Transcript Integrative Approach to Menopause

Integrative Women’s Health:
Caring for the Menopausal
Woman
Priscilla Abercrombie, RN, NP, PhD, AHN-BC
Assistant Clinical Professor
UCSF, Dept of Community Health Systems
Dept of Obstetrics, Gynecology, and
Reproductive Sciences
NCCAM Definitions
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Complementary medicine is used together
with conventional medicine.
Alternative medicine is used in place of
conventional medicine.
Integrative medicine, as defined by NCCAM,
combines mainstream medical therapies and
CAM therapies for which there is some highquality scientific evidence of safety and
effectiveness.
© 2008 Priscilla Abercrombie
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Tenets of Integrative Health Care
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Patients want health care that is safe,
effective and affordable
Patients want to be cared for as unique
holistic beings; mind, body and spirit
Patients want to explore and understand all
of the health care options available to them;
conventional, alternative and complementary
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Tenets of Integrative Health Care
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Patients are encouraged to be active participants in
their health care and to seek a collaborative
relationship with their provider that is empowering
and supportive
The provider guides the patient on their quest for
health and healing based on experience, education
and the ability to examine the scientific evidence to
support recommended treatments
Health care is healing oriented and engages the
body’s natural and innate ability to heal itself
whenever possible
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Why should providers care about CAM
therapies?
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25- 36% of their patients are using them
Only 45-56% will tell their provider about their
use
68% of patients in one study felt the herbs
improved their symptoms
Use of CAM is common among many
ethnicities (50% Hispanic, 50% Asian, 41%
White, 22% African American)
(Brett, 2007; Dailey, 2003; Kuo, 2004)
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Integrative Care for
Menopausal Symptoms:
Focus on Hot Flashes
Menopause
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12 months of amenorrhea, retrospective diagnosis
Usually occurs between 50-52 yrs old
A variety of physiological changes occur that can
have a profound impact on women’s lives.
Menopause is the result of the natural decline in the
hormones (estrogen, progesterone) produced in the
ovaries.
As hormone levels decrease, a number of
symptoms may emerge, although their presentation
and severity varies greatly from woman to woman.
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Menopausal symptoms
Vasomotor
Genitourinary
Other Systemic
Headache
Palpitations
Vaginal dryness
Dyspareunia
Fatigue
Reduced sexual
desire or arousal
Night sweats
Insomnia/
sleep
disturbance
Vaginal itching or
burning
Anxiety, irritability,
depression
Urinary frequency,
dysuria, urgency
Cognitive difficulties
Backache, stiffness
ARHP
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Hot flashes
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Hot flashes typically begin when cycles become
irregular, occur in 80% of women (Kronenberg,1990)
Usually end 1-2 years after menstruation has ceased
but can continue for 5 years or more.
Symptoms range from flushing or warmth in the face
and upper body to sweating and chills lasting an
average of 4 min., 20% women find them intolerable.
Can lead to severe sleep disturbances.
Appear to be the result of mixed signals from the
hypothalamus, resulting in altered thermoregulation,
the exact mechanism is unknown
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Conventional
Treatment
Hormone Therapy: Women’s Health Initiative - First
randomized, controlled trial in women (50-79 years)
treated with HRT
-40
-80
+41%
+26%
Breast cancer
0
+29%
Tromb. venous
40
Stroke
80
Hip fracture
+112%
120
Vertebral fracture
Disadvantages
Intestinal cancer
160
Cardiovascular
diseases
Difference % vs. placebo
6700 women with 5.2 years of follow-up
-37%
-34%
-34%
Advantages
Manson JE at al, N Engl J Med, 2003;349:523-534
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Discuss Risks and Benefits
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Routes of administration
Regimens
Types of estrogens and progestogens
Bioidentical hormones
Compounding hormones
Saliva or blood testing to monitor hormones
What is “natural” to you?
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Practice Guidelines
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Organizations:
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American College of Obstetricians & Gynecologists
Food & Drug Administration
North American Menopause Society
General Recommendations
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Use close to menopause
Start at lowest dose
Use shortest time possible
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Bioidentical hormones
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Manufactured to have the same molecular structure
as the hormones made in the body
Individualized dosages can be made in
compounding pharmacy
Dose/formulation based upon results of blood or
saliva tests for estrogen, testosterone, DHEA
Dosage changes over time based upon symptoms
and hormone levels
Safety and efficacy not well studied
Prometrium is bio-identical progesterone
17 ß-estradiol is bio-identical, available in patch
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Bioidentical HT
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Thought to mimic levels of estrogen in the body:
90% estriol, 3% estrone, 7% estradiol
Tri-Est: estriol 1mg, estrone 0.125 mg, estradiol
0.125 mg taken BID (=0.625 premarin)
Bi-Est: estriol 80% and estradiol 20%
Estriol may have protective effect against breast
cancer but not well studied
Estriol alone does increase risk of endometrial
hyperplasia and cancer
Compounded hormones are more expensive
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“Natural” hormones
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What is “natural” to you?
