A statistically significant change was reported in the quality of the sleep in the valerian group when compared to the placebo group. The average scored on the sleep scale before valerian was 9.8 and after valerian it was 6.02. The placebo group had an initial average sleep scale score of 11.1 and after placebo, 9.4. Overall, 30% of the women taking valerian and 4% taking placebo reported an improvement in their sleep quality.

Commentary:

Approximately 61% of postmenopausal women have sleep problems, which then of course can lead to other consequences including impaired function, fatigue, depression and reduced quality of life. In addition, hot flushes and night sweats, which affect 75% to 85% of postmenopausal women, can also affect sleep quality.

Valerian is the most commonly used herb for individuals suffering from insomnia and is in the top 10 herbal supplements most commonly used in general. Quite a few studies have been done on valerian and insomnia in the last 20 years but few have studied older adults and no previous studies in postmenopausal women and over a longer period of time such as the current study. Results have been inconsistent and quite varied in the design of the study. Several previous studies have reported improvement in sleep quality in individuals using valerian over time but there are only a few studies with significant improvement in sleep outcomes when compared to placebo. Fortunately, the current study has shown that valerian improves the quality of sleep in postmenopausal women with insomnia, and can add to our treatment options in a much needed area of medicine.

Reference

Taavoni S, Ekbatani N, Kashaniyan M, Haghani H. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause 2011; 18(9): 951-955.

The Maitake extract tablets contained 18 mg of an extract called “SX-fraction” (MSX), a water-soluble glycoprotein, and 250 mg of dried Maitake mushroom powder. Each patient was given 3 tablets, 3 times a day. For those who received the CC, they were given 50 mg/day from days 5 to 9 of menses and repeated up to 3 cycles. For patients who then took the combination, the same dosing regimen was used.

Twenty-six patients in the MSX group and 31 in the CC group were evaluated for ovulation with pelvic ultrasounds. The ovulation rate for MSX was 76.9% (20/26) and 93.5% (29/31) for CC. For the combination treatment, 7 of 7 patients who failed the MSX monotherapy and 6 of 8 patients who failed the CC monotherapy demonstrated ovulation.

Commentary: This study demonstrated the ability of a Maitake extract to induce ovulation in patients with PCOS and can be used as a monotherapy or as an adjunct to clomiphene citrate. The ovulation rate of 76.9% is quite impressive, even though the clomiphene citrate rate was much better at 93.5%.

Maitake extract is reported to modulate serum glucose levels, reduce blood pressure, optimize serum lipids and enhance insulin sensitivity in animal studies, all important core issues in women with PCOS.

Reference

Chen J, Tominaga K, Sato Y, et al. Maitake mushroom (Grifola frondosa) extract induces ovulation in patients with polycystic ovary syndrome: a possible monotherapy and a combination therapy after failure with first-line clomiphene citrate. J Alternative and Complementary Medicine 2010;12(12):1295-1299

A systematic review was done to assess the clinical evidence for or against the efficacy of maca for sexual dysfunction. The review included only randomized clinical trials comparing maca to a placebo in men or women with sexual dysfunction. Four randomized controlled trials (RCT) met the inclusion criteria. Two of these trials suggested a positive effect of maca on sexual dysfunction or libido in menopausal women or adult. One other RCT did not show effect of maca in cyclists. The fourth study assessed the effects of maca in men with erectile dysfunction and did show significant effects.

While the evidence is limited, there does appear to be some effectiveness of maca in improving sexual function.

