Alternative and Complementary Therapies
Publicity after publication of the Women's Health Initiative and the Million Women Study has lead to women stopping hormone replacement therapy. They may then be troubled with hot flushes and night sweats (vasomotor symptoms) or pain during intercourse (dyspareunia) and are concerned about their risk of osteoporosis. Alternative and complementary therapies are discussed.
There is little scientific evidence that complementary and alternative therapies can help menopausal symptoms or provide the same benefits as conventional therapies. Yet many women use them, believing them to be safer and “more natural”. In the UK more than one in ten adults visit a therapist each year [Thomas et al 2001]. The choice of treatments is confusing and, unlike conventional medicines, not much is known about their active ingredients, safety or side effects or how they may interact with other therapies. They can interfere with warfarin, antidepressants and anti-epilpetics with potentially fatal consequences. Some herbal preparations may contain estrogenic compounds and this is concern for women with hormone dependent disease such as breast cancer. There is also concern about contaminants such as mercury, arsenic lead and pesticides.
Phytoestrogens are plant substances that have effects similar to those of estrogens. Preparations vary from enriched foods such as bread or drinks (soy milk) to more concentrated tablets. The most important groups are called isoflavones and lignans. The major isoflavones are genistein and daidzein. The major lignans are enterolactone and enterodiol.
Isoflavones are found in soybeans, chick peas, red clover and probably other legumes (beans and peas). Oilseeds such as flaxseed are rich in lignans, and they are also found in cereal bran, whole cereals, vegetables, legumes and fruit.
The role of phytoestrogens has stimulated considerable interest since populations consuming a diet high in isoflavones such as the Japanese appear to have lower rates of menopausal vasomotor symptoms, heart disease, osteoporosis; breast, colon, endometrial and ovarian cancers. With regard to menopausal symptoms the evidence from randomized placebo- controlled trials in western populations is conflicting for both soy and derivatives from red clover. Similarly there are also debates about the effects on blood fats (lipoproteins), blood vessel function and blood pressure. The isoflavone daidzein is metabolized extensively in the gut by the human gut microflora to the more estrogenic secondary metabolite equol. That only 30% of western populations excrete high levels of equol might account for the conflicting evidence provided by clinical trials. Genistein and the synthetic isoflavone ipriflavone may maintain bone mass but the evidence is conflicting. Additionally, ipriflavone in one study induced lymphocytopenia in a significant number of women.
Black cohosh is widely used to alleviate menopausal symptoms. Early animal studies suggest an ‘estrogen like' activity; more recent work suggests the effects may result from a central activity. The results form placebo controlled trials or comparison with conjugated equine estrogens are promising, but little is known about long term safety and toxicity.
A Cochrane review concluded that it may be an effective symptomatic treatment option for anxiety but the data regarding menopausal symptoms are conflicting. Concern about liver damage has lead regulatory authorities to suspend or withdraw kava kava.
Evening primrose oil is rich in gamma linolenic acid. One small placebo-controlled randomized trial showed it to be ineffective for treating hot flushes, but it may be helpful for breast tenderness.
Dong quai is commonly used in traditional Chinese medicine. It has not been found to be superior to placebo in a randomized trial. Interaction with warfarin and photosensitization have been reported.
Use is widespread but there is little evidence to show that it improves menopausal symptoms.
Ginseng has not been found to be superior to placebo in a randomized trial. Case reports have associated ginseng with postmenopausal bleeding and breast tenderness; interactions have been observed with warfarin, phenelzine and alcohol.
Wild yam cream , St John's Wort, Agnus Castus (Chasteberry), Liquorice root and Valerian root are also popular but there is no good evidence that they have any effect on menopausal symptoms. Claims have been made that steroids( diosgenein) in yams (dioscorea villosa) can be converted in the body to progesterone, but this is biochemically impossible in humans.
