SAFETY ISSUES AFFECTING CHINESE HERBS:
The Case of Ginseng
During the 1970's, there was a huge effort made by several U.S. companies to increase sales of ginseng products to the public. Numerous books about ginseng were published between 1976 and 1978, such as The Ginseng Book (1), Ginseng (2), Korean Ginseng (3), and Ginseng: The Myth and The Truth (4). Much of the ginseng on the market at the time was from South Korea, which had been actively promoting its cultivated ginseng products since the 1960's and which held annual Symposia on ginseng starting in 1977. As China opened its markets beginning in 1976, ginseng and related products (e.g., eleuthero ginseng, notoginseng) were exported in increasing amounts. American ginseng, which had formerly been sold almost exclusively to Asia, was finally marketed in the U.S. Hsu's Ginseng Farm, in Wisconsin, has been one of the main producing and marketing agencies for American ginseng, and has helped develop some use of the herb in America. In 1981, China convened a symposium on eleuthero ginseng in Harbin, China; at an international conference on Chinese medicine held in Hong Kong in 1983 (5), ginseng was one of the selected topics for presentations (of which there were 7 reports). Ginseng became one of the most heavily traded herbs in the West and remains in the top ten list of herbs sold in the U.S. and Europe.
During the period of intensive import of ginseng, the U.S. Food and Drug Administration (FDA), having no familiarity with the herb, attempted to limit or control it. At one point, an import ban on ginseng was contemplated (it was very briefly instituted for some products, but quickly overturned). However, as the evidence about ginseng's effects was reviewed, it was found that there was no convincing data indicating harm from this herb when used in normal amounts. In fact, the FDA eventually took the unofficial position that ginseng did neither harm nor good: it was an essentially innocuous substance and went unregulated. As a result, ginseng found its way into candies, gums, soft drinks, and numerous other food products, aside from its medicinal preparations sold in the form of capsules, tablets, and liquid extracts of the herb. Today, it is included in some of the "functional food" products, where it is considered an energy enhancing ingredient.
The first known ginseng treatise was written by Li Yenwen, the father of Li Shizhen (author of Bencao Gangmu, published in 1596 A.D.). Excerpts from the ginseng treatise were included in the Bencao Gangmu, including this passage about the nature, functions, and use of ginseng, that illustrates the gentle quality of the herb (17):
Used fresh, ginseng displays a cool nature. When it is used after preparation [steamed, red ginseng], its nature is warm. The slight sweet taste strengthens the yang; the somewhat bitter taste strengthens the yin. Nature [xing] controls the genesis of things: their origin is in heaven; tastes control the completion of things; their origin is in the earth. Nature and taste, genesis and completion are realizations of yin and yang. The cool nature of fresh ginseng expresses the yang influence of spring, namely, of genesis and development. This is the yang of heaven. It has the nature of rising. Sweet is a taste that has been formed through transformation of moisture and earth. These are the yang influences of earth. They have the nature of floating. The somewhat bitter taste has been formed through reciprocal interaction of fire and earth. These are the yin influences of earth. They have the nature of descending in the body.
Taste and nature are both equally weak in ginseng. Whatever has a weak nature descends in the body when fresh, and rises when prepared. Whatever has a weak taste rises in the body when fresh and descends when prepared. In case of illness in which the earth [spleen] shows a depletion and the fire [heart] shows vigor, the weak cool nature of fresh ginseng is suited to diminish the blazing of the fire and to replenish the earth. This could be called a pure use of ginseng's nature.
In the case of illness characterized by depletion in the earth and weakness in the lung, the sweet taste and warm nature of prepared ginseng is suited to replenish the earth and to generate the metal [associated with lung]. This could be called a pure use of ginseng's taste....
Bai Feixia wrote: 'When one takes ginseng as a paste after a cyclic preparation [usually, steaming and drying with alcohol], this herb is able to restore the original qi into a utopian condition.' Whenever one suffers-after an illness-from qi depletion and from a depletion in the lung combined with cough, ginseng is appropriate. When a qi depletion exists together with fire, one should take ginseng together with ophiopogon.
