What is Ginkgo Biloba ?
Also known as Ginkgoaceae contain a number of identified flavonol, glycosides, terpene lactones, and bilobalide which are associated with perceived health benefits (Rimmer 2007; Meton 2008). It has been shown to facilitate peripheral blood flow and it is thought that this is the mechanism that promotes sexual arousal through nitric oxide scavenging abilities and relaxant effect on smooth muscle tissue (Auguet 1983; Marocci 1994).

What do the studies suggest about Ginkgo Biloba supplementation in libido improvement?
A study by Meston evaluated it’s effects on subjective and physiological (using vaginal photoplethysmography) measure of sexual function in women with sexual arousal disorder and found that there was a small but significant facilitatory effect on physiological sexual arousal compared to placebo but no effect on subjective sexual arousal.

A study that compared placebo, ginkgo biloba extract, sex therapy or sex therapy plus ginkgo biloba found that when combined with sex therapy, but not alone, long term therapy increased sexual desire and contentment beyond placebo, however, sex therapy alone improved sexual desire and contentment when compared to placebo.

In a study of women taking antidepressant induced sexual dysfunction herbal treatment was effective in alleviating antidepressant-induced sexual symptoms in 91% of women. The authors concluded that it could increase vascular flow to the genitals through the inhibition of platelet activating factors due to the enhancement of cerebral perfusion (Cohen 1998). There was also a case report of a 37-year old woman who reported improvement in sexual function with daily gingko extract (Ellison 1998).

What is the appropriate dose of Ginkgo Biloba?
A dose of 300mg/day of Gingko biloba seems to be the most common dose used.

What are potential side effects?
There is a concern that it may cause prolonged bleeding time and risk for hemorrhage through antiplatelet activity and risk of intracranial bleeding. Interactions with other anticoagulants would be of concern – so anyone taking such medications as warfarin, aspirin or lithium would not be candidates for ginkgo biloba.

Who might be helped by Ginkgo biloba?
It really seems that the only suggested benefit may be for women with sexual function issues secondary to taking anti-depressant use.


Auguet M, Clostre F. Effects of an extract of Ginkgo biloba and diverse substances on the phasic and tonic components of the contractions of an isolated rabbit aorta. Gen Pharmcol 1983;14:277-80.

Cohen AJ, Bartlik B. Binkgo biloba for antidepressant induced sexual dysfunction. J Sex Marital Ther 1998;4:139-43 .

Ellison JM, DeLuca P. Fluoxetine induced genital anesthesia reliebed by Ginkgo biloba extract. J. Clin Psychiatry 1998;59:199-200.

Kang BJ, LeeSJ, Kim MD, Cho MJ. A placebo controlled, double-blind trial of Ginkgo biloba for antidepresaant induced sexual dysfunction. Hum Psychopharmcol 2002;17:279-84.

Marocci L, Maguire JJ, Droy-Lefaix MT, Packer L. The nitric oxide-scavenging properaties of Ginkgo biloba extract EGb 761. Biochem Biophys Res Commun 1994; 201:748-55.

Meston CM, Rellini Ah, Telch MJ. Short and long-term effects of Ginkgo biloba extraction on sexual dysfunction in women. Arch Sex Behav 2008;37:530-47.

Rimmer CA, Howerton SB, Shrpless KE, Sander LC, Long SE, Murphy KE, Porter BJ, Putzbach K, Rearich MS, Wise SA, Wood LH, Ziesler R, Hancock DK, Yen JH, Betz JM, Nguyenpho A, Yang L, Scriver C, Willie S, Sturgeon R, Schaneberg B, Nelsonm C, Skamarack J, Pan M, Levanseler K, Gray D, Waysek EH, Blatter A Reich E. Characterization of a suite of ginkgo –containing standard reference materials. Anal Bioanal Chem 2007; 389:179-96.

