sive than LEEP.                                         outcomes. None of the treatments had any signif-
    The most common current treatment of                icant association with perinatal mortality, compli-
endocervical or cervical dysplasia of moderate-         cation for the infant, or fertility.
to-severe degree is a LEEP procedure, which is              Follow-up recommendations may vary depend-
generally performed in the office with cervical          ing on your overall case history and your practi-
anesthetic and is usually well tolerated and very       tioner’s perspective. Some patients treated with any
cost effective. LEEP can be used to remove the          of these conventional treatments are advised to
endocervical canal and/or the transformation            have three-month Pap smears for the first year and
zone. It also has thermal degradation at the mar-       six-month Pap smears for the next year. Others will
gins. When LEEP or laser is used, the tissue            have the recommendation of annual Pap smears
beyond the cut margin is heated and destroyed           following the conventional treatment.
for another 1 to 2 mm of penetration. Even when
the dysplasia is seen all the way to the margin of      Prevention: The HPV Vaccine
the biopsy, there is still usually complete treat-      The newest approach to conventional medical
ment of the lesion because the heat destruction         treatment of dysplasia is prevention. After a clini-
penetrates into the tissue beyond the surgical site.    cal trial done in 2002 initially showed that an
    Women treated by LEEP are more likely to            HPV-16 vaccine reduced the incidence of both
convert to HPV-negative status within one to two        HPV-16 infection and HPV-16 cervical dyspla-
years after the procedure and do so significantly        sia,93 continued research has lead to the reality of
sooner than those who are merely watched with-          an HPV vaccine to reduce the incidence of cervi-
out treatment. The LEEP can reduce cervical             cal cancer. The FDA approved a quadrivalent vac-
mucus and can occasionally cause a stenosis of the      cine in June 2006. It vaccinates women against
50   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     strains 6 and 11, which cause venereal warts, and                        are not diagnostic; they are screening tests. When
     16 and 18, which are the most common strains                             your licensed practitioner (naturopathic doctor,
     found in cervical cancer. The intended recipients                        medical doctor, osteopathic doctor, nurse-
     of this vaccine will be pubertal girls who have not                      practitioner, or physician’s assistant) recommends
     yet had intercourse. However, the vaccine has been                       that you need a colposcopy and biopsy, this is
     recommended up to age 26, because it will also                           good advice. They are not recommending treat-
     help prevent venereal warts in women who are                             ment; they are recommending accurate diagnosis.
     currently sexually active.                                                   Decisions regarding treatments such as a
         In one study young women without histories                           LEEP, cone biopsy, or cryotherapy versus one of
     of HPV infection or abnormal Pap smears who                              the natural treatment protocols require a medical
     were given the type 16 and 18 vaccine were sig-                          history, Pap smear report, colposcopy report,
     nificantly less likely to develop HPV type 16 or                          biopsy/pathology report, and a working knowl-
     18 infections or abnormal cervical cells during                          edge of the advantages and disadvantages of each
     the two-plus years of follow-up.94 In another                            of the treatments. If your conventional practi-
     study, the 6, 11, 16, and 18 vaccine decreased the                       tioner is not aware of the research on the natural
     incidence of infection by 90 percent in young                            treatment protocols or is biased without knowl-
     women compared to placebo.95                                             edge, then he or she may not be the most appro-
                                                                              priate person to help you make the right
     S E E I N G A L I C E N S E D P R I M A RY                               decision. Likewise, if your alternative practi-
     H E A LT H - CA R E P R AC T I T I O N E R                               tioner is not aware of the clinical indications for
     ( N . D. , M . D. , D. O . , N . P. , P. A . )                           the conventional treatments as distinguished
     Accurate and adequate diagnosis and evaluation                           from the clinical indications for the safety and
     is the key to knowing which is the most appro-                           efficacy of the alternative treatment plan or is
     priate treatment for your case. Colposcopy (mag-                         biased without knowledge, then he or she too
     nification) and cervical biopsies are the specific                         may not be the most appropriate person to help
     diagnostic methods for evaluation. Pap smears                            you make the right decision.
                                    CONTRACEPTION                                                      CHAPTER

OV E RV I E W                                                   ning or fertility awareness methods (often
Around the same time suffragettes were securing                 described as the rhythm method), there are three
the right to vote, other women, most notably                    general categories—hormonal contraception, bar-
Margaret Sanger, desperately sought to provide                  rier contraception and the intrauterine devices,
women a means of “family limitation,”1 later                    and abortion—that complete the list of birth con-
called birth control. The political struggle to                 trol methods. Sterilization, the most common
legitimize contraception and bring it into the                  method of fertility control, is a safe surgical proce-
medical arena was long and fierce. Sanger was                    dure for either men or women. This method is
jailed on obscenity charges more than once and                  used by about 20 percent3 of couples; yet it, too,
finally fled the country rather than face a trial she             has a failure rate of about 1 in 400.
ultimately won years later. Any public discussion
of reproduction was judged obscene under the                     KEY CONCEPTS
prevailing Comstock Law. Although women fre-
quently died in childbirth or struggled to feed                  • Consult your health-care practitioner to deter-
families of six to ten or more, they were forbid-                  mine the effectiveness, health benefits, and
                                                                   health risks of each contraceptive method.
den information concerning fertility regulation
                                                                 • Consult your health-care practitioner about cau-
that was literally lifesaving. Although diaphragms                 tions and contraindications for each method.
and condoms gradually became more readily                        • Smokers older than 35 should not use hormonal
available (the first diaphragms in use in America                   contraceptive methods.
were smuggled from Europe through Canada by                      • The choice of contraception method is based on
Sanger and her husband), it was not until the                      benefits, risks, effectiveness, cost, side effects,
Supreme Court decision Griswald v. Connecticut                     ease of use, and personal choice.
in 1966 that married women’s rights to access                    • The key to the contraceptive benefit is proper
birth control became assured.                                      use and compliance with the chosen method.
     While we modern women lament the absence                    • Pregnancy itself carries considerable health
                                                                   risks. These must also be considered when
of a perfect fertility control option, the mere fact
                                                                   choosing a method of contraception.
that the birthrate has fallen so drastically these past          • Regular annual health exams are required for
50 years illustrates both women’s desire to have                   users of hormonal contraception.
fewer children and the efficacy of the combined                   • Report any side effects that you think are
methods in achieving that goal. Nevertheless, even                 related to your method of contraception to your
with the current availability of contraception, fully              health-care practitioner.
57 percent of American pregnancies today are
unintended.2 Perhaps our difficulty with the issue
relates to our prudish roots. Safe, effective birth             F E RT I L I T Y AWA R E N E S S
control does exist, although failures, whether                  Many couples successfully rely on this drug-free
human or methodological, occur with each. The                   and device-free method that depends on identi-
best we can do is choose wisely and minimize                    fying a woman’s fertile periods and abstaining
human error. In addition to natural family plan-                from intercourse during those times. However, to
Copyright © 2008 by Tori Hudson. Click here for terms of use.
52   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     achieve the lowest failure rates of 1 to 10 percent                      tion—days 11 through 17 at least, and optimally
     requires relatively long periods of abstinence each                      seven days before and at least four days after. If a
     month—at least 10 and up to 20 days—depend-                              woman’s cycle is not this regular, another
     ing on cycle length and predictability. The                              calendar method is useful that takes into account
     average pregnancy rate with most who use this                            cycle variance. First gather information about
     method is 20 percent, clearly less than the 85                           cycle length over enough time to figure out how
     percent rate experienced with no method at all.                          wide the range is. You must know the longest and
     More pregnancies result from taking chances                              the shortest cycle length you experience—day 1
     during fertile times than from difficulty deci-                           being the first day of menses and the last day
     phering the methods.4 These methods work best                            being the one just before menses resumes. Sub-
     when women have a predictable cycle length.                              tract 20 from the shortest cycle to get the first
     Ovulation is then predicted most accurately, and                         fertile day (day 4 in a 24-day cycle). Subtract 10
     intercourse is restricted for the least amount of                        from the longest cycle (day 22 in a 32-day cycle)
     time. Barrier methods can be combined with the                           to get the last fertile day. Thus, a woman with
     calendar method pretty effectively during the                            cycles ranging from 25 to 30 days avoids inter-
     restricted time, but spermicide can obscure the                          course days 5 through 20 (25         20     5 and
     cervical mucus method. All variations of this                            30 10 20). (Read through this paragraph two
     method assume that an ovulated egg can be fer-                           or three times to make sure you understand it.)
     tilized for up to 24 hours and that sperm can sur-
     vive in the female reproductive tract for about                          Cervical Mucus
     three but possibly up to seven days.4 Amazingly,                         This method uses the recognition of “fertile
     one might become pregnant up to a week after                             mucus” to predict ovulation. It depends on the
     the last intercourse! So much for romantically                           physiological fact of the presence of slippery thin
     planning conception location or dating a preg-                           mucus at the cervical orifice around ovulation.
     nancy simply from the timing of sex.                                     You can easily learn to discern fertile mucus by
          Combining all the methods somewhat prob-                            experimenting with egg white, which resembles
     ably works the best; for example, many women                             fertile mucus. Use your index finger to gather
     are quite good at predicting when they ovulate                           mucus from as close to the uterine opening as
     from a variety of symptoms (such as pelvic pain                          possible. Fertile mucus stretches between thumb
     or mittelschmerz), but this is only something you                        and index fingers as they are separated, just like
     notice after the fact. To successfully avoid preg-                       raw egg white, without breaking in the middle.
     nancy, you have to be able to predict ovulation                          Nonfertile mucus is tackier and breaks apart
     about five to seven days in advance or else avoid                         easily at short distances between the fingers.
     exposure completely during the first half of the                          Experiment with an egg white, then try room-
     cycle. Obviously noncoital activities are permissi-                      temperature butter—you will see the difference.
     ble at all times; this method does not require                           Imagine the sperm swimming easily between
     actual abstinence, just avoidance of intercourse.                        long slippery parallel strands of mucus around
                                                                              ovulation, which is thought to ease transport into
     Calendar Methods                                                         the uterus and may also modify the sperm so that
     Rhythm, the oldest of birth control schemes,                             it is capable of fertilizing the egg. Ovulation usu-
     relies on a woman having a regular 28-day cycle,                         ally occurs in the middle or toward the end of the
     with ovulation occurring on day 14—exactly                               fertile mucus time; thus it is best to determine
     midcycle. Intercourse must be avoided for at least                       your length of fertility in advance a few cycles
     three days before and three days after ovula-                            before relying on this method. Obviously semen,
                                                                                       CONTRACEPTION        53
spermicides, vaginal creams, or lubricants can        transmission of these diseases between humans.
adulterate the mucus and make this assessment         Because some organisms, such as HIV, are intra-
unreliable. Experiment.                               cellular, they may not get exposed to the spermi-
                                                      cide during sexual intercourse, and therefore
Basal Body Temperature                                protection may be compromised. In fact,
Basal body temperature is measured by taking          nonoxynol-9 is rather irritating to some, and the
one’s temperature the very first thing in the          irritation may result in vaginal mucosa (the
morning before getting out of bed and before any      lining of the vagina) that is more susceptible to
activity at all. Wake up, reach over, take the tem-   the AIDS virus. It is safe to use nonoxynol-9
perature, record. Plotting these numbers daily        unless it irritates you; in that case, don’t.
over a few months will show a nice pattern of              Condoms should obviously be used with any
ovulation. The temperature may drop a bit (usu-       new sexual partner to protect against many, but
ally around half a degree) just before ovulation,     not all, sexually transmitted diseases. Alone as a
and then goes up about a degree from there (now       method of birth control, they can be reasonably
half a degree over baseline) just after ovulation.    effective. If used consistently and properly, fail-
Release of the egg probably occurs the day before     ure rates are reputed to be as low as 3 percent,
the elevation,3 which persists until menses. Ele-     although actual use failure rates are closer to 10
vation longer than the expected 12 to 14 days         to 14 percent. Using condoms with an intravagi-
usually indicates pregnancy. A digital thermome-      nal spermicide provides about 96 percent safety
ter will help you demonstrate this rise more accu-    from pregnancy with typical use. This combina-
rately, but you can use any thermometer if you        tion is the best over-the-counter method.
are willing to precisely plot the points.                  Healthy noninfected couples that choose
                                                      condoms may prefer the comfort of lambskin
BA R R I E R M E T H O D S                            condoms; the pores of these condoms are too
Barrier methods include anything that imposes         big to protect well against viral-size organisms,
a barrier between egg and sperm and include           but they do just fine in keeping out sperm. Con-
condoms, diaphragm, cervical cap, and any of          doms, a very old tried-and-true method, are
the spermicides. Only the condom physically           enjoying a surge in popularity.
prevents sperm from reaching the egg. The                  Caps and diaphragms work similarly; both
diaphragm and the previously available cervical       cover the cervix and hold spermicide either
cap are both methods of holding spermicide            against the cervix or facing the entrance to the
against the cervix; they don’t really keep the egg    vagina. The suction-based cervical cap is cur-
from meeting sperm. The new FemCap does               rently not available in the United States due to a
cover the cervix but doesn’t hold the spermicide      business decision by the European manufacturer.
against the cervix. Rather, it contains a groove      This had nothing to do with safety or effective-
facing the vaginal opening to store and deliver       ness. What is now available, perhaps the newest
spermicide or any microbicide. Without spermi-        method of birth control, is the FemCap. The
cide, these methods are not highly effective.         FemCap is made of nonallergenic, latex-free
Most condoms are impregnated with spermicide          material and is designed to cover the cervix. It
these days, because of the presumed protection        has a groove facing the vaginal opening that
nonoxynol-9 provides against sexually transmit-       stores and delivers spermicide. It is available by
ted diseases. Nonoxynol-9 kills gonorrhea,            prescription only but does not require a technical
herpes, trichomonas, syphilis, and HIV in vitro,4     fitting session and measurement by the health-
which may or may not translate into reduced           care provider. A FemCap must be applied before
54   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     arousal and should be kept in place for at least                         dates, IUDs are simple, cheap, highly effective,
     six hours after the last intercourse. A backup                           reversible, and have a minimal impact on underly-
     method is recommended while you are learning                             ing physiological processes.
     to use it. FemCaps have the advantage of being                               Modern IUDs became popular with the
     able to be left in with ongoing efficacy for as                           introduction of the Lippes Loop in the early
     long as 48 hours. A FemCap comes with an                                 1960s, when as many as 10 percent of women
     instructional video. (Information is available at                        who used contraceptives chose this method. The
     www.femcap.com.)                                                         failure rate was about 2 percent, although the
         A diaphragm is a latex shield that covers the                        expulsion rate (coming out with the menstrual
     cervix. Diaphragms come in several sizes, and the                        flow) was reported to be as high as 12 to 20 per-
     correct size must be determined as part of a pelvic                      cent.3 Lippes Loops are still available and in use
     exam by a health-care practitioner. Spermicide                           around the world, although not available in the
     must be placed in the diaphragm, which is then                           United States.
     placed up against the cervix. The diaphragm must                             IUDs are used much more commonly in
     be left in for at least six hours after intercourse,                     Europe than in the United States, largely because
     and any additional intercourse during that six                           of the persistent fear American women and
     hours must be preceded by the addition of an                             providers still harbor from the Dalkon Shield
     applicator of spermicide. Diaphragms with sper-                          debacle during the 1970s. Unfortunately, this
     micide have an effectiveness rate of approximately                       device traumatized the cervix on insertion, and
     94 percent.                                                              the string was made of a material that was a
         The contraceptive sponge was originally                              perfect conduit for bacteria to ascend into the
     introduced in 1983 and remained on the market                            uterus. An infection called pelvic inflammatory
     until January 1995. It was taken off the market                          disease (PID) increased dramatically in Dalkon
     because the manufacturer chose not to modern-                            Shield users, essentially due to the prevalence of
     ize the manufacturing and hygiene standards. In                          sexually transmitted diseases that ascended into
     2005, the Today sponge returned to the market-                           the uterus and/or fallopian tubes; many women
     place with a new manufacturer. The sponge is a                           acquired serious infections and in many, infertil-
     convenient, disposable, one-size-fits-all vaginal                         ity resulted. Yet the company did not recall the
     contraceptive that can be purchased over the                             device for 10 years—at least 5 years after the
     counter at most drugstores. It is used with a sper-                      problems were known. The reputation of the
     micide and offers an 82 to 92 percent effective-                         IUD was tarnished forever, and a good contra-
     ness rate.                                                               ceptive method is all but lost to women who
                                                                              might well benefit from it today.
     I N T R AU T E R I N E D E V I C E S                                         There are presently very few IUDs in the
     Intrauterine devices are in a contraceptive class all                    United States because manufacturers don’t want to
     by themselves, and they may arguably be the least                        take a chance on a device that has become so
     invasive and highest efficacy form of birth control.                      unpopular. Copper was added to IUDs to increase
     Rumors persist that Cleopatra had a gold ring in                         effectiveness in the 1980s, which allowed smaller
     her uterus that prevented pregnancy and allowed a                        and better-tolerated devices to be used. The Para-
     healthy, active love life. And the camel drivers in                      gard copper T fails less than 1 percent of the
     the same era are said to have put small rocks in                         time4 and lasts for at least 10 years. Fertility is
     their camels’ uteruses to prevent pregnancy on the                       unchanged over baseline in women who do not
     long roads they traveled. These may just be good                         contract sexually transmitted diseases. The device
     stories, but for those women who are good candi-                         comes in only one size, and so is better tolerated in
                                                                                         CONTRACEPTION         55
a uterus that has carried a pregnancy. It can be put    otic can be utilized to prevent infection. If you
in during nursing for excellent carefree contracep-     do become pregnant, the IUD should be
tion that will not interfere with lactation. The        removed. Pregnancies will be interrupted by the
mechanism of action is now fairly well docu-            IUD, and a miscarriage can occur about half the
mented as a inflammatory response in the uterine         time. If desired, ultrasound can be used to iden-
cavity. It is not felt to be an abortifacient (a sub-   tify the IUD before removal to minimize disrup-
stance that induces abortion).                          tion of a wanted pregnancy.
    IUDS can make menstrual flow heavier and
with more cramping. For those women with mod-           B I RT H C O N T R O L P I L L S ( B C P S )
erate or light menses, however, it is a method          Never has there been a more perfect love/hate
that requires no mess or loss of spontaneity, and       relationship than that between women and
IUDs can be used for years without loss of efficacy.     hormonal contraception or birth control pills
Even at a cost of $600 to $700, this is a minimal       (BCPs), also called oral contraceptives (OCs). In
expense if used over a 10-year period.                  1951, Margaret Sanger is credited with convinc-
    Women who are in monogamous relation-               ing Gregory Pincus (who ultimately synthesized
ships, have given birth, and are not at risk for        the first oral contraceptive) that his research in
sexually transmitted infections are perfect candi-      fertilization could be used to create an oral
dates for IUD use, if their periods are normal.         contraceptive. Available for the first time in the
Again, though, IUDs can increase the amount of          1960s, oral contraceptives were truly a revolu-
the menstrual flow and increase cramping. The            tionary medical option for women. Women
exception is the newer IUD called Mirena. It            readily embraced the option of having fewer
contains a progestin (Levonorgestrel) on the            children, and the dramatically lower birthrate
stem, which shrinks the endometrium and                 that resulted has persisted, undoubtedly due to
decreases menstrual flow and cramping. It can            the pill’s continued widespread use. Women’s
reduce the normal flow by 80 percent and causes          maternal burden was lifted for the first time in
a lack of menses in 15 percent of patients. The         history. That’s the good news.
Mirena lasts 5 years, and the progestin stays               Unfortunately, the hormonal content of early
active inside the uterus. It is thought that in the     birth control pills—estrogen and progesterone—
majority of women and in the majority of the            was much higher than today’s pills, and more
time, the progestin is confined to the uterus            women smoked then. Both factors affected what
without systemic absorption. However, clinicians        is always the course of any new medicine—the
will report cases of patients who appear to have        downside became obvious only with mass use. It
had systemic progestin side effects from the            soon became apparent that cardiovascular dis-
Mirena. The Mirena is an important option in            ease, including heart attacks, strokes, blood clots,
contraception—a method that provides 99 per-            and pulmonary emboli, was more frequent in
cent protection and decreases menstrual pain and        women who used birth control pills. But even
heavy flows.                                             though “more frequent,” these diseases are still
    Insertion of an IUD must be done in a prac-         exceedingly rare in the healthy population of
titioner’s office. Most women report nothing             young women who are the usual pill takers. It is
more than light cramping. STI testing for               also true that these risks are dose related and have
chlamydia and gonorrhea should precede inser-           fallen measurably as the estrogen and progestin
tion. Infections caused by the insertion itself are     content of pills has fallen 4 and 10 times respec-
rare and may occur approximately 1 percent of           tively since their initial use. The FDA-approved
the time, within 30 days of insertion. An antibi-       package insert states the following:
56   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         The information contained in this package                            one-fifth that of pregnancy. If we can manage to
         insert is principally based on studies carried                       avoid pregnancy in other ways, presumably they
         out in patients who used oral contraceptives                         are safer than the pills.
         with formulations containing 0.05 mg [50                                 There are some significant health benefits
         mcg] or higher of estrogen. The effects of                           attributable to the pill—for example, an 80 per-
         long-term use with lower-dose formulations                           cent reduction in ovarian cancer and a 50 percent
         of both estrogens and progestogens remain                            reduction in uterine cancer with about a decade
         to be determined.                                                    of use.3 Assessing an individual’s risk/benefit
                                                                              ratio requires individualization based on health
         The birth control pills in common use today                          status, family history, and so forth. If one’s risk of
     have 20 to 35 mcg of estrogen, and only one or                           cardiovascular disease doubles with use (it does),
     two formulations containing 50 mcg are even                              that sounds worrisome. But if doubling one’s risk
     available. Moreover, the studies documenting                             means going from a risk of 1 in 10,000 to 2 in
     these higher risks in the earlier days did not con-                      10,000, that doesn’t sound so bad. This is just
     trol for other risk factors such as smoking, high                        another way of looking at the same fact. Inciden-
     blood pressure, obesity, and so forth—all known                          tally, this risk is not even close to the risk we take
     to independently increase a woman’s risk of car-                         driving our car to work or school.
     diovascular disease. I like the way the late Dr.                             Smokers older than 35, however, should not
     Felicia Stewart, who dedicated much of her life                          use the birth control pill. Most other women at
     and career to designing research and policies that                       higher risk of heart disease, like those with dia-
     make safe, effective contraception and abortion                          betes, hypertension, or elevated cholesterol,
     accessible to women, describes pill risk:4                               should consider other options as well—but even
         If you were to draw a line 215 meters high                           in these conditions, pills are usually safer than an
         (the height of a 70-story building) to repre-                        undesired pregnancy. Blood pressure needs to be
         sent 100,000 young nonsmoking pill users,                            followed in all pill takers, and, if elevated signifi-
         and then draw a line beside it to represent                          cantly by use, another birth control method must
         the number of pill users in the United States                        be chosen.
         who die each year from complications relat-                          Breast Cancer and the Pill
         ed to higher-dose pills, that second line
         would be about 0.5 centimeters high [about                           Much attention has been given to the relation-
         one-fifth of an inch]. In comparison, the                             ship between the pill and breast cancer, and
         line representing the number of U.S.                                 slowly some answers emerge. The Centers for
         women who would die of pregnancy-related                             Disease Control (CDC) conducted a study in the
         problems would be just under 2.5 centime-                            1980s called the “Cancer and Steroid Hormone
         ters high [about an inch]. A line represent-                         Study” that looked at nearly 5,000 cases of breast
         ing maternal mortality in developing coun-                           cancer and 5,000 healthy control women and
         tries would be 25 centimeters to 1.5 meters                          concluded that there was no increased risk of
         tall [10 inches to just under five feet].                             breast cancer in women who had used the pill.3
                                                                              Another significant study evaluated a pooled
         Risks attendant to birth control use must be                         analysis from 54 studies involving 53,297
     measured against the risk of the pregnancies they                        women with breast cancer and over 100,000
     prevent. We are fortunate to live in the time of                         controls and concluded that there is a slight but
     the lowest maternal mortality ever—and still the                         measurable increase in the relative risk of breast
     risk of oral contraception we all worry about is                         cancer for current BCP users that declines
                                                                                         CONTRACEPTION        57
shortly after stopping the pill and disappears              The cancers in former users are generally of a
within 10 years.5 By age 50, there is no difference     less advanced stage than the cancers of nonusers,
in the risk of breast cancer in women who have          and benign breast disease (cysts, fibrosis, breast
ever used oral contraceptives versus those who          pain, swelling) is generally improved by BCP use.
have never used them. Also, the increase in risk        Overall, there appears to be no evidence of any
during use (1.24 relative risk) translates differ-      significant increase in the lifetime risk of getting
ently in a 20-year-old woman versus a 40-year-          breast cancer among women who have used oral
old woman. If the risk of breast cancer at 20 is 1      contraceptives.
in 5,000 (or less), then a relative risk of 1.24            Before deciding for or against BCPs, consider
increases it to 1 in 4,000. However, if a woman         your risk for breast cancer (although most
is 40 and the risk of breast cancer is about 1 in       women who get breast cancer are not at risk, and
250, a relative risk of 1.24 increases her risk to 1    most at risk don’t get it),6 whether pregnancy
in 200. Thus, the increase is clearly more signifi-      poses a risk, and any other health risks and ben-
cant in an older woman. In this age group, of           efits related to BCP use.
1,000 40-year-old women who take the pill, one
will contract breast cancer as a consequence.           Other Health Benefits
Only about 15 percent of breast cancers occur in        of Birth Control Pills
women younger than age 45,6 which is when               Several years ago, the FDA began to require that,
most of us take oral contraceptives.                    in addition to risks, pill manufacturers list bene-
    A very recent meta-analysis that revisited oral     fits, because they are so significant. Some women
contraceptives and the risk of breast cancer, pub-      actually take birth control pills for the health
lished in October 2006, concluded that oral con-        benefits they offer. Oral contraceptives protect
traceptives do increase the risk of premenopausal       from uterine and ovarian cancers in the general
breast cancer.7 Thirty-four case-control studies of     population, but we aren’t sure yet about those in
oral contraceptives and premenopausal breast            families with a higher incidence. They protect
cancer during or after 1980 were identified. Analy-      from pregnancy nearly 100 percent of the time,
sis of the data from these studies showed that the      although even with perfect use, there is still
risk of breast cancer was slightly increased for both   about 1 pregnancy in 1,000 women per year, and
nulliparous (having never given birth) and parous       with common human error, a 2 percent failure
(having birthed one or more times) women. In            rate is more accurate. As a bonus, they reduce
nulliparous women, the longer duration of use of        heavy, painful periods in everyone.
the pill did not significantly affect risk. In parous        About 80 to 90 percent of functional ovarian
women, the increased risk was more substantial          cysts (those related to ovulation, the most
when the oral contraceptives were used before the       common type) are eliminated in women who
first-full term pregnancy. The risk was highest in       take birth control pills.4 Those who suffer from
parous women who had used the pill for four or          endometriosis can frequently reduce their ongo-
more years before their first full-term pregnancy.       ing pain by suppressing the disease with oral
There are many limitations of this kind of review       contraceptives. Women with polycystic ovary
because there are so many variables, including race,    syndrome and abnormal male pattern hair
possible recall bias, difference in the age of first     growth can decrease hair growth with oral con-
using the pill, and poor information on when the        traceptives because they measurably reduce the
pills were last used. Taking oral contraceptives        male hormones known as androgens in these
must be decided based ultimately on the benefits         women. Interestingly, because of the thickening
compared to the risks for each woman.                   in cervical mucus that birth control pills induce,
58   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     it is less likely that women who take them will                          be that OCs interfere with gastrointestinal
     get pelvic inflammatory disease if they are                               absorption or with metabolism or binding. There
     unlucky enough to get gonorrhea or chlamydia                             seems to be general consensus in the literature
     in the cervix. Fertility is spared in this way.                          that consumption of oral contraceptives con-
          Several recent studies have shown that a seven-                     tributes to pyridoxine (vitamin B6 deficiency).9 It
     day hormone-free interval causes more of a rise in                       has been estimated that the majority of women
     follicle-stimulating hormone (FSH), which causes                         on OCs for longer than six months manifest
     ovulation. Continuous daily regimens or shorter                          abnormal tryptophan metabolism. Vitamin B6
     drug-free intervals (three or four days only) pre-                       can normalize tryptophan metabolism.
     vent ovulation. Suppression of ovulation reduces                              Although not consistent, some research has
     the cyclic symptoms some women have on the                               shown that OCs disturb folate metabolism.
     typical 21 days on and 7 days off pill regimens.                         Anemia, the gastrointestinal and genital tracts,
     There is also less breakthrough bleeding and a                           bone and heart health, and mental function are
     decrease in pregnancy rates with these shorter                           all affected by folic acid deficiencies. For this
     time-off regimens. More and more women are                               reason, folate is an important nutrient to supple-
     using their birth control daily, or for three months                     ment for women taking the pill. Oral contracep-
     at a time. Many oral contraceptives are being                            tion users have also been reported to have
     repackaged with only three or four days of hor-                          reduced levels of vitamin B12.9 This may be
     mone-free pills, and we will likely see more of this                     related to malabsorption, increased renal excre-
     in the future.                                                           tion, and enhanced tissue acidity. A woman may
                                                                              or may not acquire an anemia associated with a
     Nutritional Supplements for Pill Users                                   B12 deficiency, but long-term use of the pill may
     Apart from their hormonal effect, the hormones                           lead to this, or at least may compromise nerve
     in birth control pills have been shown to affect                         function, mood, mental function, and the health
     metabolic and nutritional factors. Women on oral                         of the digestive system. Carotenoids are also
     contraceptives may want to take nutritional sup-                         included in this formula to protect the cervix.
     plementation to adjust for some of the biochemi-                         Oral contraceptives have shown mixed results in
     cal alterations caused by the pill. Women on BCPs                        increasing abnormal changes in the cervix that
     have a higher requirement for folate,8 and this may                      can lead to cervical cancer. Beta-carotene defi-
     be especially true for women who have had cervi-                         ciency in the cervical cells may be a cofactor in
     cal dysplasia (precancerous abnormal cells of the                        the development of cervical dysplasia,10 and
     cervix). The frequent ingestion of the steroids                          decreases in plasma beta-carotene levels is found
     found in BCPs have been shown to depress levels                          in women with either cervical dysplasia or cancer
     of riboflavin, pyridoxine, vitamin B12, ascorbic                          of the cervix.11
     acid, and zinc.9 Hormones can also affect breast                              Reduced levels of ascorbic acid have also been
     tenderness, increase risk of blood clots, and induce                     observed in those who take oral contraceptives.9
     an array of side effects in some women, and they                         It is possible that the steroids of oral contracep-
     are metabolized in the liver. Providing selective                        tives increase the breakdown of ascorbic acid,
     nutritional support, supporting breast health, and                       decrease absorption, and/or change tissue distri-
     enhancing hormonal metabolism and detoxifica-                             bution. Limited research in animals has shown
     tion pathways may optimize the experience of                             that oral contraceptives lower blood levels of vita-
     using hormonal contraception.                                            min E.9 Vitamin E is the premier antioxidant for
         Riboflavin deficiency may occur with long                              lipids, protects structures against toxic com-
     periods of oral contraceptive (OC) use.9 It may                          pounds, and is important in immune function.
                                                                                          CONTRACEPTION         59
Most investigations have shown a reduction in            vaginal ecology by taking lactobacillus in the form
plasma zinc levels following the administration          of a nutritional supplement.
of OCs.9 Decreased absorption, increased uri-                Additional considerations may include liver
nary excretion, and a decrease in albumin, an            support to aid in the metabolism of the steroids.
important carrier of zinc, may account for this.         There are many options here, including a
Zinc is essential to good health and is involved in      lipotropic supplement and herbs such as dande-
many enzyme and body functions. Immune                   lion root, burdock root, and milk thistle.
function; wound healing; the nervous system;                 Little information is available about any
maintenance of vision, taste, and smell; and skin        interactions between botanicals and birth control
health are dependent on adequate levels of zinc.         pills. For now, my only real caution is with Saint-
Zinc competes with copper for absorption, there-         John’s-wort. A few case reports, as well as two
fore adding a small amount of copper is also sug-        controlled clinical trials, indicate that Saint-
gested to avoid any problems.                            John’s-wort can cause breakthrough bleeding and
    Borage seed oil is high in gamma linolenic           interferes with the metabolism of the hormones
acid (GLA), which is important in maintaining            in the pill. These observations lead me to think
pain-free breasts. GLA decreases abnormal sensi-         that the effectiveness of oral contraceptives may
tivity of breast tissue to normal hormone levels.        be reduced when taken in conjunction with
The proposed mechanism of GLA’s action is that           Saint-John’s-wort.16–18 Other speculations have
it normalizes the balance of fatty acids contained       been made about the possibility of other herbs
within the cell membranes. The steroid receptors         and nutrients interfering with the effectiveness of
in the breasts then have a reduced affinity for           birth control pills. However, hypotheses about
estrogen, dramatically reducing breast sensitivity.      chaste tree, indole-3-carbinole, soy, dong quai,
    Oral contraceptives can increase the risk of         and others have no documentation to support
blood clots, although this risk has been consider-       these concerns.
ably reduced since the lower-dose pills have
become the norm. However, these concerns still           Side Effects
deserve our attention. Bromelain has a very favor-       Many women prefer not to take birth control
able effect on inflammation of a vein. In research,       pills because they see them as an unnatural form
bromelain has been shown to reduce all the symp-         of birth control. Others are concerned, rightly so,
toms of inflammation in those who had developed           about some of the issues that have been raised
acute thrombophlebitis.12 Garlic preparations            here, but some women just plain don’t feel good
have been shown to promote fibrinolysis, which            on them. Some women have bloating, breast ten-
can offer benefit in prevention of strokes and other      derness or pain, headaches, mood swings, depres-
clotting events.13, 14 Excessive clumping together       sion, weight gain, nausea, lowered libido, and
of platelets is linked to heart disease and strokes.     breakthrough bleeding. Other women may expe-
Garlic and its volatile oils can inhibit platelet        rience significant, more serious side effects such
aggregation and thereby improve circulation.15           as complete hair loss, blood clots, high blood
    Finally, women taking hormonal contracep-            pressure, heart attack, and elevated liver enzymes.
tives can experience changes in vaginal pH, which            There are many kinds of birth control pills
can lead to changes in the balance of organisms in       today, and fortunately they are significantly lower
the vagina. Lactobacillus species are fundamental        in dose and cause far fewer side effects than in the
to maintaining a healthy ecological vaginal envi-        past. The pills vary in their estrogen and progestin
ronment, which helps to prevent yeast and vaginal        dosages and contain different kinds of estrogens
infections. It may be possible to favorably alter this   and progestins. A woman may tolerate one pill
60   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

     service and how judged they feel—most obviously                              Rather than a surgical abortion, medical abor-
     by “pro-life” practitioners, but also by their pro-                      tion with a drug called mifepristone (Ru-486) is a
     choice doctors who send them across town to a                            good option for early pregnancies, and it offers a
     clinic just because it’s easier for that doctor. If your                 method of abortion that aligns much more natu-
     gynecologist won’t help, go to one of the wonder-                        rally with our bodies. The medical abortion is just
     ful women-run and supported clinics that provide                         like a miscarriage. There is more bleeding and
     the service out of love and respect for women.                           cramping than a period, but it occurs within a 4-
     Their doctors are very experienced, with extremely                       to 24-hour period, and 98 percent of the time
     low complication rates. Emergency contraception                          avoids surgery altogether. The infection rate is
     can be obtained at most clinics as well, although                        lower, and the chance of significant uterine injury,
     emergency contraception is now available over the                        already miniscule, is further lowered. Many
     counter for women over the age of 18.                                    women are quite pleased with this method.

      Summary of Contraceptive Choices

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

      Disadvantages                                                            Advantages

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

                                                                                                                        (continued )
                                                                                              CONTRACEPTION         63
Summary of Contraceptive Choices (continued )

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

Disadvantages                                             Advantages

 May be expelled by the uterus; may perforate the          Insert up to 6 hours before intercourse
   uterus                                                  Noninvasive method
 Increases the risk for PID                                Inexpensive
 May cause heavier bleeding and menstrual cramps          Disadvantages
Effectiveness                                              Must leave in for at least 8 hours after intercourse
 97 to 99 percent                                          Must reapply spermicide for repeat intercourse
Intrauterine Device (Progestin IUD)                        Must be able to insert by oneself
                                                           Increases the risk of urinary tract infections
 Continuous contraceptive protection for at least 5       Effectiveness
  years                                                    82 to 94 percent
 Don’t need to remember to take a daily pill or use a
  device                                                  FemCap
 May decrease menstrual cramps and heavy bleeding         Advantages
                                                           Insertion before sexual arousal
Disadvantages                                              Easy fittings
 May be expelled by the uterus; may perforate the          Inexpensive
   uterus                                                 Disadvantages
 Increases the risk for PID
                                                           Must leave in for 6 to 8 hours after intercourse
Effectiveness                                              Vaginal odor and discharge
 97 to 99 percent                                          May be uncomfortable to insert

Condom (Alone)
                                                           82 to 94 percent
 Easily obtained                                          Spermicide (Alone)
 Inexpensive                                              Advantages
 Best method for protection against STIs
 Better results when used with a spermicide                Easy to obtain and use
                                                           Good results when used with cervical caps, condoms,
Disadvantages                                                or diaphragms
 May reduce sexual sensation                               Inexpensive
 Less sexual spontaneity
                                                                                                     (continued )
64   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      Summary of Contraceptive Choices (continued )

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

OV E RV I E W                                                     • Recent use of antibiotics
Ten to twenty percent of all women have some                      • Symptoms that have lasted longer than
kind of urinary discomfort or infection at least                    seven days
once a year. Acute uncomplicated cystitis (infec-                 • Diabetes
tion of the bladder) and recurrent cystitis are two               • Immunosuppression (HIV, immunosuppres-
important categories of urinary tract infections                    sive medications)
in adults. Distinguishing between uncomplicated                 Simple, short-duration therapies may not be
and complicated urinary tract infections (UTIs)                 appropriate for these situations.
is important because they may require different                     It is reassuring that most of the acute UTIs that
evaluation tests and procedures, as well as different           occur are uncomplicated. Health-care practitioners
types and duration of treatment plans. A compli-                can generally assume that a premenopausal, sexu-
cated infection is associated with a condition that             ally active woman who is not pregnant, has not
increases the risk of urinary tract infections or is            been recently treated with antibiotics, and does
associated with an increased likelihood of treat-               not have a history of a genitourinary tract abnor-
ment failure such as HIV, diabetes, or having a                 mality has uncomplicated cystitis if she presents
catheter. An uncomplicated infection is one that                with dysuria (painful or difficult urination), fre-
lasts less than one week, is unaccompanied by a                 quent urination, or urgency. It is even likely that
fever, and presents itself in low-risk individuals,             most postmenopausal women who do not have a
such as nonpregnant, otherwise healthy women.                   genitourinary tract abnormality have uncompli-
    Symptoms of uncomplicated cystitis include                  cated UTIs.
painful and frequent urination, the urge to uri-                    A narrow spectrum of microbes are responsible
nate even though the bladder may be nearly                      for the infections in young women with acute
empty, and pressure and pain in the pelvic area.                uncomplicated cystitis: Escherichia coli (80 per-
Acute cystitis is generally uncomplicated but may               cent), Staphylococcus saprophyticus (5 to 15 per-
be complicated if the individual has a catheter or              cent), and occasionally Klebsiella species, Proteus
also has a stone in the bladder. It is not always               mirabilis, or other microorganisms. Bacteriuria
possibly to classify someone as having a compli-                (bacteria in the urine) is more common in women
cated or uncomplicated UTI based on urinary                     who are sexually active, and certain forms of con-
tract symptoms alone. However, there are factors                traception are associated with urinary tract infec-
that suggest the presence of a complicated UTI                  tions. Sexual intercourse, diaphragm use with
in women. These include:                                        spermicide, spermicides used alone, oral contracep-
                                                                tives, delayed postcoital urination, and a history of
  •   Being elderly or young                                    a recent urinary tract infection all increase the risk
  •   Having a hospital-acquired infection                      of initial and recurrent infection. Sexual inter-
  •   Pregnancy                                                 course is the strongest risk factor for UTIs, inde-
  •   Having a urinary catheter                                 pendent of contraception influences. As many as
  •   Having had a recent procedure involving                   30 percent of women with cystitis symptoms may
      urinary tract instrumentation                             have subclinical upper urinary tract involvement.
Copyright © 2008 by Tori Hudson. Click here for terms of use.
66   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

 • UTIs are most commonly caused by the organism           • Increase fluid intake.
   E. coli.                                                • Urinate when you have the urge.
 • UTIs are most common in young heterosexually            • Maintain bathroom hygiene.
   active women.                                           • Wear cotton undergarments.
 • Sexual intercourse is the strongest risk factor for     • Urinate after intercourse.
   a UTI.                                                  • Consider a different contraceptive method if you
 • Spermicides, diaphragms, and hormonal contra-             are getting recurring UTIs.
   ception all increase the risk for UTIs.                 • Drink fresh juices, especially berry juices includ-
 • Pregnant women and postmenopausal women                   ing cranberry and blueberry.
   are also at risk for UTIs due to the effect of          • Eat fermented milk products containing probi-
   hormones on the flora of the vagina, urethra,              otic bacteria.
   and bladder.                                            • Reduce dietary bladder irritants such as alcohol,
 • Common diagnostic tests include the urine                 chocolate, citrus fruits, coffee, black tea, toma-
   dipstick and the urine culture.                           toes, vinegar, and sugar.

important to realize that some women may report           quantity of liquids. Water and herbal teas related
symptoms that may sound like an infection, but            to the treatment goals are the most logical
are actually symptoms from an overactive bladder,         choices. Sixty-four ounces of liquids per day is
interstitial cystitis, or a pelvic-floor problem such as   the common recommendation. Urinating after
a cystocele or uterine prolapse. Keep in mind that        intercourse is also an important bladder hygiene
some recurrent UTIs are caused by anatomic fac-           practice that can prevent recurring UTIs.
tors such as a shorter urethra-to-anus length or              The lactobacilli species are an especially effec-
birth defects in the urinary tract.                       tive means of alternative treatment for a couple of
                                                          reasons. For one, they defend against E. coli, which
OV E RV I E W O F                                         causes the majority of urinary infections. A healthy
A LT E R NAT I V E T R E AT M E N T S                     vaginal ecology is dominated by lactobacilli
For most bladder infections, a natural approach is        species,1 bacteria that defend against both UTIs
usually very effective and the infection resolves         and infectious vaginitis. Studies have shown that
quickly without recurrence or complications. The          women who have recurrent UTIs have a prepon-
primary goals of a natural therapeutics approach          derance of uropathogens on the introitus and in
are to:                                                   the vagina.2 Lactobacilli adhere to the uroepithelial
                                                          cells and inhibit the adherence of pathogenic
 • Enhance the individual’s internal defenses
                                                          organisms such as E. coli to the cells, thereby pre-
   against the infection by providing immune
                                                          venting proliferation. In addition, the H2O2-
                                                          producing lactobacilli that are most commonly
 • Restore vaginal and bladder microflora,
                                                          found in the normal bladder flora (Lactobacillus
   enhancing the flow of urine
                                                          crispatus and Lactobacillus jensenii ) can help to
 • Promote a proper pH by acidifying the urine
                                                          keep the bladder in its preferred acidic state.3
 • Prevent bacteria from adhering to the blad-
   der lining                                             Nutrition
   Simple goals, such as increasing the urinary           Since most UTIs are caused by E. coli, and this
flow, are easily accomplished by increasing the            resides predominantly in the gastrointestinal tract,
68   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     it seems reasonable that the risk for infection                          shown that cranberries and cranberry juice are
     might be altered by dietary influences and diges-                         effective in women with active urinary tract
     tive health. In fact, the risk for infection changes                     infections.8–9 In a large randomized, controlled
     with dietary modifications.4 The dietary and                              study, 300 ml (10 ounces) of cranberry juice was
     lifestyle habits of 139 women university students                        given to 153 elderly women with confirmed bac-
     with a diagnosis of an acute UTI were compared                           teruria.10 The level of bacteria in the urine and
     with those of 185 age-matched women with no                              the frequency of recurring infections was dramat-
     UTIs in the last five years. It was found that fre-                       ically decreased. In another study, 500 ml per
     quent consumption of fresh juices, especially berry                      day (17 ounces) of cranberry juice was shown to
     juices, and fermented milk products containing                           be helpful in 73 percent of the individuals with
     probiotics was associated with a decreased risk                          active UTIs.11 In an older study, 16 ounces of
     of recurring UTIs. Consuming fermented milk                              cranberry juice daily was effective in 73 percent
     products three or more times per week was better                         of individuals with an active infection.
     than less than one time per week. In this same                               This effectiveness is commonly attributed to
     study, frequency of intercourse was associated with                      cranberry juice’s hippuric acid content, antibac-
     increased risk of UTI as well.                                           terial effect, and acidity. However, studies have
          Common probiotic-containing fermented                               shown that components in cranberry juice
     milk products include lactobacillus acidophilus                          reduce the ability of E. coli to adhere to the lining
     and kefir. Increasing garlic and onions in the diet                       of the bladder and urethra.12–15
     may also be helpful due to their antimicrobial                               Often, women prefer cranberry extracts
     activity. They have been shown to inhibit the                            instead of cranberry juice as unsweetened cran-
     growth of E. coli, Proteus, Klebsiella pneumonia,                        berry juice is unpalatable and sweetened cranberry
     Staphylococcus, and Streptococcus.5–7                                    is more challenging to the immune system. Cran-
          Other logical dietary considerations for                            berry extracts are available in capsule form and
     women with recurring infections are to avoid                             have been studied for prevention of UTIs. Cran-
     excess sugar consumption, assess and avoid food                          berry extracts were compared with cranberry juice
     allergens, and eat a diet that promotes healthy                          in a one-year randomized, controlled trial in 150
     digestive function, including complex carbohy-                           sexually active women of diverse ages.16 One tablet
     drates, high fiber, fermented dairy products, and                         was given twice daily to women in one group, and
     healthy oils such as olive oil, nuts, and seeds.                         250 ml of cranberry juice was given three times
          Large amounts of fluids are highly recom-                            per day to the other group. Both decreased the
     mended for preventing UTIs, as they literally                            number of individuals who had at least one infec-
     flush out the urinary tract and dilute the concen-                        tion per year. Antibiotics were also used less in
     tration of disease-causing bacteria. Drink approxi-                      both the extract and the juice group, compared
     mately 64 ounces (two liters) per day, including                         with the placebo group.
     16 ounces (500 ml) of unsweetened cranberry                                  Cranberry extracts are less expensive than
     juice (see section on cranberry) and 8 ounces of                         cranberry juice. Another advantage of the
     blueberry juice (250 ml) daily.                                          extracts is the concern that the oxalates in cran-
                                                                              berry juice could contribute to kidney stone
     Nutritional Supplements                                                  formation. While logical, no studies have yet
        Cranberry. No natural approach to cystitis                            demonstrated an increase in kidney stones after
     would be complete without mention of cran-                               drinking cranberry juice.
     berry. Women have used cranberry juice as a                                  Cranberry extracts can also be found in
     home remedy for decades. Several studies have                            numerous combination herbal/nutritional for-
                                                                                                       CYSTITIS      69
mulations along with uva-ursi, pipsissewa,               weekly.18 Each patient had infection-free periods
Oregon grape root, marshmallow root, buchu,              ranging from four weeks to six months.
vitamin C, and others. Cranberry is safe for preg-           Lactobacilli species are safe for pregnant and
nant and lactating women.                                lactating women.

