Menopause

What takes place at menopause?

Most women reach menopause between the ages of 49 and 52, although ‘early menopause,’ also known medically as premature ovarian failure, affects up to 2% of women before the age of 40 years. Surgical menopause is a situation when menopause occurs prematurely because of surgical removal of the ovaries (oophorectomy). This may be done together with a hysterectomy (removal of the womb). Interestingly, women who just have a hysterectomy typically enter menopause around 3 years earlier than those who have not had a hysterectomy. Smokers and underweight women also typically experience menopause up to 3 years earlier than usual.

Menopause naturally takes place when a woman ‘runs out’ of eggs (oocytes) in her ovaries, or those that remain are no longer active. It’s important to note that a woman’s oocytes develop while she is still in her mother’s womb (in utero), and she is born with a limited number of them which are carried for life within her two ovaries. Every month, one ripens and is released – a process known as ovulation, which is essential part of female fertility. It is these oocytes which, as they ripen, secrete most of a woman’s oestrogen. This explains why oestrogen levels drop when oocytes are depleted. Progesterone levels also decline at menopause since progesterone is made after ovulation by the protective layer around the oocyte known as the corpus luteum. Think of the corpus luteum as the ‘egg shell,’ and essentially, when there are no more eggs, there cannot be any more shells.

Stages of menopause

Although officially ‘menopause’ means the last period has already taken place and was at least 12 months ago, most women begin to experience a variety of ‘menopausal’ symptoms long before they have their actual last period. This is why we hear phrases like, ‘I’m going through menopause’ or ‘I’m menopausal’ or ‘I’m having change of life’. These are understandable since this is a process which develops over time.

Perimenopause

Between the ages of 40-50, most women begin to experience ‘menopausal’ like symptoms, the first being most typically changes in their menstrual cycles, but may also experience a wide variety of possible physical and emotional symptoms which typically become more intense with time. This is called peri-menopause, meaning ‘around-menopause’, and essentially refers to the transitional phase before actual menopause is reached. This can last 4-7 years but ends 12 months after the last menstrual period. During this phase, women continue to menstruate, although often irregularly, and so fertility typically starts to diminish, however, a surprise pregnancy is certainly still possible and common until actual menopause is reached.

Menopause and post-menopause

The point at which menopause is reached can only be determined after the fact since you only know you are here once there hasn’t been a period for 12 consecutive months. The date of the last menstrual period can then be determined, which marks the onset of actual menopause. Although there is variation between population groups and countries, the average age of actual menopause is around 50 years of age.

What are the symptoms?

Because menopause is far more complex than simply the presence of hot flushes, we refer to the experience of menopause a ‘menopausal syndrome.’ Under this ‘umbrella’ are a wide variety of possible symptoms, and interestingly, each woman experiences menopause in her own unique way with varying degrees and combinations of symptoms. One of the most well accepted ways of measuring menopause syndrome is known as the Menopause Rating Scale (MRS) which recognises the following common menopause symptoms:

In addition to these other common symptoms include weight gain, dryness, thinning and loss of elasticity of your hair and nails, and of course the effects on the menstrual cycle, i.e. irregular cycles, (longer or shorter), heavier or lighter periods, or skipping months if you’re peri-menopausal, and if you have reached menopause, your period stops completely.

Treatment of menopause

Hormone replacement therapy (HRT)

The mainstream medical approach to the treatment of menopause is hormone replacement therapy (HRT) – this is usually the supplementation of oestrogen alone in menopausal women without a uterus or a combination of oestrogen and progestin in women who still have their uterus. HRT is commonly prescribed as a tablet, cream/gel or patches in various forms and strengths. HRT, despite being proven to reduce menopause symptoms and offer protective effects (e.g. against osteoporosis for menopausal women), has been shrouded in controversy since 2002 when some research linked the use of certain forms of HRT with the potential development of breast cancer, strokes, clots and heart disease. Although new safety data is now available on certain improved versions of HRT such as patches or gels which are absorbed through the skin, and some of the original concerns have since been refuted, many menopausal women and doctors are still reluctant to use/prescribe oestrogen-based HRT especially if there is a history of breast or other cancer influenced by oestrogen, clots (deep vein thrombosis or lung clots), heart attacks or strokes. Despite this, HRT therapy remains the conventional drug therapy of choice for treatment of menopausal syndrome and for the prevention of some health consequences of menopause.

Bio-identical hormone replacement therapy (BHRT)

The official verdict on BHRT, also known as Compounded Bioidentical Hormone Therapy (CRT) is still out with medical professionals sitting in two camps for and against this alternative to conventional HRT. Hormones used in BHRT are typically identical to the natural hormones made by your body, derived from plant origin but still obviously act as hormone supplements. The other major difference between conventional HRT and BHRT is the way in which it is applied; the use of BHRT is typically more individualised with the products being specially made on a case-by-case basis based on extensive hormonal and salivary testing on each patient first as opposed to prescribing standardised products and doses. Supporters of BHRT claim that this approach maximises benefits and reduces risks, however, there are conflicting opinions on this and evidence supporting this claim is not fully established, although some recent research into one product has had good outcomes. Officially though, it is important to note though that even BHRT is contraindicated in patients with a history of hormone dependent cancers, and some still argue that they theoretically carry all the same risks as standard HRT.

