Peppermint

November 2006

Mentha x piperita L. Peppermint is a hybrid of Mentha spicata L. (spearmint) and Mentha aquatica L. Family: Lamiaceae (mints)

Peppermint , menthol

Uses

In addition to use as a seasoning and flavoring, peppermint is used to treat irritable bowel syndrome (IBS) and other GI conditions. Menthol is available in numerous commercial preparations for respiratory tract infections and topically for cooling and warming to relieve pain. However, there is limited clinical information supporting these conditions.

Dosing

Peppermint oil has been used as a carminative at doses of 0.1 to 0.24 mL. Up to 1,200 mg of the oil in enteric-coated tablets has been used to treat IBS. Peppermint oil (40 mL) has been added to barium suspension, and also administered intraluminally (8 mL) during colonoscopy.

Contraindications

Peppermint oil should not be administered to patients with gastroesophageal reflux or active gastric ulcers, because the oil decreases esophageal sphincter pressure. Peppermint oil should not be applied to the face, especially under the nose of a child or infant. Enteric-coated preparations are not recommended for use in children younger than 8 years of age.

Pregnancy/Lactation

Documented adverse reactions. Avoid use because of emmenagogue effects.

Interactions

Peppermint oil may influence metabolism of certain drugs (including felodipine and simvastatin) via inhibition of the CYP-450 enzyme system, increasing pharmacologic and adverse reactions. Absorption of caffeine may be delayed by menthol. Decreased cyclosporine levels have been reported with consumption of a tea containing 9 herbs, including peppermint.

Adverse Reactions

Peppermint oil may cause allergic reactions characterized by contact dermatitis, flushing, and headache, and may worsen the symptoms of heartburn, hiatus hernias, and stomach ulcers.

Toxicology

Peppermint is generally recognized as safe in amounts used in seasoning or flavoring, although medicinal uses of the plant can cause adverse reactions (see Adverse Reactions).

This well-known perennial is a prototypical member of the mint family. ^1, Like all mints, it has a square, purple-green stem with dark or light green leaves and purple and lilac-colored flowers. The plant generally is sterile and spreads by means of runners. A variety of peppermint types exist and are cultivated worldwide. Pharmaceutical oil is derived from 2 varieties: white (light green leaves) and black (dark green leaves) peppermint. ^2, This is not to be confused with Japanese peppermint oil, which is similar in odor but derived from a different species. ²

First described in England in 1696, peppermint and its oil have been used in Eastern and Western traditional medicine as an antispasmodic, aromatic, and antiseptic in the treatment of cancers, colds, cramps, indigestion, nausea, sore throat, and toothaches. ^2, Today, the oil is used widely as a flavoring in chewing gum, cigarettes, mouthwash, pharmaceuticals, and toothpaste. It also is used as an ingredient in cough and cold preparations and as a carminative for irritable bowel syndrome (IBS). As the menthol component, it also is found in numerous antipruritic, antiseptic, and local anesthetic preparations. ²

Peppermint oil is extracted from the plant by steam distillation. ^2, The chemistry of peppermint oil is complex and highly variable, with more than 100 components isolated from the oil. The relative concentrations vary depending on climate, cultivar, and geographic location. ^3, , ^4, , ^5, Peppermint yields 0.1% to 1% of volatile oil composed primarily of menthol (29% to 48%), menthone (20% to 31%), and menthyl acetate (3% to 10%). ^6, Pulegone, contained in various forms of peppermint, should not exceed a concentration of 1% because it can be toxic. ^7, Other pharmacologically active ingredients include bitter substances, caffeic acid, flavonoids, and tannins. ⁸

Absorption is rapid following oral administration, and elimination is mainly via bile. Menthol-glucuronide has been identified as the main metabolite in addition to mono- or di-hydroxylated menthol derivatives. ⁹

GI use The relative safety of peppermint and the availability of randomized clinical trials in humans render data from animal trials largely irrelevant. ^2, , ¹⁰

