Background
Menopause is a transitional stage in a woman’s life that holds enormous potential for transforming a woman’s physical, mental, and emotional well-being. It often occurs over the course of several years between ages 48-52, and will have several stages and that can vary both in their length and symptom picture. Menopause (i.e. the permanent cessation of menses for 12 months resulting from estrogen deficiency and which is not associated with a pathology) can occur either due to gradual natural processes, or also be abruptly induced by artificial means (e.g. surgery, radiation, drug therapy). When it occurs as a natural part of aging, earlier on in the menopausal transition stage (i.e. perimenopause), the menstrual cycle undergoes variability of its duration, and as it progresses women will typically experience amenorrhea for a period of 60 days or more. During this time many women will also experience vasomotor symptoms (e.g. hot flashes & night sweats), however menopause affects many other body systems as well including urogenital, musculoskeletal, psychogenic, and cardiovascular. A woman will have entered the post-menopausal stage once menstruation has ceased for 1 year and supportive lab work conveys an elevated FSH level (> 40 IU/L). It is important to impart to patients that while menopause may produce some concerning and/or uncomfortable signs and symptoms, it is not to be considered a true disease state or pathology but a normal bodily response to a naturally changing hormonal rhythm. As life expectancy increases it is worth noting that women are now estimated to be spending up to one-third of their lives in the post-menopausal stage[i].
Physiology of Menopause
Neuroendocrine communication within the hypothalamic-adrenal-ovarian axis is largely responsible for the physiological changes that occur throughout a woman’s life. Gonadotropin releasing hormone (GnRH) stimulates the secretion of the anterior pituitary hormones, luteinizing hormone (LH) and follicle stimulating hormone (FSH), that ultimately control the production of the gonadal steroids estrogen & progesterone. Physiologically, menopause involves an absence of active ovarian follicles, which results in the reduced production of estrogen, progesterone, testosterone, and DHEA from the ovaries. In response to the drop in estrogen, the pituitary gland increases the secretion of FSH & LH (note: When FSH > 25 IU/L women become more likely to experience vasomotor symptoms), which continues throughout the postmenopausal stage. LH and FSH cause the postmenopausal ovaries and adrenal glands to continue to secrete the androgens androstenedione & testosterone, which can then be converted to estrogen by adipocytes, however overall circulating estradiol (E2) after menopause drops significantly, and most estrogen is derived from the peripheral conversion of androstenedione to estrone (E1). Thus, in postmenopausal woman circulating levels of estrone are higher than estradiol, and the overall androgen to estrogen ratio changes not because there is more circulating testosterone (there is in fact less) but because the ratio of androgens to estrogen has changed, and there is relatively more testosterone due to there being less estrogen to oppose it.
Herbal Approach to Menopause
The aim of using herbal medicine during menopause is to manage the patient’s symptoms while nourishing the mind and the body in a way that will assist with the adjustments to its new ovarian and adrenal hormonal levels. Our goal should not be to simply override the body’s naturally fluctuating hormonal rhythms (i.e. raise circulating levels of estrogen, progesterone, testosterone, etc.), but to support the health of the body as a whole. To this end, the holistically-minded practitioner will understand the value of taking a ‘systems’ vs. purely ‘symptoms-based’ approach to menopause, and recognize that outside of supporting hormonal balance via the reproductive system, optimizing adrenal and nervous system activity as well as liver and gastrointestinal function will also aid the body as it adjusts to its new means of hormonal production and activity. Each systems role in menopause will be explored within this paper, along with highlighting the primary indicated herbal actions with key herbal examples to address symptoms related to these systems imbalances. Depending on the patient’s individual symptom picture, certain herbs and herbal actions will vary in their level of prioritization, dosing strategy, and duration of treatment, with the goal always being to wean or withdraw treatment whenever possible. In some cases, herbs will be best used acutely in higher dosing ranges to manage more difficult symptoms causing disruption of daily life (e.g. hot flashes, insomnia), while others may require a more long-term approach, especially when the intention is to nourish the HPA axis, or aid in the prevention of complications or chronic disease states associates with the postmenopausal stage (e.g. cardiovascular disease, osteoporosis, and cancer).
