Menopause is most commonly defined as a lack of menstrual cycle for a consistent 12 month period. Although the process into menopause is biologically normal, many women experience uncomfortable symptoms such as hot flashes, sleep disturbances, vaginal dryness, resistant weight loss, low energy and mood changes. These symptoms often come and go and vary in severity as hormone levels change. It is important to keep up with your doctor’s recommended visit schedule for preventative health care and discuss your concerns at this time.
There are treatment options available for symptoms management through both conventional and alternative medicine. The most common conventional therapy used is hormone replacement therapy.
However, it is not easy to make the decision about whether or not to use hormone replacement therapy, especially since recent clinical trials have led physicians and patients to question the safety of this protocol. Hormone therapy for menopause is complex and each individual must consider the risks and benefits, which vary from the type of therapy and route used.
What is Hormone Replacement Therapy?
In the past, hormone therapy was prescribed to improve overall well being, reduce symptoms of menopause and to prevent cardiac disease. Today, although useful for symptom management, a 13 year follow up study showed estrogen and progesterone therapy increased the risk of breast cancer and blood clots when used for greater than 3-5 years. This is now leading physicians to think twice before prescribing(1).
If the benefits outweigh the risks for a patient, estradiol is considered first line treatment for women without a uterus or combined with progesterone for women with a uterus (1). A combination therapy of estrogen and progesterone is used in women with a uterus because estrogen alone has been shown to increase risk of endometrial cancer (1).
For women at high risk of cardiovascular disease, breast cancer, or blood clots, non-hormone therapies are recommended.
The Benefits of HRT
Estrogen is the most effective treatment for vasomotor symptoms (e.g. hot flashes, night sweats) and has been shown to reduce hot flashes up to 80-90% as well as decrease fracture risk. The most widely accepted approach is to take the lowest effective dose for the shortest amount of time. Transdermal or topical estrogen may be recommended in women who have a higher risk for blood clots or have medical dangers such as elevated triglycerides.
The Downsides of HRT
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In addition to the increased risk of breast cancer and cardiovascular disease mentioned above, there are more immediate side-effects to consider:
Side effects of estrogen therapy include:
- Uterine bleeding
- Breast tenderness
Side effects of progestins include:
- Breast tenderness
- Uterine bleeding
- Possible increased risk of blood clots, cardiovascular events and breast cancer (3).
Other pharmaceutical treatments for management of moderate to severe symptoms are antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) or gabapentin, pregabalin, and clonidine (2).
Since the results of the Women’s Health Initiative showing long-term adverse effects associated with hormone therapy were released, there has been an increased interest in using complementary and alternative medicine (CAM) treatments to relieve menopausal symptoms.
Women looking for more natural or safer means to treat hot flashes, night sweats, and other menopausal symptoms often turn to breathing techniques, yoga, phytoestrogens, sage, or black cohosh. Unfortunately few well-conducted studies looking at the efficacy of these treatments exist.
Nutritional interventions are often used to help deal with symptoms. Foods like soy and flax seeds contain phytoestrogens, which are estrogen-like compounds. Consuming additional estrogen can help offset some of the unpleasant side effects of menopause due to a decreased level of estrogen in the body.
Observational studies suggest a possible beneficial effect of a dietary soy supplement in the management of menopausal symptoms such as hot flashes, however, large randomized control trials are lacking (4). Even though studies have not proven that soy and flax significantly reduce menopausal symptoms, both (whole, organic) soy and flax seeds are healthy foods that you want to include in your diet. However, if you have had breast cancer, talk to your doctor before adding soy or flax foods to your diet.
Sage aka. Salvia officinalis
One of the more commonly used herbal medicinal products for the treatment of menopausal hot flashes is sage tea. In one clinical study, Salvia officinalis tincture was found to reduce hot flash frequency and intensity (6). Interestingly enough more research exists to support Salvia officinalis use in controlling hot flashes in prostate cancer patients treated with androgen deprivation therapy (7). Whether or not the same conclusions can be extrapolated to menopausal women is unknown.
Black Cohosh aka. Actaea racemosa
Out of the more natural approaches to treat symptoms of menopause, black cohosh (cimicifuga racemosa) is by far the most researched. A 2013 double blind randomized control trial showed black cohosh significantly improved subjective scores when rating the severity of hot flashes, mood disturbances, as well as sexual and physical symptoms (8). Even though this one study showed benefits over placebo, there is currently insufficient evidence to conclusively support the use of black cohosh for menopausal symptoms. The positive research that does exist however, justifies further studies in this area.
Chaste Tree aka. Vitex agnus-castus
Vitex is a herb that is currently used clinically and promoted as being effective in the management of menopause-related complaints. Large scale randomized control trials are a lacking but there is some promising research that suggests possible significant benefit. In one small randomized control trial, vitex was one component of a menopause herbal formulation called Phyto-Female Complex. This complex was found to be significantly superior to placebo for the treatment of menopausal hot flushes and night sweats in 50 healthy peri- and postmenopausal women, aged 44–65 years (9).
