St John's Wort

St John's Wort herbal tincture


St John's Wort

Whilst medical herbalists may not have so much use for St John's Wort as a wound herb as they did in the past, it is still used a lot for inflammation and bleeding in the digestive tract. Its application to the nervous system is much wider than just for stress and depression. It is employed in neuralgias, and herbalists apply its anodyne qualities to treating shingles - internally as a tea or tincture and externally as oil. It also has regenerative effects on nervous tissue. Whilst nervous tissue normally recovers only very slowly from damage, lesions from operations and accidents may be helped in their healing by St John's Wort. Hypericum also has a mild tonic action on the liver.

The focus upon St John's Wort as the herb for depression not only diverts attention away from other herbs such as Lemon Balm but also assumes that depression is an illness that can be treated with a medicine. Whilst there are some depressive states that can be seen as a result of chemical imbalance in the body and which respond well to medication, herbal or pharmaceutical, most of us recognise that "depression" is to do with our interactions with the world around us. Whilst uplifting nervine herbs may be a source of support during hard times, they are not going to remake a broken marriage, remedy someone's poverty or redundancy from work or heal the pain of an abusive childhood. The attitude that says we can sort our lives out by taking a tablet is the one that stops us listening to the messages and the learning that illness can bring.


Another general issue about the marketing of herbs by the over - the counter (OTC) industry that is highlighted by St John's Wort is that of "standardisation". Whilst people and plants are variable in their makeup, industry requires a standardised product. It is reasonable, if buying a product, to want to know that what I buy this month is of the same quality as that I purchased before. The way that the OTC industry reassures us is to calibrate levels of certain chemical constituents of a herb and to make sure that these are maintained in its products. Usually one key active constituent is taken as the marker - in the case of St John's Wort this has been the red pigment, hypericin. The implication here is that hypericin is the essence of Hypericum, and that the anti-depressive activity of the plant is generated by this compound.

Chemists have determined what they think is the optimum level of hypericin that a plant sample should contain. As a crop of St John's Wort is processed its hypericin content is assessed. If the amount is too high then some is removed. If there is not enough then more hypericin is added. The label on the finished product will then proclaim "standardised for hypericin content" and will give a percentage figure to indicate its content.

In some ways this is a modern version of what the pharmaceutical industry has done with plants for over a hundred years - identifying the "active constituent" and taking it out to turn it into a drug. Only now it is taken out and then put back into a processed sample of the same plant. We have seen that extraction and synthesis of plant chemicals has led to an increase of potency but also of unwanted side effects. There is beginning to be a suspicion that a similar charge could be levelled at standardised extracts.

There is a humorous footnote to add here. There have been many clinical trials to assess the antidepressant activity of St John's Wort, most of them with standardised extracts. More recently a trial was done with St John's Wort which had had the hypericin removed. It was found to be efficacious in relieving depression!

Side Effects

Historically the main unwanted side effect that has been noted with the use of St John's Wort has been increased sensitivity to light. Some individuals using the plant may develop a skin reaction in strong sunshine. Actually this is an effect that has been noted in livestock far more frequently than in people and it is assumed that this reaction is relatively unusual in humans.

Near the beginning of the year 2000 the Medicines Control Agency in Britain published information concerning dangerous potential interactions between St John's Wort and pharmaceutical medication. These fell into two categories: 1. Some medicines that act on the central nervous system are potentiated 2. Some medicines that are cleared from the body by the liver are cleared more quickly than usual resulting in lower amounts of the medication in the bloodstream. Those medicines in the first category included Prozac and similar antidepressive drugs. Those in the second category included drugs used to treat epilepsy and clotting disorders, those used to stop the body rejecting transplants and the contraceptive pill.

Several points can be made about this. People taking herbal medication and orthodox medicines need to be aware that there are potential interactions between them. In the marketing of Hypericum's anti-depressive action its liver function enhancing effects have been neglected, but since many herbs act on the liver it is to be expected that more herb/drug interactions will come to light. It is recommended that people taking OTC herbal remedies inform their doctors of the fact. To be on the safe side, many doctors have reacted by advising people to cease taking St John's Wort, whereas monitoring blood levels of crucial drugs would be another course of action.

The effects of St John's Wort in lowering the effectiveness of the contraceptive pill are theoretical. Given the huge OTC sales of St John's Wort (£6 billion reported in 1999) and that more women purchase the herb than men, one would expect problems to be reported. It is, however, worth bearing in mind.

All reported actual and potential drug/herb interactions with St John's Wort all relate to standardised extracts. Medical herbalists tend to regard teas and tinctures as safer products.

