Postmenopausal women experience different physical and psychological symptoms throughout their lives. One of the disturbing complaints caused by reduced estrogen levels is atrophy of the urogenital tract. Although Menopausal hormone therapy (MHT) is used as an effective treatment to reduce symptoms of urogenital atrophy during menopause, it has controversies related to an increase in breast cancer, venous thromboembolism, and stroke. Abdi et al.  performed a systematic review article regarding the impact of phytoestrogens for the treatment of urogenital menopause symptoms, which was published this year. The systematic review and meta-analysis aimed at investigating the effect of phytoestrogens on the treatment of urogenital menopausal symptoms. The guidelines of PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) were used, and several databases were systematically searched between 2000-2020. The results of the study showed that 33 studies met the inclusion criteria and a total of 2,972 individuals entered into the selected interventions. Various forms of phytoestrogens were included in the analysis, including fennel, Pueraria Mirifica, Hop plant (Humulus lupulus L.), Glycine max (L.) merr, soy, red clover, black cohosh, cimicifuga racemosa, ginseng, genistein, diadzein, glycitein and isoflavone in the form of oral capsules and pills, food supplements, enriched powder, vaginal gel, cream, and suppository in order to determine if these could improve menopausal urogenital symptoms. The investigators conclude that after using a variety of phytoestrogens in different forms the indicators of urogenital atrophy and urinary disorders improved and women’s sexual function as well. These phytoestrogens are safe and of low-risk compared to hormone therapy and are also an accessible method for women to relieve urogenital symptoms and promote the sexual satisfaction and quality of life.
Abdi et al.  reviewed the impact of phytoestrogens on the treatment of urogenital menopausal symptoms involving 33 high-quality papers. Urogenital atrophy is one of the most common pathological conditions in postmenopausal women, but the consensus of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society used the Genitourinary Syndrome of Menopause (GSM) as the new term for the condition previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy [2,3]. The GSM describes the symptoms and signs resulting from the effect of estrogen deficiency on the female genitourinary tract, such as dryness, burning, and irritation; urinary symptoms and conditions of dysuria, urgency, and recurrent urinary tract infections; and sexual symptoms of pain and dryness. Symptoms of GSM are very common, affecting approximately 27% to 84% or more than half of postmenopausal women [4,5]. The GSM often has significant adverse effects on women’s sexual health and quality of life. Women who are not sexually active also experience bothersome symptoms of GSM affecting activities of daily living .
In this commented study, the authors reviewed various forms of phytoestrogens over the treatment of urogenital menopausal symptoms. Some results of the review were as follows: the daily use of fennel seed significantly improved menopausal urogenital symptoms in postmenopausal women. Pueraria Mirifica as a vaginal gel or oral pill improved menopausal urogenital symptoms in a total of 144 postmenopausal women. A study on the impact of the combination of soy, red clover, cimicifuga racemosa involving 230 postmenopausal women found that women were satisfied with improving their urogenital symptoms compared to the control group. Comparison of isoflavones in vaginal gel, capsule, and powder form with placebo, estrogen, or acupuncture, involving 1,000 postmenopausal women, showed that the substance is effective in treating symptoms of urogenital atrophy. At the end of the review, the authors concluded that phytoestrogens were effective as hormone therapy in the treatment of urogenital menopause symptoms . There is one similar study but with a different result. Saghafi et al.  in a systematic review and meta-analysis study on the effect of phytoestrogens in alleviating the menopausal symptoms concluded that phytoestrogens had a non-significant positive effect on the vaginal atrophy index. In this review, 10 articles were included containing the trials of soy and other phytoestrogens . The difference in results in these two reviews is due to differences in the time of searching and study assessment. The 2017 Hormone Therapy Position Statement of the North American Menopause Society (NAMS) stated that hormone therapy has been shown in RCTs to effectively treat symptoms of vulvovaginal atrophy and decided that low-dose vaginal estrogen therapy (ET) is recommended over systemic ET as first-line medical therapy (Level I) . In line with NAMS’ recommendations, Rosa Lima et al.  found that the daily use of isoflavone vaginal gel in postmenopausal women led to improvements in vaginal atrophy symptoms, maturation values, vaginal pH, morphology, and expression of estrogen receptors in the vaginal epithelium . In addition, the study of Abdi  has complemented the data that various forms of phytoestrogens are safe to use to increase sexual satisfaction.
In this commented study, the location of the selected studies was geographically diverse, including Iran, Brazil, Italy, Thailand, India, United States, South Korea, Romania and Australia. It appears that phytoestrogen research is mostly carried out in Asian countries (54.54%), the rest is evenly distributed in several regions of the world. These data indicate that phytoestrogen treatment is widely used in Asian countries. Further studies are needed to validate the effectiveness of phytoestrogens at improving menopausal symptoms, including genitouriary ones, and hence be used in more countries.
In conclusion, phytoestrogens can be used as a therapy for postmenopausal complaints, including the GSM, and as a safe medication to increase sexual satisfaction. Further studies are needed to evidence their effectiveness so that they be more widely used as alternatives to estrogen hormone therapy.
Hendy Hendarto, MD, PhD
Department of Obstetrics and Gynecology
Faculty of Medicine, Universitas Airlangga –
Dr Soetomo Academic General Hospital, Surabaya, Indonesia
- Abdi F, Rahnemaei FA, Roozbeh N, Pakzad R. Impact of phytoestrogens on treatment of urogenital menopause symptoms: A systematic review of randomized clinical trials. Eur J Obstet Gynecol Reprod Biol. 2021;261:222-235.
- Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, and Athanasou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020;12(4):e7586.
- Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063-1068.
- Palma F, Volpe A, Villa P, Cagnacci A; Writing group of AGATA study. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. Maturitas. 2016;83:40-4.
- Crean-Tate KK, Faubion SS, Pederson HJ, Vencill JA, Batur P. Management of genitourinary syndrome of menopause in female cancer patients: a focus on vaginal hormonal therapy. Am J Obstet Gynecol. 2020;222(2):103-113.
- The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
- Saghafi N, Ghazanfarpour M, Sadeghi R, et al. Effects of Phytoestrogens in Alleviating the Menopausal Symptoms: A Systematic Review and Meta-Analysis. Iran J Pharm Res. 2017;16(Suppl):99-111.
- NAMS. The 2017 hormone therapy position statement of The North American Menopause Society. Position Statement. Menopause. 2018; 25,11:1362-1387.
- Lima SM, Bernardo BF, Yamada SS, Reis BF, da Silva GM, Galvão MA. Effects of Glycine max (L.) Merr. soy isoflavone vaginal gel on epithelium morphology and estrogen receptor expression in postmenopausal women: a 12-week, randomized, double-blind, placebo-controlled trial. Maturitas. 2014;78(3):205-11.
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