The Tor and sheep’s poo
The stone of the Glastonbury Tor holds the sun’s warmth and shares it with my back. I duck out of the wind, soak in the fabulous views of the Salisbury plains and reflect on the last year and half since diagnosis with Myeloma. Deep breaths of fresh air (fused with sheep poo aroma) fill my lungs. I’m sure the menopause (Meno) conundrum has been one of the most challenging and inspiring learning elements of this cancer journey. Are you ready for part three (and final for now) of the Menopause blogs? Let’s talk ‘alternative’ (read non-medical) Meno symptom management solutions and finally, my decision about what, if anything, to take. It’s probably apt that I am writing this in a place full of people living ‘alternative’ lifestyles or certainly appearing to be very happily in their own world…
The Tor, Glastonbury
Previous posts about Menopause
If you are happening upon this blog and interested in Menopause and Menopause and Cancer please see my previous posts on Menopause (part 1 and 2, links under Recent posts on the righthand side of this page). Now, let’s crack on with the next instalment, part 3, the alternatives to HRT. A rhyme? Unintentional! Any poets out there? Maybe it’s time for Meno poetry. I hear Menopause, The Musical and the comedians (Victoria Wood (rest in peace), Sandra Tsing, Kathy Burke, Angela Verges, and Jeff Allen have and are doing a fine job); room for another genre? Hey, if it gets all of us talking Meno, I’m keen. All poetic contributions welcome!!!
Menopause, The Musical
Menopause (Meno) part three (my final Menopause focussed post for now)
Wee recap; my MMmM project (Multiple Myeloma and managing Menopause symptoms) began by exploring the traditional medical models, asking my oncology team and gynaecologists for advice. I then turned to a wide range of menopause experts by experience and occupation for complementary, natural and alternatives to Hormone Replacement Therapy (HRT). I found myself falling into the world of Isoflavones, phytoestrogens, red clover black cohosh and more. Here is what I discovered…
Alternatives to HRT
Actually before we get it into alternatives, let’s be clear, one completely valid option is to take nothing and embrace the menopause process as a natural part of aging; to cope with whatever symptoms are experienced. However, for many of us, in the same way that managing difficult periods, pre-menstrual syndrome (PMS) or tension (PMT), difficult pregnancy, endometriosis, polycystic ovaries, fibroids and other gynaecological processes and concerns, it is either unnecessary to put up with unwanted symptoms or they are simply intolerable. Additional support is needed.
Below are some of the alternatives to HRT and practical solutions I encountered and many of which I have tried. Please note most complementary and alternative treatment options do not yet have robust evidence of effectiveness; though some women will experience benefit from some of these treatments.1
Isoflavones and Phytoestrogen
The definitions and characteristics (interesting nutrition and hormone stuff);
Isoflavones are crystalline compounds whose derivatives occur in many plants (especially pulses), often as glycosides. Phytoestrogens refer to a substance found in certain plants which can produce effects like that of the hormone oestrogen when ingested into the body.2
Isoflavones are oestrogenically potent phytoestrogens. The main dietary isoflavones, called genistein and daidzein, are mostly found in legumes such as soy, chick peas, lentils and beans. Lignans and prenylated flavonoids (also phytoestrogens) have potent oestrogenic activity but there are few studies about them. 2
Evidence is mixed about Soy
A recent study found a reduction in hot flushes when women used soy germ extract with 100mg of isoflavone glycosides.3 It is not clear from studies to date, whether frequent soy consumption explains the lower rate of hot flushes among different ethnic groups.4
Red clover and Promensil
Red clover, another source of isoflavones, contains compounds that are metabolised to genistein and daidzein after consumption. The most studied red clover product is Promensil. 4
- A ‘natural’, non-medical, easily accessible, alternative to HRT
- Growing evidence base that it works in improving unwanted Menopause symptoms
- A three-month dosage duration is recommended initially
- Not enough evidence yet looking at long term effects
- Just like HRT, it is unlikely to work for everyone
Managing women with phytoestrogens
There are few studies exploring Promensil and Isoflavones for the management of Menopause symptoms and other health benefits though fortunately the evidence base is slowly growing.
A recent review highlighted evidence supporting use of Promensil at 80 mg/day for treating hot flushes in menopausal women. This finding was consistent across 3 studies included in the meta-analysis. Promensil was found to be safe over the short-term duration of the studies (3 months).5
A more comprehensive review with a rather unfortunate name ‘Managing women with phytoestrogens’ also reviewed the studies mentioned above. (It makes me angry when its implied or explicitly stated women need managing!!) Setting this name issue aside, the researchers proposed that one of the most widely researched food supplements has been the phytoestrogenic preparation containing red clover isoflavones. Six randomised trials exploring the impact on vasomotor symptoms (night sweats, hot flashes, and flushes) were included, three of which displayed a significant benefit compared to placebo.6
Data from small randomised and observational trials showed benefits of using red clover isoflavones for osteoporosis and cardiovascular disease. Red clover isoflavones may also derive psychological benefits. Safety data is positive so far. The reviewers conclude with further studies would be welcome, particularly in women with significant medical risks.6
A 2018 paper describes a study of 50 patients where a combination of 40mg dose of Isoflavone along with calcium, vitamin D and inulin improved vasomotor disturbances as well as quality of life and sexual function in menopausal women. This was a small trial with a number of limitations so the results while promising, need further investigation.7
From the makers of Promensil (Check out their website and research claims)
Here are two sheets summarising clinical support for red clover Isoflavones relating to a range of health domains.
Clinical Support for Red Clover Part1
Clinical Support for Red Clover Part2
They also explain the difference between Promensil and other red clover products including soy isofalvones. Check it out here.
There had to be some debate, right? This is Menopause we’re talking about after all! Studies involving Promensil were reviewed, analysed and reported in a 2014 Cochrane review paper. 4 Only five trials met the search criteria and the authors argue that,
No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women.
On a positive note the same review highlights the possibility of a positive outcome from genistein and concludes
…benefits derived from concentrates of genistein should be further investigated.
Read the full paper here.
