Uterine Fibroids: Botanical Treatment

2011

Among Western herbalists specializing in gynecologic complaints, there is a common perception that although symptoms of uterine fibroids are not difficult to control with botanical medicines, and their growth can be arrested, they are difficult to eliminate entirely unless the fibroid is small at the onset of treatment (smaller than 12-week size). Many women are content to have symptom control over pharmaceutical or surgical intervention, as long as the fibroids present no mechanical problems. Traditional Chinese medicine (TCM) has clearly defined diagnostic constructs, many herbal formulae, and well-developed adjunctive treatment protocols (e.g., acupuncture, moxibustion) for treating uterine fibroids and has claimed success in entirely eliminating uterine fibroids.

Botanical Treatment Strategies for Uterine Fibroids

Therapeutic Goal Therapeutic Activity Botanical Name Common Name
Hormonal regulation; increase hormone biotransformation, conjugation, and improved elimination; displace with endogenous estrogen with estrogen receptor competitors. Cholagogues 

Hepatic detoxification stimulants

Berberis vulgaris 

Camellia sinensis

Chelidonium majus

Hypericum perforation

Schisandra chinensis

Barberry 

Green tea

Chelidonium

St. John’s wort

Schisandra

Hormonal regulation; increase hormone biotransformation, conjugation, and improved elimination; displace with endogenous estrogen with estrogen receptor competitors. Hormonal modulators Actaea racemosa 

Vitex agnus-castus

Chaste tree 

Black cohosh

Hormonal regulation; increase hormone biotransformation, conjugation, and improved elimination; displace with endogenous estrogen with estrogen receptor competitors. Phytoestrogens / SERMS Clycine max 

Trifolium pra tense

Soy 

Red clover

Hormonal regulation; increase hormone biotransformation, conjugation, and improved elimination; displace with endogenous estrogen with estrogen receptor competitors. Laxatives (bulk, anthraquinone) Linum ussitissimum 

Rumex crispus

Taraxacum officinale

Flax seed 

Yellow dock

Dandelion root

Improve uterine tone, reduce menorrhagic bleeding (Also see Menorrhagia in Dysfunctional Uterine Bleeding) Uterine tonics Caulophyllum thalictroides 

Leonurus cardiac

Mitchella repens

Rubus idaeus

Viburnum opulus

Blue cohosh 

Motherwort

Partridge berry

Red raspberry

Cramp bark

Improve uterine tone, reduce menorrhagic bleeding (Also see Menorrhagia in Dysfunctional Uterine Bleeding) Uterine astringents Achillea millefolium 

Alchemilla vulgaris

Capsella bursa-pastoris

Cinnamomum spp.

Erigeron Canadensis

Geranium maculatum

Hamamelis virginiana

Myrica cerifera

Rubus idaeus

Trillium erectum

Yarrow 

Lady’s mantle

Shepherd’s purse

Cinnamon

Canada fleabane

Cranesbill geranium

Witch hazel

Bayberry\

Red raspberry

Birthroot, birthwort, Beth root

Relieve pelvic stagnation and blood stasis, improve uterine circulation Uterine circulatory stimulants Angelica sinensis 

Cinnamomum cassia

Paeonia lactiflora

Paeonia suffruticosa

Prunus persicae

Zingiber officinalis

Dong quai 

Cinnamon

White peony

Peony

Peach

Ginger

Treat dysmenorrhea Uterine antispasmodics See Dysmenorrhea
Treat anemia Iron-rich supplements and herbs 

See Anemia

 

Western herbal treatment protocols include a variety of strategies (Table Botanical Treatment Strategies for Uterine Fibroids). These include weight reduction, promoting hormonal balance, specifically through the elimination of estrogens by enhancing liver detoxification mechanisms, promoting pelvic circulation while simultaneously controlling bleeding if necessary, and general improvement of uterine tone. These are integrated with the general recommendation to avoid excess exposure to xenoestrogens (environmental estrogens) and reduce overall estrogen levels, exposure to both being a risk factor for the development of uterine fibroids. Women with fibroids report greater frequency of red meat and pork intake, and less frequent green vegetable, fruit, and fish consumption. Although there is little correlation between the development of uterine fibroids and cancer, numerous studies have demonstrated a connection between diet, estrogen levels, and hormone-dependent cancers, as well as a protective effect of fruit and vegetables against cancer. No studies have evaluated the effects of US dairy consumption and the development of uterine fibroids. However, an association between dairy intake and increased risk of ovarian cancer has been reported. Herbalists recommend that patients avoid foods that increase risk, and emphasize intake of those shown to facilitate estrogen biotransformation, for example, by increasing dietary fiber, and regular intake of complex carbohydrates as found in vegetables and grains. Botanical strategies are aimed at reducing the estrogen burden through liver detoxification and improved elimination, promoting gynecologic health in general by improving pelvic circulation, reducing symptoms, and controlling fibroid size.

