Perimenopause and Black Cohosh

By Marcus Laux ND.

Until recently, when a woman entered menopause, her physician or healthcare practitioner would often recommend hormone replacement therapy (HRT). Not only because HRT eased the hot flashes, insomnia, and other distressing symptoms of menopause, but because the drugs were also believed to offer major, long-term protective health benefits, especially with cardiovascular disease (heart attacks and strokes) and osteoporosis.1-3 However, in July of 2002, researchers conducting a very large clinical study revealed the dramatic and quite unexpected results that HRT does not prevent heart attacks and strokes. It can cause them.4 And, not only are there concerns about cardiovascular disease, it can increase the risk of invasive breast cancer as well.

Many of the 20 million women taking HRT, at the time of these research findings, heard this alarming news and began immediately to search for less harmful ways to manage their menopausal symptoms. They contacted their healthcare practitioners, logged onto the Internet, and called their mothers, sisters, daughters, and friends looking for solutions.5 What they found was that they did not have to choose between suffering hot flashes or risking heart disease; there are safe, effective, and 100 percent natural nutritional supplements that effectively stop the hot flashes, reduce the mood swings, and relieve the insomnia. What better way to treat the symptoms of menopause? After all, menopause is a natural process and a normal part of aging.

What exactly happens in menopause?

Menopause signals the end of a woman’s fertility. Her body slowly stops the production of the reproductive hormones estrogen and progesterone. Her periods become less frequent and more irregular, finally stopping about 3 to 5 years later. She may experience hot flashes, mood swings, joint pain, and vaginal dryness. Because estrogen is no longer there to protect her, she is also more prone to heart disease, osteoporosis, and other health problems.3,6,7

On average, menopause occurs at about age 50. But just like the beginning of menstruation in early adolescence, the timing of menopause varies greatly among women. It’s estimated that every day in North America, over 5,400 women enter menopause (menopause is termed complete after one year without a period). Because the United States’ overall population is getting older, by the year 2015 approximately half of all the women in this country will be menopausal. Women at age 54 can easily expect to live another 30 years. About two-thirds of the total US population will survive to age 85 or longer. This means that the average American woman will spend one third to one-half of her life after menopause.3

What are the common symptoms of menopause?

Every woman’s menopausal experience is unique. Some women may have all of the symptoms of menopause; others may have just a few. The intensity of menopausal symptoms can also range from mild to quite severe.1,2

In early menopause, some women may experience mood swings, panic attacks, sleep disturbances, depression, anxiety, changes in tolerance to heat or cold, joint and muscle pain, allergies, and headaches. As production of estrogen decreases, additional menopause-related changes may include night sweats, fatigue, vaginal dryness, fluctuations in reproductive desire or response, forgetfulness, hot flashes, and weight fluctuations.1-3

If menopause is a normal part of aging, why do physicians prescribe hormones?

While menopause is not a disease, the symptoms associated with it can make a woman’s life miserable. By substituting the dwindling stores of natural estrogen with prescription synthetic or animal estrogen, the visible symptoms of menopause such as hot flashes, mood swings, and vaginal dryness can be lessened.3-5

When estrogen is given alone, however, there is an increased risk for development of cancer of the uterus. To reduce this risk, progestin (a synthetic form of progesterone) is usually added to the estrogen. This prescription drug regimen of estrogen and progestin for menopause is termed hormone replacement therapy or HRT.3-5

What did the large 2002 study show that changed the HRT recommendations?

The Women’s Health Initiative (WHI) was a groundbreaking study designed to determine, once and for all, if hormone replacement therapy (HRT) could provide safe and effective treatment of the symptoms of menopause and prevention of chronic disease such as cardiovascular disease and osteoporosis. While an estimated 20 million women in America take HRT, no one really knew for sure what its long-term benefits or risks were. The results from past HRT research were conflicting. Some showed benefit, many others did not. Because the WHI study was going to last a long time (8 years), was so large (40 clinical sites across the country), involved so many women (16,608), and was so well designed, the researchers who led the study felt certain the results would clear up the confusion. They expected to confirm that HRT was a safe and effective treatment for menopause, and for the prevention of certain chronic diseases.1

However, as they collected the data, the researchers were dismayed to discover that the women in the HRT group were developing some serious problems. The women taking HRT had significantly more heart disease, strokes, blood clots in the legs, and invasive breast cancer than the placebo group. In July 2002, the researchers, recognizing that HRT was causing more health hazards than health benefits, abruptly stopped the study. All of the WHI participants were sent letters telling them to stop taking their pills immediately and to contact their clinical center for further guidance.1 The researchers also held a press conference announcing these alarming results to the public so that all women taking HRT pills, not just those in the study, would be alerted to these health hazards.2

What exact health problems did the HRT group have?

