Natural Approaches to Menopause and Perimenopause
The menopausal transition, or ‘perimenopause’, is a defined period that begins with the onset of irregular menstrual cycles until the last menstrual period and is followed by fluctuations in reproductive hormones. This period is characterized by menstrual irregularities, and prolonged and heavy menstruation intermixed with episodes of amenorrhea, vasomotor symptoms, insomnia, mood issues, and vaginal dryness
Vasomotor symptoms (VMS; eg, hot flashes and night sweats) are the primary symptoms of menopause. VMS affect more tha
n 80% of women in menopause and are the menopause symptoms for which most women seek treatment.In the United States, 40 to 50 million women suffer from VMS. These symptoms typically last 5 to 7 years, but can persist for 15 years or more. VMS are associated with sleep and mood disturbances, as well as decreased cognitive function and reduced quality of life.
Approximately 51% of women use complementary and alternative treatments for menopause and more than 60% perceive it be effective for their symptoms.
Perimenopause can be characterized by unknown fears and ailments: Women can lose their confidence and self-esteem can get shattered with the fast-establishing menopause.
Cognitive and mood issues can be significant.
Osteoporosis and cardiovascular disease represent the most important long-term effects and seriously impact the quality of life of menopausal women.
Complementary and alternative medicine has been categorized as mind-body practices (eg, hypnosis, CBT, relaxation, biofeedback, meditation, aromatherapy), natural products (eg, herbs, vitamins, minerals, dietary supplements), and whole-system approaches (eg, traditional Chinese medicine, reflexology, acupuncture, homeopathy).
Nutraceuticals, a pharmaceutical alternative with medicinal properties, extracted from food or plants, belong to this approach.
Nonhormonal therapies represent a developing option that is characterized by medical information and discussion with the patient. The customization of the therapy is a fundamental point and depends on many factors, clinical and not, such as previous therapies, risk factors, and type of symptoms. Points of strength in nutraceutical choice are: They are user-friendly, are useful as a first approach to menopausal complaints, can be used together with drugs, and are useful if HRT is refused or contraindicated.
In the last years, nutraceuticals have gained immense popularity when compared with HRT due to their claimed ability to relieve menopausal symptoms. Nutraceuticals are foods, parts of foods, and botanicals that provide medical or health benefits, including the prevention and treatment of disease.
The philosophy behind nutraceuticals was probably introduced in Asia throughout ancient China and then improved and defined by physicians of Kampo medicine, the study of traditional Chinese medicine in Japan, especially since the seventh century. Kampo has a holistic therapeutic approach, as it considers the mind and body like one entity: The therapeutic aim is to alleviate symptoms and to bring back harmony in bodily functions. However, the traditional Chinese medicine (TCM) includes several therapeutic approaches, such as acupuncture and moxibustion, for menopausal complaints.
To date nutraceuticals include: Dietary supplements (substances which have established nutritional functions able to affect structure and function of body such as vitamins, minerals, amino acids, fatty acids, probiotics, prebiotics, antioxidants, enzymes, coenzyme Q, carnitine, etc.), herbal medicines (isoflavones, pollen extracts, cimicifuga, red clover, etc.), functional foods—any modified food or ingredient that may provide a benefit (prebiotics-oligofructose, omega-3, canola oil, stanols), and medicinal foods (transgenic cows and lactoferrin for immune enhancement, transgenic plants for oral vaccination against infectious diseases, health bars with added medications).
Among these, herbal medicines including isoflavones, black cohosh, red clover, pollen extracts, and others may be used in symptomatic menopausal women.
However, the benefits of these compound have yet to be demonstrated with certainty, and these regimens are not completely free from side effects.
Phytoestrogens
Phytoestrogens are presently the most popular form of alternative therapy for support of menopausal symptoms, besides HRT. They are plant-based compounds in about 300 plants.
The main classes are isoflavones (active in humans), lignans (active in humans), cumestan, and lactones. Food sources are various: soy flour, legumes, fruits and vegetables, cereals, olive oil, wheat, etc. Their chemical structure and efficacy are almost similar to estradiol.
Phytoestrogens are nonsteroidal plant-derived compounds commonly sourced from soy and red clover (isoflavones), flaxseed (lignans), and hops (Humulus lupulus). Phytoestrogens are thought to act estrogenically or anti-estrogenically in humans. Soy and red clover contain large amounts of the isoflavones genistein and daidzein that may produce estrogen like effects. Hops contain the phytoestrogen 8-prenylnaringenin (8-PN), which is thought to be a more potent phytoestrogen than soy isoflavone. In a systematic review and meta-analysis of phytoestrogens for VMS among peri- and postmenopausal women, researchers identified 43 RCTs, including one unpublished trial, that tested the effectiveness of dietary soy, soy extracts, red clover extracts, genistein extracts, natural S-Equol, flaxseed, Rheum rhaponticum extract, and hop extract, for at least 12 weeks. The majority of studies were too heterogeneous to be combined in the meta-analysis. Of the 43 RCTs, 5 trials investigating the effects of red clover extract (Promensil) on VMS were pooled for the meta-analysis. Results indicated that red clover extract did not significantly improve VMS symptoms compared to placebo. The authors of this review concluded that the evidence was did not support the use of phytoestrogens to reduce the frequency or severity of VMS at the time, but did recommend further investigation of genistein for menopausal symptoms.
