by Tori Hudson, N.D.
Perimenopause: signs and symptoms
Many women begin to experience an array of physical, mental and emotional symptoms long before they meet the definition of menopause. These changes that occur over a timeframe of several years, usually from around age 40 to 51, mark a transition period called "perimenopause". A narrower definition would be the shift a woman experiences from regular to irregular menses. On average, the onset of perimenopause occurs around age 47, with the average duration being 4 to 5 years.
Perimenopause is a time of instability and unpredictability. estrogen and progesterone levels fluctuate and decline. Women's hormone levels are changing not only in their total serum blood levels, but also in relationship to each other. Aging also contributes to many changes like weight gain, alterations in metabolic rate, and outlook on life. Factors such as age, stress, and body weight also begin to play a larger role in the production of the hormone estrone.
The signs and symptoms of perimenopause include menstrual irregularities and changes in the amount of blood loss, hot flashes, night sweats, vaginal dryness and vaginal thinning. Women may also notice skin changes, fatigue, decreased libido, decrease in arousal and orgasmic response, mood swings, weight gain and joint paints. Other symptoms include depression, anxiety, changes in memory and cognition, sleep disturbance, hair loss on the head, hair growth and acne on the face, heart palpitations, nausea, headaches, urinary tract infections and urinary incontinence. Perimenopause may be the time when beginning stages of osteoporosis and heart disease appear.
Symptoms can be mild, moderate, or severe. Initially, they may vary from subtle and infrequent to overt and daily. Some women will have no significant menopausal symptoms except in the menstrual cycle and others will have symptoms that are progressive and problematic for years to come.
Individual assessments and recommendations about the use of any therapies - whether phytestrogen, natural hormones, and/or conventional hormone replacement therapy, bisphosphonates for osteoporosis, lipid lowering and antihypertensive medications (to reduce cholesterol and blood pressure) need to be made for each woman based on her unique risk factors, needs and preferences.
Natural therapies are very well suited for the perimenopausal woman. Conventional hormone therapy (HRT or ERT) is not the only option available. Women who should not or do not want to take prescription hormones may turn to herbal and nutritional therapies for managing their menopausal symptoms and risk factors.
Principles of naturopathic medicine
Naturopathic medicine is its own distinct healing art and is defined best by its principles and its therapies. Simply put in modern terms, naturopathic physicians are primary health care providers, family physicians, who specialize in natural medicine.
Seven principles make up the foundation for naturopathic medicine. These provide the philosophical context for addressing the perimenopause transition, allowing practitioners to emphasize a nutritional and botanical approach, and the use of natural hormones, when needed, while de-emphasizing the use of prescription hormones.
- The Healing Power of Nature. (vis medicatrix naturae)
The body has the inherent ability to establish, maintain and restore health. The physician's role is to facilitate and augment this process with the aid of natural, non-toxic therapies; to act to identify and remove obstacles to health and recovery, and to support the creation of a healthy internal and external environment.
- First, Do No Harm (primum no nocere).
Naturopathic physicians seek to do no harm with medical treatment by employing safe, less invasive, and effective natural therapies.
- Identify and Treat the Cause (tolle causam)
Naturopathic physicians are not only trained to investigate and diagnose diseases, they are also trained to view things more holistically and look for an underlying cause, be it physical, mental, or emotional. Symptoms are viewed as expressions of the body's attempt to heal, but are not the cause of disease. The physician must evaluate fundamental underlying causes on all levels, using treatment that includes addressing the root cause rather than just the suppression of symptoms.
- Treat the Whole Person
Health and disease are conditions of the whole organism, involving a complex interaction of physical, spiritual, mental, emotional, genetic, environmental and social/cultural/economic factors. The physician must treat the whole person by taking all of these factors into account. Homeostasis and harmony of functions of all aspects of the individual is essential to recovery from disease, prevention of future health problems and maintenance of wellness.
- Physician as Teacher (docere)
The naturopathic physician's major role is to educate, empower, and motivate the patient to take responsibility for health. The physician educates about risk factors, hereditary susceptibility, lifestyle habits, and preventive measures that lead to recommendations on how to avoid or minimize future chronic health problems. A healthy attitude, diet, exercise, and other lifestyle habits serve as the cornerstone of our recommendations.
- Prevention is the Best Cure
The ultimate goal of naturopathic medicine is prevention. This is accomplished through education and promotion of life-style habits, and natural therapeutic recommendations. The emphasis is on building health rather than on fighting disease.
- Establish Health and Wellness
The primary goals of naturopathic physicians are to establish and maintain optimum health and to promote wellness. We strive to increase the patient's level of wellness, characterized by a positive emotional state, regardless of the level of health or disease.
