Menopausal Women

Abstract : The clinical trial to evaluate the estrogenic effects of the crude drug derived from dry powder of a phytoestrogen-rich Thai herb Pueraria mirifica (White Kwao Krua) under Tropical Herbal product in five female volu he signs and symptoms related to menopause such as, hot flushes, frustration, sleep disorder, skin dryness, high blood cholesterol, oligomenorrhoea and amenorrhea; with no change in the blood cells, liver and kidney functions, as well as other physiological status after four months of treatment In four volunteers, treatments were continued to complete a one-year test period with half the dose and was found to maintain their satisfied menopausal relief status. The crude drug dosage was administered at 200 mg daily for three weeks a month during the first four months of treatment and 200 mg every other day for 20 days per month for the remaining eight months. These doses were effective and safe as phytoestrogen treatment of menopausal symptoms.

INTRODUCTION
Menopause sometimes causes symptoms derived from decreased blood estrogen levels among middle-aged females. Estrogen Replacement Therapy (ERT) has been employed to protect and relieve symptoms but usually results in substantial cost and long-term treatment has a certain risk of estrogen-related cancer. Some recommendations such as lifestyle changes were proposed to minimize the menopausal symptoms. Dietary and other natural therapies, especially soy products which contain significant levels of phytoestrogens, namely isoflavones, were shown to be not only effective in eliminating certain menopausal symptoms, but also act as a potent anticancer therapy.

Pueraria mirifica (Airy Shaw et Suvatabandhu) or White Kwao Krua is a Thai indigenous herb with a long history of domestic consumption as a rejuvenating herb to promote youthfulness in both women and men. The herb was first brought to public attention in 1932 by a report that the tuberous root of the Kwao Krua herb found in the Northern Thailand contained active constituent with such rejuvenating property. That report elicited a study of the benefits of the herb and it was later proven in both animal experiment and clinical trial in a hospital by administering alcoholic crude extract of the herb. Such human benefit was also confirmed by another study. The herb was initially recognized as Butea superba, and was finally identified and clearly established as Pueraria mirifica.

Active ingredients were isolated and studied from the herbal tuber and was found to contain miroestrol which exhibited the key estrogenic effect as reported from the studies in immature female mice and ovariectomized rat. A very interesting result was obtained from a clinical trial in nine female volunteers at the Chelsea Hospital for Women in London. U.K., who were suffering from amenorrhea, as well as one volunteer with artificial menopause.

The results clearly demonstrated that this active ingredient from P. mirifica could be administered as an estrogen supplement.

Other chemical constituents were also characterized including daidzin, daidzein, genistein, coumestrol, mirificin, genistin, puerarinand kwakhurin.

The phytochemical daidzin from soy source was known to prevent bone loss. Daidzein was reported to have immune enhancing activity, inhibitory action on induced lung metastasis and on specific mutagenicity.

Genistein was shown to have a negative result in Ames test for mutagenesis and act as a specific inhibitor of tyrosine kinase, an inhibitor of human breast cancer cell proliferation, as well as reducing bone loss. Coumestrol was shown to be an estrogen supplement and an anti-osteoporosis agent. Stigmasterol was reported to have cholesterol lowering action. B-Sitosterol was shown to reduce benign prostate hyperplasia and inhibit human colon cancer growth, as were mirificoumestan and its derivatives. Recently, deoxymiroestrol, with stronger estrogenic effects than that of miroestrol was also isolated.

Thailand is the main natural habitat of Pueraria mirifica with a long history of consumption record. While soy is currently used for prevention and treatment of menopausal symptoms, this preliminary clinical trial with P. mirifica in Thai women could help evaluate its potential use for long-term phytoestrogen, supplementation and provide basic information to initiate a full-scale clinical trial. Such a trial could help us to clearly understand how the crude drug works in menopausal women.

MATERIALS AND METHODS

1. Crude Drug Preparation
The fresh tuber of P. mirifica cultivar "Tropical-III" was collected, cleaned, peeled, sliced into pieces, dried in a hot air oven until nearly completely dried, ground into fine powder of 100 mesh size particles and finally filled into capsules with the net filling amount of 200 mg per capsule.

Isoflavone contents were analyzed by high performance liquid chromatography at Japan Food Research Laboratory, Osaka, Japan, from the powder with the aid of puerarin, daidzin, daidzein, genistin and genistein as references and subsequently used as active ingredient markers.

