AVENA Autumn 2012

vena A Journal of the New Zealand Association of Medical Herbalists

Autumn 2012

Volume 12 Issue 1

Reg Lehmann - Botany & Phytochemistry: The basics of quality Angela Hywood: PCOS NHAA News Update

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vena A CONTENTS

Volume 12 Issue 1 Autumn 2012

F E AT U R E S

10 Phytotherapy for Polycystic Ovarian Syndrome (PCOS) Angela Hywood is a dynamic and well-informed

international speaker on herbal medicine and clinical practice. In this article she discusses at length the increasingly common female condition PCOS. Angela helps us to increase and clarify our understanding of this condition with her indepth discussion on etiology, signs & symptoms and diagnostics. Phytotherapeutic intervention is then built upon this solid foundation of physiologic and biochemical understanding.

16 Botany & Phytochemistry: The basics of quality

Dr Reg Lehmann discusses some of the basics of quality assessment and phytochemistry.

These topics are of great importance in manufacturing commercial herbal products and help to ensure good quality plant material and manufacturing processes are used. Reg is one of our keynote speakers at the upcoming NZAMH Conference & AGM.

NEWS

8 NHAA News

F R OM T H E C OM M I T T E E

4 President’s report 5 Treasury Report 6 PR subcommittee report 7 NZAMH Branch Meetings

REGULARS

Craig Rhodes

22 Business management 24 Clinical nutrition

Marcelli Coronet

30 DVD & Video HIre 32 NZAMH CPE Points

19 Durban. The Supplication of a Dead Man’s Hand

Vincent Di Stefano delivers a sobering exploration on the post-Durban UN Climate Change Conference, the current age we live in and the consequences of the past couple of hundred years of insane greed and technocratic raping and plundering of the earth. Ultimately however, it is a message of hope, reminding us to do what we can to preserve and perpetuate those sources of wisdom that will enable future generations to avoid the tragic errors that presently unfold around us.

16 COVER PHOTO: Hebe flowers about to open by Rob Suisted www.naturespic.co.nz

Editorial AVENA

Hi Everyone,

Editor: Mary Allan Layout/Design: Mary Allan Assistant Proofreader: Jesse Summers Printer: GEON

Welcome to the 2012 Autumn issue of Avena.

This quarter sees changes in our contributer line up.

Included in this issue is an article by Dr Reg Lehmann, who is our keynote speaker for the NZAMH Conference in May.

CIRCULATION The Journal of the New Zealand Association of Medical Herbalists (NZAMH) is published quarterly and is available to paid members of the NZAMH, and other interested subscribers, libraries and institutions.

ADVERTISING Please contact the editor at avena@ nzamh.co.nz for a copy of Information for Advertisers.

CONTRIBUTIONS Please send contributions by e-mail in an attached Microsoft Word document. Pictures should be high resolution jpg, gif, pdf or TIFF format. Please include full name and contact details. Contact the editor at avena@nzamh. org.nz for further enquiries.

DISCLAIMER Any statement of fact or purported statements of fact contained in this publication are published without prejudice, and do not necessarily reflect the views and opinions of the Editor or the NZ Association of Medical Herbalists. Any liability in respect thereto is limited accordingly. Publication of an article or advertisement does not constitute endorsement by the Editor or NZ Association of Medical Herbalists. The information contained in this publication is not intended to replace appropriate professional healthcare.

The Editor and NZ Association of Medical Herbalists take no responsibility for the use of information in this publication. Avena contents cannot be reproduced without permission.

NZAMH PO Box 12 582, Chartwell, Hamilton 3248

w w w. n z a m h . o r g . n z

The struggle to survive in New Zealand is becoming more apparent with each passing year, with Kiwi contributions to this issue of Avena waning to an all time low. Perhaps it is coincidental, but I fear that it is a sign that all is definitely not well in our country, where our people are having to work longer and harder hours to pay their bills and put food on the table. With pay cuts, attempts to sell off our country & assets, and 200,000 children living below the poverty line, I can't see this getting better in a hurry. I suggest you get to know your local plants very well, and team up together to give each other strength during the coming times.

Mary Allan, Editor

Thankfully as fate would have it, our Australian friends and colleagues have provided us with high quality articles to share with you this issue. I always make an effort to publish some Australian work in Avena, and am delighted to do so - this issue is however outstanding in that almost everything is from our Australian colleagues, and as mentioned above, does this indicate grave concerns?

Contributors Angela Hywood (Sydney) is a well known international speaker, educator and clinician. I am delighted to welcome Angela on board Avena - she has a feature article on PCOS in this issue. It is a clinically relevant, authoritative and fascinating read of whic h I am certain you will find helpful in clinic, certainly PCOS and endocrine imbalances crop up quite frequently and any help on this topic is welcome.

Vincent Di Stefano recently expressed his gratitude to being welcomed into the Avena community. However, he is changing direction and trying to give a little more time to some other works, which necessitates fewer contributions to Avena. Thus, he will continue to send us material – just a bit less frequently - maybe once or twice a year. Vincent's articles are mind expanding, earth centred and enlightening. If you haven't read them already, I suggest you do, his work is both poetic and informative, a rare combination.

After many years service, I am sad to say Vanessa Hart is leaving Avena. This is a significant loss, her Phytotherapy for Animals articles were a valuable and unique gift to Avena. Thank you Vanessa for all your hard work and dedication over your time with us, and good luck with your new projects.

Remember, Avena is all of ours, your feedback or suggestions are welcome. And, get writing Kiwi's, stay positive and may you have a blessed harvest!

Mary

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AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

NZAMH Conference & AGM 2012 May 26 - 27th Novotel Auckland Ellerslie 2012 Speakers: 1

Dr Reg Lehmann (Australia)

1

Dr Nicky Baillie (NZ)

1

Sandra Clair (NZ)

1

Valmai Becker (NZ)

1

Donna Kerridge (NZ)

1

Hannah McMenamin (NZ)

1

Jill Dunn (NZ)

1

Tony Brook (NHC)

The NZAMH conference is a fantastic opportunity to meet with other herbalists from around the country and around the world.

There is plenty of opportunity to exchange knowledge and opinions, share your ideas and experiences and feel part of the larger herbal community. You will come away with increased enthusiasm, lots of practical ideas and new friends.

Getting There The 2012 NZAMH Conference is being held in Auckland, City of Sails. This makes travel straightforward, so you can fly direct from pretty much anywhere in the country. If you're not used to driving in Auckland, just get in the correct lane well before you need to enter or exit the motorway! Go to maps.google.com to get directions.

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See you there!

NZ CO N AM H FER ENC E ANN & UA L GEN MEE E TING RAL

ABOVE: Rangitoto Island, Auckland Registrations for this event are now open. To qualify for member rates at the conference, you must be a fully paid-up NZAMH member for the 2012-2013 membership year.

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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NZAMH Committee Reports

NZAMH Committee Roles 2011/12 President: Craig Rhodes Vice President: Julia Fettes Treasurer: Gay-Lynn Mokrzecki Secretary: Jesse Summers

Sub-committees Political Leanne Halliwell (Convenor) Julia Fettes Phil Rasmussen Fiona MacDonald Publicity and Promotion Mary Allan (Convenor) Moana Hutana Conference & AGM Linda Jones (Conference Coordinator) Kate Robertson Linda Caddick Media Contact Julia Fettes Education Robyn Carruthers (Convenor) Jill Dunn Rebekah Lynch Jesse Summers Julia Fettes Hannah McMenamin Student Representatives Fiona McDonald Hannah McMenamin NHC Representative Robyn Carruthers

Non-committee roles Administration Val McArthur Avena Editor Mary Allan

For all administration or membership enquiries please contact Val McArthur:

President’s Report Welcome to the last Avena Presidents report before our annual Conference & AGM in May. 2 Yo u a l l s hou ld h a ve received your Membership Renewal Notice and Conference Craig Rhodes Registration so it’s time to be going through your CPE activities and checking that your First Aid Certificate is up to date.

Also, if you haven’t been doing it already, start putting money aside to pay these bills.

And so to an update of what’s been happening this year…

• The process of reapplication for statutory regulation under the HPCA continues. Unfortunately it’s a slow process with sufficient changes introduced by the government after the latest review to necessitate the rewriting of large sections of the • application.

We are also struggling to come up with an appropriate definition of Medical Herbalist that is inclusive and encompassing, yet ensures practitioners are appropriately qualified.

So anyway, it’s been a fairly busy year, and This is especially true when it comes next year looks likely to be just as busy. to Naturopathy as many of our As several of our committee members are members are also Naturopaths, while standing down at this years Conference, many suitably qualified Naturopaths please consider putting your name are not members. This is important, forward for nomination and help make as under HPCA, Medical Herbalists a positive difference to our profession. will have to be statutorily registered, while Naturopaths will not.

Craig • We are working on accreditation processes for Course providers as part of our CPE program with the aim of members being able to see easily just how many CPE points a course is worth.

Phone (07) 855 6724; (027) 618 3573 E-mail val@herbaltouch.co.nz

4

•

While still a work in progress, it is likely that this will result in far fewer points being allocated to courses run by product providers and more to further education and courses without a link to product marketing.

As a result it is envisaged that more courses will become available that provide information and education for its own sake rather than to sell product.

We continue the process of developing a revised audit and accreditation process for colleges.

With the number of colleges teaching herbal medicine having taken a hit in the last couple of years, it is important that graduates of the colleges that remain have good medicinal herbal knowledge, rather than being ‘naturopaths’ with a bit of herbal knowledge on the side.

We continue to lobby the Government and various ministries about issues relating to herbal medicine, such as the recent advisory from the Commerce Commission about Fair Trading Act issues around claiming to cure allergies.

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

NZAMH Committee Reports

Treasury Report

Gay-Lynn Mokrzecki

Hello everyone, It’s now time to renew your membership for 2012/13 year. You should receive your membership renewal pack by early March. This will include an order for your annual subscription and for professional members, a Continuing Professional Education Form. Your Membership Requirements are due by 1 April 2012.

Membership Requirements due by 1 April 2012 • •

Your subscription.

Professional Members – CPE and current First Aid Certificate.

Once we have received your subscription payment, an invoice/ receipt will be sent to you.

Don’t forget, that your membership will automatically lapse, if you do not meet all of your Membership Requirements by the dates specified below. Once your membership has lapsed, you will need to apply to reinstate your membership.

Professional members who chose to make split payments of $160

by 1 April 2012 and $160 by 1 September 2012, will initially receive a 6 month Practicing Certificate valid to 30 September 2012, then an updated Practicing Certificate once you have made your second payment.

If you have a genuine reason for being unable to meet your Membership commitments, please contact Val McArthur, our Administration Secretary, who manages our membership records.

NZAMH Conference Membership Rate and Discount Remember, to qualify for the conference members rate or discounted early bird rate, you will need to have paid your subscription and fulfilled your Membership Requirements. This means, your CPE, current First Aid Certificate and subscription payment all must have been received. Payment of the first Split Payment Subscription qualifies.

I wish you all well for the coming year.

With warm regards Gay-Lynn Mokrzecki

NZAMH Membership Requirements Member Category

Requirement

Due date

Cost

Professional Members

Annual Membership fee

1st April 2012

$295.00 OR split payment option:

1st April 2012 1st September 2012

$160.00 (Payment 1) $160.00 (Payment 2)

Current First Aid Certificate

1st April 2012

CPE points

1st April 2012

Associate Members

Annual Membership fee

1st April 2012

$150.00

Student Members

Annual Membership fee

1st April 2012

$50.00

Important - Your membership will automatically lapse if:

• Your Membership Requirements due by 1 April are not up to date by 1 June 2012 (a reminder will be sent out by 1 May) • Your second Split Payment is not paid by 1 November (a reminder will be sent out in August).

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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NZAMH Committee Reports

PR Sub-committee Student Talks & Benefits of Belonging

Branch Meetings Since the Summer issue of Avena, we have had a lot of interest in setting up new branch meetings. So far, four new regions have initiated local branch meetings in the past six months!

Specifically they are: Central City, South Auckland, Waikato & the Hawkes Bay. Branch meeting info packs have been sent out to all conveners with the aim to help show members how to go about setting them up and running them, plus provide them with resources and some freebies for attendees.

Hard to believe it is this time again! Talks are being planned for March/April at Wellpark College, South Pacific College of Natural Therapies, Lotus Holistic Centre and resources to International College of Herbal Medicine. In response to feedback, we are now planning presentations to Mary Allan herbal and naturopathic students about the benefits of belonging to our association earlier in the year.

This will enable students who join to have full advantage of membership by joining for a full year.

National Herbalists Association of Australia (NHAA) The NHAA have responded positively to our request to send each other an extra journal. One will be kept on file, the other will be available for members from the NZAMH library.

Bottle Labels

As I am soon to be moving abroad, I will be standing down from the NZAMH committee. Working on the committee has been an incredible experience, and I can highly recommend it to nominees or interested members. Thank you all for giving me the opportunity to serve our profession, it has truly been an honour and a blessing.

These are now available – contact Val if you would like some.

Conference/AGM Linda Jones has been busy organising the Conference.

Conference brochures are posted out to members with this issue, with a spare so you can invite interested colleagues who aren’t NZAMH members. We have another beautiful photo from Rob Suisted (Natures Pics, Wellington) for all marketing materials – Avena cover, brochures, online posters etc.

