Mostly known in the Western world as a remedy for menopausal and menstrual complaints, dong quai has been used in traditional Chinese medicine for these and other conditions since ancient times. Read on to learn about how this tonic herb might work, plus its potential side effects and drug interactions.
What Is Dong Quai?
Dong quai (當歸, also spelled danggui) is the dried root of Angelica sinensis, a plant belonging to the same family as carrots, parsley, and celery (Umbelliferae). It’s also known as Chinese angelica. The plant is native to the northwestern Chinese province of Gansu and also grows wild in mountainous areas of China, Korea, and Japan [1, 2, 3].
Dong quai has been used in traditional Chinese medicine for over 2000 years [4, 1].
Today, dong quai is used both in Eastern and Western countries. Dong quai is often called “female ginseng” due to its most common use for gynecological and hormonal imbalances in women, such as [2, 5]:
- Menopausal complaints (hot flashes, sweating, sleep disturbances, mood swings)
- Menstrual cycle disorders (menstrual cramps, absent or irregular periods)
- Premenstrual syndrome
- Recovery from blood loss after childbirth
Dong Quai vs Other Similar Plants
It’s important not to confuse dong quai, which is Angelica sinensis, with two closely related plants also called danggui and used in traditional Asian medicine: Angelica gigas and Angelica acutiloba. Both have lower levels of some active compounds (ligustilide, ferulic acid, and coniferyl ferulate) and more coumarins than dong quai, so their uses may differ [2, 3].
Unfortunately, these and other plants (Levisticum officinale and other Angelica species such as A. nitida, valida, and megaphylla) are sometimes also used to adulterate dong quai products [2, 3].
Active Compounds
The main active compounds of dong quai include [6, 7, 8, 3, 9]:
- Ferulic and other organic acids
- Ligustilide (and other similar phthalides)
- Complex sugars
- Vitamins, amino acids, and nucleosides
Of these, ferulic acid and ligustilide are the most active ones and are widely used to evaluate the quality of dong quai products. Products should contain at least 0.05% ferulic acid and 0.1-0.6% ligustilide [2, 1].
Product Quality
Since the species is endangered due to its excessive wild harvesting, give preference to dong quai that has been prepared from cultivated plants. Additionally, this plant should be obtained from reputable sources to ensure its quality and reduce the presence of contaminants such as pesticides, fungal toxins, dangerous plant alkaloids, and heavy metals [1, 10, 11, 12].
The composition of the roots (and thus their health benefits) varies depending on the time and site of collection, as well as on the processing method [2]:
- Decoctions are common and likely safe. They have less ligustilide and ferulic acid (anti-inflammatory and antioxidant compounds) but more phenolic acids (antioxidant) [13, 14, 15].
- Products made from boiling, baking, or stir-frying the root with alcohol are likely safe. This process increases ferulic acid but decreases ligustilide [16, 17].
- Avoid products that have been smoke-dried with sulfur. This speeds up the drying process but reduces some active compounds and increases heavy metals [18, 2].
Use in Traditional Chinese Medicine (TCM)
The Basics of TCM
Dong quai inevitably brings us to Traditional Chinese medicine (TCM). Although some Western medicine practitioners now also use this herb, its true roots are in TCM. This system of medicine may be hard to grasp for some, but understanding its basics can broaden our perspective about the use of dong quai in modern times.
An Energy System
Essentially, TCM is based on ancient philosophical concepts. According to its principles, the body is a miniature universe where disease is caused by the imbalance of two opposing forces (yin and yang). The inner vital energy (qi) is thought to circulate through channels (meridians) to sustain health in the different organs [19, 20, 2].
Multi-Herbal Formulas
TCM uses a holistic approach to disease in which the diagnosis and prescription are tailored to the patient’s constitution. A remedy (mostly obtained from plants, but some are animal- and mineral-based) is not prescribed alone but in combination with up to 15 other ingredients for synergistic effects. Much to the shock of Western doctors and scientists, a single formula can be used for seemingly unrelated conditions and the same condition can be improved with different formulas [19, 1].
TCM Uses
Historical uses of dong quai in TCM include [4, 1]:
- ‘Replenishing’, ‘invigorating’, and ‘moving’ blood
- Relieving pain
- Laxative
- Improving cold limbs and hemorrhoids
- Slowing aging
- Improving malaria, fever, chills, and ‘low vital energy’
This herb is commonly used for many other conditions, including all the following [1, 3]:
- Blood disorders (anemia, poor circulation, clot formation)
- Gut issues (constipation, ulcerative colitis)
- Heart disease
- Scars
- Boosting immunity
- Rheumatism
Some specific to TCM include expelling ‘wind’, clearing ‘heat’, dissipating ‘cold’, and tonifying ‘middle-jiao’ and ‘qi.’
Western Skepticism
Although TCM advocates claim that its effectiveness and safety are backed by its use over thousands of years, Western doctors and scientists generally view it with skepticism. Evidently, concepts such as qi or meridians haven’t been scientifically proven. Additional reasons for concern include the low quality of most clinical trials, the use of ingredients from endangered plant and animal species, and the potential toxicity of some remedies [20, 21, 22, 23].
