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Module 14: Advanced Gynecology Dysmenorrhea, Part 2

Hi ladies, and welcome to Part 2 of dysmenorrhea. We're going to talk about

supplements and botanicals that you can add to your toolkit.

Let's start with supplements, and I'm just going to give you the overview so I don't

make you fall asleep listening to all the studies. Basically vitamin D, very limited data,

but a study looked at large dose vitamin D 300,000 units given just before the period

for four cycles in a row, and did find in the women taking the vitamin D a substantial

reduction in pain scores. Interestingly, the greatest improvement was seen in the

women who had vitamin D deficiency at baseline. So keep in mind, similarly to PCOS,

what we really want to think about is getting women repleted to a healthy vitamin D

range, and that in and of itself becomes the important focus, and hopefully that takes

care of one of the root causes that can contribute to inflammation, insulin resistance, all

of the things that we see that can contribute to chronic inflammation and hormonal

imbalances, nutrient deficiencies.

Very limited data also on vitamin E, but two studies, one of 100 women and another of

278 women age 15 to 17 in the second group, did demonstrate that in one group after

a two cycles with vitamin E there was a 68 percent improvement in pain with

dysmenorrhea, and after three cycles a 76 percent improvement. In the other study,

there was actually significant improvement in both pain duration and pain intensity,

and a small, interestingly, reduction in blood loss with the vitamin E group compared

to placebo. The reason I say interestingly is that the one study shows a decrease in

N E W M E D I C I N E F O R W O M E N I N S T I T U T E

n m w i

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blood loss, but the other study gives the caveat that vitamin E can increase bleeding

time and so it should be avoided in patients with clotting disorders or taking an

anticoagulant. I would just say don't use vitamin E in patients with clotting disorders or

on an anticoagulant. But certainly both vitamin D and vitamin E are affordable, easy to

take, readily available supplements that if they would give women relief from

dysmenorrhea without having to use an NSAID, it's worth trying it for two to four

months, which is the length of these trials where results were seen.

Calcium has been used as an antispasmodic in general, and it is associated with uterine

spasms and contractions. And again, surprisingly limited studies for both calcium and

magnesium, both which we use to support healthy uterine contractility and relaxation.

In one study women were given — it was a substantial number of women, 497 women

were given 1200 magnesium or a placebo for three menstrual cycles, and subjective

rating scales did show a substantial reduction in pain scores in the treatment group

during the luteal phase. Interestingly, and this was by the third cycle, it was really

premenstrual pain that was relieved and not interim menstrual pain that was relieved

with the calcium in this one study.

In another study 1000 milligrams a day for three months of calcium carbonate was

considered to be effective for reducing menstrual pain compared to placebo. A study

looking at calcium and vitamin D together, interestingly, really found the greatest

benefit from calcium alone. This was 1000 milligrams of calcium carbonate I'm given

for, let's see, I think it was six cycles in this one. Oh, no, the women had had painful

cycles for the previous six cycles, and they took the calcium, calcium and vitamin D or

placebo, and that was for one cycle. In the calcium vitamin D group there was a 20

percent improvement, but in the calcium group alone there was a 32 percent

improvement. It's kind of interesting because they were given I think the same amount

of calcium in both groups, so fairly interesting. And menstrual blood loss was not

changed in either.

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Now, one supplement that I have not used in my practice for menstrual pain, only

because my tried and true root cause botanicals, adding magnesium approach has

always seemed to be really effective, but that is thiamine. I actually learned about it

about a year and a half ago and just haven't had a call to use it. There was only one

study that I could find, and it was from 1996. It was an Indian study looking at 556,

they'd described them as girls, but young women age 12 to 21, who had moderate to

severe spasmodic dysmenorrhea. They were given 100 milligrams of B1 orally for 90

days. The results were actually pretty significant. The B1 group had an 87 percent

where they described them as completely cured, 8 percent in the placebo group — I’m

sorry, let's see. Eighty-seven percent were completely quote-unquote “cured,” 8

percent had pain relieved, and 5 percent had no effect whatsoever. And interestingly,

the results actually remained the same two months later when B1 wasn't being given

any more.

You know, one study doesn't make for a strong argument. On the other hand, B1 is

safe to use at this dose, so if you had somebody with moderate to severe spasmodic

menstrual pain, I would certainly include it and see. You can either include it from the

get-go for a couple of months and see if your client or patient gets benefit, or add it in

if you're not getting the results you want from other supplements or botanicals that

you're using.

