Alternative therapies for menopause

Effects of Korean Red Ginseng (Panax ginseng C.A. Meyer) on Menopausal Symptoms in Premenopausal Women After Gynecologic Cancer Surgery: A Double-Blind, Randomized Controlled Trial

Objectives: Korean red ginseng (KRG) has been widely used as an alternative medicine to relieve menopausal symptoms. However, there is still a lack of clinical studies showing the effects of KRG on menopausal symptoms after gynecologic cancer surgery. Therefore, the authors investigated the effects of KRG on surgical menopause symptoms in premenopausal women with gynecologic cancer. Design: A double-blind, randomized, placebo-controlled clinical trial was conducted. Settings/Location: The study was performed at Severance Hospital at the Yonsei University College of Medicine in Seoul, Korea. Subjects: Fifty-five premenopausal women diagnosed with gynecologic cancer were enrolled in the study. Interventions: Patients were randomly assigned to a KRG (n = 29) or a placebo control group (n = 26). Subjects were administered either KRG (a total of 3 g per day) or placebo supplements for 12 weeks. Outcome measures: Patients' physical measurements (height, weight, and blood pressure) and blood samples (lipid profiles, hormone profiles, biochemical profiles, and neutrophil-to-lymphocyte ratio) at baseline and at 12 weeks were compared. Changes in menopausal symptoms based on the Menopause Rating Scale (MRS) were also compared between these two time points and two groups. Results: After 12 weeks, the MRS score was significantly reduced in each group (p = 0.001 and p = 0.001, respectively), but there were no significant differences between the two groups (p = 0.661). No adverse events were observed in either group. After comparing 11 MRS symptoms between the two groups, the KRG group seemed to be superior to the placebo group on the subscale of sexual complaints (p < 0.05). Conclusions: Through the study, KRG did not show absolute relief of surgical menopause symptoms in premenopausal women after gynecologic cancer surgery. However, the study did demonstrate that KRG may be effective in reducing sexual complaints. Further studies are required to evaluate the long-term effects of KRG in a larger patient population.

The Availability of Beneficial Insects-originated Materials on Women's Health following Menopause

Human health problems due to long life are becoming major issues in society, and in particular greater interest collected on women's health after menopause. Many substances can be introduced to women's health, however, materials from the substances have not shown all of the safety and efficacy properties that are not easily found. Currently, it is known about the effects of the disease on the female insect-derived material that is capable of overcoming this problem significantly. When using the insect-derived material through the results of several studies suggest that it is possible to solve a hormonal imbalance and nutritional imbalance in the elderly. Here, we'd like to try to dissertate about the new trends for women's health improvement using novel materials-derived from insects.

Effects of black cohosh on the plasminogen activator system in vascular smooth muscle cells

OBJECTIVE

The rhizome of the Cimicifuga racemosa plant (commonly known as black cohosh) has been used for menopausal complaints. Studies regarding the cardiovascular effects of black cohosh are lacking. We investigated the effect of black cohosh on the plasminogen activator system in cultured vascular smooth muscle cells (VSMCs).

METHODS

VSMCs were isolated from rat aortae. Expression of plasminogen activator inhibitor type 1 (PAI-1) and tissue-type plasminogen activator (t-PA) proteins were evaluated by Western blot analysis and enzyme-linked immunosorbent assay, respectively. The activities of PAI-1 and t-PA in the conditioned media were assessed by fibrin overlay zymography. A 40% 2-propanol extract of black cohosh was used.

RESULTS

Black cohosh extract (BcEx) stimulated the protein expression of PAI-1, but it did not affect that of t-PA. Vitamin E, a potent antioxidant, inhibited the BcEx-induced increase in PAI-1 expression, while ICI 182,780, an estrogen receptor antagonist, had no effect. Fibrin overlay zymography revealed that BcEx increased the activity of PAI-1 in the conditioned media, while concurrently decreasing that of free t-PA by inducing a binding to PAI-1.

CONCLUSIONS

BcEx induces PAI-1 protein expression in the VSMCs likely via an oxidant mechanism. It also stimulates the enzyme activity of PAI-1 and reduces that of free t-PA. These findings suggest that black cohosh might exert a negative influence on fibrinolysis.

Ginseng for managing menopause symptoms: a systematic review of randomized clinical trials

The aim of this review was to assess the effectiveness of ginseng as a treatment option for managing menopause symptoms. We searched the literature using 11 databases from their inception to 26 September 2012 and included all randomized clinical trials (RCTs) that compared any type of ginseng to a placebo controls in postmenopausal women. The methodological quality of all studies was assessed using a Cochrane risk of bias tool. Four RCTs met our inclusion criteria. Most RCTs had high risk of bias. One RCT showed that Korean red ginseng (KRG) significantly improved sexual arousal and global health compared with placebo. Another RCT reported the superiority of KRG over placebo for treating menopause symptoms on Kupperman's index and menopausal rating score. The third RCT failed to show a significant effect of KRG on hot flash frequency compared to placebo. The fourth RCT found beneficial effects of ginseng compared to placebo on depression and well-being. In conclusion, the evidence on ginseng as an effective treatment for managing menopause symptoms is limited. Most of the RCTs are burdened with a high risk of bias. Thus firm conclusions cannot be drawn. Rigorous studies seem warranted.

Mechanisms underlying the dualistic mode of action of major soy isoflavones in relation to cell proliferation and cancer risks

Isoflavones are phytoestrogens that have been linked to both beneficial as well as adverse effects in relation to cell proliferation and cancer risks. The present article presents an overview of these seemingly contradicting health effects and of mechanisms that could be involved in this dualistic mode of action. One mechanism relates to the different ultimate cellular effects of activation of estrogen receptor (ER) α, promoting cell proliferation, and of ERβ, promoting apoptosis, with the major soy isoflavones genistein and daidzein activating especially ERβ. A second mode of action includes the role of epigenetics, including effects of isoflavones on DNA methylation, histone modification and miRNA expression patterns. The overview presented reveals that we are only at the start of unraveling the complex underlying mode of action for effects of isoflavones, both beneficial or adverse, on cell proliferation and cancer risks. It is evident that whatever model system will be applied, its relevance to human tissues with respect to ERα and ERβ levels, co-repressor and co-activator characteristics as well as its relevance to human exposure regimens, needs to be considered and defined.

