by Aviva Romm, MD, Tieraona Low Dog, MD
Women’s history is woven together with plants and the healing arts, particularly botanical medicine and midwifery. In virtually every culture, women maintained knowledge of herbal healing for the prevention and treatment of common maladies that afflicted their communities, including, notably, treatments for women’s concerns.
Because transmission of herbal knowledge historically was suppressed and marginalized, information on the practices of women healers must be “carefully teased out of a few surviving works written by women healers, from relics and artifacts, from myth and song, and from what was written about women.”1 And because of their exclusion from medical institutions, even well into the early 20th century, women had to use products from the natural world around them to treat their communities, especially women and children. Women’s medicine has always been largely based on herbal therapies, yet rarely were the contributions of these female herbalists recognized by conventional medical history. For example, the “discovery” of foxglove (Digitalis spp., Plantaginaceae) as a treatment for cardiac conditions is attributed to Sir William Withering, and the treatment’s alleged source, a woman herbalist who maintained a recipe book in which she apparently described employing the herb in a formula for dropsy (edema in the lower legs), is largely forgotten.
Although women have long handed down herbal knowledge to their daughters, both orally and in the form of “stillroom” books — the herbal equivalent of family recipe books — only a minority of women from the most privileged, educated backgrounds managed to keep comprehensive records or documentation of herbal “recipes.” While a rare few contributed tomes to the herbal canon on women’s, and general, health (Hildegarde of Bingen and The Trotula [a 12th-century collection of Italian texts on medicine for women’s health], for example), these, too, were largely marginalized by history’s relegation of women’s herbal wisdom to “old wives’ tales” and witchcraft. Negligibly few women published serious medical works until recent decades. Thus, this issue of HerbalGram, dedicated to the brilliant and beloved Fredi Kronenberg, Ph.D., who dedicated her life to the endeavor of botanical research, is especially important. And, it is a great honor, like medical doctors, herbalists, and midwives, who have made it our lifelong commitment to maintain the traditions of herbal healing in our lives and communities and bridge our traditional knowledge with the best of conventional medicine and science, to bring this special issue to you.
Together, we decided that addressing the following questions in a conversational format would bring a distilled essence of the power and importance of botanical medicines for women today.
As herbalists and midwives who became MDs, do you still use herbal medicines in clinical practice? To what extent?
Aviva Romm: Despite nearly a decade of medical training, which certainly encouraged reaching for a prescription pad first, the herbalist in me remains alive and well! Herbal therapies, along with dietary and nutritional interventions and mind-body approaches, remain the mainstay of my practice as a physician. I continue to use botanical medicines in nearly 100% of my patients, and always use them preferentially over conventional pharmaceuticals whenever possible for many mild-to-moderate, acute, or even complex chronic conditions. The reality is, in most cases, with the exception of emergencies and oncology, or advanced chronic disease (and sometimes even then), botanical medicines are safer and carry fewer side effects. Many botanical medicines are as effective as conventional pharmaceuticals can be cost-effective, and are ecologically sounder than pharmaceuticals. While we’ve seen numerous conventional medications recalled, black-boxed, or reconsidered when post-market surveillance or long-term human use revealed them to be much more harmful than initially anticipated, the track record of safety and efficacy of herbs as first-line therapies for many conditions remains largely reliable.
I also commonly use botanicals and conventional therapies in conjunction with each other. For example, if a patient has severe panic attacks brought on by air travel, her conventional anti-anxiety medication may be ideal for her next flight; however, for managing her daily anxiety, a combination of meditation, magnesium, Rhodiola (Rhodiola Rosea, Crassulaceae), and lemon balm (Melissa officinalis, Lamiaceae) maybe my prescribed protocol.
Herbal therapies also remain my first choice for health in my personal life — from herbs and spices in my food to a relaxing evening tea, to support my immune system during cold and flu season, to healing during those times something more is needed.
Tieraona Low Dog: Herbs always have been an integral part of my life and my clinical practice, and that didn’t change after receiving my medical degree. There are a definite time and place for modern, conventional medicine, and my deep desire to understand “when and what” to offer was a driving force for going to medical school. While some herbalist colleagues and friends thought that medical school might destroy or diminish my love of herbs, my medical training actually deepened my understanding and appreciation for them. Listening to a pathophysiology lecture about some disease would get me thinking about how certain plants could be beneficial. When urgent care providers prescribed antibiotics for viral infections in children, I talked with parents about elderberry (Sambucus spp., Adoxaceae) syrup or gave them a recipe for homemade thyme (Thymus spp., Lamiaceae) syrup. I see many people living with stress, worry, fatigue, insomnia, and chronic pain. Conventional pharmaceuticals are not the answer for most of these problems, but I have a whole pharmacopeia of plants to draw from. I prescribe more botanicals and dietary supplements than pharmaceuticals, by far, as part of a broader approach to medicine that includes nutrition, mind-body medicine, and other lifestyle recommendations. Knowing when and how to use botanicals makes me a more effective clinician. That knowledge, that ability to weave the plants into my practice, is a gift.