In a recent RCT, women administered dried red clover leaves (40 mg) for 12 weeks reported significant improvements in menopausal symptoms (10-point mean reduction on the Menopause Rating Scale), compared with placebo. Other RCTs of phytoestrogens show mixed results. In an RCT of 102 women receiving 12 months of isoflavones compared with placebo, there were no significant reductions in hot flashes over the course of the study. Participants in both groups (isoflavones and placebo) reported increases in hot flashes. In addition, it was found that 12 weeks of isoflavones (90 mg) did not show clinically meaningful improvements in hot flash frequency. Among the 64 breast cancer survivors receiving isoflavones, there was a 25% reduction in hot flash frequency compared with the 33% reduction reported in the placebo group (n = 59). Two RCTs investigating the effects of isoflavones to placebo did not demonstrate isoflavones to be superior to placebo in reducing scores on the Kupperman Index. In contrast, an RCT comparing the effects of isoflavones to placebo among 51 women did demonstrate a clinically meaningful reduction of hot flashes (57%) after 6 months of treatment (60 mg) compared with placebo (18%).Phytoestrogens appear to be safe for 12 months of continuous use, yet the evidence to support efficacy is inconsistent. Therefore, more RCTs suing standardized methods that will allow for study comparison are needed in order to draw definitive conclusions regarding the use of phytoestrogens for menopausal symptoms.
Isoflavones
Isoflavones are the most important compound of phytoestrogens and are produced almost exclusively by the members of the Fabaceae like bean. It includes daidzein, genistein, biochanin A, formononetin, and glycitein.
They showed agonist–antagonist estrogen action and exerted elective stimulation of β-estrogen receptors (βERs) with less affinity and lower potency than estrogens. Moreover, they stimulate the synthesis of sex hormone binding globulin (SHBG).
The examination of meta-analyses of randomized controlled trials to evaluate the effectiveness of phytoestrogens in vasomotor symptoms and their side effects in postmenopausal women revealed considerable divergence among authors. Nevertheless, most reported mitigation of the symptoms, as well as improvement in the quality of life; none reported any side effects.
Another recent review argued that no conclusive evidence showed a benefit of phytoestrogen-enriched or -derived products for menopausal vasomotor symptoms, except for products containing a minimum of 30 mg per day of genistein.
It is well known that the absorption of the soy isoflavones depends on the presence of the intestinal flora that are capable of producing glycosidases and therefore to hydrolyze genistein and daidzin to the active aglycons.
Taking this into consideration, it has been suggested to combine soy isoflavones with lactic acid bacteria in the form of spores, resistant to the gastric and biliary secretion, to assure the bioavailability of soy isoflavones.
Isoflavones exert a limited beneficial effect on cognition, as increased choline acetyltransferase and brain-derived neurotrophic factor in the hippocampus and frontal cortex. However, this effect may be modified by age, gender, ethnicity, menopausal status, and length of treatment.
The topical application showed a good effect on vaginal health and dyspareunia.
There may be a significant effect on the lipid profile and inflammatory marker associated, with a lower risk of cardiovascular disease.
Herbal Derivatives
Herbal remedies are frequently used to alleviate menopause symptoms and are effective in the treatment of acute menopausal syndrome with different mechanisms.
These compounds may also interact with prescription drugs, resulting in dangerous changes in the effect of the drug.
Actaea racemosa
This herb, also called Cimicifuga racemosa or black cohosh or fairy candle, has a long history of use: Native Americans used it to treat many diseases like musculoskeletal pain, fever, cough, pneumonia, sluggish labor, and menstrual irregularities.
It’s among the most studied herbal derivatives with observational studies during the 50s and 70s, and controlled studies since the 80s for a total of 11,073 patients.
Black cohosh showed a positive effect in treating hot flashes and other menopausal symptoms like sleep quality. According to a recent study, the herb can also inhibit the growth of the myomas.
Terpene glycosides are the active compounds and bind to the estrogen receptor and selectively suppress the secretion of LH without any effect on FSH.
Gastrointestinal side effects are the most common and there has been some concern about hepatotoxicity with long-term use of black cohosh.
