The Natural Management of Menopause, Part 1
By James P. Meschino, DC, MS
In recent years, many women across North America have demonstrated a reluctance to rely upon hormone replacement therapy (HRT) to reduce menopausal symptoms, due primarily to concerns about the potential risk of breast cancer.
Only about 20 percent of women who are given prescriptions for HRT faithfully take it. A growing number of postmenopausal women have been seeking out herbal remedies as an alternative to HRT, as reflected by the rapid growth in herbal supplement sales during the past decade.
Interest in natural therapies to control menopausal symptoms is expected to escalate with the two recent alarming reports that confirm previous suggestions that hormone replacement therapy increases the risk of breast cancer, and that unopposed estrogen (usually given to women who have undergone a hysterectomy) substantially increases the risk of ovarian cancer.1,2
On July 9, U.S. researchers aborted the Women’s Health Initiative (WHI) trial of 16,000 subjects taking hormone replacement therapy (HRT), as results showed that after 5.2 years, there was a 26-percent increased risk of breast cancer in the women using hormone replacement, compared to women receiving the placebo. Women taking HRT also showed a 41-percent increased risk of stroke, and a 29-percent increased risk of heart attack (myocardial infarction) compared to women receiving the placebo. Prior to this, many doctors promoted HRT as a means of reducing the risk of heart disease in postmenopausal women, but the findings of the WHI trial provide unequivocal evidence that HRT greatly increases the risk of heart attack and stroke in this population.1,3
More bad news regarding estrogen replacement therapy appeared in the July 17 issue of the Journal of the American Medical Association. In a follow-up study of 44,241 former participants in the Breast Cancer Detection Demonstration Project, researchers discovered that the use of estrogen replacement therapy (without concurrent use of progesterone) increased the risk of ovarian cancer, with a relative risk of 1.8 in women who used estrogen replacement therapy for 10-19 years and a 3.2 relative risk in women using estrogen replacement therapy for 20 or more years.2
Previous data from the Nurses’ Health Study demonstrated that for each year a woman remained on HRT, her risk of developing breast cancer increased by 2.3 percent. Thus, a postmenopausal woman taking HRT for 10 years had a 23-percent increased risk of developing breast cancer. After 20 years of HRT use, a woman’s risk of developing breast cancer would be 46 percent greater than a woman who never used HRT during the menopausal years, according to evidence provided by the Nurses’ Health Study.37-39 As the results of these studies are reported by the popular media, a growing number of women are giving up their HRT medications and searching for credible alternative means to optimize their feeling of well being; reduce hot flashes and other menopausal symptoms; maintain an active sex life and a healthy appearance; and reduce their risk of osteoporosis, heart disease and other degenerative conditions.1
To help patients arrive at a prudent course of action, health practitioners should be informed about the current research status of various natural interventions that have a proven and safe record in the management of menopausal complaints, and health conditions affecting menopausal women.
Women live one-third of their lives in the postmenopausal years. Helping them maximize their quality of life, and lifespan, should be the intent of any nutrition, supplementation, customized to an individual’s needs. In addition to controlling hot flashes and other menopausal symptoms, there are three major health concerns that must also be factors. It is well established that postmenopausal women are at increased risk for breast cancer, osteoporosis, and heart disease.
- Heart disease is the number-one killer of postmenopausal women.
- Osteoporosis affects one in four women by 50 years of age.
