Female Transitions - Park County Chiropractic

Transcription

Your Agenda
General Female health
Premenstrual syndrome
Depression
When things go wrong
Dysmenorrhea
Polycystic ovarian syndrome
Heavy Metal issues, fertility and bone health
Menopause

Female
Transitions
Lee W Carroll B.Sc.
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Female Vitality/Health/Wellness
Female Vitality/Health/Wellness
Liver
Detoxification of estrogens and xenoestrogens
Gut
Activation of phytoestrogens
Prevent recycling of estrogens
Upper reproductive tract
Support healthy functioning of ovaries, fallopian
tubes and uterus
Reduce spasm and cramping
Muscle
Support energy metabolism
Stress
Adaptive stress response
Harmonization of the HPA axis
Cellular stress response
Hormonal balance
Prolactin/Dopamine
Estrogen
Progesterone
Androgens
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White Peony
White Peony Indications
Paeonia lactiflora peeled root is very commonly used
in traditional Chinese medicine (TCM) to treat a wide
range of gynecological problems, often in combination
with other herbs
Reduces elevated androgens
Improves low progesterone
Reduces elevated prolactin
Modulates estrogen (high or low)

PMS and Mastalgia
Hyperprolactinemia
Dysmenorrhoea
Amenorrhoea
PCOS
Endometriosis
Fibroids
Ovulatory failure
Infertility
Androgen excess
Menopause
Pain and spasm of the
abdomen and limbs
Cognitive impairment

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Shatavari – 100 Husbands
Schisandra – Five Flavors
When translated, Shatavari literally means:
Schisandra chinensis fruit has a long history of use in
traditional Chinese and Japanese medicine
Hepatoprotective
Induces Phase I enzymes
Increases Phase II enzymes
Hepatic glutathione reductase
Glutathione-S-transferase (GST)
Antioxidant
Facilitates adaptation to stress
Nervous system tonic
“She who possesses a hundred husbands”
Considered both a general tonic and a female
reproductive tonic
Promote general well being by increasing cellular
vitality and resistance to stress
Promote estrogen production and balance
Relief of menopausal symptoms
To improve libido and sexual vitality
As a tonic for general debility, fatigue, infections
Liver support/gastric ulcers and dyspepsia
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FemCo
Schisandra Indications
To enhance phase I/II detoxification
by the liver
Chronic liver damage
Fatigue/Physical stress/debility
To improve physical and mental
performance and concentration
Schisandra fruit extract 6:1
from Schisandra chinensis fruit 1.0 g
166.6 mg
White Peony root extract 4:1
from Paeonia lactiflora root 750 mg
187.5 mg
Shatavari root extract 6:1
100 mg
from Asparagus racemosus root 600 mg
Suggested use: 1 tablet 3 to 4 times daily
Contraindicated in pregnancy
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FemCo
Key Applications
FemCo Key Indications
Adjunctive treatment:
Anemia
Androgen excess and polycystic ovary syndrome
Reduced fertility and low libido
Conditions of estrogen excess such as endometriosis
and fibroids
Everyday female support
To promote, health, vitality and
wellness from adolescence to
menopause and beyond
Specific female stress support
Liver Support
Premenstrual syndrome
Irregular menstruation
Dysmenorrhoea
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FemCo Additional Indications

How to Use FemCo
Any conditions associated with elevated prolactin
Delayed puberty
Leg Cramps
Migraine headache
To improve memory and concentration
To improve physical ad exercise performance
Night sweats
Everyday for female health, vitality, wellness
FemCo becomes the foundational MediHerb product
for the premenopausal female
Female general health protocol example
FemCo, 3 tablets per day
Catalyn, 6 tablets per day
Symplex F, 3 tablets per day
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General Fertility Protocol
General Estrogen Dominance
FemCo, 3 to 4 tablets per day
Chaste tree, 1 to 2 tablets per day
Tribulus, 2 tablets 2 times per day from day 5 to 14
of the menstrual cycle
Wheat Germ Oil, 6 perles per day

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Chaste Tree, 1 to 2 tablets per day
Silymarin, 1 tablet per day
Cruciferous Complete, 3 capsules 2 times per day
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Premenstrual Syndrome (PMS)
General Androgen Excess

PMS – is a variety of psychological, behavioral and
physical symptoms that collectively occur during the
luteal phase of the menstrual cycle and subside with
the onset of the period or soon after
PMDD – Premenstrual dysphoric disorder
Premenstrual magnification of a pre-existing condition,
eg headaches, depression and anxiety increased
infection rates, IBS and hypoglycemia
Chaste tree, 2 tablets 2 to 3 times per day
Adrenal Complex, 2 to 3 tablets per day
Ovex, 6 tablets per day
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PMS – Essential Issues
Exact cause is unknown but in 50% of women ovarian
suppression removes symptoms
Hormonal, dietary, lifestyle, emotional factors are
collectively implicated
“Abnormal responses to normal hormones”
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Serotonin
GABA (gamma-amniobutyric acid)
Melatonin
Endorphins
Estrogen/progesterone balance
Progesterone receptors
Allopregnanolone
Adrenal hormones
Prolactin/Dopamine
Nutrients: Vitamin B6, E and D, Ca, Mg, Omega-3
essential fatty acids, chromium, copper, manganese
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Chaste Tree
Categories of PMS Symptoms
PMS with mood changes
Chaste tree (Vitex agnus castus) is a Western herb
with a long history of use for hormonal and
gynecological problems
Type A: anxiety, nervous tension, irritability, anger
Type B: depression, sadness, withdrawal, fatigue
Chaste Tree is dopaminergic,
specifically decreasing excess
prolactin
This has particular relevance for
women with latent
hyperprolactinaemia (LHP) where
prolactin is only increased with stress
and/or premenstrually
PMS with cravings
PMS with fluid retention
PMS with pain
PMS with declining estrogen
PMS with adrenal exhaustion
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Chaste Tree: The Research
A systematic review of herbal treatments for PMS found
that Chaste Tree was the most investigated treatment
and, after excluding trials because of poor quality or
unsuitable diagnostic criteria, identified 4 eligible trials
involving 500 women1
The review concluded that Chaste Tree was useful for
PMS
Several other trials showing benefit in premenstrual
mastalgia have also been published, including one that
demonstrated it lowered prolactin levels
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Dante G, Facchinetti F. J Psychosom Obstet Gynaecol 2011; 32(1): 42-51
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Chaste Tree - Prolactin
Frequent blood samples were taken from patients with
premenstrual mastalgia (and presumably LHP)
As a result of the stress of blood withdrawal prolactin
levels in the pathological range were observed
There were also pathological surges of prolactin
associated with LH pulses
After 3 months of a Chaste Tree formulation these
responses were not evident
Wuttke W, Jarry H, Christoffel V et al. Chaste tree (Vitex agnus-castus) – pharmacology and clinical indications.
Phytomedicine 2003; 10: 348-357
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Chaste Tree and Melatonin
Chaste Tree
According to Dioscorides (De Materia Medica AD40 to
80) when writing about Chaste Tree:
“A weight of 1 drachma in wine makes the menses
come on earlier, detaches the embryo, attracts the
milk, goes to your head and brings sleep.”
Chaste Tree is most indicated in PMS
with mood changes, anxiety,
depression and fluid retention
Chaste Tree tablets 1 to 2 per day
Upton R, Petrone C, Graff A. (eds) Chaste Tree Fruit: Vitex agnus-castus, American Herbal
Pharmacopoeia and Therapeutic Compendium, American Herbal Pharmacopoeia, Santa Cruz, CA,
2001.
