Lifestage Health - Women
Introduction
Women have lifestages which can be defined by the onset of menstruation, and the continuence of this through teenage years to middle age. This leads into the early stages of the menopause, and finally through to the post menopausal phase. Hormonal changes form an integral part of these changes and as a consequence of these hormone driven processes certain symptomatic characteristics are commonly experienced during these female life stages. These include the symptoms comprising PMS ( pre-menstrual syndrome) and the mood shifts and hot flushes characteristic of the menopause.
Many traditional and more recent nutritional and herbal preparations have been advocated to help women cope most particularly with PMS and the menopause and these are reviewed below.
Premenopause (PMS)
Premenstrual syndrome (PMS) can be seen as a collection of physical, psychological, and emotional symptoms related to a woman´s menstrual cycle. Almost 75% of all women suffer physical and/or psychological symptoms in the days (up to two weeks) before their period begins. If these symptoms significantly influence the daily activities of the woman, then she can be defined as being affected by PMS.
For most women the symptoms are mild but in 20% to 30% of females the symptoms are of sufficient severity to significantly interfere with some aspects of daily life or routine.
For about 6% of women the symptoms are so severe that they seriously impair their quality of life. This aspect of the PMS syndrome has been named premenstrual dysphoric disorder (PMDD).
The exact cause PMS is unknown. Common sense indicates it must somehow be linked to the fluctuating levels of female hormones experienced during the menstrual cycle particularly around the point of ovulation, but the central issue of why some women are more affected than others is not understood.
Although there are many types of symptoms associated with PMS, most women suffer only a few. The most common symptoms are listed below:
Psychological symptoms:
Mood swings
Fatigue
Irritability
Poor concentration
Mild depression
Physical symptoms:
Breast tenderness
Abdominal swelling or bloating
Abdominal and or lower back pain
Weight gain
Swollen ankles
Headaches or migraine
Management of PMS
A wide variety of strategies for PMS have been proposed. For women with mild symptoms, keeping to a diet that´s low in salt, fat and caffeine but high in fruits and vegetables may provide some relief to symptoms. Similarly, eating small regular meals and moderate levels of exercise can make the monthly symptoms more bearable for some women.
For many women, however, neither lifestyle change nor the use of medicines is an entirely satisfactory approach to PMS. Some may be reluctant use medicines in the longer term, due to the possibility of side effects, while others don’t want to use medications to control symptoms associated with a natural biological function.
Nutrients with substantial evidence of benefit
- Calcium
- Vitamin B6
Nutrients with some evidence of benefit
- Magnesium
- Vitex Agnus Castus (Chaste Tree)
- Evening Primrose Seed Oil
- Ginkgo Biloba
- Omega-3 (Fish and Cod Liver Oils) - menstrual pain
Nutrients with Substantial Evidence of Benefit
CALCIUM
At least two well conducted trials have demonstrated significant improvement in the entire spectrum of PMS symptoms with the supplementation of between 600mg and 1000mg of calcium per day. It would appear to be a simple and effective supplement for reduction of the majority of mood and somatic symptoms and has the advantage of being recognised as also necessary for maintenance of bone health and reduction in risk of osteoporosis later in life.
VITAMIN B6
This vitamin has been the subject of most trials for PMS, with the majority showing reduction in overall symptomology. However, most of the trials have used daily dosages of vitamin B6 of between 50-200mg. This level is significantly above the RDA of 2mg. As such, most products which contain vitamin B6 for PMS probably have little effect as the inclusion levels are so low.
Nutrients with some evidence of benefit
MAGNESIUM
Low magnesium status has often been associated with PMS to the point where low magnesium intake has been suggested as a cause of PMS. In support of this, two trials have shown that supplementation of a minimum of 300mg magnesium per day was effective in the relief of a wide spectrum of PMS symptoms. This effect seemed better where vitamin B6 was also present.
EVENING PRIMROSE OIL
Evening primrose, starflower (borage) and blackcurrent oil all contain the fatty acid GLA (gamma linolenic acid). Although early trials showed positive effects of these oils with PMS latter trials have shown little or no effect. The overall burden of proof suggests moderate benefits at best.
VITEX AGNUS CASTUS (CHASTE TREE)
This herb has been traditionally used for PMS and two trials have been conducted, both of which showed reduction in a wide spectrum of PMS symptomology. A minimum of 40mg of standardised extract per day is the recommnded minimum daily level of supplementation.
