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Endometriosis is a disorder characterized by one or more of the following: pelvic pain with menstruation, pelvic pain during non-menstrual part of the cycle, pain with intercourse, pain with bowel movements, infertility women, and a change in the menstrual cycle. Conventional therapy often starts with birth control pills and pain pills but then can move on to surgery followed by oral contraceptive pills or gonadotropin-releasing hormone agonists (GnRH-a). The GnRH-a medication reduces estrogen levels, and puts the woman in at least temporary menopause, with subsequent symptoms such as hot flashes, night sweats, reduced libido, mood changes and more. Even though the medication is designed to lower estrogen, the conventional response to the onset of the menopause symptoms is to add back low doses of estrogen therapy. Herbal menopause support is however another option, and perhaps even preferred, because we are not adding back any estrogen. Black cohosh (Actaea racemosa syn. Cimicifuga racemosa, Ranunculaceae) rhizome has been shown to ameliorate menopausal symptoms in scores of studies of perimenopausal and menopausal women. Black cohosh does not have estrogenic properties.

The purpose of this prospective, randomized, controlled study was to evaluate the effect of black cohosh compared to tibolone (a synthetic steroid hormone that acts as a Selective Tissue Estrogenic Activity Regulator [STEAR]) and is used to treat perimenopausal/menopausal symptoms; not available in the U.S.)

There were 116 women, and an average age of 28.5 years old, who received GnRH-a after their endometriosis surgery. One week after laparoscopic ovarian cyst removal surgery, all patients were treated with the first GnRH-a injection and in total, received 3 injections. At the same time as the first injection, received either black cohosh standardized extract (20 mg twice daily) or tibolone (2.5 mg/day) for 12 weeks. At baseline, 4, 8, and 12 weeks after the first GnRH-a injection, menopausal symptoms were scored using the Kupperman Menopausal Index (KMI), and hot flash score was recorded.

At 4, 8, and 12 weeks after GnRH-a therapy, there were no significant differences between the black cohosh extract and tibolone groups’ KMI scores, hot flash frequency, or measures of endometrial thickness.

The levels of 17β-estradiol (E2), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels decreased in both groups after the GnRH-a injections. After 12 weeks of treatment, the black cohosh group had significantly lower E2 and significantly higher FSH and LH levels compared to the tibolone group. These findings indicate that black cohosh does not have an estrogen-like effect, as do other studies.

There were no adverse effects regarding liver function, renal function, or serum lipids in either group and the incidence of adverse events was significantly lower in the black cohosh group than in the tibolone group. The episodes of vaginal bleeding or spotting and breast distending pain were significantly lower in the black cohosh group than in the tibolone group.

Commentary: This study is one more positive representation of the value of black cohosh standardized extracts of 40 mg/day in the treatment of perimenopause/menopausal symptoms, even in the presence of drug induced menopause. It is also reconfirming that the black cohosh extract did not affect liver function, renal function, lipid profile, or hormonal levels, and was well-tolerated.

Reference

Chen J, Gao H, Li Q, et al. Efficacy and safety of Remifemin on peri-menopausal symptoms induced by post-operative GnRH-a therapy for endometriosis: A randomized study versus tibolone. Med Sci Monit. 2014;20:1950-1957.

blackcohosh-kirklandpicA recent study using black cohosh, demonstrates a new addition to a natural medicine strategy for addressing PCOS. One hundred women with PCOS were recruited and seen in a clinic in Egypt. Women were randomly assigned to receive either 40 mg/day of black cohosh for 10 days or 100 mg/day of clomiphene for 5 days. (Clomiphene citrate is a conventional pharmaceutical prescription used as a first line approach to induce ovulation.) Treatments were given starting on day two of each cycle and continued for 3 consecutive cycles. Blood tests included follicle-stimulating hormone (FSH), luteinizing hormone (LH) and progesterone. Transvaginal ultrasound was performed to document follicular size and growth as well as endometrial thickness. If a follicle achieved a size of 18 mm or greater, human chorionic gonadotropin (HCG) was given and then intercourse was recommended.

