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St. John’s Wort

st johns wortSt. John’s wort is the most thoroughly researched natural anti-depressant. The majority of these studies have not been conducted on menopausal women, but in 37 of 39 clinical trials, St. John’s wort was shown to be superior to the placebo or equal to the conventional prescription anti-depressant medications. In general, the results have been 61% to 75% improvement in those individuals with mild to moderate depression. In the latest published Cochrane Review, a total of 37 trials, including 26 comparisons with placebo and 14 comparisons with synthetic standard anti-depressants, were evaluated. For major severe depression, the authors concluded that while current evidence regarding hypericum ( St. John’s wort) extracts is inconsistent, there are trials that suggest small benefits and others that suggest that hypericum and standard anti-depressants have similar beneficial effects.

One non-placebo-controlled clinical trial was conducted in women with menopause symptoms and found that 900 mg of St. Johns wort for 12 weeks significantly improved psychological and psychosomatic symptoms as well as a feeling of sexual
well-being.

A double-blind randomized placebo-controlled study was done earlier in 2006, which used a combination of black cohosh and St. John’s wort. Three hundred and one peri- and post menopausal women had climacteric symptoms including psychological symptoms for at least 3 months. Symptoms were evaluated by means of the Menopause Rating Scale and the Hamilton Depression Rating Scale. Patients were treated with an extract of St. John’s wort and black cohosh extract or a placebo for 16 weeks. The mean Menopause Rating Scale score decreased 50% in the treatment group and 19.6% in the placebo group. The Hamilton Depression Rating Scale score decreased 41.8% in the treatment group and 12.7% in the placebo group. In both the general menopause rating scale and in the depression scale, the St. John’s wort + black cohosh group was significantly superior to the placebo group.

Kava

Kava is a plant indigenous to Melanesia, Micronesia, and Polynesia. Its properties have been most often associated with having analgesic, sedative, anxiolytic, muscle relaxant and anticonvulsant effects. While it is typically not often thought of as an herb for menopause; anxiety, irritability, tension, nervousness and sleep disruption are common perimenopause and menopause symptoms in which kava can offer some help. Kava has been used as a social and ceremonial beverage for generations, by the people of Fiji and other islands of the South Pacific, and at least in part, to create a relaxed stress free atmosphere. In more scientific circles, kava has been shown to have significant effects in reducing anxiety in a number of studies.

kavaThree randomized controlled trials have investigated the value of kava for menopausal symptoms. In the first study, including 40 women with menopause symptoms, there was a statistically and clinically significant improvement in the anxiety scale, the general menopause symptom index, and the daily patient symptom diary by week 4. In the second study, of 40 menopausal women, the kava group was significantly better than the placebo group in the anxiety scores, depression scores, and general menopause symptom index, even within the first week. In the study by De Leo and colleagues, 40 women who were either normally menopausal or surgically menopausal were randomly assigned to receive either hormone replacement therapy (HRT) plus 100 mg of kava or placebo for 6 months. All women improved in the Hamilton Anxiety Scale score over the six months, but the women receiving HRT plus kava showed the greatest improvement.

In 2003, another valuable study evaluated the effects of kava on anxiety, depression and menopause symptoms in peri-menopausal women for 3 months. Eighty women were randomized to one of three groups. The control group knowingly received 1,000 mg of calcium per day, the second group received the calcium and 100 mg of kava, and the third group received the calcium and 200 mg of kava. There was a clear and similar reduction in depression and anxiety in the two kava dosing groups compared with the calcium alone control group, but not a clear decline in general menopause symptoms scores.

Additional Botanicals and Combination Herbal Products for Menopause

Natural food stores and drug stores are brimming with herbal menopause products these days. Most all of these combination products have not been researched, even though an individual ingredient has been. I am aware of only one herbal combination product that has been researched in a double-blind, placebo-controlled trial. I was one of two co-principal investigators on this study. This study set out to research the effects of a botanical formulation containing phytoestrogens on menopausal symptoms.

Thirteen peri- and post-menopausal women were randomly assigned to a treatment group or a placebo group. The treatment group received capsules of burdock root, licorice root, motherwort, dong quai, and wild yam root taking two capsules three times per day. After three months, women receiving the herbal product showed a greater response rate than women in the placebo group. Response rate was calculated as the percent of patients in each group who showed a decrease in either the number or severity of symptoms. One hundred percent of women taking the botanical formula had a reduction in their symptom severity, while only 67 percent of women receiving placebo showed a decrease. Seventy-one percent of women taking the herbal formula reported a reduction in the total number of symptoms, while only 17 percent of the women taking placebo reported a decrease in the total number of their symptoms. The botanical formula was most effective in treating hot flashes, mood changes, and insomnia. There were no clear effects on blood levels of estradiol or total estrogens. Serum progesterone levels also appeared to decrease in the herbal group. No clear effects of the botanical formula were apparent in HDL cholesterol, triglycerides, or total cholesterol.

This combination of herbs is an example of an herbal formulation that can be used very effectively by many women to manage either their perimenopausal symptoms or their symptoms after menopause. However, it should only be considered for relieving the symptoms of menopause, not as a substitute for dietary and lifestyle changes or nutritional supplements meant for the prevention or treatment of heart disease or osteoporosis.

commission eNumerous other herbs can be helpful for individual menopause symptoms. The German Commission E (the German agency similar to our FDA), has approved hops for mood issues such as anxiety and restlessness, and for sleep disruptions. Hops contain a group of nonsteroidal phytoestrogens called prenylflavonoids. In one randomized, double-blind, placebo-controlled study, 67 menopausal women were given either a placebo or a 100 mcg or 250 mcg standardized hops extract for 12 weeks. At 6 weeks, the 100 mcg dose was significantly superior to placebo, but not after 12 weeks. Even so, there was a more rapid decrease in menopause symptoms scored for both doses of hop extract, especially the hot flush score. The higher dose was not any better than the lower dose.

Valerian has been used for centuries by many different cultures and in modern times, mostly for anxiety and insomnia. Three randomized clinical trials have showed improvement in sleep quality, although none of these studies were specific to menopausal women.
Motherwort is another plant that has been used historically in situations that are relevant to peri-menopause and menopause. It can ease heart palpitations and act as a calming agent, known as a nervine. The German Commission E has approved its use for nervous cardiac problems.

When using botanicals to alleviate peri-menopause and menopause symptoms, I find the most effective approach is to use black cohosh or a combination formula to address the broadest array of symptoms. In addition, I would add Kava, in a case of hot flashes and anxiety, or hops and/or valerian, in a case of insomnia in a menopausal woman. For heart palpitations, I would use a combination formula that included motherwort. For a case of peri-menopausal or menopausal depression, I would typically use black cohosh, and St. John’s wort. In my experience, using a more general herb/formulation, along with the symptom specific herbs, yields the most satisfying results.

References

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  4. Uebelhack R, Jens-Uwe Blohmer, et al. Black cohosh and St. John’s wort for climacteric complaints. Obstet Gynecol 2006;107:247-255.
  5. Pittler M, Ernst E. Efficacy of kava extract for treating anxiety: a systematic review and meta-analysis. J Clin Psychopharmacol 2000; 20:84-89.
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  14. Leathwood P, Chauffard F, Heck E, Munoz-Box R. Aqueous extract of valerian root (Valeriana officinalis L.) improves sleep quality in man. Pharmacol Biochem Behav 1982;17:65.145
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  16. Motherwort herb. In: Blumenthal M, ed. The complete German Commission E monographs. Austin, TX: American Botanical Council, 1998.