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��ࡱ�>��	qs����nop������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��Q�bjbjqq	4eef�.�������JJ������������8�lE"���z��$Z;&Q&Q&Q&`'J�'�'�x�x�x�x�x�x�x$R}��LyA��'`'`'�'�'y��Q&Q&Hz�2�2�2�'v�Q&�Q&�w$�2�'�x�2�2��T�UXQ&������p����L.f5V&�w^z0�z[V�@��2L@�LUX@��UXT�'�'�2�'�'�'�'�'yy�2�'�'�'�z�'�'�'�'��������������������������������������������������������������������@��'�'�'�'�'�'�'�'�'J	S:	Safety and efficacy of traditional herbal water extract of Labisia pumila var alata on sexual well being of healthy pre- and postmenopausal women

Annie Georgea, Dale Wilsonb, Malkanthi Evansb*, Azreena Abasa Mufiza Musthapaa
aBiotropics Malaysia Berhad, Level 52, Menara TM, Jalan Pantai Baharu, 50672 Kuala Lumpur, Malaysia  
bKGK Synergize Inc., Suite 1440, One London Place, 255 Queens Avenue, London, ON, Canada N6A5R8

*Corresponding author: 	Address: KGK Synergize Inc., 
Suite 1440, One London Place, 
255 Queens Avenue, 
London, ON, 
Canada N6A5R8
Email: HYPERLINK "mailto:mevans@kgksynergize.com"mevans@kgksynergize.com
Telephone: 519-438-9374
Fax: 519-438-8314


Preliminary data on the outcome of this trial were presented at the International Conference on Natural Products. ABSTRACT
Objective:  The objective of this study was to investigate the safety and efficacy of Labisia pumila water extract on sexual health, lipid profile and inflammatory markers in healthy pre-and postmenopausal women.
Methods: This was a randomized double-blind, parallel group, placebo-controlled clinical trial conducted in 36 pre- and post menopausal women.  Eighteen women were randomized to Labisia pumila and 18 to placebo .  Participants completed the Short Form-36 Health Survey (SF-36) and the Female Sexual Function Index (FSFI) at baseline and after 6 and 12 weeks of supplementation with 200mg of  Labisia pumila water extract or placebo.  Bloodwork (plasma lipid profiles, anti-inflammatory markers, blood chemistry and hematology), urinary antioxidants, weight, and vital signs were assessed at baseline and after 6 and 12 weeks of treatment.  Adverse events were reviewed at each study visit.
Results: After 12 weeks of supplementation at a daily dose of 200mg, the SF-36 and FSFI were not significantly different between groups. Improving trends in FSFI scores were observed for age groups 30-39 yrs, 40-49 yrs and a very clear improvement in women e" 50 yrs compared to women aged 18-29 yrs.  Participants on Labisia pumila showed a significant decrease in cytokines at week 6 (IL-6, p=0.006, IL-1( p<0.001) and 12 (IL-1( p=0.001). Sexually dysfunctional women (FSFId"26) improved significantly in the  orgasmic� and �satisfaction� domain in Labisia pumila group compared to placebo (p=0.037) at 6 weeks with a increasing trend after 12 weeks. There were no statistically significant differences in safety measures between groups.
Conclusion: In this study, a water extract of Labisia pumila was efficacious in improving sexual function, anti-inflammatory markers and HDL-c.  Further, Labisia pumila at a dosage of 200mg per day for 12 weeks was safe in pre- and postmenopausal women, 18-70 yrs of age.


