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Navigating Menopause With Integrative Medicine



In our integrative medicine practice, we combine conventional medicine with alternative & holistic medicine, striving to treat mind-body-spirit as one interconnected system from the roots up. At Hearthside Medicine, we care for many patients at various stages of life under the umbrella of family medicine. We have an increasing number of patients seeking a holistic approach to transitions in their hormones--some wanting bioidentical hormones, some wanting only herbal options, and some wanting a blend of plant-based and conventional treatments.


This blog is part of a longer series on perimenopause and menopause and focuses on alternative options and non-hormone prescriptions for hormonal transitions.


We offer bioidentical hormones and testing as well as non-hormonal prescriptions for those who prefer that route as well. To read more about these topics check out the following blogs:




Integrative medicine for symptoms & hormonal health


Plant-based therapies


There are a variety of plant-based therapies used for hot flashes including isoflavones (dietary or supplements) and herbal therapies.


Plant-derived estrogens (phytoestrogens & Isoflavones )


















Phytoestrogens have been marketed as a natural alternative to hormones for menopausal symptoms.

Isoflavones are part of a group of plant-based chemicals called phytoestrogens. These chemicals act like a weaker form of estrogen in the body.


The main isoflavones in soy are genistein and daidzein. When you eat soy, bacteria in your intestines break it down into its more active forms. Broccoli and broccoli sprouts are also rich in phytoestrogens.


When isoflavones bind to some receptors, they mimic the effects of estrogen. When isoflavones mimic estrogen, they might help reduce hot flashes and other symptoms of menopause.


However, the amount of hormone-like compounds they possess are scant compared to taking HT. However, some may prefer this option, and I always advocate for plant-based medicine if it accomplishes the goal of the user and is safe.


Phytoestrogens are found in soybeans, chickpeas, lentils, flaxseed, lentils, grains, fruits, vegetables, and red clover. Isoflavone supplements, a type of phytoestrogen, can be purchased. Other foods that are being studied and are believed by many to have positive effects on estrogen balance in menopause include peaches, sesame seeds, garlic and cruciferous veggies such as broccoli and broccoli sprouts.


It’s uncertain if phytoestrogens help to reduce hot flashes or night sweats; most studies have not reported benefit or report very conflicting data.


Since phytoestrogens might act like estrogen in some tissues of the body. Many experts suggest that those with history of breast cancer avoid phytoestrogens. Others say they may actually reduce risk of breast cancer. I always advise you consult with your oncologist if you have active or history of breast cancer.


Phytoestrogens have both estrogenic and anti-estrogenic properties and are categorized as isoflavones, coumestans, or lignans.


Isoflavones and phytoestrogens have not been consistently found to be more efficacious than placebo for hot flashes, though advocates of plant-based medicine would disagree.


Two types of isoflavones, genistein and daidzein, are found in soybeans, chickpeas, and lentils and are thought to be the most potent estrogens of the phytoestrogens (although they are much weaker than human estrogens).


Lignans (eg, enterolactone and enterodiol) are found in flaxseed, lentils, grains, fruits, and vegetables.


In a review of 11 randomized clinical trials of soy or isoflavone supplementation, only three of eight trials with at least six weeks of follow-up demonstrated a beneficial effect.


In contrast, a meta-analysis of 21 trials in menopausal women with hot flashes receiving phytoestrogens reported a decrease in the number of daily hot flashes but no change in night sweat frequency. Although this was statistically significant, it may not be clinically significant for those with severe, frequent hot flashes.


When different isoflavones were analyzed separately, red clover was ineffective for hot flashes, similar to results from previous studies. Again, there are some conflicting studies that show red clover having some benefit over placebo.


Genistein (Isoflavin)


Four genistein trials suggested that doses >30 mg/day might reduce hot flash frequency compared with placebo.


Red Clover (Isoflavone)


The data on this one is conflicting at best—with many studies showing no benefit over placebo and others showing possible benefit.


