Menopausal Symptoms and CAM

Menopause is the permanent end of a woman's menstrual periods. Menopause can occur naturally or be caused by surgery, chemotherapy, or radiation. Many women use complementary and alternative medicine (CAM) for menopausal symptoms.
This fact sheet is based on findings from a 2005 National Institutes of Health (NIH) State-of-the-Science conference on the management of menopause-related symptoms. To find out more about topics and resources mentioned in this fact sheet, see For More Information.

Key Points

• Some symptoms commonly seen as menopausal may be related to aging in general.
• Menopause is a normal part of aging and should not be viewed as a disease.
• There is very little high-quality scientific evidence about the effectiveness and long-term safety of CAM therapies for menopausal symptoms. More research is needed.
• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Menopause

A woman is said to have completed natural menopause when she has not had a period for 12 consecutive months. For American women, this typically happens at around age 51 or 52. Menopause occurs immediately if the uterus or both ovaries are surgically removed, or if the ovaries are damaged in cancer treatment with radiation therapy or certain drugs.

Common Symptoms During the Menopausal Transition

Some symptoms that women experience are related to menopause and decreased activity of the ovaries. Others may be related to aging in general.

Scientific evidence of a link to menopause is strongest for the following symptoms:

• Hot flashes and night sweats (also called vasomotor symptoms, because they involve the expansion of the blood vessels)
• Sleep difficulties
• Vaginal dryness, which can lead to painful intercourse and other sexual problems

It is not certain whether the following symptoms are due to menopause, other factors that can come with aging, or a combination of menopause and these factors:

• Problems in thinking or in remembering things
• Urinary incontinence
• Physical complaints, such as tiredness and stiff or painful joints
• Changes in mood, such as depression, anxiety, and/or irritability.

The expert panel assembled for the NIH State-of-the-Science conference noted that menopause is a normal part of women's aging and advised that menopause should not be "medicalized" (or viewed as a disease).

Hormone Replacement for Menopausal Symptoms

For decades, hormone replacement therapy (HRT)—more recently known as menopausal hormone therapy (MHT)—was conventional medicine's main treatment for menopausal symptoms. In 2002, findings from a large study called the Women's Health Initiative raised serious concerns about the long-term safety of MHT. These concerns are one reason that many women are turning to CAM therapies.

What the Science Says About CAM Therapies for Menopausal Symptoms

The NIH State-of-the-Science conference panel discussed the evidence on several CAM therapies:

• Six botanicals—black cohosh, dong quai root, ginseng, kava, red clover, and soy
• DHEA (dehydroepiandrosterone), a dietary supplement.

Very little well-designed research has been done on CAM therapies for menopausal symptoms. A small number of studies have been published, but they have had limitations (such as the way the research was done or treatment periods that may not have been long enough). As a result, the findings from these studies are not strong enough for scientists to draw any conclusions. Also, many studies of botanicals have not used a standardized product (i.e., one that is chemically consistent). The National Center for Complementary and Alternative Medicine (NCCAM) is sponsoring a number of studies on botanicals using products that are both well characterized (i.e., their ingredients have been carefully studied) and well standardized and on other CAM therapies that have shown possible promise for reducing menopausal symptoms.

Because CAM products used for menopausal symptoms can have side effects and can interact with other botanicals or supplements or with drugs, research in this area is addressing safety as well as efficacy. Some findings from this research are highlighted below.

Botanicals

• Black cohosh (Actaea racemosa, Cimicifuga racemosa). This herb has received more scientific attention for its possible effects on menopausal symptoms than have other botanicals. Studies of its effectiveness in reducing hot flashes have had mixed results. A study funded by NCCAM and the National Institute on Aging found that black cohosh, whether used alone or with other botanicals, failed to relieve hot flashes and night sweats in postmenopausal women or those approaching menopause. Other research suggests that black cohosh does not act like estrogen, as once was thought.

United States Pharmacopeia experts suggest women should discontinue use of black cohosh and consult a health care practitioner if they have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice. There have been several case reports of hepatitis (inflammation of the liver), as well as liver failure, in women who were taking black cohosh. It is not known if black cohosh was responsible for these problems. Although these cases are very rare and the evidence is not definitive, scientists are concerned about the possible effects of black cohosh on the liver.

• Dong quai (Angelica sinensis). Only one randomized clinical study of dong quai has been done. The researchers did not find it to be useful in reducing hot flashes. Dong quai is known to interact with, and increase the activity in the body of, the blood-thinning medicine warfarin. This can lead to bleeding complications in women who take this medicine.
• Ginseng (Panax ginseng or Panax quinquefolius). The panel concluded that ginseng may help with some menopausal symptoms, such as mood symptoms and sleep disturbances, and with one's overall sense of well-being. However, it has not been found helpful for hot flashes.
• Kava (Piper methysticum). Kava may decrease anxiety, but there is no evidence that it decreases hot flashes. It is important to note that kava has been associated with liver disease. The FDA has issued a warning to patients and providers about kava because of its potential to damage the liver.
• Red clover (Trifolium pratense). The panel reported that five controlled studies found no consistent or conclusive evidence that red clover leaf extract reduces hot flashes. Clinical studies in women report few side effects, and no serious health problems have been discussed in the literature. However, there are some cautions. Some studies have raised concerns that red clover, which contains phytoestrogens, might have harmful effects on hormone-sensitive tissue (for example, in the breast and uterus). (See box below for more information on phytoestrogens.)
• Soy. The scientific literature includes both positive and negative results on soy extracts for hot flashes. When taken for short periods of time, soy extracts appear to have few if any serious side effects. However, long-term use of soy extracts has been associated with thickening of the lining of the uterus.