While at baseline, both the black cohosh and clomiphene groups had similar FSH, LH and FSH/LH rations, at the end of the treatment period, the black cohosh group had a significantly greater reduction in the LH level as well as the FSH/LH ratio. After receiving black cohosh, this group also had significantly greater progesterone levels and endometrial thickening. Remarkably, the black cohosh group had more pregnancies (7 vs. 4), although in terms of statistical power and 50 women in each group, this did not reach statistical significance. There were also 2 twin pregnancies in the black cohosh group vs. 1 in the clomiphene group. Again, this was not statistically significant. The black cohosh group had 1 miscarriage and 1 case of mild hyperstimulation compared with the clomiphene group that saw no miscarriages, 1 mild case and 1 moderate case of hyperstimulation. And again, this was not statistically significant.

Commentary: Polycystic ovarian syndrome (PCOS) is one of the most challenging endocrinological disorders in women. It impacts not only the menstrual cycle, fertility, and physical manifestations of androgen excess (acne, hirsutism, hair loss), it increases the risk of long term significant health issues including type 2 diabetes, dyslipidemia, hypertension and endometrial cancer. While the underlying cause of polycystic ovarian syndrome is dominantly insulin resistance, it is often the symptoms of amenorrhea, oligomenorrhea or infertility and the associated lack of ovulation or only infrequent ovulation that brings women to the medical office.

This use of black cohosh and its apparent effect on inducing ovulation is a very useful study in the complex and challenging clinical management of women with PCOS. Adding black cohosh to natural medicine strategies that increase insulin sensitivity, reduce androgen excess, reduce conversion to the more active form of testosterone in the skin, while all the time being mindful of reducing the risk of future diseases such as type 2 diabetes, cardiovascular disease and endometrial cancer is an advancement in treatment options. We are left with a desire to better understand optimal black cohosh dosing for this purpose and larger studies to see the impact on regular ovulation and rates of pregnancy.

Reference: Kamel HH. Role of phyto-oestrogens in ovulation induction in women with polycystic ovarian syndrome. Eur J Obstet Gynecol Reprod Biol. May 2013;168(1):60-63.

Sesame and OA

normal human's kneeOsteoarthritis (OA), also known as degenerative arthritis, is the most common form of arthritis and involves the joint cartilage. The inflammation and degeneration can result in pain, swelling, decreased range of motion and mobility and even changes in the shape of the joint and abnormal bone growth. The knee joints are one of the most common joints affected by OA, and especially so in women.

The current study was conducted in Iran, and involved 50 patients (40 women and 10 men) aged 50 to 70 years old who had knee OA with mild to moderate disease severity based on accepted criteria of the American College of Rheumatology (ACR).

The patients were randomly divided into 2 groups: sesame treated group and control groups. The control group received standard drug therapy of 500 mg acetaminophen twice daily and one glucosamine 500 mg/day. The study intervention group (25) received 40 g of sesame seeds, ground into a powder, per day along with the standard drug therapy, for 2 months. Patients in both groups maintained their usual diet and physical activity during the study.

The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Timed Up and Go (TUG) and the Visual Analog Scale (VAS) tests were used for clinical assessments. VAS measures subjective characteristics or attitudes. In this study, VAS was used to measure the rate and intensity of the pain. O represents no pain and 10 represents the maximum pain tolerated. The TUG is used to assess a person’s mobility. It uses the time it takes to rise from a chair, walk 3 meters, turn around, walk back to the chair and then sit down again. Scores of 10 seconds or less indicated normal mobility, 11-20 seconds are within normal limits for elderly and disabled individuals and > 20 seconds means the person needs assistance. A score of 14 seconds or more may indicated they are prone to falls. The KOOS is a test specific to the knee and assesses a person’s opinions and problems associated with their knees. It measures pain, swelling, restricted range of motion and mechanical symptoms, activities of daily living, recreation function and knee related quality of life. The KOOS scores for each of the areas measured are transformed to a 0-100 scale with 0 representing extreme knee problems and 100 representing no knee problems.

