In recent years, many women across North America have demonstrated a reluctance to rely upon hormone replacement therapy (HRT) as a means to reduce menopausal symptoms, due primarily to concerns about the potential risk of breast cancer. In fact, only about 20% of women who are given a prescription for HRT actually follow through and take it faithfully. A growing number of postmenopausal women have been seeking out the use of herbal remedies as an alternative to HRT, as reflected by the rapid growth in herbal supplement sales during the past decade.
In recent years, many women across North America have demonstrated a reluctance to rely upon hormone replacement therapy (HRT) as a means to reduce menopausal symptoms, due primarily to concerns about the potential risk of breast cancer. In fact, only about 20% of women who are given a prescription for HRT actually follow through and take it faithfully. A growing number of postmenopausal women have been seeking out the use of herbal remedies as an alternative to HRT, as reflected by the rapid growth in herbal supplement sales during the past decade. Interest in natural therapies to control menopausal symptoms is expected to escalate due to two recent alarming reports, which confirm previous suggestions that hormone replacement therapy increases the risk of breast cancer and that unopposed estrogen (usually given to women who have undergone a hysterectomy) substantially increases the risk of ovarian cancer. 1,2 On July 9, 2002, researchers announced that they were stopping the American Women’s Health Initiative (WHI) trial of 16,000 women taking hormone replacement therapy (HRT), as results showed that after 5.2 years there was a 26% increased risk of breast cancer in the women using hormone replacement than in women receiving the placebo. Women taking HRT also showed a 41% increased risk of stroke and a 29% increased risk of heart attack (myocardial infarction), compared to women receiving the placebo. Prior to this, many doctors promoted HRT as a means to reduce the risk of heart disease in postmenopausal women, but the findings of the WHI trial provide unequivocal evidence that, in fact, HRT greatly increases the risk of both heart attack and stroke in this population. 1,3 More bad news regarding estrogen replacement therapy appeared in the July 17th, 2002, issue of the Journal of the American Medical Association. In a follow-up study of 44,241 former participants in the Breast Cancer Detection Demonstration Project, researchers discovered that the use of estrogen replacement therapy (without concurrent use of progesterone) increased risk of ovarian cancer, with a relative risk of 1.8 in women who used estrogen replacement therapy for 10-19 years and a 3.2 relative risk in women using estrogen replacement therapy for 20 or more years.
Previous data from the Nurses’ Health Study demonstrated that for each year a woman remained on HRT, her risk of developing breast cancer increased by 2.3%. Thus, a postmenopausal woman taking HRT for 10 years had a 23% increased risk of developing breast cancer, compared to women who were non-users of HRT. After 20 years of HRT use, a woman’s risk of developing breast cancer would be 46% greater than a women who never used HRT during the menopausal years, according to evidence provided by the Nurses’ Health Study. 37,38,39 As the results of these studies get reported by the popular media, a growing number of women are giving up their HRT medications and searching for credible alternative means to optimize their feeling of well being, reduce hot flashes and other menopausal symptoms, maintain an active sex life and a healthy appearance, and reduce their risk of osteoporosis, heart disease and other degenerative conditions.
In order to help patients arrive at a prudent course of action, health practitioners should be informed about the current research status of various natural interventions that have a proven and safe record in the management of menopausal complaints, and health conditions affecting menopausal women.
In today’s world, women live one-third of their lives in the postmenopausal years. Helping them maximize their quality of life, and lifespan, should be the intent of any nutrition, supplementation, or lifestyle recommendations, which should be customized to an individual’s needs. In addition to controlling hot flashes and other menopausal symptoms, there are three major health concerns that must also be factored in to the decision-making process. It is well established that postmenopausal women are at increased risk for breast cancer, osteoporosis, and heart disease.
- Heart disease is the number one killer of postmenopausal women.
- Osteoporosis affects one in four women by age 50.
- Breast cancer incidence rates have increased by 40% in the last 50 years, with one in every 403 women afflicted between ages 50-59, one in 266 women afflicted between ages 60-69, and one in 220 women afflicted at age 70 and over.
