Goodbye HRT, hello herbals

This past year was a bad one for hormone replacement therapy (HRT). The US government-sponsored Women's Health Initiative study of 16,000 menopausal women using the most popular HRT pharmaceutical in the US and in most of the Western world was abandoned in July after researchers declared continuation was too hazardous for those involved.

Increases in the risk of breast cancer, heart disease, blood clotting, colorectal cancer and stroke were some of the more untoward side effects experienced by those women who had taken HRT for more than five years. In its defence, the US trial also found a reduced likelihood of bone fractures and forecast no increase in mortality rates.

The WHI study used Premarin (a form of oestrogen made from the urine of pregnant horses) and Provera (a synthetic progesterone not found in the female human body)—jointly known as PremPro. The product, made by New Jersey-based pharmaceutical conglomerate Wyeth, has now been withdrawn in many markets.

Other research in Australia, New Zealand and the UK raised further questions about similar forms of HRT, while another US study, this one conducted by the National Cancer Institute, found women who took oestrogen alone for more than 10 years significantly increased their chances of developing ovarian cancer.

As disastrous as these revelations have proven to be for Wyeth and other pharmaceutical companies involved in HRT, not to mention for the women who have suffered negative consequences from this treatment, it has served to draw attention to HRT alternatives, principally herbals. This has occurred despite a consumer press that on the whole continues to ignore holistic solutions for what is, after all, a life stage rather than a disease.

Opportunity is knocking
Large numbers of women (it is estimated six million women were using PremPro in the US alone when the WHI story broke in July 2002) have turned to their MDs, health food stores, the alternative press, Web sites specialising in menopausal advice, holistic help centres and manufacturers of natural products in search of the information they need to help them through menopause.

It is an opportunity herbal ingredients suppliers and food and supplements manufacturers are obviously keen to exploit, although many are equally keen to emphasise how important the holistic approach is. And the holistic approach is about much more than swapping your bottle of PremPro for a multi-herb supplement that, despite what it might say on the bottle, is not exactly 'one-size-fits-all.' The issue is further complicated by the need for women who have been taking HRT to wean themselves off it before moving onto new treatments.

For these reasons, independent advisors like Maryon Stewart, a nutritionist and founder of the UK-based Women's Nutritional Advisory Service (WNAS) and author of Cruising Through Menopause and Managing Menopause Naturally, are playing an increasingly important role. WNAS statistics reveal about 500,000 people were searching the Internet for natural menopausal solutions in the month of October 2002. It also found 89 per cent of surveyed women would try a natural alternative to HRT.

"I'm not surprised that the HRT trials have been aborted in the US, Australia and the UK," Stewart says. "In a way I am glad this has happened, because the side effects associated with HRT are now public knowledge and it has opened a lot of women's minds to other possibilities. The problem is a lot of alternative products are not standardised, and a woman who really needs relief from hot flushes, or whatever her particular symptom might be, needs a treatment she can trust," she adds. "But, thankfully, there are more and more standardised products coming onto the market."

Mike Brook, co-owner of UK-based certified-organic ingredients supplier The Organic Herb Trading Company, is familiar with the problem of standardisation among herbals. "Women's herbs are definitely a growth area," he points out. "But the fact is two-thirds of all herbal medicines are collected from the wild, so there is a huge variation in the standards applied to them. The European Union's Traditional Herbal Medicines Directive will have a positive effect on the industry because it will encourage standardisation." In Europe, anyway.

Cheryl Thallon, co-founder and director of UK-based vitamin and herb manufacturer Viridian, is a firm believer in customising products on a case-by-case basis. "I think this is the key point a lot of vitamin companies miss—not all women are the same," she says. "They respond differently to different inputs. There are a lot of products out there claiming to be 'women's formulas,' but we think each woman needs to work out what is best for her. Giving an herbal remedy combination formula to every woman just because she happens to be a certain age is just as bad as giving HRT to every woman."

Hence the holistic and ethical approach, which Thallon says retailers should adopt. They must enquire about their prospective customer's lifestyle. What is her diet like? How much exercise does she get? What are her stress levels? Does she smoke? Does she drink alcohol, and if so, how much? Has she been sterilised? How long was she on HRT, if at all? Just the kind of enquiries a thorough general practitioner should make before endorsing a prescription.