Again, you know, with magnesium, I've been really surprised at the limited data given

how commonly magnesium is used as a muscle relaxant in general. Basically

magnesium is a cofactor in — it not only is muscle relaxing through a number of

channels, but one of the channels is that it actually is involved in production of anti-

inflammatory prostaglandins. And remember we talked earlier about the high level of

PGF-2 alpha in the women who have much higher, seven times higher levels in women

with dysmenorrhea. This is producing a counter-regulatory or anti-inflammatory, and

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also smooth muscle relaxant form of prostaglandins. They are both inflammatory and

anti-inflammatory forms of prostaglandins.

In one trial not only was dysmenorrhea improved, but also there were therapeutic

effects on low back pain in women who took magnesium. In my practice I use

magnesium fairly consistently in my women who have dysmenorrhea. What I usually do

is I start them out on 300 milligrams a day and then go up to 600 milligrams about

three to five days before their period is due, and then stay on it for the first two to

three days of their period. If that dose doesn't really do much over the first cycle, then

in the next cycle I will have them go up to 600 milligrams a day, and then for that five

days, the three days before, two days of, go up to 1000 milligrams and see if that

helps. And often they will notice significant improvement.

Essential fatty acids, again, mixed trials, limited data, but overall enough data to

suggest that it may be beneficial. In my patients with dysmenorrhea I do include

essential fatty acids. I use fish oil in my practice and I do a relatively high dose. I will

do up to like 2 grams combined DHA and EPA.

As you see in this one trial of 42 young women with dysmenorrhea, 720 milligrams of

DHA and 1080 milligrams of EPA was found to be beneficial, with a 73 percent

reduction in subjective pain score. But interestingly, vitamin E was used as well, so it's

hard to know what the contribution is from the DHA versus the EPA.

Here's a study that actually looked at krill oil and found krill oil to be somewhat more

beneficial than fish oil. There's a lot of controversy around the sustainability of krill oil,

so I use fish oil in my practice. There's another study, this was a four arm clinical trial

looking at fish oil, B1. This was in high school students, and the young women were

randomized to receive either B1, fish oil, both, or placebo. After a two month

duration, the intensity and duration of pain significantly decreased in all the treatment

groups compared to placebo.

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In yet another trial, outcomes were improved over controls. And you know, just so

you're aware, salmon, tuna, and halibut also contain linoleic acid, which has been

shown to help relax the muscles by increasing anti-inflammatory prostaglandins, and

pumpkin seeds, flax seeds, sesame seeds, and sunflower seeds also mildly induce the

anti-inflammatory prostaglandins.

When I am treating medically, I will make sure that she's got fish in her diet, if she is

willing to eat salmon. I don't include tuna because of the high mercury. But I will

typically supplement rather than just rely on diet, and I’ll supplement for three months

and see if we get benefit. If not, then I'll go on to a different protocol. And of course,

that's all in conjunction with addressing the root causes.

All right, let's talk about one of my favorite subjects, botanicals. Ginger root is used

historically both internally and topically as what's called a warming circulatory

stimulant. It brings circulation to an area, and as such, it's thought to help relieve pain;

pain in both classical Greek medicine upon which Western medicine but also

integrative medicine are built, the eclectic medicine, and many traditional cultures like

TCM or Ayurveda look at cold as being a contributor to stagnation and pain, whereas

more fluid, flowing circulation and warmth as pain relieving.

The eclectics used ginger in many different ways for menstrual cramps. They gave it as

a hot tea, a tincture, a fomentation, or a hot bath. Interestingly, if you were listening to

the previous module of the previous lesson on PCOS, you might have heard me

clearing my throat. I had actually had some coffee with some milk in it and it caused

me to be congested right before I gave the talk. And I thought, uh-oh, I better drink

some ginger tea right before the next one. And notice the difference? I mean, literally

all I did was went from the last PCOS talk to the ginger talk, to this talk on

dysmenorrhea, and that was the difference in my throat clearing was just that ginger.

And lesson learned; don't ever use anything with dairy in it before you go on stage.

I've learned that lesson before, but it seems to be the one that I repeat as a speaker.

