Webinar Forum: Botanicals and Menopause

On October 14, 2008, Maida Taylor, MD, MPH, FACOG, presented a webinar on botanicals and menopause.

Taylor discussed some of the most popular natural products used to treat menopausal symptoms such as hot flashes and vaginal dryness. She clearly explained the available evidence for various products, including soy, black cohosh, red clover, ginseng and belladonna. A recording of this webinar is available at www.naturalstandard.com.

Taylor’s webinar is one of many upcoming complimentary webinars on integrative medicine. The next webinar, presented by Natural Standard Chief Editor Catherine Ulbricht, PharmD, on October 28 from 3 p.m. to 4 p.m. Eastern Time, will provide a general overview of the database. Whether you are new to Natural Standard or a recurrent subscriber, Ulbricht will help you understand the functionality of the database, so you can take advantage of all that Natural Standard has to offer. To participate in the next webinar, please click here and call: (616) 883-8055, access code 386-478-732

Natural Standard values the opinions and views of its readers and welcomes feedback and questions about the latest webinar event. Also, if you have any suggestions for future webinar topics, please leave a comment below or send an e-mail to questions@naturalstandard.com.

Comments

[rachel]

Women going through menopause are dealing with a lot of physical and emotional stress. On top of that, their treatments can cause more distress. Because of the side effects of traditional hormonal therapy, more women seek “natural” solutions such as botanicals. Dr. Taylor discussed that some botanicals don’t have impressive data and brings up a good point, which is -- we cannot make direct comparisons between each botanical and HRT because in each trial, not the same parameters were used.

I also appreciated the quote at the end because I am for what works. If it [any mode of therapy] is proved to show benefits with minimal risks, then it is medicine, not an alternative. After all, medicine is that art of restoring health, whether it be by drugs, surgery or meditation.

[Regina Windsor]

First of all, that was a really great seminar! Thank you so much Dr. Taylor, and to the Natural Standard staff who made this happen.

A few comments for Dr. Taylor. The use of references was great, and I look forward to reading some of the studies that you cited to see how the groups were randomized, how the data were stratified and so on. And kudos to you for bringing up the German study (per black cohosh) as an example of how a study can be cited 'ad nauseum' without anyone going back to check how the study was designed in the first place. Just a thought, and coming from somewhat of a 'languages' background, I wonder how the translation and/or how who is translating the study (or any study from another country, for that matter) affects our (i.e. as the non-native speakers) perception of the information.

I also really enjoyed learning more about the biochemical mechanisms that govern the interactions between the botanicals and the body.

I also agree that standardizing protocol for botanical trials is a good idea. I cautiously wonder if that would be possible to implement, not only on a national level, but also on an international scale, since there seems to be many studies conducted abroad that might provide further knowledge. Are there such standards for botanical trials in other countries?

I am also fascinated by this chickpea versus soy conundrum and how one hears so much about soy because there is a soy lobby.

And a few queries for Dr. Taylor, for nothing more than my own personal edification. One of my favorite classes in my MPH program was a Human Population Genetic Theory course (essentially Epigenetics). During your presentation, I was interested to hear a mention of any possible genetic mechanisms and/or comparing how two or more populations process botanicals or nutrients (such as those that are in soy). After the red clover section, you brought up the issue of why we are seeing the results that we see from these studies and mentioned (per the Kreijkamp-Kaspers, et al. study) that the intestinal flora might be different in (I believe it was) Caucasian women (that there was generally only 30-40% of the necessary intestinal flora). Fascinating!

Now a few questions. I profess my ignorance as to the process of testing for intestinal flora. Is the flora stable over long periods of time? What might affect it (antibiotics come to mind)? And related to the prior questions, could this reduced flora be due to diet, genetics or some combination of both? Did they sample only Northern European women in the Kreijkamp-Kaspers, et al. study, and if so, is that sample of women necessarily comparable to the women (culturally – i.e.
lifestyle, what they eat - genetically, etc) who took part in any of the studies in the US? (I should probably just go and read the study :-))

Per the Ginseng section of your presentation -- at the beginning, you referred to a study about the elderly, vaccinations and ginseng use (I believe), but I don't think I caught which study that was in reference to. You also mentioned that Russian Olympiads used Siberian ginseng for performance enhancement. Is there actual evidence of this?

