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Subject: St. John's wort
What Is It?
St. John's wort (Hypericum perforatum), a common shrub-like perennial, bears bright yellow flowers that contain numerous therapeutic substances when dried. Europeans have used the herb for centuries to calm jangled nerves and heal wounds, among other ills. And so it's not surprising that North Americans have recently embraced its use as a treatment for depression and conditions associated with it. Not only is St. John's wort effective and relatively free of side effects, it also costs under $20 for a month's supply, about 75% less than the most popular antidepressant drugs. In Germany, where doctors routinely prescribe herbal remedies, St. John's wort is the most common form of antidepressant--more widely used than the drugs Prozac or Zoloft because it has far fewer side effects.
Health Benefits
Although St. John's wort has been the focus of a number of well-regarded studies, researchers still don't know exactly how the herb works. A pigment called hypericin has long been identified as a key medicinal ingredient, although other compounds are now similarly believed to contribute to the herb's therapeutic effects. In general, St. John's wort appears to boost levels of the brain chemical serotonin, which affects the emotions. The National Institutes of Health (NIH), in Washington D.C., are currently conducting multiple studies on the efficacy of St. John’s Wort for many psychological conditions. Because of its widespread use among the public, the NIH is also in the process of conducting research to determine St. John’s Wort effects on other commonly prescribed drugs.
A number of other uses for St. John's wort have been proposed as well, many of them related to the herb's antidepressive actions. The herb is even being investigated as a treatment for alcoholism, panic attacks, and general anxiety.
Specifically, St. John's wort may help to:
Relieve mild to moderate depression. Careful analysis of 27 different studies of St. John's wort including 2291 study participants concluded that the herb works better than a placebo in the treatment of mild to moderate depression (1). And because it helps promote sound sleep, St. John's wort is particularly beneficial for those who suffer fatigue, low energy, or insomnia as a result of depression (2). The herb may also aid in treating depressive elements of chronic fatigue syndrome and seasonal affective disorder (also known as SAD or "wintertime blues"), a type of depression linked to the shortage of daylight in the fall and winter(3).
Control certain PMS and fibromylagia symptoms. Many women experience depression as their primary symptom of PMS (premenstrual syndrome). In such cases, St. John's wort may be worth a try. Take the herb regularly for this purpose, but be patient; it may take one or two menstrual cycles for the active ingredients to reach therapeutic levels in your system and lessen emotional upset. European women have been turning to this herbal PMS cure for years. In the case of fibromylagia, St. John's wort may not only ease depression but also improve tolerance to the widespread muscle pain associated with this chronic condition. In fact it's used in much the same way that conventional antidepressants are prescribed for fibromyalgia.
Ease anxiety, stress, and chronic pain. The depression and tension often associated with these conditions may lessen with St. John's wort.
Ward off infections. St. John's wort has been shown to have antibacterial and antiviral properties. It's particularly effective when applied topically (in the form of an ointment) for the treatment of burns, cuts, scrapes, and minor skin irritations(4,5). Some preliminary laboratory studies indicate that St. John's wort might also be useful against herpes simplex, influenza, and the Epstein-Barr virus (the cause of mononucleosis). Clinical trials are still needed to confirm these findings, however.
Relieve hemorrhoids. St. John's wort cream or ointment can soothe the pain of hemorrhoids. Burning and itching may lessen as well. The ointment may even help to shrink the inflamed and swollen tissue.
Forms tincture tablet softgel ointment cream capsule
Dosage Information
Special tip:
Although most clinical studies have been done using an extract standardized for hypericin, there seems to be some doubt as to what aspect of the herb is truly responsible for its clinical efficacy. Research findings indicate that a substance called hyperforin may even have more potent mood-enhancing properties than hypericin (6). For this reason, when treating depression, look for an extract standardized to contain 0.3% hypericin and hyperforin (3.0%).
For depression, PMS, and the majority of other ailments mentioned: Take 900 mg a day--either a 300 mg pill three times a day or a 450 mg pill twice a day. To avoid missing doses, you can also simplify the regimen by taking two 300 mg capsules in the morning and one in the evening (or vice versa). If using a tincture, follow the instructions on the bottle for dosage equivalence.
For fibromyalgia: Take 450 mg twice a day.
For skin infections and hemorrhoids: Apply St. John's wort ointment three or four times a day. Use an ointment when treating hemorrhoids, applying it several times a day and, when possible, directly after bowel movements. Be sure to check out our Dosage Recommendations Chart for St. John's Wort, which lists therapeutic dosages for specific ailments at a glance.
Guidelines for Use
St. John's wort takes some time to build up in the blood, so allow at least four weeks to see if it works for you. It can be used long term as needed.