What is the importance of today’s practitioners’ including botanical medicines as part of their clinical repertoire?
AR: Practitioners must consider a wide range of factors when prescribing: therapeutic efficacy, safety, a patient’s severity of symptoms and risks on a spectrum of health and disease, patient preference for the types of treatments she uses, costs to the patient, costs to the health care system, and public health and ecological costs (for example, antibiotic resistance or the presence of conventional pharmaceuticals as contaminants in waters, soil, and food). Our task as practitioners is to find the sweet spot among these various considerations. Botanical therapies often satisfy all of these parameters, and, as such, they provide us with the best medicine for helping our patients to heal. Further, botanicals need not be a modality we turn to for treatment alone; they are an important part of daily support and health support for the common challenges humans face — a role that most pharmaceuticals do not fill.
TLD: While conventional medicine was born out of an acute-care model of trauma and infectious disease, most of the problems we are dealing with today are the result of our modern lifestyle. We are drowning in a tsunami of obesity, diabetes, cardiovascular disease, stroke, cancer, depression, anxiety, and chronic pain. The primary approach is disease management via pharmaceuticals. While early detection is an important part of conventional care, when it comes to prevention and general health promotion, it is all lip service. There remains very little focus on medical training on nutrition, dietary supplements, mind-body therapies, or strategies for empowering people to take a more active role in their own care. Without question, botanicals have a place within this broader, integrative approach to health.
Many people with stress, worry, irritability, and fatigue do not meet the criteria for prescription antidepressants or anxiolytics, and the data are not compelling, at least for antidepressants, that they are effective for those with milder forms of depression. However, there are many herbs with a long history of use and varying levels of modern research to support their consideration for these individuals. Chamomile (Matricaria chamomilla syn. M. recutita, Asteraceae) flowers, lemon balm, passionflower (Passiflora incarnata, Passifloraceae), valerian (Valeriana officinalis, Caprifoliaceae), ashwagandha (Withania somnifera, Solanaceae), eleuthero (Eleutherococcus senticosus, Araliaceae), Rhodiola, and skullcap (Scutellaria lateriflora, Lamiaceae) are a few that rise to the top of the list.
The opioid epidemic is real. Human suffering, both physical and emotional, is real. Pain is a vicious cycle that leads to disrupted sleep, depressed mood, anticipatory anxiety, hypersensitivity, and diminished quality of life. Botanicals can be used to address many of these issues as well. Turmeric (Curcuma longa, Zingiberaceae), boswellia (Boswellia serrata, Burseraceae), devil’s claw (Harpagophytum procumbens and H. zeyheri, Pedaliaceae), corydalis (Corydalis spp., Papaveraceae), cannabis (Cannabis sativa, Cannabaceae), cramp bark (Viburnum opulus, Adoxaceae), kava (Piper methysticum, Piperaceae), ashwagandha, California poppy (Eschscholzia californica, Papaveraceae), and others can act as muscle relaxants, anti-inflammatories, analgesics, anxiety reducers, and/or mood boosters. Plants have multi-modal effects in the body. Unlike single-compound drugs, botanicals have an array of constituents that have the potential to interact with a wide range of cellular receptors. As part of an integrative strategy, plants can help our body regain its equilibrium.
What concerns, if any, do you have about the current state of herbal research or the herbal industry in general?
AR: While the number of studies on herbal therapies has increased tremendously over the past two decades, which is exciting, quality studies are, unfortunately, few and far between. This leaves many practitioners to base our herbal recommendations on a combination of the best available evidence, traditional use, and trusted professional opinions — or, understandably, to toss our hands up, confused. A limited number of botanicals are backed by high-quality studies; too often, the studies we see are poorly designed, lack adequate power, and don’t disclose enough product information, making them unreliable, clinically unhelpful, and of dubious relevance. I often find myself discarding research that comes across my desk.
Unfortunately, many manufacturers and most “online experts” in wellness and herbal medicine lack the training it takes to discern the value of published research. When these sources promulgate half-truths, exaggerated claims, and misinformation, practitioners and consumers alike are left confused and reliant on products that can be costly and ineffective. False product claims are rampant on the internet and are associated with a range of products, from those used for skincare to hormone therapy to cancer treatment. Training and information dissemination standards are needed at all levels of the wellness, botanical medicine, and supplements industry to ensure that the end-user is able to obtain both information and products that are reliable. Of course, this also means that better research is needed — and thus quality botanical research needs to be a priority at high-level institutions.
