Menopausal Symptoms (Other Than Osteoporosis)

The hormonal changes of menopause can produce a wide variety of symptoms, ranging from hot flashes and vaginal dryness to anxiety, depression, and insomnia. Many of these symptoms are undoubtedly caused by the natural decrease in estrogen production that occurs at menopause; however, the human body is so complex that other hormonal factors also play a role.

Menopause is not a disease. It is clearly a natural process, but one that has fallen out of favor in modern society. We no longer consider it as an inevitable transition but instead regard it as a condition requiring treatment. No longer do women accept as merely part of life the decrease in libido, pain during intercourse, years of hot flashes, and other uncomfortable problems that may accompany menopause. This raises an important point: How close to nature do we want to live? One of the most valued ideals of alternative medicine is the desire to trust nature, but sometimes we may want to draw a line. For example, in a state of nature, infant and maternal mortality is high. This process of survival of the fittest helps humanity as a species to be stronger, but it is not something that a compassionate society can tolerate. Thus, no matter what our ideals, we frequently find ourselves tampering with nature. The treatment of menopause is simply one example among many.

Conventional medicine recommends the use of replacement estrogen to provide three benefits: eliminating the symptoms of menopause, protecting against osteoporosis, and maintaining the protection against cardiovascular disease that premenopausal women enjoy.

Estrogen-replacement therapy is quite effective at achieving these goals. However, like most medical treatments, it creates counterbalancing risks. The most frightening issue is the increased risk of breast cancer that appears to be associated with replacement estrogen. The decision whether to use estrogen-replacement therapy should involve a careful examination of the risks and benefits in consultation with a physician. Specially modified estrogens, such as Evista (raloxifene), appear to help osteoporosis and reduce the incidence of breast cancer, but they do not reduce symptoms of menopause.

Principal Proposed Treatments for Menopausal Symptoms (Other Than Osteoporosis):

Several natural treatments may reduce menopausal symptoms. However, we do not know for sure whether any of these reduce the risk of cardiovascular disease or osteoporosis. (See the articles on atherosclerosis and osteoporosis for natural ways to reduce the risk of these conditions.)

Soy Isoflavones: May Reduce Symptoms

Soy contains phytoestrogens called isoflavones, which appear to produce far-reaching effects in the body. The most famous of these isoflavones are genistein and daidzein. These substances, perhaps along with other constituents of soy, may be effective in reducing symptoms of menopause, but results of studies have been contradictory.

In a 12-week double-blind study of 104 women, daily doses of 60 g of soy protein significantly reduced flushing associated with menopause. A 12-week study that enrolled 114 women found evidence of benefit for hot flashes and vaginal dryness, but not for menopausal symptoms as a whole. Reduction in hot flashes was seen in two 6-week double-blind trials as well. However, a 24-week double-blind study of 69 women found no benefit with either isoflavone-rich or isoflavone-poor soy. Similarly, no benefits were seen in a 3-month trial of 94 women with mild menopausal symptoms. The very high rate of placebo effect seen in most studies of menopausal symptoms may account for these discrepancies.

Some, but not all, studies suggest that soy isoflavones may be able to help one of the most feared complications of menopause: osteoporosis. There is much stronger evidence that a semisynthetic isoflavone named ipriflavone (chemically similar to what is found in soy) helps osteoporosis, although it does not reduce menopausal symptoms.(See the articles on osteoporosis, ipriflavone, or isoflavones for more information.)

Soy appears to be protective against heart disease and breast and uterine cancer. However, there are indications that soy may not be safe for those who have already had breast cancer.

For more information, including dosage and safety issues, see the full soy article.

Black Cohosh: Widely Used in Europe for Menopausal Symptoms

Black cohosh is a tall perennial herb that was originally found in the northeastern United States. Native Americans used it mainly for womens health problems but also as a treatment for arthritis, fatigue, and snakebite. European colonists rapidly adopted the herb for similar uses.

In the late nineteenth century, black cohosh was the main ingredient in the wildly popular Lydia E. Pinkhams Vegetable Compound for menstrual cramps. Migrating across the Atlantic, black cohosh became a popular European treatment for womens problems, arthritis, and high blood pressure.

Black cohosh has been approved by Germanys Commission E for use in treating menopause. However, the evidence for this use remains highly preliminary.

In addition, one study suggests that black cohosh might improve the cholesterol profile of post-menopausal women; the same study provides very weak evidence that black cohosh might help prevent osteoporosis.

What Is the Scientific Evidence for Black Cohosh?

Only two double-blind, placebo-controlled trials of black cohosh for menopausal symptoms have been reported. The first such study produced results that are difficult to trust.

This trial followed 80 women for 12 weeks, and compared the effects of black cohosh, conjugated estrogens (0.625 mg), and placebo. The results indicated that black cohosh produced significantly greater improvements in menopausal symptoms than placebo. However, estrogen proved no better than placebo, a result so surprising that it casts serious doubt on the meaningfulness of the results. Furthermore, black cohosh was found to produce estrogen-like changes in the genital tract; as described below, it is now believed that black cohosh does not have any such actions.

At the time of this trial, black cohosh was thought to be a phytoestrogen—a plant that produces influences the body in a manner similar to estrogen. However, subsequent research has shown that black cohosh does not have typical phytoestrogenic effects. For example, a well designed double-blind study that compared two different dosages of black cohosh did not find any change in vaginal-cell appearance, or indeed any other objective measurements that would indicate an estrogen-like effect. In addition, a study in animals also failed to find any estrogenic actions of black cohosh.

