Yvette C. Terrie, BSPharm, RPh
Menopause is an inevitable fact of a woman’s life that can impact her daily routine and overall quality of life. Because women experience menopause differently, the management of menopause should be tailored to suit the individual needs of each woman. Physiologic menopause is defined as the absence of menses for 1 year.1,2
In the United States, the average age of menopause is between 50 and 52 years; however, women may begin to experience the symptoms associated with menopause between the ages of 44 and 55 years.1,2
The beginning of menopause symptoms is called perimenopause and starts in most women between ages 45 and 47 years.3
During perimenopause, a woman may notice a change in the amount or length of menstrual flow and experience irregular or missed menstrual cycles.3,4
Women may experience symptoms during perimenopause and menopause such as irregular menstrual cycles, vasomotor symptoms (hot flashes and night sweats), dizziness, mood swings, insomnia or sleep disturbances, headaches, weight gain, and fatigue.1-3
These symptoms can vary in intensity and rate of occurrence. Hot flashes are the most prevalent symptom of menopause, affecting an estimated 50% of women.3
Common triggers of hot flashes include caffeine, alcohol, smoking, spicy foods, tight clothing, and foods that contain nitrates or nitrites.4
CHOOSING THE RIGHT TREATMENT
For several decades, hormone replacement therapy (HRT) has been considered the mainstay of treatment of menopause symptoms. The results of the Women’s Health Initiative (WHI) study, published in 2002, raised concerns about the longterm safety of HRT.1,2,4,5
The results of the study reported that HRT is associated with an increased risk for cardiovascular disease, cancer, stroke, and the development of an embolus.1,5
In the February 16, 2010, issue of the Annals of Internal Medicine, the National Institutes of Health (NIH) reported that new analyses from the WHI confirm that hormone therapy increases the risk of cardiovascular disease in postmenopausal women.6
Women may consider trying OTC herbal or alternative remedies that are available to manage menopausal symptoms. These products may contain phytoestrogens, black cohosh, vitamin E, evening primrose oil, and/or chastetree berry.7
In addition, according to the NIH’s National Center for Complementary and Alternative Medicine, the use of ginseng (Panax ginseng or Panax quinquefolius) may be beneficial for menopausal symptoms such as mood swings and sleep disturbances.2
Because many products are on the market for treating and managing menopausal symptoms, the selection of an appropriate product may be both overwhelming and challenging for many women. Pharmacists can be instrumental in assisting women in the selection of these products and providing them with pertinent information to help effectively manage their menopause symptoms.
Phytoestrogens are a group of naturally occurring plant compounds that mimic estrogen in the body. Phytoestrogens, including soy products and red clover products, are derived from various plant sources.7
Isoflavones are a class of phytoestrogens. Menopausal supplement products contain various types and amounts of isoflavones. Common adverse effects include gastrointestinal (GI) complaints, headaches, and allergic reactions. Soy isoflavones may have some benefits for the relief of vasomotor symptoms, but results from various studies are inconclusive.7,8
Isoflavones are comparable to endogenous estrogen, because they compete with estrogen for the same receptors and exert both estrogenic and antiestrogenic effects.8
Although many studies have investigated the use of phytoestrogens and lignans (found in whole wheat and flaxseed), to date no evidence exists that indicates whether phytoestrogen-rich foods or supplements provide relief from vasomotor symptoms or other menopausal symptoms.9
According to the American College of Obstetricians and Gynecologists, soy isoflavones may be beneficial for short-term use, but these agents should not be considered free of potential harm in women with estrogen-dependent cancers.8,10
The long-term effects of phytoestrogens have not been established, especially among those with increased risk of estrogen-dependent cancers and thromboembolic disorders.7-11
Some studies have suggested that high intake of soy may increase the risk of estrogen-responsive cancers, such as breast cancer. 2,7-11
The American Cancer Society recommends that women with breast cancer eat only moderate amounts of soy-containing foods and avoid taking dietary supplements that contain high amounts of isoflavones.7,9,12
Black cohosh is derived from the dried rhizome and roots of Cimicifuga racemosa.7
Several clinical trials have been conducted to evaluate the safety and efficacy of black cohosh, with mixed results.7,8
