No 'magic bullet': Review highlights diet, not supplements, for tackling menopause symptoms
In the review, published today in Nutrition Bulletin, the authors looked at the role of dietary patterns and supplements (including vitamins, fatty acids, herbs and botanicals) in the management of common menopausal symptoms such as vasomotor symptoms (VMS; hot flushes; night sweats), changes in bodyweight, mood and cognitive changes, and sleep disturbances.
The review highlights that healthier dietary patterns, such as Mediterranean style diets, may help to reduce the frequency and severity of several menopause symptoms. It states there is limited evidence available to suggest that taking supplements may help alleviate many of the symptoms during the menopause, including depression, anxiety and cognitive changes.
Specifically, the review advocates for a diet rich in fruit and vegetables, wholegrains, beans and other pulses, and with a higher proportion of healthier fats from foods such as oily fish, nuts and seeds.
Sara Stanner, Science Director, British Nutrition Foundation, an author of the review said: “Going through the menopausal transition can be a challenging time, with both physical and psychological symptoms occurring for many that can have a negative impact on daily lives and quality of life.
"Our new review highlights that there may be small changes we could make to our daily eating habits to consume a healthier dietary pattern that could help us maintain a healthy weight and possibly help alleviate symptoms such as hot flushes.
"But there is no ‘magic bullet’ when it comes to diet and supplements in managing menopausal symptoms, and it’s important that those going through the menopause are supported and given access to the information and tools needed to make the right changes for them.”
Menopause as an economic issue
Over one in four (29%) of those who have experienced symptoms of menopause have tried herbal remedies to ease their symptoms, and almost three in ten (30%) have tried vitamins.
The number of women aged 50–64 years who are economically active in the UK has more than doubled over the last 30 years (Office for National Statistics, 2022), and menopausal symptoms can impact economic participation due to lower productivity, reduced job satisfaction and problems with time management (Bazeley et al., 2022; Brewis et al., 2017).
In fact, one third of the UK female population is currently estimated to be perimenopausal or postmenopausal and one in ten women are leaving their jobs due to suffering menopausal symptoms.
Hormone replacement therapy (HRT) is often used to treat menopausal symptoms in accordance with national guidelines (NICE, 2015). However, it has been estimated that approximately half (51%) of UK women seek complementary and alternative medicines to manage their menopausal symptoms (Gentry-Maharaj et al., 2015; Posadzki & Ernst, 2013).
Below are a few key conclusions from the review regarding scientific literature on various supplements for hot flushes and psychological symptoms.
Red clover (Trifolium pratense L., Fabaceae) is a legume containing isoflavones such as formononetin, biochanin A, genistein and daidzein. A recent meta-analysis of 12 RCTs (Kanadys et al., 2021) included eight studies that measured the daily frequency of hot flushes.
Meta-analysis of these eight studies found a significant reduction in the daily occurrence of hot flushes in women receiving active treatment compared to placebo. However, the BNF review argues some studies had small numbers of participants and there may be individual differences in the metabolism and bioavailability of isoflavones, suggesting larger studies are needed. Similarly, evidence for the
optimal dose and duration is inconclusive (Kanadys et al., 2021).
Black cohosh (Cimicifuga racemosa or Actaea racemosa) is a herb that contains bioactive compounds such as triterpene glycosides actein and cimicifugoside, fatty acids, resins, caffeic acids, isoferulic acids
The current review notes a Cochrane review (Leach & Moore, 2012) and a subsequent meta-analysis of four RCTs (Franco et al. (2016)) which reported no significant difference between mono-preparations of black cohosh and placebo for the frequency or intensity of hot flushes among peri-and postmenopausal women. The BNF authors also note the risk of bias for most RCTs was also unclear given the limited extent of the information provided.
They state: "NICE guidelines (NICE, 2015) therefore highlight that there is currently limited evidence regarding the most appropriate formulation, dose, duration and safety of preparations of black cohosh, and cautions that interactions with medications have been reported."
Similarly, fatty acids and vitamin E Omega-3 fatty acids and vitamin E have been explored for alleviation of hot flushes but trials have provided mixed results.
A systematic review of 10 studies (n = 1100) found that vitamin E and omega-3 in combination significantly reduced the intensity of hot flushes compared to placebo, but no individual effects on the frequency or intensity of VMS were found and the authors concluded there was insufficient evidence that omega-3 supplements improve VMS (Maghalian et al., 2022).
