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

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

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

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

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

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

7. Herbs and products: pregnancy and lactation

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

9. Herbs and products: varicose veins

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

11. Herbs and products: memory and cognition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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