This presentation of the mild and beneficial nature of ginseng was turned upside down about two centuries later. Ginseng had become exceedingly rare and costly, and, as a result, it had become an object of abuse (16). Physicians and herb merchants would promise incredible results from using the rare root (which, at the time, was not cultivated and only obtained from remote forests in Northeast China and Korea). Desperate patients, and their families, would seek it out, and then use as much as possible in an attempt to overcome an obviously debilitating or fatal condition. Ginseng was even described as being able to bring back the dead (probably meaning that it would restore health to someone who appeared to be imminently dying).
When some of the ailing patients died after taking ginseng, responsibility for the death might be attributed to the ginseng. Hence, ginseng became known as a potentially dangerous herb. Zhang Lu, a physician of the Qing Dynasty period (15), commented: "Some people look upon ginseng as poison or a sword [two-edged, able to provide help, but also to destroy] and stubbornly refuse to use it."
Still, its old reputation as a healer for serious conditions and as a preventer of aging and death was retained. Ginseng eventually became known to the West through the efforts of missionary doctors living in the East. The British doctors Smith and Stuart, working in China at the end of the 19th century, wrote (18):
Ginseng, with the Chinese, is the medicine par excellance, the dernier ressort [last resort] when all other drugs fail; reserved for the use of the Emperor and his household, and conferred by Imperial favor upon high and useful officials whenever they have a serious breakdown that does not yield to ordinary treatment, and which threatens to put a period to their lives and usefulness....The ordinary ginseng of the markets has been studied and has not been found to possess any important medicinal properties. But the Chinese describe cases in which the sick have been practically in articulo mortis, when upon the administration of ginseng they were sufficiently restored to transact final items of business....It is prescribed in nearly every kind of disease of a severe character, with few exceptions, but with many reservations as to the stage of the disease in which it may be administered with the greatest benefit and safety.
It should be noted that the main use of ginseng was for those who are severely ill, and these observers noted that the Chinese expressed concerns for the particulars of the disease so that the herb could be used safely. The ginseng used by the Emperors and their households was the rare wild Manchurian ginseng; the market ginseng consisted mainly of cultivated roots (as is used now), and substitute roots of codonopsis; these were declared to be virtually worthless from a medicinal point of view (an opinion held by most researchers and physicians today). We will never know if wild Manchurian ginseng had remarkable properties not found in the cultivated roots: there isn't enough left to test clinically.
In the latter part of the 20th century, ginseng was promoted to Westerners as a health product that could improve cardiovascular functions, mental acuity, and sexual performance, prevent serious diseases (such as cancer), and help treat chronic ailments (such as diabetes). It was recommended to be taken on a daily basis much as one would use a multi-vitamin, which was the closest Western equivalent, conceptually, to ginseng at the time. In fact, a number of multi-vitamin products added a small amount of ginseng to their formulation in order to promote this very concept.
The herb was eventually being consumed by millions of Americans. Unfortunately, a very small number of consumers began using the herb in unusual ways (unusual applications of a Chinese herb similarly occurred, but on a much bigger scale, with ma-huang; see: Safety issues affecting Chinese herbs: The case of ma-huang). The result of the misuses of the herb was reports of adverse effects. In 1979, a Los Angeles physician, Ron Siegel, published a clinical note in the Journal of the American Medical Association (6) about a "ginseng abuse syndrome." In an evaluation of 133 people in the Los Angeles area who had been taking ginseng frequently (for one month to two years), it was found that 14 (10%) reported symptoms that were then depicted as being part of this syndrome (though a larger number reported one or more symptoms, falling short of the abuse syndrome). Typical symptoms were nervousness, irritability, insomnia, skin eruptions, and morning diarrhea.
In fact, the study by Siegel, which was uncontrolled, had numerous flaws (7). All of the people reporting these "adverse reactions" were consuming caffeine (mainly coffee), which has these exact side effects (except skin eruptions). Those who were in the study all reported that they experienced an energizing effect of ginseng, which implies that this was the primary reason for persistent use of the herb. Further, Siegel had later admitted that several of the cases of ginseng abuse syndrome were from people who were using ginseng in an attempt to get "high" and were sometimes administering unreasonable amounts (up to 15 grams per day). In China, ginseng is reputed to calm the disturbed spirit, being a typical remedy for anxiety, irritability, and insomnia.