A meta-analysis of randomized controlled trials assessing the effect of a specific

standardized extract of red clover isoflavones on menopausal symptoms showed a statistically moderate relationship with the reduction in the daily frequency of hot flushes


Soy


Once in your body, soy isoflavones bind to the same receptors as estrogen. Receptors are like docking stations on the surface of cells.





In a 2012 analysis of 19 studies, soy isoflavone supplements reduced the severity of hot flashes by just over 26 percent, compared to a placebo. A Cochrane review from 2013 found no firm evidence that dietary soy or isoflavone supplements eased hot flashes. But it did find a benefit from supplements that were high in genistein, one of the main isoflavones in soy.


A 2015 analysis of 10 studies found that plant isoflavones from soy and other sources reduced hot flashes by 11 percent.


In a 2012 analysis of 19 studies, soy isoflavone supplements reduced the severity of hot flashes by just over 26 percent, compared to a placebo. A Cochrane review from 2013 found no firm evidence that dietary soy or isoflavone supplements eased hot flashes. But it did find a benefit from supplements that were high in genistein, one of the main isoflavones in soy.


A 2015 analysis of 10 studies found that plant isoflavones from soy and other sources reduced hot flashes by 11 percent.


Many studies show that soy and soy isoflavones can modestly reduce the number and severity of hot flashes, but it doesn’t work as quickly as hormone therapy.


Soy products can take several weeks or more to reach their maximal benefit. For example, a 2015 review found that soy isoflavones take more than 13 weeks to reach just half of their maximum effect. Traditional hormone therapy, on the other hand, takes about three weeks to show the same benefit.


You can also take soy isoflavones in supplement form or by eating diet high in soy products such as soy milk, tofu, miso, tempeh, and edamame. The North American Menopause Society recommends starting at a dose of 50 milligrams a day.


Because soy can have estrogenic properties, its effects can vary depending on the existing level of hormones in the body. Premenopausal women have much higher circulating levels of estradiol—the major form of estrogen in the human body—than postmenopausal women. In this context soy may act like an anti-estrogen, but among postmenopausal women soy may act more like an estrogen.


Many experts suggest that dietary soy is reasonable in women with ER+ breast cancer but that dietary supplements should be avoided until safety has been established.


Licorice


This ingredient is likely in one of your menopause supplements because it is one of the most potent adaptogens for those vasomotor symptoms of hot flashes and night sweats.


However, two North American species of licorice have been found to induced these liver enzymes, meaning they can cause you to process your prescription drugs way too fast—impacting the therapeutic quality and possibly safety of your prescription.


Licorice is a potent root that has the potential to negatively affect the body in other ways, too. It contains glycyrrhizic acid, which can elevate sodium levels and reduce potassium levels, an effect that could lead to "abnormal heart rhythms, as well as high blood pressure, edema (swelling), lethargy, and congestive heart failure," according to the U.S. Food & Drug Administration. For this reason, the FDA warns black licorice lovers over 40 with hypertension or heart problems to limit how much of it they eat.


Also of note-- It increases blood pressure in some people!


Borage Oil is rich in gamma linolenic acid (GLA), some research states it is beneficial in supporting hormonal balance for women but others contradict this. GLA is said to be relatively safe. However, there are concerns that borage oil may be toxic. Evening primrose oil seems to be a safer source of GLA than borage oil.


Both borage oil and evening primrose oil may lower the seizure threshold. People who take anticonvulsant medicines should not take these oils. Some omega-6 fatty acids, such as GLA, may increase or decrease the effects of certain medicines. Talk to your healthcare provider before taking borage oil.




Black Cohosh


Commercially available preparations of black cohosh usually contain 1 mg of the active ingredients in each 20 mg dose of extract.


Many postmenopausal people use black cohosh for hot flashes, but clinical trials have shown that it is not more effective than placebo. There have been concerns that it can stimulate breast tissue like estrogen, increasing risk of recurrence in those who have had breast cancer. So far, there is no evidence that it is harmful, even in those with breast cancer. Still, some experts suggest that with breast cancer avoid black cohosh until this has been studied more extensively.


