Women's Health Update: Essential Fatty Acids and Women's Health - Part 2

Women's Health Update: Essential Fatty Acids and Women's Health -- Part 2

In December's column I discussed the influence of essential fatty acids in premenstrual syndrome, menstrual cramps and abnormal menstrual bleeding. In addition to understanding the importance of essential fatty acid (EFA) metabolism in women's health problems, I also hoped to communicate the effectiveness of using EFA supplements in the treatment of these problems. In this column, the discussion will extend to fibrocystic breasts, pregnancy and lactation, osteoporosis, and breast cancer.

Fibrocystic Breasts

Virtually all knowledgeable providers agree that the term "fibrocystic breast disease" should be abandoned in favor of more accurate physiologically based descriptions for many reasons. Benign breast conditions that are present in almost all women to some degree or another should probably never have warranted the label of "disease." Tender or lumpy breasts comprise one of the most common motivations for women entering the health care system. Since painful breasts are not always lumpy, and lumpy breasts are not always painful -- and neither is usually abnormal -- it would be more useful to create descriptive categories of symptoms and conditions to replace the generic term "fibrocystic": physiological, cyclical pain and swelling/ mastalgia/ breast nodularity or diffuse lumpiness/ and dominant masses. For the purpose of our discussion here, I will be addressing mastalgia.

Breast pain is a common disorder which affects about 40% of women of reproductive age and seriously disrupts the lives of around 10% of women. It is a disorder precipitated by ovarian hormones yet no consistent abnormalities of circulating ovarian hormone levels have ever been detected. The conclusion has been that women with breast pain have breast tissue which is unduly sensitive to normal amounts of ovarian hormones.

Results of scientific research and clinical trials have consistently shown that evening primrose oil (EPO) is effective in relieving breast pain and premenstrual cyclic breast pain.( 1-3) In the course of treatment, it has been detected that women with breast pain have unusually low concentrations of gamma linolenic acid (GLA) metabolites, and the elevations of the concentrations of GLA metabolites increases and the concentration of saturated fats in the breast decreases when supplemented with EPO, a particularly concentrated source of GLA. Breast pain has also been associated with a high consumption of saturated fats and a very low fat diet can often relieve such pain.( 4)

The pain and tenderness of benign breast disease associated with "cyclic mastalgia" has been alleviated with EPO, the only one of the many EFAs to be scientifically studied in relation to mastalgia. One of best examples of studies that were done was in 1985, when 291 women took 3 grams of EPA for three to six months. Almost half of the 92 women with cyclic breast pain experienced improvement (either no pain, or easily-bearable pain), compared with one fifth of the patients who received the placebo. For those women who experienced breast pain throughout the month, 27% responded positively to the EPO, compared to 9% on the placebo.( 1)

What is especially important to the discussion, and perhaps even more relevant to the discussion on breast cancer, is that ovarian hormone levels are normal in women with breast pain and are not changed by therapy with GLA. Yet, the abnormal sensitivity of the breast tissue to normal hormone levels does appear to be reduced by GLA supplementation. The proposed mechanism for the relief of breast pain with GLA is a shift in the balance of membrane fatty acids towards normal; the steroid receptors in the breast then have a reduced affinity for estrogen, and the excessive sensitivity of the breast to estrogen is lost.


Osteoporosis is a growing concern with postmenopausal women due to its prevalence in 75 year-olds and older and the disability and even mortality it can cause. Although EFAs have not been talked about much in relationship to this disease, there is a growing body of evidence and research to warrant our attention. EFAs have been shown to increase calcium absorption from the gut, in part by enhancing the effects of vitamin D, to reduce urinary excretion of calcium, to increase calcium that is deposited in the bone and improve the bone strength and to stimulate the synthesis of bone collagen.( 5) Other findings have demonstrated that patients with osteoporosis who are given fish oil show an increase in serum calcium levels, and others given a fish oil/evening primrose oil combination had increased osteocalcin as well an increased procollagen, all suggestions that these supplements may enhance bone formation.( 6) In this study, serum and urinary markers of bone turnover were monitored in 40 women eighty years or older, with osteoporosis. Patients were divided into four groups, each group receiving one of the following: 1) 4 g EPO 2) 4 g fish oil 3) 4 g of a mixture of EPO and fish oil and 4) olive oil. Patients were supplemented for 16 weeks. A number of meaningful parameters in the fish oil and combined groups changed as a result of the treatment. In the fish oil group alkaline phosphatase fell significantly, procollagen rose and calcium clearance rose significantly. The observations were similar in the combination group except that the osteocalcin also rose significantly. EPO alone had no significant effects.

