Topical administration of isoflavones for treatment of vaginal symptoms in postmenopausal women: A systematic review of randomised controlled trials

Effect of isoflavone supplementation on menopausal symptoms: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/OBJECTIVES

Complementary and alternative medicines can be used to alleviate climacteric symptoms that significantly affect the quality of life of postmenopausal women. Isoflavones are the most common plant-based therapies for postmenopausal changes, but the results of previous studies have been controversial.

MATERIALS/METHODS

To investigate whether isoflavones would affect menopausal symptoms as well as ovarian hormones, we performed a systematic review and meta-analysis. The PubMed and EMBASE databases were used to perform the systematic search. Included studies were limited to randomized controlled trials (RCTs) assessing the impact of isoflavone supplementation on menopausal symptoms.

RESULTS

Eleven studies were included for the final quantitative assessment. Isoflavone intervention was varied between 49.3 and 135 mg of isoflavones per day for 12 wk-2 yrs. The meta-analysis showed that supplementation of isoflavones significantly increased the estradiol levels (standardized mean difference [SMD] = 0.615, P = 0.035) and Kupperman index (SMD = 3.121, P = 0.003) but had no significant effect on hot flashes, follicle-stimulating hormone, and luteinizing hormone. However, both estradiol and the Kupperman index showed significant heterogeneity among studies (I2 = 94.7%, P < 0.001 and I2 = 98.1%, P < 0.001, respectively).

CONCLUSIONS

Although the results showed a significant SMD in estradiol and the Kupperman index, the results should be interpreted with caution due to the high heterogeneity. Further validation with a larger RCT will be necessary. Overall, isoflavone supplementation has distinct effects on the climacteric symptoms and hormonal changes in postmenopausal women.

Isoflavonoid Profiling and Estrogen-Like Activity of Four Genista Species from the Greek Flora

As part of our ongoing research on phytoestrogens, we investigated the phytochemical profile and estrogen-like activities of eight extracts from the aerial parts of four Genista species of Greek flora using estrogen-responsive cell lines. Ethyl acetate and methanolic extracts of G. acanthoclada, G. depressa,G. hassertiana, and G. millii were obtained with accelerated solvent extraction and their phytochemical profiles were compared using ultra-high-performance liquid chromatography-high-resolution mass spectrometry (uHPLC-HRMS). Fourteen isoflavonoids, previously isolated from G. halacsyi, were used as reference standards for their identification in the extracts. Thirteen isoflavonoids were detected in both extracts of G. acanthoclada and G. hassertiana, while fewer and far fewer were detected in G. millii and G. depressa, respectively. The ethyl acetate extracts of G. hassertiana and G. acanthoclada displayed 2.45- and 1.79-fold higher, respectively, estrogen-like agonist activity in Ishikawa cells compared to MCF-7 cells at pharmacologically relevant concentrations. Both these extracts, but not that of G. depressa, contained mono- and di-O-β-d-glucosides of genistein as well as the aglycone, all three of which are known to display full estrogen-like activity at lower-than-micromolar concentrations. The possibility of using preparations rich in G. hassertiana and/or G. acanthoclada extracts as a potentially safer substitute for low-dose vaginal estrogen for menopausal symptoms is discussed.

An overview of the phytoestrogen effect on vaginal health and dyspareunia in peri- and post-menopausal women

OBJECTIVE

The aim of this overview was to evaluate the effectiveness of phytoestrogens on vaginal health and dyspareunia in peri- and post-menopausal women.

MATERIAL AND METHODS

Three databases including MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials were from inception to August 2017.

RESULT

Two systematic reviews and 11 RCTs were included in the overview. According to the findings, isoflavones increased the maturation value and attenuated the vaginal atrophy in the post-menopausal women. Topical isoflavones had beneficial effects on the vaginal atrophy. Similar efficacy was found in Pueraria mirifica and conjugated estrogen cream on dryness ( p = 0.277), soreness ( p = 0.124) and irritation ( p = 0.469), as well as discharge ( p = 0.225) and dyspareunia ( p = 0.089). However, the conjugated estrogen cream was more effective compared to Pueraria mirifica ( p > 0.005) regarding maturation index improvement. Comparison of fennel 5% vaginal cream and placebo gel showed significant difference in superficial cells ( p < 0.01), parabasal cells ( p < 0.01) and intermediate cells ( p < 0.01), whereas no difference was found between the oral fennel and placebo in terms of superficial, parabasal and intermediate cells as well as Maturation value. Administration of 80 mg red clover oil had a significant effect on superficial ( p < 0.005), intermediate ( p < 0.005) and parabasal and vaginal dryness ( p < 0.005) compared to the placebo. Flaxseed had also a trivial effect on maturation value. Genistein had a more prominent effect on the genital score. The severity of dyspareunia decreased by 27%.

