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Women's health update.

Black Cohosh and Polycystic Ovarian Syndrome (PCOS): A New Option in Ovulation Induction

A recent study using black cohosh demonstrates a new addition to a natural medicine strategy for addressing PCOS. One hundred women with PCOS were recruited and seen in a clinic in Egypt. Women were randomly assigned to receive either 40 mg/day of black cohosh for 10 days or 100 mg/day of clomiphene for 5 days. (Clomiphene citrate is a conventional pharmaceutical prescription used as a first-line approach to induce ovulation.) Treatments were given starting on day 2 of each cycle and continued for 3 consecutive cycles. Blood tests included follicle-stimulating hormone (FSH), luteinizing hormone (LH), and progesterone. Transvaginal ultrasound was performed to document follicular size and growth as well as endometrial thickness. If a follicle achieved a size of 18 mm or greater, human chorionic gonadotropin (HCG) was given and intercourse was recommended.

While at baseline, both the black cohosh and clomiphene groups had similar FSH, LH, and FSH/LH ratios, at the end of the treatment period, the black cohosh group had a significantly greater reduction in the LH level as well as the FSH/LH ratio. After receiving black cohosh, this group also had significantly greater progesterone levels and endometrial thickening. Remarkably, the black cohosh group had a more pregnancies (7 vs. 4), although in terms of statistical power and 50 women in each group, this did not reach statistical significance. There were also 2 twin pregnancies in the black cohosh group vs. 1 in the clomiphene group. Again, this was not statistically significant. The black cohosh group had 1 miscarriage and 1 case of mild hyperstimulation compared with the clomiphene group, which saw no miscarriages, 1 mild case, and 1 moderate case of hyperstimulation. And again, this was not statistically significant.

Comment: Polycystic ovarian syndrome (PCOS) is one of the most challenging endocrinological disorders in women. It not only affects the menstrual cycle, fertility, and physical manifestations of androgen excess (acne, hirsutism, hair loss) but also increases the risk of longterm significant health issues, including type 2 diabetes, dyslipidemia, hypertension, and endometrial cancer. The underlying cause of PCOS is dominantly insulin resistance, but amenorrhea, oligomenorrhea, or infertility and the associated lack of ovulation or only infrequent ovulation are often what brings women to the medical office.

This use of black cohosh and its apparent effect on inducing ovulation is a very useful study in the complex and challenging management of women with PCOS. Adding black cohosh to natural medicine strategies that increase insulin sensitivity, reduce androgen excess, and reduce conversion to the more active form of testosterone in the skin, while always being mindful of reducing the risk of future diseases such as type 2 diabetes, cardiovascular disease, and endometrial cancer, is an advancement in treatment options. We are left with a desire to better understand optimal black cohosh dosing for this purpose and for larger studies to see the impact on regular ovulation and rates of pregnancy.

Kamel HH. Role of phyto-oestrogens in ovulation induction in women with polycystic ovarian syndrome. Eur J Obstet Cynecol Reprod Biol. May 2013;168(1):60-63.

Soy Isoflavones on Endometrial Tissue: Another Reassuring Study

The aim of this study was to determine if long-term isoflavone soy protein (ISP) in supplement form could affect endometrial thickness, endometrial hyperplasia, and endometrial cancer in postmenopausal women.

This randomized, double-blind, placebo-controlled trial matched 350 postmenopausal women ages 45 through 92 with a placebo group, for a period of 3 years. Women were randomized to take a daily dose either of 154 mg of ISP or a milk-protein placebo. The final study population was 224 women. The primary outcome measures were the average change in endometrial thickness as detected on transvaginal ultrasound from baseline up to 36 months, and the biopsy incidence of endometrial hyperplasia and endometrial cancer.

