Multiphasic Herbal Prescribing for Menstruating Women

Abstract

There is a tradition in Western herbal medicine of using certain herbs at different times during the menstrual cycle in women. This treatment is utilized to help restore balance to hormonal fluctuations.

Full text

126
Abstract
ere is a tradition in Western herbal medicine of using
certain herbs at different times during the menstrual cycle in
women. is treatment is utilized to help restore balance to
hormonal fluctuations.
The Concept of Multiphasic Prescribing
In women who are having menstrual cycles, regulating these
cycles is often an important part of dealing with various wom-
en’s reproductive problems. In addition, sometimes, the cycles
themselves are out of balance, causing distress and other prob-
lems, and need to be rebalanced. One approach to these issues
is to use distinct herbs at different times during the cycle to
bring the cycle back to normal, an admittedly variable state
from individual to individual.
One of our mentors (E.Y.), Silena Heron, N.D. (1947–2005,
formerly a private practitioner in Sedona, Arizona), was one
of several pioneering doctors who frequently used bipha-
sic or triphasic formulas for her patients, and many of the
ideas in this article are heavily influenced by her experiences
and theories.
e multiphasic approach in Western herbal medicine
usually involves two or three distinct formulas (biphasic
or triphasic formulations, respectively). e first formula,
or follicular formula, is generally begun after menstruation
is complete and this formula is continued until just before
ovulation begins. e second, or luteal formula, is begun
at ovulation and continued until menstruation stops. Op-
tionally, a third, or menstrual formula, is given from when
bleeding starts until it stops.
At times, the signals to change formulas are unclear or ab-
sent, such as in women who are amenorrheic or who have
anovulatory cycles. In such situations, the point is to im-
pose switches by changing formulas on whatever the normal
schedule would be for that patient. e idea is to provide
stimuli so that the body will reset to the normal pattern. is
may be particularly important in a world in which many of
the connections to nature (lunar cycles, day/night switching,
changes in the seasons, etc.) that women previously had have
been severed by artificial light, variable and unnatural work or
life schedules, and residing in places outside of nature. In ad-
dition, the widespread use of oral contraceptives has tended
to wreak havoc on normal cycles in many women. In women
with no known normal cycles, or who have been away from
normal cycles for a long time (particularly long-term oral
contraceptive users), one has to chose an arbitrary cycle, gen-
erally either by linking it to the phases of the moon or by
choosing a 28-day cycle.
For example, assume a woman was previously having nor-
mal, pain-free menstrual cycles lasting 28 days with 2 days
of heavy bleeding and 2 days of light bleeding. en she
developed menorrhagia with 35-day cycles, and the timing
of ovulation became very unclear. In such an instance, the
switch from follicular to luteal formulas should be made at
14 days, and the switch to a menstrual formula made at 28
days to mimic the original normal cycle for this woman. If
bleeding does not occur when a switch is made to a men-
strual or back to the follicular formula, then it may be nec-
essary to return to the luteal formula briefly until bleeding
occurs, or to stop all herbs until that point and then restart
the follicular formula.
Often, based on our experience, we have noted that it takes
multiple cycles for multiphasic formulas to have their full and
DOI: 10.1089/act.2009.15305 • MARY ANN LIEBERT, INC. • VOL. 15 NO. 3 ALTERNATIVE AND COMPLEMENTARY THERAPIES
JUNE 2009
Multiphasic Herbal
Prescribing for
Menstruating Women
Eric Yarnell, N.D., and
Kathy Abascal, B.S., J.D., R.H. (AHG)
15_3ACT.indd 126 5/29/09 4:23:08 PM

127
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
complete impact. Most patients should be advised that they
will have to use the formulas for a minimum of two or three
cycles to see results or to gain the totality of benefits.
Follicular-Phase Hormone Regulators
Herbs and foods rich in phytoestrogens, most notably
isoflavones, coumestans, and lignans, are important hor-
mone regulators (see Indications for Multiphasic Prescrib-
ing). Phytoestrogens are most specific to the follicular phase
(see Table 1), particularly when relative or absolute estrogen
dominance is suspected or known. Estrogen dominance can
occur any time during the cycle, when estrogen levels are ex-
cessive, as a result of either absolute high E or relative to low
P levels. Signs and symptoms of estrogen dominance include
water retention, moodiness, breast tenderness, and measured
high levels of endogenous estrogens, particularly relative to
progesterone. ese symptoms may tend to occur during the
luteal phase or in perimenopause but can definitely occur at
any time during the cycle.
Phytoestrogens act primarily as weak estrogen receptor–be-
ta (ERb) agonists.
