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Hormones beat botanicals for hot flashes but memory may suffer

My patients suffering with perimenopausal or menopausal symptoms often wonder about the safety and effectiveness of hormone therapy or botanicals (such as black cohosh and red clover) to treat their symptoms. Two recent studies will help inform wise decision making for these problems.
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The Los Angeles Times Booster Shots blog reports that according to a “government-sponsored study” of 89 women conducted by researchers at the University of Illinois-Chicago and published in the August issue of the journal Menopause, “the botanical remedies black cohosh and red clover, widely taken by middle-aged women to tame night sweats and hot flashes, took third place behind hormone replacement therapy and . . . a placebo pill in their ability to provide relief from menopausal symptoms.”
A second study of 66 women, conducted by the same group and published in the same journal, “found that women taking Prempro [estrogens (conjugated)/medroxyprogesterone], the hormone-replacement medication used in the clinical comparison, fared worse on a key cognitive complaint about menopause: memory.”
Notably, “black cohosh and red clover . . . had no negative impact on memory, nor on liver enzymes, lipid profiles, or measures of breast and endometrial safety.”
A recent review on the topic of hormone therapy and mental function concluded:

There are more than 200 published scientific papers showing that estrogen has favorable effects on brain tissue and physiology in cell culture and animal models including non-human primates.

The biological plausibility for a neuroprotective estrogen effect is overwhelming.

However, these studies, like most studies of endogenous estrogen and cognitive decline or dementia in women fail to show protection, and some suggest harm.

Failure to find any consistent association might reflect the limitations of a single time of estrogen assay or poor assay sensitivity. More than half of the observational studies of hormone therapy suggest benefit.

Nearly all long-term clinical trials fail to show benefit, and the longer trials tend to show harm.

Failure to adequately adjust for self-selection of healthier and wealthier women and publication bias could account for some, or all, of the protective effect attributed to estrogen in observational studies.

Overall, the evidence does not convincingly support the prescription of early or late postmenopausal estrogen therapy to preserve cognitive function or prevent dementia.

Another review of the topic reported:

Consistent with transitioning women’s perceived memory difficulties, perimenopause was associated with a decrement in cognitive performance, characterized by women not being able to learn as well as they had during premenopause.

Improvement rebounded to premenopausal levels in postmenopause, suggesting that menopause transition-related cognitive difficulties may be time-limited.

Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.

The North American Menopause Society (NAMS) Position Statement on Estrogen and Progestogen in Postmenopausal Women says:

Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both.

The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women.

Here are some of my most popular blogs on the topic:

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