Transvaginal ultrasound was done at baseline, 18 months, 30 months, and 36 months. Any woman with an endometrium greater than 5 mm was biopsied, as well as any woman with postmenopausal bleeding. In the soy group, which in the end evaluated 121 postmenopausal women, 9 (7.4%) underwent endometrial biopsy based on transvaginal ultrasound. The results were benign in all of these 9 cases. In the placebo group of 103 women, 7 (6.8%) underwent endometrial biopsy, and 6 of these 7 were benign with 1 woman diagnosed with complex endometrial hyperplasia with atypia. She then proceeded to a hysterectomy.

Comment: Previous studies on the effect of ISP and its effect on the endometrium have been conflicting. One pilot study in 2002 demonstrated no effect, but the study was small (27 women) and the duration only 6 months. A larger 5-year study in 2004 found a small increase in endometrial hyperplasia in the soy group (5 of 6 = 3.8%) and none in the placebo group. However, 5 of the 6 cases were simple hyperplasia with no atypia and only 1 case of complex hyperplasia and again no atypia. Unfortunately, this 2004 study did not report on any cases of postmenopausal bleeding or ultrasound monitoring but instead did uniform biopsies on all women. This study had no effect on the thickness of the endometrium or on the rates of endometrial hyperplasia or endometrial cancer in postmenopausal women who took 154 mg/day of ISP for 3 years. The only case of endometrial hyperplasia (with atypia) that did occur was in the placebo group. This confirms my comfort with daily intake of soy phytoestrogens both in the diet and in supplemental form for postmenopausal women. This amount of 154 mg of total isoflavones per day is well above 2 servings of soy in the diet daily.

Quaas A, Kono N, Jack W, et al. Effect of isoflavone soy protein supplementation on endometrial thickness, hyperplasia and endometrial cancer risk in postmenopausal women: a randomized controlled trial. Menopause. 2013;20(8):840-844.

Green Tea Improves Depression through Improving Motivation

Seventy-four healthy individuals participated in a double-blind, randomized, placebo-controlled study were given oral green tea (400 mg powder three times daily) or placebo for 5 weeks. The evaluation of reward learning and response to reward was conducted as well as mood, using the Montgomery-Asberg Depression Rating Scale (MADRS) and the Hamilton Rating Scale for Depression (HRSD-17).

Green tea had significantly decreased reaction time in response to reward trial compared with placebo, meaning that those who took green tea showed a significant increase in reward learning. In addition, individuals who took the green tea had a reduction in the MADRS and HRSD-17 scales, demonstrating improvement in depression when compared with placebo group. These findings suggest that reduced reward learning might be associated with depression. The regulatory role of green tea on reward learning raises the possibility that it may be a supplemental treatment in reversing depression via its ability to normalize the reward function.

Comment: Other studies have demonstrated that regular intake of green tea could reduce depressive symptoms. There is also evidence that a disturbance in reward learning can be associated with anhedonia, a frequent core symptom of depression and a requirement, along with depression for a diagnosis of major depressive disorder. The definition of anhedonia, per the American Psychological Association, is less interest in hobbies, apathy, and lack of enjoyment in activities that were previously enjoyed. Past research has linked dopamine deficiency and the reduction of dopamine transmission with anhedonia. Even though conventional medications address many depressive symptoms, it seems that these do not adequately address motivation and reward deficits in depression. It has been proposed that the active component in green tea, EGCG, works in part by modulating dopamine transmission.

Zhang Q, Yang 1-I, Wang J, et al. Effect of green tea on reward learning in healthy individuals: a randomized, double-blind, placebo-controlled pilot study. Nutr J. 2013; 12:82.


by Tori Hudson, ND

Dr. Tori Hudson graduated from the National College of Naturopathic Medicine (NCNM) in 1984 and has served the college in many capacities over the last 28 years. She is currently a clinical professor at NCNM and Bastyr University; has been in practice for over 28 years; and is the medical director of the clinic A Woman's Time in Portland, Oregon, and director of research and development for Vitanica, a supplement company for women. She is also a nationally recognized author, speaker, educator, researcher, and clinician.
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Author:Hudson, Tori
Publication:Townsend Letter
Geographic Code:1USA
Date:Nov 1, 2013
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