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Complementary and alternative approaches to menopause care

Complementary and alternative approaches to women’s health

Continuing Education Module
Jacques Rossouw (DSc) and Timothy J. Maher (PhD)
Goal:
To briefly review the physiology of menopause, the use of conventional hormone replacement therapy, and to examine several complementary and alternative approaches to managing menopausal symptoms. Objectives:
Following the successful completion of this module, the participant will be able to: • Describe the normal physiological changes that occur during menopause; • Compare the advantages and disadvantages of available conventional treatments for managing • Describe complementary and alternative approaches for managing menopausal symptoms and their • Describe complementary and alternative approaches for managing urinary tract infections and their Describe complementary and alternative approaches for managing water retention; Identify the major advantages and disadvantages of complementary and alternative medicine for
1. Introduction

Getting check-ups is one of the many things women can do to help stay healthy and prevent disease and
disability. Regular health examinations and tests can help find problems before they start; they also can help find
problems early, when chances for treatment and cure are better. By getting the right health services, screenings,
and treatments, women are taking steps that help their chances for living a longer, healthier life.
A woman’s age, health and family history, lifestyle choices (i.e. what she eats, how active she is, whether she
smokes), and other important factors impact what and how often she needs healthcare.
Women will experience PMS, some more severe than others; bladder/vaginal infections and ultimately
menopause. Complementary and alternative products should be considered as a treatment option over and above
the traditional medical interventions.
2. Menopause
Menopause is not a disease, rather a normal physiological stage of a woman’s life that typically occurs when she
is in her late 40s to mid 50s. Sometimes called the ‘change of life’, menopause results as the ovaries gradually
lose the ability to produce hormones in the necessary quantities for regular cyclic menstruation and/or the pool of
ovarian follicles near total depletion. In each normal menstrual cycle between menarche (first menstrual period)
and menopause, estrogen triggers the release of two or three eggs to the fallopian tubes (follicular phase) for
potential fertilization. If the egg is not fertilized, and therefore not implanted into the uterine wall, the predominance
of progesterone in the second half of the cycle (luteal phase) leads to menstruation - the sloughing off of cells
lining the uterus. Women typically menstruate monthly until they reach their mid to late forties, at which time
perimenopause begins. This phase, characterized by menstrual irregularity and other symptoms brought on by
increased estrogen to progesterone ratios, may last a few months or a few years prior to complete menopause.
Menopause, also known as the climacteric, is thus defined as the time following one year of complete cessation of
menstrual bleeding.
2.1 Menopausal changes

