From the Nutrition Science News
By By Karen Laputka Kiss, M.S., R.N., and
Beverly Whipple, Ph.D., R.N., F.A.A.N.
Choice is a
concept closely associated with the generation of women now
making their way through menopause. It is a concept that
throughout most of their lives has motivated, bitterly divided
and most of all conditioned these women to question the status
quo--from civil rights to reproductive rights. So it comes as no
surprise that when the vanguard of this generation experienced
the onset of menopause and discovered that easing their symptoms
meant choosing among their hearts, bones and breasts, they
demanded more--more research, more guarantees, more choice
in menopausal management options.
Women who are undecided about synthetic hormone replacement
therapy (HRT) want information on the more natural remedies that
provide menopausal symptom relief as well as reduce risk of heart
disease, osteoporosis and cancer. HRT appears to have a positive
effect on reducing long-term risk of heart disease and
osteoporosis but is controversial because it increases the risk
of breast cancer. Women with a strong family history of coronary
artery disease are left feeling as though choosing HRT to protect
their hearts may ultimately cost them their breasts. The
following is a synthesis of several of the better-researched and
accepted alternative natural suggestions for managing the phases
of the menopausal transition: early and middle perimenopause,
menopause and postmenopause. [1 ]
Early and Middle Perimenopause
The average age of women in the early perimenopause phase is
early to mid-30s. The phase is characterized by subtle and
clinically imperceptible hormonal changes that occur up to a
decade before menses cease.  This is an appropriate
time for a woman to assess her health care provider's practice
regarding menopause as well as the provider's ability to support
her decision to try natural menopausal therapies that may not be
in the textbooks--yet.
Despite lingering concerns about the long-term safety of HRT,
most practitioners continue to recommend these hormone
preparations, which are similar to but chemically different from
hormones found in the body, as the only choice for menopause
management. Natural therapies for menopausal symptoms, on the
other hand, include a "natural toning approach," lifestyle
choices that encompass specific diets, supplements and exercise
as well as the occasional use of hormones chemically identical to
those found in the human body, or "chemically identical HRT."
Making no lifestyle changes is not considered a "natural
Women become symptomatic during middle perimenopause--roughly
mid-30s to age 50--and frequently seek health care advice for
erratic menstrual periods, sleep disturbances, hot flashes, mood
swings, night sweats, mental confusion, muscle or joint pains,
urinary incontinence and vaginal dryness.  If the
symptoms are not severe, women often find a natural toning
approach provides adequate and safe, if not total, symptom
management. [2 ]
A natural toning approach not only provides symptom relief but
also provides reasonable and reliable protection against heart
disease, osteoporosis and cancer--conditions that arise with
changes in sex hormone ratios at the onset of menopause.
Following are some ways a natural toning approach can be
incorporated into a woman's lifestyle during the perimenopausal
years to help her avoid some of the later concerns of menopause.
|Natural options increase
women's comfort levels with this age-old rite of
Adhering to a low-fat, high-fiber diet with at least five to nine
servings of fruits and vegetables a day and limiting or
eliminating meats can go a long way toward preventing heart
disease. This diet is widely recognized to reduce an individual's
risk for heart disease, stroke, diabetes and
cancer. [3,4] Elements of a natural toning diet that
protect the cardiovascular system, particularly after menopause,
include good fats, flaxseed oil, soy, vitamins and minerals.
The omega-3 fatty acids eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA) are essential oils found in cold-water
fish such as salmon, mackerel, herring, sardines, cod and tuna.
Eating several servings of these fish a week is wise because the
oils reduce inflammation (including inflammation associated with
arthritis) and cholesterol, thin the blood, and reduce risk of
heart disease and stroke.  It is prudent to
limit the intake of albacore tuna to once a week because tuna
migrates near shores where it can pick up mercury in the coastal
Flaxseed oil is another excellent source of omega-3 fatty acids
and is recommended especially for the days fish is not
eaten.  Canola oil and olive oil are the oils of
choice for heart-healthy cooking (which does not include frying,
Soy is emerging as an important addition to the healthy diet,
especially for menopausal women. Soy is a good source of omega-3
fatty acids. The phytoestrogens in soy act as weak but protective
estrogens and decrease menopausal symptoms. 
