1. Complementary therapies for menopausal symptoms Complementary therapies for menopausal symptoms Rod Baber

2.  Estradiol was isolated in 1923 and first synthesized in 1928  The first commercial inexpensive estrogen preparation was conjugated equine estrogens (CEE or ‘Premarin’) in 1942  For western post menopausal women with troublesome symptoms CEE became the treatment of choice and remained so until publication of results from ‘The Women’s Health Initiative’ (WHI) clinical trials in 2002.  Adverse findings from those trials led many women to seek alternative therapies, mostly to alleviate troublesome menopausal symptoms  These alternatives were often based on ‘Eastern’ traditional therapies including compounded Chinese herbal preparations, Black Cohosh and Phytoestrogen preparations derived from Soy and red Clover.  Of these, by far the most widely used in ‘The West’ are phytoestrogens Some Background

3. Dietary Isoflavones reduce incidence of menopausal symptoms 0102030405060708090100 Singapore Japan China Malaysia Europe Incidence Hot Flushes (%) Rekers H. Burger HG, Boulet MJ, editors. A Portrait of Menopause. Parkridge, New Jersey: The Parthenon Publishing Group; 1991; p. 23-43. Ismael NN. A study on the menopause in Malaysia. Maturitas 1994;19(3):205-9. Tang GW. The climacteric of Chinese factory workers. Maturitas 1994;19(3):177-82. Isoflavone Excretion (nmol/day) 0250500

4. Phytoestrogens  Phytoestrogens are plant constituents with a di-phenolic structure similar to oestrogen.  They are found in a wide variety of edible plants.  They bind to estrogen receptors but preferentially to ER  They may act as weak oestrogens in some circumstances. β MoleculeRelative potency Estradiol100 Coumestrol0.202 Genistein0.084 Daidzein0.013 FormononetinConverted into Genistein & Daidzein Biochanin AConverted into Genistein & Daidzein

5. Estrogen Receptors  There are at least two different receptors for Estrogen  These receptors are found in different concentrations in different tissues throughout the body in CVS, Bone, Ovary, Brain and Urogenital tract in Breast, Uterus, Brain & Ovary  ER Beta modulates the effects of ER Alpha in cells with both receptors  Cellular sensitivity to E2 at low concentrations is reduced in cells with both receptors  There are two different estrogen receptors. β α α β β α

6. Actions of Estrogen agonists, antagonists and SERMs Effects will vary with type of SERM and organ system Receptor mediated effects blocked Normal Receptor mediated Estrogenic effects

7. Genomic and non genomic pathways Genomic (nuclear) effects eg alleviation of vasomotor symptoms. Non Genomic (rapid membrane receptor) effects eg activation of Nitric oxide synthetase leading to vasodilatation Estrogen binds to both ER α and ER β equally

8. Phytoestrogens: Mechanism of action Genomic  Binding affinity of phytoestrogens is 100-1000 times less than estradiol  Phytoestrogens bind to both ER and ER but preferentially to ER (8-40x more).  ER generally suppresses breast stimulation Non Genomic  Phytoestrogens may act as ‘endocrine disruptors’ e.g. they may increase SHBG and alter free hormone levels, may increase cycle length and can suppress LH and FSH.  Phytoestrogens also inhibit tumour growth factors such as Protein Tyrosine Kinases (PTK) and DNA Topoisomerases involved in tumorigenesis  Phytoestrogens may inhibit Vascular endothelial growth factor (VEGF)  Phytoestrogens have general antioxidant qualities e.g. Resveratrol (found in grapes and red wine) has been shown to upregulate Sirtuin genes (Sir 2 etc.) resulting in lower levels of cholesterol, blood sugar and insulin ββ α β

9. Phytoestrogens Phytoestrogens may be divided into 3 classes  Isoflavones are found in legumes with Soybeans and Soy products being the major dietary source. Isoflavones are also found in Red Clover  Lignans are found in high fibre cereals, unrefined grains and beans with flaxseed containing the largest amount  Coumestans are found in large quantities in Alfalfa and clover sprouts with lesser amounts in split peas, lima beans and pinto beans

10. Chemical Structure of Isoflavones compared to 17 B Estradiol OH OH CH 3 17  -estradiol Isoflavone O O O O H H

11. Chemical structure of Lignans and Coumestans Lignan Coumestrol

12. SOY  Richest source of dietary phyto-oestrogen  Isoflavone content 60-70% mainly Genistein and Daidzein  Asian communities consume 20 – 80mg / day of isoflavone  Western communities consume 1 – 3 mg / day

