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A Natural Approach to Menopause

April 2006

By Dale Kiefer

Black Cohosh (Cimicifuga racemosa)

Benefits of Black Cohosh

Black cohosh (Cimicifuga racemosa) is a North American perennial herb that has been used to treat gynecological complaints for centuries. Native American healers and American physicians alike have prescribed black cohosh for relief from hot flashes and other menopausal symptoms.54 Listed as an official drug in the U.S. Pharmacopoeia from 1820 to 1926, black cohosh has been rediscovered by research scientists and menopausal women.18,55 Several recent clinical trials of exacting randomized, double-blind, placebo-controlled design have shown that black cohosh is indeed effective in reducing the severity, duration, and incidence of hot flashes and night sweats.6,16,17,56

A recent study at the Mayo Clinic in Scottsdale, AZ, examined the safety and effectiveness of black cohosh in reducing hot flashes. Weekly hot flash scores were reduced by 56% among women receiving black cohosh. Researchers noted that previous studies reported relatively high placebo effects in tests of treatments for hot flashes, but in this trial, placebo effects ranged from only 20% to 30%. “The efficacy found in this trial seems to be more than would be expected by a placebo effect,” according to the researchers. Women taking black cohosh in this study also reported less trouble sleeping, less fatigue, and less sweating.57

Another recently published study compared the efficacy and safety of black cohosh extract to a standard hormone replacement regimen (low-dose estradiol administered by skin patch). The researchers concluded that the two treatments were equally effective in reducing hot flashes. Both treatments significantly lowered LDL, but only black cohosh raised beneficial HDL. In addition, both patient groups experienced significant improvements in menopause-associated symptoms of anxiety and depression. Effects were noted within the first month of treatment and continued unabated for the three-month duration of the study. Neither treatment affected liver function or altered levels of follicle stimulating hormone, luteinizing hormone, or cortisol. The estradiol treatment, but not black cohosh, slightly increased levels of the hormone prolactin.58

Because of the potential estrogenic activity of black cohosh, scientists have carefully evaluated whether it is capable of influencing the growth of hormone-dependent cancers. Researchers at Northwestern Medical School who performed a series of sophisticated laboratory analyses of the extract concluded, “Black cohosh extracts did not demonstrate estrogenic activity in any of these assay systems.”59 However, German researchers found that black cohosh appears to exert estrogenic effects elsewhere in the body. They concluded that the botanical product demonstrated “no action in the uterus, but beneficial effects in . . . bone.”60

In practical terms, this means that black cohosh, like estradiol, prevented bone loss in laboratory animals after their ovaries had been removed. Unlike estradiol, black cohosh did not appear to exert any influence on the uterus, which may account for its superior safety profile compared to hormone replacement therapy. Thus, black cohosh not only reduces hot flashes, anxiety, and depression in menopausal women, but also appears to prevent some of the bone loss associated with the natural decline in estrogens, without the risk of stimulating uterine or breast cancer.60

In 2004, the North American Menopause Society added its stamp of approval to the use of black cohosh. In fact, it recommended black cohosh as a first-line approach. Its position statement reads, in part: “In women who need relief for mild [hot flashes and night sweats], NAMS recommends first considering lifestyle changes, either alone or combined with a nonprescription remedy, such as dietary isoflavones, black cohosh, or vitamin E.”61,62

Soothing Properties of Chasteberry

Chasteberry (Vitex agnus castus), also known as monk’s pepper, has served humankind for thousands of years. To be more precise, the berries of this deciduous shrub have benefited womankind for many years. In the ancient world, chasteberry was used to treat various gynecological complaints. For the past half century, chasteberry has been used to treat premenstrual syndrome (PMS), breast tenderness, and other gynecological conditions. In Europe, it is approved for the treatment of menstrual cycle irregularities, PMS, and breast discomfort by the German Commission E, which serves as a governmental regulatory agency for herbal medicines.15,63

Studies have shown that chasteberry acts in the brain to affect the neurotransmitter dopamine, which in turn indirectly affects the release of prolactin. Oscillating prolactin levels are thought to contribute to the breast tenderness and discomfort associated with PMS. Chasteberry has been shown to beneficially regulate several hormones including progesterone.15

Clinical trials of chasteberry for the treatment of PMS have demonstrated that it reduces a number of symptoms, especially breast pain or tenderness, headache, water retention, constipation, irritability, depressed mood, and even anger.13,15,64-70 Many small limited studies have confirmed these effects.15 Recently, a more rigorously designed study added further credence to these findings. This randomized, double-blind, placebo- controlled study of 170 women with PMS found significant improvement in self- and physician-assessed symptoms of irritability, mood change, anger, headache, breast fullness, and bloating. Symptoms decreased by 50% or more for more than half of the women taking chasteberry compared to placebo. Side effects were few and mild.13 Another double-blind, placebo-controlled trial examined chasteberry’s effects on at least three menstrual cycles in 104 women. Women in the treatment group showed significant improvement in cyclical breast discomfort.71

An intriguing study conducted in 2003 found that chasteberry was at least as effective as the popular antidepressant fluoxetine (Prozac®) in relieving premenstrual dysphoric disorder, a severe form of PMS characterized by extreme emotional and physical distress. Fluoxetine was somewhat better at improving psychological symptoms, but chasteberry did a better job of diminishing physical complaints.72 Last year, Italian researchers published a comprehensive review of all the relevant clinical data and concluded, “the data available seem to indicate that [chasteberry] is a safe herbal medicine.”63 Although no drug interactions have been reported, chasteberry might interfere with dopaminergic antagonist drugs. It should also be avoided during pregnancy or lactation, according to the Italian researchers.

