Menopause

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Chapter 21 Menopause

Jon Wardle, ND, MPH

OVERVIEW

Menopause represents the natural transition from fertility to age-related non-fertility. The term ‘menopause’ specifically means the cessation of menstruation, and most often occurs between the ages of 45 and 55 years, with the average age for the last period being 51 years.

All healthy women will transition from a reproductive (premenopausal) period—marked by regular ovulation and cyclic menstrual bleeding—to a postmenopausal period marked by amenorrhoea. The onset of the menopausal transition is marked by changes in the menstrual cycle and in the duration or amount of menstrual flow (see Table 21.1). Subsequently, cycles are missed, but the pattern is often erratic early in the menopausal transition. Therefore the menopause is defined retrospectively after 12 months of continued amenorrhoea.

Table 21.1 The stages of menopause

The term ‘perimenopause’ is most often used to describe the time leading up to and directly following menopause.² During perimenopause, hormone levels fluctuate and women may experience a variety of symptoms including vasomotor symptoms (hot flushes and night sweats), vulvovaginal atrophy, emotional fluctuations and cognitive decline (memory problems). Some women experience very little in the way of these symptoms; for others this time is particularly debilitating. Low oestrogen levels postmenopause also increase the risk of a number of other physical conditions including osteoporosis and cardiovascular disease. The various symptoms of the menopausal transition are associated with a variety of physiological changes and the responses to these changes. Figure 21.1 shows the symptoms associated with changes in hormone levels.

Figure 21.1 Menopausal symptom and hormone changes over time ³

In the postmenopausal phase FSH rise to levels 10–15 times the level that can be expected during the follicular phase of a reproductive cycle, while LH levels increase to around three times that experienced during menstruation. The ovaries do continue to excrete minimal amounts of oestrogens, and continue to excrete significant amounts of androgens.²

It should also be noted that individual women will experience the menopausal transition differently. The prevalence rates of the main symptoms can vary greatly across the different stages of menopause (see Figure 21.2).⁴

Figure 21.2 Prevalence rates of the main symptoms of menopause ⁴

CONVENTIONAL TREATMENT

Conventional practitioners tend to underestimate the effects of perimenopausal symptoms on their patients.⁵ However, fewer than 25% of women experience a (relatively) symptom-free menopause and over 25% of women experience debilitating symptoms.⁶ Many women turn to conventional practitioners for explanation and reassurance rather than treatment.³

Much controversy has raged during recent years over what is termed the ‘medicalisation’ of naturally occurring life stages, of which the most publicised is menopause. Conventional practice has often viewed menopause as a condition of oestrogen deficiency, and treatment is based on the use of supplemental hormones, commonly referred to as hormone therapy (HT).

There is much conjecture and controversy surrounding the use of HT in menopause. There are definite benefits to using HT. HT is effective for vasomotor symptoms, vulvovaginal atrophy symptoms, osteoporosis-related fracture prevention, and benefits cardiovascular and central nervous systems.⁷ However, continued use of HT can increase the risk for venous thromboembolism and increases the risk of developing breast cancer.⁷

BIOIDENTICAL HORMONE THERAPY: SAFER, MORE EFFECTIVE?

Most of the data suggesting risks associated with hormone therapy have been conducted using equine or synthetic hormones, and there is little evidence of the safety or efficacy of bioidentical or natural hormones. Theoretically they are suggested to proffer advantage in that they are more closely aligned with the innate hormones seen in the body and can be individually tailored (when compounded), but they should not automatically be considered the safer option. Both the Therapeutic Goods Administration of Australia and The Federal Drug Administration in the United States of America consider the adverse effects of HT as reported to be a ‘class effect’—that is, that bioidentical hormones can be considered to have the same risks and benefits as conventional HT. In fact most conventional HT used in Australia already uses oestradiol and other forms considered to be bioidentical. However, progestin is known to have very different, often contradictory, physiological actions to natural progesterone in many women. Regardless, focusing solely on direct hormone replacement does not address the underlying causes of the symptoms experienced by perimenopausal women and therefore when used alone may not be reflective of naturopathic or holistic best practice. While HT use is ultimately a matter for discussion between physician and patient, it should form only part of the treatment strategy in the naturopathic management of menopause.

