The Society of Obstetricians and Gynaecologists of Canada
1996 West/Central C.M.E. Programme
Alternatives to H.R.T and the Menopausal Woman
By Dr. Suzanne Montemuro
There is a strong consumer driven need for information about alternative treatments for menopausal symptoms. A recent survey bv Dr. F. Kronenberg, (one of the founders of the North American Menopause Society) showed that a significant number of women use alternative therapies to relieve unpleasant menopausal symptoms. This fact is often not known by their physicians. The perception that physicians are pro estrogen replacement and against other less proven therapies keeps patients silent. Why are women pushing the boundaries of traditional medicine in their joumev through menopause'.' The use of conventional Estrogen/Progesterone therapy for treatment of menopausal symptoms is highly successful. In addition it prevents post-menopausal bone loss and lowers the risk of heart disease. Yet only about 15-20% of women take hormone replacement and many stop it after only a brief trial. There are a number of the reasons why some women prefer to look for alternatives to hormone replacement therapy. Absolute contraindication to estrogen/progesterone therapy are: current breast cancer or endometn'al cancer, acute liver disease, acute thrombophlebitis or a thromboembolic disorder, and undiagnosed vaginal bleeding.
Relative contraindications include: severe headaches with previous hormone therapy, gallbladder disease, endometriosis, large uterine fibrolds, hypertension if worsened by hormones, and personal or family history of premenopausal breast cancer. Women's fear of breast cancer is overwhelming. Information about breast cancer is 'dely publ'c'sed in the lay press. Women's experience with friends and relatives who have had breast cancer undoubtedly undoubtedly to their ears. The possibility that estrogen replacement may increase their risk of this disease is enough to stop them even considering this option. Some women have mild, short-lived menopausal symptoms they feet don't require anv therapy. Still others are unhappy about having ongoing menstrual bleeding or spotting. Many of these relative contraindications do not preclude the use of estrogen/progesterone therapy but cause such anxiety in the patient that she decides to look for alternatives first. Women view menopause as a natural stage in their reproductive lives and some women, in principal, disagree with the use of hormone replacement therapy .Given physician understanding of the variety of symptoms women may experience and the diverse beliefs women hold, makes it 'important that we physicians have knowledge about adjunctive/altemate treatments.
Many women experience severe P.M.S. svmptoms and irregular menses during the transition into menopause. Ovarian hormone secretion becomes erratic with widely fluctuating levels of estrogen and often low levels of progesterone. The Judicious use of progesterone or oral contraceptives can often control these symptoms. Other options however, should be discussed. Dietary adjustments, decreasing the intake of caffeine, sugar, salt, and alcohol while increasing the intake of vegetables/fruits, can help moderate the hormonal fluctuations that cause these symptoms. B-vitamins (especially B6-100mg per day) and essential fatty acids (found in evening primrose oil, borage oil or flax seed oil) have been used to ameliorate P.M.S symptoms. Studies carried out in Britain support the claim that essential fatty acids (containing 200mg of gamma linolenic acid) are helpful in treating P.M. S. and mastalgia. (1) Botanical medicines like Don Qual (Angelica Polymorphia Maxim) and Chaste Tree Berry (Vitex agnus-castus) are being used by women with P.M.S. and irregular menses. While there has been historical experience with these "botanical medicines" there is little scientific knowledge about their use. A helpful reference book "The Honest Herbal; a Sensible Guide to the use of Herbs and Related Remedies" by Varro E Tyler, Phd. a Professor of Pharmacognosy at Purdue University School of Pharmacy, provides a critical look at what is presently known about botanical medicines. The U.S. National Institute of Health added the Office of Alternative Medicine in 1991. Its' mandate is to evaluate the most promising alternative medicines. In 1995 they helped launch The Journal of Alternative and Complementary Medicine, a scientific Journal designed to promote and report research in this area. These initiatives will provide information about the safety and efficacy of alternative treatments used by women. Relaxation/meditation/deep breathing are modalities which, if teamed during the transition, can serve as a useful tool for dealing with symptoms during both the Transition and Menopause (2,4). Rigorous training in female athletes can cause amenoffhea and low levels of serum FSH, LH, estradiol and progesterone. Moderate exercise, especially aerobic exercise for the same reason can relieve P.M.S. stress and lessen hormonal fluctuations.The use of tranquillisers and hypnotics must be used with great caution because of their addictive potential. The understanding and support of family, friends and physicians help women to cope with the irritability and lack of control they sometimes feel during the Transition. S.S.R.I. antidepressants (which have no known addictive potential) can be useful in treating severe P.M. S. Major Depression can occur during the Transition. The cause of major depression is multifactorial; genetic predisposition, outside stress, illness etc. Hormonalfluctuations during the transition can exacerbate any depressive tendencv. If depressive svmptoms are pervasive throughout the month with no pre-menstrual fluctuation. a discussion about the need for counselling and/or anti-depressants is necessary.
