A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome

Vitex agnus castus Extract Ze 440: Diterpene and Triterpene's Interactions with Dopamine D2 Receptor

Pre-clinical studies suggest that extracts prepared from the fruits of Vitex agnus castus (VAC) interact with dopamine D2 receptors, leading to reduced prolactin secretion. In previous experiments, dopaminergic activity was mostly evaluated using radioligand binding assays or via the inhibition of prolactin release from rat pituitary cells. Diterpenes featuring a clerodadienol scaffold were identified as major active compounds, but no conclusive data regarding their potency and intrinsic activity are available. Utilising advances in chromatography, we re-examined this topic using HPLC-based tracking of bioactivity via microfractionation of the VAC extract Ze 440. Using a cAMP-based assay, we measured dopaminergic activity in CHO-K1 cells that overexpress the human D2 receptor. Six diterpenes were isolated from two active HPLC microfractions. Viteagnusin I emerged as the most potent diterpene (EC50: 6.6 µM), followed by rotundifuran (EC50: 12.8 µM), whereas vitexilactone was inactive (EC50: >50 µM). Interestingly, triterpenes were also identified as active, with 3-epi-maslinic acid being the most active compound (EC50: 5.1 µM). To better understand these interactions at the molecular level, selected diterpenes and triterpenes were analysed through molecular docking against D2 receptor structures. Our data show that the dopaminergic activity of VAC diterpenes seems to depend on the configuration and on ring substitution in the side chain. This study also highlights for the first time the dopaminergic contribution of triterpenes such as 3-epi-maslinic acid.

Plants in Menstrual Diseases: A Systematic Study from Italian Folk Medicine on Current Approaches

Background: Plant-based remedies have been used since antiquity to treat menstrual-related diseases (MD). From the late nineteenth to the early to mid-twentieth century, Italian folk remedies to treat "women's diseases" were documented in a vast corpus of literature sources. Aim: The purpose of this paper is to bring to light the plant-based treatments utilized by Italian folk medicine to heal clinical manifestations of premenstrual syndrome (PMS), dysmenorrhea, amenorrhea and menstrual disorders in an attempt to discuss these remedies from a modern pharmacological point of view. Moreover, we compare the medical applications described by Hippocrates with those utilized by Italian folk medicine to check if they result from a sort of continuity of use by over two thousand years. Results: Out of the 54 plants employed in Italian folk medicine, 25 (46.3%) were already documented in the pharmacopoeia of the Corpus Hippocraticum for treating MD. Subsequently, a detailed search of scientific data banks such as Medline and Scopus was undertaken to uncover recent results concerning bioactivities of the plant extracts to treat MD. About 26% of the plants used by Italian folk medicine, nowadays, have undergone human trials to assess their actual efficacy. At the same time, about 41% of these herbal remedies come back to in different countries. Conclusions: Active principles extracted from plants used by Italian folk healers could be a promising source of knowledge and represent strength candidates for future drug discovery for the management of MD.

Herb-drug Interactions in Neuropsychiatric Pharmacotherapy - A Review of Clinically Relevant Findings

The management of neuropsychiatric disorders relies heavily on pharmacotherapy. The use of herbal products as complimentary medicine, often concomitantly, is common among patients taking prescription neuropsychiatric drugs. Herb-drug interaction, a clinical consequence of this practice, may jeopardize the success of pharmacotherapy in neuropsychiatry. Besides the wellknown ability of phytochemicals to inhibit and/or induce drug-metabolizing enzymes and transport proteins, several phytoconstituents are capable of exerting pharmacological effects on the central nervous system. This study reviewed the relevant literature and identified 13 commonly used herbal products - celery, echinacea, ginkgo, ginseng, hydroxycut, kava, kratom, moringa, piperine, rhodiola, St. John's wort, terminalia/commiphora ayurvedic mixture and valerian - which have shown clinically relevant interactions with prescription drugs used in the management of neuropsychiatric disorders. The consequent pharmacokinetic and pharmacodynamic interactions with orthodox medications often result in deleterious clinical consequences. This underscores the importance of caution in herb-drug co-medication.

Effect of Garlic (Allium sativum) Supplementation on Premenstrual Disorders: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Premenstrual disorders involve physical, behavioral, and mood variations that affect women of childbearing age and interfere with family relationships, household responsibilities, professional duties, and social activities.

Objectives

Considering the side effects of conventional medications, their use is not recommended except in severe cases of premenstrual disorders. Nowadays, there is a tendency to use traditional and complementary medicine that offers various treatments. The purpose of the current study was to investigate the impacts of garlic as a herbal medicine on the severity of premenstrual symptoms.

Methods

This study was a double-blind, randomized, controlled trial. After identification of participants with moderate-to-severe PMS through the premenstrual symptoms screening tools questionnaire (PSST), they were randomly assigned to placebo (n = 64) or garlic (n = 65) groups. Each participant received one tablet daily for three consecutive cycles and logged the severity of their symptoms in the PSST questionnaire during the intervention period.

