Women’s Health Update

by Tori Hudson, ND

Old Problems with New Research and Clinical Favorites from the Recent Past

Green Tea Catechins for Xerostomia (Dry Mouth)

The perception of dry mouth (known as xerostomia) affects up to 40% of adults in the U.S. and can have a significant effect on quality of life. Causes can include medications, diabetes, Sjögren’s syndrome and hormonal changes such as menopause. Previous animal and laboratory studies provided evidence that green tea polyphenols could be beneficial for xerostomia.

The current human study used a double-blind, placebo-controlled, randomized design comparing green tea to xylitol. The study involved 60 individuals (58 women and 2 men) with the complaint of dry mouth and had Sjögren’s syndrome meciated salivary gland hypofunction, with 30 taking the placebo and 30 the green tea medicine. The green tea proprietary formula contained green tea catechins and other ingredients (amounts not given, but Internet search reveals the following information: xylitol, sorbitol, natural flavors, green tea [leaf], acacia gum, jaborandi extract [leaf], magnesium stearate, silicon dioxide, sucralose). The placebo contained 500 mg xylitol and other nonplant ingredients. Participants took 1 lozenge every 4 hours for a maximum of 6 lozenges per day, over an 8-week period. Quality-of-life assessments and saliva collection with volume determined were used to evaluate response.

After 8 weeks of therapy, the xylitol-containing placebo failed to affect saliva output, while the green tea catechin-containing formulated resulted in a statistically significant increase in saliva output, with a 3.8-fold increase in unstimulated saliva output and 2.1-fold in stimulated saliva output, compared with baseline. This occurred within 1 week. Both groups experienced a quality of life scored demonstrating significant improvement with no significant difference between groups.

Comment

: Most commercial products for xerostomia contain xylitol, although it has not been known if xylitol does in fact play a role in saliva output. A xylitol chewing gum, a sorbitol-containing lozenge, and a xylitol-containing spray previously showed no efficacy in stimulating saliva in patients with xerostomia. A study using a maltose-containing lozenge found a potential benefit for xerostomia, and another with a 1% malic acid spray did show a modest increase in salivary flow rates. It is not clear why there is a discrepancy between salivary output increase in the treatment medication compared with placebo vs. the similar effects on subjective quality of life measures. A longer study with more participants would hope to clarify and produce greater results in the treatment group, not only in objective measures of salivary output but also in subjective quality-of-life values. Dry mouth is one of the stubborn complaints that I regularly hear reported in my clinical practice among menopausal women. I look forward to the use of this as another option to offer.

De Rossi S, Thoppay J, Dickinson D, et al. A phase II clinical trial of a natural formulation containing tea catechins for xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118:447–454.

D-Mannose and Chronic Recurring Urinary Tract Infections

This was a prospective, randomized controlled study comparing efficacy of daily D-mannose powder intake for preventing recurrent urinary tract infection. After initial antibiotic treatment of their acute cystitis, 308 women who met the criteria were randomly assigned to three groups. Group 1 received prophylaxis with 2 g daily of D-mannose powder in 200 ml of water for 6 months. Group 2 received 50 mg of nitrofurantoin daily for 6 months, and the third group did not receive either.

Criteria for study inclusion were > 18 years old and a positive history of recurrent cystitis (at least two episodes of acute cystitis in the last 6 months and/or 3 episodes of acute cystitis in the last year). The study included a total of 308 women with acute cystitis and a positive history for recurrent cystitis as defined above. Overall, 146 patients were postmenopausal. The most commonly isolated bacteria during the acute cystitis was Escherichia coli in 236 patients (76.6%). Patients were excluded if they were pregnant, breast-feeding, or trying to conceive; had history of a current upper urinary tract infection and symptoms of systemic inflammatory response (fever over 38 ºC, WBC >12,000), urinary tract anomalies, interstitial cystitis, diabetes, taking hormone therapy, or contraception; or had previously received prophylactic antibiotics.

