Menopause and Herbal Management
Dr Dilis Clare
The menopause is a process of change
It mirrors the changes at puberty
It takes 18 months to 2-3 years
1/3 of women have no problems
1/3 have mild to moderate problems
1/3 have moderate to severe problems
Herbs support all the changes not just the hormones oestrogen and progesterone.
What else is helped by taking appropriate herbs:
Calming the heart as palpitations are common
Balancing thermoregulation by supporting liver and particularly bile flow. There is a feedback cooling effect on brain function via the Vagus nerve.
Sedative herbs help insomnia, this is common in association with poor temperature regulation, anxiety and often muscle and joint discomfort affecting sleep
General liver function support- the liver has a large task in decommissioning hormones. It actively eliminates sex hormone breakdown products.
Support adrenal function: if nothing else coping with all this busy change keeps adrenal function over-busy. Adaptogen herbs help with this.
St John’s Wort and menopause
Scientific Evidence for Herbal Medicine Blend
• Burdock root, Wild yam, Motherwort, Dong quai, Licorice root
• 100% had reduc3on in symptoms – (67% showed reduction with placebo)
• 71% had reduc3on in total number of sx. – (17% showed reduction with placebo) Mul3-botanical Formula
Hudson T, et al. JNM;1997;7(1):73-77
Black Cohosh for Menopause Symptoms in Women with Endometriosis for Women with Medication induced Menopause symptoms
June 23rd, 2015 by Tori Hudson, N.D.
Endometriosis is a disorder characterized by one or more of the following: pelvic pain with menstruation, pelvic pain during non-menstrual part of the cycle, pain with intercourse, pain with bowel movements, infertility women, and a change in the menstrual cycle. Conventional therapy often starts with birth control pills and pain pills but then can move on to surgery followed by oral contraceptive pills or gonadotropin-releasing hormone agonists (GnRH-a). The GnRH-a medication reduces estrogen levels, and puts the woman in at least temporary menopause, with subsequent symptoms such as hot flashes, night sweats, reduced libido, mood changes and more. Even though the medication is designed to lower estrogen, the conventional response to the onset of the menopause symptoms is to add back low doses of estrogen therapy. Herbal menopause support is however another option, and perhaps even preferred, because we are not adding back any estrogen. Black cohosh (Actaea racemosa syn.Cimicifuga racemosa, Ranunculaceae) rhizome has been shown to ameliorate menopausal symptoms in scores of studies of perimenopausal and menopausal women. Black cohosh does not have estrogenic properties.
The purpose of this prospective, randomized, controlled study was to evaluate the effect of black cohosh compared to tibolone (a synthetic steroid hormone that acts as a Selective Tissue Estrogenic Activity Regulator [STEAR]) and is used to treat perimenopausal/menopausal symptoms; not available in the U.S.)
There were 116 women, and an average age of 28.5 years old, who received GnRH-a after their endometriosis surgery. One week after laparoscopic ovarian cyst removal surgery, all patients were treated with the first GnRH-a injection and in total, received 3 injections. At the same time as the first injection, received either black cohosh standardized extract (20 mg twice daily) or tibolone (2.5 mg/day) for 12 weeks. At baseline, 4, 8, and 12 weeks after the first GnRH-a injection, menopausal symptoms were scored using the Kupperman Menopausal Index (KMI), and hot flash score was recorded.
At 4, 8, and 12 weeks after GnRH-a therapy, there were no significant differences between the black cohosh extract and tibolone groups’ KMI scores, hot flash frequency, or measures of endometrial thickness.
The levels of 17β-estradiol (E2), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels decreased in both groups after the GnRH-a injections. After 12 weeks of treatment, the black cohosh group had significantly lower E2 and significantly higher FSH and LH levels compared to the tibolone group. These findings indicate that black cohosh does not have an estrogen-like effect, as do other studies.
There were no adverse effects regarding liver function, renal function, or serum lipids in either group and the incidence of adverse events was significantly lower in the black cohosh group than in the tibolone group. The episodes of vaginal bleeding or spotting and breast distending pain were significantly lower in the black cohosh group than in the tibolone group.
Commentary: This study is one more positive representation of the value of black cohosh standardized extracts of 40 mg/day in the treatment of perimenopause/menopausal symptoms, even in the presence of drug induced menopause. It is also reconfirming that the black cohosh extract did not affect liver function, renal function, lipid profile, or hormonal levels, and was well-tolerated.
Chen J, Gao H, Li Q, et al. Efficacy and safety of Remifemin on peri-menopausal symptoms induced by post-operative GnRH-a therapy for endometriosis: A randomized study versus tibolone. Med Sci Monit. 2014;20:1950-1957.