Other ‘Alternatives’, Complimentary Medicine and Lifestyle choices for managing Meno symptoms
Beyond the better known isoflavones, I came across a number of other recommendations for using supplements, making lifestyle changes and employing complimentary medicine for reducing unwanted Menopause symptoms and side effects. I then went hunting for scientific evidence of each product’s effectiveness and began trying a few things out. Here is a list of the alternatives I looked into:
- Vitamins (A, C, D, E, K, Zinc)
- Omega 3
- Black Cohosh
- Chill Pillows (a new take on chill pill!).
- Chinese Medicine
- Cognitive Behavioural Therapy
- Non-hormonal pharmaceutical treatments
Some women have found benefits from natural remedies BUT the research is mixed and caution is advised. Check out these summaries; 1,8,9
Complimentary alternative therapies.
Natural remedies for hot flushes
A paper Mallhi et al with a long list of alternatives, dosage and known side effects.
Here are my discoveries in more detail; I hope they prove useful…
Probiotics and Vitamins
Now for a confession, I can’t remember exactly who told me to take probiotics and a full range of vitamin B’s, Calcium and Vitamin A, C, D and Zinc to help with menopausal symptoms (blame it on Chemo and Menopause memory impact!). I am 99% sure, I first heard this from my Nutrition therapist, then from the amazing lady who runs our local health shop and then finally I’m sure it came up in the interviews facilitated by Katie Phillips with Menopause experts that I have mentioned in my previous posts (See links below for some of the interviews and more about Katie). I take VitD, VitB and Calcium daily as part of my Cancer treatment as advised by my medical team so it has not been a hardship to add the probiotic.
Muhleisen’s paper highlights probiotics for reinstating vaginal equilibrium in menopause 10 and Britton’s paper advocates probiotics to prevent vaginal dryness and atrophy.11 Count me in!
According to a recent review, Omega-3 supplements may alleviate night sweats but not hot flushes.12
Vitamin C, D, E – more mixed results
A 2013 paper highlighted that Vitamin C and E reduce the intensity and number of hot flashes via promotion of adrenal function though it is very important that the correct dosage is used and no large doses are taken.13
In contrast, LeBlanc’s 2015 paper and 2010 studies (by Dennehy et al and Lerchbaum et al ) show there is no evidence that vitamin D or E helps vasomotor symptoms but do recommend vitamin C, D, K and calcium for maintaining bone health.14,15,16
Zinc and Vitamin K
Zinc and Vitamin K are positively associated with bone mass however I couldn’t find any evidence for either reducing unwanted menopause symptoms.17,18, 19
For healthy hair during menopause – vitamin Bs, C, Proteins and Fats
Sugar craving during Menopause – check your Vitamin C levels
Consider going VEGAN or simply eat more plants!
One study showed that vegans reported less bothersome vasomotor symptoms than omnivores.20
I couldn’t find any relevant studies regarding Vitamin A and menopause and menopause symptoms. Please let me know if you can!
While an older 2010 study found black cohosh reduced hot flushes21 a recent, more comprehensive Cochrane review concluded there is insufficient evidence to either support or oppose the use of black cohosh for menopausal symptoms.22
Chinese Medicine, Dong Quai, Ginseng
Another 2016 Cochrane review found insufficient evidence that Chinese herbal medicines were any more or less effective than placebo or HRT for the relief of night sweats and hot flushes.23
Non-hormonal pharmaceutical treatments (e.g. SSRIs often referred to as anti-depressants)
A 2010 review of studies found Clonidine, SSRIs and SNRIs, gabapentin and relaxation therapy showed a mild to moderate effect on reducing hot flushes in women with a history of breast cancer.24
A Chillmax Pillow
This is a wonderful, wonderful recommendation (thank you Sis-in-law and Mum-in-law!!) Slip it under your pillow case or lie it vertically down your pillow to provide your head and neck with a cool sensation. Ahhh, bliss.
Acupuncture may be beneficial in comparison to not taking anything though the evidence is weak at the moment.25
Ha. We can never escape this one it seems. While exercise isn’t directly linked to vasomotor symptoms of menopause including hot flushes it is recommended to support the related impact of Menopause changes and symptoms. Check out these articles – A good time to exercise and Meno and constipation.26
Cognitive Behavioural Therapy (CBT)
There is growing evidence that CBT can help reduce the impact of Menopause symptoms.27 The British Menopause Society have released a helpful leaflet that has been endorsed by the UK National Institute of Clinical Excellence (NICE).28
Alternatives to HRT and Cancer
A 2013 systematic review of soy and red clover as used by breast cancer patients or those at risk of breast cancer, found a lack of evidence showing harm from use of soy with respect to risk of breast cancer or recurrence. Soy intake in line with a traditional Japanese diet (2-3 servings daily, containing 25-50mg isoflavones) may be protective against breast cancer and recurrence. Soy does not increase circulating estradiol or affect estrogen-responsive target tissues. Prospective data of soy use in women taking tamoxifen does not indicate increased risk of breast cancer recurrence. Evidence on red clover is limited though existing studies propose that it may not possess breast cancer-promoting effects.29
A 2015 study proposed a combination of Soy and probiotics may have potential for reducing the risk of breast cancer.30
Another three-year study concluded that when compared to HRT, Promensil was safer as there was no effect on known breast cancer risk factor.31
New shoot amongst the dryness
Menopause, Sex and Vaginal Dryness
Let’s talk about sex baby, let’s talk about….sex. Remember that track by Salt n Pepa? Except I’m talking about sex during Menopause. Many women find sex painful due to vaginal dryness or don’t fancy sex at all as Meno creeps up on them. Women – you do not have to put up with this state of affairs. For dryness, there are medical issued and organic/natural products that can make a real difference. Consider trying out Yes (mostly organic) or Sylk products. Here is a link to an article 32 which includes a comparison between multiple product options. How Important is vaginal lubricant and moisturiser composition? If you are concerned that your vaginal dryness might be severe and not easily solved by a moisturising lubricant you may be interested in this presentation on Vulvovaginal Atrophy (VVA). It has some great info on the moisturising lubricants too.33
Will I go through Meno twice?