1
Physiologic doses from diets rich in phy-
toestrogenic foods provide sufficiently high levels of phyto-
estrogens to have these effects in humans.
2
In a setting of
high endogenous estrogen levels, the net effect of phytoe-
strogens seems to be antagonism of the negative effects of
estradiol and similar native estrogens, apparently by maxi-
mizing protective ERb activation by the phytoestrogens and
minimizing harmful ERa activating by estradiol.
3
If estrogen
dominance is believed to exist in the luteal phase, which is
often related to insufficient progesterone production (rela-
tive estrogen dominance), then phytoestrogens may still oc-
casionally have a role to play during that time as well.
Overdose of phytoestrogens can, on occasion, lead to estro-
gen-excess symptoms. is rarely occurs in someone who is us-
ing liquid herbal extracts and is generally only seen in patients
who are taking capsules with concentrated phytoestrogen ex-
tracts and eating a diet very high in phytoestrogen-rich foods.
Otherwise, these substances are extremely safe.
Table 1. Herbs Used in the Follicular Phase
Phytoestrogens
Foeniculum vulgare (fennel) fruit
Glycine max (soy) fruit and all other legumes to varying
degrees
Glycyrrhiza glabra (licorice) root
Humulus lupulus (hops) strobile
Linum usitatissimum (ax) fruit
Medicago sativa (alfalfa) leaf
Pimpinella anisum (anise) fruit
Pueraria montana var lobata (kudzu) root
Punica granatum (pomegranate) seed
Trifolium pratense (red clover) leaf and ower
Trifolium repens (white clover) leaf and ower
Trifolium subterraneum (subterranean clover) leaf and ower
Possible phytoestrogens
Panax ginseng (Asian ginseng) root
Panax quinquefolium (American ginseng) root
Estrogen-metabolism optimizers
Brassica oleracea (cabbage, broccoli, cauliower, etc.) leaf
and/or ower
Hormone regulators with follicular anity
Angelica sinensis (dang gui, dong quai) prepared root (de-
nitely to be avoided in menorrhagia during follicular phase)
Polygonum multiorum (he shou wu) prepared root
Notes: Formidcyclespottingorbleeding,useastringents(seelistinherbsused
in menstrual phase).
Formittelschmerz (pain associated with ovulation), use spasmolytics (see list in
herbs used in menstrual phase).
Glycine max (soy) ower. Drawing ©2009 by Kathy Abascal,B.S., J.D., R.H.
(AHG)
Trifolium pratense (red clover).
15_3ACT.indd 127 5/29/09 4:23:12 PM

128
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
As examples, Trifolium pratense (red clover), T. repens (white
clover), and T. subterraneum (subterranean clover) are isofla-
vone- and coumestan-rich herbs that have been fairly well-
studied for use as phytoestrogens. e idea that these herbs
could be simple replacements for endogenous estrogen was not
borne out by the largest, negative clinical trial on T. subterra-
neum extract in perimenopausal women.
4
Some smaller trials
have suggested that T. subterraneum extracts can provide relief
from hot flashes or improve high-density lipoprotein (HDL)
cholesterol levels in perimenopausal women.
5,6
Although it
has not yet been proven in humans, extracts of these herbs also
consistently show anticancer activity in vitro and in animal
studies.
7,8
Much work remains to be done to parse the detailed
actions and effects of these herbs. Detailed discussions on the
other phytoestrogenic herbs can be found elsewhere.
9
Coupled with knowledge about phytoestrogens, there is
growing awareness of the need to optimize catabolism of
estrogen. Studies now show fairly consistently that elevated
levels of 16-a hydroxy-metabolites of estradiol and estrone
are associated with many of the negative effects of estrogens,
while the 2-hydroxy-metabolites are much safer and possibly
even protective.
10
A simple urine assay can quickly determine if an individual
patient has an imbalanced 2-OH-E2/16-a-OH-E
2
ratio.
11
Cruciferous vegetables contain various glucosinolates, including
indole-3-carbinol, that promote metabolism of estrogens toward
the 2-hydroxylation pathway. In a clinical trial, consuming cab-
bage was associated with increased 2-hydroxylation and reduc-
tion of recurrent respiratory papillomatosis, a condition known
to be aggravated by 16-a-hydroxylation metabolites.
12
Isolated
indole-3-carbinol has also shown excellent activity against con-
ditions, such as cervical dysplasia, that are associated with high
levels of 16-a-hydroxy estrogen metabolites; these metabolites
also stimulate human papillomavirus (HPV) activity.
13
Angelica sinensis (dang gui, dong quai) prepared root is a
nonphytoestrogen hormone regulator.