Although hot flushes are experienced by 80% of menopausal women there is great individual variation in how much discomfort they cause. Treatment of hot flushes needs to by tailored to each woman's needs. The first step is to reduce dietary triggers like caffeine, alcohol, chocolate, certain spices, and hot beverages. Adiet rich in vegetables containing isoflavones (especially soy products) has been the focus of recent research (1995 International Symposium on the role of Soy in Preventing and Treating Chronic Disease (3)). Dietary cross cultural studies show a low incidence of menopausal symptoms in Japanese women who consumed a diet rich in soy products. Their urine contains high levels of Phytoestrogens. Phytoestrogens, present in soy and many other plants, are honnone-like substances which demonstrate both weak "estrogen-like" as well as "anti-estrogen-like" properties. They appear to moderate hot flushes and are thought to be the reason Japanese women don't experience hot flushes to any great extent. The low incidence of breast cancer in Japanese women is also thought to be related to the anti-estrogen properties in soy. This additional "breast cancer prevention" benefit to using soy has caught the interest of the scientific community. Other triggers like strong emotions should be addressed. Freedman(2,4) demonstrated a 40-50% reduction in hot flushes using slow deep breathing exercises. He suggested that 15 min. twice daily of slow abdominal breathing (6-8 breaths per minute) was most helpful. This technique is also useful for relieving stress and anxiety. Avoiding hot environments and wearing layered, breathable clothing is an obvious but sometimes forgotten aid. Regular exercise has been shown to improve hot flushes in research done by Hammar (5). He showed a 50% reduction in hot flushes in women who exercises regularly. More research is needed to validate these finding. Astudy on Acupuncture (6) found a significant reduction in hot flushes when compared to placebo acupuncture. Vitamin E (400-800 l.U.) has some estrogen-like activity. There are anecdotal reports of its efficacy in treating hot flushes. Other Vitamins (C plus bloflavonolds) were found to decrease hot flushes in one controlled study.(7) Bellergal and Clonidine are sometimes prescribed for hot flushes. Bellergal (a combination of phenobarbital, ergotamine and belladonna) is helpful in the short term but has too many side effects for continuous use (addictive potential , sedation and visual disturbances). Clonidine is primarily used to treat hypertension. It inhibits the release of norepinephrine from the brain and can decrease hot flushes. It's use is limited due to the frequency of side effects (drv mouth, drowsiness, dizziness and hvpotension). Many botanical medicines are used by menopausal women to reduce hot flushes. Don qual, licorice root, burdock root, wild yam root, motherwart, ginseng, black cohosh and, false unicorn are only a few. Manv of these botanicals are mixed together. Studies are presently being carried out in the U.S. by the N. I. H. to determine their efficacy and safety. Many of these herbs contain plant hormones which are responsible for their positive effects on hot flushes. Their actions may be similar to synthetic estrogens. Researchers hope that these plant hormones will in addition, have an anti-proliferative effect on breast and endometrial tissue (preventing breast and uterine cancer) while having positive estrogenic effects on hot flushes ( osteoporosts and heart disease)(8,9,10). Again this will be the focus of future research. A study, carried out in Sweden in 1993-4, reported on the use of an extract of Cimicifuga racemosa (Black Cohosh) to treat menopausal symptoms including vaginal dryness. The extract has been used for many years in Europe. This double-blind study compared the extract to .625 conjugated estrogen. The Cimicifuga racemosa extract controlled menopausal symptoms and improved vaginal atrophy as well as or better than congugated estrogen.(30) Mild hot flushes often respond to lifestyle adjustments alone. Adherence to these lifestyle changes is important even if other treatments are used. As hot flush symptoms increase, the treatment options can progress from diet and exercise to vitamins, botanicals (if the patient wishes) and finally to conventional medical estrogen/progesterone therapy. The goal here is relief of symptoms. The 'udge is the woman herself
MOOD SWINGS and INSOMNIA
These symptoms are common during the menopausal years. Their cause is mutlfactorial: hormonal changes as well as increased social and personal pressures. Leaming relaxation techniques and practising slow deep breathing exercises (4) assists some women. It takes discipline to practice on a daily basis especially when fatigue and lack of motivation are present. Exercise (aerobic and stretching) is helpful. Exercise stimulates the production of endorphins in the brain which diminish depressive symptoms(I 1) Counselling psychotherapy and support groups help women deal with the issues and pressures that arise during the menopausal years. Cognitive therapy for mild to moderate depression is effective (12). Support groups where information is shared, and women candidly discuss their thoughts about menopause are springing up in many places. These groups bring a sense of normalcy to women's experiences.
