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Steels, Elizabeth, Steele, Megan, Harold, Marianne, Adams, L., & Coul-son, Samantha(2018)A double-blind, randomized, placebo-controlled trial evaluating safety andefficacy of an Ayurvedic botanical formulation in reducing menopausalsymptoms in otherwise healthy women.Journal of Herbal Medicine, 11, pp. 30-35.

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https://doi.org/10.1016/j.hermed.2018.01.001

Accepted Manuscript

Title: A Double-Blind, Randomized, Placebo-Controlled TrialEvaluating Safety and Efficacy of an Ayurvedic BotanicalFormulation in Reducing Menopausal Symptoms inOtherwise Healthy Women

Authors: E. Steels, M. Steele, M. Harold, L. Adams, S.Coulson

PII: S2210-8033(18)30001-0DOI: https://doi.org/10.1016/j.hermed.2018.01.001Reference: HERMED 205

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Received date: 22-11-2016Revised date: 7-6-2017Accepted date: 7-1-2018

Please cite this article as: Steels, E., Steele, M., Harold, M., Adams, L.,Coulson, S., A Double-Blind, Randomized, Placebo-Controlled Trial EvaluatingSafety and Efficacy of an Ayurvedic Botanical Formulation in ReducingMenopausal Symptoms in Otherwise Healthy Women.Journal of Herbal Medicinehttps://doi.org/10.1016/j.hermed.2018.01.001

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1

A Double-Blind, Randomized, Placebo-Controlled Trial Evaluating

Safety and Efficacy of an Ayurvedic Botanical Formulation in

Reducing Menopausal Symptoms in Otherwise Healthy Women.

Efficacy of Ayurvedic Formulation in Reducing Menopausal Symptoms

Steels E, a,b, Steele M, c,d, Harold M,a Adams L,a Coulson S,b,e

a. Integrated Health Group Pty. Ltd, Brisbane, QLD Australia b. The University of Sydney, Sydney Medical School, NSW, Australia c. Queensland University of Technology, Brisbane QLD, Australia d. Research Institute Havelhöhe, Hospital Havelhöhe, Berlin, Germany e. The BRIDI Centre Pty Ltd, Brisbane, QLD, Australia

Corresponding author:

Dr Elizabeth Steels

elizabeth.steels@sydney.edu.au

Telephone: 0431 003 929

Funding source: This work was supported by Gencor Pacific, Discovery Bay, Hong Kong.

Abstract

Aims The aim of the present study was to examine the safety and efficacy of a formulated

Ayurvedic botanical combination in reducing vasomotor and other menopause-associated

symptoms in otherwise healthy women.

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Methods This was a double-blind, randomized, placebo-controlled trial conducted with 117

healthy women, aged 40 to 65 years using a formulated Ayurvedic medicine composed of

75mg Tinospora Cardifolia, 100mg Asparagus racemosus, 100mg Withania somnifera and

225mg Commiphora mukul per capsule, administered as one capsule twice per day over a

period of 12 weeks. The primary outcome measure was menopausal symptoms assessed by

the validated Menopause-Specific Quality of Life (MENQOL) questionnaire. The secondary

outcome measures included a patient-reported diary of vasomotor symptoms, serum hormone

levels and health indices (body weight, blood pressure, haematological and biochemistry

markers).

Results A significant difference was demonstrated for the total MENQOL score and the

vasomotor (p < 0.001), psychosocial (p < 0.001), physical (p = 0.02) and sexual domains (p <

0.001) between the active treatment and placebo groups after 12 weeks. There was a

significant reduction in total hot flushes, daytime hot flushes and night sweats in the active

treatment group compared to the placebo group (p ≤ 0.001). There were no significant

changes observed in serum hormone levels or health indices between the active and the

placebo group.

Conclusion This study demonstrated a combination of Tinospora cardifolia, Asparagus

racemosus, Withania somnifera and Commiphora mukul to be a safe and effective treatment

for reducing menopausal symptoms in healthy menopausal women over a duration of 12

weeks.

