Perimenopause, including Premenopause, Menopause, and Postmenopause

Perimenopausal Syndromes: considerations of symptoms, health risks and associated health problems to design an individualized prevention and treatment protocol

The term menopause comes from a French medical term that is derived from the Greek words menos and pausis, meaning "month" and "pause or cease", and from pauein, meaning "to cause to cease", and refers to the cessation of the monthly cycle of fertility mechanisms and bleeding. More importantly, though, is the subject of the normal hormonal changes that occur with this ending of the monthly menstrual cycle, and the cause of these changes. An unhealthy focus on menopause instead of the whole process, or perimenopause, in standard medicine reflects the typical allopathic view of narrow focus. Instead of helping the patient experiencing problematic symptoms and considering risks of associated health problems with a holistic understanding of their physiological changes, a narrow focus on the cessation of the menstrual cycle and subsequent treatment with hormone replacement alone occurred. At one point, it was suggested that all women should perhaps replace their natural hormone estradiol with a synthetic version. This proved profitable for the industry, but disastrous for the women, as the large Women's Health Initiative study in the 1990's discovered. The promise of lowered rates of cancer, osteoporosis and cardiovascular disease with synthetic hormone replacement were found to be just the opposite, a lie.

Today, most women, and a growing number of medical doctors, are finally considering this whole period of hormonal transition and the health concerns associated, and taking a holistic approach to care. In fact, we now know that men experience a similar transition hormonally at about the same age, and we term this andropause, usually occurring at about age 56. The ancient Taoist Chinese physicians stated that women experience a cyclical change every 7 years, and men every 8 years, hence menopause at 49 and andropause at 56. Since the vasomotor symptoms are not so dramatic for men, men are allowed the luxury of ignoring this change and hoping for the best. Since about 80 percent of women in the United States now experience some degree of vasomotor episodes, or hot flush and abnormal sweating, during perimenopausal changes, most women are having a hard time ignoring the problem.

The term menopause should be replaced with the term perimenopause, or perhaps simply called the transition. Perhaps we could just say that "I'm going through my Peri". It was enticing for women to try to ignore the hot flush and sweating episodes and take a pill, hope for the best, and pretend that you weren't aging. The smart woman, though, will take a look at this perimenopausal stage of 2 to 9 years, understand it, and make the smart and healthy moves to insure that the rest of their lovely life is of the best quality possible. Helping your body to achieve the most physiologically normal balance of hormones during the transition will prevent hot flush, abnormal sweating, sleep disturbance, and an array of potential symptoms that disrupt your life. More importantly, it will help prevent breast cancer, osteoporosis, cardiovascular problems, memory and attention span problems, and syndromes of anxiety and depression, and may even help prevent neurodegenerative disorders, such as Alzheimer's and Parkinson's disease.

In 2011, researchers at the University of Pennsylvania School of Medicine published the results of a large randomized stratified cohort study following women through perimenopause to the postmenopausal period, from 1995 to 2009, and found that women who started to experience symptoms of hormonal imbalance early in the perimenopausal period experienced an average course of hot flush and sweating episodes of nearly 12 years, while those that started experiencing these symptoms after cessation of the menstrual period averaged a course of symptoms of only 3.84 years. The average age for women experiencing the worst intensity and frequency of these symptoms was between 45 and 49 years of age, showing that the standard protocol of waiting until menopause and then prescribing hormone replacement therapy with synthetic hormones was a very misguided approach. The discouragement of Complementary and Integrative Medicine and hormonal balancing before and early in the perimenopausal course, with bioidentical hormone therapy, acupuncture and herbal and nutrient medicine has proven to be a disastrous protocol.

As women approach age 50 there are normal hormonal changes that can become problematic, and an array of therapeutic measures that may make this transition from the normal hormonal production, stimulated by the breakdown of hormonally rich ova and endometrial linings each month, to a hormonal production and regulation that is not dependent on the menstrual cycle. This transition is called menopause because it is a pause in the menstrual production of hormones and a period of adaptation to new type of hormonal balance and regulation. By understanding the physiology of this transition, women may choose sensible ways to insure that the transition is smooth and relatively free of symptoms. Historically, cultures across the planet have adapted with dietary changes and herbal regimens to make this transition smooth and healthy. In modern times, women have been given the impression that they could ignore these changes and depend upon synthetic hormone replacement when alarming symptoms occurred. We now know that this was a tragic mistake, as increased cancers, cardiovascular problems and osteoporosis resulted, and many women did not achieve a significant control of post-menopausal symptoms and found that their general health and quality of life had deteriorated with chronic use of the synthetic hormones.

Menopause transition, or perimenopause, may vary considerably from one woman to another. Fluctuating ovarian function may start to occur from 2 to 8 years before menopause, and may continue for up to 1 year after full cessation of the menstrual periods. This entire time of hormonal change is called the perimenopause by the World Health Organization. This is a confusing subject for most women, who have been given the impression that the perimenopausal state ends with premenopause and menopause. In reality, the term perimenopause defines the entire course of transition hormonally through the premenopausal changes, to menopause, and for up to a year post-menopausally. This entire perimenopausal time should be addressed when the woman and her physicians try to decrease health risks and symptoms, and make the hormonal transition as smooth as possible.

Many systems are affected by the hormonal imbalances that occur during this variable perimenopausal period, including the neuroendocrine, cardiovascular, musculoskeletal, and genitourinary systems, and even the system regulating the health of the skin and hair. The perimenopausal changes are still poorly understood in medicine, but we have accumulated much data concerning the pathology of adverse perimenopausal syndromes. Up to 1% of women in the United States may experience premature ovarian insufficiency before the age of 40, resulting in ovulatory failure and amenorrhea (no menstrual period of bleeding). A much larger percentage may experience subclinical ovarian insufficiency or dysfunction, which may account for the large percentage of women having difficulty with normal fertility and pregnancy. In recent years, certain demographic sets of women under the age of 40 have shown signs of polycystic ovarian syndrome at alarming rates causing this subclinical ovarian insufficiency or dysfunction, up to about 20 percent of women studied in many areas of the U.S. and Europe. Understanding the physiology of the healthy ovarian function is integral to solving and preventing the problems of perimenopause, premenopausal states, and menopause. Ovarian problems may even contribute to problems in post-menopause for some time after the last menstrual period is experienced, as we now know that the ovaries do continue to function postmenopausally. Ignoring this important issue of healthy ovarian function is not an option for the women wishing to take a proactive approach to better health and quality of life in their 40s.

In recent years there has been a return of an attitude unfavorable to natural hormonal health and function in standard gynecology in the United States and elsewhere, perhaps as a backlash to criticism. For instance, many younger women are now prescribed forms of synthetic hormonal birth control that cause anovulation and cessation of the monthly cycle of hormonal fluctuation and fertility pattern. Many women are told by their prescribing gynecologist that this cessation of the monthly period is perfectly healthy and perhaps more convenient. Some patients are even told that this may decrease risk of ovarian cancer. There is no truth to this advice whatsoever, and many scientific studies show just the opposite. In 2005, an expert on perimenopause and hormonal pathologies, Dr. Alessandra Graziottin of the University of Florence, Italy, stated that: "It has been reported that in contrast to the 50 percent of women who report severe symptoms following natural menopause, about 90 percent experience severe symptoms following surgical menopause (hysterectomy or ovarectomy), in which a primary source of androgens has been removed." (The Journal of Sexual Medicine 2005; 2.suppl.3; 133-145) Dr. Graziottin states that women who have undergone chemotherapy or radiation treatment that destroys follicles and Leydig cells in the ovaries irreversibly, or iatrogenic menopause, also report a higher degree of severe symptoms of hormonal dysfunction, and are often unrecognized in standard medicine. Women who have undergone surgical or iatrogenic menopause also have a much higher rate of sexual desire disorder and distress than women undergoing natural menopause. Advice that steers patients to unnecessary cessation of ovulation or surgical removal of the sexual organs does not result in better health outcomes for a large majority of these women. Whenever possible, a restoration of natural hormonal health and function will result in a better overall outcome.

Complementary and Integrative Medicine (CIM) offers women the chance to achieve a smooth menopausal transition that is healthy and reduces risks of this wide array of associated health problems, most of which are not associated directly with the menstrual period and the premenopausal changes by the patient. A complete and thorough holistic approach in Complementary Medicine works with the woman to achieve a physiologically normal hormonal balance with herbs, nutrient medicine, bioidentical hormones, dietary changes and acupuncture. Even deep tissue, or soft tissue physiotherapy has been found to be beneficial in this hormonal modulation and regulation (see the related article on this website entitled Deep Tissue Massage and It's Many Benefits). Understanding the physiological issues and goals of therapy is the key to success. Finding a knowledgeable Licensed Acupuncturist and herbalist, or Natuopathic Doctor, to assist with these goals may be the most important step.

Understanding the physiology of menopause

At birth, a woman may have up to two million oocytes, or immature eggs. These are germ cells called gametocytes, and the process of maturation of the ova to the viable egg takes about 13 months in the ovaries. Many immature eggs are lost in the process, and fail to mature. At menopause, the process of atresia (monthly degeneration and resorption of immature avarian follicles) reduces these viable immature eggs to just a few hundred. An ovarian follicle is a complex organ that contains one egg, or ova. A matured, or dominant ovarian follicle produces a quantity of the most potent natural estrogen, estradiol (E2). During menopause the most dominant form of estrogen is estrone (E1), which is still produced by the ovaries as well as the adrenal glands. Estrone is also produced in quantity by the fat cells and derived from the natural conversion of andrestenedione to estrone. Acquisition of increased midsection adipose tissue, or as we could call it, voluptuous curves, is important for the woman in her 40s. In an earlier time, such icons of beauty as Marilyn Monroe went from a skinny freckled girl to a curvy voluptuous model of female sexuality in her 40s and everyone admired this. In more recent decades, the woman is more likely to go on starvation diets to lose weight and look skinny again in midlife. This does not bode well for the production of estrone from adipose cells. A healthy amount of midsection fat appears to be important for the production of estrone during the transition of perimenopause through menopause.

As the perimenopausal woman transitions from an estradiol dominant hormonal mechanism to a more estrone dominant one, the production of androstenedione, a precursor to estrone, becomes more important. Androstenedione is synthesized in two ways in the body. The primary pathway of synthesis involves conversion of pregnenelone to dehydroepiandrosterone (DHEA) with the aid of the enzyme lyase, and the conversion of the DHEA to androstenedione with the aid of the enzyme dehydrogenase. DHEA is the most abundant hormone produced by the adrenal glands, and usually declines with age. The second pathway involves conversion of progesterone to androstenedione with the aid of lyase. The specific progesterone metabolite needed is 17-hydroxyprogesterone, a precursor to cortisol, and thus cortisol imbalances may deplete the 17-hydroxyprogesterone, and thus the androstenedione and estrone. When this happens, estradiol may become dominant in the balance of steroid hormones, and create symptoms. Stimulating increased production of pregnenelone and achieving a better cortisol balance and adrenal function is thus the emphasis in modern Complementary Medicine, as well as maintaining a physiological normal level of progesterone and a healthy PG/E2 ratio of active metabolism (progesterone to estradiol). Active hormonal metabolites measured with a saliva sample will produce a laboratory assessment of these key hormonal parameters and guide therapy for the perimenopausal woman in Complementary Medicine.

