Recommendations from others
The American College of Obstetrics and Gynecology clinical management guideline, “The use of botanicals for management of menopausal symptoms,” gives a level C recommendation (consensus and expert opinion) that “Soy and isoflavone may be helpful in short-term (2 years) treatment of vasomotor symptoms” and “black cohosh may be helpful in the short-term (6 months) treatment of women with vasomotor symptoms.” They note that “given the possibility that these compounds may interact with estrogen, these agents should not be considered free of potential harm in women with estrogen-dependent cancers.”8
The North American Menopause Society notes that behavior changes, such as moderate exercise and avoidance of hot-flush triggers, may prevent some hot flushes, although there is only anecdotal evidence for this. The efficacy of paced respiration—deep, slow abdominal breathing—to lessen hot flushes has been shown in a small trial. The society states that other alternative therapies have not been shown to be efficacious, except for moderate quantities of soy products.9 The Medical Letter says the evidence that phytoestrogens are helpful for menopausal women comes mostly from epidemiological studies. The long-term adverse effects of phytoestrogen consumption are not known.10
Clinical commentary
Laura B. Hansen, PharmD, BCPS
University of Colorado Health Sciences Center, Denver
Behavioral modifications may be the first approach to reduce the incidence of vasomotor symptoms in menopausal women. Recommendations include wearing several layers of breathable clothing; keeping a glass of cold water, ice pack, or small fan by the bedside and nearby at work; performing deep breathing relaxation techniques; and exercising routinely.
Effective nonhormonal treatments include phytoestrogens (2 years), black cohosh (6 months), clonidine, selective serotonin reuptake inhibitors, and venlafaxine. Overall, there are few well-designed clinical trials regarding the safety and effectiveness of botanical agents used for vasomotor symptoms. Since the Food and Drug Administration does not regulate the marketing and standardization of these products, patients should be advised to purchase products from reputable companies with internal standardization processes.
Additionally, patients should talk with their health care provider prior to initiating any alternative medication to avoid drug-disease and drug-drug interactions.