Maggie McKay (Host): Welcome to the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. This is the first in a series of podcasts focusing on menopause and perimenopause, a topic felt by many, but talked about by few. I'm your host, Maggie McKay.

Joining us today is Dr. Marie Nakhoul, OB-GYN, at the University of Maryland Medical Center, with additional expertise in Integrative Care and Art Therapy to discuss natural relief for menopause. Thank you so much for being here today.

Marie Nakhoul, MD: Thank you so much, Maggie, for having me. I'm very excited to be here.

Host: Oh, I can't wait to hear more about this because, like I said, people just don't talk about it. And when menopause hits you, you're on your own. So, a lot of people seek "natural" options for menopause. How do you define what natural means in this context?

Marie Nakhoul, MD: Yeah, absolutely. So in general, natural means like the non-pharmacological, non-synthetic approach. So, it can be anything that is related to mind and body medicine integrated in the regular care, some of the lifestyle changes that we can integrate, some of the herbal supplements, plant-based supplements, and not specifically like medicines or pill, but I do need people to differentiate, and it's important to differentiate between the word natural and harmless. So, not everything that is natural necessarily mean it's harmless, because some of the natural supplements we have are not actually FDA regulated and might not actually be the healthiest option.

Host: The first time I heard that I was shocked, that natural really is an easy thing to slap on your label, right? It's not necessarily approved. But what lifestyle approaches can make the biggest difference during menopause, like nutrition, sleep, exercise?

Marie Nakhoul, MD: Yeah. So, it's actually a combo of things that someone can do when they hit perimenopause to menopause, really after the age of 45. One of it is focused on the nutrition, mainly a Mediterranean diet that is actually proven to alleviate or decrease some of the perimenopause and menopause symptoms and the hot flashes up to 80% in some studies that were done.

The Mediterranean diet is rich in antioxidants, is rich in good proteins, whole grain, legumes, fish, that all have great anti-inflammatory property that can affect some of the symptoms of menopause as well as help maintaining a healthy diet help you not gain a lot of weight or maintain a healthy weight, which also removes some of the fat adipose cells in the body that can produce some of the estrogen and androgens that can counteract with the hormonal balance during that period.

Second thing is exercise. I would say regularly. Every doctor recommends the five days per week. I would say with menopause, I would add adding to the cardio a little bit. Of course, strengthening exercise like Pilates or some weights to decrease the risk of menopause in the future, focusing on the sleep and the importance of sleep. In menopause, people experience a lot of hot flashes, especially at night. So, making sure their pillows and their bedsheets are able to accommodate some of those like heat strikes that happen. And there are some in the market that can help with that, and trying to get like a consistent hours of sleep, eight or nine hours per day if they can. Of course, other things like stress management. This is where mind-body medicine take effect like yoga, meditation, acupuncture, and I can talk about that a little further along later.

Host: Are there specific herbal remedies, supplements, or maybe integrative therapies that research supports for easing symptoms like hot flashes, mood changes, sleep problems?

Marie Nakhoul, MD: Yeah. There are some like what we call like the herbal medicine or the TCM, chinese traditional medicine, that some of them are studied. The data is mixed though. So, we don't have any herbal medicine yet that is, like, "Okay, this is the standard of care and we do prescribe it." There are some studies about black cohosh, red clover, primrose, St. John's wort that looked into that. I would say black cohosh is the most famous. It helps in reducing the severity of the hot flashes. And we do have some studies that showed a better result when compared to placebo. The red clover or the flax seed as well, they have the phytoestrogen component, which is the natural estrogen that mimic what the body produces. And they're natural and they can help with alleviating the symptoms. Same for primrose, initially, it's used for PMS symptoms and breast tenderness, but it is used traditionally to help with hot flashes, but the studies are limited.

The thing with those herbal supplements is that because they're not regulated, we don't know what's the dosage that is in those supplements. So, I tell the patients to use it with care. And if they're taking any other medicine that affects their liver or their kidney, they need to follow up with their doctors and make sure that they're okay to be on those supplements again, because they're really not regulated.

Ginseng is another one that is promoted, especially the Korean red ginseng, to increase the energy and decrease the fatigue. It can be used in menopause as well. It might help with a little bit of libido. So, this is when it comes to like the herbal plants, let's say, moving more to like the supplements or the teas, which I think are a little bit safer and doesn't have a lot of side effects like chamomile, lemon balm, passionflower tea are really great. They help with insomnia. They help with some of the hot flashes as well. Melatonin is another big supplement that actually is studied and help with going into the sleep cycle and help regulating the sleep.

