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For other articles and previous issues click here. December 5, 2005 Natural
Passage Through Menopause Menopause is a natural occurrence in the female life cycle. With certain dietary and lifestyle changes, could most women avoid hormone replacement therapy? Navigating through major milestones in life can be both challenging and liberating. However, women frequently describe the journey through menopause in more colorful terms. Because each woman is unique, her experience of menopause is manifold, as are the treatments and lifestyle adjustments chosen to ease the transition into this life phase. As the true risks and benefits of pharmaceutical hormone replacement therapy are increasingly questioned, many women are looking to plant sources of estrogen for support as well as diet and lifestyle change. There is also a tendency for individuals seeking natural remedies to view menopause not as a disease but as a natural transition offering women the chance to reassess and potentially change their lives. Physical
Changes During perimenopause, progesterone production decreases gradually while estrogen levels remain the same or increase. This allows estrogen to rise unopposed, or unbalanced by, progesterone. The result is a relative estrogen excess—often called estrogen dominance. Symptoms of estrogen excess, including depression, bloating, headache, and weight gain can occur at this time.1 As progesterone continues to decline, symptoms of progesterone deficiency, including premenstrual syndrome-like symptoms, irregular or heavy periods, and anxiety, often predominate.1 Follicle stimulating hormone (FSH) and leutinizing hormone (LH) levels become erratic as the ovaries begin to skip ovulations. As a woman comes closer to menopause, FSH and LH levels start to smooth out and climb to their highest level, where they remain. At the same time, estrogen levels begin to drop. Symptoms of estrogen deficiency (augmented by rising levels of FSH) include hot flashes, night sweats, vaginal dryness, irritability, depression, mental fuzziness, and decreased libido.1 As women enter menopause, the production of estrogen in the ovaries slows. Estradiol, the most potent form of estrogen, is produced primarily in the ovaries. During menopause, levels of estradiol decrease and a less potent form, estrone, becomes more prominent. Estrone is produced primarily in the adrenal glands and fat tissue. Whether there is adequate
production to ease a woman’s transition through menopause
depends on what else is going on in her life. Stress, poor diet,
smoking, alcohol, physical illness, and emotional issues can impede
the natural production of hormones in other tissues.1 The result
can be a tumultuous mid-life transition. She recommends eliminating stimulating foods such as hot spices, sugar, caffeine, beef, and alcohol to diminish the frequency and duration of hot flashes. She also notes that regular aerobic exercise helps diminish the severity of hot flashes as well as helping prevent weight gain, mood swings, and insulin resistance. To further reduce insulin resistance and stimulate weight loss, she advocates a moderately low-carbohydrate diet and small, frequent meals featuring lean proteins and foods with a low glycemic index. This diet and meal pattern may also reduce carbohydrate cravings and mood swings. Certain nutrient supplements may be useful during menopause. For example, vitamin E may reduce the frequency and severity of mood swings and hot flashes and may prevent vaginal dryness.1,2 Daily supplementation of vitamin C with hesperidin, a bioflavonoid from citrus fruit, can moderate hot flashes by improving vascular integrity and reducing capillary permeability.1,2 Ferulic acid, a component of grains, seeds, and the herb dong quai, effectively reduces the severity of hot flashes and other menopausal symptoms.3,4 Calcium and magnesium are also recommended to protect against osteoporosis, hypertension, and heart disease.1 Vitamin D can help protect against osteoporosis and possibly breast cancer.1 Chromium may help increase insulin sensitivity, while daily supplementation with omega-3 fatty acids can promote the production of anti-inflammatory prostaglandins that prevent headache, menstrual cramps, and possibly hot flashes.1,2 In general, studies
find that nutritional supplements help reduce menopausal symptoms
slightly better than placebo. Their effectiveness probably varies