Progesterone is a steroid hormone produced by the non-selected egg follicle casing, or corpus luteum, that promotes a healthy thickening of the endometrium (uterine lining) . Progesterone is also produced in other tissues as needed, in both males and females, but the large production of progesterone in the unused egg follicles of the ovary is crucial to the menstrual cycle and viable pregnancy. This corpus luteum develops into a structure that is typically very large relative to the size of the ovary, resulting in the indistinct feeling of pressure, called "Mittelschmerz", or middle pain. A typical ovary at rest is about 3 cm wide, and a typical developed corpus luteum is about 2-5 cm in diameter, greatly increasing the size of the ovary at this stage of the cycle. If the viable egg is not fertilized, the corpus luteum of the unused egg stops secreting progesterone and decays during the menstrual bleeding. The uterine lining, or endometrium, which grows in relation to the amount of progesterone, also then decays, producing menstrual bleeding. The health of the ovary and corpus luteum is thus important during the menstrual cycle, and is important during the perimenopausal period. Progesterone balances with estrogen to maintain the normal healthy hormonal balance that is crucial to so many processes in the body.

A number of factors may contribute to lowered progesterone production during the menstrual cycle. Usually, this lowered progesterone will manifest itself as premenstrual symptoms. If premenstrual syndrome (PMS) occurs in the menstrual cycle, the perimenopausal woman should try to correct this condition to better insure a healthy perimenopausal, premenopause and menopause states. Some factors that may contribute to poor production of progesterone from the corpus luteum include polycystic ovary syndrome (unused egg follicles creating cysts), and other factors affecting the healthy formation of the corpus luteum in the ovary. The yellow color of the corpus luteum is due to its concentration of carotenoids, especially lutein, and deficiency of these nutrients may play a part in less than healthy corpus luteum. Studies have shown that the human corpus luteum concentrates carotenoids from the diet, and are probably not synthesized by the ovary. Carotenoids from the diet mainly come from fruits and vegetables with high amounts of pigments, and are considered antioxidants, but a number of nutritional supplements are popular today that contain key carotenoids, as well as herbal medicines. Beta-carotene is the most well known carotenoid, but alpha-carotene, lycopene and lutein are also now much studied. Carotenoids containing oxygen include lutein and zeaxanthin, while carotenoids without oxygen include beta-carotene, alpha-carotene, and lycopene. Carrots and apricots (orange foods) contain much carotene, but unprocessed palm oil is considered the richest food source (processed palm oil destroys this carotene). Wikipedia lists 86 chemicals in their list of naturally occurring carotenoids, though, and many healthy foods, especially fresh dark leafy green vegetables, as well as many herbs, contain valuable carotenoids that may contribute to a healthy corpus luteum. This is just one example of how the diet is very important in the overall treatment strategy for health problems related to the perimenopause through menopause states.

Since overall progesterone is created from the decay of the endometrial lining in menstruation as well, endometriosis or abnormalities of menstrual bleeding could signal a problem with progesterone creation during the menstrual years as well. Since progesterone promotes thickening of the endometrial lining in the uterus, ovarian dysfunction may lead to a precipitous drop in progesterone, both from the lack of progesterone from the corpus luteum, and also from the subsequent lack of progesterone from the thin endometrium. This is exactly what happens in perimenopause and premenopausal states. As the ovaries age and health imbalance creates problems with the healthy formation of the corpus luteum, the menstrual flow may be decreased, menstrual bleeding may be skipped, and the result is a large drop in the production of progesterone. Insufficient progesterone relative to estrogens is also the problem in PMS.

When progesterone is deficient, greater levels of unopposed estrogens occur, and this may create a number of health problems and risks, especially concerning breast, ovarian and uterine cancers. Progesterone inhibits and modulates the actions of estrogens, especially the most active and potent estrogen, estradiol, on certain tissues. The balance of progesterone to estrogens is thus important not only to the healthy function of the menstrual cycle and smooth transition during the perimenopause through menopausal time, but to a wide array of health issues, including cancerous cell mutation regulation, calcium regulation, bone health, fertility problems, thyroid function and health, and neurohormonal health. The famed medical doctor who pioneered natural bioidentical hormone therapy and balancing, Dr. John R. Lee, a family practice physician who graduated from Harvard and the University of Minnesota Medical School, and worked with the renowned hormonal researcher David Zava Ph.D., described a host of symptoms associated with estrogen dominance, usually the result of a deficiency of progesterone production within the menstrual cycle of hormonal feedback. These symptoms of estrogen dominance include mood swings, irritability, PMS, water retention and bloat, depression with anxiety, fatigue, hair loss, irregular menstruation, sluggish metabolism, decreased sex drive, and dry eyes. Pathologies associated with estrogen dominance include breast cancer, autoimmune disorders, thyroid dysfunction and hypothyroidism, uterine fibroids, hypoglycemia, worsening allergic disorders, polycystic ovaries, osteopenia, endometrial cancer, zinc deficiency, copper excess, and magnesium deficiency. This array of common health problems are often not resolved with the use of synthetic hormone therapies, but often are resolved with the healthy restoration of balance between progesterone and estrogen.

Estrogens must be balanced with progesterones in the human physiology. In TCM we call this the balance of Yin and Yang. The menopausal state occurs when the ovary no longer produces estradiol or inhibin, and the failure to create the corpus luteum in the ovary, and subsequently the endometrial lining of the uterus, results in a precipitous drop in progesterone, as well as estradiol. Since the hormonal system is a feedback system, the production of FSH (follical stimulating hormone) and LH (luteinizing hormone) in the hypothalamic pituitary axis, is also affected. The loss of natural estrogen inhibition of FSH and LH may also result in a number of hormonal symptoms. While standard medicine has insisted that the emphasis be put on the loss of estrogen as the cause of menopausal problems, the loss of progesterone may be even more important, and the changes from an estradiol dominant estrogen system to an estrone dominant system are also obviously important. The array of hormonal problems caused by imbalances between a number of hormones are what are of concern, not just the loss of estradiol from the cessation of the lack of secretion of the viable egg. Standard medicine has stubbornly refused to address this broader issue, mainly because the focus of pharmaceutical treatment is the replacement of the natural estrogens with a synthetic estradiol mixed with progestins (which are not exactly progesterone, but closer in structure to pregnenelone). The treatment and prevention of symptoms, health risks, and hormonal imbalance should begin early in perimenopause, not when the menopause occur, and restoration of natural homeostasis, not replacement, should be used whenever possible. Of course, if restoration does not work, resorting to synthetic hormone replacement temporarily might be needed for some women, but this should not be the first option.

Hormonal imbalances studied in the large University of Pennsylvania study cited above noted that relative increases in FSH and lowered levels of estradiol and inhibin also were associated with the cessation of hot flush during the perimenopause to postmenopause periods. This shows that when the body achieves the transition to estrone and estriol metabolism, from the estradiol dominant metabolism, that less inhibin is produced and FSH levels are allowed to increase, achieving the programmed hormonal balance. The use of synthetic estradiol to decrease menopausal symptoms was obviously misguided. The advice to start or resume contraceptive hormones early in perimenopause to decrease duration of these symptoms is also suspect, as synthetic hormones, dominated by synthetic estradiol, will act to decrease normal feedback controls of natural endogenous hormones. The persistent advice in standard gynecology to prescribe many years of synthetic hormones, often with a cessation of ovulation and menstruation, and often starting during the first years of menstruation and puberty, when these normal hormonal feedback mechanisms are developing in female physiology, may be the biggest contributor to the unusually long course of perimenopausal, menopausal and post-menopausal symptoms in the United States.

A wide array of symptoms may occur due to hormonal imbalances in the perimenopausal, premenopausal and menopausal states

Most of the focus in menopause has been on the menopausal symptoms, but recognizing the symptoms in the perimenopausal and premenopausal states and understanding what they mean physiologically and how to correct the underlying causes may be the most important issue. The perimenopausal period from premenopausal changes through one year after cessation of the last menstrual period is a highly variable time period. Early signs of perimenopause include a mild shortening of the menstrual cycle, typically from 29 days to 26. There is then a 50 percent incidence of anovulation, sometimes resulting in a missed menstrual cycle of bleeding. This is normal. Vasomotor symptoms related to heat flush and abnormal sweating may occur in erratic periods around these changes. Prolonged or heavy bleeding may occur, and symptoms that are less obvious, such as nervous tension and lack of energy, are also common and erratic as the perimenopausal hormonal fluctuations start to occur. A long term study entitled the Massachusett's Women's Health Study, started in 1981, found that perimenopausal women tended to have an increased incidence of musculoskeletal problems, sleep disturbances, and gastrointestinal concerns as well. Studies in recent years showed that early correction of hormonal imbalances in perimenopause results in fewer years of vasomotor symptoms persisting. Utilization of the TCM specialty may improve quality of life considerably, and is now supported by the most conservative of University Medical Schools. Click here to see the inclusion of acupuncture as a recommended therapy for the treatment of vasomotor symptoms by the Stanford University Fertility and Reproductive Medicine Center: http://www.ncbi.nlm.nih.gov/pubmed/25681847

In menopause, a precipitous drop in estradiol may accompany the already precipitous drop in progesterone as ovulation fully stops. Since many cells throughout the body have hundreds of estradiol receptors, changes in the circulating estrogens may have a lot of cellular effects. The cells and local tissues may have to convert to a dependence on higher levels of circulating estrone and estriol, and a more efficient conversion in local tissues of one hormone into another. The fat cells may have to be stimulated to produce more local estrogens as well. This makes for a very complex mechanism. Dr. Allessandra Graziottin, an expert at the University of Florence, Italy, stated in a paper published in the Journal of Sexual Medicine in 2005 that: "The quantity of total estrogen (postmenopausally) still available depends on two factors: the intensity and rate of ovarian exhaustion (the degree and extent of estrogen depletion varies extensively between individuals); and the amount of adipose tissue, which functions as an endocrine gland. A higher body mass index is associated with increased production of estrone, via conversion of adrenal and residual ovarian androgens by aromatases in adipose tissues." The attention to the early perimenopause health, and the avoidance of extreme slimming during perimenopause is thus very important. There is no one physiological or chemical action that needs to take place, but rather a complex array of homeostatic restructuring, and oversimplification of the hormonal restoration in menopause has been a disaster. As stated, the ovaries in the menopausal state continue to function, even during periods of anovulation, but now produce estrone more than estradiol. Testosterone may also convert to estradiol in local tissues with the aid of aromatase enzymes. Normalization of progesterone levels and progesterone/estrogen balance in perimenopause is very important, and maintaining levels of pregnenelone and conversion to DHEA is also a primary concern.

The changes in local hormonal receptors and conversions during perimenopause may increase the chance that cell mutations and cell apoptosis (normal programmed cell death) will be insufficiently regulated, increasing the risks of breast and uterine cancers, and a smooth overall hormonal change will greatly reduce this risk. Since steroid hormones are fluidly converting from one type to another as needed in the body, there is no isolated hormone deficiency, but rather an intrinsic problem with the quantum field of hormones. Testosterone may become deficient in this hormonal milieu as well, and numerous studies now show that naturally postmenopausal women with a measurable deficiency of testosterone, as well as women with surgical or iatrogenic menopause, and low testosterone, who experience low sexual desire, are aided by an increase in testosterone, with an increase in sexual desire, enjoyment, pleasure and orgasm. The key to health in this perimenopausal state is to aid the body as it achieves a new type of homeostasis through a complex rebalancing of hormone production and conversion, and the symptoms tell us what is going on, and what needs to work better to achieve this new homeostasis. Use of topical creams that stimulate increased pregnenelone and progesterone will insure that homeostatic balance of DHEA and testosterone will occur, but this therapy needs to be intelligently and individually monitored. Thus, working with a knowledgeable Complementary Medicine physician to evaluate and adjust therapy in a more holistic fashion is what is needed for optimal results. There is no one-size-fits-all therapy in perimenopause.

