About this Journal Submit a Manuscript Table of Contents
Advances in Pharmacological Sciences
Volume 2012 (2012), Article ID 706905, 7 pages
Review Article

The Anti-Inflammatory, Phytoestrogenic, and Antioxidative Role of Labisia pumila in Prevention of Postmenopausal Osteoporosis

Department of Pharmacology, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur campus, 50300 Kuala Lumpur, Malaysia

Received 16 November 2011; Accepted 8 January 2012

Academic Editor: Satya Sarker

Copyright © 2012 M. E. Nadia et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Osteoporosis is characterized by skeletal degeneration with low bone mass and destruction of microarchitecture of bone tissue which is attributed to various factors including inflammation. Women are more likely to develop osteoporosis than men due to reduction in estrogen during menopause which leads to decline in bone-formation and increase in bone-resorption activity. Estrogen is able to suppress production of proinflammatory cytokines such as IL-1, IL-6, IL-7, and TNF- . This is why these cytokines are elevated in postmenopausal women. Studies have shown that estrogen reduction is able to stimulate focal inflammation in bone. Labisia pumila (LP) which is known to exert phytoestrogenic effect can be used as an alternative to ERT which can produce positive effects on bone without causing side effects. LP contains antioxidant as well as exerting anti-inflammatory effect which can act as free radical scavenger, thus inhibiting TNF-α production and COX-2 expression which leads to decline in RANKL expression, resulting in reduction in osteoclast activity which consequently reduces bone loss. Hence, it is the phytoestrogenic, anti-inflammatory, and antioxidative properties that make LP an effective agent against osteoporosis.

1. Introduction

Plant has been one of the sources of medicine to treat various illnesses and diseases since ancient time. In the early 19th century, when chemical analysis first became available, scientists began to extract and modify the active ingredients from plants which later led to wide development of natural or traditional medicine that was mostly passed on orally from one generation to another. More than 35,000 plant species have been reported to be used in various human cultures around the world for their medical purposes [1]. Traditional medicine has been defined by the World Health Organization (WHO) as “health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination, to treat, diagnose and prevent illnesses or maintain well-being” [2].

Currently in Malaysia, over 2,000 species of lower plants with medicinal and therapeutic properties have been identified, and most of them have been used for many generations in various health care systems. About 17.1% of Malaysians used herbs to treat their health problems while 29.6% of them consumed herbs for their health maintenance [3]. The earliest report on medicinal plant research in Malaysia was carried out by Arthur in 1954 [4]. Subsequently, more plants were screened chemically for alkaloids, saponins, triterpenes, and steroids in the 90s [5, 6].

Amongst the famous herbs that are widely used in Malaysia by the locals are Labisia pumila (Kacip Fatimah), Eurycoma longifolia Jack (Tongkat Ali), Orthosiphon stamineus (Misai Kucing), Quercus infectoria (Manjakani), and Piper sarmentosum (daun kaduk). These plants are similar in terms of exhibiting phytochemical properties that are protective against various diseases. These herbs are known to exert antibacterial, antioxidant, and anti-inflammatory properties that make them beneficial against many types of diseases such as fever, asthma, joint pains, gastrointestinal diseases, bone disorders, and inflammatory disorders. [79]. This paper is a review which will be focusing on the content and health benefits of one of the famous Malaysian herbs, Kacip Fatimah.

Kacip Fatimah or its scientific name Labisia pumila (LP) is a member of small genus of slightly woody plants of the family Myrsinaceae. There are four known varieties of Labisia pumila found in Malaysia but only three of them are widely used by the locals, which are recognized as Labisia pumila var. pumila, Labisia pumila var. alata, and Labisia pumila var. lanceolata [10, 11]. LP is found mainly in the lowland and hillforests of peninsular Malaysia at an altitude between 300 and 700 metres. It is also known by the locals as Selusuh Fatimah, Rumput Siti Fatimah, Akar Fatimah, Pokok Pinggang, and Belangkas Hutan [12, 13]. Of all the subtypes, Labisia pumila var. alata is the most widely used by the locals [10]. Its water extract is traditionally consumed especially by the Malay women to treat menstrual irregularities and painful menstruation, help contracting birth channel after delivery, and to promote sexual health function [14, 15]. It has also been used to treat dysentery, gonorrhoea, rheumatism, and sickness in bones [16, 17].

It is the phytoestrogen, anti-inflammatory, and antioxidative properties that make LP effective against various illnesses. LP was reported to exert estrogenic properties [1820]. Theoretically, phytoestrogens can act as anti-estrogenic agents by blocking the estrogen receptors and exerting weaker estrogenic effect compared with the hormone [21]. The water extract of LP has been found to inhibit estradiol binding to antibodies raised against estradiol, suggesting the presence of estrogen-like compounds in the extract [22]. It also contains triterpene and saponins, including the compound ardisiacrispin A which were thought to be the reason behind the phytoestrogenic activity of LP [23].

