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NCCIH Clinical Digest

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Menopausal Symptoms and Complementary Health Practices:
What the Science Says

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February 2016
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Clinical Guidelines, Scientific Literature, Info for Patients: 

Natural Products

Phytoestrogens (Red Clover, Soy)

Studies of phytoestrogens such as the isoflavones found in soy and red clover have had inconsistent results on relieving menopausal symptoms. Clinical practice guidelines issued in 2011 by the American Association of Clinical Endocrinologists for the diagnosis and management of menopause state that phytoestrogens, including soy-derived isoflavonoids, result in inconsistent relief of symptoms. The guidelines advise that women with a personal or strong family history of hormone-dependent cancers, thromboembolic events, or cardiovascular events should not use soy-based therapies. Likewise, guidelines from the American College of Obstetricians and Gynecologists state that phytoestrogens and herbal supplements have not been shown to be useful for treating hot flashes.

The Evidence Base

  • The evidence base on efficacy of phytoestrogens such as red clover and soy consists of several systematic reviews and meta-analyses as well as clinical practice guidelines issued by the American College of Obstetricians and Gynecologists.

Efficacy

  • A 2015 meta-analysis and systematic review of 15 randomized controlled trials found no significant treatment effect of phytoestrogen on menopausal symptoms as compared with placebo. However, an analysis of the ten studies that reported hot flash data indicated that phytoestrogens result in a significantly greater reduction in frequency of hot flashes compared to placebo.
  • A 2014 systematic review concluded that studies of isoflavones had significant reductions on hot flashes and co-occurring symptoms during menopause and post-menopause, but replication of studies with larger sample sizes are needed.
  • A 2013 Cochrane review of 43 randomized controlled trials involving a total of 4,084 participants with hot flashes found some trials reported a slight reduction in hot flashes and night sweats with phytoestrogen-based treatment; however many of the trials included in the review were small, of short duration and of poor quality. The phytoestrogens containing high levels of genistein (a substance derived from soy) appeared to reduce the number of daily hot flashes, but needs to be further investigated. Overall, there was no indication suggesting that other types of phytoestrogens work any better than no treatment.

Safety

  • Although information on adverse effects is limited, soy extracts appear to be generally safe when taken for short periods of time. However, long-term use of soy extracts (which contain phytoestrogens) has been associated with thickening of the lining of the uterus.
  • A review of the research literature of red clover also found no apparent evidence of adverse events from short-term use (up to 16 weeks). However, the same review noted the lack of data on the safety of long-term use. There are some concerns that red clover, which also contains phytoestrogens, might have harmful effects on hormone-sensitive tissue.

Black Cohosh

Research suggests that there is overall insufficient evidence to support the use of black cohosh for menopausal symptoms.

The Evidence Base

  • Black cohosh has received more scientific attention for its possible effects on menopausal symptoms than have other botanicals. The evidence base on efficacy for black cohosh on menopausal symptoms consists of several randomized controlled trial and a Cochrane systematic review.

Efficacy

  • A 2012 Cochrane review of 16 studies involving 2,027 women found insufficient evidence to support the use of black cohosh for menopausal symptoms.

Safety

  • United States Pharmacopeia experts suggest that women should discontinue use of black cohosh and consult a health care practitioner if they have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice.
  • There have been some case reports of hepatitis (inflammation of the liver), as well as liver failure, myopathy, in women who were taking black cohosh. It is not known if black cohosh was responsible for these problems. Although these cases are very rare and the evidence is not definitive, scientists are concerned about the possible adverse effects of black cohosh on the liver.

DHEA

DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. DHEA is manufactured and sold as a dietary supplement. A few small studies have suggested that DHEA might possibly have some benefit for hot flashes and decreased sexual arousal, although small randomized controlled trials have shown no benefit.

The Evidence Base

  • The evidence base on efficacy of DHEA for menopausal symptoms consists of several randomized controlled trials as well as a few systematic reviews and meta-analyses, including a Cochrane review.