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Chaste Tree and Melatonin
The circadian rhythm of melatonin secretion was
measured in 20 healthy males aged 20 to 32 years after
the intake of placebo or various doses of an extract of
Chaste Tree (up to 480 mg/day) for 14 days in an open,
placebo-controlled study
Administration of Chaste Tree caused a dose-dependent
increase of melatonin secretion (average 60%),
especially during the night (compared to placebo
treatment)
Dericks-Tan JS, Schwinn P, Hildt C. Exp Clin Endocrinol Diabetes 2003; 111(1): 44-46
St. John’s Wort and PMS
An analysis of 15 clinical trials suggested a role for
antidepressant drugs in PMS, especially Prozac, but
there were side effects
Results of an open pilot trial of St. John’s Wort in
PMS yielded positive results
Improvement in overall PMS scores was 51% with
two-thirds experiencing at least a 50% reduction in
symptom severity
Stevinson C, Ernst E. ‘A pilot study of Hypericum perforatum for the treatment of
premenstrual syndrome’, BJOG 2000; 107(7): 870-876
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St. John’s Wort and PMS
Evening Primrose Oil
St John’s Wort is most indicated in PMS with mood and
depression
St. John’s Wort 1.8g tablets, 1 to 3 per day
Or
Nevaton tablets, 3 to 4 per day
The clinical relevance of Evening Primrose Oil use in
PMS has been questioned however a recent 2010
clinical study shows EPO is of particular value for
mild to moderate premenstrual mastalgia at 1g per
day, when used over 3 to 6 months
EPO is also indicated in PMS with pain
Required dose is 3-6g per day
N. Thakur, B. Zargar, N. Nazeer, F. Parray & R. Wani : Mastalgia – Use Of Evening
Primrose Oil In Treatment Of Mastalgia. The Internet Journal of Surgery. 2010
Volume 24 Number 2
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Ginkgo
A French study found that Ginkgo biloba extract was
effective against congestive symptoms
Design was a placebo-controlled trial involving 165
women with PMS.
Ginkgo dose was 160 mg per day
Significant improvements with Ginkgo treatment over
placebo was observed for mastalgia as well as edema,
anxiety, depression and headache
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Ginkgo
Ginkgo biloba extract reduced severity of physical
and psychologic PMS symptoms (24%) compared to
placebo (9%) (p < 0.001)
Dose was equiv. to Ginkgo Forte, 2 tablets per day
from day 16 of the menstrual cycle to day 5 of the
following cycle
Ozgoli G, Selselei EA, Mojab F, Majd HA, A randomized, placebo-controlled
trial of Ginkgo biloba L. in treatment of premenstrual syndrome. J Altern
Complement Med. 2009 Aug;15(8):845-51.
Tamborini A, Taurelle R. ‘[Value of standardized Ginkgo biloba extract (EGb 761) in the
management of congestive symptoms of premenstrual syndrome]’, Revue Francaise de
Gynecologie et d’Obstetrique 1993; 88(7-9): 447-457
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PMS – Core Treatment
PMS with Mood Changes
Mood changes, anxiety and depression
Core Support
Nevaton or St John’s Wort 1.8g, 3 to 4 tablets/day
And select as appropriate
Valerian Complex tablets (3 to 4 per day) if excessive
anxiety
Rhodiola & Ginseng Complex tablets (2 to 4 per day) if
depletion and depression
Drenamin, 6 to 9 per day
Min-Chex 6 per day
Mood swings, fatigue, breast fullness, abdominal
bloating
B6 Niacinamide, 4 to 6 per day
Taken throughout the cycle for at least 3 months
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PMS with Cravings
PMS with Fluid Retention
Cravings, increased appetite, fatigue, Irritability
Gymnema 4g, 2 to 3 tablets per day
Diaplex, 3 to 9 capsules per day
Cataplex GTF, 3 to 6 tablets per day
Magnesium Lactate 3 to 6 capsules per day
Whey Pro Complete
Breast fullness, weight gain, swollen extremities,
abdominal bloating
Core Support
Gingko Forte 3 tablets each per day from day 16 of
cycle to day 5 of following cycle
Dandelion Leaves 1:1, 5 mL 2 to 3 times per day from
day 16 of cycle to day 5 of following cycle
Evening Primrose Oil, 3 to 6 capsules per day
AC Carbamide, 4 capsules per day
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PMS with Pain
PMS with Low Estrogen
Breast pain, dysmenorrhea, reduced pain threshold,
general aches and pains
Core support
Cramplex, 2 tablets 2 to 4 times per day from late in
the luteal phase to day 4 or 5 of cycle
Evening Primrose Oil, 3 to 6 capsules per day
Chlorophyll Complex, 4 to 6 perles per day
Calcium Lactate, 3 to 6 capsules or ½ tablespoon three
times per day
Fatigue, memory, hot flashes, night sweats, headaches
Core Support
Wild Yam Complex, 3 to 4 tablets per day
Or Tribulus Forte, 3 tablets per day
Bone Complex, 3 tablets per day
Nevaton, 3 to 4 tablets per day
Ovex, 3 to 6 tablets per day
Wheat Germ Oil, 6 perles per day
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PMS with Adrenal Exhaustion
PMS Case History
Fatigue, mental fatigue, poor concentration, hot flashes
and night sweats
Core Support
Adrenal Complex, 2 to 3 tablets per day
Rhodiola & Ginseng Complex 2 to 4 tablets per day
Drenamin, 3 tablets 2 times per day
A 34 year old woman with a 3 year old child presented
with severe PMS which regularly began 6 to 7 days
before the onset of menstruation and persisted until
the first day of bleeding
Symptoms were severe depression, irritability, anxiety,
poor sleep, fluid retention and breast tenderness
Questioning revealed a history of liver problems and
increased levels of stress and devitalization caused by
not coping with the responsibility of caring for her
young child
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PMS Case History
PMS Case History
Treatment consisted of:
Chaste Tree, 1 tablet 2 times per day
Valerian Complex, 2 tablets with evening meal and 2
tablets at bed time
Withania Complex, 3 tablets per day (1 tablet am and
2 tablets at bed time
After four weeks there was a mild improvement but all
symptoms still present.
Over the next two months on the same treatment there
was steady improvement. The breast and fluid symptoms
were totally gone and the emotional symptoms and
energy levels were considerably better.
Treatment was continued and at 4 months all the
symptoms were virtually gone.
The treatment was reduced to only Chaste Tree, with
Valerian Complex symptomatically and the patient has
remained virtually symptom-free
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Depression and Female Health
Depression and BMD
The association between clinical depression & low bone
mineral density (BMD) is not new!
In one well designed study depressed patients had
6.5% lower BMD at the spine & 13.6% lower BMD at
the femoral neck compared to non-depressed controls
What is new!
Stronger effects in premenopausal women
Major depression in premenopausal women is a risk
factor for significantly low BMD
Meta-analysis of 23 studies comparing 2327
depressed with 21,141 non-depressed individuals.
Also increased urinary levels of bone resorption
markers
Michelson D, Stratakis C, Hill L et al. Bone mineral density in women with depression.
N Engl J Med 1996; 335(16): 1176-1181
Yirmiya R, Bab I. Major depression is a risk factor for low bone mineral density: a
meta-analysis. Biol Psychiatry. 2009 Sep 1;66(5):423-32. Epub 2009 May 15
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Depression and Cortisol
Neural Regulation of Bone
Plasma cortisol levels were significantly higher in
depressive patients (p = 0.001)
Lumbar and femur BMD scores were negatively
correlated with cortisol levels in the patient group
BMD was significantly lower at the lumbar spine and
proximal femur (p = 0.02, 0.01).