2. The Volunteers
Menopausal women with a history of cyst formation at the breast, uterus and / or ovary were excluded. Five accepted volunteers were the outpatients of Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand, with an age range from 35 to 52 years. These women suffered from oligomenorrhoea or amenorrhea, hot flushes, frustration, skin dryness, weakness and/or sleep disorder. The volunteers had complete blood cell count and blood chemistry analysis including hemoglobin, haematocrit, blood urea nitrogen, creatinine, SGOT, SGPT, cholesterol, triglycerides and urinalysis. The selected volunteers had to be in a normal health with normal blood chemical analysis results. They were verbally informed about the detail of the crude drug and the consumption of one 200 mg capsule a day for the first 21 days of the month for a 4 months period. If drug administration had to be extended, 1 capsule would be consumed every other day for the first 20 days of the month until the end of the 12th month. The volunteers had signed a written informed consent. Finally, 5 normal volunteers were recruited for the first 4 months trial period, whereas 4 volunteers were asked to complete the one-year test period.

3. Evaluation Criteria

3.1 Physical Examination Record
The body weight, height, breast, waist and hip sizes of the volunteers were recorded just prior to the test, as well as monthly when they came on appointment to receive a new capsule batch, and again at the end of the test.

3.2 Medical Interview
A medical doctor interviewed the volunteers with standard questions just prior to the test, as well as monthly, and finally at the end of the test.

3.3 Total Blood Count and Blood Chemistry Analysis
Blood was collected for total blood count and blood chemistry analysis. The results were analyzed just prior to the test, at the end of the 4th month test period, and at the end of the 12th month test period.

RESULTS

The results from the four-month and one year study from five selected volunteers are individually described as follows:-

Volunteer No. 1, 46 years old, weight 48 kg, height 1.47 m, had experienced amenorrhea period for 4 months with clear menopausal symptoms exhibited as hot flushes, frustration, sleep disorder and skin dryness. Physical examination as well as total blood count and blood chemistry analysis, were normal.

After completion of the 1st month test period, it was found that the patient's appetite increased, the body weight increased by 0.5 kg and recovered from hot flushes, frustration and skin dryness (especially facial skin).

After completion of the 2nd month test period, the patient had recovered from sleep disorder. After completion of the 3rd month test period, all recovering symptoms were maintained.

After completion of the 4th month test period, the recorded menopausal symptoms showed remarkable recovering from the hot flushes, frustration, sleep disorder, and skin dryness. Total blood count and blood chemistry analysis revealed that the body responded to the crude drug normally, while the patient's recorded weight increased by 0.5 kg and no recurrence of menstruation period was observed. The volunteer was satisfied with the test results and stopped consumption of the crude drug at that time.

Volunteer No. 2, 52 years old, weight 47 kgs, height 1.47 m, had experienced amenorrhea period for 5 years with obvious menopausal symptoms as exemplified as hot flushes, frustration, sleep disorder and wrinkled facial and body skin. Her physical examination was normal. The total blood count and blood chemistry analysis were normal except blood cholesterol which was recorded as 247 mg%.

After completion of the 1st month test period, the facial skin had become firm while the body weight increased by 1 kg.

After completion of the 2nd month test period, full recovery from the sleep disorder symptom had occurred and her frustration had been abolished. The body weight increased by 3 kg. Her breasts were firm and showed a 2.5 cm increase in size. Two and a half cm increase in size of the waist and the hip had occurred.

After completion of the 3rd month test period, the skin was firm and hot flushes no longer occurred. Her total blood count was normal. The blood chemistry analysis showed a sharp decrease in blood cholesterol level from 247 to 205 mg% (17.0% decrease).

After completion of the 4th month test period, the patient showed full recovery from all recorded menopausal symptoms. The facial and body skin were firm and shiny. The net weight gain was 3 kg and recurrence of the menstruation was not observed.

The volunteer kept taking the crude drug until the end of 12th month. It was found that the previously recorded recovery from menopausal symptoms as well as the facial and body skin firmness were all maintained while the menstruation did not recur. The volunteer was satisfied with the test results.

Volunteer No. 3, aged 35 years old, weighed 62 kg, 1.66 m height. This patent had had amenorrhea for 7 months, was submitted to heart surgery (PDA ligation) 18 years ago, and also regularly suffered from constipation, sleep disorder, frustration, itching and a moderate amount of facial acne. Her total blood count and blood chemistry analysis were normal.

After completion of the 1st month test period, the breast size had increased by 2.5 cm and were firmed; her body skin became healthy and shiny; her facial acne disappeared resulting in clear face appearance.

After completion of the 2nd month test period, the recovered symptoms were maintained as recorded in the 1" month.

