Phytoestrogens are plant-based compounds that have weak estrogenic activity. They appear to have SERM activity with modest agonist effect at the beta estrogen receptor. Phytoestrogens are categorized as isoﬂavones, coumestans, lignans, or ﬂavonoids. The most promoted of these groups is isoﬂavones, which are genistein, daidzein, or glycitein. Soybeans and soy products are a rich source of isoﬂavones. Several reviews and meta-analyses found mixed results on menopausal symptoms (70,85). Women who want to consume phytoestrogens should do so through food products rather than supplements, and should aim for 100 mg of isoﬂavones a day, or 25 g of soy protein. One randomized controlled trial of 366 women demonstrated endometrial hyperplasia in 3.8% of women who consumed 150 mg per day of isoﬂavones for 5 years versus 0% in the placebo arm (85).
Mind–Body Interventions Mind–body therapies for the treatment of menopausal symptoms were studied in several domains, but the trials are often small and not always high quality. In a small prospective trial of 30 women, applied relaxation was compared to estradiol. The women in the relaxation group had a 76% reduction in hot ﬂashes at 6-month follow-up versus 90% in the estradiol arm, which was reached at 12 weeks (86). In another study by Nedstrand et al., 38 women with breast cancer showed improvement in vasomotor symptoms with both applied relaxation and electro-acupuncture (86). In one randomized controlled trial, symptomatic menopausal patients who had at least five hot ﬂashes per 24 hours were randomized to either the relaxation response, to reading, or to a control group. The relaxation response group had significant reductions in hot ﬂash intensity, tension– anxiety levels, and depression compared with the control group, which had no significant changes (87). In another randomized controlled trial of symptomatic menopausal patients, women with frequent hot ﬂashes were randomized to paced respiration, muscle relaxation, and alpha-wave feedback. In the paced respiration group, there was significant reduction in the hot ﬂash frequency, whereas muscle relaxation and biofeedback showed no differences. The proposed mechanism of action is decreased central sympathetic activity (88). In a trial with 76 breast cancer patients, an intervention of counseling and emotional support was associated with an improvement in both menopausal symptoms and sexual function compared to the control arm (89). In a trial of 102 women the effect of acupuncture, applied relaxation, estrogens, and placebo were examined. Both acupuncture and applied relaxation reduced the number of hot ﬂashes significantly better than placebo (90).
Insomnia, which is another frequent symptom of menopause, is a complex, multifactorial problem. Optimal treatment is described as incorporating the following components: stress management, coping strategies, enhancement of relationships, and lifestyle changes that facilitate sleep (91).
Overall, mind–body techniques are a low-or no-cost, low-risk intervention that can decrease central nervous system adrenergic tone. They are reported to decrease hot ﬂashes and other menopausal symptoms, and provide general health benefits.