LP has been widely used by the locals in Malaysia not only to ease menstrual pain, induce labor, and promote healthy sexual function but it is also used as an alternative to estrogen replacement therapy in postmenopausal women [24, 25]. Postmenopausal women are prone to osteoporosis due to the reduction in estrogen level. Estrogen acts on estrogen receptor-α (ERα) and receptor-β (ERβ) which has high affinity towards osteoblasts and osteoclasts [26]. Activation of estrogen-receptor complex is vital in maintaining bone remodelling processes [27]. Estrogen can induce osteoclasts apoptosis and inhibit osteoblasts apoptosis, which indirectly will reduce bone resorption and increase bone-formation activity [28]. Hence, reduction in estrogen is highly associated with bone loss. Dietary phytoestrogens such as LP can be an alternative to synthetic estrogen for hormone therapy to reduce side effects of prolonged hormone therapy such as risk of breast cancer, endometrial cancer, and cardiovascular diseases [29, 30]. This paper will focus on the role of Labisia pumila in offering protection against postmenopausal osteoporosis via its anti-inflammatory properties.

2. Anti-Inflammatory Role of Labisia pumila

Osteoporosis is characterized by skeletal degeneration with low bone mass and destruction of microarchitecture of bone tissue. According to the National Institute of Health, osteoporosis is a skeletal disease which involves decline in mass and density which later leads to fracture [31]. Women, especially postmenopausal women, are more likely to develop osteoporosis than men due to tremendous decline in estrogen during menopause which will lead to decline in bone formation and increase in bone-resorption activity [32]. Osteoporosis is attributed to various factors, and there are evidences that inflammation also exerts significant influence on bone turnover, inducing osteoporosis [33, 34]. According to studies by Lorenzo and Manolagas and Jilka, certain pro-inflammatory cytokines play potential critical roles both in the normal bone remodeling process and in the pathogenesis of osteoporosis [34, 35]. For example, interleukin- (IL-) 6 promotes osteoclasts differentiation and activation [36]. IL-1 is another potent stimulator of bone resorption [37] that has been linked to the accelerated bone loss seen in postmenopausal osteoporosis [38].

Various epidemiologic studies reported an increase in the risk of developing osteoporosis in various inflammatory conditions such as rheumatoid arthritis, haematological diseases, and inflammatory bowel disease [39, 40]. Proinflammatory cytokines such as tumor necrosis factor (TNF)-α, IL-6, IL-1, IL-11, IL-15, and IL-17 are elevated in these conditions [41]. IL-6 and IL-1 may influence osteoclastogenesis by stimulating self-renewal and inhibiting the apoptosis of osteoclasts progenitors [42, 43]. They promote osteoclasts differentiation which is an important stimulator of bone resorption that has been linked to accelerated bone loss seen in postmenopausal women [36]. Receptor activator of NF-κβ ligand (RANKL) is a membrane-bound molecule of TNF ligand family which plays a crucial role in osteoclasts formation [44]. TNF is a cytokine that is involved in inflammation and is an important cofactor in bone resorption because this cytokine supports osteoclasts activation mediated by RANKL and c-Fms/macrophage colony-stimulating factor.

Estrogen is able to suppress the production of these proinflammatory cytokines [45, 46]. This is why estrogen withdrawal following menopause will lead to increase in these cytokines as proven in many studies. Studies on bone resorption demonstrated that the fall of estrogen level in postmenopausal women was able to stimulate local inflammation in the bone. Ovariectomy in rats was accompanied by increased production of IL-1 and TNF-α which later resulted in decrease in bone density. Hence, it is suggested that estrogen withdrawal can be associated with an increase in production of proinflammatory cytokines, which in turn increases osteoclasts activity resulting in profound bone loss [47]. Estrogen will stimulate production of osteoprotegerin (OPG), which is a potent antiosteoclastogenic factor. OPG acts as a decoy, blocking the binding of the RANK expressed in osteoblasts progenitors, to RANKL which is expressed in committed preosteoblastic cells [48]. This estrogen deficiency leads to upregulation of cytokines [49] and down-regulation of OPG which will result in increase in inflammatory responses and increase in bone-resorption activity. In a study by Collin-Osdoby et al., [50] increases in RANKL and OPG mRNA expression were seen in endothelial cells following an inflammatory stimulus. Therefore, suppression of these potent inflammatory mediators has been proposed to explain the deleterious effects of estrogen deficiency on the human skeletal system at menopause.

3. Phytoestrogenic Role of Labisia pumila

LP which has been opposed to exert phytoestrogen property can be used as an alternative to estrogen replacement therapy (ERT) in postmenopausal inflammation-induced osteoporosis. In contrast to ERT which can cause many harmful side effects, LP which originated from natural resources will not cause any side effect, if taken within its safe therapeutic dose. Toxicity testing of LP which was done by the Herbal Medicine Research Centre of Institute of Medical Research has shown that LD50 is safe at more than 5.0 g/kg [51]. LP extract was found to exhibit no-adverse-effect level (NOAEL) at the dose of 50 mg/kg in subacute toxicity study [52], 1000 mg/kg in subchronic toxicity study [53], and 800 mg/kg in reproductive toxicity study [51]. Therefore, LP is safe to be given at high dose as long as it does not outweigh the toxic dose.

Studies have shown that production of proinflammatory cytokines in response to estrogen withdrawal at menopause is responsible to the stimulation of osteoclastic bone resorption [5456]. A study done by Choi et al. [57] indicated that the LP extract may have good potential to be developed as novel anti-inflammatory drug due to an experimental finding of treatment with LP extract which has markedly inhibited the TNF-α production and the expression of cyclooxygenase (COX)-2. COX-2 is an enzyme that is responsible for the production of mediators involved in inflammation. In vitro experiments have revealed increased COX-2 expression after stimulation with proinflammatory cytokines, such as IL-1 and TNF-α [58].

