Efficacy of black cohosh (Cimicifuga racemosa) medicines for treatment of menopausal symptoms - comments on major statements of the Cochrane Collaboration report 2012 "black cohosh (Cimicifuga spp.) for menopausal symptoms (review)"

The influence of Black Cohosh on hippocampal and hypothalamic gene expression profiles in ovariectomized rats and its potential to treat menopausal decrease in smell discrimination

PURPOSE

Menopause is associated with a decrease in smell discrimination ability. This study assessed the impact of black cohosh on hippocampal (HC) and hypothalamic (HT) gene expression profiles in rats, to understand, if herbal treatment has an impact on neurologic changes due to menopause and whether this could address a decrease in smell discrimination.

METHODS

HC and HT tissues from female Sprague Dawley rats (total n = 19) were analyzed at three different life stages: intact tissues of the HC (n = 4) and the HT (n = 4), oophorectomized tissues 3 months after oophorectomy (OVX) of the HC (n = 4) and the HT (n = 3), and tissues after treatment with an isopropanolic extract (iCR) from the rhizomes of black cohosh (60 mg/kg) for 3 months after OVX of the HC (n = 2) and the HT (n = 2).

MAIN OUTCOME MEASURES

To reveal underlying biological processes a gene set enrichment analysis (GSEA) was performed.

RESULTS

The GSEA revealed gene ontology terms that were significantly enriched, including several genes associated with the olfactory system, indicating biological processes regulated by treatment with iCR. Six olfactory receptor genes were further analyzed by another GSEA, demonstrating the possibility of iCR treatment to compensate for oophorectomy-induced changes.

CONCLUSION

Findings suggest that herbal treatment, such as iCR, has an esteeming impact on HC and HT genes that are changed through menopause. Further studies are needed to suggest black cohosh as a treatment option for decreased smell discrimination.

Cimicifuga racemosa isopropanolic extract for menopausal symptoms: an observational prospective case-control study

OBJECTIVE

We aimed to investigate the effectiveness of isopropanolic extract of Cimicifuga Racemosa (iCR) on reducing menopausal symptoms.

MATERIALS AND METHODS

A single-center observational prospective case-control study was performed to assess the improvement of menopausal symptoms in menopausal women undergone iCR administration (cases) or no treatment (controls). Menopausal symptoms were assessed through a modified version of the Menopause Rating Scale questionnaire (mMRS) at T₀ (baseline), T₁ (1-month follow-up), and T₂ (3 months follow-up). Univariate comparisons between cases and controls were performed by using the unpaired T test for two-tailed P value with α = 0.05 significance level.

RESULTS

A total of 163 women (83 cases and 80 controls) were enrolled in the study. The difference in menopausal symptoms between cases and controls from T₀ to T₂, and from T₀ to T₁, was found significant for all analyses. In particular, the difference in all menopausal symptoms was 20.56 ± 0.90 points (95%CI: 18.77-22.33, p < .001) from T₀ to T₂, and 10.69 ± 0.6 (95%CI: 9.49-11.88, p < .001) from T₀ to T₁.

CONCLUSION

iCR may be effective in reducing menopausal symptoms, both after 1 month and after 3 months of treatment. The improvement was higher in vasomotor symptoms, sleep problems, and irritability.

Pharmacological properties of durva swaras (Cynodon dactylon L. Pers.) in an ovariectomised rat model mimicking chronic menopausal syndrome