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

 Lactobacilli Species                                     Vitamin C
 Acute infections: 24 billion organisms or more per       Acute infections: 500–2,000 mg every 2 hours for 2
   day for active treatment                                 days, then 500–2,000 mg 3 times daily for 5–10
 Chronic, recurring infections: 8–16 billion organisms      days
   per day                                                Chronic, recurring infections: 1,000–3,000 mg daily
 Prevention: 2–8 billion organisms daily                  Prevention: 500–1,000 mg daily
70   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     ale for the beneficial effects of vitamin C for both                      branes, uva-ursi is best used in combination with
     prevention and treatment of UTIs.                                        other botanicals. It is not safe for use by pregnant
          Vitamin C is likely safe for pregnant and lactat-                   women and unknown whether or not it is safe
     ing women in controlled amounts: up to 2,000 mg                          for lactating women.
     per day in women over age 19 and up to 1,800 mg
     per day for women 14 to 18.                                               Uva-Ursi

          D-Mannose. D-mannose is a naturally occur-                           Acute infections: 1–11⁄ 2 tsp tincture or 300 mg dried
     ring simple sugar contained in cranberry juice that                         herb capsule every 3 hours for 2 days, then 1–11⁄ 2
                                                                                 tsp 3 times daily for 7 days
     is helpful in treatment of UTIs. D-mannose adheres
                                                                               Chronic, recurring infections: best not to use more
     to the bladder epithelium, interfering with the abil-                       than 5 or 6 times per year; use in combination with
     ity of the E. coli to adhere21 and cause infection. It                      soothing botanicals such as marshmallow
     is likely safe for pregnant and lactating women.                          Prevention: best not to use daily for long term

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

 Sample Treatment Plans

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

 Acute UTI                                                Postmenopausal Women

   • Cranberry juice: 16 oz daily                           •   Urinate upon urge and after intercourse.
   • Increase water: 8 or more 8-oz glasses daily           •   Use condoms for intercourse.
   • Vitamin C: 2,000 mg every 2 hours for 2 days,          •   Increase fluids.
     then 2 g 3 times daily for 7–10 days                   •   Take the following supplements:
   • Combination herbal product such as cranberry,              Combination herbal product: 1–2 capsules
     Oregon grape root, bucchu, uva-ursi, pipsissewa,             daily
     marshmallow root: 2 capsules every 2 hours for 2           Cranberry extract: 400 mg twice daily
     days, then 2 capsules 3 times daily for 5–10               Cranberry juice: 8–16 oz daily
     days                                                       Oral probiotics: 8–16 billion organisms per day
                                                                Mannose: 1⁄ 2–1 tsp daily; more if needed
   • D-mannose: 1⁄ 2–1 tsp 3 times daily for 5–10
                                                                Intravaginal estriol (1 mg/g): insert 1 g twice
                                                                  daily for 2 weeks, then twice weekly as
                                                                  maintenance dose; or estriol suppositories
 Chronic, Recurring UTI (3- to 6-Month Plan)
                                                                  (1 mg): insert 1 daily for 2 weeks, then
 Premenopausal Women                                              twice weekly as maintenance dose
   •   Urinate upon urge and after intercourse.             • Consider oral hormone therapy.
   •   Use condoms for intercourse.                       With these prevention and treatment strategies, it
   •   Increase fluids.                                    will rarely be necessary to use antibiotics for
   •   Take the following supplements:                    acute, chronic, or recurring UTIs. Please consult
       Combination herbal product: 1–2 capsules daily     with your practitioners about use of these products
       Cranberry extract: 400 mg twice daily              in pregnancy and lactation or if you are taking
       Cranberry juice: 8–16 oz daily                     medications.
72   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

OV E RV I E W                                                   the unruptured follicle, rather than a result.2
Endometriosis, one of the most common yet                       Whether endometriosis causes infertility or infer-
misunderstood diseases, affects 10 to 15 percent                tility causes endometriosis, tubal scarring, adhe-
of menstruating women between the ages of                       sions, and unruptured follicles are common with
24 and 40 years. In some cases, symptoms                        women having endometriosis and infertility
begin with the onset of menstruation. In others,                problems.
symptoms begin later and progressively become                        The main risk factor for endometriosis is
worse until menopause. The triad of symptoms                    heredity. The likelihood for a woman who has a
includes dysmenorrhea (pain with menses), dys-                  first-degree relative with severe endometriosis
pareunia (pain with vaginal intercourse), and                   having endometriosis is six times higher than
infertility. Acute pain occurs before menses and                that for relatives of women without the disease.3
can last for a day or two during menses or                      Women with menstrual cycles that are shorter in
throughout the month. This pain can be a life-                  time between cycles and longer in length have
disrupting experience, affecting a woman’s social               been found to be at higher risk for endometri-
relationships, work, school, and well-being. For                osis.4 Increased or altered estrogen levels, lack of
some women, vomiting, diarrhea, and fainting                    exercise from early age, a high-fat diet, and use of
can occur along with intense labor-like pains.                  intrauterine devices have also been found to be
Other pain is described as chronic bearing-down                 risk factors. Even natural red hair color was
pain and pressure on the lower back and pelvis,                 found in one study to be a factor in the develop-
sometimes radiating down the legs. Other less                   ment of endometriosis.5
common complaints include pain with urination                        Baboons who developed endometriosis in cap-
and bowel movements and bleeding from the                       tivity were found to have higher stress levels and a
nose, bladder, and/or bowels. Endometriomas,                    decreased ability to react to stress compared to
enlarged areas of ectopic endometrial involve-                  those in the wild, suggesting a stress factor.6 Indi-
ment on the ovaries, are found in two out of                    viduals who exercised consistently from an early
three patients with endometriosis.1                             age reported a decreased risk for endometriosis,
    Early research as to the source of infertility              while those who began an exercise program later
initially led to the concept that endometriosis                 on experienced less painful periods. Although not
was a “working woman’s disease.” Women who                      all women with endometriosis have a childhood
delayed pregnancy until later in life and were                  history of abuse, a greater number of individuals
found to have endometriosis were told to “just                  with adhesions and/or endometriosis have
get pregnant.” Current research does not support                reported abuse in their history.7 Additional possi-
this concept. However, research as to altered                   ble risk factors include prenatal exposure to high
immune action within the pelvic cavity and the                  levels of estrogen and pelvic contamination with
possibility of antibody reactions to sperm has                  menstrual products, although these issues are
prompted recognition of an immunological basis                  largely theory and research is needed.
for endometriosis. Other studies suggest that                        Physical examination reveals one or more of
infertility is a cause of endometriosis, due to                 the following: tenderness of the pelvic area
Copyright © 2008 by Tori Hudson. Click here for terms of use.
76   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     and/or cul-de-sac (a deep pouch anterior to the                          uals, the implants have their own cycle, with an
     rectum, separating the uterus from the large                             ebb and flow that differ from the estrogen bind-
     intestine); enlarged or tender ovaries; a uterus                         ing during the menstrual cycle.10
     that tips backward and lacks mobility; fixed                                  Although the most commonly accepted theo-
     pelvic structures; and adhesions. Endometrial                            ries of origin today vary and sometimes seem
     tissue can be found on surgical scar tissue, in the                      contradictory, they all have their place in holistic
     vagina, and on the cervix. Physical examination                          approaches to the treatment of endometriosis.
     during the first or second day of menses high-                            The predominant theory first proposed by Dr.
     lights tender areas in the septum between the                            John Albertson Sampson in 1927 is the theory of
     rectum and vagina, most likely correlated with                           retrograde flow—that during menses, blood
     deeply infiltrating endometriosis.8                                       flows backward and becomes seeds of implants in
          An ultrasound study can determine the con-                          the pelvic cavity.11 This theory and research
     sistency of the endometriomas (areas of cystic                           showing that over 90 percent of menstruating
     endometriosis within the ovary). Evidence of                             women without endometriosis have retrograde
     endometriosis other than on the ovaries cannot                           flow have raised questions as to the biochemical
     be seen on the ultrasound. Although magnetic                             and immunological differences causing implan-
     resonance imaging (MRI) can detect endometri-                            tation within the pelvic environment.12 Endome-
     omas, cost prevents widespread use. A blood test                         trial implants from women with endometriosis
     called a CA-125 can have positive results in                             compared with normal women have been found
     endometriosis. The problem is that a high CA-                            to be biochemically different.13 Other studies
     125 cannot completely differentiate endometri-                           suggest that cells may only implant in women
     osis from uterine fibroids, cancerous growths,                            with altered cell immunity.14 As implants are
     and normal tissue. High levels of CA-125 have                            found in the nose, lungs, and other organs far
     been found in stages III and IV of endometriosis,                        from the uterus, transportation through lym-
     which are the diagnoses for more advanced endo-                          phatic channels and blood vessels has been sug-
     metriosis.9 The CA-125 test may, however, help                           gested. Still other researchers believe the implants
     in monitoring treatment and progression once                             to be of embryological origin, pieces of the uterus
     endometriosis has been confirmed. However, this                           left behind during development, which, when
     test is not used by many practitioners.                                  activated, secrete a chemical causing the nearby
          Definitive diagnosis of endometriosis can only                       capillaries to bleed.15 Research on baboons with
     be accomplished with a biopsy using either of the                        endometriosis suggests activation by environ-
     following two surgical procedures. A laparoscopy                         mental toxins that mimic estrogens.16
     is a surgical procedure in which the surgeon inserts                         Whether implants are caused by retrograde
     a scope through one of two very small pelvic inci-                       flow, decreased immune function, genetic fac-
     sions. More invasive, a laparotomy consists of                           tors, environmental influences, or embryological
     major pelvic and/or abdominal surgery.                                   development or are stimulated by high estrogen
          Endometrial implants or lesions are known to                        levels from the environment or within the body,
     have similarities to uterine tissue—featuring                            the worsening of symptoms prompts individuals
     endometrial glands, endometrial stroma, and                              to seek medical help. There is not necessarily a
     hemorrhage into adjacent tissue. Growth of this                          correlation between pain and the extent of the
     tissue may be stimulated by estrogen. Therapeu-                          disease. Women with fixed ovaries and large
     tic treatment aimed at manipulating the body’s                           endometriomas may only report mild discom-
     own level of hormones as in menopause or preg-                           fort, while those with visibly smaller lesions may
     nancy has had a positive effect. In some individ-                        report severe and chronic pain. Upon surgery,
                                                                                         ENDOMETRIOSIS        77
these lesions are found to extend more deeply;         Belgium, which also has the highest incidence of
they are possibly more influenced by circulating        severe endometriosis.27 In two studies since,
estrogens.17 Research has found that the severity      however, one in Belgium found no significantly
of symptoms is correlated with the depth of the        increased risk with dioxins or polychlorinated
lesions rather than the number of lesions.18           biphenyls,28 and in Italy, no significantly in-
    The abnormalities found in women with              creased risk of endometriosis was seen in women
endometriosis and the conditions that may pre-         who had high levels of dioxin in their blood.29
dispose them to it are complex. Some discussion,           Currently, there is no epidemiological study
however, will help guide us toward more effective      definitively linking any one class of chemicals to
management and a better understanding of treat-        the risk of endometriosis, although there appears
ment options.                                          to be some suggestion of a link with estrogen-like
                                                       compounds in the environment30 called xeno-
Genetic Factors                                        estrogens, which can disrupt estrogen and estro-
Groupings of endometriosis within families has         gen metabolism. Substances that have been
been found in clinical studies,3, 19 populations-      shown to have estrogenic effects in the body
based studies,20 and even studies of twins.21–23       include polychlorinated biphenyls (PCBs), weed
Several analyses of the locations on the genes that    killers, substances that line cans, plastics, deter-
are shared by siblings indicate abnormalities in       gents, and household cleaners.31
detoxification enzymes. This would lead to sus-             Despite this lack of identification of a defini-
ceptibilities to environmental exposures to sub-       tive link between chemical exposures and endo-
stances that could then lead to the increase in the    metriosis, we do know that women are exposed
disease. Other insights have included that the         to a multitude of chemicals in utero, in child-
genes involved are associated with tumor sup-          hood, peripubertally (the time around the
pressor genes. If these tumor suppressor genes are     appearance of secondary sex characteristics such
affected, there is susceptibility to abnormal tissue   as pubic hair), and as adults. We can identify
growth, such as the endometriosis. Aberrantly          chemicals in cosmetics, nail polish, plastics,
expressed genes can also occur during the time of      household cleaners, dry cleaning, and foods. A
implantation, which may be an explanation for          survey by the Centers for Disease Control and
some of the cases of endometriosis-associated          Prevention (the National Report on Human
infertility. Other genetic errors may occur in         Exposure to Environmental Chemicals) is cur-
multistep fashion involving both the develop-          rently underway, which monitors 145 chemicals
ment and the progression of the disease.24             in 2,500 people in the United States.32
                                                           I would assert that the roles of toxic chemicals
Environmental Factors                                  in reproductive health should not be underesti-
Information about environmental influences on           mated, and that scientific investigations that
endometriosis in humans has been gleaned by            “suggest a correlation” should be motivation
observing the negative effects of environmental        enough to reduce the toxic exposure to chemical
exposures to rhesus monkeys. Radiation exposure        estrogen-like compounds that disrupt our own
and dioxin exposure have lead to higher fre-           bodies’ hormone-receptive tissues.
quency of developing endometriosis in mon-
keys.25, 26 It would seem plausible to extend this     The Immune Connection
consideration to environmental effects on              Increasingly, we are finding evidence that a lack
women, especially when it was reported that the        of proper surveillance by the immune system in
highest dioxin pollution in the world was in           the pelvic area is the cause of endometriosis, and
78   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     alterations in other aspects of the immune system                            Numerous changes in the makeup of the
     are involved in the progression of the disease.33                        peritoneal fluid are also evident in women with
         In studies on the immunological functions of                         endometriosis. Immune cells that mediate the
     baboons with spontaneous (noninduced) endo-                              inflammatory reaction such as cytokines, macro-
     metriosis, researchers have found a correlation                          phages, T lymphocytes, and tumor necrosis factors
     between suppressed immunity and a higher                                 have all been found to be increased in concentra-
     number and greater area of lesions.34 Both types                         tion in the peritoneal fluid in women with endo-
     of immunity, cell mediated and humoral, have                             metriosis,44–46 and their increase correlates with
     been implicated in endometriosis, with immuno-                           the severity of the disease. Growth factors, angio-
     logical defects present even in the mildest forms                        genic factors (increasing blood supply to areas of
     of the disease.35 Macrophages (a kind of white                           endometriosis tissue), and lipid peroxidation in
     blood cell) that scavenge other microbes, debris,                        the peritoneal fluid may stimulate the endometrial
     and aberrant tissue are found in greater numbers                         cell growth. Targeting these proinflammatory
     in the early stages of endometriosis.36 This                             compounds and blocking their action with antiox-
     increase in macrophage activity may correlate                            idants and other compounds provide a good
     with decreased fertility and possible reaction to                        rationale for new treatment strategies, both con-
     sperm perceived by the woman’s body as for-                              ventional and with natural compounds.
     eign.37 In the peritoneal fluid (fluid aspirated                               As mentioned earlier, irregular cycles are
     from the area behind the membrane lining the                             common among women with endometriosis.
     abdominopelvic wall) of women with severe                                Anovulatory cycles (lack of ovulation), premen-
     endometriosis, natural killer cell activity has been                     strual spotting (very light bleeding before the
     found to be suppressed.38, 39 Natural killer cells                       onset of the menstrual flow), luteal phase defects
     release cell toxins and thus help keep tumor and                         (abnormal length of the second half of the men-
     other abnormal cells in check. By a decrease in                          strual cycle), and salivary progesterone secretion
     natural killer cells, the immune defense against                         are altered in women with endometriosis.47 Since
     the growth of tissue is decreased. Interestingly,                        higher estrogen levels are implicated in endome-
     studies suggest a correlation between high estra-                        triosis, it is not surprising that heavy smokers
     diol levels and decreased killer cell activity.40                        have a decreased risk for endometriosis if they
         Humoral immunity is the component of the                             began smoking earlier in life, as smoking is
     immune system that produces antibodies, more                             known to decrease estrogen levels.48 In addition,
     specifically immunoglobulins, which are pro-                              an increased body fat placement indicative of
     duced by B lymphocytes. These immunoglobu-                               increased estrogen levels was also found to be
     lins provide protection to the body by their                             correlated with a higher incidence of endometri-
     attachment to foreign substances called antigens.                        osis.49 Since estrogens are known to stimulate
     Patients with endometriosis have been found to                           endometrial implants, women on hormone
     have high levels of immunoglobulins IgG and                              replacement therapy have been known to experi-
     IgM when compared with normal controls.41                                ence a recurrence of endometriosis.50
     Higher than normal amounts of immunoglobu-
     lins cause destruction of the body’s own tissue, as                      The Role of the Liver and
     seen in autoimmune conditions. Evidence of                               the Gut in Hormone Metabolism
     high levels of autoantibodies against ovarian and                        The liver has the enormous task of breaking down
     endometrial cells is consistent with the finding of                       estrogen and secreting metabolites through the
     individuals who have both endometriosis and                              bile into the large intestine. Whether hormones
     autoimmune diseases.42, 43                                               are produced naturally within the body, are pro-
                                                                                          ENDOMETRIOSIS      79
vided through medication, or enter the body as         OV E RV I E W O F
substances from the environment that mimic             A LT E R NAT I V E T R E AT M E N T S
estrogen, optimal functioning of the liver is imper-   While analgesics, anti-inflammatories and estrogen-
ative in maintaining a healthy balance.51 Inappro-     blockers temporarily relieve symptoms, the need
priate breakdown of estrogen can result in local       for a long-term definitive treatment that involves
liver damage, continual recycling of estrogens, and    removal of the cause is imperative. A systemic
alterations in immune function. Since the liver is     approach to treatment that takes into considera-
involved in breaking down 80 to 90 percent of the      tion a multifaceted cause with long-term and
hormones in the body, it follows that optimal liver    acute symptomatic relief is the goal of alternative
function can be of benefit in treatment.                therapy. While late-stage endometriosis may
    The large intestine, which contains different      only be addressed by radical surgery, early treat-
types of microflora or gut organisms, has a unique      ment, in the form of stimulation of the body’s
role in the excretion and recycling of estrogen. The   inherent ability to heal through enhancing the
liver inactivates estrogen by attaching a bond         immune system, restoring proper inflammatory
between glucuronic acid and the estrogen molecule      responses, balancing hormones, and aiding in the
and excreting this substance with the bile. Some
“unfriendly” bacteria in the large intestine, how-      KEY CONCEPTS
ever, secrete an enzyme called beta-glucaronidase
that breaks down these bonds, releasing a strong        • A gynecological checkup is imperative with any
estrogen that is then recycled back through the           type of pelvic pain to rule out any pelvic or
body. In order to produce this enzyme, these bac-         abdominal abnormality.
teria feed on fat taken in by the body. However,        • Provide symptom relief for acute pain.
                                                        • Provide removal of cause (endocrine, immune,
the balance can be restored by greater numbers
                                                          environmental, liver).
of the “friendly” bacteria that feed on fiber
                                                        • Create a plan for treatment of the chronic
and crowd out the “unfriendly” bacteria. With a           problem.
balance of the “friendly” bacteria in the large         • Optimize nutritional intake and avoid environ-
intestine, a higher amount of inactivated estrogen        mental toxins.
metabolites leave the body through the large
intestine, preventing their reactivation and move-
ment back through the body.52                           PREVENTION
    Endometriosis is a complex disease with a
variety of interconnecting influences. Enhancing         • Eat nutritious whole foods. Include foods known
the immune system, the endocrine system, and              to reduce inflammation such as fish, curries, and
the liver’s detoxification of hormones; reducing           garlic and high amounts of fruits and vegeta-
                                                          bles, whole grains, and legumes. Reduce red
and blocking proinflammatory chemicals pro-
                                                          meat, especially grain-fed meat.
duced by the body; and providing optimal health
                                                        • Get regular exercise.
in the large intestine represent innovative and         • Avoid pesticides, chemicals, solvents, and heavy
effective approaches to the treatment of endome-          metals.
triosis. Considering the long-term consequences         • Eat organic foods.
of endometriosis—pain, disability, and disrup-          • Drink purified water.
tion in personal, family, and work activities—          • Maintain good digestion and regular bowel
innovative approaches that treat the whole body           habits.
and remove the cause promise a light at the end         • Avoid alcohol.
of the tunnel.
80   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     liver’s ability to break down environmental and                              Foods high in fiber are associated with opti-
     naturally occurring estrogen, is worthy of consid-                       mal transit time in the intestines and an optimal
     eration.                                                                 balance of friendly microorganisms within the
         Certain foods and supplements aid in enhanc-                         large intestine.56 These microorganisms, better
     ing the body’s ability to mount a natural immune                         known as gut flora, crowd out the other types of
     response. Optimal liver function involves enhanc-                        flora that play a role in metabolizing estrogen.
     ing the liver’s ability to detoxify hormones, excess                     Studies suggest that an intake of less protein and
     medicines, and toxins through two main phases,                           high fiber or a vegetarian diet lead to a decrease
     called phase I and phase II detoxification. Individ-                      of biologically active estrogens in blood plasma.54
     uals who have decreased function of the first path-                       While higher protein diets are found to provide
     way continue to recycle hormones, toxins, and                            enzymes for the detoxification pathways of estra-
     other products harmful to the body. If the second                        diol,57 vegetarian diets are of greater value due to
     detoxification pathway is dysfunctional, the meta-                        their lower fat content. Animal protein diets,
     bolic products of the first pathway build up and                          especially egg yolks, poultry, and red meat, con-
     can become even more toxic, decreasing immune                            tain large amounts of arachidonic acid, which
     response and accumulating as oxygen free radicals.                       promotes inflammatory prostaglandins and thus
     These metabolites can cause tissue injury and for-                       inflammation and pain. By enhancing your diet
     mation of adhesions.53 Healthy elimination of                            with vegetable protein, soy, almond and other
     these metabolites assures that the body doesn’t get                      nut butters, and salmon, you tip the inflamma-
     a chance to reabsorb them.                                               tory pathway toward anti-inflammatory pro-
         Nutrition, exercise, and healthy lifestyle prac-                     staglandins that inhibit tumor growth—and
     tices play a preventive role in providing immune                         possibly endometrial growth. Interestingly, a
     support and a healthy body’s response to added                           recent study in Japan demonstrated that moder-
     stressors and imbalances of hormones. Women                              ate isoflavone intake from soy was significantly
     who exercise and eat less fat and sugar produce less                     associated with a decreased risk of premeno-
     estrogen. Vegetarian women excrete two to three                          pausal hysterectomy. This data led the authors to
     times more estrogen in their feces and have half as                      conclude that moderate soy intake may decrease
     much estrogen in their blood as meat-eaters.54                           the risk for diseases like endometriosis, which
     Additional approaches in the area of mind-body                           commonly precipitate premenopausal hysterec-
     medicine recognize that belief systems and emo-                          tomies.58 Another study of 50 women with endo-
     tional health affect optimal physical health.                            metriosis examined the effect of dietary changes,
                                                                              specifically the reduction of glycemic carbohy-
     Nutrition                                                                drates, the addition of omega-3 and omega-9
     The goods news is that there are numerous nutri-                         fatty acids, and the elimination of foods with
     tional influences related to endometriosis. This                          caffeine and tyramine, and found a significant
     means we can take an active part in prevention                           reduction in symptoms after eight weeks.59
     and management of the condition.                                             By increasing intake of vegetables, specifically
         A recent retrospective study of over 500                             those that enhance liver function, the buildup of
     women with endometriosis concluded that there                            toxins and metabolites that produce cell damage
     was a significant decrease in risk of developing                          is prevented. Liver-friendly foods to increase are
     endometriosis with a greater consumption of                              carrots, kale, and the cabbage family vegetables
     green vegetables and fresh fruit, and an increase                        due to their known help in phase II of the liver’s
     in risk was associated with high intake of beef                          detoxification pathway. Indole-3-carbinol (I3C),
     and other red meat.55                                                    found in broccoli, brussels sprouts, cabbage, and
                                                                                           ENDOMETRIOSIS       81
cauliflower, favors the less active form of estro-        Dietary Recommendations
gen.60 Other liver-cleansing foods include beets,
carrots, artichokes, lemons, dandelion greens,             • Eat a high-fiber diet.
watercress, and burdock root. Onions, garlic, and          • Eat a high-protein vegetarian diet.
leeks contain organosulfur compounds that                  • Increase intake of vegetables, nuts, and seeds.
                                                           • Use turmeric, ginger, milk thistle, and
enhance the immune system and induce enzymes
that detoxify the liver. In addition, they contain
                                                           • Omit or decrease alcohol, dairy, red meat,
the bioflavonoid quercitin, which is known to                 sugar, and caffeine.
stimulate the immune response, protect against             • Eat cold water fish (salmon, tuna, sardines,
oxidation, block the inflammatory response, and               mackerel, herring) 2 or 3 times per week.
inhibit tumor growth.61 By eating as many of your          • Eat organic foods.
vegetables as possible in an organic form, you cut
down on your intake of pesticides that may also
mimic estrogen.                                         pathway to be tipped toward prostaglandins and
    Use seasonings such as turmeric (curcumin)          leukotrienes that cause inflammation, smooth
that protect against environmental carcinogens,         muscle contraction, and vascular constriction.
decrease inflammation, and increase bile secretion.      Alcohol use depletes stores of B vitamins in the
Ginger is helpful with many types of inflamma-           liver and also has estrogenic effects on the body.
tion—and helps with liver detoxification. Adding a
                                                        Nutritional Supplements
tablespoon of soaked and ground milk thistle seeds
each day can also help with liver function. Grind a     Before beginning the discussion on nutritional
tablespoon of fresh flaxseeds and place on cereals or    supplements, it is important to explain the con-
salads. The increase in lignans from these seeds aids   cepts of free radicals, antioxidants, and free radi-
in providing fiber as well as an oil that helps in the   cal scavengers. There are several ways to define a
anti-inflammatory pathway. Seasoning with fucus          free radical, but a definition I like is, “an atom or
(a seaweed) helps stimulate T cell production and       group of atoms that has at least one unpaired
absorb toxins.62                                        electron and is therefore unstable and highly
    Foods to omit or decrease include sugar,            reactive.” Antioxidants such as vitamins C and E,
caffeine, egg yolks, poultry, red meat, and alco-       selenium, carotenes, and others are molecules
hol. Sugar is known to increase estrogen levels         that defend the body from cellular damage by
in men; presumably the effect is similar in             ending the free radical chain reaction before vital
women.63 Endometriosis is found to be corre-            molecules are harmed. These are often referred to
lated with caffeine consumption. Women con-             as “free radical scavengers.”
suming 5,000 to 7,000 mg of caffeine per month              Vitamin C. Studies using vitamin C show
had a 1.2 times greater incidence of endometri-         increase in cellular immunity and decreases in
osis, while those consuming over 7,000 mg per
month had a 1.6 times increase.64 One cup of
coffee contains 120 mg of caffeine; one cup              Vitamin C
of black tea contains 60 mg; one cup of decaf-           Take 6–10 g in divided doses daily, starting with
feinated contains about 2 mg of caffeine.                1,000 mg a day, then add 1,000 mg every 4 or 5 days
    The Environmental Protection Agency esti-            until the stools become loose. At this point, back
mates that 90 percent of human dioxin exposure is        down to the previous dose of vitamin C so that the
through food, primarily meat and dairy prod-             stools are normal in consistency.
ucts.65 Egg yolks, meat, and poultry cause the lipid
82   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     autoimmune progression and fatigue.66 In addi-                           haps through the inhibition of the arachidonic
     tion, vitamin C enhances immunity and decreases                          lipid pathway. Inhibiting the arachidonic path-
     capillary fragility and tumor growth, all of which                       way helps prevent the release of chemicals that
     are involved at various levels in endometriosis.                         would normally cause edema, inflammation, and
     Studies on autoimmune progression indicate the                           smooth muscle contraction.
     effectiveness of high levels of vitamin C.67
                                                                               Vitamin E
         Beta-Carotene. Beta-carotene helps enhance
                                                                               400–800 IU daily
     immunity. Recent research shows that retinoids
     can help decrease IL-6, an inflammatory media-
     tor, which has been implicated in endometri-                                 Essential Fatty Acids. Gamma-linolenic acid
     osis.68 In addition, studies show that use of                            (borage, black currant, and evening primrose oils)
     beta-carotene increased T cell levels after seven                        and alpha-linolenic acid (flaxseed, canola, pump-
     days.69 Beta-carotene was also shown to be pro-                          kin seed, soy, and walnut oils) help decrease the
     tective against early stages of tumor growth.70                          inflammatory response on the tissue level through
     Impairment of phagocytosis (the engulfing of                              pathways that produce prostaglandins in the body.
     microorganisms, other cells, and foreign particles                       Depending on one of three main pathways of
     by white blood cells) is seen in vitamin A–                              prostaglandin production, the effects can be help-
     deficient states.71 Although vitamin A was used in                        ful or harmful to the body. Animal fats produce a
     this study, one-third of beta-carotene is converted                      pathway of prostaglandin products that increase
     to the active form of vitamin A, retinol. Additional                     inflammation, muscle constriction, and edema.
     studies suggest that immune function is due to                           However, gamma-linolenic acid and alpha-
     carotenoids rather than vitamin A.72                                     linolenic acid produce the opposite effects. These
                                                                              fatty acids taken in supplemental form can pro-
      Beta-Carotene                                                           duce the prostaglandins that are involved in
      50,000–150,000 IU daily
                                                                              inhibiting tumor growth, dilating smooth muscle,
                                                                              and decreasing inflammation.77 Since endometri-
                                                                              osis tissue, called implants, are thought to secrete
         Vitamin E. Recent research demonstrates
                                                                              chemicals that cause leakage from nearby capillary
     that free radicals may contribute to the inflam-
                                                                              beds, decreasing the permeability of these vessels
     mation and excessive growth of endometrial
                                                                              could help control the tissue destruction and
     tissue seen in endometriosis, and in these circum-
                                                                              adhesions, decreasing irritation in the pelvis.
     stances, antioxidants such as vitamin E and
                                                                              Recent research demonstrates that having a higher
     N-acetyl cysteine can act to inhibit this abnormal
                                                                              omega-3 to omega-6 fatty acid ratio may have a
     proliferation.73, 74
                                                                              suppressive effect on the in vitro survival of
         Vitamin E also helps to correct abnormal
                                                                              endometrial cells, leading the authors to conclude
     progesterone/estradiol ratios in patients with
                                                                              that omega-3 fatty acids may be useful in the man-
     mammary dysplasia (increased growth of cells).75
                                                                              agement of endometriosis by decreasing inflam-
     Since parallels have been found between abnor-
     mal tumor growth in cancer and abnormal                                   Essential Fatty Acids
     growth of lesions in endometriosis, vitamin E
                                                                               Eicosapentaenoic acid: 1,080 mg daily
     supplementation may be advantageous. While                                Docahexaenoic acid: 720 mg daily
     secondary dysmenorrhea is usually involved with                           Alpha-linolenic or gamma-linolenic acid: 300 mg
     endometriosis, studies on the use of vitamin E                              daily
     with primary dysmenorrhea76 show benefit per-
                                                                                       ENDOMETRIOSIS        83
mation.78 In an animal model, fish oils were found     Japanese herbal formulas of peony and licorice
to decrease prostaglandin production and inhibit      (Shakuyaku-kanzo-to) and peony and dong quai
the growth of endometrial implants.79                 (Toki-shakuyaku-san) was found to decrease
                                                      endometrial pain in all patients studied and was
    B Vitamins. B vitamins help the liver to inac-
                                                      even reported to promote ovulation.84 Another
tivate estrogen. Studies suggest that supplemen-
                                                      study reported both hormonal and inflammatory
tation of B vitamins may cause the liver to
                                                      modulation that led to decreased volume of
become more efficient in processing estrogen.80
                                                      endometrial implants in an animal model of
 B Vitamins                                           endometriosis through the use of Tripterygium
                                                      wilfordii, another Chinese herb.85
 50–100 mg B-vitamin complex; B6 should not exceed
  200 mg daily                                           Traditional Herbal Therapies
                                                          Chaste Tree ( Vitex Agnus Castus). Chaste
    Selenium. Selenium aids in the synthesis of
                                                      tree has traditionally been used as a treatment for
antioxidant enzymes responsible for detoxifica-
                                                      hormone imbalances in women. Through action
tion reactions within the liver. In addition, sele-
                                                      on the pituitary gland, chaste tree has a proges-
nium stimulates white blood cells and thymus
                                                      terone effect by increasing luteinizing hormone
function.81 Individuals with decreased selenium
                                                      (LH). Useful for fibroids, premenstrual syn-
levels have suboptimal cell-mediated immunity,
                                                      drome, perimenopause, and various menstrual
decreased numbers of T cells, and associated
                                                      cycle disorders, it also has an indication in endo-
                                                      metriosis, perhaps because less estrogen is avail-
 Selenium                                             able to stimulate endometrial tissue.86
 200–400 mcg daily                                        Dandelion Root (Taraxacum Officinale).
                                                      Dandelion root is one of nature’s most detoxify-
                                                      ing herbs. It works principally on the liver and
    Lipotropics. Lipotropics aid in promoting
                                                      gallbladder to help remove waste products. By
liver function and detoxification reactions. Sup-
                                                      supporting the liver, excessive estrogens and
plements that contain choline (a B vitamin),
                                                      toxins can be deactivated. Researchers in Japan
betaine, and methionine promote the flow of fat
                                                      have found a link between dandelion and antitu-
and bile (containing estrogen metabolites) from
                                                      mor activity.87 In addition, dandelion leaf con-
the liver out through the large intestine.83
                                                      tains vitamins A, C, and K and calcium, as well
 Lipotropics                                          as choline, a lipotropic substance.
 1,000 mg choline and 1,000 mg methionine or cys-         Prickly Ash ( Xanthoxylum Americanum).
   teine 3 times a day                                Prickly ash is known for its specific action on
                                                      capillary engorgement and sluggish circulation.
                                                      Through its stimulation of blood flow through-
Botanicals                                            out the body, prickly ash helps enhance the trans-
   Herbal Medicines for Pain Relief. The              port of oxygen and nutrients and the removal of
herbs appropriate for acute pain relief in endo-      cellular waste products. For women with pelvic
metriosis are the same herbs used for menstrual       congestion, this herb enhances circulation
cramps. Valerian, crampbark, black cohosh, and        throughout the pelvis.
other helpful herbs are discussed in Chapter 13.          Motherwort ( Leonurus Cardiaca). Mother-
A recent study of a cyclic administration of two      wort is antispasmodic and gently soothes the
84   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     nerves. As women with endometriosis generally                            similarities of cancer to cell growth found in the
     experience uterine cramps and pain, motherwort                           pelvis. This formula contains monkshood (Aconite
     is useful in promoting relaxation during times of                        napellus), yellow jessamine (Gelsemium semper-
     extreme “bearing-down” pain in the uterus and                            virens), bryony (Bryonia alba), and poke root (Phy-
     other regions.88 As a mild sedative, motherwort                          tolacca americana). Monkshood and yellow
     helps with the needed rest during menstrual                              jessamine contain alkaloids that have been known
     cramps.                                                                  to disrupt the assembly of microtubules that even-
                                                                              tually help in the formation of cells that differen-
      Herbal Tincture for Chronic Treatment                                   tiate and give rise to connective tissues, blood,
      Chaste tree, dandelion, prickly ash, motherwort combi-                  lymphatics, bone, and cartilage. Quite possibly,
       nation: 1⁄ 2 tsp 3 times daily for 3 months                            these herbal alkaloids interfere with the induction
                                                                              of abnormal ectopic lesions within the pelvis (con-
         Turska’s Formula. Turska’s formula is a                              sistent with the theory of cells left behind in
     favorite old naturopathic treatment for decreasing                       embryonic development). Bryonia is also known
     aberrant cancer cell growth. A tincture of this for-                     to provide antitumor effects. Poke root contains
     mula is useful in treating endometriosis due to the                      glycoproteins known to stimulate lymphocyte

      Sample Treatment Plan for Endometriosis

      Nutrition                                                                  • Lipotropics: 2–4 capsules
                                                                                 • Flax oil, evening primrose oil, or borage oil:
         • Increase the following in your diet:
                                                                                   2 to 4 capsules per day
             Vegetables (especially cauliflower, brussels
               sprouts, and carrots)                                           Botanicals
             Protein (tofu, beans, salmon, soy nuts, and small
               amounts of turkey and chicken)                                    • Acute tincture:
             Fiber (whole-grain breads, rice, raw vegetables,                       Black cohosh: 1 oz
               and flaxseed)                                                         Wild yam: 1 oz
             Omega-3 oils (especially cold water fish: salmon,                       Cramp bark: 1 oz
               tuna, sardines, mackerel, and herring)                               Valerian: 1 oz
                                                                                    1⁄ 2–1 tsp every 2–4 hours for acute pelvic pain
         • Decrease or eliminate the following:
             All saturated animal fats                                           • Chronic tincture:
             All foods containing sugar, caffeine, chocolate, or                    Chaste tree: 1 oz
               alcohol                                                              Dandelion: 1 oz
         • Avoid pesticides and heating food in plastic                             Prickly ash: 1 oz
           containers.                                                              Motherwort: 1 oz
                                                                                    1⁄ 2 tsp 3 times a day
         • Drink purified water.
                                                                                 • Turska’s formula: 5 drops 3 times daily
      Daily Supplements                                                          • Progesterone cream:
         •   Vitamin C: 6–10 g                                                      Option 1: days 1–6, no cream; days 7–26,
                                                                                      1⁄4–1⁄ 2 tsp twice a day
         •   Vitamin E: 400–800 IU
         •   Fish oils: 1,080 mg EPA and 720 mg DHA                                 Option 2: days 1–14, no cream; days 15–26,
                                                                                      1⁄4–1⁄ 2 tsp twice a day
         •   Beta-carotene: 50,000–150,000 IU
                                                                                    Option 3: days 1–20, no cream; days 21–27,
         •   Selenium: 200–400 mcg                                                    1⁄4–1⁄ 2 tsp twice a day
                                                                                         ENDOMETRIOSIS       85
transformation for immune enhancement. Poke             ultrasound or CAT scan, laparoscopy (a surgical
root also has anti-inflammatory properties. Due to       procedure to view the interior of the abdomen
its potential toxicity, however, this tincture can be   and pelvis) remains the standard for diagnosis.
provided only by a licensed health professional.        Studies have repeatedly shown that 78 to 82 per-
                                                        cent of women with chronic pelvic pain of more
 Turska’s Formula                                       than six months’ duration that does not respond
 5 drops 3 times daily                                  to nonsteroidal anti-inflammatories or oral con-
 See Resources section for sources.                     traceptives have endometriosis. A recent develop-
                                                        ment in the treatment of endometriosis is
                                                        treatment of presumptive disease without laparo-
                                                        scopic proof. Some physicians now offer this
Natural Progesterone                                    option, and if no response is seen in six months,
Progesterone has been known to modify the               they then proceed with laparoscopy.
action of estradiol by decreasing the retention of          Often, women with chronic painful periods
receptors, causing a fall in serum estradiol levels.    or pelvic pain are initially treated with non-
Women without enough progesterone are unable            steroidal anti-inflammatory medication such as
to balance out estrogen, leading to problems            ibuprofen, naproxen, or meclofenamate. As
that result from a relative excess of estrogen. In      symptoms progress, patients usually resort to
addition, progesterone has the effect of sedating       prescription analgesics and/or hormones. Since
painful uterine contractions. Chapter 13 dis-           estrogen is known to stimulate the growth of
cusses in more detail how progesterone inhibits         endometriosis, treatment is aimed at suppression
uterine contractions and reduces pain. It is possi-     of estrogen synthesis. By achieving states of
ble that this uterine sedative effect extends to        pseudopregnancy (through birth control pills) or
pain relief in the pelvic region in general. I have     pseudomenopause (through cessation of the
not used natural progesterone alone as a treat-         body’s own production of estrogen and proges-
ment for endometriosis, but it has been my              terone), women have found significant symptom
observation that progesterone is an important           relief. Benefit from birth control pills is thought
part of a comprehensive treatment plan.                 to be due to reduced menstrual bleeding, anovu-
    Natural progesterone creams can be applied          lation, and lesion regression. However, stimula-
in various regimens. For some women I recom-            tion of a lesion does occur, possibly due to a
mend 1⁄4 teaspoon two times a day for three             decrease in concentration of progesterone recep-
weeks on and the week of menses off, or apply           tor sites and lesions.
twice daily from day 15 of the cycle to day 26.             In the past, danazol was regarded as a highly
Other women just need to use it the week before         effective drug because of its suppression of the
their menses is due. Still other cases require          pituitary and inhibition of estrogen and adrenal
higher doses of natural oral micronized proges-         hormone production. Relief quite possibly is due
terone in a cyclic dosing pattern.                      to reduction of endometriosis associated with
                                                        autoimmune abnormalities. However, male pat-
C O N V E N T I O NA L                                  tern hair growth, irreversible low voice, hot
M E D I C I N E A P P R OAC H                           flashes, depression, weight gain, acne, reduced
Conventional medical treatment for endometri-           breast size, muscle cramps, fatigue, and other
osis usually involves diagnosis plus medical or         symptoms related to the medication have caused
surgical treatment. Because one cannot feel             danazol to become a less popular alternative, and
endometriosis most of the time or detect it by          it has mostly fallen out of use.
86   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         Prescription drugs called gonadotropin-                              tion, laparoscopy allows for a shorter recuperation
     releasing hormone agonists (GnRH agonists),                              time when compared to a laparotomy. During a
     such as Lupron, Synarel, and goserelin, are used to                      laparotomy, the surgeon makes a larger incision in
     produce a menopausal state. Upon stimulation of                          the abdomen, allowing for larger endometriomas
     the receptors of the brain by these hormones, a                          or adhesions to be excised.
     decrease in production of LH (luteinizing hor-                               Surgery has produced cure for some individ-
     mone) and FSH (follicle-stimulating hormone)                             uals, while it has proved to be disappointing
     is achieved and causes the individual to have a                          to others. Whether laparotomy or laparoscopy,
     low estrogen state. This causes dramatic relief                          surgical treatment varies as to type of surgery,
     of symptoms within two to three months. Side                             technique, and surgeon experience. Conservative
     effects due to low estrogen, similar to those                            surgery removes superficial endometriosis lesions
     accompanying natural menopause (insomnia,                                and/or endometriomas while leaving the uterus
     hot flashes, vaginal dryness, and osteoporosis) do                        and ovaries intact. Recurrence rates vary from 5
     occur. Current add-back therapy with low-dose                            to 20 percent per year, with a rate of 40 percent
     estrogen or a progestin reduces symptoms                                 after five years. Differences in recurrence rates
     without reducing effectiveness. Higher doses of                          with surgery may be due to the method of endo-
     hormone therapy such as oral contraceptives                              metriosis implant removal and the skill of the
     may make the lesions grow, so very low doses of                          surgeon. Laser surgery is able to penetrate deeply,
     hormones are recommended. After the GnRH                                 but without the possibility of biopsy (proving
     agonist is discontinued, recurrence of endometri-                        endometriosis), while excision by electrocautery,
     osis frequently occurs, so ovarian suppression                           which allows for meticulous biopsy, takes time
     regimens like oral contraceptives or Depo-                               and additional effort. The knowledge and experi-
     Provera injections are commonly used following                           ence of the surgeon are important in the identifi-
     GnRH therapy.                                                            cation of the implants, since color, consistency,
         Treatment with progestins helps endometrial                          appearance, and location of the implants can be
     tissue to atrophy. However, side effects include                         variable. In addition, some surgeons remove the
     nausea, weight gain, fluid retention, breakthrough                        clear peritoneal covering, as they believe that
     bleeding, and sometimes depression.                                      endometrial implants reside in this tissue.
         Combinations of estrogen and progestin such                              The disease frequently recurs unless a woman
     as those found in low-dose birth control pills sup-                      has had a hysterectomy with bilateral salpingo-
     press FSH and LH. Mild-to-moderate pain relief is                        oophorectomy (removal of uterus and both
     achieved because the body’s own estrogen produc-                         ovaries and fallopian tubes). Aggressive surgery
     tion is decreased. In addition, since the volume of                      consists of removing implants, ovaries, and
     menstrual flow is also decreased, less blood is theo-                     uterus, and sometimes, even more aggressive sur-
     retically available for reflux into the pelvic cavity.                    gery involves removing the peritoneum as well.
         Current research shows promising results in                          While surgery removes implants that adhere to
     the use of the antiprogesterone Ru-486 due to                            the ovaries, uterus, and other pelvic organs, the
     the regression of endometriosis and possible min-                        effects of ovary removal and the resulting abrupt
     imal side effects. Clinical trials are underway. Use                     cessation of hormone production have to be
     of medications that enhance the immune system                            taken into consideration. While beneficial for
     are also being studied.                                                  some individuals, medical or surgical manage-
         Laparoscopic surgery has the advantage of                            ment is not effective in all circumstances.
     extensive use of microscopic imaging so that sur-                            Physicians have seen an increase in endo-
     geons can view lesions in greater detail. In addi-                       metrioid cancer in endometriosis implants. And
                                                                                        ENDOMETRIOSIS        87
endometriosis can grow into bowels or cause            lower back pain; or pain with urination, bowel
bowel obstruction or fistulas. Therefore, finding        movements, and vaginal intercourse should be
a health-care provider who is very experienced         brought to the attention of your health-care
with endometriosis treatment is very important.        practitioner, who will listen to your symptoms,
                                                       take a medical history, and do a pelvic exam. This
S E E I N G A L I C E N S E D P R I M A RY             physical exam is valuable in determining whether
H E A LT H - CA R E P R AC T I T I O N E R             there are masses, areas of sensitivity, or abnormal
( N . D. , M . D. , D. O . , N . P. , P. A . )         findings suggestive of endometriosis. Depending
As with any pain of unknown origin, a licensed         on the exam, an ultrasound, MRI, and/or blood
primary health-care practitioner should be con-        work may be recommended. In addition,
sulted to rule out other causes of pain before         depending on these results, further recommenda-
extensive use of analgesic medications, botanical      tions may be made (such as a laparoscopy that
formulas, or supplements. The cultural bias that       can diagnose and potentially treat the endometri-
menstrual periods are supposed to be painful—as        osis at the same time).
well as a reluctance to seek help due to past abuse,       If you are reluctant to seek out help due to
trauma, or fear—can be a detriment to healing.         past trauma or just a feeling of discomfort, it is
Although the norm is changing, in the past many        essential that you find a health-care practitioner
women with endometriosis were told that the            you can trust. Have a friend (or even therapist)
pain was “in their head” or psychosomatic. An          come with you to the office and even to the
increased understanding of the pain, pattern of        exam room to hold your hand, ask questions,
symptoms, and loss of quality of life for those who    and be there for you. Since the key to prevention
experience endometriosis has drawn attention and       of further pain is early diagnosis, prompt med-
research to this disruptive problem.                   ical intervention can lead to more effective assis-
    Abnormal bleeding, pain that increases in          tance in supporting your body’s own ability to
intensity, continued pain with or without menses;      heal itself.
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                           FIBROCYSTIC BREASTS                                                      CHAPTER