Reference

Shin B, Soo Lee M, Jin Yang E, Lim H, Ernst E. Maca (L. meyenii) for improving sexual function: a systematic review. BMC Complementary and Alternative Medicine 2010;10:44

A study of St John’s wort liquid extract showed a statistically decline in hot flashes severity, duration and frequency in the SJW group compared to placebo at week 8.[1]

Another double blind randomized clinical trial demonstrated that after 3 months of treatment, women in the St. John’s wort group reported significantly better quality of life scores, and significantly fewer sleep problems compared to placebo. [2]

About ten years ago, a non placebo controlled, drug monitoring study was conducted in women with menopause symptoms using 900 mg of St. Johns wort for 12 weeks. About three quarters of the women experienced improvement in both the self-rating scale and the physician rating, and significantly improved in psychological and psychosomatic symptoms as well as a feeling of sexual well-being.[3]

The first of three studies using St. John’s wort and black cohosh was published in 1999. This double-blind, randomized, placebo-controlled trial used St. John’s wort and black cohosh made by the makers of Remifemin.[4] The Kupperman index for the combination product decreased from 31.4 to 18.7 compared with a decrease in the placebo group from 30.3 to 22.3. Psychological symptoms also improved significantly in the black cohosh/St. John’s wort combination group.

A double-blind randomized placebo-controlled study was done using a combination trial of black cohosh and St. John’s wort. The mean Menopause Rating Scale score decreased 50% in the treatment group and 19.6% in the placebo group.[5] The Hamilton Depression Rating Scale score decreased 41.8% in the treatment group and 12.7% in the placebo group. In both testing measures the St. John’s wort + black cohosh group was significantly superior to the placebo group.

Another black cohosh/St. John’s wort trial was carried out in peri or postmenopausal Korean women, and was published in 2007.[6] Mean Kupperman index scores at 4 and 12 weeks were significantly lower in the treatment group (P < 0.002). At the end of the study, the average decrease in the Kupperman Index was 20 points in the treatment group and only 8.2 points in the placebo group (P < 0.001). Vaginal dryness and low libido were two symptoms that did not improve, but the average hot flash scores were significantly lower in the black cohosh/St. Johns wort group.

Finally, a study was done in which a combination of black cohosh with or without St. John’s wort was used in 6141 women at 1287 outpatient gynecologists in Germany in a prospective, controlled open-label observational study.[7] The greatest changes occurred with the combination therapy for nervousness/irritability and mood swings, but in the area of depression, there was a reduction in both treatment groups.

St. John’s wort is emerging as an important clinical tool in treating perimenopausal/menopausal women—for hot flashes and/or depression and/or mood swings, as a single agent, or in combination with other therapies.

References

[1] Abdali K, Khajehei M, Tabatabaee R. Effect of St. John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause 2010;17(2): 326-331.

[2] Al-Akoum M, Maunsell E, Verreault R, Provencher L, Otis H, Dodin S. Effects of Hypericum perforatum (St. John’s wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial. Menopause. 2009 Mar-Apr;16(2):307-14.

[3] Grube B, Walper A, Whatley D. St. John’s wort extract: Efficacy for menopasual symptoms of psychological origin. Adv Ther 1999;16:177.

[4] Boblitz N, Schrader E, Henneicke-Von Zepelin H, et al. Benefit of a fixed drug combination containing St. John’s wort and black cohosh for climacteric patients-results of a randomised clinical trial )poster presentation from 6^th Annual Symposium on Complementary Health Care, Exeter, England, December 2-4 1999). Focus Alt Comp Ther 2000;5(1):85-86.

[5] Uebelhack R, Jens-Uwe Blohmer, et al. Black cohosh and St. john’s wort for climacteric complaints. Obstet Gynecol 2006;107:247-255.

[6] Chung D, Kim H, Park K, et al. Black cohosh and St. John’s wort (GYNO-Plus) for climacteric symptoms. Yonsei Med J 2007;48(2):289-294.

[7] Briese V, Stammwitz U, Friede M, et al. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment- Results of a large-scale, controlled, observational study. Maturitas 2007;57:405-414.

Results: The total MRS II score for women while on black cohosh treatment reduced from 17.6 to 13.6, a statistically significant reduction. Symptoms of hot flashes, sweating, sleep problems, and anxiety improved, but vaginal dryness and body aches/pains did not change. Twenty two patients reported adverse events, but none were linked with the black cohosh; 90% of the women reported the tolerability of the black cohosh extract as very good or good.