After menopause, women become less able to clear cholesterol from their blood stream. During the pre-menopausal stage of life, high circulating estrogen levels increase the production of LDL-cholesterol receptors, which enable cells to extract LDL-cholesterol (low density lipoprotein-cholesterol, which is known to increase risk of heart attack and stroke) from the blood stream and use it for various purposes. In menopause, there is a 90% drop off in circulating estrogen levels, which appears to reduce the ability of cells to produce LDL-cholesterol receptors. As a result there is a strong tendency for cholesterol to accumulate in the blood stream, stick to the walls of the arteries and cause narrowing of coronary blood vessels; leading to heart attack. As a high saturated fat diet is the main culprit in raising LDL-cholesterol levels, postmenopausal women should adjust their diet to lower their saturated fat intake (results from the Framingham Heart Study suggest individuals should ingest no more than 10 – 28 gms per day of saturated fat, based upon the presence of other risk factors such as family history, diabetes, smoking, high blood pressure etc), in order to keep their blood cholesterol levels below 200 mg per dL. This implies that the use of animal protein foods consist of chicken, turkey, Cornish hen and fish, and that all milk and yogurt products consumed are non-fat or 1% varieties. No cheese above 3% milk fat should be consumed and butter, ice cream, whipping cream, regular chocolate products, items containing coconut or palm oil, and deep fried products of all types, be avoided. Increasing soluble dietary fiber intake can also reduce blood cholesterol levels by dragging cholesterol out of the body, as well as bile acids, which can serve as precursors (building block) to the synthesis of cholesterol in the liver. Soluble fiber is found in most fruits and vegetables, oat bran, psyllium husk fiber, ground flaxseeds, and in beans and peas. Remaining physically fit and at or near one’s ideal weight, are also important lifestyle factors in preventing cardiovascular disease in the postmenopausal years.
It should also be noted that soy products and soy extract supplements are known to reduce blood cholesterol levels by 9 – 12% in patients with high cholesterol levels. The same is true for a supplement known as gamma-oryzanol, which is derived from rice bran oil. Both soy extract and gamma-oryzanol have been shown to reduce hot flashes and other menopausal symptoms and are excellent alternative therapies to the use of HRT in postmenopausal women. Gamma-oryzanol is an approved drug for the management of menopausal symptoms in Japan, where the research on this natural agent has been performed. It is very convenient that soy extract and gamma-oryzanol can help reduce menopausal symptoms, reduce cholesterol levels, and in the case of soy isoflavones, help to maintain bone mineral density.
The decline in estrogen levels that accompanies the menopausal years also permits calcium to leak out of bone into the blood stream, where it will eventually become filtered by the kidney and exit the body in the urine. This of course, leads to osteoporosis, which increases risk of fractures. Osteoporosis is reaching epidemic proportions in our society largely due to insufficient calcium intake and accumulation in bone, especially between ages 11 and 24, and loss of calcium from bone during the menopausal years. It should be noted that Canadian statistics indicate that complications from osteoporotic hip fractures (e.g., the development of pneumonia) result in more deaths each year than the combined mortality rate from breast and ovarian cancers. 18 The lifestyle recipe to prevent osteoporosis during the menopausal years is as follows:
- A.Ingest 1,500 mg per day of calcium, if not taking HRT. This can be through a combination of calcium from diet and supplements (note that calcium carbonate and calcium citrate are absorbed equally as well if taken with meals). As calcium carbonate is less expensive, it represents a more cost-effective intervention for patients. However, if the patient has had a previous history of kidney stones, calcium citrate may be preferred due to its greater solubility.
- B.Supplement with 600 to 1,000 IU of Vitamin D. For general health reasons women should consider taking a high potency multiple vitamin and mineral, which normally includes 400 IU of Vitamin D. Studies show that postmenopausal women ingesting an additional 200 to 400 IU of Vitamin D per day may reduce their risk of hip fractures by approximately 50%. A high potency multiple vitamin and mineral (including extra antioxidant protection and a B-50 complex) contains other nutrients important to bone health (calcium zinc, magnesium, copper) as well as providing comprehensive micronutrient support for other aspects of health optimization. As we age, our kidneys reduce their ability to convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, which is twice as powerful a form of Vitamin D, than is 25-hydroxyvitamin D. However, studies indicate that by increasing blood levels of 25-hydroxyvitamin D, through the intake of Vitamin D supplements (600 – 1,000 IU per day), a postmenopausal women can compensate for the drop off in 1,25-hydroxyvitamin D synthesis, and thereby, significantly reduce her risk of osteoporotic fractures.
