By Lynn Keegan, RN, PhD, HNC, FAAN
Premenstrual symptoms—such as nervousness, irritability, depression, bloating, breast tenderness, weight gain, skin problems, and digestive problems—affect many women at some point during their lives. Hormones, vitamins, dopamine agonists, non-steroidal anti-inflammatory drugs, diuretics, magnesium, calcium, lithium, exercise, lifestyle modification and, in some rare cases, even surgical intervention are among the therapies studied to manage premenstrual syndrome (PMS).
Herbal medicines long have been used in traditional healing systems to treat female conditions, such as PMS and menopausal symptoms. Chaste tree berry is one particular herb that may be helpful for alleviating PMS symptoms. For a select number of phytomedicines, including chaste tree berry, scientific investigation is elucidating the pharmacologically active constituents, mechanism of action, and clinical value.1
Chaste tree berry, which is also known as chasteberry, monk’s pepper, and vitex, comes from the fruit of Vitex agnus-castus, a shrub that grows in the valleys and along the riverbanks in the Mediterranean coastal region and in central Asia. The fruit is dark brown to black and is the size of a peppercorn. Since the berries have a peppery taste and smell, they often are used as an inexpensive substitute for the spice black pepper.2 The name chaste tree berry comes from the belief that the plant would inspire chastity. Medieval monks would use the berries or seeds as a spice to decrease sexual desire.3,4
Indications
Herbs have been used for thousands of years to ease menstrual symptoms. Chaste tree berry has been used in Europe, especially Germany, for many years to treat female reproductive tract disorders such as menstrual abnormalities, PMS, menopausal complaints, and breast pain associated with menses.2
Many popular women’s health books suggest using chaste tree berry to help relieve menstrual symptoms. Susan Love, MD, writes that Vitex agnus-castus, which acts like or increases the effect of progesterone, is among the herbs thought to be most helpful for heavy bleeding.5 Christine Northrup, MD, writes that Vitex agnus-castus helps regulate the hypothalamic-pituitary-ovarian axis to promote more progesterone.6
Constituents
Chaste tree berry contains several different constituents, including flavonoids, iridoid glycosides, and terpenoids. (See Table 1.) The whole fruit extract, rather than one of its individual constituents, appears to be necessary for the medicinal activity of chaste tree berry.3
Mechanism of Action
Chaste tree berry is believed to have anti-inflammatory and progesterone-like effects.7 It affects pituitary hormone regulation (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) and restores estrogen- progesterone balance.8
The corpus luteum is glandular tissue in the ovary that forms monthly at the site of a ruptured graafian follicle. The corpus luteum secretes progesterone, which prepares the uterus for implantation. Luteal phase defect occurs when progesterone secretion is abnormally low. This is considered a normal condition in pubescent and menopausal life phases, but during child-bearing years it produces undesirable effects, which can include heavy or frequent periods, lack of ovulation, ovarian cysts, and sometimes lack of period. Luteal phase defect also can lead to PMS.9 Chaste tree berry extracts help reinstate normal balance between estrogen and progesterone during the luteal phase of the menstrual cycle.10 Chaste tree berry seems to stimulate the production of LH, which in turn results in an increase in progesterone production. Hence it mimics corpus luteum function. Interestingly, chaste tree berry has no direct hormonal activity; it is therefore, not a phytoestrogen.2,11,12
Clinical Studies for PMS
A 1992 study evaluated the efficacy of chaste tree berry liquid extract in 1,542 women ranging in age from 13-62 years, who were diagnosed with PMS.13 Each woman received 40 drops of chaste tree berry liquid extract every morning for an average of 25.3 days. Patients and their gynecologists received questionnaires to rate each patient’s symptomatic response to chaste tree berry. Physicians rated chaste tree berry as "very good" or "good" 92% of the time. However, only 57% of the patients reported improvement in symptoms and 33% noted complete relief of their symptoms.
In a randomized, double-blind, placebo-controlled outpatient study, 178 women with PMS were given one 20 mg tablet daily of Vitex agnus-castus fruit dry extract ZE440 (standardized to casticin, 60% ethanol by mass, extract ratio 6-12:1) vs. placebo for three menstrual cycles.14 Mean difference was calculated from baseline in combined scores of a visual analog scale that included symptoms of irritability, mood alteration, anger, headache, bloating, and breast fullness. Secondary outcomes included clinical global impression of severity of condition, global improvement or deterioration, and overall treatment assessment. The treatment was well-tolerated. Mean reduction in self-assessed combined symptom scores were -78.1 in the placebo group and -128.5 in the treated group, a significant difference. There were significant differences between groups favoring chaste tree berry on irritability, mood alteration, anger, headache, breast fullness, severity of condition, improvement/deterioration, and overall assessment. There was no difference between groups in symptoms of bloating.
A multicentric, noninterventional trial to investigate the efficacy and tolerance of a solid preparation of Vitex agnus-castus fruit extract was performed in 1,634 PMS patients.15 The researchers developed a questionnaire to determine the effect of chaste tree berry on psychic and somatic complaints, on the four characteristic PMS symptom complexes (depression, anxiety, craving, and hyperhydration [DACH]), and on single groups of symptoms. After a treatment period of three menstrual cycles, 93% of patients reported a decrease in the number of symptoms or even cessation of PMS complaints. To a certain extent, this effect was observed within all symptom complexes and correlated with the global assessment of therapeutic efficacy. Whereas 85% of physicians rated it as good or very good, 81% of patients assessed their status after treatment as very much or much better. Analysis of frequency and severity of mastodynia as the predominant symptom revealed that complaints still present after three months of therapy were mostly less severe. Ninety-four percent of patients assessed the tolerance of chaste tree berry treatment as good or very good. Adverse drug reactions were suspected by physicians in 1.2% of patients, but there were no serious adverse drug reactions.
