Natural non-hormonal therapies for perimenopause and menopause

Townsend Letter for Doctors and Patients,  June, 2004  by Jacob Teitelbaum

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This month we have a special treat! I have asked Dr. Holly Lucille, a rising star in the medical community, to write a guest column on natural, non-hormonal, therapies for estrogen deficiency.

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Holly has a private practice in Los Angeles called Healing From Within Healthcare. She is currently president of the California Association of Naturopathic Medicine where she is working to ensure the availability of safe naturopathic health care for all people, most recently by spearheading a successful lobbying effort aimed at promoting consumer access to natural medicine in California. She is the author of the upcoming book, Creating and Maintaining Balance: A Women's Guide to Safe, Natural, Hormone Health (IMPAKT Health, 2004). She is frequently seen in the media, and has a heartfelt passion for the individual wellness of all people.

Introduction

While the fluctuation and decline of reproductive hormones is a normal and expected event in mid-life women, the associated symptoms are nonetheless disruptive. Until very recently, millions of women alleviated their hot flashes and night sweats with conjugated equine estrogens and medroxyprogesterone acetate (hormone replacement therapy or HRT). However, mounting evidence from several recent clinical trials, has shown that women using HRT are at significant increased risk of developing breast cancer, coronary heart disease, pulmonary embolism, and stroke.

With little room for HRT in current practice and little else in the conventional medicine chest to consider, physicians are increasingly turning to natural non-hormonal therapies for women who need relief from menopausal symptoms. As a naturopathic physician, I have used botanical medicines and other natural alternatives for many years with great success to help women create and maintain hormonal health. I've found the most effective approach combines stress management, diet, exercise and nutritional supplements to support and work with a woman's body, not against it. While each patient's treatment plan is unique, it has been my experience that most symptoms caused by menopause and/or hormone fluctuations and imbalances will respond to natural therapies.

Hot Flashes/Night Sweats

These core symptoms reflect the hypothalamic response to rapidly fluctuating and falling levels of estradiol. Hot flashes vary in severity, from a sudden sensation of warmth to acute drenching sweats and bright red flushing. Duration ranges from a few months, to a few years or not at all. By some estimates, 10-15% of women in menopause are awakened by night sweats throughout the night.

Black cohosh (Cimicifuga racemosa) is the most widely used and most thoroughly studied natural supplement for menopausal symptoms and has been clinically proven to reduce hot flashes and night sweats. While black cohosh's exact mechanism of action is unknown, compounds in the herb appear to bind to estrogen receptors without changing hormone levels in the body. Recent studies demonstrate black cohosh has no effect upon luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, prolactin or sex hormone binding globulin (SHBG).

A placebo-controlled, double blind study compared standardized black cohosh extract to conjugated estrogen. Women experiencing menopausal symptoms were randomized to receive black cohosh, conjugated estrogen, or placebo for three months. The participant's symptoms were assessed using the menopause rating scale (MRS) and individual diaries. The results showed that the women taking standardized black cohosh extract had clinical and statistical improvement of symptoms equal to the women taking conjugated estrogen. No improvement of menopausal complaints was observed in the control group. (Wuttke, et al. 2003).

Because black cohosh does not have estrogenic action and does not contain phytoestrogens it is safe for use in patients with a history of breast cancer. My usual recommendation is 40 mg of black cohosh daily, standardized to 2.5% triterpene glycosides.

Isoflavones are compounds with both hormonal and non-hormonal properties and are considered to be phytoestrogens with selective estrogen receptor modulators (phytoSERMs). Unlike estrogen, which is not tissue selective, phytoSERMs exert estrogenic effects in desired tissues such as the heart, skeletal system, and brain, but ideally have no effects in other tissues, such as the breast. The various biologic activities of isoflavones suggest that they offer many of the beneficial effects of estrogen. Controlled trials have indicated these compounds support healthy serum cholesterol levels and support healthy bone resorption.

Soy has received attention as a dietary alternative to HRT largely because it is a unique source of isoflavones. Worldwide soy consumption is highest in Japan, where urinary levels of phytoestrogen metabolites are extremely high and reported frequency of hot flushes is extremely low. The majority of clinical studies examining this inverse relationship have shown soy isoflavones to significantly reduce hot flashes.