Yoga for menopausal symptoms: a systematic review

OBJECTIVE

The aim of this study was to assess the effectiveness of yoga as a treatment option for menopausal symptoms.

METHODS

We searched the literature using 14 databases from their inception to July 2008 and included all types of clinical studies regardless of their design. The methodological quality of all studies was assessed using a modified Jadad score.

RESULTS

Seven studies met our inclusion criteria. Two randomized clinical trials compared the effects of yoga with those of walking or physical exercise. The meta-analysis of these data failed to show specific effects of yoga on menopausal complaints including psychological, somatic, and vasomotor symptoms. Two randomized clinical trials found no effects of yoga on total menopausal symptoms compared with wait-list control or no treatment. The remaining studies were either non-randomized (n = 1) or uncontrolled clinical trials (n = 3). They reported favorable effects of yoga on menopausal symptoms. These data collectively show that the results of rigorous studies of the effects of yoga for menopausal symptoms are unconvincing.

CONCLUSION

The evidence is insufficient to suggest that yoga is an effective intervention for menopause. Further research is required to investigate whether there are specific benefits of yoga for treating menopausal symptoms.

Effects of estrogen and estrogenic compounds on cognition in ovariectomized rats

OBJECTIVES

To evaluate the effects of estrogen and estrogenic compounds on cognition in ovariectomized rats.

METHODS

Female Sprague-Dawley rats (3-5 months old) weighing 250-300 g were randomly divided into seven groups: Sham, ovariectomized (OVX), OVX plus estradiol valerate, OVX plus ipriflavone, OVX plus raloxifene, OVX plus tibolone, OVX plus low-dose estradiol valerate and ipriflavone. All treatments were given orally for 3 months; whereas the drug groups received indicated drugs, the Sham and OVX control groups received saline. The escape latency of rats was tested by the Morris water maze test and the expression of amyloid precursor protein (APP) in hippocampus was determined by reverse transcription polymerase chain reaction. The level of serum estradiol and the diameter of the endometrial gland and the thickness of endometrium were also evaluated.

RESULTS

The latency of the OVX group was noticeably longer than that of the Sham group, and the latency of all treatment groups was lower than that of OVX rats. The expression of APP mRNA in the hippocampii of OVX rats was significantly increased relative to that in Sham rats; interestingly, expression of APP in treatment groups was significantly reduced relative to OVX rats.

CONCLUSIONS

Our data indicate that estrogenic compounds can antagonize cognitive impairment and that all these compounds cause only mild stimulation on the endometrium compared to estrogen. Inhibition of APP expression in the hippocampus may account for, at least partially, the protective effects of these estrogenic compounds against cognitive defects. Our data suggest that estrogenic compounds (raloxifene, tibolone and ipriflavone) may be a promising approach to antagonize cognitive impairment in postmenopausal women.

Effects of isoflavones on the coagulation and fibrinolytic system of postmenopausal women

OBJECTIVE

We evaluated the effects of soy isoflavone supplementation on hemostasis in healthy postmenopausal women.

METHODS

In this double-blinded, placebo-controlled study, 47 postmenopausal women 47-66 y of age received 40 mg of soy isoflavone (n = 25) or 40 mg of casein placebo (n = 22) once a day for 6 mo. Levels of factors VII and X, fibrinogen, thrombin-antithrombin complex, prothrombin fragments 1 plus 2, antithrombin, protein C, total and free protein S, plasminogen, plasminogen activator inhibitor-1, and D-dimers were measured at baseline and 6 mo. Urinary isoflavone concentrations (genistein and daidzein) were measured as a marker of compliance and absorption using high-performance liquid chromatography. Baseline characteristics were compared by unpaired Student's t test. Within-group changes and comparison between the isoflavone and casein placebo groups were determined by a mixed effects model.

RESULTS

The levels of hemostatic variables did not change significantly throughout the study in the isoflavone group; however, the isoflavone group showed a statistically significant reduction in plasma concentration of prothrombin fragments 1 plus 2; both groups showed a statistically significant reduction in antithrombin, protein C, and free protein S levels. A significant increase in D-dimers was observed only in the isoflavone group. Plasminogen activator inhibitor-1 levels increased significantly in the placebo group. However, these changes were not statistically different between groups.

CONCLUSION

The results of the present study do not support a biologically significant estrogenic effect of soy isoflavone on coagulation and fibrinolysis in postmenopausal women. However, further research will be necessary to definitively assess the safety and efficacy of isoflavone.

Botanical and dietary supplements for mood and anxiety in menopausal women

OBJECTIVE

This paper reviews the commonly used botanicals for treatment of mood and anxiety disorders in perimenopausal and postmenopausal women and presents information on their safety and efficacy.

DESIGN

The MEDLINE and EMBASE databases were searched for clinical trials related to the use of botanicals for depression, anxiety, and mood disturbances. Papers were excluded if they were in a language other than English, did not include midlife women as study participants, or did not report on changes in mood, depression, or anxiety.

RESULTS

Five of seven trials of St. John's wort for mild to moderate depression showed a significant improvement. The one randomized, controlled trial of ginseng in postmenopausal women reported improvements in mood and anxiety. All three randomized, controlled trials of ginkgo found no effect on depression. In four of eight controlled trials, kava significantly reduced anxiety. Black cohosh significantly reduced depression and anxiety in all studies reviewed.

CONCLUSIONS

St. John's wort and black cohosh appear to be the most useful in alleviating mood and anxiety changes during menopause. Ginseng may be effective, but more research needs to be done. Kava holds promise for decreasing anxiety in peri- and postmenopausal women; however, women should be careful in the amount and duration of use. Finally, ginkgo and valerian do not appear to be useful in reducing depression or anxiety in this population.

