Effect of ashwagandha on adrenal hormones

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 1-16-Adrenal Insufficiency
Clinical
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-4
Diep Dinh Nguyen*, Cheryl Lyda Dabon Almirante, Shilpa Swamy, Lauren A. Willard, Danielle Castillo and Romesh Khardori
Eastern Virginia Medical School, Norfolk, VA
Background:
Ashwaganda is known as “winter cherry" and “immune booster”.  The biologic basis and exact mechanism of action of W. somnifera on various hormones in human is not well known.  Some of its reported functions include maintaining proper nourishment of tissues and supporting adrenal function.  We are presenting a case of hirsutism possibly from ashwagandha use.

Clinical case: 
51 year old Caucasian female with hypothyroidism, depression, fibromyalgia, hypertension, postmenopausal, morbid obesity, presented with increased facial hair for at least 3 months and mild galactorrhea.  Initial laboratory workup by her primary care physician showed DHEA sulfate 41.5 ug/dL, TSH of 0.69 mcU/mL, prolactin was normal at 1.5 ng/dL but her testosterone levels were low with total testosterone <3 ng/dL, free testosterone <0.04 ng/dL, % free testosterone of 1.2%.  Patient had been taking ashwagandha for at least one month prior to noticing increased facial hair growth. Given the structural similarity between ashwagandha and sterols, the patient was recommended to discontinue ashwagandha and repeat hormone testing.

3 months later, her repeated labs off ashwagandha showed FSH 16.3 miU/mL, LH 22.4miU/mL, estradiol 19 ng/dL, DHEA sulfate 32.1 ug/dL, total testosterone 15 ng/dL, free testosterone 0.43 ng/dL, % free testosterone 2.9%, androstenedione 14 ng/dL, SHBG 25.9 nmol/mL. Noteworthy, her DHEA sulfate decreased and testosterone levels increased and normalized off ashwagandha. Patient's hirsutism resolved.

Conclusion:
One needs to be aware of the various effects of ashwagandha on androgen mediated processes.  We postulate that ashwagandha inhibits the adrenal conversion of androstenedione to testosterone by inhibiting aldo-keto reductase AKR1C3 (HSD17B5) causing an elevation of DHEAS and lowering of testosterone levels, which was the pattern seen in our case.  We would like to share this experience so that clinicians encountering patients using ashwagandha are aware of hormonal changes reported here.  Often these remedies are viewed as harmless, and may go uninvestigated if a unique or unexpected clinical finding is encountered.

(1)  Kalani A, et al. Ashwagandha root in the treatment of non-classical adrenal hyperplasia. BMJ Case Rep. 2012 Sep 17;2012.   (2)  Van der Hooft CS, et al. Thyrotoxicosis following the use of Ashwagandha. Ned Tijdschr Geneeskd. 2005 Nov 19;149(47):2637-8. (3)  Ahmad MK, et al. Withania somnifera improves semen quality by regulating reproductive hormone levels and oxidative stress in seminal plasma of infertile males. Fertil Steril. 2010 Aug;94(3):989-96.

Nothing to Disclose: DDN, CLDA, SS, LAW, DC, RK

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