The reversal of moderate cervical dysplasia with high-risk HPV in a 26-year-old using an escharotic, indole-3-carbinol and folate.
-Dr. Nick LeRoy, DC, MS
OBJECTIVE: Cervical dysplasia, the premalignant condition of the uterine cervix, is a common condition afflicting young women. Although standard medical intervention is effective at removing diseased cervical tissue, there are women interested in an alternative treatment of this condition. This case study examined whether a natural medicine protocol utilizing an escharotic combined with oral supplementation of indole-3-carbinol and folate could reverse moderate dysplasia in a 27-year old female with a high-risk human papilloma virus (HR-HPV) infection.
INTERVENTION: Twenty-one applications of an escharotic containing zinc chloride and bloodroot were applied twice per week to the subjects transformation zone of the cervix. Concurrently, the subject took 400 mg of indole-3-carbinol and 1600 mcg folate orally for the duration of the study.
OUTCOME MEASURES: Pre-intervention testing included a ThinPrep pap and biopsy; post-intervention testing consisted of ThinPrep paps at 3 weeks, 3 months, and 19 months.
RESULTS: All three post-intervention paps were negative for epithelial lesion or malignancy.
CONCLUSION: The use of an escharotic containing zinc chloride and bloodroot combined with oral therapy of indole-3-carbinol and folate effected a reversal of moderate cervical dysplasia in a 27-year old female with a HR-HPV infection.
Cervical dysplasia is a pre-malignant condition of the uterine cervix that if left untreated has the potential to become malignant. Current evidence suggests that the Human Papilloma Virus (HPV) causes cervical cancer and its precursor, cervical dysplasia. In the United States, there are approximately 6.2 million new HPV infections every year and approximately 2 million individuals are currently infected .(1) However, epidemiological evidence has generated uncertainty as to whether the virus alone causes cervical disease. The finding that approximately 80% of women will contract at least 1 HPV infection in their lifetime but only 28% will manifest disease has questioned whether HPV is the exclusive agent in the development of cervical dysplasia.(2,3) Recent research is demonstrating that estrogen as well as micronutrient deficiencies are necessary cofactors that assist in viral genome insertion into the DNA of cervical cells and subsequent replication. Unlike conventional dysplasia treatment that consists of physically removing abnormal cervical cellstypically with laser, electrosurgical excision, or cryosurgeryalternative therapies seek to favorably alter predisposing factors. These factors are folic acid deficiency and excessive estrogen levels and/or the production of carcinogenic estrogen metabolites. Thus, the goal of viable alternative therapies is to treat existing dysplasia while concurrently diminishing the likelihood of dysplastic reoccurrence. The purpose of this case study was to explore the viability of using natural therapies to effect a regression in a 27 year-old female with moderate dysplasia and high-risk HPV (HR-HPV). Although there has been a previous case study employing a similar protocol for the treatment of cervical dysplasia,(4) it incorporated strict dietary restrictions, the nightly use of herbally-treated tampons, and used homeopathic and nutritional supplements that lack evidentiary support. The small study utilizing the aforementioned therapeutic protocol yielded good results and a follow-up study employing the same intervention--with the exception of the addition of 10 mg folate daily--resulted in the complete regression of 38 out of 43 cases of varying degrees of cervical epithelial abnormality.(5) It has been the goal of this case study to simplify alternative intervention without compromising efficacy by relying on the last two decades of research that has provided insight into the causes as well as viable treatments for dysplasia. Additionally, this study identified a high-risk or oncogenic HPV infection in the subject whereas previous studies did not perform HPV typinga significant fact considering that low-risk HPV is more likely to regress.
Material and Methods
This study consisted of using a two-part treatment for moderate cervical dysplasia with a HR-HPV infection in an otherwise healthy 27 year-old female. Pre-treatment test results consisted of a liquid pap demonstrating "Atypical Squamous Cells of Undetermined Significance" and HR-HPV, and a cervical biopsy identifying CIN II (i.e. moderate dysplasia). The patients primary care physician recommended a Loop Electro Excisional Procedure (LEEP) which the patient refused. The therapeutic intervention was both local and systemic. Local therapy consisted of 21 applications to the cervix of an escharotic solution containing 90 gm ZnCl/60 ml sterilized water and a tincture of Sanguinaria Canadensis. The protocol for local/cervical treatment was as follows:
- A vaginal speculum was placed to visualize the cervix.