The primary outcome was the number of UTIs following treatment with D-mannose or placebo. Overall, 31.8%, or 98, patients had a recurrent UTI with an average time of 30 days from starting their prophylaxis to the onset of symptoms. The onset of symptoms did not differ significantly between the prophylaxis therapy groups; that is, the D-mannose worked as well as the antibiotic. This included 15 (14.6%) in the D-mannose group, 21 (20.4%) in the nitrofurantoin group, and 62 (60.8%) in the no-prophylaxis group. Patients in the D-mannose group and the nitrofurantoin group had a significantly lower risk of recurrent UTI episode during the prophylaxis treatment period compared with those with neither prophylaxis strategy. This is an absolute risk reduction of 45% compared with the control group. The difference between D-mannose and nitrofurantoin was not significant. Patients in the D-mannose group had significantly lower risk of side effects during prophylaxis as compared with the nitrofurantoin group.

Comment

: The overall rate of UTI recurrence in prophylaxis groups (mannose or the antibiotic) was about 30% and about 60% in the no-prophylaxis group. Since about half of the patients in this study were postmenopausal, I can attest, through a robust amount of clinical experience in the area, that adding a vaginal estrogen regimen to the D-mannose (or the prophylaxis antibiotic) will greatly decrease the recurrence rate even more. One could point out that this study was not blinded or that researches did not calculate the total number of recurrences per patient.

D-mannose has been used by alternative-minded practitioners for some time, for this exact purpose. Until now, I believe there have not been any clinical trials, and the only evidence for this has been the supposed mechanism of action in inhibiting bacterial adherence to uroepithelial cells, in vitro experiments showing that D-mannose binds to the pili of enteric bacteria, blocking their adhesion to uroepithelial cells, and reduction in bacteria in the urine in animal models. Nonetheless, it has become quite a staple in treating chronic recurrent cystitis at least in women and used as a prophylaxis regimen along with other therapies known to inhibit adherence to uroepithelium, such as certain species of Lactobacillus, and other therapies, including vaginal estrogen, especially in postmenopausal women with this condition, cranberry extracts, berberine-containing plants, and more. The results of the current study provide clear evidence that D-mannose can be an effective prophylactic agent in preventing recurrent UTIs in women.

Kranjeec B, Papes D, Altarac S. D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol. 2014;32:79–84.

Grape-Seed Extract Effect on Menopause Symptoms and More

The most common perimenopause and menopause symptoms are vasomotor symptoms, a.k.a. hot flashes and/or night sweats. In addition to having numerous perimenopause/menopause symptoms, postmenopausal women in particular are at increased risk for cardiovascular disease, dyslipidemia, hypertension, and type 2 diabetes. Plant compounds such as French maritime pine bark extract (Pycnogenol) that are rich in proanthocyanidins have been used in three studies to alleviate menopause symptoms such as vasomotor symptoms. Because of these studies and an analysis showing that grape seeds are even richer in proanthocyanidins, researchers have conducted and published a study examining the effects of grape-seed extract/proanthocyanidin on menopause symptoms, body composition, and cardiovascular markers.

A randomized, double-blind, placebo-controlled study was conducted in almost 100 premenopausal, perimenopausal, and menopausal women between 40 and 60 years old. The average age was 49 to 59 years, with 40% to 48% premenopausal women, 52% to 60% perimenopausal, postmenopausal, or surgically menopausal. Women were randomized to receive grape-seed extract tablets that contained either 100 or 200 mg/day of proanthocyanidins or placebo for a total of 8 weeks. Menopause symptoms were evaluated using the Menopausal Health-Related Quality of Life Questionnaire, the Hospital Anxiety and Depression Scale, and the Athens Insomnia Scale before the start of treatment as well as after 4 weeks and 8 weeks of treatment.

Significant changes were observed in hot flashes, anxiety, insomnia, increased muscle mass, and reduced blood pressure. The average physical symptom score for the nine items in the physical-health domain of the Menopause Health Related Questionnaire significantly improved in the high-dose grape-seed extract group after 8 weeks, as did the mean score for hot flashes. The mean depression score did not improve in any of the groups, but the anxiety subscale score improved in both the 100 mg and 200 mg groups and was significantly better in the higher-dose group than in the placebo. Mean body weight and fat mass did not change in any of the groups, but the mean lean mass and muscle mass increased significantly in both the 100 mg and 200 mg grape-seed extract groups. Lastly, the mean systolic and diastolic blood pressure was significantly reduced in both the 100 g and 200 mg groups and after as soon as 4 weeks. The mean systolic and diastolic blood pressure decreased by about 5 mm Hg with both doses after 8 weeks.

