Women s Encyclopedia of Natural Medicine (PDF)

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WO M E N’S
E NCYC LO P E D IA
o f N AT U R A L

MEDICINE
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WO M E N’S
E NCYC LO P E D IA
o f N AT U R A L

MEDICINE

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

TORI HUDSON, N.D.

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DOI: 10.1036/0071464735
Professional

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To:
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CONTENTS

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

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

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

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

ix
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ACKNOWLEDGMENTS

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.
xi
Copyright © 2008 by Tori Hudson. Click here for terms of use.
xii ACKNOWLEDGMENTS

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

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

xv
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INTRODUCTION

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
xvii
Copyright © 2008 by Tori Hudson. Click here for terms of use.
xviii INTRODUCTION

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

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

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

MEDICINE
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ABNORMAL
UTERINE BLEEDING
CHAPTER
1

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.
1
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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-
months
esterone production, which causes shorter cycles.
• The presence or absence of pain along with
As the aging process progresses, ovulation
the bleeding
becomes less frequent, resulting in a variable
• Heaviness of the ﬂow (number of pads or
length of the menstrual cycle and a variation in
tampons per day and how often they are
the duration of the ﬂow. Eventually, the lack of
changed when saturated)
ovulation puts women in an estrogen-dominant
• Contraceptive methods, if any
state in the presence of too little progesterone
• Symptoms of pregnancy
because ovulation must occur in order to pro-
• Dates and histories of past pregnancies
duce progesterone. Women who are in a state of
• Premenstrual symptoms
chronic anovulation tend to have an excess of
• Recent abdominal, pelvic, or vaginal trauma
estrogen in the body. This excess estrogen is what
• Clotting problems
disrupts the normal pattern of menstruation.
• Easy bruising or bleeding
The remaining 30 percent of cases of DUB
• Symptoms of systemic diseases
occur among women age 20 to 40, generally as a
4 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
biopsy.
• 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
diseases.
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
1⁄4
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-
Bioﬂavonoids
tors like prothrombin and clotting factors VII, IX,
and X has obvious implications for women with 1,000–2,000 mg per day
heavy or prolonged menses.7 Even when the cause
of the excessive bleeding is not a clotting disorder,
it may be prudent to use vitamin K as part of a Botanicals
comprehensive treatment plan. Fat-soluble chloro- Chaste Tree (Vitex Agnus Castus). Chaste
phyll is a good source of vitamin K and is found in tree is probably the best-known herb in all of
fresh green juices. Consider increasing the intake Europe for hormonal imbalances in women.
of green leafy vegetables and/or supplementing Since at least the time of the Greeks, chaste tree
with 150 to 500 mcg per day of vitamin K. has been used for the full scope of menstrual 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)
aggregation23
• Cranesbill (Geranium maculatum)
• Blue cohosh (Caulophyllum thalictroides)
• Beth root (Trillium erectum)
• Helonias (Chamaelirium luteum)
• Greater periwinkle (Vinca major)
• Squaw vine (Mitchella repens)
Cranesbill. This astringent herb, high in • Raspberry leaves (Rubus idaeus)
tannic acid, was relied on by early American Indi- • Life root (Senecio aureus)
ans to treat diarrhea, dysentery, leukorrhea, and Life root, also known as ragwort, is a time-
chronic menorrhagia, especially cases of prolonged honored “female regulator” that has been used
bleeding. Cranesbill was used by early practition- consistently in traditional herbal medicine for
ers of natural medicine (the eclectic physicians) to menstrual cramps, menorrhagia, suppressed men-
achieve prompt and predictable results in cases of struation, and other disturbances of the reproduc-
menorrhagia without any unpleasant side effects. tive tract. It is a classic uterine tonic that has been
Without Tannins used to tonify a soft, less-than-ﬁrm uterus, includ-
• Horsetail (Equisetum arvense) ing laxity of the uterine ligaments. It adds tone
• Goldenseal (Hydrastis canadensis) and structure to the nervous and muscular struc-
• Shepherd’s purse (Capsella bursa-pastoris) tures of the reproductive female organs and 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
ﬂow)
not to exceed recommended doses.
• Some cases may require higher doses of oral
• Essential oil of cinnamon: 1–5 drops every 3–4 micronized progesterone.
hours • Some cases may require a natural
estrogen/natural progesterone formulation that
requires more individualized dosing.

progesterone, it is generally very well tolerated by viable alternative therapy in premenopausal
women. One study found that while traditional bleeding disorders.24 You may want to read much
progestin treatments such as norethindrone can more on bio-identical hormones in Chapter 12.
decrease estradiol, follicle-stimulating hormone, The disadvantages to the natural hormone
luteinizing hormone, sex-hormone-binding include a short half-life (three to six hours) that
globulin, and high-density lipoprotein choles- requires giving it two to three times a day. Natural
terol, bio-identical progesterone offers the hor- progesterone can be delivered by injection, sub-
monal beneﬁts without these side effects and is a lingual tablets, rectal or vaginal suppositories, oral
ABNORMAL UTERINE BLEEDING 13
capsules or tablets, and topical creams. Dosing is Oral contraceptives containing estrogen and
dependent on the delivery system and the charac- progestin are also used to stop acute bleeding,
teristic bleeding problems. When treating women although they may not be as effective as the high
with DUB, the amount of progesterone given doses of estrogen alone. Three tablets of an oral
must be adequate to convert the endometrium for contraceptive containing a progestin plus 35 mcg
complete sloughing to avoid endometrial hyper- of estrogen taken every 24 hours (one tablet
plasia. Continuous progesterone can be effective every eight hours) will usually provide sufﬁcient
in controlling menorrhagia. estrogen to stop acute bleeding while 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
2

