Each month the endometrium becomes inflamed, and the luminal portion is shed during menstruation. Aberrations in menstrual physiology can lead to common gynecological conditions, such as heavy or prolonged bleeding. Menstrual dysfunction is defined in terms of bleeding patterns, for example, amenorrhea, menorrhagia or polymenorrhea; ovarian dysfunction for example, anovulation and luteal deficiency; painful menstruation and premenstrual syndrome. Certain characteristics of menstruation can be a reflection of an underlying pathologic process or may predispose a woman to the development of chronic disease. For example, metrorrhagia predisposes to anemia, and the irregular menstrual cycles associated with PCOS (see PCOS) can predispose a woman to infertility, diabetes and consequently, heart disease.
What is it, in this age of life-saving antibiotics, hormonal therapy, surgeries and other seemingly miraculous medical therapies that causes so many individuals to seek therapies outside of conventional medicine? Conventional medicine may be at its best when treating acute crises, but for the treatment of chronic problems it may fall short of offering either cure or healing, leading patients to seek out systems of treatment that they perceive as addressing the causes of their problem, not just the symptoms. According to WHO, experience has shown that there are real benefits in the long term use of whole medicinal plants and their extracts, since the constituents in them work in conjunction with each other. Globally, it is estimated that 70% of all health care is provided by traditional, nonconventional medicine. Vitex agnus castus or chaste tree is one such herb which has a long history of use for common gynecological complaints.
Keywords:Vitex agnus castus; Menstrual cycle irregularities; PMS; Hyperprolactinemia; Non Hormonal
The menstrual cycle is one of the most exquisite displays of biological rhythm. It is a fascinating combination of positive and negative feedback controls involving the hypothalamus, pituitary, thyroid, adrenals, ovaries and uterus .
The actual centre of control is the hypothalamus, which produces a gonadotropin releasing hormone (GnRH) that stimulates the anterior pituitary to release the gonadotropins follicle stimulating hormone (FSH) and luteinizing hormone (LH). Pulsatile secretion of GnRH is necessary for the pituitary to respond with adequate production of LH and FSH .
FSH is the primary hormone responsible for the maturation of follicles into fertile ova and the increased production of estrogen by the ovaries. LH causes release of the ovum, conversion of the
follicle into the corpus luteum, and the subsequent production of progesterone .
At mid-cycle, estrogen is at its peak and progesterone begins
to rise. It is at this point that FSH levels decrease and LH levels
surge to cause ovulation. In the ovary, the corpus luteum produces
progesterone. This hormone ensures sufficient blood supply to
the endometrium so that the fertilized ovum can establish itself
in the uterus. If fertilization does not occur, the corpus luteum
recedes, hormone production decreases, the endometrium is not
sufficiently supplied with blood and menses occurs. FSH and LH
levels decline until menses and the beginning of a new menstrual
cycle (Figure 1) .
Excessive or inappropriately timed bleeding from the vagina
is one of the most common complaints for which women seek
advice from medical healthcare providers . 92% of women in
India suffer from gynecological problems. In a study conducted
among the women of rural India, 60.6% were having menstrual
diseases as one of the common gynecological diseases .
One of the major issue encountered during surveys have been
underreporting. Bang et al found that only 7-8% of the women
had ever had a gynecological examination in the past, even
though 55% were aware of having gynecological disorders .
Normal menstruation requires integration of the hypothalamicpituitary-
ovarian axis with a functional uterus, a patent lower
genital outflow tract and a normal genetic karyotype of 46XX .
Cyclic symptoms in women of reproductive age have been
recognized for thousands of years. Premenstrual syndrome
(PMS) is one of the most common disorders of women of
reproductive age. The incidence of PMS peaks among women
age 30 to 40, but studies have shown that adolescents frequently
suffer the effects of PMS as well .
Hyperprolactinemia is a common endocrine disorder of
hypothalamic-pituitary ovarian axis affecting the reproductive
functions . Prevalence of mastalgia is highly variable and
reported with a rate of 51-54% in adult Indian urban population
. Prevalence rate of various menstrual abnormalities is
depicted below in Figure 2.
Various underlying disease conditions like hypothyroidism,
pituitary adenoma, PCOS, hyperprolactinemia, drug induced
(dopamine antagonists like antipsychotics, antidepressants etc.)
can lead to menstrual cycle irregularities. Hormonal imbalance
due to various underlying causes is one of the major etiologies
behind menstrual cycle irregularities (Figure 3).
PMS is a psycho-neuroendocrine disorder of unknown
etiology, often noticed just prior to menstruation. There is cyclic
appearance of large number of symptoms during the last 7-10
days of the menstrual cycle.
Prolactin is a peptide hormone produced by the anterior
pituitary gland that is primarily associated with lactation and
plays a vital role in breast development during pregnancy .
Prolactin inhibits GnRH (gonadotropin releasing hormone)
pulse secretion. Gonadotropin levels are suppressed.