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Anyway, ginger was also used as in tincture form, also something called a fomentation,

which is essentially a hot compress, and also hot baths, all for dysmenorrhea. It's also

been found to relieve nausea which makes it especially beneficial with dysmenorrhea.

Also if there's diarrhea, kind of a cold, crampy feeling in the belly. It also has been

shown to exert anti-inflammatory effects via prostaglandin synthesis, and it has activity

as a thromboxane synthetase inhibitor and prostacyclin agonist. All of these make it

responsible for both the anti-inflammatory and analgesic effects in dysmenorrhea. That

is a superscript from my textbook, but the reference is below.

There have been a limited number of trials, but actually more than with some other

things, like even more than with magnesium. There was a 2013 trial looking at ginger

on the treatment of primary dysmenorrhea in 70 college students who either got

ginger or placebo capsules during the first three days of their menstrual cycles. And

after two months, those receiving the ginger capsules had significantly less pain as

reported by a visual analog scale, a Likert scale, which is one of those sort of one to

five, very much or very little or extreme or not at all scales, and a Wilcock scale

compared to placebo.

Another trial from 2012 which was 120 college students tested efficacy of ginger

compared to placebo for primary dysmenorrhea. Two protocols were used. In the

first, 500 milligrams and placebo capsule were given two days before menstrual onset

and continued through the first three days. In the second, these were given only for

the first three days of the menstrual periods, so not during the two days before.

According to the visual analog scales, there was statistically significant improvement in

symptoms of pain for the ginger treatment groups with the first protocol where they

got total five days associated with less pain than in the second. Again, these

parenthetical references are from my textbook.

Another clinical trial in that same year with 75 students also tested two protocols. This

study also found that ginger statistically significantly improved symptoms of

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dysmenorrhea compared to controls. A 2009 study compared ginger to mefenamic

acid and Ibuprofen. One hundred and fifty women with primary dysmenorrhea were

randomized into either a ginger treatment group, a mefenamic acid group, or an

Ibuprofen group. They were given their treatment four times a day for the first three

days of the period, and outcomes were measured using a verbal scoring system at

baseline and then one after the menstrual cycle. End point scores indicated

improvements compared to baseline, but there weren't statistically significant

improvements between the treatment groups.

Now, this may sound like a negative study, right? There were no improvements

compared to each group. But think about this. You're comparing ginger to two other

forms of an NSAID, so that is a positive study for ginger. What it's saying is it worked

as effectively as the NSAIDs.

Probably the most reliable and easy way for women to take it is in a capsule. That is

because you can't really quantify the strength of the ginger that you're using in a tea.

You can also use tincture. It's spicy and strong, so I typically recommend capsules. But

ginger tea is great to sip on the first couple of days of your period. It's warming, it

feels good, it’s just nourishing. And certainly you are absolutely welcome to use things

like hot ginger baths. I have certainly done that in my practice over the years. I find it

to be a little bit more daunting for women to prepare themselves, so I typically lean

towards using the capsules in my practice.

The dose is 500 milligrams three times a day, but you can go up to 1000 milligrams a

day, so you can do up to 1000 milligrams three times a day. I typically recommend it

over the course of the day in divided doses.

And with any of these things, you can always start out with any of these interventions.

Ginger you can use acutely and give it cumulatively over time to get general

improvement so that it's preventative, but you can always add on the pharmaceutical if

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it's needed. If she's just not getting adequate pain relief, or again, she has something

to do that really requires her focus and she cannot be distracted by background pain

or significant pain, then you can always up your ante and go to the pharmaceutical for

a short duration.

Cinnamon, much like ginger, has been found to be effective for reducing pain,

menstrual bleeding, nausea, and vomiting. I typically go toward the ginger because

overall ginger has a generally safer profile. Cinnamon is generally considered safe, but

ginger is really considered across the board very safe.

One trial looked at 38 women with moderate menstrual cramps and regular menstrual

cycles. Thirty-eight received a placebo and 38 received 420 milligrams of cinnamon

bark in capsules, with two capsules taken three times a day for the first three days of

the period. The mean pain severity score and the mean duration of pain were less in

the cinnamon group than the placebo group, and the amount of bleeding actually also

decreased significantly at 24 hours and 48 hours in the cinnamon group, but not in the

placebo group. And that's not something we see a significantly with ginger. So if you

have someone who has really heavy periods and she's having a lot of pain with those, I

would recommend combining the cinnamon and the ginger together.