GINKGO BILOBA
One trial has shown reduction in symptoms such as breast and abdominal pain and headaches with the use of ginkgo biloba.
OMEGA-3 (FISH AND COD LIVER OILS)
Two trials have demonstrated significant benefit specifically with menstrual pain with the supplementation of between 1000mg and 2000mg EPA/DHA from fish oil per day.
VITAMIN E
There are some ambiguous results with regard to vitamin E, but two trials using between approximately 250-500iu of vitamin E have shown benefits in reducing menstrual pain.
Conclusions
The SC expert panel recommends that the priority in the management of PMS by the use of supplements is to ensure sufficient intake of both calcium and magnesium, together with at least 10mg of vitamin B6.
Provision of all of these nutrients is likely to have substantial additional health benefits to boot.
Finally, the herb, agnus castus, is certainly worth trying particularly if the other nutrients show little effect.
Menopause
Whereas female life expectancy is 83 years in industrialized countries, the age of spontaneous menopause has remained stable at approximately 50 years of age. Menopause is a natural biological change in the body as the woman and marks the transition from the child bearing years into middle age.
When women go into the process of menopause, they will begin to experience various symptoms associated with this life transition which include hot flushes, night sweats, depressed moods and joint and muscle pain as well as post menopausal osteoporosis, vaginal atrophy and a higher risk of cardiovascular disease.
They occur due to changes in the hormone levels in the body whereby the production of estrogen and progesterone necessary for fertility and the maintenance of the menstrual cycle begin to decrease.
There is nothing women can do to avoid or delay the onset of this natural lifestage transition. However, there are lifestyle and dietary management steps that women can take to lessen the effects of the symptoms. These include:
Increasing level of exercise – studies have shown that those women who excercised an average of over 3.5 hours per week experienced significantly reduced menopausal symptoms particularly hot flushes and depressive mood compared to those who excercised less than 3.5 hours per week.
Smoking – cigarette smoking has been found to reduce the age of onset of the menopause, approximately doubling the risk of menopause before the age of 50.
Diet – studies of different populations suggests that increasing fruit and vegetable intake particularly soy based foods and reducing consumption of meat has benefit in management of menopausal symptoms
Clearly each of these lifestyle adjustment recommendations have substantial additional benefits to health other than the management of menopause symptoms.
Hormone Replacement Therapy
For the past decade a medical debate has raged about the safety of menopausal hormone replacement therapy (HRT) which seeks to moderate the effects and symptoms of menopause by augmenting hormone levels to provide a more gradual progression into this life stage. However the debate about increased risk of several diseases as a result of the use of HRT is still unresolved. However, long before these treatments were available, women were using alternative nutritional and herbal remedies to help with menopausal symptoms to go alongside the lifestyle changes mentioned above. Again, these are now some of the most popular selling alternative remedies in the U.K., and below is a summary of their scientific merit.
Nutrients with substantial evidence of effect:
- Black cohosh
- St John´s Wort
- Soy isoflavones
Products with some evidence on menopausal symptoms
- Dong quai
- Pollen
- Vitamin E
- Vitamin C and bioflavonoids
- Gamma oryzanol
Nutrients with little or no specific evidence
- All products which include only vitamins
- Flaxseed lignans products
- Ginseng or Ginkgo products
- Evening primrose oil
- Dong Quai has very inconsistent results. Because of the limited number of researches that show a beneficial effect and the risk of growth stimulation of breast cancer cells further researches concerning the effectiveness and Safety must be done before a positive statement can be given.
Nutrients with substantial evidence of benefit
Black Cohosh
What is Black Cohosh?
Black Cohosh has been consistently marketed as an aid for the relief of symptoms of menopause has received more scientific attention for its possible effects on menopausal symptoms than have other herbals, but its mode of action remains largely unknown., particularly hot flushes, and night sweats but also to reduce mood swing and to help with the ‘feeling blue’ or mild depression which is common.
The majority but not all studies of its effectiveness in reducing hot flushes have showed good results with significant reduction being recorded compared to the placebo or ‘dummy’ pill.
Most successful trials have incorporated a daily dose of black cohosh standardized to contain at least 4mg of triterpene glycosides. Observable benefits are usually seen following about 8 weeks of supplementation. Recent evidence also suggests that black cohosh is perfectly safe under long term use.
The beneficial effects of black cohosh in combination with St. John’s Wort seems to be even superior to either individual herb especially with respect to psychological aspects.