After treatment, there was significant difference in pain intensity between the two groups. The mean score of KOOS in both treatment and control groups was significantly increased compared to baseline. The mean score of the TUG Questionnaire in both treatment and control groups was significantly decreased from baseline. There was no significant differences in pretreatment scores of KOOS and TUG between the two groups. There was significant difference in post treatment scores of the KOOS and TUG between the two groups.

Commentary: This study showed a positive effect of a rather simple dietary addition of 40 gm/day of ground sesame seeds, in improving clinical signs and symptoms in patients with osteoarthritis of the knee. It should be considered a good adjunct to acetaminophen and glucosamine.

Sesamin, a lignan derived from sesame seeds has been shown to inhibit pro-inflammatory cytokines involved in inflammatory factors. Oxidative stress also has a role in OA and sesame oil can increase antioxidant capacity, superoxide dismutase (SOD) and serum antioxidants including vitamins C and E. Improving antioxidant enzyme activity and improving oxidative status with sesame is a possible mechanism in improving symptoms and signs of OA.

Possible methods of delivery of this 40 gm/day of ground sesame seeds could be in a smoothie, in yogurt, on fruit or vegetable salads, and on top of cooked vegetables. A tablespoon is approximately 9 grams…so 4 plus tbsp. per day. Simple, safe, tasty, healthy, and hopefully a way to help with mild to moderate osteoarthritis of the knees (and maybe other joints!).

Reference

Sadat E, Haghighian K, et al. Effects of sesame seed supplementation on clinical signs and symptoms in patients with knee osteoarthritis. Int J Rheum Dis 2013; 16(5): 578-582.

Oakland Bay BridgeLicensed Naturopathic Physicians have an annual national convention every summer. This year it is going to be in Oakland, California, August 5-8th, 2015. Your first reaction might be… why Oakland?!?!?! Well, it turns out that Oakland has become well known as one of the hippest cities in America… and that’s saying a lot coming from me, who hails from “Portlandia”…. Definitely one of the hippest cities in America. As chair of the convention curriculum committee, I have been intimately involved creating the program but have been joined by my able and generous colleagues, Gillian Hanson, N.D., Bradley Bush N.D. and Amy Rothenberg N.D. We have also had a wide circle of advisors. The theme of the convention is “Fresh, Sustainable and Cage Free”.

We have 6 all day boot camps (Genomics, Lyme, Fertility, Anxiety, Environmental Medicine and weight loss. There are 12 NED (naturopathic, education, doctoring) talks (yes, a take-off on TED talks) – with unique topics such as “Fecal Implants”, Sustainable Nutrition, Cell Membranes- the Theory of Everything, The Magic of Food and 8 more!!. Our NED talks include some of the most formidable and productive naturopathic physicians of our time – including Dr.’s Joe Pizzorno, Michael Murray and Tabatha Parker. We also have 11 very personal presentations called PITH (personal insightful tales of healing.) These 11 brave fellow naturopathic physicians tell their personal health/medical challenge with a major and/or chronic illness including Dr.’s Amy Rothenberg, Lise Alschuler, Jacob Schor and 8 more. There will also be expert panels in Autism spectrum, Cannabinoids, the Gut-Brain connection, and Business practices. Three of the research updates I’m excited about are on HPV Research Update and Testing as Primary Screening, Obesogens, and Autism Research Update. All 3 of these presentations are from leading researchers and scientists in their fields. We are also proud to present a forum for naturopathic original research - on weight loss, cannabidiol, lipoic acid as an adjunct cancer therapy, and more. Lastly but not least, there are 8.5 hours of coveted pharmacy hours, and a featured keynote speaker, Paul Stamets “the mushroom man”.

