Endometriosis: Discussion Of Botanicals

For many women with endometriosis pain is the single most debilitating aspect of this condition (other than chronic fertility problems in women desiring pregnancy). Therefore, pain management should be an important focus in the care of women with this condition. Herbalists reliably employ a number of herbs for the treatment of pelvic and abdominal pain, many of which have a long history of traditional use for painful gynecologic conditions. These herbs can be used singly but are generally used in various combinations with other herbs in these categories, or as part of a larger protocol. Analgesic herbs are used for generalized or local pain of an aching or sharp quality and include black cohosh, black haw and cramp bark, chamomile, corydalis, pulsatilla, dong quai, ginger, and Jamaican dogwood. Corydalis, Jamaican dogwood, and pulsatilla are especially dependable for moderate to serious pain. Pulsatilla is considered specific for ovarian pain. Antispasmodics are typically used for cramping pain, but also may be used for sharp or dull pain, aching, and drawing pains in the lower back and thighs, and include, such as wild yam, the viburnums (cramp bark and black haw), black cohosh, chamomile, and ginger. Dong quai’s traditional traditional Chinese medicine uses for gynecologic conditions, specifically for conditions of blood vacuity and stasis, the latter of which endometriosis may be considered among, along with its antispasmodic, anti-inflammatory, and immunomodulatory qualities, make it an important herb to consider. Many antispasmodics and anti-inflammatories, such as wild yam, the viburnums, ginger, and chamomile are specific not only for uterine pain, but also for intestinal, bowel, and urinary pain and irritability, making them uniquely suitable for endometrial pain and accompanying bowel and bladder discomforts. This is important to keep in mind, because the pain of endometriosis is related to irritation of tissue by endometrium outside of its normal site in the uterus. Sedatives are useful when there is the need to induce deep rest or sleep to obtain pain relief, and include California poppy a combination of black cohosh and cramp bark, or a combination of cramp bark and Jamaican dogwood. Valerian and hops are also useful sedatives. The successful use of these herbs for pain depends largely upon adequate dosing and frequency of administration.

Immunomodulation

The exact immunologic underpinnings of endometriosis remain uncertain. There appears to be a complex interplay of hyperimmune, autoimmune, and hypoimmune function at work, either variably or concurrently-leading only to the clear understanding that there is some level of immune dysregulation that accompanies this condition. The most appropriate response seems to be twofold: (1) to look at the unique constellation of symptoms presented by each individual woman, for example, whether she is depleted and susceptible to frequent colds and repeated vaginal infections or chronic atopic conditions — and to treat accordingly, and (2) to provide botanicals which support immune regulation — notably, the adaptogens. For women who evidence a state of immune depletion in combination with endometriosis some amount of immunostimulation may be appropriate to bolster the overall immune response, and may be provided through the use of herbs such as echinacea, astragalus, or Picrorrhiza kurrhoa in combination with adaptogens such as ashwagandha, American ginseng, rhaponticum, or rhodiola. These women also may benefit greatly from medicinal mushrooms such as Reishi and Cordyceps for immune support. For women with signs of hyperimmunity, atopic conditions such as eczema or chronic rhinitis, or autoimmunity, the use of immunosupportive anti-inflammatory adaptogens may be most appropriate, such as licorice, ashwagandha, and American ginseng. It is unknown and a matter of great debate as to whether immunostimulating herbs such as echinacea and astragalus are safe and appropriate for use when there is autoimmunity. Using adaptogens for treating endometriosis makes sense in that their actions simultaneously influence and restore normalcy to the functions of the immune system and the hypothalamic-pituitary-adrenal axis, both of which appear to have dysregulated function in this condition. The uterine endometrium is a complex structure of interspersed glandular tissue and endometrial stroma, closely associated with lymphoid tissue. The inclusion of herbs that are traditionally thought to improve lymphatic circulation, such as calendula, echinacea, cleavers, and pokeroot, are commonly included in botanical protocol for endometriosis.