The rhizome is harvested in fall and may be used in fresh or dried form. Multiple RCTs have been conducted to determine the effects of Cimicifuga racemosa on menopausal symptoms. In a systematic review of 16 RCTs (n = 2027) that measured the effects of oral monopreparations of C racemosa on menopausal symptoms, including VMS, sexual dysfunction, vulvovaginal symptoms, bone health, and quality of life, researchers concluded that there was insufficient evidence to support the use of black cohosh for menopausal symptoms at this time, but that there was sufficient evidence to warrant further investiagtions. Among the studies included there was no significant difference between the intervention and placebo in the frequency of hot flashes or in menopausal symptom scores. The reviewers concluded that because of large study heterogeneity, pooling of the results was not possible and that more high-quality RCTs were necessary before recommending C racemosa for menopausal symptoms.
In an RCT comparing isopropanolic black cohosh extract in combination with ethanolic St John’s wort with placebo among 301 women, scores on the Menopause Rating Scale decreased by 50% in the treatment group compared to 19% in the placebo group. Depression also significantly decreased compared with placebo, P < .001. In a second RCT comparing the effects of black cohosh plus St John’s wort (GYNO-Plus), scores on the Kupperman Index showed significant improvements (p < .001) in the treatment group compared with placebo.However, it is difficult to conclude from these studies if black cohosh is beneficial in itself or only in combination with other herbs. More research is needed using standardized preparations. Side effects of black cohosh may include: gastrointestinal problems, rash, and acute hepatitis.
Evening Primrose Oil
Also called Oenothera biennis oil, it contains omega-6 fatty acids, which increase prostaglandin E2 that has anti-inflammatory effects.
The main application is for systemic diseases marked by chronic inflammation, such as atopic dermatitis and rheumatoid arthritis.
It is often used for several complaints such as menopausal and premenstrual symptoms. However, several studies showed that the compound has no benefit in treating menopausal flushing compared with placebo.
Oenothera biennis oil may cause mild gastrointestinal side effects or lower seizure threshold in patients taking antiepileptic drugs.
Evening primrose oil (EPO), the oil from the seed of the evening primrose plant, contains essential omega-6 fatty acids and has been used to treat multiple inflammatory diseases and women’s health conditions. In an RCT comparing the effects of EPO to placebo on VMS, it was reported that 4 g/d of EPO for 6 months was no better than placebo for reducing hot flushing. There were no significant improvements demonstrated in either group. In a recent RCT comparing 500 mg of EPO daily to placebo on VMS, hot flash frequency was reduced by 39% (EPO) and 32% (placebo) after 6 weeks. Hot flash severity and duration decreased by 42% (EPO) and 32% (placebo) and 19% (EPO) and 18% (placebo), respectively. While the differences between EPO and placebo were statistically significant, improvements in the treatment group were not clinically meaningful. Two RCTs have been conducted to investigate the effects of EPO on bone mineral density loss in premenopause and post menopause. Both groups of participants (pre- and postmenopause) were randomized to receive EPO (4.0 g) in combination with marine fish oil (440 mg) and calcium (1.0 g) (ie, Efacal) compared with calcium (1.0 g) alone. All participants, irrespective of treatment or menopause phase, showed significant increases (1%) in bone mineral density. The supplement Efacal was not significantly better than calcium alone for increasing bone mineral density. There is not enough evidence to support the use of EPO for menopausal symptoms at this time.
Foeniculum vulgare
The common name of this herb is Fennel.
It is characterized by the presence of palmitic acid and beta-sitosterol and shows antiandrogenic and anti-inflammatory effects.
Its main application is on hot flashes in postmenopausal women but it can also help anxiety in those patients with depression.
Vaginal fennel ethanol extract cream showed an improvement of vaginal atrophy and sexual functions in menopause women due to its estrogenic effects.
No critical side effects have been reported.
Ginkgo biloba
The herb was used in the treatment of attention disorders in postmenopausal women, but several studies reduced its positive action. However, a recent study showed a positive effect on the sexual desire of menopausal women, however other studies have not demonstrated and effect. The side effects include mild gastrointestinal disorders, allergic reactions, headache, and lowering of seizure threshold. Ginkgo biloba can intereact with a number of medications and should be used with caution.
Glycyrrhiza glabra
Commonly referred to as licorice, it contains terpenes, saponins, flavonoids, isoflavonoids, and steroids. It has various levels of estrogenic activities, and one clinical trial study showed that it is more effective than HRT in improving hot flash duration. Prolonged use of this herb can cause cardiovascular disease, hypercortisolism, hypokalemia, and hypernatremia and safety studies are necessary.
Hypericum perforatum
The herb, also called St. John’s Wort, showed a positive effect on the treatment for the vasomotor symptoms of postmenopausal women. A study found a chemopreventive effect in human breast cancer cells through AMPK/mTOR signaling. A systematic review showed that the combination of this compound with C. racemosa demonstrated a positive effect on climacteric complaints. The side effects are fewer and include gastrointestinal discomfort, sensitivity to light, restlessness, and fatigue.