HT may be recommended in certain circumstances—specifically, distressing symptoms or significant osteoporosis.⁷ Longer-term use of HT is generally considered a matter for discussion between the physician and the patient, with risks taken into account in addition to potential benefit to bone health and quality of life. Generally, long-term use is discouraged and physicians are encouraged to use lower therapeutic doses.

Various forms of oestrogen have been used for many years as a hormonal supplement to treat menopausal symptoms and are generally thought to be the most effective treatment for vasomotor symptoms. Oestrogen is therefore no longer recommended for prevention of chronic conditions, although it is effective and approved for osteoporosis prevention.⁴ Women with an intact uterus are usually prescribed the ‘opposed’ regimen (when oestrogen is combined with a progestin to avoid the development of endometrial hyperplasia and endometrial cancer). Testosterone may also be given to women. Examples of commonly used HT in Australia are listed in Tables 21.2 and 21.3.

Table 21.2 Oestrogens often used in menopause ³

Table 21.3 Progestogens often used in menopause

GENERIC NAME	DAILY DOSE RANGE	USUAL DAILY PROTECTIVE DOSE
Dydrogesterone	10–20 mg	10 mg
Medroxyprogesterone acetate	2.5–20 mg	10 mg
Norethisterone	1.25–5 mg	2.5 mg

However, much conventional medical treatment of menopause is comprised of educational and lifestyle management of symptoms. Several other classes of prescription medications are also used in the treatment of menopausal symptoms, including antihypertensive medications such as clonidine for hot flushes and various antidepressants or anxiolytics for psychological symptoms. Much of this research has come from the treatment of menopausal women with breast cancer, in whom hormone therapy is contraindicated.

RISK FACTORS

Although much focus tends to be drawn towards the effect that HT can have on increasing breast cancer risk, other modifiable lifestyle factors such as little exercise, smoking, postmenopausal weight gain and high alcohol consumption may increase the risk of not only breast cancer but other menopausal symptoms as well.⁸

Risk factors for severity of symptoms during perimenopause include genetics (symptoms experienced by the mother may give a guide), body mass index (BMI)—women with a higher BMI may experience a lower level of perimenopause symptoms due to the production of oestrogen by aromatase in adipose tissue (see Chapter 19 on endometriosis).

The duration of symptoms appears independent of HT but is less in those groups with higher physical activity.⁹ Other lifestyle factors, such as increased alcohol and caffeine use and smoking, are also associated with worsened menopausal symptoms.¹⁰

KEY TREATMENT PROTOCOLS

Perimenopause is a natural stage of life and not a disease or a disorder. Therefore it does not automatically require any kind of medical intervention or treatment. However, this natural transition is not always a smooth one and in certain cases the physical, mental and emotional effects associated with perimenopause can be quite severe and may significantly disrupt the lives of women experiencing them. Naturopathic treatment therefore focuses on reducing these effects and ensuring quality of life throughout this transition. Various lifestyle and dietary habits can have significant effects on the severity of menopausal symptoms, so treatment should otherwise focus on ensuring optimal health.

NATUROPATHIC TREATMENT AIMS

• Improve quality of life.

• Reduce symptoms (hot flushes, psychological symptoms and fatigue).

• Maintain ideal weight and health parameters (for cardiovascular and bone health).

• Manage stress.

• Address sexual health.

• Modify diet to improve symptoms and to reduce osteoporosis and cardiovascular risk.

Naturopathic treatment focuses on general improvement in physiology as opposed to correction or counteracting the effects of menopause with oestrogen supplementation. Many clinicians make the assumption that only climacteric symptoms are of concern in menopausal patients. As naturopathic treatment of a perimenopausal patient is focused on supportive care throughout the process, rather than correction of an aetiological or pathological condition, a broader clinical enquiry that extends beyond symptoms relating to oestrogen deficiency needs to be undertaken. Enquiries need to be made about mental state—anger and irritability, depression, moodiness, loss of self-esteem and sleeping difficulties. Sexual function and urinary function also need to be explored in depth.

Women undergoing the menopause transition turn to complementary medicines not only to seek effective treatment but also to gain greater control over their symptoms.¹⁷ It is therefore essential that a strong participatory relationship is encouraged during treatment and that the naturopath does not fall into the habit of product-prescribing only.