Efficacy on menopausal neurovegetative symptoms and some plasma lipids blood levels of an herbal product containing isoflavones and other plant extracts

OBJECTIVES

To assess the efficacy of a product containing isoflavones and other plant extracts (BIO) on whole menopausal symptomatology and plasma lipids profile.

METHODS

Multicentre, randomized, double blind, placebo controlled clinical investigation on 125 menopausal women randomly assigned to two groups treated for 6 months with placebo or one tablet daily of an herbal product containing 72 mg/dose of isoflavones of different plants origin and other plant extracts (BIO). Primary end-point: Kupperman Menopause Index (KI) variations; secondary end-point: activity on plasma lipids profile and clinical global impression (CGI) on efficacy and tolerability by investigators and patients. The usual parametric test (paired Student t test) was performed to evaluate the significance. In case of non-applicability of parametric tests, the non-parametric Mann-Whitney U test was used. The differences where considered significant at p<0.05 level.

RESULTS

At the end of treatment in both groups KI showed a significant decrease (p<0.001). However, in the BIO group the KI reduction was significantly higher (p=0.0265) than in the placebo group after 4 and 6 months of treatment. In the BIO treated patients the LDL cholesterol showed a borderline but not significant reduction compared to placebo (p=0.0608) and triglyceride (TG) a significant (p=0.0151) decrease compared to placebo. The investigator's and patient's CGI on BIO group where superior as compared to placebo. Clinical tolerability was good in booth groups.

CONCLUSION

On the basis of positive effects on KI and lipids profile as well as of good clinical tolerability, BIO can be considered one of the possible alternative therapy for conventional HRT.

A pilot study of mindfulness-based stress reduction for hot flashes

OBJECTIVE

A variety of results from both population and laboratory studies suggest that stress and hot flashes (HFs) are correlated and that HFs are more severe in women with lower coping abilities. The objective of this pilot study was to obtain information on the feasibility and effect of participation in a mindfulness-based stress reduction (MBSR) program on HF severity and menopause-related quality of life.

DESIGN

Fifteen women volunteers reporting a minimum of seven moderate to severe HFs per day at study intake attended the eight weekly MBSR classes at the University of Massachusetts Medical School. Participants were assessed for menopause-related quality of life before beginning and at the conclusion of the MBSR program. Women also kept a daily log of their HFs through the course of the 7 weeks of the MBSR program and for 4 weeks after it.

RESULTS

Women's scores on quality-of-life measures increased significantly, and the median reported HF severity, calculated as the weekly average of a daily HF severity score, decreased 40% over the course of the 11 weeks of the assessment period. The women were individually interviewed at the completion of their participation, and the results of the interviews were consistent with the results from daily diaries.

CONCLUSIONS

These results provide preliminary positive evidence of the feasibility and efficacy of MBSR in supporting women who are experiencing severe HFs, and it warrants further investigation.

Contemporary alternatives to plant estrogens for menopause

OBJECTIVES

Every year, millions of women begin the peri-menopause and may experience a number of symptoms related to this transition. Many women are reluctant to use exogenous hormone therapy for treatment of menopausal symptoms and are turning to botanical and dietary supplements (BDS) for relief. This paper reviews the literature on alternatives to plant estrogens for relief of menopausal symptoms.

METHODS

The MEDLINE database was searched for clinical trials of non-estrogenic plant extracts for menopausal symptoms. To be included, studies had to include peri- or postmenopausal women as subjects. All clinical trials (randomized-controlled trials, open trials, and comparison group studies) were included for this review.

RESULTS

Black cohosh appears to be one of the most effective botanicals for relief of vasomotor symptoms, while St. John's wort can improve mood disorders related to the menopausal transition. Many other botanicals have limited evidence to demonstrate safety and efficacy for relief of symptoms related to menopause.

CONCLUSIONS

A growing body of evidence suggests that some botanicals and dietary supplements could result in improved clinical outcomes. Health care providers should discuss these issues with their patients so they can assist them in managing these alternative therapies through an evidence-based approach.

Genistein stimulates growth of human breast cancer cells in a novel, postmenopausal animal model, with low plasma estradiol concentrations

We have demonstrated that genistein (GEN) stimulates growth of estrogen-dependent breast tumors in vivo. In this study, we evaluated whether dietary GEN can act in an additive manner with low circulating levels of 17beta-estradiol (E2). We developed an E2 delivery system using silastic implants that yield low circulating plasma E2 levels similar to those observed in postmenopausal women. We inserted various concentrations of E2 silastic implants (1:127, 1:63, 1:31, 1:15 and 1:7 = E2:cholesterol) and injected estrogen-dependent human breast cancer (MCF-7) cells into ovariectomized athymic mice. The E2 implants tested (1:127-1:7) generated 30.1-101.6 pM E2 in plasma, which is comparable to the E2 levels observed in postmenopausal women. The E2 implants stimulated MCF-7 tumor growth in a dose-dependent manner. We selected the 1:31 ratio of E2 implant to evaluate if dietary GEN acts in an additive manner with low E2 levels to influence the growth of MCF-7 tumors. Ovariectomized mice were divided into four groups: MCF-7 control, 500 ppm GEN, 1:31 E2, and 1:31 E2 + 500 ppm GEN. At week 17, the average tumor sizes were 7.6, 32.1, 67.4 and 106.8 mm2 for these groups, respectively (P < 0.05), demonstrating that 500 ppm GEN additively stimulated MCF-7 tumor growth in the presence of low levels of E2. In summary, we established a preclinical mouse model that results in E2 blood concentrations similar to those found in postmenopausal women. Further, we observed that these concentrations regulate the growth rate of MCF-7 breast tumors. Using this model, we demonstrated that dietary GEN in the presence of low levels of circulating E2 act in an additive manner to stimulate estrogen-dependent tumor growth in vivo. Results from this study suggest that consumption of products containing GEN may not be safe for postmenopausal women with estrogen-dependent breast cancer.

Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy

We sought to evaluate evidence for the benefits and risks of acupuncture, magnets, reflexology, and homeopathy for menopause-related symptoms. Search strategies included electronic searches of online databases (PubMed, PsycINFO, Medline), direct searches of target journals, and citation-index searches. A total of 12 intervention studies were identified for review. Complementary and alternative medicine (CAM) treatments resulted in few side effects. The design, study populations, and findings across acupuncture studies varied. In uncontrolled studies, acupuncture improved subjective measures of hot flash frequency and vasomotor, somatic, physical, and psychological symptoms; however, improvements were not consistent. Controlled studies of acupuncture yielded even less consistent findings. Overall, controlled studies of acupuncture did not reliably improve hot flashes, sleep disturbances, or mood when compared with nonspecific acupuncture, estrogen therapy, or superficial needling. Homeopathy significantly improved subjective measures of hot flash frequency and severity, mood, fatigue, and anxiety in uncontrolled, open-label studies. Controlled studies of magnets and reflexology failed to demonstrate any increased benefit of treatment over placebo. There is a need for additional investigations of acupuncture and homeopathy for the treatment of hot flashes and other menopausal symptoms. However, existing evidence does not indicate a beneficial effect of magnets or reflexology in the treatment of hot flashes and other menopausal symptoms. Understanding whether, for whom, and how these interventions work is crucial to building the evidence base needed to evaluate any potential for these CAM therapies in the management of menopause-related symptoms.

Drug utilization pattern of Chinese herbal medicines in a general hospital in Taiwan

PURPOSE

Drug utilization studies are important for the optimization of drug therapy and have received a great attention in recent years. Most of the information on drug use patterns has been derived from studies in modern Western medicines; however, studies regarding the drug utilization of traditional Chinese medicine (CM) are few. The present study was the first clinical research to evaluate the drug utilization patterns of Chinese herbal medicines in a general hospital in Taiwan.

METHODS

Data were collected prospectively from the patients attending the Traditional Medicine Center of Taipei Veteran General Hospital under CM drug treatments. The study was carried out over a period of 1 year, from January 2002 to December 2002. Core drug use indicators, such as the average number of drugs per prescriptions, the dosing frequency of prescriptions, and the most common prescribed CM herbs and formulae were evaluated. The primary diagnosis and the CM drugs prescribed for were also revealed. All data were analyzed by descriptive statistics.

RESULTS

A total of 10 737 patients, representing 52 255 CM drugs, were screened during the study period. Regarding the prescriptions, the average number of drugs per prescription was 4.87 and 37.21% of prescriptions were composed by five drugs. Most of prescriptions (91.38%) were prescribed for three times a day. The most often prescribed Chinese herb was Hong-Hwa (5.76%) and the most common Chinese herbal formula was Jia-Wey-Shiau-Yau-San (3.80%). The most frequent main diagnosis was insomnia (15.58%), followed by menopause (5.22%) and constipation (5.09%).

CONCLUSION

The survey revealed the drug use pattern of CMs in a general hospital. The majority of CM prescriptions were composed by 3-6 drugs and often prescribed for three times a day. Generally, the rational drug uses of CM drugs were provided with respect to the various diagnoses.

Botanical and dietary supplements for menopausal symptoms: what works, what does not

BACKGROUND

Approximately two thirds of women who reach menopause develop menopausal symptoms, primarily hot flashes. Hormone therapy long was considered the first-line treatment for vasomotor symptoms. However, given the results of the Women's Health Initiative (WHI), many women are reluctant to use exogenous hormones for symptomatic treatment and are turning to botanicals and dietary supplement (BDS) products for relief. Despite the fact that there is limited scientific evidence describing efficacy and long-term safety of such products, many women find these natural treatments appealing. Perimenopausal and postmenopausal women are among the highest users of these products, but 70% of women do not tell their healthcare providers about their use. Compounding this issue is the fact that few clinicians ask their patients about use of BDS, largely because they have not been exposed to alternative medical practices in their training and are unfamiliar with these products.

METHODS

This paper reviews the botanicals and dietary supplements commonly used in menopause (such as black cohosh, red clover, and soy products) as well as the available data on efficacy and safety. We searched the MEDLINE database from 1966 to December 2004 using terms related to BDS and menopausal symptoms for perimenopausal or postmenopausal women. Abstracts from relevant meetings as well as reference books and websites on herbal supplements were also searched. Randomized, controlled trials (RCTs) were used if available; open trials and comparison group studies were used when RCTs were not available.

RESULTS AND CONCLUSIONS

The evidence to date suggests that black cohosh is safe and effective for reducing menopausal symptoms, primarily hot flashes and possibly mood disorders. Phytoestrogen extracts, including soy foods and red clover, appear to have at best only minimal effect on menopausal symptoms but have positive health effects on plasma lipid concentrations and may reduce heart disease. St. John's wort has been shown to improve mild to moderate depression in the general population and appears to show efficacy for mood disorders related to the menopausal transition. Other commonly used botanicals have limited evidence to demonstrate safety and efficacy for relief of symptoms related to menopause.

Menopausal Symptom Management and Prevention Counseling after the Women's Health Initiative among Women Seen in an Internal Medicine Practice

OBJECTIVE

To describe the management of menopausal symptoms and the prevalence of prevention counseling among women who stopped hormone therapy (HT) after publication of the initial findings of the Women's Health Initiative.

METHODS

Telephone survey between July and September 2003 of 142 women 50 years and older, randomly selected from a large academic primary care practice, who stopped taking HT after the WHI publication, July 9, 2002 (66% response rate).

RESULTS

Among 142 women, the median age was 60 years, 63% were white, 52% had at least a college degree, and 60% were taking estrogen and progestin as of July 9, 2002. The majority (82%, n = 117) who stopped HT suffered some menopausal symptom: 25 restarted HT, 13 received another prescription medication, and 56 tried at least one complementary and alternative medicine. Women most commonly used soy (n = 40) or black cohosh (n = 25) for their symptoms, although less than one third of women found either of these treatments effective. Only 49% (57 of 117) of women with symptoms visited a doctor for their symptom. Few women reported receiving counseling about prevention topics after the WHI, such as risk of osteoporosis (34%), risk of heart disease (26%), diet (41%), and exercise (45%).