Keywords:  Labisia pumila, women�s health, Female Sexual Function Index, blood lipid profile, cytokines 


Abbreviations: LP, Labisia pumila; FSFI, female sexual function index; SF-36, short form-36 health survey; IL, interleukin; QOL, quality of life; OVX, ovariectomized; POS, polycystic ovary syndrome; ICH, international conference on harmonization; GCP, good clinical practices; NHPD, Natural Health Products Directorate; BMI, body mass index; HDL, high density lipoprotein; LDL, low density lipoprotein; SOD, superoxide dismutase; AST, aspartate aminotranferase; ALT, alanine aminotransferase; GGT, gamma-glutamyl transpeptidase; CBC, complete blood count; BUN, blood urea nitrogen; ANOVA, analysis of variance; AE, adverse events 

Introduction
A high proportion of North American women (43%) experience low sexual desire, difficulties with orgasm and painful and un-pleasurable intercourse (Pujols et al. 2010). Sexual dissatisfaction was associated with sexual dysfunction, as well; women who reported greater distress over a sexual problem also reported greater sexual dissatisfaction (King et al., 2007)
A healthy sexual life aims to promote overall health and enhance energy levels and vitality. Today, many nutritional and herbal formulas support sexual well-being, stamina and performance centers in the hypothalamus, hormonal balance, endocrine system regulation and the maintenance of healthy lipid profiles (Tan et al., 2010).
Labisia pumila var alata (family Myrsinaceae), is a well-known and popular herb for feminine vitality, sexual wellbeing and hormonal balance in South East Asia. It is used traditionally for female health (Burkill, 1966; Gimlett, 1971; Lemmens et al., 2002; Samy et al., 2005)
The root and leaves of Labisia pumila are commonly used in folk medicine. A water extract of this herb has been used for a wide range of gynecological issues, including, the reduction time in labour, placental separation and expulsion, and menstrual problems (Zhari Ismail et al., 1999) 
Previous in vitro and in vivo studies report that extracts of Labisia pumila have various immunomodulatory (Pandey et al., 2008), antioxidant (Tasduq et al., 2007) lypolysis (Al-Wahabi et al., 2007) and aphrodisiac effects (Asiah et al., 2007). Although the mechanism of action is still unknown, several single bioactive constituents have been identified in the extract including benzoquinones (Houghton et al., 1999), alkenyl resorcinols (Jamal & Houghton, 1999) and triterpenoids (Jamal, 2006). Water extracts of Labisia pumila inhibit estradiol binding to antibodies against estradiol (Husniza, 2000), suggesting the presence of estrogen-like or estrogenic compounds.  Water extracts of Labisia pumila have demonstrated estrogenic activity in various cell lines and ovarectomized animal models (IMR, 2002; Al-Wahabi et al., 2007; Fazliana et al., 2009; Fazliana, 2010). However, in human endometrial adenocarcinoma, ethanolic extracts of Labisia pumila exhibited a weak but specific estrogenic effect, while the water extracts of root and leaf did not (Jamal et al., 1999; Jamal et al., 2003) 
Labisia pumila has a long history of use in traditional medicine. However, there is limited clinical evidence on its safety and efficacy. In a pilot study, Malay women used Labisia pumila for various purposes such as relieving body aches, strengthening the womb and vaginal tightening for sexual satisfaction and during puerperium (Intan et al., 2005). A randomized, double blind, placebo-controlled trial comparing 3 different doses (highest dose 560mg/day) of a spray-dried water-soluble extract of Labisia pumila was conducted in 70 post-menopausal women between 48 and 55 years of age.  During the 6-month treatment period the Labisia pumila extract was shown to be safe in terms of clinical and laboratory evidence (Nik Hazlina et al., 2009) 
 The aim of this 12-week placebo-controlled trial was to provide more evidence-based data on the safety and efficacy of Labisia pumila while assessing its effects on improving the quality of life and sexual well being of healthy women. In addition, this trial aims to provide information on the effects of Labisia pumila on cardiovascular health.
Methods