Hormonal Balance & How Dong Quai Works
To understand the potential health benefits of dong quai for hormonal balance, we’ll first take a closer look at how hormones are produced in women throughout different phases of the menstrual cycle and what happens in menopause, once menstrual cycles cease.
Women’s Reproductive Health and Hormones
The following hormones are essential [24]:
- FSH stimulates ovarian follicles to mature; once the follicle matures, it will produce estradiol
- Estradiol spikes toward ovulation, which causes FSH to drop. Estradiol helps the egg mature and causes LH to surge
- LH spikes, which releases the egg, causing ovulation. During ovulation, progesterone will also slightly increase
- Progesterone prepares the uterus for pregnancy; if conception doesn’t occur, it’s levels will gradually fall and hormonal changes will repeat with the next cycle
Fluctuation in female sex hormone levels during the menstrual cycle. Source: [25]
In premenopausal women, various factors (including stress, eating disorders, dietary habits, intense exercise, and others) may block FSH and LH release, which prevents ovarian follicle maturation. These and other factors can affect both estrogen and progesterone levels and activity. In turn, hormonal imbalances can cause irregular menstrual cycles [26].
In menopausal women, as ovulation ceases, estradiol and progesterone levels drop while FSH increases. As mentioned, the preovulatory spike in estrogen is needed to block FSH release — and this feedback loop no longer happens after menopause. As the female body undergoes hormonal changes, the uterus and vagina will start thinning. Symptoms such as hot flashes and mood imbalances are also common [27].
Therefore, different sex hormone changes are behind both irregular menstrual cycles and menopausal symptoms. All involved hormones are important — including progesterone, LH, and FSH — but estradiol plays a key role as the main female sex hormone.
Dong Quai and Estrogen
Herbs like dong quai may be able to mimic the effects of estrogen, potentially making up for its lack or imbalance. They may also increase sensitivity to estrogen, which can help compensate for its low levels. But despite its widespread use, its estrogen-like benefits are far from evident.
In one study, an herbal mix with dong quai (QiBaoMeiRan) increased the production of estrogen receptors in rats, which may enhance the response to estradiol [28].
Dong quai combined with astragalus (Danggui Buxue Tang) activated estrogen receptors in cells, suggesting it may increase the response to estradiol. However, the benefit was mostly due to a specific flavonoid from astragalus (calycosin) [29, 30].
In turn, dong quai alone had a weaker activity and even blocked estrogen effects in one study. This may be due to the different composition of the extracts, since those with the highest ferulic acid or lowest ligustilide content were more active [31, 32, 33, 34, 35, 36].
One more study leaves us with encouraging results. In menopausal rats, different dong quai herbal mixes prevented osteoporosis, reduced the thinning of the uterus, vagina and breast glands, and restored hormone balances by increasing estradiol and reducing FSH and LH levels [37, 38, 39, 40, 41].
Side Effects & Precautions
Due to the low toxicity observed in animal studies, the FDA regards dong quai as generally safe. However, the following adverse effects have been reported in clinical trials [1, 42]:
- Headaches
- Irregular heart rate
- Low blood pressure
- Menstrual disorders (PMS symptoms, irregular cycles)
- Digestive issues
In a review of over 50 liver toxicity cases caused by traditional Chinese medicine remedies, 7 involved herbal blends with dong quai. However, it’s difficult to establish which ingredient was responsible for the damage in each case [43].
One man developed enlarged breasts after taking dong quai pills. The herb is not high in compounds similar to female sex hormones. However, these compounds can be concentrated in some formulations or even adulterated with synthetic hormones [44].
A pharmacist exposed to multiple herbal remedies developed allergic asthma in response to several of them, including dong quai [45].
A woman who may have overdosed by eating a soup made with dong quai had high blood pressure, headaches, weakness, lightheadedness, and vomiting [46].
Although no cases have been reported, dong quai may increase the skin sensitivity to sunlight due to its furanocoumarins content [47].
Precautions
Due to lack of safety information, dong quai should be avoided during pregnancy and breastfeeding. In one case, a breastfeeding mother passed dong quai to her baby who developed high blood pressure. However, she most likely took in a much higher dose than the amount usually contained in herbal remedies [48, 49].
Although the female sex hormone activity of dong quai remedies greatly varies, women with hormone-sensitive cancers (breast, uterus, ovarian) should be cautious with dong quai. Indeed, this herb and its component ferulic acid promoted the growth of breast cancer in cellular studies [30, 34, 40, 50, 29, 51, 52].
Some compounds in dong quai slow blood clotting, which may increase the risk of bleeding and bruises in people with bleeding disorders and is not recommended in those with a scheduled operation [53, 54, 55].
If you take prescription medications or have a serious health condition, talk to your healthcare provider before taking dong quai.
Drug Interactions
Dong quai slows blood clotting, so it shouldn’t be combined with drugs with similar effects such as [53]:
- NSAID painkillers (aspirin, ibuprofen, diclofenac, naproxen)
- Blood thinners (clopidogrel, dalteparin, enoxaparin, heparin, warfarin)
Indeed, blood clotting was dramatically reduced in a woman on warfarin for irregular heart rate who started taking dong quai for menopausal symptoms. It also increased the anti-blood clotting effect of warfarin in rabbits [56, 57].