One thing the gynaecologist did say is that I am very unlikely to have to go through Menopause twice; that is, it shouldn’t reverse once my chemo stops and start again at a later stage. That seems like a kind gift from the Universe. I’ll hang on to that.
Of course, I will still be part way through my own Meno journey, living with the uncertainty of not knowing whether mine will finish after 3 years, 7 years or be considerably longer lasting. Hey, so long as the symptoms are managed and I continue to feel myself, I am happy and willing to embrace this new, wondrous, challenging and clever process, my body goes through. Hopefully too, in a few months’ time, after being on my chosen treatment and monitoring symptoms, I will be much clearer about what is a Chemo or Cancer induced symptom versus a Menopause symptom. Meno and hormones may no longer be a fall-back excuse for my ‘well aren’t I moody today’ moments!
So now to my decision:
For me, taking nothing is not an option at this stage as maintaining an even mood, improved libido and reducing hot flushes are a must. Do I try Promensil and or trust in the gynaecologist who was adamant HRT was the way to go? I wonder what is holding me back. I think it is my oncologist with the anti-HRT opinion that is still bothering me; I need to have another talk with him.
My Decision(s) and a U-turn
Talking and researching must stop at some stage and a decision be made. Continued talking and researching can make decisions much harder to make; there will always be contrasting views and experiences. A stake in the ground, a baseline, is needed. I must make the decision that is right for me with the information I have today. After all, I know any decision is not set in stone, I can change it later, if new information comes my way, or my body doesn’t like the solution I try or the decision stops feeling right to me.
So, what’s it to be?
I’m going to start natural plant based bioidentical HRT gel and progesterone tablets.
Except I’m not. Deep Breath.
Just when I had decided to start natural plant based bioidentical HRT (I had even submitted the prescription) my Mum, my very precious, kind Mum, was diagnosed with breast cancer. Deep breath. I won’t talk about this now, other than to say, the all important public health system has once again appeared to have caught the little nasty early; thank you health teams, thank you Universe.
Now, with breast cancer in my family, my chances of getting secondary cancer (and breast cancer) seemed to have leapt from a statistic to a reality. Another deep breath. Talk to self; be sensible. I let my med team know and asked for a mammogram and a chat with the breast cancer team. My oncologist referred me immediately.
I had based my ‘go with HRT’ decision on two factors in the end: a) The delivery mechanism for the estrogen component is via gel and does not go directly through my liver and, b) the research investigating HRT side effects and long term effects is present and more robust than Promensil, at this stage. Although now…
Out with HRT and in with Promensil
The HRT rational above was discarded considering the increased risk of secondary cancer and my recent family diagnosis. Promensil now seemed much more appealing. Despite the lack of larger and longitudinal studies, I decided Promensil was work the risk. I needed help and I was being monitored extensively each week; if a negative impact occurred, I figured it would be picked up quickly and I could stop Promensil immediately.
Two other things helped me embrace this decision; it felt right as soon as I had made it (a better feeling than I ever had with HRT) and it fitted with the additional chat I had with my oncologist. He knows me best, is a clinical lead and has spent most time with me over the last 15 months. He has my best interests at heart and has always coped with my endless queries and requests for repeated explanations. While I do trust the others in the haemo-oncology team, I gave weight to his opinion and his caution over adding this long-term medication into the mix. He said he felt HRT would add extra risk, risk that wasn’t able to have a statistic put on it due to my individual circumstances and the few studies exploring HRT and Myeloma relapse.
Finally, I am reminded that while I usually place my store in scientific evidence, just because something hasn’t been rigorously studied yet, doesn’t mean it won’t later be discovered to be beneficial. Cannabis oil for chronic illness/pain and ketamine for some mental health disorders spring to mind, as substances we might have first thought of as harmful yet in certain doses and conditions, have been found to have positive outcomes. Mindfulness didn’t start out with an evidence base, yet now, it is well established as having beneficial outcomes in many circumstances.
Therefore, I have taken the risk (whatever that is) of introducing yet another supplement/medication into my life.
Promensil 80mg Red Clover Isoflavones
Promensil = Improvement (my case study so far)
I started Promensil while conducting this research and then stopped when I thought I’d better gather the evidence first and make a more informed decision. I was a bit reluctant to stop as I hadn’t noticed any adverse effects and there had seemed to be an improvement in Meno symptoms. When I stopped, the night-sweats returned with a vengeance.
Promensil is shaping up to be a wonder product for me. Although I am open to the possibility it is a placebo effect. Now back on it, I have taken one pill, once per day, for six weeks (the double strength version). Much to my delight the full body night-sweats with drenched bed linen and night clothes are no longer!! I don’t remember having one in the last fortnight at all! Plus, a lovely UK heat wave have meant nights have been hot (in the mid-20s Celsius/77 Fahrenheit at times). The improvement timing couldn’t have been better, otherwise I think I would set the bed and house on fire or internally combusted!
My daily hot flashes now tend to occur in the afternoon, rather than all through the afternoon and evening, are less severe and less frequent; down to 2 per day though I haven’t monitored closely. I do know I’m not stripping off clothes and putting them back on minutes later any near as often, not even every night.
For the last ten days, I have switched to taking Promensil around lunch time or a little later, as most hot flushes appeared in the afternoons or evenings, when they did occur. I have discovered this has had a positive benefit too; flushes have reduced again and while I have not been taking a log, it seems I am only getting one flush a day now.
The jury is out on other symptoms. I seem to sleep slightly better, deeper while asleep though I still wake often. I need to monitor the Meno symptoms closely at the end of each week and during my non-chemo week, to determine any changes; the chemo and steroids at the beginning of the week are likely to interfere with sleep (negatively) and energy (positively). In the middle two weeks of the six on Promensil, I thought my mood had been slightly more even, though I need to check with Hubby on this; suspect he may disagree!
Over the last two weeks with so much going on, health, family and otherwise, I have exercised and meditated less, my mind has been very occupied and I think my mood has fluctuated a lot. Feels like the Promensil was unlikely to have any positive impact on that symptom! Though, who knows maybe my mood would have been worse, if I hadn’t taken it. No science here, no objectivity, remember these are just observations, interpretations and surmising. Though, I am the expert in my own body and mind so I’m rolling with a ‘Promensil is working’ concept for now.
