Heart disease
After menopause, women become less able to clear cholesterol from their blood stream. During the pre-menopausal stage of life, high circulating estrogen levels increase the production of LDL-cholesterol receptors that enable cells to extract LDL-cholesterol-low-density lipoprotein-cholesterol that is known to increase risk of heart attack and stroke-from the blood stream and use it for various purposes. In menopause, there is a 90% drop off in circulating estrogen levels that appears to reduce the ability of cells to produce LDL-cholesterol receptors. As a result, there is a strong tendency for cholesterol to accumulate in the blood stream, stick to the walls of the arteries and cause narrowing of coronary blood vessels; leading to heart attack.⁴

Since a high saturated fat diet is the main culprit in raising LDL-cholesterol levels, postmenopausal women should adjust their diet to lower their saturated fat intake. Results from the Framingham Heart Study suggest individuals should ingest no more than 10-28 grams per day of saturated fat, based upon the presence of other risk factors such as family history, diabetes, smoking and high blood pressure, in order to keep their blood cholesterol levels below 200 mg per deciliter, a metric unit of volume equal to one-tenth liter. This implies that the use of animal protein foods consisting of chicken, turkey, Cornish hen and fish, and that all milk and yogurt products consumed should be non-fat or 1% varieties. No cheese above 3% milk fat should be consumed and butter, ice cream, whipping cream, regular chocolate products, items containing coconut or palm oil, and deep-fried products of all types, be avoided.5 Increasing soluble dietary fiber intake also can reduce blood cholesterol levels by dragging cholesterol out of the body, as well as bile acids that can serve as precursors to the synthesis of cholesterol in the liver. Soluble fiber is found in most fruits and vegetables, oat bran, psyllium husk fiber, ground flaxseeds, and in beans and peas.6 Remaining physically fit and at or near one's ideal weight also are important lifestyle factors in preventing cardiovascular disease in the postmenopausal years.^7,8

It also should be noted that soy products and soy extract supplements are known to reduce blood cholesterol levels by 9-12% in patients with high cholesterol levels.9 The same is true for a supplement known as gamma-oryzanol that is derived from rice bran oil.10,11 Both soy extract and gamma-oryzanol have been shown to reduce hot flashes and other menopausal symptoms and are excellent alternative therapies to the use of HRT in postmenopausal women. Gamma-oryzanol is an approved drug for the management of menopausal symptoms in Japan, where the research on this natural agent has been performed.12 It is very convenient that soy extract and gamma-oryzanol can help reduce menopausal symptoms, reduce cholesterol levels, and in the case of soy isoflavones, help to maintain bone mineral density.^13-15

Osteoporosis
The decline in estrogen levels that accompanies the menopausal years also permits calcium to leak out of bone into the blood stream where it eventually will become filtered by the kidney and exit the body in the urine. This, of course, leads to osteoporosis that increases risk of fractures. Osteoporosis is reaching epidemic proportions in our society largely due to insufficient calcium intake and accumulation in bone, especially between ages 11 and 24, and loss of calcium from bone during the menopausal years.16,17 It should be noted that Canadian statistics indicate that complications from osteoporotic hip fractures, such as the development of pneumonia, result in more deaths each year than the combined mortality rate from breast and ovarian cancers.18 The lifestyle recipe to prevent osteoporosis during the menopausal years is as follows:

1. Ingest 1,500 mg per day of calcium, if not taking HRT. This can be through a combination of calcium from diet and supplements. Calcium carbonate and calcium citrate are absorbed equally as well if taken with meals. Calcium carbonate represents a more cost-effective intervention for patients because it is less expensive. However, if the patient has had a previous history of kidney stones, calcium citrate may be preferred due to its greater solubility.¹⁶
2. Take supplements with 600-1,000 IU of vitamin D. For general health reasons women should consider taking a high-potency multiple vitamin and mineral that normally includes 400 IU of vitamin D. Studies show that postmenopausal women ingesting an additional 200 to 400 IU of vitamin D per day may reduce their risk of hip fractures by approximately 50%. A high potency multiple vitamin and mineral, including extra antioxidant protection and a B-50 complex, will contain other nutrients important to bone health such as calcium zinc, magnesium and copper, and provide more optimal levels of nutrients that help maintain and improve skin complexion, texture and provide other health benefits. (Editor's note: For more information on vitamin supplements, see "Successful Supplementation" by James Meschino, DC, in the June 2002 issue of Skin Inc. magazine.)
   
