Best herbs to ease menopause

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Change-of-life remedies are now jamming the shelves. But they're not all created equal. Here's what to take home with you

The variety can make you dizzy, whether you're in menopause or not. There's "Born Again" cream, "Menopause Support" capsules, "Easy Change" gel, and "Women's Balance" tablets, to name a few. On a recent visit to a health-food supermarket, we counted more than 40 different potions in the change-of-life section.

And the prices might even give your husband a hot flash: A three-week supply of cream runs a cool $24.99. Sixty vitamin supplements costs $15.99. A delicate 2-ounce vial of herbal tincture carries a $12.99 price tag.

Which made us wonder: Do these products actually do what their names imply? Will they take away the hot flashes, vaginal dryness, night sweats, mood swings, or other symptoms that can make meno-pause seem like such a hassle?

To get the straight scoop, we went to the leaders in the fields of menopause and natural therapies. (See "Our Experts," p. 160.) The consensus: There are sound reasons to believe that a number of health-food-store products might safely alleviate some discomforts of menopause. And there are sound reasons to believe that others won't.

Since so many combination products are on the shelves but so few have been tested, it's smartest to look at these remedies in terms of individual ingredients. Here's what's what:

Often helpful

BLACK COHOSH (Cimicifuga racemosa)
What it does: Evidence suggests it can relieve hot flashes, night sweats, headaches, heart palpitations, and vaginal drying and thinning. The best documented of all the herbal remedies, black cohosh has been shown to suppress the secretion of luteinizing hormone (LH), a hormone that's believed to be at the root of many of these symptoms. Some studies suggest black cohosh can reduce menopause-related headaches, depression, anxiety, and decreased libido, points out Varro Tyler, PhD, ScD, Prevention advisor and America's foremost expert on herbs.

How we know: European studies confirm that black cohosh relieves many menopausal symptoms. In fact, one double-blind study of 80 women found it reduced menopausal symptoms better than the conjugated estrogens. Black cohosh has been approved for the treatment of menopausal symptoms by German Commission E, Germany's leading author-ity entrusted with evaluating the safety and efficacy of herb remedies.

Products we found: Capsules, tablets, drops, powders. (Capsules or drops are the most practical way to take black cohosh; the dose is too small to take as a tea.) Special note: There are many brands of black cohosh. But there's one brand in particular that many of our experts said they trust: Remifemin. The brand has been around for decades in Europe, and became available in the United States in 1996. Its quality and dose are controlled by a reputable manufacturer, and many of the European studies were done with Remifemin.

How much to take: Forty milligrams (mg) a day is the therapeutic dose approved by Commission E. Many products contain more--sometimes hundreds of milligrams more-- but larger doses are unnecessary and may even be unsafe. Be sure to read the label to know how much of a product you need to take to get the equivalent of 40 mg black cohosh.

Cautions: Black cohosh can require time and money. "It takes at least three to four weeks before the effects kick in---some women want relief tomorrow, or yesterday," notes menopause expert Dixie Mills, MD, who's also a clinical assistant professor of surgery at the University of Vermont, Burlington.

Black-cohosh therapy can also be more expensive than prescription estrogen. Premarin (the most widely dispensed brand of estrogen) costs less than 40 cents a day, while Remifemin (at the recommended dose of two 20 mg tablets daily) runs about 50 to 60 cents a day. Unlike estrogen-replacement therapy, black cohosh isn't able to help prevent osteoporosis or possibly prevent cardiovascular disease.

Dr. Tyler notes that some people report upset stomachs from black cohosh. Because the long-term toxicity has not been studied, he agrees with the Commission E recommendation that women use it for no longer than six months continuously. Dr. Tyler suggests allowing several weeks between uses.

Possibly helpful

CHASTEBERRY (Vitex agnus-castus)
What it might do: Relieve hot flashes, night sweats, headaches, heart palpitations, and vaginal drying and thinning. Even though Commission E has approved chasteberry for treating symptoms of menopause, Dr. Tyler has a hunch that it's not so helpful for this time of life. Based on the herb's pharmacology, it is believed to reduce levels of prolactin, a hormone associated with PMS symptoms. "There's much more research showing it is effective for premenstrual syndrome, and that makes more sense to me," says Dr. Tyler.

