Peppermint

Peppermint

Summary
Binomial	Mentha × piperita
Family	Lamiaceae
Native range	Not native to any wild habitat: peppermint is a sterile hybrid and does not reproduce from seed. First recorded in England in the 17th century, probably arising spontaneously in cultivated mint fields near Mitcham, Surrey. Now cultivated worldwide throughout the temperate zone; principal commercial producers are the United States (Pacific Northwest and Indiana), India, and China.
Pharmacy
Pharmacology

Mentha x piperita L. -- peppermint -- is a sterile hybrid of watermint (Mentha aquatica) and spearmint (Mentha spicata) first documented in the herb gardens of 17th-century England. It reproduces only by vegetative spread and would disappear without cultivation; instead it has become the most widely grown aromatic herb in the world, its menthol extracted in quantities sufficient to scent a global industry of confectionery, personal care, and pharmaceuticals. Among medicinal herbs it holds an unusual distinction: enteric-coated peppermint oil capsules are supported by a Cochrane systematic review of nine randomized controlled trials reporting a number needed to treat of 2.5 for irritable bowel syndrome -- one of the strongest evidence-backed botanical indications in gastrointestinal medicine.

History and traditional use

Western herbal medicine (primary centroid)

Peppermint's principal traditional indications mirror its modern evidence base with unusual fidelity: flatulence and bloating, digestive cramping and colic, nausea and vomiting, dyspepsia, headache (particularly the common tension headache with a frontal or temporal distribution), nasal congestion from colds, and muscle pain. The herb has been used for these purposes in continuous Western practice from at least the 18th century, when peppermint tea became the commonest domestic remedy for an upset stomach in Britain and America. The inhalational use for nasal congestion -- peppermint steam over hot water, peppermint oil rubbed on the chest or dissolved in a steam inhaler -- has equal continuity. The topical application to the temple and forehead for headache appears in 18th- and 19th-century domestic medicine texts and was given its first controlled clinical evidence base by Gobel in 1996.

TCM: Bo He (薄荷)

Peppermint is used in Chinese medicine under the name Bo He, though the plant sourced in Chinese practice is frequently Mentha haplocalyx or other Asian Mentha species rather than M. x piperita; the volatile-oil chemistry is sufficiently similar for the indications to overlap. In the TCM framework, Bo He is classified as pungent and cool, entering the lung and liver meridians. Its primary indications are wind-heat exterior patterns (early common cold or influenza with fever, sore throat, headache) where it disperses the pathogenic wind-heat; it also clears the head and eyes for wind-heat-related headache and red eyes, and moves liver qi stagnation for irritability and distention. In formulae, it is frequently combined with Forsythia (Lian Qiao) and Lonicera (Jin Yin Hua) in standard wind-heat formulas such as Yin Qiao San.^{[citation needed]}

Ayurvedic medicine (Pudina)

Peppermint is used in Ayurvedic medicine as Pudina, described as pungent, slightly bitter, and cooling in action; it pacifies kapha and vata doshas while having mixed effects on pitta. Principal Ayurvedic indications are digestive complaints -- dyspepsia, nausea, vomiting -- and febrile conditions where its diaphoretic action is valued. It is among the aromatics used in Ayurvedic churnas (herbal powders) for digestive support.^{[citation needed]}

Islamic medicine (Na'na)

Mint was known in Arabic-speaking medicine as Na'na (نعناع) and classified as cool and drying in the Galenic-Islamic temperament system; Ibn Sina described it for digestion, fevers, headache, and nausea in the Canon of Medicine, consistent with its Dioscoridean antecedents.^{[citation needed]}

Preparations

Infusion (tea): 3 to 4 g dried leaf per cup of hot water, covered while steeping (volatile oil retention). Drunk after meals for digestive complaints; as a steam inhalant for nasal congestion (pour into a bowl and inhale steam with a towel over the head). Note that peppermint tea is the preparation with the weakest IBS evidence; the enteric-coated capsule form is the evidence-based preparation for this indication.

Tincture: 1:5 in 45 percent ethanol from dried herb; standard liquid preparation.

Enteric-coated peppermint oil capsules (Colpermin; Pepogest; Mintec; generic equivalents): the only form with robust IBS clinical trial evidence. Enteric coating is essential: the coating is designed to withstand gastric acid and dissolve at the more alkaline pH of the duodenum and small intestine, delivering the oil to the intestinal target rather than the stomach. These capsules must NOT be taken simultaneously with antacids, proton pump inhibitors, or H2 blockers that alkalinize the stomach -- premature dissolution of the enteric coat risks upper GI side effects. Standard commercial dose: 187 to 225 mg three times daily, taken before meals.

Essential oil (topical): 10 percent peppermint oil in ethanol or carrier oil, applied to forehead and temples for tension headache; 2 to 3 percent in carrier oil for massage of muscle ache or abdominal spasm; steam inhalant (2 to 3 drops in hot water) for nasal congestion. Do not apply neat oil to facial skin of children or to the face or chest of infants.

