A cigarette company made millions with its deadly, “You’ve come a long way, baby,” campaign, but it is clear the slick Madison Avenue message strikes a chord with today’s women in menopause. These women, according to Susan Love, MD, are not willing to sacrifice their busy lives to symptoms like hot flashes and mood swings. But neither are they wedded to conventional hormone replacement therapy.
“They are looking for treatment options other than traditional hormone replacement because many of these women are worried about breast and ovarian cancer,” said Dr. Love. A lot of women entering menopause these days are not convinced that estrogen can protect their cardiovascular systems.
According to Deborah Moskowitz, ND, adjunct professor of clinical research, National College of Naturopathic Medicine, Portland, repeated surveys show that between one-third and two-thirds of women who start conventional HRT drop it within the first two years. The most common reasons for discontinuation are weight gain and unwanted side effects—particularly bloating, breast tenderness and irregular bleeding.
Many women have both physiological and philosophical objections to Premarin, the conjugated equine estrogen that is the most commonly prescribed product in the US. According to Dr. Moskowitz, their concerns are not unreasonable. “Premarin contains close to a hundred distinctly different estrogens, mainly estrone sulfate, equillins, equillenins, and alpha estradiol, all of which … occur naturally in horses, with few natural to the human body,” she writes (J Am Nutraceut Assoc 200;3(3): 36–44).
But though they may have doubts about standard HRT, women do want “something because they just can’t stand doing nothing,” said Dr. Love.
From a clinician’s standpoint as well as from the patient’s, the worst aspect of menopause is, “its unpredictability. The worst is the just not knowing,” said Dr. Love. In her own case she was struggling with menorrhagia and was convinced by a colleague that she needed a hysterectomy. “But I got very busy in my practice, so I put it off. And then the bleeding stopped. So I was spared a hysterectomy by virtue of my busy schedule.”
It is this on-again-off-again aspect of menopause symptoms that can make it a medical management nightmare for women and their physicians.
Women looking for alternatives are going to find options ranging from soy and yam based products to herbal extracts. Varro E. Tyler, PhD, said the “best studied product on the market is black cohosh (Cimifuga racemosa), particularly RemiFemin Menopause.” Dr. Tyler, author of Tyler’s Honest Herbal, tells Holistic Primary Care that clinical trials in Germany demonstrated that, “the product is effective for hot flashes, vaginal dryness and mood swings. It looks favorable for bone loss as well, but actually there is very little clinical trial evidence to prove that claim.”
Dr. Tyler, emeritus dean and distinguished professor of pharmacognosy, Purdue University, added that there is still considerable controversy about the mechanism of action for black cohosh, a plant with a long traditional history of use for gynecologic symptoms. “German trials suggest that it affects the estrogen receptor in bone, but other studies suggest that it is not very estrogenic. Some studies claim it has no estrogenic effect at all.”
Physicians can anticipate getting even more inquiries about botanical menopause treatments because products like black cohosh are going prime time, said Dr. Love. For example, GlaxoSmithKline is now marketing RemiFemin, which was developed by Schaper and Bummer GmbH & Co. of Germany, and previously marketed in the US by PhytoPharmica.
As part of its marketing campaign the pharmaceutical giant is partnering with Cedars-Sinai Integrative Medicine Group and Dr. Love to develop a support network called “Powering Informed Choices” or PIC. Dr. Love promotes PIC in live Internet chat sessions on her website, www.SusanLoveMD.com. Dr. Love said that she herself is a RemiFemin user.
RemiFemin is but one of a number of available black cohosh root extract products. While many women will prefer this standardized pill form, others will prefer liquid botanical extracts. Gaia Herbs, Inc. for example, markets high-quality alcohol and water extracts of wild black cohosh root, standardized to 1.2 mg total triterpinoids per ml (regular strength), and 2.7 mg per ml total triterpinoids (extra strength).
While Drs. Tyler and Love are fans of the herbal alternative, two other menopause experts say that natural hormones offer a better approach.
Karen Halladay, MD, an internist who practices as the Kellman Center for Progressive Medicine in Manhattan, said natural hormones should also be considered. “I counsel women about the risks and benefits of hormone therapy but I don’t prescribe products like Prempro.”
Dr. Halladay said she tries to individualize treatment for each woman, and that a plan may include black cohosh, dong quai, and chaste tree as well as calcium, magnesium, vitamin D, vitamin E and omega-3 fatty acids. “Those are the standard ingredients,” she said. She also uses hormones derived from soy and yams. “I give these in pill form rather than cremes because I think compliance is better with pills,” she said. The soy and yam hormones are obtained by prescription from a compounding pharmacy.
Dr. Moskowitz noted that many compounding pharmacies around the country are able to prepare custom combinations of estriol, estrone, and estradiol which are bio-identical with the endogenous human estrogens.
“I think these products are better tolerated because they are natural rather than synthetic products made from horse urine.” Dr. Halladay said. She has treated several women who, “can’t tolerate the synthetic hormones and then they try these natural products and they work very well.” She has had only one patient who couldn’t tolerate these natural hormones—a woman who was allergic to soy and had to be taken off treatment.
Erika Schwartz, MD, who practices in Tarrytown, New York, is another internist who believes that natural hormones are the best choice for most women. She outlined her approach to hormone supplementation in a popular book entitled, Natural Energy.
“The problem with synthetic hormones is, you trade off one set of symptoms for another: your breasts swell and get tender, you have breakthrough bleeding,” she said. The reason, according to Dr. Schwartz, is that “your body recognizes that it has a foreign molecule and that foreign molecule is not getting to the root cause of hormone symptoms, which is the need for hormone supplementation not hormone replacement.”
The need for hormone supplementation is not limited to menopause and perimenopause but is actually a lifelong condition. “Balance is the key and hormones go out of balance throughout life: at 15 girls experience acne and mood swings, these are repeated in the 20s—after delivering a baby one not only has postpartum depression but night sweats and hot flashes.” But most women only become tuned into hormonal symptoms at menopause because that is when such symptoms are expected. Dr. Schwartz uses different botanical hormone supplements, mostly custom formulated by compounding pharmacies, to treat women at the various life stages.
In recent years, “the more educated women have become leery of synthetic products, and so turn to over-the-counter products such as black cohosh or oil of evening primrose, but these products don’t balance hormones,” said Dr. Schwartz. Balance could be achieved using phytoestrogens derived from soy and yams.
In her practice, unlike Dr. Halladay, she prefers cream to pills because she said, “we get better absorption with cutaneous delivery.” She usually advises patients to apply the cream twice a day to the “upper chest where the neck ends or the inner arms, or inner wrists. I would say that we have had practically no allergic reactions, just two women that I can recall. One woman reacted to estradiol and the other to the vehicle.”
Dr. Tyler is not yet convinced.
He said soy is a good source of natural hormones and is associated with a reduction of blood lipids. “But other claims about soy are not proven, although it does look promising for bones. I would not be surprised if studies confirmed that soy is beneficial.”
But based on available evidence, the same claim couldn’t be made for yams. “This business about yams has no science behind it. Yams don’t contain any diosgesaid that can be converted to hormones in the lab. These wild yam products are probably spiked with synthetic progesterone made from a plant precursor,” he said.
Though there are clearly differences of opinion on the various forms of natural HRT, Dr. Love believes there is one thing all women need, regardless of how they choose to deal with menopause: support. “I think the most important aspect of treatment is support. Symptomatic or not, women need practitioner support as well as active treatment.”
For more information about RemiFemin Menopause, visit: www.remifemin.com. For information on Gaia’s liquid black cohosh extracts visit: www.gaiaherbs.com.
