An Herbal Perspective on Menopause

 Menopause defined:

Menopause literally means ‘stopping menstruation’. The word is made up of Greek meno (monthly) and pausis (to stop). Women won’t know menopause has occurred until a year has passed since the date of the last period—the actual date can only be decided retrospectively. Menopause, then, occurs on one distinct date and is not what most people mean when they describe themselves, or the women who consult them, as ‘menopausal’. The more correct term, the ‘climacteric’, is rarely used; perimenopausal is now the favoured lay and medical term. The peri-menopause is analogous to puberty and the years when the menstrual cycle starts to become established; both are characterised by hormonal and sometimes emotional fluctuations, and menstrual irregularity.

Menopause isn’t a disease, it’s a transition, one of the most impactful of a woman’s life. It isn’t something you get cured of and, having other health conditions won’t stop the menopause; if you are diabetic and you become perimenopausal then you are perimenopausal with diabetes. One unfortunately, doesn’t preclude the other. Menopause is about change. All the change; hormonal, emotional, perspective, boundary and any other change you can think of. A lot of the time a woman is her own worst enemy, we hate ourselves, we don’t respect ourselves and we let other people walk all over us. The menopause is a very good time for a clear up and a clear out. A lot of women learn to say no at this point, because tolerances can be very different than they used to be and patience is often very much shorter. In fact, a lot of divorces happen at this point in a women’s life…….

Menopause happens because the female body stops producing oestrodiol, which is the oestrogen produced by the follicles in the ovaries as part of the ovulation process. The main purpose of this oestrogen is to thicken the tissue in the womb and the breasts to facilitate pregnancy. It is also a hormone which promotes growth. When a woman enters the peri-menopausal stage the ovaries don’t produce a follicle every month any more which is the start of the rather random symptoms as the body is started to be weaned off oestrodiol.

What happens next is that the adrenal glands start to produce precursor hormones called androgens. A precursor hormone is something that the body uses to make something else from. And in this case the androgens are turned into oestrogen. But, it is a different oestrogen to oestrodiol. The androgens go through the liver and the bowel and those two transform the androgens into oestrogen. So, if you are over stressed, have poor bowel function, or poor liver function the menopause is going to be a lot more problematic than it actually needs to be.

Herbalists don’t replace oestrodiol, we can’t and we wouldn’t if we could. I cannot give anyone oestrogen made from pregnant horse or pig urine. A lot of the problem is that everyone gets lost in the monotherapy. We have to replace the oestrogen etc, etc. When the fact is, no, we don’t and we really shouldn’t anyway. What we do do is support organs, tissues and function.   

A lot of women when they get to the perimenopause/menopause are absolutely exhausted, very stressed and the diet is not actually the best because they are the last thing on their own list. I need to repeat myself here; the liver, kidneys and gut microbiome are your most important allies in this next stage of your life. You need to look after them very well and get them as healthy as you possibly can. Which means you need to make those changes you’ve been putting off. All that; well I know I really should but….. (Insert relevant reason/excuse here) One of the questions I ask a lot of my patients, especially the stubborn ones who don’t want to make any of the changes and thinks that taking the herbs on their own is sufficient is ‘what is your health actually worth to you?' And I am not talking about money. Every decision you have made up to this point; every action, reaction, choice, you are the encapsulation of that. And one thing I also point out which, people in general don’t like, is that because of that your current health picture is your own doing. Whether unwittingly or not, because to be fair, the education that we have around diet and exercise is very, very poor. The adverts for all the crap foods on the telly full of sugar, salt, preservatives, chemicals, hormones and anything else manufacturers can put in there to preserve the shelf life and all in a shiny packet…

Exercise is a thing; it needs to be done regularly at least a couple of hours every week. You don’t have to train to climb Mount Everest, swimming, going to a dance class, hula hoop class, yoga or pilates, start the couch to 5K. Something which raises your heat beat and gets you a little sweaty, which brings me to:

Bleeding

Some women bleed a lot on the menopause. It is called flooding, with good reason too. I have had patients come to me and they dread their periods. Now they are not regular; they could have two in a month or one in three months and the blood! Their beds/bathrooms often look like someone has been murdered in there. Especially if it starts in the middle of the night. There are two main reasons for this: anaemia and poor progesterone levels. You are more likely to flood if you are anaemic, sounds counterintuitive but iron is required by the body at every stage of hormone production, so if you don’t have enough iron that will cause issues other than tiredness. Progesterone is the hormone that tells the body when to stop bleeding, so if the progesterone levels are not where they should be shenanigans ensue, unfortunately not the fun kind.  