I I Tranquillisers have an addictive potential. Although they 'mprove sleep and relaxation they should be avoided if possible. The judicious use of anti-depressants in cases where mood changes are severe, however, can be gratifying.
GENITO-URVNARY PROBLEMS AND CHANGING SEXUAL FUNCTION
A decrease in sexual desire, vaginal dryness and pain with intercourse are problems many women experience after menopause. Continued sexual activity is important for vaginal health. One study showed a 1 ificant decrease in vaginal atrophy with regular ' s gn I I intercourse( at least ' )X per month(13). The use of vaginal lubricants during intercourse (K 'el, Astroglide, Replens) are helpful. Vitamin E oil (from a Vitamin E capsule) is also used to alleviate vaginal dryness(7). Urinary stress and urgency incontinence (especially leakage during sexual relations) is an embarrassing problem for women. Inquiring about bladder problems is an important part of the mid-life assessment since women do not often raise this distressing problem on their own. Emphasising regular Kegal exercises and weight loss improves stress incontinence. Prompt treatment of bladder infections as well as the judicious use of estrogen creams is also important. Timed-voiding (holding urine for a certain length of time between voiding) helps increase bladder capacity and decreases urgency incontinence. Medications (Ditropan, Donnatal) are sometimes used to alleviate urgency incontinence. There are a number of surgical options to treat both stress and urgency incontinence. Their discussion is beyond the scope of this article. Consultation with a Urologist is advised.
PREVENTION OF LONG TERM MEDICAL PROBLEMS
An osteoporosis risk assessment is the first step in preventing and treating osteoporosis. Each risk factor needs to be discussed and dealt with. This starts with an assessment adequate intake of Calcium and Vitamin D; low fat dairy products, calcium enriched orange juice and soy milk, vegetables like broccoli and collard greens, sesame seed, and sardines. Two to three servings a day are necessary. Surveys show that 50% of all perimenopausal women consume less than 500mg/day of calcium and 25% consume less than 300 mg/day(14). Emphasising appropriate intake during the pre-menopause years can help to educate women about osteoporosis prevention.
Post-menopausal women, not taking HRT, require 1500 mg of calcium per day from either diet or supplements. Women on HRT require 1000mg per day. Recent studies have shown that for women more than 5 years postmenopause, increasing calcium intake slowed or prevented bone loss (I 5). A diet low in sodium (soft drinks), low in animal protein and low in caffeine, promotes the absorption of and decreases the excretion of calclum(27,28). There are many calcium supplements available if food sources are inadequate. Calcium carbonate is the least expensive. It should be taken in divided doses with food. Calcium citrate is more expensive but also more easily absorbed in older women who have low gastric acidity. It should be taken on an empty stomach. Oyster shell derived calcium may contain unsafe levels of contaminants such as lead(14). Calcium is often taken in combination with magnesium in a 2:1 ratio which is thought to improve absorption and bone formation. Vitamin D supplements are needed unless 3 servings of enriched dairy products are consumed per day. 400-800 l.U. per day are recommended. It promotes calcium absorption and stimulates bone formation and has been shown to reduce the frequency of fractures among frail elderly women(16) Other minerals are being investigated that might prevent osteoporosis; silica, boron, zinc, selenium, ascorbic acid(27). Regular weight bearing exercise is associated with an increase in bone mass. Exercise also helps maintain muscle tone and bulk which in turn helps to improve balance and strength thus decrease the risk of serious falls. Recent studies have shown a positive correlation between regular weight bearing exercise and a decreased bone loss after menopause.(17) Smoking is a serious health concern for many reasons. Smoking results in premature onset of menopause (average 2 years earlier than other women) and consequently increases the risk of osteoporosis. A recent report from the Framingham Heart Study revealed that smokers taking FIRT had the same hip-fracture rate as smokers not taking HRT. Smoking increases estrogen excretion and smokers who take f4RT don't appear to maintain their estrogen levels high enough to prevent osteoporosis. Not smoking is the most important lifestyle change a woman can undertaken 8). The most significant risk factors used to determine if a woman needs HRT in addition to alternative, lifestyle measures are 1) advanced age 2) post-menopausal fracture ' )) bone density > 2.5 standard deviations below normal. Women with osteoporosis who are unwilling or in whom H.R.T is contrindicated can benefit from the use of antiresorptive agents like Didronel (etidronate) and the newer Fosamax (alendronate). These are used in women who have established osteoporosis. Studies using Didronel have shown a 3-4% per year increase in bone density and a decrease in fractures.(19,20) Fosamax is now available in Canada. It is more expensive than Didronel, increases bone density and decreases fractures as well. Ongoing studies 'II show which, 'f any of these medications is superior. wi I I I I Calcitonin injections increase bone density by 3-5% per year and also reduce fractures. (20) Their use is hampered by expense and the need for frequent injections. A calcitonin nasal spray is available in the U.S. but not in Canada at this time.
