Conversation with the Experts - Toward Optimal Health: Menopause as a Rite of Passage
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JOURNAL OF WOMEN’S HEALTH
Volume 17, Number 4, 2008
© Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2008.0816
Conversation with the Experts
Toward Optimal Health: Menopause as a Rite of Passage
JODI R. GODFREY, M.S., R.D., and TIERAONA LOW DOG, M.D.
Tieraona Low Dog, M.D., is Clinical Assistant Professor of Medicine and Director of Education for the Pro-
gram of Integrative Medicine at the University of Arizona College of Medicine in Tucson, Arizona. She is
chair of the United States Pharmacopoeia Dietary Supplements and Botanicals Expert Committee. Jodi R. God-
frey, M.S., R.D., is a health and wellness specialist in private practice and contributing editor to the Journal.
T WO THIRDS OF WOMEN may experience some
level of vasomotor symptoms, such as hot
flashes and night sweats in the years around the
sessed for HT use based on symptom status and
age rather than risk of heart disease, osteoporo-
sis, or memory status and support the growing
menopausal transition, but only a small number interest in and demand for symptom-relieving al-
will feel discomfort at a level that significantly di- ternatives.
minishes their quality of life (QoL).1,2 Even so, the A number of hormone-based and nonhor-
focus of scientific research and attention has been mone-based approaches have been identified for
directed to the one third of women whose meno- vasomotor symptom management, with varying
pause-related complaints are sufficient to war- degrees of success. Nearly half of women use
rant medical intervention, chiefly for hot flashes. some type of complementary or alternative med-
The results of the Women’s Health Initiative icine (CAM).6 Use is influenced by the number of
(WHI) in 2002,3 as well as more recent clinical tri- comorbidities and health behaviors, socioeco-
als, have raised questions about the safety and nomic status, symptom intensity, and age but not
efficacy of hormone therapy (HT), prompting wo- by menopausal symptoms. Given the number of
men to reconsider their use of hormone replace- midlife women who use CAM and the potential
ment to alleviate unwanted symptoms. The more for interactions with prescribed medications,
recent subanalysis of coronary calcification in the healthcare practitioners should inquire about
WHI suggests that starting HT earlier in a woman’s CAM use and be aware of what factors influence
life may have a protective effect against cardiovas- the use of different types of CAM.7 A discussion
cular disease (CVD).4 These results, however, did of these strategies for symptom management
not move the American Heart Association (AHA) should position clinicians to face the routine and
to change its recommendation for HT use, follow- persistent inquiries from women during their
ing the premise that the benefits of HT do not out- menopausal transitions.
weigh the overall risks, given the availability of bet-
ter medications for cardioprotection.5 With the increasing number of hormonal and
These trials were conducted to assess preven- nonhormonal treatments available to manage
tion of such chronic diseases as heart disease or menopausal symptoms, what are the most
cognitive decline, and it is difficult to discern a effective and beneficial remedies for
direct impact on menopause-related symptoms clinicians to recommend?
because change in vasomotor symptomatology
was not directly measured. The findings are a re- Before we can address interventions aimed at
minder to clinicians that women should be as- alleviating menopausal symptoms, let us take a
509510 CONVERSATION ABOUT THE MENOPAUSAL TRANSITION
step back. As clinicians, we should be challeng- take something that might increase their risk for
ing the larger paradigm—the expectation that breast cancer or stroke or damage their liver just
menopause must be managed. After all, women to avoid experiencing any symptoms. Women
face other major reproductive phases. Puberty, can be counseled to adjust lifestyle factors to ease
for example, is incredibly challenging and bothersome symptoms and consider intervention
fraught with significant physical and psycholog- only if the symptoms significantly impact the
ical changes imposed by fluctuating hormones. QoL. That said, it should be acknowledged that
This natural phase in every woman’s life (meno- symptoms can be intolerable for some women,
pause) has been medicalized, just as consumer and an array of options can be discussed to de-
advertising has fostered the need to have a pill to termine the optimal approach for each woman.
solve any physiological ailment, and women ex-
pect to have to manage their menopause rather
About two thirds of women can expect to face
than accepting it as a stage of life. Furthermore,
such menopausal symptoms as hot flashes,
30% of women never experience hot flashes. They
night sweats, and vaginal dryness, yet
just seem to slide right through menopause, yet
clinicians and their patients remain conflicted
this cohort is rarely studied to see what allows
about whether and when to use HT. How does
them to transition through the hormonal changes
the use of HT fit in the current paradigm of
of menopause without significant symptomatol-
menopause symptom management?
