Menopause and Complementary and Alternative Therapies (CAM)Katie Jackson and Soraya ValenciaBenedictine UniversityOctober, 2014

Definition of Menopause

“Menopause is the cessation of menstruation that results from loss of ovarian follicular activity or depletion”1

Eden KJ, Wylie KR, 2009

Menopause Onset

Occurs 12 months after the last period.2

Can happen between the ages 40-55.3

Premature menopause before age 40.3

Mean average age in United States is 51.2

Smokers often begin earlier than non-smokers.3

Mayo Clinic and WebMD

EpidemiologyWomen’s Health Initiative (WHI)

◦60% of women aged 50-54 have hot flashes

◦23% reported moderate to severe hot flashes

◦The prevalence decreases with age4

The study of Women’s Health Across the Nation (SWAN)◦Hot flashes differ by ethnicity,

lifestyle factors, and socioeconomic status.5

◦Higher body mass index associated with physiological and vasomotor symptoms.4

Moilanen et al, 2010

EpidemiologyFailure to produce estrogen begins in the late 30s.6

70 million women is affected by estrogen6 deficiency in the U.S.A age > 50 years.

85% of menopausal women are affected by discomfort.6

Goodman et al, 2011

Goodman et al, 2011

Signs and Symptoms

Hot flashes and night sweatsVaginal drynessChanges in moodSleep problemsWeight gain and slow metabolismThinning hair and dry skinLoss of breast fullness2

Most women with menopause symptoms may experience cessation 5 years after onset.6

Mayo Clinic and Goodman et al. , 2011

EtiologyNatural decline of the

reproductive2 hormones estrogen and progesterone.2

Hysterectomy that removes the uterus, not the ovaries.2

Chemotherapy and radiation therapy.2

Ovarian insufficiency: 1% of women experience menopause < 40 years.2

Mayo Clinic

Menopause Pathophysiology

Menopause PathophysiologyMenses cessation or amenorrhea 16

Ovaries age response to pituitary gonadotropins follicle-stimulating hormone and luteinizing hormone follicular phase and ovulations shortened production of progesterone lowered16

Follicle production drops unresponsive estradiol production lowered16

Androstenedione levels are reduced by half16

Ovarian inhibin and estrogen pituitary release of LH and FSH is inhibited LH and FSH significantly in circulation16

Complications After Menopause2

Heart and

blood vessel

disease

Osteoporosis

Urinary incontin

ence

Sexual function

Weight gain

Conventional TherapyHormone Therapy:

◦Estrogens: helps relief symptoms or bone protection in the lowest dose.6

◦Progestagens: provide endometrial protection.

Hormone replacement therapy (HRT): ◦combination of estrogen and

progesterone.2

Bioidentical Hormone Therapy: 6

◦ Identical in structure to human endogenous.

Testosterone with estrogen.7

Mayo Clinic, WebMD, Goodman et al. 2011

Other TherapiesLow-dose antidepressantsPhytoestrogens: Isoflavones and

lignansGabapentin (Neurontin)Medications to prevent or treat

osteoporosisLifestyle modificationYogaAcupuncture

Goodman et al, 2011

CAM Usage

Therapy Usage Claims Side Effects

Black Cohosh Reduces hot flashes Abdominal pain, dark urine, jaundice, liver failure

Dong qui Reduces hot flashes,No estrogen activity

Bleeding complications

Kava Decreases hot flashes and anxiety

Potential to damage the liver

Red clover Reduces hot flashes Contains phytoestrogen, may have effects on hormone sensitive-tissue

Ginseng Help with mood symptoms and sleep disturbances

Allergic reactions

Soy Reduces hot flashes Long-term use thickening of the lining of the uterus

Red Clover/Vasomotor and menopausal symptoms

Red clover is a plant to make medicine with the red flower.7

Used for many conditions, not enough scientific evidence.7

Contains hormone-like chemicals (isoflavones).9

The use of red clover supplementation has reported positive effects on menopausal symptoms.9

NIH and Lipovac et al, 2012

The effect of red clover isoflavone supplementation over vasomotor and menopausal symptoms in postmenopausal women. (Lipovac et al, 2012)

Randomized double-blind

Placebo-controlled

• Control group A: 2 capsules of red clover isoflavone 40mg each

• Placebo group B: 2 capsules identical manufactured

• 90-day period• After 7-day washout

period, subjects received opposite treatment for 90-days more

• 109 postmenopausal women aged >40 years

• Non-users of HT• Moderate to

severe menopausal symptoms

• More than 5 hot flashes per day

Study Results and Conclusion

Fifty-three women completed the trialNo significant effect on BMI, weight or blood

pressureRed clover isoflavones significantly

decreased menopausal symptomsPositive effect on vaginal cytologyLipid levels decreasedNo side effects in either active compound or

placeboDespite the results, the effects over

vasomotor symptoms continues being a controversial issue.

Lipavac et al, 2012

Oral Evening Primrose oil and Menopausal hot flashesOil from the seed of evening primose plant,

Oenothera biennis10,11

Obtained through cold expression from the plant11

Rich source of omega-6 fatty acids, which may help alleviate inflammation10,11

Studies mostly on its usage to treat systemic disease

Targets women’s health problems, including menopausal symptoms (i.e. hot flashes)10

EPO tolerated well with documented side effects, including gastrointestinal and headaches.