Even though this study was short term, and it only measured markers of bone turnover and not bone density, the findings do suggest that supplementation with fish oil or a combination of fish oil and EPO may improve bone formation.

In animal studies, EFA deficiency leads to the development of severe osteoporosis along with increased calcifications in the kidney and the walls of the arteries. This is similar to what we see in elderly patients with osteoporosis, i.e. loss of bone calcium and increased calcifications in soft tissues, particularly the arteries and the kidneys. These calcifications outside the bone may be more dangerous than the osteoporosis itself, since the great majority of osteoporosis related deaths is due to a vascular problem such as a blood clot formation.

Supplementing our diet with oils high in GLA may improve absorption of calcium and enhance the calcium content in the bone. Supplementing with fish oils may improve the blood levels of calcium and help to correct a deficient calcium effect in the bone.

Pregnant and Nursing Women

Everyone would agree that good nutrition during pregnancy bodes well for a healthier pregnancy and a healthier baby. Adequate calories, a well balanced diet of complex carbohydrates, proteins, and fats with whole foods, and a minimum of sugar, refined carbohydrates and saturated fats form the foundation of good nutrition. Essential fatty acids have a unique role during pregnancy because of the rapid development of new cell growth, new tissues, and new organ systems in a developing fetus. All cells throughout the human body are surrounded by a membrane composed mostly of essential fatty acids called phospholipids. Phospholipids play a major role in determining the nature and structure of cell membranes. The type of fat is what determines the type of phospholipid in the cell membrane. A phospholipid composed of a saturated fat or a trans fatty acid is of lesser quality than a phospholipid composed of an essential fatty acid. A deficiency of EFAs in cellular membranes make it almost impossible for the cell membrane to perform its function as a selective barrier between what passes in and out of the cell. A healthy membrane leads to healthy cells and then healthy tissue and then to healthy organs or body systems and finally healthy bodies and minds. This evolution of health is dependent on EFAs because of their critical importance to the cell membrane and the development and formation of new tissues in a growing fetus.

Fetal development is associated with a high EFA requirement, and this supply is dependent on the amount and availability of EFAs from the mother. At delivery, a strong correlation is seen between the relative amounts of the various EFAs in maternal and umbilical plasma phospholipids, which emphasizes the dependence of the fetus on the maternal EFA status. In a longitudinal study, the EFA status in pregnant women progressively decreased during their pregnancy.( 7) The tendency was for the first child to have a higher docosahexaenoic acid (DHA) status than her subsequent children. This higher DHA in premature infants is correlated to head circumference, birth weight and birth length. This may imply that increasing the DHA level in the fetus could promote fetal growth and improve the prognosis of premature infants.

A maternal vegetarian diet has an influence on the essential fatty acid status of the newborn. Studies have shown that intakes of linoleic acid and the ratio of linoleic to alpha-linolenic acid were higher in vegetarian women and eicosapentaenoic acid (EPA) and DHA were absent from their diets.( 8) The vegetarian women had lower EPA and DHA in plasma phospholipids and birth weight, head circumference and length were lower in the infants born to vegetarians as compared to omnivores. This study raises the concern that vegetarian women give birth to infants with less DHA, lower body weight and possibly slower growth of the brain although it did not appear to be related to the outcome of pregnancy.

A diet higher in essential fatty acids and fish oils or supplementation with a daily complex of these fats and oils during pregnancy provides vital nutrients that supply necessary nutrition for optimal fetal development.

Fish oil may also be valuable for the prevention of preeclampsia. An uncontrolled study of ten healthy pregnant women was done where they took fish oil capsules for 28 days.( 9) The dose was 2100mg fish oil 3 times daily. Women who were susceptible to preeclampsia before the test dose were less susceptible after the 28 days, as measured by their sensitivity to angiotensin II, a predictor of preeclampsia or pregnancy-induced hypertension. Controlled trials will be important to confirm these findings. Hopefully, this potentially serious medical problem could be prevented with the help of fish oil nutritional supplementation.

Menopausal flushing

Women often think to use EPO when treating hot flashes. However, there seems to be no validation of this practice as evaluated in a randomized, double blind, placebo controlled pilot study.( 10) Study subjects included 56 menopausal women suffering hot flushes at least three times a day. Women were given four capsules twice a day of 500 mg evening primrose oil with 10 mg natural vitamin E or 500 mg liquid paraffin for six months. All of the women given placebo showed a significant positive difference between the baseline cycle and the last cycle of the study period. Women given EPO, however, did not show a significant improvement between the baseline cycle and the last available treatment cycle except for a reduction in the maximum number of nighttime flushes. Currently, there is no good scientific rationale yet for the use of EPO in treating hot flashes.