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,
15
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
FSH
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
E VA L UAT I N G A M E N O R R H E A
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,
ment.)
and they may have acquired amenorrhea because
2. Hyperprolactinemia
they have too little body fat. It is unlikely that
3. Inadequate estrogen production
overexercise alone will cause amenorrhea; it usu-
4. Chronic lack of ovulation, including poly-
ally takes a combination of low body fat and heavy
cystic ovary syndrome (PCOS)
exercise to induce amenorrhea.
In other cases such as polycystic ovarian syn- Keep in mind that causes such as thyroid disor-
drome (PCOS), about 50 to 60 percent of women ders, tumors, systemic diseases, genetic disorders,
will be overweight. In these cases, a 10 percent and others will require therapies to speciﬁcally
weight loss can lead to ovulation and also decrease address those underlying problems, which are
insulin resistance. A diet lower in starchy carbs and beyond the scope of this book.
higher in healthy protein is an important strategy
for women with PCOS, whether they are over- Nutrition
weight or not. Both weight loss and obesity can be associated
A holistic approach to treatment requires with amenorrhea. A range of weight-loss prob-
exploring the mental, spiritual, emotional, and lems are associated with amenorrhea, including
physical aspects of the patient integrated with a crash diets, malnutrition, and life-threatening
AMENORRHEA 19
anorexia nervosa. Anorexia nervosa occurs pri- insulin, and glucose intolerance, conditions that
marily in young white middle- to upper-class often co-occur with obesity and polycystic ovar-
women under age 25, yet has also been known to ian syndrome, are associated with amenorrhea
occur in young men and middle-aged women. and oligomenorrhea (infrequent menses).2, 3
The family situation of a young woman with Usually, oligomenorrhea and chronic anovula-
anorexia is very often success-achievement- tion caused by hormonal abnormalities is the
appearance oriented. The pattern usually starts cause of the menstrual irregularity in women
with a diet to control weight and a fear of excess with signiﬁcant amounts of excess body fat.2 A
weight when in fact the weight being gained is reduction in body weight by reducing calories,
due to normal maturing. There is often a preoc- increasing physical exercise, and possibly other
cupation with food that may manifest itself by weight-management interventions will result in
large intakes of lettuce, raw vegetables, and other beneﬁcial changes in the hormonal proﬁle,
low-calorie foods. Other manifestations may be including a marked reduction of androgenic hor-
chaotic eating habits and eating times, radical mones and their effects.1 A reduction of weight
diets, missed meals, and bingeing episodes. by even as little as 5 to 10 percent can not only
Bulimia is a syndrome of episodic and secre- restore regular menses, but also improve fertility.4
tive binge eating followed by self-induced vomit- Some women may have low body weight
ing, fasting, or the use of laxatives and diuretics. but do not have an eating disorder or exercise-
Bulimic behavior is frequently seen in about half induced amenorrhea. This may be a metabolism
of women with anorexia nervosa. Body weight in issue, a hereditary factor, or a diet that is ex-
“pure” bulimics ﬂuctuates but does not fall to the tremely low in fat although not low in calories.
low levels seen in anorexics. Women who take in insufﬁcient calories, such as
Teenagers with low body weight, amenorrhea, strict vegetarians who eat no animal products or
and overachievement (excellent grades and many others with extreme diets, may have insufﬁcient
extracurricular activities) need astute evaluation dietary fat and low cholesterol. Adequate choles-
for an eating disorder. Psychological counseling, terol is needed to manufacture hormones. If no
consistent support, and monitoring for calorie cholesterol is found in the diet and the liver is
intake will be needed to break the established pat- not manufacturing adequate cholesterol, these
terns. The earlier the recognition of the problem, women may have amenorrhea due to insufﬁcient
the more successful the intervention. Family hormone levels. Measuring the cholesterol level
members, friends, and health-care practitioners can be telling in such cases. If cholesterol is low
should pay particular attention to weight and diet (below 120), a change in vegetarian philosophy
in young women with amenorrhea. will probably be necessary so that some animal
Obese women exhibit several abnormalities products can be included in the diet in order to
in their hormone proﬁle. Elevated serum concen- raise the cholesterol levels.
trations of androstenedione, testosterone, and Sometimes it is difﬁcult to ﬁnd the best nutri-
DHEA-sulfate are associated more closely with tional program for one’s body type and lifestyle.
the pattern of fat distribution (abdominal vs. In these cases, nutritional counseling and nutri-
hips, in particular) than to the body fat mass.1 tional analysis with a qualiﬁed practitioner can
High levels of these hormones, called androgens, be very helpful. No one diet plan is right for
are known to be a cause of menstrual irregulari- everyone. Not everyone needs to eat from all the
ties including amenorrhea, hirsutism (abnormal food groups, not everyone can be a vegetarian,
body hair growth), and other metabolic distur- and not everyone responds well to a high-protein
bances. In addition, type 2 diabetes, elevated or high–complex carbohydrate diet.
20 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.
Combination
In 1971, a small study examined six women
with elevated serum carotene levels who had 1,200–1,500 mg per day
excessive intake of carrots or pumpkins.10 The
researcher described what he called “golden Additional Vitamins and Minerals. Many
ovaries” and noted that amenorrhea developed in other minerals and nutrients affect bone density
the two younger patients and irregular menstrual and are relevant to the prevention of osteoporo-
bleeding in the four older patients. For some sis in amenorrheic women. Magnesium, man-
time it was thought that exercise-induced amen- ganese, zinc, copper, boron, vitamin K, vitamin
AMENORRHEA 21
D, and other nutrients determine bone health, increased, and FSH values either did not change
each in their own way. In Chapter 14, I discuss or decreased slightly.
this in detail. Chaste tree also inhibits prolactin release by
the pituitary gland, particularly when elevated
Botanicals prolactin is caused by stress, by binding dopa-
Chaste Tree (Vitex Agnus Castus). Chaste mine receptors and then inhibiting prolactin
tree is probably the best-known herb in all of release in the pituitary.17, 18 Since elevated pro-
Europe for hormonal imbalances in women. Since lactin levels cause some cases of amenorrhea,
at least the time of the Greeks, chaste tree has been chaste tree is also indicated for these cases. A
used for the full scope of menstrual disorders, double-blind, placebo-controlled study examined
including amenorrhea. Chaste tree acts on the the effect of a chaste tree (vitex) preparation on 52
hypothalamus and pituitary glands by increasing women with luteal phase defects due to hyperpro-
LH production and mildly inhibiting the release lactinemia (elevated prolactin levels).19 The daily
of FSH. The result is a shift in the ratio of estro- dose of the extract was 20 mg, and the study
gen to progesterone, in favor of progesterone.13 lasted for three months. Prolactin release was sig-
Chaste tree stimulates ovulation, which in turn niﬁcantly reduced in the vitex group. The short
produces progesterone. Thus, chaste tree indi- luteal phase (second half of the cycle) was normal-
rectly raises progesterone levels,14 an effective ized, and the decreased progesterone production
treatment for some cases of amenorrhea. was normalized. No side effects were noted, and
If we were to give progesterone hormone for two women became pregnant.
several days, stop, and then a menses occurs, this When using chaste tree, don’t expect immedi-
indicates an intact reproductive system that lacks ate results. It’s not the same as giving proges-
cyclicity and ovulation, or at least regular cyclic terone, even natural progesterone. Chaste tree is
ovulation. It suggests that the body is producing more of a medium-range plan; usually it begins
enough FSH to stimulate the ovaries and that the to take effect after three or four months when
ovaries can develop follicles. Furthermore, it given daily.
indicates that follicular production of estrogen is
sufﬁcient to cause the lining of the uterus (endo- Chaste Tree
metrium) to grow and that the sloughed endo- 40 drops tincture or 175 mg .6% aucubin standardized
metrium is able to pass through the cervical extract per day
opening and the vagina. This tells us that the
problem most likely is a dysfunction in the hypo- Black Cohosh (Cimifuga Racemosa). Black
thalamus or pituitary. The ability of chaste tree to cohosh has become one of the most signiﬁcant
modulate the hypothalamus or pituitary then women’s herbs in all of botanical medicine. Also
makes this herb an obvious choice. known as snakeroot or rattleroot, this plant
The ﬁrst major study on chaste tree was belongs to the buttercup family and is indigenous
published in 1954.15 Subsequent studies have to the eastern part of North America. The native
continued to prove its effectiveness. In a study peoples of Canada and America used black cohosh
published in 1990, 20 women with secondary for many different indications, such as uterine
amenorrhea were admitted to a six-month study pains during menses and childbirth, rheumatism,
using chaste tree liquid extract at 40 drops rattlesnake bites, and general malaise. Black
daily.16 At the end of the six-month study, 10 out cohosh was introduced to Western gynecology in
of the 15 women had menstrual cycles. Testing the middle of the eighteenth century in the treat-
showed that values for progesterone and LH ment of menopausal symptoms.20
22 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
Hyperprolactinemia
Diet: A whole foods diet using plenty of grains,
beans (especially soybeans), fruits, vegetables Diet: A whole foods diet using plenty of grains,
(especially dark leafy greens), nuts and seeds beans (especially soybeans), fruits, vegetables
(especially ﬂaxseed), and ﬁsh (salmon, tuna, hal- (especially dark leafy greens), nuts and seeds
ibut, sardines) (especially ﬂaxseed), and ﬁsh (salmon, tuna, hal-
Exercise: Regular aerobic and weight-bearing exer- ibut, sardines)
cise 30 to 60 minutes, 4 to 7 days per week; Exercise: Moderate exercise 150 minutes per week
weight/strength training 2 days per week Chaste tree extract: 40 drops or 175 mg .6% aucu-
Mineral supplementation: Calcium/magnesium/ bin standardized extract per day
boron/vitamin D/other trace minerals and nutrients
(see Chapter 14) Hypoestrogenic States (Hypothalamic
Consider oral contraceptives with 30 mcg of Amenorrhea)
ethinyl estradiol: Estriol 2 mg/estradiol 0.5 mg/ These states are often associated with weight loss,
OMP 200 mg; 1 pill twice daily, 3 weeks on and 1 psychological states, and anorexia nervosa.
week off
Diet:
Consider bio-identical hormones: Estriol 2 mg/
estradiol 0.5 mg/progesterone 100 mg; 1 pill twice Increase calories, dietary protein, fat, and
daily, 3 weeks on and 1 week off carbohydrates.
Consider short-term trial (less than 6 months): Consume regular meals using whole foods.
Avoid extreme dieting.
Black cohosh extract: standardized extract,
Increase soy foods and ﬂaxseed.
40–80 mg twice daily
Maca: 2,000 mg per day Lifestyle:
Rhodiola: 3% rosavin, 200 mg per day Counseling (for eating disorders)
Polyglandular products: To stimulate the hypothala- Stress management counseling and practices
mus/pituitary/ovarian feedback mechanisms, use Reduce exercise from excessive to moderate
bovine extracts of combinations of pituitary, thy- (continued)
28 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.
CERVICAL
DYSPL ASIA
CHAPTER
3

