A BRIEF HISTORY OF MENSTRUATION IN CULTURE AND MEDICINE

Menstruation has historically been cloaked by religious, social, and cultural myths and meaning. Menstrual blood and menstruating women have been surrounded by fear, taboo,* restrictions, and worship since ancient times. Cultural views on menstruation are diverse. The Beng people of the Ivory Coast believed that “Menstrual blood is special because it carries in it a living being. It works like a tree. Before bearing fruit a tree must first bear flowers. Menstrual blood is like the flower.”² In stark contrast it has been referred to as “the curse” by Judeo-Christians and is considered a sign of uncleanliness, or even evil, in some cultures.³ Menstrual blood was used as a panacea, a medicinal ingredient, an ingredient in casting spells, and even as a pesticide capable of making caterpillars drop from plants and insects die in the fields.⁴ Menstruating women were variably considered to be possessed by evil spirits or magic. 5 6 7

Medical attitudes regarding menstruation have fluctuated over the centuries, from menstruation and menstrual blood being perceived as a natural process—a woman’s “flowers,” as menstruation was described not only by the Beng but in the Treatise on the Diseases of Women, and Conditions of Women, part of the medieval compendium known as The Trotula, which remained the definitive text on women’s medicine for several centuries—to something capable of poisoning men and deforming children, as described by Pliny and others.^2,7 Hildegarde of Bingen, the famed German nun and healer (1098–1179) used the term flowers; however, she also attributes menstruation to “Eve’s sin in Paradise,” reflecting both positive and negative attitudes toward menstruation. Hippocratic and Galenic medicine viewed menstruation as the basis of women’s unique physiology. It was considered a necessary and healthy purgation upon which the health of the entire female body was dependent. Menstruation was seen as women’s inherent constitutional “coldness.” The inabilities to “cook” their nutrients thoroughly led to an accumulation of waste in the body that could only be gotten rid of through menstruation. Lack of menses (e.g., amenorrhea) was believed to lead to a pathologic systemic state. Normal menstruation, that is, the proper amount at the proper time, was considered to reflect a state of health.²

In contrast, however, around the first century bce, Pliny, a physician and prolific medical writer, wrote that menstrual blood could drive men and dogs mad, make vines wither, sour wine, and discolor mirrors, among other powers.^5,7,8 Pliny’s views, as well as others’ of his time, represented menstruation as poisonous or noxious, views that would contribute to misogynist medical views of women that have persisted.^1,2,4 Democritus wrote that “usually the growth of greenstuff is checked by contact with a woman; indeed, if she is also in the period of menstruation, she will kill the young produce merely by looking at it.”⁶

Negative attitudes about menstruation have not only influenced the practice of women’s medicine, but also the medical education of women. Western medicine historically viewed menstruation as a disease and an opportunity to treat women as fragile and weak.⁷ Well into the nineteenth century in the United States, the fact that women menstruated was considered proof of the inferiority of the female intellect. Menstruation was used as a justification for keeping women out of medical schools, based on the grounds that menstruating women needed increased rest—mentally and bodily.⁵

Women’s health reform and self-help movements throughout the twentieth century have played a major role in transforming and reshaping women’s, society’s, and medicine’s attitudes toward menstruation. It has become a more acceptable topic for conversation, evidenced in many ways, not in the least, by the mention of menstruation on television sitcoms, the openness of menstrual products advertisements on television and in print media, and articles in popular magazines. This is a positive trend allowing women to more openly seek information and medical care about menstruation and menstrual concerns. However, advertising also directly contributes to the perpetuation of cultural menstrual taboos—that menstruation is “dirty,” and suggestions that it should remain hidden. Educational films and advertisements from menstrual product manufacturers stress products’ abilities to keep safe the secret that the girl is menstruating and to help her feel fresh and clean, perpetuating the message that menstruation is shameful and dirty.⁹

Women’s own personal and cultural views on menstruation also vary substantially. Menstruation may be considered a happy event, or a sign of uncleanliness—both attitudes persisting even in a single culture.¹⁰ A correlation has been asserted in feminist literature that a woman’s attitudes toward menstruation and can influence her physical experience of menstrual symptoms.⁷ In one study analyzing menstrual attitudes, women were asked to describe their menstrual periods. Terms were rated as positive (such as “red friend,” “my buddy”), negative (such as “the curse,” “pain in the ass”), or neutral (such as “period,” “surfin’ the crimson wave”). In the groups combined, most terms were either neutral (46%) or negative (37%). There was a tendency for women in the negative group to employ negative terms (52% of negative group women used solely negative terms versus 18% in the positive group), whereas 55% of women in the positive group employed neutral, not negative terms.⁹ Women in the negative group used negative terms significantly more than did women in the positive group. Many women consider menstruation somewhat of an inconvenience, but nonetheless, a natural event. Increasingly, American women are reframing menstruation as a celebration of women’s femininity and women’s connection to the rhythms of the earth and the moon.

WHAT IS NORMAL MENSTRUATION?

Menstruation is a cyclic process occurring in most women between 12 and 50 years of age. It generally occurs without difficulty, although there may be some normal sense of inconvenience accompanying the period. The variation in the interval between menstrual periods, the duration of each menstrual period, the amount of blood loss, the associated discomforts or lack thereof, and the subjective psychoemotional experience of menstruation among women is so great as to make it difficult to define “normal menstruation.” There is a wide range of normal variation.

It is necessary to determine whether a pattern, symptom, or concern is normal for the individual woman in the context of her own gynecologic and menstrual history, as well as against objective measures. Certain characteristics of menstruation can be a reflection of an underlying pathologic process or may predispose a woman to the development of chronic disease.¹¹ For example, metrorrhagia predisposes to anemia, and the irregular menstrual cycles associated with PCOS (see PCOS) can predispose a woman to diabetes and consequently, heart disease. Women with long or highly irregular menstrual cycles have a significantly increased risk for developing type 2 DM that is not completely explained by obesity.¹² Persistent deviations from the woman’s own norms, as well as major deviations from accepted standards, require further evaluation.

ONSET, FREQUENCY, AND DURATION OF MENSTRUATION

The onset of the first menses (menarche) typically occurs between the ages of 10 and 16 years old (see Puberty, Menarche, and Adolescence). The menstrual cycle is generally irregular and anovulatory for the first several years after menarche, reaching a regular length and duration by 5 to 7 years after menarche. Variations outside of this range are generally normal, but could be signs of precocious puberty or amenorrhea; sometimes symptoms of underlying medical disorders (see Puberty, Menarche, and Adolescence, as well as Amenorrhea).

A woman will experience from 300 to 400 menstrual cycles in her lifetime. Cycle length is controlled by the rate and quality of follicular growth and development, which varies in individual women.¹ Based on several observational longitudinal studies of thousands of women around the world, it was determined that at age 25, 40% of women had 25- and 28-day cycles, and from ages 25 to 35 60% had 25- to 28-day cycles. The average cycle length is 26 to 34 days.¹³ Only 0.5% of women experience cycles shorter than 21 days and 0.9% cycles longer than 35 days. At least 20% of women experience irregular cycles.¹ The length of the follicular phase is the primary determining factor in cycle length.

