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Women's Health and Education Center (WHEC)

Gynecology

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Alternative and Complementary Medicine for Menopause

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

Menopause is a natural event, not a disease or pathology. The average age of menopause is 51 and with it come a lot of challenging issues. Menopause is a journey, which lasts from 3 to 10 years on average, and each woman will experience it in her own unique way. Some women appear to pass through this time with very few physiological or emotional complaints, while others will experience mild hot flashes and some emotional ups and downs. Some may become debilitated by the physical and emotional manifestations of the "change". In a culture that worships youth and beauty, this time of transition can be difficult for women who are not prepared for it. Beauty takes on many forms and definitions.

This change brings about a myriad of important health risks, many of which can be eliminated or reduced with hormone replacement therapy (HRT). Despite the benefits of HRT some women are not candidates for this treatment and many others choose not to take it. For our purposes today, the context is unconventional therapies that fall under the umbrella of what is being called "Alternative and Complementary Medicine". It comprises a very wide range of therapies, including botanical and behavioral, and other practices such as acupuncture and biofeedback. "Alternative" implies "instead of" conventional treatment, whereas "complementary" refers to something used in addition to conventional treatment. Acupuncture is licensed in about 30 states but not in others, and covered by some insurance companies. Biofeedback falls within conventional therapy for migraine but is still considered unconventional therapy for cancer.

The term "integrative medicine" helps to get away from the thinking of "us versus them". The idea is to draw on the best of what exists from around the world. To achieve better medical treatment, we may "integrate" current mainstream medical practices with other approaches. The main thing is to be open to what works best for the patients.

Asian Diets and Isoflavones:
Interest in isoflavones followed observations that Asian women, who consume more isoflavones than Western women, experience fewer menopausal symptoms. A study of menopausal Thai women, for instance, demonstrated that only 27% experience hot flashes and 24% report night sweats. In contrast, up to 85% of western women experience vasomotor symptoms. Food sources of isoflavones include soy and soy products, including tofu, and sweet potatoes, legumes, carrots, garlic, red wine, barley, green beans, oats, and pumpkin. Some studies suggest that isoflavones may confer some protection to the heart and bones. Epidemiological data provide evidence that in an isoflavones-rich diet, one of three types of Phytoestrogens (naturally occurring plant sterols that are capable of exerting effects similar to estrogen) may lower the risk of hormone related cancers. Clearly more research will be needed to determine exactly what impact phytoestrogens have on cancer risk and whether the relationship is one of direct cause and effect.

Vitamin E:
Many women report that taking 800IU of vitamin E helps reduce hot flashes and there are good clinical trials looking at this. Women with breast cancer who are undergoing treatment should probably not take Vitamin E as a report from Stockholm has found a higher incidence of treatment failure. The dose should not exceed 1000IU/day.

Botanicals Commonly used for Menopause:
In general, consumers use products as therapeutic agents for treatment and cure of diseases or to stimulate the immune system, improve sleep and as a part of our daily regimen. It is very strongly advised that these herbs or natural products should not be consumed during pregnancy and lactation. Their effects have not been scientifically studied yet, and may be harmful to mother and baby both.

Suggested uses and proposed pharmacological actions are described below.

The 10 most commonly used herbs by women around menopause are:

Herbs (Botanical Name)

Uses

Actions

Side Effects

Interactions with Other Drugs

Dosage

Mode of Admini- stration

1. Black Cohosh (Cimicifuga racemosa)

Menopausal symptoms, Dysmenorrhea

Estrogen like effect, LH suppression

Gastric Discomfort

None Known

Extracts with alcohol 40-60% corresponding to 40 mg of drug. Duration not more than 6 months.

Galenical preparation for internal use.

2. Dong Quai (Angelica sinensis)

Relief of Hot Flashes, Dysmenorrhea

Estrogenic effect, Anti- inflammatory, Anticoagulant.

Heavy Menstrual cycle

Warfarin, Estrogen, Tamoxifen

1:3 tincture is 2-4 ml three times a day, for 3-6 months

Galenical preparation for internal uses

3. Evening Primrose (Oenothera biennis)

PMS, Neurological symptoms, Multiple Sclerosis, Fibromyalgia

Stimulates Immune System, Helps fluid retention and bloating.

Headaches, Diarrhea

Anticoagulants, Epilepsy Meds and state

6-8 capsules a day, with meals

Primrose oil capsules.