When looking at the literature there seems to be little relation to gross product sales (the most commonly sold complementary therapies for menopause) and specific clinical effectiveness. However, these therapies may be working on broader improvements or act on a psychosomatic level by offering the patients the opportunity to take control of their condition. For example, while acupuncture does not seem to have specific effects on menopausal symptoms such as hot flushes ¹⁸ it does seem to offer improvements to quality of life scores in perimenopausal women overall.¹⁹

For example, treatment with a combination Hypericum perforatum and Cimicifuga racemosa product for 16 weeks resulted in a 50% reduction in Menopause Rating Scale (MRS) scores, with a 41.8% reduction in the Hamilton Depression Rating Scale.²⁰

OESTROGEN-LIKE COMPOUNDS AND OESTROGEN RECEPTOR ACTIVITY

Many compounds—both natural and synthetic—may mimic endogenous sex hormones.¹¹^–¹³ Phytoestrogens may bind to and activate these oestrogen receptor sites. Given the use of hormone replacement therapy in conventional treatment, these compounds are gaining popularity amongst both the public and practitioners for relieving menopausal symptoms.

For example, the phytoestrogenic isoflavones found in Trifolium pratense and soy are thought to have beneficial effects on cognitive abilities, bone mineral density and plasma lipid concentrations in menopausal women.¹⁴ Phytoestrogenic activity may also be utilised in traditional Chinese medicine. Astragalus membranaceus and Scutellaria baicalensis are traditionally used in the treatment of menopausal symptoms in traditional Chinese medicine and exert oestrogenic activity in vivo.¹⁵

Dietary intake of phytoestrogens and an increased consumption of whole-grain foods may also be associated with a reduction in vasomotor symptoms.¹⁶

Many compounds exerting oestrogenic activity will be discussed in relation to symptoms. Many have not actually been studied extensively for menopausal symptoms, but phytoestrogens are discussed in more detail in Chapter 19 on endometriosis.

Although C. racemosa was effective in treating neurovegetative symptoms of depression in menopausal women, combination treatment was more effective than C. racemosa treatment alone.²¹ These changes seem more significant than the effects on vasomotor symptoms alone. And while H. perforatum does not seem to exert a significant effect on hot flush symptoms, it does proffer significant improvement on quality of life scales due to its effect on other symptoms associated with menopause and should therefore also be considered.²² C. racemosa also has positive effects on overall quality of life scales and other broader menopause rating scales when used alone in addition to its effects on individual symptoms.²³ Several relaxation therapies have also proven to be effective in alleviating or reducing a number of perimenopausal symptoms, rather than having specific outcomes.

Major symptoms

Hot flushes

Exercise

Because exercise has demonstrated effects on sex steroids, it may moderate at least the severity, if not the frequency, of hot flushes.^9,²⁴^–²⁶ One epidemiological study found that women who belonged to a gymnasium club reported lower incidence of hot flushes than those who were not, although their individual exercise regimens were unreported.²⁷ However, studies on exercise, while generally demonstrating reduced severity and incidence of hot flushes, suggest it has had the greatest effect on quality of life scores.

Herbal medicine

A 2007 systematic review of 17 trials of which 11 could be included showed a demonstrated effect of Trifolium pratense in reducing hot flush symptoms in menopause.³⁴ A 2005 review of trials found 12 clinical trials of C. racemosa in vasomotor symptoms,

BLACK COHOSH SAFETY

Although concerns relating to the hepatotoxicity of Cimicifuga racemosa have been raised, systematic reviews have suggested it can be generally thought to be a safe medicine, with the main side effects being mild and reversible, and no direct causal link to Cimicifuga was found in cases of severe hepatotoxicity.²⁸^–³¹ In the most recent trial, long-term supplementation of Cimicifuga for a period of 1 year was found to have no effects on hepatic blood flow or liver function.³² However, an association does exist as hepatotoxicity has occurred in several people taking supplements containing Cimicifuga. This is thought to be related to issues of product quality, concomitant medications or individual genetic susceptibility. Although the specific mechanism relating to hepatotoxicity associated with Cimicifuga use is unknown, one theory gaining credence is an immunologic reaction to triterpene glycosides in the plant in susceptible individuals, rather than the direct result of inherent toxicity.³³ Therefore these issues should be considered when advising or treating patients using these therapies, as they should for any other pharmacological intervention.

