Reference: TRICKEY, R. (1994) "Alternative therapies for menopausal problems" in BLACK, C. (ed.) Menopause: The Alternative Way. Facts and Fallacies of the Menopause Industry. Australian Women's Research Centre, Geelong, Victoria. pp. 62-80. Copyright (c) Ruth Trickey, 1994 Introduction Alternative medicine and the menopause would have to be two of the more controversial topics in medicine today. They become even more controversial when presented together, as the alternative therapists' treatment of the menopause. As with all such issues, opinions tend to become polarised. Put differently, it's very rare indeed to find anyone who feels ambivalent about either of these issues and, in my experience, there are usually two firmly opposed views. On the one hand there's the view that we have no business treating menopausal women, we're charlatans or quacks, and unscientific; our treatments haven't been investigated, they don't work or they're dangerous, and any effect is just placebo. And on the other hand it is said that natural therapists are capable of treating everything, there's a plethora of natural medications to take instead of HRT, and because they're natural, they're safe and can be used by anyone at any time and for any length of time, with no thought of side effects. What I'm going to do today is introduce a realistic perspective on alternative medicine and the complexities of the management of the menopause. To this end, I will present an overview of the relevant naturopathic philosophies and finish with some of the more common treatments available. What you will see from this presentation is that the alternative way is much more labour intensive for the woman involved; it requires a committed change of lifestyle, particularly diet and exercise patterns. Further, there is no one natural substance available which can mimic all of the effects of HRT, and this introduces a complexity in prescribing not encountered in the medical model. Despite all of this, alternative therapies are eagerly adopted by the many women who visit our clinic, and who wish to take some responsibility for their own health. A comprehensive look at the philosophies of health and healing held by alternative therapists is not within the scope of this talk. However, there are two main areas that deserve mention in relation to our topic today. These are the concepts of vitalism and the belief that our lives are ruled by the natural law which governs all cyclical events including maturation, menstruation, seasonal changes, life and death. Let us first look at Vitalism. All alternative medicines have in common the belief that if the organism has at its disposal all of the factors which ensure good health, and if these are present in the right proportions, it will be able to cure itself of disease or prevent disease occurring in the first place. This is called the vitalistic view of health and is the basic premise by which the alternative therapist works. Briefly these factors which influence vitality are: good nutrition balanced emotions a clean environment adequate exercise a state of spiritual harmony, and a healthy genetic inheritance When a menopausal woman has a consultation, I am as interested in her diet, lifestyle, exercise patterns and emotional state as 1 am in her hot flushes or, say, menstrual irregularities. According to the rules of vitalism, all of these factors are considered to have as much impact on her state of health as the levels of circulating oestrogens, and it is considered that only by looking at the whole person can true healing take place. The other factor which is relevant to menopause is the Natural Law. This cyclic ebb and flow of life is nowhere better described than by the philosophy of Traditional Chinese Medicine. From the Yellow Emperor's Inner Cannon, which was written 100 BC, and which describes female maturation and decline in phases of seven year cycles, we learn the following: "At the age of seven, the kidney qi of the female is strong, the teeth are replaced, and the hair is long. At the age of fourteen, the reproductive function matures, the menses come according to their time and she can bear children." This goes on in seven year cycles which describe the various phases of life. When she is older we learn: "At forty-two fertility wanes, the passages of earth are cut, the body deteriorates, and she can no longer bear children. At forty-nine, the essential qi weakens, the menses become irregular and finally stop." These seven year cycles continue until death. As a conclusion, we are told: "This represents the normal and natural course of development and decline." This is but one example that shows us that the rise to physical maturation and then the phases of deterioration are part of the cyclic variations which effect all living matter on the planet. Menopause is one of these phases of the woman in her passage through life. Alternative therapists don't see menopause as a deficiency disease which needs treatment. It is a normal, even desirable event, and by many, it is described as pleasurable. Sadly, in our clinic, we see many women who are well but who now seem to believe that they have a disease called menopause and that they are obliged to treat themselves. These women are so convinced of their impending doom that they feel they should take something especially if they don't take HRT. Treatment of menopause by alternative medicine is about treating conditions when they are present and preventing the advent of degenerative diseases. It is considered unsafe to administer natural medications in the absence of a complaint, and, in the case of menopause, as also going