Pharmacological inhibition of COX can provide a relief from the symptoms of inflammation and pain. Studies have shown that COX-2 plays an important role in pathophysiology of osteoporosis by stimulating the production of prostaglandin (PGE2). Excessive PGE2 production might lead to increase in bone resorption, while deficient of its production might impair the bone-formation response, both to mechanical loading and remodelling [59]. Consequently, inhibition of the COX-2 enzyme in postmenopausal women may prevent menopausal bone loss [60]. Inhibition of the main proinflammatory cytokines has proven that LP extract could be a good material for the regulation of anti-inflammation process. TNF has been shown to stimulate osteoclast differentiation, increase its activation, inhibit its apoptosis, and inhibit osteoblast differentiation [6163]. It also reduces bone formation in cultured osteoblast in vitro [64]. Similar to IL-1, TNF-stimulated induction of osteoclast-like-cell formation in bone marrow culture is mediated by increases in RANKL expression. However, in addition to increasing RANKL expression, TNF also inhibits OPG in an osteoblastic model [65]. Hence, inhibition of TNF will indirectly help in reducing bone loss.

4. Antioxidative Role of Labisia pumila

Based on previous studies, LP has been shown to exhibit antioxidative properties due to the presence of flavanoids, ascorbic acid, beta-carotene, anthocyanin, and phenolic compounds [66, 67]. According to Norhaiza et al. [68], there were positive correlations between the antioxidant capacities and the antioxidant compounds of LP extract with β-carotene having the best correlation, followed by flavonoid, ascorbic acid, anthocyanin, and phenolic content. β-carotene is one of the basic constituent of antioxidative effect. The chemical abilities of β-carotene to quench singlet oxygen and to inhibit peroxyl free radical actions are well established [69]. Flavonoid has been shown to be highly effective scavenger of free radicals that are involved in diseases such as osteoporosis and rheumatism which is associated with aging due to oxidative stress [70]. Anthocyanin and phenolic on the other hand, not only play a role as antioxidative agents, but also as anti-inflammatory agents [7173]. These antioxidative and anti-inflammatory properties of LP extract explained the effectiveness of this medicinal plant against various diseases such as osteoporosis, rheumatism, and women sexual function.

Osteoporosis in postmenopausal women can also be explained in terms of oxidative stress mechanism. Ovariectomy has been proposed by many studies as a model of postmenopausal osteoporosis. Following ovariectomy, decline in estrogen level will result in significant bone loss due to bone resorption outweighing bone-formation activity [74]. Estrogen can be considered as an antioxidant as it was found to exhibit antioxidant protection of lipoproteins in the aqueous system [75] and was also shown to increase the expression of glutathione peroxidase in osteoclasts [76]. That is why decline in estrogen will lead to increase in osteoclasts activity resulting in bone loss. Free radicals are continuously produced in the body, mostly by biochemical redox reactions involving oxygen, which occur as part of normal cell metabolism. Free radicals, mainly reactive oxygen species (ROS), are efficiently scavenged, but oxidative stress occurs when there is an imbalance between increased ROS and inadequate antioxidant activity [77] which consequently accelerates aging process and leads to degenerative diseases such as osteoporosis, rheumatism, and cardiovascular disease.

ROS alter mitochondrial and nuclear DNA integrity by increasing the risk of mutations. When DNA repair mechanisms are overwhelmed, cells undergo apoptosis which will lead to tissue damage [78]. This can be applicable in postmenopausal osteoporosis mechanism. When body is subjected to high oxidative stress following estrogen reduction, lipid accumulation will occur. Lipid peroxidation will promote osteoblast apoptosis and simultaneously upregulating ROS production [79, 80]. ROS was shown to promote osteoclast resorption activity either directly or mimicking RANK signalling and stimulating osteoclast differentiation, or indirectly, by stimulating osteoblast/osteoclast coupling and subsequent osteoclast differentiation [81]. Oxidative stress has been acceded as a major contributor to the immune response. Activation of immune response mechanism is characterized by establishment of an inflammatory response. Thus, osteoporosis can be associated with inflammatory mechanism.

Estrogen can prevent osteoblast cell death and RANKL stimulation by suppressing ROS. Estrogen deficiency is a key step in ROS-mediated stimulation of bone loss via TNF-α signalling pathway. Stimulation of this proinflammatory cytokine will induce bone resorption by indirectly affecting production of essential osteoclast differentiation factor, thereby enhancing proliferation of osteoclast lineage [82]. Glutathione peroxide (GPx) and superoxide dismutase (SOD) are the main antioxidative enzymes that play a pivotal role in counteracting oxidative stress [83]. These enzymes were found to be lowered in postmenopausal women with osteoporosis. This failure of antioxidant defences will result in deleterious effect of hydrogen peroxide on bone health [84]. Studies of antioxidant supplementation such as vitamin E on postmenopausal rat model have shown that lipid peroxidation was successfully inhibited and antioxidative enzymes were restored to acceptable level. In study by Norazlina et al. (2007), IL-6 level was high in ovariectomised rats showing high bone resorption rate, and this level was significantly reduced after three months of tocotrienol (vitamin E) supplementation. In the same study, vitamin E-deficient rats given palm vitamin E showed an improvement in bone calcium content and reduced bone resorption marker [85]. Hence, it is shown that antioxidant is effective in reducing bone-resorption activity as well as improving bone calcium content.