The doses of ginseng described in Chinese literature for typical medical applications often exceed those that most Western consumers get from commercial ginseng products, so the difference between what the Chinese claim (a calming effect) and this adverse side effect (agitation or energy stimulation) may well have nothing to do with using ginseng in high doses or for prolonged periods, but from other things taken at the same time in an effort to overcome lethargy. Nonetheless, the list of side effects from this 30 year old article are still brought out by virtually every writer who wishes to present the pros and cons of using ginseng.
Even in Chinese publications, the ginseng abuse syndrome is now mentioned, probably in an effort to show that there is a balanced view of ginseng as being both helpful (the dominant view in Asia) and potentially harmful. Thus, Chen Keji, the leading editor of the English language Journal of Traditional Chinese Medicine, published an article called "The effect and abuse syndrome of ginseng" in the first issue of his journal in 1981 (15). According to Chen, when using ginseng with care in his own clinic, he found that a few long-term users experienced insomnia and excitation. He provided the following explanations of possible adverse reactions to ginseng based on Chinese medical theory and experience:
Increasing Bodily Fire: According to the theory and clinical experience of traditional Chinese medicine, ginseng may be used for deficiency of vital energy and may be prescribed for insufficiency of yin associated with loss of bodily fire. But, the dosage should be reduced [compared to amounts used for a simple syndrome of insufficiency of bodily fire] for insufficiency of yin with moderate bodily fire. It is contraindicated in insufficiency of yin with excessive bodily fire, because ginseng has then property of increasing the bodily fire and vital energy. The longer the duration of ginseng use for the insufficiency of yin, therefore, the more the yin is consumed, especially when large doses are used. We have observed that some long term or large quantity users experienced constipation or epistaxis. Thus, for insufficiency of yin, when the medication of ginseng is considered necessary, it appears advisable to use Western ginseng [American ginseng] which is relatively richer in yin-nourishing properties.
Gastric or Abdominal Distention: Ginseng can help to increase vital energy and strengthen the spleen. In suitable dosage, it can promote the digestive function. Overdosage for a long period of time, however, may produce a feeling of distention of stomach or abdomen and loss of appetite. The above manifestation is considered to be relatively common. Some patients who do not have bodily weakness experience instant stomach distention upon using ginseng. Fresh radish juice, or decoction with radish seed at 3-6 grams, can relieve this [radish is said to counteract the tonic functions of ginseng].
Retaining Harmful Agents in the Body: Traditional Chinese medicine prescribes ginseng as an adjuvant for patients with general weakness and suffering from the common cold. Our ancient formularies said that doctors should use Ginseng and Perilla Formula (Shen Su Yin) and Ginseng and Mentha Formula (Renshen Baidu San), etc., for supplementing yang and relieving conjointly the superficial syndrome. For gentle dissipation of harms, Minor Bupleurum Combination (Xiao Chaihu Tang, which contains ginseng) should be used. For eliminating fever, use Ginseng and Gypsum Combination (Renshen Baihu Tang) and Bamboo and Gypsum Combination (Zhuye Shigao Tang, which contains ginseng). For purging therapy, use Huang Long Tang (a modification of Major Rhubarb Combination with ginseng). All of the above recipes are used for the purpose of overcoming deficiency and eliminating the harmful agents. Some practitioners hold that ginseng is synergistic to other herbs in eliminating the harmful agents in generally weak persons suffering from cold, but without replenishing action, and this view deserves further investigation. There are other factors which also need to be considered. If general weakness is not present, but the patient has the superficial syndrome of headache, fever, constipation, nausea, vomiting, and thick coated tongue, it is advisable not to use ginseng so as to avoid prolonged retention of harmful agents and aggravation of illness.