Host: I was at my friend's the other day, Doctor, and she had a basket. I'm telling you what, I can't even show you how big, because it's bigger than the screen, but it was filled with supplements and other things, and a lot of it was from menopause. I'm like, "Oh my goodness, you can't possibly take every one of these every day." And she said, "No, I take this day, that day." And I thought, "Ah, there's so many options." So, how can women evaluate whether a natural option is safe and effective, especially with so many products on the market?

Marie Nakhoul, MD: Yeah. And again, that's extremely important. There are three key things we have to take into consideration when we're focusing on natural supplement for menopause. And I'm not talking about the hormone replacement therapy. I'm talking about all the adjunct things that we can do. First, make sure you do your research. Make sure those supplements are from a reliable sources. There are some on the Menopause Society, the NAMS website. There are some on the NIH website. And there are some on the Harvard's Women's Health website, also National Center for Complementary and Integrative Health. So, those actually have a list of some of the elements and supplements that are studied or people are looking into. So, check the resources and not just listen to tales or what on social media nowadays-- which is a big thing-- to check the quality check of the product. Again, those supplements are not FDA regulated. So, make sure of what are you getting, make sure you read the labels. There's no hidden info or other elements that can be toxic to you there. You can always review them with your doctor. Always consult your healthcare provider. And if you are in doubt, like, you know, "Hey, Doctor, that's what I read about. Can you check it for me? Is it safe to take? Does it have any interaction with any other medicine I'm taking, like a blood pressure medicine, like a diabetes medicine?" So, all of those are important. And again, like natural herbal products can still cause like allergic reaction, can affect the kidneys, affect the liver. They can be contaminated. So, we should handle them with a little bit extra precaution.

Host: Sometimes I take a screenshot when I'm at the market of what I'm thinking of buying and email it to my doctor and say, "Is this okay for me?" And they get right back to you and say, "Yes," "No." So, what role do mind-body practices like yoga, meditation, acupuncture-- what kind of role does that play in managing menopause symptoms?

Marie Nakhoul, MD: So, there are a lot of studies actually on mind and body medicine, which is like my favorite aspect of integrative care. And this is my focus, especially with my art therapy background. But in general, the mind and body connection is studied and it's known to calm the nervous system and eventually reduces the symptoms of stress and that is like indirectly and directly connected to some of the symptoms that are experienced in menopause related to the sleep disturbances and the hot flashes.

So, some of the exercises that people can do, everyone's familiar with, like yoga. Yoga is actually studied and is shown to improve menopause symptoms, especially when it comes to the mood and sleep quality. It can also ease some of the physiological symptoms like the hot flashes-- if not in intensity, but more so in the frequency. Meditation and mindfulness, which is a powerful tool for stress reduction. There is a technique called mindfulness-based stress reduction. This one has been studied in menopausal women with good results when it comes to improvement in their quality of life as well as insomnia.

Acupuncture is another tool. It's part of the traditional medicine that has been there for many years. We don't know exactly the mechanism of action, but I tell my patients sort of reset the nervous system button and just the way the body responds to stressors and inflammation.

So, all of those are like complementary therapy. And when they studied yoga and acupuncture, they were both effective reducing the hot flashes more than like sham and placebo therapy. So, there are some good data there. Other things like tai chi is a great sort of an exercise help like with movement, help with balancing the mood. And really, like, any exercise that has core strengthening as well. So, pilates is one that's hot in the market nowadays. Other elements that I'm less familiar, but they are being studied is hypnotherapy, is one that's been studied to see if it has any effect on regulating the thermostat in the brain or the way the brain perceives temperature changes.

Host: How do you recommend women balance natural approaches with conventional treatments like hormone therapy, if they're considering both?

Marie Nakhoul, MD: Yeah. I would say balance is the key. And really, this is my specialty. I'm like a classically trained OB-GYN, but I have like my Integrative Medicine training. So, I try to take the best of both arms. And this is also an important topic to dwell on the difference between alternative medicine and regular medicine.