14
Although it does not
have a particular action that would make it more indicated
during the follicular phase, there is a reason this herb is of-
ten avoided during the luteal phase. Dang gui is described as
a “Blood mover” in traditional Chinese herbal medicine and
may increase menstrual bleeding. us, dang gui is generally
avoided during the follicular and menstrual phases, particu-
larly if menorrhagia is already a problem. If amenorrhea or oli-
gomenorrhea is the main issue, then dang gui may actually be
indicated. Polygonum multiflorum (he shou wu) prepared root is
another nonphytoestrogen hormone regulator that appears to
have more affinity for the follicular phase, although this affin-
ity is not well-understood.
Luteal-Phase Hormone Regulators
Very little work has been done to investigate the effect of
herbs on hormonal levels during the luteal phase exclusively.
Several herbs are traditionally considered to be hormone bal-
ancers with an affinity for the luteal phase, (see Table 2) al-
Table 2. Herbs Used in the Menstrual Phase
Astringents (for menorrhagia)
Alchemilla vulgaris (lady’s mantle) leaf
Lamium album (white deadnettle) leaf
Mitchella repens (partridge berry) leaf and fruit
Rubus spp. (blackberry, raspberry) root or leaf
Trillium ovatum (Pacic trillium) root*
Trillium grandiorum (bethroot) root*
Emmenagogues (for oligo- or amenorrhea)
Artemisia vulgaris (mugwort) leaf
Hedeoma pulegioides (American pennyroyal) leaf
Mentha pulegium(Europeanpennyroyal)leaf
Paeonia suruticosa (mu dan pi, tree peony) bark
Ruta graveolens (rue) leaf
Salvia ocinalis (sage) leaf
Styptics (for menorrhagia)
Capsella bursa-pastoris (shepherd’s purse) herb
Panax notoginseng (tienchi ginseng) root
Spasmolytics (for dysmenorrhea)
Dioscorea villosa (wild yam) root
Ligusticum walichii (chuan xiong) root
Paeonia lactiora (chi shao, red peony) root with bark
Viburnum prunifolium (blackhaw) leaf and bark
Viburnum opulus (crampbark) leaf and bark
*Threatened in the wild, use sparingly if at all.
Table 3. Herbs Without Cyclic Components
Uterine tonics
Aletris farinosa (true unicorn) rhizome
Caulophyllum thalictroides (blue cohosh) root
Chamaelirium luteum (false unicorn) root (however, Dr.
Heronconsideredthisprimarilyafolliculartonic)
Hypothalamic–pituitary-hormone regulators
Actaea racemosa(blackcohosh)root(however,Dr.Heron
considered this primarily a follicular tonic)
Paeonia lactiora (bai shao, white peony) root without bark
Vitex agnus-castus (chaste tree) fruit
Hormone regulator
Smilax spp. (sarsaparilla) root (may be a luteal-phase tonic),
mechanism unknown
Pelvic lymphagogues (almost always indicated)
Ceanothus greggii (red root) root
Fouquieria splendens (ocotillo) bark
Liver tonics (almost always indicated)
Arctium lappa (burdock) root
Silybum marianum (milk thistle) fruit
Taraxacum ocinale (dandelion) root
If amenorrhea or oligomenorrhea is
the main issue, then dang gui may
be indicated.
15_3ACT.indd 128 5/29/09 4:23:12 PM

129
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
though these have not been documented. ese include Smilax
spp. (sarsaparilla) root, Mitchella repens (partridge berry) herb,
and Alchemilla vulgaris (lady’s mantle) herb.
It is our opinion that most purported luteal-phase tonics can
be explained better by other actions that are not specialized
to the luteal phase. erefore, the main approach to the luteal
phase is essentially to remove herbs that are more focused on
the follicular phase, to maintain hormone regulators without a
cyclic component, and to manage any other symptoms. is is
also often a time when herbs are included to ensure they are
present at good levels in the body prior to the onset of menses,
particularly when premenstrual syndrome or dysmenorrhea is
a major issue.
Noncyclic Hormone Regulators
A number of hormone-modulating herbs do not have a
clear cyclic component (see Table 3). e best-understood
of these is probably Vitex agnus-castus (chaste tree*) fruit.
is herb has been shown to have dopaminergic effects in
the pituitary gland, suppressing prolactin levels, which are
often associated with premenstrual syndrome, as well as
correcting luteal-phase defects often seen in patients with
infertility and menstrual disorders.
15
ere is some evidence
for vitex specifically promoting corpus-luteum formation or
function shown in clinical trials.
16
e often-proclaimed
idea that chaste tree acts by affecting luteinizing hormone
(LH) or follicle-stimulating hormone (FSH) levels does not
have well-documented support in humans. One recent rat
study did show that chaste tree can lower LH levels.
