Vegan Lifestyle Coach

Menopause

Preventive Medicine and Nutrition

Physicians committee for responsible medicine

A Natural Approach to Menopause

Every day, in hundreds of doctors’ offices, the same conversation takes place between women going through menopause and their doctors. The doctor writes out a prescription for estrogen pills or patches, saying they will replace the hormones her body ought to be making. They will cure her hot flashes, slow her bone loss, and reduce her risk of a heart attack. The patient asks if the pills cause cancer. The doctor acknowledges that there is an increased risk of uterine and breast cancer, but argues that the benefits to the heart and bones are worth taking the chance.

Other risks enter into the discussion: strokes, blood clots, and water retention, among others. Women who have seen friends or relatives die of cancer or stroke might not find this very reassuring. They may have menopausal symptoms, and they would like a solution. But they are looking for something safe, that doesn’t cause more problems than it solves.

Take heart: there are dietary steps, other lifestyle changes, and natural hormone preparations that can make menopause much more manageable. They are better for your heart and bones than estrogen prescriptions could ever hope to be, and they accomplish these things without the side effects of estrogens.

Premarin is a commonly prescribed estrogen preparation from Wyeth-Ayerst Laboratories. Although doctors sometimes describe it as “natural” for women, it is actually a horse estrogen. On farms in North Dakota and Canada, 75,000 mares are impregnated and then confined from the fourth month through the end of their eleven-month pregnancy so their urine can be gathered in a collection harness called a “pee bag.” After they give birth, the mares are reimpregnated. Their foals usually end up as horse meat, and the urine estrogens are packed into pills. The trade name “Premarin” is simply a condensation of the words “pregnant mares’ urine”—hardly a natural substance for human beings to swallow. While Premarin contains estradiol and estrone, two types of estrogen which are made in humans, it also contains an enormous amount of equilin, a horse estrogen that never occurs at all in humans.

Estrogen supplements increase the risk of blood clots and can cause high blood pressure, gallstones, vaginal bleeding, nausea, weight gain, breast tenderness, skin discolorations, headaches, and depression. They also increase the risk of uterine and breast cancer and make existing cancers much more aggressive. Women taking estrogen supplements have 30 to 80 percent more breast cancer risk than other women.1-3

If progesterone is added to the regimen, it removes the increased risk of uterine cancer, although it does not counteract the higher risk of breast cancer. Synthetic progestins have side effects of their own, sometimes causing breast tenderness and fluid retention, and making depression worse.

So why are so many doctors prescribing them? Partly to treat menopausal symptoms. But more of the push for estrogens relates to osteoporosis and heart disease. Happily, there are healthier solutions for both problems.

Natural Changes

At around age 50, the ovaries stop producing estrogens. The adrenal glands (small organs on top of each kidney) continue to make estrogens, as does fat tissue. But the ovaries have produced the greatest share of the body’s estrogens for decades, and when they quit, the blood levels of estrogens drop dramatically.

Many women go through this change feeling fine, both physically and psychologically. Nonetheless, some women are bothered by symptoms, including hot flashes, depression, irritability, anxiety, and other problems.

There Is No Japanese Word for Hot Flashes

It has long been known that menopause is much easier for Asian women than it is for most Westerners. In a 1983 study, hot flashes were reported by only about 10 percent of Japanese women at menopause, compared to about two-thirds of women in America and other Western countries.4 And bone strength is not assaulted to the extent it often is among Western women. Broken hips and spinal fractures are much less common.

The most likely explanation is this: throughout their lives, Western women consume much more meat and about four times as much fat as do women on Asian rice-based diets, and only one-quarter to one-half the fiber. For reasons that have never been completely clear, a high-fat, low-fiber diet causes a rise in estrogen levels. Women on higher-fat diets have measurably more estrogen activity than do those on low-fat diets. At menopause, the ovaries’ production of estrogen comes to a halt. Those women who had been on high-fat diets then have a violent drop in estrogen levels. Asian women have lower levels of estrogen both before and after menopause, and the drop appears to be less dramatic. The resulting symptoms are much milder or even non-existent.

