Menopause Madness! Are you a hostage to hormones? What are the solutions? By Juliet Gellatley
MenopauseBy Juliet Gellatley
Sixty to 70 per cent of British women experience menopausal symptoms, with many feeling unable to tell their partners. Juliet Gellatley, founder & director of Viva! and nutritional therapist says don’t suffer in silence, seek help. She explores what eases menopausal symptoms safely and asks does a vegan diet help? Do ‘natural’ supplements work – Juliet shows what science reveals. And controversial HRT – is the hype on its lack of safety fair?
When reviewing health literature, two passionately opposing sides emerge about the theory of menopause and how to cope with it. One states that the menopause is a natural occurrence and that the wide list of symptoms associated with it are a fear campaign by those promoting hormone replacement therapy or HRT. This camp believes that most menopausal symptoms may have little to do with the menopause at all. They are just part of the natural ageing process. Other psychological symptoms may be due to the way you have lived your life or traumas that coincide with being middle aged, such as depression due to your children leaving home but which get labelled menopausal because of the woman’s age. This side tends to promote alternatives to HRT which include herbs and supplements based on soya and red clover.
The other camp believes that the symptoms are due to the severe disruption and depletion of sex hormones; and that HRT has its place. For some women this may mean saving their sanity, or so it feels. This side point out that although the menopause is natural, it is only relatively recently that there has been general awareness of menopause as a concept – 100 years ago, life expectancy was much shorter and few women lived long enough to experience it. Nature did not ‘bother’ to develop a smooth transition from pre- to post-menopause, because for most of our evolutionary history we haven’t lived long enough for it to matter! Therefore, balancing sex hormones via HRT is as important as giving insulin to a diabetic or thyroxine to someone with a thyroid deficiency.
There is right on both sides; I’ve scoured the science on the causes of the menopause, the safety and efficacy of soya, red clover, black cohosh, evening primrose oil and HRT. And talked to many nutritional clients about how the menopause has affected them and what they felt was their life line.
The perimenopause is when a woman’s ovaries gradually begin to produce less oestrogen. It usually starts in a woman's forties, but sometimes in her thirties. The average length of the perimenopause is four years, but for some women it lasts only a few months or, for many others, is a painfully protracted 10 years.
The perimenopause lasts until the menopause, when the ovaries stop releasing eggs and a woman stops menstruating. The average age of a woman reaching menopause is 52 in the UK.
According to women’s health specialist at Bristol Nuffield Hospital, Dr Annie Evans, most women do not move from regular menstruation to a sudden end of their periods in their early 50s. Instead they experience menstrual irregularity, perhaps very heavy, painful periods and often increased premenstrual symptoms such as breast tenderness, joint aches and headaches. She says:
“To make matters worse, other symptoms such as irritability, aggression, weepiness, panic attacks and forgetfulness often kick in, and these have often led to women mistakenly being treated for depression. The perimenopause can make life a misery for some women and affects the quality of their home, social and work lives. Often their symptoms are never properly explained, when a slight adjustment to their hormone balance could make them feel and function more normally again. Many women are left feeling that their symptoms are “all in the mind” and cannot be hormonally based as “they are too young for the change”.”
This is true of my client Katherine Hough, 46, who told me:
“I always thought of myself as a coper. The one who organised and propped things up – because I did! I’ve run my own business for years, have a family including three children and two dogs. Then I changed when I hit 44. I felt like crying when the tiniest thing went wrong; I became unreasonable with my husband; I panicked when he went away on work which I’ve never done before. I knew it was illogical but couldn’t control my feelings. PMT got much worse. I went to my (male) GP who said I was too young to be menopausal; he gave me antidepressants which I took long enough to see if they helped, they didn’t – just made me feel slightly distanced from my feelings but they didn’t stop. Months later I went back to my surgery and asked to see a female GP; she had a different attitude. She gave me HRT and that worked within three months. I wasn’t back to being completely myself but it definitely helped a lot. I improved further after seeing you and improving my diet and exercising – my energy levels soared. I am me again, warts and all, and boy am I (and my family) grateful!”