There have also been concerns about possible hepatotoxicity (abnormal liver function tests) with black cohosh but a meta-analysis of five black cohosh trials involving a total of 1117 women found no evidence of an adverse effect on liver function.


Among the alternative therapies for hot flashes, black cohosh is one of the most widely used; however, systematic reviews and meta-analyses suggest that black cohosh is no more effective than placebo for treatment of hot flashes. My thoughts? If placebo works and is safe…great!


Maca root is included for overall tonic support for the endocrine system. It is considered an adaptogen as are holy basil and ashwagandha below and has been touted to help with energy and mood and hormones.


Holy Basil


Holy Basil has powerful anti-stress properties and is an adaptogen herb. It is great source for treating anyone who experiences stressful times and/or anxiety. It supports the adrenal system, which during menopause, fluctuates hormonally.


Ashwagandah


It helps protect the immune system, supports healthy blood sugar metabolism and lowers cholesterol. It improves brain

function, such as memory changes. It reduces anxiety and depression, and enhances sexual potency for both men and women.


Using Ashwagandha on a regular basis provides positive effects. It will help balance your brain, heart, moods and even your sex drive!


Maca


Maca sometimes known as “Peruvian ginseng,” yet has no relation to ginseng. Found in Peru, and enjoyed for thousands of years for its beneficial properties. This root will increase strength, energy, stamina, libido and sexual function. It improves perimenopause and menopausal symptoms like hot flashes, night sweats, anxiety and depression.


Rhodiola offers adaptogenic and antioxidant support and some believe it helps with mood and energy that can wane or vacillate in menopause.


I appreciate the following information from Dr. Aviva Romm’s blog on herbal remedies for menopause:


Dr. Aviva’s Cool Down Extract for Hot Flashes


She recommends getting the individual extracts from Herb Pharm, Gaia Herbs, or Mountain Rose online and mixing them yourself--purchase an empty 4 oz. dropper bottle from Mountain Rose, or mix these in a glass bottle and take the recommended dose daily.


1 oz. chaste tree tincture (regulates hormones, reduces menopausal symptoms)

1 oz. lemon balm tincture (cools hot flashes, improves mood)

1/2 oz. motherwort tincture (relaxing, calming, cools hot flashes and menopausal symptoms)

1/2 oz. black cohosh tincture (80 mg twice daily, cools hot flashes, improves menopausal mood and symptoms)

1/2 oz. hops tincture (100-200 mcg for at least 12 weeks, cools hot flashes, relieves vaginal dryness)

1/2 oz. sage leaf tincture (cools hot flashes)

To prepare: Combine the different extracts in a 4 oz. dropper bottle or glass bottle.


Dose: Take 1 teaspoon in 1/4 cup hot water, 2-3 times daily. You can take this formula until hot flashes are no longer a problem.


Note: Omit sage leaf and hops extract if you have a history of estrogen receptor positive cancer as they are estrogenic.


Ginseng


3 gm. per day (3-6 capsules) of Chinese ginseng (Panax ginseng) taken daily not only reduces hot flashes, but can boost your libido and lower high cholesterol! Take in the early part of the day as ginseng can be stimulating and interfere with sleep.


Rhubarb


Rheum rhaponticum, or Rhubarb, in the form of an extract called ER731 has been shown in a clinical trial to be very effective in the treatment of hot flashes. The proprietary extract can be found in the product Estrovera by Metagenics or try Herb Pharm’s Rhubarb Extract as directed on bottle. Estrovera contains ERr 731 a special extract of rhubarb root that has been shown in clinical studies to significantly reduce menopausal hot flashes and other menopausal symptoms compared to placebo. Rhapontic Rhubarb (Rheum rhaponticum L.) Root+ Extract (ERr 731(tm))

4mg

Valerian for More than Sleep


Get your Valerian (Valeriana officinalis) in capsule form, as it has a bad taste. The dosage is 150–300 mg of a product standardized to 0.8% valerenic acid. Use one hour before bedtime or

225 mg of Valerian in capsules taken 3 times daily can dramatically reduce hot flashes after just 4 weeks of use—it may help with sleep as well


Pine Bark


Pycnogenol, an extract of pine bark, is not only an excellent antioxidant, but effective in reducing hot flashes in a dose of 60-100 mg twice daily.