- Breast cancer incidence rates have increased by 40 percent in the last 50 years, with one in every 403 women afflicted between ages 50-59, one in 266 women afflicted between ages 60-69, and one in 220 women afflicted at age 70 and over.4
After menopause, women become less able to clear cholesterol from their bloodstreams. During the premenopausal stage of life, high-circulating estrogen levels increase the production of LDL-cholesterol receptors, which enable cells to extract LDL-cholesterol (low-density-lipoprotein-cholesterol, known to increase risk of heart attack and stroke) from the bloodstream and use it for various purposes. In menopause, there is a 90-percent drop in circulating estrogen levels that appears to reduce the ability of cells to produce LDL-cholesterol receptors. As a result, there is a strong tendency for cholesterol to accumulate in the bloodstream, stick to the walls of the arteries, and cause narrowing of coronary blood vessels, leading to heart attack.4
As a high-saturated-fat diet is the main culprit in raising LDL-cholesterol levels, postmenopausal women should adjust their diets to lower their saturated fat intake (results from the Framingham Heart Study suggest individuals should ingest no more than 10-28 grams per day of saturated fat, based upon the presence of other risk factors, such as family history, diabetes, smoking and high blood pressure), to keep their blood cholesterol levels below 200 mg per dL. This implies that the use of animal protein foods consists of chicken, turkey, Cornish hen and fish, and that all milk and yogurt products consumed are nonfat or “one percent” varieties. No cheese above three percent milk fat should be consumed, and butter; ice cream; whipping cream; regular chocolate products; items containing coconut or palm oil; and deep-fried products of all types should be avoided.5
Increasing soluble dietary fiber intake can also reduce blood cholesterol levels by dragging cholesterol out of the body, as well as bile acids, which can serve as precursors (building blocks) to the synthesis of cholesterol in the liver. Soluble fiber is found in most fruits and vegetables; oat bran; psyllium husk fiber; ground flaxseeds; and beans and peas.6Remaining physically fit and at or near one’s ideal weight are also important in preventing cardiovascular disease in the postmenopausal years.7,8
It should also be noted that soy products and extract supplements are known to reduce blood cholesterol levels by 9-12 percent in patients with high cholesterol levels.9 The same is true for a supplement known as gamma-oryzanol, derived from rice bran oil.10,11 Soy extract and gamma-oryzanol have been shown to reduce hot flashes and other menopausal symptoms, and are excellent alternative therapies to HRT in postmenopausal women. Gamma-oryzanol is an approved drug for the management of menopausal symptoms in Japan, where the research on this natural agent has been performed.12 It is very convenient that soy extract and gamma-oryzanol can help reduce menopausal symptoms, reduce cholesterol levels, and (in the case of soy isoflavones) help to maintain bone mineral density.13-15
The decline in estrogen levels that accompanies the menopausal years also permits calcium to leak out of bone into the bloodstream, where it will eventually become filtered by the kidney and exit the body in the urine. This leads to osteoporosis, which increases risk of fractures. Osteoporosis is reaching epidemic proportions, largely due to insufficient calcium intake and accumulation in bone, especially between the ages of 11 and 24, and loss of calcium from bone during the menopausal years.16,17 It should be noted that Canadian statistics indicate that complications from osteoporotic hip fractures (e.g., the development of pneumonia) result in more deaths each year than the combined mortality rate from breast and ovarian cancers.18 The lifestyle recipe to prevent osteoporosis during the menopausal years is as follows:
- Ingest 1,500 mg per day of calcium, if not taking HRT. This can be achieved through a combination of calcium from diet and supplements. (Calcium carbonate and calcium citrate are absorbed equally if taken with meals.) As calcium carbonate is less expensive, it represents a more cost-effective intervention for patients. However, if the patient has a history of kidney stones, calcium citrate may be preferred due to its greater solubility.16
- Supplement with 600 to 1,000 IU of vitamin D. For general health reasons, women should consider taking a high-potency multiple vitamin and mineral, which normally includes 400 IU of vitamin D. Studies show that postmenopausal women ingesting an additional 200 to 400 IU of vitamin D per day may reduce their risk of hip fractures by approximately 50 percent. A high-potency multiple vitamin and mineral supplement(including extra antioxidant protection and a B50 complex) contains other nutrients important to bone health (calcium, zinc, magnesium, copper) and provides comprehensive micronutrient support for other aspects of health optimization.