Main antioxidative compound in LP such as flavonoid and β-carotene has been shown in previous studies to inhibit production of nitric oxide and expression of inducible nitric oxide synthase (iNOS) [86] most likely by suppression of NF-κB [87]. NF-kB is an oxidative stress-responsive transcription factor which is activated by free radicals, inflammatory stimuli, and other cytokines. Thus, free radicals may increase bone resorption through activation of NF-kB. It has previously been shown in vitro and in rodents that free radicals are involved in osteoclastogenesis and in bone resorption [88]. Oxidative stress may increase bone resorption through activation of NF-κB which plays an important role in osteoclastogenesis [89, 90]. Hence, supplementation of LP which contains antioxidative properties can reduce oxidative stress level which indirectly prevents bone loss.

According to a recent study by Nazrun et al. (2011), osteocalcin, a bone formation marker, was found to be lowered in ovariectomised rats. After being treated with LP results showed an increase in osteocalcin to the level seen in sham-operated group indicating normalisation of bone formation. Bone resorption marker, CTX on the other hand, was found to be reduced after the rats were treated with LP [91]. CTX is sensitive and specific in detection of osteoporosis [92]. This result showed that LP was as effective as estrogen in preventing changes in bone markers induced by ovariectomy.

Based on its positive effects on the bone markers of ovariectomised rats which are comparable to estrogen and its safety profile, LP has the potential to be used as an alternative treatment for postmenopausal osteoporosis. All in all, it is the anti-inflammatory, phytoestrogenic, and antioxidative properties of LP that make it an effective natural medicine in treatment and prevention of osteoporosis.


One of the authors would like to thanks University Kebangsaan Malaysia (UKM) for the grants and the Pharmacology Department staffs for their technical support.