TCM treatment for fibroids has been evaluated through several preliminary studies, which are presented in the following section. Western botanical protocol for the treatment of uterine fibroids has not been subjected to controlled trials. The Western botanical information presented in this chapter reflects the opinions of herbalists practicing in the United States, United Kingdom, Canada, Australia, and New Zealand, regarding the efficacy and safety of the primary herbs used to treat myomas. Given the general safety of the botanicals being discussed, and the lack of noninvasive long-term effective medical treatments for fibroids, it seems that investigation of the primary Western herbal protocols cited in Table Botanical Treatment Strategies for Uterine Fibroids is warranted. Nervines, laxatives, adaptogens, and other herbs included in fibroid protocol are discussed elsewhere throughout this text. Stress reduction should not be overlooked as part of the treatment protocol for women with symptomatic fibroids, as chronic uterine bleeding can cause emotional, social, financial, and medical consequences.

Traditional Chinese Medicine Treatment

Cinnamon and Peony

Traditional Chinese medicine has numerous well-developed treatment protocols and formulations, some of which have been used for several centuries for promoting gynecologic health in general and for treating uterine fibroids specifically. For a more comprehensive review of the Chinese treatments for gynecologic problems, readers are referred to the primary traditional Chinese medicine literature. Generally speaking, traditional Chinese medicine views uterine myomas as a result of poor circulation of chi (energy) and blood through the pelvic region. Many formulas are designed to dispel pelvic stagnation and increase the flow of blood to uterine and ovarian tissues and facilitate the smooth flow of blood via menses. A classic traditional Chinese medicine formula used for relieving blood stagnation is Cinnamon Twig and Poria Pill (gui zhi fu ling wan) consisting of: Cinnamomum aromaticum twigs, Poria cocos, Paeonia lactiflora root, Paeonia suffrutkosa root, and Prunus persica seed. It should also be noted that in traditional Chinese medicine, each herbal formula has specific diagnostic criteria for which it is used as well as clear contraindications and cautions. For maximum efficacy in using traditional Chinese medicine protocols, a qualified herbal traditional Chinese medicine practitioner should be consulted. In addition to herbal protocol for promoting gynecologic health and specifically treating uterine fibroids, traditional Chinese medicine also employs numerous other modalities, which may include walking to promote circulation in general and abdominal circulation specifically, moxibustion, acupuncture, external application of compresses, and other such adjunctive therapies. Specific lifestyle recommendations also can be given such as the avoidance of cold foods and drink (in traditional Chinese medicine coldness is said to cause congealment and stagnation) and constrictive clothing.

Several studies have looked at the efficacy of the Cinnamon Twig and Poria Pill formula noted in the preceding section for the treatment of uterine fibroids. Specifically, the studies investigated the effectiveness of the Japanese version of this formula (Keishi-bukuryo-gan, KBG) in an open study on 110 premenopausal women with symptomatic uterine fibroids measuring less than 10 cm in diameter. They were treated with 22.5 g / day of a freeze-dried decoction of the herbs for 12 weeks. Twenty-one women were considered “normal” and 47 women much improved by the end of the trial. This herbal formula is frequently used to treat a range of gynecologic disorders including dysmenorrhea, cervical erosion, ovarian cysts, chronic salpingitis, and endome-triosis, to name a few conditions. There is research to suggest that the Paeonia species in this formula may act as an LH-releasing hormone (LH-RH) antagonist with weakly antiestrogenic effects in the presence of estrogen. In another study, the authors applied individualized traditional Chinese medicine formulations and treatments to treat 223 cases of uterine fibroids with a reported 72% reduction of menorrhagia in 160 women complaining of this symptom, 58% improvement in backache, and an overall effectiveness rate of 92.4%. Myomas were eliminated in 29 of 223 patients and markedly diminished in 42 patients. In 32 patients, no changes were seen and there were no positive results in 12.5% of patients. If the traditional Chinese medicine treatments were tailored to the individual patients, then this can be kept with the addition I made. If the treatment was specific, a similar level of detail as the previously reported study should be given for consistency of presentation.

