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Women's Health Update: Pain Conditions in Women.

Select Pain Relief Strategies for Osteoarthritis and Fibromyalgia.

Women's health can be defined as problems that occur only in women, more often in women, or a medical problem that manifests in a unique and different clinical presentation in women. According to that definition, osteoarthritis and fibromyalgia are important primary care women's health conditions.

The incidence of osteoarthritis increases with age in both men and women, but in women, it is rare before the age of 45 years and then the incidence increases after menopause. Osteoarthritis, particularly of the hands and knees, is about twice as common in women than in men. It appears that there is a hormonal influence, especially of estrogens, on cartilage, especially since there are estrogen receptors in the cartilage. The studies on this topic are conflicting, but some do indicate that estrogen increases the volume of joint cartilage while others indicate that lower estrogen levels may even be protective. Studies of estrogen replacement therapy in postmenopausal women are also inconsistent as to their protective effect against incidence or progression of osteoarthrtis in women. Subjectively, many women do feel less joint pains when they are on estrogen replacement vs when they are off, but this is variable and individual.

Fibromyalgia affects at least 5 million adults in the US, and 80-90% of these cases are women. In that regard, it too is a women's health problem.

Three Trials of Maritime Pine Bark Extract in Osteoarthritis

The anti-inflammatory properties of plant phenols, including pine bark extract, have been of great interest in addressing the inflammation and pain of osteoarthritis. Three trials of a proprietary product, Pycnogenol, were reviewed on this topic.

Pycnogenol contains active compounds that are anti-inflammatory polyphenols, and metabolites of these polyphenol compounds are also produced in vivo due to Pycnogenol. Some of these metabolites appear in the serum within 30 minutes of ingestion, and others appear hours later, often after 14 hours. This has clinical meaning, because it means individuals might be able to get rather quick pain relief as well as sustained for many hours. Plant polyphenols and metabolites have also been detected in cartilage of the knee and in synovial fluid. Plant polyphenols reduce chronic inflammation and inhibit the enzymes that degrade cartilage.

In the current publication, the author (who is a former director of R&D for Horphag Research Ltd., makers of Pycnogenol), reviewed three randomized, double-blind, placebo-controlled clinical trials. Two hundred ninety-one patients, between the ages of 48 and 54, who had mild OA, received 50 mg of Pycnogenol or a placebo three times a day for three months in two of the studies. The third study used 100 mg/day or placebo. Pycnogenol or placebo was taken in addition to any non-steroidal anti-inflammatory drug (NSAID) they were already taking. Standard measurements of pain, stiffness, and physical function were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

All three trials reported reductions in pain and stiffness, as well as improvements to function and the overall WOMAC score. All three studies showed improvements with Pycnogenol compared to placebo, but the third study was the most significant in results with scores for pain, stiffness and physical function dropping by nearly 50%. When the details of the WOMAC scores were analyzed in more detail, patients using Pycnogenol reported significantly greater reduction in nighttime pain, pain during climbing stairs, daytime joint stiffness, improvements in rising from sitting and walking, and increased walking distance.

In addition, patients taking Pycnogenol were able to reduce their use of NSAIDS; while in the placebo groups, use slightly increased. In the third study, other factors related to NSAID use were analyzed with not only a decline of 58% use in the Pycnogenol group, but reduction in gastrointestinal complications and hospitals days. There were no adverse events due to Pycnogenol.

Commentary: Health care providers, as well as individuals seeking self-treatment might be overlooking Pycnogenol for the pain of osteoarthritis. Reducing pain and improving stiffness, mobility, and function are a priority; but we also want to be mindful of the possibility of therapies that can reduce progression, and even better yet, stimulate regeneration of joint cartilage.

Rohdewald PJ. Review on sustained relief of osteoarthritis symptoms with a proprietary extract from pine bark, Pycnogenol. J Med Food. January 2018;21(1):1-4.

Curcumin Improves Symptoms of Rheumatoid Arthritis

Curcumin, a constituent from turmeric rhizome is well known for its anti-inflammatory properties. One of the obstacles to efficacy for curcumin is its poor intestinal absorption, rapid metabolism, and limited bioavailability systemically. There are numerous methodologies that are used to overcome these issues. In this study, the researchers used a polar-nonpolar-sandwich technology in which the curcuminoids are protected inside the matrix. This randomized, double-blind, three-arm pilot study was conducted to evaluate the efficacy and safety of this specific new technology in this specific curcumin product called Acumin, from India, in individuals with rheumatoid arthritis (RA).