- C.Perform weight-bearing and/or resisted exercises 4 to 7 times per week. Weight bearing exercise such as walking or jogging, and weight training exercises, place increased stress on the spine and femurs, which respond by holding their calcium in bone to help withstand the physical stresses acting on the bone structures. Some studies reveal that postmenopausal women can increase their bone density, without using HRT, by simply ingesting more calcium and performing a series of 5 weight training exercises, twice per week.
- D.Supplement with a product that contains Black Cohosh and Soy Isoflavones. As will be discussed later, the standardized grade of Black Cohosh and Soy Extract have been shown to reduce menopausal symptoms and evidence exists to show that they can also help to preserve bone mineral density via their estrogenic effects on bone receptors.
It is well documented that women who are overweight during the postmenopausal years have approximately a three times greater risk of developing breast cancer. This is likely due to the fact that as fat mass increases there is a greater conversion of androstenedione to estrone within the stromal tissue of adipose tissue. Higher circulating estrone hormone (one of three types of estrogens made by the female body) levels are associated with increased risk of breast cancer, as estrone is known to increase the cell division rate of breast cells. In turn, this leads to a greater chance of genetic mutations occurring, which may be cancerous. This is exactly the same mechanism through which HRT has been shown to increase breast cancer risk. Thus, postmenopausal women would be well advised to attain and maintain an ideal body weight and a body mass index below 25 (24.87).
As well, avoiding the use of HRT is emerging as a significant strategy upon which to help prevent breast cancer in postmenopausal women. The best alternative approaches include a combination of Black Cohosh, Soy Isoflavones and Gamma Oryzanol, as each of these natural interventions has been shown to reduce menopausal complaints and, their use in human populations over many years suggest that they do not increase risk of breast cancer. In fact, in Japan, where soy isoflavone intake is customarily between 50 and 75 mg per day, breast cancer incidence is 75% lower than in the U.S.
Recent experimental studies involving black cohosh have shown that it exerts an anti-proliferative effect on breast cells and human breast cancer cell lines, which is consistent with a reduced risk of breast cancer, according to available scientific evidence. Therefore, in women without a previous history of breast cancer, the use of black cohosh, soy isoflavones and gamma-oryzanol, can be considered safe and effective alternatives to the use of HRT. In patients with a previous history of breast cancer, the jury is still out as to whether or not these natural agents should be used. However, in a recent survey, women with a previous history of breast cancer were 7.4 times more likely to use alternative treatments for menopause symptoms than were women with no previous history of breast cancer. Soy products, herbal remedies (including black cohosh and gamma-oryzanol) and Vitamin E were the most common alternatives to HRT.
In addition to these devastating statistics, the decline in estrogen and progesterone production that accompanies menopause, triggers a broad range of physical, psychological and aging-related signs and symptoms that can significantly interfere with a woman’s feeling of well-being. Although underutilized by medical doctors in this part of the world, substantial evidence from European and Asian studies provides convincing support that the herbal agent known as black cohosh, along with soy extract and gamma-oryzanol, can significantly reduce menopausal symptoms, help support bone density, reduce high cholesterol, prevent atrophy and dryness of vaginal tissues, and improve a woman’s feeling of well being and vitality. Unlike HRT, these natural substances are not associated with an increased risk of breast cancer, ovarian cancer or heart disease. As such, in most cases they can be employed as a significant part of a natural lifestyle program, aimed at enhancing the health and quality of life of postmenopausal women. The scientific evidence to support the concurrent use of these natural agents is as follows: (continued on next page).
Dietary Supplements In The Management Of Menopausal Symptoms
The most widely used and thoroughly studied natural supplement for the management of menopausal symptoms is the herbal agent known as black cohosh (cimifuga racemosa), which must be standardized to 2.5% triterpene content. Four major human studies have demonstrated the ability of black cohosh to help manage menopausal signs and symptoms. In the first study (open study) involving 131 doctors, who together recruited 629 female patients, 80% of patients experienced improvement of physical and psychological symptoms, associated with menopause, within 6 to 8 weeks of treatment with black cohosh extract. Significant improvement was noted in the following symptoms:
- Hot flashes
- Profuse sweating
- Heart palpitations
- Nervousness / Irritability
- Sleep disturbances
- Depressive moods
Only 7% of patients reported mild transitory stomach complaints.
