The diagnostic summary is as follows:

• Cessation of menstruation in older women for 6-12 months
• Average age of onset is 51 years
• Hot flashes in 65-80%
• Atrophic vaginitis
• Frequent bladder infections in 15%

Causes of menopause

Thought to occur when there are no eggs left in the ovaries; at birth, there are about 1 million eggs (ova), which drops to 300,000-400,000 at puberty; only 400 actually mature during reproductive years; absence of active follicles reduces oestrogen and progesterone – pituitary increases FSH in large and continuous quantities; LH and FSH cause ovaries and adrenals to secrete androgens which can be converted to oestrogen’s by fat cells of hips and thighs; converted androgens are the source of most circulating oestrogen in postmenopausal women; total oestrogen is still far below reproductive levels.

Menopause as social construct: social and cultural factors contribute greatly to how women react to menopause; modern society values allure of everlasting youth – cultural devaluing of older women; cultural view of menopause is directly related to symptoms of menopause; if the cultural view is negative, symptoms are common; if menopause is viewed in a positive light, symptoms are less frequent; study of rural Mayan Indians – no woman experienced hot flashes or any other symptom and no woman showed evidence of osteoporosis, despite hormonal patterns identical to postmenopausal women; Mayan women saw menopause as a positive event, providing acceptance as a respected elder as well as relief from child-bearing.

Oestrogen replacement therapy

Benefits of HRT: relief from hot flashes and other symptoms; reduction in osteoporosis; but dietary, exercise, and lifestyle factors offer identical benefits without risks; short-term (< 6 months) HRT for symptoms only provides temporary relief – not permanent cure and only delays the inevitable; long-term HRT not justified in most women – risks outweigh benefits; exception are women at high risk for osteoporosis; oestrogen-progesterone combinations are preferred to oestrogen alone; exception are women with or at high risk for disease aggravated by oestrogen – breast cancer, active liver diseases, and certain cardiovascular diseases – in which case progesterone alone indicated.

HRT and cancer: most likely form of cancer adversely affected by HRT is breast cancer; oestrogen replacement therapy is associated with 1-30% increase in risk of breast cancer; association increases with age and length of use; avoid HRT in specific cases (serious osteoporosis).

Types of HRT:

• Oestrogen is given alone without progestin = ‘unopposed oestrogen therapy’ – high risk for endometrial and other cancers (breast); unopposed oestrogen given 4 x daily or during 25-day cycles separated by 3-6 days without.

• To reduce endometrial cancer, oestrogen given in combination with progestin-like progesterone, either cyclically or continuously; cyclical method = oestrogen for 25 days and progestin for last 10-12 days of cycle, with 3-6 day hormone-free interval during which bleeding occurs – menstruation continues in 90% of women.

• To prevent monthly bleeding, oestrogen and progesterone given 4 x daily without hormone-free interval = ‘combined continuous HRT’.

• ‘Natural-type’ oestrogen’s preferred to synthetic, e.g.:
   - conjugated oestrogen’s (premarin, Genisis)
   - esterified oestrogen’s (Evex, Menest)
   - micronized 17-beta-estradiol (Estrace)
   - transdermal 17-beta-estradiol (Estraderm, Systen).

• Conjugated oestrogen’s are metabolised in body to active forms (17-beta-estradiol; liver catabolises active oestrogen’s before they produce effects – large amounts given, since 17-beta-estradiol is not absorbed well orally; absorbed well through skin – oestrogen patches and vaginal creams; patches are preferable to conjugated oestrogen’s – approximate body’s secretions by delivering 17-beta-estradiol in slow, sustained manner.

• Best form of progesterone is the natural derivative, medroxyprogesterone acetate – preferred to synthetic (megesterol, norethindrone, norgestrel); examples of medroxyprogesterone are Provera, Cycrin, and Amen.

Major symptoms

• Hot flashes: most common symptoms; can be accompanied by increased heart rate, Has, dizziness, weight gain, fatigue, and insomnia; 65-80% of menopausal women in the western world experience hot flashes; often first sign menopause approaching – may begin prior to cessation of menses; in most cases, most uncomfortable in first and second years after menopause; as body adapts to decreased oestrogen, hot flashes subside.