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

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90   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     Nondominant Masses                                                       Dominant Masses
     Even densities that are not symmetrical are                              These outright noncyclical unilateral lesions are
     largely due to benign nonprogressive causes, but                         clearly distinct on all sides from the surrounding
     they do require careful distinction from domi-                           breast tissue. They persist over time, and except
     nant masses. When careful palpation around the                           in the very young demand some kind of assess-
     edges of a nonsymmetrical lump reveals that the                          ment. Most commonly they are either fibroade-
     density merges in one or more places with the                            nomas or gross (obvious) cysts. A fibroadenoma
     surrounding breast tissue, it is considered non-                         is a rubbery, smooth, benign fibrous tumor
     dominant and may be comfortably observed for                             common in younger women. In women under
     change over time. When these lesions are biop-                           age 25, it can be observed over time. Fibroadeno-
     sied or, preferably, a sample of cells is taken in the                   mas generally do not grow bigger. Large cysts are
     office using a needle to be looked at microscopi-                         more common in women aged 25 to 50—an age
     cally (fine-needle aspiration), some 70 percent                           group when cancer just begins to appear. They
     will show nonproliferative changes (adenosis,                            are softer, usually squishier, and can be made to
     fibrosis, microcysts, mild hyperplasia, and more);                        disappear by draining them through a needle in
     some 20 percent will show proliferative changes                          the office; unless they recur frequently, no further
     without atypia—mostly epithelial hyperplasia.                            treatment is necessary. Recurrent large cysts have
     None of these conditions places one at increased                         been shown to slightly increase cancer risk in
     risk for cancer, and all are self-limited. Only a                        some studies but not in others;3, 4 fibroadenomas
     fraction, roughly the 5 percent that show atypi-                         do not. Unfortunately, noncyclical unilateral
     cal hyperplasia, carry a significantly increased risk                     dominant masses can sometimes be cancerous.
     of breast cancer (relative risk at 4 percent), espe-
     cially when coupled with a positive family his-                          OV E RV I E W O F
     tory (relative risk at 9 percent).2 It was this tiny                     A LT E R NAT I V E T R E AT M E N T S
     subgroup that led to the original cancer scare                           Women with fibrocystic tissue causing breast pain,
     attached to fibrocystic breasts.                                          discomfort, and lumpiness will find comfort in an
         The most useful tool a woman can bring to                            alternative perspective on their situation. Given
     her own breast health is her knowledge of and                            that this condition is not really a disease, a woman
     familiarity with the architecture of her own                             can direct her energies toward relieving symptoms
     breasts, particularly as it varies over time. Noth-                      and optimizing breast health, as well as increasing
     ing is more helpful in avoiding an unnecessary                           her motivation toward general health practices
     biopsy than a self-knowledgeable woman who                               and self-care.
     has observed the monthly variation in her own
     breasts and knows which tissue thickens cycli-                            KEY CONCEPTS
     cally. Think of the self-exam as a familiarization
                                                                               • Practice monthly breast self-exams; know your
     process, not a diagnostic one. The majority of
                                                                                 breasts; be able to detect new and unusual
     breast cancer occurs in women over age 60, and
                                                                                 changes, thickenings, and lumps.
     most women don’t get breast cancer at all. We all                         • Have a yearly breast exam by a licensed
     have plenty of time to learn our textures so that                           physician.
     our own hands are the most sensitive to any                               • Relieve symptoms of pain and tenderness.
     changes that may occur. This will occur effort-                           • Have changes, if any, evaluated by a physician.
     lessly over time with regular self-exams.
                                                                                       FIBROCYSTIC BREASTS          91
    The liver is the primary site for estrogen clear-      PREVENTION
ance or estrogen metabolism. Compromised liver
function can lead to a state of estrogen domi-             • Avoid caffeine (black tea, coffee, decaffeinated
nance, contributing to texture and density changes           coffee, cola, chocolate, and medications with
in the breast. To assure that estrogens are being            caffeine). Even decaffeinated coffee has other
metabolized properly, it may be necessary to pro-            methylxanthines, caffeine-like chemical
vide nutritional and herbal support for the liver.           compounds.
                                                           • Assure regular, daily bowel movements.
    Digestion and elimination are fundamental fac-
                                                           • Eat a diet high in fruits, vegetables, soy foods,
tors involved in hormone-related health problems.
                                                             and whole grains.
Women having fewer than three bowel movements              • Decrease dietary fats, especially saturated fats.
per week have a risk of fibrocystic breasts four to
five times greater than women having at least one
movement per day.5 The longer it takes food to            breast activity on scintigraphy; and a significant
move through the colon, the more waste products           reduction in the variability of tissue activity.7
pass into the bloodstream, creating a potentially         Maybe somewhat surprisingly, another study
toxic physiological environment. Bacterial flora in        showed a decrease in benign breast changes with
the large intestine, such as Lactobacillus acidophilus,   alcohol consumption.8 Since alcohol slows down
improve the transit time of bowel toxins, as well as      the metabolism of estrogen, it is not clear why this
improving the excretion and detoxification of estro-       study demonstrated these results.
gens. Women on a vegetarian diet excrete two to               Avoid Methylxanthines (Caffeine). Removal
three times more detoxified estrogens than women           of caffeine from the diet, an idea that originated
on an omnivorous diet.                                    with Ohio surgeon Dr. John Minton, is probably
                                                          the most well-known alternative treatment for
Nutrition                                                 fibrocystic breasts. Of the 20 uncomfortable
Epidemiological evidence supports a diet rich in          women who followed his advice to stop all caffeine
whole fruits and vegetables in the prevention of          intake, 13 said their breasts felt better as a result.9
fibrocystic breast conditions. A recent study                  Dr. Virginia Ernster conducted the first ran-
demonstrated that a reduced risk of proliferative         domized study of a larger number of women, in
and atypical breast lesions was associated with           which for four months 158 women eliminated
consumption of fresh fruits and vegetables,               caffeine (coffee, tea, cola, and chocolate) from
whereas a small but significant reduction of risk          their diets as well as caffeinated medications
was associated with soy consumption, possibly by          (theophylline and theobromine). She found a
decreasing cellular proliferation in the breast           significant reduction in clinically palpable breast
tissue.6 Another study examined the effect soy            findings in the abstaining group compared with
consumption has on breast tissue via direct imag-         the control group, although the absolute change
ing using breast enhanced scintigraphy (a nuclear         in the breast lumps was quite minor and consid-
medicine diagnostic imaging test). After one year         ered to be of little clinical significance.10
of daily soy consumption, the researchers reported            Several other studies have been done, leaving
a number of promising subjective and objective            us with mixed reports: three studies show no
results: patients and their physicians reported a         association between caffeine or other methylxan-
reduction in both breast tenderness and fibrocys-          thines and benign breast disease,11–13 and two
tic changes; a small but statistically nonsignificant      studies show a correlation with caffeine con-
decrease in both the average and maximal count            sumption.14, 15 Such is the way of science.
92   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      Caffeine Content of Common Items                                         Dietary Recommendations

      Beverage                                 Caffeine (mg)                     • Avoid caffeine.
      Coffee, drip (8 oz)                             150                        • Decrease dietary fat to 20 percent of calories.
      Coffee, perk (8 oz)                          60–120                        • Increase dietary fiber (whole grains, legumes,
      Coffee, instant (8 oz)                           70                          fruits, and vegetables).
      Coffee, decaffeinated (8 oz)                    2–5                        • Increase seafood and seaweed.
      Tea, black, 5-minute steep (8 oz)            60–100                        • Increase soy foods.
      Tea, green (8 oz)                                20
      Hot cocoa (5 oz)                               2–10
                                                                              ing the actual breast swelling and nodularity in
      Coca-Cola (12 oz)                                34
                                                                              some women.16 Reducing the dietary fat intake
      Food                                     Caffeine (mg)                  to 20 percent of total calories results in signifi-
      Milk chocolate (1 oz)                          1–15                     cant decreases in circulating estrogens in women
      Bittersweet chocolate (1 oz)                   5–35                     with benign breast disease.17
      Chocolate cake (1 slice)                      20–30                          Since fibrocystic breasts are a result of estro-
      Over-the-Counter Drugs                   Caffeine (mg)                  gen dominance, it is logical that decreasing estro-
      Anacin, Empirin, or Midol (2)                     64                    gen in the body or its influence on breast tissue
      Excedrin (2)                                     130                    would improve the symptoms of breast pain and
      NoDoz (2)                                        200                    swelling. However, a slight reduction in fat
      Aqua-Ban (2)                                     200                    intake has repeatedly showed very little, if any,
      Dexatrim (1)                                     200                    effect on breast problems, including breast
                                                                              cancer. A more rigorous approach to lowering the
                                                                              amount of fat in the diet is clearly needed.
         In clinical practice, I always recommend
                                                                                   The simplest way to accomplish the necessary
     avoiding caffeine for women with painful/lumpy
                                                                              levels of fat reduction is to avoid animal fats in all
     breasts. Many women gain mild to dramatic
                                                                              forms; a vegan diet (vegetarian, without any
     results with this simple approach, and some
                                                                              animal products at all, including dairy or eggs) is
     women receive no benefit. A fair experiment
                                                                              naturally a very low-fat diet. Of course, vegetari-
     would be to completely abstain for three months
                                                                              ans, and even strict vegans, can succumb to fat in
     and observe any changes in the pain, swelling,
                                                                              other forms like french fries, potato chips, and
     and discomfort. A decrease in the nodularity will
                                                                              other greasy fried foods. A vegan diet rich in whole
     generally take longer, as long as eight months of
                                                                              grains, legumes, fruits, vegetables, seeds, nuts,
     complete abstention.
                                                                              olives, and seaweed that is enriched with oils for
         Dietary Fat. How dietary fat affects the                             stir-frying and in salad dressings results in a diet
     human breast is still controversial, although some                       that derives about 15 to 20 percent of its calories
     research has looked at low-fat diets in women                            from fat.
     with fibrocystic breasts and at how low-fat diets
     affect the hormone levels in these women.                                Nutritional Supplements
     Reducing the fat content of the diet to 16 per-                              Vitamin E. For more than 35 years, clinicians
     cent of total calories (in contrast to the average                       have used vitamin E in the medical management
     American diet of 40 percent fat), while increasing                       of benign breast disease. This practice was initially
     complex carbohydrate consumption, has been                               based on positive reports from small numbers of
     shown to reduce the severity of premenstrual                             patients as far back as 1965 and from subsequent
     breast tenderness and swelling, as well as reduc-                        studies in 1971, 1978, and 1982.18–21 When larger
                                                                                    FIBROCYSTIC BREASTS          93
numbers of women were studied, vitamin E did             seed oil and its essential fatty acid content that
not fare so well, showing no significant effects          holds the most interest today in maintaining
either subjectively or objectively,22, 23 and the ear-   health and preventing disease.
lier results have never been duplicated.                     Evening primrose oil is rich in essential fatty
     However, this is not to say that some women         acids—polyunsaturated fats that are as essential
don’t find symptom relief from taking vitamin E.          as vitamins and minerals for the maintenance of
Two studies demonstrated that vitamin E is clin-         good health. The oil contains 74 percent linoleic
ically useful in relieving pain and tenderness,          acid (LA) and 9 percent gamma linolenic acid
whether cyclical or noncyclical.21, 24 The studies       (GLA). Although other oils such as borage oil
have been done with varying dosages: 150, 300,           and black currant oil contain higher amounts of
or 600 IU daily. In clinical practice, practitioners     GLA, evening primrose oil is by far the most
generally recommend from 400 to 800 IU of D-             popular and familiar source of this fatty acid.
alpha tocopherol with a minimum trial period of          Evening primrose oil also contains 11 percent
two months. Since vitamin E in these dosages is          oleic acid, 6 percent palmitic acid, and 2 percent
completely safe to use, this is a simple and appro-      stearic acid.
priate self-treatment method for a benign breast             Under ideal conditions, the body uses LA to
condition.                                               produce GLA. In turn, GLA is used to produce
                                                         beneficial hormone-like compounds called pro-
 Vitamin E (Natural)                                     staglandins. Specifically, GLA is used to produce
 400–800 IU daily                                        series one prostaglandins such as prostaglandin
                                                         E1 (PGE1).
    Omega-6 Fatty Acids. The pain and tender-                Prostaglandins affect the function of virtually
ness of benign breast disease associated with cyclic     every system in the body. These molecules are
mastalgia have been alleviated with evening prim-        used in the regulation of inflammation, pain,
rose (Oenothera biennis) oil, the only one of the        blood pressure, fluid balance, and blood clotting.
many essential fatty acids to be scientifically stud-     Prostaglandins also affect hormone production
ied in relation to fibrocystic breasts.                   and function.
    The evening primrose plant has been com-                 The key to understanding the important
monly known as tree primrose and sun drop.               need for supplementing with oils rich in GLA,
Evening primrose can be found in many parts              such as evening primrose oil, is that many of us
of North American and is native in the North             cannot convert LA to GLA efficiently. Dietary
Temperate Zone, especially at high altitudes. The        deficiencies, disease conditions, processed oils,
native peoples of North America, as well as the          trans-fatty acids, heated oils, alcohol, aging, viral
English and Pilgrims, were well aware of the heal-       infections, and sugar consumption block, slow
ing properties of the leaves and bark as an astrin-      down, or interfere with the enzyme that catalyzes
gent, nervine (an herb that affects the nerves and       the conversion of LA to GLA. The result is that
includes relaxants, tonics, and even stimulants),        virtually all North Americans are deficient in
and sedative. It was often used for stomach and          GLA. Supplementing with evening primrose oil
liver complaints, coughs, and female reproductive        can enrich the body’s GLA supply and restore the
problems. Even the roots were eaten as a veg-            production of beneficial prostaglandins derived
etable. The seeds were recommended as a coffee           from GLA. Research completed over the last 20
substitute in wartime and have a strong flavor            years has confirmed that supplementation with
similar to poppy seed oil. The therapeutic value of      evening primrose oil has beneficial effects in
the seed oil is a more recent discovery. It is this      numerous diseases and conditions. Benefits for
94   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

     health problems supported and/or suggested by                            oil contain higher amounts of GLA, so poten-
     scientific trials using evening primrose oil include                      tially, one could take fewer capsules to achieve the
     premenstrual syndrome, fibrocystic breast pain,                           same benefit. For example, borage oil contains 23
     eczema, rheumatoid arthritis, diabetes, heart dis-                       percent GLA versus only 9 percent in the evening
     ease, osteoporosis, and ulcerative colitis. Other                        primrose oil. That would mean instead of the 6
     conditions for which it may provide benefit                               capules of evening primrose oil it would take to
     include menopause and pregnancy.                                         achieve the 3,000 mg of evening primrose oil that
         The pain and tenderness of benign breast dis-                        was used in the study, you could conceivably use
     ease associated with premenstrual breast pain and                        at half as many capsules of borage oil.
     fibrocystic breasts has been alleviated with
     evening primrose oil in more than one scientific                           Evening Primrose Oil (Omega-6 Fatty Acids)
     study. In 1985, when 291 women took three                                 1,500 mg twice daily
     grams per day of evening primrose oil for three to
     six months, almost half of the 92 women with                                 Vitamin A. Basic science research supports
     cyclic breast pain experienced improvement com-                          the use of vitamin A by demonstrating the pres-
     pared with one-fifth of the patients who received                         ence of specific retinoid receptors in breast tissue
     the placebo. For those women who experienced                             that can modulate our genetic predisposition,
     breast pain throughout the month, 27 percent                             thereby decreasing the risk for both benign and
     (just over one-fourth of the 33 women) responded                         malignant breast changes.27
     positively to the evening primrose oil, compared                             In a study of patients with fibrocystic breast
     to 9 percent on the placebo.25 Another 73 women                          disease, 12 women were treated with 150,000 IU
     with breast pain with or without lumpiness ran-                          of vitamin A daily for three months, and 5 of the
     domly received three grams per day of evening                            9 women who completed the study showed com-
     primrose oil or placebo. After three months,                             plete or partial response.28 Some of the patients
     pain and tenderness were significantly reduced in                         experienced mild side effects of vitamin A toxic-
     both cyclical and noncyclical groups, while the                          ity, including dryness of the skin and mouth.
     women who took the placebo did not significantly                              Although the potential toxicity of vitamin A in
     improve.26 In the course of treatment, it has been                       doses this high makes it an impractical approach to
     detected that women with breast pain have unusu-                         fibrocystic breast disease, it is possible that beta-
     ally low concentrations of GLA and metabolites                           carotene could be substituted, since it has a similar
     from GLA. When patients receive supplements of                           activity without the side effects of vitamin A, or a
     evening primrose oil, the concentration of GLA                           diet high in yellow and orange fruits and vegetables.
     metabolites increases and the concentration of sat-
     urated fats in the breast decreases. This may also                        Beta-Carotene
     have long-term implications for prevention of                             50,000–150,000 IU daily
     breast diseases such as breast cancer.
         Although symptom relief can be achieved                                  Iodine/Thyroid Hormone. It has been
     through the use of evening primrose oil, it should                       known for a long time that for the thyroid gland
     not be relied on to actually reduce the number of                        to secrete thyroxine (its hormone), it requires
     developing cysts.                                                        iodine. Prescription thyroid hormone replacement
         Other omega-6 fatty acids that may have ben-                         with low or even normal thyroid function may
     eficial effects but have not been studied in relation                     result in improvement of fibrocystic breasts.29, 30
     to fibrocystic breasts are flaxseed oil, black currant                     These results suggest that iodine deficiency may be
     oil, and borage oil. Borage oil and black currant                        a causative factor in fibrocystic breasts.
                                                                                    FIBROCYSTIC BREASTS       95
    Although the exact mechanisms of action on
                                                        Aqueous Iodine
breast tissue are not known, the breast has an
affinity for both thyroid hormone and iodine.            3–6 mg daily (prescription item)
The only areas of the breast in which iodine can
be found are in the terminal and interlobular
duct cells, which are also the areas primarily              Additional Supplements
involved in cystic changes. Without iodine, the         •   B-complex: 10 times the recommended
breast tissue becomes more sensitive to estrogenic          daily dietary allowance
stimulation, which in turn produces microcysts          •   Methionine: 1 g per day
high in potassium. The potassium is believed to         •   Choline: 1 g per day
be an irritant that produces fibrosis and eventu-        •   Lactobacillus acidophilus: 1 tsp 3 times
ally cyst isolation.                                        per day
    Four types of iodine have been studied in the       •   Flaxseed oil: 1 tbs per day
treatment of fibrocystic breasts, only one of
which has been truly effective and free of side        Botanicals
effects on the thyroid gland. According to             Herbal therapies for addressing the symptoms of
research by Dr. William Ghent, although all            breast pain, swelling, and cystic nodules in the
forms of iodine relieve subjective clinical symp-      breast are largely arrived at from traditional uses
toms, the fibrocystic breast reacts differently to      of herbal medicines and from observational expe-
these different forms of iodine: sodium iodide         rience in clinical practice. Herbal diuretics are
(Lugol’s solution), potassium iodide, caseinated       useful in decreasing breast swelling and the dis-
iodine (protein-bound), and aqueous (diatomic)         comfort associated with it. The most effective of
iodine. Symptom relief varied a great deal with        these is dandelion leaf (Taraxacum officinale).
the different iodines, but only the aqueous or         Unlike synthetic diuretics, dandelion leaf does
diatomic iodine achieved both symptom relief in        not deplete potassium; instead, it actually con-
74 percent of the women and also objective             tains a high percentage of potassium. However,
reduction in nodules and resolution of fibrosis in      since potassium is possibly implicated in fibrosis
65 percent of the patients, without adverse            and potential cyst isolation, dandelion may not
effects on the thyroid gland.31                        be the ideal diuretic to use. Diuretics considered
    Women get different amounts of iodine in           to be effective for fibrocystic breasts include
their diet, depending on the iodine content of         cleavers (Galium aparine), yarrow (Achillea mille-
the soil and water, as well as the types of food       folium), and uva ursi (Arctostaphylos uva-ursi).
they prefer to eat. Plant foods grown in the so-           Additionally, poke root (Phytolacca ameri-
called goiter belt areas of the country (the Great     cana), an herb used in traditional naturopathic
Lakes region, the Midwest, and the Intermoun-          medical practices, can be applied as an oil to the
tain states) lack iodine because the soil and water    breasts and rubbed in like a lotion, reducing
are iodine deficient. Today, iodine deficiency is        painful lumpiness and nodularity.
considered rare in the United States due to the            Herbal support for the liver improves how
widespread distribution of foods from areas of         the liver metabolizes hormones. In this case, our
the country sufficient in iodine and due to the         goal is to encourage the normal pathways for the
availability of iodized salt. Certain foods, such as   metabolism, excretion, and recirculation of estro-
seafood and seaweeds, are naturally high in            gens. Traditional herbs that support the liver
iodine and might be used to supplement a diet          include burdock root, dandelion root (not leaf ),
low in iodine.                                         milk thistle, celandine, fringe tree, and beet root.
96   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      Herbal Recommendation                                                       I cannot confirm the effectiveness or safety of
                                                                              this practice, and the research is not yet clear on
         • Yarrow leaf capsules: 2–6 per day; or yarrow                       the safety of long-term natural progesterone and
           leaf liquid tincture or extract: 1⁄4–1 tsp per day                 breast health. There is more information about
         • Phytolacca oil: apply to breasts nightly for 2                     this in Chapter 12.
           weeks, then reduce to 3 times per week
                                                                               Natural Progesterone Cream
                                                                               1⁄4–1⁄ 2
                                                                                      tsp applied to breasts and palms twice a day
     Additional Natural Therapies
                                                                                 from ovulation to menses
          Natural Progesterone. Once we agree that
     fibrocystic breasts are, at least in part, due to a
     high-estrogen/low-progesterone problem, then                             C O N V E N T I O NA L
     it is logical to use progesterone therapy as a                           M E D I C I N E A P P R OAC H
     treatment. Specifically, many practitioners and                           Conventional medical literature has tended to
     women patients have experienced that the appli-                          focus more on pathologic descriptions of disease
     cation of natural progesterone in a cream or gel                         and on verifying or disproving related cancer risk
     form routinely resolves the problem. Dr. John                            rather than on exploring therapeutic options for
     Lee, the leader in the use of natural progesterone,                      symptom relief. In spite of conflicting data in the
     states that he cannot recall a single case in his                        1980s, many women added vitamin E and elim-
     own practice in which the results were not posi-                         inated coffee from their diets with noticeable
     tive.32 Lee suggests using the natural proges-                           subjective improvement and no side effects other
     terone cream or gel as prescribed by a health-care                       than those imparted by caffeine withdrawal.
     practitioner until the cysts are gone and then                           Low-fat, high complex carbohydrate diets can
     reducing the dose to the smallest amount that is                         reduce cyclical pain, and the results of studies
     still effective, to be continued monthly as needed                       with evening primrose oil have been mixed.
     through menopause.                                                           Cyclic breast pain and swelling are felt to be
                                                                              hormonal, so treatment is aimed at hormonal
      Sample Treatment Plan
                                                                              manipulation, usually by suppression. More often
      for Fibrocystic Breasts                                                 than not, oral contraceptives help to relieve mild
                                                                              or severe premenstrual pain, although for smaller
      Three-Month Period
                                                                              numbers of women the pain is worsened by this
         • Avoid caffeine and other sources of                                treatment. This paradox is explained by the fact
           methylxanthines.                                                   that oral contraceptives suppress ovarian produc-
         • Lower dietary fat to 20 percent and increase
                                                                              tion of hormones and replace this with an average
           dietary fiber (whole grains, legumes, fruits,
                                                                              synthetic dose of both estrogens and progesterone.
           vegetables, and soy foods); increase seafood
           and seaweed (for the natural iodine).
                                                                              If the replacement level is higher than the natural
         • Vitamin E: 400 IU twice per day                                    one, sore breasts may result; usually, the replaced
         • Evening primrose oil: 1,500 mg twice per day                       level is lower, and then the pain is relieved. Con-
      If there is no change after three menstrual cycles,                     tinuous oral contraceptives (no placebo break)
      then incorporate a more assertive approach utilizing                    seem to help better than cyclic regimens.
      some of the other therapies listed, or see a naturo-                        Many so-called effective conventional treat-
      pathic physician for individualized recommendations                     ments cause such serious side effects that it is hard
      and, especially, prescription aqueous iodine.                           to imagine any cases that would warrant their use.
                                                                              Danazol, which interrupts LH and FSH secretion
                                                                                   FIBROCYSTIC BREASTS         97
from the pituitary gland, was once touted as the            The side effects of most of the expensive
most effective breast pain reliever. However, it is a   drugs used to eliminate breast pain and lumpi-
male hormone and can cause facial hair, voice           ness are probably too extreme to warrant their
deepening, and other androgenic changes, quite          use for most women until the simpler remedies
unacceptable side effects for most women, and it        have proven inadequate. If elimination of caf-
can cost more than $200 per month. It is no             feine, adding vitamin E, and switching to a low-
longer used to treat fibrocystic breasts.                fat, high complex carbohydrate diet do not bring
    Similarly, GnRH agonists work at the hypo-          results, the next logical step for a conventional
thalamic level to eradicate estrogen via a tem-         practitioner would most likely be a trial of oral
porarily induced menopausal condition. This             contraceptives.
class of drugs may make danazol obsolete, but
they again do not present a good long-term solu-        S E E I N G A L I C E N S E D P R I M A RY
tion due to the side effects, including reversible      H E A LT H - CA R E P R AC T I T I O N E R
bone loss, and they cost even more money.               ( N . D. , M . D. , D. O . , N . P. , P. A . )
    Tamoxifen, an antiestrogen, has been used to        A woman might decide to see a licensed health-
treat breast cancer and can help cyclic breast          care practitioner because she needs a breast exam
pain, up to a 90 percent reduction in pain. How-        or wants to determine the exact nature of her
ever, it causes menopausal side effects, its long-      breast pain/tenderness or lumps. The practi-
term effects are unknown, and it increases the          tioner will ask about her symptoms as well as
incidence of endometrial cancer. On the other           other pertinent factors in her medical history and
hand, it has been shown to reduce breast cancer         will perform a physical examination.
risk in women who are at higher risk, including             If the practitioner considers it necessary, she
those women who have atypical hyperplasia of            or he might recommend a mammogram and/or
the breast, which is determined only by a biopsy.       ultrasound to determine the nature of a specific
For benign breast disease, it is difficult to imag-      lump and may encourage aspiration of a mass to
ine a situation where the benefits of tamoxifen          determine whether it is cystic or solid. The prac-
would outweigh the risks and side effects.              titioner will no doubt recommend that highly
    Bromocriptine is a nonhormonal drug ther-           suspicious lumps be surgically biopsied.
apy that lessens the levels of prolactin, the hor-          A lump that is new or one that is increasing in
mone that manages lactation changes, and seems          size, or a lump that does not change over the course
to work well, although it is often not tolerated        of the menstrual cycle, are all causes for concern
because of nausea or dizziness.                         and might lead to a professional evaluation.
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                                    G E N I TA L H E R P E S                                        CHAPTER

OV E RV I E W                                                   with their first episodes of genital herpes are 18
Genital herpes is the most prevalent sexually trans-            to 36 years of age. The highest annual incidence
mitted infection (STI) in the United States.1–3                 of genital herpes among women occurs at 20 to
Data about the prevalence of genital herpes in the              24 years of age and is estimated to be 210 per
United States has been collected from the                       100,000 women.
National Health and Nutrition Examination Sur-                      The diagnosis of typical genital herpes is
veys between 1976 and 1980 (NHANES II) and                      fairly straightforward most of the time but
from 1988 to 1994 (NHANES III). According to                    involves local and systemic signs. There are three
NHANES III, 45 million Americans over the age                   distinct syndromes: primary herpes, first-episode
of 12 are infected with Herpes simplex 2 (HSV-2 or              nonprimary herpes, and recurrent herpes. There
genital herpes). The prevalence increased 30 per-               are, however, atypical manifestations, and these
cent between 1988 and 1994, with the greatest                   are the ones that are not so straightforward.
increase among teenagers, and quintupled among                      The severity of symptoms varies in extent and
white teenagers and doubled among whites in                     duration according to whether the episode is
their twenties. Some 25.6 percent of women and                  the patient’s first infection with either HSV-2 or
17.8 percent of men test positive for the virus in              HSV-1, called primary herpes; initial genital infec-
their blood, and blacks have a higher prevalence                tion in a woman who has already had an infection
(45.9 percent) than do whites (17.6 percent).4                  with the other HSV type (initial, or first-episode
Testing positive in the blood is different than                 nonprimary herpes); or a recurrence of a genital
having a genital herpes eruption history. In fact,              infection with either type. A woman’s first episode
only 10 to 20 percent of seropositive individuals               of genital herpes (primary herpes) is usually the
have had a genital herpes lesion, showing us that               most severe form of the disease. Symptoms usually
the majority of cases are subclinical or undetected.            start appearing within a week after infection, if
    There are six members of the herpesvirus                    they are going to appear at all. However, symp-
family that are known to infect humans: HSV                     toms can start one day and up to 26 days after
type 1 (HSV-1) and HSV type 2 (HSV-2), vari-                    exposure to the virus. Typically, infection is char-
cella zoster virus, human cytomegalovirus,                      acterized by extensive, multiple clusters of painful
Epstein-Barr virus, and herpesvirus type 6.                     lesions involving the genitals, anus, perineum, or
Today, HSV-2 is the leading cause of genital                    surrounding areas. Symptoms and lesions of pri-
ulcer disease in the United States. As many as one              mary genital herpes vary in severity, extent, and
in five Americans is believed to be infected with                duration. Initial symptomatic episodes of HSV
HSV-2—the virus type more closely associated                    not only tend to be more severe but are followed
with genital herpes. Another virus type, HSV-1—                 within the first year of a greater likelihood of clin-
the type more closely associated with infections                ical recurrences as well as shedding of the virus
of the mouth, lips, pharynx, and eyes earlier in                without any symptoms (also known as subclinical
life through oral/genital contact—is believed to                shedding, when the outer layer of the skin or tissue
be responsible for 10 to 50 percent of new cases                harbors the virus without symptoms and then
of genital herpes.5 About 80 percent of people                  sheds, transmitting the virus). These subsequent
Copyright © 2008 by Tori Hudson. Click here for terms of use.
100   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

       PREVENTION                                                              the disease to others. Disruption of one’s sexual life
                                                                               can also manifest as significantly reduced sexual
       • Genital herpes is a sexually transmitted disease.                     pleasure and a strong sense of sexual inhibition.
         Education about recognizing the disease and its                       Many people also worry that they will be rejected
         prodromal symptoms of itching, numbness, and                          by future partners and are pessimistic about the
         tingling and protection during sexual contact or                      possibility of establishing normal sexual relation-
         abstaining during outbreaks are important in                          ships. Since many people become emotionally
         preventing transmission.
                                                                               upset upon learning of the diagnosis, a health-care
       • The virus can shed; thus, transmission of the
                                                                               provider can be extremely valuable in helping to
         disease to another individual is possible even
         without symptoms. The use of barrier methods is                       deal with anger, guilt, or anxiety. Education and
         recommended for any person who has evidence                           counseling include information about the nature
         of prior infection with HSV-2.                                        of HSV infection, most importantly prevention
       • The safest method of protecting yourself and a                        of its transmission. It is important that patients
         sexual partner is to use some sort of barrier                         also understand that the primary infection may
         method to prevent contact. The use of male con-                       have been asymptomatic and that even an initial
         doms, female condoms, dental dams, or house-                          outbreak may be a reactivation of an infection
         hold plastic wrap are all recommended options.                        acquired months or even years previously.
       • Informing one’s sexual partner of a history of
         herpes is the responsible thing to do. Before                         OV E RV I E W O F
         having sexual contact with a new partner, ask                         A LT E R NAT I V E T R E AT M E N T S
         questions about his or her past sexual history,
         history of sexually transmitted infections, and                       A susceptible host plus exposure to the herpes
         past habits and lifestyle that may have exposed                       simplex virus add up to acquiring the disease.
         the partner to the virus and other sexually                           Improving the health of the host and enhance-
         transmitted infections.                                               ment of the immune system is essential in pre-
       • A willingness to practice “safer sex” techniques                      venting and controlling herpes. There is some
         is an important health issue to discuss with a                        evidence that a defect in the immune system is
         sexual partner. One should understand that HSV                        present even in otherwise healthy individuals
         infection can be spread by oral-genital contact
                                                                               who have recurrent HSV infection. Support of
         as well as genital-genital sexual contact.
                                                                               the immune system, dietary factors, stressors,
       • Transmission from one body site to another is
         possible, and infected areas should be patted,                        skin health, and preventing and treating other
         rather than wiped, dry. Be especially careful                         non-herpes infections are all avenues for using
         about transmitting the infection from another                         natural therapies in reducing the likelihood of
         part of the body to the eye.                                          contracting herpes and in reducing the frequency
       • Enhance the immune system.                                            and intensity of recurrent herpes infections.
       • Some individuals may need to consider prophy-
         lactic suppressive antiviral medication.                              Nutrition
                                                                               A health-supportive diet is fundamental to good
      gitis, urinary or rectal dysfunction, infection in the                   health and an optimal immune system. Although
      eye, and erythema multiforme (a skin disease).                           biochemical differences may require that some of
          The impact of genital herpes on a person’s                           us eat more of some foods and less of others,
      psychological and sexual health can be quite intru-                      health-supportive diets are based on the guide-
      sive and profound. Many people withdraw from                             lines listed below.
      interpersonal relationships because of stress related                        A dietary approach for preventing recurring
      to their infection or because of fear of spreading                       herpes outbreaks that reduces high-arginine foods
                                                                                          G E N I TA L H E R P E S   103
 Dietary Recommendations                                After six months, the treatment was rated as effec-
                                                        tive or very effective by 74 percent of those receiv-
   • Maximize your intake of vegetables, whole          ing the lysine, compared to 28 percent of those
     grains, legumes, and fruit.                        receiving placebo. The mean number of herpes
   • Drink 4 to 8 glasses of water daily.               outbreaks was 3.1 in the lysine group compared
   • Reduce fat intake.                                 to 4.2 in the placebo group, and lysine-treated
   • Eliminate refined sugar and chocolate.
                                                        patients reported milder symptoms. No signifi-
   • Avoid food additives, coloring agents, pesti-
                                                        cant side effects were reported in either group.10
     cides, and herbicides.
   • Reduce salt and alcohol intake.
                                                        Another experimental study was done with 41
   • Reduce or avoid almonds, cashews, sunflower         patients who took a daily dose of 1,248 mg of
     seeds, and peanuts.                                lysine. This demonstrated a decreased recurrence
                                                        rate and a decreased severity of symptoms during
                                                        recurrences, but not a reduced healing time.11
and increases high-lysine foods has become quite            For people who want to rely on lysine supple-
popular. This concept arose out of two findings.         mentation alone, my recommendation is to take
First, we know that the replication of the herpes       one gram daily for maintenance and one gram
simplex virus requires the manufacture of proteins      three times daily during acute outbreaks. Lysine
rich in arginine, and arginine itself may be a stim-    can also be found in topical ointments to be
ulator of HSV replication. Second, laboratory           applied directly to herpes eruptions. These may be
research has shown that lysine has antiviral activity   helpful in reducing symptoms but have not been
that blocks arginine7 and that an arginine-deficient     adequately studied to prove their effectiveness.
environment suppresses HSV replication.8
    Thus, theoretically, reducing one’s intake of        Lysine
arginine and increasing one’s intake of lysine           Acute: 1 g 3 times daily
should be effective in reducing HSV replication.         Maintenance: 1 g daily
In fact, many people do observe an increased
susceptibility to outbreaks if they eat chocolate           Vitamin C and Bioflavonoids. Supplementa-
or peanuts, foods that are high in arginine. Other      tion with vitamin C may have therapeutic value in
high-arginine foods include almonds, cashews,           the treatment of recurrent external genital herpes
and sunflower seeds. Foods high in lysine include        eruptions. Using 600 mg of vitamin C and 600
most vegetables, beans, fish, turkey, and chicken.       mg of bioflavonoids three times daily for three
                                                        days after the initial onset of symptoms (in the
Nutritional Supplements                                 prodromal phase) was found to be the optimal
    L-Lysine. Scientific studies on the effective-       dosage for the most rapid disappearance of symp-
ness of lysine supplementation have not shown           toms.12 In addition, in vitro evidence supports the
consistent results, and a least one study cites         use of ascorbate in combination with copper to
dietary variability of lysine and arginine intake as    inactivate HSV-2.13 In women with active lesions,
a possible confounding factor that is often diffi-       a randomized double-bind, placebo-controlled
cult to control and is not often assessed in stud-      clinical trial was done on the topical use of a
ies.9 One study that did show positive results          water-based solution of Ascoxal, an ascorbic
was done in 52 patients with recurrent infections       acid–containing formulation, in the treatment of
(oral, genital, or both). Test subjects received        recurrent mucocutaneous herpes. A solution-
L-lysine (one gram three times daily) or a placebo.     soaked cotton pad was applied to the lesion three
They also avoided nuts, chocolate, and gelatin.         times for two minutes with 30-minute intervals
104   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      on the first day only. Both subjective and objective
                                                                                Zinc and Vitamin C
      accounts demonstrated decreased symptoms and
      healing time. In addition, viral culture after the                        25 mg zinc with 250 mg vitamin C twice daily for 6
      first day yielded HSV significantly less frequently                          weeks
      when compared to placebo.14

       Vitamin C and Bioflavonoids                                              Botanicals
       Prodromal period: 600 mg vitamin C with 600 mg                              Lemon Balm (Melissa Officinalis). Lemon
         bioflavonoids 3 times daily for 3 days                                 balm ointments have been used topically in Ger-
                                                                               many for oral cold sores, and products are now
           Vitamin E. Applying topical vitamin E to a                          available in the United States. Laboratory evi-
      lesion may provide pain relief.15 Although clinical                      dence demonstrates the anti-HSV-2 activity of
      observations have been made of only four pub-                            Melissa at nontoxic concentrations in vitro.22, 23
      lished cases (in oral primary herpes, not genital), it                   The German cream Lomaherpan is a concentrate
      would seem logical that vitamin E applied to gen-                        of 70:1 lemon balm extract. Several clinical stud-
      ital eruptions may provide a similar benefit. Dry                         ies have shown impressive results. One study
      the area around the lesion with warm air and                             demonstrated that when the lemon balm cream
      apply vitamin E oil with a cotton swab. Leave in                         was used on patients with an initial oral herpes
      place for 15 minutes. After the 15 minutes, pain                         infection, or cold sore, not a single recurrence
      relief should be evident. Repeat as needed.                              occurred. Not one patient using the cream devel-
           Further evidence for the use of vitamin E was                       oped another cold sore. The cream was also
      found in an animal study that employed a patented                        shown to be effective in reducing the healing
      combination antioxidant cream including vitamin                          time in cases of genital herpes.24
      E, sodium pyruvate, and membrane-stabilizing                                 Another study, a double-blind, placebo-
      fatty acids. It demonstrated that the ingredients                        controlled, randomized trial, used a standardized
      worked synergistically to reduce genital HSV                             topical cream (active ingredient: 1 percent Lo-
      lesion development, duration, and severity signifi-                       701—dried extract from Melissa officinalis L.
      cantly when compared to placebo or acyclovir.16                          leaves) in 66 patients with a history of recurrent
                                                                               herpes labialis of at least four episodes per year.
       Vitamin E                                                               With applications four or five times a day, subjects
       Apply vitamin E oil to dry area around lesion; leave in                 noted shortening of the healing period, prevention
        place for 15 minutes. Repeat as needed.                                of infection spreading, and rapid relief of the typ-
                                                                               ical symptoms of herpes. The authors also con-
          Zinc. A number of zinc salts have been                               cluded that the intervals between the periods with
      shown to have antiviral activity against HSV. In                         herpes might be prolonged with this treatment.25
      vitro17 and animal studies have supported use of                             The cream should be applied two to four
      zinc topically with genital infection.18–20 Supple-                      times a day during an active eruption. No side
      mentation with zinc has been observed to reduce                          effects have been observed.
      the frequency, duration, and severity of genital
                                                                                Lemon Balm
      herpes eruptions. A compound of zinc (25 mg)
      and vitamin C (250 mg) was given twice daily for                          Apply topically 2 to 4 times a day.
      six weeks. In some cases, the eruption was com-
      pletely suppressed, and in others the eruptions                              Licorice (Glycyrrhiza Glabra). Licorice has
      disappeared within 24 hours of their onset.21                            traditionally been used by naturopathic physi-
                                                                                              G E N I TA L H E R P E S   105
cians, herbalists, and other health-care practi-         plants with waxes and glandular secretions. They
tioners to support the body’s immune system and          use this resin for the construction and repair of
to defend against the effects of disease-causing         their hives. It is also placed at the entrance to the
viral infections. Laboratory studies demonstrate a       hive where the worker bees brush up against it as
component of Glycyrrhiza glabra root, gly-               they enter the hive. This sterilizes the bees from
cyrrhetinic acid, is active against viruses, specifi-     infection. The composition of propolis varies
cally in HSV where it inhibits the growth,               depending on the plants in the area that the bees
activity, and ability to replicate, irreversibly inac-   visit. Some propolis may be higher in flavonoids,
tivating the herpes simplex virus.26 In clinical         other propolis may be higher in diterpene com-
practice, I have observed that topical prepara-          pounds. Historically, propolis has been used for
tions of licorice containing glycyrrhetinic acid         its antibacterial, antifungal, antiviral, antiproto-
have helped to reduce both healing time and              zoan, antitumor, anti-inflammatory, immunomo-
uncomfortable symptoms associated with genital           dulatory, and antioxidant activities. In vitro data
herpes. Apply the ointment or gel several times          suggests propolis has both antibacterial and
daily. If used daily over several weeks or months,       antiviral properties against a variety of microor-
licorice may cause fluid retention and thereby            ganisms, including HSV.28–30
raise blood pressure in certain individuals.                 Two of my favorite natural topical therapies for
                                                         herpes lesions are honey and bee propolis. A small
 Licorice                                                study comparing topical application of honey
 Apply ointment or gel several times daily.              versus acyclovir cream found a statistically signifi-
                                                         cant shorter duration of episodes and faster healing
    Siberian Ginseng (Eleutherococcus Sentico-           time when using honey compared to acyclovir.31
sus). A randomized double-blind, placebo-                Another larger, randomized, single-blind study
controlled trial of a standardized extract of eleuthe-   showed that more subjects’ lesions healed after 10
rococcus showed a decrease in severity, duration,        days of treatment with a 3 percent propolis oint-
and frequency of outbreaks when used for at least        ment than with placebo or acyclovir.32
three consecutive months. Although not com-
                                                          Bee Propolis
monly used by alternative practitioners for the
treatment of herpes, this study supports eleuthero’s      Apply 3% bee propolis ointment several times per day.
role in suppression of herpes outbreaks.27
                                                             Aloe Vera. Aloe vera is a cactus, and the gelat-
 Siberian Ginseng                                        inous substance inside the leaf is known to have
   • Dried root: 500–3,000 mg dried root capsules        many beneficial properties. It’s not surprising that
   • Tincture (herb and alcohol or herb, alcohol,        some research shows some effects for the herpes
     and water): 1 tsp 3 times per day                   virus, and mucosal epithelial tissue appears to be
   • Fluid extract: 1⁄ 2–1 tsp 2–3 times per day         a good site for the medicinal effects of aloe. In
   • Extract (33% alcohol extract): 40–120 drops         vitro data suggests that chemical constituents of
     1–3 times per day                                   aloe vera inactivate HSV-2 both alone and syner-
   • Solid extracts made from dried, powdered root       gistically with acyclovir.33, 34 Human clinical trials
     (at least 1% eleutheroside F): 100–200 mg 3         on men support its use topically as a 0.5 percent
     times per day
                                                          Aloe Vera
   Bee Propolis. Propolis is a resinous substance         0.5% cream, apply 2–4 times daily
that bees make by combining substances from
106   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      hydrophilic cream, but not as a gel, to shorten                          binding to the virus, thereby preventing the
      healing time and decrease symptoms.35, 36                                infection of the host cells.39
                                                                                   Echinacea has shown in vitro antiviral activ-
          Myrrh (Commiphora Myrrha) and Gold-
                                                                               ity against HSV-1,40 but a human study did not
      enseal (Hydrastis Canadensis). I am not aware
                                                                               demonstrate any statistically significant reduc-
      of any research studies using myrrh and gold-
                                                                               tion in recurrent genital herpes.41
      enseal for genital herpes eruptions, but the tradi-
                                                                                   Viracea, a proprietary blend of benzalkonium
      tional use of both of these herbs is longstanding.
                                                                               chloride and derivatives from Echinacea pur-
      As an antiseptic and as an anti-inflammatory for
                                                                               purea, was found to have anti-HSV-1 and
      inflammations and sores of the mucous mem-
                                                                               -2 activity in vitro, even on strains that were
      branes, these two herbs have been very reliable
                                                                               resistant to acyclovir.42
      and may go a long way not only toward improv-
                                                                                   Chapparal (Larrea tridentate), specifically its
      ing the health of the epithelial tissue of the
                                                                               leaf resins, have been shown to have significant
      mouth and genital region but also stimulating an
                                                                               antiviral activity. The natural ingredients in the
      immune response locally in that tissue.
                                                                               leaf resin appear to the inhibit replication of the
       Myrrh                                                                   virus.43 Preparations are available in either cap-
       Oral tincture: 10–30 drops 3 times per day
                                                                                Sample Treatment Plan for Genital Herpes
                                                                                See the Resources section for formulation sources.
       Oral tincture: 10–30 drops 3 times per day
                                                                                During an Acute Episode
          Additional Botanicals. Many botanicals                                  • Apply ice, preferably during the prodrome stage
      have the ability to provide immune support                                    during symptoms of itching, numbness, or tin-
      through various mechanisms. Other plants have                                 gling or even after the eruption has appeared,
      very specific antiviral properties as well.                                    for 10-minute applications several times during
          The antiviral activity of Saint-John’s-wort                               the day. This limits the discomfort and swelling
      (Hypericum perforatum) has been demonstrated.                                 and can keep an outbreak from fully erupting.
      Laboratory studies have shown that two con-                                 • Apply lemon balm ointment several times per
      stituents in Saint-John’s-wort, hypericin and
                                                                                  • Apply licorice gel (glycyrrhetinic acid) twice
      pseudohypericin, exhibit strong antiviral activity                            per day.
      against herpes simplex virus 1 and 2 as well as                             • Lysine: 1,000 mg 3 times per day
      influenza types A and B, in addition to a virus in                           • Vitamin C: 600–800 mg with 600–800 mg bio-
      the mouth that causes vesicular stomatitis.37                                 flavonoids 3 times per day
      Momordica charantia, or bitter melon, has been                              • Zinc: 25 mg per day
      shown to have antiviral activity against both
      HSV 1 and 2 such that its effectiveness in vitro is                       Prevention
      not only greater than acyclovir, but it is also                             • Follow a diet that is high in lysine foods (veg-
      effective against acyclovir-resistant strains.38                              etables, beans, fish, turkey, and chicken) and
          Medicinal mushrooms are known for their                                   avoid foods high in arginine (chocolate, all
      antimicrobial activity against a number of                                    nuts and seeds).
      microorganisms. Recent in vitro evidence sug-                               • Lysine: 1,000 mg per day
                                                                                  • Safe sex protection
      gests that fungal beta-glucans extracted from
      Pleurotus tuber-regium exerts its antiviral effect by
                                                                                          G E N I TA L H E R P E S   107
sules or a topical lotion. One or two capsules           commonly prescribed are acyclovir, valacyclovir,
daily of the leaf resin may reduce the frequency         and famciclovir. Acyclovir (Zovirax) was the first
of outbreaks, and the topical lotion, when               FDA-approved drug for treatment of herpes and
applied at the first sign of a tingling sensation,        is available as capsules, tablets, oral suspension,
may prevent the outbreak from occurring.                 topical ointment and cream, and sterile powder
    Botanicals such as thuja (Thuja occidentalis),       for IV infusion. Valacyclovir (Valtrex) comes in
lomatium (Lomatium disectum), and astragalus             500 and 1000 mg caplets, famciclovir (Famvir)
(Astragalus spp.) have been traditionally used by        in 125 mg, 250 mg, or 500 mg tablets. The side
naturopathic physicians, herbalists, and other           effect profile of all of these meds is the same. The
health-care practitioners to support the body’s          side effects are uncommon, but those reported
immune system and to defend against the effects          are nausea, vomiting, and headache. They seem
of disease-causing viral infections. These herbs         to be dose-dependent. There does not appear to
are typically administered in liquid extracts, cap-      be any long-term harm with the use of these
sules or tablets, or teas. Lomatium may cause a          meds, and there are few, if any, drug interactions.
temporary skin rash if used in an improper dose.         Essentially, this is a very safe medication class.
                                                             These meds are used for episodic treatment and
                                                         for prevention. We now know that 5 to 10 percent
C O N V E N T I O NA L                                   of people are asymptomatic herpes shedders, so
M E D I C I N E A P P R OAC H                            suppressive daily therapy is recommended for:
Many patients prefer to use antiviral therapy to
                                                         1. A person with an initial herpes outbreak
suppress infections and to reduce recurrent
                                                         2. A person who is known to be an asympto-
episodes. The primary goals of antiviral therapy
                                                            matic shedder
are to limit the severity of the infection and to
                                                         3. Patients with oral or genital herpes who have
give the patient a sense of control over the disease
                                                            more than four episodes a year
process. Antiviral therapy is offered to normal
immunocompetent patients with either primary             The recommendation is for a year or more,
or nonprimary genital herpes. In the vast major-         depending on the patient’s interest. The usual
ity of cases, oral antiviral therapy is sufficient,       recommendation is for a year following the first
although more severe cases may require hospital-         episode of herpes, and longer if there are other
ization and intravenous acyclovir.                       cofactors.
    Episodic therapy appears to work best for                The dosing has also changed from the origi-
women who have a clearly identifiable prodrome.           nal recommendations. Acyclovir, which is avail-
Patients who desire continuous suppressive therapy       able generically, is recommended as follows:
need to discuss with their physician the advantages      Ointment for genital topical therapy used several
and disadvantages of this regimen. Medical consid-       times a day until the lesions have resolved and
erations, psychosocial needs, and cost are all factors   cream for oral lesions with the same dosing.
influencing the wisdom of such a regimen.                 Orally, it is now 400 mg twice daily for 10 days
    The advent of herpes viral testing accuracy          for an initial episode, then 400 mg twice daily for
and knowledge of the asymptomatic carrier has            5 days for recurrences. 400 mg once daily is the
led to an increase in the use of antiviral herpes        suppression dose.
treatments. The meds used to treat the virus are             Valacyclovir has a variety of dosing recom-
essentially the same as they have been for the past      mendations: For an initial outbreak of genital
10 to 20 years, but recommendations for usage            herpes, use 1,000 mg three times a day for 10
and dosing have changed. The three meds most             days. For recurrent outbreaks, use 500 mg twice
108   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      daily for 5 days. For suppression, use 500 mg per                        treatment but also a key to determining sexual
      day. For oral herpes, the recommendation is 2 g                          behavior and habits with sexual partners. Labora-
      in the morning and 2 g in the evening on one day                         tory testing using viral cultures and blood tests for
      only. For recurrent outbreaks, many practitioners                        antibodies are the most common methods that
      prescribe the 1,000 mg caplet and suggest that                           may be recommended by your practitioner.
      patients cut it in half for economic reasons and                             A qualified health-care practitioner can be
      take one half caplet twice daily.                                        extremely helpful in providing education and
          Famvir is dosed at 125 to 250 mg twice daily                         counseling to the person who has newly acquired
      for 10 days for the initial episode and 125 to                           herpes. Education includes information about the
      250 mg twice daily for 5 days for the recurrent                          nature of HSV infection, various treatment
      episodes. The suppression dose is 250 mg once                            options, effect on pregnancy, and prevention of
      daily. It is interesting that with this product, the                     transmission. Counseling includes helping patients
      suppression dosing is greater than the active                            to deal with fears, shame, guilt, and feelings of
      treatment dosing, because the drug is more rap-                          social isolation as well as developing strategies for
      idly taken up by the virus when it is in its active                      communicating with present and future sexual
      replication phase. Hence, more drug is needed                            partners.
      for suppression than for active treatment.                                   Women who are pregnant need to inform
          The drugs are eliminated through the kidneys,                        their practitioner of their history of herpes. Any
      so one may need to reconsider dosing in patients                         outbreaks during the pregnancy should be
      with renal impairment. The drugs are approved                            recorded and reported so that appropriate testing,
      throughout all ages of pediatric use, and they                           treatment, and management can be done during
      would need to be specifically dosed by a pediatri-                        the pregnancy and delivery. Whether your practi-
      cian. So far, no resistant strains are reported.                         tioner is a midwife, alternative practitioner quali-
          The most important treatment remains pre-                            fied to perform home births, obstetrician, or
      vention. Condoms do not prevent the spread of                            family physician, she or he needs to know your
      HSV genitally. Health practitioners continue to                          infection status to make appropriate recommen-
      suggest that patients refrain from sexual activity,                      dations for your health and your baby’s.
      including oral sex and kissing, when an active                               Women with recurrent genital herpes infec-
      lesion is present. We now recognize that 5 to 10                         tions may need to seek more aggressive or indi-
      percent of people with a history of herpes do                            vidualized care from an alternative practitioner
      shed virus without an active lesion. Talking to                          than the therapies discussed in this chapter.
      your partner about his or her sexual history and                         Homeopathy, additional herbal/nutritional com-
      safe sex practices are probably the most important                       bination products, or Chinese herbal medicine
      steps in dealing with herpes.                                            may be more effective in an individual case.
                                                                                   Some women may choose to use conven-
      S E E I N G A L I C E N S E D P R I M A RY                               tional pharmaceutical antiviral therapy, although
      H E A LT H - CA R E P R AC T I T I O N E R                               this is not usually medically necessary. There are
      ( N . D. , M . D. , D. O . , N . P. , P. A . )                           cases of primary or nonprimary genital herpes,
      The most appropriate method for accurate diagno-                         however, when antiviral therapy is indicated for
      sis of a genital lesion is to see a licensed health-care                 immunocompromised individuals. Cases where
      practitioner qualified to perform a gynecological                         symptoms and complications are severe enough
      exam. Accurate diagnosis of genital lesions is not                       to warrant hospitalization may require intravenous
      only an important key to effective and appropriate                       antiviral therapy.
                                      HEART DISEASE                                                 CHAPTER

