WHAT IS MENOPAUSE?

The term menopause is typically used to refer to what are actually three distinct phases: perimenopause, menopause, and postmenopause (Fig. 19-1). Perimenopause refers to the period of 2 to 8 years before the cessation of menstruation, during which regular cycles of ovulation and menses become irregular prior to terminating, a natural result of declining hormone levels, until one year after the cessation of menstruation. An elevated follicle stimulating hormone (FSH) level of 60 to 100 mIU/L on two tests done at least 1 month apart is considered indicative of menopause, although not definitive. Other hormonal indicators of the perimenopause are a luteinizing hormone (LH) level greater than 50 mIU/L and an estradiol level <50 pg/mL. The complete termination of menstrual bleeding for 12 months in the absence of another cause of amenorrhea heralds menopause and indicates that reproductive capabilities have ceased. Postmenopause is the time after complete cessation of menses. Despite ethnic, racial, and cultural variations, the median age around the world of 51 years for menopause indicates there are some common biological elements, although individuals range from ages 40 to 58 years old. However, there is a great deal of cultural disparity related to symptoms that arise during this period. For example, according to the World Health Organization (WHO), menopausal vasomotor symptoms are not as problematic for women worldwide as they are for women in the United States and other Westernized nations. Along with diet and exercise patterns, cultural attitude differences toward menopause may play some role in these epidemiologic differences.⁷

Figure 19-1 The STRAW staging system.

From Soules MR et al: Fertil Steril 2001; 76:874.

SYMPTOMS OF PERI/MENOPAUSE FOR WHICH WOMEN COMMONLY SEEK HERBAL CARE

Hot flashes, insomnia, memory problems, fatigue, heart palpitations, depression, anxiety, vaginal dryness, heavy vaginal bleeding, and incontinence are some of the most common problems for which women seek botanical therapies during the perimenopause and after. Women encounter new concerns about their heart and bones after menopause. Heart disease and osteoporosis raise the question of whether to use hormone replacement therapy (HRT) for protection. The chapters in this section present the reader with current botanical thinking, allowing practitioners to help their patients sort through the myriad of options available.

HERBAL STRATEGIES: AN OVERVIEW

Following is an introduction to the most common menopausal complaints and concerns, and the herbs most commonly used by menopausal women. The herbs are presented comprehensively throughout the remaining chapters in this section of the textbook, and many are also discussed further in Plant Profiles.

A number of botanicals are used in the symptomatic relief or treatment of peri- and postmenopausal complaints and problems—some of these, for example, soy, red clover, and black cohosh have become almost household names. Though the use of many herbs and supplements is supported by solid scientific, clinical, and historical evidence, caution is advised when considering and purschasing herbs and supplements marketed for menopause-related complaints. Menopause is a cash cow for the pharmaceutucal and supplement industries, which recognize the product sales potential in the vast number of women desiring relief from menopausal symptoms.

Botanical treatments must also be placed in the context of a holistic approach that recognizes and addresses social, emotional, psychological, and other factors that can impact women, and must be proactive in helping women to prevent the development of symptoms during this time in their lives, especially heart disease and osteoporosis.

SUMMARY

Menopause is a time of tremendous physical, emotional, and social change for women. It can be a major life milestone for some—a time of psychoemotional reckoning, evaluation, introspection, and integration, as well as a time of starting a new phase in life. For some women, this is a smooth transition; for others, it is a rocky time, accompanied by varying degrees of symptoms, some physical, others emotional. It is also a time of increased vulnerability to developing heart disease and osteoporosis, both of which can lead to major future debility and hardship. Therefore, this is a time that practitioners working with women must be aware of and address the many nuances of change women face and the enormous opportunity for preventative care. Botanicals are but one option for helping to support or restore health and balance as women face the beginning of the rest of their lives.

