Although hormone replacement therapy (HRT) is an effective treatment for many menopausal symptoms, it is also associated with potential risks. Many therapies, including botanicals and lifestyle changes, offer alternative approaches that may improve symptoms with less risk. For a more thorough discussion on hormone replacement, refer to Hormone Replacement Therapy Whole Health tool.
Hot Flashes
Many women experience hot flashes during perimenopause and menopause. For some, they can be debilitating, and for others, they are better tolerated when viewed as a surge of heat or power. In some cultures, no word even exists for hot flash.[7] Experiences may vary based on diet, lifestyle, or cultural perception.
Black cohosh (Cimicifuga racemose) is an herb with estrogenlike properties. Results are inconsistent for the effects of black cohosh on menopausal symptoms, with significant variation among the herbal preparations studied. A Cochrane review in 2012 concluded that the evidence for use of black cohosh for menopausal symptoms was insufficient; however, there is adequate justification for conducting further studies in this area.[8] The most conclusive evidence is for a commercial product Remifemin, containing 1 mg of triterpenes per 20 mg tablet. Studies show it significantly reduces menopausal symptoms and hot flash frequency when compared to placebo.[9] The standard dose is 40 mg once or twice daily. Side effects are rare; the most common is mild gastrointestinal discomfort.
Because a small number of women have experienced liver problems while taking black cohosh, consider monitoring liver function tests with prolonged use and avoid use in women with liver disease. The use of black cohosh for longer than 6 months has not been well-studied. More information is available in the Whole Health tool Top Supplements for Every Clinician to Know.
Phytoestrogens are plant compounds with structures similar to estrogen, resulting in the ability to cause estrogenlike effects on the body. The North American Menopause Societys Isoflavones Report from 2011 concluded, there are mixed results of the effects on midlife women. Soy-based isoflavones are modestly effective in relieving menopausal symptoms.[10]. The variation in therapeutic effects of phytoestrogens in the treatment of menopause may be influenced by a womans intestinal bacteria and its ability to metabolize phytoestrogens into therapeutic substances in the body (i.e. converting daldzein into equol).[11]
Multiple meta-analyses have documented improved frequency of hot flashes with use of isoflavones in doses ranging from 50-100 mg daily.[11][12][13][14][15] Refer to the Phytoestrogens Whole Health tool for increasing dietary intake. For more information on the use of soy, a particular type of phytoestrogen and its use in breast cancer, refer to the Whole Health overview Cancer Care.
Red clover (Trifolium pratense) contains isoflavones, a type of phytoestrogen. A systematic review of 10 trials concluded that red clover supplementation of 80 mg daily improved frequency of hot flashes and improved vaginal dryness, with more significant effects in women with severe hot flashes (>5/day).[16] Side effects are rare.
Regular exercise has significant benefits for overall health and well-being. However, a Cochrane review in 2007 concluded the evidence was insufficient to determine the effectiveness of exercise on hot flashes.[17] In a recent study, regular exercise did not alleviate hot flashes, but did result in improved sleep and mood.[18]
Acupuncture has been shown to reduce the frequency and severity of vasomotor symptoms in perimenopause and menopause, both individually and as adjunctive treatment.[19] Research also supports its use in reducing sleep disturbances caused by menopause-related symptoms.[20]
Yoga studies suggest that it is effective in reducing menopausal symptoms. Yoga was superior to other exercise for treatment of vasomotor symptoms.[21][22]
Other therapies some women find significant benefit from include alternative therapies and approaches such as energy work, traditional Chinese medicine, or Ayurveda for treatment of their menopausal symptoms, although extensive research has not yet been done. Use of mindfulness, meditation, and hypnosis have not shown improvement of menopausal symptoms.[23] Tai chi has been shown to improve overall general health, vitality, and bodily pain.[24] One must consider potential side effects and risks when considering these therapies.
Prescription medications have been shown to help with menopausal symptoms, particularly hot flashes. Consider a trial of clonidine, gabapentin, a selective serotonin reuptake inhibitor, SSRI), or a serotonin norephinephrine reuptake inhibitor (SNRI). Evidence specific to medications will not be reviewed here.
Mood Swings and Irritability
Menopause is often a time of transition for most women, and life stressors in combination with changing hormone levels can result in some women feeling more sad and irritable. Healthy eating, regular exercise, and self-care are important to maintaining a stable mood. There are supplements that may also help
St. Johns wort (Hypericum perforatum) is commonly used for depression, and has been shown to improve mood and climacteric complaints in menopausal women. In one particular study, women using the combination of St. Johns wort and black cohosh reported improved scores for general menopausal symptoms and depression when compared to placebo.[25] The suggested dose is 300 mg three times daily (standardized to 0.3% hypericin or 4%-5% hyperforin). St. Johns wort is generally well-tolerated, but should be used with caution in combination with other medications metabolized through the P450 system.
Vaginal Dryness
As estrogen levels decrease in menopause, some women may experience vaginal dryness, leading to irritation and painful intercourse. Intravaginal estrogen will significantly improve dryness, but there are many other products and interventions that can help.
Vaginal moisturizers. Women with vaginal dryness should use a vaginal moisturizer daily to maintain moisture and flexibility. Women should massage the product in small, circular strokes into the inner vagina and outer vulvar region once a day for five minutes, using a vibrator for internal placement and massage. Waiting two to four weeks after starting a vaginal moisturizing regimen may be necessary before resuming sexual intercourse.
When having intercourse, women should also be counseled to use a lubricant to reduce discomfort from friction. Lubricants with glycerin should be avoided if prone to yeast infections. Avoid petroleum jelly and oil-based lubricants because the vagina cannot clear oils and these substances can dissolve the latex in condoms.
Herbs and supplements. A systematic review of 17 trials suggested that soy isoflavones may decrease vaginal symptoms in menopausal women when compared to control.[26] Refer to the Phytoestrogens Whole Health tool for more information.
Sex and menopause. Despite hormonal changes, a healthy sex life is possible during and after menopause. Encourage women to actively treat vaginal dryness, to touch and be touched, and to have sex regularly. Weekly orgasms help maintain healthy blood flow and sensation.[27] For more information about sex and menopause, check out the book Better Than I Ever Expected by Joan Price.