In an interesting study by Mehl-Madrona et al., an integrated traditional Chinese medicine-Western medicine pilot study was conducted to compare the cost and efficacy of a set of therapies typically used by CAM practitioners and conventional medicine on ability to reduce uterine fibroid size. All patients were premenopausal and age 24 to 45 years, educated, employed, and from a socio-economic bracket that allowed them to pay cash for all treatments. None were on pharmaceutical treatment or hormonal contraceptives at the time of the study and all received a pelvic ultrasound before and again 6 months after treatment. Sonograms were obtained on patients who dropped out of the study as well, so sonograms were available on all patients. Uterine fibroids measured at least 6- to 8-week pregnancy size, with palpable fibroids 2 to 3 cm in diameter. Inclusion in the study required hemoglobin greater than 8 g / dL, with fibroid growth of less than 6 cm / year. CAM treatment included a combination of nutritional, herbal, acupuncture, bodywork, and psychological interventions. Acupuncture and herbal protocols were selected individually for the patient, using formulae and points traditionally indicated for the patient’s patterns: symptoms, constitution (based on traditional Chinese medicine pulse and tongue diagnosis), and condition. The comparison group used progestational agents, oral contraceptives, and NSAIDs. The results of this study demonstrated no statistically significant difference in change of symptoms between the two groups when measured after 6 months of treatment. Both experienced improvement in symptoms and fibroid size. Patients in the treatment group considered the pilot study a success because they were able to achieve results equivalent to pharmaceutical interventions using nonconventional methods.

Hormonal Modulators

Chaste Berry

Chaste berry is the primary herb employed by herbalists and integrative medicine practitioners for hormonal modulation in the botanical treatment of fibroids. It acts as a dopamine agonist, resulting in a reduction in prolactin release. Prolactin may play a role in fibroid growth. No scientific evidence in the literature has been found for the use of chaste berry specifically in the treatment of fibroids, and although its use may result in reduction of apparent estrogen excess due to relative progesterone deficiency, increased progesterone levels have been shown to result in increased mitotic division in fibroid tissue. Wuttke et al. studied the putative estro-genic effects of a chaste berry extract and found it contained substances that replaced radiolabeled estradiol from a cytosolic estrogen receptor preparation, and appeared to be agonistic to ERp. However, because the uterus expresses ERa, no effects on the uterine expression of estrogen were expected or have been experimentally observed.

Phytoestrogens and Selective Estrogen Receptor Modules

Phytoestrogens are plant compounds with a similar molecular shape and structure to endogenous estrogen molecules, and which can bind competitively to estrogen receptors, preventing the binding of more potent estrogen and estrogen metabolites. They appear to behave similarly to selective estrogen receptor modulators (SERMs). Low Dog explains their potential clinical application in conditions of estrogen excess, in relationship to the role of phytoestrogens in breast cancer treatment:

By binding to estrogen receptors in the premenopausal woman, phytoestrogens “turn down” estrogen production through negative feedback at the level of the hypothalamus and pituitary gland…when endogenous estrogen levels are high, phytoestrogens may have an antiestrogenic activity by preventing estrogen from binding to the estrogen receptor through competitive inhibition.

Legumes, including soybeans and red clover, are rich in phytoestrogens. In a study by Liu et al. methanol extracts of red clover (Trifolium pratense), chaste berry, and hops (Humulus lupulus) showed significant competitive binging to both ERa and ERp. In the same study, dong quai (Angelica sinensis) and licorice (Glycyrrhiza ura-lensis) showed weak ER binding, whereas black cohosh did not exhibit any competitive binding. Controversy abounds as to the mechanisms of action of black cohosh, which do not appear to be directly phytoestro-genic. Current research is suggesting a dopaminergic or serotonergic effect for this botanical. The application of phytoestrogens may be a promising area for further investigation for the botanical treatment of fibroids, and should be considered in the development of botanical protocols.

