CASE STUDY: Treatment plan for a 54 year old Female

Aims, Actions and Herbal Indications

Alleviate hot flushes and night sweats – Gently increase oestrogen levels – thus  decreasing follicle stimulating and luteinising hormone (LH). Use Cimicifuga racemosa, Dioscorea villosa, Medicago sativa, Astragalus membranaceus, Antiperspirant -Salvia officinalis,

Improve energy levels – Support the adrenals. This can be done by regulating the Hypothalamic-Pituitary-Adrenal (HPA) axis and progesterone- a building block of corticosteroids. Use progesteronals – Dioscorea villosa, Smilax ornata, Vitex agnus-castus. Use adaptogens- Eleutherococcus senticosus, Panax ginseng, Astragalus membranaceous, Withania somniferons. Use adrenal supports- Borago officinalis, Glycyrrhiza glabra.

Improve sleep – Use hypnotics and sedatives Humulus lupulus, Passiflora incarnata, Valeriana officinalis, Scutellaria laterifolia, Cimicifuga racemosa.

Relieve arthralgia – Salix alba, Harpagophytum procumbens, Cimicifuga racemosa, Eleutherococcus senticosus, Dioscorea villosa.

Soothe GIT – Use demulcents, anti inflammatorys and pre-probiotics- Althaea officinalis Radix, Glycyrrhiza glabra, Ulmus fulva, Matricaria recutita.

Black cohosh is the primary herb for menopausal hot flushes. Its estrogenic activity helps to decrease serum LH concentration, thus helping to reduce the hormonal bursts that precipitate hot flushes. The oestrogenic aspect will help towards rebalancing blood sugar levels, which will have been thrown into disarray by the removal of Climagest. It also acts as a mild sedative and is useful for arthritic conditions which this patient complains of. By relieving arthritis the patient may feel more able to deal with every day life’s stresses and strains -  indirectly helping with feelings of exhaustion. It  may also help to decrease her consumption of NSAIDs which may help to relieve the abdominal bloating she is experiencing. The mild sedating activity will help with the night sweats.

Wild yam has both an oestrogenic an progesteronic effect and will help in a number of ways. Its oestrogenic activity will help with this patients hot flushes via the decrease of LH. Its progesteronic activity will help by improving fat metabolism, maintaining bone density, and improving moods. Progesterone also helps protect the endometrium – particularly relevant as this patient has suffered from uterine polyps in the past. Progesterone also inhibits androgens – an undesirable effect of androgens after menopause is hair loss from the head and appearance of facial hair! Wild yam will also help support the adrenals as progesterone is a building block for corticosteroids. Corticosteroids maintain blood sugar levels, reduce inflammation and help the body fight stress more effectively (Trickey and Cooke, 2000, p35). Wild Yam is also useful for inflammation and spasm of the GIT, which maybe of some use for the reported bloating.

Because Climagest is a cyclic HRT with half of the month on oestrogen only and half on oestrogen and progesterone combined. The combination of Black cohosh and Wild yam seems particularly relevant in finding an alternative for this patient.

Sage is an oestrogenic and possesses potent anti- perspiring properties. This will especially help the patient in terms of comfort. It should also aid sleep in as much as she won’t be disturbed by a pool of sweat in the middle of the night!

The Chinese believe that regular use of Siberian ginseng will help restore vigour, memory and improve general health. It’s traditional use also includes rheumatism. All of this will be beneficial for this patient. Its mechanisms of action remain unclear. It is believed to regulate the HPA axis (Nicholls,2003) and there is  research to suggest that both the stimulation and inhibition of enzymes relating to the adrenal glands are indicated (Gaffney, Hugel and Rich, 2001, p570). It has also been found to inhibit both hypertrophy and atrophy of the adrenals. (Foster, 1996, p6).

Valerian is an effective sedative, resolving difficulty in falling asleep, discontinuous sleep and restlessness and tension. Many clinical trials have demonstrated this. An effective sedative like valerian may even help the patient sleep through the fluctuations of temperature. 

Infusion

German chamomile tea will help the bloating in the lower abdomen as it is a carminative and anti inflammatory. The proazulenes are believed to breakdown into the anti inflammatory chamazulenes on steam distillation and so this has been prescribed as a tea. It will also aid sleep.

Other recommendations

 Diet

Introduce phyto-oestrogens into the diet. Trade soya milk for dairy. A particularly pleasant soya milk is ‘Bonsoy’ which is creamier than other brands and contains the nutritious seaweed Kombu as well as barley malt. Use tofu regularly. There are many different types of tofu now available, so finding one that the patient likes shouldn’t be too much trouble. Linseeds and Alfalfa (Medicago sativa) can be added to salads.

More fruit and vegetables. This will increase vitamin and mineral intake, which can only be beneficial.

Introduce more oily fish into the diet, such as salmon, tuna, mackerel and sardines, will help keep prostaglandins in balance and nourish the nervous system.

Decrease tea and coffee. These aggravate insomnia and inhibit mineral uptake, particularly iron. The patient has reported shortness of breath on exertion so may be anaemic. Encourage more herbal teas, particularly the chamomile tea prescribed at this stage.

Reduce alcohol intake and have a resting period of 2-3 days to allow the liver to recover.

Increase mineral water to 2 litres a day.

Try to introduce weight-bearing exercise to help with arthritis and safe guard against osteoporosis.

Anticipated outcomes

 Night sweats should start to resolve within 2-3 weeks as should disrupted sleep patterns. An increase in energy is anticipated after a week to ten days.

Once the initial discomfort of irregular temperature control and exhaustion has been dealt with the following factors can be focused on to further improve health.

The fact that the patient has recently had uterine polyps removed suggests a disturbance of the endometrial tissue. This may be due to the diminished progesterone levels protective activity on the womb lining and it would be worth considering extra progesteronic activity in future prescriptions.

Extra adrenal support can be added. This will increase the glands ability to produce the smaller amounts of these sex hormones, taken over from the retired ovaries.

A greater focus could be put on the GIT, especially as the patient takes quite a heavy dose of an NSAID every evening.

Further herbs with greater analgesic and anti inflammatory properties could also be added to help with the arthritis if required