Vol.2 Issue 1
Menopause

Women are increasingly turning to alternative therapies to treat symptoms of menopause. Concerns about side effects and long-term risks of hormone replacement therapy (HRT), interest in using more "natural" approaches to maintain health, and extensive media coverage are among the factors that have contributed to the increased use of alternative therapies. Until recently, HRT (estrogen with or without progestin) was widely prescribed to treat menopausal symptoms and to prevent chronic conditions such as osteoporosis and heart disease. Last year, two large-scale studies of HRT were terminated prematurely due to increased risks identified with the use of HRT.

The first study, the Heart and Estrogen/Progestin Replacement Study (HERS II), examined more than 2,300 postmenopausal women (average age 74 years at study end) with coronary heart disease. Compared to the placebo group, women taking HRT had increased rates of venous thromboembolism and gallbladder disease and nonfavorable trends related to cardiovascular disease and fractures (Grady et al., 2002; Hulley et al., 2002). The second study, the Women's Health Initiative (WHI), included 16,608 healthy postmenopausal women (ages 50-79 years) with an intact uterus. Interim analyses revealed that HRT raised the risk of cardiovascular disease, venous thromboembolism, stroke, and breast cancer. The researchers concluded that the overall health risks of HRT outweighed the benefits (fractures and possibly colorectal cancer) and that women should not be placed on HRT for primary prevention of heart disease (Rossouw et al., 2002). Because of the unacceptable increased risk of breast cancer and some increases in cardiovascular diseases, the 8-year study was stopped after 5 years. The results of these studies have left many women and their health care providers confused and cautious.

Not surprisingly, many menopausal women are beginning to use alternative therapies, such as herbal and dietary supplements to alleviate their symptoms. A common assumption about herbal and dietary therapies is that they are "natural" and therefore "safe and effective". Herbal and dietary supplements can, however, vary in concentration of active ingredients among different brands and within different lots of the same brand; be contaminated or adulterated; or have adverse effects and toxicities. For example, recent concerns about ephedra, a Chinese herb known as ma huang, underscore the need for caution. Ephedra is found in numerous weight loss, bodybuilding, and energy-enhancing remedies and has been linked to a variety of adverse effects ranging from cardiac arrhythmias to seizures to strokes (Haller & Benowitz, 2000). Herbal and dietary therapies can also interact with prescription medications. Gingko, garlic, and ginseng can inhibit platelet aggregation and increase risk of bleeding in persons taking anticoagulants; St. John's Wort can interfere with the absorption of protease inhibitors, steroids, and coumadin (Ang-Lee, Moss, & Yuan, 2001). Health care providers can promote the safe and effective use of herbal and dietary supplements by: a) staying abreast of new information about the safety and efficacy of herbal and dietary therapies; b) carefully eliciting herbal and dietary supplement use during history taking; c) communicating effectively about the risks and benefits of these therapies for treating menopausal symptoms; and d) referring patients to reliable alternative therapy resources.

In this issue of Flyway, we explore the use of complementary and alternative therapies to manage menopausal symptoms.


Joyce Keithley, DNSc, RN, FAAN
Professor, Adult Health Nursing
Rush University College of Nursing
Chicago, Illinois

References

Ang-Lee, M.K., Moss, J., & Yuan, C-S. (2001). Herbal medicines and perioperative care. Journal of the American Medical Association, 286(2), 208-216.

Grady, D., Herrington, D., Bittner, V., Blumenthal, R., Davidson, M., Hlatky, M., et al. for the HERS Research Group. (2002). Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and estrogen/progestin replacement study follow-up (HERS II). Journal of the American Medical Association, 288(1), 49-57.

Haller, C.A., & Benowitz, N.L. (2000). Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. New England Journal of Medicine, 343(25), 1833-1838.

Hulley, S., Furberg, C., Barrett-Connor, E, Cauley, J., Grady, D., Haskell, W., et al. for the HERS Research Group. (2002). Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and estrogen/progestin replacement studyfollow-up (HERS II). Journal of the American Medical Association, 288(1), 58-66.

Rossouw, J.E., Anderson, G.L., Prentice, R.L., LaCroix, A.Z., Kooperberg, C., Stefanick, M.S., et al. Writing Group for the Women's Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the women's health initiative randomized controlled trial. Journal of the American Medical Association, 288(3), 321-333.