Numerous signs and symptoms characterize menopause. Some are classified as overt, others silent. Overt signs
include hot flashes, night sweats, insomnia, vaginal dryness, and sexual dysfunction. Fatigue, muscle aches, and
decreased energy are also common. Some women experience all of these symptoms; others may experience
only one or two. Some overt signs can be troublesome, but they often decrease in intensity over time. However,
the silent consequences of menopause continue unabated and exact a significant toll on women's long-term
health, including an increase in cardiovascular disease risk and osteoporosis-related fractures.
Of the overt symptoms, hot flashes are probably the most common complaint of perimenopausal and menopausal
women. Up to 75% of menopausal women will experience the sudden feelings of warmth with visible face, neck,
and chest flushing, followed by profuse sweating. Hot flashes are believed by many to be the result of a temporary
disruption of normal vasomotor control caused by the hormonal changes characteristic of menopause, but there is
controversy regarding the underlying mechanisms responsible for this troublesome symptom.
In early studies using sensitive temperature recording devices, investigators were able to demonstrate body-
surface temperature increases as great as 6°C in the fingers and toes during a hot-flash episode.1 In more recent
studies using tiny swallowed thermometer probes, researchers have observed elevations in core temperature
during these episodes, although the increases aren't as great.2 Although estrogen therapy as part of hormone
replacement therapy (estrogen and progestin; HRT) is generally effective against hot flashes, in addition to its
demonstrated beneficial effects on the cardiovascular and skeletal systems, few women comply with estrogen
therapy. According to one estimate, only 3-13% of patients adhere to estrogen therapy.3
Perimenopausal and menopausal women also often experience vaginal dryness, which can cause painful
intercourse. This can lead to decreased interest in sexual activity, thus disrupting normal sexual lifestyles. Some
women also experience vaginismus, painful vaginal spasms, which can create physical and psychological barriers
to sexual activity. Generally, hormone replacement therapy, especially estrogen replacement therapy (ERT),
effectively alleviates vaginal dryness. HRT with progestins may be less effective for this condition. Alternatively,
using water-based lubricants prior to intercourse may be effective for women who are not willing to consider or
adhere to HRT. Vaginal dryness often disappears as menopause progresses.
Another common problem associated with menopause is poor sleep quality caused by night sweats and other
vasomotor and psychological dysregulation. Poor sleep often leads to a poor quality of life. Many women's welfare
suffers because of lost productivity at work; daytime fatigue; and psychological consequences, such as
depression and mood swings.
Although these symptoms are usually not life threatening, they can be bothersome and lead to an extremely
compromised quality of life. Emotional despair, marital and family stresses, and declining overall health as a result
of aging can mean tumultuous times for menopausal women.
2.2 Cardiovascular health
The risk of death from cardiovascular disease is much lower in premenopausal women compared with age-
matched men, but following menopause this advantage is lost. Most researchers believe that menopausal
women's hypo-estrogenic state accounts for this silent consequence. The beneficial effects of estrogen on the
cardiovascular system are well established and include reduced total cholesterol, especially the highly
atherogenic low-density lipoproteins (LDL), and increased concentrations of the healthy high-density lipoproteins
(HDL). Estrogen also increases vascular stretching and vasodilation (caused by calcium channel blockade and
enhanced nitric oxide release), and decreases cellular adhesion molecules, renin, fibrinogen, and plasminogen
activator inhibitor. Together, these estrogen-mediated changes support healthy cardiovascular function.4
Postmenopausal women can significantly reduce their risk of cardiovascular disease by using HRT/ERT. Younger
menopausal women using HRT decreased their incidence of death from cardiovascular disease by between 35%
and 50% compared with those not using estrogen.5 In this study, both ERT and HRT were equally
cardioprotective. However, in older women, estrogen's beneficial effects on mortality were not realized despite a
10% reduction in LDL levels.6
Additional studies are needed to examine the cardiovascular effects of ERT and HRT in older women, especially
differentiating those with prior cardiovascular disease histories from those without. Finally, with newer dosage
forms of ERT becoming available (e.g., transdermal), additional studies are currently underway that may uncover
important differences between HRT and ERT on postmenopausal cardiovascular health.
2.3 Bone health
Osteoporosis is characterized by a decrease in bone mass with decreased density and enlargement of bone
spaces producing porosity and fragility. This condition is a major cause of bone fractures in aging individuals and