Menstrual bleeding lasts 3 to 6 days in most women, although there is variation in cycle length from 2 to 12 days after the start of ovulatory cycles. Longer periods (>8 days) are associated with anoluvation.¹³ The heaviest flow is consistently on day 2 of the cycle. Normal blood loss is considered 30 to 80 mL. Small clots are considered normal; large clots may suggest the need for further evaluation.⁷

The duration and amount of bleeding declines slightly (by about a half a day per cycle) in women over age 35. However, women approaching menopause often experience significantly heavier bleeding than younger women.¹³

Although some women describe their periods coming “like clockwork,” most describe some amount of irregularity over the course of menstrual life cycle, even if it is only occasional. The endocrine system is easily affected by numerous factors: stress, changes in amount of daily and nightly light exposure, sleep patterns, diet, travel, amount of exercise, illness, and so forth. It is normal for women to occasionally experience an irregular period, a lighter or heavier period, a “crampy” period, or even to miss a period in the absence of pregnancy or lactation. It is when irregularity recurs repeatedly, presents with an acute problem (e.g., sudden, heavy, or unremitting vaginal bleeding), or occurs in the absence of other explainable factors that one might suspect a disorder.

Women in their late thirties and forties often begin to experience some degree of irregularity of menstrual frequency, duration, and amount of blood loss because of a decline in ovarian function as they approach menopause. In their late thirties, women experience a shortening of their cycle because of increased production of FSH, a result of follicle numbers beginning to decline. However, between 2 and 8 years prior to menopause, the cycles again lengthen.¹ Approximately 50% of women experience a cycle of 120 days or longer in the year prior to menopause, and 20% experience a cycle of this length or longer within 2 to 4 years of their final period.¹³ The average age of menopause in the United States is 51 years old.¹⁴

FREQUENCY AND TYPES OF MENSTRUAL DISORDERS

Menstrual dysfunction is defined in terms of bleeding patterns, for example, amenorrhea (lack of menstruations), menorrhagia (excessive bleeding during menstruation), or polymenorrhea (frequent menstruation); ovarian dysfunction for example, anovulation and luteal deficiency; pain (dysmenorrhea); and premenstrual syndrome. Irregular menstruation is estimated to range from 2% to 5% of the general population, and up to 66% among athletes.¹⁵ In the United States, approximately 2.9 million office visits are made annually by women age 18 to 54 for menstrual problems.^7,16 Two-thirds of these women contact a doctor regarding menstrual problems each year, and 31% report spending a mean of 9.6 days in bed annually. Among young women, dysmenorrhea is the most common cause of time lost from work or school. The costs of menstrual disorders to US industry have been estimated to be 8% of the total wage bill, and the impact is particularly acute in industries that employ women predominantly.¹⁶ Interestingly, it is estimated that primitive, hunter gatherer women, over the course of an average lifetime, experienced only one-third as many menstrual periods as do modern women because of later age at menarche, earlier and more frequent pregnancies, and breastfeeding, suggesting that modern women experience a significantly greater lifetime exposure to estrogen, which may be partially responsible for increased health risks. Traditionally, factors such as later menarche, earlier first pregnancy, breastfeeding, and earlier menopause may have played a protective effect against, for example, breast and gynecologic cancers.¹⁶ Menstrual disorders also predispose women to other risks, for example, anemia, osteoporosis, cancer risks, diabetes, and cardiovascular disease.

In spite of the significance of menstruation in women’s lives and the high incidence of menstrually related health problems in society, there is surprisingly little epidemiologic evidence on menstrual disorders and associated risk factors, and no prioritization of research in this area.^11,16

Subsequent sections of this chapter address these dysfunctions either individually or as part of a larger syndrome in which they occur.

FACTORS AFFECTING THE MENSTRUAL CYCLE

Numerous factors influence the menstrual cycle, including a woman’s nutritional status, stress levels, body weight, exercise patterns, attitudes and beliefs about menstruation, and environmental and workplace exposures. Investigation into these can sometimes explain dysfunction; corrections can often restore physiologic and emotional balance. A holistic approach to preventing and treating menstrual dysfunction should always include consideration of possible social and lifestyle issues.

PROMOTING HEALTHY MENSTRUATION

The health care profession has an obligation to promote menstrual education. We must have an understanding of reproductive physiology in order to impart it to our patients, and we must be sensitive to the need to present a positive attitude regarding sexual and reproductive functions.

SUMMARY

Given the number of menstrual cycles a woman will experience in her lifetime, menstrual wellness and comfort are certainly desirable goals. Approaches to promoting menstrual wellness and reducing problems may include, for example, improving nutrition, ensuring enough exercise, and improving self-esteem and body image to reduce women’s tendencies to overdiet and overexercise. Conversely, obesity needs to be addressed, as does its opposite, underweight, as both are associated with increased menstrual problems. Stress reduction, menstrual health education, and improving both women’s individual and society’s attitudes toward menstruation also may influence the psychological, physiologic, and endocrine factors that lead to menstrual dysregulation.

Environmental hazards predisposing not only to such problems as hormonal dysregulation and menstrual complaints but to serious and life-threatening conditions and reproductive disasters need to be addressed. The ancients linked the earth to women, Gaia representing both. The health of women may ultimately be linked to the health of our environment. Therefore, those concerned about women’s health must necessarily also turn their attention to the health of our planet.

SIGNIFICANCE OF AGE AT MENARCHE AND PATTERNS OF EARLY MENSTRUAL CYCLES ON LONG-TERM HEALTH

There has been media attention and concern given to the fact that girls appear to be entering puberty at earlier ages than historically. In fact, there is some disagreement in the literature as to whether this is the case. One author states that in white American females, the mean age of menarche has not changed in 50 years, although the author admits that population studies may obscure the actual rates, whereas others state that evidence from the United States points to a decline in the mean age of menarche from 14.7 years at the turn of the century to age 12.8 at the end of the twentieth century.^39,41 These latter data are allegedly corroborated by European data that demonstrate a decline in age of menarche of 3 months per decade over the past 150 years.⁴¹ All authors agree that earlier menarche is noted in girls living in urban environments and relate this to heavier than average weight compared with cohorts in rural areas. Increased rates of obesity and exogenous estrogens may indeed play a significant role in the early onset of menarche, and in addition to the risks associated with being overweight, may have implications for increased adult rates of breast cancer development. In fact, early age at menarche (<12 years) is a recognized risk for breast cancer, with risk declining by 10% for each year after that in which menarche is delayed.⁴¹ This is primarily thought to be associated with greater cumulative exposure to estrogen and progesterone, especially estradiol. This risk may be reduced by the fact that girls who begin menstruating earlier are more likely to experience adolescent childbearing.