Most recent studies are limited and appropriate dosing standards anticipate clarification

The effect of oral evening primrose oil on menopausal hot flashes. (Farzaneh F et al, 2013)

Six-week randomized clinical trial

• Hot flashes commonly occur in menopausal women

• May affect quality of life due to symptom severity

• Study aim: compare efficacy of EPO versus placebo in menopausal hot flash symptom severity

• Total of 56 menopausal women

• 45-59 age range• Pre and post

intervention, participants reported characteristic of hot flash symptoms (i.e. hot flash related daily interference scale)

• Randomly assigned to 2 capsules per day

• Improvements reported

Study Results and ConclusionImprovement for frequency, severity of hot

flashes improved from 32, 32 and 18% in placebo to 39, 42 and 19% in EPO group12

The score from the HFDIS increased in two groups12

Improvement in social activities and relationships, and sexual life had a significant increase in EPO group (p <0.05)12

Oral EPO shown to alleviate hot flashes through lessened intensity and a better HFDIS score12

Valerian root and sleep quality in menopauseFlowering plant native to Europe

and Asia13

Grown in North America13

Used for its medicinal properties as a sleep aid13

Hot flashes commonly disrupt sleep in menopausal women13

The effect of valerian on sleep quality in post-menopausal women. (Taavoni S et al, 2011)

• Approximately half of postmenopausal women have sleep disturbances

• Aim of study is to evaluate valerian extract effects on sleep quality improvement in postmenopausal women

100 postmenopausal women

50 to 60 years of age Insomnia symptoms pre-

study Data obtained from

demographic form and Pittsburgh Sleep Quality Index

Two groups randomly assigned, given 530 mg valerian extract concentrate or placebo

Administered twice daily, 4 weeks

Randomized Placebo-

controlledClinical trialTriple-blind

Study Results and ConclusionIntervention group had significant increase

in sleep quality, P <0.00114

Thirty percent of subjects in valerian group versus four percent in placebo group had noted improvements in sleep quality14

Menopausal women with insomnia have higher quality sleep with the use of Valerian14

Results support reported efficacy of valerian through clinical findings of positive effects on insomnia14

Need for long-term trials

ConclusionsRed Clover

◦More research needed for effects on human body

Oral Evening Primrose Oil◦Recent studies limited ◦Dosing standards need to be clarified

Valerian root◦Need for long-term studies on

efficacy and safety

ConclusionWhole foods firstSupplements secondary, if

necessary, as long as documented efficacy and safety are present

Continued support with health care professional

References1. Eden KJ, Wylie KR. Quality of sexual life and menopause. Women’s

Health. 2009;5(4):385-396.2. Mayo Clinic. Menopause. Available at:

http://www.mayoclinic.org/diseases-conditions/menopause/basics/definition/con-20019726. Accessed on October 10, 2014.

3. WebMD. Premature menopause. Available at: http://www.webmd.com/menopause/guide/premature-menopause. Accessed on October 10, 2014.

4. Moilanen J, Aalto AM, Hemminki E, Aro AR, Raitanen J, Luoto R. Prevalence of menopause symptoms and their association with lifestyle among finish middle-aged women. Maturiatas. 201; 67: 368-374.

5. BMJ. Menopause. Epidemiology. Available at: https://online.epocrates.com/u/2923194/Menopause. Accessed on October 10, 2014.

6. Goodman FN, Cobin RH, Ginzburg SB, Katz IA, Woode DE. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice For the Diagnosis and Treatments of Menopause. AACE menopause guidelines revision task force. Endocrine Practice. 2011; 17(6): 1-25.

References7. WebMD. Menopause and perimenapause. Available at:

medicationshttp://www.webmd.com/menopause/tc/menopause-and-perimenopause-medications. Accessed on October 10, 2014.

8. NIH. Menopausal symptoms and complementary health practices. Available At: http://nccam.nih.gov/health/menopause/menopausesymptoms. Accessed on October 11, 2014.

9. Lipovac M, Chedraui P, Gruenhut C, Gocan A, Kurz C. The effect of red clover isoflavone supplementation over vasomotor and menopausal symptoms in postmenopausal women. Gynecological Endocrinology. 2012; 28(3): 203-207.

10. WedMD. Find a vitamin or supplement: Evening primrose oil. 2005-2014. Available at http://www.webmd.com/vitamins-supplements/ingredientmono-1006-evening%20primrose%20oil.aspx?activeingredientid=1006&activeingredientname=evening%20primrose%20oil

11. Bayles B et al. Evening primrose oil. American Family Physician. 2009; (12):1405-1408. Available at http://www.aafp.org/afp/2009/1215/p1405.html. Accessed October 16, 2014.

12. Farzaneh F et al. The effect of oral evening primrose oil in menopausal hot flashes: a randomized clinical trial. Arch Gynecol Obstet. 2013; (5):1075-9. Available at http://www.ncbi.nlm.nih.gov/pubmed/23625331. Accessed October 16, 2014.

13. Breus, M. Valerian: Help for post-menopausal insomnia. 2014. Huffpost Healthy Living. Available at http://www.huffingtonpost.com/dr-michael-j-breus/valerian-insomnia_b_1028544.html. Accessed October 16, 2014.

14. Taavoni S et al. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011; (9):951-5. Available at http://www.ncbi.nlm.nih.gov/pubmed/21775910. Accessed October 16, 2014.

15. Nordstrom S. Menopause: What every medical student should know. UIC College of Medicine Lecture. Available at http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med%20Ed/STUDENTS/Lectures/NORDSTROMMenopause%20talk.pdf. Accessed October 17, 2014.

16. Gass, M. Menopause. The Mercky Manual Professional Edition. 2014. Available at http://www.merckmanuals.com/professional/gynecology_and_obstetrics/menopause/menopause.html. Accessed October 17, 2014.