Danger Zone: Herbal Products that May Increasingly Be Used in a Post-Roe Era
Written by Hanh To, PharmD, CSPI and Amanda Lynn, PharmD, CSPI at the Washington Poison Center
An herbal abortifacient is an herbal substance used in the attempt to induce abortion or terminate a pregnancy. Although some herbal products make claims that the substance “restores menses” or “solves menstrual irregularities,” there is no way to ensure safety or efficacy with these herbs. Our knowledge of safety is limited, as it is difficult to find data on the prevalence of herbal abortion attempts and the symptoms associated with herbal product usage. People who use these products may be hesitant to seek medical attention for problematic symptoms. And, if they do seek care, they may be reluctant to admit to using herbal abortifacients out of fear for legal repercussions. Consequently, it may be difficult to link particular symptoms to a particular product’s consumption. It is very important that patients and providers understand how these herbs work and that attempting to use herbals to induce an abortion is risky, unsafe, and potentially fatal.
As we anticipate potential cases with herbal abortifacients, we predict several challenges for poison centers and healthcare providers:
1. Even though herbal abortifacients have been used for centuries, there is limited research on human exposures.
2. Herbal products are not regulated as medications. Products may not be consistent with their labels and/or may contain impurities.
3. Social media is highly influential with trends and (mis)information regarding herbal abortifacients. And, because social media trends change constantly, it is difficult to predict the substances people will use.
4. People may experiment with combinations of substances, different doses, and different routes of administration.
5. Individuals may also attempt to harvest and use raw plant material. This carries risks of additional toxicity if misidentification occurs or if there is incomplete understanding about a how a particular plant has been used.
Pennyroyal (Mentha pulegium): this plant has spiky purple flowers and has long been used as insect repellent. The abortifacient action is thought to be due to uterine contractions secondary to genitourinary tract irritation. Pennyroyal contains the toxic terpene pulegone. Both pulegone and its toxic metabolite menthofuran are potent GI, CNS, and hepatotoxins which deplete liver glutathione similar to acetaminophen toxicity. When concentrated essential oil is ingested, pennyroyal toxicity may cause significant gastritis, delirium, hallucinations, irreversible liver and kidney failure, seizures, and death. Treatment of toxicity consists of supportive care with close monitoring of mental status, respiratory status, coagulopathy, liver and kidney dysfunction. N-acetylcysteine may be recommended in cases of liver injury associated with pennyroyal exposure.
Mugwort (Artemisia vulgaris): a perennial plant native to Europe and parts of Asia and Africa. Mugwort has been widely naturalized, including in North America. Traditionally, mugwort was used for gastrointestinal concerns, to promote labor and circulation, and as a sedative. The plant can have significant chemical polymorphism with widely varying concentrations of toxic terpenoids including thujone, camphor, and davanones. Some evidence suggests mugwort can stimulate uterine activity, possibly due to its thujone content, which is also present in the spirit absinthe. There is insufficient reliable information about the presentation or treatment of overdose with mugwort, although thujone (a competitive antagonist of GABA) and camphor (a CNS stimulant whose precise mechanism neurotoxicity is poorly understood) could conceivably present with seizure/agitation along with GI irritant effects from the terpenoids. Treatment is supportive with benzodiazepines in cases with excessive CNS excitation.
Blue cohosh (Caulophyllum thalictroides): this plant has been used in various Native American communities to induce labor. Blue cohosh contains glycosides, which can promote contraction of the uterus, and methylcytisine, an alkaloid that acts as a nicotinic agonist. The use of blue cohosh near term (37 weeks and later) can cause life-threatening toxicity in the neonates. In large doses, methylcytisin can result in vomiting and abdominal pain. It can also cause severe nicotinic poisoning: hypertension, heart arrhythmias, muscle weakness, muscular paralysis, respiratory failures, seizures, coma, and death. Treatment is mainly supportive care.
Black cohosh (Cimicifuga racemosa): this plant is a completely different genus with a different toxic profile from that of blue cohosh, despite the similarity in their names. Black cohosh is thought to have hormonal effects and menstrual and uterine stimulant effects, which theoretically might increase the risk of miscarriage. Most common adverse effects are breast tenderness, dizziness, gastrointestinal upset, headache, irritability, rash, and tiredness. Serious adverse effects are endometrial hyperplasia and hepatotoxicity, although data are conflicting for both. Treatment is supportive care.
Parsley (Petroselinum crispum): parsley has been used orally as an abortifacient and to stimulate menstrual flow. When used orally in extremely large doses, parsley oil contains significant amounts of apiole and myristicin, which are potential toxic constituents. Apiole stimulates the activity of the uterus musculature, may cause blood dyscrasias, kidney toxicity, and liver toxicity. Myristicin may cause giddiness and hallucinations. Treatment is mainly supportive care.
Rue (Ruta graveolens): a shrub-like plant found in Mediterranean countries. Overdose of rue, which can occur with the fresh plant, the oil, and high doses of dried herb, is associated with severe abdominal pain, vomiting, hepatotoxicity, nephrotoxicity, vertigo, respiratory distress, seizures, bradycardia, delirium, and can be fatal. There is insufficient reliable information about the treatment of overdose with rue.
Jequirity bean or rosary pea (Abrus precatorius): this plant has been used as an abortifacient, oral contraceptive, and analgesic in terminally-ill patients. Jequirity bean is also used to quicken labor. Abrus precatorius seeds contain a highly poisonous and potent toxin called abrin. Similar to ricin, abrin prevents cellular protein synthesis and causes multiple system organ failure and GI necrosis. There is no known antidote to these effects, treatment is mainly supportive care. Additionally, there is no method for enhancing the elimination of abrin.
Vitamin C (ascorbic acid): although vitamin C is not an herb, high doses have been used as an abortifacient. After implantation, progesterone is needed for the lining of the uterus to continue being supportive of the fertilized egg and to prevent it from breaking down. Vitamin C starves the uterus of progesterone. There is insufficient reliable information about gastrointestinal distress from Vitamin C. Treatment is supportive care.
Consumption of herbs to terminate pregnancies is unsafe and is linked with the risk of severe morbidity and mortality. There are much safer and more reliable options if a patient chooses to have an abortion. Currently in the United States, websites such as Plan C (plancpills.org) and Safe2Choose (Safe2Choose.org) can connect people who are seeking abortions at home and provide solutions like abortion pills. People without any age limit can get mifepristone and misoprostol from Aid Access (aidaccess.org), and recent FDA changes have allowed for any community pharmacy to carry and dispense mifepristone with a valid prescription.
If you have questions or if someone experiences unwanted or unexpected side effects after using herbal products, contact the Washington Poison Center for expert guidance at 1–800–222–1222. This service is free, confidential, and available 24 hours a day.
Sources:
· https://naturalmedicines.therapeuticresearch.com/
· Anderson IB, Mullen WH, Meeker JE, et al. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and review of the literature. Ann Intern Med 1996;124:726–34.
· https://muvs.org/en/topics/t-plants/parsley-en/
· https://theanarchistlibrary.org/library/annwen-herbal-abortion
· https://www.sciencedirect.com/topics/medicine-and-dentistry/abortifacient