Researchers found that an extract of pine-tree bark -- under the brand-name Pycnogenol -- seemed to ease symptoms of women starting menopause. Fatigue, headache, vaginal dryness and menstrual problems were among the most common symptoms at the study’s start.


However, all symptoms tended to improve over six months of Pycnogenol treatment,


Dong quai


Some people say dong quai relieves symptoms such as hot flashes. Researchers are not sure whether dong quai acts like estrogen or blocks estrogen in the body. Studies are conflicting, and one study found that dong quai did not help to relieve menopausal symptoms.


Hops


Use the tincture (alcohol extract), 1-2 mL (about 40-80 drops) before bed for night sweats. It can make you sleepy, so avoid using before driving. Hops has mildly estrogenic effects so this herb is not recommended if you have risk factors for estrogen receptor positive breast cancer.



Pollen extract


A few studies suggest that pollen extract may be helpful in relieving both premenstrual and menopausal symptoms such as hot flashes. Although the mechanism by which this may occur is not well understood, pollen extract appears not to have hormonal effects. Therefore, it may be useful for breast cancer patients experiencing hot flashes. However, studies in cancer populations are needed to ensure safety, effectiveness, and to confirm that it does not negatively interact with chemotherapy drugs.


Passion Flower


One of the best herbs to promote sleep and ease anxiety--use 1-3 mL repeated every hour for 2-3 hours before bed, and every 3-6 hours during the day for mild to moderate anxiety. Caution when combining with antidepressant or psychiatric medications!


Motherwort


One of my favorite herbs for emotional irritability related to hormonal changes, motherwort relieves anxiety and is useful when there are benign heart palpitations. Dose is 2 mL of extract several times daily as needed, or capsules taken as recommended on the package.


St John’s Wort


Often used for depression, St John's wort can be used as an effective treatment for the vasomotor symptoms of perimenopausal or postmenopausal women. Do not combine with other medications that can increase serotonin such as antidepressants or 5-HTP without discussing with your provider.



Wild Yam


Wild yam is a plant. It contains a chemical called diosgenin. This chemical can be converted in the laboratory into various steroids, such as estrogen and dehydroepiandrosterone (DHEA). The root and the bulb of the plant are used as a source of diosgenin, which is prepared as an "extract," a liquid that contains concentrated diosgenin. However, while wild yam does seem to have some estrogen-like activity, it is not actually converted into estrogen in the body. It takes a laboratory to do that. Sometimes wild yam and diosgenin are promoted as a "natural DHEA." This is because in the laboratory DHEA is made from diosgenin. But this chemical reaction is not believed to occur in the human body. So, taking wild yam extract will not increase DHEA levels in people. Although wild yam cream is marketed as a source of natural progesterone, it does not contain progesterone, and the body cannot convert it into progesterone.


Wild yam is most commonly used as a "natural alternative" to estrogen therapy for symptoms of menopause, infertility, menstrual problems, and other conditions, but there is no good scientific evidence to support these or other uses.


Vitex


Vitex (chaste berry) can be used in the perimenopause if periods are irregular, and also relieves emotional symptoms.


D-mannose


While increased urinary tract infections in menopause generally need to be treated by improving associated vaginal dryness or decreased tone and fullness of the genitourinary tissues, d-mannose makes an excellent addition for its ability to help prevent infections.


Pueraria mirifica


This herb has been used in Thailand for over 700 years to help women quell perimenopausal symptoms. It is believed that it has ability to interact with the body’s own estrogen to help diminish hot flashes


It is being used in various traditional systems for treating menopausal syndrome-related ailments. The predominant phytochemical constituents are isoflavones, also known as phytoestrogens.


This herb has been traditionally used as a vitality enhancer and rejuvenating agent particularly for older women. It contains a class of phytoestrogens known as Chromenes that rival estrogen itself in potency. The herb is highly estrogenic as a result, and is considered the standard herbal 'estrogen replacement therapy' in some cultures due to its potencies.