DHEA is one of the many steroid hormones produced by the adrenal gland and blood levels drop dramatically with age. DHEA is increasingly being used in the USA , where it is classed as a food supplement, for its supposed anti-ageing effects. Some studies have shown benefits on the skeleton, cognition, well-being, libido and the vagina. There is no evidence that DHEA has any effect on hot flushes. The short-term effects of taking DHEA are still controversial and possible harmful effects of long-term use are, as yet, unknown.
Progesterone transdermal creams
Progesterone creams have been advocated for the treatment of menopausal symptoms and skeletal protection. They have recently been the subject of clinical trials. Women using the cream have reported improvements in vasomotor symptoms but there was no effect on bone mineral density. To avoid side effects of progestogens women who take systemic estrogens may use transdermal progesterone creams for endometrial protection. No consistent evidence, however, shows that transdermal progesterone creams can prevent the estrogenic stimulation of the womb lining (endometrium).
IV Diet and supplements
Vitamins and minerals
Vitamins such as E and C, and minerals such as selenium are present in various supplements. The evidence that they are of any benefit to postmenopausal women is extremely limited. While one study showed vitamin E to reduce hot flushes, the difference between the active and placebo was only one hot flush per day.
Functional foods generally are defined as foods that confer a ‘benefit' to the host beyond that of simple nutrition. Four main types of functional foods may benefit women's health: probiotics, prebiotics, synbiotics and nutraceuticals. They seem to be most effective in dealing with gastrointestinal tract disorders but may also be involved in calcium absorption.
Homeopathy is generally defined as a system of medical treatment based on the use of minute quantities of remedies that in larger doses produce effects similar to those of the disease being treated. The mechanisms underlying the biological response to ultramolecular dilutions are unclear. Data from case histories, observational studies and a small number of randmised trials are encouraging but clearly more research is needed.
VI Other complementary therapies
Other complementary therapies include acupressure, acupuncture, Alexander technique, Ayurveda, osteopathy, hypnotherapy, reflexology, Reiki and Tai Chi. A randomized controlled trial of electro-acupuncture has shown no benefit on menopausal symptoms [Sandberg et al et al 2002]. It is believed that Tai Chi may benefit older people for fall prevention and conserve bone mass. Over the last decade, the number of studies on the effect of Tai Chi has increased rapidly, although it is still limited [Ling et al 2002]. Reflexology aims to relieve stress or treat health conditions through the application of pressure to specific points or areas of the feet [Williamson et al 2002]. One randomized trial has been published so far and no improvement of vasomotor symptoms was found.
Carpenter JS, Neal JG. Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy. Am J Med 2005;118(Suppl 12B):109–17.
Hinson J, Raven P. Dehydroepiandrosterone (DHEA) and the menopause: an update. Menopause Int 2007;13:75–8.
Nedrow A, Miller J, Walker M, Nygren P, Huffman LH, Nelson HD. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006;166:1453–65.
Rees M, Mander T. Managing the menopause without oestrogen. RSM Press. 2004.
Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England : a population based survey. Complement Ther Med. 2001; 9:2-11.
Wayne PM, Kiel DP, Krebs DE, et al. The effects of Tai Chi on bone mineral density in postmenopausal women: a systematic review. Arch Phys Med Rehabil 2007;88:673-80.
Margaret Rees and Sally Hope March 2005, reviewed January 2008.
Whilst great care has been taken to ensure the accuracy of information contained in the fact sheets, the authors and the BMS cannot accept any responsibility for any errors omissions, mis-statements or mistakes or for any loss or damage arising from actions or decisions based on information contained in this publication. Ultimate responsibility for the treatment of patients and interpretation of published material lies with the medical practitioner. The opinions expressed are those of the authors, not necessarily those of the BMS. The inclusion in the publication of material relating to a particular product, method or technique does not amount to an endorsement of its value or quality, or of claims made by its manufacturer.
Margaret Rees and sally Hope January 2008
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