Many pharmaceuticals containing estradiol
are derived from soybeans or wild yam (Ex:
Estrace, Ortho-Est, Climara, Estraderm
Premarin is derived from the urine of
pregnant mares
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Pharmaceuticals
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Paroxetine (Paxil): SSRI, 2 large trials, 1025mg/d, significant reduction in hot flash
frequency, may interfere with tamoxifen, SEs:
headache, nausea, dry mouth, loss of appetite
Venlafaxine (Effexor): SNRI, 1 large trial, 37.5 or
75(ER) mg/d, decreased number of hot flashes,
increased well being, higher doses more
effective but more SE’s, can cause heavy
uterine bleeding, galactorrhea, mastodynia
Gabapentin (Neurotin): anti-convulsant, 2 trials
effective, 900mg/d, SE: dizziness and
sleepiness.
© 2008 Priscilla Abercrombie
Pharmaceuticals con’t
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Clonidine: antihypertensive, 10 trials, half
showing reduced hot flash frequency and
severity, mostly studied with women taking
tamoxifen, SE: difficulty sleeping
Many of these drugs reduced frequency of hot
flashes but not always severity, clinical
significance?
None of these drugs have FDA approval for the
treatment of hot flashes.
Be aware of drug interactions: MAO inhibitors, St
John’s Wort, tamoxifen
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Bellergal Retard®
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40 mg phenobarbital, 0.6 mg ergotamine
tartrate, and 0.2 mg levorotatory alkaloids of
belladonna, one twice daily
Only non-hormonal drug approved by the
FDA for hot flashes and other menopausal
symptoms
Side effects: addictive, dizziness, sleepiness
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Botanicals
Valerian
Black Cohosh (Cimicifuga racemosa)
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Most studies have shown significant relief of
vasomotor and other symptoms (psych, vaginal
proliferation, etc.) but inconclusive
Remifemin®: study doses ranged from 20-80
mg taken twice daily.
German health authorities and WHO endorse its
use for premenstrual discomfort, dysmenorrhea
and menopause. NAMS for mild to moderate
hot flashes.
Mechanism of action unknown but likely
nonhormonal
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Black Cohosh con’t
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Two extensive safety reviews concluded it is
without significant adverse effects; 4 case
reports linked black cohosh to acute liver
disease. A causal relationship has not been
established. Check liver enzymes.
There is no evidence that it increases risk for
breast cancer but safety not known in
women with a history of breast cancer.
NIH studies in process, negative study
published 12/06
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Chastetree fruit (Vitex agnus castus)
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German E Commission endorsed for PMS,
irregular menses, and mastalgia
Has been found to increase progesterone thus
stabilizing the endometrium (used in infertility)
Dose: 500mg/d crude herb
Few side effects; mostly GI
No RCT evaluating its use in menopause
Some estrogen receptor binding, not for use in
women with breast cancer
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Sage (Salvia officinalis L )
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Traditionally combined with other herbs for hot
flashes or night sweats
German E Commission recognizes its use for
dyspepsia and excessive sweating
May exert some weak estrogenic activity
A small number of uncontrolled studies show that it
was effective for hot flashes and night sweats
Dose: Ex: Menopause Feminine®, 15mg taken BID
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St John’s Wort (Hypercium perforatum)
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Effective for mild to moderate depression
Not studied in menopause but found in many
menopause formulas
Dose: 300mg 3x daily, of 0.3% hypericin
standardize extract
Precautions: interactions with many drugs,
including OC’s
National Cancer Institute-funded Hypericum
perforatum (St. John's wort) in Relieving Hot
Flashes in Women with Non-Metastatic Breast
Cancer phase II trial in process
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Ginseng
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Panax ginseng (Asian ginseng) and Panax
quinquefolius (American ginseng) have been
traditionally used as tonics
2 studies (American ginseng) conducted showed no
significant change in hot flashes (Wiklund1999;
Tode, 1999)
But both studies showed improved sense of
wellbeing, depression, mood and sleep consistent
with its traditional use as a tonic (invigoration or
fortification)
Dose: standardized extract ranging from 100-600
mg per day
Side effects: well tolerated, comparable to placebo
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What doesn’t seem to work
Soy
 Red clover
 Evening primrose oil
 Don Quai
 Wild yam
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Don Quai
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Phytoestrogens: Soy (Glycine max)
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Asian women report less hot flashes, this is thought
to be due to dietary intake of soy
Non-fermented soy contains isoflavones
predominantly in their glycoside form (e.g. genistin,
daidzin).
When eaten these are converted to their more
active aglycone form (e.g., genistein, daidzein).
The intestinal micoflora then further change them to
more biologically active compounds.