Results

There was no significant difference between the two groups in the baseline level of premenstrual symptoms before the intervention. After treatment with garlic for three consecutive cycles, the total score of the severity of premenstrual symptoms significantly (P < 0.001) reduced from 34.09 ± 7.31 to 11.21 ± 7.17. In the placebo group, this score changed from 33.35 ± 7.96 to 24.28 ± 7.22. The difference between mean changes in the two groups was 13.78, with a 95% Confidence Interval (CI) of 11.23–16.33. No serious side effects were observed in either group.

Conclusion

Our findings highlight the potential effect of garlic in reducing the severity of premenstrual symptoms; therefore, the use of garlic can be considered as an alternative therapy in the prevention and treatment of premenstrual disorders.

Foot-ankle functional outcomes of using the Diabetic Foot Guidance System (SOPeD) for people with diabetic neuropathy: a feasibility study for the single-blind randomized controlled FOotCAre (FOCA) trial I

BACKGROUND

Diabetic neuropathy dramatically affects musculoskeletal structure and function of the lower limbs by impairing their muscle strength and mobility. Specific muscle strengthening through physiotherapy strategies appears to be promising; however, adherence to physiotherapy treatment is low in people with chronic diseases. Thus, an internet-based foot-ankle exercise program was created as a potential telerehabilitation alternative for people with diabetes to improve their self-monitoring and self-care management. This study assessed the feasibility, safety, acceptability, and changes in foot health and neuropathy symptoms in people with diabetes after 12 weeks of the intervention program with the Sistema de Orientação ao Pé diabético - Diabetic Foot Guidance System (SOPeD).

METHODS

Fourteen individuals were recruited and randomized to either the usual care (control group) or usual care plus an internet-based foot-ankle exercise program through SOPeD (intervention group) three times per week for 12 weeks. For feasibility, we assessed contact and recruitment rates per week; program adherence, determined as completing over 70% of the 36 sessions; and participant satisfaction and safety assessed through a questionnaire and scored on a 5-point Likert scale. We assessed changes in neuropathy symptoms and foot health and functionality from baseline to 12 weeks estimating differences or median of differences and 95% confidence intervals in the intervention group.

RESULTS

In 24 weeks, of the 822 patients in the database, 192 were contacted, 65 were assessed for eligibility, and 20 were considered eligible. The recruitment rate was 0.83 participants per week. Fourteen out of the 20 eligible participants agreed to participate, resulting in recruitment success of 70%. Adherence to the program was 66.7%, and there was no dropout. Participants' median level of satisfaction was 5.0 (IQR: 4.5-5.0) and perceived safety was 5.0 (IQR: 5.0-5.0).

CONCLUSION

The internet-based foot-ankle exercise program using SOPeD is feasible, satisfactory, and safe. Although this study had moderate adherence and a zero-dropout rate, recruitment needs to be improved in the larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04011267 . Registered on 8 July 2019.

Feasibility and Preliminary Efficacy of a Foot-Ankle Exercise Program Aiming to Improve Foot-Ankle Functionality and Gait Biomechanics in People with Diabetic Neuropathy: A Randomized Controlled Trial

Foot-ankle strengthening and mobility exercises are part of international guideline recommendations for people at risk of diabetic foot disease. We examined the feasibility and preliminary efficacy of a 12-week foot-ankle exercise program on clinical, functional and biomechanical outcomes in people with diabetic neuropathy (DPN). We randomly allocated 30 people with DPN to usual care (control) or usual care plus a supervised exercise program (intervention). For feasibility, we assessed recruitment rate and participant adherence and satisfaction. For program efficacy, we assessed baseline to 12-week changes in daily physical activity level, gait speed, tactile sensitivity, ankle range of motion, DPN symptoms, quality of life, foot health and functionality, foot strength and plantar pressure during gait, using paired t-tests (p < 0.05). In 52 weeks, we recruited 45 eligible participants (0.90/week). Program adherence was 80% and participants’ satisfaction had a mean (SD) of 4.57 (0.70) out of 5. The intervention group significantly improved on toes strength, contact time during gait and DPN symptoms, and peak forefoot pressures increased over time; controls showed significantly increased heel peak pressures and force. The exercise program was feasible, based on a moderate recruitment rate and an adherent and satisfied population, and the intervention showed several positive preliminary effects over time compared to usual care.

Herbal Interaction With Chemotherapeutic Drugs-A Focus on Clinically Significant Findings

One of the most consequential risks associated with the concomitant use of herbal products and chemotherapeutic agents is herb-drug interactions. The risk is higher in patients with chronic conditions taking multiple medications. Herb-drug interaction is particularly undesirable in cancer management because of the precipitous dose-effect relationship and toxicity of chemotherapeutic agents. The most common mechanism of herb-drug interaction is the herbal-mediated inhibition and/or induction of drug-metabolizing enzymes (DME) and/or transport proteins leading to the alteration in the pharmacokinetic disposition of the victim drug. Most mechanistic research has focused on laboratory-based studies, determining the effects of herbal products on DMEs and extrapolating findings to predict clinical relevance; however, not all DME/transporter protein inhibition/induction results in clinical herb-drug interaction. This study reviews relevant literature and identified six herbal products namely echinacea, garlic, ginseng, grapefruit juice, milk thistle, and St John's wort, which have shown interactions with chemotherapeutic agents in humans. This focus on clinically significant herb-drug interaction, should be of interest to the public including practitioners, researchers, and consumers of cancer chemotherapy.