Symptoms of the perimenopause can include:
- Menstrual cycle changes: shortening of cycle length, erratic cycle, increased or decreased length of bleed
- Altered bleeds: spotting, clots, heavy bleeds or “flooding”, dark “tarry” bleeds, mid cycle bleeds, very painful bleeds
- Overwhelming tiredness, insomnia, poor quality sleep and recurrent waking, not purely related to night sweats
- Headaches and migraine (especially premenstrual/menstrual)
- Night sweats (often drenching) may occur before daytime hot flushes
- Joint aches especially on waking, including hips, knees, shoulders, hands and feet
- Cyclical breast tenderness, fluid retention and bloating before periods
- Palpitations (often occurring alongside hot flushes)
- Bladder irritability, urgency, need to get up at night to pass urine
- Loss of libido and interest in sex or difficulty with arousal and desire
- Inability to multi-task, poor concentration and forgetfulness leading to “list making”, driving in the wrong direction, losing the point of what you were saying, inability to remember names....
- Loss of emotional control (crying at sad films)
- Declining feelings of self-worth
The vegan diet, stress and the menopause
Women’s sex hormones fluctuate throughout her life. Perimenopause is similar to puberty in that it’s a time when our hormones vary more widely than normal. According to Marcy Holmes, NP, Certified Menopause Clinician:
“what’s not normal is for the fluctuations to become so extreme or erratic that they make your life miserable. That’s not perimenopause — that’s hormonal imbalance!”
Apart from oestrogen and progesterone declining, there are also changes in the cycling and ratios between oestrogen, progesterone, testosterone, DHEA, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). She explains:
“Fortunately, our bodies have back-up systems to compensate for these changes. But the cumulative effects of poor diet, chronic stress, lack of sleep, too little exercise and environmental toxins often undermine our bodies, and then our sex hormones get pushed out-of-sync. Once this happens, the problem tends to escalate over time, unless you offer your body the kind of support it needs to restore hormonal balance.”
This is where a vegan diet and destressing your life come in! For at least 12 years after the start of menopause, the ovaries produce declining amounts of oestrogen. The adrenal glands at this time, start to produce a type of oestrogen called oestrone which works alongside the declining ovary oestrogen. Therefore it is important your adrenal glands are not compromised by chronic stress.
Oestrogen and progesterone are fat-like, steroid hormones. They are made from cholesterol which is produced in the liver (we need no cholesterol in our diet as we make plenty). Testosterone (yes women have this hormone, albeit in much smaller quantities than men!) and the stress-hormone cortisol are also steroid hormones. We have to balance the production of these hormones depending on our requirements.
Nutritional therapist and author Natalie Savona, explains that if you are under a lot of stress your body produces high levels of cortisol to cope, at the expense of the other hormones. This is why sex drive diminishes when you’re stressed, because the body produces less testosterone which, in both men and women, controls sex drive.
If you are stressed during peri- or post-menopause your adrenal glands will find it hard to produce its version of oestrogen, making symptoms worse. Further, an unhealthy diet ensures the body does not have the raw ingredients it requires to produce the right amounts of hormones.
“Stress also places a greater demand on the body’s nutrient reserves, leaving you tired and in a vicious circle of feeling less able to cope with stress. You could take all the measures available to try to rebalance your hormones, but while you are stressed you are unlikely to see much difference.”
More at www.patrickholford.com
A diet high in animal fats, dairy and sugar and low in vegan wholefoods disrupts our hormone balance. For example, if we eat a diet high in refined carbohydrates such as white bread, white pasta, cakes, milk chocolate bars, jam, sugary drinks and so on it causes a rollercoaster effect on our insulin production. When we digest these types of foods, they produce glucose very rapidly and it enters our bloodstream. Insulin is released to get the glucose out of the blood and into our cells. When we eat junk food, our insulin levels rise suddenly, only to then slump.
While there is excess insulin, this can trigger increased production levels of testosterone, which in turn disrupts the production of oestrogen and progesterone! Everything is connected! Further, the erratic insulin levels can cause hot flushes by causing the blood vessels to dilate.
This is one reason why eating less refined carbs and sugar and more wholegrains, nuts and seeds, essential fats and fresh fruit and vegetables can reduce the impact of the menopause and PMT.
Declining oestrogen means a decline in bone mass, as this multi-tasking hormone is involved in making the cells that form bone. Therefore a vegan diet is important to retain bone health. Red and white meats and dairy all produce acid in our blood when they are digested, which has to be neutralised. This is done by leaching calcium from our bones. A wholegrain varied vegan diet is the most protective diet for bone health that we can have.
