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Alternative Treatments for Menopause

by Margaret Polaneczky, MD

Introduction

If you are an American woman, the odds are that you have tried some form of alternative medical treatment. In 1997, close to half of all women reported visiting an alternative medicine provider, and during that year, spending on alternative treatments in the United States totaled over 27 billion dollars.

For some women, alternative therapy is a “natural” for menopause.  After all, menopause is not a disease—it’s a life process that all women who reach a certain age will experience. Why not embrace it and use natural methods for dealing with its annoyances and inconveniences? Certain women cannot use more conventional hormonal approaches, particularly those with a personal history of breast cancer. For others, concerns about the potential risks of hormone replacement lead them to seek alternative solutions.

Whatever your reason, it’s wise not to embark on any treatment regimen, alternative or otherwise, without being well informed. “Natural” is not always synonymous with “safe.” For many alternative treatments, little or no evidence of their efficacy and safety exist. The FDA does not regulate supplements or herbs, so there are no guarantees that what’s on the label is what’s in the bottle. The term “buyer beware” has never been so applicable as in the field of complementary-alternative medicine (or CAM). Quacks and charlatans still exist. In general, beware anyone promising instant relief or miraculous cures—these are so rare as to be nonexistent.

However, some alternative medical therapies do hold promise, and in some cases may be as effective as conventional therapies. The good news is that mainstream medicine is hearing the wake-up call from the American public. The NIH has established an Office of Complementary Medicine with a budget of $68 million dollars. And more and more mainstream providers are beginning to use alternative regimens as part of overall patient care. However, not all physicians are well informed on this topic, so be prepared to do a little self-education. Hopefully, your physician will be willing to work hand-in-hand with you or your alternative medicine provider, as long as the treatments you are using are safe.

In this article, I’ve summarized those treatments that have either been shown to be effective or hold promise in the treatment of menopause. I’ll also point out those treatments that you may have heard about that are either unsafe or ineffective.
 

Simple Tricks for Managing Hot Flashes

There is one important fact you need to know before evaluating any treatment for hot flashes, alternative or otherwise. Hot flashes are diminished by almost any treatment offered to patients, including a placebo (substance containing no medication). In fact, placebo treatment can decrease hot flashes as much as 30 to 50 percent.  Thus, any treatment, alternative or otherwise, will most likely work, at least to a degree.  In order to prove a treatment effective, it must go through a randomized double-blind study. This means that in a tested population, some women will get the real treatment and some will receive a placebo, and no one in the study will know which one they are getting. In this way, the actual effectiveness of the treatment can be determined. As you will see, many of the alternative regimens have not been tested in this rigorous fashion.

Although we’ll be talking about various remedies to prevent hot flashes, there are some simple things you can do right away.

Simple solutions
First, try to remember that hot flashes are a natural phenomenon, and are harmless in and of themselves. Some women like to call them “power surges.” Wear layers so you can remove the outer clothing if you begin to feel the heat. Loose-fitting, cotton clothing is best. Keep a fan at your desk and use it when you feel hot while your office mates are not. Splash your face and hands with cold water. Stay well hydrated, and drink ice-cold water when a flash comes on. Get regular exercise and keep regular sleeping hours. Find out if certain foods trigger a hot flash for you, and avoid them. The usual suspects are alcohol (red wine is notorious), spicy foods, and caffeine.

Exercise
When most women think of nonhormonal approaches to menopause, they think of herbs and nutritional supplements.  However, probably the best nonhormonal approach for all the symptoms of menopause is physical activity. It’s been well researched, it’s safe and it’s effective.

One of the consequences of aging is a slowing metabolism. I can’t tell you how many menopausal women have come to me saying, “I haven’t changed a thing—I’m eating the same and exercising the same, but I’m still gaining weight.”  My answer: “Of course you are.”  Unless you eat less and exercise more, you will gain weight and lose muscle mass to boot. Menopause is associated with a shift of body fat from the hips to the middle, a fat redistribution linked with increased cardiac disease risk. Weight training can help prevent this change—estrogen also appears to be important.