Supplemental vitamins and minerals are also beneficial. Taking
400 IU of vitamin E protects the cardiovascular system and may
decrease menopausal symptoms. [11,12] Other vitamins and
minerals are essential as cofactors and mediators of almost every
chemical reaction of the body and quickly become depleted in
stressful situations. Adequate intake of folic acid, B6 and B12,
in particular, has been shown to prevent heart disease in women
prone to elevated homocysteine levels. It is estimated that 20 to
40 percent of all patients with heart disease have elevated
homocysteine levels. [13,14]
By further customizing their diet, perimenopausal women can
reduce bone loss. Research shows that diets high in protein and
phosphorus cause calcium excretion.  The classic
American meal such as a double cheeseburger and a soda is high in
both. The vegetarian diet emphasizes many of the aforementioned
elements of a natural toning diet, and research has demonstrated
that vegetarians have a lower incidence of osteoporosis than do
their meat-eating counterparts.  Thus, adopting a
vegetarian diet or an almost meat-free diet (meat should be
predominantly cold-water fish) may be a prudent alternative to
using hormones to protect against osteoporosis. It is important
to balance plant sources of calcium with calcium supplements to
acquire at least 1,200 mg per day. To facilitate the absorption
of calcium, 400600 IU of vitamin D should be taken
daily.  Consistent weight-bearing exercise several
times a week is a critical adjunct to preserving bone mass and
Strong, healthy bone depends on many other nutrients, including
the variety of vitamins and trace minerals that plants derive
from the soil. However, many modern farming techniques deplete
the trace mineral content of soil.  To ensure they
get enough important vitamins and minerals, perimenopausal women
should eat organic produce whenever possible and take a daily
vitamin/mineral supplement that provides adequate amounts of
vitamins B6, B12, C, D, K and folic acid, as well as boron,
magnesium, manganese and zinc. 
Because estrogen encourages cell growth, the risk of cancer
associated with HRT is thought by some researchers to be a
compelling reason to try a natural toning approach to menopausal
symptoms, particularly in middle perimenopause. Some evidence
links a woman's risk of developing cancer to the length of time
she is exposed to estrogen. 
Integrating soy into the diet may protect against cancer. [22
] Epidemiological studies link the phytoestrogens in soy to
the comparatively low rate of hormone-related cancers in Asian
men and women. Japanese people eat 3050 g of soy per day
(150200 mg of isoflavones) compared to 13 g (5 mg of
isoflavones) in the Western diet. 
Since more is not always better, at this point, it would be wise
not to exceed the Japanese daily intake. One cup of soy milk,
soybeans, tempeh or tofu represents about 3540 mg of
Managing the Transition
Regular exercise, herbal supplements and progesterone also may be
used to manage the menopausal transition.
Exercise is absolutely mandatory to preserve bone and protect the
cardiovascular system.  A recent study showed regular
exercise improved menopausal symptoms related to mood,
concentration, forgetfulness, irritability, and vasomotor
symptoms such as hot flashes and sweats. 
Several herbal preparations have been used for centuries by
menopausal women and are available in teas, tinctures, tablets,
capsules, fluid extracts and bulk. Herbs are gentle and should be
taken several weeks before their effects are judged. The method
of herb processing as well as plant quality affect the active
amount of the herb found in the purchased product. The
therapeutic level is assured when an active ingredient is in the
form of a standardized extract. [27 ] Some of these herbs
Black cohosh (Cimicifuga racemosa) has been well
studied in German clinical trials and is frequently prescribed
for hot flashes and vaginal atrophy in that country. The German
Commission E recommends that treatment with black cohosh be
limited to six months--also the standard recommended time frame
for hormone replacement therapy.  The recommended
dose is 4 mg, or two tablets, twice a day (each standardized
tablet contains 1 mg of triterpenes calculated as 27-deoxyacteine
per tablet). 
