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Menopause

Also indexed as: Change of Life, Climacteric, Hot Flashes/Flushes

Menopause is the cessation of the monthly female menstrual cycle. Women who have not had a menstrual period for a year are considered postmenopausal. Most commonly, menopause takes place when a women is in her late forties or early fifties. Women who have gone through menopause are no longer fertile. Menopause is not a disease and cannot be prevented.

Many hormonal changes occur during menopause. Primarily as a result of decreases in estrogen, postmenopausal women are at higher risk of heart disease and osteoporosis.

Checklist for Menopause

Rating Nutritional Supplements Herbs
3Stars Soy Black cohosh
2Stars Progesterone Kava (take only under medical supervision.)
1Star DHEA
Flavonoids (hesperidin)
Vitamin C
Vitamin E		 Alfalfa
Asian ginseng
Blue vervain (Verbena hastata)
Burdock
Dong quai
Licorice
Motherwort
Red clover
Sage
St. John’s wort
Wild yam
See also:  Homeopathic Remedies for Menopause
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of menopause? Several unpleasant symptoms may accompany menopause. Some, such as vaginal dryness, result from the lack of estrogen. Others, such as hot flashes and decreased sex drive, are caused by more complex hormonal changes. Some women experience depression, anxiety, or insomnia during menopause.

Conventional treatment options: The most common drug treatment for symptoms of menopause is hormone replacement therapy. This includes an estrogen, either conjugated estrogen (e.g., Premarin®), estradiol (e.g., Estrace®, Estraderm®), or ethinyl estradiol (e.g., Alesse®), and a progestin (e.g., Provera®). Some prescriptions contain both estrogens and progestins in a single tablet (e.g., Prempro®, Premphase®).

Dietary changes that may be helpful: Soybeans contain compounds called phytoestrogens that are related in structure to estrogen, though some reports show soy’s estrogenic activity to be quite weak.1 Soy is known to affect the menstrual cycle in premenopausal women.2 Societies with high consumption of soy products have a low incidence of hot flashes during menopause.3

In one double-blind trial, supplementation with 60 grams of soy protein caused a 33% decrease in the number of hot flashes after four weeks and a 45% reduction after 12 weeks.4 However, in further analysis of the data in this trial, researchers credit constituents in soybeans other than phytoestrogens for the therapeutic effect.5 In one controlled clinical trial, high intake of phytoestrogens from soy and flaxseed reduced both hot flashes and vaginal dryness; however, much (though not all) of the benefit was also seen in the control group.6

As a result of these studies, doctors often recommend that women experiencing menopausal symptoms eat tofu, soy milk, tempeh, roasted soy nuts, and other soy-based sources of phytoestrogens. Soy sauce contains very little phytoestrogen content, and many processed foods made from soybean concentrates have insignificant levels of phytoestrogens. Supplements containing isoflavones extracted from soy are commercially available, and flaxseed (as opposed to flaxseed oil) is also a good source of phytoestrogens.

Lifestyle changes that may be helpful: Sedentary women are more likely to have moderate or severe hot flashes compared with women who exercise.7 8 In one trial, menopausal symptoms were reduced immediately after aerobic exercise.9

Cigarette smoking may be related to hot flashes in menopausal women. Preliminary data have shown that women who experience hot flashes are more likely to be smokers.10 Another preliminary study found that new users of hormone replacement therapy for the relief of menopausal symptoms were more likely to be current cigarette smokers than were those who had never smoked.11

Nutritional supplements that may be helpful: Many years ago, researchers studied the effects of vitamin E supplementation in reducing symptoms of menopause. Most,12 13 14 15 16 but not all,17 studies found vitamin E to be helpful. Many doctors suggest that women going through menopause take 800 IU per day of vitamin E for a trial period of at least three months to see if symptoms are reduced. If helpful, this amount may be continued. Using lower amounts for less time has led to statistically significant changes, but only marginal clinical improvement.18

In 1964, a preliminary trial reported that 1,200 mg each of vitamin C and the flavonoid, hesperidin, taken over the course of the day helped relieve hot flashes.19 Although placebo effects are strong in women with hot flashes, other treatments used in that trial failed to act as effectively as the flavonoid/vitamin C combination. Since then, researchers have not explored the effects of flavonoids or vitamin C in women with menopausal symptoms.