Black Cohosh Effective in Treating Hot flashes/Night sweats
December 28th, 2014 by Tori Hudson, N.D.
This randomized, double-blind, placebo-controlled clinical trial was conducted in Iran with a total of 84 postmenopausal women. Women were randomly assigned to one black cohosh tablet per day (n=42) or one placebo (n=42) per day for 8 weeks. The severity of vasomotor symptoms and number of hot flashes were recorded in the pre-treatment phase and 4 and 8 weeks after intervention. In Iran, black cohosh is supplied by Goldaru Pharmaceutical Company under the name of Cimifugol and each tablet contains 6.5 mg of dried extract of black cohosh root, equal to 0.12 to 0.18 mg of 27 deoxy ectoine.
Participants were postmenopausal women ages 45 to 60 years old were included in the study if no menses for 12 consecutive months, normal blood pressure, a minimum score of 2 for vasomotor symptom severity; no history of breast or cervical cancer, liver disease, abnormal postmenopausal bleeding, depression or hyperthyroidism and no psychiatric medications or hormones or herbs used for treating menopausal symptoms. In addition, no smoking and no alcohol use were also inclusion criteria.
The primary outcome was the effect of black cohosh or placebo on vasomotor symptoms severity, using the FDA and Green climacteric vasomotor scale for both hot flashes and night sweats. For daytime hot flashes, a score of 1 = mild, without sweating. A score of 2 = average sensation of heat with sweating but no interruption of daily task functions. A score of 3 = severe, extra intense sensation of heat and sweating with dysfunction and interruption of daily tasks. For night sweats, 1= mild and they do not wake the woman up and only wake up if they realize they are sweating; 2 = average, they wake up due to heat and sweating but no change of clothing or sheets is needed; 3= severe and they wake up due to heat and sweating and do need to change their cloths or get out of bed or open windows. A minimum Green vasomotor score is 1 and the maximum is 6. There was a considerable decline in vasomotor symptom severity and number of hot flashes after 4 weeks and 8 weeks in particular, compared with placebo.
Commentary: Vasomotor symptoms are seen in approximately 75% of perimenopausal and postmenopausal women and can last from 1-10 years and even more than 10 years for some women. Hot flashes can not only be very uncomfortable if moderate to severe, they can make many women anxious, self-conscious in their work environment and can significantly interfere with sleep resulting in fatigue, poor cognitive function and labile moods. Treating the vasomotor symptoms successfully can improve and potentially even alleviate all these issues. This is not the first study where I’ve run into these very low doses of extracts of an herb, and it is difficult comparing them to products in the U.S.
Shahnazi M, Nahaee J, Moammad-Alizadeh-Charandabi S, Bayatipayan S. Effects of black cohosh on vasomotor symptoms in postmenopausal women: A randomized clinical trial. J Caring Sciences 2013;2(2):105-113
Soy Isoflavones Improve Bone Density and Menopausal Symptoms
April 25th, 2014 by Tori Hudson, N.D.
The authors of this study were testing the hypothesis that Asian women may have fewer health complaints and that this may be due to higher consumption of soy products. This double-blind, placebo-controlled randomized study assessed the effect of soy isoflavones on menopausal symptoms, bone mineral density (BMD), serum cytokines, and bone metabolism indices.
Chinese menopausal women were recruited from 3 medical centers in China. Women were between the ages of 45 and 55, had moderate menopause symptoms based on a questionnaire and were excluded if they had menopausal symptoms for more than 5 years, high blood pressure, endocrine disorders, cardiovascular disease, or were currently on hormone replacement therapy (HRT), pregnant, obese, or allergic to soy products.
Women were given capsules of soy isoflavone (22.5 mg, 52.2% genistein, 47.8% daidzein) or placebo, 2 capsules twice a day for 6 months. They were asked to limit their soy dietary consumption. A menopause symptom questionnaire and BMD of the radius and tibia (using ultrasound measurement) were done at baseline and at 6 months. Blood tests included genistein, daidzein, calcium, phosphorus, alkaline phosphatase (ALP), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α).
A total of 70 women completed the study (37 in treatment group and 33 in placebo group). There were overall significant decreases in menopausal symptoms such as hot flashes, insomnia, restlessness and tantrums, dizziness, lassitude, headache, heart palpitations, feeling of crawling skin, urinary tract infection, and state of sexual life of 11.5 points in the treatment group vs. 7.3 points in the placebo group. And, for almost all of the same symptoms in the placebo group (all P<0.05). Hot flashes specifically, significantly decreased in the isoflavone group vs. no significant decrease in the placebo group.