A cluster randomized pilot trial of a tailored worksite smoking cessation intervention targeting Hispanic/Latino construction workers: Intervention development and research design

Construction workers have the highest smoking rate among all occupations (39%). Hispanic/Latino workers constitute a large and increasing group in the US construction industry (over 2.6 million; 23% of all workers). These minority workers have lower cessation rates compared to other groups due to their limited access to cessation services, and lack of smoking cessation interventions adapted to their culture and work/life circumstances. Formative research was conducted to create an intervention targeting Hispanic/Latino construction workers. This paper describes the intervention development and the design, methods, and data analysis plans for an ongoing cluster pilot two-arm randomized controlled trial comparing an Enhanced Care worksite cessation program to Standard Care. Fourteen construction sites will be randomized to either Enhanced Care or Standard Care and 126 participants (63/arm) will be recruited. In both arms, recruitment and intervention delivery occur around "food trucks" that regularly visit the construction sites. Participants at Enhanced Care sites will receive the developed intervention consisting of a single face-to-face group counseling session, 2 phone calls, and a fax referral to Florida tobacco quitline (QL). Participants at Standard Care sites will receive a fax referral to the QL. Both groups will receive eight weeks of nicotine replacement treatment and two follow-up assessments at three and six months. Feasibility outcomes are estimated recruitment yield, barriers to delivering the intervention onsite, and rates of adherence/compliance to the intervention, follow-ups, and QL enrollment. Efficacy outcomes are point-prevalence and prolonged abstinence rates at six month follow-up confirmed by saliva cotinine <15 ng/ml.

Effect and safety of acupuncture for Hwa-byung, an anger syndrome: a study protocol of a randomized controlled pilot trial

Background

Hwa-byung (HB) is an anger syndrome caused by an inadequate release of accumulated anger that leads to somatic and psychiatric symptoms. As HB results from long-term inadequately treated negative emotions, its symptoms are complex, intractable and concomitant with other psychiatric disorders. Therefore, studies aiming to develop effective and safe treatment options for HB are needed. We plan to conduct a pilot study for a future, full-scale, randomized controlled trial (RCT) of an optimal acupuncture procedure using semi-individualized acupuncture points that consider participants’ personal disposition and type of emotional stress.

Method/design

This randomized, sham-controlled, participant- and assessor-blinded pilot trial aims to determine the study feasibility of acupuncture for HB and to explore its clinical effects and safety. This clinical trial will be conducted with two groups: one treated with real acupuncture and the other with sham acupuncture for 10 sessions over 4 weeks. The experimental group (EG) will receive semi-individualized acupuncture, whereas the control group (CG) will receive sham acupuncture, namely minimal acupuncture on non-acupuncture points. The recruitment, compliance, and completion rate and clinical evaluations, including a Visual Analogue Scale (VAS), the Korean version of the Beck Depression Inventory (BDI), the short form of the Stress Response Inventory (SRI-short form) and the Instrument of the Oriental Medical Evaluation for HB (IOME-HB), will be assessed to evaluate feasibility and possible effects and safety. Four weeks after completing treatment, follow-up assessments will be performed.

Discussion

As this is a pilot study mainly aiming to investigate trial feasibility, the results of this study will be analyzed descriptively and interpreted for the study purposes. Cohen’s d will be reported to determine the effect of acupuncture for HB and to enable comparisons with other treatment methods. This protocol is significant in that it provides optimal semi-individualized acupuncture treatment. We expect this study to offer information about the feasibility of this treatment and data about the possible effects and safety.

Trial registration

Clinical Research Information Service (CRIS), Republic of Korea: KCT0001732. Registered on 14 December 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2399-0) contains supplementary material, which is available to authorized users.

Introduction of a pilot study

A pilot study asks whether something can be done, should the researchers proceed with it, and if so, how. However, a pilot study also has a specific design feature; it is conducted on a smaller scale than the main or full-scale study. In other words, the pilot study is important for improvement of the quality and efficiency of the main study. In addition, it is conducted in order to assess the safety of treatment or interventions and recruitment potentials, examine the randomization and blinding process, increase the researchers' experience with the study methods or medicine and interventions, and provide estimates for sample size calculation. This review discusses with a focus on the misconceptions and the ethical aspect of a pilot study. Additionally how to interpret the results of a pilot study is also introduced in this review.

