While the fluctuation and decline of reproductive hormones is a normal and expected event in mid-life women, the associated symptoms are nonetheless disruptive. Until very recently, millions of women alleviated their hot flashes and night sweats with conjugated equine estrogens and medroxyprogesterone acetate (synthetic hormone replacement therapy or HRT).
However, mounting evidence from several clinical trials has shown that women using synthetic HRT are at significant increased risk of developing breast cancer, coronary heart disease, pulmonary embolism, and stroke.
With little room for HRT in current practice and little else in the traditional medicine chest to consider, physicians are increasingly turning to natural non-hormonal therapies for women who need relief from menopausal symptoms.
As a naturopathic physician, I have used botanical medicines and other natural alternatives for many years with great success to help women create and maintain hormonal health. I've found the most effective approach combines stress management, diet, exercise and nutritional supplements to support and work with a woman's body, not against it. While each patient's treatment plan is unique, it has been my experience that most symptoms caused by menopause and/or hormone fluctuations and imbalances will respond to natural therapies.
Hot Flashes/Night Sweats
These core symptoms reflect the hypothalamic response to rapidly fluctuating and falling levels of estradiol. Hot flashes vary in severity, from a sudden sensation of warmth to acute drenching sweats and bright red flushing. Duration ranges for a few months, to a few years or not at all. By some estimates, 10-15 percent of women in menopause are awakened by night sweats throughout the night.
Black cohosh (Cimicifuga racemosa) is the most widely used and most thoroughly studied natural supplement for menopausal symptoms and has been clinically proven to reduce hot flashes and night sweats. While black cohosh's exact mechanism of action is unknown, compounds in the herb appear to bind to estrogen receptors without changing hormone levels in the body. Recent studies demonstrate black cohosh has no effect upon luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, prolactin or sex hormone binding globulin (SHBG).
A placebo-controlled, double blind study compared standardized black cohosh extract to conjugated estrogen. Women experiencing menopausal symptoms were randomized to receive black cohosh, conjugated estrogen, or placebo for three months. The participant's symptoms were assessed using the menopause rating scale (MRS) and individual diaries. The results showed that the women taking standardized black cohosh extract had clinical and statistical improvement of symptoms equal to the women taking conjugated estrogen.
No improvement of menopausal complaints was observed in the control group. (Wuttke, et al 2003).
Because black cohosh does not have estrogenic action and does not contain phytoestrogens it is safe for use in patients with a history of breast cancer. My usual recommendation is 40 mg of black cohosh daily, standardized to 2.5% triterpene glycosides, daily.
Isoflavones are compounds with both hormonal and non-hormonal properties and are considered to be phytoestrogens with selective estrogen receptor modulators (phytoSERMs). Unlike estrogen, which is not tissue selective, phytoSERMs exert estrogenic effects in desired tissues such as the heart, skeletal system, and brain, but ideally have no effects in other tissues, such as the breast. The various biologic activities of isoflavones suggest that they offer many of the beneficial effects of estrogen. Controlled trials have indicated these compounds support healthy serum cholesterol levels and support healthy bone resorption.
Soy has received attention as a dietary alternative to HRT largely because it is a unique source of isoflavones. World wide soy consumption is highest in Japan, where urinary levels of phytoestrogen metabolites are extremely high and reported frequency of hot flushes is extremely low. The majority of clinical studies examining this inverse relationship have shown soy isoflavones to significantly reduce hot flashes.
There have been some concerns about the safety of soy isoflavones in women with a history of estrogen receptor positive breast cancer. These questions stem in part from limited research that showed soy increased the growth of isolated breast cells. However, the weight of evidence shows that soy supports healthy cell growth and, therefore, most practitioners feel confident recommending soy isoflavones to their patients with a personal or family history of breast cancer.
I usually begin with 100 mg soy extract and increase to 300 mg as needed. While a decrease in hot flashes begins almost immediately, maximum benefit may not be apparent for as long as 12 weeks.
DHEA (dehydroepiandrosterone) is a steroid hormone produced in the adrenal cortex. Serum levels of DHEA decline with age, peaking at age 25 to less than 20% of peak at the 70th birthday. DHEA levels are also reduced in inflammatory diseases (rheumatoid arthritis, systemic lupus), as well as cancer and acquired immunodeficiency syndrome (AIDS). Clinical research has shown that DHEA supplementation reduces menopausal symptoms as effectively as HRT (Genazzani 2003). Most research used 25mg of DHEA per day for at least 3 to 6 months.
Mood, Energy, and Well-being
While menopause has been identified as a time of depression and irrational behavior, the data does not support this perception. Research has consistently shown that depression is much more common in women who are in their third and fourth decades, not at mid-life. There are no associated increases in suicide, suicide attempts, or psychiatric hospitalizations among menopausal women.
