December 2024

In this VETgirl online veterinary continuing education blog, Dr. Justine Lee, DACVECC, DABT talks about her personal problem with supplements… after developing a hepatopathy from one! In a previous VETgirl menopause blog, I wrote about the top 5 things that helped me personally during my perimenopause to menopause journey. If you haven’t read my first blog about perimenopause and what you need to know, check it out here. Follow it up with these top 5 things that will help during menopause (because if you’re cutting cases under surgical lights, you’ll definitely need this neck fan!); however, now I’m going to recant and NO LONGER recommend the organic ashwagandha!

By Dr. Justine Lee, DACVECC, DABT
Director of Medicine / CEO, VETgirl

Personally Dealing with a Hepatopathy from Supplements

Okay, this VETgirl blog is about to get real and personal, and it’s likely a bit TMI (too much information!), but I’m going to share anyway!

Several months ago, I was dealing with some health issues. Over the summer, I started having chest pain, right over a 2X2″ area over my xiphoid. Initially, I thought my sports bra shrunk in the laundry, and made no big deal out of it. But after a few days, I realized it truly was chest pain. Aha! Maybe it’s heartburn? While I hadn’t normally had to deal with this (except during my 3rd trimester of pregnancy), it felt similar. So, I self-medicated like any good veterinarian would do and put myself on whatever leftover antacid we had in the pantry – famotidine. After a few days with no improvement, I may have started sucralfate (1 gram orally every 8 hours) from the clinic. After all, I did have a self-diagnosed stress ulcer 30 years ago during my 100-hour a week internship at Angell! (They have since dramatically changed things up to improve work-life balance there!). What the heck, I’ll add in Tums (calcium carbonate) too while I’m polypharmacy’ing.

A week later, I found myself in urgent care. The chest/sternal pain was bad enough that it was pretty constant and uncomfortable, especially when I was exercising and doing downward dog motions. I was presumptively diagnosed with a “gastritis” and changed to a proton-pump inhibitor (PPI) (since we all know H2-blockers don’t work as well as PPI’s, doh!). So, I found myself on twice-a-day omeprazole for a few weeks, then once-a-day omeprazole for a few more weeks.

A month later, I found myself in the ER. OK, now I’m really bad and my symptoms are much worse. I felt like I had gastric stasis and gastric distension. I felt like a bloated, tachypneic, tachycardiac Labrador retriever who food bloated. The good news? When you go into the ER complaining of chest pain, you get triaged and worked up really quickly. After more blood work, d-dimers, 12-lead ECG, chest rads, and urgent esophagogastroduodenoscopy (EGD) under sedation, I felt like I was on the path towards a more appropriate medical work-up. But the problem? By the time I had all this work up, my biopsies were normal (after all, it had been 8 weeks since my clinical signs developed and now I’ve been medicated with 40,000 grams of sucralfate, 2 bottles of calcium carbonate, 2 months of a PPI, and 1 month of aluminum hydroxide)! Unfortunately, despite all this, including many an ultrasound, full body CT, and 9+ tubes of blood, we were back to square 1 as I still wasn’t feeling much better. During this entire 2-month period, I had changed my diet dramatically (to minimize GERD and gastritis) and even tried dietary trials to see if that helped (e.g., lactose, celiac, etc.). I even tried a chiropractor in case it was chondritis or a rib issue!

What did I learn during these two months of feeling terribly ADR?

Four things. First, while I am very faith-based, it truly made me deal with mortality. Having lost several amazing veterinarians in my life in the previous few months (including my amazing mentor, Dr. Kathy Gloyd to pancreatic cancer and Dr. Stu Nelson, my sled dog chief vet to an acute heart attack), I realized I’m getting old and have a higher risk of neoplasia.

Second thing I learned? You truly have to be your own health care advocate. If I didn’t push for additional work-up and testing, I still would have been treated for GERD and gastritis with no improvement. Despite multiple physical examinations, I had to reiterate that the pain felt like visceral pain and convince the medical team that it wasn’t musculoskeletal, intercostal, chondritis, heartburn, GERD, etc. I had to adamantly tell my doctor that it was visceral and “under” my xiphoid. Apparently I’m very “sensitive” to organomegaly. When in doubt, use your veterinarian detective skills and push for further diagnostic work if you feel like something “ain’t right.”