Treatment of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is comprised of a cluster of affective, behavioral and somatic symptoms recurring monthly during the luteal phase of the menstrual cycle. The disorder affects 3-8% of menstruating women and represents the more severe and disabling end of the spectrum of premenstrual disorders, which includes premenstrual syndrome and premenstrual aggravation of underlying affective disorder. Rigorous and specific diagnostic criteria for PMDD were specified in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) and reaffirmed in the Diagnostic and Statistical Manual of Mental Disorders V (2013) and, consequently, there has been a marked increase in well-designed, placebo-controlled studies evaluating treatment modalities. Although the exact pathogenesis of PMDD is still elusive, treatment of PMDD and severe premenstrual syndrome has centered on neuromodulation via serotonin reuptake inhibitor antidepressants, and ovulation suppression utilizing various contraceptive and hormonal preparations. Unlike the approach to the treatment of depression, serotonergic antidepressants need not be given daily, but can be effective when used cyclically, only in the luteal phase or even limited to the duration of the monthly symptoms. Less, well-substantiated alternative treatments, such as calcium supplementation, agnus castus (chasteberry), Hypericum perforatum (St John's wort) and cognitive/behavioral/relaxation therapies, may be useful adjuncts in the treatment of PMDD. This review provides an overview of current information on the treatment of PMDD.

Effects of St John's wort (Hypericum perforatum L.) extracts on epileptogenesis

The purpose of this study was to investigate the effects of treatment with water, n-butanol and ether extracts of Hypercom perforatum L. on epileptogenesis in rabbits. Animals from the control group received solvent-ethanol, and the kindling model of epilepsy was used. Epileptic focus was induced in Chinchilla rabbits by stimulation of the hippocampus. The following parameters were determined: the minimum current strength necessary to induce after-discharge (AD) - discharges appearing after cessation of stimulation; AD duration; the number of stimulations necessary to induce spontaneous kindling; and the latency time for the development of full kindling. The results obtained indicate that epileptogenesis is influenced by Hypericum perforatum L. extract treatment. Animals treated with an ether extract of Hypericum perforatum L. required significantly weaker minimum current strengths for the development of epileptogenic focus, and displayed longer AD times, while the number of electro-stimulations necessary for full kindling was less. In contrast, animals treated with water and n-butanol extracts required increased electro-stimulations for the development of epileptic discharge, and displayed shortened AD durations versus controls.

The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Premenstrual syndrome (PMS) is a common condition. Some of the most widely prescribed medications are selective serotonin reuptake inhibitors (SSRIs), based on the hypothesized role of serotonin in the production of PMS symptoms. PMS sufferers, especially those experiencing mild to moderate symptoms, are often reluctant to take this form of medication and instead buy over-the-counter preparations to treat their symptoms, for which the evidence base with regard to efficacy is limited. Hypericum perforatum (St John's wort) influences the serotonergic system. As such, this widely available herbal remedy deserves attention as a PMS treatment.

OBJECTIVE

To investigate the effectiveness of Hypericum perforatum on symptoms of PMS.

STUDY DESIGN

This randomized, double-blind, placebo-controlled, crossover study was conducted between November 2005 and June 2007.

SETTING

Institute of Psychological Sciences, University of Leeds, Leeds, UK.

PARTICIPATION

36 women aged 18-45 years with regular menstrual cycles (25-35 days), who were prospectively diagnosed with mild PMS.

INTERVENTION

Women who remained eligible after three screening cycles (n = 36) underwent a two-cycle placebo run-in phase. They were then randomly assigned to receive Hypericum perforatum tablets 900 mg/day (standardized to 0.18% hypericin; 3.38% hyperforin) or identical placebo tablets for two menstrual cycles. After a placebo-treated washout cycle, the women crossed over to receive placebo or Hypericum perforatum for two additional cycles.

MAIN OUTCOME MEASURES

Symptoms were rated daily throughout the trial using the Daily Symptom Report. Secondary outcome measures were the State Anxiety Inventory, Beck Depression Inventory, Aggression Questionnaire and Barratt Impulsiveness Scale. Plasma hormone (follicle-stimulating hormone [FSH], luteinizing hormone [LH], estradiol, progesterone, prolactin and testosterone) and cytokine (interleukin [IL]-1beta, IL-6, IL-8, interferon [IFN]-gamma and tumour necrosis factor [TNF]-alpha) levels were measured in the follicular and luteal phases during Hypericum perforatum and placebo treatment.

RESULTS

Hypericum perforatum was statistically superior to placebo in improving physical and behavioural symptoms of PMS (p < 0.05). There were no significant effects of Hypericum perforatum compared with placebo treatment for mood- and pain-related PMS symptoms (p > 0.05). Plasma hormone (FSH, LH, estradiol, progesterone, prolactin and testosterone) and cytokine (IL-1beta, IL-6, IL-8, IFNgamma and TNFalpha) levels, and weekly reports of anxiety, depression, aggression and impulsivity, also did not differ significantly during the Hypericum perforatum and placebo cycles (p > 0.05).