On a couple of occasions, I’ve noticed if I drink a hot drink quickly or have a moment of frustration or stress, a hot flush followed very quickly. I’ll keep an eye on this and try to notice if it always happens or appears random rather than linked to hot drinks and stress. Though I believe this is not uncommon. Check out these known triggers for hot flushes.
Menopause was hard to write about
I have found Menopause hard to write about. Maybe I hesitated because I wasn’t sure whether I was going through it or not: the symptoms are so like those that accompany cancer and chemo. No, that wasn’t it really, I was embarrassed, at first. Outside of my very close friends and eventually, close clinicians, I have found it one of the hardest subjects to raise. I’m not sure why. Especially when, I am a psychologist who believes in taking the unhelpful stigma out of, well, EVERYTHING.
Menopause has been more difficult to disclose than cancer: WEIRD. Talking about menopause with and due to cancer and chemo: DOUBLE WEIRD. This combo takes Meno, ‘to another level’ (the catch phrase of 2017-18, I’m sure). Talking about some aspects of Menopause have been harder than others; vaginal dryness for instance. For some reason, I found this really hard to write/talk about. Worried I’d be judged maybe? Worried people would assume I was experiencing vaginal dryness and for some reason not wanting people to assume that everything I write about, happens to me? Strange, given mostly it does, and the blog is of a personal nature. But that’s the point isn’t it. Get talking. Reduce stigma. There is nothing to be embarrassed or awkward about. These processes are natural, they do not need to be hidden, talked about in secret or god forbid, suffered in silence.
I think underneath it all, I believe my and many European societies or so called developed countries with an individualistic tendency, associate women, during and post menopausal as old, unsexy, and past it. I know that simply isn’t true. Sophia Loren, Helen Mirren, my Mum, spring to mind – all sexy, awesome women, regardless of age. Yet I worried and continue to worry about feeling and being: old, unsexy and past it, particularly when my skin gets thin and wrinkly from steroids and chemo, my grey hair becomes more abundant and my energy or libido feel low. I worry when I stop feeling like myself.
All is not lost; applying psychology skills, and finding psychological flexibility, I constantly and consistently challenge these thoughts and feelings. Though some days it is hard to do. I remind myself of a new more helpful perspective. I take time to reflect, recognise and acknowledge that I haven’t felt old or unsexy every day or every moment of the day. In fact, I have and do feel mighty fine, a lot of the time (another rhyme?). Not bad for a woman fast approaching 50.
Menopause communities…have you found yours?
Thank goodness for the new wave of open discussion about Menopause and growing social communities like the Menopause Café movement. It’s about time. Here are two Meno stories and an episode of Loose Women about Meno. You may also want to check out the magazine Menopause Matters. I’m very grateful for Katie Phillips, her wonderful interviewees, the menopause café team, the celebs who have shared their stories (Kim Cattrall, Zoe Ball, Meg Matthews, Lorraine Kelly to name a few (see their and others’ stories here) and the ordinary (spectacular) women in my life who have disclosed their menopause journeys to me. Thanks for helping me get over my embarrassment by reminding me; I am not alone and that my Meno related decisions will be the right ones for me.
I have a lot of time for the author Christine Northrup with her interest and application of both her medical and holistic complimentary health expertise. Here is one of her books that you might find particularly useful.
The Wisdom of Menopause
Please do share the link to this blog, ask any questions you may have and do let me know:
- What has been the hardest part of your menopause or menopause with cancer journey?
- What has been the hardest part of caring for someone going through menopause or menopause and cancer?
- What have you discovered?
- Your Meno poem
Resources, References, Study papers and more:
Menopause, The Musical
Communities: The Menopause Cafe
2 English Oxford Living Dictionary (August, 2018).
Definition of isoflavones. https://en.oxforddictionaries.com/definition/isoflavone
Definition of phytoestrogen. https://en.oxforddictionaries.com/definition/phytoestrogen
Alternatives to HRT
1 Complimentary alternative therapies
8 Natural remedies for hot flashes – black cohosh, ginseng and more
9 Mallhi, T. H., Khan, Y. H., Khan, A. H., Mahmood, Q., Khalid, S. H., & Saleem, M. (2018). Managing Hot Flushes in Menopausal Women: A Review. Journal of the College of Physicians and Surgeons–Pakistan: JCPSP, 28(6), 460-465.
Soy germ and isoflavones
3 Imhof, M., Gocan, A., Imhof, M., & Schmidt, M. (2018). Soy germ extract alleviates menopausal hot flushes: placebo-controlled double-blind trial. European journal of clinical nutrition, 1.
Support for Promensil
5 Myers, S. P., & Vigar, V. (2017). Effects of a standardised extract of Trifolium pratense (Promensil) at a dosage of 80 mg in the treatment of menopausal hot flushes: A systematic review and meta-analysis. Phytomedicine, 24, 141-147.
6 Panay, N. (2011). Taking an integrated approach: managing women with phytoestrogens. Climacteric, 14(sup2), 2-7.
Controversy & Genistein
4 Lethaby A, Marjoribanks J, Kronenberg F, Roberts H, Eden J, Brown J. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD001395. DOI: 10.1002/14651858.CD001395.pub4.
Vitamins, Black Cohosh and more
Vitamins in combination with Isoflavones –
7 Vitale, S. G., Caruso, S., Rapisarda, A. M. C., Cianci, S., & Cianci, A. (2018). Isoflavones, calcium, vitamin D and inulin improve quality of life, sexual function, body composition and metabolic parameters in menopausal women: result from a prospective, randomized, placebo-controlled, parallel-group study. Przeglad menopauzalny= Menopause review, 17(1), 32.
10 Muhleisen, A. L., & Herbst-Kralovetz, M. M. (2016). Menopause and the vaginal microbiome. Maturitas, 91, 42-50.
11 Britton, R. A., Irwin, R., Quach, D., Schaefer, L., Zhang, J., Lee, T., … & McCabe, L. R. (2014). Probiotic L. reuteri treatment prevents bone loss in a menopausal ovariectomized mouse model. Journal of cellular physiology, 229(11), 1822-1830.
