Some of my patients feel that the menopause is a natural part of a woman’s life and that this means that they should either not treat it or deal with it ‘naturally’. However, as with everything in medicine, you need to weigh up the risks, benefits and reasons for coming to a choice.
We could even start with whether or not the menopause is indeed natural, or a by-product of us living far longer than we previously have ever done. Perhaps it isn’t natural to live for 30 years or so after your periods have stopped? Breaking your leg can be natural, as can having a heart attack, but medical professionals would encourage you to have treatment for these as well.
However, I totally understand that many patients would like to try a natural approach, either in the first instance, or alongside other measures.
The importance of evidence
As a doctor, trained in Western medicine in the UK, I am not at all ‘anti’ complementary treatments or medicine. I practice what is known as ‘evidence-based medicine’, which is medicine where we have evidence of efficacy and safety. This isn’t always possible with herbal or complementary therapies. They may not be suitable for a randomised controlled trial, or there may not be the funding available for such trials to create the evidence that many medics are looking for.
But this doesn’t mean that they won’t work for you. Like most doctors, I support my patients in using complementary therapies, not alternative ones. This is because ‘complementary’ implies the two forms, both traditional Western medicine and the complementary medicine working together (or at the very least informing each other of what is being offered). ‘Alternative’ suggests closing down one avenue altogether.
If it works for you and is safe, then that is brilliant. We are all after the same aim – for you to be symptom-free, well and healthy.
Are ‘natural’ remedies safe?
In order to show evidence that a medication or remedy works, it needs to be statistically significantly more effective than a placebo, which essentially is a dummy medication which contains no active ingredient. The ‘placebo effect’ is real. Patients in studies into various health conditions, not just menopausal symptoms, report improvement in their symptoms when taking a placebo. The belief that the medication will work, makes it work.
If it works for you and is safe, then that is brilliant. We are all after the same aim – for you to be symptom-free, well and healthy.
Alternatively, it is possible that symptoms improve naturally with time, and this may also be relevant with regards to menopausal symptoms. But it may not even be possible to do a trial against placebo for some alternative remedies; for example, you would know if you had acupuncture or a massage-based treatment or not.
A word of warning: natural does not necessarily, or always, mean safe. We have obtained our medicines from plants for thousands of years; for example, aspirin comes from willow bark, digoxin from the foxglove plant and certain forms of HRT from yams. So although we may now make something synthetically, it can still be derived from a plant. This means that we know that plants and herbs are effective. But it also means that they can have risks and side effects when interacting with other medication. So if you are taking any herbal medication please do inform your doctor.
Follow the regulations
A second issue is around the regulation of herbal remedies. They have not previously had the same level of regulations as other medications. This means that you could not ensure that each pill or tea contained the same amount of the relevant herb.
There is now a regulatory system in place in the UK, the Traditional Herbal Medicine Scheme (THR). If you see the THR symbol on herbal medicine you know that it has been subject to stringent regulations. Each tablet contains what it says on the label, at the dosage stated on the label. The label should also list any potential side effects or interactions with other medications. As such it is safer to only use products which have been approved and regulated by the Traditional Herbal Medicine Scheme, with the THR logo/symbol on the label.
The power of phytoestrogens
Phytoestrogens are naturally occurring oestrogen-like compounds which are found in plants. As such it is thought that they can act like oestrogen in the body, and therefore may help with menopausal symptoms.
Women in countries where the diet is naturally high in phytoestrogens – found in foods such as soy beans, eaten commonly in Japan – seem to have fewer symptoms during the menopause, particularly vasomotor symptoms. They have lower rates of heart disease, and breast, womb and colon cancer. So it would appear that eating a diet rich in phytoestrogens could help stave off symptoms. It could also have a long-term beneficial health effect, though there may well be other factors involved in reducing symptoms.
It is safer to only use products which have been approved and regulated by the Traditional Herbal Medicine Scheme, with the THR logo/symbol on the label.