TLD: As a scientist and clinician, I am, of course, a strong advocate of well-done botanical research. While more rigorous studies are being conducted, solid research is still rather scarce in our field. In clinical trials, the herb used to address a specific problem is often poorly chosen, inappropriately dosed, or so poorly described that you have no real idea of what was used. The results of a low-quality study are relatively meaningless, though this doesn’t stop believers from citing them as proof that an herb “works,” or critics from using them to say the herb is “worthless.” Because herbal research often is delivered in media soundbites by those with no familiarity with the complexities of the topic, misreporting is commonplace and contributes to the confusion around the safe and appropriate use of herbal medicines.
As far as the herbal industry is concerned, many companies make good products, but the fact that adulteration still exists is just inexcusable. In addition to legitimate concerns about quality, the sheer number of products in the marketplace is frankly overwhelming. Sorting through products with widely varying dose ranges, herbal combinations, and vague, sometimes outrageous claims, is a highly confusing experience for most consumers. I’ve been involved in practitioner education for more than two decades and can honestly say that even with training, many health care professionals report feeling overwhelmed when standing in the supplement aisle. An authoritative, easily accessible, scientifically based database that is free and understandable to the public could help people make informed decisions. Policymakers can look to Europe and Canada for other ways of addressing what claims can be made on the label to help consumers make informed decisions at the point of purchase.
How can practitioners determine which herbal products to recommend to patients?
AR: This is one of the most common questions I receive from practitioners, and perhaps the most difficult to answer because so many companies and products are on the market right now. While products must conform to a general set of quality and safety standards, there is still a tremendous amount of variability in raw materials and manufacturing practices, which ultimately determine the quality and efficacy of the medicine. When I prescribe a medicine to a patient with a medical condition, whether it be a conventional pharmaceutical or a botanical, I like to know that I can rely on its efficacy — which means it has to contain the ingredients that I am depending on for effects and outcomes, and should not contain unintended ingredients (contaminants), or intended but undeclared ingredients (adulterants). Yet in the current market, neither is guaranteed, and this is indeed a challenge. I therefore generally recommend companies that were created and are run by respected herbalists, as there is generally a higher level of respect for the need for raw material quality, and companies with high-quality assurance standards. I also recommend using products only from companies large enough to comply with Good Manufacturing Practices (GMPs),* and those that emphasize ecological practices and high-quality sourcing. Additionally, I recommend, when possible, using companies that are members of the American Herbal Products Association. I also concur with Dr. Low Dog on the additional steps you can take, as described below.
TLD: This is tough to answer, given everything that I’ve already mentioned. Clinicians can use extracts or products that have been studied in clinical trials. The fact that it was used in research gives clinicians a level of confidence in the quality and safety of the product, as well as in their dosing recommendations. However, most clinicians are unaware of which products have been used in clinical research. This is made worse by the fact that continuing medical education (CME) granting bodies do not allow speakers to mention commercial product names; they specifically ask that “generic” names be used. While this works for conventional pharmaceuticals, it is simply ludicrous when discussing herbal research. Talking about a study on “Rhodiola” tells you nothing about the species, the part used, solvent, native extract ratio, etc. One helpful tip for clinicians is that those who have access to Natural Medicines Database can view the brand names of herbs and extracts that have been studied in clinical trials under the specific botanical monograph.
Some companies have United States Pharmacopeia (USP) or NSF quality seals on their labels, another good indicator of quality, but this is not common for most botanical products. Clinicians can talk directly with companies and ask questions about their quality control and check the FDA website to see if any warning letters have been issued. Practitioners can also talk with local retailers and ask what quality processes they have in place for the supplements they sell. Some, like Pharmaca, have a very lengthy application process for companies to sell products in their stores.
Do you see herbs as “green” allopathic substitutes/alternatives, or do they hold additional meaning and value to you?
AR: I do think plants have a role as green pharmaceuticals. I often use botanicals for specific therapeutic effects based on their pharmacologic actions in place of conventional pharmaceuticals, whether it is pyrrolizidine alkaloid (PA)-free Petasites (Petasites spp., Asteraceae) root extract for migraines or lavender (Lavandula spp., Lamiaceae) oil for anxiety. But botanical medicines have the potential, for the curious and open-minded practitioner and patient, to serve as more — they can be a powerful, beautiful, meaningful bridge to connect with the innate healing power of nature, and, in doing so, with our own intrinsic healing capacities. When I prescribe a botanical remedy to a patient, it is usually a plant I have encountered — in my garden, in the woods, along a creek, roadside, or mountain hike — and I know the plant’s habitat, growth habits, resilience, and beauty. My garden has served as an opportunity to introduce patients to the plant remedies I have prescribed them — the chamomile or lemon balm they will later use in their sleep remedy, the echinacea (Echinacea spp., Asteraceae) in their tincture for a cold, or the ashwagandha in their adaptogen blend — and it is eye-opening for them, as most of us think of medicines as inaccessible, sterile, laboratory-manufactured products. It can inspire whole new respect for the planet and a desire to protect natural places.
