Perimenopause and menopause alternatives to conventional HRT for symptom management - Women's Health Update

Townsend Letter for Doctors and Patients,  Nov, 2002  by Tori Hudson

• E-mail
• Print
• Link

In light of the recent new research from the HERS II and WHI studies, I thought it was a good time to review some of the botanical, nutritional and hormonal alternatives to conventional hormone replacement therapy.

Natural therapies are very well suited for the symptoms of perimenopause and menopause. Conventional hormone replacement therapy (HRT) is not the only option. Women who should not or do not want to take hormones may turn to herbal and nutritional therapies for managing their menopausal symptoms and risk factors. These natural therapies are increasingly popular and have a growing body of scientific evidence to support their efficacy. A 1998 report indicates that 42% of adults have tried alternative medicines. (1) According to a survey in 1993 of 1,539 adults, one in three said they used at least one alternative therapy in the past year. (2)

Shortly after the July 9, 2002 release of the WHI results and early discontinuation of the federally funded study, Gallup interviewed 935 women, asking them about their use of HRT. (3) Only 37% of women tell Gallup they feel better able to make decisions about HRT as a result of recent news reports about the treatment. Another 44% say the reports have left them more confused. The majority of women are unsure if HRT is mostly harmful or beneficial; 40% of those currently taking conventional HRT say they are considering stopping their treatment as a result of reading the recent reports in the news. The majority, however, say they will not stop the treatment based on the recent news reports.

Non-hormonal alternatives for menopause symptoms are increasingly popular, despite small amounts of research to demonstrate efficacy. Many women are determined to utilize therapies that are non-hormonal, natural hormones, lower dose hormones in combination with botanicals, in order to create a risk to benefit ratio that they feel comfortable with.

Phytoestrogens

Plants manufacture thousands of chemical compounds vital to the health and function of the plant. Those chemical compounds, generally known as micro-nutrients, are consumed in the diet by humans whenever the plants are eaten. One of these classes of chemical compounds manufactured by plants are known as phytoestrogens. Over 300 plants contain phytoestrogen compounds. They comprise a large part of our diet, and are found in medicinal plants as well. There are several sub classifications of phytoestrogens; the following partial list may be helpful:

Phytoestrogen  Plant source
Lignans        Vegetables, fruits, nuts, cereals,
               spices, seeds; especially flax
               seeds
Isoflavones    Spinach, fruits, clovers, peas,
               beans; expecially soy
Flavones       Beans, green vegetables, fruits,
               nuts
Chalcones      Licorice root
Diterpenoids   Coffee
Triterpenoids  Licorice root, hops
Coumarins      Cabbage, peas, spinach, licorice,
               clover
Acyclics       Hops

In this column we will concentrate on the isoflavones. Isoflavones have a similar structure to endogenous steroidal sex hormones. They have the ability to bind to estrogen receptors on human cells, and in women, they have a preference for binding to the beta form of the estrogen receptor. As a result of this, they preferentially express estrogenic effects in the central nervous system, blood vessels, bone and skin, and they do so without causing stimulation of the breast or uterus. (4) It is estimated that soy isoflavones are 1/400th to 1/1000th the potency of estradiol. However, in that they are structurally related to endogenous estrogens, they are able to mimic some of the effects of estrogen, but to a significantly lesser degree. Uniquely, isoflavones may also act as anti-estrogens, much like "Selective Estrogen Receptor Modulators" (SERMs). Isoflavones can be thought of as one of nature's SERMs. Therapeutically, isoflavones may alleviate menopause symptoms, and lower the incidence of osteoporosis, corona ry artery disease, breast and uterine cancer. (5)

Soy Isoflavones

Several studies have now been done on the effect of soy isoflavones on vasomotor symptoms. Most show a benefit, but others do not. Numerous soy isoflavone studies have reported improvement in vasomotor symptoms in menopausal women. Six published studies report improvements with soy protein rich in isoflavones. (6-11) Four used soy protein or soy foods and two used soy extracts. Criticisms of these studies have been that relatively small numbers of women were studied, most were short term (not more than 12 weeks), the benefit only up to about a 45% reduction, and not all were double-blind clinical trials. In the year 2000, we began to see publication of studies that were not so promising. A soy product studied in breast cancer patients with hot flashes concluded that the soy did not alleviate hot flashes. (12) Some were on Tamoxifen some were not; (twice as many were on Tamoxifen), although there was no clear difference in the effect of soy on hot flashes in either group. Patients ranged in age from 18 to over 50. Perhaps the most glaring fault of the study was lack of information about who was postmenopausal versus premenopausal and who had natural menopause, chemotherapy induced menopause, or surgical menopause. The most current study on soy isoflavones and vasomotor symptoms reported disappointing results. (13) The most significant difference between the previous studies and this current study is that those six studies were over 12 weeks' time or less. This study continued for 24 weeks and symptoms generally declined in all three treatment groups during the first 12 weeks but either increased or showed no change during the last 12 weeks. The important thing to consider here is whether the earlier studies with a seemingly positive outcome in the soy groups were encouraging merely due to a short period of time in the study period.