Comment

: The menopause studies using pine bark demonstrated positive results in improving menopause symptoms at all three different doses tested in each of the studies, 60, 100, and 200 mg. Similarly, in the current study, the two doses of grape-seed extract (100 and 200 mg) both worked well for hot flashes, although the 200 mg dose was clearly better than the 100 mg dose in the anxiety subscale. This study appears to be the first report of proanthocyanidins’ affecting body composition, increasing muscle mass with both doses. The positive effect on blood pressure using proanthocyanidins, including those in grape-seed extract, is not a new finding. I have been using pine bark extract for vasomotor symptoms in perimenopause and menopause women for the past several years, with mixed results. I am intrigued by the current study and look forward to using grape-seed extract in these two doses as another nonhormonal option, especially in women who not only need vasomotor symptom relief but are also struggling with overweight and prehypertension or stage I hypertension.

Terauchi M, Horiguchi N, Kajiyama A, et al. Effects of grape seed proanthocyanidin extract on menopausal symptoms, body composition, and cardiovascular parameters in middle-aged women: a randomized, double-blind, placebo-controlled pilot study. Menopause. 2014;21(9):990–996.

Melatonin and Endometriosis

A randomized, double-blind, 2-group, parallel clinical trial conducted in Brazil comparing the effects of melatonin with a placebo on endometriosis-associated pelvic pain, brain-derived neurotrophic factor (BDNF) level, and sleep quality. Participants were randomized into melatonin (10 mg/day; n = 20), or placebo (n = 20) groups for 8 weeks.

Forty women with chronic pelvic pain, who were between 18 and 45 years old, were recruited from gynecology outpatient clinics. Chronic pelvic pain was defined as a moderate to severe pain lasting for more than 6 months and eliciting pain scores of at least 4 or greater on a 10-point pain scale that required regular analgesic use. All participants had a diagnosis of endometriosis as confirmed on laparoscopy and included patients with any stage from 1 to 4. Three patients in the melatonin group and 1 in the placebo group withdrew due to treatment inefficacy.

The primary outcome of the trial was pain, as assessed by pain score diaries within the last 24 hours, painful menstrual periods, or dyspareunia, as well as the amount of analgesic used each week throughout the treatment period and the level of BDNF. Secondary outcomes were pain during urination or defecation and sleep quality.

Results:

The melatonin group had significantly lower pain visual analogue scale (VAS) scores than the placebo-treated group, with a mean pain reduction of 39.3% in the melatonin group vs. the placebo group. The melatonin group also had significantly lower pain scored during menstruation, with mean reduction in analgesic use of 42.2% patients in the placebo group and 22.9% in the melatonin group. The placebo group was 80% more likely to require additional analgesics than the melatonin group. In the placebo group, acetaminophen was used by 66.7%, NSAIDs by 60%, and codeine or tramadol by 60%. In the melatonin group, 33.3% used acetaminophen, 40% used tramadol or codeine, and 35% used NSAIDs.

The adjusted mean BDNF level for the placebo group was 25.64 vs. 20.46 for the melatonin group with a mean difference of 5.94, which is significant; and the authors concluded that the effect of treatment on the BDNF level is not dependent on the pain level. This suggests that melatonin has a direct effect on pain pathways or on the levels of chemicals that are signals for pain. Patients in the melatonin group had better sleep quality than those in the placebo group, and melatonin produced a mean improvement of 42% in how patients felt upon waking in the morning.

Commentary: This study demonstrated that melatonin at 10 mg/day reduces endometriosis-associated chronic pelvic pain, including a reduction in pelvic pain, dysmenorrhea, dyspareunia, dysuria, and dyschezia (pain during defecation) that is statistically and clinically significant. This reduction in pelvic pain due to melatonin was of a magnitude >35% overall, as well as an 80% reduction in analgesic use.

This study is consistent with evidence from animal studies in which melatonin caused regression and atrophy of endometriotic lesions. The current study also corroborates other randomized clinical trials on melatonin and pain in treating fibromyalgia and acute postoperative pain.

The mechanisms of action may include the antinociceptive effect of melatonin involving the activation of supraspinal sites and the inhibition of spinal windup. Other experimental evidence suggests that the analgesic effects of melatonin are mediated by opioids and GABA and anti-inflammatory effects by inhibiting the release of cytokines. The effect of melatonin on chronic endometriosis-associated pelvic pain may also be explained by its effect on diverse hormonal pathways.

