Menopause is defined as when a woman stops having her period for 12 consecutive months. On average menopause starts at age 51, however, the age of onset ranges from 45 to 55 years. Since menopausal symptoms can last for several years, it is very bothersome for many women. The most common symptoms of menopause include hot flashes, night sweats, vaginal dryness, mood changes, and sleep problems. Although estrogen and progesterone are very effective for relieving symptoms of menopause, some women cannot take them or choose not to take for various reasons. Women who have severe liver disease, history of blood clot, or history of breast cancer are not good candidates for hormonal therapy. Therefore, many women are looking for alternatives to hormonal therapy for reducing menopausal symptoms.
Black cohosh (Cimicifuga racemosa, Actaea racemosa)
Black cohosh is one of the best-selling herbs for the symptoms of menopause. It is called black because the roots of the black cohosh plant are used medicinally and are very dark. Black cohosh may have some effects similar to estrogen. The recommended dosage of black cohosh tablets or capsules is 20 to 40 mg once or twice daily.
Remifemin is the most studied brand of black cohosh. One study evaluating black cohosh use found a significant reduction in symptoms of menopause at the end of 12 weeks. Another study comparing two different doses of black cohosh found the two doses provide the same level of symptom relief. However, these two studies did not include placebo for comparison.
The most common side effects of black cohosh are stomach complaints, headache, occasional rash and weight gain. The safety of black cohosh in women who have had breast cancer is unknown. Although some studies suggest black cohosh might be safe, there is some concern that it might worsen existing breast cancer. Therefore, women who have or had breast cancer or are at high risk for breast cancer should avoid black cohosh.
There have been some cases of liver toxicity associated with black cohosh. People with existing liver disease or use alcohol or other medications that affect the liver should avoid black cohosh. The North America Menopause Society recommends a trial of black cohosh for 6 months or less because of the lack of long-term safety studies.
Phytoestrogens are commonly found in many different plants including fruits, vegetables, and legumes. Phytoestrogen supplements obtained mainly from soy and red clover have been used for menopause symptoms. Soy products have large amounts of isoflavones which are the most potent and most common phytoestrogens used in supplements. Isoflavones may be helpful in reducing hot flashes caused by menopause. Approximately 50 to 80 mg of isoflavones is the amount commonly used to prevent symptoms of menopause.
The reported benefits of phytoestrogens are based on observational studies of diets in different parts of the world. Researchers noticed that only about 10% of Asian women experience hot flashes and presumed that Asian women are less likely to have hot flashes because Asian diets contain more soy protein than North America diet.
Not all clinical trials of soy showed good outcomes. Several studies found no difference between phytoestrogen treatment and placebo in reducing symptoms of menopause.
Red clover is another source of isoflavones. In a trial of 252 women experiencing at least 35 hot flashes per week, red clover supplements were not better than placebo for relief of hot flashes. Large, long-term studies are needed to further document the effects of phytoestrogens before phytoestrogens can be considered an alternative to conventional hormone therapy in postmenopausal women.
The effect of phytoestrogens on prevention and treatment of breast cancer is unknown. There is evidence that they can either protect or support tumor growth. Some research suggests that genistein (a phytoestrogen found in soy) may reduce the beneficial effect of tamoxifen in slowing breast cancer growth. Women with breast cancer or a history of breast cancer should not take soy supplements; they should use dietary sources containing phytoestrogens rather than supplements. Examples of foods rich with phytoestrogen include soybeans, tofu, soy milk, miso, soy noodles, and green soybeans.
Evening Primrose Oil
Evening Primrose Oil is derived from evening primrose seeds and widely used to relieve hot flashes. However, available data suggests that it is not useful for treatment of menopausal symptoms.
A clinical trial of women with symptomatic postmenopausal symptoms compared the effect of evening primrose oil with placebo for six months. The results indicated that evening primrose oil was no better than placebo improving their symptoms.
Adverse effects of evening primrose include headache, nausea, abdominal pain and diarrhea. Evening primrose oil might slow blood clotting, and patients taking warfarin or other medications that slow blood clotting should use this herb with caution. Despite its popular use, evening primrose oil should not be recommended to treat menopausal symptoms because it is not effective.
Wild yam is often applied to the skin in the form of a cream to relieve hot flashes and night sweats. However, there is no available scientific evidence that suggests that it is safe and effective. Wild yam is well-tolerated, but large amounts can cause vomiting. Further research is needed to better define the role of wild yam in reducing menopausal symptoms.
Chasteberry is a popular herb used by women. The dried ripe fruits or berries and the leaves are used for medicinal purposes. Users occasionally complain of stomach and intestinal side effects. Its other side effects include dry mouth, itching, acne, rashes, menstrual disorders, and headache. Chasteberry may contain progestin and estrogen in its fruit. There are some clinical trials supporting efficacy of chasteberry in improving symptoms associated with premenstrual syndrome. However, there is no evidence that it is effective for relieving menopausal symptoms.
St. John’s wort
St. John’s wort is a popular herbal remedy for treatment of depression related to menopausal symptoms. Based on results from some studies, combining St. John’s wort with black cohosh helps relieve symptoms of menopause. However, it is unknown if this benefit is due to St. John’s wort alone or the combination with black cohosh. The most commonly reported adverse effects include nausea, dry mouth, headache, and skin reactions. St. John’s worth interacts with many drugs. More research is needed to find out if St. John’s wort by itself can reduce menopausal symptoms.
Although these herbal products are the most commonly used for relieving menopausal symptoms, they should be used with caution since long-term safety and efficacy are not proven for these agents. Some herbs may interact with other medications. Inform your doctor and pharmacist before taking them. Keep in mind that these remedies should be used for a limited period of time. If a problem persists, you should get medical care right away.
Newton KM, Buist DS, Keenan NL, et al. Use of alternative therapies for menopause symptoms: results of a population-based survey. Obstet Gynecol 2002; 100:18.
Keenan NL, Mark S, Fugh-Berman A, et al. Severity of menopausal symptoms and use of both conventional and complementary/alternative therapies. Menopause 2003; 10:507.
Verhoeven MO, van der Mooren MJ, van de Weijer PH, et al. Effect of a combination of isoflavones and Actaea racemosa Linnaeus on climacteric symptoms in healthy symptomatic perimenopausal women: a 12-week randomized, placebo-controlled, double-blind study. Menopause 2005; 12:412.
Chenoy R, Hussain S, Tayob Y, et al. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ 1994; 308:501.
Nedrow A, Miller J, Walker M, et al. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006; 166:1453.
North American Menopause Society. Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. Menopause 2004; 11:11.
Harrell T, Low AK. Chapter 29. Menopausal Hormone Therapy. In: Linn WD, Wofford MR, O'Keefe M, Posey L. eds. Pharmacotherapy in Primary Care. New York: McGraw-Hill; 2009. Accessed March 08, 2014.
Hung OL. Chapter 43. Herbal Preparations. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. eds. Goldfrank's Toxicologic Emergencies, 9e. New York: McGraw-Hill; 2011. Accessed March 04, 2014.
Kalantaridou SN, Dang DK, Davis SR. Chapter 91. Hormone Therapy in Women. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 8e. New York: McGraw-Hill; 2011. Accessed March 06, 2014.
William F Crowley. Uptodate. Menopause. Accessed March 09, 2014.