Those who are trained to prescribe Chinese herbs in the West, mainly acupuncturists, have also developed serious concerns about ginseng. For example, some report that they won't use it at all, because it is too stimulating. In actuality, there is little evidence that ginseng serves as a stimulant. Its main active constituents, saponin glycosides, do not otherwise have a reputation as providing a stimulant action. In a clinical evaluation conducted by ITM in 1979 (8), participants were provided high quality ginseng powder (provided by the Ginseng Research Institute of Seoul Korea) at a substantial dose (either 3.0 or 4.5 grams per day of the powdered root; except for the placebo group) and were interviewed after three weeks of daily use of the ginseng. After accounting for minor or possible effects that were equally reported by the placebo group, only 17% of the participants identified "improved energy" as an evident response to ginseng. This change was not viewed by these participants as undesirable (e.g., did not cause nervous agitation or insomnia). Still, because of the reputation that has been developed about ginseng being a stimulant on par with caffeine, anyone who reports taking ginseng and feeling agitated, nervous, or otherwise distressed may be considered to have suffered the side effect of ginseng.
Another concern raised by professional prescribers of ginseng is that its use may worsen an acute congestive illness, such as the common cold or influenza, the last matter addressed by Chen, above. This concern is based on a traditional Chinese concept that tonification therapy, as a sole treatment method, is inappropriate when such disorders are present, but, the idea is sometimes misconstrued as indicating that tonics, especially ginseng, are always contraindicated. The underlying concept, including dire warnings, was described by Xu Dachun (16) in his brief essay on ginseng (1757 A.D., during the Qing Dynasty):
Since ginseng is a substance rich in influences [qi] and full of vigor, it is able to supplement depletion and stop the loss of proper influences, no matter whether a patient's illness is related to wind, cold, summer-heat, dampness, phlegm, fire or some binding of influences within the body. An application of ginseng is always appropriate when the evil influences that caused a patient's illness have left the body, but the proper influences are still weak, or when only a little of the evil influences remain, but the proper influences are exhausted, or when evil influences have penetrated deeply into the body and proper influences are themselves too weak to drive off the evil influences.
In order to support the elimination of evil influences by means of herbs, one must give the patient ginseng together with other herbs that are capable of driving off the evil influences. However, before one applies ginseng, one should examine whether the disorder to be treated is minor or serious, and only if this is taken into account will the effect of rescue from danger or of strengthening that what is already bent [damaged], appear as a matter of course. If one fails to investigate, though, whether evil influences are present or not, and whether the person suffers from depletion or repletion, and if one administers only warm or hot substances of a purely supplementing nature, then one will merely supplement the evil influences and help them settle down. In minor cases, the evil influences will, as a result of such mistaken therapy, never leave the body again. In serious cases, death is inevitable.
Thus, Xu has helped promulgate the basic theory that applying tonics and warming agents when a pathogen enters the body of a person who is not deficient can cause the pathogen to remain in the body. Ginseng is only one example of an herb that is of concern; the matter applies to tonification therapies as a class. The other issue is that a qi tonic herb aids in the production of fluids, and when one has an acute congestive disorder (with accumulation or discharge of excess fluids), one should not use a tonification therapy, as it will worsen the congestion. However, ginseng as a component of an appropriately designed herbal formula is not contraindicated in cases where a pathogenic influence and resulting congestion are still present. As an example, among the traditional formulas mentioned above by Chen, Ginseng and Mentha Formula (Renshen Baidu San), is designated as a treatment for these acute congestive ailments, such as common cold, cough, nasal congestion, and early stages of skin eruption (9).
An important factor in all the concerns is the dosage of ginseng that is used and the duration of its use. Commercial products containing ginseng rarely call for ingestion of more than 1-2 grams of the root per day, and many products, such as the heavily promoted Ginsana (10) provide only minuscule doses (equal to a fraction of a gram of ginseng per day). According to Mark Blumenthal of the American Botanical Council, most commercial ginseng products have from 2-4% ginsenosides (ginseng that is used by clinicians may be higher, up to about 5%). At a dose of 1-2 grams of ginseng per day, the commercial products would provide up to 80 mg of ginsenosides per day. This is barely a clinically relevant dosage (see: Platycodon and other herbs with triterpene glycosides).