Keywords

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Tinospora cardifolia, Asparagus racemosus, Withania somnifera, Commiphora mukul,

menopause, hot flushes

1. INTRODUCTION

The transition into menopause is typically a gradual process occurring over a number of years

with a loss of follicular function becoming noticeable usually around the age of 40. Early

hormonal changes include substantial fluctuations in circulating follicle stimulating hormone

(FSH), Inhibin B and oestradiol levels (Woods et al., 2014). The perimenopausal phase is

defined as having vasomotor symptoms (hot flushes and night sweats) and irregular periods;

menopause is defined as physiological termination of menstruation due to decreased ovarian

function (Lumsden, 2016; Hendrix, 2011). Standard management of menopause is based on

alleviating the most commonly reported and troublesome symptoms; to reduce vasomotor

symptoms and improve sexual function by prescribing hormone replacement therapy or the

use of specific botanical medicines.

A limited number of clinical studies have demonstrated that soy isoflavones and

Trifolium pratense (red clover) isoflavones provide significant improvement in hot flushes,

vaginal dryness, sleep, mood and libido (Lipovac et al., 2011; Franco et al., 2016). Actaea

racemose (Black cohosh) may reduce vasomotor, psychiatric and sexual symptoms (Leach &

Moore, 2012; Mohammad-Alizadeh-Charandabi et al., 2013) while Trigonella foenum-

graecum extract (Steels et al., 2017) and Pinus pinaster (maritime pine bark) (Yang et al.,

2017) reduce vasomotor symptoms and increase libido in menopausal women. It has

however, recently been acknowledged that the menopause consists of a spectrum of other

symptoms and identification of the specific cluster of symptoms may be useful in determining

the most appropriate treatment for individual women (Woods 2015; Woods et al., 2016).

Furthermore, it is now recognized that transition into and through the menopause is associated

with elevated states of anxiety and depression and these, therefore, must also be addressed

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(Siegel & Mathews, 2015). The selected botanicals, Tinospora cardifolia, Asparagus

racemosus, Withania somnifera, and Commiphora mukul, in the investigational product, were

derived from the traditional Ayurvedic medical paradigm to balance the female reproductive

system and modulate inflammatory responses, liver function and the stress response, in order

to address the symptoms of menopause via a multi-systems approach.

Tinospora cordifolia has a variety of active phytochemical constituents including

aliphatic compounds, alkaloids, steroids, lactones, glycosides, sesquiterpenoids,

polysaccharides, various fatty acids and essential oils (Hussain et al., 2015; Saha & Ghoash,

2012; Upadhyay et al., 2010). The plant also contains arabinogalactan, a branched

polysaccharide with prebiotic and immunological activity (Mishra et al., 2013). Asparagus

racemosus contains phytochemical constituents such as steroidal saponins, alkaloids, quercetin

and glycosides of quercetin. In Ayurvedic medicine, it has been used to treat conditions relating

to the female reproductive system including menopause, the immune system and the nervous

system (Potduang et al., 2008). Withania somnifera also referred to as Indian ginseng and

Ashwagandha (Dar et al., 2015) is an important herb within the Ayurvedic and Unani systems

of medicine. Phytochemical constituents of the Withania somnifera plant include alkaloids

(withanine), steroidal lactones, steroids (β-sitosterol, diosgenin, sitoinosides), flavonoids

(quercetin) and nitrogen-containing compounds (withanol) (Dar, 2015). Scientific research

(animal and in vitro) has demonstrated numerous biological activities inherent to Withania

somnifera with anti-stress and neuroprotective functions (Yenesetti, et al., 2016; Dar, 2015) It

has also been reported to modulate the γ-amino butyric acid (GABA) and acetylcholine

neurotransmitters (Mehta et al., 1991; Kulkarni & George, 1996). Commiphora mukul contains

phytochemical constituents that are responsible for its therapeutic action including volatile oils

(myrcene, di- and polymyrcene, d-limonene, coneole), steroids (guggulsterones and

guggulsterols), flavonoids (muscanone, naringenin, quercetin), guggultetrols, lignans (sesamin

and diayangambin), as well as sugars and amino acids (Sarup et al., 2015). Commiphora mukul

is traditionally used in Ayurvedic medicine for obesity, diabetes and inflammatory conditions such

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as arthritis (Sarup et al., 2015; Shen et al., 2012).

