Supplements & Herbs for
Menopause is a natural process for women as they age. Menopause can also occur as a
result of certain medical treatments that affect a woman's ovaries (see Question 1). Many
women and their health care providers have become interested in complementary and
alternative medicine (CAM) for menopausal symptoms. This fact sheet is based on
findings from a 2005 National Institutes of Health (NIH) State-of-the-Science (SoS)
conference on the management of menopause-related symptoms. It answers some
frequently asked questions and lists resources for more information.

Key Points
* Many women have few or no symptoms related to menopause, or feel that their
symptoms are not enough of a problem that they need to seek treatment. Some
symptoms traditionally seen as menopausal may be related to aging in general.

* Menopause should not be viewed as a disease, according to the SoS conference panel.

* For many years, menopausal hormone therapy (MHT; in the past, it was called hormone
replacement therapy or HRT) was the primary treatment for troubling menopausal
symptoms. Recent studies have found increased risks, however, for certain serious
health problems from prolonged use of MHT.

* Women with severe or long-lasting symptoms of menopause that have not been
adequately relieved in other ways should consult their health care providers about their
personal risks and benefits for using MHT. Certain lifestyle changes can also be helpful.

1. What is menopause?

Menopause (also called the "change of life") is a normal part of a woman's aging. It is the
time when her ability to have children comes to an end. In American women, the transition
into menopause usually begins around age 47, with the final menstrual period usually
around age 51. However, some women experience it earlier. Menopause occurs over a
period of time because the levels of a hormone called estrogen, which is produced by the
ovaries, begin to decline slowly. A woman is said to have completed natural menopause
when she has not had a period for 12 months in a row. Menopause will occur immediately
if a woman has her uterus and/or both ovaries removed surgically (an operation to
remove the uterus is called a hysterectomy). This is because at least one ovary and the
uterus are needed for a woman to have menstrual periods. Menopause also begins right
away if a woman's ovaries are damaged by cancer treatment with radiation therapy or
certain anticancer drugs.

2. What are the most common symptoms that women have during the menopausal

Some symptoms that women experience are related to menopause and decreased
activity of the ovaries. Others are related to aging in general. The scientific evidence that
certain symptoms are linked to menopause is strongest for the following symptoms:

* Hot flashes, night sweats, or perspiring excessively (these are examples of what are
called vasomotor symptoms, because they involve expansion of the blood vessels)
* Sleep difficulties
* Vaginal dryness, which can lead to painful intercourse and sexual problems

It is not certain whether the following symptoms are due to menopause, other factors that
can come with aging (such as stress, economic concerns, or changes in personal
relationships), or a combination of them:

* Changes in mood, such as depression, anxiety, and/or irritability
* Problems in thinking or in remembering things
* Urinary incontinence (that is, loss of ability to control urination)
* Painful joints or muscles, or other physical complaints, such as tiredness and stiff joints

The expert panel assembled for the NIH SoS conference noted that menopause is a
normal part of women's aging, and advised that menopause not be viewed as a disease
(that it be "demedicalized").

3. What treatment does conventional medicine offer for menopausal symptoms?

For many decades, estrogen (available by prescription with or without another hormone
called progestin) has been the main treatment in conventional medicine for menopausal
symptoms.1 For a long time this treatment was called hormone replacement therapy
(HRT), but the preferred term now is menopausal hormone therapy (MHT). MHT has been
the most effective therapy to date for women who have severe or long-lasting problems
related to menopause. It is especially effective against hot flashes and night sweats.

MHT has some other beneficial effects as well. For example, it helps to protect against
osteoporosis, an age-related disease in which the bones become brittle and can break
more easily. The risk for osteoporosis goes up in both men and women as they age, but
it is greater for women after menopause. Drug treatments other than MHT, however, are
available for reducing the risk of osteoporosis in both men and women, and certain
lifestyle changes also may help.

1 Conventional medicine is medicine as practiced by holders of M.D. (medical doctor) or
D.O. (doctor of osteopathy) degrees and by their allied health professionals such as
nurses, physical therapists, and dietitians. CAM is a group of diverse medical and health
care systems, practices, and products that are not currently considered to be part of
conventional medicine. Complementary medicine is used along with conventional
medicine. Alternative medicine is used instead of conventional medicine. Some
conventional medicine practitioners also practice CAM.

4. Why are many people concerned about the effectiveness and safety of MHT?

MHT was widely prescribed until a few years ago. In 2002, findings from a large study
called the Women's Health Initiative raised concerns about its safety and side effects.
Researchers found increased risks for serious health problems (including heart disease,
breast cancer, stroke, and blood clots) in women who had taken a combination of
estrogen and progestin for several years. Women who were taking estrogen alone had
an increased risk for stroke and blood clots.