Hormonal replacement therapy (HRT), as the first-line management of chronic menopausal syndrome (CMS) in women, has limited application due to adverse effects. We aimed to evaluate the therapeutic potential of a herbal alternative (HALT), durva swaras (DS) of Cynodon dactylon L. Pers., in a CMS rat model. Female Sprague-Dawley rats were subjected to Sham and ovariectomy (OVX) surgery. OVX rats received either 0.11 mg/kg oestrogen as a positive treatment control or 1 (DS1), 2 (DS2), and 4 (DS3) g/kg DS for 160 days. Vaginal smear tests indicated the menopausal status. Routine clinical examinations, weekly body weights (BW), serum calcium, proinflammatory cytokines, and reproductive hormones levels were monitored. Clinical chemistry, body composition, bone mineral density (BMD), uterotrophic response, bone morphometry, and histopathology of major organs were evaluated. BW of OVX rats increased by 18-25% compared to Sham. Total fat and fat percentage were significantly elevated in the oestrogen group compared to DS2, DS3, and OVX group. DS treatment groups showed the levels of TNF- α was slightly reduced, while IL-1β and IL-6 levels were significantly reduced (P < 0.05) compared to the oestrogen treated group. DS treatment restored serum calcium levels, while BMD, bone quality, osteoblast/osteoclast ratio, and collagen levels improved in both DS and oestrogen treatment groups. The uterotrophic assay demonstrated non-oestrogenic activity of DS. Endometrial hyperplastic change was observed in oestrogen-treated rats. The preclinical non-oestrogenic activity of DS has therapeutic potential in CMS through anti-inflammatory and osteo-protective effects. Further clinical research into DS, as a viable HALT to HRT, is required.

Validation and Optimization of qPCR Method for Identification of Actaea racemosa (Black Cohosh) NHPs

BACKGROUND

Actaea racemosa (black cohosh) herbal dietary supplements are commonly used to treat menopausal symptoms in women. However, there is a considerable risk of contamination of A. racemosa herbal products in the natural health product (NHP) industry, impacting potential efficacy. Authentication of A. racemosa products is challenging because of the standard, multi-part analytical chemistry methods that may be too costly and not appropriate for both raw and finished products.

OBJECTIVE

In this paper, we discuss developing and validating quick alternative biotechnology methods to authenticate A. racemosa herbal dietary supplements, based on the use of a species-specific hydrolysis PCR probe assay.

METHODS

A qPCR-based species-specific hydrolysis probe assay was designed, validated, and optimized for precisely identifying the species of interest using the following analytical validation criteria: (1) specificity (accuracy) in determining the target species ingredient, while not identifying other non-target species; (2) sensitivity in detecting the smallest amount of the target material; and (3) reliability (repeatability and reproducibility) in detecting the target species in raw materials on a real-time PCR platform.

RESULTS

The results show that the species-specific hydrolysis probe assay was successfully developed for the raw materials and powders of A. racemosa. The specificity of the test was 100% to the target species. The efficiency of the assay was observed to be 99%, and the reliability of the assay was 100% for the raw/starting and powder materials.

CONCLUSION

The method developed in this study can be used to authenticate and perform qualitative analysis of A. racemosa supplements.

Ethnobotany, Phytochemistry, Traditional and Modern Uses of Actaea racemosa L. (Black cohosh): A Review

Actaea racemosa (AR) also known as Cimicifuga racemosa, is a perennial plant from Ranunculaceae family which was used as traditional remedies in treatment of various condition like rheumatoid muscular pain, headache, inflammation and dysmenorrhea. Actaea racemosa was basically native to Canada and the Eastern United State. This chapter proposed the ethnopharmacological uses of Actaea racemosa, and its phytochemical properties. Specifically, in this article we focused on use of Actaea racemose for menopausal and post-menopausal symptoms management. Electronic databases including PubMed and Scopus were searched for studies on Actaea racemose and its administration in management of menopausal symptoms. Chem Office software was also used in order to find chemical structures. The key words used as search terms were Cimicifuga racemose, Actaea racemose, Ranunculaceae, Black cohosh, Menopausal symptoms. We have included all relevant animal and human studies up to the date of publication. The analysis on Actaea racemose showed various indications for different plant's extracts. Approximately 131 chemical compounds have been isolated and identified from Actaea racemosa. According to recently studies, the most important chemicals known of the Actaea racemosa are phenolic compounds, chromones, triterpenoids, nitrogen-containing constituents. In addition, in vivo and in vitro studies reported wide range of pharmacological activities for Black cohosh like attenuating menopausal symptoms. Mechanism of action for some ethnomedicinal indications were made clear while some of its activities are not confirmed by pharmacological studies yet. Further investigations on its pharmacological properties are necessary to expand its clinical effective use. Also, additional large clinical trials are recommended for clarifying the effect of Black cohosh.