OV E RV I E W                                                   Abdominal obesity also increases the risk of
Most of us are aware that heart disease is a pri-               high blood pressure and diabetes and may lower
mary affliction for men, but cardiovascular                      the HDL (good) cholesterol level and raise the
disease (CVD) is also the leading cause of death                triglyceride level. A desirable waist-to-hip ratio
in women. More than 500,000 women die of                        for middle-aged women is less than 0.8. To get
cardiovascular-related causes annually in the                   your waist-to-hip ratio, measure your abdomen
United States.1 Taking into account other athero-               at the largest point and divide it by your hip
sclerotic disorders resulting from damaged and                  measurement.
narrowed arteries, such as strokes, almost 4 of                     Overall weight, usually calculated in terms of
every 10 women will die of these diseases,                      body mass index (BMI), is also an important tool
approximately 100,000 prematurely (before the                   for assessing one’s risk for coronary artery disease.
age of 65).2 Starting at age 50, more women die                 To calculate your body mass index, divide your
of cardiovascular diseases than of any other con-               weight in kilograms by the square of your height
dition,3 and women younger than 55 years old                    in meters. You can also refer to the height and
who have a heart attack have a worse prognosis                  weight chart in Appendix B to help you to deter-
and higher incidence of heart attack–related                    mine your body mass index. A desirable body
death than do men of the same age who have a                    mass index is less than 25. The Nurses’ Health
heart attack, as well as a greater chance of having             Study found that women with a BMI of 29 or
another heart attack.4, 5 Cardiovascular disease is             more had triple the risk of coronary artery disease
also a major cause of disability in older women.                compared with women who were lean and with
For black women, the risk of heart-related death is             a BMI of less than 21.10 Women with a BMI of
twice as high as for white women.6                              25 to 28.9 had almost double the risk. As many
    Even though heart disease is the leading cause              as one-third of white women and one-half of
of death in both men and women, the rates of                    black women are 20 percent or more over their
coronary disease (but not necessarily death) at                 desirable body weight.
virtually every age are higher in men than in                       Between the ages of 30 and 60, and in each of
women.7 When women are in their thirties and                    the decades in this age group, women who have
forties, the difference between men and women is                had either surgical or natural menopause have
four- to fivefold. After that, the difference shrinks            twice the rate of CAD compared to women in
with increasing age. Coronary artery disease                    their age group who still have premenopausal
(CAD) is less common in premenopausal women,                    ovarian function.11 Women who have had both
and the incidence of CAD tends to be about 10 to                ovaries removed have a higher rate of CAD at an
15 years later than men, until the age of 70.8                  earlier age than women who undergo natural
    Overweight women and those with the apple                   menopause.12 The explanations for this are multi-
fat distribution (with abdominal fat) are at                    ple, but the estrogen produced by the ovaries
greater risk for developing coronary artery dis-                helps to maintain higher HDL levels, which pro-
ease than are slim women and those with the                     tect the cardiovascular system, keep the LDL levels
pear fat pattern (fat stored around the hips).9                 low, and slow the aging of the arteries. Whether
Copyright © 2008 by Tori Hudson. Click here for terms of use.
110   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

       Table 9.1        Blood Pressure Guidelines

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

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

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

       Risk Factors for Coronary Artery Disease                                cular disease, risk factors such as cigarette smok-
                                                                               ing, exercise, dietary habits, and stress can be mod-
       Medical Conditions                                                      ified to reduce a person’s risk. In fact, a recent
         Hypertension                                                          study found that the following factors are to be
         Diabetes mellitus                                                     correlated to increased hypertension: excessive
         Hyperlipidemia/lipid abnormalities                                    sodium intake, low potassium intake, physical
         Syndrome X (insulin resistance)                                       inactivity, low intake of fish oil, low calcium
         Obesity and/or excess abdominal and upper body fat                    intake, low magnesium intake, excessive coffee
           (apple shape)                                                       consumption, and excessive alcohol intake.34
                                                                                    Dietary and lifestyle changes are the founda-
                                                                               tions of heart disease prevention and treatment.
         Sedentary lifestyle                                                   Dr. Dean Ornish and his team of researchers
         High-fat diet                                                         conducted the first significant clinical trial to
         Cigarette smoking                                                     determine whether comprehensive lifestyle
         Alcohol—more than two drinks per day
                                                                               changes affect coronary atherosclerosis. Dr. Dean
                                                                               Ornish’s landmark study, called the Lifestyle
       Family History                                                          Heart Trial, published in 1990, found that
                                                                               lifestyle changes (a low-fat vegetarian diet, mod-
         Coronary artery disease
                                                                               erate aerobic exercise, stress management, smok-
                                                                               ing cessation, and group support)35 changed
      women who have had one regular lipid panel                               serum lipids as much as cholesterol-lowering
      with abnormalities, I am inclined to order these                         drugs. After one year in the program, patients
      additional, more sophisticated blood tests. The                          also showed significant overall regression of their
      more risk factors they have, such as obesity,                            coronary atherosclerosis. These results have been
      diabetes, and others, the more eager I am to eval-                       replicated in several recent studies.36–38 It is inter-
      uate them in as comprehensive a manner as pos-                           esting to note that patients who made less com-
      sible. These additional blood tests can be easily                        prehensive changes in lifestyle showed significant
      done to serve that purpose.                                              progression of their atherosclerosis, suggesting
           There are heart disease risk factors unique to                      that the conventional 30 percent–fat diet recom-
      women. These include oral contraceptive use,                             mendation made to patients with cardiovascular
      pregnancy, having had both ovaries removed, and                          disease is not low enough. See the nutrition and
      premature menopause. Additional risk factors not                         dietary factors section for more about the Dean
      related to gender include increased body fat, espe-                      Ornish low-fat diet.
      cially if it is in the abdominal area; history of smok-                       Smoking is the most important risk factor for
      ing; being sedentary; diabetes mellitus; high blood                      cardiovascular disease and heart attacks, even in
      pressure; poor lipid ratios; and family history.                         premenopausal women. Smokers have three to
                                                                               five times the risk of coronary artery disease as
      OV E RV I E W O F                                                        nonsmokers, and smoking accounts for one-fifth
      A LT E R NAT I V E T R E AT M E N T S                                    of CVD deaths.39, 40 Even smoking only one to
      Conventional and alternative medicine practition-                        four cigarettes a day doubles a woman’s risk of
      ers agree that, in most cases, atherosclerosis and                       CVD. Smoking a pack or more per day may
      cardiovascular disease are directly related to diet                      double to quadruple that.41 Tobacco smoke con-
      and lifestyle. While family history and genetic                          tains chemicals that damage the lining of the
      predisposition play an important role in cardiovas-                      arteries, raise the cholesterol level, promote the
                                                                                               HEART DISEASE      115
 KEY CONCEPTS                                            reduces blood pressure, helps to inhibit blood
                                                         clots, reduces overall body fat, and minimizes
 • Determine your individual risk for cardiovascular     damage from stress.
   disease; make an appointment with a knowl-                In many women, stress is the major cause of
   edgeable health-care practitioner for medical         their high blood pressure. Relaxation techniques
   history, physical exams, and tests.                   such as deep breathing, biofeedback, meditation,
 • Monitor blood pressure regularly.                     yoga, progressive muscle relaxation, and hypnosis
 • Monitor fasting levels of total cholesterol, HDL
                                                         have all been shown to have some value in lower-
   cholesterol, LDL cholesterol, cholesterol/HDL
                                                         ing blood pressure.43 Many recent studies on var-
   ratio, triglycerides, and blood glucose. Consult
   with your health-care provider regarding at what      ious stress reduction techniques have also shown
   age to start and how frequently ECGs, stress          improvement in blood pressure and other meas-
   ECGs, stress echocardiograms, and cardiac or
   carotid artery imaging may be needed on an             PREVENTION
   individual basis depending on symptoms and
   suspicion of CVD.                                      Prevention of Heart Disease
 • More sophisticated testing as needed or desired:       • Get regular aerobic exercise for 30 minutes, 5–7
   homocysteine, alpha-lipoprotein (a), fibrinogen,          days per week.
   C-reactive protein, HDL subfractions, LDL              • Increase fish, whole grains, fruits, vegetables,
   subfractions.                                            legumes, olive oil, and nuts and seeds intake.
 • Heart disease, and especially heart disease ear-       • Eat lean meats and poultry without the skin.
   lier in life, is a preventable disease; appropriate    • Eat low-fat or fat-free dairy (preferably organic).
   diet and exercise, emotional balance and stress        • Decrease consumption of foods high in saturated
   management, and herbal and nutritional supple-           fats, cholesterol, sugar, and simple
   mentation may substantially reduce CVD risk.             carbohydrates.
 • Benefits and risks of hormone replacement ther-         • Work toward or maintain a healthy body weight.
   apy need to be discussed with a health-care            • Do not drink more than one alcoholic beverage
   provider familiar with up-to-date research on            per day.
   this topic.                                            • Stop smoking and avoid secondhand cigarette
ability of platelets to clump together, elevate
                                                          Prevention of Hypertension
levels of fibrinogen (a clot-forming protein), and
elevate the blood pressure. Smoking is especially         • Limit sodium intake to less than 2,400 mg per
problematic in women who use oral contracep-                day.
tives. This combination increases the risk of             • Practice stress management techniques.
                                                          • Work toward or maintain a healthy body weight.
CVD by up to 39 times due to blood clots.42 The
                                                          • Exercise daily for 30 minutes or more.
good news is that women who stop smoking can
reduce their risk of CVD to that of a nonsmoker           Prevention of Hyperlipidemia
within two years of quitting.
                                                          • Decrease consumption of saturated fats and
    Exercise is a vital part of a lifestyle routine
                                                            high-cholesterol foods.
that can have lifelong benefits in preventing heart        • Increase consumption of fruits, vegetables, and
disease and strokes. Regular exercise lowers cho-           whole grains.
lesterol levels, improves the blood supply and            • Exercise daily for 30 minutes or more.
therefore the oxygen delivered to the heart,              • Increase consumption of olive oil, nuts, and
increases the strength of the heart muscle and              seeds.
thus improves the volume of blood it can move,
116   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      ures of CVD, including decreased mortality and                           as reduction of breast, ovarian, and uterine
      oxidative stress.44–49                                                   cancer risk.
          A fundamental tenant of alternative medicine                             In addition to amount of fat, the type of fat
      is that lifestyle changes that include smoking                           is also important. Understanding the harmful
      cessation, appropriate exercise, diet, and the use                       effects of some fats and the beneficial effects of
      of dietary ingredients, nutritional supplements,                         others can be confusing. A little explanation of
      and herbal extracts can prevent or reduce risks                          terms and concepts may go a long way in clarify-
      and treat cardiovascular disease. Considerable                           ing the issue. Fats are the most concentrated
      scientific research exists that demonstrates the                          source of food energy. Each gram of fat provides
      effect of these natural therapies and interventions                      9 calories, compared with only 4 calories per
      in lowering cholesterol, improving blood lipid                           gram for carbohydrates or protein. All fats are
      ratios, lowering blood pressure, preventing clots                        made from carbon, oxygen, and hydrogen. These
      and strokes, inhibiting fibrinogen, lowering                              elements are arranged in molecules called fatty
      homocysteine levels, strengthening the cardiac                           acids. The three major classes of dietary lipids are
      muscle, and preventing the oxidative damage to                           triglycerides, phospholipids, and sterols (such as
      vessel walls, all of which are implicated in cardio-                     cholesterol). Ninety-five percent of the dietary
      vascular disease risk. Ingredients such as fiber,                         fats are triglycerides. A triglyceride is a glycerol
      soy, antioxidants, folic acid, vitamins B6 and B12,                      molecule with three fat molecules attached.
      magnesium, fish oils and flax oil, garlic, haw-                            These fat molecules are called fatty acids. Lipase
      thorn berry, and others are just some of the many                        enzymes, found in our bile, break apart the
      natural therapies that give alternative practition-                      triglyceride molecules. The triglyceride is con-
      ers a great deal of confidence in their ability to                        verted into a monoglyceride, which the body can
      help women to prevent and treat heart disease.                           then absorb, along with the individual fatty acids
      Most alternative practitioners employ a diverse,                         and the glycerol.
      holistic health plan in their approach to prevent-                           Fatty acids and monoglycerides are absorbed
      ing and treating CVD. Recent research supports                           and transported by lipoproteins. These lipopro-
      the use of supplements like fish oil, oat bran, and                       teins are the very low-density lipoproteins
      plant sterols in combination with diet and exer-                         (VLDL), low-density lipoproteins (LDL), and
      cise interventions as a way to favorably effect all                      high-density lipoproteins (HDL) that we have
      lipid parameters,50 and diets focused on decreas-                        discussed earlier in the chapter. VLDL and LDL
      ing cholesterol have long-term success on par                            transport the fats from the liver to the cells in the
      with statin therapy.51                                                   body, and HDL returns the fats to the liver. Ele-
                                                                               vations of LDL or VLDL are associated with an
      Nutrition and Dietary Factors                                            increased risk for atherosclerosis (narrowing of
      Dietary habits are a fundamental area where we                           the arteries), which compromises blood flow to
      can exert a great deal of influence on our heart                          the heart, which can cause a heart attack, and
      health.                                                                  creates an artery prone to releasing a blood clot,
                                                                               which can lead to a stroke. Elevation of the HDL
          Fats. Lowering the level of dietary fat has
                                                                               is protective and is associated with a lower risk of
      been in the news for a long time now. The Amer-
                                                                               heart attacks.
      ican Heart Association says that 30 percent or
      less of our total calories should be from fat. Many                         Types of Fatty Acids. A distinction should be
      alternative practitioners advise even lower intakes                      made between different types of fatty acids. Sat-
      because of some of the additional benefits, such                          urated fatty acids are solid at room temperature
                                                                                                    HEART DISEASE        117
and are typically animal fats (found in beef,                    either PUFAs or saturated fats. Of all the types
lamb, butter, cheese, and lard). Saturated fats in               of fat, monounsaturated is the healthiest for
general are not good for the heart; they con-                    your heart.
tribute to LDL cholesterol and should be eaten                       An omega-9 oil, such as oleic acid (found in
in sparse amounts for a heart-healthy diet. A                    olive oil), is a monounsaturated fat that has the
triglyceride is a saturated fat when the carbon                  unsaturated bond at the ninth carbon molecule
molecules in the fatty acids are saturated with                  on the chain. Monounsaturated oils like canola
hydrogen molecules and can’t carry any more.                     and olive are ideal for cooking as they are made
When some of the hydrogen molecules are                          chiefly of oleic acid that is more resistant to
removed, what remains is an unsaturated fatty                    damage from the heat from cooking and light
acid, or unsaturated fat. Unsaturated fats are                   from storage. The high content of oleic acid
liquid at room temperature and, therefore, are                   make these two oils far superior to the highly
called oils. Most vegetable oils contain mainly                  polyunsaturated oils like corn, safflower, and soy
unsaturated fats. These are not as bad for you as                that are easily damaged by heat and light and
saturated fats, and they contain healthy essential               aren’t as heart-healthy. The fatty acids in these
fatty acids (discussed later), but they aren’t                   less desirable oils are changed to lipid peroxides
healthy in large quantities. Polyunsaturated fatty               with cooking, which have a toxic effect on the
acids contain more than one double bond along                    inside of the arteries. In a healthy cardiovascular
the fatty acid chain. Replacing saturated fatty                  prevention regime, one would, therefore, prefer-
acids in the diet with polyunsaturated fatty acids               entially eat the seeds and fruits that contain
(PUFAs) from vegetable oils will lower both total                monounsaturated oils; use canola, sesame, and
cholesterol and LDL levels and decrease blood                    olive oil for cooking; and leave the rest of the oils
pressure.52 However, it may also lower HDL.                      on the supermarket shelves. (See Table 9.2 for the
    The third general type of fat is monounsatu-                 fatty acid composition of different dietary oils).53
rated fat. These fats contain one double bond.                       We don’t hear a lot about sesame oil, but a
Monounsaturated fatty acids, as found in olive                   number of studies have proven its cardiovascular
oil, show either no effect on HDL or an increase                 benefits. One study showed a significant decrease
in HDL, thereby promoting a better effect than                   in blood pressure measures in patients after 45

 Table 9.2      Fatty Acid Composition of Various Dietary Oils

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

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

 *Is especially high in the preferential monounsaturated fat, oleic acid.
118   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

       Five Omega-6 and Omega-3                                                in arachidonic acid and high in omega-3 fatty
       Fatty Acids to Remember                                                 acid.82 Fish consumption not only improves lab-
                                                                               oratory values but also decreases evidence of car-
         LA: Linoleic acid. An omega-6 fatty acid found in                     diovascular disease at the blood vessel level in
          vegetable oils, nuts, and seeds. Given the proper                    terms of stenosis and other markers of atheroscle-
          conditions, the body converts LA to GLA and                          rosis in postmenopausal women who consumed
          eventually into prostaglandin 1.                                     two or more servings of fish per week.83
         GLA: Gamma-linolenic acid. LA gets converted to
          GLA by enzymes in the body. Certain foods, habits,                        Fiber. Increasing the fiber in the diet is
          and events (saturated fat, partially hydrogenated                    another vitally important nutritional habit to
          oils, stress, aging, drinking alcohol) disrupt this                  acquire. Fiber sources that form a gel such as psyl-
          conversion so that only 5 to 10 percent of LA gets                   lium seed or oat bran bind bile and cholesterol in
          converted to GLA. It may be better to get GLA                        the intestines and promote their excretion. This
          directly from evening primrose oil, black currant
                                                                               action improves the cholesterol by decreasing LDL
          oil, or borage oil supplements.
                                                                               levels while increasing HDL levels.84 A diet high
         ALA: Alpha-linolenic acid. This is an omega-3 fatty
          acid not commonly found in foods. Seven seed oils
                                                                               in whole grains, fruits, vegetables, and legumes is
          contain some ALA, with flaxseed oil being the                         the optimal high-fiber diet. Soluble fibers such as
          richest natural source. Through several biochemical                  pectin or oat bran have the most consistent bene-
          steps, the body converts ALA to EPA and then to                      ficial effects on cholesterol levels.85 Most studies
          prostaglandin 3.                                                     on fiber have shown rather impressive lipid reduc-
         EPA and DHA: Eicosapentaenoic acid and doca-                          tions, with the higher the initial cholesterol, the
          hexaenoic acid. These two omega-3 fatty acids are                    greater the benefit. One of the ways fiber helps to
          found in cold-water fish oils. EPA is a building                      lower cholesterol is to increase the rate at which
          block for the body to make prostaglandin 3; DHA
                                                                               food passes through the digestive tract, thereby
          is important for the brain, nervous system, and
                                                                               increasing the loss of cholesterol in the stool. A
                                                                               review of 20 scientific trials on the effect of oat
                                                                               products on cholesterol demonstrates that a
      vascular disease.74–79 Norwegian researchers con-                        modest reduction in blood cholesterol can be
      cluded that eating fish like mackerel, herring, and                       achieved by eating oat products daily.86 Eating one
      salmon will significantly reduce the risk of heart                        bowl of oat bran cereal or oatmeal daily (3 grams
      disease. As little as one serving of 300 grams of fish                    of oat fiber) lowers the total cholesterol by 8 to 23
      per week will provide the benefit. They suggested                         percent. These results have been achieved in as
      that the minimal dietary requirement for EPA and                         little as three weeks.
      DHA should be about 200 mg per day.80                                         A more recent study showed that dietary fiber
          Keep in mind that fish oil has anticoagulation                        intake is inversely correlated with several cardio-
      effects that may act synergistically with medica-                        vascular disease risk factors. The highest total
      tions like warfarin, and therefore caution should                        dietary fiber and nonsoluble dietary fiber (more
      be exercised in supplementing with fish oil in                            than soluble) intakes from fruit, vegetables, and
      people who are taking these medications.81                               cereals were significantly associated with a
      Lipid-lowering medication was found to decrease                          decrease in a number of cardiovascular risk
      beneficial omega-3 fatty acids and increase path-                         factors including overweight, hypertension, lipid
      ogenic arachidonic acid after only three months                          markers, and homocysteine.87 Part of fiber’s
      of use, leading the authors to conclude that these                       effect on lipids is because these higher fiber
      medications should be combined with diets low                            diets are in fact diets low in cholesterol intake.88
                                                                                            HEART DISEASE        121
Another study found that soluble fiber added              even worse if you eat high-fructose corn syrup, a
simply as a breakfast bread source was found to          very common sweetener used in packaged foods.
significantly decrease blood pressure and triglyc-        Fructose increases LDL and does not improve
eride and cholesterol levels in diabetic patients.89     HDL. A recent study showed that foods with a
Increased fiber intake (more than 3 grams of              high glycemic index have a negative effect on
cereal fiber daily or more than six servings of           HDL levels.98
whole grains per week) is also associated with               If you have elevated triglycerides, you can eat
decreased progression of coronary atherosclerosis        all the whole grains that you want, although
in postmenopausal women.90                               some diets, such as the popular Zone diet, pres-
    A number of large, recent epidemiological            ent some provocative, controversial ideas that
studies published in medicine’s most respected           may be contrary to this.
journals found that overall, increased intake of             One of the best ways to achieve a high-fiber
dietary fiber is associated with decreased cardiovas-     and low-fat diet is the vegan diet. This is a vege-
cular disease in adults91, 92 and menopausal             tarian diet in which absolutely no animal prod-
women.93, 94 Another study looked at the combi-          ucts are consumed. Strict vegan diets, which are
nation of 10 mg of simvastatin and 15 grams of           typically very low in saturated fat and dietary
psyllium (Metamucil) and found that the combi-           cholesterol and high in fiber, can help maintain
nation decreased LDL cholesterol better than the         or achieve desirable blood levels by especially
same dose of medication alone and found reduc-           lowering the total cholesterol and the LDL
tions comparable to 20 mg of simvastatin after           cholesterol.99
four to eight weeks of treatment without signifi-             Specific fruits or vegetables may also have a par-
cant changes in HDL or triglycerides.95 One study        ticular positive effect on serum lipids. Raw carrots
of a very low saturated fat diet plus a cholesterol-     may have a more potent effect on lowering choles-
lowering drug, compared to a diet high in plant          terol than do oat products. Eating a raw carrot at
sterols, including soy foods and high-fiber whole         breakfast every day for three weeks has been shown
grains, concluded that dietary intervention may be       to reduce serum cholesterol by 11 percent and
as effective as the medication.96 Continuing to eat      increase fat excretion by 50 percent.100
a diet higher in fiber as we age also provides car-           Evidence also exists demonstrating that
dioprotection. A large study found that increasing       people with a low intake of fruits and vegetables
fiber later in life can decrease risk of cardiovascular   have an increased risk for heart disease.101
disease in the elderly.97                                Numerous studies have continued to show that a
    Research has also shown that the sugars in           diet high in carotenes and flavonoids found in
fruit (fructose) significantly raise blood triglyc-       fruits and vegetables reduces the risk of heart dis-
eride and cholesterol levels. If your triglycerides      ease and strokes.102 It is thought that the antiox-
are above 150 mg/dL, or if you have additional           idants (C, E, carotenes, and flavonoids) found in
significant risk factors for heart disease such as        fruits and vegetables reduce the risk of cardiovas-
elevated blood pressure or diabetes, avoid too           cular disease by scavenging free radical species.
much fruit, fruit juice, and other simple sugars.        The antioxidants protect the unsaturated fatty
Limit them to one serving per day. Sugar can be          acids from peroxidation, thus preventing athero-
eaten in small amounts only if your triglyceride         sclerosis. Lipid peroxide concentrations are in
level is below 150 mg/dl. All sugars can increase        fact higher in individuals with atherosclerosis.103
triglycerides, but a high amount of fructose, esp-       Good dietary sources of carotenes as well as vita-
cially fructose added as a sweetener, is actually        mins C and E are green leafy vegetables, yellow-
more damaging than sucrose and glucose. It gets          orange fruits and vegetables, red and purple
122   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      fruits and vegetables, legumes, grains, and seeds.                       studies published from 1966 to 2005 found that
      Good dietary sources of flavonoids are citrus                             soy protein intake was significantly related to
      fruits, berries, onions, parsley, legumes, green tea,                    decreased total and LDL cholesterol and trigly-
      and red wine.                                                            cerides and increased HDL.106 Other studies of
                                                                               pre- and postmenopausal women found that soy
          Soy. Soy foods contain a group of non-                               is beneficial for improving lipid parameters,107, 108
      steroidal plant chemicals called phytoestrogens.                         with even more favorable effects in type 2
      These compounds are similar in their chemical                            diabetic women with hyperlipidemia,109 decreas-
      structure to estradiol, and to equol, a phytoestro-                      ing lipid peroxidation better than estrogen,110
      gen metabolite, but they are not actually estro-                         improving platelet function,111 decreasing homo-
      gens. Phytoestrogens are categorized into three                          cysteine,112 and working synergistically with
      main classes: isoflavones, lignans, and coumes-                           statins to achieve favorable cholesterol levels.113
      tans. Isoflavones contribute significantly to our                          New research states consuming 25 grams of soy
      dietary phytoestrogen intake. Isoflavones are                             protein (containing 50 mg of isoflavonoids) daily
      found in legumes and are highest in soybeans.                            for five weeks may decrease systolic blood pres-
      These isoflavones are associated with the protein                         sure by nearly 6 percent.114
      part of the soybeans and are not found in soy oils                           There are many other positive soy studies,
      or soy lecithin.                                                         too numerous to list here, but to be fair, let’s talk
          One potential dietary influence for a choles-                         about those soy studies that have not showed lipid-
      terol-lowering strategy is to consume more soy                           lowering effects. A recent study looked at daily soy
      protein. This is perhaps my favorite recommenda-                         consumption in the form of a 50-mg isoflavone bar
      tion to women because soy also offers many other                         and found no significant change in lipids, except
      potential benefits, including mild reduction of                           an increase in HDL, when consumed for eight
      menopausal symptoms and potentially reduction                            weeks. The isoflavone-enriched bar did improve
      in the risk of breast cancer and uterine cancer.                         C-reactive protein (CRP), a marker of inflamma-
      Observations in large Asian populations, whose                           tion that mediates the initiation and progression
      diet includes soybeans as a basic food group, show                       of atherosclerotic plaque lesions, but had no sig-
      a lower incidence of CVD than in populations                             nificant effect on other plasma inflammatory
      who consume a traditional Western diet.104                               markers.115 A controlled trial of 202 healthy post-
          Much research has been done on soy and its                           menopausal women aged 60 to 75 concluded that
      relationship to blood pressure, cholesterol, and                         the use of a soy protein supplement containing
      even some inflammatory biomarkers of cardio-                              isoflavones did not improve plasma lipids when
      vascular disease. In general, the studies are varied,                    started at age 60 or older.116 A 2006 review article
      with some showing clear benefit and some not                              concluded that the evidence for soy lowering
      showing any. Perhaps the best evidence comes                             cholesterol was not overwhelmingly impressive.117
      from a review of 38 scientific studies. This meta-                            Interestingly, when soy intake (30 grams of
      analysis concluded that consumption of soy pro-                          soy, including 4 grams of phytosterols) was stud-
      tein rather than animal protein significantly                             ied in the setting of a low glycemic index diet
      decreased serum concentrations of total choles-                          (a diet that does not raise blood sugar levels
      terol, LDL cholesterol, and triglycerides.105                            quickly), it demonstrated more improvement in
          The use of soy for menopausal symptoms and                           lipid parameters than the standard American
      heart disease protection continues to receive                            Heart Association Diet.118 It may in fact be that
      great interest from women, practitioners, and sci-                       soy is most effective as part of an overall healthy
      entists. Most recently, a large meta-analysis of                         diet and lifestyle plan. Substituting soy protein
                                                                                          HEART DISEASE        123
for animal protein increases the variety of nutri-     food containing refined carbohydrates. Decreas-
ent intake and adds fiber, monounsaturated fats,        ing the total carbohydrate intake in favor of
minerals, and antioxidants while avoiding the          increased protein may be advisable as well. A
saturated fats found in animal protein. Other          recent study of women found that weight loss of
studies have found that supplementing the diet         as little as 5 percent with a plan that included
with a soy protein and soy fiber lowers LDL and         decreased carbohydrates and increased exercise
total cholesterol119 and that eating any legumes,      lead to a decrease in the ability of LDL choles-
including soy, at least four times per week can        terol to cause atherosclerosis.126 Of course, this
lower the risk of cardiovascular disease.120           would presume the carbohydrates left in the diet
    Despite the lack of effect in some studies         to be complex and not refined.
on soy and lipids, when we look at the role of soy         If your triglycerides are above 150 mg/dL, or if
in other aspects important to women’s health—          you have additional significant risk factors for heart
reducing the incidence and severity of hot             disease such as elevated blood pressure or diabetes,
flashes, loss of bone mass, vaginal dryness, and        limit fruit, fruit juice, and other simple sugars to
female-related cancers—the most convincing             one serving per day. Sugar can be eaten in small
effects of soy are in fact in the area of its action   amounts only if your triglyceride level is below 150
on lipids. The North American Menopause Soci-          mg/dl. All sugars can increase triglycerides, but
ety seems to agree with this perspective in a 2000     fructose is actually more damaging than sucrose
consensus opinion.121                                  and glucose. It gets even worse if you eat high-fruc-
    With many good reasons for women to eat            tose corn syrup, a very common sweetener used in
soy, blood pressure may be another area of bene-       packaged foods. Fructose increases LDL and does
fit. New research states that consuming about 25        not improve HDL. A recent study showed that
grams per day of soy protein can decrease blood        foods with a high glycemic index have a negative
pressure.114, 122–124                                  effect on HDL levels.98
                                                           Foods with a high glycemic index are those
    Good Carbs, Bad Carbs. It seems we all love
                                                       foods that raise blood sugar levels quickly. These
carbohydrates. Complex carbohydrates, such as
                                                       foods include items such as white bread, refined
found in brown rice, whole wheat, rye, oats,
                                                       cereals, white rice, and white flour pasta. These
barley, millet, whole fruits, and vegetables are
                                                       foods greatly stress blood sugar control and cause a
high in both fiber and vitamin content and there-
                                                       rapid rise in blood sugar. In response, the body
fore the preferred form of carbohydrates. Refined
                                                       secretes insulin from the pancreas. Over time, too
carbohydrates, on the other hand, must be placed
                                                       much insulin is secreted, called hyperinsulinemia,
in the group of unhealthy foods. Sugar, a refined
                                                       and the body tissues become resistant to the
carbohydrate, is a significant factor in the devel-
                                                       insulin. These two consequences of a high glycemic
opment of atherosclerosis.125
                                                       index diet can promote the growth of cancer and
    High-sugar diets lead to elevations in trigly-
                                                       increase the risk of heart disease and diabetes.
cerides and cholesterol and also to an increase in
                                                           Reading labels on packaged foods is a good
insulin production. Elevations in insulin levels
                                                       strategy for reducing intake of refined sugars. Any
are associated with risk of cardiovascular disease
                                                       label that says sucrose, glucose, maltose, lactose,
by increasing cholesterol, triglycerides, and blood
                                                       fructose, sugar, corn syrup, or white grape juice
pressure. The prudent woman would decrease all
                                                       concentrate is a source of added dietary sugar.
sources of refined sugar in the diet by avoiding
candies, pastries, and desserts; she would also           Salt. With all this talk of lowering cholesterol
avoid sweetened cereals, white breads, or any          and improving the cholesterol ratios, it is easy to
124   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      forget how important it is to balance the blood                          more dietary saturated fats and cholesterol, are
      pressure and how foods may have a positive or a                          more likely to be smokers, and are less likely to
      negative effect on this. For example, a diet low in                      be current exercisers.130
      potassium and high in sodium is associated with                              I encourage all my patients to decrease their
      high blood pressure. By contrast, a diet high in                         coffee intake to not more than one regular coffee
      potassium and low in sodium can protect against                          drink per day. Using any stimulant to falsely raise
      elevation of blood pressure.127, 128 It has become                       energy and obscure the fact that we are tired or
      common knowledge that too much salt in our                               stressed or just plain doing too much in our lives
      diet may contribute to high blood pressure. Not                          does not seem consistent with respecting our
      so commonly known is that high blood pressure                            bodies’ normal rhythms. For women who have
      is also related to too little potassium in our diet.                     elevated cholesterol, elevated blood pressure, or
      In fact, restricting salt alone may not be enough                        generally higher risks for heart disease, the
      to lower the blood pressure. Potassium must be                           number of studies that do show a connection
      increased. Most Americans ingest twice as much                           between coffee and hyperlipidemia, hyperten-
      sodium as potassium. Nutrition researchers rec-                          sion, and coronary heart disease seem to deliver
      ommend a 5:1 potassium-to-sodium ratio that is                           an obvious message: just say no.
      easily accomplished by a diet high in fresh fruits                           In hypertensive individuals, the use of caf-
      and vegetables, which are rich in potassium.                             feinated beverages is questionable. Two studies
          Dietary recommendations in the treatment                             showed slight elevations in blood pressure or a
      of hypertension were evaluated by the federal                            potentiation of the stress-related rise in blood
      government in the Dietary Approaches to Stop                             pressure in hypertension-prone males. In a third
      Hypertension (DASH) studies. The DASH diet                               study, caffeine (75 mg per day) had no effect on
      is high in fruits, vegetables, and low-fat dairy                         the blood pressure of young, healthy subjects.131
      foods and low in saturated and total fats. It is                         In a recent study, caffeine consumption was not
      also low in cholesterol but high in fiber, potas-                         found to be related to the incidence of hyperten-
      sium, calcium, and magnesium. The DASH                                   sion but consumption of cola was.132
      diet, along with a sodium intake of less than
                                                                                   Caffeine also appears to have adverse effects
      2,400 mg per day, results in significantly lower
                                                                               on serum lipid profiles. In men, coffee intake
      blood pressures—systolic pressure that is 7
                                                                               induced higher levels of cholesterol.133, 134 More-
      points lower in patients without hypertension
                                                                               over, when men with elevated cholesterol levels
      and 11.5 points lower in those with hyperten-
                                                                               refrained from coffee for five weeks, their serum
      sion.129 The characteristics of the DASH diet are
                                                                               cholesterol dropped by 10 percent. Those who
      described in Table 9.3.
                                                                               continued to abstain from coffee showed a 13
          Caffeine. The peer pressure to become a                              percent average drop at ten weeks, and those who
      coffee drinker is no greater than the conflicting                         returned to coffee gradually reached prestudy
      evidence around the health impact of coffee.                             levels of total cholesterol.135 In women, choles-
      Some studies say it raises cholesterol; some do                          terol levels increased with increasing amounts of
      not. Some say caffeinated coffee is the problem                          coffee with a low of 214 mg/dL at one-half to
      but decaffeinated is not; others show no differ-                         one cup per day and a high of 234 mg/dL at four
      ence between the two. There is no one consistent                         cups per day.136 Almost all of the difference was
      answer on the effect of coffee on heart disease.                         due to an increase in low-density lipoprotein
      What does seem to be true is that caffeinated                            cholesterol. Cholesterol was not affected by
      coffee drinkers also drink more alcohol, consume                         decaffeinated coffee in this study.
                                                                                                HEART DISEASE    125

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

 Food                Daily        Serving                                                  Significance
 Group               Servings     Sizes                       Examples                     of Food