Take St. John's wort with meals to reduce the risk of stomach irritation.
No foods are off limits for those taking St. John's wort, not even aged cheese and red wine, which are not recommended for those on MAO inhibitors.
To prevent the risk of adverse reactions to the herb, avoid making your own preparations of the plant. Stick to standardized supplements you can buy over the counter.
General Interaction
Although rare, serious adverse reactions have been reported from the combination of a conventional antidepressant, such as Prozac and Zoloft, with St. John's wort. Don't start taking St. John's wort without consulting your doctor.
Certain medications, such as tetracycline and fluoroquinolone antibiotics, can increase the skin's sensitivity to the sun, so avoid taking St. John's wort, which can also have this effect, at the same time. Consult your doctor for more information.
Because St. John's wort and oral contraceptives are broken down and used by the body in the same way, the effectiveness of the oral contraceptives may be compromised. Consult your doctor (7,8).
A study conducted by The National Institutes of Health (NIH) showed a significant interaction between St. John's wort and indinavir, a protease inhibitor drug used to treat HIV infection (9). It showed that taking St. John's wort at the same time as indinavir greatly reduced the effectiveness of indinavir. St. John's wort may also affect other protease inhibitors--such as saquinavir--in a similar manner. Caution is advised.
Because the herb's exact mechanism of action is still unclear, it's probably not wise to combine it with MAO inhibitors, medications prescribed for depression and Parkinson's disease.
Possible Side Effects
Side effects are uncommon but can include fatigue, dry mouth, dizziness, constipation, and upset stomach.
Some people experience increased sun sensitivity when taking St. John's wort, especially if they are exposed to the sun for long periods of time (10). Skin reactions in AIDS patients taking high doses of St. John's wort were so severe in one trial that many stopped participating. So while sun sensitivity is not a problem for most people at commonly recommended doses, be sure to contact your doctor if you develop an unexpected sunburn or rash after being in the sun(11,12).
Cautions
If you are taking prescription drugs check with your physician before beginning treatment with St. John’s wort. Studies are now underway to determine the effects of possible interactions between many commonly prescribed prescription medications and St. John’s wort (13,14,15,16).
Never stop taking prescription antidepressants (or even lower the dosage) without checking with your doctor first.
Serious allergic reactions to any food, herb or medication are always possible. Fortunately, such allergies to St. John's wort are extremely rare. However, if you do develop hives or wheezing after taking the herb, get immediate medical help.
Though no adverse effects have been reported in pregnant or lactating women using the herb, there have been few studies on this group, so caution is advised.
Discuss all herbal supplements you take with your physician prior to an operation. St. John’s wort may increase the metabolism of many drugs commonly prescribed in the post-operative period (17,18).
Preliminary studies show that St. John’s wort may have a negative effect on irinotecan as a treatment for cancer. You should fully discuss any herbal supplements you take with your physician prior to undergoing treatment (19).
References
1. Linde, K. and Mulrow, C. D. St John's wort for depression. Cochrane Database Syst Rev. 2000; (2):CD000448.
2. Friede, M.; Henneicke von Zepelin, H. H., and Freudenstein, J. Differential therapy of mild to moderate depressive episodes (ICD-10 F 32.0; F 32.1) with St. John's wort. Pharmacopsychiatry. 2001 Jul; 34 Suppl 1:S38-41.
3. Kasper, S. Treatment of seasonal affective disorder (SAD) with hypericum extract. Pharmacopsychiatry. 1997 Sep; 30 Suppl 2:89-93.
4. Schempp, C. M.; Hezel,S., and Simon, J. C. [Topical treatment of atopic dermatitis with Hypericum cream. A randomised, placebo-controlled, double-blind half-side comparison study].Hautarzt. 2003 Mar; 54(3):248-53.
5. Schempp, C. M.; Winghofer, B.; Ludtke, R.; Simon-Haarhaus, B.; Schopf, E., and Simon, J. C. Topical application of St John's wort (Hypericum perforatum L.) and of its metabolite hyperforin inhibits the allostimulatory capacity of epidermal cells. Br J Dermatol. 2000 May; 142(5):979-84.
6. Laakmann, G.; Schule,C.; Baghai, T., and Kieser, M. St. John's wort in mild to moderate depression: the relevance of hyperforin for the clinical efficacy. Pharmacopsychiatry. 1998 Jun; 31 Suppl 1:54-9.
7. Henderson, L., Yue, Q. Y.; Bergquist, C., Gerden, B., and Arlett, P. St John's wort (Hypericum perforatum): drug interactions and clinical outcomes. Br J Clin Pharmacol. 2002 Oct; 54(4):349-56.