4. Ginkgo (Ginkgo biloba)

Enhance Cerebral flow, Short term Memory loss, Depression, Tinnitus, Intermittent Claudication

Anticoagulant, Antiplatelet effects

Stomach and Intestinal upset, Headaches, Allergic reactions

Aspirin, Warfarin, Dipyridamole

120-240 mg native dry extract in 2-3 doses, Duration: 8 weeks to 3 months

In liquid and solid forms for oral intake

5. Ginseng (Panax ginseng)

Relief of Menopausal symptoms, Improved Stamina

Ginsenoside the main active ingredient improves resistance to stress

Mastalgia, Vaginal Bleeding, Insomnia

None known

1-2g of root; equivalent preparation up to 3 months

Cut root for teas, powder and galenical preparation for internal use

6. Garlic (Allium sativum)

Athero- sclerosis, Hypertension, GI Symptoms, Blood clot disorders

Lowers blood cholesterol, Increases "good" cholesterol HDL

In High Doses: Stomach Upset, Allergic Skin reaction

Anticoagulation Meds, Lactating Mothers

4g fresh garlic or equivalent preparation

Capsules, Caplets, and raw cloves for oral use

7. Kava kava (Piper metysticum G.)

Nervous Anxiety, Stress, and Restlessness

Anti-anxiety, Anticonvulsive, CNS relaxant, Sedation

Yellow discoloration of skin, nails, & hair. Allergic reaction, Occulomotor equilibrium disturbances

St. John's Wort, Alcohol, Barbiturates, Psychopharma-
cologic agents

Herb preparation to 60-120 mg kava pyrones per day, up to 3 months

Comminuted rhizome and other galenical preparation for oral use

8. Red Clover (Trifolium pratense L.)

Menopausal symptoms, Dysmenorrhea, Expectorant, Skin inflammation

Antispasmodic, Expectorant, Isoflavones have estrogenic effects, Antibiotic properties

None known

None known

2 capsules three times a day with meals

Capsules for internal use, Lotion or cream for skin ulceration and Eczema

9. St. John's Wort (hypericum perforatum)

Internal Use: Depressive Moods, Anxiety or nervous unrest, External Use: Injuries, Burns, Myalgias

Inhibits Serotonin reuptake, MAO inhibitor effect

Photo- sensitization, Hypertensive crisis, Serotonin Syndrome

Antidepressive meds, MAO inhibitors, Lithium, Ephedrine

Internal Uses: 2-4g of drug or 0.2-1mg of total hypericm in other forms of drug application

Chopped herb, powder, liquid, and solid preparation, for internal use. Liquid and semisolid for Ext. use.

10.Uva Uri (Bearberry) (Arcto- staphylos uva ursi)

Minor Urinary Tract Infections, Cystitis, Prostatitis

Diuretic, Antibacterial

Tinnitus, nausea, vomiting, shortness of breath, convulsions.

Any substance which causes acidic urine

Single Dose: 3g drugs to 150ml water as an infusion or 100-210mg hydroquine calculated as water free arbutum. Daily Dose: 3g drug to 150ml up to 4 times/day or 400-840mg hydroquinone derivatives

Crushed drug powder, extractions, and solid forms for oral use.

Lifestyle Modifications:

A psychophysiological basis for the occurrence of hot flashes is supported by laboratory data that showed hot flashes could be elicited readily under controlled conditions. Based on these laboratory findings, it has been suggested that acute or chronic stress and/or the effects of midlife transitions may potentiate hot flashes by decreasing the threshold for the triggering of flushing at the hypothalamic level, similar to the proposed effects of diminishing levels of estrogen. Psychological stress during a hot flash may also affect the frequency of symptoms. For example, a state of anxiety experienced during a hot flash is likely to exacerbate the frequency and symptoms of hot flashes. Reduction in hot flash intensity, anxiety, and/or depression has been reported with relaxation and psychoeducational techniques. Among various behavioral approaches, relaxation and paced respiration are some techniques that have reduced the severity and frequency of vasomotor symptoms. Paced respiration for hot flash reduction requires slow, deep abdominal breathing at symptom onset, whereas applied relaxation therapy involves the use of 8 to 12 sixty-minute sessions to learn different aspects of techniques to induce relaxation in 30 to 60 seconds when a hot flash event is triggered. Although these approaches have limited effectiveness in improving vasomotor symptoms compared with the proven efficacy of pharmacotherapy, they are likely to be more effective in women who experience comorbid stress, anxiety, or depressive symptoms that exacerbate the frequency and severity of hot flashes. A number of coping strategies and lifestyle modifications may alleviate some of the symptoms. For example, a cool environment (18 C) alone may reduce the frequency of hot flashes, particularly during those nights when hot flashes cause awakenings. It is interesting to note that women with high perceived control have better symptom management through the use of more coping strategies, such as wearing layers of clothes to speed cool-down and by maintaining a positive attitude.