against the normal course of events to try to maintain a phase of life that has naturally passed. However, just because menopause is a natural event in a woman's life, it does not follow that she will experience no symptoms. It can be a difficult phase for some women, but there are remedies. Some women are appalled at the idea of taking a synthetic hormone for the rest of their lives; some are not. For those who are worried about the common sense of this approach, but who are in need of some relief, alternative therapies may provide the answer. So I will now outline a broad treatment protocol, and give you an idea of some of the natural remedies used, their effectiveness and safety. Usually, at a naturopathic consultation for a menopausal symptom, the most common areas of enquiry are in relation to the woman's: Digestive capabilities Diet and exercise patterns Response to coping emotionally with this phase of her life Regularly screening for cervical cancer and breast pathologies Particular menopausal symptoms Cardiovascular health is also high on the agenda, but is not classically considered to be a topic of specific relevance to the menopause. The dietary and lifestyle measures suggested to all clients have as their base a regime for the prevention of cardiovascular disease. Digestion has particular relevance to the alternative therapists' way of treating women at the time of menopause, since both digestion and subsequent absorption are vital for the prevention of osteoporosis, and indeed, many of the major degenerative disorders. The uptake of the bivalent ions, and here we are particularly concerned with calcium and magnesium tends to decline with age, and evidence of this can be elucidated from the general state of digestion. Further information will be given on this topic when we talk about bitters and bone density. For menopausal women who are well, there would typically be few herbs or supplements prescribed. The emphasis here is on prevention of any of the major degenerative diseases associated with ageing, including, but not limited to, heart disease and osteoporosis. This is achieved with dietary and lifestyle modifications. In cases where there are specific factors which may further predispose the individual to degenerative disease, for example, a history of smoking, more intensive preventative regimes would be suggested and some therapeutic agents would usually be prescribed. If a large number of risk factors for osteoporosis are evident, referral to a GP to discuss bone density screening would be suggested. In relation to treatments, most people are fascinated by the concept of oestrogenic herbs and foods, so I'll look at those first. Any natural substance which is thought to exert an oestrogen-like effect, is referred to by natural therapists as "oestrogenic". This activity is found in many plants in the form of phyto-oestrogens. These substances vary from having powerful to very weak effects. Phyto-Oestrogens in Foodstuffs alfalfa * aniseeds * apples * barley * carrots * cinnamon * cherries * elder flowers * fennel seeds * french beans * garlic * green beans * hops * licorice * lime flowers * oats * peas * plums * pomegranate* parsley root * red clover * red beans * rhubarb * rice * rye * potato * sage * sesame seeds * sunflower seeds * soya beans * wheat * yeast * We can see from the above table that a wide range of commonly eaten foods contain natural oestrogens. It is unclear how effective these foods are in reducing symptoms of menopause. In some individuals, it is known that intestinal bacteria denature plant oestrogens and render them inactive. This means that these women will experience no benefits from increased consumption. Despite this, there is some evidence pointing to desirable effects, particularly when we look at some of the historical and cultural evidence. The soya bean is listed in ancient herbals as useful in counteracting the ageing process. This is not surprising, since the active hormonal substances, the triterpenes are also found in Ginseng, one of the major tonic and longevity herbs. Japanese women seem to suffer less menopausal symptoms than their Western counterparts. This may be a cultural phenomenon, however, it is speculated that the reduction of symptoms may be related to their consumption of soya products. The common pea also deserves mention here. Apart from being considered oestrogenic it has been found to contain a contraceptive principle, which is effective only after repeated and excessive consumption. This has been observed in Tibet, where peas and barley form the staples of the diet, and the population has remained stable for the past 200 years. Whether this effect is due only to the oestrogenic principle or other agents in the pea is yet to be established, but a clear hormonal influence has been demonstrated. Alfalfa is also a member of the pea family and contains phyto-oestrogens. Research has shown that when oestrogen levels are low, the phyto-oestrogens exert some oestrogenic activity, and if there is overstimulation of the tissues, they occupy oestrogen receptor sites and therefore reduce the overall oestrogenic effect. In a laboratory experiment, where rats were fed massive doses of oestradiol, those that were concurrently fed alfalfa were protected from ovarian inhibition. Other research on stock animals, however, has shown that infertility and altered oestrus cycles will occur if an animal is fed too much alfalfa. As would be expected, this points to a dose dependent effect of the oestrogenic principles in this plant. The Pomegranate is an ancient symbol of fertility and has been found to contain an oestrogen which is