As we age, our kidneys reduce their ability to convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, which contains twice the vitamin D potency. However, studies indicate that by increasing blood levels of 25-hydroxyvitamin D, through the intake of vitamin D supplements (600-1,000 IU per day), a postmenopausal woman can compensate for the drop in 1,25-hydroxyvitamin D synthesis, and thereby significantly reduce her risk of osteoporotic fractures.19,20
- Perform weightbearing or resisted exercises four to seven times per week. Weightbearing exercises, such as walking, jogging and weight training, place increased stress on the spine and femurs, which respond by holding their calcium in bone to help withstand the physical stresses acting on the bone structures. Some studies reveal that postmenopausal women can increase their bone density, without using HRT, by simply ingesting more calcium and performing a series of five weight training exercises, twice per week.21
- Supplement with a product that contains black cohosh and soy isoflavones. As will be discussed in greater detail later, the standardized grades of black cohosh and soy extract have been shown to reduce menopausal symptoms, and evidence exists to show that they can also help to preserve bone mineral density via their estrogenic effects on bone receptors.22,23
It is well documented that women who are overweight during the postmenopausal years have approximately three times the risk of developing breast cancer than women who are not overweight.24-26 This is likely due to the fact that as fat mass increases, there is a greater conversion of androstenedione to estrone within the stromal tissue of adipose tissue. Higher circulating estrone (one of three types of estrogens made by the female body) levels are associated with increased risk of breast cancer, as estrone is known to increase the cell division rate of breast cells. In turn, this leads to a greater chance of genetic mutations occurring, which may be cancerous. This is exactly the same mechanism through which HRT has been shown to increase breast cancer risk. Thus, postmenopausal women are advised to attain and maintain an ideal body weight and a body mass index (BMI) below 25 (24.87).24
Avoiding the use of HRT is emerging as a significant strategy to help prevent breast cancer in postmenopausal women. The best alternative approaches include a combination of black cohosh, soy isoflavones and gamma oryzanol, as each of these natural interventions has been shown to reduce menopausal complaints, and their use in human populations over many years suggests that they do not increase risk of breast cancer. In Japan, where soy isoflavone intake is customarily between 50 and 75 mg per day, breast cancer incidence is 75 percent lower than in the U.S.14 Recent experimental studies involving black cohosh have shown that it exerts an anti-proliferative effect on breast cells and human breast cancer cell lines, consistent with a reduced risk of breast cancer, according to available scientific evidence.27 Therefore, in women without a previous history of breast cancer, black cohosh, soy isoflavones and gamma-oryzanol can be considered safe and effective alternatives to HRT.28,14,12 In patients with a previous history of breast cancer, the jury is still out as to whether these natural agents should be used. However, in a recent survey, women with a previous history of breast cancer were 7.4 times more likely to use alternative treatments for menopause symptoms than women with no previous history of breast cancer. Soy products, herbal remedies (including black cohosh and gamma-oryzanol) and vitamin E were the most common alternatives to HRT.29
In addition to these devastating statistics, the decline in estrogen and progesterone production that accompanies menopause triggers a broad range of physical, psychological and age-related signs and symptoms that can significantly interfere with a woman’s feeling of well-being.4 Although underutilized by medical doctors in this part of the world, substantial evidence from Europe and Asia provides convincing support that black cohosh, soy extract and gamma-oryzanol can significantly reduce menopausal symptoms; help support bone density; reduce high cholesterol; prevent atrophy and dryness of vaginal tissues; and improve a woman’s well being and vitality. Unlike HRT, these natural substances are not associated with an increased risk of breast cancer, ovarian cancer or heart disease. As such, in most cases they can be employed as a significant part of a natural lifestyle, aimed at enhancing the health and quality of life of postmenopausal women.
- Kaunitz AM. Use of combination hormone replacement therapy in light of recent data from the Women’s Health Initiative.’Medscape Women’s Health eJournal, Jul 12, 2002.
- Barclay L. Estrogen therapy, but not estrogen-progestin, linked to ovarian cancer.JAMA 2002;288:334-341,368-369.
- British Scientists Say HRT Trial Should Continue. Reuters Health Information 2002.
- Colgan M. Hormonal Health. Apple Publishing, Canada, 1996.
- Castelli WP, Griffin GC. How to help patients cut down on saturated fat. Postgraduate Medicine 1988;84(3):44-56.
- Masley SC. Dietary methods to reduce LDL levels. American Family Physician1998;57(6):1299-1306.
- Pate RR, et al. Physical activity and public health. JAMA 1995;273(5):402-407.
- Kannel WB, et al. Effect of weight on cardiovascular disease. American Journal of clinical Nutrition 1996; 63(suppl):419S-22S.