Efficacy and Safety of Nutraceutical on Menopausal Symptoms in Post-Menopausal Women: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Menopausal symptoms severely reduce the quality of life of post-menopausal women worldwide. Nutraceuticals are widely prescribed as a viable and safer alternative and complementary approach to standard therapies. The aim of this study was to evaluate the clinical efficacy and safety of a nutraceutical in post-menopausal women.

METHODS

The study was designed as a randomized, double-blinded, placebo-controlled clinical trial. Post-menopausal women aged 45-60 years old were enrolled and randomly assigned to either treatment (n = 50) or placebo group (n = 51). The intervention, a proprietary combination of soy isoflavone, black cohosh, chasteberry and evening primrose oil extracts, and the placebo, were administered to each group for total of 12 weeks. Menopausal symptoms, endocrine profiles, and blood chemistry were evaluated at baseline, 6 weeks, and 12 weeks of the study.

RESULTS

Nutraceutical supplementation demonstrated a statistically significant reduction in hot flushes and sweating (p < 0.0001), sleep problems (p < 0.0005), depressed mood (p = 0.0004) and irritability symptoms (p < 0.0003) compared with the placebo group. There were no significant differences in hormonal levels between the test and placebo groups, however levels of C-reactive protein were significantly decreased. Moreover, serum LDL-C and triglyceride levels were significantly lower than baseline levels in the treatment group at 6- and 12-week timepoints. No adverse effects were reported during the treatment.

CONCLUSION

These data indicate that a nutraceutical containing a combination of four medicinal herbs effectively and safely improved menopausal symptoms, as well as general health indicators, in post-menopausal women.

Structure-Guided Identification of Black Cohosh (Actaea racemosa) Triterpenoids with In Vitro Activity against Multiple Myeloma

Black cohosh is a well-established medicinal plant and preparations of its rootstock are used for the treatment of mild climacteric complaints. The compounds considered responsible for the therapeutic effect are triterpene glycosides, characterized by a cycloartane scaffold and a pentose moiety. Because some of these triterpenoids were found to exhibit relevant cytotoxic effects against human breast cancer cells, we decided to investigate their activity on multiple myeloma cell lines NCI-H929, OPM-2, and U266. In a systematic approach, we initially tested three known cytotoxic compounds of three different triterpenoid types, revealing the cimigenol-type triterpenoid as the most active constituent. In a second round, seven naturally occurring cimigenol derivatives were compared with respect to their sugar moiety and their substitution pattern at position C-25, leading to 25-O-methylcimigenol-3-O-α-L-arabinopyranoside as the most potent candidate. Interestingly, not only the methyl group at position C-25 increased the cytotoxic effect but also the arabinose moiety at position C-3 had an impact on the activity. The variety of cimigenol derivatives, moreover, allowed a detailed discussion of their structure–activity relationships, not only for their effect on multiple myeloma cells but also with regard to previous studies on the cytotoxicity of black cohosh triterpenoids.

Effect of CIMicifuga racemosa on metaBOLIC parameters in women with menopausal symptoms: a retrospective observational study (CIMBOLIC)

PURPOSE

To compare the influence of Cimicifuga racemosa extract (CR, Ze 450) and menopausal hormone therapy (MHT) on metabolic parameters and body weight in symptomatic menopausal women.

METHODS

In this monocentric retrospective cohort study, women over 40 years old with a first consultation between 2009 and 2016 were screened. Included in the final analysis were women treated with either MHT or CR and having at least one follow-up consultation. Metabolic serum parameters (lipids, glucose, insulin, and HOMA-IR), body weight, and menopausal symptoms [Menopause Rating Scale (MRS)-II] were the main outcome measures. Statistical analysis by uni- and multi-variable linear mixed-effects regression models assuming a linear effect of time.