contributes significantly to morbidity and mortality. As many as 20% of older patients who experience
osteoporotic-induced hip fractures will die during the following 12-month period as they become significantly less
mobile and more sensitive to opportunistic infections and comorbidities. Many who survive will become
permanently disabled. Bone health is significantly compromised during menopause when estrogen concentrations
dramatically decrease. Estrogens normally help prevent bone resorption or loss. Estrogens do not normally
enhance bone formation; rather, they prevent bone loss. Thus, it is important to promote healthy bone function
during growth periods (i.e., during the teenage and young adult years).
A number of factors can influence bone function status. Factors that generally increase bone formation include
vitamin D, exposure to light, dietary and supplemental calcium and magnesium, and weight-bearing exercise. On
the other hand, estrogen deficiency, pregnancy, nursing, and physical inactivity contribute to bone loss. While
most osteoporosis treatments are capable of slowing or stopping bone loss, after menopause few agents are
capable of enhancing bone formation. HRT and ERT both reliably improve bone status.
Osteoporosis prevention and treatment includes a healthy diet and exercise, and may involve pharmacological
agents.7a For prevention and treatment, healthcare providers often prescribe estrogen replacement therapy,
bisphosphonates (alendronate or risedronate), and selective estrogen receptor modulators (SERMs) (raloxifene).
Many additional SERMs are expected to be available soon to treat or prevent osteoporosis.
Estrogens may have other beneficial effects. Results of animal studies show that estrogens may have
neuroprotective or memory-enhancing effects, a result of their ability to enhance choline acetyltransferase activity
and increase the density of dendritic spines in the CA1 region of the hippocampus; however, studies In humans
have been less convincing.
Some researchers have suggested that estrogen use may decrease the incidence and possibly severity of
Alzheimer's disease. On the other hand, there have been no reliable studies to date that demonstrate a negative
influence of estrogen use on cognitive function in postmenopausal women. The effectiveness of HRT and ERT for
memory and cognition enhancement or neuroprotection in postmenopausal women remains an unanswered
question.
2.4 Traditional treatment options
Numerous factors including cultural and socioeconomic ones, influence women's decisions to seek healthcare
support during menopause. For some women, menopause may involve no pharmacological interventions at all.
For those who choose pharmacotherapy, traditional menopause treatments have involved HRT/ERT. In the early
1960s and 1970s, estrogen was used to manage menopause's overt and silent signs and symptoms. In the
1980s, researchers found that unopposed estrogen therapy caused endometrial hyperplasia and could increase
the incidence of endometrial carcinoma. Additionally, estrogens used alone may cause a resumption of menstrual
bleeding. Soon, products were developed that contained both estrogen and progestins. The progestins (e.g.
progesterone) may act in the endometrium to decrease estrogen receptors, convert the cells into more of a
secretory phase than a proliferative phase, and possibly increase the conversion of the potent estrogen estradiol
into estrone.
Estrone has a reduced capacity to stimulate endometrial proliferation. For women who have not undergone
hysterectomy (removal of the uterus) with oophorectomy (removal of the ovaries), estrogens can be used alone
for the beneficial cardiovascular and bone formation effects if the progestins prove intolerable. In women with
combined hysterectomies and oophorectomies (surgical menopause), using estrogens alone is safe because
there are no endometrial carcinoma concerns. Some researchers however believe there is an increased breast
cancer risk associated with long-term HRT/ERT use. The patient and healthcare practitioner will have to weigh the
cardiovascular, bone, and overall well-being benefits of ERT or HRT and the risks.
Women have access to many traditional HRT approaches. One option is cyclic and provides estrogen for 25 days
then progestins, especially medroxyprogesterone acetate, for 10 to 13 days. Many treatment schedules will
include four or five days without hormones, resulting in the sloughing off of endometrial cells and bleeding. Some
healthcare providers prefer to avoid the bleeding phase and prescribe preparations that provide continuous
hormone therapy for the entire month. While many preparations are administered orally, the transdermal route is
sometimes available and may increase compliance. However, transdermally administered HRT is not as beneficial
as oral preparations with regard to its effects on plasma lipoprotein status.
Although many effects of HRT are beneficial for the overt and silent consequences of menopause, estrogen use
also has a dark side. Subjective complaints of estrogen therapy include breakthrough bleeding, depression,
headache, fluid retention, and nausea. In addition to the concerns regarding unopposed estrogen actions on the
endometrium, estrogen may increase health risks in women with a history of blood clots, severe varicose veins,