CONCLUSIONS

Most women who stopped HT after the WHI experienced some menopausal symptoms. Few women found commonly used alternative medicines effective, and few received other prescription medications. Counseling about osteoporosis and heart disease risk was infrequent after the WHI. Future studies should focus on finding safe and effective therapies for menopausal symptoms.

Knowledge, attitudes, and behaviors of healthcare providers for botanical and dietary supplement use for postmenopausal health

OBJECTIVE

To identify the knowledge, attitudes, and behaviors of health care providers (physicians and nurses) regarding the use of botanical dietary supplements (BDS) for peri- and postmenopausal women.

DESIGN

Health care providers (physicians and nurse practitioners/nurse midwives) completed a questionnaire to assess knowledge, attitudes, and behaviors regarding botanical dietary supplement use for peri- and postmenopausal women. A total of 62 providers were included in the final analysis.

RESULTS

Two thirds of providers reported that they had limited or no knowledge about botanical dietary supplements. By far, the majority of providers had no formal training nor had they studied these supplements on their own. Although knowledge was limited, a majority of providers wanted additional training predominantly because of growing patient awareness and use and were open to using these therapies for their patients either in combination with conventional Western medicine or as the only support for relief of peri- and postmenopausal symptoms. However, only 25% of providers regularly asked their peri- and postmenopausal patients about use of botanical dietary supplements. Providers who had practiced longer (> or =11 y) were more likely to be knowledgeable about dietary supplements and to have studied on their own (P < 0.01), to believe that botanicals are part of evidence-based medicine (P < 0.05), and to have talked to their patients (P < 0.05) about use of these therapies. Increased knowledge also appeared to predict a more positive attitude on the part of providers toward their patients who use BDS (P < 0.001) as well as more proactive behavior related to referring and recommending these therapies as treatment (P < 0.01).

CONCLUSIONS

Our findings suggest that knowledge about botanical therapies among health care providers caring for peri- and postmenopausal women is quite low, but they are open to learning more about these modalities and using them for treatment, if appropriate. Our results suggest that increased years in practice is related to increased knowledge, more positive attitudes, and more proactive behaviors related to botanical dietary supplements.

Integrative Therapies for Menopause

Menopause is a transitional time for women. This gives practitioners an opportunity to focus on recommending healthy life-style changes. Hormone replacement therapy (HRT) has been the mainstay of therapy for menopausal symptoms. With recent research findings, women and their physicians are seeking alternatives that do not carry the risks associated with HRT. Exercise has been shown to help some women with symptoms of hot flashes, as have relaxation techniques and deep breathing. Dietary changes to incorporate whole foods and soy are thought by some to help with menopausal symptoms, and are recommended because of a positive impact on heart disease and obesity; soy isoflavones may also help with menopausal symptoms. Botanicals such as black cohosh and red clover have been shown in some studies to decrease severity and frequency of hot flashes. We recommend that HRT be prescribed when other measures have failed to adequately control symptoms. Bioidentical hormones are preferred in our practice.

Benefits of soy germ isoflavones in postmenopausal women with contraindication for conventional hormone replacement therapy

OBJECTIVE

To evaluate the effects of isoflavones on vasomotor symptoms and blood lipids in postmenopausal women with contraindication for conventional hormone replacement therapy (HRT).

METHODS

This prospective, double-blind and placebo-controlled study included 50 postmenopausal women randomly divided into two groups: 25 women on soy germ isoflavones (60 mg per day, capsules) and 25 women on placebo. Inclusion criteria included: non-vegetarian, non-asian women whose last menstruation dated at least 12 months prior to the beginning of the study, with FSH > 40 mIU/ml, hot flushes and contraindication for HRT, not using tamoxifen or antibiotic and no disease of the gastrointestinal tract. For 6 months, the Kupperman menopausal index (KMI), the vaginal cytological maturation value (MV) and both hormonal and lipid profiles were assessed. The t-test and analysis of variance (ANOVA) were employed to compare the two groups.

RESULTS

In both groups, a decreased KI rate was observed. However, isoflavone was significantly superior to placebo in reducing hot flushes (44% versus 10%, respectively) (P < 0.05). After 6 months, the isoflavone group showed increased estradiol levels with unchanged FSH, LH, and vaginal cytology, and a reduction of 11.8% in LDL and an increase of 27.3% in HDL (P < 0.05 ). In the placebo group, just a reduction in MV was observed after 6 months (P < 0.05 ).

CONCLUSIONS

Soy germ isoflavone exerted favorable effects on vasomotor symptoms and lipid profile, showing itself to be an interesting alternative therapy for the postmenopausal women with contraindication for conventional HRT.

Perimenopause: More Than Hot Flushes and Night Sweats for Some Australian Women

OBJECTIVE

To identify the most common perimenopausal symptoms experienced by a group of Australian women and explore the extent to which those symptoms were distressing.

DESIGN

A quantitative survey.

SETTING

All women's health centers listed with the New South Wales Women's Information and Referral Service.

PARTICIPANTS

A convenience sample of 200 healthy women, aged 45 to 55 years, drawn from a statewide population of women residing in Australia.

MAIN OUTCOME MEASURE

The Women's Health Assessment Scale.

RESULTS

Most frequently occurring perimenopausal symptoms included forgetfulness, lack of energy, irritability, and weight gain. The most distressing perimenopausal symptoms included weight gain, heavy bleeding, poor concentration, leaking of urine, and feeling as though life were not worth living. Current use of hormone replacement therapy contributed to the prediction of both symptom occurrence and symptom distress.

CONCLUSION

Perimenopause is marked by more than hot flushes and night sweats; cognitive and affective changes are other distressing symptoms. The relationships between hormone replacement therapy use and both symptom occurrence and symptom distress warrant further investigation. In addition, practitioners should address concerns related to urinary incontinence, weight gain, cognitive and affective dysfunction, and general health status.