The small doses of ginseng normally consumed in the West can be compared to ginseng decoctions used in China, where it is common to administer from 3-10 grams per day. The participants in Siegel's evaluation reported an average ginseng daily dosage of 3 grams, but a duration of use that was usually several months. In clinical practice, the higher ginseng doses are usually prescribed for only a few weeks (may be followed up by low dosage forms for much longer). In the clinical evaluation conducted by ITM, 3.0 or 4.5 grams of ginseng per day for three weeks yielded no more reports of mild adverse reactions than the placebo, and none of the severe adverse reactions. Further, the adverse effects that might be expected from improper ginseng use by TCM theory, as relayed by Chen, will generally not occur when ginseng is prescribed by a practitioner who evaluates the patient and selects an appropriate formula, rather than when it is self-prescribed.
Several of the current concerns about ginseng were presented recently by Dr. Andrew Weil, perhaps America's best known commentator on alternative, complementary, and traditional medicines who is a medical doctor. In his newsletter (Spontaneous Healing, 2000) "Focus on Herbs" section, Dr. Weil has presented a short summary entitled "The many faces of ginseng," in which he raises questions about the safety and use of this popular herb (11).
His summary is divided into three parts: The Evidence; Safety Concerns; and My Bottom Line. Under Evidence, he points out that ginseng has been used for millennia in the Orient, that laboratory studies have indicated that ginseng can increase resistance to infection, provide protection against stress, and improve endurance, and that few well-defined human studies have been published. He relays information from a recent review on ginseng saying only that "while ginseng may have some beneficial effects, studies are contradictory and more rigorous research with standardized ginseng is needed to confirm the herb's efficacy and safety." It is, in fact, the case that there is little proof of efficacy for ginseng in human applications (due to poor study design and reporting, and, perhaps, limited effects of the herb, especially at the doses used), but the safety of ginseng, in normal doses, is not really in question.
Under Safety Concerns, Dr. Weil mentions a 1978 study (12) that found that 25% of ginseng products of that time (taken from over the counter sales, not prescription items, a total of 28 items), had no ginseng at all. This is somewhat misleading, as many ginseng products sold at that time contained "eleuthero ginseng" (also known as "Siberian ginseng"), which is an herb of the same plant family that was reported to have similar uses to Panax ginseng (see Figure 1.). In most of the products containing eleuthero ginseng, the plant type was clearly specified. Eleuthero ginseng (Eleutherococcus senticosus) has different active constituents than the Panax species but the reported therapeutic benefits are the same. When the products were tested for the ginsenosides found in ginseng, none were found in the ones containing eleuthero ginseng. This doesn't mean that the eleuthero products were devoid of active constituents, only that no ginsenosides were found. At that time it was not possible to regularly and accurately test ginseng samples for ginsenoside levels, since commercial laboratories did not offer this service (it required a special project, usually one developed at a University laboratory). Therefore, ginseng of varying ginsenoside content could be purchased without control. None of the products that had little or no ginsenosides were ever shown to be unsafe.
Dr. Weil also mentions more recent tests that found 12 of 22 products either did not have adequate levels of ginseng (meaning ginsenosides) or were contaminated with lead or pesticides. This is also somewhat misleading. First, no standard has been set for the level of ginsenosides, so one cannot say that the levels are inadequate. Other studies have shown commercial products having a range of 1.9-9.0% ginsenosides (when ginsenosides are present; the 9% level is for a concentrated extract rather than a crude herb powder). Crude dried ginseng roots normally show considerable variability in content during formal testing of non-commercial products (typical range: 2.2-5.2%), with white ginseng having the lower amounts and red ginseng having the higher amounts (during drying, ordinary white ginseng loses active constituents as a result of the plant's own enzymes degrading them; to make red ginseng, the roots are steamed, which inactivates the enzymes and preserves the active constituents). American ginseng has even higher amounts of ginsenosides than Chinese ginseng. Some people seek out white ginseng based on the belief that it is more cooling than the red ginseng, which is deemed more warming. Therefore, the herb that normally has low levels of ginsenosides is sometimes the preferred one.