Menopause – Alternatives

…to hormone replacement therapy and anti-depressants


Exploring our local health food store yesterday, Van’s, reminded me to complete and post this article I’ve been working on way too long.  It also reminded me how many “natural” products are out there that tout miracles for menopausal symptoms.

‘Van’s Health Foods ‘ shelf – Natural hormone remedies

On daily basis women with menopausal symptoms often ask me if there are any “natural” remedies for their hot flashes and mood issues.  It seems lately that I’ve had more and more women asking this question.  The only thing that I have to offer them is hormone replacement therapy, some women just aren’t the best candidates for this method, and anti-depressants have their own list of unpleasant side effects.

Especially for women who are just starting the menopausal transition or having milder symptoms, natural and/or herbal remedies may be an ideal option but I wasn’t familiar enough to recommend anything in particular.  In an attempt to come up with some alternatives, I headed to the literature.


The least invasive and least risky are the behavioral therapies.  Few studies have looked at these methods of managing symptoms but a couple studies show promise with a particular kind of breathing, paced respiration.  This method of slow, deep breathing has been compared with progressive muscle relaxation, doing other relaxing leisure activities, and biofeedback.  In all cases, the paced respiration group demonstrated decreases in hot flashes (Kronenberg et al, 2002).  This is an easy practice that women can incorporate into daily life to help cope and reduce the hot flashes experienced in menopause, especially if mild severity.


While I am very much a believer in acupuncture for many things, its efficacy in menopause symptoms is still in question.  There is one study that looked at acupuncture and one issue with the study is that the treatment and control groups may’ve been too much alike; one received standard acupuncture and the other a shallow acupuncture treatment, but at the same points.  From pre-treatment to post-treatment, both groups showed a significant decrease in hot flashes but between the two there was not a difference (Kronenberg et al, 2002).  Since both groups showed an improvement following treatment, this actually suggests that acupuncture or pressure may work to help alleviate the symptoms.


As mentioned previously, the only tools I have available are hormone replacement and anti-depressants, which have their issues.  I was hoping a review of the literature would reveal more herbal options to offer but sadly it is still limited.  While many things have been touted as working: black cohosh, dong quai, evening primrose, ginseng, red clover, vitamin E, chasteberry, soy, wild yam, and progesterone creams, there are limited remedies with proven evidence that they are beneficial.

It seems that only one really has any evidence, that being black cohosh, and another soy, has promising but mixed results.  The others seem to have no clinical benefit, at least based on current literature. (Kronenberg et al, 2002; Low Dog, 2005) and while women using progesterone cream seemed to note “improvement”, it came with a risk of postmenopausal bleeding and subsequent endometrial biopsies (Leonetti et al., 1999).  This finding suggests any estrogen or progesterone-containing product over the counter may influence the uterine lining.  In women who still have a uterus, when physicians prescribe these medications, both are given in an amount to attempt and reduce the risk of uterine lining stimulation that can result in development of endometrial cancer.  Therefore, I tend to caution my patients who are using over the counter products to avoid those that are basically hormones and carry those same risks.

Black cohosh, in the form of Remifemin, is relatively well studied and has the most support for its use.  A review article found 5 controlled studies and all found that black cohosh reduced psychological symptoms, improved vaginal epithelium, and decreased measures of menopausal symptoms, particularly hot flashes and sweating (Low Dog, 2005).  It does seem to be helpful for a multitude of symptoms but a concern I have is that no studies exist on long-term use regarding hormonal stimulation on breast or uterus, so women with a history of breast cancer or at risk for endometrial cancer I would advise use with caution.