Natural therapies for perimenopause: the scientific facts
There is a growing body of scientific evidence to assess the efficacy of natural therapies for perimenopausal symptoms and disease prevention. Here is a brief summary of what the studies tell us so far:
Phytestrogen
Plants manufacture thousands of chemical compounds vital to the health and function of the plant. Those chemical compounds, generally known as micronutrients, are consumed by humans whenever the plants are eaten. One class of chemical compounds manufactured by plants is known as phytestrogens. Over 300 plants contain phytestrogen compounds. They comprise a large part of our diet, and are found in medicinal plants as well.
There are several sub-classifications of phytestrogens, including the category known as isoflavones, to be found in spinach, fruits, clovers, peas, beans, and especially in soy products.
Isoflavones are of particular interest to the perimenopausal woman since they have a structure similar to naturally occurring (endogenous) steroidal sex hormones. Isoflavones have the ability to bind to estrogen receptors on human cells, and in women, they have a preference for binding to the beta form of the estrogen receptor. As a result, isoflavones preferentially express estrogenic effects in the central nervous system, blood vessels, bone and skin, and they appear to do so without causing stimulation of the breast or uterus.[1]
However, in that isoflavones are structurally related to endogenous estrogens, they are able to mimic some of the effects of human estrogen, but to a significantly lesser degree. It is estimated that soy isoflavones are 1/400th to 1/1000th the potency of the estrogen estradiol. Uniquely, isoflavones may also act as anti-estrogens, much like "Selective Estrogen Receptor Modulators" (SERMs), synthetic hormones which act selectively as estrogen on some organs or tissues of the body and as anti-estrogens on others.
Isoflavones can be thought of as one of nature's SERMs. Therapeutically, isoflavones may alleviate menopause symptoms, and lower the risk of osteoporosis, coronary artery disease, breast and uterine cancer.[2]
Soy Isoflavones
Several studies have now been done on the effect of soy isoflavones on vasomotor symptoms, such as hot flashes and night sweats, in menopausal women. Six published studies report improvements in vasomotor symptoms from soy protein rich in isoflavones;[3] four of the studies used soy protein or soy foods, while 2 used soy extracts. Criticisms of these studies have been that relatively small numbers of women were involved, most studies were short term (not more than 12 weeks), not all were double blind clinical trials, and benefits did not exceed a 45% reduction in symptoms.
Research results published in 2000-2001 have been less promising. A soy product studied in breast cancer patients with hot flashes concluded that soy did not alleviate hot flashes.[4] However, a majority of the women (ages 18 to 50+) were on tamoxifen (a synthetic SERM used to prevent recurrence of cancer), although there was no clear difference in the effect of soy on hot flashes in either group. Perhaps the most glaring fault of the study was the lack of information provided about who was postmenopausal versus premenopausal and who had experienced natural menopause, chemotherapy-induced menopause or surgical menopause.
A 2001 study on soy isoflavones and vasomotor symptoms also reported disappointing results.[5] Unlike the previous 6 studies which followed women for 12 weeks or less, this study continued for 24 weeks. Researchers found that symptoms generally declined in all 3 treatment groups during the first 12 weeks but either increased or showed no change during the last 12 weeks.
It is important to consider whether the seemingly positive outcome in the soy groups in the earlier studies was merely due to the short duration of the study period. Based on these overall results, soy isoflavones in the treatment of vasomotor symptoms may not provide the relief we have come to hope for. Future studies may need to develop new methods or tools for collecting symptom data that are either more accurate, and/or extend over at least 24 weeks.
Data from animal and human studies suggest that increasing the soy foods in the diet may help regulate the menstrual cycle, stabilize bone density, and reduce cholesterol.[6] More research in this area needs to be done.
Red Clover Isoflavones
Red clover is a member of the legume family and has been used worldwide as a source of hay for cattle, horses and sheep and by humans as a source of protein in the leaves and young sprouts. Historically, it has also been recognized as a medicinal plant for human use and, more recently, as a menopausal herb.
In four clinical trials conducted on the effect of red clover isoflavones on vasomotor symptoms, two showed benefits and two did not. The first two published studies showed no statistically significant difference between the red clover standardized extract and the placebo during a 3 month period, although both groups did improve.[7] It was suggested that the negative results of these studies were due to inadequate controls and that women in the control group were, in fact, getting meaningful amounts of phytestrogens in their diet.