Kind regards, Mary

NZAMH National Committe Contact Details McARTHUR, Val Admin. Secretary (07) 8556724 (027) 6183573 admin@nzamh.org.nz ALLAN, Mary Committee member, Avena editor (021) 311860, (06) 835 0550 maryallan77@yahoo.co.nz CADDICK, Linda Committee member (04) 4753015 CARRUTHERS, Robyn Committee member W: (09) 5269276 robyncarruthers@xtra.co.nz DUNN, Jill Committee member (09) 4159732 jilldunn@iconz.co.nz FETTES, Julia Vice-president, Media H: (03) 3350711 W: (03) 337 0577 M: 021 0589299 juliaf@xtra.co.nz

LYNCH, Rebekah Committee member (03) 9606741 rebekah.lynch@gmail.com McDONALD, Fiona Student Rep (06) 8701046, (027) 3529708 macfi67@xtra.co.nz McMENAMIN, Hannah Student Rep (027) 4266018 hannmac@gmail.com MOKRZECKI, Gay-Lynn Treasurer 04 2933742, (027) 6960202 geewizz@slingshot.co.nz RASMUSSEN, Phil Committee member (09) 834 8041 philrasm@ihug.co.nz

RHODES, Craig President W: (09) 361 5629 M: (021) 272 3357 HALLIWELL, Leanne Committee member (027) 4588626 herblady@paradise.net.nz c-rhodes@vodafone.co.nz ROBERTSON, Kate HUTANA, Moana Committee member (06) 8733518 moanahutana@clear.net.nz Committee member kate@nectar.co.nz JONES, Linda Conference Coordinator, Committee member (03) 3133591 (027) 5713968 linda.jones@xtra.co.nz

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SUMMERS, Jesse Secretary hokiangaherbfarm@gmail.com

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

From the Committee

NZAMH:

Strengthening Herbal Community

L

ast issue's effort to promote branch meetings in our local communities was met with some enthusiastic responses.

Thanks to Maureen Verrill, Ange Haldane, Val McArthur, and Tina Brown for giving it a go, and setting up some local meetings. It is vitally important that we continue to build strong community networks to facilitate a supportive, sharing and learning environment - next issue I will focus on setting up and using the NZAMH Yahoo Chat Group. If anyone is having difficulty with setting themselves up on our chat group, please contact me at avena@nzamh.org.nz. 3 Mary Allan (Editor, PR Convener)

NZAMH Media Responses In response to ongoing concerns about the media and natural medicine, the following article hopefully offers some guidance on what NZAMH members can do when they see something in the media about medical herbalists or herbs that needs to be corrected, or have another point of view expressed.

We are all members of the NZAMH and we need everyone’s eyes and ears to be effective. It is important that you let the committee know if you see something in the media you think needs correcting. This could be in your local newspaper or on national TV or something in between. We have an email address that I want you to add to your email address book right now so you don’t have to try and find it when you need it in a hurry. It is media@nzamh.org.nz It is also on the website under 'press releases'. You don’t even have to log into the site as a member to be able to access that email address.

This email address is automatically linked to several people on the current committee and can be changed at our end as needed without you needing to use a different email address each year.

What do we need to hear from you? Most importantly, if you see anything that seems to put down medical herbalists, or express negative press about herbs in general or in particular.

Anything you know to be untrue that has been published e.g. taking Kava will kill you or that medical herbalists don’t need to be trained or are not bound by a code of ethics.

Remember this is your profession. There are many people working for free on your behalf in their own time, and they do need your support and encouragement. They would also love to have you join them if you feel you can contribute some of your time for the common good - nomination forms go out this month, if you or someone you know would like to offer your time and expertise in media or PR, (or anything else) please put forward a commitee nomination form. We all need to keep working together to keep the herbal medicine profession strong and continuing in a positive direction. 3 Leanne Halliwell

NZAMH Branch Meetings Northland Contact Shirley Belcher (09) 438 3144 shirley@wtp.co.nz Auckland Central City: Contact Ange Haldane E: ange@naturalange.co.nz Harvest Natural Health Centre, 407A Richmond Rd, Grey Lynn.

South Auck: Contact: Maureen Verrill E: healinghands.herbs@gmail.com North Shore, West Auck., Volunteers needed Waikato Contact Val McArthur H: (07) 855 6724; M: (027) 618 3573 E: val@herbaltouch.co.nz Te Aroha Contact Tina Brown: (07) 884 4018, E: vanbrown@xtra.co.nz Tauranga Contact Jenny Ager-Pratt (07) 552 0697 E: dreams@eol.co.nz Hawkes Bay Contact Thelma Metcalfe (06) 856 8664, M (027) 696 3100, E: sanctuary.sounds@gmail.com Meetings held the first Wednesday of each month at 3.30pm Whanganui Contact Glenda Wright (06) 3487092 E: glendawright@slingshot.co.nz Manawatu/Horowhenua Contact Ros Arnott (06) 355 4556 or Sara Hamer (021) 064 6187 (06) 362 7227 email: affinity@slingshot.co.nz Wellington Contact Kimberly Taylor M: (021) 338603, (04) 9719639 E: Kimberly@zestnaturalhealth.co.nz Nelson Contact Anni Tekotua (03) 5488158 E: tekotua@slingshot.co.nz Christchurch Volunteer needed Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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World News

National Herbalists Association of Australia (NHAA) disagrees with MJA article on education The National Herbalists Association of Australia (NHAA) is disappointed that the Medical Journal of Australia (MJA) published an unsubstantiated editorial

by Professors MacLennan and Morrison which comments to the spurious debate commenced by Friends of Science in Medicine (FSM) undermining valuable university education for herbalists and naturopaths.

NHAA President Leah Hechtman says “To blur the distinction between individual complementary medicine courses complicates the discussion and invalidates the growing body of evidence for the effectiveness of herbal medicine and naturopathy and the efficacy of the medicines used. Their submission highlights that these two authors are incorrectly informed and that they have not reviewed the evidence sufficiently.”

The NHAA believes that this is a retrograde step for the MJA and is concerned that this attitude could affect public safety, and delay or prohibit valuable research in herbal medicine and naturopathy.

Herbal medicine, naturopathy and nutrition are extensively researched, and continue to be validated. The MJA has in the past supported herbal medicine, nutrition and naturopathy through publishing numerous articles promoting their efficacy of prescription. Australian government reports including the La Trobe report (The Practice and Regulatory Requirements of Naturopathy and Western Herbal Medicine, 2005) clearly demonstrate the effectiveness of herbal medicine, nutrition and naturopathy and outline the importance of sustaining university training.

8

The NHAA supports the premise that in Australia and has a long history of all health professions should be supported promoting higher educational standards by university research and training and for practitioners. 3 encourages further research into herbal (NHAA Monday, 05 March 2012) medicine, nutrition and naturopathy.

Hechtman says that “the NHAA encourages university qualifications so Founded in 1920, the National that naturopaths and herbal medicine Herbalists Association of Australia is practitioners adhere to the same rigour the oldest natural therapies association of training as other health professionals in Australia, and the only national to safeguard the public from inadequately professional body of medical herbalists. trained clinicians.”

Their mission is to serve and support their membership and promote and “It is not possible to compare protect the profession and practice of Australian university training with those herbal medicine. Visit their website: from the UK or European countries” says www.nhaa.org.au Hechtman. “Many of the UK universities were quite rightly criticised for validating third party courses with degree status, often as part of a commercial arrangement (i.e. the university would get commission).

In Australia, all complementary medicine courses delivered by universities go through exactly the same accreditation process as any other health discipline.”

Professor Kerryn Phelps, President of the Australian Integrative Medicine Association (AIMA) highlights that “our Australian universities provide teaching of the highest quality, with a sound evidence-based approach to complementary medicine, Traditional Chinese Medicine and Western herbal medicine. The standard of teaching provided is acknowledged and admired the world over and indeed Australia will lose all international credibility unless these modalities are included, as supported by AMA policy, in the teaching of our new generation of doctors and other healthcare professionals.”

This news article was reproduced with kind The NHAA is the oldest and leading permission from the NHAA, Australia. association for naturopaths and herbalists

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

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Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

9

Feature Article

Phytotherapy for Polycystic

By Angela Hywood BHSC (Comp. Med/Naturopathy); Dip Bot Med, Dip Hom; Dip CN; Dip NFM; MANTA; MNHAA; ND, Director - Green Medicine Institute

P

ABOUT THE AUTHOR: Angela Hywood is an experienced naturopath & homoeopath with over 14 years in clinical practice.

She runs a busy clinic in Sydney, specializing in neuroendocrinology, women’s health and infertility.

Angela has lectured extensively at major Naturopathic Colleges in Australia, is currently a faculty member at the Texas Chiropractic College and the University of Miami School of Medicine, Integrative Medicine Department in the United States as well as being a well-known speaker at complimentary & integrative medicine conferences around the world.

Her work has been published in distinctive complimentary medicine journals in Australia and USA and she is a contributing author of the text 'Botanical Medicine for Women's Health' by Aviva Romm.

Visit Angela's website for more information: www.greenmedicineinstitute.com

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olycystic ovarian syndrome (PCOS), is a common g ynecologica l d i s ord e r c h a r a c t e r i z e d by hypergonadotrophism, hirsutism, obesity, oligomenorrhea and commonly associated with infertility.1 PCOS is a complex clinical picture and presents a multifaceted etiology related to imbalance of the hypothalamic-pituitary-adrenal (HPA) axis, thyroid involvement and metabolic syndrome (insulin resistance). 1 There is substantial evidence that PCOS should no longer be considered purely a gynecological disorder, but rather a complex endocrine disorder.2 PCOS affects approximately 5 to 10% of women of reproductive age and is one of the most common causes of anovulatory infertility.2 Menstrual disruption typically manifests in PCOS, ranging from oligomenorrhea to amenorrhea.

Etiology Despite extensive investigations, the etiology of PCOS remains poorly understood. The most recent knowledge indicates that abnormal insulin response to glucose stimulus is a key underlying factor in PCOS.2,3 Other etiological factors include derangement of the sympathetic nervous control of the ovaries,4 estrogen dominance and elevated androgens. Some of the literature suggests a genetic susceptibility to insulin stimulation of androgen secretion, blocking follicular maturation.

Insulin Resistance PCOS and insulin resistance are intimately related endocrine disorders.

The most common causes of insulin resistance are obesity, poor diet and stress.

Hyperinsulinemia is not a characteristic of hyperandrogenism in general, but is uniquely associated with PCOS.2 In obese women with PCOS, 30 to 40% have impaired glucose tolerance or diabetes. However women with ovulatory hyperandrogenism can present with normal insulin and glucose tolerance, 1,2 thus indicating additional etiological factors may be involved.

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Elevated Androgens The ovarian and adrenal glands of women with PCOS are usually the sites of production of elevated androgens. It is postulated that these women have a hyperactive production of CYP17 enzyme, which is responsible for forming androgens in the ovaries and adrenals (from DHEA-S).2 Elevated total and free testosterone correlate with the typically elevated LH levels. Serum total testosterone is usually up to twice the normal range (20 to 80 ng/dL). High androgen levels in the ovary inhibit FSH, thereby inhibiting development and maturation of the follicles.1,2 DHEA is found to be elevated in 50% of women with PCOS.2 The elevated DHEA is due to stimulation by ACTH, produced by the pituitary in response to stress. The excess DHEA then converts to androgens via adrenal metabolism, which in turn contributes to the typical elevated androgen levels in PCOS. The skin and adipose tissue add to the complex etiology of PCOS. Women who develop hirsutism have the presence and activity of androgens in the skin which stimulate of abnormal patterns of hair growth.

Aromatase and 17-beta-hydroxysteroid activities are increased in the fat cells and peripheral aromatization increases with body weight. The metabolism of estrogens by way of 2-hydroxylation and 17-alpha-oxidation is decreased. Estrogen levels increase as a result of peripheral aromatization of androstenedione. This cascade results in a chronic hyper-estrogen production (estrogen dominance).2 Hirsutism occurs in 70% of women with PCOS in the USA, as opposed to only 10 to 20% of Japanese women diagnosed with PCOS.3 This may be explained by the genetically determined differences in 5-alpha-reductase activity between different cultures, or from a holistic standpoint, may reflect differences in endocrine behavior in accordance with local diet and levels of physical fitness.

PCOS, by Angela Hywood

c Ovarian Syndrome (PCOS) Estrogen Dominance The hypothalamic-pituitary axis imbalance can contribute significantly to the etiology of PCOS. The result of increased gonadotrophin releasing hormone (GnRH) output causes an elevation in the pulsatile output of LH and results in an elevated LH to FSH ratio (typically 2:1 respectively).2,5 FSH is not increased as a result of elevated LH in this case, likely due to the hypothalamus responding via negative feedback to the already chronically elevated estrogen levels.

About 25% of PCOS patients exhibit elevated prolactin,1,2 known as hyperprolactinemia. Hyperprolactinemia results from abnormal estrogen negative feedback via the pituitary gland.

Elevated prolactin can in turn contribute to elevated estrogen levels.