- Patter SM, et al. Soy protein and isoflavones: their effects on blood lipids and bone density in postmenopausal women. Am J Clin Nutr 1998;68 (suppl):137-9.
- Yoshino G et al. Effects of gamma-oryzanol on hyperlipidemic subjects. Curr Ther Res;(45):543-552,1989.11. Yoshino G et al. Effects of gamma-oryzanol and probucol on hyperlipidemia. Curr Ther Res (45), 975-982,1989.
- Murase Y, et al. Clinical studies of oral administration of gamma-oryzanol on climacteric complaints and its syndrome. Obstet Gynecol Prac (12) 147-149,1963.
- Anderson JW, et al. Meta-analysis of the effects of soy protein intake on serum lipids.N Engl J Med 1995; 333:276-82.
- Messina M. Legumes and Soybeans: overview of their nutritional profiles and health effects. Am J Clin Nutr1999;(70)(suppl);439-50.
- Ishihara M. Effect of gamma-oryzanol on serum lipid peroxide levels and climacteric disturbances. Asia Oceania J Obstet Gynecol 1984;(10):317.
- Optimal calcium intake. JAMA 1994;272(24).
- Calcium supplementation and bone loss: a review of controlled clinical trials.American Journal of clinical Nutrition 1991;54:274S-280S.
- Osteoporosis Society of Canada. Clinical practice guidelines for the diagnosis and management of osteoporosis. CMAJ 1996.
- Supplementation with vitamin D3 and calcium prevents hip fractures in elderly women. Nutrition Reviews 51(6).
- “Rates of bone loss in postmenopausal women randomly assigned to one of two dosages of vitamin D.”American Journal of Clinical Nutrition 1995;61:1140-1145.
- Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA 1994;272(24).
- Stolze H. An alternative to treat menopausal complaints. Gyne 1982;3:1416.
- Albertzazzi P, et al. The effect of dietary soy supplementation on hot flashes. Obstet Gynecol 1998;(91):6-11.
- Toniolo P, et al. A prospective study of endogenous estrogens and breast cancer in postmenopausal women. JNCI 1995;87(3):190-199.
- Lew EA, et al. The American Cancer Society Study: Variations in mortality by weight among 750,000 men and women. J Chronic Dis 1979;32:563-76.
- Tannenbaum A. The relationship of body weight to cancer incidence. Arch Pathol1940;30 509.
- Dixon-Shanies D, Shaikh N. Growth inhibition of human breast cancer cells by herbs and phytoestrogens. Oncol Rep 1999;6(6):1383-7.
- Murray M. Remifemin: Answers to some common questions. Am J Natural Med April 1997;4(3).
- Many U.S. breast cancer survivors use alternatives to HRT. J Pain Symptom Manage2002;23:501-509.
- Warnecke G. Influencing menopausal symptoms with a phytotherapeutic agent. Med Welt 1985;36:871-4.
- Stoll W. Phytopharmacon influences atrophic vaginal epithelium:Double-blind study -cimicifuga vs. estrogenic substances. Therapeuticum 1987;1:23-31.
- Gorlich N. Treatment of ovarian disorders in general practice. Arztl Prax1962;14:1742-3.
- Limon L. “Use of Alternative Medicine in Women’s Health.”; Am Pharmaceutical Assoc Annual Meeting. A Ph A, 2000. Pharmacists Conference Summaries 2000. Medscape, Inc.
- Murkies AL, et al. Dietary flour supplementation decreases post-menopausal hot flashes: effect of soy and wheat. Maturitas 1995;(21):189-195.
- Isoflavones and menopause. Medical Post Oct. 3, 2000.
- Cassidy A, et al. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of pre-menopausal women. Am J Clin Nutr1994;(60):333-340.
- Colditz GA. Relationship between estrogen levels, use of hormone replacement therapy and breast cancer. J Natl Cancer Inst 1998;90(11):814-823.
- Health after 50. John Hopkins Medical Newsletter Nov 1999;11(9):6-7.
- Simone B. Cancer and Nutrition. Avery Publishing Group Inc., 1992:219-23.
- Brinton LA. Menopausal estrogen use and risk of breast cancer.Cancer1981;47,10:2517-22.