After completion of the 3rd month test period, the amenorrhea symptoms were fully disappeared as the volunteer exhibited menstruation period, itching was fully recovered, as well as sleep disorder and constipation. The body weight increased by 0.4 kg.

After completion of the 4th month test period, the menstruation period was recorded for 2 days, the body weight had increased by 1.5 kg, the breast size remained the same as that recorded before the test, but became firmer. The hip and waist circumferences had increased by 2.5 cm. Total blood count and blood chemistry analysis were normal.

The volunteer kept taking the crude drug until the end of 12th month. It was found that sleep disorder and frustrate symptoms were completely absent and the volunteer felt that she was in a good mood. Facial and body skin had recovered from dryness and retained firmness. The menstruation period was finally found to be irregular with increased volume. The final body weight increased by 2 kg. The volunteer was satisfied with the test results.

Volunteer No. 4, aged 49 years old, had had right ovariectomy. Her weight was 68 kg, and the height was 1.56 m. She had an irregular menstruation period, and thus, was classified as oligomenorrhoea. She had hot flushes and rheumatism, but her total blood count and blood chemistry analysis were normal.

After completion of the 1st month test period, the volunteer felt breast pain starting from the 3rd day. The result of breast examination revealed no abnormality in term of cyst formation.

After completion of the 2nd month test period, the menstruation period was found to be normal. The breast pain persisted but at a lower degree.

After completion of the 3rd month test period, the breast size had increased by 2.5 cm. She still had breast pain.

After completion of the 4th month test period, the skin became healthy and firm; backache remained; shorter menstruation period was found. Urinary problems such as mild dysuria occurred for some times. Laboratory results were normal.

The volunteer kept taking the crude drug until the end of one-year study period. Physical examination results were normal. The body weight was stable and the skin was healthy and firm. The regular menstruation period was maintained. The dysuria was investigated and white blood cells (6-10 cells / HPF) were found in urine. She was treated with ofloxacin for 7 days and the symptom was eliminated. The volunteer was satisfied with the test results.

Volunteer No. 5,39 years old, had a weight of 49.3 kg, a height of 1.58 m, and had been married for 12 years without having a baby. She had exhibited a fibro adenoma breast condition for 6 years. She was classified as oligomenorrhea due to the fact that the menstruation period had been reduced from 7 days to 3 days. She regularly had headache and frustration. The total blood count and blood chemistry analyses were normal except blood cholesterol level which was 237 mg%.

After completion of the 1st month test period, a fine acne had occurred on the face since the end of the 2nd week and thereafter developed into abundant acne for 1 week before completely disappeared. The menstruation period became normal with fresh color.

After completion of the 2nd month test period, the frustration had abated; the headaches had disappeared; the skin became healthy and firm; clear secretion was observed within the vagina; the breasts had increased by 2.5 cm in size and were firm while the waist and hip circumferences and the body weight remained the same.

After completion of the 3rd month test period, the menstruation period remained normal, as well as other parameters.

After completion of the 4th month test period, the menstruation period remained normal; the skin was healthy and firm; the body weight had increased by 1 kg. Total blood count and blood chemistry analysis were normal except blood cholesterol level which had decreased from 237 to 205 mg% (13.5% decrease).

The volunteer was asked to keep taking the crude drug until the end of the one-year study period. The normal menstruation period and the healthiness and firmness of the skin were fully maintained. The body weight had increased by 1 kg while the breasts were firm and had increased by 1 cm in size. The waist had also increased in size. The volunteer was satisfied with the test results.

The reported cases versus recovering cases in five menopausal women after 4 months consumption of P. mirifica crude drug are summarized in Table 1. The number of cases that exhibited adverse side effects is summarized in Table 2.

DISCUSSION

The crude drug prepared from the powder of P. mirifica cultivar Tropical-III was tested in five menopausal volunteers with oligomenorrhoea or amenorrhea symptoms. The test was designed for 4 and 12 months and 12 months periods.

The results (Table 1) revealed that two volunteers with oligomenorrhoea symptom showed an estrogenic response to the crude drug that reflected in clear improvement of the menstruation period. The findings implied that phytoestrogens from P. mirifica cultivar Tropical-III exhibited trophic effects to the uterus similar to those from estrogen or phytoestrogens from other sources. The trophic effects were most likely fully functional if the uterus was still in a fresh status, as in the case of oligomenorrhoea, but they might not fully work in the two cases with amenorrhea at the age of 46, lasting for 4 months and another at the age of 52, lasting for 5 years. The uterus in such cases might be developing into an atrophic status while the younger woman at the age of 35 years, lasting for 7 months could recover for the menstruation period at the end of the 3rd month. This result was most likely to occur by the same reason as that of the oligomenorrhoea. Furthermore, in one case, the clear secretion released from the vagina was noted as a sign of adverse effect (Table 2). It was most likely to result from cervical and/or vaginal secretion due to the estrogenic effect that was normally found per se in normal menstrual cycle. This finding helps confirm that estrogen receptor (ER) B is presented in human cervix or vaginal lining and can respond to P. mirifica phytoestrogen as well.