PCOS Holistic Diagnostic Criteria Menstrual irregularity ee Eight or fewer menstrual cycles per year ee Unpredictable menstrual cycles ee Amenorrhea for longer than 4 months in the absence of pregnancy or menopause ee Infertility ee History of ovarian cysts ee Irregular bleeding ee Excessive or heavy bleeding Skin complications • Adult acne • Severe adolescent acne • Cystic acne on face, neck, back shoulders • Hirsutism with excessive hair on face, body, upper lip, chin, neck, abdomen • Thinning of the head hair or male pattern balding • Acanthosis nigricans: discoloration or darkening of skin (may be in patches) around neck, groin, under arms, skin folds or skin tags (see later)

Insulin resistance • Weight gain, especially around trunk (apple body shape or android body shape, especially after the age of 30 years) • Dysglycemia • Difficulty losing weight • Family history of diabetes or menstrual irregularity Obesity is found in 50% of patient with PCOS.1,2,5 The body fat is usually located centrally around the trunk. A higher waist to hip ratio indicates an elevated risk of cardiovascular disease and diabetes.1 Insulin resistance and metabolic syndrome are commonly seen in PCOS patients and insulin resistance is now recognized as a risk factor for the development of diabetes mellitus type 2.2 Approximately one-third of obese PCOS patients have impaired glucose tolerance and up to 10% have diabetes mellitus type 2. Acanthosis nigricans, a condition in which the vulva develops thickened, pigmented velvety lesions, is considered a marker of insulin resistance in women with hirsutism. These lesions can also be found on the nape of the neck, inner thigh and below the breast. Women with severe insulin resistance can develop HAIR-AR syndrome consisting of hyperandrogenism (HA), insulin resistance (IR) and Acanthosis nigricans (AR).1,2 These women will have elevated testosterone (>150 ng/dL) and fasting insulin levels of greater than 25 mIU/dL. Insulin alters steroidogenesis (independent of gonadal production) in PCOS, as insulin and insulin-like growth factor receptors are located within the ovarian tissue.2 Associated with impaired glucose tolerance is the abnormal lipoprotein profile that can be seen commonly in patients with PCOS. The typical PCOS lipoprotein profile includes: • Elevated total cholesterol • Elevated triglycerides • Elevated low density lipoproteins (LDL) • Low high density lipoproteins (HDL) • Low apoprotein A-12 The culmination of these factors leads to a marked elevation in cardiovascular risk for the PCOS patient. Another metabolic observation that puts these women at higher cardiovascular risk is the incidence of impaired fibrinolysis, shown by elevated circulating levels of plasminogen activator inhibitor. This is associated with atherosclerosis and hypertension. When these factors are combined, PCOS women are at much higher risk of hypertension, atherosclerosis, and exhibit a seven-fold risk of myocardial infarction.2 Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

11

Feature Article Recommended Naturopathic Hormonal evaluation: • Salivary Adrenal Stress Index, including ACTH • Salivary or serum expanded female hormonal panel, including testosterone and LH to FSH ratio • Glucose tolerance test • Thyroid panel • Blood lipid profile Typical Hormonal Disturbances Associated with PCOS Diagnosis include: • LH is elevated while FSH is usually low at a ratio of 2:1 • Progesterone can be low • Sex Hormone Binding Globulin (SHBG) is usually low • Androgens such as testosterone and DHEA-S are usually elevated

Conventional Treatment Approaches The conventional treatment for PCOS is dependent on the patient’s desired goal of either menstrual regularity in order to achieve pregnancy or menstrual regularity for contraception.

Some women seek treatment for the removal of excessive male hair growth patterns, such as increased facial hair (common to women with PCOS and elevated androgens).

Women are currently being treated according to their presenting clinical symptoms, including irregular menses, hirsutism and infertility.1,2,5 Irregular Menses A combined oral contraceptive pill is commonly used to regulate the menses. By both increasing the levels of sex hormone binding globulin (SHBG) and decreasing androgen secretion, this can reduce elevated free testosterone activity. The combined pill worsens insulin resistance and if the patient falls into the categories of being overweight or obese, this therapy is relatively contraindicated.1,2 Hirsutism Hirsutism is addressed with the administration of the antiandrogens cyproterone acetate or spironolactone. The action of these drugs is to inhibit the binding of dihydrotestosterone (DHT) to the receptors at the hair follicle site.6 Infertility Clomiferine citrate is suggested to women with PCOS who are diagnosed with fertility challenges. This drug induces ovulation and does increase risk of multiple pregnancies.6 It acts by inhibiting the estrogen negative feedback at the hypothalamus, thus enhancing the pituitary’s production of FSH.

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AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Other Pharmaceutical Medications Other pharmaceutical medications which can be prescribed for PCOS include medroprogesterone acetate, gonadotrophin releasing hormone agonists, glucocorticoids, ketoconszole, flutamide, finasteride and metformin.

Overview of Botanical Protocol • Strong evidence supports the current hypothesis that the underlying cause of PCOS is due to insulin resistance (a decreased peripheral sensitivity to insulin), hence managing this aspect becomes the most important feature for the phytotherapist.

The exact mechanisms for insulin resistance are not yet known within the conventional medical community, however the holistic practitioner finds that insulin resistance has a high correlation to a diet high in refined carbohydrates coupled with a poor adrenal glycemic counterbalance. As the HPA axis becomes weakened (as a result of chronic stress), insulin sensitivity becomes heightened, adversely affecting the ovaries and thyroid. Elevated insulin and insulin-like growth factor have an effect in stimulating androgen production from the adipose tissue, ovaries and adrenals. Under chronic stress, excess cortisol is produced from the adrenal glands, triggering the release of elevated levels of prolactin and a sympathetic nervous system response.4 Prolactin has an inhibitory effect on the production of FSH and elevates the production of LH, worsening the scenario for women with PCOS. It is essential that the adrenals are well supported at a functional level with herbal adrenal tonics such as Glycyrrhiza glabra and supported by adaptogens such as Withania somnifera.

The first step in restoring ovarian function and a normal menstrual cycle in a PCOS patient is to break the pattern of hyperinsulinemia with a combination of diet and lifestyle strategies. Implementing a low refined carbohydrate diet and exercise is essential for a truly successful protocol.

Primary Herbs ĨĨ Paeonia lactiflora (White peony) ĨĨ Gymnema sylvestre (Gymnema) ĨĨ Tribulus terrestris (Tribulus) ĨĨ Vitex agnus-castus (Chaste tree) ĨĨ Caulophyllum thalictroides (Blue cohosh)

• Paeonia lactiflora (White peony) Paeonia lactiflora has been used for gynecological conditions by both Chinese and Western herbalists, and is used by Western herbalists for PCOS, hyperprolactinemia, endometriosis, ovarian failure and androgen excess. Paeonia has been shown to positively influence low progesterone, reduce elevated androgens (testosterone) and acts to modulate estrogen and prolactin.7 In vitro, the active constituent paeoniflorin has been shown to affect the ovarian follicle by its action on the aromatase enzyme.8 Aromatase is important for follicle maturation, ovulation and corpus luteum function, steroid hormone synthesis and the regulation of the conversion of androgens to estrogens. The biofeedback in the pituitary and hypothalamus rely on aromatase to regulate prolactin and GnRH. The daily dose for Paeonia is 4.5 to 9 mL of a 1:2 dried plant extract.9

PCOS, by Angela Hywood The traditional Chinese/Kanpo formula known as Shakuyaku-Kanzo-To or TJ-68, which is a decoction of Glycyrrhiza glabra and Paeonia lactiflora, has been the subject of a number of clinical trials, all of which demonstrate activity in the hormonal regulation of androgens. In one trial involving eight women with hyperandrogenism and oligomenorrhea, the formula was given for 2 to 8 weeks. This combination regulated the LH to FSH ratio. Over this period of time, serum testosterone levels decreased to less than 50 ng/dL and this resulted in seven of the eight women ovulating regularly.10 Another trial involved 20 women diagnosed with PCOS. The formula was successful in lowering testosterone in 90% of the women, of which 25% went on to conceive.11 It is suggested that it acts directly on the ovary, increasing the activity of aromatase, which promotes the synthesis of estradiol from testosterone, thus lowering serum testosterone levels. It also seems to regulate the LH to FSH ratio.12

•

Gymnema sylvestre (Gymnema)

Gymnema is a traditional Ayurvedic herb used as an antidiabetic, hypogylcemic, lipid lowering agent and to support weight reduction. Gymnema possibly has a trophorestorative action of the beta cells of the pancreas.13 The plant part used as medicine is the leaf. Gymnema is well indicated for PCOS, due to its insulin modulating activity and the added benefits of reducing the elevated triglycerides associated with PCOS. Key constituents of Gymnema include saponins, especially the gymnemic acids.

Gymnemic acid suppresses the sweet taste on the taste buds, so if taken before food masks the sweet sensation. Gymnema has demonstrated hypoglycemic activity in experimental models of diabetes and regulated blood sugar in hyperglycemia. The mechanism of action also includes the inhibition of glucose absorption in the intestine.

The daily dose of Gymnema is 3.5 to 11 mL of 1:1 liquid extract.9,14 Since conventional medical models are focussing on pharmaceutical agents such as metformin to control PCOS, Gymnema may prove to be one of the most significant herbs in the treatment of the underlying factor of insulin resistance.

• Tribulus terrestris (Tribulus) Tribulus is an endemic weed to many regions of the world, such as the Mediterranean, India, China, South Africa and Australia and is commonly known as puncture vine. The aerial parts, particularly the leaf, are used for medicinal purposes in the Western tradition.

As a result of Bulgarian research, Tribulus has become a popular herb for the treatment of female and male endocrine disorders.15 It acts as a general tonic, aphrodisiac, estrogen modulator and androgen modulator and is used to restore vitality, libido and reduce the physiological effects of stress.9,11 The Bulgarian research has identified a unique steroidal saponin class known as furostanol saponins, and extracts are standardized to contain at least 45% of these saponins, calculated as protodioscin. The leaf is noted to be higher in these unique saponins rather than the fruit or root. Other active constituents include phytosterols and spirostanol glycosides.

The tonic activities of Tribulus have been shown to act by intensifying protein synthesis and enhancing the activity of enzymes associated with energy metabolism. It increased iron absorption from the small intestines and inhibited lipid peroxidation during stress. This leads to increased muscle strength and improved endurance and stamina.9 To ensure the desired clinical results, it is recommended to use only the Bulgarian grown Tribulus standardized to 40% furostanol saponins. It is not interchangeable with the Chinese or Indian Tribulus. The daily dose of Tribulus corresponds to extracts containing furostanol saponins as protodioscin at 300 mg to 400 mg per day. In PCOS it is best used on days 5 to 14 of the menstrual cycle to restore menstrual regularity. For more information on Tribulus, see the forthcoming review which will be published in next month’s Townsend Letter.

• Vitex agnus-castus (Chaste tree) Vitex is beneficial for ovulatory factors associated with PCOS, in particular it has been shown to downregulate the production of excess prolactin, a condition known as hyperprolactinemia.16 Vitex is also postulated as having antiandrogenic properties. 16 Hyperprolactinemia is related to adrenal stress and hyperinsulinemia in PCOS. It is well documented that the active constituents in Vitex demonstrate a dopaminergic activity and dopamine inhibits the production of prolactin. The dopaminergic compounds in Vitex have been identified as the diterpene, including rotundifuran and 6ß,7ß-diacetoxy-13-hydroxylabda-8,14-diene. However, recent research is pointing to other phytochemicals which may have this activity.17 Other constituents of Vitex include essential oils, flavonoids (such as casticin) and iridoid glycosides (including aucubin and agnuside).9,14 Hyperprolactinemia, or the more subtle condition of latent hyperprolactinemia, are amongst the most frequent causes for cyclical disorders, including corpus luteal insufficiency. This can lead to premenstrual syndrome (PMS) and progesterone deficiency, secondary amenorrhea and premenstrual mastalgia.18 In an uncontrolled study, Vitex reduced elevated prolactin levels in 80% of 34 women with hyperprolactinemia at a dosage of Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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Feature Article 30 to 40 mg per day for 1 month and improved symptoms of a variety of menstrual disorders, including secondary amenorrhoea, cystic hyperplasia of the endometrium, deficient corpus luteum function, metrorrhagia, polymenorrhea and oligomenorrhea.9 Vitex reduced the thyroxin releasing hormone (TRH)induced prolactin release (essentially a pituitary-thyroid axis problem), normalized shortened luteal phases, corrected luteal phase progesterone deficiencies and reduced PMS symptoms in women with luteal phase defects due to latent hyperprolactinemia.9 Vitex should be considered first line botanical therapy for hyperprolactinemia and given for the duration of at least 3 to 6 months. In herbal writings Vitex is often attributed to increasing LH, which is not desirable in PCOS. However, clinical experience has shown that it is valuable in PCOS, especially when combined with other herbs, probably because of its action in reducing prolactin. The daily dose of Vitex to is 1 to 4 mL of a 1:2 dried plant tincture or 500 to 1000 mg of dried berries daily.9 It is best taken as a single dose in the morning.9 In PCOS it is best combined with Tribulus and Paeonia.

• Caulophyllum thalictroides (Blue cohosh) Caulophyllum thalictroides is known by the common name of blue cohosh and is native to North America. Within traditional use among the Native North Americans it was used for women as a remedy for amenorrhea and profuse menstruation, both of which are common features of PCOS. It is particularly useful to bring on the menses in PCOS. It has action as a uterine and ovarian tonic and a pelvic anti-inflammatory. The known constituents of Caulophyllum root include glycosides, caulosaponin and caulophyllosaponin, which are know to stimulate the uterus.

Other identified constituents include N-methylcystine, taspine and thalictroidine.9 The daily dose is 1.5 to 3 mL of 1:2 dried plant extract.9 Example PCOS Formula Vitex agnus-castus

1:2

12.5 mL

Glycyrrhiza glabra

1:1

12.5 mL

Paeonia lactiflora

1:2

25 mL

Gymnema sylvestre

1:1

25 mL

Schisandra chinensis

1:2

25 mL

100 mL

Dose: 15 mL per day or 5 mL three times daily ΏΏ In a case of a PCOS patient with amenorrhea, include Caulophyllum thalictroides at a dose of 2 mL per day to help induce the menses. ΏΏ When a cycle has been initiated, change to Tribulus concentrated extract, equivalent to furostanol saponins (as protodioscin) 300 to 400 mg per day on days 5 to 14 of the cycle to ensure cyclic regularity.

Dietary Modification A review of the extensive literature specific to lifestyle factors in PCOS demonstrates that an essential treatment strategy for ameliorating the symptoms of PCOS and resolving the

14

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

underlying metabolic derangements is the implementation of a low carbohydrate diet. This will tightly control blood sugar levels and resultant insulin production. High levels of insulin result in high levels of triglycerides and low levels of high density lipoproteins, which puts these patients into a high cardiovascular disease risk category. Modulating the diet not only helps the female endocrine cycle, but also serves as preventative medicine against these cardiovascular risk factors. As the insulin levels normalize, this will also improve circulating levels of SHBG, therefore limiting the problematic effects of free androgens on the menstrual cycle.2,6 Women with PCOS are urged to lose 5 to 10% body weight using a moderate protein, low refined carbohydrate diet.