Medicago sativa
Also called Alfalfa, this herb contains noncellulosic polysaccharides that exert various effects: Immunomodulatory, anti-inflammatory, antioxidant/anticancer, and growth-promoting bioactivities and, in addition, it seems to reduce the incidence of chronic disease. It also shows a slight effect on neurovegetative menopausal symptoms.
Melissa officinalis
This herb, also known as lemon balm, bee balm, or honey balm, has long been used as a medicinal plant but also as a vegetable and to add flavor to dishes. It contains volatile compounds, triterpenoids, phenolic acids, and flavonoids. It has been used for the treatment of a wide range of diseases, especially anxiety and some other mental disorders. It shows many pharmacological effects, such as anxiolytic, antiviral, antioxidant, and antispasmodic activities but also exerts action on the central nervous system, mainly on cognition and memory. One of its derivatives is caffeic acid.
Panax ginseng
Anti-inflammatory properties characterize this plant, and a recent review of randomized clinical trials showed promising results for improving glucose metabolism and moderating the immune response. Possible mechanisms of action of ginseng include hormonal effects related to those of estrogen with a slight effect on depression, mood disorders, and sexual function. The principal active compounds are ginsenosides, which have been shown to exert estrogen-like actions.
Passiflora incarnata
Also called passion fruit, it has long been used in traditional herbal medicine for the treatment of insomnia and anxiety, but also a sedative tea in North America. This plant showed analgesic, anti-spasmodic, anti-asthmatic, wormicidal, and sedative actions, but it is also used for dysmenorrhea. It has been proposed to treat early menopausal symptoms such as insomnia, vasomotor symptoms, depression, anger, or headaches. The plant has a good safety profile, and no particular side effects have been reported in the literature, although more studies are needed to widely assess this aspect.
Pimpinella anisum
Pimpinella anisum, also known as anise, contains an active compound with both estrogenic and analgesic, antioxidant, antimicrobial, anticonvulsant, and antispastic properties.. Moreover, anise exerts activity on the gastrointestinal system with an antiulcer action while the aromatic effects have been demonstrated in the palliation of nausea. The primary therapeutic target in menopause is against hot flashes.. No dangerous side effects have been reported in the literature.
Salvia officinalis
Also called sage herb, the mechanism of action is exerted through modulation of GABA receptors and serotonin transporters, which impacts on hot flashes and sweats. The active compound inhibits choline esterase in vitro, explaining why excessive use may cause a feeling of warmth, tachycardia dizziness, and epilepsy-like seizures.
Trifolium pretense
Also known as red clover, the oral intake of supplements containing isoflavones of this plant has been reported to be effective in reducing the frequency and severity of hot flashes. Moreover, it shows a chondroprotective effect on inflammation. However, this herb is contraindicated with the concomitant use of hormonal drugs.
Trigonella foenum
This herb, also called fenugreek, has been used to treat hot flashes, with some preliminary evidence for prevention of menopausal induced osteopenia.. Moreover, some studies have focused on its action for diabetes and dysthyroidism. It contains compounds of mucilage, proteins, and steroidal saponins.
Valerian officinalis
It is a traditional herb used for the treatment of anxiety and sleep disorders. It showed a sedative effect, probably due to the increase of GABA in the synaptic cleft due to inhibition of its reuptake. It has direct inhibitory effects on the contractility of the human uterus, justifying the traditional use in the treatment of uterine contractions associated with dysmenorrhea.. Moreover, this herb is used in the treatment of hot flashes in menopause.
Vitex agnus-castus
Vitex agnus-castus (also called chaste tree, chasteberry, or monk’s pepper) increases melatonin release, interacts with opioid receptors, and can play a role in vasomotor symptoms and sleep diseases. It has been used for dysmenorrhea, premenstrual dysphoric disorder, infertility, acne, cyclic breast pain, and diarrhea and flatulence. A recent study showed that V. agnus-castus and magnolia, combined with Soy isoflavones + lactobacilli, improve quality of sleep in symptomatic women.