Anti-Inflammatories and Antioxidants

Hormonal Modulation

Predicated on the belief that steroid hormones are the primary regulators of the growth and activity of ectopic endometrial tissue, therapies aimed at hormonal modulation have been the foundation of conventional therapy for endometriosis, and have also featured prominently in botanical protocol. Unfortunately, even less is known about the effects of botanical therapies on the endocrine system than about pharmaceutical medications. The goal of pharmaceutical therapies is to create an acyclic, low-estrogen environment that prevents bleeding, leads to atrophy of ectopic implants, and possibly minimizes retrograde bleeding. However, endometrial tissue may be histologically different than normal uterine endometrial tissue, and may respond differently to hormonal stimulation. Again, much remains unknown about this enigmatic condition. Several botanicals are frequently used as hormonal modulators, in conjunction with other herbs discussed in this chapter. Little research is available on their application in endometriosis. But as part of a comprehensive protocol, many herbalists and naturopathic physicians report positive outcomes for achieving the goals established earlier in this paragraph. There is also some small discrepancy in the herbal literature as to which herbs should be avoided due to potential exacerbating hormonal effects. For example, Mills and Bone caution against the use of what they refer to as “estrogen promoting herbs” such as false unicorn (Chamaelirium luteum), the use of which should primarily be avoided in clinical practice due to its endangered status) and wild yam (Dioscorea villosa); however, wild yam is used widely for abdominal and pelvic cramping pain associated with the condition, whereas the late Silena Heron included these in endometriosis protocol and authors Hobbs and Keville, in Women’s Herbs, Women’s Health, mention wild yam as an antispasmodic specifically for endometriosis. There would actually potentially be numerous plants in this category, ranging from fennel and hops to common foods such as legumes, most of which are rich in phytoestrogens, which would need to be avoided on this presupposition. One study on the estrogenic contents and activity of commonly used herbs found that soy, red clover, licorice, hops, and fo-ti have a large amount of measurable estrogen bioactivity not previously reported. Chaste tree berry, black cohosh, and dong quai did not have measurable activity with the methods used in the study. Confusion stems largely from the fact that so much remains unknown about the endocrine effects of botanicals, and until more information is available, rational conclusion are hard to draw, suggesting that caution and observation of clinical response are required. Women with a predisposition to estrogen-dependent cancers are probably wise to avoid unnecessary and excess consumption of herbs with estrogenic effects. However, it should also be considered that herbs that competitively bind with estrogen receptors might actually displace endogenous estrogen with weaker, plant-based estrogens, actually decreasing a woman’s overall estrogen response.

Blue Vervain

Blue vervain has a long history of use in traditional European herbalism as an emmenagogue and galactagogue, and a contemporary popularity among herbalists experienced in women’s reproductive care for its regulating effects on gynecologic complaints, particularly for irritability associated with PMS. A BIOSIS database search and extensive review of the herbal literature references yields very little data on the medicinal uses of this plant, although historical references to its use as a treatment for rheumatism were identified., lls A single study from 1974 on the effect of this herb on the uterus and its interactions with prostaglandins was identified but not obtainable. According to studies cited in Wichtl et al., hot water extracts of European verbena stimulates luteinizing hormone (LH) and follicle-stimulating hormone secretion. Other noted endocrine effects include antithyrotropic and abortifacient effects via inhibition of human chronic gonadotropin (hCG). Verbena has also demonstrated immunomodulatory effects, primarily through inhibition of phagocytosis by human granulocytes. The German Commission E cites its uses, among other things, for irregular menstruation, nervous disorders and exhaustions, and complaints of the lower urinary tract; however, the efficacy for these claims remains unsubstantiated. Many herbalists consider it an excellent herb for “sluggishness of the liver,” and attribute its hormonal action to stimulated liver function and subsequent actions on hormonal metabolism and elimination. It is typically used as a small part of a larger general formula aimed at treating underlying causes of endometriosis.

Chaste Berry

Chaste berry has a reputation for its ability to regulate female menstrual cycles and relieve complaints and complications stemming from dysregulation of sex hormones. Clinical trials support the use of Vitex for menstrual irregularities (secondary amenorrhea, oligome-norrhea, polymenorrhea), relief of PMS symptoms, mastalgia, latent hyperprolactinemia, and infertility due to luteal phase dysfunction. The effects of Vitex on estrogen levels remains uncertain, with one study (the full details of which were undisclosed) demonstrating its ability to elicit estrogen-like effects (increased uterine growth) in ovariectomized rats, and another reporting decreased estradiol levels, whereas other studies have reported no effects or were inconclusive. Its efficacy in the treatment of endometriosis, for which is it widely used by herbalists, is supported by clinical observation, with no research identified for its use for this condition.