Protective Action of Licorice Root

Licorice (Glycyrrhiza glabra) is native to the Mediterranean, where it has been used medicinally for thousands of years. Today, women may benefit from this sweet and fragrant root in a number of ways. Recent data indicate, for instance, that extracts of a Glycyrrhiza species exhibit estrogenic activity and put the brakes on breast cancer cells in the laboratory.73 Specifically, the licorice extract induced apoptosis, or programmed suicide, in a line of human breast cancer cells.

Licorice (Glycyrrhiza glabra)

Remarkably, this flavorful herb also exhibits activities that may ameliorate other common menopausal maladies, including depression, osteoporosis, and cardiovascular disease. In 2003, Israeli scientists reported that certain flavonoids extracted from licorice root inhibit the re-uptake of serotonin, much as estradiol does. Serotonin is a neurotransmitter that is thought to play an important role in regulating mood. Modern antidepressant drugs such as sertraline (Zoloft®) and fluoxetine (Prozac®) act in precisely this manner to alleviate depression. “This study showed that several isoflavans are unique phytoestrogens,” wrote the researchers, “and, thus, potentially may be beneficial for mild to moderate depression in pre-and post-menopausal women.”74

Noting that postmenopausal women are at greater risk of cardiovascular disease, possibly due to declining estrogen levels, another team of Israeli researchers investigated licorice root’s effects on blood vessels. Because it has estrogen-like properties, licorice extract stimulated DNA synthesis in human endothelial cells and affected the production of human vascular smooth muscle cells. “We suggest the use of glabrene [extracted from licorice root] with or without estradiol as a new agent for modulation of vascular injury and atherogenesis for the prevention of cardiovascular disease in postmenopausal women,” the scientists concluded.75

Finally, Korean researchers recently determined that glabridin, a biochemical extracted from licorice root, exerted powerful influences on bone precursor cells known as osteoblasts in the laboratory. The extract acted in several ways to promote the growth and health of these crucial bone cells. According to the researchers, “Our data indicate that the enhancement of osteoblast function by glabridin may result in the prevention of osteoporosis and inflammatory bone disease.”76 Scientists at Israel’s Tel-Aviv University have also demonstrated an osteoporosis-fighting effect of licorice components.77

A Chinese Remedy for Menopause

Dong quai (Angelica sinensis) is a traditional Chinese medicinal herb that has long been used to manage gynecological conditions. Few clinical trials of sufficient size and rigor have been conducted, so Western scientists tend toward skepticism regarding the use of this time-honored botanical for the relief of menopause symptoms. However, tantalizing research indicates that dong quai root contains a number of bioactive compounds that may help reduce menopause-related hot flashes, prevent cancer, boost immune function, and improve bone health.78-82

Not surprisingly, Chinese re-searchers have taken it upon themselves to validate claims for dong quai’s potential healing properties. Although one randomized, controlled clinical trial failed to find a significant difference between dong quai and placebo in relieving hot flashes,83 it should be noted that Chinese healers never prescribe dong quai alone. It is always administered in combination with one or more other herbs. In fact, a Chinese study of one such traditional herbal combination that included dong quai, among other botanicals, concluded that hot flashes and other menopausal complaints were reduced by 70%.80,84

Another recent study examined the effects of a combination of dong quai and chamomile in treating menopausal symptoms. This randomized, placebo-controlled study of 55 women found a significant difference in relief of hot flashes, insomnia, and fatigue between the treatment and placebo groups. Effects materialized in the treatment group within the first month of taking the herbs. “Treatment . . . seems to be effective for menopausal symptoms without apparent major adverse effects,” according to the researchers.85

A recent study of dong quai’s purported anxiety-relieving effects found that the essential oil of this Asian herb was about as effective as the prescription anti-anxiety drug diazepam (Valium®) in stress tests performed on laboratory mice.86 Another recent experiment showed that dong quai extract significantly halted replication of cancer cells in the laboratory, and induced apoptosis (programmed suicide) in the cells.81

In Chinese medicine, dong quai is often used in combination with other herbs to treat bone injuries. Seeking to understand how it affects bone health, scientists in Pennsylvania cultured human bone precursor cells with varying amounts of dong quai extract. They found that the extract stimulated proliferation of bone cells, while enhancing protein, collagen synthesis, and the activity of an enzyme associated with bone building.82


While plant-derived compounds such as phytoestrogens and lignans successfully counter menopausal symptoms in many women, others may need additional therapeutics to achieve optimal relief.

Bioidentical hormone replacement is an option for managing the uncomfortable effects of menopause. This method involves first assessing hormone levels with blood testing and then correcting deficiencies using hormones that are identical to those found naturally in the body. By restoring estrogens (using only natural forms), progesterone, DHEA, pregnenolone, and testosterone to the levels found in healthy women in their twenties, bioidentical hormone replacement therapy helps to relieve menopausal symptoms and enhance well-being. Supplementation with phytoestrogens, lignans, and cruciferous vegetable extracts may help protect against the increased cancer risk that even some natural estrogen drugs may induce.