Osteocalcin ↓ and C-telopeptide ↓
36 premenopausal women with major depression
compared with 41 controls
There is a growing body of evidence demonstrating the
potential for the neural regulation of bone
Providing increasing evidence that 5-HT (serotonin) &
5-HTT (serotonin transporter) have a role within the
skeleton
Functional pathways to respond to & uptake 5-HT have
been indentified in osteoblasts, osteoclasts &
osteocytes
Altindag O, etal, Relation of cortisol levels and bone mineral density among
premenopausal women with major depression, Int J Clin Pract. 2007 Mar;61(3):41620
Haney EM, Warden SJ. Skeletal effects of serotonin transporter inhibition: Evidence from
clinical studies. J Musculoskelet Neuronal Interact 2008; 8(2): 133-145
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Serotonin: The Gut & Bone
SSRIs
Experimental research has shown that gut serotonin
can directly control bone formation by inhibiting
osteoblast proliferation
If more gut derived serotonin reaches the bone, the
more bone is lost
And conversely the less serotonin, the denser &
stronger bones become
5-HT is unique among the neurotransmitters
because of its link with depression
5-HTT antagonists (SSRIs) are the mainstay of the
medical treatment for depression
The widespread use of SSRIs provides the
epidemiological platform for the effects of serotonin
on bone
Haney EM, Warden SJ. Skeletal effects of serotonin transporter inhibition: Evidence
from clinical studies. J Musculoskelet Neuronal Interact 2008; 8(2): 133-145
Yadav VK, Ryu JH, Suda N et al. Lrp5 controls bone formation by inhibiting serotonin
synthesis in the duodenum. Cell 2008; 135(5): 795-796
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SSRIs and BMD
SSRIs and BMD
SSRIs are linked with bone density loss
A study of BMD in 2,722 women with an average
age of 78.5 years (follow up at 4.9 years)
198 had used SSRIs for depression
SSRIs - BMD decrease 0.82% (higher at hip)
TCAs and non-SSRI users - BMD 0.47%
Prospective population-based cohort study
consisting of 7983 individuals aged 55 years & older
The use of TCA and SSRIs resulted in a 2.35 fold
increased risk of nonvertebral fractures compared to
non-users of antidepressants
Risk of fracture increases with prolonged use of
SSRIs
Ziere G, Dieleman JP, van der Cammen TJ et al. Selective serotonin reuptake
inhibiting antidepressants are associated with an increased risk of nonvertebral
fractures. J Clin Psychopharmacol 2008; 28(4): 411-417
Diem SJ, Blackwell TL, Stone KL et al. Use of antidepressants and rates of hip bone
loss in older women: the study of osteoporotic fractures. Arch Intern Med 2007;
167(12): 1240-1245
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St John’s Wort Meta-Analysis
St John’s Wort extract is superior to placebo in patients
with major depression
Treatment responses in St John’s Wort and
antidepressant groups were almost identical
St John’s Wort group reported significantly less side
effects
A total of 29 trials and 5489 patients
Linde K, Berner MM, Kriston L. Cochrane Database Syst Rev 2008;(4): CD000448
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Rhodiola and Depression
Support for Depression
Rhodiola is anti-depressive in patients with mild to
moderate depression at 340 and 680 mg/day over a 6week period
Depression, insomnia, emotional instability and
somatization, improved significantly following
treatment
At 680 mg/day self esteem increased significantly
Energy levels ↑
Down-regulation of stress activated intracellular
pathways and up-regulation of Hsp70
Rhodiola & Ginseng Complex, 1 tablet 2-4 times
daily
St John’s Wort 1.8g, 1 tablet 3 times daily
Or
Nevaton, 1 tablet 3-4 times daily
Adrenal Complex, 1 tablet 2-3 times daily
Symplex F 6 per day
Min-Chex 6 per day
Darbinyan V et al. Nord J Psychiatry 2007; 61(15): 343-348
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Ginkgo: Mood and Stress
Ginkgo: Mood and Stress
Decreased anxiety in patients with defined anxiety
disorders (240 mg/day std extract)1
Had a beneficial effect on sleep patterns in patients
with major depression being treated with trimipramine
(240 mg/day std extract)2
Addition of Ginkgo to paroxetine (SSRI) provided better
therapeutic effect than paroxetine alone in patients
with depression3
Ginkgo extract at 120 mg/day for 3 months significantly
dropped plasma cortisol levels during the stress caused
by the glucose tolerance test in healthy volunteers1
According to the scientists involved in the trial, Ginkgo
might reduce blood levels of cortisol in other types of
stress
1. Woelk H et al. J Psychiatr Res 2007; 41(6): 472-480
2. Hemmeter U et al. Pharmacopsychiatry 2001; 34(2): 50-59
1. Kudolo GB. Clin Chem 2007; 53(6, Suppl S): A186
3. Guo KF et al. Chin J Clin Rehab 2006; 10(2): 43-45
Cited in – MediHerb A Phototherapist’s Perspective 2009; 123
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Ginkgo: Sexual Dysfunction
Ginkgo Forte
Ginkgo was found to be very effective in the
treatment of antidepressant-induced sexual
dysfunction, predominantly caused by SSRIs
Women were more responsive to the sexual
enhancing effects of Ginkgo than men with success
rates of 91% (women) versus 76% men
Ginkgo had a positive effect on all 4 phases of the
sexual response cycle: desire, excitement, orgasm,
resolution
Ginkgo leaf 50:1 extract
from Ginkgo biloba leaf 3.0 g
Containing ginkgo flavonglycosides 14.4 mg
Containing ginkgolides & bilobalide 3.6 mg
60 mg
Dose: 1 tablet 2 to 4 times daily
Cohen AJ et al. J Sex Marital Ther 1998; 24(2): 139-143
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..
Diseases Linked to Dysbiosis

Crohn’s disease
Ulcerative colitis
Rheumatoid arthritis
Ankylosing spondylitis
Graves disease
Chronic active hepatitis
Guarner F. Digestion 2006; 73 (Suppl 1): 5-12
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Gut Disorders
Irritable bowel syndrome (IBS)
Flatulent dyspepsia
Certain types of food sensitivities
Chronic diarrhoea and constipation
Diverticular disease
Gastrointestinal infections and intestinal overgrowth eg
candida
Other Disorders
Allergies such as asthma and hay fever
Poor immunity
Chronic skin disorders
Breast and colon cancer
Insulin resistance and diabetes
Lack of well-being, low energy and poor digestion
Neuropsychiatric problems especially autism?
Obesity? Hypertension? Depression?
Gut Flora Complex
Anise (Pimpinella anisum) fruit ess. oil
General Estrogen Dominance
125 mg
Oregano (Origanum vulgare) leaf ess. oil
75 mg
Andrographis herb 10:1 extract
from Andrographis paniculata herb 1.0 g
Containing andrographolide 10 mg
100 mg
Phellodendron stem bark 20:1 extract
from Phellodendron amurense stem bark 1.6 g
Containing berberine 36 mg
80 mg

Cruciferous Complete, 3 capsules 2 times per day
Symplex F, 3 to 6 tablets per day
Bowel Flora Protocol for 6 to 10 weeks
Suggested Dosage: 3-6 capsules per day
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Simplified Bowel Flora Protocol
When Things Go Wrong!
Everyday of the Week

Gut Flora Complex, 1 capsule 2 twice daily
Wholefood Fibre, 1 tablespoon twice daily at the same
time as the Gut Flora Complex
As required:
Vitanox, 2 to 3 tablets daily
ProSynbiotic, 3 capsules daily
Lactic Acid Yeast, 1 to 2 wafers 3 times daily
Continue for minimum of 6 weeks.
Suitable for long term use
Dysmenorrhea
Menorrhagia (see appendix)
Amenorrhea and oligomenorrhea (see appendix)
Endometriosis (see appendix)
Polycystic ovarian syndrome
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The Usual Suspects
Dysmenorrhea
Diet/long term dietary restrictions/nutrient status
Exercise/sedentary lifestyles/over exercise
Body weight/obesity/abnormally low body weight
Stress
Mood
Sleep
Alcohol/Tobacco/Recreational drugs
Environmental toxins
Essential Features
Dysmenorrhea is painful or difficult menstruation
It is associated with a number of factors including the
production of inflammatory prostaglandins,
vasoconstriction in small arteries, ischemia, and high
cervical tone
Dysmenorrhea affects 92% of American women
It may be associated with other disorders such as
endometriosis and pelvic infection
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Dysmenorrhea Support
Dysmenorrhea
Core Support
Cramplex, 2 tablets every 4 hours,
3 to 4 times a day
Best to start a few days before
menstruation
Eases pain, reduces inflammation and
uterine spasm
Stimulates circulation and assists with
hormonal balance
Has antiemetic properties
Pain starts a few hours before or at the onset of
menstruation and often ceases within 24 hours
Pain is largely due to uterine spasm and resultant
ischemia due to excessive release of prostaglandins
Aims of treatment
Normalize the activity of the uterine muscle
Regulate hormone levels
Relieve pain
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Dysmenorrhea Support
Cramplex
Each tablet contains:
Corydalis tuber 5:1 extract
from Corydalis ambigua tuber 1.2 g
Raspberry Leaf 4:1 extract
from Rubus idaeus leaf 800 mg
Wild Yam root and rhizome 4:1 extract
from Dioscorea villosa root and rhizome 800 mg
Cramp Bark stem bark 5:1 extract
from Viburnum opulus stem bark 800 mg
Ginger rhizome 6:1 extract
from Zingiber officinale rhizome 800 mg
Dosage: 2 tablets every 4 hours, 3 to 4 times a
Best to start a few days before menstruation
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240 mg
200 mg
200 mg
160 mg
133.3 mg
day.