How we know: Germany's Commission E has approved chasteberry for treating symptoms of menopause. In clinical experience, our experts' reviews of its effectiveness have been mixed.

Products we found: Pills, tea, drops; alone and in various combinations.

How much to take: The therapeutic dose for menopause recommended by Germany's Commission E is 20 mg a day. "Capsules or drops are a practical way to take chasteberry," says Dr. Tyler. "But if you wish, you can make a tea. Use a pinch of powdered chasteberry (approximately 20 mg), and steep it in hot water for 15 minutes. Drink a cup once a day."

Cautions: While the side effects and long-term toxicity aren't well documented, we do know that chasteberry can trigger a rash in some people. It should not be used by wom-en experiencing reduced sexual desire as part of their meno-pause: The herbal literature reports that it reduces libido. (Another name for this herb is Monk's Pepper, and it really was used in monasteries.)

Possibly helpful

GINSENG (Panax ginseng)
What it might do: Erase some of the fatigue and possibly even slight depression that can come with menopause. Ginseng is a proven stimulant, notes Dr. Tyler, and in menopause, it may give a boost to your general feelings of well-being.

Some doctors believe that it might have an estrogen-like effect on the body, easing menopausal symptoms, such as vaginal dryness and hot flashes, and possibly stimulating endometrial growth and bleeding. Some women who take ginseng experience uterine bleeding long after they have gone through menopause, says Brian Walsh, MD, director of the menopause clinic at Brigham and Women's Hospital, Boston. With such a lack of research, the unanswered question is whether bleeding can be attributed to the herb itself or to the use of an inferior product.

How we know: Its effect as a stimulant is beginning to be documented in rigorous scientific studies. Two recent investigations involving more than 500 people suggest that people taking ginseng-- combined with vitamins and minerals--felt an improved quality of life. Other studies suggest boosts in psychological well-being and energy. But the evidence of an effect on specific menopause symptoms is at this point only anecdotal.

Products we found: Capsules, drops, teabags, dried herb; alone and in combination.

How much to take: No one knows the therapeutic dose for menopause, since this remedy is unproven. But for other uses, the recommended dose of a typical product containing 4% ginsenosides is two 100 mg capsules daily. Capsules or drops are a practical way to take ginseng. Or you can make a tea. Steep one teaspoonful of the dried product for about 10 to 15 minutes, once a day, Dr. Tyler suggests.

If ginseng is already in your menopause remedy but the label doesn't say how much of the active ingredient is in there, Dr. Tyler advises: If you find you can't sleep at night, you're probably taking too much.

If any type of ginseng could be effective for menopause, it would be Panax ginseng. This is the variety on which most studies have been done. Other forms of ginseng, such as Panax quinquefolius, have not been as well studied.

Possibly helpful

VITAMIN E (not an herb, but worth mentioning)
What it might do: Decrease hot flashes.

How we know: Anecdotal evidence and clinical experience. Dr. Walsh says that many of his patients have reported that vitamin E seems to reduce their hot flashes. "It makes sense," he says, "when you consider that vitamin E is structurally similar to estrogen at the molecular level." So it might act as a mild form of estrogen-replacement therapy, he explains.

Unfortunately, there are no well-controlled, large-scale studies that prove vitamin E reduces menopause symptoms. But many women and doctors, based on their experience, feel it helps. And that includes many of you. In a survey of Prevention readers' menopause remedies that we conducted in 1992, half of the women who tried vitamin E for hot flashes and night sweats reported an improvement in their symptoms. Ordinarily we don't recommend any remedy based on anecdotal evidence, but vitamin E can be smart for overall health, so taking it at menopause seems reasonable.

Products we found: Pills, in combination products, and alone.

How much to take: The experts we interviewed suggest 400 to 800 international units (IU) daily.

Approach cautiously

LICORICE ROOT (Glycyrrhiza glabra)
What it might do: Reduce hot flashes, irregular bleeding, mood swings, and vaginal dryness. Licorice root contains high levels of estrogen-like compounds, called phytoestrogens, that act like a weak estrogen in some parts of the body. That means phytoestrogens might have the ability to act like hormone-replacement therapy, quashing hot flashes and other symptoms that are believed to result from the reduction in estrogen levels that comes with menopause. However, unlike soy, another food high in phytoestrogens, licorice root has the potential for side effects, and can't be recommended, as soy can be.