MHT is being used more cautiously now. The U.S. Food and Drug Administration (FDA)
recommends that it be used at the lowest dose for the shortest period of time possible.
However, the specific risks and benefits of these low doses, and how long to use them,
are not known. The NIH SoS conference panel noted that estrogen may not be an
appropriate treatment for some menopausal complaints. This situation is one reason that
many women and their health care providers have become interested in whether CAM
treatments could be helpful for menopausal symptoms.

5. What should women consider if they are thinking about using CAM for menopausal

There is very little scientific evidence to support the effectiveness of CAM therapies for
menopausal symptoms. However, it is possible that some CAM therapies, while not as
effective as MHT, may provide some relief to women during the menopausal transition.
Here are some points to keep in mind about these therapies:

* It is important for women who are considering or using CAM therapies for any health
reason to discuss them with their health care provider. This is to help ensure safety and a
comprehensive treatment plan.
* Botanical and other dietary supplements can interact with prescription and
over-the-counter drugs, affecting how the body reacts. Supplements can pose other
safety issues as well. Some have been found to be contaminated, contain unlabeled
ingredients, or have different amounts of ingredients than are listed on the label. "Natural"
does not automatically mean "safe."
* Pharmacists can be a helpful source of information about supplements. However, their
advice should not be viewed as a substitute for the advice of a health care provider.
* The claims for many CAM therapies can be attractive, ranging from enhancing
well-being to producing health results that might seem unbelievable. Check whether such
claims are based only on personal stories (testimonials) or on the results of controlled
research studies. It is important to know whether scientific research has proven that a
therapy works (for more, see "For More Information").
* The cost of a CAM therapy may be a concern, as many CAM therapies are not covered
by insurance.

About Dietary Supplements

Dietary supplements were defined in a law passed by Congress in 1994. A dietary
supplement must meet all of the following conditions:

* It is a product (other than tobacco) intended to supplement the diet, which contains one
or more of the following: vitamins; minerals; herbs or other botanicals; amino acids; or
any combination of the above ingredients.
* It is intended to be taken in tablet, capsule, powder, softgel, gelcap, or liquid form.
* It is not represented for use as a conventional food or as a sole item of a meal or the
* It is labeled as being a dietary supplement.

Other important information about dietary supplements:

* They are regulated as foods, not drugs, so there could be quality issues in the
manufacturing process.
* Supplements can interact with prescribed or over-the-counter medicines, and other
* "Natural" does not necessarily mean "safe" or "effective."
* Consult your health care provider before starting a supplement, especially if you are
pregnant or nursing, or considering giving a supplement to a child.

CAM therapies are not the only alternatives to MHT to consider. Certain lifestyle changes
can contribute to healthy aging, including during the menopausal transition. For example,
quitting smoking, eating a healthy diet, and exercising regularly have been shown to
reduce the risks of heart disease and osteoporosis. Women may want to try one or more
of these changes as well.

6. What are phytoestrogens?

Some botanical products, such as soy and red clover, are called phytoestrogens. Plants
rich in phytoestrogens may help relieve some symptoms of menopause. However, it is
uncertain whether this relief comes from actual estrogens or from other compounds in the
plant. Much remains to be learned about these plant products, including exactly how they
work in the human body. Doctors caution that certain women need to be particularly
careful before using phytoestrogens, especially:

* Women who have had or are at increased risk for diseases or conditions that are
affected by hormones, such as breast, uterine, or ovarian cancer; endometriosis; or
uterine fibroids
* Women who are taking drugs that increase estrogen levels in the body, such as birth
control pills; MHT; or a type of cancer drug called selective estrogen receptor modulators
(SERMs), such as tamoxifen

7. What is the scientific evidence on the CAM therapies considered by the NIH SoS
conference panel?

The panel discussed the evidence on 10 of these therapies:

* Six botanicals--black cohosh, red clover, dong quai root, ginseng, kava, and soy
* DHEA (dehydroepiandrosterone), a dietary supplement
* Exercise
* Paced respiration
* Health education

Readers can find science-based information on these or any CAM therapy that interests
them through the National Center for Complementary and Alternative Medicine (NCCAM)
Clearinghouse or the PubMed database, which are listed in "For More Information."

