Modern herbal tradition: what we can learn from

practitioners who publish

- examples of Vitex and Cimicifuga

Dr Ann Walker
Senior Lecturer in Human Nutrition
Hugh Sinclair Unit of Human Nutrition
The University of Reading, UK

Member of the College of Practitioners of Phytotherapy

Member of the National Institute of Medical Herbalists
 Vitex: historical perspective of use

• Used by ancient Greeks and Romans to promote

chastity. Monks used it to reduce libido. Other uses by
the ancients included the treatment of injuries,
inflammation and epilepsy
• Mrs Grieve reports nothing on hormonal effects: “The
ripe berries are pounded to a pulp and used
in the form of a tincture for the relief of
paralysis, pains in the limbs, weakness,
etc.”
• Post WWII research in Germany established hormonal
regulating effects, including modulation of pituitary
function
• Double-blind clinical trial evidence of normalisation of
hormonal imbalance in women
• Late 20th Century use onwards by UK herbal
practitioners mainly for female hormonal imbalance
 Double-blind study
of Vitex treatment for cyclic mastalgia

Condition Number/ Significant

Duration outcome
Cyclic 20 Reduced
breast 3 symptoms
pain months compared to
placebo

Kubista et al. 1983

 Double-blind studies of Vitex
treatment for PMS

Reference Number/ Symptoms

duration significantly
< placebo
Schellenberg 170 Global PMS
2001 3 months score
 Active components of Vitex
berries
• Iridoids
• aucubin, agnuside
• Flavonoids
• casticin, isovitexin
• Other
• volatile oil (mixture of mono- and
sequi-terpenes), triterpenoids,
castine (a bitter principle), viticin (an
alkaloid)
Modern usage and perception of Vitex

• Nowadays mainly used to treat adverse

symptoms of the menstrual cycle and
menopause
• Understood from scientific studies, to aid
normalisation of both raised and lowered
plasma oestrogen - adaptogenic
• Action: modulation of pituitary function -
active component(s) of the herb mimic
dopamine, binding to dopamine receptors,
which lowers plasma prolactin
• Lowering prolactin helps counter anxiety
and reduces risk of dysfunction of hormone-
dependent tissues in both men and women
How far is the ‘modern perception’
of the therapeutic profile of Vitex
reflected in publications of herbal
practitioners?
 Vitex: Traditional use References
 Christie & Walker 1998) Eur J Herb Med 3, 29
 Williamson 2003 Potter’s Herb Cyclopaedia
 McIntyre 1994 Complete Woman's Herbal
 Mills & Bone 2000 Principles & Practice
Phytotherapy
 Bone 2003 Guide to Blending Liquid Herbs
 Ody 1993 Complete Medicinal Herbal
 Bartram 1995 Encyclopedia of Herbal Medicine
 Chevallier 1996 Encyclopedia of Medicinal
Plants
 Weiss 1988 Herbal Medicine
 BHMA 2003 Guide Traditional Herbal Medicines
 ESCOP 2003 Monographs
 Actions of Vitex

Main Actions No. citations

●●●●●●●●●
Dopaminergic

Hormone regulator

Hypoprolactinaemic
agent
●●●●●●●
Galactogogue
(promotes
lactation)
 Therapeutic use of Vitex
Uses No. citations

Menstrual irregularities, PMS ●●●●●●●●●

Insufficient lactation ●●●●●●●

Cyclical mastalgia ●●●●●●

Amenorrhoea/ infertility/acne ●●●●●●

Menopausal problems, ●●●●●

including hot flushes

Polycystic ovary syndrome ●●●

(PCOS)
Endometriosis ●●●

Hyperprolactinaemia ●●●
Calculation of “dried herb equivalents”
weight - g/day

• PER DAY
– Weight of dried herb by infusion or decoction
– Weight of powdered dried herb in capsules
– A fifth of the volume of 1:5 tincture (g)
– A third of the volume of 1:3 tincture (g) etc
– Volume of 1:1 fluid extract expressed in g
– Five times the weight of 5:1 dried broad-
spectrum extract etc
 Daily dosage ranges Dried herb equiv* g/d for
adults of Vitex agnus-castus berries according to
authoritative sources

H offm an '86

B artra m '95

Che va llier '96

ESC OP '03

B one '03

M & B '00 Engl ish-

M & B '00 Ge rm an-

0 1 2 3 4 5

*, extract as tincture (1:5), liquid extract (1:2) or fluid extract (1:1)

Cimicifuga racemosa
(Black cohosh)
 Black cohosh: historical perspective of use
• Ellingwood & Lloyd 1919
– “an efficient nerve sedative, although its most
pronounced action is on the unstriped muscles”
– “Through its influence upon the vasomotor centers
and upon the nerve ganglia, it has a beneficial
influence upon the heart.”
– Indications: angina, heart irregularily, irritable coughs, chorea, muscle
aches and rheumatic fevers, rheumatic arthritis, neuralgia, sciatica,
dysmenorrhoea, amenorrhoea, and orchitis.
– In pregnancy: “The agent is excellent in reliving irregular
pains and uterine distress occurring during the
course of pregnancy. It may be given in small
doses, and it thus prepares the patient for
parturition and undoubtedly contributes largely to a
short, easy and uncomplicated labor.”
• Mrs Grieve 1932:
– Indications: cough, whooping-cough, rheumatism and St Vitus’ dance in
children.
Ellingwood & Lloyd 1919 American Materia Medica, Therapeutics and Pharmacognosy
 Double-blind studies:
effect of 40 mg of dried black cohosh root/day for 3
months on adverse menopausal symptoms