identical chemically to oestrogen. (1.7 mg/ 100gm.) In fact, even though the pomegranate is remembered as a fertility symbol, its most common use world wide has been as a contraceptive agent or abortifacient, or in other words, as an agent to induce a miscarriage. Again, whether the plant is a fertility enhancer, a contraceptive or an abortifacient is possibly dose dependent. The common garden rhubarb has been investigated and found to contain a hormonal component which has been identified as oestrogenic. It is used by some European doctors in a herbal extract with Hops for menopausal complaints with good effect. Sage is an old menopausal remedy since it stops sweating and also contains oestrogenic principles. It is useful as a stimulant to cerebral circulation, and to encourage menstruation. Here is a common prescription for hot flushes, particularly if excess sweating is involved:Chop six to eight fresh leaves and cover with lemon juice. Leave to stand overnight. Strain the juice off in the morning and drink. This may be repeated for one month, but no longer. Herbs Obviously, I am not going to be able to discuss all of the available herbs for the management of the menopause, since there are so many. So I've chosen a few that are fairly well known to go over in some detail. Most herbal remedies are seen to be further up the scale of oestrogenic activity than foods. In other words they have a higher therapeutic index which also means that they are prone to a greater degree of other effects. In general self medication of oestrogenic herbs is not recommended, especially those in the higher therapeutic range. There are some risks and possible undesirable effects that can be experienced if they are incorrectly prescribed, given over an excessive time frame, or are taken in the wrong doses. It is also useful to note that there is no concept of side effects in alternative medicine. A medication has a range of effects, all of which are to be taken into account when that medication is prescribed. If undesirable effects are experienced by the recipient, this would be considered to be caused by an incorrect prescription which failed to take into account all of the effects of that medicine. Only effects which are positive indicate that the right choice has been made. Those who regularly self prescribe, need to take this piece of information into account. The most important thing to remember about plant oestrogens is that they do not exert the same effect on the body as does synthetic oestrogen. Nor are they traditionally ever prescribed in the same way, that is for life or for very long periods. As well, there has been no research on the ability of plant oestrogens to improve bone density, and women with osteoporosis would need to take other precautions to adequately address this condition. Different plant oestrogens also target different tissues and are effective for different manifestations of the menopause. For this reason, sage is considered to be useful for hot flushes, but not for vaginal dryness, since in herbal talk it is a drying herb. while cimicifuga is useful for both, and neither of these two would be Of any use if you suffered from insomnia with hot flushes. In this case Lime flowers or Hops would be much more useful. To discuss plant oestrogens, it is easiest to divide them into the traditional groupings which take into account their other actions. The Adaptogens Two commonly known and frequently cited adaptogens for the symptoms of menopause are Panax Ginseng and Licorice . These herbs are capable of, among other things, stabilising the body's hormone production, and are included here because of their popularity and because they are commonly self prescribed. The term adaptogen was coined because of the observation that these plants would help the body to adapt to times of stress. Panax Ginseng: This is the stress herb. It is mildly oestrogenic and anabolic and is commonly found in many of the traditional formulas world wide which are used for fatigue, insomnia, poor stamina, or any stress symptoms. Menopausal women can use Panax if they are stressed. It is more useful for fatigue, anxiety and memory loss than for hot flushes or vaginal atrophy, and so has a rather narrow sphere of action in relation to symptoms of the menopause. This is certainly a herb to be used with respect and advice should be sought before taking it. It should also not be taken for long periods. Licorice: This is another of the herbal adaptogens which has a powerful effect on all of the steroidal hormones . It is included here because it is pleasant to take as a tea, and is therefore commonly self prescribed, although, as you will see, this is not such a good idea. Among its other capabilities, herbal texts describe this plant as oestrogenic. It can also mimic the action of cortisone, an action that should alert users to potential danger. There is also a possibility of causing an increase in blood pressure and creating an imbalance in the mineral levels. This makes it a less than suitable choice for the symptoms of the menopause. Herbalists would rarely use this plant in isolation, but it is commonly used in conjunction with other plants. This is a complex herb and is only safe in the hands of an experienced herbalist. Nervines: Nervines are used for any of the many manifestations of nervousness and/or anxiety, including insomnia, anxiety depression and excessive worrying. There are many nervines used in herbal medicine, the 2 considered here are also oestrogenic and are typically recommended at the menopause: Hops: Before mechanisation, hop pickers who were exposed for many weeks to the handling of fresh