12 Mohammady, M., Janani, L., Jahanfar, S., & Mousavi, M. S. (2018). Effect of omega-3 supplements on vasomotor symptoms in menopausal women: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology.
Vitamin C & E
Support for Vitamin C & E
13 Doshi, S. B., & Agarwal, A. (2013). The role of oxidative stress in menopause. Journal of mid-life health, 4(3), 140.
No support for Vitamin E (Note – an older paper and findings may be outdated)
15 Dennehy, C., & Tsourounis, C. (2010). A review of select vitamins and minerals used by postmenopausal women. Maturitas, 66(4), 370-380.
14 LeBlanc, E. S., Hedlin, H., Qin, F., Desai, M., Wactawski-Wende, J., Perrin, N., … & Stefanick, M. L. (2015). Calcium and vitamin D supplementation do not influence menopause-related symptoms: Results of the Women’s Health Initiative Trial. Maturitas, 81(3), 377-383.
16 Lerchbaum, E. (2014). Vitamin D and menopause—A narrative review. Maturitas, 79(1), 3-7.
18 Kim, D. E., Cho, S. H., Park, H. M., & Chang, Y. K. (2016). Relationship between bone mineral density and dietary intake of β-carotene, vitamin C, zinc and vegetables in postmenopausal Korean women: a cross-sectional study. Journal of International Medical Research, 44(5), 1103-1114.
19 Jaghsi, S., Hammoud, T., & Haddad, S. (2018). Relation Between Circulating Vitamin K1 and Osteoporosis in the Lumbar Spine in Syrian Post-Menopausal Women. The open rheumatology journal, 12, 1.
17 Kim, M. S., Kim, E. S., & Sohn, C. M. (2015). Dietary intake of vitamin K in relation to bone mineral density in Korea adults: The Korea National Health and Nutrition Examination Survey (2010–2011). Journal of clinical biochemistry and nutrition, 57(3), 223-227.
21 N.B. Old study – Borrelli, F., & Ernst, E. (2010). Alternative and complementary therapies for the menopause. Maturitas, 66(4), 333-343.
22 Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007244. DOI: 10.1002/14651858.CD007244.pub2.
25 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, Issue 7. Art. No.: CD007410. DOI: 10.1002/14651858.CD007410.pub2.
23 Zhu X, Liew Y, Liu ZL. Chinese herbal medicine for menopausal symptoms. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD009023. DOI:10.1002/14651858.CD009023.pub2.
Non hormonal interventions e.g. SSRIs
24 Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C. Non‐hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD004923. DOI: 10.1002/14651858.CD004923.pub2.
Cognitive Behavioural Therapy (CBT)
28 British Menopause Society – CBT for Menopause Fact Sheet
27 Stefanopoulou, E., & Grunfeld, E. A. (2017). Mind–body interventions for vasomotor symptoms in healthy menopausal women and breast cancer survivors. A systematic review. Journal of Psychosomatic Obstetrics & Gynecology, 38(3), 210-225.
Vegan-Plant based diet
20 Beezhold, B., Radnitz, C., McGrath, R. E., & Feldman, A. (2018). Vegans report less bothersome vasomotor and physical menopausal symptoms than omnivores. Maturitas, 112, 12-17.
26 Move Over Menopause – 5 reasons why this is the best time to exercise.
Alternatives to HRT and Cancer
29 Fritz H, Seely D, Flower G, Skidmore B, Fernandes R, Vadeboncoeur S, et al. (2013) Soy, Red Clover, and Isoflavones and Breast Cancer: A Systematic Review. PLoS ONE 8(11): e81968. https://doi.org/10.1371/journal.pone.0081968
30 Toi, M., Hirota, S., Tomotaki, A., Sato, N., Hozumi, Y., Anan, K., … & Ohno, S. (2013). Probiotic beverage with soy isoflavone consumption for breast cancer prevention: a case-control study. Current Nutrition & Food Science, 9(3), 194-200.
Use of Promensil in women with a family history of Breast Cancer
31 Atkinson, C., Warren, R. M., Sala, E., Dowsett, M., Dunning, A. M., Healey, C. S., … & Bingham, S. A. (2004). Red clover-derived isoflavones and mammographic breast density: a double-blind, randomized, placebo-controlled trial [ISRCTN42940165]. Breast Cancer Research, 6(3), R170.
Some of the interviews
Katie Phillips (facilitator of week of My Menopause – interviews with menopause experts)
Celebrity Meno Stories
Importance of vaginal lubricant and vaginal moisturiser (with helpful product comparison)
32 Edwards, D., & Panay, N. (2016). Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?. Climacteric, 19(2), 151-161. https://www.tandfonline.com/doi/abs/10.3109/13697137.2015.1124259#aHR0cHM6Ly93d3cudGFuZGZvbmxpbmUuY29tL2RvaS9wZGYvMTAuMzEwOS8xMzY5NzEzNy4yMDE1LjExMjQyNTk/bmVlZEFjY2Vzcz10cnVlQEBAMA==
Vulvovaginal Atrophy (VVA)
33 Treating vulvovaginal atrophy/genitourinary syndrome of menopause: Lubricants, Moiturizers and Vaginal DHEA. Slides by Nick Panay, Imperial College London.
Ice-creams – Mark Cruz -334535
Sheep – Sam Carter -191161
The Tor in Glastonbury – Hello I’m Nic -710394
New shoot amongst the dry – Stas Ovsky -632497
Two cups – Tom Crew -661269
Boy and microphone – Jason Rosewell -60014
Four women – Menopause Musical – https://www.ents24.com/uk/tour-dates/menopause-the-musical-touring
Promensil picture 1 – me
Promensil picture 2 – https://promensil.co.uk/
Probiotics – me
Chillmax pillow – me
Article related pictures – me
Book – https://www.drnorthrup.com/
© 2018 Janine Hayward www.psychingoutcancer.com. All rights reserved.
