For a woman's well-being

Menopause is the time in a woman's life when menstruation ceases. This can occur any time between the ages of 40 and 52 and results from the loss of ovarian follicular activity. The follicles - structures that hold and release eggs within the ovaries - play a role in the production of female hormones oestrogen and progesterone, which are vital for fertility and reproduction. As a woman ages, hormone production declines progressively, resulting in irregular menstrual cycles and finally cessation of menstruation.

Today, given the increased levels of life expectancy, with more and more women living even up to four decades after the onset of menopause, it is imperative that more attention is paid to the effective medical management of menopause. For a number of years oestrogen was thought of as the magic hormone for the management of menopause. Today phyto-oestrogen or 'plant oestrogen ', which mimics the action of oestrogen in women, are becoming popular. Currently, around seven phyto-oestrogens have been identified, with isoflavones - the phyto-oestrogens found in soya - evincing the most interest.

According to Dr. Adam Carey, Medical Director, The Centre for Nutritional Medicine, London, studies have shown that soya has an impact on a number of conditions related to heart disease, osteoporosis, menopause symptom relief and possibly cancer, and these effects are attributed to isoflavones. A trained obstetrician and gynaecologist, Carey has co-authored a number of papers and has over 10 years of teaching experience. He left clinical practice in the United Kingdom's National Health Service four years ago to take up his present appointment. He is currently involved in tackling a wide variety of clinical problems that include gynaecology, weight management, reproductive endocrinology and sports nutrition.

Carey, 41, is also working on four research projects, all of which look into various treatment options for menopausal symptoms. Excerpts from an interview he gave Ravi Sharma:

Listening to the talk you gave to some of Bangalore's leading gynaecologists, it was obvious that you are a great advocate of the use of isoflavones to manage menopause. In layman's terms, what are isoflavones ?

It has been known for some time that if you are to restrict osteoporosis and build bones one needs weight-bearing exercises, building blocks (essentially vitamins and minerals) and builders (which are known to be oestrogen). But now there are other compounds and hormones that are clearly as effective in building bones as oestrogen. One of these may be progesterone, the other being isoflavones. Isoflavones, which are a compound found in soybean and other legumes, appear to have a positive effect on bones. We are also seeing that diet can have an important effect both on the building blocks and in being a builder.

How do isoflavones work?

Isoflavones are a chemical which have a structure that is similar to that of oestrogen. Hence they bind to the same kind of receptors that oestrogen binds to. Like the key of a car. It is not the original key but it still opens the door. It is a key that opens the same doors that oestrogen does, but maybe it doesn't fit so well. So it doesn't open all the doors all the time but it does most of the time.

There is a body of core research that suggests that the community should look at isoflavones in clinical use and practice.

Yes. Five years ago the climate was that oestrogen was absolutely good for everything. That climate has now changed. Oestrogen has now been found to increase the risk of breast cancer, clots in the leg (thrombosis) and cancer of the womb, and also in the short-term increases the risk of heart diseases. These risks weren't so clear five years ago. The balance has now changed and during the last five years there has been a lot of research on soya and soya isoflavones.

How did you get interested in isoflavones?

By listening to my patients. Being trained as an obstetrician and gynaecologist I was seeing a lot of patients who were coming with two basic problems. One, they were scared of traditional hormone replacement therapy (HRT), given the (possible) risks of breast cancer associated with it. They would tell me, "This is something that really troubles me, nonetheless I would do it". And second, whilst they were taking HRT they were concerned about the side-effects, particularly they didn't like to have a cyclical bleed, which occurs for the first few years post-menopause if the woman is using HRT. A cyclical bleed is very much like a menstrual period, the experience is similar and it comes every month, but it is an induced bleed. And most post-menopausal women would rather not have any bleeding. Because of these two reasons all my patients would tell me, "I don't like the side effects of HRT and I don't think (a cyclical bleed) is natural." This is what made me start thinking.

Are you advocating an alternative?

It is a complement as opposed to an alternative. I don't use it as a golden bullet. It is part of a holistic management. What I offer only goes hand in hand with conventional medical practices. My team works with doctors and dietitians seeing patients jointly. We then medically define what the patient needs in terms of her lifestyle and then the dietitian or nutritionist will take her through step by step on how she should change it.