Thirty-six men and women in India, with a mean age of 38.2 years participated in this study. There were specific entrance criteria and scores of their RA that included functionality, joint swelling, joint tenderness, C-reactive protein (CRP), and erythrocyte sedimentation rates (ESR); and all had to meet the American College of Rheumatology criteria for a diagnosis of RA. Patients were excluded if they required disease-modifying antirheumatic drugs (DMARDs) or nonsteroidal anti-inflammatory drugs (NSAIDs), had RA with significant secondary involvement of any organ, an inflammatory joint disease other than RA, a different systemic autoimmune disorder, or any surgical procedure within 12 weeks prior to the start of the study.

Drugs that might interfere with the study were not permitted for two or four weeks, depending on the drug. Patients were treated with either 250 mg twice per day with Acumin, 500 mg at two/day, or placebo for three months.

Both the lower and higher doses of the proprietary curcumin product demonstrated improvement in the differential ability scales (DAS) with a 52.6% improvement with the lower dose and 66.0% improvement with the higher, compared to baseline. On the visual analogue scale (VAS) assessment, both the lower and the higher curcumin groups had significant 62.5% and 72.3% improvement, respectively, compared with baseline. Both the DAS and VAS for the placebo group had minimal changes. On the ESR assessment, both the lower and higher dose groups had 88.1 and 88.6% decrease in the ESR, with the placebo group only 29.6%. The lower dose had a 29.9% decrease in the CRP and the higher a 51.2% decrease. The placebo group, only 11.3%.

The total swollen joints assessment improved in both groups; the 250 mg/day and the 500 mg/day groups had significant 80.4% and 84.4% improvement respectively, and only 3.7% in the placebo group. Similar results were seen for the total tender joints assessment.

Commentary: Both doses of the proprietary product, Acumin, at 250 mg twice daily or 500 mg twice daily significantly improved symptoms and laboratory measures of RA with the higher dose being slightly better. The study was small, and four of the seven authors were employees of Aurea Biolabs which funded the study. I have no experience using this specific product, but I have many years of experience using all the different options of curcumin products from the simple powdered rhizome, to one of the high-tech products and everything in between. I have yet to identify if there is one preparation of curcumin that is best. I think they all have merit, and I suspect that in time, the clinical and research community might be able to clarify that one form/delivery may be used most effectively in one clinical condition, say rheumatoid arthritis, while another may be more effective in a cancer, or in depression.

Amalraj A, et al. A novel highly bioavailable curcumin formulation improves symptoms and diagnostic indicators in rheumatoid arthritis patients: a randomized, double-blind, placebo-controlled, two-dose, three-arm, and parallel-group study. J Med Food. 2017;20(10):1022-1030

Vitamin D and Fibromyalgia

Vitamin D deficiency and insufficiency have been suspects in fibromyalgia. The current small study, hoped to test whether vitamin D supplementation might be effective in improving symptoms of fibromyalgia. This study involved 11 adult women who had been diagnosed with fibromyalgia according to the American College of Rheumatology (ACR) criteria and had widespread pain in at least three quadrants of their body lasting for more than three months with a minimum of 11 of 18 tender points.

Patients had a serum vitamin D level of 30 ng/ml or less and received 50,000 IU of oral vitamin D once every week for three months. After three months, the vitamin D level increased significantly from 15.5-25.8 ng/ml to 28-58 ng/ml. An improvement in the visual analogue scale scores was observed at three months from 90 to 30. Eight women responded very significant improvement in symptoms and a trend for reduction in the number of tender points.

Commentary: Previous studies have demonstrated an association between fibromyalgia and vitamin D deficiency or insufficiency, while others have not. In one study of 30 Arab women with fibromyalgia, hypovitaminosis D was associated with widespread pain, and an improvement in pain and fatigue was seen after two months of just one dose of vitamin D. (Abokrysha N. Vitamin D deficiency in women with fibromyalgia in Saudi Arabia. Pain Med. 2012,13:7)

This study was small, lacked a control group, and did not consider other factors such as sun exposure and sunscreen; but as a pilot study, and given the lack of good data on successful treatment options for these folks, this approach of once weekly doses of 50,000 IU of vitamin D for three months, for those with vitamin D deficiency or insufficiency, is an appealing option.

by Tori Hudson, ND

womanstime@aol.com

Friere de Carvalho J, et al. Vitamin D supplementation seems to improve fibromyalgia symptoms: Preliminary results. Israel Medical Association Journal. 2018;20:379-381.
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Author:Hudson, Tori
Publication:Townsend Letter
Date:Dec 1, 2018
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