The amounts of lead or pesticides detected were very small and easily within what are considered safe limits. Lead is a natural component of some soils and is found in one of the mountain grown ginsengs, known as tien-chi ginseng (Panax notoginseng), that comes from the mountains of Yunnan Province in China (lead is present in trace amounts in many of the foods we eat as well, with daily ingestion of this component in milligram quantities).
Pesticides (mainly fungicides) are usually used only when needed in ginseng cultivation and avoided during the weeks just prior to harvest, but trace amounts are sometimes left in the roots (just enough to reach the limit of detection); the amount of root ingested is small and the amount of pesticide ingested with it is truly minuscule. The main item of concern is quintazone, a fungicide that is sometimes used either for growing ginseng or to treat harvested roots. While this fungicide is approved for use on certain food crops (e.g., cottonseed for oil, collards, kale, mustard greens), no effort has been made to get it approved in the U.S. for ginseng, so it is not listed as approved for that application. Herb trade associations, such as the American Herbal Products Association, are aware of the quintazone situation and are taking steps to ensure that even these trace amounts are absent from the future import supply, by first establishing reliable testing methods.
Though some products in the marketplace have been called "ginseng" in order to capitalize on the value of the name (e.g., ashwaganda of the Ayurvedic tradition has been called "Indian ginseng" but is botanically and chemically unrelated, though the indications are similar), it does not take much effort to find the type of ginseng that is desired (such as Panax ginseng, sometimes referred to as "true ginseng"). Consumers who have no knowledge of ginseng at all can be easily misled by advertising that includes the term ginseng, but such consumers may not care whether the product is Panax ginseng or some other species of plant, so long as it has the advertised properties and uses. At this time, there is no evidence showing that any one type of ginseng is better than another, in terms of clinical effects or safety.
Dr. Weil states that "people with anxiety-related conditions, irritability, insomnia, or high blood pressure should use Asian ginseng with caution as it may exacerbate these conditions." In fact, Asian ginseng is indicated specifically for treating all of these conditions; the only caution in this regard is not to overdose. Clearly, this is a case of passing on information about the "ginseng abuse syndrome." Dr. Chen, in his article, suggested that such problems may occur with prolonged use of high dosages, which is not a recommended means of using ginseng. The only significant medical concern among the list of Weil's contraindications is hypertension. In Korea, one of the areas of active research is on use of ginseng to treat hypertension as well as high blood sugar and elevated lipid levels. In China, ginseng is used to raise blood pressure in persons who experience shock (sudden low blood pressure), but it is administered in very large quantities (equivalent to 10-30 grams of ginseng root), and sometimes by injection.
Dr. Weil further states that "Ginseng may have estrogenic activity, and although this concern hasn't been proven, I think its safer for women with hormonally driven cancers (such as breast, ovarian, and uterine cancer) and conditions (like uterine fibroids and endometriosis) to avoid using ginseng altogether." This statement is unnecessarily alarmist.
First, by stating that ginseng "may" have an activity for which there is no proof, an entirely speculative concern becomes the source of an important recommendation. In an ITM article, Estrogen-dependent tumors, I have argued that if a patient or doctor is concerned about any level of estrogenic activity from herbs that herbs should not be used at all. There is insufficient data to rule out any estrogenic effect of an herb. Further, the basic theory of herbal use is that it can correct imbalances so that a woman with low estrogen who takes herbs may then have a higher level of estrogen as a result, regardless of the specific herbal properties.
At this time, there is no evidence that ginseng, in the dosages commonly consumed, has any measurable estrogenic activity for humans. A typical laboratory animal study that shows some hormonal effects of ginseng involved aged animals (two year old rats; the normal life span is about two years), who are given substantial quantities of ginsenosides (much higher levels than humans would consume) to produce an increase in plasma estradiol in the absence of a control group (13). When large amounts of ginseng extracts are given to immature animals, such as rabbits and mice, it is found that there are some hormonal changes that may involve the sexual development. This is understood to be mediated by the hypothalamus and pituitary glands, eventually affecting the adrenal glands and the production of steroids. However, most studies do not reveal any significant estrogen effects (or testosterone effects) of ginseng, suggesting that the effects are mild, dose dependent, and possibly dependent on age.