Efficacy

  • Clinical practice guidelines issued in 2011 by the American Association of Clinical Endocrinologists for the diagnosis and management of menopause state that the benefits of DHEA for the treatment of menopause have not been adequately substantiated by scientific studies.
  • A 2015 Cochrane review of 28 randomized controlled trials involving a total of 1,273 postmenopausal women found no evidence that DHEA improves quality of life, but found some evidence that DHEA is associated with androgenic side effects (e.g., acne, unwanted hair growth (hirsutism)). The reviewers also noted that there is uncertainty whether DHEA decreases menopausal symptoms, but DHEA may slightly improve sexual function compared with placebo.
  • A 2014 systematic review and meta-analysis of 23 randomized controlled trials involving 1,188 women concluded that evidence warranting low confidence suggests that DHEA does not significantly impact sexual symptoms or selected metabolic markers in postmenopausal women with normal adrenal function.

Safety

  • Concerns have been raised about the safety of DHEA because it is converted in the body to hormones, which are known to carry risks. Its long-term effects, risks, and benefits have not been well studied, and it remains unclear whether it might increase the risk for breast or prostate cancer.
  • There is the possibility that even short-term use of DHEA supplements might have detrimental effects on the body.

Mind and Body Practices

Hypnotherapy and Mindfulness Meditation

There is some evidence suggesting that clinical hypnotherapy and mindfulness meditation may help improve certain menopausal symptoms such as hot flashes. A 2015 position paper from the North American Menopause Society recommends hypnotherapy for managing hot flashes but acknowledges that any favorable evidence is limited.

The Evidence Base

  • The evidence base on efficacy of hypnotherapy and mindfulness meditation for menopausal symptoms consists of only a few randomized trials and a few reviews.

Efficacy

  • 2010 review of 21 papers assessed mind and body therapies for menopausal symptoms. The researchers found that yoga, tai chi, and meditation-based programs may be helpful in reducing common menopausal symptoms including the frequency and intensity of hot flashes, sleep and mood disturbances, stress, and muscle and joint pain.
  • A 2013 randomized controlled trial in 187 postmenopausal women found that clinical hypnosis significantly reduced self-reported and physiologically measured hot flashes. Although the mechanism of how clinical hypnosis works is unknown, the women in this same study who practiced hypnosis had significantly greater levels of satisfaction than the control group. A 2008 randomized trial found that hypnosis appears to reduce perceived hot flashes in breast cancer survivors and may have additional benefits such as improved mood and sleep.
  • Findings from a 2011 randomized trial of 110 late perimenopausal and early postmenopausal women with hot flashes suggest that mindfulness training may be a clinically significant resource for reducing the distress women experience from hot flashes and night sweats.

Safety

  • Hypnosis is considered safe when performed by a health professional trained in hypnotherapy. Self-hypnosis also appears to be safe for most people. There are no reported cases of injury resulting from self-hypnosis.
  • Meditation is considered to be safe for healthy people. There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched.

Acupuncture

There is insufficient evidence to determine whether acupuncture is effective for managing symptoms of menopause.

The Evidence Base

  • The evidence base on efficacy of acupuncture for menopause consists of many randomized controlled trials and several reviews, including a Cochrane systematic review.

Efficacy

  • A 2016 randomized controlled trial of 327 Australian women found that acupuncture was no better than sham acupuncture (control) for the treatment of hot flashes. Both groups (sham acupuncture and true acupuncture) had a significant improvement in hot flash scores at the end of treatment, and this improvement was continued at 3 months and 6 months posttreatment.
  • A 2013 Cochrane systematic review of 16 randomized controlled trials involving a total of 1155 women found that compared to sham acupuncture, there was no evidence of any difference in their effect on hot flashes. When acupuncture was compared with no treatment, there appeared to be a benefit from acupuncture, but acupuncture appeared to be less effective than hormone therapy.
  • A 2010 review assessed studies that examined the use of acupuncture for hot flashes related to natural or induced menopause. The studies that the researchers included in their review were limited to acupuncture studies performed using needles stimulated by hand or electrically. The researchers found that acupuncture may reduce the frequency and severity of hot flashes; they also concluded that the effect may occur regardless of where the acupuncture needle is placed on the body. However, some studies did not provide sufficient evidence to support the use of acupuncture for hot flashes due to their small size and poor quality.