Dong quai (Angelica sinensis) has long been used by
Asian women for hot flashes, vaginal dryness, insomnia, headaches
and water retention, and to provide emotional calmness. It is
generally considered a tonic or balancing agent but should be
avoided by a woman who experiences heavy menstruation during
perimenopause, who has abnormal bleeding or fibroids, or who
takes anticoagulants such as coumarin or aspirin
regularly. [20 ] Dong quai demonstrates strong inhibiting
activity against platelet aggregation, which is why prior
bleeding conditions may be aggravated.  Also, The
Harvard Women's Health Watch cautions that dong quai may
cause sun sensitivity. 
In classic Chinese medicine, dong quai usually is combined with
other herbs. [See also NSN, March 1998, p. 107]. Susun
Weed in her book Menopausal Years: The Wise Woman Way
discusses Panax ginseng as yang (thought to balance chi
energy) used in combination with dong quai (considered yin and a
blood nourisher) for the menopausal transformation. She
recommends alternating these herbs for a period of two years, or
until the transformation is complete, at a rate of ginseng for
two weeks followed by dong quai for four weeks. 
Another example of the use of dong quai in combination with other
agents is provided by a study led by Tori Hudson, N.D. In this
double-blind, randomized, controlled trial, 13 women used a
botanical formulation of several herbs for menopausal symptoms.
In this study the formula was
2 parts burdock root (Arctium lappa)
2 parts licorice root (Glycyrrhiza glabra)
1 part motherwort (Leonorus cardiaca)
2 parts dong quai root
1 part Mexican wild yam root (Dioscores barbasco)
Capsules contained 500 mg of this combination and the subjects
took two capsules three times per day. The study results suggest
the phytoestrogens in these herbs can improve menopausal symptoms
while not raising serum estrogen or progesterone levels.
Long-term usage recommendations could not be made
Chinese or Korean ginseng (Panax ginseng) can be
used for physical and mental fatigue, anxiety and stress.
Standardized preparations of ginseng reflect ginsenoside content.
Look for a saponin content of at least 10 mg of ginsenoside Rg1
with a 2:1 Rg1 to Rb1 ginsenoside ratio. This herb can be taken
up to three times per day for general tonic effects. At the
concentration suggested, it can be delivered in any form. Ginseng
also is available in root form--you can take 46 g per
day, depending on the quality of the root. Start at a lower dose
and then increase gradually, watching for side effects including
insomnia, hypertension, breast pain, disruptive menstrual
changes, anxiety or irritability. Taper the dose to eliminate
these symptoms, or discontinue use of the herb. [27
]Since ginseng is a tonic herb, it should not be taken for
long periods, but is best used cyclically for several months at a
Chasteberry (Vitex agnus castus) is said to have a
normalizing effect on sex hormones. Weed recommends a tincture of
20 drops at a 1:5 ratio, 80 percent alcohol solution, one to two
times daily. Results become evident only after two to three
months of daily use; permanent improvement requires about a
year's commitment during the time of menopause. 
Chasteberry should not be taken with other hormone therapy or
during pregnancy. 
Ginkgo (Ginkgo biloba) is an excellent adjunct to a
natural toning approach, especially for women who do not wish to
take any HRT. Ginkgo works particularly well on the vascular
system and may relieve the cold hands and feet that often
accompany menopause.  Preliminary studies that link
HRT with a slowing of the progression of Alzheimer's disease may
give women another long-term risk factor to consider in making
their HRT decision. Ginkgo is a promising alternative to HRT in
this regard because it is increasingly recognized for its
neuroprotective effects as well as for being a general "tonic for
the mind." [35,36] There are no known adverse effects of
Progesterone deficiency rather than estrogen deficiency,
as evidenced by anovulatory cycles (no egg produced), may cause
unpleasant menopausal symptoms.  Normally,
progesterone is secreted in large amounts by the corpus luteum
after an egg ruptures from the ovarian follicle at ovulation. If no egg is produced, a progesterone surge is not
experienced. Since women still are producing sufficient estrogen
to have menstrual periods, a relative imbalance between estrogen
and progesterone occurs.