Also post-menopausal women have higher rates of heart disease, again partly due to the lack of oestrogen! A vegan diet reduces the likelihood of the build-up of plaques in the coronary arteries. A diet dripping in meat and dairy is high in animal fats which encourage the liver to produce ‘bad’ cholesterol. A vegan diet on the other hand, contains no animal fats or cholesterol but instead is steeped in antioxidants which help dissolve plaques.
Is it possible that oestrogen can play havoc with mood? Or is it all in the mind (ha!). Dr Annie Evans told me:
“It’s not so much the decline in oestrogen that causes the problems, it is the erratic rise and fall of oestrogen during peri-menopause that the brain really does not like.”
But how does oestrogen, a sex hormone, affect mood? As hinted at above, oestrogen acts everywhere in the body including the parts of the brain that control emotion. Some of oestrogen's effects include raising the levels of serotonin, our ‘happy hormone’ and the number of serotonin receptors in the brain. Oestrogen also modifies the production and the impact of endorphins, the "feel-good" chemicals in the brain. It also protects nerves from damage, and is thought to stimulate nerve growth.
Oestrogen's actions are complex and multifarious and nowhere near fully understood. For example, many women's moods improve after menopause, despite oestrogen levels being very low. Again the bad mood during PMT and peri-menopause are connected to the rollercoaster of hormones rather than the actual levels.
How does it feel to be in the midst of oestrogen’s mercurial nature? Jenny Carter recalls it vividly:
“It started at 39. I was unable to live a normal life. I cancelled my 40th birthday party because I couldn’t cope with the organisation. I became a dithering idiot! I had to run a home, look after my children, husband, run my shop but I felt so ill. I had terrible headaches, I would shake, had no energy and didn’t even want to get out of bed. I got into rages over nothing; I overreacted to everything. I took HRT but the first two types didn’t suit me. The final straw was when my coordination went and I drove into a curb. My husband took me to my GP on New Year’s Eve. He implored him to help me saying I wasn’t ‘crazy’ I was ill. The GP phoned the hospital to see if there was a different HRT and it was third time lucky. Within two months of the new HRT I felt much better. I could cope again, I was back to my normal lively self. It was a truly terrible experience so I stayed on HRT for 11 years.”
Mollifying the menopause
It is certain to me that the menopause is a very real condition; that turbulent hormones cause havoc in many women.
So what route should women take if they are a sufferer: ‘natural’ or HRT? To help inform you (the decision is yours!), I looked at the science behind the claims that the most commonly used products such as soya, red clover, black cohosh, evening primrose oil and HRT relieve menopausal symptoms, as well as at their safety.
Soya beans and red clover are two of the most commonly used plants to alleviate menopausal symptoms because of their high concentration of phytoestrogens (or plant oestrogens). These are natural plant hormones. Isoflavones are a type of phytoestrogen which have particularly beneficial effects on our health, and they are concentrated in both soya and red clover. The theory is therefore, that as a woman’s natural oestrogen declines and becomes erratic; plant oestrogens have a modifying and soothing affect as they bind to the woman’s oestrogen receptor sites and reduce menopausal symptoms (Nagata et al, 2001).
One of those symptoms is hot flushes. Oestrogen partly controls our skin temperature, hence the disruption as hormones fluctuate.
“Hot flushes are a nightmare. I used to sit in business meetings – the only woman with about 15 men – sweat pouring down me. It was so embarrassing, so uncomfortable. Soya isoflavone supplements really helped me.”
Debbie Paterson, 53.
There can be an all-over hot feeling one minute - enough to make you feel like opening all the windows in the house - and a shivering sensation the next. On average, flushes occur four or five times a day and usually last from a few seconds to a few minutes. Night sweats can cause the bed linen to be drenched and seriously disrupt sleep, leading to irritability and low mood.
This theory of plant oestrogens reducing symptoms is strengthened by the observation that only 7 per cent of Japanese and 10 to 20 per cent of Indonesian women suffer from hot flushes and night sweats as opposed to 58 to 93 per cent of Western women (Welty et al, 2007). Soya is a mainstay of the diet in Eastern nations; furthermore many soya foods are fermented (eg miso and tempeh) and this process concentrates the isoflavone content (NAMS, 2011). In stark contrast, only one in five mid-life women in the USA eat soya foods and in much lesser quantities on average than their Oriental counterparts. (NAMS 2011.)