13. Soy derived food products

14. Soy Isoflavones and vasomotor symptoms ✔ 3 recent studies of soy isoflavones containing higher doses (120,100 and 90mg) found a slight reduction in hot flushes vs placebo ✔ A study by Carmignani et al showed a reduction in flushes similar to low dose HRT ✔ A trial of a mixture of 60mg soy isoflavones and 20mg lignans in 80 women found a significant reduction in hot flushes at 3 months  A single centre RCT sponsored by NIH found difference between placebo and soy isoflavones 200mg but did not differentiate between frequency and intensity.  Trials of Lignans have generally failed to show any significant effect Beddell et al J Steroid Biochem Mol Biol 2013 on line Villaseca P Climacteric 2012;15:115-124

15. Soy isoflavones and vasomotor symptoms  A systematic review of RCTs of soy isoflavones found two out of 5 produced a significant improvement of vasomotor symptoms compared to placebo Thomas A et al. Maturitas 2014;78:263-76 ✔ A meta analysis of the effects of soy isoflavones on vasomotor symptoms found that, although only four individual studies reported a significant improvement in vasomotor symptoms for the isoflavone group, overall there was a significant improvement in symptoms for the treatment group. Chen M et al. Climacteric 2014; early on line  The study of women across the nation (SWAN) found no significant improvement in vasomotor symptoms for users of soy isoflavones. Gold E. Et al. Menopause. 2013;20:305-14

16. Red Clover Isoflavones and vasomotor Symptoms ✔ A systematic review found that in six out of seven randomized trials of red clover isoflavones there was a significant reduction in vasomotor symptoms. ✔ One trial found a reduction in cognitive symptoms for users of red clover isoflavones Thomas A et al. Maturitas 2014;78:263-76  The largest single RCT of Red Clover isoflavones found no difference in vasomotor symptoms between two active arms and placebo Tice J et al. JAMA 2003;290:207-14

17. Red Clover extracts: Hot flushes 2 preparations of Red Clover Promensil = 82 mg/day Total Isoflavones Rimostil = 57 mg/day Total Isoflavones Tice JA, Ettinger BE, Cummings SR, et al. JAMA 2003;290:207-214 Randomized, placebo-controlled, double blind study n = 252 postmenopausal women 45 – 65 years old, symptomatic

18. Phytoestrogens for vasomotor Symptoms: Cochrane summary  Dietary Soy. No evidence diets high in soy had any effect on hot flush frequency or severity  Soy Extracts.No evidence of any effect on hot flush frequency or severity  Red Clover extracts. No evidence of any effect on hot flush frequency or severity  Genistein. Doses of 30-60mg daily reduced hot flush frequency by 41-61% compared to placebo effect of 7-29%. No data on effect on severity  Equol. Reduced hot flush frequency by 61% compared to placebo 45%  Safety: No effect on endometrium. Mixed effects on Vaginal cytology  Summary. In general no conclusive evidence showed a benefit for phytoestrogens on vasomotor symptoms with the exception of Genistein. NB Only 20-30% of Caucasians (compared to 50-60% of Asians) have the necessary gut microflorae to convert daidzein to equol Roberts and Lethaby. Maturitas 2014;78:79-81

19. Phytoestrogens and Vaginal atrophy  Recent studies suggest any effect of phytoestrogens on Vulvo Vaginal Atrophy requires long term therapy  An RCT of Soy Rich diet and HRT found an improvement in cell maturation and karyopyknotic index in both groups after 6 months  A 3 arm study (90mg soy isoflavones, HRT, placebo) found improvement of symptoms in both treatment arms compared to placebo Chiechi L et al Maturitas 2003;45:241-246 Carmignani L et al Maturitas 2010.67:262-269

20. Phytoestrogens and the heart Pre Clinical  Intact soy protein reduces serum lipids and atherosclerosis  Isoflavones improve flow mediated dilatation in brachial arteries in normal women and women with the metabolic syndrome  Isoflavones reduce fasting blood glucose and insulin in women with the metabolic syndrome Clair R Hanb. Exp Pharmacol. 2005;170:301-23 Eden J Maturitas 2012;72:157-9 Squadrito et al J Clin Endocrinol Metab. 2013;98:3366-74 Irace C et al Eur J Clin Invest. 2012;43:1025-31

21. 0 5 10 15 20 25 30 35 Run-inPlacebo40mg80mg Arterial Compliance Units ** Change in FMD following treatment with Isoflavones for 12 weeks Nestel P J Clin Endocrinol Metab.1999;84:895-898

