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JUNE/JULY 2001 - St John's Wort - Hypericum perforatum
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Read on for a detailed and realistic appraisal of St John's Wort, how to prepare it, current uses, research review and more....
Written by Isla Burgess. Photos by Barry O'Brien
June 21st, St John's day, the day the harvest of the flowering tips of St John's Wort (Hypericum perforatum) was begun in the northern hemisphere. This sun loving plant is often ready for picking before the equivalent season in parts of the southern hemisphere, especially New Zealand and Australia probably due to the more intense sunlight in these places.
The old ways….
'I have oft times declared how by outward shapes and qualities of things we know their inward virtues which God put in them for the good of man. So in St John's Wort we may take notice of the leaves.One. The porosities of the holes in the leaves signify to us that this herb helps both inward or outward holes or cuts in the skin…Two. The flowers of St John's Wort when they are putrified they are like blood which teacheth us that this herb is good for wounds, to close them and fill them up.'
English translation of Paracelsus
On the Doctrine of Signatures
A simple balsam prepared from it he states'. .puts to shame all recipes and doctors, they may yell as they wish, they will only break their teeth.'
It doesn't take much stretching of the imagination to uncover yet some other 'signatures';
the perforations in the 'skin' could represent bacteria
the brilliant yellow flower focusing on the 'yellow' centre, the colour attributed in many traditions to the liver/gall bladder area
the intense red stain left after squeezing the opening bud, the blood
All early astrological references place St John's Wort under the sun's influence,
does it bring 'light' to those who use it?
The new ways….
An ancient plant, a noxious weed in some places, an invasive weed becomes one of the most researched talked about plants because of its extraordinary widespread use and effectiveness.
Many preparations are now available as whole plant and standardised fluid extracts tablets, capsules and oils. Quite difficult for the discerning buyer.
'…the aim must be to link every proprietary product and every formulation with a definite concept of the plant on which it is based, not only as regards its actions, but also its appearance and the part used whether leaf, flower or root and so on.'
Rudolph Fritz Weiss MD Herbal Medicine
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WHAT PLANT?
Botanical description and habitat
A native of Europe, this perennial wild plant is now found in many parts of the world. Sun loving and requiring room to spread St John's Wort is found on roadsides and pasture and other open areas.
Height: Approx. 0.5 metre
Roots: A creeping mat with slender rhizomes often with a reddish/pink base.
Stems: Often reddish at the tips which is more intense as the plant forms buds.
Upright and woody at the base, dying down in autumn.
Leaves: Mostly oval with smooth (entire) margins and dotted with translucent oil glands, easily seen when held up to the light. No stems.
Flowers (Inflorescence): Terminal clusters of bright yellow, with 5 petals, 5 sepals and stamens in three bundles. Flowering for two to three months after the longest day.
The flowers and buds yield a reddish/purple stain on squashing.
Seed Capsule: Small black seeds are encapsulated by a dry ovoid 6-8mm long capsule.
Growing Hints: Full sun, with little competition from other plants. Best grown in its own bed as St John's Wort can become invasive. Easily grown from root division.
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WHAT PART AND WHEN TO HARVEST?
The flowering tips with some leaf are at their best for harvesting when the first blossom in the cluster opens.
HOW TO USE TRADITIONAL USES
For Internal use;
Nervous states
- excitability
- nervousness
- neuroses
Disorders of the Spine
- neuralgia
- sciatica
- spinal injuries
For External use;
For skin ailments
- ulcers
- burns
- wounds
- bruises
- shingles
CURRENT USES
While herbalists today still use St John's Wort for all of the above, pharmacological studies have added other uses:
Viral Infections
- all the herpes infections
- chicken pox
- shingles
- glandular fever
- viral infections of the liver
Other
- mild to medium depression
- anxiety
- seasonal affective disorder
- athletic endurance
- alcoholism
- restoration of melatonin levels in some sleep disorders
HOW TO PREPARE
Medicinal preparations can be made from both dried and fresh plants.
Traditionally an infusion was likely used and now liquid extracts (fluid extracts, tinctures) and tablets are made. Many standardised preparations are available.
St John's Wort infusion
This is prepared by pouring a litre of near boiling water over 2 big handfuls of dried plant material in a covered container. That is, a litre to about 15gm of herb. Traditional preparations used 30 gm of herb.
Infusion time 2-4 hours
St John's Wort tincture
It is possible to make good quality herbal tinctures at home which are as therapeutically active as commercial preparations.
FOR DRIED PLANTS
Take 50gm. of finely ground plant material, place it in a jar with 250mls. of menstruum (the alcohol/water mix). You will need 45% alcohol or 90% proof. Blue label vodka is excellent. This makes a 1:5 preparation where one part of the herb is represented by five parts of the menstruum. Macerate (allow to sit)for 2 to 6 weeks. I prefer to macerate for at least a moon cycle the time allowed depends on when the preparation is made.
