Menopause Herbs Don't Work?
I'm interrupting Dr. Harvey-Carter's series on natural menopause
remedies to talk about a serious and newsworthy aspect of her
2002 study of herbs and other natural remedies for menopause
has been getting a lot of press. Particularly of note are its
assertions that black cohosh is the only herb shown to help in
We could incorrectly assume then that no herbs help for menopause.
However, there are some problems with that conclusion.
Let's take a look at them:
- Most herbs have not been subjected to RCT's (Randomized Controlled
Trials). What's an RCT? See this
- RCT's are not the only kind of study that provides reliable
- Herbs are hardly ever prescribed alone. Research should be
conducted on time-tested herbal formulas for menopause - not
- American researchers tend to ignore or discount research done
outside the U.S.
- Researchers' own biases affect their conclusions... no study
is perfect. Researchers may have little trouble finding reasons
to throw out a study whose conclusions threaten their beliefs.
Then I'll confess some of my own biases, and speak about what
acupuncture and herbs (from a chinese medical perspective) can
do for menopause. Plus, we'll take a look at conventional and
alternative medical perspectives on when estrogen and natural
treatments are appropriate.
1. Which herbs have been subjected to RCT's?
A quick search of MedLine for "herb randomized controlled
trial" yields only 13 results for 11 herbs and herb formulas:
- St John's Wort, Black Cohosh
- Bing gan tang, Yi zhu tang, Yi Er Gan Tang (Hep C)
- Phyllanthus, 'Jianpi Wenshen recipe', Fuzheng Jiedu Tang (Hep
- Polyporus umbellatus polysaccharide
- Echinacea (Common cold)
- Ginger (Nausea)
- 'AM' a Ugandan herb remedy (Malaria)
I know this is not the full list of well-studied herbs. The groundbreaking
1998 Journal of the American Medical Association issue on alternative
medicine included the first RCT faithful to the principles of
chinese herbal medicine, a study of herbs for IBS.
In the November 2002 study, only 10 of the 29 studies (RCT's)
they reviewed studied herbs. Of those, only two - black cohosh
(sheng ma) and dang gui - are chinese herbs. There are many chinese
herbs and herbal formulas for menopause that have not been studied
2. RCT's aren't the only kind of study.
Without a doubt, they are the best, the gold standard
eliminate the placebo effect as much as possible, etc. They're
good. But most herbs haven't had their RCT day in the sun. Why
not? Because it costs a lot of money!
Drug companies spend hundreds of thousands of dollars on each
drug to prove its safety (not necessarily its effectiveness) in
RCT's. No single company has a motivation to study an herb which
they cannot patent, own, and have the exclusive right to sell.
They may take the course of isolating one part of an herb and
patenting that, but then we've taken the herb out of its traditional
framework. Applying it like a drug puts it in the biomedical treatment
framework- the same one that assumes side effects are unavoidable.
We'd like to avoid that!
There are plenty of other kinds of studies- from smaller scale
clinical retrospectives (analyzing the data from treatment records)
to in-vitro (in a glass tube) lab studies of herbs' effects on
micro-organisms. In-vitro studies can show how a substance works,
but don't tell us how it works in humans.
A search of MedLine for "Chinese Herb" yields 626 results.
We get everything from the effect of herbs on rats in space (yes,
really) to drug-herb interactions. And we find a lot of studies
from outside the U.S. I don't have time right now to survey all
626 - sorry!
But the point is that there are a lot of studies out there that
tell us positive things about herbs even though they haven't yet
been awarded adequate funding for an RCT.
3. Herbs are hardly ever prescribed alone. Research should be
conducted on time-tested herbal formulas for menopause - not just
Most people know little to nothing about the most comprehensive
and effective traditional system of herbal prescription - Chinese
Clinical experience and research studies have shown that herbs
work better in groups (formulas) than alone. Just as certain drug
combinations have positive or negative effects, certain combinations
of herbs have special additive functions or may need to be avoided.
The first systematic herbal text was written in 200AD, the Shang
Han Lun (Cold Damage Classic). For at least 1800 years, chinese
herbs have been prescribed primarily in formulas - groups of 4-12
New research on chinese herbs should verify, refine, and build
on the last 1800 years. The idea to research single herbs comes
from the pharmaceutical drug paradigm, not the tradition to which
chinese herbs belong. It makes sense that since most American
researchers are biomedical that they would use a biomedical approach...
but it's still wrong.
4. American researchers tend to ignore or discount research
done outside the U.S.
I wasn't able to find anything to back this up, so I'll just
say that it seems as if American researchers don't acknowledge
research from other countries. Or perhaps they simply are more
skeptical of it? In any case, I notice that many of the topics
I investigate (alternative and complementary treatments) are studied
in Europe, but not in the U.S. I admit I don't have all the info
on the general level of quality of studies from different countries,
or how much and why American researchers disregard such studies.