  1. A. Lewington, Medicinal Plants and Plant Extracts: A Review of Their Importation into Europe, Traffic International, Cambridge, UK, 1993.
  2. WHO, Traditional Medicine, WHO, Geneva, Switzerland, 2003.
  3. S. Elliot, Pharmacy Needs Tropical Forests, Manufacturing Chemist, 1986.
  4. H. R. Arthur, “A phytochemical survey of some plants of north Borneo,” Journal of Pharmacy and Pharmacology, vol. 6, no. 1, pp. 66–72, 1954. View at Publisher · View at Google Scholar
  5. L. E. Teo, G. Pachiaper, K. C. Chan et al., “A new phytochemical survey of Malaysia V. Preliminary screening and plant chemical studies,” Journal of Ethnopharmacology, vol. 28, no. 1, pp. 63–101, 1990. View at Scopus
  6. A. L. Mohamed, A. Zainudin, G. H. Petol, et al., “Phytochemical and toxicity screening of plants from Fraser Hill, Pahang,” in Chemical Prospecting in the Malaysian Forest, G. Ismail, M. Mohamaed, and L. B. Din, Eds., pp. 1–8, Pelanduk, Petaling Jaya, Malaysia, 1995.
  7. G. Kaur, H. Hamid, A. Ali, M. S. Alam, and M. Athar, “Antiinflammatory evaluation of alcoholic extract of galls of Quercus infectoria,” Journal of Ethnopharmacology, vol. 90, no. 2-3, pp. 285–292, 2004. View at Publisher · View at Google Scholar · View at Scopus
  8. Z. A. Zakaria, H. Patahuddin, A. S. Mohamad, D. A. Israf, and M. R. Sulaiman, “In vivo anti-nociceptive and anti-inflammatory activities of the aqueous extract of the leaves of Piper sarmentosum,” Journal of Ethnopharmacology, vol. 128, no. 1, pp. 42–48, 2010. View at Publisher · View at Google Scholar · View at Scopus
  9. C. L. Hsu, B. O. H. Hong, Y. U. Shan, and G. C. Yen, “Antioxidant and Anti-Inflammatory effects of orthosiphon aristatus and its bioactive compounds,” Journal of Agricultural and Food Chemistry, vol. 58, no. 4, pp. 2150–2156, 2010. View at Publisher · View at Google Scholar · View at Scopus
  10. B. C. Stone, “Notes on the genus Labisia Lindl (Myrsinaceae),” Malayan Nature Journal, vol. 42, pp. 43–51, 1988.
  11. A. J. Jamia, P. J. Houghton, S. R. Milligan, and J. Ibrahim, “The Oestrogenic and Cytotoxic Effects of the Extracts of Labisia pumila var. alata and Labisia pumila var. pumila In Vitro,” Malaysian Journal of Health Sciences, vol. 1, pp. 53–60, 1988.
  12. I. H. Burkill, Dictionary of the Economic Products of the Malay Peninsula, Publisher Crown Agents for the Colonies, London, UK, 1935.
  13. M. A. Rasadah and A. S. Zainon, Database on ASEAN Herbal and Medicinal Plants, vol. 1, ASEAN Publication, 2003.
  14. M. Zakaria and M. A. Mohd, Traditional Malay Medicinal Plants, vol. 8, Penerbit Fajar Bakti, Kuala Lumpur, Malaysia, 1994.
  15. G. Bodeker, Health and Beauty from the Rainforest: Malaysian Traditions of Ramuan, Editions Didier Millet Pty, Kuala Lumpur, Malaysia, 1999.
  16. A. Fasihuddin, A. H. Rahman, and R. Hasmah, “Medicinal plants used by bajau community in sabah,” in Trends in Traditional Medicine Research, K. L. Chan, et al., Ed., pp. 493–504, The School of Pharmaceutical Sciences, University of Science Malaysia, Penang, Malaysia, 1995.
  17. J. A. Jamal, P. J. Houghton, and S. R. Milligan, “Testing of labisia pumila for oestrogenic activity using a recombinant yeast sceen,” Journal of Pharmacy and Pharmacology, vol. 50, p. 79, 1998.
  18. Institute for Medical Research, Estrogenic and Androgenic Activities of Kacip Fatimah (Labisia Pumila), Abstracts of Research Projects, Ministry of Health Malaysia, Kuala Lumpur, Malaysia, 2002.
  19. L. Manneras, M. Fazliana, W. M. Wan Nazaimoon, et al., “Beneficial metabolic effects of the Malaysian herb Labisia pumila var. alata in a rat model of polycystic ovary syndrome,” Journal of Ethnopharmacology, vol. 127, pp. 346–351, 2010.
  20. M. Fazliana, W. M. Wan Nazaimoon, H. F. Gu, and C. G. Östenson, “Labisia pumila extract regulates body weight and adipokines in ovariectomized rats,” Maturitas, vol. 62, no. 1, pp. 91–97, 2009. View at Publisher · View at Google Scholar · View at Scopus
  21. IFST, Current Hot Topics. Phytoestrogens, Institute of Food Science and Technology, London, UK, 2001.
  22. H. Husniza, Estrogenic and Androgenic Activities of Kacip Fatimah (Labisia pumila), Abstracts of Research Projects, Institute of Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia, 2002.
  23. B. Avula, Y. H. Wang, Z. Ali, T. J. Smillie, and I. A. Khan, “Quantitative determination of triperpene saponins and alkenated-phenolics from Labisia pumila by LCUV/ELSD method and confirmation by LC-ESI-TOF,” Planta Medica, vol. 76, p. 25, 2010.
  24. V. Beral, E. Banks, and G. Reeves, “Evidence from randomised trials on the long-term effects of hormone replacement therapy,” Lancet, vol. 360, no. 9337, pp. 942–944, 2002. View at Publisher · View at Google Scholar · View at Scopus
  25. R. T. Chlebowski, J. A. Kim, and N. F. Col, “Estrogen deficiency symptom management in breast cancer survivors in the changing context of menopausal hormone therapy,” Seminars in Oncology, vol. 30, no. 6, pp. 776–88, 2003.
  26. B. Komm and P. V. N. Bodine, “Regulation of bone cell function by estrogens,” in Osteoporosis, R. Marcus, D. Feldman, and J. Kelsey, Eds., pp. 305–337, Academic Press, San Diego, Calif, USA, 2001.
  27. S. C. Manolagas, S. Kousteni, and R. L. Jilka, “Sex steroids and bone,” Recent Progress in Hormone Research, vol. 57, pp. 385–409, 2002. View at Publisher · View at Google Scholar · View at Scopus