Maca (Lepidium meyenii)
Maca, a plant native to South America, of the brassica family has been used for centuries in Andean cultures as a treatment for anemia, infertility, and female hormone balance. A recent systematic review found 4 RCTs (2 were contained in 1 publication, [n = 202], testing the effects of maca in healthy women during various stages of menopause. Three studies used pregelatinized maca, and 1 study used dried maca. All studies employed a placebo control for comparison. Each of these trials indicated favorable effects of maca on menopausal symptoms as measured by the Greene Climacteric Scale and the Kupperman Index compared with placebo. However, the reviewers concluded that despite initial evidence for the benefits of maca, findings were limited by the small number of trials and lack of safety information. More data are needed to determine the efficacy and safety of maca for menopausal symptoms
Wild Yam (Diascorea)
Wild yam is a tuber that has been historically used in traditional Chinese medicine to treat multiple symptoms, including symptoms of menopause. However, there is limited and inconsistent evidence for the effects of wild yam on menopause symptoms. In a double blind, placebo controlled, cross-over study, wild yam cream was no better than placebo in reducing menopause symptoms, or improving levels of estrogen or progesterone. In contrast, a RCT of 50 women consuming 12 mg of Dioscorea alata (ie, purple yam) extract twice daily reported significant improvements (90%) in menopause symptoms (primarily psychological) compared with the placebo group (70%) as measured by the Greene Climacteric Scale. The authors note that sexual functioning symptoms did not show the same levels of improvement. Because of the small number of studies and insufficient information regarding long-term safety, more research is needed in order to determine the efficacy of wild yam for menopause symptoms.
Dong Quai (Angelica sinensis)
Dong quai is a traditional Chinese herb that is most often used in combination with other herbs to treat female reproductive problems. It is extracted from the root Angelica sinensis and administered in herbal preparations. In an RCT investigating the effects of Dong quai on vaginal cells, endometrial thickness, and menopausal symptoms among 71 women, Dong quai was not superior to placebo for the reduction of menopausal symptoms (including VMS) and did not show any estrogenic effects in endometrial tissues or vaginal cells. In an RCT comparing a combined preparation of A sinensis and Matricaria chamomilla (ie, Climex), to placebo among 55 women reporting hot flashes and refusing hormone therapy, the herbal preparation demonstrated clinically significant improvement in the frequency and intensity of hot flashes (90%-96%) compared with placebo (15%-20%) over the 3-month trial. In a double-blind, placebo-controlled RCT, A sinensis was combined with other herbs (ie, black cohosh, milk thistle, red clover, American ginseng, chaste-tree berry; Phyto-Female Complex), and tested among 50 healthy women. At 12 weeks, participants receiving the herbal preparation reported a 73% decreased in hot flushes and a 69% decrease in night sweats, compared with 38% and 29% improvement in the placebo group, respectively. The treatment group also reported greater improvements in sleep quality.87 However, it is difficult to determine the effects of A sinensis from these 2 trials due to the use of combined preparations. Dong quai may be effective only in combination with other herbs. In addition, important safety concerns exist regarding A sinensis, including interactions with other medications and herbs, photosensitization, anticoagulation, and possible carcinogenicity. Further investigations into the efficacy and safety of Dong quai are needed.
Pollen Extract
Pollen extract, made from flower pollen and sold under the brand names Serelys, Femal, Femalen, and Relizen, has not been sufficiently tested to determine efficacy or safety. One small RCT of pollen extracts for menopause symptoms was identified. Fifty-four women randomized to either Femal or placebo completed the 12-week trial. Menopause symptoms were measured using the Menopause Rating Scale and diaries. Women taking Femal reported a 22% (Menopause Rating Scale) and 27% (diary) reduction in hot flashes at 12 weeks. The placebo group reported a 4% increase in frequency of hot flashes at 12 weeks. Though there were superior improvements for the active treatment group in all symptom categories (eg, VMS, tiredness, dizziness, mood, quality of life), these improvements did not reach clinical significance. An animal study of Femal has indicated that the extract does not act estrogenically and could be a safe alternative to hormone therapy. However, more studies are needed to clarify the effectiveness of pollen extract for menopausal symptoms.
Vitamins
The beneficial effect of vitamins for the treatment of perimenopausal symptoms is limited in the literature. Vitamin E could play a decisive role in the prevention of hot flushes if consumed in the amount of 800 IU/day. The protective effect of vitamins E on sleep quality has been recently shown. It could also be an alternative to vaginal estrogen in relieving the symptoms of vaginal atrophy in postmenopausal women. In postmenopausal women with vitamin D deficiency, isolated supplementation of vitamin D3 were associated with a reduction in the metabolic syndrome risk profile, but also with a lower risk of hypertriglyceridemia and hyperglycemia. Recent studies focused on other micronutrients such as essential fatty acid, B vitamins, vitamin C, magnesium, and zinc to reducing stress and anxiety.
Vitamin E is a fat-soluble vitamin thought to act as an antioxidant in the body. There are anecdotal accounts of the benefits of vitamin E for menopausal symptoms. However, few RCTs have been conducted to investigate the use of vitamin E for menopause symptom reduction. In a crossover trial of 120 women receiving 800 IU of vitamin E followed (4 weeks) by placebo (4 weeks) or vice versa, participants reported a decrease of 1 hot flash per day with vitamin E. The authors concluded this was not a clinically meaningful difference. In a similar randomized cross-over trial, 50 women taking 400 IU of vitamin E followed by placebo or vice versa for 4 weeks each, participants showed a reduction of about 2 hot flashes per day and reduced hot flash severity with vitamin E. In an RCT comparing the effects of gabapentin to vitamin E among 115 women for VMS reduction, hot flush frequency and score decreased by 10.02% and 7.28%, respectively in the vitamin E group. At this time there is an insufficient amount of empirical evidence to conclude the effectiveness of vitamin E supplementation for menopausal symptoms.