Now, the other issue with the cinnamon is what species of cinnamon that you're

getting. You either want — typically it’s the cinnamon cassia that's being looked at in

these studies to my knowledge, so that's what you want to look for in a capsule

product. Or if she's making her own capsules you need to get that form of cinnamon,

and it's typically a capsule as opposed to a tea. And I would be careful using tea with

cinnamon because people can have topical sensitivity reactions. That's very common

with cinnamon, so I typically would use it in a capsule if I'm going to use it. But again,

it's not my go-to.

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A surprising herb for menstrual cramping is valerian. We usually think of it as for sleep.

But one study of 100 women found that 225 milligrams a day for the first three days of

the period dramatically reduced menstrual cramps compared to placebo. And it's very

safe. A lot of women experience, one, sleep disruption due to menstrual cramps, but

two, insomnia, as we talked about in the PMS lesson, around their period. For those

women I would absolutely include valerian in my protocol, and I would start it three

days before the period and then continue it into the first three days of the period. But

for women who are experiencing those sleep problems or PMS, then just go ahead and

start it on the first day of the period. Absolutely a wonderful herb for women with hot

flashes or with PMS.

And at this dose it isn't likely to make someone sleepy at all. This is a tolerable,

functional dose that they can take during the day as well. But I recommend starting it

on a day off from work when someone isn't driving and they're not having to focus and

concentrate, because some people will react quite robustly to it and don't need quite

as high a dose. I would start with a day off, see how she does. If she's not sleepy, then

you can include it on her first three days of her period regardless.

Fenugreek is another interesting one. We think of fenugreek for low milk production,

for example, but it can be used as well for premenstrual pain. A recent double blind

clinical trial found that it was used in symptoms of dysmenorrhea. This is a treatment

that goes back to ancient times. Dysmenorrhea was treated with fenugreek in ancient

Syria, for example. In this study 101 women of similar age, BMI, and baseline levels of

menstrual cramping were randomized to receive either ground fenugreek seed

capsules at 900 milligrams three times a day, or a placebo again for the first 30 days of

the period for two menstrual cycles. A visual analog scale was used to assess pain, and

both the placebo and fenugreek treatment groups exhibit lower pain compared to

baseline after two months. But the decrease observed was far more statistically

significant in the fenugreek group.

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Here's another interesting study, chamomile. We think about chamomile classically

and traditionally for abdominal pain. But this was a small study looking at chamomile,

and this was using 250 milligrams of chamomile capsules three times a day from day 21

until the first day of the period for two cycles. This was compared to mefenamic acid.

Let’s see. I've jumped ahead of myself here. In this study, after two treatment cycles,

women reported significant reduction of psychological symptoms in chamomile, and

similar results of physical symptoms. The mefenamic acid group versus the chamomile

group, both got reduction in menstrual pain, whereas the women who were getting

chamomile reported much more improvement in anger and irritability, but the

mefenamic acid was more helpful for overall pelvic pain as well as arthralgia and

muscle aches.

Chamomile is an herb that I use a lot in my practice. I love it for sleep, I love it for IBS, I

love it for IBD, general aches and pains. I have not gone to it as a primary herb for

dysmenorrhea. I include it because it's in the medical literature. I think the data is

limited. It doesn't mean that I wouldn't use it, but I typically go to my magnesium, my

ginger, and other botanicals, valerian definitely, and some of the other botanicals I'm

about to share with you.

Now, Vitex is a really interesting one. There is a lot of data around Vitex for PMS, less

so around dysmenorrhea. But in this 2014 clinical trial Vitex was compared to

hormonal treatment for the treatment of severe primary dysmenorrhea, and this was

done while assessing uterine artery blood flow via ultrasound. Who Thought of this? I

have no idea. Ninety women were enrolled in the study, 30 remained controls, and the

rest were randomized to receive either the estradiol combination or the Vitex for three

menstrual cycles. Outcomes were visual analog scale for pain, pulsatility index, and

resistance index of the uterine artery. The PI and the RI values in the women with

severe primary dysmenorrhea were significantly higher on day one, but were lowered

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during the course of the treatment, and there were no significant differences in the

treatment group observed at all. Overall this was thought to be a beneficial study.