obesity, gall bladder and pancreatic disease, and among those who smoke. Women who have a family history of
breast cancer constitute a special group where the benefit to risk ratio of estrogen use needs to be carefully
weighed.
2.4.1 Link between decline in breast cancer and HRT use
An extended analysis of cancer rates reinforces a strong association between use of HRT and increased breast
cancer incidence. Plummeting use of HRT in the mid-2002, after results of the Women’s Health Initiative (WHI)
study were announced, correlated with a steep decline in new breast cancer diagnoses that started shortly
thereafter and continued through 2003. Incidence leveled in 2004 and maintained the same low level of incidence,
the lowest rate seen since 1987.7b
The decline occurred primarily in women age 50-69 and was predominantly seen in estrogen-receptor-positive
cancer. Such cancers declined 14.7% in this time period, compared to a non-significant decline of 1.7% in
estrogen-receptor-negative tumours.
The results of WHI study, and the concomitant media-related impact, led to more than 50% of women stopping
their hormone replacement therapy (HRT) and searching for alternatives to HRT.
In summary, when women with menopausal symptoms use HRT, it effectively controls symptoms 75-90% of the
time. However, recent surveys indicate that while HRT may dramatically reduce symptoms, fewer than one in four
menopausal women for whom HRT therapy is appropriate actually follow this treatment regimen adequately.
2.5 CAM and menopause
There are many reasons why women in menopause look beyond mainstream treatment options. Many women
fear the adverse effects of hormone and estrogen replacement therapy. Despite the evidence supporting HRT's
safety in many women (although not all), few women adhere to conventional therapy.
There are many complementary and alternative products available to menopausal women today. The most
popular are classified as nutritional supplements and include isoflavones, vitamins, minerals, and herbs.
According to Kass-Annese, there are four major categories of alternative therapies for menopausal women to consider:8 • Diet and nutrition, which includes dietary modifications with an emphasis on isoflavones, vitamins and • Psychological and spiritual approaches, such as meditation; • Other alternative approaches such as homeopathy, Ayurvedic medicine, and naturopathy.
Many women use supplements to manage their symptoms with hardly any side effects.
2.5.1 Plant-based therapy
2.5.1.1 Isoflavone phytoestrogens
Isoflavone phytoestrogens (i.e., estrogen-like or estrogen-mimicking molecules from plants) have received the
most attention for alleviating many menopausal symptoms. Various foods, especially those derived from soy and
other legumes, contain these compounds that act as weak estrogen receptor agonists. A number of nutritional
supplements also contain isoflavones.
The individual isoflavones found in soy, chick peas (garbanzo beans), and other legumes as well as in bluegrass,
clover, and toothed medic are genistein, daidzein, and glycetein.9 These compounds are derived from their
corresponding glycosides: genistin, daidzin, and glycetin. Genistein and daidzein in particular have estrogenic
activity that is approximately 1/1000 the activity of the standard estrogenic agonist, estradiol. After eating soy
protein, blood concentrations of genistein are approximately 1000 times greater than estradiol levels.
In Japan and other countries where soy consumption is high, women experience fewer and less severe
menopausal symptoms than women in cultures where soy consumption is minimal, such as the United States and
Western Europe. Isoflavone use has resulted in fewer hot flashes by some reports; however, a number of studies
have failed to demonstrate a reduction in hot flashes. These disparate results may be caused in part by study
design differences (duration, supplement used, and end-points measured, for example). New studies are
underway to determine whether phytoestrogens effectively relieve menopause symptoms.
Phytoestrogens also have antioxidant activity; inhibit tyrosine kinase, an important intracellular enzyme involved in
many essential cell functions; and inhibit the growth of many different types of tumor cells via their ability to inhibit
angiogenesis. It is well known that breast and prostate cancer risk varies substantially throughout the world, a fact
some have attributed to differences in dietary phytoestrogen intakes.
Genistein supports healthy bones by stimulating osteoblast number and function, while decreasing osteoclast
activity.10 As a result, bone resorption is minimized. In one six-month human trial, a 40-g daily dose of soy protein
(containing 90mg of isoflavones) produced a more than 2% increase in spinal bone density and a favorable
change in blood lipid profiles among postmenopausal women not receiving any hormone treatments.11 The same
amount of soy protein with a lesser amount of isoflavones (56mg per day) had no effect on bone density, but did
impart a favorable blood lipid-modifying effect more rapidly than the high-isoflavone soy diet. Additionally,
phytoestrogen-enriched diets beneficially influence the LDL:HDL ratio, and thus may positively benefit
cardiovascular health in menopausal women.12, 13

