Complementary and hormonal therapy for vasomotor symptom relief: a conservative clinical approach

The history of hormone therapy use and recent controversy related to heart disease and breast cancer arising from prevention trial outcomes

The reasons for hormone therapy use have changed dramatically over time from being very popular for the purpose of preserving youth in women to menopause-related symptom management, disease prevention, and now back to menopause-related symptom management. Over time, several important risks associated with the use of hormone therapy have become evident, causing dramatic reductions in the use of hormone therapy for periods of time following identification of these risks. Most recently, randomized controlled prevention trials that evaluated hormone therapy for the purpose of reducing or preventing coronary heart disease among women have found that hormone therapy is associated with increased rather than decreased risks for coronary heart disease. The most recent of these trials again identified increased risks for breast cancer associated with estrogen plus progestogen therapy. The evolving evidence base from these randomized controlled prevention trials is complicated and in some cases contradictory. Specifically, the data suggest that the timing of when hormone therapy is initiated once a woman is postmenopausal may influence her risk for developing heart disease and breast cancer. In this article, contradictory evidence is carefully sifted so risks and benefits can be weighed by clinicians when partnering with women to individualize decisions about using hormone therapy.

Alternative and complementary therapies for the menopause

Despite a re-evaluation of risks in recent years, hormone replacement therapy is still surrounded by controversy. Almost 30% of women in a recent survey sought a natural approach to combat climacteric symptoms. Nevertheless, a large proportion of patients felt that they wanted a good safety profile and strong evidence base for treatment. This article seeks to review the evidence supporting non-hormonal approaches to treatment. There is only conflicting evidence at best to support alpha-2 agonists, e.g. clonidine and limited evidence for dihydroepiandrosterone and natural progesterones. There is limited randomized controlled trial data for gabapentin, selective norepinephrine re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs), many of these studies being related to breast cancer patients. Of the herbal medicinal products, the largest evidence base rests with phytoestrogens. A Cochrane Database review looking at all types of phytoestrogens, e.g. red clover extracts, dietary soya and soya extracts concluded that there was no evidence to support improvement in climacteric symptoms and the meta-analysis of a 178 studies on soy products was inconsistent. Nevertheless, other studies disagree. Mammographic density is not affected by soy or phytoestrogen products and recent in vitro work shows only a weakly proliferative effect of soy isoflavone on breast cancer cells and evidence that soy isoflavone blocks the proliferative effect of estradiol on these cells. There are no studies looking at clinical outcome measures for cardiovascular disease but a number of studies looking at biochemical markers including arterial wall stiffness and apolipo protein B. Recent studies have also looked at the effects of red clover isoflavone on mood and depression, using specific depression rating scales. Finally, it is important to note that herbal medicinal products should not be used without caution. Some may produce quite marked side-effects in high doses and others can interact with pre-existing medication. A strategy for which patients are suitable for herbal medicinal products is reviewed.

The effect of red clover isoflavone supplementation over vasomotor and menopausal symptoms in postmenopausal women

OBJECTIVE

To evaluate the effect of red clover isoflavone supplementation over vasomotor and overall menopausal symptoms in postmenopausal women.

METHODS

One hundred and nine postmenopausal women aged 40 or more were assigned to randomly receive either two daily capsules of the active compound (80 mg red clover isoflavones, Group A) or placebo of equal appearance (Group B) for a 90-day period. After a washout period of 7 days, medication was crossed over and taken for 90 days more. Daily hot flush and night sweat frequency and overall menopausal symptom intensity (Kupperman Index) were measured at baseline, 90, 97 and 187 days.

RESULTS

Daily hot flush/night sweat frequency and Kupperman Index values were similar in both studied groups at baseline. All indices significantly decreased after red clover phase in Group A, corresponding, respectively to a 73.5%, 72.2% and 75.4% average decrement. These decrements were significantly higher than those observed for Group B after placebo phase (8.2%, 0.9% and 6.7% respectively). In Group A, after washout and placebo phases all values significantly increased. In Group B, all indices remained similar after placebo and washout phases, however significantly dropping after red clover treatment. These values were also significantly lower than those observed in Group A after placebo phase. No side effects were encountered after treatment with the active compound or placebo.

CONCLUSION

Red clover isoflavone supplementation was more effective than placebo in reducing daily vasomotor frequency and overall menopausal intensity in postmenopausal women.

[Correlation between subjective and objective measurement of climacteric women's hot flashes]

PURPOSE

The purposes of this study were to explain the phenomena of hot flashes in climacteric women by using Mexameter, Skin Thermometer, Corneometer, and Laser Doppler Perfusion Imager (LDPI) objectively and to identify the interrelation between the subjective and objective measurements of hot flashes by comparing the two as reported in retrospective questionnaires.

METHODS

The participants were one hundred women (45-60 yr) who were not currently on hormone therapy, and had reached hot flash scores of 10 or higher. Hot flashes were measured in a temperature and humidity controlled room for 7 hr from 10 am to 5 pm. Hot flashes were measured subjectively and recorded via the Hot Flash Diary Report. When participants felt the hot flashes, they were measured objectively by Mexameter, Skin Thermometer, Corneometer, and LDPI .

RESULTS

The frequency of hot flashes in participants ranged from 1 to 7 times. When hot flashes occurred in participants, the erythema, skin temperature, skin hydration, and blood perfusion showed statistically significant changes in all measurements. But, the subjective and objective measurements of hot flashes showed only weak correlations.