A patient may be on HRT, but her HRT will be more effective if her diet is right. Some patients do not want HRT, so this is better. It may not be as effective as HRT for reduction of hot sweats, but then getting your diet right does not have any side -effects. And when you use things like isoflavone the effectiveness improves. In other words, getting your diet right improves your symptoms to a degree, when you add nutritional supplementation that has a pharmacological action similar to oestrogen, you have an even bigger effect. For some people it can be an alternative, for many a complement. Studies have also shown that they work together synergistically.

Getting your diet right seems to be the key?

Yes. For example, if an overweight patient has urinary incontinence doctors won't want to operate on them. Because we know that if they are slimmer the operation is more successful. If they have osteoporosis doctors prescribe oestrogen. We now know that if they don't get their diet right oestrogen won't have anything to work on. So they have to have their diet corrected.

Can hot flushes, one of the main manifestations of menopause, be controlled by diet?

Yes, studies have shown that you can reduce them by reducing caffeine intake. But only to a degree, though. Dietary modulation is reasonably effective but doesn't cure it. Isoflavones reduce the occurrence of hot flushes by 50 to 60 per cent. Oestrogen by about 85 to 90 per cent. Another hormone - progesterone - may also be useful in the future.

Isoflavones can be taken naturally in the form of soya. Why a capsule?

Absolutely, I'm all for the eating of whole foods. But I don't see a lot of soya being eaten in India. Dietary changes are difficult to make. Also bigger, more thorough studies have to be undertaken before a whole nation changes its diet. And even if studies have proved that soya is as effective as oestrogen and completely safe, I would still question the merit of changing a nation's cultural background.

Some communities notably in the Far East have a soya-rich diet. Are there any studies showing a lower incidence there of distressful menopausal symptoms?

Absolutely. If you look at the epidemological studies from Japan, where most of this work has been done, the Japanese have the lowest incidence of diseases associated with menopause, be it breast cancer, endometrial cancer, cardiovascular disease, osteoporosis - and in men, prostrate cancer. Illnesses that are very high risk in the United Kingdom (U.K.), the United States and now increasingly in India. Studies show that both in the U.K. and the U.S. at least 80 per cent of post-menopausal women experience one or more of these symptoms, one of three women has osteoporosis and by the age of 80 almost all of them have had at least one osteoporosis-produced fracture.

In medical journals when they talk of Asia they assume that what is happening in Japan is happening in India. My experience with Indian gynaecologists clearly shows that many more Indian women than the 5 to 10 per cent that journals indicate, suffer menopausal symptoms. A recent study in Bangalore showed that more than half the women who go through menopause experience symptoms.

In Japan the very high intake of isoflavones amongst other things is reducing the incidence of all the common diseases that are killing people in the rest of the world. Less than 10 per cent of Japanese women experience menopausal symptoms. But when they move to the U.S., within one generation they become prone to breast cancer, endometrial cancer, cardiovascular disease and so on. So it is not the genetics of the Japanese women that is protecting them, but something in the environment - either the air they are breathing or the food they are eating. We think it is the food.

Can isoflavones reverse these disorders?

You can't reverse ageing. Heart attacks cause death, but a fractured hip does not cause immediate death. But 20 per cent of women who have a break in the leg will die within the first 12 months of that fracture. This is because they contract pneumonia or whatever else. Fractures take a lot of money to put right. Fractured spines, which leave little old ladies all bent over (the Dowager's hump), cause chronic pain and disability.

It is estimated that the amount of money spent on treating osteoporosis-related cases in England is 1 billion a year. Even if we can't stop all the cases, it would help if we could delay them. Menopause was never a problem 200 years ago since all of us died before menopause. It is a problem today because many of us live up to 80. Most women have 30 years post-menopause and they get their fractures in their 70s and 80s. We are looking to push the likelihood of these fractures happening when the women are 90 or 100.

Do men experience menopausal symptoms?

Men very rarely, for example, experience hot flushes, only if they are undergoing chemotherapy. But men also have problems associated with changes in their hormonal levels as they get older. Most men after the age of 45 experience a fall of some of the androgens in their bodies. They also get osteoporosis - about a third as often as women. They are also at cardiovascular risk and often show abnormal lipid profiles. Isoflavones improve those lipid profiles.