ogy. Why are clinicians not telling women that
this is not only possible but a reality for one of The vexing question that clinicians should be
three women? asking is why so many women are looking for
It is disturbing that the current message is that CAM options. The answer may lie in the over-
women believe they must consult an expert to get whelming desire of women to have some control
through this phase of life. Worse is the common over their lives, also, there is very little downside
expectation that there are solutions that will re- to CAM strategies, such as focused breathing
move all menopausal symptoms—hot flashes, (with a 40% reduction in frequency) to get
night sweats, vaginal dryness—while revving up through a hot flash—no cost, no side effects, and
the libido. no safety concerns.8–10
In cultures that revere age and respect their el- Although a subset of women may require
ders, women appear to experience less stress and symptom intervention, many women are seeking
anxiety as they pass through menopause. In this medical resolution to their symptoms based on a
country, however, youth is desired over aging recurring message that they have problems that
(even gracefully), causing a rush to Botulinum need to be medically managed, and they buy into
toxin (Botox Cosmetic, Allergan Inc., Irvine, CA) it. Given the 10–15 minutes allotted to patient vis-
and plastic surgery as a way to forestall that its, it is a lot easier for a clinician to pull out a
harsh, if inevitable, reality. Thus, it is no wonder prescription pad than it is to talk to women about
that American women face menopause and its these QoL issues, particularly wellness strategies
concomitant symptoms with dread, wanting to that fall outside the safe zone for most practi-
eliminate any discomfort even if it means taking tioners who are not trained in CAM. This is com-
HT for the rest of their lives. Clinicians should pounded by the “It takes one to know one” fac-
not be so cavalier, as the long-term consequences tor, in which exercise tends to be recommended
of taking HT for some 20, 30, or, 40, years are just by those who exercise, those who quit smoking
beginning to become known. tend to be much stronger advocates for smoking
Rather than assume that menopause is a med- cessation, and physicians who have a very
ical condition that must be managed, one must healthy diet tend to emphasize good nutrition
think of menopause as another transition that all practices. It would follow that physicians who
women go through. Such hormonal fluctuations meditate or go to a yoga class and have had a
that allow women to be connected to their bod- positive experience or see beneficial effects in
ies put them in touch with changing needs. Wo- their patients are more inclined to recommend
men do not have to do anything to get through these strategies.
the menopausal transition. It would be wonder- A clinician should begin by discussing the
ful for clinicians to reframe our approach and re- way lifestyle habits, such as diet, physical
sponses such that women do not feel they must activity, sleep hygiene, and stress can affectCONVERSATION ABOUT THE MENOPAUSAL TRANSITION 511
symptoms.8,10,11 Interestingly, a clinical study of formulation that works best for the individual pa-
Asian ginseng’s efficacy on hot flashes in women tient. Transdermal patch and intranasal delivery
found no difference in frequency of hot flashes of estrogen allows for direct absorption, bypass-
but did find improved QoL.12 Even as their hot ing the liver, and thereby enabling a lower dose
flashes continued, the women taking ginseng re- and fewer side effects. But all modes are effective
ported improved mood, more energy, and better and acceptable to many women.16
sleep quality than their counterparts taking a The greatest confusion for many practitioners
placebo. The results are more consistent with the comes from the emerging area of bioidentical hor-
historical and traditional uses of ginseng as an mones. It is not hard to fathom why women
adaptogen, that is, a botanical that promotes would ask for a hormone (17 beta-estradiol) with
physiological adjustment during times of stress which the body is familiar. The furor over
(i.e., increased hot flashes, irritability, or poor bioidenticals heated up over “the Suzanne
sleep). An adaptogen, such as ginseng, is proba- Somers effect,” a fallout of the self-promotion of
bly most relevant for women who are having four a Hollywood star whose books, Ageless and The
to six hot flashes daily rather than those who re- Sexy Years, hyped her youthful appearance, for
port having twenty or more. Another useful which she credited bioidentical hormones. Many
adaptogen, Rhodiola rosea (golden root), is more women are approaching their doctors for
commonly used to lessen cognitive deficits, such bioidentical hormones because they want to
as forgetfulness and irritability,13 and may work achieve the Somers success are more comfortable
well in women during their menopausal transi- taking an estrogen that is produced naturally in
tion. Regardless of hot flashes, these adaptogens the human body. For example, women are ask-
promote a feeling of well-being throughout the ing for such products as Bi-Est (a combination of
day. This is consistent with other lifestyle ap- two estrogens, estriol and estradiol) and Tri-Est
proaches, such as paced breathing, a technique (a combination of three estrogens: estriol, estra-
that focuses on deep, abdominal breathing, which diol, and estrone), which can be prepared by a
when initiated at the start of a hot flash, promotes compounding pharmacy. Clinicians should help
a sense of relaxation.8,9,14,15 The concept of proper patients understand that bioidentical hormones
breathing illustrates another example of how eas- are manufactured in the laboratory, the only dif-
ily simple remedies can achieve the necessary ference being that the molecular structure more
outcome without clinical intervention. It be- closely matches that found naturally in the body.