Energy, however, or the lack thereof, can be problematic, sometimes profoundly so. Low adrenal reserve or adrenal insufficiency can be contributing factors. Many women enter menopause with chronic nutritional depletion and sub-optimal adrenal function. In milder degrees of adrenal insufficiency and low adrenal reserve, the adrenal gland still produces sufficient hormones to maintain health.
Adrenal Extracts/Adrenal Support Supplements formulated with adrenal supportive botanicals can restore vitality, increase feelings of energy, increase mental and physical performance, and improve the body's response to stress. Adrenal polypeptide fractions provide small amounts of adrenal hormones and promote improved adrenal function.
Panax Ginseng Women experiencing lack of energy due to fluctuations or depletions in their reproductive hormone levels will benefit from Panax ginseng. A double blind, placebo controlled study of postmenopausal women showed overall symptom relief and improvement in mood and wellbeing after ginseng supplementation (Wiklund 1999). I've found great success using Ginseng Phytosome, ginkgo formulated with a patented process that results in superior absorption: one part Panax Ginseng Extract, standardized to contain 37.5% ginsenosides, bound to two parts phosphatidylcholine.
Green Tea (Camellia sinensis) Green tea is a rich source of flavonoids and polyphenols that have been studied for their support of immune system health. Green tea also contains small amounts of caffeine, which supports stamina and reduces fatigue. There is some evidence that green tea supports daily energy expenditure and may be beneficial in weight management. An effective dose for women is 250mg of Leaf Extract standardized to contain 35mg of caffeine.
Rhodiola (Rhodiola rosea) While fairly new to American practitioners, rhodiola has been used to support healthy energy levels for centuries in Russia, Scandinavia, and Iceland.
Animal research demonstrates rhodiola reduces cortisol levels and boosts adenosine triphosphate (ATP) synthesis. For women struggling with energy drain related to menopause, rhodiola may support mental concentration and alertness and support healthy endurance levels.
Chaste Tree (Vitex agnus-castus) Vitex is used for the management of menstrual disorders, premenstrual syndrome (PMS), and hot flashes in menopause. The key actives in chaste tree fruit support the pituitary gland's regulation of ovarian hormone production, directing menstruation, fertility, and other processes.
Vitex preparations have been used by women with menstrual difficulties for at least 2,500 years. And recent research has validated this history. In a double blind, multi-center study, 175 female patients were randomized to receive either chaste tree extract or pyridoxine for relief of premenstrual syndrome (PMS). Using self-report and physician assessment to determine results, the women in the Vitex group had significantly reduced breast tenderness, edema, tension, headache, constipation and depression. (Lauritzen, 1997).
Sleep and Relaxation
Hormonal fluctuations in menopause and the late-luteal phase of the menstrual cycle are known to interfere with sleep quality. Researchers now believe that lack of sleep in menopausal women may account for much of the irritability and emotional ups and downs usually blamed on hormonal changes.
Valerian (Valeriana officinalis) has been clinically studied for the relief of insomnia and stress, and works well combined with hops when taken at bedtime. The active ingredient has yet to be clearly identified. While valerian's disagreeable smelling volatile oil was initially thought to be responsible for its sleep supportive effects, research now indicates a combination of volatile oil and other constituents may be involved.
Valerian improves several sleep measurements, including sleep latency, final wake time after sleep, waking frequency, and sleep quality. While it has an excellent safety profile, the presence of vivid dreams has been reported with initiation of valerian use.
L-theanine a naturally occurring amino acid found in tea leaves, has demonstrated wide-ranging physiological activity, from supporting healthy blood pressure to supporting the therapeutic activity of chemotherapeutic drugs. It does not cause daytime drowsiness, an important consideration for women with existing energy and endurance deficits.
Wiklund IK, Mattsson LA, Lindgren R, Limoni C. Effects of a standardized ginseng extract on quality of life and standardized physiological parameters in symptomatic postmenopausal women: a double-blind, placebo-controlled trial. Swedish Alternative Medicine Group. Int J Clin Pharmacol Res. 1999;19:89-99.
Wuttke W, Seidlova-Wuttke D, Gorkow C. The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers. Maturitas. 2003;44:S67-77.
Shevtsov VA, Zholus BI, Shervarly VI, et al. A randomized trial of two different doses of a SHR-5 Rhodiola rosea extract versus placebo and control of capacity for mental work. Phytomedicine. 2003;10:95-105.
Lauritzen CL. Treatment of Premenstrual Tension Syndrome with Vitex agnus-castus - Controlled, double blind study Versus Pyridoxine. Phytomedicine, 1997 4(3):183-189.
Genazzani AD, Stomati M, Bernardi F, Pieri M, Rovati L, Genazzani AR. Long-term low-dose dehydroepiandrosterone oral supplementation in early and late postmenopausal women modulates endocrine parameters and synthesis of neuroactive steroids. Fertil Steril. 2003;80:1495-501.