Medicinal plants: A great and welcome help in menopause care

By Dr. Alexandros Botsaris, OM 63175, B-Life Care

Nothing in the human organism, surpasses the complexity of responses that the female reproductive system possesses. When this miraculous system comes to the limits of it´s function potential, a wide range of symptoms, and even health problems, can arise, leading her to seek medical help. Medicine calls that perimenopause syndrome. This diagnosis encompasses an almost infinite variety of clinical situations, where hormone therapy alone, does not always resolve all complaints.

There are also situations where hormone supplementation is contraindicated, such as in cases of gynecological cancer with a positive hormone receptor. In the last 50 years, clinical and pharmacological investigation of phytochemicals, has disclosed activity in many medicinal plants traditionally used in the treatment of menopausal symptoms and complaints related to the female reproductive system, are showing potential to add more therapeutic tools to the approach to symptoms related to the female reproductive system. So, these new actors that can be added to current therapeutics can also significantly contribute to treating problems and improving quality of life during perimenopause period, at a time when healthy longevity is becoming a goal pursued by modern medicine.

We have called this fusion between conventional medicine and traditional therapeutic actions with scientific validation, "integrative medicine". This is undoubtedly a strong trend, especially when considering the movement to individualize treatments and seek well-being, and not just the correction of medical problems. The biggest challenge here is that we are integrating therapeutic tools that have very different essences and logics. Therefore, for there to be a truly and effective "integrative medicine," the healthcare team needs to be familiar with these differences and know how to take advantage of their complementarity.

One of the main paradigms that needed to be broken is that medical science methodology was developed to investigate and approve single new molecules, with strong pharmacological potency, and their safety and efficacy in treating diseases. When the concern is phytomedicines, all these parameters change to very old chemicals, that have been in close contact with human species for centuries, most of them with weak or medium pharmacological potency, whose benefit results from the complex interaction of dozens of biological active compounds and are more geared towards relieving symptoms and improving subjective well-being.

What Forty Years of Phytotherapy Teaches You

I trained as a physician in Brazil, then spent years studying integrative approaches across France, China, and Portugal. Phytotherapy has been part of my clinical practice for most of my career. Long enough to have watched the field move through several phases — from being dismissed as folklore, welcomed by society in general, and by a small group within academia that initiated scientific research in the 1990s, and finally its progressive incorporation into medicine, within an integrative perspective, by innovative medical trends in the last 15 years, as research proved it´s therapeutic value.

What that experience teaches you is that plants are not only a softer way to treat common health issues. They can be safe and effective in treating diseases, improving quality of life in severe conditions, like cancer, and enhance potency of conventional treatments with medications and other therapeutic interventions, in many diseases. The great majority have a gentle profile and an excellent degree of security. But there a some with potent pharmacologic action, capacity to modify other drugs action, or even increase risk of adverse reactions. Fortunately, these are exceptions, even though are enough common to deserve attention. All this knowledge must be known and considered when used in medical treatments, which requires a deep understanding of the recently produced science on these plant assets. The framing of "natural therefore harmless" is one misconception of therapeutic phytotherapy, in disease treatment, as efficacy or security can be compromised. Any patient in medical treatment, that desires to adopt an integrative approach, incorporating herbal medicine into his therapeutic tools, should inform this option to the doctor coordinating the treatment, and then seek help from a healthcare professional trained in prescribing phytomedicines.

Besides that, the physician using phytomedicines must learn more about how plants deal with their challenges, as we a using their powerful chemical adaptation capacity, developed on thousands and thousands of years of evolution, for our benefit. Plants never use single compounds, but complex mixtures of dozens of phytochemicals to achieve their goals. These chemical mixtures are called phytocomplexes, They work in the human body in a very different way from a single active ingredient, that predominates in modern pharmacology. Most phytomedicines need one week or more to achieve their full potency. For this kind of effect, the term “adaptogenic" was created to characterize the way phytocomplexes act.

Which herbal medicines have the strongest evidence and best results in menopause?

When evaluating phytomedicines it is necessary to use a different perspective from the one used in usual medical science. Because what we make can be compared to a circle, where, the end of the investigation, is very close to the point it begun. In modern pharmacology, a new molecule is created, with lab technology, then pass trough in vitro studies, in vivo studies, and if all goes very well, you can consider trying it in humans. So is a line with beginning, middle, and end.

Phytomedicines come from medicinal plants that were already used for very long periods of time to treat symptoms, or even diseases, before they were analyzed by the tools of modern science. So, when you begin investigating and find chemicals or pharmacological activity that support the popular use, you have already two endpoints of the rational therapeutical line filled. The probability of these two-information bias been unrelated is near zero. And as most popular medical plants uses have shown some coherence, it´s time for respecting more cultural process as a reliable source of information in the construction of scientifically accepted evidence. This already exists, although out of medical science bubble, through ethnosciences, where ethnopharmacology and ethnomedicine can be used as scientific evidence in the study of medicinal plants. So many phytomedicines meet these requirements, although they don't have a huge volume of clinical studies and meta-analyses.