There is some evidence to show that phytoestrogens reduce hot flushes, though other evidence suggests little effect. Of the trials where efficacy was shown, the trials ran for only a few months so cannot comment on long-term effectiveness. What also isn’t known is whether this kind of diet needs to be eaten over your whole life, or at least a prolonged amount of time. It’s also not known if any long-term benefits can be obtained from eating them for a shorter period of time, or starting later, such as when symptoms start.
Where can I find phytoestrogens?
Supplements are available, or you can adapt your diet to increase the amount of phytoestrogens you eat. These are found in soybeans, soy products such as tempeh (though not soy sauce). Also, in some seeds and legumes such as linseeds, lentils and wheat berries, fruit and vegetables such as yams (from which we derive much of HRT), strawberries, beansprouts, tomatoes. How much and how often is not yet clear. In order to obtain significant amounts of phytoestrogens from your diet you would probably need to eat a lot of these foods, ensuring that you ate a variety of them. However there is no harm in trying these foods, as they are all healthy options.
Red clover is a herb which contains isoflavones, which are phytoestrogens. As such red clover is often marketed for treating hot flushes and menopausal symptoms. The evidence is mixed, with some studies showing benefits but many showing no effect. Women who have or have had breast cancer, are taking tamoxifen or have other hormone-dependent cancers such as womb cancer, should avoid phytoestrogen supplements including red clover. It is possible that they could have an effect on the cancer returning. More research is required.
A closer look at herbal remedies
Herbal remedies are those made from plants and are available in health food shops and pharmacies. Remember that we obtained many of our medications from plant sources so the fact that something is herbal, or natural, does not mean that it is safe. If they work it is because there is something in them. There are various herbal remedies which have been considered useful for menopausal symptoms which are discussed below.
Agnus castus – also known as chasteberry, agnus castus can be used as a tablet or a tincture (where the herb is dissolved in alcohol). It is used for multiple women’s health issues such as period pain, heavy periods and pre-menstrual syndrome. Although often promoted for use in the perimenopause and menopause, there is little data available regarding its effectiveness on specific menopausal symptoms.
Black cohosh – also known as Cimicifuga racemosa, bugbane, or black snake root, though it is a plant not a snake; the root of it is gnarled and black, so perhaps looks like a curled up black snake. It was traditionally used by Native Americans to help with labour and period pains. It seems to affect serotonin levels in the body, and we know that medications affecting serotonin can help with hot flushes but also mood changes. However, there is no evidence that it is effective for menopausal symptoms. There previously were concerns about liver toxicity with black cohosh but that is now thought to be related to contaminants in the products. High-quality extracts of black cohosh have not been shown to affect the liver. It is recommended to avoid them if you have active liver disease, or known liver damage.
The fact that something is herbal, or natural, does not mean that it is safe. If they work it is because there is something in them.
Sage – the herb sage, which you can grow in a pot on a window sill, is traditionally used to treat hot flushes. Commercial teas containing sage extract are available, though some people simply steep the leaves in hot water. Sage extract is also available as a tablet. Research is ongoing into the effectiveness of sage, but there is some evidence to suggest that sage supplements may help with hot flushes and sweats. Again, if you are taking tamoxifen your doctor may advise you to avoid sage. It can also be an issue with high blood pressure, as it may increase the blood pressure or interfere with high blood pressure medications.
Wild yam – this would seem to make the most common sense; if scientists manufacture HRT from yams why not just take yam extract supplements, or use a cream containing wild yams? But there isn’t evidence that this works; the body cannot break down the yam into the oestrogen and progesterone needed.
A few other herbal remedies
Other herbs are available which have been marketed for use in women’s health, though not always specifically for the relief of menopausal symptoms.
Evening primrose oil – useful and effective for breast pain and mood changes or mood swings related to PMS, so may help in the menopause for these symptoms. No evidence that it is useful for vasomotor symptoms. Can lead to skin rashes and nausea.