We hope to boldly (but humbly) go where no woman or man has gone before with the AANP (American Association of Naturopathic Physicians) 2015 educational content. If you are licensed practitioner, please join us at this 2015 AANP convention and see the fruits of our and others labors… May the healing forces be with us all……

www.naturopathic.org

Both myo-inositol and D-chiro-inositol have been shown to effect ovarian function and metabolic factors in women with polycystic ovarian syndrome (PCOS). They have been shown to improve androgen levels, increase the action of insulin, reduce systolic blood pressure and more.

The purpose of the current study was to compare the effects of myo-inositol and D-chiro-inositol in women with PCOS. Fifty women were enrolled, with a diagnosis of PCOS, according to the Rotterdam criteria. They were randomized into two groups, and 25 were treated with 4 gm of myo-inositol plus 400 mcg of folic acid daily for 6 months and the other 25 were treated with 1 gm of D-chiro-inositol plus 400 mcg/folic acid per day.

In the myo-inositol group, there were statistically significant reductions of diastolic and systolic blood pressure, lowering of luteinizing hormone (LH), lowering of the LH/FSH (follicle stimulating hormone) ratio lowering of total testosterone and free testosterone and androstenedione and prolactin and the HOMA Index (homeostasis model assessment)- to check for insulin resistance. These same patients also had a statistically significant increase of SHBG (sex hormone binding globulin) and of the glycemia/immunoreactive insulin ratio.

In the D-chiro-inositol group, there was a statistically significant reduction of systolic but not diastolic blood pressure, a statistically significant reduction of the Gallwey-Ferriman Score (a measure of hirsutism), of LH, LH/FSH ratio, total testosterone, free testosterone , androstenedione, prolactin and the HOMA Index.

Both inositols reduced systolic blood pressure, LH, LH/FSH ratio, circulating androgens, prolactin and increased insulin sensitivity and SHBG. Myo-inositol may decrease in a more statistically significant way, the LH/FSH ratio, total testosterone, and the HOMA index. D-chiro-inositol is likely to reduce mostly, but not statistically significant, the LH and free testosterone levels and may increase, but not in a significant way, the glycemia/IRI ratio.

It could be concluded from this comparison that both the inositol isoforms are effective in improving the ovarian function and metabolism of women with PCOS, although myo-inositol showed the greater impact on the metabolic profile and D-chiro-inositol affected more positively the hyperandrogenism measurements. In comparing the two products pre and post treatment, there was a higher regularization of menstrual cycles in those treated with D-chiro-inositol compared to those with myo-inositol, although this was not statistically significant.

climbing or flame lily, Gloriosa superbaCommentary: Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in reproductive aged women. The majority of women with PCOS (about 74%) do not ovulate, almost half (about 42%) have insulin-resistance, and almost half (48%) have hyperandrogenism. It’s important to remember that PCOS is a syndrome… and not all women with PCOS have any one sign or symptom. Not all actually have multiple cysts on the ovaries, not all have excess body hair and not all have abnormal menstrual cycles. In women with PCOS though, the insulin-resistance is commonly associated with hyperinsulinemia which then enhances the production of androgens by the ovarian theca cells, leading to a reduction in circulating levels of sex hormone binding globulin (SHBG), which then leads to increased levels of free testosterone. Nutritional, lifestyle, nutritional supplements and pharmaceutical strategies try to address the syndrome by targeting this core issue of improving insulin sensitivity which thereby addresses the signs and symptoms of PCOS. Both myo-inositol and D-chiro-inositol in the doses used in this study, have benefit in improving ovarian function and metabolism in PCOS, but myo-inositol showed the most effect on the metabolic profile and D-chiro-inositol reduced the hyperandrogenism better.