Conversely, girls with higher estrogen levels may be less predisposed to osteoporosis owing to increased bone density accumulation in the pubertal period, as evidenced by lower rates of osteoporosis among black women compared with white women. Adolescent girls with suppressed estrogen levels should be carefully monitored for bone density and optimally all girls should consume high-calcium diets or take calcium supplements particularly in the few years after menarche when bone density accumulation is as great as 10% to 20% and ensures as much as 10 to 20 years of protection against age-related bone mass loss.³⁸

Age at menarche may be an indicator of nutritional status. Poor nutritional status or excessively low body fat percentage can lead to delayed menarche and may be a result of socioeconomic status, excessive exercise or athletic activity, or an eating disorder such as anorexia nervosa or bulimia. Vegetarian diet or low fat or carbohydrate (energy) intake also may lead to delayed menses. Unlike malnourished girls, girls with later-onset menses with adequate nutrition do not necessarily achieve demonstrably lower height by adulthood than girls with earlier-onset menstruation; however, compromised nutritional status requires social and medical attention. The fact that skeletal growth is still occurring throughout the teenage years underscores the importance of good nutrition. Girls with eating disorders are at risk for numerous medical complications and require counseling and intervention. It should be remembered that overeating leading to obesity is the most common malnutrition problem among adolescents in the United States and has been increasing in epidemic proportions. Girls with eating disorders critically need help with understanding how to nourish their bodies, but also need support in establishing positive body images and self-esteem. Adolescent pregnancy can also have a dramatic and deleterious impact on growth and development, and if adolescent pregnancy is accompanied by being overweight it can predispose the girl to problems with weight and diabetes later in life owing to alterations in growth hormone and insulin patterns. Health professionals counseling girls about their menstrual cycles have a tremendous opportunity to also counsel girls about nutrition, sexuality, lifestyle management, and a wide array of psychosocial issues that can impact their lives and long-term health.

TALKING WITH GIRLS ABOUT MENSTRUAL HEALTH AND HYGIENE

Although our culture has certainly become more open about menstruation, with overt menstrual product advertisement or mention of PMS commonplace, many girls are still reticent when discussing the topic. Girls may be generally ignorant about what is happening to their bodies, and even the more knowledgeable girls may be uncertain about such things as maintaining menstrual health and hygiene.

Learning to chart her menstrual cycles can be an important first step in a girl’s increased self-awareness and is also an important way to keep track of whether the cycles are regular and normal. Although cycles may be irregular for the first few years after menarche, this does not mean that all irregularity is normal or healthy. Even within patterns of irregularity, most menstrual cycles will range from 21 to 45 days with deviations of slightly higher or lower than this on occasion. Most periods will last from 3 to 7 days. Wildly irregular cycles, excessively heavy periods, or oligomenorrhea can be indicative of serious health problems requiring further attention, including: polycystic ovarian syndrome (PCOS), thyroid disease, Cushing’s disease, diabetes mellitus, premature ovarian failure, eating-disorder or exercise-induced amenorrhea, congenital adrenal hyperplasia, adrenal or ovarian tumors or prolactinomas, or other endocrine problems. Providing girls with calendars for recording their menstrual cycles, and instructing them on how to do this, including recording the days they are menstruating (Day 1 is considered the first day of the period and counting extends to the last day before the next period, whereupon the cycle starts again with Day 1), symptoms they might have prior to during or after menstruation (e.g., mood alterations, headaches, fatigue), and for how long the bleeding lasts and the amount of flow that is considered normal can provide them with information about themselves and is a fantastic and important gynecologic record.

A blood loss of 30 mL per cycle is considered normal, with a loss of greater than 80 mL considered abnormal, putting a girl at risk for anemia. However, there is little value in milliliter measurement as this is virtually impossible to calculate. More useful is keeping track of the number of menstrual pads changed daily and their level of saturation. Typically, a girl can expect to change her pad three to six times per day. If the pad is oversaturated, she might not be changing pads frequently enough, the pads may be of the wrong size or fit, or they may be slipping in her underwear. If after ruling out these factors, there is concern over excessive menstrual flow, evaluate further. Educating the girl about proper use of pads, how often to change them, and also about the different types of available products (e.g., tampons) and their use can help a girl to be more comfortable during her menses and also prevent the embarrassment that could come from overflowing a pad. Many girls, especially athletes, are curious about the use of tampons. This is an area in which education is particularly important. Although all tampons must now meet FDA regulatory limits on absorbency, 50% of all reported cases of TSS still occur in menstruating women. Current US FDA recommendations state that tampons should not be worn for 24 hours a day nor 7 days a week, and should be alternated with the use of pads.³⁹ Tampons should be changed at least every 4 to 8 hours; it is preferable to sleep with a pad rather than a tampon, and the last tampon at the end of menses must be remembered—it is relatively common for a girl or women to forget to remove a tampon at the end of the period. TSS should be treated as an acute medical emergency.

Encouraging girls to use the increasingly available selection of disposable menstrual hygiene products—both pads and tampons—that are made from organic cotton, encourages the use of more environmentally friendly products. Most major health food stores carry a selection of good alternatives to conventional commercial products.

MENSTRUAL IRREGULARITIES AND DIFFICULTIES IN THE ADOLESCENT FEMALE

Adolescent girls, like women, commonly experience menstrual complaints, the most common for girls being dysmenorrhea, mood changes, and acne. Irregular or abnormal bleeding, particularly menorrhagia or amenorrhea, also may occur, and should be evaluated medically if persistent. Each of these complaints is addressed separately throughout this book. Additionally, a specific overview of these complaints in relationship to the special considerations of adolescent girls and the use of botanicals with adolescents is presented in the following. In order to avoid redundancy, only a brief discussion of the botanicals is provided in this section. More detailed herbal information is provided further in this chapter and throughout the text.

EMOTIONAL AND PSYCHOLOGICAL CHALLENGES IN ADOLESCENCE

Adolescence is a challenging and confusing time for even the most stable of girls. Hormonal changes and fluctuations, physical changes leading to the sexualization of the body combined with confusing cultural messages about the role of the adolescent and sex, increasing pressures at school and the challenges of teen friendships, and problems at home (stress with parents, birth of a sibling, trouble with a sibling, parents experiencing marital discord or divorce, financial troubles, moving to a new location/home/school, death of an elderly relative such as a grandparent, or personal illness) can lead to enormous internal turbulence. It is critically important for girls at this age to have women confidants they can turn to for security, advice, reassurance, and accurate information. An anchor in the storm may be the best thing a teenage girl can have to help her stay healthy and focused on self-development rather than getting side-tracked by the many distractions available to adolescents. And this anchor needs to be available as early into puberty as possible-access to drugs and sexual experience starts in middle school for many US children. Health care providers can also provide an anchor for adolescent girls. One study, conducted in the late 1980s, looked at the major topics that teenagers wanted to discuss with their physicians. The top concerns expressed were: sexually transmitted diseases, birth control, fear of cancer, self-image, self-confidence, sexual function, and sexual abuse, yet most doctors were found only to discuss the topic of menstruation.³⁹

By charting their cycles, girls can begin to identify patterns in their mood fluctuations and how they are associated with their menstrual cycle. This can help them to recognize their emotions as cyclical changes related to hormones and not something inherently wrong with them. Teaching girls the value of good nutrition, particularly adequate protein and healthy carbohydrates combined with a good vitamin and mineral supplement, to keep sugar and caffeine consumption to a minimum, and to keep the blood sugar stable can reduce mood swings and show them that they have some control over their emotional lives. Adequate sleep (teenagers may require as much as 12 hours per day!) and moderate exercise are also important for keeping emotions level and can also support cognitive function. Journaling can be a useful tool for self-expression and may help girls to both record and vent some of the challenging emotions they feel and situations they face as they emerge into women. Finally, if emotional or behavioral conflicts are significant, girls may benefit from or require counseling, as might the family constellation. A healthy home life is an important stabilizing force as young girls emerge into women and sort through their own identity, personal and social roles, relationships, and responsibilities.