More evidence of the diet link comes from a fascinating study by a medical anthropologist from the University of California who interviewed Greek and Mayan women about their experience of menopause.5

The Greek women were subsistence farmers. Menopause occurred at an average age of 47, compared to over 50 in the United States. About three-quarters had hot flashes, but they were considered normal events, however, and did not cause women to seek medical treatment.

The Mayan women lived in the southeastern part of Yucatan, Mexico. Menopause occurred earlier than in Greece or North America, at an average age of 42. Unlike the experience of Greeks and Americans, hot flashes were totally unknown among Mayans, and, like the Japanese, they have no word for them. Midwives, medical personnel, and the women themselves reported that hot flashes simply do not occur, nor are they mentioned in books on Mayan botanical medicine.

The difference between Americans and Greeks and other Europeans on the one hand, for whom hot flashes are common, and the Mayans and Japanese on the other, for whom they are rare or unknown, appears to be diet. The Mayan diet consists of corn and corn tortillas, beans, tomatoes, squash, sweet potatoes, radishes, and other vegetables, with very little meat and no dairy products. Like the traditional Japanese diet, it is extremely low in animal products and low in fat in general. The Greek diet, while rich in vegetables and legumes, also contains meat, fish, cheese, and milk, as does the cuisine of other countries in Europe and North America. Animal-based meals affect hormone levels rapidly and strongly, and undoubtedly contribute to the menopausal problems that are common in Western countries.

Treating Hot Flashes

For women who are experiencing hot flashes, there are useful steps in addition to the low-fat, vegetarian diet which is strongly recommended for so many reasons. Regular aerobic exercise helps. A vigorous walk every day or so, or any equivalent physical activity, seems to alleviate hot flashes.

Andrew Weil, M.D., a well-known physician and author, recommends trying the herbs dong quai, chaparral, and damiana, two capsules of each taken once daily at noon, or, if used as a tincture, one dropperful in a cup of warm water. Vitamin E, in doses of 400 to 800 IU per day, has also been reported to be helpful. People with high blood pressure should use no more than 100 IU per day. Jesse Hanley, M.D., a family practitioner in Malibu, California, has found that certain Chinese herbs, called Changes for Women, by Zand Herbal, and Menofem, by Prevail, are helpful in reducing menopausal symptoms for some women. These supplements are available at most health food stores.

For those women who are considering hormone supplements, some preparations may be safer than others. Estrogens that are commonly prescribed by physicians contain significant amounts of estradiol, which is one of the forms of estrogen that has scientists and many postmenopausal women concerned about cancer risk. A different estrogen, estriol, appears to be safer. The best evidence indicates that estriol does not increase cancer risk.6-9 Plant-derived transdermal creams containing estriol and smaller amounts of other estrogens are available without a prescription. The estrogens pass through the skin and enter the blood stream, reducing menopausal symptoms. Creams containing pure estriol must be ordered by doctors, not because they are more dangerous (they are not), but because the process of concentrating them qualifies them as drugs, rather than natural preparations.

Dr. Hanley finds that a mixture of plant-derived estrogens and progesterone is often helpful. Transdermal creams containing estriol, estradiol, estrone, and natural progesterone are very effective in reducing hot flashes.

Regrettably, less research has been done on the use of estriol, compared to estradiol. Even though there is no evidence of cancer risk with estriol, Dr. Hanley recommends that if any estrogen cream, including estriol, is used, that it be accompanied by progesterone to reduce the risk of uterine cancer, and that it be monitored by a physician so it can be tailored to a woman’s individual needs. “Whatever formula is used, it should have some progesterone in it,” Dr. Hanley said. “Also, women should cycle their hormones. The cream is used from day 1 to day 26 of the cycle, followed by 4 to 6 days off.” If additional natural progesterone is used, it should be added for the final two weeks (days 13 to 26) and stopped together with use of the cream.

Natural progesterone alone helps reduce symptoms for some women. Progesterone and estrogen creams are available from Professional Technical Services (800-648-8211), Women’s International Pharmacy (800-279-5708), or Klabin Marketing (800-933-9440).

