For some women, the risks or side effects in taking hormone therapy for hot flashes, night sweats, and other uncomfortable symptoms of menopause outweigh the many benefits-and many women are exploring alternative therapies.

For Mary Levering, 65, the hot flashes and sleep deprivation of perimenopause sent her spiraling into a depression. She tried hormone therapy but quit pretty quickly because of side effects.

Instead of more drugs, the Chevy Chase, Md., attorney turned to Ayurveda, a 5,000-year-old Eastern healing tradition that relies on herbs, nutrition, exercise, and other alternative approaches to maintain health.

"The depression lifted, and it's never come back," says Levering, who began taking various herbal mixtures, following a special vegetarian diet, and doing yoga about five years ago, when her menopausal symptoms were at their worst. "I'm sleeping fine. I lost the weight. I don't even remember having a hot flash at all after I started my Ayurvedic lifestyle."

Not all women who try complementary and alternative medicine (CAM) approaches to treat their menopausal symptoms have such success. But more women are giving alternative approaches a try than ever before. And what was once called "CAM" in some cases is being evaluated and then embraced by mainstream medicine.

The Study of Women's Health Across the Nation, or SWAN, surveyed menopausal women in 2003 and found that about half had tried at least one CAM therapy in the past year. However, included in their definition of CAM therapy were therapies such as vitamin/mineral supplements; a therapy that is probably considered mainstream by many.

"The first thing I say to women is they need to look at why they're avoiding hormones and whether they understand what the real risks and benefits are,'' says Alan Altman, M.D., an assistant clinical professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.

Too many women avoid hormone therapy because they're worried about long-term risks that may not apply to them, he says. Yet estrogen therapy (with or without progestogen) remains the most effective treatment for hot flashes and other menopausal symptoms. Alternative approaches just don't seem to work for those with the most severe symptoms, he warns. 

Still, for those who want or need to avoid hormones, alternative approaches may help, says Machelle Seibel, M.D., a professor of obstetrics and gynecology at the University of Massachusetts in Worcester. Just be realistic about your expectations, he says. For instance, alternative therapies may not completely eliminate symptoms, and they may take several weeks to begin working. 

"Sometimes alternative remedies that help don't make things perfect, but they improve things enough so the symptoms can be tolerated,'' Seibel says. "You can't promise the moon, but you can promise to work with women to see what's out there, then they can make an informed choice."

Looking at Other Options
After four months, Jane Ibbs, 53, from Silver Spring, Md., decided that the side effects of her combined estrogen-progestogen therapy, particularly the headaches and nausea, were enough to motivate her to seek alternative treatments. "Even after dosage regulation and switching to a skin patch, I still felt nauseous, and the daily headaches didn't stop." Her first priority was "to look for something to help with the hot flashes."

CAM includes a diverse group of practices and products not currently used in conventional medicine.  Complementary medicine is used with traditional medicine, while alternative medicine is used in place of it.

 "A good place to start is with treatments that don't require you to take anything internally," says Tieraona Low Dog, M.D., director of the Fellowship for the Program in Integrative Medicine at the University of Arizona School of Medicine in Tucson, "because they are far less likely to cause side effects."

Some common forms of CAM therapy include the following low-risk options.

Acupuncture. Some small studies have found that acupuncture decreased the severity and frequency of hot flashes by as much as half. Further studies, funded by the National Center for Complementary and Alternative Medicine, are currently underway.

Massage, meditation, and yoga. Some women report they feel better after these treatments, but there is so little research on them it's impossible to say whether they work or not, says Low Dog.

Biofeedback. Biofeedback works by teaching you to control your body temperature and other natural functions through relaxation techniques while you watch changes in your brain waves or temperature level. One very small study of four women found biofeedback helped reduce the severity of hot flashes, but other studies didn't find any benefits. Several studies suggest biofeedback can help with urinary incontinence.

Paced respiration. Good research has proven that taking slow, deep breaths when a hot flash is starting may nip it in the bud. (See page 34 for further advice.)

In the end it's all a matter of what feels right for you. "I tell women they should go see for themselves," says Low Dog. "If you want to get a massage, just go get one. If you feel better, then massage was beneficial for you. It's a personal choice."

Herbal and Nutritional Remedies

While most non-supplement approaches are relatively safe, Low Dog notes that there is a somewhat greater risk when it comes to herbal products, particularly those sold over-the-counter  as supplements versus herbal teas and other mixtures individually prepared from plants by a trained herbalist.

If they are strong enough to potentially help your symptoms, she says, supplements are also strong enough to cause side effects. But we may not know what the risks are because, in this country, herbal supplements are not required to undergo testing for effectiveness, safety, proper dose, or purity like prescription drugs.