hooves women’s health practitioners to become It does not necessarily mean they are safer; in fact,
more familiar with Eastern types of exercise, such there are few safety data available for these com-
as yoga, Tai Chi, and Qi Gong, all of which in- pounded formulations. We should be mindful
clude a form of paced breathing. For many wo- that many women who develop breast cancer
men, these lifestyle methods are sufficient to get have never taken hormone supplements, which
them through the 1 or 2 transitional years in means that they have never been exposed to any
which menopausal symptoms are most bother- hormones other than those in their body. We can-
some. not assume that these products will not increase
the risk of breast cancer or stroke simply because
they are bioidentical.
Given the need to encourage clinicians to According to the North American Menopause
develop a clinical respect for the menopausal Society, custom compounds may provide certain
transition as a natural part of life, the benefits, such as individualized doses and mix-
question remains: Who can or should tures of products and forms that are not available
consider HT, and for how long is its use commercially.17 They may also pose risks because
reasonable? they have not been approved by the FDA and,
These are vexing clinical questions with no therefore, have not been tested for purity, po-
clear answers because of the conflicting data and tency, efficacy, or safety.
the variable needs of individual women. There is Clinicians should be aware that prescribing
nothing more effective than estrogen replacement bioidentical hormones does not necessitate the
to remediate hot flashes, because it alleviates va- need for salivary testing. Unlike thyroid hor-
somotor instability. Clinicians should use the mone, which has a specific therapeutic range, HT
lowest dose for the shortest duration and find the is given to manage symptoms, and there is no512 CONVERSATION ABOUT THE MENOPAUSAL TRANSITION
range for which to aim. The goal is to give only Botanicals are optimally used in the way that
enough to keep the patient comfortable during herbalists administer them—by blending a selec-
the 1–2 years of menopausal transition. There is tion of herbs that fit the patient based on individ-
no clinically justifiable reason to test estrogen or ual presentation and symptoms. Historically, black
progesterone levels, salivary or otherwise, for the cohosh was considered an anti-inflammatory
basic management of HT during menopause. agent, used to treat arthritis and aches and pains
In summary, regardless of the source of estro- as well as depression. Fifty years ago, its role in
gen and progesterone supplementation, the ex- menopause surfaced in Germany, but this is a rel-
pert guidelines—lowest dose, shortest dura- atively new use in the United States for this in-
tion—should be followed. digenous North American herb. Current research
suggests that black cohosh affects neurotransmit-
For the growing number of women who are ters, supporting its possible effectiveness as an an-
turning to botanicals for symptom tidepressant. Therefore, black cohosh may be most
management, what is the current evidence for effective for women who complain of muscu-
black cohosh and soy, the two most heavily loskeletal aches and pains or a depressed mood and
researched plant-based remedies/botanicals, poor sleep. Definitive studies and safety data are
which have dominated the literature and still needed, however.
received substantial consumer media attention
for relief of hot flashes? The use of selective serotonin reuptake
inhibitors (SSRIs) and serotonin-
Although there have been 14 placebo-controlled norepinephrine reuptake inhibitors (SNRIs)
clinical trials, the results on black cohosh have been has been suggested as a viable intervention
mixed, challenged by the use of different prepara- for menopausal symptoms. Is it appropriate to
tions and doses.9–11 The very small but growing use SSRIs or SNRIs to treat women in
number of case reports of liver damage may be a menopausal transition who have QoL issues
warning signal of a problem with black cohosh. At or specific symptoms, such as depressed
this time, it is unclear if there is a relationship be- mood or hot flashes?