Nonestrogen Treatment Modalities for Vasomotor Symptoms Associated with Menopause

OBJECTIVE:

To systematically review the literature regarding the efficacy and safety of nonestrogen treatments for menopause-associated vasomotor symptoms not due to cancer or chemotherapy.

DATA SOURCES:

Pertinent literature and clinical studies were identified by searching MEDLINE (1966–February 2004) and EMBASE (1959–February 2004) using the key search terms vasomotor symptoms, hot flashes, and menopause. Bibliographies of relevant articles were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION:

English-language articles reporting efficacy and safety of nonestrogen treatment modalities for perimenopausal and postmenopausal vasomotor symptoms were evaluated. All articles identified from the data sources were evaluated, and all information deemed relevant was included. Emphasis was placed on randomized, double-blind, placebo-controlled clinical trials, as these provide the best efficacy and safety data. Studies evaluating treatment of vasomotor symptoms from other causes, such as cancer or chemotherapy, were excluded.

DATA SYNTHESIS:

Prescription medications reviewed for efficacy and safety in postmenopausal vasomotor symptoms include clonidine hydrochloride, danazol, gabapentin, methyldopa, mirtazapine, progestins, propranolol hydrochloride, selective serotonin-reuptake inhibitors (SSRIs), and venlafaxine. Nonprescription therapies reviewed include black cohosh, dong quai, evening primrose oil, physical activity, phytoestrogens, and red clover.

CONCLUSIONS:

According to this systematic literature review, postmenopausal vasomotor treatments that have been shown to be safe and effective in short-term use include black cohosh, exercise, gabapentin, medroxyprogesterone acetate, SSRIs (ie, paroxetine hydrochloride), and soy protein. Initial, small reports are suggestive for efficacy in menopausal vasomotor symptoms with megestrol acetate and venlafaxine.

Herbal product use and menopause symptom relief in primary care patients: a MetroNet study

OBJECTIVES

The four study objectives were to determine (1) the prevalence of use of four herbal product types promoted to reduce menopause symptoms (phytoestrogens, St. John's wort, Ginkgo biloba, and ginseng) among primary care patients approaching or in menopause, (2) the extent to which women who use these types of herbal products report menopause-related symptoms compared with herbal product nonusers, (3) the frequency of reported symptom reduction after use, and (4) if use was disclosed to their physicians.

METHODS

A cross-section of ethnically diverse women 40-55 years of age (35.5% African American, 60.2% Caucasian) who were recruited from eight primary care centers in Michigan to complete a self-report survey. The questionnaire included demographic items, health history, recent use of four herbal product types purported to relieve menopause symptoms and perception of symptom improvement, and interest in additional herbal product information.

RESULTS

Of 397 women, 24.9% reported taking, in the previous 6 months, at least one of the four study herbs. Herbal product use did not vary by patient demographics or health characteristics. Herbal product users reported more menopause symptoms than nonusers, and 68% of the users said that the herbs improved their symptoms; 56.4% said that their physician was aware of their herbal product use.

CONCLUSIONS

Primary care patients experiencing common menopausal symptoms are likely to use herbal products that are purported to provide menopause symptom relief, and many believe that these products improve their menopausal symptoms. Healthcare providers should be aware of patient's positive attitude, use patterns, and lack of disclosure of use of herbal medicines. Inquiry of herbal product use is another way for physicians to learn about patient self-medication of bothersome symptoms.

Severity of menopausal symptoms and use of both conventional and complementary/alternative therapies

OBJECTIVE

To describe the prevalence and correlates of using conventional therapies, complementary and alternative therapies, or a combination of both types of therapies for menopausal symptoms and to examine the association between severity of symptoms and type of therapy use.

DESIGN

Data on 2,602 women aged 45 years or older were gathered through a cross-sectional telephone survey conducted in Florida, Minnesota, and Tennessee during 1997 and 1998 using the Behavioral Risk Factor Surveillance System. Participants were asked a series of questions about their menopausal status, menopausal symptoms, healthcare provider selection in relation to menopause, and therapies used for menopausal symptoms.

RESULTS

Of the eight menopausal symptoms assessed, the highest prevalence estimates were reported for hot flashes (62.9%), night sweats (48.3%), and trouble sleeping (41.1%). The average number of symptoms (range 0-8) was 3.10 (SD +/- 2.25) and, for women reporting symptoms, the average symptom severity score (range 1-24) was 6.78 (SD +/-4.63). About 45% of the women had not consulted with a healthcare provider for treatment of menopausal symptoms or for medical conditions related to menopause even though only 16.3% did not report any of the symptoms included in the survey. Forty-six percent of the women used complementary/alternative therapy either alone or in combination with conventional therapies. Age-adjusted average symptom severity scores were significantly higher among women who had undergone a hysterectomy, with removal of the ovaries (7.73; 95% CI 7.33,8.12) or without (7.60; 95% CI 7.16,8.05), than among women who experienced a natural menopause (6.42; 95% CI 6.14,6.71). Average severity scores were significantly higher among women who used both conventional and complementary/alternative therapies in relation to menopause (8.61; 95% CI 8.26,8.96) than among women who used only conventional therapies (7.09; 95% CI 6.67,7.50). This statistically significant association persisted when adjusted for age, education, income, race/ethnicity, state of residence, and menopausal category.

CONCLUSIONS

In this sample, 46% of the women used complementary/alternative therapy either alone or in combination with conventional therapies, whereas a third of the women did not use any therapy in relation to menopause. Although causal inferences cannot be made, the menopausal symptom severity score was significantly higher among women who reported using a combination of conventional and complementary/alternative therapies than among women who used only conventional therapy, only complementary/alternative, or no therapy.