The aim of the present study is to investigate the efficacy of a formulated Ayurvedic

botanical medicine comprising a combination of Tinospora cardifolia, Asparagus racemosus,

Withania somnifera and Commiphora mukul in supporting women through menopause,

reducing associated symptomology and/or modulating the stress response.

2. MATERIALS AND METHODS

2.1. Study Design

This was a single-site, double-blind, randomized, placebo-controlled clinical trial of 12 weeks

duration to assess the safety and efficacy of a formulated Ayurvedic medicine in reducing

symptoms of menopause in otherwise healthy women. It was conducted between November

2014 and March 2016 in Brisbane, Australia. The study was conducted in accordance with the

Principles of the Declaration of Helsinki and was approved by the Queensland University

Clinical Trial Human Research Ethics Committee. The trial was registered with the Australian

New Zealand Clinical Trials Registry (Trial ID: ACTRN12615000324516) and a clinical trial

notification was submitted to the Therapeutic Goods Agency.

2.2. Study Population

Participants were recruited through the contract research organization (CRO) subject

database and via public media avenues. The inclusion criteria required participants to be aged

between 40 and 65 years; to be experiencing menopausal symptoms including the presence

of hot flushes and/or night sweats scoring greater than ‘mild’ on the Menopause-Specific

Quality of Life Questionnaire (MENQOL). Women were required to be in good general health

and able to adhere to protocol requirements. Potential participants were excluded if they had

been using hormone replacement or herbal medicines for menopausal symptoms in the month

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prior to trial commencement or were currently on other investigational product(s). Women

were also excluded if they had a previous history, presence, or suspicion of oestrogen-

dependent neoplasia, neoplastic disease or treatment for any neoplastic disease within the

previous 2 years; had a partial or total hysterectomy; had active or a recent history (in the last

6 months) of thromboembolic disease; had a history of cerebrovascular accident, stroke, or

transient ischemia or had major depressive disorder, bipolar disorder, psychotic disorder or

generalized anxiety disorder requiring therapy. Women with uncontrolled diabetes, high

cholesterol or hypertension, alcohol or drug dependency were also excluded.

2.3. Intervention

The investigational product was a formulated Ayurvedic medicine (Genopause®) containing

75mg Tinospora cardifolia (spray-dried ethanolic extract of the dried stem), 100mg Asparagus

racemosus (spray-dried aqueous extract of the dried root), 100mg Withania somnifera (spray-

dried aqueous extract of the dried root) and 225mg Commiphora mukul (spray-dried ethanolic

extract of the gum exudate) in a 2-piece hard, opaque gelatin capsule. The placebo product

contained maltodextrin only, also in a 2-piece hard, opaque gelatin capsule, indistinguishable

from the investigational product. The daily dosage of the investigational products was one

capsule, twice daily (taken with breakfast and the evening meal). The investigational and

placebo product were supplied by Gencor Pacific, Hong Kong and manufactured by AZPA

Pharmaceuticals, Australia. Plant materials were identified by Dr.K.S.Krishnan of the National

Institute of Science Communication and Informatics Research, New Delhi, India. Identification

reference codes were assigned to each plant specimen - Commiphora mukul

(NISCAIR/RHMD/Consult/2016/2982-09-21); Tinospora cardifolia

(NISCAIR/RHMD/Consult/2016/2996-23-10); Asparagus racemosus

(NISCAIR/RHMD/Consult/08 – 09/1087/118/03) and Withania somnifera

(NISCAIR/RHMD/Consult/2014/2378/158-1).

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2.4. Randomization, Blinding and Monitoring

Randomization was performed independently of the investigators using Random Allocation

Software (version 1.0, May 2004). The investigational and placebo product were packed into

high-density polyethylene opaque bottles that were identical in appearance and blinded

(numbered) before being provided to the investigators. After preliminary telephone screening,

eligible participants attended a baseline interview to enrol in the study. They provided written

informed consent; completed medical history and lifestyle questionnaires (including the

MENQOL) and body weight and blood pressure were measured. Participants were provided

with Queensland Medical Laboratory (QML) pathology request forms for blood collection and

a Symptom Diary and were randomly allocated to the active treatment or placebo group.