The benefits of exercise are multiple—it  maintains and even increases bone mass as we age. It lowers cholesterol. Those who are active and have lower calorie intake (especially fat calories), live longer and maintain vigor much longer into old age than those who are sedentary. Exercise can be thought of as prevention for breast cancer, given that obesity is one of its risk factors. The endorphin release associated with regular exercise can also help battle the mood swings and depression some women experience during this time of life.

It’s important that your exercise regimen be frequent (at least five days per week) and long enough (at least 30 minutes). Strength training is critical to maintaining muscle mass and preventing bone loss. Strength training is best done with weights rather than machines, so you don’t need to join an expensive gym. A set of hand weights will do the trick. You will need your doctor’s approval before embarking on an exercise program, and may need to limit your exercise if you have any particular orthopedic problems.

The National Menopause Society recommends the book “Strong Women Stay Young,” as a great beginning for women interested in adding strength training to their exercise regimen, and so do I.
 

Calcium and Vitamin D

Whether you are taking estrogen or not, calcium is critical to maintaining a healthy bone mass. Calcium alone, however, is not enough. Adequate vitamin D is important, as is weight-bearing exercise.

Recommended daily doses are 1000 milligrams of elemental calcium if you are taking estrogen and 1500 milligrams if you are not. Calcium can only be absorbed 500 milligrams at a time, so you need to split the dose during the day, usually with meals. Good dietary sources of calcium are milk, cottage cheese, yogurt, broccoli, collard greens, sardines, and calcium-supplemented orange juice. The recommended dose of vitamin D is 400–800 IU daily.
 

Phytoestrogens and Soy

Probably the most promising alternative treatments for menopause are the phytoestrogens. Phytoestrogens are plant sterols with weak, estrogen-like activity. Phytoestrogens bind to estrogen receptors in the body, acting in some areas as estrogens, and inhibiting estrogen’s action in others.

There are two main groups of phytoestrogens: lignans (found in flaxseed oil) and isoflavones (found in soy, chickpeas, and other legumes). Whole grains, dried beans and peas, vegetables, and fruits also contain phytoestrogens, but in lesser amounts.

The initial interest in phytoestrogens stemmed from data that showed that women from Japan and other Eastern countries, who typically eat a diet rich in soy, report fewer menopausal symptoms, have less osteoporosis, and experience lower rates of breast and endometrial cancer. More recent detailed dietary studies confirm that it is the lifelong intake of soy and isoflavones that imparts many of the bone benefits to these women. Studies show that women without breast cancer have higher urinary isoflavones than women with breast cancer, suggesting that isoflavones may protect against it.

More recent studies have focused on the use of specific isoflavones for treatment of menopausal symptoms and prevention of bone loss, breast cancer, and cardiovascular disease. The ideal dose of isoflavones has yet to be pinpointed, and may in fact vary according to the effect one wishes to achieve. Because the soy content of food varies considerably, the appropriate dietary recommendations have also not yet been defined.

Isoflavones and hot flashes
In general, isoflavones appear to reduce hot flashes, although they are not as effective as estrogen. One study found that daily intake of 60 grams of soy protein over 12 weeks reduced hot flashes by 45 percent, compared to 30 percent with a placebo. Based on this data, I recommend 60 grams of soy protein to my patients. This amount can be difficult to obtain in soy foods alone and most patients resort to shakes or supplements. Be careful, because soy has calories. Be sure to read labels—not all soy products and foods are equivalent.

Promensil
Promensil is an extract of red-clover containing 40 milligrams of isoflavones that has been well-studied by its manufacturer, although the data have not appeared in scientific publications nor have they been evaluated by the FDA. A 50 percent reduction in hot flashes was reported in the manufacturer’s study, which did not employ a placebo control. It reported a 50 percent reduction in hot flashes, and their safety studies suggest that doses as high as four tablets daily carry no risk other than occasional mild stomach upset. Promensil use did not cause endometrial growth or vaginal bleeding, but data were limited to three months of use. The recommended dose is one tablet daily.