The mineral boron is known to affect estrogen metabolism. In one double-blind trial using 2.5 mg of boron per day for two months, hot flashes and night sweats worsened in 21 of 43 women, but the same symptoms improved in ten others.20 Women who are experiencing hot flashes or night sweats that have been diagnosed as menopausal symptoms and who are also supplementing boron (sometimes found in significant amounts in osteoporosis formulas and multivitamin-mineral supplements) should consider discontinuing use of boron-containing supplements to see if the severity of their symptoms is reduced.

Aging in women is characterized by a progressive decline in blood DHEA (dehydroepiandrosterone) and DHEA-sulfate (DHEAS) levels. These levels can be restored with DHEA supplementation. This process also improves the response of some brain chemicals, called endorphins, to certain drugs.21 These endorphins are involved in sensations of pleasure and pain; improving their response may explain why DHEA has an effect on mood symptoms associated with menopause. In one double-blind trial, however, menopausal women who took 50 mg of DHEA per day for three months had no improvement in symptoms compared with women taking placebo.22 Further study is needed to validate a role for DHEA in the management of menopausal symptoms.

Natural progesterone supplementation has been anecdotally linked to reduction in symptoms of menopause.23 24 25 In one trial, natural progesterone was found to have no independent effect on symptoms, and synthetic progestins were found to increase breast tenderness.26 However, a double-blind trial found that topical administration of natural progesterone cream led to a reduction in hot flashes in 83% of women, compared with improvement in only 19% of those given placebo.27 Preliminary research has found that oral, micronized progesterone therapy is associated with improved quality of life among postmenopausal women. However, oral micronized progesterone is available only by prescription in the United States.28 Hot flashes, anxiety, depression, sleep problems, and sexual functioning were among the symptoms improved in a majority of women surveyed. Synthetic progestins, also available only by prescription, have reduced symptoms of menopause.29 30 31

Progesterone is a hormone and, as such, concerns about its inappropriate use (i.e., as an over-the-counter supplement) have been raised. The amount of progesterone in commercially available creams varies widely, and the progesterone content is not listed on the label because the creams are legally regulated as cosmetics, not dietary supplements. Therefore, a physician should be consulted before using these hormone-containing creams as supplements. Although few side effects have been associated with topical progesterone creams, skin reactions may occur in some users. Effects of natural progesterone on breast cancer risk remain unclear; research has suggested both increased and reduced risk.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Double-blind trials support the usefulness of black cohosh for women with hot flashes associated with menopause.32 A review of eight trials concluded black cohosh to be both safe and effective.33 Many doctors recommend 20 mg of a highly concentrated extract taken twice per day; 2–4 ml of tincture three times per day may also be used.

In a double-blind trial, a standardized kava extract was found to be effective at reducing anxiety and other symptoms associated with menopause (see warning in this section).34 The study used 100 mg of kava extract standardized to contain 70% kava-lactones, three times per day. Most commercially available kava extracts contain up to 35% kava-lactones.

Warning: Reports from late 2001 have indicated that kava may be associated with liver damage.35 36 37 38 39 Until additional information clarifies the extent of the risk involved, it is strongly recommended that all individuals consult their physician before taking kava. In addition, based on the available information, it seems that people with liver disease and those taking medications that have the potential to damage the liver should not take kava.

A variety of herbs with weak estrogen-like actions similar to the effects of soy have traditionally been used for women with menopausal symptoms.40 These herbs include licorice, alfalfa, and red clover. In a double-blind trial, a formula containing tinctures of licorice, burdock, dong quai, wild yam, and motherwort (30 drops three times daily) was found to reduce symptoms of menopause.41 No effects on hormone levels were detected in this study. In a separate double-blind trial, supplementation with dong quai (4.5 grams three times daily in capsules), had no effect on menopausal symptoms or hormone levels.42 A double-blind trial using a standardized extract of subterranean clover (Trifolium subterraneum), a relative of red clover, containing 40 mg isoflavones per tablet did not impact symptoms of menopause, such as hot flashes, though it did improve function of the arteries.43

Sage may reduce excessive perspiration due to menopausal hot flashes during the day or at night.44 It is believed this is because sage directly decreases production of sweat. This is based on traditional herbal prescribing and has not been evaluated in clinical studies

Blue vervain (Verbene hastata) is a traditional herb for menopause; however, there is no research to validate this use. Tincture has been recommended at an amount of 5–10 ml three times per day.

