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 Each year in the United States, millions of women begin the transition to menopause. A high percentage experience troubling symptoms such as hot flashes, night sweats, sleep disturbance, depression of mood, joint stiffness and cognitive impairment (decreased memory, reduced mental focus and concentration). Approximately one-third of women receive hormonal therapy through traditional medical care. A high percentage of those remaining women not on hormonal therapy take dietary or botanical supplements marketed in a wide variety of formulations. In this brief review I will summarize the current scientific information on the most common nonhormonal therapies. Botanicals are not currently classified as drugs but as dietary supplements. These products are defined as follows: (1) possess dietary ingredients (herbs, amino acids, vitamins and minerals); (2) must be administered orally as pills, capsules, liquids or tablets; and (3) labeled as a dietary supplement. Unlike drugs, they do not treat, diagnose or prevent any condition and are not highly regulated by the FDA. They therefore possess considerable variability in purity, content and dose. They can however interact with drugs and may have side effects. Black cohosh (Cimicifuga racemosa) is the most studied of the herbal remedies for menopausal symptoms. It is a native North American plant (buttercup family) and contains as active ingredients flavonoids, aromatic acids and triterpine glycosides. Its presumed effect is on the brain's serotonin pathways, and it is nonestrogenic. Therefore, it is safe for women with breast cancer and endometrial disease. It has been studied in Germany for more than 40 years, and scientific studies there demonstrate a significant reduction in vasomotor symptoms (hot flushes) at a dose of 40-80 mg per day. However, a U.S. study in 2006 published in the Annals of Internal Medicine (145(12):869-879) by Newton did not confirm these German studies. It is often combined with St. John's Wort for relieving hot flushes, night sweats and depressed mood. Side effects may include gastrointestinal upset, headache, and nausea. It should not be taken during pregnancy and lactation due to lack of safety data. Black cohosh is marketed in a number of supplements; the best known is the brand name Remifemin. Isoflavones are dietary supplements from soy or red clover. They contain a high concentration of phytoestrogens ("plant estrogens"). These compounds have structural similarity to human estrogen (17 beta-estradiol) and can bind to estrogen receptors but are very weak when compared to human estrogen. There is no strong evidence regarding their efficacy in treating menopausal symptoms, and they generally have mild effectiveness at reducing hot flushes. However, they may have other health benefits for cardiovascular health and osteoporosis. Soy consumption may reduce cholesterol and LDL ("bad cholesterol"), and the FDA has approved the claim that soy protein (at 25 grams/day) can reduce cholesterol. Red clover may also have a positive effect, may reduce triglycerides as well and may lower the chance of developing osteoporosis. Isoflavones in general are safe, and gastrointestinal complaints are the only reported side effects. However, long-term use may adversely affect uterine endomterium (hyperplasia), and animal studies have shown breast cancer cells to be stimulated by isoflavones. Therefore safety of soy isoflavones in breast cancer patients has not been proven, and it is probably best for those individuals to avoid these products. Again, isoflavones can be found in many products marketed for menopausal health, the best known being Promensil. In summary, botanicals may reduce menopausal symptoms and have other health benefits. More research is needed to define their role. These products are available without prescription and should be discussed with your doctor. Dr. Charles Dubin graduated from UCLA medical school and is a specialist in gynecology, menopause and gynecologic minimally invasive surgery. He is in private practice in Santa Monica, Calif. He was among the first 100 physicians in the United States certified in advanced laparoscopy and hysteroscopy by the Accreditation Council for Gynecologic Endoscopy. He was cofounder of the Westside Menopause Center and a member of the North American Menopause Society. He was founder of the Endometriosis Center of Southern California. Dr. Dubin's practice caters to the needs of perimemopausal and menopausal women employing a customized, holistic approach using hormonal, herbal, dietary and lifestyle approaches. Send your questions to Charles@smartnow.com.
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