2.5.1.2 Pollen and pistil extracts

Elia and Mares (2008)14 examined the effectiveness of Sérélys (also known as Femal), a food supplement
containing vitamin E, a purified pollen extract and a mixture of cytoplasmic pollen and pistil extracts, on PMS and
menopause. The product does not contain any phyto-estrogens and has an antioxidant (due to antioxidant
enzymes) and a natural non-steroidal anti-inflammatory effect. Their study confirms the results observed in
previous studies conducted on Femal by Winther and co-workers (2005)15 concerning the frequency and intensity
of hot flushes. In addition, a search for phytoestrogens in the active agents of the product also turned out
negative, and a hormonal type action was therefore ruled out.

On the basis of this study and previous ones16,17 the authors concludes that Femal offers significant effectiveness
on the most frequent problems related to menopause - hot flushes and sweats, bringing about a significant
improvement in the quality of life of patients. Good tolerance of the product, the absence of phytoestrogens and its
non-hormonal mechanism of action enable it to be safely suggested to women who suffer from hot flushes and
menopausal sweats. The researchers noted an improvement in the frequency of hot flushes, episodes of
sweating, irritability and tiredness, quality of sleep and quality of life. They also confirmed that there were no
changes in FSH, estrogen, testosterone and SHBG, thus ruling out a hormonal type of action.14
2.5.2 Magnesium
Most South Africans, and particularly women, have a suboptimal magnesium status. This mineral is an essential
co-factor for more than 300 enzymes in the body that are involved in a number of crucial anabolic, catabolic, and
cell respiratory functions. The RDA for magnesium in women older than 50 is 320mg, or approximately 5 mg/kg.
However, the emphasis on calcium for bone health often occurs at the expense of magnesium. In fact,
magnesium also plays an important role in preventing osteoporosis. As magnesium availability decreases, the
parathyroid gland releases less parathyroid hormone, which decreases calcium absorption and retention in
bone.18 Thus, healthy bones require adequate amounts of both minerals, in addition to phosphorus and fluoride.
The optimal calcium: magnesium intake ratio should be approximately 2:1, or 1200mg calcium and 600mg
magnesium. Additionally, researchers have found that magnesium has a cardioprotective effect because of its
ability to decrease blood pressure, platelet-dependent thrombosis, and arrhythmias.19
Various magnesium salts and chelates are available and because magnesium use has a large benefit to risk ratio,
(in the absence of renal insufficiency large doses usually only cause a self-limiting laxative effect), healthcare
providers should encourage routine use by most adults, especially perimenopausal and menopausal women.
2.5.3 Omega 3 and 6 essential fatty acids
The two fatty acids - linolenic (LA, 18:2(n-6)) and alpha-linolenic acid (ALA, 18:3(n-3)) are physiologically essential
and complementary, but they compete as substrates for desaturases. Not only is the intake of ALA far too low, but
also its conversion to longer fatty acids is reduced because it has to compete with the larger quantities of LA for
the same enzyme.20 Indeed, polyunsaturated fatty acids are dramatically involved in human health and
pathologies, the ratio omega-6/omega-3 being important.20 Interestingly, dietary omega-3 fatty acids content is
largely below the recommended quantities.
ALA, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are important for preventing ischemic
cardiovascular disease in women of all ages. Omega-3 fatty acids can help to prevent the development of certain
cancers, particularly those of the breast and colon, and possibly of the uterus and the skin, and are likely to
reduce the risk of postpartum depression, manic-depressive psychosis, dementias, hypertension, toxemia,
diabetes and, to a certain extent, age-related macular degeneration. Omega-3 fatty acids could play a positive
role in the prevention of menstrual syndrome and postmenopausal hot flushes.20
3. Menstrual cycle-related discomforts
Symptoms due to the menstrual cycle may wreak havoc in women’s lives but often respond to self-care
approaches. Menstrual-related problems may or may not be self-treatable. Some problems such as
endometrioses, must be referred to a specialist for a full medical evaluation. On the other hand, pharmacists and
other healthcare professionals can provide assistance for the more common problems, e.g. premenstrual
syndrome (PMS) and dysmenorrhoea. Some of the PMS symptoms can be managed by using nutritional herbal
supplements as discussed above.
Water retention and cystitis, as experienced by many women, can also be managed by CAM products.
3.1 Water retention
Women of menopausal age often experience water retention due to fluctuations and imbalance in their hormone
levels. Other contributing factors include thyroid problems, high blood pressure, kidney disease and seasonal
changes.21
Acute water retention conditions (e.g. water retention due to sitting or standing for long periods of time, or PMS)
are experienced by the majority women almost on a daily basis. Edema is usually treated with regular diuretics.22
However, these can be habit-forming and the body may start relying on the diuretics to do the work.
Many women are opting for non-habit-forming natural remedies that contain herbs that can act as a diuretic, treat
indigestion and stomach discomfort and assists with urinary tract infections such as:23
Uva Ursi - has urinary antiseptic (in vitro activity against Citrobacter, Enterobacter, Escherichia, Klebsiella,
Proteus, Pseudomonas and Staphylococcus), astringent, diuretic, and anti-inflammatory effects in the
genitourinary tract.24
The herb neutralizes acidity in the urine, increasing urine flow, therefore reducing bloating and water retention.
Uva Ursi contains allantoin which is well known for its soothing and tissue repairing properties. It contains
chemicals, primarily hydroquinone and hydroquinone derivatives, that make it potentially useful for urinary
conditions and is used to treat infections such as cystitis, urethritis and nephritis.24
The hydroquinone derivative arbutin is the chief active compound in Uva Ursi. During urination it acts on the
mucus membranes of the urinary tract to soothe irritation, reduce inflammation, and fight infection. Interestingly,
arbutin taken alone is not as effective as the whole Uva Ursi plant in controlling urinary tract infections. That is
because intestinal bacteria can break down arbutin, but they are less likely to do so in the presence of other Uva
Ursi compounds.
The leaves contain arbutin, which acts against E. coli and increases urination. Uva ursi also fights bacteria and
cleanses the urinary tract, promotes excretion, and deters water retention, supports the kidneys, and cools
inflammatory reactions (Frohne, 1970 as cited by Pizzorno and Murray, 2000: 990).25
The increased urine action of Uva Ursi is due to arbutin which is largely absorbed unchanged and is excreted by
the kidneys. During its excretion, arbutin exercises an antiseptic effect on the urinary mucous membrane. It is
therefore used in inflammatory diseases of the urinary tract, urethritis and cystitis.
Dandelion leaf and dandelion root – a diuretic. Contains quercetin, luteolin, p-hydroxyphenylactic acid,
germancranolide acid, chlorogenic acid, chicoric acid, monocaffeiyltartaric acid, scopoletin, aesculetin, chichoriin,
faradiol, caffeic acid, taracoside, taraxasterol and large amounts of the polysaccharide inulin. Dandelion is also
high in potassium.
Sesquiterpenes lactones are responsible for diuretic effect and may contribute to dandelion’s mild anti-
inflammatory activity. According to Balch (2004),26 dandelion is also used as a diuretic to help to relieve fluid
retention in premenstrual syndrome (PMS) and counteract urine retention in bladder infection.
Recent studies suggest that dandelion root extract inhibits production of the inflammatory cytokines interleukin IL-
6 and tumor necrosis factor (TNF) - alpha. Dandelion flower extract possesses bioactive photochemical with the
ability to scavenge ROS (reactive oxygen species) and prevent DNA from ROS-induced damages.
Juniper - a diuretic. Consist of alpha-pipene (29.17%), beta-pipene (17.84%), sabinene (13.55%), limonene
(5.52%) and micrene (0.33%). Juniper essential oil has bactericidal activities against gram-positive and gram-
negative bacteria.27
The diuretic action of juniper has been attributed to the terpinen-4-ol. Stanic and co-workers (1998) suggested
that the diuretic effect is partly due to the essential oil and partly to hydrophilic constituents.28