Posted in Menopause, Symptoms and Side Effects Tagged with: Alternatives to HRT, Black Cohosh, Calcium, Cancer, Chinese Medicine, Complimentary therapies, Ginseng, HRT, Isoflavones, Menopause, Myeloma, phytoestrogen, Promensil, Psychology, Red Clover, Soy, SSRI, Treatment, Vitamin B, Vitamin D, Vitamin E, Vitamins, Zinc
I flashed my boobs to three women I barely know today. Actually, it was less of a flash and more of mid-term exposure. Sometimes I wonder if I have no dignity left or if an automatic behaviour kicks in; be matter of fact and ‘get on with it’. The women (a care assistant, chemo nurse and clinical trial doctor) were all female, super nice and respectful. That helped. It’s funny, I notice I slip into, ‘put them at their ease mode’ even though it’s my boobs that are on display, being covered in sticky pads and wired up for an ECG. I suppose it’s a way of making myself feel better. Happy medical team, more willingness to look after me, happy patient, me.
Hmmm…as happy as you can be after another day of hospital appointments: early morning blood test, five hours on the chemo ward, loads of waiting for drugs that should have been ready, sky high blood pressure, racing heart (hence ECG), and chemo. To top it off, boobs were touched up, not once, but three times, while there was a struggle to get the ECG set up and working properly. The ECG that usually takes 5 minutes, took over 30 minutes and then, of course, I had to wait for it to be ‘signed off’ and for my blood pressure to come down, before I could escape. Happy me.
Menopause (Meno) part two
Anyway…my boobs are back under wraps so this blog is again going to focus on Menopause. Men, the decisions women must make about whether to put up with symptoms, how to find and interpret information about how to manage symptoms and decide what symptom management solution to choose, can be a full-blown, time consuming project. It’s rarely straight forward. They may need your help and similarly, you may need theirs, if Andropause (Andro) impacts you. Both Meno and Andro are especially tough, if you are living with cancer or the possibility of cancer recurrence (see Menopause Part 1).
This is my menopause discovery and decision story with hope that it shares useful sources of information and pearls of wisdom. I am no menopause expert. I have done a lot of leg work which I hope saves you and your significant others, time, and leads to your discovery of rapid, helpful, tailored solutions that work for you and the women in your life. My discovery includes growing ‘Meno’ communities offering understanding, support and a safe place to talk – hurrah! Men, women, please do use this and my previous blog on Menopause, pass them on to your male and female friends and partners. Ask any questions you have.
Daily Mail Headline – Woman’s death related to Menopause
Women, please seek help, don’t put up with symptoms unless it is your conscious, measured choice to do so. Don’t lose your life to Meno – yes – sadly – it appears, one woman may have experienced severe distress related to Meno, treatment, depression and difficulties with treatment1 (Caution – it is a Daily Mail report, though her diaries appear to have provided an insight into the woman’s pain and distress).
Tummy fat and grey hair
Remember, Meno symptoms are often super challenging. They includie mood swings, hot flushes, night sweats, brain fog, short term memory loss, difficulty in finding words and stringing sentences together, fatigue, bone loss, low libido and vaginal dryness. Others I didn’t mention that are also frustrating and challenge identity for many women, are the replacement of our luscious hair with a greying, coarser version (if chemo or living with alopecia hasn’t stripped us of hair already) and the addition of tummy fat (due to a loss of estrogen, see article).
Estrogen or Oestrogen
By the way, I should have said in the last post (and for those that don’t know) estrogen (also spelt oestrogen) refers to any of a group of steroid hormones which promote the development and maintenance of female characteristics of the body.2
The arrival of tummy fat for women who have always exercised or been lucky enough to have slim tummies can be super distressing (though I don’t know one woman, whatever shape, loved or loathed, that welcomes tummy fat!!). Add to that, Meno hormone changes can increase sweet cravings – oh joy, another challenge, especially when trying to keep sugar on the down low to prevent cancer. There is good news; menopause symptom management solutions appear to positively impact tummy fat! At the very least solutions make it easier to exercise without feeling we will set the whole place on fire or internally combust. Still, for some, supplements or hormone therapy won’t be the right path and an estrogen-loss based belly, may prove difficult to budge.
MMmM, Information Sources and Standoff
The Universe aligned to bring me different sources of Menopause information right when I needed them. I know this has not been the case for many women; they have found it hard to find any information beyond their GP’s knowledge and the common offer of Hormone Replacement therapy (HRT). Often, HRT, has only been offered if the women have been listened to, heard and had their symptoms taken seriously.
My medical team
I started out on this MMmM project (my new term for Multiple Myeloma and managing Menopause symptoms) by asking my medical team. Like nutrition, gynaecology is not their world. They are haemo-oncologists and don’t, and can’t, know about everything. This is despite my expectation, wish, hope, that they would be fonts of all knowledge about any factor that might impact my cancer, treatment and living well with both. The oncologists had very little information about Menopause and symptom management. What they did have, was solely about HRT, did not consider alternatives and seemed out of date. They did not have any specific info about Myeloma and Menopause. I suppose on reflection, this should not have been surprising; Myeloma is still rare in women (it is predominantly associated with males of black populations in their 70s).
My oncologists disagreed!
One was pro use of HRT and the other thought HRT would be a bad idea. It would probably have been more apt to call this standoff, My Meno Brexit; one oncologist is English, the other European, and no agreement has been reached! This difference has ended up being the lasting concern that has made final decisions difficult.
The female oncologist suggested HRT may be a good idea due to its bone protection properties. The male oncologist was concerned that given the procedures such as stem cell transplant and additional chemotherapy I would be likely to need in the future, the addition of HRT could exacerbate the risk of secondary cancers turning up.
With this haemo-oncology, MyMenoBrexit standoff as the second layer in my context to making a menopause decision (the first being, wanting to find out what was a cancer or chemo symptom versus a menopause symptom) I sought more information on the pros and cons of HRT and alternative options (if there were any).
Other information sources used (see links at the end of the blog):
- Two appointments with a gynaecologist where I found out about some of the latest research, clinical guidelines, risks with HRT and opinions regarding Promensil (an alternative).
- The menopause exhibition I happened upon led me to info and samples of Promensil and Vaginal dryness/lube solutions (Sylk and YesVM and YesVB).
