Contrary to what some people think, menopause is normal and natural. But too often, discussions about menopause and its associated problems can make it sound like a disease or a warning of pending fragility, disability, and even death.
Even though it’s normal, menopause is not an event to ignore. A balanced approach is necessary—both naiveté and overly medical approaches are unhealthy. Menopause is the beginning of a new phase of life; for many women it will be a time of empowerment, personal growth, and positive, life-changing insights and decisions. With a proper understanding of menopause and an adequately informed and respectful health-care practitioner, most menopausal women can be healthy and happy.
As a naturopathic physician, I tailor treatment considerations to the specific needs of my patients. For menopause, I offer six options that range from minimal intervention to the most conventional pharmaceutical option. A thorough evaluation—including medical history, physical exam, and laboratory and investigative tests—is imperative for determining a woman’s risk of osteoporosis and heart disease. My advice to all women is to have a full evaluation by a practitioner who is educated in natural, hormonal, and pharmaceutical nonhormonal options—generally a licensed naturopathic physician. Based on a woman’s risk for osteoporosis and heart disease and her current symptoms, a naturopath will recommend a treatment plan that will incorporate one or more of the six treatment options below.
Many changes accompany menopause. They range from mild to severe and include hot flashes, night sweats, insomnia, heart palpitations, depression, anxiety, mood swings, decreased memory and concentration, vaginal dryness, decreased sex drive, urinary dysfunction, acne, facial hair growth, and irregular bleeding. Osteoporosis and heart disease are the two most serious problems associated with menopause.
Whether to use natural therapies or conventional hormone replacement therapy, or some combination of both, is a uniquely personal decision. A well-informed patient who has a caring, knowledgeable, and open-minded practitioner is in the best position to make appropriate decisions. Remember that no decision you make is permanent. As your feelings evolve over time regarding menopause, aging, and long-term health problems, you may decide to try something different to meet your changing needs.
For most perimenopausal women, incorporating the diet, exercise, herbs, nutritional supplements, and natural progesterone creams described in this article should relieve menopausal symptoms. Women who do not find adequate relief from these therapies should see a licensed primary-care provider who preferably is educated in the range of hormone options, both natural hormone formulations and conventional hormones.
Diet and Exercise
Love your vegetables. The optimal therapeutic and preventive diet for most menopausal women is primarily vegetarian, with a little low-fat dairy and fish. The diet should include low to moderate amounts of protein, few fats, many leafy greens, whole grains, fruits, vegetables, and a high proportion of legumes.
Eat more phytoestrogens. Soy isoflavones provide diverse benefits for menopausal women. Research shows that soy reduces hot flashes and vaginal dryness. It also improves cholesterol ratios and appears to help slow bone loss.
One way to get these benefits is to include tofu, soy milk, roasted soy nuts, cooked soybeans, and other soy foods in your diet. Supplements are another way. Both capsules and powders (good for adding to smoothies) are available. It has been estimated that 200 mg of isoflavones are equivalent to approximately 0.3 mg of the hormone drug Premarin. The average daily dose of Premarin is 0.625 mg. I usually recommend including at least 100 to 200 mg a day of isoflavones for the management of menopausal symptoms.
Flaxseeds contain a class of phytoestrogenic compounds called lignans. One tablespoon a day of flaxseed flour or meal added to cereals or smoothies can improve vaginal dryness for some women.
Build bones through diet. A diet for bone health includes ample soy foods, dark leafy green vegetables, fatty acids, and calcium. Low-fat dairy products, baked beans, soybeans, tofu, salmon, sesame seeds, and calcium-fortified foods are rich sources of calcium. Several dietary factors that may adversely contribute to the development of osteoporosis are insufficient calcium, vitamin D deficiency, high phosphorus intake, high animal protein intake, and excess salt.
Feed your heart and bones. The prevention of heart disease is largely determined by diet and lifestyle. Lowering the level of dietary fat, particularly animal fat and saturated fat, is the key to a nutritional preventive approach to heart disease. Lowering the cholesterol in the diet will lower the blood cholesterol in most individuals. Experts generally recommend reducing total fat intake to below 30 percent of total calories.
