Popular herbal remedy for hot flushes is no better than placebo
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7522.924-b (Published 20 October 2005) Cite this as: BMJ 2005;331:924All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Sir/Madam
Jerome Burne says "If, as seems to be the assumption, hot flushes are
the result of a decline in oestrogen".
Many women who experience hot flashes during menopause are found to
have no declne in oestrogen; and many women are given HRT despite having
no decline in oestrogen - one of the questions one should ask of Western
medical science is why inform women that oestrogen deficit equals
menopause, hence supplementing oestrogen is necessary to restore the
balance, when clearly that is not always the case...in fact it may be the
supplementation of oestrogen when it is not in decline that has led to so
much misery wrought on women through HRT supplementation.
Sadly, various 'alternative' treatments followed that science blindly
by applying an oestrogen-decline theory to menopause and looked for herbs
and other supplements that could supply oestrogen where none was
indicated; such measures might also have added to problems not unlike HRT.
Just because oestrogen can suppress hot flashes does not mean it is
efficacious - so might 'therapy' by NSAID or submerging a woman in icy
water, but is that considered efficacious?
Until the true mechanism of menopausal flushing is understood perhaps
those who choose to medicate this natural state ought to acknowledge that
any medication which might 'work' may not be working for the right
reasons.
The old adage "every flush is worth a guinea" probably hides a wisdom
most women have been denied with promises of medicating away any benefits
those flushes could provide. I have seen very many menopausal ladies over
the years, in TCM we interpret and treat differently and very
successfully, and it never fails to surprise me when a lady says her
physician never told her HRT would only delay, not preclude, her going to
through menopause eventually when HRT is removed - and so often I have
seen such ladies suffering that delayed menopause which returned with a
vengeance, flushes every half hour 24 hours per day, with oestrogen deline
never shown.
Perhaps an endocrinologist could offer advice on this issue for
readers herein who are concerned with the Western medical interpretations
for menopause that in so many women seem at variance with experience?
Regards
John H.
Competing interests:
None declared
Competing interests: No competing interests
Why would anyone believe that “bio-identical” progesterone
preparations were safe and only synthetic progestogens were dangerous?
Progestogen means acting like progesterone.
Exogenous progesterones are potentially carcinogenic, especially for
the breast. In contrast, avoiding the common precipitants of hot flushes
and vascular over-reactivity, like tobacco smoking, is safe and has
obvious long-term health benefits.
Progesterone use is common in the field of Complementary and
Alternative Medicine (CAM). Nutritional supplements and dietary advice is
also usually given by CAM practitioners. This helps to foster dubious
claims of efficacy for herbs with some hormonal activity but can mask the
dangers from such hormone use.
Competing interests:
None declared
Competing interests: No competing interests
As a menopausal woman, with a demanding career, who has experienced
most
of the usual symptoms of this period in life, I have sought relief from
many
sources. As I was NOT willing to risk the side effects of hormone
replacement
therapy with snythetic hormones, I have focused on herbal options and the
use
of bio-identical progesterone.
What disturbes me about "Popular herbal remedy for hot flushes is no
better
than placebo" is that it seems to take the same approach that so many
medical
studies of herbs do -- focusing on the efficacy of a single herb. This
seems to
me to ignore one of the central tenants of the herbal approach to wellness
--
the synergy of combining several herbs in treatment.
I have experimented with single herbs and experienced only modest
improvement. I have used various combinations of mutually reinforcing and
complementary herbs and had very significant improvement in unpleasant
symptoms, mood, and energy level.
I would encourage those in the medical profession who are interested
in
exploring herbs to spend some time with a qualified herbalist and start
testing
the COMBINATIONS of herbs that people have used effectively for centuries.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
We were interested to read that Black Cohosh (Cimicifuga racemosa)
has little role to play in the treatment of menopausal vasomotor
symptoms(1).
We recently saw a case of
severe jaundice and a peak bilirubin of 512. Exhaustive investigation led
to a diagnosis of severe drug induced cholestasis. The responsible agent
was Black Cohosh, which the patient had been taking for menopausal symptoms. At
the time, none of our team were aware of this herb and we were therefore
surprised to learn that it appeared to be in widespread use. More worrying
were several case reports of acute liver failure and even liver
transplantation resulting from its ingestion (2). Thankfully, after 8
weeks, the patient’s bilirubin had returned to normal.
Despite a growing market, the health benefits of herbal medications
are rarely proven and, even if present, data on safety is often lacking.
In view of this, assumptions regarding risk/benefit ratios cannot be made
by either patients, who are provided with woefully inadequate information
on what they are taking, or clinicians. This growing area of alternative
medicine is badly in need of proper regulation.
Dr W. Stableforth
SPR in Hepatology.
Dr J Mitchell
Consultant Hepatologist.
1. Dobson R. BMJ 2005;331:924
2. Thomsen M. Med J Aust 2004;180(11):598-9
Competing interests:
None declared
Competing interests: No competing interests
Although it is often assumed that black cohosh acts as a
phytooestrogen it may well not. See this paper:
Black cohosh acts as a mixed competitive ligand and partial agonist of the
serotonin receptor" J Agric Food Chem. 2003 Sep 10;51(19):5661-70.