Other Compounds
Recent evidence suggested the role of other sources such as polyphenols extracted from hop or grape seed or lipoproteins of marine origin. These compounds showed a positive role in the relief of menopausal symptoms, especially for vasomotor ones but also other positive effects.
Mind-Body Interventions for Menopause Symptoms
Hypnosis
Hypnosis, a mind-body therapy that involves a deeply relaxed state of focused attention, individualized mental imagery, and suggestion, has been investigated for menopausal symptom management. Two randomized clinical trials of 5 sessions of hypnotherapy for hot flashes among breast cancer survivors demonstrated a clinically meaningful (≥69%) reduction in hot flash severity and frequency. In addition, hypnosis improved self-reported sleep quality and sexual function
Cognitive Behavioral Therapy
CBT is an action-oriented psychological intervention that has been used to treat hot flashes, depression, and other menopausal symptoms. CBT is a time-limited treatment that focuses on changing cognitive appraisals and behavior choices to alter symptoms. CBT may include education, motivational interviewing, relaxation, paced breathing, and other strategies to improve symptoms. A study which compared the effects of a 6-week CBT intervention to usual care (eg, standard follow-up care) among 96 female breast cancer survivors and found hot flash interference was reduced on average 52%. Women receiving usual care reported a 25% decrease in hot flash interference. Hot flash frequency was reduced by 38% in both groups, 38% indicating CBT was no better than usual care for reducing the frequency of hot flashes. In a second RCT, 65% of women receiving a 4-week CBT intervention and 21% of a no-treatment control group, reported clinically significant improvements (eg, 2-point change on a 10-point numerical rating scale) in hot flush interference CBT did not demonstrate a clinically significant reduction (eg, 50%) in hot flash frequency. Both of these trials used objective and subjective measures for hot flash frequency.
In a pilot study of 39 women randomized to CBT or waitlist control, there was a statistically significant reduction in hot flash distress, but not in interference or frequency of hot flashes/night sweats, in the immediate treatment group. The authors reported a 48% positive treatment effect for the 17 women who completed the CBT program. In addition, there is some evidence to suggest that CBT may reduce mild depression in menopause comparable to placebo.
To date, no RCTs of CBT have demonstrated clinically significant improvements in hot flash frequency, but may be beneficial in reducing hot flash distress and interference and other psychological symptoms (eg, depression) associated with menopause. CBT has been recommended by the North American Menopausal Society for reducing the bothersomeness of vasomotor symptoms, but not for frequency.
Biofeedback and Relaxation Training
Biofeedback and relaxation techniques may include progressive muscle relaxation, relaxation combined with thermal control biofeedback training, paced respiration, at-home relaxation audiotapes, and applied relaxation, and have been used to treat menopausal symptoms. Biofeedback uses a device to monitor bodily functions that are normally automatic (eg, skin temperature, heart rate, or muscle tension) and provides “feedback” to the patient. Feedback and relaxation techniques (eg, guided imagery, deep breathing, and paced respiration) are then used to control stress responses. In a systematic review of psychoeducational interventions to relieve hot flashes, reviewers identified 7 randomized trials that compared relaxation with an active (eg, reading, α-electroencephalography, hormone therapy) or no-treatment control. Five of the trials reviewed indicated relaxation techniques (eg, paced respiration, progressive muscle relaxation) may reduce the frequency of hot flashes and improve psychological symptoms of menopause.
Researchers have concluded that relaxation techniques may have a positive benefit on vasomotor symptoms and stress. Relaxation may provide benefit for menopausal symptoms, yet more evidence is needed to draw conclusions.
Mindfulness-Based Stress Reduction
Mindfulness-based stress reduction (MBSR) uses a variety of exercises (eg, acceptance, mindfulness meditation, and yoga) to develop awareness and acceptance of the present moment. MBSR usually involves 8 weekly group classes lasting 1.5 hours each, an all-day weekend retreat, and daily at-home practice. A trial of MBSR has demonstrated a clinically meaningful improvement (1.0) in menopause-related quality of life and sleep quality. Perceived stress and anxiety resumed normative values in the MBSR group following treatment. MBSR is generally safe and may reduce stress and anxiety and improve sleep quality and quality of life, but does not appear to significantly reduce VMS. More research is needed to verify these effects.