Antiemetic Animal models support the theoretical effect of peppermint oil in reducing nausea, but trials in humans have suffered from poor methodology. ^11, Trials have shown that menthol and peppermint oil are more effective than placebo, ^12, , ^13, but they are not more effective than standard treatments. ^11, , ¹³

Biliary disorders Peppermint oil has been used traditionally in the management of gallstones. A choleretic action of the oil has been described. ⁹

Dyspepsia Peppermint oil alone and in combination with other herbs has been more effective than placebo in reducing symptoms of dyspepsia in adults and children. ^14, , ^15, , ^16, , ^17, , ^18, , ¹⁹

IBS Patients should be administered peppermint oil only after examination has definitely diagnosed IBS with no associated organic lesions and after other diagnoses have been eliminated. ^20, Reviews of peppermint oil's role in IBS affirm its effectiveness compared with placebo, and as standard treatment in patients with nonserious constipation or diarrhea to reduce global symptoms, pain, and bloating. ^20, , ^21, , ^22, , ^23, , ^24, , ^25, , ²⁶

Smooth muscle spasm Peppermint oil exerts an antispasmodic action on smooth muscle, considered to be caused by calcium channel blockade. ^9, , ^27, , ^28, The oil has been useful in patients with colonic ^10, , ^28, , ^29, , ^30, and esophageal spasm. ^31, , ^32, , ³³

Respiratory Tract Menthol is available in a variety of OTC products (eg, chest rubs, inhalations, lozenges, syrups) for the treatment of colds and related congestion and cough. A decrease in cough was demonstrated in children when an inhalation of menthol was compared with placebo. ^34, The mechanism by which menthol may act as an antitussive is still speculative. ^35, Menthol inhalation can cause a subjective nasal decongestant effect without any objective decongestant action. ^35, In lozenges, the main action of menthol appears to be a subjective sensation of improved nasal airflow. ^35, No effect on forced expiratory volume was shown in patients with chronic mild asthma using nebulized menthol versus placebo. However, the menthol group used fewer bronchodilators and had fewer wheezing episodes. ³⁶

Pain/sensory effects In low concentrations, topical application of menthol causes a cooling sensation, while in higher concentrations it causes local anesthesia and irritation. ^35, , ^37, , ^38, These attributes of menthol have been used to construct pain models. ^37, , ^38, The irritant effect of menthol causes local vasodilation. ^35, , ^38, , ^39, This effect has been used to aid penetration of topical drugs; higher diffusion of tetracaine has been demonstrated with menthol-enhanced gel. ^39, Menthol's sensory effects are utilized in commercial topical musculoskeletal products. ^35, , ⁴⁰

Other effects

Antibacterial Peppermint oil possesses antibacterial activity in vitro. Different commercial preparations exhibit various activities. ⁵ The essential oil and its constituents (eg, menthol, menthone) displayed activity against Escherichia coli , Helicobacter pylori , methicillin-sensitive and methicillin-resistant strains of Staphylococcus aureus , Pseudomonas spp., Enterobacter aerogenes , and Salmonella enteritidis . ^41, , ^42, , ^43, Weak antifungal activity also has been shown in vitro. ⁴³

Cancer A reduction in incidence and multiplicity of induced lung cancer has been shown in mice. ⁴⁴

CNS Peppermint oil is being studied as aromatherapy for dementia by the Cochrane Dementia and Cognitive Improvement Group. ^45, Peppermint oil in ethanol reduced pain sensitivity experienced with headaches. ^46, Peppermint oil aroma has shown an antisoporific effect. ^47, , ⁴⁸

Peppermint oil has been used as a carminative in clinical studies at doses of 0.1 to 0.24 mL. ^10, , ^49, , ^50, , ^51, Doses of peppermint oil up to 1,200 mg in enteric-coated tablets have been used in IBS ^30, , ^31, ; 40 mL of peppermint oil has been added to barium suspension, ^16, and 8 mL of peppermint oil also has been administered intraluminally during colonoscopy. ¹⁵