Study population, sampling and recruitment
	Women were included in the study if they were between 18 years and 70 years, were healthy as determined by laboratory results, medical history and physical examination and gave informed written consent. Women were excluded if they were: sexually dysfunctional, on hormone therapy, allergic to study products, pregnant or breast feeding, or had a history of  breast, uterine or ovarian cancer, autoimmune conditions, immunodeficiency, history of bleeding disorders, gynecological disease , any serious gastrointestinal, hepatic, renal, cardiovascular, neurological or hematological disorder; drug or alcohol abuse; or were on  natural health products/dietary supplements within 2 weeks prior to randomization.      
Randomisation and intervention
Women were randomly assigned to the two treatment groups in a 1:1 ratio to receive either one tablet of Labisia pumila water extract or a matching placebo once daily for 12 weeks. In order to prevent an imbalance between groups with respect to menopausal status, pre-menopausal women were randomized starting from the top of the randomization schedule and post-menopausal women were randomized starting from the bottom of the randomization schedule. In the event that it was necessary to unblind a participant�s treatment, the emergency envelope labeled with the participant�s randomization code would be opened. 
Experimental Design
After randomization at study entry/baseline (day 0, visit 2), twelve weeks of treatment with trial medication was planned for each woman with follow-up visits at 6 weeks (day 42 � 3, visit 3) and 12 weeks (day 84 � 3, visit 4). During the intervention, each participant consumed 1 daytime tablet containing either verum or placebo. Verum is a traditional herbal medical product containing as active ingredient, the special aqueous extract of Labisia pumila root and leaves (BIO LP101) manufactured under continuous quality control of Good Manufacturing Process requirements (each tablet extract 200mg extract, batch number: 30 PED 060; DER: 10:1; Biotropics Malaysia Berhad, Kuala Lumpur, Malaysia). Placebo medication corresponded to the active medication without the herbal extract.
Primary outcome measure
The primary endpoints were determined by measuring the improvement of quality of life at each visit, using the Short Form-36 Health Survey (SF-36) and the Female Sexual Function Index (FSFI) questionnaires. The SF-36 scale included questions classified in the following domains: total physical, total mental, physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotion and mental health. The FSFI questionnaire included 19 questions which overlapped six domains: desire, arousal, lubrication, orgasm, satisfaction and pain (Rosen et al., 2000). The participants were considered to be sexually inactive if their FSFI score was d" 26.
Secondary outcome measure
 The secondary outcomes that were measured included plasma lipid profiles (total cholesterol, HDL, LDL, triglycerides), antioxidants (8-isoprostane, serum SOD), anti-inflammatory properties (cytokines TNF�, IL-6, IL-1�), hormones (estradiol-17 �), blood chemistry (electrolytes, glucose, creatinine, bilirubin), liver function test (AST, ALT, G-GT), hematology (CBC), weight, and vital signs. The secondary objectives were assessed at baseline and after 6 and 12 weeks of treatment. Two first morning void urine samples were collected on two consecutive days, the day before and the day of the study visit and were pooled and analyzed for creatinine and 8-isoprostane.
Adverse events were documented at each visit and were classified according to the description, duration, severity, frequency, and outcome and relationship to the investigational product by the Medical Director.
Ethical considerations
This study was conducted in accordance with the Guideline for Good Clinical Practice (ICH-6) and Declaration of Helsinki. It was reviewed by the Natural Health Products Directorate (NHPD), Health Canada, Ottawa, Ontario Canada, and a research ethics board.  Authorization was received from the NHPD on December 09, 2009 and unconditional approval was granted by Institutional Review Board Services, Aurora, Ontario, Canada on January 08, 2010. The study was carried out from January 13 to June 19, 2010 at a single site, KGK Synergize Inc., in London, Ontario, Canada. 
This study was reviewed by Health Canada�s Natural Health Products Directorate (NHPD) and Notice of Authorization was received on December 09, 2009 (Appendix D). Both Ethics and Health Canada approval were received prior to commencement of the study.  
Data Analysis
No formal sample size calculation was conducted for this study due to the lack of efficacy data on quality of life parameters under Labisia pumila treatment. The planned sample size for this study was 36 participants with 18 women randomized equally to each of the two study arms. Allowing for an anticipated drop-out-rate of 15%, 30 women were expected to complete the trial. Drop-outs during the treatment period or participants leaving the study prematurely were not replaced. 
