Archive for March, 2010

Natural Hormone Replacement Therapy: Red Clover

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March 22, 2010 at 9:58 am

The red clover plant (Trifolium pretense, purple clover, trefoil, cow clover, meadow clover) is a perennial legume. Its red and purple flower tops are used medicinally. The flower top contains isoflavonoids (biochanin A, daidzein, formononetin, and genistein), flavonoids (pectolinarin and trifolin), volatile oil (containing furfural), saponins, coumarins (coumarin, medicagol, and coumestrol), salicylic acid, minerals, vitamins, phytoalexins, carbohydrates, and fats. Historically, Chinese medicine has taken advantage of its expectorant properties, while Russians have used it to relieve bronchial asthma. Red clover has been used to treat skin conditions such as psoriasis and eczema, but its mechanism of action for this skin improvement is unknown. The herb has also been used in the past to treat breast cancer. It has been shown to have chemoprotective, antispasmodic, and hormone replacement properties.

The isoflavones have an estrogenic effect on the body. Like soy phytoestrogens, these isoflavones may function as SERMs. It has been shown that isoflavones can have an antiestrogenic effect on premenopausal women but can have an estrogen-like effect on postmenopausal women who have low levels of endogenous estrogen. They have an affinity for the beta-estrogen receptors that are common in the heart, vasculature, bones, and bladder. The estrogenic effects may be useful for symptoms of menopause, including hot flashes, and for prevention of osteoporosis. It is controversial whether the isoflavones have any effect on bone mineral density. Also, these hormonal effects can improve the decreasing arterial compliance seen in postmenopausal women. Red clover may be indirectly involved in lowering cholesterol and producing an increase in bile acid excretion.

There are several red clover products on the market, including tea, powder blossom, powder tops, tablets, capsules, and extracts. Red clover is also available in combination with other herbs; such products include Promensil, Rimostil, Super Fem, and Avlimil.

In 2003, a 12-week clinical trial examined the use of red clover isoflavones in menopausal women who were experiencing at least five hot flashes a day. Researchers randomly assigned 250 women to Promensil 82 mg, Rimostil 56 mg, or placebo. The results provided some evidence for a biological effect of Promensil, but neither supplement had a clinically important effect on hot flashes or other symptoms of menopause. Another study performed in Amsterdam investigated the effectiveness of Promensil versus placebo in reducing hot flashes. This trial included 30 menopausal women experiencing more than five hot flashes a day. Treatment with Promensil 80 mg/day resulted in a significant decrease (about 44%) in hot flashes, compared to placebo.

Women with hormone-sensitive diseases or a history of breast cancer should avoid red clover because of its synthetic estrogen properties. It is contraindicated with the use of any other hormone therapy, such as oral contraceptives or any estrogen or progesterone compounds. It could have additive or antagonistic effects on therapy. Because red clover contains a coumarin component, it causes an increased risk of bleeding when used with anticoagulants, aspirin, or other blood-thinning herbs (e.g., ginkgo, ginger, garlic). Adverse reactions include headache, nausea, vaginal spotting, and some muscle pain and rash-like reactions. No serious side effects have been reported. Peak concentrations of these phytoestrogens vary from four to eight hours after intake, and they are excreted within 24 hours.

The usual dose of red clover is 4 g of the flower top three times daily. There are many dosage forms available. Traditionally, the dried herb is used as a tea prepared by steeping 4 g of dried flower tops in 150 mL of hot water for 10 to 15 minutes. The patient may drink up to three cups daily. The herb is available in capsule and tablet form, and patients should follow the directions on the product package labels closely. Taken as a fluid extract (1:1 in 25% alcohol), the dose is 1.5 to 3 mL three times daily.

Conclusion

The herbs discussed in this article have a long history of use as foods, spices, and medicine. Soy, black cohosh, dong quai, chasteberry, red clover, and sage are hormonal herbs that are possibly effective in treating menopausal symptoms because of their estrogenic activity. Valerian, a nervine herb, may be effective for sleep disorders, tension, and anxiety associated with menopause.

These herbs are considered relatively safe and effective if taken in recommended amounts. However, clinical safety and efficacy cannot be established completely due to insufficient evidence.As with all herbal medicines, the clinical trials conducted to date have been small, and many are flawed.