• Atrophic vaginitis: vaginal lining may become thin and dry from lack of oestrogen, causing dyspareunia, increased susceptibility to infection, and vaginal itching or burning; avoid substances which dry mucous membranes (antihistamines, alcohol, caffeine); stay well hydrated; prefer clothes made from natural fibers (cotton); regular intercourse is beneficial – increases blood flow to vaginal tissues, improving tone and lubrication; exogenous lubricant (oil or K-Y Jelly) essential.

• Bladder infections: 15% of menopausal women experience frequent cystitis from breakdown in natural defences which protect against UTIs; primary goal is to enhance normal host protective measures – increasing flow of urine via proper hydration, promoting pH inhibiting microbial growth, and preventing bacterial adherence to bladder endothelium.

• Cold hands and feet: common to women in general; three major causes: hypothyroidism, low iron, and poor circulation; use basal body temperature test to evaluate functional thyroid activity; serum ferritin is the best indicator of body Fe stores; also CBC and chemistry panel, with LDL/HDL cholesterol; ICIM Blood analysis; complete physical exam attending to any other signs of vascular insufficiency; treat identified cause directly.

• Forgetfulness with inability to concentrate: common symptoms of menopause may result from decreased oxygen and nutrient supply to brain.

Role of hypothalamus and endorphins

Many symptoms result from altered function of hypothalamus, the bridge between the CNS and endocrine system; hypothalamus is responsible for control of body temperature, metabolic rate, sleep patterns, reaction to stress, libido, mood, and release of pituitary hormones; endorphins critical to proper functioning of hypothalamus; exercise and acupuncture enhance endorphin output.

Therapeutic considerations      

   
Natural approach is to improve physiology via diet, exercise, nutritional supplements, and botanical medicines.
Baseline evaluation of menopausal women (to be repeated annually);
• detailed personal and family medical history
• breast exam and instructions on self-exam
• pelvic exam
• lab tests
• ICIM Blood analysis
• complete blood count
• blood chemistry panel
• cholesterol evaluation ; HDL, LDL, and VLDL
• thyroid function panel, including T3, T4, and TSH
• Medical Thermography (if indicated – breast screening)
• baseline bone densitometry (ultrasound) 

Bone density studies can be used as a gauge as to whether HRT is necessary.

Diet

Increase plant foods, especially phytoestrogens; reduce animal foods; consume fruit and vegetables.

• Phytoestrogen-containing foods: fennel, celery, and parsley (Umbelliferae) contain phytoestrogens; fennel has confirmed oestrogenic action; soy, nuts, whole grains, apples, and alfalfa also have phytoestrogens; lignin’s and isoflavonoids are converted by intestinal bacteria to diphenolic oestrogenic compounds which decrease hot flashes, increase maturation of vaginal cells and may inhibit osteoporosis; decrease breast, colon, and prostate cancer.

• Soy: isoflavones (genistein) and phytoesterols of soybeans have mild oestrogenic effect, 1 cup soybeans has 300mg isoflavone = 0.45 mg conjugated oestrogen’s = 1 tablet Premarin; associated with reduced risk of cancer; increase number of superficial cells lining the vagina. This increase offsets the vaginal drying and irritation that are common in postmenopausal women; the lower the protein content, the higher the level of isoflavonoids; products from whole soybean are higher in isoflavonoids than those from soy protein concentrates; protects LDL from oxidation – preventing cardiovascular disease.

• Dietary fat: positive correlation between breast cancer risk and saturated fat intake in postmenopausal women; total caloric intake not linked to increased risk of breast cancer.

Nutritional supplements

• Vitamin E: relieves hot flashes and menopausal vaginal complaints compared with placebo; improves not only symptoms, but also blood supply to vaginal wall. It is effective in 50% of postmenopausal women with atrophic vaginitis; vitamin E oil, creams, ointments, or suppositories are used topically to provide symptomatic relief of atrophic vaginitis; effective in relieving dryness and irritation of atrophic vaginitis.

