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.

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1. RED CLOVER Botanical name: Trifolium pratense Family name: Leguminosae Synonyms: Meadow clover, purple clover, trefoil Part used: Flowering tops and leaf MAJOR CHEMICAL CONSTITUENTS Isoflavondoids including biochanin A, daidzein, formo-nonetin, genistein, and others; flavonoids including kaempferol, quercetin and others; coumarins; carbohydrates, saponins, salicylic acid, and trace vitamins and minerals. PRINCIPAL USES • Prevention and treatment of menopausal...
2. SAFETY INFORMATION SAFETY INFORMATION: HERB-DRUG INTERACTIONS, TOXICITY, AND CONTRAINDICATIONS Taking a serious and concerted look at the relative safety of black cohosh products for the treatment of menopausal symptoms, particularly for women in whom HRT is contraindicated, Low Dog et al. conducted a careful review of published and unpublished safety data extending well over 100 years. Analysis...
3. WILD YAM Botanical name: Dioscorea villosa Family name: Dioscoreacaea Synonyms: Colic root, rheumatism root Part used: Root and rhizome MAJOR CHEMICAL CONSTITUENTS Glycoside and steroidal saponins, including diosgenin and dioscin, alkaloids, tannins, phytosterols, and starch PRINCIPAL USES • Spasmolytic in the treatment of uterine cramping, dysmenorrhea, and chronic pelvic pain • Spasmolytic in cases of urinary tract...