When this approach was taken in one clinical trial, 10 of the 11 subjects resumed a normal cycle within 10.5 months.2 In a similar study, such weight loss restored ovulation in 60 out of 67 previously anovulatory women.3 The dietary profile should include approximately 30% good quality fats, 40% protein and 30% complex carbohydrates.1,2,19 Literature suggests establishing an energy efficient diet of 1000 to 1500 kcal per day. It is recommenced to avoid alcohol, caffeine, smoking and psychosocial stressors. Gymnema is helpful in reducing carbohydrate and sugar cravings, and therefore improving compliance with dietary changes.9 Exercise Implementing an exercise regimen of approximately 30 minutes per day will assist weight loss and improve the endocrine regulation of stress.

Case History Case Overview Female patient aged 34 presented with irregular menses and was considering attempting to fall pregnant. She had been diagnosed with PCOS for the past 2 years. Up until 6 months prior to her consultation, she had taken the oral contraceptive in combination with Levoxyl, but suffered side effects of heightened emotional lability from these drugs.

Her menstrual cycle varied in length anywhere from 50 to 70 days and she experienced mid-abdominal cramping for 24 hours prior to the onset of her menses. The flow was medium to light and lasted for 4 to 5 days, dark red in color, starting with brown spotting for 12 to 18 hours. She had occasional menstrual clots, stringy and lumpy in nature.

Her skin was affected badly by the PCOS and she experienced painful, deep cystic acne on her face, chest and back, which was worse for up to a week before the onset of each period. She had taken two courses of isotretinoin (Accutane) within the past 5 years and regularly used a tetracycline for treatment of her acne.

Breast tenderness was an uncomfortable premenstrual feature.

She had gained 23 pounds over the past 3 years, which she had difficulty losing, despite exercise on a regular basis. She did however have a high carbohydrate diet and craved sugar intensely.

She was a shift worker in a high stress and responsibility occupation and fatigue was a daily experience.

She was taking prescribed thyroid hormone (thyroxine) for Hashimoto’s thyroiditis, diagnosed 4 years prior. At the same time she was diagnosed as having secondary osteoporosis. Recent evaluation showed her spinal density indicated osteopenia, her

PCOS, by Angela Hywood femoral density indicated osteoporosis and total hip density indicated severe osteopenia.

Additional Assessment Hormonal evaluation showed a typical pattern of a 2:1 LH to FSH ratio, with elevated testosterone and hyperlipidemia.

Treatment Protocol Vitex agnus-castus

1:2

12.5 mL

Glycyrrhiza glabra

1:1

12.5 mL

Paeonia lactiflora

1:2

20 mL

Gymnema sylvestre

1:1

20 mL

Echinacea spp. root

1:2

15 mL

Schisandra chinensis

1:2

20 mL

100 mL

Dose: 8 mL twice daily Additionally: ΏΏ Tribulus concentrated extract, equivalent to furostanol saponins (as protodioscin) 300 to 400 mg per day on days 5 to 14 of the cycle to ensure cyclic regularity. ΏΏ Fucus vesiculosus 1:1, 10 mL twice daily.

glabra and Paeonia lactiflora were included into the formula to mimic the synergy of these plants in TJ-68 to reduce elevated testosterone and induce ovulation. Gymnema sylvestre was included in the formula to treat the insulin resistance and hyperlipidemia and assist with reducing associated carbohydrate cravings. Echinacea spp. root was an important inclusion for the autoimmune mediated hypothyroid condition. Echinacea serves as an immune modulator in this case. Schisandra chinensis was included in the formula to provide liver support, in particular to improve the liver’s ability to conjugate sex hormones, and assist in reducing the circulating levels of testosterone and estrogen.

Tribulus was selected to ensure a healthy follicular phase of the cycle and as an androgen modulator. Fucus vesiculosus was indicated for thyroid support as a plant source of iodine and is traditionally recommended by herbalists to assist with weight loss associated with hypothyroidism.

Conclusion of Care After 5 months on the herbal protocol, the patient’s cycle had regulated to a 32 day cycle, with a consistent 15 day follicular phase and a 17 day luteal phase. Problematic symptoms such as mastalgia, acne and hirsutism diminished significantly during the 5 month program. The lipid profile has improved to within normal ranges, and with the inclusion of the combined regimen of Gymnema, dietary modification (low carbohydrate diet) and exercise, she lost a total of 12% body weight in the 5 months.

She went on to begin a full preconception health care program and fell pregnant in her second month. 3

Rationale Vitex agnus-castus was indicated for the hormonal imbalance and hyperprolactinemia, often resulting in the symptom of premenstrual breast tenderness. A combination of Glycyrrhiza

References 1

D’Hooghe TM, Hill J: Novak’s Gynecology, Infertility, Philadelphia, 2002, Lippincott Williams & Wilkins.

2 Hopkinson Z, Satar N, Fleming R, Greer A: Polycystic ovarian syndrome: the metabolic syndrome comes to gynaecology, BMJ, 317, 329-332, 1998.

3 Visnova H, Ventruba P, Crha I, Zanova J: Importance of sensitization of insulin receptors in the prevention of ovarian hyperstimulation syndrome, Cesca Gynekol, 68, 3, 155-62, 2003.

4 Lara HE, Ferruz LJ, Luza S, et al: Activation of ovarian sympathetic nerves in polycystic ovarian syndrome, Endocrinology, 133, 26902695, 1993.

5 Stenchever MA et al: Comprehensive Gynecology Fourth edition, Polycystic ovarian syndrome, St Louis, 2001, Mosby.

6 Sweetman S: The Complete Drug Reference (Extra PharmacopoeiaMartindale). 33rd edition, Cloth, 2002, Pharmaceutical Press.

7 Trickey R: Women, Hormones and the Menstrual Cycle, Sydney, 1998, Allen and Unwin.

8 Ota H, Fukishima M. Stimulation by Kanpo prescriptions of aromatase activity in rat follicle cell cultures, Recent advances in the Pharmacology of Kanpo (Japanese herbal) Medicines, Amsterdam, 1998, Excerpta Medicine.

9 Bone K: A Clinical Guide to Blending Liquid Herbs: Herbal Formulations for the Individual Patient, 1ed, St. Louis, 2003, Churchill Livingstone.

10 Yaginuma T, Izumi R, Yasui H, Arai T et al: Effects of traditional herbal medicines on serum testosterone levels and its induction of regular ovulation in hyperandrogenic and oligomenorrheic

11

12 13 14 15 16 17 18 19

women (author’s transl), Nippon Sanka Fujinka Gakkai Zasshi, 34, 7, 939-44, 1998.

Takahashi K, Yoshino K, Shirai T, Nishigaki A, et al: Effects of traditional medicine (Shakuyaku-kanzo-to) on testosterone secretion in patients with polycystic ovarian syndrome detected by ultrasound, Nippon Sanka Fujinka Gakkai Zasshi, 40, 6, 789-96, 1988.

Takahashi K, Kitao M: Effects of TJ-68 (shakuyaku-kanzo-to) on polycystic ovarian disease, Int J Fertil Menopausal Stud, 39, 2, 69-76, 1994.

Bone K: Clinical Applications of Ayurvedic and Chinese Herbs, Warwick, 1996, Phytotherapy Press.

Merrily A, Winston D: Herbal Therapy & Supplements, Philadelphia, 2002, Lippencott.

Bone K: Tribulus terrestris, MediHerb Professional Review, 76, 2001.

Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Edinburgh, 2000, Churchill Livingstone.

Wuttke W, Jarry H, Christoffel V, Spengler B, Seidlova-Wuttke D: Chaste tree (Vitex agnus-castus)--pharmacology and clinical indications. Phytomedicine 10, 4, 348-57, 2003.

De Cherney AH, Nathan L: Current Obstetrics and Gynecologic Diagnosis and Treatment 9th edition, Infertility, New York, 2003, Mc Graw-Hill.

Glueck CJ, Papanna R, Wang P, Goldenburg N et al: Incidence and treatment of metabolic syndrome in newly referred women with confirmed polycyctic ovarian syndrome, Metabolism, 52, 7, 908-15, 2003.

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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Feature Article

A short primer on Botany and Phytochemistry: The Basics of Quality A/Prof Reg Lehmann General Manager of Research and Development, B. App. Sc. (Chemistry), Ph. D. (Organic Chemistry), Grad. Dip. Management.

H

ABOUT THE AUTHOR: Reg gained his PhD at the University of Queensland in 1988 and following a stint in the brewing industry, has been working in the herbal medicines area since 1994. Since 1996 this has been with MediHerb (and subsequently Integria Healthcare) Australia’s largest herbal medicine company supplying exclusively to practitioners, with significant export markets in USA, SA, UK and New Zealand.

Reg has worked within the areas of Quality Assurance, Production, Technical, New Product Development and Research.

His present position is General Manager of Research and Development where he is responsible for the group’s research and product development activities, including clinical trial management, pharmacology, phytochemistry and agronomic research.

Reg is regarded as a leading phytochemist around the world and utilises this knowledge and expertise to guide the product development process underway for the various markets of Integria. Reg Lehmann is also an adjunct Associate Professor in the School of Molecular and Microbial Sciences at the University of Queensland and also within Southern Cross Plant Science at Southern Cross University in recognition of the colloborative projects presently underway with research groups within these institutions.

Strong collaborations are also in place with: Swinburne University, Griffith University, Charles Sturt University, University of New England, University of Wisconsin and the Oregon Health Sciences University.

16

aving worked in the herbal industry for almost 20 years I have been saddened and surprised by the number of examples of poor quality product and in more recent times the fraudulent activities of some suppliers. On the more positive side I have also been pleased by the efforts of a number of suppliers to work with us to improve their product offering to meet our expectations.

When I commenced in the herbal industry in 1993 it was into an industry with very little information available on what represented a good quality herbal product from a poor quality product. There were only a very limited number of products with good compositional data, let alone clinical, in the scientific literature with the exception of Ginkgo and St John’s Wort. The analytical equipment used by most manufacturers was very basic and most laboratories did little more than microbiology and simple physical testing on their products.

The progress in instrumentation since that time has been immense and equipment which was considered to be a research tool is now routinely used by many manufacturers. We have also seen an increasing number of research articles and pharmacopeial monographs appearing over this time, while this guidance has been helpful there still remains a large number of our herbal products which have little or no information on this basic phytochemistry. I have been fortunate to have made a network of connections with key academic professionals who have developed a strong interest in this area and they have been instrumental in strengthening the data on many of the herbs we use on a daily basis. Some examples of this research are:

•

The identification of the major flavonoid in Skullcap (Scutellaria laterifolia), this had been believed to be scutellarin, but was shown to be baicalin, the same as in Baical skullcap (S. bacialensis)1.

•

The explanation of why certain samples of Paeony (Paeonia lactiflora) do not contain any paeoniflorin. This was shown to be a paeoniflorin sulfonate which was an artefact formed when the raw root was bleached to make it appear whiter2.

•

The detection of the deliberate adulteration of bilberry extracts by addition of the synthetic food dye amaranth3.

•

Identification and correction of published literature related to Shatavari (Asparagus racemosus), Shatavarins I to IV were correctly identified4.

•

Identification of a new tetra-ene alkylamide from Echinacea purpurea and E. angustifolia5.

•

Identification of the saponins present in Wild Yam (Dioscorea villosa)6, Beth Root (Trillium erectum)7 and False Unicorn (Chamaelirium luteum)8

•

Pharmacognosy of different varieties of Passionf lower (Passiflora incarnata)9

•

Identification of different saponins from Tribulus (Tribulus terrestris) depending on geographic origin10. (Ref 10 - unpublished) Without solid phytochemistry data, herbal identification relies upon the traditional techniques of botanical verification of herbal specimens. A herbal specimen is a sample of the whole herb which has been collected and carefully pressed and dried. Typically for a unequivocal identification the sample

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

The Basics of Quality by Reg Lehmann must be collected in flower or fruit as these are often the most characteristic. In fact one of most critical aspects to be performed prior to undertaking any phytochemical studies is to ensure that you have the correct species to begin with. While botanical identification is possible by herbalists in years gone by, who collected their own herbs from their own surroundings it is not feasible in the modern day.

Many examples exist in the literature of phytochemical studies being undertaken on what can only be assumed to be the incorrect species, as these studies have been unable to be replicated. One of the examples encountered recently was that of the essential oil of Skullcap (S. lateriflora) being reported from a wild growing specimen in Iran, while many Scutellaria species occur in the Middle East, this is not one of them. It is for this reason that most journals now require a specimen of the plant material studied to be deposited in a recognised herbarium, this would allow future researchers to access the plant material in case of future dispute. I have been fortunate to be associated with Southern Cross University which has a dedicated herbarium, with qualified botanists and chemists to undertake herbal identifications and to store botanical specimens under the required insect free, low humidity and absence of light conditions.

Examples do exist however of variation within a species and this has been evident in the example of Tribulus (Tribulus terrestris), where chemotypes would appear to present from its very broad geographic origin. The plant occurs in the wild from the Mediterranean region, through the Middle East, India, China, Southern Africa and Australia. It is unclear how many of these locales it has been introduced to, but its presence in North America has definitely been ascribed to human translocation. The influence of plant part is also seen with Tribulus where in Asia the fruits are typically used, while in the Mediterranean the aerial parts are employed which show very different chemical profiles.

A similar instance is evident with Withania (W. somnifera); where depending on the author five different morphotypes and/or five

different chemotypes are present. Morphotypes are different growing forms of the same plant species – Withania is present as low herbaceous ground cover, through to small woody trees.

Chemotypes are same plant species which has different chemical composition and may be undifferentiable morphologically.

Figure 1: Pressed botanical specimen of Astragalus in flower - even though the plant part used medicinally is the root.

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Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

17

The Basics of Quality, by Reg Lehmann The equipment utilised for the identification of herbal components has improved dramatically and the following equipment should now be considered essential for herbal identification and phytochemisty.