   With age, the kidneys reduce their ability to convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D that is twice as powerful a form of vitamin D than is 25-hydroxyvitamin D. However, studies indicate that by increasing blood levels of 25-hydroxyvitamin D through the intake of 600-1,000 vitamin D supplements per day, a postmenopausal women can compensate for the drop off in 1,25-hydroxyvitamin D synthesis, and thereby significantly reduce her risk of osteoporotic fractures.^19,20
3. Perform weight-bearing and/or resisted exercises 4-7 times per week. Weight bearing exercise such as walking or jogging, and weight training exercises, place increased stress on the spine and femurs that respond by holding their calcium in bone to help withstand the physical stresses acting on the bone structures. Some studies reveal that postmenopausal women can increase their bone density, without using HRT, by simply ingesting more calcium and performing a series of five weight training exercises, twice per week.²¹
4. Supplement with a product that contains black cohosh and soy isoflavones. As will be discussed later, the standardized grade of black cohosh and soy extract have been shown to reduce menopausal symptoms and evidence exists to show that they also can help to preserve bone mineral density via their estrogenic effects on bone receptors.^22,23

Breast cancer
It is well documented that women who are overweight during the postmenopausal years have approximately a three times greater risk of developing breast cancer.24-26 This is likely due to the fact that as fat mass increases there is a greater conversion of androstenedione to estrone within the stromal tissue of adipose tissue. Estrone is one of three types of estrogens made by the female body. Higher circulating estrone levels are associated with increased risk of breast cancer, as estrone is known to increase the cell division rate of breast cells. In turn, this leads to a greater chance of genetic mutations occurring that may be cancerous. This is exactly the same mechanism through which HRT has been shown to increase breast cancer risk. Thus, postmenopausal women would be well advised to attain and maintain an ideal body weight and a body mass index below 25.²⁴

As well, avoiding the use of HRT is emerging as a significant strategy upon which to help prevent breast cancer in postmenopausal women. The best alternative approaches include a combination of black cohosh, soy isoflavones and gamma oryzanol, as each of these natural interventions has been shown to reduce menopausal complaints and their use in human populations over many years suggest that they do not increase risk of breast cancer. In fact, in Japan, where soy isoflavone intake is customarily between 50-75 mg per day, breast cancer incidence is 75% lower than in the United States.14 Recent experimental studies involving black cohosh have shown that it exerts an anti-proliferative effect on breast cells and human breast cancer cell lines that is consistent with a reduced risk of breast cancer, according to available scientific evidence.27 Therefore, in women without a previous history of breast cancer, the use of black cohosh, soy isoflavones and gamma-oryzanol can be considered safe and effective alternatives to the use of HRT.^12,14,28

In patients with a previous history of breast cancer, the jury is still out as to whether or not these natural agents should be used. However, in a recent survey, women with a previous history of breast cancer were 7.4 times more likely to use alternative treatments for menopause symptoms than were women with no previous history of breast cancer. Soy products, herbal remedies including black cohosh and gamma-oryzanol, and vitamin E were the most common alternatives to HRT.²⁹

In addition to these devastating statistics, the decline in estrogen and progesterone production that accompanies menopause triggers a broad range of physical, psychological and aging-related signs and symptoms that can significantly interfere with a woman's feeling of well-being.4 Although underutilized by physicians in this part of the world, substantial evidence from European and Asian studies provides convincing support that the herbal agent known as black cohosh, along with soy extract and gamma-oryzanol, can significantly reduce menopausal symptoms, help support bone density, reduce high cholesterol, prevent atrophy and dryness of vaginal tissues, and improve a woman's feeling of well being and vitality. Unlike HRT, these natural substances are not associated with an increased risk of breast cancer, ovarian cancer or heart disease. As such, in most cases they can be employed as a significant part of a natural lifestyle program, aimed at enhancing the health and quality of life of postmenopausal women. The scientific evidence to support the concurrent use of these natural agents in the management of menopausal symptoms is as follows.

Dietary supplements
Black cohosh. The most widely used and thoroughly studied natural supplement for the management of menopausal symptoms is the herbal agent known as black cohosh, cimifuga racemosa, that must be standardized to 2.5% triterpene content. Four major human studies have demonstrated the ability of black cohosh to help manage menopausal signs and symptoms. In the first open study involving 131 physicians who together recruited 629 female patients, 80% of patients experienced improvement of physical and psychological symptoms associated with menopause, within 6-8 weeks of treatment with black cohosh extract. Significant improvement was noted in hot flashes, profuse sweating, headache, vertigo, heart palpitations, tinnitus, nervousness and irritability, sleep disturbances and depressive moods. Only 7% of patients reported mild transitory stomach complaints. ^6,22,30

A second controlled study compared the effects of black cohosh to 0.625 mg C.E.E. estrogen replacement therapy or 2 mg diazepam for twelve weeks. Black cohosh out-performed both C.E.E. and diazepam using the Kupperman Menopausal Index.

