Am Fam Physician. 2005;72(5):821-824
Author disclosure: Nothing to disclose.
For centuries, chasteberry has been used to treat many hormone-related gynecologic conditions. The current literature supports the use of chasteberry for cyclical breast discomfort and premenstrual syndrome; data on its use for menstrual irregularities and fertility disorders are weak. Its traditional use as a galactagogue (i.e., a substance that enhances breast milk production) is not well supported in the literature and should be discouraged. There are no clinical data to support the use of chasteberry for reducing sexual desire, which has been a traditional application. Chasteberry is well tolerated; reported adverse effects are minor and may include gastrointestinal complaints, dizziness, and dry mouth. No herb-drug interactions have been reported, but caution is advised for its concomitant use with dopamine agonists or antagonists. Optimal standardization and dosing recommendations await clarification in clinical studies.
Chasteberry (Vitex agnus-castus), or monk’s pepper, is the fruit of the chaste tree. It is native to western Asia and southwestern Europe, and is now common in much of the southeastern United States.
|Clinical recommendation||Evidence rating||References|
|Chasteberry is not recommended for enhancement of milk production, modification of libido, or enhancement of fertility due to lack of evidence of effectiveness.||B||4,7,12,25–27|
|Evidence suggests that chasteberry is effective for relieving symptoms of premenstrual syndrome.||B||15,16,18,22,23|
|Chasteberry may be effective in patients with cyclical breast discomfort.||B||19,20|
Chasteberry has been used for more than 2,500 years to treat various conditions. In ancient Egypt, Greece, and Rome, it was used for a variety of gynecologic conditions. In medieval Europe, chasteberry was popular among celibate clergymen for its purported ability to reduce unwanted sexual libido.1 Over the past 50 years, chasteberry has been used widely in Europe for gynecologic conditions such as premenstrual syndrome (PMS), cyclical breast discomfort, menstrual cycle irregularities, and dysfunctional uterine bleeding. The German Commission E approves the use of chasteberry for irregularities of the menstrual cycle, cyclical breast discomfort, and PMS,2 and it is widely prescribed by family physicians and gynecologists in Germany.3
The berry of the chaste tree contains a number of active constituents: flavonoids (i.e., casticin, kaempferol, orientin, quercetagetin, and isovitexin), iridoid glycosides (i.e., agnuside and aucubin), and essential oils (i.e., limonene, cineol, pinene, and sabinene).4–8 Chasteberry shows central dopaminergic activity in vitro9,10 and in vivo.11 This dopaminergic effect inhibits basal- and thyrotropin-releasing hormone–stimulated prolactin release.10,11
Chasteberry’s therapeutic effects are attributed to its indirect effects on various hormones, especially prolactin and progesterone. This hormonal effect appears to be dose-dependent: low doses of extract have resulted in decreased estrogen levels and increased progesterone and prolactin levels, possibly caused by an inhibition of the release of follicle-stimulating hormone (FSH) and stimulation of luteinizing hormone (LH) levels.4,7,12 However, in some studies of persons receiving higher doses, FSH and LH levels remained unchanged,4,10,12 while prolactin release was decreased.4,12 These effects may explain why lower doses of the herb might stimulate breast milk production, whereas higher doses seem to have the opposite effect.
Uses and Efficacy
Over the past 50 years, 30 European trials of chasteberry (mostly uncontrolled or unblinded) have reported improvement of menstrual and menstruation-related disorders.13 During the past 10 years, a few small, but high quality, double-blind randomized controlled trials (RCTs) have examined various effects of chasteberry.
PMS AND CYCLICAL BREAST DISCOMFORT
Numerous double-blind RCTs have evaluated different chasteberry preparations for treating the symptoms of PMS. Two trials were of lesser quality19,20 and found little difference or small improvement of breast pain. A recent higher-quality, prospective double-blind RCT15 showed significant improvement in self-assessed symptoms associated with PMS and in physician-assessed clinical global impressions scores measuring severity of condition, global improvement, and overall benefit versus risk (P = .001; number need to treat = 4). The study, which specifically addressed breast fullness but not pain, involved 170 women with a diagnosis of PMS who received a standardized extract of chasteberry fruit (Ze 440, standardized to casticin) or placebo for three menstrual cycles. More than one half of the women experienced a 50 percent or greater reduction in symptoms. Patient acceptance was high, and side effects were few and mild.15 Another placebo-controlled, double-blind trial21 of 104 women examined the effects of two forms of chasteberry (liquid and tablet) for at least three menstrual cycles. The women in the treatment group showed improvement of cyclical breast discomfort.21
A previous study16 found comparable efficacy for chasteberry and vitaminB6, both of which decreased symptoms by almost 50 percent. This study was placebo controlled, but not double blinded, and was of suboptimal sample size. Three open trials18,22,23 involving between 400 and 1,600 patients also showed significant improvement of various PMS symptoms but were not controlled and were of lesser quality.