FemCo: 1 tablets 3 to 2 times daily throughout cycle
Reduces uterine spasm, aids in the liver processing
hormones, assists with hormone balance
Ginkgo Forte, 2 to 3 tablets per day before the period is
due to start and for several days into the period
Improves circulation, which is of benefit in
dysmenorrhea when vasoconstriction in small arteries
and ischemia occurs
Dong Quai, 1 tablet 2 to 3 times daily
Used traditionally for dysmenorrhea
Ovex P, 6 tablets per day
Utrophin, 4 to 6 tablets per day
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Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome
Common characteristic features include obesity, insulin
resistance, hyperandrogenism, anovulation and acne
Approximately 50% of women with PCOS are
overweight or obese1
In the US up to 50% of women with PCOS have
metabolic syndrome.
Hyperandrogenism was present in 87% of women with
PCOS2
Polycystic ovarian syndrome (PCOS) is a common
reproductive disorder resulting in anovulation and
amenorrhoea for many women
It occurs in approximately 5-10% of women of
reproductive age1 and is the most common
endocrine disorder causing
female infertility2
Not all women with PCOS
have polycystic ovaries
1.
2.
Boomsma CM, Eijkemans MJC et al. Hum Reprod Update 2006; 12(6): 673-683
Shroff R, Syrop C et al. Fertil Steril 2007; 88(5): 1389-1395
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Biochemical and Clinical Features
Herbal Treatment for PCOS
When the patient is overweight or obese the
number one goal of treatment must be weight loss,
especially from the abdomen
Treat metabolic disturbances eg dysglycemia, insulin
resistance
Treat hormonal disturbances
Where applicable treat disturbance in liver function
and serum lipids
Increased serum androgen (testosterone,
androstenedione, DHEAS)1 with or without
hyperinsulinaemia
Decreased SHBG levels1
Increased LH levels and serum LH to FSH ratio > 21
Increased prolactin levels1
Increased estrone levels. Estradiol can be increased,
but is typically low or normal2
Increased fasting insulin or fasting glucose1
1.
Harwood K Vuguin P et al. Horm Res 2007; 68(5): 209-217
2.
Vignesh JP, Mohan V. J Postgrad Med 2007; 53(2): 128-134
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Protocol for PCOS
Protocol for PCOS
Core Support
Gymnema 4g: 1 tablet 2 to 3 times daily
Normalise glucose metabolism, reduce insulin
resistance, reduce sugar cravings
Chaste Tree: 2 tablets 2 to 3 times daily
Reduce hyperprolactinaemia
FemCo: 2 tablets 2 times daily
Reduces elevated LH, reduces elevated prolactin
Symplex F: 3 to 6 tablets per day
Prolamine Iodine: 1 to 2 tablets per day
Core Support
Adrenal Complex: 1 tablet 2 to 3 times daily
Licorice inhibits 11 beta-hydroxysteroid
dehydrogenase Type 1 which reduces the production
of cortisol in abdominal adipocytes and causes fat loss
White Peony (FemCo) and Licorice decreased serum
free testosterone by increasing ovarian aromatase
activity
Significantly lowered LH/FSH ratio
Decreased prolactin levels in anovulatory women with
elevated serum prolactin
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Protocol for PCOS
Protocol for PCOS
Core Support for Fertility
Tribulus
1 tablet 3 times daily on days 5 to 14 of the
menstrual cycle (or to ovulation) if menstruating
or
1 tablet 3 times daily every day if non-menstruating
Additional Support
Coleus Forte: 1 tablet 3 times daily
Improve weight loss, burn fat and build lean body
mass
Silymarin: 1 tablet 2-3 times daily
Improve glycemic profile, reduce insulin
resistance, enhance liver function
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Heavy Metal Exposure
and Repeated Miscarriages
Heavy Metal Exposure
and Repeated Miscarriages
Heavy metal excretion was significantly correlated to
different immune and hormonal phenomena
The authors concluded that heavy metals appear to
have a negative impact on ovarian and pituitary
function and that the induced immunological changes
may lead to miscarriages
111 women with repeated miscarriages had their urinary
excretion of heavy metals evaluated after challenge (with a
chelating drug)
Basal Levels
180 min Challenge
Arsenic
4.80 µ/dL
15.3 µ/dL
Cadmium
0.52
0.84
Mercury
Lead
5.40
3.90
97.14
41.73
Gerhard I, Waibel S, Daniel V et al. Impact of heavy metals on hormonal and immunological
factors in women with repeated miscarriages. Hum Repro Update 1998; 4(3): 301-309
Gerhard I, Waibel S, Daniel V et al. Impact of heavy metals on hormonal and immunological
factors in women with repeated miscarriages. Hum Repro Update 1998; 4(3): 301-309
81
Mercury Excretion and Amalgam
Heavy Metal in Living Kidney Cortex
Urinary mercury excretion (ug/g creatinine)
180
160
82
Metal concentrations were determined in 109 living
Swedish kidney donors aged 24-70 years
Median kidney concentrations were:
12.9 mcg/g for cadmium
0.21 mcg/g for mercury
0.08 mcg/g for lead
H g b asal
H g 120’
H g 180’
140
120
100
80
60
40
Barregard L, etal, Cadmium, mercury, and lead in kidney cortex of living kidney
donors: Impact of different exposure sources. Environ Res. 2010 Jan;110(1):4754.
20
0
1 -5
6 -1 0
>10
N u m b e r o f a m a lg a m to o th fillin g s
Urinary Hg excretion vs no. of amalgam fillings, before and after challenge
© Lee Carroll 2012
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Cadmium
Heavy Metal in Living Kidney Cortex
Cadmium increased by 3.9 mcg/g for a 10 year
increase in age
Low iron stores (low serum ferritin) in women
increased kidney cadmium by 4.5 mcg/g
Kidney mercury increased by 6% for every
additional amalgam surface
Dental amalgam is the main determinant of kidney
mercury
Cadmium accumulates in the body, particularly the
kidney. Half-life 10-30 years
Women generally accumulate more than men
Urinary Cd (U-Cd) is a biomarker for lifetime Cd body
burden in people with lower exposures
In the absence of high-level exposure, Cd-binding
sites are not saturated, and the urine Cd level
increases in proportion to the amount of Cd stored in
the body
Barregard L, etal, Cadmium, mercury, and lead in kidney cortex of living kidney donors:
Impact of different exposure sources. Environ Res. 2010 Jan;110(1):47-54
Centers for Disease Control and Prevention (CDC) 2005; IPCS 1992
Agency for Toxic Substances and Disease Registry (ATSDR) 1999
85
Cadmium
Cd - A Potent Metallohormone
FDA Total Diet Study showed Cd exposure in the US
increased 21% from 1990 to 2003
From 8.81 to 11.06 μg/person/day
11.06 μg/person/day exposure is approximately
17% of the WHOs PTWI of 7 μg/kg/week
OSHA minimum safety standard for Cd is:
< 3 μg/g in urine (as creatinine)
< 5 μg/L in blood
At doses similar to the WHO PTWI, Cd mimics the
in vivo effects of estrogen
Strong evidence exposure to environmentally relevant
doses of cadmium may increase the risk of breast and
endometrial cancer
Prostate cancer (metalloandrogen)
Adversely effects the lung, liver, immune system
and bone
Bryne C, etal, Cadmium - A metallohormone?, Toxicol Appl Pharmacol. 2009 Aug 1;238(3):26671. Epub 2009 Apr 9
Egan SK, Bolger PM, Carrington CD, Update of US FDA's Total Diet Study food list and diet, I.
2007 Sep;17(6):573-82. Epub 2007 Apr 4
87
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Cadmium Population Study
Cadmium Population Study
OSHA minimum safety standard is 3 μg/g
NHANES data, 4,258 U.S. women >50 Yrs from MA
Risk of having hip-BMD-defined osteoporosis (OP) was
correlated with urinary Cd levels
Women with U-Cd b/w 0.50 & 1.0 μg/g had 43%
increased risk compared to women with levels
< 0.50 μg/g
Smokers did not show a statistically increased risk
U.S. women are at risk of developing OP at U-Cd levels
3 to 6 times less than the OSHA min safety std
21% of OP prevalence among women > 50 years of
age may be attributable to Cd body burden
Gallagher CM, John S. Kovach JS, and Meliker JR, Urinary Cadmium and Osteoporosis in
U.S. Women ≥ 50 Years of Age: NHANES 1988–1994 and 1999–2004, Environmental
Health Perspectives, Vol 116, 10, Oct 2008 pp. 1338-43
Gallagher CM, John S. Kovach JS, and Meliker JR, Urinary Cadmium and Osteoporosis in U.S.
