Female reproductive health and fertility is an area of health that many women struggle with, from their teenage years onwards. In a national online survey in Australia, 92% of the 4202 adolescent and young women (13 to 25 yo) respondents reported dysmenorrhoea.¹ It is estimated that one in six couples in Australia,² and indeed worldwide,³ suffer from infertility. Women with polycystic ovary syndrome (PCOS) and endometriosis are among those who are most proactive when it comes to seeking advice and using hormonal or in vitro fertilisation (IVF) treatment,⁴ but are these women aware of all available options? Evidence-based herbal and nutritional interventions offer a natural approach to supporting hormonal balance and improving fertility.^5,6

Healthy ovulation and normal luteal phase function are the cornerstones of fertility. Supporting both can also help to improve a range of menstrual disorders including amenorrhoea, PCOS, premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), dysmenorrhoea, mastalgia, and infertility.

Key therapeutic goals natural medicine practitioners should aim to address include reducing excessive prolactin secretion, supporting ovarian function and ovulation, supporting corpus luteum function and progesterone production, and reducing oxidative stress. Key nutrients that support these processes also overlap with supporting healthy thyroid function.

Figure 1: Hypothalamic-Pituitary-Ovarian (HPO) Axis^7-9

The HPO axis consists of the hypothalamus, pituitary gland and ovaries. The hypothalamus produces GnRH. GnRH causes the anterior pituitary to secrete FSH and LH. These hormones direct changes in the ovaries and endometrial lining of the uterus throughout the menstrual cycle. FSH stimulates follicular growth in the ovary. An LH surge during the follicular phase triggers the release of a mature egg from the dominant ovarian follicle (ovulation) and the formation of the corpus luteum, which produces progesterone (luteal phase). Progesterone prepares the endometrial lining for the implantation and growth of a fertilised egg. Unless pregnancy occurs, the corpus luteum degrades and becomes a corpus albicans and stops producing progesterone. This degradation is referred to as luteolysis. The prostaglandin PGF2α elicits luteolysis by reducing blood flow to the corpus luteum, downregulating receptors for LH and inhibiting progesterone synthesis. Oxidative stress reduces follicle quality and progesterone production, contributing to regression of the corpus luteum. Without progesterone maintaining the endometrial lining, menstruation occurs. Hypersecretion of prostaglandins and increased uterine contractility cause the pain associated with dysmenorrhoea. Other menstrual irregularities (i.e. amenorrhoea, mastalgia, PMS, and PMDD) occur as a result of multiple factors, including thyroid dysfunction and hyperprolactinaemia.

Abbreviations: FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinising hormone; PCOS, polycystic ovary syndrome; PGF2α, prostaglandin F2α; PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome; PRL, prolactin; ROS, reactive oxygen species

Chaste Tree

Chaste Tree is said to be a herb for the luteal phase, especially useful for gynaecological complaints occurring or worsening in the premenstrual period including acne, fluid retention and breast soreness. These complaints may be caused by lower than normal progesterone secretion and mildly elevated prolactin levels (latent hyperprolactinaemia). Chaste Tree may also be used to improve menstrual irregularities, especially cyclic changes associated with latent hyperprolactinaemia such as amenorrhoea.¹⁰

Evidence supports the use of Chaste Tree extract for the following:

- normalising levels of prolactin in women with hyperprolactinaemia within three  
  to four cycles/months^11,12

- normalising shortened luteal phases and eliminating deficits in luteal  
  progesterone synthesis¹²

- improving menstrual cycle irregularities (e.g. polymenorrhoea, oligomenorrhoea
  and amenorrhoea) in women over the course of three consecutive menstrual
  cycles¹³

- alleviating PMS symptoms^14-19

- normalising menstrual cycle duration in women with PCOS²⁰

- diminishing irritability, breast tenderness, swelling, food cravings, and cramps in
  PMDD²¹

- relieving cyclic mastalgia²²

While preparations, doses and duration of Chaste Tree treatment vary in the literature, results uniformly favour treatment. Some are standardised contents of agnuside or casticin, while others use a daily dosage of 20 to 40 mg dry fruit extract which reflects the low doses typically used in Germany. In contrast, clinicians in Australia commonly prescribe a much higher dose between 200 and 500 mg/day. The typical treatment duration with Chaste Tree is three months, though effects are apparent from the first month.²²