CONCLUSION

Results indicate a need for future research with subjective and objective measuring instruments chosen depending variations identified for the study.

The effect of soy-derived isoflavones over hot flushes, menopausal symptoms and mood in climacteric women with increased body mass index

BACKGROUND

Risk-benefit issues raised after the WHI have significantly increased the use of alternative treatments for the menopause. Despite this, data regarding the effect of soy isoflavones over mood and menopausal symptoms in high risk populations is still lacking.

OBJECTIVE

To evaluate the effect of soy derived isoflavones over hot flushes, menopausal symptoms and mood in climacteric women with increased body mass index (BMI).

METHODS

Fifty symptomatic climacteric women aged 40 to 59 with increased BMI (≥ 25) were recruited to receive oral 100 mg/day of soy derived isoflavones (Climasoy) for 3 months. Hot flushes (frequency/intensity), menopausal symptoms (Menopause Rating Scale [MRS]) and mood (Hamilton Depressive Rating Scale [HDRS]) were evaluated at baseline and at 90 days.

RESULTS

A total of 45 women completed the study. After 3 months of soy isoflavone supplementation hot flushes significantly decreased in percentage, number and severity (100% to 31.1%; 3.9 ± 2.3 to 0.4 ± 0.8 and 2.6 ± 0.9 to 0.4 ± 0.8, respectively, p < 0.001). MRS scores (total and for subscales) reflecting general menopausal symptoms also significantly decreased compared to baseline. Regarding mood, after three months total HDRS scores and the rate of women presenting depressed mood (scores ≥ 8) significantly decreased (16.3 ± 5.4 to 6.9 ± 5.2 and 93.3% to 28.9%, respectively, p < 0.05). There was no effect on blood pressure levels or BMI values after treatment.

CONCLUSION

In this high risk climacteric population, soy derived isoflavone treatment improved mood as well as vasomotor and general menopausal symptoms. More research is required to determine if the positive effect over mood is a direct or an indirect one through hot flush alleviation.

Treating vasomotor symptoms of menopause: the nurse practitioner's perspective

PURPOSE

This article reviews the pathophysiology of vasomotor symptoms (VMS) of menopause and current management options.

DATA SOURCES

Current scientific literature.

CONCLUSIONS

In most menopausal women, loss of ovarian function results in VMS, including hot flashes, night sweats, and mood and sleep disturbances. Hormone therapy (HT) has been the mainstay of VMS treatment for many years, but safety concerns raised by publication of the Women's Health Initiative (WHI) results have dramatically reduced the use of this treatment. Since the WHI published its findings, attention has focused on other novel treatments for menopausal symptoms, including low-dose oral or transdermal HT and agents such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and clonidine. Many women also use complementary and alternative medications to manage VMS, but little evidence from controlled clinical trials supports their efficacy.

IMPLICATIONS FOR PRACTICE

The increasing number of alternative treatments for VMS requires improvement in patient-provider communication about treatment risks and benefits, individualization of treatment to meet patient needs and attitudes, and careful follow-up to ensure adherence to potentially effective therapy. Nurse practitioners play a leading role in patient evaluation, discussions, and management to help women achieve control over bothersome VMS that dramatically impact their quality of life.

Determination of phytoestrogens in dietary supplements by LC-MS/MS

Labelling data quantifying the exact content of individual phytoestrogen analytes in dietary supplements are generally poor. As these products are commonly used in the management of menopause symptoms, any clinical benefits would be dependent on the exact dosage of isoflavones received. Well-established extraction procedures and updated isotope dilution mass spectrometry liquid chromatography coupled with tandem mass spectrometry detection (LC-MS/MS) have been used to accurately quantify the concentrations of ten common isoflavones in 35 dietary supplement samples on sale in the UK, Canada and Italy. Concentration-specific ionization suppression is described for biochanin A and formononetin. All supplements contained phytoestrogens. The soya isoflavones (genistein, daidzein, glycitein) were present in all products and the majority also contained the red clover isoflavones (biochanin A, formononetin) and some the Kudzu isoflavones (daidzein, puerarin). The content of total isoflavones per dose ranged from <1 to 53 mg. Trace amounts of coumestrol were found in six products. Other less common analytes, the prenylnaringenins (6-prenylnaringenin, 8-prenylnaringenin, 6,8-diprenylnaringenin) were not found in any of the products. Only 14 of 35 supplements were found to deliver more than or equal to 40 mg day(-1) of aglycone isoflavones, a consensus dose value recognized as delivering therapeutic benefit. Eleven did not match label claims. Six delivered less than 10 mg day (-1) of isoflavones. There has been little improvement in the overall quality of industry labelling in the five years since this was last investigated. Consequently, the public, retailers and healthcare professionals should consider using standardized isoflavone supplements, which are supported by analytical measurements.

Integrating phytoestrogens with prescription medicines--a conservative clinical approach to vasomotor symptom management

There is a growing body of scientific evidence that complementary therapies such as isoflavone containing phytoestrogens might help menopausal symptoms. Women are now using them, believing them to be safer and "more natural" especially following the current controversies regarding HRT. However, the choice of treatments is confusing and with some preparations, little is known about their active ingredients, safety or side effects or how they may interact with other therapies. This paper examines the available evidence for management of menopause symptoms with isoflavone containing phytoestrogens, both in terms of efficacy and safety. An algorithm is suggested to demonstrate how these preparations may be integrated with conventional therapies to effectively manage menopause symptoms.