due to individual differences in diet and lifestyle as well as the
length of the study period. Like many herbal remedies, nutritional
supplements may take time to show any effect and most long-term
benefits from nutrition therapy still seem to result from dietary
changes, not supplement use alone.5 Botanical estrogens are structurally similar to the estrogens produced in the body, and they appear to moderate the cancer-causing effects of more potent endogenous estrogens.2 Estradiol and estrone, two of the endogenous estrogens, are highly active and pose a strong risk for breast cancer. Plant estrogens will compete with estrone and estradiol for receptors in breast and uterine tissue, thereby blocking their action and protecting these tissues from cancer.7 On the other hand, phytoestrogens will augment and supplement the beneficial action of endogenous estrogens on the bone and vasculature, thus helping prevent osteoporosis, heart disease, and hot flashes.1,6-9 Their action, in fact, is similar to the class of drugs called selective estrogen receptor modulators (SERMs). These drugs, including tamoxifen and raloxifene, have a positive estrogenic effect on bone but have an antiestrogenic effect on breast and uterine tissue. They help prevent osteoporosis but do not promote cancer in estrogen-sensitive tissues, though their long-term safety has not yet been determined.11,12 Phytoestrogens, with actions similar to SERMs, seem to pose no long-term risks when taken in whole foods in moderate amounts. Of the dietary phytoestrogens, isoflavones exhibit estrogen receptor binding capacity, whereas lignans and coumestans do not.7 Most practitioners, including Guiltinan, do not advocate the use of isoflavones or large amounts of soy foods to protect against breast cancer. Studies have shown a protective effect in Asian populations with high dietary intakes of soy, but the studies also suggest that the intake of isoflavones needs to be high during preadolescence and adolescence to yield protective effects.13 Other studies have found a potential protective effect against many types of cancer, including breast, prostate, and lung, but caution is still usually expressed for women with a personal or family history of breast cancer.14 Phytoestrogens may also reduce the duration, frequency, and severity of hot flashes as well as protecting individuals from cardiovascular disease and osteoporosis. Recommended intakes for reducing hot flashes are from 45 to 160 milligrams of isoflavones per day (10 to 30 grams soy protein).1,2,7 Cardiovascular risk reduction, defined by lowered low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglycerides, as well as reduced aortic stiffness and antioxidant protection for LDL cholesterol, begins at intakes as low as 1 milligram per day of phytoestrogens (isoflavones as well as lignans).3,4 Protection from osteoporosis appears possible at intakes of 90 milligrams of isoflavones or 40 grams of soy protein per day, though researchers call for more studies and believe it takes at least one year for any noticeable changes in bone mineral density to occur at these intake levels.8 Emotional
Health and Menopause In her book The Wisdom of Menopause, Christiane Northrup, MD, begins with this description of menopause: “It is no secret that relationship crises are a common side effect of menopause. Usually this is attributed to the crazy-making effects of the hormonal shifts occurring in a woman’s body at this time of transition. What is rarely acknowledged or understood is that as these hormone-driven changes affect the brain, they give a woman a sharper eye for inequity and injustice, and a voice that insists on speaking up about them. In other words, they give her a kind of wisdom—and the courage to voice it. As the vision-obscuring veil created by the hormones of reproduction begins to lift, a woman’s youthful fire and spirit are often rekindled, together with long-sublimated desires and creative drives. Midlife fuels those drives with a volcanic energy that demands an outlet.”1 Northrup goes on to describe how most women in their reproductive years put aside their own needs and desires to support others—a role actually assisted by the reproductive hormones they produce. As hormone levels shift, needs that have been set aside, suppressed memories, and even anger can resurface. This can result in changed relationships and careers, divorce, emotional liberation, or, if left unaddressed, health crises. Looking at symptoms of menopause