Botanical Treatment Of Chronic Pelvic Pain

Effective botanical treatment of chronic pelvic pain requires a clear understanding of possible etiologies and the appropriate treatment of the underlying cause of the pain. For patients with diagnosed gynecologic conditions associated with pelvic pain, readers are referred to the relevant chapters in this textbook, such as, dysmenorrhea, interstitial cystitis, uterine fibroids, endometriosis, and so forth. Treatments discussed in the following may be used as adjunct palliative therapies for pain, inflammation, and concomitant symptoms in these conditions.

In the absence of a clearly identified pathology, the practitioner can approach treatment symptomatically via specific botanical treatments for pain reduction, and attempt to address mechanisms that may be associated with CPP, for example, inflammation. One theory of chronic pelvic pain that was popular among physicians in the early-and mid-twentieth century, and that is still considered a possibility, is that of pelvic congestion syndrome. Women with this syndrome, which is poorly defined, are thought to exhibit many of the symptoms associated with CPP, including aching and dragging sensations in the lower back, lower abdomen, and pelvis, dysmenorrhea, and dyspareunia. The theory of pelvic congestion parallels Chinese medical theory regarding various forms of gynecologic pain. Pelvic vascular congestion is thought to be a dynamic vascular process, similar to migraine headache, with drug inducible [dihydroergotamine (DHE) injection] reversibility of vascular dilatation. As with CPP, symptoms are commonly accompanied by depression, fatigue, and insomnia. Upon pelvic exam or laparoscopy, the uterus may be found to be enlarged and tender and the pelvic vessels engorged. However, there is no direct correlation between vessel engorgement and pain; some women have either pain without engorgement or vice versa. Herbalists may include herbs in a formulae to tonify and astringe the uterus and pelvic vessels, ostensibly to reduce pelvic congestion. Psychogenic causes may contribute tochronic pelvic pain. Although this should not be overemphasized, it should also not be overlooked. Chronic pain can affect nearly every aspect of a patient’s life: physically, mentally, emotionally, socially, and even economically. Because chronic pain can lead to depression and anxiety, as well as to sleep disturbance, which can create a vicious cycle of psychoemotional upset and increased pain, care should be taken to approach pain holistically, including in protocol herbs that are restorative to the nervous system, for example, adaptogens and nervines, and when needed, anxiolytics or antidepressants.

IBS and inflammatory bowel syndromes are highly associated withchronic pelvic pain. Herbs commonly used for the treatment of chronic pelvic pain are listed in Table Botanical Treatment Strategies for Chronic Pelvic Pain. Many of these herbs are discussed elsewhere in this site or in Plant Profiles.

Botanical Treatment Strategies for Chronic Pelvic Pain

Therapeutic Goal Therapeutic Activity Botanical Name Common Name
Pain relief Analgesia Anemone pulsatilla Pulsatilla
Actaea racemosa Black cohosh
Corydalis ambigua Corydalis
Eschscholzia californica California poppy
Piper methysticum Kava kava
Piscidea piscipula |amaican dogwood
Viburnum spp. Cramp bark, black haw
Also see Dysmenorrhea
Relief of pelvic muscle spasm Antispasmodics Achillea millefolium Yarrow
Angelica sinensis Dong quai
Dioscorea villosa Wild yam
Cannabis indica Marijuana
Actaea racemosa Black cohosh
Leonurus cardiaca Motherwort
Paeonia lactiflora White peony
Rehmannia glutinosa Rehmannia
Viburnum spp. Cramp bark, black haw
Zingiber officinale Ginger
Also see Dysmenorrhea
Treatment of depression and anxiety Antidepressants

Anxiolytics

Hypericum perforation St. John’s wort
Lavandula officinalis Lavender
Leonurus cardiaca Motherwort
Matricaria recutita Chamomile
Melissa officinalis Lemon balm
Piper methysticum Kava kava
Nervous system support Adaptogens Cordyceps sinensis Cordyceps
Eleutherococcus senticosus Eleuthero
Panax quinquefolius American ginseng
Rhodiola rosea Rhodiola
Withania somnifera Ashwagandha
Also see Stress, Adaptation, the Hypothalamic-Pituitary-Adrenal-Axis (HPA) and Women’s Health
Reduce inflammation Anti-inflammatories Angelica sinensis Dong quai
Clycyrrhiza officinale Licorice
Oenothera biennis oil Evening primrose
Paeonia lactiflora White peony
Salix spp Willow
Tanacetum parthenium Feverfew
Zingiber officinale Ginger
Digestive support; treatment of IBS and inflammatory bowel syndrome Antispasmodics Achillea millefolium Yarrow
Dioscorea villosa Wild yam
Matricaria recutita Chamomile
Mentha piperita Peppermint
Digestive support; treatment of IBS and inflammatory bowel syndrome Astringents Achillea millefolium Yarrow
Hydrastis canadensis Goldenseal
Digestive support; treatment of IBS and inflammatory bowel syndrome Carminatives Matricaria recutita Chamomile
Mentha piperita Peppermint
Pimpinella anisum Anise
Digestive support; treatment of IBS and inflammatory bowel syndrome Demulcents Ulmus rubra Slippery elm
Althea officinalis Marshmallow
Digestive support; treatment of IBS and inflammatory bowel syndrome Laxatives Clycyrrhiza glabra Licorice
Taraxacum officinale Dandelion root
Rumex crispus Yellow dock
Treat insomnia / sleep disorders Anxiolytics Anemone pulsatilla Pulsatilla
Nervines Piper methysticum Kava kava
Sedatives Eschscholzia califomica California poppy
Treat possible pelvic congestion syndrome Uterine tonics