Commentary: This is one more positive study using black cohosh extract for menopausal symptoms and even more meaningful, women on tamoxifen can have more problematic menopause symptoms and so a significant benefit of black cohosh is especially needed. Readers will also want to be reminded that we do have safety data on black cohosh in breast cancer patients—there is no estrogen in black cohosh, no phytoestrogens in black cohosh, no ability to stimulate breast cancer cells and laboratory data showed that black cohosh inhibited proliferation of estrogen receptor positive breast cancer cells and augmented the anti-estrogen effect when using black cohosh with tamoxifen. Black cohosh is clearly the first choice herb for menopause symptoms in breast cancer patients, and in breast cancer patients on tamoxifen.

Reference:

Rostock M, Fischer J, Mumm A, et al. Black cohosh (Cimicifuga racemosa) in tamoxifen-treated breast cancer patients with climacteric complaints – a prospective observational study. Gynecol Endocrinol. 2011 Jan 13;

While taking the cranberry extract, none of the women had a UTI over the course of the 6 months and almost all of the urine cultures were sterile (normal). Three women reported mild gastrointestinal problems and their dose was reduced to 2 capsules per day and as a result, their gastrointestinal problems subsided.

Commentary: Cranberries, in the form of juice and capsules have been shown to be effective in previous prevention and treatment of bladder infections. Both cranberries and blueberries belong to the Vaccinium species which are rich sources of dietary flavonoids, including anthocyanins and proanthocyanidins. While the exact mechanism of the benefits of cranberries has not been clearly established, it is thought that the inhibition of adherence of the main bacteria causing infection, Escherichia coli, to the uroepithelial cells that line the wall of the bladder is the main action.

Reference:

Karefilakis C, Mazokopakis E. Efficacy of cranberry capsules in prevention of urinary tract infections in postmenopausal women. J Altern Complement Med 2009;15(11):1155.

After 8 weeks, both the hops group and the placebo group had significant improvement in outcome measures compared to the baseline and actually higher average reductions in the placebo group. After 16 weeks however, only the group that was on the hops extract in the second 8 weeks had a reduction in all outcome measures whereas the placebo group in the second 8 weeks had an increase for all outcome measures. Although the overall treatment efficacy of the hops treatment compared with the placebo did not show a significant effect, the time specific uses did indicate significant reductions in the KI and the VAS for the hops group, and a marginal reduction in symptoms for the MRS after 16 weeks.

Commentary: This is the second study on an oral hops extract for menopause symptoms that I am aware of. 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. In the previous 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.[i] 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 hops extract , especially the hot flush score. The higher dose was not any better than the lower dose. Both the current study and this previous study, used a standardized hops extract at 100 mcg 8-prenylnaringenin. The current study used the lower 100 mcg dose.

This hops standardized extract may provide a useful herb for women suffering from common menopause symptoms such as hot flashes/night sweats. I have been using it in my clinical practice for approximately two years, usually along with one or more of the following: Black cohosh, St. John’s wort, Maca extract or a combination botanical of Dong Quai/burdock root/ wild yam root/ licorice root/motherwort. Hops do contain phytoestrogens and this is the likely mechanism of action.

Reference:

[i] Heyerick A, Vervarcke S, Depypere H, et al. A first prospective, randomized, double blind, placebo-controlled study on the use of a standardized hop extract to alleviate menopausal discomforts. Maturitas 2006;54:164-175.

Fifty-two patients received C. domestica extracts and 55 patients received ibuprofen with 45 patients in the curcuma and 46 patients in the ibuprofen group completing the study. The mean scores of pain on level walking, pain on stairs, and functions of the knee were significantly improved when compared with the baseline values in both groups. There were no significant differences in those measurements between the patients receiving ibuprofen and C. domestica extracts, except pain on stairs was more favorable with curcumin and a greater degree of moderate to high degree of satisfaction with treatment in the curcumin group (90.1%) vs. 82.8% in the ibuprofen group. There was a bit better compliance with the ibuprofen at twice daily than the curcumin four times daily, but there were no patients who reported dissatisfaction in the curcumin group.