  28. S. C. Manolagas, “Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis,” Endocrine Reviews, vol. 21, no. 2, pp. 115–137, 2000. View at Publisher · View at Google Scholar · View at Scopus
  29. N. E. Lane, The Osteoporosis Book: A Guide for Patients and Their Families, Oxford University Press, New York, NY, USA, 2001.
  30. E. Amir, O. C. Freedman, B. Seruga, and D. G. Evans, “Assessing women at high risk of breast cancer: a review of risk assessment models,” Journal of the National Cancer Institute, vol. 102, no. 10, pp. 680–691, 2010. View at Publisher · View at Google Scholar · View at Scopus
  31. NIH, Osteoporosis and Related Bone Disease, National Resource Centre, 2011.
  32. J. P. Bilezikian, “Osteoporosis in men,” Journal of Clinical Endocrinology and Metabolism, vol. 84, no. 10, pp. 3431–3434, 1999. View at Scopus
  33. J. R. Arron and Y. Choi, “Bone versus immune system,” Nature, vol. 408, no. 6812, pp. 535–536, 2000. View at Publisher · View at Google Scholar · View at Scopus
  34. J. Lorenzo, “Interactions between immune and bone cells: new insights with many remaining questions,” Journal of Clinical Investigation, vol. 106, no. 6, pp. 749–752, 2000. View at Scopus
  35. S. C. Manolagas and R. L. Jilka, “Mechanisms of disease: bone marrow, cytokines, and bone remodeling. Emerging insights into the pathophysiology of osteoporosis,” The New England Journal of Medicine, vol. 332, no. 5, pp. 305–311, 1995. View at Publisher · View at Google Scholar · View at Scopus
  36. S. C. Manolagas, “Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis,” Endocrine Reviews, vol. 21, no. 2, pp. 115–137, 2000. View at Publisher · View at Google Scholar · View at Scopus
  37. S. Wei, H. Kitaura, P. Zhou, F. Patrick Ross, and S. L. Teitelbaum, “IL-1 mediates TNF-induced osteoclastogenesis,” Journal of Clinical Investigation, vol. 115, no. 2, pp. 282–290, 2005. View at Publisher · View at Google Scholar · View at Scopus
  38. R. Pacifici, L. Rifas, R. McCracken et al., “Ovarian steroid treatment blocks a postmenopausal increase in blood monocyte interleukin 1 release,” Proceedings of the National Academy of Sciences of the United States of America, vol. 86, no. 7, pp. 2398–2402, 1989. View at Scopus
  39. D. Mitra, D. M. Elvins, D. J. Speden, and A. J. Collins, “The prevalence of vertebral fractures in mild ankylosing spondylitis and their relationship to bone mineral density,” Rheumatology, vol. 39, no. 1, pp. 85–89, 2000. View at Scopus
  40. T. Jensen, M. Klarlund, M. Hansen, K. E. Jensen, H. Skjodt, and L. Hydlldstrup, “Connective tissue metabolism in patients with unclassified polyarthritis and early rheumatoid arthritis. Relationship to disease activity, bone mineral density, and radiographyc outcome,” Journal of Rheumatology, vol. 31, pp. 1698–1708, 2004.
  41. K. Ishihara and T. Hirano, “IL-6 in autoimmune disease and chronic inflammatory proliferative disease,” Cytokine and Growth Factor Reviews, vol. 13, no. 4-5, pp. 357–368, 2002. View at Publisher · View at Google Scholar · View at Scopus
  42. G. Girasole, G. Passeri, R. L. Jilka, and S. C. Manolagas, “Interleukin-11: a new cytokine critical for osteoclast development,” Journal of Clinical Investigation, vol. 93, no. 4, pp. 1516–1524, 1994. View at Scopus
  43. R. L. Jilka, R. S. Weinstein, T. Bellido, A. M. Parfitt, and S. C. Manolagas, “Osteoblast programmed cell death (apoptosis): modulation by growth factors and cytokines,” Journal of Bone and Mineral Research, vol. 13, no. 5, pp. 793–802, 1998. View at Publisher · View at Google Scholar · View at Scopus
  44. K. Fuller, B. Wong, S. Fox, Y. Choi, and T. J. Chambers, “TRANCE is necessary and sufficient for osteoblast-mediated activation of bone resorption in osteoclasts,” Journal of Experimental Medicine, vol. 188, no. 5, pp. 997–1001, 1998. View at Publisher · View at Google Scholar · View at Scopus
  45. R. L. Jilka, “Cytokines, bone remodeling, and estrogen deficiency,” Bone, vol. 23, no. 2, pp. 75–81, 1998. View at Publisher · View at Google Scholar · View at Scopus
  46. D. A. Papanicolaou, R. L. Wilder, S. C. Manolagas, and G. P. Chrousos, “The pathophysiologic roles of interleukin-6 in human disease,” Annals of Internal Medicine, vol. 128, no. 2, pp. 127–137, 1998. View at Scopus
  47. R. B. Kimble, A. B. Matayoshi, J. L. Vannice, V. T. Kung, C. Williams, and R. Pacifici, “Simultaneous block of interleukin-1 and tumor necrosis factor is required to completely prevent bone loss in the early postovariectomy period,” Endocrinology, vol. 136, no. 7, pp. 3054–3061, 1995. View at Scopus
  48. L. C. Hofbauer, S. Khosla, C. R. Dunstan, D. L. Lacey, T. C. Spelsberg, and B. L. Riggs, “Estrogen stimulates gene expression and protein production of osteoprotegerin in human osteoblastic cells,” Endocrinology, vol. 140, no. 9, pp. 4367–4370, 1999. View at Scopus
  49. S. Cenci, M. N. Weitzmann, C. Roggia et al., “Estrogen deficiency induces bone loss by enhancing T-cell production of TNF-α,” Journal of Clinical Investigation, vol. 106, no. 10, pp. 1229–1237, 2000. View at Scopus
  50. P. Collin-Osdoby, L. Rothe, F. Anderson, M. Nelson, W. Maloney, and P. Osdoby, “Receptor activator of NF-κB and osteoprotegerin expression by human microvascular endothelial cells, regulation by inflammatory cytokines, and role in human osteoclastogenesis,” Journal of Biological Chemistry, vol. 276, no. 23, pp. 20659–20672, 2001. View at Publisher · View at Google Scholar · View at Scopus