RESULTS

174 women were included in the final analysis (CR n = 32, MHT n = 142). There was no difference between the groups regarding baseline characteristics (age, BMI, serum metabolic parameters, hormones, and blood pressure) and total MRS-II score, while reproductive stage differed significantly with more postmenopausal women treated with CR (83%) than MHT (55%) (p = 0.038). Median follow-up time was 12 months. In both groups, metabolic serum parameters and body weight did not change over the follow-up period, while total and MRS-II subscores improved.

CONCLUSION

Menopausal symptoms improved significantly in both groups (MHT and CR), while serum metabolic parameters and body weight did not change in MHT- or CR-treated women.

Effectiveness of the short-term use of Cimicifuga racemosa in the endothelial function of postmenopausal women: a double-blind, randomized, controlled trial

Objective: This study aimed to assess the effects of daily use of Cimicifuga racemosa on endothelial function through flow-mediated dilation of the brachial artery, when used for 28 days by healthy postmenopausal women.Methods: The double-blind, randomized, placebo-controlled study included two groups of postmenopausal women (n = 31 each). The subjects were clinically assessed and flow-mediated dilation of the brachial artery was measured before and after 28 days of treatment. Patients received dry extract corresponding to 160 mg C. racemosa (extract with 4 mg of triterpene glycosides) or placebo.Results: Mean age, time since menopause, and body mass index in the two groups were similar. The measurements of flow-mediated dilation of the brachial artery, pre and post treatment, respectively, showed a significant increase in patients who used C. racemosa (p = 0.006), unlike patients who used placebo, who did not present changes in the outcome of flow-mediated dilation of the brachial artery after 28 days of use (p ≥ 0.05). When comparing the number of women in both groups who showed an increase in flow-mediated dilation, a significant difference was found in the measurements of the treated group after the use of the medication (p = 0.018).Conclusions: Daily use of 160 mg C. racemosa extract by postmenopausal women for 28 days beneficially influences endothelial function by promoting elasticity of the brachial artery.

Menopause hormone therapy: latest developments and clinical practice

Menopause hormone therapy (MHT) is the most efficient treatment for symptoms of acute climacteric syndrome and for efficient prevention of long-term estrogen deficiency. Vaginal administration of low doses of estrogen is a therapy of choice for treatment and prevention of urogenital atrophy and its consequences. Systemic treatment may include estrogen, but an equally efficient alternative is tibolone. Nonhormonal therapy relies on phytoestrogens, black cohosh extract, and serotonin reuptake inhibitors.

Quantification of the total amount of black cohosh cycloartanoids by integration of one specific 1H NMR signal

Quantitative analysis is an important field in the quality control of medicinal plants, aiming to determine the amount of pharmacologically active constituents in complex matrices. Often biological effects of herbal drugs are not restricted to single compounds, but are rather caused by a number of often biogenetically related plant metabolites. Depending on the complexity of the analyzed plant extract, conflicts between accuracy, such as total content assays using photometric or colorimetric methods, and comprehensiveness, e.g. quantification of one or a few lead compounds can occur. In this study, we present a qHNMR approach determining the total amount of cycloartanoids in black cohosh (Actaea racemosa) rhizomes. Perdeuterated methanol containing 1,2,4,5-tetrachloro-3-nitrobenzene as an internal standard was used for extraction. Amounts of cycloartanoids were then measured by integrating ¹H NMR signals of all cycloartenoids' H-19 exo protons. Due to their unusually low chemical shifts, these signals are well separated from all remaining signals in crude extracts. Thus, accurate (recovery rates of 99.5-102.5%) and precise (relative standard deviations below 2.5%) quantification of cycloartanoids was accomplished. To the best of our knowledge, this is the first example of a quantification of the total amount of a pharmacologically relevant compound class by integration of one ¹H NMR signal characteristic for all members of this particular compound class. Additionally, we propose a new term and unit for the evaluation of medicinal plants and herbal medicinal products: the "specific partial amount of substance" of pharmacologically active constituents, indicated in mmol/g.

