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hop conesThe use of herbal medicines, including those with phytoestrogen (weak estrogen-like, but not estrogen) compounds have gained an important place in the management of menopause symptoms.

Phytoestrogens are classified in 3 main categories of flavonoids, coumestans and lignans. The hop plant contains phytoestrogens including prenylnaringenin and is thought to be the most potent of all the phytoestrogen compounds.

The current study was a double-blind controlled randomized clinical trial performed in Iran in 2013. Women enrolled were postmenopausal women aged 40-60 years, with at least 12 months since their last menstrual period, and premenopausal women who were still having menses, but less than one per month in the last 12 months, had hot flashes and had a significant Greene scale score. A total of 120 participants were divided into two groups, with one group receiving a hops tablet that contains 500 mg of the flowering part of the hop plant and 100mcg of the prenylnaringenin active ingredient and the other group placebo. Each group received one pill daily for 90 days.

Menopause symptoms were assessed using the Greene scale and hot flash diary before study medicine was given and at 4, 8 and 12 weeks of intervention. The mean Greene score was significantly lower in the hops group than the placebo group at the end of weeks 4, 8 and 12. The number of hot flashes was significantly lower in the hops group than the control group during weeks 4, 8 and 12. The hops tablet reduced the total score of the Greene Scale in premenopausal and postmenopausal women at weeks 4, 8 and 12 as 38%, 69.5% and 90% respectively compared with placebo of 1.2%, 2.6% and 3.6% respectively. The number of hot flashes in premenopausal and postmenopausal women was reduced in the hops group by 35.5%, 70.5% and 94.5% respectively and in the placebo group by 1.1%, 0.4% and 0.8% respectively.

Commentary: This is the third study using a hops tablet or hops capsule for relief of hot flashes, and other menopause symptoms. In one randomized, double-blind, placebo-controlled study, 67 menopausal women were given either a placebo, 100 mg, or 250 mg standardized hops extract for 12 weeks (Heyerick A, Vervarcke S, Depypere H, et al. A first prospective, randomized, double blind, placebo-controlled study on the use of a standardized hops extract to alleviate menopausal discomforts. Maturitas 2006;54:164-175). At 6 weeks, the 100 and 250 mg doses were significantly superior to placebo, but not after 12 weeks. Even so, there was a more rapid decrease in menopause symptoms, especially hot flashes, for both doses of hops extract.

A 2010 randomized, double-blind, placebo-controlled, cross-over pilot study was done to examine the efficacy of a hop extract for relief of menopausal symptoms. (Erkkola R, Vervarcke S, Vansteelandt S, et al. A randomized, double-blind, placebo-controlled, cross-over pilot study on the use of a standardized hops extract to alleviate menopausal discomforts. Phytomedicine 2010;17:389-396.)

Thirty six menopausal women were randomized to take either a placebo or the hops extract for a period of eight weeks and then they were switched to the opposite group for another 8 weeks. Common menopause research reporting forms were used including the Kummperman Index (KI), the Menopause Rating Scale (MRS) and a multifactorial Visual Analogue Scale (VAS). These reporting forms were used prior to starting the study, after 8 weeks and 16 weeks. After 8 weeks, both the hops group and the placebo group had significant improvement in outcome measures compared to the baseline and actually higher average reductions in the placebo group. After 16 weeks however, only the group that was on the hops extract in the second 8 weeks had a reduction in all outcome measures whereas the placebo group in the second 8 weeks had an increase for all outcome measures. Although the overall treatment efficacy of the hops treatment compared with the placebo did not show a significant effect, the time specific uses did indicate significant reductions in the KI and the VAS for the hops group, and a marginal reduction in symptoms for the MRS after 16 weeks.

Of these 3 studies, I would conclude that this current, 2015 study is the most positive report to date, on the use of an oral hop tablet or capsule for reducing menopause symptoms, and in particular, hot flashes.

Reference: Aghamiri V, Mirghafourvand M, Mohammad-Alizadeh-Charandabi S, Nazemiyeh H. The effect of Hop (Humulus lupulus L.) on early menopause symptoms and hot flashes: A randomized placebo-controlled trial. Complementary Therapies in Clinical Practice (2015),

What if I told you there was a natural therapy that boosts the immune system, lowers blood pressure, improves mood, improves sleep, reduces stress, increases energy, increases focus, and speeds the recovery from surgery…..and, is free!!! I’m guessing you would say… “I definitely want some of that!”

Forest bench - Mt. TaborTurns out the healing power of nature is not just the innate inner healing force that is the primary principle of Naturopathic Medicine, but is literally true in that being in a forest does have physiological health effects, and it’s called Shinrin-yoku (taking in the forest atmosphere or forest bathing). This term was coined in 1982 by the Japanese Ministry of Agriculture, Forestry and Fisheries. There are many studies that have been published on the effects of forest bathing, but one published paper reviewing previous research highlights the essentials. (Park B, et al. The physiological effects of Shinrin-yoku: evidence from field experiments in 24 forests across Japan. Environ Health Prev Med. 2010 Jan;15(1):18-26 ) They conducted field experiments in 24 forests across Japan. In each experiment, 12 subjects, with a total of 280 individuals, walked in a forest or city area for approximately 16 minutes and viewed a forest or city area for approximately 14 minutes. The results of this study demonstrated that forest environments promote lower concentrations of cortisol, lower pulse rate, lower blood pressure, greater parasympathetic nerve activity, and lower sympathetic nerve activity than the city walking and viewing.