In a prospective, multicenter trial, the efficacy of an Vitex agnus-castus L. extract ZE440 was investigated in 50 patients with PMS.16 The patients were treated daily with one tablet (20 mg native extract) during three menstrual cycles. Forty-three patients completed the study protocol, which encompassed eight menstrual cycles (two baseline, three treatment and three post-treatment). Thirteen of the 43 patients were receiving concomitant oral contraceptives. Dropouts included six patients who left for reasons unrelated to study medication and one patient who complained of fatigue possibly related to study medication. All evaluated patients took at least 85% of the prescribed medication. At the end of the study, PMS-related symptoms were reduced by treatment. The number of days that patients sustained PMS symptoms was reduced slightly from 7.5 to 6. Resting levels of blood prolactin remained within the physiological range throughout. No differences were seen between patients on or off oral contraceptives. No serious adverse effects were reported. Laboratory safety control parameters were not affected. The authors found the main response to treatment seemed to be related to symptomatic relief rather than to the duration of the syndrome.
Adverse Effects
Side effects of chaste tree berry may include gastrointestinal and lower abdominal complaints, allergic reactions (i.e., itching and rash), headache, and increased menstrual flow.3 Early menstruation following delivery is noted as a rare side effect.17
Contraindications/Precautions
Chaste tree berry is contraindicated in pregnancy, lactation, and in women receiving hormone replacement therapy.6 Although vitex contains progestins, the long-term effects of such "natural hormones" (e.g., the development of various hormone-medicated neoplasms) is unknown.
Drug Interactions
Chaste tree berry should not be taken by patients on neuroleptic medications such as haloperidol (Haldol) or thioridazine (Mellaril).6
Dosage
Chaste tree berry is available in powdered form in tablets and capsules, and in liquid formulations. (See Table 2 for a comparison of sample formulations and prices.) Recommended dosages are for 1 tsp of crushed fruit/cup of water 1-4 times/day, or 20-75 drops of the 1:3 liquid extract 1-4 times/day.6 In Germany, the aqueous-alcoholic extracts are recommended. Herbalists recommend 1-2 mL of the tincture tid or 40 drops of a standardized tincture daily.18 However, no strength for the tincture is given. Tea should be ingested three times a day.18 The amount of chaste tree berry in tea is unknown. A cream preparation containing chaste tree berry and wild yam also is available. Many combination products contain chaste tree berry and other herbs such as black cohosh, dong quai, wild yam, Siberian ginseng, and licorice. Many of these combination products are not standardized.
For PMS or frequent or heavy periods, chaste tree berry can be used continuously for four to six months. Women with amenorrhea and infertility can remain on chaste tree for 12-18 months, unless pregnancy occurs during treatment.
Recommendation
For women with PMS who are not taking oral contraceptives, who are not pregnant or lactating, and who do not wish to use prescription hormonal treatment, a several month trial of chaste tree berry appears warranted.
Conclusion
Based on the available evidence from clinical studies, herbal research data, and scholarly papers, chaste tree berry seems to be a reasonable treatment alternative for some patients with PMS. Practitioners who wish to recommend herbal products for women’s health conditions need to evaluate the scientific literature in order to form their own opinions about appropriate use and safety. Since the herb is prepared and packaged in many different ways, one should carefully read and follow label directions.
Dr. Keegan, Director of Holistic Nursing Consultants in Port Angeles, WA, is on the Editorial Advisory Board for Alternative Therapies in Women's Health.
References
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2. Blumenthal M, et al, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000.
3. Chaste Tree. In: The Review of Natural Products. St. Louis, MO: Facts and Comparisons; 1998.
4. Odenthal KP. Vitex agnus-castus L., traditional drug and actual indications. Phytotherapy Res 1998;12: S160-S161.
5. Love S. Dr. Susan Love’s Menopause and Hormone Book. New York: Three Rivers Press; 2003.
6. Northrup C. The Wisdom of Menopause. New York: Bantum/Random House; 2000.
7. Fetrow C, Avila J. Professional’s Handbook of Complementary & Alternative Medicines. Springhouse, PA: Springhouse Corporation; 1999.
8. Wright JV, Morgenthaler J. Natural Hormone Replacement for Women over 45. Petaluma, CA: Smart Publications; 1997.
9. Propping D, et al. Diagnosis and therapy of corpus luteum insufficiency in general practice. Therapiewoche 1988;38:2992-3001.
10. Brown DJ. Herbal Prescriptions for Health and Healing. Roseville, CA: Prima Health; 2000:232-239.
11. Blumenthal M, et al, eds. Klein S, et al. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Dallas, TX: American Botanical Council; 1998.
12. Pizzorno J, Murray M, Eds. Textbook of Natural Medicine. 2nd ed. Edinburgh: Churchill Livingstone; 1999.
13. Betz W. Commentary. Forschende Komplementarmedizen 1998;5:146-147.
14. Schellenberg R, et al. Treatment for the premenstrual syndrome with agnus castus fruit extract: Prospective, randomised, placebo-controlled study. BMJ 2001;322: 134-137.
15. Loch EG, et al. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med 2000;9:315-320.
16. Berger D, et al. Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Arch Gynecol Obstet 2000;264:150-153
17. Murray MT. Encyclopedia of Nutritional Supplements: The Essential Guide for Improving Your Health Naturally. Rocklin, CA: Prima Publishing; 1996.
18. Foster S. Herbs for Your Health. Loveland, CO: Interweave Press; 1996.
Keegan L. Chaste tree berry for premenstrual syndrome. Altern Ther Women's Health 2003;5(8):57-61.
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