Reference

Pizzo A, Lagana A, Barbara O. Comparison between effects of myo-inositol and D-chiro-inositol on ovarian function and metabolic factors in women with PCOS. Gynecological Endrocrinology 2014; 30(3): 205-208

In the current study, patients with proven and stable chronic obstructive pulmonary disease (COPD) were randomized to treatment with either N-acetyl cysteine (NAC) 600 mg twice daily or placebo, in addition to the treatments they were already using. Patients had a follow-up every 16 weeks for one year. After enrolling 120 patients with COPD who were at least 4 weeks after their last exacerbation, in the end there were 108 who completed the study with 52 in the NAC group and 56 in the placebo group. In the analysis patients were classified as a high exacerbation risk (a history of two or more exacerbations per year or a lung function forced expiratory volume < 50% or both). Those with a low exacerbation risk had a history of fewer than two exacerbations per year and a forced expiratory volume of 50% or more and no recent hospitalizationslungs xray related to COPD.

For high risk patients, this higher dose of NAC at 600 mg twice daily significantly reduced the exacerbation frequency at 8 and 12 months, a prolonged amount of time until the first exacerbation and an increased probability of having no exacerbations at one year, compared to placebo. For low risk patients, this dose of NAC did not have a significant effect.

Commentary: Chronic obstructive lung disease (COPD) includes a group of lung diseases that block airflow in the lungs and make breathing difficult. The two most common causes of COPD are chronic bronchitis and emphysema. In emphysema, the air sacs at the smallest end of the airway passages are destroyed. Chronic bronchitis is a chronic inflammation of the lining of the bronchial tubes. COPD is frequently associated with exacerbations which lead to a deterioration of lung function and quality of life. One of the primary management goals of COPD is to prevent these exacerbations. For those with a high rate of exacerbations, corticosteroid inhalers and phosphodiesterase inhibitors are frequent strategies. However, these regimens may be associated with corticosteroid inhaler induced pneumonias. Mucolytic agents have an important role in the management of COPD exacerbations because increased mucus secretions causes coughing and the mucus plugs can obstruct airways and lead to increased death.

Oral N-acetylcysteine (NAC) is known for its mucolytic effect, but also is a significant antioxidant and anti-inflammatory. NAC is also a free radical scavenger and a precursor of reduced glutathione which contributes to the inflammatory modulatory effect. This potent antioxidant and anti-inflammatory effect is best achieved with 100 mg per day or more. In one previous study, 1,200 mg/day was shown to improve exercise endurance in patients with emphysema related COPD. In another (the HIACE study), 600 mg twice daily reduced COPD exacerbations and improved small airway function. In a large 3 year trial, (the BRONCHUS study) NAC did not improve lung function or result in a decline in the frequency of COPD exacerbations, however it is suggested that this was due to a dose of only 600 mg/day.

COPD exacerbations are multifactorial (mucus hypersecretions, inflamed ciliated epithelial cells in the airway, excessive migration of neutrophils, a high amount of oxidative stress and lowered vital lung capacity.) I think this leans towards a good understanding of why NAC is the perfect supplement to reduce the frequency of exacerbations and perhaps severity, due to its antioxidant and anti-inflammatory effects, its mucolytic effects and its ability to inhibit the attachment of bacteria to the lung epithelium. It appears as though the effect is most significant in higher risk COPD patients.

Reference

Tse HN, Raiteri L, Wong KY, et al. Benefits of high dose N-acetylcysteine to exacerbation-prone patients with COPD. CHESE 2014;146(3):611-623.

Heavy menstrual bleeding is one of the more common gynecological reasonsginger-fresh and dried why women come to their health care provider. The experience and results of heavy menstrual bleeding can greatly impact quality of life just due to frequency of needing to attend to bleeding protection in the bathroom, restricting her desire or ability to go out of the house for daily activities or social engagements and limiting her exercise. Other consequences are the blood loss leading to iron deficiency anemia. Not only can this result in mild to severe fatigue, but changes in cognition, exercise tolerance, dyspnea and heart palpitations. The bigger picture is determining what is causing the heavy menstrual bleeding (defined as greater than 80 mL per menstrual cycle). Causes of heavy menstrual bleeding can include a simple anovulatory cycle due to stress or perimenopause, thyroid disorders, uterine polyps, uterine fibroids, adenomyosis, uterine pre-cancer, uterine cancer and von Willebrand syndrome. While some common herbs and medicines can be used to treat a particular episode of heavy menstrual flow, treating the underlying condition is particular to each of the causes mentioned.