The BMD of the tibia increased significantly with soy isoflavone ingestion, although the radial BMD did not change. Alkaline phosphatase, IL-6, and TNF-α decreased significantly in the treatment group as well.
Commentary: Common perimenopause and postmenopausal symptoms include hot flashes, insomnia, and night sweats. There is also a normal bone loss, especially in the first 4 years, associated with the decline of estrogen, which can increase the risk of osteoporosis and fractures. Soy isoflavones have been shown to decrease bone loss in animal and human studies, likely due to the phytoestrogens that have weak estrogenic activity. Not all published reports confirm that Asian women have less menopause symptoms than Western Caucasian women, but if they do in fact, it is hypothesized that one reason may be the higher consumption of soy products in Asia.
To summarize, in this study, soy isoflavones had a significant, positive effect on a number of subjective and objective markers of menopause including the decrease in overall symptoms of menopause and an increase in the tibia BMD. Alkaline phosphatase levels and TNF-alpha normally rise after menopause and IL-6 is partially regulated by estrogen. Because soy isoflavones possess weak estrogen-like properties, they may alter bone formation and resorption in a manner similar to estrogen. Soy isoflavones appear to decrease blood levels of ALP, IL-6, and TNF-α, suggesting again their weak estrogenic effect and favorable influence on bone metabolism. This study should not be construed as concluding that soy isoflavones have equivalent effects of estrogen therapy, on either menopause symptoms or on slowing bone loss, but this simple intervention does have endocrine effects that have clinical meaning in menopause management.
Chi X-X, Zhang T. The effects of soy isoflavone on bone density in north region of climacteric Chinese women. J Clin Biochem Nutr. September 2013;53(2):102-107
Effect of aromatherapy massage on menopause symptoms
February 17th, 2013 by Tori Hudson, N.D.
Aromatherapy is the therapeutic use of essential oils from plants. These essential oils can be utilized through inhalation, oral intake, bathing, compresses and massage. Aromatherapy massage is the most widely utilized complementary therapy in the U.S.
The purpose of the current study was to determine the effect of aromatherapy massage on menopausal symptoms. This study was a randomized placebo-controlled clinical trial conducted at a menopause clinic in Iran. A total of 90 women were randomly assigned to an aromatherapy massage group, a placebo massage group, or a control group with no massage. Each massage group received a 30 minute massage twice a week for 4 weeks. Group one received a 30 minute massage twice weekly with a mixed aroma oil blend of lavender, rose geranium, rose and rosemary in a 4:2:1:1 ratio, diluted in almond oil (90%) and evening primrose oil (10%) at a final concentration of 3%. Group 2 received a 30 minute massage twice weekly with an odorless liquid soft paraffin. Group 3 received no treatment.
Results: Of the 90 women who qualified and consented to the study, 3 of them failed to attend more than 2 sessions and dropped out during the study, leaving a total of 87 women. There were 28 women in the aromatherapy massage group, 29 in the placebo group and 30 in the control group. After 8 sessions of intervention, the Menopause Rating Scale (MRS) score differed significantly among the three groups. Menopause symptoms decreased from 21.86 to 13.11 after aromatherapy massage and from 21.72 to 19.7 after placebo massage. A statistically significant difference was found between the pre and post MRS scores for aromatherapy massage and placebo massage but did not differ significantly in the control group. When comparing the aromatherapy massage and the placebo massage groups, the menopausal score after aromatherapy massage was significantly lower than that of the placebo massage group.
In summary, both aromatherapy massage and regular massage were effective in reducing menopause symptoms but the aromatherapy massage was more effective than massage alone.
Commentary: This study included women who reported a serious level of menopause symptoms, using the 11 items of the MRS including depressive mood, irritability, anxiety, hot flushes, heart discomfort, sleeping problems, muscle and joint problems, sexual problems, bladder problems and vaginal dryness. Each symptom is scored from 0 (no complaints) to 4 (severe symptoms). The total MRS score is the sum of the scores obtained for each symptom. Women who received the aromatherapy massage twice per week for 4 weeks had the greatest reduction in menopause symptoms, although there was a reduction in the massage only group but none in the control group. These results are similar to an earlier study of aromatherapy massage on menopause symptoms. (Hur M, et al. Evid Based Complement Altern Med 2008; 5:325-328). Another trial, although done with no control group, also demonstrated improvement of menopausal symptoms through aromatherapy massage. (Murakami S, et al. J Altern Complement Med 2005;11:491-494). The mechanism of aromatherapy massage and massage alone to improve menopause symptoms is not clear. It is possible that there is a hormonal change after massage therapy, but why the essential oils add additional benefit needs additional research if we want to know. We can certainly look to small studies on lavender aromatherapy and its ability to reduce anxiety as a possible mechanism of action. But when it comes to the benefits of nice smelling oils being applied with care through warm/gentle touch… do we really need further research to explain a mechanism of action? If nothing else, it feels good and 30 minutes twice weekly out of our usual activities and work and stressors sounds pretty good to me, menopause symptoms or not.
