Alternative treatments for the menopause

Effect of Evening Primrose Oil on Postmenopausal Psychological Symptoms: A Triple-Blind Randomized Clinical Trial

OBJECTIVES

Psychological symptoms of menopause may impose a negative effect on the quality of life of menopausal women. Thus, the management of these symptoms can improve the quality of life and psychological health of such woman. The present study aimed to determine the effect of evening primrose on psychological symptoms in menopausal women.

METHODS

In this triple-blind randomized clinical trial, the effect of the evening primrose oil on postmenopausal psychological symptoms was investigated. The subjects were 100 menopausal women, referred to a healthcare center in Dastena city (Chaharmahal and Bakhtiari Province, Iran), who were randomly assigned to two groups. The intervention group used two 1 g pearls of evening primrose oil daily. The study instruments included a sub-scale of Menopause Rating Scale (MRS). Menopause data were analyzed using an independent t-test and Friedman test by the SPSS software. P values < 0.05 were considered statistically significant.

RESULTS

The two groups were balanced in demographic characteristics and psychological disorder severity before the intervention. The median (interquartile range) MRS score in the intervention group before the intervention and 2 and 4 weeks after the intervention were 11 (10-12), 6 (5-7), and 3 (2-4), respectively, and in the placebo, they were 11 (9-11), 10 (9-11), and 11 (10-12). A significant reduction was observed in the intervention group compared with the placebo group 2 and 4 weeks post-intervention.

CONCLUSION

The use of evening primrose oil can decrease postmenopausal psychological symptoms.

Double-Blind Controlled Trial of Vitamin E Effects on Serum Lipid Profile in Menopausal Women

BACKGROUND

Menopause is associated with changes in lipid profile and is a known risk factor for oxidative stress. Different therapeutical strategies have been used to control menopause complications. Vitamin E, an important anti-oxidant, can possibly affect lipid peroxidation in menopausal women. Thus, we aimed to evaluate the effect of vitamin E supplementation on the lipid profile of menopausal women.

MATERIALS AND METHODS

This double-blind, placebo-controlled, randomized, cross-over, phase I/II trial study was designed in two 4-week intervention phases with an 8-day washout period in between. Eighty-three natural menopause women participated in the study. Randomized block allocation was used to divide women into group A (n = 41) and group B (n = 42). In phase I, one group received vitamin E capsule (400 IU/day) and another group received placebo capsule for 4 weeks. After an 8-day washout period, phase II was initiated for a period of 4 weeks, where the group that received vitamin E capsule was given placebo (E-P) and the group that received placebo was given vitamin E (P-E). Plasma lipid profile levels (LDL-C, HDL-C, TC, and TG) were assessed before and after intervention separately in each phase and in each group. Lipid profile was measured by enzymatic colorimetric method. Data were analyzed according to the intention-to-treat principle. All statistical analyses were performed using SPSS software.

RESULTS

The analysis indicated no significant difference in plasma TC, LDL-C, HDL-C, and TG levels between P-E and E-P groups before intervention in phase I and II (P > 0.05). There was no significant difference in plasma lipid profile levels within the P-E and E-P groups before and after intervention in phase I and II. There was a significant difference in plasma TG within the E-P group before [141.74 ± 53.52, 138.50 (94-195)] and after [167.47 ± 71.32, 170 (108-202)] intervention in phase II (P = 0.010). There was no significant difference in terms of the mean changes in plasma lipid profile between the P-E and E-P groups in phase I and II (P > 0.05).

CONCLUSION

The study results revealed that vitamin E supplementation had no remarkable effect on the lipid profile in menopausal women.

Healthcare Utilization and Prevalence of Symptoms in Women with Menopause: A Real-World Analysis

Objective

Self-reported studies estimated that as many as 50-75% of women experience symptoms during menopause; however, limited real-world clinical data are available to support this observation. The electronic databases of Maccabi Healthcare Services were used to describe the prevalence of menopause symptoms in Israel and to characterize patients with regard to socioeconomic status, comorbidities and use of healthcare services.

Methods

Females aged 45-54 years diagnosed with menopausal symptoms (N=17,046, cumulative incidence of 8% during the study period) were identified from the Maccabi Healthcare Services electronic database and matched to female members without menopause symptoms, one-to-one on birth year and enumeration area.