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

    There are multiple reasons that coffee has this         and possibly kahweol in unfiltered coffee.
effect on serum cholesterol. Unfiltered coffee in            Another explanation came to light in a recently
particular137, 138 increases coronary artery disease        published Norwegian study140 that indicated a
risk and mortality in men and women.138, 139                dose-response between coffee consumption and
This effect is possibly explained by the presence           blood homocysteine levels: the larger the coffee
of the diterpines (removed by filtering), cafestol,          intake, the greater the homocysteine levels.
126   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

      ation, and Treatment of High Blood Cholesterol                           Therapeutic Lifestyle Changes (TLC) Diet
      in Adults, Adult Treatment Panel III (ATP).” The
      American Heart Association has adopted the                               Limits for LDL-Raising Nutrients
      NCEP III guidelines, calling for more intensive                          Saturated fats                   Less than 7% of total
      life-habit interventions to lower cholesterol and                                                         calories
      reduce the risk for heart disease and of heart                           Trans fats                       Minimal or none
      attacks. They call this the Therapeutic Lifestyle                        Dietary cholesterol              Less than 200 mg per day
      Changes (TLC) diet. Its target is to lower LDL
      cholesterol. See the following sidebar for the rec-                      Therapeutic Options for Lowering LDL
      ommendations of the TLC diet.                                            Plant stanols/sterols            2 g per day
                                                                               Soluble fiber                     10–25 g per day
         AHA Recommendations. The American Heart
                                                                               Total calories                   Adjust total calorie intake
      Association dietary recommendations are designed                                                          to maintain desirable
      to reduce high cholesterol, high blood pressure,                                                          body weight
      and excess weight. These are the dietary guidelines:                     Physical activity                Include enough moderate
                                                                                                                exercise to expend at least
       • Eat a variety of fruits and vegetables. Choose
                                                                                                                200 calories per day
         five or more servings per day.
       • Eat a variety of grain products, including                            Recommendations for Nutrient Intake
         whole grains. Choose six or more servings
                                                                                                                Percentage of
         per day.                                                              Nutrient                         Total Calories
       • Include fat-free and low-fat milk products,
                                                                               Total fat                        25–35%*
         fish, legumes (beans), skinless poultry, and
                                                                               Saturated fat                    Less than 7%
         lean meats.
                                                                               Polyunsaturated fat              Up to 10%
       • Choose fats with 2 grams or less of saturated                         Monounsaturated fat              Up to 20%
         fat per serving, such as liquid and tub mar-                          Carbohydrates**                  50–60%
         garines, canola oil, and olive oil.                                   Protein                          Approximately 15%
       • Balance the number of calories you eat with                                                            (including soy protein)
         the number you use each day. (To find that
         number, multiply the number of pounds
                                                                               *Range of percentages for total fat allows for increased
         you weigh now by 15 calories. This repre-                             intake of unsaturated fat in place of carbohydrates in people
         sents the average number of calories used in                          with metabolic syndrome or diabetes.
         one day if you’re moderately active. If you                           **Carbohydrates should be mainly from foods rich in complex
                                                                               carbohydrates and fiber, including whole grains, legumes,
         get very little exercise, multiply your weight                        fruits, and vegetables.
         by 13 instead of 15. Less-active people burn
         fewer calories.)
       • Maintain a level of physical activity that
         keeps you fit and matches the number of                                • Limit foods high in saturated fat, trans fat,
         calories you eat. Walk or do other activities                           and/or cholesterol, such as full-fat milk
         for at least 30 minutes on most days. To lose                           products, fatty meats, tropical oils, partially
         weight, do enough activity to use up more                               hydrogenated vegetable oils, and egg yolks.
         calories than you eat every day.                                        Instead choose foods low in saturated fat,
       • Limit your intake of foods high in calories                             trans fat, and cholesterol.
         or low in nutrition, including foods like soft                        • Eat less than 6 grams of salt per day (2,400
         drinks and candy that have a lot of sugars.                             mg of sodium).
                                                                                           HEART DISEASE       129
 • Have no more than one alcoholic drink per             Heart Disease. What is now known as the Ornish
   day.                                                  Lifestyle Modification Program is based on the
                                                         following four components:
    Not all low-fat diets have provided cardiovas-
                                                          1. A very low-fat, high complex carbohydrate
cular prevention. In the Women’s Health Initiative
                                                             diet rich in fruits, vegetables, whole grains,
dietary modification trial, 48,835 postmenopausal
                                                             beans, and legumes
women aged 50 to 79 years were randomly
                                                          2. Regular exercise
assigned to an intervention of intensive behavior
                                                          3. Stress management
modification to reduce total fat intake to 20 per-
                                                          4. Family/community support systems to
cent of calories and increase intakes of vegetables
                                                             maintain healthy behavior
and fruits to five servings per day and grains to at
least six servings per day.155 After an average of 8.1       The main focus is a plant food–based diet
years, this diet did not significantly reduce the risk    containing whole fruits and vegetables, whole
of CAD, stroke, or CVD in postmenopausal                 grains (brown rice, whole wheat breads, whole-
women and achieved very modest effects on CVD            grain cereals, whole wheat pasta), dried beans
risk factors. What this tells me is that an even         and legumes, soy products, lean poultry, fish, egg
more rigorous diet and lifestyle changes need to be      whites, and nonfat dairy. Plant oils are to be used
achieved in order to improve risk factors and            only lightly, and red meat, butter, and animal fats
reduce CVD risk.                                         are to be avoided, as are processed foods, high-fat
                                                         foods, sweets, and caffeinated drinks. Alcohol
    The Mediterranean Diet. The Mediterranean
                                                         and salt are to be consumed in moderation. The
diet, perhaps one of the healthiest diets in the
                                                         Ornish Lifestyle Modification Program claims to
world, emphasizes increased fiber, olive oil, fruits,
                                                         promote weight loss, improve cardiovascular
vegetables, grains, and legumes and decreased
                                                         health, help to regulate blood sugar and insulin,
refined cereals, meat products, eggs, and saturated
                                                         and lower cholesterol levels.
fats. This diet has been shown to have a beneficial
                                                             Whether it is the TLC diet, the Step 1 or Step
effect on cardiovascular health in a number of
                                                         2 diet, the Mediterranean diet, or the Ornish
large studies.156 The Mediterranean diet has also
                                                         diet, they all offer a great step toward reducing
been shown to have beneficial effects on risk fac-
                                                         the risk of heart disease. One might be more
tors for cardiovascular disease and may even
                                                         suited to you over the other. Consider reading
exceed that of the low-fat diet. Compared with a
                                                         more about each, experimenting, or speaking
low-fat diet, three months on a Mediterranean
                                                         with your health-care practitioner and/or a qual-
diet that included olive oil (one liter per week) or
                                                         ified nutritionist to determine which approach is
packets of walnuts, hazelnuts, and almonds
                                                         best for you.
decreased cardiovascular risk factors.157 Both of
these diets were associated with significant reduc-       Nutritional Supplements
tions in blood pressure, lower fasting glucose
                                                         Although dietary changes alone can have a pow-
levels, lower insulin levels in those without dia-
                                                         erful effect in reducing the incidence of heart
betes, lower triglycerides, increased HDL-C, and
                                                         disease, they may not be enough for everyone.
lower C-reactive protein levels.
                                                         Lowering cholesterol, lowering blood pressure,
   Ornish Lifestyle Modification Program. The             inhibiting blood clots, preventing oxidative
low-fat diet has been promoted by Dr. Dean               damage to the vessel walls, and several other
Ornish since the publication of his bestselling          mechanisms are all effects that can be achieved
book Dr. Dean Ornish’s Program for Reversing             with the therapeutic use of nutritional/herbal
130   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      supplements. This is an exciting and successful                          surgery), or the rate of cardiovascular events three
      area for alternative medicine to make an impact                          years later.163–165
      on a large segment of the population. Given that                             Major clinical trials of antioxidant use for the
      heart disease is the number-one cause of death in                        primary (initial) prevention of CVD are cur-
      men and women in America, these concepts                                 rently underway and include tens of thousands of
      deserve the attention and respect of individuals                         participants. In the near future, with an adequate
      and practitioners of all disciplines and all schools                     amount of high-quality scientific data, we hope
      of thought.                                                              to gain greater clarity as to the impact of antiox-
                                                                               idant combination products and multivitamin
          Antioxidant Combinations. Combination
                                                                               combinations on cardiovascular disease.
      nutritional supplements are difficult to evaluate
      because of the multi-ingredient combinations and                             Vitamin E. In the past, I went so far as to say
      the different doses of each single ingredient from                       that of all the vitamins or minerals, vitamin E may
      one product to another. Numerous observational                           offer the greatest protection for women against
      studies have, however, evaluated the effect of                           heart disease because of its ability to be easily
      antioxidant combinations on cardiovascular                               incorporated into the LDL-cholesterol molecule
      events.158–161 In one study, vitamins C and E                            and prevent free radical damage and, as a result,
      reduced coronary death and death due to all causes                       prevent atherosclerosis and CAD.166 A number of
      in elderly patients.158 In another, an antioxidant                       clinical trials have shown that vitamin E supple-
      supplement significantly lowered risk for myocar-                         mentation (alone or in combination with other
      dial infarction (heart attack) in men and women                          antioxidants) leads to increased resistance of LDL
      over 55.159 A Finnish study showed no significant                         to oxidative damage.167, 168 Doses between 500
      effect of an antioxidant supplement on death due                         and 1,500 IU have shown significant reduction in
      to coronary artery events;161 however, only 3 per-                       LDL oxidation.169 Women who took vitamin E
      cent of the people actually used an antioxidant sup-                     supplements for more than two years had about
      plement. In the very large U.S. observational study                      half the risk of CVD.170 A recent study evaluating
      of more than 1 million men and women,160 there                           childhood and adulthood dietary intake of vita-
      were modest reductions in CVD deaths among                               min E found that people who consumed the most
      women using antioxidants supplements who had                             vitamin E in their diet had a decreased risk of
      no previous history of CVD.                                              hypertension.171
          Prevention trials with antioxidant combina-                              The New England Journal of Medicine pub-
      tions have unfortunately not produced hoped-for                          lished a report showing that women who took at
      results. In the Heart Protection Study, a combina-                       least 100 IU of vitamin E per day for several years
      tion of vitamin C, vitamin E, and beta-carotene                          had 40 percent decreased likelihood of having
      appeared to cause no difference in either death                          a coronary event when compared with non-
      rates due to any cause, heart disease–related                            vitamin E users.172 Continued research has now
      deaths, heart disease events, or vascular events of                      demonstrated that doses between 400 and 800
      any kind.162 Other quality studies of an antioxi-                        IU per day dramatically reduce the risk of nonfa-
      dant supplement for secondary prevention of                              tal heart attacks, but do not reduce the number
      CVD (people who already had evidence of heart                            of deaths from CAD.173 Doses of 400 to 1,000
      disease or had a previous cardiac event) showed no                       IU per day provide additional cardiovascular
      significant effects on the rate of return of narrow-                      benefit by inhibiting platelet aggregation,
      ing of a coronary artery, the rate of restenosis (a                      increasing HDL-cholesterol, and stimulating the
      return of narrowing of the coronary artery after                         breakdown of fibrin (a clot-forming protein).
                                                                                         HEART DISEASE        131
     Levels of vitamin E in the blood may be more      more) may increase death rates, at least in those
directly related to the development of a heart         people with chronic illnesses.180 It is important
attack or stroke than are total cholesterol levels.    to point out that this type of analysis has serious
Whereas high blood pressure was predictive of a        flaws. To summarize an insightful commentary
heart attack 25 percent of the time, and high          written by a well-known clinician, Allan Gaby,
cholesterol 29 percent of the time, low blood          M.D., for the Emerson Ecologics website (emer
levels of vitamin E was predictive almost 70 per-      sonecologics.com), in these different studies,
cent of the time.174                                   patients were randomly assigned to take vitamin
     There are, though, negative studies on vita-      E, in doses ranging from 16.5 to 2,000 IU per
min E’s effect in cardiovascular disease. Although     day, or a placebo for at least one year. Most of the
vitamin E was shown in animal studies to be            patients had one or more chronic diseases includ-
beneficial for hypertension,175, 176 a human trial      ing heart disease, diabetes, Parkinson’s disease,
found that relatively modest doses, 500 IU             Alzheimer’s disease, or kidney failure. Others
mixed tocopherols per day for six weeks, led to        were at high risk of developing heart disease.
an increase in blood pressure and heart rate in        When all 19 studies were combined, the risk of
diabetic patients.177 A very large study, called the   what is called all-cause mortality, or death due to
HOPE trial, had a significant influence in dimin-        any cause, did not differ significantly between
ishing the role of vitamin E for cardioprotection      people assigned to vitamin E supplementation
in the minds of many consumers and practition-         and those who were in the placebo group. In
ers. In women and men, 55 years of age or older,       studies using doses of vitamin E less than 400 IU
who were at high risk for cardiovascular disease,      per day, the vitamin E supplementation was
treatment with 400 IU vitamin E per day for an         associated with a small although not statistically
average of 4.5 years had no apparent effect on         significant reduction in the death rate. In the 11
cardiovascular outcomes.178 The HOPE-TOO               studies using more than 400 IU per day, vitamin
trial was extended for another four years and          E supplementation increased the risk of death by
studied men and women at least 55 years old            4 percent.
who had vascular disease or diabetes.179 Again,            A number of other influences may have
there were no differences in the main cardiovas-       affected this small but statistically significant
cular outcome between those who took vitamin           increase, including additional nutrient supple-
E and those who took the placebo. In essence,          mentation, serum cholesterol levels, and the high
there was no significant effect of vitamin E on         percentage of participants with significant health
myocardial infarction (MI), stroke, cardiovascu-       problems such as high blood pressure, diabetes,
lar death, unstable angina, or total death rate. In    cigarette smoking, and severe coronary artery dis-
fact, investigators observed an increase in heart      ease. There may have also been a problem in the
failure rates in patients assigned to the vitamin E.   type of vitamin E used. (There are four different
It is not known whether this was due to chance         types of vitamin E: alpha-, beta-, gamma-, and
or whether the alpha-tocopherol form of vitamin        delta-tocopherol, and gamma-tocopherol is the
E became a pro-oxidant in these patients with          most effective as an antioxidant.)
significant disease.                                        With these flaws, and in contrast to the large
     One of the most damaging reports on vita-         body of scientific evidence that shows the bene-
min E was a meta-analysis on high-dosage vita-         fits of vitamin E in slowing the progression of
min E that compiled the results of 19 studies          Alzheimer’s disease, treating intermittent claudi-
from 1966 through August 2004 to conclude              cation, fibrocystic breast disease, premenstrual
that large doses of vitamin E (400 IU per day or       syndrome, osteoarthritis, and more, I continue
132   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      to advise the use of vitamin E supplementation.                          ated with decreased cardiovascular disease in a
      While controversial, I am not willing to give                            retrospective study of over 85,000 women.189
      up on the potential benefits of vitamin E and                                 Recent long-term studies of vitamin C do not
      cardioprotection.                                                        support its use in hypertension, however. A study
                                                                               of 500 mg daily for over five years was shown to
       Vitamin E                                                               have no effect in a group of over 400 subjects.190
       400–1,000 IU per day
                                                                                   Coenzyme Q10. CoQ10 can be used for
                                                                               high blood pressure control, atherosclerosis,
          Vitamin C. Vitamin C is probably not a
                                                                               angina, mitral valve prolapse, congestive heart
      major player in blood pressure, hyperlipidemia,
                                                                               failure, and cardiomyopathy. As an antioxidant,
      or other influences on cardiovascular disease.
                                                                               CoQ10 protects against atherosclerosis by pre-
      However, vitamin C has a positive effect on the
                                                                               venting the oxidation of LDL. In a recent study,
      cardiovascular system and, along with folic
                                                                               150 mg CoQ10 in combination with the lipid-
      acid and zinc, has been found to be low in the
                                                                               lowering medication fenofibrate worked better
      blood of hypertensive patients.181 Vitamin C
                                                                               than drug therapy alone in improving total cho-
      protects LDL cholesterol from oxidation,182
                                                                               lesterol, triglycerides, and blood pressure.191 A
      raises HDL cholesterol, and lowers total choles-
                                                                               large review study showed that CoQ10 adminis-
      terol triglycerides.183 In one recent study, 500 mg
                                                                               tration led to decreases in systolic and diastolic
      of vitamin C for 10 weeks led to significant
                                                                               blood pressure of 16 and 10 mmHg respec-
      decreases in total cholesterol and apoB, a bio-
                                                                               tively.192 A study using 60 mg CoQ10 twice daily
      marker for cardiovascular risk.184 But a combina-
                                                                               for 12 weeks led to an average decrease in systolic
      tion product that included 500 mg vitamin C,
                                                                               blood pressure readings of nearly 18 percent.193
      160 mg bioflavonoids, 600 mg magnesium, and
                                                                               These findings were similar to a previous study
      900 mg vitamin B complex led to decreased clot
                                                                               looking at 60 mg CoQ10 twice daily for eight
      formation in adults with hyperlipidemia.185 In a
                                                                               weeks in patients already receiving conventional
      recent study, 36 IU vitamin E and 250 mg vita-
                                                                               cardiovascular treatments.194 This study also
      min C two times per day dramatically decreased
                                                                               found decreases in blood sugar, insulin, and tri-
      atherosclerosis in hypercholesterolemic patients
                                                                               glycerides and increases in HDL. CoQ10 may be
      at both three and six years.186 Despite these
                                                                               coadministered with conventional medication to
      encouraging results, a long-term study of 500 mg
                                                                               increase duration of antihypertensive effect up to
      vitamin C daily did not significantly affect any
                                                                               twice as long.195 Other studies of up to 600 mg
      lipid measures except triglycerides in women
                                                                               per day allowed patients to decrease the dose or
      who had high triglycerides.187
                                                                               discontinue the conventional medication while
          Smokers may gain a particular advantage
                                                                               dramatically improving cardiovascular function-
      with vitamin C. Nicotine has been known to
                                                                               ing196, 197 and decreasing subsequent cardiovascu-
      reduce blood vitamin C levels. An increased
                                                                               lar events and mortality by nearly half in patients
      intake of dietary vitamin C has been associated
                                                                               with a prior history of MI.198 CoQ10 also works
      with decreased risk of cardiovascular disease in
                                                                               together with vitamin E in preventing damage to
      smokers,188 who are typically deficient, and
                                                                               lipids and to the vessels.199
      intake of vitamin C supplementation was associ-
                                                                                   It may be that CoQ10 can benefit those
       Vitamin C                                                               women who choose to take HRT and are con-
       1,000 mg or more per day
                                                                               cerned about the potential for increased risk of
                                                                               heart disease. A recent study showed that the
                                                                                            HEART DISEASE     133
common dose of Prempro led to a decrease in             with more significant increases in HDL.213 Cal-
CoQ10 and vitamin E levels in the blood,                cium carbonate 400 mg three times daily can
thereby increasing menopausal cardiovascular            reduce cholesterol and LDL cholesterol by about 4
risk factors in women who use HRT.200 Use of            percent and increase HDL by 4 percent.214
statins to treat high cholesterol has been associ-          While reducing cholesterol and blood pres-
ated with muscle pain and decreased exercise tol-       sure may not be calcium’s strong suits, the bene-
erance that has been correlated with a reduction        fits to bone health, tooth retention, weight loss,
in CoQ10.201–204                                        PMS, and reduction in the risk of colorectal
                                                        cancer make it one of our most important dietary
 CoQ10                                                  nutrients and nutritional supplements.
 50–150 mg per day
     Calcium. Calcium is most well known for             400–1,200 mg per day calcium carbonate or other
its effects on bone health, but it can also be used       form
to treat elevated cholesterol and hypertension.
Calcium supplementation may produce modest                  Magnesium. Many scientists and health
reductions in blood pressure, usually only 1 or 2       practitioners believe that magnesium is one of
points. But in those whose blood pressure is very       the most important nutrients for cardiovascular
sensitive to salt intake or whose dietary intake of     protection and treatment. Drs. Burton and Bella
calcium is low, supplementation may be more             Altura of NY Health Science Center have done
effective. Calcium has been related to decreases        some of the most consistent research in magne-
in systolic blood pressure,205, 206 and an analysis     sium over the last 30 years. They, and others,
of 40 well-controlled studies found that calcium        assert that magnesium contributes to the
lowers blood pressure measurements.207 Another          strength of contraction of heart muscle,215
large review of studies of calcium for hyperten-        increases HDL levels,216 inhibits platelet aggrega-
sion in pregnancy found that higher calcium             tion and prolongs the clotting time,217–219
intakes were correlated to decreased blood pres-        decreasing the risk of heart disease, strokes, for-
sure, as well as resultant preeclampsia and             mation of atherosclerotic plaque, and blood clots
death208 and that the combination of calcium            that can result in heart attack or stroke.
and linoleic acid decreases pregnancy-induced               At least 10 independent clinical studies show
hypertension as well.209, 210                           that patients with hypertension exhibit serum
     Not all studies have shown benefit, and a large     and/or tissue hypomagnesemia. On the average,
review of three randomized controlled trials inves-     patients with long-term hypertension have at
tigating the combinations of magnesium, potas-          least a 15 percent deficit in total magnesium.220
sium, and calcium found no evidence that these          A recent review of studies showed that supple-
supplements improved blood pressure or mortal-          mentation with magnesium appears to modestly
ity.211 Calcium probably has only a small role in       decrease blood pressure,221 yet another large
lowering cholesterol, but a recent randomized con-      review showed no effect at all.222 Magnesium may
trolled trial suggests that calcium may have a role     be more effective in decreasing blood pressure and
in decreasing cholesterol via its ability to improve    improving arterial function when combined with
the function of bile in the liver, thereby increasing   potassium.223 Evidence from both animals and
cholesterol excretion,212 and another study on 223      humans suggests that magnesium levels in diet
menopausal women showed that calcium supple-            and blood may affect blood lipids; the lower the
mentation did decrease cholesterol slightly and         magnesium intake, the higher the serum lipid
134   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      levels. In addition, a recent study showed that                              Niacin has been compared to several conven-
      supplementation of 600 mg daily for 12 weeks                             tional pharmaceutical drugs used to reduce choles-
      produced improvements in all lipid parameters in                         terol levels. A study published in 1994 compared
      both type 1 and 2 diabetics.224, 225 There is strong                     niacin and lovastatin over a period of 26 weeks in
      evidence suggesting a relationship between                               136 patients who were at high risk for coronary
      uncontrolled type 1 and type 2 diabetes and mag-                         heart disease.233 Lovastatin produced a greater
      nesium deficiency,220 thus magnesium deficiency                            effect on reducing LDL cholesterol, but niacin pro-
      may predispose diabetic patients to an increased                         vided better overall results. Niacin far exceeded
      incidence of cardiovascular disease and death.                           lovastatin in increasing HDL cholesterol, which is
          Magnesium also improves cardiac perform-                             a more significant indicator in reducing the risk for
      ance by enhancing blood flow in the coronary                              heart disease, and some estimates suggest that it
      arteries. It also prevents oxidation of lipoproteins                     can raise HDL by as much as 35 percent.234 Niacin
      and subsequent atherosclerosis.                                          has also been found to decrease inflammatory
                                                                               markers like C-reactive protein235 and increase
       Magnesium                                                               adiponectin, a hormone that not only decreases
       400–1,200 mg per day in divided doses                                   atherosclerosis but improves glucose tolerance,
                                                                               body mass index, and fatty liver disease.236, 237 In a
          Niacin. Niacin (nicotinic acid) has been shown                       study of patients with previous history of heart
      to favorably affect all lipids and lipoproteins, and it                  attack, niacin was found to decrease the risk of
      can be used either alone or in combination with                          repeat MI and death in patients with and without
      other lipid-lowering agents.226 We’re not sure                           metabolic syndrome.238
      exactly how it works, although it likely inhibits                            Conventional practitioners and alternative
      mobilization of free fatty acids from peripheral fat                     practitioners alike acknowledge that several
      tissue to the liver. As a result, niacin reduces hepatic                 grams of niacin per day will lower total choles-
      synthesis of very low-density lipoprotein (VLDL)                         terol and LDL cholesterol, raise HDL,239 and
      and triglyceride levels. Because there is less VLDL                      decrease atherosclerosis both alone and when
      available, LDL levels decrease.227                                       used with conventional treatments like statins.
          The Coronary Drug Project was the first trial                         The niacin and statins seem to act synergistically
      to study the effect of niacin on cardiovascular                          to improve lipid parameters at lower doses, in a
      endpoints.228 Niacin therapy in men with prior                           shorter amount of time, and more effectively
      MI reduced the five-year incidence of nonfatal                            than when either is used alone.240–242
      reinfarction by 27 percent. In addition, after a                             The major problem with the therapeutic
      mean follow-up of 15 years all-cause mortality                           dosage (1.5 to 3 grams per day) has to do with
      was 11 percent lower in niacin-treated men com-                          side effects. Flushing responses are common.
      pared with placebo-treated patients.229                                  Anecdotally, some clinicians decrease the effects
          Niacin—specifically nicotinic acid—may be                             of niacin’s flushing by having the patient start
      used to reduce total cholesterol, TG, and LDL                            with a low dose, like 500 mg per day, increasing
      levels and to raise HDL values. It is currently the                      the dose weekly to achieve the desired dose, and
      best treatment to raise HDL levels,227 and it can                        taking the dose before bed or coadministering
      reduce the risk of nonfatal MI.230 Niacin lowers                         with 81 mg baby aspirin. More seriously, liver
      LDL levels by about 5 to 25 percent, TG by 20 to                         function findings can become abnormal, and
      50 percent, lipoprotein(a) by 34 percent,231 and the                     individuals with liver disease should not take
      total cholesterol/HDL ratio by 27 percent226 while                       niacin. Immediate-release niacin is recom-
      increasing HDL levels by 15 to 35 percent.232                            mended, as sustained-release niacin has been
                                                                                         HEART DISEASE        135
associated with severe liver toxicity in doses of     cial in people over age 65 who often do not
more than 2 grams per day. Niacin can also exac-      respond well to antihypertensive drugs.
erbate elevated serum glucose levels in diabetics         Potassium supplements are available by pre-
and can worsen gout. Niacin in doses of more          scription and over the counter. The FDA restricts
than 1 gram per day are best taken under the          the potassium over-the-counter dose per tablet to
guidance of a physician, with monitoring of           99 mg due to potential problems with nausea,
liver-function tests.                                 vomiting, diarrhea, and ulcers that may result from
                                                      higher doses of the mineral. The frequency and
 Niacin (Nicotinic Acid)                              severity of side effects associated with potassium
 500 mg 1–3 times per day                             supplementation are negligible when compared
                                                      with the frequency and severity of side effects asso-
    Pantethine. Pantethine is the activated form      ciated with conventional antihypertensives.
of vitamin B5 (pantothenic acid) and a key com-           Potassium dosing should be based on individ-
ponent of coenzyme A (CoA). CoA plays a sig-          ualized need and potassium level in the blood.
nificant role in lipid metabolism and is involved      The common dose for treating hypertension is
in the transport of fats. The cells of our body       48 to 90 mEquivalents daily. Drug/potassium
need CoA to utilize fats in the form of energy.       interactions are possible, and a consultation with
Pantethine, at the typical dose of 300 mg three       your health-care provider should occur if you are
times per day, has been shown to significantly         taking ACE inhibitors, angiotensin receptor
reduce serum triglycerides, total cholesterol, and    blockers, or potassium-sparing diuretics. In addi-
LDL cholesterol, while also increasing HDL cho-       tion, certain drugs influence the nutrient levels
lesterol.243, 244 This same dose was found to be      and depletion of potassium.
effective at decreasing adverse lipid parameters in       Decreasing sodium and increasing potassium
postmenopausal women.                                 intake helps prevent heart disease, high blood
                                                      pressure, and strokes. The standard American diet
 Pantethine                                           has a poor potassium/sodium ratio; the ideal
 300 mg 3 times per day                               potassium-to-sodium ratio is greater than 5:1. A
                                                      diet rich in fruits and vegetables can produce a
    Potassium. The role of potassium in the           more beneficial ratio because most of these foods
body crosses over into many physiological events      have significantly greater potassium than sodium.
that include nerve transmission, muscle contrac-      Amongst the highest are bananas, apples, carrots,
tion, enzymatic reactions, carbohydrate synthe-       oranges, lima beans, and potatoes.
sis, basic cell functions, and acid-base balance.
Inadequate potassium intake in the diet might          Potassium
play a role in the development of high blood           99 mg–2.5 g per day
pressure, stroke, and cardiovascular disease. In
addition to increasing the potassium foods in our         L-Arginine. L-arginine is an amino acid
diet, several studies now show that potassium         involved in many areas of our physiology, includ-
supplementation can reduce blood pressure. It         ing the production of nitric oxide, an important
has been shown that potassium supplementation         messenger in the regulation of our blood vessels.
of 2.5 grams per day can lower the systolic blood     We synthesize arginine from other substances,
pressure an average of 12 points and diastolic        but dietary intake is the primary source of our
blood pressure an average of 16 points.222 Potas-     arginine levels. Arginine is the precursor of nitric
sium supplementation may be even more benefi-          oxide, a gaseous molecule involved in relaxation
136   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      of the smooth muscles of our vessels, which                              terol in individuals with hyperlipidemia251 and
      results in vessel dilation (vasodilation) and inhi-                      also decreased triglycerides in those with high
      bition of blood platelets clumping together.                             blood pressure.252 Lipoprotein(a) levels, an inde-
           The key to arginine’s cardiovascular benefits is                     pendent biomarker of cardiovascular disease risk,
      its ability to induce endothelial nitrous oxide pro-                     have also been reduced with 2 grams per day of
      duction whereby an enzyme in the endothelium                             L-carnitine, even in those with type 2 diabetes.253
      (lining) of the blood vessel, nitric oxide xynthase,                     In addition, some preliminary evidence suggests
      catalyzes a reaction that produces nitrous oxide                         carnitine may be able to attenuate the muscular
      and ornithine. The nitric oxide diffuses into the                        side effects of statin therapy.254
      underlying muscle of the vessel and causes relax-                            Numerous other cardiovascular effects of L-
      ation and dilation. Nitric oxide also helps to pre-                      carnitine are beyond the scope of this chapter,
      vent atherosclerosis in the vessels, along with its                      but improvement in exercise tolerance, func-
      dilation and clot prevention effects.                                    tional improvement in angina, peripheral vascu-
           Supplementation with arginine has been                              lar disease, treatment of heart failure, and
      shown to increase artery dilation in normal people,                      reduced death rates from heart attacks are all
      people with hyperlipidemia, and in those with                            areas of clinical effectiveness of L-carnitine.
      hypertension;245, 246 significantly improve blood
      flow and function in patients with congestive heart                        L-Carnitine
      failure;247, 248 and in some, but not all trials,                         2–3 g per day
      improve blood flow, vasodilation, exercise toler-
      ance, and quality of life in those with angina.249, 250                      Folic Acid, Vitamin B6, Vitamin B12. Much
      Therapeutic doses for cardiovascular effects seem to                     research over the years has shown that elevated
      range from 6 to 12 grams per day. L-arginine is a                        plasma levels of homocysteine are associated
      very safe supplement and has been associated with                        with significant increases in coronary artery
      only minor problems lasting a few days, including                        disease,255–257 myocardial infarction,258, 259 periph-
      diarrhea, bloating, abdominal pain, or allergic reac-                    eral occlusive disease, cerebral occlusive dis-
      tions. The exceptions are those patients with kidney                     ease,260, 261 dementia, and Alzheimer’s disease.262
      failure or liver disease. For these patients, supple-                    Two recent meta-analyses of observational studies
      mental arginine may not be able to be metabolized                        concluded that a 25 percent reduction in plasma
      or excreted as well and should be monitored.                             homocysteine concentration was associated
                                                                               with decreases of 11 to 16 percent in the risk of
       L-Arginine                                                              ischemic heart disease and 19 to 22 percent
       6–12 g per day in divided doses, 3 g at a time                          reduction in the risk of stroke.263, 264 Folate, vita-
                                                                               min B12, and vitamin B6 are inversely related to
          L-Carnitine. L-carnitine is an amino acid                            homocysteine levels, and anyone with a nutri-
      found naturally in the body. We obtain some                              tional deficiency that leads to low concentrations
      L-carnitine from the diet in foods such as red meats                     of either one or more of these nutrients is at
      and dairy products, but our bodies also synthesize                       increased risk for elevated homocysteine levels.
      carnitines from two other amino acids, methionine                        Testing for homocysteine levels is available
      and lysine. L-carnitine has a key role in the energy                     through commonly available simple blood tests.
      production within our cells and is required to                               The first meta-analysis of the Homocysteine
      transport long-chain fatty acids into our cells.                         Lowering Trialists’ Collaboration concluded that
          Two to three grams per day of L-carnitine has                        folic acid supplementation lowered homocysteine
      resulted in reductions in total and LDL choles-                          levels by about 25 percent.265 The second meta-
                                                                                         HEART DISEASE        137
analysis found a 23 percent reduction in homo-         Besides changes in diet, supplementation of var-
cysteine concentration was the maximum observed        ious oils is also warranted for many individuals.
with 800 mcg per day of folic acid.266 A 20 percent    The daily consumption of fish oils can signifi-
reduction was seen with 400 mcg and 13 percent         cantly lower blood pressure in people with hyper-
with 200 mcg per day. Due to folic acid fortifica-      tension, and low consumption may increase the
tion of foods in the United States, our plasma         incidence of hypertension, especially in diets
folate concentration has increased, and subse-         with a low fish intake.270
quently our homocysteine levels have decreased.            A group of researchers at the Johns Hopkins
For those of us who eat a diet fortified with folic     Medical School evaluated the results of 17 clinical
acid in some of the foods, folic acid supplementa-     trials using fish oil supplementation and found
tion is likely to lower homocysteine concentrations    that consuming 3 grams or more per day of fish oil
by only about 15 percent.                              led to reductions in blood pressure of individuals
    Women are more responsive to the                   with hypertension,271 lowered systolic pressure by
homocysteine-lowering effects of folic acid than       an average of 5.5 mm Hg, and lowered diastolic
are men, and the Women’s Health Initiative             pressure by 3.5 mm Hg. The effect was found
demonstrated that the risk of vascular disease was     to be greater at higher blood pressures. A meta-
stronger than the association observed in males in     analysis of 36 trials of fish oil supplementation and
the Physician’s Health Study.267 High consump-         blood pressure, with an average dose of 3.6 grams
tion of foods containing folate and vitamin B6         per day, showed that fish oil had a small effect in
may reduce the risk of heart attack268 in women by     lowering blood pressure, especially in older people
nearly 50 percent.269 A study of 80,000 female         with hypertension.272 Another meta-analysis of 31
nurses showed a direct link between the ingestion      trials also showed a small but statistically signifi-
of these two B vitamins and reduced coronary dis-      cant drop in blood pressures of about 3 points /1.6
ease. The results suggested that eating more fruits,   points at 3.3 to 7 grams per day.273 Granted, these
vegetables, and whole grains or obtaining these        are small decreases, but fish oils in conjunction
vitamins through supplementation may be as             with other nutrients, botanicals, and lifestyle
important as quitting smoking, lowering choles-        changes can be used as part of a comprehensive
terol, or controlling high blood pressure in lower-    treatment plan to achieve a reduction in blood
ing heart disease risk. Folic acid and the lowering    pressure, stroke, and risk of coronary events.
of homocysteine has recently been less impressive          There are numerous studies on the effect of
as a heart disease prevention strategy.                omega-3 fish oils and triglycerides. In a review of
                                                       human trials, about 4 grams per day of omega-3
 Folic Acid                                            fatty acids from fish oil decreased serum triglyc-
 400 mcg–2.5 mg per day                                eride levels by 25 to 30 percent.274 Both the EPA
                                                       content and the DHA content of fish oils have
 Vitamin B6                                            the triglyceride-lowering effects. Among post-
 10–25 mg per day                                      menopausal women, fish oil supplementation of
                                                       2.4 g EPA and 1.6 g DHA per day not only
 Vitamin B12
                                                       lowered triglycerides by 26 percent but also
 400–1,000 mcg per day                                 improved the triglyceride/HDL ratio.275
                                                           Another issue pertinent to women is that for
    Essential Fatty Acids. As I discussed in the       those who are on hormone replacement therapy,
nutrition section, a diet rich in omega-3 oils         C-reactive protein (CRP) and triglycerides levels
results in a much lower risk of heart disease.         can be higher. A recent clinical trial of 30 women
138   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      on HRT showed that 7 grams per day of fish oil                            rant seed oil dose of 3 grams per day was shown
      supplementation significantly decreased CRP                               to decrease LDL more than fish oil.282 A more
      and triglyceride levels.78                                               recent commercially available product, hemp
          It may be most effective to supplement fish oils                      seed and hemp seed oil, may also prove to be
      with statin medications for lowering cholesterol.                        beneficial in the lowering of lipids, homo-
      In one clinical controlled trial, 59 patients who                        cysteine, CRP, and others. Evening primrose oil
      already had coronary heart disease and hyper-                            rich in gamma-linolenic acid (GLA) may also
      triglyceridemia who were taking statins were able                        have a role in prevention of heart disease283 by
      to significantly lower their levels of triglycerides                      decreasing LDL cholesterol.
      and very low density lipoprotein (VLDL) when
      taking the fish oil and the statin.276                                     Fish Oil
          Another drug/fish oil study showed that 3.36                           1 g per day of EPA and DHA
      grams per day of fish oils were able to further                            2–4 g per day of EPA plus DHA may be useful in
      decrease the triglycerides, total cholesterol, and                          patients with elevated triglycerides
      apolipoprotein E than just the statin alone.277                           Wild salmon ranges from 1.0–1.5 g EPA plus DHA per
      The most compelling reason to give fish oils is if                         3 oz serving, with a little more DHA than EPA. Differ-
      it in fact lowers heart disease. We have evidence                         ent species range in their EPA and DHA content. Wild
      for this from 15 large studies of more than                               sockeye salmon has approximately 600 mg DHA and
                                                                                430 mg EPA per 3 oz serving.
      60,000 individuals where a decrease in deaths
      from ischemic heart disease was observed in
                                                                                Flaxseed Oil
      those who consumed fatty fish or omega-3 fatty
      acids.278 In one of these studies, 1 gram per                             1 tbs per day
      day of omega-3 EFAs was associated with a 20
                                                                                Evening Primrose Oil
      percent decrease in total deaths, a 30 percent
      decrease in cardiovascular deaths, and a 45 per-                          3–4 g per day
      cent decrease in sudden deaths.279                                        All supplemental oils should be taken with meals.
          Flaxseed oil, nature’s richest source of omega-3
      fatty acids, is the vegetable alternative to fish oil. It
      contains twice as many omega-3s and is usually less                      Botanicals
      expensive. Flaxseed oil provides the body with                               Flavonoids. Flavonoids are a group of com-
      alpha-linolenic acid (ALA), which it uses to make                        pounds found in many fruits, vegetables, nuts
      EPA, whereas fish oil provides EPA directly. There                        and seeds, and numerous medicinal plants. Over
      is some concern that humans do not readily con-                          4,000 different flavonoids have been identified in
      vert ALA to the EPA and DHA, and therefore                               foods and plants. Quercetin, rutin, catechin, and
      flaxseed oil would be a less efficient method of                           hesperidin are the most frequently used in medi-
      gaining EPA and DHA. However, there are studies                          cine. Flavonoids inhibit the peroxidation of
      on supplementation with flaxseed oil that suggest                         lipids by acting as free radical scavengers.284
      protective effects against cardiovascular disease by                     Quercetin specifically has been shown to inhibit
      inhibiting the excessive clotting of blood.280 A                         LDL oxidation.285 In addition to these direct
      recent study of flaxseed’s effect on cholesterol in                       antioxidant effects, flavonoids inhibit platelet
      postmenopausal women found decreases in LDL,                             aggregation, protect vitamin E from oxidation,
      triglycerides, and other lipid parameters.281                            and chelate iron. In numerous dietary studies,
          Other seed oils may also provide some posi-                          flavonoids have been shown to reduce cardiovas-
      tive effects on lipids. For example, a black cur-                        cular disease.286, 287
                                                                                           HEART DISEASE         139
    Green, oolong, and black tea are made from         had a 16 percent lower risk of all-cause and CVD
the leaves of the Camellia sinensis plant and are      mortality during 11 years of follow-up.
rich in cardioprotective flavonoids. Green tea is           Several studies have examined the potential
especially rich in the flavonoids called catechins.     effects of tea on blood pressure. While there may
These include catechin, epicatechin, epicatechin       be transient increases in blood pressure due to
gallate, epigallocatechin gallate, and proantho-       the caffeine, regular use appears to be associated
cyanidins. Epigallocatechin gallate is considered      with lower blood pressures.293 Both green tea and
the most significant active component of green          oolong tea intake of 120 mL /day or more can
tea. Theaflavins are the pigments found in black        significantly reduce hypertension.294 In the large
tea, formed from the catechins during the fermen-      population-based Rotterdam Study of Dutch
tation of green tea to form black tea. Green tea       men and women, the risk of heart attacks was
catechins have been studied fairly extensively as      lower in those who drank more than 375 ml (one
preventive agents for cardiovascular disease.288–290   and a half cups) per day.295
    Two recent significant studies prove the car-
                                                           Garlic (Allium Sativum). Garlic is popular
diovascular benefits of green tea. Taking a
                                                       as a lipid-lowering agent, but it has a modest
flavonoid-rich green tea extract (375mg) for three
                                                       effect. While analyses have demonstrated that
months along with a low-fat diet decreased total
                                                       garlic can reduce total cholesterol levels by 5 to
cholesterol by 11.3 percent and LDL by 16.4 per-
                                                       12 percent, recent reports suggest these studies
cent in men and women with mild to moderate
                                                       may have been too brief to draw conclu-
hypercholesterolemia.291 Another study, the
                                                       sions.296–298 There is great variability in research
Ohsaki study,292 found that green tea consump-
                                                       results, which may in part be due to the great
tion was inversely associated with mortality due to
                                                       variation in the potency of and the extracts of
all causes and inversely associated with cardiovas-
                                                       garlic used. Even the studies showing a positive
cular disease. Compared with individuals who
                                                       effect lack long-term follow-up, standardized lab-
consumed less than one cup per day of green tea,
                                                       oratory measurements, and adequate dietary
those who consumed five or more cups per day
                                                       controls. While evidence supports at least a
 Flavonoids                                            short-term benefit, the effect is typically a small
                                                       but statistically significant decrease in lipid levels.
 Quercetin                                             Since 1975, over 32 human studies have been
 200–400 mg 3 times per day                            published demonstrating the lipid-lowering
                                                       effects of garlic.299 Two meta-analyses of these
 Citrus Bioflavonoids                                   studies indicate that one to three months of
 1,000–6,000 mg per day                                treatment using 600 to 900 mg of garlic powder
                                                       tablets reduced total serum cholesterol an average
 Green Tea                                             of 9 to 12 percent and triglycerides from 8 to 27
 More than 1 cup per day, and especially more than 5   percent.300, 301 A recent study of 30 patients who
    cups per day or                                    consumed 5 grams of raw garlic for 42 days found
 1 capsule or more per day of green tea catechin       significant decreases in total and LDL cholesterol
    extract                                            and increased HDL cholesterol. These benefits
                                                       were reversed after 42 days of no garlic.302
 Black Tea                                                 Garlic has also been shown to lower blood
 More than 11⁄ 2 cups per day                          pressure slightly,303 inhibit clotting,304 and regulate
                                                       heart rhythms.305, 306 Garlic is not as aggressive at
140   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      lowering serum cholesterol and triglycerides as                          some lipid-lowering activity. One clinical trial
      some of the newer pharmaceuticals, but it also                           used 1,800 mg of artichoke extract versus
      does not have any of their side effects. For women                       placebo for six weeks for the treatment of high
      with a modest elevation of cholesterol, it will pro-                     cholesterol levels.315 The decrease in total choles-
      vide a safer and effective alternative. For women                        terol values was 18.5 percent in the artichoke
      with severe hypercholesterolemia, appropriate                            group versus 8.6 percent in the placebo group.
      drugs may be used and later replaced by garlic                           Also, LDL values fell by 22.9 percent. For
      when the desired drug effect is complete.                                patients with gallstones or other bile-duct
          Garlic is not contraindicated during preg-                           obstructions, globe artichoke supplementation
      nancy and lactation, and 800 mg per day was                              should be avoided due to the choleretic activity
      found to be a safe and effective way to decrease                         of the extract. This product is currently available
      gestational hypertension.307                                             as a nutritional supplement in the United States.
          Problems with ingestion of garlic are usually
      minor. In sensitive individuals they may include                          Globe Artichoke
      heartburn and flatulence. Some people do not                               600 mg 3 times per day
      appreciate the odor or taste of garlic. Odor-free
      or enteric-coated products may avert these unde-                             Procyanidolic Oligomers (PCO). Extracts
      sirable effects. Individuals are rarely allergic to                      from grape seeds and the bark of the maritime
      garlic. However, people taking anticoagulant                             pine tree are high in a group of flavonoids called
      drugs should take garlic with caution and be                             proanthocyanidins, also called procyanidins.
      monitored by a health-care practitioner.                                 Mixtures of proanthocyanidin molecules are
                                                                               referred to as procyanidolic oligomers (PCO).
       Garlic                                                                  These commercially prepared extracts of grape
       1 fresh raw clove of garlic per day or                                  seeds and pine bark, or PCO extracts, possess
       Garlic pill providing a minimum of 4,000 mcg allicin                    potent antioxidant activity that is far stronger
         daily                                                                 than even vitamin E or vitamin C. In animal
                                                                               studies, PCO extracts have been shown to pre-
          Ginger (Zingiber Officinale). The same                                vent damage to the arterial lining, lower blood
      ginger that is used in cooking and ginger ale                            cholesterol levels, and shrink cholesterol deposits
      has been shown to inhibit platelet aggregation                           in the arteries.316, 317 Human studies have con-
      (blood platelets sticking together),308 lower                            firmed these findings in smokers,318 and a combi-
      cholesterol,309–312 inhibit atherosclerosis,313 and                      nation of 100 mg grape seed extract and 200 mcg
      decrease blood pressure.314 Ginger stimulates                            chromium two times daily was found to signifi-
      the conversion of cholesterol to bile acids and                          cantly decrease total and LDL cholesterol up to
      increases bile secretion, thereby lowering choles-                       20 percent.319
      terol by promoting its excretion and impairing its
      absorption. Most research studies have used one                           PCO
      gram of dry powdered ginger root.                                         50–300 mg per day

                                                                                   Gugulipid (Commiphora Mukul ). The
       1 g per day powdered ginger root                                        mukul myrrh tree, native to India, Pakistan, and
                                                                               Afghanistan, is the source of standardized
          Globe Artichoke (Cynara Scolymus). The                               gugulipid extract. The extract is further concen-
      leaf extract of the artichoke has been found to have                     trated to isolate compounds known as guggul-
                                                                                             HEART DISEASE    141
sterones. The two guggulsterones important
in the management of hyperlipidemia are
Z-guggulsterone and E-guggulsterone. Gugulipid           Choose one of the following:
appears to prevent the oxidation of LDL and may          Tincture (1 part herb to 5 parts alcohol): 405 ml
regulate the level of bile acids, helping the body to      per day
excrete cholesterol. Guggulsterones are thought to       Freeze-dried berries: 1.0–1.5 g per day
be the main active constituents responsible for          Flower extract (1.8 percent vitexin or 20 percent
these effects. Studies have shown that gugulipid           procyanidins): 100–250 mg per day
can decrease total cholesterol levels by 11.7 per-       Berries or flowers (dried as a tea): 3–5 g of dried
                                                           herb per day
cent, LDL by 12.5 percent, and TG by 12.0 per-
cent, with no change in HDL values.320 Most
commercial extracts are standardized to 5 percent           Plant Sterols/Stanols. Plant sterols are natu-
guggulsterone content, and the typical treatment        rally occurring cholesterol derivatives from veg-
dose is 500 mg (providing 25 mg of guggul-              etable oils, nuts, soy, corn, woods, and beans.
sterones) three times per day.321                       The hydrogenation of plant sterols produces
    A comprehensive review of available research        stanols. Sterols and stanols are often referred to
on gugulipid suggests conflicting evidence at this       generically by the term phytosterols. Phytosterols
time.322 When using the standardized extract            have a chemical structure similar to cholesterol,
preparations, only mild abdominal discomfort is         and the consumption of these plant sterols
reported in a small number of people.                   reduces the absorption of cholesterol and thus
                                                        reduces circulating cholesterol levels. Even
                                                        modest additions have been found to lower total
 500 mg with 25 mg guggulsterones, 3 times per day      blood cholesterol and LDL cholesterol by about
                                                        10 percent.328 Sterols and stanols from a dietary
    Hawthorn (Crataegus Oxyacantha). Haw-               intake of plant sterols in the range of 1.5 to 2.5
thorn leaves, berries, and blossoms contain flavo-       grams per day reduce LDL cholesterol by 8.5 to
noids. One of these, proanthocyanidin, has              10 percent.329 A recent study found that dietary
especially good cardiovascular effect. Hawthorn         intervention with plant sterols could reduce cho-
preparations are modestly effective in reducing         lesterol levels by about 30 percent, or approxi-
blood pressure,323 in the prevention and treat-         mately the same extent as one of the statin drugs,
ment of atherosclerosis, lowering cholesterol, and      levostatin.330 Most studies have found no effect
preventing the oxidation of LDL.324 Hawthorn            of these sterols on triglyceride levels, but some
preparations improve the blood supply to the            individuals have shown effects in recent stud-
heart by dilating the coronary arteries, increase       ies.331–333 Sterols do not seem to lower HDL
the force of contraction of the heart muscle, and       levels.
regulate cardiac rhythm.323 A very recent study of          Sterols and stanols are often added to selected
79 diabetic hypertensive patients who received          brands of margarines, semisolid food spreads,
1,200 mg hawthorn versus placebo for 16 weeks           and salad dressings. As of 2000, the FDA author-
found significant reductions in diastolic meas-          ized sterol-containing products to state that they
ures, no drug-herb interactions, and only few           reduce the risk of heart disease. The lowest effec-
mild side effects.325 Two randomized control trial      tive dose for such a claim is 1.3 grams per day.
found decreases in both systolic and diastolic          Sterols and stanols are also available in dietary
measures when treatment was administered for            supplements. The supplement forms of phyto-
about three months.326, 327                             sterols are advantageous in that they do not
142   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      require refrigeration, are convenient to take, and                       flicting evidence, I still recommend policosanol in
      are largely calorie free.                                                my clinical practice due to the results I witness.
          Dietary sterols include sitosterol, campe-
                                                                                   Red Yeast Rice. Red yeast rice is made from
      sterol, and stigmasterol. Soybean oil is the prin-
                                                                               cooked white rice fermented by the yeast
      cipal source of sterol esters, followed by canola,
                                                                               Monascus purpureus, which is then sterilized and
      sunflower, and corn oils. Sterols reduce total cho-
                                                                               dried. Red yeast rice has been used as a dietary
      lesterol levels and LDL cholesterol because they
                                                                               staple, to make rice wine, and as a food preserva-
      are natural competitors of cholesterol absorption
                                                                               tive and is a cholesterol-lowering agent. The
      and resorption.
                                                                               main active ingredient in red yeast rice is mona-
       Plant Sterols and Stanols                                               colin K (lovastatin),338 which inhibits the
                                                                               enzyme that initiates the synthesis of cholesterol.
       Average dose of 3.4 g per day
                                                                               Omega-3 fatty acids, isoflavones, and plant
       NCEP III recommends 2 g per day
                                                                               sterols in red yeast rice are likely also responsible
                                                                               for its beneficial effects on lipids. In one of the
          Policosanol. Policosanol is a mixture of alco-                       early studies on red yeast rice (using 2.4 g/d
      hols extracted from sugar cane, wheat germ, rice                         Cholestin), after 8 weeks cholesterol levels were
      bran, or beeswax. Policosanol has been used to                           lowered in men and women by 17 percent, LDL
      reduce total cholesterol, LDL cholesterol, and                           by 22 percent, and triglycerides by 12 percent,
      triglycerides and to increase HDL cholesterol                            with HDL values unchanged.339
      based on over 10 years of critical trials and 30                             However, there is significant variability in qual-
      or so positive clinical trials. One recent meta-                         ity and potency of commercial red yeast rice prod-
      analysis of natural interventions for abnormal                           ucts. In addition, the lovastatin content in dietary
      and elevated lipids concluded that policosanol is                        supplements of red yeast rice was lowered due to
      more effective than plant sterols.334                                    challenges by the FDA and others. Due to legal
          However, evidence to the benefits of poli-                            issues, Cholestin is no longer available. There are,
      cosanol is conflicting. In May of 2006, a random-                         however, other effective red yeast rice products.
      ized controlled trial studied four different doses of
      policosanol compared to each other and a placebo                          Red Yeast Rice
      group.335 None of the treatment groups had a                              2.4 g per day
      decrease of LDL cholesterol of more than 10 per-
      cent, and no statistically significant difference
                                                                                  Additional Botanical Therapies. A vast
      occurred between policosanol and placebo. It may
                                                                               range of herbs have been used for decades, or
      be that combining policosanol with other lipid-
                                                                               even centuries, to treat heart and vascular system
      lowering natural agents, and especially fish oils,
                                                                               conditions. Some of these herbs are categorized
      will offer the most effect. Animal and human
                                                                               here according to their dominant action:
      studies that combined 5 or 10 mg policosanol
      with 1 gram omega-3 fatty acids showed a                                 Diuretics: dandelion leaf, lily of the valley,
      decrease in total cholesterol, triglycerides, and                           parsley
      LDL and an increase in HDL greater than when                             Heart tonics: broom, bugleweed, figwort, haw-
      fish oils alone were used.336, 337 Despite this con-                         thorn, lily of the valley, motherwort, night-
                                                                                  blooming cereus
       Policosanol                                                             Aids to circulation: broom, cayenne, ginger,
       10–80 mg per day                                                           hawthorn, horse chestnut, lime flowers,
                                                                                  mistletoe, yarrow
                                                                                           HEART DISEASE        143
Nervines (reduce anxiety and stress): lemon            performed 12 resistance exercises for one hour,
   balm, hops, lime flowers, motherwort, pas-           three times per week. After five months of exercise,
   sionflower, skullcap, valerian                       they showed decreases of 13 and 14 points in total
Antihypertensives: rauwolfia, hawthorn, mistle-         cholesterol and low-density lipoprotein cholesterol
   toe, garlic, yarrow, crampbark                      (LDL), respectively, from baseline values. Another
Anti-atherosclerosis: lime flowers, hawthorn,           study noted that previously hypertensive adoles-
   mistletoe, yarrow                                   cents who reduced their blood pressure by aerobic
                                                       exercise were able to maintain blood pressure con-
Exercise                                               trol by taking weight-lifting exercise after discon-
                                                       tinuing aerobic exercise. These results are even
Numerous studies show the great heart-health
                                                       more surprising when one considers the lack of
benefits of exercise.340–371 Physical exercise is
                                                       effect noted for aerobic exercise in plasma total and
associated with a reduction in obesity, improved
                                                       LDL and triglycerides in women.
body fat distribution, a reduced risk of type 2
                                                           The type of exercise chosen appears less signif-
diabetes, reduced blood pressure, and reduced
                                                       icant than its intensity or duration on its effects on
cholesterol levels. In women of all ages, exercise
                                                       CVD risk factors. Exercise recommendations have
has been shown to reduce the risk for cardiovas-
                                                       changed over the years and will likely continue to
cular disease by altering CVD risk factors. In
                                                       change with time. Public health recommendations
addition, it diminishes the stiffness of arteries
                                                       vary by organization. I recommend engaging in
and decreases damaging plaque in blood vessels.
                                                       40 to 60 minutes of moderate-intensity physical
Finally, exercise reduces the risk of arrhythmias,
                                                       activity such as brisk walking on most days of the
normalizes blood lipids, and increases insulin
                                                       week or at a vigorous intensity for 20 minutes per
sensitivity. A recent study suggests that exercise
                                                       day. It should be noted here that the effects of
and modest diet changes can decrease cholesterol
                                                       exercise on CVD risk factors are not permanent.
and resultant atherosclerosis comparable to cer-
                                                       Code and colleagues found that, in both men and
tain statins. Most important, by staying active
                                                       women, the effects of exercise on blood pressure
with moderate levels of physical activity, we can
                                                       disappeared within weeks after the return to a
prevent cardiovascular disease independent of
                                                       sedentary lifestyle.
other risk factors and improve our life expectancy.
    Aerobic exercise in particular is known to raise    Benefits of Exercise
HDL cholesterol levels, and in women, HDL
may be the most important cholesterol issue in          Exercise:
predicting coronary artery disease. Williams             1. Normalizes blood lipids
found an average 0.13 mg/dL plasma HDL                   2. Elevates protective HDL levels in dose-response
increase for each additional kilometer run by               fashion
                                                         3. Significantly reduces LDL
female runners per week. Similarly, other studies
                                                         4. Reduces and stabilizes blood pressure
have reported modest to significant increases in          5. Increases insulin sensitivity
HDL cholesterol following aerobic training. In           6. Stabilizes weight and decreases fat mass and BMI
one of these studies, the increase in HDL was            7. Is beneficial in congestive heart failure
measured at 7.6 mg/dL when exercise was com-             8. Reduces CVD mortality
                                                         9. Is an essential in rehabilitation after heart
bined with smoking cessation in women.
                                                            attack, stroke, or bypass surgery
    In addition to aerobic exercise, strength train-    10. Alleviates stress
ing has been found to reduce CVD risk factors as
well. In one study, previously sedentary women
144   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