Ipriflavone and osteoporosis
Several reliable Japanese and European studies show ipriflavone , another isoflavone, to be an effective treatment for menopausal bone loss. One study of 60 postmenopausal women with pre-existing bone loss found that taking a dose of 600 milligrams per day of ipriflavone was more effective in preventing bone loss than taking calcium alone. An Italian study compared women who ingested 200 milligrams of ipriflavone taken three times daily, to patients who were taking calcium alone. Women taking ipriflavone maintained their bone mass, while those taking calcium continued to decline. By measuring levels of urinary hydroxyproline, researchers showed that ipriflavone probably exerts its effects by slowing down bone turnover. A different Italian study found that 600 milligrams of ipriflavone can be combined with lower-than-usual estrogen doses to achieve similar bone-protective effects with those achieved with higher estrogen doses. A longer-term study actually showed prevention of fractures in women taking ipriflavone versus those who took calcium only.

No significant side effects have been reported to date. Irpiflavone does not appear to have an estrogen-like effect on the vagina, suggesting that it may not be associated with risks for endometrial cancer. Ipriflavone may interact with theophylline (an asthma medication), and therefore, I would advise patients not to take both at the same time.

Ipriflavone is likely to be widely marketed in the United States under various brand names and brands may vary considerably in their ipriflavone content. Be cautious and read the label. For now, I recommend a dose of 600 milligrams daily (either 200 milligrams three times daily or 300 milligrams twice daily), based on results from the above studies.

Although early data look promising, I would caution my patients using phytoestrogens that the risks of breast and endometrial cancer are as yet unknown, and that products are not FDA regulated. I prescribe ipriflavone only for those patients who are at risk for bone loss and who are unwilling or unable to use the more well-studied treatments.
 

Black Cohosh (Cimicifuga racemosa L. Nutt. Family: Ranunculaceae; aka: black snakeroot, squaw root, rattle weed, rattle top, bugbane)

Black cohosh is a flowering perennial plant, native to Eastern North America. Its gnarled black root was used by Native Americans to relieve menstrual cramps and labor pains, and was one of several herbs contained in “Lydia Pinkham’s Vegetable Compound,” a popular tonic in the early 20th century.

Black cohosh contains several hormonally active compounds that appear to interact with the body’s estrogen receptors, acting both as estrogens and as anti-estrogens. One study showed that extracts of Cimicifuga racemosa root have estrogenic activity on cells grown in the laboratory. Another laboratory study noted that black cohosh inhibits the growth of human breast cancer, suggesting that it may have protective effects.

Remifemin
Remifemin^TM is a modern standardized ethanol extract of the Cimicifuga racemosa root. Most clinical studies of black cohosh to date have utilized this formulation.

In menopausal women, Remifemin appears to inhibit the pulsatile secretion of luteinizing hormone (LH), a pituitary hormone associated with hot flashes. Unlike estrogen, it does not affect pituitary follicle stimulating hormone (FSH) levels. Remifemin seems to alleviate hot flashes and other menopausal symptoms, and probably has estrogen-like beneficial effects on vaginal dryness. There are no human data on use of black cohosh for prevention or treatment of osteoporosis. Two studies, one on bone cells in tissue culture, and another on rats, suggest that black cohosh has an estrogen-like effect on bone growth. Whether it also has estrogen-like effects on the endometrium (uterine lining) is as yet unclear. This means that we do not know whether or not use of black cohosh can, like estrogen, increase the risk for endometrial cancer.

All clinical studies to date have shown that Remifemin is effective in treatment of hot flashes and other menopausal symptoms without serious adverse effects. However, the studies have been of limited duration, some as short as three months. Several nonblinded, nonplacebo-controlled studies conducted by the manufacturer of Remifemin have described significant improvement in menopausal symptoms, including hot flashes, anxiety, and sleep disturbances. When used in doses currently recommended (one tablet twice daily), the manufacturer found no estrogen-like effects on vaginal cells.