• TLC – Thin Layer Chromatography • HPTLC – High Performance Thin Layer Chromatography • GC – Gas Chromatography • HPLC – High Performance Liquid Chromatography • MS – Mass Spectrometry – normally linked to the GC or HPLC • NMR – Nuclear Magnetic Resonance Spectroscopy – normally the domain of universities but some larger companies have their own equipment. Can be linked into a HPLC. This research background has enabled the identification of a number of issues with routine receivals from commercial suppliers which would normally not been picked up by standard pharmacopeial testing. Some of these we have published such as the bilberry and paeonia examples, but others have not. Some examples are as simple as a farmer buying seed for a new herb

crop and receiving the wrong seed from their supplier, growing a great crop and selling it as what they honestly believed it to be, and being very surprised to be told they grew the wrong product. Other more sophisticated examples involve the deliberate addition of generic flavonoids such as rutin to flavonoid containing extracts to confound simple pharmacopeal test methods. The use of rutin as an adulterant has also been found in ginkgo extracts. This adulteration is not limited to herbs but is also present in other commonly used ingredients such as essential oils like Tea Tree Oil (Melaleuca alternifolia) and organic minerals such as Selenomethionine.

The example of Damiana herb is given in the Figures 2 and 3, where the application of HPLC and HPTLC easily show the deliberate addition of rutin the herbal extract to give a good test result for total flavonoids by a generic test method only looking at total flavonoids.

These two examples show that it is still a case of buyer beware in the herbal industry and that only by using a combination of good botany, chemistry and the having the right people can you ensure that you get good quality ingredients every time. 3

Figure 3 (LEFT): HPTLC images of the same samples as above, with (R = Rutin, Td = Turnera diffusa herb specimen, ?Td = adulterated Turnera diffusa)

Figure 2 (ABOVE): HPLC trace of Damiana herb (Turnera diffusa) upper, and below sample to which Rutin has been added – the major peak.

References: 1.

2.

3.

4.

5.

18

Lehmann R, Penman K, Leach D and Waterman P, “Identification of the major flavonoid from Scutellaria lateriflora – Part I, Poster presentation Society of Medicinal Plant Congress, Zurich (2000) PY Hayes, R Lehmann, K Penman, W Kitching, JJ De Voss, “Sodium paeoniflorin sulfonate, a process derived artefact from paeoniflorin”, Tetrahedron Letters 2005; 46: 2615-2618 KG Penman, CW Halstead, A Matthias, JJ De Voss, JMU Stuthe, KM Bone, RP Lehmann, “Bilberry adulteration using the food dye amaranth” Journal of Agricultural and Food Chemistry 2006; 54: 7378-7382 PY Hayes, AH Jahidin, RP Lehmann, KG Penman, W Kitching, JJ De Voss “Structural Revision of Shatavarins I and IV, the Major Components from the roots of Asparagus racemosus” Tetrahedron Letters 2006; 47: 6965-6969 N Matovic, A Matthias, J Gertsch, S Raduner, KM Bone, RP Lehmann, JJ De Voss, “Stereoselective Synthesis, Natural Occurrence and CB2 receptor binding affinities of alkylamides from Herbal

Medicines such as Echinacea sp.” Organic and Biomolecular Chemistry 2007; 5: 169-174 6. PY Hayes, LK Lambert, R Lehmann, K Penman, W Kitching, JJ De Voss, “Complete 1H and 13C assignments of the four major saponins from Dioscorea villosa (Wild Yam)” Magnetic Resonance in Chemistry 2007; 45: 1001-1005 7. PY Hayes, RP Lehmann, K Penman, W Kitching, JJ De Voss, “Steroidal saponins from the roots of Trillium erectum (Beth root)”, Phytochemistry 2009; 70: 105-13 8. N Matovic, J Stuthe, V Challinor, P Bernhardt, R Lehmann, W Kitching, J De Voss, “The Truth about False Unicorn (Chamaelirium luteum): Total Synthesis of 23R,24S-Chiograsterol B Defines the Structure and Stereochemistry of the Major Saponins from this Medicinal Herb”, Chemistry- A European Journal 2011; 17: 7578– 7591.

9. H Wohlmuth, KG Penman, T Pearson, RP Lehmann, “Pharmacognosy and chemotypes of passionflower (Passiflora incarnata L.”) Biological and Pharmaceutical Bulletin, 2010; 33 (6): 1015-8 10. V Challinor, RP Lehmann, JJ De Voss, Unpublished.

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Durban

The Supplication of a Dead Man’s Hand

By Vincent Di Stefano

T

he UN Climate Conference held in Durban last December closed with a hollow whimper. No commitment to real action. No commitment to effective change. Just the continuing slow burn of business as usual.

The only substantive decision reached by the Conference was an agreement to form yet another committee, the Durban Platform for Enhanced Action. The Durban Platform rests on the dubious ambition of crafting a global agreement on greenhouse gas emissions by 2015. This will serve to replace the Kyoto Protocol which expires at the end of 2012. The Durban Platform will lay out the terms for legally-binding global emissions reductions that will “come into effect and be implemented by 2020.”

Executive Director of Friends of the Earth (FOE) Andy Atkins offers his assessment: “This empty shell of a plan leaves the planet hurtling towards catastrophic climate change.” And Chair of FOE international Nnimmo Bassey gives his own verdict: “Delaying real climate change until 2020 is a crime of global proportions. . . . An increase in global temperatures of 4 degrees Celsius, permitted under this plan, is a death sentence for Africa, Small Island States, and the poor and vulnerable worldwide.”

Even during the first days of the Durban Conference, the Global Carbon Project released figures showing that global carbon emissions increased by 6% - the greatest yearly increase ever recorded - between 2009 and 2010. This surge occurred in the year after the Climate Conference in Copenhagen that many had hoped would be a turning point.

Commenting on the longer-term implications of the inaction at Durban, a group of independent scientists from Climate Action Tracker concluded that: “Global mean warming would reach about 3.5°C by 2100 with the current reduction proposals on the table. They are definitely insufficient to limit temperature increase to 2°C.” This is not news. In August 2008, an article published in the UK Guardian noted that senior government scientists were projecting a 4°C rise in global temperatures based on existing evidence at that time. Of itself, such a temperature increase will affect hundreds of millions of people living in coastal areas. Such a temperature increase will likely produce a mass extinction event resulting in the loss of between 20% and 50% of all animal and plant species on the planet. Such a change in global temperature will also result in the widespread collapse of ocean ecosystems and food chains everywhere. Most alarmingly, such a rise in temperature increase will result in the painful and tragic reduction of human populations to below one billion people.

It is generally understood that even before global temperatures reach such levels, a number of tipping points will be crossed. These will push the planetary climate into completely unknown terrain. Yet this is precisely the scenario that the Climate Conference at Durban has soporifically agreed upon

2

“It is not until, as Kurt Vonnegutt Jr. put it

in 2006, “the shyte hits the fan” that any decisive (and by then largely useless) action is likely to occur.”

2

by refusing to set binding limits on emissions and choosing rather to delay action until 2020. The failure of Durban can only deepen the cynicism and frustration that have grown since the failures of Copenhagen in 2009 and Cancun in 2010.

We are a heedless and refractory species. It is not until, as Kurt Vonnegutt Jr. put it in 2006, “the shyte hits the fan” that any decisive (and by then largely useless) action is likely to occur.

Crossing to Death’s Other Kingdom

T

he problems that assail the present age reach far deeper than the oil deposits and coal seams that are fuelling an inexorable increase in carbon dioxide emissions. Carbon has become emblematic of our present crisis because its concentration in the atmosphere is by far the over-riding determinant of regional and global temperatures, ocean acidity, and global climatic patterns.

Each of these factors in turn profoundly influences the web of interconnected energies that has sustained all life on this planet over time periods far greater than the two million years that Homo sapiens has walked the earth.

Industrial civilisation has been driven by far more than the extraction of fossil fuels, even though those fuels have enabled many of the signatory elements of the present times to be realised.

These include: ΏΏ The enabling of transport systems that move hundreds of millions of people and hundreds of millions of tons of materials every day. ΏΏ The development of an agricultural system that has replaced small-scale integrated agriculture with broad-acre methods that make use of increasingly modified and genetically-manipulated seed-stock and produce increasingly chemicalised and vitiated soils. ΏΏ The creation of massive industrial infrastructures that have, since World War II, overseen the production and dispersion of over 80,000 new chemical compounds many of which are highly toxic - throughout numerous ecosystems.

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Durban. The Supplication of a Dead Man's Hand ΏΏ The intensely energy-consuming and environmentally destructive extraction of minerals and metals on every continent. ΏΏ The clear-felling of vast swathes of the world’s old-growth forests for timber and wood-chip production and the creation of new agricultural lands.

The problem is not simply one of reducing carbon emissions. It is more in the nature of attending to the numerous pathologies that have riven the body of a senescent and dying civilisation.

The Valley of Dying Stars

N

orth American physician Max Gerson was among the first to awaken to the insidious and damaging effects of agricultural chemicals on the processes that sustain all life. Gerson, who was described by Dr Albert Schweitzer as, “one of the most eminent geniuses in the history of medicine” is remembered for having independently developed a powerful nutritionally-based cancer therapy during the 1940s. In his introduction to A Cancer Therapy.

Results of Fifty Cases published in 1958, Gerson wrote: “The coming years will make it more and more imperative that organically grown fruit and vegetables will be, and must be, used for protection against degenerative diseases, the prevention of cancer, and more so in the treatment of cancer.”

Gerson’s prescient understanding has, however, been subverted and dismissed by the powerful corporate interests that control industrial agriculture, scientific medicine, the cancer establishment and the dominant media. Government health and agriculture departments have been fully co-opted in the corporate expansion of both chemical-based industrial agriculture and chemical-based cancer treatments.

Gerson’s insight arose during the course of developing treatments for chronic diseases, including cancer, during the 1930s and 1940s.

His treatment program requires, among other things, the consumption of large quantities ABOVE: Max Gerson nearly 10 kilograms daily - of fruits and instructed his patients to use vegetables in the form of freshly expressed only organically-grown fruits juices.

Gerson observed that several weeks after and vegetables for preventing starting treatment using conventionally-grown and treating cancer. fruits and vegetables, virtually all of his patients, regardless of the nature of their cancer, began to develop severe yet near-identical symptoms.

He went on to discover that this new pattern of symptoms was due to the toxic effects of

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AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

chemicals - mainly chlorinated hydrocarbons that were used universally in the industrial-scale agriculture that produced most of the fruits and vegetables available in North America at the time.

Gerson instructed his patients to thereafter use only organically-grown fruits and vegetables.

Within a short time, the distressing symptoms began to disappear and patients continued to improve. Gerson was later to write: “The soil and all that grows in it is not something distant to us but must be regarded as our external metabolism, which produces the basic substances for our internal metabolism. Therefore, the soil must be cared for properly and must not be depleted or poisoned; otherwise, these changes will result in serious degenerative diseases, rapidly increasing in animals and human beings.”

This comment, made in 1958, presaged the observation made by Thomas Berry in 1991: “It should be especially clear in medicine that we cannot have well humans on a sick planet. Medicine must first turn its attention to protecting the health and well-being of the Earth before there can be any effective human health.”

Herein lies the essence of the problem. The health and well-being of the Earth will not be restored simply by capping carbon emissions, continuing to fuel industrial civilisation using “clean” nuclear energy, or implementing Promethean geo-engineering projects. Great damage has already been done and continues to be inflicted on the earth’s forests, soils, lake and river systems, ground-waters, and marine environments.

This has been evident to the more visionary among us for decades. While Max Gerson was among the first to alert us to the effects of agricultural chemicals on human health, Rachel Carson went on to document the effects of both agricultural and industrial chemicals on wildlife ecosystems in the 1960s. She gave the ominous title of Silent Spring to her report in acknowledgement of the widespread decline in health of bird populations due to the effects of agricultural chemicals.

Soon after the publication of Carson’s seminal work, we began to learn of the unexpected effects of industrial and agricultural chemicals on the hormone systems of numerous species throughout the ecosystem. The dispersal of immense quantities of such chemicals in

By Vincent Di Stefano

2 “Let us continue individually and collectively to work towards the creation of

enduring communities, to cut through the destructive effects of greed and ignorance, and strive to preserve and perpetuate those sources of wisdom that will enable future generations to avoid the tragic errors that presently unfold around us. ” (Vincent Di Stefano)

2

the environment has already resulted in numerous reproductive abnormalities. During the 1970s, salmon stocks in the Great Lakes of North America exhibited a range of endocrine changes including thyroid enlargement, precocious sexual maturation in males, and poor egg survival (less than 15%). Bird species feeding on Great Lakes fish exhibited reproductive loss and early mortality of hatchlings.

Right across the US and throughout the UK, large numbers of the fish that inhabit freshwater rivers and lakes now show intersex characteristics. It has also become apparent in recent years that many frog species are undergoing extinction at an alarming rate while frog populations globally continue to steadily decline. On yet another front, bee populations continue to decline catastrophically throughout North America for the fifth year in succession in the phenomenon that has come to be known as Colony Collapse Disorder.

The tragedy of Fukushima has served to reinforce what is clearly understood by those like Helen Caldicott who have looked deeply into the human consequences of the nuclear project.

While engineers and politicians blithely reassure us that there is nothing to fear in the increasing levels of background radiation resulting from the unearthing and processing of radioactive elements, internal emitters such as Caesium-127 Strontium-90 Uranium-235 and Plutonium-239 are silently incorporated into our body tissues to actively seed mutations that will eventually produce cancers or will - if lodged in testes or ovaries - irreversibly alter the DNA of sperm and egg cells and project the dark shadow of industrial civilisation into the lives of future generations through the influence of genetic mutations.

Despite endless soft-soaping by the International Atomic Energy Commission and the nuclear industry, we now know that over a million people have already died as a result of Chernobyl.

Thomas Berry has spoken clearly and prophetically about the consequences of pursuing a nuclear future: “One of the most ominous expressions of the natural world has to do with nuclear energy. When we go deep into the natural world and penetrate the inner structure of the atom and in a sense violate that deepest mystery for trivial or destructive purposes, we may get power, but nature throws at us its most deadly consequences.