All randomised women on treatment were included for analysis of safety and efficacy. For primary and secondary outcomes with baseline values, between-group comparisons were made using analysis of covariance (ANCOVA) with covariate adjustment for the baseline value. Within-group changes and baseline comparisons were made using t-tests. Baseline comparisons for continuous variables were made using a t-test.  Fisher�s exact test was used for comparing frequencies between groups, with respect to baseline characteristics. Safety data and adverse events were summarized by treatment group. Between groups differences in the number of withdrawals were compared using Fisher�s exact test. The number of individuals experiencing adverse events was compared using a chi-square test for comparing proportions. Compliance, as defined as the number of pills taken, in the two groups was analysed using t-test. SAS Version 9.1 was used to perform the statistical analysis.  Probability values less than 0.05 were considered statistically significant.  
A subgroup analysis of FSFI scores of participants grouped together by age (18-29 yrs, 30-39 yrs, 40-49 yrs and e"50 yrs) was conducted on sexually active women and women who were sexually dysfunctional at baseline (FSFI scored"26), but active for the duration of the study.  A within-group analysis of the inflammatory cytokines TNF�, IL-6 and IL-8 and the hormone estradiol-17� was also conducted. SAS Version 9.1 was used to perform the statistical analysis.
Results
Participant Characteristics
A total of 49 women were screened and 36 qualified for enrollment in the study (Figure 1). Of the 18 women randomized to placebo, two women withdrew during the study: one due to an adverse event and one due to non-compliance. Of the 18 women randomized to Labisia pumila, two women withdrew from the study: one at participant�s request and one was lost to follow up where attempts to arrange a revisit were unsuccessful. At baseline participants receiving Labisia pumila had a lower body weight (p=0.014) and a lower mean fasting glucose levels (p=0.026) than those assigned to receive placebo.  All other baseline demographic and blood chemistry measures were comparable between the two groups (Table 1). The herbal group had fewer participants consuming alcohol on a weekly basis (3/18, 16.7%) compared to placebo group (8/18, 44.4%), however this was statistically insignificant. 
Compliance 
Compliance in terms of number of pills taken by the participants was similar between groups at all time points assessed and mean compliance was 93% in participants on LP and 91% in those on placebo.
Female Sexual Function Index (FSFI)
There were no significant differences between groups with respect to the total FSFI score or domain scores for desire, arousal, lubrication, orgasm, satisfaction and pain at baseline or at 6 and 12 weeks of treatment (Table 2).
Within-group analysis demonstrated a greater increase in the mean total FSFI scores from baseline to week 12 in women on LP compared to placebo (0.8 versus 0.4).
Subgroup analysis of sexually dysfunctional women at baseline (FSFI score d"26) but sexually active for the duration of the study revealed an improving trend in the  satisfaction  domain  in women receiving Labisia pumila  compared to a decrease in scores in women on placebo (N=2) at week 12. After 6 weeks of treatment, women on Labisia pumila had significantly higher �orgasm� scores compared to those on placebo (4.1 vs 2.8, p=0.037). In both treatment and placebo groups there was an improving trend in the �lubrication� domain. Women on placebo demonstrated significantly higher scores for �arousal� after 6 weeks of treatment compared to women on Labisia pumila (p=0.046).  In sexually active women there was no significant interaction between age and total FSFI score or scores for any of the six domains after 6 and 12 weeks of treatment.  However, improving trends in FSFI scores were seen for age groups 30-39 yrs, 40-49 yrs and a very clear improvement in women e" 50 yrs compared to women aged 18-29 yrs.
Short Form (36) Health Survey 
There were no statistically significant differences between treatment and placebo groups with respect to the total SF-36 score or scores for any of the domains (total physical, total mental, physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotion, and mental health) at baseline or after 6 and 12 weeks of treatment (Table 3). 
 Lipids
Women on Labisia pumila showed a trend toward improvement in lipid profile as demonstrated by reduction in total cholesterol from baseline to week 12 (p=0.077, Table 4). Women on placebo demonstrated a statistically significant increase in HDL after 12 weeks of treatment when compared to women on Labisia pumila (p=0.011).
Estradiol-17�
The levels of estradiol-17� showed no statistically significant differences between- or within- groups at baseline, week 6 or week 12 for either treatment or placebo. There was no interaction between age and hormone level between the groups. Women aged e" 50 years showed the lowest estradiol levels during the study period indicating age-related physiological changes associated with menopausal status (< 130 pmol/L). In postmenopausal women there was no change from baseline values in hormone levels during the 12 week study in either group suggesting that the supplement Labisia pumila did not adversely affect estradiol levels.
Oxidative stress markers
Oxidative stress markers showed no significant differences between groups with respect to 8-isoprostane and superoxide dismutase at each visit. However, both groups demonstrated a decreasing trend in urinary 8-Isoprostane concentrations from baseline to week 12, with women on Labisia pumila demonstrating a greater decrease (254.4nmol/L to 110.0nmol/L) versus placebo (249.9nmol/L to 123.8nmol/L).
Cytokines (TNF-alpha, IL-6 and IL-beta)