Results

Symptomatic peri- and post-menopausal women, and particularly those under 52 years, were more likely to have a higher prevalence of comorbid conditions such as depression, anxiety, osteoporosis and insomnia in the year following index. Correspondingly, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and hypnotic drug use were significantly higher in symptomatic women as was healthcare utilization including hospitalization (OR=1.10; 95% CI=1.00-1.20), primary care visits (1.90; 1.73-2.08), gynecologist visits (24.84; 22.36-27.59) and hysterectomy procedures (2.26; 1.63-3.14).

Conclusion

Medically documented menopausal symptoms are associated with increased burden of disease (particularly among women diagnosed with menopausal symptoms prior to age 52 years), healthcare utilization and greater likelihood of undergoing hysterectomy within one year of diagnosis. This burden is expected to rise further as awareness and social acceptance of peri- and post-menopausal symptoms increase.

Effect of the Mixed Herbal Medicines Extract (Fennel, Chamomile, and Saffron) on Menopause Syndrome: a Randomized Controlled Clinical Trial

Introduction: Menopause is the transition from the reproductive phase of a woman to the non-reproductive. It may impair quality of life. The study aims to determine the effectiveness of mixed herbal medicines on menopause symptoms Methods: A randomized, triple-blind, clinical trial and placebo-controlled study on 120 peri-menopausal women aged 45-65 years for 12 weeks. All participants took herbal extracts drops orally daily and randomly allocated into four groups: placebo (C), A (250 mg chamomile, 30 mg fennel, 15 mg saffron), B (1000 mg, 120 mg, 60 mg), and D (500 mg, 60 mg, 30 mg). Primary outcome was the mean change in scores of the menopause rating scale that evaluates 11 symptoms. Results: The median (IQR) physical score significantly reduced from 8.5(4) to 2(3), in psych score reduced from 12(4) to 2 (2) and in urogenital score reduced from 6.5(3) to 3(2) in group B. In group D physical score decreased from 12(6) to 8(4), in psychological score reduced from12 (3) to 8(4) and urogenital score reduced from 7.5 (3) to 8(3) at week 12. No significant differences in group A and C. With comparison the scores of physical, psych and urogenital domain of MRS questionnaire in 1th ,6th and 12th, no significant difference within group A and C were seen, but statistically significant difference was within group B (p&lt;0.001) and D (p&lt;0.001) in all weeks. The effect size was 0.92. Conclusion: A 12 weeks extracts treatment, there were significant improvement in physical, psychological and urogenital domains in group B.

Does Cimicifuga racemosa have the effects like estrogen on the sublingual gland in ovariectomized rats?

Background

Cimicifuga racemosa is one of the herbs used for the treatment of climacteric syndrome, and it has been cited as an alternative therapy to estrogen. Apart from hectic fevers, dyspareunia and so on, dry mouth also increase significantly after menopause. It has not yet been reported whether C. racemosa has any impact on the sublingual gland, which may relate to dry mouth. In an attempt to determine this, we have compared the effects of estrogen and C. racemosa on the sublingual gland of ovariectomized rats.

Results

HE staining showed that the acinar cell area had contracted and that the intercellular spaces were broadened in the OVX (ovariectomized rats) group, while treatment with estradiol (E2) and iCR (isopropanolic extract of C. racemosa) improved these lesions. Transmission electron microscopy showed that rough endoplasmic reticulum expansion in mucous and serous acinar epithelial cells and apoptotic cells was more commonly seen in the OVX group than in the SHAM (sham-operated rats) group. Mitochondria and plasma membrane infolding lesions in the striated ducts were also observed. These lesions were alleviated by both treatments. It is of note that, in the OVX + iCR group, the volume of mitochondria in the striated duct was larger than in other groups. Immunohistochemical staining showed that the ratio of caspase-3 positive cells was significantly increased in the acinar cells of the OVX group compared with the SHAM group (p < 0.05); and the MA (mean absorbance) of caspase-3 in the striated ducts also increased (p < 0.05). Estradiol decreased the ratio of caspase-3 positive cells and the MA of caspase-3 in striated ducts significantly (p < 0.05). ICR also reduced the ratio of caspase-3 positive cells and the MA in the striated ducts (p < 0.05), but the reduction of the MA in striated ducts was inferior to that of the OVX + E2 group (p < 0.05).