Polyphenols and botanical supplements, such as St John's Wort (Liu et al., 2014), evening primrose oil (Farzaneh et al., 2013; Kazemi et al., 2021), sage (Bommer et al., 2011), milk thistle (Saberi et al., 2020), ginseng (Lee et al., 2016, 2022) and combined botanical supplements (Rattanatantikul et al., 2022) have all been explored for their benefits for VMS severity.
However, following their review of the data, the BNF review states: "Despite some studies reporting positive results, concerns about methodology, study heterogeneity and insufficient large-scale interventions mean it is not possible to conclude whether a causal relationship exists for reducing VMS. Botanicals are also not recommended in clinical guidelines or position statements, due to limited and conflicting evidence regarding efficacy and safety (Mintziori et al., 2015; NICE, 2015)."
The discovery of vitamin D receptors and enzymes capable of metabolising vitamin D in the brain led to the suggestion that vitamin D may play a role in several biological processes relevant to depression.
A sub-group analysis of RCTs recruiting female participants suggested that vitamin D supplementation may benefit depressive symptoms (Mikola et al., 2022). However, within this analysis, only two RCTs recruited postmenopausal women (Mason et al., 2016; Yalamanchili & Gallagher, 2012), with neither of these studies reporting a significant beneficial effect on depressive symptoms following vitamin D supplementation.
Therefore, the BNF review states it remains unclear whether vitamin D may have any specific benefit during the menopause.
A recent review of 35 RCTs found that omega-3 PUFA (n-3 PUFA) supplementation has a small-to-modest benefit in reducing depressive symptoms in patients with major depressive disorder (Appleton et al., 2021).
"However, an EMAS position statement on the management of depressive symptoms in peri-and
postmenopausal women did not discuss n-3 PUFA supplements (Stute et al., 2020), nor did the guidelines for evaluation and treatment of perimenopausal depression from NAMS (Maki et al., 2019)," the BNF review asserts.
Analysis of findings from folic acid supplementation trials has reported a benefit in improving depressive symptoms (Altaf et al., 2021; Khalili et al., 2022; Zheng et al., 2020), although the review notes that the number of studies was small, sample sizes were generally small, a wide range of doses was used and significant heterogeneity was reported across studies.
Two meta-analyses of RCTs concluded that zinc supplementation significantly reduces depressive symptoms in adult patients when prescribed as a monotherapy (Yosaee et al., 2022) or as an adjunct to antidepressant medications (da Silva et al., 2020).
However, BNF authors note the available trials were of limited duration and sample size (da Silva et al., 2020), and no trials solely recruited women during the peri-or postmenopausal period. Therefore, it is unknown whether zinc supplementation has any specific benefit during the menopausal transition.
St John's Wort
Looking at trials testing St John's Wort for depressive symptoms in menopausal women, the review states these were inconsistent in terms of study design, intervention type and the reported effects on psychological symptoms (Briese et al., 2007; Eatemadnia et al., 2019; Grube et al., 1999; van Die et al., 2009).
UK guidance from NICE acknowledges that St John's Wort may be of benefit in less severe depression
(NICE, 2022). However, NICE (2022) advises health professionals against prescribing or advising the use
of St John's Wort for people with depression, due to uncertainty about appropriate doses, the persistence
of effect, variation in preparations and potential serious interactions with other drugs.
The review notes that several other botanicals have been trialled for treating depressive symptoms during menopause (Johnson et al., 2019; Mehrnoush et al., 2021). However, the available evidence was typically limited to a single RCT, and not all interventions reported a significant improvement in depressive or psychological symptoms.
For example, fenugreek extract resulted in a significant reduction in self-reported depressive symptoms among perimenopausal women in one trial (Khanna et al., 2020), although another RCT did not find any significant benefit (Steels et al., 2017).
Other studies have reported benefits for depressive symptoms in single trials of fennel in postmenopausal women (Ghazanfarpour et al., 2018), and Ashwagandha (Withania Somnifera) root extract in perimenopausal women (Gopal et al., 2021; Johnson et al., 2019), but the BNF review states these trials were small-scale (n = 60 and n = 100, respectively) and of short duration (12 and 8 weeks), making it difficult to draw conclusions about potential efficacy.
Source: Nutrition Bulletin
"The role of diet in managing menopausal symptoms: A narrative review"
Yelland. S., Steenson. S., Creedon, A., and Stanner. S.,