       Exercise Recommendations                                                studied 60 older patients (41 men and 19 women)
                                                                               who had had previous MI or bypass surgery and
       Prevention of Cardiovascular Disease                                    participated in a rehab program that included
       Follow the exercise guidelines outlined in Appendix A.                  treadmill running for 25 minutes, stationary
                                                                               biking for 15 minutes, and machine rowing for
       Treatment of Existing Cardiovascular Disease                            10 minutes for three and twelve months.371 The
         1. Consult a health-care provider before beginning                    results showed improved fitness and increased
            a new exercise program.                                            number and size of capillaries in the thighs.
         2. Use caution and moderation. Note that in men                           Women should be encouraged to gradually
            who seldom exercise, cardiac arrest is 56 times                    increase their exercise and engage in an exercise
            more likely during vigorous exercise than at rest.
            In men who exercise frequently, the risk is 5
                                                                               program that is safe, convenient, and hopefully
            times greater.372                                                  satisfying and even fun, at least at times. There is
         3. Walking program for heart patients:373                             no single best exercise but rather what’s best for
                                                                               you. Regular, lifelong exercise offers women
                                      Distance           Time                  more CVD benefits than any one drug, nutrient,
           Weeks                      (miles)         (min/mile)               or herbal intervention.
           1–2                             1                20
           3–4                             1              17–20
                                                                               Stress Management
           5–6                             1                15                 Women’s hearts appear more vulnerable to stress
           7–8                            1.5               15                 than men’s. Arnold suggests that negative stres-
           9–10                           1.5               14                 sors such as lack of social support and perceived
                                                                               lack of control contribute to CAD risk.375 A sim-
           To maintain the conditioning effect, exercise 20                    ilar inference can be made from the data
       to 30 minutes three to five times a week. If you stop                    obtained by Blumenthal and colleagues.376 In
       exercise for more than two weeks, start again at a
                                                                               patients with CAD or ischemia, these authors
       lower level and gradually build back up to your origi-
       nal program.
                                                                               found that a stress management program was
                                                                               approximately three times more effective at
       Examples of Moderate Exercise for Mild CAD374                           reducing cardiac events than exercise.
          • 30 minutes of brisk walking each day                                   Many simple techniques can be effective in
          • 10 minutes of brisk walking 3 times a day                          managing stress and reducing its baleful influ-
          • Swimming, biking, or working out on an exercise                    ence. Techniques such as deep-breathing exer-
            machine such as a treadmill, stair-climbing                        cises, biofeedback, transcendental meditation,
            machine, rowing machine, or stationary cycle at
                                                                               yoga, progressive muscle relaxation, and hypnosis
            moderate intensity for 30 minutes daily
                                                                               have all been shown to reduce stress and lower
       Begin slowly and increase speed gradually over time.                    blood pressure.377 The antihypertensive effect of
       If you have never exercised before, start with a few
                                                                               these techniques is not dramatic. However, they
       minutes each day and increase time gradually every
                                                                               constitute an important factor in a holistic pro-
       week until you reach 30 minutes per day.
                                                                               gram to lower blood pressure and treat and pre-
                                                                               vent heart disease.
          For several decades, exercise has been advo-
      cated for the treatment of men who have had a                            Natural (Bio-Identical) Hormone
      heart attack or stroke. Recent encouraging results                       Replacement Therapy
      suggest that it should also be prescribed for                            Whether a woman should go through the meno-
      women in similar situations. Ades and colleagues                         pausal years without hormone therapy or
                                                                                        HEART DISEASE       145
whether she should use bio-identical or conven-       more important, because it is biochemically
tional hormone therapy is a complex decision.         identical to the progesterone produced by the
The decision is especially difficult when one con-     human ovary. Natural progesterone is biochemi-
siders the many unanswered questions about            cally different than progestin, which is com-
menopause, cardiovascular disease, and natural        monly misstated as progesterone. The most
and conventional hormones. The method I               common progestin used for menopausal women
follow is to systematically evaluate each woman       is medroxyprogesterone acetate (MPA), better
with a thorough medical history, physical exam,       known as Provera.
and laboratory testing. Based on these tests and          There are few studies on natural proges-
the patient’s preferences and concerns, the prac-     terone. However, the development of oral
titioner and patient can together develop a per-      micronized progesterone (OMP) in the last 10 to
sonalized plan that is right for the patient.         15 years, together with the few side effects and
    A woman’s risk for cardiovascular disease         popularity of natural progesterone, have encour-
changes over time. The plan needs to change           aged scientific research and medical interest in
accordingly to carefully balance the benefits versus   this natural hormone. For more information on
the risks of therapy. Both practitioner and patient   the indications and effects of natural proges-
need to be open-minded so that informed and           terone, please refer to Chapter 12.
appropriate decisions are reached.                        To date, unfortunately, very few studies have
    Conventional HRT may be appropriate               addressed the possible cardiovascular effects of
for some women. When it is appropriate, it            these preparations in postmenopausal women.
behooves physicians to advise the use of the least    The study with the biggest impact on the percep-
objectionable options. Phytoestrogens and bio-        tion of natural progesterone was the Postmeno-
identical hormone therapy are perhaps the most        pausal Estrogen/Progestin Interventions (PEPI)
appropriate for some women, and I would assert,       trial.378 Although the postmenopausal women in
most women. No single protocol or approach is         this study were also given estrogen, the PEPI trial
equally appropriate for all women. Determining        demonstrated similar lipid changes for estrogen
if my patient is at low, medium, or high risk for     and progesterone that are known to occur with
CAD has been a critical tool in the path to the       administration of estrogen alone, except for HDL,
recommendations I finally make. (See the               which was significantly reduced. Perhaps what
overview section at the beginning of this chapter     merits reflection here is that, despite its other
for more about issues pertinent to HRT and car-       undesirable effects, estrogen alone has the most
diovascular disease.)                                 favorable effect on lipids. When estrogen is com-
                                                      bined with natural progesterone, HDL cholesterol
Natural (Bio-Identical) Progesterone                  does not improve quite as much, and when given
The use of natural or bio-identical progesterone      with progestin, HDL improves even less.
creams and oral micronized natural progesterone           A recent study compared the effects of natu-
has grown in popularity over the last several         ral progesterone and synthetic progestin (in the
years. However, only recently have natural prog-      form of conjugated equine estrogen) and found
esterone creams been shown to have biological         the following: the conjugated equine estrogen
activity. Progesterone is synthesized from dios-      (CEE) group had an increase in HDL levels of
genin or stigmasterol found in Mexican wild           14.4 percent after six months; the estrogen plus
yams and soybeans. This hormone end product           progestin had an increase in HDL of 4.58 per-
has come to be known as natural or bio-identical      cent; and the estrogen plus natural progesterone
progesterone both because it is plant derived and,    had an increase in HDL of 5.44 percent.379 Total
146   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      cholesterol levels were significantly decreased                           timing of when a woman starts HRT may affect
      only in the estrogen plus progestin group; triglyc-                      the risks and the benefits, see the overview sec-
      eride levels were increased only in the estrogen                         tion of this chapter.
      plus natural progesterone group; and the
      micronized progesterone was not superior to                              Natural (Bio-Identical) Estrogens
      medroxyprogesterone acetate.                                             Natural estrogens are what we have come to call
          There is evidence showing that oral                                  plant-derived bio-identical hormones. They
      micronized progesterone (OMP) may lower                                  include estradiol, estrone, and estriol. Mexican
      blood pressure. In fact, OMP administered in                             wild yam contains diosgenin and soy contains stig-
      doses of 200, 400, and 600 mg per day to hyper-                          masterol that can be converted into an estrogen
      tensive postmenopausal women and older men                               biochemically identical to that produced by our
      significantly reduced systolic blood pressure as                          ovaries. Bio-identical estradiol and estrone in a
      compared to placebo in a two-week treatment                              patented delivery system and in premanufactured
      trial.380 With the maximum dose, systolic blood                          dosages are available by prescription from
      pressure was decreased approximately 19.7 mm                             a regular pharmacy. Bio-identical estradiol, estrone,
      Hg and diastolic blood pressure about 9.6 mm                             and estriol can also be compounded in customized,
      Hg. At the lower doses, the decreases in systolic                        individualized dosages of any strength, any combi-
      blood pressure were less significant. Both OMP                            nation, and in many different delivery systems
      and progestins can cause fluid retention, although                        including lozenges, sublingual tablets, creams, gels,
      natural progesterone to a lesser extent.                                 capsules, and even injections. The distinctions
          Studies demonstrate that synthetic progestins                        between bio-identical estrogens and other forms of
      and natural progesterone have markedly different                         HRT are presented in Chapter 12. This section
      effects on the coronary vessels381 and on their                          will focus on their effect on the cardiovascular
      smooth wall muscle cells.382 The results of these                        system.
      two studies indicate that synthetic progestins                                Theoretically, if we have a dose of a bio-
      may induce spasm of the coronary arteries,                               identical estrogen that is equivalent in strength to
      whereas estrogen and/or natural progesterone                             the dose of the conventional estrogen, the cardio-
      promoted dilation.                                                       vascular benefit or risk should be the same.
          Although many women are presently using                              Nonetheless, any hormone therapy that is consid-
      natural progesterone creams as an alternative to                         ered to be an alternative to the leading form of ther-
      conventional HRT, relatively little research has                         apy (conjugated equine estrogens, i.e., Premarin)
      been done on these products—with little infor-                           must at some point be compared in order to prove
      mation about their impact on cardiovascular risk                         its worthiness and acceptability among patients and
      factors. For more information on the use of nat-                         health-care practitioners. A few studies have looked
      ural progesterone alone or in combination with                           at oral micronized estradiol alone or in combina-
      different estrogens in menopause, please refer to                        tion with bio-identical progesterone and compared
      Chapter 12.                                                              it to conjugated equine estrogens (CEE) plus
          Perhaps most interesting is that in the                              medroxyprogesterone acetate (MPA) to evaluate
      Women’s Health Initiative, women who were on                             possible effects on CAD. Ten menopausal women,
      estrogen only did not have an increased inci-                            administered the natural estrogen/progesterone
      dence of cardiovascular disease but did have an                          combination, experienced a decrease in total cho-
      increased risk of stroke,383 differing from the first                     lesterol. In contrast, this parameter did not change
      WHI study estrogen and progestin group.17 For                            significantly at 12 months over the initial choles-
      a discussion on other research and how the                               terol readings in the five women who were given
                                                                                                 HEART DISEASE     147
 Sample Treatment Plan for Cardiovascular Disease or Hyperlipidemia

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

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

       Sample Treatment Plan for Hypertension

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

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

       Table 9.4        ATP Guidelines for Drug Therapy

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

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

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

       Drugs Used to Treat High Blood Pressure

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

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

OV E RV I E W                                                   reproductive therapies for infertile couples who
Impaired fertility affects over 6 million women                 wish to have a child. Many ob-gyns, primary care
in the United States alone, and recent estimates                physicians, and complementary care providers
suggest that approximately 10 million couples                   may do couples a disservice by waiting too long to
have sought infertility services. Infertility is con-           make these referrals.
sidered a common condition and affects 10 to                        If pregnancy has not been achieved within
15 percent of reproductive age couples. Female                  one year in a woman less than 35 years old, eval-
infertility accounts for about 50 percent of the                uation of both partners should be initiated.
cases, 19 percent are due to male factor infertil-              Women who are 35 years old or older; women
ity, 17.6 percent are due to a combination, and                 who have a history of irregular menses, pelvic
about 10.5 percent of the cases are caused by                   pain, or dyspareunia (pain with intercourse); and
unknown factors.1 Female infertility most often                 women with a previous pelvic surgery, PID, or
is due to tubal and pelvic disease (40 percent) or              endometriosis should be evaluated earlier.
from a previous pelvic inflammatory infection,                       A detailed medical history is necessary to
asymptomatic chlamydia or gonorrhea, or ovula-                  determine many things that are pertinent to
tory dysfunction (40 percent). Endometriosis, a                 fertility:
diminished number of oocytes in the ovary, uterine
                                                                 •   Previous pregnancy history and outcome
abnormalities, immunologic factors, chromoso-
                                                                 •   Menstrual cycle details
mal abnormalities, environmental chemicals and
                                                                 •   Contraception history
toxins, and cancer chemotherapy or radiation
                                                                 •   Duration of time without contraception
can also cause infertility.
                                                                 •   Coital frequency
     Infertility is defined as a failure to conceive
                                                                 •   Surgeries, hospitalizations, illnesses, PID,
after 12 months of frequent intercourse without
                                                                     STIs, Pap smear history
contraception in women under 35 years of age or
                                                                 •   A review of other systems and history of any
failure to conceive after six months of intercourse
                                                                     thyroid problems, nipple discharge, acne,
without contraception in women 35 years of age
                                                                     facial hair, or hair loss
or older. Infertility is further broken down into
                                                                 •   Medications, allergies
two types: primary infertility is in women with
                                                                 •   Family history of serious illnesses, congenital
no history of prior pregnancy, and secondary
                                                                     birth defects, and reproductive health
infertility is with a history of prior pregnancy.
     Eighty-five percent of couples will conceive
                                                                 •   Lifestyle factors: smoking history, alcohol
after the first year of trying, with an increase to
                                                                     use, exercise
93 percent after two years. Most spontaneous
pregnancies occur within three years, and there is                 A physical evaluation should include height
a poor prognosis for success without treatment                  and weight, observation for signs of excess andro-
after that. This final point underscores the                     gens (facial hair, acne, and hair loss), abdominal
importance of timely specialty referrals to repro-              hip and waist circumference, and breast, thyroid,
ductive endocrinologists for evaluation for assisted            abdominal, and pelvic exam.
Copyright © 2008 by Tori Hudson. Click here for terms of use.
156   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

       Causes of Infertility in Couples

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

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

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

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

                                                        Environmental and Lifestyle Factors
    A day 3 FSH level (or day 3 and day 10 levels       Both overweight and underweight women have
if doing a full clomiphene citrate challenge test) is   increased rates of infertility. Women who are
important and helpful information in predicting         overweight are more likely to experience prob-
if a woman is less likely to become pregnant            lems with ovulation and miscarriages. An in-
beyond what would be predicted by age alone. An         crease in abdominal fat decreases insulin
elevated FSH level on cycle day 3 (or day 10) of        sensitivity, which is related to ovulation dysfunc-
greater than 11 to 12 IU/L is associated with poor      tion. Women who are underweight have infre-
chance of conception and poor results with in           quent or even lack of ovulation. This is
vitro fertilization. A FSH test that is 25 IU/L or      compounded when combined with an eating dis-
more or an age of 43 years or more are each asso-       order or excessive exercise. In a woman with a
ciated with a chance of pregnancy that is close to      body mass index (BMI) less than 25, weight loss
zero even with attempts at ovulation induction or       of as little as 5 percent can be significant in help-
with assisted reproductive technologies.                ing to normalize menses and ovulation, especially
                                                        in cases of polycystic ovary syndrome.2–4 Weight
OV E RV I E W O F                                       gain in an underweight woman is important as
A LT E R NAT I V E T R E AT M E N T S                   well. Overall, the preponderance of evidence sug-
Complementary medicine has a role in the man-           gests that a normal body weight increases the
agement of infertility both before and after a          success of assisted reproductive therapies such as
referral has been made to a reproductive endocri-       in vitro fertilization.
158   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

          Focusing on daily exercise and a whole foods                         Stress can both contribute to infertility and be a
      diet free of processed foods, alcohol, and caffeine                      consequence of difficulty in conceiving. Many
      is important to help normalize weight as well as                         women and couples decide to discontinue their
      blood sugar. However, a very recent study sug-                           fertility treatments because of too much stress
      gests that vigorous exercise of greater than four                        and upset. In addition, research suggests that
      hours per week may interfere with the success of                         past or current stress and mental illness, especially
      in vitro fertilization (IVF) and that nonexercisers                      depression, may be the cause of many cases of
      may have more success with IVF than exercisers.5                         unexplained infertility. This can be especially
      Moderate regular exercise is probably indicated                          problematic because continued inability to get
      for most individuals. In addition, in cases of                           pregnant often fuels depression, leading to a
      exercise-related reproductive dysfunction, most                          vicious cycle of emotional upset and a veritable
      of the evidence suggests that it isn’t the intensity                     roller coaster of monthly hopes and letdowns.
      of the exercise but the lack of adequate nutrition,                          Higher levels of premenstrual tension and
      specifically total calories and protein, that causes                      stress are associated with lower pregnancy rates.15
      the fertility issues.6, 7                                                Stress hormones have inhibitory effects on the
          Smoking, caffeine (even decaf ), and alcohol                         reproductive system, and, therefore, stress needs
      have been linked to decreased fertility, so avoid-                       to be addressed in anyone receiving fertility serv-
      ance is important in both partners in couples                            ices. In addition, it appears that stress decreases
      with fertility issues. Nicotine is toxic to the                          antioxidants, which are often low in both part-
      reproductive system. Smoking has been shown to                           ners in an infertile couple. Any treatment of
      cause both primary and secondary infertility in                          infertility should probably start with stress assess-
      women.8, 9 One study demonstrated that 38 per-                           ment and reduction techniques for both part-
      cent of nonsmokers conceived in their first cycle                         ners. Psychological counseling and a variety of
      attempt compared to only 28 percent for smok-                            relaxation techniques including biofeedback,
      ers. Smokers were over three times as likely to                          yoga, tai chi, Qi gong, and meditation can be
      take over one year to conceive versus nonsmok-                           helpful aspects of the treatment plan for anyone
      ers. Heavy smokers are affected more than light                          with past or present stress or depression.
      smokers.10 Smoking has also been shown to                                    In the last few years, there has been a lot of
      decrease success of fertility treatments.11 In one                       public health information available on the
      report, female smokers had lower ovarian reserves                        importance of avoiding alcohol while pregnant,
      and required more drug intervention to induce                            but when it comes to the influence of alcohol
      ovulation than did the nonsmokers.12                                     consumption on female fertility, mild to moder-
          Other considerations are the genetic damage                          ate alcohol use has not been well studied. It seems,
      and chromosomal errors caused by smoking.                                however, that alcohol does reduce conception
      Cadmium, nicotine, and some of the nicotine                              rates with a dose-related connection. Research
      metabolites have been identified in the ovaries                           demonstrated that female alcohol intake was
      (and testes) and genital fluids of smokers. Cells                         associated with two to three times the risk of
      within the ovaries are affected by one particular                        spontaneous abortion, and alcohol intake during
      nicotine metabolite, cotinine, which causes                              the week of conception increased the risk of early
      oxidative damage and developmental problems                              pregnancy loss.16 In another study, there was a
      of the follicles.13, 14                                                  greater than 50 percent reduction in the proba-
          Psychological stressors deserve to be addressed                      bility of conception during a menstrual cycle
      as well since the process of dealing with infertility                    in which women consumed alcohol. In this same
      can be very stressful and emotionally taxing.                            study, caffeine consumption did not independently
                                                                                                INFERTILITY      159
affect conception rates, but it may enhance the         formation, sperm viability, ovulation, egg viability,
negative effect of alcohol.17                           and hormone levels.
    Caffeinated beverages have been associated
with decreased fertility, increased miscarriages, and   Nutrition
lower birth weights.18 More than five cups of coffee     In addition to the issues related to weight, caf-
per day, or more than 500 mg of caffeine per day,       feine, and alcohol mentioned previously, there are
is associated with a delayed time to conception,        some specific nutritional influences on fertility in
although we don’t really understand the mecha-          women. In women who have a short menstrual
nism. One possibility is that caffeine may impair       cycle, increasing soy in the diet or taking soy
estrogen production or the metabolism of estro-         isoflavone supplements may increase the length of
gens.19 Substances other than caffeine in coffee,       the follicular phase and delay ovulation.22 Some-
tea, and other beverages may also be responsible for    thing as simple as flaxseed can lengthen the luteal
reduced fertility. Numerous caffeinated beverages,      phase of the cycle (the second half ) and increase
including coffee, soft drinks, black and green tea,     the frequency of ovulatory menstrual cycles in
and even decaffeinated coffee, contain tannins,         women who don’t ovulate regularly.23
and some contain even more tannins than regular             As far as weight loss is concerned, one can get
coffee. In animal experiments, tannins have             seriously confused these days about the value of
reduced fertility in mice and hens.20, 21               carbohydrate versus protein diets. When it comes
    Increasingly, environmental pollution and           to fertility, one study demonstrated that it did
exposure to heavy metals, pesticides, estrogen-like     not matter whether the diet was high-carbohydrate
substances, and other chemicals are implicated in       or high-protein: both groups who stuck to low-
cases of infertility in men and women. Depending        calorie diets lost weight and had improved men-
on the specific exposure, duration, and load, dif-       strual cycles and fertility.24, 25
ferent aspects of fertility can be affected. These          It is, of course, important to limit certain kinds
toxic exposures may affect sperm count, sperm           of fish that have a higher mercury content in preg-
                                                        nancy, but evidence indicates it may be wise to
                                                        do the same in cases of infertility. Studies show
 Caffeine Content                                       that infertile couples consumed more fish and had
 Item                              Caffeine (mg)        higher levels of mercury in their blood than fertile
 Coffee, brewed (8 oz)               60–120             couples.26 Consumption of biphenyl-contaminated
 Coffee, instant (8 oz)                  70             fish also has an adverse effect on fertility.27 Substi-
 Coffee, decaffeinated (8 oz)           2–5             tuting fish oils from a reliable manufacturer for
 Double espresso (2 oz)              45–100             fish consumption is a good way to keep omega-3
 Tea, black, 5-minute                                   fatty acids in the diet. Prior to pregnancy, a mini-
   steep (8 oz)                      60–100             mum daily intake of eicosapentaenoic acid (EPA)
 Tea, green (8 oz)                       20             and docahexaenoic acid (DHA), found in fish and
 Barq’s Root Beer (12 oz)                22             fish oils, is about 650 mg of each.
 Coca-Cola (12 oz)                       34
                                                            Wild salmon ranges from 1.0 to 1.5 grams
 Pepsi (12 oz)                           38
                                                        per three-ounce serving, with a little more DHA
 Chocolate milk (8 oz)                    4
 Milk chocolate (1 oz)                 1–15             than EPA. The different species of salmon (sock-
 Dark chocolate (1 oz)                   20             eye, chinook, coho) range in EPA and DHA, and
 Ben & Jerry’s Coffee Fudge                             wild sockeye contains approximately 600 mg
   Frozen Yogurt (4 oz)                   42            DHA and 430 mg EPA per three-ounce serving.
                                                        Whether you take fish oil supplements daily or
160   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      eat fish several times per week, try to average                           cadmium and lead that can adversely affect
      about 650 mg of EPA and DHA per day. Specific                             sperm development. Selenium mostly affects
      needs for DHA increase during pregnancy (see                             male fertility by maximizing sperm formation,
      Chapter 16). (During pregnancy, cod liver oil                            optimizing testosterone production, and increas-
      may be a questionable choice due to the high                             ing sperm count. (For more information on male
      content of vitamin A, a teratogen, in fish liver.28)                      fertility, see the section titled “Male Fertility”
                                                                               later in this chapter.)
      Nutritional Supplements
           Vitamin E. Some simple vitamin and min-                              Selenium
      eral supplementation may be key to fertility in                           100–200 mcg daily
      selected women, and because oxidative stress
      affects the female reproductive system and conse-                             Zinc. The most widely studied nutritional
      quently fertility, antioxidants are important con-                       supplement for fertility in both men and women
      siderations in enhancing fertility. Vitamin E is a                       is zinc. Zinc plays a vital role in cell division, and
      powerful antioxidant, combating free radical                             deficiencies are associated with reduced fertility,
      damage, and can play a beneficial role in female                          increased miscarriages, and chromosome damage.
      fertility. Most of the research on vitamin E is per-                     Less than optimal zinc levels not only reduce con-
      tinent to male fertility, such as making sperm                           ception rates, but babies have lower birth weights,
      more fertile. In one study, vitamin E was given to                       more birth defects, and can have a less developed
      both men and women and resulted in a signifi-                             brain and nervous system.31 Zinc deficiency is
      cant increase in fertility, and also assisted the                        especially important for sperm development.
      achievement and maintenance of pregnancy in
      women with repeated miscarriages.29 Other stud-                           Zinc
      ies show that adding antioxidants, including vita-
                                                                                30 mg per day
      mins C and E, to the diet of animals significantly
      reduced the decline of regular ovulation related
      to aging.30 This may have importance for women                               L-Arginine. L-arginine is an amino acid nec-
      in their 40s, who begin to experience reduced                            essary for the synthesis of protein and is found
      fertility due to diminished ovarian reserve.                             naturally in numerous animal protein foods.
                                                                               Arginine supplementation of 16 grams per day
       Vitamin E                                                               has been shown to improve uterine blood flow
       400–800 IU per day                                                      and fertilization rates in women who had previ-
                                                                               ously failed in vitro fertilization.32 Additional
          Selenium. The mineral selenium is another                            effects for enhancing sperm count and sperm
      antioxidant that protects from free radical                              quality are discussed in the male fertility section.
      damage. Free radicals are created when normal
      biochemical reactions cause oxygen molecules to
      become unstable. They are also formed by smok-                            16 g per day
      ing, barbecuing, and deep-frying food, and
      more. Selenium can protect normal tissue from                               Para-Aminobenzoic Acid (PABA). PABA is
      oxidative damage caused by the free radicals,                            a part of the folic acid molecule and is found in
      including preventing chromosome damage. Sele-                            eggs, milk, meat, and several grains. The role of
      nium may also be able to provide protection                              PABA produced by the body is not really known,
      from exposure to toxic heavy metals including                            but as an oral supplement it is FDA-approved for
                                                                                                INFERTILITY    161
difficult conditions such as scleroderma, vitiligo,
                                                        Black Cohosh
pemphigus, and dermatomyositis. It is approved
for use as a sunscreen because it acts as a filter to    20–40 mg standardized extract twice daily
block out ultraviolet radiation. In fertility, PABA
supplementation of 100 mg four times daily                 Rhodiola (Rhodiola Rosea). Rhodiola may
resulted in pregnancies in 12 of 16 women with         enhance fertility. It has been shown to enhance
a history of infertility.33                            thyroid function without causing hyperthy-
                                                       roidism in animals, and egg maturation was
 PABA                                                  enhanced as well. These and other preclinical
 100 mg 4 times per day                                research led to treating 40 women with amenor-
                                                       rhea and infertility with rhodiola (100 mg) twice
     Multiple Vitamin-Mineral. A double-blind          daily for two weeks. Normal menses were restored
trial found that taking a multivitamin-mineral         in 25 women, 11 of whom became pregnant.43, 44
supplement increased female fertility.34 A multivit-       Additional Botanicals. Numerous plants
amin and mineral in the form of a prenatal prepa-      have been used in traditional herbal medicine for
ration has much of what is needed, but women           their ability to regulate the tone of the uterus. In
who are deficient in vitamins like folic acid and       cases of infertility of undetermined cause, these
B1235–37 and minerals like magnesium and sele-         uterine tonics are thought to prepare the uterus
nium38 may need additional supplementation.            for implantation of a fertilized egg. These herbs
                                                       include dong quai (Angelica sinensis), blue cohosh
Botanicals                                             (Caulophyllum thalictroides), crampbark (Viber-
    Chaste Tree (Vitex Agnus Castus). Chaste           num opulus), false unicorn or helonias (Chamae-
tree stimulates the release of luteinizing hormone     lerium luteum), and squaw vine (Mitchella repens).
(LH) from the pituitary gland and mildly inhibits          Dong quai can tonify a weakened uterus by
FSH. The result is an indirect ability to raise or     improving the metabolism within the uterus45 as
modulate progesterone levels.39 Chaste tree also       well as regulating hormonal control and improv-
modulates the secretion of prolactin from the          ing the timing of the menstrual cycle.46 Blue
pituitary gland, and in one study prolactin was sig-   cohosh can improve the muscular tone of a hypo-
nificantly reduced while shortened luteal phases        tonic uterus and thereby was thought by early
and progesterone deficits were normalized.40            traditional herbalists to improve fertility. Cramp-
                                                       bark has been used more in cases of miscarriage
 Chaste Tree                                           rather than actual infertility. It has been used tra-
 Liquid extract 1 tsp per day or 0.6–0.75% standard-   ditionally both as a uterine sedative and a uterine
   ized extract, 175–215 mg per day                    tonic. False unicorn or helonias has been used to
                                                       improve uterine tone and decrease what has been
    Black Cohosh (Cimicifuga Racemosa).                called pelvic congestion. This herb also tends to
Similar to chaste tree, black cohosh can also stim-    be used more for women who have a history of
ulate pituitary secretion of LH and therefore lead     miscarriage or abnormal bleeding during the
to ovulation and subsequent production of prog-        pregnancy rather than true infertility. Squaw vine
esterone by the corpus luteum.41, 42 Black cohosh      is a uterine tonic that increases the circulation to
may be especially valuable for women in their          and in the uterus, thereby also reducing uterine
40s whose FSH levels may be starting to increase       congestion. It can both sedate a hypertonic uterus
as the ovary ages.                                     as well as tonify a hypotonic uterus.
162   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

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

                                                                               Additional Therapies
          Ginseng species are an important considera-                          Recent research also supports the use of manual
      tion in infertility due to their ability to enhance                      soft-tissue therapy for pelvic adhesions, which
      overall health, vitality, stamina, and endurance.                        may be implicated in some cases of infertility
      Siberian ginseng may be able to promote regula-                          where there has been a history of surgery, infec-
      tion of reproductive hormones, thereby regulat-                          tion, inflammation, or trauma. Adhesions form
      ing the timing of ovulation.47                                           as a result of the natural healing process but cause
          Phytoestrogens can be particularly useful in the                     problems by attaching to internal structures and
      IVF fertility treatments by improving implanta-                          affecting normal anatomy, mobility, and func-
      tion, pregnancy, and delivery rates.48 In addition,                      tion. The manual therapy can improve tissue
      phytoestrogens may also reverse the antiestrogen                         mobility and restore function by breaking the
      effects of clomiphene citrate, a medication fre-                         collagen cross-links that have formed during the
      quently used in the treatment of infertility.49                          healing process. The specific technique studied is
          A plant that many are not familiar with,                             the Mojzisova method, which combines both
      tribulus (Tribulus terrestris), has been studied as                      soft-tissue and osseous manipulation and is usu-
      an ovarian stimulant. A study of women taking                            ally performed by specially trained physical
      tribulus every day has demonstrated the ability of                       therapists.51
      tribulus to normalize ovulation, whereby some of                             Celiac disease, which may cause deficiencies
      the women also became pregnant.50 When using                             in a number of nutrients, requires special consid-
      the tribulus simultaneously with an ovulation-                           eration for appropriate diagnosis and manage-
      induction drug, the results with the combined                            ment. Gluten avoidance has been shown to
      use were better than the drug by itself.                                 improve fertility rates in sensitive patients.52–54
                                                                                             INFERTILITY     163
 Sample Treatment Plan for                             plaints, decreased intake of fruits and vegetables,
 Infertility Due to Lack of Ovulation                  family history of female fertility disorders, and
 or Infrequent Ovulation Cycles                        nicotine and caffeine intake.57 Therefore, it
                                                       seems prudent when dealing with a couple who
 See the Resources section for formulation sources.    want to improve their fertility that these factors
                                                       be addressed promptly, especially in patients who
 Diet                                                  have demonstrated sperm abnormalities.
  Whole foods diet high in vegetables, whole grains,   Supplements
    nuts and seeds, fruits, low-fat organic dairy
  Protein: 60 g daily                                  A number of supplements can improve sperm
  Soy foods: 1 serving daily                           quality and quantity, including vitamins C, B12,
  Flaxseed: 2 tbs per day                              and E; L-arginine; L-carnitine; selenium; zinc;
  Fish: 2–3 times per week                             and folic acid.58
                                                           Vitamins C and E. Vitamin C and other
                                                       antioxidants can decrease sperm DNA damage
  Avoid caffeine, alcohol, and smoking.                that can interfere with fertility.59 Vitamin C defi-
  Seek optimal body weight.                            ciency has been linked with significant decreases
 Nutritional Supplements
                                                       in sperm count, motility, and vitality and with an
                                                       increase in morphologically abnormal sperm.60
  Vitamin E: 400 IU per day                            Vitamin E and selenium have been shown to
  Vitamin C: 2,000 mg per day
                                                       reduce lipid peroxidation and, therefore, improve
  Zinc: 30 mg per day
                                                       sperm quality. One study looked at men who had
  Selenium: 100 mcg per day
  Prenatal vitamins: 2 per day
                                                       normal sperm counts, but low rates of fertilization
                                                       during in vitro fertilization treatments. After one
 Botanicals                                            month of daily vitamin E supplementation, the
  Chaste tree (0.6% aucubin extract capsule): 215 mg
                                                       fertilization rates increased from 19 percent to
   per day                                             29 percent, suggesting that the antioxidant effects
  Rhodiola: 200 mg per day                             of vitamin E may make the sperm more fertile.61
                                                           The combination of oral vitamin C and vita-
                                                       min E (one gram of each), administered to male
Celiac disease may lead to decreased absorption        patients with DNA damage who had previously
of fat-soluble vitamins, thereby causing deficien-      failed fertility treatments for two months, was
cies that may impair male fertility as well.           shown to decrease DNA-fragmented sperm, and
    Topical or vaginal progesterone may help           a second fertility treatment led to improvement
normalize menstrual cycles, improve implanta-          of clinical pregnancy and implantation rates.62
tion rates, and maintain pregnancies in women
with history of repeated miscarriages but should        Vitamin C
only be used under the care of a physician.55, 56       500–3,000 mg 3 times daily

M A L E F E RT I L I T Y                                Vitamin E
Low sperm counts have been attributed to a              500–1,000 IU per day
number of factors, including exposure to pesti-
cides, welding, antibiotic and other medication            L-Carnitine. The amino acid L-carnitine is
use, a history of mumps, gastrointestinal com-         essential for normal functioning of sperm. It seems
164   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      that the higher the levels of L-carnitine in sperm                           Three main types of medication are used to
      cells, the higher the sperm count and the more                           induce ovulation. Clomiphene citrate is the most
      motile the sperm. L-carnitine given as a supple-                         common, but aromatase inhibitors (AI) and
      ment helped to increase the sperm count and the                          injectable gonadotropins are also used when there
      number of normal sperm after four months.63                              is no response to other treatments. Clomiphene
                                                                               citrate is not only the most commonly used med-
       L-Carnitine                                                             ication, but it is also the most effective, inexpen-
       3,000 mg daily                                                          sive, and easiest to use and requires less monitoring
                                                                               than the other medications. Clomiphene citrate
          B12. A deficiency of B12 leads to reduced                             is primarily used to induce ovulation in women
      sperm counts and reduced sperm mobility. In                              with abnormal ovulation patterns, in women with
      men who had sperm counts under 20 million/ml,                            a luteal phase defect (abnormal length of the
      1,000 mcg of vitamin B12 per day led to an                               second half of the cycle), or in women who have
      increase to 100 million/ml.64 In another study of                        unexplained infertility. It is also used to assess ovar-
      men with low sperm counts, 6,000 mcg of vita-                            ian reserve. It is not generally effective in women
      min B12 per day showed improvements in the                               who have amenorrhea due to low estrogenic states
      sperm counts of 57 percent of them.66                                    such as hypothalamic amenorrhea.
                                                                                   Clomiphene citrate is well tolerated most of
      C O N V E N T I O NA L                                                   the time and does not often have any serious side
      M E D I C I N E A P P R OAC H                                            effects. However, because it depletes estrogen
      It is important to be aware of the latest conven-                        receptors, side effects include hot flashes, nausea
      tional treatment options for infertility and to                          and vomiting, breast discomfort, and headaches.
      gain insight into when is it timely to seek special-                     It can also have detrimental effects on cervical
      ized fertility care. The decision to pursue conven-                      mucus and the endometrial lining. Severe side
      tional modes of infertility treatment depends on                         effects occur in less than 2 percent of women
      age, the duration and cause of the infertility, the                      using it. CC can lead to an increase in multiple
      results of the ovarian-reserve assessment/testing,                       gestations at a rate of about 6 to 10 percent.
      finances, other health issues, emotional stamina,                         Most of these tend to be twins; less than 1 per-
      and thoughts and feelings about adoption or                              cent are triplets or higher-order multiples. Past
      surrogate options. Treatment options include                             concern about increasing the risk of ovarian
      intrauterine insemination (IUI) in the natural                           cancer has faded with recent research showing no
      menstrual cycle, ovulation induction using                               increased risk. About 80 percent of women using
      clomiphene citrate or gonadotropins (with or                             CC will ovulate, but only 50 percent of those will
      without IUI), and in vitro fertilization.                                conceive. Over the course of using CC for six to
           Intrauterine insemination involves introduc-                        nine cycles, the rate of pregnancy goes up to
      ing a concentrated suspension of washed sperm                            about 70 to 75 percent in those who begin to
      into the upper uterine cavity. The success of IUI                        ovulate while on CC. Obesity, elevated androgen
      varies depending on the cause of infertility. IUI                        states, and late reproductive age diminish the
      alone, without ovulation induction medications,                          response to CC.
      increases the chance of fertility in a natural cycle                         Inducing ovulation with gonadotropins is
      by only 1 to 2 percent in couples with unexplained                       indicated in women who fail to ovulate with CC,
      infertility. When clomiphene citrate (CC) is added                       don’t conceive on CC despite ovulatory cycles,
      in these couples, the fertility rate increases to 8 to                   have endometriosis, have unexplained infertility,
      10 percent.                                                              or are of advanced reproductive age, or if CC is
                                                                                                  INFERTILITY      165
contraindicated. Gonadotropin therapy involves            intercourse without contraception in women 35
injecting either FSH and LH, or FSH alone.                years of age or older. At age 35, and especially after
FSH stimulates the development of multiple fol-           age 40, time becomes of the essence, so it is a good
licles and therefore carries a higher risk of multi-      idea to seek the advice of a practitioner promptly if
ple birth than does CC use. Overstimulation               a desired pregnancy is delayed.
(hyperstimulation) of the ovaries is also a risk.             A practitioner with expertise in fertility can
These cycles require close monitoring with serial         proceed with a methodical evaluation, treat any
estradiol levels and ultrasounds. This therapy is         abnormalities that are found, provide education
usually combined with IUI.                                about the reproductive system, offer advice about
     Aromatase inhibitors (AIs) are best known for        your fertility potential, provide counsel regarding
the treatment of breast cancer, but they’ve been          all options, and provide clinical and emotional
used more recently to induce ovulation. By using          support.
AIs in the follicular phase of the menstrual cycle            Infertility in women lends itself to an integra-
(the first half, before ovulation), estradiol levels       tive approach using conventional therapies along
are reduced and the hypothalamus and pituitary            with natural therapies. A health-care team of
don’t receive their normal feedback message.              diverse practitioners—including a reproductive
This results in increased secretion of the pituitary      endocrinologist, a naturopathic physician, and
gonadotropins, which can stimulate ovulation.             perhaps an acupuncturist specializing in women’s
AIs are usually given at a dose of 2.5 to 5 mg per        health and/or a psychotherapist—who are com-
day on days 3 to 7 of the cycle. AIs are indicated        fortable working collaboratively provides an opti-
for women with infrequent or no ovulation and             mal environment for patient care.
for unexplained infertility.
     Other drugs that are used on a selective             R E S O U R C E S F O R PAT I E N T S
basis and along with other therapies include              A number of excellent resources are available to
gonadotropin-releasing hormone agonists,                  couples that are having difficulty conceiving.
gonadotropin-releasing hormone antagonists,
and human chorionic gonadotropin.                         RESOLVE. An informational clearinghouse for
                                                              infertile couples: offers educational materi-
S E E I N G A L I C E N S E D P R I M A RY                    als, a medical call-in hour, help line, physi-
H E A LT H - CA R E P R AC T I T I O N E R                    cian referrals, member-to-member support
( N . D. , M . D. , D. O . , N . P. , P. A . )                system, local chapters and support groups.
It’s important to remember that a significant                  Website: resolve.org/main/national/index
number of pregnancies occur in previously infertile           .jsp?name=hom.
couples without any treatment at all. The main            Preserving Fertility pamphlet. Available at
reason to see a health-care provider is to pursue a           resolve.org/main/national/niaw/presfert
thorough investigation of the reasons for your                .pdf.
infertility. Remember, infertility is defined as a fail-   Conquering Infertility by Alice D. Domar,
ure to conceive after 12 months of frequent inter-            Ph.D. (Penguin, 2004). A mind/body
course without contraception in women under 35                guide to enhancing fertility and coping with
years of age or failure to conceive after 6 months of         infertility.
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                           INTERSTITIAL CYSTITIS                                                     CHAPTER

