Black Cohosh

Hot flashes, mood swings, and sexual discomfort are just a few of the troublesome symptoms of menopause. The staple medical method of combating “the change” has been hormone replacement therapy (HRT). Recent studies, however, show that lately there has been a significant decrease in HRT use in favor of other drugs and supplements.

Results of an Australian study in Climacteric, the journal of the International Menopause Society (IMS), showed that 22% of women over 50 used HRT in 2000. As early as 2002, however, the Bethesda, Maryland-based National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, began reporting about possible cardiovascular and cancer risks associated with HRT, and by 2008 that number dropped to 11.8%. Researchers also found that the use of alternative medicine was rare until 2008, when 25% of women 50 and over were found trying nontraditional therapies.

Benefits vs. risks

According to the NHLBI, taking HRT mainly relieves hot flashes, vaginal dryness, night sweats, and itchy skin. Other benefits of taking HRT include:

• Reduced risk of developing osteoporosis and reduced risk of bone breakage
• Improvement of mood and overall sense of mental well-being in some women
• Decreased tooth loss
• Lowered risk of colon cancer

Risks of taking HRT include:

• An increased risk of endometrial cancer
• Increased risk of blood clots and stroke
• Increased risk of heart disease

Side effects of taking HRT include:

• Monthly bleeding
• Irregular spotting
• Breast tenderness

Heart disease and HRT

NHLBI’s Women’s Health Initiative (WHI) has been doing an ongoing research project since 1991 on the effects of HRT. The first findings showed that women 50 and over who took the drug had an increased chance of heart disease. A second study then showed that women younger than 50 who took the drug had less chance of developing cardiac problems.

A more recent study published in 2008 by the Journal of the American Medical Association reported on WHI participants after they stopped HRT. Researchers found that some health risks–including heart disease–diminished, but overall, the risks for stroke, blood clots, and cancer remained high.

Alternative Methods

Black Cohosh and Red Clover

Alternative methods like the botanicals black cohosh and red clover are not favorites among doctors.

“I don’t recommend the use of botanicals because they have not been shown to be very effective in controlling menopausal symptoms,” said Wyatt McNeill, M.D., associate professor of obstetrics and gynecology (ob/gyn) at the University of Florida (UF) College of Medicine in Jacksonville. “They are not subject to FDA [U.S. Food and Drug Administration] scrutiny and the companies that distribute these products are free to market them using claims of benefits that have not been documented by randomized trials.”

“Unfortunately,” added Andrew Kaunitz, M.D., professor and associate chairman of ob/gyn at UF, “botanicals including black cohosh and red clover have not been consistently found more effective than placebo.”

According the Drug and Therapeutics Bulletin, there were two key studies done on the subject; one compared HRT, black cohosh, red clover, and a placebo for the degree of relief they provide for the discomfort of hot flashes. After 12 days it was reported that hot flashes were decreased when black cohosh was used by 12%, red clover by 57%, HRT by 94%, and the placebo by 63%.

The second study compared the same remedies for verbal and memory functions. Researchers found that none of the botanicals had any effect, good or bad, on memory. However, the HRT drug Premro had a slight negative effect on memory.

Soy 

“Soy may be a more natural alternative,” said Todd Winters, Ph.D., a professor specializing in reproductive and nutritional endocrinology at Southern Illinois University in Carbondale. “Soy products contain weak estrogens called isoflavones or phytoestrogens. These natural chemicals are known to alleviate many of the negative side effects of menopause, without some of the negative side effects of HRT.”

In addition to alleviating negative menopausal effects, Dr. Winters said soy also has been shown to help prevent cardiovascular disease, diabetes, and certain types of cancer. “Although protective against breast cancer, soy can exacerbate breast tumors in women who already have the disease—a two edged sword,” said Dr. Winters.

Vaginal estrogen

Dr. Kaunitz said that vaginal estrogen (available in tablet, ring, or cream form) can be very useful to treat vaginal dryness and sexual discomfort associated with menopausal changes. Estrogen also prevents loss of bone density and osteoporosis in menopausal women, according to a study published in July 1997 in the American Journal of Obstetrics and Gynecology. 

Vaginal estrogen may be used by women with liver or gallbladder disease, for whom oral estrogen is not recommended.

Biophosphates and SERMs 

According to the American College of Obstetricians and Gynecologists, if a woman does not take HRT, there are other options for preventing bone loss, such as bisphosphonates or selective estrogen receptor modulators (SERMs).  

Another option is addition of the hormone calcitonin, which slows the breaking down of bone. It can be given by injection or nasal spray.

Also, bisphosphonates can be used to increase bone density and reduce the risk of fractures. Parathyroid hormone is also used for this purpose.

The SERM tamoxifen is sometimes prescribed to women as part of the treatment of breast cancer, according to Dr. Kaunitz. In women at high risk for breast cancer, tamoxifen can be prescribed as a preventative. Raloxifene is sometimes prescribed either to prevent osteoporosis or (in high-risk women) or to prevent breast cancer. “Unlike estrogen, neither of these SERMs treats hot flashes,” noted Dr. Kaunitz. “In fact, both SERMs have the potential to cause them.”

HRT contraindicated

Dr. McNeill said woman who should not take HRT are those who have:

• ●had estrogen dependent tumors, such as breast cancer;
• ●lung cancer;
• ●active liver disease;
• ●a history of a venous thromboembolism (blood clot);
• ●cardiovascular disease/stroke and coronary artery disease;
• ●been diagnosed as morbidly obese;
• ●undiagnosed abnormal vaginal bleeding; and/or
• ●inherited tendencies to form deep vein thrombosis, such as Leiden Factor V mutations.

Tailoring treatment

“Hormone therapy should not be prescribed just because a woman is menopausal,” Dr. Kaunitz said. “However, hormonal therapy is appropriate to address specific symptoms.”

Adjusting either the dosage or the form of the medication often can reduce side effects of HRT.

Dr. Winters said every woman must weigh the benefits vs. the risks. “In all cases, although elevated above someone who doesn’t take HRT, the risks of cancer and cardiovascular problems with HRT are still low,” he assured.

“That said, the shorter period of time a woman is on HRT the better,” he said, suggesting a woman may want to take HRT for a few years while she is transitioning through menopause and then “wean” herself off the HRT under a doctor’s supervision.

“It is natural for a woman’s body to undergo menopause,” concluded Dr. Winters. “Any pharmaceutical a person may take may have side effects. Each woman must have discussions with her doctor about the best strategy for her.”

–Jennifer Nunez

 Resources:

• American College of Obstetricians and Gynecologists: http://www.acog.org/
• American Journal of Obstetrics and Gynecology: http://www.ajog.org/
• Climacteric: http://www.imsociety.org 
• Drug and Therapeutics Bulletin: http://dtb.bmj.com/
• Journal of the American Medical Association: http://jama.ama-assn.org/ 
• Dr. Andrew Kaunitz: http://www.hscj.ufl.edu/obgyn/bio.asp?id=948
• Dr. Wyatt McNeill: http://www.hscj.ufl.edu/obgyn/bio.asp?id=1016
• Sciencedaily, com
• Dr. Todd Winters: http://coas.siu.edu/default2.asp?active_page_id=1435
• Women’s Health Initiative: http://www.nhlbi.nih.gov/whi/