Natural Solutions for Dryness

At menopause, vaginal blood flow falls. Dryness and irritation can occur, and bacteria infections that pass to the urinary tract are more likely.

What is to be done? First of all, even after the ovaries stop, the adrenal glands and the fat tissue continue to contribute to estrogen production after menopause. In addition, phytoestrogens in plants provide weak estrogen effects. Soy products, such as tofu, tempeh, and miso, contain huge amounts of these natural compounds.

The plant-derived estrogen and progesterone creams described above can be helpful. Used on a regular basis, these creams maintain a moist vaginal lining. They should not be used as a sexual lubricant however, as an older couple learned the hard way. A letter to the editor of the New England Journal of Medicine described a 70-year-old man who developed an enlarging left breast.10 He went to see his physician who removed the mass. Several months later, the same thing happened on the right side. It suddenly struck him that his wife was using a vaginal estrogen cream, not only twice a week to treat vaginal dryness, but also as a sexual lubricant two or three times per week. As gratified as his doctor may have been to learn that this older couple was still maintaining frequent conjugal bliss, the doctor had to conclude that the estrogen cream had caused the man’s breast enlargement. They switched lubricants and his enlarged breast went away. Estrogen cream is a medication, not a lubricant, and it goes through any skin it touches. Many women prefer to avoid hormone creams entirely and use ordinary lubricants or moisturizers instead.

The Psychology of Menopause

Hormone shifts can affect moods. To the extent that these shifts are smoothed out by dietary steps, psychological effects are more manageable. Here are the most common psychological accompaniments of menopause:

Anxiety. Women who have never had a problem with anxiety before may become more self-conscious and more worried about minor events. In some cases, panic attacks occur. Mental health professionals have a variety of effective treatments. Many people feel much better just knowing what the condition is.

The most important piece of advice is not to let anxiety restrict your activities. When anxiety or panic disorders cause people to avoid stressful situations, the result can be an ever-tightening leash that keeps them from enjoying life. Anxiety can lead to avoidance of many aspects of normal life. Prompt treatment prevents this.

Depression and Irritability. Depression seems to be particularly common when menopause is medically induced, e.g., after removal of the uterus and ovaries because of illness. Irritability is also common.

To the extent that depression, irritability, or anxiety need treatment, it is important to explore the full range of available options. The first step is to get your diet in order and to get regular exercise to help stabilize hormone shifts and reduce physical symptoms that can aggravate mood problems. Psychotherapy can be very useful, and new short-term techniques have demonstrated their effectiveness at considerably less investment than is demanded by traditional therapies. New anti-depressants and antianxiety drugs have emerged in the past years which have fewer side effects than older medications.

Poor Memory and Concentration. Some women find that menopause brings occasional memory lapses, often related to reduced ability to concentrate. This can be upsetting and annoying, but happily it seems to go away on its own with time.

Keeping or Restoring Strong Healthy Bones

Osteoporosis—thinning of the bone tissue—is common, particularly among Caucasian women, after menopause. The cause is not an inadequate calcium intake, ordinarily. The problem is abnormally rapid calcium loss, aggravated by the following five calcium wasters:

1. Animal protein. When researchers feed animal protein to volunteers and then test their urine a little later, it is loaded with calcium, which comes from their bones. Here’s why. A protein molecule is like a string of beads, and each “bead” is an amino acid. When protein is digested, these “beads” come apart and pass into the blood, making the blood slightly acidic. In the process of neutralizing that acidity, calcium is pulled from the bones. It ends up being lost in the urine. A recent report in the American Journal of Clinical Nutrition showed that when research subjects eliminated meats, cheese, and eggs from their diets, they cut their urinary calcium losses in half.11 Switching from beef to chicken or fish does not help, because these products have as much animal protein as beef, or even a bit more.
    