Mexican Yam (Dioscorea Villosa). A medicinal plant originating from the Americas, used for various health problems by the Incas and Aztecs, and later by populations in Mexico, Central America, and South America. Among its many uses were treatments for perimenstrual syndrome and menopausal symptoms. Investigations carried out analysis on this plant in the 1950s and 60s which revealed it to be rich in steroidal saponins, the main one being diosgenin. This substance showed many similarities to female sex hormones and was therefore exploited for over 30 years to produce the steroidal base of estrogens and progestogens used in the manufacture of contraceptives. Studies conducted on laboratory animals have shown that diosgenin reduces menopausal symptoms caused by the removal of the ovaries. Also, there is evidence that diosgenin increases progesterone production, even during menopause. There is few clinical data published, but Mexican Yam has been shown to increase bone mass in menopause women. It also helps a lot of old ladies with osteoarthrosis symptoms as diosgenin has anti-inflammatory effect.

Chaste-tree nut (Vitex agnus castus). A plant native to the Mediterranean region and south-central Asia, its use has been recorded for over 3,000 years. Its use in treating perimenstrual syndrome and menopause also dates back to antiquity; however, the dissemination of its medicinal use was carried out by Jesuit priests, who took it with them wherever they went. This is because it also has the property of reducing male libido, and this effect was considered miraculous. Vitex possesses several active compounds, including alkaloids, flavonoids, and triterpenes that act at different levels, either peripherally or at the pituitary level, where they inhibit the production of hormones (FSH and prolactin). Its flavonoids exhibit a weak phytoestrogenic effect. It may be indicated for menopausal patients with very high FSH, those with mood swings, and as a potentiator of hot flash reduction when combined with Black Cohosh. Chaste-tree nut has a very strong clinical evidence for perimenstrual syndrome, but there are only few clinical studies for menopause.

Dong Quai (Angelica sinensis). A plant of Chinese origin with strong ethnopharmacological support for use in various problems associated with female hormonal disorders. Legend says that Emperor Shen Nong (a mythological figure considered the creator of Chinese herbal Medicine) once went in search of a plant to help women with their problems, and returned bringing Dong Quai as his special gift to the opposite sex. Since time immemorial, this plant has been widely used in formulas for problems such as amenorrhea, dysmenorrhea, menopausal symptoms, and infertility. Modern pharmacology has not revealed any molecule with affinity for hormone receptors, but clinical research shows benefits such as improved libido, treatment of amenorrhea, menopause, and infertility. Most of the literature is published in Chinese, and therefore little valued in the West. In laboratory animals, effects such as increased copulation, increased lactation, and increased fertility have been reported. Doctors who use herbal medicine advise Angelica sinensis as a potentiator in formulas aimed at reducing symptoms such as fatigue, depression, reduced libido, insomnia and hair loss during menopause.

Soy (Glycyne max). Soybeans are a legume domesticated by humans in ancient times, originating in Central Asia. No native forms of soybeans are known, only domesticated varieties. Widely cultivated as food, it is one of the largest sources of plant protein reported by science. Soybeans began to attract attention when researchers identified that Asian populations, who consumed them in large quantities in their diet, experienced several health benefits, such as a low incidence of gynecological cancer and a low incidence of menopausal syndrome. It was also observed that the bone mass of elderly individuals in these populations was greater than that of controls who did not consume the legume in their diet. Phytochemical investigation identified compounds from the isoflavone class with affinity and capacity to stimulate estrogen receptors, with genistein being the most abundant and potent. There is ample scientific literature, including clinical studies and meta-analyses, supporting this therapeutic effect.

Black cohosh (Cimicifuga racemosa / Actaea racemosa) This plant has a reported medicinal use, ancestrally, by North American Indians. Among different uses supported by ethnopharmacological data, there is a strong reference to its use in perimenstrual syndrome and menopausal symptoms. These indications led scientists to study the plant effect on this latter clinical condition. It was demonstrated that the plant extract influences the hypothalamic-pituitary function of sex hormones, and that this may be its main mechanism of action. The standardized plant extract has been tested in several clinical series with patients experiencing menopausal symptoms, showing results, primarily in controlling hot flashes. Currently, it is even available on the formal pharmaceutical market, positioned as a conventional medication.

Sage (Salvia officinalis) Salvia is a European plant widely used almost as a panacea in the treatment of numerous clinical conditions, having been mentioned in the work of Galen. Its name comes from the Italian "salvare," as it was considered the last medicine that could be tried when all other attempts had failed. Among its strongest indications at that time was its use in complex female symptoms, known as hysteria, a disease attributed to a hormone that, at the time, was believed to be produced by the uterus. This motivated a Swiss company to investigate its use in treating menopausal symptoms, and the results were excellent, especially in controlling hot flashes, nervousness, and insomnia. Several clinical series have been conducted, with meta-analyses, but the mechanism of action is still unclear.