Dong quai didn’t enhance the anti blood-clotting effects of aspirin and clopidogrel in 2 studies on over 1200 people. However, it did increase bleeding in rats and mice given clopidogrel [58, 59, 60].
Dong quai interacts with several enzymes responsible for breaking down drugs and toxins. It increases the production or activity of some enzymes (CYP1A2, CYP2D6, CYP3A1, and CYP3A4) and has the opposite effects on some others (CYP2E1, CYP2C11, and carboxylesterases). It may alter the effects of numerous drugs broken down by these enzymes [61, 62, 63].
Genetics
Female Sex Hormone Activity
Dong quai preparations, especially in combination with astragalus, exert their female sex hormone effects by:
- Increasing the production of estrogen receptors ESR1 and ESR2 [28]
- Activating the ESR1 receptor (both directly and through the Erk1/2 pathway) [29]
Women with mutated variants of these receptors (e.g., mutations in the S118 and S167 activation sites of ESR1) may have altered sensitivity to dong quai.
Anti-inflammatory Activity
Dong quai and its active components reduce inflammation by:
- Blocking pro-inflammatory proteins such as AP-1, NF-kB, MAPK p38, ERK1/2, JNK, and COX-2 [64, 65, 64, 66]
- Decreasing the production of pro-inflammatory proteins such as COX-1, COX-2, JAK2, STAT1, and NF-kB p65 [67, 68, 69]
Variants of all these proteins may alter the response to dong quai.
Antioxidant Activity
Dong quai and its active components protect cells from oxidative damage by activating the NFE2L2 and ATF6 pathways and increasing the activity of the antioxidant enzymes SOD and CAT. The antioxidant effects of dong quai may be altered in people with different variants of these genes [70, 71, 72].
Blood-Forming Activity
Herbal mixes with dong quai increase HIF1A, triggering the production of the blood-forming hormone erythropoietin [73, 74].
Its complex sugars preserve blood cell formation by blocking IKBKB production and prevent hepcidin formation by reducing the production of SMAD4 and CEBPA and the activation of STAT3 [75, 76].
Variants of these genes may alter the effects of dong quai on blood formation.
Wound-Healing Activity
Dong quai increases the production of the blood vessel-forming protein VEGF. Its combination with astragalus also increases the production of a protein that triggers collagen formation (TGFB1). Dong quai may have altered effects on wound healing in people with certain variants of these proteins [77, 78].
Breakdown of Active Compounds
Ligustilide and ferulic acid are the main active compounds of dong quai. The enzymes that contribute the most to their breakdown in the body are CYP3A4, CYP1A2, CYP2C8, and CYP2C9. People may be more or less susceptible to dong quai’s effects depending on their variants of these enzymes [79, 80].
Forms of Supplementation & Dosing
Dong quai is normally taken orally as pills, tablets, decoctions, and tinctures. Other forms of supplementation include [1]:
- Injections
- Topical creams and pastes
- Eye drops
While this herb is available alone in Western countries, traditional Chinese medicine always prescribes it combined with other herbs. Some popular combinations with dong quai include
- Danggui Buxue Tang: used for menopausal complaints, anemia, osteoporosis, and infertility [81, 82]
- Danggui Shaoyao San: used for menstrual cramps, irregular menstrual cycles, depression, and dementia [83, 84]
- Danggui Sini Tang: used for blood circulation, heart failure, diarrhea, infectious diseases, and arthritis [85, 86]
- Danggui Honghua: used for blood circulation [87]
- Er-Xian Tang: used for menopausal complaints, osteoporosis, and delayed puberty [88]
Dosage
Because dong quai is not approved by the FDA for any conditions there is no official dose. Typical, unofficial dong quai oral doses established by users and supplement manufacturers are [47+]:
- Dried root: 3-15 g/day by decoction
- Powdered root: 1-2 g, 3x/day
- Tea: 1 cup (containing 1 g dong quai), 1x-3x/day
- Tincture (diluted to 1:2): 4-8 mL/day
- Capsules and tablets: 500 mg, 1x-6x/day
The normal dose of injected dong quai is 40-100 mL, 1x-2x/day [89, 90].
Takeaway
Dong quai is the dried root of Angelica sinensis, a plant in the same family as carrots and celery. As an important part of traditional Chinese medicine, it is most frequently used as a menstrual aid and to balance hormones. Western doctors and scientists tend to be skeptical of traditional Chinese medicine, though some clinical evidence supports dong quai’s use in hormonal imbalances.
The most common side effects of dong quai include headaches, irregular heart rate, and low blood pressure. Because dong quai has some estrogenic activity and may prevent blood clotting, it may also cause estrogenic effects and bleeding. It should not be combined with any drugs that affect estrogens or which thin the blood, such as warfarin or NSAIDs.
Dong quai is available alone or in combination with other herbs as part of traditional Chinese medicine. There is no safe and effective dose because no sufficiently powered study has been conducted to find one.