Two other studies of 40 mg standardized extract of red clover produced a 75% reduction in hot flashes after 16 weeks in 30 women. The difference between placebo and red clover isoflavones was statistically significant (p 0.<001).[8]
A similar study evaluated 40 mg of red clover standardized isoflavones for two months in 23 post-menopausal women and found that red clover users had a 54% reduction in hot flashes versus 30% in the placebo group.[9]
The 4 studies also revealed other intriguing results of red clover: no endometrial thickening, an increase in HDL ("good cholesterol"), and no abnormalities in liver function tests, CBC, or estradiol. Another study showed that red clover isoflavones may reduce coronary vascular disease by increasing arterial elasticity by 23%.[10]
Botanicals
Black Cohosh
Black cohosh has emerged as the single most important herb for the treatment of menopausal symptoms. Although the bulk of the research has been uncontrolled studies, there have been 6 well-publicized studies.[11] In one of the largest, 629 women with menopausal complaints were given a liquid standardized extract of black cohosh twice daily for 6 to 8 weeks.[12] By 4 weeks, clear improvements in menopausal symptoms, including hot flashes, night sweats, headaches, insomnia and mood swings, were seen in 80% of the women, while symptoms completely disappeared in approximately 50%. The other studies reported improvements in fatigue, irritability, hot flashes and vaginal dryness.
A recent clinical trial on black cohosh (2001) involved 85 women diagnosed with breast cancer experiencing hot flashes.[13] Fifty-nine of them (70%) were taking tamoxifen during the trial. Participants took either black cohosh standardized extract of 40 mg twice daily or placebo for two months. Both the black cohosh and placebo groups had a decline in the number and intensity of hot flashes during the first month of about 27%. Women in the black cohosh group did report a greater reduction in sweating.
Although the results of this study are not consistent with other research showing benefit from black cohosh for menopausal symptoms, it is important to note that black cohosh may not work in the presence of an anti-estrogen, such as tamoxifen. Other limitations of the study were its short duration and a high dropout rate, with most of the women who remained in the black cohosh group taking the tamoxifen.
Combination products
Most of the herbal combination products available contain 5 or more plants, some that contain phytestrogens and some that claim to have other therapeutic benefit specific to menopause. Other combination products contain a mixture of plants and nutrients such as soy or vitamin E. Most of these combination products have not been researched, even though an individual ingredient may have been studied.
One herbal combination product that has been the subject of a clinical trial contains dong quai, motherwort, licorice root, burdock root and wild yam root.[14] Women were randomly assigned to the herbal combination or a placebo, taking 2 capsules 3 times daily, for 3 months. After 3 months, 100% of the women taking the botanical formula had a reduction in the severity of their symptoms, compared to 6% taking placebo. 71% of women taking the herbal formula reported a reduction in the total number of symptoms, compared to 17% on placebo.
The botanical formula was most effective in treating hot flashes, mood changes, and insomnia. There were no clear effects on blood levels of estradiol or total estrogens, although there was actually a trend for a decrease in the treatment group. Serum progesterone levels also appeared to decrease in the herbal group. No clear effects of the botanical formula were apparent in HDL cholesterol, triglycerides, or total cholesterol.
Since there is a wide-variety of combination products on the market, more research in this area is required.
Other Botanicals
Numerous other botanicals have been used historically in the practice of traditional
herbal medicine for the treatment of menopausal symptoms. Some either have
no research, no confirming research, or only a small study showing some efficacy.
These include wild yam, dong quai, licorice, chaste tree, sage, hops and
more.
For other individual symptoms, there is research to show that St. John's wort is effective in treating mild to moderate depression,[15] and ginkgo, to improve memory.[16]
Natural Hormones
Natural hormones are defined as a plant-derived compound that has been converted in the manufacturing laboratory to a hormone that is biochemically identical to endogenous (naturally occurring) hormones. Estradiol, estriol, estrone, progesterone, and testosterone are sex steroid hormones that can be made as natural hormones.
Non-natural hormones include plant-derived compounds that are then made into non- bio-identical hormones, such as esterified estrogens or estinyl estradiol, animal hormones such as conjugated equine estrogens, and synthetics such as medroxyprogesterone acetate (MPA) and methyl testosterone.
The natural hormones estriol and estradiol tend to be combined in a bi-estrogen formula along with progesterone and sometimes testosterone. Doses can be compounded that are equivalent to conventional hormone doses, but one of the true advantages of natural hormones is that many different formulations can be compounded to individually address each woman's unique menopausal situation, or individually adjusted as the need arises.
Natural hormones have a shorter half-life (and so clear your system more rapidly), tend to be better tolerated than synthetic or animal derived hormones or hormones that are not biochemicallly identical to human hormones. They can also be combined so that the weaker estriol with its anti-estrogen effects in the breast[17] , along with the more potent and necessary estradiol (for bone protection and great symptom relief), provide an estrogen replacement that is the safest and most natural way we have to date. Natural progesterone is significantly better tolerated than MPA, and has a better effect on lipids[18] and on dilating coronary arteries.[19]
Natural progesterone by itself can also be used very effectively during the perimenopause. Problems that can be addressed include regulating the menstrual cycle, hot flashes, night sweats, mood swings, sleep disruption, and premenstrual symptoms.