The WHI results revealed that compared to the women taking the placebo pills, women in the HRT group had: • A 41 percent increase in strokes • A 29 percent increase in heart attacks • A doubling of rates of blood clots • A 22 percent increase in total heart disease • A 26 percent increase in breast cancer It’s easy to see why the researchers involved in the study were quite concerned. While the symptoms of menopause may make women miserable, the hazards of HRT are just too significant to warrant its use.1

Before this study, there were reports of side effects where certain women should not be on HRT. Is this true?

Yes. Women with a history of breast cancer, current breast cancer, or at a higher-than-normal cancer risk are usually not candidates for HRT. And for other women, use of HRT must be avoided because of uterine bleeding, liver and gallbladder disease, pancreatitis, endometriosis, uterine fibroids, or fibrocystic breast disease. In addition, some women simply feel “out of sorts” while using HRT.3-5 Fortunately there are several safe and effective nutritional supplements available to treat menopausal symptoms without the HRT-associated risks.

What natural supplements might be appropriate for a menopausal woman who does not want HRT?

Black cohosh is a highly effective treatment for menopause.8 Modern clinical research has shown that black cohosh is as effective as HRT for relief of hot flashes, night sweats, and vaginal dryness, but without its complications.8-12

How does black cohosh work?

Scientific research on the specific chemistry of black cohosh has established that this natural medicine suppresses secretion of a substance called luteinizing hormone (LH).8 One function of estrogen is to suppress the effects of LH. Menopause results in high levels of LH in the blood, which in turn causes lots of uncomfortable symptoms including, hot flashes, night sweats, headaches, heart palpitations, and vaginal dryness.3,6,7

While no one knows for sure how black cohosh exactly works to suppress LH activity, researchers believe that several chemical compounds may be involved in its beneficial activity.8

Clinical studies have shown without any uncertainty, however, the effectiveness of the herb in treating menopausal symptoms. In 1982, a German study collected data on 629 patients treated with black cohosh from 131 health care practitioners and gynecologists. The researchers found that after six to eight weeks of treatment, 80% of patients experienced beneficial effects.9

A 1987 double blind study compared estrogen replacement therapy with black cohosh for three months in 80 women. Thirty women were given estrogen, 30 were given black cohosh, and 20 received placebo. The authors concluded that the black cohosh preparation not only produced safe and effective results, but that compared to estrogen replacement therapy, it is suitable as the treatment of choice for menopausal women.10

Does black cohosh relieve the other symptoms of menopause?

While black cohosh is very effective in treating some symptoms of menopause, other herbal supplements are needed to treat fatigue, irritability, anxiety, sleep disturbances, and mood changes.

What other dietary supplements work for menopause?

There are several herbs that address menopausal symptoms and concerns.8-25

Ginseng and green tea: These herbal supplements are very effective in treating two of the most aggravating menopausal symptoms: a lack of energy and the inability to concentrate.13-15 As women pass into middle age, they are generally freed from the demands of caring for young children and have more time on to spend on themselves. However, they often discover they just feel too tired and too distracted.3 What should be an exciting time in their lives is instead a period of fatigue and frustration.

Ginseng is an ancient herb that has been used to combat fatigue and weakness. Ginseng also restores stamina and improves concentration. In a double blind, placebo controlled study with 384 symptomatic postmenopausal women, the use of ginseng extract for 16 weeks showed a significant improvement in mood and well being. Some mild ability to stop hot flashes was also attributed to the ginseng extract in this study.13

Many biologic activities have been attributed to green tea. One component is caffeine. Caffeine has been studied for its ability to increase stamina and decrease fatigue.15 Because moderation of caffeine is sometimes recommended during menopause,3 supplements should contain 50 mg of caffeine or less. Green tea is also a rich source of catechins and flavonols. These tea compounds inhibit the growth of breast and other cancers, important benefits to women of menopausal age.16,26