2. Sodium (salt). If you throw salt on a slippery sidewalk, it dissolves the ice; if you sprinkle it on your food, it can dissolve your bones, albeit by a different mechanism. Salt apparently increases calcium losses via the kidneys. For an average person, cutting sodium intake in half reduces the daily calcium requirement by about 160 milligrams.12 Grains, vegetables, fruits, and beans are very low in sodium unless salt is added to them. Snack foods, canned foods, dairy products, and meat tend to drive up the amount of sodium in the diet.
    
3. Caffeine. Whether it comes in coffee, tea, or colas, caffeine is a weak diuretic that causes calcium loss via the kidneys.13
    
4. Tobacco. Long-term smokers have 10 percent weaker bones and a 40 percent higher risk of fracture.14
    
5. Sedentary lifestyle. Bones that have nothing to do lose their strength.15
    

Healthy Calcium Sources

When you eliminate these calcium-wasters, you need less calcium in your diet. However, you will always need some calcium. If you get very little calcium, say, less than 400 milligrams per day, you may not be giving your body the calcium it needs.

Although many people try to get their calcium from milk, only about 30 percent of calcium in dairy products is absorbed. The remaining 70 percent never makes it past the intestinal wall and is simply excreted with the feces. Milk products also contain lactose sugar, animal proteins, and frequent traces of antibiotics and other contaminants.

The healthiest calcium sources are “greens and beans.” Green leafy vegetables are loaded with calcium. One cup of broccoli has 178 milligrams of calcium. What’s more, the calcium in broccoli and most other green leafy vegetables is more absorbable than the calcium in milk. An exception is spinach, which tends to keep its calcium to itself. Beans, lentils, and other legumes are also loaded with calcium. If you make green vegetables and beans regular parts of your diet, you’ll get two excellent sources of calcium.

You don’t need to eat six cups of broccoli or huge servings of beans to get enough calcium. A varied menu of vegetables and legumes can easily give you all you need, and the amount your body needs is far less when you steer clear of meats and the other calcium-depleters. The World Health Organization recommends a daily calcium intake of just 400 to 500 milligrams per day.

If you decide to add extra calcium, calcium-fortified orange juice is a good choice. It contains more calcium than milk, and it is in the form of calcium citrate, which is much more readily absorbed than that in milk or in calcium carbonate supplements.

Sunlight

As sunlight touches the skin, it turns on the natural production of vitamin D, which helps your digestive tract absorb calcium from foods and makes your kidneys hold onto it as well. For those who get infrequent sun exposure, any common multivitamin containing 5 micrograms (200 IU), taken daily, provides adequate vitamin D. For people who never go outdoors due to chronic illness, 10 micrograms (400 IU) is recommended. Higher doses of vitamin D can be toxic and should be avoided.

Restoring Strength to Bones

Natural progesterone stimulates the bones to rebuild healthy bone tissue in areas where it has been lost. Unlike estrogens, it has no known serious side effects. In a study of 100 postmenopausal women, the average patient had a 15 percent increase in bone density after three years of treatment.16 What makes this so remarkable is that doctors have been looking for ways to slow the rate of bone loss, and most never dreamed it would be possible to actually build bone. But an increasing number of clinicians are finding exactly that.17,18

Altered forms of progesterone, called progestins (e.g., Provera), are heavily promoted by drug companies and are commonly prescribed by doctors. But these unnatural chemicals do not quite fit into the body’s systems for using and eliminating progesterone. They are the biological equivalent of using the wrong replacement part in your car’s engine. While the pharmaceutical companies’ financial machinery hums along just fine, your biological machinery can have a multitude of side effects, ranging from facial hair growth and depression to heart disease, liver problems, and even breast cancer. The body was built to use natural progesterone, not inexact copies.

Here is how natural progesterone is used: Usually, a two-ounce jar is used up each month. Later, the dosage may be reduced to one ounce per month. In postmenopausal women, the cream is usually used each month for two to three weeks, then stopped until the beginning of the next month. In women who have not yet stopped menstruating, the cream is usually used from about day 13 to day 26 of the menstrual cycle. To maintain its effect, it is discontinued for at least five to seven days each month.