Supplementing with a chemically identical form of progesterone
may provide symptom relief. If an oral form of progesterone is to
be used, 100 mg of micronized oral progesterone, three times
daily on the 16th through the 27th day of each cycle, is
recommended for hot flashes. Vaginal progesterone, 2550 mg
on the same days, can be substituted if the oral progesterone
causes too much drowsiness.  While data is
accumulating on synthetic progesterone (progestins), [38
]natural transdermal progesterone products are available
without a prescription and are reported to be well tolerated and
useful in symptom management.  However, there are
limited data and much controversy regarding the safety and
efficacy of these natural transdermal progesterone
products. [40 ]
Menopause is the 12-month time frame after the last menstrual
flow. During this time, there is a shift in the dominant estrogen
in the body. Estrogen is the name for a class of several closely
related molecules, the most notable of which are estrone (E1),
estradiol (E2) and estriol (E3).  If a woman decides
to use HRT, chemically identical formulations are available. They
can be administered via a variety of routes that provide more
choices and a greater ability to tailor HRT to the individual. A
woman who thinks HRT is needed should carefully assess her
expectations. She may discover that she does not need to take
hormones that affect her whole body. She may be bothered only by
vaginal dryness and will experience symptom relief with a vaginal
hormone delivery system that significantly reduces her overall
exposure to estrogen. It is important, however, to realize that
data on the long-term effects of these chemically identical
formulations are limited, and if guarantees are important, there
are even fewer with these products than with synthetic HRT.
Monitoring and adjusting the hormone formula should be done
frequently until improvement has stabilized and then every six
months. Using a natural toning approach may help reduce the need
for higher hormone levels. Regardless of the type of HRT used,
the need for HRT should be revisited at least every five years. A
recent study analyzed the data from 90 percent of the HRT
research and concluded that a woman using HRT for five or more
years increases her risk of developing breast cancer by 35
percent.  Every couple of years, women should assess
their increasing risk for breast cancer against the symptoms or
health concerns that made them decide to take HRT in the first
place. Complete blood work (cholesterol, liver profile and a
complete blood count) should be done before HRT is started. A
woman also should have regularly scheduled Pap tests and
|Natural therapies for menopausal symptoms|
include diet, exercise and supplements.
During postmenopause, which begins one year after the last
menstrual period, E1 is the predominant estrogen. The body
produces about 40 picograms per day of estrone and 6 picograms of
estradiol. (To have a period, a woman must produce at least 50
pgms of estradiol per day. [1,42]) Studies demonstrate
that bone density decreases rapidly for approximately five years
after menstruation ceases or after estradiol levels drop
precipitously, such as after a hysterectomy or after
discontinuing HRT.  The bone-maintaining properties
of estrogen (notably estradiol) are a major reason physicians
recommend estrogen replacement to their patients. 
However, the bone-building effect of progesterone, a physiologic
effect not seen with estrogen, is just beginning to be recognized by researchers. [45,46 ]Supplementing
with progesterone rather than estrogen may be as protective, if
not more so, for bone without the exponential growth in breast
cancer risk with prolonged use.  More research
utilizing natural progesterone products is needed.
A Choice of Perspective
Women not at high risk for osteoporosis and heart disease
eventually choose for or against HRT for various reasons, not the
least of which is wishing to remain youthful. By challenging old
conceptions of menopause, activists such as Susan Love, M.D.,
provide women with a different perspective, a choice to
think of this change as a new period of growth: "Menopause has
gone from being a normal part of life to being a disease that
needs to be treated. They are calling it estrogen deficiency
disease. But if estrogen deficiency is a disease, then all men have it," Love says. "If you frame menopause as a
deficiency and ovarian failure, you end up taking drugs. But, you
can reframe it. You've got Margaret Mead with 'postmenopausal
zest,' and all these other powerful women in the world who are
postmenopausal. On the other side, consider the young girls who
have lots of self-esteem, who then hit puberty and lose it all.