CONCLUSION

Daily treatment with Hypericum perforatum was more effective than placebo treatment for the most common physical and behavioural symptoms associated with PMS. As proinflammatory cytokine levels did not differ significantly between Hypericum perforatum and placebo treatment, these beneficial effects are unlikely to be produced through this mechanism of action alone. Further work is needed to determine whether pain- and mood-related PMS symptoms benefit from longer treatment duration. Trial registration number (International Standard Randomised Controlled Trial Number Register) ISRCTN31487459.

Update on research and treatment of premenstrual dysphoric disorder

Many women in their reproductive years experience some mood, behavioral. or physical symptoms in the week prior to menses. Variability exists in the level of symptom burden in that some women experience mild symptoms, whereas a small minority experience severe and debilitating symptoms. For an estimated 5%-8% of premenopausal women, work or social functioning are affected by severe premenstrual syndrome. Many women in this group meet diagnostic criteria for premenstrual dysphoric disorder (PMDD). Among women who suffer from PMDD, mood and behavioral symptoms such as irritability, depressed mood, tension, and labile mood dominate. Somatic complaints, including breast tenderness and bloating, also can prove disruptive to women's overall functioning and quality of life. Recent evidence suggests that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose certain women to experience these mood, behavioral, and somatic symptoms. Treatments include: antidepressants of the serotonin reuptake inhibitor class, taken intermittently or throughout the menstrual cycle; medications that suppress ovarian cyclicity; and newer oral contraceptives with novel progestins.

Potential medicinal plants for CNS disorders: an overview

Although very few drugs are currently approved by regulatory authorities for treating multi-factorial ailments and disorders of cognition such as Alzheimer's disease, certain plant-derived agents, including, for example, galantamine and rivastigmine (a semi-synthetic derivative of physostigmine) are finding an application in modern medicine. However, in Ayurveda, the Indian traditional system of medicine which is more than 5000 years old, selected plants have long been classified as 'medhya rasayanas', from the Sanskrit words 'medhya', meaning intellect or cognition, and 'rasayana', meaning 'rejuvenation'. These plants are used both in herbal and conventional medicine and offer benefits that pharmaceutical drugs lack. In the present article, an attempt has been made to review the most important medicinal plants, including Ginkgo biloba, St John's wort, Kava-kava, Valerian, Bacopa monniera and Convolvulus pluricaulis, which are widely used for their reputed effectiveness in CNS disorders.

Effectiveness of kamishoyosan for premenstrual dysphoric disorder: open-labeled pilot study

The purpose of the present paper was to investigate the efficacy of kamishoyosan (TJ-24), a traditional Japanese herbal formula (kampo), for outpatients with premenstrual dysphoric disorder (PMDD) as an alternative treatment. Thirty patients with PMDD were treated with TJ-24 for six menstrual cycles. Nineteen patients (63.3%) had >50% improvement in the total score of the Hamilton Depression Rating Scale (HAM-D) Scale (17 items) in the late luteal phase. Fourteen patients (46.7%) went into remission (total HAM-D score <7). In the present study many patients with PMDD were successfully treated with TJ-24.

The Significance of "Nonsignificance" in Randomized Controlled Studies: A Discussion Inspired by a Double-Blinded Study on St. John's Wort (Hypericum perforatum L.) for Premenstrual Symptoms

OBJECTIVES

This study aimed to investigate the efficacy of St. John's wort extract (SJW) as a treatment for premenstrual symptoms.

DESIGN

The study was a randomized, double-blinded, placebo-controlled trial, with two parallel treatment groups. After a no-treatment baseline cycle, volunteers were randomized to either SJW or placebo for a further two menstrual cycles.

SETTINGS/LOCATION

A postal trial conducted from The University of Reading, Berkshire, England.

SUBJECTS

One hundred and sixty-nine (169) normally menstruating women who experienced recurrent premenstrual symptoms were recruited onto the study. One hundred and twenty-five (125) completed the protocol and were included in the analysis.

INTERVENTIONS

Six hundred milligrams (600) mg of SJW (standardized to contain 1800 microg of hypericin) or placebo (containing lactose and cellulose).

OUTCOME MEASURE

A menstrual diary was used to assess changes in premenstrual symptoms. The anxiety-related subgroup of symptoms of this instrument was used as the primary outcome measure.

RESULTS

After averaging the effects of treatment over both treatment cycles it was found that there was a trend for SJW to be superior to placebo. However, this finding was not statistically significant.

CONCLUSION

The possibility that this nonsignificant finding resulted from insufficient statistical power in the study, rather than a lack of efficacy of SJW, is discussed. Following this discussion the recommendation is made that, in future, similar studies should be powered to detect a minimum clinically relevant difference between treatments.

Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Beyond: A Clinical Primer for Practitioners

The management of adverse premenstrual symptoms has presented a difficult challenge for clinicians. However, based on numerous well-designed research studies over the last decade, we now have diagnostic criteria for the severe form of the syndrome, premenstrual dysphoric disorder, and a variety of evidence-based therapeutic strategies. This review presents a comprehensive, practical description of what the clinician needs to know to diagnose and treat adverse premenstrual symptoms at all levels of severity. Diagnostic criteria are described in detail, including a discussion of the distinction between premenstrual dysphoric disorder and premenstrual syndrome (PMS). The rationale for including prospective symptom calendars as a routine part of the diagnostic evaluation of severe symptoms is presented. The differential diagnosis of cyclic symptoms, including depression and anxiety disorders, menstrual migraine, and mastalgia, and an approach for the management of each of these problems are presented. A treatment approach is recommended that matches the treatment to the degree of problems the woman is experiencing. Serotonin reuptake inhibitors are the treatment of choice for severe symptoms, and most women with PMS/premenstrual dysphoric disorder will respond to intermittent, luteal phase-only therapy. Ovulation suppression should be reserved for women who do not respond to other forms of therapy. The role of oophorectomy is limited, and guidelines for its use are presented.

Treatment of somatoform disorders with St. John's wort: a randomized, double-blind and placebo-controlled trial

OBJECTIVE

To investigate efficacy and safety of St. John's wort (SJW) LI 160 in somatoform disorders.

METHODS

In a prospective, randomized, placebo-controlled, and double-blind parallel group study, 184 outpatients with somatization disorder (ICD-10 F45.0), undifferentiated somatoform disorder (F45.1), and somatoform autonomic dysfunction (F45.3), but not major depression, received either 300 mg of SJW extract LI 160 twice daily or matching placebo for 6 weeks. Six outcome measures were evaluated as a combined measure by means of the Wei Lachin test: Somatoform Disorders Screening Instrument--7 days (SOMS-7), somatic subscore of the HAMA, somatic subscore of the SCL-90-R, subscores "improvement" and "efficacy" of the CGI, and the global judgment of efficacy by the patient.

RESULTS

In the intention to treat population (N=173), for each of the six primary efficacy measures as well as for the combined test, statistically significant medium to large-sized superiority of SJW treatment over placebo was demonstrated (p <.0001). Of the SJW patients, 45.4% were classified as responders compared with 20.9% with placebo (p =.0006). Tolerability of SJW treatment was equivalent to placebo.

CONCLUSIONS

Administration of 600 mg of SJW extract LI 160 daily is effective and safe in the treatment of somatoform disorders, thereby confirming results from a previous study.

St. John's wort (Hypericum perforatum) as a treatment for premenstrual dysphoric disorder: case report

Premenstrual dysphoric disorder (PMDD), a menstruous dysfunction, is characterized by profoundly depressed mood, and studies have shown that antidepressants are effective for PMDD. The authors describe a case of PMDD who was initially treated with selective serotonin reuptake inhibitors. Due to intolerable gastrointestinal side effects with selective serotonin reuptake inhibitors, St. John's wort (900 mg/day) was substituted and much improvement in PMDD symptoms was noted for at least five-month follow-up. The authors propose that St. John's wort could be an alternative medication for PMDD, especially for patients experiencing intolerable side effects with selective serotonin reuptake inhibitors.

Design and analysis of pilot studies: recommendations for good practice

Pilot studies play an important role in health research, but they can be misused, mistreated and misrepresented. In this paper we focus on pilot studies that are used specifically to plan a randomized controlled trial (RCT). Citing examples from the literature, we provide a methodological framework in which to work, and discuss reasons why a pilot study might be undertaken. A well-conducted pilot study, giving a clear list of aims and objectives within a formal framework will encourage methodological rigour, ensure that the work is scientifically valid and publishable, and will lead to higher quality RCTs. It will also safeguard against pilot studies being conducted simply because of small numbers of available patients.

Drug Interactions with St John???s Wort

The purpose of this paper is to review preclinical and clinical evidence relating to drug interactions with preparations of the medicinal herb St John's wort (Hypericum perforatum). A systematic literature search was carried out in three electronic databases up to June 2004. Information about case reports classified as St John's wort drug interactions was retrieved from the WHO Collaborating Centre for International Drug Monitoring and from the UK Medicines and Healthcare products Regulatory Agency in June 2003. Against the background of proven efficacy in mild to moderate depressive disorders and an excellent tolerability profile in monotherapy, there is sufficient evidence from interaction studies and case reports to suggest that St John's wort may induce the cytochrome P450 (CYP) 3A4 enzyme system and the P-glycoprotein drug transporter in a clinically relevant manner, thereby reducing efficacy of co-medications. Drugs most prominently affected and contraindicated for concomitant use with St John's wort are metabolised via both CYP3A4 and P-glycoprotein pathways, including HIV protease inhibitors, HIV non-nucleoside reverse transcriptase inhibitors (only CYP3A4), the immunosuppressants ciclosporin and tacrolimus, and the antineoplastic agents irinotecan and imatinib mesylate. Efficacy of hormonal contraceptives may be impaired as reflected by case reports of irregular bleedings and unwanted pregnancies. Drugs with a narrow therapeutic index should be monitored more closely when St John's wort is added, discontinued or the dosage is changed. The St John's wort constituent hyperforin is probably responsible for CYP3A4 induction via activation of a nuclear steroid/pregnane and xenobiotic receptor (SXR/PXR) and hypericin may be assumed to be the P-glycoprotein inducing compound, although the available evidence is less convincing. Combinations of St John's wort with serotonergic agents and other antidepressants should be restricted to prescription-only, by experienced clinicians, due to potential central pharmacodynamic interactions. In conclusion, providing certain precautions and contraindications are followed, and adequate information is given to healthcare professionals and patients, the safe and effective use of quality-tested St John's wort products can be ensured.

