Endocrinological actions of Unkei-to, a herbal medicine, and its clinical usefulness in anovulatory and/or infertile women

The Use of Japanese Traditional (Kampo) Medicines Before and During Pregnancy in Japan: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

PURPOSE

Japanese traditional (Kampo) medicines are often used for pregnant women in Japan. However, no comprehensive studies have been conducted regarding the self-reported use of these medicines during pregnancy. This study investigated the use of Kampo medicines during pregnancy in Japan using the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study (TMM BirThree Cohort Study).

METHODS

Questionnaires were distributed to pregnant women participating in the TMM BirThree Cohort Study (July 2013 to March 2017) at approximately 12 weeks (early pregnancy) and 26 weeks (middle pregnancy). We analysed Kampo medicines use over three periods: (1) 12 months before pregnancy diagnosis, (2) the period between pregnancy diagnosis and around Week 12 of pregnancy and (3) from around Week 12 of pregnancy.

RESULTS

In total, 19 220 women were included in the analysis. The proportions using prescribed Kampo medicines were 4.1% before pregnancy diagnosis, 4.5% from diagnosis to Week 12% and 4.5% after Week 12 of pregnancy. The most frequently prescribed Kampo medicines were tokishakuyakusan (1.0%) before pregnancy diagnosis, shoseiryuto (1.3%) from diagnosis to Week 12 and shoseiryuto (1.5%) Post-week 12. Sixty of the pregnant women used Kampo medicines containing crude drugs, which should be administered cautiously during pregnancy.

CONCLUSION

The proportion of Kampo medicines use before and during pregnancy was 4%-5%. Some pregnant women used Kampo medicines containing crude drugs that should be administered cautiously during pregnancy. Further research is required to determine the safety of Kampo medicines during pregnancy.

Unkeito promotes follicle development by restoring reduced follicle-stimulating hormone responsiveness in rats with polycystic ovary syndrome

Background

Polycystic ovary syndrome (PCOS) is a common disorder resulting in irregular menstruation and infertility due to improper follicular development and ovulation. PCOS pathogenesis is mediated by downregulated follicle-stimulating hormone receptor (FSHR) expression in granulosa cells (GCs); however, the underlying mechanism remains elusive. Unkeito (UKT) is a traditional Japanese medicine used to treat irregular menstruation in patients with PCOS. In this study, we aimed to confirm the effectiveness of UKT in PCOS by focusing on follicle-stimulating hormone (FSH) responsiveness.

Methods

A rat model of PCOS was generated by prenatal treatment with 5α-dihydrotestosterone. Female offspring (3-week-old) rats were fed a UKT mixed diet or a normal diet daily. To compare the PCOS phenotype in rats, the estrous cycle, hormone profiles, and ovarian morphology were evaluated. To further examine the role of FSH, molecular, genetic, and immunohistological analyses were performed using ovarian tissues and primary cultured GCs from normal and PCOS model rats.

Results

UKT increased the number of antral and preovulatory follicles and restored the irregular estrous cycle in PCOS rats. The gene expression levels of FSHR and bone morphogenetic protein (BMP)-2 and BMP-6 were significantly decreased in the ovarian GCs of PCOS rats compared to those in normal rats. UKT treatment increased FSHR staining in the small antral follicles and upregulated Fshr and Bmps expression in the ovary and GCs of PCOS rats. There was no change in serum gonadotropin levels. In primary cultured GCs stimulated by FSH, UKT enhanced estradiol production, accompanied by increased intracellular cyclic adenosine monophosphate levels, and upregulated the expression of genes encoding the enzymes involved in local estradiol synthesis, namely Cyp19a1 and Hsd17b. Furthermore, UKT elevated the expression of Star and Cyp11a1, involved in progesterone production in cultured GCs in the presence of FSH.

Conclusions

UKT stimulates ovarian follicle development by potentiating FSH responsiveness by upregulating BMP-2 and BMP-6 expression, resulting in the recovery of estrous cycle abnormalities in PCOS rats. Restoring the FSHR dysfunction in the small antral follicles may alleviate the PCOS phenotype.

Clinical Application of Bioextracts in Supporting the Reproductive System of Animals and Humans: Potential and Limitations

There is an increasing demand of spices and herbs in developing countries due to the beneficial effects of plants and herbal preparations as medicines. The basic technological process of obtaining extracts from natural raw materials is extraction, consisting in etching with solvents. Plant extracts are extremely complex, multicomponent mixtures obtained from flowers, fruits, leaves, stems, twigs, or seeds of various plant materials. They are a rich source of polyphenols, flavonoids, phytosterols, carotenoids, and vitamins. The search for alternative methods of treatment is increasingly replacing the scientists' excessive focus on the healing properties of bioextracts. Recent research offers great hope for the development of alternative methods to improve the reproductive system. The use of animal models in experimental research has increased knowledge regarding the beneficial effects of bioextracts on both male and female reproductive systems and reproductive cells. Demonstrating the positive effect of plant extracts creates new opportunities for the use of biowaste, which is a by-product in various production sectors. The aim of this review is to present the functional properties of extracts of natural origin, a cross section of modern methods of their preparation, and a discussion of the possibilities of their use in the auxiliary reproductive system.