- A week of online interviews (approximately four each day) with Menopause experts (from both medical and holistic backgrounds) run by Katie Phillips.
- BBC Radio show about Menopause.
- Women in my life who suspected they were, were currently living with, or, had gone through perimenopause and menopause.
- Breast Cancer Now website.
The low down; My discoveries.
This and the next post are a brief synopsis of the wealth of information I gathered. Although, it may feel a wee bit long in places, I have also tried to make it comprehensive enough to be useful. If a natural, totally non-medical approach is your thing I recommend selecting and listening to the online videos of interviews with experts without medical training or with a holistic approach (link at bottom of the blog). I listened to most of the interviews and was predominantly interested in experts who talked about research, evidence and their years of experience helping women manage menopause successfully. This is what I found out…
Hormone Replacement Therapy (HRT)
- Works well (improved sleep, skin, mood, flushes) and low risk for many women
- Can reduce risk of heart, cholesterol and bone problems
- ‘Good bioidentical hormones’ versions (plant based rather than equine) are safer
- Consider gel or patches if impact on your liver is important to you
- Some cancers (e.g. hormone receptive cancers) can mean HRT is off the menu
- Despite the many pros, HRT won’t be everyone’s cup of tea
There are a lot of misinterpreted research studies, obsolete data and unhelpful myths out in the world about HRT. For many women, especially women who start taking HRT earlier (before 50) and stay on it for a short period (4-5 years) HRT appears to have many more positives than negatives going for it. It has few side effects and is not linked to getting cancer any more than being overweight, a smoker or drinking too much alcohol increases the risk of cancer, well breast cancer anyway.3 Here is a helpful graphic below showing this.
However, it is very important each woman weighs up the risks for herself, talks with her GP, Gynaecologist and medical team (if being supported for cancer or other illness) before starting HRT.
For now, I really like Dr Louise Newson’s summary of HRT and the primary care women’s health forum useful graphic.4 Check out both here – dispelling HRT myths.
An official report (though not without controversy)
If you are interested in the academic, research reports, here is a link to The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women.5 I find this report helpful because it summarises HRT research outcomes, risks and benefits relating to:
- menopause symptoms including hot flushes, mood, musculoskeletal and sexual function difficulties, and
- other important concerns including osteoporosis, cardiovascular/heart, cognition, cancer, post cancer, stroke, thrombosis/blood clots and premature ovarian insufficiency
The article also discusses pros and cons of different methods of taking HRT, pharmacological alternatives to HRT including Selective Serotonin Reuptake Inhibitors (SSRIs, often referred to in the media as anti-depressants) and doesn’t ignore the evidence for phytoestrogen solutions. Phytoestrogen refers to a substance found in certain plants which can produce effects like that of the hormone oestrogen when ingested into the body.2
Transparency, risks and criticisms
I must let you know there has been some controversy about the recommendations for HRT and the National Institute of Clinical Excellence (NICE) guidelines (2015)3. Some researchers and clinicians including oncologists have claimed the safety of the latest types of HRT have been exaggerated. However, this criticism is also controversial and has been challenged! Another standoff; there are quite a few kicking about in this world of Menopause!
Risk- House on the edge
HRT, breast cancer and risk
I’m sure you can imagine that the last thing I want to do, after undergoing treatment for Multiple Myeloma, is to then be diagnosed with breast cancer or any other cancer for that matter. Worse, if I discovered that a decision that I had made, such as to take HRT, contributed to the likelihood of me being diagnosed with breast cancer and… I hadn’t taken time to learn about the risks or weigh them up beforehand, I suspect I would become angry with myself, feel sorry for myself, be disappointed and ultimately very, very sad.
If on the other hand, I become informed as best as I can at the time (i.e. now), weigh up the pros and cons, decide to take HRT and I still get diagnosed with breast or any other cancer, I would have to say I had done my best, it was not my fault. I’d attribute my new diagnosis to be being rather bloody unlucky at that point and hopefully summon some energy to discuss and embrace a treatment plan.
My way is not the right way for every woman
I recognise that some women (and men) would rather embrace a plan recommended by a specialist or medical team, without questioning it or researching alternatives. Exercising faith that the right thing for them has been chosen and placing full trust in the people who spend time being the specialists in these areas, is one way of making decisions. No one method of deciding what is right for me, for us, for your significant women, is better than another; it’s about what works for each of us individually.
With my current diagnosis of Multiple Myeloma, I am more at risk of other cancers6 (particularly AML and MDS) so I was interested in the criticisms of both the report’s recommendations about HRT and the NICE guidelines.
Among several criticisms, on a key concern, one side says ‘up to 7000 extra cases of breast cancer within ten years’ would result from women taking HRT while the other side (also seemingly experienced researchers and clinicians) back up the Women’s Health Concern report. They argue that of 1000, 50-year old women in the UK, 23 would be expected to be diagnosed with breast cancer before they reach 60; however, if 1000, 50-year old women took combined HRT for 5 years, 28 would be expected to be diagnosed with breast cancer before 60 (an increase of five per 1000) and that taking estrogen alone is associated with even lower or no change in risk.7, 8
The Breast Cancer Now website have some very useful graphs that make risks easier to put in context. They are based on data from the Breakthrough Generations Study that aims to find out what causes breast cancer (supported by Breakthrough Breast Cancer and The Institute of Cancer Research). The graphs show that using combined HRT for fewer than five years leads to about seven extra women out of 1,000 to develop breast cancer between the ages of 50 and 54. 9,10
I have included a link to Breast Cancer Now, a link to a study about ‘the true size of the increased risk‘ and links to the write up of the controversy issued in Post Reproductive Health for you to make up your own mind. I recommend reading all of it as you will see how the critiques were also critiqued!
Final note on this…while the stats talked about here relate to women, hormones and HRT please remember men are diagnosed with breast cancer and can experience challenges with hormones also.
HRT & Multiple Myeloma
Surprise! (ok, not really). There is very little research available, particularly involving well powered studies (with enough participants for meaningful conclusions to be drawn) exploring the impact of taking HRT on the risk of Myeloma or Myeloma relapse. That might explain why the haemo-oncology team were struggling! One study with a summary of associations between reproductive factors and Myeloma (open about the caveats / limitations of their data), concluded that there is no significant role for reproductive factors or HRT related hormones in causing Myeloma. So, if I was going to set my store by this study, I would assume HRT is unlikely to make my Myeloma worse or cause a relapse.11,12
What does all this risk data and controversy mean for me, for us?