We are still helpless with regard to what to do once we have broken into the mysterious recesses of nuclear power. Forces have been let loose far beyond anything we can manage.”

Voices Singing in the Wind

B

eyond these issues which bear down increasingly in the present time, the nature and viability of a civilisation is equally reflected in the institutions, philosophies and practices that underlie it and give it direction. There is little to inspire confidence when one looks closely at the militarism, inequality, corporate greed, valueless production and commodification of nature that have come to characterise the present style.

The problems that now confront us are as much moral as practical, as much philosophical as pragmatic. The myth of endless growth that has so driven Western economies over the past two centuries is now confronted by the reality of a seriously damaged world. We have failed to honour our duty as stewards of an exquisitely beautiful planet but have rather treated the created world as an endless commodity into which we can project our technocratic fantasies and unload the toxic detritus of industrial activity without thought of consequence.

While governments dither and corporate behemoths evade and obstruct the growing collective will for a more conscious participation in our fate, we are more likely to be herded towards the flames than guided towards more appropriate ways of living on the earth in this time of growing troubles.

Let us continue individually and collectively to work towards the creation of enduring communities, to cut through the destructive effects of greed and ignorance, and strive to preserve and perpetuate those sources of wisdom that will enable future generations to avoid the tragic errors that presently unfold around us. 3

ABOUT THE AUTHOR: Vincent Di Stefano is a retired osteopath and author of “Holism and Complementary Medicine. History and Principles” published by Allen and Unwin in 2006. His blog “Integral Reflections” can be viewed at http://thehealingprojectweblog. blogspot.com/

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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Business Management:

Helping your practice succeed

By Craig Rhodes MNZAMH

Just what do you do?

Are you a Medical Herbalist or a Business person?

T

he reality for most is that to attain the measures of success you set for yourself, for most practitioners you need to be a business person first and a practitioner second.

You need to know how to: • Find and attract clients • Manage them to ensure good outcomes and keep them coming back • Develop in-clinic materials: handouts, leaflets and fliers • Do ‘the books’, and deal with GST and other tax • And more…

From years of dealing with Herbalists I suspect that the majority are into the herbalism, but less so the business stuff.

In fact for most, the business stuff is a pain in the neck, a distraction from what they want to do – work with herbs and get the most for their patients.

So what to do?

Well realistically there are only three options: 1. Do nothing and continue as usual If your practice is humming along, you’re meeting your goals, have plenty of time and are having a life you love then this is the option for you.

2. Upskill and learn the business stuff you need to survive.

This will vary depending on the practitioner, but remember all learning is good, and learning business skills is not about becoming a corporate sell out. Business skills include things such as: how to get and manage clients and keep them coming back, book keeping, or how to write newsletters and web content. They’re just skills, how (or even if) you use them is up to you, and they simply form the foundation on which you practice. How you practice is still dependant on who you are.And realistically if you still hate book keeping then you still hate book keeping!!!

3. Hire someone to do it for you.

Now hiring a full time practice manager is not realistic for most of the practitioners out there, or even hiring an ongoing part timer for that matter. But you can outsource the work you hate, or the stuff you lack the skill in, to other experts who will do it for you.

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AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Outsourcing has three benefits: 1. It frees you up to do stuff you’re better at or would rather be doing.

By outsourcing you can have more time available to see clients (earning more money) or spending time with your family or on yourself (priceless).

2. Rather than battling along using trial and error, bringing in experts means you get it done right first time.

Doing the books yourself in a ledger book might take 2 or 3 hours a week or more, every week, and doing GST and tax can be a major pain. But using a book keeper and accounting software largely takes this off your hands.

They get the job done in half the time, and one headache magically disappears.

Likewise, if you need a website, you can do it yourself ‘for free’ spending weeks figuring it out for yourself, only to find it doesn’t work properly.

Or you can get someone to do it for you in less than a week, and again the stress disappears.

3. Believe it or not hiring experts is usually cheaper than doing it yourself.

BUT If you’re doing your books yourself it’s free right?

Well not really…

If you do your books during business hours it reduces the time you have available to see clients and make a difference in your community, reducing your income by whatever your hourly rate is, as this would otherwise be time when you were seeing clients and making money.

So if your hourly rate is $90 an hour then 5 hours a week to do your books is costing you $450, so much for free…

Meanwhile if you’re doing the books after hours then that’s time away from doing what you love or spending time with your family, and that’s worth way more than your $90 hourly rate, so again you lose.

If outsourcing your book keeping by hiring a really expensive book keeper (which should cost way less) it might cost $100 an hour, but they get the job done in an hour and a half costing you $150.

Business Management Hiring a book keeper just saved you $300 compared to doing it ‘for free’ and their bill is a tax deductable business expense at the end of the year.

The same applies to any other business admin that takes you away from your clients or doing what you love. Or for acquiring skills that you’re just not interested in like marketing or web design.

Bringing in expert skills can not only save you time and money compared to going it alone, it can actually make you more money, and help you be more successful no matter how you measure it.

Life is too short to do what you hate, or sit up ‘til 3am doing GST or writing newsletters if there are things you value more that you’re missing out on in the meantime.

So look at what you do and how you do it, is there stuff that others could do better, that outsourcing would free you from, helping you to focus on doing what you love. 3

We have written a FREE article 'Breaking Free of Business Headaches' to help health practitioners break free of the business stuff they hate, to focus on what they love.

To get your FREE article Breaking Free of Business Headaches go to www.practicepro.co.nz

Craig has a background in banking and business development.

He has run a General Medicinal Herbal and Naturopathic practise north of Auckland, and currently runs a Specialist Atopy practice in Auckland. He also teaches Practice management at the New Zealand College of Chinese Medicine and South Pacific College of Natural Therapies and is the current NZAMH President

REMINDER Your NZAMH Membership Requirements are due 1 April 2012

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

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Clinical Nutrition

The Widening Spectrum of Coeliac Disease Compiled by Marcelli Coronet BNutDiet - PGradDip Functional Nutrition

Introduction

Pathophysiology

oeliac disease, also known as gluten-sensitive enteropathy, is characterized by inflammation of the small-intestinal mucosa that results from a genetically based immunologic intolerance to ingested gluten.

Coeliac disease differs from traditional immunoglobulin E (IgE)mediated food allergies in that a chronic inflammatory response is induced in the primary site of damage, the small-intestinal mucosa. The inf lammation occurring in Coeliac disease classically produces a malabsorption syndrome, with diarrhoea, steatorrhoea, and loss of weight or failure to thrive. The disease results in a wide spectrum of both pathophysiologic changes in the intestines and clinical syndromes, many of which remain undiagnosed (1, 7). Coeliac disease as an inflammatory bowel disorder is unique in that a specific food component, gluten, has been identified as the culprit (2).

C

C

Clinical Presentation

T

he classic constellation of signs and symptoms characterizing malabsorptive syndrome is a readily recognized manifestation of Coeliac disease. More common but more difficult to recognize, however, are the other diverse ways in which Coeliac disease presents. Coeliac disease may mimic many common clinical entities. These atypical modes of presentation include deficiencies of single micronutrients; non-specific gastrointestinal complaints such as bloating, abdominal pain, diarrhoea, constipation, flatulence, secondary lactose intolerance, and dyspepsia; and non-gastrointestinal complaints such as fatigue, depression, arthralgia, milk intolerance, osteomalacia or osteoporosis, and iron deficiency anaemia (1,3,2,4,5).

Most patients do not recognize a temporal association between the ingestion of gluten and the appearance of symptoms hence a delay on the diagnosis of the disease. (6) The symptoms are often ascribed to a functional cause such as irritable bowel syndrome and patients are prescribed high-fibre diets or other non-specific dietary measures to little avail which may exacerbate the condition. (3, 6) Commonly practitioners of alternative medicine are aware of the vast collection of ill effects to dietary gluten therefore prescribe wheat-free or gluten-free diets for many complaints.

This can lead to diagnostic difficulties to confirm the existence of Coeliac disease.

The objective of this informative is to highlight the importance of an accurate diagnosis of this gastrointestinal disease and the impact of misdiagnosed, ignored or mistreated outcome that can be detrimental to the patient and their families.

oeliac disease is the end result of three processes that culminate in intestinal mucosal damage: 1. genetic predisposition 2. environmental factors, and 3. immunologically based inflammation. (3) Coeliac disease may be the result of an evolutionary collision between the cultivation of wheat and the human immune system, in particular between the human leukocyte antigen (HLA) system of self identification and the specific deleterious peptide sequences in wheat (8, 1).

Genetics Coeliac disease is a heritable condition. It seems to be more common in Caucasians and family co-ocurrence is common (7–13). Coeliac disease is strongly associated with the extended human leukocyte antigen (HLA) phenotypes B8, DR3, and DQw2, but most specifically with DQw2. A small percentage of patients are DQw2 negative. These patients usually have the genotype DR5/DR7.

The genotype that encodes DQw2 includes the DQA1*0501 and DQB1*0201 alleles.

The identification of a genotype not associated with Coeliac disease may have some negative predictive value in patients who are already consuming gluten-free diets. (1, 2, 3, 4, 9) Environmental factors The most important environmental factor in Coeliac disease is gluten (19). The deleterious proteins are gliadins (wheat), hordeins (barley), secalins (rye), and possibly avidins (oats). These grain plants share a common taxonomy: all are grasses. The proteins are complex storage proteins that share some common repetitive sequences.

The exact peptide sequences involved have not been identified precisely, although peptides rich in glutamines and prolines are potent activators of the immune response in Coeliac disease. Other factors may have a role in precipitating symptoms including gastrointestinal surgery, pregnancy, highdose gluten challenge, and viral infection, which may heighten the immunologic response to gluten, thus extending the disease distally and causing clinically apparent decompensation (e.g.

Adenovirus 12). (1, 2, 3, 10, 12) Breast-feeding seems to reduce the likelihood of the infant developing Coeliac disease at an early age (5).

Immunologic factors The intestinal lesion in Coeliac disease is an immunologically mediated inflammation of the intestine that is characterized by architectural and inflammatory changes of the mucosa of the proximal small intestine. The inflammatory response

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AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Clinical Nutrition consists of increased numbers of lymphocytes, plasma cells, and macrophages in the lamina propria and increased numbers of lymphocytes in the surface layer of the epithelium. The surface enterocytes are shorter, wider, and have more poorly ordered nuclei than is normal. The normally tall, thin villi are shortened and flattened. (1, 2, 3, 10) Trigger factors Little is known about the process that leads to Coeliac disease.

In normal small intestine, Peyer patches are the immunologic sampling site. Luminal antigens are taken up by the m-cells (a specialized population of thin enterocytes) over the Peyer patch by pinocytosis and delivered to the subepithelial layer of the Peyer patch where antigen-presenting cells process the antigens.

This allows a controlled sampling of the antigenic milieu by the intestinal immune system. Primed B cells travel from Peyer patches to the mesenteric lymph nodes and return to the jejuna mucosa, where they are terminally differentiated to produce IgA directed against the antigen.

In Coeliac disease, there is a generalized increase in permeability to macromolecules, making it likely that Peyer patches are not the only site where gliadins are in contact with the immune system. Gluten peptides may encounter the gut immune system in a fashion that bypasses the normal controlled sampling, leading to sensitization or loss of tolerance to the antigen. (1, 2, 3, 4,12) Cellular immunity Cellular immunity seems to play the major role in the intestinal damage in Coeliac disease.

In vivo studies from treated and untreated patients show an early expression of human leukocyte antigen (HLA) antigen markers on cells in the surface layers of the intestinal mucosa after 2–4 h of exposure to gluten. T cell clones reacting specifically to gluten, realising interferon g and tumor necrosis factor along with other pro-inflammatory cytokines. There follows a migration of lymphocytes into the surface epithelium; subsequent recruitment of activated lymphocytes, macrophages, and plasma cells into the lamina propria; and deposition of complement in the subepithelial layer. The infiltration of T lymphocytes in this surface leads to an increase in the expression of aB and gD receptor. The gD cells may alter the transfer and presentation of antigens by the enterocyte (the proper mechanism of action is unknown). The inflammatory sequence depends on a competent cellular immune response in the small intestine and also affects the structural support and microcirculation of the villus, leading to collapse of the villus.

The extent of the damage to the intestine determines the malabsorptive consequences of the disease. Surface lymphocytic infiltration of the stomach and colon may also occur (1,2,3,10,1,121).

Humoral response A potent humoral response occurs in untreated Coeliac disease.

Increased numbers of plasma cells in the intestinal mucosa produce IgA, IgG, and IgM antibodies directed against grain peptides and connective tissue autoantigens. The antibodies are secreted as secretory IgA into the intestinal lumen and are also detectable in serum. The dynamics of the humoral response seem to parallel the cellular injury, although antibodies may arise

before mucosal relapse and disappear before healing.

Secreted IgA directed against gliadin may be a vain attempt to exclude a harmful antigen, whereas antibodies to connective tissue may target host antigens in the connective tissue of the jejunum, reticulin, umbilical cord, and endomysium.

The enzyme tissue transglutaminase (TTG) engages in a critical process termed deamidation whereby glutamine residues on the gliadin protein are converted to glutamic acid, thereby producing a negative charge that facilitates binding of gliadin to the antigen presenting cell.

Tissue transglutaminase complexes with gliadin, which may allow gliadin-responsive T cells to help tissue transglutaminase– responsive but inactive B cells to generate a potent selfdirected antibody response. A recent report suggests that transglutaminase alters the gliadin, permitting uptake and processing by the enterocyte, which is then subject to gliadin T cell–mediated damage.

Gliadin antibodies occur in other intestinal conditions but the connective tissue antibodies are highly specific to Coeliac disease. The humoral response may have a role in some of the extraintestinal processes seen in Coeliac disease, including hyposplenism, IgA nephropathy, and hypoparathyroidism. (1, 2, 3, 4, 12).