In full menopause, sudden loss of estradiol dominance creates symptoms of hot flush episodes, other vasomotor symptoms, mood disturbances, sleep disturbances, and urogenital symptoms, such as dry vaginal membranes and urinary urgency. Signs of the loss of estradiol dominance include osteopenia (loss of bone mineralization), hair loss or thinning, and thinning of the vaginal wall, with unusual bleeding and discomfort with sexual intercourse. Hot flush, or hot flashes, are the most well-known symptom, and may occur either due to neuroendocrine dysregulation (hypothalamic control of temperature) or to vasomotor changes. Other vasomotor signs include sweating, nausea, cephalalgia (headache), dizziness, heart palpitations, and "skin crawling" sensations. Some women may experience dryness in the eyes, nose and mouth as well, contributing to increased allergy symptoms. Decreased estrogens are also associated with a relative excess of androgen effects, and anxiety, hair loss on the scalp, and increased hair growth on the body may result. The body tries to respond by creating more estrone and estriol, and increasing conversion of testosterone to estradiol. Estriol is the most abundant circulating estrogen, but the least active at estrogen receptors. A large amount of estriol converts as needed to estrone, and the estrone converts to active estradiol in local tissues, where the estradiol finally converts to an active form to stimulate many key receptor types. In these local tissues, the balance in the number of progesterone receptors to estrogen receptors keys modulating celluar mechanisms that maintain healthy cells and function, and more importantly regulate the normal cell cycle of life and death, called apoptosis. The number of estrogen receptors on the outside of the cell versus the inside of the cell (estrogen receptor type 1 vs 2, or ER1 vs ER2), also plays a significant role in the regulation of cell apoptosis, and this is often altered by receptor expression changes with menopausal hormonal change and adaptation, leading to prolonged cell life and increased mutations causing cancer. Of course, if the cell cycle is prolonged, the chance of cellular dysfunction and mutations increase, which is the main cause of estrogen receptor positive cancer. A smooth transition from the menstruating estradiol dominant metabolism to the menopausal estrone dominant metabolism is important to decrease the number of cell mutations and receptor changes that stimulate cancerous growth. The increased risk of breast cancer during perimenopause is not just due to excess estrogen in total, but to imbalances in the whole steroid hormone feedback system, especially with localized conversions from one steroid hormone to another. This is why the aromatase inhibitor Tamoxifen is used, but such allopathic drug therapy comes with many symptoms of hormone imbalance as a side effect, and restoration of the normal hormonal homeostasis is a better solution. The balance of hormones is important, not just an excess or deficiency of one. Once again, in TCM this is called the balance of Yin and Yang.

Although the predominant symptoms of menopause, episodes of hot flush and sweating, are the result of loss of estrogen dominance (imbalance of estrogens versus progesterone), the exact mechanism involves a narrowing of the thermoneutral zone in the hypothalamus (increased reactivity to changes in body temperature), involving a balance of neurotransmitters (and neurotransmitter receptors) affected by the loss of estrogen dominance. Not only restoration of steroid hormone homeostasis, but restoration of hypothalamic function and regulation needs to be achieved to achieve the best outcomes. A holistic approach is sensible.

These hormonal changes of perimenopause put much stress on this complex feedback mechanism, and restoration of homeostatic controls often require a holistic and thorough treatment protocol that addresses not only hormonal balance and production of steroid hormones by a variety of tissues in the body, but also the improved function of the hypothalamus (re: adrenal-pituitary/hypothalamus axis), and a bioavailability and balance of neurotransmitters. In other words, health of the brain as well as the ovaries and adrenals, is important. In 2011, researchers at University medical schools in the U.S., United Kingdom, Australia, France, Israel, South Africa, Spain, Italy and Chile, led by the Departments of Gynecology and Obstetrics at Columbia University in New York, published the results of a broad review of menopausal symptoms entitled Menopausal hot flushes and night sweats: where are we now?, for Informa Healthcare, acknowledging that "Vasomotor symptoms, specifically hot flushes, are caused by a narrowing of the thermoneutral zone in the brain. This effect, although related to estrogen withdrawal, is most likely related to changes in central nervous system neurotransmitters. Peripheral vascular reactivity is also altered in symptomatic women." (D.F. Archer et al). To correct this health problem, rather than simply decrease it with synthetic hormone replacement forever, which comes with a wide array of adverse effects and health risks, stimulation of renewed hormone production with bioidentical hormone therapy, as well as stimulation of hypothalamic function and neurotransmitter homeostasis, and restoration of peripheral vascular health and reactivity, may be needed. While this is a more complex course of therapy, the achievement of restoration will not require chronic use of medication, and will result in an array of health improvements and decreased risk of related comorbid conditions. Quality of life will be improved along with symptom relief, and risk of hormonal cancers and cardiovascular problems will be decreased. The Complementary Medicine physician, or Licensed Acupuncturist, always approaches your therapy from a holistic perspective, and is able to help with all of these aspects of your health at once.

With full menopause, symptoms may be decreased by supplementing with a topical estriol cream of low dosage, as well as a temporary prescription of estrone by the medical doctor when necessary. The most desirable scenario is to avoid the estrone pill, but sometimes this is temporarily needed when menopausal symptoms are extreme. An array of dietary, nutrient and herbal aids may also help with symptoms as well, and acupuncture is now well studied and proven to be able to help with true menopausal symptoms as well. The use of estriol topically is very safe, but always should be balanced with the use of progesterone stimulating creams. Balance between the estradiol and progesterone is very important, and simple monitoring via saliva tests is now affordable and accurate. Such testing also helps guide the physician to prescribe the right amounts of topical creams and guide the patient in monitoring the symptoms to adjust the dosage as needed. A good understanding of the symptoms guides the patient in the daily choices of dosage of the topical creams, and utilizing the lowest effective dose is very important to achieve a quick reestablishment of the new homeostatic health and hormonal balance in the menopausal and post-menopausal state.

What may be most important to the woman as she enters the perimenopausal year or years, is the recognition of symptoms and signs of progesterone deficiency, though. Progesterone is the first of these hormones to precipitously drop in circulation during premenopausal changes, and a prior progesterone deficiency is often seen that could contribute as well. This progesterone deficiency in the years preceding perimenopause usually, but not always, manifests as premenstrual symptoms of bloating, breast tenderness, fibrocystic breasts, moodiness, menstrual migraines, and low back pain. One, all, or none of these premenstrual symptoms may occur and signal a progesterone deficiency. Skipped, late or insufficient menses may also be a sign, as well as poor blood flow, excessive clotting, and menstrual cramping. Correcting this progesterone deficiency will not only insure a less problematic PMS and menstruation, but may help to prevent symptoms and health problems in the perimenopausal through menopausal states as well.

Use of a progesterone stimulating topical cream of low dosage is very helpful to correct the progesterone metabolism, but should be combined with a holistic regimen to restore normal homeostasis and quickly end the dependence on external progesterone stimulation. The phytochemicals currently in use to achieve progesterone stimulation include a type of wild yam extract (Dioscorea villosa) containing the active diosgenin, and a specific set of phytohormonal chemicals from the soybean. While none of these chemicals are progesterone, they do stimulate increased progesterone production by acting on the progesterone receptors. Other species of Dioscorea are also well used in herbal medicine around the world, and some of these have chemicals that also are shown in studies to exert phytohormonal effects. A number of clinical studies have been designed with the mistaken notion that these extracts exert phytoestrogen effects, which they do not. Some studies have demonstrated that the wild yam based topical creams do not significantly reduce hot flush in the menopausal woman, and this is true when used alone. A balance must be reestablished in menopause, and use of the estriol and progesterone creams together is needed to correct imbalances and speed the healthy transition. Such published studies appear to be designed to discourage use. These studies do consistently show that the topical progesterone stimulating and estriol creams are safe and without significant side effects. The premenopausal woman must be aware that the improper timing and dosage of the progesterone stimulating cream will alter the changing hormonal balance within the cycle and when taken improperly may cause anovulation and amenorrhea. Professional guidance is highly recommended, and monitoring hormonal levels with saliva tests is beneficial as well.

The precursor to progesterone in the body is DHEAS (dehydroepiandosterone-S) and the precursor to this hormone is pregnenelone. We also know that pregnenelone, an abundant and beneficial hormone in the body, is available as a phytohormonal bioidentical plant chemical, and use of the pregnenelone topical cream may also increase the bioavailability of progesterone in the body. Adrenal insufficiency may be involved, and for some women, stimulating of adrenal function may eventually help the body to achieve a better hormonal homeostasis and progesterone and estrogen normalization.

Understanding the hot flash, night sweats, and other vasomotor symptoms

Numerous studies show that over 80 percent of women in the United States experience vasomotor symptoms of hot flush and abnormal sweating at various stages of the perimenopausal course. Symptoms may be mild or severe, temporary, recurrent or persistent. If these problems are not addressed properly they may continue for years postmenopausally. Each woman must make the choices concerning the need for treatment. The gonadal hormones all play a part in the regulation of the vasomotor system, and an intelligent approach assesses the abnormalities from physiologically normal levels of the three estrogens, progesterone, testosterone, DHEAS, and cortisol levels. The help of a knowledgeable TCM physician makes this often complex and confusing task much simpler.

While typical vasomotor symptoms in perimenopause are hot flush and heavy sweating, a wide array of variable symptoms may occur. Some studies have reported that over 50 percent of women with hot flashes experience chill after the episode, and such symptoms as headache with the sensation of pressure throughout the head, sensation of pressure in the chest, anxiety, changes in the heart rate and breathing, and mood disturbances are not uncommon. The reasons for these vasomotor responses center on the hypothalamic control of core body temperature, which normally oscillates in a circadian rhythm controlled mainly by cortisol levels and melatonin. Disruption of this tightly controlled hypothalamic thermostat results in exaggerated heat-loss responses of flush and sweat, and may involve changes in core circulation, such as heart rate and breathing pattern. While estrogens, especially estradiol, are potent modulators of this system, a number of hormones, neurotransmitters and even immune cytokines play important roles in the overall regulation.

Typically, hot flush and night sweats occur with a low progesterone relative to estradiol, but low testosterone, high FSH, surges of LH, increased cortisol at night, increased adrenalin (epinephrine), and low beta-endorphin levels have all been associated with hot flush and night sweat. Some studies have indicated that low levels of antioxidants with high levels of reactive oxygen species may also contribute to hot flush and night sweats. Hormonal imbalance is thought to create a potential for exagerrated emotional responses and emotional triggers that may more easily set off episodes of hot flush and sweating. The exact physiological mechanism is still not completely understood, but prominent theories state that these hormonal imbalances affect neurotransmitters and neurotransmitter receptors to trigger the episodes. A thorough treatment protocol may thus need to be established for some time before normalization of all of these parameters occurs.