It is also worth noting that problems with a particular herb or a sample of a particular herb still often result in an outcry against herbal medication in general, compared to problems with individual pharmaceutical drugs being perceived as just concerning that particular medication.

with thanks and acknowledgements to fellow medical herbalist Bendle in Sheffield

© Bendle MNIMH

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General advice to consumers on the use of herbal remedies from the Medicines Healthcare products Regulatory Agency

From the website of the Medicines Healthcare products Regulatory Agency ( Department of Health, UK

• Remember that herbal remedies are medicines. As with any other medicine they are likely to have an effect on the body and should be used with care. • Herbal remedies may sometimes interact with other medicines. This makes it particularly important to tell your doctor or pharmacist if you are taking a herbal remedy with other medicines such as prescribed medicines (those provided through your doctor or dentist). • Treat with caution any suggestion that a herbal remedy is '100% safe' or is 'safe because it is natural'. Many plants, trees, fungi and algae can be poisonous to humans. It is worth remembering that many pharmaceuticals have been developed or derived from these sources because of the powerful compounds they contain. Any medicine, including herbal remedies, which have an effect on the body should be used with care. • Treat with caution any herbalist or other person who supplies herbal remedies if they are unwilling or unable to provide written information, in English, listing the ingredients of the herbal remedy they are providing. • If you are due to have a surgical operation you should always remember to tell your doctor about any herbal remedy that you are taking. • Anyone who has previously experienced any liver complaint, or any other serious health complaint is advised not to take any herbal remedy without speaking to their doctor first.


Pregnant/Breast-feeding mothers

Few conventional medicines have been established as safe to take during pregnancy and it is generally recognised that no medicine should be taken unless the benefit to the mother outweighs any possible risk to the foetus. This rule should also be applied to herbal medicinal products. However, herbal products are often promoted to the public as being “natural” and completely “safe” alternatives to conventional medicines. Some herbal ingredients that specifically should be avoided or used with caution during pregnancy. As with conventional medicines, no herbal products should be taken during pregnancy unless the benefit outweighs the potential risk.

Volatile Oils

Many herbs are traditionally reputed to be abortifacient and for some this reputation can be attributed to their volatile oil component.(6) A number of volatile oils are irritant to the genito-urinary tract if ingested and may induce uterine contractions. Herbs that contain irritant volatile oils include ground ivy, juniper, parsley, pennyroyal, sage, tansy and yarrow. Some of these oils contain the terpenoid constituent, thujone, which is known to be abortifacient. Pennyroyal oil also contains the hepatotoxic terpenoid constituent, pulegone. A case of liver failure in a woman who ingested pennyroyal oil as an abortifacient has been documented.


A stimulant or spasmolytic action on uterine muscle has been documented for some herbal ingredients including blue cohosh, burdock, fenugreek, golden seal, hawthorn, jamaica dogwood, motherwort, nettle, raspberry, and vervain. Herbal Teas Increased awareness of the harmful effects associated with excessive tea and coffee consumption has prompted many individuals to switch to herbal teas. Whilst some herbal teas may offer pleasant alternatives to tea and coffee, some contain pharmacologically active herbal ingredients, which may have unpredictable effects depending on the quantity of tea consumed and strength of the brew. Some herbal teas contain laxative herbal ingredients such as senna, frangula, and cascara. In general stimulant laxative preparations are not recommended during pregnancy and the use of unstandardised laxative preparations is particularly unsuitable. A case of hepatotoxicity in a newborn baby has been documented in which the mother consumed a herbal tea during pregnancy as an expectorant. Following analysis the herbal tea was reported to contain pyrrolizidine alkaloids which are known to be hepatotoxic.

Breast-feeding mothers

A drug substance taken by a breast-feeding mother presents a hazard if it is transferred to the breast milk in pharmacologically or toxicologically significant amounts. Limited information is available regarding the safety of conventional medicines taken during breast-feeding. Much less information exists for herbal ingredients, and generally the use of herbal remedies is not recommended during lactation.

Paediatric Use

Herbal remedies have traditionally been used to treat both adults and children. Herbal remedies may offer a milder alternative to some conventional medicines, although the suitability of a herbal remedy needs to be considered with respect to quality, safety and efficacy. Herbal remedies should be used with caution in children and medical advice should be sought if in doubt. Chamomile is a popular remedy used to treat teething pains in babies. However, chamomile is known to contain allergenic sesquiterpene lactones and should therefore be used with caution. The administration of herbal teas to children needs to be considered carefully and professional advice may be needed.

Perioperative use

The need for patients to discontinue herbal medicinal products prior to surgery has recently been proposed. The authors considered eight commonly used herbal medicinal products (echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John’s Wort, valerian). On the evidence available they concluded that the potential existed for direct pharmacological effects, pharmacodynamic interactions and pharmacokinetic interactions. The need for physicians to have a clear understanding of the herbal medicinal products being used by patients and to take a detailed history was highlighted. The American Society of Anaesthesiologists (ASA) has advised patients to tell their doctor if they are taking herbal products before surgery and has reported that a number of anaesthesiologists have reported significant changes in heart rate or blood pressure in some patients who have been taking herbal medicinal products including St John’s Wort, ginkgo and ginseng. MCA is currently investigating a serious adverse reaction associated with the use of ginkgo prior to surgery. In this case, the patient who was undergoing hip replacement experienced uncontrolled bleeding thought to be related to the use of ginkgo.

From the website of the Medicines Healthcare products Regulatory Agency ( Department of Health, UK


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