Because of the oil's ability to relax GI smooth muscle, people with hiatus hernia may experience worsening symptoms while ingesting peppermint-containing preparations. ²⁷

Enteric-coated capsules should be swallowed whole and not crushed, broken, or chewed because peppermint oil can irritate the mouth, esophagus, and stomach. Tablets should be taken 30 to 60 minutes before meals on an empty stomach. ^17, , ⁵²

Documented adverse reactions. Avoid use because of emmenagogue effects. ⁵³

Caffeine Absorption of a single dose of caffeine 200 mg was delayed by menthol 100 mg in healthy volunteers. ⁵⁴

Felodipine Peppermint oil may influence metabolism of felodipine via inhibition of CYP-P450 3A4, elevating felodipine plasma concentrations and increasing the pharmacologic and adverse reactions. Peppermint oil 600 mg in water increased the area under the curve (AUC) of felodipine 40%. ^55, However, a study of the effect of menthol showed no effect on felodipine pharmacokinetics in healthy adults. ⁵⁶

Simvastatin Peppermint oil may influence metabolism of simvastatin via inhibition of CYP-450 3A4, elevating simvastatin plasma concentrations and increasing the pharmacologic and adverse reactions. Peppermint oil 600 mg in water increased the AUC of simvastatin 30% in healthy volunteers. ⁵⁵

Cyclosporine Decreased cyclosporine levels were reported in a patient consuming herbal tea containing peppermint and 8 other herbs. ⁵⁷

Menthol, the major component of peppermint oil, may cause allergic reactions (eg, contact dermatitis, flushing, headache) in certain individuals. ^6, , ^58, , ^59, Delayed patch-test reaction to menthol and peppermint oil may occur 6 to 14 days after application. ^60, Symptoms of contact sensitivity and ulceration from oral menthol/peppermint-containing products improved with discontinuation and avoidance of these products. ⁶¹

Following ingestion of 40 drops of peppermint oil, a patient with no known allergies reported mucosal burns and edema of the tongue and oral cavity. ^52, Excessive consumption of mint-flavored sweets caused stomatitis with oral papillary hypertrophy. ⁶²

Delayed-release peppermint oil capsules have caused a burning sensation during defecation because of unabsorbed menthol that reached the rectum. ¹⁷

Loss of libido in men following consumption of peppermint tea has been reported. ⁶³

Like other mints from which menthol is derived as a plant extract, peppermint is generally recognized as safe for human consumption as a seasoning or flavoring. ⁷

Rats fed peppermint oil in daily dosages of up to 100 mg/kg for 28 days developed dose-related brain lesions. A similar 90-day study demonstrated identical pathology, with no additional aggravation of the cyst-like spaces in the cerebellum. These were similar in nature to the neuropathy induced by hexachlorophene and attributed to the pulegone component of peppermint oil. ^7, , ⁶⁴ However, doses of this magnitude would be considered an overdosage with the oil.

A case of delirium resulting from intoxication by oral ingestion of topical Mentholatum required hospitalization in a woman with chronic alcoholism. ^65, Delirium also was experienced in a man with chronic alcoholism after possible oral ingestion of a topical menthol/alcohol-containing analgesic. ^66, Pulmonary edema and acute lung injury occurred in a patient following intravenous injection of peppermint oil. ⁶⁷

Peppermint oil should not be administered to patients with heartburn or active gastric ulcers, because symptoms may be exacerbated. The oil can decrease esophageal sphincter pressure and contribute to gastroesophageal reflux. ^27, Peppermint oil should not be applied to the face, especially under the nose of a child or infant. ^35, The application of menthol-containing ointment to the nostrils of an infant for the treatment of cold symptoms has caused instant collapse. ⁶ Enteric-coated preparations have not been studied in children younger than 8 years of age and are not recommended for use in very young children.

1. USDA, NRCS. 2006. The PLANTS Database ( http://plants.usda.gov , 11 October 2006). National Plant Data Center, Baton Rouge, LA 70874-4490 USA.

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