Third, beware supplements… Now don’t get me wrong. I’m all for evidence-based medicine and quality assurance. I use several veterinary supplements with my both my dogs (including a pre-probiotic, joint supplement, etc.) from veterinary companies that I trust implicitly (due to research and evidence). But having worked with a previous company where I helped with adverse event (AE) reporting (for both human and veterinary products), I also know that the FDA does NOT regulate supplements compared to drugs, pharmacologic agents, or anything that is systemically absorbed!

As you know from previous blogs, as I was navigating peri-menopause and menopause, I turned to dietary supplements as a natural remedy to alleviate symptoms. Based on some research, I turned to ashwagandha and black cohosh, touted for their menopause-relieving and stress-relieving properties, seemed promising. I had even told my medical doctor 2 years ago that it really resolved a lot of my symptoms, including hot flashes, irritability, and insomnia (for about 6 months, until my signs worsened and required HRT).

Well, turns out, my “GERD/gastritis” was all from presumptive hepatomegaly secondary to these supplements, which I had been on for approximately 1.5 years. Yup, that’s right.  Every. Single. Day (mixed in my kale-Greek yogurt-nut-banana shake!). My liver was so enlarged on CT that it was pushing up on my diaphragm, causing chest pain, gastric stasis and distension, and resulting in all of my clinical signs. After being off ashwagandha for 2 months (during my dietary trial), my clinical signs FINALLY resolved.

Not my liver, since it’s on a table, but that’s a pretty BIG liver. Image by Hans from Pixabay

What I learned? The critical importance of understanding potential supplement risks based off a recent study entitled “Estimated Exposure to 6 Potentially Hepatotoxic Botanicals in US Adults” published in Journal of the American Medical Association (JAMA), where Likhitsup et al retrospectively evaluated 9,685 adults; of these, 4.7% of US adults had been exposed to six potentially hepatotoxic botanicals:

  • Turmeric
  • Green Tea Extract
  • Ashwagandha
  • Garcinia Cambogia
  • Red Yeast Rice
  • Black Cohosh
Ashwa Gandha organic image

BOO. The incriminating supplement that resulted in my presumptive hepatopathy!

This study analyzed nationally representative data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative, cross-sectional survey of the general US population. Prescription drug and HDS exposure data in the past 30 days were analyzed, and 2020 US Census data were used for population estimates. Data were analyzed July 1, 2023, to February 1, 2024.

The study highlighted that users of these botanicals were typically older, more educated, and more likely to have arthritis than non-users. In other words, those who are undergoing menopause like me and looking at Dr. Google for some solutions!

Fourth? Even human medicine makes mistakes.
When I got my last abdominal ultrasound back, I had mixed feelings. YEAH! My liver size is back to normal! BOO! The report said I had a cholecystotomy and that a gall bladder was absent as consistent with a cholyecystotomy… and being that I was watching my ultrasound, I know I definitely saw a big gall bladder present. Just sayin’…

At any rate, the good news is I’m back to normal health and after extensive work up, there’s no evidence of cancer or bad news! The bad news is that all my symptoms were likely iatrogenic from my choice of supplements. It’s imperative that we realized that ANY drug, diet, supplement or chemical can potentially result in adverse effects (such as hepatotoxicity). In the United States, supplements are unregulated by the FDA, and rarely if ever monitored for adverse effects. As veterinary professionals, we should ALWAYS include supplement history in patient history collection, and remain informed on potential interactions and risks.

So, I know I previously recommended the use of ashwagandha as a perimenopause supplement, but I now recant that based on my own personal journey with developing presumptive adverse reactions from it.

When in doubt, be healthy and safe. Take care of yourself. Prioritize your health. And be a good client advocate for yourself and your loved ones!

Disclaimer: This blog is for informational purposes only. Always seek professional advice before making medical decisions.


  1. Thank you so much for sharing! I am entering my 40th year of life and personal experiences like this are very relatable. I am glad you are better and advocate for yourself!

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