Many women use progesterone creams, but there has not been much research in this area. In one study, a transdermal progesterone cream was examined for its ability to control hot flashes and to prevent bone loss. This placebo-controlled study followed 102 healthy women within 5 years of menopause for one year.[20] Women in the treatment group experienced significant improvements or resolution of their hot flashes over women on placebo. However, there was no significant difference in bone mineral density between women on progesterone cream versus placebo.
Conclusion
Women in the perimenopause transition years who are beginning to experience various and episodic perimenopausal symptoms are in a good position to try botanical and nutritional therapies to relieve their symptoms.
A health care practitioner who is educated about all the options available to the perimenopausal woman can help her manage health concerns and assess her individual risks for disease to determine which therapy or combination of therapies is appropriate. An integrative approach, which also includes adequate advice about healthy diet, exercise, nutritional supplements and emotional health, should be fundamental for all women.
Dr. Tori Hudson is a Professor at the National College of Naturopathic Medicine, Portland, Oregon [(503) 499-4343], and the Medical Director of A Woman's Time. She is the author of Women's Encyclopedia of Natural Medicine (Keats Publishing, 1999) and writes the monthly column, "Women's Health Update" for The Townsend Letter for Doctors and Patients.
This article first appeared in A
Friend Indeed (Jan/Feb 2002), the newsletter for women in menopause
and midlife.
Reviewed June 2006.
Endnotes
[1] Kuiper G, Carlsson B, Grandien K, et al. Endocrinology 1997;138:863-870.
[2] Adlercreutz H, Mazur W. Ann Med 1997;29:95-120.
[3] Respectively, Upmalis D, Lobo R, Bradley L, et al. Menopause 2000; 7:4:236-242; Albertazzi P, Pansini F, Bonaccorsi G, et al. Obstetrics and Gynecology 1998;91(1): 6-10; Brzezninski A, Adlercreutz H, Shaoul R, et al. Menopause 1997;4(2):89-94; Scambia G, Mango D, Signorile P. Menopause 2000;7(2):105-111; Quella S, loprinzi C, Barton D, et al. J Clinical Oncology 2000; 18(5):1068-1074; Washburn S, Burke G, Morgan T, Anthony M. Menopause 1999;6 (1):7-11.
[4] Queslla S, Loprinzi C, Barton D, et al. J Clinical Oncology 2000;18(5):1068-1074.
[5] Germain A, Peterson C, Robinson J, Alekel L. Menopause 2001;8(1):17-26.
[6] Respectively, Cassidy A, et al. Am J Clin Nutr 1994; 60:333-340; Arjimandi B, Alekel L, Hollis B, Amin D, Staceqicz-Sapuntzakis M, Guo P, Kukreja S. J Nutr. 1996; 126: 161-167; Blair H, Jordan S, Peterson T, Barnes S. J Cell Biochem. 1996; 61: 629-637; Anderson J, Ambrose W, Garner S. J Nutr. 1995; 125:799S; Anderson J, et al. NEJM 1995; 333(5):276-282.
[7] Knight D, Howes J, Eden J. Climacteric 1999;2(2):79-84; Baber R, Templeman C, Morton T, Kelly G, West L. Climacteric 1999;2:85-92.
[8] Jeri A, deRomana C. 9th International Menopause Society World Congress on Menopause, Yokohama, Japan 1999.
[9] Nachtigall LB, La Grega L, Lee W, Fenichel R, Nachtigall L. 9th International Menopause Society World Congress on the Menopause . Hokohama, Japan 1999.
[10] Nestel P, et al. J Clin Endocrinol Metab 1999;84:895-898.
[11] Lieberman S. J Womens Health 1998;7(5):525-9.
[12] Stolze H. Gyne 1982;3:14-16.
[13] Jacobson J, Troxel A, Evans J, et al. J Clin Oncol 2001;19:2749-45.
[14] Hudson T, Standish L, et al. J Naturo Med 1997;7(1):73-77.
[15] Schlich D, Brauckmann F, Schenk N. Psychol 1987;13:440-444; Harrer G, Sommer H. Phytomed 1994;1:3-8; Warnecke G, et al. Z Phytother 1990;11:81-86.
[16] DeFeudis F. Ginkgo biloba Extract. Pharmacological Activities and Clinical Applications. Elsevier, Paris, 1991.
[17] Lemon H. Front. Hormone Res 1978;5:155-173; Lemon H. Acta Endocrinologica1990; Suppl 233: 17-27; Lemon H, Pradeep K, Peterson C, et al. Cancer 1989 63(9):1685-1692.
[18] The Writing Group for the PEPI Trial. JAMA 1995;273(3):199-208
[19] Miyagawa K, Rosch J, Stanczyk F, Hermsmeyer K. Nature Medicine 1997;3(3):324-327.
[20] Leonetti H, Longo S, Anasti J. Obstetrics/Gynecology 1999; 94(2):225-228.