While even in 2012, most experts agreed that the exact mechanisms of the perimenopausal vasomotor hot flush and sweating is poorly understood physiologically, there has been progress in this understanding. Studies revealed that a potent vasodilator and sweat gland activator, calcitonin gene-related peptide (CGRP), is much higher in blood plasma during these episodes of hot flush and sweating. Opioid neurotransmitters, such as beta-endorphin, may regulate the expression of this protein messenger, and an array of neurohormonal chemicals may play a role in its expression. Calcitonin is a 32 amino acid peptide hormone mainly produced in the thyroid gland. Increased secretion of calcitonin is stimulated by calcium ions and gastrin, a hormone once believed to be limited to stimulation of gastric secretions, but now known to circulate and affect more receptors in the body. Increased circulation of gastrin is stimulated by norepinephrine (adrenalin), and secretion is affected by adrenal hormones and cholinergic agents that affect the autonomic nervous system and parts of the brain associated with emotion, memory and vagal regulation. Calcitonin gene-related peptide is a 37 amino acid peptide hormone that is produced in neurons, both central and peripheral, and modulates many systems in the body, including the endocrine and cardiovascular, as well as the immune and gastrointestinal systems. Inflammatory mediators such as TNF-alpha, inducible nitric oxide synthase (iNOS), and even serotonin may also regulate the expression of CGRP, showing that a more holistic restoration of homeostatic balance and function may be necessary to really control vasomotor symptoms. While allopathic medicine explores chemicals that may block the expression of calcitonin gene-related peptide to control vasomotor flush and sweating, Complementary Medicine explores ways to restore the normal homeostatic mechanisms, a more complicated but healthier approach. Of course, in time these two approaches may be integrated to achieve better results.

Cortisol is an adrenal steroid hormone, or glucocorticoid, that is secreted in a complex feedback control in the hypothalamus-pituitary-adrenal axis, and fluctuates normally in a diurnal pattern, meaning that the levels during the day should vary against the levels at night. Frequently, in the perimenopausal syndrome, cortisol imbalance due to adrenal stress or deficiency will occur, and usually an excess cortisol at night with a deficient cortisol during the day results from a sluggish adrenal-hypothalamus feedback response. This may cause a restless sleep and contribute to night sweats and flush. Vascular effects related to cortisol include blood pressure changes, vasodilation, and sodium regulation. Chronic cortisol imbalances may have a depleting effect on the hypothalamic function. Poor regulation of temperature and exaggerrated responses of vasodilation may contribute to night sweats, hot flush and other vasomotor responses.

Much is being made about the role of FSH, or follicle-stimulating hormone, rises in the perimenopausal and menopausal state. Some supposedly more alternative medical doctors state that this is due to a last-minute attempt by the body to stimulate fertility in the older woman. This is of course a fairy tale, but may sell the course of therapy for some women, which often includes some herbs and nutrient medicines, but still pushes synthetic estradiol. The truth is that the rise in FSH is due to a protein hormone called inhibin, which normally balances with activin in the ovary to help regulate FSH secretion from the pituitary. Inhibin normally inhibits FSH, and a stopping of the ovulation creates a lack of inhibin. A decrease in the number of viable egg follicles may also results in less inhibin as well, and consequently an increase in FSH. This inhibin effect is accomplished by affecting the aromatase enzymes. Inhibin levels, like FSH, vary considerably from day to day in the menstrual cycle, and even perhaps hour to hour due to the pulsatile release of the LH. Levels of FSH have little direct effect on the creation of perimenopausal symptoms, but do tell us that a complex balance of hormones is necessary to achieve a healthy hormonal homeostasis. Inhibin secretion from the ovary is not only diminished by a drop in FSH, anovulation, and decreased estrogens, but also by diminished GnRH (gonadotropin releasing hormone), and inhibin may be increased by insulin-like growth factor-1. Hypothalamic dsyfunction may play a significant role. FSH levels may be more of a marker for hormonal problems in perimenopause than a cause. In addition, low FSH levels are associated with polycystic ovary syndrome, hypothalamic insufficiency, hyperprolactinemia, and gonadotropin deficiency.

Hormonal Imbalances in Menopause, Infertility, Pre-Menstrual Syndromes, Anovulation, and the Related Health Problems

These last years have brought great clarity to the treatment of hormonal problems. The amount of knowledge from research in response to the failure of the synthetic hormone replacement therapy (HRT) has finally brought these problems and the effective restoration of hormonal balance, or homestasis, into focus. In addition, we now see exactly how the hormonal deficiencies affect a wide variety of disorders. Estrogen deficiencies are a primary cause for problems with short term memory and attention problems, poor tissue healing, inflammatory disorders related to tissue calcification, and a variety of calcium related problems, including osteopenia and osteoporosis. Progesterone deficiencies create a relative estrogen excess even in estrogen deficient states, and are responsible for most menopausal and premenstrual (PMS) symptoms, and many cases of infertility, as well as the possibility of cancerous growth. Hormone dysfunction is a prime contributor to metabolic disorders and creates an added stress that contributes greatly to insulin resistance, diabetes and weight gain.

What do we do with this wealth of medical knowledge? Has it resulted in simple herbal cures? The answer is no. The endocrine system is the most complex system in the body, and most hormonal problems are multifactorial. The endocrine system also acts in a feedback manner to achieve a constant complex regulation, and affecting just one aspect of this system with a single herb is usually not enough to restore your normal physiological homeostasis. Fortunately, there are medical practitioners, such as Licensed Acupuncturists and herbalists, with the knowledge and skills to utilize a holistic and individualized approach to these problems. The integration of simple laboratory saliva and veinous blood tests, topical herbal creams, supplements and herbal formulas, with acupuncture, and guidance in your dietary regimen and lifestyle, has created a package of care that is phenomenally effective and tailored to the individual case. Finally, the knowledge and treatment options have accumulated over time to give Complementary Medicine physicians a treatment plan with a great chance of success when integrating with standard care to correct hormonal imbalances and deficiencies. This safe and conservative approach may be tried before resorting to synthetic hormonal therapies that come with side effects and risks. Restoration of the endocrine balance when going off of synthetic hormonal therapies may also be achieved with Complementary and Integrative Medicine (CIM).

Use of strong hormonally altering drugs in fertility treatment is now commonplace. These medications do come with risks of adverse effects and even fetal mutations. Use of these strong hormone altering medications may have implications for future hormonal health and balance in perimenopause, especially if this drug therapy is prescribed after the age of 35. For this reason, and because statistics show poor success rates for the older woman, many fertility clinics have quit accepting women over the age of 40 for these fertility drug regimens. Before resorting to these drug therapies, many women are now trying to correct underlying problems inhibiting fertility with a holistic approach. A wealth of research guides this therapeutic protocol, and many fertility experts are incorporating acupuncture, herbal and nutrient medicine into their practice, even medical doctors and clinical nursing specialists. Most problems in younger women may involve subfertility issues, and a normal, safe and healthy pregnancy will occur for most of these women when a few simple health issues are resolved. Taking a more natural approach to subfertility and fertility issues creates greater assurance that your baby will be born healthy and avoid many of the health problems associated with multiparity, ART, and drug therapies.

Does Acupuncture, or TCM, and Complementary and Integrative Medicine (CIM) work to relieve symptoms of Perimenopause?

In 2007, a large women's health survey was published in the medical journal Menopause: The Journal of the North American Menopause Society (vol. 14 (3) 397-403) concerning the use and success of Complementary Medicine by symptomatic women transitioning through perimenopause in Sydney, Australia. The study followed 1,296 women from three Sydney menopause clinics, general practice clinics and government agencies. Of these women recruited in standard medical clinics and programs, 53.8 percent had acknowledged visiting a Complementary Medicine practitioner, such as a Licensed Acupuncturist and herbalist, or simply used a CAM product during the past year to treat perimenopausal symptoms. Unfortunately, only 5 percent of these women consulted a practitioner (Naturopath or Licensed Acupunturist) only when utilizing these medicines, and only 46 percent of the women utilized professional guidance at all. Most of the women simply bought products via commercial advertisement with a professional assessment. Most of these products were thus very simple and mild, such as soy isoflavones and evening primrose oil. Nevertheless, the conclusions from the study stated that the report of effectiveness from users was high, and a significant number of women taking prescription hormone replacement also utilized these herbal and nutrient medicines, as well as professional treatment in Complementary Medicine. While this shows the patient satisfaction with these therapies, the overall success could obviously be much higher if Complementary Medicine was more professionally utilized and integrated with standard medical protocol. The lack of support in standard medicine was noted (only about a fourth of these women reported even a inquiry about CAM utilization by their MD), and of course, the failure of insurance and government health organizations to provide financial support was also a significant hurdle to increased professional utilization. The burden of choosing an effective treatment for perimenopausal syndromes within the realm of Complementary Medicine is still largely the responsibility of the woman herself, who must take a proactive role, both in seeking professional care, and often, in paying for it. Perhaps this will change in the near future as more of these large studies are published.

Research and publication of scientific studies of the various treatments in Complementary Medicine to relieve symptoms of perimenopause are still sparse. In most of these small studies published in the West, study design is a problem, and there is not an adequate design model to study the effectiveness of a combined protocol of treatments, which is necessary in the treatment of perimenopause and other hormonal pathologies in Complementary Medicine. Acupuncture alone will have limited effect for most women, but a combination of acupuncture with herbal and nutrient medicine, perhaps combined with dietary changes and even healthy physiotherapies, will have a pronounced effect. The key to this protocol may lie in the inclusion of short courses of topical bioidentical hormonal creams, though, with plant hormones at a very low dose stimulating increase production of endogenous hormones, and achieving a balance of hormonal production when administered intelligently. By 2015, the research for integration of herbal and nutrient medicine in perimenopause is overwhelmingly positive despite the history of objections in standard endocrinology, though. To see an example of such published research analysis, click here: http://www.ncbi.nlm.nih.gov/pubmed/25668332

Studies of acupuncture alone to treat perimenopausal vasomotor hot flush show success, as a 2013 Cochrane Database Systems Review showed (PMID: 23897589), although only 16 studies comprising 1155 women met the criteria for high-quality randomized clinical human trials. While these trials that compared the acupuncture treatments to other treatments or no treatment showed significant benefit, and all acupuncture clinical trials showed significant benefits in reduction of severity of the vasomotor hot flush and frequency, studies comparing these effects to so-called "sham" acupuncture, showed statistically equivalent benefits for both acupuncture groups. Of course, there is no such thing as a sham acupuncture needling, and such study design is now widely questioned. By 2015, a meta-review of randomized controlled human clinical studies of acupuncture to treat perimenopausal symptoms, by experts at the University of Washington School of Medicine, department of Biobehavioral Nursing, found that "TCM therapeutics of acupuncture, CHM (Chinese Herbal Medicine) and moxibustion show promising results for the treatment of mood and pain symptoms co-occurring with hot flushes" (PMID: 25017715). These experts agreed that few studies evaluate the multiple symptom outcomes or combination of treatments due to study design bias in the West, and concluded that future studies would need a better study design to evaluate these TCM therapies. What is lacking in these human clinical trials, though, is the fact that in Traditional Chinese Medicine, an individualized protocol of combined therapies is usually needed to achieve the goal in neurohormonal restoration of balance. Simply applying a few standardized needle sticks to women, without even sufficient professional stimulation that is individualized, and then declaring that these trials prove that acupuncture may not work better than the designed so-called placebo acupuncture, is not an honest assessment of the therapeutic protocol. Stating that a standardized and dumbed-down set of needle sticks without proper needle stimulation did not perform quite as well as pharmaceutical synthetic hormone replacement therapy, but almost as well, does not negate the benefits of the thorough treatment protocol recommended in Complementary and Integrative Medicine (CIM/TCM), but instead sheds a poor light on the pharmaceutical therapy, which outperforms this very simplified treatment protocol, but not dramatically, and comes with drug dependency and numerous serious adverse effects. The adverse effects of acupuncture stimulation are almost nonexistent. More and more, intelligent patients are choosing to receive professionally guided Complementary Medicine to treat their perimenopausal syndromes. It is too bad that insurance coverage for this treatment protocol is sorely lacking, as well as Medicare acknowledgement.