OV E RV I E W                                                   then cytology tests should be done. Vaginal and cer-
Interstitial cystitis (IC) is a multifactorial syn-             vical cultures are done if the practitioner suspects a
drome whose diagnosis and cause remain elusive.                 sexually transmitted disease. Some urology experts,
Poorly understood, IC remains a significant                      especially urogynecologists, may choose to recom-
women’s health problem. About 90 percent of IC                  mend a potassium sensitivity test, which instills
patients are female.1 IC typically begins in young              potassium into the bladder, to see if the bladder has
or middle-aged women.                                           increased in permeability. If the usual pain gets
    IC is characterized by pelvic and/or perineal               worse, the test is considered positive for IC.
pain, urinary urgency, urination at night, pain                      On cystoscopy, bladder ulcers called Hunner’s
increased by holding urine (which leads to fre-                 ulcers and reduced bladder capacity are detected in
quency), and a constant urge to urinate. The pain               less than 10 percent of individuals with IC. If these
of IC can range from a mild burning or discomfort               ulcers are seen, this is considered definitive for IC.
to severe debilitating pain in the bladder, lower               More commonly, IC is characterized by petechial
abdomen, perineum, pelvis, vagina, low back, and                bladder mucosal hemorrhages, inflammation, and
thighs. Menstruation and sexual intercourse aggra-              no ulcerations.
vate symptoms in as many as 75 percent of                            IC is more common in patients with irritable
women. There are often flare-ups and remissions.                 bowel syndrome, spastic colon, abdominal
    When a woman has the classic symptoms of                    cramping, hysterectomy, rheumatoid arthritis,
urinary urgency, frequency (more than eight times               fibromyalgia, hay fever, asthma, and allergies to
per day), bladder pain, and urinating at night                  foods and medications.
(more than twice); has no evidence of a urinary                      Drug and surgical interventions have been
tract infection; and reports continuous pain or pain            used to treat this condition with limited success
with menstrual flow, then other pelvic diseases such             and potential side effects. Despite continued
as endometriosis should be given some considera-                research on IC, safe, noninvasive treatment
tion. If urinary leakage (incontinence) is present, an          options are lacking.
evaluation for the cause of the incontinence should                  Several causes have been proposed for IC,
be done. Painful or difficult urination (dysuria)                although none have been proven. The contribut-
may indicate a urinary tract or vaginal infection or            ing factors fall into two main categories: bladder
a structural problem in the urinary tract.                      epithelial permeability and inflammation. The
    Diagnostic tests for IC are mostly done to rule             exact causes are difficult to distinguish and are
out other causes. Keeping a daily diary of when you             likely to be interrelated in any one patient.
feel the need to urinate may be useful. Your health-            Because of this, a variety of treatment options may
care practitioner may use the O’Leary-Sant Index,               be used. These include vitamin A (as palmitate),
which measures pain, voiding symptoms, and qual-                bioflavonoids (from citrus), L-arginine, quercetin,
ity of life. A physical exam can help to rule out               N-acetyl glucosamine, corn silk, kava root, and
other diseases and pelvic pathology. Urinalysis and             Oregon grape root.
urine cultures are normal in patients with IC. If                    Although the cause of IC is unknown, it is
blood is visible in the urine under a microscope,               important to consider the possible causes to
Copyright © 2008 by Tori Hudson. Click here for terms of use.
168   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

       KEY CONCEPTS                                                            urine levels of these mast cell mediators. Some IC
                                                                               bladder biopsy samples contain mast cells, but it
       • IC is a noninfectious chronic condition charac-                       is known that these cells are not specific to IC
         terized by pelvic and/or perineal pain, urinary                       and can also be found in other bladder disorders.
         urgency, urinary frequency, bladder pain, and                           • Autoimmune causes. Autoimmune theories
         urination at night.                                                   are based on detecting antinuclear antibodies,
       • IC is difficult to diagnose with any test; tests                       increased urinary excretion of eosinophilic
         are mostly done to rule out other causes of the
                                                                               cationic protein, and the tendency of IC to affect
                                                                               women. Other evidence includes IgM in the
       • There is no proven cause, but bladder permeabil-
         ity and inflammation direct the variety of treat-                      uroepithelium, immune deposits in vessel walls,
         ment options available.                                               and T and B cell nodules in patients with IC.
                                                                                 • Inflammation. Most biopsies of IC bladders
                                                                               show mild chronic inflammation to significant
       PREVENTION                                                              infiltration of T cells, B cells, plasma cells, neu-
                                                                               trophils, eosinophils, and mast cells. Inflammatory
       • No specific prevention strategies have been                            mediators such as interleukin-6 are also increased.
         established, but minimizing bladder irritants                           • Infection. The possibility of an infectious
         seems logical. Classic offenders are coffee,                          cause has been suggested by the presence of
         chocolate, alcohol, carbonated drinks, citrus
                                                                               microorganisms embedded in the bladder wall
         fruits, and tomatoes.
                                                                               of patients with IC and bacterial ribosomal
                                                                               mRNA in tissues of bladder biopsies.
      understand the therapeutic basis for natural                               • Reflex sympathetic dystrophy. Bladder
      treatments. Because IC is a multifactorial syn-                          sympathetic innervation may be interrupted by
      drome, it is likely that several of these factors may                    injury to peripheral nerves from prior UTIs,
      be true in your case. Short descriptions of possi-                       hysterectomy, or childbirth. This may lead to an
      ble factors in IC follow:                                                increased transmission of pain impulses from
                                                                               the bladder and reduced circulation, facilitating
        • Bladder epithelial permeability. One of                              inflammatory cell infiltration and leading to
      the more recent theories for IC is that the                              bladder ulceration, fibrosis, and atrophy.
      bladder epithelium is abnormally permeable,
      allowing components of urine to penetrate and                                Each of these theories has supportive and
      irritate the bladder. The most common explana-                           detractive evidence. As stated earlier, the cause of
      tion of the permeability is that the bladder                             IC may vary in different people, or multiple fac-
      epithelium is deficient in glycoproteins and                              tors may be in operation.
      glycosaminoglycans (GAG). Several studies have
      shown that IC patients had decreased levels of                           OV E RV I E W O F
      glycoproteins and GAG in both the bladder and                            A LT E R NAT I V E T R E AT M E N T S
      the urine.                                                               Therapeutic options, both conventional and
        • Mast cell activation. This theory proposes                           alternative, are as varied as the theories on the
      that bladder mast cells are activated and release                        cause of IC. Almost no studies have been done to
      histamine, prostaglandins, leukotrienes, and                             help practitioners identify which patients would
      other substances that affect bladder smooth                              likely respond best to which treatments. Treat-
      muscle and sensory nerve terminals. Several stud-                        ment choices are made individually for each
      ies have shown that IC patients have increased                           patient, and in most cases, several treatments
                                                                                       INTERSTITIAL CYSTITIS          169
should be used concurrently until symptom relief         Foods to Avoid
occurs. After that, a careful, gradual process of
reducing dosages or simplifying the treatment            Alcohol                 Lentils            Apples
interventions is appropriate.                            Lima beans              Aspartame          Limes
    The most commonly used treatment by both             Avocados                Mayonnaise         Bananas
                                                         Nuts*                   Cantaloupes        Onions
conventional and alternative practitioners is
                                                         Carbonated drinks       Oranges            Cheese**
dietary changes. Patients with IC will often
                                                         Peaches                 Chicken livers     Pickled herring
report that certain foods increase their symp-           Chilies/spicy foods     Pineapple          Chocolate
toms. Classic offenders are coffee, chocolate,           Plums                   Citrus fruits      Prunes
alcohol, carbonated drinks, citrus fruits, and           Coffee                  Raisins            Corned beef
tomatoes. Acid or potassium content is often sus-        Rye bread               Cranberries        Saccharine
pected as the mechanism. Responses to these              Grapefruit              Sour cream         Grapes
foods is hugely variable, and there is no consis-        Soy sauce               Tomatoes           Guava
tent diet that works for all IC patients.                Strawberries            Vinegar            Lemons
    The following natural treatment plan may             Tea                     Yogurt
seem complex, but consider that the average
                                                         *Except almonds, peanuts, and pine nuts
patient with IC has symptoms three to four years         **Except American, cottage, ricotta, and cream cheese
prior to diagnosis. In my experience with treating       Source: K. Whitmore2
IC patients over a one-year period with this proto-
col, significant improvements are usually seen
within the first three months. Continued improve-            Glycosaminoglycans and Bladder Epithe-
ment (75 percent better or greater) is seen after six   lial Permeability. The bladder epithelial perme-
months while maintaining the same doses. Within         ability hypothesis is a compelling and active area
the second six months and beyond, gradual reduc-        of research. This theory asserts that the bladder
tion of dosage can be done on an individual basis.      epithelium is abnormally permeable in IC, so
I have found that IC patients are so thrilled with      urine components penetrate and irritate the
their improvement that they hesitate to reduce the      bladder. Several lines of indirect evidence sup-
supplements and do so carefully. With this natural      port this hypothesis:
medicine approach, IC patients can proceed with
optimism and be reassured that there is likely help     1. Some IC patients have increased pain after
for their very chronic condition.                          eating foods such as citrus fruits and toma-
                                                           toes that are acidic and high in potassium.
Nutrition                                               2. Some IC patients have pain when potassium
Some foods and beverages seem to exacerbate                chloride is instilled into the bladder, while
symptoms for many women. Although not fully                most healthy controls do not.3, 4
investigated, about 53 percent of patients with         3. Taking fluorescein orally yields higher blood
IC associate a flare-up of their symptoms with              fluorescein levels in IC patients than in con-
dietary influences, especially citrus fruits and            trols, attributed to increased fluorescein
other acidic foods and beverages.2 Many women              reabsorption across the bladder wall.5
find it helpful to avoid certain foods. If you avoid     4. In one of the only direct bladder permeability
these foods for two weeks and your symptoms                studies, radio-labeled diethylenetriamine pen-
improve, this is good news for the bladder.                taacetic acid (DTPA) was instilled in the blad-
Making these dietary changes is a good self-help           der and blood samples showed that IC
strategy in managing this condition.                       patients had higher blood levels of DTPA than
170   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

         healthy controls, although the small study of                         cases.22, 27, 28 Vitamin A also plays an essential role
         10 IC patients and 9 controls was not able to                         in maintaining and protecting epithelial integrity
         demonstrate statistical significance.6                                 and mucosal surfaces and their secretions,
      5. Glycosaminoglycans (GAGs) normally line                               including those of the bladder.26, 29
         the epithelium and are thought to con-                                    Vitamin A may also be of benefit in the man-
         tribute to the permeability barrier. Several                          agement of IC as it is essential to proper immune
         studies have shown that IC patients have                              function30, 31 and stimulates epithelial repair and
         decreased levels of GAGs in both the blad-                            growth.30, 32, 33 Vitamin A increases immune
         der and urine.7–12                                                    response mainly due to its effect on T-helper cells.34
                                                                               In addition, evidence supports the theory that
          GAG supplementation is used to treat IC
                                                                               Vitamin A may also attend to the GAG repair.35
      based on the rationale that the GAG may supple-
      ment or replace the deficient epithelial GAGs.                             Vitamin A
      The GAG studies with published trials include                             5,000 IU per day
      PPS (pentosan polysulfate sodium) Elmiron,13–19
      heparin,20 and hyaluronic acid (Cystostat).21 These
                                                                                   L-Arginine and Inflammation. Nitric oxide
      studies showed treatment efficacy over placebo
                                                                               (NO) may play an important role in the patho-
      for each of these treatments. No studies have
                                                                               genesis of IC in that it activates the cyclooxyge-
      been published on over-the-counter preparations
                                                                               nase (COX) enzymes, leading to production of
      of chondroitin sulfates and glucosamine prepara-
                                                                               proinflammatory prostaglandins that exacerbate
      tions; however, a link has been established between
                                                                               the inflammatory response.36 NO also plays a
      chondroitin and IC.22 A GAG in the form of
                                                                               role in IC in the regulation of smooth muscle
      N-acetyl glucosamine or glucosamine sulfate can
                                                                               relaxation, immunological responses, and blad-
      be used as part of a multifactorial approach to
                                                                               der neurotransmission and blood flow.37, 38
      repair the bladder epithelium.
                                                                               Luminal nitric oxide is elevated in IC, correspon-
       Glucosamine Sulfate                                                     ding to symptom severity, and can be used as a
                                                                               marker for mucosal inflammation in such
       750 mg twice daily
                                                                               cases.39–41 Nutrients such as arginine (a precursor
       N-Acetyl Glucosamine                                                    to NO synthase) and antioxidants like vitamin
                                                                               A help to elevate urinary nitric oxide levels and
       500 mg twice daily
                                                                               may play an important role in the management
                                                                               of interstitial cystitis.36, 40, 42, 43 Oral supplemen-
          Vitamin A. Vitamin A has been shown to                               tation with arginine changes urine levels of
      inhibit mast cell growth and proliferation, and                          NO,44 and three studies demonstrated symptom
      deficiency may aggravate the clinical manifesta-                          improvement over placebo.40, 45, 46 Another
      tions of inflammatory reactions due to mastocy-                           study reported that a six-month course of oral
      tosis.23–26 Vitamin A also helps to elevate urinary                      L-arginine increased nitric oxide–related enzymes
      nitric oxide levels. (See the section on L-arginine                      and metabolites in the urine of patients with IC.
      and inflammation for more information on the                              This result was correlated with a decrease in IC
      role of nitric oxide in IC.) In addition, vitamin A                      symptoms.37
      deficiency has been linked to a higher level of
      tissue damage due to inflammation, both as an                              L-Arginine
      etiological and aggravating factor, and supple-                           500 mg twice daily
      mentation may decrease inflammation in these
                                                                                        INTERSTITIAL CYSTITIS      171
    Calcium Glycerophosphate (Prelief ). Cal-               has been reported to be aggravated by stress49, 50
cium glycerophosphate has been shown to help                and associated with panic disorder,51 two condi-
reduce bladder pain and urinary urgency in IC               tions that may be ameliorated by kava.52
patients when it is used with acidic foods and
beverages. Calcium glycerophosphate, sold under              Kava Extract
the trade name Prelief, is a food-grade mineral,             Kavalactones: 70 mg 3 times daily
available in granulated form. When added to
acidic foods and beverages, it removes the acid                 Quercetin. Another proinflammatory culprit
and helps to reduce bladder pain and urinary                in IC is the mast cell, an immune modulatory cell
urgency associated with these foods.                        that secretes its damaging contents in a process
    However, from a naturopathic medicine                   called degranulation in response to factors such as
standpoint, this should be done sparingly. This is          stress and toxins. Mast cells can directly damage
like taking a heartburn medicine but still eating           the bladder mucosa, leading to bladder inflamma-
spicy Polish sausages. The food is still aggravating        tion. Some researchers speculate that treatment
you, you are just temporarily protected from the            of IC must include mast cell stabilizers.45, 53, 54
immediate bodily response. The fact that these              Quercetin and other bioflavonoids may be helpful
foods are causing symptoms means that they are              in mast cell stabilization, inhibiting degranulation
causing irritation and inflammation.                         and the release of damaging mediators.55–59
                                                                Quercetin and other bioflavonoids also con-
 Calcium Glycerophosphate (Prelief)
                                                            tribute in other ways to mitigate the inflammatory
 2 packets 3 times daily with meals                         process. Quercetin may be beneficial to connective
 Add 2 packets of powder to a serving of acidic food        tissue by limiting inflammation and associated
 or beverage. (It will not dissolve in alcoholic drinks.)   tissue degradation, improving circulation, and
 Also take 2 packets at bedtime if desired. You can use     promoting a strong collagen matrix.60, 61 Quercetin
 more if needed.                                            also plays a part in modulation of the inflamma-
                                                            tory response, at least in part by modulating pros-
Botanicals                                                  taglandin synthesis and cytokine production.62

    Kava (Kava Methysticum). A permeable or                  Quercetin
“leaky” bladder may allow chronic diffusion of               500–1,000 mg twice daily
urinary potassium, leading to sensory symptoms
and tissue damage. This appears to be a major                Bioflavonoids
factor in the pathogenesis of interstitial cystitis.47       500–1,000 mg twice daily
Kava is known historically as a urinary antispas-
modic, and recent reports support its use as a                  Oregon Grape Root (Berberis Aquifolium).
smooth muscle relaxer, likely through inhibition            Oregon grape root, a berberine-containing
of calcium channels.48 In addition, kava blocks             botanical, is an immune modulator, specifically
sodium and calcium ion channels in neural tissue            in mucosal membranes, and, like vitamin A, may
and thereby alters potassium potentials.47 Abnor-           be effective in treating allergic and inflammatory
mally elevated potassium levels may induce                  conditions like IC due to its effect on T-helper
heightened nervous and electrical sensitivity and           cells.63, 64 In addition, evidence suggests that
increase mucosal sensitivity in patients with IC.           berberine may also decrease inflammation by
Kava may help to reduce this effect by altering             inhibiting arachidonic acid metabolism in
the potassium channel activity. In addition, IC             endothelial cells.65
172   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

       Sample Treatment Plan

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

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

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

OV E RV I E W                                                   no pregnancy, toxic chemical exposures, treat-
There are currently 43 million American women                   ment of childhood cancers with chemotherapy
who are postmenopausal, and their numbers are                   and radiation, epilepsy, and cognitive scores in
expected to increase to 60 million by the year                  childhood (the higher the score, the later the
2020. By the year 2015, nearly 50 percent of the                menopause). There appears to be no link
women in the United States will be menopausal.                  between age of menopause and history of hor-
This rapid expansion in the menopausal popula-                  monal contraception, socioeconomic or marital
tion is related both to an increase in longevity (to            status, race, or age of first menstrual cycle.
an average life expectancy of approximately 84                      Premenopause refers to the period of life from
years) and to the maturation of the baby boomer                 the first menstrual period up to the final men-
generation into the menopausal age group.                       strual period, but this term is often used incor-
    Understanding the terminology and defini-                    rectly. To avoid confusion, it’s probably best to
tions can be helpful in understanding the natural               not even use this term. Perimenopause is the
biological process of aging. The term menopause                 period immediately before menopause. Peri-
is derived from meno (month, menses) plus pausis                menopause starts with changes in the menstrual
(pause, cessation); in other words, it is a pause in            cycle and ends 12 months after the final men-
menstruation. A spontaneous or natural meno-                    strual period. In the early stage of peri-
pause is the permanent cessation of menstruation                menopause, the menstrual cycle length begins to
following the loss of ovarian activity and is                   vary by as much as 7 days from the normal cycle.
strictly defined as the point after 12 consecutive               So, rather than having a 28-day cycle, maybe the
months of no menses following the final men-                     cycle begins to be a 20- to 21-day cycle from day
strual period. The average age of menopause has                 1 of the menses to the next day 1. In the later
been estimated to be between 50 and 52. In the                  stage of perimenopause, we start to see two or
Massachusetts Women’s Health Study, the largest                 more missed menses in a year, and the cycle
and most comprehensive study of middle-aged                     being 60 days or more. Some people call peri-
women, the median age for menopause was 51.3                    menopause the menopause transition or the
years.1 The range is generally from age 40 to 58                climacteric. The average age of onset of the peri-
years of age, although some women reach meno-                   menopause or menopause transition is age 47.5.
pause prematurely in their thirties and a few as                For most women, this transition lasts about four
late as in their sixties. Despite our aging popula-             years. Only a very small number of women stop
tion and greater life expectancy, the age of meno-              having their menses abruptly. Most of us experi-
pause has not changed in the last few centuries.                ence the irregular pattern of bleeding.
Three important factors influence the age of                         Postmenopause begins after the time of the
menopause: current smoking, familial factors,                   final menstrual period, whether it was a natural
and genetic factors involving the estrogen recep-               or medically induced menopause, and continues
tors. Other influences may also affect the timing                until the end of life. It is defined as stage 1
of menopause: increased body mass index (being                  (early postmenopause) and stage 2 (late post-
overweight), more than one pregnancy, history of                menopause). The early postmenopause stage is
Copyright © 2008 by Tori Hudson. Click here for terms of use.
176   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      five years, which includes the first year since the                            The term induced menopause is used when
      final menstrual period and the next four years.                           the menses ceases after surgical removal of both
           Menopause should be regarded as a normal,                           ovaries. This is referred to as ovariectomy or
      natural event of aging except when it is brought                         bilateral oophorectomy and may or may not
      about by surgery, medications, or radiation. As we                       include the removal of the uterus (hysterectomy).
      discuss problems that can be associated with meno-                       A hysterectomy is actually only the surgical
      pause for some women, it can quickly be viewed as                        removal of the uterus. These surgeries can be
      a disease process and a sign of pending fragility, dis-                  done separately or together. The incidence of
      ability, and even death. It is important to appreciate                   hysterectomy and oophorectomy in the United
      that menopause is or can be the beginning of a                           States is substantial. Women who undergo a
      new phase of life, with fewer family obligations,                        bilateral oophorectomy have an increased risk of
      new options, new learning opportunities, and new                         developing osteoporosis, coronary artery disease,
      adventures. With a proper understanding of peri-                         and/or atrophy of the genital area at a younger
      menopause and menopause, and an adequately                               age. Probably the most dramatic entry into
      informed and respectful health-care practitioner,                        menopause is to have both ovaries removed.
      the majority of menopausal women can be healthy                              From 1994 through 1999, an estimated
      and happy and use this time period as an opportu-                        3,525,237 hysterectomies were performed among
      nity to foster a preventive health-care plan and                         U.S. women aged 15 years or older.4 During
      lifestyle as well as an opportunity to assess their life.                this time, the overall hysterectomy rate for U.S.
           Women can enter menopause by several dif-                           women was 5.5 per 1,000 women. The hysterec-
      ferent routes and pass through more than one                             tomy rates for women living in the South (6.5 per
      phase. Premature menopause (also called prema-                           1,000) is significantly higher than those in the
      ture ovarian failure, or POF) is a combination of                        Northeast (4.3) or West (4.8). For women living
      secondary amenorrhea, menopausal symptoms,                               in the Midwest, it was 5.4 per 1,000. About 55
      and a persistent elevation in follicle-stimulating                       percent of women who had a hysterectomy had a
      hormone (FSH) levels greater than 20 IU/L                                bilateral oophorectomy (both ovaries removed).
      before 40 years of age. One in 100 women                                 Uterine fibroids, endometriosis, and prolapse of
      between the ages of 15 and 40 will spontaneously                         the uterus are the most frequent reasons for these
      develop premature menopause.2 In two-thirds of                           surgeries in women aged 15 years and older. With
      cases, no apparent cause for the premature ovar-                         new laparoscopic-assisted hysterectomies, ovaries
      ian failure will be found.3 These cases are called                       are removed more easily (and this is unfortunate if
      idiopathic. In one-third of cases, causes of prema-                      the ovaries are healthy) and removal of the ovaries
      ture menopause include metabolic and systemic                            has increased significantly, from 20.4 percent in
      disease, chromosome abnormalities, immunologic                           1994 to 42.5 percent in 1999.
      disorders, infections, lack of blood supply to the                           When the ovaries are removed, the onset of
      ovaries, cigarette smoking, ovariectomy or bilateral                     menopause is immediate. The sudden onset of
      oophorectomy (both ovaries removed), pelvic irra-                        hot flashes, mood changes, sleep disturbances,
      diation, and chemotherapy.                                               and loss of sexual arousal is accompanied by a
           Some women may experience a temporary                               slower onset of fatigue, headaches, dry skin, bone
      menopause in which normal ovarian function is                            and joint pain, loss of vaginal lubrication, and
      interrupted temporarily and the menses stops (for                        painful vaginal sex. This overwhelming barrage
      12 months or more). Some medications that are                            of symptoms results from the sudden drop in
      used to treat conditions such as endometriosis or                        hormone production—estrogen, progesterone,
      certain cancers may cause this.                                          and testosterone.
                                                                                              M E NO PAU S E   177
     Women who have had a hysterectomy but              words, the ovaries and the adrenal glands are
still retain one or both ovaries will go through        responsible for producing all of a woman’s testos-
menopause more naturally most of the time,              terone, either directly or indirectly. The adrenal
although sometimes earlier than they would have         glands also produce androstenedione. Andro-
otherwise. Without the uterus and the monthly           stenedione is converted to estrogen (estrone) in
bleeding, it may be harder to know when meno-           the body fat and to a lesser degree in some other
pause arrives. All the typical symptoms can             tissues and organs including the muscle and skin.
occur, though. If you are fortunate to not have         For some women, this source of estrogen is ade-
any of the overt menopausal symptoms, you can           quate to counter some of the menopausal symp-
estimate that you’ll have gone through meno-            toms, and they have an easier time.
pause somewhere between ages 48 and 53. The                 Although this adrenal source of hormonal sup-
FSH blood test may be used to determine meno-           port is a blessing, the adrenal glands produce their
pausal status.                                          maximal amount of androgens in the presence of
     Other methods of inducing menopause                fully functioning ovaries. The function of the
include chemotherapy, medications, or pelvic            cortex of the adrenal glands is linked to the func-
radiation therapy, which causes the ablation of         tions of the ovaries due to their shared original
ovarian function. Women who have been treated           group of cells in the developing embryo. If you
with chemotherapy may go into menopause either          don’t have your ovaries, then the adrenal glands
temporarily or permanently. About 30 percent of         will not produce their potential amount of andro-
these women will have a return of their menses          gens. In natural menopause, the ovaries continue
sometime within the first year. Irradiation of the       producing androgens (typically referred to as male
pelvic or abdominal area can also induce meno-          hormones) that help maintain the potential for
pause. Tamoxifen, another cancer drug used              sexual arousal.5 Several studies have shown that
mostly for women who have breast cancer, can            surgically induced menopausal women have lower
either induce menopause in premenopausal                sexual desires and subjective arousal compared to
women or increase menopause symptoms in post-           women who have retained their ovaries; treating
menopausal women.                                       these post-oophorectomy women with estrogen
     Several drugs can induce menopause that is         and androgens results in a greater sexual response
reversible once the drugs are discontinued. These       than treatment with estrogen alone.6 Surgical
include Lupron and Synarel, which are usually           menopause may also have a psychological impact
given to suppress menses in the case of endome-         on women. Not only is this related to the sudden
triosis and to shrink fibroids before surgery.           change in hormone status, but the severity of
Menopausal symptoms tend to be not as severe as         depression that may develop can often be corre-
in surgical menopause but worse than natural            lated to body image, sexual identity, cultural back-
physiologic menopause.                                  ground, and family issues.7
     Fortunately, all of the sex hormones are not           The natural transition from the reproductive
lost with menopause or even with surgical meno-         years to the postmenopausal years is not necessar-
pause. For example, about 50 percent of our             ily a smooth one, even though it is a normal
testosterone comes from the ovaries and adrenal         process of aging. Though not a disease, there can
glands; the other 50 percent comes from many            be health problems associated with menopause.
different parts of the body, including the liver, the   For many women, symptoms of these hormonal
skin, and the brain. These tissues manufacture          changes occur intermittently for a number of
testosterone from precursor hormones that are           years. Dr. Susan Love calls this period “puberty
made in the ovaries and the adrenals. In other          in reverse.” Just as the hormonal highs and lows
178   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      of puberty brought sleepiness, acne, mood                                   uterine lining, and there is not enough tissue
      swings, and unpredictable menses, this end of                               to produce a menses.
      the spectrum with its own hormonal fluctuations                            • The specific reason why menopause occurs
      may bring hot flashes, insomnia, mood swings,                                is the ultimate loss of follicles in the ovaries.
      acne, poor concentration and memory, and                                    This leads to the loss of progesterone pro-
      unpredictable menses again.                                                 duction and declining estrogen influence.
          No two women’s menopause transition is alike.                           This coincides with an increase in FSH and
      Many women begin to experience an array of                                  LH (luteinizing hormone).
      physical, mental, and emotional symptoms long
                                                                                   The symptoms of decreased hormone levels
      before they meet the definition of menopause.
                                                                               and perimenopause are varied, unpredictable,
          During perimenopause, several biological
                                                                               and often go unrecognized as perimenopausal
      changes occur:
                                                                               symptoms. The signs and symptoms of peri-
       • The number of ovarian eggs (oocytes)                                  menopause can include menstrual irregularities,
         reaches very low levels                                               hot flashes, vaginal dryness and thinning, skin
       • The menstrual cycle begins to vary, usually                           changes, fatigue, decreased libido, mood swings,
         shortening from one menses to the next.                               depression, changes in memory and cognition,
       • The levels of FSH in the body increase. This                          sleep disturbance, hair loss on the head, hair
         rise is one of the first signs of an aging repro-                      growth and acne on the face, heart palpitations,
         ductive system. Health-care practitioners often                       nausea, headaches, urinary tract infections, joint
         measure FSH levels to determine if one’s                              pains, and the beginning stages of osteoporosis
         symptoms are related to menopause. There are                          and heart disease.
         two problems with this test, however: varying
         patterns of FSH may occur even in the same                            Menopausal Symptoms
         woman, and the FSH is often normal even in                            The transition to menopause usually begins
         a perimenopausal woman.                                               sometime in a woman’s 40s. Symptoms tend to
       • Ovarian production of estradiol, proges-                              begin and increase over a span of months and can
         terone, and testosterone decreases with the                           last about four to seven years. Seventy-five to 90
         onset of true menopause.                                              percent of women will have transient symptoms
       • Although hormone levels will eventually                               that resolve within this time period and stop
         decrease, lower estrogen levels aren’t experi-                        without any treatment. Maybe 10 to 25 percent
         enced until six months to one year before                             will have symptoms that persist. Vaginal dryness
         true menopause. It’s only in the last year of                         and thinning and problems related to this tend
         perimenopause that estrogen levels begin to                           not to be transient and in fact tend to get worse
         decrease. Near menopause, estrogen levels                             with time.
         rise very high and then drop very rapidly.                                The changes associated with menopause can
         Declining progesterone levels precede                                 be mild, moderate, or severe. Some women may
         declining estrogen levels. Some of the peri-                          have no significant menopausal symptoms, and
         menopause symptoms may in fact be due to                              others will have symptoms that are progressive
         lowered progesterone levels or a relative                             and problematic for many years. The most
         change in the relationship of estrogen to                             common prevalent symptoms are vasomotor
         progesterone.                                                         symptoms (hot flashes and night sweats), sleep
       • Eventually, the lower levels of estrogen are                          disturbances, and vaginal dryness. A comprehen-
         no longer adequate to cause a buildup of the                          sive list of symptoms includes the following:
                                                                                            M E NO PAU S E   179
 •   Decline in fertility (perimenopause)             ronments, alcohol, and caffeine are the most
 •   Irregular bleeding (perimenopause)               common triggers. Hot flashes are sudden, tran-
 •   Vasomotor symptoms                               sient episodes ranging from just feeling warm or
 •   Sleep disturbances                               overheated to intense heat and perspiration.
 •   Urinary problems (urinary leakage, urinary       Women tend to describe a wavelike sensation over
     urgency, urinary frequency, infection, pelvic    the body, particularly of the upper torso, face, and
     relaxation)                                      head. If the hot flashes occur at night and are asso-
 •   Vulvovaginal changes (dryness, irritation,       ciated with what can be drenching perspiration,
     discomfort during sexual activity, discharge,    they are called night sweats.
     itching, inflammation, infection)                      The number of women in the United States
 •   Headaches                                        who are affected by hot flashes is remarkable.
 •   Mood swings                                      About 75 percent of women will experience hot
 •   Depression and anxiety                           flashes, and 15 percent are severely affected.9 The
 •   Memory changes                                   occurrence of hot flashes is highest in the first
 •   Sexual function effects                          two years postmenopause, although information
 •   Body aches                                       is scanty on the total time over which hot flashes
 •   Skin, mouth, eye dryness                         are experienced. Women with surgically induced
 •   Fatigue                                          menopause often report particularly persistent,
                                                      more intense, and more frequent hot flashes. It
More rare symptoms might include voice impair-
                                                      has been determined by one large study that for
ment, shoulder problems, and sometimes strange,
                                                      most women hot flashes last about 2 years,
rare, and peculiar symptoms that don’t seem to be
                                                      although some women experience them for 5 to
related to anything else but are due to hormonal
                                                      10 years.9 As many as 15 percent of women may
changes. These might include numbness and
                                                      still report hot flashes 16 years after menopause.
tingling sensations, dizziness, and nerve pain, to
                                                      Hot flash frequency is particularly variable and
name a few.
                                                      ranges anywhere from several episodes in a year
    Hot Flashes, Night Sweats. Hot flashes and         to every hour throughout each day.
night sweats in perimenopausal and menopausal              Not all cultures report the same incidence of
women are often referred to clinically as vasomo-     hot flashes or other menopausal symptoms. For
tor symptoms. The traditional vasomotor symp-         example, Japanese and Indonesian women report
toms, commonly referred to as hot flashes and          far fewer hot flashes than do women from Western
reported by about 85 percent of menopausal            societies.10 Mayan women in the Yucatan do not
Western women, are related to the decline in ovar-    report any symptoms at menopause other than
ian function.8 Hot flashes are the most common         menstrual cycle irregularity.11 Many researchers
symptom associated with the menopausal period         have attributed these differences to biological,
and second to irregular menses during the peri-       psychological, social, and cultural factors.
menopausal period. We still do not understand              The clearest explanation for hot flashes is that
the physiology of hot flashes, the mechanism of        they appear to be the body’s response to a sudden
lowered estrogen levels and hot flashes, the average   but transient downward resetting of the body’s
age of onset, triggers, duration, frequency, or why   thermostat, which is located in the hypothala-
they are prominent in some cultures and absent in     mus.12 This temporary alteration of the set point
others. A few triggers may affect the frequency       would cause the sensation of intense heat and
and/or severity of hot flashes in some women.          flushing. What we don’t know is what triggers
Stress, hot or spicy foods, hot drinks, warm envi-    this event. A logical correlation between low
180   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      estrogen levels and hot flashes exists. Estrogen                          bleeding needs to be evaluated by a licensed
      levels have been found to be lower in premeno-                           health-care practitioner. Fortunately, in the vast
      pausal women with hot flashes than in those                               majority of cases there is nothing serious, and the
      without hot flashes.13 However, not all studies                           solutions are straightforward and effective. At
      are consistent, and some women never have hot                            times, the bleeding can become too chaotic, and,
      flashes, while others have persistent ones, and                           of course, there are other causes of abnormal
      yet others have them only sporadically. Prior to                         bleeding other than perimenopause such as a
      puberty, girls have low estrogen levels, but not                         uterine polyp, hypothyroid, uterine fibroids, and
      hot flashes. Also, hot flashes are reported during                         endometriosis, to name a few. Chapter 1, on
      pregnancy, when the estrogen level is high. Some                         abnormal bleeding, is an important chapter to
      researchers believe that hot flashes are due to an                        read to help understand these distinctions.
      imbalance in beta-endorphins and other opiates                           Normal menstrual blood loss is approximately 40
      in the brain that in turn may influence the tem-                          mL. Blood loss greater than 80 mL is considered
      perature regulation center.14 Estrogen and prog-                         heavy, especially if there are blood clots or if you
      esterone may alter the activity of these naturally                       become anemic. If the bleeding is prolonged,
      occurring opiates, and it is possible that lower                         longer than seven days, and/or the cycle is now
      levels of estrogen and progesterone cause a with-                        shorter than 21 days, and/or bleeding or spotting
      drawal of opioids, triggering a hot flash.                                occurs between menses or after sexual activity,
           What may seem like a hot flash due to peri-                          then these symptoms require investigation by a
      menopause or menopause may in rare cases be                              health-care practitioner and effective treatments.
      caused by another condition such as thyroid                                  Although perimenopausal women are at risk
      disease, epilepsy, infection, insulin-producing                          for endometrial hyperplasia (a thickening of the
      tumors, pheochromocytoma, carcinoid syn-                                 lining of the uterus), the majority with abnormal
      dromes, leukemia, pancreatic tumors, autoim-                             perimenopausal bleeding do not have hyperplasia.
      mune disorders, or allergic disorders.                                   In postmenopausal women who bleed and who
           Irregular Uterine Bleeding. In the transition                       are not taking HRT, the bleeding is generally due
      phase of menopause, changes in the amount of                             to atrophy (thinning of the lining of the uterus).
      flow and the frequency of the flow are the main                            Any uterine bleeding that occurs after the actual
      signs of perimenopause. These changes and irregu-                        menopause (12 consecutive months since the last
      larities in the cycle are due to decreased frequency                     menstrual period) should be reported to your
      of ovulation and unpredictable fluctuating levels of                      practitioner. In women on HRT, abnormal bleed-
      the ovarian hormones, estrogen and progesterone.                         ing can be due to too little estrogen, too much
      The menses can become lighter or heavier, bleed-                         estrogen, too little progesterone, or too much
      ing for fewer days, even less than two, or more days                     progesterone. It is important to see your licensed
      than your usual length. The cycles can become                            health-care practitioner in order to determine the
      shorter by at least a week, as well as longer than the                   correct hormonal solution and also to determine if
      pattern you have become accustomed to. At some                           further testing with a pelvic ultrasound and/or
      point, most women will just skip one or more                             uterine biopsy is necessary. These issues are dis-
      menstrual cycles. Basically, changes can occur any                       cussed further in Chapter 1.
      which way, and each woman will have to identify                              Fertility Changes. The decline in fertility
      what is an irregular bleeding pattern for her.                           during perimenopause is related to several factors,
           Even though these hormonal changes are                              including that word we don’t want to hear, “aging”
      normal, the woman with abnormal uterine                                  of the ovaries and the uterus. Other specific
                                                                                                 M E NO PAU S E   181
changes are going on as well: rising levels of follicle-   awakenings are also signs of depression and anx-
stimulating hormone (FSH) and changes in the               iety. These emotional changes are also associated
feedback mechanism that regulates the menstrual            with menopause for some women.
cycle. This increase in FSH is a reflection of the              In addition to the direct influence of hor-
lower number of follicles within the ovaries and the       monal changes and hot flashes on insomnia, this
less viable quality of the follicles. Fewer follicles,     time in a woman’s life, quaintly called midlife,
poor quality, and irregular or lack of ovulation con-      can also be a time of significant life changes
tribute to this decline in fertility. The blood level of   and challenges. Job stress, relationship loss, child
FSH on day 3 of the menstrual cycle is a good indi-        care, parent care, or medical problems can alter
cator of infertility related to aging ovaries.             brain chemistry and sleep patterns. Insomnia can
    On the other hand, some women mistakenly               also be a result of sleep-related disordered breath-
think that if they are in their mid- to late 40s or        ing due to snoring or apnea, chronic pain such as
early 50s, having some perimenopause symptoms,             arthritis or fibromyalgia, thyroid conditions, rest-
and haven’t menstruated for a few months, they             less leg syndrome, asthma, or medications.
cannot become pregnant. On the contrary,                       Mood Swings, Depression, and Anxiety.
unplanned pregnancies are common during this               The psychological conditions associated with
time period. If pregnancy is not desired, contracep-       menopause have been a source of conflicting
tion must be used until you have not had a menses          scientific data and controversy. Even though the
for 12 consecutive months, or until levels of FSH          relationship between menopause and depression
are consistently above 30 IU/L.                            has been extensively studied, the results have
    Insomnia/Sleep Disturbances. Sleep prob-               been inconsistent. Some studies have shown
lems are especially common in perimenopausal               more frequent depressive moods among peri-
women, increasing after age 40 and plateauing by           and postmenopausal women compared to pre-
age 50. Sleep problems also contribute to fatigue,         menopausal women, while other studies have
poor concentration, low motivation, irritability,          not. It may be that the psychosocial and cultural
depression, and anxiety. Insomnia comes in many            factors that influence variations in moods affect
sizes and shapes, including difficulty falling asleep,      women more at the time of menopause.15
difficulty staying asleep, restless sleep, and waking           The Massachusetts Women’s Health Study
early and not being able to go back to sleep. These        concluded that women who were depressed pre-
problems may last only a few days or a few weeks           menopausally had higher rates of depression in
or become chronic with persistent problems more            perimenopause; for the women who were not
than three nights per week. The longer or more             depressed during the premenopause years, the
frequent the insomnia, the more it leads to poor           rate of depression was slightly increased during
coping skills, fatigue, and depression.                    perimenopause and was highest for women who
    A primary problem for many women with                  remained perimenopausal for at least 27 months.16
hot flashes and nighttime sweats is sleep disrup-           Researchers observed that the rate of depression
tion. Some women are awakened during sleep                 begins to decrease as women move from peri- to
due to a night sweat, but sleep disturbances are           postmenopause and is lowest for those women
not always a result of hot flashes, and not all hot         who have been postmenopausal for at least 27
flashes disrupt sleep. Most nighttime hot flashes            months. These results show that depression is
are associated with waking up, but almost half             moderately associated with perimenopause and
the time a waking episode is not associated with           that the depression is transient and will decline
hot flashes. Sleep disturbances and early morning           about two years after menopause.
182   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

          A 1997 study was able to demonstrate that                            matic after childbirth or after bilateral oophorec-
      depression and anxiety were higher in post- than                         tomy (both ovaries being removed). Short-term
      in perimenopausal women,17 although not all                              memory impairment is also a common cognitive
      studies confirm this. This study also showed that                         change in women with natural menopause. Diffi-
      depression and anxiety scores were reduced to                            culty concentrating, difficulty with previously
      values below those of perimenopausal women                               simple technical tasks, decrease in memory, and
      when the women took hormone replacement                                  lack of mental clarity are typical states that can
      therapy (HRT). Women who take estrogen alone                             then be worsened by difficulty sleeping and sleep
      seem to do best mood-wise, compared to women                             interruptions.
      who take estrogen plus synthetic progestogens,                               An evaluation of significant cognitive impair-
      called progestins.18                                                     ment may be necessary to assess for a thyroid
          Mood changes may not be as prominent as                              imbalance, medication problems, overuse of seda-
      depression or anxiety. Many women are plagued                            tives or alcohol, and dementia. Alzheimer’s disease
      by irritability, melancholy, weepiness, short                            (AD) is the most common cause of dementia and
      temper, feeling overwhelmed, and a lower toler-                          affects 1.5 to 3 times more women than men.19
      ance of stressors. Up to 10 percent of peri-                             For women on hormone therapy, adjustments in
      menopausal women experience mood changes.                                the dose may improve mental function.
      Some of these mood changes are due to sleep
                                                                                   Vaginal Dryness and Thinning. Vaginal
      deprivation with or without night sweats. In
                                                                               dryness, vaginal thinning, and what is called
      these circumstances, successful treatment for the
                                                                               atrophy are very common problems for meno-
      moods requires treatment of the night sweats
                                                                               pausal women but usually do not become trou-
      and/or insomnia.
                                                                               blesome until several years after menopause.
          Decreased Memory and Concentration.                                  Estrogen is responsible for the thickened, elastic,
      Trouble concentrating, planning, and learning                            lubricated tissue of the vagina and vulva (external
      new things and difficulty remembering names,                              genital area). When estrogen levels decline, the
      words, or what you went into the kitchen to                              vulva loses its collagen, fat, and water-retaining
      retrieve are common changes experienced by                               ability. As a result, it becomes flattened, thin, and
      women in the menopause and menopause transi-                             dry and loses tone. With estrogen loss, the vagina
      tion. Many of us experience some degree of                               also shortens and narrows, and the vaginal walls
      change in memory and concentration and clarity                           become thinner, less elastic, and pale in color.
      of thinking as we age, but there are also specific                        Problems of vaginal dryness, vaginal discharge,
      cognitive changes that occur when estrogen,                              and pain with vaginal sex are reported by two out
      progesterone, and androgens are rapidly with-                            of three women at the age of 75.20 The change
      drawn from the system, most commonly short-                              that is usually noticed first is a feeling of dryness
      term memory loss. The relatively rapid transition                        of the vagina. The cause is atrophy of the mucus-
      from the menstruating/reproductive years to                              producing glands of the vaginal wall. With a loss
      menopause appears to be a factor in these cogni-                         in lubrication and a thinning of the tissue, the
      tive changes, and related to these hormonal                              vagina is more prone to infections and mechani-
      declines, especially in estrogen. Estrogen affects                       cal injury from vaginal penetration. Small pin-
      numerous neurotransmitters in our brain, includ-                         point bleeding, itching, and burning can result.
      ing acetylcholine, serotonin, noradrenalin, and                          Other tissue in the same area also becomes thin
      dopamine. All of these have influences on concen-                         and atrophied. The urethral tissue (exit route for
      tration, learning, and memory. This is most dra-                         urine), the labia (the “lips” of the external genital
                                                                                             M E NO PAU S E   183
region), and the vaginal wall can all atrophy.             According to at least one large study, as many
These changes can result in increased bladder          as 30 percent of women have low sexual desire,
infections, involuntary loss of urine (inconti-        and about 50 percent of these feel distressed
nence), and prolapse of the bladder, rectum, or        about it.21 Not all sexual problems come in the
uterus. As the atrophy progresses, women may           form of low desire. Female sexual disorder (FSD)
experience an increase in urinary urgency or dif-      is defined in four main categories: desire disor-
ficulty holding the urine.                              ders, arousal disorder, orgasmic disorders, and
                                                       pain disorders. Sexual desire disorders include
    Urinary Problems. Urinary incontinence
                                                       hypoactive sexual desire disorder (HSDD),
and recurring urinary tract infections become
                                                       which is a recurrent consistent deficiency or
more common in postmenopausal women. Uri-
                                                       absence of sexual thoughts, fantasies and/or
nary incontinence (recurring involuntary leakage
                                                       interest in sexual activity, and sexual aversion
of urine) is common and affects from 10 to 30
                                                       disorder, a persistent or recurrent aversion to
percent of women between the ages of 50 and
                                                       and/or avoidance of sexual contact with a part-
64. Urge incontinence occurs when there is a
                                                       ner. HSDD increases with age and is more
sudden strong desire to urinate, and stress incon-
                                                       common in women after age 60. In fact, it is
tinence is urinary leakage with coughing, laugh-
                                                       thought that HSDD is more related to age than
ing, sneezing, or lifting. Stress incontinence is
                                                       to menopause.22, 23 Sexual arousal disorder is
more common during perimenopause and does
                                                       defined as the inability to attain or maintain
not tend to increase over time, whereas urge
                                                       sexual excitement and a lack of response to sexual
incontinence tends to increase with time.
                                                       stimulation such as lubrication. Orgasmic disor-
    Other urinary changes include increased uri-
                                                       der is difficult, delayed, or absent orgasm after
nary frequency, sudden urges to urinate even
                                                       adequate sexual stimulation and arousal. Sexual
when the bladder is not full, frequent nighttime
                                                       pain disorders include dyspareunia, genital pain
urination (nocturia), and increased frequency of
                                                       associated with vaginal penetration; vaginismus,
urinary tract infections. As estrogen levels
                                                       involuntary spasm of the musculature of the
decline, the end of the urethra, where we urinate,
                                                       entrance to the vagina that interferes with pene-
becomes shorter, and this reduces our defense
                                                       tration; and sexual pain related to sexual stimula-
against the bacteria that cause urinary tract infec-
                                                       tion other than intercourse.
tions (UTI). Lower estrogen levels also cause our
                                                           Numerous variables affect sexual function,
vagina, urethra, and bladder to become more
                                                       including emotional and psychological factors,
alkaline, which also leaves these areas prone to
                                                       medical problems causing fatigue and/or pain,
infections. Vaginal estrogen therapy is an impor-
                                                       certain medications (see the following sidebar),
tant option in restoring the acidic environment
                                                       and hormonal influences.
of the vagina and the bladder.
                                                           Testosterone is necessary for a normal sex
    Changes in Sexual Response and Sex                 drive in women and men, helping to determine
Drive. Changes in sexual response and libido are       desire, arousal, and sexual sensation. During per-
common throughout life, can be due to a host           imenopause, estrogen levels are fluctuating but
of influences, and tend to increase with aging.         ultimately are declining, and testosterone pro-
With an increasing number of menopausal                duction is also declining. The hormonal issues
women, an aging population, and an increased           influencing sexual function in women aren’t
openness about the topic of sexuality, women are       totally understood, but fluctuating testosterone
increasingly coming to their health-care practi-       levels have been associated with a decrease in
tioners wanting help in this area.                     libido (desire).24, 25 Most, but not all, sexual
184   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