How we know: Anecdotal evidence and speculation. "There are simply no studies that show licorice root can affect symptoms of menopause in human beings," says Dr. Tyler. While this is similar to what we know for remedies like vitamin E, we put lico-rice root in the "approach cautiously" category because of its potential for sometimes serious side effects.

Products we found: Pills, drops, teabags, and in bulk; alone and in combination.

How much to take: If you're still determined to try this, and you have your doctor's okay, at least use a safe dose. According to Germany's Commission E, that's up to 15 grams (g) a day, for no longer than four weeks. To get 15 g from tea, you'd need to steep 2 to 3 teaspoons of the dried product for 10 to 15 minutes, and drink 3 to 4 cups a day. If taking it in other forms, check the label for the right amount to equal 15 g.

Cautions: Licorice root really shouldn't be used without consulting a doctor. Licorice contains compounds that affect the adrenal hormones in potentially harmful ways. "It can raise blood pressure and lower potassium, and there's even a reported case of a cardiac arrest," says Adriane Fugh-Berman, MD, chair of the National Women's Health Network and nationally recognized authority on alternative medicine. While the trouble in these cases was caused by people addicted to licorice laxatives or imported licorice candy (black licorice in this country is flavored with anise, not real licorice), "That doesn't negate the fact that high doses of licorice can be harmful," she adds. The point is, it shouldn't be used without consulting a doctor or other health-care practitioner knowledgeable about herbs.

Probably not helpful

DONG QUAI (Angelica sinensis) (The Chinese name is also spelled dong kwai)
What it probably won't do: Relieve any symptoms of menopause. The best dong quai can offer: compounds in it that make it a mild laxative and central-nervous-system stimulant.

How we know: There has been at least one well-controlled clinical study on dong quai for menopausal women in the United States, and it showed no benefit.

"If anything, dong quai lowers the circulating levels of estradiol (one of the body's own estrogens), rather than raising them," says David T. Zava, PhD, who's researched this herb and who is one of the nation's leading experts on plant estrogens.

One reason some reports may have turned up positive for anti-menopause effects is that in traditional Chinese medicine--where this herb and menopause have been linked--dong quai is always combined with other herbs. Dr. Zava speculates this herb may need to be complemented with other herbs to be helpful.

Products we found: Pills, drops, powder in bulk; alone and in various combinations.

Cautions: Dong quai can cause skin problems, especially when skin is exposed to the sun. "Women who use it should wear a sunscreen," says Dr. Tyler. Research assistant professor Gail Mahady, RPh, PhD, from the University of Illinois, Chicago, adds another important caution: "Dong quai is not for women who have excessive vaginal bleeding--it might make it worse."

ILLUSTRATIONS

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By Cathy Perlmutter

COMPARED WITH ESTROGEN...
How does the health-food-store route compare with hormone-replacement therapy? Here are a few important ways: Pluses

+ Some prescription estrogens are plant-derived, while some--most notably, Premarin--contain estrogen extracted from pregnant mares' urine. For women who want to avoid those forms of prescription estrogen that do come from animals, the herbal remedies may be a good option.

+ Experts are optimistic that some of the herbs used for menopause don't cause endometrial cancer or possibly increase the risk of breast cancer, unlike estrogen. For example, European studies have not shown that black cohosh promotes breast cancer or other estrogen-related cancers. However, no one has studied the long-term effects of any of the other herbs on cancer.

Minuses Unlike estrogen, no single herb is proven to prevent osteoporosis.

The alternative products may work best for mild symptoms. If a woman has very severe symptoms, she might respond much better to conventional hormone-replacement therapy.

Alternative products can be just as expensive as prescription products.

NOT AN HERB, BUT...
"Tofu and other soy products may be more promising for menopause than any herbs," says Varro Tyler, PhD, ScD. Soy may be effective for soothing hot flashes, eliminating vaginal dryness, slowing bone loss, and protecting the heart. No one can say for sure how much you need, but many experts think that taking in soy products containing 30 to 50 milligrams (mg) isoflavones a day may be enough. That's about 1 1/2 cups of low-fat soy milk, a half cup of tofu, or 2 tablespoons of roasted soy nuts.

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