Maybe we need estrogen to domesticate us enough so that we'll
reproduce the race, and then we get liberated from it in
menopause and reclaim our 8-year-old selves." 
Consider also many indigenous cultures in which menopause is seen
as a rite of passage, bringing women to a respected, wise-woman,
elder status. Women in such cultures do not experience the
symptoms women experience in Western cultures--not
coincidentally, the same nations that value youth and decry
aging. Perhaps there's a lesson to be learned here. [49
Beverly Whipple, Ph.D., R.N., F.A.A.N., is a professor in the
College of Nursing at Rutgers, The State University of New
Jersey. She is president of the American Association of Sex
Educators, Counselors and Therapists.
Karen Laputka Kiss, M.S., R.N., is an acute care educator and
adult nurse practitioner in
Authors' Note: The quality of chemically
identical hormonal preparations is assured by a compounding
pharmacist with experience customizing hormonal preparations. To
identify a pharmacist with this type of expertise, call the
International Academy of Compounding Pharmacists, 800-927-4227.
The use of any hormonal therapy should be done under the
supervision of a health care practitioner. If a woman fears
discussing matters pertaining to her health care with the
practitioner, then she needs a new practitioner.
Is It Natural, or Is It Synthetic?
After more than 40 years of conventional hormone replacement
therapy, nearly everyone from the mainstream media to
pharmaceutical companies has misinformed and confused the public
about "natural" versus "synthetic" hormones.
The term "natural sex hormones" is defined as sex hormones
molecularly identical to those produced by the human body.
"Natural hormone replacement" therefore means to replace the
presumed deficient sex hormones with "bioidentical" sex hormones.
Examples of bioidentical human hormones include DHEA,
pregnenolone, progesterone (not the synthetic progestin or
progestinlike Provera®), testosterone, estradiol (E2)
and estriol (E3). These "naturals" are derived from plants
(Mexican yam or soybean) and are made to be biochemically
Conventional medicine's hormone replacement therapy (HRT) and
estrogen replacement therapy (ERT) nearly always use
nonbioidentical estrogens and synthetic progestin that have been
changed to be more potent--not to mention patentable and
therefore more profitable.
There are many types of estrogen, and it is important to know the
specific type and exact name before any meaningful decision about
its use can be made. For example, when a newspaper reports "New Estrogen Study Confirms Cancer Risk," a
customer currently using estrogen prescribed by her doctor needs
to ask, "Was the estrogen used in the study the same type
estrogen that I am using? Is there a relationship between the
two?" There are conjugated equine estrogens (CEE) such as
Premarin®; naturally occurring estrogens such as
estrone (E1), estradiol (E2), and estriol (E3); and
phytoestrogens such as those from soy, red clover, flaxseed and
black cohosh. Phytoestrogens are the herbalist's choice because
of their relatively weak estrogenic effects compared to the
body's own estradiol (E2). However, these herbals are NOT
considered "natural" estrogens because they still differ from
those found in the human body. True human estrogens have a more
profound effect in the body than phytoestrogens.
Premarin is derived from horse urine (PREgnant MARes urINe) and
therefore by strict definition is also not "natural," despite a
statement on the pharmaceutical package that reads, "Estrogens
Obtained Exclusively From Natural Sources." While it may be true
that these conjugated equine estrogens are obtained from horses
(natural to the horse), they do not match the human hormones and
consequently often have side effects. There are more than 10
types of estrogen in a single Premarin tablet, most of which are
much more potent than the human body's own estrodial.
--Michael L. Bennett
Michael L. Bennett, Pharm.D., a practicing clinical
pharmacist, is founder and president of Optimal Healthspan,
health care consultant company in Vista, Calif. His recent books
are Wild Yam--Nature's Source of Phytohormones and The
Flax Seed RevolutionNature's Source of Omega-3s, Lignans,
and Fiber (self-published 1997, 1998, respectively).
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