FROM FRESH PLANTS
This is a little more involved because we have to take the amount of water in the plant into consideration. St. John's Wort on average has 70% water in the fresh plant.
Place 100gms of finely chopped fresh plant in 230 mls of 45% alcohol. This will give a 1:10 preparation and 34.5% alcohol, not optimum but fine for home use.
The maceration time is as for dried plant tinctures.
When the maceration is complete, the plant material is pressed out. It is important that as much as possible of the precious liquid is squeezed out. This can be done using a citrus or wine press or squeezing the liquid through a square of cotton or cheese cloth. The tincture can now be bottled, preferably in amber glass, stored away from the light and at an even temperature. Some herbalists also filter the liquid at this stage.
St John's Wort oil
Collect the flowering tips after the dew has dried. Allow to wilt for a day in the shade. Finely chop the plant material and loosely pack it into a jar. Cover it well with a cold pressed oil or extra virgin olive oil.
Seal the jar, put it in brown paper bag in the sun for 2 weeks.
Strain when ready and leave to settle for 2-3 days. Some moisture will collect at the bottom of the jar and needs to be removed. Decant 1 or 2 times as necessary.
HAVE FUN!
HOW MUCH TO USE
For infusions at 15gms per litre the suggested dose would be 1 cup or 200mls. 2x/day equal to 3gms a dose.
For 1:5 tincture 7.5-15mls daily in divided doses
For oils, use topically as required.
For tablets the equivalent of 2-5gms dried herb per day
How long to use St John's Wort depends on the condition and person for which it is used.
At least 4-6 weeks are required for the treatment of medium to mild depression.
SAFETY
There have been a few reports of people becoming light sensitive with doses higher than those mentioned above and it should not be self prescribed in the first trimester of pregnancy or if on other medication.
YOUR QUALIFIED MEDICAL HERBALIST KNOWS WHEN IT IS SAFE TO USE
RESEARCH REVIEW
A REALISTIC APPRAISAL OF ST JOHNS WORT
An evaluation of recent articles, news items and reports.
Sometime between AD 60-78, Dioscorides in De Materia Medica wrote about St Johns wort (Hypericum perforatum) giving it no greater praise than any other plant used at that time. Now, two centuries of use later, this humble, noxious weed is one of the most examined, used and tested medicinal plants.
Evaluating recent articles, news items and reports on St. Johns wort from a 'evidence-based medicine' perspective provides some interesting guidelines for its use.
That Hypericum is efficacious in treating mild- to- moderate depression is now not being contested. At least 31 studies support this, one example being a study published in December 1999 in the British Medical Journal (Philipp et al., 1999). The authors of this report concluded that, at an average dose of 350 mg three times daily, St. John's wort extract was more effective than placebo and at least as effective as 100 mg of imipramine daily in the treatment of mild-to-moderate depression. This British Medical Journal paper also noted that patients tolerated St. John's wort extracts better than they did tricyclic antidepressants and that, in terms of adverse events, the St. John's wort group was comparable to the placebo group.
The Journal of the American Medical Association, (JAMA) Vol. 285, No. 15, presented the results of a Randomised controlled trial by Shelton, R.C., et al, which the authors claimed negated all the previous studies but it was studying the markers on the Hamilton rating scale for major depression and did not compare the use of St. John's wort with other anti-depressants. No other study has been carried out using St. John's wort for major depression.
Interaction with conventional anti-depressants
E Ernst published an article in The Lancet December 1999 stating that the 'mode of action for Hypericum extracts is thought to be similar to that of conventional serotonin re-uptake inhibitors' but that it has a 'unique and as yet unknown mechanism of action unlike conventional anti-depressant drugs'.
Until we have more information it would be reasonable to suggest that St. Johns wort could interact like conventional anti-depressants with monoamine oxidase inhibitors (MAOI'S). There have been no reports of interactions between St John's wort and benzodiazepines.
Interaction with other drugs
Most of the more recent publicity has focused on the interaction of St John's wort with some conventional drugs. All the recent reports do need to be evaluated against the fact that Hypericum has an extraordinary widespread use, $6 billion in Europe alone in 1999. We can only estimate that this would be comparable in the United States amounting to several hundred million doses.
Different reports each suggest that St John's wort may influence cytochrome P450 enzymes and thus affect the metabolism and efficacy of certain drugs. Most report that it induces the hepatic cytochrome P450 system and one (in vitro) showed an inhibitory effect.
While any one report is not conclusive, together they need to be taken seriously although it should also be noted that grapefruit juice, cruciferous vegetables, red wine, charcoal-grilled beef, a high protein low carbohydrate diet have all been demonstrated to induce Cytochrome P450.