This index is one of the most utilized assessments in clinical studies of menopause. This quantitative assessment of menopausal symptoms is achieved by grading of severity:
         Severe = 3
         Moderate = 2
         Mild = 1
         Not present = 0

After grading each symptom, the total score is achieved by adding all of the symptom scores together. Symptoms assessed include depressive moods, feelings of vertigo, headache, heart palpitations, hot flashes, joint pain, loss of concentration, nervousness and irritability, profuse sweating and sleep disturbances.³¹

The third double-blind study compared the effects of black cohosh to 0.625 mg C.E.E. estrogen replacement therapy or a placebo for twelve weeks. In this study, black cohosh produced better results in controlling menopausal symptoms according to the Kupperman Menopausal Index and produced greater improvement in the vaginal lining than estrogen or the placebo. In the black cohosh group, the number of hot flashes per day dropped from an average of 5 to less than 1. In the estrogen group, this number dropped from 5 to 3.5 hot flashes per day on average.²⁸

In a fourth double-blind study, black cohosh was compared to a placebo in a study following 110 women. The black cohosh group demonstrated significant improvement in menopausal symptoms and blood hormone measurements. In addition to relieving hot flashes, it once again produced impressive age-reversal results on the vaginal lining as confirmed by vaginal smear analysis.

Since 1956, more than 1.5 million menopausal women in Germany have used black cohosh extract with noted success and without significant side effects. Physiologically, black cohosh extract appears to mimic the effects of estriol, a form of estrogen made by the body. Estriol is a weaker form of estrogen than estrone or estradiol, and is not associated with an increased risk of reproductive cancers. Like other forms of estrogen, estriol helps to maintain bone density and aids cholesterol removal from the blood stream. Black cohosh extract also has been shown to inhibit the over-secretion of leutinizing hormone (LH), providing proof of its estrogen-like properties.^28,32

Remarkably, the triterpene saponins, unique to black cohosh, also have been shown to serve as a precursor for the synthesis of progesterone in the body.33 As there is a 66% decline in progesterone levels at menopause, black cohosh supplementation may help to preserve progesterone balance, which is important to preserving bone health, maintaining libido and psychological well-being.4 The dosage that is proven to be beneficial in the treatment of menopausal symptoms is 40 or 80 mg, taken twice per day, the standardized grade containing 2.5% triterpene glycoside content.²⁸

Soy isoflavones. Soy extract, yielding a minimum of 50 mg of soy isoflavones, has been shown to reduce hot flashes and other menopausal symptoms in various clinical trials.14,34,36 Some studies show up to a 40% reduction in hot flashes with the use of soy isoflavone products.14 Soy isoflavones also possess phytoestrogen activity-plant-based estrogen. Like the triterpene saponins found in black cohosh, soy isoflavones are a type of Selective Estrogen Receptor Modulator, or SERM, that preferentially stimulates beta estrogen receptors on reproductive and other tissues. In turn, this provides weak estrogenic support to reproductive tissue and bones, without over-stimulating breast and endometrial cells, as may HRT. HRT stimulates the alpha-receptors on breast tissue that increases their rate of cell division and the likelihood of developing cancerous mutations. Stimulation of the beta-receptors by soy isoflavones and black cohosh triterpenes has been shown to slow down the rate of cell division of breast and endometrial cells in the presence of the body's own estrogen; an effect associated with a decreased risk of reproductive cancers.³⁵

Investigation into the biological actions of soy isoflavones suggests that they provide a number of additional protective effects. These include antioxidant protection against free radicals, the slowing of cellular proliferation, reducing the synthesis of estrone hormone by inhibiting the estrogen synthase-aromatase, enzyme in fat tissue, increasing the detoxification of potentially harmful chemicals and hormones, and by competing with the body's more powerful estrogen for attachment and stimulation of estrogen receptors on the breast and other tissues expressing estrogen receptors.

Soy isoflavones also have been shown to support bone mineral density in postmenopausal women and help keep cholesterol levels within a safer range.¹⁴

Gamma-oryzanol. Supplementation with 150 mg of gamma-oryzanol twice a day has been shown to reduce the secretion of leutinizing hormone (LH) by the pituitary gland and promote endorphin release by the hypothalamus. Hot flashes and other menopausal symptoms such as profuse sweating and mood changes result indirectly from the over-secretion of LH, which is attempting to initiate the start of another ovulatory cycle. The lack of response by the immature egg cells in the ovaries at the outset of menopause results in over-secretion of follicle stimulating hormone (FSH) and LH by the pituitary, contributing to the onset of hot flashes and related symptoms. Clinical trials reveal that 67-85% of women treated with gamma-oryzanol have experienced a significant reduction in menopausal symptoms.12 As previously noted, gamma-oryzanol, supplemented at the above noted dosage, also is known to reduce high cholesterol by up to 12%.^10,11,15