hops, experienced symptoms which we would recognise today as having a hormonal basis. The women pickers developed menstrual irregularities, and the men became impotent. Hops are mainly useful for symptoms of anxiety and insomnia, although they can also be used for hot flushes, especially those that accompany stress and worry. They are particularly recommended at menopause even though nervines such as valerian are considered to be stronger. Decoctions or extracts of hops are used, but are very unpleasant to take due to a bitter principal that they contain. This is also useful as a bitter digestive, a topic we will cover later. Lime Flowers: Lime flowers are one of the herbal remedies which are safe for self administration, are pleasant to take and arc useful for insomnia, palpitations, mild anxiety and night sweats. They are only weakly oestrogenic. Tilia Europa is the Latin name for this herb. It is readily available in health food stores and can be taken every night in the form of a herbal tea for many months while symptoms persist. Other Oestrogenic Herbs Cimicifuga: Cimicifuga has a high therapeutic index' and a narrow dose range which make it unsuitable for self prescribing. Traditional uses of this plant have been for a large range of gynaecological complaints and for rheumatic conditions. It is considered specific for the musculo-skeletal disorders which may accompany menopause. Recent German research has shown Cimicifuga to contain 3 types of hormonally active substances one of which could suppress Luteinising Hormone (LH) secretion after prolonged treatment, and another two of which were oestrogenic. LH is the hormone most often thought to cause the unpleasant flushing associated with menopause, and so regulation of this hormone is most desirable. This plant has also been studied for its effect on the vaginal cells of menopausal women. It is found both topically and orally to alter the cells in the same way as do oestrogen treatments. This is not achieved rapidly and administration is required for some months. We usually give the herb orally initially, then change to topical application only, if continued use is required. Significant Non Oestrogenic Herbs Eleuthrococcus: This is another adaptogenic herb, but is not classically seen as being oestrogenic. It has been extensively studied and found to be virtually non-toxic. This herb increases the ability to cope with stress, and also improves mental alertness, lowers scrum cholesterol, stops abnormal blood clotting, reduces blood pressure, or increases blood pressure when the pressure is low. It is useful for a variety of psychological disturbances including insomnia, and has been shown to increase resistance to infection and to various laboratory induced cancers. It can also regulate carbohydrate tolerance in maturity-onset diabetes. For women, I consider eleuthrococcus to be one of the best adaptogens for this phase of life. Its additional benefits make it even more desirable. It has no immediate impact on the low oestrogen symptoms of menopause, and other treatments for this would need to be pursued. Bitters: As already discussed, one of the main areas of treatment in alternative therapies is to improve digestion and assimilation. You've probably heard the old saying: "You are what you cat." Natural therapists tend to change this to: "You are what you absorb and assimilate." To improve this major determinant of good health, we employ the bitters which come in the form of foods and herbs. BITTERS FOODS: endive, chicory, silverbeet, radicchio, cos (outer leaves), mustard greens, dandelion leaf, grapefruit HERBS: st. mary's thistle, gentian, barberry, centaury, hops, artichoke leaves (outer), dandelion root (coffee) The taste of bitterness is an extremely common feature of many herbal remedies, and a bitter is defined as any herb or food with a bitter taste. The action of a bitter substance is mediated by the bitter-sensitive taste buds in the mouth which are connected via the nervous system to the gut in such a way that their stimulation leads to the release of gastric acid, digestive enzymes and bile. Bitters enhance the whole upper digestive function, to improve assimilation of nutrients into the system. In traditional medicine, this property is extremely highly regarded, as leading to a real tonic improvement in health in even the most debilitated circumstances. Traditional cultures used to include these foods regularly in their diets and this continues today for example in Greek, Italian, and Indian cuisine. Supplements for the Menopause Vitamin C and the Bioflavonoids: The bioflavonoid hesperidin, has been shown by research to reduce hot flushes. Clinically, we have noted the same response from moderate to high doses of Vitamin C. It is speculated that this may be due to the Vitamin C increasing the bio-availability of oestrogens in the body, but further research is needed. Vitamin E: Numerous studies and our own clinical experience have demonstrated that Vitamin E reduces the severity of hot flushes and other symptoms associated with menopause. In the clinical trials, doses ranged from 10-100 mg daily. (100 IU = 67 mg) We recommend around 100-200 IU. Do not take Vitamin E if you have high blood pressure or are on anticoagulants, unless supervised. Bone Strength Normal bone metabolism is dependent on an intricate interplay of hormonal, lifestyle, nutritional, and environmental factors. A comprehensive plan that addresses all of these offers greatest protection against developing osteoporosis, and the least likelihood of producing side effects. This plan should encompass the dual aims of: Preserving adequate mineral mass