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
31
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
dysplasia.
ally transmitted. Many cofactors serve as cocar-
• Cervical dysplasia is classiﬁed as either low-grade cinogens in the development of cervical dysplasia,
or high-grade and, if left untreated or if the body including smoking, nutrient deﬁciencies, immune
is not able to reverse it on its own, can progress deﬁciency, and possibly oral contraceptives. Where
to cervical cancer, especially if a person is natural medicine diverges in its approach is in
infected with the oncogenic strains of HPV. advising patients what they can do about these
• Cervical cancer of squamous cells is a preventable cofactors. In addition, there are nutrients that can
disease. be used in supplement form both to prevent the
• Pap smears are screening tests, not diagnostic progression of cervical dysplasia to cervical cancer
tests.
and to reverse some cases of dysplasia.
36 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.
(continued)
CERVICAL DYSPLASIA 41
Criteria and Guidelines for Treatment Selection (continued )

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

Toxicity studies prove its safety up to 8,000 similar protocols were used including the
mg per day by mouth for up to three months as escharotic treatment with some of the more
well as its efﬁcacy in chemoprevention in cancer, severe cases. I discussed this in more detail in the
including cervical cancer. section of this chapter on carotenes. Indications
The Escharotic Treatment. The escharotic and directions for use of the escharotic treatment
treatment is a topical caustic treatment of the are given later in this chapter.
cervix used to remove abnormal cells. It involves
the use of zinc chloride mixed with a botanical, Botanical Formula I
Sanguinaria canadensis (bloodroot). I have used Red clover: 1 oz
the escharotic treatment for more than 24 years, Dandelion root: 11⁄ 2 oz
and at one time I conducted a small study using Licorice root: 1 oz
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
Topical
Beta-carotene: 150,000 IU daily
Week 1: vitamin A suppository nightly for 6 nights Folic acid: 10 mg daily
Week 2: herbal vaginal suppository nightly for 6 Multiple vitamin/mineral: follow label directions
nights Green tea capsules: 1 capsule daily
Week 3: vitamin A suppository nightly for 6 nights Botanical Formula I: 1⁄ 2 tsp twice daily
Week 4: herbal vaginal suppository nightly for 6
Use systemic treatment for 3 months until follow-up.
nights
Week 5–12: green tea suppository 2 nights per week Constitutional
Systemic Vegetarian diet for 3 months until follow-up
Folic acid: 10 mg daily Additional Therapies to Consider
Vitamin C: 6 g daily
Beta-carotene: 150,000 IU daily Zinc: 30 mg daily
Multiple vitamin/mineral: follow label directions Vitamin E: 400 IU daily
Green tea capsules: 1 capsule daily Selenium: 400 mcg daily
Botanical Formula I: 1⁄ 2 tsp, twice daily Green tea suppository: twice per week
DIM: 200 mg daily
Use systemic treatment for 3 months until follow-up.
Comments: A follow-up Pap smear in 3 to 6 months
Constitutional that is still abnormal warrants colposcopy and biopsies.
Vegetarian diet for 3 months until follow-up
Maintenance Plan for 3 Months
Alternative Naturopathic Plan (After Normal Pap Smear)
Topical Vitamin C: 2 g daily
Week 1: vitamin A suppository nightly for 6 nights, Beta-carotene: 150,000 IU daily
Vag Pack suppository 1 night per week Folic acid: 2.5 mg daily
Week 2: herbal vaginal suppository nightly for 6 Multiple vitamin/mineral: follow label directions
nights, Vag Pack suppository 1 night per week Green tea capsules: 1 capsule daily
Week 3: vitamin A suppository nightly for 6 nights, Vegetarian diet
Vag Pack suppository 1 night per week

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

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

or practicing safer sex if the partner has known ically possible, and there are conditions when the
genital warts may be advisable. It is considered HPV virus may lodge in the larynx and oral
very low risk for the virus alone to be transmitted cavity. However, these cases are extremely rare,
between women, although it is theoretically pos- and so it is left to each person to make that judg-
sible. Both heterosexual and homosexual women ment on her own. If one of the partners is
ask about the risk of transmitting or contracting immunocompromised (HIV-positive, a trans-
the virus through oral sex. Again, this is theoret- plant patient, or has chronic hepatitis), then she
44 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
Topical
products included in these treatment plans.
Escharotic treatment twice per week for 4 weeks
Initial Naturopathic Plan After the last escharotic treatment:
Topical Week 1: vitamin A suppository nightly for 6 nights
Week 2: papilloma suppository nightly for 6 nights
Week 1: vitamin A suppository nightly for 6 nights,
Week 3: vitamin A suppository nightly for 6 nights
2 Vag Pack suppositories for 1 night
Week 4: papilloma suppository nightly for 6 nights
Week 2: herbal vaginal suppository nightly for 6
Weeks 5–12: green tea suppository twice per week
nights, 2 Vag Pack suppositories for 1 night
Week 3: vitamin A suppository nightly for 6 nights, Systemic
2 Vag Pack suppositories for 1 night
Folic acid: 10 mg daily
Week 4: herbal vaginal suppository nightly for 6
Vitamin C: 6 g daily
nights, 2 Vag Pack suppositories for 1 night
Multiple vitamin/mineral: follow label directions
Week 5: vitamin A suppository nightly for 6 nights,
Beta-carotene: 150,000 IU daily
2 Vag Pack suppositories for 1 night
Green tea capsules: 1 capsule daily
Week 6: herbal vaginal suppository nightly for 6
Botanical Formula I: 1⁄ 2 tsp twice daily
nights, 2 Vag Pack suppositories for 1 night
Weeks 7–12: green tea suppository twice per week Use systemic treatment for 3 months until follow-up.