22. CEE, Soy phytoestrogens & atheroscelerosis Mikkola & Clarkson Cardiovascular research 53 (2002) 605-619

23. Red Clover Isoflavones enriched with formononetin lower LDL Cholesterol Clifton Bligh P, Clifton Bligh R, Baber R Eur J Clin Nutrit. 2014 1-9 e pub  2 year double blind randomized controlled trial  Serum LDL dropped 2% in Controls and 12% in treatment arm (p=0.005)

24. Red Clover Isoflavones enriched with formononetin lower LDL Cholesterol Clifton Bligh P, Clifton Bligh R, Baber R Eur J Clin Nutrit. 2014 1-9 e pub

25. Phytoestrogens and Serum Lipids  Dewell and colleagues performed an extensive literature search using major search engines and cross referencing of articles  Articles were evaluated based on levels of experimental control as well as statistical, quantitative and clinical analysis  Overall the differences in plasma cholesterol concentrations seen with soy protein and isoflavone supplementation were primarily statistical in nature rather than reflecting quantitative differences in the hypocholesterolaemic effects detected Dewell A et al J Clin endocrinol Metabol 2006;91:772-780

26. Phytoestrogens and Cardiovascular Health: Summary  The American Heart Association concluded that soy reduced plasma LDL-C by 3% with no effect on HDL-C, triglyderides, lipoprotein (a) or blood pressure  No effect was seen in 19 studies of soy isoflavones  Thus any effect of soy on cardiovascular health would be minimal at best  Despite this NAMS advises caution in drawing hasty conclusions Sacks F et al Circulation 2006;113:1034-44 NAMS Isoflavone Report. Menopause 2011;18:732-53

27.  In human osteoblasts, isoflavones  exert estrogenic effects, increasing osteoblast numbers  enhancing their functional activities including matrix synthesis and alkaline phosphatase activity  May tip the balance in favor of enhanced bone formation relative to resorption and thus to increase bone mass MM Muir, S Sivagurunathan, G Nowak, RS Mason. International Congress for Endocrinology, Sydney, November 2000 The effects of Isoflavones on human Osteoblasts

28. Phytoestrogens and bone health A systematic review  737 studies identifed; 36 were suitable  Isoflavones appear to stimulate osteoblasts and inhibit osteoclasts  Isoflavones in high doses showed beneficial effects on bone health in peri and post menopausal women but results were inconsistent  Inconsistency of results confirmed in a recent review Castel Branco C et al Climacteric 2011;14:204-211 Clifton Bligh and Baber Eur J Clin Nutr. 2014 1-9 e pub

29. Phytoestrogens for bone Loss: a review  Cross sectional studies of soy food in the USA found a positive effect only in pre-menopausal women  Cross sectional studies in Scottish, Danish and Iranian women showed a reduction in bone turnover or increased BMD with high soy diets  No reliable data from prospective observational studies  No data from RCTs that soy foods have any effect on BMD  Most RCT’s of soy enriched foods have found no change in BMD  Most RCT’s of single isoflavone tablets have found no benefit although two Italian RCT’s reported increase in bone density with genistein 54mg daily  RCT’s of multiple Isoflavone tablets have generally found no change in BMD. Lagari V and Levis S J Steroid Biochem Mol Biol 2013 (in press)

30. Phytoestrogens and the Breast Pre Clinical  Isoflavones bind preferentially to ER B receptors and are less potent than E2  Isoflavones can alter metabolism of endogenous estrogens  Non genomic effects include: - Antiproliferative effects - Tyrosine kinase inhibition - Modulation of steroid hormone metabolizing enzyme activity - Induction of apoptosis - Reduction of circulating and intra-breast estradiol concentrations NAMS Isoflavone Report. Menopause 2011;18:732-53

31. Effects of Phytoestrogens on Breast cells in vitro  At low concentrations Genestein, Resveretrol and Quercetin have selective effects on breast cells which may inhibit growth of malignant MCF -7 cells and maintain the survival of normal MCF-10A cells in vitro  This finding supports the epidemiological hypothesis that phytoestrogens have antiproliferative activity at low concentrations via an ER dependent mechanism  At low concentrations these phytoestrogens did not have anti proliferative effects on normal breast cells in vitro and exerted growth stimulation via a non ER dependent mechanism  Although phytoestrogens may not be helpful in preventing breast cancer, their use in women with breast cancer need not be restricted Chen F and Chien M Climacteric 2014;17:1-10