Vitex is not a typical herb that I go to, nor do herbalists go to for dysmenorrhea, unless

somebody, for example, has luteal phase defect and we have them on it for, for

example, low progesterone. But that really doesn't have that much of an impact on

the dysmenorrhea. It may have an impact on premenstrual migraines and other

symptoms. Again, I include this one more for the fact that it's in the literature and it's

interesting, as opposed to it being one that I go to for menstrual pain. I literally never

do.

Fennel is a really interesting one. Like fenugreek, fennel goes back to ancient times for

the treatment of dysmenorrhea. It's thought to be related to the antispasmodic effects

that we see from fennel essential oil, which is why we use fennel essential oil for babies

with colic; it's an anti-spasmodic. Recent data does show some promise in the

treatment of dysmenorrhea. A three month, three cycle clinical trial of 30 women,

people clearly like the number three in that study, compared the efficacy again of

mefenamic acid with a 2 percent fennel seed essence extract. The first cycle was a

control cycle with no anything administered. In the second, women were given the

pharmaceutical, and in the third cycle women received the fennel extract, and results

were based obviously on a subjective self-scoring system, that's how pain is typically

scored. Both treatment groups showed improvements in symptoms compared with

the control cycle. Mefenamic acid had a more potent effect than fennel on the second

and third menstrual days. However, the differences really weren't significant on the

other days. There were no complications reported in either group. However, there

were five women that withdrew from the study because they didn't like fennel odor,

and one person reported a mild increase in the amount of her menstrual flow, which

actually wouldn't be entirely surprising because there is some increase in estrogen with

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essential oils. It shouldn't be substantial, and so it might not have had anything to do

with the fact that she was taking it, but it's also not out of the question.

I would say that you can certainly include fennel seed oil in a capsule form. I definitely

have some concerns about giving essential oils orally in concentrated form, so I always

personally go to my ginger, my magnesium, and again, some of the herbs I'm going to

show you like cramp bark. But fennel is absolutely something you could include in a

protocol if you weren't getting results from those other approaches.

A couple more studies looking at fennel seed extract, one again showing improvement

in visual analog scale and also something called the McGill questionnaire, as well as

three other questionnaires. And in this one, interestingly, women had not only

decreased pain but also less nausea and decreased duration of menstruation. For

women who have very prolonged periods you might consider that. That would be sort

of the opposite of the estrogen argument. And in this one, this was looking at

reduction in intensity of oxytocin and PGE2 induced contractions specifically with

fennel oil.

Again, something to consider. The studies are limited, but they're more than

magnesium or some of the other supplements we have, and certainly safe and

something to consider. And you can do this just in the days prior to menstruation, so

it's not like you're giving it all month long. Honestly I would consider it a safer bet than

using something like Ibuprofen for three to five days of the month.

All right. Some of my favorite herbs are cramp bark, black haw, and also black cohosh

for menstrual cramps, and really no clinical data at all. But if you look into the eclectic

literature, remember the eclectics were the doctors before our modern day doctors

and were basically run out of town for them. These were the primary pharmaceuticals

that they were using. Cramp bark is obviously pathognomonic for what it does, right?

It helps with cramps. These botanicals had been looked at in the early 1900s. There

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were various studies looking at, for example, muscle contractility in vitro, observational

data from the eclectics. And interestingly, cramp bark was actually listed as a sedative

and an antispasmodic in the U.S. Pharmacopoeia from 1894 to 1916 and in the

National Formulary all the way until 1960. So these were considered conventional

pharmaceuticals.

And what we're using now for pain relief, ladies, is not so great when you think about

the narcotics epidemic we're experiencing. If you can get benefit from using

something that's gentle and safe, even in the absence of data, I would say really, really

worth trying. In my practice, no doubt that these for many women are very beneficial,

and I'm going to share some specific formulas that I use in my practice, and you can

find products on the market that have similar combinations, or you can teach your

clients to buy the individual tinctures and then combine them herself.

Black haw and black cohosh are very similar in their chemical constituent profile.

They're both in the Viburnum family, that's a tree family, and so they can basically be

used interchangeably. Cramp bark is the one that's more readily available on the

market. And in my practice, I use these in liquid extract or tincture form. The typical

dosing is anywhere from 2 to 4 milliliters repeated anywhere from three times a day to

every two hours if you're really having significant dysmenorrhea.