Daily dosage
It is now possible to find combination supplement products that provide all three nutrients-black cohosh, soy isoflavones and gamma-oryzanol-in a single product formulation. As these three nutrients work synergistically, recommending a combination formula of this nature gives the patient the best possible opportunity to control her symptoms and improve the state of well-being, without having to rely on HRT. Not all cases respond to the use of natural supplementation; however, studies suggest that the majority of patients report extremely positive results. To summarize the doses and standardized grades of each nutrient the following guide should prove helpful:

1. Black cohosh extract-consider 80 mg, twice per day, standardized to 2.5% triterpene content.
2. Soy extract-250 mg, yielding 25 mg of soy isoflavones, twice per day.
3. Gamma-oryzanol-150 mg, twice per day.

Low-risk menopausal women can use this combination of nutrients safely as a viable alternative to HRT. Monitoring of bone density and blood lipids should be performed periodically, and by women who have contraindications to estrogen replacement therapy such as fibrocystic breast disease, endometriosis, uterine fibroids, liver or gallbladder disease, pancreatitis or unexplained uterine bleeding.28,14,12 As well, women taking HRT may want to use a combination formula such as this for general nutrient support, in order to acquire important isoflavones and related phytoestrogens.

Estheticians and other skin care professionals should consider making available to their clients a premium product that contains the exact doses and standardized grades of these important nutrients for their menopausal and postmenopausal clients. This provides clients with an additional service and increases profitability of the clinic, as a high percentage of clients are in a stage of life where they would benefit from this type of supplementation. The sale of these products can represent a substantial income to the clinic or esthetician.

Due to the bothersome side effects and fear of breast cancer, less than 20% of North American postmenopausal women were using estrogen replacement therapy before this most recent report in July 2002.4 It is anticipated that many users will choose to quit HRT or be advised to do so by their physician, based upon the latest findings of the American Women's Health Initiative trial.¹

Through proper guidance directed toward nutrition, exercise and supplementation, practitioners can greatly influence a woman's quality of life and health risk profile during the menopausal years. Many of the proven principles of natural menopausal management have been largely overlooked by traditional medicine and thus, it is incumbent upon more holistic practitioners to enlighten their female patients regarding these matters, particularly in light of the recent negative outcomes associated with HRT.

The combination of black cohosh, soy isoflavones and gamma-oryzanol, as outlined above, can be used for the following conditions and concerns:

1. As a natural alternative to estrogen replacement or HRT for postmenopausal women who demonstrate normal bone density and cholesterol levels.
2. As an important source of phytoestrones and phytonutrients for women of all ages to help reduce the risk of female-related diseases throughout their lifetime. The dosage can be cut in half for pre-menopausal women and teenagers.
3. As a supplement for women with PMS, fibroids, endometriosis and fibrocystic breast disease.
4. As an alternative treatment for postmenopausal women with contraindications to estrogen replacement therapy.
5. As a dietary adjunct to estrogen replacement therapy or the birth control pill in order to help tone down the over-stimulation effect of these drugs on breast and uterine tissues.

Wellness management
By age 50 all women should have a bone mineral density test to determine their bone status. If osteoporosis is not found to be present, then most women simply can follow the lifestyle program outlined in this article. If there has already been significant bone loss, then the attending physician may wish to consider the use of biphosphonate drugs that have been shown to slow the loss of calcium from bone, or the use of raloxifene or other SERMs such as tamoxifen. The point is that all postmenopausal women should have their bone density tracked periodically to monitor the effectiveness of the program to which they are subscribing, be that the use of lifestyle and natural substances or the use of conventional drugs.

Blood work to determine fasting cholesterol and triglyceride levels and other biomarkers of cardiovascular disease also should be included as part of regular screening. What is now clear, however, is that the use of HRT as a means to manage menopausal symptoms and prevent heart disease in postmenopausal women has fallen out of favor, even in the most traditional medical circles. Patients are seeking the help of knowledgeable professionals who are able to guide them to evidence-based natural interventions that are proven to be safe and effective.

With a baby boomer turning 50 every seven seconds, there is a tremendous need for allied health practitioners to disseminate credible wellness information that can enhance the quality of people's lives and help individuals avoid illness and other maladies where science has shown that such conditions can be prevented, postponed or safely and effectively managed. This information should enable estheticians and other skin care professionals interested in wellness management to provide scientifically sound advice to their female clients regarding the natural management of menopausal symptoms and the prevention of serious and often life-threatening health conditions that are common in the postmenopausal stage of life.

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