Women who completed the study reported a 73% decrease in the number of hot flushes at the end of the 3-month treatment period in compared with 38% in the placebo group (9). Finally, the number of night sweats was reduced by 69% in the treatment group and 29% in the control group which meant better sleep quality! While these findings are encouraging larger RCT should be conducted to determine the true magnitude of effect.
Promising New Research: Using a combination approach
A recent 2017 study shows promising effects for the treatment of hot flashes and sleep disturbances. Combined, these symptoms negatively affect the quality of life of postmenopausal women. Almost half of all menopausal women complain of sleep disorders, frequently associated with hot flashes and mood disturbances (5). This randomized control study combined herbs, agnus-castus and magnolia, with soy isoflavones and lactobacilli. Results from this study showed that this combination can effectively and safely be used in symptomatic postmenopausal women, mainly when quality of sleep is the most disturbing complaint (5).
Diet & Lifestyle:
Of all the alternative therapies for menopausal symptoms, soy and soy isoflavones (discussed above) have the strongest evidence for reducing the number of and severity of hot flashes. In addition to adding soy products into the diet, menopausal women struggling with the symptom of hot flashes may consider some of these other diet and lifestyle interventions.
Firstly, exercise has been shown to be beneficial. There is nothing as inexpensive as exercise that offers as many health benefits, such as improved cardiovascular and bone health (10). In fact, a sedentary lifestyle, meaning less than 30 minutes of physical activity three times per week, is associated with a higher severity of menopausal symptoms including hot flashes (11). As a woman enters menopause, It is thought that concentration of endorphins decreases as estrogen production declines. Exercise may improve menopausal symptoms through increased endorphin production, however, current evidence is limited and does not totally support this theory.
Other lifestyle interventions thought to increase endorphins include having sex, laughing, consuming dark chocolate, surrounding yourself with friends, listening to music, and managing stress. And lastly, as a baseline it is important to support overall health (especially adrenal health) during this time with a healthy diet rich in whole, nutrient-dense foods.
In order to promote optimal health it is important to start with mastering the fundamentals, diet and lifestyle. Even if dietary changes, lifestyle, and natural therapies do not completely resolve your symptoms, their effects may be enough to significantly improve your quality of life. Next, educate yourself on all your options as well as the benefits and risk and benefits of each treatment. Consider what your symptoms are when making your individual choice on a therapy. If you speak with your doctor and decide hormone replacement treatments are for you, make sure to attend follow up appointments and continue your doctors suggested routine screening recommendations.
- Hill, D., Crider, M. and Hill, S. (2017). Hormone Therapy and Other Treatments for Symptoms of Menopause. [online] Aafp.org. Available at: http://www.aafp.org/afp/2016/1201/p884.html#afp20161201p884-b3 [Accessed 26 Sep. 2017].
- North American Menopause Society : The 2012 hormone therapy position statement of the North American Menopause Society. Menopause 2012; 19: pp. 257-271
- Schiff I, Tulchinsky D, Cramer D, et al.JAMA.1980;244:1443-1445.
- Cianci, A., et al. “Soy isoflavones, inulin, calcium, and vitamin D3 in post-menopausal hot flushes: An Observational Study.” Clinical and experimental obstetrics & gynecology 42.6 (2015): 743-745.
- De Franciscis, Pasquale, et al. “Adding Agnus Castus and Magnolia to Soy Isoflavones Relieves Sleep Disturbances Besides Postmenopausal Vasomotor Symptoms-Long Term Safety and Effectiveness.” Nutrients 9.2 (2017): 129.
- Rahte, Sinikka, et al. “Salvia officinalis for hot flushes: towards determination of mechanism of activity and active principles.” Planta medica 79.09 (2013): 753-760.
- Vandecasteele, Katrien, et al. “Evaluation of the efficacy and safety of Salvia officinalis in controlling hot flashes in prostate cancer patients treated with androgen deprivation.” Phytotherapy Research 26.2 (2012): 208-213.
- Mohammad-Alizadeh-Charandabi, Sakineh, et al. “Efficacy of black cohosh (Cimicifuga racemosa L.) in treating early symptoms of menopause: a randomized clinical trial.” Chinese medicine 8.1 (2013): 20.
- van Die, Margaret Diana, et al. “Vitex agnus-castus (Chaste-Tree/Berry) in the treatment of menopause-related complaints.” The Journal of Alternative and Complementary Medicine 15.8 (2009): 853-862.
- Anderson, Todd J., et al. “2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult.” Canadian Journal of Cardiology 29.2 (2013): 151-167.
- Moore, Thea R., Rachel B. Franks, and Carol Fox. “Review of Efficacy of Complementary and Alternative Medicine Treatments for Menopausal Symptoms.” Journal of Midwifery & Women’s Health (2017).
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