Table 1. Number of cases suffering with reported symptoms and that recovered after four months consumption of Pueraria mirifica crude drug.

Table 2. Number of cases exhibited the adverse effects after four months consumption of P. mirifica crude drug.

The breasts increased in size in three cases, and transient enlargement occurred in one case. The enhancement of breast firmness, a sign of breast restitution, resulted in an increase in breast elasticity in two cases. Such findings should indicate the response of breast tissues to P. mirifica phytoestrogens by an increase in the elasticity of the breast skin as well as by greater accumulation of water and/or fat within the breast tissue. Breast pain which occurred rapidly in one case should result from increasing pressure in situ derived from water retention within the breast tissue, as always occurs by estrogen just prior to the menstrual period. In this case such pain was prolonged and finally partially habituated. It was mainly due to the body maintenance of high level phytoestrogens after long-term consumption of the crude drug.

The skin appeared to be healthy as shown to be shiny and firm in all volunteers after consumption of the crude drug. Its response to P. mirifica phytoestrogens was mediated by increasing water retention, and fat and/or collagen fiber accumulation could also be observed in the case of estrogen treatment. Such accumulation would definitely result in increasing firmness in that particular tissue and organ. Interestingly, all volunteers expressed this type of estrogenic response and thus should imply that ERR is present abundantly in the skin and this type of response is very unique for P. mirifica phytoestrogen treatment.

The acne previously existed before treatment, or was initiated as a result of the crude drug consumption, would disappear soon. This phenomenon might be mainly due to the novel balance of estrogen as phytoestrogens from P. mirifica could competitively bind to ERa. It could show an antagonistic effect to estrogen through an increase in the degradation of estrogen and/or a decrease in the activity of estrogen. The influence of P. mirifica upon acne formation and clearance as clearly demonstrated in this study could be explained by the presence of high amount of phytoestrogens in this plant.

The completed 4 months tested volunteers showed normal total blood count and blood chemistry analysis results especially the kidney and liver function tests. The results revealed that the designed dosage of 200 mg/day with maximum 21 times/month of the crude drug derived from P. mirifica cultivar Tropical-III was not toxic to the human body especially female, whereas the 3 months sub chronic toxicity test in rats also revealed that the blood chemistry might change mildly at the dose of 1,000 mg/ kg BW while normal findings were reported at the dosage of 10 and 100 mg/kg BW45. This dose employed should be most likely an effective dose as it could eliminate some menopausal symptoms within the 1" month of the test period and of nearly all menopausal symptoms within the A* month of the test period without any serious adverse effects. One of the most interesting points was that this crude drug treatment fully abolished all previous menopausal symptoms, except the amenorrhea which was resolved in only one out of 3 volunteers. It might imply that the crude drug at the employed dosage might not be strong enough to help recovering of such symptoms. In the contrary, it might be an advantage to administer this crude drug as it could help recovering the main menopausal symptoms without or mildly affecting the initiation or renewal of menstruation period in amenorrhea. Furthermore the reduction of the crude drug consumption to approximately half the dose of the previous one and keeping on for one year resulted in full recovery of menopausal symptoms. It could be implied from this study that half the dose was enough to maintain the recovering status whereas the full dose was necessary to boost the recovering within a definite period which was found to be not longer than 4 months. Some recovering symptoms could even be observed since the end of the 1st month test period.

The body weights of 4 volunteers were found to increase slightly at the end of the test. This phenomenon might be related to the increase in appetite which was clearly recorded in one volunteer. It might also be related to the recovering of the facial and body skin dryness and/or wrinkles in all volunteers that was most likely to be due mainly to the increase of dermal fat and oil accumulation.

The decreases of blood cholesterol in 2 volunteers that were 13.5 and 17.0% reduction, might result from suppression of cholesterol biosynthesis in specific tissue or increasing degradation of blood cholesterol or increasing uptake of blood cholesterol at peripheral tissues. The decreasing in blood cholesterol level was also reported in a toxicology study in rats which was more marked in the male than female.