Also, concerning the kudzu root study -- you mentioned the type used in the study to which you referred was a different kind of kudzu from what is typically used in the West, I believe? Are there significant differences between the two kinds of kudzu that might impact their mechanisms of action? Not to be too reductionistic, but if we actually looked at the molecules of the main chemical components of the two different types, I am wondering how they would differ.

I hope not to bombard you with too many questions. I am just fascinated by all of this. Overall, I thought the presentation was thorough and informative, and again, I truly thank you for your time.

[tara s.]

Rachel, I agree with you about viewing therapies that work as medicines and not alternatives. I think people, including me, hesitate to see herbs and supplements as effective as other drugs and conventional medicine. If it works for you, then I don't see why you can't give it a try. This webinar looks interesting, and I hope future ones look into frequently used natural therapies for other common conditions.

[Carrie]

Does anyone know if black cohosh or other herbs can interact with hormone therapy? My aunt is currently on HT and really wants to take something else. I'm wondering whether she has to stop HT completely or if she can take herbs in addition to HT?

[Marcia]

I think the fact that there is research about the use of herbs for menopausal symptoms is great news! I have heard that hormone therapy, which is commonly used for menopausal symptoms, is not right for everyone. There are also possible risks such as stroke, blood clots and heart disease.

[Dan C.]

Since these herbal therapies are beginning to prove themselves to be effective through increased research, I hope this urges research to be conducted in a more standardized manner. This is the only way we will be able to compare results and move forward with herbal remedies.

[Sue C.]

It’s nice to hear more information about menopause and botanicals. I try to keep up with the news on this, and it’s certainly confusing. I’ve heard a few stories on NPR, some saying that the evidence points to zero effect from herbal remedies, and others say that herbs like black cohosh might help some but need more study, and can even be dangerous in certain circumstances and amounts. I gather it is particularly difficult to run studies that can clear this up, but we need the evidence to be fully informed. I’m also curious about whether any research has been done about links between using herbal treatments and cancer rates? Some research has shown that there’s been a drop in cancer rates because of a drop in the use of hormone therapy for menopausal symptoms.

[maxime]

Very informative seminar. I really enjoyed it. I now have a bit of information to tell my mom when she has questions for me regarding some of the herbs for menopausal symptoms.

[Rita]

It is hard to compare HRT with botanicals because data for botanicals are limited, and I come from an evidence-based medicine environment. As Dr. Taylor mentioned, the criteria, measurable variables and methods among these trials -- HRT and botanicals -- are all so different that it makes it impossible to compare them head-to-head. I am not against the idea of botanicals as a therapy for menopause, but anticipate new data. HRT is traditional and is that way for a very good reason.

[Maida Taylor]

Dear Gina,

1. Intestinal flora and metabolism of isoflavones and population variability -- see the following
For more detailed info see:

Flavonoids: Chemistry, Biochemistry, and Applications
By Oyvind M. Andersen, Kenneth R. Markham
Contributor Oyvind M. Andersen, Kenneth R. Markham
Published by CRC Press, 2006
ISBN 0849320216, 9780849320217
1,237 pages

Within this text, studies are cited that compared isoflavone metabolism in children to adults (pages 376ff). In children and infants who were fed soy formula early in life, excrete isoflavone metabolites is high, while in those fed cow's milk, excretion is low. So the flora appears to be "cultivated" earlier in life. But in adults, chronic ingestion of soy isoflavones does not appear to alter the metabolism of isoflavones in the gut. This suggests that the bacterial strains involved in isoflavone metabolism must be established early in life.