There were no statistically significant differences between groups with respect to serum levels of TNF�, IL-6 and IL- 1� at baseline, week 6 or week 12. However, within group analysis of cytokines demonstrated that there were significant decreases in serum IL-6 from baseline to week 6 in both Labisia pumila and placebo (p=0.006 and p=0.012 respectively) but these differences were not sustained through week 12. IL-1� was significantly decreased in women on Labisia pumila from baseline to week 6 and week 12 (p<0.001 and p=0.001 respectively; Table 5).
Safety Evaluation
No serious adverse events were reported during the study. The number of participants reporting an adverse event (AE) was similar in both groups ( p=0.457). A total of 23 AEs occurred in 12 participants (66.7%) on Labisia pumila and 22 AEs occurred in 14 participants (77.8%) on placebo. In the placebo group, 6 AEs were classified as �not related�, 9 as �unlikely� and 7 AEs with a �possible� relation to the treatment, were reported by 4 participants (Table 6). In the Labisia pumila group, 10 AEs were classified as �not related�, 8 as �unlikely� and 5 AEs were rated as �possible� related to the product (Table 6). All AE�s except one resolved from the events without any intervention.  One woman required a concomitant medication for her AE (menstrual cramps, LP), which resolved within one day. The AEs were classified as mild or moderate in intensity.  All gynecological AEs �possibly� related to the medication were reported in premenopausal women (Table 6, Labisia pumila: age group 18-29 years, placebo: age group 30-39 yrs).
One woman on placebo discontinued her product due to an AE after week 6 (mood alteration) and one woman on Labisia pumila interrupted her intake regimen for a period of 3 days due to stomach flu.  
Vital signs, biometrics, hematological, clinical chemistry parameters and urinalysis were similar in both groups and showed no statistically significant differences or clinically relevant findings between groups during the 12 weeks treatment period. There were no changes in liver function test (AST, ALT, and GGT) seen over time. There was significant increase of sodium in participants of the placebo group at week 12 but these values were within the normal range and were of no (p=0.017) clinical relevance. 
Discussion
Traditionally, extracts of Labisia pumila have a long history in maintaining reproductive system function and enhancing sexual function among South-East Asian women.  There are no controlled clinical studies that have been conducted to date that corroborate the historical evidence. This pilot study was the first to investigate the product Labisia pumila in a randomized double-blind placebo-controlled study, therefore the optimal dosing regimen for its efficaciousness was lacking. 
The results of the current study showed that there were no significant differences between treatments in total FSFI scores or scores for any of the six domains after 6 and 12 weeks of treatment. The FSFI scores demonstrated a similar pattern in Labisia pumila participants with an initial increase in scores from baseline to week 6 and then a decrease in scores from week 6 to week 12. 
Subgroup analysis of FSFI scores on sexually active females, showed that participants aged 30-39 years and 40-49 years performed better than females who were 18-29 years when on herbal treatment. This age related improvement in females above 50 years of age on Labisia pumila suggests that the herb may have greater efficacy in older females. In previous studies, Labisia pumila was shown to possess mild estrogenic effects (Jamal et al., 2003). It is possible that Labisia pumila may be efficacious in older females deficient in female hormones. This study recruited healthy women regardless of their level of sexual function. However, based on an FSFI cut off score of d"26, seven (2.3%) of the participants were classified as sexually dysfunctional while 79% of the participants presented with FSFI scores indicating satisfaction in their sexual lives.  Three of these participants were on Labisia pumila and four participants on placebo. These factors may have contributed to results not showing a difference between the active and the placebo. It is possible that more relevant and significant results may have been obtained if recruitment was limited to women with a lower FSFI score at recruitment. 
Between groups differences of participants identified as sexually dysfunctional at baseline (FSFI d" 26) showed that women on Labisia pumila reported significantly improved scores in  orgasm domain  as compared to those on the placebo by week six of the study. While higher scores continued to be reported at week 12 in women on Labisia pumila, these did not reach significance.  These results are consistent with the literature as Labisia pumila is reported to have aphrodisiac properties (Asiah et al., 2007). Participants in both the Labisia pumila and placebo groups showed increasing trends in the �domains of lubrication�. While the �satisfaction domain� improved in participantss on Labisia pumila, those on placebo showed a decreasing trend. The total FSFI scores were improved in women identified with sexual dysfunction in both Labisia pumila and placebo. The results of the self-reporting RAND Short Form Health Survey (SF-36) were not influenced by Labisia pumila or placebo. Participants in both groups presented with high scores at baseline. Results from a previous study in middle aged women showed that significant predictors of quality of life were serious illness, employment and marital status, but hormone replacement therapy use and menopausal status were not significantly associated with life satisfaction nor quality of life in women (SF-36) (O'dea et al., 1999).