Preventing loss of the organic matrix and other structural components of bone Mineral Mass. The major factor for bone strength is bone density, which is primarily influenced by the amount of calcium we have available in our blood stream. Calcium: Below, we have a list of those conditions that will positively and negatively effect the uptake of calcium. These factors also effect the absorption of other minerals implicated in maintaining good bone strength. Factors Which Positively Influence The Uptake of Calcium: Presence of calcium rich foods and plenty of vegetables in the diet. Limited or no "junk foods" Good gastric acid levels The type of calcium taken - best forms seem to be citrates and hydroxyapatite. Factors Which Negatively Effect The Uptake of Calcium Certain drugs Chronic diarrhoea Factors in the food which affect calcium absorption eg: phytates Over consumption of alcohol, coffee, sugar, or salt Poor diets and/or frequent dieting Low gastric acid levels Rather than discuss these, since they are often well known to many people interested in menopause and osteoporosis, I will instead spend some time discussing calcium supplementation. Calcium carbonate is the most commonly prescribed form of calcium. It Is also considered to be the most difficult to absorb, particularly in the absence of good gastric acid levels. Studies of postmenopausal women have shown that about 40% are severely deficient in stomach acid and can only absorb about 4% of an oral dose of calcium as calcium carbonate. The inclusion of dietary or herbal bitters can remedy this, but other forms of calcium exist that would seem to be a better choice if osteoporosis is to be seriously tackled. Women with low stomach acid should be using a soluble and ionised form of calcium, such as calcium citrate, lactate, aspartate or gluconate. Even with low gastric acid levels, up to 45% of the calcium as calcium citrate is absorbed. Another newer form is calcium hydroxyapatite which is also readily absorbed. Calcium Retention in Bone: Calcium deposited in bone may not necessarily stay there. The following list shows the major factors responsible for maintaining and reducing bone density. Factors which Influence Retention of Calcium in the Bone Negative Factors: certain drugs; smoking; excess bed rest; frequent dieting; excess alcohol or coffee; excess sugar consumption; certain diseases such as hyperthyroidism, diabetes; aluminium; stress; over consumption of phosphorous (in carbonated drinks); over consumption of animal protein. Positive Factors: oestrogen; ovovegetarian or low animal protein intake, especially after menopause; exercise; increased magnesium intake; increased boron intake. There are many other minerals involved in bone density, too many to cover in a short talk, however the mineral which deserves mention is magnesium. Magnesium: Magnesium supplementation is as important as calcium in maintaining proper bone health since individuals with osteoporosis have been shown to have abnormal bone magnesium content. Despite this, over the counter or prescribed supplements for the prevention of osteoporosis rarely contain this mineral. New Research on Minerals: Boron and Strontium are two trace minerals which have been shown to have a major impact on bone integrity. They are included here to further highlight the complexity of bone metabolism, and to draw attention to the fact that substances other than oestrogen can affect bone density. Boron: The trace mineral boron has been recently shown to have a positive effect on calcium and active oestrogen levels in post menopausal women. Supplementing the diet with 3 mg of Boron daily reduced urinary calcium excretion by 44% and dramatically increased the levels of the most biologically active oestrogen, oestradiol. Fruits and vegetables which are organically grown are the main sources of boron, while animal proteins are a poor source of this mineral. Many Australian soils are deficient in boron and supplementation may be required, but at present we suggest dietary sources only. Strontium: This trace mineral is known mostly because of its radioactive form. In its non-radioactive form, it is non-toxic, accumulates in bone, occurs naturally in food and has a beneficial effect on bone health. Strontium has been shown to improve signs and symptoms of osteoporosis significantly. In one study of strontium supplementation, 85% of the subjects experienced a marked reduction in bone pain and 75 In finishing I would like to say that menopause is for a great many women a natural event which does not effect their quality of life or need treatment. Prevention of osteoporosis, however, should be a major focus for all health care practitioners, and it would seem prudent for all women to live in a way which maximises bone density. For women who can't or don't want to take HRT and for those who are increasingly realising that there can be more to the treatment of the menopause than a synthetic hormone, suitable and safe holistic alternatives are available. There is nothing natural to mimic the action of synthetic oestrogens. Instead, a varied and committed approach is needed to rectify the symptoms of menopause and to increase bone density. These strategies require more work, and much more input from the woman concerned. It is not as easy as popping a pill every day, but it does allow women to maintain some control over their health in the time honoured ways of good diet and exercise, and with the knowledge that maturation is proceeding as nature intended. For more information visit the women's health section of the W.I.S.E. website: http://www.infoxchange.net.au/wise/HEALTH/index.htm.