Effects of black cohosh and estrogen on core body and tail-skin temperatures in ovariectomized rats by telemetric monitoring with dual thermistor probes

OBJECTIVES

To investigate the effects of black cohosh and estrogen on the temperature in ovariectomized rats, the core body temperature (CBT) and tail-skin temperature (TST) were simultaneously monitored and the relationship between these two temperatures was explored.

METHODS

Twenty-four female Sprague-Dawley rats aged 8 weeks were randomly divided into four groups: sham-operated (SHAM), ovariectomized (OVX), OVX treated with estradiol valerate (OVX + E), and OVX treated with isopropanolic black cohosh extract (OVX + ICR). Rats were sham-operated or ovariectomized and were implanted with telemetry transmitters with dual thermistor probes. Two weeks after surgery, the animals were treated with drugs for 4 weeks. During the last week of the treatments, the dynamic temperature profiles of the CBT and TST were collected.

RESULTS

The average CBT and TST, TST fluctuation frequency, and the average amplitude fluctuation were significantly higher in OVX than in SHAM rats. In addition, dramatic fluctuations of TST in OVX rats occurred at the time points of the day when the CBTs were lower in OVX rats than in SHAM rats. Treatment of OVX rats with estradiol valerate or isopropanolic black cohosh extract markedly decreased the average CBT and TST, TST fluctuation frequency, and the average amplitude fluctuation. Moreover, CBT was found to be significantly higher, while TST was lower in OVX + E than in OVX + ICR rats.

CONCLUSIONS

Both black cohosh and estradiol treatments ameliorated the abnormal thermoregulation in OVX rats. In particular, black cohosh reduced CBT better than estradiol and estradiol reduced TST better than black cohosh.

Motivations for Botanical Use by Socioeconomically Diverse, Urban Adults: Does Evidence Support Motivation?

OBJECTIVE

The study objectives were to characterize botanical dietary supplement (BDS) use and to compare the motivations for botanical supplement (BS) use to the efficacy of the botanical in a socioeconomically and racially diverse urban adult population.

METHODS

Subjects were from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, a 20-year prospective health disparities study with African American and white adults from Baltimore, Maryland. All study participants completed two dietary recalls and a dietary supplement (DS) questionnaire in Wave 3 (n = 2140). Diet quality was evaluated by the Healthy Eating Index-2010 and the Mean Adequacy Ratio for 17 micronutrients. A comparison of reported motivations to efficacy reported in the literature of single BS was conducted.

RESULTS

Approximately 50% (1062/2140) of participants took DS. Of these, 8% (n = 178) reported taking either BS or BDS. It was found that BDS users had better diet quality than DS users as well as nonusers of DS. The top three motivations for BDS users were to improve overall health, to maintain health, and to supplement the diet. There is limited evidence for the efficacy of most BS. Review of the efficacy of the 15 BS reported by ≥5% of the study population revealed beneficial health roles for only fiber, gingko biloba extract EGb 761, and hawthorn berry.

CONCLUSION

To the authors' knowledge, this study is the first to report a better quality diet with BDS use for a racially diverse urban population. Yet, improvement in diet is needed because overall quality did not achieve current recommendations. To improve overall health, it may be beneficial for this population to focus on dietary modifications to reduce the risks associated with chronic diseases. In general, the reported motivations for BS use were not supported by clinical evidence.

Management of sexuality, intimacy, and menopause symptoms in patients with ovarian cancer

Issues of sexuality, intimacy, and early menopause significantly impact the quality of life of patients following the diagnosis and treatment of ovarian cancer. These are undertreated problems. Successful treatment requires the provider's awareness of the problem, ability to identify it, and willingness to treat it. Unfortunately many providers do not address these issues in the pretreatment or perioperative period. Furthermore, patients do not often alert their providers to their symptoms. While systemic hormone therapy may improve many of the issues, they are not appropriate for all patients given their action on estrogen receptors. However, other nonhormonal treatments exist including selective serotonin reuptake inhibitors, antiepileptics, natural remedies, and pelvic floor physical therapy. In addition psychological care and the involvement of the partner can be helpful in managing the sexual health concerns of these patients. At the time of diagnosis or at initial consultation, women should be informed of the potential physiologic, hormonal, and psychosocial effects of ovarian cancer on sexuality and that there is a multimodal approach to dealing with symptoms.