Reference Total number Symptoms

of women in significantly
trial < placebo?
Wuttke et al 62 Yes, and
2003 ≡ oestrogen
Osmers et 304 Yes
al (p = < 0.001
2005
How far is the ‘modern perception’
of the therapeutic profile of Black
cohosh reflected in publications of
herbal practitioners?
 References for Black cohosh

 Williamson 2003 Potter’s Herbal Cyclopaedia

 BHMA 2003 Guide to Traditional Herbal Medicines

 BHP 1983 British Herbal Pharmacopoeia

 ESCOP 2003 Monographs
 Mills & Bone 2000 Principles & Pract Phytotherapy
 Bone 2003 Guide to Blending Liquid Herbs
 McIntyre 1994. Woman's Herbal
 Ody 1993 Complete Medicinal Herbal
 Bartram 1995 Encyclopedia of Herbal Medicine
 Chevallier 1996 Encyclopedia of Medicinal Plants
 Weiss 1988 Herbal Medicine
 Hoffman 1986 The Holistic Herbal
 Actions of Black cohosh
Main Actions No. citations
Sedative (cardiac) ●●●●●●●

Antirheumatic ●●●●●●

Uterine tonic/ stimulant emmenagogue/ ●●●●●●

parturient
Antitussive/ expectorant ●●●●●●

Antispasmodic ●●●●●

Hormone regulator/SERM*/ dopaminergic ●●●●●

Antiinflammatory agent/ Anodyne/ antiarthritic ●●●●

Diuretic ●●

Hypotensive/ vaso-dilator ●●

*, selective oestrogen receptor modulator

 Therapeutic use of Black cohosh - 1
Uses References

“Rheumatism” neuralgia/ intercostal myalgia/ ●●●●●●●●

cramps/ stiff neck/ post-exercise muscle

pain/ sciatica/ low back pain/ headaches
/migraine with hormonal element
Menopausal symptoms including hot flushes ●●●●●●●

and depression
Menstrual disorders: dysmenorrhoea/ ●●●●●●●

amenorrhoea/ menorrhagia/ ovarian pain/

PMS
Tinnitus ●●●●●●●

Arthritis, including rheumatoid ●●●●●●

Respiratory tract disorders: Whooping cough/ ●●●●●●

asthma
 Therapeutic use of Black cohosh - 2

Uses References
Child birth/ partus preparator/ uterine tonic ●●●●

Conditions with raised luteinising hormone: ●●●●

infertility/ miscarriage/ ovarian cancer/

polycystic ovary syndrome/ breast pain
Chorea ●●

Infections/ fevers/ scarlet fever ●●

Hypertension ●
 Daily dosage ranges of dried-herb equivalent
(g/day) for adults of Black cohosh according to
authoritative sources

B one '03 Engi sh-

M & B '00 Engl ish-

Che va llier '96

B H P '83

ESC OP '03 Ge rm an-

B one '03 Ge rm an-

M & B '00 Ge rm an-

0 1 2 3 4 5 6 7

*, extract as tincture (1:5), liquid extract (1:2) or fluid extract (1:1)

 Historical perspective on safety
• 19th century Eclectic and Physiomedical herbal
practitioners in 19th Century knew that overdose caused:
“….general relaxation, dimness of
vision, dizziness, tremors, slowing of
the pulse, fall of arterial pressure,
vomiting or gastric irritation: it
simulates expectoration and
perspiration, causes intense
headache and prostration.”
• According to ESCOP: “Although side effects of
overdose of Black cohosh was well known by the 19th
Century American herbalists, older data suggest that
daily doses of at least 5 g of unprocessed herb or 12 g of
fluid extract (equivalent to 12 g of dried herb) are needed
to cause any symptoms. These dosages are far in
excess of those which would be used by herbal
practitioners
Drs Ellingwood and LloydinAmerican
the UK.”Materia Medica, Therapeutics and Pharmacognosy (1919)
 Current Perspective on safety
• Williamson 2003 Potter’s Cyclopaedia
– “Mutagenicity, teratogenicity and other toxicity studies
have proved negative, and it is now considered to be
safe in women for whom conventional hormone-
replacement therapy is contraindicated.”
• ESCOP 2003 monograph
– “..caution that patients with existing oestrogen-
dependent tumours should not use the herb, remains
speculative.”
– “… the weight of evidence indicates that Black cohosh
does not influence the latency or development of
mammary tumours and it may even have an inhibitory
effect. Contradictory results have been resulted from
in vitro experiments on cancer-cell lines, but clinical
experience suggests no risk in the use of the herb.”
 • Contraindications
– “Patients with oestrogen-dependent
tumours, during pregnancy (except
to assist with birth). Do not use
during lactation without professional
advice.”
– “Black cohosh is best avoided in
patients with oestrogen-dependent
tumours, such as breast cancer, until
more information is available
regarding possible oestrogenic
activity.”
• Pregnancy
– Category B2 “No increase in frequency of
malformation or other harmful effect on the foetus
from limited use in women. Animal studies are
lacking.”
 Conclusions
• The writings of modern herbal practitioners
are an important resource for posterity for the
following reasons:-
– Reflect a modern perspective on the therapeutic
profile of a herb built from a synthesis of:
• Traditional use from ancient texts
• Traditional practitioner use for more than a
century
• Modern scientific findings
– Give physiological actions, lacking in ancient texts
– Give dosages, which are lacking in ancient texts
– Give indications for diseases which are
understandable in terms of our modern concept of
medicine