       Selected Medications That                                                  A woman’s total estrogen production decreases
       Can Affect Sexual Function                                              by 70 to 80 percent in menopause, while andro-
                                                                               gen production decreases by about 50 percent. If
       Reduction in Sexual Desire                                              one has a surgical menopause, the plasma levels
                                                                               of testosterone are decreased significantly more
         Barbiturates                                                          than in women in natural menopause,27 and this
         Selective serotonin reuptake inhibitors (SSRIs)                       can result in an even greater incidence of sexual
         Tricyclic antidepressants                                             dysfunction than in women who went through a
         Beta blockers                                                         natural physiologic menopause.
         Spironolactone                                                             Acne, Facial Hair, and Hair Loss. Many
         Oral contraceptives                                                   peri- and postmenopausal women have problems
         Histamine H2-receptor blockers                                        related to the change in the ratio of estrogen to
                                                                               testosterone. Even though both hormones have
       Reduction in Arousal                                                    declined, there is a relative increase in testos-
         Antihistamines                                                        terone because there is less estrogen to block its
         Antihypertensives                                                     effects. In addition, women have individual sen-
         SSRIs                                                                 sitivities to androgens. Some women only react
         Tricyclic antidepressants                                             to very high levels, while others are especially
                                                                               sensitive to what are considered normal androgen
       Reduction in Orgasmic Response
                                                                               levels. In addition, women have different kinds
         Amphetamines                                                          of receptor site and tissue sensitivity. Some will
         Antipsychotics                                                        develop acne, some thinning hair, and some
         Narcotics                                                             excess body and/or facial hair.
                                                                                    Excessive hair growth occurs in areas where
                                                                               hair follicles are the most androgen-sensitive.
         Tricyclic antidepressants
                                                                               These include the face, chin, skin under the jaw-
                                                                               bone, upper lip, sideburn area, and cheeks. Other
      problems in postmenopausal women are related                             sensitive areas include the area below the belly
      to estrogen loss to the genitals. Decreased estro-                       button, the lateral pubic area, midline of the
      gen levels are responsible for most of the changes                       chest, around the nipple area, and the low back
      and decrease in lubrication during sexual arousal,                       over the sacrum. Hirsutism (excess body hair) is
      vaginal tone, vaginal elasticity, and genital                            most notably correlated with elevated free testos-
      engorgement. This can manifest as a lack of ade-                         terone, but testosterone must be converted by an
      quate vaginal lubrication with sexual arousal,                           enzyme in the skin to be fully active in the skin.
      bleeding after vaginal sex, and pain with vaginal                        This enzyme is probably higher in women who
      sex. Vaginal dryness is not only associated with                         have excess body and facial hair. These enzyme
      painful vaginal sex, but also with a decrease in                         levels may change in postmenopausal women, or
      sexual desire.26 It is not hard to understand why                        the hair follicle may become more sensitive to the
      anticipation of painful sex would dampen one’s                           activated testosterone in some postmenopausal
      desire for sex. With a loss of estrogen, relaxation                      women.
      of vaginal tissue and decreased muscle tone                                   Hair thinning and hair loss are often trau-
      also occur, which leads to a decrease in sexual                          matic for women and cause a great deal of anxi-
      response.                                                                ety. Androgenic alopecia (hair loss) is the most
                                                                                                 M E NO PAU S E   185
common alopecia in humans and is genetically                 Skin, Eye, and Dental Changes. We already
determined. Androgens modulate hair growth.              talked about how hormone changes can be
The follicle responds to the androgens and is            related to acne. Specifically, acne can be the effect
dependent on the amount present and the pres-            of excess testosterone on the glandular secretions
ence and number of androgen receptors. The               in the skin. Estrogen also has important func-
thinning of hair that can be seen in menopausal          tions in the skin. It determines the skin collagen,
women is more likely to be diffuse but is most           skin thickness, and texture. Collagen, a major
common on the top of the head (the vertex)               protein in the skin, is dependent on estrogen,
and next most common at the crown. Some                  and 30 percent of skin collagen is lost during the
women have a receding hairline and thinning at           first few years after menopause. As time goes on,
the temples.                                             more collagen is lost, resulting in increasing
    Weight Gain. One of the more troubling               laxity of the skin, wrinkling, and loss of elasticity.
changes to women during the menopause transi-            The skin also becomes dry more easily.
tion is weight gain, which is often about five                A variety of changes occur in the eye relative
pounds. We don’t understand very clearly if or           to hormonal status. Postmenopausal women
how a drop in hormones, and if or how prescrib-          report dry eyes, burning, pressure, light and tem-
ing hormones, affects weight. What we do know            perature sensitivity, blurring, tearing, eye fatigue,
is that aging itself and lifestyle are associated with   swollen eyelids, and a feeling of scratchiness. Dry
weight gain. Lean body mass, muscle mass, and            eye syndrome can, oddly enough, cause excess
the metabolic rate decrease with age, which              tearing, and it appears to also be affected by
means we burn fewer calories. These changes,             drops in testosterone levels.
combined with being more sedentary as we age,                Fluctuations in hormones during peri-
can easily lead to weight gain. Hormonal changes         menopause and lower levels in menopause are
in menopausal women are probably associated              involved in inflammation of the gums, sensitivity
with an increase in insulin resistance, leading to       of the teeth, tooth loss, and a burning sensation
increased fat storage, increased abdominal fat,          in the mouth and tongue. These symptoms may
and weight gain.                                         be a sign of more serious problems as well. Tooth
                                                         loss may be associated with low bone density and
    Headaches. Hormonal changes may play a
                                                         osteoporosis. Burning sensations in the mouth
role in headaches, especially in perimenopause
                                                         can be a symptom of diabetes or anemia, and
and especially in women with migraine head-
                                                         gum inflammation may be related to an
aches. Migraine headaches tend to be worse on
                                                         increased risk of cardiovascular disease.
one side of the head and worse with light and
noise, can be associated with nausea and vomit-              Heart Palpitations. A palpitation can feel
ing, and tend to be moderate to severe. The hor-         like a rapid heart rate, missed heartbeats, or irreg-
monal changes associated with the menopause              ular heartbeats. Not all heart palpitations are
transition can increase the frequency and inten-         related to a decrease in estrogen levels but may be
sity of headaches, especially for those women            a symptom of anxiety, panic disorder, fears, or
who have a history of menstrual-related head-            depression. Fortunately, women in their 40s and
aches. During times of more stable estrogen              early 50s, during the most common time of the
levels, such as during pregnancy, or once meno-          menopause transition, are not likely to have a
pause has been reached, most women will expe-            serious cardiac problem. Nonetheless, these
rience a resolution of their headache patterns,          symptoms should be evaluated, especially if they
especially migraine headaches.                           occur with exercise, are associated with shortness
186   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      of breath or chest pain, or if you have a family                         pause). The follicle stimulating hormone (FSH)
      history of early heart disease or heart attack (men                      test is not as accurate as we would like, but if it is
      less than age 50 and women less than age 60).                            consistently elevated above 30 mIU/mL, a diag-
                                                                               nosis of menopause can be established. The diffi-
          Joint Pains. Another symptom commonly
                                                                               culty with FSH tests is that they can fluctuate
      reported during menopause is joint pain and/or
                                                                               immensely, especially in perimenopause. The
      body aches. This is not currently well under-
                                                                               other problem is that FSH tests are frequently
      stood, but it is likely there is a connection
                                                                               normal in perimenopausal women. It can also be
      between hormones, immune function, and
                                                                               very difficult to use the FSH test if women are on
      inflammation in the joints. Osteoarthritis, specif-
                                                                               hormonal contraceptives or hormone replace-
      ically, is a common joint disease that increases
                                                                               ment therapy (HRT or HT).
      with age and affects women more than men.
                                                                                   There is a recent popular notion that saliva or
          Osteoporosis and Cardiovascular Disease.                             serum testing can be done to determine estrogen,
      While the symptoms of hot flashes, mood swings,                           progesterone, and testosterone levels or individ-
      insomnia, sexual dysfunction, and the rest are                           ual estrogen levels including estriol, estrone, and
      annoying at best, and can significantly impact                            estradiol. However, saliva testing has yet to be
      quality of life, the most significant changes                             proven accurate for the testing of these hor-
      associated with menopause are osteoporosis and                           mones, although the FDA has approved saliva
      cardiovascular disease. These conditions can dra-                        tests for cortisol and DHEA levels. I will focus
      matically alter and even shorten one’s life. For a                       my comments on blood serum testing.
      comprehensive discussion on osteoporosis, refer to                           For the perimenopausal woman, it is difficult
      Chapter 14, and for heart disease, refer to Chapter                      to gather conclusions on test results when the
      9. Prevalence, risk factors, evaluation, and alterna-                    hormones are in such a fluctuating state. There
      tive and conventional approaches and treatments                          are so many peaks and valleys and so much
      are covered in these chapters.                                           erratic hormone activity that testing offers little
                                                                               value in most situations. For the women taking
      Menopause Evaluation                                                     HRT, it is tempting to think that we could test
      The onset of perimenopause is an important                               the blood to determine what dose to take. This is
      time for a comprehensive health and lifestyle                            a popular recommendation in some consumer
      evaluation. A thorough medical history, com-                             menopause books. However, I would point out
      plete physical exam, and selected tests depending                        that there is no mathematical grid comparing
      on your age, your symptoms, and other medical                            values of estrogen or progesterone or of testos-
      problems should be done by a licensed health-                            terone levels in the blood and how that would
      care practitioner.                                                       equate with a certain dose of the comparable hor-
          While it may seem surprising, there is no one                        mone. There are reference ranges for these hor-
      test for menopause. Tests to determine ovarian                           mones, but practitioners don’t know exactly what
      function are not routinely done because the diag-                        dose to give to keep a woman in the reference
      nosis of perimenopause or menopause is largely                           range. Women absorb and metabolize hormones
      able to be made based on the medical history.                            differently. The form of hormones and the deliv-
      Practitioners can use hormone testing on an indi-                        ery method—oral, transdermal, sublingual, or
      vidual basis, mostly to differentiate menopause                          injection—also behave differently from woman
      from thyroid problems, abnormal causes of a lack                         to woman. In selective cases, testing may be a
      of menses such as elevated prolactin levels, or                          helpful guide. These are generally cases in which
      premature ovarian failure (premature meno-                               a woman is on HRT and not doing well, and
                                                                                               M E NO PAU S E   187
despite the practitioner’s best efforts with a good    when a fasting plasma glucose test is 126 mg/dL or
medical history and adjusting the dose, she still      greater on two or more occasions or the blood glu-
does not feel well. But clearly, the majority of the   cose is 200 mg/dL or greater two hours after a dose
time, it requires the practitioner’s experience and    of glucose is ingested.
menopause expertise and time to listen to the              Other important situations also warrant test-
patient to know what dose, what dosing adjust-         ing and are discussed in the appropriate chapters
ments, and what forms and deliveries of hor-           in this book. To name a few, abnormal uterine
mones may work best. Even if testing is done, the      bleeding may need thyroid blood tests, pelvic
decision basically comes down to good clinical         ultrasound, or endometrial biopsy. Urinary tract
judgment and the willingness of the woman and          infections can be tested with urinalysis and urine
her practitioner to try various approaches.            cultures. Cervical cancer can be screened for
    Testing can be done to facilitate assessing a      with Pap smears. Breast cancer can be screened
woman’s risk for diabetes, heart disease, and osteo-   for with mammograms.
porosis. Risk assessment for heart disease is dis-
cussed in Chapter 9 and for osteoporosis, Chapter      OV E RV I E W O F
14. Diabetes risk assessment is a combination of       A LT E R NAT I V E T R E AT M E N T S
history and physical exam, glucose screening, and      The fundamental goals of an alternative
lipid panel testing. Diabetes mellitus is diagnosed    approach to menopause are to provide relief from
                                                       common menopausal symptoms and to prevent
 KEY CONCEPTS                                          and/or treat osteoporosis, heart disease, and
                                                       other diseases of aging. The goal is to do this with
 • Find a good menopause practitioner to work          methods that do not increase the risk of life-
   with. Seek the advice of practitioners who can      threatening diseases such as breast cancer, blood
   inform you about the spectrum of options.           clots, and strokes.
 • Seek out an initial comprehensive evaluation.           In order to accomplish these fundamental
 • Managing menopause symptoms is distinct from
                                                       goals, the menopausal woman and her practi-
   prevention of significant diseases such as heart
                                                       tioner must embrace an individualized approach.
   disease and osteoporosis.
 • Attempt to determine individual risks for signifi-
                                                       An alternative and comprehensive approach is
   cant diseases—osteoporosis, heart disease,          distinct in that the evaluation of each woman
   breast cancer, and diabetes.                        lends a great deal of attention not only to indi-
 • Hormone testing is not routinely recommended        vidual symptoms, but also to her individual risks
   and offers limited help in knowing how to           for future diseases. This requires a comprehensive
   manage your menopause symptoms.                     health history; judicious use of tests to assess risks
 • Be well informed about the process of               for osteoporosis and heart disease; an apprecia-
   menopause.                                          tion of risk factors for breast cancer, diabetes, and
 • Be well informed about the spectrum of alterna-
                                                       Alzheimer’s disease; a willingness to individualize
   tive and conventional treatment options.
                                                       the treatment very carefully; and an ability to uti-
 • Realize that menopause and aging are processes
   that evolve over time.
                                                       lize the whole spectrum of interventions, includ-
 • What you decide today is not permanent; you         ing diet, exercise, stress management, nutritional
   can change your treatment decisions based on        supplements, herbal therapies, all available hor-
   your changing health, changes in medical under-     mone options, and prescription and over-the-
   standing and research, and newly available          counter pharmaceuticals.
   treatment options.                                      Although more and more conventional HRT
                                                       regimens are becoming available and new non-
188   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      hormonal drugs are being developed, a practi-                            The Naturopathic Approach
      tioner who has an understanding of the whole                             In the naturopathic approach to menopause,
      spectrum of options from the most natural to the                         therapeutic intervention is determined following
      most conventional is in the ideal position to                            a comprehensive assessment of symptom severity
      properly advise and prescribe a customized opti-                         and scope and an evaluation of risk factors for
      mal treatment and prevention plan. A licensed                            osteoporosis, heart disease, Alzheimer’s, diabetes,
      naturopathic physician is currently the only pri-                        and breast cancer. A determination of low,
      mary health-care provider trained in all these                           medium, or high risk, especially for osteoporosis
      options, although he or she may have to refer for                        and heart disease, is especially directive in provid-
      some selected expertise in osteoporosis, heart dis-                      ing choices regarding alternative and/or conven-
      ease, gynecology, or endocrinology. In the past,                         tional therapies. Once the symptoms have been
      conventional medicine largely approached the                             pinpointed and the risks have been assessed, then
      situation as “HRT for all and forever.” Since                            treatments are recommended. Treatment consid-
      2002 and the first Women’s Health Initiative                              erations include a spectrum of options. The seven
      research results,28 women and many of their doc-                         treatment categories are:
      tors abandoned HRT almost overnight.
          At the other extreme is an absolute fear and                         1. Diet, exercise, lifestyle, and stress
      bias against using HRT for any reason or for any                            management
      amount of time. The use of nonhormonal natu-                             2. Nutritional supplementation
      ral therapies has thrived in this environment,                           3. Botanical supplementation
      both in the form of women treating themselves                            4. Compounded bio-identical hormones
      and for those seeking advice from licensed alter-                        5. “Friendlier” conventional HRT
      native practitioners. In either case, caution                            6. “Less friendly” conventional HRT
      should be exercised in presuming that just treat-                        7. Nonhormonal prescription medications
      ing the symptoms of menopause is adequate.                                   You may be surprised to see the inclusion of
      Keep in mind our fundamental goals: symptom                              conventional hormone replacement therapy in
      relief, disease prevention, and disease treatment.                       my list of options. Choosing to use hormones,
      While there are many effective nonprescription                           whether compounded bio-identical or conven-
      natural therapies for symptom relief, this does                          tional pharmaceutical preparations, is a matter of
      not adequately address greater long-term con-                            weighing the benefits and the risks. Hormonal
      cerns such as bone density, blood pressure, cho-                         therapies should be utilized in the lowest dose,
      lesterol levels, breast health, or vaginal tissue                        shortest duration, and safest way possible that
      health. The identification of disease risks may not                       meets the goals that have been identified. These
      be very important in the early perimenopausal                            issues are addressed in the section on hormones.
      years, but it acquires increasing importance as the                          Diet/exercise/lifestyle and/or nutritional sup-
      postmenopause years accumulate. This is why I                            plements and/or botanical therapies will be effec-
      recommend that women seek the advice of a                                tive for the management of menopause symptoms
      licensed naturopathic physician with a strong                            in the majority of women. When these are not
      experience in women’s health, and menopause in                           adequate, individualized formulations of bio-
      particular.                                                              identical hormone options should be used. If
          In this section on natural medicine, we will                         these are not adequate, then “friendlier” hor-
      focus on symptom relief. See the chapters on                             mone therapy (also bio-identical) is preferred
      heart disease and osteoporosis for prevention and                        over “less friendly” (synthetic and semisynthetic
      treatment of those diseases.
                                                                                           M E NO PAU S E   189
and not bio-identical) HRT. (The distinctions        well as an antiestrogen effect, depending on the
between the different kinds of hormones are dis-     tissue involved and the dose consumed.
cussed in the hormone section.) Determining the          There are hundreds of studies on soy and
treatment approach is a combination of subjec-       dozens on hot flashes, some showing effect and
tive and objective findings resulting from the        others not, making it difficult to make conclu-
medical history, physical exam, any lab or diag-     sions. For now, I’d like to pass on the results of
nostic imaging tests, and the personal perspective   two systematic reviews of isoflavones and meno-
and values of each woman. The specifics of these      pausal symptoms and one consensus opinion
options and therapies will be expanded on as we      from the North American Menopause Society
discuss nutrition, exercise, nutritional supple-     that offer a good summary of the research. The
mentation, botanicals, bio-identical hormones,       first systematic study was a review of the literature
conventional HRT, and nonhormonal drugs.             for the randomized controlled clinical trials on
                                                     soy and perimenopausal symptoms.29 Ten trials
Nutrition                                            were evaluated, and only four were positive and
                                                     showed benefit for perimenopausal symptoms.
An alternative approach to menopause isn’t com-
                                                     There were no serious safety concerns with soy
plete without proper nutrition. This includes gen-
                                                     products for the treatment periods, which were
eral considerations such as a diet rich in whole
                                                     up to six months. In the second systematic review,
natural and unprocessed foods, with an emphasis
                                                     25 trials involving approximately 2,300 women
on fruits, vegetables, whole grains, beans, seeds,
                                                     met the study criteria.30 Soy and red clover
nuts, and healthy fats, and low in saturated fats,
                                                     isoflavones were evaluated in this review, includ-
fried foods, white flour, alcohol, sugar, and salt.
                                                     ing soy foods, beverages, or powders; soy extracts;
    The Value of Soy. One of the important           and red clover extracts, for a total of 25 studies.
dietary recommendations for all menopausal           Only one soy food trial and two soy extract trials
women may be to increase foods that are high in      showed the ability to reduce hot flushes.
phytoestrogens, although their benefits may be            The final report comes from a consensus
more for preventing osteoporosis, heart disease,     opinion of the North American Menopause Soci-
and even breast cancer than for the relief of        ety,31 which acknowledges that some data does
menopause symptoms such as hot flashes.               support the efficacy of isoflavones in reducing
    A large number of plants, especially legumes,    the incidence and severity of hot flashes but that
contain compounds called phytoestrogens.             many studies have not found any difference. It
Phytoestrogens are mainly, but not exclusively,      also concluded that there was not adequate data
nonsteroidal in structure and are either of plant    to evaluate the effect of isoflavones on breast and
origin or derived from the body’s metabolism of      other cancers, bone mass, and vaginal dryness
precursors present in dietary components. The        but that there were convincing health benefits of
most important dietary phytoestrogens are the        isoflavones and lipids in reducing low-density
phenolic phytoestrogens, which include the           lipoproteins and triglycerides and increasing
isoflavones and the lignans. Soybeans are the         high-density lipoproteins. Perhaps the best evi-
richest food source of isoflavones, containing 1      dence that soy lowers cholesterol comes from a
to 2 mg of isoflavones per gram of soy protein.       review of 38 scientific studies. This meta-analysis
The two main isoflavones of soy are genistein         concluded that consumption of soy protein rather
and daidzein. Isoflavones have a unique ability to    than animal protein significantly decreased serum
weakly bind to estrogen receptors in the body        concentrations of total cholesterol, LDL choles-
and seem to have both a weak estrogen effect as      terol, and triglycerides.32
190   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

          In terms of menopause symptoms and hot                               ative comments and concerns about soy are in
      flashes in particular, I’m sure the three reviews are                     some cases incorrect and in other cases highly
      disappointing news for advocates of soy. It’s                            exaggerated. Some have pointed out problems
      important to appreciate, though, that statistical                        with thyroid function, inhibition of mineral and
      significance is not the same as clinical signifi-                          protein absorption, and concerns about hor-
      cance for any one person. For some women, and                            monal effects.
      this has been borne out in some studies, soy pro-                            Some of the controversy about soy lies not
      tein and soy isoflavones can be helpful in reduc-                         only in its ability to bind to estrogen receptors
      ing the frequency and severity of hot flashes. For                        but in its content of phytates and trypsin
      the specifics in regard to bone effects and cardio-                       inhibitors, interference with thyroid function,
      vascular effects, please refer to the osteoporosis                       and difficult digestibility for some individuals.
      and heart disease chapters.                                              Soy foods, especially cooked soybeans, are diffi-
          If you choose to increase soy foods or take                          cult for some people to digest, causing gas and
      soy beverages, powders, or supplements, a word                           stomach upset. Soy’s content of trypsin inhibitors
      about dosages and addressing some of the highly                          can block the enzymes needed for protein diges-
      publicized controversies about soy is important.                         tion. When the protein is improperly digested,
      A reasonable approach would be to ingest a daily                         fermentation and gas production ensues. How-
      level of isoflavones that does not exceed the                             ever, many researchers believe that so few trypsin
      amount consumed in ethnic diets that contain                             inhibitors are left behind after processing the soy
      high amounts of isoflavones. From a review of                             food that for most people, their digestion is not
      those diets, it appears that this amount is some-                        affected.
      where between 50 to 150 mg of isoflavones per                                 The phytate content in soybeans has been
      day for adults. The isoflavone content of soy                             another cause for concern with soy foods. Phy-
      foods varies with the form. A listing of the                             tates are compounds found in grains and legumes
      isoflavone content of some of these soy foods will                        that can compete with the uptake of minerals
      offer some help in calculating your daily intake                         such as calcium, magnesium, iron, and zinc.
      (see Table 12.1).                                                        Although the phytate content of soybeans is
          There have been some controversies about                             higher than that of other grains or legumes, the
      soy, and based on the actual research, these neg-                        mineral-blocking effect of phytates is reduced

       Table 12.1           Isoflavone Content of Soybeans

       Soy Food                                      Amount                                   Isoflavones (mg)

       Textured soy protein granules                   1⁄4    cup                                   62
       Roasted soy nuts                                1⁄4    cup                                   60
       Tofu, low-fat and regular                       1⁄ 2   cup                                   35
       Tempeh                                          1⁄ 2   cup                                   35
       Soy beverage powders                      1–2 scoops                                      20–50 (varies with manufacturer)
       Regular soy milk                                 1 cup                                       30
       Low-fat soy milk                                 1 cup                                       20
       Roasted soy butter                                2 tbs                                      17
       Cooked soybeans                                 1⁄ 2   cup                                   35
                                                                                              M E NO PAU S E   191
when eaten with meat or fish. If you eat soy            from a paper citing over 280 references.36 In
products in the context of a healthy, varied diet,     reviewing animal, laboratory, and human studies,
you should get adequate minerals. Phytates are         the study’s authors conclude that while there is
also reduced in fermented products such as             some conflicting data as to whether soy is protec-
tempeh and miso.                                       tive against breast cancer or is safe or harmful for
    The genistein and daidzein in soy can also         breast cancer patients, it is clear from reading this
inhibit thyroid hormone synthesis. High-               research that the data significantly favors safety
soybean diets have been implicated in diet-            and even protection if consumed from a young
induced goiter. This problem is not likely to          age. The authors concluded that moderation in
occur with an average amount of soy in the diet        intake is probably wise and should mimic the
and again in the context of a healthy, varied diet,    Asian soy intake of one to two servings per day.
especially a diet that is adequate in iodine, which    Doubts as to the significance of the breast cancer
is now mostly the case in this country. In some        protective effects of soy and the safety of soy will
susceptible individuals, or in some who take very      remain until there has been a prospective study
high doses of nutritional supplementation of soy       on soy comparing women on a high-soy diet
isoflavones (above 200 mg per day) or have an           with women on a low-soy diet over the span of
extreme diet low in other nutrients and high in        many years with identical risk factors in other
soy, it is prudent to be aware of potential but        areas. One specific word of caution to breast
extremely rare problems with soy ingestion.            cancer patients undergoing treatment with
    One of the greatest fears for women contem-        tamoxifen: until it has been determined if soy is
plating menopause treatment options is the con-        beneficial in addition to tamoxifen or if it inter-
cern about estrogen replacement therapy and            feres with tamoxifen, I would recommend
breast cancer. Although we will be addressing          against daily soy ingestion while on tamoxifen.
this in the hormone and conventional medicine              For the most part and in most individuals,
sections of this chapter, there are several lines of   soy foods will not interfere with thyroid func-
evidence and logic that support the conclusion         tion, protein digestion, or the uptake of minerals,
that not only is soy safe, but there is actually a     and they are more associated with reducing the
relationship between increased soy intake and          risk of hormone-dependent cancers than with
breast cancer prevention. Several studies con-         increasing it. Any potential negatives with soy are
cluded that Asian women who consume a tradi-           not likely to occur with one to two servings of
tional low-fat, high-soy diet have a four- to          soy foods daily, with adequate iodine in the diet,
sixfold lower risk of developing breast cancer.33      using soy in the context of a healthy, varied diet
The constituents in soy are remarkable in their        and focusing on organic sources. Organically
activities against a variety of cancers via several    grown soybeans are grown without pesticides and
different mechanisms. Dietary phytoestrogens           are not from genetically modified seeds. This is
also inhibit cancer cell growth by competing with      an important issue for soy foods in particular, as
estradiol for the type II estrogen binding sites.34    genetically modified soy crops have increasingly
Even more convincing evidence for the breast           dominated in the agriculture business. Fortu-
cancer protection benefit of soy comes from             nately, there are farmers and manufacturers who
animal studies.35 Soy supplementation has              are committed to raising and producing organic
reduced the number and size of tumors induced          soy products.
with a carcinogenic substance.                             The optimal use of soy would be to start early
    The most comprehensive review of the litera-       in life and eat a diverse array of soy foods with a
ture on soy and its effects on the breast comes        total dietary intake of 50 to 150 mg of soy
192   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      isoflavones per day. If you don’t like soy foods, take                     Dietary Recommendations
      a high-quality soy protein powder or capsule.
                                                                                  Reduce saturated fats (cheese, butter, beef, pork).
          Flaxseed. Another significant dietary source                             Avoid trans fats (deep fried foods, margarine, par-
      of phytoestrogens to consider is flaxseed.                                     tially hydrogenated oils).
      Flaxseed contains lignans, two of which,                                    Reduce refined grains and flours, sugar, and salt.
      matairesinol and secoisolariciresinol, are known                            Use only a modest amount of low-fat dairy products.
      to have estrogenic activity. Other lignans are                              Increase fruits, vegetables, legumes (especially soy),
      modified by intestinal bacteria to form estrogenic                             whole grains, nuts and seeds, olive oil, and cold-
      compounds. Lignans from plants such as flaxseed                                water fish (salmon, tuna, mackerel, herring, hal-
      are absorbed in the circulation and have both                                 ibut, and sardines).
      estrogenic and antiestrogenic activity37 much like
      soy, although to a lesser degree.
                                                                               necessary dietary changes have a significant advan-
          Flaxseed flour and its defatted meal (flaxseed
                                                                               tage in being able to age healthfully and reduce the
      meal) are the highest plant producers of lignans.
                                                                               risk of heart disease. Lowering the level of trans fats
      The lignan content of flaxseed meal is 75 times
                                                                               and saturated fats while increasing omega-3 fats
      higher than that of seaweeds (the second highest
                                                                               and monounsaturated fats from olive oil are keys to
      lignan-containing group) and 804 times higher
                                                                               a nutritional preventive approach to heart disease.
      than that of fruits (the lowest lignan-containing
                                                                               Diets that are high in cholesterol and saturated fats
                                                                               (beef, pork, lamb, butter, cheese, palm oil, and
          The evidence that lignans can reduce the risk
                                                                               coconut oil) contribute to poor fat ratios and ele-
      for cancer is still unclear, although the biologic
                                                                               vated cholesterol. Even though total fat intake
      properties of lignans and data from various cul-
                                                                               should be reduced, switching from saturated fats to
      tures suggest that they do. Many lignans have
                                                                               vegetable oils will lower total cholesterol levels.
      antitumor, antioxidant, weak estrogenic, and
                                                                               Olive oil is your best choice for salads and cooking.
      antiestrogenic characteristics.38–42 Adding to the
                                                                                    Increasing fiber in the diet with whole grains,
      evidence, urinary excretion of lignans has been
                                                                               fruits, vegetables, and legumes is the optimal
      found to be lower in nonvegetarians and in post-
                                                                               high-fiber diet. Soluble fiber such as the pectin in
      menopausal women with breast cancer as com-
                                                                               apples or oat bran has the most consistent bene-
      pared with healthy women.43–45
                                                                               ficial effect on cholesterol levels.46 Specific fruits
          Foods for Bone Health. Several dietary factors                       or vegetables can also have a positive effect on
      affect bone health and are involved in the develop-                      blood levels of fat. Raw carrots, for example, may
      ment of osteoporosis: insufficient calcium intake,                        have a more potent effect in lowering cholesterol
      vitamin D deficiency, low calcium and high phos-                          than oat products.47 People with a low intake of
      phorus intake, low fatty acid intake, insufficient                        fruits and vegetables have an increased risk for
      dark leafy greens, a high-protein diet, excess salt                      heart disease.48 See Chapter 9 for dietary and
      intake, and excess alcohol. See Chapter 14 for                           lifestyle factors, supplements, herbs, hormones,
      dietary and lifestyle factors, supplements, herbs,                       and other conventional medications for preven-
      hormones, and other conventional medications for                         tion and treatment of heart disease.
      prevention and treatment of bone loss.
          Foods for Heart Health. Heart disease is the                         Nutritional Supplements
      other major concern in the postmenopausal years.                         Following are the nutritional supplements that are
      The prevention of heart disease is largely deter-                        used to treat some of the symptoms of menopause.
      mined by diet and lifestyle. Women who make the                          For an in-depth look at some of the nutritional
                                                                                              M E NO PAU S E   193
supplements used to treat and prevent heart dis-      the problem in the past. Results of research and
ease and osteoporosis, consult Chapters 9 and 14.     clinical trials have consistently shown that EPO is
    Bioflavonoids. Bioflavonoids, such as rutin,        effective in relieving breast pain and premenstrual
hesperidin, and quercetin, are usually known for      cyclic breast pain.54–56 (See Chapter 7 for more
their antioxidant and anti-inflammatory proper-        information about this and other treatments for
ties and their ability to strengthen capillaries.     painful and lumpy breasts.)
Some evidence exists to show that giving bio-
                                                       Evening Primrose Oil
flavonoids in combination with vitamin C will
help to relieve menopausal hot flashes.49               1,500–3,000 mg per day

                                                          Gamma-Oryzanol. Gamma-oryzanol is a
 1,000 mg per day plus 1,000–1,500 mg vitamin C       substance found in grains and is isolated from
                                                      rice bran oil. This ferulic acid compound is pres-
    Vitamin B6. Vitamin B6, or pyridoxine, plays      ent in rice, wheat, barley, oats, tomatoes, aspara-
a critical role in the manufacture of serotonin as    gus, olives, berries, peas, citrus fruits, and other
well as other amino acid neurotransmitters. Vita-     foods. The concentrations are higher in whole
min B6 levels are typically quite low in depressed    grains than in refined grains and flours.
patients, especially women taking birth control           Gamma-oryzanol was initially shown to be
pills or conjugated equine estrogens (Pre-            effective in relieving menopausal hot flashes in the
marin).50–52 An insufficiency of vitamin B6 may        early 1960s,57 and at least one additional study has
also cause insomnia and irritability. Since depres-   confirmed that finding.58 The typical dosage of
sion, insomnia, and irritability are typical meno-    gamma-oryzanol is 100 mg three times daily.
pausal symptoms, this vitamin may be a helpful
addition to a supplement program.                      Gamma-Oryzanol
                                                       100 mg 3 times per day
 Vitamin B6
 50–200 mg per day                                        Vitamin E. The considerable reputation of
 Warning: chronic intake of dosages greater than      vitamin E as a remedy for hot flashes comes from
 200 mg per day can be toxic over a period of many    studies done as far back as 1945.59–62 The problem
 months or years.                                     is that vitamin E has received very little scientific
                                                      attention for this use since those early studies. Only
    Evening Primrose Oil. Currently, natural          recently has there been renewed research interest,
products for menopause often include evening          largely born of the need to provide menopausal
primrose oil (EPO) because it has a reputation        breast cancer patients with safe and effective medi-
for alleviating vasomotor symptoms such as hot        cines for symptom relief.63 Patients received four
flashes. However, a study on the effects of gamma      weeks of vitamin E (800 IU per day), then four
linolenic acid (GLA) from evening primrose oil        weeks of an identical placebo, or vice versa. Hot
found it to offer no benefit over placebo in treat-    flash frequency decreased by 25 percent in the vita-
ing menopausal flushing.53                             min E group and 22 percent in the placebo group.
    Cyclic breast pain is a common symptom in         Although this is considered a statistically significant
menstruating women before their period. In peri-      difference, the clinical impact of this reduction was
menopausal women, this symptom can be exacer-         marginal, and the patients did not particularly
bated or can occur in women who have not had          show a preference for vitamin E over placebo.
194   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

                                                                               they preferentially express estrogenic effects in
       Vitamin E
                                                                               the central nervous system, blood vessels, bone,
       400–800 IU per day                                                      and skin without causing stimulation of the
                                                                               breast or uterus, at least in typical doses.66
      Botanical Medicines                                                           Dong Quai (Angelica Sinensis). Dong quai,
          Phytoestrogens. As discussed in the nutri-                           also known as tang-kuei, dang-gui, and Chinese
      tion section, phytoestrogens are plant-derived                           angelica, is an aromatic herb widely used through-
      substances that are able to activate the estrogen                        out Asia. In Asia, dong quai is to women’s health
      receptors in mammals. They are mainly, but not                           what ginseng is to men’s. It has predominantly
      exclusively, nonsteroidal in structure and are                           been used as a female remedy to treat menopausal
      either of plant origin or derived by the body’s                          hot flashes, menstrual cramps, lack of menstrua-
      metabolism of precursors present in dietary com-                         tion, or frequent menstruation and to promote
      ponents. Phytoestrogens are present in virtually                         a healthy pregnancy and easy delivery. The
      every plant in varying amounts.                                          coumarins in dong quai are found largely in the
          Phytoestrogens are capable of exerting weak                          root. The potential estrogen-like activity of dong
      estrogenic effects in some parts of the body, and                        quai has been assumed because of its observed tra-
      they also have antiestrogenic effects due to their                       ditional uses and clinical effects, and evidence
      ability to occupy estrogen receptor sites and                            includes its ability to cause an initial increase in
      block the estrogen produced by our own bodies                            uterine contraction, followed by relaxation67 and
      from binding. Since the phytoestrogens are so                            its effect in increasing uterine weight when given
      much weaker than the body’s estrogen, the net                            to mice.68 These observations may be a partial
      effect is significantly less estrogenic stimulation                       explanation as to why dong quai may be useful in
      in the target organ.                                                     menopause, although clearly there is some benefit
          Phytoestrogens are found in many medicinal                           at least for issues related to missed menses or fre-
      herbs with a historical use in conditions that are                       quent menstruation.
      now treated by estrogens. The weak estrogenic                                 In a 12-week study conducted by Kaiser Per-
      effects of phytoestrogen-containing herbs can                            manente, using dong quai as a solo agent for the
      provide some benefit in relieving menopause                               relief of menopausal symptoms such as hot
      symptoms. One advantage of phytoestrogens is                             flashes and sweats did not prove to be effective.69
      that they have not been associated with increas-                         More research is needed on use of dong quai in
      ing the risk of breast cancer. In fact, epidemio-                        combination with other herbal preparations.
      logic data and experimental studies in animals                                Dong quai may increase the flow of a period
      have demonstrated that phytoestrogens are                                or bring on a menses. In a perimenopausal woman
      extremely effective in inhibiting mammary                                who is either already having heavy flow problems
      tumors, not only because they occupy estrogen                            or may have missed a menses for several months,
      receptors but also through other unrelated anti-                         this may be alarming. In this case, dong quai is
      cancer mechanisms.64, 65                                                 probably not the best herbal choice for your
          The common phytoestrogen compounds, the                              menopausal symptoms.
      isoflavones, have a similar structure to the body’s                        Dong Quai
      sex hormones. They have the ability to bind to
                                                                                Dry herb used in combination with other herbs in cap-
      estrogen receptors on human cells, and in
                                                                                  sule form or
      women they have a preference for binding to the
                                                                                Tincture: 1⁄ 2–1 tsp 1–3 times per day
      beta form of the estrogen receptor. As a result,
                                                                                                 M E NO PAU S E   195
    Ginkgo (Ginkgo Biloba). Ginkgo is the
                                                        Ginkgo Biloba
world’s oldest living species of tree with fossil
records as old as 200 million years. The leaves of      40–80 mg standardized extract capsules or 1⁄ 2–1 tsp
young, cultivated trees are used in modern herbal        tincture 3 times per day
preparations. Two groups of active constituents—
the terpene lactones and the ginkgo flavone glyco-          Ginseng (Panax Ginseng). There are many
sides—are the most critical compounds of               types and grades of ginseng and ginseng extracts
standardized herbal products. Many forms and           that include related species. Panax ginseng, also
methods of preparation of ginkgo are available,        known as Korean or Chinese ginseng, is the most
although a high quality of Ginkgo biloba extract is    widely used. A standardized extract of ginseng
typically standardized to 24 percent ginkgo            has been shown to improve depression and well-
flavone glycosides and 6 percent terpene lactones.      being in 384 postmenopausal women.79 Another
The actions of these constituents include improv-      randomized controlled trial found that one
ing blood flow to the brain70 and to the hands and      month of Korean red ginseng increased energy
feet.71, 72 Although ginkgo extract has not been       and decreased insomnia and depression.80
specifically studied in menopausal women with               Historically, ginseng has been used as a “tonic
memory or cognition problems, it has been used         for invigoration and fortification in times of
to improve memory.                                     fatigue and debility and for declining capacity for
    Clinical studies have demonstrated the efficacy     work and concentration.”81 Ginseng can help in
of Ginkgo biloba extract (GBE) for the treatment of    reducing mental or physical fatigue,82–85 enhanc-
memory loss, depression, and disorientation associ-    ing the ability to cope with physical and mental
ated with cerebrovascular insufficiency in geriatric    stressors by supporting the adrenal glands,86 or
patients.73–75 Two studies have shown gingko to be     treating the atrophic vaginal changes due to lack
effective for patients with mild to moderate pri-      of estrogen.87
mary dementia of the Alzheimer’s type or multi-
                                                        Panax Ginseng
infarct dementia.76, 77 Patients who received ginkgo
showed memory and attention improvements and            Standardized extract capsules: 200 mg 5% ginseno-
significant improvement in cognitive function tests        sides or 100 mg 10% saponin ginsenoside per day
and depression. Relative differences for dementia       High-quality root: 4–6 g per day
were not observed. I think it is important to
include ginkgo for menopausal women because                Licorice (Glycyrrhiza Glabra). The major
changes in mental clarity, memory, and concentra-      active constituent in licorice root is glycyrrhizin.
tion are common, and it may be that ginkgo will        Much of the attention on licorice root has cen-
have an increasing role in improving these symp-       tered on its anti-inflammatory, antibacterial,
toms for this group of women.                          antiviral, and expectorant (promotion of the
    Another commonly reported change in peri-          elimination of mucus from the lungs or bronchi)
and postmenopausal women is a drop in their sex        properties, but for menopausal symptom relief
drive. Extract of ginkgo appears to be remarkably      we are more interested in the estrogenic activity
effective in reversing antidepressant-induced          of some of its phytoestrogen components, includ-
sexual dysfunction in women as well as men.78          ing beta-sitosterol, formononetin, coumarin, and
Although the sexual dysfunction in this study          others, in particular beta-sitosterol, which is
                                                       1⁄400 th as active as estradiol.88 However, the gly-
was drug-induced rather than the result of
changing hormones, I recommend trying this             coside of glycyrrehetinic acid has been shown to
safe and simple approach.                              have an antiestrogen activity, inhibiting the effect
196   W O M E N ’ S E N C Y C L O P E D I A O F N AT U R A L M E D I C I N E

      of estradiol on uterine growth in ovariectomized                         with the placebo group, the hot flashes were
      animals.89 It may be that licorice has both hor-                         reduced more rapidly in the group receiving 82
      mone and antihormone effects, or it may in fact                          mg of isoflavones.95
      lower estrogen levels while simultaneously raising                           Other effects of red clover also have implica-
      progesterone levels. This creates some confusion                         tion in menopausal women. One published
      in thinking about why and when to take it, and                           study showed that red clover isoflavones may
      at this time we cannot really clear up the confu-                        reduce the risk of coronary vascular disease by
      sion because there is insufficient research to                            increasing arterial elasticity, although it did not
      account for the use of licorice as a single meno-                        improve cholesterol levels.96 Red clover isoflavones
      pausal herb. Licorice may, however, be used in                           may also slow bone loss of the spine.97
      combination with other herbs as part of an effec-                            There have been no significant adverse or
      tive formulation for symptom relief.                                     intolerant reactions with red clover, no signifi-
                                                                               cant change in blood parameters used to measure
       Licorice                                                                toxicity, and no evidence of uterine bleeding or
       Dry form used in combination with other herbs in cap-                   increased endometrial thickness. In fact, an 80
         sules or                                                              mg red clover extract did not increase the thick-
       Tincture: 1⁄ 2–1 tsp 1–3 times per day                                  ness of the lining of the uterus in postmeno-
                                                                               pausal women, despite its high content of
          Red Clover (Trifolium Praetense). Red                                phytoestrogens.98
      clover, a member of the legume family, has been                              I cannot offer women who have a history of
      used worldwide as a source of hay for cattle,                            breast cancer the same degree of reassurance about
      horses, and sheep, and the leaves and young                              using red clover as I can with black cohosh. I do
      sprouts have been used by humans as a source of                          not consider it definitely contraindicated, because
      protein. Historically, it has also been recognized                       in fact red clover has a rich history in herbal med-
      as a medicinal plant for humans and, more                                icine as a treatment for cancers of all kinds. One
      recently, as a menopausal herb.                                          can see the logic of its use in cancer because of its
          At least six clinical trials have been conducted                     genistein and daidzein constituents, both known
      on the effect of red clover isoflavones on vasomo-                        inhibitors of tumor growth and cancer cell divi-
      tor symptoms. Three show benefit, and three do                            sion. However, the results of an experiment that
      not. The first two published studies on red clover                        compared the relative effects of several different
      and vasomotor symptoms showed no statistically                           herbs on estrogen-receptor positive breast cancer
      significant difference between the red clover stan-                       cells in vitro raised concern.99 Surprisingly, the
      dardized extract and the placebo.90, 91 Two other                        breast cancer cells in the laboratory responded the
      studies showed positive results in reducing hot                          same to red clover as they did to estradiol. The
      flashes.92, 93 The two most recent studies con-                           question of safety or concern with using red clover
      tinue the contradictions. In a 2002 study, 80 mg                         extracts in postmenopausal women with a history
      of isoflavones per day resulted in a significant                           of estrogen receptor positive breast cancer remains
      reduction in hot flashes as compared to base-                             unanswered.
      line.94 Another recent study, called the ICE
      study, compared two different doses of red clover                         Red Clover
      isoflavones with placebo. The reductions in the                            Standardized extract of 40 mg total isoflavones,
      mean daily hot flash count at 12 weeks were sim-                             1 tablet 1–2 times per day or
      ilar for groups receiving 82 mg of isoflavones, 57                         Dry herb capsule (500 mg): 1 per day
      mg, and the placebo. However, in comparison
                                                                                              M E NO PAU S E   197
Nonphytoestrogen Herbs                                     In a double-blind, randomized, placebo-
                                                       controlled study, a combination of black cohosh
    Black Cohosh (Cimicifuga Racemosa). Black          and Saint John’s wort was studied.111 The Saint
cohosh, Actaea racemosa or Cimicifuga racemosa, is     John’s wort plus black cohosh group was signifi-
a member of the buttercup family and is used for a     cantly superior to the placebo group on scales
variety of women’s health conditions. In the last 25   measuring menopause symptoms and depression.
years, it has emerged as the most studied of the           The average recommended dose of the stan-
herbal alternatives to hormone replacement ther-       dardized extract of black cohosh is 40 to 80 mg
apy for menopause symptoms. Since the 1980s            per day. The clinical studies performed prior to
and up through 2005, numerous studies, including       1996 used doses of 40 to 140 mg of standardized
several randomized controlled trials, have been car-   extract. Although there is still some confusion
ried out using a standardized extract of black         about which dose of black cohosh may be most
cohosh, with encouraging but mixed results.100–106     effective, the dosage used in most clinical trials to
In one of the largest studies, 629 women with          date is 20 to 40 mg of the standardized extract
menopausal complaints received a liquid standard-      twice daily.
ized extract of black cohosh at 40 drops twice per         Despite the two negative studies in 2006, the
day for six to eight weeks. As early as four weeks     collective study findings and clinical anecdotal
after beginning the therapy, a clear improvement in    evidence on black cohosh teach us that it is effec-
the menopausal ailments was seen in approxi-           tive for menopause symptoms of hot flashes,
mately 80 percent of the women. After six to eight     mood swings, sleep disorders, and body aches.
weeks, complete disappearance of symptoms                  Left unanswered is, how does black cohosh
occurred in approximately 50 percent.107               work? Early studies found it to have estrogenic
    In 2006, one study using a standardized            activity,112 whereas other studies in the last few
extract of black cohosh seemed to indicate bene-       years have demonstrated no phytoestrogens in
ficial effects on bone metabolism by stimulating        black cohosh and no estrogen-like effects on LH
bone-building cells and a weak effect on matura-       or FSH. In addition, prolactin levels, estradiol,
tion of vaginal cells,108 and another showed no        and endometrial thickness were not affected by
effect on menopausal symptoms.109                      black cohosh.113, 114 Most recently, scientists
    In a third study, the Herbal Alternatives for      from the University of Illinois have reported that
Menopause (HALT) Study, five groups were                constituents in black cohosh bind to opiate
studied: black cohosh (160 mg/daily), a multi-         receptors and activate responses, including core
botanical herbal formula including black cohosh,       temperature regulation.115 At the moment, the
a multibotanical formula plus dietary soy, conju-      mechanism of action is not clear, although some
gated equine estrogen (0.625 mg/daily), and            have postulated an effect on serotonin levels.
placebo.110 Hot flash frequency and intensity did           Over these same 25 years, safety and toxicity
not differ between the herbal interventions and        studies have also been conducted on black
placebo at 3, 6, or 12 months with one excep-          cohosh, and it has been subjected to incr