Independent studies have supported the efficacy of Remifemin in treatment of menopausal symptoms, but unlike the manufacturer’s results, they indicate an estrogen-like effect on vaginal cells. However, these studies did use a higher dose of Remifemin, suggesting that this particular effect may be dose-dependent. One double-blind study in 80 patients compared Remifemin with both conjugated estrogens (0.625 milligram daily) and placebos over a 12-week period. Remifemin users actually had greater improvement in menopausal symptoms than estrogen users, though proliferation of vaginal lining cells was also shown. Another study compared Remifemin to both estrogen and Valium. Remifemin had a beneficial effect on menopausal symptoms as well as an estrogen-like effect on vaginal cells. In another trial with 110 women, black cohosh proved better than the placebo in relieving hot flashes and reducing dryness in the vaginal lining.

The German Commission E, a scientific body that evaluates herbal therapies, has approved black cohosh for treatment of PMS, painful menstruation, and menopausal symptoms. They advise to limit its use to six months, since there are no long-term data.  I agree with this advice. In fact, in my own practice, I do not actively prescribe black cohosh. For those who are using this treatment, I advise against use for longer than six months. I also perform careful monitoring of the uterine lining with ultrasound and biopsies if indicated for these patients.

The recommended dose of black cohosh is 40 milligrams per day of an extract standardized to contain two-and-a-half percent triterpene glycosides, or a total of two milligrams triterpene glycosides or deoxyactein per day. For liquid extracts, the total dose is 40 drops of standardized extract containing five percent triterpene glycosides. Do not use nonstandardized preparations.

At recommended doses, the only reported side effect is occasional gastric upset. Overdose of the herb can cause nausea, vomiting, headache, dizziness, bradycardia (slowing of the pulse rate), and perspiration. Since it is unclear to what extent black cohosh can act as estrogen, women with a history of estrogen-dependent tumors (breast, endometrial cancers) should consult their physician before using black cohosh.

Black cohosh should not be confused with blue cohosh, an entirely different herb.
 

Evening Primrose Oil (Oenothera biennis L. family: onagraceae; aka: King’s Cure-all)

The small seeds of the evening primrose, a plant native to North America, contain essential fatty acids, most notably gamma linoleic acid (GLA). GLA is found in high concentrations in breast milk, but is limited in most adult diets. GLA is converted to prostaglandin E1, which is thought to inhibit inflammation, decrease platelet aggregation and blood clot formation, relax blood vessels, and lower cholesterol.

Evening primrose appears to be useful in treating breast pain, a common symptom in perimenopause. In one study, gamma linoleic acid was 97 percent effective over the course of six months in the relief of breast pain in Asian women. Other studies have reported efficacies ranging from 27 to 45 percent. One study found fatty acid profiles in women with mastalgia (breast pain) to be abnormal. Treatment with evening primrose oil did not necessarily reduce symptoms, while it did improve the fatty acid profiles toward normal. I prescribe evening primrose in my practice for treatment of breast pain that does not respond to other treatments or measures.

Heart disease is an increasing concern as women enter menopause. Data in both animals and humans suggest that GLA may prevent heart disease by lowering cholesterol levels and affecting platelet function to decrease formation of atherosclerosis.

There is little data to suggest that evening primrose has a particular role in the treatment of menopausal symptoms other than breast pain. One study to date has examined the use of GLA to treat hot flashes, with disappointing results. When compared to the placebo, the only significant improvement in GLA users was a very slight reduction in the maximum number of night time hot flashes.

Although evening primrose is a commonly-used remedy for premenstrual syndrome (PMS), all studies to date are unanimous in showing that GLA is no more effective than the placebo in the treatment of this disorder.

The recommended amount of evening primrose oil is 500 to 1,000 milligrams two or three times daily, or about 150 to 250 milligrams of GLA daily. Side effects from the use of evening primrose oil are limited to occasional mild nausea, which can be avoided if it is taken with food, and occasional skin rashes.
 