By 2014, only a small percentage of women with perimenopausal syndromes are being helped by standard medicine, and even this small percentage, estimated now to be under 20 percent, are concerned about the known adverse effects and risks of long-term treatment. Use of CIM/TCM and a thorough and individualized protocol of care that combines bioidentical hormone creams, herbal and nutrient formulas, herbal tinctures that capture lipid-based phyothormonal chemicals, acupuncture, and deep tissue physiotherapy, or Tui na, may be combined with an intelligent use of dietary and lifestyle changes in a proactive manner to achieve restoration of hormonal homeostasis during these perimenopausal changes. It is obvious that such a holistic approach is needed. The obvious need to find safe and effective therapies for perimenopausal vasomotor symptoms of episodic flush, sweat and other symptoms is prompting more serious research into TCM, acupuncture and CIM finally, utilizing clinical study designs that are less biased against the acupuncture and TCM profession. For example, at the University of Melbourne, in Victoria, Australia, a randomized and controlled human clinical trial with 360 women experiencing a minimum of 7 episodes of hot flush per day and are typed as Kidney Yin Deficient (to match a suitable treatment protocol), were assigned an actual TCM physician trained in the specific needle techniques used, and only the patients are blinded to the needling this time, not the treating physicians, allowing the acupuncturists to actually provide real "real" needle stimulation or try to mimic the experience with a sham procedure (in this case stimulation of the points with a blunt needle). The treatment includes 10 sessions over 8 weeks. It is believed that this type of study design will allow the actual assessment of efficacy over the placebo effect more accurately. The outcome measures were not narrowly defined to a single measurement, but included a score of intensity and frequency of hot flush and sweat for each patient compared to their baseline normal experience (which is variable from patient to patient), and secondary measures of quality of life measures, mood regulation, and each individual's mind-body parameters of expectancy and belief in acupuncture, as well as adverse events, which are not expected. Such a study is presenting a new design that objectively assesses the benefits within an integrated protocol, and is expected to produce better working guidelines for acupuncture in perimenopausal care. To see this study design, click here: http://www.ncbi.nlm.nih.gov/pubmed/24925094 . Such progress in scientific clinical trials is expected to provide evidence for the standardized integration of safe and inexpensive courses of acupuncture into standard care and insurance reimbursement (PMID: 24925094). Of course, the addition of a full array of herbal and nutrient medicines in the therapy, and potentially deep tissue physiotherapy, could improve overall outcomes dramatically, although standard clinical trial design only allows one type of treatment to be studied at a time, not an integrated and holistic array of treatments, as is commonly seen in TCM therapy.

What do you do to correct your hormonal problems with integrative Complementary Medicine? You need to spend the time for a thorough history and consult with a knowledgeable practitioner, such as a Licensed Acupuncturist and herbalist. You may try to find an endocrinologist that is open to integrative approaches. When you and your health providers are on the same page you can expect to get great results. In Complementary Medicine you need to take a proactive approach to the therapeutic course and the adjustments in therapy that are needed. You need to gain an understanding and work with your physicians to insure that lasting success is obtained. A number of articles are provided on this website to help you gain a thorough understanding. You'll be glad you did in the long run.

Problems with utilizing HRT (hormone replacement therapy with synthetic hormones such as estradiol sulfate) alone in the treatment of menopause

While some women with severe symptoms are going to utilize HRT to decrease symptoms, a number of choices in this protocol is sensible, not just the binary question of pharmaceuticals versus alternatives. When taking these HRT chemicals, reducing the need of dosage, using the least problematic course of therapy, and integrating Complementary Medicine into the treatment protocol presents many benefits, both in the short and long terms. By 2015, prominent researchers, such as Dr. F.H. Comhaire of the University of Ghent, have finally published their findings that synthetic hormone replacement therapy should be utilized as estradiol only therapy only in later life, perhaps 10 years after menopause, to avoid numerous health risks, and that there are indeed natural medicines that could relieve symptoms and improve health during perimenopause and early postmenopause, such as estriol creams and herbal and nutrient medicines, and that evidence suggests that there is no risk of breast cancer with estriol bioidentical hormone cream, or risk for women treated for a prior breast cancer, as has been long suggested in standard medicine, completely unsupported by clinical evidence. Such experts as Dr. Comhaire suggest that starting hormone replacement therapy after age 69 would present more benefits than risks for 90 percent of patients. So see such research published in standard medical journals, click here: http://www.ncbi.nlm.nih.gov/pubmed/25668235

Sensible protocols to treat perimenopausal symptoms should include holistic regimens individualized to both subsets of women and stages of perimenopause, not a one-size-fits-all therapy. First trying holistic therapies in Complementary and Integrative Medicine, with bioidentical phytohormones combined with acupuncture and herbal nutrient medicine, is sensible. Resorting to synthetic hormone replacement comes with considerable risk and inadequate outcomes for most patients, but is sometimes necessary for a short period of time. Decreasing the number of years that the synthetic estradiol or natural estrone pharmaceuticals are taken is important for the overall health, though. While the long-term risks of synthetic hormone replacement medication are now well known, increasing risk of cancer, cardiovascular disease, osteoporosis, etc., few long-term studies beyond 5 years have been conducted. The Harvard Nurses' Health Study found that women that took estrogen medications after menopause for ten years or more were 50 percent more likely to develop asthma than women who never took the HRT medications. The risks increased with dosage and time of use. A total of 121,701 women were followed from age 33 on in this study. Declining estrogen levels in studies were associated with asthma risks as well, presenting a dilemma for medical doctors who only prescribe pharmaceuticals. This is just one example of the various neurohormonal immune dysfunctions that are linked to long-term synthetic hormone use. The answer, of course, is to integrate effective Complementary Medicine into the protocol to help normalize hormonal balance and metabolism. This is still rarely inititated by the MD, though, and the wise patient will request this integration of specialties.

While the asthma example is just one health aspect, it is revealing in its scope. Of course, the Women's Health Initiative is now well known and the results of long term study show many health risks and adverse effects related to HRT, especially with long term use. To read more about the negatives of HRT, go to the article entitled Hormone Replacement / Contraception on this website.

Health Problems associated with HRT have prompted a need for a different pharmaceutical approach, but the U.S. FDA did not approve the first new drugs studied to control the menopausal hot flush and sweat

In March of 2013, an expert advisory panel to the U.S. Food and Drug Administration soundly rejected 2 drugs seeking approval for use to control menopausal hot flush, the anti-seizure medication gabapentin (Neurontin), and the antidepressant paroxetine (Paxil). The expansion of uses for these drugs, that inhibit neurotransmitters, reuptake of neurotransmitters, or function at neuroreceptors, has been extensive, but controversial. In studies of treatment of menopausal and post-menopausal hot flush, these drugs barely outperformed placebo, and the experts stated that the reduction of hot flush episode was not clinically significant, while the side effects were were a cause of concern. Gabapentin has a significant incidence of dizziness, fatigue, weight gain, and peripheral edema, with a higher incidence associated with aging. In addition, liver and kidney toxicity, increased mood swings, and difficult with mental concentration, as well as hyperactivity, have been reported in clinical trials. The U.S. FDA issued a warning of an increased risk of depression and suicidal thoughts as well. The decrease of one hot flush per day in women experiencing 12 such episodes per day was not considered to be enough of a benefit to outweigh the risks. Paroxetine also produced common side effects in clinical studies, with nausea and somnolence affecting more than 20 percent in clinical trials, and asthenia, sweating, dizziness, insomnia, dry mouth, constipation, tremor, and sexual dysfunction occurring in more than 10 percent of study participants. Again, the decrease in the number of episodes of hot flush over placebo was not clinically significant for women experiencing considerable numbers of episodes.

Despite these common problems with paroxetine (Paxil), the FDA approved a version of this drug for postmenopausal hot flush in 2013, called Brisdelle, or paroxetine mesylate. The FDA advisory committee voted 10 to 4 to not approve this drug, an anti-depressant, which barely outperformed placebo in clinical trials, and had significant risks and side effects, but the FDA considered that standard medicine desperately needed a non-hormonal treatment, and this drug used a lower dose of paroxetine than Paxil. Hopefully, an integrated approach in standard medicine will emerge, with the prescription of Brisdelle combined with Complementary Medicine to help women control perimenopausal symptoms without synthetic hormone replacement.

While there are still few large human controlled trials conducted to evaluate bioidentical hormones, herbal and nutrient medicine, or acupuncture for the treatment of menopausal symptoms, the evidence of clinical success of these therapies, especially applied together in an individualized protocol, is mounting. Studies in recent years, in a number of countries, have surveyed women on their use of Complementary Medicine to treat menopausal symptoms, and many of these large surveys in Europe, Australia, and even the United States, report that a high percentage of women successfully utilize these therapies (see studies below). In addition, a number of controlled randomized small human clinical trials of acupuncture and herbal medicines have shown remarkable success. Early studies, centering on black cohosh, are frequently cited, with differing reports of success, but professional herbalism has long relied on other herbs, and herbal formulas, and now combines herbs and nutrient chemicals, utilizing the latest research. The Licensed Acupuncturist and herbalist is a Complementary Medicine physician that can provide quality herbal and nutrient medicines, and individualize treatment with acupuncture and these medicines.