Yoga
Yoga originates from Hindu disciplines, but many different forms of yoga have appeared as the popularity has grown globally. Because of a branching off of many different styles, yoga practices can vary (eg, intensity level, temperature of the session, specific props used). All practices generally involve physical poses or movement sequences, conscious regulation of breathing, and mindfulness techniques to increase present awareness or positivity
A systematic review and meta-analysis47 including 5 RCTs concluded that there was moderate evidence for the short-term effects of yoga on psychological symptoms in menopause. However, there was no evidence found for the improvement of VMS, somatic, urogenital, or total menopausal symptoms and the reviewers caution that more rigorous studies are needed to support the evidence for yoga on psychological menopausal symptoms.
Additional RCTs have been conducted that indicate yoga maybe beneficial for psychological symptoms and fatigue related to menopause. However, the evidence to support the use of yoga for other menopausal symptoms is inconsistent.
There is high variability between studies assessing the use of yoga for various ailments, which makes conclusions about efficacy difficult. These inconsistencies are mostly because of the branching off of many yoga types which vary in the level of importance given to the spiritual and physical elements of yoga.
The consensus from the compilation of research seems to be that yoga is safe and may be effective for psychological symptoms. More research is needed to determine its effects on VMS and other menopausal symptoms.
Aromatherapy
Aromatherapy, also referred to as essential oil therapy, uses naturally extracted aromatic essences from plants to treat various physiological and psychological imbalances. The scented oils are believed to reduce anxiety and increase relaxation, which may be beneficial in easing stressful menopausal symptoms.
Chien and colleagues56 found 12 weeks of lavender inhalation to improve self-reported sleep compared with health education control. A double-blinded 12-week clinical crossover trial of 100 women, lavender essential oil reduced hot flash frequency by 50% compared with <1% reduction in the placebo (diluted milk) control, demonstrating a clinically significant difference. Three additional RCTs of aromatherapy combined with massage, found aromatherapy massage to be more beneficial than massage alone or a control in reducing physical (eg, VMS) and psychological (eg, depression) symptoms.
The addition of aromatherapy to other CAM interventions may provide additional symptom relief. However, there is insufficient evidence to support aromatherapy as a stand-alone treatment for menopausal symptom management.
Reflexology
Reflexology is a specific type of massage performed on the feet and hands that is believed to stimulate corresponding glands and organs. The principle behind reflexology states that there are reflex points on the hands and feet that correspond to certain body zones, and when pressure is applied to these points, disease-causing energy blockages are eliminated from the corresponding body zone.
Only 2 RCTs have examined the use of reflexology for menopausal symptoms. Both studies compared reflexology with a nonspecific foot massage control. Williamson and colleaguesfound no significant differences between nonspecific foot massage and reflexology on symptoms of anxiety, depression, and VMS. However, in a more recent RCT of 120 women randomized to reflexology or nonspecific foot massage control, VMS, and sexual dysfunction symptoms (MENQOL) were significantly improved among women receiving foot reflexology compared to control (P < .001). Hot flash frequency reduced by 56% after 12 twice-weekly reflexology sessions.153
Because of the small number of RCTs and inconsistent findings, more research is needed to determine the efficacy of reflexology for menopausal symptoms.
Acupuncture
Acupuncture techniques come from traditional Chinese medicine and involve insertion of small needles into the skin at certain points on the body, which are called acupoints. The foundation of acupuncture is a belief that diseases and symptoms occur because of disruptions in an individual’s qi, or life force energy.
There have been several RCTs of traditional acupuncture for various menopausal symptoms, some of which are noted in the section on traditional Chinese medicine because of their combination with additional modalities. Four trials found no significant difference between acupuncture and placebo of superficially placed needles or needling at non-acupoints. One study found that an acupuncture plus auricular acupressure intervention was not significantly better than a hormone replacement control at improving hot flash severity. Six trials showed that acupuncture could improve vasomotor, sleep, or somatic symptoms more significantly than placebo.
An additional acupuncture technique that has been studied for use in menopause is electroacupuncture, which includes the passing of a small electrical current between acupuncture needles. Three trials assessed the use of electroacupuncture. One study found significant improvements in mood only. Two studies found no significant difference from placebo.
More research with precise methods is needed to uncover the true efficacy and the mechanisms behind the benefit some participants receive from acupuncture.
Traditional Chinese and East Asian Medicine
Traditional Chinese medicine can include the use of herbs, self-massage, acupuncture, diet, or meditative exercise (eg, Tai Chi). What ties these modalities together is the ancient technique and tenets of qi (life force energy) and yin and yang (harmony between opposite forces) behind their use.
A trial using a Chinese herbal medicine formula found that compared to placebo control, herbal treatment significantly improved hot flash frequency. However, hot flash reduction was larger in a third hormone replacement group. Two trials reported no significant difference between hormone replacement therapy and Chinese herbs in reducing self-report VMS, anxiety, and depression. Another study using Japanese traditional medicine found greater improvement in VMS and psychological symptoms for a Paroxetine control than with herbal treatment.