Herbal Approach to The Reproductive System & Hormonal Decline
Many of the uncomfortable symptoms of menopause are due in large part to the body’s inability to respond to decreases in not only estrogen, but also progesterone, testosterone and DHEA (dehydroepiandrosterone). Fluctuations in estrogen are largely responsible for vasomotor symptoms as well as the cognitive changes which can occur when estrogen rapidly declines leading to “brain fog” and short term memory loss (which can be worsened by difficulty sleeping). Moreover, these hormonal changes are also largely responsible for the increased risk of osteoporosis, cardiovascular disease, and urogenital atrophy caused by thinning of the reproductive tissues and leading to vaginal dryness/discomfort, urinary symptoms, and painful intercourse. Conventionally, hormone therapy (HRT) is used to treat vasomotor symptoms and prevent vaginal/urogenital atrophy, as well as preserve a healthy lipoprotein profile and prevent bone loss. In menopausal women, the administration of physiologic doses of estradiol (E2) and/or a combination of estrogen-progestin therapy results in a rapid and sustained decrease in LH & FSH levels which can decrease the severity and frequency of hot flashes, improve urogenital atrophy and sleep disturbance, and prevent osteoporosis and associated fractures. However, HRT is still known to carry serious risks (e.g. increased risk of breast cancer, ovarian cancer, thromboembolism, stroke and coronary heart disease). Such risks do not appear to be associated with herbal medicines which appear to act as Selective Estrogen Receptor Modulators (SERMs).[ii]
Plant constituents which appear primarily responsible for such estrogen modulating effects are collectively referred to as phytoestrogens due to the fact that many structurally resemble estradiol and thus can act in a similar manner. They are present in common foods such as soybeans, grains, fruits and vegetables, and can compete with endogenous estrogen and bind to ER-alpha & beta receptors in the body however with much lower and variably affinity[iii]. Some phytoestrogens appear to display different affinities to either ER-alpha or beta receptors, and their cellular effects can be influenced by many factors, including concentration, receptor status, amount of endogenous estrogens present, and target tissue.[iv] Overall, they are proposed to act primarily as modulators of estrogen activity, capable of recruiting co-activators to either elicit or repress an estrogenic response rather than to promote one directly. Thus they may have both agonistic and antagonistic effects, acting as either partial agonists or antagonists. In high estrogen environments they can lead to the displacement of endogenous estrogen, and in low estrogen environments they can potentially create a net estrogenic effect.[v] Interestingly, many phytoestrogens must first be hydrolyzed by bowel flora before becoming biologically active (are inactive when present in their natural bound form as glycosides), indicating the importance of a healthy gut flora and a system-based approach when addressing hormonal imbalances with herbal medicine. Epidemiological studies have suggested a decreased incidence of breast cancer and lower occurrence of menopausal symptoms and osteoporosis in women from countries with a high consumption of phytoestrogens (found mainly in soy products).[vi]
Chemical Classes of Plant Phytoestrogens with Herbal Examples
- Isoflavones
Include genistein, diadzein (equol), biochanin A, formononetin, 8-prenylnaringenin found in Soy (Glycine max), Red Clover (Trifolium pratense), Hops (Humulus lupulus) - Lignans
Include enterodiol & enterolactone, formed by bacterial action on the precursor secoisolariciresinol diglucosides found in Flax seed (Linum ussitatissimum) - Saponins
Include protodioscin found in Tribulus terrestis (Tribulus), diosgenin & dioscin found in Wild Yam (Dioscorea villosa) & Shatavari (Asparagus racemosus), ginsenosides found in Asian Ginseng (Panax Ginseng), glycyrrhizin found in Licorice (Glycyrrhiza glabra) - Coumestans
Include coumestol found in Red Clover (Trifolium pratense) & Alfalfa (Medicago sativa) - Stilbenes
Include Resveratrol found in Grapes (Vitis vinifera)
Given the concerns regarding potential adverse effects of hormone replacement therapy, phytoestrogens have played a significant role in the exploration for alternatives for the treatment of menopausal symptoms, and their effects specifically on the alleviation of vasomotor symptoms and the maintenance of bone mineral density have demonstrated some promising results. [i], [ii], [iii], [iv].Though our understanding of their precise mechanism of action in the body is still being elucidated, several theories currently being explored include possible mechanisms such as their effect on estrogen biosynthesis and excretion, interactions with estrogen receptors, and overall effect on cellular growth and proliferation[v]. Phytoestrogens are also potent anti-inflammatories, and may help promote indirect estrogenic effects in part through modification of the hypothalamic-pituitary-adrenal axis[vi]. In postmenopausal women phytoestrogens may interact with secondary ER receptors (such as in the hypothalamus and/or pituitary gland) to decrease the symptoms of estrogen withdrawal by binding to vacant receptors and reducing the symptoms of hot flashes by convincing the body that there is more estrogen present in the bloodstream than there actually is. Being much weaker in comparison to endogenous estrogen, another theory is that the body may respond to their weak estrogen signalling by increasing FSH and thus increasing the production of estrogen precursors from the adrenal cortex. It is important to mention that other herbs such as Chaste Tree (Vitex agnus-castus) do not appear to act via phytoestrogenic mechanisms, but still play important roles in managing symptoms related to hormonal fluctuations via proposed activity upon the pituitary gland leading to downstream progestogenic effects.