Total �mental� scores demonstrated some degree of improvement in participants on Labisia pumila from week 6 to week 12 in comparison to participants on placebo. In a previous  placebo-controlled double-blind study water extract of Labisia pumila in 192 women between the ages of 40 to 60 years of age, the authors reported that a water extract of Labisia pumila reduced anxiety levels by 55% compared to placebo.
There were no significant differences between the two treatment groups in their serum concentrations of estradiol-17� even though participants on LP showed increase in estrogen levels from baseline to week 12. In the current study, 44.4% of females on placebo consumed alcohol weekly in comparison to 16.7% on Labisia pumila. Furthermore, 11.1% of participants on Labisia pumila were current smokers while none were smokers in the placebo group. As alcohol consumption increases circulating estrogen and androgen levels and smoking has anti estrogenic effects, it is possible that these demographic differences impacted the results of the study (Purohit, 1998; Tank� & Christiansen, 2004). Furthermore, participants on placebo had a significantly higher BMI and body weight at baseline in comparison to participants on Labisia pumila. As increased BMI, waist circumference, and hip circumference are associated with increased levels of estrone, estradiol, and free estradiol (McTiernan et al., 2006). It is possible that these factors may also have influenced the results of the current study. Conclusions regarding the interaction between age and estradiol levels are difficult, since these parameters are depended on the stage of the menstrual cycle at the time of blood sampling as well as the presence or absence of menstruation in the age groups. Previous data from a randomized double-blind trial did not show significant fluctuations in follicle-stimulating hormone, luteinizing hormone and estradiol during a 280mg/day intake of Labisia pumila sprayed-water extract for six months in 29 postmenopausal women when compared to placebo (Nik Hazlina et al., 2009). 
In the current study there was a decreasing trend in total cholesterol with participants on Labisia pumila showing a trend towards a decrease by week 12 compared to placebo (p=0.077). Recently, clinical data showed a significant reduction in triglyceride during a 280mg/day of sprayed-dried water extract of Labisa pumila intake for six months (Nik Hazlina et al., 2009). 
Though not statistically significant, participants consuming Labisia pumila for 12 week showed a decreasing trend of urinary 8-isoprostane concentration from baseline to week 12 compared to placebo.Eight-isoprostane is regarded as one of the best indices of lipid peroxidation and oxidative stress (Harman et al., 2003). It is possible that LP may have a function in decreasing CVD risk in postmenopausal women.  There were no between-group differences in cytokines, but this may have been due to the healthy status of participants enrolled in the study.  
The analysis of renal and liver function tests, CBC and other clinical chemistry parameters showed that the LP was safe and well tolerated at a dose of 200mg/day in the population studied. This is consistent with data from a six-month randomized placebo-controlled trial in postmenopausal women using dose regimen of up to 560mg sprayed-dried water extract of Labisia pumila (Nik Hazlina et al., 2009; Nik Hazlina et al., 2009; Nik Hazlina et al., 2008).      
There are a few limitations to this study. It is possible that participants may have shown better long term effects of Labisia pumila with respect to FSFI scores, if dose escalation had been considered after 6 weeks of product administration. Increase in daily dose after week 6 may have improved scores as response times may be impacted by the stage of the menstrual cycle as 91% of the women on Labisia pumila and 88% of the women on placebo were postmenopausal. A small sample size and the inability to do justice to stratification by age may have further impacted the results of this study.
Conclusion
In this study, water extract of Labisia pumila BIO LP101 demonstrated efficacy in improving cardiovascular health and showed improving trends in sexual functions, oxidative stress and anti-inflammatory activities. Analysis of renal and liver function tests, complete blood count and other clinical chemistry parameters along with vital measurements and adverse events indicated that water extract of Labisia pumila at a dosage of 200mg per day for 12 weeks on was safe in pre- and postmenopausal women, 18-70 yrs of age. 
Acknowledgments
We wish to thank the volunteers who took part in this study for their willingness and diligence in complying with the study protocol.  This study was conducted at KGK Synergize Inc., London, Ontario, Canada under the supervision of the Medical Director Dale Wilson, MD.  The authors wish to thank Sonya Barss for overseeing the conduct of the study, Larry Stitt, Biostatistician, University of Western Ontario for statistical analysis and Eh-Sanus Fahim for overseeing data management.  We thank Joshua Baisley for regulatory and quality activities and for his technical support.  This study was sponsored by Biotropics Malaysia Berhad.