MENSTRUAL DISORDERS, AMENORRHEA, AND FERTILITY
Results of a small RCT25 involving 96 women with fertility disorders (38 women with secondary amenorrhea, 31 with luteal insufficiency, and 27 with idiopathic infertility) suggested that patients receiving chasteberry achieved pregnancy more readily than did women in the placebo group. The subjects received chasteberry or placebo twice daily for three months. Hormone levels did not differ, but in women with amenorrhea or luteal insufficiency, pregnancy occurred in the active treatment group more than twice as often as in the group receiving placebo. However, the total number of patients conceiving was small (15 women), the treatment was only administered for three months, and the product used (Mastodynon, not currently available in the United States) contains five additional herbs that are not approved by the German Commission E reports.2
In another small RCT26 involving 52 patients with luteal phase defects, women in the active treatment group were found to have reduced prolactin release, normalized luteal phases, improved luteal phase progesterone synthesis, and increased luteal phase estradiol. This study appears to support the use of chasteberry for luteal phase disorders, but the actual effect on fertility was not mentioned. A recent double-blind placebo-controlled pilot study27 of 30 women showed an increasing trend in midluteal phase progesterone level and an increased number of pregnancies in the 15 women who took a nutritional supplement containing chasteberry for five months.
LACTATION AND LIBIDO
There is insufficient evidence to support chasteberry’s traditional use to enhance breast milk production (i.e., as a galactagogue). Some evidence suggests that low doses might increase milk production in women who are lactating.4,7 A small study12 involving 20 healthy men showed increased prolactin levels in those receiving a low dose of chasteberry (120 mg per day) but a decrease of prolactin secretion with higher doses (480 mg per day).
Interactions, Adverse Effects, and Contraindications
Chasteberry usually is well tolerated, with only minor adverse effects reported; in many studies these effects are similar to placebo. Side effects generally are dopaminergic in nature and may include mild gastrointestinal complaints, dizziness, headache, tiredness, and dry mouth.6,10,11,29–31 One report32 described a case of nocturnal seizures in a patient taking black cohosh, evening primrose oil, and chasteberry; however, a causal relationship with chasteberry is doubtful.
The use of chasteberry during pregnancy is contraindicated, and its use during lactation is controversial. Until further studies have been conducted, its use to support lactation should be discouraged.
Dosage and Preparations
The dosages and preparations of chasteberry used in different clinical trials vary widely. In many studies, 4 mg per day of an extract standardized to 6 percent of the constituent agnuside has been used. In the United States, this formulation is available as Femaprin from Nature’s Way.
The few existing high-quality clinical studies on chasteberry are small or of limited duration, which limits the ability to apply the findings to a larger population. Evidence appears to support the use of chasteberry for symptoms of PMS and cyclical breast discomfort, with some preliminary evidence for infertility. Evidence for its use in other conditions remains inconclusive.
Chasteberry is well tolerated, with few side effects and no reported herb-drug interactions. Recommended dose and treatment regimens vary depending upon brand, formulation, and anecdotal experience; optimal standards await clarification in clinical studies. Table 1 lists the efficacy, safety, tolerability, and cost of chasteberry.
|Efficacy||Cyclical breast discomfort: possibly effective|
|Premenstrual syndrome: possibly effective|
|Fertility disorders: possibly effective based on preliminary evidence|
|Modification of libido: insufficient evidence|
|Stimulating lactation: insufficient evidence|
|Adverse effects||Infrequent: mild gastrointestinal complaints, dizziness, headache, tiredness, and dry mouth|
|Interactions||No significant reports of herb-drug interactions|
|Dosage||Varies depending on brand and formulation (available in liquid form, capsules, and tablets)|
|Cost||$7 to $14 for three- to four-week supply, depending on brand|
|Bottom line||A safe, well-tolerated herbal medicine that may be effective in treatment of cyclical breast discomfort and premenstrual syndrome|