Preliminary evidence suggests that supplementation with St. John’s wort extract (300 mg three times daily for 12 weeks) may improve psychological symptoms, including sexual well-being, in menopausal women.45

A double-blind trial found that Asian ginseng (200 mg per day of standardized extract) helped alleviate psychological symptoms of menopause, such as depression and anxiety, but did not decrease physical symptoms, such as hot flashes or sexual dysfunction, in postmenopausal women who had not been treated with hormones.46

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Acupuncture may be helpful in the treatment of menopausal symptoms. Animal research suggests that acupuncture may help normalize some biochemical changes that are associated with menopausal disturbances of memory, mood, and other functions.47 One preliminary trial in humans demonstrated a significant reduction (more than 50%) in hot flashes in menopausal women receiving either electroacupuncture (acupuncture with electrical stimulation) or superficial acupuncture (shallow needle insertion).48 Other preliminary trials support these results49 50 and suggest additional menopausal symptoms may also respond to acupuncture.51 However, no placebo-controlled trials have been done to conclusively prove the effectiveness of acupuncture for menopausal symptoms.

References:

1. Baird DD, Umbach DM, Landsedell L, et al. Dietary intervention study to assess estrogenicity of dietary soy among postmenopausal women. J Clin Endocrinol Metab 1995;80:1685–90.

2. Cassidy A, Bingham S, Setchell KDR. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clin Nutr 1994;60:333–40.

3. Knight DC, Eden JA. A review of the clinical effects of phytoestrogens. Obstet Gynecol 1996;87:897–904 [review].

4. Albertazzi P, Pansini F, Bonaccorsi G, et al. The effect of dietary soy supplementation on hot flushes. Obstet Gynecol 1998;91:6–11.

5. Albertazzi P, Pansini F, Bottazzi G, et al. Dietary soy supplementation and phytoestrogen levels. Obstet Gynecol 1999;94:229–31.

6. Brezinski A, Adlercreutz H, Shaoul R, et al. Short-term effects of phytoestrogen-rich diet on postmenopausal women. Menopause 1997;4:89–94.

7. Ivarsson T, Spetz AC, Hammar M. Physical exercise and vasomotor symptoms in postmenopausal women. Mauritas 1998;29:139–46.

8. Hammar M, Berg G, Lindgren R. Does physical exercise influence the frequency of postmenopausal hot flushes? Acta Obstet Gynecol Scand 1990;69:409–12.

9. Slaven L, Lee C. Mood and symptom reporting among middle-aged women: the relationship between menopausal status, hormone replacement therapy, and exercise participation. Health Psychol 1997;16:203–8.

10. Staropoli CA, Flaws JA, Bush TL, Moulton AW. Predictors of menopausal hot flashes. J Womens Health 1998;7:1149–55.

11. Greenberg G, Thompson SG, Meade TW. Relation between cigarette smoking and use of hormonal replacement therapy for menopausal symptoms. J Epidemiol Community Health 1987;41:26–9.

12. Perloff WH. Treatment of the menopause. Am J Obstet Gynecol 1949;58:684–94.

13. Gozan HA. The use of vitamin E in treatment of the menopause. NY State J Med 1952;52:1289.

14. Christy CJ. Vitamin E in menopause: Preliminary report of experimental and clinical study. Am J Obstet Gynecol 1945:50:84.

15. Finkler RS. The effect of vitamin E in the menopause. J Clin Endocrinol Metab 1949;9:89–94.

16. Rubenstein BB. Vitamin E diminishes the vasomotor symptoms of menopause. Fed Proc 1948;7:106 [abstract].

17. Blatt MHG, Weisbader H, Kupperman HS. Vitamin E and climacteric syndrome: failure of effective control as measured by menopausal index. Arch Intern Med 1953;91:792–9.

18. Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol 1998;16:495–500.

19. CJ Smith. Non-hormonal control of vaso-motor flushing in menopausal patients. Chicago Med 1964;67:193–5.

20. Nielsen FH, Penland JG. Boron supplementation of per-menopausal women affects boron metabolism and indices associated with macromineral metabolism, hormonal status and immune function. J Trace Elements Exp Med 1999;12:251–61.

21. Stomati M, Rubino S, Spinetti A, et al. Endocrine, neuroendocrine and behavioral effects of oral dehydroepiandrosterone sulfate supplementation in postmenopausal women. Gynecol Endocrinol 1999;13:15–25.

22. Barnhart KT, Freeman E, Grisso JA, et al. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life. J Clin Endocrinol Metab 1999;84:3896–902.

23. Lee JR. Natural Progesterone. The multiple roles of a remarkable hormone. Sebastipol, CA: BLL Publishing, 1993, 31–7.