Hyperprolactinaemia inhibits ovarian steriodogenesis
Hyperprolactinaemia causes secondary amenorrhea in about
30% of women. There is anovulation and hypogonadotropic
Hypoestrogenism with anovulatory infertility and a decrease
in menstruation, amenorrhea, menstrual irregularities, women
who are not pregnant or nursing may begin producing breast
milk, loss of libido, breast pain, vaginal dryness.
a) Hormonal/OCTs/COCs (Progesterone alone or
combination with estrogen): Possibility of unwanted
‘premenstrual symptoms’ including (bloating, oedema,
headache, depression and reduced libido), Irregular
breakthrough bleeding, development of blood clots, gall
bladder disease .
b) Androgens (Danazole): Weight gain, deepening of voice
& Monitor lipid profile and liver function .
c) Dopamine agonists (Bromocriptine, Cabergoline): 28-
55% have reported of nausea, vomiting, abdominal pain,
headache, postural hypotension, dizziness, drowsiness
Botanical treatment can provide treatment and support
for numerous fertility-related problems, such as hormonal
dysregulation, thyroid and adrenal disorders, genitourinary
infections, immune dysregulation, and stress-related problems
with hormone like effects and minimal side effects .
Vitex agnus castus is one such herb which has a long history
of use for gynecologic complaints. Chaste berry should be
considered a first-line botanical therapy for infertility associated
with secondary amenorrhea, hyperprolactinemia, and luteal
insufficiency . It is approved in various European countries
since year 1968 for various indications like: menstrual cycle
irregularities, PMS, Mastalgia.
Vitex agnus castus, also known as chaste tree, is a shrub with
finger-shaped leaves and slender violet flowers. Vitex agnus
castus grows in creek beds and on river banks in valleys and
lower foothills in the Mediterranean and Central Asia .
In an observational study conducted on 211 females with
complain of Polymenorrhea, Oligomenorrhoea, Amenorrhea,
Dysmenorrhea, Menometrorrhagia; the use of 20mg VAC for 3
menstrual cycles has shown improvement in menstrual cycle
irregularities among 79-85% also 60-88% females showed
improvement in menstrual bleeding disorders .
Another study conducted on 2,447 women with a variety
of menstrual problems, use of VAC has shown improvement
in symptoms by both patients and physicians. Also the safety
profile of herb was excellent with only 2.3% reporting minor
side effects .
In a randomised active controlled study conducted on 80
females with hyperprolactinemia and cyclic mastalgia, efficacy of
both drugs (VAC and bromocriptine) was assessed by measuring
serum prolactin levels on day 5-8 of menstrual cycle and pain
severity for mastalgia was evaluated using visual analog scale
(VAS) . (Figure 6&7) Multicentric trial of VAC conducted on
1634 patients with symptoms of PMS demonstrated decrease
in number of symptoms by 93% females in turn qualifying the
efficacious and safe use of herb in females with PMS symptoms
In a double blind study conducted on 80 female students
with primary dysmenorrhea, authors had tried to evaluate the
efficacy of VAC, mefenamic acid and placebo for duration of 3
menstrual cycles. Severity of dysmenorrhea was assessed using
pain severity measurement tool. Menstrual pain severity was
lower with VAC as compared to mefenamic acid and placebo 
When compared with analgesics (NSAID), hormones, or SSRi
(selective serotonin reuptake inhibitors), which help only in
symptom alleviation, VAC is an effective treatment for relieving
not only the physical but also the mental symptoms of PMS
In a randomized controlled trial conducted in 100 infertile
cases with PCOS, females were randomised to either clomiphene
citrate or combination of VAC and clomiphene citrate to evaluate
the pregnancy rate. Pregnancy rate encountered in group
receiving clomiphene citrate plus VAC was 60% while only 30%
was observed clomiphene citrate group which confers that the
pregnancy rate can be doubled by adding VAC to conventional
therapy while treating infertile females .
In spite of the significance of menstruation in women’s lives
and the high incidence of menstrual related health problems
in society, there is surprisingly little epidemiologic evidence
on menstrual disorders and associated risk factors. Certain
characteristics of menstruation can be a reflection of an
underlying pathologic process or may predispose a woman to
the development of chronic disease. For example, Metrorrhagia
predisposes to anemia, and the irregular menstrual cycles
associated with PCOS (see PCOS) can predispose a woman to
infertility, diabetes and consequently, heart disease .
Each treatment option has overt and hidden costs, including
emotional, physical, and financial burdens, often without
justification because of lack of successs . Oral progestogens
are the most widely used medical treatment for dysfunctional
uterine bleeding (DUB)/ menstrual cycle irregularities. Despite
this, their efficacy is poorly established, both for ovulatory and
anovulatory . Disadvantages of hormonal therapy arises the
need of alternative treatment with similar or better efficacy and
Vitex agnus castus being non-hormonal therapy has
been used for centuries in menstrual cycle irregularities,
hyperprolactinaemia & premenstrual syndrome and also used in
clinical practice to assist with withdrawal from hormone therapy.
Efficacy & Tolerability of VAC is evidenced by >30 clinical trials
with >10,000 patients.
Vitex agnus castus is approved by German Commission E
and European Medicine Agency’s (EMA) for management of
menstrual cycle irregularities, PMS and hyperprolactinemia.
Up to 85% response rate has been documented in menstrual
cycle irregularities like polymenorrhea, Oligomenorrhea and
amenorrhea while up to 88% response rate has been observed
in menstrual bleeding disorders like dysmenorrhea, intermenstrual
bleeding, hypermenorrhea, menometrorrhagia,
In view of the associated adverse effects of current therapy,
the need of the hour is to explore alternative options which have
at par efficacy & superior safety profile compared with modern
medicine drugs. Vitex agnus castus having efficacy similar to
conventional drugs with relatively superior safety profile is one
such non-hormonal therapy which can be recommended as first
line therapy in the management of menstrual cycle irregularities
& infertility associated with secondary amenorrhea,
hyperprolactinemia, and luteal insufficiency.