Participants were monitored for compliance by telephone and email communications and the

number of returned capsules were counted at completion of study to determine dosage

adherence.

2.5. Objective and Outcomes

2.5.1. Primary outcome

The primary outcome measure was the validated Menopause-Specific Quality of Life

Questionnaire. The MENQOL assesses the participants’ subjective symptoms that can

significantly impact on a woman’s quality of life. It is self-administered and consists of a total

of 29 items in a Likert-scale format. Each item assesses the impact of one of four domains of

menopausal symptoms, as experienced over the previous 4 weeks, including vasomotor,

psychosocial, physical and sexual symptoms (Hilditch et al., 1996).

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2.5.2. Secondary outcomes

The vasomotor symptoms were assessed independently from the MENQOL, with the number

of daytime hot flushes and night sweats experienced by participants recorded over a 7-day

period at baseline and at each time point of week 4, week 8 and week 12. The serum hormone

profiles included oestradiol, progesterone, testosterone, free testosterone,

dehydroepiandrosterone (DHEA), luteinizing hormone (LH), follicle stimulating hormone (LSH)

and sex hormone binding globulin (SHBG) and were measured at baseline and again at week

12. These were taken in a fasting state, at the same time of day (between 8am and 9am) to

minimize daily variations in hormonal levels. Safety measurements included body weight,

blood pressure, haematological parameters and biochemistry including fasting blood glucose

(FBG), full blood count (FBC), electrolyte / liver function (E/LFT), total cholesterol (TC),

triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein

cholesterol (HDL-C), performed at baseline and week 12. Blood samples were collected and

analysed by QML pathology using standard validated protocols. Any adverse events were

documented by participants in their study diaries over the 12 weeks of the study. Participants

were instructed to alert the study coordinators if any adverse events were experienced.

2.6. Sample Size and Statistical Analysis

A minimum number of 49 participants per group were required to achieve a statistical power

of 80% on the basis of a 20% improvement in symptoms as measured by the total domain

score of the MENQOL. Demographic data were summarized by mean and standard deviation

(SD) or as proportions. The MENQOL total and domain scores were analyzed using a

generalized estimating equations (GEE) model with an autoregressive covariance structure to

account for the multiple observations per person. The number of total flushes, day-time hot

flushes and night sweats during four seven-day periods were described as mean ± SD and

analyzed using GEE with an autoregressive covariance structure and Poisson distribution.

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The hormone data were nonparametric and described as median and interquartile range

(IQR). For both treatment groups, baseline hormone levels were compared to levels at week

12 using the Wilcoxon test. All analyses were conducted in R version 3.3.1 and GEE models

were run using the geeglm function in the geepack package.

3. RESULTS

3.1. Demographics and baseline data

A total of 180 women were assessed for eligibility from which a total of 117 women were

eligible and were recruited into the study, with 61 women randomized to the active treatment

group and 56 randomized to the placebo group. From the active treatment group, 7 women

withdrew allowing for 54 evaluable participants and from the placebo group 6 women withdrew

allowing for 50 evaluable participants (Figure 1). The active treatment and placebo groups

were well matched at baseline. The mean age of women in the active treatment group was

53.2 ± 3.8 years while in the placebo group was 53.6 ± 4.0 years. The mean body weight was

comparable at baseline between the active and placebo groups, 71.5 ± 11.4 kg and 71.5 ±

13.7 kg, respectively. In the active treatment group, 46 (85.2%) women reported being married

or in a relationship, compared to 33 (66%) women in the placebo group (Table 1).