At the end of the day we need to ask ourselves;
Whether you have or have had cancer or not; Will the benefits of relief from Menopause symptoms outweigh the risks of developing breast or other cancers?
Now, a few other things to consider (as if the long list above wasn’t enough already!)
Lovely horse called Prince
No horse for me please!
Plants, horses, bioidentical hormones and HRT delivery mechanisms
I love horses, they are beautiful…and I simply don’t fancy any of their hormones inside me, thanks. Years ago, ‘bad’ synthetic hormones seemed to be all you could get when it came to HRT. Pills manufactured in a lab, based on hormones extracted from horses’ urine were given to women to help with Meno symptoms. I hope GPs no longer prescribe such versions as apparently, the body finds it easier to break down plant based hormones.
These days, the reputation of bioidentical hormones (manmade hormones originating from plant oestrogens that are chemically identical to those the human body produces13) is becoming more positive, even ‘good’. For some people, anything that goes near a lab is ‘unnatural’. For others, a plant based hormone, structurally identical to those in humans, is natural enough.
Pill or gel or patch?
The other thing to think about is the form in which to take HRT. A pill can be easy and easily tolerated by many. Although, a pill does mean the liver needs to get involved and process it. For those of us who for whatever reason need to be especially kind to our liver and not give it anything else to directly process/worry about (for instance as they continue with chemotherapy) a gel or patch delivery mode may be better. In summary, if I decide to go with HRT, I will be asking for a good plant based bio identical hormone delivered via gel or a patch.
Let’s take a breather.
Need a breather? I do. Coming up in part 3; Alternatives to HRT, including ‘Take nothing’, Isoflavones and Phytoestrogens. I will find an easy to understand description of what these are all about. Before I go, a small bit about Tinnitus and an important bit about a fabulous group of women.
HRT may help prevent tinnitus! I wouldn’t know what to do with myself if I decided to take HRT and it ended up positively impacting my tinnitus. I’d probably become evangelical about the stuff! More about this here (or ‘ear’!) 14
The wonder of women
Last month, I managed to get away from hospital life for a few days and hang out with a fabulous bunch of straight talking, fun loving, wise, wonderfully womanly women. They are diverse: their ages, pasts, lives, loves, and losses. They laugh a lot, are bound together by long standing, friendship and family, and friendship within family. When they talk over the top of each other (yet still hear everything), squabble, give each other a hard time – the depth of love, caring, empathy, loyalty and commitment to being there for each other is still palpable. It was a safe place to talk about health, a safe place to talk about menopause and a fab space to ignore both topics for a while. A tonic. You know who you are. Thank you.
Share, like and comment please…
Please do pass the link to this blog on, like the PsychingOutCancer facebook page, ask any questions you have and do let me know….
- What has been the hardest part of your menopause or menopause with cancer journey?
- What have you discovered?
Articles and summaries:
Symptoms, updates on HRT safety, antidepressants
1 Daily Mail reporting as it might be, her diaries provided an insight into the woman’s pain and distress http://www.dailymail.co.uk/news/article-5900653/Woman-hanged-struggling-cope-menopause.html
4Myths about HRT and info on Menopause generally – Dr Louise Newson https://menopausedoctor.co.uk/news/world-menopause-day-dispelling-hrt-myths/
Some of the interviews with menopause experts.
Katie Phillips (facilitator of week of My Menopause – interviews with menopause experts)
References, papers and guidelines
2 English Oxford Living Dictionary (July, 2018).
Definition of estrogen. https://en.oxforddictionaries.com/definition/us/estrogen
Definition of phytoestrogen. https://en.oxforddictionaries.com/definition/phytoestrogen
3 NICE Menopause guidelines here https://www.nice.org.uk/guidance/ng23
5 The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women http://journals.sagepub.com/doi/pdf/10.1177/2053369116680501
Criticism, support, risk and HRT
1 Post Reproductive Health http://journals.sagepub.com/doi/full/10.1177/2053369116629288 (second part of paper with numbers may require payment unfortunately re war of words and numbers – reference below)
Increased risk – true size – Jones, M. E. et al. (2016). Menopausal hormone therapy and breast cancer: what is the true size of the increased risk? Br. J. Cancer, 115, 607–615 https://www.ncbi.nlm.nih.gov/pubmed/27467055
7 Brown, S. (2016). NICE menopause guidelines: A war of words and a war of numbers. Post Reprod Health. 22(1):11-2.
8 Daily mail report referenced in S Brown’s NICE menopause guidelines: A war of words and a war of numbers. New HRT advice is biased and misleading
9 Breast Cancer Now – HRT and Breast cancer risk
10 Breast Cancer Now – HRT and Breast cancer risk – underestimated? http://breastcancernow.org/news-and-blogs/news/effect-of-combined-hrt-on-breast-cancer-risk-likely-to-have-been-underestimated
Breast Cancer Now website and Generations Study
Myeloma and HRT
Second Cancers After Multiple Myeloma
11Reporoductive factors and Multiple Myeloma http://cebp.aacrjournals.org/content/cebp/early/2015/12/29/1055-9965.EPI-15-0953.full.pdf
12 Italian Study https://www.ncbi.nlm.nih.gov/pubmed/15554564 (note this study wasn’t corroborated by other, though smaller studies)
Hormone replacement therapy decreases the risk of tinnitus
Cat_dog – Paul J Everett_standdown (Flickr and Creative commons_public use)
Horse (Prince) – me
Swaggy – Christin-Hume
House – Cindy Tang – 25654
© 2018 Janine Hayward www.psychingoutcancer.com. All rights reserved.
Posted in Menopause, Symptoms and Side Effects Tagged with: bioidentical, Breast Cancer, Cancer, estrogen, Hormone Replacement Therapy, hormones, HRT, Menopause, Myeloma, oestrogen, phytoestrogen, Tinnitus