St. John’s Wort
This herb is the most heavily studied of the botanicals for treatment of depression. Although most studies have been conducted on non-menopausal population it has been shown to provide significant reduction in severity and duration of mild to moderate depression with minimal side effects.
St. John’s wort appears to show effectiveness in regulating mood swings and relieving the mild to moderate depression, which is often associated with the menopause.
Clinical trials indicate that the dosage required to produce effective outcomes is a minimum of 900mg of St John´s wort per day standardized to contain 0.35% hypericin (minimum 3.15mg hypericin) which appears to be the major active ingredeient. The duration of supplementation necessary to observe effects is typically 2-3 months.
Phytoestrogens
Several types of food and herbal plants are known to contain phytoestrogens. These are compounds which mimic the action of the hormone estrogen which decreases significantly during menopause. Hence the idea of increasing foods such as soy and red clover in the diet during and following menopause is that here is a very mild aspect of hormone replacement. In this regard approximately 300mg of soy isoflavones is equivalent to about 0.45g of oestrogen.
Trials of increased intake of isoflavones to over 200mg per day have demonstrated significant reduction in symptoms such as hot flushes and night sweats as well off setting vaginal dryness and irritation which is common in post menopausal women. However some other trials have shown little benefit.
Additional advantages of increasing intake levels of isoflavone are evidence of significantly improved retention in bone mass density during and following menopause and possibly benefits in helping maintain heart health.
The daily intake of isoflavones required to provide a likely dlivery of intended benefits is greater than 50mg with a probability of increased effects up to 300mg per day.
The duration of increased intake required to observe benefits is about 2-3 months.
Overall there is no reason why there should be a difference in effectiveness of red clover, and hop isoflavones compared to soy isoflavones. However, red clover may possibly be less effective in reduction of menopausal symptoms but more effective in maintaining bone mass during and following the menopause. However, the SC expert panel has assumed equivelanxce in soy and red clover isoflavones when making their assessments.
Nutrients with some evidence of benefit
Dong Quai
Dong Quai is often used as a component of menopausal remedies but the results of recent studies show inconclusive results. Anecdotal evidence and some small studies showed a positive effect on menopausal symptoms but recent better conducted studies have shown little if any effect.
Pollen
There are only very few research data concerning the use of pollen extracts as a remedy for menopausal symptoms and only very few products include pollen extracts as a component. One study showed a beneficial effect on menopausal symptoms including hot flashes but further long term studies on the effectiveness and safety have to be done.
Vitamin C and bioflavonoids
One early clinical trial found that high levels of vitamin C and bioflavonoids (1200mg and 900mg respectively per day) reduced, hot flushes and nocturnal leg cramps. Again, these results have not been repeated or confirmed in more recent trials.
Vitamin E
Some very early studies found vitamin E at levels of 400i.u to be effective in reduction of hot flushes and vaginal complaints during meneopause. Later trials however have failed to demonstrate the same effects.
Gamma oryzanol
Gamma oryzanol is found in grains and is isolated from rice bran oil. Two reasonably well conducted but older trials found this nutrient at 300mg per day was effective in reducing overall levels of menopausal symptoms particularly hot flushes. No recent trials have been conducted to confirm this effect.
Nutrients with little or no evidence of specific effect
Ginseng
Ginseng has been used traditionally as a tonic and energy boosting herb for centuries and studies have confirmed effects including slight improvement in symptoms of depression relief of fatigue, reduction of sleep disturbances, and improvement in overall sense of well-being. Because it is used mainly in combination products its effects are not clear. These effects may make ginseng a useful addition in a combination product but there is no evidence of effects on specific menopausal symptoms.
Ginkgo
Ginkgo is likely to have a positive effect on some specific symptoms of menopause such as forgetfulness and lack of concentration and also may have benefits on the common menopausal complaint of cold hand ansd feet. Both of these effects are due to the improvement in circulatory function which is recognized with ginkgo. As such, although there are no major studies demonstrating specific effects on menopausal women, this herb may be useful in combination products.
Vitamins and minerals
Many combination products for menopause contain various vitamins and minerals. With the exception of those mentioned above these nutrients do not have any specific merit in relieving menopausal symptoms. However, it is important that menopausal and post-menopausal women have a sufficient intake of vitamins and minerals to maintain general health. By doing this they well observe indirect benefits during the menopausal years and this is the justification for many menopausal products being based on a multivitamin and mineral foundation. An effective alternative to some of the combination products however could be a good quality multivitamin and mineral combined with a specific menopausal symptom lowering product such as black cohosh.