Melatonin is well tolerated by most patients and appears to represent an effective option for pain symptoms related to endometriosis. A 2013 observational study on N-acetylcysteine also resulted in significant reduction of pain and size of ovarian cysts associated with endometriosis. I consider the two nutrients mainstays in our treatment strategies for endometriosis.

Schwertner A, Conceicao dos Santos C, Costa G, et al. Efficacy of melatonin in the treatment of placebo endometriosis: A phase II, randomized, double-blind, placebo controlled trial. Pain. 2013;154(6):874–881.

Clinical Favorites from the Recent Past

Several nutritional supplements and botanicals have made their way into a dominant place in my women’s health practice in 2014. Whether studies were published in 2013 or 2014 or even earlier, these natural agents have come to play a reliable role in my women’s health practice of the last 30 years and in some of the most challenging cases in women’s health. I’ve written about many of these in past Townsend Letter columns, but the purpose here is to emphasize their role and to encourage others to incorporate them more widely in women’s health.

Valerian/Lemon Balm in Menopausal Sleep Problems

The purpose of this study was to determine whether a combination of valerian/lemon balm could improve sleep problems in menopausal women. A total of 100 postmenopausal women aged 50 to 60 years with sleep disorders were studied. Women were selected randomly after fulfilling the entrance criteria. The Pittsburgh Sleep Quality Index (PSQI) questionnaire was completed to assess the status of their sleep disorder in the month prior. The PSQI consists of various measurements, including general description of individual sleep quality and patterns, delay in the onset of sleep, sleep duration and pattern as well as waking in the night, use of tranquilizers, and daily performance problems due to lack of sleep. A score of 5 or greater constitutes a sleep disorder and the 100 women selected were those with a scoring. Women were randomly divided into two groups, with 50 in the herbal treatment group, which received two capsules containing 160 mg of valerian and 80 mg of lemon balm, and 50 in the control group, which received capsules containing starch. Participants and investigators and the statistician were all blinded. The duration of the intervention was one month and then followed by another PSQI questionnaire.

One month following use of the valerian/lemon balm supplement, 36% of the treatment group and 8% of the placebo group showed an improvement in the quality of their sleep. Sleep disorder scores decreased by 5 points, which was statistically significant.

Comment

: Perimenopausal and menopausal women are faced with hormonal changes that can result in not only nighttime hot flashes that can disrupt sleep, but lengthened time it takes to fall asleep, frequent awakenings, waking and poor return to sleep, early morning waking, and nonrestorative sleep. Botanical options that can improve any or all aspects of sleep disruption are an important part of a comprehensive approach to treating this. However, addressing sleep disorders in this population usually also involves strategies that target the fundamental issue, which is hormonal changes and the impact on neurotransmitters, cortisol, stress adaptation, and sleep cycle physiology.

In 2011, another study of valerian and insomnia was published. The participants were generally healthy women aged 50 to 60 years who were menopausal for at least 1 year, not using hormone therapy, and experiencing insomnia. One group was given capsules containing 530 mg of concentrated valerian extract twice per day and the other group placebo, twice per day, for 4 weeks. A statistically significant change was reported in the quality of the sleep in the valerian group when compared with the placebo group. The average scored on the sleep scale before valerian was 9.8 and after valerian it was 6.02. The placebo group had an initial average sleep scale score of 11.1 and after placebo, 9.4. Overall, 30% of the women taking valerian and 4% taking placebo reported an improvement in their sleep quality.

Although not all research on valerian and insomnia has shown positive results, these two studies bring more focus to using valerian in menopausal women for sleep disorders.

Taavoni S, Ekbatani N, Kashaniyan M, Haghani H. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011;18(9):951–955.

———. Valerian/lemon balm use for sleep disorders during menopause. Complement Ther Clin Pract. 2013;19:193–196.

Oral Lavender Essential Oil in Generalized Anxiety Disorder

This randomized, double-blind, placebo-controlled trial investigated two doses of oral lavender essential oil in comparison with a selective serotonin reuptake inhibitor, paroxetine, in patients who have been diagnosed with generalized anxiety disorder (GAD). The primary outcome of this study was the effect of lavender essential oil in comparison with placebo, on GAD, as measured by the Hamilton Anxiety Scale (HAMA) total score. This scale assesses 14 symptoms of anxiety through a scale ranging from 0 (absent) to 4 (severe). The secondary outcome was the effect of lavender essential oil compared with paroxetine on GAD.