8. Pfrunder, A.; Schiesser, M.; Gerber, S., Haschke, M.; Bitzer, J., and Drewe, J. Interaction of St John's wort with low-dose oral contraceptive therapy: a randomized controlled trial. Br J Clin Pharmacol. 2003 Dec; 56(6):683-90.
9. Hennessy, M.; Kelleher, D.; Spiers, J. P.; Barry, M.; Kavanagh, P.; Back, D.; Mulcahy, F., and Feely, J. St Johns wort increases expression of P-glycoprotein: implications for drug interactions. Br J Clin Pharmacol. 2002 Jan; 53(1):75-82.
10. Schempp, C. M.; Ludtke, R.; Winghofer, B., and Simon, J. C. Effect of topical application of Hypericum perforatum extract (St. John's wort) on skin sensitivity to solar simulated radiation. Photodermatol Photoimmunol Photomed. 2000 Jun; 16(3):125-8.
11. Schempp, C. M., Muller, K., Winghofer, B., Schulte-Monting, J., and Simon, J. C. Single-dose and steady-state administration of Hypericum perforatum extract (St John's Wort) does not influence skin sensitivity to UV radiation, visible light, and solar-simulated radiation. Arch Dermatol. 2001 Apr; 137(4):512-3.
12. Schempp, C. M., Winghofer, B., Muller, K., Schulte-Monting, J., Mannel, M., Schopf, E., and Simon, J. C. Effect of oral administration ofHypericum perforatum extract (St. John's Wort) on skin erythema and pigmentation induced by UVB, UVA, visible light and solar simulated radiation. Phytother Res. 2003 Feb; 17(2):141-6.
13. Brazier, N. C. and Levine, M. A. Drug-herb interaction among commonly used conventional medicines: a compendium for health care professionals. Am J Ther. 2003 May-2003 Jun 30; 10(3):163-9.
14. Markowitz, J. S. and DeVane, C. L. The emerging recognition of herb-drug interactions with a focus on St. John's wort (Hypericum perforatum). Psychopharmacol Bull. 2001 Winter; 35(1):53-64.
15. Ernst, E. The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. Ann Intern Med. 2002 Jan 1; 136(1):42-53.
16. Wang, L. S., Zhou, G., Zhu, B., Wu, J., Wang, J.G., Abd El-Aty, A. M., Li, T., Liu, J., Yang, T. L., Wang, D., Zhong, X. Y., and Zhou, H. H. St John's wort induces both cytochrome P450 3A4-catalyzed sulfoxidation and 2C19-dependent hydroxylation of omeprazole. Clin Pharmacol Ther. 2004 Mar; 75(3):191-7.
17. Ang-Lee, M. K.; Moss, J., and Yuan, C. S. Herbal medicines and perioperative care. JAMA. 2001 Jul 11; 286(2):208-16. 18. Kistorp, T. K. and Laursen, S. B. [Herbal medicines--evidence and drug interactions in clinical practice]. Ugeskr Laeger. 2002 Sep 2; 164(36):4161-5.
19. Mathijssen, R. H.; Verweij, J.; de Bruijn, P.; Loos, W. J., and Sparreboom, A. Effects of St. John's wort on irinotecan metabolism. J Natl Cancer Inst. 2002 Aug 21; 94(16):1247-9.
Ailments Dosage
ADHD 450 mg twice a day with food, if depression is also present.
Anxiety and Panic 300 mg 3 times a day or 450 mg twice a day
Chronic Fatigue Syndrome 450 mg twice a day or 300 mg 3 times a day
Chronic Pain 300 mg 3 times a day or 450 mg twice a day
Depression 300 mg 3 times a day (or 450 mg twice a day or 600 mg in the morning and 300 mg in the evening)
Fibromyalgia 450 mg twice a day or 300 mg 3 times a day with food
Hemorrhoids Apply oil or ointment 2 or 3 times a day, as needed.
High Cholesterol 450 mg twice a day for anxiety
Irritable Bowel Syndrome 450 mg twice a day or 300 mg 3 times a day
Memory Loss/Impairment 300 mg 3 times a day or 450 mg twice a day
Menopause 450 mg twice a day or 300 mg 3 times a day
Migraine 300 mg 3 times a day (or 450 mg twice a day or 600 mg in the morning and 300 mg in the evening)
Perimenopause 450 mg twice a day or 300 mg 3 times a day
PMS 300 mg 3 times a day (or 450 mg twice a day)
Stress 300 mg 3 times a day or 450 mg twice a day
Tobacco Dependence 300 mg 3 times a day (or 450 mg twice a day).
Weight Loss 450 mg twice a day
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