A diet high in cold-water fish such as salmon, tuna, halibut, and sardines provides an excellent source of omega-3 oils, which are linked to the prevention of heart disease. Another way to reduce the risk of heart disease and lower cholesterol is to increase fiber intake. A diet high in fruits, vegetables, whole grains, beans, seeds, some nuts, and fish is low in fat but high in fiber and antioxidants; this combination prevents damage to the vessel walls.
No osteoporosis or heart disease prevention plan is complete without regular exercise. Bone health depends on strength training, weight-bearing exercise, and consistency. A well-balanced preventive regimen for bone and heart health should include about thirty minutes of aerobic exercise four times a week and strength training twice a week.
Only a few supplements effectively treat menopausal symptoms. These include vitamin E, bioflavonoids with vitamin C, and gamma-oryzanol.
Vitamin E was first used in 1937 to control hot flashes, and several confirmatory studies followed. Research shows it helps treat about 50 percent of postmenopausal women with atrophic vaginal tissue. About 400 IU of vitamin E per day is generally effective. Relief of hot flashes may take several months for some women; for vaginal dryness, you need to keep taking vitamin E continuously to maintain the benefits.
Bioflavonoids with vitamin C may also relieve hot flashes. In one study, approximately 1,000 mg of bioflavonoids with 1,200 mg of vitamin C every day for four weeks relieved hot flashes in 53 percent of women and reduced the frequency in 34 percent.
Gamma-oryzanol is a substance isolated from rice bran oil. It was first shown to be effective in relieving menopausal hot flashes in the 1960s, and at least one study since then has confirmed that finding. In the initial research, women were given 300 mg daily for about one month. More than 67 percent of the women had a 50 percent or greater improvement in their menopausal symptoms. In the later study, a 300 mg daily dose was effective in 85 percent of the menopausal women.
Bone and heart supplements can offer important protection during menopause. Calcium, magnesium, and vitamin D have significant research to show their ability to prevent or slow bone loss—and in the case of vitamin D, reduce fracture rates. Boron and other trace minerals have also been studied for their positive effects on bone density, bone architecture, or bone fragility.
Natural medicine is extremely strong in preventing cardiovascular disease but also in treating and in some cases reversing heart disease. A large body of research on fish oils, niacin, vitamins E and C, Co-enzyme Q10, folic acid, vitamins B6 and B12, potassium, and pantetheine documents the ability of nutritional supplementation to lower blood pressure, prevent lipid oxidation, lower total cholesterol and triglycerides, and prevent platelets from aggregating.
Herbal therapies are ideal for relieving a broad range of menopausal symptoms. Hot flashes, insomnia, depression, mood swings, anxiety, vaginal dryness, and heart palpitations are some of the symptoms that respond well to either individual plant preparations and/or botanical combination formulations.
Black cohosh has been studied in several research designs. In one of the largest studies, published in 1982, approximately 80 percent of the women reported a clear improvement in menopausal ailments such as hot flashes, mood swings, and insomnia. After six to eight weeks, complete disappearance of symptoms occurred in approximately 50 percent. Another study showed black cohosh was comparable to estrogen in its ability to improve moods and relieve hot flashes, headaches, and heart palpitations.
Several different doses of black cohosh extract have been studied, ranging from 40 to 160 mg a day. For my patients, I recommend 40 to 80 mg of the standardized extract, taken twice daily.
Vitex, or chaste tree berry, stands at the top of the list for managing abnormal menopausal bleeding. Whether the flow is frequent or infrequent, heavy or light, or long or short, bleeding abnormalities associated with menopause can vary widely. Vitex improves the regularity of ovulation and may result in more regular menstrual cycles and more normal blood flow. It can also ease the transition to menopause with less chaotic bleeding.
