Ashwagandha is a supplement that is often mentioned as “regulating hormones” and “balancing menstrual cycles” – mostly related to the stress aspect. Let’s check it out and see if it might be beneficial, harmful, or have no impact on regaining periods missing due to hypothalamic amenorrhea (HA) / no periods (a component of female athlete triad or Relative Energy Deficiency in Sport). For info on other supplements and their helpfulness with restoring missing cycles, see this post.
The latin name for ashwagandha is withania somnifera, also known as winter cherry, indian ginseng, and ashwagandha. The active components are withanolide glycosides (also known as sitoinosides), and withanolide aglycones.
It seems from my reading that the major impact of ashwagandha is thought to be on stress reduction. So what does the medical literature have to say?
I’m actually going to begin with side effects and contra-indications (cases in which one should not take ashwagandha). There isn’t a huge amount of evidence of detrimental effects, but I find it in enough places as to warrant some thought and concern – I don’t think this is necessarily a case where this supplement is completely benign. So read through the potential negatives, weigh them against the positives, talk with your doctor, and make a decision together as to whether this is something that might be useful for you.
Side effects and contra-indications for Ashwagandha
Overall, adverse events in the studies I review below were minimal and unlikely to be related to consumption of ashwagandha extract. However, one paper did note that those allergic to herbs belonging to the Solanaceae family (tomatoes, potatoes, peppers etc.) should not take ashwagandha.
There are also random links you can find that suggest other potential side effects… (including links to medical articles which is nice) – but their reading of some of the evidence is somewhat different from mine. The author here suggests constipation as a side effect of ashwagandha, but I read the adverse events in the same paper as 5-6 completely unrelated symptoms in as many people (out of 32 treated) and similar events reported in the placebo group so I would not suggest constipation as a “common” side effect. Not to say that it couldn’t happen in some people… but I think it’s quite unlikely.
This post has a rundown of possible side effects and times when one should not use ashwagandha (including use not recommended during pregnancy and breastfeeding).
The pregnancy recommendation is interesting. The only scientific study I found was described in this article, with absolutely no negative effects of up to 2000 mg/kg/day in rats taking ashwagandha while pregnant (and a similar finding in non-pregnant rats) which is equivalent to a dose of about 324mg/kg/day for a human – about 19 grams per day in a 130lb person. No effect on pregnancy rate, number of eggs ovulated, number of live or miscarried babies, no difference in male v female ratios. very few birth defects, and actually more birth defects in the control group.
However, the report that has led to the recommendation against use while pregnant and breastfeeding is this study – it assessed anecdotal reports of toxicities by traditional medicine practitioners in areas of the world where these herbs grow. I would tend to discount this as “evidence” as it’s anecdotal… but… ashwagandha was reported as leading to abortion or sterility by 17-22 practitioners out of 80 who were interviewed… that seems like a high proportion and gives one pause.
Another possible side effect is ventricular tachycardia. A series of 12 patient who came into an ER over time complaining of heart-related incidents was assessed for supplement usage. This was not an easy task and only completed for 7/12, two of whom had used ashwagandha and were found to have ventricular tachycardia. One can obviously not prove cause and effect here… but the authors state, “…development of symptoms such as vague feelings of illness, dizziness and chest discomfort following herbal drug ingestion warrants the immediate discontinuation of such drugs, a close monitoring of blood pressure and cardiac rhythm, an echocardiographic assessment and prompt treatment of the accompanying arrhythmia.”
On the other hand, there are also a few articles discussing the use of ashwagandha to protect the heart from damage caused by chemotherapy…so really, who knows?
Finally, I also came across a report of thyroid toxicity. This was in a woman who started taking ashwaghanda to potentially help with chronic fatigue syndrome. She started experiencing clinical signs of thyroid toxicity (along with changes in bloodwork) that went away when she stopped the ashwagandha. It is important to note this is only a single case. But as I describe below there is evidence that ashwagandha can increase T3 and T4 and decrease TSH in those who are hypothyroid – so may not be ideal for someone who is already hyperthryoid (e.g. higher T3 and T4, low TSH).