The management of sexuality, intimacy, and menopause symptoms (SIMS) after prophylactic bilateral salpingo-oophorectomy: How to maintain sexual health in "previvors"

"Previvors", or "pre-survivors", are individuals who do not have cancer but have a genetic predisposition to cancer. One such example is women with BRCA mutations. As a result of their predisposition to cancer, many will undergo a bilateral salpingo-oophorectomy when they are premenopausal. For premenopausal women, the removal of ovaries results in the depletion of estrogen, immediate menopause, and, in many cases, resultant Sexuality, Intimacy, and Menopausal Symptoms (SIMS). Furthermore, they may undergo changes in body image. SIMS are underreported by patients and underdiagnosed by practitioners. At the time of diagnosis or at preoperative visits, women should be informed of the potential physiologic, hormonal, and psychosocial effects of their risk-reducing surgery. There are many modalities for management of these symptoms. Successful treatment requires the provider's awareness of the problem, ability to identify it, and willingness to treat it.

An interpretive review of consensus statements on clinical guideline development and their application in the field of traditional and complementary medicine

BACKGROUND

Despite ongoing consumer demand and an emerging scientific evidence-base for traditional and complementary medicine (T&CM), there remains a paucity of reliable information in standard clinical guidelines about their use. Often T&CM interventions are not mentioned, or the recommendations arising from these guidelines are unhelpful to end-users (i.e. patients, practitioners and policy makers). Insufficient evidence of efficacy may be a contributing factor; however, often informative recommendations could still be made by drawing on relevant information from other avenues. In light of this, the aim of this research was to review national and internationally endorsed consensus statements for clinical guideline developers, and to interpret how to apply these methods when making recommendations regarding the use of T&CM.

METHOD

The critical interpretive review method was used to identify and appraise relevant consensus statements published between 1995 and 2015. The statements were identified using a purposive sampling technique until data saturation was reached. The most recent edition of a statement was included in the analysis. The content, scope and themes of the statements were compared and interpreted within the context of the T&CM setting; including history, regulation, use, emerging scientific evidence-base and existing guidelines.

RESULTS

Eight consensus statements were included in the interpretive review. Searching stopped at this stage as no new major themes were identified. The five themes relevant to the challenges of developing T&CM guidelines were: (1) framing the question; (2) the limitations of using an evidence hierarchy; (3) strategies for dealing with insufficient, high quality evidence; (4) the importance of qualifying a recommendation; and (5) the need for structured consensus development.

CONCLUSION

Evidence regarding safety, efficacy and cost effectiveness are not the only information required to make recommendations for clinical guidelines. Modifying factors such as burden of disease, magnitude of effect, current use, demand, equity and ease of integration should also be considered. Uptake of the recommendations arising from this review are expected to result in the development of higher quality clinical guidelines that offer greater assistance to those seeking answers about the appropriate use of T&CM.

60 years of Cimicifuga racemosa medicinal products : Clinical research milestones, current study findings and current development

Cimicifuga racemosa (CR) extracts are important worldwide as therapy for menopausal symptoms. The first medicinal product from CR has been available since 1956 (Germany, Remifemin® [Schaper & Brümmer, Salzgitter, Germany], isopropanolic extract iCR). This review describes how CR developed, via clinical studies on safety (breast, breast cancer, endometrium, liver) and efficacy, into a successful and safe medicinal product in Germany, Europe and the world. In line with developing legal frameworks for medicinal products in Germany and Europe, clinical studies on CR were observational during the 50s and 70s, and controlled studies since the 80s. The first placebo-controlled study emerged 1986. From 2000 to 2015, a total of 28 clinical studies in Europe, America and Asia were published on the efficacy of CR. In these studies, 11,073 patients received a CR-based medicinal product, 93% thereof iCR. A meta-analysis of all nine placebo-controlled studies published until 2013 confirmed the reliable efficacy of CR-based medicinal products for menopausal symptoms.