Integrative medicine is not alternative. It's really integrating the care into a regular practice. So, many people have to know that HRT, hormone replacement therapy, is still the most effective treatment for hot flashes. So if someone is like so miserable from the menopause symptoms and they qualify for hormone replacement therapy, they are superior to the other natural remedies. But a lot of people don't want to be on hormones, and many people are not good candidates to be on those hormones. So, we can't just tell them, "Okay, I'm sorry, you're not a good candidate for hormones. You can just go home and cry in the corner." No, there are many other things we can integrate in their care. And it's where it's important to talk to the doctor, see what's available, and how that can be integrated and using a personalized care, personalized approach. Each patient is different. Some people respond to things differently. Not everyone has the same relief or the same effect on a specific either herbal or hormonal management.

Host: And let's talk about misconceptions. What misconceptions do you often hear about natural menopause care, and how do you guide women through those myths?

Marie Nakhoul, MD: Yeah. There are few myths about natural therapy. First, natural means safe. This is not true a hundred percent of the time. It does not mean safe. It just mean it's taken from a natural product. The dosage, the context matters. And the byproducts that are part of it also matters. So, it's important to check that out.

And if it's natural, it's proven to work. Also, that's not true. There are some historical anecdotal use of things that are not really evidence-based. So also, patients have to check with their healthcare provider.

And natural remedies can a hundred percent replace conventional medicine in all cases, that's also not too true. What might work for you does not really work for other people. And the bioidentical or like the compounded hormones and those are actually hormones that are non-conventionally done or not really done in the lab the way the actual HRT is. So, those are natural and safe to be used, I wouldn't claim that either, because the bioidentical hormones mean they're just chemically identical to what your body makes, but not necessarily equal effect. And they're not FDA regulated. So, I have a little bit of extra precaution when someone is on bioidentical just for the claim that they're more natural.

And the last one is menopause is a natural process. So, you might as well deal with it. That's also not true. I mean it is a natural transition, but it does not mean someone should live in misery or in suffering just because they are dealing with those symptoms. Medicine is improving by the day. There's a lot of research, there's a lot of new modalities that are being implemented. So, no, you don't have to suffer. There's a lot of things we can do to make this transition that is natural, but make it more of a blissful transition or more like a transformation into the new you.

Host: I think a lot of women would be like, "Well, that's a good description." I mean, that's a positive, hopeful way to put it. If a woman wants to start exploring natural approaches to menopause, what's the first step you suggest she take with her healthcare provider?

Marie Nakhoul, MD: I would say have an integrative consultation to look into what are the modalities that are available and see what her interest is. Is she more into mind and body medicine? Because some people don't like meditation, like they can't just do meditation or they don't believe in meditation. So, it does not necessarily work for her specifically. But she should get exposed to the different options that are available and just consult with her healthcare provider, see what's available for her, what they can do, and come up with a personalized-- really, one of the importance of that concept, like a personalized care approach when it comes to menopause and any other GYN issue actually, because like from an integrative perspective, we might not be able to cure everything, but we work on healing. And there's a difference between curing a disease and healing. Everybody can be involved in healing and get a healing experience, even if what they have is not cured. In menopause, it's more like a transition. So, it's not really a disease, but also we can do a lot of work in that aspect and look into the root cause of those symptoms and treat them from the roots.

Host: Do you have any key takeaways from our discussion?

Marie Nakhoul, MD: Yeah. So, always when you go follow up with your physician or provider, make sure you have your history. I would say I recommend like a little menopause diary where you put your information: How many hot flashes? Are they bothering you? Is that what's making you come to this visit? How often are they coming? What are your goals and preferences? Some people have hot flashes, and they're living fine through them. It doesn't affect them that much. But like the sort of depression or lack of sleep is what bothers them the most. Some people are the opposite. They're doing mentally fine and emotionally fine, it's just the hot flashes. They're very symptomatic.

So, try to stratify what's bothering you the most. Put it on a diary. Ask a specific question. What are you afraid of? What are your dietary restrictions? Have you tried anything natural before? And yeah, always rule out other causes as well. It might be your thyroid. It might be other organic causes that are contributing to your symptoms. And always your integrative physician will help you come up with a plan with shared decision-making, coming up with a plan and following up with like little milestones at a time.

Host: That's all really useful information. Thank you so much for sharing your expertise. This has been so informative. I have learned a lot and I'm sure everybody watching and listening will as well. So, thank you so much for being here.

Marie Nakhoul, MD: Thank you so much. It's my pleasure to be here and provide those information.

Host: Again, that's Dr. Marie Nakhoul. Find more shows just like this one at umms.org/podcast and on YouTube. Thank you for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media. If you have questions about menopause or perimenopause that you would like us to consider addressing in a podcast, you can email them to wellness@umm.edu.