Menopausal women use many alternative therapies that do not have clinical data supporting efficacy claims. Pharmacists should provide their patients with as much information as possible regarding the uses, side effects, and interactions of these products. Always check a reliable herbal medicine reference for drug, disease state, and herbal interactions. These references include Natural Medicines Comprehensive Database, Facts and Comparisons Review of Natural Products, and Micromedex.

Pharmacists should also make the following recommendations to their patients regarding the use of herbal products:

Inform your health care provider and pharmacist of which herbal supplements you take.
Keep a list of herbal products that you use and take it with you to medical appointments.
If you are thinking of starting herbal therapies, consult with your health care provider and pharmacist to ensure that the products will not interact with other medications you are taking.
Never take more than the recommended dose listed on the label.
Do not use a product that does not have the manufacturer’s name, address, and telephone number on the label.
Avoid taking products that do not have expiration dates or lot numbers on the label.
Avoid taking products that have an expiration date that is not at least one year from the purchase date.

Pharmacists should encourage their patients to provide the information on herbal products that they have found on the Internet so that the pharmacists can assist in evaluating its accuracy and validity. Pharmacists are in a unique position to assist the consumer in this area of health care and should become informed so that they may provide the best care to their patients.

Menopause | Tags: Valerian

Natural Hormone Replacement Therapy: Valerian

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March 22, 2010 at 9:58 am

The dried root and rhizome of valerian (Valeriana officinalis, amantilla, all-heal, baldrian, garden heliotrope) are used medicinally. The chemical constituents found in the plant include iridoid triesters known as valepotriates (valtrate and isovalerate), volatile oil (bornyl acetate and bornyl isovalerate), sesquiterpenes (valerenic acid and derivatives), and pyridine alkaloids (actinidine and valerianine). The valepotriates may act as prodrugs in the body and are highly unstable. Gamma amino benzoic acid has been reported in fair concentration in aqueous extract; however, its bioavailability is questionable. The presence of lignans (pinoresinol, hydroxypinoresinol, and acetoxypinoresinol) in valerian should also be noted because they have the ability to bind to benzodiazepine receptors.

Valerian is reported to have sedative-hypnotic, anxiolytic, antidepressant, anticonvulsant, and antispasmodic actions. It may also have hypotensive and mild analgesic properties. Oral valerian has been used as a sedative-hypnotic and anxiolytic to treat restlessness and sleeping disorders associated with nervous conditions. It is also used for mood disorders, infantile convulsions, mild tremors, epilepsy, attention-deficit/hyperactivity disorder, rheumatic pain, anxiety, nervous asthma, nervous headaches, gastric spasms, colic, menstrual cramps, nervous complaints, and hot flashes associated with menopause. In menopausal women, valerian is used to treat insomnia.

Though the nervine effect of valerian may reduce hot flashes, there is insufficient clinical proof of this. Valerian does not actually treat hormonal symptoms but is effective in reducing conditions associated with menopause, such as insomnia, tension, and anxiety. When used to treat insomnia, valerian must be taken for about two to four weeks before an effect is seen. No effects were noted with single doses, but multiple doses appear to reduce slow-wave sleep latency and sleep perception.

Valerian is available as dried cut root, powder root, extracts, capsules, and tablets; examples of combination products include Avlimil, PMS Tonic, Valerian Compound, and Menstrual-Ease.

Oral valerian may cause headache, excitability, uneasiness, cardiac disturbances, and insomnia. Use of valerian has also been associated with morning drowsiness, so pharmacists should caution patients about driving or operating dangerous machinery while using this herb. Valerian toxicity manifests as trouble walking, hypothermia, and increased muscle relaxation. After an extended length of therapy, patients should taper doses slowly to avoid a benzodiazepine-like withdrawal.

Concomitant use with barbiturates, benzodiazepines, and other agents and herbs with sedative properties (e.g., California poppy, Siberian ginseng, German chamomile, gotu kola, hops, kava, St. John’s wort) may result in additive therapeutic and adverse effects. Despite a lack of clinical evidence, valerian should potentiate the sedative effects of alcohol.

The maximum dose of valerian root is 15 g/day. The simple tincture is commonly taken as 1 to 3 mL several times per day. Amounts of extract equivalent to 2 to 3 g of the root are also taken several times a day.