24. Gaby AR. Commentary. Nutr Healing 1996;June:1,10–1.

25. Wright JV. Hormones for menopause. Nutr Healing 1996;June:1–2,9.

26. Greendale GA, Reboussin BA, Hogan P, et al. Symptom relief and side effects of postmenopausal hormones: results from the Postmenopausal Estrogen/Progestin Interventions Trial. Obstet Gynecol 1998;92:982–8.

27. Leonetti HB, Long S, Anasti JM. Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstet Gynecol 1999;94:225–8.

28. Fitzpatrick LA, Pace C, Wiita B. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. J Women’s Health Gender-Based Med 2000;9:381–7.

29. Bullock JL, Massey FM, Gambrell RD Jr. Use of medroxyprogesterone acetate to prevent menopausal symptoms. Obstet Gynecol 1975;46:165–8.

30. Morrison JC, Martin DC, Blair RA, et al. The use of medroxyprogesterone acetate for relief of climateric symptoms. Am J Obstet Gynecol 1980 138:99–104.

31. Schiff I, Tulchinsky D, Cramer D, Ryan KJ. Oral medroxyprogesterone in the treatment of postmenopausal symptoms. JAMA 1980;244:1443–5.

32. Liske E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecological disorders. Advances Therapy 1998;15:45–53.

33. Lieberman S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause. J Womens Health 1998;7:525–9.

34. Warnecke G. Psychosomatic dysfunctions in the female climacteric. Clinical effectiveness and tolerance of kava extract WS 1490. Fortschr Med 1991;119–22 [in German].

35. Stafford, Ned. Germany may ban kava kava herbal supplement. Reuters, Nov. 19, 2001. http://www.reutershealth.com/frame2/eline.html

36. Escher M, Desmeules J, Giostra E, Mentha G. Hepatitis associated with kava, a herbal remedy for anxiety. BMJ 2001;322:139.

37. Kraft M, Spahn TW, Menzel J, et al. [Fulminant liver failure after administration of the herbal antidepressant Kava-Kava.] Dtsch Med Wochenschr 2001;126:970–2 [in German].

38. Strahl S, Ehret V, Dahm HH, Maier KP. [Necrotizing hepatitis after taking herbal remedies.] Dtsch Med Wochenschr 1998;123:1410–4 [in German].

39. Russmann S, Lauterburg BH, Helbling A. Kava hepatotoxicity. Ann Intern Med 2001;135:68–9 [letter].

40. Crawford AM. The Herbal Menopause Book. Freedom, CA: Crossing Press, 1996.

41. Hudson TS, Standish L, Breed C, et al. Clinical and endocrinological effects of a menopausal botanical formula. J Naturopathic Med 1997;7(1):73–7.

42. Hirata JD, Swiersz LM, Zell B, et al. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril 1997;68:981–6.

43. Nestel PJ, Pomeroy S, Kay S, et al. Isoflavones from red clover improve systemic arterial compliance but not plasma lipids in menopausal women. J Clin Endocrinol Metab 1999;84:895–8.

44. Duke JA. CRC Handbook of Medicinal Herbs. Boca Raton, FL: CRC Press, 1985, 420–1 [review].

45. Grube B, Walper A, Wheatley D. St. John’s Wort extract: efficacy for menopausal symptoms of psychological origin. Adv Ther 1999;16:177–86.

46. Wiklund IK, Mattson LA, Lindgren R, et al. Effects of a standardized ginseng extract on quality of life and psychological parameters in symptomatic postmenopausal women: a double-blind, placebo-controlled trial. Int J Clin Pharm Res 1999;19:89–99.

47. Toriizuka K, Okumura M, Iijima K, et al. Acupuncture inhibits the decrease in brain catecholamine contents and the impairment of passive avoidance task in ovariectomized mice. Acupunct Electrother Res 1999;24:45–57.

48. Wyon Y, Lindgren R, Hammar M, Lundeberg T. Acupuncture against climacteric disorders? Lower number of symptoms after menopause. Lakartidningen 1994;91:2318–22 [in Swedish].

49. Popivanov P. Menopausal indices as criteria for the effectiveness of acupuncture treatment of the climacteric syndrome. Vutr Boles 1983;22:110–3 [in Bulgarian].

50. Kraft K, Coulon S. Effect of a standardized acupuncture treatment on complaints, blood pressure and serum lipids of hypertensive, postmenopausal women. A randomized, controlled clinical study. Forsch Komplementarmed 1999;6:74–9 [in German].

51. Lianzhong W, Xin Z. 300 cases of menopausal syndrome treated by acupuncture. J Trad Chin Med 1998;18:259–62.