- The content of one capsule of powdered bromelain was applied to the area of the cervical os. The bromelain was rinsed after 15 minutes with water.
- Using a cotton-tipped applicator, the escharotic was carefully applied to the cervix in the area of the os and the endocervical canal, avoiding contact with adjacent tissue. After 1 minute this solution was rinsed off with water. The escharotic stains abnormal cervical tissue similar to that of acetic acid, typically used in colposcopic examination, and provides an ongoing visual determination of the response to therapy.
- A tampon was placed against the cervix to which an herbal compound was applied. This preparation contained Hydrastis canadensis, Melaleuca alternifolia, Thuja occidentalis and Citrus vulgaris. The tampon was left in place for 24 hours and removed by the patient.
- 200 mg indole-3-carbinol BID with food.
- 800 mcg of 5-formyl tetrahydrofolate BID with food.
At the onset of therapy an area of approximately 1.5 cm on the ectocervix stained yellow/white with the escharotic compound (see Figure 1).
Throughout the course of therapy the amount of staining present with each application of escharotic was used to determine the need for continued applications. After the 21st application the cervix no longer stained after the escharotic application and the local/cervical part of the intervention was concluded (see Figure 2).
Three weeks later the patient had a ThinPrep pap performed that was "Negative for epithelial lesion or malignancy". Two more ThinPrep paps were performed, three months later and nineteen months later, that were both "Negative for epithelial lesion or malignancy".
The last two decades of research have provided valuable insight into the mechanisms involved in HPV-mediated cervical dysplasia as well as viable treatment and prevention of the pre-cancerous condition. It is now evident that the Human Papilloma Virus alone is insufficient to cause dysplastic changes in cervical epithelium. Numerous studies have identified at least two cofactors that are necessary for the evolution of HPV-mediated dysplasia: estrogen and folate deficiency. There is both circumstantial and direct evidence that indicates that estrogen increases the risk that HPV-infected cells will become precancerous and possibly malignant. The most compelling circumstantial evidence is that the most estrogen-sensitive region of the cervix is the transformation zone, the location of > 90% of dysplasia and cervical cancer.(6) This zone displays a high level of conversion of estradiol to 16α-hydroxyestrone,(7) and there is an eight-fold increase in this activity when HPV16 DNA immortalizes these cells.(8) 16α-hydroxyestrone is a carcinogenic estrogen metabolite that dramatically increases growth of HPV-infected cells.(9) The HPV16-transgenic mouse model exemplifies direct evidentiary support. This mouse has transgenes for HPV16 that when chronically exposed to estrogen develops cervical cancer.(10) Estrogen also increases proliferation of estrogen-sensitive cells, including HPV-infected cells,(9,11) and prevents apoptosis.(12,13) The use of indole-3-carbinol in this study was based, in part, on this research demonstrating the relationship of estrogen and its metabolites on cervical dysplasia. Indole-3-carbinol (I-3-C) is a phytochemical that is present in all members of the cruciferous vegetable family including broccoli, Brussels sprouts, kale and cabbage. It has been shown to induce apoptosis in human cervical cancer cells and in HPV16 transgenic preneoplastic cervical epithelium.(14) The mechanism by which I-3-C elicits these effects is at least in part due to its ability to modify estrogen metabolism. Indole-3-carbinol, through its action on cytochrome P-450, increases the production of 2-hydroxyestrone, a benign metabolite, while decreasing the amount of the carcinogenic 16α-hydroxyestrone metabolite.(15) Women with CIN II/III have lower 2-hydroxyestrone/16α-hydroxyestrone ratios than without cervical pathology.(11) A placebo-controlled trial of indole-3-carbinol in the treatment of CIN II/III demonstrated a statistically significant regression of CIN in patients treated with I-3-C orally compared with placebo. The 2/16α-hydroxyestrone ratio in this test group changed in a dose-dependent fashion, with increasing amounts of I-3-C increasing this ratio.(16) Folic acid deficiency was linked with cervical dysplasia as early as 1966.(17) Since then research has implicated folate deficiency in the genesis of a variety of cancers including cervical cancer. Folate acts as a DNA stabilizer by methylating DNA. Although the methylation profile of DNA is evidently important for carcinogenesis, the mechanisms for this are poorly understood.(18,19) What is becoming clear is that folate deficiency may induce hypomethylation only at specific sites on cancer-related genes.(18) There is also evidence emerging that folate deficiency may lead to hypermethylation of sites within the promoter regions for certain tumor suppressor genes leading to gene silencing.(20,21) The concentration of plasma homocysteine is considered to be a functional marker of intracellular folate status. Weinstein et al.(22) and Ziegler et al.