Ironically, while working on reviewing the literature for this post our pharmacy department came out with a memo that addressed soy as a recommended “pharmaceutical” for reducing mild menopausal symptoms.  The studies I found suggest only modest benefits, mostly for hot flashes, and the benefits by 6 weeks decreased.  Interestingly, there was a 50-60% reduction in symptoms in both the soy and placebo groups in the studies.  Foods containing soy certainly seem a safe addition and may help with mild symptoms so supplementing your diet with beans is a benign way to start.  However, it is difficult to make a statement about high-dose isoflavones, with the most common doses being between 50-150mg daily and in women with a history of breast cancer it’s best avoided (Umland, 2008).  Like most things, the lowest dose possible to help with the symptoms should be the guiding principle.

While less than I had hoped to offer patients with menopausal symptoms, at least this provides a few options to suggest to my patients with some confidence thanks to support from the research.


Kronenberg F and Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: A review of randomized controlled trials.  Annals of Int Med. 2002;137:10:805-813.

Leonetti HB, Longo S, Anasti JN.  Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss.  Obstet Gynecol. 1994;94:225-8.

Low Dog T.  Menopause:  A reiew of botanical dietary supplements.  Am J of Med. 2005;118:12B:98S-108S.

Umland EM. Treatment strategies for reducing the burden of menopause-associated vasomotor symptoms.  Suppl to J Managed Care Pharm. 2008;14:3:S14-S19.


Chasteberry, Vitex agnus-castus

An Herb for the Gynecologist’s Toolbox

Chastetree, vitus-agnus-castus
Top Tropicals Website


Chastetree (Vitex agnus-castus) has been used since ancient Greece and is thought to have many gynecologic uses due to some of the plants compounds similar to human sex hormones.  In medieval Europe, it was thought to reduce sexual libido and was used by clergymen, hence it’s other name of “monk’s pepper”.  The plant found it’s way to Germany and in the 1940-50’s; research took place supporting its use in menstrual disorders, without affecting sexual libido.

Irregular periods, premenstrual syndrome (PMS), and cyclic breast pain encompass a majority of the common gynecologic complaints in my daily practice.  Really, the only conventional pharmaceuticals available are hormones, in the form of birth control pills to regulate cycles or anti-depressants for the psychological symptoms.  For women who don’t need a contraceptive method, I find most want to avoid taking hormones.  Others with the emotional premenstrual symptoms fear the side effects of anti-depressants.

In an attempt to offer alternatives that are supported by current evidence and potentially with fewer side effects, I came across chastetree.  This plant sounded like a good alternative and I wanted to see if there was actual research to support its use for some of these common gynecologic issues.

At it’s mechanistic level it appears the main way chastetree works is by its effects on prolactin and progesterone.  By binding dopamine receptors in the brain it inhibits prolactin, which has been shown to reduce breast pain.  Additionally, it also seems to increase progesterone secretion, and that can help regulate the second half of the menstrual cycle (Du Mee 1993).

Compared to some of the side effects of the normal hormonal methods or anti-depressants that I often prescribe, the side effects described are mild.  These include gastrointestinal complaints, dizziness, headache, tiredness and dry mouth (Roemheld-Hamm 2005).

In other countries, herbal medicine seems to be much more accepted and many physicians in Germany prescribe chastetree formulations to their patients, so why can’t we?  Specifically, in the case of chastetree, the German Commission E, a group evaluating the use of herbs, has approved it for irregular cycles, PMS and breast pain (Blumenthal 2000).  Maybe it’s time that the United States researches and, if evidence suggests, embrace alternative methods for the health benefit of its citizens.  The bulk of research in the United States is conducted by pharmaceuticals and they have little to gain from herbal remedies (but that’s for another blog entry) so the little research that is out there comes from other countries or in some cases, from academic institutions.

So, what is out there in terms of research?  Very little randomized studies, but a couple that supports its use.

In one randomized study, after 3 months more than half of 170 women experienced a 50% or greater reduction in premenstrual symptoms (Schellenberg 2001). Another showed improvement in self-reported severity of PMS symptoms, with global improvement and overall benefit versus risk (p=0.001; NNT=4). In another trial, chastetree reduced symptoms of edema, constipation, irritability, depressed mood, anger, headache, and breast pain (Roemheld-Hamm 205).  Cyclic breast pain was the focus in another study that demonstrated a decrease compared to placebo after 3 menstrual cycles (Wuttke et al 1997).