One of the mechanisms of forest bathing is that you breathe in phytoncides, (wood essential oils), which are antimicrobial volatile organic compounds derived from trees, and include a-pinene and limonene. But the healing power of nature does not stop at just the one sense of odor, but also the effects on all the five senses including listening to the sound of a running stream and taking in the beauty of the forest scene.

As precious forests in the West are burning this summer due to extensive droughts and extended hot weather, it only continues to remind me of the profound nourishment and fundamental human importance of our natural surroundings. I could go on and on, but then you’d have to keep reading and this would keep you from being out in nature, amidst the beauty and healing power of the forest.

Melatonin is a hormone secreted mostly by the pineal gland in response to the normal variations in the circadian cycle. As a dietary supplement, melatonin is one of the most common nutraceutical supplements that individuals try for self-treatment of their sleep problems and many trials have been done to assess its effectiveness in treating primary sleep disorders.

Primary sleep disorders are sleep problems that are not associated with a medical condition, substance use or a psychological disorder. Nine percent of Americans report insomnia and thirty-five to forty percent have problems falling asleep or are excessively sleepy during the day.

sleepwellThe current paper is a meta-analysis of melatonin for the treatment of primary sleep disorders. Nineteen studies involving 1683 individuals were included. Melatonin was significantly effective in reducing the time it takes to fall asleep (sleep latency) as well as increasing total sleep time. Trials that used higher doses of melatonin and conducted over a longer duration demonstrated even greater effects on these two sleep issues, and overall sleep quality was also significantly improved in melatonin users. Doses in adults included in the study were as low as 0.1 mg/day and as high as 5 mg/of. Three studies were in children and doses used were as low as 0.05 mg/kg and up to 5 mg/day.


While the results of this meta-analysis demonstrated what might be considered only modest results with supplementing melatonin in individuals with primary sleep disorders and improvement in sleep latency, total sleep time and sleep quality, these results support the use of melatonin as a nutrient intervention for many folks with chronic sleep problems. Multi-ingredient formulas that contain herbs that have demonstrated efficacy (ex/ valerian, passion flower, lemon balm, hops), along with melatonin may provide the opportunity to help more individuals.


Ferracioli-Oda E, Qawasmi A, Bloch M. Meta-Analysis: Melatonin for the treatment of primary sleep disorders. PLOS ONE 2013; 8(5)

Green tea plantationGreen tea has been studied for its beneficial effects on cardiovascular and metabolic diseases. Epigallocatechin gallate (EGCG) is the most abundant green tea catechin and is considered the most bioactive constituent that can reduce body weight by decreasing fat cell differentiation and proliferation. One study has demonstrated that green tea extracts and drinks could reduce body weight and body mass index in obese individuals in 2 months. (Basu A, et al. Green tea supplementation affects body weight, lipids, and lipid peroxidation in obese subjects with metabolic syndrome. J Am Coll Nutr 2010;29:31-40.) On the other hand, a study by some of the same authors of the current study found that 302 mg of EGCG daily did not reduce weight in obese women. (Hsu C, Sai T, Kao Y, et al. Effect of green tea extract on obese women: a randomized, double-blind, placebo-controlled clinical trial. Clin Nutr 2008;27:363-370.) The current study set out to increase the concentration of EGCG to a daily dose of 856.8 mg/day to examine the effects on weight in obese individuals.

This randomized, double-blind trial was conducted in 115 women with central obesity with 102 of them having a body mass index (BMI) >27 kg/m2 and a waist circumference > 80 cm. Women were randomized to either a high dose green tea group or placebo group for 12 weeks. One capsule of green tea or placebo was given three times per day, 30 minutes after meals for a total daily dose of 856.8 mg EGCG.

Body weight decreased from 76.8 kg to 75.7 kg after 12 weeks in the EGCG group. BMI and waist circumference were reduced from 31.0 cm to 30.6 cm and 95.1cm to 92.8 cm respectively. In the placebo group, only waist circumference and hip circumference reached significant reduction from 95.7 cm to 91.5 cm and 107.2 cm to 103.7 cm respectively. No differences were seen in weight or BMI.

The study also demonstrated a trend of decreased total cholesterol and decreased LDL cholesterol. Significantly lower ghrelin levels and elevated adiponectin levels were also seen in the green tea group than in the placebo group.

Commentary: Obesity is one of the most challenging issues in women’s health care. No one strategy produces consistent results in all women. Nutritional modifications, exercise programs, behavioral therapy, and agents that can affect insulin resistance, fat burning, fat oxidation and metabolic rates occupy central roles in efforts. Green tea and its main components, the catechins, including EGCG, are thought to influence body weight through mechanisms of thermogenesis and fat oxidation. The results of the current study with significant weight reduction and decreased ghrelin levels after EGCG treatment implies that a high dose of EGCG might increase energy metabolism and interrupt lipid accumulation and directly inhibit ghrelin secretion.

For perspective on dosing, one might look for a capsule of green tea extract of approximately 330 mg of which 45% is EGCG. If 2 capsules 30 minutes after each meal (three times per day), this would then be close to 900 mg of EGCG per day, slightly more than the 856.8 mg in the current study.


Chen I, Liu C, Chiu J, Hsu C. Therapeutic effect of high-dose green tea extract on weight reduction: a randomized, double-blind, placebo-controlled clinical trial. Clinical Nutrition 2015 1-8 (article in press)

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.


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!).


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……

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.


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.


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.

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