Hot flushes

The symptom that consistently correlates with being menopausal is hot flushes. About three-quarters of all menopausal women experience some form of hot flushes; and about one-third of these women will find them debilitating enough to seek treatment. Two studies indicate that almost 40 per cent of menopausal women experienced ‘troubling’ hot flushes, but not all women took medication or sought help for their symptoms. Flushes are likely to be as different as the women who have them. Some have transient episodes of feeling a bit hot or sweaty; others might be drenched with perspiration, feel uncomfortably hot, go red in the face and be troubled by palpitations. Sometimes headaches, a sense of increased pressure in the head, vagueness, transient chills, fatigue, dizziness and nausea follow or accompany a hot flush. The body usually adjusts to the changing hormones after about one year and the hot flushes disappear completely. Rarely, they will last for five to ten years after the period has stopped. Many women feel embarrassed and uncomfortable when they have a flush. They lose concentration, or they feel as though they won’t be taken seriously. Some women do obviously perspire and flush in the face, but most of the time, other people don’t notice hot flushes. Flushing is related to oestrogen decline—women who have never menstruated do not flush unless they have been given oestrogen that is then withdrawn. Hot flushes are more severe when a woman is very thin, probably because body fat is an alternative source of oestrogen (oestrone). Women who become menopausal suddenly, or at a younger age than usual, often experience hot flushes that are more severe, perhaps because the body is not prepared for the abrupt change in oestrogen status. Even so, it is not the oestrogen itself that fluctuates when a woman has a hot flush. Instead, luteinising hormone increases because of a flurry of activity in the hypothalamus and the release of gonadotrophin releasing hormone. This leads to the usual symptoms associated with flushing.

Afterwards, there is often a slight drop in temperature caused by loss of body heat from sweating. Temperature fluctuations can cause the on-again, off-again problem with clothing and lead to a serious disturbance in sleep patterns. Some women seem to flush more, or only flush, when they are tired or over-worked. Natural therapists believe that exhaustion is related to unhealthy function of adrenal glands. These types of symptoms have historically been treated with a group of remedies called the adrenal adaptogens like Borago officinalis. Some menopausal women can find that even apparently mild emotional response will trigger disproportionately severe flushes. Being ‘flushed with excitement’ takes on a whole new meaning for a menopausal woman. As does being ‘hot and flustered’, ‘hot-headed’ or any number of other idioms that indicate the relationship between the nervous system, body heat and the emotions. A number of common medicinal herbs are used for menopausal symptoms aggravated by stress or anxiety.

Herbal treatment of hot flushes:

An herbalist will take several factors into account when prescribing for hot flushes. The primary group of herbs is chosen from those that have a specific hormone modulating effect to moderate the symptoms of declining oestrogens (often referred to as ‘oestrogenic herbs’). A second group of herbs will be selected to specifically address the type of hot flush that the woman experiences. Herbs might need to be added that also take into account other symptoms of the menopausal syndrome, as already described. Finally, individual herbs can be selected to manage the factors that contribute to the menopausal symptoms—exhaustion, stress or anxiety, for example. Although this makes the treatment more complex, an individuated herbal formula is much more likely to improve symptoms as well as addressing underlying contributing factors. Herbs with an oestrogen-like effect have been used for centuries for the management of hot flushes and other oestrogen-related symptoms. All oestrogen-like components in plants are rather weak and have been estimated to be many times less potent than synthetic or endogenous oestrogens. However, when a woman becomes menopausal and produces virtually no oestrogen of her own, herbal medicines can assist with the process of hormone modulation until the symptoms of the transition phase have ceased. Of particular interest to herbalists is Cimicifuga racemosa, long recognised and used by Europeans, Native Americans and Chinese for menopausal symptoms. It has been the subject of a number of open and double-blind trials, particularly in Germany where many doctors prescribe it routinely for menopausal symptoms, and where it is often combined with Hypericum perforatum. The results are extremely favourable, especially for hot flushes, vaginal dryness and mood changes.

Other herbs that are often referred to as being ‘oestrogenic’ are those that contain steroidal saponins, such as

Dioscorea villosa,

 Aletris farinosa,

Tribulus terrestris,

Asparagus racemosa,

or the herbs from the Chinese pharmacopoeia such as

Angelica sinensis,

Paeonia lactiflora,

Rehmannia glutinosa.

One or a number of these are often combined with Cimicifuga racemosa to form the basis of the herbal formula.

Flushing accompanied by severe sweating:

Herbs to consider here include Salvia officinalis and Astragalus membranaceus A simple home remedy for the treatment of hot flushes and sweating is as follows: Chop about 6 fresh sage leaves and soak overnight in lemon juice. In the morning, strain and drink the juice. Seven to ten days of this mixture will usually control flushing and sweating, and also improve digestion and concentration. It should not be continued for longer than two weeks without a break.

Night sweats:

Zizyphus spinosa is specific for night sweats and may be combined with Withania somnifera if sleep latency is poor.