A total of 616 patients were recruited and then 536 patients randomized to treatment. These were men and women, between ages 18 and 65 year old, from 57 general practice and psychiatric practices in Germany, who had a diagnosis of moderate to marked severity of GAD for an average of 2.5 years. Inclusion criteria were those individuals with a HAMA score of ≥18, and with scores for anxious mood and tension symptoms of 2 or greater, in addition to a score of 21 or less for psychic anxiety. An additional anxiety scale was used as well, the Cover Anxiety Scale (CAS), and the inclusion criteria were those with a score of 9 or greater. Individuals with any additional psychiatric illnesses were excluded. Psychiatric medications other than the paroxetine were not allowed during and for 30 days prior to entering the study. A total of 128 were in the 160 mg lavender group, 135 in the 80 mg/day group, 137 in the paroxetine group, and 136 in the placebo group.

Individuals were given a lavender essential oil made from the steam-distilled fresh flowering top of lavender that has then been standardized to contain approximately 70% of two constituents, linalool and linalyl acetate. The product was given as either a 80 or 160 mg dose and then 1 placebo or 2 placebo pills daily. The paroxetine was given in capsules of 20 mg. Treatment was given for 10 weeks, and measurements of safety and efficacy were done at 2, 4, 6, 8, and 10 weeks. During a week of “down-titration” following the study, patients on the paroxetine took the treatments every other day to account for any withdrawal problems caused by paroxetine. Patients in the lavender essential oil group took placebo.

After 4 weeks of the study and at other time points, the intake of 160 mg/day of lavender essential oil resulted in a significantly greater change in the HAMA score compared with placebo (p < 0.01). After 6 weeks and beyond, those taking the 80 mg/day of lavender essential oil had a significantly greater change in the HAMA scores compared with placebo (p = 0.02). At week 6, the HAMA score in those taking paroxetine approached significance (p = 0.06) but then were not significantly better than placebo after that point.

Significantly more patients in the 160 mg/d lavender group showed an improvement in the HAMA score of 50% or more compared with the placebo group (60.3% vs. 37.8%). This was also observed in the 80 mg/d group (51.9% vs. 37.8%). The HAMA score was <10 in significantly more of those patients taking the lavender product compared with the placebo (46.3% vs. 29.6%). According to the clinical global impression (CGI), all three treatment groups (the 80 mg/day, 160 mg/day, and paroxetine) contained a greater percentage of patients who were “much/very much improved” or had a “moderate/marked” therapeutic effect as compared with the placebo group. The adverse events reported were 25% of those in the 160 mg/day lavender group, oddly higher of 34.8% in the 80 mg/day group, 40.9% in the paroxetine group, and 30.9% in the placebo group. These adverse events were reported as gastrointestinal disorders, infections, and nervous system problems.

Comment

: Both doses of oral essential oil of lavender were effective in treating GAD and more effective than the conventional medicine, paroxetine. Adverse events in those taking lavender were similar in those taking placebo and lower than those taking paroxetine. This is another welcomed positive study in using an oral lavender essential oil standardized to linalool and linalyl acetate in the treatment of GAD. Conventional medications, whether antidepressants, anxiolytics, or barbiturates, are fraught with side effects, which makes the lavender essential oil product that much more appealing.

Kasper S, Gastpar M, Müller WE, et al. Silexan is effective in generalized anxiety disorder – a randomized, double-blind comparison to placebo and paroxetine. Int J Neuropsychopharmacol. Epub January 23, 2014:1–11. doi:10.1017/S1461145714000017.

N-Acetylcysteine and Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in reproductive-aged women, with multiple manifestations and consequences. It affects approximately 6% to 10% of reproductive-aged women, and the metabolic disturbances associated with it have immediate and long-term potential outcomes, including infertility, hyperandrogenism, type 2 diabetes, cardiovascular disease, and even uterine cancer.