THE MEDICALIZATION OF MENOPAUSE

During the 1960s, with the popularization of hormone replacement, menopause became a treatable medical problem—and big business. Hormones became “the cure,” enabling women to remain “forever female.” The norm of care for middle- and upper-class white menopausal women in the United States from the mid-1960s to the present has been some form of hormonal supplementation: a combination of estrogen and progesterone for women who still have their uterus, estrogen for those without. It is now recognized that HRT increases the risk of endometrial and breast cancer. 11 12 13 15 16

Given the volumes of press devoted to HRT, one might assume that most US women use hormonal therapies at menopause; however, this is not the truth. One survey found that 52% of women wanted to avoid the use of hormones and 58% preferred alternative therapies for menopausal symptoms.¹⁷ Even before the recent cancellation of one large double-blind study of HRT, only half of all women over 50 had ever filled a prescription for estrogen or hormone replacement, and only one-third of those ever refilled the prescription. It is estimated that as many as 85% of the 37 million postmenopausal women [in the United States] do not want to use HRT.¹⁸ With growing concerns over the safety of HRT, many women—and even some physicians—are turning to alternatives. An understanding of the appropriate use of herbal medicines to nourish women during this transitional time and address common complaints associated with menopause, can ease this transition and promote health for women entering their “wisdom years.”

REFRAMING MENOPAUSE: WOMEN’S MYSTERY STORIES

Menopause is not simply an artifact of technology that has allowed us to expand our life expectancy and outlive our usefulness. Kristen Hawkes of the University of Utah studies hunter-gatherer cultures. Her “grandmother hypothesis,” based on observing the vigor and effectiveness of postmenopausal women in these cultures, demonstrates that postmenopausal women were critical to the health of their grandchildren, their community members, and the culture as a whole, and suggests that the presence of menopausal women in a society provides a survival advantage.¹⁹ The most industrious members of the Hazda culture are women in their fifties, sixties, and seventies says Dr. Hawkes. “The older woman knows the land, and its water, the seasons, the movements of the game, and the time to harvest each plant, she is not a sentiment, she is a requirement.”¹⁹ “Among many non-Western groups, the older woman enjoys increased status in the family and greater freedom in society at large. Menopause and the cessation of childbearing become positive events in a woman’s life. …“²⁰ Reframing menopause from a “problem” to a “gift” is a direct help to most women. Women in cultures in which menopause is regarded as a gift have fewer problems with the physical and emotional changes that accompany it.²¹ A vigorous life keeps women vital. Vigorous exercise and a whole foods diet can help us live longer; reframing menopause can help us enjoy each passing year: gray hair, wrinkles, and all.

Women’s mysteries are the great events of a woman’s life—menarche, pregnancy, lactation, menopause—and the stories and ceremonies associated with these life-changing times. Women’s mystery stories reveal important and surprising truths from a woman-centered perspective that has been lacking in “modern” medicine. The stories, ceremonial themes, and herbal remedies that are shared here from these mystery teachings evoke and rely on the millions of careful observations and experiments made by wise women over hundreds of generations. The mystery stories of menopause are gifts to modern women from their foremothers, the ancient healers: women who were deeply intuitive and in tune with women’s needs, emotional and spiritual as well as physical.

Using the mystery stories of menopause, we can ease a woman’s menopausal distress by reframing her experience. Reframing is done in a variety of effective ways, including one-on-one counseling, peer group sessions, teaching, performance arts, storytelling, and through the written word. Reframing menopause allows women to think outside the box of victim-centered cultural beliefs. Because both orthodox and alternative practitioners in the United States believe that menopausal symptoms indicate a lack or an imbalance, they frequently prescribe hormones for healthy, but symptomatic, menopausal women. This makes it easy for women to remain in the role of victim: She is a victim of menopause, a victim of a body that is undependable and unable to age without medical intervention.