Also for your consideration:
E. Bowey, H. Adlercreutz and I. Rowland. Metabolism of isoflavones and lignans by the gut microflora: a study in germ-free and human flora associated rats. Food Chem Toxicol. 2003 May;41(5):631-6 PMID: 12659715.

2. Kreijkamp-Kaspers was done in the Netherlands, and we assume most of the subjects were native Dutch -- there were women in the study who were good equol producers and others not. They did not assess past dietary habits and current equol metabolism.

3. Ginseng and enhanced response to vaccines:
Scaglione F, Cattaneo G, Alessandria M, Cogo R. Efficacy and safety of the standardised Ginseng extract G115 for potentiating vaccination against the influenza syndrome and protection against the common cold Drugs Exp Clin Res. 1996;22(2):65-72.Erratum in:Drugs Exp Clin Res 1996;22(6):338. PMID: 8879982.

4. Dowling EA, Redondo DR, Branch JD, Jones S, McNabb G, Williams MH. Effect of Eleutherococcus senticosus on submaximal and maximal exercise performance. Med Sci Sports Exerc. 1996 Apr;28(4):482-9. PMID: 8778554.

5. Kuzdu -- from Wikipedia -- a good summary:

Kudzu, Pueraria lobata (syn. P. montana, P. thunbergiana), (sometimes known asfoot a night vine, mile a minute vine, Gat Gun, Ge Gan[1] and The vine that ate the South) is one of about 20 species in the genus Pueraria in the pea family Fabaceae, subfamily Faboideae. It is native to southern Japan and southeast China in eastern Asia. The name comes from the Japanese word for this plant, kuzu. The other species of Pueraria occur in southeast Asia, further south.

Pueraria mirifica (also known as Kwao Krua) is a root found in northern and north eastern Thailand and Myanmar.In Thailand, the plant "Kwao Krua" is considered to be a rejuvenating adaptogenic herb and has a history in folk medicine. Although the name "Kwao Krua" had been applied to several species of plants having tuberous roots, it was definitively identified as Pueraria mirifica -- and an estrogenic phenol miroestrol supposedly has been identified. This species is being promoted as the miracle from Thailand -- for menopause, breast enlargement, and other complaints. The constituent isoflavones appear to have some estrogenic activity. Whether these will prove to have clinical utility remains to be seen, and will they act like estrogens or like SERMs is the important question. We have lots of estrogens...what is needed are beta receptor specific agonists

6. Matsumura A, Ghosh A, Pope GS, Darbre PD. Comparative study of oestrogenic properties of eight phytoestrogens in MCF7 human breast cancer cells. J Steroid Biochem Mol Biol. 2005 Apr;94(5):431-43. Epub 2005 Mar 21. PMID: 15876408.

[Marcy A, RD]

Dr. Taylor,

Thank you for providing such an informative webinar: Botanicals and Menopause. I am a dietitian who facilitates individual nutrition counseling and group nutrition education classes with an emphasis on healthful lifestyle choices for weight management. Many of my clients are perimenopausal or menopausal, and some of them have asked me to comment on the risks associated with consuming soy protein. I have informed my clients that some research encourages soy intake and some research discourages soy intake, especially if one has, or is at risk for developing, breast cancer. What literature would you suggest that I read in preparation for answering this question thoroughly?

Any information that you may be able to share with me would be very helpful. Thank you for your time and consideration.

[Maida Taylor]

Dear Marcy,

The most authoritative source on the subject of soy in American diets and in menopause is Ken Setchell from Children's in Cincinnati (http://www.cincinnatichildrens.org/svc/find-professional/s/kenneth-setchell.htm). Here is a list of his most recent publications:

1. Lephart ED, SETCHELL KDR, Lund TD (2005) Phytoestrogens: hormonal action and brain plasticity.Brain Res Bull65:193-198.

2. Setchell, KDR, Brzezinski A, Brown NM, Desai PB, Melhem M, Meredith T, Zimmer-Nechimias L, Wolfe B, Cohen Y, Blatt YPharmacokinetics of a slow-release formulation of soybean isoflavones in healthy postmenopausal women.J Agric Food Chem 2005; 53(6):1938-1944.