Not everyone has the microflora needed to make
this last conversion - only 35% of Westerners
Fermented soy products have higher levels of the
active compounds
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More on soy
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Appears to have weak estrogenic and anti-estrogenic
activities
Studies used a variety of soy isoflavones in different
dosages and combinations, doses ranged from 50100mg/day
There is some evidence that increasing the intake of soy
foods may help with menopausal symptoms though results
of randomized clinical trials are contradictory (Nelson,
2006; Low Dog, 2005)
Does not appear to effect mammographic breast density
Long term treatment with soy (high dosages of isoflavones)
has been associated with endometrial hyperplasia
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Phytoestrogens: Red Clover
(Trifolium pratense)
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Semi-purified isoflavones from the blossoms have
been studied as Promensil® and Rimostil®
They have differing types and amounts of isoflavones
5 controlled trials have been conducted: no significant
reduction in hot flashes in systematic reviews (Nelson,
2006; Low Dog, 2005; Krebs, 2004)
Does not appear to effect mammographic breast
density (Atkinson, 2004) or endometrium (CliftonBligh, 2001)
Safety in women with breast cancer unknown
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Don Quai (Angelica sinensis)
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Traditionally used as a tonic in TCM for
many centuries (not for menopause),
combined with other herbs
Usual dose is 3-6 g/day in 3 doses
One study failed to find a reduction in hot
flashes (Hirata, 1997)
May interfere with warfarin, may increase
menstrual bleeding, safety in women
with a history of breast cancer not known
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Evening primrose oil (Oenothera biennis)
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Extracted from the wildflower's seeds, rich in
linoleic acid
Standardized to 320-360 mg of linoleic acid
and 40 mg y-linolenic acid per capsule
Usual dose: 3-6 g/day
Well tolerated, some GI side effects,
aggravation of temporal lobe epilepsy?
One small study did not find benefit for hot
flashes (Chenoy1994)
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Wild Yam (Dioscorea villosa)
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Wild yam contains diosgenin which
can not be converted in the body
Is converted in the lab to make a
number of steroids including
progesterone
Sold as herbal cream sometimes
with progesterone OTC
One RPCT showed no effect on
menopausal symptoms or blood
hormone levels (Komesaroff, 2001)
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Preventive Health
Medical Conditions More Common After
Menopause
Osteoporosis
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Incidence substantially increased after menopause
Estrogen reduction increases bone resorption
Atherosclerotic disease
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Rates in women increase after age 50
Total cholesterol, LDL cholesterol, and triglyceride levels
increase; HDL cholesterol level decreases
The leading cause of death in both women and men
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Recommended Screening Exams
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Clinical breast exam
Mammogram
Pap smear
Cholesterol, glucose, liver enzymes
Colon cancer screening
Others as appropriate: TSH, CBC, FSH etc.
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Supplements
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Multivitamin: natural vitamin E, mixed
carotenoids, B vitamins
Calcium
Vitamin D
Magnesium
Fish Oil
Others as appropriate
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Nutrition
General Recommendations
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5-7 servings of vegetables and fruits
Whole grains
Healthy fats
Calcium rich foods
Anti-inflammatory herbs and spices
Mushrooms
Hydrate
Avoid hot flash triggers: hot foods, spicy
foods, alcohol, limit caffeine
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Physical Activity
General Recommendations
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Aerobic exercise thought to reduce hot flashes and
improve quality of life, mixed results in studies
Physical activity reduces cardiac disease, cancer,
obesity (CDC) and depression (Dunn, 2005)
Essential for weight management
Moderate intensity exercise 5-7 times a week (CDC)
Walking for weight bearing: pedometer for objective
measurement
Resistance training and strengthening important
Identify barriers and preferences
Provide resources
© 2008 Priscilla Abercrombie
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Mind/Body/Spirit
Mind/Body Health
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Paced breathing found to be more beneficial than
neurofeedback with alpha wave training
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(Freedman, 1995)
Trained relaxation techniques for 20 minutes each
day better than diary (Irwin, 1996)
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Recommendation:
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Try mind/body practices for symptom relief and stress
reduction: guided imagery, MBSR, breath work, yoga,
tai chi, qi gong, massage
Seek therapy for depression
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Lifestyle and behavioral changes
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Identify hot flash triggers
Modify environment: keep ambient
temperature cool, wear cool clothes, drink
chilled beverages
Practice journaling
Learn sleep hygiene strategies
Seek social support and ability to share
experiences
Address spiritual needs: life transition, finding
meaning in the experience
© 2008 Priscilla Abercrombie
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Alternative Therapies
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Acupuncture studies
show mixed results
(Vincent, 2007; Huang,
2006; Wyon, 2004)
Homeopathy studies
show improvement in
symptoms and quality
of life (Jacobs, 2005;
Clover, 2002)
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Resources
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Reviews:
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Low Dog, T. (2005) Menopause: a review of botanical
dietary supplements, American Journal of Medicine, 118,
985.
Nelson, H., et al. (2006). Nonhormonal therapies for
menopausal hot flashes. Systematic review and metaanalysis. JAMA, 295, 2057.
Hickey, M. et al. (2005) Treatment of menopausal
symptoms, what should we do now? Lancet,
366(9483):409
Natural Standard or Natural Medicine database for
herbs and supplements, CAM therapies
Consumerlabs.com evaluates supplements
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Summary
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Providing integrative health care for women during
the menopause transition involves incorporating
many different avenues of healing.
There are a number of CAM treatments that can be
safely integrated into care although their
effectiveness has not been adequately studied in
many cases.
Integrative practitioners are ideally suited to provide
holistic care for the perimenopausal woman;
addressing her mind, body and spirit.
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