  51. M. F. Wan Ezumi, S. Siti Amrah, A. W. M. Suhaimi, and S. S. J. Mohsin, “Evaluation of the female reproductive toxicity of aqueous extract of Labisia pumila var. alata in rats,” Indian Journal of Pharmacology, vol. 39, no. 1, pp. 30–32, 2007. View at Scopus
  52. G. D. Singh, M. Ganjoo, M. S. Youssouf et al., “Sub-acute toxicity evaluation of an aqueous extract of Labisia pumila, a Malaysian herb,” Food and Chemical Toxicology, vol. 47, no. 10, pp. 2661–2665, 2009. View at Publisher · View at Google Scholar · View at Scopus
  53. S. C. Taneja, Sub-Chronic (90 days) Oral Toxicity Studies of Aqueous Extract of Labisia pumila in Wistar Rats (250, 500&1000 mg/kg b. wt. only), Indian Institute of Integrative Medicine, Jammu, India, 2004.
  54. B. L. Riggs, S. Khosla, and L. J. Melton, “Sex steroids and the construction and conservation of the adult skeleton,” Endocrine Reviews, vol. 23, no. 3, pp. 279–302, 2002. View at Publisher · View at Google Scholar · View at Scopus
  55. F. Syed and S. Khosla, “Mechanisms of sex steroid effects on bone,” Biochemical and Biophysical Research Communications, vol. 328, no. 3, pp. 688–696, 2005. View at Publisher · View at Google Scholar · View at Scopus
  56. R. T. Turner, B. L. Riggs, and T. C. Spelsberg, “Skeletal effects of estrogen,” Endocrine Reviews, vol. 15, no. 3, pp. 275–300, 1994. View at Publisher · View at Google Scholar · View at Scopus
  57. H. K. Choi, D. H. Kim, J. W. Kim, S. Ngadiran, M. R. Sarmidi, and C. S. Park, “Labisia pumila extract protects skin cells from photoaging caused by UVB irradiation,” Journal of Bioscience and Bioengineering, vol. 109, no. 3, pp. 291–296, 2010. View at Publisher · View at Google Scholar · View at Scopus
  58. L. J. Crofford, “COX-1 and COX-2 tissue expression: Implications and predictions,” Journal of Rheumatology, vol. 24, no. 49, pp. 15–19, 1997. View at Scopus
  59. H. Yasuda, N. Shima, N. Nakagawa et al., “Osteoclast differentiation factor is a ligand for osteoprotegerin/osteoclastogenesis-inhibitory factor and is identical to TRANCE/RANKL,” Proceedings of the National Academy of Sciences of the United States of America, vol. 95, no. 7, pp. 3597–3602, 1998. View at Scopus
  60. J. H. M. Feyen and L. G. Raisz, “Prostaglandin production by calvariae from sham operated and oophorectomized rats: effect of 17β-estradiol in vivo,” Endocrinology, vol. 121, no. 2, pp. 819–821, 1987. View at Scopus
  61. M. R. Forwood, “Inducible cyclo-oxygenase (COX-2) mediates the induction of bone formation by mechanical loading in vivo,” Journal of Bone and Mineral Research, vol. 11, no. 11, pp. 1688–1693, 1996. View at Scopus
  62. K. Fuller, C. Murphy, B. Kirstein, S. W. Fox, and T. J. Chambers, “TNFα potently activates osteoclasts, through a direct action independent of and strongly synergistic with RANKL,” Endocrinology, vol. 143, no. 3, pp. 1108–1118, 2002. View at Publisher · View at Google Scholar · View at Scopus
  63. S. E. Lee, W. J. Chung, H. B. Kwak et al., “Tumor necrosis factor-α supports the survival of osteoclasts through the activation of Akt and ERK,” Journal of Biological Chemistry, vol. 276, no. 52, pp. 49343–49349, 2001. View at Publisher · View at Google Scholar · View at Scopus
  64. L. Gilbert, X. He, P. Farmer et al., “Inhibition of osteoblast differentiation by tumor necrosis factor-α,” Endocrinology, vol. 141, no. 11, pp. 3956–3964, 2000. View at Scopus
  65. S. Kumar, B. J. Votta, D. J. Rieman, A. M. Badger, M. Gowen, and J. C. Lee, “IL-1- and TNF-induced bone resorption is mediated by p38 mitogen activated protein kinase,” Journal of Cellular Physiology, vol. 187, no. 3, pp. 294–303, 2001. View at Publisher · View at Google Scholar · View at Scopus
  66. L. C. Hofbauer, C. R. Dunstan, T. C. Spelsberg, B. L. Riggs, and S. Khosla, “Osteoprotegerin production by human osteoblast lineage cells is stimulated by vitamin D, bone morphogenetic protein-2, and cytokines,” Biochemical and Biophysical Research Communications, vol. 250, no. 3, pp. 776–781, 1998. View at Publisher · View at Google Scholar · View at Scopus
  67. J. Huang, H. Zhang, N. Shimizu, and T. Takeda, “Triterpenoid saponins from Ardisia mamillata,” Phytochemistry, vol. 54, no. 8, pp. 817–822, 2000. View at Publisher · View at Google Scholar · View at Scopus
  68. M. Norhaiza, M. Maziah, and M. Hakiman, “Antioxidative properties of leaf extracts of a popular Malaysian herb, Labisia pumila,” Journal of Medicinal Plant Research, vol. 3, no. 4, pp. 217–223, 2009. View at Scopus
  69. G. G. Duthie, P. T. Gardner, and J. A. M. Kyle, “Plant polyphenols: are they the new magic bullet?” Proceedings of the Nutrition Society, vol. 62, no. 3, pp. 599–603, 2003. View at Publisher · View at Google Scholar · View at Scopus
  70. H. Sies and W. Stahl, “Vitamins E and C, β-carotene, and other carotenoids as antioxidants,” American Journal of Clinical Nutrition, vol. 62, no. 6, pp. 1315S–121S, 1995. View at Scopus
  71. L. Bravo, “Polyphenols: chemistry, dietary sources, metabolism, and nutritional significance,” Nutrition Reviews, vol. 56, no. 11, pp. 317–333, 1998. View at Scopus