(Figure 1. Flow diagram of participant recruitment, follow-up and analysis)

Table 1. Demographic baseline data

Characteristics Active group

(n = 54)

Placebo group

(n = 50)

p-value

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Age (years), mean (SD) 53.2 (3.8) 53.6 (4.0) 0.69

BMI (kg/m2), mean (SD) 26.7 (4.4) 26.7 (4.6)

(N=37)

0.64

Weight (kg), mean (SD) 71.5 (11.4) 71.5 (13.7) 0.67

Waist : hip ratio, mean (SD) 0.8 (0.1) 0.8 (0.1) 0.37

Current smokers, n (%) 6 (11) 5 (10) 0.15

Social drinkers, n (%) 36 (67) 29 (58) 0.95

Undertake regular weekly exercise, n (%) 42 (78) 33 (66) 0.79

Married or in a relationship 46 (85.2) 33 (66) 0.02

3.2. Outcome measures

3.2.1. Primary outcome

The severity of menopausal symptoms was assessed using the validated MENQOL

questionnaire at baseline, 4-weeks, 8-weeks and 12-weeks. There was no significant

difference in total MENQOL score at baseline between the two groups (p = 0.5). There was a

significant reduction in the total MENQOL score over 12 weeks in the active treatment group

compared to placebo, 26.4% versus 2.3%, respectively (p < 0.001). There were significant

reductions in all of the four domains: vasomotor, psychosocial, physical and sexual domains

(Table 2). The vasomotor domain symptoms including “day flushes”, “night sweats” and

“sweating” were significantly improved in the active treatment group compared to the placebo

group at week-12 (p<0.001). There was a statistically significant improvement in the

psychosocial domain questions of “accomplishing less tasks” (p = 0.013), “feeling depressed

or blue” (p = 0.022) and “being impatient with other people” (p = 0.018) in the active treatment

group compared to the placebo group at week-12. Within the physical domain, there was a

statistically significant improvement in the questions “feeling worn out” (p = 0.003), “aches in

the back of the neck or head” (p = 0.048) and “decreased stamina” (p = 0.044) and “decreased

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facial hair” (p = 0.010). In the sexual domain, there was a statistically significant improvement

in questions relating to “vaginal dryness” (p = 0.031) and “avoidance of intimacy” (p = 0.005)

within the active treatment group compared to placebo (Table 2).

Table 2. Mean MENQOL scores (total and for each individual domain) between the

active and placebo groups at baseline, week-4, week-8 and week-12.

Time T0 weeks

Mean ± SD

T4 weeks

Mean ± SD

T8 weeks

Mean ± SD

T12 weeks

Mean ± SD

P value*

Vasomotor

Active 5.4±1.5 4.0±1.4 3.5±1.5 3.8±1.7 <0.001

Placebo 4.8±1.8 5.1±1.7 5.0±1.8 5.0±1.8

Psychosocial

Active 4.1±1.6 3.2±1.5 3.0±1.4 3.2±1.5

<0.001

Placebo 4.2±1.9 4.3±2.1 4.1±1.9 4.1±1.9

Physical

Active 4.5±1.3 3.7±1.2 3.3±1.1 3.6±1.3

0.002

Placebo 4.2±1.6 4.0±1.5 3.8±1.5 3.9±1.5

Sexual

Active 4.2±2.2 3.5±1.9 3.2±1.9 2.9±1.9

<0.001

Placebo 4.3±2.4 4.4±2.4 4.0±2.4 4.1±2.4

TOTAL

Active 18.2±3.9 14.4±3.8 13.0±3.8 13.4±4.2

<0.001

Placebo 17.5±5.6 17.8±5.8 16.9±5.8 17.1±5.5

* Generalized estimating equations *Significance at p<0.05, GEE, autoregressive covariance used.

3.2.2. Secondary outcomes

The median number of combined daytime hot flushes and night sweats (total) in the active

treatment and placebo groups was similar at baseline (W=1000, p=0.4). Participants in both

active and placebo groups reported more daytime hot flushes than night sweats (Table 3). A

significant reduction in total flushes was observed in the active treatment group (p<0.001),

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reducing by 43% at 4-weeks from baseline, by 52% at 8-weeks and by 67% at 12 weeks. In

the placebo group, hot flushes did reduce by 19% by week 8 with no further improvement

observed. There was a significant reduction in the active treatment group in both the daytime

flushes (p<0.001) and night sweats (p<0.001) compared to placebo over the 12-week

treatment. These results are consistent with the results observed for the vasomotor domain

symptoms of the MENQOL.