Role of the ER/NO/cGMP Signaling Pathway in the Promotion of Osteogenic Differentiation of Rat Bone Marrow Mesenchymal Stem Cells by Actaea racemosa Extract

Purpose/Objective. To investigate the effect of Actaea racemosa (AR) extract on in vitro osteogenic differentiation of rat bone marrow mesenchymal stem cells (BMSCs) via the ER/NO/cGMP signaling pathway. Methods/Materials. Rat BMSCs were treated with osteogenic differentiation-inducing medium containing AR; estrogen receptor antagonist, ICI 182,780 (10^-6 mol/L); and nitric oxide synthase inhibitor, L-nitro arginine methyl ester (L-NAME, 6 × 10^-3 mol/L). Markers of osteogenic differentiation (alkaline phosphatase [ALP] activity, osteocalcin secretion, and calcium ion deposit levels) and the levels of key signaling molecules (nitric oxide synthase [NOS], nitric oxide [NO], and cyclic guanosine monophosphate [cGMP]) were assessed. Results. AR (10^-1-10^-6 g/L) increased ALP activity in a dose-dependent manner, and the highest ALP, osteocalcin, and osteoprotegerin activities were achieved at an AR concentration of 10^-4 g/L. Therefore, the concentration of 10^-4 g/L was used for promoting osteogenic differentiation of BMSCs in subsequent analyses. At this concentration, AR increased the levels of NO and cGMP, and such effects could be blocked by the estrogen receptor antagonist (ICI 182,780) and nitric oxide synthase inhibitor (L-NAME). Conclusion. AR induced osteogenic differentiation of rat BMSCs through the ER/NO/cGMP signaling pathway. This finding provides the theoretical foundation for the mechanism of AR in the treatment of postmenopausal osteoporosis.

An update on drugs for the treatment of menopausal symptoms

INTRODUCTION

Vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) are recognized as the most frequent and bothersome symptoms associated with menopause. There are different treatments for both groups of symptoms, being necessary to individualize them.

AREAS COVERED

There are different therapies for VMS including hormonal treatments with estrogen, with and without progestins; the new alternative, tissue-selective estrogen complex (TSEC), tibolone, phytoestrogens and only progestins. Evidence also shows efficacy with selective serotonin reuptake inhibitors. Other nonhormonal alternatives exist as second-line treatments, all with not conclusive results. The GSM can be treated with nonhormonal treatments such as vaginal lubricants and moisturizers, other alternatives as vaginal laser needs to have more evidence. On the other hand, there is the possibility to use the hormonal treatments with systemic or local estrogen, which are the most effective treatment, the TSEC and the newest selective estrogen receptor modulator (SERM), ospemifene. Therapies with testosterone and dehydroepiandrosterone (DHEA) are still under study. The GSM can be treated with nonhormonal treatments such as vaginal lubricants and moisturizers, and other alternatives as vaginal laser need to have more evidence. On the other hand, there is the possibility to use the hormonal treatments with systemic or local estrogen, which are the most effective treatment, the TSEC and the newest SERM, ospemifene. Therapies with testosterone and DHEA are still under study.

EXPERT OPINION

The increasing numbers of therapies for menopausal symptoms open up new options, but we must individualize treatments. New possibilities arise in patients who did not have them and which can improve compliance and is also important to design strategies using combined or sequential treatments.

A systematic review of non-hormonal treatments of vasomotor symptoms in climacteric and cancer patients

The cardinal climacteric symptoms of hot flushes and night sweats affect 24-93% of all women during the physiological transition from reproductive to post-reproductive life. Though efficacious, hormonal therapy and partial oestrogenic compounds are linked to a significant increase in breast cancer. Non-hormonal treatments are thus greatly appreciated.

This systematic review of published hormonal and non-hormonal treatments for climacteric, and breast and prostate cancer-associated hot flushes, examines clinical efficacy and therapy-related cancer risk modulation.

