When I receive an advertisement for a conference claiming to feature the “world’s leading experts in complementary and alternative medicine,” the first thing I do is check to see how many NDs are on the speaker list. Early in my studies, a dearth of NDs felt like a blow to my professional esteem. Now, more than a decade later, I know better: It means a high probability that the organizers are neither knowledgeable nor serious about integrative medicine and are simply hoping to profit from the popularity of natural therapies.
The same applies to books and journals, so when I read through the contributor list for Aviva Romm’s Botanical Medicine for Women’s Health (Churchill Livingstone, 2009), I was nearly giddy. Not only did 8 outstanding naturopaths contribute, but the list of herbalists really does include the “world’s leading experts.” Then there is Aviva Romm herself, who holds an MD degree from Yale University and is a certified professional midwife and president of the American Herbalist Guild. This is not some family doctor who took a weekend course and now wants to teach you about supplements. This woman is the real deal.
This is immediately apparent in the first part of the 5-part text, aptly titled “Foundations of Botanical Medicine.” In these first hundred pages, Romm discusses foundations in several senses. First is why should we study this in the first place and her general views about integrated healthcare: notably her views on both the limitations and the promise of various kinds of evidence in botanical medicine. Next is in the sense of historical background (for all my many undergraduate hours of women’s studies courses, it was not until I read this section that I realized how inherently feminist the practice of patient-centered botanical and naturopathic medicine is). And finally, in the sense of safety guidelines and a basic primer for the practice of herbal medicine.
I do not think naturopathic doctors and professional herbalists will find much here that is new to them or changes the way they practice, but there will be something of use. I was happy to see some summary charts that expanded my knowledge of what herbs will work well in alcohol-free preparations, as well as a useful suppository recipe. Even without those things, it was enormously satisfying to see it all organized in one place; I am envious of the beginning students who have access to this text.
The next 3 parts of the text are chapters on women’s health conditions organized chronologically along the lifespan: “General Gynecologic and Menstrual Health Concerns,” “Fertility and the Childbearing Cycle,” and “The Menopausal Years.” These chapters follow a fairly consistent format beginning with an overview of the condition, followed by an overview of the conventional medical approaches, and then a discussion of strategies a botanical prescriber might take with each condition.
Romm does not present the herbs using a ranking scheme. Instead, “to avoid bias, [she] chose to arrange herbs alphabetically, in order to allow the reader to make her/his own determination of what to use based on their own values in ranking the evidence.” This works well if you are a reader who values clinical trials above other kinds of evidence, as the studies are described in detail. But it is less effective for the readers who are more inclined toward expert consensus.
One of my best professors at Bastyr University started his first lecture by explaining that there were herbs that we needed to know to pass our licensing exam and/or because of research, historic, market, or media attention they had received. Then there were herbs we needed to know because, used correctly, they worked, he said. These were not always the same herbs. He was uninterested in diplomacy and did not apologize for herbs that he knew to work brilliantly but had yet to prove themselves in a lab. However, he was addressing an audience of budding naturopaths, and Romm is aiming toward a broader and more skeptical audience.
I imagine her in a lecture hall. On one side of the room there is a curly red-haired herbalist with a book on the doctrine of signatures, singing songs to a bag of herbs tied to her waist, while on the opposite side a white-haired MD in his lab coat taps his foot and reads a print copy of Quackwatch. With the noble intention that her book should build bridges and contribute to mutual understanding, Romm stands in the middle trying to deliver a lecture that offends neither of them. Unfortunately, I believe this neutrality works against clarity. Like my professor, Romm does not want us to miss out on the unresearched yet effective botanical therapies and makes an eloquent case for expert opinion, clinical experience, and traditional use as important and valid parts of the evidence in evidence-based medicine. However, it is difficult to be impartial and reveal very much of her or her contributors’ personal opinions. So, rationales are clearly described—such as supporting the liver to improve hormone balance, or using nervines for a condition strongly influenced by stress, followed by lists of the herbs that do those things, often in beautiful summary charts. A sense of whether Romm feels any enthusiasm for these as effective strategies or which herbs in a list may be especially reliable is difficult to decipher. A greater volume of personal editorial commentary would also lend clarity to the presentation of research. In particular, the authors’ take on conflicting research findings can help the reader sort out the details. The research on chaste tree presented in detail in the PMS chapter makes for a confusing read because it has enormous dose discrepancies, from 3.5 mg to 1000 mg, and some insight and interpretation would be helpful.
This is not to say that the clinician’s voice is entirely absent. It really shines through in the case histories, which offer a context to reveal the authors’ choices. I hope subsequent editions will feature more case histories and expand descriptions of clinical thinking within them. Besides being interesting and inspiring, sharing multiple case histories for the same condition demonstrates the individualized nature of naturopathic medical treatment discussed throughout the book.
"Fertility and the Childbearing Cycle" is the clearest, strongest, most readable section of the book, and the chapter on postpartum care is especially lovely.
Another highlight is the generous use of summary tables. Students are going to find them invaluable. I find that when I have a favorite and dependable approach for something, my mind goes blank about other options. These charts will be especially useful in those cases or to quickly rethink a stuck case and make sure the basics are covered.
Part three of the book, “Fertility and the Childbearing Cycle,” is the clearest, strongest, most readable section of the book, and the chapter on postpartum care is especially lovely. This is a separate chapter from the breastfeeding chapter, which, one might imagine, as part of the same topic. Separating them underscores an important message in the postpartum chapter: once that baby arrives, the mother’s healthcare needs are often ignored—both by her care providers and by herself. A new mother needs more than just galactagogues. I am very eager for the next new mother in my life or my clinic so that I can feed her barley and make her teas, washes, and baths. Likewise, I am eager to employ some new strategies for hot flashes from the shortest but certainly not least important section, “The Menopausal Years.” The brevity is one of its strong suits; it has an excellent, clear, concise, yet thorough coverage of hormone replacement therapy.
Part 5 has a monograph for 10 of the herbs discussed in the text, and a summary table of all the herbs with doses. The 10 monographs offer little that is not discussed in earlier chapters. The summary chart and the quick reference dose chart that follows are just the kind of things you want in your clinic, and they have already proved their usefulness in mine. Romm advocates that even advanced prescribers make frequent use of reference texts and says that practicing safely “requires quick access to information and can still leave the practitioner with a sense of uncertainty.” I find it a comfort that I am in such good company with my sense of uncertainty.
Romm has done an excellent job of making the available information well organized and quickly available but could ease more of the uncertainty in two ways: more passion and better proofreading. There really are a large number of errors. Very few of these errors actually lead to misinformation, but the collective effect of them creates doubt, especially without the reassurance of knowing where the author stands. Romm says that her fondest wish is that her book will “provide readers with the confidence to begin safely integrating botanical therapies” leading to “a small alleviation of suffering for those women who use botanical medicines as part of their medicine.” This seems too timid to me. I am confident that she already has and will continue to accomplish far more than this.
There is so much here that is practical and empowering. I am grateful for this book on behalf of myself and especially for the new students interested in patient-centered integrative healthcare. I hope that there will be subsequent editions, that they will be bolder, with more case histories, and that we can glean a stronger sense of the remarkable woman behind the writing.