A number of studies have indicated that a moderate level of physical activity may be therapeutically effective in reducing menopausal vasomotor symptoms. Women who regularly exercised reported hot flashes with reduced frequency compared with those in the control group: 21.5% vs 43.8%. Workouts such as jogging and swimming are considered as intense activities, whereas cycling and recreational walking are categorized as less intense and least intense activities, respectively. In a prospective study of 438 women, factors such as age, follicle-stimulating hormone (FSH) levels, and physical activity were compared with the occurrence of hot flashes. Results showed that the hot flash index (a combination of hot flash frequency and severity) was greater in women with higher levels of circulating FSH and decreased in relation to age and exercise levels. A number of over-the-counter plant/herbal remedies, lifestyle modifications, and coping strategies have shown some positive results in alleviating vasomotor symptoms, although the available evidence for the effectiveness of these treatments is relatively weak.

Conclusions:

Consumer use of herbs and medicinal plant products in the United States over the past two decades has become a mainstream phenomenon. The size of herb market in the USA was at about $ 1.6 billion in 1994, and by 1997 it grew to $ 4.4 billion, an average expenditure of $ 58 per person annually. No longer relegated primarily to health food stores, mail order houses, and multilevel marketing organizations, herbs and phytomedicines have become one of the fastest growing segments in retail pharmacies, supermarkets, and other mass market outlets. In addition, major health insurance companies are beginning to include herbs as covered modalities of "alternative therapies" and herb products are being considered for use by some managed care organizations.

Discuss with your health care provider if herbs or complementary medicine will be of any benefit to you in the management of your care.

Resources:

  1. World Health Organization
    Guidelines for the Regulation of Herbal Medicines in the South-East Asia Region

  2. National Institutes of Medicine (NIH)
    Clinical Trials in Alternative Medicine and Menopause

  3. National Center for Complementary and Alternative Medicine (NCCAM)
    Menopausal Symptoms and Complementary and Alternative Medicine

Suggested Reading:

  1. Newton KM, Buist DS, Keenan NL et al. Use of alternative therapies for menopause symptoms: results of a population-based survey. Obstet Gynecol 2002;100:18-25
  2. Pockaj BA, Gallagher JG, Loprinzi CL et al. Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG Trial NO1CC1. J Clin Oncol 2006;24:2836-2841
  3. Faure ED, Chantre P, Mares P. Effects of a standardized soy extract on hot flashes: a multicenter, double-blind, randomized, placebo-controlled study. Menopause 2002;9:329-334
  4. Upmalis DH, Lobo R, Bradley L et al. Vasomotor symptom relief by soy isoflavone extract tablets in postmenopausal women: a multicenter, double-blind, randomized, placebo-controlled study. Menopause 2000;7:236-242
  5. Uebellhack R, Blohmer JU, Graubaum HJ et al. Black cohosh and St. John's for climacteric complaints: a randomized trial. Obstet Gynecol 2006;107:247-255
  6. Nelson HD, Vesco KK, Haney E et al. Non-hormonal therapies for menopausal hot flashes: systemic review and meta-analysis. JAMA 2006;295:2057-2071
  7. van de Weijer PH, Barentesen R. Isoflavones from red clover (Promensil) significantly reduce menopausal hot flash symptoms compared with placebo. Maturitas 2002;42:187-193
  8. Williamson-Hughes PS, Flickinger BD, Messina MJ et al. Isoflavone supplements containing predominantly genistein reduces hot flash symptoms: a critical review of published studies. Menopause 2006;13:831-839
  9. Carmody J, Crawford S, Churshill L. A pilot study of mindfulness-based stress reduction for hot flashes. Menopause 2006;13:760-769
  10. Tremblay A, Sheeran L, Aranda SK. Psychoeducational interventions to alleviate hot flashes: a systemic review. Menopause 2008;15:193-202

Published: 23 September 2009

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