A wide variety of over the counter, prescription and herbal medicines can be used. Some of these address the acute episode and others address the desire to control the blood loss for the next cycle. Conventional treatments include non-steroidal anti-inflammatory medications (NSAIDS), oral progestins, oral progesterone, hormonal contraception (oral, transdermal, intravaginal, intra-uterine) and tranexamic acid.

Herbal therapies for acute intervention have included herbal anti-inflammatories, herbal astringents, and herbal coagulants. Ginger has proven to be an excellent women’s herb, for dysmenorrhea, morning sickness, and now a randomized double-blind, placebo-controlled clinical trial.

In the current study, Iranian high school students had regular menstrual cycles and a recent history of at least one heavy menstrual cycle. These were girls who also had no gynecological disease, were not regularly taking hormonal medications or NSAIDS, did not have a vaginal or pelvic infection and were not overweight or obese. In the end, there were 46 girls in each group. Three consecutive menstrual cycles were monitored and scored for blood loss, before starting the ginger or placebo. Ginger capsules contained 250 mg of dried ginger, and took 1 capsule three times daily or placebo capsule 3 times daily starting from the day before menstrual bleeding until the third day of the menstrual period for a total of four consecutive days for the three months of menstrual cycles.

A scoring system for blood assessment was charted. Of the initial 92 participants, 71 completed the trial with 38 in the ginger group and 33 in the placebo group. The level of menstrual blood loss dramatically decreased during the three intervention cycles in the ginger group and was significantly better than in the placebo group. The average decrease in heavy menses in the ginger group started the very first month, and was even better the second month and then a little better the third month. There were no average hemorrhage changes in the placebo group. After the intervention, the ginger group decreased in mean hemorrhage by 46.6% and the placebo group by 2.1 %. Three girls had adverse events in each group: ginger= 1 heart burn, 1 abdominal pain, 1 diarrhea; placebo= 1 abdominal pain, 2 flatulence.

Commentary: I have been using ginger for acute heavy menses for years, although mostly in combination formulas with other herbs, so I am not surprised by the very good results of this study. Serum levels of Prostaglandin E2 and Prostacyclin are higher in women with heavy menstrual bleeding, which results in the vasodilatation and local platelet accumulation in addition to lower amounts of prostaglandin F2alpha which is responsible for vasoconstriction. Women with heavy menstrual bleeding also have more PGE2 receptors. It would be logical then that herbs and/or foods and/or medications that inhibit prostaglandin synthesis and leukotriene formation may provide the needed anti-inflammatory effect to decrease heavy menstrual blood loss. Other research has documented the anti-inflammatory and prostaglandin inhibitory effects of ginger. My most recent two favorite studies of ginger in women’s health has been for acute dysmenorrhea. Given that acute dysmenorrhea and heavy menses often come together, ginger becomes a leading candidate for this common combination of symptoms. However, don’t forget my earlier comments that it is always important to come to some determination as to the cause…. even if the conclusion is temporary anovulatory heavy bleeding.

Reference

Kashefi F, Khajehei M, Alavinia, et al. Effect of ginger on heavy menstrual bleeding: a placebo-controlled randomized clinical trial. Phytotherapy Research 2015;29:114-119.

happinessRhodiola rosea was recently studied for its safety and efficacy compared to a prescription anti-depressant, sertraline for mild to moderate depressive disorder. Sertraline (aka Zoloft) is an antidepressant in a class of antidepressants called selective serotonin reuptake inhibitors anxiety disorders, post-traumatic stress disorder and premenstrual dysphoric disorder.