It has been tested numerous times for reducing menopausal symptoms (as estrogen replacement therapy itself is quite effective), and despite the universal promise it shows many studies are not blinded and not run against a placebo; on the topic of menopausal symptoms, this is a significant problem as placebo can be very potent (Black Cohosh is an example, as the placebo effect in menopause has been reported to reach up to a 50% reduction in symptoms).


Based on the preliminary evidence, it does appear promising and effective for menopausal symptoms, but much more research is needed before it can be considered a main opinion. There is currently no evidence to support the notion that this herb is somehow safer than estrogen replacement therapy, so their benefits and risks should be seen as interchangeable for the time being.


Amantilla and Babuna


These natural medicines originate from the valerian plant (Valeriana officinalis) and the flower of the manzanilla plant (Matricaria recutita, commonly known as chamomile), respectively. In a double-blind, randomized, placebo-controlled multicentered study, Amantilla was 82.5 percent effective in helping patients sleep, while Babuna was 68.8 percent effective. On nights when you’re keyed up, try 15 drops of Babuna thirty minutes before going to bed, followed by 15 drops of Amantilla at bedtime.


DIM


DIM (diindolylmethane) is the active ingredient in cruciferous vegetables; it promotes proper hormone metabolism. Although research on DIM is still quite limited, it’s thought to help balance estrogen levels in your body


Observational studies associate high cruciferous vegetable intake with a reduced risk of certain cancers, including breast and prostate cancer.


While cruciferous vegetables are the primary food source of DIM, you would need to eat several servings every day to reap this compound’s benefits. People looking to treat a specific condition like acne or prostate issues may seek a concentrated dose in the form of a DIM supplement.


DIM works in two ways. First, it blocks the enzyme that converts testosterone into estrogen. So if you have a tendency to aromatize your testosterone to estrogen (like me), DIM can be very helpful (a DUTCH test will show this).


DIM can be very helpful but it’s NOT helpful if---


Your estrogen levels are low.. If you begin taking DIM, it is likely to lower those levels, even more, aggravating symptoms like night sweats and hot flashes.


You’re taking megadoses (50-200 mg is plenty). More is not better in this situation.


You’re not having regular bowel movements… estrogen is eliminated in bowel movements and constipation or other gut health issues keep it in the body.


DIM is generally well-tolerated with a few mild symptoms for a few days. Side effects of DIM include:


Headache

Fatigue

Brain fog

Dark urine (pink to orange to brownish)

The consensus is that darkened urine is harmless and will return to normal once you stop taking your DIM supplement. Some say it’s a good sign that DIM is working on your liver to neutralize estrogen metabolites.


Due to a lack of research in humans, little is known about the long-term safety and side effects of DIM supplements.


Current human research doesn’t show DIM supplements to be toxic or have serious side effects. The most common side effects include darkening of the urine, an increase in bowel movements, headaches, and gas.


Less common side effects include nausea, vomiting, diarrhea, and skin rash.


As DIM supplements interact with estrogen levels, they may affect people with hormone-sensitive cancers or who are on hormone therapies. Such individuals should steer clear of DIM supplements unless under the supervision of a medical professional.


A dose of about 15 mg per day of actual DIM in an absorbable formulation is advised. These amounts can be increased up 3-4 times this amount on an individual basis.


Since pure DIM must be provided in an absorption-enhancing formulation, the dose for DIM sometimes specifies the weight of the absorbable formulation, which is only one-fourth, or 25 percent DIM. The suggested dose of 100 to 200 mg per day refers to milligrams of such an absorbable formulation. This dose range corresponds to 25 to 50 mg per day of actual DIM.


Glucoraphanin


This substance is derived from high concentration broccoli and broccoli sprouts. Proponents claim it helps protect estrogen-sensitive tissues by promoting healthy estrogen metabolism and supporting detoxification of harmful estrogen metabolites and xenoestrogens (estrogen-like compounds found in things like microplastics). Some companies will combine DIM and Glucoraphanin into an estrogen-balance blend. This is found in broccoli and broccoli sprouts.