Our test results might open a new criterion to apply this phytoestrogen-rich herb to treat hypercholesterolemia or even arthrosclerosis that is very common in aging population including menopausal women.

P. mirifica phytoestrogens also exhibited nervous response as the recorded frustration which happened in 4 cases, sleep disorder in 3 cases, and hot flushes in 3 cases, were fully recovered and replaced by a better mood in those 4 cases, as well as better appetite in one case. These findings were hard to monitor. The elevation of mood in 4 cases contributed to the sign of better quality of life which was very important in menopausal women as stress from bad mood or frustration not only affected the subject itself but also more or less affected nearby people. Although some minor adverse effects were found after consumption of the crude drug, such as backache in 1 case, some minor benefit effects were also found such as elimination of headache, rheumatism, itching, constipation and acne- These findings convinced

that the crude drug could exhibit more benefit than adverse effects after consumption. For example, the vaginal and/or cervical secretion reported in one case was classified as adverse effect in one hand as it did not happen in the volunteer before the test, it might also be recognized as trophic effect in the other hand as it could help recovering from vaginitis and dyspareunia. The breast size increase was classified as adverse effect by the same criteria but this phenomenon might be recognized as a trophic effect as well, due to the fact that breast enlargement was the benefit criteria for cosmetic purpose.

P. mirifica cultivar Tropical-III contains significant amount of isoflavone as analyzed by high performance liquid chromatography. The 100 g dried powder contains 169.1 mg total isoflavone whereas miroestrol, deoxymiroestrol and other minor chemicals are present in very small amount and can not be easily detected routinely by this method. It was then deduced that isoflavones could at least be the main chemical marker in the crude drug, and part of the menopausal symptom recovering as observed in this study could result partially from the high isoflavone content in P. mirifica cultivar Tropical-III as it was demonstrated before in MCF-7 cell line that isoflavone from P. mirifica could also exhibit estrogenic effects.

Phytoestrogens can competitively bind to ERa in a Premenopausal woman who still has significant amount of estrogen. P. mirifica phytoestrogen supplementation could result in reducing the risk of estrogen-related cancer in this group of woman. Supplementation of phytoestrogens including P.mirifica in menopausal women with trace amount of estrogen could be a natural choice for estrogen supplementation in one hand. It may, in the other hand, increase the risk of estrogen-related cancer as found in estrogen supplementation, which is stronger on the other hand, due to the agonistic effects of phytoestrogens which are nearly totally dominated in the absence of estrogen. Very low amount of phytoestrogen supplementation especially genistein could promote the growth of human breast cancer cell in vitro. In this study, there was no volunteer who had breast cancer or any other cancer during the 4 or 12 months studied period. It may be reasonable to conclude that P. mirifica cultivar Tropical-III crude drug at this dose may be in the high dosage level and thus exhibits mainly cytotoxic or neutral but not trophic effect to the pre-existing breast cyst (if present). It also does not stimulate the occurrence of a new breast cyst- All animal treated with P. mirifica or miroestrol, the key chemical of P. mirifica also exhibited no report of breast cancer occurring, as well as the clinical trial with miroestrol.

However, the number of the volunteers in this study is very small and thus may not be strong enough to conclude that P. mirifica can protect against breast cyst formation in menopausal women. It may be worth also testing the topical application at P. mirifica extract directly to the breast area whether t can protect against breast cancer or not if applied long term.

The number of menopausal women is currently increasing in developed countries. ERT is at present the choice of effective treatment for such reputation. Phytoestrogen could be then a novel alternative as it could do both functions at the same time, exhibiting estrogenic effects as well as functioning as an anticancer agent. Previous studies have clearly indicated that the estrogenic effects of P.mirifica are far stronger than those of soy which is a popular commercialized natural phytoestrogen supplementation at present. We can therefore stress that this study has initiated an attractive invitation for researchers to investigate deeply into P. mirifica phytoestrogens and manipulate them to serve the need for alternative medicine or Phytoestrogen Replacement Therapy (PRT) for menopausal women with a reduced cancer risk which has been previously seen in those taking soy phytoestrogens, and with a higher degree of success in relieving menopausal symptoms.

ACKNOWLEDGEMENTS
The authors wish to thank Japan Food Research Laboratory, Osaka Branch, Japan, for HPLC isoflavone analysis with the sample of White Kwao Krua, P. mirifica cultivar Tropical-III, to Ramathibodi Hospital, Mahidol University and the Office of Academic Affairs, Chulalongkorn University for partial support.