Dong quai, when researched by itself, has not fared so well in the management of menopausal symptoms. However, when studied in combination with four other herbs—motherwort, licorice, wild yam, and burdock root—this formula reduced symptom severity in 100 percent of women taking it, and 71 percent of women reported a reduction in the total number of symptoms.
Red clover standardized extracts that contain as much as 40 mg of isoflavones are now available. Although two recent studies on red clover isoflavone extracts showed no significant relief for women experiencing hot flashes, one of these studies and a third unrelated study indicate red clover may contribute to a healthier heart.
Other herbs include St.-John’s-wort for depression, kava extract for anxiety, valerian for sleep disruption, and ginkgo for memory and concentration. Asian ginseng (P. ginseng) reduces fatigue, enhances the ability to cope with stressors, and treats atrophic vaginal changes due to lack of estrogen. These herbs can be combined with other herbs and formulations that are specifically for menopause.
As with nutritional supplements, many herbal therapies have been effectively studied and utilized in clinical settings to address cardiovascular problems. Many plants have proven track records in this arena, including gugulipid and ginger, which lower cholesterol, and garlic, which lowers both blood pressure and cholesterol. However, botanical therapies have not been studied for their ability to prevent or reverse osteoporosis.
One of the greatest areas of confusion in natural medicine today is the subject of natural hormones. Natural hormones are defined as those that are biochemically and molecularly identical to the human hormone form and which have been derived from plants. The hormones are not found in the plants; they’re manufactured from ingredients in the plants.
The natural hormones (biochemically identical to human estradiol, estrone, estriol, progesterone, testosterone, and DHEA) can be made into formulations determined by a physician and made by a specially trained compounding pharmacist. Depending on the dose and the formulation, relief of symptoms and prevention of osteoporosis and heart disease can be comparable to that from conventional hormone therapies.
If you’re thinking about taking progesterone creams, consider the following.
• If you still have your uterus and are taking an estrogen of any kind, do not use progesterone cream as a replacement for oral progesterone or synthetic progestins. Progesterone cream has not been proven to protect the uterus from estrogen’s effect on the lining of the uterus. If you’re taking an oral estrogen or an estrogen patch, preferably use a prescription dose of oral micronized progesterone, 100 mg daily, or medroxyprogesterone acetate, the synthetic.
• Progesterone creams have not been proven to prevent or reverse osteoporosis. Although there is some anecdotal information suggesting a correlation, it has not been confirmed in research. Progesterone creams often successfully relieve hot flashes and may also help with other symptoms as well. A recent study showed that progesterone cream relieved hot flashes in 83 percent of the women, compared to 19 percent in the control group.
Friendlier Conventional Hormones
This category of conventional hormones includes those that are also plant derived and biochemically identical to human estrogen but are manufactured by a pharmaceutical company and therefore contain a patented ingredient. This ingredient may be an adhesive in the patch, a preservative or binder or filler in the tablet, or some other unique item in the delivery method. Estradiol, estrone, and progesterone are all now manufactured by pharmaceutical companies.
There is reason to believe that both natural hormones and friendlier conventional hormones are metabolized differently than either synthetic or nonbiochemically identical hormones. The natural and friendlier hormones appear to produce metabolites that the body is familiar with. It is some people’s contention, including mine, that these biochemically identical hormones are more easily metabolized, conjugated, and excreted by the body, and subsequently produce fewer side effects.
Less Friendly Conventional Hormones
In my clinical practice, I have observed that two kinds of hormones are often associated with a greater number of side effects, both short and long term. These are the synthetic hormones (estinyl estradiol, medroxyprogesterone acetate, methyl testosterone) and the hormones derived from a natural substance but are not biochemically identical to human hormones (conjugated equine estrogens, esterified estrogens). Even with this potential downside, they still have a place and are appropriate for some women. Unfortunately, though, this category of hormone replacement therapy is the option most likely to be prescribed in conventional medicine.
Tori Hudson, N.D., is a professor at the National College of Naturopathic Medicine in Portland, Oregon. She is also medical director of A Woman’s Time, a private clinic, and author of Women’s Encyclopedia of Natural Medicine (Keats, 1999).