Black cohosh, again, is full of surprises, isn't it? We saw it in PCOS and here we're

seeing it again for its antispasmodic and anti-inflammatory effects, which was actually

primarily how it was traditionally used. It has many constituents in it. It does have a

small amount of salicylates in it, so I don't recommend it for people who have a known

aspirin allergy. But for everyone else there is not significant amount of contraindication

that you ever hear about cautions around the salicylates with a black cohosh. And it is

approved by the German Commission E for what they call premenstrual complaints and

dysmenorrhea. It's indicated for musculoskeletal pain, nervous tension, and classically

for its anti-inflammatory and analgesic effects. In fact, it's one of the herbs that I

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classical use for the flu symptoms instead of Ibuprofen. Again, similar dosing around 2

to 4 milliliters, and this time, I usually recommend it not more than six times a day, but

typically every four hours for dysmenorrhea.

Motherwort I've mentioned to you before, “she,” as I call her, is absolutely my favorite

herb in the world. Again, no or very limited clinical data, but what we do know is that

from a phytochemical constituent profile it acts as an anti-inflammatory and also acts as

a muscle relaxant. Here you see it enhancing the anti-inflammatory PGE2 series

compared to the PGF2 alpha, which are the pro-inflammatory ones that we see more in

dysmenorrhea. I typically use the Leonurus cardiaca. There are a number of different

forms. The Leonurus cardiaca is the one typically that we use for dysmenorrhea.

Here are a couple of herbal formulas. These are from my textbook, but also ones that I

use in my medical practice today, still to date. This is combining equal parts of either

cramp bark or black haw, wild yam, which is an anti-inflammatory and anti-spasmodic

classically used for uterine cramping, motherwort and black cohosh as well as ginger.

You get a 100 milliliter bottle. An ounce is 28 milliliters, so it's basically a 4 ounce

bottle or 100 milliliters depending on what size bottle the company you purchase from

sells. You can get bottles from a company online like Mountain Rose where they will

sell you a very small amount of bottles, so you can buy a bottle, or four bottles if you

want to mix this yourself. Be mindful that any practitioners who mix and sell products

in their practice are liable for the products. So if something happens, you want to be

careful, or you can send someone to a company to get — you can find many, many

products on the market that will have similar combinations; Vitanica, Herb Pharm, Gaia

Herbs, Herbalist, and Alchemist are all examples of companies that will have similar

products.

The dose is two to four milliliters up to three times a day, although I, in my practice,

actually will exceed that and even go up to six times a day of the 2 milliliter dose.

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If you have someone who has severe cramping pain, you can add 1 milliliter of

Jamaican dogwood every two hours, not to exceed six doses a day for two days. Or

alternatively, you can make a Jamaican dogwood combination with cramp bark,

Jamaican dogwood, corydalis, and Pulsatilla. The dosing on this has to be explicitly

stated as much, much lower. It's 1.5 milliliters every 20 minutes, and then 20 milliliters

every 30 minutes for up to four doses. And you can repeat that twice daily, but do not

exceed that range. You're not doing the higher dosing, you're doing a lower dosing in

a shorter, more concentrated period of time. Or what you can do is get — preferably

much easier to get dosing on and get a product, get the Gaia Herbs turmeric Pain PM.

It has Jamaican dogwood in it, and I believe it has corydalis in it as well.

You do have to be careful with Jamaican dogwood and Pulsatilla. Overdoses of them

can be toxic, so I don't recommend using that formula unless you're incredibly

comfortable with botanicals. I would stick with the first formula, and then the 1

milliliter dosing of Jamaican dogwood as instructed there. And again, Mountain Rose

Herbs, great go-to because you can buy the bottles and you can buy these singly, or

your client can, or she can just get a combined product from somewhere like Herb

Pharm.

All right, back to peony and its benefits. We've talked about peony and licorice a

number of times. Peony actually is specifically beneficial for both primary and

secondary dysmenorrhea. It's used in TCM for many, many different gynecologic

purposes, but it is specifically also used for dysmenorrhea and muscle cramping. It's

thought to be a compound in it called paeoniflorin that has smooth muscle relaxing

activity which has been seen in vitro in rat stomach and rat uterus muscle testing. This

is how muscles are tested.