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

is more vulnerable to contracting HPV, and 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.
Systemic
Initial Naturopathic Plan Vitamin C: 6 g daily
Beta-carotene: 200,000 IU daily
Topical
Folic acid: 10 mg daily
Escharotic treatment twice per week for 5 weeks Selenium: 400 mcg daily
After the last escharotic treatment: Multiple vitamin/mineral: follow label directions
Green tea capsules: 1 capsule daily
Week 1: vitamin A suppository nightly for 6 nights
DIM: 200–400 mg daily
Week 2: herbal vaginal suppository nightly for 6
Botanical Formula II: 1⁄ 2 tsp twice daily
nights
Week 3: vitamin A suppository nightly for 6 nights Use systemic treatment for 3 months until follow-up.
Week 4: herbal vaginal suppository nightly for 6
nights Constitutional
Weeks 5–12: green tea suppository twice per week Vegetarian diet for 3 months until follow-up

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

Smoking may also alter immune function Oral Contraceptives
and affects the levels and distribution of ascorbic Earlier studies suggested that oral contraceptive
acid. Ascorbic acid in the cells of the cervix and (OC) use increased the risk of cervical neoplasia,
the vagina and plasma levels of ascorbic acid are both invasive and precancerous cervical dysplasias.83
reduced in smokers.82 Recently, however, studies that are controlled for
46 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
Topical
Beta-carotene: 200,000 IU daily
Escharotic treatment twice per week for 5 weeks Folic acid: 10 mg daily
After the last escharotic treatment: Selenium: 400 mcg daily
Week 1: vitamin A suppository nightly for 6 nights Multiple vitamin/mineral: follow label directions
Week 2: herbal vaginal suppository nightly for 6 Green tea capsules: 1 capsule daily
nights DIM: 200–400 mg daily
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.
nights
Weeks 5–12: green tea suppository twice per week Constitutional
Vegetarian diet for 3 months until follow-up
Systemic
Folic acid: 10 mg daily Additional Therapies to Consider
Vitamin C: 6 g daily
Zinc: 30 mg daily
Beta-carotene: 180,000 IU daily
Vitamin E: 800 IU daily
Selenium: 400 mcg daily
Selenium: 400 mcg daily
Multiple vitamin/mineral: follow label directions
Pyridoxine: 50 mg 3 times a day
Green tea capsules: 1 capsule daily
Lomatium isolate: 5 drops twice daily
Botanical Formula II: 1⁄ 2 tsp twice daily
Alternating sitz baths twice weekly for 4 weeks dur-
Use systemic treatment for 3 months until follow-up. ing suppository routine

Constitutional Maintenance Plan for 1 Year
Vegetarian diet for 3 months until follow-up Vitamin C: 3 g daily
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
leakage.
1. Insert speculum and visualize the cervix. 9. After the last escharotic treatment, use the fol-
2. Blot the cervix dry with large cotton swab or lowing treatment plan:
cotton ball on the end of a ring forceps.
3. Dip a large cotton swab into the distilled water Week 1: vitamin A suppository nightly for 6
and then squeeze out the water. Place the damp nights
swab into the bromelain and thickly cover the Week 2: herbal vaginal suppository nightly for 6
face of the cervix with the powder, repeating as nights, or in cases with HPV, use condyloma
needed to cover the cervix completely. Apply suppository
the powder in the endocervical canal using Week 3: vitamin A suppository nightly for 6
small, dampened cotton tip applicators (use a nights
new applicator each time). Week 4: herbal vaginal or papilloma suppository
nightly for 6 nights

moderate and severe dysplasias (CIN 2, CIN 3). inadequate prior treatment with residual cells
Tissue destruction beyond the dysplastic lesions that then persist and regrow.
occurs in all of these procedures to varying Cryotherapy is the oldest and cheapest of these
degrees to help prevent recurrences. Recurrences procedures and is a simple ofﬁce procedure per-
are usually due to new infection, reactivation of formed with a blunt probe applied to the cervix
the virus because of immune system changes, or and tubing that supplies concentrated nitrous
CERVICAL DYSPLASIA 49
oxide to cause the probe to get very cold. Tissue opening to the cervix. The advantage of LEEP is
penetration is several millimeters. This procedure that it can be done in the ofﬁce, is well tolerated,
takes approximately two to three minutes and is and is minimally expensive.
associated with cramping at the time, which These techniques are all relatively safe and
resolves quickly and is rarely present for more than effective for preventing future cervical cancer.
a day. The devitalized tissue is sloughed as a watery However, their effects on future fertility and preg-
discharge over the next 10 to 14 days. The cervix nancy outcomes are unclear. Some say that done
is usually well healed within a month. properly, none of these procedures affects fertility,
Conization is employed primarily for endo- sexuality, or pregnancy. There is no adequate data
cervical dysplasia. A cold-knife procedure is per- from randomized controlled trials to evaluate
formed in the operating room under anesthesia these potential effects. In one analysis of 27 obser-
and employs a scalpel to remove a cone-shaped vational trials comparing the fertility and preg-
piece of cervix and cervical canal. Conization has nancy of women who underwent ablation or
the advantage of more clearly evaluating the mar- excision of CIN lesions to women who were not
gins, because there is no thermal artifact. Laser treated with these therapies, LEEP and cold-knife
ablation of the transformation zone can be per- conizations were both associated with signiﬁcantly
formed in the operating room or the ofﬁce and increased risk for preterm delivery. LEEP was asso-
allows for precise management of lesions but ciated with an increased risk for preterm rupture
does not provide tissue for pathology. Laser of membranes, and the cold-knife cone was asso-
conization obtains tissue similar to the cold-knife ciated with an increased risk for cesarean section.
cone procedure, with some thermal destruction The laser cone and the laser ablation had no asso-
at the margins, and is signiﬁcantly more expen- ciation with any signiﬁcant change for any of the
sive than LEEP. outcomes. None of the treatments had any signif-
The most common current treatment of icant association with perinatal mortality, compli-
endocervical or cervical dysplasia of moderate- cation for the infant, or fertility.
to-severe degree is a LEEP procedure, which is Follow-up recommendations may vary depend-
generally performed in the ofﬁce with cervical ing on your overall case history and your practi-
anesthetic and is usually well tolerated and very tioner’s perspective. Some patients treated with any
cost effective. LEEP can be used to remove the of these conventional treatments are advised to
endocervical canal and/or the transformation have three-month Pap smears for the ﬁrst year and
zone. It also has thermal degradation at the mar- six-month Pap smears for the next year. Others will
gins. When LEEP or laser is used, the tissue have the recommendation of annual Pap smears
beyond the cut margin is heated and destroyed following the conventional treatment.
for another 1 to 2 mm of penetration. Even when
the dysplasia is seen all the way to the margin of Prevention: The HPV Vaccine
the biopsy, there is still usually complete treat- The newest approach to conventional medical
ment of the lesion because the heat destruction treatment of dysplasia is prevention. After a clini-
penetrates into the tissue beyond the surgical site. cal trial done in 2002 initially showed that an
Women treated by LEEP are more likely to HPV-16 vaccine reduced the incidence of both
convert to HPV-negative status within one to two HPV-16 infection and HPV-16 cervical dyspla-
years after the procedure and do so signiﬁcantly sia,93 continued research has lead to the reality of
sooner than those who are merely watched with- an HPV vaccine to reduce the incidence of cervi-
out treatment. The LEEP can reduce cervical cal cancer. The FDA approved a quadrivalent vac-
mucus and can occasionally cause a stenosis of the cine in June 2006. It vaccinates women against
50 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
4

