Natural medicine has much to offer menopausal women who are unwilling to take Prempro or any other form of “conventional” HRT.
“It starts with lifestyle and diet,” said Elena Barengolts, MD, an endocrinologist at the University of Illinois, Chicago. “You need to look at a lot of other things besides hot flashes.” Dr. Barengolts believes a heart-healthy diet and regular exercise can do more for both immediate menopausal symptoms and long term health than any therapeutic intervention, conventional or otherwise.
If a woman is concerned about breast cancer risk, the answer is simple: 30% of the total risk is related to body weight and dietary factors. “If you exercise regularly and maintain a healthy body weight, you cut the risk by 30%. This is far in excess of any benefit you might obtain from estrogen replacement. So if you want to do something good for yourself, you’ll exercise, eat well, and maintain a good weight.” Yoga is a particularly good form of exercise for many women.
The reality is, though, many women want fast relief from the hot flashes, mood swings, and vaginal changes of menopause. And they want it in pill form. Dr. Barengolts reviewed the various natural approaches, and offered the following suggestions.
Bioequivalent Hormones: There are many alternatives to Prempro. Dr. Barengolts recommended estrogens and progesterones that are biochemically equivalent to human hormones. Use the lowest dose possible for controlling symptoms, and for the shortest time possible. For many women, a 0.3 mg estrogen dose will work as well as the standard 0.625 mg.
A patient with an intact uterus will probably need progesterone to protect the endometrium from hyperplasia. Dr. Barengolts recommends the bioequivalent Prometrium, 100 mg, used in the evening. It need not be used every day; 2 or 3 times per week usually suffices.
Phytoestrogens: There are 3 main classes of plant-based estrogens: isoflavones, lignans, and coumestans. These are found in varying concentrations and combinations in soy and other legumes, Red Clover (Trifolium pratense), Black Cohosh (Cimicifuga racemosa), Chaste Tree (Vitex agnus), and other common medicinal plants.
Though clearly estrogenic in some tissues, the phytoestrogens appear to function more like selective estrogen receptor modulators (SERMs), producing estrogenic effects in some organ systems and anti-estrogenic effects in others.
For women who like soy, it is an excellent source of phytoestrogens. To get symptom relief, one needs 50–100 mg isoflavones daily, meaning a woman must consume 40–80 grams of soy. Roasted soy nuts are a great way to get it, as is soymilk. One glass of soymilk contains roughly 40 mg isoflavones. Many women are able to control symptoms with just 2 glasses per day. Dr. Barengolts advises patients to buy soymilk supplemented with calcium, since soy does not naturally contain calcium. There are also a host of soy isoflavone products in just about any form one could imagine: tablets, capsules, soft-gels, liquids and powders for shakes.
For patients who dislike or cannot tolerate soy, herbs are the way to go. The keyword is “standardization,” she said. “Look for products made by manufacturers that at least attempt to insure batch consistency.” Promensil, made by Novogen (www.promensil.com) contains isoflavones from Red Clover, and Dr. Barengolts has found it highly effective. “It is standardized to 40 mg of isoflavones, meaning you can dose it once a day to start, and increase to twice a day only if needed.” Two recently published small placebo-controlled studies indicate that Promensil can reduce hot flashes by nearly 50% (Jeri AR. Female Patient 2002; 27: 35–37; Van der Weijer PHM, Barentsen R. Maturitas 2002; 42: 187–193).
Though less well characterized than soy or Red Clover, Black Cohosh has a long historical precedent as a menopause remedy, and a growing body of data to support its use. Again, Dr. Barengolts prefers a standardized tablet, and gets good results with Remifemin, a popular Black Cohosh product in Germany, now marketed in the US by GlaxoSmithKline. Four mg, twice daily, can control vasomotor symptoms for many women. Though they are different, Promensil and Remifemin can be safely combined if either alone is not giving full relief.
Dr. Barengolts acknowledged that many botanical medicine practitioners—and many women—frown on tablet formulations of compounds isolated from whole herbs. In truth, liquid extracts are more bioavailable, and there is wisdom in using products that contain the entire spectrum of compounds in a plant. Her contention is simply that many patients may have difficulty finding high-quality whole plant botanicals that can guarantee dose consistency over time.
Ginseng for Energy: Many menopausal women find their overall energy and vitality diminishing. Ginseng, a root long recognized in both Chinese and Western herbal medicine as an energy tonic, can help. While there are no data on ginseng for controlling hot flashes, a recent study from Sweden showed that women taking ginseng had significant improvements in self-rated energy and overall well being. Ginseng does not contain phytoestrogens, and won’t likely affect vasomotor symptoms, but it can dispel the lethargy and fatigue.
Dr. Barengolts recommends simply taking ginseng powder in capsules, beginning with 200 mg per day and going up to 2 g daily if needed. She prefers North American ginseng species grown in Wisconsin (www.Aginseng.com), where it is indigenous. Whole ginseng root itself can also be used in soups or teas.
Calcium, Vitamin D for Bone Health: “I give a very generous dose of both calcium and vitamin D,” said Dr. Barengolts, who has spent many years researching osteoporosis. The most economical approach is to give 50,000 IU vitamin D (ergocalciferol) in capsule form, once per month. Since Vitamin D will store in body fat, monthly dosing is usually sufficient for most women. Menopausal women should take at least 1.5 grams of calcium daily. There are many excellent calcium/mineral formulations available. She has found that many patients do well with the widely available Oscal-D, a combination of 1.5 mg calcium plus 400–800 IU calcium carbonate.
She added that isoflavones from soy and red clover have been shown to slow bone loss. A recent trial comparing Promensil to placebo showed that the yearly loss of lumbar spine mineral density was twice as great in women on placebo compared with Promensil (–1.5% per year versus –0.8%).
Herbs for Sleep Loss: Insomnia is one of the big perimenopausal complaints. While a number of herbs including Chamomile (Matricaria recutitia) and Kava Kava (Piper methysticum) are effective for inducing sleep, Valerian (Valeriana officinalis) is Dr. Barengolts’ personal favorite for menopausal women. At a dose of 300–600 mg, this herb works quickly, but does not leave patients foggy in the morning. There are some double-blind trials supporting valerian. But this does not mean other herbs have no place. There are also a number of good multi-herb combinations for promoting sleep.