We have come to believe, patient and practitioner alike, that normal aging is a failure of our glands and that hormones—not just estrogen, but progesterone, testosterone, DHEA, and melatonin—are fountains of youth that will provide for us when our bodies fail. Reframing our view leads not only to a different attitude about normal menopausal symptoms, but to radically different treatments, in which herbs are not used as natural hormones, but as sources of the rich variety of helpful phytochemicals available from nature. Reframing menopause gives women a greater sense of self-worth. We reframe “loss of fertility” into “acquisition of postmenopausal zest.” This gives women something to look forward, a reward for passing through the gates of menopause. One manifestation of this reframing is the “Crone’s Crowning Ceremony.” This honoring ceremony, which celebrates a woman’s passage through the menopausal years, has become increasingly popular in the United States, especially among “the culturally creative” and women engaged in natural lifestyles. 2 23

We reframe mood swings and depression into “menopausal women need more time alone,” validating a core need experienced by many menopausal women. Taking quality alone time during menopause appears to be a critical factor for mental and physical health. Time out can give the menopausal woman an opportunity to try out new ways of dressing, being, serving her community. It provides the freedom to experiment, and the privacy to feel safe doing it. Quiet time alone in nature, or sitting in a comfortable chair listening to soothing music allows the hidden thoughts and feelings that have accumulated since menarche to arise. Menopause encourages us to sort through those “holdings” and discard those that are no longer needed.

Women also find ways to reframe the “aggravating hot flash” into a “movement of energy.” Women have described themselves riding hot flashes like a surfer on a wave, skiing them like a snowboarder on a fresh snowy slope, luxuriating in them like a hot bath, and enjoying them like an especially intense orgasm. Women who reframe their hot flashes often report that doing so gives them an increased sense of empowerment.

MENOPAUSE SUPPORT GROUPS

Menopause support groups help women form alliances and are a natural extension of the groups women tend to form throughout different stages of their lives, for example, alliances of young mothers at the playground sharing the joys and challenges of child rearing, or breast cancer support groups. Menopause support groups give women a safe place to tell their stories without interference or judgment. Support groups help women share remedies, ways of coping, and prevent isolation as women experience shifting roles in their personal lives, which may include having an “empty nest,” divorce, or changes in work or social life. Talking about and listening to others helps us to remember that we are not the only ones going through changes, that we are part of the web of women.

A WHOLE FOODS DIET FOR MENOPAUSE AND BEYOND

The healthiest diet for most women, before, during, and after menopause, is a whole foods diet including whole grains and beans, nuts, seeds, a variety of organic fruits and vegetables, organic lean meats, cold water fish, good-quality oils, and organic dairy products. A whole foods diet is heart-healthy and less likely to promote diabetes, cardiovascular, and nutritional deficiencies that become more common as we age.

Adequate, high-quality fat intake is essential; human steroid hormones are synthesized from cholesterol. Interestingly, studies have shown an inverse correlation between milk consumption and breast cancer. After tracking 4,697 Finnish women ages 15 to 90 for 25 years, researchers discovered that those “women who habitually drank the most milk had only half the breast cancer risk of those who drank the least.”²⁵ A recent study done in the United States came to the same conclusion: Women who drank milk as children and continued to drink at least three glasses a day as adults had half the rate of breast cancer as those who drank little or no milk.²⁶ Is it possible that cholesterol-rich foods, eaten as part of a healthy whole foods diet are health promoting, and that hydrogenated and partially hydrogenated vegetable fats are the real culprits in heart disease?²⁷ A study of 61,000 Swedish women between the ages of 40 and 76 found that consumption of the monounsaturated fats, even from meat, milk, cheese, and butter, lowered the risk of breast cancer. For each 10 grams of monounsaturated fat [from dairy products and meat], the risk of breast cancer fell by 55%. For each 5 grams of polyunsaturated fat [from vegetable oil], the risk rose by 70%.²⁸ Studies on the relationship between dairy and cancer, however, are often conflicting, with other studies demonstrating a direct correlation between dairy consumption and ovarian cancer.

The healthiest women in the world may be the women of Greece. They have some of the lowest rates of heart disease and breast cancer in the world.²⁹ Their diets contain lavish amounts of olive oil, goat cheese, nuts, fresh vegetables, and meat. There is an inverse correlation between the amount of olive oil a Greek woman eats and her risk of breast cancer.³⁰

HERBAL MEDICINES FOR THE MENOPAUSAL YEARS

Goals for helping women experience a healthy menopausal transition may include:

The core approach to a healthy menopause achieves these goals through the use of nourishing herbal infusions, reframing counterproductive menopausal beliefs via counseling and/or group support, a whole foods diet that includes good-quality oils, calcium sources (e.g., organic yogurt), and healthy sources of phytoestrogens (not concentrated soy isolate supplements), and incorporates consistent, adequate exercise. Personal empowerment, time for reflection, and pursuing one’s dreams are also important for ease during this transition.