HERBS AND ADOLESCENT GIRLS: SAFE USE VERSUS WRONGFUL ADVERTISING

In 2000, a national advertising campaign was launched for an herbal product called Bloussant® Breast Enhancement Tablets. The fall 2001 issue of Teen Vogue and the September 2001 issue of Seventeen ran full and quarter-page ads, respectively, for this product. These advertisements feed into the already prevalent idea that bigger breast size is better that led nearly 4,000 females 18 and younger to have breast augmentation surgery in the year 2000 alone (representing 2% of all such surgeries that year), a 425% increase over 1997 rates. This represents a growing trend of misuse of herbal products by teenagers.⁴² Marketing of herbal products to teens has become increasingly popular, and teens are receptive to this marketing, many of them believing that natural means safer.⁴³ In fact, the prevalence of use as determined by limited population surveys appears to mirror that of national use by adults with nearly have of all teens surveyed reporting CAM use, with the use of herbal products at approximately 12%. 43 44 45 Teens primarily appear to base their use on perceived parental or friend use, and primarily appear to use herbs without parental knowledge.⁴⁵ Many are concurrently using other pharmacologically active substances, including medications, other herbal products, or recreational drugs or alcohol. Common conditions for which teens use herbal products include PMS, urinary tract infections (UTIs), obesity, pregnancy, and enhancement of athletic performance or stamina. Adolescent girls are more likely than boys to seek health care, including CAM therapies, although the rate of supplement use is higher for adolescent male athletes than their female athletic counterparts (29% vs. 12%).⁴³

Because little to no clinical research has been done on the safety of botanical medicines in the distinct population of adolescent females, extra care should be taken during this period of rapid growth and development and hormonal change. Further, the combined use of herbs and pharmaceutical drugs, not to mention recreational use of pharmaceutical or “natural” drugs is also largely unstudied, and may be an area in which teenagers either experiment or unknowingly use potentially harmful combinations. Teens may therefore be at additional risk compared with the adult population when using herbal remedies. Much like with young children or pregnant and lactating women, additional precautions should be taken to minimize the use of botanical therapies that might inappropriately affect the endocrine system during this developmental stage. Adolescents should be educated and cautioned about the use of products such as those for breast augmentation and athletic enhancement, and should be advised about the hazards of using such herbs as ephedra or other stimulant herbs for athletic performance or weight loss. Finally, adolescents should be encouraged to seek the help of a qualified herbal practitioner when choosing to use herbs for the treatment of health problems, and should be told to inform their primary care provider of the use of any herbal products, particularly if being prescribed a pharmaceutical drug or medical treatment. Adolescents should be informed that natural does not mean safe and that there are potential hazards associated with the use of herbal products. Practitioners should not make the broad assumption that herbs that are safe for adult women are always and entirely safe for adolescent girls, and considering the unknowns of herbs for this population; short-term therapies (i.e., for 3 months or less followed by a rest) may be preferable to using herbs for long courses of treatment. More research in this area is warranted.

COMMON PROBLEMS OF PUBERTY AND MENSTRUATION IN ADOLESCENT FEMALES AND THEIR BOTANICAL TREATMENTS

Mood Changes

The Botanical Practitioner’s Perspective

Mood swings are common among adolescent girls and may be particularly prevalent in the week or days just prior to the onset of menstruation, not dissimilarly to PMS, or they may occur more frequently and unpredictably than monthly or cyclically. Frequently, girls start exhibiting mood swings as early as age 11, which many parents assume to simply be a behavioral problem rather than recognizing the beginning of hormonally mediated mood changes. Mood swings may be extreme, ranging from hysteria to euphoria in a matter of moments. Dramatic behavior is not uncommon. Girls also may find that their cognitive functioning is not as sharp, especially just prior to menstruation, making it more difficult to concentrate and perform in school, especially in the more linear subjects such as science and mathematics. Tests in school just prior to menstruation may be especially challenging for some girls. These emotional and cognitive changes are typically the result not only of hormonal influences but also of dietary inadequacies and sleep deficiency so common to adolescence. Declining blood sugar associated with hormonal changes along with inadequate consumption of high-quality protein and carbohydrates and an over-reliance on simple sugar for energy can lead to marked decline in mood and concentration. Inadequate rest as a result of staying up late at night and getting up early for school can exacerbate poor mood or concentration problems (also see Premenstrual Syndrome).

Adolescent girls are also subject to hormonal dysregulation that can lead to irritability, depression, and anxiety as frequently occurs with PMS. This period of time can be trying for parents and is difficult for the girl herself, who may be unhappy and feel out of control. Therefore, a great deal of support, encouragement, and reassurance may be needed as part of the health consultation. Conventional treatment relies on medication—either to regulate hormones, regulate mood (e.g., birth control pills, antidepressants) or both. In some cases medication may be appropriate, but counseling, lifestyle support, and appropriate nutritional and herbal supplements are preferable first line approaches when possible versus starting an adolescent on a course of hormonal or psychiatric drugs, whose long-term effects in the adolescent population are also frequently not well studied or understood. If depression is severe or thoughts or fears of suicide have been expressed, psychological counseling and medical intervention are essential. See Table 5-1 for a summary of mood changing herbs.

TABLE 5-1 Summary of Herbs Used for Adolescent Mood Changes

Discussion of Botanical Protocol

A number of herbs can be used to calm and nourish the nervous system. The gentlest of those that are used for promoting short- and long-term relaxation with a high safety profile when used in correct dosages include chamomile (Fig. 5-1), passion flower, and lavender, all of which are mild and nonaddictive. Ashwagandha is used over time as a tonic for the nervous system, and may exhibit beneficial effects on immunity, hemoglobin levels, and may have uterine antispasmodic activity as well, making it particularly beneficial when there is also dysmenorrhea. 46 47 48 49 For significant irritability and emotional lability many herbalists include the herbs motherwort or blue vervain in formulas. These bitter nervine herbs are applied in much the same principle as herbs for liver qi stagnation are applied in TCM with the understanding that herbs that improve the smooth functioning of the liver (possibly through liver detoxification mechanisms) have a regulatory effect on the female endocrine system. St. John’s wort is included when depression is a component of the emotional picture.⁵⁰ Additionally, bacopa, reputed for its ability to enhance cognitive function and retain newly learned information, is used to improve concentration while dong quai is used in formulas, when there is anemia.⁴⁹ Vitex is used when there is emotional lability associated with the menstrual cycle, particularly when there is also menstrual cycle irregularity.⁴⁶ It has a high safety profile, with no contraindications reported in the German Commission E Monographs, although it is generally considered contraindicated for use during pregnancy. Bohnert considers simultaneous use with hormone therapy and oral contraceptives to be contraindicated. 46 47 48^,51 In rare cases, short-term use of Vitex has been seen clinically to worsen depression; if this is observed discontinue its use immediately (Box 5-2).