Thus, says Altman, there's no guarantee you're getting what the label promises. For instance, supplements may be contaminated with harmful ingredients that aren't listed on the label. "Buying an over-the-counter herbal supplement is a shot in the dark," he says.

He prefers to refer his patients to a reputable herbalist. The practitioner should take a medical history to make an informed recommendation on what herbs to try and in what doses, Altman says. "That's better than relying on the advice of a health food store clerk."

Many of today's herbal supplements are highly concentrated and much stronger than the original herbal teas, says Low Dog. Don't assume that an over-the-counter product is safe just because it's based on thousands of years of tradition-it could have many times the recommended dosage, she warns. 

What Do We Know About Herbal Supplements?

When it comes to herbal supplements for relieving menopause symptoms, the quality of evidence is fairly weak, says Low Dog. However, the National Institutes of Health has funded studies of black cohosh, red clover, and soy for the treatment of menopause symptoms.

Here's what we know about common remedies. As all of the therapies listed can cause side effects and most interact with medications, make sure your clinician agrees that it's safe for you to try them. 

Black cohosh. This herb appears to be the most promising for relieving hot flashes, although the results are not conclusive, says Low Dog. A 2002 review of existing evidence found that three of the four reviewed trials showed a potential benefit with mild hot flashes. Only mild side effects have been noted. However, more research is needed before this herb can be strongly recommended, particularly for long-term use. There are more studies showing the effects of black cohosh in progress.

Soy. Consuming isoflavones, weak estrogen-like compounds most commonly found in soy foods, has been found in some studies to reduce mild hot flashes by 15 percent, but many other studies show no effect at all. Eating one or two servings of soy foods daily may bring greater benefit than soy supplement pills. Diets high in soy are considered safe, Low Dog notes, but supplements that provide highly concentrated doses of isoflavones are more questionable.

Red clover, evening primrose oil, vitamin E, wild yam, dong quai. Studies are unimpressive on the benefits of these supplements in relieving menopause symptoms, notes Low Dog.

St. John's wort. This supplement may be helpful for women who are experiencing some mood problems along with menopause symptoms, says Low Dog, with several studies documenting efficacy for relieving mild depression. Side effects include gastrointestinal upset, fatigue, and increased sensitivity to sunlight. Users should avoid sun exposure. The herb should not be taken with psychotropic medications and may decrease the activity of blood-thinners and other prescription medication.

Mary Levering believes that herbal products should only be used as a single component in a holistic approach to treating menopause, not on their own. Through Ayurveda, she notes, she's overhauled her entire lifestyle, adopting a vegetarian diet, daily massage, and yoga sessions-all of which work together.
 "My body works about a hundred times better than it ever did,'' she says. "I sleep better and my energy's back. I'm going to have a healthier old age because of Ayurveda and yoga."

And Jane Ibbs is still searching for the "wonder cure." Although she is very positive about the improvements she has experienced through her use of soy products and a black cohosh supplement, she does still experience the odd hot flash. "I try to avoid hot flash situations. I have tried to reduce stress in my life by working fewer hours, and I do follow a sensible diet-avoiding alcohol and spicy foods as well as aiming toward a heart-healthy diet. I believe that if I incorporate many positive lifestyle changes that will reduce my symptoms, and if things continue to improve, I'll never need to go back to prescription hormone therapy."

The Placebo Effect

When researchers study products for the treatment of menopausal symptoms, most studies find over 30 percent of women improve even when they're given a pill with no active ingredients in it.

This is the placebo effect. Just thinking that you're receiving the treatment, whether or not you actually do, seems to improve symptoms in many people. In well-designed clinical trials, researchers compare the real treatment to a placebo so they can tell whether the treatment really worked, or whether the benefit it produced was due to the placebo effect. Not that the placebo effect is necessarily a bad thing.

 "So they get better with a placebo, so what?" says Machelle Seibel, M.D., a professor of obstetrics and gynecology at the University of Massachusetts in Worcester. "What does it matter if 30 percent (of women) are seeing improvement in hot flashes?"'

For instance, Seibel says, many women who add soy foods to their diets and claim their hot flashes improved may be experiencing a placebo effect rather than a real benefit from the soy. But if they feel better and that improves their quality of life, why worry so long as the treatment is safe?

The Facts

The following resources offer information on quality herbal products:

U.S. Pharmacopeia
This nonprofit company sets quality standards and verifies compliance for supplement makers. www.usp.org/USPVerified/  

The National
Sanitation Foundation
An independent nonprofit that tests supplements to make sure they contain what they promise www.nsf.org

Consumer Lab
Unbiased testing information for better quality health and nutritional products.

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