Mouthwash and confectionery: standardized products are not medicinal preparations but carry genuine antimicrobial and breath-freshening effects from the menthol content.

Pharmacokinetics

Menthol is rapidly absorbed from the gastrointestinal tract following oral ingestion of non-enteric-coated preparations; enteric-coated formulations delay absorption to the small intestine, which is the therapeutic intent for IBS. Menthol undergoes hepatic glucuronidation and sulfation; the conjugated metabolites are excreted renally, with menthol glucuronide detectable in urine as a biomarker of exposure. The elimination half-life of menthol is approximately one to two hours. Following topical application, menthol is absorbed dermally at a rate sufficient to produce detectable plasma concentrations; dermal absorption is faster with ethanol-based compared to oil-based vehicles.^{[citation needed]}

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Titration and dosing

Internal preparations

Infusion: 3 to 4 g dried leaf per cup, three to four times daily, ideally after meals. Cover the vessel while steeping; the volatile oil evaporates readily.

Tincture: 1 to 2 ml three times daily, diluted in water.

Enteric-coated peppermint oil capsules (for IBS): 187 to 225 mg three times daily, 30 to 60 minutes before meals. Do not crush or chew. Separate from antacid use by at least two hours. The full therapeutic effect in IBS develops over two to four weeks of regular use; do not assess as a failure after a single dose.

External preparations

Tension headache: 10 percent peppermint oil in ethanol, applied by cotton ball or rollerball applicator to forehead and both temples at headache onset; repeat at 15 and 30 minutes as needed. Keep well away from eyes. This is the protocol used in the Gobel trials.

Muscle tension and spasm: 2 to 3 percent essential oil in carrier oil, applied by massage to affected area.

Nasal congestion: 2 to 3 drops essential oil in a bowl of hot water; inhale steam for 5 to 10 minutes with a towel draped over head and bowl. Do not use this method with children under 12, or with infants under any circumstances.

Recreational dose ladder

Peppermint has no established recreational dose structure. Menthol's TRPM8-mediated cooling sensation is pleasurable and widely exploited in confectionery, oral hygiene, and tobacco products; however, the sensation is immediate, topical, and non-dose-escalating -- there is no psychoactive intensification with increasing dose, and no recreational culture of peppermint use as a psychoactive agent exists in any documented tradition. At high oral doses, menthol produces nausea and GI discomfort rather than pleasure; the pharmacological ceiling of the desirable effect is reached at modest concentrations. No dose ladder is warranted.

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Effects

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Interactions

Separate from antacids by 2 hours (enteric coat dissolution risk). Theoretical CYP3A4 interaction; case report of cyclosporine elevation. Additive CNS relaxant effect with sedatives.

Antacids, proton pump inhibitors, H2 receptor antagonists: alkalinization of gastric pH by any of these agents can dissolve the enteric coating of peppermint oil capsules prematurely, causing upper GI side effects (heartburn, nausea, belching) and reducing delivery to the intended intestinal target. Antacids should be separated from enteric-coated capsule dosing by a minimum of two hours.

Central nervous system depressants: additive effects possible with sedating medicines and herbal preparations; peppermint has mild CNS-relaxing effects at therapeutic doses.

Cyclosporine: case reports suggest possible elevation of cyclosporine plasma levels in transplant recipients using peppermint oil preparations; a potential CYP3A4 interaction. Transplant patients on cyclosporine should not use peppermint oil preparations without specialist input.^{[citation needed]}

Cyclosporine aside, cytochrome P450 inhibition by peppermint oil at standard enteric-coated capsule doses (187 to 225 mg three times daily) has not been documented as clinically significant in pharmacokinetic interaction studies.

Monitoring

No routine monitoring required for infusion use or enteric-coated capsules at standard IBS doses in otherwise healthy adults. Patients with GERD on enteric-coated capsules: symptom monitoring for worsening reflux. Transplant patients on cyclosporine: if using peppermint oil, check cyclosporine levels within two to four weeks of starting or changing dose.

Patient counseling

The formulation distinction is the most important thing to convey to patients using peppermint for IBS: only enteric-coated capsules have the clinical evidence base, because only they deliver the oil to the intestinal target. Peppermint tea, while pleasant and acceptable for mild general digestive symptoms, has not been tested for IBS and should not be substituted for the enteric-coated capsule in patients with established IBS diagnosis.

For tension headache, the topical preparation (10 percent peppermint oil in ethanol on forehead and temples) requires patient instruction on avoiding the eyes; a rollerball applicator is more practical than cotton-ball application for self-use. The effect onset is rapid -- patients should expect some relief within 15 to 30 minutes, earlier than with oral paracetamol.

Parents of infants and young children should be advised specifically that peppermint oil and all mentholated preparations should not be applied to the face, nose, or chest of children under five, and not at all to the face of infants.

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