Insulin-sensitizing agents have emerged as an important strategy in addressing the fundamental underlying cause of PCOS, insulin resistance. In conventional medicine, the focus has been on metformin, an insulin-sensitizing agent and can decrease the levels of insulin, improve glucose tolerance, increase sex hormone binding globulin (SHBG), decrease circulating androgens, and increase ovulation rates in women with PCOS. N-acetylcysteine (NAC) is used by many alternative practitioners as a mucolytic medication and antioxidant effects. Lesser known is its role as an insulin regulatory agent. And previous studies have shown that it can improve circulating insulin levels and insulin sensitivity in hyperinsulinemic women with PCOS as well as being used successfully as an adjunct treatment with clomiphene citrate for ovulation in women with PCOS.

The purpose of the study reported on here was to evaluate the effects of metformin and NAC in patients with PCOS. This prospective trial randomly divided 100 women to receive either metformin, 500 mg t.i.d. or NAC 600 mg t.i.d. for 24 weeks. Evaluations included hirsutism scoring, body mass index, serum samples for follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone-sulfate (DHEAS), 17 OH-progesterone, total testosterone, free testosterone, androstenedione, thyroid stimulating hormone (TSH), SHBG, prolactin, glucose tolerance tests (including glucose and insulin), tumor necrosis factor-alpha (TNF-alpha), and lipids.

Women were ages 17 to 38, and 75 of the 100 women with PCOS completed the study. All women in the NAC group completed the study and 5 of the 35 women in the metformin group did not complete the study. At baseline, there were no differences between the treatment groups. Following treatment, LH, total testosterone, and free testosterone decreased significantly and SHBG increased significantly in both groups. Hirsutism improved significantly in both groups, and the difference between the metformin group and NAC group was not significant. Menstrual regularity was restored in 9 patients in the metformin group and 11 patients in the NAC group (36% vs. 34 %), and both metformin and NAC women significantly improved menstrual irregularity. In the metformin group, total serum cholesterol levels were significantly lowered, but no significant changes were observed in LDL, triglycerides, and HDL. In the NAC group, total cholesterol and LDL decreased significantly, but no changes were observed in triglycerides and HDL. The changes in lipid profiles between the two groups were not significant.

Both metformin and NAC had positive effects on reducing fasting insulin levels, without change in fasting glucose, but this means that glucose-insulin rations were increased significantly following treatment with both medicines and, in addition, both led to a significant improvement in the HOMA (homeostatic model assessment) and were considered comparable. TNF-alpha levels were increased in both groups but not significant from baseline and similar in both groups.

Comment

: Conventional medical treatments for PCOS have come to include a combination of hormonal contraceptives, progestins, statins, and insulin-sensitizing agents, especially metformin. This combination of treatments has not clearly led to adequate prevention of consequences of PCOS such as cardiovascular disease and type 2 diabetes and insufficient treatment of anovulatory infertility, hirsutism, and weight management in those PCOS women who are overweight/obese. In addition, these approaches are fraught with side effects, and for metformin this typically includes gastrointestinal symptoms that can lead to intolerance of the drug, as it did with the high dropout rate in the metformin group in the current study. However, metformin has been a very important addition to PCOS management and two systemic reviews have shown that metformin reduces menstrual irregularity and improves ovulation rates, although has poor impact on hirsutism.

A treatment such as NAC is a welcomed addition to improve insulin sensitivity in the management of PCOS. It turns out to be very well tolerated with no adverse effects. In the current study, both metformin and NAC reduced menstrual irregularity, resulted in regression of hirsutism, and reduced hyperinsulinemia in women with PCOS. In the current study, there were also significant reductions in free testosterone and total testosterone in both groups, likely due to decreasing insulin levels and increasing SHBG levels, and decreases in total cholesterol and insulin, which bodes well for long-term prevention issues as they relate to cardiovascular disease and type 2 diabetes.

Oner G, Muderris I. Clinical, endocrine and metabolic effects of metformin vs N-acteyl-cysteine in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2011;159:127–131.

Dr. Tori Hudson graduated from the National College of Naturopathic Medicine (NCNM) in 1984 and has served the college in many capacities over the last 28 years. She is currently a clinical professor at NCNM and Bastyr University; has been in practice for over 28 years; and is the medical director of the clinic A Woman’s Time in Portland, Oregon, and director of research and development for Vitanica, a supplement company for women. She is also a nationally recognized author, speaker, educator, researcher, and clinician.