Burdock - can help eliminate excess fluids in the body and stimulate the elimination of toxic waste materials,
which relieves liver disorder and improves digestion.26 Burdock root contains approximately 50% inulin, a fibre
widely distributed in fruits, vegetables and plants.
Several studies have confirmed that burdock seeds, roots and leaves exhibit antioxidant activities, as well as an
anti-inflammatory and an ability to inhibit the potent inflammation-causing chemical platelet activating factor.29,30
Parsley powder - medicinal properties: stimulant, diuretic, carminative and anti-inflammatory. The diuretic effect
of the herb is mediated through an increase in K+ retention in the lumen and is mediated through an inhibition of
the Na+ - K+ pump that would lead to a reduction in Na+ and K+ re-absorption thus leading to an osmotic water
flow in the lumen and ultimately diuresis.31
Golden Rod - used to counter inflammation (by inhibiting elastase) and irritation caused by bacterial infections.
The use of an herbal remedy such as goldenrod with a complex action spectrum (anti-inflammatory, antimicrobial,
diuretic, antispasmodic and analgesic) is especially recommended for the treatment of infection and
inflammation.32
Potassium, vitamin B6 and magnesium - many diuretics raise renal output of these solutes. Replacing these
essential electrolytes is thus important.
Potassium is an essential mineral needed to regulate water balance, levels of acidity and blood pressure.
Potassium (K) depletion usually is due to excessive losses of K in the urine or stool.33
Magnesium may also help to reduce other premenstrual symptoms, such as abdominal bloating and fluid
retention, whereas vitamin B6 (pyridoxine) is thought to help in cases of mild fluid retention.34

3.2 Urinary tract infections/cystitis

Urinary tract infection (UTI) refers to the presence of clinical signs and symptoms arising from the genitourinary
tract plus the presence of one or more micro-organisms in the urine exceeding a threshold value for significance
(ranges from 102-103 colony-forming units/mL).35 Cystitis is a chronic urinary bladder disorder characterized by
thinning or ulceration of the bladder epithelial layers.
Cystitis occurs primarily in women and symptoms are exacerbated by stress, ovulatory hormones and certain
foods.36
3.2.1 Treatment