5. Researchers' own biases affect their conclusions. No study
is perfect. Researchers can easily find a reasons to be skeptical
about any study that opposes their own beliefs.
This is backed up by a meta-study I found
researchers found that those who reviewed studies were more likely
to criticize its methodology if its conclusions disagreed with
their bias, and more likely to approve of its methodology if its
conclusions agreed with their bias.
There is no such thing as a perfect study. Good research tries
to keep problems affecting the results and interpretation at a
minimum, but imperfections are unavoidable. That means that if
someone doesn't like the results of your study, they can find
a reason to discredit the study.
This reminds me of the standard joke about statistics: "97%
of all statistics are false." This implies, of course, that
it could itself be false. Statistics, like anything else, can
be deceiving. Inaccuracies of commission or omission (conscious
or unconscious) can "spin" the truth toward the reader's
So What's the Truth? My Biases
As a seeker of truth, like most researchers and scientists, I
want to attempt to be objective and find out what really is and
is not true... what treatments will or won't work.
I admit that, as a healer on the natural/alternative side of
the spectrum, I have certain biases. Here are some of them:
- I would always rule out serious medical conditions
with modern lab tests and visual studies. To accomplish this
for patients, we must work together with biomedical physicians.
- I would look for an option that led to healing rather than
just a permanent crutch. We should be especially cautious
of inteventions that lead to permanent dependence.
- They may not have been subjected to RCT, but traditional
healing treatments carry some merit by virtue of their usage
by generations upon generations of physicians. Of course, there
is some error and inaccuracy that can occur without the benefit
of controlled studies... but to assume the remedies don't work
or to assume they are unsafe is to show disrespect to these
generations of physicians. Skepticism is both the call and burden
of the scientific investigator, but taken too far, skepticism
can become arrogance and disrespect. Research will refine traditional
- In non-emergency situations, I would always try a traditional
natural healing method first. This should be guided by an
educated, licensed professional. Patients should not administer
remedies to themselves.
- The practice of medicine is as much art as science.
Clinicians draw from both science and convention (tradition).
Chinese medicine practitioners draw from both science and tradition.
- Personally, I regard every chinese medical tradition a hypothesis.
I test it in clinic. It's not a randomized controlled trial,
but it either works or it doesn't. Placebos only work one-third
of the time. Chinese medicine appears to help at least two-thirds
of the time. Also, interventions with herbal formulas and acupuncture
seem to lead to permanent healing changes more often than drugs
do. This means that practicing according to tradition leads
to significant healing... more than just wishful thinking!
Traditional Chinese Medicine (Herbs and Acupuncture) for Menopause
The review of RCT's
on herbs for menopause shows that many herbs still need to
be investigated. However, RCT's are not the only reliable proof
that medicines are effective and safe.
At least 1000 years of tradition indicate that chinese herbal
medicine helps balance women in menopause. Acupuncture has been
used for somewhere between 2,000-30,000 years.
Acupuncture and herbs for menopause help alleviate many symptoms;
most commonly responsive are hot flashes, depression, and vaginal
dryness. Salivary hormone tests in clinical settings often show
changes in testosterone and progesterone.
Another interesting point about the November 2002 study is that
neither black cohosh nor dang gui are used alone in chinese herbal
remedies for menopause. Black Cohosh can cause headaches and dizziness,
but might be safely used in an herbal formula for menopause. Dang
gui is similar- it is a warming herb, so by itself it could even
increase the heat in hot flashes!
The moral of the story: See a chinese
medical practitioner and use formulas, not single herbs.
Conventional and Alternative Perspectives on Menopause Treatment
An MD's letter to the editor in the New York Times, Nov
13th, 2002 proposes some telling advice from a biomedical
- "If a woman is experiencing severe hot flashes
and other menopause symptoms, estrogen treatment is appropriate."
- "She is likely to accept the very small increase in
stroke risk to get a decent night's sleep."
- "Preventive measures, however, have to meet a higher
standard to 'do no harm' because the patient is not sick."
I disagree with all three points.
First, what if the woman only has mild hot flashes? She
should just deal with it? She doesn't have to. Herbs can help.
Second, she need only accept a risk of stroke if there
is no viable alternative. If patients are unaware of such alternatives
and think estrogen treatment is the only option, then they may
accept such a risk. However, it would be unethical for biomedical
practitioners to (by ignoring or downplaying the weight of chinese
herbal medicine's tradition and experience) suggest that there
are no alternatives.
Third, almost no biomedical treatment meets the 'do no harm'
standard. Side effects are considered acceptable, but they are
harm nonetheless. Plus, because sick people have less strength
to tolerate with harsh medications, medical error and drug therapy
can be much more injurious to them, so treatments of sick people
need to meet the higher standard. People who are well can
come back from minor medical errors easier because they have more
health resources with which to return to health. Preventive health
actually has more breathing room than disease treatment.
If you are interested in these kinds of results, check with your
local acupuncturist. To find an acupuncturist near you, read our
"Resources for Finding Acupuncturists
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