Treatment of pelvic congestion syndrome incorporates a combination of therapeutic actions, including anti-inflammatory, uterine tonics, and herbs used as vascular tonics. Uterine tonics, which historically have included herbs such as blue cohosh, goldenseal, lady’s mantle, motherwort, partridge berry, red raspberry leaf, and cramp bark and black haw, are thought to exert their efforts by improving the overall tone of the uterine smooth musculature and vasculature. Goldenseal, for example, typically regarded for its antimicrobial effects, was used extensively by the Eclectics for the treatment of uterine bleeding resulting from a variety of conditions, including endometriosis, fibroids, and changes associated with menopause. Although no clinical studies have been conducted using whole herb, in vitro trials using berberine, one of the primary alkaloids in goldenseal, have demonstrated both uterine smooth muscles stimulant and inhibitory activity. Aqueous extracts of red raspberry leaf also have demonstrated both stimulatory and inhibitory effects on uterine smooth muscle. In fact, this paradoxic effect is seen with several of the herbs commonly used as both uterine tonics and spasmolytics, for example, cramp bark and black haw. It is thought that the effect of these dual activities is a normalization of uterine activity, and the promotion of smooth, nonspasmodic uterine muscle activity, thus improving tone and reducing pain.
Several herbs with venotonic activity should be considered for the treatment of pelvic congestion in CPP. Most notable are blue cohosh and horse chestnut. Blue cohosh has demonstrated uterine tonic, vasoconstrictive activity, and continues to be used for the treatment of many gynecologic formulae in which a uterine tonic is required. Historically, it has been used for labor induction, amenor-rhea, dysmenorrhea, menorrhagia, and to induce abortion. Blue cohosh is listed in the British Herbal Pharmacopoeia (1983) as a spasmolytic and emmenagogue. It also may be used as an ovarian tonic and for the treatment of a variety of menstrual complaints, including menorrhagia, amenorrhea, dysmenorrhea, and pelvic congestion syndrome. Horse chestnut is used to improve circulation through vascular tonifica-tion, to improve venous tone in venous insufficiency, and for the relief of aching discomfort in the lower limbs associated with varicosities and for complaints associated with chronic venous insufficiency (CVI). Traditionally, it was used in the treatment of neuralgia and “conditions of venous congestion particularly with dull, aching pain and fullness.” One studied demonstrated safe use for 56 months without harmful effects. Horse chestnut extract is the third most widely sold herbal product in Germany, where it is used long-term in clinical practice apparently without adverse effects. There appears to be very low risk associated with proper administration, although it is recommended that only product standardized to its presumed active ingredient, escin (aescin) be used, and not to exceed 12 weeks at recommended doses. Adverse effects from use of horse chestnut seed extract have included GI upset and calf spasm most commonly, with headache, nausea, and pruritus occurring less commonly. Overall, adverse effects are extremely rare, in an observational study occurring at a rate of less than 0.6% in more than 5000 subjects.