The specific drugs named for potential interaction are; warfarin and digoxin; anti-convulsants used to treat epilepsy; theophylline, used for asthma; SSRI's used for depression; triptans, used to treat migraines; cyclosporin; indinavir; and others used for HIV infection and oral contraceptives.
The studies on most of these drugs do point to some interaction although most used a standardised preparation of St. John' wort, where the level of one constituent is regulated. Medical herbalists generally use a whole plant extract, particularly important for St. John' wort as its therapeutic actions are now thought to be due to the synergistic effects of all its constituents as found in the plant. The standardised extracts could have a different clinical outcome. The clinical implications are that if St. John' wort is added to the treatment regime for patients an increase in dosage requirements can be anticipated due to an accelerated clearance and conversely discontinuation of St. John' wort may increase the blood levels of certain drugs.
Interaction with Oral Contraceptives?
An example of exaggerated reporting has its roots in a letter from the Swedish Medicines Product Agency (MPA) in The Lancet 2000;355:548 suggesting a potential interaction between St. John' Wort and the contraceptive pill. Eight cases of intermenstrual bleeding and one of changed menstrual bleeding were reported by a manufacturer. When evaluated against the extraordinary widespread use of St. John' Wort and that 'more women use Hypericum than men' (Ernst, Lancet, 1999) so it follows that as considerable number of women are using both, one would expect many more reports that the eight cited cases above. One should also note that intermenstrual bleeding is a well documented occurrence in women taking the low dose oral contraceptive. Taking both the report and the side effects of oral contraceptives into consideration can these few cases be said to be clinically significant?
RECENT STATISTICS
For the 52 weeks ending Jan 7, 2001 HerbalGram No. 51
In USA $55,987,692 of St John's Wort sold
In units =6,841,275units
In 1999 in Europe an estimated $6 billion
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DEFINITIONS AND DESCRIPTIONS
STANDARDISED EXTRACT
Where a chemical constituent in the plant is at a set level between batches of the commercial preparation. In the case of St John's Wort the level is set at that which has been used in the clinical trials.
LIQUID EXTRACT
These are tinctures made by maceration, or fluid extracts generally prepared by percolation usually using alcohol to extract the plant constituents.
They are used by herbalists because a more precise dose and more personalised formulation can be prepared.
TABLETS
A great degree of processing is required to achieve a therapeutic dose in a tablet.
Also precise formulations and dosing are difficult to achieve.
CAPSULES
Convenient but many would have to be taken to achieve a therapeutic dose.
INFUSIONS AND DECOCTIONS
These were the traditional ways of preparing herbal medicines. Many herbalists continue to use these and they are especially useful for the treatment of people with fevers and urinary tract infections, as well as for nourishment.
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REFERENCES
BOOKS
Burgess, I., WEEDS HEAL A Working Herbal, Viriditas Publishing, 1998
Fisher, C., and Painter, G., Materia Medica of Western Herbs for the Southern Hemisphere, C. Fisher/G.Painter, 1996
Mills, S.Y., and Bone, K., Principles and Practice of Phytotherapy, Churchill livingston, 2001
Mills, S.Y., The Dictionary Of Modem Herbalism, Melboume: Lothian, 1985.
Mills, S.Y., Out Of The Earth, London, Penguin, 1991.
Weiss, R.F., Herbal Medicine, Beacons field, Beaconsfield Publishers, 1988.
JOURNALS
Bailey DG et al, Grapefruit juice-drug interactions. Br J Clin Pharmacol 46(2):101-110,1998
Chan WK et al, Mechanism based on inactivation of human cytochrome P450 3A4 by grapefruit juice and red wine. Life Sci, 1998;62(10):135-142
Ernst E. Second Thoughts About The Safety of St John's Wort. Lancet,1999;345:2041-2016
Jobst KA, et al, Safety of St John's Wort. Lancet 2000;355:575
McIntyre M, A Review of the Benefits, Adverse effects, Drug Interactions, and Safety of St John's Wort. J Alt Compl Med 2000;6:2, 115-124
Philipp M et al, Hypericum extract versus imipramine or placebo in patients with moderate depression. BMJ, 1999;319:1534-1539
Shelton RC et al, Effevtiveness of St John's Wort in major Depression. JAMA 2001;285:15
Vistisen K,et al, Cytochrome P450 1A2 activity in man measured by caffeine metabolism:effect of smoking, broccoli and exercise. Adv Exp Med Biol, 1991;283:407-411
REFLECTIONS
- Does a standardised preparation mean less of other constituents in an extract? This is important when the active constituents in St John's Wort at least for use in treating mild to medium depression is unknown.
- How does the change in the process of extraction i.e. from water based to alcohol extract, or the use of plant material directly as in tablets or capsules, affect its action?
- If the growth of a plant is situation dependant i.e. full sun, does the level of constituents alter around the globe? Eg. Plants growing in Europe compared with those growing in New Zealand.
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