To prevent the development of end-stage cystitis, aggressive and early detection, combined with a multi-modality
therapy approach may help stop the progression of the disease over time.37
Re-occurrence of UTI is common, causing frustration in the patient and the potential for developing antibiotic
resistance.38 Recurrence requiring interventions are usually defined as two or more episodes over 6 months or
three or more episodes over 1 year.35 Herbal medicines could be effective in the treatment of cystitis, by
decreasing inflammation and healing the bladder tissues:
Cranberry - bacteriostatic, especially in the urinary tract; astringent.24
Cranberry treatment is a safe, well tolerated supplement that does not have significant drug interactions.39 It is
commonly used for the prevention and treatment of UTI.35,40
Against specific bacteria, cranberry proanthocyanidins and flavonols inhibit the growth of Streptococcus mutants,
whereas cranberry phenolic groups showed antibacterial activity against Helicobacter pylori. Some of the
chemicals in cranberry keep the UTI-causing bacteria E. coli from sticking to the cells that line the urinary tract
walls of the bladder where they colonize.41 One of the components is fructose which inhibits the mannose-
sensitive type-1 fimbrial adhesion in yeast aggregation assay.42,40 The second inhibitor is a high molecular weight
compound which act on the mannose-resistant P fimbriae or pili expressed by uropathogenic E. coli.43
Cranberry also has antioxidant and anti-inflammatory activities, which includes the inhibition of cyclo-oxygenase.
Cranberries contain salicylic acid which is similar to aspirin, assisting with pain management.44 Cranberry juice
consumption is often recommended along with low-dose oral antibiotics for prophylaxis for recurrent UTI.38,45
Quercetin - a bioflavonoid which is well tolerated and provides significant symptomatic improvement in most
inflammatory diseases.46 It protects against various diseases such as osteoporosis, certain cancers,47
cardiovascular disease, and bladder infections.48 Quercetin has the ability to scavenge highly reactive species
such as peroxynitrite leading to beneficial health effects.48,49
Bromelain - is a complex mixture of proteinases typically derived from pineapple stem. It has anti-edematous,
anti-inflammatory, antithrombotic and fibrinolytic activities. Beneficial therapeutic effects of bromelain have been
suggested or proven in several human inflammatory diseases and animal models of inflammation, including
arthritis and inflammatory bowel disease. It lowers kinogen and bradykinin serum and tissue levels and has an
influence on prostaglandin synthesis, thus acting as an anti-inflammatory.
Papain - papain-like cysteine proteases have been divided into two subfamilies represented by mammalian
enzyme cathepsin L and cathepsin B, respectively. Cathepsin B is a lysosomal cysteine protease, it functions in
intracellular protein catabolism and in certain situations may also be involved in other processes, such as
processing of antigens in the immune response, hormone activation and bone turnover. Cathepsin B is also
involved in the pathology of chronic inflammatory diseases of airways and joints, cancer and pancreatitis.
Buchu - has several activities, including urinary antiseptic, anti-inflammatory, and anti-cystitic. Buchu leaf
preparations have a long history of use in traditional herbal medicine as a urinary tract disinfectant and diuretic.50
Buchu contains both diposmin and hesperidin, which indicates it may have anti-inflammatory, hypolipidemic and
vasoprotective action. Buchu leaves extract contains isomenthone and disphenol which is very useful in resolving
the symptoms of cystitis and other urinary disorders.
Hibiscus - an aromatic herb with diuretic properties, also providing vitamin C (antioxidant). Additionally, it has
antiseptic, antibacterial, demulcent, emollient, and anti-inflammatory properties.51 The anthocyanins contribute to
the health-protecting effects.52

4. Conclusion

When it comes to integrative, holistic healthcare, no single treatment or mélange of treatments and remedies will
suit all sufferers, as each woman’s pathology and psychology is unique. Optimal healing can however be
experienced when an individually formulated treatment plan, which takes into account each person’s distinctive
situation, is mindfully implemented, in a collaborative patient-practitioner partnership. CAM products should be
part of this treatment plan.
References

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3. Leiblum S, et al. 1983. Vaginal atrophy in the postmenopausal woman: the importance of sexual activity and hormones. JAMA; 249:
2195-2198.
4. Wood MJ, Cox JL. 2000. HRT to prevent cardiovascular disease. Postgrad Med., 108: 59-72.
5. Grodstein F, et al. 1996. Postmenopausal estrogen and progestin use and the risk of cardiovascular disease. N Engl J Med., 335: 453-
461.
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