CONCLUSION

Phytoestrogens have various effects based on administration route and type on the vaginal atrophy.

Biological evaluation of isoflavonoids from Genista halacsyi using estrogen-target cells: Activities of glucosides compared to aglycones

The purpose of this study was to evaluate the response of estrogen target cells to a series of isoflavone glucosides and aglycones from Genista halacsyi Heldr. The methanolic extract of aerial parts of this plant was processed using fast centrifugal partition chromatography, resulting in isolation of four archetypal isoflavones (genistein, daidzein, isoprunetin, 8-C-β-D-glucopyranosyl-genistein) and ten derivatives thereof. 7-O-β-D-glucopyranosyl-genistein and 7,4΄-di-O-β-D-glucopyranosyl-genistein were among the most abundant constituents of the isolate. All fourteen, except genistein, displayed low binding affinity for estrogen receptors (ER). Models of binding to ERα could account for the low binding affinity of monoglucosides. Genistein and its glucosides displayed full efficacy in inducing alkaline phosphatase (AlkP) in Ishikawa cells, proliferation of MCF-7 cells and ER-dependent gene expression in reporter cells at low concentrations (around 0.3 μM). ICI182,780 fully antagonized these effects. The AlkP-inducing efficacy of the fourteen isoflavonoids was more strongly correlated with their transcriptional efficacy through ERα. O-monoglucosides displayed higher area under the dose-response curve (AUC) of AlkP response relative to the AUC of ERα-transcriptional response compared to the respective aglycones. In addition, 7-O-β-D-glucopyranosyl-genistein and 7,4΄-di-O-β-D-glucopyranosyl-genistein displayed estradiol-like efficacy in promoting differentiation of MC3T3-E1 cells to osteoblasts, while genistein was not convincingly effective in this respect. Moreover, 7,4΄-di-O-β-D-glucopyranosyl-genistein suppressed lipopolysaccharide-induced tumor necrosis factor mRNA expression in RAW 264.7 cells, while 7-O-β-D-glucopyranosyl-genistein was not convincingly effective and genistein was ineffective. However, genistein and its O-glucosides were ineffective in inhibiting differentiation of RAW 264.7 cells to osteoclasts and in protecting glutamate-challenged HT22 hippocampal neurons from oxidative stress-induced cell death. These findings suggest that 7-O-β-D-glucopyranosyl-genistein and 7,4΄-di-O-β-D-glucopyranosyl-genistein display higher estrogen-like and/or anti-inflammatory activity compared to the aglycone. The possibility of using preparations rich in O-β-D-glucopyranosides of genistein to substitute for low-dose estrogen in formulations for menopausal symptoms is discussed.

Can the use of probiotics in association with isoflavone improve the symptoms of genitourinary syndrome of menopause? Results from a randomized controlled trial

OBJECTIVE

To evaluate the effect of isoflavone administration, either in conjunction with probiotic use or not, on the symptoms of genitourinary syndrome of menopause, and compare the effects with those of hormone therapy.

METHODS

A randomized clinical trial was conducted on 60 postmenopausal women aged 40 to 60 years, randomly assigned to receive oral isoflavone (150 mg dry extract of glycine max) alone or isoflavone plus probiotic (Lactobacillus acidophilus, Lactobacillus casei, Lactococcus lactis, Bifidobacterium bifidum, and Bifidobacterium lactis) or hormone therapy (1 mg estradiol and 0.5 mg norethisterone acetate). The urogenital symptom subscale of the Menopause Rating Scale and International Consultation on Incontinence Questionnaire-Short Form were used to assess genitourinary symptoms. Vaginal maturation value, pH, vaginal health score, and vaginal flora were used to evaluate vaginal atrophy. Equol, equol intermediate, O-dimethylangolensin, and aglycones were measured using gas chromatography coupled to mass spectrometry.

RESULTS

After 16 weeks of treatment, the urogenital symptoms, mainly vaginal dryness and sexual problem complaints, improved significantly in the hormone therapy group. There was a significant increase in the daidzein, glycitein, equol intermediate, and O-dimethylangolensin contents after 16 weeks in the isoflavone plus probiotic group. The maturation value, vaginal pH, and vaginal flora improved in the hormone therapy group. The vaginal health score increased in the isoflavone and hormone therapy groups.