There is some evidence that black cohosh might have selective estrogenic effects, meaning that it acts on some tissues (such as bone) and not others (such as the uterus) However, the evidence for such an effect is still weak, and in any case the consensus remains that black cohosh does not have estrogen-like effects on cells of either the uterus or vagina.

Thus, something appears to have gone seriously wrong in the double-blind trial described above. Some experts in the field have even speculated that researchers conducting the first trial mixed up the black cohosh and estrogen groups, or skewed the results in some other way.

If this study is dismissed, only one double-blind placebo-controlled trial supporting the use of estrogen remains, one published so far only in abstract form. This trial enrolled 97 post-menopausal women who complained of having more than three hot flashes daily. Participants were divided into the same three groups as in the first study.

The results showed that both estrogen and black cohosh improved menopausal symptoms to a greater extent than did placebo. However, while use of estrogen caused thickening of the wall of the uterus, black cohosh did not do so. This is consistent with current thinking that black cohosh is not a phytoestrogen.

This latter study is the only meaningful evidence supporting the use of black cohosh for menopausal symptoms. Several other studies are also often cited as evidence, but in reality they prove nothing at all. In these trials, all participants received black cohosh; there was no placebo group. While women reported improvements in symptoms, there is no way to know that black cohosh was responsible. Women given placebo reliably report improvements in menopausal symptoms too; a 50% reduction in hot flashes is fairly typical. Thus, it is perfectly possible that the benefits seen in these uncontrolled studies had nothing to do with black cohosh.

Putting all this information together, it is fair to say that at present there is only scant supporting evidence for the use of black cohosh in menopausal symptoms.

For more information, including dosage and safety issues, see the full black cohosh article.

Other Proposed Treatments for Menopausal Symptoms (Other Than Osteoporosis):

One double-blind placebo-controlled study suggests that cream containing the hormone progesterone (available over the counter) is effective against hot flashes. However, contrary to widespread advertising, in this trial progesterone did not offer any benefits for osteoporosis. Wild yam is widely touted as a source of progesterone; however, there is no progesterone in wild yam unless it is added to the product, and the body does not appear to be able to make progesterone out of wild yam constituents.

Highly preliminary research suggests that flaxseeds may help decrease menopausal symptoms.

Vitamin C; bioflavonoids; essential fatty acids; an extract of rice bran called gamma oryzanol; and the herbs St. Johns wort, licorice, suma, and chasteberry are sometimes used for menopause. However, there is as yet little to no scientific evidence that they are effective.

Although vitamin E is often recommended for menopausal hot flashes, there is no real evidence that it is effective. One 9-week double-blind placebo-controlled trial followed 104 women with hot flashes associated with breast cancer treatment, but it found marginal benefits at best.

Isoflavone-rich extracts of the herb red clover have been suggested as a treatment for menopausal symptoms as well, but study results are conflicting.

In a 12-week, double-blind, placebo-controlled trial of 30 postmenopausal women, use of red clover isoflavones at a dose of 80 mg daily significantly reduced hot flash symptoms as compared to placebo.

However, two other studies failed to find benefit with red clover. One, a 28-week, double-blind, placebo-controlled crossover study of 51 postmenopausal women, found no reduction in hot flashes among those given 40 mg of red clover isoflavones daily. The negative results of this trial suggest that perhaps a higher dosage is necessary. No benefits were seen in another double-blind, placebo-controlled trial, which involved 37 women given isoflavones from red clover at a dose of either 40 or 160 mg daily; though this three-way study may have involved too few women to identify a treatment effect.

Alfalfa has been investigated in the laboratory (but not yet evaluated in people) as a source of plant estrogens, which might make it helpful for menopause.

The herb dong quai is also frequently recommended for menopausal symptoms, but a recent double-blind study failed to find any effect.

Estriol: A Safer Form of Estrogen?

For over a decade, some alternative medicine practitioners have popularized the use of a special form of estrogen called estriol, claiming that, unlike standard estrogen, it doesnt increase the risk of cancer. However, this claim is unfounded.

There is no real doubt that estriol is effective. Controlled and double-blind trials have found oral or vaginal estriol effective for reducing hot flashes, night sweats, insomnia, vaginal dryness, recurrent urinary tract infections, and osteoporosis.

Estriol may cause less vaginal bleeding as a side effect than other forms of estrogen, although this has not been proven.

However, like other forms of estrogen, oral estriol stimulates the growth of uterine tissue. This leads to risk of uterine cancer.

In a placebo-controlled study of 1,110 women, uterine tissue stimulation was seen among women given estriol orally (1 to 2 mg daily) as compared to those given placebo. Another large study found that oral estriol increased the risk of uterine cancer. In another study of 48 women given estriol 1 mg twice daily, uterine tissue stimulation was seen in the majority of cases.

In contrast, a 12-month double-blind trial of oral estriol (2 mg daily) in 68 Japanese women found no effect on the uterus. It may be that the high levels of soy in the Japanese diet altered the results.

Additionally, test tube studies suggest that estriol is just as likely to cause breast cancer as any other form of estrogen.

The bottom line: If you use estriol, you should consider it like any other form of estrogen.