A second study (controlled study) compared the effects of black cohosh to estrogen replacement therapy (0.625 mg C.E.E.) or diazepam (2 mg) for 12 weeks. Black cohosh out-performed both Premarin (C.E.E.) and Valium (diazepam) using the Kupperman Menopausal Index.
This index is one of the most utilized assessments in clinical studies of menopause. This quantitative assessment of menopausal symptoms is achieved by grading of severity:
- Severe = 3
- Moderate = 2
- Mild = 1
- Not present = 0
After grading each symptom, the total score is achieved by adding all of the symptom scores together. Symptoms assessed are:
- Depressive moods
- Feelings of Vertigo
- Heart Palpitations
- Hot flashes
- Joint Pain
- Loss of Concentration
- Nervousness / Irritability
- Profuse sweating
- Sleep disturbances
In a fourth study, (double-blind) black cohosh was compared to a placebo in a study following 110 women. The black cohosh group demonstrated significant improvement in menopausal symptoms and blood hormone measurements. In addition to relieving hot flashes, it once again produced impressive age-reversal results on the vaginal lining as confirmed by vaginal smear analysis.
Since 1956, over 1.5 million menopausal women in Germany have used black cohosh extract with noted success and without significant side effects. Physiologically, black cohosh extract appears to mimic the effects of estriol, which is a form of estrogen made by the body. Estriol is a weaker form of estrogen than estrone or estradiol, and is not associated with an increased risk of reproductive cancers. Like other forms of estrogen, estriol helps to maintain bone density and aids cholesterol removal from the blood stream. Black cohosh extract has also been shown to inhibit the over-secretion of leutinizing hormone (L.H.), providing proof of its estrogen-like properties.
Remarkably, the triterpene saponins, unique to black cohosh, have also been shown to serve as a precursor (building block) for the synthesis of progesterone in the body. As there is a 66% decline in progesterone levels at menopause, black cohosh supplementation may help to preserve progesterone balance, which is important to preserving bone health, maintaining libido and psychological well being. The dosage that is proven to be beneficial in the treatment of menopausal symptoms, is 40 or 80 mg, taken twice per day (standardized grade containing 2.5% triterpene glycoside content).
Soy extract, yielding a minimum of 50 mg of soy isoflavones, has been shown to reduce hot flashes and other menopausal symptoms in various clinical trials. Some studies show up to a 40% reduction in hot flashes with the use of soy isoflavone products. Soy isoflavones also possess phytoestrogen activity (plant-based estrogen). Like the triterpene saponins found in black cohosh, soy isoflavones are a type of “selective estrogen receptor modulator” or SERM, which preferentially stimulates beta estrogen receptor on reproductive and other tissues. In turn, this provides weak estrogenic support to reproductive tissue and bones, without over stimulating breast and endometrial cells, as may HRT. HRT stimulates the alpha receptors on breast tissue, which increases their rate of cell division, and the likelihood of developing cancerous mutations. Stimulation of the beta receptors, by soy isoflavones and black cohosh triterpenes, has been shown to slow down the rate of cell division of breast and endometrial cells, in the presence of the body’s own estrogen; an effect associated with a decreased risk of reproductive cancers.
Investigation into the biological actions of soy isoflavones suggests that they provide a number of additional protective effects. These include antioxidant protection against free radicals, the slowing of cellular proliferation, reducing the synthesis of estrone hormone by inhibiting the estrogen synthase (aromatase) enzyme in fat tissue, increasing the detoxification of potentially harmful chemicals and hormones, and by competing with the body’s more powerful estrogen for attachment and stimulation of estrogen receptors on the breast, and other tissues expressing estrogen receptors.
Soy isoflavones have also been shown to support bone mineral density in postmenopausal women, and help keep cholesterol levels within a safer range, as mentioned earlier.
Supplementation with gamma-oryzanol (150 mg, twice per day) has been shown to reduce the secretion of leutinizing hormone (LH) by the pituitary gland and promote endorphin release by the hypothalamus. Hot flashes and other menopausal symptoms (profuse sweating, mood changes) result indirectly from the over-secretion of LH, which is attempting to initiate the start of another ovulatory cycle. The lack of response by the immature egg cells in the ovaries at the outset of menopause results in over-secretion of follicle stimulating hormone (FSH) and LH by the pituitary, contributing to the onset of hot flashes and related symptoms. Clinical trials reveal that 67 – 85% of women treated with gamma-oryzanol have experienced a significant reduction in menopausal symptoms. As noted previously, gamma–oryzanol, supplemented at the above noted dosage, is also known to reduce high cholesterol by up to 12%.