Dietary considerations in Perimenopause transition

A variety of dietary considerations are important with optimizing perimenopausal homeostasis and resolving symptoms. Health studies have shown that a more plant-based diet rich in healthy essential fatty acids and balanced omega 3 and 6 are proven to benefit women in perimenopause. Whole grains, beans and legumes, green leafy vegetables, healthy oils, fresh nuts and seeds, and an array of healthy fruits is recommended. As always, the proper balance of these foods in the diet is most important, not just eating a single food that is advertised as the supposed miracle cure. The choices are complex, but this is not a bad thing when considering your diet, as complexity may equal enjoyment when eating and experimenting with healthy foods and recipes. When the symptoms and health problems underlying imbalance become complex, it may be best to consult a knowledgeable Complementary Medicine physician, such as a Licensed Acupuncturist and herbalist, or a Naturopathic doctor. Below are just some of the researched considerations and explanations for why specific dietary changes may be chosen. As always, this is an individualized consideration, and while some dietary principles may be universal, each woman has some degree of individual needs. Studied supplements now recommended include pycnogenol (pine bark extract), Maca, DIM, various antioxidants such as pomegranate extract and melatonin, and various vitamins and minerals. To see such recommendations click here: http://www.ncbi.nlm.nih.gov/pubmed/25668332

1. Carotenoids: carotenoids are a family of fat-soluble nutrients that are categorized as either xanthophylls or carotenes. These yellow to orange pigments are widespread in plants, and when the green chlorophyll declines in the fruits and roots of these plants, foods rich in carotenoids will develop a strong yellow to orange color from carotenoid pigments. As stated, carotenoids from the diet are important to the healthy development of the corpus luteum of the egg follicle that matures in the menstrual cycle but is not released. This corpus luteum provides the needed shot of progesterone that is needed to maintain the menstrual homeostasis. Since progesterone in the premenopausal stages is often dropping precipitously, carotenoids may be a valuable food in the early perimenopausal changes. The most studied carotenoids are beta carotene, lutein, lycopene, and zeaxanthin. The oxygen containing carotenoids include lutein and zeaxanthin, while the non-oxygen containing carotenoids include beta-carotene, alpha-carotene, and lycopene. Astaxanthin, a carotenoid found in krill oil, as well a crustaceans and fish possessing pink flesh, such as trout and salmon, is now well studied and proven to benefit a number of age-related hormonal and metabolic imbalances. Unfortunately, synthetic astaxanthin is now widely used in fish farming, such as salmon farming, to produce pink flesh, and patients should be beware of this synthesized nutrient, linked to health problems. Some nutritional supplement formulas deliver these key phytochemicals, but a number of nutritious food sources should also be considered. Beta-carotene is abundant in carrot juice, but also in any bright yellow to orange fruit or vegetable. Lutein is found in high concentrations in many dark leafy greens. Lycopene is found in high concentration in many red colored fruits and vegetables, such as red grapes, pink grapefruit, red bell pepper, and watermelon. Lycopene also gives the reddish tint to unprocessed palm oil, purported to be the richest source of carotenoids. The Chinese herb seabuckthorn (Sha ji, or Hippophae rhamnoides) contains a high concentration of carotenoids, which explains its medicinal use. The pulp oil of sea buckthorn contains the highest concentration by far, whereas the seed oil contains a relatively low concentration (beware of commercial products). Retinols (carotenes and cryptoxanthin derived) are also found in high concentration in dark leafy green vegetables (especially collards and turnip greens) and apricots (dried or fresh), as well as cantaloupe. Bananas and orange juice contain a small concentration. Red berries, mangos, papayas, kumquats, persimmons, and a host of tasty red, yellow and orange fruits are full of carotenoids. The foods and herbs with the highest concentration of beta-carotene include noni, chrysanthemum, sorrel, jujube, spinach, carrot, barleygrass, comfrey, gotu kola, watercress, papaya, and artemesia absinthia, in that order. Alpha-carotene is also found in carrot, and small concentrations in corn, tangerine, orange, avocado, raspberry and plantain. Lutein is found in rhubarb, bilberry, plum, black currant, avocado, pear, kiwi, grape, raspberry and watermelon, in that order of concentration. Lycopene is found in watermelon and carrot. Eat and enjoy.
2. Lignans: in 2006, Italian researchers at the University of Insubria, in Varese, found that the concentration of plant lignans in the Norway spruce, mainly hydroxymetairesinol, converts to a significant amount of the human hormones enterolactone and enterodiol, which are produced by normal intestinal bacteria, and produce a significant estrogen effect at receptors while also inhibiting estrogen dominance in a modulatory manner. This was a significant finding, and subsequent studies showed that a percentage of women with perimenopausal and postmenopausal hot flushes benefited from the supplement. Of course, establishing a healthy intestinal flora and fauna, or microbial colony, is thus also important when consuming lignans. If there are intestinal problems, clearing these and then using a professional probiotic regimen will help allow these dietary lignans to help with perimenopausal hormone balance. The supplement medicinal NuLignan may also be very helpful. Various lignans are found in sesame seeds, flax seeds, rye, steel cut oats, barley, barleygrass, pumpkin seeds, beans, broccoli and berries. Lignans may also be applicable for prevention or treatment of breast cancer, colon cancer, liver cancer, prostate cancer, osteoporosis, cardiovascular disease, and hyperlipidemia, as well as obesity and insulin resistance. Herbs containing lignans include Siberian ginseng (Ci wu jia), Du zhong, Luo shi teng, Hong hua, Pa jiao lian, Zanthoxylium, and various medicinal berries. Many herbs have chemicals related to lignans in Chinese medicine, though, and the artemesias, cinnamons, magnolias, salvias, and Chai hu are examples of commonly used herbs that have effects related to lignans.
3. Isoflavanoids and bioflavonoids: isoflavones, lignans and coumestans are the 3 major classes of phyotestrogens, which exert modulatory effects on the steroid hormone metabolism via evolved metabolic processes. Isoflavonoids, found in soy and many other healthy foods, are polyphenic compounds that are related closely to isoflavones. They exert significant antioxidant benefits as well. Soy isoflavone supplements have been well researched and many beneficial effects have been found, but are not an effective treatment for perimenopausal symptoms and osteoporosis on their own. Eating of soy is problematic as the soy bean contains a number of chemicals that make it hard to digest. Heavily promoted soy milk and poorly formed soy food products do present some adverse chemistry. This is why Asian civilizations created fermented soy products such as tempe, and utilized a number of elaborate steps and herbal chemicals in creating a healthy tofu. Commercial tofu in the United States may not always be a healthy product. The isoflavones genistein and daidzein, though, are found in a variety of supplement formulas, and in various foods and herbs besides soy. Green beans, mung bean sprouts, alfalfa sprouts, cowpea and kudzu contain significant concentrations. Fermented soy miso has a more concentrated isoflavone profile than other soy products. Chick pea (garbanzo), lima bean, and peanut are good sources. Herbal sources include Red Clover (trifolium), which explains why this tincture works so well for many women with perimenopausal symptoms. Other bioflavonoids (flavonoids) include quercetin, epicatechin, kaempferol, apigenin, anthocyandidins, and myricetin. These too are found in a significant number of foods and herbs. Red Clover (Trifolium pratense) is highly touted as a source of isoflavonoids that benefits many women with perimenopausal symptoms. Red Clover contains a balanced array of flavonoids, coumarins and coumestol, which may explain why it works so well for many women. Separating these chemicals from their naturally evolved balance may have much reduced effect. A quality Red Clover tincture is recommended to capture the most esssential chemicals in extraction. While isoflavones are not a panacea for perimenopausal pathology, they are a healthy addition to the diet, and provide a number of benefits. Studies do show that higher doses of these phytohormonal nutrients do not appear to increase benefits, though, and a daily small dose, mainly from the diet, is the recommended course of therapy. Eating a variety of beans may be the most essential component to this protocol, but a wide variety of vegetables, nuts, seeds, legumes and oils provide these three phytohormonal nutrient classes, isoflavones, lignans and coumestans. Research, enjoy, experiment and cook.
4. Essential fatty acids: depending on the diet that one has been eating, an essential fatty acid imbalance may occur, and now numerous studies point to the healthy outcomes when these imbalances are corrected. Unfortunately, the public is not paying attention to the word balance, and instead relies on commercial marketing to make the choices of what essential fatty acid sources to purchase. The most well known and studied of these are the class of omega 3 essential fatty acids, because the typical modern diet in the United States has been very imbalanced with excess meat and simple starches, creating a deficiency of omega 3 fatty acids. On the other hand, vegan diets may create an omega 6 deficiency. The two most well prescribed sources of this in pill form are krill oil, with a balance of the main essential omega 3s, and GLA, an omega 6 from seed oil. Taking both could not hurt if deficiency is suspect. Many health problems, but especially chronic inflammatory states, and chronic health problems with the intestinal tract, create essential fatty acid deficiencies as well as the poor diet. While fish oil supplements and salmon consumption have exploded in popularity, this comes with some serious negatives. Most salmon, and in fact, many ocean fish today, now come from unhealthy fish farms in the ocean that create diseased conditions that require a huge amount of antibiotics and other chemicals to keep the fish healthy and promote fast growth. Disease from these fish farms is spreading to the wild fish populations, decimating them in many areas, and the oils from these fish are proven to have reduced concentrations of key beneficial chemicals. The public needs to demand healthy practices of fishing and raising fish if this is to change. The governments of the world are doing almost nothing to stop this bad practice.
5. Alkilinizing foods: many problems in perimenopause may be related to chronic acidity, which inhibits a number of physiological processes. Of course, restoring gastric function may lie at the heart of this problem, but dysfunction in the calcium metabolism (calcium is the main alkilizer utilized in the body), excess consumption of acidic foods (red meat, orange juice, and simple carbohydrates such as brekfast cereals and sugary foods), liver stress (excess alcohol, cigarettes, fatty foods), and kidney stress (excess carbonated beverages) may also play important roles in chronic acidic states. Eating alkilinizing foods may help over time within a broader protocol. Most alkilinizing foods are fresh vegetables, and the percentage of fresh vegetables in the diet should be increased. Raw vegetable juices are alkilinizing, but too much may be difficult for your digestive system to deal with, and this is perhaps not sensible for all persons, especially if gastric hypofunction issues exist. Dark leafy green vegetables are especially alkilinizing, as well as sprouts, and most of these have no drawbacks, although some may produce an excess of chemicals that may lead to gallstones and kidney stones in particular individuals, such as beet greens and kale. Collard green, mustard greens, brussell sprouts, cabbage, celery, cucumber, dandelion greens, parsley and spinach are good foods to alkilinize. Onions, shallots, garlic, asparagus and beets are also recommended. Seaweeds, such as kelp, dulce, sheets of toasted nori, and kombu are not only alkilinizing, but supply iodine and minerals. Spirulina, barley grass powder, and chlorella are also alkilinizing and provide a host of beneficial nutrients. Whole grains such as amaranth cooked as a breakfast porridge with steel cut oats, buckwheat, quinoa, lentils, lima beans, and a variety of dried beans easily cooked in soups or as bean salads, also provide alkalinization with a host of other beneficial nutrients. Coconut, almonds, flax, pumpkin and sesame seeds are alkalinizing. Cantaloupe, apricot, banana, berries, dried figs, currants, pears and avocado are alkalinizing fruits. To achieve more dramatic effects on systemic regulation of acidity, though, these dietary changes should be a part of a more holistic protocol that is individualized.

Dietary Supplements that may be beneficial in perimenopause

Each individual may have different needs and nutritional deficiencies in perimenopause, and some of these are measurable. The hormone called Vitamin D is a good example. Many perimenopausal women have a Vitamin D deficiency, and this hormone (not really a vitamin) is important in the regulation of calcium metabolism and many other cellular processes. Dietary deficiency is not the most important concern, or cause, of D3 deficiency, though. Most of our D3 (cholecalciferol, the prohormone that creates the prehormone calcidiol that creates the ability to synthesize actual hormone vitamin D) comes from health cholesterol converting to the cholecalciferol in the layers of the skin that are exposed to midday sun. Even sun exposure (without sun block) may not be the crucial issue, though, as the regulation of the D hormone and calcium metabolism is complex. A holistic approach to hormonal restoration is recommended to restore the body's ability to produce D hormone as needed. Taking a high dose liquid supplement, though, does help the deficiency and may reduce related symptoms and risks temporarily. Since the body has a rate limiting mechanisms where about 25,000 IUs can be synthesized per day, taking more than 5000 IUs per day may be counterproductive. We want our bodies to synthesize D3. Correcting the underlying problems is the key, though, and generating healthy cholesterols, achieving a fatty acid balance, and promoting improved liver and kidney/adrenal health is important. A simple veinous blood stick test can be used to monitor the levels of circulating hormone vitamin D and guide therapy.