8. What is known about the effectiveness and safety of these therapies for menopausal

As mentioned in Question 5, very little well-designed research has been done on CAM
therapies for menopausal symptoms. A small number of studies have been published,
but they have had limitations (such as the way the research was done or treatment
periods that may not have been long enough). As a result, the findings from these studies
are not strong enough for scientists to draw any conclusions. Also, many studies of
botanicals have not used a standardized (that is, chemically consistent) product. NCCAM
is sponsoring a number of studies on botanicals using products that are both well
characterized and well standardized (that is, their ingredients have been carefully studied
and the dosages are controlled), and on other CAM therapies that have shown possible
promise for reducing menopausal symptoms. The aim is to learn more about their safety
and effectiveness and how they work in the body.

It is important to know that botanicals and other supplements can have side effects and
can interact with herbs, other supplements, or drugs. A small number of these issues are
listed below. In addition to consulting your health care provider, see "For More
Information" for ways to find out about side effects and safety issues.


* Black cohosh (Actaea racemosa, Cimicifuga racemosa). This herb has received more
scientific attention for its possible effects on menopausal symptoms than have other
botanicals. Studies of its effectiveness in reducing hot flashes have had mixed results.
Recent research suggests that black cohosh does not act like estrogen, as once was
thought. Black cohosh has had a good safety record over a number of years. Some
concerns have been raised about whether it may cause liver problems, but an
association has not been proven.
* Red clover (Trifolium pratense). The panel reported that five controlled studies found no
consistent or conclusive evidence that red clover leaf extract reduces hot flashes. Clinical
studies in women report few side effects, and no serious health problems have been
discussed in the literature. However, there are some cautions. Animal studies have
raised concerns that red clover might have harmful effects on hormone-sensitive tissue
(for example, in the breast and uterus).
* Dong quai (Angelica sinensis). Only one randomized clinical study of dong quai has
been done. The researchers did not find it to be useful in reducing hot flashes. Dong quai
is known to interact with, and increase the activity in the body of, the anticoagulant drug
warfarin. This can lead to bleeding complications in women who take this medicine.
* Ginseng (Panax ginseng or Panax quinquefolius). The panel concluded that ginseng
may help with some menopausal symptoms, such as mood symptoms and sleep
disturbances, and with one's overall sense of well-being. However, it has not been found
helpful for hot flashes.
* Kava (Piper methysticum). Kava may decrease anxiety, but there is no evidence that it
decreases hot flashes. It is important to note that kava has been associated with liver
disease. The FDA has issued a warning to patients and providers about kava because
of its potential to damage the liver.
* Soy. The scientific literature includes both positive and negative results for soy extracts
on hot flashes. When taken as a food or dietary supplement for short periods of time, soy
appears to have few if any serious side effects. However, long-term use of soy extracts
has been associated with thickening of the lining of the uterus.


DHEA (dehydroepiandrosterone) is a naturally occurring substance that is changed in the
body to the hormones estrogen and testosterone. It is also manufactured and sold as a
dietary supplement. The only randomized clinical trial of DHEA that has been done so far
found no benefit for hot flashes. The NIH SoS conference panel added that a few small,
nonrandomized studies have suggested that DHEA might possibly have some benefit for
hot flashes and decreased sexual arousal, but this has not been confirmed. The side
effects, risks, and benefits of using DHEA for longer than a few months have not been
well studied.

Concerns have been raised about whether DHEA is safe and effective. For this reason,
NCCAM is providing additional information. DHEA has been used in conventional
medicine for a range of health problems other than symptoms of menopause, but there is
no good scientific evidence to support these uses. Because levels of natural DHEA in the
body decline with age, some people believe that taking DHEA as a supplement can help
treat or prevent conditions related to aging. However, there is no good scientific evidence
to support this popular notion.

NCCAM does not recommend that consumers use over-the-counter DHEA supplements
for any health concerns, including for menopausal symptoms. Little is known about the
long-term safety of DHEA, and scientists are not certain whether it might increase the risk
for breast or prostate cancer. Therefore, consumers who have questions about whether
DHEA could be of benefit for their personal situation should discuss those questions with
their health care provider.

Other CAM Therapies

The NIH SoS conference panel chose to address the three other therapies below, which
they considered CAM "behavioral interventions." They noted that these treatments may
be an important area for further research because they cause few, if any, health
problems. However, their effectiveness has not yet been proven through large,
well-designed studies.

* Exercise has improved the quality of life in women with menopausal symptoms.
However, it has not had any effect on vasomotor symptoms or vaginal dryness.
* Paced respiration (also called paced breathing) is a technique of slow, deep breathing.
One small study found that it appeared to be helpful for hot flashes.
* Health education involves educating women about what to expect from menopause and
what they themselves can do. It has been found to improve women's knowledge, but not
to have effects on menopausal symptoms.
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