Ease Into Menopause Naturally

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

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.

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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 ]

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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. [1] 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 approach."

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. [1] 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 passage

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Heart Disease

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. [57] 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 waters.

Flaxseed oil is another excellent source of omega-3 fatty acids and is recommended especially for the days fish is not eaten. [8] Canola oil and olive oil are the oils of choice for heart-healthy cooking (which does not include frying, however). [9]

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. [10]

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]

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Osteoporosis

By further customizing their diet, perimenopausal women can reduce bone loss. Research shows that diets high in protein and phosphorus cause calcium excretion. [15] 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. [16] 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. [17] Consistent weight-bearing exercise several times a week is a critical adjunct to preserving bone mass and flexibility. [18]

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. [19] 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. [20]

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Cancer

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. [21]

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. [23]

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 isoflavones. [24]

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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. [25] A recent study showed regular exercise improved menopausal symptoms related to mood, concentration, forgetfulness, irritability, and vasomotor symptoms such as hot flashes and sweats. [26]

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 follow.

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. [28] 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). [29]

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. [30] Also, The Harvard Women's Health Watch cautions that dong quai may cause sun sensitivity. [31]

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. [20]

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 conclusively. [32]

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 time.

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. [20] Chasteberry should not be taken with other hormone therapy or during pregnancy. [33]

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. [34] 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 long-term use.

Progesterone deficiency rather than estrogen deficiency, as evidenced by anovulatory cycles (no egg produced), may cause unpleasant menopausal symptoms. [37] 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. [2] 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. [39] However, there are limited data and much controversy regarding the safety and efficacy of these natural transdermal progesterone products. [40 ]

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Menopause

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). [1] 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. [41] 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 mammograms.

Natural therapies for menopausal symptoms include diet, exercise and supplements.

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Postmenopause

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. [43] The bone-maintaining properties of estrogen (notably estradiol) are a major reason physicians recommend estrogen replacement to their patients. [44] 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. [47] More research utilizing natural progesterone products is needed.

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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." [48]

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
primary care.

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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 identical. 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™, a 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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