CONCLUSIONS

Probiotics improved the metabolism of isoflavones after 16 weeks of treatment. However, the increase in the contents of isoflavones and their metabolites failed to yield an estrogenic effect on the urogenital tract and relieve the vulvovaginal symptoms.

Effect of Herbal Medicine on Vaginal Epithelial Cells: A Systematic Review and Meta-analysis

Objectives

The present meta-analysis aimed to assess the effect of the herbal medicine on the vaginal epithelial cells (VECs) among the menopausal subjects.

Methods

The literature related to VECs exposed to various herbal medicines in menopausal women were searched on three databases, MEDLINE (1966–August 2017), Scopus (1990–August 2017) and Cochrane Library (Cochrane Central Register of Controlled Trials; 2014).

Results

Totally, the meta-analysis was conducted on 11 randomised controlled trials. Based on the findings, the standardized mean difference (SMD) of maturation value (MV) was observed to be elevated by 0.48% (95% interval confidence [CI], 0.108–0.871; P = 0.012), as well as the heterogeneity was high (I² = 84%; P < 0.001). The MV revealed a significant increase in soy group (SMD, 0.358; 95% CI, 0.073–0.871; P = 0.014) compared to the control group.

Conclusions

The herbal medicines exhibited a statistically significant effect on the VECs. A significant effect on the VECs was also found in the subgroup analysis of the patients, who received soy. However, further and extensive studies are required to achieve reliable outcomes.

Effect of Foeniculum vulgare (fennel) on vaginal atrophy in postmenopausal women: A double-blind, randomized, placebo-controlled trial

Objectives This study was conducted to evaluate the effects of orally administered fennel on vaginal atrophy. Materials and methods In this double-blind, randomized, placebo-controlled trial, 60 postmenopausal women living in Mashhad, Iran, were randomly divided into an oral fennel group (n = 30) and a placebo group (n = 30). The Maturation Vaginal Index and maturation values were measured once at baseline and again upon a three-month follow-up. Results The paired t-test showed statistically significant changes in the Maturation Vaginal Index (i.e. a decline in the parabasal cells and an increase in the intermediate and superficial cells) and maturation values in both the fennel and placebo groups at the end of the trial compared to at baseline. Nonetheless, no significant differences were observed in the percentages of the parabasal (P = 0.191), intermediate (P = 0.219) and superficial (P = 0.82) cells, which was also the case for the maturation values (P = 0.64). Conclusion Fennel had no significant positive effects on vaginal atrophy in postmenopausal women. Nonetheless, more studies are recommended to be conducted using higher doses of fennel and larger sample sizes so as to verify the results of this study.

The Effect of Short-term Treatment with Fennel on Bone Density in Postmenopausal Women: A Randomized Controlled Trial

Objectives

The goal of this study is to assess the effect of fennel on bone density.

Methods

This was a double-blind, randomized, placebo-controlled trial, which studied sixty eligible postmenopausal women, who were randomly assigned to fennel and placebo groups. Then, the dual energy X-ray absorptiometry was utilized to measure bone mineral density (BMD) and bone mineral content (BMC) of the spine, femoral neck, intertrochanter, and trochanter at the baseline and after three-month follow-up.

Results

The mean BMD and BMC at lumbar spine (P = 0.14, P = 0.504), total hip femoral (P = 0.427, P = 0.471), trochanter (P = 0.075, P = 0.07), intertrochanter, (P = 0.864, P = 0.932) and femoral neck (P = 0.439, P = 0.641) was not significantly different between the fennel and placebo groups.

Conclusions

The results of this study did not approve the effect of fennel on bone density in post-menopausal women. However, to gain deeper insights, further studies with longer durations and larger sample sizes are recommended.

Oral isoflavone supplementation on endometrial thickness: a meta-analysis of randomized placebo-controlled trials

Background

Isoflavone from soy and other plants modulate hormonal effects in women, and the hormone disorder might result in different caners including endometrial cancer. However, it's effect on the risk of endometrial cancer is still inconclusive. We aimed to assess the effects of isoflavone on endometrial thickness, a risk factor of endometrial cancer in peri- and post-menopausal women.