Menopause | Tags: Chasteberry

Natural Hormone Replacement Therapy: Chasteberry

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March 22, 2010 at 9:57 am

In early times, Hippocrates discussed use of chasteberry (Vitex agnus-castus, chaste tree, agnus castus, hemp tree, and monk’s pepper) as a medicinal agent. The dried ripe fruit is used medicinally. The chemical constituents consist of iridoids (aucubin and agnuside), flavonoids (isovitexin, kaempferol, and quercetagetin), volatile oil (cineol, pinene, limonene, caryophyllene, and cardinene), and fatty acids, including linoleic acid. In addition, the leaves and flowers contain progesterone, hydroxyprogesterone, testosterone, and epitestosterone.

The effects of chast eberry, which appear dose dependent, may be caused by its indirect effects upon various hormones. Lower doses (approximately 120 mg/day) are thought to diminish follicle-stimulating hormone release and increase luteinizing hormone release, leading to decreased estrogen levels and increased progesterone and prolactin levels. Higher doses (approximately 480 mg/day) result in decreased prolactin release. Chasteberry may also have antibacterial and antifungal effects.

Chasteberry has been used orally for menstrual irregularities, including dysmenorrhea, secondary amenorrhea, metrorrhagia, oligomenorrhea, and polymenorrhea. It has also been used for symptoms of menopause, PMS, acne, female infertility, fibrocystic breasts, benign prostatic hyperplasia, impotence, decreased libido, nervousness, dementia, rheumatic conditions, colds, and dyspepsia; preventing miscarriage in patients with progesterone insufficiency; reducing sexual desire; controlling postpartum bleeding; aiding in expulsion of placental material; and increasing lactation. Chasteberry products are available alone and in combination form. Some examples are Vitex, Wild Yam & Chaste Tree, Menopause, Phytoestrogen, and Phytoprogest.

Although chasteberry possibly is effective in treating symptoms of PMS and in treating menstrual disorders, there is insufficient evidence available to determine its effectiveness in treating symptoms of menopause.

The adverse effects associated with the use of chasteberry include gastrointestinal upset, headache, nausea, itching, urticaria, rash, acne, and intramenstrual bleeding. Some patients have experienced alopecia, fatigue, agitation, tachycardia, and dry mouth. Side effects are rare, occurring in 2% to 5% of patients. Chasteberry may interfere with the action of dopamine antagonists, as it has dopaminergic effects. It may interfere with the efficacy of oral contraceptives and hormone replacement therapy (HRT) because of its hormone-regulating activity. There are no known herbal or dietary supplement interactions.

Women with hormone-sensitive cancers or conditions should avoid the use of this herb.

Dosing recommendations vary by manufacturer. The pharmacist should recommend that the patient follow the dosing recommendations on the package label and not exceed the recommended dose.

Menopause | Tags: Dong Quai

Natural Hormone Replacement Therapy: Dong Quai

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March 22, 2010 at 9:57 am

Dong quai (Angelica sinensis, Chinese angelica, danggui, dong qua, and tang kuei) is widely used in traditional Chinese medicine and is typically combined with other herbs. The plant’s roots are used medicinally. The chemical constituents include alkyl phthalides (ligustilides, angelicide, and butylphthalide), furanocoumarin (archangelicin, bergapten, and imperatorin), coumarins (angelol G and angelicone), terpenes (cadinene and carvacrol), phytosterols (beta-sitosterol and stigmasterol), organic acids (ferulic, succinic, and myristic), and an immune-stimulating polysaccharide. Phthalides and coumarins are believed to act as antispasmodics, vasodilators, and central nervous system stimulants. Dong quai is taken orally for gynecologic complaints, including menstrual cramps, irregularity, retarded flow, weakness during menstrual period, and symptoms of menopause. It has also been used as a “blood purifier,” to manage hypertension, rheumatism, ulcers, anemia, and constipation, and for the prevention and treatment of allergic attacks.

Clinical trials of dong quai have not demonstrated its efficacy for treating menopausal symptoms. One study found that dong quai had no effect upon endometrial wall thickness or menopausal symptoms when used alone. Dong quai is believed to act by competitively inhibiting estradiol binding to estrogen receptors and inducing transcriptional activity in estrogen-responsive cells. There is a need for human studies evaluating the efficacy of dong quai used in combination with other ingredients for treating menopausal symptoms.

Dong quai is available alone and in combination with other herbs, vitamins, and minerals. Some examples are Dong QuaiSingle Herb Capsules, Dong QuaiStandardized Extract Tablets, Avlimil, Phyto Estrogen Power, Menopausal Formula, and Menstrual-Ease.