3. Setchell KDR, Clerici C, Lephart ED, Cole SJ, Heenan C, Castellani D, Wolfe B, Nechemias L-Z, Brown N, Baraldi G, Lund TD, Handa RJ, Heubi JE. S-Equol, a potent ligand for estrogen receptor-beta, is the exclusive enantiomeric form of the soy isoflavone metabolite produced by intestinal bacterial flora.American Journal of Clinical Nutrition 2005; 81:1072-1079.

4. Messina M, Erdman J, Jr., Setchell KD (2004) Introduction to and perspectives from the Fifth International Symposium on the Role of Soy in Preventing and Treating Chronic Disease.J Nutr 134:1205S-1206S.

5. Lephart ED, Setchell KDR, Handa RJ, Lund TD. Behavioral Effects of Endocrine-disrupting Substances: Phytoestrogens.Ilar J 2004; 45:443-454.

6. Lephart ED, Porter JP, Lund TD, Bu L, Setchell , KDR, Ramoz G, Crowley WR (2004) Dietary isoflavones alter regulatory behaviors, metabolic hormones and neuroendocrine function in Long-Evans male rats.Nutr Metab (Lond) 2004; 1:16.

7. Erdman JW, Badger TM, Lampe JW, Setchell KDR, Messina M. Not all soy products are created equal: Caution needed in the interpretation of research results.American Journal of Clinical Nutrition 2004; 134:1229S-1233S.

8. Setchell KDR, Brzezinski A, Brown NM, Desai PB, Meredith T, Zimmer-Nechmias L, Wolfe B, Cohen Y, Blatt Y.Pharmacokinetics of a slow-release formulation of soybean isoflavones in healthy postmenopausal women.Journal of Agricultural Food Chemistry 2005; 53:1938-1944.

9. Lund TD, Munson DJ, Haldy ME, Setchell KDR, Lephart ED, Handa RJ. The phytoestrogen equol acts as an anti-androgen to inhibit prostate growth and hormone feedback.Biology of Reproduction 2004; 70:1188-1195.

10.Lydeking-Olsen E, Beck Jensen J-EB, Setchell KDR, Holm-Jensen T. Soymilk or progesterone for the prevention of bone loss: A 2-year randomized placebo-controlled trial.European Journal of Nutrition 2004; 43:246-257.

[mari]

This was a very informative webinar that really helped me understand the herbal remedies that are out on the market today for menopause. It is great to review these therapies from an unbiased perspective, as so many patients have questions about them, and I often only learn new information about these treatments from biased advertisements. Thanks so much to Dr. Taylor for providing us with this information!

[maureen]

Finding "alternative" therapies for menopause is always a popular topic. As mentioned in the webinar, soy, black cohosh, red clover, ginseng and belladonna have been studied and proved effective. But how about other herbs/spices/botanicals that have been traditionally used for years in Chinese or Indian cultures? For example, ginger, fennel seeds and fenugreek mixture was always a favorite of my grandmother. Taking a teaspoonful of the powdered mixture was a bedtime ritual for her. Its interesting to note these herbs/spices also had a prominent place in her cooking; by including them in cooking, your taste buds will always tell you if there's too much.

[DP]

The Women’s Health Initiative study exposed the associated dangers of hormone replacement therapy (such as stroke and heart disease) and significantly reduced the use of HRT for menopause treatment. This ultimately reduced conventional therapy options for the treatment of postmenopausal symptoms. I highly recommend Dr. Taylor’s webinar on botanicals and menopause. It gives an informative review on the most popular natural products to treat menopausal symptoms such as hot flashes and vaginal dryness.

[liz]

I found the webinar to be interesting and informative. I agree with Rachael that menopausal women undergo not only physical but also emotional stress. It seems with some of the herbs, such as hypericum and ginseng, there is no association with menopause (vasomotor symptoms); however, I believe that for those women who experience depression or stress, hypericum and ginseng, respectively could be beneficial.