Women ≥ 50 Years of Age: NHANES 1988–1994 and 1999–2004, Environmental Health
Perspectives, Vol 116, 10, Oct 2008 pp. 1338-43
89
Cadmium Swedish Study
Cadmium related effects on bone in 820 women
(53-64 years of age)
U-Cd was 0.67 μg/g creatinine
Bone mineral density, parathyroid hormone, and urinary
deoxypyridinoline (U-DPD) were adversely associated
with U-Cd (p < 0.05) in all subjects
Smokers did not show a statistically increased risk
For U-DPD, there was a significant interaction
between cadmium and menopause (p = 0.022)
Low-level cadmium exposure:
Has negative effects on bone
Increases bone resorption
Intensifies bone loss after menopause
Akesson A, etal, Cadmium-induced effects on bone in a population-based study of women.
Environ Health Perspect. 2006 Jun;114(6):830-4.
Akesson A, etal, Cadmium-induced effects on bone in a population-based study of women.
Environ Health Perspect. 2006 Jun;114(6):830-4.
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ChelaCo
Also looked at Lead (Pb)
Pb accumulates in bone by replacement of Ca
The skeleton contains as much as 90% of the lead
body burden
Bone markers showed clear associations with blood
lead
↑ Blood lead = ↑ Bone Resorption
Akesson A, etal, Cadmium-induced effects on bone in a population-based study of
women. Environ Health Perspect. 2006 Jun;114(6):830-4.
Garlic bulb powder
from Allium sativum bulb 100 mg
Containing alliin 2.0 mg
100 mg
Hawthorn flowering tops extract 3:1
from Crataegus monogyna
flowering tops 300 mg
100 mg
Milk Thistle seed extract 70:1
from Silybum marianum seed dry 7.0 g
Containing flavanolignans as silybin 80 mg
100 mg
Dose: 1 enteric coated tablet, 3 times daily with meals
93
Primary Indication
Environmental exposure to heavy metals
Suggested Use
Preventing / minimizing the
gastrointestinal absorption of
environmental metals
Promoting the excretion of
metals from the body
Antioxidant
In anemia and cases where iron
supplementation is required, do not
take simultaneously with meals to
iron supplements
Heavy Metal Support
Core Support
ChelaCo, 1 tablet 3 times daily
or
Garlic 5000mg, 1 tablet 2 to 3 times daily
And
Parotid PMG, 2 tablets 3 times daily
Zinc Liver Chelate, 1 tablet 3 times daily
Cholacol II, 4 tablets twice daily on an empty
stomach
95
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24
Zinc and Bone
Onions and Bone Density
Zinc (Zn) is an important mineral required for
normal bone development
Bone Zn content has been shown to decrease in
aging, with skeletal unloading and postmenopausal
conditions
Zn has a stimulatory effect on osteoblastic bone
formation and mineralization and it stimulates
cellular protein synthesis
More NHANES data 2003 - 2004
Onion consumption has a beneficial effect on bone
density in peri and post menopausal non-Hispanic
white women 50 years and older
Participants were divided into:
Onions less than once a month
Twice a month to twice a week
Three to six times a week
Once a day or more
Yamaguchi M. Role of nutritional zinc in the prevention of osteoporosis. Mol Cell
Biochem. 2009 Dec 25. [Epub ahead of print]
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98
The Menopausal Change
Onions and Bone Density
Bone density increased as the frequency of onion
consumption increased
Individuals who consumed onions once a day or more
had an overall bone density that was 5% greater than
individuals who consumed onions once a month or less
(P < 0.03)
Older women who consume onions most frequently
may decrease their risk of hip fracture by more than
20% versus those who never consume onions
Not all women experience menopausal symptoms
About 70% experience hot flashes and 40% suffer
from depression
Other symptoms such as sweating, fatigue, irregular
menstruation and insomnia occur in 20-40% of
perimenopausal women
Matheson EM, etal Assoc b/w onion consumption and bone density in peri & post
menopausal white women ≥50 years. Menopause 2009 Jul-Aug;16(4):756-9
99
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25
The aims of herbal treatments are to:
assist the adjustment to this
important change
provide symptomatic alleviation of the
effects of estrogen withdrawal
During the transitional years, hormone levels can
fluctuate wildly, causing erratic, irregular periods,
some much heavier than normal
Other physical symptoms of the menopausal transition
may include:
vaginal dryness
bladder irritability
hot flushes with or
without sweats
insomnia with or
without night sweats
Herbal treatment should not be
prescribed indefinitely, although it may
be required for several years
101
Herbal Strategy
Phytoestrogens
Support and manage the changing estrogen environment
with estrogenic herbs
Wild Yam
Shatavari
Black Cohosh
Tribulus
Epimedium
Kudzu
Red Clover
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Phytoestrogens compete strongly for estrogen
receptors, however their stimulation of these
receptors is much weaker than estradiol
Phytoestrogens are selective
Can function as estrogen agonists OR antagonists
depending on the hormonal milieu
Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine.
Churchill Livingston, Edinburgh, 2000, pp 54-56
104
26
SERMs
Estrogen Receptor Complexities
Estrogen receptors are present in almost all organs of
the body
There are two main classes of estrogen receptors (ERα
and ERβ) which are distributed unevenly in body
tissues
ERα predominates in the uterus, pituitary, kidney
and breast and is the classical estrogen receptor
ERβ are found in bone, prostate, brain (hypothalamus)
and reproductive organs
G protein–coupled receptor (GPER-1) is a recent
discovery
Selective estrogen receptor modulators
Estradiol is a pure estrogen agonist
In contrast to pure estrogen agonists or antagonists,
SERMs have a mixed or selective pattern of estrogen
agonist/antagonist activity, which depends on the tissue
targeted and the type of receptor stimulated
105
Phytoestrogens
106
Wild Yam
In lower estrogenic environments as in post
menopausal women, they provide a net estrogenic
effect
In a high estrogen environment such as in
premenopausal women, their displacement of
endogenous (& exogenous) estrogens is thought to
have an antiestrogenic effect
However, even this net estrogenic effect is subtle, and
because of their selective behavior towards the
different estrogen receptors they act more like SERMs
Menopausal
symptoms
Spasmodic
dysmenorrhea
Intestinal colic
Diverticulitis
Ovarian pain
Female infertility
Rheumatoid
arthritis
Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine.
Churchill Livingston, Edinburgh, 2000, pp 54-56
107
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27
Wild Yam
Authenticity of Wild Yam
The oral application of Wild Yam (Dioscorea villosa)
must be clearly differentiated from its use in
“progesterone creams”
Steroidal saponins from Wild Yam are not bioavailable
through the skin
“Progesterone cream” advocates exploit the confusion
between the phytochemicals in Wild Yam and
progesterone
Yams (Dioscorea spp.) are used as a source of
precursors in the production of human identical
progesterone
Many extracts of Wild Yam are sold standardized to
diosgenin which is NOT found in the herb and is an
indication the herb has been enzymatically degraded
during the dried process
The predominant steroidal compound in Wild Yam was
thought to be dioscin, a steroidal glycoside precursor of
diosgenin
Research undertaken by MediHerb, has shown that
dioscin is only present in small quantities
Newly identified compounds methylparvifloside and
methylprotodeltonin are the key actives and precursors
to diosgenin
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Is Black Cohosh Estrogenic?
Shatavari
Black Cohosh is a well known treatment for menopausal
symptoms
The obvious conclusion to draw is that it has estrogenic
properties
This has resulted in safety concerns (eg in breast
cancer survivors) and over long-term use (eg causing
breast cancer)
But is Black Cohosh really estrogenic and what does
“estrogenic” really mean in the context of plant
chemicals?
Support for menopausal symptoms
Promote general well being by increasing cellular
vitality and resistance to stress
To improve libido and sexual vitality
As a tonic for general debility, fatigue, infections
Gastric ulcers and dyspepsia
Liver support
111
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28
Is Black Cohosh a SERM?
Is Black Cohosh a SERM??
