Lecture 17 November 1st -- Menopause

1MEN’S AND WOMEN’S HEALTH – NOVEMBER 1ST, 2007 MENOPAUSE LECTURE 17 •

Lower levels of sex hormone binding globulin: get male pattern hair loss. Get increased levels of circulating testosterone. Can increase SHBG through vegetarian diet to reduce circulating testosterone.

Symptoms of perimenopause • Traditional therapy for menopause: hormone replacement, anti-depressives, SSRI.

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Women’s health initiative study: will talk about this on Monday. Study on women using HRT; found it was doing more harm than good. Stopped study early because women were dying from therapy. Docs are now moving away from this type of therapy into other options: we can do a lot to help with the symptoms.

Chart on hot flashes: • Sudden onset of vasodilation. To do with the rate of decline of estrogen: the speed at which it is declining. Provide with phytoestrogens? One of the main indications for HRT is hot flashes.

Mayo clin proc. 2002; 77: 1207-1218 • •

Correlation with stress, insomnia. Tend to be worse at night. Alcohol, spicy foods: involved in pathway. Elicits response of NT, changes “setpoint” of brain. Body needs to lose heat: movement of blood to periphery, increase sensation of heat, profuse perspiration. Women are having to get up and change sheets in night, get cold after sweating in hot flash. Yin deficiency picture.

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The hot flashes are caused by the same pathway that causes LH release.

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Beneficial purpose to hot flash? Can call the “power surges”… is there a role in detoxification?

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Botanicals we can use for hot flashes? Nervines: passiflora, valerian

Sleep disruption • Strain on adrenal glands due to decrease in estrogen levels: contributing to cortisol levels and keeping her up at night? MEN’S AND WOMEN’S HEALTH, NOVEMBER 1ST 2007 – PAGE 1

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Support her with phytoestrogenic herbs: Cimicifuga is excellent. Then look at individual symptoms and prescribe other herbs for other hormone deficiencies.

Anxiety and depression • Increases around the time of menopause. Maybe women who are more prone to it are more likely to experience it. • Some symptoms of menopause are similar to post-partum symptoms. If you had post-partum sxs, you are also more likely to have perimenopausal effects. • • •

Estrogen has a positive effect on mood What can we prescribe? 5-HTP, acupuncture… Withania: Indian ginseng. Very gentle, calming adaptogen. Have to be careful of warming herbs if she is already experiencing hot flashes. Eleuthrococcus can be warming, maybe choose something else.

Memory loss and changes in cognition • Inconclusive results: may be a link to HRT? Will talk about this study in more detail on Monday. Atrophic changes • Lack of estrogen (large influence on tissues and secretions) = atrophy • See thinning of vaginal epithelium. Less activity of cells, less lactobacillis activity, less acidity. This can lead to increase in chance of infection. • Painful intercourse • Can apply estrogen topically. We can’t prescribe estrogen therapies, but she can talk to MD to recommend cream. • We can recommend calendula creams, Vitamin E creams, phytoestrogens to increase lubrication of vaginal wall. • Don’t assume that symptoms of burning, itching are the result of atrophy. May be emotional component, other biological process. • Test to assess effect on vaginal tissue: Maturation index: take PAP broom and take cells from vaginal epithelium. Maturity of cells will be assessed. • Can usually just tell on exam: pinpoint bleeding, pale, friable tissue. Labia will also be affected. • Sexual intercourse can increase the integrity of tissue, can encourage this with patient. Decreased Libido • Vaginal atrophy may cause pain, change in hormone levels. • Very complex topic: should be a class here! Many hormones involved, emotional components. • Overall testosterone levels fall: can use herbs to increase libido if testosterone levels are an issue. • Adrenal function? If she is burnt out, won’t be hormonally inclined to sex. • Encourage sexual activity without intercourse if this is uncomfortable. Will increase circulation to pelvic region. • Herbs: eg. Gingko • Cultural link to menopause: role as an individual in family, society, self. Explore these areas too. Skin and Hair Changes • Decreased ratio of estrogen to testosterone (although testosterone is dropping, estrogen is relatively lower. • Changes in enzyme function: 5-alpha reductase (forms testosterone peripherally) • These hormones affect hair (increase, decrease) • Question of sensitivity of receptors • Work with diet to affect SHBG (fibre, phytoestrogens) Serenoa repens: affects 5-alpha reductase. Irregular bleeding • Common. In perimenopausal years, may have very heavy periods. • Drop in progesterone, estrogen may still be high. Unopposed estrogen. Hyperplasia of endometrium, can also include neoplasm. • Can use same herbs as you would in menorrhagia etc. • Irregular bleeding in someone who is post-menopausal (after 1 year of bleeding, has period): REFER FOR ENDOMETRIAL BIOPSY! Have to consider cancer. Don’t just assume that bleeding is due to atrophy. Musculoskeletal problems • Significant influence of estrogen on bone mass MEN’S AND WOMEN’S HEALTH, NOVEMBER 1ST 2007 – PAGE 2

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OP: one of most important health concerns This is one reason for HRT: do risks of OP outweigh risks of HRT? Have to think about bone mass throughout life span. Look at nutrients relating to bone. Alkalinize diet, weight-bearing exercise. Women who are overweight: less risk of OP: increased weight bearing, and also increased aromatisation of estrogen in periphery. (however, obesity will predispose her to breast cancer)

Cardiovascular disease • Leading cause of death in women. Estrogen has beneficial impact on CV system. • Risk of CV disease in men/women: equalizing • Estrogen therapy increases risk of CV events: increases coagulation, heat-sensitive CRP (risk factor for CV disease), despite positive effect on lipid profile. • Phytoestrogens: will improve risk of heart disease. Management of perimenopause and menopause • Phytoestrogens: adaptogenic action. Can increase or decrease esgtrogen in body. Will depend on amount and type of endogenous estrogens. • Phenolic: major source in diet. More structurally similar to endogenous estrogens. • Triterpenoid, steroidal saponins: more medicinal herbs that we can use to treat withdrawal. • Isoflavones (type of phenolic): most active. Most active. (genistein found in soy) (don’t need to know chemistry) • Concern with phytoestrogen re: estrogen-dependent cancers. Consensus is that it is safe, UNLESS PATIENT IS ON TAMOXIFEN (blocks estrogen receptors). Wait until therapy completed: may be interaction. •

Is it best to isolate compound or give as whole food? What is more effective? Studies are conflicting. Eg. Soy isoflavones (extracted): seem to have some effect on hot flashes, BMI, but missing fibre which has a very important role too. There aren’t safety studies on soy isolates as extracts. Don’t know if the people that don’t metabolize soy will have a problem with this, or would it be of any benefit to them? Allergies to soy? Is sprouted soy better? Lots of questions.

Additional nutrients Vitamin E is tricky: Mixed tocopherols are best: food sources are best? Alpha-tocopherol can increase risk of CV incident Chart of herbs: works on modulating hormones. Isoflavones are not well-extracted in water. Alfalfa and red clover tea? May not have phytoestrogenic effects. Might have other benefits, but don’t have isoflavones. Encapsulated form is best. Tincture? (don’t know) Black cohosh: not using isoflavones as MOA Dong quai: very good Yin tonic: great in menopause Two volumes by Bensky: 1 is Chinese patents: will explain herbs in the formulas. Second volume is materia medica. Chinese Herbal Medicine: Formulas and Strategies and Chinese Herbal Medicine: Materia Medica Kidney Yin deficiency: extremely common: LV yin deficiency too.

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