In February 2015 The University of Oxford published a study research in The Lancet which examined the link between Hormone Replacement Therapy and the risk of ovarian cancer. It included 52 epidemiological studies and 12 110 women where 55% (6601) of them “who have used Hormone Replacement Therapy (HRT) have developed ovarian cancer”. The results are even more troublesome as the risk of ovarian cancer was associated with less than 5 years of HRT use which falls in the time frame recommended by Health services (Collaborative Group on Epidemiological Studies of Ovarian Cancer, 2015; NHS choices, 2014).
The use of HRT not only carries the risk of developing ovarian cancer but also some studies have suggested that it may cause breast cancer, endometrial cancer, venous thromboembolism and stroke, especially in women who use HRT for longer than 5 years, are aged 60 and over and use combined hormone replacement therapy (Panay et al., 2013). Despite the evidence, HRT is still consider “safe and most effective” treatment for vasomotor symptoms of menopause, outweighing the “benefits” in favor of potentially decreased risk in osteoporosis related fractures and low possibility of ischemic heart disease in women aged less than 60 (De Villiers, et al., 2013).
On the other hand, the growing popularity of Complementary and Alternative therapies (CAM) in the UK become more popular and many women have turned to CAM therapies for various health problems including menopause. Although it is not known the exact number of women using CAM therapies for menopausal symptoms, it has been reported that one in ten adults visit CAM therapist per year, of which herbal medicine represents 15% of frequent visits (Thomas and Coleman, 2004; Nedrow, et al, 2006).
In the UK herbal medicine is considered as part of complementary therapy, although its regulation status has been postponed. All medical herbalists in the UK are required to undergo thorough clinical training before practicing and must finish at least 500 clinical hours, exam observed by a GP and complete modules in anatomy and physiology, pharmacology, differential diagnosis to name few. The herbal medicine treatment involves a holistic approach, dealing with not only physical symptoms but also psychological as well. During an herbal medicine consultation, a thorough medical history is taken, physical examination is carried out and also diet and life style choices are recorded to enable the practitioner to decide the best course of action. If necessary individualized prescription is made for the patient based on alcoholic herbal extracts, teas or pills to suit patients specific needs.
Vitex and menopause
One of the most traditionally used herbs among herbalist in the UK for menopause is Chaste Tree (Vitex agnus castus).
Chaste Tree (Vitex agnus castus) has a long traditional history of use for women health problems dating back to Plato and Discorides who recommended it to use it as an aphrodisiac and as anti-inflammatory for the uterus complaints (Romm, 2009; Trickey, 1998). In ancient Greece Chaste tree was considered a sacred herb and flowers for gynecological problems and was only worn during festivals, a tradition that is still continues in some parts of Italy. However the name of Chaste tree became more popularized during middle ages by monks who used it to control their libido (Foster, 2009).
The first study on Vitex did not happen until early 20th century which revealed that chaste tree berry extract increases breast milk secretions in women suffering from posttraumatic stress disorder. These findings lead to hypothesis that Vitex may stimulate ovarian hormones via pituitary axis and therefore may have hormone balancing action (Foster, 2008).
This hypothesis was studies by Merz et al, (1996) who found that lower doses of Vitex berry extract (120mg) increase prolactin level in does depended manner and higher doses (204-480mg) decrease it respectively (Merz, et al., 1996). Despite the positive results, Vitex’s action upon the sex hormones could not have any clinical significance as healthy men were used in the study design instead of women which was an unfortunate study design flaw.
Several components from Vitex were thought to have “hormone modulating” mechanism of action as well. Apigenin, a flavonoid found in the Vitex berry extract exhibited selective affinity to bind to oestrogen type B in the study of Wuttke et al., (2003). In this in vitro study, the chaste tree extract did not only exhibit specific oestrogen type B binding found to be responsible for regulating fat tissue, but also it expressed dopaminergic activity which lead to suppression of prolactin release from pituitary gland (Wuttke, et al., 2003). Interestingly enough Vitex extract have also shown to possess weak osteoporosis protecting effect but it was not statistically significant (Wuttke, et al., 2003).
Other constituents responsible for “hormone modulating” action in Vitex extract were attributed to the presence of Vitex phytoestrogen, natural plant sterols that mimic oestrogen found in the body (Hassan, et al., 2014). Hassan et al., (2014) in vivo study has found that Vitex had a hormone normalizing effect on oestrogen via pituitary and hypothalamus axis, but also helped to normalize and stabilize the levels of Luteinizing hormone while decreasing Follicle Stimulating Hormone (Hassan, et al., 2014).