Figure 5-1 Chamomile (Matricaria recutita).

Photo by Martin Wall.

BOX 5-2 Botanical Prescription for Adolescent Mood Changes

A typical protocol for when there is slight menstrual irregularity, irritability, and emotional lability is as follows:

• Give Vitex agnus castus (chaste tree) 5 mL once daily (usually given in the morning).

• Also give the following formula:

Chamomile	(Matricaria recutita)	25 mL
Ashwagandha	(Withania somnifera)	25 mL
Passion flower	(Passiflora incarnata)	25 mL
Motherwort	(Leonurus cardiaca)	20 mL
Lavender	(Lavendula officinalis)	5 mL
		Total: 100 mL

Dose: 5 mL twice daily or 2.5 mL as needed throughout the day not to exceed six doses.

If there is poor concentration or memory difficulty, take 5 mL Bacopa moniera (Bacopa) 1:1 one time daily or two 2.5-mL doses.

PATHOPHYSIOLOGY

The pilosebaceous unit consists of a hair follicle and its associated sebaceous gland. Acne is caused by the following constellation of four pathogenic factors at the pilosebaceous unit:

During adolescence androgen levels increase, explaining the prevalence of acne during this time. However, elevated androgen levels are not always a finding; in 60% of women with acne, serum androgen levels are normal but there is significantly elevated 5α-reductase at the sebaceous gland, indicating a heightened sensitivity to androgen. This also may explain the persistent or recurrent acne that might occur well into a woman’s forties.⁷² Increased 5α-reductase results in higher rates of conversion of androgens, specifically conversion of testosterone into its active metabolite dihydrotestosterone.⁷³ There is clearly an association between acne and menstruation with a premenstrual flare noted as common among 3394 women who completed a survey on the prevalence of acne in females in France.⁷⁴ Emotional stresses have also been demonstrated to increase acne outbreaks. Additionally, hyperandrogenic conditions including polycystic ovarian syndrome (PCOS), 21-hydroxylase deficiency, adrenal androgen excess, and some medications (e.g., steroids) are clearly implicated causes of acne.^70,72,73,, 75 76 77 P. acnes converts sebum to free fatty acids and individuals who are hypersensitive to these free fatty acids may experience the more uncommon forms of severe nodular acne.⁷³ Hyperinsulinemia also may play a role in the etiology of acne, evidenced by the increased glucose levels at the sebaceous gland of those with acne, and the prevalence of acne and PCOS in those with hyperinsulinemia, although a causal association is not conclusive.

SIGNS AND SYMPTOMS OF ACNE

The characteristic clinical manifestations of acne vulgaris are the appearance of comedones (“blackheads”) or pustules (“whiteheads”) typically appearing on the face, back, chest, and upper arms, the distribution of outbreaks making it among the most visible of dermatologic complaints. Inflammation may or may not be considerable. Diagnosis of hyperandrogenic and hyperinsulinemic states is essential to proper treatment. (See Polycystic Ovarian Syndrome.)

DIAGNOSIS

A diagnosis of acne is made upon visual inspection and exclusion of other causes. Acne may be dismissed as an unimportant consequence of adolescence or cyclic hormonal fluctuation; however, this may a gross underestimation of the significance of the problem.⁶³ In a 1994 study conducted by the AMA, 89% of adolescent girls reported worrying about their complexion and 50% believed it was the first thing people noticed about them.⁷⁸ Therefore, quick diagnosis and treatment from the time of onset of acne is important, particularly in the adolescent population when it tends to be the most severe and has the greatest social impact. Conventional therapy also calls for dermatologists to be adept at recognizing and treating resultant psychiatric disturbances in patients with acne.⁶¹ Furthermore, the appearance of acne may be indicative of more serious problems, such as PCOS, which predisposes to obesity, diabetes, and cardiovascular problems.⁷⁷

CONVENTIONAL TREATMENT

Acne vulgaris is not considered a curable disease by conventional medicine; however, symptoms are frequently well controlled and scarring prevented by a combination of systemic (internal) and topical therapies, with patients typically prescribed a combination of therapies as suggested by the causes and severity of the case.^60,79,80 Effective treatments are aimed at treating the four pathogenic factors mentioned in the preceding. Combination therapies are considered to be the most effective.⁶⁰ However, in mild cases, topical treatment sometimes may be adequate.⁸¹

Botanical Treatment of Acne

Philosophical View

Botanical therapy for acne begins with the belief that the health of the skin is a reflection of the overall health of the organism. The skin, a major organ of elimination, is believed to bear an excess burden of elimination when other eliminatory and detoxification organs (e.g., bowels, lymph system, liver) are not functioning optimally or are overtaxed. Thus, topical treatments are almost universally accompanied by systemic treatments that address the health of these other systems. An entire category of herbs, known historically and to this day as alteratives, and referred to colloquially as blood cleansers, are included in the treatment of most skin condition for their perceived stimulatory effects on the lymph system and liver. Many herbalists rely on the use of gentle choleretics to stimulate bile flow and improve bowel regularity and frequency, and herbs improve hepatic function, the long-term result of which is often found to be improved skin health. It is likely that the mechanisms of action include hepatic detoxification and a reduction in excess circulating hormonal load (i.e., excess estrogen, testosterone) via increased bile conjugation and intestinal elimination. Herbalists typically include botanical antimicrobials and anti-inflammatories as topical and systemic therapeutic agents. Additionally, herbalists view the skin as the interface between the individual and the world, “…being the vehicle through which we express, communicate, and perceive. Thus the psychological and spiritual aspects of an individual will impact and be impacted by the skin,”² corroborating what medical science now recognizes as the impact of emotional stress on the health of the skin and the influence of skin problems on emotional health.

As more information on the role of herbs on endocrine functions emerges, herbs are increasingly being considered for treatment of hormonal dysregulation in acne, such as hyperandrogenism. Based on the suspected hormonal etiology of Acne vulagaris there clearly appears to be a role for herbal hormonal modulation as an alternative to OCs and corticosteroids. (See PCOS if this is a suspected or confirmed diagnosis, of which the acne is symptomatic.) Hyperinsulinemia also should be evaluated for and treated if present, as this may be an etiologic factor in hypersensitivity to androgens.

The botanical medicine practitioner takes a multifactorial approach by incorporating dietary and nutritional modifications, attention to the individual female’s hormonal patterns, and the effects of stress on and from acne into a comprehensive treatment plan. Supporting evidence below focuses on herbs that directly target the skin through anti-inflammatory, antimicrobial, or hormonal effects. Table 5-4 provides suggestions for adjunct therapies that might be considered in conjunction with these direct acting agents, for example, the use of nervines or adaptogens.

TABLE 5-4 Botanical Treatment Strategies for Acne

It should be noted that immediate results are not expected when treating chronic acne. Improvement may take place over several weeks or longer, and when acne is associated with menstruation, over several cycles.