17
e
historical use of chaste tree for both galactorrhea and insuf-
*For more information on chaste tree, see “Chaste Tree Extract in
Women’s Health: A Critical Review” by Tieraona Low Dog, M.D.,
in this issue.
Taraxacum ocinale (dandelion).
The Chinese Herbal Articial Cycle
A concept similar to biphasic prescribing also exists in modern
applicationsoftraditionalChineseherbalmedicine.Onepracti-
tioner reported* using four distinct formulas to support normal
menstrual cycles in women with infertility issues, coupled with
acupuncture treatments. This practitioner’s treatment program
is outlined briey below.
Phase 1, postmenstrual (proliferative), Follicle
Stimulation Formula
Humanplacenta(ziheche)
Curculigo orchoides (xian mao) rhizome
Cuscuta chinensis (tu si zi) seed
Dioscorea opposita (shan yao) root
Polygonum multiorum (he shou wu) prepared root
Angelica sinensis (dang gui) prepared root
Ligustrum lucidum (nu zhen zi) seed
Dipsacus asperoides (xu duan) root
Rehmannia glutinosa (shou di huang) steamed root
Lycium barbarum (gou qi zi) fruit
Epimedium spp. (yin yang huo) herb
Note: Most of these herbs are Kidney yin or yang tonics or
other tonifying herbs.
Phase 2, midcycle, Ovulation Stimulation Formula
Curculigo orchoides (xian mao) rhizome
Cnidium monnieri (dong chuan xiong) fruit
Lycopus lucidus (ze lan) herb
Epimedium spp. (yin yang huo) herb
Leonurus heterophylla (chong wei zi) seed
Achyranthes bidentata (niu xi) root
Paeonia lactiora (chi shao) root with bark
Carthamnus tinctoria (hong hua) ower
Liquidamber spp.
Angelica sinensis (dang gui) prepared root
Cyperus rotundus (xian fu) rhizome
Vaccaria segetalis (wang bu liu xing) seed
Note:ThisformulaaddsmanyherbsthatinvigoratetheBlood,
aswellasherbstoregulateLiverqi ow.
Phase 3, premenstrual (secretory), Corpus Luteum
Stimulation Formula
Rehmannia glutinosa (shou di huang) steamed root
Angelica sinensis (dang gui) prepared root
Dioscorea opposita (shan yao) root
Epimedium spp. (yin yang huo) herb
Cistanche deserticola (rou cong rong) herb
Codonopsis pilosula (dang shen) root
Curculigo orchoides (xian mao) rhizome
Cuscuta chinensis (tu si zi) seed
Glycyrrhiza uralensis (gan cao) root
Cinnamomum cassia (rou gui) bark
Rubus chingii (fu pen zi) fruit
Phase 4, Menstruation Regulation Formula
Angelica sinensis (dang gui) prepared root
Prunus persica (tao ren) seed
Lycopus lucidus (ze lan) herb
Paeonia lactiora (chi shao) root with bark
Carthamnus tinctoria (hong hua) ower
Achyranthes bidentata (niu xi) root
Cnidium monnieri (dong chuan xiong) fruit
Cyperus rotundus (xian fu) rhizome
Leonurus heterophylla (chong wei zi) seed
Rehmannia glutinosa (shou di huang) steamed root
Citrus reticulata (qing pi) immature peel
Citrus reticulata (chen pi) mature peel
*TangBJ.TraditionalChineseherbalandacupuncturetreatmentoffemaleinfertil-
ity.IntJOrientalMed1991;16:91–99.
15_3ACT.indd 129 5/29/09 4:23:14 PM

130
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
ficient lactation strongly suggests that chaste tree has a bal-
ancing action on hypothalamic and/or pituitary secretions,
or at least on prolactin.
Although Actaea racemosa (black cohosh) root was long be-
lieved to be a phytoestrogen, and although Dr. Heron consid-
ered this herb to be primarily a follicular tonic, there is now
fairly good evidence that black cohosh actually acts in the
hypothalamus and/or pituitary gland to regulate hormone
levels in the body.
18
Studies have suggested that black cohosh
may have serotonergic effects.
19
It is clinically quite helpful
in many instances when there is hormonal imbalance, though
this herb is most indicated for patients with concomitant ar-
thritis or myalgia.
Paeonia lactiflora (bai shao, white peony) root without
bark, and probably P. lactiflora (chi shao, red peony) root with
bark, are also apparently generic sex-hormone (estrogen and
progesterone) balancers without having hormonal compo-
nents, perhaps even extending to balancing androgens.