A PubMed search included literature up to June 19, 2014 without limits for initial dates or language, with the search terms, (hot flush* OR hot flash*) AND (clinical trial* OR clinical stud*) AND (randomi* OR observational) NOT review). Retrieved references identified further papers. The focus was on hot flushes; other symptoms (night sweats, irritability, etc.) were not specifically screened. Included were some 610 clinical studies where a measured effect of the intervention, intensity and severity were documented, and where patients received treatment of pharmaceutical quality. Only 147 of these references described studies with alternative non-hormonal treatments in post-menopausal women and in breast and prostate cancer survivors; these results are presented in Additional file 1.

The most effective hot flush treatment is oestrogenic hormones, or a combination of oestrogen and progestins, though benefits are partially outweighed by a significantly increased risk for breast cancer development.

This review illustrates that certain non-hormonal treatments, including selective serotonin reuptake inhibitors, gabapentin/pregabalin, and Cimicifuga racemosa extracts, show a positive risk-benefit ratio.

Key points

Several non-hormonal alternatives to hormonal therapy have been established and registered for the treatment of vasomotor climacteric symptoms in peri- and post-menopausal women.

There are indications that non-hormonal treatments are useful alternatives in patients with a history of breast and prostate cancer. However, confirmation by larger clinical trials is required.

Effect of Isopropanolic Cimicifuga racemosa Extract on Uterine Fibroids in Comparison with Tibolone among Patients of a Recent Randomized, Double Blind, Parallel-Controlled Study in Chinese Women with Menopausal Symptoms

Objective. Effect of isopropanolic Cimicifuga racemosa extract (iCR) on uterine fibroid size compared with tibolone. Method. The randomized, double-blind, controlled study in China enrolled 244 patients aged 40-60 years with menopausal symptoms (Kupperman Menopause Index ≥ 15). The participants were treated with either iCR of 40 mg crude drug/day (N = 122) or tibolone 2.5 mg/day (N = 122) orally for 3 months in 2004. Now, we investigated the subset of all women (N = 62) with at least one uterine fibroid at onset of treatment for the effect of iCR (N = 34) on fibroid size compared with tibolone (N = 28) by transvaginal ultrasonography. Results. The median myoma volume decreased upon iCR by as much as -30% (P = 0.016) but increased upon tibolone by +4.7%. The percentage of volume change, mean diameter change and geometric mean diameter change of the iCR group compared to tibolone were statistically significant (P = 0.016, 0.021, 0.016 respectively). Conclusion. Our results suggest that iCR (Remifemin) is a valid herbal medicinal product in patients with uterine myomas as it provides adequate relief from menopausal symptoms and inhibits growth of the myomas in contrast to tibolone.

Effects of remifemin treatment on bone integrity and remodeling in rats with ovariectomy-induced osteoporosis

This study aims to evaluate the effects of Remifemin (isopropanolic extract of Cimicifuga Racemosa) on postmenopausal osteoporosis. 120 female Sprague-Dawley rats were randomly assigned to four groups: sham surgery with vehicle, ovariectomy with vehicle, ovariectomy with estradiol valerate, or ovariectomy with Remifemin. Daily oral administrations of the vehicle, estradiol valerate, or Remifemin began 2 weeks after surgery and lasted to 4, 8, or 12 weeks. Ten rats in each group were sacrificed at each timestep with assessment of bone mineral density, trabecular bone structure, and biomechanical parameters of the femur and lumbar vertebra. Bone turnover markers were evaluated 12 weeks after surgery. Both drugs prevented bone density loss in the distal end of the femur and preserved the trabecular bone structure in both the lumbar vertebra and distal end of the femur following ovariectomy. Both drugs protected bone stiffness at the tested regions and reduced bone reabsorption in ovariectomized rats. The preventive effects of Remifemin against bone-loss can rival those of estradiol valerate if treatment duration is adequately extended. In conclusion, Remifemin may demonstrate equivalent effects to estradiol valerate in terms of preventing postmenopausal osteoporosis.