Herbs for Menopause
Herbs for Menopause
By Lennie Martin, RN, FNP, DPH and Pam Jung, BA
Since ancient times, women have used numerous plants, trees, flowers, and roots to make medicinal preparations. In recent years a "green revolution" has led to resurging interest in herbal remedies.1 In increasing numbers, women are seeking self-care methods that are natural, safe, and ecological for easing the often troublesome symptoms they experience during the transition of menopause. These symptoms include hot flashes, night sweats, cognitive and mood changes, sleep disturbances, and congestive effects (fluid retention, bloating, PMS, pelvic pressure, breast tenderness, heavy flow). This review will focus on three herbs that may be useful for relieving or alleviating some of these symptoms: black cohosh, vitex, and kava.
Black Cohosh: Estrogenic Effects
Native to eastern North America, black cohosh (Cimicifuga racemosa) has a long history of traditional use by American Indians for female conditions, rheumatism, and snake bites, and as an insect repellent.
The active ingredient is thought to be triterpene glycosides (xylosides, actein, 27-deoxyactein, cimicifugoside). Other compounds isolated from the root include fatty acids, tannins, resins, and butyric, salicylic, and oleic acids.2 Studies have shown that compounds of the root bind to estrogen receptors, though this has been interpreted as blocking the receptor rather than activating it.3,4
Widely used in Europe for more than 40 years, black cohosh has been studied since the 1940s as a natural treatment for menstrual problems and menopausal symptoms, including hot flashes, insomnia, depression, anxiety, and forgetfulness. A German prospective, placebo-controlled study of 110 menopausal women who took 8 mg/d of black cohosh extract for eight weeks found estrogen-like effects on gonadotropin-releasing hormones.5
Most clinical studies have utilized RemifeminTM, a standardized commercial isopropanolic extract of black cohosh. Animal studies found no estrogenic effects on uterine growth in mice or on the maturation of vaginal cells in rats.6 Studies with menopausal women taking 40 drops of Remifemin bid have found 80% improvement of symptoms after four weeks,7 and decreases in menopausal symptoms with improvements in mood after 12 weeks.8
A 12-week, non-blinded, controlled study divided 60 women into three treatment groups: 40 drops of Remifemin bid, 0.625 mg/d of conjugated estrogens, or 2 mg/d of diazepam (ValiumTM).9 All three therapies decreased menopausal symptoms and improved mood. A 12-week, randomized, double-blind controlled trial (RDBCT) of 80 women compared Remifemin (8 mg/d of deoxyactein in tablet form) with conjugated estrogens 0.625 mg/d and placebo.10 Black cohosh improved menopausal symptoms and anxiety as much as estrogen; no improvement occurred when taking placebo. There was greater effect on growth of vaginal epithelium with black cohosh than with estrogen.
Black cohosh appears to be safe; no health hazards or serious side effects have been reported with proper administration at therapeutic dosages: 40 mg standardized herb extract (2 mg triterpene glycosides/d) or 40 drops standardized extract (5% triterpene glycosides/d). Gastric discomfort is a common minor adverse effect. Very high doses (greater than 5 g tablets or 12 g extract) can cause vomiting, headache, dizziness, limb pain, and low blood pressure.11
Vitex: Progestogenic and Hormone-Balancing Actions
Vitex (Vitex agnus castus), commonly called chaste tree or monk’s pepper, has been used since ancient times to suppress libido and calm sexual desire. The chaste tree produces small, reddish-black berries that contain iridoid glycosides (agnuside, aucubin), flavonoids (including casticin), volatile oils (including 1,8-cineol, alpha- and beta-pinenes), and fatty oils.11 Indigenous to the Mediterranean coast and central Asia, the dried ripe fruit and leaves have been used medicinally in Europe for years to treat PMS, breast pain, and menopausal symptoms.12
Vitex appears to act in areas of the brain that regulate pituitary hormones. By increasing secretion of luteinizing hormone and decreasing secretion of follicle stimulating hormone, vitex use results in a relative increase in progesterone and relative decrease in estrogens.13 Pituitary gonadotropin regulation provides the basis for the "female-balancing" effects of vitex, since many PMS and perimenopause symptoms result from estrogen excess. Considered a normalizing herb for the female reproductive system, vitex restores estrogen-progesterone balance, which helps regulate menstrual cycles, and stimulates prolactin release, which helps enhance lactation.14 By binding with dopamine receptors, it may support the serotonin-norepinephrine-dopamine system in the brain, resulting in positive mood enhancement.15 It also may activate the pituitary gland after delivery, resulting in early menstruation.12
Studies of abnormal menstrual cycles and PMS are pertinent, as these symptoms often intensify during the last years of perimenopause. Early research found vitex improved heavy bleeding and excessively short menstrual cycles in 65% of subjects, with 46% reporting complete resolution of abnormalities.16
In a recent German RDBCT on PMS, 127 women were placed in groups taking 3.5-4.2 mg standardized vitex extract capsules, 200 mg capsules pyridoxine (vitamin B6), or placebo.17 PMS symptoms included breast tenderness, fluid retention, tension, headache, constipation, and depression. After three months, 77.1% of subjects taking vitex reported improvement compared to 60.6% of those taking pyridoxine.