Sho-Based Kampo Medicine Combined With Assisted Reproductive Technology Is Effective for Refractory Infertility and Early Recurrent Miscarriage: A Case Report

Assisted reproductive technology (ART) is an effective treatment developed for infertile couples in the world. As a result, women suffering from infertility benefit from ART treatment. However, even when ART treatment is successfully performed, there are cases where conception is not achieved or maintained. Kampo medicine was originally developed in Japan, and Sho is the central part of Kampo concept. Although it is thought that Kampo medicine is useful for various women-specific symptoms in modern Japan, evidence is still lacking regarding the effectiveness of combination of Sho-based Kampo and Western medicine such as ART. In this article, we report a case of a patient with refractory infertility and early recurrent miscarriage (ERM) of unknown cause who successfully became pregnant with combination therapy of Kampo based on Sho and ART. The patient was a 34 year-old Japanese woman and had been treated with ART in a nearby clinic. In a 3 year period, she had undergone oocyte retrieval twice, frozen embryo transfer (FET) seven times and conceived twice. Since both conceptions ended in miscarriages and pregnancy could not be established thereafter, her clinic referred her to our hospital for Kampo treatment. As result of the diagnosis of her Sho-pattern, we chose Kampo medicine. Finally, she succeeded in conception 1.5 years after beginning treatment and was able to carry the fetus to term successfully. The current case showed that although our patient had been unable to give a birth after undergoing various western medical treatments for infertility, pregnancy was established and kept to term after addition of Sho-based Kampo treatment. Kampo medicine chosen by the Sho-patterns is useful for refractory infertility and ERM. It is important to note that examinations for evaluting the Sho-patterns are essential for selecting appropriate Kampo medicine. Sho-based Kampo leads to an increase in the effectiveness of ART treatment, and accumulation of evidence that clarifies Sho-pattern is required.

Effect of a derived herbal recipe from an ancient Chinese formula, Danggui Buxue Tang, on ovariectomized rats

ETHNOPHARMACOLOGICAL RELEVANCE

Radix Astragali (root of Astragalus membranaceus (Fisch.) Bge. var. mongholicus (Bge.) Hsiao, RA), Radix Angelicae sinensis (root of Angelica sinensis (Oliv.) Diels, RAS) and Folium Epimedii (leaves of Epimedium brevicomum Maxim., FE) are three of the extensively applied herbal remedies among traditional Chinese medicines for gynecological disorders and osteoporosis. A derivative herbal recipe-RRF, composed of the three medicines with a weight ratio of 5:1:5, is derived from a famous Chinese herbal formula-Danggui Buxue Tang (DBT). RRF has shown noteworthy protective effect in ovariectomized rats, which might represent a promising candidate for the treatment of perimenopausal disorders. The aim of this study was to investigate the herbal recipe RRF for its efficacy on perimenopausal disorders and the underlying mechanisms via ovariectomy (OVX) models.

MATERIALS AND METHODS

An experimental model of OVX female rats was applied. Vehicle (Sham and OVX group), RRF (564, 282 and 141 mg/kg/d) and conjugated equine estrogens (CEE, 0.1mg/kg/d, reference drug) were all administrated orally once daily for 16 weeks post operation. After the treatment, radioimmunoassay for estradiol (E(2)), lutenizing hormone (LH), follicle stimulating hormone (FSH) and β-endorphin (β--EP), neurotransmitter determination by high-performance liquid chromatography with electrochemical detector (HPLC-ECD) for norepinephrine (NE), dopamine (DA), 5-hydroxytryptamine (5-HT) and 5-HIAA (5-hydroxyindoleacetic acid), bone mineral density (BMD) assay as well as lipid peroxidation assessment, were carried out to probe into the effectiveness of RRF.

RESULTS

(1) RRF treatment enhanced E(2) synthese while diminished the elevated serum FSH and LH levels; in terms of neurotransmitter, β-EP syntheses rallied whereas the hypothalamic NE, DA and 5-HT release experienced varying mitigation in OVX female rats. (2) Repeated administration of RRF was able to attenuate osteoporosis by elevating the BMD levels of total body, and arrest the bone trabeculae degradation. (3) RRF exposure decreased serum levels of constituent MDA and increased endogenous SOD activity.