all but one of which demonstrated benefit,³⁵ and a later non-specific review found significant benefit also.³⁶

C. racemosa may act through a number of pathways independent of its activity as a phytoestrogen. Recent evidence suggests that it may have an effect on opiate receptors.³⁷ Cimicifuga extract has also been demonstrated to exert dopaminergic activity in vitro.³⁸ This may in part also explain the effects of Cimicifuga in menopause as dopaminergic drugs are often used to treat menopausal symptoms such as hot flushes. Some studies have suggested that Cimicifuga has an equipotent effect to oestrogen³⁹ although this does not seem reflective of the entirety of the data.^40,⁴¹ It should be noted, however, that significant heterogeneity exists in the results for differing formulations, suggesting that quality issues need to be considered before prescribing.

Angelica sinensis and Matricaria recutita in combination has been demonstrated to reduce hot flushes and improve sleep in menopausal women,⁴² but other trials have failed to demonstrate these results when Angelica sinensis was used alone.^43,⁴⁴

Humulus lupulus supplementation over 12 weeks was found to reduce discomforting symptoms of menopause, particularly hot flushes, even at low doses.⁴⁵ This is thought to be due to the oestrogenic nature of H. lupulus.⁴⁶ Salvia officinalis was also demonstrated to improve symptoms of hot flushes and nights sweats in perimenopausal women.⁴⁷

Psychosocial interventions

Several trials have shown that relaxation training can have positive effects on hot flush symptoms.⁴⁸^–⁵¹ These include biofeedback, breathing exercises and meditation. Yoga may also be beneficial in reducing menopausal symptoms exacerbated by mental stress.^52,⁵³

Psychological interventions

Panax ginseng has been demonstrated to improve psychological symptoms, particularly fatigue, insomnia and depression, in menopausal women.⁵⁴

In menopausal women with psychological and psychosomatic symptoms, sole therapy using Hypericum perforatum demonstrated significant improvement (76.4% self-evaluation and 79.2% physician evaluation), including improved sexual wellbeing.⁵⁵

Piper methysticum as an adjuvant treatment has been demonstrated to reduce anxiety in perimenopausal women.⁵⁶ It may also be useful in treating sleep disorders not associated with vasomotor symptoms that are often experienced by perimenopausal women (see Chapter 14 on insomnia).

Sexual function and libido

Women undergoing the perimenopausal transition often experience changes in libido or dyspareunia which can be influenced by a number of physiological or psychosocial ways. Hormone changes may influence sexual function in a number of ways. Low levels of oestrogens and androgens seem to be directly related to libido, as do low levels of testosterone.⁵⁷ Physical changes enacted by alterations in hormone levels—for example, vaginal dryness associated with lower levels of oestrogen—will have a significant negative effect on sexual response. Lack of lubrication can result in soreness and tenderness, and ultimately less enjoyment during sexual encounters for these reasons. Anticipation of painful sex due to lack of lubrication after a negative experience may further decrease desire. Patients need to be counselled adequately on the practical implications of the menopausal transition as many women may not have previously needed to apply measures such as endogenous lubrication. Oestrogens also have a vasodilatory effect that can result in increased blood flow in vaginal, clitoral and urethral areas; this may reduce during menopause, and loss of oestrogen is also associated with relaxation of vaginal tissue and muscle tone in genital areas. Encouraging circulation and tone in these areas—for example, through pelvic floor exercises or more general regimens such as exercise, yoga or tai chi—may also be useful.

Physical changes alone are not solely responsible for the negative effects of the perimenopausal transition on sexual function and libido. Psychological changes such as depression, anxiety and low self-esteem can all affect sexual desire and enjoyment, as can many of the medicines prescribed for these conditions. Conversely, the effects of menopausal changes on a woman’s sex life can also precipitate psychological changes. The social construct of menopause in modern society can also have a deleterious effect in this regard. Menopause in Western societies is often viewed negatively, particularly in relation to the loss of femininity. This is in stark contrast to many traditional cultures, who often view the transition as a positive one that affords them respect as elders and relief from child-bearing. Patients need to be counselled appropriately throughout this period, encouraged to explore their femininity and sexual selves and reminded that these aspects of themselves need not diminish once menstruation ceases. One study has shown that while yoga therapy did not increase general self-esteem, it was significant in improving esteem relating to perceived sexual attractiveness.⁵⁸