"We don't do combination products because we don't think they are appropriate for dealing with individual needs. We are much keener on programme selling. Through our education programme, we encourage our retailers to look at a person's symptoms and nutritional requirements and her lifestyle choices and then work out three or four different nutrients and maybe an herbal to get her through the particular ailment she is dealing with," she says. "We'd rather they sold their customers three or four products for several months, and then after that the consumer may need to go down to a multivitamin; but we see that as being a better way to deal with consumers rather than telling them they need to be on something for the rest of their lives when they don't."

"The psychology is very important as well. I think if a lot of women viewed menopause as they viewed puberty, it would be seen in a very different way. You wouldn't dream of finding a remedy for a moody 14-year-old. We need to embrace menopause as being another phase of life, which for many women is a relief to be ending the menstrual cycle."

Herbals at play
That said, herbals such as black cohosh, red clover, chaste tree berry, dong quai, licorice, motherwort, milk thistle, evening primrose oil and wild yam are commonly formulated in combination products and do offer alternatives to HRT, if only for some of its milder symptoms. They may not be perfect, but they are popular. Other ingredients range from soy isoflavones to minerals such as calcium, manganese, silicon and boron; and vitamins A, B, D and E (often to increase absorption and metabolism); to St John's wort (to ease the mild depression that can accompany menopause). Relaxants such as SAMe, 5-HTP, kava kava, eleuthero (ginseng), passionflower and valerian also find their way into many supplements, while natural progesterone creams are also popular.

We know soy has a lot of isoflavones, but they are not oestrogenic until they are converted in the body, and that leads to a big drop-off in delivery
These products are gaining demand among consumers who are increasingly keen to self-medicate, a trend that pre-dates last year's HRT scare. According to Multisponsor Survey data from the US, there was a nine per cent increase from 2000 to 2001 in the use of supplements formulated specifically for stage-of-life and gender, and 11 per cent of regular vitamin users took supplements specifically designed for menopause in 2001. Thirty-four per cent took women's supplements in 2001. This is hardly surprising, given a rapidly ageing and increasingly nutrition-savvy population keen to maintain their quality of life well into their golden years.

"One hundred years ago, average life expectancy was only about 50 years in the industrialised world. Many women simply didn't have to face menopause. Now you have a third of your life to go and you want to be able to enjoy it in good health, otherwise what is the point of living?" asks Stewart.

"Women don't learn about what to do during menopause in school, and they don't learn about it in their adult life, so if they need help, they can turn to centres like ours for advice."

Robin Ward, sales and marketing manager at Swiss-based botanicals supplier Linnea, notes that even before the HRT scare, many women were turning away from the treatment because they found it to be ineffectual.

"The rise in the use of alternatives was gaining pace long before the bad press HRT received, because a lot of women weren't getting good results from HRT regardless of any potential negative side effects," Ward says. "The key with herbals like red clover or black cohosh or some of the other ingredients is that you are not really looking at hormone replacement; you are employing molecules that mimic the activity of the hormones but in a much weaker way. You are looking to activate the DNA to mimic the presence of the hormone, not to replace it. It is a much gentler process.

"In the case of red clover, at first people thought of it only as being high in isoflavones, whereas it is also high in polyphenols and other enzymes. So there is now a lot of specific clinical data that show it to be a complete treatment for menopause, which a lot of other ingredients don't have."

Take soy. "We know it has a lot of isoflavones, but they are not oestrogenic until they are converted in the body, and that leads to a big drop-off in delivery. So there are a lot of reasons why red clover is a better ingredient," says Ward.

Holistic care
With clinical data affirming the efficacy of herbals for treating menopausal symptoms such as hot flushes, insomnia, weight gain, depression, anxiety, mood swings, night sweats, heart palpitations, vaginal dryness, concentration and memory problems, and loss of libido, the medical fraternity can only become more supportive of natural alternatives for menopausal relief.

On The World Wide Web:
The Organic Trading Company:
Sam Jacobs, MD, associate professor of reproductive endocrinology and infertility in the Department of Obstetrics and Gynecology at Robert Wood Johnson Medical School, New Jersey, and a practising doctor, agrees. "The question is, 'Is HRT the best way to treat menopause?' Increasingly it's being shown not to be," he says. "What is becoming common in the US is that HRT is being recommended only for short-term symptomatic relief except for women who have had a hysterectomy, who may be able to take oestrogen for longer periods of time. But I believe a combination of diet, exercise and herbals is the best means of treatment, and that is why we at this centre are no longer recommending HRT to our patients."

It is also why herbal products manufacturers are in an enviable position—if they play their cards right. Says Thallon: "It may seem crazy to recommend against taking a supplement for life, but only ongoing holistic health management is going to reap the rewards for our business in the long term."

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