Methods

A meta-analysis of randomized controlled trials was conducted to evaluate the effect of oral isoflavone supplementation on endometrial thickness in peri- and post-menopausal women. Electronic searches were performed on the PubMed, Embase, the Cochrane Library, web of science, CINAHL, and WHO ICTRP to August 1^st, 2015. Reviews and reference lists of relevant articles were also searched to identify more studies. Summary estimates of standard mean differences (SMD's) and 95%CIs were obtained with random-effects models. Heterogeneity was evaluated with meta-regression and stratified analyses.

Results

A total of 23 trials were included in the current analysis. The overall results did not show significant change of endometrial thickness after oral isoflavone supplementation (23 studies, 2167subjects; SMD:-0.05; 95%CI:-0.23, 0.13; P=0.60). Stratified analysis suggested that a daily dose of more than 54mg could decrease the endometrial thickness for 0.26mm (10 trials, 984subjects; SMD:-0.26; 95%CI:-0.45, −0.07; P=0.007). Furthermore, isoflavone supplementation significantly decrease the endometrial thickness for 0.23mm in North American studies (7 trials, 726 subjects; SMD:-0.23; 95%CI:-0.44, −0.01; P=0.04), but it suggested an increase for 0.23mm in Asian studies (3 trials, 224 subjects; SMD: 0.23; 95%CI:-0.04, 0.50; P=0.10).

Conclusion

Oral isoflavone supplementation might have different effects in different populations and at different daily doses. Multiple-centre, larger, and long-term trials are deserved to further evaluate its effect.

Clinical update on the use of ospemifene in the treatment of severe symptomatic vulvar and vaginal atrophy

The physiological decrease in vaginal estrogens is accountable for the emergence of vulvar and vaginal atrophy (VVA) and its related symptoms such as vaginal dryness, dyspareunia, vaginal and/or vulvar irritation or itching, and dysuria. The repercussion of these symptoms on quality of life often makes it necessary to initiate treatment. Up until now, the treatments available included vaginal moisturizers and lubricants, local estrogens, and hormonal therapy. However, therapeutic options have now been increased with the approval of 60 mg ospemifene, the first nonhormonal oral treatment with an agonist effect on the vaginal epithelium and an endometrial and breast safety profile which makes it unique. This is the first selective estrogen receptor modulator indicated in women with moderate-to-severe vaginal atrophy not eligible for local estrogen treatment. Considering that "local estrogen noneligible women" are those in whom such treatment cannot be administered either because it is contraindicated or due to skill issues, who are averse to the mode and convenience of vaginal products' administration or to their use on account of potential systemic absorption, or those who demonstrate dissatisfaction in terms of efficacy and safety, it is clear that there is a significant unmet medical need in VVA management. In fact, a great number of women show lack of adherence, dropping out of at least one VVA treatment, including nonhormonal moisturizers and lubricants, which they consider to be ineffective and uncomfortable. If they could choose, many of them may opt for oral treatment. In Phase III studies, ospemifene demonstrated efficacy in vaginal dryness and dyspareunia, regenerating vaginal cells, improving lubrication, and reducing pain during sexual intercourse. Symptoms improved in the first 4 weeks and endured for up to 1 year. Additionally, it demonstrated a good endometrial, cardiovascular system, and breast safety profile.

Short-Term Isoflavone Intervention in the Treatment of Severe Vasomotor Symptoms after Surgical Menopause: A Case Report and Literature Review

Isoflavones are soy phytoestrogens that potentially exert various favorable effects in postmenopausal women, for example, alleviating vasomotor episodes, attenuating bone loss, and stimulating vaginal epithelial maturation. There has, however, been lack of consensus regarding those therapeutic effects. Most clinical studies of isoflavones have been conducted with women who had undergone natural menopause, but not those who had undergone surgical menopause. This study reports on a 51-year-old woman who presented with severe vasomotor episodes after undergoing a hysterectomy and a bilateral oophorectomy due to hypermenorrhea secondary to myoma uteri. She refused hormone therapy due to fear of adverse drug reactions so was treated with oral soy isoflavones (two capsules twice daily, equivalent to at least 100 mg daily dose) for 8 weeks. The number and severity of hot flushes and her menopause-specific quality of life dramatically improved from baseline values. The serum bone resorption marker (beta C-telopeptide) decreased markedly, while vaginal epithelial maturation improved slightly, suggesting the potential of isoflavones in attenuating bone loss and stimulating vaginal maturation. The intervention did not adversely affect the hormonal profile (FSH, LH, and estradiol) and liver or renal functions. Thus, isoflavones could be an option for women experiencing severe vasomotor episodes after surgical menopause.