Conclusion

Both estradiol and iCR can inhibit subcellular structural damage, and down-regulate the expression of caspase-3 caused by ovariectomy, but their effects were not identical, suggesting that both drugs confer a protective effect on the sublingual gland of ovariectomized rats, but that the specific location and mechanism of action producing these effects were different.

Electronic supplementary material

The online version of this article (doi:10.1186/s40659-017-0115-x) contains supplementary material, which is available to authorized users.

Induction of NAD(P)H:Quinone Oxidoreductase 1 (NQO1) by Glycyrrhiza Species Used for Women's Health: Differential Effects of the Michael Acceptors Isoliquiritigenin and Licochalcone A

For the alleviation of menopausal symptoms, women frequently turn to botanical dietary supplements, such as licorice and hops. In addition to estrogenic properties, these botanicals could also have chemopreventive effects. We have previously shown that hops and its Michael acceptor xanthohumol (XH) induced the chemoprevention enzyme,

NAD(P)H

quinone oxidoreductase 1 (NQO1), in vitro and in vivo. Licorice species could also induce NQO1, as they contain the Michael acceptors isoliquiritigenin (LigC) found in Glycyrrhiza glabra (GG), G. uralensis (GU), G. inflata (GI), and licochalcone A (LicA) which is only found in GI. These licorice species and hops induced NQO1 activity in murine hepatoma (Hepa1c1c7) cells; hops ≫ GI > GG ≅ GU. Similar to the known chemopreventive compounds curcumin (turmeric), sulforaphane (broccoli), and XH, LigC and LicA were active dose-dependently; sulforaphane ≫ XH > LigC > LicA ≅ curcumin ≫ liquiritigenin (LigF). Induction of the antioxidant response element luciferase in human hepatoma (HepG2-ARE-C8) cells suggested involvement of the Keap1-Nrf2 pathway. GG, GU, and LigC also induced NQO1 in nontumorigenic breast epithelial MCF-10A cells. In female Sprague-Dawley rats treated with GG and GU, LigC and LigF were detected in the liver and mammary gland. GG weakly enhanced NQO1 activity in the mammary tissue but not in the liver. Treatment with LigC alone did not induce NQO1 in vivo most likely due to its conversion to LigF, extensive metabolism, and its low bioavailability in vivo. These data show the chemopreventive potential of licorice species in vitro could be due to LigC and LicA and emphasize the importance of chemical and biological standardization of botanicals used as dietary supplements. Although the in vivo effects in the rat model after four-day treatment are minimal, it must be emphasized that menopausal women take these supplements for extended periods of time and long-term beneficial effects are quite possible.

A comparison of the effects of estrogen and Cimicifuga racemosa on the lacrimal gland and submandibular gland in ovariectomized rats

This study aims to observe the effects of estradiol and Cimicifuga racemosa on the lacrimal gland and submandibular gland of ovariectomized rats. We randomly divided 20 adult female SD rats into four groups-a sham-operated group (SHAM), ovariectomized (OVX) group, ovariectomized group treated with estradiol (OVX+ E), and ovariectomized group treated with the isopropanolic extract of Cimicifuga racemosa (OVX+ iCR). The SHAM group and OVX group used distilled water to instead the drugs. Two weeks after ovariectomy, the estradiol and iCR were administered for 4 weeks. Next, we used H&E staining and electron microscopy to observe any histological changes in the lacrimal and submandibular glands and immunohistochemical staining to observe the expressions of cleaved caspase-3 (Casp-3) and Cu-Zn SOD (superoxide dismutase). The H&E staining find that both drugs can prevent the cells of area from shrinkage in the two kinds of gland. But under the electron microscopy, estradiol and iCR have different efficacy. Estradiol is more effective at protecting mitochondria in lacrimal gland acinar cells than iCR, and iCR is more effective at suppressing endoplasmic reticulum expansion than estradiol. Both estradiol and iCR have a similar protective function on mitochondria in the submandibular gland. The protective function of the two glands may inhibit apoptosis by suppressing the expression of Casp-3. In addition, iCR increases the expression of Cu-Zn SOD in duct system of submandibular gland. The results suggest that both estradiol and iCR confer a protective effect on the lacrimal and submandibular glands of ovariectomized rats via different mechanisms.