Alternatives to HRT?

Despite new safety data and forms of HRT, there is still a demand for non-hormonal therapies to alleviate the symptoms of menopause despite driven by the well-publicised awareness of the risks of HRT or in situations where the use of HRT is simply contraindicated.

Phytoestrogens are plant-based estrogen-like substances which have a similar chemical structure to estrogen, and because of this, they can attach to and ‘switch on’ oestrogen receptors, and therefore have an estrogen-like effect in the body. Many foods contain phytoestrogens, including foods of the pea family, i.e., soya and other legumes, as well as seeds such as linseeds. These are in relatively low concentrations in their natural food format though, so they can’t really have much effect as foods unless they are concentrated. Soy isoflavones are one of the most well-researched and established types of phytoestrogens for menopausal symptoms and concentrated extracts of these have proven effective in the treatment of menopause syndrome, however, it is important to note that even the use of phytoestrogen supplements is still considered contraindicated where there is a history of hormone dependent cancers as they are able to mimic estrogen and cause estrogen-like effects which is not desirable in these situations.

Herbal medicine (Phytotherapy) offers a few researched, plant-based medicines which may offer relief for various aspects of menopausal syndrome. Some of the most established include Black cohosh, Red clover, Sage leaf, Tribulus leaf and Vitex agnus castus. For best results, it’s always ideal to consult with a registered phytotherapist on what the best option is on an individual basis, especially if you have any of the hormonal risks mentioned, as some of these may have oestrogen-like effects. Contact the South African Association of Registered Phytotherapists (SAARP) to find a practitioner near you.

Various published clinical trials support the use of Homoeopathy as a non-hormonal intervention for the treatment of menopause symptoms – since homoeopathic remedies do not interact with estrogen receptors, the mimicking of estrogen is avoided, making them a safe alternative treatment for menopause in patients who are contraindicated for HRT or products which induce estrogen-like effects. There are some good homeopathic formulas available over the counter to support menopausal syndrome, but an individually prescribed medicine by a registered homeopath is ideal especially in more difficult cases. To find a registered homeopath in your area, contact the Homeopathic Association of South Africa.

A.Vogel Menoforce – Hot Flush and Night Sweat Remedy

A.Vogel Menoforce Hot Flush and Night Sweat Remedy is a herbal medicine made from fresh sage leaf for the supportive treatment of menopausal syndrome and associated hot flushes and night sweats, as well as for the supportive treatment of hyperhidrosis (excessive sweating) that does not contain oestrogen or have an oestrogen-like action.

Supported by two clinical trials, in menopausal women A. Vogel Menoforce it is used to:

• Reduce the frequency and intensity of hot flushes and night sweats
• Improve sleep quality
• Improve mental focus (cognitive function) and anxiety
• Improve fatigue
• Improve somato-vegative (flushes, sweats, palpitations) symptoms

Mode of action:

The latest laboratory research into how it works shows that A. Vogel Menoforce may control flushes and sweats by interacting with receptors in the body’s thermostat area of the brain and directly with receptors on sweat glands and blood vessel walls. It also interacts with receptors which positively affect mood and anxiety, which supports what was found in the latest clinical trial where it produced healthy, relaxed brain waves in menopausal women under stressful conditions. Sage tincture used to make A. Vogel Menoforce was also shown not to have any oestrogen-like activity in laboratory research.

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  Complete the Menopause Rating Scale (MRS)

References and additional reading:

1. Bommer S, Klein P, Suter A. 2011. First time proof of sage’s tolerability and efficacy in menopausal women with hot flushes. Adv Ther. 28(6): 490-500. Available from: https://pubmed.ncbi.nlm.nih.gov/21630133/
2. Bommer S, Dipah G.N, Suter, A, Dimpfel, W. 2019. Salvia extract for the treatment of menopausal symptoms: a randomized, controlled, blind clinical trial. Planta Med, 85, P-420. Available from: https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0039-3400129
3. Harper-Harrison G, Shanahan MM. Hormone Replacement Therapy. Updated 2020 Jun 3. In: StatPearls Internet. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493191/
4. Harvey B, Spangler M. 2020. Compounded Bioidentical Hormone Therapy. US Pharmacist. 45(9): 27-9. Available from: https://www.uspharmacist.com/article/compounded-bioidentical-hormone-therapy
5. The Menopause Rating Scale (MRS). Available from: http://www.menopause-rating-scale.info/publications.htm
6. Rahte S, Evans R, Eugster PJ, Marcourt L, Arcourt L, Wolfender JL, Kortenkamp A & Tasdemir D. 2013. Salvia officinalis for hot flushes: towards determination of mechanism of activity and active principles. Planta Med, 79, 753-60. Available from: https://pubmed.ncbi.nlm.nih.gov/23670626/
7. Tober C. and Schoop R. 2019. Modulation of neurological pathways by Salvia officinalis and its dependence on manufacturing process and plant parts used. BMC Complementary and Alternative Medicine 19(1): 128. Available from: https://bmccomplementmedtherapies.biomedcentral.com/articles/10.1186/s129060192549xs129060192549xs129060192549x