The use of dong quai has been associated with photosensitivity and photodermatitis. The use of dong quai with anticoagulant and antiplatelet drugs may cause potentiation of their therapeutic and adverse effects. Concomitant use with warfarin causes an increase in anticoagulant effect and risk of bleeding. Because dong quai contains coumarins, it should be used cautiously with herbs that have an anticoagulant or antiplatelet action (e.g., angelica, anise, capsicum, chamomile, celery, garlic, ginkgo, ginseng, licorice, passionflower, red clover), as concomitant use may increase the risk of bleeding. Women with hormone-sensitive cancers or conditions should avoid the use of dong quai, as it may have estrogenic effects.

The recommended dosage of dong quai depends upon the manufacturer. The pharmacist should counsel the patient to follow the dosing instructions on the package label and not to exceed the dosage for any reason. There are many dong quai species, and they differ in their chemical, pharmacological, and toxicological actions. When making recommendations, the pharmacist should be aware of which species is under discussion.

Menopause | Tags: Sage

Natural Hormone Replacement Therapy: Sage

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March 22, 2010 at 9:56 am

The leaves and flowering aerial parts of the sage plant (Salvia officinalis, garden sage, meadow sage, true sage, and scarlet sage) are used medicinally. Its chemical constituents include a volatile oil (thujone, 35% to 60%; camphor, 18%; borneol, 16%; and cineol, 15%), isoflavones (apigenin and genkwanin), terpenoids (picrosalvin and ursolic acid), and caffeic acid derivatives (rosmerinic and chlorogenic acids). Sage has both phytoestrogenic and antihydrotic mechanisms. It is used in most hormone replacement therapy (HRT) herbal products to reduce night sweating and hot flashes. Sage is available as a spice and in herbal blends, which include Female Sage, Super Fem, Avlimil, and Preserve.

Sage is also used for loss of appetite, dysmenorrhea, diarrhea, gastritis, galactorrhea, reduction of saliva secretion, and digestive problems, including flatulence, bloating, and dyspepsia. Sage has antioxidant, antimicrobial, and antiviral activity.

Adverse effects associated with sage include cheilitis, stomatitis, dry mouth, and local irritation to the mouth. Large amounts or prolonged use have been associated with restlessness, vomiting, vertigo, tachycardia, tremors, seizures, and kidney damage. Sage interacts with herbs that have sedative properties (e.g., Siberian ginseng, gotu kola, kava, ashwaganda, St. John’s wort, valerian). Drugs known to interact with sage include anticonvulsants, hypoglycemic agents, and sedatives. Sage may interfere with blood glucose control in diabetic patients. Sage should be avoided in patients with seizures, as it may precipitate seizures.

The recommended dose of sage is a 1- to 2-g leaf/day or 1 to 4 mL of liquid extract (1:1 in 45% alcohol) three times daily. It is not recommended for long-term use. The herb sage should not be confused with red sage or the brush sage of the desert.

Menopause | Tags: Black Cohosh

Natural Hormone Replacement Therapy: Black Cohosh

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March 22, 2010 at 9:55 am

Black cohosh (Actaea racemosa, Cimicifuga racemosa [previous name], baneberry, black snake root, bugbane, squawroot) is a perennial herb and was an ingredient in Lydia Pinkham’s Vegetable Compound, marketed in the early 1900s. The rhizomes and roots are used medicinally. Black cohosh constituents contain alkaloids (N-methyl-cytisine and related unknown alkaloids), terpenoids (actein, deoxyactein, cimicifugoside, and neocimiside), isoflavones (formononetin, genistein, and keamferol), resins (cimicifugan), tannins (polyphenolic compounds), organic acids (acetic, butyric, formic, isoferulic, oleic, palmitic, and salicylic), and volatile oils.

Black cohosh is taken orally for the symptoms of menopause, premenstrual syndrome (PMS), dysmenorrhea, nervous tension, dyspepsia, rheumatism, fever, sore throat, and cough and is used to induce labor and as a mild sedative. The mechanism of action of cohosh is unknown. Available products include powder root-rhizome and extract of black cohosh. Combination formulas include Estroven, Avlimil, Black Cohosh Extra Plus, Menopause, Menopause Formula, and Menopause Support.

Black cohosh may be effective in reducing menopausal symptoms such as hot flashes. The differences seen were not statistically significant when compared with hormone replacement therapy (HRT). Most clinical studies have used a standardized formulation (Remifemin) that contains 1 mg triterpene glycosides, calculated as 27-deoxyacetin. There was no evidence that black cohosh affects the endometrium, which may negate the risk of endometrial cancer.