Other vitamins may be as effective in helping with menstrual symptoms.  For instance, another study found that Vitamin B6 and Chasteberry both decreased symptoms by nearly 50%, but the sample size was small (Lauritzen et al 1997).

Another issue is that the studies use varying doses and formulations. Fruit extract dose is 20-40mg daily but I also came across doses of 240-500mg daily and higher doses (up to 1800mg daily) being used.  Extracts (40 drops daily) and tincture (35-45 drops three times a day) are also available.  In the United States there is a marketed product called Femaprin (325mg), which also contains Vitamin B (100mg) by Nature’s Way, which would likely be safest to recommend to patients.

Based on these findings and the fact that physicians in other countries recommend chastetree, I feel comfortable now making the recommendation for irregular periods, premenstrual symptoms, and cyclic breast pain.

Finally, another tool in my gynecology toolbox that can potentially benefit my patients!



1. Blumenthal M (2000).  German Federal Institute for Drugs and Medical Devices.  Commission E.  Herbal Medicine:  Expanded Commission E monographs.  1st ed, Newton, Mass:  Integrative Medicine Communications.

2. Du Mee C (1993).  Vitex agnus castus.  Aust J Med Herbalism; 5:63-65.

3. Lauritzen C, Reuter HD, Repges R, Bohnert KJ, Schmidt U.  Treatment of premenstrual tension syndrome with Vitex agnus castus.  Controlled double-blind study versus pyridoxine.  Phytomedicine 1997;4:183-9.

4. Roemheld-Hamm B (2005).  Chasteberry.  Am Fam Physician; 72,5:821-824.

5. Schellenberg R (2001).  Treatment for the premenstrual syndrome with agnus castus fruit extract: Prospective, randomized, placebo controlled study.  BMJ 322:134-7.

6. Wuttke W, Splitt G, Gorkow C, et al.  Treatment of cyclical mastalgia; Results of a randomized, placebo-conrolled, double-blind study [in German] Geburtshilfe Frauenheilkd 1997;57:569-74.


DISCLAIMER:  **Speak to your own gynecologist before starting any medication, as this product hasn’t been FDA approved.  Your personal physician should evaluate potential causes of your symptoms before recommending management.**




Acupuncture and In Vitro Fertilization (IVF)

Together – does it equal more babies?

Ironically, this past week the question of acupuncture and IVF came to me from two different directions.  First, I received an e-mail from a patient who was going to be starting IVF in the near future and wondered if the addition of acupuncture would help increase her chances. Second, my sister mentioned she has a friend who is on her third cycle of IVF and plans to try acupuncture this time around, because she knows others who did it and now have children.

Because I didn’t know the answer I thought I’d look into so I could make a recommendation.  Being a little short on time this week I went straight to reviews and meta-analysis on this topic.

For both my patient and my sister’s friend, the answer is promising!  The best study I found was a meta-analysis from the British Medical Journal, suggesting that acupuncture done at the time of embryo transfer increased one’s chances of pregnancy and live birth.

The study by Manheimer 2007 identified 7 randomized controlled trials with a total of 1,366 participants that met their specific criteria.  They specifically were evaluating acupuncture as it pertains to embryo transfer, and there are many steps before one gets to this stage in the IVF process.  However, this review included those women who didn’t make it to the embryo transfer point, as they were often randomized at the start of their IVF “cycle”.   A cycle begins when a woman starts stimulating her ovary to produce eggs that are ultimately retrieved, fertilized with her partner’s/donor’s sperm, and then placed back into the uterus.  This has the effect of actually underestimating the potential benefits of acupuncture once a woman reaches the embryo transfer stage, however it prevents the researchers from saying there is a difference when in actuality there isn’t any.  They required that acupuncture be administered within one day of the procedure, which could be before, after or done both before and after an embryo transfer.  In fact, most of their studies had two sessions.