Breast cancer and dietary fat

There has been a great deal of confusion and controversy about the relationship of dietary fats and breast cancer. For years, scientific researchers have been able to confirm a relationship between a high-fat diet and a higher incidence of breast cancer. Years ago, the fat intake of many countries was plotted on a graph against breast cancer rates.( 11) With few exceptions, the more fat individuals in that society consumed, the higher the risk of breast cancer. Ten out often international studies looking at large differences in fat intake from one country to another continued to confirm this relationship between higher dietary fat levels and higher rates of breast cancer.( 12) But in 1992, the nurses' Health Study group found no such link.( 13) Because this study received so much press, the doubt about dietary fat and breast cancer has resurfaced. There have been many critiques of this study to show the inaccuracy of the results, but perhaps the most compelling is that of the five categories of dietary fat that were analyzed, the group with the lowest amount of fat was still only slightly lower than 29%. This is significantly higher than the 20% many researchers believe to be the beginning of where women would receive the protective benefit.

Many studies have proven that if you drop your dietary fat to 20% or below, this will be accompanied by a decrease in estrogen levels.( 14) The key to the relationship between fat and cancer is probably estrogen. Dietary fat increases body weight, increasing the size and, to some extent, the number of fat cells. Fat cells make estrogen or convert other hormones into estrogen, which can then promote breast cancer. Women who consume high levels of fat have, on average, higher levels of active estrogen( 15) and putting women on a low-fat diet reduces their estrogen levels.( 16, 17)

What remains in the discussion on breast cancer and fats is a discussion on the effects of supplementing the diet with essential fatty acids, and the effect of alpha-linolenic acid, gamma linolenic acid, and the fish oils DHA and EPA on breast cancer. I will attempt to address this controversial topic in a future column.

(1.) Pye J et al. Clinical experience of drug treatments for mastalgia. Lancet 1985;ii:373-377.

(2.) Gately C et al. Drug treatments for mastalgia: 17 years experience in the Cardiff mastalgia clinic. J Roy Socy Med 1992;85:12-15.

(3.) Mansel et al. Effects of essential fatty acids on cyclical mastalgia and noncyclical breast disorders. In: Horrobin D ed., Omega-6 Essential Fatty Acids: Pathophysiology and Roles in Clinical Medicine. New York: Wiley-Liss 1990:557-566.

(4.) Boyd N et al. Effect of low-fat, high-carbohydrate diet on symptoms of clinical mastopathy. Lancet 1988;ii:128-132.

(5.) Kruger M, Horrobin D. Calcium metabolism, osteoporosis and essential fatty acids: a review. Prog Lipid Res 1997;36(2-3):131-151.

(6.) Van Papendorp D Coetzer B, Kruger M. Biochemical profile of osteoporotic patients of essential fatty acid supplementation. Nutrition Research 1995;15(3):325-334.

(7.) Hornstra G et al. Essential fatty acids in pregnancy and early human development Eur J Obstet Gynecol Reprod Biol 1995;61(1):57-62.

(8.) Reddy S, Sanders T, Obeid O. The influence of maternal vegetarian diet on essential fatty acid status of the newborn. Eur J clin Nutr 1994;48(5):358-368.

(9.) Adair C et al. The effect of high dietary n-3 fatty acid supplementation on angiotensin II presser response in human pregnancy. Am J Obstet Gyn 1996;175:688-91.

(10.) Chenoy R et al. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ 1994;308:503-506.

(11.) Carroll K et al. Dietary fat and mammary cancer. Can Med Assoc J 1968;98:590-593.

(12.) Goodwin P, Boyd N. Critical appraisal of the evidence that dietary fat intake is related to breast cancer risk in human. J Natl Cancer Inst 1987;39:473-485.

(13.) Willett W et al. Dietary fat and fiber in relation to risk of breast cancer. JAMA 1992;268:2037-2044.

(14.) Longcope C et al. The effect of a low fat diet on estrogen metabolism. J Clin Endocrinol Metabol 1987;64:1246-1250.

(15.) Goldin B et al. The relationship between estrogen levels and diets of Caucasian American and Oriental immigrant women. Am J Clin Nutr 1986;44:945-953.

(16.) Prentice R et al. Dietary fat reduction and plasma estradiol concentration of healthy postmenopausal women. J Natl Cancer Inst 1990;82:129-134.

(17.) McDougall J. Preliminary study of diet as an adjunct therapy for breast cancer. Breast 1984;10:18-21.

Townsend Letter for Doctors & Patients.


By Tori Hudson

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