Herbal Approach to The Reproductive System & Hormonal Decline
Primary Symptoms
- Vasomotor symptoms (e.g. hot flashes, night sweats, and sleep disturbance)
- Vaginal dryness/painful intercourse
- Low Libido
- Hair thinning, facial hair & acne
- Frequent infections (e.g. urinary tract)
Key Herbal Actions
- Selective estrogen receptor modulators (SERMS)
- Pituitary adjuvant*
Key Herbal Examples
- Trifolium pratense (Red Clover)
- Angelica sinensis (Dong Quai)
- Tribulus terrestis (Tribulus)
- Asparagus racemosa (Shatavari)
- Glycyrrhiza glabra (Licorice)
- Panax ginseng (Korean ginseng)
- Actacea (Cimicifuga) racemosa (Black Cohosh)
- Dioscorea villosa (Wild Yam)
- Humulus lupulus (Hops)
- Paeonia lactiflora (Peony)
- Vitex agnus-castus (Chaste Tree)*
Herbal Approach to the Adrenals & Nervous System
Research into the physiological changes which take place during peri-menopausal and menopausal stages is revealing that in addition to the hormonal shift which brings an end to menstruation, the adrenal and nervous systems are also undergoing dramatic changes.[i] The cessation of ovarian estrogen production has the potential to influence central nervous system function as well as a number of neurological disorders that can affect women during the menopausal transition including memory loss and mild cognitive impairment.[ii] Additionally, the adrenal cortex is now recognized as an important contributor to the foundation of endocrine health and to a woman’s healthy aging, and changes in circulating steroid hormones released from the adrenals during the menopausal transition may in fact be more important than the decline of ovarian function in terms of affecting estrogen and androgen balance.[iii] As ovarian hormone production slows, the adrenal glands become primarily responsible for balancing the body’s endocrine function, thus supporting adrenal function is imperative to maintaining optimal health and reducing uncomfortable symptoms during menopause.
Truly the importance of herbal Adaptogens cannot be overlooked. Interestingly, the consumption of foods containing phytoestrogens has also been found to potentially alter adrenocortical function as well as cortisol and androgen production.[iv]
Another important and complementary action group alongside herbal Adaptogens are the herbal Nervines (Tonics & Relaxants), and often these actions can be synchronized to work together alongside each other in a way that will benefit the body on multiple levels.
Nervine Tonics & Relaxants are a group of herbs that help relieve stress through promoting parasympathetic nervous system (“rest & digest”) dominance. They are used primarily to support symptoms related to stress, pain, sleep disturbance, anxiety, and depression, and will strengthen & nourish the nervous system when coping with excessive or prolonged periods of tension and/or exhaustion, in some cases helping to restore central and peripheral tissues directly, and/or modulate the action of various neurotransmitters (e.g. GABA, Serotonin). It is worth noting that conventional approaches to managing vasomotor menopausal symptoms include the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) and Gabapentin (though it is not FDA-approved for this use). Many herbal nervines have overlapping antispasmodic/analgesic effects, and alongside adaptogens both are ideally used long-term (minimum 1-2 months) for best therapeutic effects. Key herbal examples have been outlined in Table 4.
Herbal Approach to the Adrenals & Nervous System
Primary Symptoms
- Mood disorders (e.g. anxiety, depression, mood swings)
- Stress & Irritability/Agitation
- Insomnia & sleep disturbance
- Cognitive changes (e.g. impaired memory, concentration)
- Low Libido
Key Herbal Actions
- Adaptogens
- Nervine Tonics & Relaxants
Key Herbal Examples
Adaptogens
- Withania somniferum (Ashwagandha)
- Schisandra chinensis (Schisandra)
- Rhodiola rosea (Rhodiola)
- Glycyrrhiza glabra (Licorice)
- Eleutherococcus senticosus (Eleuthero)
- Panax ginseng (Asian ginseng)
Nervine Tonics & Relaxants
- Zizyphus spinosa (Zizyphus)
- Hypericum perforatum (St John’s wort)
- Salvia officinalis (Sage)
- Turnera diffusa (Damiana)
- Piper methysticum (Kava)
- Valerian officinalis (Valerian)
Note: A combination of Valerian and Kava can be particularly effective for patients with sleep-onset insomnia. For sleep-maintenance insomnia, a combination of Chaste tree (at doses equivalent to 1500 to 2000 mg/day) and kava should be considered.