Based on all this… I don’t feel comfortable saying “there are no downsides” to taking ashwagandha. It’s likely fine – as I said, there were no serious adverse events reported in the studies below… but… there are negative reports out there and one cannot completely discount them.
Ashwagandha and stress
Overall, the clinical studies support that ashwagandha is helpful for reducing stress, both perceived and hormonally. Therefore, if one has HA and it is likely that stress is a component, ashwagandha may be helpful. Please do consult with your physician prior to taking it however, given the potential side effects and contra-indications.
In a clinical study (sponsored by a company that sells ashwagandha), 130 subjects were enrolled (27% women), and received either placebo, 125mg, 250mg , or 500mg ashwagandha per day. They completed written stress assessments prior to beginning the supplements and again after 30 and 60 days, and various blood markers were measured (cortisol, C-reactive protein, DHEAS, hemoglobin, fasting blood glucose, total cholesterol, LCL-C, HDL, vLCL-C, and triglycerides), along with blood pressure and heartrate. 32 subjects did not complete the study, 12 of whom withdrew for lack of efficacy and were not included in the analysis. Although interestingly, the dropout rate was dose dependent: 15 placebo, 11 from the 125mg/day group, 6 from the 250mg/day group, and only 1 from the 500mg/day group.
Subject stress, as measured by the written assessment, was significantly alleviated by treatment with ashwagandha. Every stress component showed a reduction at 30 days, with further reduction at 60 days: fatigue, flushing, perspiration, loss of appetite, headache and muscle pain, feelings of impending doom, palpitations, dry mouth, sleeplessness, forgetfulness, irritability, and inability to concentrate. The other measured parameters all showed improvements over baseline, in a dose dependent manner. Most importantly for recovering from hypothalamic amenorrhea, a decrease in fasting, morning cortisol of 14.5% in the 125mg group, 24.2% in the 250mg group, and 30.5% in the 500mg group.
Interestingly, cardiac risk ratios (calculated based on cholesterol measures) improved also. Fasting blood glucose decreased by 0.6% in the 125mg group, 4.7% in the 250mg group, and 6.1% in the 500mg group – this is not necessarily a positive for HA recovery where we seem to need reasonable glucose levels as described in No Period. Now What? on p. 115 – however, in the studies that have examined responsiveness of GnRH neurons to glucose, glucose levels were decreased 98%… so these decreases are unlikely to have a negative impact.
No adverse effects were noted in any study group.
If this was the only study to show such effects, I might be a bit suspicious, as the results seem too good to be true (and the study was published by a company that sells the herb). However, additional studies in both humans and animals support these findings, which makes them more believable.
A second study also looked at cortisol levels and stress assessments. This study comprised 64 patients, 36% female, treated with either 600mg ashwagandha extract per day, or placebo. Two in the ashwagandha group and one in the placebo group did not complete the study, but were included in adverse event reporting.
Similar to the first study, this group found significant reduction in the reported stress, by about 70% in the ashwagandha treated group, compared with scores that were +/- 10% from baseline in the placebo group. Cortisol was reduced by 27% in the treated group versus 7.9% in the placebo group. Other biochemical measures were tested, but in contrast with the first study, no significant differences were found.
As far as adverse events, nasal congestion (rhinitis), constipation, cough and cold, drowsiness and decreased appetite were seen in the ashwagandha group. In the placebo-control group, dryness of mouth, tiredness, fever, headache, abdominal pain and diarrhea, and tremors in legs during examination were seen. Events were all mild and assessed as unlikely related to the ashwagandha use.
Another study compared “naturopathic care” with psychotherapy. Both groups were taught deep breathing relaxation techniques, those in the naturopathic care groups received a multivitamin and ashwagandha 2x/day, those in the psychotherapy group received a placebo. Stress was measured using multiple written assessments. Both groups showed a reduction in stress levels by all assessments, but the reduction was more substantial in the ashwagandha treated group (p-values from 0.012 to <0.0001) .