Hormone Excretion and Biotransformation

Greater than 50% of all estrogen metabolism and conjugation occurs in the liver, suggesting a basis for the belief among herbalists that herbs that improve liver function may increase estrogen excretion and either treat or lower the risk for uterine fibroids. Herbalists commonly include liver-specific herbs in formulae for treating fibroids. Several herbs actively effect phase 1 and phase 2 liver detoxification systems and CYP450, an enzyme system partially involved in the metabolism of estrogen. These effects and their relationship to uterine fibroid treatment, if any, have not been formally investigated but are often applied by modern herbal practitioners in putatively reducing estrogen burdens. Cholagogues, herbs which stimulate the release of bile from the gallbladder, also may be useful for clearing estrogen through increased bowel clearance resulting from their indirect laxative action. Examples of cholagogues include bayberry and chelidonium.

Uterine Tonics, Astringents, and Hemostatics

Because bleeding is a common symptom of uterine fibroids, numerous antihemorrhagic herbs are used in botanical medicine protocols (see Menorrhagia in Dysfunctional Uterine Bleeding). Yarrow dried plant infusion is perhaps one of the most widely used uterine antihemorrhagics, reliably reducing acute uterine bleeding, but conversely promoting menstrual flow when suppressed. It has been used since ancient times as a styptic. Either dry or fresh plant can be used as a tea or tincture. Many herbalists believe that yarrow herb taken as tea is more quickly effective for stopping acute uterine bleeding than other preparations. Other traditionally used uterine antihemorrhagic herbs include lady’s mantle, shepherd’s purse (fresh only), cranesbill geranium, witch hazel, bay-berry, red raspberry, and bethroot. These are all generally taken in tincture form in 2- to 4-mL doses repeated every 15 minutes as needed until bleeding subsides, or combined into larger formulae for the treatment or prevention of chronic menorrhagia. Shepherd’s purse in particular has been used traditionally as a uterine antihemorrhagic. The 1986 Commission E monograph recommends daily oral doses of 10 to 15 g of crude herb (or equivalent in extract) for mild gynecologic bleeding. Extracts of the drug contain a hemostyptic action, likely owing to the presence of a peptide that has demonstrated oxytocin-like activity in vitro. Many modern Western herbalists believe that it is imperative to prepare Shepherd’s purse from fresh, not dry, plant material. Lady’s mantle’s mechanism of action lies in its high tannin content, indicating it for bleeding, diarrhea, and wound healing, a likely mechanism for many of the other herbs used as uterine antihemorrhagics. The combination of Cinnamomum and Erigeron was relied upon by the Eclectics for uterine hemorrhage, and is still employed by midwives today for the treatment of nonemergency postpartum bleeding, and by herbalists for the treatment of menorrhagia. Red raspberry leaf is typically used more as a long-term uterine tonic than to arrest acute bleeding. Blue cohosh has been used historically for its utero-tonic actions. It is listed in the 1918 US Dispensatory for the treatment of menorrhagia and dysmenorrhea, and is still widely used by herbalists for these conditions.

WARNING: Soaking more than two maxi-pads in 30 minutes is considered a uterine hemorrhage. If this occurs seek medical care immediately.

“Great Flood” Formula (tincture)

Yarrow (Achillea millefolium) 40 mL
Lady’s mantle (Alchemilla vulgaris) 20 mL
Bayberry bark (Myrica cerifera) 15 mL
Shepherd’s purse (Capsella bursa-pastoris) 15 mL
Cinnamon (Cinnamomum cassia) 10 mL

Total: 100 mL

Dose: 2 to 4 mL as needed, repeated up to every 15 minutes for 1 hour until bleeding subsides or is arrested.

Relieving Uterine Stasis: Circulatory Stimulants

Improving pelvic circulation and relieving stasis is a common approach to fibroid treatment in both Western and traditional Chinese herbal medicine, based on the belief that relieving stagnation and congestion in the pelvis will facilitate the removal of “blockages” and growths (e.g., fibroid tissues), remove wastes, and promote greater health and nourishment of the pelvic organs in general. Decreasing pelvic stagnation is also thought to help reduce uterine hemorrhage. Ginger and cinnamon are both traditionally used to increase circulation to the reproductive organs. Further, cinnamon has been used historically to reduce uterine bleeding, making it specific for the treatment of uterine fibroids with menorrhagia or metrorrhagia. White peony, an ingredient in Keishi-bukuryo-gan, discussed in the preceding, is a common herb used in traditional Chinese medicine for the treatment of women’s disorders, including menstrual dysfunction and uterine bleeding. Red peony is often combined with white peony and peach seed to dispel blood stasis, and conditions associated with it, including excessive uterine bleeding, particularly with the presence of thick, purple clots.