Herbal Approach to the Liver & Digestive System
The holistically-minded practitioner understands just how crucial digestive health is to the overall healthy functioning of the body. The daily toxic and metabolic burden imposed upon the gastrointestinal tract and its accessory organs (e.g. the liver) have the potential to affect our mental, emotional, and physical health in profound ways. Moreover, the intestinal microbiome, along with the enteric nervous system and its relationship to the central nervous system are key and often overlooked components of conventional treatment approaches to the symptoms menopause. The severity of GI symptoms, including abdominal pain, altered bowel habits, and bloating, occur often but vary widely across patients during the menopause transition with one possible mechanism being declining or low ovarian hormone levels. [i] When GI symptoms are found alongside mood swings, and headaches, often the patient is in need of supportive work surrounding liver detoxification or clearance to ensure adequate metabolism of excess hormones. Additionally, recent herb–microbiota interaction studies are providing a deeper understanding of the importance of the overall activity and bioavailability of orally consumed herbal medicines in relation to the patient’s gut microbiome.[ii] What is becoming abundantly clear is the importance of a healthy digestive system not only for the health of the body as a whole, but also for the bioactivity of many of our herbal medicines. For example, some common properties of most phytoestrogens include their metabolism by gut flora to additional derivatives with varying estrogenic activity (e.g. Equol is produced from daidzein by the action of intestinal flora, though this metabolic conversion is estimated to occurs in only 30% of the population).[iii] Herbals which may have a supportive role in GI health during menopause are outlined in Table 5.
Herbal Approach to the Liver & Digestive System
Primary Symptoms
Liver
- Abdominal bloating & indigestion
- Dysfunctional bowel motility (e.g. Diarrhea/constipation)
Gastrointestinal System
- Dysfunctional bowel motility (e.g. Diarrhea/constipation)
Key Herbal Actions
Liver
- Bitters/Hepatics & Hepatoprotectives
Gastrointestinal System
- Bulking Laxatives
Key Herbal Examples
Liver
- Taraxacum officinalis radix (Dandelion root)
- Schisandra chinensis (Schisandra)
- Silybum marianum (Milk/St. Mary’s Thistle)
- Hydrastis Canadensis (Goldenseal)
- Cynara scolymus (Artichoke)
Gastrointestinal System
- Ulmus fulva (Slippery Elm)
- Plantago psyllium (Psyllium)
- Linum usitatissimum (Flax seed)
- Aloe barbadensis (Aloe vera gel)
Conclusion
The aim of using herbal medicine during menopause is to address key symptomatic complaints while taking a whole-body or systems-based approach to this transitional period in a woman’s life. Mental, emotional, and physical aspects of health should all be acknowledged while assisting with the adjustments to the body’s new circulating levels of ovarian and adrenal hormones. Beyond supporting hormonal balance via the reproductive system, optimizing adrenal and nervous system activity as well as liver and gastrointestinal function should all be prioritized. Depending on the patient’s individual symptom picture, certain herbs and herbal actions will vary in their level of prioritization, dosing strategy, and duration of treatment, with the goal always being to wean or withdraw treatment whenever possible. In some cases, herbs will be best used acutely in higher dosing ranges to manage more difficult symptoms causing disruption of daily life (e.g. hot flashes, insomnia), while others may require a more long-term approach, especially when the intention is to nourish the HPA axis, or aid in the prevention of complications or chronic disease states associates with the postmenopausal stage (e.g. cardiovascular disease, osteoporosis, and cancer). As always, when used alongside appropriate diet and lifestyle practices, herbal medicine continues to prove its value and unique ability to improve health outcomes. Though the exact nature of herbal treatment should depend on the factors identified in the individual case, an effective treatment approach should be selected from the following:
- Consider plants with estrogen-modulating effects (e.g. SERMs, phytoestrogens).
- Provide ongoing adrenal & nervous system support through the use of herbal adaptogens & nervines.
- Optimize gastrointestinal health & the diversity of the intestinal microbiome.
- Support liver detoxification processes through the use of hepatic stimulants & protectants.