FemaleLeuciscus lepidusMay Be a New Alternative for Fish Oil Supplements

The proximate composition of male and femaleLeuciscus lepidusin Beyşehir Lake was investigated. The fatty acid profiles of total lipid, phospholipid, and triacylglycerol in muscle and liver of male and femaleL. lepiduswere evaluated by gas chromatography. Proximate analyses showed that meat of male and femaleL. lepidushad 15.13 ± 0.04 and 18.75 ± 0.11% fat, 20.42 ± 0.45 and 22.21 ± 0.56% protein, 65.47 ± 1.37 and 61.28 ± 1.03% moisture, and 1.51 ± 0.05 and 1.50 ± 0.03% ash, respectively. The percentage of total saturated fatty acids was higher in liver than in muscle, whereas the total polyunsaturated fatty acid (PUFA) content was the lowest in all fatty acid profiles. The phospholipids contained more PUFAs than triacylglycerol. Analysis of variance indicated significant differences (P<0.05) between male (47.51%) and female (49.98%) muscle PUFAs in total lipid. The proportion of omega 3 (ω3) to omega 6 (ω6) fatty acids of total lipid was 3.15 in male and 3.68 in female. The ratio is an important indicator for comparing the value of fish oil. Therefore, it was concluded thatL. lepiduswas considered to be a high quality product for healthy food choice. Additionally, femaleL. lepidusmay especially be used to produce fish oil supplements from freshwater fish combined with vegetable oils.

A cycloartane glycoside derived from Actaea racemosa L. modulates GABAA receptors and induces pronounced sedation in mice

23-O-Acetylshengmanol 3-O-β-D-xylopyranoside (Ac-SM) isolated from Actaea racemosa L.-an herbal remedy for the treatment of mild menopausal disorders-has been recently identified as a novel efficacious modulator of GABAA receptors composed of α1-, β2-, and γ2S-subunits. In the present study, we analyzed a potential subunit-selective modulation of GABA-induced chloride currents (IGABA) at GABA concentrations eliciting 3-8% of the maximal GABA response (EC3-8) through nine GABAA receptor isoforms expressed in Xenopus laevis oocytes by Ac-SM with two-microelectrode voltage clamp and behavioral effects 30 minutes after intraperitoneal application in a mouse model. Efficacy of IGABA enhancement by Ac-SM displayed a mild α-subunit dependence with α2β2γ2S (maximal IGABA potentiation [Emax] = 1454 ± 97%) and α5β2γ2S (Emax = 1408 ± 87%) receptors being most efficaciously modulated, followed by slightly weaker IGABA enhancement through α1β2γ2S (Emax = 1187 ± 166%), α3β2γ2S (Emax = 1174 ± 218%), and α6β2γ2S (Emax = 1171 ± 274%) receptors and less pronounced effects on receptors composed of α4β2γ2S (Emax = 752 ± 53%) subunits, whereas potency was not affected by the subunit composition (EC50 values ranging from α1β2γ2S = 35.4 ± 12.3 µM to α5β2γ2S = 50.9 ± 11.8 µM). Replacing β2- with β1- or β3-subunits as well as omitting the γ2S-subunit affected neither efficacy nor potency of IGABA enhancement by Ac-SM. Ac-SM shifted the GABA concentration-response curve toward higher GABA sensitivity (about 3-fold) and significantly increased the maximal GABA response by 44 ± 13%, indicating a pharmacological profile distinct from a pure allosteric GABAA receptor modulator. In mice, Ac-SM significantly reduced anxiety-related behavior in the elevated plus maze test at a dose of 0.6 mg/kg, total ambulation in the open field test at doses ≥6 mg/kg, stress-induced hyperthermia at doses ≥0.6 mg/kg, and significantly elevated seizure threshold at doses ≥20 mg/kg body weight. High efficacy and long biologic half-life of Ac-SM suggest that potential cumulative sedative side effects upon repetitive intake of A. racemosa L. preparations might not be negligible.

Effects of black cohosh and estrogen on the hypothalamic nuclei of ovariectomized rats at different temperatures

ETHNOPHARMACOLOGICAL RELEVANCE

Cimicifuga racemosa (L.) Nutt. (CR), known as black cohosh, has been used in Europe as a medicinal plant for more than a century and its roots have been widely used for the treatment of menopausal symptoms. Remifemin, the main ingredient in liquid or tablet medications prepared from isopropyl alcohol extracts of black cohosh rhizome, has also been evaluated in clinical studies.