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Tasduq, S. A., Reeta, D. & Sandeep, S. P. (2007). Anti-oxidant and cytoprotective activity of water extract from Labisia pumila. Poster presented at Women's Health and Asian Traditional Medicine.  
Zhari Ismail, Kementerian Kesihatan Malaysia, Norhayati Ismail, & Jaafar Lassa (1999). Malaysian herbal monograph, Volume 1. Kuala Lumpur: Malaysian Monograph Committee.



Figure Legends
Figure 1: Flow chart showing disposition of study subjects

Table 1: Demographics and characteristics all subjects randomized into the studyLabisia pumila
(N=18)Placebo
(N=18)p-valueMean � SDMean � SDAge (years)39.1 � 13.040.4 � 12.50.756aWeight (kg)61.2� 7.168.6 � 10.70.019aBMI (kg/m2)22.8 � 3.425.5 � 4.30.041aAlcohol Use [f/n (%)]None6/18 (33.3%)1/18 (5.6%)0.059bOccasional9/18 (50.0%)9/18 (50.0%)Weekly3/18 (16.7%)8/18 (44.4%)Tobacco Use [f/n (%)]Current2/18 (11.1%)0/18 (0.0%)0.241bFormer2/18 (11.1%)5/18 (27.8%)Never14/18 (77.8%)13/18 (72.2%)a Between group comparisons were made using analysis of variance (ANOVA).  Probability values P<0.05 are statistically significant.
b Between group comparisons were made using a t-test.  Probability values P<0.05 are statistically significant.


Table 2: Total FSFI score of all subjects randomized into the study at baseline, 6 weeks and 12 weeks.   Labisia pumilaPlacebop-value[N] Mean � SD[N] Mean � SDFSFI Total 
(Score Range 2.0 � 36.0, Higher is better)Week 0 (Baseline)[17] 24.6 � 9.7[15] 26.9 � 7.70.473aWeek 6[17] 25.9 � 7.5[17] 28.9 � 6.10.320bWeek 12[15] 24.8 � 10.2[16] 26.1 � 11.30.863ba Between group comparisons were made using a t-test. Probability values P<0.05 are statistically significant.
b Between group comparisons were made using analysis of covariance (ANCOVA) using baseline as a covariate.  Probability values P<0.05 are statistically significant.