Safety

  • Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of non-sterile needles and improper delivery of treatments.
  • When not delivered properly, acupuncture can cause serious adverse effects, including infections, bleeding, pneumothorax and injury to the central nervous system.

Yoga

There is insufficient evidence to determine whether yoga has a beneficial effect on menopausal symptoms.

The Evidence Base

  • The evidence base on efficacy of yoga for menopausal symptoms consists of only a few randomized controlled trials.

Efficacy

  • A 2014 randomized controlled trial involving 249 women found that a 12-week yoga class, compared with usual activity, did not improve the frequency or bother of vasomotor symptoms, but reduced insomnia symptoms.
  • A 2011 randomized controlled interventional study concluded that yoga is effective in reducing menopausal symptoms and should be considered as an alternative therapy for the management of symptoms of menopause.

Safety

  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. It is not uncommon for practitioners to have some minor, transient discomfort, like in most physical activity programs.
  • However, injuries from yoga, some of them serious, have been reported in the popular press.
  • People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

References

  • Acupuncture for treatment of menopausal hot flashes. Annals of Internal Medicine. 2016;164(3):1-24.
  • Borud E, White A. A review of acupuncture for menopausal problems. Maturitas. 2010;66(2):131-134.
  • Carmody JF, Crawford S, Salmoirago-Blotcher E, et al. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause. 2011;18(6):611-620.
  • Chen MN, Lin CC, Liu CF. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2015;18(2):260-269.
  • Coon Jt, Pittler MH, Ernst E. Trifolium pratense isoflavones in the treatment of menopausal hot flushes: a systematic review and meta-analysis. Phytomedicine. 2007;14(2-3):153-159.
  • Dodin S, Blanchet C, Marc I, Ernst E, Wu T, Vaillancourt C, Paquette J, Maunsell E. Acupuncture for menopausal hot flushes. Cochrane Database of Systematic Reviews. 2013;7: CD007410.
  • Elkins G, Marcus J, Stearns V, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Oncol. 2008;26(31):5022-5026.
  • Elkins GR, Fisher WI, Johnson AK, et al. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause. 2013;20(3):291-298.
  • Elraiyah T, Sonbol MB, Wang Z, et al. Clinical review: The benefit and harms of systematic dehydroepoandrosterone (DHEA) in postmenopausal women with normal adrenal function: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2014;99(10):3536-3542.
  • Goodman NF, Cobin RH, Ginzburg SB, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract. 2011;17(Suppl 6):1-25.
  • Innes KE, Selfe TK, Vishnu A. Mind-body therapies for menopausal symptoms: a systematic review. Maturitas. 2010;66(2):135-149.
  • Joshi S, Khandwe R, Bapat D, et al. Effect of yoga on menopausal symptoms. Menopause Int. 2011;17(3):78-81.
  • Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database of Systematic Reviews. 2012;9:CD007244.
  • Lethaby A, Marjoribanks J, Kronenberg F, et al. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database of Systematic Reviews. 2013;12:CD001395.
  • Mahady GB, Low Dog T, Barrett ML, et al. United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause. 2008;15(4 Pt 1):628-638.
  • Newton KM, Reed SD, Guthrie KA, et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause. 2014;21(4):339-346.
  • Scheffers CS, Armstrong S, Cantineau AEP, et al. Dehydroepiandrosterone for women in the peri- or postmenopausal phase. Cochrane Database of Systematic Reviews. 2015;1:CD011066.
  • The North American Menopause Society. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society. 2015;22(11):1-28.
  • Thomas AJ, Ismail R, Taylor-Swanson L, et al. Effects of isoflavones and amino acid therapies for hot flashes and co-occurring symptoms during the menopausal transition and early postmenopause: a systematic review. Maturitas. 2014;78(4):263-276.

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH's Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH Web site at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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This page last modified February 24, 2016