Adverse events reported were almost identical in the ashwagandha and placebo treated groups. Two instances of GI upset, two of overstimulation, one of increased frequency of night cramps and one of mild hair loss, in both groups. One person in the placebo group experienced a rash, and one in the treated group reported “feeling warm.”
Another research group took a different tactic, examining the potential of ashwagandha to improve female sexual function. The study group consisted of 50 women with hypoactive sexual desire disorder, female sexual arousal disorder, female orgasmic disorder, or combined genital and subjective arousal disorder (essentially women with abnormally low libido or response to sexual stimulation). Once again the subjects were randomly divided into two groups, 25 per group, with one group receiving placebo and the other 600mg/day ashwagandha. Both groups received counseling. I thought this was worth looking at as there may be a hormonal component. Unfortunately, no hormones were measured during the study, only self-reported scores on various questionnaires. The results showed a fairly large improvement in both the “placebo” treated arm and the ashwagandha arm, with the latter showing larger, significantly different, improvements in overall all sexual functioning.
There were no adverse events reported and the 25 women in the treatment arm continued through the study.
I tried ashwagandha myself to see if it might help my libido, but did not feel like it made any difference. I did keep my dose on the lower side at two capsules per day; perhaps more would have made a difference, but overall, I did not notice any change in either perceived stress or libido. (The authors actually make a point of mentioning this is expected, “In our study, HCARE supplementation failed to improve sexual ‘desire’…”)
Ashwagandha and thyroid
Another topic I came across as I was researching ashwagandha was effect on thyroid. This was initially found in a study looking at use of ashwagandha for bipolar disorder – they happened to monitor thyroid hormones due to some earlier studies in mice that showed effects – and discovered some sizeable changes. This led to a double-blind, placebo controlled study being performed…
50 people with subclinical hypothyroidism (TSH between 4.5-10 uIU/L) were randomized to two groups of 25 each. Currently levothyroxine is the common therapy for hypothyroidism, but often only prescribed when TSH is over 10. For those with subclinical hypothyroidism there is no standard treatment. Subjects were given 600mg of an aqueous extract of ashwagandha in capsule form (5% withanolides) each day for 8 weeks. Thyroid hormones were measured at baseline, 4 weeks, and 8 weeks. A significant increase in T3 and T4 (9.6% at 4w and 19.6% at 8w) was seen in the ashwagandha group, and a decrease in TSH.
As far as adverse events, physical, hemotological (blood) and vital parameters showed no changes, and only one patient in the ashwagandha group and three in the placebo group reported other events; fever, asthenia, cough, or headache.
A small study in mice likewise found an increase in T4. This suggests that if you are currently hyperthyroid, ashwagandha may not be appropriate.
Ashwagandha and bones
As an interesting side note, this study found that in rats taking ashwagandha, bone loss following removal of ovaries was prevented. It’s far and away not enough evidence to support recommending Ashwagandha for bone loss prevention… but interesting nonetheless.
Summary
The evidence seems quite clear that ashwagandha can help reduce both perceived stress and blood markers of stress. This may be helpful in recovery of missing periods, especially in someone who experiences a lot of stress and anxiety.
However, the side effects and toxicities mentioned do give me pause and prevent me from recommending this as a “no brainer.” No serious events were seen in any of the clinical studies I looked at – however, there were adverse events reported elsewhere in the medical literature which suggest that there are a few people who can respond negatively to ashwagandha.
In addition, I would probably not take it while pregnant. The animal studies suggest no issue, but almost a quarter of alternative medicine practitioners who have experience with ashwagandha reported it as causing “abortion and/or sterility” which one cannot discount completely. A single report I would not give much credence to, but multiple reports make the effect more likely – and unfortunately given the sources of the evidence it is unlikely we will be able to get more detailed information or any kind of investigation into the truth of the claims.
Any questions, drop them in the comments!
Nico
P.S. Because I read every paper I discuss in these blog posts, it takes many hours to put them together. If you find this work useful, I would appreciate your supporting the work as a Patreon. Thanks!!