Discussion of Botanicals

Given the prevalence of skin complaints, there is a remarkable paucity of studies on botanicals for their treatment. The following discussion reviews the traditional and contemporary clinical uses of herbs for the treatment of acne.

Burdock Root: Internal/Topical

A comprehensive database search for uses of burdock root yields a long list of articles demonstrating its historical and traditional use for the treatment of sores, boils, and abscesses. It is discussed in King’s American Dispensatory as an alterative, aperient, and specific herb for impaired nutrition of the skin, specifically recommended for eczema, psoriasis, and dry scaly eruptions.⁸² Burdock root is used as an alterative and gentle laxative. The root extract has mild antibiotic activity, attributed to its polyacetylene constituents, which however, may not be present in commercially available dried material.^83,84 According to Wichtl, the European use of burdock as an herbal drug is nearly obsolete. The German Commission E did not support its therapeutic use owing to insufficient evidence.⁸⁵ No clinical studies using burdock have been identified in the literature. Nonetheless, it remains widely used by herbalists as a decoction or tincture to be taken internally for the treatment of skin conditions, including acne. However, there is controversy among herbalists about its efficacy for skin conditions, and some have reported exacerbations of inflammatory skin conditions. It is typically used internally, although it may be used topically as well.

Calendula: Internal/Topical

The effectiveness of calendula blossoms in the treatment of skin inflammations is well documented. Although the active principles have not been clearly defined, it contains both anti-inflammatory flavonoids and retinoids.^83,85 Calendula, a bitter, cooling herb, exerts systemic antiseptic and anti-inflammatory activity when used orally, and is considered specific for the treatment of sebaceous cysts and acne.^86,87 Limited uncontrolled studies on the antimicrobial activity of calendula have been conflicting, and tend to discount its efficacy, although it has demonstrated anti-inflammatory activity.⁸⁸ Its demonstrated effects include promoting epithelialization of surgical wounds, and bactericidal action against S. aureus.³² Herbalists continue to rely on it, finding it highly effective clinically for skin inflammation and infection, used both internally as a decoction and topically as a wash, steam, or fomentation. It is considered specific when there are swollen lymph nodes, and used internally, is considered to promote lymphatic circulation and drainage.

Chamomile: Internal/Topical

Chamomile is indicated externally for treatment of inflammation of the skin and mucosa, used as a wash or steam. Its effects may be largely owing to the chamomile flavones, e.g., apigenin, that exert a local anti-inflammatory effect with topical application. Apigenin is not only adsorbed at the skin, but penetrates to deeper layers.⁸³ Although no reports on the use of chamomile for the treatment of acne were identified, several reports indicate beneficial effects from topical use of standardized chamomile creams in the treatment of eczema, with two trials showing chamomile cream to have equal, or superior effects to topical steroidal and nonsteroidal anti-inflammatory medications.^87,89,90 It is recommended in the German Commission E Monographs for inflammations and bacterial conditions of the skin. No studies were identified on its specific use for acne. Allergic irritating skin reactions have been reported with the use of chamomile flowers topically, but such reports are very rare.⁸³ Internal use is appropriate as an adjunct treatment for stress and anxiety associated with acne.

Chaste Berry: Internal

Chaste berry is sometimes recommended for the treatment of acne, and in particular, menstrually or hormonally related skin problems.* Its use for acne appears partly based on a study conducted in 1968 by Giss and Rotheberg demonstrating clinical effectiveness in a group of 118 men and women (70% were women, some with PMS), including recurrence of acne with lapses in herbal treatment and complete healing in 70% of patients who had previously been unresponsive to long-term conventional therapy. Mills and Bone suggest the therapeutic efficacy seen in this study may be attributed to the mild antiandrogenic effects of Vitex, although this remains unknown.⁹³ Low Dog, however, argues that it seems illogical to give chaste tree for the treatment of acne given that acne seems to be aggravated in the progesterone dominant luteal phase of the menstrual cycle when Vitex appears to increase LH and progesterone levels.⁹⁰ Clearly, there is a great deal still not understood about the interactions of herbs with the endocrine system. Vitex has a good safety profile and may be of benefit in some women with acne; however, at this time there appears to be no scientific justification of its routine use as an acne treatment.

Chinese Skullcap: Internal/Topical

Scutellaria baicalensis, or “scute,” is considered specific in TCM for clearing “damp heat,” a category of diagnosis in which acne may commonly fall. It is clinically remarkable for reducing inflammation in dermatologic conditions and should be considered an important herb in formulations for treating acne and other skin conditions. It has also shown antimicrobial activity against a broad spectrum of microorganisms.⁹¹ It can be used orally for its systemic anti-inflammatory effects and/or topically in cream or wash form as a local anti-inflammatory (Fig. 5-2).

Figure 5-2 Chinese skullcap (Scutellaria baicalensis).

Photo by Martin Wall.

Cleavers: Internal

Cleavers is used internally for the treatment of a wide range of skin conditions.^83,87 It is particularly indicated when there are enlarged lymph nodes, and for inflammatory, eruptive skin conditions.⁸⁴ Its use is based on traditional evidence.

Dandelion Root: Internal

Dandelion root is an alterative and perhaps one of the best-regarded tonics for the liver.⁸³ Traditionally, it has been included in formulae for skin conditions such as acne. No human clinical trials have been conducted to support the uses of dandelion root for skin conditions.^90,92 Its use as a bitter, cholagogue, and aperient to promote and enhance liver function, bile secretion, and bowel elimination, respectively, may suggest some of the mechanisms of action in treating acne.

Echinacea: Internal/Topical

Echinacea has been used traditionally to clear inflammatory skin problems. It was used in the treatment of boils, abscesses, and eruptive skin conditions. Echinacea is believed to exert its benefits in the treatment of skin conditions via enhancing the activity of the lymph system, improving local elimination and reducing inflammation.⁹³ Echinacea also may be applied locally (topically) for inflammatory skin conditions. The polysaccharides are being investigated as possible active ingredients in its external activity.⁸³ Echinacea has demonstrated important immunomodulatory effects. It may be included in internal use formulae for chronic acne, as a general anti-inflammatory and immunotonic herb. Echinacea has been used successfully as a local anti-inflammatory for minor wounds and may be considered as part of a rinse or cream-based topical preparation.⁹³

Figwort: Internal

Figwort, an herb not commonly known outside of herbal and naturopathic practitioners, is an alterative used specifically in the treatment of skin conditions, usually reserved for those that are intractable, aggressive, or longstanding.⁹³ It is considered eliminative, having mild laxative, diuretic, as well as lymphatic activity. Hoffmann cites figwort as having cardiac stimulant activity, and cautions against its use in patients with tachycardia and those on cardiac glycosides, which it might potentiate.⁸⁴ It is otherwise unexpected to cause side effects when used at the recommended dosage.

