Clinical Review

Treating hot flushes without hormone replacement therapy

OBG Manag. 2002 May;14(5):70-81

Many women who are either unwilling or unable to take hormone replacement therapy seek plant-based remedies to alleviate vasomotor symptoms that accompany the menopausal transition. Here, the author outlines the primary alternative therapies used to combat hot flushes.

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References

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Key points

About 21% of women surveyed use complementary or alternative therapies alone, and 25% said they used both conventional and alternative methods.
Women who take 50 mg of soy isoflavones daily typically report a 40% to 50% reduction in hot flushes.
Black cohosh yields up to an 80% improvement in hot flushes.
Doses of 40 mg of red clover per day effect a significant reduction in hot flushes.

Roughly 4,000 women in the United States turn 50 daily, joining the ranks of the 40 million American women currently menopausal. A survey published by the North American Menopause Society in 1998 found that the most common reason that women in this age group visit their physicians is to seek relief from everyday menopausal symptoms such as hot flushes. While temporary, hot flushes can last up to 2 years and are a result of changes in estrogen levels.

Women in Western countries have an 80% incidence of hot flushes.

Despite HRT’s proven efficacy in treating this plaguing symptom, many patients are fearful that HRT might lead to an increased risk of breast or uterine cancer or that it may cause unpleasant side effects such as mood swings, depression, or continued menstrual periods.¹ One study of 2,500 postmenopausal women found that 20% to 30% never fill their initial HRT prescriptions, 10% of those who use estrogen do so only intermittently, and an additional 20% discontinue their therapy within 8 months.² Furthermore, HRT is contraindicated in about 10% of postmenopausal women.³

With such an enormous number of women either unwilling or unable to take HRT, it is important to consider what alternatives an Ob/Gyn can offer for treating vasomotor symptoms. These choices certainly aren’t new. If we look back to the 1899 Merck Manual, recommendations included ammonia, camphor, Cannabis indica, opium, and suc ovarian (the “juice” from cow ovaries crushed at the slaughterhouse). While these therapeutic agents have fallen by the wayside, a number of alternative treatments for hot flushes are in use today by an increasing number of menopausal women.

How pervasive are alternative therapies?

So-called alternative approaches to menopause are used so widely that it might be more accurate to consider HRT as the true alternative medicine. Statistics presented at the National Institutes of Health on October 27, 2000, indicate that nearly half of all menopausal women are using complementary therapies, including vitamins, herbs, and soy products, to help treat their symptoms. Twenty-one percent of the women surveyed used complementary or alternative therapies alone, and 25% said they used both conventional and alternative methods. Taken together, that is more than twice the 19% who said they used conventional HRT only. Given this enormous usage, it should come as no surprise that, in 2001, the dietary supplement industry likely exceeded $12 billion in sales in the United States alone.⁴ For many women, the decision to use an alternative is not so much dissatisfaction with conventional treatment, but that they regard the complementary agents as more congruent with their own values, beliefs, and philosophical orientations toward health and life.⁵ This article will review some of the more commonly used alternatives that women use for the treatment of hot flushes. Patients should take an alternative for at least 1 month before initiating another one, to determine if it is achieving the desired effect.

Soy

Much of the excitement about the health benefits of soy, a staple of the Asian diet for 5,000 years, stems from epidemiological studies. The Asian diet, which is rich in isoflavones, is associated with a reduced risk of breast cancer, heart disease, and osteoporosis. Asian women also report fewer hot flushes than do their Western counterparts.⁶ One study showed that women in Western countries have an 80% incidence of hot flushes, while Asian women living in China have an incidence of only 20%.⁷ Clearly, factors other than soy also must be considered before we can make a direct cause-and-effect correlation. To that end, many studies have been conducted on the health benefits of soybeans, a rich source of the isoflavones genistein and daidzein.

Data suggest that soy is safe and effective in dosages of 40 g of soy protein or 50 mg of soy isoflavones per day.

Isoflavones are phytoestrogens with a heterocyclic phenol structure that is similar to estrogen. Their potency is between 1×10⁴ and 1×10³ the activity of 17β-estradiol.⁸ Although their potency is low, their serum concentrations can reach levels several orders of magnitude higher than those of physiologic estrogens. It is generally believed that isoflavones act as a selective estrogen receptor modulator (SERMs), exerting antiestrogenic effects in the high-estrogen environment of premenopause and estrogenic effects in the low-estrogen environment of postmenopause.