This phase II randomized placebo controlled clinical trial involved 57 individuals who were randomized to 12 weeks of a standardized extract of Rhodiola rosea, sertraline or placebo. The Rhodiola rosea was a 340 mg powdered extract standardized to 3.07% rosavin. Study evaluation tools used were the Hamilton Depression Rating (HAM-D), the Beck Depression Inventory (BDI) and the Clinical Global Impression Change (CGI/C). Changes in scores over time were used for each group and compared.

Results: While the results were considered statistically non-significant, there were modest reductions for HAM-D, BDI and CGI/C scores for all the depression conditions. The decline in HAM-D scores were greater for those taking sertraline (-8.2 with a range of -12.7 to-3.6) versus Rhodiola rosea (-5.1, with a range of -8.8 to -1.3), and placebo (-4.6, with a range of -8.6 to -0.6). The odds of improving were greater for sertraline than Rhodiola (1.9 vs. 1.39), however, there were more individuals who reported adverse events on the sertraline (63.2%) than the Rhodiola (30.3%) or placebo (16.7%).

Commentary: While Rhodiola was less effective as an antidepressant than the sertraline, there were also significantly less adverse events and it was much better tolerated. For this reason, for many patients, Rhodiola may have a more favorable risk to benefit ratio for those with mild to moderate depression.

A small trial was published in 2008 in those with a diagnosis of general anxiety disorder. Participants received 340 mg daily of Rhodiola rosea extract for 10 weeks. Significant decreases in the mean Hamilton Anxiety Rating Scale were seen.

Rhodiola rosea, or “golden root”, is an herb that has been used in Russia, Eastern Europe, Scandinavia and Asia for generations. It has much more recently been introduced in the West. Traditionally, Rhodiola rosea was used in folk medicine with a reputation to increase physical endurance, productivity, longevity, resistance to high altitude sickness, fatigue, depression, anemia, impotence, gastrointestinal ailments, infections and disorders of the nervous system. The roots were used as bouquets to enhance fertility in young Siberian couples prior to their marriage. The tea was used for colds and flus during the hard winters in Asia. Rhodiola was highly coveted as a trade item by outsiders, and in exchange, they gave up their fine wines, fruits and honey.

The Vikings of Scandinavia used the herb to enhance their physical strength and endurance – something they came to be famous for. All of this folklore first led to investigations of its phytochemistry in the early 1960s that identified adaptogenic compounds in the roots of the plant. These adaptogens, as well as the later discovered antioxidant and neuromodulating compounds in Rhodiola rosea, are responsible for its medicinal properties.

Reference

Reference: Mao J, Xie S, Zee J, et al. Rhodiola rosea versus sertraline for major depressive disorder: A randomized placebo-controlled trial. Phytomedicine 2015;22(3): 394-399.

vittlesThere have been only 2 randomized clinical trials addressing whether or not vitamin and mineral supplements are effective for the prevention of cardiovascular disease. One of these, the Physicians’ Health Study II did not find an association between the use of a multivitamin-mineral (MVM) supplement and cardiovascular disease (CVD) in either incidence or mortality after an average of 11 years, in male U S physicians 50 years or older. The other study, the French Supplementation en Vitamines et Mineraux Antioxydants, randomly assigned women and men (women 35-60 y.o.; men 45-60 y.o.) to receive either the daily antioxidant combination (not an MVM – vitamin C, alpha tocopherol, beta carotene, selenium and zinc) or placebo and after 7.5 years CVD incidence was not statistically different between the two arms. In 2010, a large Swedish cohort study of women found that multi vitamins,(MV) without minerals, were associated with a reduced risk of myocardial infarction, and if they used them greater than 5 years, the association was even stronger.

The current study set out to examine the association between MVN and MV use and CVD mortality in US adults who did not previously have CVD. The researchers linked the NHANES II data and the 2011 National Death Index to examine the association between MVM and MV use and mortality due to CVD. These two large surveys provide data on over 10,000 adults 40 years and older. Data points included history of myocardial infarction, stroke, coronary heart disease, cardiovascular disease, non skin cancers, diabetes, alcohol, smoking, height, weight, blood pressure, cholesterol, triglyceride, glucose/glycolated hemoglobin testing, age, race, education, dietary supplements (vitamins, minerals, herbs) , and over the counter and prescription medications. A MVM was defined as 3 or more vitamins and at least 1 mineral. A MV was a vitamin combination without minerals. There were also 3 duration categories of < 1 year, 1-3 years and > 3 years.