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
51
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
Nordette
can ﬁt into a healthy life.
Portia
The pill is not a natural form of birth control, Seasonale
but for some women the beneﬁts outweigh the
downside. If you do choose to use birth control
pills, remember that one of the advantages to appears to result primarily from an inhibition or
barrier methods of contraception (diaphragm, delay of ovulation and does not disrupt an
FemCap, condoms) is the reduced incidence of already established pregnancy.
sexually transmitted infections (STIs), especially It is also possible to use more pills of a birth
pelvic inﬂammatory disease. Oral contraceptives control pill that you might already have on hand
do not signiﬁcantly protect against most STIs. for emergency contraception.
Condoms are the best method of contraception
that also offers a “safer sex” method. Diaphragms 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
bleeding
Advantages
Continuous contraceptive protection when taken Effectiveness
correctly 99 percent or greater
Reversible
Other possible health beneﬁts Tubal Ligation

Disadvantages Advantages

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

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

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

Disadvantages Advantages

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

Effectiveness
Condom (Alone)
82 to 94 percent
Advantages
Easily obtained Spermicide (Alone)
Inexpensive Advantages
Best method for protection against STIs
Better results when used with a spermicide Easy to obtain and use
Good results when used with cervical caps, condoms,
Disadvantages or diaphragms
May reduce sexual sensation Inexpensive
Less sexual spontaneity
(continued )
64 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
intercourse
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.
65
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-
support
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
days
daily for 2 weeks, then twice weekly as
maintenance dose; or estriol suppositories
Chronic, Recurring UTI (3- to 6-Month Plan)
(1 mg): insert 1 daily for 2 weeks, then
Premenopausal Women twice weekly as maintenance dose
• Urinate upon urge and after intercourse. • Consider oral hormone therapy.
• Use condoms for intercourse. With these prevention and treatment strategies, it
• Increase ﬂuids. will rarely be necessary to use antibiotics for
• Take the following supplements: acute, chronic, or recurring UTIs. Please consult
Combination herbal product: 1–2 capsules daily with your practitioners about use of these products
Cranberry extract: 400 mg twice daily in pregnancy and lactation or if you are taking
Cranberry juice: 8–16 oz daily medications.
72 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
estriol.
for 7 to 21 days. A “test-of-cure” culture should be
done approximately 5 to 7 days after completing
therapy. In rare cases, when the response to the
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
6

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
75
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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
ﬂaxseeds.
that detoxify the liver. In addition, they contain
• Omit or decrease alcohol, dairy, red meat,
the bioﬂavonoid quercitin, which is known to sugar, and caffeine.
stimulate the immune response, protect against • Eat cold water ﬁsh (salmon, tuna, sardines,
oxidation, block the inﬂammatory response, and mackerel, herring) 2 or 3 times per week.
inhibit tumor growth.61 By eating as many of your • Eat organic foods.
vegetables as possible in an organic form, you cut
down on your intake of pesticides that may also
mimic estrogen. pathway to be tipped toward prostaglandins and
Use seasonings such as turmeric (curcumin) leukotrienes that cause inﬂammation, smooth
that protect against environmental carcinogens, muscle contraction, and vascular constriction.
decrease inﬂammation, and increase bile secretion. Alcohol use depletes stores of B vitamins in the
Ginger is helpful with many types of inﬂamma- liver and also has estrogenic effects on the body.
tion—and helps with liver detoxiﬁcation. Adding a
Nutritional Supplements
tablespoon of soaked and ground milk thistle seeds
each day can also help with liver function. Grind a Before beginning the discussion on nutritional
tablespoon of fresh ﬂaxseeds and place on cereals or supplements, it is important to explain the con-
salads. The increase in lignans from these seeds aids cepts of free radicals, antioxidants, and free radi-
in providing ﬁber as well as an oil that helps in the cal scavengers. There are several ways to deﬁne a
anti-inﬂammatory pathway. Seasoning with fucus free radical, but a deﬁnition I like is, “an atom or
(a seaweed) helps stimulate T cell production and group of atoms that has at least one unpaired
absorb toxins.62 electron and is therefore unstable and highly
Foods to omit or decrease include sugar, reactive.” Antioxidants such as vitamins C and E,
caffeine, egg yolks, poultry, red meat, and alco- selenium, carotenes, and others are molecules
hol. Sugar is known to increase estrogen levels that defend the body from cellular damage by
in men; presumably the effect is similar in ending the free radical chain reaction before vital
women.63 Endometriosis is found to be corre- molecules are harmed. These are often referred to
lated with caffeine consumption. Women con- as “free radical scavengers.”
suming 5,000 to 7,000 mg of caffeine per month Vitamin C. Studies using vitamin C show
had a 1.2 times greater incidence of endometri- increase in cellular immunity and decreases in
osis, while those consuming over 7,000 mg per
month had a 1.6 times increase.64 One cup of
coffee contains 120 mg of caffeine; one cup Vitamin C
of black tea contains 60 mg; one cup of decaf- Take 6–10 g in divided doses daily, starting with
feinated contains about 2 mg of caffeine. 1,000 mg a day, then add 1,000 mg every 4 or 5 days
The Environmental Protection Agency esti- until the stools become loose. At this point, back
mates that 90 percent of human dioxin exposure is down to the previous dose of vitamin C so that the
through food, primarily meat and dairy prod- stools are normal in consistency.
ucts.65 Egg yolks, meat, and poultry cause the lipid
82 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-
inﬂammation.82
metriosis, perhaps because less estrogen is avail-
Selenium able to stimulate endometrial tissue.86
200–400 mcg daily Dandelion Root (Taraxacum Ofﬁcinale).
Dandelion root is one of nature’s most 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
7

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.

89
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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
8

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
99
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
history
know you are infected or have ever been infected.
6. Condom use for protection from sexually
Men are more likely to have asymptomatic HSV-2
transmitted infections
infections than women.6
7. Types of sexual activity: oral sex with part-
The classic herpes lesion begins as a red
ner, mutual oral sex, penile/vaginal sex,
papule, evolving within two to three days to a
penile/anal sex
vesicle containing clear ﬂuid, and then 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
Goldenseal
See the Resources section for formulation sources.
Oral tincture: 10–30 drops 3 times per day
During an Acute Episode
Additional Botanicals. Many botanicals • Apply ice, preferably during the prodrome stage
have the ability to provide immune support during symptoms of itching, numbness, or tin-
through various mechanisms. Other plants have gling or even after the eruption has appeared,
very speciﬁc antiviral properties as well. for 10-minute applications several times during
The antiviral activity of Saint-John’s-wort the day. This limits the discomfort and swelling
(Hypericum perforatum) has been demonstrated. and can keep an outbreak from fully erupting.
Laboratory studies have shown that two con- • Apply lemon balm ointment several times per
day.
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
9