Recent in vivo models generally show a lack of
estrogenic effects on reproductive tissues1,2
Positive effects were observed (due to estrogenic
effects) in animal models of osteoporosis3,4
There was no growth acceleration in animal models in
uterine5 or breast cancer6
1.
2.
3.
4.
5.
6.
In general the growth of breast cancer cells in vitro
was inhibited1,2
Clinical studies showed amelioration of menopausal
symptoms and favorable effects on bone metabolism
But with no effect on endometrial thickness and
variable effects on vaginal cytology3,4,5
Borrelli F, Izzo AA, Ernst E. Life Sciences 2003; 73(10): 1215-1229
Zhang L, Khan IA, Willett KL et al. J Herb Pharmacother 2003; 3(3): 33-50
Nisslein T, Freudenstein J. J Bone Miner Metab 2003; 21(6): 370-376
Seidlova-Wuttke D, Hesse O, Jarry, H et al. Eur J Endocrinol 2003;149(4): 351-362
Nisslein T, Freudenstein J. Toxicol Lett 2004; 150(3): 271-275
Freudenstein J, Dasenbrock C, Nisslein T. Cancer Res 2002; 62(12): 3448-3452
1.
Bodinet C. Freudenstein J. Menopause 2004; 11(3): 281-289
2.
Hostanska K, Nisslein T, Freudenstein J et al. Breast Cancer Res Treat 2004; 84(2): 151-160
3.
Wuttke W, Seidlova-Wuttke, D, Gorkow C. Maturitas 2003; 44(Suppl 1): S67-S77
4.
Hernandez Munoz G, Pluchino S. Maturitas 2003; 44(Suppl 1): S59-S65
5.
Liske E, Hanggi W, Henneicke-von Zepelin HH et al. J Womens Health Gend Based Med 2002;
11(2): 163-174
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Tamoxifen
Black Cohosh and Tamoxifen
50 breast cancer patients with Tamoxifen treatment
100% patients had surgery, 87% had undergone
radiation therapy and approximately 50% had received
chemotherapy
Every patient was treated with an extract of Black
Cohosh (up to 10 mg/day) for 6 months
Black Cohosh treatment statistically significantly
improved hot flashes, sweating, sleep problems, and
anxiety
No adverse events, and 90% reported the tolerability of
the black cohosh extract as very good or good
115
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Rostock M et al. 2011, Black cohosh in tamoxifen-treated breast cancer patients with
116
climacteric complaints - a prospective observational study. Gynecol Endocrinol. Jan 13
29
St John’s Wort
Korean Ginseng
Four clinical studies have investigated the use of a
combination of St John's Wort and Black Cohosh
The placebo-controlled trials found the combination to
be effective in reducing menopausal symptoms,
including the psychological component1-3
The observational study found the combination was
superior to Black Cohosh alone in alleviating
menopausal mood symptoms4
1
Boblitz N et al. Focus Altern Complement Ther 2000; 5: 85
2
Uebelhack R et al. Obstet Gynecol 2006; 107: 247
3
Chung DJ et al. Yonsei Med J 2007;48: 289
4
Briese V et al. Maturitas 2007; 57: 405
TCM uses include tonification of the vital
energy and spleen, calming the nerves,
chronic general weakness with irritability
and insomnia and organ prolapse
In western herbal medicine, Korean
Ginseng is used as an adaptogenic tonic
indicated for physical or mental
exhaustion and depressive states
associated with sexual inadequacy
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Korean Ginseng
119
Sage
Clinical trials have reported beneficial results in
treating postmenopausal symptoms1
Korean Ginseng improved psychological test scores in
postmenopausal women with symptoms of fatigue,
insomnia and depression, compared to those without
symptoms
The improvement was at least partially due to an
anti-stress effect, demonstrated by a decrease in the
cortisol/DHEA ratio2
Traditionally Salvia officinalis has been used to
restrain excessive sweats and for debility of the
nervous system including nervous exhaustion1,2
A recent study showed sage extract improved
memory and attention and an in-vitro analysis
demonstrated the extract had cholinesterase
inhibiting properties3
2
1. British Herbal Pharmacopoeia. Bournemouth: BHMA, 1983
1
Frawley D, Lad V. The Yoga of Herbs: An Ayurvedic Guide to Herbal Medicine, 2nd Edn.
Lotus Press, Santa Fe, 1988.
Briese V et al. Maturitas 2007; 57: 405
2. Felter HW et al. King’s American Dispensatory, 18th Edn, 3rd revision, 1905, reprinted
Portland: Eclectic Medical Publications, 1983.
120
© Lee Carroll 2012
3. Scholey AB, etal, Psychopharmacology (Berl). 2008 May;198(1):127-39. Epub 2008
Mar
121
30
Wild Yam Complex
Sage
Wild Yam root and rhizome 4:1 extract
100 mg
from Dioscorea villosa root and rhizome 400 mg
A product containing Salvia officinalis and Alfalfa
extracts improved menopausal symptoms (hot
flashes/flushes, night sweating) in an open trial
conducted for 3 months1
Salvia officinalis reduced sweat production in patients
with hyperhydrosis (excessive sweating) in a number
of open studies2
1
De Leo V et al. Minerva Ginecol 1998; 50: 207
2
ESCOP Monographs: The Scientific Foundation for Herbal Medicinal Products, 2nd Edn.
ESCOP, European Scientific Cooperative on Phytotherapy, Exeter, 2003
Shatavari root 4:1 extract
from Asparagus racemosus root 400 mg
100 mg
St John’s Wort herb flowering top 6:1 extract
100 mg
from Hypericum perforatum herb fl top 600 mg
Containing hypericins 300 mcg
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123
Tribulus
Wild Yam Complex
Sage herb 5:1 extract
from Salvia officinalis herb 290 mg
58 mg
Black Cohosh root 5:1 extract
from Cimicifuga racemosa root 100 mg
20 mg
Korean Ginseng root 5:1 extract
from Panax ginseng root 75 mg
Containing ginsenosides as Rg1 & Rb1 1.3 mg
15 mg
Tribulus (Tribulus terrestris) is one of the bestresearched examples of the use of a steroidalsaponin containing herb in menopause
Like Wild Yam and Shatavari, Tribulus leaf is rich in
steroidal saponins
Tribulus leaf is a popular herb in Eastern Europe for
the treatment of menopausal symptoms
Dosage: 3-4 tablets per day. 6 per day can be used in
the first few weeks of treatment to accelerate the effect
124
© Lee Carroll 2012
Stuthe J, et al. Poster presentation: 50th Conference Society of Medicinal Plant
Research (GA) in Spain, 2002
125
31
Tribulus
Tribulus
In an open study, a group of 50 women were first given
placebo and then Tribulus leaf extract
52% of patients were experiencing natural menopause,
48% had post-operative symptoms after removal of
their ovaries
Predominate symptoms included hot flashes (100%),
sweating (78%) and insomnia (82%)
After active treatment, 98% experienced symptom
improvement. No effect was seen for placebo
The dosage of leaf extract prescribed varied, but
generally a standardized extract corresponding to
200-300 mg of furanosterolic saponins was reached
after higher initial doses
Treatment did not result in significant changes in FSH,
LH, prolactin, estradiol, progesterone and testosterone,
although FSH tended to be lower
Zarkova S. Tribestan: Experimental and Clinical Investigations. Chemical Pharmaceutical Research
Institute, Sofia, Bulgaria.
Zarkova S. Tribestan: Experimental and Clinical Investigations. Chemical Pharmaceutical Research
Institute, Sofia, Bulgaria.
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126
Menopause Support
Menopause Support
Core Support
Wild Yam Complex, 3 to 4 tablets per day. Increasing
up to 6 tablets with severe symptoms for short periods
of time
Symplex F, 3 tablets 2 times per day
Prolamine Iodine, 1 to 4 tablet per day
Additional Support (as required)
Tribulus, 3 to 4 tablets per day if hot flashes are still a
problem
Bone Complex, 1 tablet 3 times daily where low bone
mineral density is an issue
Additional Support (as required)
Chaste Tree, 1 to 3 tablets per day for erratic periods
and exaggerated PMS in the perimenopause phase
Adrenal Complex, 2 to 3 tablets per day if stress
aggravates the hot flashes
Thyroid Complex, 3 to 4 tablets per day, for K TSH
Drenamin, 3 tablets 2 times per day
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Simplified Bowel Flora Protocol
Osteoporosis
Osteoporosis (OP) is a chronic
progressive skeletal disease
characterized by:
Microarchitecture deterioration
Low bone mass
As a result the bones become fragile
with the increased risk of fracture,
especially of the hip, spine & wrist
Everyday of the Week
Gut Flora Complex, 1 capsule 2 twice daily
Wholefood Fibre, 1 tablespoon twice daily at the same
time as the Gut Flora Complex
As required:
Vitanox, 2 to 3 tablets daily
ProSynbiotic, 3 capsules daily
Lactic Acid Yeast, 1 to 2 wafers 3 times daily
Continue for minimum of 6 weeks.