Dr. Taylor pointed out some of the flaws in the studies. In order to avoid flaws and get complete evidence-based information, I agree with Dr. Taylor that there should be a standardized protocol trial.

[LC]

Does Dr. Taylor recommend any specific herbs for menopausal symptoms?

[kelly]

I found the webinar to be interesting and informative. I wonder if there is specific herb that works better than others for menopause. The studies Dr. Taylor presented do have flaws, and she did point out these flaws, which are mostly non-standardized studies. So, my question is how can we know which herbs are more effective in treating vasomotor symptoms?

[kyla]

I really appreciate being able to listen to Dr. Taylor's webinar. I learned a lot of useful information about herbs used to treat menopausal symptoms, something I have come across previously in my career and did not have much information on at the time. Thanks Dr. Taylor!

[Dr. Maida Taylor]

Estrogen is documented to treat vasomotor symptoms. Current recommendations are for the shortest dose for the shortest period of time. Many botanicals are said to have estrogenic activity and are recommended for menopause-related symptoms. The phtyosterols often do interact with the estrogen receptor, but behave more like selective estrogen receptor modulators than like to estrogens.

Commonly recommended botanicals or botanical-based products are:
*Soy foods
*Soy isoflavone isolates
*Red clover based isoflavone isolates
*Black cohosh
*Ginseng

Most studies involving botanicals suffer from inadequate or poor study design. The data on all products are inconsistent and contradictory. The products listed offer mild relief but do not perform better than placebo.

The short-term use of these is botanicals generally safe. There have been reports of liver damage associated with black cohosh, but causality is uncertain. Caution should be exercised when recommending black cohosh to anyone with any history of hepatic dysfunction or illness.

Long-term use of isoflavone isolates in amounts greater than the isoflavone content of soy foods in an typical Asian diet may not be safe (40-60 mg of the aglyconic forms). There is some evidence of estrogenic effects on vaginal mucosa and in endometrium. Therefore, again, long-term use may not be safe.

Given the fact that these products all have limited evidence of efficacy, and since the quality branded products (those most likely to have documentation of good manufacturing practice) are expensive, no specific products are brands are recommended. If a patient presses for a specific recommendation, the branded products used in some of the well-designed trials might be the most reliable ones to recommend since documentation of safety has been published in peer-reviewed journals. But again, efficacy data are inconsistent. These include:

1) Red clover based isoflavones - Promensil®
2) Black cohosh - Remifemin®
3) Ginseng - Ginsana®

Soy foods may offer other health benefits and substitution of soy protein for animal protein in the diet is safe. Other products are being studied, but as yet, there is insufficient evidence to make formal recommendations, again due to small study size or poor study design. These include Siberian rhubarb, maca and kudzu (pueraria mirifica). The efficacy and safety of these have not been adequately documented

[Nicole]

It’s great that more research is being done on herbs/botanicals and menopause. It’s encouraging to see that more and more women are interested in learning more. It’s exactly this type of response that will promote more standardized studies on the effects of herbs. But an important point to all those supporting these studies: it's also important to educate women on the potential side effects and potential interactions of these herbs with traditional treatments for menopause or any other condition they may be suffering from. I appreciated the comments that say: herbs are medicines; not alternatives. It conveys the impact of herbal intervention.

[tommy]

With so many people getting older, it’s no surprise to me the number of older women asking about alternative remedies at the pharmacy I work at. In my opinion, knowledge is critical in effective treatment. Knowing more about available treatments and their effectiveness, especially with alternative medication, is just as important as the treatment itself. Webinar forums will become increasingly valuable as a new means to educate patients.

[Becca]

It is understandable that there is a lot of fear and distrust in conventional medicine due to the risks versus benefits. I was surprised to find out that some of the herbals may contain products from animals such as cows. It makes sense that like anything nutritional taken in supplement form, soy is safe when consumed in foods rather than supplement, which we tend to take to in excess, resulting in negative side effects.