Venotonics

Aesculus hippocastanum Horse chestnut
Caulophyllum thalictroides Blue cohosh
Alchemilla vulgaris Lady’s mantle
Hydrastis canadensis Goldenseal
Mitchella repens Partridge berry
Rubus idaeus Red raspberry
Viburnum spp. Cramp bark, black haw

Analgesia

The history of botanical medicine reveals many herbs that have been used for the treatment of a variety of types of pain. Many traditional medicines have actions such as inhibition of platelet-activating factor, cyclooxy-genase, prostaglandin formation, or arachidonic acid pathways. Although not typically as fast-acting as conventional medications, repeated appropriate dosing over a short period of time, such as 1 to 2 hours, and continued as needed, often leads to satisfactory temporary alleviation of pain. Several herbs are reputed for their efficacy in the treatment of pain of gynecologic origin, as well as more generally (see Dysmenorrhea).

Black Cohosh

Black cohosh has historically been used by Northeast Native American tribes as an analgesic and as an emmen-agogue. The Eclectics used a resin of black cohosh specifically as a uterine tonic and in the treatment of dysmenorrhea and a number of other painful spasmodic or cramping gynecologic complaints. It was also used in the treatment of deep muscle drawing in the legs, loins, and back, dull aching of the bowels, ovarian pains of a dull, aching quality, dragging uterine pain, and delayed menses with dull pain and muscle soreness. Felter specifically describes a condition called “rheumatism of the uterus” for which this herb was prescribed.” The plant’s anti-inflammatory and analgesic properties are attributed to its aromatic acids, which appear to inhibit prostaglandin production. The herb is approved for use in Germany for the treatment of premenstrual discomfort and menstrual cycle pain.

California Poppy

California poppy traditionally has been prescribed for reducing pain and producing calm sleep without the potential dangers of conventional opiate drugs. It may be useful for painful conditions in which there is irritation or stimulation of afferent pain fibers, in disturbed sleep, and for anxiety. Its medical use as an analgesic and sedative in the United States dates as far back as the late nineteenth century, even being included in the Parke-Davis catalog for these purposes, and as an excellent alternative to morphine without its side effects. Today, California poppy is widely used by herbalists in tincture form. Pharmacologic data demonstrate sedative activity in vivo, as well as GABAergic activity, sedative and anxiolytic action, and dose-dependent analgesia (when administered by injection). Two controlled clinical trials, the herb, combined with Corydalis cava, both standardized extracts, demonstrated normalization of disturbed sleep without carryover effects or addiction.

Corydalis

The Chinese botanical corydalis, is a strong and reliable analgesic. It is commonly used for headache, lumbar pain, abdominal pain, joint pain, menstrual pain, and other neurologic pain, making it specific for the symptoms associated withchronic pelvic pain. Alcohol and acetic acid extractions are the strongest, although powdered herb is considered effective as well. The mechanism of action of analgesia is thought to be inhibition of the reticular-activating system in the brainstem. Corydalis can increase the pain threshold significantly. Continuous use of corydalis results in tolerance and may theoretically lead to a cross-tolerance to morphine. However, from a Chinese medical perspective the effects of corydalis are more than palliative as it is used to help promote pelvic circulation and therefore may treat underlying pelvic congestion. The alkaloids in this herb have sedative and hypnotic effects and act synergistically with barbiturates. Chinese pharmaceutical companies have produced several preparations from corydalis alkaloids for use as analgesics. The available preparations include a 30-mg tablet containing all alkaloids and a 10% tincture used in doses of 5 mL three times daily. Overdose leads to muscle relaxation and CNS depression. Corydalis is contraindicated in pregnancy.

Cramp Bark and Black Haw

Cramp bark and black haw were similarly used for the treatment of pelvic pain, particularly of a spasmodic nature, and specifically when accompanied by a sensation of dragging pressure in the groin and drawing pain in the legs.

