Menopause is having a moment: the market is awash with products claiming to be rooted in ancient traditions that have allegedly given women relief from menopausal symptoms over many centuries. But do the claims hold any water, or are vulnerable women being ‘meno-washed’ into buying products that do little or nothing by a multi-billion-dollar industry?
In its latest position statement, the Menopause Society (previously known as the North American Menopause Society) has looked at the literature relating to the most common supplements and herbal remedies and rated them according to three levels of evidence:
Here’s what it’s come up with.
One of the reasons cited for the widely held but not entirely correct belief that Asian women have fewer vasomotor symptoms is that they consume a lot of soy-based foods. Soy contains isoflavones, which are a class of non-steroidal phytochemicals that bind to estrogen receptors, predominantly ER-β, and can have both estrogen-agonist and estrogen-antagonist properties.
So far so good, but the panel assessing the data on soy found mixed evidence on soy. The studies were often short term, small in size and difficult to compare due to different ways of taking the soy or combining it with other ingredients.
Some studies showed benefits for reducing the severity of vasomotor symptoms, but others showed no benefit over placebo, or less benefit than other treatments.
The panel also note that the ability to metabolise soy is crucial for women to glean any benefits from soy’s “potential estrogenic effects”—but not many studies have considered this. An observational study from the United States found only 35% of the 365 women involved metabolised the soy isoflavone daidzein to equol, which is the form associated with symptom reduction. Currently no tests for this are commercially available. Again, findings were mixed for supplementing with equol, and sample sizes were small.
Overall, the panel concluded that the evidence for soy foods, soy extracts, and the soy metabolite equol was mixed, “from widely diverse studies, with some significant limitations.”
Black cohosh (Actaea racemosa L. or previously Cimicifugae racemosae) is one of the most commonly touted and purchased remedies for menopause symptoms.
It was once thought to have estrogenic or selective estrogen-receptor modulator-like effects. But the position statement notes that a 2012 Cochrane Review of 16 RCTs found it was no better than placebo, and as this article explains, the evidence to date is mixed.
The panel concluded that “at this time, there is insufficient evidence to support the use of black cohosh for vasomotor symptoms.”
It’s important to note that black cohosh has been associated with possible hepatotoxicity. A US Pharmacopeial Convention Dietary Supplements-Botanicals Expert Committee found 30 reports possibly related to black cohosh and issued a directive that black cohosh products carry a warning statement: “Discontinue use and consult a healthcare practitioner if you have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice.”
You might think that since body-identical hormones are often synthesised from yams, this one would be a winner. Going by the names Dioscorea barbasco, D mexicana, wild yam root, and D villosa or Mexican yam, it contains diosgenin, a steroid precursor used in the manufacture of synthetic steroids.
Unfortunately, as the panel explained: “Diosgenin is converted in vitro to progesterone, but there is no biochemical pathway for this conversion in vivo.”
Evidence for vasomotor symptoms is limited and the panel warned that creams often don’t contain any yam extract. Furthermore, “many have been adulterated with undisclosed steroids, including estrogens, progesterone, and medroxyprogesterone acetate,” they write.
“Because of the potential harm that may result from adulterants and lack of efficacy data, yam creams are not recommended” for vasomotor symptoms.”
Dong quai, also known as Angelica sinensis, dang gui, and tang kuei, is derived from the root of the Angelica sinensis (Oliv.) plant. It makes a regular appearance in menopause supplements, but studies show it doesn’t appear to help with vasomotor symptoms. The panel added there are “a number of safety concerns, including possible photosensitization, anticoagulation, and carcinogenicity.”
Again, evening primrose is a popular ingredient in supplements with claims made for its ability to relieve breast pain and other menopause symptoms, including vasomotor symptoms. Unfortunately, the studies don’t back the hype. In a single trial, 56 women were randomised to take 500 mg of evening primrose oil per day or placebo for 6 months. Evening primrose oil showed no benefit over placebo for vasomotor symptoms.
Maca (Lepidium Meyennii Walp, Lepidium peruvianum Chacon), is a new sweetheart of the supplement industry. It’s a traditional foodstuff from South America and contains a weak phytosterol (β-sitosterol). Once again though, no in vivo studies have found any estrogenic effects. Four studies showed improvements in menopause symptom scalesbut because of study quality, design, sample sizes, or limited reporting of data, there is currently not enough evidence to support using maca for vasomotor symptoms.