Diagnosis of Coeliac Disease

T

he major challenge is not in confirming the diagnosis but in identifying those individuals who may have Coeliac disease and selecting the appropriate tests to screen for it.

The cost and invasiveness of endoscopy and biopsy have been significant factors in pushing Coeliac disease lower on the differential list; additionally, the disease may not even be considered by specialists unfamiliar with it.

With the advent of sensitive serologic tests, screening for Coeliac disease is now within reach of all practitioners.

Coeliac disease should be considered in anyone with conditions associated with a high risk of the disease, such as type 1 diabetes, autoimmune thyroid disease, T cell lymphoma, osteoporosis, and infertility, and in those with a family history of Coeliac disease or dermatitis herpetiformis. (1, 2) Screening tests for Coeliac disease Several noninvasive tests of malabsorption can be used to help to screen the disease. These tests may be important for identifying malabsorption but have variable sensitivity for Coeliac disease.

These include tests of deficiency states, such as measurements of hemoglobin and red cell indexes, carotene, vitamin D, prothrombin time, and iron and folate concentrations; tests of absorption, including the Dxylose test; qualitative or quantitative fecal fat tests and contrast radiography.

An important factor to consider with all tests is whether the patient has been consuming a gluten-free diet before testing.

Results on all of the tests, including intestinal biopsies, may return to normal with consumption of gluten-free diets, making confirmation difficult without a gluten challenge.

Practitioners should consider screening at-risk family members, including siblings, children, and possibly parents; ≥50% of patients with Coeliac disease have a family member with undiagnosed disease. Serologic screening tests could be used for asymptomatic relatives, but those with symptoms suggestive of Coeliac disease should undergo interstitial biopsy. Children may

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Clinical Nutrition have to be screened more than once. Family members should also be ingesting gluten to maximize the accuracy of the screening tests. (1, 2, 3) Serological testing Serological studies have been used to evaluate patients with suggestive symptoms such as unexplained bloating or abdominal distress, chronic diarrhoea with or without malabsorption, and abnormalities on laboratory tests that might be caused by malabsorption (i.e., folate deficiency and iron-deficiency anaemia), as well as to screen high-risk individuals that may or may not have symptoms (first degree relatives with Coeliac disease,Type I diabetes, Down’s Syndrome, Turner syndrome, and other conditions known to be associated with Coeliac disease).

The antigliadin antibodies (IgA and IgG) are found in the intestinal secretions as well as the serum of patients with untreated Coeliac disease. Unfortunately, use of these antibodies to diagnose Coeliac disease has fallen out of favour due to their decreased sensitivity and specificity. These antibodies are found in a wide variety of autoimmune disorders and therefore have low diagnostic utility. Antireticulin antibodies, likewise, are not used currently as there has been an advent of more sensitive and specific antibodies- namely, the antiendomysial antibody and anti-TTG (Enzyme Tissue Transglutaminase) antibody.

Antiendomysial (EMA) IgA antibody is currently the best diagnostic serological test for Coeliac sprue, with specificity approaching 100%. However, testing for TTG, which is the autoantigen for the development of antiendomysial antibody, is much cheaper and less operator dependent, and thus the use of this serological test is growing. Overall, sensitivities for both of these tests are quite high and surpass all the other serologic antibody tests. The table below lists the various serologic tests and their respective sensitivity and specificity.

Antibody Test

Sensitivity (%)

Specificity (%)

IgA EMA

75-98

96-100

IgA anti-TTG

98.5

98

IgA antigliadin

53-100

65-100

IgG antigliadin

57-100

42-98

Since titers of endomysial and TTG antibodies correlate with the degree of mucosal damage, partial villous atrophy may not be detected by serological screening. Likewise, individuals who have already started a gluten-free diet may also not have a positive result for Coeliac disease by serology due to relative healing of the mucosa as a result of omitting dietary gluten.

Selective IgA deficiency is 10 times more common in patients with Coeliac disease relative to the normal population.

As a result, Coeliac patients with selective IgA deficiency are likely to have false negative results when serologies for antiendomysial antibody and anti-TTG antibodies are sent, since these are IgAderived antibodies. In these cases, it becomes necessary to screen these individuals using IgG-based antibodies including IgG antigliadin and IgG anti-TTG.

26

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Genetic Testing Coeliac disease is associated with two HLA haplotypes: HLADQ2 is present in 95% of those with the disease while the remaining 5% of Coeliac individuals have HLA-DQ8.

Since essentially all individuals with Coeliac sprue have one of the alleles, the absence of these alleles virtually excludes the diagnosis. Thus, HLA testing may be used to help elucidate the diagnosis of Coeliac disease when other diagnostic testing is indeterminate. (2) Coeliac antibody profile: Coeliac Antibody Panel is a semiquantitative analysis of serum Anti-Tissue Transglutaminase IgA (tTg IgA), in addition to IgG and IgA antibodies specific for gliadin.

Anti-Tissue Transglutaminase IgA (tTg IgA) is a highly sensitive (about 98%) and specific (>95%) marker for untreated Coeliac disease in an IgA competent individual. Anti-Gliadin IgA and Anti-Gliadin IgG are useful markers to monitor compliance to a gluten-free diet.

Food Allergy Panels: IgE: IgE antibodies are found primarily in mucous secretions. An IgE reaction occurs immediately after exposure to the allergen, a food or inhalant. The early phase reaction usually occurs within 15 minutes of exposure to the allergen. The late phase reaction may then occur 4-6 hours later and persist for days with increased edema and inflammation IgG: IgG antibodies represent the most prevalent class found in the blood. The inflammatory process is gradual and may take anywhere from several hours to several days, which is why this type of reaction is called 'delayed'.

IgA: IgA antibody testing provides additional information to identify suspected food or inhalant triggers; IgA represents a primary immune reaction with a half-life of about 5-6 days when compared to IgG, which has a half-life of about 20-24 days.

Secondary tests to consider in order to identify absorption Intestinal Permeability test (lactulose/mannitol test): measures the ability of two sugar molecules - mannitol and lactulose - to permeate the intestinal lining therefore helping to identify malabsorption and increased permeability.

Comprehensive Stool Analysis with or without Parasitology: a powerful clinical tool to assess digestive and absorptive functions, the presence of opportunistic pathogens and to monitor the efficacy of therapeutic remediation of GI disorders.

Red Blood Cell Elements: is an invaluable diagnostic method for assessing insufficiency or excess of elements that have important functions within cells or on blood cell membranes

Clinical Nutrition Nutritional Intervention

Digestive Support

P

Due to the increased immune activation in the intestinal tract of people with Coeliac disease, the digestive and absorptive processes of those affected may be compromised. Targeted enzyme blends provides noticeable improvement for those with digestive distress / food intolerances.

rofessional dietary advice is a necessity for the proper management of the disease.

The goal of the gluten-free diet is to achieve healing and maintain health through the adoption of a well-balanced, varied diet that avoids gluten.

Hidden sources of gluten are frequently present in what seem to be safe foods. Suspicious ingredients include hydrolyzed vegetable protein, modified food starch (and starch in foreign foods), malt or malt flavoring, vegetable gum (oat), mono- and diacylglycerols, and natural flavorings. Listings of gluten-free foods must be reviewed regularly for changes in the manufacturer’s ingredient list.

Secondary lactose intolerance is common but usually resolves once the damage to the gut has healed. Temporary restriction of lactose ingestion or use of a lactase preparation may suffice for treatment. Many patients with Coeliac disease report intolerances to other non-gluten-containing foods. The mechanism of these intolerances is not known. (2) Specific nutritional supplementation is required to correct nutritional deficiency status and should be based on individual’s needs.

The following nutrients are suggested in order to provide an adequate support to minimize the risk of the complications that people with Coeliac disease suffer from the most.

Gut support Gut support is essential to repair the damage caused within the intestinal mucosa as well as reducing inflammation.

Probiotics: help to maintain a healthy intestinal lining; promote beneficial gut flora; stimulates immune cell proliferation; activates macrophages to recognize, ingest and destroy pathogens (Innate immunity); activates B cells that precede increased concentrations of antibodies.

(Acquired immunity); modulates the immune system by acting upon the production of cytokines (IL-2, IL-6, IL8) that act as “go-betweens” to coordinate the actions of the immune system; reduces the amount of transforming growth factor (TGF-b) that inhibits innate and acquired immunity. Different strains have clinically proven to shown health benefits therefore it is really important that each strain remains alive as they travel through the digestive tract to the distal end of the small intestine.

L-glutamine: is the most prevalent amino acid in the bloodstream; it promotes gastrointestinal and immune health, nourishing and healing the gut promoting normal gut permeability.

Botanical compounds: like Deglycyrrhizinated licorice, Marshmallow root lemon balm and chamomile contain various constituents with GI calming potential, including polysaccharides, terpenes, flavonoids and polyphenols, to soothe and protect the GI tract, supporting mucosal integrity.

Some of these compounds may also maintain healthy histamine activity promoting a healthy GI motility. Some of these compounds may also maintain healthy histamine activity and promote healthy GI motility

Digestive enzymes: It is essential to offer a variety of enzymes to support protein, carbohydrate, fat, fiber and dairy digestion and to promote optimal nutrient bioavailability and absorption.

Vitamins and Minerals Vitamins and Minerals play an important role in protecting intestinal mucosa as well as decreasing mucosa damage, and correcting nutritional deficiencies.

B complex vitamins: B vitamins malabsorption is common in untreated Coeliac disease as the proximal small intestine is predominantly affected. Folate deficiency can cause changes in the small-intestinal mucosa that resemble those of CD therefore aggravate gluteninduced small-intestine damage. Supplementation with folate can mask the diagnosis of vitamin B12 deficiency, really common in CD. In addition supplementation with B vitamins seems to have a protective role against the effect of villous atrophy levels.

It is important for these individuals that the B Vitamins are in their active forms to enhance bioavailability Iron: iron deficiency is common in patients with CD, and may result from a combination of decreased intestinal iron absorption, intestinal blood loss, and increased loss of iron from rapid turnover of intestinal epithelial cells.

Zinc: Intestinal zinc malabsorption and low plasma or serum zinc levels have been found to be common in patients with untreated and treated CD. L-carnitine: studies suggested that serum carnitine concentrations were significantly lower in patients with untreated and treated CD than in healthy controls.

L-carnitine also supports energy metabolism and relieves chronic fatigue, a common complaint in CD. Vitamin A, Vitamin E, Selenium: are also decreased in patients with untreated and treated CD due to malabsorption.

Copper: the anaemia associated with CD may in some cases be due to copper deficiency, particularly when neutropenia and/or granulocytopenia are also present.

Vitamin K: Bleeding due to vitamin K deficiency has been reported in children and adults with newly diagnosed and untreated CD. Calcium, magnesium, Vitamin D: Bone Mineral Density (BMD) can be significantly low in patients with CD. Supplementation with micronutrients such as calcium, magnesium, vitamin D as well with other nutrients that play a role in bone health, might accelerate the gain in BMD resulting from a gluten-free diet.

Essential Fatty Acids Support: corrects EFA’s deficiency, decreases inflammation by increasing Prostaglandin series 1 and 3 Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

27

Clinical Nutrition Conclusion Coeliac disease should be considered in many clinical scenarios, including chronic diarrhoea with or without steatorrhoea, lactose intolerance, fat-soluble vitamin deficiency, persistent iron deficiency anaemia, folate or vitamin B-12 deficiency, osteopenic bone disease, abnormal results on liver blood tests, and unexplained short stature and in patients with a close relative with Coeliac disease.

The correct diagnosis as well as the proper management of nutritional requirements based on individual’s needs (requirements) will lead to a better outcome for the patient.

References: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

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Food allergy: adverse reactions to food and food additives. (book) By Dean D. Metcalfe, Hugh A. Sampson, Ronald A. Simon Murray J, The widening spectrum of Coeliac disease. Review Article Am J Clin Nutr 1999;69:354–65 Gastrointestinal and Liver Disease Nutrition Desk Reference. Book by Gerard E. Mullin, Laura E. Matarese, Melissa Palmer Hadjivassiliou M, Sanders D et al., Gluten sensitivity: from gut to brain. Lancet Neurol 2010; 9: 318–30 Ivarsson A, Hernell O, Stenlund H, Åke Persson L. Breast-feeding protects against Coeliac disease. Am J Clin Nutr 2002;75:914–21.

Lankisch PG, Martinez Schramm A, Petersen F, Dröge M, Lehnick D, Lembcke B. Diagnostic intervals for recognizing Coeliac disease. Z Gastroenterol. 1996 Aug;34(8):473-7.

Sapone A, et al. Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Coeliac disease and gluten sensitivity BMC Medicine 2011, 9:23 doi:10.1186/1741-7015-9-23 Greco L. From the Neolithic revolution to gluten intolerance: benefits and problems associated with the cultivation of wheat. J Pediatr Gastroenterol 1997;24:S14–7.