20–22
ese herbs are also useful analgesics, spasmolytics, and in-
flammation modulators.
23–25
e indigenous U.S. herb P.
brownii (Brown’s peony) root is believed to have similar ac-
tions according to the late, great herbalist Michael Moore
(1942–2009), formerly of the Southwest School of Botanical
Medicine, in Bisby, Arizona.
26
Miscellaneous Supportive Herbs
Herbs that support normal uterus tone and function are
often important for helping resolve chronic issues with this
organ (see Comparison of Views of Women’s Herbs). ese
herbs should be included throughout the menstrual cycle.
ere is no research on these herbs, so their use is based solely
on traditional practice. Aletris farinosa (true unicorn) rhizome,
Caulophyllum thalictroides (blue cohosh) root, and Chamaeliri-
um luteum (false unicorn) root are three classic uterine tonics.
(Although Dr. Heron considered false unicorn to be primarily
a follicular tonic, there is no clear understanding of why she
had this idea). False unicorn is threatened in the wild as a result
of slow growth, overharvesting, habitat loss, and overgrazing
by deer, and should only be obtained from cultivated or sus-
tainably harvested sources.
Indications for Multiphasic Prescribing
An eort should be made to identify and correct the cause(s)
of each patient’s problem and not just use herbal prescribing
as that could mask symptoms and cause recurrent or chronic
problems. Problems with many possible causes on the list below,
such as menorrhagia or infertility, are assumed to be benign,
idiopathic, and with no discernable pathologic causes (or with
known causes but with the cycle still imbalanced despite treat-
ing those causes).
Menorrhagia
Lengthenedorshortenedcycle
Femaleinfertility
Anovulatory cycles
Premenstrual syndrome
Dysmenorrhea—sometimes the follicular formula is
unnecessary
Lutealphasedefect
Oligo-oramenorrhea
Uterine broids
Endometriosis
Ovariancysts
Support after discontinuation of oral contraceptives
Any other conditions associated with a dysregulated menstrual
cycle
Humulus lupulus (hops).Paeonia lactiora (paeonia; white peony) ower. Photo ©2009
byEricYarnell,N.D.
15_3ACT.indd 130 5/29/09 4:23:23 PM

131
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
Pelvic lymphagogues are also almost always indicated in
women with chronic reproductive problems. e mechanism
of action of these herbs is also unknown; the herbs are used
based on empirically derived knowledge. Fouquieria splendens
(ocotillo) bark from the desert southwestern United States/
northern Mexico is the most important of these herbs, al-
though Ceanothus greggii (red root) root can be used when this
herb is not available.
Naturopathic physicians and herbalists commonly pre-
scribe liver tonics to women with dysregulated cycles or
conditions related to these, on the premise that these ton-
ics help the liver to metabolize sex hormones properly. One
Comparison of Views of Women’s Herbs
There is some dierence of opinion among scholars and practitioners about the primary actions and eects of various herbs used
primarily for women’s health. The chart below highlights this and supports the strength that comes from diversity within the profession of
herbalism.Incaseswhenadistinctspecieswasrecommendedbytheauthor(usuallytheAmericannativeherb,incontrasttotheEurasian
native herb), this is indicated.
Opinions on the Primary Actions of Herbs
Herb Trickey
*
Moore
†, ‡
Soule
§
Gladstar
#
Achillea millefolium Antihemorrhagic Antihemorrhagic Spasmolytic, Antihemorrhagic,
antihemorrhagic, spasmolytic
emmenagogue
Actaea racemosa Hormonebalancer Hormonebalancer Spasmolytic, Hormoneregulator
(A. arguta) uterine tonic
Alchemilla vulgaris Antihemorrhagic Antihemorrhagic Anodyne, Antihemorrhagic,
(A. occidentalis) antihemorrhagic spasmolytic
Aletris farinosa Uterine tonic — — Digestive tonic
Angelica sinensis Uterinetonic Femaletonic Circulatorystimulant, Uterinetonic
hormone balancer
Artemisia vulgaris Emmenagogue Bitterdiaphoretic Emmenagogue Emmenagogue
(A. ludoviciana)
Capsella bursa-pastoris Antihemorrhagic Anti-hemorrhagic Antihemorrhagic Antihemorrhagic
Caulophyllum thalictroides Uterinetonic — Uterinetonic Emmenagogue
Chamaelirium luteum Uterinetonic — Uterinetonic Hormonebalancer,uterinetonic
Dioscorea villosa — — Spasmolytic Hormonebalancer
Lamium album Anti-hemorrhagic — — —
Leonurus cardiaca Cardiotonic, Emmenagogue Uterineamphoteric Uterineamphoteric
spasmolytic
Mentha pulegium Emmenagogue Emmenagogue Emmenagogue Emmenagogue
Mitchella repens — — Antihemorrhagic Uterine tonic, hormone balancer
Paeonia lactiora Hormonebalancer Hormonebalancer, — —
antihemorrhagic,
spasmolytic (P. brownii)
Pulsatilla vulgaris Anodyne Sedative (P. occidentalis) — —
Rubus idaeus Uterine tonic Antihemorrhagic Uterine tonic Uterine tonic
Ruta graveolens Emmenagogue — — —
Salvia ocinalis Emmenagogue Anti-hemorrhagic — Antilactation
Tanacetum parthenium Anodyne — Emmenagogue, —
spasmolytic
Trillium erectum Antihemorrhagic Antihemorrhagic — —
(T. ovatum)
Viburnum prunifolium Spasmolytic Spasmolytic (V. edule) Spasmolytic (V. opulus) Spasmolytic
Vitex agnus-castus Hormonebalancer — Hormonebalancer Hormonebalancer
*
TrickeyR.Women,Hormones,andtheMenstrualCycle.HerbalandMedicalSolutionsfromAdolescencetoMenopause.Australia:AllenandUnwin,1998.