No matter the type, ginseng is a disappointment when it comes to vasomotor symptoms too. Whether it be Panax ginseng, Panax quinquefolius, Siberian ginseng (Acanthopanax senticosus or Eleutherococcus senticosus), or Korean red ginseng, studies have found the results are no better than placebo.
A double-blind, 24-week RCT randomised 119 women aged 41 to 55 years experiencing menopause symptoms to receive either treatment with these herbal compounds or placebo.
By the end of the trial, both groups had experienced symptomatic improvement.
As such, the authors concluded “there were no significant differences in menopause symptoms between treatment and placebo groups.”
Chasteberry, in particular Vitex agnus-castus, is very popular for menopause symptoms due to its reported estrogenic properties. Again, however, there is very little data to support the claim. The panel noted that trials vary in terms of rigor and the compounds used, saying it wasn’t possible to conclude that Vitex alone improves vasomotor symptoms.
A member of the Asteracease family, milk thistle (Silybum marianum) is a herb used therapeutically for fever and kidney and spleen disease.
One RCT randomised 80 women to receive either 400 mg per day of Silybum marianum extract or placebo. After 12 weeks, the treatment group had a significantly greater reduction in vasomotor symptoms than the placebo group.
However, the panel noted one trial is insufficient to support a positive recommendation.
Often associated with heart health, omega 3 supplements have also been studied for vasomotor symptoms. While some trials showed improvements, the panel reported “there is mixed and inconclusive evidence” for their use in managing vasomotor symptoms.
Vitamin E might be good for various things, but it appears vasomotor symptoms are not among them. The panel noted studies conducted to date have been small or found limited evidence for vitamin E versus placebo, so once again – not recommended.
This is another buzz compound with a long list of alleged benefits, but relief of vasomotor symptoms does not appear to be one of them.
Data evaluating the relationship between cannabinoids and menopause symptoms is very limited, the panel said.
“A systematic review found only three small studies that evaluated cannabis use and its associations with menopause symptoms, including VMS, insomnia, mood, and depression/anxiety. Based on the lack of available evidence, cannabinoids cannot be recommended for the treatment of VMS,” they write.
Ammonium succinate is said to improve energy, libido and menopause symptoms such as fatigue, joint pain and vasomotor symptoms, but apart from two manufacturer-sponsored studies, there is little to support the claims.
One of the studies found an increase in serum estradiol levels in women in the ammonium succinate-supplement group. However, the limited number of studies and their manufacturer-sponsored nature led the panel to put it in the not recommended basket.
Lactobacillus acidophilus YT1 was studied in one multi-centre, double blind, placebo-controlled RCT (N = 67). After 12 weeks, there were improvements in total Kupperman Index scores and quality of life based on the Menopause-Specific Quality of Life questionnaire. But given it was one study that has not yet been replicated, it gets the thumbs down.
Siberian rhubarb (Rheum rhaponticum) is eaten as a food and used medicinally to treat constipation, diarrhoea, and other gastrointestinal complaints.
One commercial product contains a proprietary rhubarb extract called rhaponticin or extract ERr 731 and has estrogenic properties. One RCT found women randomised to receive ERr731 (n = 54) experienced significantly greater improvements in vasomotor symptoms than those in the placebo group (n=55). However, the placebo group only had a 12.7% retention rate.
One other trial had an open-label design. The lack of solid evidence led the panel to place rhubarb in the not recommended basket.
A proprietary extract made from flower pollen is available under various brand names including Relizen, Serelys, Femal, and Femalen. Some small studies have shown positive results for pollen extract versus placebo in reducing vasomotor symptoms, but the panel said that “based on expert opinion and limited scientific research for the management of [vasomotor symptoms] VMS, pollen extract is not recommended.”
With not a single recommendation for any dietary supplement, the take home message from the position statement is ‘don’t waste your money.’
For more on non-hormonal treatments for menopausal symptoms, check out these two articles which sum up the evidence for non-hormonal prescription drugs and lifestyle strategies:
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