Mood changes

Women suffer from depression twice as often as men, and menopause or other hormonally related conditions have been suggested as causes. Declining hormone levels may cause changes in neurotransmitters or the limbic system and increase feelings of depression and anxiety. One theory suggests that oestrogen acts on neurotransmitters to prevent depression in a similar fashion to the antidepressant drugs the SSRIs, and that the fall in oestrogen levels is the reason for mood change. However, depression has been shown to decline with age, and by 60 the incidence of depression or other mood change is almost half that experienced by younger women. Depression commonly accompanies menopausal flushing, particularly when sleep is disturbed. The most reliable herbs are Hypericum perforatum and Lavandula officinalis, combined with Withania somnifera and the ginsengs.

Palpitations

A rapid decline in oestrogens can give rise to a state of transient hyperthyroidism because thyroxine becomes more biologically available. Leonurus cardiaca is prescribed for menopausal symptoms which are accompanied by anxiety, insomnia and palpitations; and Verbena officinalis for anxiety associated with thyroid dysfunction.

Bleeding

Some women bleed a lot on the menopause. It is called flooding, with good reason too. I have had patients come to me and they dread their periods. Now they are not regular; they could have two in a month or one in three months and the blood! Their beds/bathrooms often look like someone has been murdered in there. Especially if it starts in the middle of the night. There are two main reasons for this: anaemia and poor progesterone levels. You are more likely to flood if you are anaemic, sounds counterintuitive but iron is required by the body at every stage of hormone production, so if you don’t have enough iron that will cause issues other than tiredness. Progesterone is the hormone that tells the body when to stop bleeding, so if the progesterone levels are not where they should be shenanigans ensue, unfortunately not the fun kind.  

Hot flushes

The symptom that consistently correlates with being menopausal is hot flushes. About three-quarters of all menopausal women experience some form of hot flushes; and about one-third of these women will find them debilitating enough to seek treatment. Two studies indicate that almost 40 per cent of menopausal women experienced ‘troubling’ hot flushes, but not all women took medication or sought help for their symptoms. Flushes are likely to be as different as the women who have them. Some have transient episodes of feeling a bit hot or sweaty; others might be drenched with perspiration, feel uncomfortably hot, go red in the face and be troubled by palpitations. Sometimes headaches, a sense of increased pressure in the head, vagueness, transient chills, fatigue, dizziness and nausea follow or accompany a hot flush. The body usually adjusts to the changing hormones after about one year and the hot flushes disappear completely. Rarely, they will last for five to ten years after the period has stopped. Many women feel embarrassed and uncomfortable when they have a flush. They lose concentration, or they feel as though they won’t be taken seriously. Some women do obviously perspire and flush in the face, but most of the time, other people don’t notice hot flushes. Flushing is related to oestrogen decline—women who have never menstruated do not flush unless they have been given oestrogen that is then withdrawn. Hot flushes are more severe when a woman is very thin, probably because body fat is an alternative source of oestrogen (oestrone). Women who become menopausal suddenly, or at a younger age than usual, often experience hot flushes that are more severe, perhaps because the body is not prepared for the abrupt change in oestrogen status. Even so, it is not the oestrogen itself that fluctuates when a woman has a hot flush. Instead, luteinising hormone increases because of a flurry of activity in the hypothalamus and the release of gonadotrophin releasing hormone. This leads to the usual symptoms associated with flushing.

Afterwards, there is often a slight drop in temperature caused by loss of body heat from sweating. Temperature fluctuations can cause the on-again, off-again problem with clothing and lead to a serious disturbance in sleep patterns. Some women seem to flush more, or only flush, when they are tired or over-worked. Natural therapists believe that exhaustion is related to unhealthy function of adrenal glands. These types of symptoms have historically been treated with a group of remedies called the adrenal adaptogens like Borago officinalis. Some menopausal women can find that even apparently mild emotional response will trigger disproportionately severe flushes. Being ‘flushed with excitement’ takes on a whole new meaning for a menopausal woman. As does being ‘hot and flustered’, ‘hot-headed’ or any number of other idioms that indicate the relationship between the nervous system, body heat and the emotions. A number of common medicinal herbs are used for menopausal symptoms aggravated by stress or anxiety. 