Although the exact mechanism of action of black cohosh is unknown, it is thought that black cohosh competes with estrogen for binding sites and exerts a positive estrogenic effect. Newer data suggest it may act as a selective estrogen receptor modulator, depending on the tissue receptors, and that it also may exert an agonistic effect on serotonin receptors.8
In addition, black cohosh may decrease luteinizing hormone, leading to a reduction in hot flashes.8
Black cohosh is the most studied and perhaps the most popular herb for the treatment of hot flashes.7,8
The adverse effects associated with its use include GI effects, headache, rash, nausea, dizziness, and weight gain.7
Acute hepatitis has also been associated with black cohosh.2,7
The use of this agent for more than 6 months is not recommended due to insufficient data on its long-term effects.7,8
The North American Menopause Society recommends a trial of OTC products, including black cohosh, for mild vasomotor symptoms.7
This position statement acknowledges that current clinical trial data are not sufficient but supports the short-term use of black cohosh because of its overall safety profile.7
Studies are currently investigating the safety and efficacy of OTC products for menopause relief. Results are due in fall 2010 from a 12-month study investigating black cohosh and red clover. This study is a collaborative effort between the Center for Botanical Dietary Supplements Research of the University of Illinois at Chicago and Northwestern University, and was sponsored by the NIH’s National Center for Complementary and Alternative Medicine and the Office of Dietary Supplements. The researchers are hoping the data will help determine the safety and efficacy of these agents with regard to menopause symptom relief.11
Patients electing to use OTC products for the relief of menopause symptoms should always consult with a health care professional first, especially if they have preexisting medical conditions or are taking any other medications, to avoid possible contraindications or drug interactions.
During counseling, pharmacists should remind patients to avoid potential triggers of vasomotor symptoms, and direct them to helpful resources. When a woman reaches menopause, the risk of developing cardiovascular disease and osteoporosis can increase; therefore, it is imperative that postmenopausal women discuss preventive measures and treatment with a health care professional. It is also important to maintain routine medical visits and incorporate lifestyle modifications, such as practicing relaxation techniques, getting sufficient rest, eating a balanced diet, and establishing an exercise routine.
Menopause: Time for a Change
—an excellent patient education publication from the NIH’s National Institute of Aging:
Information on OTC menopause products from the NIH’s National Center for Complementary and Alternative Medicine:
Facts about menopausal hormone therapy from the NIH:
Information from the North American Menopause Society:
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
1. Lund KJ. Menopause and the menopausal transition. Med Clin North Am
.2008 Sep; 92(5):1253-71.
2. Menopausal Symptoms and Complementary and Alternative Medicine. National Institutes of Health National Complementary and Alternative Medicine Web site. http://nccam.nih.gov/health/menopause/menopausesymptoms.htm. Accessed April 1, 2010.
3. Weismiller DG. Menopause. Prim Care.
4. Menopause. Online Edition of the Merck Manual for Healthcare Professionals. Merck Manual Web site. http://www.merck.com/mmpe/sec18/ch245/ch245a.html#sec18-ch245-ch245a-193bAccessed April 2, 2010.
5. Women’s Health Initiative Postmenopausal Hormone Therapy Trials. United States National Institutes of Health website. http://www.nhlbi.nih.gov/whi/whi_faq.htm.Accessed April 1, 2010.
6. WHI Study Data Confirms Short-Term Heart Disease Risks of Combination Hormone Therapy for Postmenopausal Women, National Institutes of Health Web site. http://www.nih.gov/news/health/feb2010/nhlbi-15.htm. Accessed April 2, 2010
7. McQueen C and Orr K. Natural Products. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 16th
Ed. Washington, DC: American Pharmacists Association; 2009:1000-1002.
8. Carroll DG. Nonhormonal therapies for hot flashes in menopause. Am Fam Physician
.2006 Feb 1; 73(3):457-64.
9. Menopause patient education. MD Consult Web site. http://www.mdconsult.com/das/patient/body/192821278-2/0/10041/9391.html. Accessed April 1, 2010.
10. AAFP 2006 Evidence Based Complementary and Alternative Medicine: What Should Physicians Know? Medscape Web site. http://www.medscape.com/viewarticle/549067. Accessed April 3, 2010.
11. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention. American Cancer Society Web site. http://documents.cancer.org/6753.25/6753.25.pdf. Accessed April 2, 2010.
12.More Women Seek Nonprescription Remedies for Menopause Symptoms. Medical New Today Web site. http://www.medicalnewstoday.com/articles/156336.php. Accessed April 1, 2010.