Additionally, it's been thought in TCM that dysmenorrhea is related to chi and blood

stasis. Again, back to what I talked about earlier about that cold congestion. And

dysmenorrhea has been treated with peony and licorice root combination, as well as

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other botanicals, including a formulation that has peony in the form called suffruticosa,

another herb called Poria, and then cinnamon, which you see here, and Prunus persica,

which is actually peach pit.

There have been several clinical trials that have been conducted with a formula called

Shakuyaku-kanzo-to for the treatment of dysmenorrhea. That is peony and licorice

formula that you've heard me mention several times. So definitely a go-to in my

practice is peony and licorice formula for many different gynecologic concerns. And

very often even without doing a TCM differential diagnosis, if I have a patient with

dysmenorrhea, I will use this peony and licorice formula. And I will also use it, we saw

this in PCOS, will see it in endometriosis, so for secondary dysmenorrhea as well. This

is just sort of reiteration that the peony and licorice combination may be helpful

specifically through preventing inflammatory prostaglandin production.

I wouldn't be complete in a lesson on menstrual pain without discussing one of the

herbs that women are most likely to self-medicate with, which is cannabis. This image

here is from a product that was distributed when botanicals and pharmaceuticals were

the same exact thing, and this was a specific product called dizmanine [phonetic]

compound. And if you look at the first ingredient here, this is cannabis. This was a

picture given to me by Ethan Russo, who's a pediatric neurologist, but one of the

foremost international researchers on the medicinal use of cannabis. He used behind

Sativex and other products that had been created pharmaceutically and a strong

proponent of the use of cannabis pharmaceutically for women with menstrual cramps.

And as I said, this is one of the most common go-tos for women to self-medicate. And

not only has it been found to be beneficial for menstrual pain by women clinically, but

also for nausea, headache, abdominal cramping, general musculoskeletal pain, and

even for some women for anxiety. There's very strong historical and self-medicating

data.

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One study that is in the literature concluded that CB-1, cannabinoid 1, and to a lower

extent cannabinoid 2 receptor activation, and there are a tremendous number of

cannabinoid receptors in the uterus, results in selective inhibition of myometrial

contraction without unspecific relaxation. Generally you're getting sort of this very

specific uterine muscle relaxation, and that may be why cannabis is effective for

menstrual cramps. It acts as a tocolytic, meaning that it reduces uterine contraction.

Interestingly, as of 2017, the New York State Assembly was considering adding

dysmenorrhea to the very limited list of medical conditions for which doctors can

legally authorize a patient to use medical marijuana. Medical marijuana is now legal in

New York state. I don't know whether they have, in fact, as of this time of recording in

early 2018 added that officially to the bill. But just to give you a perspective, New York

State is a very restrictive state when it comes to its medical laws, and there's a very

short list of what doctors can legally prescribe for. That gives you a sense that this

would be actually something considered beneficial.

Whether to recommend your patients use or not and self-medicate or not, it gets more

complicated based on legalities. Obviously you don't want to recommend illegal things

to your patients, particularly if you have a license that you could lose. If they're already

self-medicating, you might just not criticize it and actually support their use by saying,

well, there is literature and that, you know, I can support that. In legal states you can

certainly refer them to someone who has prescribing ability. Certainly if they're using

illegally, you want to really encourage them to be incredibly careful about their

sourcing because it can be contaminated with anything, even PCP. I've seen that

happen. Actually it happened to a family member of a friend, a dear friend, and it was

very traumatic for their college age child who accidentally got dosed with PCP. It’s

called illy when PCP is in pot. The other options are to use CBD oil. Again, no data

behind it that I know of. Some people do get high or anxious from CBD oil just the

way they do from cannabis, and if somebody has an anxiety disorder and cannabis

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makes them more anxious, I would steer them away from it and toward the other

things.

And you can also actually get cannabis tincture. In fact, at one point somebody gave

me a lovely cannabis and cramp bark tincture that my daughter, when she was in early

high school, went through a short period of time where she had what seemed like a

stress headache, possibly a migraine, and she used it for symptomatic relief, not in

school of course, and found it to be tremendously beneficial. Again, Ethan Russo is the

researcher. If you're somebody who’s interested in cannabis and women's health, his

work is the work to go to.

Just a few adjunct therapies, continuous low level topical application of heat, whether

using a hot water bottle or a heating pad has been shown to be as effective as

Ibuprofen. Acupuncture has become a popular treatment for menstrual pain, and the

NIH does recommend it, either by itself or along with other treatments. And there is a

small study that did find that women treated with acupuncture had less pain and

needed less medication. And also an acupuncture study found that women benefited,

who had acupuncture and Ibuprofen, were better than placebo at reducing pain.

