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Am Fam Physician. 2003;67(7):1586

Complementary and alternative medicines have long been used by women for relief of menopausal symptoms such as hot flushes, joint pain, sleep problems, forgetfulness, and fatigue. Treatments have included herbal preparations, chiropractic care, meditation, dietary supplements, and foods containing phytoestrogens. Kronenberg and Fugh-Berman reviewed randomized, controlled clinical trials of complementary and alternative therapies for menopausal symptoms.

Twenty-nine studies from different countries were found, including 10 trials of herbs. The herb trials were small, and the results were not conclusive. Black cohosh was the most studied herb. Three of the four studies demonstrated benefit in the treatment of hot flushes, but none of the trials lasted more than six months. The mechanism of action and the active ingredient of this herb are not known, and safety trials are lacking.

Red clover, an herb containing phytoestrogens, failed to relieve hot flushes in two short trials. Dong quai did not relieve hot flushes and contains coumarins that can cause bleeding when administered with warfarin; in addition, the furocoumarins in dong quai can cause photosensitization. Oil of evening primrose, which contains precursors of prostaglandin E1, is a benign treatment. It was not found to be useful in the one study included. Ginseng, which can alter the International Normalized Ratio in patients taking warfarin and has been reported to be associated with postmenopausal bleeding, was not shown to relieve menopausal symptoms better than placebo.

Phytoestrogens, including isoflavones, lignans, and coumestans, are found in many food plants. These foods include soybeans, other types of legumes, clover, alfalfa, whole grains, fruits, vegetables, and rye. The plant compounds are converted in the body to phytoestrogens. Results were conflicting in the 11 trials that studied the effects of soy or isoflavone supplementation on hot flushes. Benefits were modest; most benefits disappeared after six weeks. Interestingly, symptoms decreased in all trial groups, including those taking the placebo, by as much as 60 percent.

Vitamin E was not demonstrated to be more effective than placebo in managing menopausal symptoms. Studies of the management of these symptoms with acupuncture also had inconclusive results. Biofeedback and progressive muscle relaxation training demonstrated some decrease in hot flushes. Topical wild yam preparations, which contain diosgenin, and progesterone creams were tested. The wild yam preparations demonstrated no efficacy in relieving menopausal symptoms. Results with 20 mg of progesterone, applied daily as a transdermal cream preparation, were improvement in hot flushes in a small group of women treated for one year. Almost one fourth of the women treated with the progesterone cream had vaginal bleeding, requiring biopsies.

The authors conclude that most complementary and alternative therapies are ineffective in the treatment of hot flushes, the main menopausal symptom that women try to alleviate. Results in studies with black cohosh are unclear, and the potential risks include endometrial and breast tissue stimulation. Behavioral approaches have shown some success and should be explored further. Natural progesterone cream is probably not useful. Herb preparations may have subtherapeutic doses, and few safety or efficacy data support their use. Patients should be cautioned about the use of these alternative methods of managing menopausal symptoms.

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