†
MooreM.MedicinalPlantsoftheMountainWest,rev.ed.SantaFe:MuseumofNewMexicoPress,2003.
‡
Ref.26.
§SouleD.TheWoman’sBookofHerbs.NewYork:CitadelPress,1995.
#
GladstarR.HerbalHealingforWomen.NewYork:SimonandSchuster,1993.
—, indicates that herb was not discussed.
15_3ACT.indd 131 5/29/09 4:23:24 PM

132
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
preliminary clinical trial using a complex formula (including
Silybum marianum [milk thistle] seed, Taraxacum officinale
[dandelion] root, and Cynara scolymus [artichoke] leaf, three
liver tonics) showed that these herbs could have effects on
follicular metabolism of androgens.
27
More research is need-
ed, but there may be some validity to using these herbs for
women with hormonal issues.
Herbs for Symptom Management
Frequently, while working on the hormonal or other bases
of female reproductive problems, it is necessary to reduce ex-
cessive bleeding, stimulate bleeding when little or none is oc-
curring, manage pain, or otherwise handle symptoms. While
these outcomes should not be the only objectives of treatment,
they can be very important.
ere are two classes of herbs that can help reduce excessive
bleeding, spotting, or midcycle bleeding (see Table 2). e as-
tringents contain tannins, and although they are not generally
believed to be systemically absorbed to any significant extent,
are still often effective for controlling excessive vaginal bleeding.
Perhaps one of the most famous among herbs specific to the
female reproductive tract would be the Trillium genus, although
these herbs are slow-growing, and their forest habitats are threat-
ened, so the much more sustainable Rubus spp. or Alchemilla spp.
should generally be used instead. One European trial suggested
that Alchemilla can be effective for addressing menorrhagia.
28
Nontannin-containing styptic herbs that can also reduce
excessive bleeding include Capsella bursa-pastoris (shepherd’s
purse) herb and Panax notoginseng (tienchi ginseng) root.
Punica granatum (pomegranate).
Table 4. Dr. Selena Heron’s Base Biphasic Formulas*
Follicular Base Formula
Latin name Part Form Proportion
Chamaelirium luteum Root Tincture 15%–30%
Medicago sativa Herb Glycerite 15%–30%
Angelica sinensis Decoctedroot Tincture 5%–15%
Actaea racemosa Root Tincture 5%–15%
Glycyrrhiza glabra Root Fluidextract 5%–15%
Mitchella repens Leafandfruit Tincture 5%–15%
Taraxacum ocinale Root Tinctureorglycerite 5%–15%
Vitex agnus-castus Fruit Tincture 5%–15%
Luteal Base Formula
Latin name Part Form Proportion
Taraxacum ocinale Root Glycerite 15%–25%
Smilax ornate Root Tincture 5%–15%
Alchemilla mollis Leaf Tincture 5%–15%
Silybum marianum Seed Tincture 5%–15%
Dioscorea villosa Root Tincture 5%–15%
Mitchella repens Leafandfruit Tincture 5%–15%
Viburnum prunifolium Bark Tincture 5%–15%
Vitex agnus-csatus Fruit Tincture 5%–15%
Eleutherococcus senticosus Root Tinctureoruidextract 5%–15%
*Thedoseforbothoftheseformulaswasintendedtobe1tsp(5mL)threetimesperdayforanaverage-sizedadultwoman.Theseformulasshouldalwaysbeindividualizedto
the specic patient.