The use of herbs by pregnant and childbearing women: a risk-benefit assessment

This paper reviews some of the evidence in relation to herbal remedies, and considers both their efficacy and safety for pregnant and childbearing women. It concludes with some suggested guidelines for midwifery and obstetric practice.

Premenstrual Syndrome and the Use of Alternative Therapies

Premenstrual syndrome is a collection of symptoms that may be encountered by up to 95% of the population, although it is estimated to affect 5% of women severely. The use of complementary and alternative therapies is high among this group, but does not seem to compromise conventional treatment. It has been established that complementary therapies are used by a large proportion of the developed world, but their efficacy and safety are not always proven. This is partly due to the difficulty of studying alternative practices and the cost, but also with respect to premenstrual syndrome, problems with defining the condition and specifying end points are encountered. The difficulties in evaluating unorthodox therapies are elucidated and the evidence base for nonprescribed treatments for premenstrual syndrome is presented. Overall these women are a neglected group for whom the evidence for conventional therapy is sparse and controversial. Since the majority of women self-diagnose and self-medicate, it is important that physicians have an understanding of the variety of interventions tried and their worth.

An integrative medicine approach to premenstrual syndrome

Complementary and alternative medicine (CAM) approaches are widely used by women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). This article provides a comprehensive review of the medical literature on clinical applications of CAM for these conditions. The information was collected via a Medline review dating back to 1966 and subsequent selected review of bibliographies from these articles for non-Medline referenced but relevant clinical studies. For many of the therapies discussed, there is a lack of conclusive evidence either confirming or refuting efficacy. For other therapies, including certain herbal and nutritional approaches, the use of exercise, and the use of mind-body approaches, there is substantial evidence of efficacy. This review will be relevant to the practicing clinician seeking to become aware of and to understand the relevance of the complementary/alternative therapies being used by his/her patients for PMS and PMDD.

Current update of hormonal and psychotropic drug treatment of premenstrual dysphoric disorder

This review discusses the current status of diagnosis and treatment of premenstrual dysphoric disorder (PMDD), with an emphasis on studies that have been published in the medical literature during the 2001 to 2002 interval. Serotonergic antidepressants are effective for PMDD, and are currently considered the first-line treatment. Recent clinical trials have shown that selective serotonin reuptake inhibitors, taken only during the symptomatic luteal phase, are also effective for PMDD. One study reported efficacy for a slow-release formulation of fluoxetine that was taken two times during the menstrual cycle. Oral contraceptives still lack definitive evidence of efficacy as a treatment for PMDD, although a new contraceptive formulation has appeared promising for the mood and behavioral symptoms of the disorder. The results of a meta-analysis of the published trials of progesterone and progestins further indicate that these hormones are not effective in the management of PMDD.

Isoflavones from red clover (Promensil) significantly reduce menopausal hot flush symptoms compared with placebo

OBJECTIVES

To investigate the effectiveness and safety of a red clover isoflavone dietary supplement (Promensil, Novogen Ltd., Australia) versus placebo on the change in hot flush frequency in postmenopausal women.

METHODS

In this randomized, double blind, placebo-controlled trial 30 women with more than 12 months amenorrhoea and experiencing more than five flushes per day were enrolled. All received single blind placebo tablets for 4 weeks and were subsequently randomized to either placebo or 80 mg isoflavones for a further 12 weeks. Efficacy was measured by the decrease in number of hot flushes per day and changes in Greene Climacteric Scale Score.

RESULTS

During the first 4 weeks of placebo the frequency of hot flushes decreased by 16%. During the subsequent double blind phase, a further, statistically significant decrease of 44% was seen in isoflavones group (P<0.01), whereas no further reduction occurred within the placebo group. The Greene score decreased in the active group by 13% and remained unchanged in the placebo group.

CONCLUSION

In this study, treatment with 80 mg isoflavones (Promensil) per day resulted in a significant reduction in hot flushes from baseline. At the end of the study there was a significant decrease in hot flushes of 44% between the active and placebo group, demonstrating the effectiveness of Promensil in the management of hot flushes.