Dong Quai (Dong Qui, Angelica polymorpha Maxim var. Sineses Oliv; also called Angelica sineses (Oliv) Diels. Family: Apiaceae)

Dong quai is the root of a type of Angelica plant that grows at high altitudes in China. It is one of the most widely used herbs in China, where it is used to treat menstrual disorders in women. It may also act as a mild laxative and mild diuretic.

According to Dr. Maida Taylor, who has written and studied extensively on alternative medical therapies, although a “substantial body of literature exists about dong quai in Chinese medical literature, none of the recent citations relates to clinical studies of menopause.” In the only U.S. study to date, researchers at Kaiser Permanente in Oakland, California randomized 71 menopausal women to either dong quai or placebo. There was no significant difference between the groups in the incidence of hot flashes or other menopausal symptoms, and dong quai had no estrogen-like effects on the uterus or vagina in these women. Critics of the study argue that dong quai in this study was used alone, and that in most cases, dong quai should be used in combination with other herbs.

Although it appears to be safe, there is the potential for toxicity from dong quai use. Dong quai contains derivatives of coumarin, which may interact with blood-thinning medications. Certain substances (furocoumadins) in dong quai have been associated with photosensitivity, potentially leading to severe sunburn or rash. Don quai also contains safrole oil, which in pure form can be carcinogenic.

According to the American Pharmaceutical Association Practical Guide to Natural Medicines, problems with toxicity tend to be associated with purified compounds of dong quai, not the crude extract. Traditional Chinese herbalists prohibit use of dong quai in pregnancy. Women taking blood thinners should also avoid its use.

I do not prescribe don quai in my practice, and in fact I advise against its use, as the only available data to date suggest that it is ineffective.
 

Kava (Piper methylsticum)

This psychoactive plant has been used in the Polynesian Islands for years in a special ceremony called the kava ceremony. Several well-conducted placebo-controlled trials have shown kava to be an effective treatment for anxiety. To date, only one study has been done in menopause, which examined kava for treatment of menopausal symptoms. For eight weeks, 40 women were randomized to 100 milligram-doses of kava extract or placebo three times daily. Kava users had significant improvement in anxiety levels after only one week of treatment. After eight weeks, all showed significant improvement in subjective well-being, depressed mood, and Kupperman index scores (a measure of menopausal symptoms), compared with the placebo users. Side effects at these doses are generally few, and are limited to nausea, headache, dizziness, and allergic skin reactions. It is recommended that kava use be limited to short periods, no more than a few months.

Due to lack of long-term data, as well as risks of overdosage or abuse, I advise against Kava use. Kava may affect vision, and heavy doses can lead to a drunk-like state. Heavy chronic use causes yellowing of the skin and development of a skin condition called kava dermopathy. The potential for interaction with other psychoactive medications may exist.
 

Vitamin E (alpha-tercopherol)

Vitamin E has been a popular estrogen alternative for treatment of hot flashes for many years. Unfortunately, there is no evidence to suggest that it is effective, and I have yet to hear any of my patients report that it worked for them. There has been only one thorough study to date, which examined the use of vitamin E for control of hot flashes in breast cancer survivors. The frequency of hot flashes decreased by 25 percent, similar to the effect of placebo (22 percent). Only one dose was tested and further research is needed.

However, don’t let this keep you from getting enough vitamin E in your diet. Vitamin E is one of the important groups of antioxidant vitamins, which also includes vitamin C, selenium, and carotene. These vitamins appear to be important in prevention of cancers and heart disease. The U.S. RDA for vitamin E is five micrograms. Rather than taking expensive supplements, I advise my patients to get their antioxidants in their natural form—fruits and vegetables. USDA Food Guide Pyramid recommends two to three servings of fruit and three to five servings of vegetables per day.
 

Relaxation Therapies

Various relaxation techniques have been advocated for managing the effects of menopause. These include deep breathing and massage. Little objective data exists to substantiate their effects on menopausal symptoms, and the placebo effect is likely to be important in success with their use. Nevertheless, all of these techniques are safe and may have other important physical and mental health benefits.  Be forewarned—not all those who offer massage are well-trained or appropriately licensed, so do your homework.

Conclusion

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