Summary Of Daily Dosage
It is now possible to find combination supplement products that provide all three nutrients (black cohosh, soy isoflavones and gamma-oryzanol) in a single product formulation. As these three nutrients work synergistically, recommending a combination formula of this nature gives the patient the best possible opportunity to control their symptoms and improve their state of well being, without having to rely on HRT. Not all cases respond to the use of natural supplementation, however, studies suggest that the majority of patients report extremely positive results. To summarize the doses and standardized grades of each nutrient the following guide should prove helpful:
Black cohosh extract: consider 80 mg, twice per day (standardized to 2.5% triterpene content).
Soy extract: 250 mg (yielding 25 mg of soy isoflavones), twice per day
Gamma-oryzanol: 150 mg, twice per day
This combination of nutrients can be used safely by low-risk menopausal women as a viable alternative to HRT (monitoring of bone density and blood lipids should be performed periodically), and by women who have contraindications to estrogen replacement therapy (fibrocystic breast disease, endometriosis, uterine fibroids, liver or gallbladder disease, pancreatitis, or unexplained uterine bleeding). As well, women taking HRT may want to use a combination formula such as this for general nutrient support, in order to acquire important isoflavones and related phytoestrogens.
As stated previously, due to bothersome side effects and fear of breast cancer, less than 20% of North American postmenopausal women were currently using estrogen replacement therapy prior to this most recent report in July 2002. It is anticipated that many users will choose to quit HRT or be advised to do so by their physician, based upon the latest findings of the American Women’s Health Initiative trial.
Through proper guidance directed towards nutrition, exercise, and supplementation, practitioners can greatly influence a woman’s quality of life and health risk profile during the menopausal years. Many of the proven principles of natural menopausal management have been largely overlooked by traditional medicine and thus, it is incumbent upon more holistic practitioners to enlighten their female patients in regards to these matters, particularly in light of the recent negative outcomes associated with HRT. From my experience the combination of black cohosh, soy isoflavones and gamma-oryzanol, as outlined above, can be used for the following conditions and concerns:
- As a natural alternative to estrogen replacement or HRT for postmenopausal women, who demonstrate normal bone density and cholesterol levels.
- As an important source of phytoestrones and phytonutrients for women of all ages to help reduce the risk of female-related diseases throughout their lifetime (cut the dosage in half for premenopausal women and teenagers).
- As a supplement for women with PMS, fibroids, endometriosis and fibrocystic breast disease.
- As an alternative treatment for postmenopausal women with contraindications to estrogen replacement therapy.
- As a dietary adjunct to estrogen replacement therapy or the birth control pill, in order to help tone down the over-stimulation effect of these drugs on breast and uterine tissues.
By age 50 all women should have a bone mineral density test to determine their bone status. If osteoporosis is not found to be present, then most women can simply follow the lifestyle program outlined in this review. If there has already been significant bone loss, then the attending physician may wish to consider the use of biphosphonate drugs, which have been shown to slow the loss of calcium from bone, or the use of Raloxifen or other SERMs such as Tamoxifen. The point is that all postmenopausal women should have their bone density tracked periodically to monitor the effectiveness of the program to which they are subscribing, be that the use of lifestyle and natural substances and/or the use of conventional drugs. Blood work to determine fasting cholesterol and triglyceride levels and other biomarkers of cardiovascular disease should also be included as part of regular screening. What is now clear, however, is that the use of HRT as a means to manage menopausal symptoms and prevent heart disease in postmenopausal women has fallen out of favor, even in the most traditional medical circles. Patients are seeking the help of knowledgeable professionals, who are able to guide them to evidence-based natural interventions that are proven to be safe and effective. With a baby boomer turning 50 years of age every seven seconds, there is tremendous need for allied health practitioners to disseminate credible wellness information that can enhance the quality of people’s lives and help individuals avoid illness and other maladies, where science has shown that such conditions can be prevented, postponed and/or safely and effectively managed. The information contained in this report should enable health care professionals, interested in wellness management, to provide scientifically sound advice to their female clients in regards to the natural management of menopausal symptoms and the prevention of serious and often life threatening health conditions, that are common in the postmenopausal stage of life.
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