A FEW WORDS ON EXERCISE

Although exercise alone is not sufficient to prevent heart attacks, osteoporosis, or fractures, it is vitally and tremendously important in their prevention and for the promotion of healthy hearts, healthy bones, and longevity.⁵¹ Exercise not only strengthens bone, it also increases muscular flexibility and improves balance. A broken bone can cause a fall, but poor balance leads to more falls and more broken bones. Plus, of course, exercise improves the functioning of the heart, counters depression, and may even help prevent breast cancer. The amount of exercise needed varies, but 30 minutes daily is a goal most women can easily achieve and maintain. Any kind of exercise helps, but best results are found with a mix of strength building (such as weight training), simple walking—brisk if possible, and flexibility improvement with tai chi and yoga. Best of all, we are never too old and never too unfit to begin benefiting from some form of exercise.

SUMMARY

Menopause is a natural transition for most women. Reframing the menopause into a life—and age—affirming opportunity and transformation can improve women’s experiences of this time. Emotional and nutritional supports—including nourishing herbal infusions and a whole foods–based, phytoestrogen-rich diet plus exercise—are often sufficient to alleviate mild to moderate acute symptoms and provide a basis for long-term health of bones, heart, and breasts, and the whole, wise woman.

CONVENTIONAL TREATMENT APPROACHES

Until relatively recently, the allopathic gold standard of treatment for menopause has been HRT. Approximately 38% of postmenopausal women in the United States in 1995 used HRT, estrogen with or without progestin, to treat symptoms of menopause and prevent chronic conditions such as cardiovascular disease and osteoporosis.⁵⁵ In 2000, 46 million prescriptions were written for Premarin (conjugated equine estrogens), making it the second most frequently prescribed drug in the United States.⁵⁶ HRT was indicated for the classic symptoms of hot flashes and night sweats, which related to declining estrogen levels and are reported by 85% of US menopausal women. 57 58 HRT can effectively treat menopausal symptoms such as vasomotor instability (hot flashes), mood swings, concentration difficulties, dyspareunia, and vaginal irritation caused by dryness.⁵⁹

For women with an intact uterus, HRT includes both an estrogenic agent and a progestin. Progestins are generally indicated to offset the increased risk of endometrial cancer with the use of unopposed estrogen. For women using both an estrogenic agent and a progestin, there is a choice between cyclic and continuous dosing regimens. With the cyclic dosing regimens (intermittent high-dose progestin and estrogenic withdrawal), women can anticipate resuming a predictable (but artificial) menstrual cycle. With the continuous regimens (continual estrogen and low-dose progestin, without withdrawal), women can anticipate amenorrhea with occasional erratic spotting. Progestins are usually not recommended for women who have had a hysterectomy.⁶⁰

The preventive effects of HRT on long-term health outcomes are now challenged by new data from clinical studies. In terms of beneficial effects, randomized clinical trials have proved that HRT is effective for vasomotor and urogenital symptoms.⁶¹ A meta-analysis of estrogen treatment (oral or intravaginal) for urinary incontinence revealed a significant improvement in subjective symptoms, but no improvement in objective measures such as urodynamic testing.⁶² It is unclear if HRT helps directly with depression and other nervous system disorders. A “domino” effect may occur; for example, relieving hot flashes may improve sleep, which may improve mood.⁶³

Other allopathic treatments for hot flashes include a combination of ergotamine, belladonna alkaloids, and phenobarbital, which has been used for many years to relieve climacteric symptoms. Alpha-adrenergic agents, e.g., clonidine, are used for the relief of vasomotor symptoms. Physicians also prescribe serotonin reuptake inhibitors (SSRIs) to treat depression and mood disturbances related to menopause. “Off-label” use of megestrol acetate may help control hot flashes.