Suitable for long term use
Sambrook P, Cooper C. Osteoporosis, Lancet 2006;
367(9527): 2010-2018
130
Central Role of Estrogen
131
Central Role of Estrogen
Estrogen plays a fundamental role in bone homeostasis
in both men & women
Osteoblasts, osteocytes & osteoclasts all have estrogen
receptors
Estrogen deficiency enhances osteoclast formation &
prolongs the resorption phase by reducing the
apoptotic rate of osteoclasts
Thus the balance between withdrawal & deposition is
tipped in favor of withdrawal
Weitzmann MN, Pacifici R. Estrogen deficiency and bone loss: an inflammatory tale.
Journal of Clinical Investigation 2006; 116(5): 1186-1194
Raisz LG. Pathogenesis of Osteoporosis. Journal of Clinical Investigation 2005; 115(12): 3318-3325
132
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Bone Complex
Bone Complex
Epimedium herb top 12:1 extract
from Epimedium sagittatum herb top 2.4 g
Containing icariin 20 mg
200 mg
Red Clover herb flowering top 5:1 extract
from Trifolium pratense herb flowering top 500 mg
Containing isoflavones 8 mg
100 mg
Kudzu root 10:1 extract
from Pueraria lobata root 700 mg
Containing puerariae isoflavones calculated as
diadzin, puerarin, daidzein 28 mg
70 mg
Black Cohosh root 4:1 extract
from Cimicifuga racemosa root 80 mg
20 mg
Dose: 1 tablet, 3 times daily
Indications:
Pre-treatment and treatment of osteopenia,
(particularly in postmenopausal women)
In conjunction with weight-bearing exercise
A healthy diet containing food sources of calcium
and vitamin D
Management of osteoporosis
Support and maintain healthy bone density
Beneficially influence bone remodelling
Support during menopause
134
135
Exercise
Exercise, Isoflavones & BMD
Exercise is often recommended for increasing BMD,
possibly by stimulating estrogen receptors
However the increases in BMD are often small with
exercise alone
But when exercise is combined with isoflavone therapy
much larger increases in BMD have been observed
Exercise is often recommended for increasing BMD,
possibly by stimulating estrogen receptors
However the increases in BMD are often small with
exercise alone
But when exercise is combined with isoflavone therapy
much larger
increases in BMD and
muscle have been
observed
Chilibeck PD, Cornish SM. Effects of estrogenic compounds (estrogen or phytoestrogens)
combined with exercise on bone and muscle mass in older individuals. Appl Physiol Nutr
Metab 2008; 33(1): 200-212
136
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Menopausal OP Protocol
Bone Complex, 1 tablet 3 times daily
Ostrophin PMG, 2 tablets 3 times daily
Calcifood powder, 1 to 2 tablespoons per day or
Calcifood Wafers, 6 wafers 1 to 2 times per day
Cataplex D, 1 tablet 3 times daily
Zinc Liver Chelate, 1 tablet 3 times daily
Whey Pro Complete and/or Protofood
Garlic 5000mg or ChelaCo , 1 tablet 2 to 3 times
daily
Bowel Flora Protocol yearly
Exercise
Acknowledgements
Special thanks to Associate Professor Kerry Bone for
his help with this presentation

138
139
APPENDIX SLIDES
Questions?
© Lee Carroll 2012
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35
Pregnancy and Lactation:
Some Golden Rules
Pregnancy and Lactation
A safe and widely-used herb does not
suddenly become a dangerous cocktail
just because a patient is pregnant
Most concerns over herbs in
pregnancy and lactation are
speculative, unfounded or vastly
exaggerated
A few simple rules can be followed
1. Only recommend what is truly needed
2. Be particularly cautious in the first trimester
3. Be particularly cautious if there is a history of
miscarriage, although the right herbs can help to
avoid this
4. Avoid toxic herbs
5. Be careful of laxative herbs
6. Refer to the resources mentioned
7. If it is contraindicated in the catalog – don’t use it!
Menorrhagia
Menorrhagia - Common Causes
Abnormally heavy period with a normal cycle length
Most causes are functional: nothing essentially wrong
but there is abnormality in function
Need to know the cause before treating

Hypothalmic Pituitary unit
The ovary
Excessive stimulation of the endometrium by estrogen
Failure to produce progesterone
Imbalance in prostaglandin levels
Hypothyroidism, low Iron stores, clotting dysfunction
Uterine tone, infections and fibroids
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© Lee Carroll 2012
Functional
Uterine Fibroids and Polyps
Endometriosis
Pelvic Inflammatory Disease (PID)
Contraceptive causes
Non-Gynecological causes
Pregnancy
145
36
Functional Menorrhagia
May reflect an excessive estrogen to progesterone ratio
accompanied by prostaglandin imbalance
Saturated fat intake may be too high.
May be complicated by fibroids, endometriosis or
infection
Check iron status
Chaste Tree is a Key Herb
An improvement was reported in 66% of patients
with heavy or frequent bleeding (uncontrolled trial)
For 58 cases of menorrhagia, average duration of
bleeding decreased from 8 to 5 days (uncontrolled
trial)
Doses may need to be higher than for PMS - up to 5
tablets per day or 5 mL of 1:2, throughout the cycle
146
Protocol for Functional Menorrhagia
Capsella Complex Phytosynergist
This combines well with Chaste Tree
Shepherd’s Purse is antihemorrhagic one of the best
Dong Quai is a general female tonic and
False Unicorn is a uterine tonic
White Peony to correct hormonal
imbalance
Can be taken throughout the cycle with
increased doses during menstruation
Core Support
Capsella Complex Phytosynergist,
5 mL 3 times per day during the cycle
Additional Support
Fe-Max Iron Tonic: 5 mL twice a day
To replenish iron reserves if they are
low
148
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149
37
Amenorrhea and Oligomenorrhea
Amenorrhea is the absence of the period
Amenorrhea is divided into primary and secondary
Primary: menstruation has not commenced by the
age of seventeen or within 2 years of physical
maturation
Secondary is a cessation for 6 months or more or for
more than 3 cycles when the cycles are longer than
normal
Oligomenorrhea is menstruation that is markedly
diminished
Secondary Amenorrhea
Common causes
Uterine causes eg obstruction or
endometrial tissue destruction
Hypothalamic
Stress
Weight loss
Rigorous exercise
Severe chronic illness
Post - Pill amenorrhea
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Secondary Amenorrhea
Protocol Secondary Amenorrhea
Pituitary
Pituitary insufficiency
Failure to ovulate
PCOS (see PCOS)
Breastfeeding
Thyroid conditions
Cushings syndrome
Core Support
Reduce hyperprolactinaemia
Tribulus
1 tablet 3 times daily every day
Once period starts switch to
1 tablet 3 times daily on days 5 to 14 of the
menstrual cycle (or to ovulation)
Assists with hormone balance
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Protocol Secondary Amenorrhea
Endometriosis
Additional Support
Dong Quai, 1 tablet 2 to 3 times daily
Has been traditionally for amenorrhea
Ovex, 6 tablets per day
Cataplex E, 6 tablets per day
Endometriosis is a chronic inflammatory disease,
characterised by implantation and growth of
endometrial tissue outside the uterine cavity
In most cases lesions are found in the peritoneal
cavity but can occur anywhere in the body
It is one of the most frequent diseases in
gynaecology, affecting 15-20% of women in their
reproductive life
Matarese G, De Placido G et al. Trends Mol Med 2003; 9(5): 223-228
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Endometriosis
Endometriosis
The pathophysiology of endometriosis still remains
unclear1
The retrograde menstruation theory has been widely
accepted, however retrograde menstruation occurs
in most women of reproductive age, so there must
be other factors at play
There is substantial evidence linking alterations in
both cell-mediated and humoral immunity with the
pathogenesis of endometriosis2
1.