Many herbal medicines have been used to increase libido. Asparagus racemosus is colloquially referred to as ‘she with one thousand husbands’ in the Ayurvedic tradition in reference to its effects on sexual function and has demonstrated positive results in animal studies, but is yet to be tested through human trials.⁵⁹ This situation is also true of other traditionally used aphrodisiac herbs such as Turnera diffusa and Tribulus terrestris. A product containing Panax ginseng, Turnera diffusa, Ginkgo biloba and l-arginine has been found to significantly increase libido in women at all stages of the menopausal transition compared to placebo in two small trials.^60,⁶¹

Treating the psychological symptoms associated with menopause may also improve libido. Hypericum perforatum—a herb commonly used to treat the psychosocial problems associated with menopause—was found to improve libido when used to treat seasonal affective disorder ⁶² and improved sexual wellbeing in 80% of perimenopausal women when prescribed for psychosocial symptoms.⁵⁵ Trigonella foenum-graecum has been used for postmenopausal vaginal dryness in the North American naturopathic tradition.⁶³

Vaginal atrophy and incontinence

After menopause the vaginal lining may thin due to lower oestrogen levels. This may result in painful intercourse and a greater susceptibility to vaginal infections. Regular intercourse may be beneficial as it increases blood flow to the genitalia, but adequate lubrication is required—natural or supplemental. Naturopathic treatment options for recurrent bladder infections are covered in Chapter 27.

Vitamin D may have a role in reducing vaginal atrophy. Supplementation with vitamin D has reduced vaginal atrophy in one small trial.⁶⁴

Incontinence incidence may increase in postmenopausal women. Many women may resign themselves to this being a normal part of the ageing process, but there are several therapeutic options available. Pelvic floor exercises may reduce the incidence of incontinence in postmenopausal women and improve quality of life.⁶⁵ Increased physical exercise more generally may also be beneficial in reducing the incidence or severity of urinary incontinence.⁶⁶

Urinary tract infections

Approximately 15% of menopausal women will experience frequent bladder infections.² General recommendations for urinary tract infections are discussed in Chapter 27 on urinary tract infection, but there are several factors to take into consideration when treating urinary tract infections in perimenopausal women, such as decreased acidity of the urine, loss of bladder elasticity, due to lower oestrogen levels and the fact that urinary tract infections are often symptomless during the menopause.

Long-term considerations

Although much focus tends to be drawn towards the association between hormone therapy and increasing breast cancer, other modifiable lifestyle factors such as little exercise, smoking, postmenopausal weight gain and high alcohol consumption have similar rates of increased risk of breast cancer.⁸ And although fat intake alone is not associated with

increased risk of breast cancer, attention to this lifestyle factor can help to improve the cardiovascular outcomes usually associated with the menopausal transition.⁶⁷ Attention needs to be paid to the long-term consequences of the menopausal transition as well as short-term symptomatic treatment.

Dietary modification is an essential part of treating the perimenopausal patient. Not only are long-term risks such as osteoporosis and cardiovascular health significantly affected by dietary intakes, but dietary factors also have important effects on symptom severity during the menopausal transition. No consultation is complete without investigation of the dietary component.

Osteoporosis

In a clinical setting osteoporosis is often addressed in the context of menopausal treatment because it is found in postmenopausal women and can be largely prevented by correcting oestrogen deficiency. Approximately 30% of postmenopausal women are estimated to have osteoporosis.⁶⁸ The hypo-oestrogenic state leads to loss of bone density in postmenopausal women by activation of the bone remodelling units with an excess of bone resorption compared to bone formation.⁶⁹

Adequate dietary intakes are necessary for prevention and treatment of osteoporosis.