One group found that an herbal extract was significantly more effective than placebo at improving VMS frequency, VMS severity, and sexual functioning. Studies have reported significant improvement in depression or QOL over placebo, but no difference for VMS. Other trials reported that Chinese herbs were significantly more effective than placebo at improving self-report menopause symptom improvement, tension, and insomnia, but no improvement of self-report hot flashes specifically.
One RCT used acupuncture paired with traditional Chinese medicine (diet therapy and Tuina self-massage) and found that this combination significantly improved hot flash frequency, irritability, and sleep problems from baseline to endpoint and significantly greater than a waitlist control. Several RCTs found no significant difference between Chinese medicinal herbs and placebo in hot flash severity, hot flash frequency, sleep quality, or menopause related quality of life.
While there is some evidence that traditional Chinese medicine can be effective in relieving menopausal symptoms, there are mixed findings overall. In addition, the heterogeneity among studies makes drawing conclusions difficult. As is the case for many other CAM modalities, it is inherently difficult to conduct controlled research of a treatment that is focused on individualization and techniques based on ancient beliefs. Patterns explaining which modalities work best for which symptoms remain unclear
Conclusions
Existing research indicates that mind-body interventions such as relaxation, mindfulness, and CBT therapy can reduce stress and bothersomeness associated with menopausal symptoms.
Hypnosis intervention for hot flashes has been shown to result in a clinically significant reduction (ie, 50% or more) in hot flashes and associated symptoms. However, hypnosis for hot flashes is not widely available, thus limiting accessibility.
Mind-body interventions have few negative side effects and seem to provide safe treatment options worthy of consideration.
The effects and safety of herbal preparations is difficult to ascertain due to large variations in the RCTs that have been conducted. Investigations of standardized herbal preparations may provide a path for better understanding their effects and safety.
There are no herbal treatments that have demonstrate consistent clinically meaningful benefits for menopausal symptoms. This lack of consistent evidence may not be due to the ineffectiveness of the treatments, rather it may indicate the need for more rigorously conducted RCTs regarding each of these modalities on menopausal symptoms.
Some CAM interventions show promise (e.g. aromatherapy, acupuncture, reflexology), but lack empirical support due to the limited number of studies. Health care decisions regarding CAM therapies for menopausal symptoms can be informed by existing scientific evidence for effectiveness and safety.
More high-quality RCTs are needed for each CAM intervention. Among herbal products (eg, black cohosh, phytoestrogens), RCTs of standardized preparations given in consistent methods would allow for more systematic reviews and meta-analyses of these interventions.
Hypnosis is a mind-body intervention that has been shown to reduce the frequency and bothersomeness of menopausal symptoms. Future research is needed to determine optimal delivery of effective self-hypnosis training in order to achieve wider dissemination.
Researchers should consider potential mechanisms action in regard to improvements in VMS and other menopausal symptoms. Higher quality studies with larger populations are needed to determine efficacy and safety among all reviewed CAM interventions for menopausal symptoms.
CAM interventions for menopause, including mind-body practices, herbal products, and other whole system alternative medicine approaches are commonly used to treat menopausal symptoms.
Not all CAM interventions are efficacious and safe. It is important for women to be informed about the risks and benefits of CAM for menopausal symptoms. Women view health care providers as the most reliable sources of information on CAM interventions, but seldom seek their guidance in choosing CAM.
Mind and body practices including hypnosis and CBT have been demonstrated to be safe for treating some of the most common and problematic symptoms of menopause (eg, vasomotor, sexual dysfunction, sleep regulation). Other mind and body practices (biofeedback, MBSR, relaxation techniques) may reduce stress and improve quality of life for women transitioning through menopause, but have not shown efficacy for specific menopausal symptoms. Hypnosis has consistent evidence for clinically significant reduction of hot flashes. However, trained practitioners are not widely available, thus limiting its use.
Herbal products are frequently used. However, there is no consistent evidence to support their efficacy and safety. There is the added concern that when used in combination with other medications, some herbal products could pose serious health risks. Vitamins and minerals may be important for women who are at risk for deficiencies, but do not seem to reduce menopausal symptoms.
Physician-initiated discussions of CAM with women transitioning through menopause will help to promote an integrative model of care that will ensure the highest level of patient care.
References
J Evid Based Integr Med. 2019; 24: 2515690X19829380.
Complementary and Alternative Medicine for Menopause
Alisa Johnson, PhD,1 Lynae Roberts, MA,1 and Gary Elkins, PhD1
Medicina (Kaunas). 2019 Sep; 55(9): 544.
A Nutraceutical Approach to Menopausal Complaints
Pasquale De Franciscis,1 Nicola Colacurci,1 Gaetano Riemma,1 Anna Conte,1 Erika Pittana,1 Maurizio Guida,2 and Antonio Schiattarella1,*