St John’s wort – also called Hypericum perforatum. Is effective for anxiety and depression, but interacts with many other medications such as the oral contraceptive pill and antidepressants. Please check with your pharmacist or doctor before starting. Also remember that the current guidance suggests that if anxiety or depression start during the perimenopause or menopause that antidepressants should not be given first line, but to consider HRT instead. So if this is extrapolated, St John’s wort should also not be given primarily to treat anxiety and depression which starts related to the menopause.
Ginkgo biloba – reputed to improve circulation and aid memory. Not proven to be effective in memory or concentration difficulties related to the menopause. Must not be taken with drugs which prevent blood clotting such as warfarin as it can increase their effects and increase the risk of bleeding.
Are complementary therapies worth it?
There are many forms of complementary therapies, involving massage, exercise and much more. Some complementary therapies which have been promoted as useful for menopausal symptoms are covered here. While it may be difficult to obtain evidence of efficacy for these treatments, they may well have added value in that they can be relaxing and reduce stress.
Indeed, the opportunity to talk to a professional for an hour about your symptoms and concerns can be helpful in itself. It may be that the why it works, or how it works is not as important as whether or not it works for you.
If it works for you, and it is safe, then you must do what helps you. Just please do always tell your doctor. Complementary medicine should be just that: complementary, running alongside Western medicine – or at the very least let us know.
What therapies can I try?
Traditional Chinese medicine – can involve a combination of herbal medicine, acupuncture, massage and exercise such as t’ai chi. Acupuncture is also used by medical doctors, for example to relieve pain, and involves inserting very fine needles into the body in specific places depending on the symptoms experienced. There is some evidence to suggest that acupuncture may help with hot flushes, but the latest study did not compare it to a placebo group (because this would not be possible with acupuncture; you know if you have had the needles inserted or not), though the study was promising.
Complementary medicine should be just that: complementary, running alongside Western medicine – or at the very least let us know.
Ayurveda – a traditional system of medicine from India, involving herbal remedies, diet changes, massage, meditation, yoga and exercise. There are some studies which show the benefits of yoga for menopausal symptoms such as insomnia, but again it is not possible to have a placebo-controlled trial, as you would be aware if you were practising yoga. You may find that massage and meditation are helpful to relieve stress and promote relaxation, which can be very helpful.
Magnet therapy – magnets are thought to promote healing and balance the nervous system. Some women report that wearing a magnet on their underwear reduces menopausal symptoms, though there is no evidence to support this finding.
Homeopathy – involves diluting a plant or herb, often one which has similar properties to the symptoms you may be having, to minute amounts. Many of the herbal products described above will be available as homeopathic remedies. There is no official evidence to support their use, but they are unlikely to cause harm.
Reflexology – involves massage to the feet, applying pressure on specific points thought to be related to or correspond to different body parts or bodily functions. Again, there is no traditional evidence that this is effective. It is very difficult to obtain a randomised controlled trial, since you will know if you have had a session of reflexology or not. Patients often describe reflexology as relaxing, which has its own benefits.
Aromatherapy – this involves using essential oils from plants, either in the bath or with massage. The practitioner chooses the oil or mix of oils depending on your symptoms. Lavender is thought to help with insomnia and sleep and chamomile and geranium to help with anxiety or to help you feel calm. There is little evidence of efficacy, but also little evidence of harm.
There are many complementary therapies available, and many claim that they improve menopausal symptoms. Remember that it can be difficult to carry out randomised controlled trials to prove efficacy for many complementary treatments.
If you are going to use a herbal remedy, look for the Traditional Herbal Registry (THR) mark to ensure that the product is regulated. And always inform your doctor of any herbal remedies or complementary therapies you are taking/having as there can be interactions with other medications.
Dr Philippe Kaye is the author of The M Word, Everything You Need to Know About The Menopause, £9.99, Amazon.com