Since calcium is perhaps the most highly regulated molecule in the body, taking any old calcium supplement in perimenopause is not a good idea to correct problems related to calcium metabolism. In fact, numerous studies have shown that many types of calcium supplement not only do little good, but have the potential to creat tissue calcifications, joint inflammation, kidney stones, and gallstones. The chemical attached to the calcium is the most important consideration when taking supplements, and a professional Complementary Medicine physician can supply the right type of calcium for specific needs, as well as design an individualized treatment protocol to restore a healthy calcium and hormonal metabolism. A number of common medication protocols may also play roles in preventing absorption of calcium, especially the gastric inhibitors so often prescribed for any complaint of heartburn whatsoever without a proper diagnostic workup. In a majority of these cases, gastric hypofunction may be the problem, not simple excess production of stomach acids. Antidepressants have now been shown to play negative roles in calcium regulation since serotonin is the key neurotransmitter in the gut regulating the absorption of calcium from the diet, and the utilization of calcium. Since more and more medications that affect serotonin metabolism are being prescribed for a wide variety of health problems, this subject and the array of health warnings is becoming complex. Certain antibiotics, pain medications, and other drugs have received warnings concerning creation of serotonin imbalances. In certain areas of the United States a large percentage of women over the age of 40 have been shown to have a hormone vitamin D deficiency as well. Since this D hormone is produced in the kidneys as needed, and plays a vital role in all calcium metabolism, absorption from the diet to deposition and withdrawal from the bone stores, restoring hormone vitamin D metabolism may be very important. The way to do this is to assess the levels, take a high dose of the prohormone D3 cholecalciferol as needed, obtain adequated midday sun exposure, and correct kidney and adrenal dysfunction. Looking at the whole picture of calcium in the body may be necessary to correct problems with calcium metabolism.

Essential minerals besides calcium may play a large role in many neurohormonal processes, and may easily become deficient when the hormonal regulation is stressed in perimenopause. An essential mineral supplement of quality may help restore this essential metabolism. This subject may best be addressed with the help of a professional, though, that performs a thoughtful assessment and prescribes individually, rather than adopting a one-size-fits-all approach.

DIM (diindolylmethane) is a well-studied nutritional chemical that the body produces from I3C (indole-3-carbinol), which in turn is derived from the breakdown of glucobrassicin, a compound in cruciferous vegetables, that is found in such foods as broccoli, but is most concentrated in cauliflower. Cauliflower and broccoli are actually the same plant with different flowers, and now the broccoflower, or green cauliflower is available as well. Getting the body to produce a lot of DIM from eating cruciferous vegetables, which includes Brussel sprouts and cabbages as well, is difficult, though, and a professional DIM supplement is recommended. ProDIM affects the estrogen metabolism in a beneficial way, helping the body to balance the 3 types of estrogens in the body, and acts on the aromatization of the estrogen at the receptors, and the aromatization of testosterone to estrone in local tissues. The more beneficial local estrogens, 2-hydroxy estradiol and 2-hydroxy estrone may be increased with DIM use, while the local tissue metabolites 16-hydroxy estrone and 4-hydroxy estrone may be decreased. Originally researched for its benefits in preventing breast cancer, a number of studies and human clinical trials have demonstrated the benefits of DIM in the treatment of perimenopausal estrogen dominance. In perimenopause, slow or dysfunction estrogen metabolism may create an excess of the more active estradiol, and an excess of estrogen metabolites that act as reactive oxygen species. The promotion of the 2-hydroxylation pathway of estrogen has been shown to be associated with decreased risk for breast cancer, while the immune modulating effects of DIM have been shown to prevent neurodegenerative disease via inhibition of lipopolysaccharides from low level bacterial and fungal infections, and reduction of the pro-inflammatory NF-kb cytokine . While DIM may not be a miracle cure, it is proven to exert valuable effects to help the woman experiencing perimenopause maintain a balanced hormonal homeostasis and prevent breast cancer and neurodegeneration (see studies below in Additional Information).

NuLignan is a concentrated patented form of lignan supplement that is derived from the Norway spruce and proven in clinical trials to benefit hormonal balance for a high percentage of women experiencing perimenopausal changes. Once again, while this supplement may not have an immediate and dramatic effect, the chemical effects are well studied and proven, and the woman can be assured that the benefits are being derived, and that she will be healthier in the long run taking this nutritional supplement.

Quality sources of omega-3 and omega-6 essential fatty acids should be utilized periodically. As stated, if the diet has been focused on red meat and simple carbohydrates, omega-3 fatty acids in the form of krill oil is recommended. If the diet has been predominantly vegan, GLA, an important omega-6, is recommended. For all patients, periodic supplementation of both of these may be beneficial as the hormonal changes create increased demands.

What to avoid in the diet during perimenopause

Unhealthy fats and a diet centered on a high percentage of meat and simple carbohydrates should be avoided in perimenopause. The Nurses' Health Study, began in 1976, and associated with such institutions as Harvard University School of Public Health, is the gold standard for long term studies in this regard. In 2003, a large study showed a high association of increased breast cancer risk during perimenopause for women with high intake of red meat and butterfat, with a 75% increased risk. The researchers studied nearly 100,000 women over decades, and concluded that a more plant-based diet, and healthier fats in the form of unprocessed vegetable, nut and seed oils should be promoted. This is just one example of the numerous studies finding association with a typical American diet and menopausal pathologies.

Information Resources / Additional Information and Links to Scientific Studies

A large and increasing number of research studies of perimenopause, premenopause, menopause and post-menopausal states is avaible to physicians and patients today. An array of confusing advice and information has been presented, though, mostly to increase sales of particular pharmaceutical medicines, but also to promote specific herbal and nutrient products with sometimes inaccurate claims. Below is a set of links to studies and information resources that seem sound and accurate, but by no means reflect the vast array of scientific studies.