Hull Ml, Escareno Cr et al. am J Pathol 2008; 173(3): 700-715
2.
Ulukus M, Arici A. Minerva Ginecol 2005; 57(3): 237-24
© Lee Carroll 2012
It is associated with increased secretion of
pro-inflammatory cytokines, intrinsic anomalies of
the refluxed endometrium and impaired immune
function1
Genetic predisposition, environmental factors and
alterations in immune and endocrine functions are
believed to play significant roles in the
establishment and maintenance of endometriosis2
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1.
Matarese G, De Placido G et al. Trends Mol Med 2003; 9(5): 223-228
2.
Ulukus M, Cakmak H, Arici A. J Soc Gynecol Investig 2006; 13(7): 467-476
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Endometriosis
Endometriosis Symptoms
Endometriosis has been considered to be an
autoimmune disease because it is often associated
with the presence of autoantibodies and other
autoimmune diseases1
In one study anti-endometrial antibodies were
detected in 60% of endometriosis patients
These autoantibodies may be partially responsible
for the frequency of miscarriage/poor implantation
associated with this condition2
Dysmenorrhoea
Pelvic pain and cramping may begin before and
extend several days into menstruation and may
include lower back and abdominal pain, nausea
and diarrhoea
Pain at other times
Pelvic pain during ovulation
Sharp pain deep in the pelvis during intercourse
Pain during bowel movements or urination
Ulukus M, Arici A. Minerva Ginecol 2005; 57(3): 237-24
Gajbhiye R, Survawanshi A et al. Reprod Biomed Online 2008; 16(6): 817-824
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Endometriosis Treatment
Endometriosis Symptoms
Alleviate symptoms eg dysmenorrhea
Reduce inflammation
Modulate immunity
Regulate hormones
Support liver to eliminate toxins and excessive
estrogen
Aim to prevent/treat complications eg scarring

Excessive bleeding
Occasional heavy periods (menorrhagia)
Bleeding between periods (menometrorrhagia)
Spotting during the cycle is a common sign of
endometriosis
Infertility
Endometriosis is often first diagnosed in women
who are seeking treatment for infertility
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Protocol for Endometriosis
Core Treatment
Reduce estrogen dominance
Echinacea Premium: 1 tablet 2 to 3 times daily
Modulate immunity and increase NK cells
LivCo: 1 tablet 3 times daily
Aid elimination of excessive hormones & toxins
Dong Quai: 1 tablets 3 times daily
As a uterine tonic and to regulate menstruation.
Use up to ovulation and not during heavy bleeding
Protocol for Endometriosis
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Pharmacokinetics
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Pharmacokinetics
Intestinal metabolism of isoflavones to their aglycone
forms is crucial for ensuring bioavailability &
therapeutic activity
The health of intestinal microflora is pivotal in the
healthy metabolism of estrogenic phytochemicals
Individual differences in intestinal microflora have been
proposed as a possible reason why there is some
inconsistency in the clinical effects of phytoestrogens
The bioavailability of phytoestrogens & isoflavones in
particular is dependant on a number of factors
Isoflavones are present in plants & plant extracts as
glycosides (sugar + aglycone) and are inactive in this
form
The active principles are derived from the aglycone
component
The GIT needs to hydrolyse the bond between the
sugar & aglycone via intestinal glucosidase enzymes
Vatanparast H, Chilibeck PD. Does the Effect of Soy Phytoestrogens on Bone in
Postmenopausal Women Depend on the Equol-Producing Phenotype? Nutr Rev 2007;
65(6): 294-299
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Additional Support
Boswellia Complex: 1 to 2 tablets 3 times daily
Reduce inflammation and exert antioxidant activity
Rehmannia Complex: 1 tablet 3 times daily
Reduce autoantibodies and inflammation
Gotu Kola Complex: 1 tablet 3 times daily
To promote healing and reduce scarring
Cramplex: 2 tablets 2 to 3 times daily
For dysmenorrhea
Capsella Complex: 5 mL 2 to 4 times per day
For associated heavy menstrual bleeding
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Gut
Metabolism
of
Isoflavones
&
Steroidal
Saponins
Turner NJ, Thomson BM, Shaw IC.
Bioactive Isoflavones in Functional
Foods: The Importance of Gut
Microflora on Bioavailability. Nutr Rev
2003; 61(6): 204-213
Gut Metabolism of Diadzin
The best studied example of this is the isoflavone
diadzin
Diadzin is reduced to the aglycone diadzein by
enzymes (glucosidases) produced by the gut
microflora
Diadzein is then subjected to further reduction as a
result of the action of the gut microflora to produce
equol, which is the active estrogenic compound
Vatanparast H, Chilibeck PD. Does the Effect of Soy Phytoestrogens on Bone in
Postmenopausal Women Depend on the Equol-Producing Phenotype? Nutr Rev 2007;
65(6): 294-299
166
Non-responders to Isoflavones
167
Non-responders to Isoflavones
Oral antibiotics are known to reduce equol production1
Numerous clinical experiences in treating women with
menopausal symptoms with herbal extracts containing
isoflavones have demonstrated that a gut flora
balancing protocol is beneficial in bringing about a
therapeutic effect in those clients that do not respond
initially
This provides the rationale for the gut flora protocol for
non-responders
There are large individual variances in the capacity to
produce equol (up to 400 fold) & hence a therapeutic
effect
Dietary fat consumption is known to reduce this
capacity1
Dietary supplementation with fructooligosaccharides
such as inulin are known to increase the capacity to
produce equol2
1. Rowland IR, Wiseman H, Sanders TAB. Interindividual Variations in Metabolism of Soy
Isoflavones and Lignans: Influence of Habitual Diet on Equol Production by the Gut
Microflora. Nutr Cancer 2000; 36(1): 27-32
1. Halm BM, Franke AA, Ashburn LA et al. Oral antibiotics decrease urinary isoflavonoid
excretion in children after soy consumption. Nutr Cancer 2008; 60(1): 14-22
2. Tokunaga T. Novel physiological functions of fructooligosaccharides. Biofactors 2004;
21(1-4): 89-94
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Epimedium: Clinical Trial
Epimedium
Epimedium-derived icariin and isoflavones
demonstrated beneficial effects in late postmenopausal
women, without resulting in a detectable hyperplasia
effect on the endometrium
24-month randomized double-blind placebo-controlled
clinical trial
100 postmenopausal women with lumbar spine BMD,
with T scores of between -2 & -2.5
Licentious Goat Wort or
Horny Goat weed
A TCM herb that tonifies the kidneys & fortifies the
yang. Actions which strengthen bones
Indicated for weak limbs
Epimedium contains a unique flavonoid icariin, along
with the isoflavones genistein and daidzein
Many OP experimental studies have been conducted
on either the herb or Icariin
Zhang G, Qin L, Shi Y. Epimedium-derived phytoestrogen flavonoids exert beneficial effect
on preventing bone loss in late menopausal women: a 24-month randomized, doubleblind and placebo controlled trial. J Bone Miner Res 2007; 22(7): 1072-1079
Bensky D, Gamble A. Chinese Herbal Medicine: Materia Medica. Eastland
Press, Seattle, 1993, pp 341-342
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Active group (n=50) received a daily dose of
Epimedium extract containing 60 mg icariin, 15 mg
diadzein and 3 mg genistein
Placebo group (n=50)
Both groups received 300 mg of calcium as citrate daily
Epimedium significantly ↓ levels of deoxypyridinoline at
12 months (43% p=0.000) and 24 months (39%
p=0.000), with no change in the placebo group
Osteocalcin increased 5.6% (p=0.530) at 12 months
and 10.7% (p=0.267) at 24 months. No change in
placebo group
Serum estradiol, no change in the Epimedium group
Zhang G, Qin L, Shi Y. J Bone Miner Res 2007; 22(7): 1072-1079
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BMD (lumbar spine) treatment group
↑ 1.0% at 12 months
BMD (lumbar spine) placebo group
↓ 1.7% at 12 months
Difference b/w placebo at 12 months p = 0.044
Difference b/w placebo 24 months p = 0.006
BMD (femoral neck) treatment group
BMD (femoral neck) placebo group
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