CONCLUSIONS

Results of the current studies revealed that RRF was capable of acting at multiple targets which presumably underlay its potential protective effect in OVX rats mimicking symptoms as observed in perimenopausal women. Hence, RRF might represent a promising candidate in the treatment of perimenopausal disorders in midlife women.

Clinical efficacy of macrophage-activating Chinese mixed herbs (MACH) in improvement of embryo qualities in women with long-term infertility of unknown etiology

Despite the recent technological advances in in vitro fertilization and embryo transfer (IVF-ET), a significant proportion of women still do not become pregnant after long-term infertility, whether it is originally due to older age or other undetermined factors. In the present study, macrophage activating Chinese herbs (MACH) were evaluated for their effects on embryo qualities in women who were undergoing repeated IVF-ET because of long-term infertility. Thirty women, who had significantly low rates of developing good quality cleaved embryos and did not become pregnant after three or more cycles of Assisted Reproductive Technology (ART) procedure, were included in the study. Oral administration of MACH significantly increased the percentage of good quality early stage blastocysts (the number of grade 1 or grade 2 cleaved embryos/the number of retrieved oocytes) from 18.7 ± 16.2% to 36.1 ± 27.1% (1.9-fold increase, p < 0.01). The rate of good quality early stage blastocysts increased in all patients. In 19 patients who desired embryo transfer using late stage blastocysts, MACH significantly increased the percentage of late stage blastocysts from the initial value of 14.8 ± 11.2% to 21.1 ± 23.1% (1.4-fold increase, p < 0.05). The rate of embryonic progress into late stage blastocyst increased in 52.6% (10/19) of the patients. Furthermore, treatment with MACH significantly decreased the plasma follicle stimulating hormone (FSH) concentration on the day of oocyte retrieval from 14.4 ± 3.2 to 10.5 ± 2.4 mIU/ml (p < 0.05). No adverse events were observed with MACH supplementation, and there was no patient dropout. Administration of MACH resulted in improved embryo quality in the difficult cases. The present study demonstrates a new benefit of this herbal blend in women with refractory infertility of unknown etiology.

Effects of Switching to Wen-Jing-Tang (Unkei-To) from Preceding Herbal Preparations Selected by Eight-Principle Pattern Identification on Endocrinological Status and Ovulatory Induction in Women with Polycystic Ovary Syndrome

The objective of this study was to investigate the effects of switching therapy to Wen-jing-tang (Unkei-to) from previous selected herbal preparations on endocrine levels and induction of ovulation in women with polycystic ovary syndrome (PCOS). Sixty-four anovulatory women diagnosed with PCOS were enrolled in the study. After Kampo diagnosis, subjects received matched Kampo preparations (43 cases: Dang-gui-shao-yao-san, 21 cases: Gui-zhi-fu-ling-wan) selected by the matching theory of eight-principle pattern identification and Kampo diagnosis based on concepts of the qi, blood, and fluids as the physiologic activity. Fifty-four women who failed to ovulate after an 8-week treatment were randomly allocated to continuation of treatment with the preceding Kampo prescription (continuation group, n = 27) or treatment with Wen-jing-tang (switching group, n = 27). Plasma FSH, LH and estradiol levels were measured and ovulation rates were determined at the beginning and after an 8-week treatment with the preceding Kampo prescription, as well as after the subsequent 8-week treatment with the same preparation or Wen-jing-tang. No decrease in mean plasma LH level was observed in the 54 women who failed to ovulate among the 64 treated with a Kampo preparation. After the 8-week treatment with Wen-jing-tang, plasma LH levels were decreased by 58.2% ( p < 0.0001) and 49.4% ( p = 0.0005) in the groups switched from Dang-gui-shao-yao-san and Gui-zhi-fu-ling-wan, respectively. In the group switched from Dang-gui-shao-yao-san, a tendency towards increase in plasma estradiol level was observed (1.51-fold, p = 0.055), which was significant compared with that in the group switched from Gui-zhi-fu-ling-wan ( p = 0.032). The ovulation rate with switching of treatment to Wen-jing-tang was significantly higher (59.3%) than that with continued use of the same preparation (7.4%, p = 0.0036).

This study confirmed that Wen-jing-tang was effective in improving endocrine condition in the treatment of disturbances of ovulation in patients with PCOS without taking eight-principle pattern identification into consideration. This finding indicates that Wen-jing-tang is appropriate for use in treating PCOS in women with various constitutions (as determined by the matching theory of eight-principle pattern identification) in clinical practice and may prove to be a potent therapeutic agent with a wide therapeutic spectrum.