Darsareh F, Taavoni S, Joolaee S, Haghani H. Effect of aromatherapy massage on menopausal symptoms: a randomized placebo-controlled clinical trial. Menopause 2012;19(9):995-999
St. John’s Wort and Chaste Tree Combination for PMS Symptoms in Peri-menopausal Women
December 14th, 2009 by Tori Hudson, N.D.
The objective of this study was to evaluate the effectiveness of a combination of St. John’s wort and chaste tree berry in the treatment of PMS-like symptoms in peri-menopausal women. This clinical trial was conducted over 16 weeks and information was collected at 4 week intervals rating PMS scores in peri-menopausal women who were experiencing irregular menses.
The daily dose of herbal products given were 3 tablets containing 5400 mg of St. John’s wort standardized to contain 990 mcg hypericin, 9 mg hyperforin and 18 mg flavonoid glycosides. The daily dose of chaste tree berry was one tablet of an extract equivalent to 1000 mg of dry fruit. This was not a standardized extract. There was a matching placebo group. Participants recorded the severity of their PMS symptoms using the Abraham’s Menstrual Symptom Questionnaire.
The active treatment group was statistically superior to placebo for total PMS-like symptoms as well as subgroups of PMS depression and PMS food cravings.
Commentary: Based on previous research in PMS and chaste tree berry and PMS and St. John’s wort, as well as my clinical experience, it is not surprising that a combination of the two plants would be effective. PMS symptoms are common in regularly menstruating women, and it is also a common phenomenon in peri-menopausal women whose cycle and hormonal regularity is beginning to change. While this study evaluated a small group of women, it does address a significant population of women— those who are peri-menopausal and newly or still, experiencing PMS symptoms.
Van Die M, Bone K, Burger H, et al. Effects of a combination of Hypericum perforatum and Vitex agnus-castus on PMS-like symptoms in late-perimenopausal women: Findings from a subpopulation analysis. J Alternative and Complementary Medicine 2009;15(9):1045-1048.
St. John’s Wort and Menopause
June 30th, 2010 by Tori Hudson, N.D.
Several studies of St. John’s wort alone and St. John’s wort with black cohosh have been able to demonstrate that these products are good options for perimenopausal and menopausal women with hot flashes, mood issues, sleep problems and quality of life.
In the newest of the St. John’s wort studies in perimenopausal/menopausal women, a total of 100 Iranian women with an average age of 50 participated in a randomized, double-blind, placebo-controlled clinical trial comparing St. John’s wort with placebo in the treatment of hot flashes. 50 women received 20 drops three times daily of St. John’s wort extract (Hypericin) that contained hypericin 0.2 mg/mL and 50 women received a placebo of distilled water. The study duration was two months. Clinical exams and interviews were performed at baseline, 4 weeks and 8 weeks. Treatment effectiveness was measured evaluating frequency, duration and severity of hot flashes as the main objective of the study.
In women taking St. John’s wort, the frequency began to decline during the 1stand 2nd months, but showed more improvement during the 2nd month. There was no statistical change in hot flash frequency during the first month of placebo but did improve during the second month. Women who used St. John’s wort showed more improvement in hot flash frequency than placebo. The decline in duration of hot flashes was statistically significant at week 8 and the decline was much more evident in the St. John’s wort group. The severity of hot flashes was relieved in the St. John’s wort group during the 2 months of treatment and was more significant in the second month. Women in the placebo group did not show any significant decrease in severity of hot flashes during the 1st month, but they did have some improvement during the 2nd month, but not as great as those women in the St. John’s wort group.
St. John’s wort has emerged as an important clinical tool in treating perimenopausal/menopausal women—for hot flashes and/or depression and/or mood swings, and/or sleep problems either as an encapsulated standardized extract from 300 mg twice per day to three times per day, or a tincture/liquid extract ½ tsp 2-3 times per day, or in combination with other menopause therapies such as black cohosh, maca extract, kava or others.
 Abdali K, Khajehei M, Tabatabaee R. Effect of St. John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause 2010;17(2): 326-331.