Other medications presently under investigation for the treatment of osteoporosis are slow release fluoride, tamoxifen, raloxafen(a selective estrogen receptor modulator), iproflavone (a derivative from soy beans) and injectable parathyrold horrnone.(20)
Every woman needs information about the prevention of heart disease. Maintaining heart health is paramount for a good quality life after menopause. Heart disease is linked to a high fat diet. Decreasing the fat content of the diet is of primary importance. A recent study (2 1) showed that a diet limiting total fat intake to 20% of calories and saturated fat to 7% along with physical activity produced significant reductions in LDL , total cholesterol and blood pressure. Increasing the intake of vegetables, fruits and whole grains (including soy products) lowers cholesterol and promotes a weight loss. (22) High blood pressure and cholesterol should be treated (diet, exercise, and low salt intake before drugs). Smokingandheartdiseasearedirectlylinked. Smokingmustbestoppedltf(18) Anti-oxidant vitamins E, C, beta-carotene may help to prevent heart disease(23) They work by 1) inhibiting oxidation of low density lipoprotein cholesterol 2) trapping free radicals and 3) by enhancing immune function. Red wine reduces heart disease because of the presence of flavonolds (anti-oxidants)(3 1). Whether it is preferable to consume vitamins in their natural state ( food) rather than in a purified form (vitamin '11) is still unknown. There have been conflicting results from studies try' pi I mg to use vitamins to prevent heart disease and cancer. Many more studies are currently investigating this matter. Regular aerobic exercise (30 min. per day) is beneficial for heart health. These exercises range from walking, gardening, and dancing to biking, and climbing. There benefit comes from cardiac conditioning and improved oxygen utilisation by the heart. Low dose ASA intake (325 mg every 2 days) decreases the incidence of heart attacks. Women need to be aware of its ulcerogenic side effects(24,25) and advised to take it with food. Botanical medicines that women take for heart disease prevention include garlic, p 'I, and bloflavonolds. hawthorn berry, ginko biloba, 'nseng, don qual, flax seed oi Omega-' ) alpha-linolenic acid in flax seed oil is thought to reduce tn'glyceride and/or cholesterol thus preventing heart diseased) Interest in using botanical medicines is consumer driven (26). More research is necessary to validate their use.
HOW TO HELP WOMEN GET STARTED
Menopause and the Transition is a time of change; "from within". This changing inner environment can cause significant discomfort. Discomfort drives women to seek relief As physicians we are able to educate our patients and act as facilitators In order to help them deal with the symptoms that are causing them distress. We can give women a good understanding of the physiology of menopause and help them to identify where they are along the continuum of change. A good understanding of how lifestyle affects their future can assist them in setting realistic goals. A list of which goals are most important leads them to identifying the steps needed to attain these goals. In this way Nvomen become caretakers of their own health and we become facilitators. Follow-up is necessary to assess the success of various lifestyle manoeuvres and to help make future decisions during this ever changing challenge .... menopause. Keeping an open mind and being prepared to involve other health care professionals in education, counselling or recreation provides an ideal melieu for a woman to successfully pass through menopause and on to healthy future.
Page created on May 27th, 1997
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