In 2010, the North American Menopause Society reviewed the most scientifically rigorous studies on the impact of soya on hot flushes in women on the five years after the menopause. Eleven out of the 14 studies showed a significant reduction in the number of hot flushes – they decreased between 24 and 60 per cent. Soya was particularly effective in women experiencing at least four hot flushes a day. A minimal dose of 50mg isoflavones/day was effective and 12 weeks is long enough to know if there will be an impact. Supplements providing pure or higher proportions of the isoflavone, genistein, showed the strongest benefit. (NAMS 2011.)
If you prefer to obtain the soya isoflavones from soya as a food; the best forms are those that have been least processed (as certain processing removes the isoflavones). Soya products high in isoflavones include edamame (raw green soya beans); miso soup; soya flour; soya protein isolate and tempeh – 100g of any of these contain the minimal dose of isoflavones needed daily to have an effect. Tofu and soya milk are lesser sources; soya hot dogs and soya sauce are poor sources. (NAMS 2011.)
Other studies on soya also show that isoflavones may bind with brain oestrogen receptors and have a beneficial impact on women under (but not over) 65. In one three month trial of 60mg soya isoflavones/day or a placebo; in women aged 50 to 65; soya led to greater improvements in verbal and figural memory and executive function but did not influence anxiety or depression (Duffy, 2003). In another study using 60mg isoflavones/day for six months in women 46 to 65 (versus placebo), soya led to significant improvements in working memory and did reduce depression and fatigue (Casini, 2006). Finally, another rigorous study of 84 middle-aged women who were given either soya protein or cows’ milk protein daily, found that those on the soya had significantly improved sexual desire and much decreased hot flushes but no effect on fine motor skills. (Basaria, 2009.)
Red clover is considerably less studied and the limited research shows that isoflavones from this plant may help increase bone density in peri- and post-menopausal women; they also reduce hot flushes and triglycerides but had no impact on forgetfulness. Importantly, isoflavones from both soya and red clover are considered safe. Very few safety outcomes are beyond mild side effects, the most common of these being stomach pain, loose stools and diarrhoea. The Department of Obstetrics and Gynecology at the National Center of Excellence in Women’s Health, Chicago, USA recommend daily isoflavone doses (from soya and/or red clover) of 80 to 120 mg as having the greatest effect with very few risks. They also state that as it is so safe to take them (soya allergy not withstanding), and that it is beneficial for peri-and postmenopausal women to include soya and red clover in their diet (Geller et al, 2006).
Black Knight to the Rescue
Black cohosh is a tall, flowering plant found in rich, shady woods in eastern areas of North America. Native Americans discovered that this member of the buttercup family’s root helped relieve menstrual cramps as well as symptoms of the menopause, such as moodiness, irritability, sleep disturbances and hot flushes. Today, this herb is used by women across Europe and the USA for the same reasons. But is there any science to endorse these claims?
The University of Maryland Medical Center, USA reviewed the clinical studies. They state: “Quite a few clinical studies confirm that the use of black cohosh is effective for improving menopausal symptoms, although some have found no improvement. Early German studies found black cohosh improved physical and psychological menopausal symptoms, including anxiety, hot flushes, night sweats, and vaginal dryness.
“In a clinical study of 120 women with the menopausal symptoms, black cohosh was more effective in relieving hot flushes and night sweats than the antidepressant fluxetine (Prozac).” A 2010 review by researchers found that black cohosh provided a 26% reduction in hot flushes and night sweats.
However, experts do not agree on the effectiveness and safety of using black cohosh to relieve symptoms of menopause. The American College of Obstetricians and Gynecologists (ACOG) reports that many of the early studies were poorly designed and did not evaluate the safety and effectiveness of black cohosh beyond six months of use. Still, the ACOG recognizes the value of black cohosh for menopausal symptoms. Until more research is undertaken, some doctors recommend only short-term (less than 6 months) use of this herb for the relief of hot flushes. (University of Maryland Medical Center, 2011.)
Evening Primrose Oil
Another useful remedy for some is evening primrose oil (starflower oil) which contains an essential fatty acid called gamma linoleic acid (GLA), commonly used for breast pain and tenderness. The UK’s NHS state that it may also be helpful for mood swings but randomised trials have not shown any effect on hot flushes (Umland et al 2012). The strength and potency can vary. The NHS recommend 240mg daily for at least two months for maximum effect. The dose can then be reduced as required (Menopause Clinic, NHS 2011).