(23) were able to demonstrate a significant increase in risk of invasive cervical cancer for women with elevated plasma homocysteine in population-based case-control studies. Similar effects have been shown for noninvasive cancer.(24) The persistence of HPV infection is reported to be a key factor determining risk of developing intraepithelial cervical lesions and cervical cancer.(25) Piyathilake et al.(26) reported that higher circulating concentrations of folate are independently associated with a lower likelihood of becoming positive for HR-HPV and of having a persistent HR-HPV infection and a greater likelihood of becoming HR-HPV negative. In a recent study the same authors found that HPV-16-positive women with low red blood cell folate were significantly more likely to be diagnosed with CIN > or = 2 than were HPV-16-positive women with higher red blood cell folate.(27) The use of folate in this study was founded on this research. The local/cervical treatment part of this study using a topical application of an escharotic containing ZnCl and bloodroot was based on its use historically,(28) as well as its use in previous studies.(4,5) Either, or both of these substances, may facilitate the regression of cervical dysplasia. It is uncertain what the effect of ZnCl is on cervical epithelium. There is evidence that cellular exposure to ZnCl may result in increased oxidative stress, thereby facilitating apoptosis.(29) If this is true, I-3-C and ZnCl may work synergistically to effect apoptosis of HPV-infected cervical cells. It must also be entertained that the ZnCl could be simply acting as a "driving" agent by disrupting cellular membrane integrity allowing for deeper penetration of the bloodroot. Sanguinaria canadensis (bloodroot) has been shown to have antimicrobial, anti-inflammatory, and antioxidant properties in addition to possessing several isoquinoline alkaloids--sanguinarine being the best researched. Ahmad et al. demonstrated that sanguinarine imparts cell growth inhibitory responses in human squamous carcinoma cells via an induction of apoptosis.(30) The authors thought it noteworthy that sanguinarine treatment did not result in apoptosis of normal human epidermal keratinocytes at a similar dose. In a later study these authors showed that sanguinarine causes an apoptotic death of immortalized human keratinocytes via modulations in the mitochondrial pathway.(31) Additional studies have found that sanguinarine causes apoptosis and G0-G1 phase cell cycle arrest in human pancreatic and prostatic carcinoma cells.(32,33) Although research investigating the effects of bloodroot on cervical dysplasia and cervical cancer have not been conducted, this author found the preceding evidence compelling justification for its use in this study. Although conventional treatment of cervical dysplasia is effective at least in the short-term, there are women who find these approaches aggressive and lacking in preventive mindfulness. Those that are better informed and concerned with cervical integrity are not willing to undergo repeated surgical procedures for subsequent re-occurrences of dysplasia. In this regard, conventional medicine has seemingly ignored the overwhelming data justifying the use of natural substances for dysplasia prevention. Aggressiveness characterizes medical standard-of-care with regard to cervical dysplasia triage. In cases where immediate intervention is not recommended, a "wait-and-see" protocol is prudently offered, however, patients are not usually given the option of taking neither folic acid nor indole-3-carbinol. This conservative conventional approach ends up being a "wait-and-do-nothing" intervention that likely results in eventual invasive therapies. Although this study did not evaluate the efficacy of using indole-3-carbinol and folate in preventing a re-occurrence of dysplasia from the same HPV type or another, research suggests their use in this capacity. This case study demonstrated the reversal of moderate dysplasia in an otherwise healthy 27 year-old female with HR-HPV using a natural medicine protocol. Although at least a couple of previous studies employing a similar protocol obtained favorable results, this case study differed in its simplicity. This case study intervention relied on only two oral supplements, whereas previous studies employed numerous botanicals and homeopathics possessing little or no evidentiary support. Additionally, the fact that a restrictive diet was not used in this study is significant because many patientsdespite usually having a need forare not often willing to comply with dietary restrictions. It is this authors assertion that greater compliance can be gained with this protocol as opposed to previous protocols and without a loss in efficacy. Clearly, there is not enough research justifying the use of escharotics for the treatment of cervical dysplasia in place of conventional therapies. It remains, however, a plausible alternative therapy for individuals seeking natural medicine options. Future research should consist of randomized clinical trials using this protocol to evaluate its efficacy and cost. Additional research also seems warranted to evaluate the effects of using only indole-3-carbinol and folate for the treatment of cervical dysplasia as well as for prevention of HPV infection.