Table 3: Total SF-36 score of all subjects randomized into the study at baseline, 6 weeks and 12 weeks.   Labisia pumilaPlacebop-value[N] Mean � SD[N] Mean � SDSF 36 Total  
(Score Range 0.0 � 100.0, Higher is better)Week 0 (Baseline)[18] 89.5 � 5.9[18] 90.6 � 4.90.520aWeek 6[18] 88.2 � 5.2[18] 87.1 � 9.80.442bWeek 12[16] 88.9 � 6.1[17] 88.2 � 8.70.676ba Between group comparisons were made using a t-test. Probability values P<0.05 are statistically significant.
b Between group comparisons were made using analysis of covariance (ANCOVA) using baseline as a covariate.  Probability values P<0.05 are statistically significant.


Table 4: Total cholesterol values at baseline, week 6 and week 12 for all randomized subjectsLabisia pumilaPlacebop-value[N] Mean � SD[N] Mean � SDTotal Cholesterol (mmol/L)Week 0 (Baseline)[18] 5.0 � 1.0[18] 4.9 � 1.10.882aWeek 6[18] 4.9 � 1.1[18] 4.9 � 1.00.791bWeek 12[16] 4.8 � 1.0[17] 5.2 � 0.90.077ba Between group comparisons were made using a t-test. Probability values P<0.05 are statistically significant.
b Between group comparisons were made using analysis of covariance (ANCOVA) using baseline as a covariate.  Probability values P<0.05 are statistically significant.

Table 5: Cytokine profile during treatment, demonstrating the differences from baseline to week 6 and to week 12Labisia Pumila
(N=18)p-valueaPlacebo
(N=18)p-valuea[N] Mean � SD[N] Mean � SDTNF-� (pg/mL)Difference from Baseline to week 6[18] -0.1 � 0.60.493[18] 0.6 � 6.50.686Difference from Baseline to week 12[16] 0.4 � 1.50.339[17] -0.9 � 2.50.147IL-6 (pg/mL)Difference from Baseline to week 6[18] -1.2 � 1.60.006a[18] -1.0 � 1.50.012aDifference from Baseline to week 12[16] -0.0 � 1.30.954[17] 1.0 � 4.90.411IL-1� (pg/mL)Difference from Baseline to week 6[18] -0.5 � 0.5<0.001a[18] -0.3 � 1.00.234Difference from Baseline to week 12[16] -0.6 � 0.60ϫ۫<+<-<.<Y<Z<[<h<i<s<x=���궜��lT<l/h�C�h��CJOJQJ^JaJmHnHsH	u/h�C�h�'�CJOJQJ^JaJmHnHsH	u/h�C�h�i�CJOJQJ^JaJmHnHsH	u/h�C�h�hCJOJQJ^JaJmHnHsH	u3hseh�h0J"CJOJQJ^JaJmHnHsH	u2jh�hCJOJQJU^JaJmHnHsH	u/h�hh�hCJOJQJ^JaJmHnHsH	uU)h�hCJOJQJ^JaJmHnHsH	ux=�=�=�=�=�=�=>>>k>�ι��~iWE/+h�C�hT5�CJOJQJ^JaJmH	sH	"hTCJOJQJ^JaJmH	sH	"h�.�CJOJQJ^JaJmH	sH	(h�C�h�.�CJOJQJ^JaJmH	sH	+h�.�h�.�5�CJOJQJ^JaJmH	sH	%h�.�5�CJOJQJ^JaJmH	sH	"h�.�CJOJQJ^JaJmH	sH	(h�C�h�i�CJOJQJ^JaJmH	sH	/h�C�h�i�CJOJQJ^JaJmHnHsH	u2h�C�h�i�6�CJOJQJ^JaJmHnHsH	u
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Table 6: Adverse Events with �possible� causal relation to the study medicationStudy groupAdverse events �possibly� related to the medication listed for each subjectLabisia pumila
4 subjectsNausea
Menstrual cramps
Vaginal spotting, mood alteration
Stomach gasPlacebo
4 subjectsBreast tenderness
Increased vaginal wetness, increased flatulence
Nausea
Headache, mood alteration, constipation










		 PAGE   \* MERGEFORMAT 19




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