with an eye for imbalance in one’s physical and emotional state, however, can be illuminating and lead to positive life changes. Guiltinan also considers the impact society has on a woman’s passage through menopause. She has observed that women in cultures where value is placed on things other than youth and beauty report few to no menopausal symptoms. The emotional impact of menopause is one of the first things she addresses with patients. She finds that women with a positive view of their lives and of their own value often pass through menopause with less difficulty than women who see themselves as losing their youth, beauty, and potential. On a physical level, the effects of stress and negative emotions can be measured and can influence health during menopause. Thoughts and perceptions are transferred through the sympathetic nervous system and translated to the rest of the body by hormones. The primary hormonal messengers of the sympathetic nervous system are epinephrine and norepinephrine. These adrenal hormones cause heart rate, blood glucose, and blood pressure to rise. When they are elevated, digestion is put on hold and decisions are made from more primitive areas of the brain. Elevated levels of these hormones also cause cortisol levels to rise. Chronically elevated cortisol levels can produce weakened bones, thinned skin, insulin resistance, weight gain, fluid retention, and depression. Cortisol levels normally drop at midnight and rise at dawn. Stress can invert this balance, causing cortisol to be higher at night, thus impairing restful sleep, and lower in the morning, making it difficult to awaken and start the day. Stress can also lead to decreased production of progesterone, one of the body’s natural calming agents.1 Time
for Change Guiltinan describes her treatment approach as being akin to a ladder: She begins with simple diet and lifestyle changes, adding other treatments as needed. As a last resort, she will prescribe hormone replacement therapy. She emphasizes the importance of emotional support and always begins treatment at that level. Certainly, if a woman is at high risk for heart disease or osteoporosis, pharmaceutical treatment may help prevent the onset of these diseases after menopause. For many others, dietary and lifestyle change, as well as some healthy self-awareness, may be all that is needed to experience menopause in a positive fashion. — Rita E. Carey, MS, RD, CDE, is on staff at Yavapai Regional Medical Center in Prescott, Ariz.
2. Philp HA. Hot flashes—a review of the literature on alternative and complementary treatment approaches. Alt Med Rev . 2003;8:284-302. 3. Murase Y, Iishima H. Clinical studies of oral administration of gamma-oryzanol on climacteric complaints and its syndrome. Obstet Gynecol Pract. 1963;12:147-149. 4. Ishihara M. Effect of gamma-oryzanol on serum lipid peroxide level and clinical symptoms of patients with climacteric symptoms. Asia Oceania J Obstet Gynecol. 1984;10:317-323. 5. Lichtenstein AH, Russell RM. Essential nutrients: Food or supplements? Where should the emphasis be? JAMA. 2005;294:351-358. 6. Shandler N. Estrogen. The Natural Way. Villard; 1997. 7. Keinan-Boker L, van Der Schouw YT, Grobbee DE, et al. Dietary phytoestrogens and breast cancer risk. Am J Clin Nutr. 2004;79:282-8. 8. Arjmandi BH. The role of phytoestrogens in the prevention and treatment of osteoporosis in ovarian hormone deficiency. J Am Coll Nutr. 2001;20:298S-402S. 9. Van der Schouw YT, et al. Higher than usual dietary intake of phytoestrogens is associated with lower aortic stiffness in postmenopausal women. Arterioscler Thromb Vasc Biol. 2002;22:1316-1322. 10. de Klein MJJ, van der Schouw YT, Wilson P, et al. Dietary intake of phytoestrogens is associated with a favorable metabolic cardiovascular risk profile in postmenopausal U.S. women: The Framingham study. American Society for Nutritional Sciences, 2002. 11. Cummings SR, Eckert S, Krueger KA, et al. The effect of raloxifene on risk of breast cancer in postmenopausal women. JAMA. 1999;281:2189-2197. 12. Willet WC, et al. Postmenopausal estrogens-opposed, unopposed, or none of the above. JAMA. 2000;283:534-535. 13. Shu XO, Jin F, Dai Q, et al. Soyfood intake during adolescence and subsequent risk of breast cancer among Chinese women. Cancer Epidemiol Biomarkers Prev. 2001;10:483-8. 14. Schabat MB, et al.
Dietary phytoestrogens and lung cancer risk. JAMA. 2005;294:1493-1504.
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