Table 3. Average total flushes, daytime hot flushes and night sweats for the formulated

Ayurvedic medicine and placebo at baseline, week-4, week-8 and week-12.

Baseline

Median (IQR)

Week 4

Median (IQR)

% change

Week 8

Median (IQR)

% change

Week 12

Median (range)

% change

p-value

Day-

time

Hot

Flushes

Active 28 (14-42)

20 (5-29)

↓ 30%

14 (2-25)

↓ 50%

10 (3-24)

↓ 64%

<0.001

Placebo 18 (7-38)

17 (7-36)

↓ 6%

18 (8-38)

0%

22 (10-38)

↑ 22%

Night

Sweats

Active 14 (7-24)

7 (1-16)

↓ 50%

7 (1-13)

↓ 50%

4 (0-12)

↓ 71%

<0.001

Placebo 11 (3-28)

7 (1-19)

↓ 36%

8 (0-16)

↓ 27%

10 (1-21)

↓ 9%

Total

Flushes

Active 42 (23-60)

24 (9-44)

↓ 43%

20 (4-41)

↓ 52%

14 (5-35)

↓ 67%

<0.001

Placebo 36 (14-56)

29 (14-54)

↓ 19%

29 (14-53)

↓ 19%

37 (15-59)

↑ 3%

The results are taken from a 7-day diary completed at Baseline, week-4, week-8 and week-12.

*Significance at p<0.05, GEE, auto-regression covariance, Poisson distribution used.

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3.2.3 Serum hormone levels

Serum oestradiol levels were comparable between the two groups at baseline (W=1147,

p=0.9). The median serum oestradiol levels in the active treatment group and placebo group

were 50 pmol/L (IQR = <42-148) and 60 pmol/L (IQR = <42-148), respectively (Table 4). The

lower limit of detection for oestradiol was 42pmol/L, of which 43% of women in the active group

and 42% in the placebo group were already below at baseline. These levels were indicative

of levels expected for postmenopausal women. In both groups, oestradiol levels were

negatively correlated with age at baseline (active: r2 = -0.44, p = 0.001, placebo: r2 = -0.43, p

= 0.002). There was no correlation between BMI and oestradiol levels. In the active group,

oestradiol increased from 50 pmol/L at baseline to 60 pmol/L at 12 weeks, however this

difference was not statistically significant. There were no statistically significant differences (all

p>0.5) between hormone levels at baseline and week 12 in the active or placebo group (Table

4).

Table 4. Serum hormone levels for the formulated Ayurvedic medicine and placebo at

baseline and week-12.

Hormones

Active group (n=54) Median (IQR)

Placebo Group (n=50) Median (IQR)

Baseline Week 12 Baseline Week 12

Estradiol (pmol/L) 50 (<42*-148) 60 (<42*-120) 60 (<42*-270) 60 (<42*-180)

Progesterone (mmol/L) <1* <1* <1* <1*

Testosterone (mmol/L) 1 (0.7-1.3) 0.9 (0.7-1.3) 1 (0.5-1.3) 1 (0.7-1.4)

Free Testosterone (pmol/L)

11 (7-17) 13 (9-17) 12 (8-19) 12 (8-18)

LH (IU/L) 60 (42-75) 60 (33-80) 55 (37-70) 55 (38-70)

FSH (IU/L) 130 (82-215) 143 (70-220) 145 (110-185) 140 (101-188)

SHBG (mmol/L) 60 (45-80) 58 (42-69) 62 (38-78) 56 (42-76)

*Lower limit of detection

Significance at p <0.05, t-tests were used. No significant changes were detected.

3.3. Health Indices and adverse events

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No changes were observed in blood pressure, body weight, blood glucose levels, lipid profiles

(total cholesterol, triglycerides, LDL-C or HDL-C), total protein or albumin after 12 weeks of

treatment within the active or placebo group (Table 5). Furthermore, electrolytes, liver

enzymes and renal function tests remained within reference range in both active and placebo

groups. The investigational product was well tolerated over the 12-week study duration with

no major adverse events reported.