Ultimately, the bottom line is that they found the odds of a clinical pregnancy were increased by 65% in the group who underwent acupuncture compared to those who didn’t.  When they calculated the number of women who would need to be treated for one additional pregnancy, they found that for every 10 patients who received acupuncture an additional pregnancy would result.

After reading this article, it is something I’d recommend patients try, if they are open to the idea of Eastern medical practice.  Given the high cost of IVF treatment, in terms of actual monetary cost and time expended, it seems that anything that may increase the chances for success are worth trying and if nothing else, may give someone the sense of control over something where there is very little.  If one finds a reputable acupuncturist the risks are low and the benefits potentially life changing.



Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman B, Bouter L (2007).  Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilization: Systematic review and meta-analysis.  British Medical Journal; Online First; pg1-8.

Tea Tree Oil vs Vaginal Yeast Infections

…seems tea tree may just win

In the same week, both a patient and my brother-in-law mentioned they used tea tree oil for different purposes; so I decided this was a sign to review it’s uses and the research out there.

My patient used a tea tree oil mixture to treat candida vaginitis and my brother-in-law mentioned he was using the tea tree oil to reduce his chances of getting sick by swabbing his nose with it.  I love my tea tree shampoo and I have used a drop of tea tree on pimples before (only because someone else said it worked – not because I knew the research) but never really thought about any medical properties.

I do recall swimming in a pond surrounded by tea trees when I was in Australia many years ago.  Following that swim, my skin and hair felt amazing, and I felt refreshed.  Was it just my imagination?  Maybe, but known as Melaleuca alternifolia, Australian aboriginals used the leaves of the tea tree for healing purposes for generations.

Since I am an Ob/Gyn, of course I had to look most into the treatment my patient was using and just how successful it might be to treat her yeast.  I had no comment really when she mentioned she was doing this, other than “I hope it works”.   Next time someone mentions this treatment, I want a better response.

The active ingredient in tea tree oil appears to be Terpinen-4-ol (terpene) that gives it an antimicrobial and antifungal effect (Carson & Riley, 1995). Even fewer reviews of tea tree oils on viruses and protozoas exist; however, there is a suggestion that there is activity against both (Carson, Hammer & Riley, 2006).

In bacteria and fungus/yeast, the terpenes are thought to work by entering the cell membrane, causing potassium leakage, and ultimately leading to rupture of the cell wall (Cassella, Cassella & Smith, 2002; Carson, Hammer, & Riley, 2006). This would include the Candida albicans species of yeast that is so common with vaginal yeast infections.  While laboratory studies are promising, there are no clinical studies in humans.  The pharmaceutical companies have little interest in this type of research.  Interestingly, the natural vaginal bacteria, lactobacilli, are more resistant to exposure from tea tree (Cassella, Cassella & Smith, 2002).  This suggests that some of the natural flora of the vagina would be protected.  There is a rat model of vaginal candidiasis that supports the use of tea tree for the treatment of this type of yeast infection. (Mondello, De Bernardis, Girolamo, Salvatore, & Cassone, 2003).

While literature on clinical application in humans is lacking, based on in vitro (lab studies using cells/organisms alone) and the support of it’s use in an animal model, there does seem to be a role for tea tree oil use in treating vaginal candidiasis.  However, with the positive benefits, it’s also important to remember that even things that provide such benefits can result in toxic outcomes if used incorrectly.

If ingested, it can be poisonous.  If used orally, swallowing should be avoided.  The main reports note that tea tree can cause irritation to the skin.  Using a well-formulated product, lower in concentration, and by diluting with other components such as oils or creams irritation is reduced.  While allergic reactions have been reported (De Groot & Weyland, 1992), it appears it may be due from oxidation products from aged or poorly stored oils rather than from the oil itself (Hausen, Reichling, & Harkenthal, 1999).