HRT: good for me?
There is no doubt that hormone replacement therapy or HRT relieves many symptoms of the menopause.
For example, HRT remains the most effective treatment for hot flushes and night sweats. According to the most recent Cochrane review, hormone therapy reduces the frequency and severity of hot flushes by a whopping 75 to 79 per cent.
Memory improves. For example a study of HRT versus placebo, showed that women (age 40 to 60) have significantly improved working, everyday and verbal memory after using HRT for three months (Stephens et al, 2006). Science has also shown that HRT alleviates vaginal dryness (if you take low-dose oral or transdermal HRT, you may need to add a vaginal oestrogen to get relief). HRT eases an overactive bladder—that “gotta go” problem—and maybe even recurring urinary tract infections with vaginal oestrogen. It protects your bones. Standard-dose HRT helps prevent bone fractures later in life. Good scientific evidence shows women who use HRT have a lower risk of developing type 2 diabetes. It may also reduce the pain of both osteo- and rheumatoid arthritis and reduce the incidence of colon cancer. It can also reduce mood swings and improve a general sense of well-being.
More at www.familydoctor.co.uk and www.familyhealthguide.co.uk
For nutrition client Hayley Bell, 48, HRT was her saviour:
“I seem to have experienced most, if not all, of the classic perimenopausal symptoms in my late 40s. For me the worst of it was my insomnia and mood swings. I felt that I was not in control of my emotions and frequently overreacted to things that wouldn’t have upset me before. I felt unable to function normally and this interfered with work, friendships and my relationship with my husband. I am now taking HRT and still have my moments and the odd night where I can’t sleep, but overall life is a lot brighter and I feel like I am back in control.”
Since many problems associated with the menopause are believed to be due to reduced oestrogen levels, the main component of hormone replacement therapy (HRT) is oestrogen. If the womb is still present, then oestrogen is taken with a progestogen which prevents oestrogenic thickening of the womb lining and possibly cancer of the womb. Progestogens are mostly made from plant sources and resemble the naturally occurring progesterone, usually produced from the ovary in the second half of the menstrual cycle.
There are two basic forms used for replacing oestrogen:
- Oestradiol, is an exact replica of women’s own oestrogen, derived from plant sterols from yam and soya (found in most of the HRT formulations available in the UK and Europe).
- Conjugated equine oestrogen is derived from horse’s urine, involves terrible cruelty and is found in the Premarin range of HRT, extensively prescribed in the States and obviously, to be avoided.
Risks of HRT
Given the list of positives for taking HRT, why has the media, many health professionals and women turned against it? Dr Annie Evans at Bristol Nuffield hospital specialises in treating menopausal women. She says:
“Many women are extremely wary of taking HRT and those who do are often made to feel guilty that have not been “strong enough” to cope “naturally” with the menopause transition and are criticised for taking something that others believe is associated with great risk, especially of breast cancer, and which could cause more harm than benefit.”
It was widely believed in the 1980s and 90s that the huge list of benefits of HRT would outweigh the risks. These attitudes radically changed after two major trials in the early 2000s, the WHI trial (Women’s Health Initiative) from the USA and the UK MWS (Million Women Study), were published. However, both of these trials had serious flaws, both in design and interpretation.
Dr Evans explains:
“The HRT arm of the WHI trial recruited 17,000 women who had no symptoms of the menopause who had not had a hysterectomy, and so would need both oestrogen and progestogen. They were randomly allocated to either taking one form of HRT or a placebo. The intent was to follow these women for perhaps 10 to 15 years and collect data on rates of bone fracture, heart disease and stroke, breast cancer and bowel cancer.
“This arm was stopped early after just over five years because of reportedly unacceptably increased rates of breast cancer, heart attack and stroke in the women on the HRT rather than placebo.
The serious flaws that have subsequently come to light are principally in the average age of the women recruited into the trial, 63yrs, with 23 per cent being over the age of 70. This is not the “normal” age of women starting on HRT in the UK, where 96 per cent of HRT users start below the age of 60.
Sadly a large proportion of women in this older age range will already be developing arterial and heart disease, and they were not excluded from the trial. Over a third of the women were medically obese, and an equal proportion had hypertension (high blood pressure). Obesity not only increases the risk of heart disease, but also of breast cancer.