Menopause

Elevating women from the nadir of ovarian hypofunction has been a major driving force in developing hormonal strategies for the management of menopause. As indicated by recent evidence, however, this may have resulted in unacceptable morbidity in several women. Likewise, the use of menstrual cessation as the hallmark of menopause may have served the counterproductive effect of delaying the onset of appropriate preventive pharmacologic and non-pharmacologic strategies until the later years of life. Preventive and therapeutic strategies that target the menopausal phase of life exclusively are grossly inadequate. Unquestionably, the controversies that surround the precise health implications of menopause deal mainly with the risk of chronic disease. Health professionals are best advised to develop menopausal intervention strategies that parallel the continuum of a woman's life, beginning in adolescence and extending into later life. Preventive screening includes the following: History Relevant medical history Develop risk profile of chronic diseases (e.g., cardiovascular disease, cancer, osteoporosis) Dietary history Sexual history Physical exercise history Medication history Physical examination Body mass index evaluation Breast examination and instruction in examination technique Bimanual pelvic examination Nutritional assessment Investigation Cholesterol levels Stool for occult blood Thyroid function tests Papanicolaou smears HIV testing if positive risk factors Psychosocial evaluation Family relationships Job satisfaction Sexuality High-risk social behaviors Review perception of self-health Annual health examination is encouraged in all perimenopausal women. Additionally, preventive screening should be instituted, as appropriate, in all women of reproductive age.

Pharmacological effects of Cimicifuga racemosa

Cimicifuga racemosa is widely employed to relieve menopause symptoms for its hormonal-like action. However, recent experimental studies have not found an estrogenic action by this plant. The purpose of this systematic review is to analyse all experimental studies (in vivo and in vitro) performed on C. racemosa to elucidate its mechanism of action. Animal and in vitro experiments on C. racemosa were identified through a computerised literature searches performed on Medline (PubMed), Embase, Amed, CISCOM and Cochrane Library databases. In addition, bibliographies of the articles thus located were scanned for further relevant publications and manufactures of commercial C. racemosa preparations were asked to contribute published and unpublished material. No language restrictions were imposed. A total of 15 animal and 15 in vitro studies on C. racemosa have been found. Their results suggest that C. racemosa possesses a central activity instead of a hormonal effect. Further biological and chemical investigations are required to define its mechanism of action and to identify the compounds responsible of its actions.

A pilot study comparing the clinical effects of Jia-Wey Shiau-Yau San, a traditional Chinese herbal prescription, and a continuous combined hormone replacement therapy in postmenopausal women with climacteric symptoms

OBJECTIVES

Interest in use of alternative remedies for managing menopausal symptoms is increasing exponentially during these years. Jia-Wey Shiau-Yau San (JWSYS), one of the traditional Chinese herbal prescriptions, is a famous herbal remedy used for the management of various menopausal-related symptoms. A randomized, controlled pilot study was performed to evaluate the clinical effects of JWSYS compared with those of a continuous combined hormone replacement therapy, Premelle, on quality of life in non-hysterectomized postmenopausal women.

METHODS

The present trial compared the effect of a l6-week treatment with JWSYS or HRT (Premelle) in postmenopausal women with climacteric symptoms. The Greene Climacteric Scale was used to assess the clinical effects at baseline and after 16 weeks' treatment with either JWSYS or Premelle. The physiological parameters, such as follicle-stimulating hormone and estradiol levels, were also recorded at the same time points.

RESULTS

The results showed that JWSYS had a relatively lower discontinuation rate due to adverse effects, in particular the bleeding and breast tenderness. Both JWSYS and Premelle effectively alleviated most of the menopausal symptoms with no significant differences between treatment groups, whereas the beneficial effects of JWSYS were not mediated by hormone replacement-like effects. Moreover, JWSYS showed a good compliance and safety without estrogenic effects and metabolic alterations.

CONCLUSIONS

It was suggested that JWSYS was a safe and efficacious therapy and might be an alternative choice for relief of climacteric symptoms in postmenopausal women. However, the exact efficacy and clinical roles of JWSYS have not been convincingly demonstrated in this study because of the blinding approach and some statistical concerns, and only the possibility of its efficacy has been raised. Therefore, a blinding trial with more patient numbers to evaluate the efficacy of JWSYS deserves further study.

Association of complementary and alternative medicine use, demographic factors, and perimenopausal symptoms in a multiethnic sample of women: the ENDOW study

Complementary and alternative medicine (CAM) use is common in the United States, particularly among middle-aged women for symptoms commonly reported during perimenopause. The study examined the relationship between women's report of perimenopausal symptoms and the use of CAM and socioeconomic or cultural factors. The prevalence of CAM use was 33%; approximately 94% reported use of CAM therapies and 23% used CAM practitioners. Those who used CAM were younger and better educated; more often they reported pelvic pain and painful intercourse. The only demographic factor to predict use of alternative medicine was education.

Ethnic differences in use of complementary and alternative medicine at midlife: longitudinal results from SWAN participants

OBJECTIVES

We estimated the prevalence and longitudinal correlates of use of complementary and alternative medicine (CAM) at midlife among participants of the Study of Women's Health Across the Nation (SWAN).

METHODS

Multiple logistic regression was used to evaluate the relationship between baseline survey-reported symptoms and use of herbal, spiritual, and physical manipulation therapies 1 year later.

RESULTS

Almost half of all women had used CAM in the past year. Baseline psychological symptoms were associated with subsequent use of spiritual therapies among White and Chinese women. Baseline CAM use was a major predictor of subsequent use in White, Japanese, and Chinese women.

CONCLUSIONS

Baseline CAM use, rather than presence of symptoms, was the major predictor of subsequent CAM use. Premenopausal health behaviors are important determinants of choice of therapy during midlife.

Allopathic and complementary alternatives to hormone replacement therapy

Management of the menopause is a rapidly growing concern due to the ageing human population. The overall female lifespan has increased over the last century and up to a third of a woman's life is now spent in menopause. To that end, significant attention has been placed on maximising the quantity and quality of life in the menopausal years. The optimal management strategies are ones that are highly flexible and sensitive to an individual's expectations and concerns. Thus, while traditional oestrogen replacement therapy has been in place for > 20 years, there is now a greater interest in alternatives to this modality for those women who cannot or will not use it. This article reviews some of the alternative therapies that are being incorporated both in the allopathic and complementary medicine arenas.