[Tamara.S]

Dong quai (Angelica sinensis) root contains phytosterols, essential oils, coumarins and other substances that can inhibit blood clotting and improve circulation, so it's promoted as a general treatment for women's health. However, I was wondering whether it has estrogen-like effects. Some studies show it does not, but it's usually not given alone, and it's given together with other herbs. What about using it for premenopausal women with histories of endometriosis and uterine polyps and who still have difficult periods?

[K. Kelley]

This was an interesting history of botanical therapies for menopause. One has to wonder if the variability of soy for menopausal effects is a result of not knowing more about the source and growing area of the soy used in the many studies on soy. We know that where botanicals are grown can significantly impact their active constituents and concentration of other components. Anyone in the market for a botanical remedy to treat menopause should look for kudzu grown in Thailand!

[SUMA]

I thought that the presenter was very knowledgeable about this subject and offered a lot of information on different types of botanicals that are used for menopause. Several studies were presented for interpretation. The limitations of the various studies were explained in detail, and I found it helpful when the presenter identified these limitations. Many of the studies presented did not demonstrate significant results for certain products. I realize this identifies the need for future studies related to this topic; however, I was hoping to get a better idea of botanicals that do demonstrate significant results to offer patients dealing with menopausal symptoms. Perhaps these studies do not yet exist.

[Regina Windsor]

Dear Dr. Taylor,

You are welcome. And I apologize for not being in touch sooner...have been a bit busy.

Thanks so much for elucidating my questions. I look forward to your future webinars.

[inna h.]

I agree with DP that being informed about botanicals and their effect on menopause gives women the options and can reduce the conventional therapies for the treatment of vasomotor symptoms related to menopause. Why use HRT if you know HRT is associated with so many dangerous side effects (stroke, heart diseases). The webinar gives a comprehensive review on the herbs that can be used to treat menopausal symptoms.

[Crystal]

I think in addition to treating the symptoms of menopause, phytoestrogens have produced promising data in some studies, indicating that they may also reduce the risk for breast cancer. I think soy is an example of a phytoestrogen that is commonly used to reduce menopausal symptoms such as hot flashes and also has data for risk reduction of breast cancer. We are moving towards eating healthier, and soy products are increasing, as they should, in my opinion.

[Elizabeth Smith]

I was just reading an article in a health magazine about women and menopause. I am not at that age personally yet; however, in a few more years I will be at perimenopause, which is supposed to give a person the same symptoms as menopause. I did watch my mother go through menopause, and she constantly complained about the hot flashes. Many women suffer for years with difficult periods and PMS and then problems with perimenopause and menopause. When does it end for us?

I think it is great that there are herbs that can help, yet many types of herbs cannot be taken with prescribed medications, which many people are on, so it’s best to check with your doctor first before mixing anything. As I said before, I am almost at perimenopause, and I have already experienced a few hot flashes, and I do find that soy milk helps a lot.

[Sean]

It is good to see that webinars like this exist to educate professionals and patients about herbal products for menopause. It would be great to see more standardized trials, as well as trials to compare them directly to HRTs to see how they fare vs. "conventional" therapy. If these herbs work and are safe, they should be considered just like other medications. If they do show superiority over conventional therapies, treatment guidelines should be modified to include them as well.

[Sophia]

Very informative webinar! I really enjoyed it, and it was well presented in an understandable manner. I feel more confident that I may be better able to answer any questions my mother or any other woman may have regarding alternative therapies for menopause. I have already been asked by several people about alternative treatments for menopause, so I know there is great interest out there. I hope this is enough to encourage further research in this area.

[Jamie]

Excellent webinar! I found this very informative, and I now feel more confident answering some of the questions I receive from my patients regarding alternative therapies. Thank you!

[hair loss during menopause]

Thanks for this very informative article. Keep up the good work. Can you post something about the symptoms of menopause? Thanks.