1. Centers for Disease Control and Prevention. Genital HPV InfectionCDC Fact Sheet. Centers for Disease Control and Prevention. 2004.
2. Syrjanen K, Hakama M, Saarikoski S, et al. Prevalence, incidence, and estimated life-time risk of cervical human papillomavirus infections in a nonselected Finnish female population. Sex Trans Dis 1990;17:15-19.
3. Kiviat NB, Koutsky LA. Specific human papillomavirus types as the causal agents of most cervical intraepithelial neoplasia: implications for current views and treatments. J Natl Cancer Inst 1993;85:934-935.
4. Hudson TS. Consecutive case study research of carcinoma in situ of cervix employing local escharotic treatment combined with nutritional therapy. J Naturopathic Med 1991;2:6-10.
5. Hudson TS. Escharotic treatment for cervical dysplasia and carcinoma. J Naturopathic Med 1993;4:23.
6. Paavonen J, Koutsky LA, Kaviat N. Cervical neoplasia and other STD-related genital and anal neoplasias. In: KK Holmes, PA Mardh, PG Sparling, PJ Wiegener (eds.). Sexually Transmitted Diseases, pp. 561-592. New York: McGraw-Hill, 1990.
7. Autier P, Coibion M, Huet F, Grivegnee AR. Transformation zone location and intraepithelial neoplasia of the cervix uteri. Br J Cancer 1996;74:488-490.
8. Auborn KJ, Woodworth C, DiPaolo JA, Bradlow HL. The interaction between HPV infection and estrogen metabolism in cervical carcinogenesis. Int J Cancer 1991;49:867-869.
9. Newfield L, Bradlow HL, Sepkovic DW, Auborn K. Estrogen metabolism and the malignant potential of human papillomavirus immortalized keratinocytes. ProcSoc Exp Biol Med1998;217:322-326.
10. Arbeit JM, Howley PM, Hanahan D. Chronic estrogen-induced cervical and vaginal squamous carcinogenesis in human papillomavirus type 16 transgenic mice. Proc Natl Acad Sci 1996;93:2930-2935.
11. Newfield L, Goldsmith A, Bradlow HL, Auborn K. Estrogen metabolism and human papillomavirus-induced tumors of the larynx: chemo-prophylaxis with indole-3-carbinol. Anticancer Res 1993;13:337-341.
12. Huang Y, Ray S, Reed JC, et al. Estrogen increases intracellular p26Bcl-2 to p21Bax ratios and inhibits Taxol-induced apoptosis of human breast cancer MCF-7 cells. Breast Cancer Res Treat 1997;42:73-81.
13. Spyridopoulos I, Sullivan AB, Kearney M, et al. Estrogen-receptor-mediated inhibition of human endothelial cell apoptosis. Estradiol as a survival factor. Circulation 1997;95;1505-1514.
14. Chen D, Qi M, Auborn K, Carter TH. Indole-3-carbinol and diindolylmethane induce apoptosis of human cervical cancer cells and in murine HPV16-transgenic preneoplastic cervical epithelium. JN 2001;3294-3302.