15_3ACT.indd 132 5/29/09 4:23:25 PM

133
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
Again, these herbs have rich historical traditions for use but
have been poorly researched.
29
Tienchi ginseng was shown to
be antihemorrhagic when it was applied topically in at least
one clinical trial.
30
When insufficient menstruation occurs, emmenagogues are
used. ese are potentially abortifacient and should be used
cautiously as a result. Again, very little information is available
about how these herbs work, and their use is based on histori-
cal herbal medicine. If they do not work at usual doses, then
higher doses are not recommended because they have some
potential to result in excessive uterine bleeding.
For addressing uterine spasms or dysmenorrhea, herbal spas-
molytics are often effective. Dioscorea villosa (wild yam) root,
now widely though inaccurately believed to have progesteronic
or androgenic effects, is actually primarily an excellent uter-
ine relaxer. In fact, none of the studies on this herb exploring
progesteronic or androgenic effects have produced any support
for this concept,
31,32
and it seems to have come from a mis-
understanding that, industrially, the saponins in wild yam can
be converted to steroid hormones. However, the human body
is simply not able to do the same thing. Several other herbs are
listed in Herbs by eir Primary Actions.
Conclusion
is article has provided basic information for practitioners
so they can implement multiphasic prescribing of herbs more
widely. e Western and Eastern traditions of doing so coin-
cide and suggest that there is significant power in this approach.
Refinement of which herbs are used at what points during the
cycle is urgently needed, along with better understanding of
how the herbs work, so that they can be targeted more se-
lectively. Hormone-balancing herbs, tonifying and supporting
herbs, and symptom-managing herbs should all be utilized in
individualized formulas for treating menstruating women with
apparent hormonal imbalances. n
Conict-of-Interest Disclaimer
Dr. Yarnell is part owner of Heron Botanicals in Poulsbo,
Washington (the company founded by Dr. Heron, based on
her personal dispensary), which sells many of the products
mentioned in this article. ese products are also readily avail-
able from other sources.
References
1. Harris DM, Besselink E, Henning SM, et al. Phytoestrogens induce dif-
ferential estrogen receptor alpha- or beta-mediated responses in transfected
breast cancer cells. Exp Biol Med 2005;230:558–568.
2. Rowland I, Faughnan M, Hoey L, et al. Bioavailability of phyto-oestrogens.
Br J Nutr 2003;89(suppl1):S45–S58.
3. Katzenellenbogen JA, Muthyala R. Interactions of exogenous endocrine ac-
tive substances with nuclear receptors. Pure Appl Chem 2003;75:1797–1817.
4. Atkinson C, Warren RML, Sala E, et al. Red clover-derived isoflavones
and mammographic breast density: A double-blind, randomized, placebo-
controlled trial [ISRCTN42940165]. Br Cancer Res 2004;6:R170–R179.
5. van de Weijer PHM, Barentsen R. Isoflavones from red clover (Promensil®)
significantly reduce menopausal hot flush symptoms compared with placebo.
Maturitas 2002;42:187–193.
6. Samman S, Wall PML, Chan GSM, et al. e effect of supplementation
with isoflavones on plasma lipids and oxidisability of low density lipoprotein
in premenopausal women. Atherosclerosis 1999;147:277–283.
7. Yanagihara K, Ito A, Toge T, Numoto M. Antiproliferative effects of isofla-
vones on human cancer cell lines established from the gastrointestinal tract.
Cancer Res 1993;53:5815–5821.
8. Cassady JM, Zennie TM, Chae YH, et al. Use of a mammalian cell culture
benzo(a)pyrene metabolism assay for the detection of potential anticarcino-
gens from natural products: Inhibition of metabolism by biochanin A, an iso-
flavones from Trifolium pratense L. Cancer Res 1988;48:6257–6261.
9. Yarnell E, Abascal K. Herbal medicine for treating menopausal symptoms.
Altern Complement er 2003;9:299–306.
10. Mueck AO, Seeger H, Lippert TH. Estradiol metabolism and malignant
disease. Maturitas 2002;30;43:1–10.
11. Lord RS, Bongiovanni B, Bralley JA. Estrogen metabolism and the diet–
cancer connection: Rationale for assessing the ratio of urinary hydroxylated
estrogen metabolites. Altern Med Rev 2002;7:112–129.
12. Auborn K, Abramson A, Bradlow HL. et al. Estrogen metabolism and
laryngeal papillomatosis: A pilot study on dietary prevention. Anticancer Res
1998;18(6B):4569–4573.
13. Bell MC, Crowley-Nowick P, Bradlow HL. Placebo-controlled trial of in-
dole-3-carbinol in the treatment of CIN. Gynecol Oncol 2000;78:123–129.