Once the concern is raised, Dr. Weil suggests instances for avoiding ginseng altogether, without any reference to the dosage of ginseng that he thinks may cause a problem because of putative estrogenic activity. The term "estrogenic activity" is such a non-specific one that it can be applied to the actions of dozens of ordinary foods (many people are familiar with soybeans in this role, but it also applies to many legumes, including peanuts and lima beans), common spices and flavors (e.g., fennel, anise, fenugreek, and licorice), and Chinese herbs (tang-kuei is often said to have estrogenic activity without any evidence to support it; in fact, there is good evidence to contradict it). Some herbal estrogenic activities are also anti-estrogenic in relation to cancers (because there are several estrogen receptors with differing effects of stimulation). Obviously, women with hormonally driven cancers might want to avoid large doses of ginseng (or any of the other items mentioned in this regard), but should not be put in fear of small amounts of ginseng or other herbs used in formulas. Ginseng is often a minor component of formulas prescribed to such women by health professionals. Also, there is no valid reason to fear using ginseng during chemotherapy or radiation therapy when cancer cells are strongly inhibited by the medical therapy.
Dr. Weil gives his Bottom Line: that in his own experience, high quality ginseng may help restore energy in patients who have chronic fatigue syndrome, cancer, recovering from illness or injury, or under extreme stress. Unfortunately, this "energy-boosting" aspect of ginseng is overly emphasized in the promotional literature and is not the only-or even the main-use of ginseng by health professionals. One may question how he came to his conclusion that ginseng worked in these conditions, since it is doubtful that his patients only took ginseng and did nothing else different, in order to get their alleged symptom relief. Nor did he have a means, with mere personal experience, to distinguish his observations from placebo effects or setting effects, something that can only be discovered through carefully controlled clinical trials.
In all, this presentation by Dr. Weil reflects the view of ginseng that has become prevalent in the popular literature, particularly in the literature that focuses on negative aspects of herbs: problems with their identity, content of active ingredients, side effects, and lack of efficacy. The article implies that significant safety concerns exist with use of ginseng or ginseng products, though only high dosage administration (a rarity) or abuse of the products should be questioned (and then, not only for ginseng, but any herb or drug). He relays the lack of clinical evidence for ginseng's efficacy from carefully conducted studies in a cautionary tone, but a few paragraphs later relays his own positive experience without acknowledging the limitations of his method of evaluation. He raises undue worries about the herb in relation to estrogen without considering the situations in which women may find themselves, such as using small amounts of the herb successfully, especially during chemotherapy or radiation treatments. He doesn't direct women with estrogen-dependent cancers or other serious conditions to work with doctors that prescribe herbs rather than continuing to self-prescribe over-the-counter herbs. Thus, The many faces of ginseng presents faces that are not representative of the situation. It should be viewed as only one way of looking at ginseng.
One of the issues not raised in the article is the alleged interaction of ginseng with warfarin (see: Interactions of herbs and drugs). The first reported case of this was with Ginsana. According to the report (14) about a "probable interaction," a patient taking Warfarin had a blood coagulation test that declined notably after two weeks of using Ginsana and then returned to normal two weeks after ceasing use of the herb. Interestingly, while ginseng and its ginsenosides are sometimes credited with having a slight effect of reducing platelet aggregation, in this case it was implied that it reduced the platelet inhibiting action of warfarin. In this case, there is only one data point to suggest the interaction and, if one examines the data presented for prior blood tests for the patient, there was already a possible trend towards warfarin failure in this patient. Although the patient took more Ginsana than recommended on the label, the amount of ginsenosides ingested was probably too little to produce an interaction with the drug.
Figure 1: Panax ginseng.