Gynecology: select topics

Menopause, premenstrual syndrome, dysmenorrhea, female fertility, and mastalgia are common problems not easily treated by conventional medicine. Women often seek alternative therapies to help address these conditions. Some evidence points to the efficacy of black cohosh, exercise, and possibly Kava and St. John's wort, in the treatment of menopausal symptoms. Clinical trials indicate that symptoms of premenstrual syndrome may be alleviated with calcium, magnesium, vitamin E. Thiamine, omega-3 fatty acids, the Japanese herbal concoction, TSS, and calcium have proved useful in treating women with dysmenorrhea. Symptoms of mastalgia may be attenuated by evening primrose oil, chaste tree and flaxseed oil may be helpful.

Premenstrual syndrome and premenstrual dysphoric disorder

It is almost impossible to cover all the options available for the treatment of premenstrual syndrome and premenstrual dysphoric disorder. This article discusses the most common and relevant options.

The role of complementary and alternative therapies in women's mental health

The advent of the newly evolving field of Integrative Medicine has provided women with an opportunity to expand the health care resources available to prevent and treat mental health conditions. Aided by evidence-based science, practitioners can now broaden the scope of their therapeutic armamentarium and allow women to use the best of what western and complementary medicine has to offer in the field of mental health care. Acupuncture, medication, herbalism, and guided imagery are included in a list of therapeutic modalities designed to augment traditional care. It is clear that by providing such comprehensive care, a woman's physical and mental wellness and her longevity are optimized.

St John's wort (Hypericum perforatum L.): a review of its chemistry, pharmacology and clinical properties

The chemical composition of St. John's wort has been well-studied. Documented pharmacological activities, including antidepressant, antiviral, and antibacterial effects, provide supporting evidence for several of the traditional uses stated for St John's wort. Many pharmacological activities appear to be attributable to hypericin and to the flavonoid constituents; hypericin is also reported to be responsible for the photosensitive reactions that have been documented for St. John's wort. With regard to the antidepressant effects of St John's wort, hyperforin, rather than hypericin as originally thought, has emerged as one of the major constituents responsible for antidepressant activity. Further research is required to determine which other constituents contribute to the antidepressant effect. Evidence from randomised controlled trials has confirmed the efficacy of St John's wort extracts over placebo in the treatment of mild-to-moderately severe depression. Other randomised controlled studies have provided some evidence that St John's wort extracts are as effective as some standard antidepressants in mild-to-moderate depression. There is still a need for further trials to assess the efficacy of St John's wort extracts, compared with that of standard antidepressants, particularly newer antidepressant agents, such as the selective serotonin reuptake inhibitors (recent comparative studies with fluoxetine and sertraline have been conducted). Also, there is a need for further studies in well-defined groups of patients, in different types of depression, and conducted over longer periods in order to determine long-term safety. St John's wort does appear to have a more favourable short-term safety profile than do standard antidepressants, a factor that is likely to be important in patients continuing to take medication. Concerns have been raised over interactions between St John's wort and certain prescribed medicines (including warfarin, ciclosporin, theophylline, digoxin, HIV protease inhibitors, anticonvulsants, selective serotonin reuptake inhibitors, triptans, oral contraceptives); advice is that patients taking these medicines should stop taking St John's wort, generally after seeking professional advice as dose adjustment of conventional treatment may be necessary.

Effects of natural products and nutraceuticals on steroid hormone-regulated gene expression

BACKGROUND

There is an increasing trend in the use of complementary and alternative therapies to treat or prevent hormonally dependent pathologies. Methods determined whether several of these natural products and nutraceuticals, commonly taken for hormone-related effects, possess steroid hormone activity. The agonist and antagonist estrogenic, androgenic, and progestational activities of 20 natural products and nutraceuticals were assessed using an in vitro tissue culture indicator system. Two steroid-regulated proteins (pS2 and prostate-specific antigen [PSA]) were quantified, using ELISA-type immunoassays, as markers of agonist and antagonist activity.

RESULTS

Four of the products tested, two isoflavone preparations, Promensil and Estro-Logic, chamomile, and grapeseed extracts, were found to have weak estrogenic agonist activity, with the latter two also demonstrating weak progestational activity. Several of the products tested exhibited antagonistic (blocking) activity, including antiestrogenic activity by Prostate-Ease, wild yam root, and dong quai, and antiandrogenic activity by dong quai, Promensil, and rosehips.

CONCLUSIONS

Several of these natural products demonstrate weak steroid hormone activity.

The case for uncontrolled clinical trials: a starting point for the evidence base for CAM

Clinical research into the effectiveness of any therapy usually progresses in a series of steps that are aimed at providing evidence that will lead to improved patient care. One important early step is the uncontrolled trial. Uncontrolled trials serve several crucial purposes, including establishing firmly that there is a clinical effect worth investigating, identifying the most suitable patients and the most appropriate treatments, and providing information on how large the effect might be. They can be conducted relatively easily by practitioners in the course of their normal work, and are an excellent first step for anyone interested in clinical research. Such studies are not only satisfying, but develop skills in searching the literature and writing protocols, and promote rigorous thinking and attention to detail. The ultimate purpose of uncontrolled trials is to facilitate subsequent definitive studies that will help define the place of CAM in health care.