14. Zhu D. Dong quai. Am J Chin Med 1985;15:117–125.
15. Wuttke W, Jarry H, Christoffel V, et al. Chaste tree (Vitex agnus-castus)—
pharmacology and clinical indications. Phytomedicine 2003;10:348–357.
16. Gerhard I, Patek A, Monga B, et al. Mastodynon® for female infertility:
Randomized, placebo-controlled, clinical double-blind study [in German].
Forsch Komplementärmed 1998;5:272–278.
17. Ibrahim NA, Shalaby AS, Farag RS, et al. Gynecological efficacy and
chemical investigation of Vitex agnus-castus L. fruits growing in Egypt. Nat
Prod Res 2008;22:537–546.
18. Liske E, Hänggi W, Henneicke-von Zepelin HH, et al. Physiological
investigation of a unique extract of black cohosh (Cimicifugae racemosae rhi-
zoma): A 6-month clinical study demonstrates no systemic estrogenic effect. J
Women Health Gend Based Med 2002;11:163–174.
19. Powell SL, Gödecke T, Nikolic D, et al. In vitro serotonergic activity of
black cohosh and identification of N(omega)-methylserotonin as a potential
active constituent. J Agric Food Chem 2008;56:11718–11726.
20. Yasui T, Irahara M, Aono T, et al. Studies on the combination treat-
ment with clomiphene citrate and toki-shakuyaku-san. Jpn J Fertil Steril
1995;40:83–91.
21. Aizawa H, Niimura M. Serum androgen levels in women with acne vul-
garis: e effect of shakuyaku-kanzo-to (SK). Skin Res 1996;38:37–41.
22. Tanaka T. Effects of herbal medicines on menopausal symptoms induced
by gonadotropin-releasing hormone agonist therapy. Clin Exp Obstet Gyne-
col 2001;28:20–23.
23. Tsai HY, Lin YT, Tsai CH, Chen YF. Effects of paeoniflorin on the
formalin-induced nociceptive behaviour in mice. J Ethnopharmacol 2001;
75:267–271.
24. Kumada T, Kumada H, Yoshiba M, et al. Effect of shakuyaku-kanzo-to
(Tsumura TJ-68) on muscle cramps accompanying cirrhosis in a placebo-con-
trolled double-blind parallel study. J Clin er Med 1999;15:499–523.
25. Fujiwara H, Urabe T, Ueda K, et al. Prevention of arthralgia and myalgia
from paclitaxel and carboplatin combination chemotherapy with shakuyaku-
kanzo-to [in Japanese]. Gan To Kagaku Ryoho 2000;27:1061–1064.
15_3ACT.indd 133 5/29/09 4:23:26 PM

134
ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2009
MARY ANN LIEBERT, INC. • VOL. 15 NO. 3
26. Moore M. Medicinal Plants of the Pacific West. Santa Fe: Red Crane
Books, 1993.
27. Greenlee H, Atkinson C, Stanczyk FZ, Lampe JW. A pilot and feasibility
study on the effects of naturopathic botanical and dietary interventions on
sex steroid hormone metabolism in premenopausal women. Cancer Epidemiol
Biomarkers Prev 2007;16:1601–1609.
28. Petcu P, Andronescu E, et al. Treatment of juvenile meno-metrorhaggia
with Alchemilla vulgaris fluid extract [in Romanian]. Clujul Med 1979;52:
266-270.
29. Schumann E. Newer concepts of blood coagulation and control of hemor-
rhage. Am J Ob Gyn 1939;38:1002–1007.
30. Fan GD, Song J, White CM. A comparison of the hemostatic effects of
notoginseng and yun nan bai yao to placebo control. J Herbal Pharmacother
2005;5:1–5.
31. Zava DT, Dollbaum CM, Blen M. Estrogen and progestin bioactivity of
foods, herbs, and spices. Proc Soc Exp Biol Med 1998;217:369–378.
32.
Araghiniknam M, Chung S, Nelson-White T, et al. Antioxidant activity
of dioscorea and dehydroepiandrosterone (DHEA) in older humans. Life Sci
1996;59:PL147–PL157.
Eric Yarnell, N.D., is president of the Botanical Medicine Academy, a specialty
board for using medicinal herbs, and is a faculty member at Bastyr University
in Kenmore, Washington. Kathy Abascal, B.S., J.D., R.H. (AHG), is executive
director of the Botanical Medicine Academy in Vashon, Washington.
To order reprints of this article, e-mail Karen Ballen at: Kballen@liebertpub.com
or call (914) 740-2100.
15_3ACT.indd 134 5/29/09 4:23:27 PM