Kava has the potential for significant, albeit rare, side effects. Cases of hepatotoxicity severe enough to require transplant were reported (81). Other side effects include dermatitis, and a movement disorder similar to Parkinson’s disease but reversible. It was removed from many European markets. The use of kava is not recommended, but if patients are using this botanical (which is available over the counter), they should be informed of the risks, and advised to avoid taking kava in conjunction with other anxiety-reducing agents, with alcohol, or acetaminophen, and have liver function tests performed periodically.
St. John’s Wort
The leaves and the tips of the ﬂowers of the plant St. John’s wort (Hypericum perforatum)have been used medicinally, primarily as an antidepressant. It is used for anxiety, and in Germany, it is used to treat menopausal mood swings.
Although its mechanism of action is unclear, St. John’s wort does appear to be beneficial in relieving mild to moderate depression, with 60% improvement in mood, energy, and sleep with a dose of 300 mg three times daily. Standardization is controversial, but it is believed to have at least two active ingredients, namely hypericin and hyperforin. Most research was done on products standardized to 0.3% hypericin. The first trial to examine its use for menopausal symptoms was done in 1999. Patients not taking hormone therapy were given 300 mg of St. John’s wort three times daily, and symptoms were evaluated at baseline and at 5, 8, and 12 weeks by both the patients and physicians. At baseline, 80% to 90% of all symptoms were moderate to marked in severity. By 12 weeks, 20% to 30% remained at this level, whereas most patients had only slight symptoms or were symptom free. There was no change in vasomotor symptoms; 80% of patients reported that their sexuality was substantially enhanced. Of 106 patients, 4 reported adverse effects. These effects included skin rash with sun exposure, gastrointestinal upset, headache, and fatigue (82). In a randomized trial of 301women using a combination of black cohosh and St. John’s wort, the treatment was superior to placebo for both climacteric and psychological symptoms (83). St. John’s wort induces the cytochrome P450 complex. Specifically, lower levels of oral contraceptives, theophylline, cyclosporine, and antiretroviral drugs were reported. Interactions were described with buspirone, statins, calcium channel blockers, digoxin, and carbamazepine. There are no apparent significant interactions with Coumadin.
Chasteberry (Vitex agnes) has a long history of uses by civilizations ranging from Greeks to the monks of medieval times. Among the uses is treatment of menopausal symptoms. Although its use was recommended for this indication, the efficacy of chasteberry in menopause is not demonstrated.
Ginkgo biloba is often promoted for the improvement of libido in menopausal women. Muira puama plus ginkgo had a significant effect in 65% of the patients in one study (84). Side effects include gastrointestinal upset and headaches, and drug interactions can occur with estrogens, statins, and calcium channel blockers. Ginkgo has an anticoagulant effect.