Aromatherapy, I mentioned aromatherapy oil massage earlier in this module, in this

lesson, and that has been found to be effective for women, so not just massage alone.

Massage alone may be beneficial and acupressure massage may be beneficial, but

acupressure or massage with a combination essential oil and rose and lavender seem

to be the sort of two oils that have been found to be beneficial, at least in two studies.

I typically recommend Arvigo massage to my patients. I recommend finding an Arvigo

massage practitioner. Arvigo massage, I believe I've mentioned it earlier in the course,

but it was created by my long term colleague and friend Rosita Arvigo, who

apprenticed with a man in Belize who then passed on his tradition to her. Mayan

abdominal massage is a classic traditional massage, and Rosita took that and kind of

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created a system and created her own brand around it. You can look for Arvigo

certified massage therapists. There are no studies that have been done in it, but I do

often recommend it in my practice for women with chronic pelvic pain, for women with

interstitial cystitis, for women with dysmenorrhea, fertility issues, and uterine prolapse.

Restorative yoga is something I recommend all the time in my practice. I encourage

my patients to get Yoga Glow and try the trial for their two weeks that you can try it for

free, and use their restorative yoga. There are also some specific yoga practices for

women with menstrual cramps, so I recommend they go to those. One study actually

did look at cat, cobra, and fish pose among 92, they call it girl students, but women 18

to 22 years old, and did find that there was a significant reduction in pain intensity and

duration in the yoga group.

And then of course, anything that can help with cognitive reframing, because certainly

how we think about our pain both in our bodies and culturally is really important. And

certainly any women, for example, with a history of sexual abuse, any pain or trauma in

their pelvic region, certainly can be exacerbated and amplified by their trauma history,

so meditation, visualization, relaxation. And if there's a trauma history, working with

someone who can help them to address the relationship if that comes up for them

around trauma and pelvic pain.

The opposing view on all of this is basically that almost nothing really works. And I feel

like it's important for me to, you know, give you an unbiased view as much as possible.

The Cochrane review of 2016 included 27 RCTs with over 3000 women, and they found

that most participants were students in their late teens or early twenties with primary

dysmenorrhea. They found that most studies were conducted in Iran, interestingly

also. As I mentioned earlier, I get so many studies from Iran sent to me to review.

There is no high quality evidence to support the effectiveness of any dietary

supplement for dysmenorrhea according to this Cochrane, and evidence of safety is

lacking. However, for several supplements there was some low quality evidence of

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effectiveness and more research has justified. Comparatively, a BMJ Clinical Evidence

Handbook review did state that thymine and vitamin E we're likely to be helpful. Just

to give you a well-rounded perspective. It doesn't change my use of supplements and

botanicals for dysmenorrhea, but I want you to have the full review of the literature

there.

As we always want to do, we also want to revisit what the meaning of evidence is.

According to David Sackett, who I've mentioned in the course before, the father of

what we now consider evidence based medicine, he, unlike what we — it's a little bit

like the way some people have interpreted paleo compared to the way Conner and

Boyd first wrote about paleo. People interpret evidence to be something much more

limited than it actually is. When we want to think about clinical evidence, when we

want to think about evidence based medicine, we always want to remember that there

are three pillars to it: clinical expertise, best available evidence, and patients’ values

and preferences.

Certainly from what I can say in my 35 years, hopefully I'm bringing you a strong base

of clinical expertise, particularly having written the textbook on women's botanical

medicine from many, many years of experience — I had over 20 years of experience in

botanicals at the point that I started that textbook — and also patients’ values and

preferences. And for women who are coming to you, and for women who are coming

to me, most likely they're looking for an integrative and more natural approach.

Starting with the gentle, safe, historically safe botanicals that we know, and then

progressing onto pharmaceuticals is always, in my opinion, the safest and wisest way to

practice clinically.

Ladies, our next lesson is on cyclic mastalgia, fibrocystic breasts and breast health. It

will be a shorter lesson, so it will give you a little bit of breathing room, and it will

largely be a review of some of what you already know applied to how we take care of

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our clients’ breast health and help them do the same. So I will see you over in the next

lesson.