• Hesperidin and vitamin C: hesperadin improves vascular integrity and relieves capillary permeability; combined with vitamin C, citrus flavonoids may relieve hot flashes, nocturnal leg cramps, nose bleeds, and easy bruising.

• Gamma-oryzanol (ferulic acid): is a growth-promoting substance in grains and isolated from rice bran oil, it enhances pituitary function and promotes endorphin release by the hypothalamus; helpful in women with post-oophorectomy menopause; extremely safe natural substance; no significant side-effects produced in experimental and clinical studies; lowers blood cholesterol and triglyceride levels.

Botanical medicines

• ‘Uterine tonics’ are beneficial; effects are from phytoestrogens and the ability to improve blood flow to female organs; nourish and tone female glandular and organ system = non-specific mode of action making many botanicals useful.

• Phytoestrogens: not associated with adverse side-effects; very effective in inhibiting mammary tumours – by occupying oestrogen receptors and by other unrelated anticancer mechanisms; oestrogenic effects only 2% as strong as oestrogen; low activity has balancing action – if oestrogen is low, phytoestrogen effect will counterbalance this; if high, phytoestrogen binding to oestrogen receptors competes with oestrogen, decreasing oestrogen effects; this balancing action allows the same plants to be used for PMS and menopause.

• Angelica sinensis (Dong Quai): historic use in Asia for hot flashes contraction followed by relaxation; increases uterine weight and glucose utilisation by liver and uterus in lab animals – reflect oestrogenic activities; efficacy may be based on mild oestrogenic effects and other components acting to stabilise blood vessels.

• Glycyrrhiza glabra (licorice): oestrogen-like activity responsible for many of its beneficial effects.

• Vitex agnes castus (chaste tree): native to Mediterranean; berries historically used for female complaints; profound effects on pituitary function; beneficial effects in menopause may be due to altering LH and FSH secretion.

• Cimicifuga racemosa (black cohosh): widely used by American Indians and later by American colonists for menstrual cramps and menopause; relieves hot flashes, depression and vaginal atrophy; noticeable benefits within 4 weeks after beginning cimicifuga therapy; after 6-8 weeks complete resolution symptoms achieved in most patients; very well tolerated; only 7-10% of patients report mild transitory stomach complaints or other mild side-effects; no contraindications or limitations of use – suitable natural alternative to HRT for menopause, especially when HRT is contraindicated (e.g. history of cancer, unexplained uterine bleeding, liver and gall bladder disease, pancreatitis, endometriosis, uterine fibroids, or fibrocystic breast disease).

• Ginkgo biloba: indicated for its effects on vascular system; useful in improving cold hands and feet, and forgetfulness accompanying menopause; improves blood flow to hands and feet in human clinical trials; effective in treating peripheral vascular disease of extremities; improves mental health in patients with cerebral vascular insufficiency and may exert similar effects in menopause; increases blood flow to brain; enhances energy production within brain, increasing uptake of glucose by neurons, and improving transmission of nerve signals – transmission rate of nerve signals is critically important to memory, which is directly related to speed at which nerve impulse can be transmitted; improves memory in elderly and college-aged women; should be taken consistently for at least 12 weeks to determine effectiveness.

Lifestyle factors

• Exercise: clinical studies indicate that regular physical exercise decreases frequency and severity of hot flashes; women exercising can pass through a natural menopause without HRT; physically active women who have no hot flashes whatsoever spend 3.5h/week exercising; women who exercise less are more likely to have hot flashes; regular exercise also beneficial to mood, bone health, and cardiovascular wellness.

• Cigarette smoking: greatly increases risk of early menopause – double the risk of menopause between ages 44 and 55; former smokers have lower risk, showing partial reversal of effect.

Therapeutic approach

In most cases HRT is unnecessary; for women at high risk for osteoporosis or with already documented significant bone loss, HRT may be indicated; for atrophic vaginitis, use topical vitamin E; if the woman is smoking, facilitate smoking cessation program.

The following approach is used by the Irish Centre of Integrated Medicine (ICIM) therapeutically:

• Diet: increase phytoestrogens – soyfoods; fennel, celery, parsley; high-lignin flaxseed oil; nuts and seeds.

• Lifestyle: regular exercise program – at least 30 min three times a week.