15. Niwa T, Swaneck G, Bradlow HL. Alterations in estradiol metabolism in MCF-7 cells induced by treatment with indole-3-carbinol and related compounds. Steroids 1994;59:523-527.
16. Bell MC, Crowley-Nowick P, Bradlow HL, et al. Placebo-controlled trial of indole-3-carbinol in the treatment of CIN. Gynecol Oncol 2000;78(2):123-129.
17. Crews MG, Taper LJ, Ritchey SJ. Effects of oral contraceptive agents on copper and zinc balance in young women. Am J Clin Nutr 1980;33:1940-1945.
18. Razin A, Cedar H. DNA methylation in cancer genetics and gene expression. Microbiol Rev 1991;55:451-458.
19. Fearon ER, Jones PA. Progressing towards a molecular description of colorectal cancer development. FASEB J 1992;6:2783-2790.
20. Pogribny IP, Basnakian AG, Miller BJ, et al. Breaks in genomic DNA and within the p53 gene are associated with hypomethylation in livers of folate/methyl deficient rats. Cancer Res 1995;55:1894-1901.
21. Pogribny IP, James SJ. De nova methylation of the p16INK4a gene in early preneoplastic DNA from folate/methyl deficient rats. Cancer Lett 2002;187:69-75.
22. Weinstein SJ, Ziegler RG, Rongillo EA, et al. Low serum and red blood cell folate are moderately, but not significantly associated with increased risk of invasive cervical cancer in US women. J Nutr 2001;131:2040-2048.
23. Ziegler RG, Weinstein SJ, Fears TR. Nutrtional and genetic inefficiencies in one-carbon metabolism and cervical cancer risk. J Nutr 2002;132:2345-2349.
24. Thompson SW, Heimburger DC, Cornwell PE, et al. Effects of total plasma homocysteine on cervical dysplasia risk. Nutr Cancer 2000;37:128-133.
25. Schlecht NF, Kulaga S, Robitaille J, et al. Persistent human papillomavirus infection as a predictor of cervical intraepithelial neoplasia. J Am Med Assoc 2001;286(24):3106-3114.
26. Piyathilake CJ, Henao OL, Macaluso M, et al. Folate is associated with the natural history of high-risk human papillomaviruses. Cancer Res 2004;64(23):8788-8793.
27. Piyathilake CJ, Macaluso M, Brill I, et al. Lower red blood cell folate enhances the HPV-16-associated risk of cervical intraepithelial neoplasia. Nutrition 2007;23(3):203-210.
28. Phelan J, Milgrom H, Stoll H, Traenke. The use of Mohs chemosurgery technique in the management of superficial cancers. Surger Gynec Obstet;114(1):25-30.
29. Dean A, Wiseman, Sandra M, et al. Endothelial response to stress from exogenous Zn2+ resembles that of NO-mediated nitrosative stress, and is protected by MT-1 overexpression. Am J Physiol Cell Physiol 2006;291:555-568.
30. Ahmad N, Gupta S, Husain MM, et al. Differential antiproliferative and apoptotic response of sanguinarine for cancer cells versus normal cells. Clin Cancer Res 2000;6:1524-1528.
31. Adhami VM, Aziz MH, Mukhtar H, Ahmad N. Activation of prodeath Bcl-2 family proteins and mitochondrial apoptosis pathway by sanguinarine in immortalized human HaCaT keratinocytes. Clin Cancer Res 2003;9:3176-3182.
32. Adhami VM, Aziz MH, Reagan-Shaw SR, et al. Sanguinarine causes cell cycle blockade and apoptosis of human prostate carcinoma cells via modulation of cyclin kinase inhibitor-cyclin-cyclin-dependent kinase machinery. Mol Cancer Ther 2004;3(8):933-940.
33. Ahsan H, Reagan-Shaw SR, Breur J, Ahmad N. Sanguinarine induces apoptosis of human pancreatic carcinoma AsPC-1 and BxPC-3 cells via modulations in Bcl-2 family proteins. Cancer Lett 2007;249(2):198-208.