Gynecology: select topics

Menopause, premenstrual syndrome, dysmenorrhea, female fertility, and mastalgia are common problems not easily treated by conventional medicine. Women often seek alternative therapies to help address these conditions. Some evidence points to the efficacy of black cohosh, exercise, and possibly Kava and St. John's wort, in the treatment of menopausal symptoms. Clinical trials indicate that symptoms of premenstrual syndrome may be alleviated with calcium, magnesium, vitamin E. Thiamine, omega-3 fatty acids, the Japanese herbal concoction, TSS, and calcium have proved useful in treating women with dysmenorrhea. Symptoms of mastalgia may be attenuated by evening primrose oil, chaste tree and flaxseed oil may be helpful.

Maximizing health in menopausal women with disabilities

There are nearly 30 million women with disabilities in the United States. Of these, more than 16 million are over the age of 50. Years ago, women with disabilities did not commonly live to the age of menopause, and, if they did, they reached this stage of life in a very debilitated condition. Now, women with disabilities are entering their mature years as active members of society who can look forward to productive futures. Because the health needs of women with disabilities might differ from those of other women, special attention should be focused on how physiological changes of perimenopausal and menopausal states affect this population. In addition to functional changes that might affect menopausal women with disabilities, basic health maintenance issues may be adversely affected by environmental factors. Physical barriers can influence compliance with preventive health screening that is essential in aging populations. Treatment options might need to be tailored to the individual. The disabling condition itself may progress, resulting in secondary conditions requiring creative interventions. A comprehensive evaluation and the development of a suitable management plan, which takes into account the multifactorial nature of aging as a disabled woman, are essential in delivering optimal care to this population.

Phytoestrogens in the management of the menopause: up-to-date

Despite the benefits of conventional hormone replacement therapy, some women are not candidates for this treatment and many others choose not to take it. As a result, there is growing interest among patients about natural alternatives. There is some evidence that phytoestrogens may offer protection against a wide range of human conditions, including breast cancer, cardiovascular disease, brain dysfunction, osteoporosis, and menopausal symptoms. The literature on the possible health benefits of phytoestrogens has expanded exponentially since the 1980s, mainly in response to funding initiatives by the U.S. government and soybean industries, and more lately by European and UK Ministries of Food. The physiological effects of phytoestrogens also have created a marketing opportunity that has been used by industry, particularly in soybean-producing countries such as the U.S. and Australia. Nevertheless, clinical applications for phytoestrogens are still in their infancy, and more interventional trials are required to reach definitive conclusions regarding their efficacy and safety, although they appear to represent a promising group of compounds, which may be useful in the future for the treatment of the menopausal syndrome. Also, the lack of clinical data presently available must signal caution in relation to the possible risk of adverse effects.

TARGET AUDIENCE

Obstetricians and Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to identify the various types of phytoestrogens, list the sources of phytoestrogens, and summarize the various effects of phytoestrogens.

Promoting health among perimenopausal women through diet and exercise

PURPOSE

To review the literature related to health promotion during the perimenopausal years and suggest methods for integrating those changes into the lifestyles of women in primary care.

DATA SOURCES

Selected scientific literature and guidelines for exercise programs.

CONCLUSIONS

The transition into perimenopause presents an opportunity for addressing health promotion issues, such as diet and exercise. As a woman senses perimenopausal changes, health awareness emerges. Such personal insight motivates the woman to implement lifestyle changes.

IMPLICATIONS FOR PRACTICE

Considering the average women will spend approximately one third of her life past menopause, a concerted effort is needed to ensure her well-being. Diet and exercise represent two modifiable areas of concern for perimenopausal women. Dietary selections of phytoestrogens, calcium, fiber and fat along with exercises plans are relatively simple interventions to begin the process of change.

The medicalization of menopause: critique and consequences

Menopause is in the process of becoming medicalized. Midlife and older women are being told that natural menopause is actually a deficiency condition requiring replacement hormones to maintain health and increase longevity. The three major diseases that are being linked with the lower estrogen levels of midlife and older women are heart disease, osteoporosis and, most recently, Alzheimer's disease. Primary prevention of these diseases is the rationale used for urging healthy women to take long-term hormones. Although there have been many challenges to these links and warnings against the widespread use of hormones, they have been either ignored or trivialized. In this article, the author examines mortality and morbidity statistics across and within nations and over time, critiques the major arguments used to support the notion that menopause places women at an increased risk of disease and that exogenous hormones reduce this risk, and discusses the adverse consequences of defining all midlife and older women as hormonally deficient and in need of medical intervention.

A comprehensive approach to the menopause: so far, one size should fit all

Although extensive studies have indicated that the benefits of hormone replacement therapy outweigh the risks, many women and health care providers have concerns about safety and side effects. Many alternative therapies are popular with patients, and menopausal women in the United States spent more than $600 million in 1999 alone purchasing these therapies. Several of the more commonly used alternative therapies for the menopause are critically appraised in this article. For women who choose not to take estrogen, and for those who do, the additional benefits of calcium, vitamin D, exercise, stress reduction, and different dietary and lifestyle adaptations may enhance the quality of life as they age. Although they have the potential for being effective and safe options, there has been limited clinical research for the other alternative therapies. Gynecologists and other health care providers should be aware of the lack of evidence for the effectiveness of most of these therapies when they address patient's questions and concerns. Our information about alternative therapies will increase in the coming years. Ultimately, the growing number of available treatment choices will allow individualization of the treatment. Nevertheless, until prospective studies with prolonged follow-up are conducted to evaluate the risks and benefits of different alternative therapies, hormone replacement therapy, which is better studied, will remain the treatment of first choice, and "one size fits all" will continue to describe the management plan for most peri- and postmenopausal women at least in the near future.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the various alternatives to hormonal therapy for menopausal symptoms, describe the effects of phytoestrogens in the management of menopausal symptoms, and explain the origin and clinical use of the more common herbal therapies.