  72. S. Y. Wang and H. Jiao, “Scavenging capacity of berry crops on superoxide radicals, hydrogen peroxide, hydroxyl radical's, and singlet oxygen,” Journal of Agricultural and Food Chemistry, vol. 48, no. 11, pp. 5677–5684, 2000. View at Publisher · View at Google Scholar · View at Scopus
  73. A. Cassidy, B. Hanley, and R. M. Lamuela-Raventos, “Isoflavones, lignans and stilbenes: origins, etabolism and potential importance tohuman health,” Journal of the Science of Food and Agriculture, vol. 80, no. 7, pp. 1044–1062, 2000.
  74. P. P. Lelovas, T. T. Xanthos, S. E. Thorma, G. P. Lyritis, and I. A. Dontas, “The laboratory rat as an animal model for osteoporosis research,” Comparative Medicine, vol. 58, no. 5, pp. 424–430, 2008. View at Scopus
  75. M. Badeau, H. Adlercreutz, P. Kaihovaara, and M. J. Tikkanen, “Estrogen A-ring structure and antioxidative effect on lipoproteins,” Journal of Steroid Biochemistry and Molecular Biology, vol. 96, no. 3-4, pp. 271–278, 2005. View at Publisher · View at Google Scholar · View at Scopus
  76. J. M. Lean, C. J. Jagger, B. Kirstein, K. Fuller, and T. J. Chambers, “Hydrogen peroxide is essential for estrogen-deficiency bone loss and osteoclast formation,” Endocrinology, vol. 146, no. 2, pp. 728–735, 2005. View at Publisher · View at Google Scholar · View at Scopus
  77. B. Halliwell and J. M. C. Gutteridge, Free Radicals in Biology and Medicine, Oxford University Press, New York, NY, USA, 2007.
  78. K. Naka, T. Muraguchi, T. Hoshii, and A. Hirao, “Regulation of reactive oxygen species and genomic stability in hematopoietic stem cells,” Antioxidants and Redox Signaling, vol. 10, no. 11, pp. 1883–1894, 2008. View at Publisher · View at Google Scholar · View at Scopus
  79. D. Maggio, M. Barabani, M. Pierandrei et al., “Marked decrease in plasma antioxidants in aged osteoporotic women: results of a cross-sectional study,” Journal of Clinical Endocrinology and Metabolism, vol. 88, no. 4, pp. 1523–1527, 2003. View at Publisher · View at Google Scholar · View at Scopus
  80. M. Almeida, L. Han, M. Martin-Millan et al., “Skeletal involution by age-associated oxidative stress and its acceleration by loss of sex steroids,” Journal of Biological Chemistry, vol. 282, no. 37, pp. 27285–27297, 2007. View at Publisher · View at Google Scholar · View at Scopus
  81. F. Wauquier, L. Leotoing, V. Coxam, J. Guicheux, and Y. Wittrant, “Oxidative stress in bone remodelling and disease,” Trends in Molecular Medicine, vol. 15, no. 10, pp. 468–477, 2009. View at Publisher · View at Google Scholar · View at Scopus
  82. Y. Hayase, Y. Muguruma, and M. Y. Lee, “Osteoclast development from hematopoietic stem cells: apparent divergence of the osteoclast lineage prior to macrophage commitment,” Experimental Hematology, vol. 25, no. 1, pp. 19–25, 1997. View at Scopus
  83. N. K. Lee, Y. G. Choi, J. Y. Baik et al., “A crucial role for reactive oxygen species in RANKL-induced osteoclast differentiation,” Blood, vol. 106, no. 3, pp. 852–859, 2005. View at Publisher · View at Google Scholar · View at Scopus
  84. A. N. Sontakke and R. S. Tare, “A duality in the roles of reactive oxygen species with respect to bone metabolism,” Clinica Chimica Acta, vol. 318, no. 1-2, pp. 145–148, 2002. View at Publisher · View at Google Scholar · View at Scopus
  85. M. Norazlina, P. L. Lee, H. I. Lukman, A. S. Nazrun, and S. Ima-Nirwana, “Effects of vitamin E supplementation on bone metabolism in nicotine-treated rats,” Singapore Medical Journal, vol. 48, no. 3, pp. 195–199, 2007. View at Scopus
  86. J. Gonzalez-Gallego, S. Sanchez-Campoz, and M. J. Tunon, “Anti-inflammatory properties of dietary flavonoids,” Nutricion Hospitalaria, vol. 22, no. 3, pp. 287–293, 2007.
  87. Y. L. Lin and J. K. Lin, “Epigallocatechin-3-gallate blocks the induction of nitric oxide synthase by down-regulating lipopolysaccharide-induced activity of transcription factor nuclear factor-kappaB,” Molecular Pharmacology, vol. 52, no. 3, pp. 465–472, 1997. View at Scopus
  88. N. Mody, F. Parhami, T. A. Sarafian, and L. L. Demer, “Oxidative stress modulates osteoblastic differentiation of vascular and bone cells,” Free Radical Biology and Medicine, vol. 31, no. 4, pp. 509–519, 2001. View at Publisher · View at Google Scholar · View at Scopus
  89. J. H. E. Fraser, M. H. Helfrich, H. M. Wallace, and S. H. Ralston, “Hydrogen peroxide, but not superoxide, stimulates bone resorption in mouse calvariae,” Bone, vol. 19, no. 3, pp. 223–226, 1996. View at Publisher · View at Google Scholar · View at Scopus
  90. R. Kitazawa, R. B. Kimble, J. L. Vannice, V. T. Kung, and R. Pacifici, “Interleukin-1 receptor antagonist and tumor necrosis factor binding protein decrease osteoclast formation and bone resorption in ovariectomized mice,” Journal of Clinical Investigation, vol. 94, no. 6, pp. 2397–2406, 1994. View at Scopus
  91. A. S. Nazrun, P. L. Lee, M. Norliza, M. Norazlina, and N. S. Ima, “The effects of Labisia pumila var. alata on bone markers and bone calcium in a rat model of post-menopausal osteoporosis,” Journal of Ethnopharmacology, vol. 133, pp. 538–542, 2011.
  92. H. N. Rosen, A. C. Moses, J. Garber et al., “Serum CTX: a new marker of bone resorption that shows treatment effect more often than other markers because of low coefficient of variability and large changes with bisphosphonate therapy,” Calcified Tissue International, vol. 66, no. 2, pp. 100–103, 2000. View at Scopus