Cotton Root

Cotton is predominantly used as a uterine tonic and to stimulate uterine contractions. Gossypol, the active ingredient in the roots and seeds of cotton, has been used in the treatment of gynecologic disorders ranging from uterine myomas to menopausal bleeding, based on the discovery that regular cooking with cottonseed oil over long periods of time leads to amenorrhea and endometrial atrophy in females. Several studies over a 15-year period have demonstrated short-term efficacy of up to almost 90% in the treatment of endometriosis, and long-term effectiveness after 1 to 3 years of 54% to 63%. Treatment is typically accompanied by amenorrhea persisting for up to 6 months in 80% of women, and up to 1 year in 16% of women, with 4% experiencing amenorrhea lasting longer than 1 year. Gossypol is reported to antagonize the actions of estrogen and progesterone, and may mimic a pseudomenopausal state. A frequent side effect of gossypol treatment is hypokalemia, which is treated with administration of slow-releasing potassium salts. High-dose programs can lead to elevated liver enzymes, nausea, edema, and palpitations, as well as possible rash, reduced appetite, fatigue, and possible inhibition of thyroid function and mitochondrial energy metabolism. This compound is not available in the West, and would be considered a pharmaceutical drug rather than a botanical product were it made so. Studies on the use of cotton root bark, used, as a partus-preparator, emmenagogue, and abortifacient by Western herbalists, as an herbal extract for endometriosis have not been conducted.

St. John’s Wort

According to modern clinical research, St. John’s wort is commonly used for the treatment of mild to moderate depression and additionally has been shown to exhibit antiviral activity. In traditional herbal medicine currently and historically, it is used internally for anxiety and as a general nervous system tonic, whereas externally it is used as a primary application for scrapes and burns. Recent concerns regarding the interaction between St. John’s wort and numerous pharmaceutical drugs have led to a host of contraindications for use of this herb. One such contraindication is the use of oral contraceptives, as it has been shown to induce the activity of cytochrome P450 3A4 (CYP3A4) and increase the clearance of numerous drugs and steroids, such as cortisol and ethinyl estradiol. This interaction suggests the potential for use of St. John’s wort to positively interfere with estrogen binding in states of estrogen excess, for example, in endometriosis. A limited number of studies have evaluated the estrogen-binding capacity of St. John’s wort extracts. One study by Simmen et al. found that estrogen binding was 50% inhibited by the bioflavonoid 13,118-biapigenin at micromolar concentration in the CNS. Use of St. John’s wort to deliberately modulate estrogen levels represents a potentially novel application for this botanical. This herb should also be considered in endome-trioses treatment for its beneficial role in the treatment of mild to moderate depression, which may accompany this condition in women who suffer with it chronically.

Hepatics, Aperients, and Cholagogues

The use of herbs to improve hepatic function and affect the improved metabolism and elimination of excess hormones has been discussed throughout this text. Herbs for these purposes are commonly included in many gynecologic formulae in which there is estrogen dominance or excess, including endometriosis. Popular choices include calendula, fringe tree, tumeric, rosemary, schizandra, milk thistle, and dandelion root. Mechanisms of action are not clearly elucidated for many of these herbs, but likely include increased bile release leading to enhanced bowel elimination of estrogens, increased CYP450 activity, and improved liver health through antioxidant activity.

Uterotonics and Emmenagogues

Although the effect of uterotonic herbs, commonly included by herbalists in formulae for endometriosis, on endometrial tissue outside the uterus is dubious, uterotonic herbs may play a role in reducing retrograde menstruation via tonic and expulsive action, or other unknown mechanisms, for example, unidentified hormonal actions. Herbs that are commonly included as uterotonics in endometriosis formulae include blue cohosh, Lady’s mantle, and yarrow.