Guggul: Internal

Guggul (equivalent to 25 mg gugulsterone) was found to decrease the number of inflammatory acne lesions by 68% in a small, randomized study (n = 20), compared with 65.2% with tetracycline (500 mg). The response in inflammatory lesions (papules, pustules, nodules, cystic lesions) was better than that in noninflammatory lesions (comedones). It is thought that the antilipolytic activity of gugulsterones reduces the output of sebum and inhibits the lipolysis of triglycerides by bacteria to free fatty acids.⁹⁴ The study design was not considered methodologically rigorous.⁹⁵

Licorice: Internal

Licorice has demonstrated increased cortisol effects (primarily in ulcerative bowel conditions). 95 96 97 98 99 Glycyrrhizin, a saponin of licorice root, and its derivative, glycyrrhetinic acid (GA), have been found to inhibit 11-beta-hydroxysteroid dehydrogenase, the enzyme that catalyzes conversion of cortisol to cortisone. One study found that 2% GA combined with hydrocortisone enhanced the local effects of the hydrocortisone. Because GA is already touted as a topical anti-inflammatory for dermatitis and psoriasis, this may point to a potential concomitant use of GA with hydrocortisone not only to enhance local effects but also to reduce systemic adverse effects with acne treatments.¹⁰⁰ It is used by herbalists as part of internal formulae for the treatment of acne and other inflammatory skin conditions. Licorice has not been directly studied for its effects in the treatment of acne; however, it should be considered for patients who wish to switch from corticosteroid treatments to a more natural approach to acne treatment, which should be done under the supervision of an experienced practitioner.⁹⁷

Oregon Grape Root: Internal/Topical

Oregon grape root has a long history of use for the treatment of a wide variety of chronic skin conditions, including acne, and was listed as a bitter tonic in the USP until 1916 and the National Formulary until 1947 as a bitter tonic, which as discussed, holds implications for its use in treating acne. One placebo-controlled clinical trial of nine male and female patients aged 12 to 30 years using a topical cream of 10% Oregon grape tincture in a 1:10 extract versus placebo, applied topically twice daily for 8 weeks, showed positive results with both groups demonstrating a reduction in skin oiliness and lesions, but only the Oregon grape group showing a decrease in sebum production. However, the study was considered too small and the preparation possibly too dilute to demonstrate a significant therapeutic effect. 101 102 103 Kraft lists Oregon grape as a primary treatment protocol for acne and seborrhea, citing its anti-inflammatory effects.¹⁰⁴ Mitchell suggests that when thinking of Oregon grape, one should think of the skin-digestive system connection. He states that most cases of acne, eczema, and psoriasis are eased symptomatically by using this herb (Fig. 5-3).¹⁰⁵

Figure 5-3 Oregon grape (Berberis aquifolium).

Photo by Martin Wall.

Tea Tree: Topical

Tea tree oil is a popular external application for skin problems. It has antibacterial and antifungal activity, in vivo, against a number of organisms, although its antiviral activities have not been conclusively demonstrated. A randomized control trial (RCT) of a 5% tea tree oil lotion demonstrated effectiveness as a topical antiseptic in the treatment of acne, slightly less effective than benzoyl peroxide in treating acne, although with fewer side effects. One hundred twenty-four patients were randomized to receive either tea tree oil or 5% benzoyl peroxide lotion for 3 months. Both groups showed improvement in the number of inflamed lesions, the number of non-inflamed lesions, and skin oiliness. Side effects in the tea tree group included skin dryness, pruritus, stinging, burning, and redness.^83,106 The German Commission E Monographs include skin inflammations and wound healing as indications for its use.⁸⁵ As with other essential oils, allergic dermatitis is a common side effect of tea tree oil, both from direct application to the skin (contact), as well as from inhalation of the vapors and ingestion.^83,102 Skin irritation appears to increase with the age of the tea tree product, possibly as a result of oxidation products, thus product freshness and storage practices may influence the rates of dermatitis.¹⁰²

Witch Hazel: Topical

The astringent and anti-inflammatory herb witch hazel has been used successfully for the treatment of dermatological conditions (inflammation and eczema) and may be used topically as a facial wash or in a cream base. Witch hazel distillate has demonstrated noteworthy effects in the treatment of topical inflammation after UV exposures, and witch hazel creams and ointments have shown anti-inflammatory effects in patients suffering from atopic neurodermatitis, psoriasis, and eczema in a total of six different clinical trials.⁹⁹

Yellow Dock: Internal

Yellow dock is a mild laxative, cholagogue, and alterative. Herbalists consider it a valuable herb in the treatment of chronic skin conditions, especially when there is accompanying constipation or digestive sluggishness.^87,105

Topical Applications

The topical application of herbs for acne treatment relies on those that are antimicrobial, astringent, and anti-inflammatory. Treatments may include the use of facial steams, washes, compresses, and creams. Topical use of neat (undiluted) essential oils is contraindicated owing to their irritating nature; their use may exacerbate the condition or cause tissue damage.

Differential Topical Treatment: Dry vs. Oily Skin

Practitioners must be sensitive to the skin type and preferences of individual patients when choosing topical medications.⁶⁹ Agents containing a higher volume of alcohol may be preferable to patients with oily skin and drying to those whose skin is already dry. Conversely, patients with dry skin may prefer moisturizing bases such as creams, ointments, or oils.

Facial Steams

Hot facial steams are helpful for opening the pores and allowing delivery of antiseptic volatile oils to the affected areas. The patient is instructed to bring a large pot of water to a boil, and while doing so have ready a large bath towel, the necessary essential oils, and a trivet. The trivet is placed in a sink and when the water comes to a boil, the pot is placed on it. The lid is quickly opened and three to five drops of essential oil are added and the lid quickly replaced. The patient is then to form a small tent over the head and sink and carefully remove the lid allowing the steam to bathe the face. The face should be kept at least 18 inches from the pot and care must be taken to avoid burning from the steam. The steam exposure should be maintained for 3 minutes, after which the patient should rinse the face with cool water or an astringent herbal infusion (e.g., witch hazel distillate). Lavender, tea tree, and rosemary essential oils are all excellent antimicrobials and may be used alone or in combination. This treatment can be repeated several times weekly, and may be accompanied by systemic treatment. Herbalists often use lavender as a mild soothing topical antiseptic. Although no clinical trials using the extract or flowers have been identified, its aromatic nature enhances topical applications and inhalation of the essential oil has been shown to induce relaxation.^85,87 Witch hazel may be used as a cool rinse after the steam to tonify the pores. Additionally, the steam water can be substituted with an infusion of any number of botanicals for the skin including a combination of the antiseptic and anti-inflammatory herbs: calendula, chamomile, lavender, and witch hazel to which the essential oils are added.

Botanical Formulae for Acne

See Boxes 5-7 to 10.

BOX 5-7 Botanical Prescription for Acne vulgaris

Tincture for Internal Use

Chinese skullcap	(Scutellaria baicalensis)	20 mL
Oregon grape	(Berberis aquifolium)	10 mL
Echinacea	(Echinacea spp.)	20 mL
Dandelion	(Taraxacum officinale)	20 mL
Licorice	(Glycyrrhiza glabra)	20 mL
Ashwagandha	(Withania somnifera)	10 mL
Total: 100 mL

Dose: 3 mL bid-tid depending upon severity. Provide formula for 12 weeks, then re-evaluate formula based on progress. The tincture can also be used at this dose during acute flare-ups only.