Adverse reactions seen with black cohosh include gastrointestinal upset, headache, dizziness, weight gain, feeling of heaviness in the legs, and cramping. An overdose of black cohosh can cause nausea, vomiting, nervous system and visual disturbances, reduced heart rate, and perspiration. There are no known drug interactions or herbal or dietary supplement interactions. Women with hormone-sensitive conditions, such as breast, uterine, and ovarian cancer, endometriosis, or uterine fibroids, should avoid the use of black cohosh due to its estrogenic effects. Therapy for longer than six months is not recommended, as there are no available data regarding long-term use. Black cohosh is not the same herb as blue or white cohosh and should not be confused with them.

Menopause | Tags: Soy

Natural Hormone Replacement Therapy: Soy

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March 22, 2010 at 9:54 am

The soy plant (Glycine max, soybean, shoyu, and soya) belongs to the pea or legume family, and its beans are used medicinally. Soybeans were first cultivated in China as far back as the 11th century BC and are now grown in the U.S. and other parts of the world, including Japan and Europe.

Soybeans contain up to 25% fixed oil, 24% carbohydrates, and 50% protein. They are rich in minerals and vitamins and are considered a good source of fiber. The specific constituents include isoflavones (daidzein, genistein, biochanin A, and formononetin), coumestans (coumestrol and other coumestans), lignans (matairesinol and secoisolariciresinol), phytosterols (beta sitosterol), saponins (saponin B1 and B2), phytates (phytic acid), and protease inhibitors (Bowman-Birk inhibitor and Kunitz-trypsin inhibitor). Among these constituents, the isoflavones, coumestans, and lignans have chemical structures that are similar to estrogen. These are referred to as phytoestrogens. The most commonly studied isoflavones are daidzein and genistein. Since the phytoestrogens are similar in structure to the naturally occurring hormone estrogen, they have similar activities in the body. The metabolism of these agents in the body is variable. Soy has been used to treat hyperlipidemia and menopausal symptoms and to prevent osteoporosis and breast cancer. Soy has also been used for cyclic breast pain, hypertension, constipation, diarrhea, slowing the progression of kidney disease, decreasing urinary protein excretion, preventing hot flashes in breast cancer survivors, and preventing prostate and endometrial cancer.

The isoflavones bind to both alpha- and beta-estrogen receptors but have a higher affinity for the beta-receptors, which are predominantly found in the heart, vasculature, bones, and bladder. Soy estrogens may act as selective estrogen receptor modulators (SERMs). In premenopausal women, soy phytoestrogens have an antiestrogen effect, whereas in postmenopausal women with low estrogen levels, soy has a weak estrogen effect.

Soy is found in a variety of foods and herbal medicines. A few examples of food products are soy flour, soymilk, and candy-covered and roasted soybeans. Some examples of herbal products that contain soy phytoestrogens are Menopause Formula, Menopause Multiple, Soy Essentials, and Soy Isoflavone.

The clinical evidence varies regarding the efficacy of soy isoflavones for treating hot flashes associated with menopause. As with all herbal medicines, the clinical trials perf ormed to date have been small, and many are flawed. The FDA has approved the labeling of soy products for cholesterol reduction when used in combination with a low-fat diet. There is evidence of soy’s ability to reduce total and LDL cholesterol levels, with no effect on HDL cholesterol. Epidemiological studies have indicated that Asian women who consume a high-soy diet have fewer hot flashes. Although some clinical studies have shown a modest improvement, others show no improvement over that seen with placebo. Soy has been shown to be ineffective in preventing hot flashes in breast cancer surviviors. It may be effective in reducing the risk of osteoporosis by increasing bone mineral density. Because soy isoflavones do not appear to have a stimulatory effect upon the endometrium, they may not carry the risk of endometrial cancer associated with estrogen therapy.

The adverse effects of soy include gastrointestinal symptoms such as constipation, bloating, and nausea. It may cause an allergic reaction that manifests as a skin rash and itching. Other statements about soy’s risks need further research. These include claims regarding increased risk of breast cancer, stomach cancer from fermented soy products, and cognitive impairment in later life.