Table 5: Effect of formulated Ayurvedic medicine and placebo on health indices at

baseline and week-12.

Health Indices Active group (n=54) Mean (SD)

Placebo Group (n=50) Mean (SD)

Baseline Week 12 Baseline Week 12

Blood pressure (mmHg)

Systolic

Diastolic

120.3 (10.8)

78.3 (8.6)

119.7 (9.5)

77.2 (6.9)

121.6 (13.1)

78.1 (7.7)

120.2 (10.2)

77.8 (6.9)

Weight (kg) 71.5 (11.4) 71.8 (11.9) 71.5 (13.7) 71.5 (13.7)

Fasting blood glucose

(3.0-6.0 mmol/L)*

4.9 (0.4) 5.0 (0.5) 4.9 (0.7) 4.9 (0.6)

Total Cholesterol

(3.6-6.9 mmol/L)*

5.6 (0.8) 5.5 (0.9) 5.5 (0.9) 5.4 (0.8)

LDL-C

(0.3-2.2 mmol/L)*

3.1 (0.8) 3.1 (0.8) 3.0 (0.9) 2.9 (0.8)

HDL-C

(0.3-2.2 mmol/L)*

1.8 (0.5) 1.8 (0.5) 1.8 (0.5) 1.9 (0.5)

HDL-C : LDL-C ratio 3.2 (0.9) 3.3 (1.1) 3.2 (1.0) 3.1 (0.9)

Triglycerides

(0.3-2.2 mmol/L)*

1.0 (0.6) 1.0 (0.8) 1.1 (0.7) 1.0 (0.7)

Red cell count

(3.6-5.2 x1012/L)* 4.6 (0.3) 4.6 (0.3) 3.6 (0.3) 4.6 (3)

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Haematocrit

(0.33-0.46)* 0.41 (0.03) 0.41 (0.02) 0.41 (0.03) 0.47 (0.05)

Mean cell volume

(80-98 fL)* 90 (3.9) 90 (5) 89 (5) 90 (8)

Mean cell haemoglobin

(27-35 pg)* 30.0 (1) 30 (2) 29 (2) 30 (2)

Total protein

(60-80 g/L)* 71 (4) 70 (5) 69 (4) 70 (4)

Albumin

(35-55 g/L)* 42 (3) 41 (2) 41 (3) 41 (3)

* QML reference ranges

Health indices were assessed at baseline and week-12. Significance at p <0.05, t-tests were used. No

significant changes were detected.

4. Discussion

This clinical study examined the therapeutic efficacy of a formulated Ayurvedic medicine

containing Tinospora cardifolia, Asparagus racemosus, Withania somnifera and Commiphora

mukul in relieving menopausal symptoms in otherwise healthy women. These botanicals have

not, to the best of the authors’ knowledge, previously been investigated individually or in this

specific combination for the treatment of menopausal symptoms. The selected botanicals

were derived from the traditional Ayurvedic medical paradigm to balance the female

reproductive system, inflammatory responses and liver parameters and to modulate the stress

response; however little scientific validation for such effects exists. The results of this study

demonstrated that supplementation with this formulation resulted in a significant improvement

in vasomotor symptoms, with a significant reduction in reported daily total hot flushes, daytime

flushes and night sweats. There was also a significant improvement in sexual function that

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was accompanied by improvements in physical and psychosocial symptoms. The

improvement in menopausal symptoms was not associated with changes in the levels of

DHEA, estradiol or testosterone. Furthermore, there were no statistically significant changes

in red blood cells, blood glucose, lipid metabolism, liver and renal markers after 12 weeks of

supplementation.