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
109
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-
Lifestyle
tions of heart disease prevention and treatment.
Sedentary lifestyle Dr. Dean Ornish and his team of researchers
High-fat diet conducted the ﬁrst signiﬁcant clinical trial to
Cigarette smoking determine whether comprehensive lifestyle
Alcohol—more than two drinks per day
changes affect coronary atherosclerosis. Dr. Dean
Stress
Ornish’s landmark study, called the Lifestyle
Family History Heart Trial, published in 1990, found that
lifestyle changes (a low-fat vegetarian diet, mod-
Coronary artery disease
erate aerobic exercise, stress management, 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
smoke.
ability of platelets to clump together, elevate
Prevention of Hypertension
levels of ﬁbrinogen (a clot-forming protein), and
elevate the blood pressure. Smoking is especially • Limit sodium intake to less than 2,400 mg per
problematic in women who use oral contracep- day.
tives. This combination increases the risk of • Practice stress management techniques.
• Work toward or maintain a healthy body weight.
CVD by up to 39 times due to blood clots.42 The
• Exercise daily for 30 minutes or more.
good news is that women who stop smoking can
reduce their risk of CVD to that of a nonsmoker Prevention of Hyperlipidemia
within two years of quitting.
• Decrease consumption of saturated fats and
Exercise is a vital part of a lifestyle routine
high-cholesterol foods.
that can have lifelong beneﬁts in preventing heart • Increase consumption of fruits, vegetables, and
disease and strokes. Regular exercise lowers cho- whole grains.
lesterol levels, improves the blood supply and • Exercise daily for 30 minutes or more.
therefore the oxygen delivered to the heart, • Increase consumption of olive oil, nuts, and
increases the strength of the heart muscle and seeds.
thus improves the volume of blood it can move,
116 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
vision.
review of 20 scientiﬁc trials on the effect of oat
products on cholesterol demonstrates that a
vascular disease.74–79 Norwegian researchers con- modest reduction in blood cholesterol can be
cluded that eating ﬁsh like mackerel, herring, and achieved by eating oat products daily.86 Eating one
salmon will signiﬁcantly reduce the risk of heart bowl of oat bran cereal or oatmeal daily (3 grams
disease. As little as one serving of 300 grams of ﬁsh of oat ﬁber) lowers the total cholesterol by 8 to 23
per week will provide the beneﬁt. They suggested percent. These results have been achieved in as
that the minimal dietary requirement for EPA and little as three weeks.
DHA should be about 200 mg per day.80 A more recent study showed that dietary ﬁber
Keep in mind that ﬁsh oil has anticoagulation intake is inversely correlated with several cardio-
effects that may act synergistically with medica- vascular disease risk factors. The highest total
tions like warfarin, and therefore caution should dietary ﬁber and nonsoluble dietary ﬁber (more
be exercised in supplementing with ﬁsh oil in than soluble) intakes from fruit, vegetables, and
people who are taking these medications.81 cereals were signiﬁcantly associated with a
Lipid-lowering medication was found to decrease decrease in a number of cardiovascular risk
beneﬁcial omega-3 fatty acids and increase path- factors including overweight, hypertension, lipid
ogenic arachidonic acid after only three months markers, and homocysteine.87 Part of ﬁber’s
of use, leading the authors to conclude that these effect on lipids is because these higher ﬁber
medications should be combined with diets low diets are in fact diets low in cholesterol intake.88
HEART DISEASE 121
Another study found that soluble ﬁber added even worse if you eat high-fructose corn syrup, a
simply as a breakfast bread source was found to very common sweetener used in packaged foods.
signiﬁcantly decrease blood pressure and triglyc- Fructose increases LDL and does not improve
eride and cholesterol levels in diabetic patients.89 HDL. A recent study showed that foods with a
Increased ﬁber intake (more than 3 grams of high glycemic index have a negative effect on
cereal ﬁber daily or more than six servings of HDL levels.98
whole grains per week) is also associated with If you have elevated triglycerides, you can eat
decreased progression of coronary atherosclerosis all the whole grains that you want, although
in postmenopausal women.90 some diets, such as the popular Zone diet, pres-
A number of large, recent epidemiological ent some provocative, controversial ideas that
studies published in medicine’s most respected may be contrary to this.
journals found that overall, increased intake of One of the best ways to achieve a high-ﬁber
dietary ﬁber is associated with decreased cardiovas- and low-fat diet is the vegan diet. This is a vege-
cular disease in adults91, 92 and menopausal tarian diet in which absolutely no animal prod-
women.93, 94 Another study looked at the combi- ucts are consumed. Strict vegan diets, which are
nation of 10 mg of simvastatin and 15 grams of typically very low in saturated fat and dietary
psyllium (Metamucil) and found that the combi- cholesterol and high in ﬁber, can help maintain
nation decreased LDL cholesterol better than the or achieve desirable blood levels by especially
same dose of medication alone and found reduc- lowering the total cholesterol and the LDL
tions comparable to 20 mg of simvastatin after cholesterol.99
four to eight weeks of treatment without signiﬁ- Speciﬁc fruits or vegetables may also have a par-
cant changes in HDL or triglycerides.95 One study ticular positive effect on serum lipids. Raw carrots
of a very low saturated fat diet plus a cholesterol- may have a more potent effect on lowering choles-
lowering drug, compared to a diet high in plant terol than do oat products. Eating a raw carrot at
sterols, including soy foods and high-ﬁber whole breakfast every day for three weeks has been shown
grains, concluded that dietary intervention may be to reduce serum cholesterol by 11 percent and
as effective as the medication.96 Continuing to eat increase fat excretion by 50 percent.100
a diet higher in ﬁber as we age also provides car- Evidence also exists demonstrating that
dioprotection. A large study found that increasing people with a low intake of fruits and vegetables
ﬁber later in life can decrease risk of cardiovascular have an increased risk for heart disease.101
disease in the elderly.97 Numerous studies have continued to show that a
Research has also shown that the sugars in diet high in carotenes and ﬂavonoids found in
fruit (fructose) signiﬁcantly raise blood triglyc- fruits and vegetables reduces the risk of heart dis-
eride and cholesterol levels. If your triglycerides ease and strokes.102 It is thought that the antiox-
are above 150 mg/dL, or if you have additional idants (C, E, carotenes, and ﬂavonoids) found in
signiﬁcant risk factors for heart disease such as fruits and vegetables reduce the risk of cardiovas-
elevated blood pressure or diabetes, avoid too cular disease by scavenging free radical species.
much fruit, fruit juice, and other simple sugars. The antioxidants protect the unsaturated fatty
Limit them to one serving per day. Sugar can be acids from peroxidation, thus preventing athero-
eaten in small amounts only if your triglyceride sclerosis. Lipid peroxide concentrations are in
level is below 150 mg/dl. All sugars can increase fact higher in individuals with atherosclerosis.103
triglycerides, but a high amount of fructose, esp- Good dietary sources of carotenes as well as vita-
cially fructose added as a sweetener, is actually mins C and E are green leafy vegetables, yellow-
more damaging than sucrose and glucose. It gets orange fruits and vegetables, red and purple
122 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,
strawberries,
tangerines
Low-fat or 2–3 8 oz milk Skim or 1% milk; Sources of
nonfat 1 cup yogurt nonfat or low-fat calcium, protein
dairy foods 1.5 oz cheese yogurt, buttermilk,
and cheese; part-skim
mozzarella cheese
Meat, including 2 or 3 oz cooked meat, Select lean; trim away Sources of
poultry and ﬁsh fewer poultry, or ﬁsh visible fats; broil, roast, protein and
or boil instead of frying; magnesium
remove skin from
poultry
Nuts, seeds, 4–5 1.5 oz or 1⁄ 3 cup nuts Almonds, ﬁlberts, Sources of energy,
legumes per 1⁄ 2 oz or 2 tbs seeds mixed nuts, peanuts, protein, ﬁber,
week 1⁄ 2 cup cooked walnuts, sunﬂower magnesium, protein
legumes seeds, kidney beans,
lentils