Theoretically, soy may competitively inhibit effects of estrogen replacement therapy. There is a preliminary indication that soy may antagonize the antitumor effects of tamoxifen; therefore, concurrent use should be avoided. No herbal or dietary supplement interactions have been reported to date. Individuals with asthma are at increased risk of soy hull allergy, as are people with allergic rhinitis. Patients who have breast cancer or a personal or family history of the disease should use soy cautiously, as its effects upon breast-cell proliferation are not yet well known. Soy should be used cautiously in hypothyroid patients, as it can inhibit thyroid hormone synthesis. Because soy may increase the risk of kidney stones due to its high oxalate content, patients with a history of kidney stones should avoid excessive consumption of soy. People with milk allergies may also be sensitive to soy and should be counseled to use soy products with caution or to avoid them altogether.

The recommended dose of soy protein varies depending upon the desired result: for lowering cholesterol, 20 to 50 g/day; for osteoporosis prevention, 40 g/day; and for hot flash prevention, 20 to 60 g/day (providing 30 to 90 mg of isoflavones per day).

Menopause | Tags: Black Cohosh, Chasteberry, Dong Quai, Red Clover, Sage, Soy, Valerian

Natural Hormone Replacement Therapy

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March 21, 2010 at 8:03 pm

The average age of menopause for women in the United States is 51.4 years. Menopause is the cessation of menses following loss of ovarian follicular function. It can occur spontaneously or be induced via medical interventions such as surgery or chemotherapy. Menopause is defined as 12 months of amenorrhea following the final menstrual period. Perimenopause is the one- to two-year period prior to actual menopause that may be accompanied by the signs and symptoms of impending menopause (e.g., hot flashes, night sweats, sleep disturbances, irritability, mood disturbances). The intermediate phase may be accompanied by physiologic changes such as vaginal atrophy, stress incontinence, and skin atrophy. Later in life, estrogen deficiency can lead to other problems, including osteoporosis, cardiovascular disease, Alzheimer’s disease, and cancer.

Replacement of estrogen during menopause has been associated with a reduction in hot flashes, irritability, and other symptoms of menopause. Estrogen has the long-term benefits of prevention of osteoporosis, certain cancers, and Alzheimer’s disease.

Although oral/systemic hormone replacement therapy (HRT), usually consisting of estrogen plus progestin, has been the treatment of choice for menopausal symptoms for many years, findings from the NIH’s National Heart, Lung, and Blood Institute Women’s Health Initiative (WHI) study have led many women to discontinue it. The agency decided to terminate early one of the treatment arms (Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women) due to concern about increased risk of invasive breast cancer, coronary heart disease, stroke, and pulmonary embolism. Since July 2002, when the study was terminated, a great deal of information has been published, including results from the WHI Memory Study, indicating the risk of probable dementia in women ages 65 years and older who use these hormones. Recent reports on these hormones include an increase in breast cancer, abnormal mammograms, coronary heart disease, and atherosclerosis.

Despite the possible benefits of HRT (e.g., decreased risk of colorectal cancer and of hip and total fracture), many women have discontinued the treatment, even with the small absolute risk of adverse events and the lack of increase in overall all-cause mortality. Instead, many women seek alternative therapies for managing the symptoms of menopause. Pharmacists, as health counselors, need to be aware of the alternative therapies that women are using.

National surveys indicate that 12% to 17% of Americans have tried herbal remedies, with the majority being women. Menopausal women are one of the largest groups of users of herbal medicines. About 80% of menopausal women ages 45 to 60 have reported the use of nonprescription therapy for symptom management. Many people believe that herbal medicines are safe and effective because they are “natural,” and many are not aware of their side effects and contraindications. The pharmacist can provide information to users of herbal medicine in a nonjudgmental manner and can also educate about herbs, side effects, and recommended duration of use.

Some herbal medicines commonly used for the relief of menopausal symptoms include soy, black cohosh, garden sage, dong quai, chasteberry, valerian, and red clover. Due to insufficient data and concerns about safety, herbal medicines should not be used during pregnancy and lactation.

Pharmacists need to understand the categorization of herbs. Hormonal herbs have estrogenic and other hormonal effects (e.g., soy, black cohosh, red clover, garden sage, dong quai, chasteberry). Tonic herbs assist in maintaining the body’s normal balance (e.g., celery, angelica, garlic). Adaptogenic herbs help the body adapt to changes in the environment and include ashwaganda and varieties of Asian, American, and Siberian ginseng. Nervine herbs have a calming and relaxant effect (e.g., valerian, chamomile, passion flower). Herbs used to treat menopausal symptoms may fit into more than one category. Moreover, some products on the market combine herbs to treat a variety of symptoms.