Women’s Health Update

by Tori Hudson, ND

New Clinical Options in Women’s Health

N-Acetylcysteine and Trichotillomania

Trichotillomania is considered an obsessive-compulsive disorder characterized by the repetitive pulling of the hair. There is currently no FDA-approved treatment for trichotillomania, and there have been only 6 published small placebo-controlled trials of pharmacological agents.

Dysfunction in the glutamate system has been implicated in the pathogenesis of obsessive-compulsive disorder, including trichotillomania. In a 12-week, double-blind, placebo-controlled trial (Grant et al.), 45 women and 5 men with the condition were randomly assigned to N-acetylcysteine (NAC) or placebo. Participants were at first given NAC 1200 mg/day or a placebo for 6 weeks. At the end of 6 weeks, the dose was increased to 2400 mg/day for another 6 weeks, unless hair-pulling had completely ceased for the previous 3 week period. Eighteen individuals (72%) in the NAC group were given the dose increase, 22 patients (88%) in the placebo group received the increased dosage of placebo. Patients were evaluated using the Trichotillomania Diagnostic Interview, and severity of trichotillomania was reported using the self-rated Massachusetts General Hospital Hair Pulling Scale (MGH-HPS). Investigators used the Psychiatric Institute Trichotillomania Scale (PITS). Anxiety symptom severity was rated using the Hamilton Anxiety Rating Scale (HAM-A), depression was assessed using the Hamilton Depression Rating Scale (HAM-D), psychosocial functioning was evaluated using the Sheehan Disability Scale (SDA), and quality of life was evaluated with the Quality of Life Inventory. Participants were seen every 3 weeks for 12 weeks.

Results

: Those receiving NAC had a significantly greater reduction in hair-pulling symptoms using the MGH-HPS scale (P < .001) and the PITS scale (P = .001). Fifty-six percent of patients reported “much or very much improved” with NAC compared with 16% taking placebo. Significant improvement was first detected after 9 weeks of NAC. Of those receiving NAC, 44% (n = 11) had a 50% or greater reduction in the MGH-HPS compared with 0% in the placebo group. Improvement in the CGI scale score was also significant by the end of the 12 weeks. However, NAC did not show a greater response than placebo in psychosocial functioning. Although there was an improvement in functioning and quality of life to a greater extent than placebo, neither the SDS total score nor the Quality of Life Inventory score was significantly different between NAC and placebo.

Comment

: As most readers know, NAC is an amino acid, and it is a known glutamatergic modulator, shown in other studies to be useful for repetitive or compulsive disorders. NAC is converted to cystine and allows for the uptake of cystine, a substrate for the glutamate-cystine antiporter causing the reverse transport of glutamate into the extracellular space. This then stimulates inhibitory glutamate receptors and thus reduces the release of glutamate from the synapses. By restoring the extracellular glutamate concentration, this seems to block compulsive behaviors. While there was a robust group of NAC nonresponders, the positive results show at least a way of trying to help these folks, while still needing to look for individualities in patients and other psychiatric coexisting disorders that may preferentially respond to serotonergic agents or other interventions. I have rarely seen trichotillomania in my 26-year practice, but the next time I do, I will remember this treatment.

Grant J, Odlaug B, Won Kim S. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania. Arch Gen Psychiatry. 2009;66(7):756–763.

Combination Botanical for Menopause Symptoms

A proprietary product called Nutrafem is a combination of botanical extracts derived from Vigna radiate (mung beans) and Eucommia ulmoides bark. A phase II, double-blind, randomized, placebo-controlled, multicenter clinical study was conducted with 159 postmenopausal women who had at least 21 hot flashes per week. Of these, 131 women completed the study. One group received the product containing 75 mg of E. ulmoides plant extract and 150 mg of V. radiate plant and were given 2 capsules morning and night for 12 weeks; the other, placebo.

Results

: The botanical combination reduced the number of vasomotor symptoms by 46% from baseline compared with 26% in the placebo group. Forty-three percent of women taking the botanical had at least a 50% reduction in the number of symptoms compared with only 6% in the placebo group.

Comment

: New options in botanical interventions for menopause-related hot flashes are always welcomed. Mung beans are familiar to many as a dietary source of nutrients, whether in sprouted form or other use. They are typically consumed for their protein and essential fatty acid content. E. ulmoides is rich in polyphenolic compounds such as lignans and flavonoids. I look forward to continued research on botanical therapies for menopause symptoms and the ability to expand our treatment options.

Garcia J, Gonzaga F, Tan D, et al. Use of a multibotanical (Nutrafem) for the relief of menopausal vasomotor symptoms : a double-blind, placebo-controlled study. Menopause. 2010;17(2):303–308.

Vitamin C and Antibiotics for Chlamydia

First-line therapy for cervical chlamydia infection is typically an oral antibiotic. Chlamydial cervicitis is characterized by erythema, edema and friability of the cervix, purulent yellow or green endocervical discharge, and dyspareunia.

A randomized, double-blind trial was done to compare the effect of vitamin C on dyspareunia and vaginal discharge in women being treated with oral doxycycline and triple sulfa vaginal cream for chamydial cervicitis.

Eighty women with signs of chlamydia and a positive C. trachomatis IgM result were included in this study. Thirty-nine women received doxycycline capsules 100 mg twice daily plus triple sulfa vaginal cream once daily for 10 days, and 41 received oral doxycycline capsules 100 mg twice daily and triple sulfa vaginal cream once daily plus vitamin C tablets 250 mg once daily for 10 days.

Results

: Before treatment, most of the women in both groups had a mucopurulent discharge. After treatment, the majority of women in the vitamin C tablet group plus the oral and vaginal antibiotics were cured, and there was a statistically significant difference in the discharge compared with placebo (P = 0.005), 22.2% in the vitamin C group vs. 43.2% in the antibiotic-only group. Women receiving the vitamin C tablet plus antibiotics showed more improvement in dyspareunia severity compared with the antibiotic-only group (P < 0.001), 8.3% in vitamin C group vs. 29.7% in the antibiotic-only group.

Comment

: To my knowledge, this is the first study investigating vitamin C as an adjunct to antibiotics for the treatment of chlamydial cervicitis. It appears that the vaginal vitamin C tablet improves the outcomes of the oral and vaginal antibiotics. This should not really be surprising in that vitamin C has a role as an antioxidant on the immune response, phagocyte function, T-cell proliferation, and production of inflammatory cytokines. It is also a cofactor for collagen synthesis and repairing connective tissue. A 250 mg vitamin C tablet inserted in the vagina for 10 days while using oral and vaginal antibiotics for chlamydia is a simple way to improve response to conventional treatment. I will likely extrapolate this study to the use of concomitant vaginal vitamin C tablets in bacterial vaginosis – a condition I see much more often than chlamydial cervicitis.

Khajehei M, Keshavarz T, Tabatabaee H. Randomized double-blind trial of the effect of vitamin C on dyspareunia and vaginal discharge in women receiving doxycycline and triple sulfa for chlamydial cervicitis. Aust N Z J Obtet Gynaecol. 2009;49:525–530.

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 25 years. She is currently a clinical professor at NCNM and Bastyr University, has been in practice for 25 years, and is the medical director of the clinic A Woman’s Time in Portland, OR, 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.