PMS and Integrative Medicine (Part II): Botanicals

Chastetree, Black cohosh, Ginkgo biloba and Evening primrose are the most commonly used botanicals to treat premenstrual syndrome in the United States. Of those listed, Chastetree has been the most widely studied.

Some of the descriptions below refer to "The German Commission E". The German Commission E Monographs are a therapeutic guide to herbal medicine. There is an English translation by the American Botanical Council, with 380 monographs evaluating the safety and efficacy of herbs for licensed medical prescribing in Germany. Though the German Commission no longer exists, in Germany only those herbs with Commission E approved status are legally available.
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Chastetree Berry (Vitex agnus-castus) is the dried ripe fruit of the chaste tree. In a number of well conducted studies chastetree berry has been effective in reducing PMS symptoms, especially breast discomfort, when compared to placebo. The German Commission E has approved the use of chastetree berry for irregularities of the menstrual cycle, premenstrual symptoms and breast pain.

Chastree is considered safe. Possible side effects are mild and reversible. They include mild headache, diarrhea, abdominal cramps, decreased appetite, rash and itching. Possible drug interactions could include anti-psychotics, some antidepressants and estrogen-containing compounds. However all potential drug interactions are theoretical.

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Black Cohosh (Actaea racemosa) was used by American indigenous peoples for the treatment of respiratory complaints, muscuoskeletal pain and to aid in childbirth. It was most likely used for its anti-inflammatory and muscle relaxant properties.

Compounds in black cohosh bind to the 5-HT7 (serotonin) receptor which may explain its positive effect on depressive and anxiety symptoms in PMS. A study published by Dittmar in 1992 demonstrated a reduction of the PMS symptoms including anxiety, tension and depression. A number of studies show a benefit for various menopausal symptoms such as hot flashes, profuse sweating, sleep disturbance and depressed moods. Because these symptoms often exist in those suffering from PMS, many clinicians have recommended the use of black cohosh in this population, too. Black cohosh is approved by the German Commission E for use in women suffering from premenstrual symptoms, painful menstruation (i.e. dysmenorrhea) and menopause.

Side effects and drug interactions: Black cohosh is generally safe and well tolerated when used for 6 months; and has not been well-studied beyond 6 months duration. Caution should be exercised as there have been multiple case reports of liver damage while using black cohosh. As stated above, Black Cohosh has been studied as a therapy for menopausal symptoms, not PMS. At this time that there is insufficient evidence to support or refute the use of black cohosh for PMS.
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Ginkgo (Ginkgo biloba): Ginkgo is commonly used to sharpen mental focus and improve circulation. One well-done study suggests the ginkgo is more effective in decreasing psychological and congestive symptoms ( e.g. breast pain, breast tenderness and fluid retention) than placebo in PMS sufferers. More studies need to be conducted before strong recommendations can be made to support or refute the use of ginkgo for PMS.

Ginkgo is generally well tolerated and considered safe with similar side effect rates as placebo in several reviews. Ginkgo is thought to have a blood-thinning effect. Therefore, possible drug interactions can occur with anti-coagulants such as warfarin and aspirin.
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Evening Primrose Oil (Oenothera biennis): A systematic review of the literature published in 1996 included seven studies. Unfortunately, none of the studies found a beneficial effect of evening primrose oil for PMS symptoms; this included two well-designed, randomized, placebo-controlled trials that were adequately powered.

Potential side effects include headache, seizures among people with seizure disorder or taking anesthetics, nausea, vomiting, anorexia, diarrhea, hypersensitivity reactions, rash, inflammation and immunosuppression with long-term use. Possible drug interactions include anticoagulants, phenothiazines and other anti-seizure medication. In lite of the currently available information, EPO is not a recommended treatment for PMS.

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Other biologically based therapies: St. John’s Wort (Hypericum perforatum) is primarily used to alleviate depressive symptoms. Kava (Piper methysticum) has been proven effective for treating anxiety, though has a questionable safety profile. Valerian (Valeriana officinalis) is a common over-the-counter ingredient for sleep preparations and relaxants. Don Quai (Angelica sinensis) as a tonic for women with fatigue and low vitality. None have yet been adequately studied for the treatment of PMS.

References:
1. Daniele C, et al. Vitex agnus castus: a systematic review of adverse events. Drug Saf
2. Dittmar FW, et al. Premenstrual syndrome: treatment with a phytopharmaceutical. Therapiwoche Gynakol 1992;5:60-8.
3. Budeiri, D, Li Wan Po A, Doman JC. Is evening primrose oil of value in the treatment of premenstrual syndrome? Control Clin Trials 1996;17:60-8.
4. Tamborini A, Taurelle R. Value of standardized Ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome. Rev Fr Gynecol Obstet
5. Blumental M, et al., eds. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin: American Botanical Council and Boston: Integrative Medicine communications, 1998.
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