Home' Australian Pharmacist : Australian Pharmacist July 2015 Contents Australian Pharmacist July 2015 I © Pharmaceutical Society of Australia Ltd.
HRT’s loss of the biggest cohort of baby boomer women is a gain for
In terms of therapeutic categories,
complementary medicines (CM) almost
made menopause their own following
the negative publicity surrounding safety
of conventional HRT after the aborted
WHI trial in 2002.
Use of HRT fell drastically worldwide
(so did the incidence of breast cancer2)
and CM rushed in to fill the vacuum.
Despite subsequent efforts by various
menopause societies to lift HRT
, according to a 2013 review
of international surveys, use of CM for
menopausal symptoms remains high
Sales of menopause CMs
from Australian pharmacies that year
totalled $12.24m, about a fifth of the
total spend in the women’s health
category, more than half of which is on
phyto-oestrogens (e.g. soy and red clover
products) and a quarter on the herb
black cohosh alone.
Recent Cochrane reviews7,8
interventions – as well as acupuncture9,
– for vasomotor
symptoms (i.e. hot flushes) all show that
although no CM treatment has not yet
accrued the evidence for efficacy of HRT,
to patients it seems a moot point when
they compare the risk–benefit ratio for
managing a natural condition with a
strong placebo effect and highly variable
and individual symptom picture over
Phyto-oestrogen family of
The most common types of
phytoestrogens are coumestans, lignans
and isoflavones, which are similar
structurally to oestradiol (E2) and have
weak oestrogenic activity through
selective oestrogen receptor modulation
Both soy and red clover
(Trifolium pratense) are both well-studied
sources of isoflavones, and Promensil is
the most studied red clover CM.
A 2013 Cochrane review found that no
evidence suggested that a high-soy diet,
or soy or red clover supplements, had a
positive effect on hot flush frequency
or severity. However, it did find that
supplementation with the isoflavone
genistein reduced the numbers of hot
flushes, albeit to a lesser extent than HRT.
Black cohosh – well
researched but still little
Extracts of the root of Cimicifuga
racemosa is the most extensively
researched herbal medicine for
menopausal symptoms, and of these
Remifemin, standardised to triterpene
glycosides (0.8–1.2 mg/tablet); BNO 1055,
an aqueous–ethanol mixture; and Ze 450,
sold in Australia as Femular, are among
the most clinically researched.
Although some double-blind RCTs12–14
have shown clinically significant effects
of these extracts, the heterogeneity of
types, dosing regimes and comparators
has meant that results are inconsistent in
systematic reviews8,15,16; and some trials
have shown little efficacy compared to
The pharmacology of black cohosh is still
uncertain, however it is not thought to
be oestrogenic, may have SERM activity
and it is generally agreed that it reduces
lutenising hormone secretion.
of the rhizome was spotlighted in 2006
when the TGA announced that several
» COMPLEMENTARY MEDICINES
Steven Chong, BA (Communications), is Editor of
Healthy & Heartwise and Pure Animal, Founding
Editor of The Journal of Complementary Medicine
(2002–2009) and a writer for the Australian Journal of
case reports indicated a rare, idiosyncratic
but causal association with hepatitis,
necessitating a label warning on products.
However, the North American Menopause
Society, which is always cautious about
complementary medicines, recommends
short-term use from a reputable supplier
for menopausal symptoms.
1. Rossouw JE, Anderson GL, Prentice RL, et al. Risks
and benefits of estrogen plus progestin in healthy
postmenopausal women: principal results From the
Women’s Health Initiative randomized controlled trial. JAMA
2. Canfell K, Banks E, Moa AM, et al. Med J Aust
3. Sturdee DW, Pines A, et al. Updated IMS recommendations
on postmenopausal hormone therapy and preventive
strategies for midlife health. Climacteric 2011;14:302–20.
4. Posazki P, et al. Prevalence of complementary and alternative
medicine (CAM) use by menopausal women: A systematic
review of surveys. Maturitas 2013;75:34–43.
5. Aztec Pharmacy Scan Data, $ sales, MAT 8 Dec 2013.
6. MacLennan AH, et al. Oral oestrogen and combined
oestrogen/progestogen therapy versus placebo for
hot flushes. Cochrane Database Syst Rev 2004 Oct
7. Lethaby A, et al. Phytoestrogens for menopausal vasomotor
symptoms. Cochrane Database Syst Rev 2013 Dec
8. Leech MJ, Moore V. Black cohosh (Cimicifuga spp.) for
menopausal symptoms. Cochrane Database Syst Rev 2012
9. Dodin S, et al. Acupuncture for menopausal hot flushes.
Cochrane Database Syst Rev 2013 Jul 30;7:CD007410.
10. Daley A, et al. Exercise for vasomotor menopausal symptoms.
Cochrane Database Syst Rev 2014 Nov 28;11:CD006108.
11. Saensak S, et al. Relaxation for perimenopausal and
postmenopausal symptoms. Cochrane Database Syst
Rev 2014 Jul 20;7:CD008582.
12. Liske E. Therapeutic efficacy and safety of Cimicifuga
racemosa for gynecological disorders. Advances Therapy
13. Nappi RE, et al. Efficacy of Cimicifuga racemosa on
climacteric complaints: a randomized study versus low-dose
transdermal estradiol. Gynecol Endocrinol 2005;20:30-5 .
14. Schellenberg R, et al. Dose-Dependent Effects of the
Cimicifuga racemosa Extract Ze 450 in the Treatment of
Climacteric Complaints: A Randomized, Placebo-Controlled
Study. Evid-Based Complement Altern Med 2012, 10, Article
15. Palacio C, et al. Black cohosh for the management of
menopausal symptoms: a systematic review of clinical trials.
Drugs Aging2009;26:23–36 .
16. Borrelli F, Ernst E. Alternative and complementary therapies
for the menopause. Maturitas 2010;66:333–43.
17. Newton KM, et al. Treatment of vasomotor symptoms
of menopause with black cohosh, multibotanicals, soy,
hormone therapy, or placebo: a randomized trial. Ann Intern
18. Braun L, Cohen M. Herbs & Natural Supplements: An
Evidence-Based Guide, 2nd edn. Sydney: Churchill
19. Gass M. Supplement safety: black cohosh & menopausal
symptoms. MenoPause Blog, 31.10.2012, accessed 11.6 .2015.
Women’s health: menopause
BY STEVEN CHONG
This column was supported through an
unrestricted grant from Flordis.
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