Paeonia

Paeonia is for the treatment of PMS, PCOS, hyperprolactinaemia, ovulatory failure, infertility, endometriosis and adenomyosis, androgen excess, and mastalgia. These conditions have at their core various hormonal irregularities including elevated androgens (testosterone), low progesterone, high or low oestrogen, and elevated prolactin, all of which Paeonia can influence. Improvements in menstrual pain also occur with administration of Paeonia.¹⁰

A Paeonia and Licorice decoction has been shown to improve symptoms of hyperprolactinaemia and hormone levels in women with schizophrenia. Several cases of amenorrhoea, abnormal menstruation, galactorrhoea, reduced libido, and sexlessness also improved in the herbal treatment group of this preliminary study.²³

Chamomile

Recent findings show that the flavonoid apigenin, present in Chamomile, is a potential phytoprogestin. The natural progesterone-like molecule interacts with the progesterone receptor to lessen oestrogen receptor-mediated uterine proliferation.²⁴ An in vivo study provides histological evidence adjacent to this, demonstrating that Chamomile extract supports the development of dominant follicles in polycystic ovaries and leads to better endometrial tissue arrangement.²⁵ Furthermore, Chamomile itself possesses antispasmodic properties that can relieve painful cramps associated with menstruation.²⁶ As such, Chamomile may be beneficial for PCOS and endometriosis.²⁷

Evidence from clinical trials show that Chamomile is beneficial for improving serum prolactin levels in women with idiopathic hyperprolactinaemia,²⁸ reducing the severity of PMS symptoms^29-31 and decreasing pain intensity and duration in dysmenorrhoea.³²

Zinc and Manganese

Zinc can reduce the synthesis of prostaglandins, acting as an antioxidant and anti-inflammatory agent that improves the microcirculation of endometrial tissue.³³ Both copper zinc superoxide dismutase (Cu/Zn-SOD) and manganese SOD (Mn-SOD) are present in the corpus luteum and protect against oxidative stress. Zinc deficiency has been reported in women suffering from PMS, specifically during the luteal phase,^34-36 and other research suggests that low manganese intake (<1.8 mg/day) increases the risk of anovulation.³⁷

Zinc supplementation has been shown to markedly improve clinical symptoms of hyperandrogenism and oxidative stress in women with PCOS compared to placebo.³⁸

Several other randomised, controlled trials indicate that zinc supplementation (7 or 50 mg elemental zinc) is also useful for alleviating symptoms of PMS.^39-42

Significant improvements in pain have also been reported with the use of zinc for primary dysmenorrhoea in three randomised, controlled trials.^43-45

Selenium

Low selenium intake (<55 μg/day) is associated with increased risk of sporadic ovulation, likely due to its antioxidant properties,³⁷ whereas a significantly higher level of glutathione peroxidase (GPx) activity, an antioxidant selenoenzyme, has been observed in menstruating women compared to women without regular menstruation.⁴⁶

Iodine

Menstrual irregularities are common among hypothyroid patients.⁴⁷ Given the essential role iodine plays in thyroid gland function and that its concentrations in the human body are highest in the thyroid and ovaries,^48,49 iodine deficiency is considered an underlying factor for infertility⁵⁰ and luteal phase defect.⁵¹

NB: zinc⁵² and selenium^53,54 are also involved in maintaining healthy thyroid function.

Vitamin B6

Vitamin B6 participates in neurotransmitter synthesis⁵⁵ and modulates steroid hormone activity (particularly progesterone).⁵⁶ Vitamin B6 supplementation is often used to support the stress response and mood,⁵⁷ and reduce symptoms of PMS in combination with other micronutrients.^58-60

Research supports its use in alleviating emotional symptoms of PMS (i.e. depression, irritability and tiredness)⁶¹ and cyclic mastalgia.⁶²

Taken together, a combination of these herbs and nutrients are well indicted for relieving menstrual cycle irregularity, supporting women with menstrual disorders (especially PMS and PCOS) and ovulation problems achieve better hormonal balance and improve fertility.

*For more information refer to the Support for the Luteal Phase of the Female Reproductive Cycle Phytotherapist’s Perspective.

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