It is well accepted that psychosocial symptoms of anxiety, irritability, nervousness,

stress and depression are common during the menopausal transition phase. This supports

previous research demonstrating an association between high anxiety and sexual dysfunction

in early post-menopausal women (Santoro & Taylor, 2011; Santoro, 2016). It is likely that the

addition of Withania somnifera and Asparagus racemosus contributed to the efficacy in reducing

psychosocial symptoms. In a recent systematic review, Pratte et al. (2014) concluded that

supplementation of Withania somnifera was more effective than placebo in reducing anxiety

and stress. Furthermore, a recent study demonstrated that Withania somnifera has GABAergic

activity which may explain why key constituents of Withania somnifera exert therapeutic

activity for general anxiety disorders and provide neurological support during menopause

(Candelario et al., 2015). Most recently, Takanari et al. (2016) assessed the efficacy of an

enzyme-treated Asparagus racemosus extract on decreasing psychological stress parameters

in healthy individuals and reported it had beneficial effects against the stress response;

reducing dysphoria and fatigue, improving sleep quality and increasing salivary IgA levels.

It is possible that the improvement in sexual function could also be attributed to

Asparagus racemosus. A polyherbal formula containing Asparagus racemosus has previously

been found to be effective in reducing vasomotor symptoms of menopause (Singh & Kulkarni,

2002). The galactogogue activity of Asparagus racemosus was demonstrated in a clinical study

in which it was shown to improve prolactin levels in lactating women (Gupta & Shaw, 2011).

Moreover, a recent animal model demonstrated that a dose-dependent aqueous extract of

Asparagus racemosus significantly stimulated the secretion of hypothalamic-pituitary-gonadal

axis hormones including gonadotropin releasing hormone (GnRH), FSH, LH, estrogen and

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progesterone hormones (Jashni et al., 2016). Tinospora cardifolia and Commiphora mukul are

botanicals that have been shown to modulate liver function and have anti-inflammatory activity in

animal models. There were no changes in liver function in this study, however women were

within healthy reference ranges at baseline. A recent study reported that postmenopausal

women who had a higher BMI, demonstrated higher levels of hs-CRP which was interpreted

as low-grade chronic inflammation and hence increased cardiovascular disease risk (Alves et

al., 2016). The BMI of women in the active group ranged from 18.4 – 38.1 with 61% of this

group having a BMI higher than 25. A reduction in inflammation would therefore prove

beneficial, however inflammatory markers were not assessed in this study and therefore it

cannot be determined if this formulation reduced inflammation in this cohort. Hussain et al.

(2015) recently demonstrated Tinospora cordifolia extract to have significant anti-pyretic,

analgesic and anti-inflammatory activity in a dose-dependent manner in an animal model. The

authors suggested that the inhibition of pain, inflammation and fever was probably due to the

presence of flavonoids and alkaloids. Furthermore, Kumari et al. (2016) demonstrated that

Tinospora cordifolia modulates lipid metabolism by inhibiting cholesterol and glucoronide

synthesis. The pharmacological activity of Commiphora mukul has been demonstrated in animal

and human studies for its anti-inflammatory (Singh et al., 2003), hypolipidemic (Ulbricht et al.,

2005) and anti-diabetic activities (Bellamkonda et al., 2011), as well as the amelioration of

hypothyroidism (Panda & Kar, 2005).

The limitations to the present study included a small sample size of women

representing various stages of menopausal transition; varying levels of symptom severity and

a wide range in oestradiol levels (ranging from <42 to 1090 pmol/L). The average symptom

duration of the menopause transition period and into the postmenopausal period is

approximately 10 years; symptoms rising sharply 2 years before the final menstrual period,

peaking at 1 year after the final menstrual period and not returning to premenopausal levels

until about 8 years after the final menstrual period (Politi et al., 2008). Hence, observing

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significant hormonal changes within such a short period, when they are naturally fluctuating

and declining, is expectedly unlikely.

5. Conclusion

In conclusion, we have demonstrated that over a 12-week period, a formulated Ayurvedic

medicine containing Tinospora cardifolia, Asparagus racemosus, Withania somnifera and

Commiphora mukul is safe and effective in relieving vasomotor symptoms of menopause and

improving psychosocial and adverse sexual symptoms that are typically associated with

menopause. Further clinical and pharmacological studies, including those of longer duration,

are required to understand the mechanistic actions of this Ayurvedic botanical combination in

menopausal women.

Conflict of interest

All authors have declared no conflict of interest.

Funding

This work was supported by Gencor Pacific, Hong Kong.

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