Plants also have been used ceremonially throughout the world and across cultures — from incense in India or a Catholic church to burning spices at the close of the Sabbath in Jewish tradition, or burning sage (Salvia officinalis, Lamiaceae) and cedar (Juniperus spp., Cupressaceae) in a sweat lodge — they can be part of the connection we make, if we allow it, between ourselves and whatever you consider spirit in your life. Rituals can have a profound role in slowing down, going within, healing, and tapping into innate body wisdom. Plants play a role in my life every day, and each time I connect with one of these healers in nature, I am reminded that I am part of all of this beautiful creation — not separate from it — and that there is great wisdom in nature, in my body, and in each of my patients.
TLD: Plants often do represent a safer, greener alternative to a pharmaceutical drug. That’s important in and of itself. But that’s not all there is. There is something about using herbal medicine that’s missing with pharmaceuticals: connection. One day as a medical student, after seeing a patient with strep throat, my attending physician asked me to write a prescription for amoxicillin. As I sat looking at the blank prescription form, he asked if I needed help. I said no but then asked, “How exactly is amoxicillin made? Where does it come from? From a fungus, like penicillin?” The attending physician said he didn’t know and then asked why it mattered. I told him, “I’ve never given anybody a medicine I didn’t make myself. It feels strange.”
You see, I’d been gathering and growing plants and making them into teas, tinctures, syrups, and salves for years. I tasted them. I used them. I gave them to my babies. I gave them to hundreds and hundreds of people and learned what did and didn’t work. I used them in the clinic. I used them in ritual. I had my own personal experience with them, not just from reading books or listening to experts, but from directly interacting with them. I’ve wandered the deserts, forests, and mountains of New Mexico for decades looking for medicine. And I found it everywhere. I learned where the plants lived. I learned how to use their gifts. I learned their stories.
So, is there something deeper? Definitely.
Aviva Romm, MD, and Tieraona Low Dog, MD, are long-time members of the American Botanical Council (ABC) Advisory Board. The views expressed in this Q&A are their own and do not necessarily reflect those of ABC and HerbalGram.
Aviva Romm, MD, is a midwife, herbalist, and Yale-trained MD, board-certified in family medicine with obstetrics, who has been bridging what she considers the best of traditional medicine with good science for more than three decades. She focuses on identifying and reversing the root causes of chronic health conditions in women’s, maternal, and pediatric health. She is considered a leader in botanical medicine and is the author of seven books on natural medicine, including the textbook Botanical Medicine for Women’s Health (Elsevier), which won the 2010 ABC James A. Duke Excellence in Botanical Literature Award, and The Adrenal Thyroid Revolution (Harper One). She is also a co-author of The American Herbal Products Association’s Botanical Safety Handbook, 2nd edition (CRC Press). For more than a decade, Romm served as both the president of the American Herbalists Guild and medical director of the American Herbal Pharmacopoeia and as a botanical industry consultant. She is the co-founder of the Yale Integrative Medicine Curriculum. Romm lives and practices medicine in the Berkshires and New York City, respectively.
Tieraona Low Dog, MD, is a physician, author, and thought leader in integrative medicine. Her background in herbal medicine, midwifery, massage, and martial arts made her a natural choice to lead the fellowship program at the University of Arizona Center for Integrative Medicine, where she oversaw the training of more than 600 physicians and nurse practitioners. Low Dog is one of the nation’s foremost experts in dietary supplements and botanical medicine and has been honored with many awards from academia, public health, and industry throughout her 40-year career. A prolific scholar, she has authored or co-authored 52 peer-reviewed journal articles, 22 chapters for medical textbooks, and five books, including four with National Geographic; and was co-editor of Integrative Women’s Health (Oxford University Press). She has chaired expert panels for supplement/botanical safety at the United States Pharmacopeia, including joint reviews with the Department of Defense, for the past 20 years. Low Dog has been an invited speaker at more than 600 conferences, reaching more than 50,000 people every year with her message of integrative medicine, compassionate care, and deep ecology. She lives and practices outside of Santa Fe, New Mexico.
1. Achterberg J. Woman as Healer: A Panoramic Survey of the Healing Activities of Women from Prehistoric Times to the Present. Boston, MA: Shambhala; 1991. In: Romm A. Botanical Medicine for Women’s Health, 2nd ed. St. Louis, MO: Elsevier; 2017.