One of the most pressing health questions facing women at midlife in the Western world is whether to begin daily hormone replacement therapy to offset menopausal symptoms and prevent related disease. While the decision is unique to each individual, those interested in alternatives can find answers in the food on their plates.
Researchers are investigating claims that a diet rich in phytoestrogens (isoflavones, lignans and coumestans), the hormonelike compounds found in certain foods including soy, can prevent problems associated with menopause. Others believe a phytoestrogen-rich diet can even protect against serious illnesses such as cardiovascular disease, dementia and diabetes.
An estimated 40 million American women have reached menopause, and 4,900 join their ranks daily, according to the North American Menopause Society in Mayfield Heights, Ohio. With average life expectancy increasing (about two-thirds of the population survive to 85 or older), most women will live one-third to one-half of their lives postmenopause. The Bethesda, Md.-based National Institutes of Health estimates that 40 million women will go through menopause in the next two decades, forcing them to weigh the risks and benefits of HRT and alternatives, including phytoestrogens.
Women clearly want alternatives to HRT. According to the American Association of Clinical Endocrinologists, about 25 percent of those who agree to HRT never fill their first prescription, another 25 percent stop within eight months and only 30 percent of all menopausal women use it regularly. Women doubt its need, benefits, safety and usefulness. They worry about bleeding, cancer risks and side effects, including headaches, breast tenderness, bloating, nausea and mood changes. Further, only one-third of gynecologists prescribe estrogen to most of their menopausal patients.
Responding to women's increased use of natural alternatives, the American College of Obstetricians and Gynecologists recently issued a statement doubting the benefits of many botanical treatments, such as wild or Mexican yam. But more importantly for natural foods retailers, ACOG noted that "soy and isoflavones may be helpful in the short term (two years or less) for menopausal symptoms such as hot flashes and night sweats," but cautioned, "While safe in dietary amounts, the consumption of extraordinary amounts of soy and isoflavone supplements may interact with estrogen and may be harmful to women with a history of estrogen-dependent cancer, and possibly to other women as well."
Women in their mid-30s begin experiencing normal biological changes that usually end between the ages of 45 and 55. These changes lead to menopause, which is marked by the absence of menstruation for at least one year. Women's bodies continue to produce hormones, but in much smaller quantities than before.
Surgical menopause occurs when the uterus and/or ovaries are removed, immediately stopping menstruation and the related organs' hormone production.
Changes in a woman's physiology include hot flashes (experienced by up to 60 percent of menopausal women, and often beginning years earlier), sleep disturbances, mood swings, vaginal dryness and urinary tract changes, including stress incontinence and susceptibility to infection.
Menopause-related estrogen reduction promotes mineral depletion, which contributes to osteoporosis, hip fractures, spinal curvatures and pain. It may affect blood fats, including cholesterol, and the fibrinogen that controls clotting, thus increasing risk of heart disease and stroke.
Although numerous studies indicate HRT can counter or reverse these effects, some researchers believe presumed benefits actually reflect HRT use by healthier or health-conscious women. Some studies show HRT has little or poor effects on heart disease.
Another major concern is that estrogen replacement alone increases risk of endometrial (uterine lining) cancer, which is minimized by taking both progestin and reduced estrogen doses. However, there is considerable concern that HRT may increase risk of ovarian and breast cancers. The National Institutes of Health has sponsored the Women's Health Initiative, a national, 15-year clinical trial evaluating HRT's effect on heart disease, osteoporosis and cancers.
Food For Health
"Eaten consistently, estrogen-rich foods can be very useful in preventing menopausal symptoms and long term may prevent heart disease and osteoporosis," says Marilyn Glenville, Ph.D., a nutritional therapist and psychologist based at London's Hale Clinic.
Her recent book, Natural Alternatives to HRT Cookbook (Celestial Arts, 2000), is a feast of international cuisine with mouthwatering photos of dishes to suit every meal and appetite. "All recipes are healthy for the whole family," says Glenville, with the exception, of women with underactive thyroids, who she says should avoid soy. "These recommendations could decrease prostate cancer mortality and may slow early-onset puberty in girls."
Glenville recommends at least 45 mg of isoflavones daily, a little more than a 2-ounce serving of tofu or a pint of soy milk. She advises dietary variety: soy in its most natural form (beans, milk, tofu, flour, sauce and miso, but not pressed, grits or bars), beans of all kinds, garlic, celery, seeds, grains, fruits and vegetables.
Diet can help alleviate menopausal dryness of skin, membranes and joints; she advises essential fatty acids from walnut, sunflower and sesame oils, mackerel, tuna and salmon. "No-fat and low-fat diets cause many symptoms associated with menopause," she says. "Nutrients and quality are more important than calories. If they get it right, they'll lose menopausal weight gains." She suggests substituting linseed oil or sprinkling a tablespoon of cracked linseeds (flax) on food for its omega-3 and -6 oils and high concentrations of lignans (a phytoestrogen absent in isoflavone-rich soy).
While generally agreeing, American Dietetic Association spokeswoman Barbara Gollman, R.D., M.S., author of The Phytopia Cook (www.phytopia.com, 1998), notes that each 25 grams of protein or a tablespoon of oil contain 100 calories. "That sounds small, but can add several pounds per year, and too much protein is hard on kidneys," she cautions.
Practitioners and researchers have expressed concern that phytoestrogens may increase breast cancer risk.
"Despite some evidence that soy might predispose cells to turn cancerous, genistein, soy's main phytoestrogen, is on the National Cancer Institute's list of chemo-prevention candidates," says Rochester, Minn.-based Mayo Clinic researcher Charles Loprinzi, M.D., professor and chair of medical oncology. "We honestly don't know, although studies found no hot-flash benefits. We don't recommend soy or phytoestrogen in supplements or pills, but don't see any problems with eating it."
Most medical experts prefer foods to supplements because of potential benefits of the whole-food complex, uncertainty about what causes toxic effects and because it's harder to overdose on tofu than pills. But while eating some is good, several daily servings of phytoestrogen-packed foods may be detrimental.
"Absolutely tell physicians about consumption. We don't recommend ERT and HRT with too much phytoestrogen, because that can stimulate irregular vaginal bleeding, bloating and breast tenderness," says reproductive endocrinologist Kenneth Gelman, M.D., F.A.C.E., of Hollywood, Fla., and a member of AACE's reproductive medicine committee. If women are not at risk for breast or uterine cancer, he advises them to add a daily cup of soybeans, a twice-daily tablespoon of flaxseed oil and other phytoestrogen-rich foods.
Ongoing Research Shifts Medical Resistance
"Differences between HRT and phytoestrogens are not as great as once believed," says Wake Forest University School of Medicine researcher Mary Anthony, Ph.D., of Winston-Salem, N.C. "Although it may be less effective than HRT in preventing hot flashes and osteoporosis, not everyone has those problems. It may be as good at decreasing coronary disease risk, and may decrease estrogens associated with increased cancer risk." Anthony adds, "I wouldn't have told mom to go off HRT before, but we're more willing to do so now."
Wendy Lee Bonifazi, R.N., C.L.S., A.P.R., of Fort Collins, Colo., has earned 15 national journalism awards, including a National Press Club Honor, for her coverage of health and health care.
Natural Foods Merchandiser volume XXII/number 10/p. 56-57