H Ascher, I Krantz, L Rydberg, P Nordin, B Kristiansson. Influence of infant feeding and gluten intake on coeliac disease Archives of Disease in Childhood 1997;76:113–117 H Ascher, I Krantz, L Rydberg, P Nordin, B Kristiansson. Parallels between Pathogens and Gluten Peptides in Coeliac Sprue. PLoS Pathogens February 2008 -Volume 4 - Issue 2 -e34 R T Przemioslo, K E A Lundin, L M Sollid, J Nelufer, P J Ciclitira. Histological changes in small bowel mucosa induced by gliadin sensitive T lymphocytes can be blocked by anti-interferon y antibody. Gut 1995; 36: 874-879 Ciccocioppo R, Di Sabatino A, Corazza R. The immune recognition of gluten in coeliac disease. 2005 British Society for Immunology, Clinical and Experimental Immunology 140: 408–416

AVENA Journal of the New Zealand Association of Medical Herbalists Autumn 2012

Book Review

Botanical Medicine for Women’s Health

By Aviva Romm CPM, RH(AHG), President, American Herbalists Guild; Executive Editor, Journal of the American Herbalists Guild, Canton, GA, USA Contributors: Kathy Abascal, Lise Alschuler, Bhaswati Bhattacharya, Mary Bove, Isla Burgess, Bevin Clare, Mitch Coven, Robin Dipasquale, Margi Flint, Lisa Ganora,

Paula Gardiner, Wendy D Gube, Mary L Hardy, Christopher Hobbs, David Hoffmann, Sheila Humphrey, Angela Hywood, Laurel Lee, Roberta Anne Lee, Clara Lennox, Elizabeth Mazanec,

Amanda McQuadeCrawford, Simon Mills, Linda Ryan, Jillian Stansbury, Ruth Trickey, Roy Upton, Susun Weed, David Winton, Eric Yarnell, Suzanna Zick

ISBN: 978-0-443-07277-2 Churchill Livingstone Elsevier (2010) Paperback, 694 pages Book Review by Mary Allan MNZAMH Aviva Romm, a practicing herbalist, midwife and President of the American Herbalists Guild (AHG) has brought together valuable knowledge from a range of very skilled and experienced herbal practitioners, and placed their wisdom together in one convenient coherent text.

This text offers a powerful blend of both traditional and evidence based herbal medicine and encourages us to embrace the richness both approaches have to offer, and thus help us give our patients the best that we possibly can. Romm has edited and rewritten a substantial amount of the contributors work, whilst attempting to maintain the original intention and tone of the contributing author. This gives the text a harmonious continuity despite it being made up of so many different authors.

A large, well-organised paperback book made up of 19 chapters (694 pages) its typesetting is beautiful and user friendly. The book is divided into five parts: Part I: Foundations of Botanical Medicine (Chapters 1-4) 1: Botanical Medicines, CAM, and Integrative Medicine: Definitions and Use 2: History of Herbal Medicines for Women 3: Fundamental Principles of Herbal Medicine 4: Guidelines for Herbal Medicine Use Part II: General Gynecologic and Menstrual Health Concerns (Chapters 5-10) 5: Menstrual Wellness and Menstrual Problems 6: Endocrine Disorders and Adrenal Support 7: Conditions of the Reproductive Organs 8: Vaginal Infections and Sexually Transmitted Diseases 9: Urinary Complaints 10: Breast Cancer

Part III: Fertility and the Childbearing Cycle (Chapters 11-18) 11: Pregnancy and Botanical Medicine Use and Safety 12: Fertility Challenges 13: Pregnancy: First Trimester 14: Pregnancy: Second Trimester 15: Pregnancy: Third Trimester 16: Labor and Birth 17: The Postpartum 18: Breastfeeding and Botanical Medicine Part IV: The Menopausal Years (Chapter 19) 19: Menopausal Health Part V: Plant Profiles: black cohosh, blue cohosh, chaste tree, dong quai, ginger, kava, red clover, St John’s wort, uva ursi and wild yam.

At the beginning of each chapter is the list of authors who contributed to that particular chapter. For example, chapter 5 “Menstrual Wellness and Menstrual Problems” acknowledges: Aviva Romm, Bevin Clare, Jill Stansbury, Linda Ryan, Ruth Trickey, Laurel Lee and Angela Hywood. Each subject within that chapter then also specifies its authorship from the above list.

Each condition is thoroughly explored including pathology, signs and symptoms, differential diagnosis, and conventional treatment, followed by extensive botanical treatments and discussion. It is by no means a “this for that” type approach. Indeed, almost 100 pages in part I are dedicated to the history, fundamental principles and guidelines of herbal medicine (four chapters in total). Each section is headed and sub-headed making it very easy to access information quickly and easily. The index is also very detailed. The book is absolutely packed with tables, sample formulae and beautiful photos which break up and balance the substantial text.

Highly recommended.

Price: About $50-60 from Amazon.

For more information do a search at www. sciencedirect.com or www.amazon.com

Autumn 2012 Journal of the New Zealand Association of Medical Herbalists AVENA

29

NZAMH DVD, Video & Audio Hire It is our aim to inspire our members with some of the great speakers we have in Herbal Medicine. The following recordings are a resource for the NZAMH and its members. They can be used at branch meetings or for personal use. Hireage is for two weeks.

Any contributions to the media library are welcomed. The full range of recordings is listed in the members section of our website, www.nzamh.org.nz, with a .pdf order form and instructions on how to go about hiring an item.

Library Additions 2011 1.

Dr Joseph Pizzorno – Optimal Nutrition and Digestion DVD 1 of 2 2.

Dr Joseph Pizzorno – Optimal Nutrition and Digestion DVD 2 of 2 3.

Dr Joseph Pizzorno – Cellular Environment & Energy Production.

4.

Dr Joseph Pizzorno – Toxin Avoidance and Effective Detoxification DVD 1 of 2 5.

Dr Joseph Pizzorno – Toxin Avoidance and Effective Detoxification DVD 2 of 2 NZAMH Conference May 2010 1.

Simon Mills - Acupharmacology / Simon Y Mills – Integrating Chinese and Western Herbal Medicine.

2.

Dr Nicky Baillie – Insights into Clinical Practice. Phil Rasmussen – Optimal Dossage in Herbal Medicine 3.

Rob McGowan – Rongoa Maori and NZ Herbal Medicine. Kaye Keats – An Anthroposphic Apporach to Childhood

Illnesses. Craig Rhodes – Creating a Soccessful Practice.

NHAA 6th International Conference on Phytotherapeutics Sept 2007 1.

Proceedings, abstracts, notes and presentations.

2.

MPS Audio CD 1 and CD 2 Michael J McCammon N.D. 1.

Herbal Medicine & Iridology 2.

Integrated Herbal Medicine & Iridology

Library Additons 2010 1.

2.

3.

4.

Earth Whisperers/Papatuanuku (NZ) - Released in 2009 by Wick Candle Films, this documentary focuses on 10 earth- centred visionary New Zealanders.

Healing Jounerys (NZ) - Another film from Wick Candle Films, this follows the journeys of eleven cancer patients to health.

Numen: The Nature of Plants (USA) - released in 2009, this film features amazing footage of Nature's healing medicinal plants and the people who work with them. www.numenfilm.com Herbal Manufacturing (Rob Santich) - Rob is a well-known speaker from Australia, he co-wrote "Healthy children" with Kerry Bone.

Video Tapes available from Women, Herbs And Health 1998 International Gathering Now also available in DVD’s * Tape

Speaker

Topic

1*

Amanda McQuade-Crawford (USA) Francesa Naish (AUST)

Women, Herbs and Health: Current Issues, Current Practices Preconception Care for Infertility/Miscarriage/Healthy Babies

2*

Amanda McQuade-Crawford (USA) Phil Rasmussen (NZ)

Identification and Treatment of Female Reproductive Infections Stress Management for Women

3*

Nick Burgess (AUST) Ruth Trickey (AUST)

Fatigue Epidemic of the 90’s Blood Building Herbs

4*

David McLeod (AUST) Isla Burgess (NZ)

Diagnostic Signs of Use in Women’s Health Herbal Medicine and the Endocrine System

5*

Kerry Bone (AUST) Nicky Baillie (NZ)

Herbal Influence on Female Hormones The Dance of the Hormones and Vitex agnus-castus

6*

David McLeod (AUST)

The Herbal Treatment of Reproductive Cancers

NZAMH DVD,Video & Audio Hire 7*

Amanda McQuade-Crawford (USA) Phil Rasmussen (NZ)

Depression and Phytotherapy Herbal Medicine in the Treatment of Addiction

8*

Assunter Hunter (AUST) Robert McGowan (NZ)

Cimicifuga racemosa – Pharmacology and Clinical Usage Traditional Maori Medicine in Practice (Waiere o terra Ngati Haua)

10

Whitefeather (USA) Whitefeather (USA)

Seven Directions Movement Meditation Awakening the Wise One Within

11 Francesca Naish (AUST)

Angela Spence (NZ)

An Overview of Natural Fertility Management Herbs During Pregnancy; A Midwife’s perspective

12

Juliette de Bairacli Levy (AZORES) Dr Ajit (NZ)

Natural Childcare Ayurveda and Pregnancy

13

Susun Weed (USA) Robert McGowan (NZ)

Healthy Breasts – In Our Hands Native Plant Walk

14 Elisabeth Brooke (UK)

Debbie Harper (NZ)

Astrology and Herbal Medicine; The Roots of European Herbal Philosophy; Medicine and the Four Humours Not Only Skin Deep: Remedies for Skin Problems

16

Assunter Hunter (AUST) Juliette de Bairacli Levy (AZORES)

Menopausal Symptoms: Food, Herbs, Prevailing Views Story Telling

17*

Robert McGowan and the women from Te Ronga Maori Elisabeth Brooke (UK)

Traditional Maori Medicine in Practice

18*

Susun Weed (USA) Amanda McQuade-Crawford (USA)

Spirit in Practice of the Wise WomanTradition Women, Herbs and Health; Current Issues, Current Practices

30.

Michael McCammon (NZ)

Integrated Herbal Medicine and Iridology

31

Mediherb Seminar Audiotape and notes

Thyroid Dysfunction

The Emotional/Ritual/Psychic use of Herbs for Milestones of Women

Video tapes available from the 2001 4th International Conference on Phytotherapeutics Tape

Speaker

Topic

1

Nicolas Burgess Nigel Wynn Kerry Bone

Welcome Pesticides and Health A Critical Look at Herb-Drug Interaction Information

2

Hans Wohlmuth Berris Burgoyne Dr Rajen Coopan

Standardised Extracts – A Critical Appraisal Herb-Drug Interactions – Theory and Reality Herbalised Oils in the Management of Health and Disease

3

Kakib Li Warraweea Dr Hong Roos Ruth Trickey

Traditional Aboriginal Ya-idtmidtung Medicine Treatment of Urogenital Disturbances Breast Cancer – Supportive Treatment From Diagnosis and Beyond

4

David McLeod Dianne Jackson Clinical Forum

Death with Dignity – the place of natural medicine in palliative care Childhood Leukemia and Herbs Cancer and Terminal Conditions

5

Jude Moss Melanie Koeman

Spiritual Awareness and Applications in the Treatment of Disease Male Infertility and Sub-fertility – a Multifaceted Approach

6

Mary Melling Patricia Baxter Patricia Collins

Post-partum Measures – Eastern and Western Approaches The Client has left the Building Learn to Recognise and use Local Medicinal Herbs

Guidelines for Continuing Professional Education - Due 1st April 2012 Total annual requirement for NZAMH professional membership: 30 Points

This is a list activities through which you can obtain Continuing Professional Education (CPE) points. Each year, you will be sent a CPE form to fill out along with your membership renewal form.

Herbal Medicine Activity - 20 points compulsory minimum This education requirement is directly related to the practice of herbal medicine. For example the research of medicinal plants, New Zealand Native herbs, herbal medicine professional and industry issues, the historical and traditional aspects of herbal medicine and the philosophical issues related to the practice of herbal medicine. (May also include company seminars that include herbal content).

Medical Science Activities Activities of a continuing education nature which related to nutrition, human biochemistry, physiology, pathology, symptomatology, diagnosis, pharmacology, internal medicine, epidemiology, psychology, psychiatry, health-related research and also the study of other health care modalities not regarded as herbal medicine, such as remedial body work, naturopathy, homeopathy, kinesiology etc.

Other Subject Activities Activities that relate to the practice of herbal medicine, but may not be classifiable as either herbal medicine or medicinal science topics.This covers areas such as business development, marketing and promotion, health promotion, general health care philosophy, ethics and history. This may also include writing government submissions on related CAM health issues.

Other Criteria Must have current St John’s or Red Cross First Aid Certificate (or equivalent), unless special conditions apply.

STUDYING… Borrowing from the NZAMH (or herbal college) library

Book, DVD, video or cassette Formal studies at a tertiary institution

Including classes, external work, assignments, exams Subscription to a peer reviewed journal

Not Avena, minimum 4 pages, paper or electronic PRESENTING……

Presenting to the public a health related topic Presenting to a professional audience a health related topic Undergraduate or Postgraduate teaching/lecturing a health related topic ATTENDING/PARTICIPATING …

NZAMH Branch meetings and/or National Committee meetings NZAMH Conference/AGM weekend Subscription to Yahoo chat line forum Seminar/telephone or conference attendance – Herbal medicine predominant Seminar/telephone or conference attendance - Nutrition predominant PUBLISHING… General media – publish health related article (e.g. Avena, Herbal Gram, NZ Charter magazine, NZ Woman’s Weekly, Sunday News) Peer reviewed journal – publish secondary health related research i.e. review article (e.g. Alternative Medicine Review, BMJ, NZ Doctor, Journal of Ethnopharmacology) Peer reviewed journal – published original research study (e.g. Alternative Medicine Review, BMJ, NZ Doctor, Journal of Ethnopharmacology).

Writing a health-related book OTHER… Mentoring a graduate medical herbal student Volunteer in a public herbal garden or herbal dispensary

1 point/item

Max 5 points

1 point/hour

Max 5 points

2 points/issue

Max 6 points

4 points/talk 6 points/talk 1 point/6 hrs

Max 12 points Max 18 points Max 5 points

2 points/mtg 10 points/day 2 points 2 points/hr 2 points/ hr

Max 10 points Max 20 points Max 30 points Max 15 points

4 points/article Max 20 points 20 points/article Max 20 points 30 points/ study 6points/chptr

Max 24 points

2 points/hr 1 point /hr

Max 10 points Max 10 points

If you have undertaken a relevant activity that does not fit into one of the above categories you may apply to NZAMH for approval of credit toward your CPE point total.

2 6 th - 2 7 th M Ay

2012

Novotel ellerslie, AucklANd

NZAMH CONFERENCE & ANNUAL GENERAL MEE TING

SPEAKERS: A/Prof Reg Lehmann Dr Nicky Baillie Donna Kerridge Sandra Clair Valmai Becker Jill Dunn Tony Brook

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