This was a rat study which found that "black cohosh extract had no
estrogenic or antiestrogenic properties in the ovariectomized rat model"
Instead it seems to work on the serotonin receptors targeted by SSRI
anti-depressants: "A 40% 2-propanol extract of black cohosh was tested
against 10 subtypes of the serotonin receptor, revealing the presence of
compounds with strong binding to the 5-HT(1A), 5-HT(1D), and 5-HT(7)
subtypes"
If, as seems to be the assumption, hot flushes are the result of a
decline in oestrogen then its effect is probably due to placebo plus
raising of mood. However few people who take supplements take only one and
black cohosh is regularly compbined with those containing phytoestrogens
such as red clover. Plenty of anecdotal evidence for its effectiveness. However, the research evidence is very mixed. One very recent review article was positive for black cohosh, finding that it “is safe and effective for reducing menopausal symptoms, primarily hot flashes and possibly mood disorders”.[1] But it was fairly negative about phytoestrogens such as soy foods and red clover, which “appear to have at best only minimal effect on menopausal symptoms."
Another review involving twenty-five trials and 2348 participants was even more negative about phytoestrogens[2]:
"Red clover trials showed no improvement in hot flush frequency" and "out of the 8 soy food trials reporting hot flush frequency outcomes, 7 were negative."
But then a recent pilot trial was very positive about phytoestrogens.[3] A nutritional supplement containing isoflavones from kudzu and red clover, produced a "46% decrease in reported hot flushes" , and a similar improvement in quality of life.
So the choice is between a combination of HRT (well-docemented
increased risk of heart problems and cancer) plus an SSRI (well documented
raised risk of suicide and serious withdrawal problems) or a combination
of black cohosh plus red clover (side-effects unlikely to be in same
league).
Jerome Burne
Competing interests:
None declared
Geller SE, Studee L. Botanical and dietary supplements for menopausal symptoms: what works, what does not.
J Womens Health (Larchmt). 2005 Sep;14(7):634-49.
Krebs EE, Ensrud KE, MacDonald R, Wilt TJ. Phytoestrogens for treatment of menopausal symptoms: a systematic review.
Obstet Gynecol. 2004 Oct;104(4):824-36.
Lukaczer D, Darland G, Tripp M, Liska D, Lerman RH, Schiltz B, Bland JS. Clinical effects of a proprietary combination isoflavone nutritional supplement in menopausal women: a pilot trial.
Altern Ther Health Med. 2005 Sep-Oct;11(5):60-5.
Competing interests: No competing interests
- In our country, we have aproached a general consensus about
hormonal therapy in Menopausic conditions in woman with uterus. Estrogen
and progesteron therapy is just indicated in patients with high risk of
bone fractures, and low risk of cardiovascular disease and breast cancer
AND simultaneosly intolerable symptoms (e.g hot flushes). This scenario is
really infrecuent so the presciption of hormone therapy replacement is
probably declining now.
- But what can we do to manage of climaterium symptoms?
- As the other correponsal said the differences published in the
Maturitas journal paper(1), commented by Roger Dobson(2), are really
clinical significant. An Absolute Risk Reduction between placebo (21%) and
Black cohosh (35%), represent OR: 06, Relative Risk reduction 40% and
Number Need to Treat (NNT) of 7 (seven). In other words, it is necessary
to treat seven patients with Black cohosh, more than placebo, to obtain
one aditional benefit in relieve a women with hot flushes (nothing
bad!!!).
- We have not reviewed Maturitas journal paper, but the mathematics
are very simple. 351 women assigned to five regimens for a period of one
year (not taking in mind drop outs and looses), determine, more or less,
70 patients in each branch. This small sample size in each arm, leads the
study to loose power and does not permit to reject the Null Hypothesis
(Type II error).
In the other hand, there is no information about side effects. We think
probably more severe with hormones.
- So, meanwhile, why not use herbal medication????.
- References:
- 1. Maturitas 2005;16:134–46
- 2. BMJ 2005;331:924 (22 October), doi:10.1136/bmj.331.7522.924-b
- JAIRO ECHEVERRY M.D.
Associated Professor,
Faculty of Medicine,
Universidad Nacional de Colombia.
jecheverryr@unal.edu.co
- PATRICIA AGUALIMPIA M.D.
Pediatrician,
Universidad Nacional de Colombia.
Competing interests:
None declared
Competing interests: No competing interests
There is no detailed statistics in the BMJ - but the reduction of hot
flushes by 35% for black cohosh versus 21% with placebo and menopausal
general symptoms by 27% for black cohosh versus 15% for placebo looks
different to me. The numbers might be so small that these figures are not
significant - but the title suggesting there is no difference between
placebo and black cohosh is false. As a GP with a special interest in
complementary medicine including acupuncture, homeopathy and phytotherapy,
I have certainly seen many patients benefit significantly from black
cohosh preparations. Dosage might be important.
Competing interests:
None declared
Competing interests: No competing interests
Reasons for hot flushes
As John Heptonstall correctly points out hot flushes are not related
to actual oestrogen levels but can occur at high or low blood levels. HRT
tachyphylaxsis results when higher and higher doses of oestrogens are
given in an attempt to suppress severe withdrawal flushings when very high
hormone levels fall.
Hot flushes should be recognised as warnings of biochemical
abnormalities hindering normal physiological adaptability in amine
pathways. Enzyme co-factor zinc and magnesium deficiencies are commonly
undiagnosed. Repletion of essential nutrient deficiencies is not so much a
“remedy” as a method of restoring physiological flexibility. The menopause
is not a disease in a healthy woman.
Competing interests:
None declared
Competing interests: No competing interests