Comparison of effects of vitamin E and wen-jing-tang (unkei-to), an herbal medicine, on peripheral blood flow in post-menopausal women with chilly sensation in the lower extremities: a randomized prospective study

We examined the association between blood flow and chilly sensation in the lower extremities, comparing the changes in blood flow induced by the vitamin E and herbal therapy (Wen-jing-tang) in perimenopausal women with chilly sensation. One hundred sixty-one perimenopausal women aged 42-61 years (mean: 50.4 +/- 3.8 years) with chilly sensation in the lower extremities participated in the study. The participants were randomized for treatment with Wen-jing-tang or a vitamin E preparation containing 600 mg tocopherol nictinate per day for 8 weeks. Blood flow measurement was performed by laser Doppler fluxmetry to determine tissue under the jaw, in the middle finger, and in the third toe. Wen-jing-tang significantly increased the peripheral blood flow in the skin surface in the tiptoe (12.8 +/- 8.8, p = 0.0068) from basal levels (6.0 +/- 5.1), although no significant change was observed in the blood flow in fingertip or under the jaw during treatment. The rate of increase of blood flow in the skin surface of in the lower extremities was significantly higher in the Wen-jing-tang treating group (116.4 +/- 46.5%) than in the vitamin E group (39.8 +/- 21.3%) (p < 0.0001). When the effects of herbal treatment and vitamin E treatment were compared in the subjects with baseline upper extremity blood flow above the mean + 1.5 SD, mean blood flow through the upper extremities was found to have been significantly decreased after Wen-jing-tang treatment (from 57.7 +/- 4.8 to 43.1 +/- 4.2, p = 0.0277), whereas it remained unchanged after treatment with vitamin E. Classical monographs described Wen-jing-tang as being particularly useful in curing chilly sensation in lower extremities. The present study using a laser Doppler fluxmeter demonstrated that treatment with this herbal medicine significantly increased blood flow through the periphery of lower extremities in patients with chilly sensation. It also showed that this herbal medicine suppresses excessive blood flow through the upper half of the body and thus stimulates restoration of physiological distribution of blood flow throughout the entire body.

Phytoestrogens and reproductive biology

Phytoestrogens are naturally occurring plant substances that can either mimic or antagonize the action of endogenous estrogens. This is because of the similarity of the functional structure of phytoestrogens and endogenous estrogens. In premenopausal women, phytoestrogen intake might induce a decrease in luteinizing hormone, follicle-stimulating hormone and estradiol (E₂), which are associated with a longer follicular phase. The circulating transport protein, sex hormone-binding globulin, is increased, resulting in less cellular availability of E₂. Phytoestrogens inhibit the activities of E₂ synthetic enzymes through adenylate cyclase and tyrosine kinase cascades. This might decrease of risk of hormone dependent cancers. A phytoestrogen-rich diet might reproduce normal body composition, affecting the course of polycystic ovary syndrome (PCOS). Some herbs used in traditional Japanese medicine contain phytoestrogens that influence endogenous hormone levels to directly regulate the pituitary-ovarian system, in particular, the chemotactic effects on ovaries. (Reprod Med Biol 2005; 4: 225 -229).

In vitro stimulation of granulosa cells by a combination of different active ingredients of unkei-to

Unkei-to is widely used in traditional Japanese herbal medicine for its ovulation-inducing effect. In the present study, we investigated the in vivo effects of unkei-to and its compounds on the steroidogenesis and cytokine secretion in human granulosa cells. Unkei-to stimulated the secretions of 17beta-estradiol and progesterone from highly luteinized granulosa cells obtained from in vitro fertilization patients; the stimulated effect on estradiol secretion occurred with 0.3 microg/ml, while a significant effect on progesterone secretion was obtained at 10 microg/ml. The unkei-to stimulation of estradiol secretion could be accounted for by the effects of its ingredients, Shakuyaku (paeoniae radix, Paeonia lactiflora Pallas) and Keihi (cinnamomi cortex, Cinnamomum cassia Blume); while dose response curves for unkei-to and Keihi to induce progesterone production were superimposable. Exposure of the cells to unkei-to caused dose-dependent increases in the concentrations of interleukin (IL)-1beta, IL-6 and IL-8 in the culture medium. Similar results were obtained when cells were incubated with the ingredient Ninjin (ginseng radix, Panax ginseng C.A. Meyer), but not Shakuyaku and Keihi. These results indicate that unkei-to has direct stimulatory effects on human granulosa cells to stimulate the steroidogenesis and secretion of cytokines (IL-1, IL-6 and IL-8). The various beneficial actions of unkei-to on the ovary may result from a combination of different ingredient herbs with different stimulatory effects on both steroidogenesis and the ovulatory process within the ovary, as well as stimulatory effect on the hypothalamus-pituitary axis.