Valerian, theanine, and hops: Sleep disturbances are common during menopause. Poor sleep at night can lead to difficult, irritable days. Women may find they have even less ability to conimpressive. centrate after a poor night’s sleep.3,5,6 Use of prescribed sleep and sedative medications will eliminate these problems in menopausal women. However, these medications also have significant side effects, including dry mouth, daytime drowsiness, and depression. Tolerance and addiction to these drugs may also occur.27

Valerian is a remarkably effective herbal supplement that decreases the time it takes to fall asleep, improves the quality of sleep, and reduces the number of night awakenings, all without any associated daytime drowsiness. Several clinical trials have shown these impressive properties in valerian.20-24,28,29

While hops is best known as an ingredient in beer, it has also been used medicinally. Many years ago, workers who picked hops were noted to tire easily, apparently as a result of the accidental transfer of some hop resin from their hands to their mouths. Hops and valerian have been found to work synergistically and are often used together in sleep formulas.25

Theanine was discovered as an amino acid in green tea. Japanese people (the longest-lived people on earth) have known about the calming effect of theanine for centuries. Theanine readily crosses the blood-brain barrier and helps the brain relax. The effect is often compared to taking a hot bath or a relaxing massage. Theanine is different than other herbal calmatives, such as kava, because it doesn’t cause drowsiness. And unlike tranquilizing drugs, theanine doesn’t interfere with the ability to think. Studies have shown that theanine enhances the ability to learn and remember, increases concentration, and focuses thoughts.17,18

Can women for whom HRT is especially high risk use natural products?

Yes, two clinical trials conducted in gynecological practices studied the use of black cohosh in women who had either refused HRT or were suffering from health conditions such that HRT was contraindicated. The results were conimpressive. The doctors noted clear improvement in their patients’ menopausal ailments within four weeks with black cohosh extract therapy. The women experienced an overall decrease in complaints such as hot flashes, as well as marked improvement in psychological symptoms including decreases in fatigue, depression, irritability, and increases in energy and mood. In other words, they improved not only physically but emotionally as well.31,32

What if a woman has a history of breast cancer or other type of cancer?

Because of its assured safety, black cohosh can be used to relieve menopausal symptoms in all women, including those women with a history of breast, uterine, or ovarian cancer. Black cohosh is not, however, a treatment for cancer.

What should consumers look for in a quality menopause formula?

The black cohosh should be standardized to 2.5% triterpene glycosides. Women should look for a product from a reputable company with a focus on quality and scientific validation. For more troubling symptoms of menopause, look for a formula that combines herbs to alleviate a broader spectrum of symptoms like green tea and ginseng for daytime alertness and energy, and theanine, valerian and hops to ensure quality sleep and muscle relaxation.

Menopause - Conclusion

While menopause may very well be a normal part of aging, it can also be quite challenging. Fears that women might have to make a choice between hot flashes or heart disease, however, fortunately need not be part of this challenge. Black cohosh, ginseng, green tea, valerian, theanine, and hops can safely reduce the symptoms of menopause. Most importantly, these effective supplements provide women with an empowering ally in this natural transition to the second half of their lives.

Perimenopause References

1. The Woman’s Health Initiative Study Group. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-333.

2. Wallis C. The truth about hormones. Time Magazine 2002;12:43-50.

3. Basic facts about menopause. The North American Menopause Society (NAMS). Available at: htttp://www.menopause.org/pfaq.htm. April 3, 2001.

4. Young LY, Koda-Kimble MA, Eds. Menopause. In: Applied Therapeutics: The Clinical Use of Drugs. 6th ed. Vancouver, Wash: Applied Therapeutics, Inc; 1995:Chapter 46, 23-26.

5. Lehne RA. Hormone replacement therapy after menopause. In: Pharmacology for Nursing Care. 3rd ed. Philadelphia, Pa: W.B. Saunders; 1998: 629-630.

6. Mehring PM. Menopause. In: Porth CM. Pathophysiology: Concepts of Altered Health States. 5th ed. Philadelphia, Pa: Lippincott; 1998: 1183-1184.

7. Guyton AC, Hall JE. Menopause. In: Textbook of Medical Physiology. Philadelphia, Pa: W.B. Saunders Company; 2001: 939-940.

8. Foster S. Black Cohosh: Cimicifuga racemosa. Austin, TX: American Botanical Council. 2000: 1-6.

9. Stolze H. An alternative to treating menopausal complaints. Gyne. 1982;3:14-16.

10. Stoll W. Phytopharmacon influences atrophic vaginal epithelium. Double-blind study: cimicifuga versus estrogenic substances. Therapeuticum. 1987;1:23-31.