In a 1992 PMS study, 1,542 women, aged 13-62, received 40 drops of vitex liquid extract for an average of 25.3 days.18 Physician questionnaires rated vitex as "very good" or "good" 92% of the time. In contrast, 57% of the patients reported symptom improvement and 33% noted complete symptom relief.
At commonly recommended doses (20-40 mg/d of 50-70% liquid or dry extract, or 175-225 mg/d in tablet form standardized to 0.5% agnusides), vitex has not caused significant side effects.19 Infrequently, it may cause gastrointestinal disturbances, headache, rash, or itching.14,17 Vitex may interfere with some drugs including dopamine-receptor antagonists, birth control pills, and other hormones, and is contraindicated during pregnancy.17
Kava: Anxiety, Insomnia, Stress
Throughout the South Pacific islands, kava is used for ceremonial, health, and social purposes. Kava is prepared from the rhizomes and roots of the perennial shrub Piper methysticum, a member of the pepper tree family. The shrub is indigenous to Indonesia and widely cultivated, with several varieties found on different islands.20 Reports about the pharmacological effects of kava drinking have prompted numerous studies during the past 130 years, leading to classification of its major components.21 The active chemical compounds, called kavalactones, consist of methysticin, dihydromethysticin, yangonin, dihydrokawain, and kawain. Brain uptake of kavalactone is rapid, providing anticonvulsant effects.22 The soothing action of kavalactones on the amygdala, the brain’s alarm center, modulates emotional processes, which is thought to explain kava’s anti-anxiety, mood-elevating, and sleep-promoting properties.20,23
In many parts of the Pacific, kava has been taken to soothe nerves, induce relaxation and sleep, and counteract fatigue.24 It has been found helpful for asthma, rheumatism, and urinary problems.25 Hawaiian kahunas used kava for debility, headaches, stomach disorders, chills, and head colds.24
In a RDBCT, two groups of 29 patients were treated with a standardized extract of kava rhizome (70 mg kavalactones tid for four weeks) or placebo.26 Kava was clinically effective over placebo in reducing anxiety, tension, and excitation (not associated with mental illness). There were no adverse reactions. In multicenter RDBCT, 101 outpatients with severe anxiety and phobias were given a capsule of kava extract containing 70 mg kavalactones or placebo tid for 25 weeks.27 Both short- and long-term effectiveness of kava was superior to placebo, with more than half of the kava group rated as "very improved" in anxiety, fear, tension, and insomnia. Adverse reactions were mild and rare. The researchers concluded that kava could be an effective treatment alternative to both benzodiazepines and antidepressants for anxiety disorders.
Commonly recommended dosages range from 70-100 mg tid for anxiety and stress to 180-210 mg one hour before bedtime for sleep. Products should be standardized to 30-55% kavalactones. At 10 times the recommended dose taken for many months, kava drinkers in the Polynesian islands have developed kava dermopathy, a scaly rash and yellowing of the skin, associated with muscle spasms, vision disturbances, shortness of breath, and metabolic abnormalities.20,23 These problems have not been reported in the United States or Europe. Kava should not be combined with benzodiazepines, as disorientation and lethargy may occur.28 In Parkinson’s disease patients, kava may worsen muscular weakness and twitching.23 It may enhance the action of alcohol, antidepressants, other tranquilizers, and sleeping pills.29 Gastrointestinal disturbances, accommodation disorders, pupil dilation, and disorders of oculomotor equilibrium have been reported.29 Kava is contraindicated during pregnancy and breast-feeding.15,29 People taking the recommended doses of kava can usually drive an automobile and focus on work without sedation or diminished concentration.23
Conclusion
With increasing frequency, women are choosing to approach the transition of menopause from a holistic perspective. A number of herbal alternatives are available for menopausal women. Using recommended dosages of standardized herbal products, women may obtain significant relief from estrogen deficiency with black cohosh; from progesterone-estrogen imbalances with vitex; and from mood and stress related symptoms with kava.
Those women interested in exploring herbal remedies for the management of menopausal symptoms should seek the advice of a reputable herbal practitioner and discuss all products, pharmaceutical drugs and dietary supplements, with their health care provider. With the growing popularity of herbal remedies and many patients’ reluctance to disclose usage, nurses should routinely ask all patients about supplement use.
Dr. Martin is Emeritus Professor of Nursing at Sonoma State University and has a women’s health practice at Sierra Family Medical Clinic in Nevada City, CA. Ms. Jung is a health researcher and a women’s health consultant in Nevada City, CA.
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