Reference

Kuptniratsaikul V, Thanakhumtorn S, Chinswangwatanakul P, et al. Efficacy and safety of Curcuma domestica extracts in patients with knee osteoarthritis. J alternative and Complementary Medicine 2009;15(8): 891-897

This meta-analysis was done to assess the association between tea consumption and endometrial cancer. A total of 7 studies with 2 cohort studies and 5 case-control studies met the criteria for inclusion in this meta-analysis. Green teas and black teas were included in the search. A total of 3487 cases and of endometrial cancer and 104,643 non cases appeared in the pooled analysis. The results suggested that tea consumption was statistically significantly associated with reduced risk of endometrial cancer. The combine relative risk for ever drinkers vs. non/lowest drinkers was 0.85. Compared with non/lowest drinkers, the relative risk was 0.88 for low to moderate drinkers and 0.75 for high drinkers. An increase in tea intake of 2 cups per day was associated with a 25% decreased risk of endometrial cancer. In analysis by subgroup, green tea consumption was significantly associated with decreased risk whereas an association with black tea was not observed.

Commentary: The mechanisms whereby tea reduces the risk of endometrial cancer are multifactorial. Tea, even green tea, contains caffeine, which lowers free estrogen levels. A number of antioxidants are in green tea, and these “catechins” affect carcinogenesis in numerous ways including inducing apoptosis (cell death), inhibiting estrogen-induced activation of endometrial cells and scavenging free radicals. Tea also contains phytoestrogens and can have an estrogen antagonist effect on endometrial cells. Tea consumption also modifies genetic polymorphisms relevant in the development of endometrial cancer.

Reference

Tang N, Hua L, Qiu Y, Zhou G, Ma J. Tea consumption and risk of endometrial cancer : a metaanalysis. Am J Obstet Gynecol 2009;201:605.e1-8

In the newest of the St. John’s wort studies in perimenopausal/menopausal women, a total of 100 Iranian women with an average age of 50 participated in a randomized, double-blind, placebo-controlled clinical trial comparing St. John’s wort with placebo in the treatment of hot flashes.[1] 50 women received 20 drops three times daily of St. John’s wort extract (Hypericin) that contained hypericin 0.2 mg/mL and 50 women received a placebo of distilled water. The study duration was two months. Clinical exams and interviews were performed at baseline, 4 weeks and 8 weeks. Treatment effectiveness was measured evaluating frequency, duration and severity of hot flashes as the main objective of the study.

In women taking St. John’s wort, the frequency began to decline during the 1^st and 2^nd months, but showed more improvement during the 2^nd month. There was no statistical change in hot flash frequency during the first month of placebo but did improve during the second month. Women who used St. John’s wort showed more improvement in hot flash frequency than placebo. The decline in duration of hot flashes was statistically significant at week 8 and the decline was much more evident in the St. John’s wort group. The severity of hot flashes was relieved in the St. John’s wort group during the 2 months of treatment and was more significant in the second month. Women in the placebo group did not show any significant decrease in severity of hot flashes during the 1^st month, but they did have some improvement during the 2^nd month, but not as great as those women in the St. John’s wort group.

Comments

St. John’s wort has emerged as an important clinical tool in treating perimenopausal/menopausal women—for hot flashes and/or depression and/or mood swings, and/or sleep problems either as an encapsulated standardized extract from 300 mg twice per day to three times per day, or a tincture/liquid extract ½ tsp 2-3 times per day, or in combination with other menopause therapies such as black cohosh, maca extract, kava or others.

Reference

[1] Abdali K, Khajehei M, Tabatabaee R. Effect of St. John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause 2010;17(2): 326-331.