“The negative impact with regard to heart disease and stroke of the HRT formulation used in this trial, with an “unfit” population of women, cannot be extrapolated to the usual users of HRT in Europe and the UK. At the time the trial was stopped early, the HRT users were shown to have a reduction of bone fracture, both in the spine and the hip, and a reduction in colorectal cancer rates and, overall, to have NO difference in death rates from all causes, but the focus, especially in the media, was on the increase in breast cancer amongst users and the increase in stroke risk.
“The way risk is reported has a massive effect on how it is viewed. The reports in the media of the trial stated the 26% increase in breast cancer risk, not that it was an increase from 30 to 38 women per 10,000 women per year. The 41% increase in risk of stroke in the HRT users, which hit the headlines of all the newspapers in the UK was actually an increase from 21 to 29 women per 10,000 women per year, and has to be viewed from the perspective of the age of the women enrolled in the trial, some of whom were 79 when the trial was stopped early!”
In reality, in the 5.2 years duration of the HRT arm of the WHI Trial, there were:
7 extra heart attacks and 8 extra strokes per 10,000 women in the HRT group
Maybe these figures put the reality into perspective? See Dr Evan’s informative web site for further explanation and much more information on the menopause and choices to control symptoms at www.drannieevans.com
Whichever way you move forward, rest assured you are not alone! If you are having difficulties with the menopause, you are not going mad. Your hormones are! And their tumultuous behaviour can be gently controlled so that you – the real you – reemerges; one that is able to embrace all the advantages and wonder of life in a different era.
- Basaria, S et al, 2009. Effect of high-dose isoflavones on cognition, quality of life, androgens, and lipoprotein in postmenopausal women. J Endocrinol Invest, 32: 150-155
- Duffy, R et al, 2003. Improved cognitive function in postmenopausal women after 12 weeks of consumption of a soya extract containing isoflavones. Pharmacol Biochem Behav, 75: 721-729
- Casini, ML et al. Psychological assessment of the effects of treatment with phytoestrogens on postmenopausal women: a randomised, double-blind crossover, placebo controlled study. Fertil Steril. 85: 972-978
- Evans, A. The perimenopause, http://www.drannieevans.com/The-Perimenopause.html
- Geller, SE et al. Soy and red clover for midlife and aging. Climacteric, 9 (4): 245-263
- Marcy Holmes, NP, Certified Menopause Clinician, Menopause & perimenopause, http://www.womentowomen.com/menopause/perimenopause.aspx
- Oestrone by adrenal glands: http://www.menstruation.com.au/fertility/oestrogen.html
- MacLennon, AH et al, 2004. Oral oestrogen and combined oestrogen progestin therapy in healthy postmenopausal women versus placebo for hot flushes. Cochrane Database Syst Rev, 4:CD002978
- Menopause Clinic NHS Dumfries and Galloway,. 2012. Alternatives to HRT. http://www.menopausematters.co.uk/pdf/Alternatives%20to%20HRT%202012.pdf
- Mental Health Centre; 2011. Oestrogen and women’s emotions http://www.webmd.boots.com/mental-health/oestrogen-and-womens-emotions. Medically Reviewed by Dr Rob Hicks on September 09, 2011
- NAMS, 2011. Isoflavones Report, The role of soy isoflavones in menopausal health: report of the North American Menopause Society/Wulf H. Utian Translational Science Symposium in Chicago, IL (October 2010), Menopause, 18 (7), 732-753
- Nagata, C et al, 2001. Soy product intake and hot flushes in Japanese women results from a community-based prospective study. American Journal of Epidemiology, 153 (8), 790-793
- Savona, N. Stress on hormone balance: Hormone problems can be balanced naturally, Nutritional therapist, author and TV presenter Natalie
- Savona, www.patrickholford.com/index.php/advice/lifestagearticle/135/
- Stephens, C et al, 2006. HRT and Everyday Memory at Menopause: A Comparison of Two Samples of Mid-Aged Women. Women & Health, 43 (1), 37-57
- University of Maryland Medical Center, 2011. Black cohosh. http://www.umm.edu/altmed/articles/black-cohosh-000226.htm#ixzz2JZPFr8XQ
- Umland, EM et al, 2012. Treatment options for vasomotor symptoms in menopause: focus on desvenlafaxine. International Journal of Women’s Health, 4: 305-3019
- Welty, F et al, 2007. The association between soy nut consumption and decreased menopausal symptoms. J Women’s Health (Larchmt), 16 (3): 361-369