About Phytoestrogens

Some botanical products, such as soy and red clover, contain estrogen-like compounds called phytoestrogens. Plants rich in phytoestrogens may help relieve some symptoms of menopause. However, it is uncertain whether this relief comes from phytoestrogens or from other compounds in the plant. Much remains to be learned about these plant products, including exactly how they work in the human body. Doctors caution that certain women need to be particularly careful about using phytoestrogens, especially:

• Women who have had or are at increased risk for diseases or conditions that are affected by hormones, such as breast, uterine, or ovarian cancer; endometriosis; or uterine fibroids
• Women who are taking drugs that increase estrogen levels in the body, such as birth control pills; MHT; or a type of cancer drug called selective estrogen receptor modulators (SERMs), such as tamoxifen.

DHEA

DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. It is also manufactured and sold as a dietary supplement. A few small studies have suggested that DHEA might possibly have some benefit for hot flashes and decreased sexual arousal, although small randomized controlled trials have shown no benefit. Because levels of natural DHEA in the body decline with age, some people believe that taking a DHEA supplement can help treat or prevent conditions related to aging; however, there is no good scientific evidence to support this notion.

Concerns have been raised about whether DHEA is safe and effective. Its long-term effects, risks, and benefits have not been well studied, and scientists are not certain whether it might increase the risk for breast or prostate cancer. Before using DHEA for any purpose, people should talk to their health care provider about potential benefits and risks.

If You Are Considering CAM for Menopausal Symptoms

Although there is very little scientific evidence to support the effectiveness of CAM therapies for menopausal symptoms, it is possible that some CAM therapies may provide some relief to women during the menopausal transition. Here a few important points to keep in mind if you are considering these therapies:

• Tell your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.
• Keep in mind that although many dietary supplements (and some prescription drugs) come from natural sources, "natural" does not always mean "safe." For example, the herbs comfrey and kava can cause serious harm to the liver. Also, a manufacturer's use of the term "standardized" (or "verified" or "certified") does not necessarily guarantee product quality or consistency.
• Be aware that an herbal supplement may contain dozens of compounds and that its active ingredients may not be known. Researchers are studying many of these products in an effort to identify active ingredients and understand their effects in the body. Also consider the possibility that what's on the label may not be what's in the bottle. Analyses of dietary supplements sometimes find differences between labeled and actual ingredients.
  Women who are looking for alternatives to MHT should be aware that CAM therapies are not their only option. Certain lifestyle changes can contribute to healthy aging, including during the menopausal transition. For example, quitting smoking, eating a healthy diet, and exercising regularly have been shown to reduce the risks of heart disease and osteoporosis. The NIH State-of-the-Science conference report (see "Selected References") discusses several commonly used non-CAM interventions for relief of menopause-related symptoms.

NCCAM Research on CAM for Menopausal Symptoms

NCCAM supports a number of studies on CAM treatments (such as botanicals and mind-body practices) for menopausal symptoms, as do some of the other institutes and centers at NIH. Recent examples of NCCAM-funded projects include:

• An initiative to improve measures of hot flashes, which is expected to add to the understanding of hot flashes and to aid future clinical studies
• A study of whether black cohosh can help with the anxiety that may be experienced as a symptom of menopause
• A study to identify botanicals from Central America that have been used by the native population for menopausal symptoms and to develop and test standardized extracts from these plants
• Several studies looking at the effect of acupuncture on the recurrence and severity of hot flashes in postmenopausal women and others who may suffer from hot flashes, such as men being treated for prostate cancer
• A study to determine the effects of mindfulness-based stress reduction (a type of meditation) on hot flashes in menopausal women
• A study to understand how soy supplements might affect hot flashes and night sweats.
  In addition, NCCAM and other NIH components are cofunding an initiative to establish a network of research centers looking at potential new treatments for menopausal symptoms.

Selected References

National Heart, Lung, and Blood Institute. Facts About Menopausal Hormone Therapy. National Heart, Lung, and Blood Institute Web site. Accessed on May 1, 2007

National Institute  of Arthritis  and Musculoskeletal and Skin Diseases. Phytoestrogens and Bone Health. National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site. Accessed on May 1, 2007.

National Institute on Aging. Pills, Patches, and Shots: Can Hormones Prevent Aging?. National Institute on Aging Web site. Accessed on May 1, 2007.

National Institutes of Health. NIH State-of-the-Science Conference Statement on Management of Menopause-Related Symptoms. National Institutes of Health Web site ( PDF). Accessed on May 1, 2007.

National Women's Health Information Center. Menopause and Menopause Treatments. National Women's Health Information Center Web site. Accessed on May 1, 2007.