Interestingly chaste tree extract also have demonstrated affinity to bind oestrogen type A receptors and progesterone receptors as well (Jianghua, et al., 2001). In the future progesterone combination with oestrogen and antiresorptive medication (slowing down bone loss) may play a vital role in protecting women from bone loss during menopause, as data from randomized controlled trials suggests that bone loss may be less severe in progesterone therapy in perimenopausal women (Seiferet-Klauss & Prior, 2010).
Vitex may not only help with physical symptoms experienced during menopause but also it may help to alleviate mood changes, anxiety, headaches, irritability and fatigue (Webster, et al., 2011). The likely mechanism responsible for alleviation of mood changes may due to fact that Vitex binds selectively to dopamine D2 receptors (Meier et al., 2000). Dopamine is neurotransmitter responsible for a feeling of pleasure and disturbance in regulation has been directly linked to the possible cause of the depression in animal and postmortem studies (Dunlop & Nemeroff, 2007). Especially in experimental animal study deregulation in D2 receptors resulted in depression like states however since the data is lacking of human studies it cannot be confirmed that Vitex may help to alleviate mood changes (SK, et al., 2005).
Low oestrogen and therefore serotonin levels have also been proposed to affect mood, behavior and cognition in menopausal women (Douma, et al., 2005). Since oestrogen levels naturally decline during menopause it is possible that Vitex may indirectly improve mood, behavior and cognition via oestrogen-monoamine oxidase-serotonin-dopamine pathway which will be hard to demonstrate as no such a studies exists. The only studies that can confirm the effects of Vitex on symptoms of depression and anxiety in perimenopausal women was self reported small scale randomized controlled study which showed both improvement in women suffering from anxiety and depression using combination of St John’s Wort and Vitex (Diana van Die, et al., 2009). The lack of evidence supporting the use of chaste tree extract in mood disorders is due to the fact that Vitex has been extensively researched for Premenstrual Syndrome Disorders but not for menopause alone.
However, there are still studies available to support the use of Vitex for symptomatic relief of hot flushes. Abbaspoor, Hajikhani & Afshari (2011) demonstrated that symptoms of hot flushes improve gradually with daily use of Vitex. Most notable changes were observed during the 2nd and 8th week of treatment with Vitex (40 drops daily) and were superior to placebo (Abbaspoor, Hajikhani & Afshari, 2011). Another randomized double blind controlled study examined Phyto-Female Complex which consisted of: black cohosh (Cimicifuga racemosa) root extract, dong quai (Angelica sinensis) root extract, milk thistle (Silybum marianum) herb extract, red clover (Trifolium pratense) flower extract, American ginseng (Panax quiquefolim) root extract and chaste-tree berry (Vitex agnus castus) fruit extract for hot flushes, nights sweats and insomnia (Rotem & Kaplan, 2007). By the end of the 12 weeks the number of hot flushes has improved by 73%, night sweats by 69% and quality of sleep by 70% when compared to placebo 38%, 29% and 21% respectively (Abbaspoor, Hajikhani & Afshari, 2011).
Safety and contraindication of Vitex agnus castus for menopausal symptoms
Chaste tree extract has quite nice taste, is relatively safe (maximum 5ml a week) and well tolerated herb to take, however, there are some reports of mild gastrointestinal disturbance, dizziness, headaches, tiredness and dry mouth (Roemheld-Ham, 2005; Thomsen &Gennat, 2009). Due to its dopaminergic action, Vitex may not be safe to take with Parkinson’s medication such as bromocriptine and metoclopromide (Roemheld-Ham, 2005). Vitex should also not be taken during pregnancy and lactation.
Vitex has a long traditional history of use for women health complaints and unfortunately there is not enough good quality evidence to suggest that it can be used exclusively for menopausal vasomotor symptoms. However Vitex is much safer and causes fewer side effects than HRT medication.
Moreover it has to be remembered that in Herbal Medicine the prescription will be more likely to contain more than one herb, being specifically designed to address whole patient rather than only singular symptom, alongside diet and lifestyle choices as well. Therefore more studies are needed to explore the benefits of Western Herbal Medicine treatment such as Vitex and the quality of care for vasomotor symptoms in menopausal women.
Judyta Zyrek BSc Herbal Medicine MNIMH
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