Another dietary intervention that may be beneficial for osteoporosis in postmenopausal women is omega-3 fatty acids. Several human and animal studies have shown significant decreases in bone resorption and a protective effect on bone with omega-3 fatty acids.⁷⁰^–⁷²

Adequate calcium and vitamin D consumption are essential in the treatment of osteoporosis. It is generally recommended that 1500 mg of calcium and 800 IU per day of vitamin D are recommended for postmenopausal women.⁷ Dietary sources of calcium are listed in Table 21.4. However, dietary intake of calcium alone may not be sufficient, particularly in women who have undergone early menopause.⁷³ Sunlight exposure of 5–10 minutes per day may be required, particularly considering that older people may synthesise vitamin D less well over time. Supplementation of both calcium and vitamin D may be necessary. However, large studies such as the Women’s Health Initiative have shown that reliance on supplementation can be fraught, as compliance can be low—only 59% of women were taking more than 80% of their recommended supplementation towards the study’s end.⁷⁴ Dietary modification should therefore form the basis of treatment. More dietary recommendations for bone health can be found in Chapter 22 on osteoarthritis.

Table 21.4 Calcium content of foods ⁴

FOOD	AMOUNT	CALCIUM CONTENT (MG)
Yoghurt	200 g (1 small tub)	520
Calcium-enriched milk	250 mL (1 cup)	475
Skim milk	250 mL (1 cup)	400
Tahini	20 g	310
Full fat milk	250 mL (1 cup)	300
Calcium-enriched soy milk	250 mL (1 cup)	290
Sardines	5 whole	286
Cheddar cheese	30 g (1 slice)	232
Parmesan cheese	20 g	230
Salmon (tinned)	½ cup with bones	220
Prawns	1 cup	132
Mussels	6 whole	120
Dried figs	3	108
Tofu	80 g	96
Ice-cream	60 g (2 scoops)	90
Soy beans, chickpeas or kidney beans	½ cup	70
Dried apricots	10 halves	42
Silverbeet or spinach	½ cup	38
Oranges	1 whole	35
Broccoli	1 cup	25

Phytoestrogenic therapy may offer a limited protective role.⁷⁵ Considering that HT and SORM therapy are both used to prevent the effects of osteoporosis, this is worth exploring. Increased soy consumption may inhibit bone resorption and stimulate bone formation^76,⁷⁷ and population studies indicate that the incidence of osteoporosis is lower in countries with higher soy consumption.¹⁴

Regular exercise can increase bone density in postmenopausal women.⁶⁸ However, high impact exercise may be counterproductive as more severe forms of exercise may result in micro-damage, increasing the risk of fracture.⁷⁸ Regular tai chi exercise may improve bone density scores and offer protection against fracture in postmenopausal women.⁷⁹ Further benefits of specific exercises are discussed in Chapter 22 on osteoarthritis.

Cardiovascular health

Women are offered a higher degree of protection against cardiovascular disease before the menopause due to higher oestrogen levels. However, reductions in oestrogen levels postmenopause result in women having the same incidence of cardiovascular disease as men by the age of 70 years.⁸⁰ Despite this protective mechanism it is still estimated that 94% of adverse cardiovascular risk in women is associated with modifiable risk factors such as type II diabetes, hypertension, diet, stress, smoking and obesity.⁸¹ Therefore women who have previously not had to consider cardiovascular health implications may need to investigate this issue in more depth (see the section on the cardiovascular system).

Exercise

As well as the benefits of regular exercise in treating specific menopausal symptoms such as hot flushes previously outlined, exercise confers a number of other benefits in the perimenopausal patient. These benefits include decreased bone loss, improved circulation,

Figure 21.3 Naturopathic treatment decision tree—menopause

cardiovascular function and risk profile, improved mental wellbeing and stress reduction and increased endurance and energy. Perimenopausal patients usually comprise an older demographic than the typical patient, and encouraging healthy behaviours can ensure healthy ageing and protection against many age-related conditions.

As menopause is not a defined medical condition but rather a collection of symptoms associated with a transitional stage through life, many of the treatments are covered in other relevant chapters. Table 21.5 focuses on vasomotor symptoms.

Table 21.5 Review of the major evidence

INTEGRATIVE MEDICAL CONSIDERATIONS

Acupuncture

Acupuncture does offer specific effects on menopausal symptoms such as hot flushes,^24,⁸² but demonstrates significantly greater improvements to quality of life scores in perimenopausal women more broadly.¹⁹ Traditional Chinese medicine has a long history of treating menopausal symptoms and, typically, acupuncture would not be used alone.⁸³ However, to be effective these treatments need to be prescribed according to traditional Chinese medicine theory.