Besides, the above-mentioned, there is many others, some less used, others with less scientific evidence, but that have been used by many integrative professionals, on special occasions. Between the most popular, I can quote the following: Hibiscus, Flaxseed Oil, Red Clover, Chamomile, St. John's Wort, Fenugreek, Licorice, Goji Berry, Mulberry and Maca.

How to obtain real balance and symptoms relief with phytomedicines?

In my opinion, more than 50% of female patients, can be treated with phytotherapy alone, controlling main complains, although the combination of low dose estrogen through transdermic route, can obtain better results, combined with medicinal plants (integrative approach). Together the two do better than in separated approaches. But to have good results with phytotherapy, the doctor needs to learn the main principles of how to associate the plants, because they do well only in formulas. 

One of the main lessons that worldwide ethnomedicine teaches us is that herbs must always be used in combination, to work properly. In all different cultures that have developed, along humankind history, in the five continents of earth, medical herb approaches, plants were always combined. This cannot be a coincidence. It is evidence. But as doctors are trained to see associations as increased risk (because this is the rule for synthetic drugs), they think is the same with logic with most phytomedicines. But I do not see them worried about what are you going to eat, although some foods also interfere in medication. 

And what we see in epidemiologic evaluations is that rich food in vegetables is good for health. So nutrition says you should eat at least 4 or 5 different vegetables a day. You do not get upset if you eat a mixed salad. But Cabbage has glucosinolates and isothiocyanates both helping liver detoxification; Lettuce produces flavonoids (quercetin), luteolin, procyanidin, with antioxidant properties; Onion produces Sulphurated essential oils, that helps digestion, and has an antiviral effect; Beetroot, is rich in betaine, a substance that improves body methylation process, besides anthocyanidins, and free citrulline a vasoactive amino acid that improves cerebral circulation.

There is no plant that cannot synthetize hundreds of active substances, because they would not survive if they had no chemical adaptation system.  That allows them to adapt to climate variations, to defend themselves against the same pathogens that attack mankind (virus, bacteria, fungus, parasites) and to promote their vital processes. There are cases of plant drug interactions, but they are rare. It is not enough risk, not to use them for our benefit. So, when a doctor associates 4 or 5 herbs to treat menopause, there is no significant risk in doing so.

In the other hand, plant association allows you to adjust the formula to the specific corollary of symptoms presented by the patient, in the face of ovarian failure. If the patient has a lot of hot flashes, you can choose Sage, Black Cohosh, and Vitex, as the main ingredients. If bone mass is the question, prescribe Dong Quai, Mexican Yam and Soy, and so on. Just to give an example. In general, every patient has her complexity, and the more you know about the patient, better your intervention will be,

How is the treatment of Menopause with phytotherapy and integrative medicine.

Although Menopause is not a disease, it is an adaptation crisis, to a new reality, were the body must learn to live, with much less female hormonal support than usual, as the woman's reproductive capacity has been exhausted, and the stimuli necessary for reproduction cease. In general, this is a fast change and can even be almost abrupt. So if is not a disease, because is expected in all individuals, most of them have intense feeling of capacity decrease in many areas, besides symptoms as disrupt sleep, fatigue, hot flashes, mental depression, acceleration of aging, etc.

So, like in other human development crises (childhood, adolescence, and pregnancy itself), to have medical support makes a lot of difference in preventing future conditions, and improving quality of life. Most women (more than 80%) get symptomatic with menopause, and even those who are asymptomatic should have medical supervision. So routine blood evaluation, including hormones, metabolism, blood cels, urine and stool, besides bone mass and internal organs image assessment, is mandatory from time to time, to prevent or to promote early treatment of degenerative problems that can come with menopause.

Many of the interventions required, may need to be kept for a long time, and others can be suppressed if the woman is well and without symptoms. But the rule, for most patients, is that menopause support will be followed by geriatric support. Another very common aspect, in our clinic, is that, the treatment proposed always is very personalized. We see every person as a unique complexity, and our goal, at B life, is do adjust every therapeutic to the specific needs of each of our clients.

We do also have a deep respect for our clients beliefs and values. So this  directive that helps us to build our strategy of treatment. If the patient does not want to be submitted to any kind or interference, this will be respected, and we will find another way to treat her, with our best knowledge. And for patients with that profile, integrative medicine is a choice that fits better than any other.

Dr. Alexandros Botsaris (OM 48985) is a physician with over forty years of international clinical experience in primary and integrative care, trained in Brazil, France, China, and Portugal. He holds a degree from the Federal University of Rio de Janeiro and a Master's from the University of Lisbon, and specialised in Internal Medicine, Infectious Diseases, Acupuncture, and Phytotherapy. He leads B-Life Care, the continuous care membership at B-Life Clinic, where the method — Investigation, Direction, Care — supports women in menopause through personalised medicine, evidence-based phytotherapy, and continuous clinical oversight.