Jamaican Dogwood

Jamaican dogwood is a reliable analgesic and spasmolytic herb with mild sedative properties. It was prescribed by the Eclectics for neuralgias, spasmodic complaints, migraines, dysmenorrhea, nervous tension, insomnia, and nervous excitability, although Felter cautioned about potential toxic effects (including convulsions) in large doses.” Ellingwood elaborated on its effects in quieting uterine pains of labor, promoting rest, and having a specifically relaxing influence, in addition to its general analgesic effects. He stated that the herb “acts in close harmony with the vegetable uterine remedies, promoting the influence of Macrotys [Actaea racemosa-black cohosh], the viburnums … pulsatilla and dioscorea among others.” The spasmolytic activity of Jamaican dogwood may be attributable to its isoflavone constituents; however, this plant has been only minimally studied. Combined in equal parts with cramp bark or black cohosh, this author has found it a highly effective treatment for gynecologic and pelvic pain of neuromuscular origin, for dysmenorrhea, endometrial pain, urinary tract infection, and other pelvic pain. It also may be used postsurgically as an alternative to conventional pain medications. Regarding its toxicity, it is advisable that the recommended dosage range not be exceeded and that the herb not be used by pregnant women, or patients with bradycardia or cardiac insufficiency.

Kava kava

Kava kava has been used traditionally as a muscle relaxant to reduce anxiety and may be considered for the treatment of muscle spasms associated withchronic pelvic pain. Both aqueous and lipid soluble extracts of kava have demonstrated antinociceptive activity through nonopiate receptor mechanisms. It is commonly used by herbalists for the treatment of pain as well as anxiety. (See Plant Profiles: Kava Kava for safety considerations.)

Pulsatilla

Pulsatilla, also called pasque flower, has analgesic and sedative properties. It is listed in the British Herbal Compendium for the treatment of painful spasmodic conditions of the female reproductive systems and dysmenorrhea. It is generally used in tincture form. Fresh herb contains potentially irritant and toxic compounds; therefore, only dried plant should be used, and the herb should not be used during pregnancy. Overdose can lead to gastric irritation, coma, and convulsions; thus, it is essential that patients stay within the proper dosage range, and use be monitored by an experienced practitioner. This herb is more commonly prescribed by naturopathic practitioners than herbalists in the United States, although it is also used by European herbalists.

Black Cohosh, Cramp Bark, and Black Haw

Black cohosh, cramp bark, and black haw are traditionally used as uterine antispasmodics and analgesics, and are discussed throughout this text for these properties (see Dysmenorrhea and Plant Profiles). This three-herb combination administered as a tincture is especially effective for the treatment of pelvic aching and pain. (See Plant Profiles: Black Cohosh for safety considerations with this herb.)

Dong Quai and Peony

Dong quai and peony, in addition to their significant analgesic and spasmolytic actions, are considered herbs that “move blood” and relieve stasis or stagnation in traditional Chinese medicine.’ The traditional Chinese medicine concept of uterine stasis is consistent with the Western concept of pelvic congestion syndrome described in the preceding. Additionally these herbs, often used together in combination, and often with the addition of licorice (Glycyrrhiza glabra or G. uralensis) are considered effective for the treatment of a number of gynecologic conditions that may be involved in the etiology of CPP, such as dysmenorrhea, polycystic ovarian syndrome (PCOS), and uterine fibroids. The Japanese traditional formula TJ-68, Shakuyaku-kanzo-to (Chinese: shao-yao-gan-cao-tang), which contains concentrated white peony root and licorice, has been approved by the Japanese government for clinical use in the treatment of pain and acute muscle spasm, including dysmenorrhea.

Botanical Treatment Of Chronic Pelvic Pain: Marijuana

Botanical Treatment Of Chronic Pelvic Pain: Motherwort

Antidepressants and Anxiolytics

Herbs of note that possess both antidepressant or anxiolytic activity, as well as analgesic or antispasmodic activity, include St. John’s wort, kava kava, motherwort, and ashwagandha, the latter of which is also a respected adaptogen and whose analgesic effects are discussed elsewhere in this text (see Plant Profiles). Gentle nervines that are commonly used as adjunct teas in the treatment of mild depression include chamomile, lemon balm, and lavender. Lavender also may be used externally in baths for its soothing aromatherapeutic effects, as well as for mild topical analgesia for the vulva.

Adaptogens

The use of adaptogens in the treatment of chronic pelvic pain is primarily for the reduction of stress and anxiety, modulation of inflammation, and improvement of sleep disorders. They are part of a long-term treatment plan rather than quick-acting for specific symptoms. Ashwagandha has specific analgesic activity, and is among the most specific of choices forchronic pelvic pain.

Botanical Treatment Of Chronic Pelvic Pain: Anti-inflammatories

Uterine Tonics: Venotonics