11. Lieberman S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause. Journal of Womens Health. 1998;7:527-528.

12. Duker EM, Kipanski L, Jarry H, et al. Effects of extracts from Cimicifuga racemosa on gonadotropin release in menopausal women and ovariectomized rats. Planta Medicine. 1991;57:420-424.

13. Wiklund IK, Mattsson LA, Lindgren R, Limoni C. Effects of a standardized ginseng extract on quality of life and physiological parameters in symptomatic postmenopausal women: a double-blind, placebo-controlled trial. Swedish Alternative Medicine Group. International Journal of Clinical Pharmacological Research. 1999;19:89-99.

14. Tode T, Kikuchi Y, Hirata J, Kita T, Nakata H, Nagata I. Effect of Korean red ginseng on psychological functions in patients with severe climacteric syndromes. International Journal of Gynaecol Obstet. 1999;67:169-174.

15. Fleming T., ed. In: Green tea. In: PDR® for Herbal Medicines. Montvale, NJ: Medical Economics Company; 2000: 369-372.

16. Nakachi K, Suemasu K, Suga K, Takeo T, Higashi Y. Influence of drinking green tea on breast cancer malignancy among Japanese patients. Japan Journal of Cancer Research. 1998; 89;254-261.

17. Yokogoshi H, Mochizuki M, Saitoh K. Theanineinduced reduction of brain serotonin concentration in rats. Biosci Biotechnol BioChemistry. 1998;62:816-817.

18. Yokogoshi H, Kobayashi M, Mochizuki M, Terashima T. Effect of theanine, r-glutamylethylamide, on brain monoamines and striatal dopamine release in conscious rats. Neurochem Research. 1998;23:667-673.

19. Atelle AS, Xie JT, Yuan CS. Treatment of insomnia: an alternative approach. Alternative Medicine Review. 2000;5:249-259.

20. Leathwood PD, Chauffard F, Heck E, Munoz-Box R. Aqueous extract of valerian root (Valeriana officinalis L.) improves sleep quality in man. Pharmacological Biochemistry Behavior. 1982;17:65-71.

21. Leathwood PD, Chauffard F. Aqueous extract of valerian reduces latency to fall asleep in man. Planta Medicine. 1985;51:144-148.

22. Lindahl O, Lindwall L. Double blind study of a valerian preparation. Pharmacological Biochemistry Behavior. 1989;32:1065-1066.

23. Balderer G, Borbely AA. Effect of valerian on human sleep. Psycho-Pharmacology. 1985;87:406-409.

24. Schulz H, Stolz C, Muller J. The effect of valerian extract on sleep polygraphy in poor sleepers: a pilot study. Pharmacopsychiatry. 1994;27:147-151.

25. Foster S, Tyler VE. The Honest Herbal. New York, NY: The Haworth Herbal Press;1999:

26. Valcic S, Timmerman BN, Alberts DS, et al. Inhibitory effect of six green tea catechins and caffeine on the growth of four selected human tumor cell lines. Anti-Cancer Drugs. 1996;7:461-486.

27. Benzodiazepines. In 2001 Lippincott’s Nursing Drug Guide. Philadelphia, Pa: Lippincott Williams & Wilkins;2001:29-31.

28. Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I. Critical evaluation of the effect of valerian extract on sleep structure and sleep quality. Pharmacopsychiatry. 2000;33:47-53.

29. Dominguez RA, Bravo-Valverde RL, Kaplowitz BR, Cott JM. Valerian as a hypnotic for Hispanic patients. Cultur Divers Ethni Minor Psychol. 2000;6:84-92.

30. Lehmann-Willenbrock E, Riedel HH. Clinical and endocrinological examinations concerning therapy of the climacteric symptoms following hysterectomy with remaining ovaries. Zentralbl Gynakol. 1988;110:611-618.

31. Daiber W. Artzl Praxis. 1983;35:1946-1947. 32. Vorberg G. ZFA. 1984;60:626-629.




Marcus Laux

Author Marcus Laux is a licensed naturopathic medical doctor.




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Menopause Topics
Life-stages, perimenopause, treatment safety, bio-identical hormones, progesterone cream, and estriol lotion.