OBJECTIVES

To observe changes in the expression of the c-Fos protein in the hypothalamic nuclei of four groups of rats-sham-operated group (SHAM), ovariectomized (OVX) group, ovariectomized group treated with estrogen(OVX+E), and ovariectomized group treated with the isopropanol extract of Cimicifuga racemosa (OVX+ICR)-and to investigate the mechanisms of black cohosh and estrogen that take place in the hypothalamic nuclei of ovariectomized rats.

METHODS

Fifty rats were assigned to each of the four groups and placed in incubators at 4 °C, 10 °C, 25 °C, 33 °C, or 38 °C for 2 h. They were then anesthetized, and their brains were removed after heart perfusion. c-Fos expression in the hypothalamic nuclei was evaluated using immunohistochemical methods.

RESULTS

In the median preoptic nucleus (MnPO), ventromedial preoptic nucleus (VMPO), and suprachiasmatic nucleus (SCh) of the SHAM group, in the anterior hypothalamic area (AH) and supraoptic nucleus (SO) of all four groups, and in the paraventricular nucleus (PVN) of the SHAM, OVX and OVX+E groups, the c-Fos-positive cell densities all changed in a similar manner: the cell density decreased when the temperature was less than 25 °C and the density increased when the temperature was greater than 25 °C, demonstrating a V-type curve. The c-Fos density was lowest at 25°C. The other nuclei demonstrated irregular changes. The positive cell densities in the MnPO, AH, and PVN of the SHAM, OVX+E, and OVX+ICR groups were greater than the densities measured in the OVX group at all temperatures, except 25 °C. Positive cell densities in the SHAM, OVX+E, and OVX+ICR groups were greater than the densities measured in the OVX groups in the MPA at 25 °C, in the VMPO at 4 °C, 33 °C, and 38 °C, in the SO at 4 °C, 10 °C, and 38 °C, and in the SCh at 33 °C.

CONCLUSION

Regardless of the temperature, positive cell densities were lower in the MnPO, MPA, VMPO, AH, SCh, SO, and PVN of the OVX groups in comparison with the densities measured in the same sites in the SHAM group. Following the administration of black cohosh and estrogen, the positive cell densities in the OVX groups increased and became closer to, or exceeded, those measured in the SHAM group, suggesting that both drugs may act on the hypothalamic nuclei and have therapeutic effects on menopausal symptoms.

Hops (Humulus lupulus) inhibits oxidative estrogen metabolism and estrogen-induced malignant transformation in human mammary epithelial cells (MCF-10A)

Long-term exposure to estrogens including those in traditional hormone replacement therapy (HRT) increases the risk of developing hormone-dependent cancers. As a result, women are turning to over-the-counter (OTC) botanical dietary supplements, such as black cohosh (Cimicifuga racemosa) and hops (Humulus lupulus), as natural alternatives to HRT. The two major mechanisms which likely contribute to estrogen and/or HRT cancer risk are: the estrogen receptor-mediated hormonal pathway; and the chemical carcinogenesis pathway involving formation of estrogen quinones that damage DNA and proteins, hence initiating and promoting carcinogenesis. Because, OTC botanical HRT alternatives are in widespread use, they may have the potential for chemopreventive effects on estrogen carcinogenic pathways in vivo. Therefore, the effect of OTC botanicals on estrogen-induced malignant transformation of MCF-10A cells was studied. Cytochrome P450 catalyzed hydroxylation of estradiol at the 4-position leads to an o-quinone believed to act as the proximal carcinogen. Liquid chromatography/tandem mass spectrometry analysis of estradiol metabolites showed that 4-hydroxylation was inhibited by hops, whereas black cohosh was without effect. Estrogen-induced expression of CYP450 1B1 and CYP450 1A1 was attenuated by the hops extract. Two phenolic constituents of hops (xanthohumol, XH; 8-prenylnaringenin, 8-PN) were tested: 8-PN was a potent inhibitor, whereas XH had no effect. Finally, estrogen-induced malignant transformation of MCF-10A cells was observed to be significantly inhibited by hops (5 μg/mL) and 8-PN (50 nmol/L). These data suggest that hops extracts possess cancer chemopreventive activity through attenuation of estrogen metabolism mediated by 8-PN.