Herbal treatment of hot flushes

An herbalist will take several factors into account when prescribing for hot flushes. The primary group of herbs is chosen from those that have a specific hormone modulating effect to moderate the symptoms of declining oestrogens (often referred to as ‘oestrogenic herbs’). A second group of herbs will be selected to specifically address the type of hot flush that the woman experiences. Herbs might need to be added that also take into account other symptoms of the menopausal syndrome, as already described. Finally, individual herbs can be selected to manage the factors that contribute to the menopausal symptoms—exhaustion, stress or anxiety, for example. Although this makes the treatment more complex, an individuated herbal formula is much more likely to improve symptoms as well as addressing underlying contributing factors. Herbs with an oestrogen-like effect have been used for centuries for the management of hot flushes and other oestrogen-related symptoms. All oestrogen-like components in plants are rather weak and have been estimated to be many times less potent than synthetic or endogenous oestrogens. However, when a woman becomes menopausal and produces virtually no oestrogen of her own, herbal medicines can assist with the process of hormone modulation until the symptoms of the transition phase have ceased. Of particular interest to herbalists is Cimicifuga racemosa, long recognised and used by Europeans, Native Americans and Chinese for menopausal symptoms. It has been the subject of a number of open and double-blind trials, particularly in Germany where many doctors prescribe it routinely for menopausal symptoms, and where it is often combined with Hypericum perforatum. The results are extremely favourable, especially for hot flushes, vaginal dryness and mood changes.

Other herbs that are often referred to as being ‘oestrogenic’ are those that contain steroidal saponins, such as

Dioscorea villosa,

 Aletris farinosa,

Tribulus terrestris,

Asparagus racemosa,

or the herbs from the Chinese pharmacopoeia such as

Angelica sinensis,

Paeonia lactiflora,

Rehmannia glutinosa.

One or a number of these are often combined with Cimicifuga racemosa to form the basis of the herbal formula.

Flushing accompanied by severe sweating:

Herbs to consider here include Salvia officinalis and Astragalus membranaceus A simple home remedy for the treatment of hot flushes and sweating is as follows: Chop about 6 fresh sage leaves and soak overnight in lemon juice. In the morning, strain and drink the juice. Seven to ten days of this mixture will usually control flushing and sweating, and also improve digestion and concentration. It should not be continued for longer than two weeks without a break.

Night sweats:

Zizyphus spinosa is specific for night sweats and may be combined with Withania somnifera if sleep latency is poor.

Palpitations

A rapid decline in oestrogens can give rise to a state of transient hyperthyroidism because thyroxine becomes more biologically available. Leonurus cardiaca is prescribed for menopausal symptoms which are accompanied by anxiety, insomnia and palpitations; and Verbena officinalis for anxiety associated with thyroid dysfunction.

Tissue Changes

Declining oestrogen levels are associated with changes in the mucous membranes and skin, and can affect the tissues of the vagina, vulva and urethra, or the eyes and mouth. Skin ages more rapidly when oestrogen levels are low, while oestrogen replacement reduces skin wrinkles and dryness, the risks associated with hormone replacement use mean that doctors are now reluctant to use oestrogen for cosmetic reasons. Eye changes are also common around menopause, although whether this is related to androgens or oestrogen is not clear. Vaginal dryness, thinning of the vaginal walls and/or urinary symptoms usually occur after menopause, but can affect some perimenopausal women. A range of symptoms might be experienced, from none at all to varying degrees of burning, dryness and irritation, and can have a serious impact on the quality of life. Urinary frequency and urge or stress incontinence can worsen around menopause because of pelvic tissue weakness and mucous membrane changes associated with ageing. When urethral tissue is affected by declining oestrogens, frequency, burning, cystitis and incontinence can be recurring problems. Essential fatty acids are some of the most effective treatments for this; Sea Buckthorn, Omega-3, Evening primrose and Starflower.

Libido

Women can experience changes in libido or difficulties with painful intercourse around the menopause, which are believed to be influenced by a number of physical and hormonal changes, and/or psychosocial aspects of this phase of their lives. In general, sexual activity declines around the menopause, but not necessarily sexual satisfaction. When women experience difficulties with relationships or have pre-existing sexual problems, sexual activity might be adversely influenced during the menopausal transition. Other health problems or other menopausal symptoms such as hot flushes and sleep deprivation can also reduce libido. Herbs that can improve libido in women can be divided into two broad categories—those that mimic the action of testosterone (testosteromimetics), and those that have general tonic and rejuvenating effects and may act as mild aphrodisiacs. The testosterone-like herbs are Serenoa repens, Turnera diffusa and Smilax spp. Of these, Turnera has been traditionally used for low libido in women, and Smilax has general tonic effects. Tribulus terrestris and Asparagus racemosa, are general tonics and have been traditionally used for low libido and additionally contain steroidal saponins which may impart some hormone-like activity. Gingko biloba has been successfully used to improve libido when women are taking SSRIs

Fatigue

Women with insufficient stamina to meet their daily needs often think that their symptoms must be due to menopause. In reality, they may be due to any of the usual causes of fatigue including poor diet, hypoglycaemia, iron deficiency, adrenal exhaustion or depression. Assessment of the menopausal woman must first exclude these non-hormonal causes. Women who are well, but fatigued, respond to combinations of the appropriate herbs for the nervous system, adaptogens and vitamin B complex, along with appropriate dietary changes and increase in exercise. Eleutherococcus senticosus 500 mg–1 g twice daily, combined with vitamin B complex 1 twice daily, is often effective.