Butterfly on Tea Tree Blossoms

Tea Tree


If I had a patient who really did not want to try the standard treatment of clotrimazole cream or fluconazole pill, or had a bad reaction to either of them then I’d certainly recommend they try this option.  It appears there is the potential for benefit with very little risk.  Even if they had another type of bacterial infection, the data suggest these tea tree mixtures may still treat those.  In fact, if I have another yeast infection, I may just give one of these recipes a try.

There are a few different recipes out there.  The majority make a tea tree suppository with a gel capsule. The mixture contains 1/3 tea tree oil (2-3 drops) combined with 2/3 vitamin E oil, calendula oil, olive oil, sweet almond oil, vegetable oil or water (4-6 drops).  This is then used for at least 6 nights (Van Kessel, Assefi, Marrazzo, & Eckert, 2003).  Using a gel capsule prevents the oil from getting on the outside skin to decrease risk of irritation.

According to, in a similar fashion, a tea tree oil tampon can be used nightly instead.  Using the same mixture, saturate a clean and sanitary tampon. Afterwards, insert the saturated tea tree oil tampon into your vagina.  Avoid the outside skin as much as possible.  While Van Kessel et al 2003, suggested a 6 night course, this website article recommended using nightly for up to six weeks.

As with most treatments, the least effective dose possible can prevent the side effects.  I’d try 6 days and see if there was a positive effect with potential for additional use, if necessary.  However, if things don’t seem to be improving after those 6 days, and especially if you haven’t already seen a physician to make the diagnosis, it’d be important to be evaluated for other potential causes of vaginal discharge, some which can be serious.  There have been studies that looked at how well women diagnosis their own yeast infections, and many women over-diagnosed this as a cause of there vaginal irritation or discharge, be sure to see your ob-gyn for evaluation.

Be sure to use only high quality Organic Essential Tea Tree Oil


Carson CF, Hammer KA, and Riley TV, 2006.  Melaleuca alternifolia (tea tree) oil: A review of antimicrobial and other medicinal properties.  Clinical Microbiology Reviews 19(1):50-62.

Carson CF and Riley TV (1994).  Susceptibility of Propionibacterium acnes to the essential oil of Melaleuca alternifolia.  Lett Appl Microbiol 19; 24-25.

Carson CF and Riley TV (1995).  Antimicrobial activity of the major components of the essential oil of Melaleica alternifolia.  J Applied Bacteriol, 78;264-269.

Cassella S, Cassella JP, and Smith I (2002).  Synergistic antifungal activity of tea tree (melaleuca alternifolia) and lavender (Lavandula angustifolia) essential oils against dermatophyte infection.  Int J Aromather 12; 2-15.

De Groot AC and Weyland JW, 1992.  Systemic contact dermatitis from tea tree oil.  Contact Dermatitis 27: 279-280.

Hausen BM, Reichling J, and Harkenthal M. 1999.  Degradation products of monoterpens are the sensitizing agents in tea tree oil.  Am J Contact Dermatitis 10:68-77.  Kristi Patrice Carter, article on bacterial vaginosis treatments.  Accessed:  February 12, 2012.

Mondello F, De Bernardis F, Girolamo A, Salvatore G, and Cassone A (2003).  In vitro and in vivo activity of tea tree oil against azole-susceptible and resistant human pathogenic yeast.  J Antimicrob.  Chemother.  51: 1223-1229.

Pena EF (1962).  Malaleuca alternifolia oil – its use for trichomonal vaginitis and other vaginal infectsion.  Obstet Gynecol 19; 793-795.

Van Kessel K, Assefi N, Marrazzo J, & Eckert L .  (2003).  Common complementary and alternative theraies for yeast vaginitis and bacterial vaginosis: A systemic review.  Obstetrical and gynecological survey 58;351-358.