It is spread on areas of thin skin, such as the insides of the arms or legs, the neck, upper chest, and abdomen, covering as wide an area as possible and varying the areas to which it is applied. It takes a while for progesterone to build up in the fat tissue, so it may take two or three months to be effective.

Because progesterone facilitates the effects of thyroid hormone, women taking thyroid medications may need to reduce or discontinue their thyroid medications after beginning progesterone, which should be done in consultation with their doctors.

Postmenopausal women who are taking estrogens are often advised to cut their estrogen dose in half when starting progesterone, because progesterone temporarily increases the body’s sensitivity to estrogen. Many women find that they no longer need estrogen at all after a few months using the progesterone cream.

Women who are currently using an artificial progestin, such as Provera, can easily switch to natural progesterone, but should taper off the progestin gradually. A typical regimen would be to cut the progestin dose in half for the first month that progesterone cream is used. In the second month, it should be cut in half again, using it every other day, if necessary. By the third month, the progestin can be safely discontinued.

While prescription estrogens are sometimes used to reduce the risk of heart disease, a combination of a vegetarian diet, daily modest exercise, smoking cessation, and stress reduction is much more effective, and has been shown to actually reverse existing heart disease in 82 percent of patients. And while estrogens increase cancer risk, these healthy lifestyle changes actually reduce the risk of cancer and several other illnesses.

References

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2. Yang CP, Daling JR, Band PR, Gallagher RP, White E, Weiss NS. Noncontraceptive hormone use and risk of breast cancer. Cancer Causes and Control 1992;3:475-9.
3. Bergkvist L, Adami HO, Persson I, Hoover R, Schairer C. The risk of breast cancer after estrogen and estrogen-progestin replacement. N Engl J Med 1989;321:293-7.
4. Lock M. Contested meanings of the menopause. Lancet 1991;337:1270-2.
5. Beyene Y. Cultural significance and physiological manifestations of menopause: a biocultural analysis. Culture, Medicine, and Psychiatry 1986;10:47-71.
6. Follingstad AH. Estriol, the forgotten estrogen? JAMA 1978;239:29-30.
7. Heimer GM. Estriol in the postmenopause. Acta Obstet Gynecol Scand 1987;Suppl 139:3-23.
8. Molander U, Milsom I, Ekelund P, Mellstrom D, Eriksson O. Effect of oral oestriol on vaginal flora and cytology and urogenital symptoms in the post-menopause. Maturitas 1990;12:113-20.
9. Gerbaldo D, Ferraiolo A, Croce S, Truini M, Capitanio GL. Endometrial morphology after 12 months of vaginal oestriol therapy in post-menopausal women. Maturitas 1991;13:269-74.
10. DiRaimondo CV, Roach AC, Meador CK. Gynecomastia from exposure to vaginal estrogen cream. N Engl J Med 1980;302:1089-90.
11. Remer T, Manz F. Estimation of the renal net acid excretion by adults consuming diets containing variable amounts of protein. Am J Clin Nutr 1994;59:1356-61.
12. Nordin BEC, Need AG, Morris HA, Horowitz M. The nature and significance of the relationship between urinary sodium and urinary calcium in women. J Nutr 1993;123:1615-1622.
13. Massey LK, Whiting SJ. Caffeine, urinary calcium, calcium metabolism and bone. J Nutr 1993;123:1611-4.
14. Hopper JL, Seeman E. The bone density of female twins discordant for tobacco use. N Engl J Med 1994;330:387-92.
15. Mazess RB, Barden HS. Bone density in premenopausal women: effects of age, dietary intake, physical activity, smoking, and birth-control pills. Am J Clin Nutr 1991;53:132-42.
16. Lee JR. Osteoporosis reversal; the role of progesterone. International Clin Nutr Rev 1990;10:384-91.
17. Prior JC. Progesterone as a bone-trophic hormone. Endocrine Rev 1990;11:386-98.
18. Prior JC, Vigna Y, Alojado N. Progesterone and the prevention of osteoporosis. Canad J Ob/Gyn 1991;3:178.