The effect of soy-derived isoflavones over hot flushes, menopausal symptoms and mood in climacteric women with increased body mass index

BACKGROUND

Risk-benefit issues raised after the WHI have significantly increased the use of alternative treatments for the menopause. Despite this, data regarding the effect of soy isoflavones over mood and menopausal symptoms in high risk populations is still lacking.

OBJECTIVE

To evaluate the effect of soy derived isoflavones over hot flushes, menopausal symptoms and mood in climacteric women with increased body mass index (BMI).

METHODS

Fifty symptomatic climacteric women aged 40 to 59 with increased BMI (≥ 25) were recruited to receive oral 100 mg/day of soy derived isoflavones (Climasoy) for 3 months. Hot flushes (frequency/intensity), menopausal symptoms (Menopause Rating Scale [MRS]) and mood (Hamilton Depressive Rating Scale [HDRS]) were evaluated at baseline and at 90 days.

RESULTS

A total of 45 women completed the study. After 3 months of soy isoflavone supplementation hot flushes significantly decreased in percentage, number and severity (100% to 31.1%; 3.9 ± 2.3 to 0.4 ± 0.8 and 2.6 ± 0.9 to 0.4 ± 0.8, respectively, p < 0.001). MRS scores (total and for subscales) reflecting general menopausal symptoms also significantly decreased compared to baseline. Regarding mood, after three months total HDRS scores and the rate of women presenting depressed mood (scores ≥ 8) significantly decreased (16.3 ± 5.4 to 6.9 ± 5.2 and 93.3% to 28.9%, respectively, p < 0.05). There was no effect on blood pressure levels or BMI values after treatment.

CONCLUSION

In this high risk climacteric population, soy derived isoflavone treatment improved mood as well as vasomotor and general menopausal symptoms. More research is required to determine if the positive effect over mood is a direct or an indirect one through hot flush alleviation.

A study of new referrals to a menopause clinic and their initial outcomes: how can we improve the service we provide?

This retrospective case-note study was performed to examine the ways in which an already established menopause clinic could improve service to its patients. The management of 151 patients was examined. Most were referred by their general practitioner and the most common reason for referral was to seek an alternative to hormone replacement therapy (HRT). The consultant saw 17% of the patients, and with the trainee was most likely to discharge the patient. Better information on alternatives to HRT, more consultant input and better use of telephone consultation for follow-up would enhance the service provided by the menopause clinic.

Hot flushes: are there effective alternatives to estrogen?

Hot flushes are the most common indication for the prescription of hormone replacement therapy (HRT) since it is effective in over 80% of cases. In 1995, 37% of American women took HRT, principally for this purpose. However, over the last five years, publications such as those from the Women's Health Initiative (WHI) have caused concern among women since they perceive that the risks outweigh the benefits. Following this publication, half of the women taking HRT in the UK, USA and New Zealand discontinued HRT. With the discontinuation of estrogen many women re-developed hot flushes; however only a small number (18%) of women report restarting hormone therapy. The majority of these (76%) for the recurrence of severe hot flushes or night sweats. Alternatives are available, but limited knowledge on aetiology and mechanisms of hot flushing represents a major obstacle for the development of new, targeted, non-hormonal treatments, and no current alternatives are as effective as estrogen.

Safety of herbal medicinal products in women with breast cancer

OBJECTIVE

To review and summarise current evidence on the efficacy and safety of herbal medicinal products for the relief of hot flushes in women with previous breast cancer.

METHODS

A literature search was conducted in the databases of Medline, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), PSYCHINFO, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine).

RESULTS

Black cohosh and phytoestrogens have received the most research attention but there is currently insufficient evidence to recommend either for relief of flushes. Black cohosh use appears safe in women with previous breast cancer. Opposing advice has been given regarding the safety of dietary phytoestrogen use for women with previous breast cancer, but there is emerging data that soyfood phytoestrogen intake may have a beneficial effect on tumour recurrence.

CONCLUSIONS

The majority of studies, regarding the efficacy of herbal treatments for hot flushes, have not been conducted in women with breast cancer and many are of short duration. Increased pharmacovigilance practices for herbal medicines are required with initiatives to stimulate reporting of suspected adverse reactions.