There are multiple reasons that coffee has this and possibly kahweol in unﬁltered coffee.
effect on serum cholesterol. Unﬁltered coffee in Another explanation came to light in a recently
particular137, 138 increases coronary artery disease published Norwegian study140 that indicated a
risk and mortality in men and women.138, 139 dose-response between coffee consumption and
This effect is possibly explained by the presence blood homocysteine levels: the larger the coffee
of the diterpines (removed by ﬁltering), cafestol, intake, the greater the homocysteine levels.
126 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. 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

Ginger
Gugulipid (Commiphora Mukul ). The
1 g per day powdered ginger root mukul myrrh tree, native to India, Pakistan, and
Afghanistan, is the source of standardized
Globe Artichoke (Cynara Scolymus). The gugulipid extract. The extract is further concen-
leaf extract of the artichoke has been found to have trated to isolate compounds known as guggul-
HEART DISEASE 141
sterones. The two guggulsterones important
Hawthorn
in the management of hyperlipidemia are
Z-guggulsterone and E-guggulsterone. Gugulipid Choose one of the following:
appears to prevent the oxidation of LDL and may Tincture (1 part herb to 5 parts alcohol): 405 ml
regulate the level of bile acids, helping the body to per day
excrete cholesterol. Guggulsterones are thought to Freeze-dried berries: 1.0–1.5 g per day
be the main active constituents responsible for Flower extract (1.8 percent vitexin or 20 percent
these effects. Studies have shown that gugulipid procyanidins): 100–250 mg per day
can decrease total cholesterol levels by 11.7 per- Berries or ﬂowers (dried as a tea): 3–5 g of dried
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
Gugulipid
modest additions have been found to lower total
500 mg with 25 mg guggulsterones, 3 times per day blood cholesterol and LDL cholesterol by about
10 percent.328 Sterols and stanols from a dietary
Hawthorn (Crataegus Oxyacantha). Haw- intake of plant sterols in the range of 1.5 to 2.5
thorn leaves, berries, and blossoms contain ﬂavo- grams per day reduce LDL cholesterol by 8.5 to
noids. One of these, proanthocyanidin, has 10 percent.329 A recent study found that dietary
especially good cardiovascular effect. Hawthorn intervention with plant sterols could reduce cho-
preparations are modestly effective in reducing lesterol levels by about 30 percent, or approxi-
blood pressure,323 in the prevention and treat- mately the same extent as one of the statin drugs,
ment of atherosclerosis, lowering cholesterol, and levostatin.330 Most studies have found no effect
preventing the oxidation of LDL.324 Hawthorn of these sterols on triglyceride levels, but some
preparations improve the blood supply to the individuals have shown effects in recent stud-
heart by dilating the coronary arteries, increase ies.331–333 Sterols do not seem to lower HDL
the force of contraction of the heart muscle, and levels.
regulate cardiac rhythm.323 A very recent study of Sterols and stanols are often added to selected
79 diabetic hypertensive patients who received brands of margarines, semisolid food spreads,
1,200 mg hawthorn versus placebo for 16 weeks and salad dressings. As of 2000, the FDA author-
found signiﬁcant reductions in diastolic meas- ized sterol-containing products to state that they
ures, no drug-herb interactions, and only few reduce the risk of heart disease. The lowest effec-
mild side effects.325 Two randomized control trial tive dose for such a claim is 1.3 grams per day.
found decreases in both systolic and diastolic Sterols and stanols are also available in dietary
measures when treatment was administered for supplements. The supplement forms of phyto-
about three months.326, 327 sterols are advantageous in that they do not
142 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).
elevated
• Strive for healthy body weight.
Pantethine: 300 mg 3 times per day
• Practice stress management such as meditation
Other supplements based on speciﬁc situation
or relaxation exercise 15 minutes each day.

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

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

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.
problems
Eighty-ﬁve percent of couples will conceive
• Lifestyle factors: smoking history, alcohol
after the ﬁrst year of trying, with an increase to
use, exercise
93 percent after two years. Most spontaneous
pregnancies occur within three years, and there is A physical evaluation should include height
a poor prognosis for success without treatment and weight, observation for signs of excess andro-
after that. This ﬁnal point underscores the gens (facial hair, acne, and hair loss), abdominal
importance of timely specialty referrals to repro- hip and waist circumference, and breast, thyroid,
ductive endocrinologists for evaluation for assisted abdominal, and pelvic exam.
155
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
disease
• Infection: pelvic inﬂammatory disease, sexually
• Postpubertal mumps
transmitted disease, septic abortion,
• Hypogonadism
endometritis, pelvic tuberculosis
• Genital radiation or chemotherapy
• Surgical history: dilation and curettage, rup-
• Hypospadias
tured appendicitis, adnexal surgery, leiomyoma
• Testicular cancer (less than 0.1% of cases)
(ﬁbroids)
• Retrograde ejaculation or other dysfunction
• Contraception and pregnancy history: prior
• Development abnormalities: vas deferens
intrauterine device use, DES exposure in utero,
absence (related to cystic ﬁbrosis), impaired
ectopic pregnancy, frequent abortion
testicular function (chromosome abnormality)
• Endometriosis
• Exposure to excessive heat (hot tubs, saunas),
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
L-Arginine
biochemical reactions cause oxygen molecules to
become unstable. They are also formed by smok- 16 g per day
ing, barbecuing, and deep-frying food, and
more. Selenium can protect normal tissue from Para-Aminobenzoic Acid (PABA). PABA is
oxidative damage caused by the free radicals, a part of the folic acid molecule and is found in
including preventing chromosome damage. Sele- eggs, milk, meat, and several grains. The role of
nium may also be able to provide protection PABA produced by the body is not really known,
from exposure to toxic heavy metals including but as an oral supplement it is FDA-approved for
INFERTILITY 161
difﬁcult conditions such as scleroderma, vitiligo,
Black Cohosh
pemphigus, and dermatomyositis. It is approved
for use as a sunscreen because it acts as a ﬁlter to 20–40 mg standardized extract twice daily
block out ultraviolet radiation. In fertility, PABA
supplementation of 100 mg four times daily Rhodiola (Rhodiola Rosea). Rhodiola may
resulted in pregnancies in 12 of 16 women with enhance fertility. It has been shown to enhance
a history of infertility.33 thyroid function without causing 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
Lifestyle
antioxidants can decrease sperm DNA damage
Avoid caffeine, alcohol, and smoking. that can interfere with fertility.59 Vitamin C deﬁ-
Seek optimal body weight. ciency has been linked with signiﬁcant decreases
Nutritional Supplements
in sperm count, motility, and vitality and with an
increase in morphologically abnormal sperm.60
Vitamin E: 400 IU per day Vitamin E and selenium have been shown to
Vitamin C: 2,000 mg per day
reduce lipid peroxidation and, therefore, improve
Zinc: 30 mg per day
sperm quality. One study looked at men who had
Selenium: 100 mcg per day
Prenatal vitamins: 2 per day
normal sperm counts, but low rates of fertilization
during in vitro fertilization treatments. After one
Botanicals month of daily vitamin E supplementation, the
Chaste tree (0.6% aucubin extract capsule): 215 mg
fertilization rates increased from 19 percent to
per day 29 percent, suggesting that the antioxidant effects
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
11