1. A 1998 article in the medical journal Endocrine Reviews by researchers at the University of British Columbia and Vancouver Hospital and Health Sciences Center in Vancouver, British Columbia, Canada, clearly outlines the history of misinformation concerning the complex physiology of the perimenopausal state, and how this physiology was largely ignored in studies to promote menopausal drug therapy: http://edrv.endojournals.org/content/19/4/397.full
2. A 2005 article by an expert in perimenopause and hormonal pathology, Dr. Alessandra Graziottin of the University of Florence, Italy, published in the Journal of Sexual Medicine 2005, issue 2, supplemental 3, 133-145, outlines the pathophysiology of perimenopause more holistically, focusing on the biology and psychosocial pathophysiology of sexual dysfunction during perimenopause and the effects of both estrogens and testosterone and proandrogens on the pathology of diminished sexual desire and function: http://www.alessandragraziottin.it/ew/ew_voceall/37/1402%20-%20etiology%20of%20FSD.pdf
3. A 2011 study at the University of Pennsylvania School of Medicine shows that in a randomized and stratified long-term cohort study following women through perimenopause to postmenopause from 1995 to 2009, that symptoms of hormonal imbalance, such as hot flush and sweating, averaged over 10 years, and that women who experienced these symptoms early in the perimenopausal state produced a symptom duration averaging 11.57 years, while those that experienced onset of symptoms late in the perimenopausal state, after the cessation of menstrual cycles, averaged only 3.84 years. This study followed women during the period where a high percentage of women were prescribed hormone replacement therapy, which fell out of favor after 2003 with large studies proving health risks. Obviously, hormone imbalance needs to be addressed early in perimenopause: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085137/
4. The U.S. FDA released this elaborate warning guideline concerning hormone replacement therapy (HRT) in 2009, showing the increased risks for cardiovascular disease, breast cancer and dementia (Alzheimer's disease etc.), and noting that past advice that more women should take these synthetic hormones to reduced these risks were indeed false. The FDA noted that risk versus benefit should be more seriously discussed before starting HRT with synthetic estradiol and progestins, that the lowest effective doses should be used, and that complementary therapies should be integrated into this protocol to address adverse effects and related health problems. The FDA also noted that common side effects of this HRT regimen with synthetic estradiol and progestins included irregular vaginal bleeding, stomach pain, headaches, breast pain, nausea and hair loss, with less common side effects including breast, ovarian and uterine cancers, dementias, stroke and heart attack, gallbladder disease and blood clots, or peripheral vascular disease: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm135339.htm
5. A 2013 FDA announcement explained the approval of the first non-hormonal drug to treat perimenopausal hot flush, paroxetine mesylate, or Brisdelle, a lower-dose version of Paxil (paroxetine), despite a 10 to 4 committee recommendation against approval, minimal effects greater than placebo, and a number of warnings, for risks of suicidal thoughts, increased episodes of bleeding, and a risk of a syndrome that results in episodes of rapid heart rate and confusion, called serotonin syndrome: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm359030.htm
6. A 2013 review of current therapy in standard medicine for vasomotor symptoms of hot flush and sweating in menopause and other hormonal pathologies, by the University of Glasgow School of Medicine, United Kingdom, found that prescription of synthetic hormone replacement therapy is still the standard therapy, but that less than 20 percent of women in the U.S., U.K. and New Zealand now utilize this treatment, after the alarming findings of adverse health risks were published in the Women's Health Initiative studies. They also reported that the women that utilize these synthetic estrogens report a return of the vasomotor symptoms when discontinuing the therapy, but that only about 18 percent of these women choose to resume the hormone replacement therapy due to adverse health effects of the medication. Obviously, standard medicine is not providing adequate treatment for vasomotor hot flush and sweating in perimenopause and other hormonal pathologies. Alternatives to this problematic course of therapy are available, but those in standard medicine have not proven effective. Complementary Medicine does provide a holistic integrated therapeutic protocol that is able to achieve restoration of hormonal and neurohormonal balance without drug dependency, but has consistently been discouraged in standard medicine. These researchers also note that limited knowledge of the exact physiology of vasomotor hot flush hampers development of therapies that could be used as an alternative to synthetic hormone therapy: http://www.ncbi.nlm.nih.gov/pubmed/23848489
7. A 2012 study at the University of British Columbia School of Medicine, and Vancouver Coastal Health Research Institute, found in a randomized controlled human clinical trial that progesterone decreased the number and intensity of vasomotor hot flush and night sweat episodes in menopause significantly, reducing the number to about half, with a short course of therapy. This research also found that in patients with hypothyroidism, the progesterone therapy increased free T4 levels in circulation as well. Unlike synthetic estrogen therapy, the progesterone therapy did not have a significant rebound effect when stopped. The use of bioidentical hormone creams to increase progesterone production would provide further benefits in restoration of natural progesterone production and hormonal balance, with no side effects or risks: http://www.ncbi.nlm.nih.gov/pubmed/22849758
8. A 2012 study at Sun Yat-sen University, in Guangzhou, China, showed that not only estrogens and progesterone were pertinent to health problems associated with perimenopausal and postmenopausal syndromes, but that serum testosterone and sex hormone binding globulin (SHBG) were highly associated with metabolic syndrome in perimenopausal and postmenopausal syndromes. A holistic attention to hormonal balance and function of the endocrine axis, from the adrenals to the hypothalamus, is important in perimenopausal therapy: http://www.ncbi.nlm.nih.gov/pubmed/22455743
9. A 2011 study at Pescara University in Italy showed that the lignans found in pine bark, standardized as Pycnogenol, significantly improved symptoms associated with perimenopause, such as hot flush, night sweats, mood swings, and vaginal dryness: http://www.ncbi.nlm.nih.gov/pubmed/22108479
10. A 2015 study at the Daegu Haany University School of Medicine showed that the combination of pomegranate extract and red clover extract potentiated the effects in relieving menopausal hot flush and sweat, osteoporosis, and post-menopausal obesity: http://www.ncbi.nlm.nih.gov/pubmed/25912038
11. A 2011 study at the University of California in Berkeley found that the nutritional supplement DIM (Diindolymethane), a metabolite of I3C (found in Brassica vegetables), significantly raised levels of 2-hydroxyestrone (2-OHE1), DIM, and cortisol in the circulation and tissues, showing the DIM significantly raised the 2-hydroxylation of estrogen in postmenopausal women with early stage of breast cancer, a hormonal metabolic pathway previously associated with decreased cancer risk and mortality: http://www.ncbi.nlm.nih.gov/pubmed/15623462
12. A 2014 study at Seoul National University, in Seoul, South Korea found that the nutritional supplement DIM significantly attenuated lipopolysaccharide-induced inflammation in the brain, as well as the pro-inflammatory NF-kb cytokine associated with neurodegenerative diseases such as Parkinsons and Alzheimers. The chemical DIM, but not I3C, significantly protected neurons in key areas of the brain to prevent neurodegeneration with aging : http://www.ncbi.nlm.nih.gov/pubmed/24162184
13. A 2009 study at the Royal Melbourne Institute of Technology University, in Victoria, Australia, showed that a simple tincture of Vitex agnus and Hypericum perforatum significantly reduced the PMS symptoms or PMS-like symptoms associated with early perimenopause, such as anxiety and depressive mood swings, dryness and food cravings: http://www.ncbi.nlm.nih.gov/pubmed/19757982
14. A 2009 study at the University of Quebec, Canada, showed in a randomized double-blinded human clinical trial that a tincture of Hypericum perforatum (St. John's Wort) may significantly improved quality of life in perimenopausal women, with 12 weeks of use resulting in fewer hot flush episodes, reduced intensity of hot flush, fewer sleep problems, and improved quality of life: http://www.ncbi.nlm.nih.gov/pubmed/19194342
15. A 2009 study at Shanghai Medical College of Fudan University, in Shanghai, China, found that electro-acupuncture effectively modulated hypothalamic function in perimenopausal states to affect normalization, affecting neurotransmitters, and neuropeptide synthesis and release. Thus, electroacupuncture serves as an important part of the overall treatment strategy to normalize perimenopausal homeostasis, along with herbal and nutrient medicine: http://www.ncbi.nlm.nih.gov/pubmed/19583940
16. A 2008 study at Ahui College of Chinese Medicine found that electroacupuncture on the point SP6 alone resulted in significant regulation of serum estradiol, FSH and LH, and improved perimenopausal symtpoms: http://www.ncbi.nlm.nih.gov/pubmed/18928120
17. A 2013 study at Catholic University of Daegu, South Korea, found that acupuncture 3 times per week for 4 weeks reduced severity in menopausal hot flush 70-95% in all patients, as well as significantly reducing total number of hot flush episodes, and 4 weeks after this course of therapy, these positive effects were maintained: http://www.ncbi.nlm.nih.gov/pubmed/23383974
18. A 2012 controlled randomized study at Copenhagen University Hospital, Denmark, found that acupuncture significantly relieved hot flush and sleep disturbances in menopausal women with breast cancer: http://www.ncbi.nlm.nih.gov/pubmed/22906948
19. A 2011 meta-review of all scientific study of the treatment of perimenopausal vasomotor hot flush by the University of Texas MD Anderson Cancer Center, advised reluctantly that acupuncture may warrant consideration in standard treatment, while the safety of hormone replacement medications is in question, and antidepressants may have some potential. The treatment outlook in 2011 for women experiencing perimenopausal hot flush and hot flush induced by hormonal ablation in cancer therapies was not promising to standard medicine, and a strong reluctance to introduce a safe and healthy holistic protocol was still widely expressed: http://www.ncbi.nlm.nih.gov/pubmed/22042786
20. This 2014 large randomized controlled human clinical trial of acupuncture to treat hot flush and night sweats during perimenopause, at the University of Melbourne, Australia, notes that current standard therapy is very problematic, and that acupuncture is commonly now used in Australia to reduce perimenopausal symptoms, yet few large high quality studies have been funded so far. This study will utilize single blinding, instead of insisting that the physician is also blinded to the real versus sham acupuncture, allowing for actual acupuncture stimulation by trained acupuncturists, and not allowing the use of alternate real acupuncture stimulation as the so-called sham, which is expected to produce results as well, and has been used in study design to achieve a less than needed difference between the real and so-called sham acupuncture. The outcome measures will include a holistic assessment of effects as well, instead of a narrow focus on the benefits to acupuncture. We see from such studies that the field of standard medicine is finally giving up the practice of biased study design to create false results showing and insufficient benefit over these so-called sham acupuncture stimulations, which has been a shameful practice to discourage acupuncture treatment for decades: http://www.ncbi.nlm.nih.gov/pubmed/24925094
21. A 2009 study at the Royal Melbourne Institute of Technology, in Victoria, Australia, found that pharmacological evidence supports a role for the herb Vitex agnus in alleviation of perimenopausal symptoms: http://www.ncbi.nlm.nih.gov/pubmed/19678775
22. A 2010 survey of 1203 perimenopausal women by the Menopause Survey Collaborative Group, Bologna, Italy, found that 33.5 percent reported using Complementary Medicine, with 23.5 percent consulting at least one Complementary Medicine Physician. The study points out that little research has been conducted to determine which treatments work the best: http://www.ncbi.nlm.nih.gov/pubmed/20187964
23. A 2012 randomized controlled trial, at Linkoping University, in Sweden, of electroacupuncture administered once per week for 12 weeks to treat perimenopausal symptoms, with a 2-year follow-up, found that electroacupuncture decreased hot flush and sweating about as well as hormone replacement drug therapy (approximately 80 percent improved and sustained), and improved quality of life parameters, such as sleep quality, distressing mood, anxiety, and depressed vitality at least as well as hormone replacement therapy, without the risks and side effects. The cost of a 3 month course of electroacupuncture compared to years of hormone replacement drugs is of course much less: http://www.ncbi.nlm.nih.gov/pubmed/21468626
24. A 2012 study at Linkoping University, Linkoping, Sweden, found that acupuncture significantly reduced vasomotor hot flush and sweat in perimenopausal women, and in men after drug regimens that used castration of normal hormones to treat prostate cancer. These researchers believe that acupuncture stimulation may work by affecting the opioid neurotransmitters, which modulate the calcitonin gene-related peptide (GGCP), a vasodilator and sweat gland activator that increases greatly in blood plasma during these hot flush and sweating episodes. These researchers cite the need to find alternatives to synthetic hormone replacement due to the great number of side effects and risks with this drug therapy: http://www.ncbi.nlm.nih.gov/pubmed/22110545
25. A 2011 study at Linkoping University, Linkoping, Sweden, shows that designing a study to prove that acupuncture directly affects calcitonin gene-related peptide (CGRP) levels to control vasomotor flush and sweat presents an array of problems concerning variables, but these researchers nevertheless are seriously studying the array of measurable effects of acupuncture, and trying to improve future treatments, perhaps integrating drug therapy with acupuncture. In this study, the CGRP did not rise dramatically in plasma during vasomotor hot flush and sweating episodes in women or men with the acupuncture group, a positive finding, but showing a direct relationship in this setting is inconclusive. More research is planned. : http://www.hindawi.com/journals/ecam/2012/579321/
26. A 2004 study at Linkoping University, Linkoping, Sweden, shows the problems with standard human clinical study design of acupuncture to treat perimenopausal hot flush and other symptoms, with such so-called "placebo" acupuncture chosen as using superficial needle insertion, which itself has proven effects. In this 2004 study, electroacupuncture performed comparably to hormone replacement therapy, with daily hot flush episodes reduced from 7.5 to 3.5, and 11 of 15 women experiencing at least a 50 percent reduction, maintained for 24 weeks after a once per week treatment for 12 weeks. The superficial needling stimulation had a similar effect on hot flush decrease, but later study found that superficial needling had less effect on measurable parameters of benefit in the central nervous system and neurohormonal changes. These Swedish researchers recommended that using superficial needling as the placebo be discontinued: http://www.ncbi.nlm.nih.gov/pubmed/15497904
27. A large multicenter 2012 controlled randomized trial of acupuncture to treat vasomotor hot flush and sweating was conducted at Cedars-Sinai Medical Center in Los Angeles, California, and Georgia Health Sciences University, Birmingham, United Kingdom, which showed significant benefit in reduction of vasomotor hot flush and sweating by both traditional acupuncture and so-called sham acupuncture, compared to patient receiving no treatment on a wait list. The measurable difference was the fact that the traditional acupuncture showed effects on the hypothalamic function, and the problems with use of so-called sham acupuncture stimulation was discussed. Ultimately, these trials prove that the treatment is successful, but are inconclusive due to the fact that other acupuncture points chosen as so-called placebo also have significant effects. These researchers are using this study to better design a larger study in the near future: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246091/
28. A 2012 randomized controlled study at Beijing University in China found that electroacupuncture at 2 common points used to treat perimenopausal syndrome, Ren4 and SP6, showed that in laboratory animals with the ovaries removed, that this simple treatment significantly modulated levels of hormones that may cause menopausal symptoms and present risks of cancer and cardiovascular disease. The estradiol (E2) levels in the uterus were decreased, and the FSH, LH and GnRH levels were increased significantly compared to control subjects, showing that such electroacupuncture stimulation affects the endocrine axis broadly in a modulating homeostatic manner to help relieve menopausal symptoms and promote a healthier hormonal balance: http://www.ncbi.nlm.nih.gov/pubmed/22574563
29. A 2009 randomized controlled study of acupuncture at 3 common points used to treat gynecological symptoms, Ren4, SP6 and SP8, showed that this stimulation modulated a number of hormones in a beneficial way to achieve symptom relief. In the acupuncture group, circulating estradiol, FSH and LH were reduced significantly compared to controls, and in the uterine tissues of these laboratory animals, the expression of progesterone was increased. Gonadotropin releasing hormone (GnRH), a key determinant of menstrual function, was beneficially modulated in both the hypothalamus/pituitary and the uterine tissues. Such studies clearly show that common acupuncture therapy has a significant modulating effect on hormonal homeostasis: http://www.ncbi.nlm.nih.gov/pubmed/19526799
30. A large multicenter 2012 controlled randomized trial of TCM psychotherapy (simple cognitive and behavioral advice) combined with herbal formulas to treat vasomotor hot flush and sweating was conducted at Guangzhou University in China, with the results indicating that such holistic protocol produced significant benefits in treating menopausal syndrome: http://www.ncbi.nlm.nih.gov/pubmed/23304198
31. A randomized controlled trial of a simple herbal formula versus placebo to treat perimenopausal syndrome, at the Shady Canyon Medical Group in Irvine, California, U.S.A. showed that this simple formula of Cynanchum wilfordii, Phlomis umbrosa, and Angelica gigas, significantly improved overall symptoms without adverse effects. The corresponding Chinese herbal names to these California native herbs in EstroG-100 are Xu chang qing / Bai wei / Ge shan xiang, Cao su, and Dang gui: http://www.ncbi.nlm.nih.gov/pubmed/21887807