If acne is associated with the premenstrual period, give 5 mL Vitex agnus castus each morning from the end of the menstrual period to the beginning of the next, for 3 consecutive months.

Rationale: Chinese skullcap, Oregon grape, echinacea, licorice, and ashwagandha appear in the formula for their alterative and anti-inflammatory effects; Oregon grape and dandelion are choleretic, hepatic bitters; Oregon grape, echinacea, and licorice are anti-viral, and licorice and ashwagandha are adaptogens included for general HPA support.

Rinse for External Use

Prepare a strong infusion using equal parts of the following herbs:

Calendula blossoms	Lavender flowers	St. John’s wort
Witch hazel bark	Rosemary leaf

Steam or wash the face or affected areas with hot water, then rinse the face or other affected areas once or twice daily with this infusion (either warm or at room temperature). Repeat daily as needed. This infusion also may be used as a warm compress rather than as a rinse.

BOX 5-8 “Alterative” Prescription for Treating Acne

Tincture for Internal Use

Echinacea	(Echinacea spp.)	25 mL
Dandelion root	(Taraxacum officinale)	25 mL
Red clover	(Trifolium pratense)	25 mL
Cleavers	(Galium aparine)	25 mL
		Total: 100 mL

Dose: 5 mL bid.

BOX 5-9 Nervine Prescription

Tincture for Internal Use:

Chamomile	(Matricaria recutita)	30 mL
Lemon balm	(Melissa officinalis)	30 mL
Blue vervain	(Verbena officinalis)	30 mL
Lavender	(Lavandula officinalis)	10 mL
		Total: 100 mL

Dose: 2 to 5 mL tid, or 3 mL as needed.

These herbs can also be used as tea; taken one to two cups daily. Omit the vervain or motherwort if taken as a tea (both are bitter in tea).

*Blue vervain may be replaced with motherwort (Leonurus cardiaca).

BOX 5-10 Prescription for Constipation

Tincture or Infusion for Internal Use:

Infusion Dose: Prepare as for standard infusion, one cup taken daily as warm tea in the morning.

Tincture Dose: 5 mL bid

Nutritional Considerations

Diet is an important part of any herbal treatment protocol. Cultures maintaining traditional diets other than Western diets clearly have lower rates of acne.^109,110 Optimal nutrition with an emphasis on foods and nutrients that promote skin health as well as those that minimize the load on the eliminative organs is recommended. Red meat should be minimized in the effort to reduce the overall inflammatory response. Specifically important is evaluating the diet for the presence of unhealthy oils and excessive refined carbohydrate intake.

Although there has been no scientifically proven correlation between chocolate consumption and acne, many adolescents and women report aggravated acne after consuming it in large amounts. Chocolate cravings also may indicate unmet nutritional needs, which should be met through diet and supplementation. Low Dog suggests that individuals should avoid those foods that they themselves believe to be aggravating.⁹⁰

Treatment Summary for Acne Vulgaris

• The skin is a reflection of overall health, thus herbalists take a systemic approach along with the use of local, topical applications.

• Digestive eliminative functions can be improved with the use of aperients such as dandelion root, yellow dock root, and flax seed and should be considered when acne is associated with chronic constipation or sluggish digestion.

• Hormonal regulation is considered important when there is acne associated with menstrual problems and other hormonally related problems such as PCOS. Chaste berry is commonly used.

• Herbalists traditionally use herbs categorized as “alteratives” to improve lymphatic function and hepatic elimination, hormonal conjugation, and excretion. The most commonly used are burdock root, calendula, cleavers, yellow dock root, figwort, dandelion root, and red clover.

• An anti-inflammatory diet is recommended and anti-inflammatory herbs can be used internally and topically. These include licorice root, witch hazel, lavender, chamomile, and Chinese skullcap.

• Herbs can be used topically and internally to reduce infection and aid in reduction of inflammation. These include echinacea, lavender, Oregon grape, and tea tree.

• Stress can aggravate a tendency toward acne, and chronic acne can cause significant stress and depression. Herbal nervines, anxiolytics, and antidepressants can be included in formulae and include St. John’s wort, lemon balm, skullcap, and blue vervain. Adaptogens can be used long term to improve the stress response, enhance immunity, regulate the HPA-axis, and reduce inflammation. Ashwagandha should be considered. Other adaptogens are discussed in Chapter 7.

• Topical applications include washes, steams, and compresses. They are usually comprised of antimicrobial and anti-inflammatory herbs.

• Important nutritional considerations include an emphasis on optimal nutrition with good quality oils, Brewer’s yeast, vitamin A, zinc, vitamin B₆, and vitamin C.

• Stress reduction and counseling can be beneficial in cases of severe and chronic acne.

What to Expect with Treatment

Chronic acne typically requires 2 to 3 months of systemic and topical treatment before significant and consistent improvement is noticeable. Reduction in inflammation may be observable after several days of topical treatment with steams and skin rinses.

The following supplements have been shown to have a beneficial impact on acne:

• Brewer’s Yeast: 2 to 3 g tid may reduce insulin sensitivity and in one study showed a clinical improvement in acne patients. This supplement is contraindicated for those taking MAO inhibitors as concomitant use may cause hypertension.⁷¹

• Vitamin A: Retinoic compounds are a mainstay of acne treatment. Use of vitamin A as a treatment for acne may require intake of high (100,000 IU/day for 1 month followed by 25,000 to 50,000 IU per day for 3 months) and possibly unsafe dosages leading to hypervitaminosis A and if the use is prolonged, vitamin A toxicity. Kohani states that doses of 25,000 IU daily are safe and effective for acne treatment. Foods high in vitamin A (carrots, squash, sweet potatoes, apricots) can also be consumed as a regular part of the diet. Vitamin E assists in retinal regulation in humans and when combined with zinc may enhance the efficacy of the lower daily dose of vitamin A.¹⁰⁹

Warning: Vitamin A in large doses (>5,000 IU daily) is teratogenic. Supplementation in pregnant women or those planning to conceive should not exceed the normal amount present in a prenatal vitamin supplement and should only be taken as part of the prenatal vitamin. Extreme care should be taken in supplementation in those younger than 18 years old other than what is typical in a daily nutrient supplement.

• Zinc: Zinc is intrinsically important to the health of the skin, the healing of wounds, and to optimal immune functioning. There has been controversy over its effectiveness as an acne treatment with some studies demonstrating effectiveness and others not showing benefit. The recommended dose for adolescents is 25 mg zinc picolinate twice daily for 2 weeks and then once daily for 2 months, taking care not to exceed these recommended dosages.^71,109

• Vitamin B₆ (pyridoxine) has been shown to be beneficial when there is premenstrual aggravation of acne. Vitamin B₆ plays a role in steroid hormone metabolism and in animal studies B₆ deficiency appears to increase testosterone uptake and sensitivity.¹⁰⁹

• Vitamin C has been suggested at a dose of 250 mg tid as a natural anti-inflammatory.¹⁰⁹