32. Effects of Genistein on growth of MCF-7 (ER+) and MDA-MB-231 (ER-) cells Genistein(M) Relative Growth MCF-7 MDA-MB-231 010 -9 10 -8 10 -7 10 -6 0.5 1.0 1.5 2.0 Wang et al, Carcinogensis 1996 ; 17 : 271 10 -5 10 -4 0.0 2.5

33. Phytoestrogens and the Breast Clinical ✔ In Dutch women high circulating genistein levels were associated with reduced breast cancer risk ✔ A Singapore study of 35,000 women found reduced breast cancer risk amongst women with highest quintile soy intake (mostly post menopausal) ✔ The Shanghai women’s health study of 75,000 women found almost 50% less breast cancer for the highest quartile soy users (mostly pre menopausal)  The Japan Collaborative Cohort of 30,000 women found no association between soy food intake and breast cancer risk  Several recent case control studies from Asia reported an inverse association between soy food consumption and breast cancer risk irrespective of ER status  The associations appear stronger for adolescent consumption of soy foods rather than in adulthood suggesting a life stage specific benefit NAMS Isoflavone Report. Menopause 2011;18:732-53

34. Phytoestrogens and The Breast Clinical  4 epidemiological studies reported a 28-60% reduction in BrCa risk among Asian American women if they had commenced soy consumption in early childhood or adolescence and persisted for more than 10 yrs.  Studies on Lignans and breast cancer have found that there is a reduction in breast cancer risk for the highest quartile of lignan consumers compared to the lowest quartile  Studies have not found any impact of phytoestrogens on the efficacy of Tamoxifen  There is inadequate data on the effect of phytoestrogens on aromatase inhibitors Beddell S J Ster. Biochem Mol Biol 2013

35. What is the problem?  Most trials are too small and too short  Many trials have significant confounding variables.  Factors other than phytoestrogens may be implicated e.g. Diet high in phytos is low in animal fats  There has been little concordance in dose or type of isoflavones trialled  Bioavailability is individually variable  Few human trials on pure pharmaceutical products  Clinical effects appear modest at best and placebo effect is high in RC vasomotor trials

36. Acupuncture for menopausal vasomotor symptoms  Comparing acupuncture with sham acupuncture, found no evidence of a significant difference in their effect on menopausal vasomotor symptoms.  Comparing acupuncture with no treatment appeared to show a benefit from acupuncture, but acupuncture appeared to be less effective than HT.  These findings should be treated with great caution as the evidence was low or very low quality and the studies comparing acupuncture versus no treatment or HT were not controlled with sham acupuncture or placebo HT. Data on adverse effects were lacking. Dodin S et al Cochrane database Syst Rev. 2013 Jul 30;7:CD007410

37. Black Cohosh for Menopausal Symptoms  Sixteen RCTs, recruiting a total of 2027 perimenopausal or postmenopausal women, were identified. All studies used oral mono preparations of black cohosh at a median daily dose of 40 mg, for a mean duration of 23 weeks.  There was no significant difference between black cohosh and placebo in the frequency of hot flushes or in menopausal symptom scores  Compared to black cohosh, hormone therapy significantly reduced daily hot flush frequency (three trials; data not pooled) and menopausal symptom scores  There is currently insufficient evidence to support the use of black cohosh for menopausal symptoms. Leach M and Moore V Cochrane Database Syst Rev 2012 Sep 12;9:CD007244

38. Cognitive Behavioural therapy for Breast Cancer survivors with VMS  Hot flush problem rating reduced after 9 weeks irrespective of time since diagnosis menopausal status at diagnosis or type of cancer treatment  The effect was greater in women not receiving chemo, those with higher baseline psychological distress and in non white women Chilcot J, Norton S and Hunter M. Maturitas 2014;78:56-61 TAU: treatment As usual

39. Conclusions  A US NIH survey found that 36% of Americans use some form of complementary and alternative medicine (CAM).  Increased dietary soy and other forms of phytoestrogens reduce menopause symptoms similar to that of placebo.  Soy isoflavones may inhibit the progression of atherosclerosis.  Regular consumption of soy isoflavones in the diet may offer breast cancer protection if exposure occurs during breast development.  There is no evidence of fracture prevention for users of phytoestrogens  Acupuncture reduces hot flashes and improves sleep patterns in postmenopausal women similar to that of sham acupuncture.  Relaxation therapy reduce menopausal symptoms similar to placebo  Cognitive Behavioural Therapy (CBT) is effective in alleviating VMS in breast cancer survivors