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
167
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
symptoms.
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
following:
Nutrition Tomatoes
Coffee
Avoid the following foods:
Chocolate
Alcohol Lentils Apples Alcohol
Lima beans Aspartame Limes
Avocados Mayonnaise Bananas Supplements
Nuts* Cantaloupes Onions
N-acetyl glucosamine: 500 mg 3 times daily; or
Carbonated drinks Oranges Cheese**
glucosamine sulfate: 750 mg 2 times daily
Peaches Chicken livers Pickled herring
L-arginine: 500 mg 3 times daily
Chilies/spicy foods Pineapple Chocolate
Quercetin: 500–1,000 mg twice daily
Plums Citrus fruits Prunes
Vitamin C (buffered, noncitrus source):
Coffee Raisins Corned beef
1,000–2,000 mg daily
Rye bread Cranberries Saccharine
Corn silk: 300 mg 3 times daily
Grapefruit Sour cream Grapes
Kava extract: 1 capsule 3 times daily
Soy sauce Tomatoes Guava
Vitamin A: 5,000 IU daily
Strawberries Vinegar Lemons
Tea Yogurt

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

Oregon Grape Root
slippery elm (Ulmus fulva), marshmallow (Althea
ofﬁcinalis), oat seed (Avena sativa), and comfrey
500 mg per day (Symphytum ofﬁcinale).
It can be crucial to use herbs that provide
Corn Silk (Zea Mays). Another botanical, pain relief while the other therapies attempt to
corn silk, has been found to be a potent inhibitor repair the lining of the bladder. Common choices
of proinﬂammatory cytokines as well.66 Corn silk would be kava (Piper methysticum), crampbark
also has historical evidence for its application in a (Viburnum opulus), wild yam (Dioscorea villosa),
variety of urinary conditions and may be helpful in and valerian (Valeriana ofﬁcinalis).
the treatment of IC due to its demulcent effects.67
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
12

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
175
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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
Antipsychotics
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.
Digoxin
Spironolactone Acne, Facial Hair, and Hair Loss. Many
Oral contraceptives peri- and postmenopausal women have problems
Histamine H2-receptor blockers related to the change in the ratio of estrogen to
testosterone. Even though both hormones have
Reduction in Arousal declined, there is a relative increase in testos-
Antihistamines terone because there is less estrogen to block its
Antihypertensives effects. In addition, women have individual sen-
SSRIs sitivities to androgens. Some women only react
Tricyclic antidepressants to very high levels, while others are especially
sensitive to what are considered normal androgen
Reduction in Orgasmic Response
levels. In addition, women have different kinds
Amphetamines of receptor site and tissue sensitivity. Some will
Antipsychotics develop acne, some thinning hair, and some
Narcotics excess body and/or facial hair.
SSRIs
Excessive hair growth occurs in areas where
Trazodone
hair follicles are the most androgen-sensitive.
Tricyclic antidepressants
These include the face, chin, skin under the jaw-
bone, upper lip, sideburn area, and cheeks. Other
problems in postmenopausal women are related sensitive areas include the area below the belly
to estrogen loss to the genitals. Decreased estro- button, the lateral pubic area, midline of the
gen levels are responsible for most of the changes chest, around the nipple area, and the low back
and decrease in lubrication during sexual arousal, over the sacrum. Hirsutism (excess body hair) is
vaginal tone, vaginal elasticity, and genital most notably correlated with elevated free testos-
engorgement. This can manifest as a lack of ade- terone, but testosterone must be converted by an
quate vaginal lubrication with sexual arousal, enzyme in the skin to be fully active in the skin.
bleeding after vaginal sex, and pain with vaginal This enzyme is probably higher in women who
sex. Vaginal dryness is not only associated with have excess body and facial hair. These enzyme
painful vaginal sex, but also with a decrease in levels may change in postmenopausal women, or
sexual desire.26 It is not hard to understand why the hair follicle may become more sensitive to the
anticipation of painful sex would dampen one’s activated testosterone in some postmenopausal
desire for sex. With a loss of estrogen, relaxation women.
of vaginal tissue and decreased muscle tone Hair thinning and hair loss are often trau-
also occur, which leads to a decrease in sexual matic for women and cause a great deal of anxi-
response. ety. Androgenic alopecia (hair loss) is the most
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
group).37
(beef, pork, lamb, butter, cheese, palm oil, and
The evidence that lignans can reduce the risk
coconut oil) contribute to poor fat ratios and ele-
for cancer is still unclear, although the biologic
vated cholesterol. Even though total fat intake
properties of lignans and data from various cul-
should be reduced, switching from saturated fats to
tures suggest that they do. Many lignans have
vegetable oils will lower total cholesterol levels.
antitumor, antioxidant, weak estrogenic, and
Olive oil is your best choice for salads and cooking.
antiestrogenic characteristics.38–42 Adding to the
Increasing ﬁber in the diet with whole grains,
evidence, urinary excretion of lignans has been
fruits, vegetables, and legumes is the optimal
found to be lower in nonvegetarians and in post-
high-ﬁber diet. Soluble ﬁber such as the pectin in
menopausal women with breast cancer as com-
apples or oat bran has the most consistent bene-
pared with healthy women.43–45
ﬁcial effect on cholesterol levels.46 Speciﬁc fruits
Foods for Bone Health. Several dietary factors or vegetables can also have a positive effect on
affect bone health and are involved in the develop- blood levels of fat. Raw carrots, for example, may
ment of osteoporosis: insufﬁcient calcium intake, have a more potent effect in lowering cholesterol
vitamin D deﬁciency, low calcium and high phos- than oat products.47 People with a low intake of
phorus intake, low fatty acid intake, insufﬁcient fruits and vegetables have an increased risk for
dark leafy greens, a high-protein diet, excess salt heart disease.48 See Chapter 9 for dietary and
intake, and excess alcohol. See Chapter 14 for lifestyle factors, supplements, herbs, hormones,
dietary and lifestyle factors, supplements, herbs, and other conventional medications for preven-
hormones, and other conventional medications for tion and treatment of heart disease.
prevention and treatment of bone loss.
Foods for Heart Health. Heart disease is the Nutritional Supplements
other major concern in the postmenopausal years. Following are the nutritional supplements that are
The prevention of heart disease is largely deter- used to treat some of the symptoms of menopause.
mined by diet and lifestyle. Women who make the For an in-depth look at some of the nutritional
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

Bioﬂavonoids
Gamma-Oryzanol. Gamma-oryzanol is a
1,000 mg per day plus 1,000–1,500 mg vitamin C substance found in grains and is isolated from
rice bran oil. This ferulic acid compound is pres-
Vitamin B6. Vitamin B6, or pyridoxine, plays ent in rice, wheat, barley, oats, tomatoes, aspara-
a critical role in the manufacture of serotonin as gus, olives, berries, peas, citrus fruits, and other
well as other amino acid neurotransmitters. Vita- foods. The concentrations are higher in whole
min B6 levels are typically quite low in depressed grains than in reﬁned grains and ﬂours.
patients, especially women taking birth control Gamma-oryzanol was initially shown to be
pills or conjugated equine estrogens (Pre- effective in relieving menopausal hot ﬂashes in the
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 herb