Approximately 45% of the individuals evaluated had used a dietary supplement in the previous 30 days. MVMs were the most frequently used (21%) and MVs 14 %.

Results: Neither MVM nor MV use was associated with a lower risk of CVD mortality when they compared users with nonusers. However, when they looked at the length of time of use, there was indeed a significant inverse association for MVM use of > 3 years with a more than 35% reduced risk of CVD mortality in women, but not men. MV only, was not significantly associated with CVD mortality when combining men and women, although men only who had used MV for 1-3 years did have reduced CVD related mortality.

Commentary: It’s reassuring to see some positive data for MVM users and prescribers, and useful to see that longer use, in this case > 3 years is clearly associated with reduced mortality from cardiovascular disease. All kinds of critiques can be lodged against this kind of study, since it is not the gold standard randomized controlled trial. However, even RCT can be criticized because they are often of short duration and have a more homogeneous population of individuals being studied. The current study is strong in the robust diversity of individuals as well as a large sample that were older than 65, which is especially useful when looking at cardiovascular disease mortality.

There are many research studies on individual minerals, vitamins, amino acids, fish oils and herbs that show efficacy in both prevention and intervention in different areas of cardiovascular disease. Examples include magnesium intake and an inverse association with risk of strokes, reduced risk of ischemic heart disease and CVD mortality; protective CV effect of vitamin D; Hawthorne to improve outcomes of congestive heart failure; the many and diverse cardiovascular benefits in prevention and treatment for fish oils (strokes, CVD mortality, blood pressure, type 2 diabetes and more).

As a result of the current study, I will be more eager to recommend long term use of MVM for women in my practice and in my teachings.

Reference

Bailey R, Fakhouri T, Park Y, et al. Multivitamin-mineral use is associated with reduced risk of cardiovascular disease mortality among women in the United States. J Nutrition 2015 doi:10,3945/jn.114.204743

military ptsdData on post-traumatic stress disorder (PTSD) in women military personnel was evaluated at the Veterans Administration to determine the association between PTSD within 1 year of delivery and risk or a history of a prior diagnosis of PTSD and the risk of preterm birth.

In more than 16,000 deliveries, 19% were in women with PTSD including 12% with active PTSD. The risk for spontaneous preterm delivery was higher among women with active PTSD (9%) than those with a history of PTSD (8%) or those with no PTSD (7%). The majority of the women with active PTSD had experienced sexual trauma while in the military as well as depression disorders.

In a separate study of prenatal stress, researchers randomized 64, low income, pregnant urban black women who entered the study at 16-21 weeks of their pregnancy to receive either a supplement of 450 mg of docosahexaenoic acid (DHA) or placebo until their delivery. At 30 weeks gestation, those who were in the DHA group had a lower perception of stress than those in the placebo group. Those who received DHA also had lower cortisol output in response to arriving at the research facility and a better ability to modulate their response to a social stress test.

Commentary: I have to say that the aspect of these two studies that was the most striking was the high prevalence of sexual trauma experienced by women while in the military. Moving beyond that, both of these studies highlight the important impact of maternal stress and maternal well-being on birth outcomes. This study also highlights the potential of DHA in improving the maternal response to stress during pregnancy, yet one more reason for the importance of supplementing with fish oil during pregnancy. Clinicians should also conclude the importance of inquiring about traumatic experiences past and present and employ strategies to help manage trauma and stress.

References

Shaw J, et al. Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstet Gynecol 2014 Dec ;124:1111

Keenan K, et al. Association between fatty acid supplementation and prenatal stress in African Americans. A randomized controlled trial. Obstet Gunecol 2014 Dec; 124:1080

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