tween black cohosh and hepatotoxicity or if hepa-
totoxicity is due to the presence of other species Women can struggle with QoL issues just as
(e.g., Asian) of black cohosh or other adulterants in readily at age 35 as at age 65, meaning symptoms
products. Because it appears that there may be a are not necessarily related to menopause. Essen-
rare risk of trouble, however, Canada, Australia, tially, anything and everything that does not feel
and several European countries have mandated a right has been linked to hormonal fluctuations.
cautionary statement on black cohosh product la- We must be careful not to make every emotion
bels. Similarly, the U.S. Pharmacopeia now recom- or physical symptom experienced by women be-
mends that companies in the United States do the tween the ages of 45 and 60 a menopause-related
same so that women will be aware that certain problem. After all, it is a period of life during
symptoms, such as dark urine and abdominal pain, which a great many stresses and responsibilities
should lead to prompt discontinuation and imme- exist within the context of daily living. Although
diate medical attention. there is modest evidence of efficacy of SSRI/
The longest clinical trial, the Herbal Alternatives SNRIs, generalizability is limited.8,20 Given the
for Menopause (HALT) study, that lasted 12 adverse effects and cost, these therapies may be
months, failed to show any benefit in reducing hot most useful for highly symptomatic women who
flashes among those women taking black cohosh.18 cannot take estrogen.
There were some confounding variables in the
study, however, including the cessation of the From WHI findings, we know that there are
WHI, which affected some women who were in- woman’s health risks after 5 years on
cluded in both studies. Additionally, independent continuous HT, but are there benefits for any
analysis of the combination formula that was used woman to stay on HT indefinitely?
in one treatment arm of HALT failed to find three Women should consider the fact that taking a
herbs that were purported to be in the preparation. naturally imposed hormone break, as occurs dur-
Black cohosh appears effective for some women in ing pregnancy or nursing, may offer protection
early menopause who exhibit severe symptoms.19 against breast cancer. Although long-term HT isCONVERSATION ABOUT THE MENOPAUSAL TRANSITION 513
not advisable, clinicians can only present the facts ical trials for hot flashes are mixed, but the data
as they understand them to insistent patients. There support its safety.8 St. John’s wort alone and in
is a small minority of women who may suffer with combination with black cohosh has also been
hot flashes and night sweats for up to 15 years af- shown to reduce hot flashes.8 St. John’s wort is
ter menopause. These women may need to use HT now in a phase II clinical trial at the National Can-
for a significant length of time. For most women, cer Institute (NCI) for women with breast cancer
however, the symptoms that prompted medical in- who are experiencing hot flashes. Other herbs
tervention will taper off within 1–2 years, elimi- that appear useful include hops, damiana, valer-
nating the need for HT. Not knowing the length of ian, and maca.1,8,9,24
time hot flashes will remain severe is another rea-
son for limited duration prescribing of any course
of therapy (be it HT or botanicals) for easing un- ADDITIONAL RESOURCES
manageable symptoms during menopause.
Low Dog T, Micozzi MS. Women’s health in comple-
The data on soy remain controversial and mentary and integrative medicine: A clinical guide.
elusive. However, it is popular and New York: Elsevier, 2004.
Marini H, Minutoli L, Polito F, et al. Effects of the phy-
convenient. How much must be taken to
toestrogen genistein on bone metabolism in osteopenic
achieve a reduction in hot flashes? postmenopausal women: A randomized trial. Ann In-
Recent studies show that reduction in hot tern Med 2007;146:839. Summary for patients. 2007;
flashes is significantly related to baseline hot flash 146:I34.
National Institutes of Health. State-of-the-Science Confer-
rate and the dose and ratio of isoflavones stud-
ence on Management of Menopause-Related Symptoms.
ied.8,21 Even more than this, the effectiveness of March 21–23, 2005, Bethesda, Maryland. Available at
soy for hot flashes may be related to women be- consensus.nih.gov/2005/2005MenopausalSymptoms
ing equol converters. When nonfermented soy is SOS025Program.pdf
eaten, the isoflavone diazin must first be con- Newton KM, Reed SD, LaCroix AZ, et al. Treatment of
verted to daidzein and then to equol, which is the vasomotor symptoms of menopause with black cohosh,
most potent form of phytoestrogen derived from multibotanicals, soy, hormone therapy, or placebo: A
randomized trial. Ann Intern Med 2006;145:869.
soy. This conversion is dependent on the type of
intestinal microflora present, however, and only
a third of people in the Western hemisphere ap-
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2000;96:906. E-mail: jgodfrey31@verizon.netYou can also read
