Family doctor

Are alternative therapies useful for menopausal women?

An increasing number of women are seeking alternative therapies to control the troublesome symptoms of menopause. There is a growing perception being promoted amongst women, largely by the alternative therapy manufacturers, that conventional HRT is not "natural", despite the fact that many of the prescription HRT formulations include oestrogens derived and purified from natural sources. There is also a widespread view, reinforced by sensationalised media reports, that HRT causes clotting and breast cancer, so many women understandably do not want to take agents which they perceive to be putting their health at risk.

There are a number of alternative therapies available in New Zealand, which can be classified into three groups:

• Transdermal wild yam/progesterone creams
• Oral herbal preparations
• Oral soy-based phyto-oestrogens

Transdermal wild yam/progesterone creams have recently been reclassified as prescription medicines, whereas the oral herbal and phyto-oestrogen preparations are presently classified as dietary supplements and are freely available in health food stores, pharmacies and supermarkets. The problems we are now facing with these agents stem mainly from the fact that unlike the pharmaceutical industry, the present legislation covering the natural food industry in New Zealand is not easily enforced, so claims are being made for some of these products without the support of randomised clinical trial data.

The transdermal wild yam creams are marketed on the basis that the body contains an enzyme which can convert wild yam extract into important endogenous hormones including progesterone and oestradiol, but no such enzyme has ever been identified.

Unlike endogenous progesterone which is present at much higher levels in serum than saliva, transdermal progesterone has been shown to reach levels 20 times higher in saliva than in serum, and the biochemical significance of this paradox is not yet understood.

The recent popular literature has described a study in which spinal bone density increased by up to 23 percent in early postmenopausal women who used transdermal progesterone cream for three years. This magnitude of bone density increase is generally seen only in patients taking anabolic steroids, and the report does not mention the fact that a number of the women were also taking conventional HRT, which makes the data very difficult to interpret. However, extrapolating from the PEPI study which showed no statistically significant difference in bone density between women who received oestrogen + high dose oral natural progesterone and those who received oestrogen alone, it seems unlikely that transdermal progesterone would have had any independent beneficial effects on bone density in these women.

In the absence of relevant randomised clinical trial data, transdermal progesterone cannot be regarded at this time as more than an expensive placebo for symptomatic control in menopausal women or maintenance of bone density in later life. Of increasing concern, however, is the number of women who are now substituting transdermal progesterone cream for the oral progestogen component of their conventional HRT. These women are essentially taking unopposed oestrogen, and after a few years of doing so may be at increased risk of uterine cancer.

Herbal/phyto-oestrogen cocktails

Emerging data for the soy-based phyto-oestrogens, or isoflavones, are more encouraging in terms of symptom control, and indicate a beneficial effect on lipids and bone turnover. However, there is still no good data for the important endpoints of cardiovascular event rates, bone density or fracture risk.

There is some evidence that cocktails of high-dose evening primrose oil, St John's wort and a phyto-oestrogen product may reduce symptom severity, if not frequency, in 75% to 80% of menopausal women who cannot for whatever reason use HRT. The literature in this respect can be difficult to interpret in view of the subjective nature of many symptoms of menopause which may vary in frequency and severity from one week to the next. Nevertheless, our local anecdotal experience of these cocktails suggests that they may be worth a trial in menopausal women with troublesome symptoms in whom HRT is contraindicated or not tolerated.

* Reproduced with kind permission from Medicom Publications and Roche Products New Zealand Ltd.